OSCE Skills

2012 – 2013
Stephanie Reid

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OSCE Skills List
(based on DP tutorials 2012/2013)

History Taking
 Full history  Neurological upper limb exam
 Cardiovascular history  Neurological lower limb exam
 Respiratory history  Skin examination
 Asthma history  ENT examination
 Genitourinary history  Eye examination
 Chronic renal failure history
 Gastrointestinal history Procedures and Consent
 Diabetes history  Surgical hand wash
 Sexual history  Vital Signs / Obs
 Upper limb history  Basic life support (BLS)
 Lower limb history  Performing ECG
 Neurological history  Venepuncture
 Cognitive testing  Injections
 Mental state exam (MSE)  Arterial blood gases
 Suicide Risk Assessment  Nebuliser, oximetry, oxygen
 Asthma education
Examination  DRE / Rectal and prostate
 Cardiovascular examination examination
 Cardiac auscultation  Urinalysis
 Respiratory examination  Nasogastric tube insertion
 Genitourinary examination  Pelvic exam and pap smear
 Gastrointestinal examination  IV cannulation
 Breast examination  Suturing sterile field
 Testicular examination  Plastering
 Inguinal-scrotal examination  Urinary catheterisation
 Thyroid examination
 Endocrine screen Interpretation
 Diabetic examination  ECG
 Upper limb examination  ABGs
 Shoulder  Urinalysis
 Elbow  Spirometry
 Hand  Peak flow
 Lower Limb examination  Liver function tests
 Hip  X-Ray Interpretation:
 Knee  Chest
 Ankle  Abdomen
 Back examination  Upper limb: shoulder, elbow,
 Cranial nerve examination hand
 Lower Limb: hip, knee, ankle
 Description of masses/lesions

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 Contents
History - Cardiovascular ...................................................................................................................... 1
History - Respiratory ........................................................................................................................... 1
History - Gastrointestinal .................................................................................................................... 2
History - Genitourinary ....................................................................................................................... 2

5 History - Sexual (Male) ........................................................................................................................ 3

History - Sexual (Female) .................................................................................................................... 3
History - Joint ...................................................................................................................................... 5
History - Neurological ......................................................................................................................... 5
History - Continued ............................................................................................................................. 6

10 History - System Review...................................................................................................................... 6

History - Asthma ................................................................................................................................. 7
History - Diabetes................................................................................................................................ 7
Examination - Cardiovascular ............................................................................................................. 9
Examination – Respiratory ................................................................................................................ 13
15 Examination – Genitourinary ............................................................................................................ 18
Examination – Gastrointestinal ......................................................................................................... 22
Examination – Breast ........................................................................................................................ 26
Examination – Male Genitalia ........................................................................................................... 30
Examination – Inguinal-Scrotal ......................................................................................................... 34

20Examination - Thyroid ....................................................................................................................... 37

Examination - Endocrine ................................................................................................................... 40
Examination - Diabetic ...................................................................................................................... 43
Examination – Shoulder .................................................................................................................... 48
Examination – Elbow......................................................................................................................... 52
25 Examination – Hand .......................................................................................................................... 54
Examination – Hip ............................................................................................................................. 58
Examination – Knee .......................................................................................................................... 61
Examination – Ankle ......................................................................................................................... 64
Examination – Back ........................................................................................................................... 67
30 Examination – Cranial Nerves ........................................................................................................... 70
Examination – Neurological Upper Limb .......................................................................................... 74
Examination – Neurological Lower Limb .......................................................................................... 77

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 Examination – Skin ............................................................................................................................ 81
Examination – Ear, Nose, Throat ...................................................................................................... 84

35 Examination – Eye ............................................................................................................................. 87

Procedure – Surgical Handwash ....................................................................................................... 89
Procedure – Vital Signs and Observations ........................................................................................ 90
Procedure – Basic Life Support ......................................................................................................... 92
Procedure – ECG ............................................................................................................................... 95
40 Procedure – Venepuncture ............................................................................................................... 99
Procedure – Injections .................................................................................................................... 103
Procedure – ABGs ........................................................................................................................... 106
Procedure - Nebuliser, Oximetry and Oxygen ................................................................................ 109
Procedure - Asthma Education ....................................................................................................... 110
45 Procedure – Digital Rectal Exam ..................................................................................................... 113
Procedure - Urinalysis ..................................................................................................................... 116
Procedure – Nasogastric Tube ........................................................................................................ 118
Procedure - Pelvic Exam and Pap Smear ........................................................................................ 121
50 Procedure – IV Cannulation ............................................................................................................ 126
Procedure – Suturing ...................................................................................................................... 129
Procedure – Plastering .................................................................................................................... 133
Procedure – Catheterisation ........................................................................................................... 134
MSE and suicide
55 Sterile Field
Interpretations

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History - Cardiovascular History - Respiratory
History History
1. Chest pain 1. Dyspnoea
2. Pain on exertion 2. Cough
3. Silent infarct 3. Sputum
4. Dyspnoea 4. Haemoptysis
5. Palpitation 5. Wheeze
6. Syncope 6. Stridor
7. Claudication (MHx: previous TIA/stroke) 7. Chest pain
8. Oedema (swelling) 8. Fever, sweats or rigors
9. Cough (HF), fatigue (HF, anaemia) and GI or GU 9. Night sweats
symptoms of HF (weight gain, abdo pain, swelling and 10. Snoring / OSA / sleep disturbance
oliguria) 11. Hoarseness
12. Weight loss or weight gain
Diagnoses
 Angina Diagnoses
 AMI  Acute infection (pneumonia, common cold,
 PE, DVT tracheobronchities, bronchopneumonia, viral
 Pericarditis (pleuritic pain) pneumonia, acute on chronic bronchitis, pertussis),
 Aortic dissection  Chronic infection (bronchiectasis, TB, CF),
 Heart failure, previous AMI  Airway disease (asthma, chronic bronchitis)
 Peripheral vascular disease  Parenchymal diseases (emphysema, chronic
 TIA or stroke interstitial lung fibrosis, sarcoidosis)
 Anaemia  Pulmonary oedema (acute, HF)
 Arrhythmia  Tumours (lung carcinoma)
 Valve disease  Foreign bodies
 Postural hypotension  Croup, epiglottitis, foreign bodies, congenital airway
 Hypovolaemia disorders
 Pneumothorax
Non Cardiovascular Diagnoses  Bronchiolitis
 Respiratory: pneumonia, acute pulmonary oedema,
pneumothorax, lung cancer, Non-Respiratory Diagnoses
 Gastrointestinal: GORD  Cardiovascular: HF, ACS (AMI, angina), PE, pericarditis,
 Musculoskeletal aortic dissection
 Neuro: psychogenic  Musculoskeletal: Rib fracture, costochrondritis,
 Drugs, caffeine muscle strain, spinal disease
 Endocrine: hyperthyroidism  Renal: AKI, CKD
 Other: GORD, psychogenic

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History - Gastrointestinal History - Genitourinary
History History
1. Abdominal pain 1. Change in urine
2. Change in bowel habit a. Appearance
a. Diarrhoea b. Volume
b. Constipation c. Odour
c. Blood in stool 2. Blood in urine
d. Mucus in stool 3. Stream
e. Malaena a. Hesitancy
3. Nausea and vomiting b. Poor flow
a. Hematemesis c. Intermittent
4. Change in appetite d. Terminal dribbling
5. Change in weight 4. Change in micturition
6. Heartburn or indigestion a. Anuria
7. Dysphagia b. Urgency
8. Jaundice c. Pain (dysuria)
9. Pturitis (itching) d. Frequency
10. Abdominal bloating / swelling e. Urinary retention
11. Lethargy/fatigue 5. Nocturia
12. Fever (appendicitis, diverticulitis) 6. Incontinence
7. Pain in abdomen, back or pelvis
Diagnoses 8. Incontinence
 GORD 9. Fever, sweats or rigors
 Peptic ulcer 10. Symptoms of CKD: fatigue, weight change, appetite
 Pancreas disease change, oedema, bruising, hiccups
 Biliary pain Sexual History
 Renal colic 11. Sexual activity
 Gastroenteritis 12. Sexual function and libido
 Bowel obstruction (ileus, tumour, diabetic 13. Discharge or rash
neuropathy) Reproductive history
 Bowel cancer 14. Menses
 Inflammatory bowel disease 15. Infertility
16. Pregnancies
 Irritable bowel syndrome (IBS)
 Appendicitis
Diagnoses
 Diverticulitis
 Urinary tract infection
 Malabsorption
 Cystitis
− Coeliac disease
 Pyelonephritis
− Inflammatory bowel disease
− Dietary, alcoholism  Renal calculi
 STI/STDs
Non-Gastrointestinal Diagnoses  Incontinence (stress, overflow, urge)
 AAA  Benign prostatic hyperplasia
 Drugs, bulimia,  Prostate cancer
 Stroke, achalasia  Prostatitis
 Musculoskeletal
 GU / sexual causes

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 It is unusual to take this history, as unlikely to contribute to
History - Sexual (Male) changes in management. Ask only if indicated
 Onset of and pace of progression of puberty
Sexual History − Begins 8-14 in girls
 Sexual activity (current or past) − Begins 9-14 in boys
 Partners (gender, new partners)  Development of breast buds, scrotal and penile
 Discharge (urethral or vaginal) changes (size and volume), pubic hair development
 Pain (abdominal, testicular, dysuria, coital)  Height gain and rate of slowing of growth
 Skin lesions  Any dysfunction in erection or ejaculation
 Libido  Undescended testes
 Erectile dysfunction, impotence
 Infertility Diagnoses
 Lump  Enlarged prostate
 Renal stone (calculi)
Additional Sexual History  UTI
 Age of sexual activity  STI
 Number of sexual partners in the past 2 months  Paraphimosis
 Have you ever, or do you regularly practice
− Anal sex
− Penile-vaginal intercourse
History - Sexual (Female)
− Oral sex (fellatio)
− Any other forms of sex I haven’t mentioned? (this Sexual History
might uncover any number of fetish sexual  Sexual activity (current or past)
practices)  Partners (gender, new partners)
− Fetish Sex  Pain (abdominal, vaginal, pelvic, dysuria, coital)
 Have you ever felt at personal risk related to your  Discharge (urethral or vaginal)
sexual practices?  Skin lesions or rash
 Have you ever felt like your practices have placed  Libido
others at risk?  Post-coital bleeding
 Do you take any precautions against pregnancy?
Additional Sexual History
Sexually Transmitted Diseases  Age of sexual activity
 Have you ever been treated for a sexually transmitted  Number of sexual partners in the past 2 months
disease?  Have you ever, or do you regularly practice
 Do you take any precautions against STDs? − Anal sex
 Soreness or a rash anywhere on or near your genitals? − Penile-vaginal intercourse
 Ask about unusual lumps or sores − Oral sex (fellatio)
 Itch − Any other forms of sex I haven’t mentioned? (this
 pain when urinating (dysuria) might uncover any number of fetish sexual
 unusual discharge from genitals practices)
− Fetish Sex
Reproductive History  Have you ever felt at personal risk related to your
 Difficulties conceiving? sexual practices?
 Have you had any problem with erections?  Have you ever felt like your practices have placed
 Have you noticed any difficulty with ejaculation? others at risk?
 Had a vasectomy?  Do you take any precautions against pregnancy?
 Past or family history of infertility?
Sexually Transmitted Diseases
Psychological Factors  Have you ever been treated for a sexually transmitted
 Are you and your partner satisfied with your quality disease?
and frequency of sex?  Do you take any precautions against STDs?
 Have you ever any problematic sexual encounters?  Have you had any soreness or a rash anywhere on or
(history of sexual abuse) near your genitals?
 Ask about unusual lumps or sores
Sexual Development History IF INDICATED  Itch

