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Clinical Skills Handbook

Clinical Skills PMC Module


MEDN 40060

Dr G Chadwick/Dr AB Mongey
September 2015

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INTRODUCTION TO HISTORY TAKING

It is extremely important that you should do the following each time


before taking a History or performing a Clinical Examination on a
Patient:
1. Introduce oneself to the patient.
2. Ask the patient how he/she would like to be addressed e.g. Mary or Mrs. Smith
3. Explain what you would like to do e.g. ask some questions, perform an
examination etc.
4. Obtain consent for same. REMEMBER THAT IF THE PATIENT DOES NOT
GIVE HIS/HERCONSENT YOU CANNOT CONTINUE.
5. Ensure patient is comfortable.

Recommended Textbook: Clinical Examination. A systematic guide to


Physical Diagnosis by N.J. Talley and S. OConnor

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CARDIOVASCULAR WORKSHOP A
Cardiovascular (CVS) History
Aims:
To be able to take a cardiovascular history
To be familiar with common cardiovascular symptoms
To know the risk factors for coronary artery disease.
To be familiar with the common causes of chest pain.
Enquire re patients name and age
Identify the patients presenting complaint i.e. reason for coming to see a
physician and take history.
COMMON SYMPTOMS OF CARDIAC DISEASE:

Chest pain/tightness/heaviness
Dyspnoea/orthopnoea / paroxysmal nocturnal dyspnoea
Ankle swelling
Palpitations
Syncope

CHEST PAIN
Where?
How long?
How did it occur?
Does it radiate anywhere?
How severe is the pain? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the pain?
Does anything make the pain better or worse?
Is there any other symptoms with the pain? Ask about cardiovascular symptoms.
Does the pain interfere with your ability to perform certain functions/activities?
Have you ever had the pain previously? If yes, when, where, how often etc.
DYSPNOEA (difficulty with breathing)
When does it occur?
How long has it been occurring?
Does it wake the patient from sleep? = Paroxysmal Nocturnal Dyspnoea
Does it occur when lying supine? = Orthopnoea
How many pillows are needed to prevent the orthopnoea
How severe is the dyspnoea? e.g. does it interfere with talking?
Is it getting better or worse?
Is it intermittent or constantly present?
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Does anything bring on the dyspnoea? does exertion brings on the dyspnoea, and if so,
how much exertion?
Does anything make the dyspnoea better or worse?
Are there any other symptoms with the dyspnoea? Ask about other cardiovascular
symptoms.

Does the dyspnoea interfere with your ability to perform certain functions/activities?
Have you ever had the dyspnoea previously? If yes, when, where, how often etc.
ANKLE SWELLING
How far up the legs does the swelling extend?
Did it come on suddenly or gradually?
Is it intermittent or constantly present?
Any precipitating factors, such as standing or sitting for prolonged periods of time?
When is the swelling worse? Does it improve with elevation/overnight?
Are there any other factors associated with the swelling?
PALPITATIONS
When do they occur?
Is the heartbeat slow or fast, regular or irregular?
How long have they been occurring?
How long do they last?
Are they increasing or decreasing in frequency?
Anything that precipitates the palpitations?
Anything that relieves the palpitations?
Are there any other factors associated with the palpitations? e.g. dizziness/blackouts/
chest pain
SYNCOPE
When did it occur? What were the circumstances? e.g. rising from a seated position?
How long did it last?
Were there any warning symptoms that preceded the blackout?
Has it occurred previously?
Were there any other factors associated with the blackout? e.g. palpitations/dizziness/
chest pain?
See Appendix I for clinical descriptors of cardiac symptoms

Past (Medical & Surgical) History:


Enquire re previous history of heart disease and if so what type and what therapies
were used to treat it, including angioplasty or coronary artery bypass graft surgery
Enquire re conditions known to predispose to cardiac disease such as: Diabetes,
hyperlipidemia, hypertension, thyroid disease; rheumatic fever,
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Family History:
Enquire re family history of coronary artery disease/ischaemic heart disease (IHD)
and if so, what age was the family member when he/she developed IHD?
Enquire re history of Diabetes or hyperlipidemia among family members.

Social History:
Ask if patient is smoker or non-smoker; if smoker enquire as to how many
cigarettes patient smokes/day & for how long; if non-smoker enquire if patient was
a former smoker.
Ask is patient drinks alcohol & determine their usual daily/weekly consumption.
Enquire as to the patients occupation and whether the patient can still perform his/
her occupation.
Medications:
Obtain a list of medications that the patient is taking including OTC medications.
Enquire if the patient has any medication allergies.

Risk Factors for Coronary Artery Disease


1. Previous coronary artery disease
2. Smoking
3. Raised Cholesterol (targets: Total Cholesterol <5, LDL Cholesterol <3, HDL
Cholesterol >1)
4. Hypertension
5. Family History (first degree relative under 60 yrs of age)
6. Diabetes mellitus

TAKE A HISTORY

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CARDIOVASCULAR WORKSHOP B
CVS Examination I
Aims:
To take the arterial pulse accurately & be able to comment on rate, rhythm &
character of same
To measure blood pressure completely and accurately
To be familiar with the peripheral signs of cardiac disease
To assess and measure the JVP

1. EXAMINATION OF THE ARTERIAL PULSE


Arterial pulsation reflects various cardiac events in the cardiac cycle as well as certain
characteristics of the systemic arteries. Information about cardiac status can be
obtained from any artery that is palpable the radial artery is used most commonly
because of its accessibility.
Palpate the radial artery at the wrist just medial to the radius using the forefinger and
middle finger pulps of the examining hand
Characteristics of an Arterial Pulse:
1. Rate:
Count for 15 seconds; multiply by 4 to convert to beats per minute. Count for 60
seconds if pulse is irregular. Normal rate is between 60 and 100 beats/minute.
Bradycardia refers to a rate less then 60 per minute and tachycardia refers to rate
greater than 100 per minute
2. Rhythm:
Check whether the rhythm is regular or irregular. If the rhythm is irregular, check if it
is regularly irregular or irregularly irregular. A regularly irregular pulse may be due to
extrasystoles or due to sinus arrhythmia (pulse increases with each inspiration and
decreases with each expiration). An irregularly irregular pulse that is chaotic with no
pattern occurs in atrial fibrillation.
3. Character & Volume:
These are better assessed with the carotid or brachial artery. A collapsing pulse occurs
in aortic regurgitation and a small volume pulse occurs in aortic stenosis.
Evaluating for Radio-femoral Delay:
While palpating the radial pulse, also palpate the femoral pulse with the fingers of the
other hand (femoral pulse is detected below the inguinal ligament 1/3 of the way up
from the pubic tubercle). Delay between the two pulses suggests coarctation of the
aorta.
Causes of Bradycardia

Causes of Tachycardia
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Physiological e.g. athletes


Drugs e.g. beta-blockers, digoxin
Hypothyroidism
Raised intracranial pressure
Hypothermia
Inferior myocardial infarction

Hyperdynamic circulation e.g.


exercise, fever, hyperthyroidism,
pregnancy, anaemia
Drugs e.g. beta-agonists
Hypovolaemia

2. BLOOD PRESSURE MEASUREMENT


Systolic blood pressure is the peak pressure occurring in the artery following
ventricular systole. Diastolic blood pressure is the level to which pressure in the artery
falls during ventricular diastole. Normal blood pressure is 140/90 or less. An indirect
measurement of blood pressure is obtained with a sphygmomanometer.
The Sphygmomanometer consists of:
a) an armlet or cuff (a rubber bladder covered with inextensible material),
b) a pump (a rubber bulb with valves) which inflates the cuff &
c) a pressure gauge (a mercury or aneroid manometer) which measures the
pressure in the inflated cuff.

Procedure for measuring Blood Pressure


1. Seat the patient with their bare arm resting on a table so the midpoint of the upper
arm is level with the chest
2. Locate the brachial artery on the inner side of the arm just above the antecubital
fossa and medial to the biceps tendon. Place the cuff so the midline of the bladder
is over the arterial pulse and wrap snugly around patients bare arm.
3. While palpating the radial pulse, inflate the cuff and note the pressure at which the
pulse disappears and subsequently reappears during deflation. This is the Palpation
Method (of Riva-Rocci) and gives a preliminary estimate of systolic blood
pressure. This preliminary estimation is important to avoid subsequent inaccurate
readings of blood pressure by auscultation in patients with very high or very low
blood pressures.
4. Place the bell of the stethoscope over the brachial artery just above antecubital
fossa but below the edge of the cuff.
5. Inflate the bladder rapidly to about 20mmHg above the estimated systolic blood
pressure. Then partially open the valve and deflate the bladder at a rate of about
2mmHg/sec while listening for the appearance of Korotkov sounds.
6. Note the pressures at which the sounds appear (phase I), the sounds become
muffled (phase IV) and the sounds disappear (phase V). This is the auscultatory
method of Korotkov. In Europe the diastolic pressure is taken as the point at which
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sounds become muffled. In North America it is taken as the point at which sounds
disappear.
7. In practice, blood pressure should be measured on two separate occasions with a
period of a few minutes between. Record the blood pressure readings as follows
Phase I (SBP Palp)
Phase IV V

eg

140 (138 palp)


