Gastrointestinal System

Presenting Complaints
Appetite changes anorexia, hyperphagia Weight loss (malabsorption, malignancy, diabetes, thyroid, IBD, eating disorder, depression) Weight gain Dysphagia (oesophagus, nodes, goitre) Indigestion / heartburn reflux Nausea / vomiting onset, frequency, contents (infection, inflammation, obstruction) Haematemesis frank or coffee ground (ulcer, varices, Mallory Weiss tear, malignancy) Abdominal pain colicky (biliary, GI), severe (peritonitis) Jaundice (haemolysis, liver, biliary) Change in bowel motions volume, frequency, consistency, colour, tenesmus, blood

Examination
Patient lying supine with one pillow Inspection General age, gender, comfort/distress Mental state alert, confused, coma Body habitus weight, wasting, oedema, hydration Colour pallor, jaundice, haemochromatosis Vital signs Temp, HR, BP, RR, O2 Hands leukonychia (albumin), koilonychia (spooning, iron), clubbing (cirrhosis, IBD), pallor in palmar creases, palmar erythema (oestrogen), wasting, dupuytrens contracture Hepatic flap Arms/shoulders spider naevi (oestrogen), bruising, wasting, scratch marks (?obs jaundice) Eyes xanthelasma, icterus, conjunctival pallor, uveitis, KayserFleisher rings (Wilsons disease) Salivary glands parotid & submandibular glands & ducts Lips hydration, agular cheilitis, ulceration, pigmentation, telangiectasia Mouth foetor, stomatitis, candidiasis/leukoplakia (L wont scrape off, C will), gums, glossitis, central cyanosis, teeth Lymph nodes cervical & axillary Chest spider naevi (oestrogen), loss of hair distribution, gynaecomastia (oestrogen) Abdomen scars, striae, bruising, stoma, distension (8 Fs), masses, veins, peristalsis, pulsations

Red Flags
Sudden onset of pain Increasing severity of pain Syncope / pre-syncope Vomiting Haematemesis Abdominal distension Pallor & sweating Tachycardia & atrial fibrillation Hypotension Fever Rebound tenderness, guarding, rigidity Oliguria / anuria Positive pregnancy test

Palpation Superficial tenderness, masses Deep masses, guarding, rigidity, rebound tenderness, McBurneys point,Rosvings sign Liver & gallbladder (Murphys sign) Spleen Kidneys Abdominal aorta

Percussion Liver Bladder Shifting dullness Auscultation Bowel sounds Epigastric bruits Renal bruits Other

Patient History
PMH abdominal surgery Family colorectal cancer, haemochromatosis, IBD, ulcers Medications NSAIDs (ulcers), metformin (diarrhoea), opioids (constipation), antibiotics (bowel changes), bisphosponates (oesophagitis), SSRIs (nausea) Social smoking, alcohol, IV drugs, travel, vaccinations, birth country

DRE inspection (fissure, fistula, tags, blood, rash, ulcer, mucus); palpation (wall consistency; prostate size, surface, tenderness) Urinalysis Pregnancy test Bowel chart

Respiratory System
Presenting Complaints
Cough nature, onset, wet (viral, LRTI, COPD, bronchiectasis), dry (viral, asthma, GI reflux, restrictive, ACEi), night (asthma LVF, post-nasal drip), morning (smoking), whooping, bovine (laryngeal nerve), croup Sputum colour, volume, type (purulent, mucoid), blood Haemoptysis acute (malignancy), chronic (bronchiectasis), pink frothy (pulmonary oedema) Dyspnoea / shortness of breath onset, nocturnal (asthma/LVF), on waking (COPD), duration, relieving factors, severity, exertional change Wheeze (high pitch) when, with coughing, exercise (asthma) Stridor (inspiratory rasp) onset (respiratory obstruction) Chest pain nature, intensity, exertional change (chest wall, pleura or mediastinal causes) Sleep apnoea snoring or waking up dyspnoeic (airway obstruction) Voice change - dysphonia, aphonia

