Pelvic Exam, Breast Examination, the Musculoskeletal Physical Examination, and the Neurological Exam, condensed to the highest-yield technique and findings.
| Topic | One-glance facts |
|---|---|
| External genital landmarks | Mons pubis (hair-covered fat pad, inverted-triangle pattern) → labia majora → labia minora (forms anterior prepuce) → vestibule (urethral meatus, introitus). Skene's glands flank the urethral meatus; Bartholin's (greater vestibular) glands open at 5 and 7 o'clock; perineum spans introitus to anus. |
| Internal structures | Vagina runs between bladder and rectum (rugae absent in children/post-menopause; fornices surround cervix). Uterus angles forward over the bladder; external os is round (nulliparous) or slit-like (post-childbirth). Ovaries suspend at the ASIS level; Pouch of Douglas is the retrouterine cul-de-sac, palpable on rectal exam. |
| Exam prep & positioning | Empty the bladder first — a full bladder impairs bimanual palpation and causes discomfort. Elevate head/shoulders to relax the abdomen, keep arms at the sides (never overhead, which tenses the abdomen), depress the drape midline for eye contact, and narrate each step before proceeding. |
| Equipment pearls | Correctly sized speculum, good lighting (pen light if no speculum light adapter), and water-soluble lubricant only — gel lubricant interferes with Pap smear cytology. Pap kit: cotton swab, spatula, brush, glass slide, fixative spray. |
| External inspection & Bartholin's palpation | Assess Tanner staging and inspect for inflammation, ulceration, or discharge; retract labia to expose structures. Palpate Bartholin's glands with index finger internal (posterior introitus) and thumb external, at the 5 and 7 o'clock positions. |
| Speculum insertion & cervical inspection | Enlarge the introitus with two-finger downward pressure posteriorly; insert the closed speculum at a 45° downward angle along the posterior wall, then rotate to horizontal once fully inserted. Open the speculum and "cup" the cervix into view to inspect os color, position, and pathology. |
| Pap smear collection | Cotton swab samples the endocervix (rolled and painted on the slide), spatula scrapes the squamocolumnar junction in a full circle, and the cervical brush is rotated within the os. |
| Bimanual exam | Palpate the cervix and fornices — normal is 1-2cm of movement without pain. "Grasp" the uterus between the abdominal and pelvic hands; palpate each ovary via the corresponding fornix plus the abdominal hand. |
| Rectovaginal exam | Change to a new outer glove; index finger in the vagina, middle finger in the anus (patient bears down) to palpate the rectovaginal septum and posterior fornix, and assess sphincter tone on withdrawal. |
| Topic | One-glance facts |
|---|---|
| Breast anatomy | Spans the 2nd–6th rib, 2/3 superficial to pectoral muscle and 1/3 superficial to serratus anterior. Glandular tissue forms lobes around the nipple, each with its own duct dilating at the areola during lactation. Cooper's ligament suspends skin from breast fascia; adipose surrounds the glandular tissue superficially and deeply. |
| Vascular supply | Medial quadrants: internal thoracic artery perforators + anterior intercostal artery branches. Lateral quadrants: thoracoacromial (pectoral branches) + lateral thoracic artery (external mammary branch). |
| Lymphatic drainage | ~75% of breast lymph empties into axillary nodes. Medial portions drain to internal mammary (parasternal) nodes; some vessels cross to the contralateral breast; inferior lymphatics can reach subdiaphragmatic/abdominal/hepatic pathways. |
| Axillary node groups | Pectoral (anterior, drains most breast tissue), subscapular (posterior), lateral (upper humerus), central (high in axilla, most frequently palpable), and infra-/supraclavicular (receive from central nodes). |
| Tanner staging (breast) | 1: nipple elevation only, no bud. 2: breast bud — round mound, wider areola. 3: further enlargement, areola/breast still confluent. 4: areola/nipple form a secondary mound above the breast. 5: nipple projects alone as areola recedes to breast contour. |
