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Clinical Examinations in General Medicine

The Universal Sequence (for any system)

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1. GENERAL / SYSTEMIC EXAMINATION

1a. Overall Inspection

• Build: thin/obese, nutritional status, hydration
• Conscious level: alert, drowsy, confused (GCS if needed)
• Appearance: distressed, comfortable, jaundiced, pale, cyanosed
• Posture and gait (briefly, walking into the room)
• Speech: dysarthria, aphasia, hoarseness

1b. Vital Signs

• Systolic leg pressure is normally up to 20 mmHg higher than arm - reversed = coarctation or aortic dissection
• "White coat hypertension": BP >130/80 in clinic but <130/80 out of clinic, no end-organ damage
• Ankle-Brachial Index (ABI): ankle systolic ÷ higher brachial pressure. Low ABI = peripheral arterial disease; powerful predictor of cardiovascular mortality

1c. Hands

• Clubbing: loss of nail-fold angle; 5 causes per system (lung cancer, fibrosis, bronchiectasis, cyanotic heart disease, liver cirrhosis, IBD)
• Peripheral cyanosis: blue/cold fingers (low flow)
• Koilonychia: spoon-shaped nails - iron deficiency anaemia
• Leukonychia: white nails - hypoalbuminaemia
• Pallor: palmar crease pallor = Hb <9 g/dL roughly
• Asterixis (flap): outstretched hands, wrists extended - hepatic, uraemic, or CO2 retention encephalopathy
• Dupuytren's contracture: palmar fibrosis - liver disease, diabetes, familial
• Splinter haemorrhages: infective endocarditis, vasculitis
• Osler's nodes / Janeway lesions: endocarditis
• Tremor (resting, postural, intention): see Neurology section

1d. Face

• Eyes: jaundice (sclerae), anaemia (conjunctivae), Horner's (ptosis + miosis + anhidrosis), exophthalmos (thyroid), xanthelasma, arcus cornealis
• Mouth: angular stomatitis (B12/iron def), central cyanosis (tongue and lips), leukoplakia, oral candidiasis, gum hypertrophy (phenytoin, CCBs, leukaemia)
• Parotid enlargement: alcoholic liver disease
• Malar flush: mitral stenosis
• Facies: myxoedema, Cushingoid, acromegaly, Parkinsonism (hypomimia), progressive supranuclear palsy (worried expression)

1e. Neck

• JVP: see CVS section (very important bedside venous pressure measure)
• Lymph nodes: anterior/posterior cervical, supraclavicular (Virchow's node = gastric/lung cancer), axillary, inguinal
• Thyroid: palpate from behind, swallows on swallowing; auscultate for bruit
• Carotid bruit: auscultate at angle of mandible

1f. Oedema

• Peripheral: pitting oedema at ankles/sacrum - cardiac, hepatic, nephrotic, nutritional
• Non-pitting: lymphoedema, myxoedema
• Press firmly for 10-15 seconds - depth of pit correlates roughly with severity

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2. CARDIOVASCULAR SYSTEM (CVS) EXAMINATION

Sequence: Position patient at 45°, adequately exposed from waist up.

2a. Jugular Venous Pressure (JVP)

• Use the internal jugular vein (preferred - direct line to RA; external JV is valved)
• Measure the vertical height of venous pulsation above the sternal angle (angle of Louis) at 45°
• Normal: <4.5 cm above sternal angle at 45°
• Tip: pulsations above the clavicle in the sitting position are always abnormal (RA is ≥10 cm below clavicle)

• a wave - RA presystolic contraction (after P wave on ECG); absent in AF; cannon a wave = AV dissociation (VT!)
• x descent - RA pressure fall after tricuspid opening
• c wave - tricuspid bulging into RA during early systole
• v wave - atrial filling during ventricular systole; giant v wave = tricuspid regurgitation
• y descent - tricuspid opens, RA empties
• Prominent y descent + pericardial knock = constrictive pericarditis

• Elevated JVP: fluid overload, right heart failure, tamponade, SVC obstruction
• Elevated JVP with elevated JVP rising on inspiration (Kussmaul's sign): constrictive pericarditis, restrictive cardiomyopathy
• Elevated JVP (>10 mmHg) predicts pulmonary wedge pressure >22 mmHg (PPV 88%)

2b. Arterial Pulse

• Best assessed at the carotid for character; radial for rate and rhythm
• Rate, rhythm, volume, character, radio-radial/radio-femoral delay, vessel wall

Pulsus paradoxus measurement: inflate BP cuff above systolic; slowly deflate; note the pressure at which Korotkoff sounds are heard only in expiration, then the pressure at which heard in every beat. Difference >10 mmHg = positive.

