1. Before you start: RR count (observe for 30 seconds), SpO2 — do these before touching the patient.Normal RR 12–20. SpO2 ≥95% on air in most adults. COPD baseline may be lower — know the patient's usual.
2. General inspection (end of bed): Distress? Accessory muscle use? Central cyanosis? Cachexia? Pursed-lip breathing (COPD)? Oxygen in use?Standing back and looking costs nothing and tells you a lot. A patient sitting upright, leaning forward and distressed = this is not a routine examination.
3. Hands: Clubbing (lung cancer, bronchiectasis, pulmonary fibrosis), peripheral cyanosis, CO₂ retention flap (asterixis — only assess if encephalopathy is a concern).In GP, clubbing with respiratory symptoms = urgent CXR and likely 2WW referral. Don't just note it — act on it.
4. Face and neck: Central cyanosis (look at tongue and mucous membranes, not lips), tracheal deviation (gently palpate suprasternal notch — deviated towards collapse, away from effusion/tension pneumothorax).JVP in the neck: if elevated with breathlessness, think cor pulmonale (COPD) or cardiac cause.
5. Chest inspection: Barrel chest (COPD hyperinflation), kyphoscoliosis (restrictive pattern), scars (thoracotomy, VATS ports), intercostal recession, abdominal breathing pattern.The shape of the chest tells a story. A barrel chest and pursed-lip breathing = COPD before you've touched the patient.
6. Expansion: Hands placed flat on lower chest posteriorly (or anteriorly), thumbs lifted from skin and meeting at midline. Ask patient to breathe in deeply. Reduced expansion on one side = collapse, effusion, or consolidation on that side.You're assessing symmetry, not the amount of expansion. Both sides should move equally.
7. Percussion: Compare each zone side to side — apices, upper, mid, and lower zones anteriorly and posteriorly. Resonant = normal. Dull = consolidation (solid) or effusion. Stony dull = effusion. Hyperresonant = emphysema or pneumothorax.Always compare symmetrically — don't go all the way down one side then up the other.
8. Auscultation: Diaphragm of stethoscope. Listen in same zones as percussion. Vesicular = normal. Bronchial = consolidation. Wheeze = airflow obstruction (expiratory = obstructive; inspiratory = fixed obstruction). Crackles: fine = fibrosis / early pulmonary oedema; coarse = secretions, infection. Pleural rub = pleurisy.Don't forget the axillae — lower lobe pathology often heard best laterally.
9. If relevant: Peak flow (asthma/COPD — compare to predicted and patient's personal best). Listen to lung bases if heart failure query. Cervical lymph nodes if TB or malignancy concern.

• Measured RR and SpO₂ before touching patient
• Inspected from end of bed before approaching
• Examined hands (clubbing, cyanosis)
• Checked for central cyanosis (tongue/mucous membranes)
• Assessed tracheal position
• Inspected chest shape and breathing pattern
• Assessed expansion — bilateral and symmetrical
• Percussed systematically — comparing both sides
• Auscultated all zones including axillae
• Documented peak flow if asthma or COPD
• Communicated findings clearly to assessor/patient
• Write-up includes RR, SpO₂, and all positive findings

• Measured objective observations (RR, SpO₂) before touching patient
• Stood back and inspected before approaching — made purposeful observations
• Correct technique for chest expansion (hands flat, thumbs lifted at midline)
• Systematic percussion comparing sides — correct finger placement, good resonance technique
• Stethoscope placed directly on skin (not over clothing)
• Covered all zones including axillae
• Correctly characterised breath sounds and any added sounds
• Interpreted findings in clinical context (not just listed)
• Communicated with patient throughout
• Documentation accurate and clinically relevant
• Contextual choice appropriate (correct examination for this clinical scenario)

1. Before you start — position at 45°. JVP is only assessable at 45°. If you start the patient sitting upright you'll miss it.For auscultation of a possible mitral stenosis murmur, you'll need left lateral decubitus later. For aortic regurgitation murmur, sitting forward.
2. General inspection: Distress? Malar flush (mitral stenosis — rare but classic)? Cushingoid appearance? Cachectic? Dyspnoeic at rest?
3. Hands: Clubbing (endocarditis, cyanotic heart disease), splinter haemorrhages (endocarditis — multiple linear haemorrhages under nails), peripheral cyanosis, capillary refill (<2 seconds normal), xanthomata (hyperlipidaemia).Splinter haemorrhages: a few are usually traumatic; multiple in a febrile patient with a murmur = endocarditis until proven otherwise.
4. Pulse: Radial — rate (count 15 seconds × 4), rhythm (regular / regularly irregular / irregularly irregular). Character: assess at carotid if relevant — collapsing (AR), slow-rising (AS), bounding (CO₂ retention, sepsis), small volume (shock, AS). Radio-radial delay if aortic dissection concern.Irregularly irregular = AF until proven otherwise. Always document rhythm, not just rate.
5. Blood pressure: Both arms if new finding, dissection concern, or coarctation. Document which arm and position.Difference >15 mmHg between arms = investigate. In routine hypertension review, use the arm with the higher reading consistently.
6. Face: Xanthelasma (periorbital fat deposits — hyperlipidaemia), corneal arcus (hyperlipidaemia if <50 years), central cyanosis.
7. JVP: With patient at 45°, identify internal jugular pulsation (medial to sternocleidomastoid — pulsatile, not palpable, obliterated by gentle pressure). Measure vertical height from sternal angle. >3–4 cm elevated = raised JVP.Raised JVP in heart failure, cardiac tamponade, SVC obstruction, tricuspid regurgitation. Practise identifying it — it's one of the most underused signs in GP.
8. Precordium inspection: Scars (midline sternotomy = CABG/valve surgery, left lateral = thoracotomy), visible pulsations, pacemaker pocket (left or right infraclavicular).
9. Apex beat: Locate with fingertips — normally 5th ICS, mid-clavicular line. If displaced (outside MCL or below 5th), suggests cardiomegaly. Character: heaving = pressure overload (AS, hypertension); thrusting/hyperdynamic = volume overload (AR, MR, VSD).If you can't find the apex beat, try the left lateral position — it brings the apex forward.
10. Heaves and thrills: Left parasternal heave (palm flat, 3rd–5th ICS left sternal border) = RV hypertrophy. Thrill = palpable murmur (≥grade 4).
11. Auscultation — 4 areas:
    • Mitral: 5th ICS, MCL — diaphragm (and bell for MS rumble)
    • Tricuspid: 4th/5th ICS, left sternal border
    • Pulmonary: 2nd ICS, left sternal border
    • Aortic: 2nd ICS, right sternal border
    Heart sounds: S1 = mitral/tricuspid close (start of systole). S2 = aortic/pulmonary close (end of systole). S3 (after S2) = heart failure or young normal. S4 (before S1) = stiff non-compliant ventricle (hypertension, AS).
12. If murmur heard: Grade it (1–6 Levine scale), identify timing (systolic/diastolic), quality (harsh/soft/blowing), radiation (axilla for MR; carotids for AS). Sit forward for AR (aortic regurgitation), left lateral for MS (mitral stenosis).
13. Peripheral oedema: Ankle and sacral pitting oedema (check sacrum in bed-bound patients). Grade: mild (ankles only), moderate (to mid-calf), severe (to knee/above).
14. Lung bases: Auscultate if heart failure suspected — fine crackles bibasally.

