Preface

This guide is based on Macleod's Clinical Examination, Bates' Guide to Physical

Examination books & notes from rounds, it was aimed to help students apply
physical examination early in the rotation, not just before the OSCE exam.

It's a brief straight forward guide that covers what is needed for the OSCE exam
step by step; it will provide you with key terms and complete examination
sequence, but it does not exclude the importance of Macleod's Clinical Examination
book as the main reference for history taking & physical examination in medical
student life.

To achieve maximum usefulness of this guide, make sure to watch Macleod's

videos.

 Contents
 Introduction… ....................1
 Neck examination ………….. 2
 Anterior chest ……………….. 10
 Posterior chest ………………. 13
 Precordium ……………………. 14
 Abdomen …………………….... 16
 SUMMARY …………………….. 22
Introduction
 Before you start the physical examination you must address the following:
1. Introduce yourself & take permission.
2. Patient privacy.
3. Proper position and exposure. ( explained later by system)

Others: hand washing, room lighting & temperature …. etc.

o In real life hand hygiene is a top priority before & after examining the
patient.

 HOW do you introduce yourself & take permission?

Eng: hello I am Mohammad a 4th year medical student, would you allow me to
examine you.
Ara: ‫مرحبا انا محمد طالب طب سنة رابعة تسمحلي افحصك‬

Note: in the exam, there are 2 marks on introduction & permission so make it
a part of your practice during the rounds, so that you don’t forget it.

 In internal medicine you are going to be asked to do one of the following:

1. Respiratory exam: either anterior chest or posterior chest.
2. Precordium exam.
3. Abdominal exam.

 The physical examination part of the OSCE exam is about 5-7 minutes, if you
was practicing well during the rounds, you can finish it in about 3 minutes &
spend the rest of the time chatting with the examiner.

 In the exam the patient will have findings, so be prepared & don't rush the
examination results as you memorized the normal results from your studying.

 The examiner will focus on the technique & that you did all the steps, also the
findings will have little marks on them & will be easy to identify (ex: wheezing,
pansystolic murmur, prosthetic valve click, organomegaly).

 Remember inspect, palpate, percuss, auscultate and report findings.

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 Neck examination
Introduction
Wash hands

Introduce yourself

Gain consent

Exposure and position: sitting position and adequately expose the neck to the clavicles

General inspection
Voice – weak/hoarse?

Note any dyspnoea or stridor

Identify any scars on the neck – previous surgery (e.g. thyroidectomy) / radiotherapy

 Any skin changes – e.g. erythema

Observe for any obvious masses in the neck

Inspect from the front and both sides

If a mid-line lump is present:

 Ask the patient to take a sip of water, hold it in their mouth and swallow the water on
command – thyroid masses and thyroglossal cysts will rise
 Ask patient to protrude tongue – thyroglossal cyst will rise /and thyroid masses will not
Look for systemic signs that may relate to neck pathology:

 Cachexia – malignancy
 Exophthalmos / proptosis – Graves’ disease
If there is a mid-line lump/scar or systemic signs suggestive of thyroid disease, ask the
examiner if a full thyroid status examination should be performed.

Palpation
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 Lymph nodes
Note: Sometimes asking the patient to slightly tilt their head forward can help to relax the neck muscles.

Lymph nodes can become enlarged for a number of reasons – infection/malignancy

Lymph nodes are usually smooth, rubbery, with some mobility.

An enlarged, hard, irregular lymph node would be suggestive of malignancy.

Palpate the lymph nodes:

 Supraclavicular – left sided enlarged lymph node – Virchow’s node

 Anterior cervical chain

 Posterior cervical chain

 Sub-mental

 Sub-mandibular

 Occipital

 Pre-auricular

 Post-auricular

 Parotid

Note: You do not need to follow this specific routine but be clear in your own mind so that you cover all
regions of the neck.