82 - 78

3. SIGNS OF CARDIAC DISEASE


General inspection:
Is patient dyspnoeic or cyanosed?
Nutritional status
Examination of hands:
Note temperature / colour of hands/ presence of nicotine stains
Check for clubbing
Check for splinter haemorrhages( e.g., subacute bacterial endocarditis)
Check for cyanosis (peripheral)
Clubbing: This is characterized by an increase in the soft tissue of the distal portion of
the digits. Initially there is increased fluctuance of the nail bed, which feels boggy, and
loss of the angle between the nail bed and the digit. The fingernail needs to be
inspected from the side to determine if there is loss of the angle. Then an increase in the
longitudinal curvature of the fingernail develops. Finally the soft tissue of the distal
portion of the digits (overlying the distal phalanx) becomes enlarged and develops a
club like appearance.
Cardiac causes include: Cyanotic congenital heart disease; Infective endocarditis
Examination of head and neck:
Check the sclera for anaemia
Check mouth for central cyanosis
Look for xanthomata
Locate the carotid pulse and assess
Abdominal Examination:
Palpate the abdomen for enlarged liver this can be seen with right sided failure.
Peripheral Oedema:
Check for pitting ankle oedema
Chest Examination:
Percuss and auscultate the chest to check for pulmonary oedema/pleural effusion
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4. JUGULAR VENOUS PULSE ASSESSMENT


Position patient at 45 angle
Ask the patient to turn his/her head to one side, in order to relax the
sternocleidomastoid (SCM) muscle
Locate the internal jugular vein medial to the clavicular head of the SCM muscle.
Measure the vertical height from the sternal angle (zero point) to the highest point
of the JVP - the vertical height should not be > than 3cm.
Assess the character of the JVP wave

Features of a JVP:
Visible but not palpable
Diffuse waveform
Increases with expiration; decreases with inspiration
Can be obliterated; fills from above
Abdominojugular reflux test (Hepatojugular reflux) is a means of testing for ventricular
failure. Pressure exerted over the middle of the abdomen or liver for 10 seconds will
increase venous return to the atrium resulting in a transient rise in the JVP. The test is
positive if it remains elevated for the duration of the compression: this is indicative of
right ventricular failure or elevated left atrial pressure.
Abnormalities of JVP:
Causes of elevated JVP:

right ventricular failure;


tricuspid regurgitation;
pericardial tamponade;
superior vena caval obstruction

Giant a waves:

pulmonary hypertension
tricuspid stenosis

Cannon waves:

nodal rhythm (regular rhythm)


complete heart block (irregular rhythm)

Absent a waves:

atrial fibrillation

Large v waves:

tricuspid incompetence

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CARDIOVASCULAR WORKSHOP C
CVS Examination II
Aim: To locate the apex beat and listen to the heart sounds
Inspection of praecordium e.g. for scars, pulsations or pacemakers.
Palpation of the heart:
Locate the apex beat and assess its nature
Palpate over the apex and valvular areas for thrills (palpable murmur).
Palpate over the left parasternal area to assess for a heave indicative of right
ventricular enlargment
Apex Beat:
The apex beat is an impulse generated by the systolic contraction of the left ventricle.
It is the most inferior and lateral palpable pulsation. Normally it is located in the 5th
left intercostal space, mid-clavicular line. The apex beat may be displaced laterally
and/or inferiorly when the heart is enlarged. The apex beat may not be palpable in
some patients, such as those with over-inflated lungs. If the apex beat is not palpable
with the patient lying down a further attempt should be made with the patient in an
upright position and if still not palpable with the patient on their left side.
The quality of the pulsation of the apex beat should also be noted e.g. a tapping apex
beat may be felt in mitral stenosis.
Note that the apex beat cannot be localized accurately with the patient in the left
lateral position but information may be obtained regarding its quality.

Auscultation of Heart:
Listen for heart sounds, added sounds, murmurs, pericardial rub.
The first heart sound occurs at the beginning of systole and is the sound of
the mitral and tricuspid valves closing.
The second heart sound occurs at the end of systole and is the sound of the
aortic and pulmonary valves closing.
Murmurs are generated by turbulent blood flow, which usually results from structural
abnormalities of the heart valves or abnormal communications between the chambers
of the heart.
If a heart valve is stenosed (narrowed) then is will generate a murmur when
the valve is open, e.g. aortic stenosis results in a systolic murmur, mitral
stenosis causes a diastolic murmur.
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If a valve is incompetent/regurgitant (not closing properly) then the


murmur will occur when the valve is supposed to be closed e.g. mitral
incompetence results in a systolic murmur; aortic incompetence results in a
diastolic murmur.

Ausculatation of the heart sounds is performed with both the bell and diaphragm of the
stethoscope over the 4 valvular areas to evaluate for murmurs:
Aortic area (Right 2nd intercostal space)
Pulmonary area (Left 2nd intercostal space)
Tricuspid area (Left sternal border, 5th interspace)
Mitral area (Left 4th intercostal space, just medial to the mid-clavicular line)
When a murmur is detected one needs to determine:
its timing i.e. whether it is systolic or diastolic which is determined using the
carotid pulse
its intensity
if/where it radiates to e.g. mitral incompetence murmur radiates to the axilla.
Certain manoeuvres can be used to augment the sound of individual murmurs:
Right sided murmurs become louder during inspiration and left sided murmurs are
louder during expiration.
Ask patient to lean forward and hold breath in expiration, listen at the left sternal
border for Aortic Regurgitation
Ask patient to turn to the left and hold breath in expiration, listen to the mitral area
for Mitral Stenosis murmur.
Please refer to Clinical Examination textbook by N.J. Talley and S OConnor for
further information regarding characteristics of murmurs.

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RESPIRATORY WORKSHOP A
Respiratory History
Aim:
To obtain a complete history for the respiratory system
Enquire re patients name and age
Enquire re patients presenting complaint, and obtain a history of the presenting
complaint
COMMON SYMPTOMS FOR RESPIRATORY DISEASE:

Dyspnoea
Cough
Sputum
Haemoptysis
Wheeze
Chest pain

DYSPNOEA (difficulty with breathing)


When does it occur?
How long has it been occurring?
Does it wake the patient from sleep?
How severe is the dyspnoea? e.g. does it interfere with talking?
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the dyspnoea? does exposure to dusts, allergens, exercise etc.
bring on the dyspnoea, and if so, how much exertion?
Does anything make the dyspnoea better or worse?
Are there any other symptoms with the dyspnoea? Ask about other respiratory
symptoms
Does the dyspnoea interfere with your ability to perform certain functions/activities?
Have you ever had the dyspnoea previously? If yes, when, where, how often etc.
COUGH
When does it occur?
How long has it been occurring?
Is the cough productive of sputum or is it a dry cough?
How severe is the cough? e.g. does it interfere with talking?
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the cough? e.g. exposure to dusts, allergens, exercise etc.
Does anything make the cough better or worse?
Are there any other symptoms with the cough? Ask about other respiratory symptoms
Have you ever had the cough previously? If yes, when, where, how often etc.
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SPUTUM
How long have you been coughing up sputum?
How much sputum do you cough up per day? e.g. teaspoonful/teacupful etc x times per
day
What colour is the sputum?
Any other factors associated with the production of sputum?
HAEMOPTYSIS (coughing up of blood)
How long have you been coughing up blood?
How much blood do you cough up per day e.g. teaspoonful/teacupful etc x times per
day
What colour is the blood? e.g. bright red or rusty colour etc
Any other factors associated with the production of sputum? e.g. weight loss, night
sweats
Common causes of Haemoptysis: Pneumonia, TB, Malignancy, Pulmonary Infarction
WHEEZE
When does it occur?
How long has it been occurring?
How severe is the wheeze? e.g. does it interfere with talking?
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the wheeze? e.g. exposure to dusts, allergens, exercise etc.
Does anything make the wheeze better or worse?
Are there any other symptoms with the wheeze? Ask about other respiratory symptoms
Have you ever had the wheeze previously? If yes, when, where, how often etc.
CHEST PAIN
Where?
How long?
Does it radiate anywhere?
How severe is the pain? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the pain?
Does anything make the pain better or worse? e.g. does breathing or coughing
aggravate the pain
Are there any other symptoms with the pain? Ask about other respiratory symptoms
Have you ever had the pain previously? If yes, when, where, how often etc.
OTHER SYMPTOMS:
Fever
Hoarseness
Night sweats
Past Medical History:
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Enquire re current, past and childhood illnesses, including Asthma, TB, Chronic
Bronchitis.
Enquire as to any previous surgery.
Family History:
Check for Family history of respiratory disease. Enquire about Asthma, Cystic
Fibrosis, and Emphysema. Also enquire re family history of TB.

Social History:
Enquire re current employment, and previous employment particularly any
exposure to asbestos, dusts, chemicals etc.
Ask patient specifically what they do at work as this may give major clues to
possible diagnosis.
Exposure to dusts, animals and birds may all be relevant.
Improvement in symptoms over the weekend or when patient is away from work,
may suggest an occupational lung disease.
Check re smoking status (in pack years).
Enquire re alcohol intake (can increase risk of TB, and aspiration pneumonias).
Ask about the patients housing.
Any recent travel?
Also enquire about any hobbies (esp keeping budgerigars or pigeons)
Medications:
Enquire if patient is taking any medications including OTC medications and herbal
supplements
Ask about the use of medications such as NSAIDs and beta-blockers which may
worsen asthma
Enquire re allergies

TAKE A HISTORY

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RESPIRATORY WORKSHOP B
Respiratory Examination I
Aim: To carry out a respiratory system examination on a patient Part I

General inspection:
Observe general appearance. Is patient breathless, in distress, or cyanosed?
Determine the rate of patients breathing and note the depth and regularity of the
respirations
Comment on any chest deformities, or asymmetry
Check for use of accessory muscles
Are there any obvious scars? e.g., thoracotomy scar
Inspection & Examination of hands:
Assess hands for colour/ temperature
Check for nicotine staining
Check for clubbing
Test for asterixis (flapping tremor of CO2 retention)
Respiratory causes for Clubbing: Bronchial carcinoma; chronic lung suppuration e.g.
abscess, bronchiectasis, Cystic fibrosis, Interstitial lung disease, mesothelioma
Inspection & Examination of head & neck:
Check sclera for signs of anaemia
Horners syndrome (apical lung cancer)
Inspect mouth for central cyanosis
Palpate the cervical, infraclavicular, and axillary lymph nodes
Trachea:
Palpate for tracheal deviation. Place index and middle finger on either side of
trachea, in suprasternal notch.
The trachea can be displaced towards or away from the side of the lung lesion. What
are the causes of tracheal displacement?
Assess the distance between the cricoid cartilage and the suprasternal notch for
hyperinflation
Palpation of chest:
Palpate for equal chest expansion, comparing each side. Use measuring tape to
measure chest expansion:- normal is 2 inches or 5 cms.
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Test for tactile fremitus, by placing the flat of the hands on the chest and asking the
patient to say ninety-nine. Compare each side with the other.