• Patient positioned at 45° before starting
• Both hands examined (clubbing, splinters, capillary refill)
• Pulse rate AND rhythm correctly assessed
• BP documented (both arms if indicated)
• JVP assessed correctly at 45°
• Apex beat located — position and character noted
• Left parasternal heave and thrill assessed
• All 4 auscultation areas listened to
• If murmur heard — grade, timing, radiation assessed
• Ankle and sacral oedema assessed
• Lung bases auscultated if heart failure suspected
• Findings documented with specific measurements and positions

• Correctly positioned patient at 45° before starting
• JVP assessment technique correct — identified correct vessel, measured correctly
• Apex beat located correctly — described position in ICS/MCL
• Used correct technique for heaves and thrills (palm, correct position)
• Used diaphragm for high-pitched sounds, bell for low-pitched (S3, MS)
• If murmur — correctly graded, timed, and radiation assessed
• Manoeuvres used appropriately for murmur characterisation
• Correctly identified clinical context (e.g. AS pattern, heart failure pattern)
• Communicated with patient throughout examination
• Documentation complete with all measurements and landmarks

1. Before you start — position the patient flat. One pillow allowed. Legs uncrossed. Abdomen exposed from xiphisternum to pubic symphysis. Patient must be relaxed — a tense patient makes palpation meaningless.Ask the patient to tell you if you press anywhere that hurts — and watch their face, not your hand, during palpation.
2. General inspection (from the end of the bed): Jaundice? Cachexia? Abdominal distension? Is the distension central (ascites/bowel obstruction/obesity) or localised? Scars visible from here?The 5 Fs of distension: Fat, Fluid (ascites), Flatus (bowel gas), Faeces, Fetus.
3. Peripheral signs of liver disease: Hands — leuconychia (hypoalbuminaemia), koilonychia (iron deficiency), Dupuytren's contracture, palmar erythema, asterixis (flap — hepatic encephalopathy). Face/trunk — jaundice of sclerae, spider naevi (>5 on trunk significant), gynaecomastia (males).Spider naevi: central arteriole with radiating vessels on trunk, face, upper arms. >5 + palmar erythema = significant liver disease until proven otherwise.
4. Abdominal inspection — look systematically: Scars (appendicectomy [RIF], cholecystectomy [RUQ/laparoscopic ports], midline laparotomy), stomas (location = clue to type), visible peristalsis (intestinal obstruction in thin patients), distension pattern, dilated veins (caput medusae = portal hypertension), hernias (ask patient to cough/raise head from pillow — observe all hernia sites).
5. Palpation — light first, then deep. Always start in the quadrant FURTHEST from the pain. Use flat of fingers, not fingertips. All 9 regions or 4 quadrants. Looking for: guarding (voluntary or involuntary), rigidity, rebound tenderness (but use gentle percussion instead — less distressing), tenderness, masses.Watch the patient's face during palpation. If they wince or hold their breath when you reach the painful area, you'll feel the muscle tension even if they don't say anything.
6. Organomegaly — liver: Start in the right iliac fossa (you might miss a grossly enlarged liver if you start in the RUQ). Place right hand flat, fingers pointing up. Ask patient to breathe in deeply — advance fingers cephalad on expiration. Normal liver not palpable. If felt: measure distance below costal margin (cm), describe surface (smooth/irregular), edge (sharp/blunt), consistency, tenderness.
7. Organomegaly — spleen: Start in the right iliac fossa (same reason as liver). Move diagonally towards the left upper quadrant with each inspiration. Only palpable when enlarged >2–3× normal. If enlarged: measure from costal margin, cannot get above it (unlike left kidney), dull to percussion, has a medial notch.If you feel a mass in the left upper quadrant and can't get your hand above it — it's spleen (or stomach). If you can get above it — it's likely kidney.
8. Organomegaly — kidneys (ballottement): Place one hand posteriorly in the flank, the other anteriorly. Ballot: push posteriorly and receive the kidney as it bounces. Kidneys only palpable if enlarged. Right is easier (lower). Differentiate from spleen: you can get above a kidney, it's resonant to percussion (bowel in front), moves with respiration less.
9. Percussion: Liver borders (dullness over liver). Ascites: percuss from umbilicus outward — dull in flanks, resonant centrally. If dullness in flanks: test for shifting dullness (mark border, roll patient, percuss again — border shifts with gravity if ascites present).
10. Auscultation: Bowel sounds over any one location for 30 seconds. Normal = occasional gurgling. Absent = ileus (especially post-surgery, peritonitis). Tinkling / high-pitched = intestinal obstruction. Bruits (over aorta, renal arteries) if clinically indicated.
11. Inguinal hernias: Ask patient to cough and inspect/palpate inguinal region. Cough impulse = hernia. Reducible = push back, ask patient to stand, cough again. If relevant: distinguish direct (straight out through Hesselbach's triangle) from indirect (follows inguinal canal — lateral to epigastric vessels).
12. Always mention: "I would normally complete this examination with a PR examination." — and be prepared to perform one if indicated.

• Patient flat with one pillow, abdomen adequately exposed
• Inspected from end of bed before approaching
• Peripheral stigmata of liver disease checked (hands, face, trunk)
• Abdomen inspected fully before palpation
• Palpation started AWAY from the area of pain
• Both light and deep palpation performed systematically
• Liver felt starting from RIF — moved with inspiration
• Spleen felt starting from RIF — moved towards LUQ
• Kidneys ballotted if relevant
• Percussion performed — liver borders and shifting dullness if indicated
• Bowel sounds auscultated
• Hernia orifices assessed
• PR examination mentioned or performed

• Patient correctly positioned and adequately exposed
• Looked for peripheral signs before touching abdomen
• Systematic palpation technique — correct pressure, covered all regions
• Started palpation away from the pain — watched patient's face
• Correct technique for liver (started RIF, moved with inspiration)
• Correct technique for spleen (started RIF, moved diagonally)
• Percussion used appropriately to delineate organs and test for ascites
• Any mass fully characterised (site, size, consistency, mobility, tenderness)
• PR examination handled appropriately (performed or appropriately indicated)
• Communicated with patient throughout — explained each step
• Documentation complete and includes all positive and clinically relevant negative findings

Start with three screening questions:

1. "Do you have any pain or stiffness in your muscles, joints, or back?"
2. "Can you dress yourself completely without difficulty?"
3. "Can you walk up and down stairs without difficulty?"

