Bazeed MRCS-Merged

Communication skills
[Document title]
 There are two communication stations in the exam.
 One to communicate with a patient (always an actor) and
another one to make phone call with consultant.
 Each station is preceded by another station called
preparatory station.
 In communication skills station, you will have one minute
to read the stem on the door and whole nine minutes
either to communicate with patient or to make a phone call
with a consultant.
 You will have the patient file in the preparatory station and
also another one in communication station.
 In communication skills station, you will have pencil and
paper if you want to illustrate anything to your patient.
 In communication skills station, there will be two
examiners:
 Surgeon examiner responsible for 12of 20 marks, you
will be evaluated for medical information and layman
examiner responsible for 8 of 20 marks, you will be
evaluated for on the following items body language
including head nodding and eye to eye contact, rapport to
the patient, use of layman language not medical one
(tummy for abdomen, bleeding for haemorrhage) and
show a sympathy (offer a seat and apologize).
 In communication station, introduce yourself, offer a
seat for your patient, use layman language, and actively
listen (sit on the edge of the chair, head nodding and eye
to eye contact), use your body language including your
hands and facial expression) and show a sympathy (offer
a seat and apologize), give warning shots before break
bad news, answer patient questions, summarize your
case, offer help and thank your patient.
COMMUNICATION SKILLS
[Document title]
Preparatory station
One minute to read the stem on the door and another nine
minutes, you are going to spend them reading patient file and
you will have pencil and paper to write your notes and you can
take the notes to the communication station where you can have
another file for the same patient again.
What to write in the notes?
 Patient details (name, age, date of admission, date of

surgery and date of investigations).
 Your details (name of hospital you work in, your level of
training (ST 1 for example) and the name of your
consultant).
 Name of the consultant you will speak with and purpose
of the call like transfer the case, ask for advice, or update
him with a case.
 Positive clinical radiological laboratory findings.
During phone call
 You will introduce yourself (your name, level of training,

consultant you work for and name of your hospital).
 Emphasize the purpose of the call (transfer the case, ask
for advice, or update him with a case).
 Summarize your case.
 Answer the consultant questions.
[Document title]
COMMUNICATION WITH A PATIENT

OR A RELATIVE
Discharge against medical advice

(DAMA)
Middle aged male patient has fracture ribs and sub capsular
hematoma but he is hemodynamically stable. HB falls from 10
to 9.Patient is under conservative treatment.
He decided to leave the hospital you have been asked to talk

to him.
Hello Mr....., I am..... One of the surgical doctors, I have been

told that you want to leave the hospital, I just want to explain
to you your case before you decide.
You have what we call (splenic hematoma) which means a
collection of blood around the capsule of your spleen (spleen is
an organ which is present right here in the upper left side of
your tummy), this was due to fracture to your ribs. Your blood
count dropped also by 1 gram which gives the possibility of
continued bleeding which may lead to serious deterioration and
danger to your life.
But Staying in hospitals is disappointing and frustrating.
Ok, I understand that staying in hospitals is frustrating and

disappointing but you have to know that people are only kept
in hospitals when absolutely necessary.
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My wife has cancer and I have to go with her to her doctor.
I definitely understand your situation as you have to look also

for your own health. If something bad happened to you, your
wife's condition will be worse as nobody will look after here. I
can arrange with our social workers to find a way to give help
to your wife until your condition improves.
Also I have a job interview.
I understand your situation but I need you to reconsider as you

have to look for your health first and don’t endanger yourself,
after that you could search another job.
Ok Mr....., can you repeat for me what I have told you about
your condition so as to be able to know if you understand me
right or not.
……………………..
Mr......, as I cannot discharge you medically, you will have to
sign a legal document stating the exact details of your case and
that the continued admission was medically advised and that
the potential sequences have been explained and that you take
the responsibility of any adverse outcomes.
Ok I will sign that.
Ok, if you felt that your state is deteriorating like feeling

drowsy or having non bearable tummy pain, I suggest that you
should attend to the A&E department immediately and ask
them to contact me or the SHO in charge directly.
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Mr....., you have decided to self-discharge and you are going to

sign the appropriate documents, so I am going to sum up what
we have been through. You knew that you have a splenic
hematoma and that the medical advice is to keep you in
hospital. You understood the risks of not being in hospital
which include becoming more unwell and possible even may
lead to a danger to your life. You have accepted the
responsibility of those risks.
Also we have discussed what signs to look for out and that you
will return to hospital if you were more unwell If you have any
other questions please ask me.
We are all here to help and support you and to dive you a hand
at any time. If you have any inquires don’t hesitate to contact
meat any time. I will leave my phone number for you with the
nurse.
Thank you for understanding.
[Document title]
Counselling for OGD dilatation and

biopsy
(holding a tissue because he is salivating a lot)
Patient with dysphagia, barium swallow has been performed;
showed lower oesophageal narrowing. OGD is planned.
You have been asked to council the patient for this procedure
Hello Mr......., I am....... One of the surgical doctors, I have

been asked to talk to you about an investigation we would like
to arrange for you. Can I ask you what do you know so far
about this?
......................................
Ok, this is what we call oesphageo-gastro-dudonoscopy which

can be abbreviated to OGD. The camera is called the
endoscope which will be inserted through your mouth down
to your food pipe then to your stomach then along the first
part of your small bowel. This camera will relay the image to
a TV screen so we can have a look inside. We shall also make
a widening of the narrow part of your food pipe which was
discovered previously on the barium image. We may also take
some samples from the lining of your food pipe which may
help us in figuring out your case.
Is it painful?
This will be typically under sedation which will make you

slight drowsy and feel no pain.
[Document title]
Is there any risk?
No procedure is without risks. The possible risk may include:

. Damage to your teeth from the introduction of the scope
. Infection such as chest infection
. Bleeding from the sites of tissue samples
. The most serious risk is cutting through your food pipe wall
which may need a surgical operation for repair
Ooh my god I don’t want to perform the operation?
Listing those risks doesn't mean that they will essentially

happen. My advice is to accept doing this investigation as it is
very crucial in determination of your case. Also you have to
know that only skilled and experienced surgeons are the only
allowed to perform such procedures.
Why I keep salivating?
This is most probably due to the narrowing present inside

your food pipe which hinders your regular secretions to flow
downwards smoothly.
Is it cancer?
Still early to confirm that, we will have to wait until the

results of this
Investigation appear and probably we may need to do further
investigations to figure it out.
[Document title]
When the result of my sample will appear?
It usually appear within two weeks’ time frame, I can

understand your apprehension and will make sure to contact
you once it is available.
Do I have to stay in the hospital?
Typically you will discharged home after you regain your

conciseness (two to four hours).you will not be able to drive
in the next 24 hours you will need someone to drive you
home.
Have you seen my investigation?
Yes
Is there anything abnormal?
I will chick for you or (tell him the result).
Mr……, to summarize what we have been through, we need

you carry out an investigation called OGD for you. This will
be under sedation, also I have listed the possible risks and
importance of this investigation: you have to sign the consent
if you agree.
nurse.
[Document title]
Counselling a patient before

stopping warfarin
(blind and wears black glasses)
Old man who is blind (dark glasses) and lives alone with history
of prosthetic valve and he is on warfarin. Recurrent hernia
surgery is planned for him.
You have been asked to counsel the patient before stopping

warfarin
Hello Mr. ......., I am dr. ....... one of the surgical doctors in this
department, I have been told that you are having some concerns
regarding stopping your warfarin pills, can you tell me more
about your apprehension towards this?
My doctor told me that I shouldn’t stop it because stopping will

threaten my life.
First let me explain what warfarin is and how it acts. Warfarin

is a medication that thins the blood by preventing the
production of certain chemicals. It is prescribed for patients to
prevent or treat the formation of clots in the blood. In your case
you have been prescribed by warfarin to prevent formation of
clots over your artificial valve. As we are going to operate upon
you, we will have to stop this blood thinning effect of warfarin
for the fear that it might cause bleeding during or after the
operation. The problem here is that warfarin has a long duration
of action, so to eliminate its action we have to stop it 5 days
before your surgery. But we cannot leave you without
protection for this period, so to keep you safe from formation
in clots in the blood , you will be given another injectable drug
[Document title]
which is called (heparin) that will be equivalent in effect to

warfarin but has a shorter duration of action, so it can be
stopped only for 12 hours before surgery.
Why heparin?
Both of them are providing the same required blood thinning

effect that will protect you from formation of clots over your
artificial valve, but the difference is that warfarin has a long
duration of action which means it will be acting up to 5 days of
its stoppage while the injectable heparin is having only 12
hours of action. So as I told you it can be stopped shortly before
your surgery.
When can I resume warfarin?
After your surgery is finished and if we are satisfied that there

will be no more bleeding, we will continue giving you this
injectable heparin together with your warfarin tablets till we get
sure through some blood investigations that the blood thinning
effect of warfarin is regained. In this time we will stop
injectable heparin.
Is it necessary to stay in the hospital prior to the operation?
Yes, during this period in which we are stopping warfarin and

started injectable heparin you will stay in hospital. This will be
about five days prior to your surgery.
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Is it necessary to stop my antianxiety medication before the

operation?
You should not stop your diazepam tablets till the morning of
surgery but only with a small sip of water.
Mr, lets summarize up what we have been through, you have to

stop warfarin five days before the operation. During this period
you should receive heparin which will be stopped 12 hours
prior to the surgery and resumed 12 hours after surgery.
Warfarin will be also resumed after surgery and when we
ensure that no further bleeding. Heparin will be stopped when
the laboratory test indicates that warfarin has resumed its action
effectively.
nurse.
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Anxious mother
(Actor is worried and crying)
A five-year-old child who has fallen down from a height (a
tree). He has brought shocked to the hospital with his father
(drunken).resuscitation and FAST have been performed and
suggested a rupture spleen. Now he is operated (laparotomy).
Now, you have been asked to talk to his anxious mother to

answer her inquires.
Hi, I am..... One of the surgical doctors, I apologize that you

have not been contacted before. I will tell you everything
about your child condition but let me know first what so far
did you know about what happened?
.....................................
Mrs....., your child apparently felt off his climbing frame and
probably seriously himself. I apologize that you couldn't see
him before taken to the theatre but the case was an emergency
and we could not wait until you arrive.
How has he got the injury?
His father told us that he was playing in the garden when he

has fallen from a tree.
What is the result of the scan?
Unfortunately, the scan we have made when he came in

suggested that he had a ruptured spleen and he is now being
operated to fix that.
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[Document title]
What is meant by spleen and what is its importance?
Spleen is an organ present inside his tummy in the upper left

side. The spleen has some functions in the body's defence
mechanism.
Is it serious condition?
A ruptured spleen is definitely a serious condition, that's why

he was taken urgently to the theatre. You have to know that he
is now in very good and experienced hands, however his
condition remains serious to the extent that may affect his life.
What did his father told you?
His father told us that your child was playing at garden when
he suddenly called out in pain as he had fallen from a height.
He noticed a big bruise on the left side of his chest so he
called an ambulance.
But his father is drunk and I want to protect my son could you
help me?
I will have to share this information. In any case like yours we

have to make extra precautions to ensure that your child is
going to be safe. We will take some standard procedures like
finding out about your child situation at home. Also we will
need to involve a child protection consultant. We routinely
involve child protection services to make sure that anything
we do will be in your child best interest.
Is there any medications will be required after the operation?
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[Document title]
If his spleen is going to be removed, he will need to be

vaccinated after that to protect him against potential infections
he may get. Also it will be recommended to receive lifelong
protective antibiotics.
How long could the operation last? Could you take a look and
tell me?
It will be difficult to determine how long the operation will

last and I am afraid I can’t get in the operation room because I
don’t want to interrupt the surgical staff.
When I can see him?
You can see him as soon as get out from the operation room.
When could I take him back to home?
You have to make sure that our first priority is your chid
medical care. We will ensure that he will make a good
recovery. We will not discharge him until we have undertaken
full clinical examination and make sure that his GP is aware
about any concerns.
Mom, lets summarize up what we have been through, your

child has fallen down from a tree and he has got a rupture
spleen. Now, he has got a rupture spleen and he is operated by
very good and experienced hands and you can see him as soon
as he get out of the operation room. He will remain in the
hospital until his condition improves.
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nurse.
(offer her a seat, give her a tissue, assure her, don’t make
physical touch)
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Anxious mother
(Actor is worried and crying and feels guilty)
A girl with acute appendicitis has been brought to the hospital
by her neighbour. The mother was at work when she was told
that her daughter is in the hospital. She became anxious when
she realize that Mr. Mann is the same surgeon who did an
operation for her husband who died.
You have been asked to talk to her anxious mother to answer

her inquires.
Hello, I am dr....... One of the surgical doctors, I was told to

speak with you about your child condition. Can you first tell
me what do you know so far?
- .....................................
First, you don't have to feel guilty because this could happen
anyway. Your daughter was brought by your neighbour
complaining of tummy pain. Our initial investigation revealed
the suspicion of acute appendicitis. She was managed by our
registrar and received some IV fluids and antibiotics. We are
now waiting for the consultant who will operate upon her.
Are you sure that my daughter has acute appendicitis?
We are suspecting acute appendicitis as this is common

condition and also her signs and symptoms denotes this. But
we cannot make sure by 100% until we operate upon her.
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[Document title]
Is it dangerous?
In children specifically there is less fat inside the abdomen, so

perforation can be particularly dangerous. In such case your
child may go to a higher care area.
Will the wound be disfiguring?
A small horizontal wound will leave a little scar, but we may

need to expand the wound and this may be disfiguring.
Is there any other problems could occur?
Yes probably, severe infection can block the reproductive

tubes in young girls, so future sub fertility may happen.
Do you mean that she can’t get pregnant in the future?
I understand your apprehension mom, no need to worry

because she has another fine working tube on the other side.
But Mr. Mann did operation for my husband and he died?
I am so sorry to hear that. Please accept my sincere

condolences. May I ask when and how he died?
Mr. Mann did operation for him because he had colon cancer
and he died few weeks after the operation at home.
I am so sorry to hear that again. I think those are two different

situations. I think your husband died from the cancer not the
surgery and MR. Mann one of best surgeon we have in the
hospital.
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Can I see her?
Of course mom. I will see what I can do for you mom.

child has been brought here by your neighbour complaining of
tummy pain our initial investigation revealed acute appendicitis
and we are now waiting the consultant to operate upon her and
I’ve explained the risks and benefits of this operation.
nurse.
(offer her a seat, give her a tissue, assure her, don’t make
physical touch)
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Angry patient
(actor will be very angry till the end of the station)
Male patient working as postman with meniscal injury
postponed once before due to long operative list. Now, the
consultant has been called for an emergency and the operation
will be postponed again.
You have to talk to the patient and tell him that his operation
is cancelled.
Good morning Mr........., my name is..........., I am the

orthopedic trainee covering for my consultant
Is it my turn now for the operation?
I understand that you have come today for your knee operation.
Mr.... I am very sorry to say that but unfortunately my
consultant has been called away for an emergency case and we
will be unable to carry out your case today.
What do mean by that? Do you mean that my operation is not

an emergency?
Again I do apologize. I can see that your knee has been really
troubling you. It has bern good to have been able to have it
done today. I understand your frustration as I see from your
notes that you were postponed once before. However surgical
emergencies have to be prioritized and this is why my
consultant was called away. I am really sorry for that.
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Would you call him now?
Sorry, as I told you he is busy now with that emergency case

and he will be unable to pick up my call.
I need another consultant to do it now.
Mr...., it is your right to choose your doctor but I am afraid

that also will be time consuming as the new consultant will
study your case from the start.
So could you do it?
I am sorry but I am not authorized to do such operations

without supervision.
So give me another appointment now
I am sorry but I cannot give you the next available date just
now. We will call you once we put in a date. But I promise I
will mention your circumstances and emphasize the
importance of having you listed the next possible soonest
session.
Promise me not to be postponed again
I am sorry sir, but if such an emergency should rise again, it

will need to be prioritized.
How can work now?
I can write a letter to your employer explaining the medical

reason of why you will not be able to carry out your job as a
post man for now and that you will need more sick-leave as
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your procedure has been postponed. Even if you want I can

call him for you.
Can I walk on my legs?
Well, there will be some wearing and tearing. However, you

should remain active with non-weight bearing exercises such
as swimming to keep the muscles around your knee strong. I
can also refer you to a physiotherapist who will recommend
some good exercises to strengthen your knee.
I need another medication as I feel heart burn.
I can prescribe a different type of pain killer. You should stop

diclofenac as it increases the risks of stomach ulcers. Again
accept my sincerest apologies.
Mr, lets summarize up what we have been through, your

operation has been postponed because the consultant has been
called for an emergency. We apologize again and we will
contact you soon for another appointment.
nurse.
(When the patient stands, don’t stand, offer him a seat and
apologize)
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Angry wife
Male patient with massive ascites, the ascites has been tapped
and the fluid sent to cytology which has revealed the presence
of malignant cells. Abdominal CT has been ordered. The CT is
not working.
You have been asked to speak to the patient wife who is angry.
Hello, Mrs....., I am.......... One of the surgical doctors. I am

very sorry that you have been waiting for too long to see Mr.
Mann.
You are not Mr Mann, are you?
No, I am not, I am very sorry he has been called for an

emergency. I am here to see what is wrong and talk to you about
what I can do for you. Definitely I will tell Mr. Mann that you
were here and I can arrange another appointment to meet him.
I know that is a very tough situation. I knew that he came in
couple of days ago having some tummy swelling for 6 weeks
and he was sent to do CT scan. But unfortunately we have some
problems in our CT machine.
Why CT is required?
We know that had a tummy swelling due to accumulation of

fluids inside. Some of these fluids were taken for analysis
which showed the presence of cancer cells. What we need to
know from this investigation is what the kind of this cancer is
and where it is coming from and how much it spreads.
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[Document title]
Is there any alternative?
As a temporary alternative, we can do an ultrasound scan (like

the jelly scan of the pregnant women) which will give us an
idea about his liver and whether it contains any suspicious spots
or not, also it will give us an idea about the amount of fluids.
Another alternative also is MRI scan which can be equally
helpful as CT, but we have to take Mr. Mann opinion in that.
Our last option is that we may transfer him to another hospital
to do the scan.
Transfer if this is a small hospital. Why did not you transfer

him from the start?
I am so sorry, I agree that we may be a small hospital and

probably not having over resources but we routinely do all the
required investigations for such patients within 2 weeks’ time
frame. So, we will not leave him suffer if we found that he
needs to be moved to somewhere else.
Is it cancer?
Well, to tell somebody that he is having cancer, I have to be

ready to answer questions like where it comes from, what is its
stage, what are the options of treatment. For your husband, the
only thing that we have in hand is the fluids analysis which tells
that there is cancer.
Do you think that he will need a surgery?
We do operations for cancers that we only think it may

improve. In your husband’s case, the presence of tummy fluids
gives an impression of an advanced cancer. In cases like this, it
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will be unkind to put the patient in suffer and pain with only
little benefit.
But he could not breathe well right now.
Yes, this is due to the presence of much fluids inside his tummy
pushing his lungs so he cannot breathe well. I will discuss with
Mr. Mann if we can withdraw some of the fluids from his
tummy. Also, there are certain medications which can help him
to get rid of these much fluids.
His brother is not here right now he is travelling, should I tell

him?
I understand your worries mom. I think it is wise to wait for

the result of his CT.

husband has tummy swelling which revealed that contain nasty
cells. Unfortunately our CT machine is not working and I
explained to you the alternatives.
nurse.
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[Document title]
Communication skills: phone call

Oliguria pod one
(After right hemicolectomy for cecal tumour)
Call the on duty consultant to consult him about the case.
Hello, I’m......... (SHO, ST1, CT2) working for Mr...... I am

calling to speak to Mr. .......to ask him an advice about a patient
who underwent right hemicolectomy for cecal tumour, he has
been oliguric now. Could I check that I am speaking to........?
Who is the consultant of the case?

Mr........
Summarize your case?
Mr.... Is ....y old , he has been operated 24 h ago by right

hemicolectomy for cecal tumour, his urine output in the last 8
hours is about (10-20 ml) ,I checked the urinary catheter which
was not blocked. He is tachycardia, has low grade fever, with
mild hypotension, his abdomen is lax.
His bloods show his Hb dropped from 12-10, urea is
moderately raised, and creatinine is borderline high.
What do you think the cause is?
I think the patient is dehydrated, he received only 1100 ml of

normal saline for pod1. Also on checking the operative notes,
there was a blood loss but he received 2 units of blood
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Plans of action?
I will start fluid resuscitation by giving 1 litter of normal saline

over 1 hour and will continually monitor the patient in the ward.
I will repeat bloods tomorrow morning, if no response to fluid
challenge overnight, I will transfer the patient to HDU to insert
a central line and monitor. If bloods shows Hb more dropping,
I will start blood transfusion.
Do you think that the patient is bleeding?
May be, but I will monitor the vital signs continuously, I will
do serial abdominal examinations. If I found any signs of
bleeding I will let you know.
Do you think it is anastomotic leak?
For now, the patient is not toxic, his abdomen is lax, but I will
do serial abdominal examinations and prepare for abdominal
ultrasound and will let you know if the patient becomes
peritonitic.
If you need me to come back?
I will start fluid challenge, will update you subsequently.
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Bile leakage pod4 after lap. Interval

cholecystectomy
Call the hepatobiliary surgeon in another hospital to transfer the

case.
Hello, I am......... (SHO, ST1, CT2) working for MR...... In......

Hospital. I am calling to speak to MR. ......., the hepatobiliary
consultant to ask him an advice about a patient, can I check
that I am speaking to Mr....
Mr..... Is.... Y old previously fit and well who underwent lap.
Cholecystectomy 4 days ago. He has been complaining of
abdominal pain since. Today we noticed bile in his abdominal
drain. Clinically, he is tachycardia, pyrexic, slightly jaundiced,
has generalised abdominal pain, but his abdomen is lax. His
bloods (taken 2 days ago) show elevated bilirubin, elevated
TLC and increased CRP. We have arranged for an abdominal
ultrasound which showed free intra-abdominal collection. We
think that this patient has had a bile leakage and we were
hoping to transfer him to your specialist care for definitive
treatment.
What are the possible sources of bile leakage?
May be due to:
 Cystic duct stump leakage due to slipped clippage or

retained CBD stone.
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 CBD injury.
 Accessory cystic duct.
 Leakage from the liver bed.
What will be your management?
 I started fluid resuscitation and antibiotics.

 I will order new set of bloods when I am off the phone.
 We need to make an ERCP to delineate the source of
leakage and probably to put a stent, but this is not
available in our hospital now.
Is this urgent?
Yes, for the fear of developing biliary peritonitis.
Do you need to arrange with anyone?
Yes, with the bed manager of both hospitals to discuss

creating bed whether by facilitating discharge or
repartitioning of patients.
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Refer polytraumatized patient to a

cardiothoracic consultant
Call the cardiothoracic surgeon in another hospital to transfer

the case.
Hello, I am......... (SHO, ST1, CT2) working for Mr........

In......... Hospital. I am calling to speak to Mr....... The
cardiothoracic consultant to ask him to accept a referral of a
polytraumatized patient with a widened mediastinum on the
chest x ray. Could I check that I am speaking to Mr.....?
A man aged...... Came to us on motorcycle RTA, on

examination, his GCS= 14, his pulse rate was 120/ min, his BP=
100/80, he has a swollen left thigh. We did a chest x ray which
revealed a widened mediastinum with bilateral haemothorax,
we put a chest drain which drained 200 cc of fresh blood, and
we could not make CT as the machine is being serviced for the
next 3 hours. His AXR showed absent psoas shadow, his x-ray
on the femur showed fracture of the shaft. His bloods: Hb 8.9,
PH 7.32, with low HCO3, the patient is known to be diabetic.
We started fluid resuscitation by 4 litres of crystalloids and we
cross matched 6 units of blood but not yet transfused.
What will you do for the cervical spine?
I will support it using a hard collar.
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What will you do for the leg?
I will use a Thomas splint.
What will you do for the blood pressure?
We started fluid resuscitation and cross matched for blood, but

we should not let the blood pressure rises for the fear of
increased haemorrhage.
Why having metabolic acidosis?
Patient has a closed fracture of the femur, so compartment

syndrome is a possible cause the patient has a haemorrhagic
shock the patient may have diabetic ketoacidosis.
What about the abdomen?
Absent psoas shadow denotes the presence of intra-abdominal

collection, so he may require exploratory laparotomy.
Who will accompany the case?
I will come with one of our anaesthesia colleagues or ITU

colleagues.
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Call consultant to update him about

a pod2 mastectomy patient who her
daughter wants to discharge her
against medical advice
Ring the on-call consultant surgeon, who is not the patient’s

consultant, and explain that this patient’s daughter wants to
take her mother home. (DAMA)
78 y old lady, with a background of COPD, mild LVF,

underwent mastectomy + axillary clearance for breast cancer,
pod2 she developed axillary discomfort with axillary swelling
with SOB Her daughter wants to take her home.
The daughter of the patient whose notes you have, has arrived
at the hospital. The patient was due to go home tomorrow but
some complications have arisen. Notwithstanding this the
daughter wants to take her mother home this afternoon to her
house which is 60 miles away. She has persuaded her mother
that this would be the best course of action. You have spent the
last 20 minutes trying, unsuccessfully, to persuade the daughter
that discharge today is not in the patient’s best interest
especially to a house 60miles away. The patient was keen to go
home to her own bungalow, however in view of her
complications she should stay in hospital until she is better
The daughter is very determined and wants to have her own
way and does not suffer fools gladly. She is convinced that her
mother will be fine going home with her today .You have
perceived that it would certainly be a lot more convenient for
31
[Document title]
the daughter because it will save her from coming to visit her
mother in hospital or at her bungalow She has convinced her
mother that it will be best for her to go home with her today,
although the patient would almost certainly prefer go to her
own house when she is well enough to go home. The daughter
is a school teacher and is out at work all day, as is her husband.
They have two teenage daughters and a Labrador so the house
is busy and noisy. The patient has another daughter who lives
near to the hospital, but she is a paranoid schizophrenic.
Mrs Janice green 78 y old who had mastectomy with axillary

clearance 2days ago for breast cancer, now she has an axillary
swelling and her wound suction drain has 90 ml of fresh blood
, also she experiences SOB. The patient has also a background
of COPD and mild LVF. Now her daughter wants to take her
home which is 60 miles away. I spent 20 min trying
unsuccessfully to persuade her daughter that discharge today
will not in the patient best interest.
Has the patient made her own decision or has she been bullied
into making a decision to go home today?
I think the daughter has convinced her mother that it will be

best for her to go home with her today, although the patient
would almost certainly prefer go to her own house when she is
well enough to go home.
Is the patient is sufficiently alert to make her own decision?
Yes, she has the competence to make an informed decision.
32
[Document title]
Have you checked the patient?
Yes and unfortunately I couldn’t convince her to stay
What do you think has happened to this patient?
In view of the fresh blood in the vacuum drain and the swelling
in the axilla, there is a possibility of a reactionary haemorrhage
in the wound site Also I have to consider the presence of DVT
and pulmonary embolism or acute exacerbation of COPD in the
view of SOB.
What will be your plans of action in the event of these

complications?
As for haemorrhage, I will order FBC to check Hb if there was

continued bleeding. A wound hematoma may require
evacuation later on. If I suspect DVT and PE, I would arrange
for a CTPA and duplex for the arm and I will manage
accordingly.
So, what will you do if they were insisting to go home?
I will inform the patient and her daughter about the possible
complications which may occur due to this premature discharge
especially for a 60 miles away home. Also I will inform that the
patient will have to sign on a legal document stating that she
has the full responsibility of the discharge against medical
advice. Also I will inform the patient about the warning signs
and symptoms that she has to be alert for such as increasing
wound discharge or being more unwell and increasing
33
[Document title]
shortness of breathing and that she has to seek advice

immediately in a nearby hospital or to come back here.
Will you remove the drain before this discharge?
No I will leave it.
Who would take care of her at home?
Her GP via home visits.
Write a letter to her GP, what will you mention in it?

…………………
34
[Document title]
Update the trauma head about a

trauma case
(RTA, open tibiofibular fracture, pulseless foot and abdominal

Collection)
Call the trauma team head to update him about the case.
Hello, I am...... (SHO, ST1,), I am calling to speak to MR.....to

update him about a trauma case, could I check that I am
speaking to MR.....
21 y old male came to A&E department after RTA, his GCS is

15 at time of examination, and he is hemodynamically stable.
He has an open tibiofibular fracture on his left lower limb.
Abdominal ultrasound shows free intra-abdominal collection,
on examination of the left distal pulses, there was no felt pulses
on the left foot.
What is the most urgent?
Possible vascular injury and intraabdominal collection.
Why vascular injury takes a priority in this case?
The patient has an open fracture with an arterial damage on his

left lower limb, so it is urgent to interfere with him to avoid
ischemia and compartment syndrome.
35
[Document title]
What are the causes of pulseless foot?
Vascular injury most probably, also I have to consider arterial

spasm or compartment syndrome.
Is the patient is wearing a c-collar?
(Info. Is not given in the notes), sorry I don’t have this

information, I will check for this.
Is the patient dehydrated?
(Info. Is not given in the notes), sorry I don’t have this

information, I will check for this.
Plans of action?
 I will inform the orthopedic consultant and the vascular

consultant.
 I will reduce and immobilize the fracture.
 I will order Ct - abdomen and pelvis.
 I will order CT- head and brain.
What is the missed investigation?
Duplex.
Why are you calling me?
To inform you about the case.
36
[Document title]
Speak to ITU registrar to book a

postoperative bed and ask about
pre-op. Advice
(COPD, perforated viscus, ARF and metabolic acidosis)
73 y old lady brought by her daughter due to sudden abdominal

pain and confusion after she ate her breakfast. Assessment
revealed suspected perforated viscus. Urgent laparotomy was
required.
(Call the ITU registrar to book a postoperative bed and ask
about pre-op. Advice).
(Remember to write down his advice, he will ask you to

repeat at the end).
Hello, my name is Mr....... I am the surgical SHO working for

Mr .......at........ Hospital. I am calling to speak to the ITU
registrar to ask advice on an unwell patient who has been today
admitted and is going to require a laparotomy. I would also like
to arrange an HDU bed postoperatively. Could I check who I
am speaking to, please?
Mr...... Is a 73 year old with a background of COPD, presented

with a perforated viscus and has gone into acute renal failure,
with hypokalaemia. His bloods tests show a Potassium of... a
creatinine of ...up from a baseline of........
Her ABG shows a metabolic acidosis, with a high lactate and
high negative base excess.
37
[Document title]
Please could I have some advice on optimisation before theatre

and would it be possible to arrange an HDU bed post-
operative?
Why do you think it is a perforated viscus?
On examination, there is signs of peritonism, Hb dropped by 2

g, abdominal ultrasound showed free intraabdominal
collection.
What fluid resuscitation will you do?
I will start by crystalloids, rapid flush, then to colloids if poor

response, I will cross match for blood in view of rapid Hb
drop.
What are the pre-operative arrangements do you suggest?
 ECG: to look for arrhythmias, AF, signs of hypoxaemia.

 Repeat CXR.
 IDC insertion.
 Antibiotics.
 Check if the patient is on steroids, to give IV
hydrocortisone.
 I will keep the o2 saturation lower in the view of chronic
COPD.
 I will contact the anaesthetist to review the patient pre-
operative.
What are the criteria of admission to ITU?
 2 organ systems impaired with acute reversible causes.
38
[Document title]
 Impaired respiratory system requiring mechanical

ventilation.
 1:1 nursing care.
 1 organ system chronically impaired with a possible 2nd
system is being affected.
Type of o2 mask for COPD?
Venturi mask.
How much Fio2 suitable to be delivered to COPD patient?
24-28%.
How do you calculate potassium deficit?
Normal serum potassium is 3.5 to 5 mmol/L. reduction of

serum potassium by 0.3 mmol/l suggests a total body deficit of
100 mmol. Based on this formula, a patient with a serum
potassium of 2.6 mmol/l needs at least 300 mmol of potassium
for the correction of the deficit.
How to replace potassium?
1. Serum Potassium < 3.0 mEq/L (total body deficit 200-300

meq) • Give KCl 10 meq IV slowly every hour for 5 doses,
then recheck level.
2. Serum Potassium: 3.0 to 3.5 mEq/L (total body deficit 100-

200 meq) • Give KCl 10 meq IV slowly every hour for 3
doses, then recheck level.
39
[Document title]
What if I only have one ITU bed left and there is asthmatic
young lady coming first?
I will continually monitor the patient in the recovery room

until a bed is available.
40
[Document title]
Call a vascular consultant to refer a case of

acute limb ischemia
Lady admitted for mild diverticulitis, symptoms improving
with I.V Abs and I.V fluids, now complaining of sudden acute
right lower limb pain. ECG AF and preventricular complex,
sudden right acute limb ischemia. ABG showing metabolic
acidosis, hypokalaemia. Arterial duplex showing acute
ischemia.
Call the vascular surgeon in another hospital to transfer the

case.
Hello, I am......... (SHO, ST1, CT2) working for MR...... In......

Hospital. I am calling to speak to MR. ......., the vascular
consultant to ask him an advice about a patient, can I check that
I am speaking to Mr.....
.
Mrs…. admitted for mild diverticulitis, symptoms improving

with I.V Abs and I.V fluids, now complaining of sudden acute
right lower limb pain. Arterial duplex showing acute ischemia
ECG revealed AF and preventricular complex, ABG showed
metabolic acidosis, hypokalaemia. We were hoping to transfer
her to your specialist care for definitive treatment.
Is it urgent, can you send it tomorrow morning instead?
Yes, it is urgent, patient has acute limb ischemia, and so early

intervention is extremely needed for the fear of losing the limb.
41
[Document title]
Do you need cardiologist to review for PVC before transfer?
I think the limb is more serious and PVC can be assessed later
on as PVC can result from electrolyte imbalance.
What do you think of her presumed diagnosis of

diverticulitis?
Now, in view of acute limb ischemia and AF, I have to consider

the presence of mesenteric ischemia as a cause of this patient
abdominal pain.
Do you want to scan the abdomen first?
We will need to scan her abdomen, but I think after the transfer.
Could it be mesenteric ischemia?
Yes, it could be, but for now the abdomen is soft and not tender,
I will do serial abdominal examination and if we need we may
do CT scan of the abdomen with contrast if the renal functions
were normal after the transfer.
What if the renal function is not normal?
I will perform abdominal duplex for mesenteric vessels or

Magnetic resonance angiography.
How could manage this case?
 Correction of hypokalaemia.
 Correction of AF.
42
[Document title]
 Anticoagulation.
 Correction of metabolic acidosis.
How would manage AF?
I will arrange with ICU to start cardioversion and anticoagulant

to be completed to the way to the hospital
What type of ambulance will you need?
Ambulance well equipped with monitoring and Cardioversion

and CPR equipment.
Which type of anticoagulant you will give?
Unfractionated heparin 5000IU bolus then, 15IU/kg/hr

infusion and follow up by APTT is between 45 to 60 seconds.
How could manage the ischemic limb?
If the limb is viable I will perform thrombolysis, embolectomy

or bypass operation with or without fasciotomy, if the limb is
not viable I will go for amputation.
What will you tell her family?
I will tell them that the patient has developed acute reduction
of circulation in her lower limb which may need an urgent
intervention and that is why we are going to transfer her to a
vascular consultant.
Ok you can send the patient over.
43
History taking
Approach to History Taking

You will have pencil and paper
A. Greet the patient and introduce yourself (Hello. I am Mahmoud Bazeed one
of the exam candidate).
B. Confirm patient name and age (May I confirm your name and age) except for
hospitalized persons like confusion and depression.
C. Get verbal consent (Today I’ve been asked to ask you few questions regarding
your condition, are you OK with this?).
D. Ask for chaperon in impotence station, offer analgesia and switch off light in
Headache station.
E. Open Question, Patient statement: How can I help you today? What seems
to be your problem? (Don’t interrupt the patient).
F. Analysis of patient complain: onset, course, duration, severity, aggravating
and relieving factors and associated factors (for differential diagnosis most
important). (Interrupt the patient if you have to).
G. Past medical or surgical history
1. Have you ever visited your GP for any other medical problems?
2. Have you ever had surgeries?
H. Drug history: Doses and allergy.
1. Do you take any prescribed or over the counter medications?
2. Do you have any allergy against any drug?
I. Family history.
Is there anyone else in the family has had a similar problem?
J. Social history (May I ask personal question?)
1. Occupation
2. Home situation (Who is at home with you?).
3. Mobility (do you have any difficulties using stairs?).
HISTORY TAKING
History taking
4. Smoking (do you smoke? How many packets per day? Have you
considered quitting? ).
5. Alcohol (Do you drink Alcohol? How many units per week? Have you
considered quitting?).
K. Ideas, concerns and expectations: Before I go any further could I ask
1. Idea: What do you think the cause is?
2. Concern: What are you the most concerned about?
3. Expectations: What are you hoping us to do for you?
L. Other system review.
Respiratory: cough Dyspnea wheezes
Cardiovascular: chest pain, orthopnea
Urinary: Dysuria
M. Anything else you want to add.
N. Thank the patient.
O. Present your case including provisional and differential diagnosis and
investigations.
P. Answer the examiner questions.
Try to practice history taking at least four times.
HISTORY TAKING
History taking
HISTORY TAKING
History taking
 Two history stations in the exam.
HISTORY TAKING
History taking
 Each station is 20 marks station.

 Each station lasts for ten minutes.
 You will have one minute to read the stem on the door of
station.
 Six minutes to take history from the patient.
 Three minutes to present your case and answer the
examiner questions.
 The patient is always an actor.
 Two examiners present in each history station:
1. Surgeon examiner responsible for 15 of 20marks and he will
evaluate you on three main items history taking from the
patient, presentation and knowledge.
2. Layman examiner responsible for 5 of 20 marks and he will
evaluate you on the following items body language including
head nodding and eye to eye contact, rapport to the patient
(how can I help you sir, so sorry to hear that), use of layman
language not medical one (tummy for abdomen, bleeding for
hemorrhage) and end of conversation (answer patient
questions, anything else I have missed and thank your patient)
HISTORY TAKING
History taking
Positive findings
Symptom Provisional diagnosis Differential Diagnosis
(also you have to
consider)
Bleeding per rectum Cancer colon 1.IBD
(Bleeding per rectum, 2.Anal causes (fissure,
disturbed bowel habits, hemorrhoids)
Positive family history) 3. Diverticular disease.
4. Bleeding tendency.
5. Sever gastroenteritis.
6. Diverticular disease.
Dysphagia Cancer Esophagus 1. Achalasia.
(Dysphagia to solids 2. GORD.
then solids and fluids, 3. Goiter.
hematemesis, 4. Pharyngeal pouch.
unintentional weight 5. Esophagitis.
loss, heavy smoker and 6. Autoimmune disease
alcohol drinker) (Myasthenia Gravis,
(past history of cancer Scleroderma).
testis on chemotherapy, 7. Neurological
Hip replacement on disorders (UMNL).
NSIADs).
Abdominal pain and IBD (Crohn's disease). 1. IBS.

Diarrhea 2. Cancer colon.
(Abdominal pain and 3. Gastroenteritis.
diarrhea associated with 4. Diverticular disease.
mucous discharge
Pain increased by
passing stool, weight
loss and extra intestinal
manifestation erythema
nodosum )
HISTORY TAKING
History taking
Female with neck 1. Toxic multinodular

swelling goiter.
(neck swelling, increase 2. Simple multinodular
in size, positive goiter.
compression and toxic 3. Thyroid neoplasm.
symptoms)
Chronic Lower Limb Chronic Ischemia 1. Spinal canal stenosis.
Claudication 2. Disc prolapse
(Claudication calf pain (Sciatica).
increase by cold
weather and walking
and decrease by rest)
Hematuria Bladder Cancer 1. UTI, Stones.
(painless total 2. Bleeding Tendency.
hematuria ,weight loss, 3. Traumatic.
anorexia and work in 4. BPH.
dye factory ) 5. Cancer prostate.
6. Renal cell carcinoma.
Chronic Urine Retention BPH 1. Cancer Prostate.

