1 

 
ENT HEAD AND NECK
CLINICAL EXAMINATION
Examination of theThyroid
NEUROLOGIC EXAMINATION
- IF you feel any pain or discomfort during the
Cranial Nerve Examination examination, please let me know and I will stop. I will
‐ Inspection: scar marks, asymmetry of face, eyes, be gentle.
pupils, wasting - Ask patient to remove clothing and wash hands!
‐ I – ask patient to smell - Inspection:
‐ II – PEARL, Funduscopy, VA, pinhole test, visual o General appearance: appropriate dressed
fields, for the weather
‐ III, IV, VI – ptosis; presence of asymmetry of eyes and ƒ hyperthyroidism:
pupils; extraocular movements; accommodation anxious/restless/agitated, weight
‐ V – sensation (ophthalmic, maxillary, and mandibular) loss
and motor (clench teeth - masseter; open mouth and ƒ hypothyroidism:
push to close – pterygoid muscles; if weakened jaw depressed/sad/dull/apathic/anxiou
deviates to affected side); corneal reflex; jaw jerk s/restless/agitated/ hoarse
(UMN) voice/sluggish
‐ VII – close eyes and don’t let me open them, smile, o Neck: look for swelling, scar marks, dilated
wrinkle forehead, puff up cheeks veins (retrosternal extension), redness
‐ VIII – whisper test; rinne test and weber (256) (thyroiditis)
‐ IX and X – hoarseness; cough; ask to sip water to o Ask patient to sip water and look for
check problems with swallowing; Gag reflex and uvula movement during deglutition; check border;
‐ XI – raise shoulder and SCM ask patient to protrude tongue
‐ XII – tongue - MASS: 4S (site, size, shape, suface), 4C (color,
consistency, contour, compressibility), 3T
TIA Examination (temperature, tenderness, transillumination), 2F
‐ Face: asymmetry of face, ptosis, eyes/pupil of equal Fluctuation, Fixation), pulsatile, reducible, signs of
size, redness/swelling; PEARL; ophthalmoplegia; inflammation
accommodation; funduscopy - Palpation (from behind)
‐ JVP, carotid pulse and bruit o Palpate both lobes and isthmus
‐ Upper/Lower limb neurologic examination o Sip of water and look for all characteristics
of the mass (soft: adenoma; cystic: cyst;
Neurological Examination of the Upper Limb firm: goiter; hard: cancer; tenderness:
‐ Inspection: signs of head injury, facial asymmetry, thyroiditis; immobile: cancer); palpable thrill
ptosis, muscle wasting and fasciculation o Cervical lymph nodes (submental –
‐ Palpate muscles for tenderness, Pronator drift submandibular – preauricular –
(UMN/cerebellar lesion), tremors, postauricular – anterior cervical – posterior
‐ Tone cervical – occipital)
‐ Power (shoulder grasp, biceps and triceps power, o Look at position of trachea from front (if
flexion and extension of wrist, grasp, flexion and displaced may be retrosternal extension)
extension of fingers; adduction and abduction of - Percussion: from upper part of manubrium from one
fingers side to the other (change from resonant to dull
‐ Reflexes: biceps, triceps, brachioradialis indicates restrosternal goiter)
‐ Sensation - Auscultation: listen for each lobe for any bruit
‐ Vibration and Proprioception (increased blood supply due to hyperthyroidism)
‐ Finger-to-nose test and alternating movements - Pemberton sign: ask patient to lift both arms as high
(dysdiadochokinesia) as possible and look for plethora, cyanosis, respiratory
distress, or neck vein distention Æ signifies thyroid
Neurological Examination of the Lower Limb gland is closing the thoracic inlet and impedes venous
‐ Inspection: wasting of muscles, tremors, flow to the heart
fasciculations, surgery marks, deformity - Hands, nails and skin
‐ Gait assessment: observe for limping o Hyperthyroidism: warm, sweaty, palmar
‐ Walk on heels: L5 erythema; onycholysis (nail separating from
‐ Walk on toes: S1 bed); tremors; shiny and smooth
‐ Squatting o Hypothyroidism: cold, dry, swollen, thick
‐ Romberg test skin, anemia; dry and coarse
‐ Heel-Toe Walking - Pulse for rate and rhythm and Blood pressure
‐ Palpation for tenderness of muscles - Reflexes
‐ Power (hip flexion and extension, knee flexion and o Hyperthyroidism: brisk reflexes
extension, adduction, abduction, inversion, eversion, o Hypothyroidism: delayed relaxation
plantar flexion, dorsiflexion) - Proximal myopathy: hyperthyroidism
‐ Reflexes (knee, ankle, babinski, clonus) - Face
‐ Sensation o Hyperthyroidism: fine shiny hair, proptosis,
‐ Vibration and Proprioception lid lag and retraction, chemosis (edema of
conjunctiva), conjunctivitis, corneal
‐ Cerebellar: Heel-to-shin, foot tapping test
ulceration, ophthalmoplegia
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o Hypothyroidism: brittle, dry and coarse, asymmetry of the face? Any disturbance in function of
alopecia, loss of eyebrows, periorbital your face? Any change in taste sensation? Any
edema, facial puffiness, xanthelasma (lipid problems with swallowing, hearing or breathing?
deposits over the lower eyelids), swollen Hoarseness? do you have any pain or swelling in the
tongue gum while chewing?
- Other signs (Hypocalcemia): ‐ How is your general health?
o Schvostek: twitching of facial muscles upon ‐ PMHx of cancer or radiation therapy?
tapping of the facial nerve along the angle of ‐ FHx of cancer
the mandible ‐ SADMA?
o Trousseau: flexion of wrist and MCP joints