Then observe:

For any specific joint, use the LOOK — FEEL — MOVE framework:

Key Clinical Features — Inflammatory vs Mechanical Back Pain

Spinal Examination — What to Look For

Associated Extra-Spinal Features (Ask and Look)

Look — Feel — Move

Special Tests (GP with MSK Interest)

• Observed posture and head position from front and side
• Palpated midline spinous processes for step-deformity or tenderness
• Assessed all 5 movements with normal ranges in mind
• Asked about radiation into arm/hand (dermatome)
• Performed Spurling if radiculopathy suspected
• Checked upper limb reflexes and grip if radiculopathy suspected
• Specifically asked about red flag symptoms (bladder, bilateral weakness, gait)

• Assessed all planes of movement systematically
• Correctly interpreted restricted rotation in clinical context
• Performed and correctly interpreted Spurling test
• Recognised need for upper limb neurology assessment alongside neck examination
• Red flag features specifically documented
• Communicated diagnosis and urgency clearly

Look — Feel — Move

Special Tests

• Observed gait and spinal alignment from front, side, and behind
• Forward flexion assessed and rib hump checked for structural scoliosis
• Modified Schober test performed if spinal mobility reduced
• SLR performed and angle + symptom reproduction documented
• Dermatomal distribution of pain mapped (L4, L5, S1)
• Lower limb power, reflexes, and sensation checked if radiculopathy suspected
• Cauda equina questions asked (bladder, bowel, saddle anaesthesia)

• Systematic spinal assessment — not just SLR in isolation
• Correctly interpreted SLR angle and leg pain pattern
• Distinguished mechanical from inflammatory back pain clinically
• Cauda equina red flags specifically screened and documented
• Lower limb neurology appropriate to clinical question
• Appropriate management communicated including urgency level

Look — Feel — Move

Special Tests

• Examined from front and behind — noted muscle wasting and asymmetry
• Palpated ACJ, subacromial space, and bicipital groove
• Assessed painful arc 60–120°
• External rotation assessed with elbow at side (frozen shoulder screen)
• Hawkins-Kennedy and/or Neer performed if impingement suspected
• Empty can test performed if rotator cuff tear suspected
• Scapular rhythm observed during abduction

• Correctly identified location of pain in arc (60–120 vs end-range vs throughout)
• Correctly performed and interpreted Hawkins-Kennedy
• Distinguished impingement from rotator cuff tear from frozen shoulder
• Palpated correct anatomical landmarks
• Communicated diagnosis and management plan clearly

Look — Feel — Move

Special Tests

• Inspected carrying angle and olecranon bursa
• Palpated lateral and medial epicondyles separately
• Assessed full extension — noted if restricted
• Pronation and supination assessed
• Cozen test performed if lateral epicondylitis suspected
• Ulnar nerve palpated at medial epicondyle if medial symptoms

• Distinguished lateral from medial epicondylitis correctly
• Correctly performed and interpreted Cozen test
• Noted extension loss as indicator of joint effusion
• Considered and screened for ulnar nerve involvement
• Communicated management plan including activity modification advice

Look — Feel — Move

Special Tests

• Inspected both dorsal and palmar surfaces
• Noted which joints involved — MCP, PIP, DIP, CMC (pattern points to diagnosis)
• MCP squeeze test performed
• Wrist range of movement measured
• Thenar and hypothenar wasting assessed
• Phalen and Tinel performed if CTS suspected
• Anatomical snuffbox palpated if fall with radial wrist pain
• Nails inspected for psoriatic changes

• Correctly identified joint distribution pattern and linked to diagnosis
• Performed Phalen and Tinel correctly
• Assessed grip strength objectively
• Anatomical snuffbox assessed if clinically indicated
• Linked findings to diagnostic pattern and management plan

Look — Feel — Move

Special Tests

• Gait observed — Trendelenburg pattern noted
• Leg lengths measured (true and apparent)
• Greater trochanter palpated for tenderness
• Internal rotation assessed first — compared bilaterally
• Thomas test performed if fixed flexion deformity suspected
• FABER test performed to screen hip and SIJ
• Groin vs lateral vs posterior hip pain distinguished

• Gait assessment purposeful — identified pattern correctly
• Thomas test performed correctly with lordosis eliminated
• Internal rotation assessed and identified as early OA marker
• Pain location interpreted correctly (groin = joint; lateral = bursitis/tendinopathy)
• Communicated referral criteria and management clearly

Look — Feel — Move

Special Tests

• Alignment assessed and effusion detected (both methods)
• Quadriceps wasting measured and compared bilaterally
• Medial and lateral joint lines palpated separately
• Full extension tested — noted if restricted
• McMurray performed if meniscal tear suspected
• Lachman test performed if ACL injury suspected
• Collateral ligament stability tested

• Correctly detected effusion using appropriate technique for size
• Joint line tenderness correctly localised
• McMurray performed correctly — click vs pain differentiated
• Lachman preferred over anterior drawer — performed correctly
• Communicated diagnosis, urgency, and need for imaging appropriately

Look — Feel — Move

Special Tests

• Arch and hindfoot alignment assessed standing and non-weight-bearing
• Bony landmarks palpated (malleoli, navicular, 5th MT base)
• Ottawa rules applied if injury history
• Achilles tendon palpated for thickening and tenderness
• Thompson test performed if Achilles rupture suspected
• Plantar fascia heel insertion palpated
• MTP squeeze performed if inflammatory arthritis suspected

• Ottawa rules correctly applied and reasoning documented
• Thompson test correctly performed — result interpreted correctly
• Achilles tendinopathy distinguished from rupture clinically
• Gout vs inflammatory vs mechanical arthritis pattern identified
• Appropriate urgency applied — Achilles rupture referred same day
• Communicated diagnosis and management plan clearly

1. Position — standing first. Ask the patient to stand. Many scrotal abnormalities (varicocele, inguinal hernia) are more apparent standing and disappear when lying. You will then ask them to lie down for detailed palpation.Always examine standing first. A varicocele that is only present standing will be completely missed if you start with the patient supine.
2. Inspection (standing):
   • Penis: skin condition, phimosis (non-retractable foreskin), meatal position (hypospadias/epispadias), any lesions, ulcers, or discharge
   • Scrotum: skin (erythema = epididymo-orchitis; thickened/brown = chronic inflammation), size and symmetry (left normally hangs lower than right — this is normal), visible masses
   • Ask patient to cough: inguinal swelling appearing with cough = hernia (note: it may also appear in scrotum for indirect hernia)
3. Palpation of each testis (standing, then confirm lying): Use thumb and first two fingers in a gentle bimanual technique. For each testis assess:
   • Size: Normal adult testis roughly 4 cm in long axis
   • Consistency: Firm but slightly rubbery (like a hard-boiled egg without the shell)
   • Surface: Smooth and uniform — any irregularity is concerning
   • Tenderness: Normal testes are slightly tender to firm pressure
   Always palpate both testes. Asymmetry in consistency is the key finding — one firm smooth testis and one with an irregular hard area = refer urgently.
4. Epididymis (each side): Lies posterolateral to the testis — a firm, elongated cord-like structure. Normal epididymis is smooth and slightly tender. Tenderness + warmth = epididymitis. Smooth firm globular structure separate from testis = epididymal cyst (common, benign).The epididymis is POSTERIOR to the testis. If you feel a lump and can't tell if it's epididymis or testis — it probably needs imaging. "Get above it": if you can clearly separate a lump from the testis, it's likely epididymal. If inseparable from the testis = cancer until proven otherwise.
5. Spermatic cord: Trace from each testis upwards through the inguinal canal. Normal: smooth, firm cord. "Bag of worms" in the cord (worse standing, better lying, increases with Valsalva) = varicocele. Note: left varicocele is common (L testicular vein drains at right angles into L renal vein); new right-sided varicocele = investigate (may indicate obstruction of IVC or right renal vein).
6. Trans-illumination — for any scrotal swelling: In a darkened room, place a torch (pen torch or phone torch) behind the swelling.
   • Transilluminates (glows red/pink) = fluid-filled: hydrocele, spermatocele
   • Does NOT transilluminate = solid content: tumour, haematocele, epididymo-orchitis
   A hydrocele surrounds the testis — the testis is often impalpable within it. Trans-illumination is easy and takes 30 seconds. There is no excuse for not doing it when there is a scrotal swelling.
7. Inguinal region: Palpate for lymphadenopathy (drain from testes via para-aortic nodes, not inguinal — but penile/scrotal pathology drains to inguinal nodes). Inguinal hernia assessment if indicated.

