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Resource name Medicine clinical examination

Resource Medicine clinical examination
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Bow Road 153-159
E3 2SE, London
Telephone: +44(0)2089800039
Mobile: +447940433068
Email: info@samsonplab.co.uk

MEDICINE CLINICAL EXAMINATIONS

II-VI CRANIAL NERVES EXAMINATION

A) II cranial nerve:

Mr Brown is a 50 year old gentleman who sustained a head injury. Please perform
examination of cranial nerves II-VI.

1. Inspection Front Discharge, redness, swelling, scars, sinuses,

excess lacrimation, lid retraction, ptosis, eyes on
same level

Back proptosis = exopthalmus (ask the patient

to look up to the ceiling)

2. Reflexes

a. Red reflex - stand ½ half a meter away and 15 ° from the centre

b. Light reflex Direct light reflex

Consensual light reflex

 c. Accommodation reflex – Ask the patient to look at the wall behind you and then at
your finger.

NB: If you ask the patient look in front do not obstruct him.

3. Visual acquity

1. Finger counting
2. If cannot count fingers then wave hands
3. If cannot see hand then shine light
4. If cannot see bright light then he/she has total blindness

Ideally, I will use an Ischihara chart for colour vision and a Snellen chart visual acquity.

N.B: In the PLAB exam, patients are usually able to count fingers.

4. Peripheral visual field

Principles:

1. Check one eye at a time.

2. The patient and the examiner should cover eyes which are located on one side.
3. Move the fingers or the white pin slowly from the periphery centrally, until the
patient can see it. In the exam always use a white pin, not your finger.

B) III, IV, VI cranial nerves:

Instructions:

I will be moving my finger in front of your face, please follow it with your eyes but do
not move your head. Whenever you see double let me know.

Make an H:

N.B: Do it up and down, and side to side. Do not be too fast.

Check for nystagmus, ophthalmoplegia, and diplopia.
C) V cranial nerve:

Sensory Function Motor Function

Instructions:

Sensory: Mr Jones this is a wisp of cotton, I will be touching it on your face.

This is how it feels (touch on the sternum)
Whenever you feel me touching you just say ‘ yes’ .

Motor: Check for muscles of mastication (masseter and temporalis)

Place your hands on the sides of the patients face (warn before touching them) and
ask patient to clench his teeth.

Ideally, I will test corneal reflex and jaw jerk reflex.

NB: Do not drag the wisp of cotton, just touch.

D) VII cranial nerve:

Taste Muscles of expression

(anterior 2/3 of tongue)

1. Do you have any problem with tasting food?

2. Can you please close your eyes tight; I will try to open them but do not allow me to do
it.
3. Can you show me your teeth by saying yeeee?
4. Can you frown at me?
5. Can you puff out your cheeks?

DIPLOPIA
Mrs Chola has been experiencing double vision, Please examine her eyes to find the cause of
her double vision. Please give your findings to the examiner while you are doing the
examination.

1. Inspection:
 Front: DRSSS ptosis Back: Proptosis/ exopthalmus
Eyes on same level

2. Reflexes

1. Red reflex:

Use an ophthalmoscope, dim the lights, and shine the light in her eye. You will see a
red dot on the eye. This is the red reflex. It can sometimes be seen in photographs.

2. Light reflex - Direct and Consensual

3. Accommodation reflex

Instructions:

Can you please look at the wall and then at my finger.

NB: Do it 2 times and place your finger 1 metre from her eyes.

3. Visual acquity

1. Finger counting
Ideally, I will use a Snellen chart

2. Colour vision
Ideally I will use an lschihara chart

4. III, IV, VI Cranial nerve

Make an H:
 RULES OF DIPLOPIA

i. The outer image is a false image or the image which is furthest away from the eye
is the false image.
ii. The eye that sees the false image is the affected eye.
iii. Double vision is maximum in the direction of gaze of the affected muscle.

Types of Diplopia:

There are 2 types of diplopia:

Monocular Diplopia: You see double vision with one eye.

Binocular Diplopia: You see double vision only when both eyes are open.

In PLAB, usually you will have binocular diplopia, which means only when a person has both
eyes open he will see double. The moment one eye is covered the patient will not see double.

How to analyse diplopia:

Make sure you finish the whole ‘ H’ movement before you start to analyse diplopia.

Do you see double here? (YES)

Do you see these images as an inner image and an outer image? (YES)

Can you please cover your right eye.

