General Examination Checklist

1. Introduce yourself and examiner

2. Explain intention to patient and ask for consentGeneral Inspection:Concious, alert with time place and personLying supine or propped 45 degress/ sittingCannula attached to limbs, which sideRespiratory distress and painEstimate height and weight or thin/medium/big size

3. Inspection of Palm of handa. Pale/Pinkb. Palmar erythemac. Dry/Sweatyd. Muscle wastinge. Deformity

4. Inspection of Dorsum of handa. Warm/Coldb. Muscle wasting

5. Inspection of fingers and nailsa. Clubbing/Leuconychia/Koilnychia/Splinter hemorrhage/Nicotine stainb. Capillary Refill (for adults)

6. Radial Pulsea. Rateb. Good/Poor Volumec. Regular/Irregular Rhythm

7. Forearma. Venapuncture marksb. Tattooc. Scarsd. Ecchymosis

8. Blood Pressure

9. Heada. Jaundice/ Not Jaundice sclerab. Pale/Pink Conjuctiva

10. Moutha. Angular stomatitisb. Central Cyanosisc. Oral Hygiene (Average/Poor etc)d. Stomatitise. Glossitisf. Palate

11. Necka. Lymph nodes enlargementb. Swellingc. Jugular Venous Pressured. Virchow nodes

12. Femoral Pulsea. Volumeb. Rhythmc. Radio-Femoral delay

13. Pitting edema (press at bony prominence) a. Medial Maleolusb. Mid-legc. Kneed. Sacrum

14. Dorsalis Pedis and Posterior Tibialis

Cranial Nerve Examination1. Introduce yourself and examiner

2. Explain intention to patient and ask for consent

3. Positioning of patient in sitting position.

First Cranial Nerve (Olfactory)1. Ask patient to close one nostril and close both eyes.2. Use a fragrant and move it towards unclosed nostril.3. Ask patient whether they can smell the fragrant.4. Do it to both nostril.

2nd Cranial Nerve (Optic)1. Inspect for Exopthalmos2. Test for Pupillary Reflex Test. 3. Ask patient to cover one eye. Tell the patient to say Yes if can see fingers moving at a fixed position. Glasses are permitted.4. Ask patient to cover one eye. Tell patient to say Yes when they can see your fingers moving towards patients nose. Glasses are permitted. Do the same for the other eye.5. Test for Blind Spot. Glasses are permittent.6. Ask patient to read from Snellen Chart.

3rd, 4th & 6th Cranial Nerve

1. Test for Horizontal and Vertical Nystagmus. Move pen as if writing Letter H.2. Test for Eye convergence. Ask for double vision.

5th Cranial Nerve (Trigeminal Nerve)

1. Touch Maxillary, Mandibular and areas. Ask patient to close eyes. 7. Corneal Reflex. Apply cotton wool to sclera. Patient with normal reflex will blink both eyes immediately when sclera is touched.2. Tap jaw for Jaw reflex. Absence of Jaw reflex is normal.3. Clench Teeth. Feel for Temporalis Muscle.

7th Cranial Nerve (Facial Nerve)1. Ask patient to:a. Frown faceb. Smilec. Puff cheekd. Close eyes tightly. Try to open them.

8th Cranial Nerve1. Whisper to one ear while closing the other ear. Ask patient what you whispered.2. Rinne Test. Using 512 Hz tuning fork, place vibrating tuning fork at Mastoid process and tell patient to say when they can no longer hear any noise. Quickly place the vibrating part of tuning fork 1-2 cm from auditory canal. Ask patient again the same thing.3. Weber Test. Place tuning fork at middle of forehead and ask patient to say which ear hear the noise better. Normal finding is when noise are equally distributed to both ears.

9th Cranial Nerve1. Open mouth. Inspect the uvula. Normal uvula should not deviate from midline.

10th Cranial Nerve ( Vagus Nerve)1. Gag reflex

11th Cranial Nerve 1. Ask the patient to shrug shoulder. Push down on the shoulder while telling them to resist you.2. Ask the patient to look to Right side. Push patient face in opposite direction while telling them to resist your movement.

12th Cranial Nerve1. Ask patient to push tongue against cheek. Push the tongue inwards while telling the patient to resist your movement.

Upper limb Examination1. Introduce yourself and examiner

2. Explain intention to patient and ask for consent

3. Positioning of patient can be propped up 45 degrees or sitting

4. Look a. Expose both upper limbs.b. Look for any deformity, muscle wasting and circulation.c. Compare both upper limbs in length.d. Examine for Pronator Drift. Ask patient to lift both limbs in front of body and close one eye.