(urine retention and use 2. Urethral stricture.
of nasal spray containing 3. UTI, stones.
alpha blocker) 4. Neurological (UMNL
LMNL).
5.Bladder cancer
Back Pain (female ) Mechanical pain 1. Disc Prolapse.

(long standing history of 2. Ankylosing
Social stress
back pain ,worse in the spondylitis.
last 3 years ,MRI mild 3. TB.
degenerative changes, 4. Metastatic.
Disabled husband, work 5. Osteoporosis.
commitment, increase 6. Cauda equine.
by activity and decrease
by rest)
Back Pain (Male) Cauda equine 1. Disc Prolapse.

(sudden pain, red flags)
HISTORY TAKING
History taking
2. Ankylosing
spondylitis.
3. TB.
4. Metastatic.
5. Osteoporosis.
6. Mechanical pain.
Chest Pain Pulmonary Embolism 1. Chest infection.
(sudden chest pain 2. Chest malignancy.
,stabbing ,increase by 3. MI.
breathing ,sever and no 4. Musculoskeletal Pain.
history of trauma)
Knee Pain Post traumatic 1. Cruciate Ligament
(history of trauma, and Osteoarthritis Injury.
operation , can’t play 2. Meniscal Injury.
football now, pain 3. Septic arthritis.
increase at night 4. Referred from the
,crepitus) back.
5. Extra intestinal
manifestation of IBD.
Groin swelling Inguinal hernia 1. Lymph node.

(Gym trainer referred 2. Abscess.
from GP with groin 3. infected
swelling typical of pseudoanurysm.
inguinal hernia, past
history of genitourinary
infection, stoma tonics,
patient will ask question
about hernia and
surgery)
Groin Swelling Infected femoral 1. Groin Abscess.
(referred from GP with pseudoaneurysm. 2. Lymph nodes.
groin abscess) 3. Inguinal Hernia.
Unilateral tonsillar 1. Infective Causes.

enlargement 2. Neoplastic causes.
3. Asymmetrical tonsils.
HISTORY TAKING
History taking
Headache Subarachnoid 1. Meningitis.

(headache with hemorrhage. 2. Brain tumor.
photophobia, polycystic
kidney , positive family
history of brain
aneurysm)
Depression Reactive post-operative
(feeling down after Depression.
gastrectomy)
Seizures Brain tumors 1. Epilepsy.
(focal seizures, Rt arm 2. Meningitis.
shaking, not 3. Encephalitis.
generalized, late onset, 4. Head trauma.
no post ictal 5. TIAs.
manifestation negative
past history of epilepsy)
Impotence 1. Psychogenic.
(Social stress, atenolol 2. Drug induced.
,smoker and 3. Organic.
hypertensive)
Abdominal Pain IBS 1. Biliary colic.
(abdominal pain 2. IBD.
relieved by passing stool 3. Cancer colon.
or flatus ,bloating ,social 4. Gastroenteritis.
history and past history
of gall bladder stones)
Abdominal Pain Acute Pancreatitis 1. Acute Cholecystitis.
(female patient, smoker 2. perforated peptic
alcohol drinker, past ulcer.
history of peptic ulcer 3. MI.
on lansoprazole 4.MVO
presented with
epigastric pain after
drinking in wedding)
Abdominal Pain Chronic Pancreatitis 1. Pancreatic
(chronic epigastric pain pseudocyst.
addict to alcohol, 2. Peptic ulcer disease.
patient take morphine
for pain)
HISTORY TAKING
History taking
Preoperative Confusion Dementia Other causes.

(Old female patient
prepared for THA ,nurse
noted confusion)
Anxiety
Shortness of Breath 1. Chest infection.
(prepared for lap 2. Chest malignancy.
cholecystectomy and 3. MI.
she has been 4. Musculoskeletal Pain.
investigated before for
SOB and free)
HISTORY TAKING
History taking
Bleeding per rectum

Hello. I am Mahmoud Bazeed one of the exam candidate
May I confirm your name and age please?
Nice to meet you Mr. …. Today I’ve been asked to ask you few questions
regarding your condition, are you OK with this?
How can I help you today?
I am so sorry to hear that.
(Onset, course, duration, severity, aggravating and relieving factors and
associated factors)
Did this started suddenly or gradually?
When you did first noted this?
Does this bleeding comes and goes. Does it get previously worse?
What is the color of the blood? , how much blood you notice every time?
Streaks?
Teaspoon? More? Is that bleeding is painful when you pass stool?
Is there anything makes this bleeding stops
Is there anything makes that bleeding increases?
(Associated factors for differential diagnosis)
1. Cancer Colon
Do you have any disturbances regarding bowel habits?
How has your appetite been?
Have you noticed any unintentional weight loss?
2. IBD:
Have you noticed any slime or discharge? Or pain in your tummy especially with
bowel opening?
Have you had any mouth ulcers? Fever? Painful red eye? Joint or back pain? Or
skin problems?
10
HISTORY TAKING
History taking
3. Bleeding tendency:
Have you noticed bleeding from any other orifices?
4. Anal causes:
Have you noticed itching around your back passage? Or any swelling?
5. Gastroenteritis:
Have you been abroad recently? If so, where?
Do you have the urge to pass stool in spite of passing little amount?
Do you have long standing history of constipation?
(Past medical or surgical history, Drug history, Family history, Ideas, concerns
and expectations, other system review)
Do you have any other medical conditions, see your GP for anything, ever had
surgeries?
Do you take any medications? Dose? Do you have any allergy against any drug?
Do you mind if I ask personal questions?
What is your occupation?
Who is at home with you?
Do you have any difficulty with the stairs?
Do you smoke? How many packs/ day
Do you drink alcohol? How many units/ week
Before I go any further, could I ask?
What are you the most concerned about?
What are you hoping us to do for you?
resp., cvs: is there any chest pain, SOB, cough
Urinary: any problems in passing urine?
11
HISTORY TAKING
History taking
Rheumatic: any muscle or joint pain?

Anything else you want to add?
Thank you
(Order of questions)
What is the color of the blood? , how much blood you notice every time?
Streaks?
Teaspoon? More? Is that bleeding is painful when you pass stool?
Is there anything makes this bleeding stops
bowel opening?
Have you noticed itching around your back passage? Or any swelling?
12
HISTORY TAKING
History taking
skin problems?
surgeries?
Thank you
Positive findings:
(Bleeding per rectum, disturbed bowel habits, Positive family history)
13
HISTORY TAKING
History taking
Questions
What is the most important investigation to carry out?
As I am suspecting colorectal cancer, the most important investigation is a
colonoscopy +/- biopsy to examine the whole colon.
If immediately available in clinic, a rigid sigmoidoscopy may be carried out in the
first instance
• Hematology: FBC (anaemia, leucocytosis of infective colitis, inflammatory
bowel disease, ischemic colitis), low platelets (bleeding disorder), clotting
screen, group and save / cross match for transfusion.
• Biochemistry: U&Es, LFTs (hepatic failure with variceal bleed, malignancy)
• Arterial blood gases: Raised lactate (ischemia), metabolic acidosis.
• ECG: Mesenteric ischaemia, atrial fibrillation (emboli).
• Endoscopy: OGD (to exclude upper gastrointestinal cause), sigmoidoscopy /
proctoscopy (haemorrhoids, anorectal lesion, distal colitis, rectal ulcer) and
colonoscopy (malignancy, diverticular disease, colitis, angiodysplasia).
• Mesenteric angiography (CT or invasive) / Technetium scan / Labelled red cell
scan, if source not identified by endoscopy (looking for angiodysplasia / Meckel’s
diverticulum).
• Radiology: AXR (obstruction, toxic megacolon of inflammatory bowel disease)
and US scan / CT (if suspected malignancy, for liver metastases and staging).
• Microbiology: Stool cultures (infective colitis).
14
HISTORY TAKING
History taking
Dysphagia
Hello. I am Mahmoud Bazeed one of the exam candidate.
associated factors)
Is there anything makes this difficulty stops?
Is there anything makes that difficulty increases?
Do you experience this difficulty of swallowing to solid or to liquid foods or both?
Have you vomited at all? If so, was there any blood?
1. Cancer esophagus
Have you vomited at all? If so, was there any blood? (Already been asked)
Have you noticed any unintentional weight loss? How many kilos over how long?
2. Goiter:
Have you noticed any neck swelling?
3. Pharyngeal pouch:
Does the food get stuck in your throat when swallowing?
Have you noticed having bad-smelling breath recently?
Do you ever feel a lump in your throat?
Do you ever notice gurgling or a wet voice after swallowing?
15
HISTORY TAKING
History taking
4. GORD:
Do you ever taste acid at the back of your mouth? Heartburn? Pain in your
tummy?
5. Achalasia:
Have you noticed that difficulty more to fluids than solids?
6. Esophagitis:
Have you noticed pain during swallowing?
7. Autoimmune disease (Myasthenia Gravis, Scleroderma):
Do you suffer with painfully cold hands? Dry eyes or mouth?
8. Neurological disorders (UMNL):
Have you noticed any weakness anywhere? Any problems walking?
surgeries?
16
HISTORY TAKING
History taking

Thank you.
Do you experience this difficulty of swallowing to solid or to liquid foods or both?
Have you noticed that difficulty more to fluids than solids?
Have you noticed pain during swallowing?
Have you vomited at all? If so, was there any blood?
Do you ever taste acid at the back of your mouth? Heartburn? Pain in your
tummy?
Have you noticed any neck swelling?
Does the food get stuck in your throat when swallowing?
Have you noticed having bad-smelling breath recently?
Do you ever feel a lump in your throat?
Do you ever notice gurgling or a wet voice after swallowing?
17
HISTORY TAKING
History taking

Do you suffer with painfully cold hands? Dry eyes or mouth?
Have you noticed any weakness anywhere? Any problems walking?
surgeries?
Thank you.
Positive findings:
(Dysphagia to solids then solids and fluids, hematemesis, unintentional weight
loss, heavy smoker and alcohol drinker)(Past history of cancer testis on
chemotherapy, hip replacement on NSIADs).
18
HISTORY TAKING
History taking
Questions
Investigations:
- Full clinical examination checking for lymphadenopathy
- Bloods –FBC, U&Es, LFTs and clotting and bone profile
- Chest X-ray
- Esophageal manometry: achalasia, GORD
- Barium swallow
- Endoscopy and biopsy
- Esophageal end luminal US, also for staging of carcinoma.
- Video fluoroscopy –assessing for aspiration
- Staging CT scan, depending on what the previous investigations reveal
Treatment:
Operable cases: oesphagectomy + chemo radiotherapy
Non-operable cases: palliation: self-expanding metallic stent, palliative
chemotherapy and radiotherapy, feeding jeujnosomy.
19
HISTORY TAKING
History taking
Abdominal pain and Diarrhea

(Site, Onset, course, duration, character, radiation, timing, severity,
aggravating and relieving factors and associated factors)
(SOCRATES) analysis of pain
Where did you feel that pain? Could please point to the site?
Does it move anywhere?
When did you first notice that pain?
Did it start suddenly or gradually?
Did it come and go? Has this changed recently?
Is there any specific time during the day that the pain increase?
Is there anything makes this pain stops?
Is there anything makes that pain increases?
Could please describe that pain for me? Is it colicky, cramping, or stabbing?
How badly is this affecting your day-to-day life?
If you had to rate the pain from 1 to 10, with 10 being the worst pain you can
imagine, how would you rate it?
Analysis of diarrhea
How many motions per day?
What are the stools like? Are they watery, semi-solid or solid? Can be easily
flushed? Is there any blood?
20
HISTORY TAKING
History taking
(Associated factors for differential diagnosis of abdominal pain)

1. IBD:
bowel opening?
skin problems?
2. Cancer Colon
3. Gastroenteritis:
5. IBS
Did the tummy pain relieved by passing stool?
Did it increase by social stress?
surgeries?
21
HISTORY TAKING
History taking

Thank you.
22
HISTORY TAKING
History taking

Did the tummy pain relieved by passing stool or increased?
How many motions per day?
What are the stools like? Are they watery, semi-solid or solid? Can be easily
flushed? Is there any blood? Have you noticed any slime or discharge?
skin problems?
surgeries?
23
HISTORY TAKING
History taking

Thank you.
(Positive findings)
(Abdominal pain and diarrhea associated with mucous discharge Pain increased
by passing stool, weight loss and extra intestinal manifestation erythema
nodosum)
Questions
Investigations:
-Abdominal examination including DRE
-Routine bloods – FBC, U&E, CRP, LFTs, calcium, magnesium, phosphate,
Coagulation screen, -
Group and Save. (Looking for raised inflammatory markers, dehydration,
electrolyte disturbance
Secondary to diarrhea, albumin as a guide of nutritional status, coagulation
defects.)
-Stool sample
-Faecal occult blood test
-Abdominal Radiograph - assess for toxic megacolon
-+/-CT or MRI abdomen and pelvis if concerning features on examination and for
pre-operative planning if surgery is indicated - Colonoscopy
Treatment:
24
HISTORY TAKING
History taking
Medical: mesalazine, prednisolone, immunomodualtors (infliximab)

Conservative: dietary control (low residue diet)
Surgical: in toxic megacolon, IO, malignant transformation, fistulation,
refractory cases
25
HISTORY TAKING
History taking
Abdominal pain
Female referred from her GP as chronic calcular
cholecystitis
1. IBS
Did the tummy pain relieved by passing stool?
26
HISTORY TAKING
History taking

Do you have bloating?
2. IBD
bowel opening?
skin problems?
3. Cancer Colon
4. Gastroenteritis:
5. Biliary colic:
Does the pain move to your RT shoulder?
Have you noticed that the pain increase by fatty meal?
Have you noticed yellowish discoloration of your eyes?
surgeries?
27
HISTORY TAKING
History taking

Thank you.
Does it move anywhere? Does the pain move to your RT shoulder?
28
HISTORY TAKING
History taking

Did the tummy pain relieved by passing stool or increased?
Have you noticed any slime or discharge?
skin problems?
surgeries?
29
HISTORY TAKING
History taking

Thank you.
(Positive findings)
(Abdominal pain relieved by passing stool or flatus, bloating, social history and
past history of gall bladder stones)
Questions
Investigations: abdominal ultrasound, AXR, colonoscopy, stool analysis, FBC
Treatment: fibre diet, antispasmodics, antidepressants
30
HISTORY TAKING
History taking
Abdominal Pain
1. Acute pancreatitis
Does the pain move to your back?
Does the pain relieved by leaning forward?
31
HISTORY TAKING
History taking
2. Acute cholecystitis:
Does the pain move to your RT shoulder?
Have you noticed that the pain increases by fatty meal?
3. Perforated peptic ulcer:
Did you throw up? Is there blood?
Do you ever taste acid at the back of your mouth? Heartburn?
4. MI:
Have you noticed chest pain?
Have you been investigated before for any cardiac problems?
5. Mesenteric vascular occlusion:
Have you noticed blood in the stool?
surgeries?
32
HISTORY TAKING
History taking

Thank you.
Does it move anywhere? Does the pain move to your back or to your RT
shoulder?
Is there anything makes this pain stops? Does the pain relieved by leaning
forward?
Is there anything makes that pain increases? Have you noticed that the pain
increase by fatty meal?
Have you noticed chest pain?
Have you noticed blood in the stool?
33
HISTORY TAKING
History taking
Have you been investigated before for any cardiac problems?

surgeries?
Thank you
(Positive findings)
(Female patient, smoker alcohol drinker, past history of peptic ulcer on
lansoprazole presented with sudden sever epigastric pain radiated to the back
after drinking in wedding)
34
HISTORY TAKING
History taking
Abdominal Pain
40 year. Old divorced male with chronic epigastric pain radiating to the back for
the past 1 year, with steatorrhea, takes 5 glasses of beer/ day, previously
admitted for acute pancreatitis. Takes 30 mg of morphine / day to numb the
pain, depressed
35
HISTORY TAKING
History taking

1. Chronic Pancreatitis:
Does the pain move to your back?
Does the pain relieved by leaning forward?
Have you noticed that the stool is difficult to flush?
2. Pancreatic pseudocyst:
Have been feverish or being ill?
Have you noticed any lump in your tummy?
3. Peptic ulcer disease:
surgeries?
36
HISTORY TAKING
History taking

Thank you.
I am so sorry to hear that
Does it move anywhere? Does the pain move to your back?
Is there anything makes this pain stops? Does the pain relieved by leaning
forward?
Is there anything makes that pain increases? Have you noticed that the pain
increase by fatty meal?
37
HISTORY TAKING
History taking
Have you noticed that the stool is difficult to flush?

Have been feverish or being ill?
Have you noticed any lump in your tummy?
surgeries?
Thank you.
(Positive findings)
(Chronic epigastric pain addict to alcohol, patient take morphine for pain)
38
HISTORY TAKING
History taking
(Questions)
What do you think about the history of taking 30 mg of morphine, what should
be the normal dose?
15-30 mg /4hours as needed
Investigations:
- Secretin stimulation test
- Serum amylase and lipase (elevated)
- Serum trypsinogen
- CT scan (pancreatic calcifications)
- MRCP: identify the presence of biliary obstruction and the state of the
pancreatic duct
- Endoscopic ultrasound
Treatment:
Medical treatment of chronic pancreatitis:
1- Treat the addiction: ■ Help the patient to stop alcohol consumption and
tobacco smoking
■ Involve a dependency counsellor or a psychologist
2-Alleviate abdominal pain:
■ Eliminate obstructive factors (duodenum, bile duct, pancreatic duct)
■ Escalate Analgesia in a stepwise fashion
■ Refer to a pain management specialist
■ for intractable pain, consider CT/EUS-guided coeliac axis block
3- Nutritional and digestive measures:
■ Diet: low in fat and high in protein and carbohydrates
■ Pancreatic enzyme supplementation with meals
■ Correct malabsorption of the fat-soluble vitamins (A, D, E, K) and vitamin B12
39
HISTORY TAKING
History taking
■ Medium-chain triglycerides in patients with severe fat malabsorption (they

are directly absorbed
By the small intestine without the need for digestion)
■ reducing gastric secretions may help Treat diabetes mellitus
4- Treat DM
The role of surgery is to overcome obstruction and remove mass lesions
40
HISTORY TAKING
History taking
Hematuria
associated factors)
Is it only when you pass urine? Is there any chance it could be coming from
elsewhere? What colour is it? Have you recently eaten any beetroot?
Is there anything makes this bleeding stops?
Is there always blood in your urine or does it come and go? Have you had this
before?
Is the blood present at the start of urination, the end or throughout?
Do you pass any clots?
1. Bladder cancer:
Any pain in your tummy or back?
2. UTI / stones
41
HISTORY TAKING
History taking
Do you have any pain when you pass urine? Any pain in your tummy or back? If
so, SOCRATES
How many times do you go to toilet to pass urine during daytime?
Do you get sudden irrepressible urges to pass water?
Have you been unwell recently, or had any fever or chills?
3. Bleeding tendency
4. Trauma:
Have you had any trauma to your tummy or groin recently?
5. BPH:
How often do you get up at night to pass urine?
Do you have difficulty getting the stream started?
Is there prolonged dribbling at the end?
Is your stream powerful or weak?
42
HISTORY TAKING
History taking
surgeries?
Thank you
43
HISTORY TAKING
History taking

elsewhere? What color is it? Have you recently eaten any beetroot?
before?
so, SOCRATES
44
HISTORY TAKING
History taking
Have you had any trauma to your tummy or groin recently?
surgeries?
45
HISTORY TAKING
History taking

Thank you
(Positive findings)
(Painless total hematuria, weight loss, anorexia and work in dye factory)
(Questions)
Management:
- Urine dipstick to confirm hematuria, assess infection, send a sample for
cytology
- Bloods: FBC, U&E, clotting screen, PSA
- Cystoscopy and biopsy
- U/s, CT
Treatment:
Depends on the stage and the grade of the tumor
- Surgical: TURBT, Radical cystectomy
- Non- surgical: chemotherapy and radiotherapy and immunotherapy
46
HISTORY TAKING
History taking
Chronic Urine Retention

associated factors)
1. BPH:
2. Prostatic cancer:
Have you noticed back pain?
Do you have any problems with erections recently?
3. Bladder cancer:
Any redness or blood in your urine? If present
47
HISTORY TAKING
History taking

before?
4. UTI /stones:
so, SOCRATES
48
HISTORY TAKING
History taking

5. Neurological causes:
Have you noticed numb leg? Weak legs?
6. Urethral stricture:
Same questions as BPH
surgeries?
Anything else you want to add? Thank you
49
HISTORY TAKING
History taking
Did this start suddenly or gradually?
Any redness or blood in your urine? If present

before?
50
HISTORY TAKING
History taking
Do you have any problems with erections recently?
Have you noticed back pain?
Have you noticed numb leg? Weak legs?
surgeries?
51
HISTORY TAKING
History taking

Thank you
(Positive findings)
(Urine retention and use of nasal spray containing alpha blocker)
(Questions)
Management:
Investigations:
- Full clinical examination including DRE
- Bloods: PSA, Urine analysis, U&E
- Imaging: abdominal u/s, Trans rectal u/s
Treatment:
Medical:
- Tamsulin (1alpha adrenergic blocker)
- Finasteride (5 alpha reductase inhibitor)
Surgical:
TURP
52
HISTORY TAKING
History taking
Impotence
regarding your condition including personal questions, I am here to help you and
everything you will tell me will be confidential, are you OK with this?
Ask for chaperon. Look for the examiner and say: Can I have a chaperon here?
associated factors) and specific questions for organic causes:
Do you have difficulty obtaining an erection?
Is there anything makes this difficulty improve?
Is there anything makes that difficulty getting worse?
Do you experience nocturnal/ morning erections?
Is the erection suitable for penetration?
Can the penetration be maintained until partner has achieved orgasm?
Does ejaculation occur & if yes, is it premature?
Do both partners experience sexual satisfaction?
Is their associated pain/ discomfort - if yes, were, etc.?
Is penile curvature a problem?
Psychological history:
Have you noticed any episodes of feeling down?
Have you had any difficulties in getting to sleep?
Have you been feeling overly tired?
53
HISTORY TAKING
History taking
Have you noticed a change in your appetite?

Have you noticed a change in your libido?
Is there any problems/ tension in sexual relationship? Any stress from work/
other sources like Family or social pressures?
Any anxiety related to performance?
Sexual history
Are you married?
When was your last sexual contact?
Do you use contraceptive?
Was there any previous sexual contacts in the last3months?
Do you have any other medical conditions, see your GP for anything, Any history
of pelvic surgery/ trauma, previous prostate surgery, irradiation to prostate?
Any past history of:
Thyroid dysfunction, Hypertension, Rheumatic, Epilepsy, Asthma, Diabetes,
Stroke, MI, Jaundice ever had surgeries?
Do you take any medications? Antihypertensive, anti-ulcer (e.g. PPI), lipid
lowering, 5a-reductaseAntidepressants, testosterone anabolic steroids Dose?
Do you have any allergy against any drug?
54
HISTORY TAKING
History taking

Cardiovascular
Chest pain, Sob, orthopnea, palpitations, dizziness, ankle swelling
Respiratory
Sob, exercise tolerance, PND, wheeze, chest pain, cough, hemoptysis,
Hoarseness
Gastrointestinal
Change in appetite/ diet, Kg loss, dysphagia, odynophagia, change in bowels
Urogenital
Abdominal pain, F of micturition, dysuria, urgency, polyuria, hematuria
CNS & PNS
Fits, faints, headache, LoC, tremor, m. weakness, paralysis, sensory changes
MSK
Muscle/ bone/ joint pain, deformity, swelling, stiffness, limb weakness
Metabolic system
Change in BMI/ appetite, alteration in build/ appearance?
Thank you
Positive findings
(Social stress, atenolol, smoker and hypertensive)
(Questions)
Investigations:
- Hematology: FBC, erythrocyte sedimentation rate, hematinic, clotting screen,
group & save. -
- Glycated hemoglobin (cardiovascular risk assessment).
55
HISTORY TAKING
History taking
- • Biochemistry: U&Es, LFTs, CRP, lipid profile.

- • Prostate specific antigen (if relevant history).
- • Serum free testosterone.
- • Serum prolactin.
- • Serum FSH / LH.
- • ACTH (synacthen) stimulation test.
- • Urinalysis: Microscopy to exclude a genitourinary cause.
- • Radiology: –Duplex ultrasonography to assess vascular function of the penis.
Ultrasonography of the testes to exclude any abnormality.
- –Trans rectal ultrasonography to exclude any pelvic or prostatic abnormality.
- Angiography: It can be useful for planning vascular procedures /
reconstruction, particularly following trauma.
- Injection of prostaglandin E1: This outpatient investigation includes the
injection of prostaglandin
E1 directly into the corpora cavernosa and to assess rigidity after ten minutes.
While it can help to evaluate the vasculature, a positive result may still be found
with mild vascular disease. It can also be utilized to assess penile deformities to
aid planning of surgical correction.
Treatment:
- Risk factor modification by controlling lipidaemia and diabetes, weight loss,
smoking cessation, increase exercise.
- Phosphodiesterase-5 inhibitor therapy (sildenafil)
- Intercavernous injection therapy (alprostadil)
- Placement of a penile prosthesis which may take the form of either a semi rigid
or inflatable implant.
56
HISTORY TAKING
History taking
Depression
You have been asked to take history from depressed patient hospitalized due
to gastrectomy due to bladder cancer, so you will not ask for name or age or
Past medical or surgical history, Drug history, Family history, Ideas, concerns
and expectations, other system review.
Hello Mr.…. I am Mahmoud Bazeed one of the exam candidate. How have you
been feeling recently?
Core symptoms of depression (depression, anhedonia and fatigue)
In the past days during your hospital stay have you.
Felt down, depressed or hopeless?

Found that you no longer enjoy, or find little pleasure in life?
Been feeling overly tired?
Biological symptoms of depression:
Sleep cycle:
How has your sleep pattern been recently?
Have you had any difficulties in getting to sleep?
Do you find you wake up early, and find it difficult to get back to sleep?
Mood:
Are there any particular times of day that you notice your mood is worse?
Does your mood vary throughout the day?
Do you find that your mood gradually worsens throughout a day?
Appetite:
Have you noticed a change in your appetite?
What is your diet like at the moment?
What are you eating in a typical day?
Libido:
Have you noticed a change in your libido?
57
HISTORY TAKING
History taking
Since you have been feeling this way, have you noticed a difference in your sex
drive?
Past psychiatric History:
Previous episodes of depression or dysthymia:
Have you ever felt like this before?
Have you ever had any other periods of feeling particularly low?
In the past, have you had any problems with your mental health?
Have you had any counselling for any issues before?
Have you ever been admitted to hospital because of your mental health? If so,
obtain details –time, method of admission, result.
Positive finding
(Positive core and biological symptoms of depression)
(Questions)
Management:
Mild:
- Regular exercise
- Advice on sleep hygiene (regular sleep times, appropriate environment)
- Psychosocial therapy –CBT
Moderate to severe:
- Regular exercise, advice on sleep hygiene,
- CBT
- Medication –SSRIs
- High-intensity psychosocial intervention (CBT or interpersonal therapy)
- Immediate and considerable high risk to themselves or others: Admit to
psychiatric ward (use Mental Health Act if necessary)
58
HISTORY TAKING
History taking
Dementia
You have been asked to take history from female patient hospitalized due to
THA, nurse noted confusion, so you will not ask for name or age or Past
medical or surgical history, Drug history, Family history, Ideas, concerns and
expectations, other system review.
Hello, I’m Mahmoud Bazeed One of exam candidate, how are you today?
-Would you mind if I asked you some questions to test your memory?
Abbreviated mental test scoring:
How old are you?
What time is it to the nearest hour?
Can you remember this address? 24 West St. I will ask you this at the end
What year is it?
What is the name of this place?
What is my job? And what is the job of this person (e.g. a nurse)?
What is your date of birth?
When did WW2 end?
Who is the current prime minister?
Can you count backwards from 20-1?
What was that address I asked you to remember?
Positive findings
Score < 6 suggests dementia or delirium to complete my assessment of the
patient I will do MMSE (mini mental state examination).
The patient has acute confusion with het AMTS SCORE of 2/10 which suggests
delirium or dementia
59
HISTORY TAKING
History taking
(Questions)
What is your differential diagnosis?
Management:
Observations:
• Early Warning Scores can be useful
• BP / Pulse – ↓BP ↑Pulse may indicate sepsis / dehydration
• Temperature, respiratory rate and oxygen sats are all important diagnostic
clues.
CT head:
• Ischemic stroke
• Intracranial bleeds (from trauma or spontaneous)
60
HISTORY TAKING
History taking
• Space occupying lesions

Bloods:
• FBC – white cells for signs of infection, anemia, increased MCV (macrocytic
anemia can be caused by B12 or folate deficiency which can have a variety of
origins: leukemias, alcohol use, lack of intake, lack of absorption (i.e. post-
gastrectomy), pernicious anaemia; hypothyroidism, liver disease.)
• U&E – deranged electrolytes can cause confusion (consider sodium, but
relative to what is normal for the patient).
• LFTs – confusion can be caused by liver failure, malnutrition or be based on
the background of alcohol abuse.
• INR – can be useful to know if the patient is on Warfarin & you are concerned
about intracranial bleeding
• TFTs – confusion is more common in hypothyroid states.
• Calcium – Hypercalcemia often causes confusion/delirium – Bones, moans,
psychotic groans
• B12 + folate/hematinic – macrocytic anemias, and B12/folate deficiency can
compound confusion
• Glucose – hypoglycemia is a common cause of confusion
CXR – As part of a sepsis screen to identify infection source –? Pneumonia
Blood cultures if appropriate – as part of sepsis screen
Urine dipstick/culture – UTI is a very common cause of delirium in the elderly
History: take history from the patient (as possible), from the notes, from her
relatives
Fitness for the operation?
Not fit for giving a consent, as she cannot retain information and she cannot
make an informed decision
Should the operation go ahead?
No. The operation is non urgent, therefore it can be postponed until the cause
of the confusion has resolved. I would talk to my consultant and the anesthetist
61
HISTORY TAKING
History taking
in charge of the case to inform them of the confusion and ask their advice before
cancelling it.
If the cause of confusion was only senile dementia, how you will consent for
the operation?
As the patient lack capacity, consent should be recorded using consent form 4
with 2 consultant signatures
62
HISTORY TAKING
History taking
Seizures
Analysis of seizures
1. Description
Can you talk me through what happened exactly?
Where and when?
What were you doing at the time?
Did anyone witness the episode? How did they describe the episode?
Did you trip over anything or slip?
2. Date of first seizure (early for epilepsy or late for brain tumors)
When did you first experience you first seizure?
3. Aura
How did you feel immediately before the episode? Chest pain, anxious or
Fearful? Did you have any warning that something was about to happen?
4. Ictal manifestation
Did you lose consciousness? How long for?
Did you hit your head?
Did your whole body shake or only part of it?
Did you bite your tongue?
Did you wet or soil yourself?
63
HISTORY TAKING
History taking
Have you noticed head or eye deviation toward one side? (Frontal lobe),
excessive eye blinking (occipital lobe) or lip smacking (temporal lobe)
5. Post ictal
How did you feel immediately after the fall/when you regained consciousness?
Were you confused? Drowsy? Aching muscles? Unable to speak?
6. Previous episodes
Has something like this ever happened before? If yes, can you describe exactly
what happened those times?
7. Diurnal variation (morning for epilepsy late for frontal lobe)
Did it occur in morning time or night time?
8. Triggering factors
Have you noticed that those fits occurs with events like sleep disturbance.
Alcohol consumption, having a fever or with certain medications?
9. Frequency
How frequent do you experience your fits?
How many times per week?
11. past medical history:
Have been investigated before for of CNS infections (meningitis, encephalitis),
head injuries, brain tumors or cerebrovascular disease?
12. Signs of brain tumors
Have you had any arm or leg weakness?
Any visual disturbances?
Any other sensory disturbance?
Did you throw up?
64
HISTORY TAKING
History taking
surgeries?
Thank you
65
HISTORY TAKING
History taking
Can you talk me through what happened exactly?

Where and when?
What were you doing at the time?
Did anyone witness the episode? How did they describe the episode?
Did you trip over anything or slip?
When did you first experience you first seizure?
How did you feel immediately before the episode? Chest pain, anxious or
Fearful? Did you have any warning that something was about to happen?
Did you lose consciousness? How long for?
Did you hit your head?
Did your whole body shake or only part of it?
Did you bite your tongue?
Did you wet or soil yourself?
Have you noticed head or eye deviation toward one side? (Frontal lobe),
excessive eye blinking (occipital lobe) or lip smacking (temporal lobe)
How did you feel immediately after the fall/when you regained consciousness?
Were you confused? Drowsy? Aching muscles? Unable to speak?
Has something like this ever happened before? If yes, can you describe exactly
what happened those times?
Did it occur in morning time or night time?
Have you noticed that those fits occurs with events like sleep disturbance.
Alcohol consumption, having a fever or with certain medications?
How frequent do you experience your fits?
How many times per week?
Have been investigated before for of CNS infections (meningitis, encephalitis),
head injuries, brain tumors or cerebrovascular disease?
66
HISTORY TAKING
History taking

Did you throw up?
surgeries?
Thank you
(Positive finding)
(Focal seizures, RT arm shaking, not generalized, late onset, no post ictal
manifestation negative past history of epilepsy)
67
HISTORY TAKING
History taking
(Questions)
Investigations
- Blood glucose
- CBCD
- Electrolytes, BUN, creatinine, calcium, magnesium, anion gap, lactate,
prolactin (will be elevated after seizure, sometimes used if not sure if event was
a seizure)
- ABG, U/A, LP
- CT head if trauma, suspected intracranial hemorrhage, suspected structural
lesion in first time seizure, prolonged altered mental status, focal neurological
deficit, anticoagulated patient, HIV/Cancer patients
- If infection – may require full septic w/u (LP, cultures, etc)
- EEG – most likely to be done as an outpatient
- MRI – in consultation with neurology
Treatment
- If the patient is seizing
Move to safe place
Turn to side (recovery position) if possible
Observation for specific activity and progression and duration
Prepare to assess/monitor once seizure subsides (ABC’s)
Consider treatment if patient is in status
Postictal
Seizure precautions
ABC’s and monitors, O2
Benzodiazepines may be used to prevent further seizures
Consider anticonvulsant therapy
Phenytoin (Dilantin) 300-600mg PO tid
68
HISTORY TAKING
History taking
Phenobarbital 60-200mg PO daily

Valproic acid (Epival) 15-60mg/kg daily divided bid or tid
Carbamazepine (Tegretol) 400-1200mg daily divided tid/qid
Status epilepticus – 30+min of active seizing or no recovery/consciousness
between
IV line, O2, monitors
Consider intubation
Benzodiazepines (diazepam 10-20mg IV, or lorazepam 4-8mg IV)
Phenytoin 18-20mg/kg IV @ 25mg/min
- Stereotactic biopsy and resection or debunking of brain tumors
69
HISTORY TAKING
History taking
Headache
(Patient can’t speak because of the headache and photophobia)
Do you need analgesic?
Do you want me to switch off the light? So sorry to see you like that.
Where did you feel that pain? Could please point to the site? Frontal, occipital,
temporal, unilateral, all over
70
HISTORY TAKING
History taking

1. Subarachnoid hemorrhage
Have you banged your head, had a fall recently?
Are you sensitive to light?
Do you have any neck stiffness?
2. Meningitis
Have you noticed a rash anywhere?
Have you been feeling ill or had a fever?
3. Brain tumors
Have you ever had seizures or blacked out?
Have you ever lost consciousness?
Did you throw up?
surgeries?
71
HISTORY TAKING
History taking

Thank you
Do you need analgesic?
Do you want me to switch off the light? So sorry to see you like that.
Where did you feel that pain? Could please point to the site? Frontal, occipital,
temporal, unilateral, all over
72
HISTORY TAKING
History taking

Are you sensitive to light?
Do you have any neck stiffness?
Have you ever had seizures or blacked out?
Have you ever lost consciousness?
Have you noticed a rash anywhere?
Have you been feeling ill or had a fever?
Did you throw up?
Have you banged your head, had a fall recently?
surgeries?
73
HISTORY TAKING
History taking

Thank you
(Positive findings)
(Headache with photophobia, polycystic kidney, positive family history of brain
aneurysm)
(Questions)
Management:
I would manage him in an ABC manner, ensuring that he is stable and arrange
appropriate bloods and a plain CT head.
Investigations:
- CT BRAIN
- CSF Tapping
Treatment:
- I would refer this patient to a neurosurgical unit.
- Bed rest, 3L of IV fluids /24h.
- Oral nimodipine 60mg every 4 hours, and laxatives
- Attempt to coil the aneurysm is made
- Burr holes
- Craniotomy
- Discuss in neurovascular MDT
74
HISTORY TAKING
History taking
Chest pain
1. Pulmonary embolism
Have you noticed a cough? Do you bring anything up? Any blood?
Do you get breathless?
Have you had a recent surgery?
75
HISTORY TAKING
History taking
Have you noticed painful legs?

2. Chest infection
Have you been ill or having a fever?
Do you get wheezy chest?
3. Chest malignancy
4. MI
Do you ever get breathless when lying flat?
How many pillows do you sleep with at night?
Do you ever wake up gasping for breath?
5. Musculoskeletal
Is the pain worse on movement? Does it hurt to press on the area?
surgeries?
76
HISTORY TAKING
History taking

Urogenital Abdominal pain, F of micturition, dysuria, urgency, polyuria,
hematuria
Thank you
77
HISTORY TAKING
History taking
surgeries?
78
HISTORY TAKING
History taking

hematuria
Thank you
(Positive findings)
(Sudden chest pain, stabbing, increase by breathing, sever and no history of
trauma)
(Questions)
Management:
Investigations:
- CTPA
- V/Q scan
- CXR
- ECG
- ABG
Treatment:
- ABC PROTOCOL
- Non massive: heparin until APTT 50-60 sec.
- Massive: thrombolysis/ embolectomy
79
HISTORY TAKING
History taking
Shortness of breath (SOB)

In pre-admission clinic Lady planning for cholecystectomy, SOB for few
minutes, increasing in frequency 6 weeks after being scheduled for operation
When did you first notice that breathlessness?
Is there any specific time during the day that the breathlessness increase?
Does anything help you get your breath back? If you rest for a while, does it
improve? Do inhalers help?
Does anything make it worse?
How far can you walk before the breathlessness stops you? Can you climb a flight
of stairs in one go? If not, how many can you manage?
Do you suffer from chest pain? If so
80
HISTORY TAKING
History taking
1. Pulmonary embolism
2. Chest infection
3. Chest malignancy
4. MI
Are you aware of your heart beats?
5. Musculoskeletal
81
HISTORY TAKING
History taking
6. Anxiety
Do you only get breathless when you are anxious?
surgeries?
hematuria
Thank you
82
HISTORY TAKING
History taking
When did you first notice that breathlessness?
Is there any specific time during the day that the breathlessness increase?
Does anything help you get your breath back? If you rest for a while, does it
improve? Do inhalers help?
Does anything make it worse?
How far can you walk before the breathlessness stops you? Can you climb a flight
of stairs in one go? If not, how many can you manage?
Do you only get breathless when you are anxious?
Do you suffer from chest pain?
83
HISTORY TAKING
History taking
surgeries?
Do you smoke? How many packs/ day?
Urogenital Abdominal pain, micturition, dysuria, urgency, polyuria, hematuria
84
HISTORY TAKING
History taking

(Positive findings)
(Prepared for lap cholecystectomy and she has been investigated before for SOB
and free)
(Questions)
Management:
- I should contact the GP to get hold of all the notes regarding investigation of
the patient’s chest pain.
- I would examine the patient and ensure that we repeat the patient’s bloods,
ECG, CXR and get a baseline ABG on room air.
- I would want to ensure she had a recent echo and angiogram and discuss these
with a cardiologist.
- I would reassure the patient that she is going to be well looked after, and ask
her is there was anything we could do to allay her fears.
- I would also suggest that we involve her close relatives or friends so that she
has an adequate support network in place before and after the operation
Can the operation go ahead?
As long as we have no documented evidence that there is no cardiac or resp.
Illness, the operation should go ahead
85
HISTORY TAKING
History taking
Female with hyperthyroidism

When did you first notice that lump?
Is there any specific time during the day that lump increase in size?
Is there anything makes that lump increase in size?
Is there anything makes that lump decrease in size?
1. Compressive symptoms
Have you noticed a change in your voice recently?
Do you have difficulty during swallowing?
Have you noticed breathlessness?
2. Toxic symptoms
Have you noticed a change in the size of your eyes?
Have you noticed a change in your vision?
Do you menstruate regularly?
Do you have difficulty getting sleep?
86
HISTORY TAKING
History taking
Does your mood change through the day?

