Systemic Examination

Cardiovascular System:

1. Pulse:

• a. Rate
• b. Rhythm
• c. Volume
• d. Character
• e. Condition of the vessel wall
• f. Radio-femoral delay
• g. Radio-radial delay

2. Neck veins (JVP), hepatojugular reflux (if needed)

3. Blood Pressure.

Precordium 

(Sequentially—Inspection, Palpation, Percussion and Auscultation)

A.Inspection:

1. Any deformity of the chest

2. Visible cardiac impulse

3. Other impulses (epigastric, suprasternal, supraclavicular or other impulse)

4. Any scar mark (midsternal or thoracotomy)

5. Pacemaker or cardioverter defibrillator box (mention, if any).

B. Palpation:

1. Apex beat:

• a.Site (that intercostal space)
• b. Distance from midline (in cm)
• c. Nature (normal, tapping, heaving, thrusting, diffuse or double apex).

2. Thrill:

• a. Site (that intercostal space, apical or basal or other site)
• b. Nature (systolic or diastolic or both).

3. Left parasternal heave

4. Palpable P2

5. E pigastric pulsation.

C.Percussion:

Area of cardiac dullness (Not a routine. However, it is important to diagnose pericardial effusion,

where area of cardiac dullness is increased and in emphysema, where area of cardiac dullness is

obliterated).

Auscultation:

1. 1st and 2nd heart sounds

2. Other heart sounds (3rd and 4th)

3. Murmur: 5

• a. Site
• b. Nature (systolic, diastolic or both)
• c. Radiation (towards left axilla or neck)
• d. Relation with respiration, posture (in left lateral position with breathing hold after expiration
• or bending forward with breathing hold after expiration)
• e. Grading (1, 2, 3...)

4. Added sounds (pericardial rub, opening snap, ejection click, metallic plop)

5. Auscultate back of the chest (to see bilateral basal crepitations in pulmonary edema).

1. Inspection:

• a. Shape of the chest
• b. Deformity (flattening of the chest, kyphosis, scoliosis, etc.)
• c. Drooping of the shoulder
• d. Movement of the chest
• e. Intercostal space (indrawing or fullness)
• f. Visible impulse
• g. Visible or engorged vein (if present, see flow)
• h. Others (scar marks, suprasternal and supraclavicular excavation, prominent accessory muscles,gynecomastia, needle puncture mark, tattooing, radiation mark).

2. Palpation:

• a. Position of trachea
• b. Apex beat
• c. Chest expansion
• d. Chest movement (symmetrical or asymmetrical)
• e. Tracheal tug
• f. Cricosternal distance
• g. Vocal fremitus
• h. Local rib tenderness.

3. Percussion:

• a. Percussion note
• b. Liver dullness
• c. Area of cardiac dullness (not done routinely, only if emphysema is suspected).

4. Auscultation:

• a. Breath sound
• b. Vocal resonance
• c. Added sounds (rhonchi, crepitations, pleural rub, post-tussive crepitations).

Gastrointestinal System:

(Always start examining from mouth and pharynx, then abdomen).

Mouth and pharynx:

Upper GIT: 

• 1. Lips
• 2. Teeth and gum
• 3. Oral mucous membrane
• 4. Tongue
• 5. Palate and movement of soft palate
• 6. Tonsils
• 7. Fauces.

Abdomen (Examine Systematically—Inspection, Palpation, Percussion and Auscultation)

A.Inspection: 

• 1. Shape of the abdomen
  
• 2. Flanks
• 3. Movement with respiration
• 4. Visible peristalsis
• 5. Visible pulsation
• 6. Umbilicus
• 7. Engorged veins (if present, see the direction of flow both above and below the umbilicus)
• 8. Striae
• 9. Any scar mark
• 10. Pigmentation
• 11. Swelling or mass (tell the site)
• 12. Campbell de Morgan’s spot
• 13. Groin, pubic hair and genitalia (with permission of the patient)
• 14. Cough impulse.

B.Palpation:

• 1. Superficial palpation and local temperature
  
• 2. Deep palpation (tenderness, rigidity, mass)

A. Liver:

• a. Size (in cm)
• b. Margin
• c. Surface
• d. Tenderness
• e. Consistency
• f. Upper border of the liver dullness
• g. Auscultation (to see bruit or rub).

B. Spleen (size in cm)

• a. Size (in cm)
• b. Margin
• c. Surface
• d. Tenderness
• e. Consistenc
• spleenic angle 
• spleenic rub 

C. Kidneys

D. Gallbladder (if palpable, mention the size, tenderness, consistency, surface, margin) 

E. Fluid thrill (if ascites is suspected)

F. Any mass (if present, first see whether it is intra-abdominal or extra-abdominal). Then see the

following points:

• a. Site
• c. Size
• d. Shape
• e. Surface
• f. Consistency
• g. Tenderness
• h. Mobility

Others: (whether pulsatile, feel for get above the swelling).

• a. Para-aortic lymph nodes
• b. Hernial orifice
• c. Testis (with permission of the patient)
• d. Per-rectal examination (though it is a part of physical examination, usually it is never done in an examination setting).

3.Percussion:

• A. Liver dullnessb.
• b. Splenic dullness
• c. Shifting dullness (if ascites is suspected or present).