• Consent documented explicitly
• Chaperone present — name and role documented
• Patient examined standing first
• Inspection of penis, scrotum and inguinal region performed
• Both testes palpated separately (size, consistency, surface, tenderness)
• Both epididymides palpated
• Spermatic cords assessed bilaterally
• Cough impulse assessed for hernia
• Trans-illumination performed for any swelling
• Clearly distinguished intratesticular from extratesticular any mass
• Inguinal lymph nodes assessed
• Appropriate urgency communicated for any suspicious finding

• Managed consent and chaperone professionally and explicitly
• Examined patient standing first — not just supine
• Correct bimanual palpation technique (thumb + 2 fingers)
• Located and palpated epididymis correctly (posterior position)
• Assessed spermatic cord and identified abnormality if present
• Trans-illumination performed correctly if swelling present
• Correctly determined if mass was intra- or extratesticular
• Appropriate safety-netting and urgency demonstrated for any suspicious finding
• Communicated with patient throughout in appropriate language
• Documentation complete and includes anatomical precision

1. Position: Dorsal position — patient semi-recumbent (not fully flat), feet together with knees falling apart. Alternatively left lateral (Sims') position for difficult examinations. Adequately draped — expose only what is necessary.A good light source is essential. Point it directly at the introitus. You cannot examine properly in poor light.
2. External inspection: Inspect the vulva — skin condition (atrophy, lichen sclerosus plaques, ulcers, condylomata), labial abnormalities, bartholin's glands area (swelling at 4 and 8 o'clock = Bartholin's cyst/abscess), urethral meatus (prolapse, caruncle, discharge).Don't rush past the external inspection. Lichen sclerosus, vulval intraepithelial neoplasia, and genital warts are all visible at this stage.
3. Speculum examination:
   • Hold Cusco's speculum with blades vertical (handle pointing down), insert at 45° angle initially (directed posteriorly), then rotate to horizontal as you advance
   • Once fully inserted, open the blades and find the cervix
   • If cervix hard to visualise: ask the patient to place clenched fists under her buttocks — this tilts the pelvis and brings the cervix into view
   • Inspect cervix: colour (pink = normal; blue/violet = pregnancy), os (open/closed), ectropion (reddish area around os — columnar epithelium, common, usually benign), erosions, polyps, contact bleeding (if touched)
   • Discharge: describe colour, consistency, odour. Mucopurulent = infection (chlamydia, gonorrhoea). Curd-like = candida. Offensive, fishy = BV.
   • Take samples if required (smear, HVS, endocervical swab) before removing
   • On withdrawing: slowly open blades slightly and inspect vaginal walls as you remove (looking for prolapse, lesions)
4. Bimanual pelvic examination:
   • Put on gloves and apply water-based lubricant
   • Insert index and middle fingers of dominant hand into vagina, palm facing up
   • External hand (non-dominant) placed on lower abdomen, pressing gently inward
   • The internal fingers lift the uterus towards the external hand
5. Bimanual — assess the cervix first: Feel the cervix with internal fingers — position (anterior/posterior), consistency (firm = normal; soft = pregnancy, fibroids). Then gently move the cervix side to side — this is the test for cervical motion tenderness (CMT). Any pain on this movement = positive CMT = significant finding.CMT is also called "chandelier sign" — patients with severe PID can jump off the table when you test this. Test it gently. Document it explicitly.
6. Bimanual — assess the uterus: With internal fingers beneath the cervix and external hand pressing down, bring the uterus between the two hands. Assess: size (normal = 7–8 cm, compare to pear), shape (regular or irregular = fibroids), consistency, mobility (freely mobile vs fixed = endometriosis/PID adhesions), tenderness.Anteverted uterus (most common): felt easily. Retroverted (20% normal): lies towards the sacrum and may be harder to feel anteriorly — try to feel it posteriorly with internal fingers. Not pathological.
7. Bimanual — adnexa: Move internal fingers laterally into each fornix. Press external hand into corresponding iliac fossa. Assess each side: ovaries and tubes are normally not palpable. Any palpable adnexal mass or tenderness = abnormal. Bilateral adnexal tenderness + CMT = PID until proven otherwise.
8. Complete: Withdraw fingers gently. Offer the patient tissues. Explain findings in appropriate language. Document immediately.

• Explicit verbal consent obtained and documented
• Chaperone — name and role documented
• Good light source in place before patient positioned
• Equipment prepared BEFORE patient asked to undress
• External genitalia inspected before speculum insertion
• Speculum warmed in water (NOT lubricant if taking samples)
• Cervix fully visualised — os, discharge, and surface described
• Required samples taken correctly
• Vaginal walls inspected on speculum withdrawal
• Bimanual performed after speculum removed
• Cervical motion tenderness SPECIFICALLY tested and documented
• Uterus characterised (size, position, tenderness, mobility)
• Both adnexa assessed
• Patient offered tissues, explained findings in appropriate language

• Consent and chaperone managed professionally and explicitly
• Equipment prepared before patient asked to undress (no mid-examination scrambling)
• Speculum insertion technique correct — correct angle, opened at right time
• Cervix correctly identified and fully visualised
• Vaginal walls inspected on withdrawal
• Bimanual technique correct — internal hand palm up, external hand active
• CMT specifically tested — result documented (positive or negative)
• Uterus characterised with appropriate terms (size, position, mobility, tenderness)
• Both adnexa assessed — not just one side
• Communicated sensitively with patient throughout each step
• Findings interpreted in clinical context and acted upon appropriately
• Documentation complete including all positive and negative findings