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 Thyroid gland
1. Place the three middle fingers of each hand along the midline of the neck below the chin

2. Locate the upper edge of the thyroid cartilage (“Adam’s apple”)

3. Move inferiorly until you reach the cricoid cartilage/ring

4. The first two rings of the trachea are located below the cricoid cartilage and the thyroid
isthmus overlies this area

5. Palpate the thyroid isthmus using the pads of your fingers

6. Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the
isthmus

7. Ask the patient to swallow some water, whilst you feel for symmetrical elevation of the
thyroid lobes (asymmetrical elevation may suggest a unilateral thyroid mass)

8. Ask the patient to protrude their tongue once more (if a mass is a thyroglossal cyst, it will rise
during tongue protrusion)

9. If a thyroid mass is present, feel above and below it. Assess retrosternal extension by
percussion on the sternum and assess vascularity by auscultation.

10- Trachea Note any deviation of the trachea – may be caused by a large thyroid mass
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 Submandibular gland
The submandibular glands can be bilaterally palpated inferior and posterior to the body of the
mandible.

Move inwards from the inferior border of the mandible near its angle with the patient’s head
tilted forwards.

Submandibular gland swellings are usually singular (whereas lymph node swelling often involves
multiple nodes).

Salivary duct calculi are relatively common and may be felt as a firm mass within the gland.

Assessing a neck lump

Size – width / height / depth

Location – can help narrow the differential – anterior triangle / posterior triangle / mid-line

Shape – well defined?

Consistency – smooth / rubbery / hard / nodular / irregular

Fluctuance – if fluctuant, this suggests it is a fluid-filled lesion – cyst

Trans-illumination – suggests mass is fluid-filled – e.g. cystic hygroma

Pulsatility – suggests vascular origin – e.g. carotid body tumour/aneurysm

Temperature – increased warmth may suggest inflammatory / infective cause

Overlying skin changes – erythema / ulceration / punctum

Relation to underlying/overlying tissue – tethering/mobility (ask to turn head)

Auscultation – to assess for bruits – e.g. carotid artery aneurysm

General examination and special test for the thyroid gland

Behaviour
Does the patient appear hyperactive? – agitation / anxiety / fidgety (hyperthyroidism)

Hands
Inspect the patients hands for…

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 Dry skin (hypothyroid)

Increased sweating (hyperthyroid)

Thyroid acropachy – phalangeal bone overgrowth – Graves’ disease

Palmar erythema – reddening of the palms at the thenar / hypothenar eminences –

hyperthyroidism

Peripheral tremor

1. Ask the patient to place their arms straight out in front of them

2. Place a piece of paper across the backs of their hands

3. Observe for a tremor (the paper will quiver)

Peripheral tremor can be a sign of hyperthyroidism.

Pulse
Assess the radial pulse for…

Rate:

 Tachycardia (hyperthyroidism)
 Bradycardia (hypothyroidism)

Rhythm – irregular (atrial fibrillation) – thyrotoxicosis

Face
Inspect the face for…

Dry skin – hypothyroidism

Sweating – hyperthyroidism

Eyebrows– loss of the outer third – hypothyroidism (rare)

Eyes
Exophthalmos (anterior displacement of the eye out of the orbit)
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 Inspect from the front, side and above

 Note if the sclera is visible above the iris (lid retraction) – seen in Graves’ disease
 Inspect for any redness / inflammation of the conjunctiva

Bilateral exophthalmos is associated with Graves’ disease, caused by abnormal connective tissue
deposition in the orbit and extra-ocular muscles.

Eye movements

1. Ask the patient to keep their head still and follow your finger with their eyes

2. Move your finger through the various axes of eye movement (“H“ shape)

3. Observe for restriction of eye movements and ask the patient to report any double vision or
pain

Eye movement can be restricted in Graves’ disease due to abnormal connective tissue deposition in the
orbit and extra-ocular muscles.

Lid lag

1. Hold your finger high and ask the patient to follow it with their eyes, whilst keeping their head
still.

2. Move your finger downwards

3. Observe the upper eyelids as the patient follows your finger downwards

If lid lag is present the upper eyelids will be observed lagging behind the eyes’ downward movement (the
sclera will be visible above the iris). Lid lag occurs as a result of the anterior protrusion of the eye from
the orbit (exophthalmos)which is associated with Graves’ disease.