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  pain when urinating, (dysuria)
 unusual discharge from genitals Cervical Screening
 Last smear- date and result
Menses  Any abnormal smears and management
 Age of onset  HPV vaccination
 Frequency / regularity
− Amenorrhoea (absence) Psychological Factors
− Oligomenorrhoea (infrequent)  Are you and your partner satisfied with your quality
− Polymenorrhoea (shorter time intervals) and frequency of sex?
 Duration  Have you ever any problematic sexual encounters?
 Volume/heaviness (measure) (history of sexual abuse)
− Menorrhagia (abnormally heavy and prolonged
periods)
Sexual Development History IF INDICATED
 Last period (date)
It is unusual to take this history, as unlikely to contribute to
 Pelvic pain
changes in management. Ask only if indicated
 Dysmenorrhoea (painful periods)
 Onset of and pace of progression of puberty
 Intermenstrual bleeding
− Begins 8-14 in girls
− Begins 9-14 in boys
Fertility and Reproductive (Obstetric) History
 Development of breast buds, scrotal and penile
 Children? changes (size and volume), pubic hair development
 Pregnancies:  Height gain and rate of slowing of growth
− number  Any dysfunction in erection or ejaculation
− date (ages)  Undescended testes
− gestation at delivery
− type of delivery (vaginal, caesarean)
− complications
− birthweight
− any medical problems in child
− difficulty breast feeding.
 Have you had any other pregnancies? (termination
and miscarriages)
 Infertility
 Past infertility, miscarriage or stillbirth (especially
recurrent)
− Family history of above or family history of
infertility or miscarriage

Fertility history is a subset of reproductive history

Shorthand:
G4P3 = 4 gravida (pregnancies) and 3 Partum
(deliveries); TOP- 15 wks" = termination of pregnancy at
15 weeks gestation; NVD" =normal vaginal delivery;
"LUSCS "lower uterine caesarean section"

Contraceptive history
 When did you start contraception
 Why did you start?
 Current?
 Any problems or changes? Any prior methods?
 Any accidents or chances of pregnancy while on
contraception?
− How well do you manage it?
 Side effects
 Sexual partner’s contraception

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History - Joint History - Neurological
History History
1. Pain 1. Pain
a. Sleep disturbance, proximal or distal changes, a. Headache
motor and sensory changes, treatment, b. Neck or back pain
events c. Facial pain
2. Stiffness 2. Fits, faints and funny turns
3. Swelling or deformity 3. Dizziness or vertigo
4. Limitation of movement / restriction on DALYs / 4. Disturbances of vision, hearing, smell or taste
Impact on life 5. Disturbances of gait
5. Locking 6. Loss of or disturbed sensation in limbs
6. Giving way 7. Weakness in limbs
7. Fatigue 8. Loss of sphincter control (bladder, bowel)
8. Cracking / Clicking 9. Peripheral neuropathy (numbness, tingling)
9. Constitutional symptoms (fever, sweats, appetite 10. Involuntary movements (jerking, tremors,
and weight) incoordination or restlessness? Any inability to
10. Systematic enquiry – rashes, fever, eyes, move)
photosensitivity, mouth ulcers 11. Speech and swallowing disturbances (dysarthria,
11. Change in gait dysphonia, dysphasia or dysphagia)
12. Altered cognition (confusion, delirium or dementia)
Diagnoses 13. Changes in personality
 Arthritis
− Osteoarthritis Diagnoses
− Rheumatoid arthritis  TI/Stroke
 Septic arthritis  Epilepsy
 Gout  UMN lesion
 Seronegative spondyloarthritides:  LMN lesion
− Ankylosing spondylitis  Migraine
− Psoriatic arthritis  Meningitis, encephalitis
− Reactive  Raised ICP - worse in morning, learning forward, vomit.
 Synovitis  Dementia
 Tendonitis  Delirium
 Trauma / injury  Myasthenia gravis
 Ligamentous injury  Parkinson’s
 Fracture  Huntington’s
 Autoimmune disease - SLE  Guillian Barre
 Connective tissue disease  Trigeminal neuralgia
 Acoustic neuroma, Meniere’s disease

Non-Neurological Diagnoses
 Hypoglycaemia, AF
 Disc degeneration and herniation
 Spondylosis
 Tension or cluster headache
 Arrhythmia
 Syncope
 Temporal arteritis
 Sinusitis

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 − Domestic exposure to dusts, allergens, chemicals
History - Continued etc
 Ability to perform ADLs
 What Is the patient most concerned about  Home circumstances: partner, children, who lives at
 What do they want to gain from this consultation home
 Obesity
PHx / MHx: Past Medical History  Stress levels (relationship, work, children, etc)
 Open questions  Hobbies
 Medical conditions  Pets
 Surgeries:


Hospitalisations:
Tests
History - System Review
 Systems Qs
− These symptoms are either positive (present)  General: weight, appetite, sleep, energy, fevers or
symptoms or relevant negatives. night sweats?
 How this is affecting the patient; what are their main  Cardiorespiratory : Chest pain or ankle swelling
concerns and fears  Respiratory: difficulty breathing or cough
 Gastrointestinal: constipation, diarrhoea or blood in
1. When/how was it diagnosed? the stool?
2. How is it/was it managed? (surgeries,  Genitourinary: change in urination?
medication, lifestyle interventions)  Haematological: noticed any bruising or increased
3. Active/inactive bleeding?
4. Severity?  Endo: changes in skin, temperature tolerance?
5. How does it affect you now?  Reproductive: any discharge or rashes?
- Ongoing monitoring and review
 Neurological: Mobility, cognition, sleep, tingling or
(medial and allied health)
shooting pains? Changes in sight, smell or hearing?
 Musculoskeletal: any pain in your muscles or joints?
Medications  Mental status: Changes in mood?
 Prescribed
 OTC, vitamins, supplements and herbal remedies
 Compliance / frequency of use

Vaccination status

Allergies (+nature of reaction)

 Nature of the allergy

Family History
 Age of death and cause

Sexual History
 Multiple partners, unprotected sex, sex between men

SHx: Social History

 Smoking
− Current or previously, started/ finished, cigarettes
daily, bought or self-made
 Alcohol
 Recreational drug use / IV drug use  risk of infective
endocarditis
 Exercise tolerance and amount of physical activity
− How far they can walk
− Changes they’ve had to make
 Travel history
 Occupation

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History - Asthma History - Diabetes
To Do Current Diabetes
 Type (I or II)
 Duration
 Age of onset
 How diagnosed (symptoms or routine labs)
 Glucose control:
 Frequency of monitoring
 Time of day before meals (AC) or after (PC)
 Value in morning (AM)
 Value at night (PM)
 Hypoglycaemic events, DKA, hyperglycaemic
coma
 Frequency
 Severity
 Medications (how it is managed)
 Prescribed, OTC, vitamins, supplements and
\ herbal remedies
 Name and dose
 Oral hypoglycaemics (type II only,
sulfonylureas, metformin,
thiazolidinediones, α-glucosidase inhibitor)
 Insulin – who injects? Where?
 Dose adjustments
 Other drugs: CV drugs, diuretics, OTC,
steroids, B-blockers
 Diet prescribed
 Compliance / frequency of use

PHx / MHx: Past Medical History

 Medical conditions
 Risk factors: hypertension, cholesterol,
BMI/obesity
 Associated disease: pancreatitis, Cushing’s
syndrome
 Previous tests: HbA1c, urinalysis
 Hospitalisations, surgeries
 Relevant: MI, CVA, DKA, hypoglycaemia,
hyperosmolar nonketotic state
 How this is affecting the patient / ADLs
 What are their main concerns and fears

 Family history
 Age of death and cause
 Relevant: diabetes, cardiovascular
 Sexual and obstetric history
 Social history
 Modifiable risk factors:
• Smoking,
• Alcohol
• Diet
• Inactivity / exercise
 Finances, work, stress, mental health
 Occupation (risk of hypos)

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  Other: Living arrangements, family,  Urinary albumin excretion rate (timed
overnight or 24hr) OR early morning
Complications microalbumin creatinine ratio
 Acute events  Thyroid Function Test (type I due to
 Hypoglycaemic episodes - Associated with increased risk)
significant metabolic stress and morbidity:  Urea, Creatinine and Liver Function Tests.
MI, stroke, fractures  Referral: Ophthalmologist (or some optometrists)
 DKA (high glucose, no insulin) for assessment of the retina, Endocrinologist,
 Hyperglycaemic hyperosmolar coma Nephrologist, Diabetes Educator, Podiatrist,
 PVD (poor healing) and foot care: ulcers, Dietician, Exercise Physiologist, Pharmacist.
claudication
 Neuropathy Management
 Peripheral neuropathy: loss of sensation in  Tight glycaemic control - daily BG measurements
glove/stocking pattern and HbA1c regularly
 Autonomic neuropathy: erectile  Reduce risk factors
dysfunction, postural hypotension,  Diet and nutrition – quality vs quantity, high
gastroparesis and constipation fibre and low glycaemic index foods, gives
 CN mononeuritis glycaemic control, decreases
 Nephropathy: renal disease, proteinuria, hyperinsulinaemia & lowers lipids.
albuminaemia, creatinine  Exercise 60-70% 3-4d/wk– to prevent or
 Retinopathy: blurred sigh delay T2D, lower BP, improve insulin action,
 Macro vascular: IHD/angina, CVD/SOB, CHF, MI, GLUT4 insertion, reduced oxidative enzymes
PVD  Smoking cessation
 Infections: skin, genitourinary, feet, dental  Aim BP <130/80; younger patients or
microalbuminuric +ve <125/75
Investigations  Lipid control: TC<4.0, LDL<2.0,TG<1.5,
HDL>1.0
 Measure Hyperglycaemia
 Antiplatelet agents (aspirin) - all diabetics
 Random plasma glucose (RPG) - without
with a risk factor +/or >40 y.o
regard to time of last meal
 ACEI -drug of choice for BP, consider in
 Fasting plasma glucose (FPG) - before
normotensive with CVD
breakfast
 Oral glucose tolerance test (OGTT) - 2 hours  Education – website, pamphlet
after a 75-g oral glucose drink  Medications – oral hypoglycaemics and insulin
 Postprandial plasma glucose (PPG) - 2 hours  Immunizations
after a meal
 Haemoglobin A1c (A1C) - reflects mean
glucose over 2–3 months
 Fructosamine/glycated serum protein -
reflects mean glucose over 1–2 weeks.
 Estimated average glucose (eAG)
 Diagnosis of diabetes (if not already)
 Glucose Challenge Test (GCT)
 Oral Glucose Tolerance Test (OGTT) 75gm
glucose load
• DM: Fasting (8 hours) ≥ 7.0, 2hrs post
glucose load: >11.1
• Impaired fasting glycaemia: Fasting 6.1
-6.9, 2hrs post glucose load: <7.8
 Routine Investigations
 Glucometer: blood glucose monitoring,
 Screening for complications
aiming for 4.0 - 6.0 mmol/L pre meal, 4.0 -
 Foot care/eye care
8.0 mmol/L post meal
 Nephropathy screening and treatment
 Hb-A1c every 3-6months
 Neuropathy
 Annual investigations
 CVD screening and treatment
 Lipid profile

