OSCE example 1: Breast examination 236
OSCE example 2: Scrotal pain history 236
The breasts are modified sweat glands. The openings of
the lactiferous ducts are on the apex of the nipple, which is
erectile tissue. The nipple is in the fourth intercostal space in
the mid-clavicular line, but accessory breast/nipple tissue may
develop anywhere down the nipple line (axilla to groin) (Figs 11.1
and 11.2). The adult breast is divided into the nipple, the areola
and four quadrants (upper outer to lower inner), with an axillary tail
(of Spence) projecting from the upper outer quadrant (Fig. 11.3).
The size and shape of the breasts are influenced by age,
hereditary factors, sexual maturity, phase of the menstrual cycle,
parity, pregnancy, lactation and nutritional state. Fat and stroma
surrounding the glandular tissue determine the size of the breast,
except during lactation, when enlargement is mostly glandular. The
breast responds to fluctuations in oestrogen and progesterone
levels. Swelling and tenderness are common in the premenstrual
phase. The glandular tissue reduces and fat increases with age,
making the breasts softer and more pendulous. Lactating breasts
are swollen and engorged with milk, and are best examined
Benign and malignant conditions of the breast cause similar
symptoms but benign changes are much more common. The
most common presenting symptoms are a breast lump, breast
pain, and skin and nipple changes. Men may present with
gynaecomastia (breast swelling). Women are often worried that
they have breast cancer, whatever breast symptom they have,
and it is important to explore these concerns.
The history of the presenting symptoms is crucial. Find out
the nature and duration of symptoms, any changes over time
and any relationship to the menstrual cycle.
Ask about risk factors for breast cancer, in particular:
• previous personal history of breast cancer
• family history of breast or ovarian cancer and the age of
• use of hormone replacement therapy
• previous mantle radiotherapy for Hodgkin’s lymphoma.
Not all patients have symptoms. Women may present with an
abnormality on screening mammography or concerns about
• Is it a single lump or multiple lumps?
Fig. 11.1 Accessory breast tissue in the axilla.
Fig. 11.2 Cross-section of the female breast.
The physical examination • 203
10.4 Adrenal causes of endocrine hypertension
Condition Hormone produced in excess Associated features
Conn’s syndrome Aldosterone Hypokalaemia
skin thinning, violaceous striae, hypokalaemia
Phaeochromocytoma Noradrenaline (norepinephrine),
Paroxysmal symptoms, including hypertension, palpitations, sweating
insufficiency, the pituitary increases ACTH secretion in
response to low cortisol levels. High levels of ACTH increase
melanocyte-stimulating hormone, leading to increased skin
pigmentation (most striking in white Caucasians). Vitiligo
(depigmentation of areas of skin) occurs in 10–20% of
Addison’s disease cases (Fig. 10.12A).
• Measure the blood pressure and test for postural
hypotension (p. 51), resulting from salt and water loss due
to inadequate mineralocorticoid.
• Look for signs of weight loss.
• Examine the skin for abnormal or excessive pigmentation.
This is most prominent in sun-exposed areas or epithelia
subject to trauma or pressure: skin creases, buccal mucosa
(Fig. 10.12B) and recent scars. In primary adrenal
The gonads (testes and ovaries) secrete sex hormones
(testosterone and oestrogen) in response to gonadotrophin
(FSH and LH) release by the pituitary. The reproductive system
Most commonly, men present with androgen deficiency, whereas
women present with hyperandrogenism.
Hypogonadism can be primary (failure of the gonad itself) or
secondary (where reduced gonadotrophin levels cause gonadal
failure). Klinefelter’s syndrome (47XXY) is the most common cause
of primary hypogonadism in men (1:600 live male births; Fig.
10.13). Secondary hypogonadism may be caused by pituitary
disease, extremes of weight, or drugs that suppress hypothalamic
gonadotrophin releasing hormone release (such as anabolic
steroids or opiates). Presenting symptoms in men include loss
of libido, erectile dysfunction, loss of secondary sexual hair,
reduction in testicular size and gynaecomastia (p. 214).
Hyperandrogenism in women usually presents with hirsutism
(excessive male-pattern hair growth; Fig. 10.14), acne and/or
oligomenorrhoea, and is commonly due to polycystic ovarian
syndrome (PCOS; usually also associated with obesity).
