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Appendix 1
Clinical examinations
Focused cardiovascular examination
• Expose the patient appropriately (ask permission first).
• Position the patient correctly (ideally at 45°).
• Inspection – pallor, cyanosis, scars, oedema, clubbing, JVP.
• Palpation – pulses (rate, rhythm), BP, apex beat, heaves, thrills.
• Auscultation – apex and carotid area (more detailed auscultation required if murmur heard). Listen to lung bases.
Focused respiratory examination
• Expose the patient appropriately (ask permission first).
• Position the patient at 45° ideally.
• Inspection – check hands for clubbing and peripheral cyanosis. Check tongue for pallor/cyanosis. Check respiratory rate and check chest for scars.
• Palpation – check for position of trachea and chest expansion. Check for cervical lymphadenopathy.
• Percussion – front and back of chest ideally.
• Auscultation – listen at front and back.
Focused gastrointestinal examination
• Expose the patient appropriately (ask permission first).
• Lie the patient flat if possible, with arms to the side.
• Inspection – check for jaundice, pallor, spider naevi or gynaecomastia. Check hands for clubbing, cyanosis, palmar erythema or Dupuytren’s contracture. Check abdomen for distended veins or masses.
• Palpation – check for cervical lymphadenopathy. Palpate each area of the abdomen then palpate liver, spleen, kidneys and bladder (or focus depending on history).
• Percussion – liver, spleen and for shifting dullness if relevant.
• Auscultation – check for presence and quality of bowel sounds.
Neurological examination
Cranial nerves
| I | Olfactory | Have you noticed any change in your sense of smell or taste? |
| II | Optic | Any problems with your vision? If so, check visual acuity with Snellen chart. Also check visual fields. Fundoscopy. |
| III | Oculomotor | Accommodation, visual movements, direct/consensual light reflex. |
| IV | Trochlear | As for oculomotor tests. |
| V | Trigeminal | Check sensation on both sides of the face and compare (branches of trigeminal nerve). |
| VI | Abducens | Same as oculomotor and trochlear tests. |
| VII | Facial | Raise eyebrows, clench teeth, blow cheeks out, close eyes tightly and stop me from opening them. |
| VIII | Vestibulo-cochlear | Check gross hearing by whispering in each ear. If any concerns with hearing perform Rinne’s and Weber’s tests. |
| IX | Glosso-pharyngeal | Taste sensation as above. |
| X | Vagal | Say ‘aaaagghh’ (look for deviation of the uvula). |
| XI | Accessory | Please can you shrug your shoulders? Check power in sternocleidomastoid muscles by moving neck side to side against resistance. |
| XII | Hypoglossal | Can you stick your tongue out? (check for deviation, atrophy and fasciculations). |
Whispered speech test
• To make a basic assessment of a patient’s hearing, you need to mask the non-test ear by blocking it with your finger, and then ask them to repeat random numbers that you speak into the test ear.
• You can start with a whisper, and if they are unable to hear this then increase the volume in incremental steps.
Rinne’s test
• Strike a 512 Hz tuning fork and place the fork behind the ear, firmly on the mastoid process.
• Then hold the vibrating fork a few inches away in front of the ear.
• In a normal ear, the patient should hear the tuning fork louder in front of the ear than behind.
• If a patient has a conductive hearing loss, they will hear the bone conduction behind the ear louder than the air conduction.
Weber’s test
• Strike a 512 Hz tuning fork and place the base of the fork on the patient’s forehead.
• A patient with normal hearing should hear the sound equally on both sides.
• If a patient has unilateral conductive hearing loss, the sound will localise to the affected ear.
• If a patient has unilateral sensorineural loss, the sound will localise to the opposite ear.
Thyroid examination
• Hands – check pulse, check for tremor.
• Eyes – check for exophthalmos and lid lag.
• Neck – inspect, check swallowing and tongue protrusion, palpate neck for mass, percuss neck swelling, auscultate for bruits.
• Check reflexes.
Shoulder examination
• Expose both shoulders (ask permission first).
• Look – from front, side and rear inspecting for scars, erythema, muscle wasting, asymmetry, swelling and any deformity of the shoulder joint.
• Feel – check temperature, palpate bony landmarks, joint line and surrounding muscles for any tenderness, crepitus or effusions.
• Move – check active/passive movements of abduction/adduction, flexion/ extension, internal/external rotation.
• Function – arms behind head and scratching back.
• Cross arm test – ask the patient to place their hand on their opposite shoulder. If gentle pressure on the joint elicits pain, this is indicative of acromioclavicular joint inflammation.
• Drop arm test – passively abduct the patient’s shoulder. Then ask the patient to lower the abducted arm slowly to the waist. A rotator cuff tear can be identified if the arm drops ...
