Académique Documents
Professionnel Documents
Culture Documents
2012 – 2013
Stephanie Reid
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OSCE Skills List
(based on DP tutorials 2012/2013)
History Taking
Full history Neurological upper limb exam
Cardiovascular history Neurological lower limb exam
Respiratory history Skin examination
Asthma history ENT examination
Genitourinary history Eye examination
Chronic renal failure history
Gastrointestinal history Procedures and Consent
Diabetes history Surgical hand wash
Sexual history Vital Signs / Obs
Upper limb history Basic life support (BLS)
Lower limb history Performing ECG
Neurological history Venepuncture
Cognitive testing Injections
Mental state exam (MSE) Arterial blood gases
Suicide Risk Assessment Nebuliser, oximetry, oxygen
Asthma education
Examination DRE / Rectal and prostate
Cardiovascular examination examination
Cardiac auscultation Urinalysis
Respiratory examination Nasogastric tube insertion
Genitourinary examination Pelvic exam and pap smear
Gastrointestinal examination IV cannulation
Breast examination Suturing sterile field
Testicular examination Plastering
Inguinal-scrotal examination Urinary catheterisation
Thyroid examination
Endocrine screen Interpretation
Diabetic examination ECG
Upper limb examination ABGs
Shoulder Urinalysis
Elbow Spirometry
Hand Peak flow
Lower Limb examination Liver function tests
Hip X-Ray Interpretation:
Knee Chest
Ankle Abdomen
Back examination Upper limb: shoulder, elbow,
Cranial nerve examination hand
Lower Limb: hip, knee, ankle
Description of masses/lesions
1
Contents
History - Cardiovascular ...................................................................................................................... 1
History - Respiratory ........................................................................................................................... 1
History - Gastrointestinal .................................................................................................................... 2
History - Genitourinary ....................................................................................................................... 2
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Examination – Skin ............................................................................................................................ 81
Examination – Ear, Nose, Throat ...................................................................................................... 84
1
History - Cardiovascular History - Respiratory
History History
1. Chest pain 1. Dyspnoea
2. Pain on exertion 2. Cough
3. Silent infarct 3. Sputum
4. Dyspnoea 4. Haemoptysis
5. Palpitation 5. Wheeze
6. Syncope 6. Stridor
7. Claudication (MHx: previous TIA/stroke) 7. Chest pain
8. Oedema (swelling) 8. Fever, sweats or rigors
9. Cough (HF), fatigue (HF, anaemia) and GI or GU 9. Night sweats
symptoms of HF (weight gain, abdo pain, swelling and 10. Snoring / OSA / sleep disturbance
oliguria) 11. Hoarseness
12. Weight loss or weight gain
Diagnoses
Angina Diagnoses
AMI Acute infection (pneumonia, common cold,
PE, DVT tracheobronchities, bronchopneumonia, viral
Pericarditis (pleuritic pain) pneumonia, acute on chronic bronchitis, pertussis),
Aortic dissection Chronic infection (bronchiectasis, TB, CF),
Heart failure, previous AMI Airway disease (asthma, chronic bronchitis)
Peripheral vascular disease Parenchymal diseases (emphysema, chronic
TIA or stroke interstitial lung fibrosis, sarcoidosis)
Anaemia Pulmonary oedema (acute, HF)
Arrhythmia Tumours (lung carcinoma)
Valve disease Foreign bodies
Postural hypotension Croup, epiglottitis, foreign bodies, congenital airway
Hypovolaemia disorders
Pneumothorax
Non Cardiovascular Diagnoses Bronchiolitis
Respiratory: pneumonia, acute pulmonary oedema,
pneumothorax, lung cancer, Non-Respiratory Diagnoses
Gastrointestinal: GORD Cardiovascular: HF, ACS (AMI, angina), PE, pericarditis,
Musculoskeletal aortic dissection
Neuro: psychogenic Musculoskeletal: Rib fracture, costochrondritis,
Drugs, caffeine muscle strain, spinal disease
Endocrine: hyperthyroidism Renal: AKI, CKD
Other: GORD, psychogenic
1
History - Gastrointestinal History - Genitourinary
History History
1. Abdominal pain 1. Change in urine
2. Change in bowel habit a. Appearance
a. Diarrhoea b. Volume
b. Constipation c. Odour
c. Blood in stool 2. Blood in urine
d. Mucus in stool 3. Stream
e. Malaena a. Hesitancy
3. Nausea and vomiting b. Poor flow
a. Hematemesis c. Intermittent
4. Change in appetite d. Terminal dribbling
5. Change in weight 4. Change in micturition
6. Heartburn or indigestion a. Anuria
7. Dysphagia b. Urgency
8. Jaundice c. Pain (dysuria)
9. Pturitis (itching) d. Frequency
10. Abdominal bloating / swelling e. Urinary retention
11. Lethargy/fatigue 5. Nocturia
12. Fever (appendicitis, diverticulitis) 6. Incontinence
7. Pain in abdomen, back or pelvis
Diagnoses 8. Incontinence
GORD 9. Fever, sweats or rigors
Peptic ulcer 10. Symptoms of CKD: fatigue, weight change, appetite
Pancreas disease change, oedema, bruising, hiccups
Biliary pain Sexual History
Renal colic 11. Sexual activity
Gastroenteritis 12. Sexual function and libido
Bowel obstruction (ileus, tumour, diabetic 13. Discharge or rash
neuropathy) Reproductive history
Bowel cancer 14. Menses
Inflammatory bowel disease 15. Infertility
16. Pregnancies
Irritable bowel syndrome (IBS)
Appendicitis
Diagnoses
Diverticulitis
Urinary tract infection
Malabsorption
Cystitis
− Coeliac disease
Pyelonephritis
− Inflammatory bowel disease
− Dietary, alcoholism Renal calculi
STI/STDs
Non-Gastrointestinal Diagnoses Incontinence (stress, overflow, urge)
AAA Benign prostatic hyperplasia
Drugs, bulimia, Prostate cancer
Stroke, achalasia Prostatitis
Musculoskeletal
GU / sexual causes
2
It is unusual to take this history, as unlikely to contribute to
History - Sexual (Male) changes in management. Ask only if indicated
Onset of and pace of progression of puberty
Sexual History − Begins 8-14 in girls
Sexual activity (current or past) − Begins 9-14 in boys
Partners (gender, new partners) Development of breast buds, scrotal and penile
Discharge (urethral or vaginal) changes (size and volume), pubic hair development
Pain (abdominal, testicular, dysuria, coital) Height gain and rate of slowing of growth
Skin lesions Any dysfunction in erection or ejaculation
Libido Undescended testes
Erectile dysfunction, impotence
Infertility Diagnoses
Lump Enlarged prostate
Renal stone (calculi)
Additional Sexual History UTI
Age of sexual activity STI
Number of sexual partners in the past 2 months Paraphimosis
Have you ever, or do you regularly practice
− Anal sex
− Penile-vaginal intercourse
History - Sexual (Female)
− Oral sex (fellatio)
− Any other forms of sex I haven’t mentioned? (this Sexual History
might uncover any number of fetish sexual Sexual activity (current or past)
practices) Partners (gender, new partners)
− Fetish Sex Pain (abdominal, vaginal, pelvic, dysuria, coital)
Have you ever felt at personal risk related to your Discharge (urethral or vaginal)
sexual practices? Skin lesions or rash
Have you ever felt like your practices have placed Libido
others at risk? Post-coital bleeding
Do you take any precautions against pregnancy?
Additional Sexual History
Sexually Transmitted Diseases Age of sexual activity
Have you ever been treated for a sexually transmitted Number of sexual partners in the past 2 months
disease? Have you ever, or do you regularly practice
Do you take any precautions against STDs? − Anal sex
Soreness or a rash anywhere on or near your genitals? − Penile-vaginal intercourse
Ask about unusual lumps or sores − Oral sex (fellatio)
Itch − Any other forms of sex I haven’t mentioned? (this
pain when urinating (dysuria) might uncover any number of fetish sexual
unusual discharge from genitals practices)
− Fetish Sex
Reproductive History Have you ever felt at personal risk related to your
Difficulties conceiving? sexual practices?
Have you had any problem with erections? Have you ever felt like your practices have placed
Have you noticed any difficulty with ejaculation? others at risk?
Had a vasectomy? Do you take any precautions against pregnancy?
Past or family history of infertility?
Sexually Transmitted Diseases
Psychological Factors Have you ever been treated for a sexually transmitted
Are you and your partner satisfied with your quality disease?
and frequency of sex? Do you take any precautions against STDs?
Have you ever any problematic sexual encounters? Have you had any soreness or a rash anywhere on or
(history of sexual abuse) near your genitals?
Ask about unusual lumps or sores
Sexual Development History IF INDICATED Itch
3
pain when urinating, (dysuria)
unusual discharge from genitals Cervical Screening
Last smear- date and result
Menses Any abnormal smears and management
Age of onset HPV vaccination
Frequency / regularity
− Amenorrhoea (absence) Psychological Factors
− Oligomenorrhoea (infrequent) Are you and your partner satisfied with your quality
− Polymenorrhoea (shorter time intervals) and frequency of sex?
Duration Have you ever any problematic sexual encounters?
Volume/heaviness (measure) (history of sexual abuse)
− Menorrhagia (abnormally heavy and prolonged
periods)
Sexual Development History IF INDICATED
Last period (date)
It is unusual to take this history, as unlikely to contribute to
Pelvic pain
changes in management. Ask only if indicated
Dysmenorrhoea (painful periods)
Onset of and pace of progression of puberty
Intermenstrual bleeding
− Begins 8-14 in girls
− Begins 9-14 in boys
Fertility and Reproductive (Obstetric) History
Development of breast buds, scrotal and penile
Children? changes (size and volume), pubic hair development
Pregnancies: Height gain and rate of slowing of growth
− number Any dysfunction in erection or ejaculation
− date (ages) Undescended testes
− gestation at delivery
− type of delivery (vaginal, caesarean)
− complications
− birthweight
− any medical problems in child
− difficulty breast feeding.
Have you had any other pregnancies? (termination
and miscarriages)
Infertility
Past infertility, miscarriage or stillbirth (especially
recurrent)
− Family history of above or family history of
infertility or miscarriage
Contraceptive history
When did you start contraception
Why did you start?
Current?
Any problems or changes? Any prior methods?
Any accidents or chances of pregnancy while on
contraception?
− How well do you manage it?
Side effects
Sexual partner’s contraception
4
History - Joint History - Neurological
History History
1. Pain 1. Pain
a. Sleep disturbance, proximal or distal changes, a. Headache
motor and sensory changes, treatment, b. Neck or back pain
events c. Facial pain
2. Stiffness 2. Fits, faints and funny turns
3. Swelling or deformity 3. Dizziness or vertigo
4. Limitation of movement / restriction on DALYs / 4. Disturbances of vision, hearing, smell or taste
Impact on life 5. Disturbances of gait
5. Locking 6. Loss of or disturbed sensation in limbs
6. Giving way 7. Weakness in limbs
7. Fatigue 8. Loss of sphincter control (bladder, bowel)
8. Cracking / Clicking 9. Peripheral neuropathy (numbness, tingling)
9. Constitutional symptoms (fever, sweats, appetite 10. Involuntary movements (jerking, tremors,
and weight) incoordination or restlessness? Any inability to
10. Systematic enquiry – rashes, fever, eyes, move)
photosensitivity, mouth ulcers 11. Speech and swallowing disturbances (dysarthria,
11. Change in gait dysphonia, dysphasia or dysphagia)
12. Altered cognition (confusion, delirium or dementia)
Diagnoses 13. Changes in personality
Arthritis
− Osteoarthritis Diagnoses
− Rheumatoid arthritis TI/Stroke
Septic arthritis Epilepsy
Gout UMN lesion
Seronegative spondyloarthritides: LMN lesion
− Ankylosing spondylitis Migraine
− Psoriatic arthritis Meningitis, encephalitis
− Reactive Raised ICP - worse in morning, learning forward, vomit.
Synovitis Dementia
Tendonitis Delirium
Trauma / injury Myasthenia gravis
Ligamentous injury Parkinson’s
Fracture Huntington’s
Autoimmune disease - SLE Guillian Barre
Connective tissue disease Trigeminal neuralgia
Acoustic neuroma, Meniere’s disease
Non-Neurological Diagnoses
Hypoglycaemia, AF
Disc degeneration and herniation
Spondylosis
Tension or cluster headache
Arrhythmia
Syncope
Temporal arteritis
Sinusitis
5
− Domestic exposure to dusts, allergens, chemicals
History - Continued etc
Ability to perform ADLs
What Is the patient most concerned about Home circumstances: partner, children, who lives at
What do they want to gain from this consultation home
Obesity
PHx / MHx: Past Medical History Stress levels (relationship, work, children, etc)
Open questions Hobbies
Medical conditions Pets
Surgeries:
Hospitalisations:
Tests
History - System Review
Systems Qs
− These symptoms are either positive (present) General: weight, appetite, sleep, energy, fevers or
symptoms or relevant negatives. night sweats?
How this is affecting the patient; what are their main Cardiorespiratory : Chest pain or ankle swelling
concerns and fears Respiratory: difficulty breathing or cough
Gastrointestinal: constipation, diarrhoea or blood in
1. When/how was it diagnosed? the stool?
2. How is it/was it managed? (surgeries, Genitourinary: change in urination?
medication, lifestyle interventions) Haematological: noticed any bruising or increased
3. Active/inactive bleeding?
4. Severity? Endo: changes in skin, temperature tolerance?
5. How does it affect you now? Reproductive: any discharge or rashes?
- Ongoing monitoring and review
Neurological: Mobility, cognition, sleep, tingling or
(medial and allied health)
shooting pains? Changes in sight, smell or hearing?
Musculoskeletal: any pain in your muscles or joints?
Medications Mental status: Changes in mood?
Prescribed
OTC, vitamins, supplements and herbal remedies
Compliance / frequency of use
Vaccination status
Family History
Age of death and cause
Sexual History
Multiple partners, unprotected sex, sex between men
6
History - Asthma History - Diabetes
To Do Current Diabetes
Type (I or II)
Duration
Age of onset
How diagnosed (symptoms or routine labs)
Glucose control:
Frequency of monitoring
Time of day before meals (AC) or after (PC)
Value in morning (AM)
Value at night (PM)
Hypoglycaemic events, DKA, hyperglycaemic
coma
Frequency
Severity
Medications (how it is managed)
Prescribed, OTC, vitamins, supplements and
\ herbal remedies
Name and dose
Oral hypoglycaemics (type II only,
sulfonylureas, metformin,
thiazolidinediones, α-glucosidase inhibitor)
Insulin – who injects? Where?
Dose adjustments
Other drugs: CV drugs, diuretics, OTC,
steroids, B-blockers
Diet prescribed
Compliance / frequency of use
Family history
Age of death and cause
Relevant: diabetes, cardiovascular
Sexual and obstetric history
Social history
Modifiable risk factors:
• Smoking,
• Alcohol
• Diet
• Inactivity / exercise
Finances, work, stress, mental health
Occupation (risk of hypos)
7
Other: Living arrangements, family, Urinary albumin excretion rate (timed
overnight or 24hr) OR early morning
Complications microalbumin creatinine ratio
Acute events Thyroid Function Test (type I due to
Hypoglycaemic episodes - Associated with increased risk)
significant metabolic stress and morbidity: Urea, Creatinine and Liver Function Tests.
MI, stroke, fractures Referral: Ophthalmologist (or some optometrists)
DKA (high glucose, no insulin) for assessment of the retina, Endocrinologist,
Hyperglycaemic hyperosmolar coma Nephrologist, Diabetes Educator, Podiatrist,
PVD (poor healing) and foot care: ulcers, Dietician, Exercise Physiologist, Pharmacist.
claudication
Neuropathy Management
Peripheral neuropathy: loss of sensation in Tight glycaemic control - daily BG measurements
glove/stocking pattern and HbA1c regularly
Autonomic neuropathy: erectile Reduce risk factors
dysfunction, postural hypotension, Diet and nutrition – quality vs quantity, high
gastroparesis and constipation fibre and low glycaemic index foods, gives
CN mononeuritis glycaemic control, decreases
Nephropathy: renal disease, proteinuria, hyperinsulinaemia & lowers lipids.
albuminaemia, creatinine Exercise 60-70% 3-4d/wk– to prevent or
Retinopathy: blurred sigh delay T2D, lower BP, improve insulin action,
Macro vascular: IHD/angina, CVD/SOB, CHF, MI, GLUT4 insertion, reduced oxidative enzymes
PVD Smoking cessation
Infections: skin, genitourinary, feet, dental Aim BP <130/80; younger patients or
microalbuminuric +ve <125/75
Investigations Lipid control: TC<4.0, LDL<2.0,TG<1.5,
HDL>1.0
Measure Hyperglycaemia
Antiplatelet agents (aspirin) - all diabetics
Random plasma glucose (RPG) - without
with a risk factor +/or >40 y.o
regard to time of last meal
ACEI -drug of choice for BP, consider in
Fasting plasma glucose (FPG) - before
normotensive with CVD
breakfast
Oral glucose tolerance test (OGTT) - 2 hours Education – website, pamphlet
after a 75-g oral glucose drink Medications – oral hypoglycaemics and insulin
Postprandial plasma glucose (PPG) - 2 hours Immunizations
after a meal
Haemoglobin A1c (A1C) - reflects mean
glucose over 2–3 months
Fructosamine/glycated serum protein -
reflects mean glucose over 1–2 weeks.
Estimated average glucose (eAG)
Diagnosis of diabetes (if not already)
Glucose Challenge Test (GCT)
Oral Glucose Tolerance Test (OGTT) 75gm
glucose load
• DM: Fasting (8 hours) ≥ 7.0, 2hrs post
glucose load: >11.1
• Impaired fasting glycaemia: Fasting 6.1
-6.9, 2hrs post glucose load: <7.8
Routine Investigations
Glucometer: blood glucose monitoring,
Screening for complications
aiming for 4.0 - 6.0 mmol/L pre meal, 4.0 -
Foot care/eye care
8.0 mmol/L post meal
Nephropathy screening and treatment
Hb-A1c every 3-6months
Neuropathy
Annual investigations
CVD screening and treatment
Lipid profile
8
Examination - Cardiovascular
Student Guidelines and one Lecture (‘Cardio Exam’)
Indications
Cardiac symptoms (SOB, chest pain)
A systemic disease with cardiac or vascular involvement (atherosclerosis, diabetes, SBE)
Following cardiac history
A full body examination
Contraindications
Chest pain
Patient declines examination
Equipment
1. Sphygmomanometer
2. Watch
3. Stethoscope
4. Torch
5. Ophthalmoscope
9
Nicotine staining
Stigmata of infective endocarditis (Osler’s nodes, Janeway lesions) infective
endocarditis
Pale palmar creases anaemia
Feel temperature and sweatiness of of hands
Warmth, sweaty peripheral vasodilation hyperthyroidism
Cool and dry peripheral cyanosis
Tendon xanthomata type II hyperlipidaemia
Tremor hyperthyroidism
Wrist
Radial pulse: Rate, rhythm, volume, character
Tachycardia left heart failure, PE, aortic dissection, palpatations
Respiration rate
Tachypnoea left heart failure (pulmonary oedema), PE
Radio-radial delay
Radio-femoral delay coarctation of the aorta
Arms:
IV drug injection scars increased risk of bacteraemia and infective endocarditis
Tendon xanthomata type II hyperlipidaemia
Blood pressure lying
Blood pressure standing
Hypotension left heart failure
Face, eyes and mouth:
Facies
Apprehension, pain AMI, angina
Thyroid stare / myxoedema facies hypothyroidism, hyperthyroidism
Mitral facies / malar flush (rosy cheeks surrounded by bluish tinge) pulmonary HT and
mitral stenosis with low CO
Jaundice hepatic congestion due to congestive HF
Xanthelasmata hyperlipidaemia
Pale conjunctiva anaemia
Icterus (jaundice of sclera) congestive heart failure
Central cyanosis left heart failure (pu
High arched palate Marfan’s syndrome congenital heart disease
Poor dentition, decay risk of infective endocarditis
Petechiae infective endocarditis
Neck:
Carotid pulsations
Carotid pulse - both sides, one at a time
Character: Amplitude (strong, gentle, weak), shape (single waveform), volume
Auscultate for carotid bruit (bell over SCM over medical clavicle whilst holding breath)
JVP (right internal jugular)
Normal height: less than 3 cm above sternal angle
Normal character: double waveform (flicker’s twice every cardiac cycle)
Normal: ‘a’ wave (first flicker) and non-visible ‘c wave’) occurs with S1. ‘v’ wave occurs with
S2.
Elevate JVP right ventricular failure
Hepatojugular reflex (press over the right upper quadrant for 15s)
Normal: transient rise in the JVP
Abnormal: sustained rise in JVP left or right ventricular failure
10
Visible pulsations (visible apex beat, pulsation over pulmonary artery)
Palpation (examine painful area last):
Pacemaker/defibrillator (if present, palpate)
th
Apex beat (normal: left 5 intercostal space at MCL, gentle quality, size of 20c)
Describe: presence or absence, deviation, character
Pressure loaded (heaving – forceful and sustained) aortic stenosis, HT
Volume loaded (displaced, diffuse, non-sustained impulse) left heart failure, dilated
cardiomyopathy, mitral regurgitation
Double impulse hypertrophic cardiomyopathy
Dyskinetic (uncoordinated impulse felt over a larger area than normal) ventricular
dysfunction, previous AMI.
Tapping (S1 is actually palpable) mitral stenosis, tricuspid stenosis
Parasternal impulse
Heel lifted RV or LA dilation (right ventricle pushed anteriorly)
Thrills and heaves (apex, L sternum, heart base)
Thrill turbulent blood flow valve pathology
Percussion NONE
Rarely performed. CAN be used to define the cardiac outline
Auscultation: (normal: S1, S2, nil added)
Extra sounds (S3 and S4), thrill, snaps/clicks/rub etc : describe:
S3 increased atrial pressure and reduced ventricular compliance ventricular failure.
S4 high-pressure atrial wave reflected back from poorly compliant left ventricle
hypertension or valve stenosis.
Murmurs
Systole or diastole, site loudest (e.g. apex or base), radiation, intensity 1-6
Check for mitral stenosis
Technique: Lay the patient on their left side (away from you, the “left lateral position’). Ask
them to breathe in, then out and hold it out. Listen over the apex and axilla with the bell of
the stethoscope.
Tapping beat palpable or middle and late systolic murmur audible mitral stenosis
Examination D) Abdomen
***ask patient to lie flat on one pillow***
Inspection:
Scars (coronary bypass scar midline)
Pulsations AAA, pulsatile liver
Distension, ascites severe right heart failure
Palpation:
Liver border
hepatomegaly right heart failure
pulsatile liver tricuspid incompetence
Spleen border
splenomegaly infective endocarditis
Abdominal aorta
Pulsatile and expansitile aneurysm, AAA
Percussion:
Liver
11
th
Technique: down from above 6 rib in MCL until resonance to dullness is heard (upper
border), and then until the dullness to resonance is heard (lower border)
Spleen
Technique (from lectures notes): percuss from nipple down to identify upper border, then
percuss from umbilicus to left flank to identify lower border
Shifting dullness
Technique: from midline to left flank until dullness is heard, roll patient towards you,
percuss same site to check if now resonant.