Examination
Patient sitting upright, general inspection then entire back exam entire front exam Inspection General age, gender, body habitus, oxygen equipment, posture (?dyspnoeic), respiratory distress, cough, sputum Hands clubbing (pus in lungs), peripheral cyanosis, wasting (brachial plexus), pallor in creases Asterixis (CO2 retention) Radial pulse, respiratory rate, breathing (Cheyne-Stokes = alternating, Kussmaul = shallow) Eyes conjunctival pallor, Horner syndrome (miosis, partial ptosis, lower lid elevation, enopthalmos, anhydrosis) Nose (straight in) polyps, enlarged turbinates, displaced septum Mouth central cyanosis, erythema, tonsils, exudates, candidiasis Voice Sinuses frontal, ethmoidal, maxillary Lymph nodes cervical & axillary Trachea cartilage, tug, deviation Chest shape, symmetry, scars, tattoos, scoliosis, pigeon chest, funnel chest, barrel chest, breathing Other Palpation Back chest expansion, tenderness, spring chest (front, back, sides), tactile fremitus Front tenderness, tactile fremitus, apex beat (lying) Percussion Lungs (remember dullness over liver & heart) Auscultation Breath sounds - vesicular (normal), bronchial (hollow, consolidation) Added sounds stridor (inspiratory, upper airway obstruction) wheezing (narrowed airways), crackles (fine=fibrosis, medium=pulmonary oedema, coarse=pneumonia/COPD), pleural rub (pneumonia, infarction) Vocal resonance

Red Flags
Haemoptysis URTI, LRTI, bronchiectasis, bronchial carcinoma Sudden onset dyspnoea ? PE or pneumothorax Sudden onset stridor anaphylaxis, inhaled foreign body, acute epiglotitis (may block airway), gas inhalation

Temperature Pulse oximetry Spirometry FVC, FEV1, PEFR

Patient History
PMH hay fever, eczema, HIV Family atopy, CF, 1-antitrypsin, TB asbestos, same symptoms Occupation asbestos, chemicals Meds ACEi, -blockers, NSAIDs Social smoking, travel, pets

Cardiovascular System
Presenting Complaints
Chest pain crushing (MI), angina (tight, retrosternal, exertional), sharp inspiratory (pericarditis, pleuritic), interscapular (dissecting aneurysm, back pain), acid taste/burping (GI reflux), chest wall (costochondritis, rib fracture, skin) Dyspnoea precipitating factors, exertional (CCF, angina), orthopnoea (CCF, LVF), paroxysmal nocturnal dyspnoea (LVF, silent MI) Palpitations fast (SVT, heart cond., hyperthyroid, stress, meds), slow Peripheral oedema where, when, pitting (CCF), generalised (kidney, liver), unilateral (DVT, lymph obstr.) Syncope / pre-syncope postural (postural hypotension), lightheaded, sudden collapse (arrhythmia) Sputum pink frothy (LVF) Leg pain calf (DVT), exertional (intermittent claudication)

Examination
Patient sitting initially and lying at 45 (starting at neck) Inspection Sitting General age, gender, comfort, dysmorphism (Downs, Turner, Marfan), mental state, body habitus, oedema Surroundings - cigarettes, O2 devices, GTN spray, holter monitor, ECG leads Colour pallor (anaemia/ vasoconstriction), cyanosis Hydration status Hands pallor of nail bed, peripheral cyanosis, capillary refill, clubbing (congenital heart disease, IE), xanthomata, signs of infective endocarditis (Janeway lesions, splinter haemorrhages, Osler nodes) Arms - radial pulse (rate, rhythm), radio-radial delay (aortic coarctation, subclavian stenosis), respiratory rate, blood pressure (+pulsus paradoxus) Eyes xanthelasma, conj. pallor Mouth central cyanosis, higharched palate (Marfan), gums, dentition (poor ?IE) Neck (lying 45) JVP, carotid pulse (rhythm, character) Chest Lying 45 Inspection scars, deformities, pacemaker / defibrillator, visible apex beat Palpation - apex beat, thrill (LVF), heave (palpable murmur) Diaphragm of steth (A,P,M,T,axilla) heart rate, heart sounds (S1, S2, S3, S4), carotid, murmurs (intensity, timing, location, breathing inspright, expleft) Bell of steth mitral area Left lateral position (MS) Sitting forward holding breath after expiration (AS, AR, pericardial rub)

Red Flags
Irregularly irregular pulse (arrhythmia e.g. AF) Six Ps (acute limb ischaemia) pallor, pulseless, pain, paraesthesia, perishing cold Unilateral leg swelling (DVT) Very sudden & severe tearing pain (thoracic aortic dissection)