Other less common causes should be considered (such as
congenital adrenal hyperplasia). Virilisation is suggested by
male-pattern baldness, deepening of the voice, increased
muscle bulk and clitoromegaly; if present in women with a short
history of severe hirsutism, consider a testosterone-secreting
• thirst: due to the resulting loss of fluid
• weight loss: due to fluid depletion and breakdown of fat
and muscle secondary to insulin deficiency.
Other common symptoms are tiredness, mood changes and
blurred vision (due to glucose-induced changes in lens refraction).
Bacterial and fungal skin infections are common because of the
combination of hyperglycaemia, impaired immune resistance
and tissue ischaemia. Itching of the genitalia (pruritus vulvae in
women, balanitis in men) is due to Candida yeast infection (thrush).
Past medical, drug, family and
• Previous glucose intolerance or gestational diabetes, which
are risk factors for progression to type 2 diabetes.
• Other autoimmune conditions such as thyroid disease
(increased incidence of type 1 diabetes).
• Drug therapy: glucocorticoids can cause steroid-induced
• Family history of diabetes or autoimmune disease.
Monogenic diabetes is usually inherited in an autosomal
dominant manner. Patients are often slim (unlike those with
type 2 diabetes) but do not require insulin at diagnosis (unlike
those with type 1 diabetes). Monogenic diabetes should be
considered in people presenting with diabetes under the age
of 30 who have an affected parent or a family history of
early-onset diabetes in around 50% of first-degree relatives.
• Smoking habit: combines with diabetes to increase the
risk of vascular complications.
• Alcohol: raises the possibility of pancreatic diabetes.
Fig. 10.13 Klinefelter’s syndrome. Tall stature, gynaecomastia, reduced
The pancreas lies behind the stomach on the posterior abdominal
wall. Its endocrine functions include production of insulin (from beta
cells), glucagon, gastrin and somatostatin. Its exocrine function
is to produce alkaline secretions containing digestive enzymes.
Diabetes mellitus is characterised by hyperglycaemia caused
by absolute or relative insulin deficiency.
Diabetes may be primary or secondary. Primary diabetes is
• type 1: severe insulin deficiency due to autoimmune
destruction of the pancreatic islets. These patients are
susceptible to acute decompensation due to hypoglycaemia
or ketoacidosis, both of which require prompt treatment.
• type 2: commonly affects people who are obese and
insulin-resistant, although impaired beta-cell function is
also important. These patients may decompensate by
developing a hyperosmolar hyperglycaemic state.
Secondary causes of diabetes and the associated history and
examination features are described in Box 10.5.
Diabetes mellitus commonly presents with a classical triad of
• polyuria (and nocturia): due to osmotic diuresis caused by
Assessment of a patient with newly
• Look for evidence of weight loss and dehydration.
Unintentional weight loss is suggestive of insulin deficiency.
• Check for clinical features of acromegaly or Cushing’s
• Look for Kussmaul respiration (hyperventilation with a
deep, sighing respiratory pattern) or the sweet smell of
ketones, both of which suggest insulin deficiency and
• Skin: look for signs of infection such as cellulitis, boils,
abscesses and fungal infections, paying particular attention
to the feet (see later). Look for signs of insulin resistance
such as acanthosis nigricans (Fig. 10.15A). Necrobiosis
lipoidica, a yellow, indurated or ulcerated area surrounded
by a red margin indicating collagen degeneration (Fig.
10.15B), may occur on the shins in type 1 diabetes and
often causes chronic ulceration.
• Look for xanthelasmata and xanthomata (Fig. 10.15C; see
Fig. 4.6); these are suggestive of dyslipidaemia, which may
• Measure the pulse and blood pressure, and examine the
cardiovascular and peripheral vascular systems, with a
particular emphasis on arterial pulses in the feet (p. 69).
• Examine the central nervous system, with a particular
focus on sensation in the lower limbs (p. 143).
• Test visual acuity and perform fundoscopy (p. 164; see
• Perform urinalysis for glycosuria.
