Foundation Block CSSC Manual

CSSC Manual – Foundation Block ME 1/13
© International Medical University
INTERNATIONAL MEDICAL UNIVERSITY

MALAYSIA
Bachelor of Medicine
&
Bachelor of Surgery
ME 1/13
Foundation Block
(18 Feb 2013 – 23 Aug 2013)
CSSC Manual
1
INTRODUCTION
Welcome to the Clinical Skills and Simulation Centre
In your Foundation Block, you will be taking your first steps into the world of
learning medicine. In learning medicine, you will not only be concentrating
on theoretical teaching but also learning clinical skills as you go along. This is
to ensure that you are well versed with the clinical aspects of medicine, which
will be important in complementing and reinforcing your theoretical teaching.
The CSSC teaching for your Foundation Course will be divided into two major
components:
1. Communication Skills
In the Communication Skills component, you will be learning the methods

to effectively communicate with the patients. This includes theoretical
classes, workshops, hospital visits and video recording, as well as Skills
Centre sessions to put into practice what you have learnt.
For more information regarding the Communications Skills component,

please refer to the Communications Skills manual.
2. Clinical Skills
In the Clinical Skills component, you will be learning the essential basic
clinical skills you will need to function effectively in a clinical setting. Here
the learning experience will be concentrated on small-group, scenario
based teaching on elements such as Standard Precautions, Taking Vital
Signs and Physical Examination.
This manual will be your guide to the Clinical Skills component of your
Foundation Course but it is not the only source of reference you have at your
disposal.
Scattered throughout the manual are questions marked . The questions

are designed to promote self-learning – you are encouraged to discover the
answers on your own.
Finally we hope you will enjoy your Foundation Block at the CSSC and find it
beneficial to your learning medicine at IMU.
2
CONTENT
SECTIONS IN THIS MANUAL Pages
Introduction 2
Content 3
Standard Precautions 5
Hand Washing 7
Gloving 9
Aseptic Technique 10
Safe Injection Practices 11
Vital Signs 12
Temperature 13
Pulse Rate 16
Respiratory Rate 17
Blood Pressure Measurement 18
Body Mass Index 23
Introduction to Physical Examination 29
The General Examination 38
Examination of the Ear, Nose and Throat 55
3
STANDARD
PRECAUTIONS
4
OBJECTIVES
1. To understand the definition and importance of standard precautions.
2. To discuss the various precautions to prevent transmission of pathogens

from doctor to patient and vice versa.
3. To be able to demonstrate the correct technique of hand washing.
STANDARD PRECAUTIONS
Standard precautions (or universal precautions) are the minimum infection

prevention practices that apply to all patient care, regardless of the infection
status of that patient, at any health care facility.
This is to prevent:
1. Transmission of infective organism from patient to health care professional;
2. Transmission of infective organism from health care professional to a

different patient
As a future doctor, you have to assume that all patients are potentially
infectious – even if they do not have and symptoms or signs of disease.
Some standard precautions which need emphasis among doctors are as

follows:
1. Hand hygiene
Proper hand hygiene, including hand washing, at all times prevents
nosocomial infection transmission effectively. Please see the section
below on hand washing for more details.
2. Use of personal protective equipment

Personal protective equipments are devices used to protect health care
providers from being contaminated by infective organisms from a patient.
3. Safe injection practices

This involves proper handling and disposal of sharps (needles, cannulas) as
well as other items involved in phlebotomy, intravenous cannula insertion
and the administration of parenteral medications.
5
For CSSC sessions, you will be limited to standard precaution aspects which
primarily apply to doctors. However it is wise to also know about other aspects
of standard precautions which may not be directly applicable to you.
The nurses at CSSC will be giving a presentation on Standard Precautions

where the above areas will be covered.
For further information on Standard Precautions, please refer to:
Ministry of Health Malaysia, Policies and Procedures on Infection Control

(pg. 13 – 29)
http://www.moh.gov.my/images/gallery/Polisi/infection_control.pdf
6
HAND WASHING
Transmission of pathogens via contaminated hands from a healthcare

professional to another patient is well described as the most common method
of nosocomial pathogen transmission in a health care setting.
Not only are patients at risk, these pathogens may be inadvertently be

transmitted to the healthcare provider him/herself as well as any individual
who comes into contact with the person.
The easiest way to combat this is remarkably the simplest – hand hygiene.
Bacteria growing on an LOOK MOM!

agar plate after hand printing I WASHED MY HANDS!
from unwashed hands
When do you hand wash?
1. Before you touch a patient, even when gloves are to be worn
2. Before exiting a patient care area, after you have touched a patient or
the patient’s immediate environment
3. After coming into contact with blood, bodily fluids and excretions
4. Before performing an aseptic task, such as placing an intravenous access

cannula
5. After removal of gloves
7
What do you use to hand wash?
The recommended product used for routine hand hygiene is the alcohol-
based hand rub, except for visibly soiled hands with patient’s bodily fluids or
when caring for patients with infectious diarrhoea, where soap and water is
recommended.
FIND OUT ABOUT THE DIFFERENT HANDWASH PROUDCTS THAT ARE WIDELY
USED, AND THEIR INDIVIDUAL ADVANTAGES AND DISADVANTAGES.
How do you wash your hands?
Hand washing technique is best learnt by watching and then practicing it.
Please watch the video on Hand Washing on the E-Learning portal before
coming for your CSSC session!
Remember, whether you wash your hands with soap and water or with an
alcohol rub, all the steps apply.
MAKE THIS ONE HARD HABIT TO BREAK!!!!
8
GLOVING
Wearing gloves is one of the mainstays of standard precautions.
It is able to reduce the risk of transmission of pathogens from patient onto the
healthcare provider, and at the same time it also reduces risk of transmitting
pathogens between patients.
There are two types of gloves:
1. Non-sterile gloves
These are used in situations where sterility is not required, but where there
is a risk of coming into contact with the patient’s bodily fluid, secretions
and excretions.
2. Sterile gloves
These are used in situations where sterility is required – mainly where there
will be direct contact with large amounts of patient’s bodily fluids,
secretions and excretions, or when contamination with pathogens from
the healthcare provider may be harmful.
Examples where sterile gloves need to be worn are in surgical procedures,

placing of long-term or deep vascular access and also in preparation of
intravenous drugs or medications for administration to the patient.
REMEMBER TO WASH YOUR HANDS AFTER REMOVING THE GLOVE!
The technique of wearing sterile gloves will be demonstrated during the CSSC
sessions.
For more information about gloving and its importance please go to:
WHO Glove Information Leaflet

http://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf
9
ASEPTIC TECHNIQUE
Some procedures done by medical personnel involve penetrating or

bypassing the natural protective barriers of the body (e.g. surgery, insertion of
tubes into organ or body cavities). When performing such procedures it is
necessary to ensure the minimum contamination of the area of the body
involved as well as the equipment used so as to minimize entrance of harmful
organisms from the environment into the body. This is called the aseptic
technique.
The principles of the aseptic technique include:
1. Proper hygiene
These include handwashing and wearing of personal protective

equipment. Avoid wearing of possible contaminants (rings, watches, ties
etc.)
2. Maintenance of a sterile field
A sterile field may include the area of the body involved (after cleaning)
as well as the area where sterile equipments used are placed. Avoid
contamination of the sterile field by paying attention to your, and your
assistant(s) actions.
3. Procedural techniques
You must know the steps involved in performing the procedure, including
method of cleaning the affected area. A quick but thorough attention to
the procedure will minimise time of exposure to contamination, and
hence risk of infection.
4. Waste Disposal
Proper waste disposal minimises risk of infection after the procedure.
In your CSSC session these principles will be demonstrated using wound

dressing as an example. Please remember these principles as aseptic
techniques will be covered in procedures associated with subsequent
systems.
10
SAFE INJECTION PRACTICES
Doctors and other healthcare professionals frequently come into contact with
sharps in our daily routine activities.
Sharps can be broadly defined as any device that can potentially puncture
or lacerate the skin. The definition can be broadened to include devices or
objects which are normally not able to puncture or lacerate skin, but can do
so once it is broken.
Common sharps used in the healthcare setting include needles and syringes,
blades, scissors and glass products such as test tubes and microscope slides.
The main concern with sharps is the potential to transmit pathogens from one
patient to the healthcare provider, another patient or the public by accident.
The two important aspects of sharps management are:
1. Sharps Handling
These include proper way of dealing with sharps from the start of use to
the point of disposal.
2. Sharps disposal
These include the proper method of disposing sharps once they have
been used.
Please identify and know the sharps container where SHARPS MUST be
disposed into after use!
In CSSC sessions, sharps management will not be emphasised now; these will
be reinforced later in the relevant systems where procedures requiring
handling of sharps will be taught.
11
VITAL SIGNS
12
THE VITAL SIGNS

