Physical Diagnosis 1 · Exam 3 — Study Guide

1 · Pelvic Exam (Female Genitalia)

1.1 · Objective 1 — Review the anatomy of the female internal & external genitalia

Internal structures: the vagina (hollow muscular tube between the bladder and rectum, mucosal rugae absent in children/post-menopause, fornices surrounding the cervix); the uterus (body at a right angle to and inclined forward over the bladder; fundus = domed superior area; cervix's external os is round in nulliparous women, slit-like after childbirth); fallopian tubes (fimbriated distal ends) and ovaries (suspended at the level of the ASIS (anterior superior iliac spine)); and the Pouch of Douglas (retrouterine peritoneal cul-de-sac, reachable on rectal exam).

1.2 · Objectives 2 & 3 — Clinical skills: exam preparation & positioning

Equipment: good lighting, pen light (if the speculum lacks a light adapter), correctly sized vaginal speculum, water-soluble lubricant (never gel — it interferes with the Pap smear), and Pap smear equipment (cotton swab, spatula, brush, glass slide, fixative spray).

1.3 · Objectives 2 & 3 — Clinical skills: external, speculum, bimanual & rectovaginal technique

2 · Breast Examination

2.1 · Objectives 1 & 2 — Anatomy of the breast & axillary nodes; lymphatic drainage

The breast lies between the 2nd and 6th rib, 2/3 superficial to the pectoral muscle and 1/3 superficial to the serratus anterior. Glandular tissue is organized into lobes around the nipple, each drained by its own duct (dilating at the areola to accumulate milk during lactation). Cooper's ligament is the fibrous suspensory ligament connecting skin to breast fascia; adipose tissue surrounds the glandular tissue both superficially and deeply.

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).

2.2 · Objective 3 — Stages of breast development

Pregnancy: enlargement (glandular hyperplasia, increased vascularity), increased nodularity, nipples/areolae darken and enlarge, colostrum (thick yellow discharge) late in pregnancy. Aging: breasts diminish in size, glandular tissue atrophies and is replaced by adipose tissue, ducts become palpable as firm strands.

2.3 · Objectives 4 & 5 — Clinical skills: inspection & palpation technique

No equipment needed; be sensitive to the patient (premenstrual breasts are more tender). Sitting position for inspection (exaggerates dimpling/retraction) — static (arms at sides) then dynamic (arms overhead, hands pressed on hips, lean forward if pendulous), observing for skin tethering, retraction, dimpling, and asymmetric movement. Note color (redness = cancer/inflammation), thickening (cancer), size/symmetry (some asymmetry is normal), contour, and masses. Nipple: inversion can be a normal variant, but retraction is concerning for cancer; rash/discharge suggests Paget's disease.

Axillary lymph nodes are palpated systematically (pectoral, subscapular, lateral, central, apical, infra-/supraclavicular), assessing size, consistency, mobility, and tenderness.

3 · Musculoskeletal Physical Examination

3.1 · Objective 1 — Review the anatomy of the joints

Articular structures: joint capsule, articular cartilage, synovium/synovial fluid, intra-articular ligaments, juxta-articular bone. Extra-articular: periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, overlying skin.

3.2 · Objectives 2 & 3 — Clinical skills: exam order (IPROMS) & muscle grading

Order of examination — IPROMS: Inspection (LOOK: posture, symmetry, deformity, curvature, wasting, swelling), Palpation (FEEL: tenderness, warmth, irregularities), Range of motion, and Special maneuvers. Active ROM = the patient moves the joint; passive ROM = the examiner moves it (compare end points; note pain and crepitus).

3.3 · Objectives 2 & 3 — Clinical skills: TMJ, spine, and upper & lower extremities

Temporomandibular joint: place fingertips just in front of the tragus; test open/close, lateral, protrude/retract. Shoulder joints: glenohumeral (humeral head + glenoid fossa), sternoclavicular (medial clavicle + sternum), acromioclavicular (lateral clavicle + acromion); rotator cuff = SITS (supraspinatus, infraspinatus, teres minor, subscapularis). Elbow: the ulnar nerve is palpated posteriorly between the olecranon and the medial epicondyle.

4 · Neurological Exam (Central & Peripheral Nervous System)

4.1 · Objective 1 — Review the anatomy of the nervous system & dermatomes

The neuro exam has six categories: mental status, cranial nerves, motor system, reflexes, sensory system, and coordination/station/gait. The central nervous system is the brain and spinal cord; the peripheral nervous system is the 12 cranial nerves and 31 pairs of spinal nerves (anterior/ventral motor root, posterior/dorsal sensory root).

4.2 · Objectives 2 & 3 — Clinical skills: mental status

Orientation: person, place, time = ×3; adding event = ×4. Also assess language (aphasia — comprehension, repetition, naming), memory (recent/remote), calculation (serial sevens, spelling “WORLD” backwards), visuospatial (copy shapes), and abstract reasoning (proverbs).