2c. Blood Pressure

• Both arms; >10 mmHg difference = subclavian/atherosclerotic disease, coarctation, dissection
• Systolic legs > arms normally; reversed = coarctation
• Measure ABI in peripheral arterial disease

2d. Precordial Examination

• Visible apex beat: midclavicular line, 5th ICS in thin adults
• Visible pulsations elsewhere = abnormal
• Right parasternal pulsation = ascending aortic aneurysm

• Patient supine 30°, enhanced in left lateral decubitus
• Apex beat: location (normally ≤5th ICS, midclavicular line), size (<2 cm), character
  • Heaving/sustained = LV hypertrophy (pressure overload: AS, hypertension)
  • Hyperdynamic/thrusting = LV volume overload (MR, AR)
  • Displaced/diffuse = dilated cardiomyopathy
• Parasternal heave: RV enlargement (pressure or volume overload)
• Thrills (palpable murmurs): grade 4+ murmurs; location identifies origin
• Loud P2 palpable at left upper sternal border = pulmonary hypertension

2e. Cardiac Auscultation

• Aortic: 2nd right ICS
• Pulmonary: 2nd left ICS
• Tricuspid: left lower sternal border (4th/5th ICS)
• Mitral: apex (5th ICS, midclavicular line) - listen with bell for low-pitched sounds

• Mitral + tricuspid closure
• Loud S1: early rheumatic mitral stenosis, short PR interval, hyperkinetic states
• Soft S1: late rheumatic MS (calcified leaflets), long PR interval, LV systolic dysfunction, beta-blockers
• Splitting: heard in young patients and RBBB (delayed tricuspid closure)

• Aortic (A2) + pulmonary (P2) closure
• Physiologic splitting: widens on inspiration (more right-sided filling), narrows on expiration
• Wide splitting: RBBB, severe MR (early aortic closure)
• Fixed splitting: ASD (no respiratory variation) - classic sign
• Reversed/paradoxical splitting: components audible at end-expiration, narrow on inspiration - LBBB, RV pacing, severe AS, HOCM, acute MI
• Loud P2: pulmonary hypertension (may be palpable)
• Narrow single S2: pulmonary hypertension

• Low-pitched, early diastolic; heard at apex with bell
• In adults: always pathological - LV failure, dilated cardiomyopathy
• In children/young adults: can be normal ("physiologic S3")
• Sounds like "Ken-TUCK-y"

• Low-pitched, late diastolic (pre-systolic); heard at apex
• Reflects stiff ventricle (LVH, ischaemia, hypertrophic cardiomyopathy)
• Sounds like "TEN-nes-see"
• Never normal in adults

• Valsalva: decreases preload - most murmurs softer; HOCM and MVP murmur louder
• Squatting: increases preload and afterload - HOCM murmur softer
• Standing: decreases preload - HOCM murmur louder
• Handgrip: increases afterload - MR/AR louder, AS softer

2f. Peripheral Vascular Examination

• Palpate all peripheral pulses: radial, brachial, carotid, femoral, popliteal, dorsalis pedis, posterior tibial
• Auscultate for bruits: carotid, subclavian, renal (epigastric), femoral
• Bruit extending into diastole or with thrill = severe obstruction
• Check for lower limb oedema, skin changes (lipodermatosclerosis, venous ulcers), temperature asymmetry

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3. RESPIRATORY SYSTEM EXAMINATION

Position: Patient sitting, examine posterior chest first, then anterior.

3a. Inspection

• Rate and pattern: tachypnoea (>20/min), bradypnoea, Cheyne-Stokes (central apnoeic cycles - heart failure, CNS disease), Kussmaul (deep, sighing - metabolic acidosis), Biot's (irregular - brainstem damage)
• Accessory muscle use: sternocleidomastoid, scalenes - respiratory distress
• Intercostal recession: severe obstruction in children
• Barrel chest: AP diameter equal to transverse; COPD/emphysema
• Kyphoscoliosis: can cause restrictive defect
• Asymmetric expansion: collapse, pneumothorax, effusion on affected side
• Tracheal position: midline? Deviation away from effusion/tension pneumothorax; towards collapse

3b. Palpation

• Tracheal position (finger in sternal notch)
• Chest expansion: thumbs meet at midline over lower posterior chest; should expand symmetrically ≥5 cm
• Tactile (vocal) fremitus: place ulnar aspect of hand or palm on chest; say "99"
  • Increased = consolidation (fluid-filled alveoli transmit better)
  • Decreased/absent = effusion, pneumothorax, thick chest wall

