1) Urinary Catheterization

 WIPPPPE
- Ask for a chaperone.
- Chlorohexidine allergy? When did they last voided?
- Position: Supine (M), Knees flexed & legs apart (F).
- Exposure: genital area to mid-thigh.
Position & exposure are done after finishing preparation.
 Preparation:
- Rewash your hands & wear gloves.
- Open the bag & prepare the equipments.
- Test the catheter balloon.
 Cleaning:
1. Apply drapes:
- Non-fenestrated: under the patient.
- Fenestrated: cut a hole & put over penis/vestibule, remember that the shiny side is
placed on (facing) the patient.
2. Forceps & cottons:
- M: 3 cottons, start from the meatus in an outward circular motion x3.
- F: 5 cottons, downward stroke motions (labia majora x2, labia minora x2, meatus x1).
Prior cleaning, don’t forget to use ur non-dominant hand to grab the penis/spread labia.
 Catheterization:
1 Place receiver below patient.
2 Lubricate generously (at least 2 inch).
3 Insert catheter:
- M: keep inserting until you reach the catheter bifurcation regardless of resistance.
- F: after urine starts to drain, insert for 2 inches more.
4 Inflate the balloon.
5 Attach the urine bag & keep it at a level below lower than the patient.
6 Pull the catheter gently until it stops (anchored by the bladder neck).
7 Tape the catheter to patient anterior thigh (M), inner thigh (F).
 Conclude:
- Summarize findings.
- Cover & thank the patient.
- Remove gloves & wash hands.
 2) Abdominal Examination
 WIPPPPE
- Position: flat with knee flexed.
- Exposure: from above the nipples to mid-thighs.
 General inspection: ABCDEV
 Local (Abdominal) Examination
1. Inspection: inspect from 3 sides: pt right side, eye at pt level, & pt foot.
- 6Ss (Swelling, Symmetry or hernias, Stomas, Scars, Spider nevi, Striae).
- Abdominal distention (5Fs: Fat, Fluid, Fetus, Feces, Flatus).
- Umbilicus (everted/inverted).
- Dilated abdominal veins (caput medusa).
- Cullen’s sign / grey turner’s sign.
- Pigmentation.
- Visible pulsations.
- Comment on breathing.
2. Percussion:
- Liver span.
- Spleen.
- Shifting dullness (if +ve —> fluid thrill).
3. Auscultation:
- Bowel sounds (4 quadrants).
- Bruits (aortic & renal).
- Liver hum.
- Friction rub of liver & spleen.
4. Palpation:
- Superficial palpation (tenderness, rigidity, guarding, superficial masses).
- Deep Palpation (tenderness, organomegaly, liver edge, masses).
- Kidney ballotment.
- Abdominal aorta.
5. Special tests:
- Appendicitis: McBurney's sign, Rovsing’s sign, Iliopsoas sign, Obturator sign.
- Cholecystitis: Murphy sign.
- Peritonitis: percussion/rebound tenderness, cough test.
- Carnett's test.
 Further assessment:
- Genital examination, Digital rectal examination, Hernial orifice.
 Conclude: Summarize findings, Cover & thank the patient, Remove gloves & wash hands.
 3) Stoma Assessment

