1. Environment, general appearance
2. Nails, hands, arms
3. Trochlear, axillary nodes
4. Eyes, mouth
5. Cervical, supraclavicular nodes
6. Chest, abdomen
7. Abdominal nodes
8. Inguinal nodes
9. Legs

Environment

• Sterile room (infections).

General appearance

• Pt. lies flat, one pillow under head.
• Race, gender:
  • Mediterranean descent (thalassemia).
  • African descent (sickle-cell anemia).
  • African descent female (SLE).
  • Female (Felty's)
  • Northern European descent, blue eyes, premature gray hair (pernicious anemia).
• Colors: pale (anemia), jaundice (hemolytic anemia). See Skin Colors Reference.
• Dyspnea, wheeze, difficulties.
• Bruising.
• RA posture (Felty's).
• AIDS features.
• Ask pt. if tenderness anywhere, so 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), rhythm, character.

Arms

• Blood pressure.
• Scratch marks (lymphatic CA, myeloproliferative dz).
• Palpable purpura (dysglobulinema).

Trochlear nodes

• Cup Dr's R hand below pt's R elbow.
• While holding pt's elbow, Dr's thumb reaches over pt's cubital fossa to palpate 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 bent, so 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 (macroglobulinemia, etc).
  • AIDS ocular lesions (toxoplasmosis, CMV).
  • Hemorrhages.
  • See Fundus Examination.

Mouth

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

Cervical, supraclavicular 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 Trachea Examination.
• Assess bone pain (bone CA):
  • Compress sternum with hands.
  • Compress clavicle with hands.
  • Tap spine with fist.

Abdomen

• Pt. lies down, one pillow under head.
• Abdominal breathing: more than normal.
• Inspect, palpate liver, spleen (infections) for enlargement.
• See Abdominal Examination and Hepatosplenomegaly Reference.
• If bowel CA or GI bleeding suspected, perform Rectal Examination.

Abdominal nodes

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

Inguinal nodes

• Palpate nodes:
  • Superficial inguinal: superior, horizontal, inferior 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 Fingernails and Hands.