OBJECTIVES
1. To demonstrate the correct way to take the temperature, pulse and

respiratory rate of a patient.
2. To learn the proper way to handle a mercury thermometer and

sphygmomanometer.
3. To demonstrate the proper technique of taking a blood pressure using the

palpatory method and auscultatory method.
4. To recognise the Korotkoff sounds.
5. To recognise the normal readings of all the vital signs.
What Are The Vital Signs?
The vital signs consist of:
1. Temperature
2. Respiratory Rate
3. Pulse Rate
4. Blood Pressure
These are called vital signs because they are VITAL!!!!
They provide important insight to the very basic vital functions of the heart,
lungs and to some extent, the brain.
As doctors, these measurements will most likely be done by the nurses;

however it is imperative that the doctor be as well versed as the nurses in
performing these measurements.
Please watch the video on Temperature/Pulse rate/Respiratory rate

measurement on the E-Learning portal before coming for your
CSSC session!
13
TEMPERATURE
Our body temperature is kept within a range to ensure proper function of the
cells in the body. However in certain conditions, the body temperature may
be elevated above this normal range while in others, the body temperature
may be decreased below this range.
The body temperature may be taken at various sites. In adults, this is most
commonly taken in the oral cavity – thus this is called the oral temperature. In
babies and small children however the rectal temperature is taken.
A mercury thermometer is commonly used to measure the body temperature.

You may have experienced this when you visited a doctor for an illness. The
body temperature is usually recorded is degree Celsius (ºC).
The accepted average body temperature is 37C. For oral temperature, the
mean temperature range is 36.8C ± 0.4C (Harrisons Principles of Internal Medicine)
Please be aware that body temperature differs between the time of the day,
as well as the area measured.
Generally a temperature above 37.5C is called pyrexia (commonly known

as fever), while below 35C is hypothermia.
FIND OUT THE OTHER AREAS WHERE THE BODY TEMPERATURE MAY BE MEASURED.
OF THE VARIOUS AREAS, FIND OUT THE SITES THAT WOULD GIVE A
MEASUREMENT CLOSEST TO THE ACTUAL BODY (CORE) TEMPERATURE.
14
How to measure the oral temperature
You will take the patient’s temperature in the following sequence:
 Explain procedure to the patient and get permission.
 Ensure that the patient has not just had a hot drink or cigarette as this
may elevate the temperature of the mouth where you will be placing
the thermometer.
 Use a soft clean tissue to wipe the thermometer. DO NOT hold the
thermometer by the bulb.
 Grasp the stem of the thermometer between thumb and forefinger and
firmly shake the thermometer with a snapping wrist (flicking) movement
until the mercury level is well below the lowest marking.
 Insert the thermometer into a thermometer sheath and remove the

external plastic cover.
 Ask the patient to open his mouth and try to touch his tongue to the roof
of his mouth. Then place the mercury bulb of the thermometer under the
tongue of the patient.
 Instruct the patient to hold the thermometer with his/her lips and not to
bite it.
 Leave the thermometer in position for two minutes.
 Remove the thermometer and discard the thermometer sheath in the

clinical waste bin.
 Read the level of the mercury against the markings.
 Thank the patient and record your findings.
FIND OUT OTHER METHODS USED FOR TAKING TEMPERATURE. WHAT ARE
THE ADVANTAGES AND DISADVANTAGES OF EACH METHOD?
15
PULSE RATE
The pulse is the transmitted pressure wave of blood passing through the
arteries which can be felt at the skin surface. As this pressure wave
corresponds closely to contraction of the left ventricle of the heart, this is
useful in determining how fast the heart is pumping.
The presence of the pulse also corresponds closely to the systolic blood
pressure. A systolic blood pressure above 50 mmHg is normally required to
detect femoral or brachial artery pulses and corresponding higher values are
necessary for more distal pulses to be detected.
The radial artery is one of the most accessible of the peripheral arteries and is
commonly used for palpating the pulse. The other commonly used site is the
carotid pulse in the neck.
How to measure the pulse rate
Using your pulps (tips of your fingers) of your index, middle and ring fingers feel
for the radial pulse at the right wrist (lateral to the tendon of flexor carpi
radialis).
Count the number of pulses felt in one minute.
The normal pulse rate is 60 – 100 beats/minute.
Above 100/minute = TACHYCARDIA

Below 60/minute = BRADYCARDIA
The other important features of a pulse to note are as follows:
a. Rate
b. Rhythm
c. Character
d. Volume
e. Radioradial delay/radiofemoral delay
You will learn these in more detail in your cardiovascular system examination.
16
RESPIRATORY RATE
Breathing is the process of moving air in and out of the lungs, and is essential
to our survival. Breathing is divided into two parts: inspiration (when you draw
air into the lungs from the environment) and expiration (when you expel air
from the lungs into the environment).
This process can be observed physically; and this rate of breathing is called
the respiratory rate.
The respiratory rate gives an insight into the function of the lungs, heart and
kidney. However there are many other factors which may alter the rate of
breathing of an individual, which you will learn in due course.
How to measure the respiratory rate
Watch the breathing movements of the chest wall by looking at the rise and
fall of the chest. Each cycle of rise and fall of the chest is equivalent to one
breath.
Count the number of breaths in 30 seconds, and multiply that number by 2 to

give the respiratory rate in one minute.
You may also count the respiratory rate by observing the movements of the
abdomen.
The normal respiratory rate at rest is between 12 - 20 breaths/minute
Above 20/minute = TACHYPNOEA

Below 12/minute = BRADYPNOEA
17
BLOOD PRESSURE
The blood pressure is the pressure imparted by circulating blood upon the wall
of the blood vessels. There are two types of blood pressure: the arterial blood
pressure and the venous blood pressure. For all intents and purposes, blood
pressure normally refers to the arterial blood pressure unless mentioned
otherwise.
The blood pressure is traditionally

measured using a device called
a sphygmomanometer.
Blood pressure is described by the

systolic blood pressure (SBP) and
the diastolic blood pressure (DBP).
These are the maximum and
minimum range of the pressure
exerted on the blood vessels at
any one time, and has a
correlation to the cardiac cycle.
The blood pressure is reported as

SBP/DBP in mmHg (‘SBP over
DBP’).
The American Heart Association gives a desired range of SBP from 90 – 119
mmHg, and a desired DBP from 60 – 79 mmHg. The accepted ‘normal’ blood
pressure in adults is 120/80 mmHg, but there are variations among gender
and age.
18
How to measure the blood pressure
Please watch the video on Blood Pressure Measurement on the E-Learning

portal before coming for your CSSC session!
1. Getting Ready to Measure Blood Pressure
 First find out whether the patient has factors which might affect the
blood pressure measurement. This should be taken into account when
interpreting the blood pressure result.
Common factors which might affect the blood pressure measurement

include:
a. Recent exercise or strenuous activity, within last 30 minutes
b. Pain
c. Having caffeinated drinks
d. Smoking
e. Alcohol consumption
f. Lack of sleep
g. Stress or anxiety
h. Use of medications (e.g. anti-hypertensives)
Ask if the patient has hypertension, and whether he is taking

medications for the condition; if he is, ask whether he has been taking
them as instructed. Non-compliance to medication is the most
common cause for a high blood pressure reading in a patient with
underlying hypertension.
 Check to make sure the examining room is quiet and comfortably

warm.
 Make sure the arm selected is free of clothing.
 Examine the arm. There should be no arteriovenous fistulas for dialysis,

scarring from prior brachial artery cutdowns, or signs of lymphedema
(seen after axillary node dissection or radiation therapy).
 Palpate both the radial and brachial arteries to confirm they have
detectable pulses.
19
 Position the arm so that the brachial artery, at the antecubital crease, is
at the same level with the heart – roughly level with the 4th intercostal
space at its junction with the sternum. If the brachial artery is much
below heart level, blood pressure appears falsely high.
 If the patient is seated, rest the arm on a table a little above the
patient’s waist; if standing, try to support the patient’s arm at the mid-
chest level.
2. Selecting the Correct Blood Pressure Cuff
 Width of the inflatable bladder of the cuff should be about 40% of

upper arm circumference (about 12-14 cm in the average adult).
 Length of inflatable bladder should be about 80% of upper arm

circumference (almost long enough to encircle the arm).
 Cuffs that are too short or too narrow may give falsely high readings.
Using a regular-size cuff on an obese arm may lead to a false diagnosis
of hypertension.
THERE ARE VARIOUS TYPES OF BLOOD PRESSURE MEASUREMENT DEVICES.

