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Osce-Summary-Systems
Medicine (A100)
Queen Mary University of London
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Gastrointestinal System
Presenting Complaints
- Appetite changes – anorexia,
hyperphagia - Weight loss (malabsorption, malignancy, diabetes, thyroid, IBD, eating disorder, depression)
- Weight gain
- Dysphagia (oesophagus, nodes,
goitre)
- Indigestion / heartburn – reflux
- Nausea / vomiting – onset, frequency, contents (infection,
inflammation, obstruction) - Haematemesis – frank or coffee ground (ulcer, varices, Mallory Weiss tear, malignancy) - Abdominal pain – colicky (biliary,
GI), severe (peritonitis)
- Jaundice (haemolysis, liver, biliary)
- Change in bowel motions – volume, frequency, consistency, colour, tenesmus, blood
Patient History
- PMH – abdominal surgery
- Family – colorectal cancer,
haemochromatosis, IBD, ulcers - Medications – NSAIDs (ulcers), metformin (diarrhoea), opioids (constipation), antibiotics (bowel changes), bisphosponates
(oesophagitis), SSRIs (nausea) - Social – smoking, alcohol, IV drugs, travel, vaccinations, birth country
Examination Red Flags
- Sudden onset of pain
- Increasing severity of pain
- Syncope / pre-syncope
- Vomiting
- Haematemesis
- Abdominal distension
- Pallor & sweating
- Tachycardia & atrial fibrillation
- Hypotension
- Fever
- Rebound tenderness, guarding, rigidity
- Oliguria / anuria
- Positive pregnancy test
Patient lying supine with one pillow
Inspection - General – age, gender, comfort/distress - Mental state – alert, confused, coma - Body habitus – weight, wasting, oedema, hydration - Colour – pallor, jaundice, haemochromatosis
Vital signs – Temp, HR, BP, RR, O 2
- Hands – leukonychia (↓albumin), koilonychia (spooning, ↓iron), clubbing (cirrhosis, IBD), pallor in palmar creases, palmar erythema (oestrogen), wasting, dupuytren’s contracture
Hepatic flap
- Arms/shoulders – spider naevi (oestrogen), bruising, wasting, scratch marks (?obs jaundice)
- Eyes – xanthelasma, icterus, conjunctival pallor, uveitis, Kayser- Fleisher rings (Wilson’s disease)
- Salivary glands – parotid & submandibular glands & ducts
- Lips – hydration, agular cheilitis, ulceration, pigmentation, telangiectasia
- Mouth – foetor, stomatitis, candidiasis/leukoplakia (L won’t scrape off, C will), gums, glossitis, central cyanosis, teeth
Lymph nodes – cervical & axillary
- Chest – spider naevi (oestrogen), loss of hair distribution, gynaecomastia (oestrogen)
- Abdomen – scars, striae, bruising, stoma, distension (8 Fs), masses, veins, peristalsis, pulsations
Palpation
- Superficial – tenderness, masses
- Deep – masses, guarding, rigidity, rebound tenderness, McBurney’s point,Rosving’s sign
- Liver & gallbladder (Murphy’s sign)
- Spleen
- Kidneys
- Abdominal aorta
Percussion - Liver - Bladder - Shifting dullness
Auscultation - Bowel sounds - Epigastric bruits - Renal bruits
Other - DRE – inspection (fissure, fistula, tags, blood, rash, ulcer, mucus); palpation (wall consistency; prostate size, surface, tenderness) - Urinalysis - Pregnancy test - Bowel chart
Respiratory System
Presenting Complaints
- Cough – nature, onset, wet (viral, LRTI, COPD, bronchiectasis), dry (viral, asthma, GI reflux, restrictive, ACEi), night (asthma LVF, post-nasal drip), morning (smoking), whooping, bovine (laryngeal nerve),
