For each section - relevant information only

General examination

• General condition, body build, BP/P/Temp, P/J/C/LN (pallor, jaundice, cyanosis, LN)

System specific examination

• IPPA

Remember this sequence even if all not required

1. GI disease: hepatobiliary and pancreatic, upper GI - most common (must know how to examine)
2. Urological disease
3. Vascular disease
4. Br disease
5. Endocrine
6. Subspecialties: H&N, ENT, Plastic, Neurosurgery, Orthopaedic

What particular points in the history would you like to ask? How would you perform the physical examination?

• Unlikely to be surgical emergency: history 1m
• Malignant: anorexia, wt loss significant

• Pain (site, duration, nature, radiation, progress, aggravating and relieving factors)
• Nausea, dysphagia or vomiting (nature, volume, frequency, relation to meal)
• Change in bowel habit (frequency, constipation / diarrhoea, any mucus (benign polypoid cancer), any per rectal bleeding, malaena, pale stool in long-term obstructive jaundice)
• Tea-colour urine (suggests obstructive jaundice: BR < mmol/L)
• Anorexia, weight loss, fever (wt loss due to anorexia, or intake normal, how much wt loss)
• Systemic review
• RS: lung metastasis -> dyspnoea, pleural effusion
• MSS: back, bone pain
• Cancer: first spreads to lung, then to bone
• LN
• Tachycardia secondary to dyspnoea (but must mention RS first)
• eg. Malaena and 2d of epigastric pain -> blood loss - anaemia - tachycardia

Relevant past history: Eg. Peptic ulcer, liver disease, previous malignancy

Drug history: Eg. NSAIDs, steroids

Social history: Alcohol intake (gastritis, peptic ulcer), Smoking

Family history: Eg. Any GI malignancy

• General condition, body build (e.g. ? cachexic), hydration
• Pallor, jaundice, supraclavicular lymph node (P, J, LN)
• Vital signs (temp, BP/P)
• Chronic stigmata of liver disease (if suspected liver disease) -> palmar erythema, clubbing, telangiectasia, spider angioma (DDx: HCC of left lobe of liver, which lies at epigastrium)

Abdomen

• Inspection (scar, dilated veins, distension, obvious mass)
• Palpation (any tenderness, liver/spleen/kidney, mass)
• Percussion (any ascites: shifting dullness, gaseous distension)
• Auscultation (bowel sounds, renal artery stenosis - noise with systole, bruits)

REMEMBER to examine hernia orifice (inguinal hernia- ask Pt to cough), ext. genitalia (eg. testicular cancer with metastasis to epigastrium)

REMEMBER per rectal examination (rectal mass, blood) -> must tell examiner you want to perform (even if Pt doesn't allow)

What particular points in the history would you like to ask? How would you perform the physical examination?

• Haematuria rarely causes shock -> but clots can block ureter, Pt cannot void, need Foley catheter
• Differentiate malignant from benign -> RCC, transitional ca of ureter, BPH, stones, benign infection (TB)

• Pain (loin/flank/groin)
• Dull aching -> cancer
• Acute colicky -> stone
• Haematuria (duration. constant or intermittent, whole stream?)
• Dysuria/ frequency/ urgency/ nocturia: dysuria, freq -> UTI
• Incontinence: eg. Multiparous females
• Weight loss, fever: high grader fever -> benign
• Relevant past history / family history / social history (including venereal exposure)

• General condition, body build (e.g. ? cachexic),
• Hydration
• P, J, supraclavicular LN
• Vital signs (temp, BP/P)

• Inspection (scar, obvious mass)
• Palpation (any loin tenderness, ballotable kidney, palpable bladder or pelvic mass)
• Percussion
• Auscultation

REMEMBER to examine, ext. genitalia

REMEMBER per rectal examination: rectum, prostate, cervix

INSPECT URINE (and simple bedside dipstix test)

What particular points in the history would you like to ask? How would you perform the physical examination?