upon inflating the BP cuff above systolic. Physical examination
- Chest: gynecomastia in hyperthyroidism; pleural ‐ General appearance
effusion (hypothyroidism) ‐ Vital signs
- CVS: hyperdynamic circulation (arrhythmia and ‐ ENT: Inspection, palpation (site, size, shape, surface,
cardiac failure) and systolic flow murmurs; pericardial contour, consistency, compressibility, temperature,
effusion (hypothyroidism) tenderness, transillumination, fixation, fluctuation,
- Myopathy: sit and stand Æhyperthyroidism reducible, pulsatile, signs of inflammation, discharge,
- Legs: pretibial myxedema (bilateral firm, elevated, ulceration, vascularity), Lymph nodes (submandibular,
dermal nodules on the shin, may be of different colors submental, anterior and posterior auricular, occipital,
– hyperthyroidism anterior and deep cervical LN), Facial nerve testing:
asymmetry, close eyes and don’t allow to open them,
Examination of a Patient with Facial Trauma smile, clench teeth, Do check oral cavity using mouth
and torch (dental problem or ulcers of mouth and
- Ask for consent tongue); parotid duct:: palpate from inside of the
- Inspection (Look): there is a bruise on the left side of mouth and check for discharge and salivary stone
the cheek; no obvious asymmetry or swelling is noted;
no obvious fracturers; in the eyes there is no raccoon Diagnosis and Management
eyes (purplish discoloration around the eyes: orbital ‐ For examiner: We are presented with a middle-aged
floor fracture) or any swelling or redness; on the nose man who presents with a long-standing mass on the
there is no obvious fracture; no obvious drainage of face which is suggestive of a parotid enlargement. On
fluid. Ask patient to open the mouth and look for any examination, the mass is noted to be well-
loss of tooth or injury. On the ears look for any injury, circumscribed firm mass without signs of facial nerve
bleeding, or fluid. There is no battle sign (discoloration involvement which is highly suggestive of a benign
of mastoid due to basal skull fracture) On the neck tumor called pleiomorphic adenoma.
and head, there is no obvious swellings, bumps,
deformities ‐ For patient: From history and examination you have a
- Feel: feel surrounding area for fracture or tenderness; condition called pleiomorphic adenoma of the parotid
take torch to look for pupillary light reflex; do EOM gland. Let me assure that it is a benign swelling and to
(diplopia); ask for funduscopy and visual acuity; take further confirm it, I will refer you to the surgeon. He will
pin to check for sensation; clench teeth; corneal reflex; do a CT scan or MRI to see the overall dimension and
close eyes and do not let patient open them; open tissue invasion and FNAC to determine whether the
teeth and smile for me; feel head for any injury or tumor is benign or malignant.
swelling; feel cervical spine and paraspinal muslces to ‐ Differential Diagnosis: Warthin’s tumor, Sebaceous
look for tenderness; cyst, lymphoma, metastasis from primary growth,
- Move: do ROM of neck; parotid abscess, lipoma, pre-auricular adenoma,
Chronic parotitis
Pleiomorphic Adenoma ‐ Once confirmed the surgeon will remove it through a
procedure called Superficial parotidectomy. In this
Case: A middle-aged man comes in to your GP clinic with a surgery, the lump is removed and the facial nerve is
swelling on the left side of his face just above the angle of his preserved. Complications include: hemorrhage,
jaw between the mastoid and mandible. A picture of the swelling anesthetic complications (aspiration), facial nerve
is provided. injury, salivary fistula, recurrence
‐ Reading materials, refer and review.
Task ‐ For cancer: Total parotidectomy or block neck
a. History (lump x 5 years noticed when he was shaving; dissection with radiotherapy
slowly growing, not painful, came in due to cosmetic
reasons, + smoker x1/2 pack) RESPIRATORY SYSTEM EXAMINATION
b. Physical examination (3x3, irregular, firm, nontender,
rounded/bosselated, well-circumscribed, no punctum, Examination of the Respiratory System
redness, discharge or scar marks, no LN enlargement,
facial nerve examination) - Consent
c. Diagnosis and management - Inspection: sitting comfortably on the bed and does
not appear to be SOB, conscious and alert, not
History cyanosed, not attached to oxygen, no medications, or
‐ Can you tell me more about it? When? Is it growing IV lines. He does not appear cachectic.
suddenly or slowly? Painful or not painful? Does it - Hands: cyanosis, clubbing, nicotine stains, test
move when you feel it? It is firm or hard when you feel patient's resistance to adduction (brachial plexus
it? Any ulceration, infection or bleeding from this site? involvement in pancoast/apical lung tumor), press
Any other lumps and bumps in the body? Any weight wrist and note tenderness (hypertrophic pulmonary
loss or change in appetite? Did you notice any osteoarthropathy - results from periosteal
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inflammation secondary to pancoast tumor), pulse and o Auscultation: bell of stethoscope at apex
RR, wrist extension for 30 mins and look for flapping beat;
tremors for CO retention

