Cerebellar Examination
This station involves examining the gait and co-ordination. You may get a different station asking you
to examine one or the other so use this as a guide for examining either.
Subject steps
1. Begin by introducing yourself to the patient. Explain to them what the examination involves
and obtain consent to continue.
2. Gait:
3. Ask the patient to stand up. Observe the patient’s posture and whether they are steady on their
feet.
Ask the patient to walk, e.g. to the other side of the room, and back. If the patient normally
uses a walking aid, allow them to do so.

Ask the patient to walk
4. Observe the different gait components (heel strike, toe lift off). Is the gait
shuffling/waddling/scissoring/ swinging?
Observe the patients arm swing and take note how the patient turns around as this involves
good balance and co-ordination.
Ask the patient to walk heel-to-toe to assess balance.

Heel-to-toe test
5. Perform Romberg’s test by asking the patient to stand unaided with his eyes closed. If the
patient sways or loses balance then this test is positive. Stand near the patient in case he falls.

Romberg’s test
6. Co-ordination:
7. Look for a resting tremor in the hands.

Look for a resting tremor in the hands
8. Test tone in the arms (shoulder, elbow, wrist).

Test tone in the shoulder

Test tone in the elbow

Test tone in the wrist
9. Test for dysdiadochokinesis by showing the patient how to clap by alternating the palmar and
dorsal surfaces of the on hand. Ask them to do this as fast as possible and repeat the test with
the other hand.

Palm up

Palm down
10. Perform the finger-to-nose test by placing your index finger about two feet from the patients
face. Ask them to touch the tip of his nose with his index finger then the tip of your finger. Ask
them to do this as fast as possible while you slowly move your finger. Repeat the test with the
other hand.

Finger-to-nose test
11. Perform the heel-to-shin test. Have the patient lying down for this and get him to run the heel
of one foot down the shin of the other leg, and then to bring the heel back up to the knee and
start again. Repeat the test with the other leg.

Heel-to-shin test
12. Finish by thanking the patient. Summarise your findings to the examiner and offer a
differential diagnosis.
Common conditions include Parkinson’s disease and cerebellar ataxia.
Cranial Nerve Examination
Cranial nerve examination involves a number of steps as you are testing all 12 of the nerves in one
station. Therefore be certain to know which nerve is being tested next and what tests you must
perform for that nerve.
Personal techniques may be adopted for this station so that it flows best for you, however, this guide
will take you through each nerve systematically.
Subject steps
1. The Olfactory nerve (CN I) is simply tested by offering something familiar for the patient to
smell and identify – for example coffee or vinegar.
2. The Optic nerve (CN II) is tested in five ways:

Acuity

Colour

Fields

Reflexes

Fundoscopy
3. The acuity is easily tested with Snellen charts. If the patient normally wears glasses or contact
lenses, then this test should be assessed both with and without their vision aids.

Snellen chart
4. Colour vision is tested using Ishihara plates which identify patients who are colour blind.

Ishihara color test plate
5. Visual fields are tested by asking the patient to look directly at you whilst you wiggle one of
your fingers in each of the four quadrants. Ask the patient to identify which finger is moving.
Visual inattention can be tested by moving both fingers at the same time and checking the
patient identifies this.

Visual fields test 1

Visual fields test 2
6. Visual reflexes comprise direct and concentric reflexes.
Place one hand vertically along the patients nose to block any light from entering the eye which
is not being tested. Shine a pen torch into one eye and check that the pupils on both sides
constrict. This should be tested on both sides.

Shining light into eye
7. Finally fundoscopy should be performed on both eyes.

Fundoscopy
8. The Oculomotor nerve (CN III), Trochlear nerve (CN IV) and Abducent Nerve (CN VI) are
involved in movements of the eye.
Asking the patient to keep their head perfectly still directly in front of you, you should draw
two large joining H’s in front of them using your finger and ask them to follow your finger
with their eyes. It is important the patient does not move their head.
Always ask if the patient experiences any double vision, and if so, when is it worse?

Oculomotor examination
9. The Trigeminal nerve (CN V) is involved in sensory supply to the face and motor supply to the
muscles of mastication.
Initially test the sensory branches by lightly touching the face with a piece of cotton wool
followed by a blunt pin in three places on each side of the face:

around the jawline,

on the cheek and,

on the forehead.
The corneal reflex should also be examined as the sensory supply to the cornea is from this
nerve. Do this by lightly touching the cornea with the cotton wool. This should cause the
patient to shut their eyelids.