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RESPIRATORY WORKSHOP C
Respiratory Examination II
Aim: To carry out a respiratory system examination on a patient Part II
Percussion of the chest:
The principle underlying percussion is that air gives a resonant percussion note and
fluid or solid tissue a dull note.
Technique for Percussion: Place middle finger of non dominant hand on the area of
the chest you want to percuss. Lift the other fingers off the chest wall (so they wont
dampen the vibrations). Hold the middle finger of the percussing hand at a 90 angle
and tap the dorsum of the applied middle finger with the tip of the percussing finger.
Keep the fingers of the percussing hand immobile and move the percussing hand from
the wrist.
Percuss chest. Start at apex of lung, comparing each side. Both anterior and
posterior chest walls should be percussed in addition to the lateral chest walls and
clavicles.
Determine if resonance is normal, increased or decreased. Localize areas of
hyperresonance or dullness to the different lobes of the lungs using your knowledge
of anatomy. Note the character of the dullness e.g stony dull suggests a pleural
effusion.
Auscultation of chest:
Ask patient to take deep breaths. Auscultate chest with diaphragm of stethoscope.
Start at apex, compare each side. Auscultate over the anterior, posterior and lateral
chest walls.
Note whether air entry is normal or reduced.
Note whether the inspiratory:expiratory ratio is normal or if one of the phases are
prolonged.
Note whether breath sounds are vesicular or bronchial.
Are there any adventious sounds?
Breath sounds:
Breath sounds are reduced in pneumothorax, or pleural effusion.
The expiratory phase of the breath sounds is prolonged in airway obstruction (e.g.
asthma).
Normal breath sounds are described as vesicular.
Bronchial breathing occurs when air is passed from the bronchi through fluid filled
alveoli to the chest wall, the classic situation in which this occurs is pneumonia.
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Adventitious sounds are extra sounds in addition to breath sounds- rhonchi are
whistling sounds which occur when air passes through narrowed bronchi e.g., asthma;
crepitations are crackling sounds due to fluid in the alveoli e.g.infection
(bronchopneumonia), pulmonary oedema or alveolitis.

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GI WORKSHOP A
Gastro-Intestinal (GI) History
Aims:
To obtain a complete history for the Gastrointestinal system
Be familiar with the differential diagnosis of abdominal pain
Enquire about the patients name, age and occupation.
Enquire about the patients presenting complaint and the history of the
presenting complaint.
COMMON SYMPTOMS FOR GASTROINTESTINAL DISEASE:

Abdominal Pain
Nausea
Vomiting
Diarrhoea
Constipation
Bleeding per rectum
Abdominal Swelling
Weight loss
Dysphagia

ABDOMINAL PAIN
Where?
How long?
How did it occur?
Does it radiate anywhere?
How severe is the pain? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the pain?
Does anything make the pain better or worse?
Are there any other symptoms with the pain? Ask about GI symptoms
Have you ever had the pain previously? If yes, when, where, how often etc.
NAUSEA
When does it occur?
How long has it been occurring?
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the nausea? e.g taking certain foods or medications
Does anything make the nausea better or worse?
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Are there any other symptoms with the nausea? Ask about other GI symptoms such as
vomiting, diarrhoea etc.
Have you ever had nausea previously? If yes, when, where, how often etc.

VOMITING
When does it occur?
How long has it been occurring?
Is it getting better or worse?
How frequently does it occur?
Does anything bring on the vomiting? e.g taking certain foods or medications
Does anything make the vomiting better or worse?
Are there any other symptoms with the vomiting? Ask about other GI symptoms
Have you ever had vomiting previously? If yes, when, where, how often etc.
How much do you vomit up?
What is the colour and consistency of the vomitus?
Is there any blood with the vomitus (heamatemesis)?
DIARRHOEA
When does it occur?
How long has it been occurring?
Is it getting better or worse?
How frequently does it occur?
Does anything bring on the diarrhoea? e.g taking certain foods or medications
Does anything make the diarrhoea better or worse?
What is the volume of the diarrhoea?
What is the colour and consistency of the diarrhoea?
Is there any blood or mucus with the diarrhoea?
Are there any other symptoms with the diarrhoea? Ask about other GI symptoms
Have you ever had diarrhoea previously? If yes, when, where, how often etc.
CONSTIPATION
How long has it been occurring?
Is it getting better or worse?
How frequently do you have a bowel movement?
What is the consistency of the stool?
Does anything bring on the constipation? e.g taking medications
Does anything help the constipation?
Is there any blood with the stool?
RECTAL BLEEDING
When does it occur?
How long has it been occurring?
How frequently does it occur?
Is it getting more or less frequent?
What is the volume of the blood that is passed?
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What is the colour of the blood? e.g. bright red or dark


Is there any mucus or diarrhoea with the blood?
Are there any other symptoms? Ask about other GI symptoms
Have you ever had rectal bleeding previously? If yes, when, where, how often etc.
Any change in the colour of the stool? E.g. black tarry stool indicates upper GI bleed

ABDOMINAL SWELLING
Did it come on suddenly or gradually?
Is it increasing or decreasing?
Are there any other factors associated with the swelling? e.g. pain
Have you ever had abdominal swelling previously?
WEIGHT LOSS
How much?
Over what time period?
How is your appetite/intake?
DYSPHAGIA (Difficulty in swallowing)
How long has it been occurring?
Can you swallow solids and/or liquids?
Have you lost weight?
Do you have to regurgitate the food?
Is it associated with pain?
Have you ever had heartburn?
Past Medical History:
Current or previous illnesses including history of GI disorders such as peptic
ulcer disease etc.
Enquire re previous surgery.
Family history:
Family history of GI diseases such as cancer of the colon or inflammatory
bowel disease.
Social History:
Enquire re alcohol and cigarette consumption.
Enquire as to present and past employment e.g. potential exposure to hepatitis
B & C.
Enquire re recent travel.
!21

Medications/ Drug history:


Enquire as to present and previously prescribed medications.
Nonsteroidal anti-inflammatory medications may cause upper GI bleeding.
Liver disease can occur with medications such as paracetamol, tetracyclines
etc.

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GI WORKSHOP B
Gastro-Intestinal (GI) Examination
Aim:

To perform an examination of the Gastro-Intestinal system

General Inspection:
Observe patients general appearance; nutritional status.
Check for any evidence of jaundice or pigmentation.
Inspection & Examination of hands for the following:
Clubbing
Nail signs e.g. leuconychia which is seen with hypoalbuminaemia
Palmar erythema
Dupuytrenss contracture
Check for liver flap (liver failure)
Inspection & Examination of head, neck and thorax:
Inspect sclera for anaemia, jaundice, iritis
Inspect mouth for ulceration, pigmentation, atrophic glossitis.
Examine the neck for lymphadenopathy
Examine the upper body for gynaecomastia, spider naevi (signs of liver
disease).
Abdominal Examination:
Inspection:
Check for scars of previous surgery
Distension
Striae
Bruising
Pigmentation
Localised masses
Palpation:
Superficial palpation: Begin by examining the region furthest from pain or discomfort.
Examine each of the 9 regions. Check for any tenderness, guarding and any masses.
Deep palpation: Follow by deep palpation. Check for organomegaly and any abnormal
masses.
Palpation of the Liver: Ask patient to breathe in and out. Start in the right lower
quadrant, and feel for the liver edge using the flat of the hand or the fingertips.

!23

Palpation of the Spleen: As for the liver, start in the right lower quadrant and move
towards the splenic area.

Ballotment of the Kidneys: Position the patient close to the edge of the bed, and ballot
each kidney using deep bimanual palpation.
Palpation of the Aorta: Palate the aorta, at a point midway between the xiphisternum
and the umbilicus, using the thumb and the index finger of the palpating hand.

Percussion:
Percuss the lower and upper borders of the liver (usually found in 4th intercostal
space).
Percuss the spleen.
If abdominal distension, check for shifting dullness (ascites)
Percuss the suprapubic area for dullness (bladder distension)

Auscultation:
Check for bowel sounds
Check for aortic bruit over the abdominal aorta
Check for renal artery bruits (above and lateral to the umbilicus, suggests renal
artery stenosis)
In a real patient situation you would also:
Perform a Rectal examination, check for blood, masses.
Examine the groins (checking hernial orifices with patient standing)
Examine the Genitalia

Acute Abdomen Assessment


Aims:
To examine a patient presenting with an acute abdomen
To become familiar with the differential diagnosis of an acute abdomen.
In patients presenting with an acute abdomen, it is vital to determine whether
they will need urgent surgery or not.
General Inspection:
Observe patients general appearance. Is the patient distressed? Is patient in
obvious pain?
Assess patients vital signs, and recheck frequently.- is the patient tachycardic,
hypotensive, sweating?
!24

Abdominal Examination:
Start with inspection:
Observe the abdomen for movement with respiration. - Peritonism is
associated with lack of movement
Distension - What are the causes of abdominal distension?
Check for scars of previous surgery
Any lumps or masses
Palpation:
Superficial palpation: Begin by examining the segment furthest from pain or
discomfort. Examine each of the 9 regions. Check for any tenderness, guarding and
any masses.
If Tenderness is detected check for rebound tenderness which is indicative of
peritonitis in which pain occurs when inflamed peritoneal surfaces are moved
relative to each other.
Deep palpation: Follow by deep palpation. Check for organomegaly and any abnormal
masses. Also check for pulsatile masses such as aortic aneurysm.
For abdominal masses determine the following: site, tenderness, size, surface, edge,
consistency, mobility with movement and respiration, and whether it is pulsatile or not.
If a pulsatile mass is detected check for expansile pulsation which is characteristic of
an aneurysm.
Check for Murphys sign if suspect cholecystitis.
Percussion:
Perform light percussion over areas of tenderness pain that occurs on
percussion suggests underlying peritonism.
Percuss over masses to assess for dullness e.g. ovarian cyst.
Auscultation:
Check for bowel sounds and assess their quality Are they present/absent?
Are they normal/ increased or diminished?
Bowel sounds are absent in peritonitis; absent/reduced in ileus; increased in bowel
obstruction.
Check peripheral pulses if suspect a ruptured/dissecting aortic aneurysm.
See Appendix II for Differential diagnosis of acute abdomen.

