1 · Anus & Rectum Examination
Instructional Objectives
- Review the anatomy of the rectum.
- Discuss the proper clinical skills for a comprehensive examination of the rectum.
- Demonstrate the proper clinical skills for a comprehensive examination of the rectum.
Objective 1 — Anatomy of the rectum
The rectum is the terminal ~12 cm of the large intestine, continuous with the sigmoid colon proximally and the anal canal distally, and marked internally by the transverse rectal folds (valves of Houston). The anal canal (~3–4 cm) is divided by the dentate (pectinate) line — columnar/transitional mucosa above, squamous below — and is guarded by the internal anal sphincter (involuntary smooth muscle) and external anal sphincter (voluntary skeletal muscle). In males, the prostate is palpable through the anterior rectal wall.
1.1 History & Positioning
Key anorectal history: hematochezia (bloody stool), pain on defecation, and any anal/perianal lesions. The standard exam position is side-lying (left lateral), hips and knees partially flexed, patient appropriately draped throughout.
1.2 Inspection & DRE (digital rectal examination) Technique
On inspection, note lesions, ulcers, inflammation, rashes, excoriations, external skin breakdown, and any masses or tenderness — palpate any abnormal area found on inspection.
DRE (digital rectal examination) steps
- Lubricate a gloved index finger.
- Insert the fingertip into the anal canal.
- Ask the patient to squeeze the anal sphincter (assesses tone).
- Palpate the rectal surface circumferentially.
1.3 Abnormal Findings & Special Maneuvers
| Finding | Notes |
|---|---|
| Hemorrhoids | Common anorectal abnormality |
| Anal fissures / warts | Common anorectal abnormality |
| Sphincter tightness or laxity | Assessed via the squeeze maneuver during DRE (digital rectal examination) |
| Perianal abscess | Common anorectal abnormality |
| Malignancy | Common anorectal abnormality |
Special maneuvers: a prostatic examination (palpating the prostate's posterior surface anteriorly during the DRE (digital rectal examination)) and a rectovaginal examination (performed in the lithotomy position).
2 · Male GU (genitourinary) & Prostate Examination
Instructional Objectives
- Review the anatomy of the male internal and external genitalia.
- Discuss the proper clinical skills for a comprehensive examination of the following: male genitalia; prostate; inguinal and femoral hernias.
- Demonstrate the proper clinical skills for a comprehensive examination of the following: male genitalia; prostate; inguinal and femoral hernias.
Objective 1 — Anatomy of the male genitalia
The external genitalia are the penis (root, body, and glans, covered by the prepuce unless circumcised) and the scrotum, which houses the testes, epididymides, and spermatic cords. Internally, each testis produces sperm that pass through the epididymis and vas deferens; the seminal vesicles, prostate, and bulbourethral glands add seminal fluid. The inguinal canal transmits the spermatic cord and is the site of indirect (through the deep inguinal ring) and direct (through the posterior wall / Hesselbach's triangle) inguinal hernias; femoral hernias pass below the inguinal ligament.
2.1 History & Patient Comfort
Key history: lower urinary tract symptoms, urinary incontinence, penile discharge/lesions, scrotal/testicular pain-swelling-lesions, erectile dysfunction, and painful/irregular/curved erections.
Expose only the area being examined at any time (gown over the chest/abdomen, drape at mid-thigh), and always wear gloves. In younger patients, review sexual maturity rating to document findings accurately.
2.2 Physical Exam Technique
- Inspect the penis, urethral meatus, and scrotum.
- Palpate the shaft of the penis.
- Assess for groin hernias by inspection and palpation, both without and with Valsalva.
- Palpate the epididymis and each testis.
- Examine the spermatic cord.
2.3 Special Techniques & Prostate Cancer
| Maneuver | Purpose |
|---|---|
| Inguinal/femoral hernia evaluation | Inspection and palpation, with and without Valsalva |
| Transillumination | Assess scrotal contents (for example, hydrocele) |
| Testicular self-examination | Patient self-screening technique, taught during the visit |
| Prostate palpation | Posterior surface, via the anterior rectal wall during DRE (digital rectal examination) |
3 · Abdominal Examination
Instructional Objectives
- Review the anatomy of the abdomen.