Jawline

Right cheek

Forehead

Corneal reflex test
10. To test the motor supply, ask the patient to clench their teeth together, observing and feeling
the bulk of the masseter and temporalis muscles.
Ask the patient to then open their mouth against resistance.
Finally perform the jaw jerk on the patient by placing your left index finger on their chin and
striking it with a tendon hammer. This should cause slight protrusion of the jaw.

Muscles of the head and neck

Masseter muscles

Temporalis muscles
11. As previously mentioned the Abducent nerve (CN VI) is tested in the same manner as the
oculomotor and trochlear nerves, again in eye movements.
12. The Facial nerve (CN VII) supplies motor branches to the muscles of facial expression.
This nerve is therefore tested by asking the patient to crease up their forehead (raise their
eyebrows), close their eyes and keep them closed against resistance, puff out their cheeks and
reveal their teeth.

Crease forehead

Closed against resistance

Puff out their cheeks

Showing teeth
13. The Vestibulocochlear nerve (CN VIII) provides innervation to the hearing apparatus of the ear
and can be used to differentiate conductive and sensori-neural hearing loss using the Rinne and
Weber tests.
To carry out the Rinne test, place a sounding tuning fork on the patient’s mastoid process and
then next to their ear and ask which is louder. A normal patient will find the second position
louder.
To carry out the Weber’s test, place the tuning fork base down in the centre of the patient’s
forehead and ask if it is louder in either ear. Normally it should be heard equally in both ears.

Rinne test - mastoid process

Rinne test - beside ear

Weber test
14. The Glossopharyngeal nerve (CN IX) provides sensory supply to the palate. It can be tested
with the gag reflex or by touching the arches of the pharynx.

Glossopharyngeal nerve examination
15. The Vagus nerve (CN X) provides motor supply to the pharynx.
Asking the patient to speak gives a good indication to the efficacy of the muscles. The uvula
should be observed before and during the patient saying “aah”. Check that it lies centrally and
does not deviate on movement.
16. The Accessory nerve (CN XI) gives motor supply to the sternocleidomastoid and trapezius
muscles. To test it, ask the patient to shrug their shoulders and turn their head against
resistance.

Sternocleidomastoideus

Trapezius

Accessory nerve examination 1

Accessory nerve examination 2
17. The Hypoglossal nerve (CN XII) provides motor supply to the muscles of the tongue.
Observe the tongue for any signs of wasting or fasciculations. Ask the patient to stick their
tongue out. If the tongue deviates to either side, it suggests a weakening of the muscles on that
side.

Hypoglossal nerve examination
Lower Limb Neurological Examination
A full neurological examination includes assessment of the motor and sensory systems. You may be
asked to examine one or both of these, but this guide will include both (view Upper Limb
Neurological Examination).
Subject steps
1. As with all examinations, the best method is your own – one with which you are comfortable
and familiar. The one explained here takes the following format:

Tone

Power

Reflexes

Function

Sensation
2. The patient should have their lower body exposed, although in an exam situation the patient
will be in shorts.
Initially, observe the patient’s legs, look for any muscle wasting, fasciculations or asymmetry.
3. Start by examining the tone of the muscles. Roll the leg on the bed to see if it moves easily,
then pull up on the knee to check its tone. Check for ankle clonus by placing the patients leg
turned outwards on the bed, moving the ankle joint a few times to relax it and then sharply
dorsiflexing it. Any further movement of the joint may suggest clonus.

Assess leg tone

Assess knee tone

Check for ankle clonus
4. Next assess the power of each of the muscle groups. Again, start at the hip asking the patient to
abduct, adduct, flex and extend against your hand so you can assess how much force they can
overcome. Do the same for flexion and extension at the knee and ankle as well as the toes.

Assess hip flexion

Assess hip extension

Assess knee flexion

Assess knee extension

Dorsiflexion

Plantarflexion

Toe dorsiflexion

Toe plantarflexion
5. Move on to test the patient’s reflexes. There are three reflexes in the lower limb:

the patellar reflex

the ankle jerk

the plantar reflex (elicited by stroking up the lateral aspect of the plantar surface)
6. The patellar reflex is tested by placing the patient’s leg flexed at roughly 60º, taking the entire
weight of their leg with your arm, and hitting the patellar tendon with the tendon hammer. It is
vital to get your patient to relax as much as possible and for you to take the entire weight of
their leg.

The patellar reflex test
7. The ankle jerk is elicited by resting the patient’s leg on the bed with their hip laterally rotated.
Pull the foot into dorsiflexion and hit the calcaneal tendon.

