Physical Examination of Hands and Arms

• These are notes on how to conduct a physical examination, including what to look for and what the findings might indicate

Hands and Arms

• Pink/perfused color indicates normal status
• Pallor indicates anemia or hypoperfusion and should be followed up with Hb, BP and fluid status checks
• Warm hands and arms indicate normal status
• Cool, cold, or hot hands and arms may indicate hypoperfusion or sepsis; check BP and fluid status
• Normal fingernail shape indicates normal status
• Clubbing, koilonychias, or leukonychia may indicate liver failure, inflammatory bowel disease, or malabsorption
  • Koilonychias may indicate iron deficiency anemia
  • Leukonychia may indicate hypoalbuminemia
• Absence of edema indicates normal fluid status
• Edema may indicate liver failure or heart failure
• Normal palm color indicates normal status
• Palmar erythema or Dupuytren’s contracture may indicate liver failure, pregnancy, or rheumatoid arthritis
  • Palmar erythema may also indicate an increase in estrogen
  • Dupuytren's contracture may indicate liver cirrhosis
• No abnormal movement during asterixis test indicates normal status
• Asterixis (flapping tremor) may indicate liver failure or hepatic encephalopathy; check CVS and respiratory systems for CO2 retention
• Normal arm color and axillae hair indicate normal status
• Loss of axillae hair, darker areas of skin, recent tattoos, or IV use may indicate acanthosis nigricans or hepatitis B/C
  • Acanthosis nigricans can indicate non-alcoholic fatty liver disease, cancer, Cushing’s syndrome or insulin resistance

Face, Neck and Upper Thorax

• Pink mucous membranes and white sclera indicate normal eyes
• Pallor and jaundice may indicate anemia or liver failure
• Normal cheek shape indicates normal status
• Round cheek shape, bilateral parotid swelling or spider naevi anywhere on the face may indicate Cushing’s syndrome or chronic alcohol abuse
• Intact lips indicate normal status
• Mouth sores may indicate iron deficiency, B12 deficiency, Folate deficiency, Crohn’s disease or malabsorption
• Pink, moist mucous membranes indicate a normal mouth
• Pallor or dry mouth may indicate iron deficiency, B12 deficiency, or Folate deficiency
• Angular stomatitis at the edges of the mouth may indicate iron deficiency, B12 deficiency, or Folate deficiency
• Intact teeth indicate normal status
• Poor dentition may indicate poor diet or malabsorption
• Pink, intact gums indicate normal status
• Gingivitis may indicate iron deficiency, B12 deficiency, or Folate deficiency
• Soft, non-inflamed, non-hard cervical lymph nodes indicate normal status
• Palpable, hard, or painful lymph nodes may indicate infection, malignancy, or inflammation
• Normal upper thorax indicates normal status
• Spider naevi, gynaecomastia, or petechiae may indicate liver failure, clotting disorder, or pregnancy

Abdomen

• A non-distended abdomen indicates normal shape
• A distended abdomen, masses, ascites, or organomegaly may indicate constipation, hernias, tumors, or portal hypertension
• A symmetrical abdomen indicates normal status
• An asymmetrical abdomen may indicate hernias or visible mass
• Absence of scarring indicates normal status
• Fresh or old scars may indicate surgical scars such as appendicitis or midline
• Absence of lesions indicates normal skin
• Rash, wounds, or bruising may indicate trauma or local infections
• No signs of portal hypertension indicate normal status
• Spider naevi, collateral venous circulation, or caput medusa may indicate chronic liver disease, liver cirrhosis, or obstruction to the inferior vena cava
• No petechiae or bruising indicates normal status
• Petechiae or bruising over the abdomen or retroperitoneal area may indicate abdominal bleeding, clotting disorder, or liver failure
  • Retroperitoneal area bruising may indicate a clotting disorder, haemorrhagic pancreatitis, or AAA
  • Lower abdominal bruising/pain may indicate ectopic pregnancy, MSK, or pelvic issues
• No peristalsis on tangential inspection indicates normal status
• Peristalsis on inspection may indicate obstructed small bowel or colon
• Absence of pulsations above the umbilicus on inspection indicates normal status
• Pulsating and expansile mass may indicate aortic aneurysm
• Bowel sounds in all 4 quadrants indicate normal auscultation
  • Clicks/gurgling sounds should be present 5-35 times per minute
  • Borborygmi (very loud, prolonged growling/rumbling bowel sounds) are normal
  • Absent bowel sounds (no sounds for more than 5 minutes) are abnormal
  • Hyperactive bowel sounds (>35 clicks/gurgles per minute, high pitched sounds) are abnormal
  • Hypoactive bowel sounds (infrequent sounds in one area of the abdomen) are abnormal and may indicate peritonitis
• Absence of signs on appendicitis tests indicates normal status
• Positive McBurney’s point, psoas, or obturator signs may indicate appendicitis, pelvic disease, or bony pain
• Soft, non-tender abdomen without masses during light palpation indicates normal status
• Firmness, pain, masses, guarding, or rigidity during light palpation may indicate a tumor, hernias, or acute abdomen with rigidity
• Soft, non-tender abdomen without masses during deep palpation indicates normal status
• Firmness, pain, masses, or rebound tenderness during deep palpation may indicate a tumor, hernias, or peritonitis
• Non-palpable liver indicates normal liver palpation
• Palpable liver edge or hepatomegaly may indicate fatty liver, liver failure, or liver mass
• Absence of pain while the patient breathes in during cholecystitis test indicates normal status
• Positive Murphy’s sign (pain while patient breathes in) may indicate respiratory pain or disease
• No renal tenderness on palpation of the flank indicates normal status
• Painful, tender flank may indicate a UTI, renal disease, renal abscess, calculus, or infarction
• Tympanic percussion throughout all 9 areas indicates normal status
• Dullness on percussion may indicate a mass, stool, or fluid
• Liver not noticed on percussion indicates normal status
• Lower liver margin identified below ribs on percussion may indicate fatty liver, liver failure, or liver mass

Special Tests

• Negative shifting dullness test indicates absence of ascites
• Positive shifting dullness test may indicate portal hypertension or chronic liver failure
• Negative fluid wave test indicates absence of ascites
• Positive fluid wave test may indicate portal hypertension or chronic liver failure
• Normal rectal exam indicates normal status
• Signs of bleeding or enlarged prostate during a rectal exam may indicate haemorrhoids, malignancy, or urine flow obstruction
• Normal pelvic exam indicates normal status
• Abnormal bleeding, pain, bruising, or infection during a pelvic exam may indicate infections, STIs, malignancy, or PID
• Only one appendicitis test needs demonstrated for appendicitis in OSCE
• Rectal/pelvic exams are not performed in OSCE and should only be assessed in practice with the student’s supervisor present