| Pregnancy & aging changes | Pregnancy: enlargement (glandular hyperplasia, increased vascularity), increased nodularity, darkened/enlarged nipples-areolae, late colostrum (thick yellow discharge). Aging: overall size diminishes, glandular tissue atrophies and is replaced by adipose, ducts become palpable as firm strands. |
| Inspection technique | Sitting position (exaggerates dimpling/retraction): static (arms at sides) then dynamic (arms overhead, hands on hips, lean forward if pendulous). Note color (redness = cancer/inflammation), thickening (cancer), size/symmetry (mild asymmetry normal), contour, and masses; nipple inversion can be normal, but retraction is concerning for cancer, and rash/discharge suggests Paget's disease. |
| Palpation technique | Supine, pillow under the ipsilateral shoulder, arm over/behind the head to spread the breast evenly. Use finger pads of fingers 2-4 in a vertical-strip pattern with light, medium, and deep pressure to assess consistency, tenderness, nodules, and mobility; in implant patients, press firmly at the implant edges to feel the ribs beneath. |
| Axillary node palpation | Systematically palpate pectoral, subscapular, lateral, central, and infra-/supraclavicular groups, assessing size, consistency, mobility, and tenderness. |
| Topic | One-glance facts |
|---|---|
| Support structures | Ligament = bone to bone; tendon = muscle to bone; cartilage = collagen matrix over bone; bursa = synovial-fluid pouch cushioning tendon/muscle over bone. |
| Joint types | Synovial = freely movable (articular cartilage + synovial cavity/fluid); fibrous = no movement (skull sutures); cartilaginous = slightly movable (fibrocartilage discs with nucleus pulposus). |
| Synovial subtypes | Spheroidal / ball-and-socket (shoulder, hip — wide-ranging); hinge (elbow, IP joints — flexion/extension one plane); condylar (knee, TMJ — surfaces not dissociable). |
| Exam order — IPROMS | Inspection (LOOK), Palpation (FEEL), Range of motion, Special maneuvers. Active ROM = patient moves; passive ROM = examiner moves (compare end points; note pain, crepitus). |
| Muscle strength 0-5 | 0 none; 1 trace; 2 full ROM but not vs gravity; 3 vs gravity not resistance; 4 vs gravity + some resistance (weak); 5 full resistance (normal). |
| TMJ | Fingertips just in front of the tragus; test open/close, lateral, protrude/retract. |
| Cervical spine ROM | Flexion 45°, extension 55°, lateral bend 40° (C2-C7), rotation 70° (C1-C2). Spinous process most prominent at C7/T1. |
| Thoracolumbar ROM | Forward flexion 40-60° (touch toes), extension 20-35°, lateral bend 15-20°, rotation 3-18°. Scoliosis = lateral curvature (inspect from behind). |
| Shoulder | Joints: glenohumeral (humeral head + glenoid fossa), sternoclavicular (medial clavicle + sternum), acromioclavicular (lateral clavicle + acromion). Rotator cuff = SITS (supraspinatus, infraspinatus, teres minor, subscapularis). ROM: flexion, extension, ab/adduction, internal/external rotation. |
| Elbow | Flexion 160°, extension 0 to −5°, pronation/supination at 90°. Ulnar nerve palpated between olecranon and medial epicondyle. |
| Wrist & hand | Wrist flexion 75-90°, extension 65-90°, radial deviation 20-25°, ulnar 30-55°. Finger flexion ~90°. Thumb opposition = touch thumb to little finger. |
| Hip | Flexion 110-130° (knee to chest, supine), extension 30°, ab 35-50°/adduction 25-30°, internal 40°/external 45° rotation. Stabilize the opposite hip during ab/adduction. |
| Knee | Flexion ~130°, extension 0-15°. Palpate patella/tendon, femoral condyles, tibial tuberosity, tibial plateaus, joint lines. |
| Ankle & foot | Dorsiflexion 10-20°, plantar flexion 35-50°, inversion 30°, eversion 20°. Lateral ankle ligaments: anterior talofibular, calcaneofibular, posterior talofibular. |
| Topic | One-glance facts |
|---|---|
| Six exam categories | Mental status, cranial nerves, motor system, reflexes, sensory system, coordination/station/gait. |
| CNS vs PNS | CNS = brain + spinal cord. PNS = 12 cranial nerves + 31 pairs of spinal nerves (anterior/ventral motor root, posterior/dorsal sensory root). |
| Sensory/motor tracts | Spinothalamic = pain & temperature; posterior columns = vibration & proprioception; corticospinal = voluntary motor (tested by the plantar/Babinski response). |