Have you noticed heat or cold intolerance?
Have you noticed changes regarding your bowel habits? How many motions per
day?
3. Malignancy
Have you noticed a change in your voice?
4. Thyroiditis
Is that swelling painful?
surgeries?
87
HISTORY TAKING
History taking

hematuria
Thank you
Is there any specific time during the day that lump decrease in size?
Is that swelling painful?
Have you noticed a change in your voice recently?
Have you noticed a change in the size of your eyes?
Have you noticed a change in your vision?
Do you menstruate regularly?
Do you have difficulty getting sleep?
Does your mood change through the day?
88
HISTORY TAKING
History taking
Have you noticed heat or cold intolerance?

Have you noticed changes regarding your bowel habits? How many motions per
day?
surgeries?
hematuria
Thank you
(Positive findings)
(Neck swelling, increase in size, positive compression and toxic symptoms)
89
HISTORY TAKING
History taking
(Question)
Management:
Triple easement:
. Full clinical examination
. Ultrasound imaging
. FNAC
Other investigations: radioisotope scan
Possible causes of sudden enlargement:
- hemorrhage inside a cyst.
- Malignant: papillary, follicular, medullary carcinoma
Treatment: thyroidectomy (hemi, near total or total) with such compressive
symptoms
90
HISTORY TAKING
History taking
Unilateral tonsillar swelling

1. Neoplastic (SCC or NHL)
Have you noticed that the lump rapidly increase in size?
Have you or your partner noticed snoring while sleeping?
Have you noticed night fever?
91
HISTORY TAKING
History taking
2. Infective (follicular tonsillitis, quinsy, glandular fever)

Is swallowing painful?
Have you been ill or having fever recently?
Have you noticed wheezy chest?
Have you noticed cough? Do you bring anything? Is there blood?
Have you noticed tummy pain or swelling?
Have you been abroad recently?
3. Asymmetrical anatomic position
surgeries?
hematuria
92
HISTORY TAKING
History taking

Thank you
Have you noticed that the lump rapidly increase in size?
Have you or your partner noticed snoring while sleeping?
Is swallowing painful?
Have you noticed wheezy chest?
Have you noticed cough? Do you bring anything? Is there blood?
Have you noticed tummy pain or swelling?
Have you been ill or having fever recently?
93
HISTORY TAKING
History taking
Have you noticed night fever?

Have you been abroad recently?
surgeries?
hematuria
Thank you
(Questions)
Management:
Investigations:
- Tonsillectomy for biopsy
94
HISTORY TAKING
History taking
- Biopsy with flowcytometry

- CT or PE -CT to rule out lymphoma
- Panendoscopy: examination of the upper aerodigestive tract (pharynx, larynx,
upper trachea and oesophagus).
-FBC: looking for raised WCC associated with infection
-U+E’s: looking for renal impairment if patient has had decreased oral intake
-LFT’s: derangement may indicate glandular fever or metastasis
-Monospot test (detecting glandular fever)
Treatment:
- Staging: MRI neck, CT neck, u/s liver
- Discuss in MDT
- Block neck dissection (radical, modified radical, selective)
- Radiotherapy
95
HISTORY TAKING
History taking
Inguinal hernia
Worried gym trainer with inguinal hernia. You
have to interrupt the patient to save time.
Is it on RT side or LT side or both?
1. Inguinal hernia
What were you doing when you first noticed the bulge?
Is there straining while passing stool or urine?
Have you noticed that the lump increase with size with straining while passing
urine or stool, or with cough?
Have you noticed that the lump decrease in size when you lie down?
Have you noticed redness or hotness in the overlying skin?
96
HISTORY TAKING
History taking
Is that lump painful? If so

Have you noticed that the lump decrease in size even with lying down?
Do you have tummy pain?
Did you throw up?
Do you have distension or bloating?
2. Abscess
Is there wound or sore over the bulge?
Did the lump bring anything? (Discharge)
3. Lymph node (inflammatory or neoplastic)
97
HISTORY TAKING
History taking
surgeries?
Stamina tonic: what are the components of it? Is it contains any steroids
Visit of the GUM clinic, foreign travel: did you make test for HIV, when you came
back, did you repeat it?
(Answer patient questions)
How does a hernia happen?
With straining like you do, there will be muscle tearing, and some gut will
protrude through the defect.
Could it be better?
It usually needs a surgical operation for repair, the operation may be in open
fashion or keyhole surgery.
Where to get back to work?
Few weeks
hematuria
98
HISTORY TAKING
History taking
What were you doing when you first noticed the bulge?
Is that lump painful? If so
99
HISTORY TAKING
History taking

Did the lump bring anything?
Did you throw up?
surgeries?
Stamina tonic: what are the components of it? Is it contains any steroids
Visit of the GUM clinic, foreign travel: did you make test for HIV, when you
came back, did you repeat it?
100
HISTORY TAKING
History taking
How does a hernia happen?

With straining like you do, there will be muscle tearing, and some gut will
protrude through the defect.
Could it be better?
It usually needs a surgical operation for repair, the operation may be in open
fashion or keyhole surgery.
Where to get back to work?
Few weeks
hematuria
Thank you
(Positive findings)
(Gym trainer referred from GP with groin swelling typical of inguinal hernia, past
history of genitourinary infection, stoma tonics, and patient will ask question
about hernia and surgery)
101
HISTORY TAKING
History taking
Infected pseudoaneurysm
Referred from GP as groin abscess
1. Infected pseudo aneurysm
Is it painful? If so
102
HISTORY TAKING
History taking
Did you notice any blood coming out from the swelling?
Did you have any recent injection or trauma in your groin?
Do you feel that this swelling is having pulses? Is it beating?
Do you feel any limb pain or coldness or colour changes or limb swelling?
Do you have any limb numbness?
2. Groin abscess
Did you notice any discharge from the Lump?
3. Lymph node (inflammatory or neoplastic)
4. Inguinal hernia
103
HISTORY TAKING
History taking
Did you throw up?

surgeries?
hematuria
Thank you
Hello, I am Mahmoud Bazeed one of the exam candidate.
104
HISTORY TAKING
History taking
Is it painful? If so
Did you notice any discharge from the Lump?
Did you notice any blood coming out from the swelling?
Did you have any recent injection or trauma in your groin?
Do you feel that this swelling is having pulses? Is it beating?
105
HISTORY TAKING
History taking

Did you throw up?
surgeries?
106
HISTORY TAKING
History taking

hematuria
Thank you
(Positive findings)
(Referred from GP with groin abscess and turn to be infected pseudo aneurysm)
(Questions)
Investigations:
- Duplex ultrasonography
- CT angiography
Treatment:
- Ligation of the involved artery with delayed revascularization.
- Non operative treatment: Duplex ultrasound-guided compression and
percutaneous thrombin injection
- Define pseudo aneurysm: is a collection of blood that forms between the two
outer layers of an artery, the tunica media and the tunica adventitia. It is usually
caused by a penetrating injury to the vessel, which then bleeds, but forms a
space between the above two layers, rather than exiting the vessel. It may be
pulsatile and can resemble a true aneurysm
- True aneurysm: involves all three layers of the blood vessel
107
HISTORY TAKING
History taking
Back pain
1. Disc prolapse (cauda equine)
Does the pain travel down your legs?
Have you had any strange sensations down your legs or buttocks?
Have your legs been feeling weaker than usual?
Have you had any problems with your waterworks? Bowels?
108
HISTORY TAKING
History taking
Have you had any difficulty in gaining an erection?

2. Ankylosing spondylitis
Is your back stiff in the morning? If so, how long does that last for?
3. TB
Have you been ill or having a fever especially at night?
Do you suffer night sweat?
Do you have any neck swelling?
Do you cough? Do you bring anything? Is there blood?
4. Metastatic
Have you noticed any significant weight loss over the past few months?
How is your appetite?
5. Osteoporosis
Did you have any bone fractures that occur easily than usual?
6. Trauma
Have you had trauma to your back recently?
7. Non spinal causes
Do you have tummy pain? Or tummy swelling
surgeries?
109
HISTORY TAKING
History taking

hematuria
Thank you
Does it move anywhere? Does the pain travel down your legs?
110
HISTORY TAKING
History taking

Is your back stiff in the morning? If so, how long does that last for?
Did you have any bone fractures that occur easily than usual?
Have you had trauma to your back recently?
Have you had any strange sensations down your legs or buttocks?
Have your legs been feeling weaker than usual?
Have you had any problems with your waterworks? Bowels?
Have you had any difficulty in gaining an erection?
Have you been ill or having a fever especially at night?
Do you suffer night sweat?
Do you have any neck swelling?
Do you cough? Do you bring anything? Is there blood?
Do you have tummy pain? Or tummy swelling
surgeries?
111
HISTORY TAKING
History taking

hematuria
Thank you
(Positive findings)
First scenario (female patient, long standing history of back pain ,worse in the
last 3 years ,MRI mild degenerative changes, Disabled husband, work
commitment, increase by activity and decrease by rest) Mechanical low back
pain.
Second scenario (male patient, sudden pain and red flags) cauda equina.
(Questions)
My main differential diagnosis will be:
- Functional back pain (Mechanical lower-back pain):
.localized pain that worsens with movement and changes in posture
.history of heavy lifting
. History of previous similar episodes over a number of years
. No features of systemic illness, nor neurological symptoms
- I have also to rule out organic pathology: Prolapsed intervertebral disc, spinal
mets, Seronegative spondyloarthropathy (ankylosing spondylitis),Spinal canal
stenosis, Non-spinal causes of back pain( AAA, fibromyalgia, pancreatitis, renal
calculi)
Cauda equina:
- Urinary and faecal incontinence
112
HISTORY TAKING
History taking
- Sensory numbness of buttocks and backs of thighs and weakness of legs
Investigations:
- A full examination is required, particularly looking for perianal sensory loss and
anal tone.
- I would carefully check for a reduction in power and decreased reflexes.
- Back examination and lower-limb neurological examination
113
HISTORY TAKING
History taking
- Bloods –FBC, LFTs, U&Es, CRP and ESR Chest X-ray and QuantiFERON-TB Gold
if TB suspected
- MRI (not needed if the history suggests uncomplicated mechanical back pain)
- Urgent MRI/CT scan if cord compression or cauda equina is suspected
- X-ray and a subsequent DEXA scan if a crush fracture is suspected
Management:
Simple back pain (including prolapsed intervertebral disc):
- Advise to stay active and avoid prolonged bed rest Physiotherapy, regular
analgesia and consider short-course muscle relaxants
- Serious pathology or red-flag symptoms: Cord compression –dexamethasone
and urgent surgery; radiotherapy in malignancy
- Cauda equina syndrome –urgent surgery
- refer to social worker
114
HISTORY TAKING
History taking
Knee pain
Footballer, had right knee injury 30 years ago, had knee
operation that he has no idea about, developed worsening
right knee pain 4 months ago

1. Osteoarthritis
Does the pain present all the day and increase at night?
115
HISTORY TAKING
History taking
Did you notice any changes in the shape of your knee?

Was there any history of trauma?
2. ACL injury
Did you experience giving away when walking?
3. Meniscus injury
Did you experience locking of your knee?
4. Rheumatoid arthritis
Have you noticed any stiffness in your joint(s) when you wake up in the
morning? How long does that last for?
5. Septic arthritis
Have you noticed swelling of your knee? Or redness?
Is there any discharge?
6. Referred from the back
Have you noticed weak or numb legs?
Do you have back pain?
7. Extra intestinal manifestation of IBD
Have you noticed any rashes anywhere on your body?
Have you had any diarrhea?
Have you had painful or red eyes?
8. Malignancy
surgeries?
116
HISTORY TAKING
History taking

hematuria
Thank you
117
HISTORY TAKING
History taking

Does the pain present all the day and increase at night?
Did you notice any changes in the shape of your knee?
Did you experience giving away when walking?
Did you experience locking of your knee?
Have you noticed swelling of your knee? Or redness?
Have you noticed any stiffness in your joint(s) when you wake up in the
morning? How long does that last for?
Do you have back pain?
Have you noticed weak or numb legs?
Have you noticed any rashes anywhere on your body?
Have you had any diarrhea?
Have you had painful or red eyes?
surgeries?
118
HISTORY TAKING
History taking

hematuria
Thank you
(Positive findings)
(History of trauma, and operation, can’t play football now, pain increase at
night, crepitus) secondary OA.
(Questions)
My main differential will be:
- OA (traumatic)
- RA
- Referred pain from hip or spine pathology
Investigations:
- Knee x- ray (standing and weight bearing): a-p, lateral views
119
HISTORY TAKING
History taking
Treatment:
Conservative
• Maintain or achieve a healthy weight i.e. aim to decrease weight, and
therefore force, going through a joint
• Regular exercise, with particular attention to strengthening the muscles
around the joint. For example in OA of the knee, cycling is beneficial
• Analgesia: care to be taken with NSAID's with relation to gastric irritation
• Heat application to the joint may offer relief
• Physiotherapy
• Intra-articular steroids
Surgical:
. Arthroscopy and arthrocentesis
• Realignment osteotomy
• Total or partial knee replacement
Will the patient be likely to play soccer in 9 months? No
120
HISTORY TAKING
History taking
Lower limb claudication

1. Chronic lower limb ischemia
Is it relieved by rest?
Is it made worse if you walk faster or up a hill?
Does cold weather affect it?
Have you noticed any skin breech in your legs or feet?
121
HISTORY TAKING
History taking
How far can you walk before stopping?

2. Spinal canal stenosis
Do you have any numb or weak legs or feet?
Do you have any back pain?
surgeries?
hematuria
Thank you
122
HISTORY TAKING
History taking

Is it relieved by rest?
Is it made worse if you walk faster or up a hill?
Does cold weather affect it?
How far can you walk before stopping?
Have you noticed any skin breech in your legs or feet?
Do you have any back pain?
Do you have any numb or weak legs or feet?
surgeries?
123
HISTORY TAKING
History taking

hematuria
Thank you
(Positive findings)
Claudication pain in calf increased by col and walking and decreased by rest
Chronic ischemia.
(Questions)
How to diff. between spinal and vascular claudication:
Peripheral vascular disease:
- Claudication pain is a cramping pain in the calf, thigh or buttocks
- Brought on by exercise and relieved by rest (patients often pretend to ‘window-
shop’ until the pain disappears)
- Exacerbated by walking faster or up hills and also by cold weather
124
HISTORY TAKING
History taking
- Risk factors/associated factors for atherosclerosis: Diabetes

Hypercholesterolemia Stroke
- Rest pain may indicate critical limb ischaemia
Spinal claudication:
- Often relieved when walking up a hill
- Often has associated limb numbness
Sciatica:
- Shooting pain down the back of a leg to the feet
- History of lower-back pain
Investigations:
- Full peripheral vascular, cardiovascular and neurological examination
- Assess gait and balance
- Arterial duplex
- CT angiography (if surgical intervention was needed)
- MR Angiography
Treatment:
- optimize blood sugar, cholesterol, blood pressure
- Antiplatelet agents: aspirin, clopidogrel
- Antilipemic agents: simvastatin
- Surgical treatment: endovascular stenting, surgical bypass, amputation
125
HISTORY TAKING
History taking
126
HISTORY TAKING
History taking
127
HISTORY TAKING
History taking
128
HISTORY TAKING
History taking
129
HISTORY TAKING
clinical
examination
CONTENTS
APPROACH TO EXAMINATION 1
POSITIVE FINDINGS 3
SPINE AND LOWER LIMBS EXAMINATION 16
FOOT DROP EXAMINATION 27
HIP EXAMINATION 37
KNEE EXAMINATION 47
ANKLE EXAMINATION 60
HAND EXAMINATION 68
SHOULDER EXAMINATION 85
CHRONIC LOWER LIMB ISCHEMIA 95
VARICOSE VEINS EXAMINATION 107
ARTERIOVENOUS FISTULA EXAMINATION 120
CEREBELLAR EXAMINATION 132
CRANIAL NERVES EXAMINATION 144
CHEST EXAMINATION 164
CARDIOVASCULAR EXAMINATION 177
ABDOMINAL EXAMINATION 196
BREAST EXAMINATION 213
CCRISP 223
INGUINAL HERNIA EXAMINATION 233
HYDROCELE EXAMINATION 242
THYROID GLAND EXAMINATION 252
PAROTID GLAND EXAMINATION 267
SUBMANDIBULAR GLAND EXAMINATION 277
SUPERFICIAL LUMP EXAMINATION 287
CLINICAL EXAMINATION
Approach to Examination
A. Wash your hands.
B. Greet the patient and introduce yourself (Hello. I am Mahmoud Bazeed one
of the exam candidate). Just to be familiar with the patient (you don’t have to
remember the name and age, also you don’t have to mention during
presentation.
C. Confirm patient name and age (May I confirm your name and age).
D. Explain examination in layman language and get verbal consent (Today I’ve
been asked to examine your tummy that would include looking feeling and
listening to your tummy, are you OK with this?).
E. Ask the examiner for a chaperon if you are going to examine the genitalia or
female breast.
F. Ask patient politely to remove his or her clothes and if you have to keep
patient underwear for patient dignity e.g. hip examination inform the examiner.
G. During examination: patient position, explain every step to the patient if
possible, ask for permission to examine the patient from the back, before
moving any limb ask the patient if there is any pain at hip or shoulder, try to
protect the patient from falling during walking, you are not allowed to wear
gloves even during examination of patient genitalia, only during oral
examination.
H. Review patient chart or files if present.
I. Thank the patient, ask him to cover himself and help him if needed and wash
your hands.
J. Look at the examiner and tell him to complete my examination I would like to
perform ……
K. Present your case (you don’t have to mention patient name and age) mention
positive and important negative signs, provisional and differential diagnosis. You
can mention investigation and treatment options without asking but better to
wait to the examiner to ask.
L. Answer the examiner questions.
1|Page
 There are four clinical examination station in the exam.

 Each station will last for ten minutes.
 One minute to read the stem written on the door of the examination
room.
 Six minutes to examine the patient.
 Three minutes to present your case and answer the examiner questions.
 The patient could be real patient or an actor.
 If the patient can’t speak Arabic, you will find a translator.
 You will not be provided by pen and paper.
 Each station is 20 marks station.
 one examiner (Surgeon examiner) is present in each clinical examination
station: responsible for 20 of 20marks and he will evaluate you on three
main items clinical examination, presentation, knowledge and patient
communication skills.
2|Page
Positive findings
Examination Type of Diagnosis Positive findings
patient
Spine actor Disc prolapse Tender lumber region, inability
to perform heel walking,
limited range of motion,
positive straight leg raising test
with positive lasegue sign,
limited or absent sensation
over anterolateral part of leg
and dorsum of foot for both
light touch and pin prick (L5)
and weak or absent
dorsiflexion of big toe(L5).
Hip Real LT hip Trendelenburg gait, positive
patient osteoarthritis, Trendelenburg sign (when the
or RT superior patient stands on RT leg only,
actor gluteal nerve LT side of the pelvis sags down
injury and trunk lurch to the RT side
), scar over RT hip joint,
positive Thomas test (fixed
flexion deformity of LT hip),
Limited range of motion of
both hips, leg length
discrepancy 4cm of femoral
origin (positive Galeazzi test)
and supra-trochanteric origin.
Knee real Osteoarthritis limited range of motion
knee especially flexion, crepitus and
antalgic gait.
Knee Actor 1.Lateral 1. Lateral meniscus and lateral
two meniscus and collateral tear: Antalgic gait,
scenari lateral collateral tender later aspect of the
os tear 2. Medial knee, limited range of motion
meniscus tear (locking) positive McMurray
test for lateral meniscus and
positive varus stress test for
lateral collateral ligament.
3|Page
2. Medial meniscus tear:

Antalgic gait, tender medial
aspect of the knee, limited
range of motion (locking) and
Positive McMurray test for
medial meniscus.
Ankle actor Ankle sprain Antalgic gait, tender lateral
(calcaneofibular aspect of ankle joint, painful
ligament injury) limited range of motion,
positive talar tilt test for
calcaneofibular ligament.
hand actor Carpal tunnel Paresthesia over radial three
syndrome and half fingers, positive
Phalen test and Positive Tinel
sign.
shoulder actor 1.Subacromial 1.Positive empty can Test and
impingement. (Painful Arc) pain with arm
2. Rotator cuff abducted in scapular plane
tear from 60° to 120°.
(not sure) 2.positive test according to the
torn muscle.
Chest real COPD Central cyanosis, barrel-
shaped chest, equal expansion
on both sides, by Percussion
Hyperresonance on both sides
and by auscultation equal air
entry on both sides harsh
vesicular breathing with
expiratory wheezes and
normal vocal resonance on
both sides.
CVS real Aortic stenosis Apex is displaced (may felt in
6th intercostal space), palpable
thrill at 2nd intercostal space
Rt parasternal and over carotid
vessels in the neck, audible
ejection systolic murmur over
second intercostal space Rt
parasternal, propagated to
4|Page
carotid and accentuated on

leaning forward.
CVS real Mitral Audible pan-systolic murmur
regurgitation over the apex, propagated to
axilla and accentuated in Lt
lateral position.
CVS real Peace maker Lt infra-clavicular scar.
CVS real Valve Midline sternotomy scar and
replacement audible metallic click of
prosthetic valve.
CVS real Valve Midline sternotomy scar and
replacement audible metallic click of valve
and Mitral replacement with pan-systolic
regurgitation murmur over the apex,
propagated to axilla and
accentuated in Lt lateral
position.
Abdomen real Gynecomastia Diffuse bilateral breast
and breast enlargement with or without
tender disc felt under the
areola and diffuse abdominal
enlargement with central
umbilicus (obesity).
Abdomen actor Acute Tender RT iliac fossa, positive
appendicitis Rebound tenderness, and
Rovsing, Obturator and Psoas
sign.
Abdomen actor Acute Tender Rt hypochondrium and
cholecystitis positive Murphy sign.
Abdomen actor Acute Tender LIF
diverticulitis
Abdomen real Paraumbilical or There is a swelling in the peri-
Incisional hernia umbilical
region (elsewhere over the
abdomen in
incisional hernia), increasing in
size on
coughing. Scar of previous
operation (in incisional
hernia), there is a palpable
5|Page
mass in the periumbilical

region (supra,
infra, Rt, Lt) to the umbilicus
(or over the
scar of previous operation in
incisional
hernia), the swelling is not
tender, shows
expansile impulse on cough,
doughy in
consistency, reducible and
defect size is ~ cm or ~ fingers.
Groin real Inguinal hernia 1. RT indirect inguinal hernia:
(two scenarios) By inspection: the swelling
turned to be in right groin
region occupying right inguinal
(Inguinoscrotal) region, shows
visible impulse on cough and
other side is free. By palpation:
lies above and medial to pubic
tubercle, palpable impulse on
cough, reducible (unless the
patient couldn’t reduce the
swelling or it was painful to
reduce), DIR test is positive (or
I couldn’t be elicited), swelling
is not tender, not
compressible, not pulsating
and not associated with
inguinal lymphadenopathy
and separable from testis, not
trans-illuminating, and scrotal
neck was full.
By auscultation, there were
some (no) gurgling sounds
indicating presence (absence)
of bowel
2.Bilateral inguinal hernia:
By inspection: the swelling
turned to be in right groin
6|Page
region occupying right inguinal

region, shows visible impulse
on cough and also the other
side. By palpation: lies above
and medial to pubic tubercle,
palpable impulse on cough,
reducible (unless the patient
couldn’t reduce the swelling or
it was painful to reduce), DIR
test is negative (or I couldn’t be
elicited), swelling is not
tender, not compressible, not
pulsating and not associated
with inguinal
lymphadenopathy and
separable from testis, not
trans-illuminating, and scrotal
neck was empty.
By auscultation, there were
some (no) gurgling sounds
indicating presence (absence)
of bowel
Groin real hydrocele By inspection: The swelling is
completely scrotal with no
visible swelling in Rt groin
region, 3x4cm in size, Oval in
shape, Regular surface, no
visible impulse on cough and
other side is free. By palpation:
The swelling is purely scrotal,
with smooth surface, soft
consistency, not tender, not
compressible, not pulsating
and not associated with
inguinal lymphadenopathy
and scrotal neck is empty, isn’t
separable from testis and
shows transillumination.
7|Page
CCrISP actor POD6 Lower abdominal midline

anastomotic incision (you will offer to
leak remove the plaster), light
abdominal palpation revealed
sever tenderness, so I shifted
to CCrISP: airway is patent,
breathing: No central cyanosis
trachea is central, equal chest
wall movement bilaterally,
normal percussion note
bilaterally and equal air entry
bilaterally with no added
sounds (Anterior and Lateral
walls only no posterior),
circulation: No signs of
dehydration, no congested
neck veins and normal heart
sounds, Disability : Patient is
alert, Exposure: Patient is
wearing TEDS( you will offer to
remove it) and calf muscles are
not tender and by reviewing
patient charts I noticed rising
temp, rising pule rate,
decreasing blood pressure,
increasing o2 requirements,
leukocytosis in FBC, and AF in
ECG.
CCrISP actor Pulmonary Lower abdominal midline or
embolism hip scar, airway is patent,
breathing: No central cyanosis
trachea is central, equal chest
wall movement bilaterally,
normal percussion note
bilaterally and equal air entry
bilaterally with no added
sounds (Anterior , Lateral and
posterior walls ), circulation:
No signs of dehydration, no
congested neck veins and
8|Page
normal heart sounds, Disability

: Patient is alert, Exposure: calf
muscles are tender and by
reviewing patient charts I
noticed Tachycardia and
increasing o2 requirements .
Neuro actor Cerebellar broad based gait with
ataxia (posterior unsteadiness, and inability to
cranial fossa perform tandem gait, negative
tumor) Romberg sign, Staccato
speech, no nystagmus. UL
examination shows: positive
Pronator drift sign, positive
Rebound phenomenon,
dysdiadokinesia, intentional
tremors, Inco-ordination (past
pointing), Hypotonia and
Bilateral normal reflexes.
Examination of both lower
limbs shows normal tone,
bilateral normal reflexes and
incoordination. Examination of
last cranial nerves were
normal
Neuro actor Foot drop High steppage gait with
difficulty in heel walking, there
is stab avulsion scar over the
leg, Tinel sign is negative,
decreased sensations over
anterolateral part of leg and
dorsum of foot for both light
touch and pin prick sensations,
weak ankle dorsiflexion and
eversion
Neuro actor Cranial nerves 1. (bitemporal hemianopia)
(three scenarios) (pituitary adenoma).
2. Unilateral conductive
hearing loss and
hemotympanum (fracture
skull base).
9|Page
3. dementia, Defective lateral

gaze (abducent), bilateral
anosmia and bilateral
decreased visual acuity on
Snellen chart (anterior cranial
fossa tumor).
vascular real Ischemia By inspection: Skin trophic
changes of LL chronic
ischemia, in the form of pale
skin especially Lt LL, thin shiny
skin, hair loss, venous
guttering of LL. By palpation:
Slight decrease in temperature
of LL, delayed capillary refill,
Buerger’s angle in LL was 40,
with positive Buerger’s test, all
pulses of both LL were
palpable except for (dorsalis
pedis and posterior tibial
arteries), I used the hand-held
doppler for dorsalis pedis &
posterior tibial arteries pulse
which revealed dampened
monophasic sound. By
auscultation: there was no
audible bruits over femoral
and iliac arteries, I started to
do ABPI measuring for Lt LL but
I couldn’t finish due to time.
vascular real Varicose veins 1.primary Varicose veins:
(two scenarios) multiple varicosities along the
distribution of (LSV or SSV),and
also there are multiple
incompetent perforators
above and below knee, there
are some signs of chronic
venous insufficiency over LL in
the form of
lipodermatosclerosis, venous
eczema, (atrophie blanche,
10 | P a g e
hemosiderin deposition,
venous ulcers), Trendelenburg
test was positive indicating SFJ
incompetence, I did tourniquet
test above & below the knee
which revealed presence of
multiple incompetent
perforators above & below
knee, modified Perthe’s test
were negative, Perthe’s test
couldn’t be done as complete
occlusion of superficial system
of veins couldn’t be achieved
due to presence of multiple
incompetent perforators and
assessing SFJ by doppler it was
incompetent
2.secondery Varicose veins:
multiple varicosities along the
distribution of (LSV or SSV) and
in the lower abdomen
(multiple dilated veins above
inguinal ligament), and scar in
the upper thigh most probably
Trendelenburg operation
(ligation of SFJ) ,
Trendelenburg test indicates
incompetent perforators,
tourniquet test revealed
presence of multiple
incompetent perforators
above and below knee,
modified Perthe’s test were
positive and Perthe’s test
couldn’t be done as complete
occlusion of superficial system
of veins couldn’t be achieved
due to presence of multiple
incompetent perforators.
11 | P a g e
Vascular real AV-fistula The swelling is in anterior

(Dialysis aspect of forearm in
associated steal antecubital fossa, most
syndrome) probably brachio-cephalic AV
fistula, 3x4cm in size Oval in
shape, irregular surface, there
is overlying scar, the skin
overlying has brown
pigmentation, Arm elevation is
positive and pale skin distally.
Palpable thrill, radial pulse is
absent or weak and is heard by
handheld doppler, with
positive pulse augmentation
test Compression Radial pulse
is augmented with fistula
compression (check with
doppler)
On auscultation:
There are audible soft,
machinery, low-pitched bruits
with systolic and diastolic
components heard over the
swelling.
Thyroid real Simple or toxic on inspection: the swelling
multinodular turned to be in the front of
goiter (two neck in midline, 5x7cm in size,
scenarios) butterfly in shape, with regular
surface, the swelling is mobile
with swallowing and not
mobile with tongue
protrusion. By palpation:
nodular surface, well defined
edges, firm in consistency, the
swelling in mobile , not tender,
not pulsatile, not compressible
and not reducible, not
attached to overlying skin and
not attached to underlying
structures and not associated
12 | P a g e
by lymphadenopathy and not

attached to overlying or
underlying structures (partially
overlapped by sternomastoid
muscle) and I could get below
the swelling, carotid pulses
were equally felt bilateral and
Trachea was central . By
percussion: The upper end of
sternum is resonant denoting
no retrosternal extension of
the swelling. By auscultation:
There are no audible bruits
heard over the swelling. On
examination of thyroid status:
Patient is in euthyroid status in
simple multinodular goiter,
thyrotoxic in toxic
multinodular goiter.
Submandibular Real or (Sialo-lithiasis, on inspection, the swelling is in

gland actor tumor) the anterior triangle of neck,
Or normal (two Submandibular region,(I can’t
scenarios) roll up the gland above the
mandible), 2x1 cm in size, Oval
in shape, regular surface,
inspection of oral cavity for
Wharton’s duct revealed no
surrounding inflammation and
clear saliva and the
contralateral side is free and
assessment of marginal
Mandibular and hypoglossal
nerves was normal. By
palpation: The swelling has
nodular surface, well defined
edges, Firm consistency,
mobile, not tender, not
pulsatile, not compressible
13 | P a g e
attached to overlying skin but

attached to underlying
by lymphadenopathy, and on
palpation of Wharton’s duct,
there is no stones felt. On
bimanual examination of the
floor of mouth, the swelling is
bimanually felt and
assessment of lingual nerve is
normal on both sides. The
mass is not trans illuminating
and no audible bruit is present
over the mass, and the other
side is free
2.Normal examination in a
case of actor.
Parotid gland real Pleomorphic by inspection, the swelling is in
adenoma the Rt parotid gland, 2x1 cm in
(tumors)or size, Oval in shape, regular
Sialo-lithiasis surface, inspection of oral
cavity for Stenson’s duct
revealed no surrounding
inflammation and clear saliva
and the contralateral side is
free and assessment of facial
nerve branches bilaterally was
normal. By palpation: The
swelling has nodular surface,
well defined edges, Firm
consistency, mobile, not
tender, not pulsatile, not
compressible and not
reducible, not attached to
overlying skin and not
attached to underlying
by lymphadenopathy on
palpation of Stenson’s duct,
there is no stones felt. On
14 | P a g e
bimanual examination of the

floor of mouth, the deep lobe
couldn’t be felt. The mass is
not trans illuminating and no
audible bruit is present over
the mass, and the other side is
free.
Superficial real Lipoma on inspection, the swelling is
lump On the back of in the back of his neck, , 5x10
the neck cm in size, Oval in shape,
regular surface, overlying skin
does not show signs of
inflammation or scars By
palpation: The swelling has
regular surface, slippery
edges, soft in consistency,
mobile, not tender, not
pulsatile, not compressible
attached to overlying skin or
underlying structures and not
associated by cervical or
axillary lymphadenopathy. The
mass is not trans illuminating
and no audible bruit is present
over the mass.
15 | P a g e
Spine and lower limbs examination

Stem1: examine patient present with low back pain.
Stem 2: examine patient present with lower limb claudication.
How could you differntiate between neurological and vascular claudication
while reading the examination stem?
Neurological Vascular
(spine examination) (arterial examination)
Stem (paper written on ABPI done by GP and is (Do ABPI if there is

the door of exam room) normal enough time)
Inside the examination Hammer, cotton wall, Doppler
room, you will find neurotip
Patient Type: Actor.

Patient position: start by standing.
Patient Exposure: patient will keep only his shorts. (trunk and both legs).
Provisional diagnosis: L4/5-disc herniation with involvement of L5 nerve root.
Positive Finding: Tender lumber region(L4-5), inability to perform heel walking,
painful range of motion, positive straight leg raising test with positive lasegue
sign, limited or absent sensation over anterolateral part of leg and dorsum of
foot for both light touch and pin prick (L5) and weak or absent dorsiflexion of
big toe(L5).
In any joint examination; you will look, feel and move.

In any joint examination; you have to examine the joint below and joint above
to complete your examination.
16 | P a g e
Order of items of examination

1.inspection
A. Gait: (gait, walking on heels and walking on toes).
B. Back:(from the front, side and back) for (scars wasting
deformities).
C. Walking aid: crutches.
2. palpation: temperature and tenderness.
3.perform Schober’s test.
4.Active movement of the spine (not passive) (flexion, extension and lateral
rotation).
5. straight leg raising test.
6.sensation (pin brick and light touch).
7.Motor power.
8. Coordination.
9.Reflexes (knee and ankle reflexes).
10. Tone (leg lift and leg roll) and clonus.
11. Femoral nerve stretch test.
FROM 1 TO 4 PATIENT WILL BE STANDING.