FIND OUT THEIR ADVANTAGES AND DISADVANTAGES.
3. Technique
You should take steps to make sure your measurement will be accurate.
Proper technique is important and reduces the inherent variability arising from
the patient or examiner, the equipment, and the procedure itself.
 Centre the inflatable bladder over the brachial artery. There is usually a
marker on the cuff which indicates where the brachial artery should be.
Use that as an indicator to assist placement of the bladder.
 The lower border of the cuff should be about 2.5 cm above the
antecubital crease.
 Secure the cuff snugly. A loose cuff or a bladder that balloons outside
the cuff leads to falsely high readings.
 Position the patient’s arm so that it is slightly flexed at the elbow.
20
The blood pressure is then measured using a two-step method:
Palpatory Method
This is done to estimate the systolic blood pressure. It also helps to eliminate an
inaccurate reading due to the presence of an auscultatory gap.
 Locate the radial (or brachial) pulse with the fingers of one hand.
 With the other hand rapidly inflate the cuff by 10 mmHg at a time until
the radial/brachial pulse disappears.
 Then further inflate the cuff to 20 mmHg above the point where the
palpated pulse disappears.
 Deflate cuff slowly (2 – 3 mmHg per second) until you feel the radial
pulse again.
 THIS is the estimated systolic blood pressure. Record THIS reading.
 Deflate the cuff promptly and completely and wait 15 to 30 seconds.
FIND OUT ABOUT THE AUSCULTATORY GAP. HOW DOES IT AFFECT THE
BLOOD PRESSURE READING AND YOUR INTERPRETATION?
Auscultatory Method
This is done to accurately determine the systolic and diastolic blood pressure.
 Now place a stethoscope lightly over the brachial artery, taking care to
make an air seal with its full rim. The sounds to be heard (Korotkoff
sounds) are relatively low in pitch.
 Inflate the cuff rapidly again to a level 20 mmHg above the estimated
systolic blood pressure.
 Deflate it slowly at a rate of about 2 to 3 mmHg per second.
 Note the level at which you hear the sounds of at least two consecutive
beats. This is the systolic blood pressure.
21
 Continue to lower the pressure slowly until the sounds become muffled
and then disappear. To confirm the disappearance of sounds, listen as
the pressure fails another 10 to 20 mmHg, then deflate the cuff rapidly
to zero.
 The disappearance point, which is usually only a few mmHg below the
muffling point, enables the best estimate of true diastolic blood
pressure in adults. In some people, the muffling point and the
disappearance point are farther apart. Occasionally, as in aortic
regurgitation, the sounds never disappear. If there is more than 10 mm
Hg difference, record both figures (e.g., 154/80/68).
 Read both the systolic and the diastolic levels to the nearest 2 mm Hg.
Record the readings.
 Wait 2 or more minutes and repeat. Average your readings. If the first
two readings differ by more than 5 mm Hg, take additional readings.
READ ABOUT THE KOROTKOFF SOUNDS. HOW ARE THEY FORMED?
Blood Pressure Measurement: Changes during measurement, auscultatory findings and Korotkoff sounds
22
BODY
MASS INDEX
(bmi)
23
BODY MASS INDEX
OBJECTIVES
1. To demonstrate how to take a proper weight and height measurement.
2. To be able to calculate the Body Mass Index (BMI) of a patient and

explain its clinical significance.
3. To be aware of other clinically relevant forms of anthropometric

measurements.
Anthropometric Measurements
Anthropometric measurements are specific physical measurements taken for

the purpose of assessing the growth and/or nutritional status of an individual.
Examples of anthropometric measurements and the aspects they assess are

in the table below:
Anthropometric
Growth Nutritional Status
Measurement
Weight Physical growth
Height Physical growth
Head circumference Brain development
BMI Under- or Over-nutrition
Waist circumference Body fat distribution
Waist-to hip ratio Body fat distribution
Mid upper arm
Body fat percentage
circumference
Fat skinfold thickness
Body fat percentage
e.g. triceps skinfold thickness
24
MEASURING THE BODY MASS INDEX
Body mass index (BMI) is a ratio of the weight of the patient relative to his/her
height and it gives an indication of the general nutritional status of the
patient.
Arithmetically, the BMI is given as:
Weight (in kg)

BMI =
Height (in m)2
Thus to calculate the BMI, you will need to measure the weight and height of
the patient.
Measuring the Weight
Use a calibrated weighing scale to measure the patient’s weight. An

electronic weighing scale is favoured these days, although you might still see
the traditional beam balance weighing scales in some of the more rural
health care facilities.
The steps for measuring the patient’s weight are:
1. Place weighing scale on hard and even surface.

2. You may choose to calibrate the weighing scale with a standard 10 kg
weight.
3. The patient should wear light clothing and remove watch, wallet, keys or
any other heavy objects that could contribute to the weight. Remove the
shoes and other footwear.
4. Check that scale is reading zero.
5. Get the patient to step on the scale platform without support and ask the
patient to stand straight. This should distribute the weight evenly over both
feet.
6. Once the scale has stopped fluctuating, read and record the weight
indicated on the scale to the nearest 0.1 kg.
25
Measuring the Height
Use a stadiometer for measuring the height

of the patient. If this is not available, a
height measuring instrument attached to a
weighing scale, or a microtoise can be
used. As a last resort, a simple standardised
wall height measure may also be
employed.
The steps for measuring the patient’s height

are as follows:
1. Place the microtoise on a smooth

surface wall and flat floor surface.
2. Pull down the microtoise and make
sure the reading is zero on the floor
surface.
3. Attach the upper side (2 meter height
from the floor) on the wall.
4. Check that the reading is still zero on
the floor surface before each
measurement.
5. The patient should be barefooted,
and any head accessory (bandana,
hat, etc.) removed except the
headscarf for Muslim ladies.
6. Patient should stand with feet together
and the heels, buttocks and upper
part of the back touching the wall.
7. Instruct the patient to look straight
ahead. Ensure the head is in the
Frankfurt Plane (lower edge of the eye
socket is in the same horizontal plane
as the tragion, the notch superior to
the tragus of the ear).
8. Place the head of the measuring
board firmly down on the top of the
head (vertex), crushing the hair as
much as possible.
26
9. Read the scale on the red marker, preferably at the same level as the
marker. Record the height to the nearest 0.1 cm.
How do you interpret the BMI reading?
The World Health Organisation (WHO) in 1998 came up with a body weight
classification according to the BMI, as well as its associated risk of co-
morbidities. This is still the standard which is used worldwide today.
It was argued that the Asian population is of a smaller build than Caucasians
which was primarily used for the WHO definition, and thus underestimated the
risks for the overweight and obese Asian population.
In 2004, WHO Expert Consultation group agreed to retain the BMI cut-off
points, but added cut-off points for public health action for the Asia-Pacific
population.
The Ministry of Health Malaysia has adopted these recommendations as

below:
Clinical Practice Guidelines on Management of Obesity (2004), Ministry of Health Malaysia
FIND OUT THE CO-MORBIDITIES THAT ARE ASSOCIATED WITH OBESITY.
27
OBESITY
The WHO has defined obesity as ‘a disease state in which excess fat has
accumulated to the extent that health may be adversely affected.’
The BMI, although a widely used indicator for determining obesity, can be
misleading if not applied in the proper context.
For example, a 100 kg bodybuilder and a 100 kg clerk both measuring a

height of 1.7m has a BMI of 34.6 each but there is a critical difference: in the
bodybuilder his weight comprises mostly of muscle, while in the clerk it will very
likely be composed mainly of fat. Even though the BMI of both individuals fall
into the obese range, the clerk will be the one at increased risk of co-
morbidities.
Please be aware of this important limitation when using BMI to assess obesity
as a risk factor for cardiovascular related disease.
It is actually the body fat percentage and its distribution which is now
believed to be more specific indicators of cardiovascular health risk
compared to BMI.
Other anthropometric indicators such as the waist circumference and waist-

to-hip ratio measure fat distribution and are better indicators of
cardiovascular risk when used in concert with BMI than using BMI alone.
FIND OUT ABOUT THE WAIST CIRCUMFERENCE AND WAIST-TO-HIP RATIO.