Special tests
1. Reflexes – e.g. biceps reflex – hyporeflexia is associated with hypothyroidism

2. Inspect for pretibial myxoedema – associated with Graves’ disease

3. Proximal myopathy:

 Ask the patient to stand from a sitting position with arms crossed

 An inability to do this suggests proximal muscle wasting

 Proximal myopathy is associated with hyperthyroidism

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 Suggest further assessment and investigations
 Thyroid status examination
 Examination of the lymphoreticular system
 Examination of oral cavity, oropharynx and nasal cavity to exclude mucosal lesion
 Ultrasound scan of lesion
 Fine needle aspiration – to allow histological diagnosis
 Routine bloods – FBC/U+E/CRP – may be useful if considering infection / malignancy
 Early referral to ENT – if there is suspicion of malignancy / presence of red flags

Differential diagnosis of a neck lump

Red flags
The following features are red flags that should raise your suspicion of malignancy in the context
of a neck lump:

 Hard, fixed mass

 Patient is over 35 years old
 Presence of mucosal lesion in the head or neck
 A history of persistent hoarseness or dysphagia
 Trismus
 Ear pain (referred from tongue base)

Differential diagnosis
The location of the lump within the neck can sometimes be useful in narrowing the differential diagnosis.
However, it should be noted that this is not an absolute rule, with further investigations required to
confirm a particular diagnosis.

Mid-line

Lymph nodes – often multiple, may suggest infection or malignancy

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Lipoma – painless/smooth mass

Dermoid cyst – cysts formed along the lines of embryological fusion, painless swellings that do
not move with tongue protrusion (more common in children and young adults).

Sebaceous cyst

Thyroid gland – located below thyroid cartilage

Thyroid nodule – can be single or multiple – adenomas/cysts/malignancy

Thyroglossal cysts – painless/smooth /cystic – rises on tongue protrusion

Laryngocele – reducible tense mass – mass returns on sneezing or nose blowing

Anterior triangle – area of the neck anterior to sternocleidomastoid

Lymph nodes

Lipoma – painless/smooth mass

Sebaceous cyst

Salivary gland swelling – doesn’t move on swallowing

Branchial cyst – present from birth – noticed in early adulthood when it manifests as an infected neck
lump

Carotid artery aneurysm – pulsatile mass – bruit present on auscultation

Carotid body tumour – transmits pulsation – can be moved side to side but not up and down (due to
carotid sheath)

Laryngocele – reducible tense mass – mass returns on sneezing or nose blowing

Posterior triangle – area of the neck posterior to sternocleidomastoid

Lymph nodes – often multiple – can be rubbery or hard depending on aetiology

Lipoma – painless/smooth mass

Sebaceous cyst
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Subclavian artery aneurysm – pulsatile mass

Pharyngeal pouch – may present as a reducible mass

Cystic hygroma – most commonly on left side – fluctuant mass – transilluminates

Branchial cyst

Tail of parotid mass – could be a pleomorphic adenoma or malignancy

Note: Lymph nodes in any of any of these regions can also be caused by lymphoma and tuberculosis, so a
comprehensive history is key to provide a clinical context for your findings.

Source: https://geekymedics.com

Videos:

https://www.youtube.com/watch?v=oVhKjmOrzwM

https://www.youtube.com/watch?v=ziaYBkgEZNU

Respiratory system
 Anterior chest:
1. Introduce yourself & take permission.
2. Ensure patient privacy.
3. Position the patient at 45° angle & expose him above the umbilicus or above
the waist.

What to say in the exam:

I will position the patient in the middle of the bed at 45° degree.

4. Inspection:
a. At the foot of the bed: chest symmetry & deformity.
Chest deformities examples: barrel shaped (COPD), pectus
excavatum, pectus carinatum.
b. At the right side: scars, skin lesions, dilated veins.
c. Respiratory rate & signs of respiratory distress.
- Respiratory rate can be taken from foot of the bed or from the right
side while distress signs from the right side.(source: internal resident)
- Signs of distress: tachypnea, using of accessory muscles, retractions,
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 cyanosis, audible wheezes without stethoscope.

Note: Mostly the examiner will tell to skip point "c" but you must mention it.

5. Palpation:
a. Palpate the chest generally for any tenderness.
b. Tracheal position (to detect upper mediastinal shift).
c. Cardiac Apex beat (to detect lower mediastinal shift).  explained in cvs
d. Chest expansion (must be symmetrical with at least 5 cm expansion).
e. Tactile vocal fremitus.