Ascites right heart failure
Auscultation:
Renal arteries renal stenosis
Aortic bruits AAA, aortic stenosis
Investigations
ECG to diagnose current or previous AMI or arrhythmias
Echocardiogram
Fundoscopy of eyes is relevant if infective endocarditis is suspected, if the patient has diabetes or
hypertension.
Temperature if there are signs of infective endocarditis
Urinalysis looking for diabetes or infective endocarditis
12
Examination – Respiratory
From Student Guidelines, one lecture (Resp Exam)
Indications
Following respiratory history Equipment
Respiratory symptoms 1. Watch
As part of a full body exam 2. Torch
3. Stethoscope
Contraindications
Patient declines examination
13
Ask patient to cock wrists back
Wasting and weakness of finger aBductors lung tumour infiltrating T1 brachial plexus
Flapping tremor / asterixis severe CO2 retention late COPD, renal or liver failure
Fine tremor B2 agonist use asthma
Wrist
Wrist tenderness hypertrophic pulmonary osteoarthropathy (HPOA)
Radial pulse rate, rhythm, regularity, character
Tachycardia PO, PE, RED FLAGS (Pneumonia)
Respiration rate (1/3 inspiration, expiration and rest) • RR over 30
Dyspnoea / tachypnoea pneumonia, emphysema, asthma, • systolic BP less than 90
PE, PO • O2 less than 92%
Shorter inspiration, long expiration obstructive disease • acute onset confusion
Arms • arterial /venous) pH less
Palpate for lymphadenopathy in both axillae than 7.35
Blood pressure • PaO2 less than 60 mm Hg
Lying • multilobar on CXR
Standing
Face, eyes and mouth
Eyes: Pale conjunctiva anaemia, Horner’s Syndrome indicated by ptosis (drooping eyelid),
miosis (constricted pupil) and anhidrosis (lack of sweating) apical lung tumour
compressing SNS nerves in neck
Cheeks: Facial plethora COPD or cyanosis
Nose: patency, polyps asthma, enlarged turbinates allergies, deviated septum nasal
obstruction
Mouth: enlarged tonsils or red pharynx URTI, blue under tongue central cyanosis, soft
palate is oedematous and erythematous obstructive sleep apnoea
Palpate the sinuses
Trachea and neck:
Signs of sleep apnoea (thick neck, receding chin, small pharynx) sleep apnoea
Wasted accessory muscles of respiration
Tracheal tug (trachea and therefore skin above sternum is drawn in with inspiration
airflow obstruction, COPD
Feel SCM contraction
Feel for tracheal deviation carcinoma, diseases of upper lobes of lung penumothorax
With the index and ring fingers on the sternal notch, use your middle finger to examine
JVP (usually decreases with inspiration and decreases with expiration) cor pulmonale, HF
Cervical lymph nodes (**from behind patient**)
supraclavicular, cervical or axillary lymphadenopathy carcinoma
14
Chest expansion (posteriorly, lower lobe)
Place the hands firmly on the chest wall with the fingers extending around the sides of
the chest. The thumbs should almost meet in the middle line and should be lifted slightly
off the chest so that they are free to move. As the patient to take a deep breath
Normal: the thumbs move symmetrically apart at least 5 cm.
Unilateral delayed or decreased chest expansion pathology on that side
pneumonia (consolidation), pneumothorax
Bilateral reduction in chest expansion e.g. COPD, diffuse pulmonary fibrosis.
Compress ribs for tenderness rib fracture
Palpate any relevant scars
Percussion
**Ask patient to bring their elbows forward to move scapulae**
**percuss and auscultate down mid-clavicular line, 2 intercostals apart**
**percuss axillary apex, mid axilla then anterior and basal axilla **
Percuss back (posterior lungs), axillae
Resonance normal (fluid-filled organ)
Dull percussion lobar pneumonia
Stony dullness pleural effusion
Hyper-resonance pneumothorax, COPD
Auscultation
**with diaphragm **ask patient to breathe deep and slowly through the mouth**
** auscultate and auscultate down mid-clavicular line, 2 intercostals apart**
**auscultate axillary apex, mid axilla then anterior and basal axilla**
Auscultate back (posterior lungs), axillae
Assess breath sounds (character, intensity)
Normal: normal/vesicular breath sounds bilaterally of normal
intensity, lung fields clear, nil adventitious sounds
Decreased breath sounds sound slower in air COPD
pneumonia, large tumour or pulmonary collapse.
Decreased breath sounds increased distance between lung and
chest wall emphysema, pleural effusion, pneumothorax
Decreased breath sounds no air entering lung consolidation
Repeat auscultation for vocal resonance (“99”)
Increased vocal resonance (i.e. numbers are clearly audible
because sound travels better in fluid than air ) consolidation
/ pneumonia (solid), pleural effusion (fluid)
Decreased vocal resonance (i.e. numbers inaudible ) pleural effusion, thickening
15
Examination C) Anterior Chest
Inspection
Shape and symmetry, scars, lesions, movement of chest wall (symmetrical, diminished,
hyper)
Intercostal recession/indrawing with breathing
Paradoxical movement of abdomen (inward during inspiration = diaphragm paralysis
Palpation
Supraclavicular lymph nodes (ask patient to shrug shoulders)
Subcutaneous emphysema (crackling sensation felt on skin of the chest or neck) air
tracking from the lungs pneumothorax
Chest expansion (anteriorly)
Watch clavicular movement from above to assess upper and middle lobe expansion
Apex beat
Movement due to lesion
Non-palpable can be normal, can indicate hyperinflation
Vocal fremitus (not recommended) – say 99 and feel vibration
Percussion:
Supraclavicular fossa and front of chest
Clavicles
Liver dullness
down the anterior chest in the midclavicular line
th
Normal: 5 rib in the midclavicular line
th
Abnormal: resonate below 5 rib hyperinflation emphysema, asthma
Cardiac dullness
Decreased emphysema, asthma
Auscultation:
**use the diaphragm except at lung apex – use the bell**
As above: supraclavicular fossa and front of chest
As above: Breath sounds, adventitious sounds, vocal resonance
Normal: normal/vesicular breath sounds bilaterally or normal intensity, lung fields clear, nil
adventitious sounds
Repeat auscultation for vocal resonance (99)
Pemberton’s sign (for SVC obstruction)
With patient sitting up, ask them to lift their arms over their head for 1min. Look for facial
plethora, cyanosis, inspiratory stridor, non-pulsatile elevation of JVP SVC obstruction
carcinoma compressing SVC
Investigations
Chest X Ray (CXR) (haemoptysis always requires CXR)
Bronchoscopy (from haemoptysis as CXR can be normal in lung cancer)
16
Bedside assessment of lung function / lung function tests
Bedside vital capacity: counting aloud (normal >20)
Forced expiratory time: ask patient to fully inspire, then exhale forcefully and completely
through open mouth. Normal <3 sec.
Increased expiratory time airway obstruction COPD. Peak flow meter or spirometer
is more accurate
Peak flow meter
Spirometer
Sputum: microscopy, C&S, cytology
FBE (WCC) CRP and ESR (raised pneumonia)
(HR) Computerised tomography (CT) of the chest
Llavage and lung biopsies
Admission (to hospital): Exacerbations of COPD and asthma, acute pneumonia and interstitial disease
17
Examination – Genitourinary
From Student Guidelines
Indications Contraindications
It’s not routinely performed Declining examination
Suspected or known renal disease Note: Pain is not a contraindication –
Symptoms of kidney disease, UTI examine this area last
Equipment
1. Stethoscope
18
Reduced skin turgor hypovolaemia / dehydration
Test capillary refill
Ask patient to extend wrists (more than 20 sec)
Asterixis (flap) extreme uraemia in end-stage chronic renal failure)
Radial pulse
Tachycardia, bounding pulse fluid overload (SNS, RAAS, vasopressin) due to renal
failure
Tachycardia hypovolaemia
19
Sacral oedema: renal failure, nephrotic syndrome fluid overload (SNS, RAAS,
vasopressin) sacral oedema
Check for vertebral tenderness
Technique: strike vertebrae gently with little finger side of clenched fist
Vertebral tenderness Tenderness myeloma, renal disease low vitamin D and Ca
osteomalacia
Auscultate the lung bases
Crackles: renal failure, nephrotic syndrome fluid overload (SNS, RAAS, vasopressin),
hypertension congestive HF, pulmonary oedema
Crackles: renal failure uraemic lung disease (a non-cardiogenic pulmonary oedema)
or uraemic cardiomyopathy.
Murphy’s kidney punch (rarely used)
Technique: gentle strike of clenched fist in renal angle, looking for renal tenderness
Examination B) Abdomen
**roll the patient to inspect the flanks!**
Inspection (normal = “soft and non-tender abdomen, with not palpable masses
present”)
Tenckhoff catheter (peritoneal dialysis catheter)
Surgical scars: nephrectomy or renal transplant, peritoneal dialysis
Nephrectomy scars may lie posteriorly over the loin area.
Renal transplant scars are usually located in the left or right iliac fossae.
A renal transplant may appear as a bulge under the scar
Distension of the abdomen ascites, nephrotic syndrome, peritoneal
dialysis fluid)
Abdominal pulsations
Inspect the external genitalia
Scrotal masses
Genital oedema
20
Technique: percuss from te umbilicus until dullness can be heard. Measure distance of
extension in cm from the pelvic brum
Enlarged bladder towards umbilicus distension measure distance of dullness
Auscultation:
Renal bruit renal artery stenosis
Technique left and right of midline at the level of the umbilicus
Complications
Embarrassment
Exacerbating pain when kidneys or bladder is palpated
21
Examination – Gastrointestinal
From Student Guidelines and one lecture (Gastro Exam).
Indications Contraindications
GI symptoms – pain, jaundice, Declining examination
Following GI history Note: Pain is not a contraindication –
Full body examination examine this area last
Equipment
2. Torch
3. Tape measure
4. Stethoscope
22
Palms:
Pale palmar creases anaemia
Palmar erythema liver disease / cirrhosis
Tremor
Dupuytren’s contracture (fixed finger flexion) alchoholism, manual
labour, familial, diopathic
Ask patients to cock wrists back for >20 seconds
Asterixis / flap liver failure and subsequent hepatic
encephalopathy
Arms
Skin lesions: Petechiae (minor haemorrhages), spider naevi aka spider
angioma, bruising
Scratch marks peritis due to liver disease, IV track marks Hep C
Muscle wasting
Check for axillary lymphadenopathy (behind pectoralis major)
Face
Eyes
Conjuntival pallor anaemia
Icterus (i.e. jaundice of the eyes)
Iritis (dry eyes)
Xanthelasma hypercholesterolemia, primary biliary cirrhosis
Mouth, teeth, gums (pen torch)
Uremic fetor (bad breath) hyperuricaemia CRF Figure 1: Petechiae
Mouth ulcers and oral candidiasis Crohn’s disease
Tongue glossitis B12 deficiency
Petechiae, telangectasis Osler Weber Rendu, patches of pigmentation
Peutz Jeghers
Neck
Measure JVP Telangiectasia
Raised JVP portal hypertension
Palpate cervical lymph nodes (enlarged, unilateral, hard or soft)
Feel salivary glands
Parotid or submandibular swelling → alcoholism
Palpate supraclavicular lymph nodes
‘Virchow’s node’ or a ‘sentinal node’. metastatic abdominal or pelvic
malignancy
If cervical lymph nodes are palpable, examine axillae and groin lymph nodes for lymphadenopathy
lymphoma, leukaemia, AIDS
Chest
Spider naevi (more than 5) increased oestrogen due to liver cirrhosis
Gaenocomastia (males) impaired liver detoxification e.g. due to alcoholism and liver cirrhosis
Paucity of hair (males)
Breast atrophy (females)
Examination B) Abdomen
Inspection (normal = “soft and non-tender abdomen, with not palpable masses present”)
Prominent veins / caput medusa portal hypertension due to liver cirrhosis
Abdominal distension / swelling five F’s: fat, fluid, faeces, flatus, fetus
Ascites (fluid forced out of gut capillary bed and into the peritoneal space) portal hypertension
due to liver cirrhosis
Visible pulsations or visible peristalsis bowel obstruction, abdominal aorta
Localised swelling (mass, loop of bowel, organomegaly)
Scars, stoma, fistula
Hernia
Palpation: nine areas
23
**warm hands, use flat hand with fingers together, use lateral surface of the right hand, flex at the MCPs,
painful area last, watch the patient’s face, make talk to distract, may need to ask them to bend knees to
relax abdomen**
** each of the regions is palpated lightly (for tenderness or lumps) and then more deeply (to detect any
deeper masses and organomegaly **
Light palpation: looking for tenderness, lumps, peritoneal inflammation and peritonitis
rebound tenderness (increased tenderness when hand is released)
rigidity (constant involuntary contraction of abdominal muscles, always associated with
tenderness)
guarding (contraction of abdominal muscles over an area of peritoneal inflammation – can be
voluntary e.g. due to anxiety or tenderness, or involuntary with peritonitis).
Deep palpation looking for masses or organomeglay
Mass describe site, tenderness, size, surface, edge, consistency, mobility, resonance
Pulsatile Aortic aneurysm
Palpate Liver
Normal: smooth, non-tender, soft, regular with well-defined border, may be felt just below the
right costal margin on deep inspiration in thin patients
Enlarged liver border Hepatomegaly caused by cirrhosis, carcinoma, heart failure,
myeloproliferative or lymphoproliferative disorders
Hard, tender, irregular, pulsatile liver border neoplasm, nodular liver surface, small
cirrhotic liver or necrotic liver.
Gall bladder
A focal, rounded mass that moves down with inspiration enlarged gallbladder
Palpate Spleen (enlarges inferiorly and medially)
Splenomegaly alone Chronic myeloid leukaemia, Myelofibrosis
Hepatosplenomegaly chronic liver disease with portal hypertension, hemolytic anemias,
neoplasm (e.g. leukema, lymphoma)
Ballot Kidneys (enlarge inferiorly and straight down)
Aorta (using both hands)
Expansile aorta aortic aneurysm/AAA
Others: bladder, inguinal lymph nodes, testes
Percussion:
Percuss each of four quadrants and umbilicus
Resonance = normal = air in bowel
Percuss for and measure total liver span
th
Starting from above the 6 rib, percuss down right midclavicular line, until the edge where the
liver was palpable. Percuss from below (resonant areas) up to the lower liver border.
th
Normal: Resonant to dull at 6 rib (upper border), dull to resonant at palpable liver edge (lower
border). Normal span: less than 13cm and below the right costal margin
Resonance over liver: gas in the peritoneal cavity e.g. perforated bowel.
Percuss for splenomegaly
Lecture notes: Percuss from nipple down to identify upper border, then percuss from umbilicus
to left flank to identify lower border.
Talley: Percuss over the lowest intercostal space in the left anterior axillary line in both (full)
inspiration and expiration. Dullness on full expiration suspect splenomegaly
Measure shifting dullness
Resonance ascites due to liver disease or malignancy
Percuss the bladder
Dullness and tenderness distended bladder
Auscultation: three sites
Bowel sounds (below umbilicus) describe whether present or absent
Normal = normal sounds present 1 every 10 sec
Increased bowel sounds gastroenteritis, early bowel obstruction
Absent bowel sounds ileus (post-surgery due to opiates), hypokalaemia
Abdominal aortic bruit (epigastric region) Atherosclerosis, aneurism
Renal bruit (left and right of midline at level of umbilicus) Atherosclerosis
24
Investigations (often part of an abdominal exam)
A DRE / rectal examination rectal masses, constipation, melaena, prostatomegaly
Hernial orifices exam herniae
External genitalia examination:
Males: penis, scrotum and testes testicular atrophy
Females: labia, pelvic exam
Urinalysis at this point including a pregnancy test in females
Analysis of faeces and vomitus
Abdominal X-Ray
25
Examination – Breast
From Student Guidelines, online videos
Indications Contraindications
Pain (mastalgia) Patient declines examination
Lump
Nipple change Equipment - none
Nipple discharge
Screening (recommended in combination Complications
with mammography, when patient gets pap Lack of communication leading to the
smear or pill) patient feeling uncomfortable, legal
ramifications, etc
Consent
** Competence (assumed), complete information (including risks), understanding, voluntariness,
authorization**
Indications: to encourage awareness and detect any early breast changes,
Ask if have they’ve had a breast examination before
Were there any difficulties?
Ask about breast pain, other symptoms or past surgery/radiotherapy in the area
It will involve 3 parts
First, I will look the beast tissue and how it moves on the chest when your arms are in different
positions.. This will involve you following some of my arm movements. I will be looking for any
slight changes in the skin
Second, I need to feel the breast tissue for any lumps or changes, which will involve circular
movements across all the breast tissue while you’re sitting up and lying down.
Finally, I will feel the lymph nodes in the armpit and above the collarbone
Exposure: Will need you to undress from the waist up, including you bra
Privacy: Will ensure the curtains are closed and there will be a gown provided.
Inform that they can stop the examination at any time or if uncomfortable
Importance of proceeding/reassurance: will feel a bit uncomfortable but it’s absolutely crucial
Ask if they understand. Ask if they have any concerns or questions
Offer a chaperone
Gain consent
Communication:
Inspection:
“I’m going to lower your gown to begin the visual inspection. I will be looking quite closely so don’t
be alarmed. “
“Now I would like to check how the breast tissue moves on the chest wall and I will need you to
move your arms. Could you follow my arms movements please?”
Inspection is finished. You can pull the gown up and when you are ready lie down.
Palpation of Breast tissue
When you’re ready, I will uncover one breast
I am now going to feel your breast, one at a time
I have completed the examination of that breast now. You can cover that side and can you please
uncover the other breast
Palpation of Lymph Nodes
Now I will examine the lymph node areas in your armpit and behind your collarbone.
26
If the patient has pendulous breasts
Inspection: ask her to lift her breasts so that the tissue underneath can also be inspected
Palpation: place a pillow under the side to be examined
If the patient has small breasts you may be able to palpate only while sitting
Examination A) Inspection
Patient preparation: patient sitting over edge, stand arm’s length away
** look at both breasts, compare both sides ** ensure patient is warm and ease
nervousness** warn that you’ll be looking quite closely **
General inspection
Pain
Lumps or thickenings
Change in shape or size, asymmetry, differences in breast height
Enlarged veins
Nipple retraction and
Skin lesions orange peel skin
Puckering, skin tethering or dimpling cancer involving ligaments
Sores or ulcers
Redness or inflammation
“Orange peel” skin
Nipple
Changes in alignment of the nipples
Nipple retraction (drawing in of the nipple) or nipple deviation
cancer involving ligaments
Colour change Paget’s disease of the nipple
Rash on or around nipple Carcinoma of lung causing elevation,
Discharge (texture, colour, etc) dimpling and nipple retraction
Arms/armpit
Swelling or lumps in armpit
Swelling of upper arm
Technique:
Inspect in different positions to see the effect of tension
1. Hands by side
2. Hands over head
3. Hands on hips (tensing pectoral muscles )
4. Leaning forward (creating tension in Cooper’s ligaments) (if they
have large breasts, they may need to stand)
Impaired movement of breast tissue, tethering, dimpling, retraction etc.
**cover patient with gown once complete**
27
Examination B) Palpation of Breast Tissue
Patient preparation: patient lying supine and covered
Where tumours most commonly occur
Technique
Ask if they have any abnormalities, if they have any pain and to
you if they experience any pain
Start with the normal side first
Uncover and feel one breast at a time
Maintain eye contact to check for discomfort. Rule of 1/3 – 1/3
at breast, 1/3 at patient’s face, 1/3 in distance
Use pulps of the three middle fingers in a circular motion to
press tissue against the chest wall
Have a small amount of tissue between fingers and the chest
wall
Start with light pressure and then firmer pressure
Slide fingers to the next area, keeping hand in contact to feel any
changes
Start at the top of the breast and move down, and up again,
ensuring that you slightly overlap the last panel
Rolling to the right (toward you) flattens out medial right breast
and lateral left breast. Ask the patient to roll to ensure there is a
small amount of tissue between the fingers.
It is usually easiest to start from the left lateral edge of the left
breast and work medially, and for the right breast, to start
medially and work laterally (i.e. toward you)
Cover all breast tissue, including the breast tail and nipples (warn the patient it will be tender)
Ask the patient to raise her arm while palpating the breast tissue on the lateral side and the breast
tail extending up towards the axilla.
Technique (alternative from provided Flinder’s video)
Feel in columns, from superior to inferior
1) With the patient sitting up, feel across the top 5-6cm of the breast.
2) With the patient lying down on their back, feel the medial lower half of the breasts and under
the breasts
3) Ask the patient to roll onto their side and lift their arm (to expose the axillary tail) to feel across
the lateral lower half of the breasts and under the breasts
4) In this position also feel above the nipple and the areola (try to flatten the tissue between your
hands)
Lumps normal breast nodularity, fibroadenoma, cysts, breast cancer 10 point description
Location: Quadrants are used rather Mobility: is it movable or fixed deep
than the clock face or superficially
Size: in diameter Borders: poorly defined or discrete
Shape: round, regular or irregular Retraction: altered breast contour,
Consistency: firm to soft any dimpling
Tenderness: how tender
Significant features of a breast lump:
Painless
No fluctuation with menstrual cycle
Increasing in size
Recent development.
**re-gown the patient and ask to sit up**
28
Examination C) Palpation of Lymph Nodes
Patient preparation: patient sitting over edge and covered
Technique
Axillary lymph nodes (central and lateral breast) palpable
Technique
Go to shake the person’s hand (to use the correct hand)
Cup the patient’s elbow with the fingers of that (opposite)
hand; support the patient’s forearm with your (opposite)
forearm
Now with the other hand, using small circular movements,
examine the five groups of lymph nodes
2) Medial / Central: move the patient’s arm until it is relaxed
right by their side and feel as far into the top of the axilla as
possible.
1) Pectoral / anterior: Just above and behind the anterior
axillary fold (fold of muscle at the front of the armpit)
3) Subscapular / posterior: in front of the post-axillary fold under the
scapular
4) Lateral: Laterally (along arm) and anteriorly
5) Apical and infraclavicular: In front of the posterior axillary fold
under clavicle
Enlarged inflammation, malignancy
Supraclavicular lymph nodes (internal and axillary lymph nodes)
Technique:
Stand behind the patient and ask patient to shrug their shoulders
Place three middle fingers behind the collarbone laterally, and ‘walk’
them medially to the sternoclavicular joint
Enlarged inflammation, malignancy
Enlarged lymph node size, shape, firmness, mobility, border
If a lymph node is palpable, note the size, shape, firmness and
mobility.