Abdomen Palpate tenderness, masses, organomegaly, AAA Auscultate aortic, renal, iliac, femoral bruits

Patient History
PMH HTN, lipids, BMI, diabetes, CKD, AF, previous cardiac events, rheumatic fever, renal disease, Marfan / Downs / Turner syndrome Family IHD, lipids, HTN, CKD, DM, sudden cardiac death Meds T4 (angina), -agonists (HR), -blockers (HR) Social smoking, IV drugs (IE), alcohol (AF, HTN), job (pilot / driver)

Back Sitting

Inspect scars, deformities Palpate sacral oedema Percuss lung bases (effusion) Auscultate lung bases

Lower Limbs Inspection varicose veins, colour, trophic s (thin/dry/shiny skin, hair, nails, ulcers), xanthomata, clubbing Palpation temp., tenderness, pulses (F, P, PT, DP), pitting oedema

Musculoskeletal System
Presenting Complaints
Pain site, symmetry, radiation, mono/polyarticular, acute/chronic, bone, nociceptive/neuropathic, inflammatory/noninflammatory Morning joint stiffness brief & worse w/ movement (osteoarthritis) vs. prolonged & improved with exercise (rheumatoid arthritis) Muscle stiffness (polymyalgia rheumatica) Joint abnormalities - locking (loose body, meniscal tear), instability (ligamentous stretching / rupture), triggering (tendon thickening) Swelling location, shape, size, consistency, surface texture, mobility, tenderness, pulsation Tenderness (inflamm., infection) Skin changes erythema, shiny skin, ulceration, rash (psoriasis, SLE) Loss of function Other symptoms fever, weight loss, bowel symptoms, urethritis, uveitis, conjunctivitis, dry mouth Simple backache mechanical pain in 20-55 y.o. Nerve root pain unilateral leg pain, motor / sensory change Cauda equina syndrome urinary/ faecal incontinence, perineal anaesthesia, leg weakness Feel

Red Flags
Regular night sweats Unintentional weight loss Constant (day & night) pain >50 or <20 years old Significant trauma History of cancer or osteoporosis IV drug user Immunosuppressed

Knee Examination
Look General age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Rashes, scars, erythema, swelling, gluteal folds, popliteal folds, bursae (supra-, infra-, pre-patellar) Muscles (wasting, spasm) esp. quadriceps Deformities genu valgum (knock-knee), genu varum (bow-leg), genu recurvatum (back-knee) Gait & posture leg length, 10 steps, sitting, squat Special Tests Patella apprehension (patella dislocation) apply laterally directed force on medial patella with thumbs (feels like patella will dislocate) Collateral ligament stress test supine (once 20 once straight); brace medial knee & apply varus force (medial collateral ligament), brace lateral knee & apply valgus force (lateral collateral ligament) Anterior & posterior draw test (start by looking for posterior draw) sit on patients foot, both hands around upper tibia, thumbs over tibial tuberosity, pull forwards (anterior cruciate lig), push backwards (posterior cruciate lig) (laxity/pain) Lachmans Test (anterior cruciate ligament) supine, 15 of flexion, examiners knee under their knee, stabilise femur & apply pressure to posterior upper tibia (laxity/pain) McMurrays test valgus force on lateral knee, flex to 90, hold sole of foot, rotate leg internally & extend knee (lateral meniscus); varus force on medial knee, flex to 90, hold sole of foot, rotate leg externally & extend knee (lateral meniscus) (pain) Applys grind test prone, knee flexed to 90; compress knee while internally & externally rotating (medial & lateral menisci), pull on knee while internally & externally rotating (collateral ligaments)

Skin temperature Quadriceps - tenderness, wasting, spasm Bursae supra-/infra-/pre-patellar, popliteal Bony landmarks joint line, femoral condyles & epicondyles, fibular head, Gerties tubercle, patella Ligaments & tendons M & L collateral ligaments, biceps, semimembranosus, semitendinosus tendons Patella tap slide hand down thigh to upper edge of patella, tap on patella (clunk effusion) Bulge test stroke hand medial, up & around to lateral patella (bulge in medial patella effusion)

Patient History
PMH joint or back problems, IBD, anterior uveitis, urethritis, malignancy Family RA, OA, gout, osteoporosis Meds analgesics, NSAIDs Loss of function brushing teeth (elbow), buttoning shirt (wrist, hands, walking (lower limb)