!25

Examination for a Hernia:


Groin Hernias are divided into Inguinal and Femoral. Typically a groin hernia presents
as a lump in the groin region that appears with standing or activities which raise intraabdominal pressure. Examination should occur with the patient in the standing
followed by the supine position.
Inspection:
Location of the swelling/lump
Scars
Assess for cough impulse

Palpation:
Position
Size
Tenderness
Cough Impulse
Check if the hernia is reducible/irreducible.

!26

GI WORKSHOP C

GU (Genito-Urinary) Examination, Rectal Examination

Aim:

To perform an examination of the Male Genitalia

It is essential to wear gloves when performing an examination of the male genitalia.


Inspection of the Male Genitalia for:

Ulceration including the Glans Penis


Other lesions such as warts
Urethral discharge
Scrotal oedema and/or erythema
Check that left testis hangs lower than the right

Palpation:
Begin by gently palpating each testis using the thumb and fingers.
Check for:
Presence of both testes
Size of testis
Tenderness
Swelling
Consistency
Masses
Palpate the epididymis

Features of a Scrotal Mass:


In describing a scrotal mass, you need to address the following features:
Position
Size
Tenderness
Fixed or mobile
Is it translucent?
Is it possible to get above the mass? if not it is most likely an inguino-scrotal
hernia
Does it fell like a bag of worms? (varicoele)

!27

Rectal Examination and Insertion of Urinary Catheter


Aims:
To perform a rectal examination on a manikin

Before procedure:
1. Introduce self to patient
2. Explain what you are about to do. Advise that patient may find procedure
uncomfortable but not painful.
3. Obtain consent from patient for same
4. Ensure patient is comfortable. Lie patient on their left hand side, with knees
drawn up to chest.
5. Request patient to remove trousers and underwear.
6. Be aware of the sensitive nature of intimate examinations and try to put patient
at their ease.
7. It may be necessary to request a chaperone. (For the purposes of this exercise a
manikin is provided)

Rectal examination:
Firstly put on a pair of gloves
Separate the buttocks and inspect the anus and skin surrounding the anus.
Check for:
!"external thrombosed piles (tense bluish swellings at anal marginpainful)
#"skin tags
$"rectal prolapse (may only be apparent when patient asked to strain)
%"anal warts (condylomata acuminata), may be confused with skin tags.
&"anal fissure (crack in anal wall, may be too painful to allow rectal
examination). Usually occur posteriorly and in the midline.
'"pruritis ani (may lead to irritation, redness or weeping of surrounding
skin)
("carcinoma of the anus (rare, may be visible as a fungating mass at the
anal margin)
)"excoriation (may occur secondary to chronic diarrhoea)
*"fistula-in-ano may occur in Crohns disease.

Next lubricate index finger of examining hand.


Ask patient to breathe in and out quietly through the mouth.
Place index finger over anus, as if pointing in the direction of the genitalia
Insert lubricated finger into the anus and slowly advance into the rectum.
!28

During insertion external sphincter tone can be assessed. Tone can also be
assessed by asking patient to squeeze down on finger.
Rotate the finger clockwise and check for masses.
In men the prostate gland can be assessed through the anterior rectal wall. The
normal prostate is firm, rubbery and bi-lobed. A hard nodule may represent
carcinoma of the prostate.
In women the cervix may be palpated through the anterior rectal wall.
Remove the finger and examine the glove for colour of faeces, blood and
mucous. Dispose of gloves appropriately in clinical waste.
Advise patient examination is finished and that may dress self again.

!29

ENDOCRINE WORKSHOP A
Endocrine History
Aims:
To obtain a history for endocrinologic disorders
To be familiar with symptoms for Diabetes Mellitus and Thyroid disease

Enquire about the patients name, age and occupation.


Enquire about the patients presenting complaint and the history of the
presenting complaint.
COMMON SYMPTOMS FOR ENDOCRINE DISORDERS

Weight Change
Polydipsia/Polyuria
Heat/cold intolerance
Change in Bowel habit
Palpitations
Fatigue
Skin/Hair changes
Parasthesias

WEIGHT CHANGE
Has there been a loss or gain in weight/
How much? If patient does not weigh themselves inquire requiring need to increase or
decrease in their clothes size.
Over what time period?
How is your appetite?
Take a dietary history and try and quantify daily caloric intake?
POLYDIPSIA/POLYURIA
Are you drinking more fluids and if so how many glasses per day?
Are you urinating more frequently?
Are you passing bigger volumes of urine?
How long?
HEAT/COLD INTOLERANCE
Are you more sensitive to cold temperatures i.e. feeling cold in environments where
others do not feel cold?
Are you more sensitive to the heat i.e. feeling hot in environments where others do
not?
How long?
Is it getting better or worse?
!30

CHANGE IN BOWEL HABIT


Have you noticed a change in the frequency of passing a bowel movement and if so
what is the difference? i.e. increased/decreased
Has the consistency of your stool changed? i.e. more loose or harder
How long?
Is it getting better or worse?
PALPITATIONS
When do they occur?
Is the heartbeat slow or fast, regular or irregular?
How long have they been occurring?
How long do they last?
Are they increasing or decreasing in frequency?
Anything that precipitates the palpitations?
Anything that relieves the palpitaions?
Are there any other factors associated with the palpitations? e.g. dizziness/blackouts/
chest pain
FATIGUE/LETHARGY
How long?
How severe? e.g. does it interfere with social activities or ability to work
How much sleep do you get?
Is it getting better or worse?
SKIN CHANGES
What type of changes?
Any bruising or skin fragility?
Has your skin become drier?
Has the colour of your skin changed? e.g become more tanned (hyperpigmented)
Have you had any increase in hair growth?
Have you noticed any hair loss? If so where?
PARAESTHESIAS/NUMBNESS
Peripheral neuropathy occurs as a complication of Diabetes Mellitus and carpal
tunnel syndrome(CTS) with hypothyroidism
Where?
How long?
How severe? Is it getting better or worse?
Is it intermittent or constantly present?
!31

When does it occur? e.g. during the daytime or at night. CTS symptoms occur more
frequently at night.
MISCELLANEOUS
Have you had any sweats?
Have you or any of your family members noted any change in your appearance?
Have you noticed any change in your vision?
Any difficulties with attaining/sustaining penile erections?

Past Medical History:


Current or previous illnesses including history of endocrine disorders including
gestational diabetes.
Enquire re previous surgery including thyroidectomy, or abdominal surgery.
Obtain a detailed menstrual history.
Family history:
Family history of endocrine diseases such as diabetes mellitus, thyroid
disorders, osteoporosis, parental hip fractures.
Social History:
Enquire re alcohol and cigarette consumption.
Possible exposure to radiation.
Medications/ Drug history:
Enquire as to present and previously prescribed medications in particular the
use of glucocorticoidsteroids, thiazides.

TAKE A HISTORY

!32

ENDOCRINE WORKSHOP B
Examination of a Diabetic Patient: Evaluation for Peripheral Vascular
Disease and Peripheral Neuropathy
COMPLICATIONS OF DIABETES MELLITUS
Aim:

To assess a patient for complications of Diabetes Mellitus

Examination for Diabetic complications:

General inspection: Comment on signs of obesity


Examine upper limbs for nail changes, eg fungal infection, and injection sites.
Perform Fundoscopy looking for retinopathy.
Check mouth for signs of thrush
Check skin for injection sites, scars, ulcers, necrobiosis etc.
Check for quadriceps muscle wasting.
Check for peripheral neuropathy.
Examine the legs for vascular abnormalities.

Peripheral Neuropathy
Loss of sensation starts at the most distal portion of the extremeties in a symmetrical
pattern. Initially the posterior spinal columns, which carry light touch, vibration and
proprioception, are affected followed by the spinothalamic columns which carry pain
and temperature sensation.
Ask if the patient has noted altered sensation, such as numbness or tingling, in any part
of their body. If the answer is negative, show the patient what each of the following
feel like with their eyes open and them check that they can appreciate them on the
distal phalanx of the index finger and hallux with their eyes closed:
Vibration is tested with a 128 Hz tuning fork on bony prominences
Joint position sense (Proprioception) is tested by asking the patient to identify the
direction of movement of the distal phalanx.
Light touch with your finger tip or by touching (not stroking) the skin with cotton
wool
Pinprick with a neurotip or tooth pick with the patients eyes open asking whether
they can feel that it is sharp and hurts like a pin. Patient is asked to differentiate
between sharp and dull.
!33

If the patient reports an abnormality map out its extent with light touch or pinprick
testing or compare the two sides and draw it on a body chart.