Internal mammary nodes (drain medial breast) are inaccessible
Conclusion
Thank the patient
State that the examination is complete and the patient can get
dressed (leave them to do so)
Document entire procedure.
Encourage monthly self-breast exams
Arrange mammography as an adjunct
Explain that if anything changes, please contact immediately
Registrar level – present findings to patient, order tests (explain test, why needed, what’s involved and
when they will get their results)
The legal onus is on the examiner to follow up all findings and communicate results
Investigations
Every suspicious pathology requires the triple test – breast exam, mammography and biopsy
Mammography as a diagnostic tool (X ray, used for women over 40)
Ultrasound as a diagnostic tool (used in women under 40)
Biopsy - fine needle aspiration biopsy for pathology, under US guidance
Core biopsy used for hard masses (fibroadenoma), under US guidance
29
Examination – Male Genitalia
From Student Guidelines, video links and tute prep
Equipment
1. Gloves
Consent
** Competence (assumed), complete information (including risks), understanding, voluntariness,
authorization**
Indication/why: identify and change in the testicles in the scrotum
Ask if have they’ve had a one before
Were there any difficulties?
What it involves: Involves 3 parts.
Looking at the penis, including under the foreskin, for any changes or abnormalities.
Looking and gently feeling the scrotum for normal and any abnormal structures.
Taking any specimen samples, such as a swab, if necessary.
Exposure: Will need you to undress from the waist down including underwear
Privacy: Go behind the curtain, undress from the waist down. Will ensure the curtains are closed
and in a private, uninterrupted area and there will be a gown/sheet provided.
Explain any further tests you may need to do e.g. swabs, biopsy
Ask about pain other symptoms, past surgery in the area
Inform that they can stop the examination at any time or if uncomfortable
Importance of proceeding/reassurance: will feel a bit uncomfortable but it’s absolutely crucial
Ask if they understand. Ask if they have any concerns or questions
Offer a chaperone of the same gender as the patient
Gain consent
Examination
** Compare left to right****Begin with patient lying down**
Patient preparation: Patient on bed, undressed waist down and covered by gown
Ensure ongoing communication
Put on gloves
Ask the patient to show you any areas of concern (e.g. a mass)
30
Examination - PENIS
Inspection
Hair distribution: alopecia, infestation, shaven pubic hair ( dermatitis or
folliculitis).
Inspect the base of the penis (gently pulling back any pubic hair), the
shaft, and the glans
If assessing puberty: assess the amount of hair, size of penis and testes,
and the colour of the scrotal sac
Skin: warts (a result of infection), pearly penile papules (normal variant), Above: Pearly papules
rashes including tinea cruris (“Jock Itch”), inflammation (normal); below: warts
Ulcers (esp on glans) Herpes, malignancy (SCC), syphilis, chancroid, (abnormal)
other uncommon contions
Retract the foreskin: **ask/warn patient**
Painful or difficult STOP phimosis
Retracted foreskin that cannot be restored paraphimosis
Position of the urethral meatus hypospadias
Discharge (squeeze glans)
Discharge at base of penis in uncircumcised penis candida
infection ‘balanitis’
Palpate along the shaft of the penis
Tenderness
Collect any specimen as necessary
Ensure retracted foreskin has been restored.
Paraphimosis
31
Feel for size, consistency and contour
Immobilize one testis, drawing the scrotal skin gently around it so that it is easily palpable. Check
each pole and the entire circumference
Testicular size: estimated, or measured with orchidometer. Small differences are normal.
Testicular consistency: a healthy testicle is soft and rubbery. Hardness suggests pathology.
Tenderness: may indicate orchitis or torsion.
Any testicular masses: these should be described in terms of Site, Size, Shape & Consistency
Feel for the epididymis and spermatic cord for nodules or swellings
Normal epididymis is almost impalpable. Spermatic cord feels rubbery.
Thickened linear mass swelling or cyst of the epididymis.
Spermatic cord lump cyst, neoplasm, scar of a vasectomy procedure, or
Feel for abnormal masses: Hydrocele, epididymis cyst, varicocele,
communicating inguinal hernia 1. Site (region)
1. Can you get above it? No = likely a hernia. Yes = scrotal lump. 2. Tenderness
3. Size (measure) and shape
2. Cystic or solid?
4. Surface (regular or irregular)
3. Part of the teste (testicular pathology) or separate (cyst)? 5. Edge (regular or irregular)
Soft swelling that you can get above with upper border in 6. Consistency (hard or soft)
scrotum hydrocele 7. Mobility (e.g. mobile or fixed),
‘Bag of worms’, may or may not get above torsion and movement with inspiration
Soft elastic mass with no upper border in scrotum inguino‐ 8. Pulsatile or not
scrotal hernia 9. Whether one can “get above the
Continuous with epididymis epididymitis, epididymal cyst mass”
10. Percussion note (resonant, dull)
Soft elastic mass with no upper border in scrotum inguino‐
scrotal hernia
**ask patient to stand, examine scrotum in standing position**
Palpation while standing
May now be able to appreciate a varicocoele or a sliding hernia protruding into the scrotum
Ask patient to cough while feeling mass
Transilluminate any masses
Transilluminating mass hydrocele
Mass which does NOT transilluminate varicocoele, inguino‐scrotal hernia
32
Investigations
DRE
Urethral swab (gold standard for STDs)(discharge, suspicion of STDs)
Skin scraping
Urinalysis (chlamydia and gonorrhoea)
Referral to urologist (suspicion of testicular cancer)
Ultrasound of scrotum and/or groin (testicular tumour diagnosis, hydrocele)
Alpha-fetoprotein (AFP) and beta-hCG (blood tests, tumour markers for testicular cancer)
Patient Education
Reassure the patient that the appearance and size of genitalia is normal.
Encourage self-examination
Complications
Patient feels uncomfortable or assaulted (legal ramifications) due to inadequate information, poor consent
process, or perceived unnecessary or vigorous contact – communicate at all times!
Exacerbation of pain with palpation
Forgetting to return the foreskin can cause paraphimosis, which is painful oedema of the glans due to the
foreskin becoming trapped behind the glans. If this persists for several hours, I can be a medical emergency
that will cause gangrene.
33
Examination – Inguinal-Scrotal
From Student Guidelines
Equipment
1. Gloves
Consent
** Competence (assumed), complete information (including risks), understanding, voluntariness,
authorization**
Indication/why: to inspect any abnormal masses or herniae
Ask if have they’ve had a one before
Were there any difficulties?
What it involves: There are 4 parts and this exam is best done standing.
First I will have a look at the hernia orifices. These are in the groin next to the genitals.
Secondly, I will gently feel for any lumps or changes in this region near the groin.
Third, I will perform special manoeuvres, which involve pressing down on the area while you
cough.
Finally, I will tap and listen to the masses with my stethoscope.
Exposure: Will need you to undress from the waist down including underwear
Privacy: Go behind the curtain, undress from the waist down. Will ensure the curtains are closed
and in a private, uninterrupted area and there will be a gown/sheet provided.
Ask about pain other symptoms, past surgery in the area
Inform that they can stop the examination at any time or if uncomfortable
Importance of proceeding/reassurance: will feel a bit uncomfortable but it’s absolutely crucial
Ask if they understand. Ask if they have any concerns or questions
Offer a chaperone of the same gender as the patient
Gain consent
Examination
** Compare left to right****Begin with patient lying down then ask patient to stand**
Patient preparation: Patient on bed, undressed waist down and covered by gown
Patient best examined standing up but start lying down to put the patient at ease
Ensure ongoing communication
Put on gloves
Ask the patient to show you any areas of concern (e.g. a mass)
Inspection:
Visible peristalsis ( herniated bowel)
Skin: Redness, shininess, oedema, tenderness, rashes, scars ( recurrent hernia)
Mass, asymmetry (e.g. bilateral vs unilateral)
34
Mass at superficial ring direct inguinal hernia, a congenital hydrocoele, a varicocoele or a
mass of the spermatic cord
Mass at deep ring indirect inguinal hernia
Ask patient to cough and look for a swelling
Cough impulse
No impulse obstructed or strangulated hernia, omental hernia
Palpation
** compare left to right!**
Feel any masses for: temperature, tenderness, consistence and
1. Site (region)
border/ extent of swelling (e.g. feel for top, extension into
2. Tenderness
scrotum)
3. Size (measure) and shape
Firm and rubbery omentum
Soft and elastic bowel 4. Surface (regular or irregular)
“Bag of worms” varicocoele 5. Edge (regular or irregular)
Palpate for cord structures 6. Consistency (hard or soft)
Measure distance of mass to pubic tubercle 7. Mobility (e.g. mobile or fixed),
Above and lateral to pubic tubercle inguinal hernia and movement with inspiration
Below and lateral to pubic tubercle femoral hernia 8. Pulsatile or not
Perform exam of testicles and penis. Check for absent testis. 9. Whether one can “get above the
Place hand over swelling and ask patient to cough. Repeat mass”
with hand over deep and superficial rings 10. Percussion note (resonant, dull)
Cough impulse
No impulse obstructed or strangulated hernia, omental hernia
Special manoeuvres (useful only in the presence of pathology)
Internal ring occlusion test (for direct vs. indirect)
Place finger over deep inguinal ring (midpoint of ligament)
Ask patient to cough
Indirect hernia will be prevented from emerging while a direct hernia will emerge
Ziemans technique
Stand at patients right side as they are standing
Place palm of right hand over right lower abdomen
Spread and position fingers
Middle finger along inguinal ligament with the fingertip on the superficial (medial) ring
Index finger over the deep inguinal ring
Ring finger over femoral canal
Ask patient to perform valsalva manoeuvre or strain
Repeat procedure on left side with left hand
**Lie patient down**
Reduction
Lie the patient down.
Attempt manual reduction. Check reducibility of the
hernia.
If it can’t be reduced, look for signs of obstruction:
tenderness, shiny skin, or overlying erythema.
Invagination test (for direct vs indirect)
In the lying position, push from the bottom of the scrotum
to palpate the pubic tubercle. Use the pulp of the finger. Then rotate the finger and push
up to the superficial inguinal ring.
Patient is asked to cough, a palpable impulse will confirm diagnosis
Impulse on pulp direct. Impulse on tip indirect
35
Palpation (again)
Palpate the lymph nodes
Horizontal
Vertical
Deep vertical chains
Percussion: Percuss the swelling
Resonance hollow Bowel with gas contents
Dull Omentum
Auscultation: Auscultate mass for bowel sounds (both masses and
abdomen)
Investigations
Testicular examination should follow
DRE
Ultrasound (determine indirect vs direct hernia)
Complications
Patient feels uncomfortable or assaulted (legal ramifications) due to inadequate information, poor consent
process, or perceived unnecessary or vigorous contact – communicate at all times!
Exacerbation of pain with palpation
Rupturing an irreducible hernia when attempting to reduce
36
Examination - Thyroid
From Student Guidelines and associated video
Indications
Neck mass / goitre Infertility, galactorrhoea, changes in
Change in appetite and weight menstrual cycle amenorrhoea
Changing in sweating Headaches
Eye changes Polyuria, polydipsia
Cold or heat intolerance Following endocrine history
Change in hair distribution Discomfort, dysphagia or SOB caused by
Constipation or diarrhoea neck mass
Lethargy and fatigue
Skin changes, pigmentation Contraindications
Changes in stature Patient declines examination
Impotence or loss of libido
Equipment
1. Cup of water with straw
2. Stethoscope
3. Red hatpin
4. Tendon hammer
37
Dry and cool hypothyroidism
Examine for tremor
Technique: palms facing down, use a piece of paper
Tremor hyperthyroidism
Wrists
Radial pulse
Tachycardia, bounding pulse hyperthyroidism
Atrial fibrillation hyperthyroidism
Bradycardia hypothyroidism
38
Examination C) The Face, Eyes and Limbs
Face and Eyes
Technique: Look from above in the plane of the forehead
Hyperthyroidism
Thyroid stare hyperthyroidism (all forms)
Lid retraction and proptosis hyperthyroidism (all forms)
Exophthalmos (significant proptosis due Grave’s disease) Graves /
Thyroid eye disease Grave’s disease specifically (Grave’s triad)
Hypothyroidism
Myxoedema facies of
Dry, coarse hair hypothyroidism
hypothyroidism
Loss of the outer third of eyebrow hypothyroidism
Myxoedema facies* (facial swelling) hypothyroidism
Periorbital oedema (puffy eyes) hyperthyroidism
Dry, waxy skin (waxy skin) hypothyroidism
Peaches and cream complexion (smooth pale yellow skin, and peachy
cheeks) hypothyroidism
Test for Ophthalmoplegia
Technique: Draw a ‘H’ pattern and ask patient to report double vision
Blurred or double vision ophthalmoplegia thyroid eye disease
Grave’s disease
Blurred or double vision ocular muscle weakness hyperthyroidism
(all forms)
Test for Lid Lag
Technique: Ask patient to keep head still and follow finger, move quickly from
above to below, repeat on left and right
Lid lag hyperthyroidism, Grave’s Disease
Upper and lower limbs
Pre-tibial myxoedema Grave’s Disease specifically (Grave’s triad)
Purpura, poor healing ulcers hypothyroidism
Test for proximal myopathy (chicken manuver) Exophthalmos (thyroid eye
disease of Grave’s
Technique: Ask patient to bend their elbows and hold up, push down on the disease)
proximal limbs and ask the patient to resist
Technique: Ask patient to stand with arms across chest
Proximal myopathy / weakness hyperthyroidism, hypothyroidism
Reflexes:
Upper limb: brachioradialis, biceps, triceps
Lower limb: Patella and Achilles
**remember to do both sides**
Brisk reflexes hyperthyroidism
Delayed relaxation phase hypothyroidism
Investigations
Thyroid function tests (TFTs)
Serum antibodies
Thyroid uptake test (radioidine)
Normal thyroid tissue will take up iodine
Cold nodule: Thyroid cancers (follicular carcinoma) poorly take up iodine/technetium less well
Follow body scan (uptake of radio iodine – mets will take up some iodine)
Cytology (not very helpful, normal tissue, adenomas and carcniomas all look the same = follicular cells)
Test for visual acuity (if Grave’s disease suspected)
39
Examination - Endocrine
From Talley and O’Connor, Student Guidelines and Tute prep
Indications
Neck mass / goitre Infertility, galactorrhoea, changes in
Change in appetite and weight menstrual cycle amenorrhoea
Changing in sweating Polyuria, polydipsia
Eye changes Following endocrine history
Cold or heat intolerance Discomfort, dysphagia or SOB caused by
Change in hair distribution neck mass
Hirsutism and virilisation Failure to mature, failure to thrive
Constipation or diarrhoea DKA, hypoglycaemia, hyperglycaemia
Lethargy and fatigue
Skin changes, pigmentation
Changes in stature Contraindications
Impotence, gynacomastia, loss of libido Patient declines examination
Headaches
Equipment
1. Scales
2. Measuring tape
3. Opthalmoscope
4. Tendon hammer
Examination
Patient preparation: patient sitting upright over edge of bed
General inspection
Facies
Coarse features acromegaly
Moon face Cushing’s
Thyroid stare hyperthyroidism
Myxoedema facies ( hypothyroidism, Grave’s disease)
Peaches and cream complexion (smooth pale yellow skin, and peachy cheeks)
hypothyroidism
Goitre (thyroid enlargement) (hyperthyroidism, hypothyroidism)
Sweating hyperthyroidism, hypoglycaemia, acromegaly, menopause
Overweight (hypothyroidism) or underweight ( thyrotoxicosis, hyperthyroidism)
Appropriate dress for the temperature hyperthyroidism, hypothyroidism
Alopecia (loss of hair) hypothyroidism
Hirsutism increased androgens, tumour, PCOS, anorexia
Galactorrhoea or gynecomastia prolacinoma
40
Height /stature acromegaly
Skin
Paleness of skin hypothyroidism, hypoparathyroidism
Increased pigmentation primary adrenal insufficiency, Cushing's syndrome or
acromegaly
Decreased pigmentation hypopituitarism, vitiligo
Measure body weight
Measure body height
Nails
Thyroid acropachy (clubbing and swelling of digits) Grave’s Disease specifically (Grave’s
triad)
Onycholysis
Hands
Enlarged hands acromegaly
Palmar erythema, tremor hyperthyroidism
Feel the palms
Palmar erythema, moist, warm or sweaty hyperthyroidism
Dry and cool hypothyroidism
Radial pulse
Tachycardia, bounding pulse hyperthyroidism
Atrial fibrillation hyperthyroidism
Bradycardia hypothyroidism
Arms
Loss of axillary (and pubic) hair androgen insufficiency, hypogonadism,
adrenal insufficiency
Blood pressure – lying and standing
Hypertension Cushing’s, acromegaly, phaochromocytoma
Postural hypotension Addison’s disease
Trousseau's sign hypocalcaemia and tetany
Test for proximal myopathy (chicken manuver)
Technique: Ask patient to bend their elbows and hold up, push down on
the proximal limbs Troussea's sign
Proximal myopathy / weakness hyperthyroidism, hypothyroidism, Cushing’s,
acromegaly
Axillae
Loss of axillary hair hypopituitarism
Acanthosis nigricans acromegaly
Skin tags acromegaly
Face
Facies (as above)
Enlarged, coarsened facial features acromegaly
Hair
Temporal recession of the scalp hair in women androgen excess
Absence of facial hair in men androgen insufficiency, hypogonadism
Hirsutism panhypopituitarism
Dry, coarse hair hypothyroidism
Loss of the outer third of eyebrow hypothyroidism
Skin
Fine-wrinkled hairless skin panhypopituitarism
Skin greasiness, acne or facial plethora Cushing’s
Dry, waxy skin (waxy skin) hypothyroidism
Eyes
Proptosis, lid retraction, lid lag hyperthyroidism (all forms)
Exophthalmos Grave’s disease specifically (Grave’s triad)
Puffy eyes‘ hyperthyroidism
Fundoscopy
41
Neovascularisation, haemorrhages, cotton-wool spots diabetes, diabetes
secondary to acromegaly (GH counters insulin)
Mouth
Protrusion of the chin and enlargement of the tongue acromegaly
Buccal pigmentation Addison’s disease
Neck
Midline neck mass
Goitre (thyroid enlargement) hyperthyroidism, hypothyroidism
Thyroglossal cyst (a midline mass that can present at any age)
Parathyroid glands (very rare)
Neck webbing Turner’s syndrome
Thyroidectomy scar: a ring around the base of the neck hypothyroidism
Palpate for supraclavicular fat pads Cushing’s
Chest
Hirsutism, loss of body hair, reduction in breast size panhypopituitarism
Gynaecomastia, loss of body hair panhypopituitarism
Nipple pigmentation Addison’s disease
Abdomen
Hirsutism, central fat deposition, purple striae Cushing’s
External genitalia
Virilisation or atrophy.
Lower Limbs
Ulcers and diabetic changes diabetes, hypothyroidism
Pre-tibial myxedema Grave’s Disease specifically (Grave’s triad)
Assess reflexes:
Brisk reflexes hyperthyroidism
Delayed relaxation phase hypothyroidism
Investigations
Hormone evaluation:
prolactin, GH, IGF1, T3/T4, LH/FSH/testosterone / E2 and progesterone
urinary free cortisol (metabolites of cortisol in urine), morning serum cortisol
Anterior pituitary function tests: GnRH stimulation, TRH stimulation and insulin tolerance test
(stimulating GH and ACTH secretion)
Short synacthen (synthetic ACTH) test [SST]
Dexamethasone (synthetic glucocorticoid) cortisol supression test (DXST)
Urinalysis
MRI Pituitary and visual fields test
42
Examination - Diabetic
From Student Guidelines and tute prep
Indications
Diabetes known or suspected Leg cramps
High blood glucose Asymptomatic glycosuria detected on
Polyuria routine physical examination
Polydipsia (excessive thirst) Diabetic ketoacidosis
Poor healing, ulcers, sores and boils − Coma
Blurry vision Identification and control of
Pins and needles complications of diabetes
Weakness and fatigue
Contraindications:
Signs of DKA (air hunger, thirst, dehydration, nausea and vomiting) give insulin immediately
Type I diabetic with vomiting, fever or infection, persistent hyperglycaemia give insulin
immediately
Equipment
1. Stethoscope 5. Opthalmascope
2. Sphygomanometer 6. Monofilament
3. Snellen chart 7. 128MHz tuning fork
4. Red hat pin 8. Tendon hammer
43
Signs of DKA: excessive thirst (polydipsia), dehydration, Kussmaul's breathing ('air hunger') (→ lack of
glucose → fat metabolism → excess acetyl-CoA→ acidic ketone bodies → acidosis), nausea, vomiting
and/or abdominal pain, acetone smell on breath, weakness or fatigue, confusion / drowsiness / coma
Take Vital Signs
Heart rate
Tachycardia ( infection, hyperglycemia, dehydration)
Bradycardia ( B-blocking medication concealing signs)
Resp. rate
Tachypnoea ( ketoacidosis)
Temperature
High: ( infection due to high blood sugar increasing risk)
Blood pressure lying
Hypertension ( diabetic nephropathy and fluid overload and/or cardiovascular disease)
Blood pressure standing
Postural hypotension (15-20 drop systolic, >10 diastolic significant) ( diabetic autonomic
neuropathy, dehydration)
Take Vital Statistics/Measurements
Height (on bare feet)
Weight (on firm surface)
Waist
Measure directly on skin, halfway between lowest rib and the top of the iliac crest, roughly in line
with umbilicus
Normal: < 80 cm for female and < 94cm for males is healthy
Calculate BMI (kg / height squared in m2)
Normal: 20 – 25 is healthy
44
Asymmetry in movement or reporting of diplopia (→ CNIII mononeuropathy → CNIII
Nerve palsy )
Fundoscopy
Silver wiring (hypertension), microaneurysms, haemorrhages, exudates. Proliferation of
vessels diabetic retinoapthy
Neck
Skin rashes ( tinea corporis)
Acanthosis nigricans (back of neck, folds of neck, axillae, below breasts) (→ insulin resistance)
Scleroedema diabeticorum (rare, thickened skin over back and neck)
Thyroid
Goitre ( more common in diabetics)
Ask patient to swallow
Auscultate the carotid arteries
**Patient to hold their breath while you listen**
Carotid bruits (→ carotid atherosclerosis → vascular disease)
45
Toe web spaces
macerated interdigital skin ( increased risk of tinea corporis)
Necrobiosis lipoidica diabeticoru (on shins, specific but rare)
Neurological Assessment
Ask patient to answer yes when felt. Widespread reduced sensation
then test more proximally until sensation defined.
6/10 or less loss of protective sensation
Stocking distribution of sensation loss diabetic neuropathy
Risk of causing ulcer
2) Dorsal column function (proprioception sense)
Grasp great toe either side of distal IP.Show patient up and down.
Ask them to close their eyes and detect movement.