Move Supine, stabilise pelvis with other hand Active passive (crepitus) resisted Flexion (closing), extension (opening), internal rotation, external rotation

Hip Examination
Look General age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Deformities (true/false scoliosis), swelling, scars, gluteal folds, popliteal creases, ASIS level Muscles (gluteus, adductors, iliopsoas, quads) wasting, spasm Gait & posture walking 10 paces, sitting, squatting

Ankle & Foot Examination

Look General age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Footwear abnormal, asymmetric, poor fit, orthotic Ankles swelling, bruising, deformities, tibialis posterior, FDL, FHL Feet posture, arch, skin changes, colour, swelling, rashes, ulcers, infection ,calluses, plantar surface Toes alignment (straight, hammer, claw, mallet), nail changes, swelling, hallux valgus (bunions)

Spinal Examination
Look General age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast), gait, cushingoid facies Skin scars, rashes, ulcers Muscles bulk, wasting, spasm Joints swelling, deformities (scoliosis, thoracic kyphosis, loss of lumbar lordosis) Foot posture

Feel Supine Swellings (hernia) Landmarks greater trochanter of femur, ASIS, PSIS, ischial tuberosity, pubic symphysis Muscles gluteus, adductors, iliopsoas, quadriceps Leg length true (ASIS medial malleolus) vs. apparent (umbilicus medial malleolus)

Feel

Temperature Ankle distal 1/3 of fibula, malleoli, tendons (peroneal, tibialis posterior), joint line, PT pulse Foot navicular bone, calcaneus (medial tubercle), MTP & IP joints, metatarsal heads, tendons (TA, FHL, FDL), DP pulse

Feel Supine Muscles (wasting / spasm) levator scapulae, trapezius, semispinalis capitus, rhomboids Prone Bones & ligaments costochondral & sternochondral joints Muscles (wasting / spasm) SCM, scalenes, levator scapulae, erector spinae, gluteal, hamstrings Bones & ligaments spinous processes, interspinous ligaments, cervical facet joints, costovertebral articulation, sacroiliac joint

Move Supine, stabilise pelvis with other hand Active passive resisted Flexion (anterior), extension (posterior, prone), adduction (medial), abduction (lateral), internal rotation, external rotation

Move Active passive resisted Tibiotalar joint dorsiflexion, plantar flexion Subtalar joint inversion, eversion Chopards joint toe dorsiflexion & plantar flexion Move

Special Tests Thomas test (fixed flexion hip deformity) patient supine, bring knee a to chest (leg b raises off ground deformity in leg b) Trendelenberg test (glut med weakness, short femoral neck, unstable hip) hold patients hands, ask them to stand on foot a and lift foot b off ground (hip b falls)

Cervical flexion (down), extension (up), L / R lateral flexion (tilt), L / R rotation (turn), extension + rotation Thoracic & lumbar extension (back), flexion (forward), L / R rotation (sitting, turn), L / R lateral flexion (hand down thigh)

Special Tests Thompsons test (calcaneal tendon) prone, foot over edge of bed, squeeze calf muscles (no passive plantar flexion)

Special Tests Femoral nerve stretch (L3 radiculopathy) prone, flex knee with hand on hamstring (pain in femoral nerve distribution) Straight leg raise (sciatic nerve) supine, flex hip with leg straight (pain in back of leg from 30-70)

Shoulder Examination
Look General age, gender, body habitus, comfort Skin changes, symmetry, posture, swelling, deformities (scoliosis, dislocation) Muscles (wasting / spasm) deltoids, biceps, triceps, supraspinatus, infraspinatus, trapezius, rhomboids, pectoralis major, latissimus dorsi Scapular winging (push against wall)

Apprehension/relocation test (anterior stability) supine, abduct patients arm to 90 & externally rotate & apply posterior pressure to humerus (apprehension of dislocation), internally rotate & apply anterior pressure (relocation) Neers test (subacromial impingement) flex patients straight arm with their thumb down (pain)

Wrist Examination
Look General age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Scars, rashes, colour, wounds, nail changes, wasting, swelling, ganglia, deformities, symmetry Nerve lesions wrist drop (radial), hand of benediction (median), claw hand (ulnar)