croup - Sputum – colour, volume, type (purulent, mucoid), blood - Haemoptysis – acute (malignancy), chronic (bronchiectasis), pink frothy
(pulmonary oedema) - Dyspnoea / shortness of breath – onset, nocturnal (asthma/LVF), on waking (COPD), duration, relieving
factors, severity, exertional change - Wheeze (high pitch) – when, ∆
with coughing, exercise (asthma) - Stridor (inspiratory rasp) – onset
(respiratory obstruction) - Chest pain – nature, intensity, exertional change (chest wall, pleura or mediastinal causes) - Sleep apnoea – snoring or waking
up dyspnoeic (airway obstruction) - Voice change - dysphonia, aphonia
Patient History
PMH – hay fever, eczema, HIV
- Family – atopy, CF, α1-antitrypsin, TB asbestos, same symptoms
Occupation – asbestos, chemicals
Meds – ACEi, β-blockers, NSAIDs
- Social – smoking, travel, pets
Examination Red Flags
- Haemoptysis – URTI, LRTI, bronchiectasis, bronchial carcinoma
- Sudden onset dyspnoea –? PE or pneumothorax
- Sudden onset stridor – anaphylaxis, inhaled foreign body, acute epiglotitis (may block airway), gas inhalation
Patient sitting upright, general inspection then entire back exam → entire front exam
Inspection - General – age, gender, body habitus, oxygen equipment, posture (?dyspnoeic), respiratory distress, cough, sputum - Hands – clubbing (pus in lungs), peripheral cyanosis, wasting (brachial plexus), pallor in creases
Asterixis (CO 2 retention)
- Radial pulse, respiratory rate, breathing (Cheyne-Stokes = alternating, Kussmaul = shallow)
- Eyes – conjunctival pallor, Horner syndrome (miosis, partial ptosis, lower lid elevation, enopthalmos, anhydrosis)
- Nose (straight in) – polyps, enlarged turbinates, displaced septum
- Mouth – central cyanosis, erythema, tonsils, exudates, candidiasis
Voice
- Sinuses – frontal, ethmoidal, maxillary
Lymph nodes – cervical & axillary
Trachea – cartilage, tug, deviation
- Chest – shape, symmetry, scars, tattoos, scoliosis, pigeon chest, funnel chest, barrel chest, breathing
Palpation - Back – chest expansion, tenderness, spring chest (front, back, sides), tactile fremitus - Front – tenderness, tactile fremitus, apex beat (lying)
Percussion - Lungs (remember dullness over liver & heart)
Auscultation - Breath sounds - vesicular (normal), bronchial (hollow, consolidation) - Added sounds – stridor (inspiratory, upper airway obstruction) wheezing (narrowed airways), crackles (fine=fibrosis, medium=pulmonary oedema, coarse=pneumonia/COPD), pleural rub (pneumonia, infarction) - Vocal resonance
Other - Temperature - Pulse oximetry - Spirometry – FVC, FEV 1 , PEFR
Musculoskeletal System
Presenting Complaints
- Pain – site, symmetry, radiation, mono/polyarticular, acute/chronic, bone, nociceptive/neuropathic, inflammatory/non-
inflammatory - Morning joint stiffness – brief & worse w/ movement (osteoarthritis) vs. prolonged & improved with exercise (rheumatoid arthritis)
- Muscle stiffness (polymyalgia rheumatica)
- Joint abnormalities - locking (loose body, meniscal tear), instability (ligamentous stretching /
rupture), triggering (tendon thickening) - Swelling – location, shape, size, consistency,
surface texture, mobility, tenderness, pulsation
Tenderness (inflamm., infection)
- Skin changes – erythema, shiny skin, ulceration, rash (psoriasis, SLE)
Loss of function
- Other symptoms – fever, weight loss, bowel symptoms, urethritis, uveitis, conjunctivitis, dry
mouth
- Simple backache – mechanical pain in 20- 55 y.