The ankle jerk test
8. Finally, with their leg out straight and resting on the bed, run the end of the handle of the
tendon hammer along the outside of the foot. This gives the plantar reflex. An abnormal reflex
would see the great toe extending.
9. If you struggle with any of these reflexes, asking the patient to clench their teeth should
exaggerate the reflex.
10. Function is a very important part of any neurological examination as this is the area which will
affect people’s day to day lives the most. For the lower limb you should assess the patient’s
walking. Observe their gait and check for any abnormalities. Whilst they are standing you
should perform Romberg’s test. Ask the patient to stand with their feet apart and then close
their eyes. Any swaying may be suggestive of a posterior column pathology.

Assess patient walking

Romberg's test
11. The final test is sensation which is assessed in a number of ways. You should test light touch,
pin prick, vibration, and joint position sense, or proprioception.
12. Ask the patient to place their legs out straight on the bed. Lightly touch the patient’s sternum
with a piece of cotton wool so that they know how it feels.
With the patient’s eyes shut, lightly touch their leg with the cotton wool. The places to touch
the patient should test each of the dermatomes – make sure you know these! Tell the patient to
say yes every time they feel the cotton wool as it felt before.
Then repeat this using a light pin prick.

Sensation test with cotton wool

Sensation test with a pin prick
13. To assess vibration you should use a sounding tuning fork. Place the fork on the patient’s
sternum to show them how it should feel.
Now place the tuning fork on their medial malleolus and ask them if it feels the same. If it
does, there is no need to check any higher. If it feels different you should move to the tibial
epicondyle and then to the greater trochanter until it feels normal.

Vibration test
14. Finally assess proprioception. Hold the distal phalanx of the great toe on either side so that you
can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that
represents ‘Up’ whereas when you hold it flexed that represents ‘Down’. Ask the patient to
close their eyes and, having moved the joint a few times hold it in one position – up or down.
Ask the patient which position the joint is in.

Flex the interphalangeal joint up

Flex the interphalangeal joint down
Upper Limb Neurological Examination
A full neurological examination includes assessment of the motor and sensory systems. You may be
asked to examine one or both of these, but this guide will include both (view Lower Limb
Neurological Examination).
Subject steps
1. As with all examinations, the best method is your own – one with which you are comfortable
and familiar. The one explained here takes the following format:

Tone

Power

Reflexes

Function

Sensation
2. The upper body should be exposed for this examination. Initially, observe the patient’s arms,
look for any muscle wasting, fasciculation’s or asymmetry.

Observe the patients arms
3. Start by examining the tone of the muscles. Start proximally at the shoulder, feeling how easy
the joint is to move passively. Then move down to the elbow, wrist and hand joints, again
assessing each one’s tone in turn.

Assess arm tone

Assess wrist and hand tone
4. Now assess the power of each of the muscle groups. Again, start at the shoulder asking the
patient to abduct and adduct against your hand so you can assess how much force they can
overcome. Do the same for flexion and extension at the elbow and wrist, as well as the fingers;
also checking abduction and adduction of the thumb.

Assess power of the shoulders

Elbow flexion

Elbow extension

Wrist flexion

Wrist extension

Finger flexion

Finger extension

Finger abduction

Abduction of the thumb
5. Now test the patient’s reflexes. There are three reflexes in the upper limb – the biceps, triceps
and supinator reflexes.
6. The biceps reflex is tested by supporting the patient’s arm, with it flexed at roughly 60º,
placing your thumb over the biceps tendon and hitting your thumb with the tendon hammer. It
is vital to get your patient to relax as much as possible and for you to take the entire weight of
their arm.

Biceps reflex test
7. The triceps reflex is elicited by resting the patient’s arm across their chest and hitting the
triceps tendon just proximal to the elbow.

Triceps reflex test
8. Finally, with their arm rested on their abdomen, locate the supinator tendon as it crosses the
radius, place three fingers on it and hit the fingers. This should give the supinator reflex. If you
struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate
the reflex.

Supinator reflex test
9. Function is a very important part of any neurological examination as this is the area which will
affect people’s day-to-day lives the most. To assess the upper limb, you should ask the patient
to touch their head with both hands and then ask them to pick up a small object such as a coin
which each hand.
10. The final test is sensation which is tested in a number of ways. You should test light touch, pin
prick, vibration, and joint position sense (proprioception).
11. Ask the patient to place their arms by their sides with their palms facing forwards. Lightly
touch the patient’s sternum with a piece of cotton wool so that they know how it feels. Then,
with the patient’s eyes shut, lightly touch their arm with the cotton wool. The places to touch
them should test each of the dermatomes – make sure you know these! Tell the patient to say
“yes” every time they feel the cotton wool as it felt before.
Next repeat this using a light pin prick.