4.3 · Objectives 2 & 3 — Clinical skills: central nervous system (cranial nerves)

4.4 · Objectives 2 & 3 — Clinical skills: peripheral NS, cerebellar function & reflexes

Motor: inspect bulk, assess tone (resistance to passive stretch), and grade strength 0–5 (5 = full movement against resistance without fatigue).

Sensory: test pain/temperature (spinothalamic), position/vibration (posterior columns, 128 Hz fork), and discriminative sensations — stereognosis (recognize object by touch), graphesthesia (number drawn on the palm), two-point discrimination (<5 mm on finger pads), and extinction (double simultaneous stimulation). Key dermatomes: C6 thumb, C7 middle finger, C8 little finger, T4 nipple, T10 umbilicus, S1 lateral foot.

Coordination/station: rapid alternating movements (cerebellar), Romberg (stand feet together, eyes open then closed — tests position sense), and pronator drift (arms extended palms up, eyes closed).

5 · Beyond the Objectives — Clinical Findings & High-Yield Extras

5.1 · Pelvic exam — extras

• Abnormal external findings: on inspection, note inflammation, ulcerations, discharge, nodules, vesicles, or masses.
• Hymen: the membrane that covers the introitus in the virginal state.
• ThinPrep vs. conventional Pap: the ThinPrep suspends the collected cells in liquid (a cleaner slide, with fewer cells obscured by blood or mucus), whereas the conventional Pap is smeared/painted directly onto the slide.

5.2 · Breast exam — extras

• Surface anatomy: Montgomery tubercles (glandulae areolares) are sebaceous glands on the areola; the nipple is usually everted, though long-standing inversion can be a normal variant.
• Characterizing a mass/abnormality: describe its location, size, shape (round, disc-like, regular vs. irregular), consistency (soft, firm, hard), tenderness, and mobility (freely mobile vs. fixed to skin or chest wall).
• Warning signs of malignancy: skin redness (cancer or inflammatory conditions), skin thickening / peau d'orange, new nipple retraction or inversion, dimpling accentuated on maneuvers, and a hard, irregular, fixed mass.
• Augmented breasts: press firmly inward at the breast edge (until you feel the ribs) to examine the tissue around the implant.
• Physiologic changes: pregnancy → glandular hyperplasia, increased vascularity/nodularity, nipple enlargement; aging → glandular atrophy replaced by adipose tissue, decreased size.

5.3 · Musculoskeletal exam — extras

• Joint types: synovial (freely movable, articular cartilage + synovial cavity/fluid — e.g., shoulder, knee), cartilaginous (slightly movable — e.g., intervertebral discs), and fibrous (essentially immovable — e.g., skull sutures).
• Articular vs. extra-articular structures: articular = joint capsule, articular cartilage, synovium/synovial fluid, intra-articular ligaments; extra-articular = periarticular ligaments, tendons, bursae, muscle, fascia, bone.
• Special/stress maneuvers (provocative joint tests) are introduced but largely deferred to PD III; every joint exam still follows IPROMS (Inspection, Palpation, Range of motion, Special maneuvers).

5.4 · Neuro exam — extras

• CN II testing: assess visual acuity with a Snellen chart, and perform the fundoscopic exam (red reflex, optic disc, vessels).
• Reinforcement (Jendrassik) maneuver: if a deep-tendon reflex is hard to elicit, have the patient clench the jaw or clasp the hands and pull them apart for ~10 seconds while you strike; grade the reflex as reinforced.
• Superficial abdominal reflex: lightly stroke each quadrant — above the umbilicus tests T8–T10, below the umbilicus tests T10–T12.
• Motor strength by nerve root (quick reference): shoulder abduction C5–C6 (deltoid/axillary); elbow flexion C5–C6 (biceps); elbow extension C6–C8 (triceps); wrist extension C6–C8 (radial); grip C7–T1; finger abduction/adduction C8–T1 (ulnar); hip flexion L2–L4 (iliopsoas/femoral); hip extension S1 (gluteus maximus); knee extension L2–L4 (quadriceps); knee flexion L4–S2 (hamstrings); ankle dorsiflexion L4–L5 (tibialis anterior); ankle plantarflexion S1 (gastrocnemius/soleus).
• Deep-tendon-reflex roots: biceps C5–C6, brachioradialis C5–C6, triceps C6–C7, patellar L2–L4, Achilles S1.

6 · Writing the History & Physical and Progress Notes

6.1 Communication & the interview IO 1

The history and the physical are taught separately but are intertwined: the history guides the examination, and examination findings send you back for more history. The first encounter sets the tone for every later visit — focus, avoid distractions, use open posture and appropriate eye contact, and learn about the patient rather than only their problem.

There is no perfect formula. Structure matters but is not everything; adapt to the patient. Direct the conversation, but do not control it so tightly that the patient's story is affected — that is how omissions and errors get in.