Peripheral Vascular Disease


Aim: To perform a peripheral vascular system examination
Examination of Arterial Pulse
Arterial pulsation reflects various cardiac events in the cardiac cycle as well as certain
characteristics of the systemic arteries. Information about cardiac events can be
obtained from any artery whose pulsation can be felt on the surface the radial artery
is used most commonly because of its accessibility.
In order to assess the peripheral arterial system, several pulses must be examined
radial, brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis. Palpation
of arteries should always be light and done with the palmar aspect of the fingers.
Inspection:
1. Inspect for skin changes, e.g. pallor, pigmentation, varicose eczema in the gaiter
area, loss of hair.
2. Look for signs of gangrene: black toes, amputated toes etc.
3. Check for scars e.g. from previous varicose vein surgery or bypass surgery
4. Look for signs of ulceration: describe the site, size, shape, edge, & surrounding
skin of ulcer.
Venous ulcers more commonly occur above the medial malleolus, are usually
shallow, and painless, and may be associated with varicose veins, and varicose
eczema.
Arterial ulcers are painful, have a punched out appearance, and may be
associated with pallor and hair loss.
5. Check for varicose veins, with the patient standing.
6. Check for any limb oedema.
Palpation:
Firstly check skin temperature, with the back of your hand, and compare both legs.
Next check for capillary refill. Select a nail bed and compress it for several seconds. It
should take less than 2 seconds for the normal red colour to return.
Palpate for any varicose veins. Tenderness on palpation may suggest thrombophlebitis.
If oedema is present determine if it is pitting or non pitting.
Non pitting oedema may be suggestive of chronic venous insufficiency.
Next examine for peripheral pulses:
Femoral: At the inguinal ligament.
Popliteal: In the popliteal space with knee flexed and foot resting on the bed.
!34

Posterior Tibial: Behind the medial malleolus


Dorsalis Pedis: Lateral to the extensor tendon of the big toe.

Special Tests:
Trendelenburgs test:
First elevate leg to 90 to drain the veins. Apply a tourniquet to the upper thigh, and
then ask the patient to stand up. The veins should gradually fill in the next 30 seconds.
Release the tourniquet. If sudden additional filling of the veins occurs, then there is
sapheno-femoral incompetence.
Buergers Test:
Lift the patients legs to 45. Rapid pallor occurs with poor arterial supply. Then ask
the patient to dangle the legs over the side of the couch. Cyanosis occurs with PVD.
Auscultation:
Check for aortic bruit over the abdominal aorta
Check for Femoral bruits.

!35

ENDOCRINE WORKSHOP C
Thyroid Gland Examination; Breast Examination

Aims:
To perform an examination of the thyroid gland on a patient
To perform a breast examination

Thyroid Gland Examination:


Expose the neck fully, and comment if any thyroid swelling
Give the patient a glass of water and ask patient to swallow. Comment on your
observations.
Examine the neck from behind. Comment on size, shape, consistency,
tenderness, and nodularity of the thyroid.
Palpate thyroid movement on swallowing. Is the gland mobile or fixed?
Examine for any lymph gland swelling.
Move to the front and palpate again note if trachea is deviated.
Listen for any bruits.

Signs of Thyroid Disease


Examine the eyes. Check for exophthalmos (Graves disease); lid lag; lid
retraction.
Check for proximal muscle weakness.
Check reflexes delayed relaxation is a sign of hypothyroidism.
Pulse rate; rhythm.
Check for tremor, palmar erythema, sweating (hyperthyroidism).

BREAST EXAMINATION
Inspection
Position the patient sitting up with the chest fully exposed.
Inspect the nipples for abnormalities such as retraction (may indicate underlying
cancer) or a unilateral redness of the nipple (which may be a sign of Pagets disease).
Inspect the skin of the surrounding breast for any dimpling, peau dorange or
unilateral visible veins (which could again suggest a cancer).
Ask the patient to fix her hands on her hips and press against her hips. This causes her
pectoralis muscles to contract and highlights any subtle dimpling or fixation in the
breast tissue.
!36

Next ask the patient to raise her hands above her head. Inspect carefully again for any
asymmetry. This manoeuvre will especially make obvious if one of the nipples is fixed,
as it will not move symmetrical to the other nipple.

Palpation
Position the patient lying down. Palpation is performed with the palmar surface of the
middle three fingers, lying flat against the surface of the breast. Roll the fingers over
the breast tissues while pressing in lightly. Avoid use of the finger tips.
One needs to palpate all 4 quadrants of the breast systematically. One can visualise the
breast as a clock, and palpate each time zone from areola to periphery as one system of
ensuring that you do not miss any section.
Next palpate the axillary tail of the breast, between your thumb and fingers.
Check for lumps behind the nipple and if any fluid can be expressed.
Finally, palpate the axillary and supraclavicular lymph nodes systematically. When
examining the right axillary lymph nodes, rest the patients right arm on your right
forearm. Then use your other hand to palpate the five main groups of lymph nodes:
central, lateral, pectoral/ medial, infraclavicular, subscapular.
Features of a breast lump:
In describing a breast lump, you need to address the following aspects:
Posi%on''
Size'and'shape'
Consistency'(hard'or'so5)'
Tenderness''
Fixed'or'mobile'
Single'or'mul%ple'

!37

MUSCULOSKELETAL WORKSHOP A
Musculoskeletal (MSK) History
Aim: To be able to obtain a locomotor (musculoskeletal) history

Enquire re patients name and age


Enquire as to why the patient has come to see the doctor and what is his/her major
complaint

Screening Questions (GALS questionnaire) for MSK disease:

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

If all negative patient is unlikely to have a musculoskeletal problem.


If positive need to obtain a more detailed history.

COMMON MUSCULOSKELETAL SYMPTOMS:

Joint pain
Joint swelling
Joint stiffness
Muscle pain
Muscle weakness
Difficulty with function such as walking etc.

JOINT PAIN:
Where?
How long?
How did it occur?
Does it radiate anywhere?
How severe is the pain? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the pain?
Does anything make the pain better or worse?
Are there any other symptoms with the pain? Ask about swelling and stiffness
of the joints.
Does the pain interfere with your ability to perform certain functions/activities?
Have you ever had the pain previously? If yes, when, where, how often etc.
!38

SWELLING:
Where is it located?
Did it come on suddenly or gradually?
Is it intermittent or constantly present?
Any precipitating factors, such as injuries?
Are there any associated factors, such as pain, redness, warmth?
When is the swelling worse? Does it improve with elevation/overnight
STIFFNESS:
Which part of the body is affected?
When does it occur? Is it worse in the morning or in the evening?
How long does it last?
Need to determine if the Musculoskeletal symptoms are likely secondary to a problem
resulting from a joint disorder Arthritis
Questions to ask if the problem may be related to Arthritis
Does the problem arise from a joint?
Is the condition acute or chronic?
Is it an Inflammatory or Non-Inflammatory form of arthropathy?
What is the number of joints involved?
Monoarticular: only one joint involved
Pauciarticular: 2- 4 joints involved
Polyarticular: > 4 joints involved
Axial: predominant involvement of the spine
What is the pattern of affected joints?
What is the impact of the condition on the patients life?
Need to assess both physical and psychologic impact
Past Medical History:
Enquire about any previous episodes of similar symptoms
Enquire about any other illnesses
Ask about any prior injuries or surgeries
Family History:
Ask if any family member suffers from joint or muscle problems
Social History:
Ask about current and previous employment
Ask if symptoms interfere with patients ability to work or take care of
themselves
Ask about use of alcohol
Medications:
Ask if patient has taken any medication(s) for the problem
Obtain a complete list of all the medications that the patient is taking currently
Ask about medication allergies
!39

Systems Review:
Obtain a complete review of systems - in particular, any rashes, hair loss,
dryness of eyes or mouth, change of colour of digits upon exposure to cold
ambient temperatures, fevers, fatigue or change in weight.

!40

MUSCULOSKELETAL WORKSHOP B
Musculoskeletal (MSK) Examination Upper Extremity
GENERAL PRINCIPLES OF JOINT EXAMINATION: Look; Feel; Move.
LOOK:

FEEL:

Scars
Swelling
Rashes
Muscle wasting

is it sore

Temperature
Swelling
Tenderness

Range of Movement Active and Passive

MOVE:

FUNCTION:
Functional assessment of joint

Examination of the Upper Extremity


Aim: To perform a musculoskeletal examination of the upper extremity

EXAMINATION OF THE HAND AND WRIST


Inspect the backs of the hands for muscle wasting, scars, deformity or swelling.
Decide if the changes are symmetrical or asymmetrical and which joints or other
structures are mainly involved.
Look for skin and nail changes
Ask patient to turn their hands over and note any pain or difficulty in doing so.
Inspect the palms for signs of muscle wasting as seen with some neuropathies
and for swelling of the tendon sheaths.
Check wrist for carpal tunnel release scar.
Feel for radial pulse, tendon thickening, and bulk of thenar and hypothenar
eminences.
Assess skin temperature at the patients forearm, wrist and MCP joints using the
back of your hand. Is there any difference?
Squeeze MCP joints to assess for tenderness (watch the patients face for
evidence of discomfort)
!41

Bimanually palpate the MCP, PIP and DIP joints and note any swelling,
tenderness or warmth.
Check for tenderness and squaring of the 1st CMC joint.
Bimanually palpate the wrists.
Ask the patient to straighten their fingers fully and note inability to do so.