Touch sensation top of the arm

Touch sensation lower arm
12. To assess vibration you should use a sounding tuning fork. Place the fork on the patient’s
sternum to show them how it should feel. Then place it on the bony prominence at the base of
their thumb and ask them if it feels the same. If it does, there is no need to check any higher. If
it feels different you should move to the radial stylus and then to the olecranon until it feels
normal.

Vibration test
13. Finally, proprioception. Hold the distal phalanx of the thumb on either side so that you can flex
the interphalangeal joint. Show the patient that when you hold the joint extended, that
represents ‘Up’ whereas when you hold it flexed that represents ‘Down’. Ask the patient to
close their eyes and, having moved the joint a few times hold it in one position – up or down.
Ask the patient which position the joint is in.

Thumb position up

Thumb position down
Assessment of Mental State
This station involves assessing how the patient appears and any abnormal thoughts or beliefs they may
have. It does not involve a cognitive assessment.
Subject steps
1. Start by introducing yourself to the patient and explain that you would like to talk to him about
his thoughts.
2. There are 8 components to this assessment.
To assess appearance, behaviour and speech begin by asking some general open questions:
3. 1) Appearance and behaviour

Appearance: dress, posture, facial expression, mannerisms

Activity: sitting still/fidgeting

Social and emotional behaviour: apathy, irritable, co-operative
4. 2) Speech

Rate

Tone

Quality

Form: thought blocking, loosening of associations, flight of ideas, neologisms

Content: depressive ideas, delusions
5. Now ask more specific questions relating to the other parts of the assessment:
6. 3) Mood

Symptoms of anxiety: e.g. sweating, palpitations

Current mood state: (both subjective and objective)

Any biological symptoms: e.g. sleep, appetite, libido

Suicidal ideation
7. 4) Phobias and obsessions

Phobias: determine the stimulus, its psychological and physiological effect and the nature
of any avoidance behaviour

Obsessions: determine the underlying thoughts, the nature of the obsession, the effect on
daily life and if it’s a senseless obsession?
8. 5) Abnormal experiences

Illusions/misperceptions

Hallucinations: visual, ophthalmic, auditory (second or third person)
9. 6) Abnormal experiences

Illusions/misperceptions

Hallucinations: visual, ophthalmic, auditory (second or third person)
10. 7) Abnormal beliefs

Delusions
11. 8) Insight: to determine this you should ask a few directed questions.

What do you think is wrong with you?

Do you think you need any treatment?

What do you think the treatment will do for you?
12. 9) Cognition: this should be done by the mini mental state examination, although this is
generally not part of the OSCE.
13. Thank the patient for speaking to you.
Summarise your findings for the examiner, offering a differential diagnosis.
Assessment of Suicide Risk
In this station you wish to assess the patients likelihood to attempt suicide. It is basically a psychiatric
history station and you must establish a good rapport with the patient.
Subject steps
1. Introduce yourself to the patient and explain that you wish to talk to them about their recent
attempt to harm themselves.
2. The assessment has 6 main components to it:..
3. 1) The history of the current episode of self harm.

What precipitated the attempt?

Was it planned?

What method did they use?

Was a suicide note left?

Was the patient intoxicated (drugs/alcohol)?

Was the patient alone?

Were there any precautions against discovery (e.g. waited until house empty)?

Did the patient seek help after the attempt or were they found and brought in by someone
else?
4. 2) Assess risk factors for suicide