- Face: pallor, jaundice, Horner syndrome, check for ƒ MS: mid-diastolic (bell); ask
tenderness of maxillary and frontal sinuses, nose for patient to turn on left side Æ feel
swelling, polyps, and deviated nasal septum, open hand for palpable thrill; auscultate
mouth to check for focus of infection, speak a murmur heard clearly;
sentence for hoarseness, ask px to cough for bovine ƒ MR: pansystolic (diaphragm);
cough radiates to axilla;
ƒ AS: ejection systolic murmur;
- Neck: Lymph node and trachea, JVP (if indicated) Neck;
ƒ AR: early diastolic murmur; ask
Chest patient to lean forward; then
- Inspection: pectus carinatum/excavatum, deformities, breathe in and out Æ hand and
scars, radiation marks, erythema and signs of auscultate
inflammation, tattoos, barrel-shaped chest, ƒ Systolic murmurs: radiate
kyphoscoliosis, spine central ƒ Diastolic murmurs: accentuated by
- Palpation: check chest expansion (breathe in and out change of position
by mouth): upper lobe expansion (equal rising of ƒ Dynamic auscultation: Pinch nose
clavicles), middle and lower lobe: thumbs should and ask patient to breathe in and
move at least 5cm, sacral edema, tactile fremitus (with try to breath out thru the ears
hands over chest) valsalva Æ auscultate at left
- Percussion: supraclavicular area sternal edge for systolic murmur of
- Auscultation: air entry, added sounds, vocal fremitus HOCM
Examine anterior chest as well - Back:
o Inspect: scars, deformity, bamboo spine
- Do Peak expiratory flow rate (PEFR) (PR)
o F: 400L/min and M: 600L/min o Feel: sacral edema, pleural effusion
o Auscultation: crepitation, pleural effusion (no
CARDIOVASCULAR AND PERIPHERAL VASCULAR breath sound)
o Radiofemoral delay: listen to scapula Æ
Cardiovascular Examination COA
- Position patient to 45 degrees and expose neck and - Abdomen: lying flat with one pillow
chest up to lower abdomen o Abdomino-jugular reflex
- General inspection: lying comfortably at 45 degrees, o Palpate liver and spleen
not cyanosed and dyspneic, not cachectic (cardiac o Ascites
cachexia Æ weight loss due to heart failure), no o Aortic aneursym
features of down, marfan, turner syndrome, not - Lower limbs for edema, pulse
attached to oxygen, ECG monitor or drugs on the side - Urine dipstick, funduscopic, hematuria, HTN changes,
of the patient Roth spots in infective endocarditis
- Hands/nails: check for cyanosis, splinter
hemorrhages, clubbing, CRT, nicotine stains, palmar Murmurs:
erythema, Janeway lesions (painless red macular - MS: normal pulse, reduce in volume
patches on palms), Osler nodes (tender nodules on - MR: pounding pulse
the pulp of the fingers), anemia/pallor, tendon - AS: slow-rising pulse
xathomas - AR: collapse pulse
- Arms: Radial artery pulse for rate and rhythm,
compare both pulses for Radioradial delay (subclavian Systolic murmur at aortic area (DDx)
artery stenosis) or Radiofemoral delay (COA), - AS radiate to carotid
collapse impulse (AR), BP (sitting and standing) - Aortic Sclerosis (doesn’t radiate)
- Face: anemia, jaundice, xanthelasma, malar flush - HOCM functional systolic murmur
(SLE, MS, pulmonary stenosis), tongue and lip for - Pregnancy
central cyanosis, high-arched palate (marfan - Thyrotoxicosis
syndrome), petechia, telangiectasia (IE), - Fever
stomatitis/gingivitis; - Anemia
- Neck: carotid pulse, JVP (patient at 45 degrees: use 2
ruler: 1 ruler straight up at manubrio-sternal angle Main causes of AS
then measure in cm Æ add 5cm Æ >8cm is raised - Increased age
JVP) - Congenital bicuspid valve
- Precordium:
o Inspection: scars (middle Main causes of MR
sternotomy/thoracotomy), pacemaker - Rheumatic fever
(below clavicle, subcutaneous), - MVP/rupture of chordate tendinae
kyphoscoliosis, pulsations, deformity - MI
o Palpation: apex beat (5th mleft ICS, 1cm - Infective endocarditis
medial to the midclavicular line; check - Dilated cardiomyopathy
whether
forceful/tapping/displaced/diffuse/parasterna
l impulse), heave (palm), thrill at base of
heart (pulmonary and aortic area Æ using
fingers)
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Examination of the Lower Extremities Æ impulse or thrill will be felt
expanding and travelling down the
- Introduce yourself. I understand from your notes that long saphenous vein
you’re having pain on the leg. My task is to do the ƒ Marked dilated long saphenous
physical examination. During this examination, I will vein in fossa ovalis (saphena
look and will be palpating/feeling some parts of the varix) will confirm incompetence
leg. I will also need to listen to some of the vessels on Æ disappearas when patient lies
your leg with the use of my stethoscope. down
- AT this moment I would like to ask you if you have any - Special tests: Trendelenburg test (checks the level of
pain. I will ask for your permission to expose your incompetence) Æ long saphenous vein, short
thighs and legs (usually up to the nipple area but saphenous vein and perforators
cover abdomen and expose only when required).
While you undress I would just like to wash my hands. o Patient lies down and leg is elevated to 45
- Inspection: deg. To empty the veins
o Abdomen: check for visible pulsation (AAA – o Apply torniquet with sufficient pressure to
left of the midline), scar marks; prevent reflux over the upper thigh
o Groin: pulsation, scar marks; o Patient stands
o thigh and legs: muscle wasting, joint o Long saphenous system will remain
deformities, atrophy of the skin, loss of hair, collapsed if there are no incompetent veins
change of color of skin, shiny skin; below the level of fossa ovalis. When
o feet: obvious deformity, ulcers (include toes, pressure is released, the vein will fill rapidly
raise legs, under heels), hallus valgus; if the valve at the saphenofemoral junction is
discoloration/cyanosis/blackening of nails; incompetent
look for signs of amputation in toes; obvious o Doubly POSITIVE: is when veins fill rapidly
edema and signs of inflammation before the pressure is released and then
- Palpation: check for capillary refill time (<3secs); feel with a rush when released (coexisting
for temperature (with dorsum of hands); pinch shins incompetent perforators and long
for any edema; feel the PULSES (dorsalis pedis, saphenous vein)
posterior tibial, popliteal, femoral, abdomen); - Perthes Test
- Auscultation: listen for bruits (AAA); both sides (renal) o Put tourniquet on mid-thigh Æ ask patient to
then femoral; Buerger test: raise your legs 45 deg for stand and up and down on the toes for 10x
10-15 seconds (if there is pallor – suspect PVD) then I after releasing some of the blood.
would like you to sit down and hang your legs from the o Collapsed veins are normal
edge of the bed (check for cyanosis or dusky red) o If superficial veins increase in prominence or
- What is the ABI? pain Æ deep vein are occluded or
perforators are incompetent
Examination of Varicose Veins (Case 148R8) o If veins are unusual in distribution Æ
exclude pelvic neoplasm/mass that is
Risk factors obstructing the deep vein system
- Female sex - Confirmatory: venous Doppler ultrasound
- Family history
- Pregnancy Management
- Multiparity - Refer for Doppler ultrasound for accurate diagnosis
- Age - Use supportive stockings (apply in the morning before
- Occupation standing out of the bed)
- Diet (low fiber) - Avoid scratching skin over the veins
- Sit with legs on a foot stool
Examination - Maintain ideal weight
- Inspection: - Eat high fiber diet
o Distribution: - Treatment options
ƒ Below the femoral vein in the groin o Sclerotherapy (use a small volume of
to medial side of the thigh to lower sclerosing agent Æ particularly below the
leg Æ saphenous vein knee)
ƒ Back of leg to calf area Æ short o Surgical ligation and stripping Æ remove
saphenous vein obvious varicosities and strip perforators
o Signs of inflammation, cutaneous venous
flares, pigmentation, edema, Complications
lipodermatosclerosis, dermatitis/eczema, - Superficial thrombophlebitis
venous ulcers, loss of hair, atrophy of skin, - Skin eczema
color change of the skin (deep blue, black, - Skin ulceration
purple), venous impulse at saphenofemoral - Bleeding
junction - Calcification
- Palpation - Marjolin ulcer (SCC)
o Hard: thrombosis; tender: thrombophlebitis
o Temperature
o cough impulse
ƒ Place fingers over line of vein
immediately below the fossa
ovalis (saphenofemoral
junction)Æ ask patient to cough
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EXAMINATION OF THE ABDOMEN Perforated Peptic Ulcer