5. Motor Power Grading of Upper Limba. Examine Tone of upper limbb. Estimate muscle power grading of Shoulder joint i. Push up and down on shoulder with resistance (chicken wing position)ii. Pull front and back on shoulder with resistancec. Estimate muscle power grading for Elbow Jointi. Push against extensionii. Pull against flexiond. Estimate muscle power grading for Wrist Jointi. Push up and down on wrist with resistancee. Estimate Muscle power grading for Metacarpo-Phalangeal Jointi. Push up and down on MCP Joint with resistancef. Estimate Muscle power grading for Fingersi. Enclosed Fingersii. Ask patient to make a circle with thumb and index finger. Try to break that circle.iii. Paper holdingg. Estimate gripping power of hand. Ask patient to grip your finger and dont let go.

6. Sensation of Upper Limba. Test sensation of patient using cotton wool to areas of dermatome of upper limb . First test it prick to centre of chest or distal end of limb.b. Test for prioprioception or Vibration sense using 128 Hz tuning fork. Apply the vibrating tuning fork at bony prominences.

7. Reflexes of Upper Limb a. Biceps Tendon reflexb. Triceps Tendon Reflexc. Supinator Tendon Reflex

8. Assessing coordinationa. Ask patient to move fingers as if playing piano.b. Ask patient to rub both hands together.c. Ask patient to tap hands on another hand then shift between palm and dorsum of hand. Try to do it as fast as patient can.d. Finger-Nose Test. Ask patient to touch their nose then touch your finger alternately. Shift position of your finger continuously.

Lower limb Examination1. Introduce yourself and examiner

2. Explain intention to patient and ask for consent

3. Positioning of patient can be propped up 45 degrees or sitting

4. Ask patient to walk normally to a distance. Assess the Gait.5. Ask patient to walk back as if walking on a very small bridge.6. Ask patient to stand in one spot then close your eyes. Observe for swinging movement. Later pull back on patient looking for normal proprioception reflex.

7. Look a. Expose both upper limbb. Look for any deformityc. Compare both limb in length

8. Motor Power Grading of Upper Limba. Examine Tone of upper limbb. Assess Clonus. Pull on the heel. Normal would yield no response.c. Estimate muscle power grading of Hip jointi. Push and pull on hip joint with resistanced. Estimate muscle power grading for Knee Jointi. Push up against extensionii. Pull down against flexione. Estimate muscle power grading for Ankle Jointi. Push down and up on Ankle with resistanceii. Push in and out during eversion and inversion respectively on Ankle joint f. Examine the Knee-Shin Test

9. Sensation of Upper Limba. Test sensation of patient using cotton wool to areas of dermatome of upper limb b. Test for prioprioception or Vibration sense using 128 Hz tuning fork. Apply the vibrating tuning fork at bony prominences.

10. Reflexes of Upper Limb a. Patella Tendon reflexb. Ankle Jerkc. Babinski Sign

Thyroid Examination

1. Introduce yourself and examiner

2. Explain intention to patient and ask for consent

3. Positioning of patient in sitting position

4. Inspect the neck for:a. Abnormal enlargement in the neckb. Lymph nodes enlargementc. Visible pulsationd. Surgical Scarse. Ask the patient to take a sip of water but tell them not to swallow until you say so. Inspect the neck while patient is swallowing the sip of water.

5. Palpate the neck for:a. Trachea deviationb. Thyroid border ( from behind)c. Lymph nodes of the head and neck (from behind)d. Ask the patient to take a sip of water but tell them not to swallow until you say so. Palpate the thyroid border while patient is swallowing.

6. Percuss superior part of Sternum.

7. Auscultate for Thyroid Bruit using Bell.

8. Put both hand in front while placing paper on top of them. Check for tremors.9. Examine hand for:a. Warmthb. Excessive sweatingc. Radial Pulse10. Ask patient to follow motion of pen moving in H direction.11. Do Eye Lid Lag test.12. Ask patient to shrug shoulder while telling them to resist you pushing it down.13. Check Knee Jerk Reflex of Patient.14. Ask the patient to squat then stand up.

Abdominal Examination1. Introduce yourself and examiner

2. Explain intention to patient and ask for consent

3. Positioning of patient must be lying flat on bed

4. Inspection of abdomena. Abdominal distensionb. Scars / Striaec. Umbilicus (inverted/everted)d. Caput Medusae (Dilated veins)e. Peristaltic wave

5. Superficial Palpation ( 9 regions)

6. Deep Palpation ( 4 quadrant or 9 regions)

7. Liver a. Palpationi. Palpate Liver from Right Iliac Fossa to Right Costal Marginii. Ask the patient to breathe through mouthiii. Palpate when patient is inhalingiv. Do not move hand until completed 2 breathe cycle (inhale & exhale is 1 breath cycle)v. Try to feel for mass with border of Index fingervi. If mass palpable, comment on:1. Number (one or multiple)2. Site (regions of abdomen)3. Size (ex: 5 cm by 5cm)4. Shape (Irregular, circular)5. Surface (Smooth, rubbery) 6. Edge (Visible and palpable)7. Consistency (hard, firm, soft)8. Tenderness9. Fixity to skin, fat or muscle10. Mobility11. Reducibility12. Temperature13. Translucency & Pulsatility*Note: Try to get over the mass under right costal margin, if cant, the mass is definitely Liver

b. Percussioni. Percuss Liver from Right Iliac Fossa ORPercuss Liver from Sternal Angle

ii. Measure Liver Span (Normal Liver is 7-12 cm)