- Discuss the proper clinical skills for a comprehensive examination of the abdomen.
- Demonstrate the proper clinical skills for a comprehensive examination of the abdomen.
Objective 1 — Anatomy of the abdomen
The abdomen is described in four quadrants (RUQ, LUQ, RLQ, LLQ) by the midline and transumbilical plane, or in nine regions. Key organ locations: liver and gallbladder (RUQ); stomach, spleen, pancreatic tail (LUQ); appendix and cecum (RLQ); sigmoid colon (LLQ); with the aorta and umbilicus in the midline. The kidneys and pancreas are retroperitoneal. This organ map underlies the auscultation, percussion, and palpation findings below.
3.1 Exam Order & Inspection
Tips for a good exam: empty bladder, comfortable patient, warm hands/stethoscope, examine the painful area last ("one finger" localization), watch the patient's face, and trim nails.
Inspect for skin changes, the umbilicus, scars, striae, dilated veins, rashes/lesions, contour (flat, round, protuberant, scaphoid), symmetry, visible organs, peristalsis, and pulsations (a visible aortic pulsation in the epigastrium can be normal).
3.2 Auscultation
Use the diaphragm, listening in all 4 quadrants for at least one full minute if sounds seem absent. Normal bowel sounds are clicks and gurgles, 5–34/minute (borborygmi = prolonged hyperperistaltic gurgling). Document as absent, normoactive, hyperactive, or hypoactive.
| Finding | Significance |
|---|---|
| Bruit (aorta, renal, iliac, femoral) | Vascular turbulence — listen with the diaphragm over each |
| Friction rub (liver/spleen) | Peritoneal surface inflammation of that organ |
| Venous hum (epigastrium/umbilicus) | Portal-systemic collateral circulation (for example, hepatic cirrhosis) |
3.3 Percussion
Tympany predominates over gas/hollow organs; dullness occurs over fluid, feces, or solid organs. Liver span: percuss the lower border of dullness starting below the umbilicus in the right MCL (midclavicular line) moving upward, and the upper border from the nipple line downward. Spleen: percuss Traube's space (left costal margin); a positive splenic percussion sign (a change from tympany to dullness with deep inspiration at the lowest left interspace, anterior axillary line) suggests splenomegaly.
3.4 Palpation
| Technique | Key points |
|---|---|
| Light palpation | <1cm depth; tenderness, muscular resistance, superficial masses; painful area last |
| Deep palpation | Two-handed, 3–4cm depth, all 4 quadrants, watch the patient's face |
| Liver (bimanual) | Left hand lifts right flank; right hand presses in/up below costal margin on inspiration |
| Liver (hooking) | Stand facing patient's feet, hook fingers under right costal margin on inspiration |
| Spleen | Usually not palpable; left hand wraps left flank, right hand presses below left costal margin on inspiration |
| Kidney (capture technique) | Left hand lifts flank, right hand presses down at peak inspiration to "capture" the kidney; right kidney more often felt (lower than left) |
| CVA (costovertebral angle) tenderness | Patient sits up; fist strikes palm placed over costovertebral angle |
| Aorta | Normal width ≤3.0 cm, assessed bimanually in patients >50 |
4 · Lung & Thorax Examination
Instructional Objectives
- Review the anatomy of the thorax and lungs.
- Discuss the proper clinical skills for a comprehensive examination of the following: thorax; lungs.
- Demonstrate the proper clinical skills for a comprehensive examination of the following: thorax; lungs.
4.1 Anatomy & Landmarks
The angle of Louis (sternal angle) is a key landmark: it's continuous with the 2nd rib (used to count ribs/intercostal spaces), marks the tracheal bifurcation into the main bronchi, and corresponds to the upper border of the atria. The right lung has 3 lobes (upper, middle, lower); the left has 2 (upper, lower, with a lingular segment).