3c. Percussion

• Middle finger of non-dominant hand as pleximeter; tap with middle finger of dominant hand
• Percuss comparing side to side symmetrically
• Normal: resonant
• Dull: consolidation, collapse, pleural effusion, mass
• Stony dull: pleural effusion (classically)
• Hyper-resonant: pneumothorax, emphysema
• Diaphragm excursion: mark dullness at end-expiration and end-inspiration (normal excursion ~5 cm)

3d. Auscultation

• Use diaphragm; compare sides methodically
• Breath sound character:

• Added sounds:

• Whispered pectoriloquy: ask patient to whisper "1-2-3"; if clearly heard = consolidation
• Bronchophony: say "99"; louder than normal = consolidation
• Egophony: say "EEE"; if you hear "AHH" = consolidation (pneumonia); not heard in fibrosis

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4. ABDOMINAL EXAMINATION

Position: Patient supine, one pillow, adequately exposed from xiphisternum to pubic symphysis. Ask them to keep arms at sides and legs flat.

4a. Inspection

• Scars: location suggests prior surgery (RIF appendicectomy, midline laparotomy, RUQ cholecystectomy)
• Distension: generalised (the 5 Fs: Fat, Fluid/ascites, Faeces, Flatus, Fetus/mass) vs localised
• Prominent veins: periumbilical - portal hypertension (caput medusae); inferior epigastric collaterals - IVC obstruction
• Visible peristalsis: small bowel obstruction, pyloric stenosis (epigastric, left to right)
• Hernias: umbilical, epigastric, inguinal (ask patient to cough/stand)
• Skin: striae (purple = Cushing's; white = pregnancy/obesity), spider naevi (>5 = liver disease), jaundice, Grey-Turner's/Cullen's sign (bruising in flanks/periumbilical = retroperitoneal haemorrhage, severe pancreatitis)
• Asymmetry: organomegaly, mass

4b. Auscultation (before palpation/percussion in the abdomen)

• Bowel sounds: listen in one spot (e.g., right iliac fossa) for 15-30 seconds
  • Normal: intermittent gurgles
  • Increased/hyperactive: early obstruction, gastroenteritis, after eating
  • Absent (>3 min silence): paralytic ileus, peritonitis, late obstruction
  • Tinkling/high-pitched: mechanical obstruction
• Bruits: renal arteries (lateral to umbilicus - renovascular hypertension); aortic (epigastric - aneurysm/stenosis); hepatic bruit (hepatocellular carcinoma)
• Note: routine auscultation for bowel sounds has limited value in patients without abdominal pain

4c. Percussion

• Cursory light percussion across all 9 regions first - dullness, tympany, unexpected tenderness
• Liver size: upper border of dullness in midclavicular line (MCL) on full expiration, lower border dullness in MCL on full inspiration; normal span 6-12 cm
• Splenomegaly: percussion in left upper quadrant near 10th rib posterior to midaxillary line - dullness distinct from gastric tympany suggests spleen
• Ascites: percuss for flank dullness (flanks dull, central tympany); if dull, test for shifting dullness: percuss flank to mark dullness, keep finger there, roll patient away - if line of dullness shifts upward = positive (most sensitive bedside sign for ascites)
• Fluid thrill (for massive ascites): flick one flank while pressing midline with other hand's edge, second hand on opposite flank detects impulse

4d. Palpation

• Watch the patient's face, not the abdomen
• Detect guarding (voluntary or involuntary muscle spasm), tenderness, superficial masses
• Involuntary guarding + rigidity = peritonism

• Grade I: just palpable
• Grade II: to umbilicus
• Grade III: into RIF (massive)

• Murphy's sign: 2 fingers in RUQ, patient takes deep breath; arrest of inspiration due to pain = positive = acute cholecystitis (false positive: hepatitis)
• McBurney's sign: tenderness at McBurney's point (1/3 from ASIS to umbilicus) = appendicitis
• Rebound tenderness (Blumberg's): press slowly, release rapidly - pain worse on release = peritoneal irritation
• Rovsing's sign: pressure in LIF causes pain in RIF = appendicitis
• Obturator test: flex and internally rotate right hip - pain in RIF = inflamed appendix/pelvic abscess
• Psoas sign: extend right hip (patient left lateral) - pain in RIF = retrocaecal appendicitis
• Carnett's test: patient tenses abdominal wall (head lift) - if tenderness worse = abdominal wall source; if less = intra-abdominal source

4e. Rectal Examination

• Inspect perianal area: fissures, fistulas, haemorrhoids, skin tags
• Digital: assess anal tone, rectal wall circumferentially for masses, prostate in males (size, consistency, tenderness), cervix in females