• Ischaemia -> claudication

• Pain (claudication, rest pain, walking distance): eg. How many km, how many streets, how many floors; rest pain: more severe than claudication
• Duration of disease, aggravating and relieving factor: worse in winter and at night (VC); relieving: under blankets
• Skin ulceration/ Gangrene: skin ulceration: Hx of trauma, painful
• Limb sensation / motor function: eg. Acute obstruction: lost limb sensation (emergency). If left for > 6h -> amputation
• Almost all vascular disease is benign

• Predisposing or associated disease
• Eg. Hypertension, DM, ischaemic heart disease, cerebrovascular accidents)

• Smoking

• Vascular disease

General

• General condition, obesity, pallor, cyanosis
• BP/Pulse

• Inspect (signs of chronic ischaemia e.g. pallor, loss of hair, atrophic skin, pallor, cyanosis/any ulcer or gangrene)
• Palpate (check temperature with back of hand, capillary refill, all peripheral pulses)
• Auscultate (any bruit) - esp. femoral artery (bruit with obstruction)
• Special test: e.g. Buerger's test

• Carotid pulse and bruit, any abdominal aneurysm (pulsatile mass), heart examination, BP (important to measure BP in vascular problem)
• Systemic review: palpitation, angina, dizziness, transient numbness (TIA, CVA)

What particular points in the history would you like to ask? How would you perform the physical examination?

• Benign: fibroadenoma, cyst, post-traumatic fat necrosis, cystic disease
• Malignant: ca br

• Previous breast disease, menstrual history
• HAVE to ask, Pt won't realise relationship between previous breast disease and present
• Menstrual history: relationship between menarche and br ca

• Use of oral contraceptive pill, previous pregnancies

• Any family history of breast disease

General condition

P, J, supraclavicular LN

• Inspect (asymmetry of breast size, any obvious lump, inflammation, ulcer, peau d'orange, nipple retraction)

• Palpate - breast lump (site, size, consistency, tenderness, fixation)
• Any nipple discharge
• Axillary lymph node enlargement
• Note: Inflammatory breast cancer ® Young women during pregnancy ® Hormone-> erythema ® But usually, inflammation -> benign

• Eg. Any hepatomegaly, any pleural effusion

• Classical Hx: Graves disease

• Neck swelling (duration, progression, painful)

1. Concern: differentiate benign from malignant (thyroid ca common in females)
2. Occasionally, thyroid cancer can be functional and secrete thyroxin (but mostly they are non-functional)
3. Long duration: more likely benign

• Symptoms of hyperthyroidism (e.g. heat intolerance, weight loss, tremor, nervousness, diarrhoea)
• Symptoms of hypothyroidism (e.g. constipation, amenorrhoea)
• Other symptoms e.g. hoarse voice (affects recurrent laryngeal nerve)

• Past history / social history / family history (e.g. Grave's disease)

General examination

• Body build, facial appearance
• Cancer/ Thyroid: lose weight
• Thyroid disease: typical facial appearance
• Voice
• Eye signs (e.g. lid retraction (can see upper part of white), exomthalmos (view from above; whole eye ball bulges out), lid lag (Pt to follow finger, eye moves faster than lid), diplopia (muscle affected) conjunctival oedema - timosis) -> Hyperthyroidism
• Hand signs (sweating, tremor (piece of paper), pulse (atrial fibrillation - irregularly irregular)

• Inspect (Diffuse or nodular swelling, moves up with swallowing?)

1. Nodular: cancer
2. Diffuse, smooth: simple goitre, Graves disease
3. Moves with swallowing: confirms it is thyroid

• Palpate (from back of Pt): - thyroid (diffuse or nodular, moves up with swallowing, consistency, tenderness, fixation)

1. Hard: suspect cancer

• Any cervical lymph node (site, size, consistency, tenderness, fixation)
• Other structures (trachea deviation, carotid)

1. Trachea deviated? Due to big mass; emergency (upper aw obstruction), emergency intubation, stridor sometimes
2. Carotid: invades by ca, carotid cannot be felt

• Auscultate (any bruit)

1. Hypervascularity: Graves disease
2. Most ca in thyroid not vascular