Recent hematemesis in a 50-year-old man (Chronic Liver Case: You are an HMO in ED and a middle-aged man comes to
Disease) you because of acute abdominal pain. He had low back pain last
week and was prescribed NSAIDs. He is a smoker and an
Case (Condition 70): You are an intern in the ED and a 50-year- alcoholic beverage drinker.
old male having had hematemesis for about 500ml of fresh
blood 2 hours ago accompanied by transient feeling of Task
lightheadedness and sweating. The patient is alcoholic and a. Focused examination
likely to have chronic liver disease on the basis of history that b. Diagnosis and management
you have taken.
Case 2: John aged 45 years presents to ED of a local hospital
Task where you are working as HMO 1. He had severe abdominal
a. Perform relevant and focused PE of the patient pain since this morning which is getting worse now. He had
b. Explain actions and what you are looking for to vomited once but now had only dry retching. He took panadol
examiner and neurofen but with no relief. He had not experienced such
c. Describe findings as you proceed pain in the past. He is a smoker and drinks moderate amount of
d. No need to take further history alcohol on weekends.

Physical examination Task

- Is my patient hemodynamically stable a. History (started after breakfast, 10-11 in severity,
- Consent epigastric, takes panadol and neurofen for knee pain)
- Exposure: midchest to symphysis pubis b. Physical examination (unwell, tired, BMI 24, PR:
- Inspection: 120/min, mild dehydration, rebound, guarding and
o General appearance: Patient lying rigidity)
comfortably. Abdomen moving with c. Differential diagnosis and management
respiration. He is not cachectic. There is no
obvious jaundice or pigmentation. He is well Examination
oriented. IV drug marks - Is my patient hemodynamically stable
o Hands: clubbing, cyanosis, leukonychia, - General appearance: lying on bed, unwell and in pain.
pallor, CRT, palmar erythema, dupuytren offer painkiller (morphine 2.5mg IV + metoclopramide)
contractures - Vital signs (BP with postural drop)
o Raise hands Æ flapping tremor/asterixis - Inspection:
(20-30 seconds) o Abdomen not moving with respiration
o Arm: Spider nevi, bruising/petechia, scratch o General inspection of abdomen: scars,
marks, IV drug marks, tattooing or body distention, jaundice, pigmentation
piercing - Palpation:
o Face: anemia and jaundice, Kayser- o Where do you feel the pain?
Fleischer rings, parotid gland enlargement, o Superficial palpation Æ tenderness
fetor hepaticus, flushing/congestion of the o Guarding, boardlike rigidity, rebound
face; Mouth: stomatitis, gingivitis, tenderness on deep palpation
ulcerations, telangiectasias - Auscultation: Bowel sounds
o Lymph nodes: cervical, axillary, inguinal - Hernia orifices
o Chest: spider nevi and gynecomastia - DRE
- Abdomen
o Inspection: distention, caput medusa, visible Investigations
pulsations, visible peristalsis, striae, - FBE, ESR/CRP, blood group and crossmatching
bruising, hernia orifices - U&CE, LFTs, BSL,
o Inspect at level of tummy: ask patient to - Amylase and lipase
breathe in and out through the mouth Æ - Erect CXR (free gas under diaphragm) and Xray of
look for visible masses abdomen (supine and upright)
o Palpation: Ask if patient has pain anywhere
in the stomach; Relax and breathe in and Differential Diagnosis
out; mass or tenderness on superficial - Perforated viscus
palpation; deep palpation; palpate liver - Acute pancreatitis
o Liver span: from midclavicular line (Normal: - Mesenteric ischemia
6-12) - Acute cholecystitis
o Spleen - AMI
o Percussion: shifting dullness for ascites - If female: Ectopic pregnancy, ovarian cyst
(percuss from right towards left side) rupture/torsion; PID; miscarriage
o Auscultation: bowel sounds and venous
hum (between umbilicus and xiphisternum) Management
o Testicular atrophy - Admit and call surgical registrar because it is an acute
o Scratch marks in legs and edema; abdomen most likely due to peptic ulcer
sensations - Pass 2 IV line and start fluids for full resuscitation
o DRE!!!! - Pass NGT to decompress stomach
- NPO
- Insert indwelling catheter to monitor I&O
- Start IV antibiotics
- Surgery (Exploratory laparotomy)
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Examination of an Inguinal Hernia o Three finger test
ƒ Put index, middle and ring fingers
Case: You are a GP and your next patient is a 40-year-old in the 3 openings: one finger at
laborer. 2 weeks ago, he felt pain in his right groin after heavy 4cm above and below the pubic
lifting at work and a week later, noticed a lump in the groin tubercle, other finger at the DIR
which was not there before. and SIR Æ ask patient to cough
Æ where you feel the impulse
Task then diagnostic
a. Perform focused physical examination o Palpate the LN, femoral pulse
b. Diagnosis and management - Describe hernia to examiner: femoral/inguinal,
reducible/irreducible, direct/indirect
Differential Diangosis
- Hernia Management
- Lymph node - Keep an ideal weight
- Undescended testes - Adjust diet to avoid constipation
- Lipmoma - Avoid activities that increase intra-abdominal pressure
- Hydrocele (heavy lifting, straining and coughing)
- Saphenovarix - Avoid smoking
- Aneurysm - Referral for surgical consultation. Done usually by
- Neuroma laparoscopic surgery
- Complications: infection, bleeding, anesthesia
Examination complications, swelling, damage to nearby organs
- Consent (inferior epigastric vessels or inguinal nerves),
- Do you have any pain in this area? recurrence
- On standing:
o Inspection: site of swelling (whether medial MUSCULOSKELETAL EXAMINATION OF THE BACK
or lateral to pubic tubercle), size, shape,
color of underlying skin, and contour, signs Examination of Low back
of inflammation. scar marks
Case: A patient presented to your GP clinic complaining of back
o Scrotum (extent of hernia; varicocele and pain.
visible pulsation for saphenovarix)
o Ask patient to reduce swelling, look at other Task
side then cough a. Perform physical examination of the low back
o Palpate the scrotum (can get above the
swelling: hydrocele, epididymal cyst, lipoma, ‐ Inspection: walk on heel, trendelenberg,
varicocele Æ testicular swellings) ‐ Palpation: spinal and paraspinal, greater trochanter,
- On lying:
o Check if swelling is reducible then check for Red flags for back pain
cough impulse; borders, temperature, ‐ Incontinence
tenderness; palpate testes, epididymis and ‐ Perianal area numbness
spermatic cord ‐ Loss of rectal tone
o Determine whether femoral or inguinal:
ƒ Femoral: if it lies 4 cm below and Examination
4 cm lateral to pubic tubercle ‐ Inspection: Hairy patch on the back (spina bifida), café
ƒ Direct inguinal: above pubic au lait spots, stigmata of neurocutaneous disease,
tubercle and inguinal ligament; 1 muscle wasting or erythema, extended lordosis,
cm above pubic tubercle; lies kyphosis, scoliosis, equal leg length, hip and shoulder
medial to the inferior epigastric length level
vessel; sac lies behind spermatic ‐ Assess gait (normal phases of walking without
cord limping, walking on heels, toes, squat (proximal bulk
ƒ Indirect inguinal: above pubic of muscles)
tubercle; lateral side of inferior ‐ Palpation: with two thumb, palpate for spinal
epigastric vessel; sac lies within tenderness, sacroiliac joints, iliac crest, greater
the spermatic cord so it can trochanter, ischial tuberosities, ASIS, PSIS
descend to the testes ‐ ROM: flexion, extension, lateral flexion, lateral
rotation; Trendelenburg test
o Ring occlusion test ‐ Schoberg test: 10 cm above and 5 cm below the
ƒ Occlude deep inguinal ring and dimple of venus and ask patient to touch toes Æ
ask patient to cough Æ if it’s should be >20cm
coming out Æ direct inguinal ‐ Ask patient to sit at edge of the bed and test reflexes
hernia Æ release pressure again (ankle and knee, clonus and babinski); hip flexion
then hernia comes out Æ direct against resistance, then sensory levels
inguinal hernia ‐ ROM of hip: hip flexion with knee extended - 90, and
ƒ Trace finger into spermatic cord with knee flexed 135, Internal and external rotation
into superficial inguinal ring and (look at position of patella), flexion and extension of
ask patient to cough Æ if sac hits knee, inversion/eversion and flexion/extension of foot,
finger Æ indirect inguinal hernia dorsiflexion and plantar flexion of great toe, extension
of hip;
‐ Power of hip and knee against resistance
7 
 
