1. Environmentgeneralappearance
2. Nailshandsarms
3. Trochlearaxillarynodes
4. Eyesmouth
5. Cervicalsupraclavicular nodes
6. Chestabdomen
7. Abdominal nodes
8. Inguinal nodes
9. Legs

Environment

• Sterile room (infections).

General appearance

• Pt. lies flatone pillow under head.
• Racegender:
  • Mediterranean descent (thalassemia).
  • African descent (sickle-cell anemia).
  • African descent female (SLE).
  • Female (Felty's)
  • Northern European descentblue eyespremature gray hair (perniciousanemia).
• Colors: pale (anemia)jaundice (hemolytic anemia). See SkinColors Reference.
• Dyspneawheezedifficulties.
• Bruising.
• RA posture (Felty's).
• AIDS features.
• Ask pt. if tenderness anywhereso do not overpalpate painful nodes.

Nails

• Nicotine stains.
• Koilonychia (iron deficiency).
• Pale nails (anemia).
• See Nails Reference.

Hands

• Pallor of palmar creases (anemia 2° to blood loss).
• RA joints (Felty's).
• Tophi (Gout 2° to myeloproliferative dz).
• Connective tissue dz's (anemia 2° to inflammation).
• Noticeable heat (infections).
• Pulse: rate (anemia has tachycardia)rhythmcharacter.

Arms

• Blood pressure.
• Scratch marks (lymphatic CAmyeloproliferative dz).
• Palpable purpura (dysglobulinema).

Trochlear nodes

• Cup Dr's R hand below pt's R elbow.
• While holding pt's elbowDr's thumb reaches over pt's cubital fossa topalpate a spot anterior and proximal to pt's medial epicondyle.
• Palpate enlargement. See Nodes Reference.

Axillary nodes

• Pt raises arm over head.
• Dr's L fingers insert deeply into pt's R axilla.
• Pt's elbow is bentso forearm rests on Dr's forearm during palpation.
• Palpate enlargement of all nodes. See Nodes Reference.

Eyes

• Conjunctiva: pale (anemia).
• Sclera: jaundice (hemolytic anemia)hemorrhages (polycythemia).
• Eye fundus:
  • Papilloedema (macroglobulinemiaetc).
  • AIDS ocular lesions (toxoplasmosisCMV).
  • Hemorrhages.
  • See FundusExamination.

Mouth

• Gum hypertrophy (leukemia).
• Gum bleeding.
• Scurvy (Vit C. deficiency so might be others).
• Tongue: glossitis (iron deficiencymegaloblastic anemia).
• Waldeyer's ring inflammation (non-Hodgkin's).

Cervicalsupraclavicular nodes

• Pt sits up.
• Dr. examines from behind pt.
• Palpate nodes in order:
  • Submental
  • Submandibular
  • Deep cervical
  • Preauricular
  • Postauricular
  • Occipital (classically Rubella)
  • Supraclavicular
  • Infraclavicular
  • Posterior triangle
• See Nodes Reference.

Chest

• Trachea for deviation from nodes. See TracheaExamination.
• Assess bone pain (bone CA):
  • Compress sternum with hands.
  • Compress clavicle with hands.
  • Tap spine with fist.

Abdomen

• Pt. lies downone pillow under head.
• Abdominal breathing: more than normal.
• Inspectpalpate liverspleen (infections) for enlargement.
• See Abdominal Examination and Hepatosplenomegaly Reference.
• If bowel CA or GI bleeding suspectedperform RectalExamination.

Abdominal nodes

• Palpate nodes:
  • Para-aortic
• See Nodes Reference.

Inguinal nodes

• Palpate nodes:
  • Superficial inguinal: superiorhorizontalinferior groups
  • Deep inguinal
• See Nodes Reference.

Legs

• Legs showing same symptoms as Arms.
• Ulcers.
• Foot drop (anemia 2° to lead poisoning).
• Peripheral neuropathy (Wernicke's encephalopathy 2° to B12 deficiency).
• Popliteal node if possible (heel lesions). See Nodes Reference.
• Toenails and foot showing same symptoms as Fingernailsand Hands.

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