FROM 5 TO 11 PATIENT WILL BE LYING ON THE
BED.
17 | P a g e
Examination Scenario
Wash your hands.
May I confirm your name and age please.
Today I’ve been asked to examine your back and legs that would include looking
feeling and moving your back and legs, are you OK with this?
Would you please take off your gown?
Would you please stand up for me?
(Look for the presence of walking aid like crutches).
Would you please walk a few steps for me toward the wall?
Would you please turn around and try to walk over your heels?
Would you please walk over the tips of your toes?
(gait inspection, walk on heels L5, walking on toes S1).
(Try to support your patient during walking to prevent him from falling by
walking beside him with one arm in front of him and the other arm behind
him)
Now, I would take a close look to your head and shoulders. (inspect position of
head and relation to both shoulders)
Now, would you look to the RT side? (inspect from the side for cervical
lordosis, thoracic kyphosis, lumbar lordosis).
Now, I am going to examine you from the back are you ok with this?
Thank you, I will start by taking a close look to your back. (inspect from the
back for scoliosis scars, muscle wasting, abnormal hair growth and scars).
Now, I am going to feel your back, do you have any pain at the moment?
(using the dorsum of both hands to feel temperature from downward upward)
(start palpation from cervical (non tender region) to lumber region (tender
region) (spinous processes, paraspinal muscles and sacroiliac joints).
18 | P a g e
Now I am going to make a mark and some measurements on your back are you
ok with this? Would you please try to bend forward and try to touch your toes
with your fingers? (Schober’s test)
(Identify position of the posterior superior iliac spine (PSIS) – “dimples of
Venus”p, mark the skin in the midline 5cm below PSIS, mark the skin in the
midline 10cm above PSIS, ask the patient to touch their toes – full lumbar
flexion, measure the distance between the two lines (started at 15cm)
Normally the distance between the two marks should increase to >20cm.
Reduced range of motion can indicate conditions such as ankylosing
spondylitis).
Would you please do as I do (flexion, extension and lateral flexion) (active
only).
Would you please lie down for me?
Do you have any pain in the hip at the moment?
Now, I am going to raise your legs? Please tell me if you have any pain?
Now, I am going to bend your ankle please tell me if the pain increases.
(positive lasegue sign)
Now, I am going to bend your knee, please tell me if the pain decreases.
(straight leg raising test, do the same for the other side)
( straight leg raise: positive in sciatic nerve root impingement due to prolapsed
disc, position the patient supine on the bed, holding the ankle, raise the leg
(passively flexing the hip) – keeping the knee straight, Normal ROM is
approximately 80-90o of passive hip flexion, once the hip is flexed as far as the
patient is able, dorsiflex the foot, the test is positive if the patient experiences
pain in the posterior thigh / buttock, if this causes pain in lower back /thigh/
buttocks, it suggests sciatic nerve root impingement).
Now, I am going to test your sensations, do you feel this? (touch him in the
arm or chest)
Would you please close your eyes and say yes, every time you feel this?
(Sensation, test for sensation both light touch (dorsal column) using cotton
and pin prick for spinothalamic tract in contralateral side in comparison to the
19 | P a g e
ipsilateral side, S1 above lateral malleolus, L5 dorsum of foot, L4 above medial

malleolus, L3,2,1 anterior surface of the thigh).
Now, I am going to put my hand below your knee and I need to stop me from
lifting your legs off the bed. ((hip extension) (L4, L5))
Would you please raise your leg off the bed & stop me from pushing it down?
((hip flexion) (L2, L3))
Would you please, bend your knee & stop me from straightening it? (knee
Flexion (L5, S1)).
Would you please, would you please, straighten your knee against my hand?
(knee extension (L3, L4)).
Would you please, press against my hand with the sole of your foot?
Would you please, point your foot towards your head & don’t let me push it
down? (dorsiflexion (L4, L5))
Would you please, point your big toe towards your head? Then don’t let me
push it down? (hallux extension (L 5))
(muscle power, do the same for the contralateral side in comparison to the
ipsilateral side.)
Would you please bend your RT knee, and touch your LT knee with your RT
ankle, run your heel down the other leg from the knee & repeat in a smooth
motion
Could you please repeat what you did on the other side?
(Co-ordination).
Now I am going to test your reflexes.
(reflexes, knee and ankle reflexes both sides in comparison).
Now I am going to move your leg Do you feel any pain at the moment, please
tell me if you have?
(leg roll, roll the patient’s leg and watch the foot it should flop independently
of the leg, do the same for the other leg).
Now I am going to lift your knee.
20 | P a g e
(Leg lift, briskly lift leg off the bed at the knee joint – the heel should remain in
contact with the bed, do the same for the other leg).
Now I am going to move your ankle.
(clonus, Position the patient’s leg so that the knee and ankle are 90o flexed,
rapidly dorsiflex & partially evert the foot, keep the foot in this position, do
the same for the other side, Clonus is felt as rhythmical beats of
dorsiflexion/plantarflexion (>5 is abnormal)).
would you mind if you lie on your belly?
Now, I am going to bend your knee, do you have any pain at the moment?
(Femoral nerve stretch test, do the same for the other side).
(positive in femoral nerve root compression, position patient prone, flex knee,
extend hip, plantar-flex foot, positive test if pain felt in thigh/ inguinal region.
Now I am going to remove the mark on you back.
Thank you, sir, you may dress now, do you need any help?
Wash your hands.
21 | P a g e
22 | P a g e
coordination
Schober’s test
23 | P a g e
Straight leg raising test
Femoral nerve stretch test
24 | P a g e
presentation
To complete my examination, I would like to examine cervical spine and both
hips.
Today I have examined this gentleman who present with low back pain. I
noticed that the Patient could not perform heel walking. On closer inspection
to his back, I noticed normal cervical lordosis, thoracic kyphosis, lumber
lordosis, there was tenderness over the lower back, also, there was painful
range of movement of the spine with negative Schober’s test. Straight leg
raising test were positive in RT lower limb (sciatic nerve root) with positive
lasegue sign, femoral stretch test was negative bilaterally.
On peripheral neurological examination, normal tone, coordination and
reflexes with no clonus. I noticed decreased sensation over anterolateral part
of the leg and dorsum of the foot for both light touch and pin prick and on
testing motor power which is normal except for big toe extension which is
weak.
MY provisional diagnosis is L5 nerve root involvement due to L4/L5 nerve root.
Also, I have to consider: -
1. spinal canal stenosis
2. Diabetes Mellitus (peripheral neuropathy)
3. Vitamin B12 deficiency (subacute combined degeneration of the cord)
4. Drug therapy (e.g. anti-retroviral, thalidomide, phenytoin)
5. Heavy metal/chemical exposure (lead, arsenic, mercury)
6. Carcinoma (most likely spinal metastases)
7. Tabes dorsalis (syphilitics myelopathy).
Questions
Imaging:
x ray on lumbosacral spine (anteroposterior and latera; view).
MRI of lumbosacral spine.
Treatment:
Conservative.
Surgical: discectomy, laminectomy.
25 | P a g e
I examined this patient presented low back pain
Look
Gait Normal gait, +/- walking aid

Spine No shoulder asymmetry,
inspection No abnormal curvatures
No scars, deformities, muscle wasting or abnormal hair.
Feel
tenderness There is lower back tenderness

No tender paraspinal muscles or sacroiliac joints
Move
Range of Painful range of movement in flexion, extension or

motion lateral flexion
Schober test No limitation in forward flexion
Special tests
Straight leg Positive on affected side

raising test and
Lasegue test
Femoral Negative bilaterally
stretch test
Peripheral Lower limb neurological examination
Power All are normal except weak big toe extension

Sensory Decreased sensations over anterolateral part of leg
and dorsum of foot for both light touch and pin prick
Reflexes Normal reflexes
Tone Normal tone, no clonus
Coordination Normal co-ordination
26 | P a g e
Foot drop Examination

Stem: examine this patient present numbness after radio-frequency ablation for
right lower limb varicose veins.
Patient Type: actor.
Patient position: standing then lying on the couch.
Patient Exposure: patient will be wearing his shorts. (lower limbs)
Provisional diagnosis: Common peroneal nerve injury.
Positive Finding: High steppage gait with difficulty in heel walking, there is stab
avulsion scar over the leg, Tinel sign is negative, decreased sensations over
anterolateral part of leg and dorsum of foot for both light touch and pin prick
sensations, weak ankle dorsiflexion and eversion.
27 | P a g e

1.Inspection
A. Gait: (gait, walking on heels and walking on toes).
B. Walking aid: crutches.
C. scars, swelling, wasting and deformities.
2. palpation:
A. Temperature.
B. Tenderness (course of common peroneal nerve).
C. masses in popliteal fossa.
D. Tinel sign.
3.sensation (pin brick and light touch).
4.Motor power.
5. Coordination.
6.Reflexes (knee and ankle reflexes).
7. Tone (leg lift and leg roll) and clonus.
Only During Inspection PATIENT WILL BE

STANDING.
FROM 2 TO 7 PATIENT WILL BE LYING ON THE
BED.
28 | P a g e
Wash your hands.
Today I’ve been asked to examine your legs that would include looking feeling
and moving your legs, are you OK with this?
Would you please walk a few steps for me toward the wall?
Would you please turn around and try to walk over your heels?
Would you please walk over the tips of your toes?
(gait inspection, walk on heels L5, walking on toes S1).
him)
Do you mind If I examined you from the back?
Would you please turn around for me, I will take a close to your knees?
(inspect popliteal fossa for the presence of popliteal masses also from the
sides and front for scars, swelling, fasciculation or deformities)
Would you please lie down on the bed?
Now, I am going to feel your legs, do you have any pain at the moment?
(using the dorsum of both hands to feel temperature from downward upward)
(start palpation for tenderness along the course of the common peroneal
nerve). (positive tenderness)
(palpate popliteal fossa for the presence of any masses)
Now, I am going to tap and please tell me if you feel needles or pin like
sensation?
29 | P a g e
(Tinel’s sign (lightly tap over the nerve at the fibular head; tingling or “
pins and needles” in the nerve distribution indicates a lesion here)
(positive Tinel sign)
Now, I am going to test your sensations, do you feel this? (touch him in the
arm or chest)
Would you please close your eyes and say yes, every time you feel this?
(Sensation, test for sensation both light touch (dorsal column) using cotton
and pin prick for spinothalamic tract in contralateral side in comparison to the
ipsilateral side, S1 above lateral malleolus, L5 dorsum of foot, L4 above medial
malleolus, L3,2,1 anterior surface of the thigh).
(decreased sensation over the dorsum of the foot and anterolateral surface of
the leg)
Now, I am going to put my hand below your knee and I need to stop me from
lifting your legs off the bed. ((hip extension) (L4, L5))
Would you please raise your leg off the bed & stop me from pushing it down?
((hip flexion) (L2, L3))
Would you please, bend your knee & stop me from straightening it? (knee
Flexion (L5, S1)).
Would you please, would you please, straighten your knee against my hand?
(knee extension (L3, L4)).
Would you please, press against my hand with the sole of your foot?
Would you please, point your foot towards your head & don’t let me push it
down? (dorsiflexion (L4, L5))
Would you please, point your big toe towards your head? Then don’t let me
push it down? (hallux extension (L 5))
(muscle power, do the same for the contralateral side in comparison to the
ipsilateral side.)
(weak ankle dorsiflexion and eversion)
30 | P a g e
motion
(Co-ordination Heel to chin).
Now I am going to test your reflexes.
Now I am going to move your ankle.
(clonus, Position the patient’s leg so that the knee and ankle are 90o flexed,
rapidly dorsiflex & partially evert the foot, keep the foot in this position, do
the same for the other side, Clonus is felt as rhythmical beats of
dorsiflexion/plantarflexion (>5 is abnormal)).
Wash your hands.
31 | P a g e
32 | P a g e
coordination
33 | P a g e
Presentation
To complete my examination, I would like to perform spine, hip and knee
examination.
Today I have examined this gentleman who present with foot numbness, I
noticed high steppage gait with difficulty in heel walking, there is stab avulsion
scar over the leg, Tinel sign is positive, tenderness among the course of common
peroneal nerve, decreased sensations over anterolateral part of leg and dorsum
of foot for both light touch and pin prick sensations, weak ankle dorsiflexion and
eversion and , normal tone, coordination and reflexes with no clonus
MY provisional diagnosis is Common peroneal nerve injury.
Also, I have to consider Sciatic nerve injury, L4, L5 disc herniation, central
causes and other causes like DM, vit. B12 deficiency, alcohol misuse.
Questions
Foot drop causes:
1- Common peroneal nerve injury: (in this case may be due to radio-frequency
ablation, fracture head, neck of fibula, prolonged tight plaster cast, fracture
dislocation of the knee)
weakness of foot dorsiflexion (tibialis anterior muscle),
Weakness in toe extension (extensor digitorum longus muscle and extensor
hallucis longus muscle),
Weakness in foot eversion (peroneus longus and brevis muscles),
sensory loss in dorsum of foot.
sensory loss of the anterolateral aspect of the lower leg
2- Sciatic nerve injury involving common peroneal division (fracture dislocation
of the hip, fracture femur,
3- L4, L5 disc herniation with L5 nerve root compression
(weak hip abduction)
4- Central causes (motor neuron disease, multiple sclerosis, stroke, brain
tumors, or Parkinsonism)
34 | P a g e
positive Babinski sign, hyperactive tendon reflexes

5- Other causes: DM, vit. B12 deficiency, alcohol misuse.
Investigations
1- Electrodiagnostic studies (EMG/NCS)
2- MRI lumbar spine
3- Blood analysis for a possible metabolic cause like diabetes or alcoholism
Treatment
1- consider an ankle foot orthosis to support the foot while walking and to
reduce risk of falling.
2- Consider physiotherapy for specific muscle training if weakness is severe.
3- Surgical treatment:
exploration, decompression or repair
Tendon transfer
35 | P a g e
I examined this patient presented by foot drop
On inspection (walking & standing)
Gait High steppage gait with difficulty in heel walking.

Scar There is stab avulsion scar over the leg.
Muscle No muscle wasting or fasciculations.
Swelling No swelling.
On palpation (lying on bed)
Tenderness There is tenderness over the course of common

peroneal nerve.
Swelling in No swelling in popliteal fossa.
popliteal fossa
Tinel sign Tinel sign is positive.
Peripheral LL neurological examination
Power All are normal except weak ankle dorsiflexion and

eversion.
Sensory Decreased sensations over anterolateral part of leg
and dorsum of foot for both light touch and pin prick
sensations.
Reflexes Normal reflexes.
Tone Normal tone, no clonus.
Coordination Normal co-ordination.
36 | P a g e
Hip Examination
Stem: examine this patient present with hip pain.
Patient Type: real patient or actor.
Patient Exposure: patient will keep only his shorts. (trunk and both legs).
Provisional diagnosis: LT hip osteoarthritis, RT superior gluteal nerve injury.
Positive Finding: Trendelenburg gait, positive Trendelenburg sign (when the
patient stands on RT leg only, LT side of the pelvis sags down and trunk lurch to
the RT side ), scar over RT hip joint, positive Thomas test (fixed flexion deformity
of LT hip), Limited range of motion of both hips, leg length discrepancy 4cm of
femoral origin (positive Galeazzi test) and supra-trochanteric origin.

In any joint examination; you have to examine the
joint below and joint above to complete your
examination.
37 | P a g e

1.inspection (Front, sides and back).
2.Gait. (Trendelenburg gait).
3. Trendelenburg sign.
4.Palpation: (temperature, pulse and tenderness).
5.Thomas test.
6.Movement (active flexion, abduction and adduction on both sides).
(Passive IR, ER, abduction, adduction on both sides, extension on
RT side).
7.LLD
A. measure apparent LLD.
B. measure true LLD.
C. perform Galeazzi test.
D. measure subtrochanteric distance.
FROM 1 TO 3 PATIENT WILL BE STANDING.

FROM 4 TO 7 PATIENT WILL BE LYING ON THE BED.
38 | P a g e
Wash your hands.
Today I’ve been asked to examine your pelvis and legs that would include
looking feeling and moving your hips and legs, are you OK with this?
I will start by taking a close look to your hips.
(Inspection for scars, wasting, swelling or deformities)
Would you please turn to RT side?
(Note scar over RT hip)
Would you please turn to LT side?
Do you mind if I examined you from the back?
Would please turn around for me, and roll up your shorts.
(inspect for gluteal muscles wasting)
Would you please walk few steps for me toward the wall?
Would you please turn and walk toward me?
(Gait, note Trendelenburg gait)
him)
Now, I need you to put your hands over my elbow, and I will support you don’t
worry.
Now I need you to stand using only your RT leg.
(Trendelenburg sign (when the patient stands on RT leg only, LT side of the
pelvis sags down and trunk lurch to the RT side) (sound side sags).
39 | P a g e
(Non operated side or side without scar will sag).

Now I need you to stand using only your LT leg.
May you please lie down on the bed?
Now, I am going to feel your legs and hips.
(Temperature, use dorsum of both hands to feel temperature from feet
toward hip)
Now I am going to feel your pulse.
(Feel femoral pulse on both sides)
Would you please push against my hand?
(put your hand medial to your patient knee, ask him to push against your
hand (adduct) to make adductor muscle more prominent and follow the
muscle to reach adductor tubercle then palpate inguinal ligament then ASIS
then greater trochanter)
(repeat palpation in the other side)
(be careful during palpation in the operated side RT one)
(during palpation look to the patient face to notice tenderness)
(Palpation for tender bony prominences, muscles or ligaments)
Now, I am going to put my LT hand behind your back, and I need you to bring
both knees toward your chest.
Would you please straighten your RT leg?
Now, I need you bring your RT knee again toward your chest and straighten
only your LT leg.
(Thomas test for fixed flexion deformity (it means that the patient cannot
extend his hip), note that Thomas test will be positive on the LT side due to
osteoarthritis).
(During Thomas test put your LT hand behind the patient spine to make sure
that lordosis disappeared as it compensates for flexion deformity and with
your RT hand support both knees toward patient chest).
(Fixed flexion deformity occurs in OA hip due to tight iliopsoas muscle).
40 | P a g e
Thank you, you can straighten both legs now.

Now I need you to bring your Rt knee only toward your chest.
Straighten it please
(movement; active flexion and extension)
Would you do the same for the LT one also.
Now, I will move your hips. Do you have any pain at the moment?
(passive flexion, extension, IR and ER)
Would you please bring RT leg out of the bed?
Thank you, you can relax now, would you please do the same for the LT leg?
Would you please bring your RT leg inward to cross the LT leg?
Thank you, you can relax now, would you please do the same for the other leg?
Now I will move.
(active and passive abduction and adduction)
(During passive adduction and abduction, support the pelvis by putting your
LT hand over symphysis pubis)
Would you please lie on your LT side, I will straighten your RT hip?
(passive extension in RT side only as LT side has fixed flexion deformity and
the patient cannot extend his hip).
Thank you, would you please lie down again on your back?
Now, I will make some measurement.
(make sure the trunk and legs are in the same line and correct pelvic tilt if
present then put both two medial malleoli together and notice if there is one
malleoli is higher than the other, if present then measure apparent and True
LLD and perform Galeazzi test and measure subtrochanteric distance from
greater trochanter to tibial tubercle)
(Apparent leg length discrepancy LLD: from xiphisternum or umbilicus to
medial malleolus both RT and LT side, True LLD from ASIS to medial malleolus
both RT or LT)
41 | P a g e
(Galeazzi test: ask the patient to flex both knees and make sure that both
malleoli are together then inspect the position of both knees from front and
side, you will notice short femur from the side as long femur will be in front
short one) LLD will be femoral.
(last step, measure distance from greater trochanter to tibial tubercle and
compare both RT and LT side, they will be equal it means that LLD is supra
trochanteric origin).
(there will be LLD only if the patient is real)
Wash your hands.
42 | P a g e
Galeazzi test
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Trendelenburg sign
44 | P a g e
Presentation
To complete my examination, I would like to perform complete neurovascular
examination of both lower limbs and examine spine and both knees.
Today I have examined this gentleman presented with hip pain, I kept patients
shorts for the patient dignity. (exposure should be from umbilicus to feet)
I noticed a scar over RT hip joint indicates previous surgery and patient exhibited
Trendelenburg gait and positive Trendelenburg sign as the patient stands on RT
leg only, LT side of the pelvis sags down and trunk lurch to the RT side.
On palpation, I noticed tender anterior aspect of LT hip. Thomas test were
positive on the LT side means fixed flexion deformity and range of motion were
limited on both sides and leg length discrepancy 4cm of femoral origin (positive
Galeazzi test) and supra-trochanteric origin (if the patient is real).
My main differential diagnosis is LT hip osteoarthritis, RT superior gluteal nerve
injury.
Also, I have to consider rheumatoid arthritis, pseudogout, gout, inflammatory or
infective arthritis and a reactive arthritis.
Q: How would you investigate and manage this patient?

I would take routine bloods, paying particular attention to raised inflammatory
markers, which would alert me to possible infection, and order hip and knee X-
rays. If required an MRI of the affected joint could also be ordered but may be
unnecessary.
If this patient had osteoarthritis then management is aimed at alleviating pain
and improving the patient’s functional status.
Non-operative measures include weight loss, exercise, physical and
occupational therapy. Simple analgesia such as regular paracetamol and prn
NSAID can be prescribed. More invasive measures such as a corticosteroid
injection can be considered, but ultimately the patient may need surgery in the
form of an arthroplasty.
45 | P a g e
I examined this patient presented with hip pain
Look
Gait Trendelenburg gait, +/- walking aid

Skin No erythema, (+ scar on lateral side for previous
Muscle operation)
No muscle wasting
Swelling No swelling
Asymmetry No pelvic tilt
Deformity No visible deformity
Trendelenburg Positive Trendelenburg test (sagging of non-operated
test side)
Feel
Temperature Normal skin temperature
Tenderness No tenderness (+/- tender anterior part of OA side)
Effusion No effusion
Leg length Equal bilateral leg length if actor.
discrepancy If real patient leg length discrepancy 4cm of femoral
origin (positive Galeazzi test) and supra-
trochanteric origin.
Thomas test Positive on non-operated side (fixed flexion
deformity)
move
No limitation of movement (extension in OA side not done due to fixed
flexion deformity.
46 | P a g e
Knee Examination
Stem1: examine this patient present with knee pain.
Stem 2: examine this patient present with knee pain after playing football.
Osteoarthritis knee Sport injury
old young
Real patient actor
Patient Type: real patient in (Osteoarthritis knee) or actor in (. Lateral

meniscus and lateral collateral tear or Medial meniscus tear).
Patient Exposure: patient will keep his shorts.
Provisional diagnosis: Osteoarthritis knee or (Lateral meniscus and lateral
collateral tear or Medial meniscus tear).
Positive Finding: three scenarios.
In Osteoarthritis knee: limited range of motion especially flexion, crepitus and
antalgic gait.
In Sport injury either:
1. Lateral meniscus and lateral collateral tear: Antalgic gait, tender later aspect
of the knee, limited range of motion (locking) positive McMurray test for
lateral meniscus and positive varus stress test for lateral collateral ligament.
2. Medial meniscus tear: Antalgic gait, tender medial aspect of the knee,
limited range of motion (locking) and Positive McMurray test for medial
meniscus.

examination.
47 | P a g e

1.Inspection (front, side and back) (standing)
A. Walking aids.
B. Gait.
C. Scars, deformities, swelling and wasting.
2. Palpation. (lying down till the end for the exam)
A. Tenderness.
B. Temperature.
C. Popliteal pulse and popliteal fossa for masses.
D. Effusion.
A. patella tab test.
B. Bulge test.
E. Quadriceps circumference.
3. Movement.
A. Active.
B. Passive.
4. Special Tests.
A. Posterior sag sign.
B. Anterior Drawer test.
C. Posterior Drawer test.
D. Valgus stress test.
E. Varus stress test.
F. MacMurray’s test.
48 | P a g e
TIPS
1.Sport injury patient could refuse to walk because of the pain, don’t force him
to walk and offer analgesia and inform the examiner during presentation you
couldn’t test the gait because the patient is in pain.
2.During performing passive range of movement and special tests: tell the
patient that you will be gentle with him, if the patient agonizing in pain
because of your movement, don’t proceed with the test and consider that test
positive (because examiner could cancel the exam) and apologize to the
patient and offer analgesia.
49 | P a g e
Wash your hands.
Today I’ve been asked to examine your knees and legs that would include
looking feeling and moving your knees and legs, are you OK with this?
I will start by taking a close look to your knees.
Would please turn around for me.
(inspect for Backers cyst)
(sport injury patient could refuse to walk because of the pain, don’t force him
to walk and offer analgesia and inform the examiner during presentation you
couldn’t test the gait because the patient is in pain)
(antalgic gait in osteoarthritis and sport injury patients).
Could you please lie down on the bed?
Now I am going to feel your legs, do you have any pain at the moment?
Could you please, point to the site of the pain?
I am so sorry for that; I am going to be gentle with you?
(Palpation for temperature, tenderness, pulsation, effusion and quadriceps
circumference).
(Do the same for the other knee).
50 | P a g e
(feel the temperature with the dorsum of both hands starting of feet toward
the level above the knee)
(start bimanual palpation (bony prominences) starting from chin of tibia, tibial
tubercle, medial, lateral, superior and inferior borders of patella, medial and
lateral femoral and tibial condyles, head of fibula and joint line for tenderness)
(Also palpate patellar, quadriceps tendon and collateral ligaments for
tenderness)
(Popliteal fossa – feel for any obvious collection of fluid (e.g. a Baker’s cyst))
Now I am going to feel your pulse? Would you please bend you knee?
(feel the popliteal pulse with knee flexed 15 degrees and both thumbs over
the anterior surface of patella and rest of fingers are behind the knee).
(then perform patella tab test for large effusion: Empty the suprapatellar
pouch by sliding your left hand down the thigh to the patella. Keep your left
hand in position and use your right hand to press downwards on the patella
with your fingertips. If fluid is present you will feel a distinct tap as the patella
bumps against the femur.)
(If patella tab test is negative, perform Bulge test for small effusion: Empty the
suprapatellar pouch with one hand whilst also emptying the medial side of the
joint using an upwards wiping motion. Now release your hands and do a
similar wiping motion downwards on the lateral side of the joint. Watch for a
bulge or ripple on the medial side of the joint. The appearance of a bulge or
ripple on the medial side of the joint suggests the presence of an effusion).
Now, I am going to make some measurements.
(Measure quadriceps circumference ten 10 cm above patella and compare
both sides for the presence of quadriceps muscle atrophy).
Would you please your knee as possible as you can?
Would you please straighten your knee as possible as you can?
Now, I am going to move your knee and I am going to be gentle with you sir?
(Range of movement passive and active and feel crepitus).
(In Osteoarthritis knee: limited range of motion, crepitus).
(In sport injury: limited range of motion (locking))
51 | P a g e
(Perform special tests; Anterior and posterior Drawer tests, Lachman’s test
Valgus stress test, Varus stress test and MacMurray’s test)
(Do the same for the other knee).
(MacMurray’s test for medial and lateral menisci)

(To test the medial meniscus, the examiner palpates the postero-medial
aspect of the knee while extending the knee and externally rotating the tibia.
To test the lateral meniscus, the examiner palpates the postero-lateral joint
line while extending the knee and internally rotating the tibia.
If pain is felt by the subject or if a ‘click’ is felt by the subject or examiner, the
test is considered positive).
(Varus stress test for lateral collateral ligament)

(Extend the patient’s knee fully, hold the patient’s ankle between your elbow
and side, place your right hand along the medial aspect of the knee, place your
left hand on the lower limb (e.g. calf or ankle), push steadily outward with your
right hand whilst supplying an opposite force with the left, if the LCL is
damaged your hand should detect the lateral aspect of the joint opening up).
(If after this assessment the knee appears stable you can further assess the
collateral ligaments by repeating this test with the knee flexed at 30°. At this
position the cruciate ligament is not taught so minor collateral ligament laxity
can be more easily detected).
(Valgus stress test for medial collateral ligament)

(Extend the patient’s knee fully, hold the patient’s ankle between your elbow
and side, place your right hand along the lateral aspect of the knee, place your
left hand on the lower limb (e.g. calf or ankle), push steadily inward with your
right hand whilst supplying an opposite force with the left).
(If the MCL is damaged your hand should detect the medial aspect of the joint
opening up.
(If after this assessment the knee appears stable you can further assess the
collateral ligaments by repeating this test with the knee flexed at 30°. At this
position the cruciate ligament is not taught so minor collateral ligament laxity
can be more easily detected).
52 | P a g e
(Lachman’s test for anterior cruciate ligament)

The knee is flexed at 20–30 degrees with the patient supine, the examiner
should place one hand behind the tibia and the other grasping the patient’s
thigh, it is important that the examiner’s thumb be on the tibial tuberosity, the
tibia is pulled forward to assess the amount of anterior motion of the tibia in
comparison to the femur).
(Anterior and posterior Drawer tests for anterior and posterior

cruciate ligaments) and posterior sag sign for (posterior cruciate
ligament).
(flex the patient’s knee to 90º, inspect for evidence of posterior sag as this can
give a false positive anterior drawer sign, wrap your hands around the
proximal tibia with your fingers around the back of the knee, rest your
forearm down the patient’s lower leg to fix its position, position your thumbs
over the tibial tuberosity, ask the patient to keep their legs as relaxed as
possible (tense hamstrings can mask pathology), pull the tibia anteriorly –
significant movement suggests anterior cruciate laxity /rupture, push the tibia
posteriorly – significant movement suggests posterior cruciate laxity
/rupture).
(During performing passive range of movement and special test : tell the
patient that you will be gentle with him, if the patient agonizing in pain
because of your movement, don’t proceed with the test and consider that test
positive( because examiner could cancel the exam) and apologize to the
patient and offer analgesia).
(1. Lateral meniscus and lateral collateral tear: positive McMurray test for
lateral meniscus and positive varus stress test for lateral collateral ligament.
2. Medial meniscus tear: Positive McMurray test for medial meniscus).
Thank you, sir, you may dress now, do you need any help? Wash your hands.
Posterior Sag sign
53 | P a g e
patella tab test
54 | P a g e
55 | P a g e
Presentation
To complete my examination, I would like to perform hip and ankle examination
and complete neurovascular examination of both lower limbs.
First scenario
Today I have examined this gentleman presented with knee pain. Patient
exhibited antalgic gait and on closer inspection to his knees, I did not notice
scars, swelling, deformities, muscle wasting or effusion.
On palpation, temperature, popliteal pulse and quadriceps circumference were
equal bilaterally with negative patella tap and bulge tests.
Regarding range of motion, both active and passive motion were limited
especially flexion with crepitus.
Anterior and posterior Drawer tests, Lachman’s test Valgus stress test, Varus
stress test and MacMurray’s test were negative.
My main differential diagnosis is osteoarthritis knee.
Also, I have to consider rheumatoid arthritis, pseudogout, gout, inflammatory or
infective arthritis and a reactive arthritis.
Second scenario
To complete my examination, I would like to perform hip and ankle examination
and complete neurovascular examination of both lower limbs and examine
patient knee under general anesthesia.
Today I have examined this gentleman presented with knee pain after sport
injury. Patient exhibited antalgic gait (or I could not assess the gait as the patient
could not walk) and on closer inspection to his knees, I did not notice scars,
swelling, deformities, muscle wasting or effusion.
On palpation, temperature, popliteal pulse and quadriceps circumference were
equal bilaterally with negative patella tap and bulge test with tender lateral
aspect of RT knee.
Regarding range of motion of RT knee, both active and passive motion were
limited especially extension (locked), with normal range of motion of LT knee
Varus stress test and MacMurray’s test for lateral meniscus of RT knee were
positive while anterior and posterior Drawer tests, Lachman’s test Valgus stress
56 | P a g e
test, and MacMurray’s test for medial meniscus were negative and also negative
special tests of LT knee.
My main differential diagnosis is lateral meniscus and lateral collateral ligament
tear of RT knee.
Also, I have to consider Medial collateral ligament tear, Cruciate ligament
injuries, bony injuries or Combination injuries.
Third scenario
Medial meniscus tear.
Questions
If sport man has knee pain 25 years later?
Post traumatic osteoarthritis.
What investigations would you perform?
A: Initially I would arrange a weight bearing X-ray of the knee; however, the most
important investigation would be a knee MRI.
What to look for in MRI in meniscal tear?
Increased internal signal intensity in the meniscus or abnormal meniscus shape.
Management of meniscus tear?
Nonoperative treatments:
Rest (with weight bearing as tolerated or with crutches), ice, compression
bandaging, elevation of the affected limb to minimize acute swelling and
inflammation.
Operative:
Arthroscopic repair or partial meniscectomy.
X ray of osteoarthritis knee?
There are four main radiographic signs in osteoarthritis:
1-Narrowing of the joint space.
2-Subchondral sclerosis.
3-Cyst formation.
57 | P a g e
4-Osetophyte formation.
Q: How is osteoarthritis of the knee managed?
A: Conservative
Maintain or achieve a healthy weight i.e. aim to decrease weight, and therefore
force, going through a joint, regular exercise, with particular attention to
strengthening the muscles around the joint. For example, in OA of the knee,
cycling is beneficial, analgesia: care to be taken with NSAID’s with relation to
gastric irritation, heat application to the joint may offer relief, Physiotherapy and
Intra-articular steroids.
B: Surgical
Arthroscopy and arthrocentesis.
Realignment osteotomy.
Total or partial knee replacement.
58 | P a g e
I examined this patient presented with knee pain

look
Gait +/- walking aid & antalgic gait or I could not assess
the gait as the patient could not walk.
Skin No scars or erythema.
Muscle No muscle wasting.
Swelling No swelling, effusion, bursae or baker cyst.
(including back)
Asymmetry No asymmetry.
Deformity No visible deformity.
Feel
Temperature Normal skin temperature.
Tenderness Tender lateral aspect of joint in scenario two and
Tender lateral aspect of joint in scenario three.
Effusion No effusion.
Quadriceps Equal quadriceps circumference bilaterally.
circumference
Move
Range of motion (limited ROM and crepitus in OA), (limited ROM
extension “locking” in in scenario two and three).
Hyperextension No hyperextension.
Special Tests
Cruciate Intact anterior and posterior cruciate ligaments
ligaments
Collateral Intact bilaterally in OA knee, (positive varus stress

ligaments test in scenario two).
Menisci No meniscal injury in OA knee, (positive McMurray
test in meniscal injury in scenario two and three).
59 | P a g e
Ankle Examination
Stem: examine this patient present with ankle pain.
Patient position: sitting on the bed.
Patient Exposure: knee to feet.
Provisional diagnosis: ankle sprain (calcaneofibular ligament tear).
Positive Finding: Antalgic gait, tender lateral aspect of ankle joint, painful
limited range of motion, positive talar tilt test for calcaneofibular ligament.

examination.
60 | P a g e

1.Inspection (front, and back) sitting and walking
A. Walking aids.
B. Gait.
C. Scars, deformities, swelling and wasting.
2. Palpation (Sitting till the end of the exam)
A. Tenderness and squeeze test.
B. Temperature.
C. pulse.
3. Movement. (planter and dorsiflexion, eversion and inversion)
A. Active.
B. Passive.
4. Special Tests.
A. Talar tilt test,
B. Anterior Drawer test.
C. Simmonds test. (kneeling on the chair with feet hanging off).
.
You can perform ankle examination with patient

either sitting or lying down
61 | P a g e
Examination scenario
Wash your hands.
Today I’ve been asked to examine your ankles and legs that would include
looking feeling and moving your ankles and legs, are you OK with this?
I will start by taking a close look to your ankles.
(inspect the ankle from behind)
(antalgic gait no heel strike)
Could you please have a seat again?
Could you please, point to the site of the pain?
I am so sorry for that; I am going to be gentle with you and please tell me if you
have any pain to stop?
(Palpation for temperature, tenderness, pulsation),
(Do the same for the other ankle).
(feel the temperature with the dorsum of both hands starting of feet toward
the level of the knee)
(start bimanual palpation (bony prominences) starting from chin of tibia, head
of fibula, medial and lateral malleoli, joint line metatarsal bone and toes and
perform squeeze test for metatarsal heads and observe patient’s face for
discomfort)
62 | P a g e
(Also, palpate tendoachilis tendon, medial and lateral collateral ligaments for
tenderness)
(Feel the dorsalis pedis pulse on both feet).
Would you please push your feet downwards, like pushing a car pedal?
(plantarflexion)
Would you please point your feet towards your head?
(dorsiflexion)
Would you please point the soles of your feet toward each other?
(Inversion)
Would you please point the soles of your feet away from each other?
(Eversion)
Now, I will move your ankle and I will be gentle with you please tell me if you
have any pain to stop?
(painful limited range of movement)
(After assessment of passive movement, assess active movement and perform
special tests).
(perform talar tilt test and the anterior drawer test of the ankle).
(Anterior drawer test of the ankle assesses the integrity of the

anterior talofibular ligament (ATFL).
Technique: With the patient sitting and 10° of plantarflexion, stabilize the
tibia, with one hand and cup the heel with the other, apply an anterior force
to the foot.
Positive test: As with the anterior drawer test in the knee, asymmetrical
anterior movement of the hindfoot in relation to the tibia confirms an ATFL
injury).
(Talar tilt test is a lateral ligament stress test and helps identify a deltoid
or calcaneofibular ligament injury.
63 | P a g e
Technique: With the patient sitting with the knee flexed to 90°, a valgus or
varus force is applied across the ankle joint, with one hand cupping the heel
and the other the tibia.
Positive test:
Asymmetrical opening up in valgus stress indicates a deltoid or medial
ligament injury.
Asymmetrical opening up in varus stress indicates:
ATFL injury: if with planter flexion.
CFL injury: if with neutral ankle.
PTFL injury: if with dorsi flexion).
(Positive talar tilt test in neutral position (CFL injury), negative anterior drawer
test).
Would you mind if I examined you from the back?
Would you please, kneel on a chair with your feet hanging off the edge?
Now I am doing to squeeze your calf?
(Simmonds’ test used to assess for rupture of the Achilles tendon.

Normally the foot should plantarflex. If the Achilles tendon is ruptured there
will be no movement of the foot).
(intact Achilles tendon).
(perform special tests for both ankles).
Wash your hands.
64 | P a g e
65 | P a g e
Presentation
To complete my examination, I would like to perform knee examination and full
neurovascular examination of both lower limbs
Today, I have examined this gentleman presented with ankle pain, Patient
exhibited antalgic gait and on closer inspection to his ankles, I did not notice
scars, swelling, deformities, muscle wasting or effusion.
On palpation, temperature and dorsalis pulse were equal bilaterally with tender
lateral aspect of RT ankle.
Regarding range of motion of RT ankle, both active and passive motion were
limited and painful with normal range of motion of LT ankle.
Talar tilt test was positive when ankle is neutral on the Rt ankle, anterior drawer
test was negative and tendoachilis was intact and confirmed using Simmonds
test.
My main differential diagnosis is calcaneofibular ligament tear (ankle sprain) of
RT ankle.
Also, I have to consider Fracture lateral malleolus, base of fifth metatarsal,
cuboid, cuneiforms or Combination injuries.
Questions
Investigation?
X-ray on ankle joint (AP lateral and mortise view)
MRI ankle.
Treatment?
Conservative
Mild: Rest, ice, elevation to reduce edema and bandage.
Moderate to severe: Back slab, non-weight bearing.
IF X-ray showed undisplaced fracture of fibula with swelling of the ankle?
Back slab, non-weight bearing, analgesia, Rest, ice, elevation to reduce edema
66 | P a g e
I examined this patient presented with ankle pain

Look
Gait antalgic gait & +/- walking aid.

Skin No scars or erythema.
Muscle No muscle wasting.
Swelling No swelling, effusion.
Asymmetry No asymmetry.
Deformity No visible deformity.
Feel
Temperature Normal skin temperature.
Tenderness Tender lateral aspect of ankle joint.
Pulse Intact equal pulse.
Move
Limited ROM in active and passive movements
Special Tests
Simmonds test Intact Achilles tendon.
Anterior Intact ATFL.
drawer test
Talar tilt test Intact deltoid ligament, possible injury to
calcaneofibular ligament.
67 | P a g e
Hand Examination
Stem: examine this patient present with hand pain.
Patient position: sitting on a chair and putting his hands on a pillow.
Patient Exposure: hands up to elbow.
Provisional diagnosis: carpal tunnel syndrome.
Positive Finding: Paresthesia over radial three and half fingers, positive Phalen
test and Positive Tinel sign.
(weakness of the median-innervated hand muscles (LOAF muscles) could
be positive)

examination.
68 | P a g e
Order of items of hand examination

1.Inspection (dorsum and palm of hands and elbows).
Scars, swelling, deformities, skin changes, muscle wasting or nail changes.
2. Palpation
A. Temperature.
B. Radial and ulnar pulses.
C. Tenderness and squeeze test.
D. Bimanual examination of wrist, metacarpal bones, carpal bone, DIP, PIP,
MPJ and snuff box
E. Ulnar border of elbow from elbow to hand for the presence of rheumatic
nodules.
3. Movement.
1. (wrist, fingers and thumb)
A. Active.
B. Passive.
2. FDP and FDS and extensor of each finger.
3. extensor and flexor of thumb.
4. Hand function.
A. Power grip,
B. Pincer grip.
C. Precession grip.
5. Neurological examination (sensory, motor, special tests).
A. Median (Tinel and Phalen tests).
B. Ulnar (Froment’s sign).
C. Radial.
D. Anterior interosseous.
69 | P a g e
Wash your hands.
Today I’ve been asked to examine your hands that would include looking feeling
and moving your hands, are you OK with this?
Would you roll up your sleeves and put your hands on this pillow please?
I will start by taking a close look to your hands.
Would you please turn around your hands?
Would you please bend your elbows so I can have a look to your elbows?
(inspection of dorsum and palm of hands and elbows for scars, swelling,
deformities, skin changes, muscle wasting or nail changes)
(detailed inspection)
Dorsum
Inspect hand posture – asymmetry / abnormalities
Scars or swellings
Skin color:
Erythema – e.g. cellulitis (erythema) / palmar erythema
Pallor – e.g. peripheral vascular disease / anemia
Deformities:
Bouchard’s nodes (PIP) / Heberden’s nodes (DIP) – OA
Swan neck deformity – distal interphalangeal (DIP) joint hyperflexion with
proximal interphalangeal (PIP) joint hyperextension – RA
Z-thumb – hyperextension of the interphalangeal joint, in addition to fixed
flexion and subluxation of the metacarpophalangeal (MCP) joint – RA
Boutonnieres deformity – PIP flexion with DIP hyperextension – RA
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Nail changes:
Nailfold vasculitis – small areas of infarction
Pitting and onycholysis – associated with psoriasis
Palms:
Inspect hand posture – asymmetry / abnormalities (e.g. clawed hand)
Scars – e.g. carpal tunnel release surgery
Swellings
Skin color:
Erythema – e.g. cellulitis (erythema) / palmar erythema
Pallor – e.g. peripheral vascular disease / anemia
Deformity – Dupuytren’s contracture
Thenar/ hypothenar wasting – isolated wasting of the thenar eminence is
suggestive of carpal tunnel
syndrome.
Elbows – psoriatic plaques or rheumatoid nodules.