‐ Modified Straight leg-raising Test (L4-S1) Æ tests Management of axillary nerve injury
root tension L3-4, L4-5, L5-S1 Æ passively lift the leg ‐ In many cases, spontaneous resolution happens
while the patient is supine to maximum he can spontaneously and no treatment is needed. It may
tolerate, raise the leg to just below the level and take as long as one year.
dorsiflex the foot ‐ If there is any pain, we can give you medication such
‐ Slump Test: patient at the edge of the bed and as paracetamol in mild pain or if severe/stabbing pain,
slumping and bed head forward to maximum, lift up other medications such as gabapentin or TCAs can
head as if doing SLR test, release leg until pain also be given.
disappears, and put pressure by putting dorsiflexion, ‐ If not controlled refer to surgery and surgical options
release neck and dorsiflexion include nerve grafting/reconstruction.
‐ Refer to physiotherapy to regain muscle strength and
Clinical Features function of nerve.
L2 Weakness of Iliopsoas muscle (Hip flexion)
Loss of sensation over the thigh and the lower Examination of the Hand
part of the groin
Reflex: None - Joints, Pulse, Nerves, Muscles and Tendons!!!
L3 Weakness of quadriceps (Knee extension) - If with trauma: Pulse, nerve function, tendons, joint,
Loss of sensation over the patella muscle
Reflex: Knee jerk - If rheumatological examination: joint,
L4 Weakness of quadriceps and inversion at subtalar tendons/nerves, muscles, pulse
(Ankle dorsiflexion and cannot walk on the - Inspection: nails Æ psoriatic nails (pitting,
heel) onycholysis, hyperkeratosis), subluxation, muscles,
Reflex: Knee shiny, tighetened skin, thickening of tendons,
L5 Extensor hallucis and digitorum longus (Great toe erythema, clubbing, deformity of small joints of the
dorsiflexion and long extensors and everters) hand (phalanges, MCP or wrist joint), nodules on the
Reflex: None level of elbow swelling, signs of inflammation,
deformity, no muscle wasting or thickening of
hypothenar or thenar muscles, pallor, dupuytren
contracture
S1 Flexor hallucis and digitorum longus and tendon o Radial deviation of wrist
Achilles: weakness of Plantar flexion and foot o Z deformity thumb – flexion of MCP and
eversion (Toe walking) extension of PIP (RA)
Reflex: Ankle Jerk o Boutonierre deformity – flexion of PIP,
‐ Do PR extension of DIP (RA)
o Swan neck deformity – flexion of DIP and
MUSCULOSKELETAL EXAMINATION OF UPPER LIMBS extension of PIP (RA)
o Heberden – DIP (OA)
Examination of the Shoulder o Bouchard nodes – PIP (OA)
o Sausage-shaped fingers – telescoping of
Book Case: fingers (psoriasis and scleroderma)
- Consent - Palpation: temperature; elbow, radius, ulna, lower end
- Inspection: check for symmetry; check joints both of the ulnar styloid processes with 2nd finger,
shoulders are equal; contour of muscles; no muscle (denotes RA Æ especially radial styloid and
atrophy; bone, muscle, skin and joint; comment on associated with de Quervain tenosynovitis, severe
neck (neurocutaneous stigmata of associated disease, OA), wrist and bones of the hand (with thumb), press
bruise, deformities, erythema, neck contour is fine), from the side and up to detect for any effusion,
temperature is equal, musculoskeletral structures look crepitation, dupuyren contracture, wasting of
in place. thenar/hypothenar muscles, radial pulse, CRT,
- Injury to circumflex nerve if there is shaving of deltoid sensation
- Palpation: both clavicles, acromioclavicular joint, - ROM (Active then passive); open and close hand to
bursa, bicipital tendon, suprasinous muscles, midline check for crepitus/tenosynovitis
and paraspinal areas and infraspinatus, examine o Elbow: flexion and extension
police patch (circumflex nerve), compare pulse, o Wrist: flexion, extension, lateral and medial
- Check full ROM: flexion and extension of shoulder deviation, supination and pronation; degree
joint, abduction to glenohumeral joint, scapula sliding of flexion and extension
over thoracic cage, adduction to 0 and across the o Thumb: flexion, extension, adduction,
body, internal and external rotation, touch tip of abduction, opposition
scapula and scratch thumb between scapula o Hand: abduction and adduction
(combined adduction and internal rotation) then - Power
combined abduction and external rotation, then - Nerve Tests:
circumduction o Pin touch test: median nerve
- Stool: passive movement o Crush finger with thumb: ulnar nerve
- Test power of muscles: resists hands on biceps (full o Full extension of wrist: radial nerve
flexion and extension); do chicken wings o Fromen’s test
(abduction/adduction); full external/internal rotation - Vibration and Proprioception: may avoid
- Pulses! - Carpal tunnel
- Neurocutaneous structures: use pin and cotton o Phalen test
- Throw a ball: apprehension test: impending o Tinnel
dislocation/subluxation/joint unstable if positive o Finkelstein
8 
 