- Nerve root pain – unilateral leg pain, motor /
sensory change - Cauda equina syndrome – urinary/ faecal incontinence, perineal anaesthesia, leg weakness
Patient History
- PMH – joint or back problems, IBD, anterior uveitis,
urethritis, malignancy
Family – RA, OA, gout, osteoporosis
Meds – analgesics, NSAIDs
- Loss of function – brushing teeth (elbow), buttoning shirt (wrist, hands, walking (lower limb)
Red Flags
Regular night sweats
Unintentional weight loss
Constant (day & night) pain
>50 or <20 years old
Significant trauma
History of cancer or osteoporosis
IV drug user
Immunosuppressed
Knee Examination
Look - General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) - Rashes, scars, erythema, swelling, gluteal folds, popliteal folds, bursae (supra-, infra-, pre-patellar)
- Muscles (wasting, spasm) – esp. quadriceps
- Deformities – genu valgum (knock-knee), genu varum (bow-leg), genu recurvatum (back-knee)
- Gait & posture – leg length, 10 steps, sitting, squat
Feel - Skin temperature
- Quadriceps - tenderness, wasting, spasm
- Bursae – supra-/infra-/pre-patellar, popliteal
- Bony landmarks – joint line, femoral condyles & epicondyles, fibular head, Gertie’s tubercle, patella
- Ligaments & tendons – M & L collateral ligaments, biceps, semimembranosus, semitendinosus tendons
- Patella tap – slide hand down thigh to upper edge of patella, tap on patella (clunk → effusion)
- Bulge test – stroke hand medial, up & around to lateral patella (bulge in medial patella → effusion)
Move Supine, stabilise pelvis with other hand Active → passive (crepitus) → resisted - Flexion (closing), extension (opening), internal rotation, external rotation
Special Tests - Patella apprehension (patella dislocation) – apply laterally directed force on medial patella with thumbs (feels like patella will dislocate) - Collateral ligament stress test – supine (once 20° once straight); brace medial knee & apply varus force (medial collateral ligament), brace lateral knee & apply valgus force (lateral collateral ligament) - Anterior & posterior draw test (start by looking for posterior draw) – sit on patient’s foot, both hands around upper tibia, thumbs over tibial tuberosity, pull forwards (anterior cruciate lig), push backwards (posterior cruciate lig) (laxity/pain) - Lachman’s Test (anterior cruciate ligament) – supine, 15° of flexion, examiner’s knee under their knee, stabilise femur & apply pressure to posterior upper tibia (laxity/pain) - McMurray’s test – valgus force on lateral knee, flex to 90°, hold sole of foot, rotate leg internally & extend knee (lateral meniscus); varus force on medial knee, flex to 90°, hold sole of foot, rotate leg externally & extend knee (lateral meniscus) (pain) - Apply’s grind test – prone, knee flexed to 90°; compress knee while internally & externally rotating (medial & lateral menisci), pull on knee while internally & externally rotating (collateral ligaments)
Hip Examination
Look - General – age, gender, body habitus, comfort,
assistance devices (stick, brace, sling, cast) - Deformities (true/false scoliosis), swelling, scars,
gluteal folds, popliteal creases, ASIS level - Muscles (gluteus, adductors, iliopsoas, quads) – wasting, spasm - Gait & posture – walking 10 paces, sitting, squatting
Feel Supine
- Swellings (hernia)
- Landmarks – greater trochanter of femur, ASIS,
PSIS, ischial tuberosity, pubic symphysis
- Muscles – gluteus, adductors, iliopsoas, quadriceps
- Leg length – true (ASIS → medial malleolus) vs. apparent (umbilicus → medial malleolus)
Move Supine, stabilise pelvis with other hand Active → passive → resisted
- Flexion (anterior), extension (posterior, prone), adduction (medial), abduction (lateral), internal rotation, external rotation
Special Tests
- Thomas test (fixed flexion hip deformity) – patient supine, bring knee a to chest (leg b raises off ground → deformity in leg b)
- Trendelenberg test (glut med weakness, short femoral neck, unstable hip) – hold patient’s hands, ask them to stand on foot a and lift foot b off ground (hip b falls)
Ankle & Foot Examination
Look - General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) - Footwear – abnormal, asymmetric, poor fit, orthotic - Ankles – swelling, bruising, deformities, tibialis posterior, FDL, FHL - Feet – posture, arch, skin changes, colour, swelling, rashes, ulcers, infection ,calluses, plantar surface - Toes – alignment (straight, hammer, claw, mallet), nail changes, swelling, hallux valgus (bunions)
Feel
- Temperature
- Ankle – distal 1/3 of fibula, malleoli, tendons (peroneal, tibialis posterior), joint line, PT pulse