1. Inspection — Position 1: Sitting upright, arms by sides. Look for: symmetry (minor asymmetry is normal; significant change from usual is not), size change, shape, skin changes (erythema, peau d'orange, dimpling, ulceration), nipple changes (inversion — note if longstanding or new, eczema/Paget's, discharge).Peau d'orange (skin resembling orange peel) = lymphoedema of the skin from blocked lymphatics = underlying carcinoma until proven otherwise.
2. Inspection — Position 2: Hands pressed firmly on hips. This contracts the pectoralis major, accentuating any tethering or dimpling of the overlying skin by a deep tumour. Look for asymmetrical dimpling or puckering not visible at rest.
3. Inspection — Position 3: Arms raised above head. Again looking for tethering of skin or nipple that becomes visible when the skin is stretched. Also reveals lower pole pathology.
4. Palpation — position the patient: Ask the patient to lie back at 45°, with the ipsilateral arm raised behind the head. This flattens the breast against the chest wall and makes palpation much more accurate.Never examine a sitting patient — the breast hangs away from the chest wall and lumps are easily missed. The arm must be behind the head for the examination to be meaningful.
5. Palpation — technique: Use the flat pads of the fingers (not fingertips), with gentle but firm circular movements. Keep fingers flat against the chest wall. Work systematically through all areas:
   • Upper outer quadrant (most common site for breast cancer) + axillary tail
   • Upper inner quadrant
   • Lower inner quadrant
   • Lower outer quadrant
   • Subareolar area (under the nipple)
   The axillary tail (tail of Spence) extends into the axilla. Don't forget it — it contains breast tissue and is a site for lumps.
6. If a lump is found — characterise it fully:
   • Site: Which quadrant, distance from nipple, clock position
   • Size: Estimate in cm using fingers/ruler
   • Shape: Round, oval, irregular
   • Consistency: Soft, firm, hard
   • Surface: Smooth, irregular, nodular
   • Borders: Well-defined vs poorly-defined / indistinct
   • Mobility: Mobile vs fixed to skin above or to deep tissues below
   • Skin tethering: Ask patient to raise arm — does skin dimple over the lump?
   • Tenderness: Note, but benign lumps can be tender and malignant ones often aren't
7. Nipple examination: Inspect for inversion (ask if new), eczema, ulceration, Paget's disease (eczema-like change of nipple = refer). Gently express: use two fingers of each hand placed either side of the areola and press towards the nipple. Document: any discharge colour (clear, milky, green/brown = non-concerning; blood-stained = refer).
8. Axillary lymph nodes: Ask the patient to rest their arm on your forearm (relaxes the axilla). Place your hand into the apex of the axilla and palpate all four axillary groups:
   • Apical (deep in axilla — upper)
   • Anterior / pectoral (along anterior axillary fold)
   • Posterior / subscapular (along posterior fold)
   • Lateral / humeral (along upper humerus)
9. Supraclavicular fossa: Standing or sitting behind the patient, palpate both supraclavicular fossae. Any firm node here with an ipsilateral breast lump = metastatic spread.
10. Repeat for the other breast. Bilateral examination is always required.

• Explicit consent and chaperone documented
• Inspection performed in all THREE positions (arms by sides, hands on hips, arms raised)
• Patient correctly positioned for palpation (45°, arm behind head)
• Pads of fingers used (not fingertips)
• Systematic palpation covering ALL quadrants including axillary tail
• Subareolar area palpated
• Nipple examined and gently expressed
• Axillary lymph nodes palpated (all four groups)
• Supraclavicular fossae palpated bilaterally
• Bilateral examination performed (both breasts)
• Any lump fully characterised (site, size, shape, consistency, borders, mobility, tethering)
• Appropriate urgency communicated for any suspicious finding

• All three inspection positions used systematically
• Patient correctly positioned for palpation (arm behind head, not flat or sitting)
• Correct palpation technique (flat pads of fingers, circular movements, systematic)
• Axillary tail specifically palpated
• Nipple inspection and gentle expression performed
• Axillary lymph node technique correct (arm supported, all four groups)
• Supraclavicular fossae assessed bilaterally
• If lump found: fully characterised using all descriptors, skin tethering tested
• Clinical impression stated and appropriate referral/safety-netting communicated
• Communicated sensitively with patient throughout
• Documentation complete, precise, and supports clinical decision-making

1. Inspection: Wasting (LMN), fasciculations (LMN, especially MND), abnormal posture, tremor at rest (Parkinson's) vs intention tremor (cerebellar).
2. Tone: Upper limbs — roll at wrist and elbow. Lower limbs — roll knee/hip passively. Increased (spastic/rigid) vs decreased (flaccid). Cogwheel rigidity (Parkinson's) — felt as ratchet during passive movement.
3. Power: Test against resistance, grade using MRC scale (0–5). Upper limbs: shoulder abduction, elbow flexion/extension, wrist extension, finger extension, finger abduction. Lower limbs: hip flexion, knee flexion/extension, ankle dorsiflexion, plantarflexion.Pyramidal (UMN) weakness pattern: shoulder abductors, elbow extensors, wrist extensors in arms; hip flexors, knee flexors, ankle dorsiflexors in legs.
4. Reflexes: Biceps (C5/6), triceps (C7), supinator (C5/6), knee (L3/4), ankle (S1). Plantar reflex (stroke sole of foot lateral to medial — normal = flexor toes; extensor = UMN). Absent reflexes = LMN or severe UMN in acute phase.
5. Co-ordination: Finger-nose test (cerebellar = intention tremor, past-pointing). Heel-shin test. Dysdiadochokinesis (rapidly alternating movements).
6. Sensation (if relevant): Light touch, pin prick, vibration sense (tuning fork at bony prominence), proprioception. Pattern of loss guides diagnosis: glove-and-stocking = peripheral neuropathy; dermatomal = nerve root; hemibody = central.
7. Gait: Watch the patient walk. Hemiplegic gait (circumduction, arm held flexed — UMN). Foot drop/steppage gait (LMN, common peroneal nerve). Wide-based ataxic gait (cerebellar). Festinant gait (Parkinson's). Antalgic gait (musculoskeletal).

• Examination targeted to the clinical question from the history
• Inspected for wasting, fasciculations, posture, tremor
• Tone assessed correctly (passive rolling technique)
• Power graded using MRC scale and recorded
• Reflexes tested — and plantar response elicited correctly
• Co-ordination tested (finger-nose and/or heel-shin)
• Gait observed
• Sensation tested if clinically indicated
• UMN vs LMN pattern correctly identified
• Findings linked to diagnosis and clinical plan

• Targeted the examination to the clinical scenario rather than performing routinely
• Correct tone assessment technique — passive, relaxed limb movement
• Correct power testing technique and MRC grading
• Correct reflex technique — appropriate tendon hammer, correct position
• Plantar response correctly performed and interpreted
• Correctly identified UMN vs LMN pattern from findings
• Gait observed and characterised correctly
• Communicated findings and diagnosis clearly with appropriate next steps
• Documentation accurately reflects findings and clinical reasoning

1. Visual acuity: Snellen chart at 6 metres (or near vision card). Each eye separately, with glasses/contacts if worn. Record as 6/6, 6/9, 6/18 etc. (6/6 = normal). If chart unavailable: count fingers, detect hand movement, perceive light.
2. Pupils: Size, symmetry, reaction to light (direct and consensual). Swinging torch test for RAPD (relative afferent pupillary defect — pupil dilates when you swing torch to it = optic nerve lesion that side).
3. Eye movements: "Follow my finger." Cover all directions of gaze — horizontal and vertical. Look for: diplopia, nystagmus (rhythmical jerking of eyes), failure of conjugate gaze (cranial nerve palsy — III, IV, VI).
4. Visual fields (confrontation): Sit opposite the patient at arm's length. Compare your own visual field. Bring a wiggling finger from outside the field inward — patient to say when they see it. Tests four quadrants each eye. Gross screening only — identifies large field defects.
5. External eye: Conjunctiva (red, pale), sclera (jaundice, episcleritis/scleritis), cornea (ulcers, arcus), eyelids (entropion, ectropion, ptosis, lid swelling).