Feel

Elbow Examination
Look Feel Bony landmarks olecranon, lateral & medial epicondyles, head of radius, radiohumeral joint Muscles flexors & pronators (medial), extensors & supinators (lateral), brachioradialis Tendons (triceps, biceps), ulnar nerve General age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Swelling, asymmetry, deformities, nodules Rashes anterior (eczema), posterior (psoriasis)

Feel

Temperature Bony landmarks SC joint, clavicle, AC joint, acromian, subacromial space, coracoid, scapula, thoracic vertebrae Muscles as above

Dorsal wrist distal forearm, ulna, radius, lunate, metacarpals, snuff box, PIP & DIP joints Palmar wrist - pisiform, hook of hamate, flexor retinaculum, Guyons canal Hand swelling, tenderness, warmth, nodules

Move Bilaterally at the same time for comparison Active passive restricted Flexion (forward), extension (backward), abduction (laterally, externally rotate at 90), drop-arm test (internally rotate while coming down) adduction (medial), internal rotation, external rotation (flexed 90), push shoulders back

Move Active passive resisted (not resisted for wrist) Wrist flexion, extension, ulnar deviation, radial deviation, pronation, supination Fingers flexion, extension, abduction, adduction Thumb opposition, abduction, adduction, flexion, extension

Special Tests Applys scratch test patient reaches over opposite shoulder (adduction), behind neck (adduction & external rotation), behind back (internal rotation) Supraspinatus tests resisted internal rotation into abdomen (Napoleon test); resisted internal rotation away from back (lift off test); resisted abduction from 90 + resisted abduction from 30 while internally rotated (empty can test) (pain) Hawkins-Kennedy test (impingement) flex patients elbow & shoulder to 90, support shoulder & forcibly internally rotate shoulder (pain)

Move Active passive resisted Flexion, extension, pronation (palm down), supination (palm up), flexion in semipronation (brachioradialis) Special Tests Lateral epicondylitis tests resisted wrist extension with extended elbow; resisted middle finger extension; tight fist (pain) Medial epicondylitis resisted wrist flexion (pain) Valgus & varus stress tests elbow flexed to 20 and supinated, support humerus and gently stress medial side (lateral ligaments) and then lateral side (medial ligaments) of the elbow joint Nerve entrapment tests extend thumb (radial), abduct thumb (median), adduct thumb (ulnar)

Special Tests Phalens test (median nerve compression) reverse prayer sign (flex wrists), normal prayer sign (pain) Tinels sign (carpel tunnel syndrome) percuss over flexor retinaculum (paraesthesia) Nerve entrapment tests extend thumb (radial), abduct thumb (median), adduct thumb (ulnar)

Neurological System
Presenting Complaints
Headache onset, severity, location, aggravating factors, relieving factors Vision changes blurring, diplopia, flashes Hearing/balance changes vertigo, tinnitus, hearing loss Weakness in face, arms, legs time course, generalised / specific, unilateral / bilateral, proximal / distal, sudden (vascular) Burning, tingling, numbness Fits, faints, mood changes aura, LOC, tongue biting

Cranial Nerve Examination

Patient sitting on edge of bed Inspection craniotomy scars, neurofibromas, facial asymmetry, ptosis (Horners, oculomotor lesion, myasthenia gravis), exophthalmos, enothalmos, eye deviation, pupils Olfactory (CN I) ask patient re: smell, inspect nares, present smells Optic (CN II) visual acuity, visual fields (peripheral & central), fundoscopy (disc, retina) Eye reflexes (CN II, III) inspection (shape, size, ptosis), direct response (ipsilateral), consensual response (contralateral), swinging light test (partial), accommodation Eye movement (CN III, IV, VI) modified H, asking about diplopia Trigeminal (V) sensation (light touch, pain), corneal reflex (opthalmicfacial), muscles of mastication & jaw jerk (mandibular) Facial (VII) raise eyebrows, close eyes, smile, puff out cheeks Vestibulocochlear (CN VIII) otoscopt, auditory acuity (rub fingers), Webers test (forehead), Rinnes test (mastoidear) Throat (IX, X) say ahh, gag reflex, hoarseness, cough Hypoglossal (XII) protrude tongue, deviate each side, push vs. cheek Accessory (XI) torticollis (tilted head), turn head vs. resistance (SCM), shrug vs. resistance (traps)