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5. NEUROLOGICAL EXAMINATION

5a. Philosophy: Start During the Interview

• Hypomimia (expressionless face) = Parkinsonism or depression
• Worried/astonished expression = progressive supranuclear palsy
• Ptosis = myasthenia gravis or brainstem lesion
• Speech = dysarthria, aphasia, spasmodic dysphonia
• Involuntary movements during history-taking

5b. Mental Status

• Orientation: time, place, person
• Attention: months backwards, serial 7s
• Memory: 3-word recall (immediate and 5-minute)
• Language: naming, repetition, comprehension, reading, writing
• Calculation, visuospatial function, executive function (frontal lobe)
• Validated tools: MMSE (30 points), MoCA (for mild cognitive impairment, 30 points)

5c. Cranial Nerves (CNs)

5d. Motor System

• Wasting, fasciculations (LMN)
• Involuntary movements: tremor, chorea, dystonia, myoclonus, hemiballismus

• Spasticity (velocity-dependent resistance, clasp-knife): UMN - stroke, MS, cord lesion
• Rigidity (equal resistance throughout range): extrapyramidal - Parkinson's (lead-pipe or cog-wheel with tremor)
• Hypotonia/flaccidity: LMN, cerebellar, acute UMN shock
• Test: flex/extend limbs passively at each joint

• Pushup from floor, rising from chair without arms = proximal power
• Walk on toes (S1/gastrocnemius), walk on heels (L4-5/tibialis anterior)
• Pronator drift: arms outstretched, palms up, eyes closed; weak arm drifts down and pronates

5e. Reflexes

• Grading: 0 (absent), 1+ (reduced), 2+ (normal), 3+ (brisk), 4+ (clonus)
• Clonus: >5 beats = UMN lesion
• Hoffman's reflex: flick distal middle finger = thumb flexion; UMN sign in upper limb
• Plantar (Babinski): extensor (big toe extends, toes fan) = UMN lesion

• Abdominal reflexes: stroke toward umbilicus in each quadrant (T8-T12)
• Cremasteric reflex: stroke inner thigh = testis rises (L1-L2)

5f. Coordination

• Dysdiadochokinesis - rapidly alternating movements (forearm pronation/supination)
• Ataxia - gait (broad-based, staggering), Romberg's negative (cerebellar)
• Nystagmus - fast phase to side of lesion (horizontal)
• Intention tremor - finger-nose test (tremor increases approaching target), heel-shin test
• Scanning speech - dysarthric, monotone, staccato
• Hypotonia - reduced tone

5g. Sensory Examination

• Pain/temperature (spinothalamic tract): pinprick; temperature
• Light touch: cotton wool
• Vibration sense (posterior column): 128 Hz tuning fork on bony prominences (great toe, malleolus, knee, anterior iliac spine, sternum - go distal to proximal)
• Proprioception (joint position sense, JPS) (posterior column): grip the toe/finger at the sides, move up or down; patient identifies direction with eyes closed

• Graphesthesia: write number on palm
• Stereognosis: identify object in hand
• Sensory extinction: stimulate both sides simultaneously; parietal lesion extinguishes contralateral stimulus

5h. Gait Assessment

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6. THYROID EXAMINATION

• Inspection: neck swelling? Moves on swallowing (thyroid tissue) vs protrusion of tongue (thyroglossal cyst)
• Palpation: stand behind patient; use 2-3 fingers bilaterally to palpate lobes and isthmus; ask patient to swallow sip of water; feel for size, consistency, tenderness, nodules, tracheal deviation
• Percussion: retrosternal extension? Percuss over sternum
• Auscultation: thyroid bruit = hyperthyroidism (increased vascularity)
• Signs of hyper/hypothyroidism: pulse rate, AF, tremor, eye signs (exophthalmos, lid lag, lid retraction, ophthalmoplegia in Graves'), proximal myopathy, pretibial myxoedema, onycholysis, reflexes (brisk in hyper, delayed relaxation in hypo)
• Pemberton's sign: raise both arms above head; facial plethora/congestion = SVC obstruction from retrosternal goitre

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7. MUSCULOSKELETAL EXAMINATION

"GALS" Screening (Gait, Arms, Legs, Spine)

Joint Examination Sequence (any joint):

1. Look (swelling, deformity, erythema, wasting, rash)
2. Feel (temperature, tenderness, swelling type: bony/synovial/effusion, crepitus)
3. Move (active then passive range of motion; end-feel)
4. Special tests (joint-specific)
5. Function (grip strength, gait, ADLs)