- Functions of the hand - Palpation: hip lying on the same level by palpating
o Grip strength with thumb the ASIS, greater trochanter (tenderness if
o Key hole test there is subtrochanteric bursitis), femoral pulse
o Comb hair midpoint between ASIS and pubic tubercle), palpate
o Write name lateral to femoral pulse to check for tenderness on
o Undo buttons femoral head (osteoarthritis), muscles on the inner
side of the hip and front (adductor tendinitis)
Other features of RA - Measure leg length: Apparent and true leg length
- Skin: rheumatoid nodules (measuring tape)Æ discrepancy in true leg length
- Head: scleritis in eyes signifies pathology of hip joint; if in apparent leg length
- Lungs: nodules, fibrosis, Caplan syndrome means tilting of pelvis
(pneumoconiosis) - Active and Passive Movements then Power:
- Heart: pericarditis o Hip flexion: raise leg to chest
- Abdomen: splenomegaly o Extension: can ask patient to lower the leg
- Hematologic: neutropenia (felty syndrome = RA + down or at the back ask patient to raise the
neutropenia + splenomegaly), anemia leg while knee is flexed; palpate the dimple
of venus or press hip (sacroiliac joint
Osteoarthritis tenderness Æ sacroilitis)
- Usually carpometacarpophalangeal and DIP o Abduction and Adduction (support hip)
o Internal and external rotation (flex and
MUSCULOSKELETAL EXAMINATION OF THE LOWER support the knee)
EXTREMITY - Thomas Test: flexion deformity of the hip; keep hand
under spine and flex both hips and knees and ask the
patient to lower one leg; if not done properly, flexion
Examination of the Hip (Trochanteric Bursitis) deformity will be disguised by lumbar lordosis
compensatory movement
Case: A 45-year-old female complained of pain in the right outer - Squeeze Test: flex knee at 90 degrees ask patient to
hip that travels down to her legs since last week. squeeze thighs in hand Æ (+) in adductor
tendinitis/osteitis pubis
Task - Tests for Sciatica
a. Examine the patient o Modified Straight Leg Test (L4-S1)
b. Diagnosis and management o Tibial Nerve Stretch Test (L4-S3)
o Femoral nerve Stretch Test (L2-4)
Features:
- Inflammation of bursitis or tendinopathy of the gluteus Diagnosis and Management
medius tendon - Most likely you have a condition called trochanteric
- Common in patients on sports or gardening, increased bursitis. The bony prominence of the thigh bone in the
weight/BMI upper part is the greater trochanter. There is a
- Pain around lateral aspect of hip traveling down the protective shock absorber over the bone called
leg “bursa”. The muscles of the buttock is also attached to
- Trendelenburg test may be positive this bone by the tendons. If there is inflammation of
- Female >45-50 the tendon or bursa, it is called trochanteric bursitis or
- Tenderness of the greater trochanter and/or pain tendinitis.
on abduction - You need to rest and reduce the activity for about a
- Treatment: NSAIDS, RICE, strengthening exercises, few days. Put an ice pack on the painful side and I will
injection therapy give you some painkillers to relieve the pain or
analgesic creams for massage. Please avoid sleeping
Differential Diagnosis on the affected side. You can use sheep skin mat or a
- Avascular necrosis of femoral head small pillow to elevate the involved area
- Osteoarthritis of the hip - I will refer you to a physiotherapist for strengthening
- Lumbar spine radiculopathy exercises.
- Iliopsoas tendinitis (flexors of the hip) Æ pain on - If severe pain: local anesthetic + corticosteroids;
stretching of the hip flexor or resisted hip flexion surgery (rarely)
- Investigations: XRay Æ rule out osteoarthritis; USD:
Examination can demonstrate the pathology
- Expose from waist down - Overweight: lifestyle modification
- Assess gait (limping), walk on heels (L5) then toes
(S1); squat and stand; Gait and Hip Examination (Osteoarthritis of the Hip)
- Trendelenberg test (checks abductors of the hip Æ
gluteus medius): Æ leg which the patient is standing Case: A 64-year-old man with a history of pain on his right hip
is the one being tested Æ SOUND/NORMAL side is joint for the last 6 months comes to your GP clinic. The pain is
going to SAG worse with activity. He tried panadol but didn’t get relief from the
- pain.
o Tests gluteus medius muscles
o Problem in hip joint (severe OA) Task
o Shortening of neck of femur due to fracture a. Relevant hip examination and give commentary
o SCFE (kids) (limping, unable to walk heels and toes and squat,
- Inspection: both hips straight, swelling, deformity, trendelenburg unable to do on the right side because
signs of inflammation, wasting of the muscles, flexion of the pain, leg length is normal, tenderness over the
deformity (side), back (spine is centered, wasting,
deformity)
9 
 