 Tracheal position: Gently place the tip of your right index finger into the suprasternal notch
and palpate the trachea. This can be uncomfortable; be gentle and explain what you are
doing. (2 fingers method can be used)
 Chest expansion: Place your thumbs along each costal margin, your hands along the lateral
rib cage. As you position your hands, slide them medially a bit to raise loose skin folds
between your thumbs. Ask the patient to inhale deeply. Observe how far your thumbs
diverge as the thorax expands, and feel for the extent and symmetry of respiratory
movement. (most used method by doctors & residents during my rounds in internal)
 Tactile fremitus: use either the ball (the bony part of the palm at the base of the fingers) or
the ulnar surface of your hand. Ask the patient to repeat the words “‫ ”تسعة و تسعين‬or “ ‫اربعة و‬
‫اربعين‬.”

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6. Percussion:
a. Sites of percussion (bilateral)
- Supra-clavicular area (lung apex)
- Lung fields anteriorly & laterally
b. Maintain quality & symmetry

- Quality: Strike the center of the middle

phalanx of your left middle finger with the
tip of your right middle finger, using a
loose "swinging movement of the wrist
and not the forearm".
- Symmetry: Percuss the anterior and lateral chest, comparing both
sides.

How to comment on a normal patient? Bilateral resonant chest

7. Auscultation:

Listen:

 Anteriorly from above the clavicle down to the sixth rib.

 Laterally from the axilla to the eighth rib.
 Posteriorly down to the level of the 11th rib.

a. Listen to the chest anteriorly and laterally as the patient breathes with
mouth open, on the same areas of percussion.
b. Maintain quality & symmetry
c. Comment on auscultation
- Air entry & its symmetry
- Vesicular or bronchial breathing
- Added sounds (wheezing, crackles, pleural friction rub)

 Examples:
o In a normal patient you would comment:
bilateral symmetrical air entry, vesicular breathing with no added
sounds
o In an asthmatic patient:
bilateral air entry, vesicular breathing with expiratory wheezes heard
mostly over the left lung.

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 d. Vocal resonance:
Ask the patient to repeat the words “‫ ”تسعة و تسعين‬or “‫ ”اربعة و اربعين‬while
you auscultate to assess the quality and amplitude of vocal resonance.

8. Cover the patient.

================================================================

 Posterior chest: same as anterior

1. Introduce yourself & take permission.
2. Ensure patient privacy.
3. Position & exposure.
a. Exposure: same as anterior chest.
b. Position: the patient should be sitting upright; his arms should be folded
across the chest with hands resting, if possible, on the opposite shoulders.
This position swings the scapulae laterally and increases access to the lung
fields.

Note: ask the patient to sit at the side of the bed while you examine him
from the other side (back), but this is not always applicable, so just make
him sit upright in the middle of the bed.
4. Inspection:
a. Symmetry.
b. Deformities:
- Spine: Kyphosis or scoliosis.
c. Scars, skin lesions, dilated veins.

Normal patient:

Symmetrical chest, no chest or spine deformities and no scars, skin lesions or

dilated veins.

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 5. Palpation:
a. Palpate the chest generally for any tenderness.
b. Chest expansion (must be symmetrical with at least 5 cm expansion)
c. Tactile vocal fremitus.

6. Percussion:
percuss lung fields posteriorly & laterally, maintaining quality & symmetry.

7. Auscultation:
Listen over the same areas of percussion.
a. Maintain quality & symmetry.
b. Comment on the auscultation.
c. Vocal resonance.

8. Cover the patient.

Cardiovascular system

 Precordium:
A great rule for memorizing precordium examination steps is "3+3=6", it
means 3 steps for inspection plus 3 steps for palpation and 6 steps for
auscultation. There is no percussion in precordium examination.

1. Introduce yourself, take permission & ensure privacy.

2. Position the patient at 45° angle & expose him above the waist.

3. Inspection: (3 steps)
a. Chest symmetry.
b. Chest deformity.
c. Scars (name, site) & visible pulsations.
4. Palpation: (3 steps)
a. Apex beat & its position.
b. Parasternal heaves.
c. Thrills.