Male sex

Age > 45 years

Unemployed

Divorced, widowed or single

Physical illness

Psychiatric illness

Substance misuse

Previous suicide attempts

Family history of depression, substance misuse or suicide
5. 3) Assess the patients mood, especially noting if they are depressed or angry
6. 4) Will the patient be returning to the same situation, e.g. problems at home?
7. 5) What does the patient think about the future?
8. 6) Ask about current suicide thoughts.
9. Thank the patient for speaking to you.
You should summarise your findings to the examiner stating the patients suicide risk. You
should also suggest what to do next, e.g. hospitalisation.
The Inhaler Technique
This station tests several examination skills. Specifically it tests your knowledge of how to use an
inhaler, your knowledge of asthma, and your ability to communicate both of these areas to the patient.
Subject steps
1. Initially it is worth checking the patient’s understanding of their condition. If they do not
understand fully, explain what is happening and why they find breathing more difficult when
they have an exacerbation.
2. Discuss the inhaler with the patient; inform them that it contains medication and explain to
them how it works.
Describe the steps of using the inhaler. These are:
1. Remove the inhaler cap.
2. Shake the inhaler.
3. Hold the inhaler upright with your index finger on the top.
4. Hold the inhaler close to your mouth and breathe out completely.
5. Put the mouthpiece in your mouth, breathe in deeply and firmly press on the
canister simultaneously.
6. Inhale fully so that the dose goes deep into the lungs.
7. Hold your breath for 10 seconds.
8. Breathe out and, if necessary, repeat the procedure.
Once you have described the steps, show the patient how to do it yourself.

Remove cap

Position the inhaler

Inhale fully
3. After you have demonstrated the technique, ask the patient to show you how they would do it.
Check that they are doing it correctly and correct any mistakes they are making.
4. End the consultation by asking the patient if they have any questions or concerns about the
process.
Peak Expiratory Flow Rate Technique
As with describing inhaler technique, this station tests your knowledge of asthma as well as your
knowledge of peak expiratory flow rate (PEFR) measurement. It also tests your ability to
communicate with patients.
Subject steps
1. It is benefitial to check the patient’s understanding of their condition. If they do not fully
understand then you should explain what is happening and that when they have an exacerbation
they will find breathing more difficult. Furthermore, you should explain why measuring their
PEFR is important as a guide to how well-controlled their asthma is at this time.
2. Explain to the patient that they should be checking their PEFR regularly, particularly if their
asthma is worse than usual.
3. Start by describing the different steps in PEFR measurement to the patient. These are:
1. Connect a clean mouthpiece.
2. Ensure the marker is set to zero.
3. Stand up or sit upright.
4. Take as deep a breath in as you can and hold it.
5. Place the mouthpiece in your mouth and form as tight a seal as possible
around it with your lips.
6. Breathe out as hard as you can.
7. Observe and record the reading.
8. Repeat the process 3-4 times and record the highest reading.
9. Note down the reading in a diary to allow comparison with readings on other
days.

Connect mouthpiece

Reset gauge

Blow into mouth piece

Observe measurement
4. Once you have discussed the process with the patient, you should show the patient how to
perform the measurement. Do this by measuring your own PEFR.
5. Once the technique has been demonstrated, ask the patient to show you how they would
perform the measurement themselves. Make sure they are doing it correctly, and resolve any
mistakes which they might be making.
6. Finish by asking the patient if they have any questions or concerns about either their asthma or
taking their PEFR measurement
7.
Blood Glucose Measurement
Blood glucose monitoring is a common procedure performed on wards, especially for diabetics who
will be used to doing this themselves. This is also a procedure used in A&E for someone who is
unconscious for unknown reasons.
Subject steps
1. Ensure you have all necessary equipment for the procedure:


gloves

an alcohol wipe

a glucose monitor

test strips

spring loaded lancet

cotton wool
Blood glucose measurement equipment
2. Explain the procedure to the patient. They may be used to performing this procedure on
themselves, however it is important to make sure of this.
3. Turn on the glucose monitor and ensure that it has been calibrated. If not, insert the calibration
strip and allow it to calibrate.
4. Clean the tip of one of the patient’s fingers with an alcohol wipe and allow it to dry. Note that
any sugar on the patient’s finger from a sweet/candy will give a false reading.

Clean finger-tip
5. Prepare the test strip, ensuring that it is still in date. Load it into the glucose monitor.

Prepare the test strip
6. Prick the side of the patient’s finger with the lancet and squeeze the finger.
Wipe away the first drop of blood and squeeze the finger again to form another drop.
Place this drop on the test strip so that it covers the strip entirely.

Prick the side of the finger

Place drop on the test strip
7. Give the patient a piece of cotton wool to stop the bleeding and record the reading from the
glucose monitor.
Basic Life Support
Basic life support is one of the most important skills you will learn at medical school. As such, you are
likely to be examined on this station regularly so make sure you know it!
Subject steps
1. You are likely to be presented with a resus mannequin and told that you have found the patient
collapsed, either on a corridor in the hospital or somewhere outside. Either way, the algorithm
to follow is fairly similar.
2. The basic train of though is “Dr. ABC”, or rather:
Danger, Response, Airway, Breathing, and Circulation.
3. Danger
Initially you should assess if there is any danger in the situation either for you or for the
patient.
4. Response
You should check if there is any response from the patient. Do this by gently shaking the
patient’s shoulders and loudly shouting into both ears, asking them “Can you hear me?”.
If there is no response you should shout for help.