Ask the patient to make a full fist can s/he tuck their fingers into the palm? If
not move the fingers passively to determine if the problem is with the joints of
the tendons.
Asses wrist flexion and extension actively (prayer sign) and passively.
Assess grip strength.
Assess fine precision pinch by asking patient to pick up a small object.
EXAMINATION OF THE ELBOW
Look for scars, swellings, redness, muscle wasting, nodules or rashes.
Look from the front for the carrying angle and from the side for flexion
deformity.
Assess skin tenperature
While holding the elbow at 90, palpate over the head of radius and joint line
with your thumb for tenderness, swelling or warmth.
Palpate the medial and lateral epicondyles and olecranon process for tenderness.
Assess full flexion and extension actively and passively.
Assess pronation and supination, both actively and passively, in addition to
feeling for crepitus.
Assess function e.g. hand to nose or mouth.
EXAMINATION OF THE SHOULDER
Inspect the shoulder from in front, from the side and from behind checking for
symmetry, muscle wasting, scars etc.
Assess skin temperature over the front of the shoulder.
Palpate the bony landmarks (SC joint, AC joint, acromion process and around
the scapula) and surrounding muscles
Palpate the anterior and posterior joint line and bicipital groove.
Assess movement and function: hands behind head, hands behind back. How far
up the spine can s/he reach?
Assess movements of the shoulders, both actively and passively.
Observe scapular movement while patient is abducting the arm.
Movements of the shoulder:
Abduction: Request patient to raise arms above head, making the palms touch
(180)
Adduction: Request patient to move arm across front of chest (50)
Flexion: Request patient to raise arm forwards (180)
!42

Extension: Request patient to move arm backwards, with elbow bent (65)
Internal rotation: Request patient to turn arm in towards chest wall (90)
External rotation: Request patient to rotate arm laterally as far as possible (60)
with elbow at 90.
See Appendix III for further shoulder examination techniques.

!43

MUSCULOSKELETAL WORKSHOP C
Musculoskeletal (MSK) Examination Lower Extremity and Spine
Aims:
To perform a musculoskeletal examination of the lower extremity &
spine

EXAMINATION OF THE HIP


With the patient standing:
Observe the patients gait. Does s/he have an antalgic (painful) or Trendelberg
(commonly manifested as waddling) gait?
Look for gluteal muscle bulk.
Perform the Trendelenberg test: Ask the patient to alternately stand on each
leg alone; in an abnormal test the pelvis on the contralateral side will dip. This
test is used to assess proximal muscle strength.
With the patient lying on the couch:
Look for flexion deformity and leg length disparity.
Check for scars.
Palpate over the greater trochanter for tenderness (sign of trochanteric bursitis).
Assess abduction and adduction.
With the hip at 90 assess full hip flexion, internal and external rotation.
Perform Thomas test: with one hand under the patients back to ensure that
lumbar lordosis is removed fully flex the hip and observe the other leg. If it lifts
off the couch then there is a fixed flexion deformity in that hip.

EXAMINATION OF THE KNEE


With the patient standing:
Assess the patients gait.
Look for varus/valgus deformity and popliteal swellings.
With the patient lying on the couch:
Look, from the end of the couch, for symmetry, alignment, varus (lower leg
deviated medially)/valgus (lower leg deviated laterally) deformity, muscle
wasting, scars, rash and swelling.
Look from the side for fixed flexion deformity.
Assess skin temperature, comparing one side with the other.
With the knee slightly flexed palpate the borders of the patella for tenderness.
Swelling.
!44

With the knee flexed to 90 palpate the joint line, patellar tendon and tibial
tuberosity for tenderness and swelling.
Feel behind the knee for a popliteal (Bakers) cyst.
Perform the patellar tap to assess for an effusion.
Assess for the bulge sign (cross fluctuance)
Assess full flexion and extension, both actively and passively, and note range of
movement. Feel for crepitus.
Assess the stability of the collateral ligaments by flexing the knee to 15 and
alternately stressing the joint line on each side.
Assess the stability of the cruciate ligaments using the anterior and posterior
draw tests. Initially look from the side of the knee to check for a posterior sag or
step-back of the tibia which suggests PCL damage.

EXAMINATION OF THE FOOT AND ANKLE


With the patient standing:
Assess the patients gait cycle (heel strike, stance, toe-off)
Look at the forefoot for toe alignment,
midfoot (foot arch) for foot arch position &
hindfoot for Achilles tendon thickening/swelling and alignment.
With the patient lying on the couch:
Look at dorsal and plantar surfaces of the foot for symmetry, rashes, nail
changes, clawing and alignment of the toes, swelling and callus formation.
Assess skin temperature over the forefoot and ankle.
Squeeze the MTP joints and observe the patients face for any discomfort.
Palpate the midfoot, ankle joint line and subtalar joint for tenderness, swelling
and warmth.
Assess both active and passive movement at the:
ankle/tibiotalar (dorsi- and plantar flexion),
subtalar (inversion and eversion),
mid-tarsal (inversion and eversion with immobilisation of the heel) &
1st MTP (dorsi- and plantar flexion) joints.
Look at the patients footwear for abnormal wear

EXAMINATION OF THE SPINE


With the patient standing:
Inspect from the side and from behind for muscle wasting, asymmetry or
scoliosis of the spine.
Palpate the spinous processes, paraspinal muscles and sacroiliac joints for
tenderness.

!45

Assess movement of the cervical spine: flexion (chin to chest), extension (look
at the ceiling), rotation (look over each shoulder) and lateral flexion (ear to
shoulder).
Assess movement of the lumbar spine: flexion, extension, and lateral flexion
use the Schobers test to measure forward flexion.
Schobers test: With patient standing erect make a mark over midpoint between the
posterior superior iliac spines and another 10 cm higher; ask patient to bend forward
and re-measure between the 2 points: an increase of 5 cm is normal

With the patient sitting on the couch and arms crossed in front:
Assess thoracic rotation (with your hands on the patients shoulders to guide the
movement)
With the patient lying on the couch:
Perform straight leg raising (SLR) test: flex hip with knee straight until limit is
reached; then dorsiflex the ankle: -if positive, the leg pain is aggravated (this
confirms stretching of the sciatic nerve).
Asses limb reflexes and strength of the dorsi-flexors of the big toe.

!46

NEUROLOGY WORKSHOP A
Neurology History
Aim: To obtain a neurological history
Enquire re patients name, age & occupation
Enquire about the patients presenting complaint and the history of the presenting
complaint

Common symptoms are as follows:

Headache.
Weakness of the face, trunk or limbs
Paraesthesia (tingling/pins and needles) or numbness
Disturbance of vision
Disturbance of hearing
Disturbance of speech.
Disturbance of sphincter control (bladder or bowel)
Ataxia (loss of coordination)
Gait disturbance
Difficulties with cognition and/or memory
Tremor or involuntary movements.

HEADACHE
Where?
How long?
What type of pain? e.g. throbbing, sharp, dull etc.
What were you doing when it started it?
Does it radiate anywhere?
How severe is the headache? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the headache?
Does anything make the headache better or worse?
Are there any other symptoms with the headache? Ask about other neurologic
symptoms
Have you had headaches previously? If yes, when, how often etc.
WEAKNESS
Where?
How long?
How did it occur? e.g did it come on suddenly or gradually
How severe is the weakness?
Is it getting better or worse?
!47

Is it intermittent or constantly present?


Does it interfere with your ability to perform certain functions and if so what?
Are there any other symptoms with the weakness? Ask about other neurologic
symptoms
Have you ever had any weakness previously? If yes, when, which part of the body etc.

PARAESTHESIAS/NUMBNESS
Where?
How long?
How severe? Is it getting better or worse?
Is it intermittent or constantly present?
When does it occur? e.g. during the daytime or at night
Does anything bring on the paraesthesias/numbness? e.g such as certain movements
Are there any other symptoms? Ask about other neurologic symptoms
Have you ever had the parathesias/numbness previously? If yes, when, where, how
long did it last etc.

DISTURBANCE OF VISION
What type of disturbance? e.g. loss of vision, blurring of vision, double vision etc.
Does it involve one or both eyes?
How long?
How severe? E.g. is it total or partial
What were you doing when it began?
Is it getting better or worse?
Is it intermittent or constantly present?
Are there any other symptoms? Ask about other neurologic symptoms.
Have you ever had the disturbance of vision previously? If yes, when, where, how long
did it last etc.

DISTURBANCE OF HEARING
What type of disturbance?
Does it involve one or both ears?
How long?
How severe? E.g. is it total or partial
What were you doing when it began?
Is it getting better or worse?
Is it intermittent or constantly present?
Are there any other symptoms? Ask about other neurologic symptoms
Have you ever had difficulties previously? If yes, when, where, how long did it last etc.

DISTURBANCE OF SPEECH
What type of disturbance? e.g. is it difficulty in finding or saying the words?
How long?
!48

What were you doing when it began?


Is it getting better or worse?
Is it intermittent or constantly present?
Are there any other symptoms? Ask about other neurologic symptoms
Have you ever had the speech difficulty previously? If yes, when, where, how long did
it last etc.

DISTURBANCE OF SPHINCTER CONTROL


What type of disturbance? i.e bowel or bladder or both
How long?
How severe? e.g. is it total or partial
What were you doing when it began?
Is it getting better or worse?
Is it intermittent or constantly present?
Are there any other symptoms? Ask about other neurologic symptoms and back pain
Have you ever had problems with incontinence previously? If yes, when, where, how
long did it last etc.

ATAXIA
What type of disturbance?
Which part of the body is involved?
How long?
How severe? e.g. is it total or partial
What were you doing when it began?
Is it getting better or worse?
Is it intermittent or constantly present?
Are there any other symptoms? Ask about other neurologic symptoms
Does it interfere with your ability to perform certain functions and if so what?
Have you ever had similar symptoms previously? If yes, when, where, how long did
they last etc.

GAIT DISTURBANCE
What type of disturbance?
How long?
How severe? e.g. can you walk independently
What were you doing when it began?
Is it getting better or worse?
Are there any other symptoms? Ask about other neurologic symptoms including
vertigo, numbness, weakness etc.
Have you ever had similar symptoms previously? If yes, when, where, how long did
they last etc.