- Foot – navicular bone, calcaneus (medial tubercle), MTP & IP joints, metatarsal heads, tendons (TA, FHL, FDL), DP pulse
Move Active → passive → resisted - Tibiotalar joint – dorsiflexion, plantar flexion
- Subtalar joint – inversion, eversion
- Chopard’s joint – toe dorsiflexion & plantar flexion
Special Tests - Thompson’s test (calcaneal tendon) – prone, foot over edge of bed, squeeze calf muscles (no passive plantar flexion)
Spinal Examination
Look - General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast), gait, cushingoid facies
- Skin – scars, rashes, ulcers
- Muscles – bulk, wasting, spasm
- Joints – swelling, deformities (scoliosis, thoracic kyphosis, loss of lumbar lordosis)
- Foot posture
Feel Supine - Muscles (wasting / spasm) – levator scapulae, trapezius, semispinalis capitus, rhomboids - Bones & ligaments – costochondral & sternochondral joints Prone - Muscles (wasting / spasm) – SCM, scalenes, levator scapulae, erector spinae, gluteal, hamstrings - Bones & ligaments – spinous processes, interspinous ligaments, cervical facet joints, costovertebral articulation, sacroiliac joint
Move - Cervical – flexion (down), extension (up), L / R lateral flexion (tilt), L / R rotation (turn), extension + rotation - Thoracic & lumbar – extension (back), flexion (forward), L / R rotation (sitting, turn), L / R lateral flexion (hand down thigh)
Special Tests - Femoral nerve stretch (L3 radiculopathy) – prone, flex knee with hand on hamstring (pain in femoral nerve distribution) - Straight leg raise (sciatic nerve) – supine, flex hip with leg straight (pain in back of leg from 30-70°)
Neurological System
Presenting Complaints
- Headache – onset, severity, location, aggravating factors,
relieving factors - Vision changes – blurring, diplopia, flashes - Hearing/balance changes –
vertigo, tinnitus, hearing loss - Weakness in face, arms, legs – time course, generalised / specific, unilateral / bilateral, proximal /
distal, sudden (vascular)
- Burning, tingling, numbness
- Fits, faints, mood changes – aura, LOC, tongue biting
Patient History
- PMH – neurological events, HTN,
DM, AF, CV risk factors, pregnancy - Family – neurofibromatosis, tuberose sclerosis, Hungington’s
disease, Friedrich’s ataxia, DMD
- Medications
- Social – toxin exposure, alcohol, smoking, level of function
Grading Guide
- Tone – flaccid, decreased, normal,
increased - Power - 0 (no contraction), 1 (flicker), 2 (w/o gravity), 3 (vs. gravity), 4 (mild resistance),
5 (normal) - Reflexes – 0 (absent), + (reduced), ++ (normal), +++ (~increased), ++++ (greatly increased
Cranial Nerve Examination
Patient sitting on edge of bed - Inspection – craniotomy scars, neurofibromas, facial asymmetry, ptosis (Horner’s, oculomotor lesion, myasthenia gravis), exophthalmos, enothalmos, eye deviation, pupils - Olfactory (CN I) – ask patient re: smell, inspect nares, present smells - Optic (CN II) – visual acuity, visual fields (peripheral & central), fundoscopy (disc, retina) - Eye reflexes (CN II, III) – inspection (shape, size, ptosis), direct response (ipsilateral), consensual response (contralateral), swinging light test (partial), accommodation - Eye movement (CN III, IV, VI) – modified H, asking about diplopia - Trigeminal (V) – sensation (light touch, pain), corneal reflex (opthalmicfacial), muscles of mastication & jaw jerk (mandibular) - Facial (VII) – raise eyebrows, close eyes, smile, puff out cheeks - Vestibulocochlear (CN VIII) – otoscopt, auditory acuity (rub fingers), Weber’s test (forehead), Rinne’s test (mastoidear) - Throat (IX, X) – say ahh, gag reflex, hoarseness, cough - Hypoglossal (XII) – protrude tongue, deviate each side, push vs. cheek - Accessory (XI) – torticollis (tilted head), turn head vs. resistance (SCM), shrug vs. resistance (traps)
Upper Limb Neuro Examination
Patient sitting on edge of bed
Inspection - Posture ( decerebrate), nerve signs (wrist drop, claw hand, hand of benediction), muscles ( wasting, fasciculations), tremor at rest, abnormal movements, skin change - Positional drift – (arms out, eyes closed) - down & pronation (weakness), up & pronation (cerebellar disease), all directions (loss of proprioception)
Motor - Tone – active movement, passive movement (elbow & wrist), grade (flaccid, , normal, )
- Power – movement vs. resistance
- Reflexes – biceps (C5, C6), triceps (C7, C8), supinator (C5, C6)
- Coordination – finger-nose test (their nose examiner’s finger), rapid alternative movement (quickly turning hand over)
Sensory
- Pain – dermatomes
- Vibration (128Hz) – pulp of middle finger, ulnar styloid process, olecranon, clavicle etc.