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8. QUICK REFERENCE: BEDSIDE DIAGNOSTIC TESTS ACROSS SYSTEMS

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9. ORDER OF A COMPLETE GENERAL MEDICINE WARD ROUND EXAMINATION

1. End of bed inspection: general appearance, IV lines, O2, monitoring
2. Hands: nails, palms, asterixis, temperature, pulses
3. Face/neck: eyes, mouth, JVP, lymph nodes, thyroid
4. Vital signs: BP (both arms if needed), pulse, RR, SpO2, temperature
5. CVS: precordium, heart sounds, peripheral pulses, oedema
6. Respiratory: trachea, chest expansion, percussion, auscultation
7. Abdomen: inspection, auscultation, percussion, palpation; offer PR
8. Neurology (if indicated): conscious level, cranial nerves, motor, reflexes, sensation, cerebellar, gait
9. Lymph nodes, skin: full body skin check if relevant
10. Genitalia/hernias: if clinically indicated
11. Fundoscopy: HTN, diabetes, raised ICP, endocarditis
12. Urine dipstick: routine in most medical patients

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• Harrison's Principles of Internal Medicine 22E (2025, McGraw Hill Medical) - Chapter 246 (Cardiovascular Examination), Chapter 262 (Respiratory Examination)
• Goldman-Cecil Medicine, International Edition - Chapter on Abdominal Examination
• Bradley and Daroff's Neurology in Clinical Practice - Chapter 1 (Neurological Examination)

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Musculoskeletal (MSK) Examination - Complete Guide

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CORE FRAMEWORK: LOOK - FEEL - MOVE - STRESS

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STEP 1: GENERAL SURVEY (Before Touching the Patient)

Posture (patient standing, in underwear)

• Compare heights of: shoulders, scapulae, pelvic brim, gluteal creases
• Inspect the spine: normal cervical lordosis, thoracic kyphosis, lumbar lordosis
• Look at feet in neutral standing position
• Any asymmetry = scoliosis, leg length discrepancy, joint deformity

Gait (ask them to walk across the room and back)

Trendelenburg test: ask patient to stand on one leg. Normally the pelvis stays level or rises slightly. If the pelvis drops to the opposite side = positive = weak hip abductors on the standing leg.

Functional MSK Screen (GALS equivalent)

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STEP 2: INTERPRETATION PRINCIPLES

Types of Swelling - How to Distinguish

Inflammation vs Damage vs Mechanical

Key rule: Pain in ALL directions of movement = synovitis. Pain in ONE plane = localised articular or periarticular problem. Pain THROUGHOUT range = OA.

Active vs Passive vs Resisted Movement

Tenderness Location

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STEP 3: REGIONAL EXAMINATION

3.1 HANDS AND WRISTS

LOOK

• Small muscle wasting: interossei wasting (guttering between tendons) = RA, ulnar nerve, T1 lesion
• Tendon nodules: over extensor tendons = RA
• Deformities (critical to recognise):

• Palmar erythema (liver disease, pregnancy, RA)
• Dupuytren's contracture (flexion contracture of ring/little finger)
• Thenar wasting (median nerve/carpal tunnel syndrome, T1)
• Hypothenar wasting (ulnar nerve)

• Psoriatic plaques
• Nail pitting (>20 pits = psoriasis), onycholysis, ridging
• Splinter haemorrhages (endocarditis, vasculitis)
• Periungual erythema (dermatomyositis, SLE)
• Raynaud's changes (colour, ulcers)
• Calcinosis (systemic sclerosis)
• Gottron's papules over MCPs/PIPs (dermatomyositis)
• Tight, thickened, bound-down skin (systemic sclerosis - scleroderma)

FEEL

• Warmth: use dorsum of YOUR hand, compare both sides
• Squeeze across all MCPs together (composite tenderness test) - positive if tender = MCP synovitis
• Palpate each MCP individually: index finger on dorsal joint line, thumb beneath - feel for boggy synovial thickening
• Palpate PIPs and DIPs: using "interlocking C" technique - index and thumb of both hands around joint; feel for warmth, synovitis, bony swelling
• Palpate tendon sheaths during movement: crepitus = tenosynovitis

MOVE

• Active: make a tight fist (all fingers should fully flex to touch palm); observe palmar blanching on release (grip strength)
• Pinch grip: thumb to each finger individually (tip-to-tip, lateral)
• Grip strength: patient squeezes your two fingers; grade or use dynamometer
• Wrist: active flexion/extension; note if full extension achievable ("hands-praying" position tests bilateral wrist extension)
• Passive wrist: flexion (normal ~80°), extension (normal ~70°), radial deviation (15°), ulnar deviation (30°)
• Hypermobility test: passively extend 5th finger to >90° at MCP = one criterion of Beighton score