3) Vibration sense
Demonstrate a) vibration and b) stopped on sternum. Ask patient
to close their eyes and report a) vibration and 2) when it stops.
Start on MCP joint of toe. If unreliable or incorrect, move to
ankle, tibial tubercle and ASIS.
loss of proprioception diabetic neuropathy, diabetic
pseubatobes (damage to large nerve fibers)
4) Reflexes – knee, ankle and plantar
Reduced or absent reflexes diabetic neuropathy
Palpation
Feel warmth of foot PVD, diabetic ischaemia
Capillary refill
Pulses – dorsalis pedis, posterior tibial, popliteal and femoral
Auscultation
Femoral bruits
Investigations
If unconscious, always treat as a hypoglycaemic event. Give the patient a source of sugar e.g. honey on the
tongue and sides of mouth
Blood ketones: 0.6mm/L or over may need medical attention. Over 1.5mmol/L requires intensive
intervention)
Acute symptoms
Glucometer blood glucose (normal is 3.5-8mm/L, 3.-6 befor emeals, 4-8 after meals)
Urine Analysis for glycosuria (positives test is >10mmol/L), ketones(ketoacidosis, poorly controlled
diabetes, insufficient insulin, infection, etc), proteinuria (→ diabetic nephropathy), nitrites and/or
blood (→ asymptomatic UTI)
Blood ketones (over 0.6mm/L concerning. Over 1.5mmol/L requires intensive intervention)
Measure Hyperglycaemia
Random plasma glucose (RPG) - without regard to time of last meal
Fasting plasma glucose (FPG) - before breakfast
Oral glucose tolerance test (OGTT) - 2 hours after a 75-g oral glucose drink
Postprandial plasma glucose (PPG) - 2 hours after a meal
Haemoglobin A1c (A1C) - reflects mean glucose over 2–3 months
Fructosamine/glycated serum protein - reflects mean glucose over 1–2 weeks.
Estimated average glucose (eAG)
Diagnosis of diabetes (if not already)
Glucose Challenge Test (GCT)
Oral Glucose Tolerance Test (OGTT) 75gm glucose
load
DM: Fasting (8 hours) ≥ 7.0, 2hrs post glucose
load: >11.1
Impaired fasting glycaemia: Fasting 6.1 -6.9, 2hrs
post glucose load: <7.8
46
Routine Investigations
Glucometer: blood glucose monitoring, aiming for 4.0 - 6.0 mmol/L pre meal, 4.0 - 8.0 mmol/L post
meal
Hb-A1c every 3-6months
Annual investigations
Lipid profile
Urinary albumin excretion rate (timed overnight or 24hr) OR early morning microalbumin creatinine
ratio
Thyroid Function Test (type I due to increased risk)
Urea, Creatinine and Liver Function Tests.
Referral: Ophthalmologist (or some optometrists) for assessment of the retina, Endocrinologist, Nephrologist,
Diabetes Educator, Podiatrist, Dietician, Exercise Physiologist, Pharmacist.
Treatment of Hypoglycaemia
Mild hypoglycaemia is often managed effectively with the self-administration of 15 g of carbohydrate (e.g.,
three 5-g glucose tablets, ½ cup of fruit juice)
Moderate hypoglycaemia may require larger amounts of carbohydrate (15–30 g).
Severe hypoglycaemia, requires immediate treatment, with I.V. glucose as the standard treatment
Glucagon may be used as an effective adjunct, especially in patients who do not respond clinically to
intravenous glucose. Glucagon given via a 1-mg I.M. dose has been found to be most effective in adults.
Following delivery of glucagon, oral glucose should be administered to aid in hepatic glycogen repletion
Treatment of DKA
1.Insulin therapy
2.Rehydration
3.Sodium bicarbonate for acidosis management
4.Potassium replacement
5.Treatment of leading causes
6.Supportive and symptomatic treatment of complications
Complications
Causing a diabetic ulcer with monofilament
47
Examination – Shoulder
From Student Guidelines
Examination – SHOULDER
Ensure adequate exposure of both shoulders and privacy. Lift bra as
necessary
Look: Inspection
*with the patient standing, inspect from the front, side and behind*
General: how patient undresses, pain, posture, how they hold the
shoulder
Deformities (dislocation of AC joint or GH joint, valgus, valrus),
Glenohumeral dislocation
muscle wasting or asymmetry (deltoid), swelling, scars (athroplasty),
skin (inflammation, erythema, bruising, lacerations, psoriasis,
ulceration, rashes)
Biceps rupture
Posteriorly: position, contour and symmetry of the scapula,
supraspinatus and infraspinatus fossa, wasting of infraspinatus or
supraspinatus
48
Bulge of biceps
rupture
Check hands for Raynaud’s phenomenon
Feel: Palpation
* look their face while examining* start with normal side* examine painful
area last* use one finger * ask them to report pain *
Feel temperature inflammation, infection, septic joint
Feel bony landmarks: SC joint, clavicle, AC joint, acromion
process, sub-acromion bursae, coracoid process (inferior and Subluxation (partial dislocation) of
medial to the acromion), from the acromion to the spine of the AC joint
scapula
Tenderness, deformity or crepitus of the bones fracture,
dislocation
Tenderness of the joint bursitis, inflammation in and around
joint
If fracture present, check for pneumothorax (rarely caused by
clavicular fracture)
Feel muscles of the rotator cuff: around the head of the humerus Biceps tendon in
Head of humerus (lateral and below acromion)
Biceps tendon in the intertubercular groove / bicipital
groove (2cm lateral to coracoid, should feel it flick)
Supraspinatus: Lateral to acromion process as patient extends
shoulder
Feel for distal pulses if suggestion of vascular compromise eg:
dislocation (medial emergency)
Test sensation if suggestion of nerve injury eg: axillary nerve in
dislocation (medial emergency)
Palpate axillary lymph nodes if suspecting infection or neoplastic
disease
Move
* start with active movement * compare L to R, starting with normal
side*then carefully perform active mvt*
Apley Scratch Test Screen for Limitation
Patient first reaches over the opposite shoulder, then reaching behind the neck and
finally reaching under behind the back. This does move the shoulder the most
movements. If the patient reports pain, test specific ranges
Abduction and adduction
Adduction: patient moves the arm across the front of the chest (which requires a small
degree of external rotation as well)
Abduction: Stand behind the patient, place one hand on the inferior pole of the scapula.
Measure the angle of abduction occurring at the GH before mvt of the scapula begins.
Then asses their range with the combination of scapula movement and the GH joint.
Repeat while pressing down on the abducting shoulder
Painful resisted abduction and external rotation rotator cuff disease,
partial/full thickness tear of the tendon, tear or inflammation of teres minor or
infraspinatus
Flexion / Extension:
The arm is flexed up as high as possible and swung backwards as far as possible. Assess
for limitation with or without pain and joint crepitus are assessed.
External rotation
External rotation (infraspinatus and teres minor): The patient holds their arms at their
sides and flexes their elbow up to 90°, bringing the forearm perpendicular to the torso.
Ask them to turn the forearms out laterally as far as possible.
Internal rotation
The patient places their hand behind their back and is asked to touch up as high on the
back as possible with the thumb. Grade by looking at the position of the thumb. Usually
only proceed to Jobe’s empty can test if this internal rotation is limited.
If positive, Jobe’s test (empty can test)
Ask patient to hold point thumbs to the floor (as if emptying cans) and lift the
arms up (shoulder flexion 90°ish). This puts them in maximal internal rotation.
Push down on the hands and ask them to resist your downward pressure. Assess
power out of 5.
Pain or weakness damage to supraspinatus tendon
Passive movement range greater than active tendonitis (minimal force is transmitted into
the tendons during passive movement)
Passive movement range = active movement range intra-articular process (arthritis)
Global painful restriction of the shoulder of unknown aetiology → adhesive capsulitis /
‘frozen shoulder’
Measure
Measure angles with tape or goniometer (in rehab or medicolegqal cases)
Normal: abduction to 90°, adduction to 50°
Normal: flexion to 180° (GH also contributes 90°), extension to 65°
Normal: external rotation to 65°, internal rotation to 90°
Special Tests
Apley scratch test performed in MOVE
1) Hawkin’s test for Impingement
Forward flex the arm to 90° and the elbow the elbow also to 90°. Forcibly
internally rotate the humerus. This rotates the greater tuberosity under
the acromion and impinges the supraspinatus tendon between the
humeral head and the acromion process
2) Sulcus test for laxity
Ask the patient to flex the forearm to 90° and hold the the patient’s elbow
(this distracts the joint). Grasp the forearm with your other hand and pull
the humerus inferiorly. We are looking for a sulcus between the acromion
and the humeral head. It will be visible anteriorly or laterally
3) Apprehension/relocation test for instability
* patient lies on the bed supine *look at the patient’s face*
This can be performed sitting or supine with the shoulder just off the edge
of the bed, but the body safely centred on the bed. The shoulder abducted
to 90° and elbow is flexed to 90°. The examiner holds the patient's wrist
with one hand. The other hand applies counter pressure at the anterior
humerus to control any forward movement of the humerus (i.e.
anterior dislocation), should any dislocation start to occur. The wrist is
moved towards the patient’s head so that the shoulder is gently
externally rotated. This applies pressure to the shoulder in an anterior
and inferior position. The more abducted, the more unstable the joint
and apprehension will be elicited with this pressure. Ehen discomfort is
reached, apply pressure over the anterior humeral head (relocation) to
relieve the pain.
Pain or apprehension relieved with relocation Positive test anterior shoulder
instability
Resisted elbow flexion
The patient flexes the elbow with the forearm supinated and the shoulder in the neutral
position. Resist flexion. Tenderness in the bicipital groove → biceps tendonitis
Investigations
XRAY: Suspected trauma/fracture/dislocation, calcification of the rotator cuff due to tendonitis,
established arthritis (joint space narrowing), bony changes associated with malignancy, trauma,
congenital
US: Great for shoulder pathology, quantifying bursitis and tendon injury, depends on US operator skill
CT: Can be useful, but if cost is no barrier MRI should be used instead as it better visualises the soft
tissues with bone and has less radiation
Nuclear medicine tests: US preferred for tendon pathologies. Can demonstrate active tendonitis, or
detect hyperplastic bone lesions
Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis
Complications
Causing patient more pain/trauma whilst trying to perform an examination
Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a medical
emergency
Examination – Elbow
From Student Guidelines
Investigations
XRAY: Suspected trauma/fracture/dislocation (may not be visible), established arthritis (joint space
narrowing), bony changes associated with malignancy, trauma (black fat pads), congenital
US: Great for quantifying bursitis and tendon injury, depends on US operator skill. US preferred for
tendon pathologies. Can demonstrate active tendonitis, or detect hyperplastic bone lesions
CT: Can be useful, but if cost is no barrier MRI should be used instead as it better visualises the soft
tissues with bone and has less radiation
Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis
Complications
Causing patient more pain/trauma whilst trying to perform an examination
Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a medical
emergency
Examination – Hand
From Student Guidelines
Examination – HANDS
Patient preparation: sitting on bed with hands resting pronated (palms down) on a pillow
Ensure adequate exposure of hands, wrists and forearms, and privacy.
General inseption
Signs of systemic diseases (RA, psoriasis, gout, stigmata of scleroderma (beak nose, puckered
lips and small mouth)), systemically well, pain, presence of walking aids, splints, how they
hold the hand, how they uses or do not use their hands when moving or manipulating
Look: Inspection
Trauma ( fracture, scaphoid fracture), deformities ( OA, RA), swelling ( OA, RA),
symmetry and distribution/pattern of affected joints
Stigmata of RA: ulnar deviation of phalanges at MCPs, swan neck deformities (distal IP flexion
with proximal IP hyperextension), Z thumb and boutonniere deformities (the opposite),
Stigmata of OA: Heberden’s nodes (osteophytes at distal IPs, most common), Bouchard’s
nodes (osteophytes at proximal IPs)
Muscle wasting or asymmetry (thenar wasting, hypothenar wasting)
Stigmata of psoriatic arthritis: sausage fingers and onycholysis
Nodules ( RA), gouty tophi ( gout),
Skin: scars (carpal tunnel surgery), inflammation, erythema ( RA), bruising, lacerations
(risk of tendon or nerve damage), psoriatic plaques ( PA), ulceration, rashes, onycholysis
( PA)
Raynaud’s phenomenon ( systemic sclerosis, scleroderma/SLE)
Check elbows for RA nodules, gouty tophi and for psoriatic plaques
Feel: Palpation
*always ask permission before feeling or moving a joint* look their face while
examining* start with normal side* examine painful area last* ask them to report pain *
Feel temperature inflammatory arthritis (RA), crystalline arthropathy
(gout or psuedogout), septic joint (infection)
Palpate wrists
**use thumb and index finger of both hands, thumbs on dorsum**
Tenderness RA
Palpate MCP joints, distal IP joints and proximal IP joints
**use thumb and index finger**
Tenderness and swelling arthritis, gout
Synovitis (feels “boggy”) and synovial effusion septic
joint, inflammatory arthritis (RA, PA), gout, trauma
Sublaxation (partial dislocation) RA
Hard nodules (classically on extensor aspect) RA
Osteophytes OA
Palpate anatomical snuffbox
Tenderness scaphoid fracture
Palpate thenar and hypothenar eminences Synovitis (soft tissue joint swelling) is seen
Check capillary refill in inflammatory arthritis i.e. RA and PA
Feel for radial pulse and ulnar pulse
Vascular compromise eg: fracture, dislocation treat as medial emergency
Move
* in hand examination, start with passive mvt * compare L to R, starting with normal
side* perform active also*
Passive:
Wrist flexion an extension
Normal: 75°
MCP, PIP and DIP joints
↑ mvt / hypermobile sublaxation (partial dislocation) RA
Feel for crepitus and ROM
Active
Wrist flexion (prayer position)
Wrist extension (reverse prayer position)
Make fist and straighten out (MCP and IP mvts)
Ill-defined, swollen knuckles synovitis RA, PA
Thumb opposition (oppose thumbs and individual fingers)
Measure (hand function)
* No hand examination is complete without a practical assessment of hand function!!!*
Opposition strength (examiner forces open the “OK” sign)
Grip strength (ask patient to squeeze examiner’s first two fingers)
Key grip
Holding and turning a key; undoing and doing up a button; undo a screw-top jar;
write something
Special Tests
1) Carpal tunnel syndrome tests:
Phalen’s test: Patient holds both wrists in forced flexion (the reverse prayer
position) for 30-60 secs. This increases the contents and pressure in the carpal
tunnel. Ask the patient if they feel a burning, tingling or numb sensation over the
thumb, index, middle and ring fingers (positive test characteristic symptoms
of carpal tunnel syndrome. Note: it’s not sensitive or specific.
Tinel’s tests: tap over the flexor retinaculum to reproduce
symptoms of carpal tunnel syndrome. This is much less reliable. This
test can also be done for the ulnar at the elbow and the common
peroneal at the knee)
2) Neurological quick survey: Check the unique sensory islands and muscle uniquely innervated by
the median, ulnar, and radial nerves.
Median nerve:
Sensory: lateral tip of index finger
Motor: hand palm-up, raise thumb to ceiling (abductor pollicis brevis)
Fromet’s sign test
Ulnar nerve:
Sensory: medial (outer) tip of little finger
Motor: hold piece of paper against resistance (first dorsal interossei / T1).
Best between middle 2 fingers
Radial nerve: (no muscles in hand)
Sensory: first dorsal webbed space
Motor: thumb extension (away in plane of hand) (extensor pollicis longus)
or extension of the wrist
Diminished or absent sensation in the hand injuries of the nerves in the axilla,
arm or forearm, nerve root injury (dermatomal distribution).
If trauma has occurred, specifically test and document sensation, movement and
circulation that may have been affected by the injury.
Investigations
XRAY: Suspected trauma/fracture/dislocation, arthritis (joint space narrowing), bony changes
associated with malignancy, trauma, congenital
OA: joint space narrowing, subchondral sclerosis, subchondral cysts and osteophytes
RA: joint space narrowing, periarticular osteoporosis and erosions
Serum / blood tests (need to rule out septic arthritis and osteomyelitis)
Inflammatory markers (CRP, ESR)
FBE: Hb and WCC
Serum immunoglobulins
Synovial fluid aspiration
Gram stain and culture for septic arthritis:
Gout crystal arthritis: urate and negative for birefringment crystals
Pseudogout crystal arthritis: highly positive for birefringment crystals
Nerve conduction studies if the site of the injury is still unclear.
MRI: Visualises the soft tissues with bone and has less radiation so better than CT, good for bone,
cartilage and soft tissues. Osteomyelities plus inflammatory changes in adjacent muscle
US: Cheap and detailed soft tissue imaging, great for quantifying bursitis, tendonitis and tendon injury,
depends on US operator skill
CT: Can be useful for clarifying bone anatomy, but if cost is no barrier MRI should be used instead
Examination – Hip
From Student Guidelines
Examination – HIP
Ensure adequate exposure of both hips and privacy. Lift underwear as necessary
Look: Inspection
*with the patient standing, inspect from the front, side and behind*
General: how patient undresses, pain, walking aids or orthopaedic shoes, posture
Gait: normal, pain, limp, antalgic limp, weakness, symmetry, tilt, bear weight through both
legs, stiffness, deformity, length or instability, contact of feet with floor
From front: Alignment (valrus, vlagus), deformities (flexion contractures, short externally
rotated leg), muscle wasting and asymmetry of muscle bulk, oedema, scars (total hip
replacement)
From side: excessive lumbar lordosis flexure contracture/ fixed deformity of hip
From behind: symmetry of the gluteal and hamstring muscle bulk,
symmetry of popliteal creases,
Trendelenburg’s sign (from behind)
Place hands on iliac crests and thumb at the PSIS (dimples). Ask
patient to stand on one leg.
Normal test: Pelvis is level or rises on side of lifted leg
Positive Trendelenberg sign: Pelvis falls on the side of the lifted leg when patient
stands on the affected leg positive test
Ask patient to climb onto bed (observe this also)**
Feel: Palpation
*the patient should now be supine on the bed; look their face while examining*
If suggestion of vascular compromise eg: dislocation, feel for distal pulses
ASIS, the anterior aspect of the hip joint (distal to the midpoint of the inguinal ligament)
and the greater trochanter (with index and middle fingers)
Tenderness bursitis, inflammation in and around joint
Measure: estimate distance from each iliac spine to the greater trochanter
Palpate inguinal lymph nodes if suspecting infection or neoplastic disease
Move
* start with active movement; if range of movement is limited, carefully test passive mvt * compare L
to R*
Ensure patient is lying flat and the pelvic brim is perpendicular to the spine.
Flexion / Extension:
Normal flexion: 135°, normal extension: few degrees
Thomas’s Test
Place hand palm up under patient’s lumbar spine.
Ask patient to bend the opposite knee and bring it up to their chest (hip
flexion) while keeping the other leg (side with examiners hand under it)
extended. Feel for obliteration of the lumbar lordosis and look at the opposite
leg.
Normal test: The extended leg remains fully extended
Positive Thomas test: extended leg rises, measure flexure contracture of
hip, commonly due to OA
Internal / External Rotation
Usually tested in leg flexion in children and in leg extension in adults
Flexion/children: With hip and knee both flexed at 90°, move foot laterally for IR and
medially for ER
Extension/adults: Standing at the foot of the bed, hold the patient’s ankle and rotate
the leg inwards (IR) and outwards (ER)
Normal external: 50-60°, normal internal: 45°
Abduction/Adduction:
Lay left forearm across pelvis with hand and elbow on the two ASIS. With right hand,
hold ankle and abduct leg until reach point where ASIS starts to move – this is the
limit of hip abduction, and further movement is occurring in the lumbar spine. Repeat
with adduction by moving the leg across the body
Normal: abduction 30-40°, normal adduction: 20°
Extension (optional):
With patient lying prone, ask patient to lift each leg off the bed
Passive movement range greater than active tendonitis (minimal force is transmitted into
the tendons during passive movement)
Passive movement range = active movement range intra-articular process (arthritis)
Measure
*with patient supine, ensure both legs are in same position)
1) Measure apparent leg length: Umbilicus to medial malleolus (compare left to right)
Apparent shortening = deformity at the hip, no loss of bone length
Altered in pelvic tilt e.g. due to flexure deformity, OA
2) Measure true leg length: ASIS to medial malleolus (compare left to right)
True leg shortening = loss of bone length
Altered in hip pathology or shortening of long bones
Should be within 1cm of opposite leg. Difference of >2cm is significant.
Special Tests
Trendelenburg’s sign – completed in INSPECTION
Thomas’s test – completed in MOVE
Investigations
XRAYS (most valuable for hip except in infants): congenital, infective, traumatic, neoplastic, traumatic
US – good for infants due dominant cartilage. Adults – tendon, bursae
Nuclear Med: Inflammatory, infective, traumatic, metabolic, neoplastic bone lesions
CT, MRI: MRI is better as there is less radiation, better soft tissue information
Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis
Complications
Causing patient more pain/trauma whilst trying to perform an examination
Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a medical
emergency
Examination – Knee
From Student Guidelines, videos shown in tutorial and internet
Examination – KNEE
Ensure adequate exposure of both knees and privacy.
Look: Inspection
*with the patient standing, inspect from the front, side and behind, then inspect while supine*
General: how patient undresses, pain, walking aids or orthopaedic shoes, posture
Gait: normal, alignment of legs, limp, antalgic limp, weakness, symmetry, bear weight through
both legs, stiffness, deformity (valgus, valrus), instability
Standing: neutral alignment, scars, leg alignment, symmetry of popliteal creases,
oedema (particularly posteriorly), deformities (valgus, valrus), wasting or
asymmetry of muscle bulk (quads, hamstrings, gastrocs), swelling, contracture,
skin (erythema, bruising, lacerations, psoriasis, ulceration)
*Ask patient to climb onto bed (observe this also) and SIT*
Observe patella tracking
*ask patient to lie supine* Arthroscopic 'port'
Supine: partial flexion of knee, oedema (localised and generalised), scars can be subtle
inflammation, scars, wasting or asymmetry of muscle bulk (quads)
Feel: Palpation
*patient supine; look their face while examining*
Feel temperature of knee inflammation, infection, septic joint
Patella tap for large joint effusions
One hand grasps the lower quadriceps muscle and compresses the suprapatellar bursa
towards the knee. The other hand pushes the patella downwards.
Positive sign: Patella sinks to touch femur large joint effusion
Bulge sign for small joint effusions
The left hand compresses the suprapatellar pouch (as above) while the fingers of the
right hand are run along the groove beside the patella on one side and then the other.
Positive sign: A bulging of the opposite groove to the side being compressed due to a
fluid wave small joint effusion
Move the patella laterally and medially across the
underlying femoral condyles and palpate the under-
surface of the patella medially and laterally
Tenderness Chondromalacia Patella
Palpate the joint
*have knee slightly flexed*
Palpate the joint margins, epicondyles, the full length
of the ligaments and insertion of the patella ligament
on the tibial tuberosities.
