All 9 Exam 2 exam topics — Anus & Rectum, Male GU (genitourinary) & Prostate, Abdominal, Lung & Thorax, Skin/Hair/Nail, Eye, General Survey & Vital Signs, Cardiovascular & Peripheral Vascular, and HENT — condensed to the highest-yield technique and findings.
| Topic | One-glance facts |
|---|---|
| History | Key questions: hematochezia (bloody stool), pain on defecation, any anal/perianal lesions. |
| Positioning | Side-lying (left lateral) position, hips and knees partially flexed, patient appropriately draped throughout. |
| Exam sequence | Fixed order: inspect sacrococcygeal/perianal areas → inspect the anus → perform the DRE (digital rectal examination). |
| Inspection | Note lesions, ulcers, inflammation, rashes, excoriations, skin breakdown, and any masses or tenderness; palpate any abnormal area found on inspection. |
| DRE technique | Lubricate gloved index finger → insert into anal canal → have patient squeeze sphincter (assesses tone) → palpate rectal surface circumferentially. |
| Abnormal findings | Hemorrhoids, anal fissures/warts, sphincter tightness or laxity (via squeeze maneuver), perianal abscess, and malignancy. |
| Special maneuvers | Prostatic exam palpates the prostate's posterior surface anteriorly during the DRE; rectovaginal exam is performed in the lithotomy position. |
| Topic | One-glance facts |
|---|---|
| History | Lower urinary tract symptoms, urinary incontinence, penile discharge/lesions, scrotal/testicular pain-swelling-lesions, erectile dysfunction, and painful/irregular/curved erections. |
| Patient comfort | If an erection occurs during exam: calmly explain it's a normal physiologic response, complete the exam, stay composed. If the patient refuses, discuss their reasons rather than proceeding. |
| Draping/exposure | Expose only the area being examined (gown over chest/abdomen, drape at mid-thigh), gloves always worn; review sexual maturity rating in younger patients. |
| Exam sequence | Inspect penis/urethral meatus/scrotum → palpate the shaft → assess groin hernias (with/without Valsalva) → palpate epididymis and each testis → examine spermatic cord. |
| Hernia evaluation | Inguinal/femoral hernias assessed by inspection and palpation, performed both without and with Valsalva. |
| Transillumination | Used to assess scrotal contents, for example to identify a hydrocele. |
| Prostate/prostate cancer | Prostate's posterior surface palpated via the anterior rectal wall during DRE. Most frequently diagnosed cancer in US men, rare before age 40, higher incidence in African American men; screened with PSA (prostate-specific antigen). |
| Topic | One-glance facts |
|---|---|
| Exam order | The abdomen is the exception to standard body-region order: Inspection → Auscultation → Percussion → Palpation (IAPerPal) — auscultation goes first so bowel sounds aren't artificially altered. |
| Exam tips | Empty bladder, warm hands/stethoscope, examine the painful area last ("one finger" localization), watch the patient's face, trim nails. |
| Inspection | Skin changes, umbilicus, scars, striae, dilated veins, contour (flat/round/protuberant/scaphoid), symmetry, visible organs/peristalsis; a visible aortic pulsation in the epigastrium can be normal. |
| Auscultation | Diaphragm, all 4 quadrants, ≥1 minute if sounds seem absent. Normal bowel sounds 5–34/min. Bruit (vascular turbulence), friction rub (peritoneal inflammation), venous hum (portal-systemic collaterals, e.g. cirrhosis). |
| Percussion | Tympany over gas/hollow organs, dullness over fluid/feces/solid organs. Liver span via percussion from below umbilicus upward + nipple line downward. Positive splenic percussion sign (tympany→dullness with deep inspiration, Traube's space) suggests splenomegaly. |
| Palpation | Light (<1cm, tenderness/masses) then deep (two-handed, 3–4cm, all 4 quadrants). Liver via bimanual or hooking technique; spleen usually not palpable; kidney capture technique (right more often felt); CVA tenderness via fist-on-palm strike; aorta normal ≤3.0cm, assessed bimanually if age >50. |
| Wall vs. intra-abdominal mass | Have the patient tense abdominal muscles (raise head/shoulders): a wall mass stays palpable, an intra-abdominal mass becomes obscured by the contraction. |
| Topic | One-glance facts |
|---|---|