| Equipment | 128 Hz tuning fork = vibratory sense; 512 Hz fork = Rinne & Weber hearing tests; reflex hammer; penlight. |
| Levels of consciousness | Alert (responds fully) → lethargic (drowsy, rouses to voice) → obtunded (opens eyes, responds slowly) → stupor (rouses only to pain) → coma (unarousable, no response to pain). |
| Mental status | Orientation: person/place/time = ×3, + event = ×4. Assess language (aphasia), memory, calculation (serial sevens, spell WORLD backward), visuospatial, abstract reasoning (proverbs). |
| Cranial nerves I-VI | I olfactory (smell); II optic (acuity, fundi, fields, pupillary reflex — acuity before light); III oculomotor (PERRL, lid, most EOM); IV trochlear (superior oblique, SO4); V trigeminal (face sensation + mastication); VI abducens (lateral rectus, LR6). |
| Cranial nerves VII-XII | VII facial (expression: brows, eyes, smile, cheeks); VIII vestibulocochlear (balance, hearing); IX/X glossopharyngeal/vagus (say Ah, gag, swallow); XI accessory (shrug, turn head); XII hypoglossal (protrude tongue, watch for deviation). |
| Motor exam | Inspect bulk; assess tone (resistance to passive stretch); grade strength 0-5 (5 = full movement against resistance, no fatigue). |
| Deep tendon reflexes | Biceps C5,C6; brachioradialis C5,C6; triceps C6,C7; patellar (quadriceps) L2,L3,L4; Achilles S1. Grading: 0 absent, 1+ diminished, 2+ normal, 3+ brisk, 4+ hyperactive with clonus. |
| Cutaneous reflexes | Abdominal (upper T8-10, lower T10-12); plantar/Babinski (L5,S1) — normal adult is downgoing toe flexion, upgoing = corticospinal lesion; anal S2-S4. |
| Sensory exam | Pain/temp (spinothalamic); position/vibration (posterior columns, 128 Hz). Discriminative: stereognosis (object by touch), graphesthesia (number on palm), two-point (<5 mm finger pads), extinction (double simultaneous stimulation). |
| Key dermatomes | C6 thumb; C7 middle finger; C8 little finger; T4 nipple line; T10 umbilicus; L1 inguinal; S1 lateral foot / 5th toe. |
| Coordination & station | Rapid alternating movements (cerebellar); Romberg (feet together, eyes open then closed — position sense); pronator drift (arms out, palms up, eyes closed). |
| Topic | One-glance facts |
|---|---|
| Chief complaint | Patient's OWN WORDS + duration. Why they sought care, how long it has been present. |
| 7 attributes of a symptom | Location · Quality · Quantity/severity · Timing · Onset · Palliative/provocative · Associated manifestations. |
| Pertinent positives / negatives | Positives argue FOR a diagnosis; negatives RULE OUT alternatives. Both belong in the history of present illness. |
| FIFE (patient's perspective) | Feeling (fears) · Ideas (nature/cause) · Function (effect on life) · Expectations (of illness, clinician, health care). |
| Communication techniques | Active listening · empathetic responses · guided questioning (general→specific, open→focused) · echoing · clarification · validation · summarization · transitions (signposting). |
| Barriers to communication | Emotional · sensory · cultural differences · disabilities and other health problems · language · terminology. |
| Medications | Dosage, route, frequency, indication, compliance — prescription, over-the-counter, vitamins/supplements. |
| Allergies | Medication, food, environment + REACTION and SEVERITY. Verify at every appointment. |
| Family history | THREE generations, oldest to youngest: age, living/deceased, health status, diseases. |
| Vital signs (assignments) | FIRST element of the physical exam, bulleted, METRIC. Blood pressure records the arm and the position. |
| Documenting the exam | Document what you OBSERVED, general survey first, then all systems. Avoid abbreviations — when in doubt, spell it out. Avoid vague conclusions (normal/abnormal/appropriate). |
| Exam section not performed | Document as ‘Not done’ WITH an explanation — e.g. “Rectal examination: Not done, patient refused.” |
| Differential diagnoses | THREE or more. Most likely FIRST, argued from history and exam evidence; others explain why considered and why less likely. |