Now I am going to feel your hands and elbows, do you feel any pain at the
moment, please tell me if you have?
(Palpation for temperature, tenderness, pulsation)
Feel temperature using dorsum of both hands.
Feel both radial and ulnar pulses.
Feel for the presence of rheumatic nodules on the ulnar border of elbow from
elbow to hand.
Bimanual examination of wrist, metacarpal bones, carpal bone, DIP, PIP, MPJ
and snuff box for tenderness.
Squeeze test for the head of metacarpals if positive inflammatory arthropathy.
Would you please make a fist for me?
Would you please splay your fingers?
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Would you please put the palms of your hands together to straighten your wrist?
Would please put the back of both hands together to bend your wrist?
Would you please do as I do please?
(thumb flexion, extension abduction, adduction and opposition)
Now I am going to move your hands and elbows? Do you have any pain at the
moment?
(Active and passive movement of wrist and fingers including flexion and
extension, and thumb flexion, extension abduction, adduction and
opposition).
Now I am going to stabilize you finger and I need you to bend it, OK?
(Test separately for both sets of flexor tendons:
Flexor digitorum profundus: stabilize the PIPJ and ask the patient to flex at the
DIPJ.
Flexor digitorum superficialis, isolate the finger being examined by holding the
other fingers in extension, then ask the patient to flex at the PIPJ).
(Also test extensor of fingers, and extensor and flexor of thumb)
Would you please, squeeze my fingers with your hands?
(Power grip)
Would you please, squeeze my finger between your thumb and index?
(Pincer grip)
can you pick up this small coin out of my hand?
(Precession grip)
Sir, do you feel this? (touch him with cotton wool in the arm)
Now I need you to close your eyes and say yes ever time I touch you.
(Volar aspect of index finger for median, volar tip of little finger for ulnar and
first dorsal web space for radial).
Now, I will tap, do you have any pain at the moment?
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(Tinel’s test is used to identify nerve irritation and is therefore can be useful in
the diagnosis of carpal tunnel syndrome.
The test involves the following: tap over the carpal tunnel and if the patient
develops tingling in the thumb and radial two and a half fingers this is
suggestive of median nerve irritation and compression).
(Positive Tinel sign)
Would you please, push the back of your hands together like this and tell me if
you feel numbness?
(Phalen test: If the h examination findings are suggestive of carpal tunnel
syndrome this test may be used to further support the diagnosis:
Ask the patient to hold their wrist in complete and forced flexion (pushing the
dorsal surfaces of both hands together) for 60 seconds
If the patient’s symptoms of carpal tunnel syndrome are reproduced then the
test is positive (e.g. burning, tingling or numb sensation over the thumb)
(Positive Phalen sign)
Would you please point your thumb toward the ceiling?
(motor function of Median Nerve: test the function of abductor pollicis brevis;
with patient’s palm facing up, stabilize the rest of patient’s hand on the table
and ask them to point with the thumb to the ceiling).
(weakness of the median-innervated hand muscles (LOAF muscles) could
be positive)
Would you please straighten your fingers and wrist against my hand?
(motor function of radial nerve: ask the patient to extend the fingers and wrist
against resistance).
Would you please adduct your finger together against me?
(Palmar interossei –adduct the fingers)
Would you please abduct your fingers against me?
(Dorsal interossei –abduct the fingers)
I need you to grasp this piece of paper between your index finger and the thumb.
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And prevent me from pulling the paper away?

(Ulnar Nerve: Palmar interossei –adduct the fingers
Dorsal interossei –abduct the fingers
Froment’s sign: ask the patient to grasp a piece of paper between the index
finger and the thumb. You then try to pull the paper away. If there is an ulnar
nerve lesion, the distal phalanx of the thumb flexes (due to action of the
unaffected flexor pollicis longus) to compensate for the weak muscle
(adductor pollicis) that is supplied by the ulnar nerve. This is a positive
Froment’s sign)
Now, I need you to make an OK sign like this and I need you to prevent me from
separating your thumb and index.
(motor power of anterior interosseous nerve which supply FPL and FDP of
index finger)
Wash your hands.
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Presentation
To complete my examination, I would like to perform elbow examination and
full neurovascular examination of both upper limbs.
Today I have examined this gentleman hands, I noticed equal temperature,
radial and ulnar pulse of both hands, also intact grip pincer and precession
functions and paresthesia over radial three and half fingers and positive Phalen
test and Positive Tinel sign.
(weakness of the median-innervated hand muscles (LOAF muscles) could be
positive)
My main differential diagnosis is carpal tunnel syndrome, also I have to consider
cervical disc disease and diabetic neuropathy.
Questions
The following have been associated with higher risk of CTS.
1. Increasing age.
2. Female sex.
3. Increased body mass index (BMI).
4. Square-shaped wrist, short stature, dominant hand.
5. Race (white).
6. Strong family susceptibility.
7. Wrist fracture (Colle’s).
8. Acute, severe flexion / extension injury of wrist.
9. Space-occupying lesions within the carpal tunnel (e.g., flexor
tenosynovitis, ganglions, hemorrhage, aneurysms, anomalous muscles,
various tumors, edema).
10.Diabetes.
11.Thyroid disorders (usually myxedema).
12.Rheumatoid arthritis and other inflammatory arthritis of the wrist.
13.Recent menopause (including post-oophorectomy).
14.Renal dialysis.
15.Acromegaly.
16.Amyloidosis.
17.Repeated activity involving severe force and extreme posture of the wrist/
vibrating activity.
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Investigations
Electrophysiologic studies including electromyography (EMG) and nerve
conductions studies (NCS) are the first-line investigations in suggested CTS.
MRI scan can exclude underlying causes in the carpal tunnel.
laboratory: blood glucose, thyroid functions
Treatment
Treatment of underlying disease, if any.
Conservative management of mild to moderate disease (EMG and NCS) includes:
Splinting the wrist at night time for a minimum of three weeks –Steroid injection
into the carpal tunnel –Non-steroidal anti-inflammatory drugs (NSAIDs) and / or
diuretics
Surgical treatment is indicated for severe disease, or when conservative
management fails and includes carpal tunnel release.
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I examined this patient presented hand pain and paresthesia

Look
Skin No scars or erythema

Muscle No muscle wasting
Swelling No swelling
Asymmetry No asymmetry
Deformity No visible deformity
Nails No abnormality
Elbow No visible nodules
Feel
Tenderness No tenderness
Elbow No palpable nodules
Move
No limitation of movement.
Function
Intact power & pincer grip and intact fine functions
Neurological examination of upper limb

Motor Intact motor functions
Sensory Paresthesia over radial three and half fingers
Special tests
Tinel test Positive Tinel sign
Phalen test Positive Phalen test
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Shoulder Examination
Stem: examine this patient present with shoulder pain.
Patient position: standing.
Patient Exposure: trunk and upper limbs.
Provisional diagnosis: 1. Subacromial impingement.
2. Rotator cuff tear
(not sure).
Positive Finding: 1. Positive empty can Test and (Painful Arc) pain with arm
abducted in scapular plane from 60° to 120°.
2.positive test according to the torn muscle.

examination.
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1.Inspection (front, side and back)
(scars, swelling, wasting, deformities and arm sling).
2. Palpation (Sitting till the end of the exam)
A. Tenderness.
B. Temperature.
C. Radial and brachial pulse.
3. Movement. (Flexion, extension, abduction, adduction, internal and
external rotation) and feel crepitus.
A. Active.
B. Passive.
4. Special Tests.
A. Empty Can and painful arc Test for supraspinatus.
B. External rotation against resistance for infraspinatus.
C. External rotation in abduction (Hornblower’s sign) for teres
minor.
D. Internal rotation against resistance (Gerber lift-off test) for
subscapularis.
5.Neurological Examination.
A. Sensory and motor examination for axillary nerve.
B. Motor examination for long thoracic nerve.
Patient will be standing

Examiner will be standing posterior to the
patient in passive movement and special tests
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Wash your hands.
Today I’ve been asked to examine your shoulders that would include looking
feeling and moving your shoulders, are you OK with this?
(Look for the presence of arm sling).
I will start by taking a close look to your shoulders.
(Inspection for scars, wasting, swelling or deformities anteriorly and from
sides)
Would you please turn around so I can take a look?
(inspect the both shoulders from the back)
Now I am going to feel your shoulders and arms, do you have any pain at the
moment?
(Palpation for temperature, tenderness, pulsation)
(palpate temperature using dorsum of hands)
(palpate brachial and radial pulses)
(palpate for tenderness over Steno-clavicular joint, Clavicle, acromio-clavicular
joint, Coracoid process – 2cm inferior and medial to the clavicular tip, Head of
humerus, Greater tuberosity of humerus, Spine of scapula)
Would you please, raise your arms forwards until they point upwards?
(Flexion)
Would you please, keep your arms straight and straighten them behind you?
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(Extension)
Would you please, lift your arms away from their sides as far as possible?
(Abduction)
Would you please, bring your arms across your trunk to the opposite sides?
(Adduction)
Now I need you to hold your elbows to your body flexed at 90° and then move
your forearms outwards in an arc-like motion?
(External rotation)
Would you please, put your hands as far up your back as you can?
(internal rotation)
(or you can assess active movement by telling the patient; (Would you please,
do as I do?) to save time).
Now I will move your shoulder, do you have any pain at the moment? Please tell
me if you have any pain?
(passive movement)
(Ask the patient to fully relax and allow you to move their arm for them. Warn
them that should they experience any pain they should let you know
immediately. Repeat the above movements passively feel for
any crepitus during movement of the joint. Stand behind the patient while
testing passive movement stabilize shoulder with one hand and move arm by
the other arm)
Would you please do as I do? Now I will push your arm down and I
need you to resist me?
(Empty Can test for supraspinatus).
(This test assesses for weakness in the supraspinatus and/or impingement.
Weakness may represent a tear in the supraspinatus or pain due to
impingement)
Now I will raise your arm and I need you to return your arm to neutral
position slowly?
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(painful arc Test for supraspinatus)

(Impingement/supraspinatus tendonitis typically causes pain between 60-
120° of abduction, however this test is not specific as many other conditions
can cause pain in this arc of motion and therefore it should not be used in
isolation for diagnosis)
Would you please move your arm like me?

Now, I need you to move your arm against me.
(External rotation against resistance for infraspinatus)
(Position the patient’s arm with the elbow flexed at 90°and in slight abduction
(the abduction tests whether the patient can keep the arm externally rotated
against gravity and passively externally rotate the arm to its maximum.
Pain on resisted external rotation may suggest infraspinatus tendonitis.
If the arm falls back to internal rotation or there is a loss of power it may
suggest a tear in the infraspinatus tendon or muscle wasting)
Now I am going to move your shoulder, could you keep your shoulder
in this position please?
(External rotation in abduction (Hornblower’s sign) for teres minor).
(Position the arm in 90° of abduction and bend the elbow to 90° and passively
externally rotate the shoulder to its maximum degree. If the patient is unable
to keep the arm in this position (i.e. the arm falls back to internal rotation) this
may represent a positive “Hornblower’s” sign (pathology in the teres minor)
Do you mind if I examine you from the back?

Now I need you to place the dorsum of your hand on your lower back,
could you please move your hand off your back against me?
(Internal rotation against resistance (Gerber lift-off test) for subscapularis)
(Ask the patient to place the dorsum of their hand on their lower back, apply
light resistance to the hand (pressing it towards their back),ask the patient to
move their hand off their back, an inability to do this (loss of power) indicates
pathology of the subscapularis (e.g. tendonitis/tear)).
Do you feel this?
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(touch him with cotton wool and again with neurotome in his chest)
Now I need you to close your eyes and tell me if you feel this?
(test pin prick and light touch in badge area which is supplied by axillary nerve)
Would you please, do as I do?

Now I need you to move your arm against me?
(Motor branch of axillary nerve: Test for abduction from 15-90 degrees)
Would you please push against the wall with your arm straightened?
(Ask the patient to push against a wall with his/her hands outstretched at
chest level. If the scapula is elevated like a wing this suggests damage to the
long thoracic nerve)
Wash your hands.
Active and Passive movement
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Long thoracic nerve
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Presentation
To complete my examination, I would like to examine cervical spine, elbow and
complete neurovascular examination of upper limb.
Today I have examined this gentleman who present with shoulder pain my.
The positive findings are ( not sure).

1. Positive empty can Test and (Painful Arc) pain with arm abducted in scapular
plane from 60° to 120° for subacromial impingement or supraspinatus tendinitis.
2.positive test according to the torn rotator muscle.
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Chronic lower limb Ischemia

Stem: examine this patient present with intermittent claudication.
How could you differntiate between neurological and vascular claudication
while reading the examination stem?
Neurological Vascular
(spine examination) (arterial examination)
Stem (paper written on ABPI done by GP and is (Do ABPI if there is

the door of exam room) normal enough time)
Inside the examination Hammer, cotton wall, Doppler
room, you will find neurotip.
Patient Type: real.

Patient position: Lying on the couch.
Patient Exposure: patient will be wearing his shorts. (from umbilicus to feet)
Provisional diagnosis: atherosclerotic or diabetic peripheral vascular disease.
Positive Finding: By inspection: Skin trophic changes of LT LL suggesting chronic
ischemia, in the form of pale skin especially Lt LL, thin shiny skin, hair loss,
venous guttering of LL. By palpation: Slight decrease in temperature of LL,
delayed capillary refill, Buerger’s angle in LL was 40, with positive Buerger’s test,
all pulses of both LL were palpable except for (dorsalis pedis and posterior tibial
arteries), I used the hand-held doppler for dorsalis pedis & posterior tibial
arteries pulse which revealed dampened monophasic sound. By auscultation:
there was no audible bruits over femoral and iliac arteries, I started to do ABPI
measuring for Lt LL but I couldn’t finish due to time.
Positive findings in chronic lower limb ischemia patient are

tailored according to the patient as the patient is real.
It is normal that you could not finish the examination in six
minutes because it is a long station.
It is a must to train yourself to use doppler in vascular
stations.
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A. General examination (Hands)
(nicotine staining, tendon xanthomata, nail fold infarcts and splinter
hemorrhages, nail changes and skin and hair for changes suggestive of arterial
disease, i.e., thin/shiny skin and hair loss).
(Capillary refilling time and radial pulse).
B. Local examination (Lowe limbs)
1.Inspection.
A. color and hair loss.
B. scars.
C. Venous guttering.
D. Ulcers.
E. signs of chronic venous insufficiency (lipodermatosclerosis, venous
eczema and atrophy blanche).
F. Tissue loss in the form of gangrene or amputation.
G. Deformities like pes cavus, claw toes.
H. atrophic pulp of the toes.
2.Palpation.
A. Temperature.
B. capillary refilling time.
C. Buerger’s angle and test.
D. Pulses (Femoral, popliteal, posterior tibial and dorsalis pedis) and
doppler.
3.Auscultation (iliac and femoral bruits).
4.Ankle brachial Pressure Index.
Patient will be Lying on the couch
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Wash your hands.
and moving your legs, are you OK with this?
I will start by taking a close look to your hands.
(Inspect the hands looking for nicotine staining, tendon xanthomata, nail fold
infarcts and splinter hemorrhages and nail changes)
Now, I am going to feel your pulse.
(Radial pulse and capillary filling time)
I will take a close look to your legs and feet.
(Inspection: Look at the skin and hair for changes suggestive of arterial disease,
i.e., thin/shiny skin and hair loss ,Look at the legs for Color of the legs do they
appear pale, cyanosed or red? scars suggestive of previous surgery (e.g.,
femoro-distal bypass) or amputated digits, Signs of venous insufficiency such
as lipodermatosclerosis, venous eczema and atrophy blanche, venous
guttering seen when veins collapse in limbs with peripheral vascular disease
and appear as shallow grooves, ulceration comment on the location, shape
depth and size of the ulcer , gangrene, deformities like pes cavus, claw toes
and atrophic pulp of the toes.
NB: Arterial ulcers typically have a “punched out” appearance and are
generally found around pressure areas, i.e., lateral and medial malleoli, tips of
the toes, head of the 1st and 5th metatarsals, the heel and the interdigital
clefts –so remember to look between toes and under the heel. (May often be
confused with neuropathic ulceration; venous ulceration commonly occurs
around the gaiter region (medial side) of the leg)
(Look between the toes and heels and also other legs)
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(Palpation for temperature, capillary refilling time)

Do you have any pain at your hips? I am going to raise your leg.
(BUERGERS ANGLE AND TEST: With the patient lying supine, ask if they have
any pain or restriction in hip movements. Then lift patient leg slowly (ideally
in about 10-degree increments and waiting for 10 seconds at each stage) and
evaluate the angle at which the leg becomes pale or white. This is known as
Buerger’s angle in normal subjects it should be greater than 90 degrees (even
if the limb is flexed further at the hip, there should be no color change in the
limb). In patients with peripheral vascular disease, the limb may go pale as it
is lifted and reaches a certain angle. If the angle is less than 25-30 degrees, it
suggests severe ischemia.
Once you have established Buerger’s angle, sit the patient up and swing the
legs over the side of the couch. Watch for the foot to reperfuse –in normal
subjects there should be no color change but in patients with peripheral
vascular disease, you will observe the legs becoming a dusky crimson/purple
color, which is caused by reactive hyperemia. This represents a positive
Buerger’s test).
(Repeat the test on the other leg)
Now, I am going to feel your pulse.
(Start proximal to distal from femoral to dorsalis pedis and start from normal
leg and then the ischemic limb and if you cannot feel the pulse ask for doppler)
(Femoral –felt in the mid-inguinal point, halfway between the pubic symphysis
and ASIS. Popliteal –felt deep in the midline of the popliteal fossa with the
knee flexed to ~30 degrees. Posterior tibial –felt posterior to medial malleolus,
2/3rd of the way between the medial malleolus and the insertion of the
Achilles tendon. Dorsalis pedis felt in the 1st webspace, just lateral to the
extensor hallucis longus tendon on the dorsal surface of the foot (dorsiflexion
of the hallux may aid palpation)
(Remember also to check the radial pulse and assess for radio-femoral delay)
Now, I am going to listen to your pulse.
(Auscultation: for iliac above mi inguinal point and femoral bruits in mid
adductor canal using cone of stethoscope)
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ABPI: =Ankle Systolic Pressure/Brachial Systolic Pressure

The ABPI gives an indication of the severity of peripheral vascular disease
where present.
A normal ABPI is >1.0
If the ABPI is:
0.7 –1 = mild disease (i.e., patient may present with intermittent claudication)
0.5 –0.7 = moderate disease (i.e., likely to have rest pain)
< 0.5 –0.3 (or absolute pressure <50mmHg) = severe disease (i.e., critical
ischemia)
(Left ABPI = (Highest pressure of either left PTA or DP) ÷ (Highest brachial
pressure)
Right ABPI = (Highest pressure of either right PTA or DP) ÷ (Highest brachial
pressure)
Example
 Right brachial artery: 120 mmHg
 Left brachial artery: 125 mmHg
 Right DP: 80 mmHg
 Right TP: 75 mmHg
Right ABPI = 80/125 = 0.64
Thank you, sir, (remove the gel you used in doppler), you may dress now, do you
need any help?
Wash your hands.
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Presentation
To complete my examination, I would like to perform complete full neurological
examination of lower limbs, full cardiovascular examination, vascular
examination of upper limbs and to feel the abdomen for the presence of an
aortic aneurysm and to auscultate for aortic bruit.
Today I have examined this gentleman presented by claudication pain. I kept
the patient shorts for patient dignity. On inspection I noticed skin trophic
changes of LL suggesting chronic ischemia, in the form of pale skin especially LT
LL, thin shiny skin, hair loss and venous guttering of LT LL. By palpation: Slight
decrease in temperature of LL, delayed capillary refill, Buerger’s angle in LL was
40, with positive Buerger’s test, all pulses of both LL were palpable except for
(dorsalis pedis and posterior tibial arteries), I used the hand-held doppler for
dorsalis pedis and posterior tibial arteries pulse which were audible. By
auscultation: there was no audible bruits over femoral and iliac arteries, I started
to do ABPI measuring for Lt LL but I couldn’t finish due to time.
My main differential would be atherosclerotic or diabetic peripheral vascular
disease.
Questions:
Imaging:
arterial duplex
CT angiography
MR angiography
Lab:
Blood glucose level
Lipid profile (LDL)
treatment:
1- the patient should have an assessment of their risk factors and be actively
discouraged from smoking, have their cholesterol, blood pressure and blood
sugar control optimized and be considered for an antiplatelet agent.
2- The patient will probably need surgical or endovascular intervention. Options
include endovascular stenting of a stenosed portion of an artery, surgical bypass
or amputation of the affected part of the limb.
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3- Conservative treatment alone is only an option if the patient were unfit or

unwilling to have surgery.
Critical limb ischemia:
Critical ischemia can be defined by the presence of ischemic pain at rest, or
tissue loss in the form of gangrene or ulcers. It is consistent with an ABPI of <
0.4.
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I examined this patient presented by (Rt or Lt) LL claudication pain
On inspection: The patient had
Skin changes Skin trophic changes of LL suggesting chronic ischemia,

in the form of pale skin especially LT LL, thin shiny skin,
hair loss.
Scars No Scars of previous surgery

Venous There is venous guttering of LT LL.
guttering
Ulcers No Arterial ulcers were noted
Gangrene No tissue loss or previous amputation scars seen
On palpation: There is
Temperature Slight decrease in temperature of LL

Capillary Delayed capillary refill
Buerger’s
refill Buerger’s angle in LL was 40, with positive Buerger’s
angle test
& test
Pulses All pulses of both LL were palpable except for (dorsalis
pedis & posterior tibial arteries)
+/- Doppler I used the hand-held doppler for dorsalis pedis and
posterior tibial arteries pulse which were audible.
On auscultation:
There were no audible bruits over femoral & iliac arteries ABPI: I started
to do ABPI measuring for Lt LL but I couldn’t finish due to time.
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Varicose Veins Examination

Stem: examine the venous system of RT lower limb.
Patient Type: real.
Patient Exposure: patient will be wearing his shorts. (umbilicus to feet)
Provisional diagnosis: 1. primary Varicose veins.
2. secondary Varicose veins (after ligation of SFJ).
Positive Finding:
1.primary Varicose veins: There are varicosities along the distribution of (LSV or
SSV),and also there are multiple incompetent perforators above and below
knee, there are some signs of chronic venous insufficiency over LL in the form of
lipodermatosclerosis, venous eczema, (atrophie blanche, hemosiderin
deposition, venous ulcers), Trendelenburg test and tourniquet test was positive
indicating SFJ incompetence and incompetent perforators, I did tourniquet test
above & below the knee which revealed presence of multiple incompetent
perforators above & below knee, modified Perthe’s test were negative, Perthe’s
test couldn’t be done as complete occlusion of superficial system of veins
couldn’t be achieved due to presence of multiple incompetent perforators and
assessing SFJ by doppler it was incompetent.
2.secondery Varicose veins (after ligation of SFJ): scar in the upper thigh,
multiple dilated veins above inguinal ligament, Trendelenburg test and
tourniquet test indicate incompetent perforators and , multiple tourniquet test
revealed presence of multiple incompetent perforators above and below knee,
modified Perthe’s test were positive and Perthe’s test couldn’t be done as
complete occlusion of superficial system of veins couldn’t be achieved due to
presence of multiple incompetent perforators.
You are only allowed to have only one tourniquet in

the exam
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1. Inspection.
A. Distribution of varicose veins (long saphenous or short saphenous).
B. Blowouts.
C. Saphena Varix (impulse on cough).
D. Signs of chronic venous insufficiency (lipodermatosclerosis, venous
eczema, atrophy blanch or ulcers).
E. Scars
2.Palpation.
A. Varicose veins
1. Temperature.
2. Tenderness.
3. Blowouts (Fegan test).
4. Schwartz test.
5. Lower limb edema.
B. Saphena varix
1.Thrill.
2. impulse on cough.
3. Pulse.
4. compressibility.
3.Special tests.
A. Trendelenburg’s test.
B. Modified Perthes test and Tourniquet test.
C. Multiple Tourniquet test.
4.Hand held doppler for SFJ
(Patient will be standing)
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Wash your hands.
and moving legs, are you OK with this?
Would you stand up for me?
I will start by taking a close look to your legs.
Would you please turn around for me?
(Inspection for distribution of varicose veins (long saphenous or short
saphenous), blowouts, saphena Varix (impulse on cough), signs of chronic
venous insufficiency (lipodermatosclerosis, venous eczema, atrophy blanch or
ulcers) or scars)
In primary varicose veins: varicosities along the distribution of (LSV or SSV),
and also there are multiple incompetent perforators above and below knee,
there are some signs of chronic venous insufficiency over LL in the form of
lipodermatosclerosis, venous eczema, (atrophie blanche, hemosiderin
deposition, venous ulcers).
In secondary varicose veins: scar in the upper thigh, multiple dilated veins
above inguinal ligament.
Now, I am going to feel your legs? do you have any pain at the moment?
(Temperature, tenderness, blowouts (Fegan test), Schwartz test, lower limb
edema)
(Feel the temperature with the dorsum of your hand, palpate for lower limb
edema and feel down the leg over the course of the long saphenous and then
short saphenous veins for tenderness along the veins which may indicate
perforator incompetence (blowouts))
109 | P a g e
(Schwartz test A tap is made on the lower part of the leg on the long saphenous
varicose vein with one hand. If an impulse can be felt at the saphenous
opening with the other hand, Schwartz's test is positive. The impulse is felt at
the saphenous opening because of the incompetence of the valves in the
superficial venous system)
Would you cough for me?
(feel saphena varix for thrill, impulse on cough, pulse and compressibility)
(Feel the sapheno-femoral junction (~4cm below and lateral to the pubic
tubercle) for a sapheno varix. If a swelling is present check for a palpable thrill
and a cough impulse which indicates an incompetent valve between the
superficial and deep systems)
(feel the thrill with the palmar surface of your hand rather than your finger,
cough impulse test)
Would you please lie down for me?
Now, I am going to lift your leg and feel your leg do you have any pain at your
hip?
I am going to press here.
Now, I am going to release my hand.
(Trendelenburg’s test):
With the patient lying supine, lift his/her leg to about 45 degrees and gently
empty the veins (this may be aided by “milking” the veins)
Occlude the sapheno-femoral junction and ask the patient to stand up
ensuring that the finger or thumb is firmly over the junction
If the superficial veins do not fill and the varicosities are controlled at the level
of the sapheno-femoral junction by occluding it, it strongly suggests sapheno-
femoral incompetence. This can be confirmed by releasing the pressure from
the sapheno-femoral junction that will cause the blood to return from the
femoral vein into the saphenous vein (through the incompetent sapheno-
femoral junction), resulting in the varicosities becoming prominent.
110 | P a g e
As the patient stands, if the veins fill from below with the sapheno-femoral
junction occluded, incompetent perforators are the most likely cause for the
varicosities.
(primary varicose veins: Trendelenburg test and tourniquet test were positive
indicating SFJ incompetence and incompetent perforators and incompetent
perforators in secondary varicose veins)
Would you please lie down again for me? I am going to lift your leg again and I
am going to tie this tourniquet.
Could you please walk few steps for me in your place?
Now I am going to release the tourniquet?
(modified Perthe’s test and tourniquet test at same time)
(modified Perthe’s test: The test is done by applying a tourniquet at the level
of the sapheno-femoral junction to occlude the superficial pathway, and then
the patient is asked to move in situ. If the deep veins are occluded, the dilated
veins increase in prominence).
(modified Perthe’s test were negative in primary varicose veins and positive in
in secondary varicose veins)
(Tourniquet test is Trendelenburg test but instead of occluding SFJ using your
hand, you will use you’re a tourniquet)
Look at your examiner and ask for more tourniquets, the examiner will refuse,
So, you will perform multiple tourniquet test using one tourniquet, by applying
a tourniquet at SFJ and ask the patient to stand then release the tourniquet
(You already did that in tourniquet test). So, you will ask the patient to lie
down again and apply the same tourniquet again above the knee and ask the
patient to stand and release the tourniquet, ask the patient to lie down again
and repeat the same step with a tourniquet below the knee).
(multiple tourniquet test used to locate sites of incompetent perforators in
primary and secondary varicose veins).
Now, I am going to listen.
(hand held doppler assessment):
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hold the Doppler probe at a 45-degree angle to the skin at the level of the
sapheno-femoral junction and the squeeze the patient’s calf. In a patient
with a competent sapheno-femoral junction you will hear a short “swoosh”
as you squeeze, but this ceases as soon as you let go of the calf. If, however,
the sapheno-femoral junction is incompetent, there is a more prolonged “
swooooosh” of blood as it regurgitates back down though the incompetent
valve.
(assessing SFJ by doppler it was incompetent only in primary)
(you will hold the doppler and the probe using one hand and squeeze the calf
using the other hand and the patient will be standing, the examiner will not
help you to carry the doppler nor the patient)
(locate the site of femoral artery using doppler then move few centimeters
below and medial , hold the doppler probe at a 45-degree angle to the skin
and do not compress the skin with the prob , and squeeze the calf of the
patient and listen)
(repeat every test on both legs in primary varicose veins)
The Perthes test (not done) is a clinical test for assessing the patency of the
deep femoral vein prior to varicose vein surgery.
The limb is elevated and an elastic bandage is applied firmly from the toes to
the upper 1/3 of the thigh to obliterate the superficial veins only. With the
bandage applied the patient is asked to walk for 5 minutes. If deep system is
competent, the blood will go through and back to the heart. If the deep system
is incompetent, the patient will feel pain in the leg.
need any help?
Wash your hands.
112 | P a g e
tourniqut test
113 | P a g e
Trendelenburg Test
114 | P a g e
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116 | P a g e
Presentation
To complete my examination, I would like to examine the arterial system of both
lower limbs and the abdomen.
First scenario
Today I have examined this gentleman presented with RT varicose veins. I kept
the patient shorts for patient dignity. I noticed multiple varicosities along the
distribution of (LSV or SSV),and also there are multiple incompetent perforators
above and below knee, there are some signs of chronic venous insufficiency over
LL in the form of lipodermatosclerosis, venous eczema, (atrophie blanche,
hemosiderin deposition, venous ulcers), Trendelenburg test was positive
indicating SFJ incompetence and incompetent perforators , I did tourniquet test
above & below the knee which revealed presence of multiple incompetent
perforators above & below knee, modified Perthe’s test were negative, Perthe’s
test couldn’t be done as complete occlusion of superficial system of veins
couldn’t be achieved due to presence of multiple incompetent perforators and
assessing SFJ by doppler it was incompetent.
My main differential diagnosis is primary varicose veins due to with incompetent
saphenofemoral junction and above and below knee multiple incompetent
perforators.
Second scenario
Today I have examined this gentleman presented with RT varicose veins. I kept
the patient shorts for patient dignity. I noticed multiple varicosities along the
distribution of (LSV or SSV) and in the lower abdomen (multiple dilated veins
above inguinal ligament), and scar in the upper thigh most probably
Trendelenburg operation (ligation of SFJ) , ,Trendelenburg test indicates
incompetent perforators, tourniquet test revealed presence of multiple
incompetent perforators above and below knee, modified Perthe’s test were
positive and Perthe’s test couldn’t be done as complete occlusion of superficial
system of veins couldn’t be achieved due to presence of multiple incompetent
perforators.
My main differential diagnosis is secondary varicose veins due to Ligation of SFJ
and incompetent perforators.
117 | P a g e
Questions
What further investigations would you arrange?
Venous duplex: Duplex ultrasound scan to determine the site of valvular
incompetence, ensure patency of the deep venous system.
What are her management options?
Depends on symptoms and effect on quality of life.
Conservative: Graduated compression stockings, leg elevation, exercise and
avoidance of prolonged sitting or standing.
Invasive, non-operative: Foam sclerotherapy, radiofrequency or
photocoagulation (Laser) ablation (under local anesthesia).
Invasive, operative (under general anesthesia): Varicose vein surgery is reserved
for symptomatic patients with skin complications. It can involve ligation of the
vein (long or short saphenous) near the site of incompetence and excision (for
the long saphenous) by stripping through small skin incisions to reduce the risk
of recurrence. Varicose veins can be avulsed through small stab incisions
(phlebectomies), followed by compression bandaging.
No surgery for secondary varicose veins.
Female with varicose veins and she use oral contraceptive pills, what is your
advice?
OCP could increase the risk of DVT, she should stop OCP and shift to another
medication.
118 | P a g e
I examined this patient presented by Rt varicose veins
On inspection
Varicosities & There are varicosities along the distribution of (LSV or

perforators SSV), and also there are multiple incompetent
perforators above & below knee.in 1st and 2nd
scenarios.
Dilated veins in lower abdomen in 2nd scenario.
Venous There are some signs of chronic venous insufficiency
insufficiency over LL in the form of lipodermatosclerosis, venous
signs eczema, (atrophie blanche, hemosiderin deposition,
venous ulcers) in 1st and 2nd scenario.
Scars There are no scars of previous operations 1st scenario
or scar for Trendelenburg operation in upper thigh in
2nd scenario.
Edema No LL edema
On palpation
Saphena varix There is no palpable Saphena varix. 1st and 2nd

scenarios.
Tenderness There is no tenderness over sites of varicosities and
incompetent perforators. 1st and 2nd scenarios.
Special tests and doppler
Trendelenburg Trendelenburg test was positive indicating SFJ

test incompetence in 1st scenario.
Tourniquet I did tourniquet test above & below the knee which
test revealed presence of multiple incompetent
perforators above & below knee in 1st and 2nd
scenarios.
Modified Positive in 2nd scenario only.
Perthe’s test
Perthe’s test Perthe’s test couldn’t be done as complete occlusion
of superficial system of veins couldn’t be achieved
due to presence of multiple incompetent perforators.
in 1st and 2nd scenarios.
SFJ Doppler By assessing SFJ by doppler it was incompetent in first
scenario only.
119 | P a g e
Arteriovenous fistula examination

Stem: examine this chronic kidney disease (CKD) patient and on dialysis (AVF)
present with numbness and bluish discoloration of his RT hand.
RT forearm swelling.
Patient Type: real.
Patient position: Lying on the couch with hand on pillow.
Patient Exposure: arm and chest
Provisional diagnosis: Dialysis ischemic steal syndrome (DASS).
Positive Finding: The swelling is in anterior aspect of forearm in antecubital
fossa, most probably brachio-cephalic AV fistula, 3x4cm in size Oval in shape,
irregular surface, there is overlying scar, the skin overlying has brown
pigmentation, Arm elevation is positive and pale skin distally.
Palpable thrill, radial pulse is absent or weak and is heard by handheld doppler,
with positive pulse augmentation test Compression Radial pulse is augmented
with fistula compression (check with doppler)
On auscultation:
There are audible soft, machinery, low-pitched bruits with systolic and diastolic
components heard over the swelling.
It is a must to train yourself to use doppler in vascular

stations.
120 | P a g e

1. Inspection:
A. Fistula (6S):
1. Site.
2. size.
3. Shape.
4. surface.
5.Scars.
6.overlying skin.
B. upper extremity
1.colour.
2.EDema.
3. venous collateralization over the chest or
shoulder (central venous outflow obstruction).
2. Arm elevation test
3. Palpation
A. Temperature.
B. Tenderness.
C. Radial pulse and Doppler.
D. Pulsatility.
E. Thrill.
F. Skin pinch test.
G. Direction of flow.
4.Augmentation test.
5. Fistula and heart auscultation.
Patient will be lying on the couch with hand on pillow
121 | P a g e
Wash your hands.
Today I’ve been asked to examine your RT arm and hand that would include
looking feeling and moving your arm and hand, are you OK with this?
Would you please take off your gown and relax your hand on this pillow?
I will start by taking a close look to your arm and hand.
(Inspection for fistula, signs of ischemia and signs of central venous occlusion)
(Fistula: site, size, shape, surface, scar, aneurysmal dilatations and signs of
inflammation)
(Site of fistula could be in the wrist if radio cephalic, in elbow if
brachiocephalic, transposed basilic or cephalic vein if present in (long scar
from axilla to elbow).
(signs of inflammation: redness, hotness)
(liability to rupture: thin, brownish skin and ulceration)
(signs of ischemia: pallor or bluish discoloration, ulcers or gangrene)
(signs of central venous occlusion: edema and venous collateralization over
the chest or shoulder)
Now, I am going to lift your arm, do you have any pain at your shoulder?
(arm elevation test: If the arm is elevated to a level above that of the heart,
the normal AV fistula will collapse. Even if the patient has a large “mega-
fistula,” it will at least become flaccid. However, if a venous stenosis is
present, that portion of the AV fistula distal to the lesion will remain distended
while the proximal portion collapses. If the entire fistula collapses when the
patient’s arm is elevated, one can conclude that the outflow of the fistula is
normal.)
Now I am going to feel your arm, do you have any pain at the moment?
122 | P a g e
(Temperature, tenderness, radial and brachial pulse, Pulsatility, thrill, skin

pinch test, direction of flow and Augmentation test)
(Palpate temperature using dorsum of your hands)
(During palpation of tenderness, look to your patient face)
(Pulsatility: The pulse in the fistula may be best appreciated using the fingers
(not the palm or thumb) and should be evaluated along the length of the
fistula from the arteriovenous anastomosis through the venous outflow.
Normally fistula is not pulsatile or very little pulse)
(Thrill: best evaluated using the palm of the hand, rather than the fingers.
The normal hemodialysis arteriovenous fistula is characterized by a soft,
continuous, diffuse thrill that is palpable over the course of the fistula and
most prominent over the arteriovenous anastomosis. It should have both a
systolic and diastolic component)
(With stenosis, the thrill is increased, localized to area of lesion, and systolic
only)
(skin pinch test: if you cannot catch skin over the fistula could be a sign of
liability to rupture)
(Direction of flow: The direction of flow can be easily determined by
occluding the fistula with the tip of the finger and palpating on each side of
the occlusion point for a pulse. The side without a pulse is the downstream
(i.e., in the direction of flow) side)
(Arterial pulse: All upper limb pulses have to be evaluated, if any not
palpable use handheld doppler)
(Augmentation test: When the normal fistula is occluded a short distance
from the arteriovenous anastomosis, the arterial pulse at the wrist should be
increased or augmented)
Now, I am going to listen.
(Listen using cone of stethoscope)
(The bruit over a well-functioning fistula has a low-pitched, soft, machinery
like rumbling sound and, like the thrill, has both a systolic and diastolic
component. The bruit is also more accentuated at the arterial anastomosis)
123 | P a g e
(With a stenotic lesion, the bruit becomes high in pitch and has only a systolic
component)
Now, I am going to listen to your heart.
(Listen for the presence of murmurs)
need any help?
Wash your hands.
124 | P a g e
125 | P a g e
Palpation of thrill with palm of hand. (A) Normal thrill is soft and continuous,
systolic, and diastolic. (B) With stenosis, the thrill is increased, localized to area
of lesion, and systolic only
Listening to bruit. (A) In the normal situation, the bruit is low pitched and with
systolic and diastolic components. (B) With a stenotic lesion, the bruit becomes
126 | P a g e
high in pitch and has only a systolic component.
Palpation of pulse with fingertips. (A) Normal pulse is soft and compressible.
(B) With stenosis downstream, the pulse is increased
Pulse augmentation test. (A) The arteriovenous fistula is occluded. (B) The
pulse is assessed for augmentation.
127 | P a g e
128 | P a g e
Presentation
To complete my examination, I would like to perform neurovascular
examination of upper limb and complete my cardiovascular examination.
Today I have examined this gentleman who present with RT forearm swelling.
By inspection: the swelling is in anterior aspect of forearm in antecubital fossa,
most probably brachio-cephalic AV fistula, 3x4cm in size Oval in shape, irregular
surface, there is overlying scar, the skin overlying has brown pigmentation, Arm
elevation is positive and pale skin distally.
By palpation: palpable thrill, radial pulse is absent or weak and is heard by
handheld doppler, with positive pulse augmentation test Compression Radial
pulse is augmented with fistula compression.
On auscultation:
There are audible soft, machinery, low-pitched bruits with systolic and diastolic
components heard over the swelling with no murmurs heard over the heart.
My main differential diagnosis is Dialysis ischemic steal syndrome is also I have
to consider Ischemic monomelic neuropathy.
Questions:
How could differentiate between Dialysis ischemic steal syndrome and
Ischemic monomelic neuropathy?
Two clinical variants of ischemia are recognized, both with characteristic
findings on physical examination
1-Dialysis ischemic steal syndrome:
hands appear pale or cyanotic and feels cool to the touch
The radial pulse is generally diminished or absent
Compression of the fistula augments the distal pulse and may temporarily
relieve painful symptom
Using a Doppler to listen to the bruit over the distal artery frequently aids in
this examination. The sound is significantly augmented when the fistula is
occluded.
129 | P a g e
With chronic ischemia, ulceration and gangrene at the fingertips may be

present
2-Ischemic monomelic neuropathy:
characterized by ischemic changes that are confined to the nerves of the hand
and spare other tissues
paresthesia; and numbness in the hand.
diffuse motor weakness or paralysis.
Poor wrist extension (radial nerve), poor function of the intrinsic hand
musculature (ulnar nerve), and poor thumb opposition (median nerve) are
typically present.
The hand is warm, and often a palpable radial pulse or audible Doppler signal is
present.
Investigations
Arterial duplex study
Treatment options
1- Restriction of fistula flow through banding, or modulation through surgical
revision.
2- ligation of the fistula and creation of a more proximal fistula in the same or
the contralateral limb.
130 | P a g e
I examined this patient presented by forearm

swelling
On inspection
Site The swelling is in anterior aspect of forearm in

antecubital fossa, most probably brachio-cephalic AV
fistula.
Size It is 3x4cm in size.
Shape Oval in shape.
Surface Irregular surface.
Scars There is overlying scar.
Skin The skin overlying has brown pigmentation, no
erythema
(+/- aneurysmal dilatation, if positive thin, shiny, ulcer,
??impending rupture)
Arm elevation positive arm elevation test.
Ischemia Pale skin distally, without ulcer or gangrene.
Edema No edema.
Venous No venous collateralization over the chest or shoulder.
collateralization
On palpation
Temperature On palpation the skin has normal temperature.