 WIPPPPE
- Adequately expose the patient’s abdomen.
- Position the patient lying flat on the bed.
- Ask the patient if they have any pain or if they have had any recent issues with their stoma
(e.g. bleeding, change in output) before proceeding with the clinical examination.
 Stoma Assessment
1. Site:
- Right iliac fossa (RIF): Ileostomy – Urostomy.
- Left iliac fossa (LIF): Colostomy.
2. Number of Lumens:
- 1 lumen in RIF: end ileostomy or urostomy.
- 1 lumen in LIF: end colostomy.
- 2 lumens in RIF: loop ileostomy.
- 2 lumens in LIF: loop colostomy.
3. Spout:
- Present: Ileostomy – Urostomy.
- Absent: Colostomy.
4. Effluent:
- Ileostomy: liquid faeces.
- Colostomy: semisolid faeces.
- Urostomy: urine.
5. Surrounding skin:
- Check for any erythema, tissue breakdown and/or fistulation.
 Stoma Complications:
- Parastomal hernia (stoma enlargement, bulging of an area at stoma border, Increased size of
hernia when coughing/sneezing, a reducible parastomal mass on examination).
- Stoma infarction (pain at the stoma site, necrosis of the stoma -appears black in color).
- Stoma prolapse (stoma appearing longer than normal).
- Stoma retraction (stoma sinking below skin level, with a concave, bowl-shaped appearance).
- Stoma hemorrhage.
 Further Assessments:
- Full abdominal examination.
 Conclude Examination:
- Summarize findings, cover & thank the patient, remove gloves & wash hands.
 4) Breast Examination
 WIPPPPE
- Bring a chaperone.
- Exposure: ideally from neck to umbilicus (both breasts should be exposed during inspection to
compare, while in palpation, expose one & drape over the other).
- Position:
Inspection, 3 position (sitting, sitting w/ hand on hips, sitting w/ hand behind head).
Palpation, patient laying flat w/ ipsilateral hand (of breast examined) behind head.
 General inspection: ABCDEV
 Local (breast) inspection:
- Make sure both breast are exposed, and inspect the patient in 3 positions
- Don’t forget to check axilla & supraclavicular fossae for obvious lymphadenopathy.
Breast Nipple Areola
 Symmetry  Nipple direction  Cracking or fissures
 Obvious masses (normal is forward & laterally)  Skin irritation
 Skin changes - Pushed downward  Raised Montgomery
 Dimpling* - Nipple retraction* glands*
 Ulceration (Ask if congenital or not)
 Dilated veins  Nipple ulceration*
 Rashes*  Nipple discharges
 Peau d'orange* (If +ve hx of discharge but not seen in the
 Redness clinic, ask pt to squeeze nipple themselves)
What has * next to it, is what the mannequin has.
 Palpitation:
- Palpate with pulp of the 3 middle fingers
- Start palpating one breast (while draping over the other one) clockwise pattern to
cover all 6 areas: upper outer quadrant, lower outer quadrant, upper inner quadrant,
lower inner quadrants, axillary tail, & retro-areolar space.
- If you find a mass, mention that you’ll get back to it at the end to assess it.
 Mass assessment:
- location (which quadrant? how far from the nipple? Which clock?), single or multiple), size (3
dimensions), shape (regular or irregular), surface, edge (well defined or not), consistency
(soft/firm/hard), tenderness, attachment (skin/muscle).
 Lymph Node Assessment:
- With patient sitting, examine both LNs even if mass is only in one breast.
- Axillary LNs: anterior (pectoral), posterior, central, lateral, medial (apical).
- Regional LNs: supraclavicular & infraclavicular.
- If you find an enlarged LN, describe it.
 Further Assessments: Head & neck LNs examination, abdominal examination, respiratory
examination, examine spine & hip bones for tenderness.
 Conclude: Summarize findings, cover & thank the patient, remove gloves & wash hands.
 5) Neck examination
 WIPPPPE
- Exposure: neck & upper chest at least to the clavicles.
- Position: sitting.
 General inspection: ABCDEV
- Hyperthyroidism: cachexic, sweaty, nervous patient and agitated…
- Hypothyroidism: obese, depressed pt w/ masked facial expressions & brittle skin...
- Mention if the patient has a hoarse voice, warm or sweaty hands as you great them.
 Local (neck) inspection: stand in front of the patient
- Visible lymphadenopathy, scars, visible pulsations, skin changes (erythema), masses (if
present, describe), SCM atrophy, dilated veins.
- Ask patient to open their mouth to check for waldeyer’s ring.
- If mass is present, Ask patient to swallow (ideally drink water).
- If mass is present, Ask patient to protrude tongue.
- Illicit the Pemberton’s Sign.
 Palpation: palpate from the patient’s back & use your fingertips
- Thyroid gland.
- Masses (site, size, number, shape, edge, consistency, surface, tenderness,
temperature, fixation, transilluminability, pulsations, fluid thrill).
- Trachea (check for any deviation).
 Percussion:
- Manubrium (checking for retrosternal thyroid extension).
 Auscultation:
- Thyroid bruits.
 Lymph Nodes Assessment: make sure the patient maintains a neutral head position
- Submental LNs, submandibular LNs, parotid LNs, pre-auricular & post- auricular LNs,
anterior & posterior triangle LNs, deep cervical chain, Jugulodigastric (tonsillar) nodes,
occipital LNs, supraclavicular & infraclavicular LNs.
- If any LN is palpable, describe it.
 Conclude:
- Summarize findings.
- Cover & thank the patient.
- Remove gloves & wash hands.
 6) Vascular examination (& diabetic foot)