Do you still see double? (NO)

Which image do you see, the inner or the outer?

Can you please cover your left eye.

Do you still see double? (NO)

Which image do you see, the inner or the outer?

Give your finding to the examiner: Which eye, which muscle and which cranial nerve.

5. Test for Latent Squint:

Cover - uncover test

Cover - cover test
N.B: Use a covering pad for cover – uncover and cover – cover test.

VISUAL FIELD EXAMINATION

Mr Jackson was involved in a road traffic accident and sustained a head injury. Please
examine the visual field of this patient.

A. Peripheral visual field:

1. Use a white pin.

2. Sit 1 metre from the patient, check with your hand.

Possible Findings:

These diagrams are not complete, we will shade them in during the class.

1. Normal Visual Field

2. Right Homonymous Hemianopia

3. Left Homonymous Hemianopia

4. Bitemporal Hemianopia
5. Tunnel Vision

Pitfalls:

1. Generally, when checking visual acquity you place fingers or object 1 metre away from
the
Patient and put on the centre.

2.Patient with hemianopia or tunnel vision, place your fingers centrally when checking for
visual acquity.

B. Central field of vision: (blind spot and central scotomas)

BLIND SPOT:

1. Use red pin

2. Check first for a blind spot
3. Both the doctor and patient cover one eye each just like when checking peripheral
visual field
4. Stay 1 metre from the patient
5. Place the red pin between patient and yourself
6. Move the pin from centre to periphery slowly

Instructions:

Miss Richards, can you see this red pin? I need you cover one of your eyes and I will then be
moving the pin in front of your eyes. Please tell me it disappears and when it reappears.
Pin movement:

1. Move the pin from the centre of the eye to the temporal side, ask the patient to tell
you when it disappears and when it reappears.
2. Move the pin back to the blind spot and then do the same, moving the pin upwards
and then downwards.
3. Repeat the same steps on the other eye.

CENTRAL SCOTOMA:

Move the red pin like in peripheral field, but you are interested to see if the red pin will
disappear after being seen by the patient. Therefore, after the patient has seen the pin as
red, continue moving it towards the centre to see if it will disappear at any time.
EIGHTH (8th) NERVE EXAMINATION
Mr Ferdinand is a 57 year old gentleman who has been experiencing dizziness and hearing
problems. Please examine the 8th nerve of this patient and give your findings to the examiner.

1. Inspection of ears: Discharge, redness, swelling, scars, sinuses and mastoid bruising.

2. Palpation: Temperature, tenderness and tragus test

3. Ideally I will do Otoscopy

4. Hearing test (rubbing fingers)

5. Rinne's and Weber's tests – Use tuning fork 512Hz or 256Hz)

6. Ideally I will do Hallpike and Caloric test

7. Nystagmus –move the pin left, right, up and down.

8. Romberg's test – ask the patient to stand with his feet together and look straight
ahead.

9. Marching test – ask the patient to lift their hands straight in front of them, march on
the spot and then close eyes and continue marching)

10. Gait

11. Tandem walking – ‘ Can you walk in a straight line with your heels touching your
toes?’

Findings: Sensorineural hearing loss on one side and positive Romberg’ s test.

N.B:
Rinne’ s Test: First place the tuning fork behind the ear (on the mastoid bone) and then in
front of the ear.

Weber’ s Test: Place it in the middle of the forehead, and ask the patient to tell you in which
ear he hears it better.

ALCOHOLIC /DIABETIC FOOT EXAMINATION

Mr. Williams is a 72 year old gentleman who is known to be alcoholic. Please do sensory
examination of lower limbs and check for reflexes.

(Sometimes the question says do neurological examination, which is the same as sensory and
reflexes)

Neurological examination:

1.Touch sensation
2.Vibration sensation
3.Position sensation
4.Pain sensation (Neuropin)
5.Reflexes (only ankles and knee reflexes)

Instructions to the patient:

This is a buzzing instrument, I will be placing it on your legs and you will feel it like this
(demonstrate on the sternum – ‘ can you feel the vibration?’ ). Whenever you feel it say
‘ yes’ .