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Examination - Cardiovascular
Student Guidelines and one Lecture (‘Cardio Exam’)

Indications
 Cardiac symptoms (SOB, chest pain)
 A systemic disease with cardiac or vascular involvement (atherosclerosis, diabetes, SBE)
 Following cardiac history
 A full body examination

Contraindications
 Chest pain
 Patient declines examination

Equipment
1. Sphygmomanometer
2. Watch
3. Stethoscope
4. Torch
5. Ophthalmoscope

Introduction / Communication / Consent

 Hand hygiene,
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Involves: Look and feel of your arms, face, chest, back, abdomen and legs.
 Exposure: Exposure of arm for blood pressure and chest to listen to heart and lungs, including
bra, close curtains, cover with sheet and expose when necessary
 Indications / importance of proceeding, ask if they understand, have any concerns or questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain
 Pain or ‘discomfort’ at rest, especially for >10mins, pain associated with HF or syncope
Contraindication, treat immediately  Give aspirin, morphine, oxygen, nitro-glycerine and
call ambulance (if not in hospital). Anticoagulate (clexane). Be ready to administer BLS
 Severely SOB, sweaty, pale nauseated and anxious  acute pulmonary oedema (APO)  resuscitate: sit
patient up, give oxygen, positive airway pressure, nitroglycerine, IV furosemide and morphine

Examination A) Chest and Heart:

 Patient preparation: patient lying at 45°
 General Inspection
 Look ill? Respiratory effort and rate, distress, sweatiness
 Skin colour (pale, cyanotic, jaundiced),
 Cachexia (severe weight loss and muscle wasting)
 Syndromes associated with cardiac disease: Marfan’s, Down’s, Turner’s, Acromegaly
 Bedside clues: meds, IV fluids, glucometer, O2, respirator, ECG, IV cannula, signs
 Nails
 Clubbing  infective endocarditis, cyanotic congenital heart disease, respiratory
causes (lung carcinoma, bronchiectasis, abscess, empyema, pulm fibrosis)
 Splinter haemorrhages  infective endocarditis, vasculitis, trauma
 Capillary refill
 Hands
 Peripheral cyanosis

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  Nicotine staining
 Stigmata of infective endocarditis (Osler’s nodes, Janeway lesions)  infective
endocarditis
 Pale palmar creases  anaemia
 Feel temperature and sweatiness of of hands
 Warmth, sweaty  peripheral vasodilation  hyperthyroidism
 Cool and dry  peripheral cyanosis
 Tendon xanthomata  type II hyperlipidaemia
 Tremor  hyperthyroidism
 Wrist
 Radial pulse: Rate, rhythm, volume, character
 Tachycardia  left heart failure, PE, aortic dissection, palpatations
 Respiration rate
 Tachypnoea  left heart failure (pulmonary oedema), PE
 Radio-radial delay
 Radio-femoral delay  coarctation of the aorta
 Arms:
 IV drug injection scars  increased risk of bacteraemia and infective endocarditis
 Tendon xanthomata  type II hyperlipidaemia
 Blood pressure lying
 Blood pressure standing
 Hypotension left heart failure
 Face, eyes and mouth:
 Facies
 Apprehension, pain  AMI, angina
 Thyroid stare / myxoedema facies  hypothyroidism, hyperthyroidism
 Mitral facies / malar flush (rosy cheeks surrounded by bluish tinge)  pulmonary HT and
mitral stenosis with low CO
 Jaundice hepatic congestion due to congestive HF
 Xanthelasmata  hyperlipidaemia
 Pale conjunctiva  anaemia
 Icterus (jaundice of sclera)  congestive heart failure
 Central cyanosis  left heart failure (pu
 High arched palate Marfan’s syndrome  congenital heart disease
 Poor dentition, decay risk of infective endocarditis
 Petechiae  infective endocarditis
 Neck:
 Carotid pulsations
 Carotid pulse - both sides, one at a time
 Character: Amplitude (strong, gentle, weak), shape (single waveform), volume
 Auscultate for carotid bruit (bell over SCM over medical clavicle whilst holding breath)
 JVP (right internal jugular)
 Normal height: less than 3 cm above sternal angle
 Normal character: double waveform (flicker’s twice every cardiac cycle)
 Normal: ‘a’ wave (first flicker) and non-visible ‘c wave’) occurs with S1. ‘v’ wave occurs with
S2.
 Elevate JVP  right ventricular failure
 Hepatojugular reflex (press over the right upper quadrant for 15s)
 Normal: transient rise in the JVP
 Abnormal: sustained rise in JVP  left or right ventricular failure

Examination B) Praecordium (from separate and cardio student guidelines)

 Inspection:
 Pacemaker (can be left or right), cardiac defibrillator box (usually below clavicle)
 Scars: midline stenotomy scar  coronary bypass grafting, valve surgery
 Skeletal abnormalities and deformity e.g. barrel chest, funnel chest, scoliosis  Marfan’s

10
  Visible pulsations (visible apex beat, pulsation over pulmonary artery)
 Palpation (examine painful area last):
 Pacemaker/defibrillator (if present, palpate)
th
 Apex beat (normal: left 5 intercostal space at MCL, gentle quality, size of 20c)
 Describe: presence or absence, deviation, character
 Pressure loaded (heaving – forceful and sustained)  aortic stenosis, HT
 Volume loaded (displaced, diffuse, non-sustained impulse)  left heart failure, dilated
cardiomyopathy, mitral regurgitation
 Double impulse  hypertrophic cardiomyopathy
 Dyskinetic (uncoordinated impulse felt over a larger area than normal)  ventricular
dysfunction, previous AMI.
 Tapping (S1 is actually palpable)  mitral stenosis, tricuspid stenosis
 Parasternal impulse
 Heel lifted  RV or LA dilation (right ventricle pushed anteriorly)
 Thrills and heaves (apex, L sternum, heart base)
 Thrill  turbulent blood flow  valve pathology
 Percussion NONE
 Rarely performed. CAN be used to define the cardiac outline
 Auscultation: (normal: S1, S2, nil added)
 Extra sounds (S3 and S4), thrill, snaps/clicks/rub etc : describe:
 S3 increased atrial pressure and reduced ventricular compliance  ventricular failure.
 S4  high-pressure atrial wave reflected back from poorly compliant left ventricle 
hypertension or valve stenosis.
 Murmurs
 Systole or diastole, site loudest (e.g. apex or base), radiation, intensity 1-6
 Check for mitral stenosis
 Technique: Lay the patient on their left side (away from you, the “left lateral position’). Ask
them to breathe in, then out and hold it out. Listen over the apex and axilla with the bell of
the stethoscope.
 Tapping beat palpable or middle and late systolic murmur audible  mitral stenosis

Examination C) Back and lungs

***ask patient to sit up and lean forward over the bed***
 Inspection: deformities, scars
 Palpation: sacral oedema  right heart failure
 Percussion: lung fields  fluid overload / pulmonary oedema
 Auscultation: lung bases
 Inspiratory crackles  left heart failure (pleural effusion)
 Pleural rub pneumonia, PE or musculoskeletal

Examination D) Abdomen
***ask patient to lie flat on one pillow***
 Inspection:
 Scars (coronary bypass scar midline)
 Pulsations  AAA, pulsatile liver
 Distension, ascites  severe right heart failure
 Palpation:
 Liver border
 hepatomegaly  right heart failure
 pulsatile liver  tricuspid incompetence
 Spleen border
 splenomegaly  infective endocarditis
 Abdominal aorta
 Pulsatile and expansitile  aneurysm, AAA
 Percussion:
 Liver

11
 th
 Technique: down from above 6 rib in MCL until resonance to dullness is heard (upper
border), and then until the dullness to resonance is heard (lower border)
 Spleen
 Technique (from lectures notes): percuss from nipple down to identify upper border, then
percuss from umbilicus to left flank to identify lower border
 Shifting dullness
 Technique: from midline to left flank until dullness is heard, roll patient towards you,
percuss same site to check if now resonant.
 Ascites  right heart failure
 Auscultation:
 Renal arteries  renal stenosis
 Aortic bruits  AAA, aortic stenosis

Examination E) Lower Limbs

 Inspection:
 Scars (e.g. vascular harvest), ulcers, varicosities, ischaemia, amputations
 Oedema (note upper level of oedema)  right ventricular failure
 Trophic changes: hair loss, shiny skin, trophic nails  peripheral vascular disease
 Colour of feet: cyanosis, white, red
 Rare: clubbing, tendon xanthomata
 Palpation
 Feel temperature
 Feel for calf tenderness  claudication, PVD
 Capillary refill of toenail
 Abnormal: >3 secs. Proceed to Buerger’s test)
 Pitting oedema (slow refill of skin)  congestive cardiac failure
 Pulses (bilaterally)
 Femoral
 Popliteal
 Posterior tibial
 Dorsalis pedis
 Auscultation
 Femoral artery bruits  femoral artery stenosis

Investigations
 ECG to diagnose current or previous AMI or arrhythmias
 Echocardiogram
 Fundoscopy of eyes is relevant if infective endocarditis is suspected, if the patient has diabetes or
hypertension.
 Temperature if there are signs of infective endocarditis
 Urinalysis looking for diabetes or infective endocarditis

12
Examination – Respiratory
From Student Guidelines, one lecture (Resp Exam)
Indications
 Following respiratory history Equipment
 Respiratory symptoms 1. Watch
 As part of a full body exam 2. Torch
 3. Stethoscope
Contraindications
 Patient declines examination

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Obtain informed consent
 Rationale / indication
 Involves: Look and feel of your hands, face, neck and chest, listen to your chest.
 Exposure: Exposure of chest to listen to lungs including bra, cover with sheet and expose
when necessary, curtains
 Indications / importance of proceeding, ask if they understand, have any concerns or
questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain
 Severe dyspnoea and distress and oedema  give oxygen
 Severely SOB, sweaty, pale nauseated and anxious  acute pulmonary oedema (APO) 
resuscitate: sit patient up, give oxygen, positive airway pressure, nitroglycerine, IV furosemide and
morphine