| Angle of Louis | Sternal angle landmark: continuous with the 2nd rib (counts ribs/interspaces), marks tracheal bifurcation into main bronchi, and the upper border of the atria. Right lung has 3 lobes; left has 2 lobes plus a lingular segment. |
| Inspection | Shape/symmetry, A/P diameter, scoliosis/kyphosis/tracheal displacement, pectus deformities, cyanosis, nail beds, breath odor, respiratory rate/pattern. |
| Palpation | Tenderness, pulsations/bulges/crepitus, chest excursion, tactile fremitus, tracheal position. Chest expansion technique: hands at 10th rib, thumbs meeting at midline, watch symmetric thumb separation on deep inhalation. |
| Percussion & diaphragmatic excursion | Percuss superior→inferior, side to side, 4–5cm intervals. Diaphragmatic excursion: mark level on held exhalation, then again after deep inhale-hold; normal 3–5.5cm (up to 7–8cm if well-conditioned), often higher on right (liver). |
| Decreased excursion causes | Pleural effusion, atelectasis, emphysema, pain, ascites. |
| Breath sounds | Vesicular: inspiration>expiration, soft, low pitch (most fields). Bronchovesicular: inspiration=expiration, intermediate. Bronchial/tracheal: expiration>inspiration, loud, high pitch. |
| Voice sounds | Bronchophony (louder "99"), egophony ("E"→"A"), whispered pectoriloquy (whispered words heard clearly) — all suggest consolidation. |
| Topic | One-glance facts |
|---|---|
| Skin layers | Epidermis (most superficial), dermis (glands, hair follicles, nerve terminals), subcutaneous tissue. |
| Skin color | Melanin (brownish, genetics/sun), hemoglobin (bright red oxyhemoglobin vs. darker bluish deoxyhemoglobin), carotene (yellow, subcutaneous fat), bilirubin (yellow-brown, heme breakdown). |
| Glands & hair | Sebaceous glands everywhere except palms/soles; eccrine sweat glands widely distributed; apocrine glands primarily axillary/groin. Vellus hair = fine/lightly pigmented; terminal hair = coarse/pigmented. |
| History | Hair loss, rashes, growths, sores, lumps/bumps, dryness, itching, changes (especially moles changing size/shape/color/sensation); family history of skin cancers and atopic conditions. |
| Exam technique | Skin: inspect color/uniformity/thickness/lesions, palpate moisture/texture/temperature/turgor/mobility. Hair: inspect color/distribution/quantity, palpate texture. Nails: inspect pigmentation/length/ridging/pitting, palpate texture/firmness/adherence. |
| Nail landmarks | Normal nail base angle (proximal nail fold to nail plate) is 160 degrees; the lunula is the white half-moon at the proximal nail bed. |
| Draping | Patient undressed and gowned open in back, makeup/nail polish removed; uncover only the area being examined at a time, recover with gown when finished. |
| Topic | One-glance facts |
|---|---|
| Extraocular muscles | Superior rectus (CN III, elevation), inferior rectus (CN III, depression), medial rectus (CN III, adduction), lateral rectus (CN VI, abduction), superior oblique (CN IV, intorsion & depression), inferior oblique (CN III, extorsion & elevation). |
| Vision testing | Always test visual acuity before any test shining light directly into the eye. Acuity recorded as chart distance / distance a normal eye reads that line (e.g., 20/40). Visual fields by confrontation (monocular finger-wiggle) screens visual pathway lesions; color vision via pseudoisochromatic plates. |
| External exam | Inspect palpebral fissures, eyebrows/lashes/lids, lacrimal apparatus, conjunctiva/sclera, cornea (oblique lighting), iris, pupils (size/shape/symmetry in dim light; small <3mm, large >5mm). |
| Pupillary reactions | Direct (constriction in illuminated eye), consensual (constriction in opposite eye), near reaction (constriction with convergence; checked if light reaction impaired). |
| Alignment & motility | Corneal light reflection assesses ocular alignment (should fall slightly medial of pupil center). Extraocular movements tested in an "H" pattern through 6 cardinal gaze positions, pausing at extremes to check for nystagmus. |
| Ophthalmoscopic exam | Darken room, use same-side hand/eye as the eye examined, check red reflex from ~15 inches before moving in; adjust diopters to focus; inspect optic disc (margins/color/cup size) and retina (arteries lighter/smaller, veins darker/larger, AV crossings, macula/fovea). |
| Topic | One-glance facts |
|---|---|
| Patient identity | Confirm with 2 identifiers: name and date of birth. |