Tenderness or palpable abnormality
Tibial tuberosity tenderness Osgood Schlatter disease
Move
* Ask patient to perform active mvt and then perform passive mvt to check for greater range; if range
of movement is limited, carefully test passive mvt* compare L to R, starting with the normal knee*
Flexion / Extension: Ask patient to flex and extend knee
Normal flexion: 0 - 140°
Normal extension: 5-10° off the bed (hold the femur down)
Passive movement range greater than active tendonitis (minimal force is
transmitted into the tendons during passive movement)
Passive movement range = active movement range intra-articular process (arthritis)
Measure
Goniometer rarely used (e.g. in medicolegal cases or when monitoring of an injury or
pathology). Need to ensure legs are in the same position when supine
Special Tests
**with the patient supine** compare normal to R**
1) Collateral ligaments (medial and lateral)
Hold the ankle with the right hand, slightly flex the knee (approx.
30°) and slip the left hand under the femur (just above the knee).
Alternatively, squeeze the foot under the opposite armpit and hold
the knee with both hands (right). Ensure that the knee is not locked
and is slightly flexed (full extension makes the cruciate ligaments
taught and they will provide lateral stability even if the collateral ligaments are
defective; in flexion, lateral stability is only provided by the collateral ligaments).
Medial ligament: apply a valgus force (move the foot outwards, pull femur medially).
Lateral ligament: apply a varus force (move foot inwards, pull femur out). You may also
repeat with the knee locked to test not only the relevant collateral ligament damaged
but also at least one cruciate ligament.
Significant abduction or adduction ligament disruption or injury
Unusually lax ligaments ‘normal’ for some
2) Cruciate ligaments (anterior and posterior)
Anterior and posterior drawer (ACL and PCL): Bend both knees to
90° with the hips flexed to 45° and sit on the foot. Use both hands to
hold the upper tibia and use the index fingers to ensure the
hamstring tendons are relaxed. When the patient is relaxed, pull the
tibia forwards to test the ACL and backwards to test the PCL. Normal:
a couple of mms of mvt, no anterior movement of the tibia
suggesting the ACL is intact. This is the best test for the PCL
The Lachman’s test is the best test for the ACL. Flex the knee to 30°
so it’s off the bed . Have one hand on the thigh above the knee and the other on the leg
below the knee. Forcefully lift the tibial towards the ceiling while keeping the femur
still.
Posterior (PCL): Lift both legs into the air so that both hips and both
knees are flexed to 90°. From the side, ensure the tibial tubercles are
level and for sagging of the tibia posteriorly.
3) The Menisci (medial and lateral)
McMurray Test: Flex the knee (to compress both menisci between
condyles. Place one hand on the knee (anteriorly) to feel both joint
lines. The other holds the foot.
Medial meniscus: Invert the foot / externally rotate the leg and push
the knee upwards and outwards (varus). Gently flex and extend the
knee.
Lateral meniscus: Evert the foot / internally rotate the foot. Push the
knee in medially (a valgus force, inwards and upwards). Gently flex
and extend.
Click, pop, crepitus or pain while straightening the knee meniscal
disruption
4) Patella apprehension test
Apply lateral force to the patella as the knee is moved from full
extension to flexion. Ensure that you are looking at the patient for a http://www.youtube.com/
watch?v=ohSzjNj-KCA
look of apprehension.
Apprehension of the patient or resists flexion tendency/risk of
patella dislocation.
5) Apley’s Grind Test
**ask patient to roll onto stomach**
Ask patient to flex knees to 90°. Grasps the tibia and repeatedly
internally and externally rotates the tibia while pushing it directly
downward into the bed.
Positive test = Pain
Investigations
XRAYS (most valuable for knee): fractures, arthritis, malignancy
US – good for infants due dominant cartilage. Adults – tendon, bursae
Nuclear Med (limited use in knee): Inflammatory, infective, traumatic, metabolic, neoplastic bone
lesions
CT, MRI: CT can be useful but MRI is better as there is less radiation, shows both bone and soft tissue,
better soft tissue information, and most pathology of the knee occurs in soft tissues
Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis
Complications
Causing patient more pain/trauma whilst trying to perform an examination
Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a medical
emergency
Examination – Ankle
From Student Guidelines
Examination – ANKLE
Ensure adequate exposure of both ankles (bare feet) and privacy.
Look: Inspection
General: removing shoes and socks, pain, walking aids or
orthopaedic shoes, posture
Deformity (hallux valgus i.e bunions) or crowding of toes RA,
sausage shaped toesPA, AS), athropathy (joint disease, esp
in toes), muscle wasting or asymmetry, oedema/swelling,
scars, skin (inflammation, erythema, bruising, lacerations,
psoriasis, ulceration), psoriatic nail changes, calluses
(sublaxation)
Integrity of the arches for flattening
longitudinal medial arch (from heel to first MT- joint)
transverse arch (under MT-P joints)
flattening RA
Gait: asymmetry or abnormality of mvt, misalignment (over pronation or supination),
ability to bear weight, stiffness, instability
Feel: Palpation
*normal ankle first* look their face while examining*
Lateral and medial malleoli oedema
The joint line
Squeeze MT-P joints (with 1st and 5th metatarsals between hands)
Tenderness RA
Metatarsal heads
The base of the 5th metatarsal avulsion fracture
Medial and lateral ligaments
Feel temperature of ankle inflammation, infection, septic joint
Palpate Achilles tendon
Tenderness Achilles tendonitis
RA nodules RA
Move
* start with normal side* ask patient to perform mvts first, then perform passive mvts*
It is usually difficult to give an exact range of movements in degrees and describing the
movement as a percentage of the other side or what a normal person can do is usually all that
can be done
Ankle joint / Talar joint (tibia and fibula with talus)
Dorsiflexion and plantarflexion
Measure angle from right angle of ankle.
Normal: dorsiflexion 20°, plantarflexion 50°
Subtalar joint (talus with calcaneus)
Inversion and eversion
Hold the toes in one hand and the tibia in the
other. Twist the forefoot.
Normal inversion: 20-30°
Normal eversion: 5-10°
Midfoot (multiple joints, mostly talus mvt with
navicular)
Hold the calcaneus still in one hand (i.e. fix the hindfoot) and hold the distal
metatarsals in the other. Twist the forefoot
The metatarsals can move dorsally (extension), plantarward (flexion), medially
(adduction), laterally (abduction), rotate in (supination) and rotate out
(pronation).
Tenderness on movement
Passive movement range greater than active tendonitis (minimal force is transmitted
into the tendons during passive movement)
Passive movement range = active movement range intra-articular process (arthritis)
Measure
Special Tests
Investigations
In trauma, examine and decide whether you need to perform an XRay of the ankle or the foot
(base of 5th meta-tarsal suspected)
XRAYS fractures, arthritis, malignancy
US – good for infants due dominant cartilage. Adults – tendon, bursae
Nuclear Med (limited use in knee): Inflammatory, infective, traumatic, metabolic, neoplastic
bone lesions
CT, MRI: CT can be useful but MRI is better as there is less radiation, shows both bone and soft
tissue, better soft tissue information, and most pathology of the knee occurs in soft tissues
Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis
Complications
Causing patient more pain/trauma whilst trying to perform an examination
Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a
medical emergency
Examination – Back
From Student Guidelines
Indications
Complaints of back pain Equipment
Suspect back is the source of a 1. Measuring tape
pathology i.e. pain radiating down leg 2. Pen
3. Tendon hammer
Contraindications: none 4. Neurological exam – cotton wool,
Cord compression, cauda equina neurotip, tuning fork, etc
syndrome or trauma, esp. cervical
spine medical emergency
Examination:
Patient preparation: patient standing with their back to you
INSPECTIONs
overall posture, including scapula position,
curves of the back (normal curves, pathological curves), scoliosis
landmarks: waist creases, ASIS alignment
muscle wasting
surgical scars - possible surgery to the spine
PALPATION
Palpate each spinous process – can do sitting or standing.
Identify surface landmarks of spine
C7 is the most prominent of the cervical vertebrae
T3/T4 is approximately level with the spine of the
scapula
T7 is approximately level with the inferior angle of the
scapula in neutral position
T10 may be located by following medially the angle of
the 12th rib to the midline or count down from T7
L4 spinous process (L4/5 disc) is at or just below the
level of the iliac crests
Feel for the tone of the erector spinae muscles (lateral to spine)
spasm in the muscles area of pain
PERCUSS **warn patient**
Percuss each spinous process, facet joints and sacro‐iliac joints.
MOVE
**watch face during all movements for any signs of pain**
Feeling for pain or misalignmnt
Cervical spine **whilst sitting**
forward flexion “put your chin to your chest” (normal 0 – 80°)
extension “look up at the ceiling” (normal 0 – 50°)
lateral flexion “put your ear to your shoulder (normal 0 – 45°)
rotation “look over your shoulder” (normal to 80° each side)
Thoracic spine **whilst sitting to keep hips fixed**
rotation – ask the patient to sit, keep their hips still, cross their arms over their
chest and rotate their shoulders
flexion – bend forward as far as you can
extension - arch your shoulders backward and push your abdomen out forwards
lateral flexion - slowly lower your right hand down towards the floor (repeat with
left)
Lumbar spine **whilst standing**
flexion – “bend forward as far as you can” / “try to touch your toes”
Extension “arch your back and push your tummy out”
Lateral flexion “ run your hand down the side of your leg towards the floor”
Functional examination of gait (optional)
Ask patient to walk to the wall and back. Classically lumbar spinal stenosis causes
pain that is worse with walking
SPECIAL TESTS
Schober’s test for forward flexion **standing**
Assesses whether movement is occurring in the lumbar spine
or the hip joint and is critical for lumbar spine assessment.
Mark the skin in the midline at the level of the dimples of
Venus (i.e. the left and right PSIS) which overlie the sacroiliac
joints. Using a tape measure, draw two marks, one 10cm
above and one 5cm below this.
Place the end of the tape measure on the upper mark and ask
the patient to ‘touch the toes’.The distance ... should increase
from 15cm to more than 20cm.”
Distance is less then 20 spine is fixed ankylosing
spondylitis
Also may indicate scoliosis
Straight Leg Raise test **lying supine**
Ask the patient to one leg straight up (actively) and measure
their range (with the knee extended).
Then, place one hand under the Achilles tendon and one over
the knee (to keep the knee extended) and gently passively
raise the leg up further. Once leg is raised, internally rotate and dorsiflex. Ask
patient to lift head off bed.
Ask the patient to report pain or symptoms, where it is and whether this is
normally the site of pain (and not hamstring pain)
Negative test: no pain or symptoms, this is not sciatica.
Positive test for sciatica: reproduction of symptoms, significant difference
between sides, or if symptoms are reproduced at the end of range when adding
extra sciatic nerve tension. Record the angle of flexion which produces the pain
Reflexes
Lower limb: knee jerk, ankle jerk and plantar reflex.
Upper limb reflexes should be examined if any pathology of the Cx spine
Neurological examination:
Indicated where there are confusing signs, pain below the hip/buttocks, decreased
mobility/strength/senses. May be of the upper or lower limb, or for spincter tone
Tone, power, reflexes (done), coordination, sensation
Examination – Cranial Nerves
From Student Guidelines
Indications
Injury (sports, MVA) History suggesting nerve lesion
History of cerebrovascular disease or General neurological examination
neuropathy Complete medical examination
Known neck pathology (tumour,
infection)
Contraindications: - none
Equipment
1. Bottle scents 6. Cotton wool
2. Snellen chart 7. Neurotip pin
3. Target (e.g. hat pin) 8. Tuning fork
4. Ophthalmoscope 9. Tendon hammer
5. Flashlight
Examination:
Patient preparation: ask patient to sit level with you
General inspection
Abnormalities of head shape or size (hydrocephaly, acromegaly, Paget’s disease)
Ptosis, Proptosis, Pupillary inequality (remember a patient will have a glass eye!)
Deviation of gaze (squint) , head tilt
Facial asymmetry
Scars, Cachexia
Hearing aids, glasses
Rashes or skin lesions
CNI (olfactory) nerve:
Ask if the patient has noticed any problems with their sense of smell/taste
Inspect for rash, deformity of the nose, ensure both nostrils are clear (oedematous
polyps non‐neurological anosmia)
Ask patient to block one nostril and report which scent they can detect as the various
essences are presented (coffee, vanilla and peppermint). Use separate scents for
each nostril
Anosmia usually non-neurological (blocked nose, medication related), early
Parkinson’s sign
CNII (optic) nerve:
Visual acuity – Snellen’s Chart
Ask if the patient normally wears glasses or contacts for long distance, ask them
to wear these during the assessment. note both unaided and aided visual acuity
for each eye
Test each eye separately
Ask the patient to cover their right eye with their hand (or eye cover) and read as
far down the Snellen chart with their left eye. Repeat on other eye
Record the smallest line read for each eye and report visual acuity grade (usually
6/x)
A pass is typically 2 errors or less.
Report these errors e.g. 6/6 -2
If the patient is unable to read even the largest letter, grade their acuity as:
Count fingers
See hand movement
Perceive light
No perception at all
Visual fields – Confrontational Test
Explain to the patient that you are testing their eyes against your eyes
Position the patient and yourself so that you are arms length apart with your
eyes at the same level and directly opposite.
Ask them to cover one eye, as you cover your opposite eye (on the same side).
Ask them to fix their gaze on your eye, and explain they are not to look for the
target (red hat pin or moving finger), but to report when it comes into the
periphery of their vision (“tell me when you see then pin out of the corner of your
eye” / tell me when you can see its red).
Start with the target centrally half way between yourself and the patient and
confirm they can see it clearly.
Position the target peripherally in each quadrant of the visual field and move it
centrally. This tests peripheral vision in four quadrants in this eye.
Repeat on the opposite eye
Report whether there are any gross visual field defects – hemianopia, stroke
Blind spot: Not expected to be done in OSCEs
Fundoscopy
Ask the patient to fix on a distant visual target (over your shoulder)
Check first for a red reflex from a distance (if absent consider a cataract or an
artificial eye)
Start with the ophthalmoscope on +20 lens to inspect the cornea and iris, then
rack down the magnification and move closer to the patient to progress from
lens, to vitreous then eventually focus on the fundus. The fundus has two main
landmarks – the optic disc and the macula, and each of these should be
inspected, as well as each quadrant and the vessels
CNIII (oculomotor) nerve, CNIV (trochlear) nerve, CNVI (abducens) nerve:
Draw H – Assess motor:
Ask the patient to keep their head still and follow the target. Ask to report if they
see any double vision. Draw a “H” pattern and look for nystagmus and
symmetrical eye movements
Light reflex – direct and consensual reflexes in each eye.
Ask patient to focus on a distance object behind you. Shine light from the side
into the eye being tested. Observe constriction of the pupil of that eye (direct
response). Shine the light a second time and observe constriction of the eye that
is not being tested (consensual response).
Normal: Both pupils should dilate as the light is removed.
Swinging-flashlight test (for afferent pupil defect):
If direct testing suggests a ↓ light reflex, move the torch quickly from eye to eye.,
resting on each eye for 1-2 seconds
As the torch is swung to the eye with the relative afferent pupillary defect
(RAPD), both eyes will constrict less (therefore appearing to dilate paradoxically)
→ Marcus Gunn sign optic nerve lesion.
Accommodation reflex:
Ask the patient to first fix on a distant object and then focus on the target in front
of them when you say. Bring a target (hair pin or finger) held close to their face.
Say ‘now”
Normal: The eyes should converge and pupils should constrict symmetrically
CNV (trigeminal) nerve:
Sensory – Light touch
Demonstrate the touch on the chest. Ask patient to close their eyes and say
when they feel the touch on their face. Using a wisp of cotton wool, perform light
touch (touch not stroke) on 3 regions (ophthalmic, maxillary and mandibular)
Repeat on the opposite side.
Repeat with warm hand vs cold tuning fork
Sensory –Facial pain
Repeat with the neurotip pin assesses pain
Report normal sensation of the face
Motor – Muscles of Mastication
Ask patient to bite down/clench teeth. Palpate masseter, temporalis and
pterygoid muscles look for muscle wasting
Ask patient to open their mouth and resist opening jaw against your hand
(pterygoid)
Report normal bulk of the muscles of mastication
Reflexes (2)
Corneal reflex: using a wisp of cotton wool touched to the cornea . Warn the
patient that you’re testing their blink reflex. Don’t approach within the visual axis
Jaw jerk: rest your fingers on the jaw. Ask patient to relax jaw. Tap your own
finger with a tendon hammer. Little or no movement is normally elicited, while an
exaggerated jerk suggests pathology
CNVII (facial) nerve:
Motor: Facial Muscles
“Raise your eyebrows”
“Screw your eyes tightly shut and don’t let me open them”
“Show me your teeth”
“Puff out your cheeks” and “don’t let me push the air out”
Sensory: Anterior tongue
Ask if any changes in taste anterior 2/3 of tongue (salt, sweet, sour, bitter)
CNVIII (Acoustic) nerve
Whisper numbers (gross hearing loss)
classically ‘68’ and ‘100’ into one ear while blocking hearing in the other by
rubbing your fingers over their opposite ear.
Weber’s test (sensorineural):
Rest the stem of the tuning fork on the forehead in the midline. Ask whether the
patient hears one louder than the other.
Sound localises to the affected ear with conductive loss
Sound localises to the contralateral ear with sensorineural hearing loss.
Rinne’s test (conduction):
Tuning fork stem on the mastoid process and ask the patient to report when the
vibration is inaudible Bring the fork to the external auditory meatus.
If there is normal conduction the patient will report the sound as louder when
next to their ear.
If it is not lounder / they can’t hear it, there is reduced air conduction in the
middle ear (and if this the same ear as was louder in the Weber’s test, it confirms
the conduction loss in that ear)
Balance
Ask patient to stand up and close eyes. If easy, ask to stand on one foot.
CNIX (glossopharyngeal) nerve and CNX (Vagus) nerve:
Inspect tongue in mouth for wasting, fasciculations. Use a torch!
Ask the patient to say “Ahhh”. Observe for any asymmetry as the uvula is drawn
upwards.
Deviation = uvula deviates to the strong, functional side as the palate elevates
and pulls the uvula towards it.
Gag reflex - a spatula is touched to back of the soft palate.
Glossopharyngeal (afferent)
Vagus (efferent)
Palatal incompetence
Place a cold, flat object under their nostrils and ask the patient to say “pop, pop,
pop”. Incompetence will result in frosting as humid air is expelled from the
nostrils.
CNXI (accessory) nerve (innervates trapezius):
Inspect for trapezius atrophy or asymmetry.
Ask patient to shrug their shoulders and resist resistance (push down on shoulders –
“don’t let me push your shoulders down”)
Ask patient to turn their head against resistance (“try to turn your head against my
hand”)
CNXII (hypoglossal) nerve:
Ask patient to stick out tongue
Tongue deviation LMN lesion, deviation toward the affected side
Complications
Discomfort or harm to the patient (e.g. with corneal or gag reflex)
Investigations
Imaging: Brain CT or MRI
NCS (Nerve Conduction Studies) - Stimulate nerves and measure latency, amplitude and
conduction velocity between two point
Examination – Neurological Upper Limb
From Student Guidelines
Indications Contraindications
Neurological history
General neurological exam
Full medical examination
Equipment
1. Tendon hammer
2. Cotton wool
3. Neurotip
4. 128Hz tuning fork
REFLEXES
If difficult to elicit a reflex, a reinforcing manoeuvre should be used. This can be getting the
patient to clench their teeth or perform a valsava manoeuvre.
Described as: absent, reduced, normal, brisk/increased, markedly increased/clonus
Patient needs to relax limb in a neutral position (e.g. folded on lap on pillow). There are
four to test:
Biceps (C5,C6) (hand pronated)
Brachioradialis (C5,C6),
Triceps (C7,C8),
Finger Jerk (C8) (hand supinated) should be no contraction, marked contraction
indicates UMN lesion
COORDINATION
Finger‐nose test
This movement is repeated both briskly and slowly, and the examiner’s finger is mov
ed about to alter the target. Ensure the patient is in their extremes of movement to
(i.e. fully outstretched arm) to reveal subtle tremours.
gross in‐coordination or intention tremor cerebellar disease
past‐pointing less severe cerebellar disease
Rapidly alternating movements
The patient is observed pronating and supinating their hand rapidly.
Dysdiadochokinesia Parkinson’s, MS, cerebellar lesion
Rebound
The patient is asked to rapidly lift (flex) their arms from their side forward and stop
on your command
SENSATION
Pain, light touch, vibration, proprioception, temperature if indicated
Pain (neurotip) followed by light touch (cotton wisp)
Demonstrate on sternum. Ask patient to close eyes and report when
they feel it and whether it feels the same on both sides. If reduced,
repeat testing.
C5 – shoulder tip
C6 – lateral aspect forearm, thumb
C7 – middle finger
C8 – little finger
T1 – medial aspect upper arm and elbow
Temperature (optional)
Note that objects will feel cooler at the periphery compare to
proximally
Vibration (posterior column)
Demonstrate on sternum. Ask patient to report whether they can feel
vibration and to report when it stops
Rest the tuning fork on distal IP joints (or another distal bony
prominence)
If it is not felt, move the form more proximally DIPs ulnar head
at the wrist olecranon at the elbow
Proprioception (posterior column)
Ask patient to close their eyes. Move the distal IP joint of the little finger up and
down, first demonstrating then asking the patient to report the direction. Hold the
joints on the side (not top and bottom)
Investigations
NCS (Nerve Conduction Studies) - Stimulate nerves and measure latency, amplitude and
conduction velocity between two points
Best for testing neuropathy, allows you to pinpoint the site of descreptancy,.
Decreased amplitude indicates amplitude problems
Prolonged latency and decreased conduction velocity indicates demyelinating
Better for extremities rather than proximal nerves where they’re deeper
Conduction block: there will be a pulse more proximally, but the pulse wave will be flat
more distally. Most common cause is compression or ischaemia (which causes focal
demyelination).
EMG – fine needle electrode, recording MU action potentials (i.e. when a muscle cell is activated)
Helps differentiate neuropathic from myopathic, and helps localise conditions.
EMG allows you to pick out individual muscles and show where the neuropathic changes
are.
Cerebral spinal fluid (CSF) collection
Increased CSF gamma globulin levels may be due to diseases such as multiple sclerosis,
neurosyphilis, or Guillain-Barre syndrome.
Increased glucose in
X-Ray if impingement (e.g. radiculopathy) is suspected
Complications
Prick wounds or injuries from neurotip
Examination – Neurological Lower Limb
From Student Guidelines
Indications Contraindications
Neurological history
General neurological exam
Full medical examination
2. Pin (neurotip) for pain sensation
Equipment 3. Cotton wool
1. Tendon hammer
4. 128 Hz tuning fork
TONE
Ask patient to relax. Move the knee joint passively; move the ankle joint passively. Do a
fast movement than a slow movement. Distract or ask them to grit their teeth If
necessary. Graded as hypotonic, normal or hypotonic,
Hypertonia / spasticity sign of an UMN lesion.