Examination A) General Inspection

 Patient preparation: Patient lying at 45°
 General Inspection
 Respiratory effort, pattern (quick and shallow, deep and long), accessory muscles (SCM,
shoulders), dyspnoea, tracheal tug, diaphragm splinting) give O2 to reduce hypoxia 
pneumonia, COPD, asthma, PE, acute PO, interstitial disease
 Increased WOB  COPD, asthma,
 Respiratory sounds: stridor (urgent), wheeze, hoarseness (laryngitis, recurrent laryngeal
nerve palsy due to lung tumour)
 Does patient have a cough? Ask patient to cough several times
 Describe cough +/- sputum (colour, volume, type, blood)
 Skin colour: pallor, cyanosis (chronic bronchitis COPD, PE), flushed ( emphysema COPD)
 Nutritional status: Weight loss (cachexia  lung carcinoma) or weight gain (steroid use)
 Bedside clues: meds, inhaler (asthma, COPD), O2 (COPD), cigarettes (lung carcinoma),
temperature chart (fever  pneumonia, bronchiectasis), sputum cup (colour, amount,
blood, sputum)
 Sputum cup (yellow / green  chest infection, rusty/purelent  pneumonia, pink and
frothy  pulmonary oedema, red streaks  carcinoma)
 Nails and Fingers
 Finger clubbing  hypoxia  carcinoma, bronchiectesis, empyema, lung fibrosis, CF,
abscess,
 Peripheral cyanosis
 Nicotine staining  emphysema COPD, carcinoma
 Hands
 Feel temperature of hands
 Palmar erythema  CO2 retention

13
  Ask patient to cock wrists back
 Wasting and weakness of finger aBductors  lung tumour infiltrating T1 brachial plexus
 Flapping tremor / asterixis  severe CO2 retention  late COPD, renal or liver failure
 Fine tremor  B2 agonist use  asthma
 Wrist
 Wrist tenderness  hypertrophic pulmonary osteoarthropathy (HPOA)
 Radial pulse  rate, rhythm, regularity, character
 Tachycardia  PO, PE, RED FLAGS (Pneumonia)
 Respiration rate (1/3 inspiration, expiration and rest) • RR over 30
 Dyspnoea / tachypnoea  pneumonia, emphysema, asthma, • systolic BP less than 90
PE, PO • O2 less than 92%
 Shorter inspiration, long expiration  obstructive disease • acute onset confusion
 Arms • arterial /venous) pH less
 Palpate for lymphadenopathy in both axillae than 7.35
 Blood pressure • PaO2 less than 60 mm Hg
 Lying • multilobar on CXR
 Standing
 Face, eyes and mouth
 Eyes: Pale conjunctiva  anaemia, Horner’s Syndrome indicated by ptosis (drooping eyelid),
miosis (constricted pupil) and anhidrosis (lack of sweating)  apical lung tumour
compressing SNS nerves in neck
 Cheeks: Facial plethora  COPD or cyanosis
 Nose: patency, polyps  asthma, enlarged turbinates  allergies, deviated septum nasal
obstruction
 Mouth: enlarged tonsils or red pharynx  URTI, blue under tongue  central cyanosis, soft
palate is oedematous and erythematous  obstructive sleep apnoea
 Palpate the sinuses
 Trachea and neck:
 Signs of sleep apnoea (thick neck, receding chin, small pharynx)  sleep apnoea
 Wasted accessory muscles of respiration
 Tracheal tug (trachea and therefore skin above sternum is drawn in with inspiration 
airflow obstruction, COPD
 Feel SCM contraction
 Feel for tracheal deviation  carcinoma, diseases of upper lobes of lung penumothorax
 With the index and ring fingers on the sternal notch, use your middle finger to examine
 JVP (usually decreases with inspiration and decreases with expiration)  cor pulmonale, HF
 Cervical lymph nodes (**from behind patient**)
 supraclavicular, cervical or axillary lymphadenopathy  carcinoma

If the trachea is deviated, start with the anterior chest. Otherwise, it is

recommended to start with the posterior chest as there are often more
signs present.

Examination B) Posterior Chest

** ask patient to sit over the edge of the bed**
** compare LEFT with RIGHT**
 Inspection
 Shape and symmetry of chest and spine
 Barrel chest  emphysema, severe asthma
 Scars (e.g. pneumnonectomy scar, thoracotomy scar
under axilla)
 Movement of chest wall, symmetry of expansion
intercostal indrawing
 Prominent veins (determine direction of flow)
 Palpation
 Subcutaneous emphysema (rice bubble pops under skin)

14
  Chest expansion (posteriorly, lower lobe)
 Place the hands firmly on the chest wall with the fingers extending around the sides of
the chest. The thumbs should almost meet in the middle line and should be lifted slightly
off the chest so that they are free to move. As the patient to take a deep breath
 Normal: the thumbs move symmetrically apart at least 5 cm.
 Unilateral delayed or decreased chest expansion  pathology on that side 
pneumonia (consolidation), pneumothorax
 Bilateral reduction in chest expansion  e.g. COPD, diffuse pulmonary fibrosis.
 Compress ribs for tenderness  rib fracture
 Palpate any relevant scars
 Percussion
**Ask patient to bring their elbows forward to move scapulae**
**percuss and auscultate down mid-clavicular line, 2 intercostals apart**
**percuss axillary apex, mid axilla then anterior and basal axilla **
 Percuss back (posterior lungs), axillae
 Resonance  normal (fluid-filled organ)
 Dull percussion  lobar pneumonia
 Stony dullness  pleural effusion
 Hyper-resonance  pneumothorax, COPD
 Auscultation
**with diaphragm **ask patient to breathe deep and slowly through the mouth**
** auscultate and auscultate down mid-clavicular line, 2 intercostals apart**
**auscultate axillary apex, mid axilla then anterior and basal axilla**
 Auscultate back (posterior lungs), axillae
 Assess breath sounds (character, intensity)
 Normal: normal/vesicular breath sounds bilaterally of normal
intensity, lung fields clear, nil adventitious sounds
 Decreased breath sounds  sound slower in air  COPD
pneumonia, large tumour or pulmonary collapse.
 Decreased breath sounds  increased distance between lung and
chest wall  emphysema, pleural effusion, pneumothorax
 Decreased breath sounds  no air entering lung  consolidation
 Repeat auscultation for vocal resonance (“99”)
 Increased vocal resonance (i.e. numbers are clearly audible
because sound travels better in fluid than air )  consolidation
/ pneumonia (solid), pleural effusion (fluid)
 Decreased vocal resonance (i.e. numbers inaudible )  pleural effusion, thickening

Abnormal breath sounds

 Bronchial breath sounds (not over manubrium)  lobar pneumonia / consolidation, effusion, fibrosis
 Reduced breath sounds  fluid and air  COPD, pleural effusion, pneumothorax, non-lobar
pneumonia, large tumour or pulmonary collapse
 Increased breath sounds  solid lung fibrosis or consolidation
 Wheeze (usually expiratory)  airway obstruction  asthma (high pitch), COPD (low pitch), airway
obstruction, bronchiectasis, allergies, partial obstruction
 Crackles (inspiratory):
 Early inspiratory  small airway disease  chronic bronchitis, COPD
 Early unilateral inspiratory  bronchial infection, pneumonia
 Late or pan-inspiratory crackles (fine, medium, coarse)  alveolar disease, pneumonia
 Fine crackles  pulmonary interstitial fibrosis.
 Medium crackles  left ventricular HF / pulmonary oedema, pneumonia
 Coarse crackles  secretions/mucus, change with coughing  bronchiectasis
 Basal Crackles  pulmonary oedema (LHF), pleural effusion? (LHF, RHF)
 Stridor (inspiratory)  upper airway obstruction  foreign body, croup, laryngeal tumour
 Pleural friction rub  inflammation of pleura  pneumonia, PE, pleuritic or musculoskeletal (NOT
pleural effusion, as this separates the adjacent rubbing walls!)

15
Examination C) Anterior Chest
 Inspection
 Shape and symmetry, scars, lesions, movement of chest wall (symmetrical, diminished,
hyper)
 Intercostal recession/indrawing with breathing
 Paradoxical movement of abdomen (inward during inspiration = diaphragm paralysis
 Palpation
 Supraclavicular lymph nodes (ask patient to shrug shoulders)
 Subcutaneous emphysema (crackling sensation felt on skin of the chest or neck)  air
tracking from the lungs  pneumothorax
 Chest expansion (anteriorly)
 Watch clavicular movement from above to assess upper and middle lobe expansion
 Apex beat
 Movement due to lesion
 Non-palpable  can be normal, can indicate hyperinflation
 Vocal fremitus (not recommended) – say 99 and feel vibration
 Percussion:
 Supraclavicular fossa and front of chest
 Clavicles
 Liver dullness
 down the anterior chest in the midclavicular line
th
 Normal: 5 rib in the midclavicular line
th
 Abnormal: resonate below 5 rib  hyperinflation  emphysema, asthma
 Cardiac dullness
 Decreased  emphysema, asthma
 Auscultation:
**use the diaphragm except at lung apex – use the bell**
 As above: supraclavicular fossa and front of chest
 As above: Breath sounds, adventitious sounds, vocal resonance
 Normal: normal/vesicular breath sounds bilaterally or normal intensity, lung fields clear, nil
adventitious sounds
 Repeat auscultation for vocal resonance (99)
 Pemberton’s sign (for SVC obstruction)
 With patient sitting up, ask them to lift their arms over their head for 1min. Look for facial
plethora, cyanosis, inspiratory stridor, non-pulsatile elevation of JVP  SVC obstruction 
carcinoma compressing SVC

Examination D) Other (if relevant) Systems

 Cardiovascular system (JVP, apex beat) DONE for evidence of cor pulmonae and pulmonary
hypertension
 Abdomen
 Lay patient supine
 Inspect for signs of Horner’s syndromehyper-expanded lungs
 Palpate for liver
 Pulsatility, tenderness, nodularity
 Enlarged  tumours (metastases), cor pulmonale
 Breasts and axillary nodes for tumours
 Lower limbs
 Oedema of ankles, calf tenderness, cyanosis, DVT
 Examine for primary malignancy if suspected (e.g. lung metastasis or malignant pleural effusion) – go
on to examine breasts, abdomen, rectum, lymph nodes etc.