 WIPPPPE
- Position: sitting (upper limbs), supine (abdomen & lower limbs).
- Exposure: patient’s limbs and abdomen.
 General inspection: ABCDEV
- Amputation? Walking aids?
 Local inspection:
Upper limbs Neck Abdomen Lower limbs
 Color:
o Erythema
 Color:
o Erythema o Cyanosis
o Cyanosis o Pallor
o Pallor  Tissue loss:
o Gangrene
o Nicotine staining  Scars
 Scars o Muscle wasting
 Tissue loss:  Pulsatile mass
 Pulsatile mass o Non-healing ulcers
o Gangrene  Dilated veins
 Dilated veins  Scars
o Muscle wasting  SCM
 Xanthoma
o Non-healing ulcers
 Dilated / varicose veins
 Scars
 Hair loss
 Xanthoma
 Shiny dry skin
 Thick brittle nail
 Abnormal joint
 Palpation: most important three are temperature, pulses, & capillary refill
Upper limbs Neck Abdomen Lower limb
 Temperature
 Pulses
 Temperature
o Femoral
 Pulses
 Pulses o Femoral-radial delay
o Radial
 Pulses o Abdominal aorta o Popliteal
o Radial-radial delay
o Carotid  Pain o Posterior tibial
o Brachial
 Thrill  Thrill o Dorsalis pedis
Comment on rate & rhythm
o carotid o Abdominal aorta  Capillary refill
 Capillary refill
o Renal arteries  Pain
 Pitting edema
 Pitting edema
 Pain
 Thrill
o Femoral arteries
 Auscultation:
Upper limbs Neck Abdomen Lower limb
 Carotid  Abdominal aorta
x  Femoral arteries
If +ve bruit, don’t palpate  Renal arteries
 Ulcer Assessment
- Type: arterial / venous / neuropathic (diabetic).
- If ulcer is inspected describe 6Ss:
site, single or multiple, size, shape of margin (oval, rounded, irregular), state (granulation, discharge), surrounding
skin: thick & pigmented (venous ulcer), thin & dark (arterial ulcer), red & edematous (diabetic ulcer).
 Neurological Assessment:
- Mono-filament test.
- Pinprick Sensation.
- Vibration Sensation (using tuning fork 128Hz).
- Proprioception (Sense of Joint Position).
- Reflexes (ankle jerk reflex).
 Special tests: Buerger’s test.
 Power & Movement.
 Gait: symmetry, balance, turning, limping, analgia/broad based, foot drop/high stamping, slippers stepping out of feet
 Conclude: Summarize findings, cover & thank the patient, remove gloves & wash hands.
 7) Inguinal hernia examination
 WIPPPPE
- Bring a chaperone.
- Exposure:
Nipple line to mid-thigh/knee, expose what you’re examining while covering the other parts.
Position: standing.
 General inspection: ABCDEV
- Wearing a hernia truss or belt?
 Local inspection: inspect both sides.
- Ask the patient to point where the lump has been seen or felt.
- Inspect & pay careful attention to scars from previous surgery.
- Look for obvious lumps / swellings on both sides & Comment on the 6Ss:
Site, Shape, Size, Surface, Skin, Sliding Movements.
- Cough impulse Inspection.
 Palpitation:
- Swelling: temperature, tenderness (facial expressions).
- Other structures: spermatic cord (scrotal neck test), testis, pubic tubercle (confirm hernia site)
Above & medial the inguinal ligament: Inguinal (direct and indirect).
Below & lateral the inguinal ligament: Femoral.
- Consistency of hernia: soft & elastic (enterocele), firm & doughy (omentocele), tense & tender
(strangulated hernia), bag of worms (varicocele).
- Cough Impulse (or Zieman’s Technique as an alternative).
- Reducibility: The best one to reduce is the patient him/herself.
Do not attempt reduction if skin redness or edema is present over the mass
 Deep Ring Occlusion Test: (to occlude the deep inguinal ring).
 Finger Invagination Test.
 Percussion:
- Hernias containing bowel will be resonant on percussion.
- Others are dull to percuss (contain omentum for example).
 Auscultation:
- Hernias containing bowel will sometimes have bowel sound.
 Looking for any possible cause for the hernia:
- Abdominal examination: ascites, scars, weak abdominal muscle, malgaigne’s bulges.
- Rectal examination: Enlarged Prostate (in the elderly).
- Urethral examination: palpate inferior aspect of penile shaft to check for urethral strictures.
 Conclude: Summarize findings, cover & thank the patient, remove gloves & wash hands.

 Differential diagnosis:
Above the inguinal ligament Below the inguinal ligament
 Femoral hernia
 Inguinal hernia  Lymph node
 Undescended testis  Saphena varix
 Encysted hydrocele or lipoma of the cord  Femoral aneurysm
 Iliacnode
 Psoas abscess

Shatha Algahtani
Remember this is a SUMMARY