Lead pipe rigidity (stiff regardless of velocity)
Cogwheel rigidity (form of hypertonia, variable) associated with Parkinson’s
disease
Hypotonia / rigidity: sign of a LMN lesion.
Spastic catch (clasp knife effect after moving it quickly)
Test for Clonus
With the knee slightly bent, the ankle is sharply dorsiflexed to stretch the Achilles
tendon. If clonus is present the calf muscles will contract repeatedly against your
hand. Count the number of beats and compare for asymmetry.
Clonus sign of a UMN lesion.
REFLEXES
If difficult to elicit a reflex, a reinforcing manoeuvre should be used. This can be getting the
patient to clench their teeth or perform a valsava manoeuvre.
Described as: absent, reduced, normal, brisk/increased, markedly increased/clonus
There are 3 to elicit:
Knee Jerk (L3-L4) (knee slightly flexed)
Ankle Jerk (S1-S2) (manually dorsiflex and rotate first)
Plantar reflex (L5, S1, S2) (laterally near heel across metatarsal heads)
Norma: great toe flexes at the MTP joint.
Extension of the toe “upgoing Plantar” UMN lesion of corticospinal tract
COORDINATION
Tests multiple components – vision, cerebellum, motor power, joint integrity
Toe-Finger test
The patient uses their great toe to touch the examiner’s finger with their knee bent.
This may demonstrate an intention tremor (tremor increases as target is approached)
Heel-shin test
Ask the patient to run their heel up and down the shin of the opposite leg.
Abnormal cerebellar lesion
Foot-tapping test
The patient is asked to tap their toe rhythmically against the examiner’s hand.
SENSATION
Pain, light touch, vibration, proprioception, temperature if indicated
Pain (neurotip) followed by light touch (cotton wisp)
Demonstrate on sternum. Ask patient to close eyes and report
when they feel it and whether it feels the same on both sides. If
reduced, repeat testing.
L1 – anterior groin area
L2 – proximal anterior thighL3 – immediately superior to
the knee anteriorly
L4 – medial calf
L5 – lateral calf and middle of dorsum foot
S1 – lateral heel
S2- posterior midline thigh
S3 , S4, S5 – concentric rings in ‘saddle area’ around the
anus
If there is reduced sensation, repeat testing in the
abnormal area.
Vibration (posterior column)
Demonstrate on sternum. Ask patient to report whether they
can feel vibration and to report when it stops
Rest the vibrating fork on the great toe.
If vibration sensation is reduced or absent, it is progressively tested more proximally:
great toe ankle patella anterior superior iliac spine.
Proprioception (posterior column)
Ask patient to close their eyes. Move the distal IP joint of the great toe up and down,
first demonstrating then asking the patient to report the direction. Hold the joints on
the side (not top and bottom)
Common patterns: Distal / glove and stroking, single nerve, dermatomal, hemispheric
Unusual patterns: Crossed, dissociated (disturbance affects one pathway but spares the
other), suspended (central court syndrome)
Investigations
NCS (Nerve Conduction Studies) - Stimulate nerves and measure latency, amplitude and
conduction velocity between two points
Best for testing neuropathy, allows you to pinpoint the site of descreptancy,.
Decreased amplitude indicates amplitude problems
Prolonged latency and decreased conduction velocity indicates demyelinating
Better for extremities rather than proximal nerves where they’re deeper
Conduction block: there will be a pulse more proximally, but the pulse wave will be flat
more distally. Most common cause is compression or ischaemia (which causes focal
demyelination).
EMG – fine needle electrode, recording MU action potentials (i.e. when a muscle cell is activated)
Helps differentiate neuropathic from myopathic, and helps localise conditions.
EMG allows you to pick out individual muscles and show where the neuropathic changes
are.
Cerebral spinal fluid (CSF) collection
Increased CSF gamma globulin levels may be due to diseases such as multiple sclerosis,
neurosyphilis, or Guillain-Barre syndrome.
Increased glucose in
X-Ray if impingement (e.g. radiculopathy) is suspected
Complications
Prick wounds or injuries from neurotip
Examination – Skin
Indications
Skin lesion
Symptoms of malignant cancers
Contraindications
Equipment
1. Magnifiers
Lumino dermlite (polarized illuminated hand-held magnifier)
Magnifying glass
Head loup
2. Dermatoscope
3. Wood’s lamp
4. Camera
Examination Summary:
Patient preparation: Good lighting, complete skin surface exposed.
Assess general illness
Examine the entire surface of the skin
Examine special sites – scalp, nails, mouth and ask about ano-genital region
Describe lesion morphology and distribution
2. Distribution of lesions / full skin examination
Any pigmented lesions: assess with dermatoscope
Examination:
Patient preparation: Good lighting, complete skin surface exposed.
General inspection: is this patient ill
Generalised redness
Facial redness with fever
Widespread distribution of lesions
multiple bullae or erosions
palpable (or impalpable) purpure
multiple skin infarcts
Examine the entire skin surface
Ensure you don’t miss any areas: behind the ears, back of the neck under hair,
between the toes, the back and buttocks, genital region, axillae
Examine all relevant lymph nodes if a suspicious lesion is found.
Examine special sites – scalp, nails, mouth and ask about ano-genital region
Examine scalp skin and hair – psoriasis, lice, nits (eggs)
Examine nails – infection (bacterial or fungal), lifting of nail, psoriasis
Examine mucosae – dermatosis, lichen planus, Stevens–Johnson syndrome
Ask about ano-genital region – dermatosis, lichen planus, lichen sclerosis
Further Investigations
Dermatoscopy with oil
Pigmented lesions
Skin swab for culture or PCR
suspected bacteria, viruses (to perform PCR)
Nail clippings for microscopy and culture
suspected toe nail fungal disease (onychomycosis, tinea unguium)
Skin scrapings (transferred to glass slide, 10% KOH added and examined under light
microscope)
suspected fungal infections (dermatophytosis)
Microscopy
Suspected lice in hair, scabies (scrape the burrow/papule),
Wood’s lamp
Erythrasma (corynobacterium fluoresces coral pink), vitiligo (depigmentation is
white)
Skin prick testing
Suspected type 1 hypersensitivity
Patch testing
Suspected type 4 hypersensitivity as in allergic contact dermatitis
Skin biopsy for histopathology
If unsure of the clinical assessment, but only AFTER a provisional clinical diagnosis
has been made
Skin biopsy is often of little value for inflammatory disease
Biopsy is important to confirm clinical diagnosis in neoplastic skin disease
Select the correct technique
Always make a clinical diagnosis before biopsy a pigmented lesion
Provide pathologist with as much clinical information as possible
Talk with the histopathologist if the pathology report doesn’t fit the clinical diagnosis
Examination – Ear, Nose, Throat
From Student Guidelines
Indications
Pain Contraindications
Discharge
Ringing
Deafness
Equipment
1. Otoscope with clean earpiece
2. Nasal speculum
3. Tongue depressor
4. Pen light
5. Tuning fork (512 ideal)
Indications Contraindications
Vision loss or deterioration
Diplopia
Optic neuritis Equipment
Stroke or other causes of field loss 1. Snellen chart
Changes in vision 2. Eye paddle
3. Flashlight
4. Red hatpin
5. Opthamoscope
Procedure:
Preparation
Switch of room lights, should be dim but not dark
Warn the patient that the bright light can temporarily dazzle them
Patient shoud be sitting up.
Test visual acuity – Snellen Chart
Seat the patient 6m from the Snellen chart
Allow the patient to wear glasses if they usually wear them, and the results are referred to as
"best corrected vision".
Examine the right eye first
Ask the patient to obscure their left eye with an ‘eye paddle’ or card – enough to occlude
vision but not pressed against the eye. This is important to prevent cheating.
Ask the patient to read from the top of the chart down with their right eye.
Record the last line completed accurately as the acuity for distance vision for which eye.
Numerator = number of meters standing away
Denominator = which line read (60 for top line, 6 for lowest
line)
Repeat with the opposite (left) eye.
Near vision test (Hand-help acuity chart)
Test colour vision
Use the Ishihara Colour Plates to test colour vision
Test response to light
Shine a light in the left eye, looking for constriction of both the left pupil AND the right pupil.
Repeat in the other eye
Test visual fields
Sitting an equal distance from the patient, ask them to cover one eye with their hand or an
eye paddle
Using both hands (an equal distance between yourself and the patient), hold up one-to-two
fingers on each hand.
Try to hold one hand in a left/temporal field and the other in a right/nasal field and ask the
patient to tell you how many fingers you’re holding up.
Switch visual fields and repeat.
Repeat on the other eyes.
Test extra-ocular movements
Ask the patient to keep their head still and follow the red dot with their eyes
Ask them to report any double vision
Using the red hatpin, draw a H-pattern in the air.
Observe for full movement of the eyes, any nystagmus, and any reported diplopia
Perform fundoscopy
Pupil dilatation (with one drop tropicamide 1% in each eye and wait for 15 minutes) is useful
to acquaint yourself with the normal fundus but may not always be possible, especially in
neurology patients or those with a head injury.
It is important to get your patient to fixate on a precise area (for example, the corner of the
room or curtain rail). If you are too vague about this they will move their eyes. Instruct the
patient to look at this spot no matter what—even if you get in the way. This spot should be
located so that they are looking slightly away from you when they are examined—that is, to
the left when you examine the right eye and vice versa.
It is best to examine the patient's left eye with your own left eye and right eye with your own
right eye—this takes practice. Try to keep your other eye open. Certainly, in an examination,
such as for membership of the Royal College of Physicians (MRCP) part 2, you shouldn't close
your other eye while examining the retina.Place your hand on the patient's forehead so that
your fingers are splayed but your thumb is on the upper lid. This is important as you will use
your thumb to hold the patient's lid open and also the joint of your flexed thumb is exactly
where your forehead needs to end up.
Other investigations
Panoptic Ophthalmoscope
Direct Ophthalmoscope
Slit Lamp
Procedure – Surgical Handwash
To Do.
Procedure – Vital Signs and Observations
Patient Questions
Alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the
exam?
Never take an BP on an arm with;
Arterio-venous fistula
Lymphoedema
Same side as a mastectomy
Recent radial harvest for coronary artery graft surgery
• Avoid an arm with a cannula in-situ
Heart Rate
Index and middle finger. If the radial can’t be felt, use the carotid pulse
Rate: 60-100 normal (normal bradycardia, tachycardia)
Rhythm: regular or irregular, irregularly irregular = AF
Volume/character: weak, strong or bounding
Where the pulse was taken
Radio-radial delay, radiofemoral delay
Respiration Rate
Rate: 12-20 normal (normal bradypnoea or tachypnoea)
Pattern: Regular and unlaboured (no distress, Kussmal)
Ratio to pulse: 1:4
Use of accessory muscles
Blood Pressure
Take towards end to minimise white-coat hypertension. Arm should be level with heart (if too
hair, the BP will be high). Palpate for the brachial artery. Wrap the sphygmo 2.5cm above the
artery. Wait 2 mins before repeating on same arm.
Normal, hypertension (140/90),
Manner: Sitting or standing, L or R
Lying and standing (drop in more than 15 = postural hypotension)
Left and right (variation of up to 10mmHg is acceptable)
Stethoscope:
Warm it in your hands before use
General tips
In a patient with a possible vascular event, such as a dissecting thoracic aneurysm, take pulses in
all extremities.
In some patients, it may be difficult to palpate a pulse, for example due to obesity
Specialists (for example vascular surgeons) may use a Doppler device if necessary to find pulses.
Never rely on a monitor or any electronic device for the heart rate – you should always check the
pulse manually as well.
Do not auscultate the heart over clothing
Blood pressure can be influenced by physical activity, posture, the respiratory cycle, smoking,
caffeine and anxiety.
It is normal to feel slight variation in the regular pulse. This is due to the effect of inspiration and
expiration on the tone of the vagus nerve. This will be noticed as an regularly irregular pulse.
Factors that can influence temperature are biological rhythms, hormones, environmental factors,
exercise, eating food and age
Mercury thermometer : Must shake before use. Slowly being phased out of use in
healthcare. Can be used to measure oral, axillary and rectal temperature
Digital thermometer : Can be used to measure oral, axillary and rectal temperature
Procedure – Basic Life Support
Dangers:
Eliminate dangers to yourself, then to the victim
Warn any bystanders of danger
Protect cervical spine!
CPR must be on flat, DRY surface
Response
Commands:
− Can you hear me
− Squeeze my hand, open your eyes
Actions:
− Squeeze shoulders
− Sternal rub
Airway
Check airway is CLEAR
− If suspect fluid or vomit in lungs
Tilt head to side
Put on left side
Open airway
− Hold forehead
− Tilt HEAD back
− Chin lift
If cervical spine injury is suspected:
− Bystander stabilises head
− Jaw thrust to open airway without extending the neck
− Fingers under jaw and lift
− Use thumbs to open mouth
Breathing
Look
Feel
Listen
Compressions:
Kneel on the patient’s right side
30 compressions then 2 breaths
− 2 compressions per second
− 100 compressions a minute;
− Count aloud
Heel of hand on lower half of sternum, middle finger over nipple
Fingers interlocked over left of chest/heart
Arms straight, elbow extended
Compress straight down – do not rock
Rescue Breaths
− Close nostrils
− Tilt chin further back as you breathe in
− LOOK for lungs inflating and fall of chest
− LISTEN for breathing
Defibrillator
Use IMMEDIATELY
Take clothes OFF, DRY person if wet
Put battery in
Press green button to turn on
Put pads on
Plug in pads
TELL EVEYRONE TO STAND BACK
Re-commence compressions until shock is advised
Begin compressions immediately after shock
Constantly:
Continue checking for
− Dangers
− Response/breathing
Instructing Others
CPR
− Do you know CPR?
− Are you willing to perform CPR? / Do you think you can learn it?
− Look where my knees are. Position your knees in the same way so you can lean
− Arms straight, elbows extended, and use your upper body
− Interlace one hand over the other
− Press one 3rd the depth of the chest,
− Number of compressions, count aloud
− Hard and fast compressions, followed by 2 breaths
− Stop compressions when giving breaths
Defib
− Open it
− Put the battery in
− press the green button to turn it on
− Unstick the paddels and pass them to me
− Plug the padels in
Special Cases
Infants
− Use 2 fingers to compress
Stomach Distended
− do not apply pressure to stomach
Pregnant
− Put pillow/jumper under right buttock
− Keep shoulders flat
− Pelvic tilt to the left
Procedure – ECG
Indications
Chest pain Electrolyte abnormalities (E.G. k+)
Shortness of breath (SOB) Syncope/fainting
Palpitations Monitoring of drug effects and toxins
Chronic or acute heart failure Routine medical examination e.g.
Hypertension medical insurance
Congenital cardiac abnormalities Baseline ECG e.g. with HT or diabetes
Contraindications: none
Ideally, the patient should not have had alcohol, tobacco, caffeine, or performed physical
exercise within 30 minutes of the exam. The exception is when a patient has performed exercise as part
of an exercise stress test)
Equipment
1. Disposable razor and sharps bin (if necessary)
2. Electrodes (disposable or reusable with electrode gel)
3. ECG machine
• Charged or plugged in to AC power
• Adequate paper to print
4. Cables
Confirm (i.e. double check) the correct the ECG cable is attached to each electrode.
− ECG cables are colour-coded and labelled with a position
Ensure lead wires are in straight lines and not crossing over each other (minimise interference on
the tracing)
Ensure the patient is lying still, comfortable and quiet
− This minimises non-cardiac muscle contraction.
Check the ECG for any artefacts and stable baseline
Record the ECG
− The tracing should be made in the following order
− I II III AVR AVL AVF V1 V2 V3 V4 V5 V6
Machine should be switched off, electrodes removed and the patient allowed to dress.
Documentation: The tracing should be marked with the following as soon as it is printed:
− Patient name, UR number and DOB
− Date and time recorded
− Any reports of chest pain or discomfort
− Patient position
− Medications taken for pain e.g. GTN
Examine the ECG tracing immediately
The patient should be informed of the findings of the ECG
Cleaning:
− Clean electrode placement sites on patient
− For reusable electrodes, clean away electrode gel with hot soapy water or 70% alcohol
wipes
− ECG cables – cleaned with hot soapy water or 70% alcohol wipes
Storage:
− ECG should be plugged into AC power when not in use
− Adequate paper should be stored in the ECG machine
Perform hand hygiene
Complications
Misplacement of leads causes false interpretations
Interference / confounding of results by tremors, shivering, speaking, movement, etc
Procedure – Venepuncture
Indications
To obtain a sample of venous blood for laboratory testing for monitoring and diagnostic purposes.
Venepuncture must be necessary - you can’t get the result in some other way
Bacteriological: blood cultures
Haematological: LFTs, glucose, cardiac enzymes, INR and PT, ESR, transfusion samples (storage for later use in
patients requiring blood transfusions)
Biochemical: Urea and electrolytes (U+Es), Ca, Mg, phosphate, etc
Cytological: FBE
Note Venesection: removal of blood as treatment of certain diseases
Site of Venepuncture
SITE: Selecting a suitable site and vein for venepuncture should include an assessment of:
Age of the patient
Condition of the veins (location, size) – see below
Patient’s condition
Patient preference / dominant hand
Damage to veins from previous venepuncture
First preference veins: large, visible, palpable, bouncy veins on non-dominant arm which refill when
released, fixed to surrounding
VEIN: Place index finger over the vein, press lightly and release. Assess the elasticity and rebound filling (sense
of touch more important than vision)
Contraindications:
Veins and sites to avoid whenever possible include:
Inflamed, bruised or painful veins
Broken skin, Cellulitis or Phlebitis at site
Hard, cord-like, fibrosed or thrombosed veins
Sclerosed veins ‐ these feel hard and bumpy
Veins in the lower extremities e.g. the feet, due to risk of embolism and thombophlebitis
Very small and non-palpable veins
Veins which have been repeatedly used
Venous obstruction and lymphangitis of the extremity
Administration of intravenous fluid distal to the proposed site:
If this is the only possible site: Cease IV infusion, wait 5-10 mins, conduct venepuncture distal to
cannulation site, ensure results are not diluted.
Limb being preserved for vascular surgery
Extremity on same side as a mastectomy
If patient has had a double mastectomy, DO NOT take blood from the arms!
Arterio‐venous fistula
Care in patients with a known coagulopathy (relative contraindication)
Procedure:
Collect equipment in a kidney dish (you have already performed hand hygiene and can access sterile stock)
Check the request slip to determine which blood tubes are necessary (check tube information found in
all clinical areas if necessary).
Where venepuncture is anticipated to be difficult, a 21G needle and 10 or 20mL syringe may be used
Ensure the sharps bin is within arm’s reach.
Put on PPE (glasses +/- gown)
Wash hands using an antiseptic soap solution and water
Position the patient – ensure the patient is comfortable in a seated or reclined position with arm at or below
heart level
If history of fainting, perform supine (lie them down)
Topical subcutaneous anaesthetic is not recommended but may be used for patients with anxiety
Place a bluey under the arm
Select appropriate vein/site for venepuncture
Consider handedness; avoid:, legs, previous IV, bruises
Absolute contraindications: fistula, mastectomy, skin issues, infections, burns damaged veins
Feel vein: it should feel round, firm, bouncy, elastic and have rebound filling
Apply the tourniquet 10cm above the chosen site
Tighten to prevent venous return. You should be able to slip 1 finger
under the tourniquet. Do not occlude arterial circulation! If a vein is very mobile or skin
Clean skin with an alcohol swab. Allow 30s to dry! tissue is frail, a 21‐gauge
Prepare vacuatainer system butterfly needle will assist
with needle stability
Remove the needle cap and place needle into the holder
In bacterial bottles, disinfect bung (i.e. the rubber stopper on top of
bottle)
Fix the vein: place the thumb parallel to the vein; draw the skin taut immediately
below (distally) to the site
Warn the patient of a sharp scratch
Insert the needle bevel-up at a 15º angle directly in line with the
course of the vein (See Figure 2).
Only 2 puncture attempts should be undertaken, if unsuccessful request
assistance (state that you have made two failed attempts and would then
request assistance)
Insert the blood tube into the Vacutainer® holder and allow filling until the vacuum is exhausted. Repeat for
each blood tube required (the tourniquet helps encourage blood flow)
Loosen the tourniquet
Place a cotton ball over the needle insertion site and gently remove the needle.
Dispose immediately, NEVER recap a needle.
Apply pressure over the venepuncture site until bleeding ceases (usually 1‐
2 minutes). You may ask the patient to apply firm pressure if they are able
Apply cotton ball/tape.
Invert the tubes to ensure blood mixes with heparin
Label the tubes and fill out the pathology request form
All blood tubes must be labelled at the patient’s bedside
Full name, DOB and UR are minimum on bottle labels
Document the date and time on the pathology request and sign your name
Provide contact number in case of positive culture
Put the specimens in the plastic specimen bag with the request form in the front pocket of the bag.
Specimens are sent to the pathology laboratory.
Make sure patient is feeling alright: in pain, anxious or light headed?
Wash hands
Complications
Pain
Haematoma loosen tourniquet, remove needle, apply pressure
Syncope/fainting
Local irritation
Infection (local cellulitis or infections)
Injury to vessels, nerves, ligaments or tendons
Thrombosis (blood clot)
Needle stick injury – Hep B and C, HIV, HTLV1, syphilis flush with water, post-exposure prophylaxis
Haemolysis of blood in tube
may affect results e.g. potassium
Inadequate amount of blood to fill tubes use paediatric tubes in difficult venepuncture
Prolonged tourniquet
Significant increases can be found in total protein, aspartate aminotransferase (AST), total lipids,
cholesterol & iron.
Affects packed cell volume and other cellular elements
Filling Order:
Blood tubes must be filled in the following order:
No additive tubes (eg. Blood cultures)
• Aerobic and anaerobic bottles – need to
sample in both
• Aerobic is followed by anaerobic
Serum tubes (without gel- citrate and ACD)
Serum tubes (with gel)
Coagulation tubes (exact amount stipulated on tube
is required)
Tubes with other additives (Heparin, EDTA, Glucose,
ESR)
• ethylenediaminetetra-acetic acid (EDTA)
contains K+
Reporting
Positive results may be reported by phone
Antibiotic cover until specific sensitivity is found.
Protocols
Troubleshooting
Can’t feel a distended vein
A) Ask the patient to clench and unclench a fist a few times and/or B) Place a covered heat pack on the
venepuncture site or place the arm or hand in warm water for 5‐10 minutes
No blood flows into blood tube
Confirm needle in correct position
Advanced needle forward
Needle is advanced through the vein wall
Needle needs to be pulled back into vein
Bevel of the needle is at an incorrect angle
Angle of the needle needs to be adjusted
The vein has collapsed
Slightly tighten tourniquet and ask the patient to gently clench and unclench the fist on that side.
Haematoma formation
A hematoma forms under the skin adjacent to the puncture site
Release the tourniquet immediately and withdraw the needle. Apply firm pressure.