4.2 Inspection & Palpation
Inspect: shape/symmetry, A/P diameter, scoliosis/kyphosis/tracheal displacement, pectus deformities (excavatum/carinatum), skin (cyanosis), nail beds, breath odor, and respiratory rate/pattern.
Palpate: tenderness, pulsations/bulges/depression/crepitus, respiratory (chest) excursion, tactile fremitus, and tracheal position.
4.3 Percussion & Diaphragmatic Excursion
Percuss systematically, superior to inferior, comparing side to side at 4–5cm intervals. For diaphragmatic excursion: percuss down the scapular line on held exhalation to mark the diaphragm level, then again after a deep inhale-and-hold; the distance between marks is the excursion.
| Finding | Normal / abnormal |
|---|---|
| Diaphragmatic excursion | Normal 3–5.5 cm (up to 7–8 cm if well-conditioned); may be higher on the right (liver) |
| Decreased excursion | Pleural effusion, atelectasis, emphysema, pain, ascites |
4.4 Auscultation & Voice Sounds
| Sound | Characteristics |
|---|---|
| Vesicular | Inspiration > expiration, soft, low pitch (most of lung fields) |
| Bronchovesicular | Inspiration = expiration, intermediate intensity |
| Bronchial/tracheal | Expiration > inspiration, loud, high pitch |
Adventitious sounds: crackles (rales), rhonchi, wheezes, friction rubs. Voice transmission tests: bronchophony (louder "99"), egophony ("E" → "A"), whispered pectoriloquy (whispered words heard clearly) — all suggest consolidation.
5 · Skin, Hair & Nail Examination
Instructional Objectives
- Review the anatomical structures of the integumentary system.
- Discuss the proper clinical skills for a comprehensive examination of the following: skin; hair; nails.
- Demonstrate the proper clinical skills for a comprehensive examination of the following: skin; hair; nails.
5.1 Anatomy & Skin Color
Skin has 3 layers: epidermis (most superficial), dermis (glands, hair follicles, nerve terminals), and subcutaneous tissue. Skin color depends on melanin (brownish, genetics/sun-dependent), hemoglobin (bright red oxyhemoglobin versus darker bluish deoxyhemoglobin), carotene (yellow, subcutaneous fat), and bilirubin (yellow-brown, from heme breakdown).
Sebaceous glands are present everywhere except palms/soles. Eccrine sweat glands are widely distributed; apocrine glands are primarily axillary/groin. Vellus hair is fine/lightly pigmented ("peach fuzz"); terminal hair is coarse and pigmented.
5.2 History
Common/concerning symptoms: hair loss, rashes, growths, sores, lumps/bumps, dryness, itching, and changes (especially moles changing size/shape/color/sensation). Family history should include skin cancers and atopic conditions (eczema, asthma, allergies).
5.3 Examination Technique
| Structure | Inspect for | Palpate for |
|---|---|---|
| Skin | Color, uniformity, thickness, symmetry, lesions, rashes, dryness | Moisture, texture, temperature (dorsal hand), turgor, mobility |
| Hair | Color, distribution, quantity | Texture |
| Nails | Pigmentation, length, symmetry, ridging/pitting, cleanliness | Texture, firmness, thickness, adherence to nail bed |
Patients should be undressed and gowned open in back, with makeup/nail polish removed; only uncover the area being examined at a time, and recover with the gown when finished.
6 · Eye Examination
Instructional Objectives
- Review the anatomy of the eye.
- Identify anatomic landmarks of the eye during the ophthalmoscopic exam.
- Discuss the proper clinical skills for a comprehensive examination of the eye and surrounding structures.
- Demonstrate the proper clinical skills for a comprehensive examination of the eye and surrounding structures.