Exam Tips:
1. Always start from the toes going up when you are checking for sensation and find the
level of loss of sensation.
2. Be clear with your instructions to the patient and always demonstrate especially for
the position and vibration sensation.
3. Use a neuropin for pain sensation. In the exam the task may say use the blunt side
instead of sharp side.
4. Throw the neuropin in the sharps bin.
5. Check sensation on both the medial and lateral aspect of the limbs, to make sure it is
not dermatomal loss.
6. Use monofilament for sensation on the sole of the foot.

DIABETIC FOOT:

Mr Robinson is a 67 year old man who is a known diabetic. He has recently been complaining
of a feeling of pins and needles in his lower limbs. Please do relevant examination of his
lower limb.
(Examine the patient for lower limb complications of diabetes).

1. Inspection – Front and back (DRSSS, pigmentation, ulcers, hair distribution, skin shininess).
Lift legs –> Ulcers on pressure area and fungal infection in between the toes.

2. Gait (high stepping or normal)– ideally I would ask my patient to walk to check the gait.

3. Temperature – Feel feet and calves (feet are not cold, calves are not warm)

4. Tenderness – Feet and calf

5. Capillary refill is <2sec (press for 5 seconds on the nail bed)

6. Dorsalis pedis and posterior tibialis on both sides at the same time

7. Neurological – Sensation →
 Touch (wisp of cotton)
 Position (demonstrate to the patient which position is up and which is down)
 Vibration (use a 128Hz tuning fork, placing the tuning fork on the bony
prominences of the joints beginning from the big toe upwards)
 Pain (use a neuropin, and dispose of it in the sharps bin afterwards)
 Reflexes (ensure the patient relaxes the leg then you cross it by yourself and
dorsiflex the ankle before striking. Then do the knee jerk)
Usually there is loss of sensation in a gloves and socks pattern.

N.B: Sometimes you get the alcoholic foot, so approach it exactly like diabetic foot
examination.

LYMPHORETICULAR EXAMINATION
Mr. Joseph Nkonde is a 28 year old gentleman who is suspected of having leukemia. Please
do the lymphoreticular examination.

Exposure: Complete exposure but you can remain in your briefs.

Purpose of this examination: To examine the glands in your body.

EXAMINATION:

1. Sitting: Cervical and head Lymph nodes

N.B: Make sure patient sits in the chair and not on the couch when checking lymph
nodes of the head and neck.

2. Standing: Axillary lymph nodes

 `
3. Lying down: Head to toe

 Head: alopecia

 Ears: signs of infections
 Nose: crusting, bleeding
 Mouth: gum hypertrophy, pigmentation, dental abscess. (use a pen torch)
 Ideally I will do posterior rhinoscopy to check for adenoids (use torch and
tongue depressor to check the tonsils)
 Neck: engorged neck veins, trachea central
 Chest: Ideally I will do CT scan to check for Thymus gland and
Mediastinal group lymph nodes
 Abdomen: palpation of liver and spleen (the technique must be good)
 Ideally I will do CT scan to check for the intra-abdominal group of
lymph nodes

4. Inguinal lymph nodes: Warn the patient: Joseph I need to feel for some glands in
your groin. It might be uncomfortable, please bare with me.

5. Popliteal lymph nodes and cubital/epitrochlear lymph nodes

N.B: The technique of liver and spleen palpation must be correct. Ensure you get to the liver
and spleen during the exam. Again, if the patient is sitting on the couch, ask him to move to a
chair before you do the cervical lymph node examination.

Cervical lymph node group:

 Submental
 Submandibular
 Jugulodigastric
 Pre-auricular
 Post-auricular
 Occipital
 Anterior cervical
 Posterior cervical
 Supraclavicular

Axillary group:

 Anterior
 Central/Medial
 Apical
 Posterior
 Lateral
 CARDIOVASCULAR EXAMINATION
Mr White is a 60 year old gentleman who had a heart attack. He has been getting short of
breath recently. Please do cardiovascular examination looking for signs of heart failure.

Sit the patient at 45 degrees for this examination.

Exposure: Above the waist

1. General inspection: No pallor, clubbing, koilonychia, no splinter haemorrhages, no

palmar erythema, no sweating, no osler's nodes, no janeway lesions.