RESISTED TESTS (Tendon/Enthesis)

• Resisted wrist extension (elbow extended) → pain at lateral epicondyle = lateral epicondylitis (tennis elbow)
• Resisted wrist flexion → pain at medial epicondyle = medial epicondylitis (golfer's elbow)

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3.2 ELBOW

LOOK

• Para-olecranon groove: first place to see elbow joint effusion (fills the groove, making it convex)
• Olecranon bursa: discrete fluctuant swelling directly over olecranon = bursitis (gout, septic, trauma, RA)
• Rheumatoid nodules: firm, non-tender, subcutaneous, over olecranon and extensor surface
• Carrying angle: normal valgus ~10-15° women, ~5° men; increased = cubitus valgus (ulnar nerve risk); decreased = cubitus varus

FEEL

• Lateral epicondyle: tender = lateral epicondylitis
• Medial epicondyle: tender = medial epicondylitis; check ulnar nerve (tender, thickened) in groove posterior to medial epicondyle
• Para-olecranon groove (either side of olecranon): synovial swelling = joint disease
• Skin laxity: assess for hypermobility syndrome

MOVE

• Passive extension (normal = 0°; hyperextension = hypermobility)
• Passive flexion (normal ~145°)
• Supination/pronation (elbows at 90°, tucked in to stabilise shoulder): normal ~90° each way; restricted in radioulnar arthritis

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3.3 SHOULDER

LOOK

• Asymmetry of scapulae, level of shoulders
• Muscle wasting: deltoid (axillary nerve, C5), supraspinatus/infraspinatus fossae (suprascapular nerve, rotator cuff tear)
• Step deformity at AC joint: ACJ disruption
• Swelling at anterior shoulder: glenohumeral effusion

FEEL

• Trapezius midpoint: tender spot = fibromyalgia, trapezius strain
• Supraspinatus (just posterior to the mid-clavicle): tender = rotator cuff pathology
• AC joint line: tender = ACJ OA, ACJ injury; step deformity
• Bicipital groove (anterior shoulder, arm slightly externally rotated): tender = bicipital tendinitis

MOVE

• Arms to the side, elevate in the plane of the scapula: painful arc 60-120° = rotator cuff impingement or subacromial bursitis
• Hands behind head (abduction + external rotation) = tests external rotation and abduction
• Hands behind back, reach up spine (adduction + internal rotation) = tests internal rotation; note highest spinal level reached (normally T6-T8)

• Abduction (normal 180°), flexion (180°), extension (50°), external rotation (90° with elbow bent at side), internal rotation (70°)

• Neer's test: examiner passively forward-flexes the arm with elbow extended and forearm pronated, forcing the supraspinatus against the acromion. Pain = subacromial impingement
• Hawkins-Kennedy test: arm forward-flexed to 90°, elbow flexed 90°, examiner forcibly internally rotates the arm. Pain = subacromial impingement
• Empty can test (Jobe's): arm abducted 90° in scapular plane, 30° forward, thumb pointing down ("empty can"); examiner pushes down while patient resists. Weakness or pain = supraspinatus tear
• Resisted external rotation: elbow 90° at side; patient resists internal rotation. Weakness = infraspinatus/teres minor tear
• Speed's test: elbow extended, forearm supinated, arm at 60° flexion; resist further flexion. Bicipital groove pain = bicipital tendinitis
• Yergason's test: elbow flexed 90°, forearm pronated; patient supinates against resistance. Bicipital groove pain = long head of biceps pathology

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3.4 CERVICAL SPINE

LOOK

• Normal lordosis or loss/reversal (hyperextension secondary to thoracic kyphosis)
• Head position: tilted, rotated? (torticollis)

FEEL

• Percuss each spinous process: localised bony tenderness = fracture, infection, myeloma
• Paraspinal muscles: spasm, tenderness (trapezius, cervical paraspinals)

MOVE (active, guide to maximum with your hands)

Lateral rotation and extension lost early in ankylosing spondylitis affecting the cervical spine.