Microvascular, neuropathic and macrovascular complications
of hyperglycaemia can occur in patients with any type of diabetes
mellitus, and may be present at diagnosis in patients with
Glycosuria is in keeping with diabetes; the presence of urinary
(or blood) ketones suggests insulin deficiency and the possibility
of diabetic ketoacidosis. Other investigations to consider are
In established diabetes, vital aspects of the history (Box
10.6) and examination should be reviewed at least once
The physical examination will differ, depending on whether this
is a new presentation of diabetes or a patient with established
diabetes attending for their annual review.
10.6 Routine history taking as part of the annual
• Ask about frequency of blood glucose testing and frequency and
awareness of symptoms of hypoglycaemia
• When relevant, give guidance on driving and/or pre-pregnancy
• Enquire about any lumpiness (lipohypertrophy), bruising or
Symptoms of macrovascular disease
• Ask whether there has been any angina, myocardial infarction,
claudication, stroke or transient ischaemic attack since the last
Symptoms of microvascular disease
• Ask whether there has been any change in vision or any numbness
or altered sensation in the feet
• Ask about neuropathy and peripheral vascular symptoms as above
• Enquire about any breaks in the skin, infections or ulcers
• Enquire about erectile dysfunction in men
• Ask about postural hypotension, sweating, diarrhoea and vomiting in
10.5 Causes of secondary diabetesa
Cause of diabetes Examples Clinical features
Pancreatic disease Pancreatitis Abdominal pain
Trauma/pancreatectomy Surgical scar
Cystic fibrosis Chronic cough, purulent sputum
Haemochromatosis Skin pigmentation (‘bronze diabetes’)
Endocrinopathies Acromegaly, Cushing’s syndrome p. 202
Drugs Glucocorticoids (e.g. prednisolone)
Antipsychotics (e.g. olanzapine)
Features of Cushing’s syndrome (see Fig. 10.11)
Immunosuppressants (e.g. ciclosporin, tacrolimus) Gum hypertrophy may be seen with ciclosporin use
Pregnancy Gestational diabetes may develop in the third trimester Gravid uterus
Glucokinase deficiency Glucokinase deficiency is present from birth with
Based on classification by the American Diabetes Association.
The physical examination • 207
Up to 40% of people with diabetes have peripheral neuropathy and
40% have peripheral vascular disease, both of which contribute
to a 15% lifetime risk of foot ulcers (Fig. 10.16).
Early recognition of the ‘at-risk’ foot is essential. There are
• Neuropathic: neuropathy predominates but the major
• Neuroischaemic: reduced arterial supply produces
ischaemia and exacerbates neuropathy.
Infection may complicate both presentations.
• Look for hair loss and nail dystrophy.
• Examine the skin (including the interdigital clefts) for
excessive callus, skin breaks, infections and ulcers. Look
for any discoloration. Distal pallor can suggest early
ischaemia, while purple/black discoloration suggests
• Ask the patient to stand so that you can assess the foot
arch; look for deformation of the joints of the feet.
• Feel the temperature of the feet.
• Examine the dorsalis pedis and posterior tibial pulses. If
absent, arrange Doppler studies and evaluate the
ankle:brachial pressure index (p. 69).
• Test for peripheral neuropathy: use a 10-g monofilament
to apply a standard, reproducible stimulus. The technique
Routine review of a patient with diabetes
• Weigh the patient: weight gain in type 2 diabetes is likely
to be associated with worsening insulin resistance while
weight loss in type 1 diabetes often suggests poor
glycaemic control and inadequate insulin dosage.
• For patients on insulin, examine insulin injection sites for
evidence of lipohypertrophy (which may cause
unpredictable insulin release), lipoatrophy (rare) or signs of
• Measure the pulse and blood pressure.
• Test visual acuity and perform fundoscopy (p. 164; see
• Examine the feet (see the next section).
• Perform routine biochemical screening (Box 10.7).
Fig. 10.15 Diabetes and the skin. A Acanthosis nigricans.
B Necrobiosis lipoidica. C Eruptive xanthomata.
10.7 Investigations in diabetes
Investigation Indication/comment
To make a diagnosis of diabetes.