Procedure – Injections
From Student Guidelines
Indications
No oral form of drug available (vaccinations)
Faster onset of action
Higher doses tolerated systemically
Patient is ‘nil orally’
Medications altered during ingestion i.e. insulin
Medications needed for steady or long-term infusion
Contraindications
Allergies
Issue with patient or medication confirmation
Expired medication
Patient declines
Equipment
1. Gloves 6. Syringe
2. Kidney dish 7. Medication
3. Sharps container 8. Injecting needle
4. Alcohol swab 9. Cotton wool
5. Drawing up needle 10. Medication chart
A) Intramuscular
2-5mls, 23G-25G long 25mm needle
Depends on muscle bulk, age and site, choose smallest possibl
If 25G inject very slowly
Delivers: Vaccines, analgesia, adrenaline, anti-emetics, antibiotics, antipsychotics (rapid systemic action,
large drug doses)
Sites:
Deltoid (2 fingers below acromion, centre of arm). Hep B, tetanus (vaccines)
Ventrogluteal (index on ASIS, middle on iliac crest, between v’s of fingers)
Dorsogluteal (superior-lateral quadrant of buttocks) safer than gluteal
Vastus lateralis (anterolateral thigh, hand’s breadth down from greater trochanter and a hand’s
breadth from the knee): preferred for children <12months as larger than the arm
Deltoid and ventrogluteal sites are the preferred sites for adults.
Deltoid: good for bedbound patients (better circulation) and small injections
Gluteal: good for thin patients, patients with muscle wasting
Volumes
Up to 5mls in the thigh (average adult)
2mls in the thigh (small adult or child)
Up to 2mls in the arm
Procedure
The limb should be positioned to rest the specific muscle. Ask the patient to RELAX
Assess the thickness of the subcutaneous layer
Pull the skin to flatten the subcutaneous layer (also prevents back-leak of medication)
Insert needle at 90° (if patient or muscle is small, grasp the muscle and inject at 45°)
Aspirate to check for blood. If you aspirate blood, remove and get a new syringe of medication and
a new needle
SLOWLY inject medication over 5 seconds. There is not a lot of pain when you insert the needle
into the muscles but there will be pain from tissue distension as you inject.
B) Subcutaneous
Less than 1ml, 25G shorter 16mm needle
Delivers: Insulin, heparin, clexane (low molecular weight heparin) and some immunisations. (for frequent
injections and slow, controlled absorption)
Procedure:
Pinch a wad of skin at a fatty site
Place needle on skin for 3 seconds at 45°-90°
Push needle through skin
Release pinched skin
Hold barrel with dominant hand and aspirate needle to check for blood
If you aspirate blood, remove and get a new syringe of medication and a new needle
Inject medication
C) Intradermal
Less than 0.1mls, 25G shorter 16mm needle
Delivers: allergy testing, tuberculin testing, or local anaesthetics.
Procedure:
Use an alcohol swab to cleanse the skin. This is not necessary if the skin is clean
Hold skin taught with index and thumb of non-dominant hand
Insert needle bevel up at 10-15°
Bevel should only just be in skin, no further
No need to aspirate (there are no significant blood vessels in the area)
Inject until bleb/wheel appears
Complications
Medication error Ecchymosis (bruising – esp with
Pain anticoagulants)
Local irritation Injury to nerves (esp. sciatic) and vessels
Infection (local and systemic) Scar tissue (esp in diabetics)
Haematoma Anaphylaxis/allergic reaction
Procedure – ABGs
From Student Guidelines and two videos on DSO
Indications
Establish changes in acid-base homeostasis
To diagnose acidosis or alkalosis
Suspicion of hypoxemia and hyper(hypo)capnia
Establish severity of condition e.g. respiratory failure, metabolic acidosis in sepsis
Diagnosis e.g. respiratory failure
Manage ICU patients and guide therapy (e.g. o2 administration, ventilation, alkali treatment)
Monitor patients during cardiopulmonary surgery, cardiopulmonary exercise testing or sleep
studies
Determine prognosis of critically ill patients
Contraindications
Bleeding tendency e.g. coagulation AV fistula, synthetic graft (femoral
therapy artery)
Overlying infection or burn at site Same side as mastectomy
Absent collateral circulation (Allen’s test) Severe atherosclerosis at site
Reynaud’s disease
Equipment
1. Gloves 7. Pre-package ABG syringe with heparin
2. Gown ball, a 22G needle and cap for transport
3. Protective eye wear (face shield, glasses) 8. 2 sterile gauze swabs / cotton wool
4. Specimen bag with ice (gives 1 hr for 9. Tape
reading) 10. Patient’s label
5. Sharps bin 11. Patient’s request slip
6. Antiseptic swab
Complications
Painful
Bleeding (haematoma)
Bruising
Arterial occlusion – thrombus /dissection
Infection (local or septic)
Embolism
Nerve damage
Procedure - Nebuliser, Oximetry and Oxygen
To Do!
Procedure - Asthma Education
Explanation of Asthma
Asthma results from hypersensitivity of the lungs to harmless triggers in the air, such as allergens, pollens,
smoke, cold air and many other things.
Often worse at night or early morning, may be seasonal, and brought on by triggers (allergic & irritant).
When people who are affected breathe in a trigger, the airways:
start to spasm (smooth muscle constriction)
become inflamed and swell (oedema of bronchial mucosa)
and start secreting mucus (secretions of mucous glands)
All of these effects cause the airways to become narrow, making it difficult to get air in and out. This is what
we call an asthma attack or an acute episode
Its characterised by cough, wheeze, and difficulty breathing (only 1 or all 3).
However, asthma is considered a reversible obstructive airway disease, because with the proper prevention
and treatment, we can relax the airways and
A "normal" peak flow rate is based on a person's age, height, sex and race. A standardized "normal" may be
obtained from a chart comparing the patient with a population without breathing problems.
Approximation is: PEFR (L/min) = [Height (cm) - 80] x 5:
Indications for Short-term monitoring (2-8 weeks)
To help to identify asthma triggers
To monitor response to a new treatment or a change in dose (up or down)
To calculate the "trigger point" for a written asthma action plan.
Indications for Long-term monitoring (daily)
For people with asthma who have frequent exacerbations (flare-ups)
For people with moderate to severe asthma who have little warning of exacerbations
For people with asthma who are anxious or tend to over-treat minor events
For people with asthma who are ‘poor perceivers' of airway narrowing.
Procedure – Digital Rectal Exam
From Student Guidelines
Indications Contraindications
Screening for rectal or prostate cancer, or Refer to a specialist when:
prostate enlargement Patient declines examination (absolute)
Diagnosis of rectal abnormalities Anal fissures present or suspected (painful,
As part of a complete physical examination may further open)
in men Prolapsed and thrombosed haemorrhoids
Patient request a DRE and PSA (discuss first) (painful)
Following an abdominal exam Paediatric patients
Rectal bleeding (e.g. in stool)(haemorrhoids, Active inflammation of the bowel: CD, UC,
cancer) diverticulitis
Anal discomfort (pain, itching, burning, Recent surgery, trauma, radiotherapy in the
stinging, fissures, haemorrhoids) area
Change in bowel function (colorectal Immunocompromised (e.g. chemotherapy)
carcinoma, +faecal occult) or at risk of increased bleeding
Change in urinary function (BPH – hesitancy, Recent history of abuse
FUN, poor stream, dribbling) Spinal patients: may cause autonomic
Faecal incontinence (anal sphincter tone, dysreflexia
prostate, chronic constipation causing Recent AMI
overflow incontinence) Valvular heart disease, prosthetic valves:
Check anal tone (spinal cord compression) may require antibiotic prophylaxis.
General symptoms of cancer (LOW, malaise) Latex allergy
Following a GU/sexual history
As part of a gynaecological exam in women
Equipment
1. Gloves (2 pairs)
2. Lubricant
3. Bluey
4. Tissues
Examination
Patient preparation: left lateral position (on left side, facing wall with knees drawn up towards chest)
If the patient has difficulty climbing onto the table, examine standing and leaning over the couch
Put on gloves (ensure fingernails are short)
Place bluey under patient’s buttocks
Consistently communicate with the patient about what you’re doing
Monitor the patient’s responses and consistently ask if you are causing any discomfort
Use non-dominant hand to lift the patient’s upper (right) buttocks.
Inspect the anus and perianal area
Thrombosed external haemorrhoids (piles)
Skin Tags
Rectal Prolapse
Anal Fissure
Fistula-in-ano
Condylomata Acuminata (anal warts)
Carcinoma of the anus
Pruritus ani
Excoriation
Ask the patient to bear down to check for:
Haemorroids
Prolapse
Anal incontinence
Lubricate the tip of your index finger of your dominant hand
Reassure the patient that they will feel uncomfortable (like they need to pass a bowel movement) but this
is normal and they will not actually pass anything.
Draw the patient’s right buttock up with the left hand and place the pad of the right index finger against the
anus, with the finger pointing in the direction of the patient’s front.
Ask the patient to breathe deeply through their mouth (to assist reflex sphincter relaxation).
Wait for reflex sphincter relaxation, and gently press on the anus until the anal sphincter gives and gently
insert the finger into the rectum, pointing the finger now in the direction of the patient’s head.
Do not proceed if insertion is difficult. This may be due merely to apprehension or a tight
sphincter. A tight sphincter can be due to anal stricture, fibrosis of anal muscles and anal
carcinoma. You will cause resistance and severe pain if you force the finger in.
If due to apprehension, when you feel resistance on advancing your finger, stop moving forward,
hold your finger in place and wait, with the patient breathing slowly, until the sphincter is felt to
relax, then advance.
If the patient has an anal fissure, the anal sphincter goes into spasm which cannot be overcome by
relaxation, patience or gentleness. Search the anal area for a tear. A DRE can sometimes only be
performed under a general anaesthetic
Examine the posterior wall: Use the pulp of the index finger to sweep around the rectal wall from 2
(relative to the patient’s spine) clockwise to 10 o’clock at 3 different levels
The walls of the rectum should be smooth and uninterrupted. Feel for masses (polyps, cancers)
and ulcers.
Each level feels 1-2cm. This way, the first 7-8cm of rectal wall should be felt.
Posteriorly, you are able to feel the hollow of the sacrum and the coccyx
Examination of the anterior wall: clockwise from 10 o’clock (relative to the patient’s spine) to 2 o’clock at 3
different levels. Kneel down if necessary.
In the male, this is where you will feel the prostate. When you palpate the prostate, the patient
may feel that they are going to pass urine, but reassure them that they will not.
CONSITENCY: A rubbery, smooth, firm, bi-lobed mass with a groove (median sulcus) running down
the centre.
MOBILITY: The lobes should be symmetrical and smooth, with no nodules or irregularities.
SIZE: With age, the prostate becomes firmer, increases in size, and loses the groove.
In the female, the cervix can usually be felt through the anterior rectal wall, feeling like a smooth
lump
Finally, return your hand to the initial position and ask the patient to bear down so that, when you sweep
with your examining finger, you can feel an extra centimetre of the rectal walls
Note any masses or ulcers
Asses the consistency, mobility and size of the prostate (or cervix)
Note the consistency of the rectal contents (It is not uncommon to feel faeces in the rectum)
Ask the patient to clench your finger to assess external sphincter tone
The normal muscle tone should grip the finger firmly.
Relaxed or weakened anal sphincter may be due to torn or lacerated anal muscles or atony of the
muscles from neurological lesions.
Ask the patient to relax and breathe deeply.
Remove the finger
Look at the glove for finger for colour, blood, mucus or pus. Save it for faecal occult blood testing if
indicated.
The gland should be bi-lobed, soft and the surface should be smooth.
If pathological, the gland can be enlarged, firm, nodular or craggy.
Investigations
PSA (in combination with DRE can indicate the risk of prostate cancer) – needs to be done before the DRE
Faecal occult blood test
Referral to urologist or gastroenterologist (esp if a mass is felt)
Patient Education
Complications
Patient feels uncomfortable or assaulted (legal ramifications) due to inadequate information, poor consent
process, or perceived unnecessary or vigorous contact – communicate at all times!
Exacerbation of pain or discomfort with the procedure or with palpation
Anal trauma
Re-opening of an anal fissure
Tenesmus (urge to defacate)
Considerations for this sensitive area
Abnormal Findings
Sphincter: Loss of tone, patulous: ?Cauda equina syndrome
Contents: Hard, impacted, foreign body present
Rectal wall: Pelvic masses in women
Mucous membrane: irregular, mass present (cancer)
Prostate (normally 2.5cm long)
Smooth, large , firm and non-tender (Benign enlargement)
Hard, irregular nodule or fixed hard mass (Cancer, chronic prostatitis)
Large, boggy and tender (Acute prostatitis)
Stools:
Bloody: (Haemorrhoids, bleeding rectal lesion)
Black: (Upper GI bleed, iron, some antacids)
Procedure - Urinalysis
From Student Guidelines and tute prep
Indications Pregnancy
Genitourinary symptoms As part of a general examination
Renal symptoms Screening or diagnosis of pathology
Gastrointestinal history
Diabetes history Contraindications: none
Equipment
1. Gloves
2. Yellow-top sterile urinary pathology specimen container
3. Urinalysis dipstick strip
4. Watch
5. If necessary:
Urine pregnancy test (beta HCG)
Procedure
Check the strips you are about to test for their use-by date and the correct colour for the untested strip
Strips left exposed to the atmosphere may have discoloured and be inaccurate.
Check the time different parts of the strip are to be red (usually 30s and 1min)
Cleanse the area around the urinary opening with clean water
Instruct the patient on sample collection (preferably first specimen in the morning and mid-stream in case
you need to send the specimen off for further testing):
Midstream: Clean the tip of the penis or vulval area with water or sterile towelette. Retract the foreskin or part
the labia with your fingers and hold the open sterile container with the other. Do not touch inside the jar. Let
the first part of the urine stream go into the toilet. Collect the middle part of the stream in the sterile jar.
Return the sample for testing immediately or put it in the fridge if there will be a delay.
Put on gloves
Assess the urine’s COLOUR, TRANSPARANCY and SMELL
Normal fresh urine is clear, pale to dark yellow or amber in colour and clear.
Normally the odour is ‘urinoid’.
Presence of absence of any visible strands, crystals, blood clots
Note the time
Remove a dipstick strip, being sure to re-seal the jar
Dip the strip in to the urine
If performing a beta HCG, follow the directions for the particular test kit you are using (times and
procedures vary from kit to kit)
At the appropriate time, compare the colour change on each segment of the strip to the colour chart
provided (usually on the side of the container)
Different parts of the strip are read at different times (some at 30sec, some at 1 minute)
The dipstick should be ‘read’ at the allotted times – often if the stick is left for an extended period
of time, some of the test blocks will be positive. This is not accurate after the designated time.
At the appropriate time, read the urine BHCG test.
Re-seal the urine sample
Dispose of the dipstick
Document findings and interpret results:
pH: Low (acidic) = acidosis, high protein diet, acidic fruits, high (alkaline) = alkalosis, vegetarian diet
Specific gravity (urine concentration): Low = hydration, inability to concentrate (generalised renal
impairment or nephrogenic diabetes insipidus); High: dehydration
Protein: nephrotic syndrome, glomerular nephritis, renovascular, glomerular or tubulo-interstitial
renal disease, overflow of abnormal proteins in diseases such as multiple myeloma.
Blood: menstrual, UTI, nephritic syndrome, renal stones, renal carcinoma, glomerular nephritis
Nitrites: bacteria (a negative test doesn’t rule out UTI because not all produce nitrites and some
take time to develop)
Leukocytes(pyuria): whole or lysed WBCs (if negative, infection is unlikely, however patients can still
have a UTI without pyuria), contamination (vagina, foreski), URTI or pneumonia,
Glucose: diabetes mellitus,
Ketones: DKA or starvation
Bile, bilirubin and urobilinogen: conjugated bilirubin = liver disease, bile duct obstruction, high
urobilinogen = haemolytic disease or hepatocellular disease
Investigations
Urine microscopy, culture and sensitivity (MCS) if UTI suspected to confirm
Determines the responsible organism and its antibiotic sensitivities, which is important if the infection does not
respond to treatment
Complications
False-positive readings
Procedure – Nasogastric Tube
From Student Guidelines, Tute Prep Answers and Associated Video
Indications
To introduce fluids, nutritional support and medication administration, radioactive materials or
activated charcoal into the stomach (cases of anorexia, dehydration in infants, drug overdose, etc)
To decompress the gastrointestinal tract (GIT), by aspiration of gastric contents (fluid, air, blood).
E.g. Bowel obstruction and associated vomiting
E.g. Ileus (common after surgery) and associated vomiting
E.g. Severe pancreatitis and associated vomiting and ileus
To assist in the clinical diagnosis through analysis of substances found in gastric contents.
To removal gastric contents to facilitate endoscopic visualisation of the mucosa
Contraindications
Head trauma, maxillofacial injury, facial traumaor anterior fossa skull fracture. There is the risk of
intracranial penetration by inserting a NG tube blindly through the nose. This has the potential of
passing through the cribriform plate, thus causing penetration of the brain by the NGT.
A nostril with any type of obstruction (previous broken nose with limited space to pass NGT), polyps
etc.
History of oesophageal stricture, oesophageal varices, alkali ingestion, as these pose a risk of
oesophageal perforation.
Comatose patients and unconscious patients have the potential of vomiting during NGT insertion.
Intubation/airway protection is the first priority and the airway must be secured prior to NGT
insertion. This is due to the risk of aspiration if NGT is inserted, triggering gag reflex and vomiting,
which can result in aspiration if the patient is unable to protect their airway (loss of coughing reflex).
Caution should be utilized when passing a NG tube in a patient with suspected cervical spine injury.
Manual stabilization of the head is required during the procedure to prevent further Cx injury.
Excessive manipulation or movement by the patient during placement including coughing or gagging
may potentiate cervical injury.
Orogastric tubes are not as well tolerated by conscious patients but are associated with less
complications, for example, sinusitis and nasal erosion and are suitable for intubated or unconscious
patients
Equipment
1. Gloves 9. Cup of water with straw
2. Gown 10. Catheter-tip (Toomey) syringe
3. Protective eye wear (face shield or glasses) 11. Stethoscope
4. Bluey 12. pH stick
5. Kidney dish/basin 13. Non-allergenic tape
6. Topical anaesthetic 14. Safety pin
7. NG tube (appropriate size) 15. Drainage bag if required
8. Water soluble lubricant
Procedure:
Ensure correct patient, privacy and that informed consent has been obtained
Collect equipment (hands have been washed, can access sterile stock)
Patient preparation:
If patient awake: sit patient in an upright position
If unconscious: intubate first and lie patient in the left lying position if possible
Ask patient if they’ve ever had any nasal polyps or issues with their oesophagus
Determine which nostril should be used
Inspect the nostrils for polyps
Have the patient blow through one nostril at a time to assess their patency
Place bluey on patient’s chest
Provide the patient with a basin/kidney dish to minimise contact with aspirated gastric content.
Apply topic anaesthetic to the nasal cavity and/or the oral cavity
Determine NGT length
First, measure distance from the tip of the nose to the lobe of the ear
From the lobe of the ear, measure to the xiphisternum.
Mark the summative length with a pen or piece of tape.
Insert the NG tube
Position patient upright in the sniffing position – neck flexed, head extended
Lubricate the first 5 cm of the NG tube liberally.
Gently insert tube along floor of the nose in a posterior direction parallel to the floor
When it is evident that the NGT is in the oropharynx (reached the back of the throat) the
patient will start to gag.
At this time encourage the patient to facilitate the tube passage by swallowing. Sips of water
will assist in swallowing (if they can’t drink, ask patient to mimic the action of swallowing).
Continue to insert tube, trying to coordinate tube advancement with swallowing
Once the tube is past the larynx, guide it to the predetermined length.
Ensure that the patient is not in respiratory distress
Ask if the patient is okay, can they breath and speak. If they cannot, remove the tube immediately
Confirm the tube is in the correct position with the following techniques
1) Push 30cc/ml of air down the NGT whilst listening over epigastrium with a stethoscope. If
successful, you should be able to hear the air entering the stomach with “a whooshing”
sound.
2) Use the syringe to then aspirate gastric content. Test it on litmus paper (acidic)
3) If unsure, place the open end of the NGT in to a cup of water. Persistent bubbling may
indicate the NGT has passed through the larynx.
4) If any substances will be added, order a chest XRay to confirm position. The radio-opaque
tip of the NGT should travel below and sit below the diaphragm in the stomach area.
If unable to positively confirm the NGT has been placed in the correct position remove and
reattempt
Once correct position confirmed, secure the NGT
Ensure the skin of the nose is clean.
Take a strip of tape and tear it horizontally for one half of its length
Placing the fill end of tape from the bridge to the tip of the nose and the two tails wrapped in
opposite directions around the tube itself.
Tincture of benzoin can help keep the tapes secure to the nose if patient sweats a lot.
Clamp or connect the NG tube as desired.
To deter the NG tube from dangling and possible dislodgment:
Curve and tape the tube to the patient’s cheek to prevent unnecessary tugging on the nostrils.
Attach the tube to the patient’s gown. (Do not tape to the patient’s forehead as this will put
pressure on the nares.)
Wrap a small piece of tape around the tube near the connection creating a tab.
Loop a rubber band in a slip knot near the connection and pin to the patient’s gown.
Give clear instructions written and verbal about suction, aspiration and recording of observations
Complications
Nasal irritation, sinusitis, epistaxis, rhinorrhoea, sore throat, skin erosion or oesophagotracheal fistula.
Oesophageal perforation, trachea-oesophageal fistula
Tracheal/bronchial/airway intubation remove tube immediately
Respiratory difficulty and distress
Hypoxia, cyanosis, or respiratory arrest due to accidental tracheal intubation.
Aspiration pneumonia secondary to vomiting, aspiration or introduction of agents into lungs
Pneumothorax
Note: These may well be less marked if the patient has decreased conscious state as they may
not cough in response to tracheal intubation.
Intracranial placement e.g. through cribriform plate (look for change in consciousness, neurological
signs)
Procedure - Pelvic Exam and Pap Smear
From Student Guidelines, videos on DSO
Indications Contraindications
Pap smear or other swab Most require consideration of the patient’s context
Pregnancy and whether to perform carefully or to not perform
GU symptoms Patient declines examination (absolute)
STI symptoms (dysuria, discharge) Vaginismus
Following a sexual history Female circumcision (some forms)
Screening in women who are sexual active or Pain (relative)
who have a new sexual partner Paediatric case
Past sexual abuse
Equipment
1. Gloves Pencil
Use nitrile gloves if allergic to latex Spatula
2. Bluey Cytobrush
3. Small pillow (to elevate pelvis) Slide
4. Light Spray
5. Lubricant Container
6. Speculum (of correct size) Liquid preparation vial (Thinprep)
7. Sponge older forceps 11. Tissues
8. Gauze squares 12. Sanitary pad (if bleeding occurs)
9. Swabs (if necessary)
10. Smear test (if necessary)
Examination
Patient preparation: Supine at 30° with frog legs (pull heels together towards buttocks and flop knees
out)
This allows the examiner to maintain eye contact and relax abdomen
Alternatively, bend knees with feet 20cm.