Investigations
 Chest X Ray (CXR) (haemoptysis always requires CXR)
 Bronchoscopy (from haemoptysis as CXR can be normal in lung cancer)

16
 Bedside assessment of lung function / lung function tests
 Bedside vital capacity: counting aloud (normal >20)
 Forced expiratory time: ask patient to fully inspire, then exhale forcefully and completely
through open mouth. Normal <3 sec.
 Increased expiratory time airway obstruction  COPD. Peak flow meter or spirometer
is more accurate
 Peak flow meter
 Spirometer
 Sputum: microscopy, C&S, cytology
 FBE (WCC) CRP and ESR (raised  pneumonia)
 (HR) Computerised tomography (CT) of the chest
 Llavage and lung biopsies
 Admission (to hospital): Exacerbations of COPD and asthma, acute pneumonia and interstitial disease

17
Examination – Genitourinary
From Student Guidelines

Indications Contraindications
It’s not routinely performed  Declining examination
 Suspected or known renal disease  Note: Pain is not a contraindication –
 Symptoms of kidney disease, UTI examine this area last

Equipment
1. Stethoscope

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself
 Confirm the correct patient - ask name, DOB and UR number
 Obtain informed consent
 Rationale / indication
 Procedure: Look and feel of the hands, arms, face, chest and abdomen and legs, listen to the
chest, lungs and abdomen
 Exposure: exposure of chest and abdomen, undress from the waist up, cover with sheet and
expose when necessary
 Discomfort, risks and complications
 Importance of proceeding, ask if they understand, have any concerns or questions
 Gain consent
 Ask if the patient has any pain
 Offer the patient a chaperone

Examination A) Inspection and Vital Signs

 Patient preparation: lying supine (flat), with one pillow and arms by their side
 General Inspection
 Skin colour: pallor (renal failure  decreased EPO, anorexia, haemolysis and/or hepcidin 
anaemia), sallow/grey (uraemia)
 Bedside clues: urine sample, temperature chart (infection), glucometer, weight, bladder
diary (used in incontinence)
 Stigmata of renal failure:
 Uraemic tinge (sallow, grey complexion) (uraemia  renal failure)
 Uraemic fetor (ammoniacal fish breath) (uraemia  renal failure)
 Hyperventilation (metabolic acidosis  uraemia  renal failure)
 Hiccuping (uremia  renal failure)
 Drowsiness, poor response and mental state (nitrogen + toxin retention  renal failure)
 Hydration state
 Oedema and acities  fluid overload (SNS, RAAS, vasopressin)  due to renal failure
and/or overhydration in correcting acute kidney injury
 Dehydration / hypovolaemia (dry membranes  risk of causing acute kidney injury or
due to the fluid restrictions of renal failure)
 Weight
 Anorexia and malnutrition
 Fatigue, lethargy, watch their movement
 Myoclonic jerks (twitching), tetany and seizures (renal failure  low serum calcium and
nitrogen retention)
 Subcutaneous nodules (high PO4 binding up Ca  calcium phosphate deposition)
 Hands
 Leuconychia  hypoalbunaemia  due to nephrotic syndrome
 Pale palmar creases  anaemia  due to renal failure
 Skin turgor

18
  Reduced skin turgor  hypovolaemia / dehydration
 Test capillary refill
 Ask patient to extend wrists (more than 20 sec)
 Asterixis (flap)  extreme uraemia in end-stage chronic renal failure)
 Radial pulse
 Tachycardia, bounding pulse  fluid overload (SNS, RAAS, vasopressin) due to renal
failure
 Tachycardia  hypovolaemia

 Wrists and Arms

 Scars of carpal tunnel (common in patients with renal failure)
 AV fistula (haemodialysis access  renal failure)
 Vasculitis (a cause of renal failure)
 Skin changes associated with uraemia due to renal failure)
 Bruising (nitrogen retention)
 Skin pigmentation
 Scratch marks (uraemitc itch) Vasculitis
 Uraemic frost (very rare)
 Signs of peripheral neuropathy  diabetes  renal disease
 Muscle wasting (indicating myopathy)
 Palpate for bone tenderness
 Tenderness  renal disease  low vitamin D and Ca  osteomalacia
 Blood pressure lying
 Blood pressure standing
 Hypertension  a cause and result of renal failure
 Postural hypotension  hypovolaemia
 Face
 Skin and eyes
 Anaemia
 Jaundice
 Band keratopathy (calcium deposits beneath cornea)
 Mouth
 Uremic fetor (ammonia smell on breath) (hyperuricaemia  renal failure)
 Mucosal ulcers, thrush/ candidia (patient with renal failure are prone to infection)
 Rash or skin tethering of connective tissue diseases: scleroderma or systemic lupus
erythematosus  causes of renal failure
 Gingival (gum) hyperplasia  side effect of the immunosuppressive drugs cyclosporine
and tacrolimus  kidney transplant
 Hearing aids (renal failure associated with hearing loss in Alport’s syndrome)
 Neck
 Parathyroid surgery scar  renal failure  increased blood PO4  tertiary
hyperparathyroidism
 Auscultate for carotid bruits
 Bruits  atherosclerosis  increased risk of renal artery stenosis and kidney disease
 JVP
 Elevated = fluid overload due to renal failure
 Low = dehydration  risk of causing acute kidney injury
 Chest
 Vascular access catheters (or punctures) for dialysis (‘vascath’)
 Auscultate for heart sounds
 Murmurs: renal failure  fluid overload (SNS, RAAS, vasopressin),
hypertension (cause or effect)  valve incompetence
 Pericardial friction rub: renal failure  retained metabolic toxins  pericardial effusion
 pericarditis
 Back
 Palpate for sacral oedema

19
  Sacral oedema: renal failure, nephrotic syndrome  fluid overload (SNS, RAAS,
vasopressin)  sacral oedema
 Check for vertebral tenderness
 Technique: strike vertebrae gently with little finger side of clenched fist
 Vertebral tenderness  Tenderness  myeloma, renal disease  low vitamin D and Ca
 osteomalacia
 Auscultate the lung bases
 Crackles: renal failure, nephrotic syndrome  fluid overload (SNS, RAAS, vasopressin),
hypertension  congestive HF, pulmonary oedema
 Crackles: renal failure  uraemic lung disease (a non-cardiogenic pulmonary oedema)
or uraemic cardiomyopathy.
 Murphy’s kidney punch (rarely used)
 Technique: gentle strike of clenched fist in renal angle, looking for renal tenderness

Examination B) Abdomen
**roll the patient to inspect the flanks!**
 Inspection (normal = “soft and non-tender abdomen, with not palpable masses
present”)
 Tenckhoff catheter (peritoneal dialysis catheter)
 Surgical scars: nephrectomy or renal transplant, peritoneal dialysis
 Nephrectomy scars may lie posteriorly over the loin area.
 Renal transplant scars are usually located in the left or right iliac fossae.
 A renal transplant may appear as a bulge under the scar
 Distension of the abdomen  ascites, nephrotic syndrome, peritoneal
dialysis fluid)
 Abdominal pulsations
 Inspect the external genitalia
 Scrotal masses
 Genital oedema

 Palpation: Kidneys and Bladder

 Palpate for renal or loin tenderness  renal or ureteric stones
 Palpate along the path of the ureters
 Tenderness (rare)  renal obstruction
 Ballott the kidneys bimanually
 Technique: The posterior hand flicks the kidney upwards (flex at the MCPs) from the renal
angle, while the other hand lies anteriorly in the right or left upper quadrant and feels the
kidney move upwards against it. The right hand lies over the right kidney, and vice versa
 Normal: inferior pole of R kidney palpable, L kidney not palpable (usually)
 Enlargement (forward): renal masses, cysts, tumours, abscess, collection
 An enlarged kidney moves inferiorly, while an enlarged spleen moves inferior medially
 Palpate any renal transplants in iliac fossa (right or left)
 Palpate the bladder
 Normal: not palpable unless distended
 Palpable  distension above pubic bone  urinary retention
 Palpate the liver
 Hepatomegaly  liver enlargement due to hepatic cysts due to PCOS
 Palpate for abdominal aorta
 Percussion:
 Shifting dullness
 Technique: Percuss from the midline to the left lateral flank, until a dull note is heard. The
index finger remains on the resonant side, and the middle finger remains on the dull side,
straddling the fluid-air level. Ask the patient to roll towards you (onto their right side) and
wait 20sec. Percuss the dull area to ensure it is still dull.
 Shifting dullness  fluid retention and ascites
 Bladder size

20
  Technique: percuss from te umbilicus until dullness can be heard. Measure distance of
extension in cm from the pelvic brum
 Enlarged bladder towards umbilicus  distension  measure distance of dullness
 Auscultation:
 Renal bruit  renal artery stenosis
 Technique left and right of midline at the level of the umbilicus

Examination C) Lower Limbs

 Inspection
 Vasculitis (a cause of renal failure)
 Odema  renal disease  fluid overload
 Skin changes associated with uraemia due to renal failure)
 Bruising (nitrogen retention)
 Skin pigmentation
 Scratch marks (uraemitc itch)
 Uraemic frost (very rare)
 Signs of peripheral neuropathy  diabetes  renal disease
 Muscle wasting (indicating myopathy)
 Palpate for bone tenderness
 Tenderness  renal disease  low vitamin D and Ca  osteomalacia

Further Investigations (often part of an abdominal exam)

 External genitalia (part of routine examination)
 Male: penis, scrotum and testes
 Female: labia, pelvic exam
 Urinalysis including a pregnancy test in females
 A DRE / rectal examination (especially in men with prostatic symptoms)
 Perineal sensation: If incontinence present, assess perineal sensation with cotton wool (spinal cord
lesions, MS)
 Lower-limb neurological examination: indicated if neurological disturbance is suspected (urinary
retention or incontinence)
 IV pyelogram for anatomy of the urinary track (contrast excreted by kidneys)

Complications
 Embarrassment
 Exacerbating pain when kidneys or bladder is palpated

21
 Examination – Gastrointestinal
From Student Guidelines and one lecture (Gastro Exam).

Indications Contraindications
 GI symptoms – pain, jaundice,  Declining examination
 Following GI history  Note: Pain is not a contraindication –
 Full body examination examine this area last

Equipment
2. Torch
3. Tape measure
4. Stethoscope

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself
 Confirm the correct patient - ask name, DOB and UR number
 Obtain informed consent
 Rationale / indication
 Procedure: Look and feel of the hands, arms, neck, chest and abdomen, listen to abdomen
 Exposure: exposure of chest and abdomen, cover with sheet and expose when necessary
 Discomfort, risks and complications
 Importance of proceeding, ask if they understand, have any concerns or questions
 Gain consent
 Ask if the patient has any pain

Examination A) Inspection and Vital Signs

 Patient preparation: lying supine (flat), with one pillow and arms by their side
 General Inspection
 Pain, comfort and movement
 Stillness  peritonism
 Writhing around  renal colic
 Sitting up and leaning forward pancreatitis
 Mental state  hepatic encephalopathy
 Weight and fluid retention:
 Obesity, wasting
 Abdominal distension, distended veins
Spider Naevi
 Skin involvement:
 Jaundice  hyperbilirubinaemia due to hepatitis, liver failure, liver cancer.
 Scars
 pigmentation, ancanthosis nigricans, systemic sclerosis, Peutz-
Jeghers syndrome, hereditary haemorrhagic telangiectasia,
porphyria cutanea tarda
 Tract marks and tattoos  Hep C
 Record weight
 Vital signs
 Heart rate
Leukonychia
 Respiration rate
 Blood pressure
 Temperature
 Hands
 Nail changes:
 Leukonychia (pale/white nails)  low K+
 Clubbing

22
  Palms:
 Pale palmar creases  anaemia
 Palmar erythema  liver disease / cirrhosis
 Tremor
 Dupuytren’s contracture (fixed finger flexion)  alchoholism, manual
labour, familial, diopathic
 Ask patients to cock wrists back for >20 seconds
 Asterixis / flap  liver failure and subsequent hepatic
encephalopathy
 Arms
 Skin lesions: Petechiae (minor haemorrhages), spider naevi aka spider
angioma, bruising
 Scratch marks  peritis due to liver disease, IV track marks  Hep C
 Muscle wasting
 Check for axillary lymphadenopathy (behind pectoralis major)
 Face
 Eyes
 Conjuntival pallor  anaemia
 Icterus (i.e. jaundice of the eyes)
 Iritis (dry eyes)
 Xanthelasma hypercholesterolemia, primary biliary cirrhosis
 Mouth, teeth, gums (pen torch)
 Uremic fetor (bad breath)  hyperuricaemia  CRF Figure 1: Petechiae
 Mouth ulcers and oral candidiasis  Crohn’s disease
 Tongue  glossitis  B12 deficiency
 Petechiae, telangectasis  Osler Weber Rendu, patches of pigmentation
 Peutz Jeghers

