CLINICAL SKILLS

Respiratory Examination
CV Examination
CNS Examination
REMS
GI Examination
History Taking
Rectal Examination
Blood Pressure
CPR
Urinalysis

Respiratory Examination
1. Wash hands, introduce, clarify identity, explain and consent
2. Sitting up, exposed from waist up
3. Inspect
- comfortable, tachypnoiec, scars, symmetry, rate (front + back),
shape
- hands clubbing, nicotine staining, pallor, palmar erythema,
cyanosis, flapping, radial pulse
- face tongue (colour), redness or cyanosis of face, under eyes
4. Palpation
- tracheal deviation, fin apex pulse, 5th IC Space
- chest expansion
- vocal resonance
5. Percussion
- 3 Parts + Auxiliary
6. Auscultation
- Deep breaths
- Just breathing sounds then vocal resonance
7. Palpate for lymph nodes
8. Repeat for back as well
CV Examination
1. Introduction and hand washing
2. Check if unwell or breathless
3. Inspect
- Hands clubbing staining anaemia or splinter haemorrhages
- Radial pulse collapsing pulse maybe be exaggerated by
raising arm, take BP, rate, character, volume, rhythm
- Face colour, anaemia, corneal arcus or xanthalasma, central
cyanosis
- Jugulo-venous pressure turn head to side (right first),
hepatojugular reflex
- Praecordium inspection, apex beat, right ventricular heave,
thrills in upper chest + neck
4. Auscultation

apex, tricuspid area, 2nd IC Space left (pulmonary) and right

(aortic)
Neck at carotid artery
Turn on left side for mitral stenosis
Sat up and left sternal edge for aortic regurgitation

CNS Examination
Upper Limb
1. Introduction/ wash hands
2. Inspection
- Comfortable/posture, obvious deformities, gait, symmetry,
position of limbs, wasting/hypertrophy, tremor
- Check for fasciculation
- Pronator drift
3. Tone
- Assess tone, including check for cog-wheeling
4. Power
- Shoulder flexion and extension
- Elbow - flexion and extension
- Wrist - flexion and extension
- Fingers grip, thumb, flexion, extension, ab/adduction
5. Reflexes
- Bicep
- Triceps
- Supinator
6. Coordination
- Finger to nose
- Dysdiadochokinesis
Lower Limbs
1. Intro/wash
2. Inspection and fasciculations
3. Tone
- Hip roll
- Knee lift
- Ankle flexion and dorsiflexion (sudden)
4. Reflexes knee jerk
5. Ankle jerk
6. Plantar (Babinski sign)
7. Coordination
- Heel-shin
- Heel toe walk

REMS
Hips
1. Intro/wash
2. Scars, deformity, gluteal muscle wasting, symmetry

3. Measure apparent and real leg length

4. Palpate
- Greater trochanter
- Heat and redness
5. Movement
- Flexion/extension
- External/internal rotation
- Ab/adduction
- All active and passive
6. Additional
- Thomas Test
- Trendelenbergs Test
- Gait and check shoes
Knee
1.
2.
3.
4.

Intro/wash
Position correctly
Muscle wasting, symmetry, scars, valgus/varus deformity
Palpation
- Temperature
- Tenderness at 90
- Behind knee for bakers cyst
- Patellar tap
- Cross fluctuation
5. Movement
- Flexion and extension, feel for crepitus on passive
- Posterior sag
- Anterior draw test
- Medial and lateral
6. Stand and gait, check shoes
Back
1. Intro/wash
2. Inspect
- Scoliosis
- Abnormal kyphosis or lordosis
3. Palpate
- Spinous processes
- Sacroiliac joint
- Paraspinal muscles
4. Move
- Touch toes and lean back
- Again whilst palpating two spinous processes
- Lateral flexion
- Rotation
- Head backwards and forwards
- Over each shoulder
- Lateral flexion of neck
- Jaw side to side
5. Additional
- Hips raise and dorsiflexion