6.1 Anatomy & Extraocular Muscles
| Muscle | CN (cranial nerve) | Action |
|---|---|---|
| Superior rectus | III | Elevation |
| Inferior rectus | III | Depression |
| Medial rectus | III | Adduction |
| Lateral rectus | VI | Abduction |
| Superior oblique | IV | Intorsion & depression |
| Inferior oblique | III | Extorsion & elevation |
6.2 Vision Testing
Always test visual acuity before any test that shines light directly into the eye. Acuity is recorded as two numbers: distance from chart / distance a normal eye can read that line (for example, 20/40 = at 20 ft, patient reads what a normal person reads at 40 ft). Visual fields by confrontation (monocular static finger-wiggle test) screens for anterior/posterior visual pathway lesions. Color vision is screened with pseudoisochromatic plates.
6.3 External & Pupillary Exam
Inspect palpebral fissures, eyebrows, eyelashes, eyelids, lacrimal apparatus, conjunctiva/sclera, cornea (oblique lighting), iris, and pupils (size/shape/symmetry in dim light; small <3mm, large >5mm).
| Reaction | Definition |
|---|---|
| Direct | Constriction in the illuminated eye |
| Consensual | Constriction in the opposite eye |
| Near reaction | Constriction with convergence; performed if light reaction is impaired |
Corneal light reflection assesses ocular alignment (reflection should be slightly medial of pupil center). Extraocular movements are tested in an "H" pattern through the 6 cardinal gaze positions, pausing at extremes to check for nystagmus.
6.4 Ophthalmoscopic Exam
Darken the room, use the same-side hand/eye as the patient's eye being examined, check the red reflex from ~15 inches away before moving in. Adjust diopters (minus/red for myopia, plus/green for hyperopia) to focus. Inspect the optic disc (margins, color, physiologic cup size) and retina (arteries lighter/smaller, veins darker/larger, AV (atrioventricular) crossings, macula/fovea).
7 · General Survey & Vital Signs
Instructional Objectives
- Discuss the proper clinical skills for a comprehensive examination of the following: general survey; vital signs; pain assessment.
- Demonstrate the proper clinical skills for a comprehensive examination of the following: general survey; vital signs; pain assessment.
7.1 Introduction & Pain Assessment
Confirm identity with 2 identifiers: name and date of birth. Pain history uses OPQRST (onset, palliative/provocative, quality, radiation, severity, timing). Acute pain: typically <3–6 months. Chronic pain: typically >3–6 months or recurrent. Nociceptive pain = tissue damage; neuropathic pain = nervous system damage/disease. On a 1–10 scale, always ask the patient what their personal "10" is.
7.2 General Survey
The general survey is the initial overall impression on entering the room: apparent state of health, discomfort/distress, skin color, dress, grooming, affect, posture/gait, and body habitus.
7.3 Temperature & Pulse
| Vital sign | Normal / technique |
|---|---|
| Temperature | Varies by site (oral, rectal, tympanic, temporal); diurnal variation exists |
| Heart rate | Normal adult: 60–100 bpm; auscultate carotid before palpating |
Palpate pulses in 8+ locations (radial, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis). Never palpate both carotids simultaneously — risk of decreased cerebral blood flow and syncope.
7.4 Respirations & Blood Pressure
Normal adult respiratory rate: 12–20/min. Count discreetly (for example, while appearing to palpate the pulse).
8 · Cardiovascular & Peripheral Vascular Examination
Instructional Objectives
- Review the anatomy of the heart and great vessels.
- Discuss the relationship between cardiac anatomy and superficial anatomy of the thorax.
- Discuss the relationship between jugular venous pressure and volume status.
- Discuss appropriate utilization of the diaphragm and bell of the stethoscope.
- Discuss the relationship between the events in the cardiac cycle and physical examination findings including: first and second heart sounds (S1, S2); physiologic splitting of S2 (A2, P2); rate, rhythm, and characteristics/quality of heart sounds and pulses.
- Discuss the proper clinical skills for a comprehensive examination of the following: heart; peripheral vasculature.
- Demonstrate the proper clinical skills for a comprehensive examination of the following: heart; peripheral vasculature.
8.1 Cardiac Anatomy & Conduction
The SA (sinoatrial) node is the natural pacemaker (60–100 bpm); the AV (atrioventricular) node delays the impulse before the bundle of His/Purkinje fibers. Cardiac output = heart rate × stroke volume; stroke volume depends on preload, contractility, and afterload. Normal ejection fraction ≈ 60%.