5. Airway
Check for response
Check if the patient’s airway is patent. Perform the head tilt (unless there is any chance of
cervical spine injury) and jaw thrust to open the airway. Ensure that there is no physical
blockage by their tongue, vomit, or anything else.

Check patient's airway
6. Breathing and Circulation
Check the patient’s breathing and circulation simultaneously. Do this by maintaining the head
tilt and jaw thrust, placing your face and ear over the mouth to feel for any respiratory effort,
whilst observing the chest for any movement. At the same time you should place two fingers
over the carotid pulse to assess circulation.

Check for breathing and circulation
7. If breathing and circulation are normal, place the patient in the recovery position and find help.

Recovery position
8. If breathing and/or circulation are absent you should call for the emergency services.
This number is 999 in the UK, or typically 911 or 112 internationally (check and know your
local number). From within the hospital, call the crash call number (commonly 2222, but again
check for local differences).
9. Once you have called for support, you should start chest compressions.
Place one hand over the sternum roughly in the middle, interlock your fingers and lock your
elbows positioning yourself vertically above your hands. Depress the sternum 4-5 centimeters
and release the pressure. Repeat this 30 times at a rate of 100 per minute.

Start chest compressions
10. Start to give a combination of 2 rescue breaths and 30 chest compressions. For the rescue
breaths ensure the head tilt and jaw thrust are in place, pinch the soft part of the nose so that it
is closed, open the mouth, seal your lips around theirs and blow steadily for 2 seconds. Watch
the chest to check that it rises and falls with the breath. Once the breaths are given, return to
giving 30 chest compressions.

Pinch nose and tilt head

Breathe into patient
11. If there is anyone who can assist, you should share out the work. One of you should perform
the breaths and the other the compressions, swapping when tired.
12. You should continue this cycle of 2 rescue breaths and 30 chest compressions until either
further help arrives, the patient regains consciousness, or you can no longer physically
continue.
Abdominal Examination
An abdominal exam, like with any other system examination, not only includes examining the
abdomen. There are other areas of the body which can give signs of pathology within the
gastrointestinal system. As such the examination starts with the hands, then the face, chest and finally
the abdomen.
Subject steps
1. This procedure requires that you have a chaperone present.
Introduce yourself to the patient and ensure that you have explained the procedure. Inform
them that if they feel any discomfort then they are to let you know.

Introduction
2. Begin by making a general inspection of the patient. You should be looking for:

whether they are comfortable at rest

do they appear to be tachypnoeic

are there any obvious medical appliances around the bed (such as patient controlled
analgesia)

are there any medications around
Each of these should be reported to the examiner.

General inspection
3. Move on to examine the patient’s hands. You are looking for the presence of:

Koilonychia

Leukonychia

Nail clubbing

Palmar erythema

tar staining

Dupuytren’s contracture
Ask the patient to hold their hands out in front of them looking for any signs of a tremor. Them
to extend their wrists up towards the ceiling keeping the fingers extended and look for a liver
flap.

Inspect the patients hands

Inspect for clubbing

Look for a 'liver flap'

Leukonychia

Nail clubbing

Dupuytren's contracture
4. Now is a good time to assess the radial pulse. There is some argument as to whether this should
be performed or not in an abdominal exam; however, it can be a good indication of sepsis or
thyroid disease.

Check the radial pulse
5. Move on to examine the face.
Initially check the conjunctiva for pallor which could be a sign of anaemia.
Check the sclera for jaundice.
Next move to the mouth asking the patient to open it. Look at the buccal mucosa for any
obvious ulcers which could be a sign of Crohn’s disease.
Also look at the tongue. If it is red and fat it could be another sign of anaemia, as could angular
stomatitis.

Assess the patients eyes

Inspect the patient's tongue

Angular cheilitis
6. Move down to the neck to examine the left supraclavicular lymph node.
A palpable enlarged supraclavicular (Virchow’s) node is known as Troisier’s Sign. This is the
node which drains the thoracic duct. This receives lymph drainage from the entire abdomen as
well as the left thorax. Enlargement of this node may therefore suggest metastatic deposits
from a malignancy in any of these areas.

Inspect the left supraclavicular lymph node