 Apex beat: Locate it by lying your fingers on the chest parallel to the rib spaces; if
you cannot feel it, ask the patient to roll on to his left side. Once you have found the
apical impulse, make finer assessments with your fingertips, and then with one finger.
The apex beat is normally in the fifth left intercostal space at, or medial to, the mid-
clavicular line.
 Heaves: Apply the heel of your right hand firmly to the left parasternal area and feel
for a right ventricle heave. Ask the patient to hold his breath in expiration. 14
 Thrills: Palpate for thrills at the apex and both sides of the sternum using the flat of
your fingers.
5. Auscultation: (6 steps)
a. 4 cardiac areas with the diaphragm.
b. 4 cardiac areas with the bell.
c. Radiation toward carotid arteries. (aortic stenosis)
d. Radiation toward axilla. (mitral regurgitation)
e. Ask the patient to roll to his left side; listen at the apex with the bell for
mid-diastolic murmur of mitral stenosis.
f. Ask the patient to sit up and lean forwards, then to breathe out fully
and hold his breath. Listen over the left sternal 3rd intercostal space
(Erb's point) with the diaphragm for the murmur of aortic
regurgitation.
6. Check for peripheral edema.
7. Cover the patient.
PS.: before you cover the patient tell the examiner that you want to examine:
1) Hepatomegaly (sign for heart failure): Palpate liver edge & assess its span.
2) Femoral & brachial pulses: to check for barchiofemoral delay for coartication of aorta.

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How to comment on a normal patient?
Symmetrical chest with no deformities, no scars, no visible pulsations.

Apex beat is located at 5th intercostal space on the mid clavicular line.

No heaves or thrills.

Normal S1, S2 with no murmurs

================================================================

Gastrointestinal system
Regarding the OSCE exam, the question won't be "do abdominal examination for
this patient!!"… It will be for eg. "perform the inspection phase for this patient,
palpation or auscultation!!"

 Abdominal examination:

1. Introduce yourself, take permission & ensure privacy.

2. Position the patient comfortably supine with the head resting on only one
or two pillows to relax the abdominal wall muscles. Expose him from
nipple to mid-thigh.

3. Inspection:
a. At the foot of the bed:
i. Contour (flat, distended, scaphoid).
ii. Symmetry.
iii. Movement with respiration.
iv. Central inverted umbilicus.
b. At the right side of the patient:
i. Comment on everything you see (hair distribution, scars,
dilated veins, skin lesions, visible pulsations or peristalsis).
ii. Inspect hernial orifices (ask the patient to cough).

Note: - to see visible pulsations you should bend your knees.

- For any scar mention its name & site.

How to comment on a normal patient?

Symmetrical flat abdomen, moves with respiration & a central inverted umbilicus.

Normal male/female hair distribution, no scars, no skin lesions, no dilated veins, no

visible pulsation, no visible peristalsis.

Intact hernial orifices.

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 4. Palpation:
a. Ask the patient if there is any painful area.
b. Superficial palpation, observing the patient’s face (eye contact) for
any sign of discomfort throughout the examination. Begin with light
superficial palpation away from any site of pain, using the palm of
your hand not the finger tips.
c. Deep palpation.
d. Organomegaly:
i. Liver (liver edge + liver span)
ii. Spleen
iii. Both Kidneys
e. Palpate hernial orifices. (ask the patient to cough)

o Hepatomegaly examination:

 Palpation: (liver edge)

1) Place your hand flat on the skin of the right iliac fossa.
2) Some examiners like to point their fingers up toward the patient’s head,
whereas others prefer a somewhat more oblique position, in either case,
press gently in and up.
3) Ask the patient to breathe in deeply through the mouth.
4) Feel for the liver edge as it descends on inspiration.
5) Move your hand progressively up the abdomen, 1 cm at a time, between
each breath the patient takes, until you reach the costal margin or detect
the liver edge.
6) If you feel a liver edge, describe:

■ Size ■ surface: smooth or irregular ■ edge: smooth or irregular

■ Consistency: soft or hard ■ tenderness ■ whether it is pulsatile.

Note: normally, on inspiration liver edge is palpable 1-3 cm below the costal
margin in the midclavicular line. But don’t worry if you can't feel it.