Patients will also monitor capillary blood
glucose to adjust their treatment
HbA1c Can be used for diagnosis of type 2
diabetes and to assess glycaemic burden
Ketones suggest insulin deficiency,
which occurs in type 1 diabetes and in
diabetes due to pancreatic pathology
To confirm a diagnosis of autoimmune
HbA1c An important measure of glycaemic
control over the preceding 3 months;
predicts risk of complications
Urea and electrolytes To assess for the presence of diabetic
Lipid profile To aid estimation of cardiovascular risk
and guide treatment with lipid-lowering
Thyroid function tests To screen for the commonly associated
To assess for early signs of diabetic
nephropathy (microalbuminuria)
To screen for diabetic retinopathy and/or
GAD, glutamic acid decarboxylase.
and the best sites to test are shown in Fig. 10.17. Avoid
areas of untreated callus. Sensory loss typically occurs in
• Assess dorsal column function by testing vibration and
• Undertake a foot risk assessment to guide management
Hair loss and nail dystrophy occur with ischaemia. Feet are
warm in neuropathy and cold in ischaemia. Ischaemic ulcers are
typically found distally: at the tips of toes (see Fig. 10.16B), for
example. There may be skin fissures or tinea infection (‘athlete’s
foot’). Loss of sensation to vibration (p. 143) and proprioception
(p. 144) are early signs of diabetic peripheral neuropathy. Sensory
neuropathy is present if the patient cannot feel the monofilament
on the sites shown in Fig. 10.17. This suggests loss of protective
pain sensation and is a good predictor of future ulceration.
With significant neuropathy, the foot arch may be excessive or
collapsed (rocker-bottom sole). Both conditions cause abnormal
pressures and increase the risk of plantar ulceration (see Fig.
10.16C), particularly in the forefoot. Charcot’s arthropathy is
disorganised foot architecture, acute inflammation, fracture and
bone thinning in a patient with neuropathy. It presents acutely
as a hot, red, swollen foot and is often difficult to distinguish
10.8 Risk assessment of the diabetic foot
Level of risk Definition Action required
High Previous ulceration or amputation, or more than one risk factor
Annual screening should be undertaken by a specialist
Active foot disease Ulceration, spreading infection, critical ischaemia or an
unexplained red, hot, swollen foot
Prompt referral to a multidisciplinary diabetic foot team is
Fig. 10.16 Diabetic foot complications. A Infected foot ulcer with
cellulitis and ascending lymphangitis. B Ischaemic foot: digital gangrene.
C Charcot arthropathy with plantar ulcer.
Fig. 10.17 Monofilament sensory testing of the diabetic foot.
A Apply sufficient force to allow the filament to bend. B Sites at highest
risk (toes and metatarsal heads).
The physical examination • 209
Please examine her thyroid status
• Introduce yourself and clean your hands.
• Palpate the pulse for bounding pulse, tachycardia and atrial fibrillation.
• Test eye movements for ophthalmoplegia and lid lag.
• Auscultate any goitre for bruit.
• Examine the shins for pretibial myxoedema and test for hyper-reflexia.
• Thank the patient and clean your hands.
These findings suggest autoimmune thyrotoxicosis (Graves’ disease).
Thyroid function tests, thyroid receptor autoantibodies and thyroid scintigraphy.
Mr Birnam, 67 years old, has type 2 diabetes and presents with pain in his lower limbs.
• Introduce yourself and clean your hands.
• Inspect the skin for excessive callus, infections and ulcers.
• Palpate the feet to assess the temperature of the skin.
• Palpate the dorsalis pedis and posterior tibial pulses.
• Test for peripheral neuropathy using a 10-g monofilament and tuning fork.
• Thank the patient and clean your hands.
Doppler studies to evaluate the ankle : brachial pressure index. Review of diabetes control.
retinopathy (fundoscopy) and nephropathy (test urine for microalbuminuria).