Tenderness The swelling was non-tender .
Thrill With normal thrill.
Pulse Radial pulse is absent and is heard by handheld doppler.
Pulsatilty The swelling was not pulsatile (pulsatile if there is

outflow obstruction).
Pulse With positive pulse augmentation test.
augmentation
Compression Radial pulse is augmented with fistula compression
(check with doppler).
On auscultation:
There are audible soft, machinery, low-pitched bruits with systolic and
diastolic components heard over the swelling
There are no murmurs heard over the heart
131 | P a g e
Cerebellar examination
Stem: examine this patient present posterior cranial fossa tumor.
Patient position: standing then sitting the lying on the couch.
Patient Exposure: no specific exposure except for reflexes.
Provisional diagnosis: Cerebellar ataxia due to posterior fossa tumor.
Positive Finding: Broad based gait with ataxia, and inability to perform tandem
gait, positive Romberg sign, Staccato speech, no nystagmus. UL examination
shows: positive Pronator drift sign, positive Rebound phenomenon,
dysdiadokinesia, intentional tremors, Inco-ordination (past pointing), Hypotonia
and Bilateral normal reflexes. examination shows normal tone, bilateral normal
reflexes and incoordination.
132 | P a g e

1.Romberg sign
2.Gait.
A. heel to toe gait.
B. Tandem gait.
3.Head and neck
A. Eye movement for nystagmus.
B. Speech
C. glossopharyngeal and vagus nerve examination (open your mouth
and say AHH, cough).
D. Spinal accessory nerve examination (shoulder shrugging and turn
head against resistance).
E. Hypoglossal nerve (Tongue protrusion).
4. Upper limb
A. Tone.
B. Coordination (Finger to nose and test for dysdiadokinesia).
C. Pronator drift.
D. Rebound phenomenon.
E. Intentional tremors.
F. Reflexes (biceps, Triceps and supinator).
5. Lower limbs
A. Tone (leg roll and leg lift).
B. Reflexes (ankle and knee).
C. Coordination (heel to chin).
133 | P a g e
Wash your hands.
Today I’ve been asked to examine your nervous system and reflexes that would
include looking feeling and moving your arm and legs, are you OK with this?
Would you please put your feet together, keep your hands by your side and close
your eyes, and I will support you from falling?
(negative Romberg sign)
(positive Romberg’s test indicates that the unsteadiness is due to a sensory
ataxia (damage to dorsal columns of spinal cord) rather than a cerebellar
ataxia)
Thank you, you can open your eyes now.
Could you please walk a few steps for me?
Thank you, would you please turn around and walk on your heel?
Could you please walk on your toes?
Could you please walk with one foot in front of the other?
(Gait: Stance – a broad based gait is noted in cerebellar disease. Stability – can
be staggering and often slow & unsteady – can appear similar to a drunk
person walking. Tandem (‘Heel to toe’) walking – Ask patient to walk in a
straight line with their heels to their toes. This is a very sensitive test and will
exaggerate any unsteadiness).
Thank you, you may have a seat now?
Would you please say (British constitution or Baby hippopotamus)?
(staccato speech)
Would you please keep your head steady and follow my finger using your eyes?
(H shaped extraocular movement for assessment of nystagmus)
134 | P a g e
(negative nystagmus)
Would you please open your mouth and say AHH?
Would you please cough for me?
(glossopharyngeal and vagus nerve examination)
Now I need you to turn your head against my hand?
Could you please raise your shoulder against me?
(spinal accessory nerve examination)
Could you please stick out your tongue?
Could you please put your tongue to touch your cheek and push against my
finger?
(Hypoglossal nerve examination)
(intact last four cranial nerves)
Now I am going to move your arms, do you have any pain at the moment?
(Tone: Support the patient’s arm by holding their hand & elbow. Ask the
patient to relax and allow you to fully control their arm. Move the arm’s
muscle groups through their full range of movements. Is the motion smooth
or is there some resistance?)
(Hypotonia in UL)
Now, I am going to tap, do you have any pain at the moment?
(◌Reflexes: Assess the patient’s upper limb reflexes, comparing left to right.
Biceps (c5, c6), Triceps (c7), Supinator (c6))
(Bilateral normal reflexes)
Would you please close your eyes and place your arms outstretched forwards
you’re your palms facing up?
(Pronator drift: Ask patient to close eyes and place arms outstretched
forwards with palms facing up Observe the hands / arm for signs of pronation
/ movement. A slow upward drift in one arm is suggestive of a lesion in the
ipsilateral cerebellum).
135 | P a g e
Would you please close your eyes and place your arms outstretched forwards
and to keep your arms in that position as I press down on your arms?
(Rebound phenomenon: Whilst the patient’s arms are still outstretched and
their eyes are closed: Ask the patient to keep their arms in that position as you
press down on their arm. Release your hand.
Positive test = Their arm shoots up above the position it originally was (this is
suggestive of cerebellar disease).
Now, I need you to touch your nose with the tip of your index finger, then touch
my finger tip?
(Co-ordination)
Finger to nose test: Ask patient to touch their nose with the tip of their index
finger, then touch your finger tip. Position your finger so that the patient has
to fully outstretch their arm to reach it. Ask them to continue to do this finger
to nose motion as fast as they can manage. Move your finger, just before the
patient is about to leave their nose, to create a moving target.
(↑sensitivity). An inability to perform this test accurately (past
pointing/dysmetria) may suggest cerebellar pathology.
Intentional tremors.
Now I need you to do as I do?
Dysdiadokinesia.
(Demonstrate patting the palm of your hand with the back/palm of your other
hand to the patient. Ask the patient to mimic this rapid alternating movement.
Then have the patient repeat this movement on their other hand. An inability
to perform this rapidly alternating movement (very slow/irregular) suggests
cerebellar ataxia)
Would you please lie down and take off your gown?
136 | P a g e
Now I am going to tap?
motion
(Co-ordination Heel to chin).
(normal tone, bilateral normal reflexes and incoordination)
Wash your hands
137 | P a g e
coordination
138 | P a g e
Dysdiadokokinesia
139 | P a g e
140 | P a g e
Presentation
To complete my examination, I would do full neurological examination
including: Cranial nerves and Upper and lower limbs
Today I have examined this gentleman presented by posterior cranial fossa
tumors and I have noticed broad based gait with unsteadiness, and inability to
perform tandem gait, negative Romberg sign, Staccato speech, no nystagmus.
UL examination shows: positive Pronator drift sign, positive Rebound
phenomenon, dysdiadokinesia, intentional tremors, Inco-ordination (past
pointing), Hypotonia and Bilateral normal reflexes. Examination of both lower
limbs shows normal tone, bilateral normal reflexes and incoordination.
Examination of last cranial nerves were normal.
My main differential diagnosis will be cerebellar ataxia due to posterior fossa
tumors also I have to consider:
cerebellar metastases due to lung or breast cancer.
Head trauma.
cerebrovascular stroke.
TIA.
MS.
Questions
Posterior fossa tumors:
cerebellar astrocytoma
Primary neuroectodermal tumors
Medulloblastoma
Ependymoma and ependymoblastoma
Choroid plexus papilloma and carcinoma
Dermoid tumors
Hemangioblastoma
Metastatic tumors
Brainstem gliomas
141 | P a g e
investigations:
plain x-ray skull: It may show calcification.
MRI brain (enhanced) with gadolinium
CT brain: CT scan of the posterior fossa is inferior to MRI in diagnostic value
because of the artifact produced from the surrounding thick bone. However, CT
scan is helpful for postoperative
follow-up.
CT (whole body) to detect primary tumors
guided biopsy
Treatment:
Excision
142 | P a g e
I examined this patient presented by posterior cranial fossa tumors on

examination of
Gait Broad based gait with ataxia, and inability to perform

tandem gait.
Romberg sign negative Romberg sign.
speech Staccato speech.
Eye movement No nystagmus.
Last four Normal examination.
Cranial nerves
Upper limb
Pronator drift positive Pronator drift sign.
Rebound positive Rebound phenomenon.
phenomenon
Tone Hypotonia.
Reflexes Bilateral normal reflexes.
Co-ordination Inco-ordination (past pointing).
Dysdiadokinesia With dysdiadokinesia.
Intentional And intentional tremors.
tremors
Lower limb
Tone Normal tone.
Reflexes Bilateral normal reflexes.
Coordination Inco-ordination (heel to shin).
143 | P a g e
Cranial Nerves Examination

Stem1: examine cranial nerves of this patient referred from his GP by headache.
Stem2: examine ears and related cranial nerves of this patient who had road
traffic accident and referred for head injury.
Stem3: examine cranial nerves of this patient present with blurring pf vision and
test his memory.

Patient position: sitting on a chair.
Patient Exposure: No specific exposure.
Provisional diagnosis:
1. bitemporal hemianopia.
2.Unilateral conductive hearing loss and
hemotympanum.
3. anterior cranial fossa tumor.
Positive Finding:
1. (bitemporal hemianopia) (pituitary adenoma).
2. (Bone conduction is better than air conduction
(Rinne’s negative)) and (sound is heard louder on the side of the affected ear
using weber test) Unilateral conductive hearing loss and hemotympanum
(fracture skull base).
3. dementia, Defective lateral gaze (abducent),
bilateral anosmia and bilateral decreased visual acuity on Snellen chart (anterior
cranial fossa tumor).
144 | P a g e

1. Olfactory nerve.
2.Optic nerve.
A. Visual acuity.
B. color vision (not done).
C. Direct and consensual light reflex.
D. Accommodation reflex.
E. Confrontation test for visual field.
F. Fundoscopy (only offer to use it)
3.Occlumotor (eye movement).
4.Trochlear nerves (eye movement)
5.Trigeminal
A. sensory
B. muscles of mastication.
C. Reflexes (Jaw and corneal reflexes) (not done).
6. Abducent (eye movement).
7. Facial nerve.
A. Taste sensation.
B. Motor for Facial muscles.
8. Vestibulocochlear nerve.
A. whisper test.
B. Rinne’s test.
C. Weber test.
D. March on spot test.
9 and 10. Glossopharyngeal and vagus.
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A. Look for any deviation of uvula and soft palate. (open your
mouth and say AHH).
B. Asses adduction of both vocal cords by vagus nerve (ask
patient to cough).
C. Gag reflex (not done).
11. Spinal accessory
A. Trapezius.
B. Sternomastoid.
12. Hypoglossal nerve (tongue protrusion).
You will be asked to perform ear examination

and use otoscope on plastic model and identify
hemotympanum picture in stem two.
You will be asked to offer and show the examiner
how to use ophthalmoscope in stem one.
You will be asked to do memory test (AMTS)
In stem three.
The patient should stand at six meters from the
Snellen chart, but in exam station the distance
will be less than six meters and the examiner will
tell you to consider that the distance is six
meters.
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Wash your hands.
Today I’m going to be testing the nerves that supply your face, are you OK with
this?
Have you noticed any recent change in your sense of smell?
Now, with your eyes closed, I need you to identify various scents, is it OK?
(coffee, vinegar)
(Olfactory nerve)
Now, I need you to cover you RT eye and read the letter I will point to in this
chart?
(bilateral anosmia in third scenario)
(Visual acuity)
(Stand the patient at 6 meters from the Snellen chart. If patient normally uses
distance glasses, ensure they wear them for the assessment. Ask the patient
to cover one eye & read to the lowest line they can manage. Visual acuity is
recorded as chart distance (numerator) over number of lowest line read
(denominator). Record the lowest line the patient was able to read (e.g. 6/6
which is equivalent to 20/20))
(The patient should stand at six meters from the Snellen chart, but in exam
station the distance will be less than six meters and the examiner will tell you
to consider that the distance is six meters)
(Bilateral decreased visual acuity on Snellen chart in third scenario)
Would you please focus on the clock on the wall?
Now, I need you to look to my finger?
(Accommodation reflex)
(Ask patient to focus on a distant point (clock on a wall / light switch). Place
your finger/object approximately 15cm in front of the eyes. Ask the patient to
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switch from looking at the distant object to the nearby finger / object. Observe
the pupils, you should see constriction & convergence bilaterally)
Would you please, cover your left eye with your left hand and I need you to keep
your head and your eyes steady and say yes, every time you see my fingertip
wiggling?
(Confrontation test for visual field)
(Ask the patient to cover their left eye with their left hand. You should cover
your left eye and be staring directly at the patient (mirror the patient). Ask
patient to focus on your face & not move their head or eyes during the
assessment. Ask the patient to tell you when they can see your fingertip
wiggling. Outstretch your arms, ensuring they are situated at equal distance
between yourself & the patient. Position your fingertip at the outer border of
one of the quadrants of your visual field. Slowly bring your fingertip inwards,
towards the centre of your visual field until the patient sees it. Repeat this
process for each quadrant – at 10 o’clock /2 o’clock / 4 o’clock / 8 o’clock. If
you are able to see your fingertip but the patient cannot, this would suggest a
reduced visual field. Map out any visual field defects you detect. Repeat the
same assessment process on the other eye)
(Bitemporal hemianopia in first scenario)
Now, I will shine a light into your eye, it may feel uncomfortable, ok? (dim the
light of the room)
(Pupillary reflexes)
(Direct reflex: shine torch into eye and look for pupillary constriction in that
eye. Consensual reflex – shine torch into eye – look for pupillary constriction
in opposite eye)
(Fundoscopy) (offer only to use it)
(Assess for red reflex: Position yourself at a distance of around 30cm from the
patient’s eyes. Looking through the ophthalmoscope observe for a reddish /
orange reflection in the pupil. An absent red reflex may indicate the presence
of cataract, or in rare circumstances neuroblastoma. Move in closer & examine
the eye with the fundoscope: Begin medially & assess the optic disc – colour /
contour / cupping. Assess the retinal vessels – cotton wool spots / AV nipping
/ neovascularization. Finally assess the macula – ask to look directly into the
light – drusen noted in macular degeneration)
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(Optic nerve: Visual acuity, color vision (not done), direct and consensual light
reflex, accommodation reflex, confrontation test for visual field and
Fundoscopy (only offer to use it))
Now, I need you to keep your head still and follow my finger with your eyes?
(oculomotor, trochlear and abducent) (eye movement)
(Ask the patient to keep their head still & follow your finger with their eyes.
Move your finger through the various axis of eye movement (“H” shape).
Ask the patient to report any double vision. Observe for restriction of eye
movement)
(Defective lateral gaze (abducent) in third scenario)
Do you feel this? (touch him with cotton wool in the arm)
Would you please, close your eyes and say yes ever time you feel this?
(Ophthalmic: forehead, Maxillary: cheek bones, Mandibular: jaw angles)
Would you please, close your jaw against my hand?
Would you please, open your jaw against my hand?
Now, I need you to clench your teeth, and I will feel your face? (feel masseter
and temporalis)
(motor part of trigeminal nerve: muscles of mastication)
(Trigeminal: sensory, motor, Reflexes (Jaw and corneal reflexes) (not done).
Would you please raise your eye brows? (Temporal)
Would you please close your eyes and don’t let me open them? (Zygomatic)
Would you please blow your cheeks? (Buccal)
Would you please show me your teeth? (Marginal mandibular)
Would you please tense your neck muscles? (Cervical)
Have you noticed any problems in your taste sensation? (Chorda tympani)
(Facial nerve: taste sensation and muscles of facial expression)
Have noticed any change in your hearing recently?
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Now, I am going to cover your RT ear and say a word or number and I’d like to
repeat it back to me?
(Whisper test)
(Explain to the patient that you’re going to say a word or number and you’d
like them to repeat it back to you. With your mouth approximately 15cm from
the ear, whisper a number or word. Mask the ear not being tested by rubbing
the tragus. Ask the patient to repeat the number or word back to you. If the
patient repeats the correct word or number, repeat the test at an arm’s length
from the ear (normal hearing allows whispers to be perceived at 60cm). Assess
the other ear in the same way)
Now, I need you to tell me if you hear this?
Now, I will put the fork behind your ear, do you her it now?
Is it better to hear behind your ear or in front?
(Rinne test: Tap a 512HZ tuning fork & place at the external auditory meatus
& ask the patient if they are able to hear it (air conduction). Now move the
tuning fork (whilst still vibrating), placing its base onto the mastoid process
(bone conduction). Ask the patient if the sound is louder in front of the ear
(EAM) or behind it (mastoid process). Normal = Air conduction > Bone
conduction (Rinne’s positive). Neural deafness = Air conduction > Bone
conduction (both air & bone conduction reduced equally). Conductive deafness
= Bone conduction > Air conduction (Rinne’s negative))
Now, which is better to hear RT or LT ear?
(Weber test: Tap a 512HZ tuning fork & place in the midline of the forehead.
Ask the patient where they can hear the sound: Normal = sound is heard
equally in both ears Neural deafness = sound is heard louder on the side of the
intact ear Conductive deafness = sound is heard louder on the side of the
affected ear)
Now, I need you to march in your place with your eyes closed and your arms are
outstretched?
(Vestibular testing: Ask patient to march on the spot with arms outstretched
and eyes closed: Normal – patient remains in the same position. Vestibular
lesion – patient will turn towards the side of the lesion)
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(Vestibulocochlear nerve: whisper test, Rinne’s test, Weber test and

March on spot test).
(Inspect for other signs of fracture skull base like raccoon eye and battle sign)
(you will use otoscope in plastic model)
(Bone conduction is better than air conduction (Rinne’s negative)) and sound
(is heard louder on the side of the affected ear using weber test) Unilateral
conductive hearing loss) in second scenario.
Would you please open your mouth and say AHH? (look for any deviation of
uvula and soft palate)
(glossopharyngeal and vagus nerve)
Now I need you to turn your head against my hand?
Could you please raise your shoulder against me?
(spinal accessory nerve)
finger?
(Hypoglossal nerve)
Do you mind if I asked some questions to test your memory?
How old are you?
What year is it?
When did WW2 end?
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(Abbreviated mental test scoring)
(Score less than 6/10 suggests dementia / delirium in third scenario)
Thank you, sir.
Wash your hands
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Eye movement
Snellen chart
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Presentation
First scenario
Today I have examined this gentleman cranial nerves except which not needed
to be done. The examination revealed that all cranial nerves required for
examination are intact except I noticed bitemporal hemianopia on optic nerve
examination.
My main differential diagnosis is pituitary adenoma also, I have to consider
craniopharyngioma, meningioma, anterior communicating artery aneurysm.
Second scenario
Bone conduction is better than air conduction (Rinne’s negative)) and (sound
is heard louder on the side of the affected ear using weber test) Unilateral
conductive hearing loss and hemotympanum (fracture skull base). I also checked
for other signs of fracture base like battle sign and raccoon eye and are negative.
Third scenario
dementia, Defective lateral gaze (abducent), bilateral anosmia and bilateral
decreased visual acuity on Snellen chart (anterior cranial fossa tumor).
Questions
Bitemporal Hemianopia
Where might the lesion be to cause this symptom?
A bitemporal hemianopia is suggestive of a lesion affecting the optic chiasm,
where the more medial fibers cross over to the contralateral eye. This may be
either a lesion of the optic chiasm itself or a mass pressing on it (e.g. a pituitary
tumor, craniopharyngioma, meningioma, anterior communicating artery
aneurysm)
What else might you expect if a pituitary tumor were the cause of this lady’s
bitemporal hemianopia?
The other signs and symptoms of a pituitary tumor can be general or specific to
hormone production:
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General: raised intracranial pressure may cause papilledema (as seen on

fundoscopy) or headaches.
Specific: hyperpituitarism: this depends on the type of hormone secreted. The
most common are growth hormone and prolactin from pituitary adenomas. The
former causes acromegaly and the latter hyperprolactinemia.
Signs of acromegaly - prognathism, prominent brow, macroglossia, thickening
of the skin, enlargement of hands and feet, hyperhidrosis, carpal tunnel
syndrome.
Signs of hyperprolactinemia - increased lactation, loss of libido, erectile
dysfunction in males, amenorrhea and infertility (anovulatory) in females.
Investigations:
hormone assays
MRI
CT (disadvantages: poor soft tissue visualization, need for contrast)
Treatment
ant prolactin (bromocriptine)
Surgery (trans-sphenoidal, trans-frontal)
Hemotympanum
What did you see in this picture and identify structures in the picture?
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DD of hemotympanum:
nasal packing, epistaxis, blood disorders and blunt trauma to the head,
especially when temporal bone fracture or middle ear infection.
How could you differentiate RT from LT tympanic membrane in otoscopy?
Right ear drum, the handle of the malleus is clearly visible going from the upper
right to the lower left and ends somewhere in the center of the ear drum. From
there a triangular light reflex goes to the bottom right somewhere at about 4–5
o’clock. The opposite is true for the left ear (7 o’clock).
Cause of conductive hearing loss in this patient?
Hemotympanum secondary to skull base fracture
What cranial nerves to examine together?
Vestibulocochlear+ facial (they exit together from IAM)
How to fit otoscope?
Pull the pinna upwards & backwards – to straighten the external auditory
meatus, position otoscope at the external auditory meatus:
Otoscope should be held in your right hand for the patient’s right ear and vice
versa.
Hold the otoscope like a pencil and rest your hand against the patient’s cheek
for stability.
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Advance the otoscope under direct vision.

Look for any wax, swelling, erythema, discharge or foreign bodies
Examine the tympanic membrane:
Colour – pearly grey & translucent (normal) / erythematous (inflammation)
Erythema or bulging of the membrane? – inspect for a fluid level e.g. otitis media
Perforation of the membrane? – note the size of the perforation
Light reflex present? – absence / distortion may indicate ↑ inner ear pressure
e.g. otitis media.
Scarring of the membrane? – tympanosclerosis – can result in significant hearing
loss.
Withdraw the otoscope carefully.
Management
Ct brain, audiometry, ENT review
Anterior cranial fossa tumor

Do AMTS:
Abbreviated mental test scoring:
How old are you?
What year is it?
When did WW2 end?
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Scoreless then 6/10 suggests dementia / delirium
What do you want to look for in fundoscopy?
Ophthalmoscopy serves to identify:
Papilledema suggestive of sustained raised intracranial pressure (e.g. caused
by a tumor or hydrocephalus). This may be absent in the context of acutely
raised intracranial pressure, or there may be atrophic changes in longstanding
chronic disease.
Hemorrhage into the vitreous humor (Terson’s syndrome) or other
intraocular hemorrhage secondary to a subarachnoid hemorrhage.
Differential diagnosis of anterior cranial fossa tumor
Meningioma, olfactory neuroblastoma, Sino nasal malignancies
Management
CT scan
MRI with gadolinium
Stereotactic biopsy
Involve neuro-oncology MDT
Treatment
Surgical resection and proton beam radiotherapy
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Olfactory Stem 3 Bilateral anosmia

Optic Stem 3 Visual acuity: bilateral decreased acuity
to 20/50 on Snellen chart
Optic Stem 1 Field: Defective temporal field on both
sides (bitemporal hemianopia)
Optic Stem 1 & Pupils: normal direct, consensual and
3 accommodation reflexes
Optic Not Color vision

done
Optic Stem 3 Fundoscopy: offer only to do and
possibilities will be discussed (optic disc
cupping)
Oculomotor, Stem 1 Free in all directions
Trochlear,
Oculomotor, Stem 3 Defective lateral gaze (abducent)
Trochlear,
Abducent
Trigeminal Stem 1 & Normal findings
3
Trigeminal Not Pin prick sensation, jaw jerk & corneal
done reflexes
Facial Stem 1,2 Normal findings
&3
Vestibulocochlear Stem 1 & Normal findings
3
Vestibulocochlear Stem 2 Unilateral conductive hearing loss
Glossopharyngeal, Stem 1 & Normal findings
Vagus 3
Glossopharyngeal, Not Gag reflex
Vagus done
Accessory Stem 1,3 Normal findings
Hypoglossal Stem 1 & Normal findings
3
AMTS Stem 3 Score < 6/10 suggesting dementia
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Chest Examination
Stem: examine respiratory system of this patient prepared for elective hernia
repair.
Patient Type: real.
Patient position: semi sitting on couch.
Patient Exposure: Chest and abdomen.
Provisional diagnosis: COPD.
Positive Finding: Central cyanosis, barrel-shaped chest, equal expansion on both
sides, by Percussion Hyperresonance on both sides and by auscultation equal air
entry on both sides harsh vesicular breathing with expiratory wheezes and
normal vocal resonance on both sides.
You don’t have to count the RR and HR in one minute

10 seconds is enough
And during presentation refer to HR is regular and you
don’t have to say number
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1.Inspection
A. General
1. Bed side medication, O2 cylinder or chars.
2.legs (edema and tender calf muscles).
3.Hand (Tar staining, clubbing and radial pulse and
Respiratory rate).
4.Neck (Neck veins and trachea).
5.Mouth (central cyanosis, dehydration and oral hygiene).
6. Eye (pallor).
B. Chest
1. Chest shape.
2. Scars.
2. Palpation
A. Chest expansion
3. Percussion
4. Auscultation
A. Quality.
B. Volume.
C. Added sounds.
D. Vocal resonance.
5. Cervical lymph nodes.
6. Repeat inspection, palpation, percussion and auscultation on the back of
the chest and palpate for sacral edema.
Patient will be semi sitting from one to four.
Patient will be sitting in five and six.
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Wash your hands.
Today I’ve been asked to examine your chest that would include looking feeling
and listening to your chest and also examining your legs and hands, are you OK
with this?
I will start by taking a close look to your legs?
Do you have any pain at the moment, I will feel your legs?
(Legs: edema and tender calf muscles).
May I see your hand please?
Now, I will feel your pulse?
Would you please bring your fingers like this? (clubbing)
(Hands: Tar staining, clubbing, tremors, radial pulse and Respiratory rate).
Now, I take a close look to your neck, would you please look to your LT side?
Now, I am going to feel your wind pipe?
(Neck: Neck veins and trachea)
Would you please open your mouth for me?
Could you please stick up your tongue?
(Mouth: central cyanosis, dehydration and oral hygiene)
(There is central cyanosis)
Would you please lower your lower eye lid for me?
(Eye: pallor).
Would you please, take off your gown and put your hands behind your head?
I will take a close look to your chest?
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(Scars for thoracotomy and chest shape)

(Inspect the chest from the side and the end of the bed)
(Barrel-shaped chest)
Now, I will feel your chest?
Would you take a deep breath for me?
(Chest expansion: Place your hands on the patient’s chest, inferior to the
nipples. Wrap your fingers around either side of the chest. Bring your thumbs
together in the midline, so that they touch. Ask patient to take a deep breath.
Observe movement of your thumbs, they should move apart equally. If one of
your thumbs moves less, this suggests reduced expansion on that side.
Reduced expansion can be caused by lung collapse / pneumonia)
(Equal expansion on both sides)
Do you have any pain at the moment, I will tap on your chest?
(Place your non-dominant hand on the chest wall. Your middle finger should
overlie the area you want to percuss (between ribs). With your dominant
hand’s middle finger, strike the middle phalanx of your nondominant hand’s
middle finger. The striking finger should be removed quickly, otherwise you
may muffle resulting percussion note.)
(Percuss the following areas, comparing side to side: Supraclavicular (lung
apices), Infraclavicular, Chest wall (3-4 locations bilaterally) and Axilla)
(Hyperresonance on both sides)
Now, I am going to listen to your chest?
Would you please take deep breath every time I put the stethoscope on your
chest?
Now, I need you to say “99” every time I put the stethoscope on your chest?
(44 for Arabic speakers)
(from the same levels of percussion: Ask patient to take deep breaths in and
out through their mouth. Assess quality – Vesicular (normal) / Bronchial (harsh
sounding) – consolidation. Assess volume – quiet breath sounds suggest
reduced air entry – consolidation / collapse / fluid. Added sounds: Wheeze –
asthma / COPD, Coarse crackles – pneumonia / fluid, Fine crackles – pulmonary
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fibrosis and Vocal resonance: Ask patient to say “99” repeatedly & auscultate
the chest again: Increased volume over an area suggests increased tissue
density – consolidation/fluid/tumor)
(equal air entry on both sides harsh vesicular breathing with expiratory
wheezes and normal vocal resonance on both sides)
Now, I am going to feel your neck?
(Cervical Lymph node)
Now, I will feel your back?
Now, I will tap on your chest, do you have any pain at the moment?
Now I will listen to your chest.
Now, I need you to say “99” every time I put the stethoscope on your chest?
(44 for Arabic speakers)
Now I will feel your back.
(Repeat inspection, palpation, percussion and auscultation on the back of the
chest and palpate for sacral edema)
(Cover your patient)
Wash your hands.
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Presentation
To complete my examination, I would like to perform cardiovascular
examination of this patient.
Today I have examined this gentleman who is prepared for hernia repair.
I noticed central cyanosis on general examination. on inspection and palpation
of his chest I noticed barrel-shaped chest, equal expansion on both sides, by
Percussion Hyperresonance on both sides and by auscultation equal air entry
on both sides harsh vesicular breathing with expiratory wheezes and normal
vocal resonance on both sides.
Questions
Main diagnosis is COPD in a smoker of this age; however, asthma is also a
possibility
Who would you inform about this?
I would inform an anesthetist, ideally the consultant who will be doing the case,
otherwise the coordinating anesthetic consultant and the operating surgeon.
What further investigations would you arrange?
A chest X-ray to rule out a preop pneumonia or underlying malignancy
Spirometry and respiratory function tests.
A baseline ABG to identify preoperative paO2 and PaCO2
How could you try to reduce the risks in a patient with COPD about to undergo
an operation?
I would ask the GP to optimize medication before the operation and refer to a
respiratory medic if necessary.
Any infection should be treated before the operation.
The patient should be encouraged to stop smoking.
I would arrange chest physio before and after surgery to encourage excretion of
excess mucus.
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In addition, I would inform HDU in case more intensive care is required post
operatively.
Use open surgery, not laparoscopic because of co2 pneumoperitoneum.
Use regional anesthesia instead of general anesthesia.
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I examined this patient

By inspection and palpation
General
SOB No SOB
O2 cylinder No oxygen cylinder or mask
or
mask
Drugs No drugs (may be inhaler)
Mouth There is central cyanosis

Neck Trachea is central
Lymph nodes No palpable LNs
Nails Clubbing
Tar staining Tar staining
Radial pulse Radial pulse is ~, regular rhythm
Chest
Scars No chest wall scars
Shape Barrel-shaped chest
Chest wall Equal expansion on both sides
movement
Respiratory Respiratory rate is ~
rate
Percussion
Hyperresonance on both sides.
Auscultation
equal air entry on both sides harsh vesicular breathing with expiratory
wheezes and normal vocal resonance on both sides.
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Cardiovascular examination
Stem: examine CVS of this patient prepared for elective hernia repair.
Patient Type: real.
Patient position: semi sitting on the couch.
Positive Finding and Provisional diagnosis:
1. Aortic stenosis: Apex is displaced (may felt in 6th intercostal space),
palpable thrill at 2nd intercostal space Rt parasternal and over carotid vessels in
the neck, audible ejection systolic murmur over second intercostal space Rt
parasternal, propagated to carotid and accentuated on leaning forward.
2. Mitral regurgitation: Audible pan-systolic murmur over the apex,
propagated to axilla and accentuated in Lt lateral position.
3. Peace maker: Lt infra-clavicular scar.
4. Valve replacement: Midline sternotomy scar and audible metallic click
of prosthetic valve.
5. Valve replacement and mitral regurgitation: Midline sternotomy scar and
audible metallic click of valve replacement with pan-systolic murmur over the
apex, propagated to axilla and accentuated in Lt lateral position.
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Tips and Tricks

Inspect patient chest for scars:
If you noticed Lt infra-clavicular scar the diagnosis is Peace maker.
If you noticed Mid line sternotomy scar the diagnosis is Valve replacement.
If you noticed no scar listen the heart:
If you noticed the murmur is propagated to LT axilla the diagnosis is Mitral
regurgitation.
If you noticed the murmur is propagated to carotid the diagnosis is Aortic
stenosis. You will measure blood pressure unless it is provided in the stem.
You don’t have to count the HR in one minute, 10 seconds is enough and during
presentation refer to HR is regular and you don’t have to say number .
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1.Inspection
A. General
1. Bed side medication, O2 cylinder or chars.
2.legs (edema, vein graft harvest scars and tender calf
muscles).
3.Hand (Tar staining, clubbing and radial pulse and radio
radial delay, capillary refilling time, collapsing pulse and signs of infective
endocarditis like splinter hemorrhage and Janeway lesions).
4.Neck (Neck veins, carotid pulsation and trachea).
6. Eye (pallor).
B. Chest
1. visible apex pulsation.
2. Scars.
2. Palpation
A. Apex beats.
B. Heaves.
C. Thrills (carotid and heart).
3.Auscultation (heart, carotid and lung bases).
4.Palpate for the presence of sacral edema.
5. Measurement of blood pressure.
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Wash your hands.
Today I’ve been asked to examine your heart that would include looking feeling
and listening to your heart, also examining your hands and legs, are you OK with
this?
(Legs: edema, vein graft harvest scars and tender calf muscles).
Do you have any pain in your shoulder, I will lift your arm? (collapsing pulse)
(Hands: Tar staining, clubbing and radial pulse and radio radial delay, capillary
refilling time, collapsing pulse and signs of infective endocarditis like splinter
hemorrhage and Janeway lesions).
(Neck: Neck veins, carotid pulsation and trachea)
(Eye: pallor).
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Would you please take off your gown and put your hands behind your head, I
will take a close look to your chest?
(scars: sternotomy, thoracotomy, infraclavicular and visible apex pulsations)
(midline sternotomy scar in VR, or Lt infra-clavicular scar in pace maker)
(Inspection from the side of the bed and from the end of the bed)
Now, I will feel your chest?
(Palpate for: apex beat, Heaves (ventricular hypertrophy) and Thrills (palpable
murmurs))
(Apex beat: Located at the 5th intercostal space / midclavicular line. Palpate
the apex beat with your fingers (placed horizontally across the chest). Lateral
displacement suggests cardiomegaly)
(Heaves: A parasternal heave is a precordial impulse that can be palpated.
Parasternal heaves are present in patients with right ventricular hypertrophy.
Place the heel of your hand parallel to the left sternal edge (fingers vertical) to
palpate for heaves. If heaves are present you should feel the heel of your hand
being lifted with each systole)
(Thrills: A thrill is a palpable vibration caused by turbulent blood flow through
a heart valve (the thrill is a palpable murmur). You should assess for a thrill
across each of the heart valves in turn. To do this place your hand horizontally
across the chest wall, with the flats of your fingers and palm over the valve to
be assessed)
(In aortic stenosis: palpable thrill at 2nd intercostal space Rt parasternal and
over carotid vessels)
Now, I will listen to your heart.
(Auscultation)
(Put your left hand on the carotid pulse to time systole and diastole)
(Mitral area: 5th ICS midclavicular line, pan systolic murmur radiating to the
axilla. Tricuspid area: 4th ICS left parasternal edge. Pulmonary area: 2nd ICS
left parasternal edge. Aortic area: 2nd ICS right parasternal edge, Ejection
systolic murmurs radiating to the carotids)
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Accentuation maneuvers: These maneuvers cause particular murmurs to

become louder DURING expiration: Roll onto left side & listen to mitral area
with bell during expiration – mitral murmurs (stenosis & regurgitation). Lean
forward & listen over aortic area during expiration – aortic murmurs are louder
(stenosis & regurgitation).
(Metallic heart sounds: One metallic click corresponding to S1= mitral valve
replacement Two metallic clicks corresponding to s2 = aortic valve
replacement)
(Palpate the carotid pulse to determine the first heart sound. Auscultate
‘upwards’ through the valve areas using the diaphragm of the stethoscope:
Mitral valve – 5th intercostal space – midclavicular line (apex beat) Tricuspid
valve – 4th or 5th intercostal space – lower left sternal edge, Pulmonary valve
– 2nd intercostal space – left sternal edge, Aortic valve – 2nd intercostal space
– right sternal edge. Repeat auscultation across the four valves with the bell
of the stethoscope. Auscultate the carotid arteries with the patient holding
their breath to check for radiation of an aortic stenosis murmur (this is known
as an accentuation maneuver). Sit the patient forwards and auscultate over
the aortic area during expiration to listen for the murmur of aortic
regurgitation (this is known as an accentuation maneuver). Roll the patient
onto their left side and listen over the mitral area with the bell during
expiration for mitral murmurs (regurgitation/stenosis).
(Mitral resurge: Audible pansystolic murmur over the apex, propagated to
axilla and accentuated in Lt lateral position. Aortic stenosis: Audible ejection
systolic murmur over 2 I C space Rt parasternal, propagated to carotid and
accentuated on leaning forward. Valve replacement: Audible metallic click of
prosthetic valve. Valve replacement + MR: Audible metallic click of valve
replacement with pansystolic murmur over the apex, propagated to axilla
and accentuated in Lt lateral position.)
Would you please, hold your breath, I will listen?
(Carotid bruits using cone of stethoscope)
I will listen to your chest. (lung bases)
I will feel your back. (sacral edema)
Now, I will measure your blood pressure.
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Wash your hands.
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Presentation
To complete my examination, I would like to perform respiratory examination
and vascular examination of both UL and LL.
First Scenario
Today I have examined this gentleman prepared for elective hernia repair and I
noticed that the apex is displaced (may felt in 6th intercostal space), palpable
thrill at 2nd intercostal space Rt parasternal and over carotid vessels in the
neck, audible ejection systolic murmur over second intercostal space Rt
parasternal, propagated to carotid and accentuated on leaning forward.
My main differential diagnosis is Aortic stenosis.
Second Scenario
Mitral regurgitation: Audible pan-systolic murmur over the apex, propagated
to axilla and accentuated in Lt lateral position.
Third scenario
Peace maker: Lt infra-clavicular scar.
Fourth scenario
Valve replacement: Midline sternotomy scar and audible metallic click of
prosthetic valve.
Fifth scenario
Valve replacement and mitral regurgitation: Midline sternotomy scar and
audible metallic click of valve replacement with pan-systolic murmur over the
apex, propagated to axilla and accentuated in Lt lateral position.
Questions
What investigations would you order preoperatively?
This patient appears well, but would require a baseline ECG and echo
preoperatively. In addition, he would require bloods including an INR as he is
on warfarin
How would you manage this patient’s anticoagulation?
Here are some general guidelines for stopping anticoagulation. you should
always check local policy and ask the advice of a hematologist.
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Low thromboembolic risk:

stop warfarin 5 days pre-op;
restart warfarin post-op as soon as oral fluids are tolerated.
High thromboembolic risk:
stop warfarin 4 days pre-op and start low molecular weight.
Heparin (LMWH) at therapeutic.
Stop the (LMWH) 12-18h pre-op;
Restart (LMWH) 6hours post-op (assuming hemostasis achieved);
Restart Warfarin when oral fluids are tolerated;
Stop (LMWH) when INR is in range again.
The patient presents with fever 5 days postoperatively?
Might have infective endocarditis
Causes of valve lesions:
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Note the pacemaker spikes, no p- waves
Indications of pacemaker:
Permanent Pacemaker Indication:

Symptomatic Sinus Bradycardia.
S A Node Disease.
Symptomatic A V Node Disease.
Hypertrophic Obstructive Cardiomyopathy (HOCM).
Dilated Cardiomyopathy (DCM)
Long Q T Syndrome.
Who would you inform about the pacemaker?
An anesthetist, ideally the consultant who will be doing the case. I would
ensure it is clearly documented in the notes.
What precautions would you take?
I would arrange a pacemaker check pre- and postoperatively and contact their
pacemaker follow up clinic to inform them of the operation and ask for advice.
During the operation I would avoid monopolar completely, or limit its use to
short bursts only.
The return electrode should be placed so that the pathway between the
diathermy electrode and return electrode is as far away from the pacemaker
and leads as possible I’d ensure that appropriate resuscitation equipment
was available.
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Clinical difference between RT and LT sided heart failure?
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I examined this patient

By Inspection & Palpation
Walking aid No walking aids.