2. Pulse: regular, good volume, there is no radial-radial delay. Ideally I will do radio-
femoral delay.

3. Collapsing pulse

4. The blood pressure is 120/80 mmHg (if given in the question) or ideally I will check the
blood pressure.

5. Eyes: Look up – no pallor

Look down – no icterus

6. Mouth: Open your mouth and roll your tongue up – no central cyanosis

7. Can you turn your head to the left please?

JVP not raised
I will be touching your tummy – No hepatojugular reflux

8. I will be touching your legs – there is peripheral oedema

9. There is no Precordium bulge – from foot end

8. There is no parasternal heave - from the side

9. The apex beat is in the 5th Intercostal space left mid-clavicular line

10. No parasternal heave on palpation, no palpable thrills, and palpate for carotid pulse

11. Auscultate for heart sounds, whilst you palpate for the carotid, as follows:

First use the diaphragm

Apex, Tricuspid, Pulmonary, Aortic

I. Then use the bell on all four areas

 Apex, Tricuspid, Pulmonary, Aortic

II. Now auscultate for specific murmur

a) Apex with a bell and while lying on the left side while expiration
b) While patient is sitting up and leaning forward (pulmonary area inspection,
aortic area in expiration)

12. Lung base –no basal crepitations

13. Sacral oedema – Findings: I + II heart sounds, no murmur, no added sounds and no
basal crepitations.

14. Auscultate for the carotids (for bruit) – use diaphragm.

RESPIRATORY EXAMINATION

Exposure: Above the waist

Purpose of examination: To examine your chest and hands

1. General inspection: Pulse, blood pressure, pallor, JVP and flapping tremor.

2. Do inspection of the chest

Foot end  chest moving symmetrical with respiration, patient is comfortable and
not in distress, no medication around the bed to suggest treatment for respiratory
disease.

Close range:
 DRSSS
 Deformity
 Intercostal recession/ sternal recession
 Flaring of ala nasae
 Cyanosis
 Ideally I will check the respiratory rate for 1 minute (from foot end)
 Use of accessory muscles
 Not in obvious respiratory distress

3. Palpation:
 Chest expansion
 Trachea central
 Vocal tactile
  Chest wall tenderness

4. Percussion: Comparison pattern.

5. Auscultation: For breath sounds

Vocal response (every time I touch your chest with the stethoscope please say
99)

6. Go posterior and repeat all of the examinations (inspection, palpation, percussion,

auscultation).

N.B: First finish all of the examinations anteriorly and then move posterior.

CEREBELLAR EXAMINATION
A 65 year old man has been complaining of unsteadiness on his feet. Please do an
examination of the cerebellum.

Exposure: Complete exposure but can remain in his/her briefs

1. Sitting:
1. Speech: say British Constitution (scanning speech)
2. Nystagmus (vertical or horizontal nystagmus)
3. Flip-flop (no dysdiadochokinesis)
4. Finger-nose (past-pointing)

2. Standing:
1. Romberg's (first do it with eyes open – this is cerebellar ataxia and then with eyes
closed this is now Romberg test which is for sensory ataxia)
2. Marching or turning test
3. Gait
4. Tandem walking (walk in a straight line with your heels touching your toes)

3. Lying:
1. Heal-shin test
2. Neurological examination:
 Tone
 Reflexes (both upper and lower limbs)
 Power
 Plantar reflexes and pupillary reflexes
 Muscle bulk– Ideally I would use a measuring tape for muscle bulk but
on inspection there is no muscle wasting.
DIZZINESS/VERTIGO
Mr. William is a 60 year old man who has been complaining of dizziness. Please do relevant
examination to reveal the cause of her symptoms.

1. Inspection of ears: DRSSS, mastoid bleeding

2. Palpation around the ear for: Temp, Tenderness.

3. Tragus test. Ideally I will do otoscopy

4. Hearing test: Finger rubbing

5. Rinne and Weber’ s tests

6. Check for cerebellar signs:

 Speech: say British Constitution (scanning speech)

 Nystagmus (vertical or horizontal nystagmus)
 Flip-flop (no dysdiadochokinesis)
 Finger-nose (past-pointing)

7. Ideally I will do hallpike manoevre and Caloric test

8. Romberg's test

9. Marching or turning test

10. Gait

11. Tandem walking

12. Lying:
 Heel-shin test
 Neurological examination - power, reflexes, tone, plantar and muscle bulk

N.B: When doing the finger-nose test, make sure the patient stretches his arms fully.

GLASGOW COMA SCALE

 HOW TO CHECK THE GCS
1. Look for spontaneous eye opening

2. Use your voice:‘ Hello! Hello! Are you alright? Are you alright?

 Eye response: Can you open your eyes for me?