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Common presenting symptoms 212
Female reproductive system 216
Common presenting symptoms 217
Obstetric history and examination: the booking visit 225
Drug, alcohol and smoking history 225
Routine antenatal check in later pregnancy 226
Common presenting symptoms 226
Common presenting symptoms 231
OSCE example 1: Breast examination 236
OSCE example 2: Scrotal pain history 236
The breasts are modified sweat glands. The openings of
the lactiferous ducts are on the apex of the nipple, which is
erectile tissue. The nipple is in the fourth intercostal space in
the mid-clavicular line, but accessory breast/nipple tissue may
develop anywhere down the nipple line (axilla to groin) (Figs 11.1
and 11.2). The adult breast is divided into the nipple, the areola
and four quadrants (upper outer to lower inner), with an axillary tail
(of Spence) projecting from the upper outer quadrant (Fig. 11.3).
The size and shape of the breasts are influenced by age,
hereditary factors, sexual maturity, phase of the menstrual cycle,
parity, pregnancy, lactation and nutritional state. Fat and stroma
surrounding the glandular tissue determine the size of the breast,
except during lactation, when enlargement is mostly glandular. The
breast responds to fluctuations in oestrogen and progesterone
levels. Swelling and tenderness are common in the premenstrual
phase. The glandular tissue reduces and fat increases with age,
making the breasts softer and more pendulous. Lactating breasts
are swollen and engorged with milk, and are best examined
Benign and malignant conditions of the breast cause similar
symptoms but benign changes are much more common. The
most common presenting symptoms are a breast lump, breast
pain, and skin and nipple changes. Men may present with
gynaecomastia (breast swelling). Women are often worried that
they have breast cancer, whatever breast symptom they have,
and it is important to explore these concerns.
The history of the presenting symptoms is crucial. Find out
the nature and duration of symptoms, any changes over time
and any relationship to the menstrual cycle.
Ask about risk factors for breast cancer, in particular:
• previous personal history of breast cancer
• family history of breast or ovarian cancer and the age of
• use of hormone replacement therapy
• previous mantle radiotherapy for Hodgkin’s lymphoma.
Not all patients have symptoms. Women may present with an
abnormality on screening mammography or concerns about
• Is it a single lump or multiple lumps?
Fig. 11.1 Accessory breast tissue in the axilla.
Fig. 11.2 Cross-section of the female breast.
Fractures, dislocations and trauma • 279
Establish the mechanism of injury. For example, a patient who
has fallen from a height on to their heels may have obvious
fractures of the calcaneal bones in their ankles but is also at
risk of fractures of the proximal femur, pelvis and vertebral
Use the ‘Look – feel – move’ approach. Observe patients
closely to see if they move the affected part and are able to
• See if the skin is intact. If there is a breach in the skin and
the wound communicates with the fracture, the fracture is
open or compound; otherwise it is closed.
• Look for associated bruising, deformity, swelling or wound
• Gently feel for local tenderness.
• Feel distal to the suspected fracture to establish if
sensation and pulses are present.
Fractures, dislocations and trauma
A fracture is a breach in the structural integrity of a bone. This
• normal bone from excessive force
• normal bone from repetitive load-bearing activity (stress
• bone of abnormal structure (pathological fracture, see Box
13.18) with minimal or no trauma.
The epidemiology of fractures varies geographically. There
is an epidemic of osteoporotic fractures because of increasing
elderly populations. Although any osteoporotic bone can fracture,
common sites are the distal radius (Fig. 13.47), neck of femur
(see Fig. 13.33), proximal humerus and spinal vertebrae.
Fractures resulting from road traffic accidents and falls are
decreasing because of legislative and preventive measures such
as seat belts, air bags and improved roads. A fracture may occur
in the context of severe trauma.
Fig. 13.46 Ruptured Achilles tendon. A Site of a palpable defect in the
Achilles tendon (arrow). B Thomson’s test. Failure of the foot to
plantar-flex when the calf is squeezed is pathognomonic of an acute
rupture of the Achilles tendon.
Fig. 13.47 Colles’ fracture. A Clinical appearance of a dinner-fork
deformity. B X-ray appearance.
280 • The musculoskeletal system
• Establish whether the patient can move joints distal and
• Do not move a fracture site to see if crepitus is present;
this causes additional pain and bleeding.
Describe the fracture according to Box 13.19. For each
suspected fracture, X-ray two views (at least) at perpendicular
planes of the affected bone, and include the joints above and
Fig. 13.48 Ankle deformity. A Clinical appearance. B Lateral X-ray
view showing tibiotalar fracture dislocation.