!49

DIFFICULTIES WITH COGNITION OR MEMORY


What type of difficulties?
How long?
Is it getting better or worse?
Are there any other symptoms? Ask about other neurologic symptoms.
Have you ever had similar symptoms previously? If yes, when, where, how long did
they last etc.
Obtain a collateral history (information from a family member/friend) if possible.

Past (Medical & Surgical) History:


Enquire re previous diagnosis of neurological disease or other diseases that may
predispose to neurologic disorder
Enquire re previous surgery.
Family History:
Enquire re family history of neurological disease/ medical conditions.
Social History:
Enquire about smoking history
Ask if patient drinks alcohol & what their usual weekly consumption is.
Enquire as to the patients occupation.
Enquire about patients ability to function e.g. doing activities of daily living etc.
Medications:
Ask patient what medications they are on, including prescribed and OTC
medications
Allergies:
Enquire if the patient has any medication allergies
Systems Review:
Systematic review of symptoms involving body systems.

!50

NEUROLOGY WORKSHOP B
Cranial Nerves Examination
Aims: To perform a mini-mental state examination
To carry out an examination of the cranial nerves

HIGHER FUNCTIONS
Ask if the patient is left or right handed. Establish if the patient is alert and able to give
a clear history. If relevant, test for dysphasia, examine the mental state and perform the
Mini Mental State Examination (see Appendix V).

EXAMINATION OF THE CRANIAL NERVES


Cranial Nerve I Olfactory nerve: (need containers with coffee or peppermint)
Ask if the patient can appreciate taste and smell. Further testing is not necessary unless
the patient complains of abnormal taste or smell or there is a special reason to test
olfaction. If testing is needed check that the airway is clear and test each nostril with a
basic smell, such as peppermint or coffee.
Cranial Nerve II - Optic nerve: (need 3- or 6-metre Snellen chart and pinhole)
Visual acuity
Ask patient if they are aware of reduced vision in either eye. Test visual acuity wearing
distance glasses, if worn, in each eye separately with Snellen chart. Use 3-metre chart
at 3 metres or 6-metre chart at 6 metres, which produce equivalent results.
If visual acuity less than 6/6 use a pinhole. Record visual acuity right (VAR) X/60
with/without aid of pinhole/glasses and visual acuity left (VAL) Y/60 with/without aid
of pinhole/glasses.
Visual fields (need 7 mm red pin)
Ask patient if they are aware of a field defect in either eye. Establish that the small red
pin target (7 mm) is visible with each eye. Test extent of visual field by testing each
eye from each quadrant asking the patient to state as soon as they can see the pinhead
at all (regardless of colour).
Fundoscopy (need ophthalmoscope and darkened room)
Use the ophthalmoscope to examine the fundus of each eye separately with the other
eye fixating in the distance. Hold ophthalmoscope correctly (examining right eye with
ophthalmoscope in right hand and using right eye and examining left eye with
ophthalmoscope in left hand and using left eye unless good reason not to be able to do
so). The index finger should be on the focussing wheel. Assess red reflex for presence
!51

of media opacities. View fundus at an appropriate distance from the patient and focus
the ophthalmoscope.

Cranial nerves III, IV and VI Oculomotor, trochlear and abducent nerves:


(need torch)
Inspect for ptosis (drooping eyelid), pupil size, strabismus (squint), proptosis.
Test for pupil light reaction and accommodation in each eye separately.
Look for nystagmus within a 30o range.
Cranial Nerve V Trigeminal Nerve: (need cotton wool, pin or neurotip, tendon
hammer)
Ask if the patient has any numbness or altered sensation in the face.
Test light touch in each of the three divisions of the trigeminal nerve.
If an abnormality is found determine its extent with a pin.
Test the corneal reflex with a wisp of cotton wool, touching cornea not sclera. Avoid
touching eyelashes and eliciting a threat reaction.
Motor division: Ask patient to clench teeth, open and the close mouth against
resistance. Test for jaw jerk also.
Cranial Nerve VII Facial nerve:
Look for facial asymmetry.
Test frontalis ask patient to wrinkle the forehead/raise their eyebrows.
Test orbicularis oculi ask patient to close eyes tightly: look for burying of the
eyelashes.
Test orbicularis oris the patient is asked to show their teeth.
Ask patient to blow out their cheeks.
Ask about taste.
Cranial Nerve VIII Auditory and vestibular nerves: (need 256 or 512 Hz tuning
fork and auroscope)
Ask if the patient has a problem with their hearing. Test by first speaking and then
whispering numbers at three feet with masking of the non-tested ear using a piece of
paper held over the non-test ear and scratching it when speaking or whispering.
If hearing loss is reported (history or examination) first perform the Weber test. Strike
a 256 or 512 Hz tuning fork on your knee and apply it firmly to the patients forehead.
Ask whether they hear it more on one side or the other or equally. The tuning fork
lateralises to the side of greater conductive loss or the side with the better cochlea in
sensori-neural hearing loss. Then perform the Rinne test with the same tuning fork.
First apply the tuning fork firmly to the mastoid process and then hold it in front of the
external auditory meatus. Ask the patient which is louder. Patients with normal middle
ear function hear better by air than bone conduction.
Examine the external auditory meatus and tympanic membrane with an auroscope.

!52

Examination of the vestibular nerve includes testing stance and gait, see below, and for
nystagmus, see above.
Cranial Nerve IX Glossopharyngeal nerve:
Not necessary.

Cranial Nerve X Vagus nerve: (need torch, tongue depressor)


Ask about difficulty swallowing. Test articulation (for dysarthria), coughing and
elevation of the soft palate on saying Aah! If any of these are abnormal test gag reflex
by touching the posterior pharyngeal wall on each side with an orange stick and
comparing the responses.
Cranial Nerve XI Spinal- Accessory nerve:
Test sternocleidomastoid examined with the head tilted to the opposite side and with
resistance against the testers hand placed at the angle of the jaw. The muscle belly is
visible and may be palpated. Neck flexion is a useful screening test but not sufficient.
Test trapezius by asking the patient to shrug the shoulders and palpating the muscles,
with shoulders elevated.
Cranial Nerve XII Hypoglossal nerve: (need torch)
Observe the tongue rest in the floor of the mouth for wasting and fasciculation.
Observe protrusion of the tongue and note deviation.
Observe tongue movements for slowness seen in UMN lesions.
After the workshop you should familiarise yourself with the features of the various
cranial nerve palsies, eg 3rd nerve palsy, 6th nerve palsy etc.

!53

NEUROLOGY WORKSHOPS C AND D


Peripheral Neurologic Examination I and II
Aim: To perform an examination of the peripheral nervous system

ORDER FOR EXAMINATION OF THE NERVOUS SYSTEM


The conventional order for describing the examination is:

General appearance
Stance and gait
Higher functions
Cranial nerves
Motor system
Sensory system

STANCE AND GAIT


Ask the patient to rise from a chair without using their hands and stand still with their
feet together.
Ask the patient to stand on their toes and then their heels, steadying the patient by
gently holding their hands.
Watch the patient walk across the room turn round and come back to you looking for:
Whether the gait is normal or abnormal
Painful gait
Unsteadiness
Foot drop
Hemiparetic gait
Spastic gait
Stooped posture, slowness and loss of arm swinging
Others: marche petit pas, Waddling gait
If, and only if, the patient is steady, test heel-toe walking
The upper and lower limbs are examined separately. The examination of the upper or
lower limbs is divided into six parts:

Inspection
Tone
Power
Coordination
Sensation
!54

Reflexes

Tone:
Tone is an assessment of the freedom of movement of a joint when moved passively,
and is described as being normal, reduced (hypotonia), or increased (hypertonia).
Power:
Power is tested by comparing the examiners strength against the patients full
resistance. Power can be graded as follows:
Grade

Paralysis

Flicker

Movement when gravity excluded

Movement against gravity

Movement against some resistance

Normal Power

EXAMINATION OF THE MOTOR SYSTEM


UPPER LIMBS
The patient should be seated with the upper limbs exposed to show the shoulders and
their arms outstretched and the hands supinated and then pronated.
Observation
Look for:
Any obvious abnormality
Skin changes (including scars, ulcers, caf au lait patches, neurofibromas)
Deformity (including joint swelling, asymmetry)
Wasting (especially first dorsal interosseous, abductor pollicis brevis, shoulder
muscles)
Involuntary movements (fasciculation, tremor, dystonia, chorea, myoclonus).

!55

Tone
Test wrist pronation-supination for a pronator catch in spasticity. Test for rigidity by
slow rotation of the stabilised wrist.

!56

Power
Test the following muscle groups in order, comparing each side as you progress. Each
movement should be tested in isolation: thus to test elbow flexion you must fix the
upper arm with your free hand.
Movement

S t a r t i n g Note
position

Shoulder abduction

900 abduction

Elbow flexion

900 flexion

Elbow extension

900 flexion

Wrist extension

Full extension

Extensor digitorum communis Full extension

Apply pressure over PIP joints

Grip

Open patients grip

First dorsal interosseous

Full abduction

Test in isolation

Abductor pollicis brevis

Full abduction

in a plane at right angles to the


palm

Reflexes
You will recall from physiology that when a muscle is stretched receptors will fire, and
a spinal reflex will cause the muscle to contract in response. This is the principle
behind eliciting tendon reflexes. When you strike a tendon correctly, with a tendon
hammer the attached muscle is stretched and will reflexly contract in response.
Test Biceps, Supinator (=brachioradialis) and Triceps Reflexes.
If the reflexes are absent, use reinforcement.
Co-ordination
The cerebellum controls coordination of muscle movements. The following tests can
be used to test coordination in the limbs:
Finger nose test:
Ask the patient to touch the tip of your stationary finger, at full stretch, accurately and
gently, and then the tip of their own nose with first one and then the other index finger.
Intention tremor increases as the target is approached and past pointing is overshooting
of the target. Note this test is performed with the subjects eyes open. Asking the
patient to touch his nose with the eyes closed is a test for proprioception.
Test for dysdiadochokinesis:
Ask the subject to pronate and supinate one hand on the dorsum of the other as quickly
as possible. Difficulty with this test is called dysdiadochokinesis and is a sign of
cerebellar dysfunction.
!57

Bradykinesia
Test fine finger movements to detect bradykinesia if parkinsonism is suspected.