GI Examination
1. Intro/wash
2. Inspection
- Jaundice, pale, obese, underweight
- Clubbing, palmar erythema or fibrosis
- Radial pulse
- Head pallor, conjunctiva, sclera jaundice, mouth for
dehydration
- Neck lymphadenopathy
- Abdomen distension, hernias, scars, stoma, fistula, sinus
3. Palpate
- Tenderness in 4 quadrants, guarding/ rebound tenderness ask
- Palpate again but more deeply
- Palpate for organomegaly live, spleen and kidneys
- Liver - deep breath then move hand up right side on expiration
- Spleen same but move across to left and place hand behind
left ribs
- Kidneys - between ribs and iliac crest and other hand on
abdomen, only noticeable if extremely swollen
4. Percussion
- Liver + Spleen again
- Check for ascites percuss down side and then roll
5. Auscultation
- Bowel sounds and aortic bruit
6. Additional
- Femoral artery
- Rectal exam
History Taking
1. Intro and consent
2. Presenting complaint
3. History of presenting complaint
4. Medical history
5. Family history
6. Medications and allergies
7. Social history
8. Anyone at home
9. Lifestyle
10.ICE
11.Summarise

CV

SITE
ONSET
CHARACTER
RADIATION
ASSOCIATED SYMPTOMS
TIME
EXACERBATING/RELIEVING FACTORS
SEVERITY

Breathlessness exertion, nocturnal (pillows), duration

Chest pain
Oedema ankle or abdominal swelling
Palpitation
Dizziness vertigo? postural?
Peripheral vascular symptoms pain in calves, cold hands or
feet, rest pain

Cough, sputum?
Sputum colour, quantity, type, blood
Breathlessness
Wheeze
Chest pain
Hoarseness
Weight loss
Sweating

Ab pain micturition, rectal pain, back pain (pancreatic),

shoulder pain (gall bladder), chest pain, headache
Appetite
Difficulty swallowing
Vomit, reflux, heartburn
Belching, flatulence
Ab enlargement
Weight loss
Bowel habits
Jaundice
Malabsorption

Loss of consciousness
Mental state
Headache
Weakness (muscle)
Gait
Numbness
Dizziness
Vision
Tremors
Deafness

Respiratory

GI

CNS

Musculoskeletal
-

Joint swelling
Pain
Stiffness
Mechanical dysfunction

Rectal Examination

1. Explain procedure, explain may be uncomfortable, ask if they would like a

chaperone
2. Wash hands
3. Get patient on left side with knees tuck into chest
4. Examine outside for redness, fistula, fissure, piles, discharge, tags
5. Lubricate index finger
6. Tell patient about to enter
7. Press down on top of anus to open sphincter
8. Aim towards umbilicus
9. Feel left, right, anteriorly and posteriorly for abnormalities and symmetry
10.Feel prostate for warts and symmetry
11.Ask patient to squeeze your fingers
12.Slowly remove fingers
13.Check for blood, mucus, faeces
14.Wipe backside
15.Dispose of gloves
16.Explain findings and further tests if needed

Blood Pressure
1. Introduce and check name/DoB
2. Explain procedure
3. Wash hands
4. Ensure patient is comfortable
5. Palpate brachial artery
6. Choose cuff size
7. Apply cuff correctly
8. Palpate radial artery
9. Estimate systolic
10.Apply stethoscope correctly
11.Take BP
12.Accurate, normal/hypo/hypertensive, which arm, sitting/standing
13.Would measure again until 2 reproducible results
14.Would measure standing for postural hypotension
CPR
1.
2.
3.
4.
5.
6.
7.

Danger
Response shake, can you hear me?
Ask for help and bring defib
Airway head tilt
Breathing face and ear over mouth 10 sec
Normal put in recovery position, absent call ambulance
2 rescue breaths, chest compressions 30 at rate 0f 100-120/minute, 5-6cm
deep
8. Continue until ambulance arrives, regains consciousness or no longer
physically able to, swap if possible

Urinalysis
1. Introduce and check
2. Explain purpose of procedure and gain consent
3. Describe sample collection technique midstream, prevent contamination,
fresh sample
4. Safety wash hand don apron and gloves, check label on sample bottle,
check expiry date of strips
5. Inspection colour, clarity, odour
6. Dip for 2 seconds and tap off
7. Interpretation hold dipstick correctly, check results after 30s2min,comment on +ve and ve findings
8. Summarise and explain
9. Reassure of explain further tests
10.Dispose and wash hands
11.Record results