 Neck
 Measure JVP Telangiectasia
 Raised JVP  portal hypertension
 Palpate cervical lymph nodes (enlarged, unilateral, hard or soft)
 Feel salivary glands
 Parotid or submandibular swelling → alcoholism
 Palpate supraclavicular lymph nodes
 ‘Virchow’s node’ or a ‘sentinal node’.  metastatic abdominal or pelvic
malignancy
 If cervical lymph nodes are palpable, examine axillae and groin lymph nodes for lymphadenopathy
 lymphoma, leukaemia, AIDS
 Chest
 Spider naevi (more than 5)  increased oestrogen due to liver cirrhosis
 Gaenocomastia (males)  impaired liver detoxification e.g. due to alcoholism and liver cirrhosis
 Paucity of hair (males)
 Breast atrophy (females)

Examination B) Abdomen
 Inspection (normal = “soft and non-tender abdomen, with not palpable masses present”)
 Prominent veins / caput medusa  portal hypertension due to liver cirrhosis
 Abdominal distension / swelling  five F’s: fat, fluid, faeces, flatus, fetus
 Ascites (fluid forced out of gut capillary bed and into the peritoneal space)  portal hypertension
due to liver cirrhosis
 Visible pulsations or visible peristalsis  bowel obstruction, abdominal aorta
 Localised swelling (mass, loop of bowel, organomegaly)
 Scars, stoma, fistula
 Hernia
 Palpation: nine areas

23
 **warm hands, use flat hand with fingers together, use lateral surface of the right hand, flex at the MCPs,
painful area last, watch the patient’s face, make talk to distract, may need to ask them to bend knees to
relax abdomen**
** each of the regions is palpated lightly (for tenderness or lumps) and then more deeply (to detect any
deeper masses and organomegaly **
 Light palpation:  looking for tenderness, lumps, peritoneal inflammation and peritonitis
 rebound tenderness (increased tenderness when hand is released)
 rigidity (constant involuntary contraction of abdominal muscles, always associated with
tenderness)
 guarding (contraction of abdominal muscles over an area of peritoneal inflammation – can be
voluntary e.g. due to anxiety or tenderness, or involuntary with peritonitis).
 Deep palpation  looking for masses or organomeglay
 Mass  describe site, tenderness, size, surface, edge, consistency, mobility, resonance
 Pulsatile  Aortic aneurysm
 Palpate Liver
 Normal: smooth, non-tender, soft, regular with well-defined border, may be felt just below the
right costal margin on deep inspiration in thin patients
 Enlarged liver border  Hepatomegaly caused by cirrhosis, carcinoma, heart failure,
myeloproliferative or lymphoproliferative disorders
 Hard, tender, irregular, pulsatile liver border  neoplasm, nodular liver surface, small
cirrhotic liver or necrotic liver.
 Gall bladder
 A focal, rounded mass that moves down with inspiration  enlarged gallbladder
 Palpate Spleen (enlarges inferiorly and medially)
 Splenomegaly alone  Chronic myeloid leukaemia, Myelofibrosis
 Hepatosplenomegaly  chronic liver disease with portal hypertension, hemolytic anemias,
neoplasm (e.g. leukema, lymphoma)
 Ballot Kidneys (enlarge inferiorly and straight down)
 Aorta (using both hands)
 Expansile aorta  aortic aneurysm/AAA
 Others: bladder, inguinal lymph nodes, testes
 Percussion:
 Percuss each of four quadrants and umbilicus
 Resonance = normal = air in bowel
 Percuss for and measure total liver span
th
Starting from above the 6 rib, percuss down right midclavicular line, until the edge where the
liver was palpable. Percuss from below (resonant areas) up to the lower liver border.
th
 Normal: Resonant to dull at 6 rib (upper border), dull to resonant at palpable liver edge (lower
border). Normal span: less than 13cm and below the right costal margin
 Resonance over liver: gas in the peritoneal cavity e.g. perforated bowel.
 Percuss for splenomegaly
 Lecture notes: Percuss from nipple down to identify upper border, then percuss from umbilicus
to left flank to identify lower border.
 Talley: Percuss over the lowest intercostal space in the left anterior axillary line in both (full)
inspiration and expiration. Dullness on full expiration  suspect splenomegaly
 Measure shifting dullness
 Resonance  ascites due to liver disease or malignancy
 Percuss the bladder
 Dullness and tenderness  distended bladder
 Auscultation: three sites
 Bowel sounds (below umbilicus)  describe whether present or absent
 Normal = normal sounds present 1 every 10 sec
 Increased bowel sounds  gastroenteritis, early bowel obstruction
 Absent bowel sounds  ileus (post-surgery due to opiates), hypokalaemia
 Abdominal aortic bruit (epigastric region)  Atherosclerosis, aneurism
 Renal bruit (left and right of midline at level of umbilicus)  Atherosclerosis

24
Investigations (often part of an abdominal exam)
 A DRE / rectal examination  rectal masses, constipation, melaena, prostatomegaly
 Hernial orifices exam  herniae
 External genitalia examination:
 Males: penis, scrotum and testes  testicular atrophy
 Females: labia, pelvic exam
 Urinalysis at this point including a pregnancy test in females
 Analysis of faeces and vomitus
 Abdominal X-Ray

25
Examination – Breast
From Student Guidelines, online videos

Indications Contraindications
 Pain (mastalgia)  Patient declines examination
 Lump
 Nipple change Equipment - none
 Nipple discharge
 Screening (recommended in combination Complications
with mammography, when patient gets pap  Lack of communication leading to the
smear or pill) patient feeling uncomfortable, legal
ramifications, etc

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number

 Consent
** Competence (assumed), complete information (including risks), understanding, voluntariness,
authorization**
 Indications: to encourage awareness and detect any early breast changes,
 Ask if have they’ve had a breast examination before
 Were there any difficulties?
 Ask about breast pain, other symptoms or past surgery/radiotherapy in the area
 It will involve 3 parts
 First, I will look the beast tissue and how it moves on the chest when your arms are in different
positions.. This will involve you following some of my arm movements. I will be looking for any
slight changes in the skin
 Second, I need to feel the breast tissue for any lumps or changes, which will involve circular
movements across all the breast tissue while you’re sitting up and lying down.
 Finally, I will feel the lymph nodes in the armpit and above the collarbone
 Exposure: Will need you to undress from the waist up, including you bra
 Privacy: Will ensure the curtains are closed and there will be a gown provided.
 Inform that they can stop the examination at any time or if uncomfortable
 Importance of proceeding/reassurance: will feel a bit uncomfortable but it’s absolutely crucial
 Ask if they understand. Ask if they have any concerns or questions
 Offer a chaperone
 Gain consent

Communication:
 Inspection:
 “I’m going to lower your gown to begin the visual inspection. I will be looking quite closely so don’t
be alarmed. “
 “Now I would like to check how the breast tissue moves on the chest wall and I will need you to
move your arms. Could you follow my arms movements please?”
 Inspection is finished. You can pull the gown up and when you are ready lie down.
 Palpation of Breast tissue
 When you’re ready, I will uncover one breast
 I am now going to feel your breast, one at a time
 I have completed the examination of that breast now. You can cover that side and can you please
uncover the other breast
 Palpation of Lymph Nodes
 Now I will examine the lymph node areas in your armpit and behind your collarbone.

26
  If the patient has pendulous breasts
 Inspection: ask her to lift her breasts so that the tissue underneath can also be inspected
 Palpation: place a pillow under the side to be examined
 If the patient has small breasts you may be able to palpate only while sitting

Examination A) Inspection
 Patient preparation: patient sitting over edge, stand arm’s length away
 ** look at both breasts, compare both sides ** ensure patient is warm and ease
nervousness** warn that you’ll be looking quite closely **
 General inspection
 Pain
 Lumps or thickenings
 Change in shape or size, asymmetry, differences in breast height
 Enlarged veins
Nipple retraction and
 Skin lesions orange peel skin
 Puckering, skin tethering or dimpling  cancer involving ligaments
 Sores or ulcers
 Redness or inflammation
 “Orange peel” skin
 Nipple
 Changes in alignment of the nipples
 Nipple retraction (drawing in of the nipple) or nipple deviation 
cancer involving ligaments
 Colour change  Paget’s disease of the nipple
 Rash on or around nipple Carcinoma of lung causing elevation,
 Discharge (texture, colour, etc) dimpling and nipple retraction
 Arms/armpit
 Swelling or lumps in armpit
 Swelling of upper arm
 Technique:
 Inspect in different positions to see the effect of tension
1. Hands by side
2. Hands over head
3. Hands on hips (tensing pectoral muscles )
4. Leaning forward (creating tension in Cooper’s ligaments) (if they
have large breasts, they may need to stand)
 Impaired movement of breast tissue, tethering, dimpling, retraction etc.
 **cover patient with gown once complete**

27
Examination B) Palpation of Breast Tissue
 Patient preparation: patient lying supine and covered
Where tumours most commonly occur
 Technique
 Ask if they have any abnormalities, if they have any pain and to
you if they experience any pain
 Start with the normal side first
 Uncover and feel one breast at a time
 Maintain eye contact to check for discomfort. Rule of 1/3 – 1/3
at breast, 1/3 at patient’s face, 1/3 in distance
 Use pulps of the three middle fingers in a circular motion to
press tissue against the chest wall
 Have a small amount of tissue between fingers and the chest
wall
 Start with light pressure and then firmer pressure
 Slide fingers to the next area, keeping hand in contact to feel any
changes
 Start at the top of the breast and move down, and up again,
ensuring that you slightly overlap the last panel
 Rolling to the right (toward you) flattens out medial right breast
and lateral left breast. Ask the patient to roll to ensure there is a
small amount of tissue between the fingers.
 It is usually easiest to start from the left lateral edge of the left
breast and work medially, and for the right breast, to start
medially and work laterally (i.e. toward you)
 Cover all breast tissue, including the breast tail and nipples (warn the patient it will be tender)
 Ask the patient to raise her arm while palpating the breast tissue on the lateral side and the breast
tail extending up towards the axilla.
 Technique (alternative from provided Flinder’s video)
 Feel in columns, from superior to inferior
 1) With the patient sitting up, feel across the top 5-6cm of the breast.
 2) With the patient lying down on their back, feel the medial lower half of the breasts and under
the breasts
 3) Ask the patient to roll onto their side and lift their arm (to expose the axillary tail) to feel across
the lateral lower half of the breasts and under the breasts
 4) In this position also feel above the nipple and the areola (try to flatten the tissue between your
hands)
 Lumps  normal breast nodularity, fibroadenoma, cysts, breast cancer 10 point description
 Location: Quadrants are used rather  Mobility: is it movable or fixed deep
than the clock face or superficially
 Size: in diameter  Borders: poorly defined or discrete
 Shape: round, regular or irregular  Retraction: altered breast contour,
 Consistency: firm to soft any dimpling
 Tenderness: how tender
 Significant features of a breast lump:
 Painless
 No fluctuation with menstrual cycle
 Increasing in size
 Recent development.
 **re-gown the patient and ask to sit up**