LOWER LIMB
Then ask the patient to recline on a couch undressed to shorts if possible

!58

Observation
Look for:

Any obvious abnormality

Skin changes (including hair loss, ulcers)

Deformity (including joint swelling, pes cavus, claw toes)

Wasting (especially quadriceps and tibialis anterior (when the tibia


stands out like a keel)

Involuntary movements (fasciculation, tremor).


Tone
Check that the patient does not have pain in their limbs. Roll the leg on the couch and
then quickly flex the knee to detect a quadriceps catch (present in spasticity). Test for
ankle clonus.

Power
Test the following muscle groups in order, comparing each side as you progress:
Movement

Starting position

Note

Hip flexion

Max voluntary flexion

Knee straight

Hip extension

Lying flat

Hand under knee

Knee flexion

900 flexion

Knee extension

900 flexion

Ankle dorsiflexion

Full dorsiflexion

Ankle plantar flexion

Full plantar flexion

Extensor hallucis longus

Full dorsiflexion

Test for L5 root lesion or


peripheral neuropathy

Co-ordination
Ask the patient to lift the heel high and then carefully place it on the knee of the other
limb and run it down the shin once. This test is difficult to interpret if hip flexion is
weak.
Reflexes
Examine the knee and ankle reflexes (with the joints at 900) and (with an orange stick)
the plantar responses. If the reflexes are absent, use reinforcement.
!59

See Appendix IV for Aid to examination of motor function

EXAMINATION OF THE SENSORY SYSTEM


Ask if the patient has noted altered sensation in any part of their body. If the answer is
negative, show the patient what each of the following feel like with their eyes open and
them check that they can appreciate them on the distal phalanx of the index finger and
hallux with their eyes closed:
Light touch with your finger tip or by touching (not stroking) the skin with cotton
wool
Pinprick with a neurotip or tooth pick with the patients eyes open asking whether
they can feel that it is sharp and hurts like a pin. Patient is asked to differentiate
between sharp and dull.
Vibration is tested with a 128 Hz tuning fork on bony prominences
Joint position sense (Proprioception) is tested by asking the patient to identify the
direction of movement of the distal phalanx.
Temperature is tested using test tubes filled with cold and hot water (in practice
temperature sensation is inconvenient to test and is only performed in rare and specific
situations)

If the patient reports an abnormality map out its extent with light touch or pinprick
testing or compare the two sides and draw it on a body chart.
Pain and temperature sensation are carried in the lateral spinothalamic columns.
Light touch, vibration and proprioception are carried in the posterior spinal columns.

!60

APPENDIX I
Common causes of Chest pain:
Angina / myocardial infarction
Pericarditis
Pneumothorax
Pneumonia
Pulmonary embolism
GORD
Oesophageal spasm
Costochondritis
Some Characteristics of Chest pain:
Angina is commonly described as a heaviness, tightness or choking sensation.
Angina most commonly presents as retro-sternal /central chest tightness which
may radiate up to the jaw or down the arms. It typically occurs with exertion but
may occur at rest also. It is also relieved by nitrates.
Pain secondary to pericarditis may be relieved by sitting forward.
2. Dyspnoea
Typically occurs on exertion due to failure of left ventricular output to increase
with exercise.
Paroxysmal Nocturnal Dyspnoea wakes patient from sleep with sudden shortness
of breath due to sudden failure of left ventricular output.
3. Ankle Swelling
Ankle oedema due to cardiac causes is usually symmetrical, worse in the
evenings and improves during the night
Can be due to bi-ventricular failure or right ventricular failure 2 to lung disease
Other causes include hypoalbuminaemia, e.g. nephrotic syndrome and cirrhosis
Non-pitting oedema may be due to hypothyroidism or lymphoedema
Unilateral lower limb oedema may be caused by DVT or compression of large
veins by tumour / lymph nodes
4. Palpitations
Term is imprecise; Usually refers to awareness of heartbeat
Examples:
missed beat followed by heavy beat = probable APC / VPC
sudden onset = probable cardiac arrhythmia
gradual onset = probable sinus tachycardia
completely irregular rhythm = atrial fibrillation

5. Syncope / Dizziness
Syncope refers to transient loss of consciousness due to cerebral anoxia
Examples:
!61

Simple faint (vasovagal episode) e.g. overcrowded room


Postural (standing suddenly). Check if patient is on anti-hypertensives
Micturition syncope, Tussive syncope (precipitated by coughing)
Cardaic arrhythmia
Exertional syncope can occur with aortic stenosis or HOCM

APPENDIX II
Differential Diagnosis for Acute Abdomen
Severe abdominal pain, with generalised rigidity:
Perforated peptic ulcer
Perforated bowel
Ruptured AAA
Severe pancreatitis
Tenderness/rigidity right hypochondrium:
Acute cholecystitis
Acute pyelonephritis
Perforated DU
Subphrenic abscess
Hepatitis
Cholangitis
Right sided pneumonia
Tenderness/rigidity left hypochondrium:
Pancreatitis
Diverticulitis
Acute pyelonephritis
Ruptured spleen
Left sided pneumonia
Tenderness/rigidity in RIF
Appendicitis
Salpingitis
Ruptured ectopic pregnancy
Crohns disease
Psoas abscess
Tenderness/rigidity in LIF
Sigmoid diverticulitis
Salpingitis
Ruptured Ectopic Pregnancy
Crohns disease
Epigastric area:
!62

Myocardial Infarct
PUD
Acute cholecystitis

APPENDIX III
Examination of the Shoulder
Bicipital Tendinitis

Tenderness over the bicipital tendon - tender area will migrate with bicipital
groove as arm is abducted & externally rotated.

Speeds Test: pain in the bicipital groove with forward flexion of the shoulder
about 30 against resistance with elbow extended and arm fully supinated

Yergasons test: pain in the bicipital groove with resisted supination of the
pronated forearm with the elbow at 90 and shoulder adducted.

Tests for Impingement

Neer or passive painful arc test - passive flexion of the glenohumeral joint
while preventing shrugging

Hawkins test - with the patients shoulder stabilized with one hand and with
the patients elbow flexed at 90 the clinician internally rotates the shoulder
with the other hand

Yocums test - the hand of the affected side is placed on the shoulder of the
patients unaffected shoulder; the elbow is then raised without elevation of the
shoulder

!63

APPENDIX IV
Aid to examination of motor function
MOVEMENT

MUSCLE

UMN

Shoulder Abd.

deltoid

Elbow Flex
cutaneous

biceps

C5/6

musculo-

Brachio-radialis

C6

radial

radial

++

ROOT

REFLEX

C5

NERVE
axillary

Elbow Ext.

triceps

C7

Radial Wrist Ext.

ECRL

C6

Finger Ext.

EDC

C7

(+)

PIN

Finger Flex

FPL + FDP index

C8

AIN

FDP ring + little


Finger Abd.

1st DI

radial

ulnar
++

APB
++

T1

ulnar

T1

median

L1/2

femoral

Hip Flex.

iliopsoas

Hip Add.

adductors

L2/3

Hip Ext.

gluteus max.

L5/S1

sciatic

Knee Flex.

hamstrings

S1

sciatic

Knee Ext.

quadriceps

Ankle dorsiflex.
peroneal

tib. ant.

Ankle eversion
sup.peroneal

peroneii

L5/S1

Ankle plantarflex.

gastroc./soleus S1/S2

++

L3/4
++

L4

!64

++

obturator

femoral
deep

tibial

Big toe ext.


peroneal

EHL

L5

!65

deep

APPENDIX V

Mini Mental State Examination

This examination is commonly undertaken in the elderly if dementia is suspected. The


maximum score on the test is 30. A score of <25 suggests dementia but remember that
acute confusional states or depression may also give a lower than normal reading.
Ask the patient the following questions:
1. What day of the week is it? (1 point)
2. What is the date today?(day/ month/ year)( 1 point each)
3. What is the season?(1 point)
4. Can you tell me where we are now (what country are we in)?(1 point)
5. What is the name of this town/city?(1 point)
6. Can you name 2 nearby streets(1 point)
7. What floor of the building are we on?(1 point)
8. What is the name of this place (or what is the address)(1 point)
9. Give patient the following instruction- I am going to give you a piece of paper .
Please take the piece of paper in your right hand. Fold the paper in half with both
hands, and put the paper down on the floor.(1 point for each of the 3 actions)
10. Show patient a pencil and ask what it is called (1 point)
11. Show patient a watch and ask what it is called (1 point)
12. Say, I am going to say something and I want you to repeat it after me, No ifs,
ands, or buts(1 point)
13. Tell patient to, read the following and carry out the action requested. Hand them a
piece of paper with the instruction CLOSE YOUR EYES written on it.(1 point)
14. Request patient to write a complete sentence on a sheet of paper (1 point)
15. Show patient a drawing of two 5 sided figures intersecting to form a 4 sided figure.
Request patient to copy the drawing (1 point) Patient scores if intersection is a 4
sided figure, and all angles are preserved.
16. Next tell patient that you are going to name 3 objects. Ask patient to repeat all
three. Ask patient to remember objects as you will ask them to name them again in
a few minutes.(1 point each)
17. Now ask patient to subtract 7 from 100, and to keep subtracting 7 until you tell
patient to stop. Continue for 5 subtractions (5 points)
18. Ask patient to repeat the 3 objects from earlier (1 point each)

!66