Barriers to communication: emotional, sensory, cultural differences, disabilities and other health problems, language, and terminology.

6.2 The history and physical, section by section IO 4

Information is not obtained in the order it must be documented. The interview is freeform and moves general to specific; the document follows guidelines.

6.3 Documenting the physical examination IO 4

Document what you observed, starting with the general survey and moving through all body systems.

When part of the examination is not performed, document that section as ‘Not done’ with an explanation — for example “Rectal examination: Not done, patient refused,” “… deferred by preceptor,” or “… deferred per assignment instructions.”

For program assignments, vital signs are the first element of the physical examination, best documented as a bulleted list in metric units — height in centimetres, weight in kilograms, blood pressure in millimetres of mercury with the arm and position, heart rate and rhythm, respiratory rate, temperature in degrees Celsius with the route, and oxygen saturation with the delivery.

6.4 Differential, assessment & plan IO 5

Differential diagnoses — aim for three or more. The first is the most likely, explained with evidence from the history and examination; the rest explain why they were considered and why they are less likely, and may note what testing would rule them in or out.

Steps for building one: identify abnormal findings → consider anatomic location → look for patterns (one problem, several related, or unrelated?) → look for probable cause → generate hypotheses → test them with labs, imaging, or more history and examination.

Assessment — a simple list. All the arguing was done in the differential statements. Includes chronic conditions and concurrent diagnoses.

Plan — addresses every item in the assessment: disposition (inpatient/outpatient), testing, treatment (pharmacologic — indication, drug name, dosage, route, frequency — and non-pharmacologic), referrals, patient education (detailed), and follow-up.

6.5 The progress note IO 4

A standardized way to document encounters, usually for daily evaluation of hospitalized inpatients, and more focused than a full history and physical.

6.6 Where notes go wrong IO 2 IO 3

7 · The SOAP Note & Oral Case Presentations

7.1 What a SOAP note is IO 4

Subjective · Objective · Assessment · Plan. It is a standardized way to document an encounter, and it is more focused than a history and physical.

7.2 Describing a symptom IO 4

The seven attributes of a symptom: location · quality · quantity or severity · timing · onset · palliative or provocative factors · associated manifestations.

Four pain mnemonics appear in this lecture. They collect the same information in different orders — learn one well, and recognise the rest.

7.3 How far the examination reaches IO 4

Examine the systems pertinent to the chief complaint and the positive history. When in doubt, go a system up and down from the affected system. Two questions decide the rest:

• What needs to be examined to rule in or rule out the worst-case scenario?
• What are your differentials, and how can you rule them in or out?

All examinations generally include cardiac and respiratory, and every objective section includes a general assessment or impression.

7.4 Differential, assessment and plan IO 5

Differential diagnoses: aim for three or more. The first is the most likely — explain why using evidence from the history and examination. The others explain why they were considered and why they are less likely, and may name the tests that would settle them. The test of a good differential is that another provider can follow your thought process from it.

Assessment: the final diagnosis, based on history, physical examination and diagnostic testing, plus any other condition needing assessment or treatment — chronic conditions and concurrent diagnoses.

7.5 The worked sample note IO 5

The lecture builds one case end to end: a 25-year-old with three days of right facial pain and pressure with thick yellow-green mucus, on a week of allergy symptoms. It is worth reading as a model of how much detail each section carries.

• Subjective — pain 3/10 at onset, 5/10 now, 7/10 on leaning down, smiling and chewing; her 10 is childbirth; two allergy tablets daily for four days, dosage unknown, no longer working. Denies sore throat, headache, ear pain, shortness of breath, cough, and sick contacts. Siblings have the same seasonal allergies.
• Objective — temperature 38°C orally; maxillary sinuses tender bilaterally with frontal sinuses nontender; no transillumination on the right, present on the left; thick green mucus in the right nasal passage with erythematous, edematous turbinates.
• Differential — acute sinusitis, allergic rhinitis, viral upper respiratory infection, retained nasal foreign body, each with a statement tying the patient's findings to it.
• Assessment — #1 acute sinusitis, #2 allergic rhinitis.
• Plan — fluticasone 50µg nasal spray, one spray each nostril twice daily for seven days then once daily as needed; education on technique with a caution against spraying the septum; follow up if not improved in five days, sooner if anything worsens.

7.6 The oral case presentation IO 4

A well organised vignette describing the patient and the clinical problem, so listeners can visualise the patient and understand the problem. You will give one to preceptors and supervising physicians, to consulting practitioners, on rounds, and on phone calls.

It carries only information relevant to the patient's condition, and conveys four things: what the patient told you, what you found, what you concluded, and what you want to do about it. The order is the same as a written report — chief complaint and history of present illness, past medical and surgical history, childhood illnesses, medications and allergies, social and family history, review of systems, examination, labs, assessment, plan.

7.7 Documentation principles IO 2 · IO 3