1. Prepare the room: Dim the lights — not completely dark, just dimmer than usual. This dilates the pupil slightly and gives you a bigger window to work through. You cannot adequately examine an undilated pupil in bright light.In GP, formal dilation drops (tropicamide) are used for diabetic eye checks. For general assessment, room dimming is usually sufficient.
2. Set up the ophthalmoscope: Turn it on. Set the dial to zero (0) — this focuses for emmetropic (normal) eyes. If the patient is very short-sighted (myopic), rotate dial into minus (red numbers). If very long-sighted (hypermetropic), into plus (green/black numbers). Start at zero and adjust as needed.The dial adjusts focus — it does NOT change brightness. Use it to bring the retina into sharp focus for each patient.
3. Which eye to use — always match: To examine the patient's RIGHT eye, use YOUR right eye and hold the ophthalmoscope in your RIGHT hand. To examine their LEFT, use your LEFT eye and left hand. This lets you get close without bumping heads.This feels unnatural at first if you are right-handed. Practise both sides.
4. Starting position and angle: Stand approximately 30 cm from the patient. Approach from about 15° lateral (not straight on). Shine the light at the pupil — you should see a bright orange glow through the pupil. This is the red reflex. Absent red reflex = dense cataract, vitreous haemorrhage, or retinoblastoma (in a child — urgent referral).
5. Move in slowly and follow the vessels: Once you see the red reflex, slowly move closer while keeping the light on the pupil. As you get within a few centimetres, you will start to see retinal details. Follow a blood vessel towards the optic disc — vessels converge on the disc like spokes on a wheel. The disc is usually nasal (towards the nose).
6. Examine the optic disc first: The disc is a pale pink/cream circle. Assess:
   • Colour: Normal = pink. Pale = optic atrophy (MS, glaucoma, compression)
   • Margins: Normal = sharp. Blurred/indistinct = papilloedema (raised intracranial pressure — urgent)
   • Cup-to-disc ratio: Normal = <0.5. Large cup = glaucoma suspect
7. Follow the vessels: Trace arteries and veins out to each quadrant. Arteries: narrower, brighter red. Veins: wider, darker. Look for: AV nicking (artery compressing vein at crossing = hypertension), silver wiring (arteries look bright/reflective = hypertension), haemorrhages, exudates.
8. Look for haemorrhages and exudates:
   • Dot/blot haemorrhages: Small round = diabetes (microaneurysms)
   • Flame haemorrhages: Superficial, spreading = hypertension, CRVO
   • Hard exudates: Bright yellow, sharp edges = lipid deposits in diabetes/hypertension
   • Soft exudates ("cotton-wool spots"): Fluffy white = nerve fibre layer infarction (diabetes, hypertension)
9. Check the macula: Ask the patient to look directly at the light. The macula is just temporal (towards the ear) from the disc. It looks slightly darker. Macular degeneration appears as drusen (yellow deposits) or pigment changes.

• Room dimmed before starting
• Correct eye matching used (right eye to right eye, left to left)
• Red reflex checked before moving in
• Optic disc found and assessed (colour, margins, cup)
• Vessels followed — haemorrhages and exudates looked for
• Macula assessed (patient asked to look at light)
• Visual acuity and pupils assessed
• Findings correctly interpreted and documented
• Appropriate urgency recognised for papilloedema or absent red reflex

• Dimmed room appropriately before starting
• Used correct eye matching technique
• Assessed red reflex correctly
• Moved close enough to the patient to see disc detail
• Correctly identified and described optic disc
• Followed vessels and identified any pathology
• Interpreted findings correctly — grade of retinopathy if present
• Communicated findings to patient in accessible language
• Recognised clinical urgency of papilloedema if present

1. Choose the right speculum size: Adult ears — use the largest speculum that fits comfortably. Smaller speculums reduce visibility. Keep a range available.
2. Position the patient: Sitting, tilting their head slightly away from you. In children — head tilted to the side, parent holds the child.Never force a speculum. If the canal is very narrow or swollen, note the limit of visibility and do not push through pain.
3. Straighten the ear canal — direction matters:
   • Adults: Pull the pinna (outer ear) up and back with your non-dominant hand. This straightens the S-shaped adult canal.
   • Children under ~7: Pull the pinna straight back or slightly downwards. The infant canal curves differently.
   This step is the most commonly skipped — and the most important. Without it you are looking at the canal wall, not the eardrum.
4. Insert gently: Holding the otoscope like a pen (unless you have been trained in places like Leeds — where you hold it upside down, which is the safer technique), brace your hand (or your little finger with the upside-down technique) against the patient's head so any movement doesn't drive the speculum deeper. Insert at a slight downward and forward angle. You should see the ear canal — a skin-lined tunnel. Advance slowly until the eardrum comes into view.
5. What to look at once you can see the eardrum (tympanic membrane): See the interpretation guide below.

1. External inspection: Swelling, asymmetry, skin change over nose.
2. Anterior rhinoscopy (using otoscope or dedicated speculum): Tilt head back slightly. Use a large speculum. Lift the tip of the nose to see inside each nostril. Look for: nasal septum position (deviated?), turbinates (enlarged/swollen — pale and oedematous in allergic rhinitis, red in infectious), polyps (pale, fleshy, grape-like masses blocking the nasal passage), discharge (watery = allergy, mucopurulent = infection, unilateral = foreign body in a child or tumour).
3. Check patency: Ask patient to close mouth and breathe through each nostril alternately — assesses airflow.

1. Position: Good light (pen torch). Ask patient to open wide and say "ahh" — this lowers the tongue and opens the oropharynx.
2. Tonsils and oropharynx: Look for: tonsillar size (graded I–IV), erythema, exudate (white patches on tonsils = bacterial tonsillitis vs viral), pus in tonsillar crypts, uvula deviation (quinsy = peritonsillar abscess, uvula pushed to opposite side).
3. Tongue and floor of mouth: Note any ulceration (apthous ulcers — benign; persistent painless ulcers >3 weeks = 2WW referral), coating, pallor.
4. Centor / FeverPAIN criteria in practice: Use to guide antibiotic decision for sore throat. FeverPAIN score ≥4: consider antibiotics. Centor score ≥3: streptococcal infection more likely.

• Correct pinna pull used (up-back in adults, back/down in children)
• Both ears examined
• TM described (colour, light reflex, integrity, position)
• Wax noted if obstructing view
• Nasal examination performed if symptoms present
• Throat examined with adequate light
• Tonsils, uvula, and posterior oropharynx assessed
• Red flags recognised (stridor, uvula displacement, persistent ulcer)

• Correct otoscope technique — appropriate speculum, correct pinna pull
• Braced hand technique used — safe speculum insertion
• TM correctly identified and findings accurately described
• Correctly distinguished normal TM from AOM, OME, or perforation
• Throat assessment systematic — tonsils, uvula, posterior wall
• Appropriate use of FeverPAIN/Centor criteria in throat assessment
• Red flag findings recognised with appropriate urgency

1. Adequate exposure and lighting: Examine in good light. Examine the whole area — don't just look at the lesion the patient is pointing at. Check regional skin for satellite lesions.
2. Characterise the lesion — use the ABCDE framework:
   A — Asymmetry

   Irregular shape — one half doesn't mirror the other

   B — Border

   Ragged, notched, or blurred edges

   C — Colour

   Variation within lesion — mixed brown, black, red, white

   D — Diameter

   >6 mm — but melanomas can be smaller

   E — Evolution

   Changing over time — the most important feature in GP

3. Also assess: Site (sun-exposed?), size (measure in mm), surface (smooth/rough/ulcerated/bleeding), elevation (flat/raised/nodular/pedunculated), surrounding skin (erythema, satellite lesions, induration).
4. Describe the primary lesion type: Macule (flat, colour change only), papule (<5mm raised), plaque (>5mm raised flat-topped), nodule (deep raised), vesicle (small fluid-filled), bulla (large fluid-filled), pustule (pus), wheal (urticaria), ulcer (skin loss).
5. Regional lymph nodes: Palpate relevant draining lymph nodes if malignancy is suspected. Melanoma of the back → axillary nodes. Melanoma of the leg → inguinal nodes.

