How to Examine Patients. A guide split into the various parts.

Dr. Amen's Abdominal Examination

• Introduce yourself and ask permission to examine the patient.
• Expose abdomen down to inguinal region and lie the patient flat
• Stand back
• Look at the patient having a deep breath in and out
• Look at the hands clubbing, leuconychia, Dupuytren's contracture, liver palms, splinter haemorrhages, spider naevi
• Eyes - check for jaundice and anaemia
• Tongue
• Check for spider naevi on face, and chest
• Look at the back and palpate the neck
• Palpate the nipples in men for gynaecomastia

• Kneel on the floor
• Ask where the pain is.
• Lightly palpate (starting in left iliac fossa unless painful)
• Palpate deeply
• Palpate left kidney (keep your right hand anterior)
• Palpate spleen (start at right iliac fossa)
• Palpate right kidney (keep right hand anterior)
• Palpate liver
• Feel for bladder

• Percuss out spleen and liver
• Percuss for ascites - test for shifting dullness
• Feel for aortic aneurysm

• Auscultate right of the umbilicus for bowel sounds
• Left and above the umbilicus for an aortic bruit
• Iliac fossae for iliac bruits
• Examine for herniae
• Mention that you would normally examine the genitalia, perform a p/r and dipstick the urine.

Dr. Amen's Cranial Nerve examination

• Introduce yourself and ask permission to examine the patient.
• I
  • 'Has there been any change in your sense of smell'
• II
  • Ask the patient to read a card, or ask how many fingers the examiner is holding up (examine one eye at a time)
  • Check visual fields
  • Swing light over each eye twice - looking at same eye, and then the other
  • Examine fundi
• III, IV, VI
  • Check eye movements and accommodation by holding the patient's chin and ask the patient to follow your finger in an H-shape and bring the finger in towards the patient's nose in one smooth movement (look for nystagmus)
• V
  • Facial sensation - compare both sides with cotton wool in six places
  • Corneal reflex 'Open your mouth and don't let me close it'
  • 'Clench your teeth' and feel masseter and temporalis
  • Jaw jerk
• VII
  • Raise eyebrows
  • Close eyes tightly and resist opening
  • Smile
  • Show teeth
  • Blow out cheeks
• VIII
  • Cover ears in turn 'Repeat the number I am whispering'
  • Rinne's and Weber's
• IX and X
  • 'Open your mouth' 'Say Ahh..' - look for elevation of uvula
  • Gag reflex
• XII
  • Stick tongue out and move it from side to side
  • Check for deviation
• XI
  • Ask the patient to push against your hand on left and right with the chin - test for sternocleidomastoid
  • 'Shrug your shoulders' against resistance -test for trapezius.

Dr. Amen's Cardiovascular System examination

• Introduce yourself and ask permission to examine the patient.
• Expose and sit at 45 degrees.
• Stand back Look for pallor, dyspnoea, cyanosis, sternotomy scar.
• Ask patient to lift arms to look for scar of coarctation repair
• Look at hands and nails for clubbing, spinter haemorrhages, koilonychias etc

• Pulse and compare with other pulse
• In a young person check for radiofemoral delay - eg coarctation of aorta
• Lift the arm to check for a collapsing pulse
• Look at the antecubital fossa for a catheter scar
• BP
• Eye - anaemia, Argyll Robertson pupil
• Look at tongue
• Palpate carotid pulse for volume, character, thrill
• JVP waveform and height
• Palpate for apex beat and count it down
• Check for heaves and thrills at the apex, left and right of the sternum

• Auscultation at apex with bell, repeat in left lateral position
• Reposition Using the diaphragm, check the apex (mitral valve) (if there is a murmur, move to the axilla)
• Check below the sternum
• *Left sternal edge (base - tricuspid valve, second intercostal space on left - pulmonary valve)
• *Second right intercostal space (aortic valve)
• Listen for carotid bruits
• (Repeat * with the patient sitting forward and breath held in expiration)
• Listen at lung bases
• Inspect for sacral and ankle oedema
• Examine the peripheral pulses

Dr. Amen's Lower Limb examination

Always compare sides

• Introduce yourself and ask permission to examine the patient.
• Expose legs
• Observe wasting and fasciculation

• Tone
• 'Let your leg go loose and let me move it for you'
• Roll leg straight
• Roll foot around ankle, then pull it up suddenly to check for clonus.
• Flick up leg at knee.
• Flex leg at hip and knee.

• Power
• 'I'm going to test the strength of some of your muscles in your legs'
• 'Keep your leg straight and lift. Don't let me stop you.'
  • Hip flexion (Iliopsoas L1, L2)
• 'Push your leg into the bed. Don't let me stop you'
  • Hip extension (glutei L4, L5)
• 'Push out against my hand.'
  • Hip abduction (glutei L4, L5)
• 'Push in against my hand'
  • Hip adduction (adductor group L2, L3, L4)
• 'Bend your knee and pull your heel to your bottom. Don't let me stop you.'
  • Knee flexion (hamstring L5, S1)
• 'Now straighten your knees out'
  • Knee extension (quadriceps L3,L4)
• 'Pull your foot up and don't let me stop you.'
  • Ankle dorsiflexion (tibialis anterior and long extensors L4, L5)
• 'Push your foot down against my hand'
  • Ankle plantar flexion (gastrocnemius S1)
• 'Push your foot out against my hand'
  • Ankle eversion (peronei S1)
• 'Push your foot in against my hand'
  • Ankle inversion (tibialis anterior and posterior L4)

 

• Reflexes
• Knee L4
• Ankle S1
• Plantar response
• Start on lateral surface of sole and sweep up and medially

• Sensation
• Pinprick
• Light touch
• Vibration
• Temperature
• Joint position sense

• Coordination
• Heel shin test.
• Now close eyes to test dorsal columns.
• Romberg's test
• Examine the gait.