STRESS / SPECIAL TESTS

• Spurling's test (foraminal compression): tilt head to affected side + extend + apply downward pressure on crown. Reproduces radicular arm pain = cervical radiculopathy (foraminal stenosis)
• Distraction test: lift head gently upward - relief of radicular pain = positive

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3.5 THORACIC AND LUMBAR SPINE

LOOK

• Kyphosis: increased thoracic kyphosis (osteoporosis, vertebral fractures, AS, Scheuermann's disease)
• Scoliosis: lateral curvature; ask patient to bend forward - if rib hump visible on bending = structural scoliosis; if disappears = functional (postural, leg length discrepancy)
• Loss of lumbar lordosis: muscle spasm (acute disc prolapse), AS
• Pelvic tilt: check level of ASIS and PSIS bilaterally
• Buttock and thigh wasting

FEEL

• Percussion along each spinous process: localised tenderness = fracture, infection, metastases, myeloma
• Paraspinal muscles: bilateral spasm = protective (acute disc) or chronic spondylosis

MOVE (Lumbar)

1. Mark a point 10 cm above and 5 cm below the level of the posterior iliac spine dimples (dimples of Venus) while patient stands erect
2. Ask patient to flex forward maximally
3. Measure the new distance between the two marks
4. Normal: increases by ≥5 cm (so original 15 cm should become ≥20 cm)
5. Abnormal (<5 cm increase): restricted lumbar flexion = AS, spondylosis, lumbar OA

In normal hypermobile individuals, hands may lay flat on the floor; the Schober test specifically measures lumbar mobility, not hamstring flexibility.

STRESS / SPECIAL TESTS

• Patient supine; examiner slowly raises the straightened leg, holding ankle
• Normal: no pain until ~70-80°
• Positive: sciatica (radiating pain below knee in dermatomal distribution) reproduced between 30-70° = L4, L5, or S1 nerve root compression
• Sensitise: dorsiflex ankle at point of pain (Bragard's sign) - increases stretch on sciatic nerve, increases radicular pain
• Crossed SLR: raising the normal leg reproduces pain in the affected leg = large central disc prolapse

• Patient prone; examiner holds ankle and passively flexes knee as far as possible
• Positive: pain in ipsilateral anterior thigh = L2, L3, or L4 nerve root tension (high lumbar disc prolapse)

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3.6 HIP

LOOK

• Wasting of buttock or thigh muscles (disuse)
• Leg position at rest: external rotation + shortening = fracture neck of femur; fixed flexion with external rotation = hip OA
• Measure leg length if pelvic tilt present:
  • True leg length: ASIS to medial malleolus (structural shortening)
  • Apparent leg length: umbilicus to medial malleolus (pelvic tilt causing apparent shortening)

FEEL

• Palpate for tenderness to locate the structure:
  • Greater trochanter: trochanteric bursitis or gluteus medius tendinopathy (lateral hip pain in women, very common)
  • Anterior hip/inguinal region: true hip joint pain (groin), hip flexor tendinopathy
  • Ischial tuberosity: hamstring enthesopathy, ischial bursitis
  • Pubic symphysis: pubic symphysitis (athletes)

MOVE

Internal rotation is the first movement restricted in hip joint pathology (OA, AVN, hip effusion). Reproduce the patient's pain.

1. Flex both hips fully (eliminates lumbar lordosis)
2. Hold the unaffected hip in full flexion
3. Lower the affected leg - if it cannot reach the couch flat = positive fixed flexion deformity
4. Measure the angle from the couch = degree of fixed flexion

• Patient supine; place the ankle of the test leg on the opposite knee (figure-4 position)
• Gently press down on the flexed knee while stabilising the opposite ASIS
• Positive: hip or groin pain = hip joint pathology; SI joint pain (posterior) = sacroiliac joint pathology

• Patient stands on one leg (affected side); observe pelvis from behind
• Positive: pelvis drops to the contralateral side = weak gluteus medius (hip abductors) ipsilaterally
• Causes: hip OA, superior gluteal nerve palsy, L5 radiculopathy, hip fracture, coxa vara

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3.7 KNEE

LOOK

• Alignment:
  • Valgus (knock-knees, genu valgum) = lateral compartment OA, RA
  • Varus (bow-legs, genu varum) = medial compartment OA
• Flexion deformity: cannot fully extend at rest = fixed flexion deformity
• Swelling: effusion (suprapatellar pouch fullness), prepatellar bursitis, infrapatellar bursitis
• Wasting of quadriceps (vastus medialis specifically): even small effusions inhibit VMO by reflex
• Baker's cyst: visible or palpable in popliteal fossa (associated with knee OA, RA)

FEEL

• Temperature: use dorsum of hand; compare both sides; warm knee = active effusion/inflammation
• Patellar tap: compress suprapatellar pouch with one hand (to push fluid below patella), then push patella downward with two fingers of other hand; clunk = large effusion
• Bulge sign (fluid sweep/wipe test): for small effusions; stroke medial compartment upward (emptying it), then sweep down the lateral side; watch for medial bulge appearing = fluid returning to medial compartment = positive
• Joint line palpation: palpate medial and lateral joint lines with knee slightly flexed; tenderness = meniscus, OA, ligament
• Collateral ligaments: medial and lateral joint lines; tender = collateral ligament injury