 Percussion: (liver span)

1) Percuss downwards from the right 2nd intercostal space in the mid-
clavicular line, listening for the dullness that indicates the upper border of
the liver.
2) Percuss upward from the right iliac fossa until you reach the dullness.
3) Measure the distance between the 2 points. (Normal liver span 6-12 cm)

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o splenomegaly examination:

1) Place your hand on the right iliac fossa. Keep your hand stationary and ask
the patient to breathe in deeply through the mouth
2) Move your hand diagonally upwards towards the left hypochondrium 1cm
at a time between each breath the patient takes.
3) Feel for the splenic edge as it descends on inspiration.
4) If you cannot feel the splenic edge, ask the patient to roll towards you and
on to his right side and repeat the above. Palpate with your right hand,
placing your left hand behind the patient's left lower ribs, pulling the
ribcage forward.

Note: normally spleen isn't palpable, unless it is 3 times larger than normal size.

o Kidneys examination: Bi-manual examination

 Palpation of the Left Kidney:

Place your left hand behind the patient’s back below the 12th rib and
your right hand anteriorly over the upper quadrant. Firmly, but gently,
push your hands together as the patient breathes out. Now, ask the
patient to breathe in deeply, feel for the kidney moving down between
your hands. If this happens, gently push the kidney back and forwards
between your two hands to demonstrate its mobility. This is ballotting,
and confirms that this structure is the kidney.
 Palpation of the Right Kidney:
Use your left hand to lift up from the back, and your right hand to feel
deep in the right upper quadrant, proceed as before.

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  In an adult, the kidneys are not palpable. A normal left kidney is rarely
palpable. However, a normal right kidney may be palpable, especially when
the patient is thin.

Note: ballottement is done when you feel an enlargement or a mass in the kidney.

5. Percussion:
a. General percussion of the abdomen. ( 9 regions of the abdomen)
b. Shifting dullness.
c. Transmitted thrill.

o Ascites
1. Shifting dullness:
a. Percuss from the midline out to the flanks. Note any change
from tympany to dull.
b. Keep your finger on the site of dullness in the flank and ask the
patient to turn on to his opposite side.
c. Pause for 10 seconds to allow any ascites to gravitate, then
percuss again. If the area of dullness is now resonant, shifting
dullness is present, indicating ascites.

2. Transmitted thrill:
a. Place the palm of your left hand flat against the left side of the
patient’s abdomen and flick a finger of your right hand against
the right side of the abdomen.

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 b. If you feel a ripple against your left hand, ask the patient to place
the edge of his hand on the midline of the abdomen.
This prevents transmission of the impulse via the skin rather than
through the ascites. If you still feel a ripple against your left hand,
a fluid thrill is present.

Note: transmitted thrill is only detected in gross ascites.

6. Auscultation:
a. Bowel sounds: place your stethoscope diaphragm to the right of
the umbilicus. Listen for 1 minute (normally 3-15 sounds).
b. Aorta: listen above the umbilicus over the aorta for arterial
bruits.
c. Renal arteries: listen 2–3 cm above and lateral to the umbilicus
for bruits from renal artery stenosis.
d. Listen for bruits over the iliac arteries & the femoral arteries.
e. Listen over the liver for venous hum & friction rubs.
f. Listen over the spleen for friction rubs.

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 Note: points "a, b, c" are the main steps, and what you are going to be
asked to do mostly.

7. Genitalia & rectal examination

Just tell the examiner that you want to examine the genitalia & do DRE.

8. Cover the patient.

Example 1 of a normal patient:

 Palpation: non tender soft lax abdomen, no hepatomegaly (liver edge not felt & the span
is 8 cm), spleen & kidneys were not palpable.
 Percussion: tympanic abdomen with no signs of ascites.
 Auscultation: active/audible bowel sounds, no aortic or renal bruits.

Example 2 of a normal patient:

 Palpation: non tender soft lax abdomen, no hepatomegaly (liver edge is smooth and felt 2
cm below the costal margin & the span is 9 cm), spleen & kidneys were not palpable.
 Percussion: tympanic abdomen with no signs of ascites.
 Auscultation: active/audible bowel sounds, no aortic or renal bruits.

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