O2 cylinder No oxygen cylinder or mask.
or
mask
Drugs No drugs (or Warfarin in Valve replacement).
Head and neck
Face No malar rash.

Eye No mucous membrane pallor, no xanthelasma, no
corneal arcus.
Mouth Proper oral hygiene.
No central cyanosis.
Neck Neck veins are not congested.
Carotid pulses are equal bilaterally with no palpable
thrill (positive thrill in AS).
Upper limbs
Nails Average capillary refill time

No clubbing.
Tar staining No tar staining.
IE signs No signs of IE.
Radial pulse Radial pulse is ~, regular rhythm, no R-R delay, no
collapsing pulse.
BP ABP is ~.
Lower limbs
Scars No scars of graft harvest.
Edema No edema.
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Chest
Scars No scars (or midline sternotomy scar in VR, or Lt infra-

clavicular scar in pace maker).
Apex beats Apex beats are felt in 5 I C space MCL (or displaced in
AS)
Heaves No heaves (or LV heaves in AS).
Thrill No thrill (or thrill at 2 I C space Rt parasternal in AS,
thrill at apex in MR).
Auscultation
Mitral Audible pansystolic murmur over the apex, propagated

resurge to axilla and accentuated in Lt lateral position.
Aortic Audible ejection systolic murmur over 2 I C space Rt

stenosis parasternal, propagated to carotid and accentuated on
leaning forward.
Valve Audible metallic click of prosthetic valve.
replacement
Valve Audible metallic click of valve replacement with
replacement pansystolic murmur over the apex, propagated to axilla
+ and accentuated in Lt lateral position.
MR
Carotid No carotid bruits.
bruits
Basal No basal crepitations.
crepitations
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Abdominal Examination
Patient type, Provisional diagnosis and Positive findings
Acute cases (Actor)

Stem1: examine this patient present with Right upper quadrant pain.
Stem2: examine this patient present with Right lower quadrant pain
Stem3: examine this patient present with left lower quadrant pain and long
history of constipation.
Stem4: perform abdominal examination of this patient present with shoulder
tip pain and shortness of breath six days after LT hemicolectomy.
Anastomotic leak will be explained in CRISP protocol in stem4
Diagnosis and stem Positive Findings

Acute appendicitis Tender RT iliac fossa, positive
Right lower quadrant pain Rebound tenderness, and Rovsing,
Obturator and Psoas sign.
Acute cholecystitis Tender Rt hypochondrium and
Right upper quadrant pain positive Murphy sign.
Acute diverticulitis Tender LIF
with left lower quadrant pain and
long history of constipation
Cold cases (Real patient) Paraumbilical or Incisional hernia:
Stem5: perform abdominal examination.
There is a swelling in the peri-umbilical region (elsewhere over the abdomen in
incisional hernia), increasing in size on coughing. Scar of previous operation (in
incisional hernia), there is a palpable mass in the periumbilical region (supra,
infra, Rt, Lt) to the umbilicus (or over the scar of previous operation in incisional
hernia), the swelling is not tender, shows expansile impulse on cough, doughy
in consistency, reducible and defect size is ~ cm or ~ fingers).
Patient position: Lying on the bed.
Patient Exposure: nipple to mid-thigh. (keep patient shorts).
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1.Inspection
A. General:
1. Bed side medication, O2 cylinder or chars or ECG.
2.legs (edema or tender calf muscles).
3.Hand (pallor, clubbing, leukonychia, Koilonychia
Asterixis)
4. Arms and Trunk (spider naevi, purpura, petechiae,
scratch marks or Gynecomastia)
4.Neck (Neck veins, carotid pulsation and Virchow lymph
node).
6. Eye (pallor).
B. Abdomen:
2.Superfacial Palpation and hernia palpation.
3.Deep Palpation and percussion
A. Rebound tenderness, Rovsing, Obturator and psoas sign
B. palpate liver, Murphy sign and percussion for liver.
C. palpate and percussion for spleen.
D. Bimanual palpation for kidneys.
E. Aortic palpation.
F. Percussion for bladder.
G. Shifting dullness for ascites.
4.Auscultation A. Bowel sounds.
B. Arterial bruit (Aorta, renal and iliac arteries)
C. Liver bruit.
D. Auscultate hernia.
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Tips and tricks

During examination of hernia and while the patient is lifting his head off the
bed or coughing, examine hernia like any swelling and don’t forget to
measure and listen to hernia.
During superficial palpation, last area to palpate in acute appendicitis is right
iliac fossa, in acute cholecystitis in upper right quadrant ang in acute
diverticulitis is left iliac fossa.
Don’t do deep palpation of left iliac fossa on acute diverticulitis
Don’t percuss liver in acute cholecystitis.
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Wash your hands.
Today I’ve been asked to examine your tummy that would include looking
feeling and listening to your tummy, also examining your hands and legs, are
you OK with this?
(Legs: edema and tender calf muscles).
Hands pallor, clubbing, leukonychia, Koilonychia Asterixis and radial pulse)
(Arms and Trunk: spider naevi, purpura, petechiae, scratch marks or
Gynecomastia)
(Neck: Neck veins, carotid pulsation, Virchow lymph node)
(Eye: pallor).
Now, I will take a close look to your tummy?
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Would you please lift your head of the bed?
(Inspection from the side and end of the bed)
(Inspection for: Scratch marks Swelling, distension, Caput medusae, Skin
changes (bruising, signs of weight loss), Scars Striae, Any visible pulsations. Ask
the patient to cough or lift his/ her head off the bed to reveal any hernia or
signs of peritonism (the patient will experience pain in LIF))
(In hernia inspect for: site, size, shape, surface, scars and signs of
inflammation)
Now, I will feel your tummy, do you have any pain at the moment?
(Ask the examiner for a chair and complete the examination sitting)
(Superficial palpation followed by deep palpation)
(In Superficial palpation, palpate all nine distinct areas of the abdomen
starting furthest from you, unless the patient indicates an area of pain, last
area to palpate in acute appendicitis is right iliac fossa, in acute cholecystitis
in upper right quadrant ang in acute diverticulitis is left iliac fossa)
(During examination of hernia and while the patient is lifting his head off the
bed or coughing, examine hernia like any swelling and don’t forget to measure
and listen to hernia)
(palpation of hernia: Temperature, tenderness, consistency, pulsatility, edges,
Surface, reducibility and fluctuation)
(Kneel down at the patient’s right side. Ask the patient if there is any
generalized pain or localized pain. Palpate all nine distinct areas of the
abdomen starting furthest from you, unless the patient indicates an area of
pain, in which case palpate this area last. Look at patient’s face for signs of
pain while palpating. Palpate the abdomen with flattened fingers. start by
superficial palpation of the nine quadrants then by deep palpation and feel the
presence of any masses)
(Deep palpation: after palpation of liver, percuss upper border of liver
perform Murphy’s test and after palpation of spleen percuss the spleen then.
Bimanual palpation for kidneys, aortic palpation, percussion for bladder and
shifting dullness for ascites)
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(Rebound tenderness, Rovsing, Obturator and Psoas signs)

(Rovsing’s sign: Pressure in the LIF causes pain in the RIF with appendicitis.
Obturator sign: Ipsilateral hip and knee are flexed; internal rotation of the hip
(heel moves outwards) stretches obturator internus, which causes pain if in
contact with an inflamed appendix. Psoas sign: Inflammatory processes in the
retroperitoneum irritate the psoas muscle, causing ipsilateral hip flexion,
Straightening the leg causes further pain)
(Don’t do deep palpation of left iliac fossa on acute diverticulitis, don’t percuss
liver in acute cholecystitis)
(Liver: Start in the right iliac fossa, asking the patient to take deep breaths in
and out. Move your hand upwards towards the costal margin during
inspiration until you feel a liver edge on expiration. If the liver is palpable check
the: Size (record enlargement in cm below costal margin). Texture (soft / firm
/ hard / nodular). Edge (smooth / irregular) An irregular liver edge suggests
metastases. Murphy’s test: With your hand in the position of the gallbladder,
fingers pointing up, ask the patient to take a deep breath in and out. Pain on
expiration as the gallbladder comes to rest against your fingertips is a positive
Murphy’s test)
(Liver: Start in the right iliac fossa, asking the patient to take deep breaths in
and out. Move your hand upwards towards the costal margin during
inspiration until you feel a liver edge on expiration. If the liver is palpable check
the: Size (record enlargement in cm below costal margin), Texture (soft / firm
/ hard / nodular), Edge (smooth / irregular) An irregular liver edge suggests
metastases, Murphy’s test: With your hand in the position of the gallbladder,
fingers pointing up, ask the patient to take a deep breath in and out. Pain on
expiration as the gallbladder comes to rest against your fingertips is a positive
Murphy’s test)
(Spleen: Start palpating in the right iliac fossa, using the same breathing
technique as for liver palpation. However, this time move gradually towards
the left upper quadrant. Note the size, texture and edge of the spleen)
(Kidneys: ‘Ballot’ the kidneys using both hands)
(Abdominal aorta: Palpate in the region of the lower epigastrium/ upper
umbilical area, slightly towards the left of the mid-line, deeply for a pulsatile
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mass. Note the approximate diameter by using both hands to feel the lateral
edges of the mass)
(Percussion: Upper liver border, Spleen, Bladder, Ascites: Start by percussing in
the midline towards either flank and note any change in pitch from resonant
to dull, indicating fluid. If there is dullness, keep your finger on this area and
ask the patient to roll onto his/ her side so that the dull area is now superior.
Percuss again and note any change in pitch back to resonance. If present, this
is shifting dullness)
Now, I will listen to your tummy? (using cone of stethoscope)
(Auscultation: Over the left iliac fossa for bowel sounds, Over the liver for a
bruit, Over the aorta, iliac vessels, Bowel sounds and the renal arteries for
bruits and over hernia if present)
Wash your hands.
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Presentation
To complete my examination, I would like to feel the hernial orifices, examine
external genitalia (e.g., for testicular atrophy in chronic liver disease) and
perform digital rectal examination.
Acute appendicitis
Today I have examined this gentleman who present with Rt iliac fossa pain. I did
not notice any abnormality in general examination of the patient. ON
examination of his abdomen I noticed Right iliac fossa tenderness, rebound
tenderness, positive rovsing, obturator and psoas signs. Both liver and spleen
are not palpable, no abnormality regarding bimanual palpation of both kidneys.
By percussion upper border of liver is in # ICS. no audible bruit over aorta, iliac
or renal arteries by auscultation.
My main differential diagnosis is acute appendicitis.
Also, I have to consider acute appendicitis, leaking duodenal ulcer, pelvic
inflammatory disease, salpingitis, ureteric colic, inflamed Meckel’s
diverticulum or Crohn’s disease.
Acute cholecystitis
Tender Rt hypochondrium and positive Murphy sign.
Acute diverticulitis
Tender LIF.
Paraumbilical or Incisional hernia:
There is a swelling in the peri-umbilical region (elsewhere over the abdomen in
incisional hernia), increasing in size on coughing. Scar of previous operation (in
incisional hernia), there is a palpable mass in the periumbilical region (supra,
infra, Rt, Lt) to the umbilicus (or over the scar of previous operation in incisional
hernia), the swelling is not tender, shows expansile impulse on cough, doughy
in consistency, reducible and defect size is ~ cm or ~ fingers).
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Questions:
Acute diverticulitis
Differential diagnosis of LIF pain:
Diverticulitis.
irritable bowel syndrome.
pelvic inflammatory disease.
rectal carcinoma.
ulcerative colitis.
ectopic pregnancy.
If CT shows only sigmoid wall thickening with one locule of gas seen, what will
be your management?
antibiotics: co-amoxiclav, garamycin, clindamycin.
Bowel rest.
DVT prophylaxis.
If no response to antibiotics, what will you do?
percutaneous drainage.
Hartman’s procedure.
Acute cholecystitis
Differentials:
Acute cholecystitis
Ascending cholangitis
PUD
Lower lobe pneumonia
Acute pancreatitis
Renal pathology
Investigations:
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liver function tests

Urea and electrolytes
Full blood count
CRP
Abdominal ultrasound may show dilated CBD and IHBR or my show CBD stone
MRCP
Treatment:
conservative treatment: (nil by mouth, intravenous fluids, antibiotics /3rd
generation cephalsporins + metronidazole, nasogastric suction if appropriate)
Surgical treatment: cholecystectomy in 5 days if conservative treatment fails
Acute appendicitis
Differentials:
acute appendicitis
leaking duodenal ulcer
pelvic inflammatory disease
salpingitis
ureteric colic
inflamed Meckel’s diverticulum
ectopic pregnancy
Crohn’s disease
Complicated ovarian cyst
Investigations:
urine analysis
Urea and electrolytes
Full blood count
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Abdominal ultrasound
Ct abdomen and pelvis
Treatment:
Appendectomy (open - laparoscopic)
What will you do if you encountered blood in the peritoneal cavity while doing
appendectomy?
I will call for an obstetric surgeon (may be ruptured ectopic pregnancy)
I will order group and save.
I will have to perform appendectomy eventually.
Paraumbilical hernia
Treatment
open or laparoscopic mesh repair is possible. At open surgery, the mesh can be
inserted as an onlay, inlay, sublay or intraperitoneal position.
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Diverticulitis Cholecystitis Appendicitis Paraumbilical and

Incisional hernia
General - No jaundice or pallor- No signs of dehydration- No enlarged cervical
lymph nodes- No skin changes over the trunk- No asterixis, no clubbing
or nail changes
Local - No swelling - There is a swelling in
1. the peri-umbilical region
Inspection (elsewhere over the
abdomen in incisional
hernia) - Increasing in
size on coughing
Local - No scars - Scar of previous
Inspection operation (in incisional
hernia)
Local - No abdominal distention- No scratch marks- No skin changes- No
Inspection visible pulsations
Light - No palpable masses - There is a palpable
palpation mass in the peri-
Light Tender LIF Tender Rt Tender RIF umbilical
- There is region (supra,
a palpable
palpation hypochondrium mass in the peri-
umbilical region (supra,
infra, Rt, Lt) to the
umbilicus (or over the
scar of previous
operation in incisional
hernia) - The swelling is
not tender, shows
expansile impulse on
cough, doughy in
consistency, reducible -
Defect size is ~ cm
Deep - No palpable masses - There is a palpable
palpation mass in the peri-
umbilical region (supra,
infra, Rt, Lt) to the
umbilicus (or over the
scar of previous
hernia)
- The swelling is not
tender, shows
cough, doughy in
consistency, reducible -
Defect size is ~ cm
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Deep Don’t do LIF Don’t do Rt Elicit - There is a palpable

palpation hypochondrium Rebound mass in the peri-
tenderness umbilical region
(supra, infra, Rt, Lt) to
the umbilicus (or over
the scar of previous
hernia) - The swelling
is not tender, shows
cough, doughy in
consistency, reducible
- Defect size is ~ cm
Palpation & - Liver is not enlarged- Spleen is not enlarged- Kidneys show not tender
Percussion renal angle- No palpable pulsatile masses- No abdominal collection by
percussion
Special - Murphy sign - Rebound
signs tenderness
- Rovsing
- Obturator
- Psoas
Auscultation - Normal bowel sounds

- No audible bruits over aorta, renal, iliac arteries
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Breast Examination
Stem: male patient,50-year-old man, drinks 30units per week, 20cigarrettes
examine patient breast or abdomen and breast.
Patient position: start by sitting on the bed
Provisional diagnosis: Gynecomastia.
Positive Finding: Diffuse bilateral breast enlargement with or without tender
disc felt under the areola and diffuse abdominal enlargement with central
umbilicus (obesity), or free.
Either you will be asked to examine the patient breast only and, in this case,
offer to examine patient abdomen or you will be asked both breasts and
abdomen.
There could be no positive findings and the patient is free. So, the examiner
will ask you what will you do to this patient if he had gynecomastia.
You will ask for a chaperon if the patient is female only. IN MRCS, BREAST
PATIENT IS MALE.
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1. Inspection
A. Arm by sides
1. Scars.
2. Asymmetry.
3. skin changes.
4. Nipple changes.
5. masses.
B. Hands on hips (tense pectoralis muscle).
C. While arms above the head
1. Dimpling.
2. Puckering.
3. masses.
D. Patient pushes against examiner shoulder (tense serratus
anterior).
2. Palpation (breast and axillary tail)
A. Superficial Palpation
B. Deep Palpation.
3. Palpation for axillary, cervical, supraclavicular and infraclavicular lymph
nodes.
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Wash your hands.
Today I’ve been asked to perform a breast examination, do you understand what
this will involve? The examination will involve me first inspecting the breasts,
then placing a hand on the breasts to assess the breast tissue. Finally, I will
examine the glands of your neck and armpit.
Would you please, sit upright on the side of the bed?
I will start by taking a close look to your breasts.
Would you please squeeze your RT nipple, Lt one?
Would you please, put your hands on your hip and press? (Pectoralis major)
Would you please, put your arms above your head and lean forward?
Would you please, push against my LT shoulder using your Rt hand? (serratus
anterior)
(Inspection: Arms by side: Position the patient with their hands on their thighs
relaxed. Scars – small scars (lumpectomy) / large diagonal scars (mastectomy),
Asymmetry – healthy breasts are often asymmetrical, Masses – note the size
and position- look for overlying skin changes. Skin changes: Erythema –
infection / superficial malignancy, Puckering – may indicate an underlying
malignant mass Peau d’orange – cutaneous oedema – inflammatory breast
cancer. Nipple changes: Retraction – congenital / underlying tumour / ductal
ectasia, Discharge – may indicate infection or malignancy, Scale – may indicate
Eczema or Pagets disease. Hands on hips: Ask patient to place hands on their
hips and push inwards (to tense pectoralis major). Repeat inspection. Observe
for any masses once again: If a mass is noted, observe to see if the mass moves
with the pectoralis muscle This is known as tethering and suggests invasive
malignancy. Arms above head: Ask patient to place both hands behind their
head. Inspect the breast tissue for any evidence of: Masses, Asymmetry,
Dimpling / puckering. Ask the patient to now lean forwards, keeping their
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hands behind their head. Repeat inspection of the breast tissue as above. This
position will exacerbate any skin dimpling / puckering which may relate to an
underlying mass.)
Would you please, lie down on the bed and put your RT hand behind your head?
Now, I will feel your breast, do you have any pain at the moment?
(Palpation: Breast: Examine the “normal” asymptomatic breast first. Ensure to
warm your hands before touching the patient. Position the patient laid on the
bed at a 45-degree angle. Ask the patient to place their hand on the side being
examined behind their head. Use the flat of your fingers to compress the breast
tissue against the chest wall, feeling for any masses. Use a systematic
approach to ensure all areas of the breast are examined: Clock face method –
examine each “hour” of the breast. Spiral method – start at the nipple and
work outwards in a concentric circular motion. Axillary tail: Palpate the axillary
tail of breast tissue. Nipple: ask the patient to squeeze the nipple to
demonstrate the presence of discharge: Yellow / green discharge – suggestive
of infection, Bloody discharge – more suspicious of malignancy – e.g.
papilloma).
Would you please sit up at the edge of the bed?
Now, I will feel tour armpit, do you have any pain at the moment?
(Axilla: Have the patient sit on the edge of the bed facing you. Support the
patient’s arm on the side being examined with your forearm. If you’re
examining the right axilla, use your right arm to support the patient’s (vice
versa for left). Palpate the axilla with your free hand, ensuring to cover all
areas of the axilla: Medial / lateral / anterior / posterior walls Apex of the
axilla, Note any lymphadenopathy – malignancy / infection. Other lymph
nodes: Finally perform a general lymph node examination of the following
areas: Cervical, Supraclavicular, Infraclavicular and Parasternal).
Wash your hands.
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Presentation
To complete my examination, I would like to:
Examine Visual field to rule out hyperprolactinemia.
Check thyroid status to rule out Hypothyroidism.
Do Chest examination to rule out Bronchial carcinoma.
Do abdominal examination to detect liver enlargement (Liver Cirrhosis) Check
sign of Renal failure.
Examine external genitalia to rule out Hypogonadism.
Examine both testes to rule out Testicular tumors.
Today I have examined this gentleman presented by bilateral breast
enlargement and on inspection (arm by side, on hips, above head) I noticed
bilateral symmetrical breast enlargement, no scars, masses or nipple discharge
or retraction and on palpation no masses and there is palpable tender or non-
tender disc under the areola. Axillary tail and axillary lymph nodes are free
My main differential diagnosis is bilateral gynecomastia.
Questions
Bilateral gynecomastia which may be due to:
liver cirrhosis due to alcoholism (the main probable cause in this patient) as a
result of failure of the liver to metabolize estrogens.
Bronchial carcinoma.
Pituitary tumors (prolactinoma).
Hyperthyroidism.
Testicular tumors.
Renal failure.
Hypogonadism.
Drug related.
Senility.
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Workup:
Laboratory studies:
serum chemistry panel may be helpful in evaluating for renal or liver disease.
Free or total testosterone, luteinizing hormone (LH), estradiol, and
dehydroepiandrosterone sulfate levels are used to evaluate a patient with
possible feminization syndrome.
thyroid-stimulating hormone (TSH) and free thyroxine levels if hyperthyroidism
is suspected.
Serum prolactin levels, if pituitary tumors were suspected.
Testicular tumor markers.
Imaging studies:
mammogram if one or more features of breast cancer are apparent upon
clinical examination.
This can be followed by fine-needle aspiration or breast biopsy, as the case
merits.
Testicular ultrasonogram if the serum estradiol level is elevated and the clinical
examination findings suggest the possibility of a testicular neoplasm.
Abdominal ultrasound to detect liver cirrhosis.
Chest x ray to rule out chest malignancies.
Treatment:
treatment of the underlying cause.
Surgical:
Reduction mammoplasty or mastectomy with preservation of the areola and
nipple can be performed.
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I examined this patient presented by bilateral breast enlargement
On inspection (arm by side, on hips, above head)
Skin There is no erythema.

Asymmetry Both breasts are symmetrical.
Mass No visible masses.
Scars There is no overlying scar.
Nipple No nipple retraction or discharge.
On palpation (semi-sitting 45-degree, hand on side & behind head)
Mass There are no palpable masses over the breast or

axillary tail.
Nipple No nipple discharges.
Axilla Axillary walls are free.
Axillary LN No palpable LNs.
Lymphadenopathy No other lymphadenopathy.
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CCrISP
(Care of the Critically Ill Surgical Patient)
Two station either pulmonary embolism or
anastomotic leak
How could you differntiate between anastomotic leak and pulmonary
embolism?
Anastomotic leak Pulmonary embolism

LT hemicolectomy Either abdominal surgery or total hip
arthroplasty
Post-operative day six Post-operative day 8
(POD 6) (POD8)
Presented by shortness of breath and Presented by chest pain, no tummy
LT shoulder tip pain pain
Patient is wearing TEDs NO TEDs
You will not examine the chest from You will examine the chest from the
the back back
Lower abdominal midline incision Lower abdominal midline or hip scar,
(you will offer to remove the plaster), airway is patent, breathing: No
light abdominal palpation revealed central cyanosis trachea is central,
sever tenderness, so I shifted to equal chest wall movement
CCrISP: airway is patent, breathing: bilaterally, normal percussion note
No central cyanosis bilaterally and equal air entry
trachea is central, equal chest wall bilaterally with no added sounds
movement bilaterally, normal (Anterior , Lateral and posterior walls
percussion note bilaterally and equal ), circulation: No signs of
air entry bilaterally with no added dehydration, no congested neck
sounds (Anterior and Lateral walls veins and normal heart sounds,
only no posterior), circulation: No Disability : Patient is alert, Exposure:
signs of dehydration, no congested calf muscles are tender and by
neck veins and normal heart sounds, reviewing patient charts I noticed
Disability : Patient is alert, Exposure: Tachycardia and increasing o2
Patient is wearing TEDS( you will requirements .
offer to remove it) and calf muscles
are not tender and by reviewing
patient charts I noticed rising temp,
223 | P a g e
rising pule rate, decreasing blood

pressure, increasing o2
requirements, leukocytosis in FBC,
and AF in ECG.
Stem1: examine patient or patient abdomen who is presented with shortness

of breathing POD 6, left shoulder tip pain, after left hemicolectomy.
Stem2: examine patient or patient chest who is presented with chest pain POD
8 after hip replacement or abdominal surgery.
Patient Type: actor

Patient position: Lying on the bed.
You will be provided with patient file including vital

charts, FBC and ECG
You will examine Patient and read charts in six
minutes
You will examine the chest from the back only in
pulmonary embolism
You don’t have to have to measure pulse or blood
pressure because they are provided in patient chart
224 | P a g e

1.Superfacial palpation of the abdomen in a case of anastomotic leak or
notice that the patient has chest pain.
2.Start CCrISP.
A. Airway.
B. Breathing.
1.mouth for cyanosis.
2. Trachea central or not.
3.Chest wall movement.
4. Percussion
5. Auscultation
C. Circulation
1. mouth for dehydration.
2.eye for pallor.
3.neck veins.
4. Heart auscultation.
D. Disability (AVPU)
E. Exposure
1. Offer to expose wound dressing.
2. Squeeze Calf muscles for tenderness.
3. Review Patient charts and file
(You have to examine the patient in the order of ABCDE of CCrISP)
(You will examine the patient in supine position)
225 | P a g e
Wash your hands.
May I remove your oxygen mask, so I can hear you? (pulmonary embolism)
Today I’ve been asked to examine your tummy (POD6 Anastomotic leak) or
chest (pulmonary embolism) that would include looking feeling your tummy or
your chest, also, examining other parts of your body, are you OK with this?
Do you have any pain at the moment? Would You please point to the site of the
pain, please?
Do You mind if I feel your tummy and please tell me if you feel any pain, I will be
gentle with you? (anastomotic leak)
Now, I will uncover you.
(Start superficial palpation of RT iliac fossa, patient will jump in pain, so you
will shift to CCrISP because this is an acute abdomen)
(In pulmonary embolism, after the patient tells you that he has chest pain start
CCrISP or you can ask the patient (do you have tummy pain?) He will say NO,
after that start CCrISP).
(Airway: patient is speaking: patent airway)
Could you please, open your mouth and stick out your tongue, could you please
stick up your tongue?
Now, I am going to feel your wind pipe.
Now, I am going to take a close look to your chest?
Now, I am going to feel your chest.
Now, I am going to listen to your chest.
(Breathing: mouth for cyanosis and signs of dehydration, then Trachea
central or not, then chest wall movement then percussion and lastly
auscultation)
Would you please sit upright for me?
226 | P a g e
Now, I am going to take a close look to your chest?

Now, I am going to feel your chest.
Now, I am going to listen to your chest.
(examine chest from the back only in pulmonary embolism)
Would you please, lower your eyelid for me?
Now, I am going to take a close look to your neck.
Now, I am going to listen to your heart.
(Circulation: mouth for dehydration (already done in the previous step), then
eye for pallor, then neck veins then heart auscultation)
(Disability (AVPU): A: Alert, V: respond to verbal, P: respond to pain, U
unconscious) (Patient is alert)
May I expose the wound dressing? (Ask examiner)
Now, I will squeeze your leg?
(Exposure: offer to expose wound dressing, Squeeze Calf muscles for
tenderness)
Thank you, sir.
(Cover your patient and return O2 mask in a case of pulmonary embolism)
Wash your hands.
May I see patient charts and file? (Ask examiner)
(rising temp., rising blood pressure, increasing o2 requirements FBC
(leukocytosis) and his ECG shows AF in Anastomotic leak)
(Tachycardia, increasing o2 requirements, (O2 saturation is …. On …..L O2 )
227 | P a g e
Early Warning Chart (POD6 Anastomotic leak) (rising temp., rising blood
pressure, increasing o2 requirements)
228 | P a g e
Presentation
Anastomotic leak
I examined this patient presented by shortness of breath, Left shoulder tip pain.
On general inspection, the patient looks obviously having shortness of breath
and generalized abdominal pain. I started by doing light palpation on his right
iliac fossa , which showed that the patient was having severe abdominal
tenderness, so this patient looked critically ill and therefore I started assessing
the patient according to the CCRISP his airway is patent and assessing his
breathing: no central cyanosis, equal chest wall movements, percussion note
was normal, equal air entry with no added sounds and assessing his circulation:
no congested neck veins, no signs of dehydration and normal heart sounds. The
patient was alert. There was no any swelling or pain in his calves. His charts
showed: rising temp., rising blood pressure, increasing o2 requirements FBC
(leukocytosis) and his ECG shows AF.
So, my main diagnosis for that case is generalized peritonitis secondary to
anastomotic leakage which caused the patient to have sepsis. Shoulder tip pain
in such case may be due to the presence of intrabdominal collection causing
irritation of the diaphragm
Pulmonary Embolism
This patient presented with acute pleuritic chest pain and shortness of breath 8
days after a hip operation. He is hemodynamically stable, but had saturations
of 88% on 2L. This improved with high flow oxygen. They also had a swollen
painful left calf. Otherwise examination showed a clear chest with good bilateral
air entry and a normal percussion note making a pneumonia and pneumothorax
unlikely. An MI is possible but less likely due to the nature of the pain, however
I am awaiting an ECG and troponin.
My top differential is a pulmonary embolus.
229 | P a g e
Questions
Pulmonary Embolism
What investigation would you arrange now?
Assuming renal function was within acceptable limits I would arrange a CTPA to
exclude a PE.
Chest x-ray.
D- dimer.
ABG: respiratory alkalosis.
ECG: Right ventricular strain pattern – T wave inversions in the right precordial
leads (V1-4) ± the inferior leads (II, III, aVF).
Right axis deviation.
SI QIII TIII pattern – deep S wave in lead I, Q wave in III, inverted T wave in III.
What is the management of a pulmonary embolism?
Management follows the usual ALS sequence of securing the airway before
moving on to breathing where high flow oxygen is essential and then circulation.
Assuming this was all done, the management can be spilt into massive PE and
non-massive PE. Massive PE is characterized by hemodynamic compromise and
may require thrombolysis. I would put out a crash call if the patient presented
in this way to get urgent help.
If the patient is stable, treatment initially with a therapeutic dose of
subcutaneous heparin, followed by warfarin is warranted. I would involve the
appropriate medical team to follow this patient up.
If you were scrubbed in the theatre and have been updated with the patient
condition, what will you do?
I will put a crash call immediately
230 | P a g e
Anastomotic leak
Managment
NBM.
Urinary catheter to monitor output.
NG tube for suction and bowel rest.
May refer the patient to HDU to insert a central line and monitor Fluid
resuscitation by crystalloids.
I.V antibiotics.
Bloods: ABG, U&E.
Chest x-ray to rule out any respiratory problem.
CTPA to rule out PE.
Abdominal ultrasound to detect any abdominal collections.
CT with gastrograffin enema to identify the leaking anastomosis.
This patient will need urgent laparotomy:
Harman’s procedure plus good peritoneal toilet plus drainage.
231 | P a g e
POD6 Anastomotic Chest pain

leak
Light abdominal Very tender (start from Not tender (in
palpation RIF) abdominal
surgery scenario)
Scar Lower abdominal midline Lower abdominal
incision midline or hip scar
Airway - Patent
Breathing - No central cyanosis
- Trachea is central
- Equal chest wall movement bilaterally
- Normal percussion note bilaterally
- Equal air entry bilaterally with no added sounds
Anterior and Lateral walls Anterior, Lateral and

Posterior walls
Circulation - No signs of dehydration

- No congested neck veins
- Normal heart sounds
Disability - Patient is alert
Exposure - Wearing TEDS - Not wearing TEDS

- No swelling on - Tender (right or left)
tenderness on both calves calf
Chart review - rising temp. - Tachycardia
- rising pule rate - increasing o2
-decreasing blood requirements
pressure
- increasing o2
232 | P a g e
Inguinal hernia Examination

Stem: examine this patient groin.
Patient Type: real.
Patient Exposure: umbilicus to feet.
Provisional diagnosis and Positive Finding
1.(indirect) by inspection: the swelling turned to be in right groin region
occupying right inguinal (Inguinoscrotal) region, shows visible impulse on cough
and other side is free. By palpation: lies above and medial to pubic tubercle,
palpable impulse on cough, reducible (unless the patient couldn’t reduce the
swelling or it was painful to reduce), DIR (Deep inguinal ring) test is positive (or
I couldn’t be elicited), swelling is separable from testis, not trans-illuminating,
and scrotal neck was full.
2.(direct) Bilateral. By inspection: the swelling turned to be in right groin region
occupying right inguinal region, shows visible impulse on cough and also the
other side. By palpation: lies above and medial to pubic tubercle, palpable
impulse on cough, reducible (unless the patient couldn’t reduce the swelling or
it was painful to reduce), DIR test is negative (or I couldn’t be elicited), swelling
is not tender, not compressible, not pulsating and not associated with inguinal
lymphadenopathy and separable from testis, not trans-illuminating, and scrotal
neck was empty.
You will ask for a chaperon and you will not wear gloves during examination.
Best one to reduce the hernia is the patient himself.
The examination will be carried out while the patient is standing except if the
patient cannot reduce the hernia in standing position in DIR test then, he can
sleep down on the bed and reduce it.
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1. Inspection (Ask patient to cough, the other side too and inspect posterior
scrotum)
A. site.
B. size.
C. Shape.
D. scars.
E. Surface.
F. Overlying skin.
2. Palpation (ask patient to cough, and palpate the other side also).
A. Temperature.
B. Tenderness.
C. Edges.
D. Consistency.
E. Surface.
F. Pulsatility.
J. Compressibility.
K. Mobility.
L. Reducibility and DIR test and relation to pubic tubercle and inguinal
ligament.
M. Scrotal palpation
1. Scrotal neck examination.
2. palpate if the mass separable from the testis or not)
N. associated inguinal lymphadenopathy
3.Transillumination and measurement of the size.
4.Auscultation.
(standing position)
234 | P a g e
Wash your hands.
Today I’ve been asked to examine the lump present in your groin that would
include looking feeling and listening to the lump, one of the staff members will
be present throughout the examination, acting as a chaperone, is this ok?
Would you please take off your shorts and stand up for me?
I will start by taking a close look to your groin.
Would you please lift up your scrotum?
(Inspection: Site, Size, Shape, Scars, Surface, Overlying skin and visible impulse
on cough)
(inspection for the other side and external genetalia and posterior scrotum)
Now, I am going to feel the lump, do you have any pain at the moment?
Do you have any pain at the moment, could you reduce the lump?
Thank you, now I will put my hand on your groin, you can relax your hand.
(Palpation: relation to pubic tubercle and inguinal ligament, Temperature,
Tenderness, Edges, Consistency, Surface, Pulsatility, Compressibility, Mobility
(skin pinch test), Fluctuation, inguinal lymphadenopathy, Reducibility and DIR
test) (Scrotal palpation: Scrotal neck examination and palpate if the mass
separable from the testis or not)
(Tenderness: usually start palpation by tenderness to see if the examination is
painful or not)
(Temperature: using the dorsum of your hand and compare to the surrounding
skin)
(Consistency: superficial and deep palpation using palmer surface of your
fingers)
235 | P a g e
(Edges: feel the edges with the radial border of your index)
(skin pinch test: hold the skin between your thumb and index to see if the skin
is adherent to the mass)
(Pulsatility: feel pulsation using tips of index, middle and ring fingers)
(Fluctuation: is tested by placing the index and thumb finger of the one hand
(somewhat apart) on the swelling, with the index and thumb finger of the
other hand placed in between these two fingers. ... Fluctuation occurs when
the fingers of the one hand are forced upwards when pushing downwards with
the fingers of the other hand is medium size mass like direct hernia. In large
masses like indirect hernia, hold the mass between two hands, Fluctuation
occurs when the fingers of the one hand are forced upwards when pushing
downwards with the fingers of the other hand)
(Tenderness: Press on the lump and look at the patient’s face to see if they
grimace. Ask the patient if the lump is painful. Is the whole lump tender or just
a part of it? Temperature: Palpate the temperature using the back of your
hand, comparing to surrounding tissue, significantly increased temperature
suggests infection (e.g. abscess) and will normally be associated with
erythema, Consistency: Comment whether the lump is hard, firm, soft or
nodular Hard corresponds to the feel of your forehead, firm to the tip of your
nose, and soft to your lip. Tethering: Is the lump freely mobile, or is it tethered
to a structure such as skin or muscle? Malignant lumps are often fixed to
surrounding tissue. Pulsatility: Is the lump pulsatile? Pulsatility suggests
underlying vascular etiology (e.g. an aneurysm) Lymphadenopathy Palpate
the lymph nodes that drain the area the lump is located within (commonly the
inguinal lymph nodes are assessed when an inguinal hernia is suspected)
Lymphadenopathy surrounding the lump suggests either infective or
malignant etiology)
(Deep inguinal ring test: Ask the patient to reduce the hernia himself while
standing, then occlude the deep inguinal ring at midpoint of inguinal ligament
and ask the patient to cough, if could not reduce the hernia himself while
standing, ask the patient to lie down and then try again. If the patient can’t
reduce the hernia himself or he feels pain or refuse, don’t try to reduce it and
tell the examiner that you could not complete the test.)
(if nothing protrudes so it is indirect inguinal hernia, if something protrude it is
direct inguinal hernia)
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(Palpate inguinal lymph in the medial surface of the thigh and across the
inguinal ligament)
(Scrotal neck examination: full or not: full in indirect inguinal hernia, empty in
direct inguinal hernia)
(palpate if the mass separable from the testis or not)
(By palpation: lies above and medial to pubic tubercle, palpable impulse on
cough, reducible (unless the patient couldn’t reduce the swelling or it was
painful to reduce), DIR test is positive in indirect (or I couldn’t be elicited),
swelling is not tender, not compressible, not pulsating and not associated with
inguinal lymphadenopathy and separable from testis, not trans-illuminating,
and scrotal neck was full)
(measure the size of the hernia using measure tape)
(Transillumination: Ask the examiner to dim the light of the room, and put the
light source into the hernia, look through the cone (you will make from piece
of paper) Transillumination suggests that the lump is cystic (e.g. hydrocoele))
(hernia is not trans-illuminating)
Now, I will listen to your lump.
(Auscultation)
(there were some (no) gurgling sounds indicating presence (absence) of bowel)
Wash your hands.
237 | P a g e
Presentation
To complete my examination, I would like to perform complete abdominal
examination and chest examination.
Rt indirect inguinal hernia
Today I have examined this gentleman presented by RT groin swelling.
By inspection: the swelling turned to be in right groin region occupying right
inguinal (Inguinoscrotal) region, shows visible impulse on cough and other side
is free. By palpation: lies above and medial to pubic tubercle, palpable impulse
on cough, reducible (unless the patient couldn’t reduce the swelling or it was
painful to reduce), DIR test is positive (or I couldn’t be elicited), swelling is not
tender, not compressible, not pulsating and not associated with inguinal
lymphadenopathy and separable from testis, not trans-illuminating, and scrotal
neck was full.
By auscultation, there were some (no) gurgling sounds indicating presence
(absence) of bowel.
My main differential diagnosis is RT indirect inguinal hernia.
Also, I have to consider femoral hernia, lymph nodes, varicocele or a swelling
related to the testes, such as a hydrocoele, epididymal cyst, lipoma of the cord
or testicular tumor. Other differentials include infection such as orchitis or
epididymitis, testicular torsion, and a spermatocele.
Bilateral direct inguinal hernia
Today I have examined this gentleman presented by RT groin swelling.
By inspection: the swelling turned to be in right groin region occupying right
inguinal region, shows visible impulse on cough and also the other side. By
palpation: lies above and medial to pubic tubercle, palpable impulse on cough,
reducible (unless the patient couldn’t reduce the swelling or it was painful to
reduce), DIR test is negative (or I couldn’t be elicited), swelling is not tender, not
compressible, not pulsating and not associated with inguinal lymphadenopathy
and separable from testis, not trans-illuminating, and scrotal neck was empty.
By auscultation, there were some (no) gurgling sounds indicating presence
(absence) of bowel.
My main differential diagnosis is bilateral direct inguinal hernia.
238 | P a g e

related to the testes, such as a hydrocoele, epididymal cyst, lipoma of the cord
or testicular tumor. Other differentials include infection such as orchitis or
epididymitis, testicular torsion, and a spermatocele.
Questions
What are the differentials for a scrotal swelling?
Common differentials include a hernia e.g. an inguinal or femoral hernia, lymph
nodes, varicocele or a swelling related to the testes, such as a hydrocoele,
epididymal cyst, lipoma of the cord or testicular tumor. Other differentials
include infection such as orchitis or epididymitis, testicular torsion, and a
spermatocele.
Management
Inguinal hernia: mesh repair (open). Laparoscopic if bilateral or recurrent.
239 | P a g e
Types of repair:
Lichtenstein repair: Once the hernia sac has been removed and any medial
defect closed, a piece of mesh, measuring 8 × 15 cm, is placed over the
posterior wall, behind the spermatic cord, and is split to wrap around the
spermatic cord at the deep inguinal ring. Loose sutures hold the mesh to the
inguinal ligament and conjoint tendon.
Modified Bassini`s Herniorrhaphy: Conjoined tendon and inguinal ligament are
approximated using interrupted non- absorbable monofilament sutures
(polypropylene).
240 | P a g e
I examined this patient presented by Rt groin swelling,
On inspection
Site The swelling turned to be in right groin region occupying

right inguinal (Inguinoscrotal) compartment
Scars There is (+/-no) scar of previous operation
Skin The skin shows no signs of inflammation
Cough The swelling shows visible impulse on cough
Other side Inspection of other side is free
On palpation
Other side By palpation, the other side was free