 Verbal response: (Orientation in Person, Place and Time)

I. Can you tell me your name?
II. Do you know where you are? Can you tell me where you are?
III. Do you know what time of the day it is?

3. Apply pain – only if you did not get the answers while using verbal stimulus
 Apply pain on the pre-orbital area. At this point concentrate on eye
opening and if patient says something.
 Apply pain again on the nail bed, this time concentrating only on motor
response.

N.B: If you are experienced enough you can apply pain and get all 3 components
of GCS, but in the exam I would suggest you do it as above to avoid mistakes.

4. Break down the GCS: e.g. my patient is opening eyes to pain stimulus which is 2, he
has incomprehensible sounds which is 2 and he is withdrawing from pain which is 4.
Therefore, the GCS of my patient is 8, I will call the anaethetist to intubate the
patient.

N.B: A GCS card may be provided or may not be provided. Either way, please memorize the
table. If it is provided in the exam, please use it even if you have memorized it.

UNCONSCIOUS PATIENT
Mr Williams was involved in a road car accident. Primary and secondary has been done, do
GCS and neurological examination.

I will take universal precautions before I approach the patient.

1. GCS: Look for spontaneous eye - opening

Check for response, are you alright
If no response apply pain on pre-orbital area looking on at the eyes and listen for
verbal response
Now re-apply pain on the nail bed and look for motor (hands) response

2. Break down of GCS and give overall GCS score to the examiner. e.g. my patient is opening
eyes to pain stimulus which is 2, he has incomprehensible sounds which is 2 and he is
withdrawing from pain which is 4. Therefore, the GCS of my patient is 8, I will call the
anaethetist to intubate the patient.

3. Neurological exam: Reflexes, tone, pupil reflexes, plantar reflexes

(Please note that you can continue to 4 only if the question says do
relevant examination and when the cause of unconsciousness is not
trauma)

4. Head to toe:
 Head: bruises, laceration
 Ear: signs of infection, mastoid bruising
 Neck: strangulation marks, engorged neck veins, trachea central, smells
(ketotic, alcohol, urea)
 Mouth: dental abscess, smell
 Hands: IV infections, bracelets, rash
 Chest: Spider naevi, rash
 Abdomen: rashes
 Thigh: IV infection, rash

Cover Patient – Ideally do PR examination

HEADACHE EXAMINATION/MENINGITIS EXAMINATION

Mr. Lawson is a 46 year old gentleman who has been complaining of headaches for the past
2 days. Please do headache examination and discuss management with the examiner.

Examination:

1. Universal precautions

2. Check response

3. Offer pain killers and dim the lights

4. Do GCS

5. Meningeal signs:

a) Can you touch your chest with your chin? (neck stiffness)
b) Please bare with me, I would like to do it once more (Bend the neck yourself to
make the chin touch the chest = Brudzinski sign)
c) I will be lifting your leg (Bend one of the lower limbs 90 degrees at the knee
and 90 degrees at the hip and then try to straighten it = Kernig's sign)

6. Head to toe– Tell the patient you need full exposure

a) Ear: signs of infections

b) Mouth: dental abscess
c) Hands: IV infections, rash
d) Chest/Abdomen: Rash
e) Thighs: Rashes, palpate for abscess on both thighs

7. Neurological: Reflex, plantar reflex, tone, bulk

8. Cover the patient

Management:

1. I will take care of the ABC of the patient. Inform my seniors, connect patient to all the
monitors.
2. Analgesia: paracetamol, codeine, ibuprofen
3. Blood culture
4. Bloods: FBC, U&E, CRP, LFT, clotting screen, glucose
5. Antibiotics: Intravenous -> According to hospital protocol
6. CT scan of head
7. Admit –Isolate, arrange lumbar puncture

Exam Tips:

a. If patient is covering his face on examination, ask if you can help remove his hand
 from his face. Let him do it, just offer support.

b. Assist the patient to lie properly on the couch if he is not lying properly.

c. Reassure the patient as much as you can e.g. I have dimmed the lights, I am here to
help you; I know this is uncomfortable for you. Please bare with me. I can just ask you
to place your hand down (at the same time offer support, but do not force)

d. Maintain the order of examination

1. GCS
2. Meningeal signs
3. Head to Toe examination
4. Neurological examination

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Resource start date 2013-06-30 04:14
Resource end date 2023-07-01 04:14

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