Dr. Amen's Respiratory Examination

• Introduce yourself and ask permission to examine the patient.
• Expose and sit at 45 degrees.
• Stand back- look for a sputum pot, oxygen, inhalers
• Ask the patient to have a deep breath in and out
• Look at the hands, and nails for clubbing
• Take pulse, and count respiratory rate (14-16 is normal for adults)
• Look at eye - ask the patient to look up and down
• Tongue out and up and look at lips for central cyanosis
• Check JVP
• Check if trachea is central

• Front
• (Measure chest expansion with a tape measure)
• Anterior chest expansion in upper, mid, and lower chest (keep thumbs of chest)
• Palpate apex beat and count down from the angle of the sternum ( if not felt turn the patient on to the left side)
• Percuss clavicles, above the clavicles and under the clavicles, down the chest comparing sides.
• Tacile vocal fremitus
• Auscultate anteriorly
• Vocal resonance

• Back
• Sit the patient forward
• Feel the neck
• Chest expansion by palpation, upper, mid, and lower chest
• Percuss including axillae
• Palpate for tactile vocal fremitus
• Auscultate including axillae
• Auscultate for vocal resonance
• Mention that you would do spirometry or peak flow
• Thank the patient.

• Some causes of clubbing
• Lungs
  • Severe chronic cyanosis eg. Congenital heart disease
  • Chronic suppuration of chest - bronchiectasis and empyema
  • Carcinoma of lung
  • Pulmonary tuberculosis
• Abdominal
• Polyposis of colon
• Crohn's Disease
• Ulcerative colitis
• CVS
• Subacute bacterial endocarditis

Dr. Amen's Upper Limb examination

Always compare sides

• Introduce yourself and ask permission to examine the patient.
• Expose arms
• Observe wasting, fasciculation and scars

• Tone
• 'Let your arms go loose and let me move them for you'
• Passively rotate wrist, flex elbow, and abduct shoulder.

• Power
• Hold your arms out and close your eyes - look for weakness, parietal drift and oscillations
• 'I am going to test the strength of your muscles'
• 'Hold your arms out to your sides like this, keep them up. Don't let me push them down'
  • Shoulder abduction (deltoid C5)
• 'Now push them in towards you and don't let me stop you'
  • Shoulder adduction (pectorals C6, C7, C8)
• 'Pull me towards you'
  • Arm flexion (biceps C5)
• 'Now push me away'
  • Arm extension (triceps C7)
• 'Clench your fists and bend your wrists up towards you. Don't let me stop you'
  • Wrist flexors C7
• 'Now push the other way'
  • Wrist extensors C7 '
• Grip my fingers tightly'
  • Use two fingers (long and short flexors C8, T1)
• 'Put your hand down flat like this (palm up) and point your thumb towards your nose. Keep it there don't let me push it down'
  • Thumb abduction (abductor pollucis brevis, median nerve C8,T1)
• 'Spread your fingers wide apart. Don't let me push them together'
  • Finger abduction (dorsal interossei, ulnar nerve, T1)
• 'Now hold this piece of card between your fingers and don't let me pull it out'
  • Finger adduction (palmar interossei, ulnar nerve, T1)

 

• Grading of power
• 0 No movement
• 1 Flicker on voluntary contraction
• 2 Movement but not against gravity
• 3 Movement against gravity but not against resistance
• 4 Movement against resistance but not full power
• 5 Full power

• Reflexes
• Biceps (C5)
• Supinator (C6)
• Triceps (C7)

• Sensation
• Pinprick
  • Test centrally first - 'This is sharp, this is blunt. Close your eyes. Is this sharp or blunt'
  • Check each dermatome.
• Light touch
  • 'Say yes if you feel this cotton wool'
• Joint position sense
  • Distal interphalangeal joint of each hand held by the sides 'This is up. This is down. Close your eyes. Is this up or down?'
  • If the patient cannot tell, then move up the arm.
• Vibration
  • Hit the tuning fork on your elbow. Put it on the sternum. Then on a distal interphalangeal joint If not felt then, move proximally.
• Coordination
  • 'Touch my finger with your index finger, then touch your nose.' 'Now close your eyes' checks dorsal column integrity
  • 'Tap your hand like this'. Dysdiadochokinesia is a sign of cerebellar ataxia. It is the impaired ability to execute rapidly repeating movements.

Dr. Amen's Neck Examination

• Introduce yourself
  Expose the neck
  
• Inspection of the neck
  Look for scars, swellings, etc
  Ask patient to swallow (give the patient a glass of water) and look for movement of any swelling (?a thyroid swelling)
  Ask the patient to protrude the tongue, and see if any midline swelling moves upwards (?thyroglossal cyst)
  
• Palpation
  Submental
  Submandibular
  Upper Deep Cervical
  Middle Deep Cervical (+ midline)
  Lower Deep Cervical
  Supraclavicular area
  Lower posterior triangle
  Middle of posterior triangle
  Upper posterior triangle
  Preauricular
  Postauricular
  Occipital
• Auscultation - Listen for thyroid bruits
  
• If mass found look for:
  Site
  Size
  Movement on Swallowing
  Consistency
  Fixity
  Pulsation – transmitted or direct
  Transillumination
  State of overlying skin
  Temperature
  Colour