HOW DO YOU MEASURE THEM?
28
INTRODUCTION
TO
PHYSICAL
EXAMINATION
29
OBJECTIVES
1. To learn the correct approach to examining the patient.
2. To be able to demonstrate general physical examination of a patient

which includes:
a. general inspection
b. inspection of hands & arms, head & face, neck and trunk, and
the lower limbs
3. To be able to demonstrate the examination technique to look for the

following signs:
a. Clubbing
b. Cyanosis
c. Capillary refill
d. Pallor
e. Jaundice
f. Hydration status
g. Oedema
4. To discuss the various external manifestations of various diseases and their

significance.
5. To learn the correct method of reporting findings of your general physical

examination.
INTRODUCTION
Getting ready to perform a physical examination entails some amount of

preparation.
You must have some prior knowledge about terminology of the various
anatomical parts of the body, medical terminology as well as definitions of
symptoms and signs.
You may get them from Clinical Examination books such as:
1. Macleod’s Clinical Examination, 12th ed.

 Chapter 3 – The General Examination
 Chapter 4 – The Skin, Hair and Nails
30
2. Talley and O’Connor: Clinical Examination, 6th ed.

 Chapter 2 – The General Principles of Physical Examination
3. Hutchinson’s Clinical Methods

 Part 1- Setting the Scene
Please read them before you come for your CSSC sessions.
As time is limited, these sessions would be best served by showing you the flow
and sequence of the examination rather than being bogged down in
explaining the various medical terminology or signs.
Also try to imagine the examination flow and sequence in your mind, and
how you would perform them; the more enthusiastic of you might even
attempt to perform an examination on a friend to get a feel on what you
would experience during an examination.
Prepare some basic equipment you will need when examining the patient
such as stethoscope, pen torch and a tendon hammer.
Before going ahead to the physical examination proper, a little introduction

regarding the diagnostic process will give you an overview of where the
physical examination lies in the process.
Remember that the physical examination is not an independent component,

but is part of a continuous process.
THE DIAGNOSTIC PROCESS
A patient sees you with a complaint(s) (his problem). Your aim as a doctor is
to tackle his complaint(s) and to provide a solution to his problem.
To do this you will have to follow a set of steps in order to systematically first,
come to an educated guess of the underlying diseases which caused the
patient’s complaint(s), and subsequently call on tests to finally diagnose the
disease that is causing his complaint(s). Only then would you be able to treat
the disease and finally relieve him of his complaint(s).
The process that you will have to follow in order to do this is called the
diagnostic process (see below).
31
THE DIAGNOSTIC PROCESS
HISTORY TAKING
INITIAL AND POSSIBLE

DIAGNOSES
PHYSICAL EXAMINATION
Confirm or refute diagnoses
PROVISIONAL AND
DIFFERENTIAL DIAGNOSES
INVESTIGATIONS
Confirm or refute diagnoses
FINAL DIAGNOSIS
32
History Taking
History taking is the first step. Here you attempt to gather specific information
from the patient pertaining to his/her complaint(s). These complaint(s) are
usually referred to as symptoms. Apart from eliciting his symptoms, you will also
inquisitively ask other aspects of his/her life that may have contributed to
his/her symptoms or complaints. This may include the patient’s medical
history, presence of diseases in the family, the patient’s occupation as well as
other pertinent information.
By gathering and analysing the information, you will be able to build a

sequence of the patient’s problems leading up to his/her symptoms.
At the end of this history taking process, you should have a good idea on the
possible diseases that may have caused the patient’s symptoms.
It is said that up to 70% of diagnoses can be made just by taking a good and
thorough history.
Physical Examination
The physical examination is the next step in the diagnostic process.
Diseases processes produce specific physical evidence on or in the patient’s

body. These are called signs.
From your history taking you will already have an idea of the site or location of
the most likely disease process that is causing the patient’s symptoms. You will
then look for the signs of disease and analyse them. They may confirm or
refute your diagnoses from the history taking.
Apart from this, the physical examination also:

 Provides reassurance to patient
 Increases rapport between doctor and patient
 Patients feel they are being taken seriously
 May reveal aspects of the history that had been left out inadvertently, or
which the patient had not thought to be important enough to mention
15% of diagnoses are made on the basis of physical examination findings.
33
If your examination findings to not support your initial diagnoses based on the
history taking, it would be time to relook into the patient’s history or to repeat
the examination in case you have missed a sign.
Provisional and Differential Diagnoses
Once you have completed your history taking and physical examination you
will now be ready to commit a provisional diagnosis and hopefully, a few
other possible diagnoses (differential diagnoses).
This is done by analysing the patient’s symptoms and other aspects of the
history with the signs elicited from the physical examination and coming to
most likely disease that will present with the symptoms and signs you have
elicited.
Investigation
Subsequently you will need to confirm your provisional and differential

diagnoses. Most diseases would have a series of tests which will confirm the
presence or absence of the disease.
Performing these tests is called investigation, and will ultimately help provide
the final diagnosis by confirming presence or absence of the disease in the
patient.
If you are unable to confirm the diagnosis through investigation, you will have
to relook your history and physical examination findings and repeat the
processes if necessary.
Final Diagnosis
Once you have obtained the final diagnosis, you are now ready to confront
the patient and proceed to treating his/her disease.
34
THE PHYSICAL EXAMINATION PROCESS
PREPARATION
 Prepare the examination room. Allow for and respect the patient’s privacy.
 Ensure the equipment you need is available and in working condition.
GETTING STARTED
 Introduce yourself to the patient giving your name and role.

 Explain in simple terms what you want to do and why and (briefly) explain
what this will involve. Do not use medical jargon.
 Ask for their consent. Inform them that a chaperone will be present.
 Clean your hands (wash with soap or use alcohol rub/gel).
THE EXAMINATION PROPER
 Position the patient.

 Expose the patient adequately. Expose only the relevant areas you want to
examine. If you are planning to expose multiple areas, do it one at a time.
 Perform your examination. Try to be quick but thorough. Give the relevant
instructions clearly. Pay attention to patient’s discomfort.
CONCLUSION
 Thank the patient!

 Allow the patient to get dressed (help if necessary) and ensure that they
are comfortable.
 Clean your hands.
 Take time to explain what you have found and what you plan to do next.
Do not use medical jargon. Where possible, try to get the patient involved
in your care plan.
 Report or record your findings.
35
SEQUENCE OF EXAMINATION
Physical examination should be conducted in a standardised sequence so

that the examination is smooth yet thorough. It also gives a good impression
to the patient.
The physical examination generally consists of two parts:
1. The General Physical Examination
This is an initial quick examination that will provide you with an idea to
the general condition of the patient, as well as provide clues to the
particular organ system you would be likely to examine.
2. The Systems Examination
This is a focused examination which is concentrated on the likely organ

system that contains the pathology. The systems examination would
likely consist of:
a. Inspection - looking
b. Palpation - feeling
c. Percussion - tapping
d. Auscultation - listening
Not all of these steps are always applicable. For example, you cannot
tap the thyroid gland or listen to the teeth!
In adults, try to follow this sequence strictly. In children, you may need
to change the sequence, for example you may choose to auscultate
first before percussing the child.
There are also examination variations from the above, for example in
musculoskeletal examination the corresponding steps are:
a. Look
b. Feel
c. Move
d. Special tests
e. Associated structures
f. Function
36
ALWAYS LOOK FIRST, THEN FEEL AND TOUCH, AND FINALLY LISTEN!
You will also need to have a systematic technique of performing the

examination of a particular area. Each doctor will have their own technique;
it is up to you to find one that you are comfortable with.
For example when examining the hands, one technique may be structure
based – you visualise all the structures that are present in the hand, and
examine them in a particular sequence, from deeper structures to the more
superficial ones or vice versa. Another technique may be to look at the hand
from the palmar, and then the dorsal aspect.
The examples given in the following sections are suggested techniques of

examination – you may choose to follow them or develop your own.
Minor variations in the sequence or technique of clinical examination are

entirely acceptable. You will see such variations among your tutors. Everyone
has a slightly different “style” — as you would for example doing a sport. It
does not mean one way is “right” and another “wrong”. Aim to develop a
style of your own with which you feel comfortable.
KEY FEATURES OF A GOOD PHYSICAL EXAMINATION

