Exam Summary


1. Introduction

  • Introduce yourself and the exams
  • Get the patient to lie flat on the bed
  • Hand hygiene

2. Observations

  • Respiratory Rate
  • Oxygen Saturation
  • Heart Rate
  • Temperature - consider febrile neutopaenia
  • Blood Pressure

3. General Inspection

Look for:
  • Pallor - a sign of anaemia
  • Ethnicity - People of African, Asian, Indian, Middle-Eastern or Mediterranean origin may have thalassaemia.
  • Bruising - May be due to a deficiency in clotting factors or platelets.
  • Jaundice - May be a sign of haemolytic anaemia.
  • Scratch marks - May occur in Lymphoma or Myeloproliferative disease.
  • Cachexia - loss of weight due to chronic disease
Jaundice.jpg
Jaundice

4. Hands and Arms

  • Look for:
    • Koilonychia - Spoon-shaped nails, A sign of iron deficiency anaemia.
    • Digital Infarction - May occur if there are unusual globulins (for example cryoglobulinaemia)
    • Palmar crease pallor - A sign of anaemia
    • Bruising - May be due to a deficiency in clotting factors or platelets (see thrombocytopaenia).
    • Rheumatoid Arthritis - If associated with Splenomegaly and neutropenia is known as Felty's Syndrome
    • Gouty tophi - May be a manifestation of myeloprolifearative disease. (Also see Gout)
    • Purpura or Petechiae - due to haemorrhage. If they are raised they may be due to vasculitis or bacteraemia.
  • Feel radial pulse.
Koilonychia.jpg
Koilonychia
Rheumatoid Arthritis2.jpg
Rheumatoid Arthritis
Gout.jpg
Gout
Petechiae.gif
Petechiae (in Dengue Fever)
radialpulse.jpg
Radial Pulse

5. Epitrochlear and Axillary nodes

  • The epitrochlear nodes are on the ulnar side of the forearm, above the cubital fossa. They are best felt by flexing the elbow to 90⁰, slightly abducting the arm, placing the palm of your hand underneath the elbow and palpating with the thumb. An enlargement may be due to local infection, Non-Hodgkin Lymphoma or Syphilis.
  • Palpate axillary lymph nodes
    • Behind anterior axillary fold
    • In front of posterior axillary fold
    • Corresponding positions on he upper part of the arm
    • Move the patient's arm down to her side and feel deep into the top of the axilla.
Arm lymph nodes.png
Lymph nodes of the arm

6. Face

a. Eyes

Jaundice_eye.jpg
Scleral Jaundice
conjunctivapallor.jpg
Conjunctival Pallor

b. Mouth and Tongue

Glossitis.jpg
Glossitis

7. Cervical and Supraclavicular nodes

Feel from behind:
  • Submental nodes
  • Submandibular nodes
  • Anterior cervical chain
  • Posterior cervical chain
  • Post-auricular
  • Occipital
  • Supraclavicular nodes

8. Bones

Feel for bone tenderness (see bone pain) which may be caused by multiple myeloma, lymphoma, carcinoma or metastases.
  • Sternum
  • Clavicles
  • Shoulders
  • Spine

9. Abdomen

  • Attempt to palpate the spleen starting from the right lower quadrant and moving towards the left upper quadrant. Palpate when the patient is inspiring. Repeat with the patient rolled over on their right side at 45º. If the spleen is palpable then it is enlarged (See Splenomegaly). Percuss over the lowermost intercostal space in the left axillary line.
  • Palpate the liver while the patient breathes in deeply. The liver can also be percussed from above and below to measure it size. (See Hepatomegaly, Hepatosplenomegaly)
  • Request:
    • Per-rectal examination
    • Per-vaginal examination
    • Testicular examination

10. Inguinal Nodes

  • Along Inguinal Ligament
  • Along Femoral Vessels

11. Legs

a. Inspection

b. Neurological

  • Neurological deficiencies which could be due to vitamin B12 deficiency
    • Glove and stocking pattern
    • Light touch
    • Pain
    • Vibration
    • Proprioception

c. Popliteal Nodes

  • Feel behind the knee when slighty bent

12. Conclude

Thank the patient and offer assistance

See Also

Leukaemia
Lymphoma

Citation

Talley and O'Connor - Clinical Examination 7th Edition pp270-278, 279(summary)

Jaundice image: "Jaundice08" by James Heilman, MD - Own work. Licenced under CC BY 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Jaundice08.jpg#/media/File:Jaundice08.jpg
Gout image: By Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA via http://creativecommons.org/licenses/by-sa/3.0/ from http://wikidoc.org/index.php/Gout_(patient_information)
Rheumatoid Arthritis image: "Arthrite rhumatoide" by Original source: http://nihseniorhealth.gov/arthritis/toc.htmlOriginally from fr.wikipedia; description page is/was here.. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Arthrite_rhumatoide.jpg#/media/File:Arthrite_rhumatoide.jpg
Radial Pulse image: "Radial pulse". Licensed under Public Domain via Wikimedia Commons -https://commons.wikimedia.org/wiki/File:Radial_pulse.jpg#/media/File:Radial_pulse.jpg
Petechiae image: "Positive-tourniquet-test" by Centre for disease control and prevention - http://ci.vbi.vt.edu/pathinfo/pathogens/Dengue1.html. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Positive-tourniquet-test.gif#/media/File:Positive-tourniquet-test.gif
Arm lymph nodes: "Gray606" by Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 606. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Gray606.png#/media/File:Gray606.png
Scleral Jaundice: https://commons.wikimedia.org/wiki/File:Radial_pulse.jpg#/media/File:Radial_pulse.jpg
Conjunctival Pallor image: http://image.frompo.com/4f21b9b2c559bfd71fc1c2f6c49d4c08
Koilonychia image: from https://yourfingernails.wordpress.com/tag/skin/