| Pain assessment | OPQRST (onset, palliative/provocative, quality, radiation, severity, timing). Acute pain typically <3–6 months; chronic typically >3–6 months or recurrent. Nociceptive = tissue damage; neuropathic = nervous system damage/disease. Always ask the patient what their personal "10" is. |
| General survey | Initial overall impression on entering the room: apparent state of health, discomfort/distress, skin color, dress, grooming, affect, posture/gait, body habitus. |
| Temperature | Varies by site (oral, rectal, tympanic, temporal); diurnal variation exists. |
| Pulse | Normal adult heart rate 60–100 bpm; auscultate carotid before palpating. Palpate 8+ pulse locations. Never palpate both carotids simultaneously — risk of decreased cerebral blood flow and syncope. |
| Respirations | Normal adult rate 12–20/min; count discreetly (e.g., while appearing to palpate the pulse). |
| Blood pressure | Cuff ~2.5cm above antecubital crease. Palpatory systolic estimate (inflate until radial pulse disappears, add ~30 mmHg) avoids missing an auscultatory gap; deflate at 2–3 mmHg/sec. Orthostatic vitals: BP/HR supine, then again standing. |
| Topic | One-glance facts |
|---|---|
| Conduction & output | SA node = natural pacemaker (60–100 bpm); AV node delays the impulse before the bundle of His/Purkinje fibers. Cardiac output = heart rate × stroke volume; stroke volume depends on preload, contractility, afterload. Normal ejection fraction ≈60%. |
| Heart sounds | S1 = mitral/tricuspid (AV) valve closure, best heard at apex (mitral) and LLSB (tricuspid). S2 = aortic/pulmonic (semilunar) valve closure, best heard R 2nd ICS (aortic) and L 2nd–3rd ICS (pulmonic). Pulse pressure = systolic − diastolic, normal 30–40 mmHg. |
| Carotid safety | Always auscultate for carotid bruits before palpating — palpating an artery with an undetected bruit risks dislodging plaque and causing stroke. Never palpate both carotids simultaneously. |
| Precordium palpation | Heaves felt with palms/fingers flat, thrills with the ball of the hand, at aortic/pulmonic/Erb's point/tricuspid/mitral areas. Normal PMI (point of maximal impulse): 5th ICS, left MCL, ~2.5cm, brisk gentle tap. |
| Peripheral vascular anatomy | Arterial layers: intima (atherosclerosis site), media (smooth muscle/elastin), adventitia. Arterioles are resistance vessels controlling systemic vascular resistance. Veins hold up to 2/3 of circulating blood volume. |
| Abnormal pulses | Pulsus parvus = weak pulse, seen in atherosclerotic PVD (peripheral vascular disease). Pulsus tardus = sluggish pulse, seen in aortic stenosis or low cardiac output. |
| Capillary refill | Normal ≤2–3 seconds. Epitrochlear nodes are usually not palpable when healthy. |
| Topic | One-glance facts |
|---|---|
| Exam sequence | HENT (like most body regions) uses the standard order: Inspection → Palpation → Percussion → Auscultation (IPalPerA) — unlike the abdomen's IAPerPal exception. |
| Head/face inspection | Size/shape/contour, lesions/dandruff, color/distribution/texture, asymmetry/expression/edema. |
| Ear exam | TM (tympanic membrane) landmarks: pars flaccida (small, loose, above malleus), pars tensa, umbo, cone of light. Otoscope technique: pull auricle up, back, slightly away to straighten canal; brace hand against patient's head; insert gently, angled down and forward. |
| Auditory testing | Whispered voice (2 ft behind patient, occlude untested ear; normal 3/6 correct). Weber (tuning fork on vertex; normal heard midline). Rinne (mastoid/bone then near canal/air; normal air>bone). |
| Weber/Rinne interpretation | Weber lateralizes to the affected ear in conductive loss, and to the unaffected ear in sensorineural loss. Rinne shows bone ≥ air conduction in conductive loss. |
| Nose & oral cavity | Nasal: inspect deformities/polyps/turbinates/mucosa/septum; palpate frontal/maxillary sinuses; transilluminate (decreased glow = fluid-filled sinus). Oral: Stensen's duct (parotid, buccal mucosa) vs. Wharton's duct (submandibular, floor of mouth); "ah" checks symmetric soft palate/uvula rise. |
| Neck & thyroid | Inspect symmetry, masses, gland enlargement, visible nodes, tracheal midline position. Palpate trachea (compare distance to SCM bilaterally) and thyroid (anterior or posterior approach with swallow); normal thyroid often not palpable. 10 cervical lymph node groups; roll a palpable node to differentiate from muscle/artery. |