Follows a good history
Systematic and structured
Thorough but adjusted to the context
Fluent but unhurried
Considerate to the patient at all times
Accompanied by good patient communication
Accompanied by THINKING about the findings and what they mean
Clearly and thoroughly documented
Followed by reflection and improvement
37
THE
GENERAL
Physical
EXAMINATION
38
THE GENERAL PHYSICAL EXAMINATION
The physical examination starts the moment you set eyes on the patient. This
can be done as you approach the patient while he is on the hospital bed, or
as he walks into the consultation room.
You gather an initial impression of the patient from his/her appearance,

expression and demeanour, as well as the presence or absence of objects on
him/her.
Introduce yourself to the patient, explaining your role and the purpose of the
physical examination. In brief tell the patient what it will require him/her to do,
as well as what he/she will be going through.
Shake the patient’s hands.
The touching of the hand may reassure the patient and serve as a gentle and
symbolic introduction to the more intimate physical contact of the
examination which follows the history. Whether the patient shakes your hands
or not, and the strength of the handshake may give you an impression of his
physical and psychological well-being.
Inform about the presence of, and the role of a chaperone before performing
the examination.
Finally ask for permission before you continue!
Remember hand hygiene before you start.
Stand on the right side of the patient. By convention, all examination is done
from the right side of the patient; you may move to the left side if the
examination you wish to perform cannot be properly done from the right.
GENERAL INSPECTION
Some of the more obvious things to look out for are:
1. Level of consciousness
Look at the patient. Is he alert and responding to your presence? Is he not
aware of your presence, or is he semi-conscious? Or is he unconscious?
This gives an insight into higher brain function.
39
2. Distress/discomfort
Look for obvious distress or discomfort. There are various forms of distress,
and may vary in severity. It could be physical as in pain, or difficulty
breathing; or emotional as in anxiety or anguish. You will very likely need
to reduce the level of distress prior to continuing the examination.
3. Gross deformities
Look for any obvious deformities of the patient’s body, for example an
amputated leg, or a missing ear, or large open wound.
4. Build and nourishment

Look for the general size and build of the patient. You will need to know
and be able to appreciate the normal body size and build of the
population you are in. Even among the local population there is a wide
variation of build and size among the people in the population.
Remember that Caucasians are generally of a larger size, and are taller
than Asians.
5. Hygiene and grooming

Look at the patient’s hygiene and grooming. A normal person would have
a sense of proper hygiene and grooming. Lack of these may indicate an
underlying disease process such as a psychiatric disorder, but could also
indicate social neglect or poverty unrelated to a disease process.
6. Facial expression
Look at the patient’s face. The facial expression of the patient can give
remarkable insight into the patient’s condition. You would already be
familiar with expressions of pain, anxiety, fear, anger and anguish.
However lack of these expressions, or presence of it at inappropriate times
may indicate a physical or psychiatric disorder.
7. Abnormal or lack of movements

Look at the patient’s head and the limbs at rest or when it is being moved.
At rest or in motion, there should not be any involuntary movements of the
head and limbs. If present, these may point to a muscular or nervous
disorder. One common abnormal movement is the ‘pill-rolling’ tremor of
Parkinson’s disease which is visible in the hands while at rest. In cerebellar
disease, the abnormal movement may be more prominent when the limb
is in motion.
40
Also look for lack of movement, which may indicate paralysis or refusal to
move due to pain.
8. Natural position/posture
Look at the natural position or posture of the patient. It could be a sign of
disease, or give a clue to the location of the pathology. For example,
he/she could be slumped forward because of stomach pain, or may be
propped up due to breathlessness; the leg may be flexed at the hip
because of pain.
9. Odour and sounds

Listen carefully, and pay attention to the smell coming from the patient as
you approach. They may provide a clue to the underlying disease, as
some of them are characteristic of certain pathologic conditions. For
example, stridor indicates an upper airway obstruction, while wheezing is
characteristic of airway narrowing as in bronchial asthma; you might
appreciate the pungent smell of urine in the breath of a patient with
chronic renal failure, or the alcoholic breath of an intoxicated person with
head trauma.
10. Gait
Where possible, observe the patient when they walk. The gait gives a
good clue to the underlying pathology. For example, an antalgic (painful)
gait may indicate a painful swelling of a joint on the affected limb while a
Trendelenburg gait points to a hip pathology.
11. Gadgets and surrounding items

Look around the patient. Items around the patient, or that is used to assist
patient often gives a clue to the underlying condition. If the patient is on
supplemental oxygen with an oxygen mask, there is a high chance that
he has a respiratory disease, or if he comes in on a wheel chair, he has a
pathology that limits his own mobility.
For the General Physical Examination, you will usually examine the patient in
this order:
1. Hands (including nails),
2. Forearms and Arms,
3. Head and Face,
4. Neck and Trunk, and
5. Legs
41
Expose the patient in the order of your examination as it will minimise

discomfort and embarrassment. Remember to cover the area once you
finished the examination before moving on to the next!
HANDS
Ask the patient to show you their hands. Look first at the palmar and then the
dorsum. After that feel the hands.
1. General appearance
Make a note of the size of the hands and fingers. They may be generally
enlarged in acromegaly, or a person with Marfan’s syndrome may have
long spindly fingers. Also count the number of fingers. Some people may
have additional digits (polydactyly).
2. Bone and joints

Look for gross deformities of the hand – an abnormal shape, or swelling
arising from the bony structure of the hand due to past trauma or disease.
Look then at the joints, especially at the fingers for swellings.
3. Muscle
Next, look at and feel the muscle bulk of the hands. This is most
appreciable at the thenar (below the thumb) and hypothenar (below the
little finger) eminences on the palmar surface, and the interossei muscles
in between the fingers on the dorsum. Loss of the muscle bulk indicates
muscle wasting, and is an important feature in malignancy (cancer) and
other systemic conditions, as well as localised limb and nerve disorders.
4. Skin and subcutaneous tissues

Look at the skin overlying both surfaces of the hands for overt injuries,
scars, pigmentation changes (an increased pigmentation is called
hyperpigmentation while a decreased pigmentation is called
hypopigmentation), discolouration, lumps and bumps, and abnormal skin
changes (rashes, ulcers, etc.)
Feel the temperature, moisture and surface of the hands. A warm hand
may indicate fever while a cold and clammy hand may indicate
hypovolaemic shock. A dry, rough skin may indicate eczema.
42
5. Movements
Look at the hands as they are outstretched in front of you, from the sides.
You may appreciate coarse and fine tremors. Coarse tremors are
obviously visible tremors (such as pill-rolling tremor of Parkinson’s disease)
while fine tremors may be more appreciable by putting a piece of paper
on top of the hands and looking for the movement of the paper instead
of the hands.
A special type of tremor maybe elicited in certain conditions such as

hypercapnia (elevated levels of carbon dioxide in the blood), or in
hepatic or uraemic encephalopathy. This tremor is called flapping tremor,
and will be taught at a later stage.
NAILS
Look at the patient’s nails. Have a quick look at all the nails, as most systemic
diseases cause changes in all the nails while local conditions may affect only
a certain number of nails.
1. Shape
From the side, look at the shape of the nail. It may appear to bulge as in
clubbing (see below), or depressed as in koilonychia.
2. Colour
Look at the colour of the nail. The normal nail looks pinkish white. A
change in the colour may indicate systemic disease – bluish colour may
indicate cyanosis while white nails is called leuconychia and is a
manifestation of a few conditions. Please look especially for the yellowish
discolouration of nicotine stains in chronic cigarette smokers.
3. Nail lines
Look for lines visible on the nail surface. They maybe horizontal in nature
and usually traverse the whole width of the nail. They maybe
manifestation of disease processes.
4. Surface
The surface of the nail may be abnormal – these maybe grossly deformed
as in fungal infections, or pitted as in psoriasis.
43
Look at the skin around the nails (peri-ungal area) as this may be affected in
conditions affecting the nail.
Then test for capillary refill (see below).
There are THREE important signs that can be appreciated in the hands and
nails:
Cyanosis
Cyanosis is a bluish discolouration of the surface being examined. This results
from an increased amount of deoxygenated blood at the underlying tissues,
and is an indirect indicator of lung and cardiac function. In the nails and
hands this is called peripheral cyanosis. It is very important to note that
peripheral cyanosis can occur when there is reduced perfusion to the
extremities, and not only in hypoxaemia (reduced amount of oxygenated
blood).
Clubbing
Clubbing is a drumstick appearance of the distal end of the finger and
fingernails. The exact pathophysiology is unknown. It is an indicator of an
underlying systemic disease, usually but not exclusively related to
hypoxaemia; however clubbing may also be found in healthy people without
any underlying disease.
There are a few methods to look for clubbing:

