Medicine – General
Physical Examination
A. Before
you
start
• Know
that
all
examinations
will
be
in
a
normal
patient.
(As
the
Dr.
mentioned)
• You
should
know
the
indication
of
each
procedure.
• Remember
to
always
examine
from
the
right
side
of
the
patient.
(If
you’re
left
handed,
tell
your
examiner)
• After
general
appearance,
people
usually
start
with
the
hand,
but
if
you
want
to
start
with
the
head
then
there’s
no
problem
with
that.
• For
the
findings,
you
should
say
the
negatives:
“There’s
no
clubbing,
no
splinter
hemorrhage,
no
leukonychia…”
and
the
same
applies
to
the
rest
of
the
body.
B. Introduction:
(WIP3E)
1. Wash
hands: Wash your hands in front of the examiner or bring a sanitizer with you.
2. Introduce
yourself:
My name is “…”, I'm a third year medical student.
3. Explain
the
examination: “I'm going to do some physical examination on you which
mainly involves looking at your hand and face, and feeling some pulses.”
4. Permission:
After explaining, take permission to proceed. “Do you mind?”
5. Position:
The position should be at 45°
6. Privacy:
I should maintain the patient’s privacy. (Close the curtains).
7. Exposure
of
the
trunk:
“Can you take off your shirt please?”
C. General
appearance:
(ABC2DE)
1. Appearance: “The patient is (young, middle aged or old) and looks well.”
2. Body
built: “He looks (normal, thin or obese).”
3. Connections: “The patient is not connected to any.”
4. Color: “He doesn't look pale or jaundiced.”
5. Distress: “The patient looks comfortable and he’s not using any accessory muscles to
breath, and so, he doesn't appear to be in any pain or respiratory distress.”
6. ELSE: “He is conscious and well orientated.”
D. Vital
signs:
1. Pulse Rate: (Measure the radial pulse)
I.
Rate (Measure over 30 seconds and tell your examiner that ideally it should be
measured over 1 minute. Normal rate is between 60-100).
II. Rhythm: Regularly regular. Abnormal: irregularly irregular or regularly irregular or
irregularly regular
III. Synchronization: Check other radial pulse to see if there’s a radio-radial delay and
tell your examiner that ideally you’d also check for radio-femoral delay)
IV. Volume: determined from the carotid.
2. Respiratory rate: Try to take it while taking the pulse rate. Usually the normal range is
between 16-25 breaths per minute.
3. Temperature: Normal temperatures range from 36.6-37.2
4. Blood Pressure: (Explained below) – ideally, you would check BP in both arms.
E. The
hand:
First,
start
with
inspecting
and
feeling
the
hand.
E.g.:
“Hands
look
normal
in
color
and
feel
symmetrically
warm.
There
aren’t
any
signs
of
cyanosis
and
no
nicotine
staining.”
–
Be
careful!
Sometimes
the
patient
might
be
a
smoker
and
have
nicotine
staining.
Nails:
1. Clubbing*: Ask the patient to bring his two nail beds of his two index fingers together to
check for clubbing. Clubbing can be a sign of lung cancer, pulmonary fibrosis, bronchiectasis
and IBD.
2. Splinter hemorrhage*: Found in infective endocarditis.
3. Leukonychia*: sign of hypoalbuminemia, liver disease or nephritic syndrome.
4. Koilonychia*: sign of iron deficiency anemia.
Palm:
1. Osler’s nodes & Janeway lesions*: signs of infective endocarditis.
2. Palmar xanthomata*: sign of hyperlipidemia
3. Palmar erythema*: sign of liver cirrhosis, polycythemia, and pregnancy.
4. Pigmentation of palmar creases: sign of Addison’s disease but may be normal in
Asians and black people.
5. Paleness of palmar creases: sign of anemia.
*
Look
at
the
pictures
at
the
end
of
the
document
6. Dupuytren’s contracture*: sign of alcoholism.
7. Raynaud’s phenomenon: abnormal response of fingers and toes to cold. First turns white
(ischemia), then blue (cyanosis) then red (revascularization).
Dorsum:
1. Muscle wasting: decrease physical activity
2. Pigmentations
3. Skin lesions. (Including scars)
4. Tendon Xanthomata: sign of hyperlipidemia
Flapping tremor & fine tremor:
1. Flapping tremor: sign of CO2 retention, hepatic encephalopathy or renal failure. To
examine: ask the patient to extend their arms and raise their wrists to 90 degrees.
2. Fine tremor: it could be normal. If not, may indicate hypoglycemia or Parkinson’s.
F. The
head:
Scalp:
Hair
deficiency
or
excess.
Mouth:
1. Central cyanosis (Blue discoloration): Ask the patient to open his mouth and lift his
tongue up. Sign of hypoxemia (deoxygenated hemoglobin)
2. Oral/dental hygiene.
3. Dryness of the mouth: dehydration
4. Any lesion: ulcer, bleeding
5. Special smell:
a. Fetor hepaticus: “Sweet smell”: sign of liver disease.
b. Uremic fetor: “Fish breathe”: sign of renal failure.
c. Cigarette smell in smokers.
Eyes:
1. Jaundice (in the sclera, better seen in daylight): sign of liver disease, hemolytic
anemia.
2. Pallor (in the conjunctiva): sign of anemia
3. Xanthelasma: (Patches of yellow skin around the lower or upper eyelids): sign of
hyperlipidemia or primary biliary cirrhosis
G. The
neck:
(If there is any swelling, describe it: site, size, shape, skin, and surrounding tissue)
1. Lymph nodes†: Submental, submandibular, tonsilar, parotid, preauricular, post auricular,
occipital, cervical and supraclavicular.
2. Salivary gland
3. Thyroid
Lymph nodes:
(If you feel a lymph node you should describe it as you describe any lump)
4. Epitrochlear
5. Axillary
6. Cervical
7. Supraclavicular
8. Inguinal
H. The
lower
limb:
1. Lower limb edema
2. Peripheral pulses: popliteal, posterior tibial and dorsalis pedis pulses.
3. Any change in the nails, dorsal, or the sole of the foot.
I. The
back:
Sacral edema
J. Thank
the
patient
(Now
he
can
wear
his
shirt)
†
Look
at
the
pictures
at
the
end
of
the
document
Pictures:
Splinter
Hemorrhage
Leukonychia
Clubbing
Palmar
erythema
Koilonychia
Tendon
Xanthomata
Dupuytren’s
contracture
432 OSCE TEAM
DONE BY: Hossam AlAwaad & Abdulmohsen Al;Mshary
Revised by: [Link] AlRowais
OSCE Team Leaders: Shaimaa AlRefaie & Roqaih AlDoueb