Upper Limb Neuro Examination

Patient sitting on edge of bed Inspection Posture (decerebrate), nerve signs (wrist drop, claw hand, hand of benediction), muscles (wasting, fasciculations), tremor at rest, abnormal movements, skin change Positional drift (arms out, eyes closed) - down & pronation (weakness), up & pronation (cerebellar disease), all directions (loss of proprioception)

Upper Limb Neuro Examination

Patient supine Inspection Gait - 10 steps Walking on heels (L4/L5), toes (L1) Tandem walking R heel in front of L toe etc. (cerebellar lesion) Proximal myopathy sit & rise without assistance, Trendelenberg test (stand on one foot, supported) Proprioception stand, feet together, eyes open (station), closed (Romberg test) General inspection skin, muscles (wasting, fasciculations)

Patient History
PMH neurological events, HTN, DM, AF, CV risk factors, pregnancy Family neurofibromatosis, tuberose sclerosis, Hungingtons disease, Friedrichs ataxia, DMD Medications Social toxin exposure, alcohol, smoking, level of function

Motor Tone active movement, passive movement (elbow & wrist), grade (flaccid, , normal, ) Power movement vs. resistance Reflexes biceps (C5, C6), triceps (C7, C8), supinator (C5, C6) Coordination finger-nose test (their nose examiners finger), rapid alternative movement (quickly turning hand over)

Motor Tone active movement, passive movement Clonus push on superior patella, rotate then dorsiflex ankle (UMN) Power movement vs. resistance Reflexes knee (L3, L4), ankle (S1, S2), Babinski (L5, S1, S2) Coordination drag heel down shin & back up; toe-finger test (bed examiners finger), rapid alternating movement (tap foot against palm of hand quickly)

Grading Guide
Tone flaccid, decreased, normal, increased Power - 0 (no contraction), 1 (flicker), 2 (w/o gravity), 3 (vs. gravity), 4 (mild resistance), 5 (normal) Reflexes 0 (absent), + (reduced), ++ (normal), +++ (~increased), ++++ (greatly increased

Sensory Pain dermatomes Vibration (128Hz) pulp of middle finger, ulnar styloid process, olecranon, clavicle etc. Proprioception distal IP joint Soft touch - dermatomes

Sensory Pain dermatomes Vibration (128Hz) 1st metacarpal head, malleoli, patellae, ASIS Proprioception distal IP joint Soft touch - dermatomes

Urinary System
Presenting Complaints
Dysuria infection or inflammation Frequency infection, inflammation, outlet obstruction, decreased capacity Polyuria excess water intake, diabetes mellitus, diabetes insipidus, kidney disease Nocturia Urgency Hesitancy / dribbling Incontinence urge / stress incontinence Weak stream obstruction Change in urine colour haematuria (infection, trauma, stones, cancer), medications, foods (beetroot) Pain abdominal, loin

Diabetes
Complications of Diabetes
Metabolic - acute Diabetic ketoacidosis dehydration, Kussmaul breathing Nonketotic hyperosmolar coma - dehydration Hypoglycaemia agitation, weakness, SNS activation Macrovascular Coronary artery disease angina, MI Stroke Peripheral vascular disease claudication, gangrene Infection Microvascular Retinopathy macular oedema, retinal damage & angiogenesis Neuropathy abnormal / sensation Nephropathy chronic renal failure

Urinary Examination
Patient sitting on edge of bed General confusion, drowsiness, hyperventilation (metabolic acidosis), hydration Hands leukonychia, pallor of palmar creases, asterixis (severe kidney failure) Arms AV fistula, bruising, pigmentation, scratch marks, sensation (peripheral neuropathy), pulse, blood pressure (other arm if AV fistula is present) Face pallor, jaundice, uraemic foetor (kidney failure), mouth ulcers, candidiasis, gingivitis Neck JVP (fluid overload), carotid bruits Chest (auscultate) signs of CCF, pulmonary oedema, pericardial rub, consolidation Abdomen o Inspect peritoneal dialysis catheter, scars (nephrectomy, transplant), distension (ascites) o Palpate masses, liver, kidney, bladder, AAA o Percuss shifting dullness, bladder o Auscultate renal bruit (renal artery stenosis) o DRE prostatomegaly Back palpate vertebral column (bony tenderness), renal angle (renal tenderness), sacral oedema Legs Inspect oedema, purpura, pigmentation, scratch marks, gouty tophi Palpate pitting oedema, peripheral pulses, sensation (peripheral neuropathy) Fundi changes due to hypertension / diabetes Temperature Urinalysis