• What bone(s) is/are involved?
• Is the fracture open (compound) or closed?
• Is the fracture complete or incomplete?
• Where is the bone fractured (intra-articular/epiphysis/physis/
• What is the fracture’s configuration (transverse/oblique/spiral/
comminuted (multifragmentary)/butterfly fragment)?
• What components of deformity are present?
• Translation is the shift of the distal fragment in relation to the
proximal bone. The direction is defined by the movement of the
distal fragment, e.g. dorsal or volar, and is measured as a
• Angulation is defined by the movement of the distal fragment,
• Rotation is measured in degrees along the longitudinal axis of
the bone, e.g. for spiral fracture of the tibia or phalanges.
• Shortening: proximal migration of the distal fragment can cause
shortening in an oblique fracture. Shortening may also occur if
there has been impaction at the fracture site, e.g. a Colles’
fracture of the distal radius.
• Is there distal nerve or vascular deficit?
• What is the state of the tissues associated with the fracture (soft
tissues and joints, e.g. fracture blisters, dislocation)?
13.20 Common musculoskeletal investigations
Investigation Indication/comment
Protein Glomerular disease, e.g. SLE, vasculitis
Secondary amyloid in RA and other chronic arthropathies
Drug adverse effects, e.g. myocrisin, penicillamine
Blood Glomerular disease, e.g. SLE, vasculitis
Full blood count Anaemia in inflammatory arthritis, blood loss after trauma
Neutrophilia in sepsis and very acute inflammation, e.g. acute gout
Leucopenia in SLE, Felty’s syndrome and adverse effects of antirheumatic drug therapy
Erythrocyte sedimentation rate/plasma viscosity Non-specific indicator of inflammation or sepsis
C-reactive protein Acute-phase protein
Urea and creatinine ↑ in renal impairment, e.g. secondary amyloid in RA or adverse drug effect
Uric acid May be ↑ in gout. Levels may be normal during an acute attack
Calcium ↓ in osteomalacia; normal in osteoporosis
Alkaline phosphatase ↑ in Paget’s disease, metastases, osteomalacia and immediately after fractures
Angiotensin-converting enzyme ↑ in sarcoidosis
Urinary albumin : creatinine ratio Glomerular disease, e.g. vasculitis, SLE
in up to 15% of normal population. Superseded by anti-cyclic citrullinated peptide antibodies
RA. Occasionally found in Sjögren’s syndrome
Anti-Ro, Anti-La Sjögren’s syndrome
Common investigations in patients with musculoskeletal disease
13.20 Common musculoskeletal investigations – cont’d
Investigation Indication/comment
Anti-ribonucleoprotein Mixed connective tissue disease
Schirmer tear test, salivary flow test Keratoconjunctivitis sicca (dry eyes), Sjögren’s syndrome
bone changes in Paget’s disease, pseudofractures (Looser’s zones) in osteomalacia
Detection of bursae, tendon pathology and osteophytes
Magnetic resonance imaging Joint and bone structure; soft-tissue imaging
Computed tomography High-resolution scans of thorax for pulmonary fibrosis
vertebral assessment for fractures
Synovial fluid microscopy Inflammatory cells, e.g. ↑ neutrophils in bacterial infection
Negatively birefringent needle-shaped crystals – monosodium urate monohydrate (gout)
Bacteriological culture Organism may be isolated from synovial aspirates
Biopsy and histology Synovitis – RA and other inflammatory arthritides
RA, rheumatoid arthritis; SLE, systemic lupus erythematosus.
OSCE example 1: Right shoulder pain
Mr Hunt, 38 years old, has a 2-month history of right shoulder pain with no history of trauma.
• Introduce yourself and clean your hands.
• Expose both of the patient’s shoulders and arms.
• Comment on acromioclavicular deformity and muscle wasting; look for winging of the scapula.
• Compare the right shoulder to the normal left shoulder.
• Finally, examine the arm, looking for conditions such as biceps rupture.
• If all movements of the shoulder are normal, conduct a full examination of the neck.
• Thank the patient and clean your hands.
Suggest a differential diagnosis
post-traumatic), long head of biceps rupture and referred pain from the neck.
282 • The musculoskeletal system
• Introduce yourself and clean your hands.