• Examined lesion in good lighting with adequate exposure
• ABCDE framework applied to any pigmented lesion
• Size measured in mm
• Surrounding skin and satellite lesions checked
• Evolution history asked if not already in history
• Regional lymph nodes palpated if malignancy suspected
• NICE 2WW criteria applied correctly
• Lesion photographed for records if uncertain or referred

• Systematic ABCDE approach used — not just "looks fine"
• Surrounding skin and satellite lesions specifically checked
• Evolution history specifically asked about
• Correctly differentiated benign from suspicious appearances
• Appropriate urgency applied to suspicious findings
• Documentation precise and supports clinical decision

1. Consent and chaperone: Explicit verbal consent. Chaperone name and role documented. Explain: "I'm going to do a rectal examination — I'll gently place one finger into your back passage. I'll be as quick as possible and will stop immediately if you ask me to."
2. Position: Left lateral position (patient on left side, knees drawn up towards chest — "like a ball"). This is the standard position for GP. Dorsal lithotomy (on back) is an alternative.Left lateral is usually more comfortable for the patient and gives good access for the examiner. Ensure the patient is draped appropriately — expose only what you need to.
3. External inspection first: Before inserting a finger, look at the perianal skin. Look for: skin tags (haemorrhoids, Crohn's), external haemorrhoids (blue/purple), fissures (painful crack at 6 or 12 o'clock — patient may wince on inspection alone), fistula openings, condylomata (warts), erythema, ulceration.
4. Lubricate generously: Apply lubricating gel to your gloved index finger. Adequate lubrication is both more comfortable for the patient and makes the examination more informative — a dry examination creates false resistance.
5. Insertion: Place the tip of your lubricated index finger at the anal verge. Ask the patient to breathe out slowly. As they exhale and relax, gently apply pressure until the sphincter relaxes and your finger passes in. Do NOT push past resistance.If the patient tenses, pause, reassure, and ask them to breathe out again. Never force entry. If entry is impossible due to pain — stop, document, and consider fissure or anal stenosis.
6. Assess sphincter tone: Normal tone = firm resistance around your finger but not painful. Reduced tone = lax sphincter (neurological cause, previous surgery, obstetric injury). Increased tone = hypertonia (fissure, anxiety, infection).
7. Rotate systematically: Rotate your finger 360° to assess the rectal mucosa in all directions. Feel for: masses (hard, irregular = concern for carcinoma), tenderness (anterior = prostatitis or pelvic pathology), mucosal irregularity.
8. Prostate assessment (male patients): Feel anteriorly. Normal prostate: smooth, rubbery, bilobed with a central sulcus, non-tender. Abnormal findings — see table below.You cannot reliably assess the entire prostate per rectum — only the posterior surface. A normal PR does not exclude prostate cancer. PSA is complementary.
9. Withdraw and inspect the glove: Note: stool colour (normal brown, black = melaena, bright red = lower GI bleed), blood (fresh red = haemorrhoids/fissure/cancer), mucus. Document glove findings explicitly.

• Explicit consent and chaperone documented
• Patient in left lateral position, adequately draped
• External inspection performed before insertion
• Generous lubrication applied
• Sphincter tone assessed and documented
• Full 360° rotation of finger — mucosa assessed
• Prostate assessed in male patients (if indicated)
• Glove inspected on withdrawal — colour, blood, mucus documented
• Appropriate action taken for abnormal prostate findings

• Consent and chaperone managed professionally
• External inspection performed before insertion
• Correct insertion technique — slow, with patient breathing out
• Sphincter tone correctly assessed and described
• Prostate characterised correctly if assessed
• Glove inspected and findings documented
• Communicated sensitively throughout
• Appropriate urgency for suspicious findings

1. Cervical lymph nodes (most commonly assessed in GP): Standing behind the patient. Use both hands simultaneously — compare sides. Feel for nodes systematically: submental (under chin), submandibular, anterior cervical (anterior triangle), posterior cervical (posterior triangle), pre-auricular, post-auricular, occipital, supraclavicular.Supraclavicular fossa: palpate with patient's head tilted slightly towards you — relaxes the SCM. A hard node in the left supraclavicular fossa (Virchow's node / Troisier's sign) = gastric or abdominal malignancy until proven otherwise.
2. Axillary lymph nodes: Rest the patient's arm on yours. Cup your hand and place into the apex of the axilla. Bring fingers down the medial wall. Palpate all groups: apical (in the dome), anterior (pectoral), posterior (subscapular), lateral (along humerus), central.
3. Inguinal lymph nodes: Horizontal chain (along inguinal ligament — drains lower limb, perianal skin, external genitalia). Vertical chain (along great saphenous vein). Note if superficial or deep.
4. Characterise every palpable node:
   • Size: in cm
   • Consistency: soft and tender (reactive/infection) vs firm (lymphoma) vs hard and fixed (metastatic carcinoma)
   • Mobility: mobile vs tethered/matted
   • Tenderness: tender = reactive/infection; non-tender = lymphoma or malignancy
   • Number and distribution: single region = local cause; multiple regions = systemic cause

1. Inspection: Stand in front. Ask patient to swallow (give them a glass of water). Normal thyroid not visible. A goitre moves with swallowing — this distinguishes thyroid from non-thyroid neck swelling.
2. Palpation: Stand behind the patient. Place both hands around the neck, fingertips meeting in the midline. Identify the isthmus (just below the thyroid cartilage). Feel each lobe lateral to the trachea. Ask the patient to swallow again — feel the gland move under your fingers.A thyroid swelling that doesn't move with swallowing is likely not thyroid — consider lymph node, dermoid cyst, or other neck lump.
3. Characterise the gland: Diffuse enlargement (goitre) vs multinodular vs single nodule. Tender (thyroiditis) vs non-tender. Retrosternal extension (cannot get below gland).
4. Tracheal deviation: Is the trachea central? A very large thyroid or retrosternal extension may deviate the trachea.
5. Auscultation: If diffuse goitre — place bell of stethoscope over the gland. A bruit = increased vascularity = Graves' disease (thyrotoxicosis).
6. Signs of thyroid dysfunction:
   • Hyperthyroid: Fine tremor (hands), warm moist palms, tachycardia, lid lag, lid retraction, exophthalmos (Graves')
   • Hypothyroid: Dry skin, bradycardia, periorbital oedema, dry hair, slow relaxing reflexes