right femoral head, flexion deformity on right side, Diagnosis and management
limited in range of movements on the right side, ‐ It is a condition called osteoarthritis of the hip. It is a
thomas test positive) condition resulting from wear and tear as a result of
b. Diagnosis and management excessive use of your joints over the years and also
due to old injuries in the affected joint. The cartilage
Case 2: You are working in a hospital followup outpatient clinic. the covers and protect s the ends of the bones
This 35-year-old man sustained a posterior dislocation of the gradually wears away causing the joint to become
right hip in a MVA years ago. There were no associated rough and stiff. Most cases are mild and with
injuries, the dislocation was reduced and he had a period of bed treatment, you can cope with it.
rest within traction followed by graduated ambulation and weight ‐ Investigation: I will do an Xray of the hip joint to check
bearing. He has been well since and has no problems apart for bony spurs and narrowing of joint spaces.
from occasional aching on prolonged exercise. He presents to ‐ Management:
you for a checkup for insurance purposes. o Relative rest during acute pain, analgesia
and crutches
Task: o Weight loss
a. Perform PE of the hip with commentary o Heat: hot water bottle, warm shower, electric
b. Advise patient of your opinion about the condition of blanket to reduce stiffness and pain
his hip o Refer to physiotherapy for strengthening of
c. Advise patient of any further test which are required muscles and
o Occupational therapist for walking aids
o Surgery: hip joint is replaced by metal or
plastic and is successful in >90%

Adductor Tendinitis

Case: Your next patient in GP practice is a 20-year-old man

complaining of pain in the right groin.

Task
a. History for 2 minutes (playing football when suddenly
twisted and heard popping sensation; upper groin pain
Features radiating to the thigh)
‐ Most common form of hip disorder b. Perform Physical examination
‐ Intrinsic disorder of articular cartilage or to secondary c. Diagnosis and management
OA
‐ Risk factors: previous trauma, DDH, septic arthritis, Case: David aged 27 years presents to your surgery in a busy
acetabular dysplasia, SCFE, past inflammatory afternoon. He tells you he is having pain in his right leg and
arthritis finds it hard to play Footy nowadays. He is a professional player
‐ M=F, usually bilateral; insidious; worse with activity, and represents his team at state level. He had no injury or
relieved by rest and then nocturnal and after resting; trauma and denies any fall also. He had got some treatment by
stiffness, limp and deformity; referred pain to groin, team Physio and had used Panadol and Neurofen with no relief.
medial aspect of thigh, buttock or knee David is otherwise well and works as a salesman in a well-
‐ PE: antalgic gait, gluteal and quadriceps wasting, first reputed firm
hip movements lost: IR and extension, fixed flexion
deformity, hip held in flexion and ER (atfirst) Æ IR,
extension, abduction, adduction, flexion, ER Task
‐ Treatment: a. Further history (right leg 2-3 weeks especially in the
o Weight loss right upper medial thigh or groin area)
o Relative rest b. Physical examination (resisted adduction increases
o Crutches for acute pain pain, + Squeeze test,
o Analgesia c. Probable diagnosis and management advise
o Walking stick
o Physiotherapy Differential Diagnosis
o Physical therapy (isometric exercise) ‐ Adductor tendinitis
o Surgery: with severe pain or disability ‐ Iliopsoas problems
unresponsive to conservative measures; ‐ Stress fracture of femoral neck
total hip replacement (old); femoral ‐ Osteitis pubis (chronic pain)Æ inflammation of
osteotomy (younger patients); hip periosteal bone of symphysis pubis; pain on lower
resurfacing (<60 years; >90% achieve good tummy/pubic bone; point tenderness in symphisis
results; last 15-20 years) pubis;
‐ Hernia (Sport inguinal-femoral)
Differential Diagnosis ‐ Referred pain from lumbosacral spine
‐ Osteoarthritis ‐ Osteoarthritis of the hip joint
‐ Avascular necrosis ‐ Urologic disorders

Features
‐ Acute groin pain with history of twisting injury and
popping/snapping
‐ Pain Æ inner thigh
10 
 