1. Ask the patient to put both their index fingers together, with the nails
touching each other. In a normal person, doing this will reveal a diamond
shaped window in between the contact surfaces of the nail and finger
(Schamroth sign). In clubbing, this window disappears. You can
demonstrate this with the other fingers as well.
2. From the side of the patient’s index

finger, look at the angle between
the nail bed and nail fold (Lovibond
angle). In a normal person this
angle is <165º; in clubbing, this
angle is >165º.
3. Press on the nail bed (as you would do for capillary refill) repeatedly. There
is an increased fluctuation of the underlying nail bed (it feels more
‘bouncy’) in clubbing.
44
Presence of clubbing will prompt you to look for associated underlying

systemic disorders.
Capillary refill
Capillary refill tests the perfusion of blood to the underlying structure. This is an
indirect indicator of cardiac function (pump) as well as the patency of the
underlying vessels (distribution system).
To test for capillary refill, use your thumb and

index finger to compress the distal half of the
patient’s nail and pulp of the finger for 10
seconds. The compressed section will blanch
(turn white) as blood is prevented from
flowing into that area. After the 10 seconds,
release the pressure and count how long it
takes the area to refill with blood. In a
normal person this should take less than two
seconds; if it takes longer than this, it is called
delayed capillary refill.
You will only need to test the capillary refill of

one or two fingers on one limb. Then move
to the other limb. In a normal person
capillary refill times should be equal on both
limbs, unless there is a problem with blood
flow to one particular limb.
FOREARMS AND ARMS
Expose the entire length of forearm and arm. Look at the forearms and arms
in their natural position. Do not forget to move the limb to have a look at the
posterior aspect.
Make a note of the size of the arms and forearms. They may be enlarged
in a condition called lymphoedema.
45
2. Bone and joints

Look for gross bony deformities of the forearms and arms, perhaps from a
poorly-healed fracture. Look then at the joints, especially at the shoulder,
elbow and wrists for swelling and deformities.
3. Muscle
Look at, and feel the muscle bulk of the forearms and arms.

Look at the skin overlying surfaces of the arms and forearms for overt
injuries, scars, pigmentation changes, evidence of bleeding (petechiae,
purpura), discolouration and abnormal skin changes (rashes, swelling,
ulcers, etc.)
Look for needle puncture marks on the skin overlying the veins of the
forearms, as well as the anterior aspect of the elbow (cubital fossa) as
these are common sites for intravenous drug injections.
Then check for skin turgor (see below).
5. Movements
Ask the patient to move their forearms and arms. Look for restricted
movement, as well as for tremors or abnormal movements that becomes
more prominent when the limb is in motion.
6. Blood vessels
Look at the blood vessels. See if there are any prominent, dilated veins.
The arterial vessels will usually not be visible.
If prominent veins are seen, look for an artificially created arteriovenous

fistula (communication between an artery and a vein) – these are
created for patients with chronic renal failure whom require
haemodialysis. They are usually located at the wrist (radial artery) or elbow
(brachial artery). Feel for thrills (vibration felt at the surface overlying areas
of turbulent blood flow) if present.
Feel for the radial pulse, and take the blood pressure.
46
Hydration status and skin turgor

Measuring skin turgor is one way of assessing the hydration status (adequacy
of water content) of the body.
Pinch the patient’s skin over the

middle part of the forearm and lift is
slightly above the forearm; release it
and watch how fast it returns to its
normal shape and position. In a
normally hydrated person, the skin
snaps back almost immediately but
in a person who is dehydrated, the
skin returns to its normal shape
slowly, or very slowly depending on
the severity of the dehydration. This
is called decreased skin turgor.
This can also be done at the dorsum of the hands, as well as the skin over the
abdomen.
HEAD AND FACE
Look at the patient’s head. This involves examining the front, sides, top as well
as the back of the head. For the sides and back of the scalp, you may need
to run your hand along the surface of the scalp to feel for abnormalities
hidden under the hair.
1. Size and shape

Look at the size and shape of the head from the front and the side.
The head may be generally enlarged (macrocephaly) in a person with

hydrocephalus, or reduced in size (microcephaly) as in a child with
congenital rubella. In a person with Down’s Syndrome, the occiput is
flattened giving rise to brachycephaly (shortened anterior-posterior
diameter).
2. Skull
Look for any obvious bony deformities or defects in the skull. Defects in the
skull may be due to trauma, or surgery such as a craniectomy (removal of
part of the skull bone).
47
Expansion of the marrow cavity in chronic anaemia such as thalassaemia

may give rise to deformity of the skull – anterior protrusion of the frontal
bone (frontal bossing) and prominence of the maxilla (cheek).
3. Muscle
Look at, and feel the temporalis muscle over the temple on both sides. This
is one of the earliest muscles to lose their bulk in chronic disease or
malnutrition – you might see flattening and eventually a depression where
the muscle bulk used to be.
4. Skin and scalp

Look at the skin overlying the surface of the head and scalp for overt
injuries, scars, pigmentation changes, evidence of bleeding (petechiae,
purpura), discolouration, lumps and bumps, and abnormal skin changes
(rashes, ulcers, etc.). You may need to part the hair to get a better look at
the underlying skin.
Look at the hair in terms of hair distribution, areas of alopecia (hair loss),
condition and colour of the hair as well as the underlying scalp, and finally
note presence of parasites such as mites.
Feel the skin surface under the hair as there may be hidden injuries or
swellings which may not be obviously visible.
5. Face
Look at the patient’s face for symmetry (both sides should look the same).
In Bell’s palsy (a cranial nerve palsy affecting one side of the face) the
affected side will look different from the normal side.
Look at the complexion of the face. It may appear pale (as in

hypovolaemic shock or anaemia), sallow (a yellowish colour, as in renal
failure) or flushed (as in polycythaemia).
Note any abnormal features on the face such as scars, rashes, ulcers or
skin swellings.
6. Eyes
First look at the periorbital region (region surrounding the eyes) for swelling
or evidence of inflammation, or bruising in the case of trauma. Cholesterol
deposits called xanthelasma may be visible in this region.
48
Look at the patient’s eyes, comparing it with the opposite side. Ask the
patient to look straight ahead and assess the position of the eyeballs.
Squints may be obvious.
Then look at the upper and lower eyelids for symmetry, crusting or
evidence of infection, such as styes. Pull down the lower eyelid to reveal
the conjunctiva to assess for pallor of anaemia (see below).
Next, look at the sclera (white of the eye) for redness, foreign bodies or
jaundice (see below).
Use a pen torch to illuminate the iris and pupils from the side. Look at the
cornea and iris for evidence of inflammation, foreign bodies or a ring
around the outer edges of the cornea (arcus), and finally the pupils to see
the pupillary reaction to light.
7. Nose and Ear

Take a quick glance at the nose, noting any obvious injury, deformity or
discharge (blood, mucus) coming from it.
Similarly, take a quick look at the ear externally looking for obvious injury,
deformity or discharge (blood, fluid) coming from the auditory meatus.
Remember to look at the back of the pinna as well as the area covered
by it for injuries or infection.
Examination of the nose and ear (with auriscopy) is explained in greater

detail in the next section.
8. Mouth
For the mouth, oral cavity and throat, perform the examination of all the
major structures in a sequential manner from front to back – lips, oral
mucosa, teeth and gums, tongue and base of tongue, and finally palate
and uvula, tonsils and pharyngeal wall.
Examination of the mouth and throat is explained in greater detail in the

next section.
49
There are THREE important signs which are best appreciated in the head and
face:
Cyanosis
Cyanosis noticed in the lips and tongue is called central cyanosis. This is more
likely due to hypoxaemia than peripheral cyanosis as the perfusion is less likely
to be compromised compared to the limbs in the event of hypotension.
Please note that central cyanosis if present, will always be accompanied by
peripheral cyanosis (true cyanosis) but peripheral cyanosis (due to poor
perfusion) will NOT be accompanied by central cyanosis.
Pallor
Pallor is a physical manifestation of
anaemia, which is the decreased
amount of haemoglobin in the patient’s
blood. As it is haemoglobin that gives
our blood the familiar red colour, any
significant decrease in haemoglobin
levels will manifest in the mucous
membranes as being pale (less red).
Pallor is best appreciated in the conjunctiva of the eyes. To do this, ask the
patient to look up and pull both lower eyelids down simultaneously to expose
the conjunctiva.
Pallor can also be well seen in the mucous membranes of the mouth, but less
well in the extremities such as the nail beds. This is because colour of the
extremities is dependent on perfusion; reduced perfusion results in reduced
blood flow, resulting in the affected areas looking pale.
Jaundice
Jaundice is a yellowish discolouration of the skin or mucous membrane, due
to deposit of bilirubin in the tissues. Generally jaundice maybe appreciated in
any skin surface or mucous membrane, but it is especially noticeable on the
sclera as the yellow discolouration stands out well against the white of the
sclera.
50
To demonstrate jaundice, lift both upper eyelids simultaneously with your