1. Observe before touching — the general impression: General behaviour (alert and interactive vs listless and disengaged), how the child is held by the parent, work of breathing from across the room, skin colour (pink vs pale vs mottled vs cyanosed), hydration (eyes sunken, mucous membranes dry, skin turgor), obvious distress or absence of it.A child who is watching you, reaches for objects, and interacts with the parent is very unlikely to be seriously unwell. A child who stares blankly and does not respond to stimulation is a red flag before you have measured anything.
2. Vital signs — always: Temperature, pulse, respiratory rate (count for a full 30 seconds — reference ranges vary significantly by age), oxygen saturations (normal ≥95% in room air for any age), capillary refill time (press on sternum or forehead for 5 seconds — normal <2 seconds).NICE Feverish Illness guidance (traffic light) uses these observations systematically. Know the red and amber features for age-specific tachycardia and tachypnoea — they differ from adult thresholds.
3. Fontanelle (if age-appropriate — under ~18 months): With the child upright and calm, gently palpate the anterior fontanelle. Bulging = raised intracranial pressure. Sunken = dehydration. Normal = flat and soft.
4. Ears and throat: If upper respiratory infection is suspected — otoscopy (both ears), throat inspection (tonsils, exudate, redness, uvula position). In children, ear examination requires pulling the pinna straight back rather than up and back.
5. Chest: Respiratory rate counted on inspection. Recession severity: subcostal, intercostal, sternal. Auscultate both sides — air entry (equal or reduced), wheeze (expiratory = bronchiolitis/asthma), crackles (consolidation). Oxygen saturations confirm clinical impression.
6. Abdomen: If abdominal pain, vomiting or gastroenterological symptoms — inspection, light palpation in all quadrants. Note: guarding, tenderness, organomegaly. Start away from area of pain.
7. Rash assessment: If rash present — describe morphology, distribution, blanching. Tumbler test (press glass on rash firmly): blanching = usually benign (viral exanthem, urticaria); non-blanching = meningococcal disease until proven otherwise → 999 immediately.A petechial or purpuric rash that does not blanch is a paediatric emergency. Do not wait for more features. Call 999 and administer IM benzylpenicillin if available and not contraindicated.
8. Document red-flag negatives explicitly: In a well child, document the absence of key danger signs: "no grunting, no severe recession, no non-blanching rash, alert and interactive, capillary refill <2 seconds, saturations 98% on air." This protects the child and you.

• General appearance assessed from doorway before approaching
• Full vital signs including RR (full 30 seconds), temp, HR, SpO₂, CRT
• Fontanelle assessed if under ~18 months
• Ears and throat examined if respiratory/ENT symptoms
• Chest — work of breathing, recession severity, auscultation
• Rash assessed with tumbler test if present
• Red-flag negatives documented explicitly
• NICE traffic light features considered
• Safety-netting given to parent — specific, timed, clear

• Assessed child's general appearance before approaching — used this to calibrate examination
• Vital signs correctly measured with age-appropriate reference ranges in mind
• Correctly performed tumbler test if rash present and interpreted result
• Correctly characterised severity (mild/moderate/severe) based on findings
• Red-flag features specifically documented (positive or negative)
• Safety-netting to parent specific, timed, and actionable
• Communication with parent clear and reassuring or appropriately urgent

1. Inspect both legs with the patient lying flat:
   • Colour: Pink = normal. Pale = reduced arterial supply. Dusky/cyanosed = venous congestion or critical ischaemia. Red/brown pigmentation = chronic venous disease (haemosiderin deposition)
   • Skin changes: Hair loss on dorsum of foot and lower leg = chronic arterial insufficiency. Lipodermatosclerosis (woody, indurated skin above medial malleolus) = chronic venous disease
   • Ulcers: Site, size, base, edge, depth. Arterial ulcers: punched-out, painful, pale/necrotic base, on pressure points (toes, heels, lateral malleolus). Venous ulcers: irregular edge, shallow, sloughy/granulating base, medial gaiter area (above medial malleolus). Neuropathic ulcers: painless, over pressure points, associated with peripheral neuropathy
   • Varicose veins: Distribution (long saphenous vs short saphenous territory), any associated skin changes
   • Swelling: Oedema — symmetrical (cardiac/venous/hypoalbuminaemia) vs asymmetrical (DVT, cellulitis, lymphoedema)
2. Assess temperature: Dorsum of your hand, comparing both limbs from distal to proximal. Cold feet with a marked temperature gradient at a specific level suggests peripheral arterial disease with occlusion at that level.
3. Capillary refill time: Press the toe or finger for 5 seconds. Normal: <2 seconds. Prolonged = reduced peripheral perfusion (arterial disease, dehydration, cold).
4. Palpate peripheral pulses — compare both sides:
   • Femoral: In groin, mid-inguinal point
   • Popliteal: Patient's knee slightly flexed, thumbs on tibial tuberosity, fingers meet in popliteal fossa posteriorly — difficult in obese patients
   • Dorsalis pedis (DP): Dorsum of foot, lateral to extensor hallucis longus tendon
   • Posterior tibial (PT): Behind and below the medial malleolus
   Absent DP + PT pulses = significant peripheral arterial disease. Absent pulses + symptoms = refer for vascular assessment and ABPI.
5. Calf assessment (if DVT suspected): Calf tenderness on palpation, calf swelling (measure both calves at a fixed point — >3 cm difference is significant), erythema, warmth. Use the Wells score to guide imaging decision. Do not rely on any single sign — DVT can present with all signs absent.
6. Buerger's test (if arterial disease suspected): Elevate legs to 45° for 1–2 minutes. Arterial insufficiency: legs blanch (pallor on elevation). Lower legs to 45° below horizontal. In arterial disease, a reactive hyperaemia develops (dusky red/purple colour — "sunset foot") as blood refills under gravity. Positive Buerger's = significant arterial disease.
7. ABPI (ankle-brachial pressure index): Not performed in routine GP examination but should be arranged in any patient with claudication, non-healing leg ulcer, or suspected PAD. Normal ABPI ≥1.0. ABPI 0.5–0.9 = mild-moderate PAD. ABPI <0.5 = severe ischaemia. ABPI >1.3 = calcified vessels (common in diabetes — falsely reassuring).

• Both legs fully inspected — colour, skin changes, ulcers, oedema
• Temperature comparison — both legs, distal to proximal
• Capillary refill time measured bilaterally
• All four peripheral pulses palpated bilaterally (femoral, popliteal, DP, PT)
• Calf assessed if DVT suspected (tenderness, swelling, warmth)
• Ulcer characterised fully if present (site, size, base, edge, pain)
• ABPI arranged if PAD suspected
• Acute limb ischaemia red flags assessed — escalated immediately if present

• Correct inspection sequence — colour, skin, ulcers, veins, oedema
• Peripheral pulses located and assessed correctly (correct anatomical landmarks)
• Correctly differentiated arterial from venous ulcer if present
• Buerger's test performed if arterial disease suspected
• Communicated findings and management plan clearly including cardiovascular risk
• Recognised acute limb ischaemia features and would escalate appropriately
• Documentation complete and management-relevant