4.Auscultation:

• a. Bowel sounds
• b. Hepatic bruit or rub
• c.Renal bruit
• d. Bruit of aortic aneurysm
• e. Splenic rub

Nervous System:

Higher Psychic Functions (HPF):

• 1. Appearance
• 2. Behavior
• 3. Consciousness
• 4. Memory
• 5. Intelligence
• 6. Orientation of time, space and person
• 7. Emotional state
• 8. Hallucination
• 9. Delusion
• 10. Speech.

Motor functions:

• 1. Bulk of the muscle
• 2.Tone of the muscle
• 3. Power of the muscle
• 4. Fasciculation
• 5. Involuntary movement (mention the type, e.g. tremor, chorea, athetosis, hemiballismus, etc.)
• 6. Coordination test:
• 7. Finger nose test
• 8. Heel shin test
• 9. Romberg’s sign
• 10. Gait and posture.

Reflexes (superficial and deep)

Superficial reflexes:

• 1. Plantar reflex
  
• 2. Abdominal reflex
• 3. Corneal reflex
• 4. Palatal reflex
• 5. Cremasteric reflex.

Deep reflex: 

• 1. Biceps 
• 2. Triceps 
• 3.Knee jerk 
• 4.Ankle jerk

Clonus:

• 1. Ankle
• 2. Patellar.

Others: Gordon’s sign and Oppenheim’s sign (both in leg) and Hoffman’s sign.

Sensory functions:

• 1. Pain
• 2. Touch
• 3. Temperature
• 4. Position sense
• 5. Sense of vibration
• 6. Tactile localization
• 7. Tactile discrimination
• 8. Recognition of size and shape, weight and form of object
• 9. Romberg’s sign.

Signs of meningeal irritation:

• 1. Neck rigidity
• 2. Kernig’s sign
• 3. Brudzinski’s sign.

Examination of cranial nerves:

1. Olfactory nerve (sense of smell or hallucination of smell)

2. Optic nerve: 9

• a. Visual acuity
• b. Field of vision
• c. Color vision
• d. Light reflex (direct and consensual)
• e. Fundoscopy (see last)

3.. Oculomotor, trochlear and abducent nerve:

• a. Ptosis
• b. Squint
• c. Ocular movements
• d. Diplopia
• e. Nystagmus
• f. Pupils (size, shape, light reflex)
• g. Accommodation reflex.

5. Trigeminal nerve:

• a. Motor
• b. Sensory
• c. Corneal reflex.

7. Facial nerve (both sensory and motor)

8. Vestibulocochlear nerve: (ask about any hearing abnormality, vertigo or dizziness or giddiness).

• a. Look at the external auditory meatus (for any wax, rash)b. Rinne’s test and Weber’s test.

9. Glossopharyngeal and vagus nerve:

• a. Look for nasal voice, nasal regurgitation, hoarseness of voice, bovine cough
• b. Movement of palate
• c. Gag reflex
• d. Taste sensation (in posterior 1/3 of tongue).

11. Accessory nerve (spinal part): see the action of sternomastoid and trapezius

12. Hypoglossal nerve (look at the tongue and see):

• a. Wasting
• b. Fasciculation
• c. Movement of tongue.

Locomotor System:

Bones:

• A. Shape
• b. Swelling
• c. Tenderness
• d. Deformity
• e. Sinus.

Joints:

A.Inspection:

• 1. Swelling, local muscle wasting (unilateral or bilateral), any deformity
• 2. Redness
• 3. Skin change (psoriatic patch).

B. Palpation:

• 1. Temperature
• 2. Tenderness
• 3. Dry or moist
• 4. Fluctuation
• 5. Crepitus.

C. Movement:

• a. Observe the range of active movement while gently palpating the joint for abnormal clicks or crepitus
• b. If restricted, gently perform passive movement and check for crepitus
• c. Perform passive stretching maneuvers to detect joint instability or ligament injury (when appropriate).

D.Spine:

• a. Look for any kyphosis, scoliosis, lordosis
  
• b. Any swelling of vertebral column (local swelling, Gibbus)
• c. Tenderness of vertebral column
• d. Movement of vertebrae (perform Schober’s test, if appropriate).

Examination of nerve root compression:

• a. Straight leg raise: With the patient lying supine, flex the hip with legs extended. Normally, up to 90° hip flexion is possible. But when there is root compression, it will be restricted (patient will

feel pain in the lumbar region)

• b.Lasegue’s sign: With the knee flexed, flex the hip up to 90°. Now gently extend the knee. The patient will feel pain.

Sacroiliac joint examination:

• a. With the patient in prone position, apply firm pressure over the sacrum with the hand With the patient lying on his side, press down on the pelvic brim.
• b.Others (according to suspicion of cause, examine the individual joint accordingly. For example, in case of rheumatoid arthritis, examine the joints of hands, wrist, feet, etc.).

Genitourinary System:

Inspection:

• a. Scar (nephrectomy)
• b. Scar of transplanted kidney in the right or left iliac fossa
• c. Visible mass (including mass of transplanted kidney)
• d. Small scar of dialysis
• e. Abdominal distension
• f. Inspection of scrotum for mass or swelling or edema and penis (with permission of the patient).

Palpation:

• a. Renal angle
• b. Kidneys
• c. Urinary bladder.

Percussion:

• a. Bladder.

Auscultation: 

• a. Renal bruit.

After completing all of the above, proceed as follows:

Bedside investigations (if applicable):

• a. Urine for sugar (If diabetes mellitus)
• b. Urine for albumin (If nephrotic syndrome)