| Building a differential | Identify abnormal findings → anatomic location → look for patterns → probable cause → generate hypotheses → test them. |
| Assessment | A SIMPLE LIST — the arguing happened in the differential statements. Includes chronic and concurrent diagnoses. |
| Plan | Disposition (inpatient/outpatient) · testing · treatment (pharm: indication, drug, dose, route, frequency; non-pharm) · referrals · patient education (DETAILED) · follow-up. |
| Progress note = SOAP | Subjective (updates since last note, NOT a full retelling) · Objective (updated vitals, labs, FOCUSED exam of pertinent systems) · Assessment · Plan. Usually daily inpatient; more focused than an H&P. |
| Where notes go wrong | TECHNICAL: missing components, terminology, word errors, inconsistency. CONTENT: too little information, H&P vs progress-note confusion, vague details. ORGANIZATION: hard to follow the exam or the story, information in the wrong section. |
| Legal weight | The note is a legal document — your signature makes you responsible for the accuracy of the content. |
| Topic | One-glance facts |
|---|---|
| SOAP | Subjective · Objective · Assessment · Plan. Standardized encounter documentation; MORE FOCUSED than an H&P. |
| Subjective | “What the patient said.” Narrative, like the history of present illness. Pertinent positives/negatives, medical & surgical history, family, social, review of systems, medications, allergies. |
| What is pertinent? | DEPENDS ON THE CASE. Related to the chief complaint · prior/related episodes · risk factors · anything that rules differentials in or out. |
| 7 attributes of a symptom | Location · Quality · Quantity/severity · Timing · Onset · Palliative/provocative · Associated manifestations. |
| OPPQRST | Onset · Palliative · Provocative · Quality · Radiation · Severity (1–10 — what is a 10 for them?) · Timing. |
| OLD ChARTS | Onset · Location · Duration · Character · Alleviating/aggravating · Radiation · Temporal pattern · Symptoms associated. |
| ChLORIDEPP | Character · Location · Onset · Radiation · Intensity · Duration · Extra symptoms · Palliative · Provocative. |
| LOCQSMAT | Location · Onset · Chronology · Quality · Severity · Modifying factors · Additional symptoms · Treatment. |
| Objective | “What you found.” Observations, measurements, tests done at the encounter. ALWAYS includes a general assessment/impression. All exams generally include CARDIAC + RESPIRATORY. |
| How wide to examine | When in doubt, go a system UP AND DOWN from the affected one. Ask: what rules in/out the WORST-CASE scenario? |
| Differential diagnoses | Aim for 3 or more. First = MOST LIKELY, justified from history + exam. Others: why considered, why less likely. Reader must follow your thought process. |
| Assessment | Final diagnosis from history + exam + testing. Also chronic conditions and concurrent diagnoses. |
| Plan | Disposition (inpatient/outpatient) · testing · treatment · referrals · patient education · follow-up. Pharmacologic needs INDICATION, DRUG, DOSE, ROUTE, FREQUENCY. |
| Sample note — key numbers | Pain 3/10 → 5/10 now, 7/10 leaning down/smiling/chewing; her 10 = childbirth. Temp 38°C oral. Maxillary sinuses tender bilaterally, frontal nontender. NO transillumination on the RIGHT. |
| Sample note — conclusion | Differential: acute sinusitis, allergic rhinitis, viral upper respiratory infection, retained nasal foreign body. Assessment #1 acute sinusitis, #2 allergic rhinitis. Fluticasone 50µg, 1 spray each nostril twice daily × 7 days, then daily as needed; avoid the septum; follow up 5 days. |
| Oral case presentation | Organised vignette; SAME ORDER as written reports. Conveys: what the patient told you · what you found · what you concluded · what you want to do. |
| How much to present | New patient = COMPLETE history. Established in clinic = chief complaint + active problems. Follow-up = status of active problems, new concerns, changes. |
| Presentation pearls | Stay relaxed · keep order · DON'T read your notes · tell a story · err on saying LESS (they can ask). |
| KISS | Keep It Simple Students. Head-to-toe progression, headings, be SPECIFIC (“normal” says nothing), concise, short phrases, AVOID ABBREVIATIONS — when in doubt, spell it out. |