Cough Showing palpable impulse on cough
Temperature On palpation the skin has normal temperature
Tenderness The swelling was non-tender
Relation to It lies above and medial to pubic tubercle
pubic
tubercle
Reducibility The swelling was reducible (unless the patient couldn’t
reduce the swelling or it was painful to reduce)
DIR test positive (or I couldn’t be elicited)
On examining the scrotum:
Scrotal neck The scrotal neck was full (inguinoscrotal) or empty

(bubonocele)
Testis The swelling is separable from testis
Transillumination The swelling is not trans illuminating
By auscultation
There were some (no) gurgling sounds indicating presence (absence) of
bowel
241 | P a g e
Hydrocele Examination
Stem: examine patient groin.
Patient Type: real.
Patient Exposure: umbilicus to feet.
Provisional diagnosis: Hydrocele.
Positive Finding: By inspection: The swelling is completely scrotal with no visible
swelling in Rt groin region, 3x4cm in size, Oval in shape, Regular surface, no
visible impulse on cough and other side is free. By palpation: The swelling is
purely scrotal, with smooth surface, soft consistency, not tender, not
compressible, not pulsating and not associated with inguinal lymphadenopathy,
scrotal neck is empty, isn’t separable from testis and shows transillumination.
The examination will be carried out while the patient

is standing.
You will ask for a chaperon and you will not wear
gloves during examination.
242 | P a g e

1. Inspection (Ask patient to cough and inspect posterior scrotum and the
other side too)
A. site.
B. size.
C. Shape.
D. scars.
E. Surface.
F. Overlying skin.
2. Palpation (ask patient to cough, and palpate the other side also).
A. Temperature.
B. Tenderness.
C. Edges.
D. Consistency.
E. Surface.
F. Pulsatility.
G. Compressibility.
H. Reducibility
I. Mobility
J. Scrotal neck examination.
K. palpate if the mass separable from the testis or not)
L. associated inguinal lymphadenopathy (palpate inguinal lymph node).
3.Transillumination and measurement.
4.Auscultation.
(standing position)
243 | P a g e
Wash your hands.
Today I’ve been asked to examine your groin and genetalia that would include
looking feeling, one of the staff members will be present throughout the
examination, acting as a chaperone, is this ok?
Would you please take off your shorts and stand up for me?
I will start by taking a close look to your groin.
Would you please lift up your scrotum?
(Inspection: Site, Size, Shape, Scars, Surface, Overlying skin and visible impulse
on cough)
(inspection for the other side, groin and posterior scrotum)
(The swelling is completely scrotal with no visible swelling in Rt groin region,
3x4cm in size, Oval in shape, Regular surface, no visible impulse on cough and
other side is free)
(Palpation: relation to pubic tubercle and inguinal ligament, Temperature,
Tenderness, Edges, Consistency, Surface, Pulsatility, Compressibility, Mobility
(skin pinch test), Fluctuation, inguinal lymphadenopathy, Reducibility, Scrotal
neck examination and palpate if the mass separable from the testis or not)
painful or not)
skin)
fingers)
244 | P a g e
the fingers of the one hand are forced upwards when pushing downwards with
the fingers of the other hand is medium size mass like direct hernia. In large
masses like indirect hernia, hold the mass between two hands, Fluctuation
occurs when the fingers of the one hand are forced upwards when pushing
downwards with the fingers of the other hand)
malignant etiology)
(Palpate inguinal lymph in the medial surface of the thigh and across the
inguinal ligament)
(Scrotal neck examination: full or not: full in indirect inguinal hernia, empty in
direct inguinal hernia and hydrocele)
(palpate if the mass separable from the testis or not)
(measure the size of the mass using measure tape)
245 | P a g e
(The swelling is purely scrotal, fluctuating, with smooth surface, soft

consistency, not tender, not compressible, not pulsating and not associated
with inguinal lymphadenopathy. scrotal neck is empty, isn’t separable from
testis)
light source into the scrotum, look through the cone (you will make from piece
of paper) Transillumination suggests that the lump is cystic (e.g. hydrocoele))
(shows transillumination)
(Auscultation for bruit using cone of stethoscope)
Wash your hands.
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247 | P a g e
248 | P a g e
Presentation
To complete my examination, I would like to perform complete abdominal
examination and chest examination.
Today I have examined this gentleman. By inspection: The swelling is completely
scrotal with no visible swelling in groin region, 3x4cm in size, Oval in shape,
Regular surface, no visible impulse on cough and other side is free. By palpation:
The swelling is purely scrotal, fluctuating, with smooth surface, soft consistency,
not tender, not compressible, not pulsating and not associated with inguinal
lymphadenopathy. scrotal neck is empty, isn’t separable from testis and shows
transillumination
My main differential diagnosis is hydrocele.
related to the testes, such epididymal cyst, lipoma of the cord or testicular
tumor. Other differentials include infection such as orchitis or epididymitis,
testicular torsion, and a spermatocele
Questions:
What are the differentials for a scrotal swelling?
Common differentials include a hernia e.g. an inguinal or femoral hernia, lymph
nodes, varicocele or a swelling related to the testes, such as a hydrocoele,
epididymal cyst, lipoma of the cord or testicular tumor. Other differentials
include infection such as orchitis or epididymitis, testicular torsion, and a
spermatocele.
Management
249 | P a g e
250 | P a g e
Inspection
Site The swelling is completely scrotal with no visible
swelling in Rt groin region
Size It is 3x4cm in size
Shape Oval in shape
Surface Regular surface
Scars There are no scars of previous operation
Skin The skin shows no signs of inflammation
Cough There is no visible impulse on cough
Other side Inspection of other side is free
Palpation
Groin Rt groin region is free
Scrotum The swelling is purely scrotal
Surface With smooth surface
Tenderness The swelling is non-tender
Consistency And soft consistency
Scrotal neck The scrotal neck is empty

Separation And isn’t separable from testis
Transillumination The swelling shows transillumination
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Thyroid Gland examination

Stem: examine this patient present with neck swelling.
Patient Type: real.
Patient Exposure: expose his neck
Provisional diagnosis: Simple or toxic multinodular goiter.
Positive Finding: on inspection: the swelling turned to be in the front of neck in
midline, 5x7cm in size, butterfly in shape, with regular surface, the swelling is
mobile with swallowing and not mobile with tongue protrusion. By palpation:
nodular surface, well defined edges, firm in consistency, the swelling in mobile ,
not tender, not pulsatile, not compressible and not reducible, not attached to
overlying skin and not attached to underlying structures and not associated by
lymphadenopathy and not attached to overlying or underlying structures
(partially overlapped by sternomastoid muscle) and I could get below the
swelling, carotid pulses were equally felt bilateral and Trachea was central . By
percussion: The upper end of sternum is resonant denoting no retrosternal
extension of the swelling. By auscultation: There are no audible bruits heard
over the swelling. On examination of thyroid status: Patient is in euthyroid status
in simple multinodular goiter, thyrotoxic in toxic multinodular goiter.
Palpate Thyroid, submandibular, parotid and cervical

lymph node from the back.
252 | P a g e

A. Inspection
1. Mass(gland) (swallow water and tongue protrusion).
A. site.
B. size.
C. Shape.
D. scars.
E. Surface.
F. Overlying skin
2.inspect neck veins.
B. Palpation
(From the back)
1. Mass(gland) (swallow water and tongue protrusion).
A. Temperature.
B. Tenderness.
C. Edges.
D. Consistency.
E. Surface.
F. Pulsatility.
G. Compressibility.
H. Reducibility
I. Mobility.
J. Feel below the gland
2.. associated cervical lymphadenopathy (palpate cervical lymph node).
3. Exophthalmos.
(From front)
253 | P a g e
1. Palpate trachea.
2.Feel carotid pulse.
3. Relation to sternomastoid.
C. Percussion.
C. Auscultation.
E. Thyroid status
1.Hands (Tremors, radial pulse, biceps reflex).
2. Eyes (lid lag and eye movement).
3. Legs (pretibial myxoedema, knee reflex and proximal myopathy)
(Patient will be sitting except in proximal

myopathy)
254 | P a g e
Wash your hands.
Today I’ve been asked to examine your neck that would include looking feeling
and listening to your neck and moving your arms and legs, are you OK with this?
Would you please, lower down the collar of your gown
I will start by taking a close look.
Would you please take a sip of water for me?
Would you swallow it for me?
Would you please stick out your tongue for me?
(Inspection from both sides and from the back)
(Inspection:) (swallow water and tongue protrusion)
(Site, Size, Shape, Scars, Surface, Overlying skin and inspect neck veins)
Do you mind if I examine you from the back? Do you feel any pain at the
moment?
Would you please take a sip of water for me?
Would you swallow it for me?
Would you please stick out your tongue for me?
((gland) (swallow water and tongue protrusion).
(Temperature, Tenderness, Edges, Consistency, Surface, Pulsatility,
compressibility, Reducibility, Mobility, associated cervical lymphadenopathy)
(Palpate the gland from the back with your thumbs behind the patient neck
and the rest of your finger in front of the patient neck)
(During palpation of the RT lobe, relax patient neck to the RT side, push the
LT lobe with your LT hand and palpate the RT lobe using your RT hand, and
vice versa for the LT lobe)
255 | P a g e

painful or not)
skin)
fingers)
(Feel below the gland)
(Palpation: Tenderness: Press on the lump and look at the patient’s face to see
if they grimace. Ask the patient if the lump is painful. Is the whole lump tender
or just a part of it? Temperature: Palpate the temperature using the back of
your hand, comparing to surrounding tissue, significantly increased
temperature suggests infection (e.g. abscess) and will normally be associated
with erythema, Consistency: Comment whether the lump is hard, firm, soft or
underlying vascular etiology (e.g. an aneurysm) Lymphadenopathy Palpate the
lymph nodes that drain the area the lump is located within (commonly the
malignant etiology)
Would you please raise your head little bit backward for me?
(look for the presence of exophthalmos)
Would you please push against my hand using your chin?
(Relation to sternomastoid)
(Percussion)
Would you please hold your breath, I will listen?
256 | P a g e
(Auscultation for bruit) (use the cone of the stethoscope)

Now, I will feel your wind pipe, it may feel uncomfortable?
(Palpate trachea)
Now, I will your neck pulse?
(Feel carotid pulse)
Would you please keep your head steady and follow my finger using your eyes
only?
(lid lag and eye movement)
(lid lag: Hold your finger high & ask the patient to follow it with their eyes
(head still) Move your finger downwards. Observe the upper eyelid as the
patient follows your finger downwards.)
(eye movement: Ask the patient to keep their head still & follow your finger
with their eyes. Move your finger through the various axis of eye movement (
“H “shape). Observe for restriction of eye movements & ask the patient to
report any double vision or pain)
Would you please, stretch your arms in front of you and close your eyes, (I will
put a paper on your hands)?
(Tremors)
Now you can open your eyes, I will your pulse?
(radial pulse)
(biceps reflex) (make sure patient arm is exposed during examining the reflex
and notice the contraction)
Would you please expose your legs, I will take a close to your legs?
(pretibial myxoedema)
(knee reflex) (make sure patient thigh is exposed during examining the reflex
and notice the contraction) (you can test ankle reflex instead)
Would you please, cross your arms across your chest and stand up for me?
257 | P a g e
(proximal myopathy)
Wash your hands
258 | P a g e
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261 | P a g e
262 | P a g e
263 | P a g e
Presentation
Today I have examined this gentleman presented by neck swelling and on
inspection: the swelling turned to be in the front of neck in midline, 5x7cm in
size, butterfly in shape, with regular surface, the swelling is mobile with
swallowing and not mobile with tongue protrusion. By palpation: nodular
surface, well defined edges, firm in consistency, the swelling in mobile , not
tender, not pulsatile, not compressible and not reducible, not attached to
lymphadenopathy and not attached to overlying or underlying structures
(partially overlapped by sternomastoid muscle) and I could get below the
swelling, carotid pulses were equally felt bilateral and Trachea was central . By
percussion: The upper end of sternum is resonant denoting no retrosternal
extension of the swelling. By auscultation: There are no audible bruits heard
over the swelling. On examination of thyroid status: Patient is in euthyroid status
in simple multinodular goiter, thyrotoxic in toxic multinodular goiter.
My main differential diagnosis is simple multinodular goiter (First scenario).
My main differential diagnosis is toxic multinodular goiter (Second scenario).
Also, I have to consider other cause like infection and malignancy.
Questions
How would you manage this patient?
I would perform a triple assessment, taking a history as well as my

examination, arrange an ultrasound and a fine needle aspiration or a biopsy.
Also, I have to check thyroid functions.
If the patient come back with pain on swallowing, difficulty in breathing few
months later, does it change your management?
Yes, these are obstructive symptoms requiring thyroidectomy.
Her FNA comes back showing a follicular cell tumor. The report says “
unable to differentiate carcinoma from adenoma”. Why is this?
264 | P a g e
Follicular carcinomas are differentiated from follicular adenomas as they

invade the tumor capsule or surrounding vessels. Therefore, histology rather
than simply cytology is needed.
What is the next step in the patient’s management following this

histological result?
This lady needs to be discussed in the MDT and worked up for a total or
hemithyroidectomy 5year survival rate of follicular carcinoma: more than 90%.
265 | P a g e
I examined this patient presented by front neck swelling
On inspection: the swelling turned to be

Site Front of neck in midline
Size About 5x7cm in size
Shape butterfly in shape
Surface With regular surface
Scar No scars of previous operations
Skin Overlying skin doesn’t’ show any signs of
inflammation
Neck veins Neck veins aren’t distended on both sides
Swallowing The swelling is mobile with swallowing
Tongue And not mobile with tongue protrusion
protrusion
On palpation: the swelling has

Surface Nodular surface
Edge Well defined edges
Consistency Firm in consistency
Temperature Skin overlying has normal temperature
Tenderness The swelling is not tender
Trachea Trachea was central
Lymph nodes There are no palpable lymph nodes
Pulsatility The swelling is not pulsatile
Fixity The swelling in mobile and not attached to overlying
or underlying structures (partially overlapped by
sternomastoid muscle)
Get below I could get below the swelling
Pulse And carotid pulses were equally felt bilateral
Do but not say Swallowing & tongue protrusion
On percussion:
The upper end of sternum is resonant denoting no retrosternal extension
of the swelling
On auscultation:
There are no audible bruits heard over the swelling
On examination of thyroid status:
Patient is in euthyroid status or thyrotoxic
266 | P a g e
Parotid Gland Examination

Stem: examine this patient present swelling in his face.
Patient Type: real.
Patient position: Sitting on a chair.
Patient Exposure: face and neck (unbutton the first two button in T shirt).
Provisional diagnosis: Pleomorphic adenoma.
Positive Finding: by inspection, the swelling is in the Rt parotid gland, 2x1 cm in
size, Oval in shape, regular surface, inspection of oral cavity for Stenson’s duct
revealed no surrounding inflammation and clear saliva and the contralateral side
is free and assessment of facial nerve branches bilaterally was normal. By
palpation: The swelling has nodular surface, well defined edges, Firm
consistency, mobile, not tender, not pulsatile, not compressible and not
reducible, not attached to overlying skin and not attached to underlying
structures and not associated by lymphadenopathy on palpation of Stenson’s
duct, there is no stones felt. On bimanual examination of the floor of mouth, the
deep lobe couldn’t be felt. The mass is not trans illuminating and no audible bruit
is present over the mass, and the other side is free.
Ask the patient to point out the lump if not clearly

visible.
You will wear gloves in this station.
267 | P a g e

A. Inspection
1. Mass(gland) and Other side. A. site.
B. size.
C. Shape.
D. scars.
E. Surface.
F. Overlying skin
2.Oral cavity (Stenson’s duct).
3.Facial nerve benches.
B. Palpation 1. Mass(gland) and Other side. A. Temperature.
B. Tenderness.
C. Edges.
D. Consistency.
E. Surface.
F. Pulsatility.
G. Compressibility.
H. Reducibility
I. Mobility.
J. associated cervical lymphadenopathy (palpate cervical lymph node).
C. Measurement, Transillumination and auscultation.
D. Bimanual palpation of deep lobe of the gland and Stenson’s duct.
(Patient will be sitting)
268 | P a g e
Wash your hands.
Today I’ve been asked to examine the gland present in your face that would
include looking feeling the gland, are you OK with this?
Would you please, lower down the collar of your gown?
I will start by taking a close look to your face.
Could you please clench your teeth for me?
(Inspection from both sides and from the front for both glands)
(Inspection: Site, Size, Shape, Scars, Surface, Overlying skin)
Would you please raise your eye brows? (Temporal)
Would you please close your eyes and don’t let me open them? (Zygomatic)
Would you please blow your cheeks? (Buccal)
Would you please show me your teeth? (Marginal mandibular)
Would you please tense your neck muscles? (Cervical)
(Facial nerve branches examination)
(inspect the stensen’s duct (at the level of the upper 2nd molar tooth), use
tongue depressor to visualize the duct opening or the patient can visualize the
duct opening using his finger)
Do you mind if I examined you from the back, I will feel the gland?
(Palpation for both glands: Temperature, Tenderness, Edges, Consistency,
Surface, Pulsatility, compressibility, Reducibility, Mobility, associated cervical
lymphadenopathy)
painful or not)
269 | P a g e
skin)
fingers)
(Palpation: Tenderness: Press on the lump and look at the patient’s face to
see if they grimace. Ask the patient if the lump is painful. Is the whole lump
tender or just a part of it? Temperature: Palpate the temperature using the
back of your hand, comparing to surrounding tissue, significantly increased
malignant etiology)
light source into the mass, look through the cone (you will make from piece of
paper)
Would you please open your mouth for me, I will feel inside?
(Bimanual palpation of deep lobe and stensen’s duct)
(wear gloves and put your index and middle finger in the vestibule of the cheek,
other hand on the gland outside and palpate the deep lobe, then bimanually
palpate the stensen’s duct)
270 | P a g e
Thank you, sir.

Wash your hands.
271 | P a g e
Parotid gland swelling and cervical lymph node examination
272 | P a g e
Palpation of parotid lymph node
Bimanual palpation
Facial nerve examination
273 | P a g e
Presentation
To complete my examination, I would like to perform ENT examination and
examine other salivary glands.
Today I have examine gentleman present by swelling in his RT parotid area and
by inspection, the swelling is in the Rt parotid gland, 2x1 cm in size, Oval in
shape, regular surface, inspection of oral cavity for Stenson’s duct revealed no
surrounding inflammation and clear saliva and the contralateral side is free and
assessment of facial nerve branches bilaterally was normal. By palpation: The
swelling has nodular surface, well defined edges, Firm consistency, mobile, not
tender, not pulsatile, not compressible and not reducible, not attached to
lymphadenopathy on palpation of Stenson’s duct, there is no stones felt. On
bimanual examination of the floor of mouth, the deep lobe couldn’t be felt. The
mass is not trans illuminating and no audible bruit is present over the mass, and
the other side is free.
My main differential diagnosis is parotid gland tumors (pleomorphic
adenoma). Also, I have to consider Infective causes like: parotitis,
Inflammatory causes like: Sjogren syndrome, Mikulicz’s syndrome
Benign neoplasm: pleomorphic adenoma, Warthin’s tumor
Malignant neoplasm: mucoepidermoid carcinoma, adenoid cystic carcinoma,
adenocarcinoma, lymphoma
Questions
Differential diagnosis of parotid lump:

Infective: parotitis
Inflammatory: Sjogren syndrome, Mikulicz’s syndrome
Benign neoplasm: pleomorphic adenoma, Warthin’s tumor
Malignant neoplasm: mucoepidermoid carcinoma, adenoid cystic carcinoma,
adenocarcinoma, lymphoma
Investigations:
CT, MRI to assess the extent of local, bony, or perineural invasion.
274 | P a g e
Us.
FNAC.
TREATMENT
Superficial parotidectomy.
275 | P a g e
I examined this patient presented by neck swelling which revealed that

On inspection
Site The swelling at the area of Rt parotid gland
Size 3x4 cm in size
Shape Oval in shape
Surface With irregular surface
Scars No scars of previous surgeries
Skin And skin has no signs of inflammation
Duct By inspecting the oral cavity for Stenson’s duct opening,
“Stenson” it has no signs of surrounding inflammation with clear
salivary secretions
Other side The contralateral side is free (not swollen, no scars)
Facial Assessment of facial nerve branches bilaterally was
Nerve normal
On palpation
Surface The swelling has nodular surface
Consistency Firm consistency
Temperature With normal skin temperature
Tenderness The swelling was not tender
Pulsatility The swelling was not pulsatile
Fixity And not fixed to overlying structures or skin
Duct On palpating the duct, there is no palpable stones
“stenson ”
Other side. The contralateral side is free on palpation
Bimanual On bimanual examination, the deep lobe couldn’t be
felt
Lymph nodes There were no palpable lymph nodes
276 | P a g e
Submandibular Gland Examination

Stem: examine this patient present with neck swelling.
Patient Type: real patient or an actor.
Patient Exposure: face and neck (unbutton the first two button in T shirt).
Provisional diagnosis: 1. Sialo-lithiasis in real patient.
2. Normal examination in a case of actor.
Positive Finding: 1. on inspection, the swelling is in the anterior triangle of neck,
Submandibular region,(I can’t roll up the gland above the mandible), 2x1 cm in
size, Oval in shape, regular surface, inspection of oral cavity for Wharton’s duct
revealed no surrounding inflammation and clear saliva and the contralateral side
is free and assessment of marginal Mandibular and hypoglossal nerves was
normal. By palpation: The swelling has nodular surface, well defined edges, Firm
reducible, not attached to overlying skin but attached to underlying structures
and not associated by lymphadenopathy, and on palpation of Wharton’s duct,
there is no stones felt. On bimanual examination of the floor of mouth, the
swelling is bimanually felt and assessment of lingual nerve is normal on both
sides. The mass is not trans illuminating and no audible bruit is present over the
mass, and the other side is free
2.Normal examination in a case of actor.
Ask the patient to point out the lump if not clearly

visible.
You will wear gloves in this station.
277 | P a g e

A. Inspection
1. Mass(gland) and Other side. A. site.
B. size.
C. Shape.
D. scars.
E. Surface.
F. Overlying skin
2.Oral cavity
3.Marginal mandibular.
4.Hypoglossal nerve and lingual nerve.
B. Palpation 1. Mass(gland) and Other side A. Temperature.
B. Tenderness.
C. Edges.
D. Consistency.
E. Surface.
F. Pulsatility.
G. Compressibility.
H. Reducibility
I. Mobility.
J. associated cervical lymphadenopathy (palpate cervical lymph node).
C. Transillumination and auscultation.
D. Bimanual palpation of gland and Wharton’s duct.
(Patient will be sitting)
278 | P a g e
Wash your hands.
Today I’ve been asked to examine the gland present in your neck that would
include looking feeling the gland, are you OK with this?
Would you please, lower down the collar of your gown?
Would you please point to the side of the swelling?
I will start by taking a close look to your face.
(Inspection from both sides and from the front for both glands)
(Inspection: Site, Size, Shape, Scars, Surface, Overlying skin)
Would you please show me your teeth?
(Marginal mandibular)
finger?
(Hypoglossal nerve)
Would you please open your mouth for me and stick up your tongue?
(inspect the Wharton duct on either side of the lingual frenulum, use tongue
depressor to visualize the duct opening by lifting up the tongue and light
source)
Do you mind if I examined you from the back, I will feel the gland?
(Palpation for both glands: Temperature, Tenderness, Edges, Consistency,
Surface, Pulsatility, compressibility, Reducibility, Mobility, associated cervical
lymphadenopathy)
(roll up the gland against border of the mandible, in submandibular swelling,
you can’t roll up the gland above the mandible)
279 | P a g e

painful or not)
skin)
fingers)
(Palpation: Tenderness: Press on the lump and look at the patient’s face to
see if they grimace. Ask the patient if the lump is painful. Is the whole lump
tender or just a part of it? Temperature: Palpate the temperature using the
back of your hand, comparing to surrounding tissue, significantly increased
malignant etiology)
light source into the mass, look through the cone (you will make from piece of
paper)
Would you please open your mouth for me, I will feel inside?
(Bimanual palpation of the gland and Wharton duct)
280 | P a g e
Do you feel this? (touch him in chest using cotton wool)

Could you please, close your eyes and say yes, every time I touch you in your
tongue?
(Marginal mandibular)
Thank you, sir.
Wash your hands.
281 | P a g e
Bimanual examination
Cervical lymph node examination
282 | P a g e
Marginal mandibular nerve
Hypoglossal nerve examination
283 | P a g e
Presentation
To complete my examination, I would like to perform ENT examination and
examine other salivary glands.
1. Submandibular sialolithiasis
Today I have examine this gentleman presented with neck swelling and on
inspection, the swelling is in the anterior triangle of neck, Submandibular
region,(I can’t roll up the gland above the mandible), 2x1 cm in size, Oval in
shape, regular surface, inspection of oral cavity for Wharton’s duct revealed no
surrounding inflammation and clear saliva and the contralateral side is free and
assessment of marginal Mandibular and hypoglossal nerves was normal. By
palpation: The swelling has nodular surface, well defined edges, Firm
reducible, not attached to overlying skin but attached to underlying structures
and not associated by lymphadenopathy, and on palpation of Wharton’s duct,
there is no stones felt. On bimanual examination of the floor of mouth, the
swelling is bimanually felt and assessment of lingual nerve is normal on both
sides. The mass is not trans illuminating and no audible bruit is present over the
mass, and the other side is free
My main differential diagnosis is Submandibular sialolithiasis. Also, I have to
consider Submandibular neoplasm.
2.Normal examination in a case of actor.
Questions
Submandibular sialolithiasis
Submandibular neoplasm
How would you investigate this patient?
ultrasound
Sialogram if a salivary stone is suspected
X- ray
Ct scan
FNA if a neoplasm is suspected
284 | P a g e
What are the treatment options?
Conservative management: Analgesia, oral antibiotics, good hydration and

gland massage
Sialogram can occasionally be therapeutic, as the injection of contrast can
‘wash out’ the gland If the stone is within the duct then the duct can be laid
open and the stone retrieved. The duct is then left open as suturing would
result in a stricture
Sialendoscopy: stone retrieval via endoscopic techniques.
Submandibular gland excision
285 | P a g e
I examined this patient presented by neck swelling

On inspection
Site The swelling is in the anterior triangle of neck,
Submandibular region
Size 2x1 cm in size
Shape Oval in shape
Surface regular surface
Scar No scars of previous operation
Skin Skin overlying shows no signs of inflammation
Duct Inspection of oral cavity for Wharton’s duct
revealed no surrounding inflammation and clear
“Wharton”
saliva
Other side The contralateral side is free
Marginal Assessment of marginal Mandibular and
Mandibular hypoglossal nerves was normal
Hypoglossal
On palpation
Surface The swelling has nodular surface
Consistency Firm consistency
Pulsatility And not pulsatile
Fixity The swelling is fixed to surrounding structures but not to
skin
Duct On palpation of Wharton’s duct, there is no stones felt
“Wharton”
Other side Other side palpation is free
Bimanual ex On bimanual examination of the floor of mouth, the
swelling is bimanually felt
Lymph nodes There are no palpable cervical lymph nodes
lingual Assessment of lingual nerve is normal on both sides
286 | P a g e
Superficial lump Examination

Stem: examine this patient present with nape swelling or RT thigh swelling.
Patient Type: real.
Patient position: sitting on a chair in the case of nape lipoma, or lying down in
the case of thigh lipoma.
Patient Exposure: expose patient neck in the case of nape lipoma or both LL in
the case of thigh lipoma.
Provisional diagnosis: Lipoma On the back of the neck, or RT thigh.
Positive Finding: on inspection, the swelling is in the back of his neck, , 5x10 cm
in size, Oval in shape, regular surface, overlying skin does not show signs of
inflammation or scars By palpation: The swelling has regular surface, slippery
edges, soft in consistency, mobile, not tender, not pulsatile, not compressible
and not reducible, not attached to overlying skin or underlying structures and
not associated by cervical or axillary lymphadenopathy. The mass is not trans
illuminating and no audible bruit is present over the mass.
Don’t forget to measure, trans illuminate and listen to

the mass.
287 | P a g e

1. Inspection
A. site.
B. size.
C. Shape.
D. scars.
E. Surface.
F. Overlying skin.
2. Palpation
A. Temperature.
B. Tenderness.
C. Edges.
D. Consistency.
E. Surface.
F. Pulsatility.
G. Compressibility.
H. Reducibility
I. Mobility (skin pinch test and contraction of underlying muscle)
J. associated lymphadenopathy.
K. Fluctuation.
3. measurement using measure tape.
4.Transillumination.
5.Auscultation.
288 | P a g e
Wash your hands.
Today I’ve been asked to examine the lump on the back of your neck, that will
include looking feeling and listening to the lump, are you OK with this?
Would you please, lower down the collar of your gown
I will start by taking a close look.
(Inspection from both sides and from the back)
(Site, Size, Shape, Scars, Surface and Overlying skin for signs of inflammation)
(Oval in shape, regular surface, overlying skin does not show signs of
inflammation or scars)
Would you please, look down?
(If the mass gets more prominant, it means it is superficial to the muscle, if not
it means id is deep)
(Palpation: Temperature, Tenderness, Edges, Consistency, Surface, Pulsatility,
Compressibility, Reducibility, Mobility (skin pinch test and contraction of
underlying muscle), Fluctuation and associated lymphadenopathy)
(Tenderness: usually start palpation by tenderness to see if the examination
is painful or not)
(Temperature: using the dorsum of your hand and compare to the
surrounding skin)
fingers)
289 | P a g e
(Mobility: hold the mass between your index and thumb and move into two
direction, ask the patient to look down and move the mass again to see if it is
adherent to the underlying muscle)
the fingers of the one hand are forced upwards when pushing downwards
with the fingers of the other hand)
malignant etiology)
Would you please, look down?
(move the mass again and test the mobility again into two direction and look
if the mass is adherent to the underlying muscle)
(in the case of thigh lipoma, if it is present in the medial side of the thigh,
abduct the thigh and test the mobility, anterior surface of the thigh, flex the
knee)
(measure the mass using measure tape)
(regular surface, slippery edges, soft in consistency, mobile, not tender, not
pulsatile, not compressible and not reducible, not attached to overlying skin or
290 | P a g e
underlying structures and not associated by cervical or axillary

lymphadenopathy)
light source into the lump, look through the cone (you will make from piece of
paper) Transillumination suggests that the lump is cystic (e.g. hydrocoele))
(The mass is not trans illuminating)
(no audible bruit is present over the mass)
Now, I will feel your armpit.
(axillary and cervical lymph nodes)
(inguinal lymph node in thigh lipoma)
((Axilla: Have the patient sit on the edge of the bed facing you. Support the
patient’s arm on the side being examined with your forearm. If you’re
examining the right axilla, use your right arm to support the patient’s (vice
versa for left). Palpate the axilla with your free hand, ensuring to cover all
areas of the axilla: Medial / lateral / anterior / posterior walls Apex of the
axilla, Note any lymphadenopathy – malignancy / infection. Other lymph
nodes: Finally perform a general lymph node examination of the following
areas: Cervical, Supraclavicular, Infraclavicular and Parasternal).
Wash your hands
291 | P a g e
292 | P a g e
Presentation
Today I have examine this gentleman presented with nape swelling and on
inspection, the swelling is in the back of his neck, , 5x10 cm in size, Oval in shape,
regular surface, overlying skin does not show signs of inflammation or scars By
palpation: The swelling has regular surface, slippery edges, soft in consistency,
mobile, not tender, not pulsatile, not compressible and not reducible, not
attached to overlying skin or underlying structures and not associated by
cervical or axillary lymphadenopathy. The mass is not trans illuminating and no
audible bruit is present over the mass.
My main differential diagnosis is lipoma. Also, I have to consider Sebaceous
cyst, abscess, bone tumor and vascular malformation.
Second scenario lipoma on the medial surface of the thigh.
Questions
Lipoma.
Sebaceous cyst.
Abscess.
Soft tissue tumor.
Bone tumor.
Vascular malformation.
Investigations:
Superficial Ultrasound.
FNAC or True- cut biopsy.
Treatment:
Excision.
How could differentiate lipoma from sebaceous cyst?
Punctum.
293 | P a g e
I examined this patient presented by nape swelling or thigh

swelling
Inspection
Site The swelling is in the back of the neck or on the

medial surface of the thigh.
Size 5x10 cm in size
Shape Oval in shape
Surface regular surface
Scar No scars of previous operation
Skin Skin overlying shows no signs of inflammation
Palpation
Surface The swelling has smooth surface

Edge slippery edges
Consistency soft consistency
Pulsatility And not pulsatile
Mobility The swelling is not fixed to surrounding structures or to
skin
Compressibility Not compressible
Reducibility Not reducible.
Lymph nodes There are no palpable cervical or axillary lymph nodes
in nape lipoma or inguinal lymphadenopathy in thigh
lipoma.
Fluctuation Not fluctuant.
Transillumination
Not trans illuminating.
Auscultation
No audible bruit.
294 | P a g e

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Communication skills

What to write in the notes?

 Patient details (name, age, date of admission, date of

During phone call

 You will introduce yourself (your name, level of training,

COMMUNICATION WITH A PATIENT

Discharge against medical advice

He decided to leave the hospital you have been asked to talk

Hello Mr....., I am..... One of the surgical doctors, I have been

But Staying in hospitals is disappointing and frustrating.

Ok, I understand that staying in hospitals is frustrating and

My wife has cancer and I have to go with her to her doctor.

I definitely understand your situation as you have to look also

Also I have a job interview.

I understand your situation but I need you to reconsider as you

Ok I will sign that.

Ok, if you felt that your state is deteriorating like feeling

Mr....., you have decided to self-discharge and you are going to

Thank you for understanding.

Counselling for OGD dilatation and

Hello Mr......., I am....... One of the surgical doctors, I have

Ok, this is what we call oesphageo-gastro-dudonoscopy which

This will be typically under sedation which will make you

Is there any risk?

No procedure is without risks. The possible risk may include:

Ooh my god I don’t want to perform the operation?

Listing those risks doesn't mean that they will essentially

Why I keep salivating?

This is most probably due to the narrowing present inside

Still early to confirm that, we will have to wait until the

When the result of my sample will appear?

It usually appear within two weeks’ time frame, I can

Do I have to stay in the hospital?

Typically you will discharged home after you regain your

Is there anything abnormal?

I will chick for you or (tell him the result).

Mr……, to summarize what we have been through, we need

Thank you for understanding.

Counselling a patient before

You have been asked to counsel the patient before stopping

My doctor told me that I shouldn’t stop it because stopping will

First let me explain what warfarin is and how it acts. Warfarin

which is called (heparin) that will be equivalent in effect to

Both of them are providing the same required blood thinning

When can I resume warfarin?

After your surgery is finished and if we are satisfied that there

Is it necessary to stay in the hospital prior to the operation?

Yes, during this period in which we are stopping warfarin and

Is it necessary to stop my antianxiety medication before the

Mr, lets summarize up what we have been through, you have to

Thank you for understanding.

Now, you have been asked to talk to his anxious mother to

Hi, I am..... One of the surgical doctors, I apologize that you

How has he got the injury?

His father told us that he was playing in the garden when he

What is the result of the scan?

Unfortunately, the scan we have made when he came in

What is meant by spleen and what is its importance?

Spleen is an organ present inside his tummy in the upper left

A ruptured spleen is definitely a serious condition, that's why

What did his father told you?

I will have to share this information. In any case like yours we

Is there any medications will be required after the operation?