28
Examination C) Palpation of Lymph Nodes
 Patient preparation: patient sitting over edge and covered
 Technique
 Axillary lymph nodes (central and lateral breast) palpable 
 Technique
 Go to shake the person’s hand (to use the correct hand)
 Cup the patient’s elbow with the fingers of that (opposite)
hand; support the patient’s forearm with your (opposite)
forearm
 Now with the other hand, using small circular movements,
examine the five groups of lymph nodes
 2) Medial / Central: move the patient’s arm until it is relaxed
right by their side and feel as far into the top of the axilla as
possible.
 1) Pectoral / anterior: Just above and behind the anterior
axillary fold (fold of muscle at the front of the armpit)
 3) Subscapular / posterior: in front of the post-axillary fold under the
scapular
 4) Lateral: Laterally (along arm) and anteriorly
 5) Apical and infraclavicular: In front of the posterior axillary fold
under clavicle
 Enlarged  inflammation, malignancy
 Supraclavicular lymph nodes (internal and axillary lymph nodes)
 Technique:
 Stand behind the patient and ask patient to shrug their shoulders
 Place three middle fingers behind the collarbone laterally, and ‘walk’
them medially to the sternoclavicular joint
 Enlarged  inflammation, malignancy
 Enlarged lymph node  size, shape, firmness, mobility, border
 If a lymph node is palpable, note the size, shape, firmness and
mobility.
 Internal mammary nodes (drain medial breast) are inaccessible

Conclusion
 Thank the patient
 State that the examination is complete and the patient can get
dressed (leave them to do so)
 Document entire procedure.
 Encourage monthly self-breast exams
 Arrange mammography as an adjunct
 Explain that if anything changes, please contact immediately
 Registrar level – present findings to patient, order tests (explain test, why needed, what’s involved and
when they will get their results)
 The legal onus is on the examiner to follow up all findings and communicate results

Investigations
 Every suspicious pathology requires the triple test – breast exam, mammography and biopsy
 Mammography as a diagnostic tool (X ray, used for women over 40)
 Ultrasound as a diagnostic tool (used in women under 40)
 Biopsy - fine needle aspiration biopsy for pathology, under US guidance
 Core biopsy used for hard masses (fibroadenoma), under US guidance

29
Examination – Male Genitalia
From Student Guidelines, video links and tute prep

Indications  History suggestive of genital pathology

 Testicular mass/lump
 Undescended testis in child
 Infertility
 Skin changes
 Suspicion or symptoms of STIs (dysuria,
discharge, skin abnormalities)
 Suspicion of testicular cancer
 Systemic pathology which can affect genitals
e.g. mumps
 Screening for testicular cancer is high risk
 Acute scrotal pain  treat as testicular
torsion (medical emergency) until proven
otherwise.
 Abdominal pain (referred from testes)
Contraindications
 Patient declines examination

Equipment
1. Gloves

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number

 Consent
** Competence (assumed), complete information (including risks), understanding, voluntariness,
authorization**
 Indication/why: identify and change in the testicles in the scrotum
 Ask if have they’ve had a one before
 Were there any difficulties?
 What it involves: Involves 3 parts.
 Looking at the penis, including under the foreskin, for any changes or abnormalities.
 Looking and gently feeling the scrotum for normal and any abnormal structures.
 Taking any specimen samples, such as a swab, if necessary.
 Exposure: Will need you to undress from the waist down including underwear
 Privacy: Go behind the curtain, undress from the waist down. Will ensure the curtains are closed
and in a private, uninterrupted area and there will be a gown/sheet provided.
 Explain any further tests you may need to do e.g. swabs, biopsy
 Ask about pain other symptoms, past surgery in the area
 Inform that they can stop the examination at any time or if uncomfortable
 Importance of proceeding/reassurance: will feel a bit uncomfortable but it’s absolutely crucial
 Ask if they understand. Ask if they have any concerns or questions
 Offer a chaperone of the same gender as the patient
 Gain consent

Examination
** Compare left to right****Begin with patient lying down**
 Patient preparation: Patient on bed, undressed waist down and covered by gown
 Ensure ongoing communication
 Put on gloves
 Ask the patient to show you any areas of concern (e.g. a mass)

30
Examination - PENIS
 Inspection
 Hair distribution: alopecia, infestation, shaven pubic hair ( dermatitis or
folliculitis).
 Inspect the base of the penis (gently pulling back any pubic hair), the
shaft, and the glans
 If assessing puberty: assess the amount of hair, size of penis and testes,
and the colour of the scrotal sac
 Skin: warts (a result of infection), pearly penile papules (normal variant), Above: Pearly papules
rashes including tinea cruris (“Jock Itch”), inflammation (normal); below: warts
 Ulcers (esp on glans)  Herpes, malignancy (SCC), syphilis, chancroid, (abnormal)
other uncommon contions
 Retract the foreskin: **ask/warn patient**
 Painful or difficult  STOP  phimosis
 Retracted foreskin that cannot be restored  paraphimosis
 Position of the urethral meatus  hypospadias
 Discharge (squeeze glans)
 Discharge at base of penis in uncircumcised penis  candida
infection ‘balanitis’
 Palpate along the shaft of the penis
 Tenderness
 Collect any specimen as necessary
 Ensure retracted foreskin has been restored.

Paraphimosis

Examination – TESTICLES / SCROTUM

 Inspection
** lift the penis out of the way or ask the patient to do so **
**Inspect anterior aspect and gently lift to inspect posterior aspect**
 Position of the tests: cepho-caudal orientation, left hangs lower than right, symmetrical
 Horizontally orientated or more proximal  torsion, varicocele
 Tone of the scrotal (cremaster) muscle
 Tightly contracted due to cold or pain this may prevent effective examination.
 Swellings, redness, veins, nodules, rashes
 Palpation (testicles, epididymis, spermatic cord and masses)
** use the thumb, index and middle fingers to palpate specifically ** **feel one and repeat for the other **
 Confirm both testes can be felt in the scrotum
 Absent testis  undescended or partially descended teste, contraction by cremaster muscle
into inguinal canal

31
  Feel for size, consistency and contour
Immobilize one testis, drawing the scrotal skin gently around it so that it is easily palpable. Check
each pole and the entire circumference
 Testicular size: estimated, or measured with orchidometer. Small differences are normal.
 Testicular consistency: a healthy testicle is soft and rubbery. Hardness suggests pathology.
 Tenderness: may indicate orchitis or torsion.
 Any testicular masses: these should be described in terms of Site, Size, Shape & Consistency
 Feel for the epididymis and spermatic cord for nodules or swellings
 Normal epididymis is almost impalpable. Spermatic cord feels rubbery.
 Thickened linear mass  swelling or cyst of the epididymis.
 Spermatic cord lump  cyst, neoplasm, scar of a vasectomy procedure, or
 Feel for abnormal masses: Hydrocele, epididymis cyst, varicocele,
communicating inguinal hernia 1. Site (region)
 1. Can you get above it? No = likely a hernia. Yes = scrotal lump. 2. Tenderness
3. Size (measure) and shape
 2. Cystic or solid?
4. Surface (regular or irregular)
 3. Part of the teste (testicular pathology) or separate (cyst)? 5. Edge (regular or irregular)
 Soft swelling that you can get above with upper border in 6. Consistency (hard or soft)
scrotum hydrocele 7. Mobility (e.g. mobile or fixed),
 ‘Bag of worms’, may or may not get above  torsion and movement with inspiration
 Soft elastic mass with no upper border in scrotum  inguino‐ 8. Pulsatile or not
scrotal hernia 9. Whether one can “get above the
 Continuous with epididymis  epididymitis, epididymal cyst mass”
10. Percussion note (resonant, dull)
 Soft elastic mass with no upper border in scrotum  inguino‐
scrotal hernia
**ask patient to stand, examine scrotum in standing position**
 Palpation while standing
 May now be able to appreciate a varicocoele or a sliding hernia protruding into the scrotum
 Ask patient to cough while feeling mass
 Transilluminate any masses
 Transilluminating mass  hydrocele
 Mass which does NOT transilluminate  varicocoele, inguino‐scrotal hernia

32
Investigations
 DRE
 Urethral swab (gold standard for STDs)(discharge, suspicion of STDs)
 Skin scraping
 Urinalysis (chlamydia and gonorrhoea)
 Referral to urologist (suspicion of testicular cancer)
 Ultrasound of scrotum and/or groin (testicular tumour diagnosis, hydrocele)
 Alpha-fetoprotein (AFP) and beta-hCG (blood tests, tumour markers for testicular cancer)

Patient Education
 Reassure the patient that the appearance and size of genitalia is normal.
 Encourage self-examination

Complications
 Patient feels uncomfortable or assaulted (legal ramifications) due to inadequate information, poor consent
process, or perceived unnecessary or vigorous contact – communicate at all times!
 Exacerbation of pain with palpation
 Forgetting to return the foreskin can cause paraphimosis, which is painful oedema of the glans due to the
foreskin becoming trapped behind the glans. If this persists for several hours, I can be a medical emergency
that will cause gangrene.

33
Examination – Inguinal-Scrotal
From Student Guidelines

Indications  Suspected obstructed hernia or

 Inguinal lump (mandatory) strangulation  medical emergency needing
 Pain when straining or coughing immediate referral
 Pain between nipples and mid-thigh
 Suspected infection in lower limb Contraindications
 Skin changes – rashes  Patient declines examination
 Suspicion or symptoms of STIs (dysuria,
discharge, skin abnormalities)

Equipment
1. Gloves

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number

 Consent
** Competence (assumed), complete information (including risks), understanding, voluntariness,
authorization**
 Indication/why: to inspect any abnormal masses or herniae
 Ask if have they’ve had a one before
 Were there any difficulties?
 What it involves: There are 4 parts and this exam is best done standing.
 First I will have a look at the hernia orifices. These are in the groin next to the genitals.
 Secondly, I will gently feel for any lumps or changes in this region near the groin.
 Third, I will perform special manoeuvres, which involve pressing down on the area while you
cough.
 Finally, I will tap and listen to the masses with my stethoscope.
 Exposure: Will need you to undress from the waist down including underwear
 Privacy: Go behind the curtain, undress from the waist down. Will ensure the curtains are closed
and in a private, uninterrupted area and there will be a gown/sheet provided.
 Ask about pain other symptoms, past surgery in the area
 Inform that they can stop the examination at any time or if uncomfortable
 Importance of proceeding/reassurance: will feel a bit uncomfortable but it’s absolutely crucial
 Ask if they understand. Ask if they have any concerns or questions
 Offer a chaperone of the same gender as the patient
 Gain consent

Examination
** Compare left to right****Begin with patient lying down then ask patient to stand**
 Patient preparation: Patient on bed, undressed waist down and covered by gown
 Patient best examined standing up but start lying down to put the patient at ease
 Ensure ongoing communication
 Put on gloves
 Ask the patient to show you any areas of concern (e.g. a mass)
 Inspection:
 Visible peristalsis ( herniated bowel)
 Skin: Redness, shininess, oedema, tenderness, rashes, scars ( recurrent hernia)
 Mass, asymmetry (e.g. bilateral vs unilateral)