fingers while asking the patient to look downwards. Look at the exposed
sclera for the yellow discolouration of jaundice.
Please note that in some elderly individuals the sclera may not appear white
but greyish yellow – this is not jaundice, and is often described as a ‘dirty
sclera’.
NECK AND TRUNK
The neck and trunk is usually not examined under the general examination as
they are more thoroughly covered in the systems examination, but a quick
look at the neck and trunk may be warranted if signs are suspected to be
present.
The trunk refers to the chest (thorax) and abdomen as a whole.
Look at the neck first from the front, sides as well as the back. Inspect for any
obvious swelling, discolouration of the skin and distended veins. Look closely
for any abnormal pulsations in the neck.
Then move down to the chest. Look at the movement of the chest wall as it
moves up and down with breathing – both sides should move equally. Look
specifically for any deformities of the chest wall, abnormalities and
discolouration of the skin (especially surgical scars), lumps and bumps, and
obvious injuries. As in the neck, look for distended veins especially in the upper
part of the chest.
Finally look at the abdomen. See whether the abdominal wall moves up and
down with breathing. As in the chest, look at the abdomen for its distension
(how ‘bulging’ the abdomen is), abnormalities and discolouration of the skin
(especially surgical scars), lumps and bumps, and obvious injuries. Look for
distended veins on the abdominal wall, especially around the umbilical
region.
Please remember to look at the sides as well as back of the trunk.
51
LOWER LIMBS
Ask the patient to expose both their legs, preferably from the groin
downwards.
Make a note of the size of the limbs as well as any particular position the
limbs are in, comparing both limbs.
2. Bone and joints

Look for gross deformities of the lower limbs. Look then at the joints – hip,
knee and ankle for any swelling or deformities. Many inflammatory
conditions affect the large joints such as hip and knee and present with
swelling, deformity and/or inflammation.
3. Muscle
Look at, and feel the muscle bulk of the lower limbs. Focus on the thigh
and calf muscles, as these are lost early in conditions where the patient is
immobile, as in a stroke.
Occasionally the muscle bulk may be increased but the limb is weak. This
is due to muscle cell hypertrophy, and is seen in Duchenne muscular
dystrophy.
4. Blood vessels
Look for any prominent, dilated veins. These are called varicose veins and
are very common. You may need ask the patient to stand (or at least sit
up with the legs overhanging the bed) as varicose veins are more
prominent when the legs lie lower than the body.
If varicose veins are present, look for associated venous skin changes in
the ankle area (venous ulcers, hyperpigmentation) as well evidence of
venous thrombosis.

As elsewhere, look at the skin overlying the surfaces of the lower limbs for
overt injuries, scars, pigmentation changes, discolouration, lumps and
bumps, and abnormal skin changes (rashes, ulcers, etc.).
Feel the temperature of the lower limbs. A cold lower limb especially
towards the extremities indicated peripheral arterial disease.
52
If a swelling is present, there is a need to determine the presence and

subsequently the level of oedema (see below).
Oedema
Oedema is an abnormal accumulation of fluid in and around cells, tissues or
body cavities. It may arise from a variety of causes, but the important ones to
remember are heart and kidney failure. Oedema tends to manifest on the
dependent (the lowest part) parts of the body due to gravity. If a person is
mobile or at least able to sit, oedema will manifest in the lower limbs; if a
person is unable to sit and lies supine most of the time, oedema will manifest
in the sacral region.
To test for pitting oedema, you need

to compress the tissue against an
underlying hard surface such as
bone. Press the overlying tissue with
your thumb against the medial
malleolus at the ankle, or against
the tibia along the leg for at least 15
seconds. Then remove your thumb
and look or feel for the pit that is left
behind.
Demarcate the upper level of the

oedema by performing the
examination from distal to proximal.
THERE ARE TWO TYPES OF OEDEMA: PITTING AND NON-PITTING OEDEMA.

FIND OUT THE DIFFERENCE BETWEEN THE TWO.
53
REPORTING YOUR FINDINGS
Your findings on general examination need to be reported at the end of the

examination. A summary of the positive and negative findings relevant to the
scenario is sufficient.
You will need to use medical terminology when you report the findings so a
good grasp of terms commonly seen signs is very important.
First introduce the patient and demographic data if necessary...
“Mr James is a thin, 42 year-old Asian man...” or “Mr James is a thin, young
Asian gentleman...”
Then your general inspection findings...
“who is lying propped up on the hospital bed with mild tachypnoea and
respiratory distress despite being on supplemental oxygen...”
Finally your general examination findings...
“On general examination, he has clubbing and cyanosis of his hands. His
pulse rate is 92 beats per minute with a regular rhythm and normal volume. He
is neither pale nor jaundiced, but has central cyanosis. He has pitting leg
oedema up to the level of the knee.”
At the end you may present your conclusion...
“From my examination findings I believe Mr James has a cyanotic heart

disease with evidence of heart failure.”
54
EXAMINATION
OF THE
EAR, NOSE,
MOUTH AND
THROAT
55
OBJECTIVES
1. To demonstrate the correct technique to examine the nose and ear,

including the correct usage of an auriscope.
2. To demonstrate the correct technique to examine the mouth and throat
including the correct use of spatula/tongue depressor.
3. To understand the various significant structures in the nose, mouth and
throat and the common pathologies affecting them.
As in the general examination, the examination of the ear, nose and throat
follows a customisable technique according to the examiner.
The technique of examination suggested below is from external to internal

(outside moving inwards), examining each main structure of the organ as you
go along.
INTRODUCTION
You must have some prior knowledge about terminology of the various
anatomical parts of the ear, nose and throat, medical terminology as well as
definitions of symptoms and signs.
You may get them from Clinical Examination books such as:
1. Macleod’s Clinical Examination, 12th ed.

 Chapter 13 – The Ear, Nose and Throat
2. Talley and O’Connor: Clinical Examination, 6th ed.

 Chapter 13 – The Eyes, Ears, Nose and Throat
Please read them before you come for the Clinical Skills sessions.
As time is limited, these sessions would be best served by showing you the flow
and sequence of the examination rather than being bogged down in
explaining the various medical terminology or signs.
Also try to imagine the examination flow and sequence in your mind, and
how you would perform them; the more enthusiastic of you might even
attempt to perform an examination on a friend to get a feel on what you
would experience during an examination.
56
The basic equipment you will need when examining the ear, nose and throat
is a stethoscope, pen torch and an auroscope (otoscope).
For the examination of Ear, Nose and Throat, you are to sit at level of the
patient’s face i.e. opposite patient, facing the area to be examined (sitting if
patient is seated on a chair, standing if patient sitting on a couch)
NOSE
Examination of the nose