Put on gloves
Place bluey under patient’s buttocks
Consistently communicate with the patient about what you’re doing
Monitor the patient’s responses and consistently ask if you are causing any discomfort
Examination C) Bimanual Examination of the Uterus, Ovaries and Tubes and the inguinal lymph nodes
Stand at the patient’s right side
Lubricate the index and middle finger of your dominant hand
Use the finger and thumb of your other non-dominant hand to separate the labia
Enter with the index and middle finger on a vertical axis, tucking the ring and little fingers into your
palm.
Keep any pressure posteriorly, as pressure anteriorly on the urethra is very uncomfortable.
Once you have entered, turn the hand clockwise so that the fingers are facing palm-up on the
horizontal axis.
Attempt to feel the cervix: With the internal hand, feel the cervix above your fingers and push up on
(”tip”) the cervix. When you push on the cervix, it moves the anteverted uterus (66% of women) and
you can feel it between your hands.
Once you find it, place your left hand on the patient’s abdomen at the suprapubic region (ensure it’s
not lubricated) and try to feel the uterus tip your external hand.
You cannot always feel the uterus. It depends on the size of the patient (more difficult in
obese women), the tightness of the abdominal muscles, the mobility of the pelvic organs, the
angle of the uterus (retroverted uteri not felt as easily this way) and the size of the uterus.
In a non-pregnant woman, it should be the size of a pear.
If you feel it, it suggests enlargement due to pregnancy or fibrosis.
To feel a retroverted uterus, slide your fingers behind the cervix so you’re in the posterior
fornix and press the abdominal wall.
Attempt to feel the adnexae (collective name for ovaries and tubes): move the vaginal fingers into
the right fornix and move the abdominal hand over to the patient’s right iliac fossa. Again, gently try
to tip the ovaries.
The ovary is not usually felt between the hands unless it is enlarged, or the patient is very
slim.
Abnormalities in the adnexae: ovarian mass, PCOS, malignancy endometrioma, tubo-
ovarian abscess, fallopian mass (ectopic, hydrosalpinx, fibroma), non-gynaecological
problems (appendix, diverticular abscess)
Repeat in the left adnexa.
Remove the hand and \check the glove for the presence of blood or discharge.
Offer some tissues to the patient so that she can wipe herself
Check the inguinal lymph nodes.
Investigations
Pap smear (as above): cells are transferred directly to slide for viewing
Liquid-based cytology (as above): sample cells are placed in liquid solution for transport to the lab,
whereby they are extracted for cytologic analysis.
Vaginal swabs
Urinalysis (esp for chlamydia and gonorrhoea if they have discharge)
Urine PCR (screening for STIs)
Patient Education
Pap smear testing is recommended in Australia every 2 years for every woman who has ever been
sexually active from the age of 18 until 70. If sexual activity starts after 18, Pap smears should
commence 2 years after sexual activity. ‘Sexual activity’ includes lesbian sexual activity.
Pelvic examination is an important part of assessment of a pregnant woman
Complications
Patient feels uncomfortable or assaulted (legal ramifications) due to inadequate information, poor
consent process, or perceived unnecessary or vigorous contact – communicate at all times!
Exacerbation of pain or discomfort with the procedure or with palpation
Procedure – IV Cannulation
From Student Guidelines
Indications (delivery)
Administration of drug therapy (especially low-bioavailable drugs or when patient can’t eat)
Fluid replacement and maintaining fluid-electrolyte balance
Blood transfusion or transfusion of blood products
Unconscious patient (resuscitation)
Contraindications
cubital fossa veins
joint areas e.g. wrist, knee – as for cubital fossa veins (bending will kink the tube)
veins of the legs & feet in adults ( increased risk of DVT and phlebitis)
previous intravenous sites (e.g. for venepuncture)
bruised areas
the patient’s dominant arm, if possible
never use the following sites except in an immediate life threatening situation
a fistula or arteriovenous shunt
arm on the side of a mastectomy, or axillary resection (usually performed for breast
cancer)
scarred or injured areas e.g. burns
veins damaged by infiltration or phlebitis
infected areas ( sepsis)
areas infiltrated by dermatological conditions
sclerotic or thrombosed veins
Equipment
1. Gloves Syringe (5 ml)
2. Apron Non‐bevelled drawing up needle
3. Glasses Sterile sodium chloride (NaCLl)
4. Sharps container 0.9% solution (saline)
5. ‘Bluey’ 12. Transparent bi-occlusive dressing
6. Tourniquet 13. Micropore® silk tape
7. Antiseptic solution 14. Scissors
0.5 ‐ 1% Chlorhexidine with 70% 15. Additional
isopropyl alcohol EMLA Local anaesthetic (e.g. 1%
Use an aqueous based alternative lignocaine) or anaesthetic cream
if there is a known allergy to 3‐way tap or triflow
alcohol Short extension tube
8. IV cannula (correct length/diameter) Blood collection tubes and
9. Cannula ‘bung’ or valve ‘vacutainer’ adaptor
10. Gauze Giving set (if setting up an IV
11. Flush infusion)
Prescribed IV fluid Splint and bandage (for children)
Procedure:
Note: student guidelines say to wash hands and put on gloves, before choosing the vein and applying
tourniquet.
Collect equipment (hand hygiene has already been performed and you may access sterile stock)
Ensure the sharps bin is within arm’s reach.
Put on PPE – glasses +/- gown
Wash hands
Position the patient: ensure the patient is comfortable with the arm resting on a pillow
Place a bluey under the arm
Apply the tourniquet
Place arm dependent if increased venous filling is necessary
Select a vein:
Consider handedness; avoid: joints, legs, previous IV, bruises
Absolute contraindications: fistula, mastectomy, skin issues, infections, burns damaged veins
Feel vein: it should feel round, firm, bouncy, elastic and have rebound filling
Put non-sterile gloves on
Clean skin with antiseptic solution. Using a circular motion working from inside out for approximately
5cms, swab skin. Allow 30s to dry!
chlorhexidine in alcohol or Persist Plus swab stick for skin disinfection
Use an aqueous based alternative if there is a known allergy to alcohol
Clip hair if necessary.
While waiting, use the syringe to draw up the saline flush. Replace into the syringe’s sterile packet.
Inspect the cannula for any obvious defects
Rotate the cannula on the needle to release it
Fix the vein by holding the skin taught with other hand
With the cannula bevel-up and pointing in the direction of the blood flow (up the arm), insert the
cannula at a 20-30°
Stop when blood is seen in the flashback chamber.
Lower the angle of insertion almost to skin level.
Advance the cannula itself a few mms off the needle into the vein, and then stop again.
Do not advance against resistance.
Lower the cannula until it is almost flush with the skin and gradually advance the cannula until it has
entered the vein to the hub
lf blood tests are required, attach Vacutainer System@ to end of cannula, release your non-dominant
hand and insert tubes into Vacutainer System@ until required quantity of blood acquired
Release the tourniquet
Apply fingertip pressure at the distal end of the cannula tip to prevent flow of blood onto the patient
and sheet
Hold the introducer and discard it immediately into an appropriate sharps container.
Attach a bung /extension tubing/IV giving set (as required)
Flush the cannula and line with 5 mls Normal Saline (prevents clotting).
Cover skin and cannula hub with transparent dressing.
Write the insertion date/time sticker on transparent dressing
Secure further as required e.g. tape the tubing to the skin, splint arm, bandage etc
Document the procedure in the relevant medical record (date, time, site and operator)
Cannula should be removed within 48hrs to minimise risk of infection. This is your
responsibility.
Ensure patient is comfortable. Clean up any splashes. Check daily for infections.
Wash hands
Cannula should be removed within 48hrs to minimise risk of infection. This is your responsibility.
Complications
Leaving the cannula in for more than 48hrs
Check daily for infections.
Cannula should be removed within 48hrs to minimise risk of infection. This is your
responsibility.
Remove immediately if they are no longer needed for treatment
Thrombophlebitis (inflammation of the vein associated with thrombosis/clot)
Infiltration (extravasation of fluid into the tissues either because of damage to the vein or
dislodgement of the cannula)
Haematoma (a localized collection of blood outside the blood vessels, usually in the tissue)
Nerve, tendon or ligament damage
Infection
Local cellulitis
Systemic Infection (sepsis)
Catheter‐related Bloodstream Infection (CRBSI)
Infective Endocarditis (sometimes requiring valve replacement)
Osteomyelitis (metastatic infection to bone)
Sepsis
Local reactions/allergy
Emboli – air, catheter fragment
DEATH
Procedure – Suturing
From Student Guidelines
Indications
Almost all types of wounds
Most traumatic wounds
Stabilisation of external lines and tubes (central venous lines, chest tubes, surgical drains)
Contraindications
Unqualified to suture
Other injuries that have priority (e.g. threat to airway, internal organ damage with penetrating trauma)
Underlying structures requiring attention – nerves, tendons, named arteries, joint capsules internal organs,
compound fractures
Contamination requiring formal cleaning in operating theatre
Large skin defects – where skin needed for primary closure has been lost (e.g. motorbike accident) and
grafting will be required
Extended interval between injury and repair – there is a maximum time (“golden period” over which a
wound may be safely closed
Allergy to local anaesthetic/latex
Adrenaline should not be injected near end-arteries such as in fingers, toes, nose or penis
Alternative Techniques
Wound staples are often used on lacerations of the scalp or extremities and offer the advantage of rapid placement
but do not allow the meticulous wound-edge approximation afforded by suturing.
Tissue adhesives and wound tapes ( steri-trips, Dermabond) are often used for smaller or superficial lacerations but
are not suitable alone for lacerations subject to significant tension.
Equipment
Many hospitals stock pre-packaged suture trays that contain most of the necessary equipment
1. Light
2. ‘Bluey’ (to protect work surface/patient clothing)
3. Glasses
4. Gown +/- mask if risk of splatter
5. Gloves (non- powdered)
6. Sharps container
7. Skin cleansing agent (chlorhexidine, providence iodine)
8. Sterile gauze
9. Drawing up needle
10. 25G needle (anaesthetic)
11. Local anaesthetic (+/- adrenaline 5mcg/ml)
12. 5- or 10-mL syringe
13. Saline (irrigation)
14. 30- to 60-mL syringe with splash guard for irrigation
15. Sterile bowl
16. Sterile drape
17. Suturing
Suture needle and material
Needle holder
Toothed forceps (Adson Brown)
Dissecting forceps
Scalpel (with blade and handle)
Suture scissors
18. Dressing to go over closed wound
Procedure: (LACERATE)
Look, Anaesthetic, Cleaning, Equipment, Repair, Assess results and complications, Tetanus status and Education
Assess whether suturing should be performed (see above)
Position patient: supine and at level for suturing either standing or sitting
Perform and document a thorough neurovascular and functional examination of structures distal to the
wound
Position light
Put on PPE – glasses, gown and gloves
Prepare equipment
Cover the wound with cleansing disinfectant solution (chlorhexidine, Betadine).
Give this time to be effective (2-5 minutes)
Prepare anaesthetic
Use a drawing up needle to draw up anaesthetic lignocaine (‘lidocaine’) in a syringe
Put a 25G needle onto the syringe
Inject local anaesthetic:
Puncture the skin superficially into the dermis at a 45° angle
Aspirate back on the syringe to check that you are not in a blood vessel
Inject 1–2 ml of anaethetic). A small "bleb" will appear, allowing you to push the needle in further
and deeper.
Continue to inject the local anaesthetic along the line of the cut or where you will suture,
aspirating as you go
Allow the anaesthetic time to work
Scrub a wide area of skin surface surrounding the wound with an antiseptic solution (standard 10%
povidone-iodine or chlorhexidine gluconate (Hibiclens) solution)
This will remove contaminants that might be carried into the wound by instruments, suture
material, dressings, or the clinician’s gloved hand.
It is important to remove all particulate matter; any material left in the dermis may become
impregnated in the healed tissue and result in a disfiguring “tattoo” effect.
Irrigate the wound profusely with saline solution, via a 30- to 60-mL syringe and splash guard until all
visible, loose particular matter has been removed.
Vigorous irrigation is required to remove bacteria and particulate matter.
Minimum recommended volumes of irrigation fluid vary with the size of the wound and the
potential for contamination; there is no standard volume per length of wound.
Disinfect the skin surface adjacent to the wound (NOT the wound itself) with a standard 10% povidone-
iodine or chlorhexidine gluconate (Hibiclens) solution.
Paint the solution widely on the skin surrounding the wound but do not allow it to seep into the
interior of the wound itself as it can damage the tissue.
Place a single fenestrated over the wound site with the window over the wound
Use a metal probe or forceps to explore the entire depth and the full extent of every wound under direct
visualization with good lighting in an
Attempt to locate: hidden foreign bodies, particles, bone fragments
Identify any injuries to underlying structures that may require repair.
Debride dead tissue i.e. tissue embedded with foreign matter, bacteria, or tissue that otherwise impairs the
ability of the wound to resist infection and prolongs the period of inflammation.
Debridement of devitalized tissue is vital.
Dead tissue will not heal and acts as a resevour for infection.
Suture (see technique below)
Dressing:
Wipe away blood and cover the wound with a non-adherent dressing
Splint if over a joints e.g. fingers, hands, wrists, extensor surface of elbow, posterior legs, plantar
surface of feet, extremities when skin grafts have been applies
Elevate injured extremities is important in all injuries
Technique
General tips
The total number of sutures will vary by laceration. Enough sutures should be placed so that the
wound edges are fully approximated.
The spacing between sutures should generally be equal to the bite width of each suture.
Avoid placing an excessive number of sutures as this may increase the risk of infection, increase
scarring and unnecessarily injure delicate tissues.
As you progress with the repair and the wound edges become approximated, you can drive the
needle through both sides of the laceration in a single pass, again using a gentle supination of the
wrist.
Wounds under considerable tension may need more sutures closer together.
Often if there is significant tension an alternative approach to wound closure (such as additional deep
internal sutures), or specialist consultation is advisable as wounds closed under tension often fail to heal or
heal with a poor cosmetic result.
Suture Removal
Face - ↓ tram tracking of scar, can remove alternate suture early
3 – 5 days
follow with papertape or steristrips
Limbs
7 – 14 days
Trunk/Back
10 – 14/21 days
Delayed healing w DM and chronic CS use = 14 – 21 days
Complications
Breakage
Scaring
Adverse reactions
Infection
Procedure – Plastering
To Do
Procedure – Catheterisation
From Student Guidelines, tute prep and two videos
Indications – By Purpose
Should only be used when non-invasive means are not appropriate or fail. Use non-invasive methods first
Diagnostic
Obtain sterile urine sample for testing
Monitor urine output (during surgery, critically ill, AKI)
Deliver contrast media for imaging
Measuring post-urination residual volumes
Therapeutic
Drain bladder (e.g. urinary retention)
Care of bedridden patients
Instillation of medication
Bladder irrigation (flushing when patient has haematuria, to remove blood and clots)
Indications – By Duration
1. Intermittent catheterisation
Collection of sterile urine sample.
Provide relief of discomfort from bladder distension.
Decompression of the bladder.
Measure residual urine.
Management of patients with spinal cord injury, neuromuscular degeneration, or incompetent
bladders.
2. Short-term indwelling catheterisation
Post-surgery and in critically ill patients to monitor urinary output.
Instil medication for local intravesical therapy.
Prevention of urethral obstruction from blood clots with continuous or intermittent bladder
irrigations Instillation of medication into the bladder.
Instilling contrast media for imaging procedures,
Surgical procedures involving pelvic or abdominal surgery repair of the bladder, urethra, and
surrounding structures.
Urinary obstruction (e.g. enlarged prostate), acute urinary retention.
3. Long-term indwelling catheterisation
Refractory bladder outlet obstruction
Neurogenic bladder with urinary retention.
Prolonged and chronic urinary retention.
To promote healing of perineal ulcers where urine may cause further skin breakdown.
Contraindications
ABSOLUTE: Urethral injury, confirmed or suspected, usually in the setting of pelvic fracture
Suggested by blood at meatus, gross heamaturia, perianal hematoma and high riding prostate
gland
If suspected, perform a genital and rectal exam, and retrograde urethrography
ABSOLUTE: Spinal cord injury (SCI)
Urethral stricture
Recent urethral or bladder surgery
Increased infection risk
Aggressive, combative or uncooperative patient
Routine incontinence – use non-invasive methods (pads, intermittent catheterisation, penile-sheath
catheters)
Equipment
1. Apron Male: 16Fr or 18Fr (more rigid, easier
2. Glasses to insert past prostate)
3. Light Females: 12fr. 14Fr (up to 16Fr.)
4. Towel 13. 10 ml syringe with luer lock tip.
5. ‘Bluey’ 14. 10mL sterile water
6. Bin 15. Urine collection
7. Sterile catheter pack (with sterile field, Closed bladder drainage unit, e.g.,
sterile gloves, forceps, swabs and sterile leg bag with tap and leg straps
fenestrated drape) OR
8. Sterile gloves Jug for urine (for larger volumes)
9. Skin cleansing lotion (aqueous chlorhexidine OR
0.1% or sterile water) Specimen jar, request form and
10. Kidney bowl labels for pathology specimens
11. Lubricant (Lubafax, Lignocaine Gel, pre- 16. Catheter straps (Cathstrap) or Tape
packed 10ml syringe containing lignocaine (alternative means of strapping catheter to
gel 2% with chlorhexidine 0.05%) leg).
12. Catheter x2
Procedure:
Collect equipment (hand hygiene has already been performed and you may access sterile stock)
Put on PPE – glasses and gown
Place the towel and bluey under the patient’s buttocks
Patient preparation: Ask the patient to lie in supine position. Females should have their knees bent, hips flexed,
knees apart and feet resting apart up on bed.
If needed, raise pelvis with pillow, blanket or inverted bedpan.
Turn on and position light
Perform hand hygiene (2)
Open urinary catheter pack to generate sterile field
Open sterile equipment onto the sterile field –
Sterile gloves
Cleaning solution (into tray)
Lubricant (into tray)
Syringe
Catheter
Sterile water – have standing ready, put under the sterile field, or pour into sterile tray
Perform hand hygiene (3)
Don sterile gloves
Don blue sterile gloves from the catheter pack
Use your non dominant (left) hand to open the labia majora / retract the foreskin. This hand is non-sterile.
Cleanse the skin using the yellow tweezers, cotton wool/swabs and cleansing solution (aqueous chlorhexidine 0.1%
or sterile water),
Females: labia minora and meatus area from front to back.
Males: meatus and around the glans penis.
Remove blue gloves
Place fenestrate drape over the perineum / penis
Place the kidney dish near perineum / penis
User sterile syringe to draw up sterile water
Open plastic covering of catheter (at the perforation) to expose the tip of the catheter
Check inflation of the catheter balloon (while still in the packet)
Lubricate
Females: Lubricate catheter tip. Use non-dominant hand to open and pull up labia majora.
Males: Use a sterile swab in the non-dominant hand around the penis to retract the foreskin. Instil
lignocaine gel 2% with chlorhexidine into the urethra
Insert:
Females: Gently insert the catheter into the clean urethra in a slightly upward direction until urine drains.
Male: extend the penis vertically and insert catheter along the urethra. Hold penis either side - do not exert
pressure on the underside of the penis as this may block the urethra. Insert the catheter until resistance felt
(external sphincter at ~18cm), and then lower the penis to horizontal position.
As insertion proceeds slowly withdraw the plastic covering; do not entirely withdraw as this can catch the first urine.
Insert catheter a little further into the bladder to ensure the balloon is clear of the bladder neck.
If any contamination of the catheter occurs during insertion, use another sterile catheter.
Urine should flow if you have inserted the catheter correctly into the bladder (most of the time)
No urine flow: obstructed catheter (clot), wrong site or empty bladder.
If no urine, flush the catheter with saline and urine or saline should return
ONLY once there is urine flow, inflate the balloon with sterile water with amount denoted on the catheter.
Never inflate the balloon until urine has been visualized and is draining.
If there is not urine flow and you are not sure you have the catheter in the correct position (in the bladder)
do not inflate the balloon. This prevents trauma to the urethra.
Cease inflation immediately if the patient experiences pain or discomfort.
Gently pull the catheter so that the balloon is sitting up against the bladder orifice.
Males: The prepuce (foreskin) MUST be returned to its normal position after the catheter is inserted.
Attach sterile drainage bag to catheter. Ensure there is urine flowing into the drainage bag
Catheter is secured to the medial thigh with tape or the catheter strap (catrap).
Attach leg bag to thigh or calf with bag straps. It should be in a dependant position e.g. below the bed.
Ensure patient is comfortable. Clean up any splashes.
Wash hands
Removal
Warn patient
Deflate the balloon
Gentle remove
Throw into clinical waste
Documentation
Time and date of catheterisation.
Reinsertion date
Amount and character of the urine obtained.
Catheter – brand, size, balloon size and amount of sterile water
Residual urine amount.
Any difficulties with insertion.
Complications
The best way to prevent complications is to avoid catheterisation whenever possible.
Females”.
Most common: infection and trauma to urethra and bladder
Traumatic injury may cause strictures, narrowing, and scarring of the urethra.
Within 48 hours, up to 85% of catheters may be colonized with bacteria, which may lead to bacteriuria.
Male:
UTIs are common (3-10% of patients per day of catheterisation). Although many infections are limited to
asymptomatic bacteriuria, in some instances, pyelonephritis, bacteremia, and urosepsis develop. The
potential for serious illness or death is real, since nosocomial urinary tract infections have been shown to
extend hospital stays by three days and to triple the mortality rate in catheterised patients. Patients at
increased risk for catheter-related infections include the elderly, persons with diabetes, and those with
underlying renal insufficiency or advanced, life-threatening illnesses
Trauma to the urethra and bladder.
Paraphimosis (trapping of foreskin under glans penis, can become medical emergency)
Occasionally, it may not be possible to deflate the retention balloon, owing to obstruction of the secondary
lumen or malfunction of the valve.
Non-deflation of the balloon
Autonomic Dysreflexia – a hypertensive crisis which can be triggered by catheterisation in persons with complete or
incomplete (SCI) at or above the T6 level with catastrophic hypertensive complications. If AD is untreated the blood
pressure may rise to extreme levels that may result in brain haemorrhage or seizures
Risk Minimisation
The best way to prevent complications is to avoid catheterisation whenever possible.
Diligent preparation and meticulous attention to proper sterile technique
Continually review need for catheter
Removal of the catheter as early as clinically possible, and vigilance are mandatory.
The routine use of prophylactic antibiotics is not beneficial and encourages the proliferation of resistant species.
However, antibiotic treatment should be considered for patients at high risk for infection and for those undergoing
certain invasive procedures, such as transurethral resection of the prostate and renal transplantation.