- Proprioception – distal IP joint
- Soft touch - dermatomes
Upper Limb Neuro Examination
Patient supine
Inspection
- Gait - 10 steps
- Walking on heels (L4/L5), toes (L1)
- Tandem walking – R heel in front of L toe etc. (cerebellar lesion)
- Proximal myopathy – sit & rise without assistance, Trendelenberg test (stand on one foot, supported)
- Proprioception – stand, feet together, eyes open (station), closed (Romberg test)
- General inspection – skin, muscles (wasting, fasciculations)
Motor - Tone – active movement, passive movement - Clonus – push on superior patella, rotate then dorsiflex ankle (UMN)
- Power – movement vs. resistance
- Reflexes – knee ( L3, L4), ankle ( S1, S2), Babinski ( L5, S1, S2)
- Coordination – drag heel down shin & back up; toe-finger test (bed examiner’s finger), rapid alternating movement (tap foot against palm of hand quickly)
Sensory - Pain – dermatomes - Vibration (128Hz) – 1st metacarpal head, malleoli, patellae, ASIS
- Proprioception – distal IP joint
- Soft touch - dermatomes
Urinary System
Presenting Complaints
Dysuria – infection or inflammation
Frequency – infection, inflammation, outlet obstruction, decreased capacity
- Polyuria – excess water intake, diabetes mellitus, diabetes insipidus, kidney disease
Nocturia
Urgency
Hesitancy / dribbling
Incontinence – urge / stress incontinence
- Weak stream – obstruction
Change in urine colour – haematuria (infection, trauma, stones, cancer), medications, foods (beetroot)
- Pain – abdominal, loin
Urinary Examination
Patient sitting on edge of bed
General – confusion, drowsiness, hyperventilation (metabolic acidosis), hydration
Hands – leukonychia, pallor of palmar creases, asterixis (severe kidney failure)
- Arms – AV fistula, bruising, pigmentation, scratch marks, sensation (peripheral neuropathy), pulse,
blood pressure (other arm if AV fistula is present) - Face – pallor, jaundice, uraemic foetor (kidney failure), mouth ulcers, candidiasis, gingivitis
Neck – JVP (fluid overload), carotid bruits
Chest (auscultate) – signs of CCF, pulmonary oedema, pericardial rub, consolidation
- Abdomen o Inspect – peritoneal dialysis catheter, scars (nephrectomy, transplant), distension (ascites) o Palpate – masses, liver, kidney, bladder, AAA o Percuss – shifting dullness, bladder o Auscultate – renal bruit (renal artery stenosis)
o DRE – prostatomegaly
Back – palpate vertebral column (bony tenderness), renal angle (renal tenderness), sacral oedema
- Legs
- Inspect – oedema, purpura, pigmentation, scratch marks, gouty tophi
- Palpate – pitting oedema, peripheral pulses, sensation (peripheral neuropathy)
- Legs
Fundi – changes due to hypertension / diabetes
Temperature
- Urinalysis
Diabetes
Complications of Diabetes
Metabolic - acute - Diabetic ketoacidosis – dehydration, Kussmaul breathing - Nonketotic hyperosmolar coma - dehydration - Hypoglycaemia – agitation, weakness, SNS activation Macrovascular - Coronary artery disease – angina, MI - Stroke - Peripheral vascular disease – claudication, gangrene - Infection Microvascular - Retinopathy – macular oedema, retinal damage & angiogenesis - Neuropathy – abnormal / sensation - Nephropathy – chronic renal failure
Diabetic Examination
Inspection – age, sex, body habitus, hydration, signs of Cushings / acromegaly / haemochromatosis, consciousness (ketoacidosis), Kussmaul breathing (short & shallow, ketoacidosis)
Legs o Inspect – skin colour, skin quality (dry, cracked, hairless), ulcers, infections (tinea, gangrene), muscles o Palpation - temperature ( cold/blue vascular disease, hot/red DVT), capillary refill, peripheral pulses o Sensation – light touch, pain, vibration, proprioception o Motor – knee & ankle reflexes, squat & stand (proximal myopathy) tone, power, coordination
Arms – nail candidiasis, blood pressure (lying & standing)
Eyes – visual acuity, reflexes, eye movements
Mouth – signs of infection
Ears – signs of infection
Neck – carotids (palpate & auscultate)
- Abdomen – liver
Investigations - Urinalysis – glucose, ketones, protein - Fasting glucose – short term control
- HbA1C - ~3-month control
Osce-Summary-Systems
Module: Medicine (A100)
University: Queen Mary University of London
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