8.2 Cardiac Cycle & Auscultation Areas
| Sound | Origin | Best heard |
|---|---|---|
| S1 | Mitral/tricuspid (AV (atrioventricular)) valve closure | Apex (mitral) & LLSB (tricuspid) |
| S2 | Aortic/pulmonic (semilunar) valve closure | R 2nd ICS (aortic) & L 2nd–3rd ICS (pulmonic) |
Pulse pressure = systolic − diastolic; normal 30–40 mmHg.
8.3 Cardiac Exam Technique
Palpate the precordium for heaves (palms/fingers flat) and thrills (ball of hand, firm pressure) at the aortic/pulmonic/Erb's point/tricuspid/mitral areas. Normal PMI (point of maximal impulse)/apical impulse: 5th ICS (intercostal space), left MCL (midclavicular line), ~2.5cm, brisk gentle tap.
8.4 Peripheral Vascular Anatomy & Exam
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 pulse | Meaning |
|---|---|
| Pulsus parvus | Weak pulse — atherosclerotic PVD (peripheral vascular disease) |
| Pulsus tardus | Sluggish pulse — aortic stenosis or low cardiac output |
Normal capillary refill ≤2–3 seconds. Epitrochlear nodes are usually not palpable when healthy.
9 · HENT (Head, Ears, Nose, Throat) Examination
Instructional Objectives
- Review the anatomy of the head, ears, nose, and throat/neck.
- Discuss the proper clinical skills for a comprehensive examination of the following: head, face, and scalp; ears; nose and sinuses; oral cavity; oropharynx; neck.
- Demonstrate the proper clinical skills for a comprehensive examination of the following: head, face, and scalp; ears; nose and sinuses; oral cavity; oropharynx; neck.
Objective 1 — Anatomy of the head, ears, nose & throat/neck
Review the relevant anatomy: the head (skull, scalp, face, temporomandibular joint, salivary glands); the ears (auricle, external canal, tympanic membrane, and the middle-ear ossicles); the nose and paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) with the nasal septum and turbinates; the oral cavity and oropharynx (teeth, gums, tongue, palate, tonsils); and the neck (cervical lymph-node chains, thyroid gland, trachea, and the carotid/jugular vessels).
9.1 Head, Face & Ear Exam
Head/scalp/hair/face inspection covers size/shape/contour, lesions/dandruff, color/distribution/texture, and asymmetry/expression/edema. Ear TM (tympanic membrane) landmarks: pars flaccida (small, loose, above the malleus), pars tensa, umbo, cone of light. Otoscope technique: pull the auricle up, back, and slightly away from the head to straighten the canal; brace your hand against the patient's head; insert gently, angled down and forward.
9.2 Auditory Testing
| Test | Technique | Normal |
|---|---|---|
| Whispered voice | 2 ft behind patient, occlude/rub tragus of untested ear | 3/6 correct |
| Weber | Tuning fork on vertex | Heard midline |
| Rinne | Mastoid (bone) then near canal (air) | Air > bone |
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.
9.3 Nose & Oral Cavity Exam
Nasal exam: inspect deformities/asymmetry/polyps/turbinates/mucosa/septum; palpate frontal/maxillary sinuses (press up, avoiding the eyes); transilluminate in a darkened room (decreased glow = fluid-filled sinus). Oral cavity: identify Stensen's duct (parotid, buccal mucosa) and Wharton's duct (submandibular, floor of mouth). Have the patient say "ah" to check symmetrical soft palate/uvula rise.
9.4 Neck & Thyroid Exam
Inspect for symmetry, masses, gland enlargement, visible nodes, and tracheal midline position. Palpate the trachea (index fingers on each side, compare distance to SCM (sternocleidomastoid) bilaterally) and thyroid (anterior, facing the patient; or posterior, displacing the trachea toward the palpating side while the patient swallows). A normal thyroid is often not palpable.