‐ Tenderness on palpation of the inner muscles of the Task
thigh and pain on adduction; squeeze test (+) a. Focused examination of the knee
‐ RICE b. Differential diagnostic plan
‐ Prevention: stretching;
Inspection:
Landmarks
- Patella
- Tibial tuberosity
- Popliteal fossa
- Quadriceps femoris
- Suprapatellar pouch
- Medial and lateral pouches Æ Peripatellar pouches
(obliterates when there is effusion)
- Anserine bursa
- Fractures, muscle wasting, scars (longitudinal Æ
TKR, keyhole) , effusion, erythema, neurocutaneous
stigmata
- Anterior plane: varus or valgus deformity
- Lateral: hyperextension or flexion abnormalities
- Posterior: swelling or baker cyst
- Observe gait: normal gait, limping, fixed flexion
deformity
- Squat and stand up (power and ROM Æ full flexion
and extension)
History
‐ Can you tell me more about what happened? Palpation
SORTSARA? Were you able to walk after that? Is it - Temperature (of knee is 1 degree lesser than body),
for the first time? Did you have any numbness, tingling Pulses (while seated – popliteal, dorsalis pedis,
or weakness? Swelling? Bruising? Did you take any posterior tibial), sensation (pain and light touch),
medications? Previous medications? General health? reflexes,
History of joint problems? - Passive movement
- Knees flexed: palate quadriceps, suprapatellar
Diagnosis and management pouches, patella, patellar tendon, shin of tibia, lateral
‐ Most likely you have a condition called Groin strain or malleolus and fibula, head of the fibula, and joint line,
adductor tendinitis. It happens because of too much iliotibial band, knee hip joint, adductor muscle,
stress on the muscles of your groin/thigh called gastrocnemius, Achilles tendon
adductor muscles. If these muscles are tensed too - Patellar tap test and bulge test (mild effusion Æ
forcefully or suddenly they can tear causing pain. It is effusion
a common condition during sports activity. - Valgus and Varus stress test (+ if more than 10
‐ Avoid activity until pain gets settled. Apply for 20-30 degrees)
minutes for 3-4 hours until pain-free. You can also - Anterior and posterior drawser (+ if more than 10
compress the thigh with the help of elastic bandage or degrees)
tape. - Menisci
‐ I will give painkillers and refer you to physiotherapy. If o Apley’s Grinding test
still not relieved, I can refer you for corticosteroid o External rotation, valgus and flexion or
injection. internal rotation, varus and extension
‐ Please come back if the pain is persistent. If we might - Patellar apprehension test (impending subluxation or
do ultrasound and Xray. dislocation of patella)

Examination of ankle joint

‐ Prevention: Do warm and stretching before doing - Inspection: try to walk first; change in color of skin,
physical activity. bruises, deformity
- Palpation:
Examination of the Knee o Lateral: lateral malleolus, posterior tip of
lateral malleolus and 6 cm above, anterior
Case (book pg229/280): A patient in your GP setting has past talofibular ligament, calcaneofibular
history of twisting his right knee 6 months ago when foot got ligament, posterior talofibular ligament,
caught on a broken pavement. He fell on the knee and it peroneal tendons, base of 5th metatarsal,
became swollen and painful on the inner side. The swelling (sinus tarsi, distal syndesmotic ligament,
caused a painful limp for several days and then subsided with anterior calcaneal process Æ not
easing of symptoms. necessary)
o Media: medial malleolus, medial joint line
Since then he has had intermittent attacks of pain on the inner with 6 cm above, 3 strips of ligament,
side of the knee with swelling, which settles within 24 hours, and navicular, anterior joint line, Achilles tendon,
has had difficulty in straightening the leg fully. He is, on heel, pulse, CRT
occasion, apprehensive when twisting to the right. Between - ROM: plantar flexion, dorsiflexion, inversion, eversion,
attacks of pain he can walk normally with only a minor feeling of neurovascular sensation, reflexes, power
pain on the inner side of the knee. He is otherwise well. This is - Tests for ankle instability: anterior drawer, talar tilt,
the first time he has consulted a doctor about this problem. and squeeze tests (signals high ankle/syndesmotic
injury Æ patient needs MRI and referral for ORIF
11 
 
Lower Leg Examination of a Patient with Diabetes Mellitus Treating cuts and injuries
(Diabetic Foot) - Clean would with mild antiseptic (liquid savlon or dilute
betadine)
Case: Your next patient is a 55-year-old female with long- - Cover with clean gauze
standing diabetes. - See GP if does not heal within 2 days or there are
signs of infection
Task - Refer to podiatrist, dietitian, diabetic educator,
a. Perform physical examination of the lower limbs. ophthalmologist and nephrologist

- Ask patient to walk looking for gait and normal phases

of gait Æ high-stepping gait (indicates loss of
proprioception or joint position sense)
- Inspection:
o Needle marks and fat hypertrophy/atrophy,
wasting (especially quadriceps); charcot
joints (deformed knee joints)
o Skin: loss of hair, atrophy of the skin,
redness, cyanosis, signs of inflammation,
edema
o Feet for obvious deformities, boils, corns
and calluses, hammer toes (proximal
phalanx is flexed); mallet toe (DIP is flexed);
toe clawing (flexion of both DIP and PIP),
hallux valgus, bunions, tinea
o Nails (thickening, ingrown toe nail, change
of color, cyanosis), toes (cracks, ulcers)
- Palpation:
o CRT, temperature, edema, pulses
o Neurologic examination: sensation, vibration
(toe Æ medial/letaral malleolus Æknee Æ
ASIS) proprioception, power (ankle and not
knee), tone, reflexes (ankle, knee Æ may
be decreased or absent)
- Urine dipstick, BSL, funduscopy

Diabetic Foot care

- Keep diabetes under good control and do not smoke
- Check feet daily (sores, infection or unusual signs)
- Wash feet daily with lukewarm water, dry thoroughly
especially toes and soften dry skin especially around
the heels; applying methylated spirits between toes to
help stop dampness
- Attend to toenails regularly (clip straight across with
clippers, do not cut them deep into corners or too
short across, file any rough edge)
- Wear clean cotton or wool socks daily
- Exercise your feet each day to help circulation
- Check insides of shoes to make sure no nails are
pointing into the soles
- Annual foot examination in doctor’s office

How to avoid injury

- Wear good-fitting, comfortable leather shoes
- Shoes should never be broken-in (should fit from the
start)
- Shoes must not be too tight or too loose
- Do not walk barefoot especially outdoors
- Do not cut your own toenails if with poor eye sight
- Avoid home treatments and corn pads that contain
acid
- Be careful when walking around the garden and home
- Do not use hot-water bottles or heating pads on your
feet
- Do not test temperature of water with your feet
- Take extra care when sitting in front of an open fire or
heater