Diabetic Examination
Inspection age, sex, body habitus, hydration, signs of Cushings / acromegaly / haemochromatosis, consciousness (ketoacidosis), Kussmaul breathing (short & shallow, ketoacidosis) Legs o o o o Inspect skin colour, skin quality (dry, cracked, hairless), ulcers, infections (tinea, gangrene), muscles Palpation - temperature (cold/blue vascular disease, hot/red DVT), capillary refill, peripheral pulses Sensation light touch, pain, vibration, proprioception Motor knee & ankle reflexes, squat & stand (proximal myopathy) tone, power, coordination

Arms nail candidiasis, blood pressure (lying & standing) Eyes visual acuity, reflexes, eye movements Mouth signs of infection Ears signs of infection Neck carotids (palpate & auscultate) Abdomen liver

Investigations Urinalysis glucose, ketones, protein Fasting glucose short term control HbA1C - ~3-month control

Thyroid
Presentations
Hyperthyroidism - appetite, weight loss, diarrhoea, sweating, dry skin, hair thinning, preference for cold Hypothyroidism - appetite, weight gain, constipation, lethargy, heavy periods, preference for warm weather

Haematological System
Presenting Complaints
Tiredness Weakness Dyspnoea Fatigue Postural dizziness Bruising Blood in stool Lumps neck, armpit, groin

Thyroid Disease Examination

Hyperthyroidism General Hands Weight loss, anxiety Tremor, onycholysis (nail separates from bed), clubbing, palmar erythema, sweaty palms Sinus tachycardia / atrial fibrillation Exophthalmos (sclera visible below iris & eye protruding beyond orbit Graves disease), lid retraction (sclera visible above iris), lid lag Hypothyroidism Mental / physical slowness, voice change Peripheral cyanosis, pigmentation, cool / dry hands, pallor bradycardia Skin pigmentation (hypercarotinaemia), skin thickening, alopecia (hair loss), periorbital oedema, xanthelasma, swelling of tongue

Patient History
PMH infections, fever, chills Social diet (meat) Menstrual history blood loss

Pulse Face

Examination
General - age, gender, racial origin (thalassaemia), pallor (anaemia), bruising (coagulopathy), jaundice (haemolytic anaemia), scratch marks (lymphoma) Hands koilonychias, pallor of nail beds / palmar creases, bruising Radial pulse (tachycardia) Lymph nodes (site, size, fixation, consistency, tenderness) cervical, axillary, trochlear, supraclavular Face scleral icterus (jaundice), conjunctival pallor, gums, oral mucosa, tongue (glossitis), tonsils Chest press sternum & clavicles with heel of hand, push shoulders together Abdomen masses, liver, spleen, inguinal nodes Legs bruising, pigmentation, scratch marks, ulcers, sensation, popliteal nodes Other fundoscopy (papiloedema, haemorrhage), temperature, urinalysis, rectal / pelvic examination

Thyroid Examination
Patient sitting on edge of bed Inspection - scars (thyroidectomy), veins (retrosternal goitre), redness (suppuratives thyroiditis), swelling (generalised / localised), during swallowing (moves superiorly normal, goitre, thyroglossal cyst) Palpation (from behind; lobes & isthmus) size; shape; nodules; thrill (hyperthyroidism); fixation (carcinoma); consistency: firm (goitre), rubbery hard (Hashimotos thyroiditis), stony hard (thyroiditis), tenderness (thyroiditis) Percussion upper part of manubrium (retrosternal goitre) Auscultation over each lobe for bruits (hyperthyroidism, antithyroid medication) Pebertons sign (thoracic inlet obstruction e.g. retrosternal goitre) patient lifts both hands as high as possible, look for signs of congestion / cyanosis / respiratory distress Chest (auscultate heart & lungs) systolic flow murmur, CCF, pericardial / pleural effusion (all hyperthyroidism) Legs pretibial myxoedema (bilateral, firm, elevated dermal nodules; Graves disease), non-pitting oedema (hypothyroidism), reflexes ( hyperthyroidism, hypothyroidism)