MOVE

• Active: extend (should reach 0° or slight hyperextension) and flex (normal ~135°); assess end-feel
• Passive: same ranges; note any block to full extension (locked knee = bucket handle meniscal tear)
• Crepitus on movement: patellofemoral = fine crepitus; tibiofemoral OA = coarser

STRESS TESTS

• Knee in slight flexion (~20-30°); stabilise thigh
• Valgus stress (push tibia medially) = tests medial collateral ligament (MCL); opening on medial side = MCL tear
• Varus stress (push tibia laterally) = tests lateral collateral ligament (LCL); opening on lateral side = LCL tear

• Anterior Drawer Test: knee flexed 90°; sit on patient's foot; pull tibia forward. Anterior movement >5 mm = ACL tear
• Lachman's Test (more sensitive than anterior drawer): knee flexed 20°; stabilise femur with one hand, pull tibia anteriorly with other. Soft end-feel + anterior translation = ACL tear
• Posterior Drawer Test: same position as anterior drawer; push tibia posteriorly. Posterior movement = PCL tear

• McMurray's Test: patient supine, hip and knee flexed maximally; examiner holds heel and knee, rotate tibia externally while extending knee (tests medial meniscus); then internally while extending (tests lateral meniscus). Positive: palpable/audible click + joint line pain = meniscal tear
• Apley's Test (grinding): patient prone, knee flexed 90°; compress tibia onto femur (press down on heel) and rotate. Pain = meniscal tear. Then distract (pull heel up) and rotate - pain = ligamentous problem

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3.8 FOOT AND ANKLE

LOOK (standing + walking)

• Longitudinal arch: normally raised on medial side; pes planus (flat foot) = loss of arch; pes cavus (high arch) = hereditary neuropathy (CMT), polio
• Heel alignment: valgus (eversion, pronation) = pes planus; varus (inversion, supination) = pes cavus
• MTP joints: swelling separating toes ("daylight sign") = MTP synovitis (RA)
• Hallux valgus: lateral deviation of great toe at MTP joint (bunion) = OA, RA
• Claw toes: extension at MTP + flexion at PIP and DIP
• Hammer toe: PIP flexion + MTP extension (usually 2nd toe)
• Callosities under metatarsal heads = pressure from subluxed MTP joints (RA)

FEEL

• Squeeze across all MTPs together: composite tenderness = MTP synovitis (RA, psoriatic)
• Palpate individual MTPs: each joint line for swelling and tenderness
• Achilles tendon: tender insertional pain = enthesitis (AS, reactive arthritis, psoriatic); tender mid-substance = Achilles tendinopathy
• Plantar fascia origin (medial calcaneal tubercle): tender = plantar fasciitis
• Lateral ligaments (anterior talofibular + calcaneofibular): tender after inversion sprain

MOVE

• Ankle: active dorsiflexion (normal ~20°) and plantarflexion (normal ~50°)
• Subtalar joint (hindfoot): grasp heel between thumb and index finger; move heel medially (inversion, normal ~30°) and laterally (eversion, ~20°); restricted = subtalar OA, AS
• Midtarsal joint (Chopart's): hold heel fixed, rotate forefoot; restricted = midtarsal OA
• MTPs: passively flex and extend each toe; dorsiflexion of great toe >70° = normal

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3.9 SACROILIAC JOINTS AND PELVIS

LOOK

• Assess from behind: pelvic tilt, buttock wasting, dimples of Venus (posterior iliac spines)

FEEL

• Direct sacral pressure (sit on sacrum): pain = SI joint inflammation or sacral fracture
• FABER test (as described in Hip section): posterior pain = SI pathology

STRESS TESTS

• FABER (Patrick's test): described above
• FADIR test: hip Flexion-ADduction-Internal Rotation; hip or posterior pain = posterior impingement, SI joint, piriformis
• Pelvic springing (distraction and compression): apply downward pressure on both ASIS simultaneously (springing the SI joints); pain = SI joint disease

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STEP 4: INTERPRETING THE PATTERN - WHAT DOES THE DISTRIBUTION TELL YOU?

Number of Joints

Joint Size

Symmetry

The "Hand at a Glance" Diagnoses

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STEP 5: HYPERMOBILITY - BEIGHTON SCORE

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STEP 6: PAIN CHARACTERISATION SUMMARY

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