We can only perform a limited
examination of the nose and the nasal
cavity with a torchlight.
Using a nasal speculum (left) or an

auriscope may give better visualisation of
the nasal cavity, but ideally an endoscope
is used for a throrough examination of the
nasal cavity.
1. Have a quick look at the nose for the general shape and size, and
surrounding skin. Deformities, swelling and evidence of inflammation may
be evident.
2. Look for any discharge from the nostril.
57
3. With your right hand, hold the patient’s head to stabilise it; then use your
thumb to lift the tip of the nose slightly to visualise the nasal cavity. Then,
use a pen torch to illuminate the nasal cavity (pic above).
4. Look inside the nasal cavity for deviation of nasal septum, erythema,
abnormal swelling/growth, or foreign body. Pay attention to the nasal
turbinates (or concha), as they may be enlarged in some conditions.
5. Where necessary, you may need to

assess the paranasal sinuses.
Sinuses are a collection of air cells
within the skull. These sinuses are
usually filled with a small amount of
fluid; these fluid drain into the nasal
cavity via openings covered by the
nasal turbinates. When the openings
are blocked the fluid may become
infected leading to a condition
called sinusitis.
Using your pulps of your thumbs, gently press on the skin overlying the
sinuses (pic above), looking for tenderness. If tenderness is present, then
the diagnosis of sinusitis is likely.
MOUTH AND THROAT
1. Sit opposite the patient and ask for permission.
2. First look at the perioral region (region surrounding the mouth) for infection
and skin lesions especially at the angles of the mouth (angular stomatitis).
3. Then look at the lips. An obvious defect such as cleft lip or a surgical scar
may be clearly evident.
Note the colour, moisture and surface of the lips. Central cyanosis may be
obvious at the lips. The lips may appear dry and cracked in a dehydrated
patient. The lips may also be abnormally pigmented in certain conditions.
4. Ask the patient to open his mouth. If dentures are present you will need to
remove them first.
58
5. First look at the mucosa of the oral vestibule (inside of the upper and lower
lips, buccal mucosa). You will need to use a spatula to part away the
mucosa from the gums. Look for mucosal changes (ulcers, growths) or
evidence of infection. Pigmentation changes may also be present.
Look at the openings of the parotid duct which are directly opposite the
2nd upper molar teeth.
6. Then look at the gums and teeth for dentition and caries, abnormal gum
pigmentation, evidence of gingivitis or other causes of gum swelling.
7. Now look at the tongue. Note the size, colour and appearance of the
surface of the tongue. The surface of the tongue appears irregular due to
presence of papillae. In certain nutritional deficiencies, the loss of the
papillae may give rise to a smooth tongue. Central cyanosis will also be
obvious at the tongue.
Ask the patient to protrude the tongue and note the movement. Any
deviation may indicate pathology of the nerve innervating muscles of the
tongue.
Finally ask the patient to touch the tip of his tongue to the roof of the
mouth. Look at the base of the tongue, frenulum and openings of the
submandibular ducts for abnormal growths and evidence of infection.
8. Next look at the palate. The palate is divided into the hard palate
anteriorly, and the soft palate posteriorly. The soft palate on both sides will
merge in the midline to form the uvula.
Look out for midline defects in the palate – this is called cleft palate and
may affect the entire hard and soft palate, or part of them.
9. Ask the patient to say “Ahh…” and look at the pharyngeal wall (back of
the throat), uvula and the tonsils. If you are unable to visualize the throat,
you might need to use a spatula to depress the tongue to get a better
view.
Place the spatula on the anterior part (anterior 1/3 to anterior half) of the
tongue and use it to push the tongue downwards. Do not put the spatula
too far to the back of the tongue as you can accidentally trigger a gag
reflex which is uncomfortable to the patient.
59
The tonsils lie in the tonsillar

fossa in between the two
palatal folds of the mouth:
anteriorly the palatoglossal
fold (arch) and posteriorly
the palatopharyngeal fold.
It is important to identify the

folds as the tonsils may not
be evident in some
individuals (atrophied
tonsils) or absent (after
tonsillectomy).
Look for evidence of infection on the pharyngeal wall (pharyngitis) or

enlarged and inflamed tonsils (tonsillitis). Look for the presence of pus
discharge from the tonsils.
As the patient says “Ahh…” also watch the uvula and the soft palate for
abnormal movements.
This completes the examination of the mouth and throat.
60
EAR EXAMINATION AND AURISCOPY
Auriscopy (or otoscopy) is an examination

technique whereby a device called the
auroscope is used to visualise the external
auditory canal and tympanic membrane.
This gives valuable insight into the function

of the tympanic membrane and middle
ear. It also visualises clearly any
abnormalities of the external auditory
canal.
1. Obtain permission to examine and explain the purpose of the

examination. Sit facing the ear on the side you intend to examine.
Hold the auriscope with your hand of the side of the patient you are
examining; if you are examining the left ear, hold the auriscope with your
left hand and vice versa.
2. Inspect the outer ear/pinna (including the back of the pinna) for any skin
lesions, swelling, or discharge. Note presence of a hearing aid. Also check
the area behind the ear usually covered by the pinna. This area is called
the mastoid area, and may be tender and inflamed in mastoiditis.
3. Choose the largest size of ear pieces that can snugly fit into the auditory
meatus of the patient. Attach it to the auriscope, and ensure that it is
tightly attached.
4. Using your left hand, gently pull the ear cartilage upwards and
backwards, so as to straighten the auditory meatus. Hold the auriscope
like holding a pen with your right hand, and insert the ear piece slowly into
right ear.
5. Through the viewing window, inspect the wall and lumen of the external
auditory canal for evidence of inflammation, abrasions, and skin lesions
such as vesicles of herpes zoster. Blood and discharge may be visible as
well.
Also note the presence of ear wax, which may obstruct your view of the
tympanic membrane.
61
6. You should see a pearly grey tympanic membrane with the handle of the
malleus in the middle and a cone of light at 4 – 5 o’clock position on the
right (and 7 – 8 o’clock position on the left).
Right tympanic membrane Left tympanic membrane
Inspect the tympanic membrane for:

 Loss or blurring of the cone of light – early evidence of otitis media
 Colour – erythema of otitis media, dark red of haemotympanum
 Swelling/bulging – presence of fluid/pus/blood
 Defects – perforation of the tympanic membrane
 Abnormal growth – cholesteatoma
 Presence of a grommet (transtympanic tube for drainage of fluid/pus
in chronic otitis media)
7. Repeat for the left ear but use your left hand to hold the auriscope, and
right hand to pull the pinna.
You can practice on the ear models available at the Skills Centre to enhance
your auriscopy skills.
REPORTING YOUR FINDINGS
As in the general physical examination, you will need to report your findings at
the end of the examination.
62
NOTES
63
NOTES
64
NOTES
65

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CSSC Manual – Foundation Block ME 1/13

© International Medical University

INTERNATIONAL MEDICAL UNIVERSITY

Welcome to the Clinical Skills and Simulation Centre

In the Communication Skills component, you will be learning the methods

For more information regarding the Communications Skills component,

Scattered throughout the manual are questions marked . The questions

SECTIONS IN THIS MANUAL Pages

Safe Injection Practices 11

Blood Pressure Measurement 18

Body Mass Index 23

Introduction to Physical Examination 29

The General Examination 38

Examination of the Ear, Nose and Throat 55

1. To understand the definition and importance of standard precautions.

2. To discuss the various precautions to prevent transmission of pathogens

3. To be able to demonstrate the correct technique of hand washing.

Standard precautions (or universal precautions) are the minimum infection

1. Transmission of infective organism from patient to health care professional;

2. Transmission of infective organism from health care professional to a

Some standard precautions which need emphasis among doctors are as

2. Use of personal protective equipment

3. Safe injection practices

The nurses at CSSC will be giving a presentation on Standard Precautions

For further information on Standard Precautions, please refer to:

Ministry of Health Malaysia, Policies and Procedures on Infection Control

Transmission of pathogens via contaminated hands from a healthcare

Not only are patients at risk, these pathogens may be inadvertently be

Bacteria growing on an LOOK MOM!

When do you hand wash?

1. Before you touch a patient, even when gloves are to be worn

4. Before performing an aseptic task, such as placing an intravenous access

5. After removal of gloves

What do you use to hand wash?

How do you wash your hands?

MAKE THIS ONE HARD HABIT TO BREAK!!!!

Wearing gloves is one of the mainstays of standard precautions.

There are two types of gloves:

Examples where sterile gloves need to be worn are in surgical procedures,

REMEMBER TO WASH YOUR HANDS AFTER REMOVING THE GLOVE!

WHO Glove Information Leaflet

Some procedures done by medical personnel involve penetrating or

The principles of the aseptic technique include:

These include handwashing and wearing of personal protective

2. Maintenance of a sterile field

Proper waste disposal minimises risk of infection after the procedure.

In your CSSC session these principles will be demonstrated using wound

SAFE INJECTION PRACTICES

The two important aspects of sharps management are:

THE VITAL SIGNS

1. To demonstrate the correct way to take the temperature, pulse and

2. To learn the proper way to handle a mercury thermometer and

3. To demonstrate the proper technique of taking a blood pressure using the

4. To recognise the Korotkoff sounds.

5. To recognise the normal readings of all the vital signs.

What Are The Vital Signs?

The vital signs consist of:

These are called vital signs because they are VITAL!!!!

As doctors, these measurements will most likely be done by the nurses;

Please watch the video on Temperature/Pulse rate/Respiratory rate

A mercury thermometer is commonly used to measure the body temperature.

Generally a temperature above 37.5C is called pyrexia (commonly known

How to measure the oral temperature