• In this case there is swelling of two MCP joints on the right, and one PIP joint on the left.
• Normal nails and skin (therefore psoriatic arthropathy is unlikely).
• Ask first what is sore and seek permission to examine gently.
• Tender, soft swelling of the MCP and PIP joints in the hands and left elbow.
• In feet: tender across her MTP joints on squeeze test but no palpable swelling.
in limitation of hand function.
Suggest a differential diagnosis
Suggest initial investigations
Integrated examination sequence for the locomotor system
• Ask the patient to undress to their underwear.
• Ask the GALS (gait, arms, legs, spine) questions and perform the GALS screen.
• Identify which joints require more detailed examination:
• What is the pattern of joint involvement?
• Is it likely to be inflammatory or degenerative?
• Assess the general appearance:
• Look for pallor, rashes, skin tightness, evidence of weight or muscle loss, obvious deformities.
• Check the surroundings for a temperature chart, walking aids and splints, if appropriate.
• Examine the relevant joint, or all joints if systemic disease suspected:
• Ask about tenderness before examining the patient.
• Look at the skin, nails, subcutaneous tissues, muscles and bony outlines.
• Feel for warmth, swelling, tenderness, and reducibility of deformities.
• If systemic disease is suspected, go on to examine all other systems fully.
• Consider what investigations are required:
• Joint aspiration for synovial fluid analysis or culture.
Common presenting symptoms 285
Past medical and drug history 285
Supplementary examination techniques 291
OSCE example 2: Pigmented lesion 293
Integrated examination sequence for the skin 293
284 • The skin, hair and nails
Dermatological conditions are very common (10–15% of general
practice consultations) and present to doctors in all specialties.
In the UK, 50% are lesions (‘lumps and bumps’), including skin
cancers, and most of the remainder are acute and chronic
inflammatory disorders (‘rashes’), including infections, with genetic
conditions accounting for a small minority.
Dermatological diagnosis can be challenging: not only is there a
vast number of distinct skin diseases, but also each may present
with a great variety of morphologies and patterns determined by
intrinsic genetic factors, with the diagnostic waters muddied still
further by external influences such as rubbing and scratching,
infection, and well-meaning attempts at topical and systemic
treatment. Even in one individual, lesions with the same pathology
can have a very variable appearance (for example, melanocytic
naevi, seborrhoeic keratoses and basal cell carcinomas).
Many skin findings will have no medical significance, but it is
important to be able to examine the skin properly in order to
identify tumours and rashes, and also to recognise cutaneous
signs of underlying systemic conditions. The adage that the skin
is a window into the inner workings of the body is entirely true,
and an examination of the integument will often provide the
discerning clinician with important clues about internal disease
processes, as well as with information about the physical and
psychological wellbeing of an individual.
The skin is the largest of the human organs, with a complex
anatomy (Fig. 14.1) and a number of essential functions
(Box 14.1). It has three layers, the most superficial of which
is the epidermis, a stratified squamous epithelium, containing
melanocytes (pigment-producing cells) within its basal layer, and
Langerhans cells (antigen-presenting immune cells) throughout.
The dermis is the middle and most anatomically complex layer,
containing vascular channels, sensory nerve endings, numerous
cell types (including fibroblasts, macrophages, adipocytes and
smooth muscle), hair follicles and glandular structures (eccrine,
sebaceous and apocrine), all enmeshed in collagen and elastic
tissue within a matrix comprising glycosaminoglycan, proteoglycan
The deep subcutis contains adipose and connective tissue.
Dermatoses (diseases of the skin) may affect all three
layers and, to a greater or lesser extent, the various functions
Fig. 14.1 Structures of the skin.
Deep cutaneous vascular plexus
• Protection against physical injury and injurious substances, including
• Anatomical barrier against pathogens
• Appreciation of sensation (touch, temperature, pain)
• Absorption – particularly fetal and neonatal skin
• Psychosexual and social interaction
Hair plays a role in the protective, thermoregulatory and sensory
functions of skin, and also in psychosexual and social interactions.
There are two main types of hair in adults:
• vellus hair, which is short and fine, and covers most of the
• terminal hair, which is longer and thicker, and is found on
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