8. Spleena. Palpationi. Palpate Spleen from Right Iliac Fossa (if mass present) ORPalpate Spleen from Umbilicus (if no mass present)ii. Ask patient to breathe through mouthiii. Palpate until reaching 9,10, 11 left costal marginiv. If Spleen not palpable then, do not move hand, ask the patient to move to his Right sidev. Palpate Spleen with right hand while left hand pulling left costal margin from posterior aspectb. Percussioni. Percuss Traube SpaceDull percussion indicate Spleen

9. Kidney Ballota. Bimanual Technique

10. Shifting Dullness and Fluid Thrill

11. Abdominal Auscultationa. Auscultate right or left side of umbilicus from bowel soundb. Auscultate for Kidney Bruit

12. End the examination by doing External Genitalia, Groin Hernia Examination and Per Rectal

Cardiovascular Examination1. Introduce yourself and examiner

2. Explain intention to patient and ask for consent, ask to take off shirt

3. Propped the patient 45 degrees

4. Inspection of Chest and Precordiuma. Median Sternotomy scar and leg scarsb. Pacemakerc. Visible palpitationd. Jugular Venous Pressure (may be done in general examination)e. Chest deformityf. Dilated veins

5. Palpation of Chesta. Identify Apex beat (Supine, Left Lateral if cant find Apex beat)b. Show the position of Apex beatc. Parasternal heaved. Pulmonary heavee. Aortic heave

6. Auscultation of hearta. Auscultate Mitral and Pulmonary areas with Diaphragm, thumb at carotid arteryb. Running commentary on Mitral and Pulmonary areas1st and 2nd heart sound heard with normal intensity

c. Auscultate Mitral area until axilla with Diaphragm, thumb at carotid arteryd. Running commentary on Mitral area until axilla No pansystolic murmur radiating to axilla suggesting mitral regurgitation

e. Auscultate Mitral area with Bell in Left Lateral Position, thumb at carotid arteryf. Running Commentary on Mitral Area with BellNo rumbling of mid-diastolic murmur suggesting of Mitral Stenosis

g. Auscultate Tricuspid area with Diaphragm while asking patient to inhale and hold breath, thumb at carotid arteryh. Running commentary on Tricuspid area with DiaphragmNo pansystolic murmur intensifying with respiration suggesting of Tricuspid Regurgitation

i. Auscultate Pulmonary and Aortic areas with diaphragm, thumb at carotid arteryj. Auscultate neck at Carotid artery area, left and right with Bellk. Running commentary on Carotid artery areaNo ejection systolic murmur radiating to carotid arteries suggesting of Aortic Stenosis

l. Auscultate Lower Sternal border with diaphragm, thumb at carotid artery while asking patient, bend 45 degrees forward, inspire and expire full breath and hold for a whilem. Running commentary on Lower sternal border with DiaphragmNo blowing early diastolic murmur suggesting of Aortic Regurgitation

Respiratory Examination1. Introduce yourself and examiner

2. Explain intention to patient and ask for consentAsk patient to take off shirt

3. Positioning of patient can be propped up 45 degrees or sitting4. Count Respiratory Rate for 15 seconds

5. Inspect chesta. Shape of chest =the chest shape is ellipticalBarrel shape chestTransverse diameter of chest is greater than AP diameterb. Chest symmetryc. Scarsd. Nodulese. Dilated veinf. Chest wall move with respirationg. No respiratory distress

6. Palpation of chesta. Examine TracheaTrachea is in midline & not deviated=could you please look straight &head still.it will be quite uncomfortable,please bear with me

b. Identify Apex beatapex beat is felt below the nipple and not displaced

c. Identify breathing movement by placing both palm at upper chestThe chest movement is symmetry

d. Identify chest expansion by placing both palm at lower chestThe chest expansion is 5cm and symmetry

e. Test for Tactile fremitus. Place medial part of both hands at intercostals space. Ask patient to say 999.tactile fremitus is equal on both side

7. Percussion of Chesta. Percuss at area above clavicleb. Percuss at claviclec. Percuss at area below clavicle. 2nd intercostals space downwards. there is resonance upon percussion on both side of the chest

8. Auscultation of Lungs (Only with Bell)a. Auscultate upper, middle and lower part of chest alternating between right and left. Begin at normal side first.b. Compare of loudness of breath sounds between right and leftc. Listen for any abnormal soundsVestibular sound are heard with normal intensitythere is normal vestibular breath sound &no added breath sound including bronchi breath soundEg:rhonchi crepitation

d. Assess vocal resonance by auscultating while asking patient to say nine, nine, nine vocal resonance are normal on both side