34
  Mass at superficial ring  direct inguinal hernia, a congenital hydrocoele, a varicocoele or a
mass of the spermatic cord
 Mass at deep ring  indirect inguinal hernia
 Ask patient to cough and look for a swelling
 Cough impulse
 No impulse  obstructed or strangulated hernia, omental hernia
 Palpation
** compare left to right!**
 Feel any masses for: temperature, tenderness, consistence and
1. Site (region)
border/ extent of swelling (e.g. feel for top, extension into
2. Tenderness
scrotum)
3. Size (measure) and shape
 Firm and rubbery  omentum
 Soft and elastic  bowel 4. Surface (regular or irregular)
 “Bag of worms”  varicocoele 5. Edge (regular or irregular)
 Palpate for cord structures 6. Consistency (hard or soft)
 Measure distance of mass to pubic tubercle 7. Mobility (e.g. mobile or fixed),
 Above and lateral to pubic tubercle  inguinal hernia and movement with inspiration
 Below and lateral to pubic tubercle  femoral hernia 8. Pulsatile or not
 Perform exam of testicles and penis. Check for absent testis. 9. Whether one can “get above the
 Place hand over swelling and ask patient to cough. Repeat mass”
with hand over deep and superficial rings 10. Percussion note (resonant, dull)
 Cough impulse
 No impulse  obstructed or strangulated hernia, omental hernia
 Special manoeuvres (useful only in the presence of pathology)
 Internal ring occlusion test (for direct vs. indirect)
 Place finger over deep inguinal ring (midpoint of ligament)
 Ask patient to cough
 Indirect hernia will be prevented from emerging while a direct hernia will emerge
 Ziemans technique
 Stand at patients right side as they are standing
 Place palm of right hand over right lower abdomen
 Spread and position fingers
 Middle finger along inguinal ligament with the fingertip on the superficial (medial) ring
 Index finger over the deep inguinal ring
 Ring finger over femoral canal
 Ask patient to perform valsalva manoeuvre or strain
 Repeat procedure on left side with left hand
**Lie patient down**
 Reduction
 Lie the patient down.
 Attempt manual reduction. Check reducibility of the
hernia.
 If it can’t be reduced, look for signs of obstruction:
tenderness, shiny skin, or overlying erythema.
 Invagination test (for direct vs indirect)
 In the lying position, push from the bottom of the scrotum
to palpate the pubic tubercle. Use the pulp of the finger. Then rotate the finger and push
up to the superficial inguinal ring.
 Patient is asked to cough, a palpable impulse will confirm diagnosis
 Impulse on pulp  direct. Impulse on tip  indirect

35
  Palpation (again)
 Palpate the lymph nodes
 Horizontal
 Vertical
 Deep vertical chains
 Percussion: Percuss the swelling
 Resonance  hollow  Bowel with gas contents
 Dull  Omentum
 Auscultation: Auscultate mass for bowel sounds (both masses and
abdomen)

Investigations
 Testicular examination should follow
 DRE
 Ultrasound (determine indirect vs direct hernia)

Complications
 Patient feels uncomfortable or assaulted (legal ramifications) due to inadequate information, poor consent
process, or perceived unnecessary or vigorous contact – communicate at all times!
 Exacerbation of pain with palpation
 Rupturing an irreducible hernia when attempting to reduce

36
 Examination - Thyroid
From Student Guidelines and associated video

Indications
 Neck mass / goitre  Infertility, galactorrhoea, changes in
 Change in appetite and weight menstrual cycle amenorrhoea
 Changing in sweating  Headaches
 Eye changes  Polyuria, polydipsia
 Cold or heat intolerance  Following endocrine history
 Change in hair distribution  Discomfort, dysphagia or SOB caused by
 Constipation or diarrhoea neck mass
 Lethargy and fatigue
 Skin changes, pigmentation Contraindications
 Changes in stature  Patient declines examination
 Impotence or loss of libido

Equipment
1. Cup of water with straw
2. Stethoscope
3. Red hatpin
4. Tendon hammer

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Involves: Look and feel of the hands, neck, face and legs, test eye movements and reflexes
 Exposure: Exposure of neck and shoulders
 Indications / importance of proceeding, ask if they understand, have any concerns or questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain

Examination A) General Inspection and the Hands

 Patient preparation: patient sitting upright over edge of bed
 General Inspection
 Goitre (thyroid enlargement) (hyperthyroidism, hypothyroidism)
 Appropriate dress for the temperature (hyperthyroidism, hypothyroidism)
 Overweight (hypothyroidism) or underweight ( thyrotoxicosis, hyperthyroidism)
 Lethargy (hyperthyroidism, hypothyroidism)
 Signs of hyperthyroidism:
 Thyroid stare  hyperthyroidism
 Sweatiness, anxiety, agitation, hyperactivity  hyperthyroidism
 Signs of hypothyroidism
 Myxoedema facies  hypothyroidism, Grave’s disease
 Paleness of skin  hypothyroidism
 Alopecia (loss of hair)  hypothyroidism
 Confusion or slow thinking  hypothyroidism
 Hands
 Onycholysis  hyperthyroidism
 Thyroid acropachy (clubbing and swelling of digits)  Grave’s Disease specifically (Grave’s triad)
 Feel the palms
 Moist, warm (palmar erythema) or sweaty  hyperthyroidism

37
  Dry and cool hypothyroidism
 Examine for tremor
 Technique: palms facing down, use a piece of paper
 Tremor  hyperthyroidism
 Wrists
 Radial pulse
 Tachycardia, bounding pulse  hyperthyroidism
 Atrial fibrillation  hyperthyroidism
 Bradycardia  hypothyroidism

Examination B) The Neck

**look from the front and the side**
 Inspection
Normal thyroid: lies below cricoid cartilage. Isthmus at least should be visible. A
straight line between cricoid and suprasternal notch.
 Midline neck mass
 Goitre (thyroid enlargement)  hyperthyroidism, hypothyroidism
 Thyroglossal cyst (a midline mass that can present at any age)
 Submental lymph nodes
 Parathyroid glands (very rare)
 Thyroidectomy scar (ring around neck base)  hypothyroidism
 Redness of skin over gland  suppuratives thyroiditis
 Prominent veins  thoracic inlet obstruction
 Observe the patient while swallowing water
Technique: ask patient to take a sip of water, hold it in their mouth, and
swallow. Note the lower border of the thyroid as the gland rises.
 Masses which rise with swallowing
 Goitre (attached to larynx, will always rise)  hyperthyroidism,
hypothyroidism
 Thyroglossal cyst (attached to hyoid bone, will rise)
 Masses which may not rise with swallowing
Goitre
 Thyroid gland fixed by neoplastic infiltration
 Ask patient to poke out tongue (if midline cyst present)
 Midline mass moves with protrusion of the tongue and a stationary jaw  thyroglossal cyst
 Midline mass does not move  goitre
 Palpation
** from behind **ask patient to flex neck slightly to relax SCM ** use pulps of fingers**
Normal: Feel two lobes and isthmus, identify gland borders
 Palpate thyroid gland
 Tenderness  hyperthyroidism, hypothyroidism
 Diffuse enlargement  hyperthyroidism, hypothyroidism
 Thyroid thrill  hyperthyroidism
 Palpate thyroid gland while the patient is swallowing
 Palpate cervical lymph nodes
 Percussion (performed if there is a goitre)
 Percuss the manubrium both sides, from superior to inferior
 Retrosternal extension of goitre  hyperthyroidism, hypothyroidism)
 Auscultation
 Auscultate both thyroid glands
Technique: Ask patient to take in a deep breath and hold, use diaphragm
 Thyroid bruits hyperthyroidism

38
Examination C) The Face, Eyes and Limbs
 Face and Eyes
Technique: Look from above in the plane of the forehead
 Hyperthyroidism
 Thyroid stare  hyperthyroidism (all forms)
 Lid retraction and proptosis  hyperthyroidism (all forms)
 Exophthalmos (significant proptosis due Grave’s disease)  Graves /
Thyroid eye disease  Grave’s disease specifically (Grave’s triad)
 Hypothyroidism
Myxoedema facies of
 Dry, coarse hair  hypothyroidism
hypothyroidism
 Loss of the outer third of eyebrow  hypothyroidism
 Myxoedema facies* (facial swelling)  hypothyroidism
 Periorbital oedema (puffy eyes)  hyperthyroidism
 Dry, waxy skin (waxy skin)  hypothyroidism
 Peaches and cream complexion (smooth pale yellow skin, and peachy
cheeks)  hypothyroidism
 Test for Ophthalmoplegia
Technique: Draw a ‘H’ pattern and ask patient to report double vision
 Blurred or double vision  ophthalmoplegia  thyroid eye disease 
Grave’s disease
 Blurred or double vision  ocular muscle weakness  hyperthyroidism
(all forms)
 Test for Lid Lag
Technique: Ask patient to keep head still and follow finger, move quickly from
above to below, repeat on left and right
 Lid lag  hyperthyroidism, Grave’s Disease
 Upper and lower limbs
 Pre-tibial myxoedema  Grave’s Disease specifically (Grave’s triad)
 Purpura, poor healing ulcers  hypothyroidism
 Test for proximal myopathy (chicken manuver) Exophthalmos (thyroid eye
disease of Grave’s
 Technique: Ask patient to bend their elbows and hold up, push down on the disease)
proximal limbs and ask the patient to resist
 Technique: Ask patient to stand with arms across chest
 Proximal myopathy / weakness hyperthyroidism, hypothyroidism
 Reflexes:
 Upper limb: brachioradialis, biceps, triceps
 Lower limb: Patella and Achilles
 **remember to do both sides**
 Brisk reflexes hyperthyroidism
 Delayed relaxation phase  hypothyroidism

Investigations
 Thyroid function tests (TFTs)
 Serum antibodies
 Thyroid uptake test (radioidine)
 Normal thyroid tissue will take up iodine
 Cold nodule: Thyroid cancers (follicular carcinoma) poorly take up iodine/technetium less well
 Follow body scan (uptake of radio iodine – mets will take up some iodine)
 Cytology (not very helpful, normal tissue, adenomas and carcniomas all look the same = follicular cells)
 Test for visual acuity (if Grave’s disease suspected)

39
 Examination - Endocrine
From Talley and O’Connor, Student Guidelines and Tute prep

Indications
 Neck mass / goitre  Infertility, galactorrhoea, changes in
 Change in appetite and weight menstrual cycle amenorrhoea
 Changing in sweating  Polyuria, polydipsia
 Eye changes  Following endocrine history
 Cold or heat intolerance  Discomfort, dysphagia or SOB caused by
 Change in hair distribution neck mass
 Hirsutism and virilisation  Failure to mature, failure to thrive
 Constipation or diarrhoea  DKA, hypoglycaemia, hyperglycaemia
 Lethargy and fatigue
 Skin changes, pigmentation
 Changes in stature Contraindications
 Impotence, gynacomastia, loss of libido  Patient declines examination
 Headaches

Equipment
1. Scales
2. Measuring tape
3. Opthalmoscope
4. Tendon hammer

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Involves: Look and feel of the hands, neck, face and legs, test eye movements and reflexes
 Exposure: Exposure of neck and shoulders
 Indications / importance of proceeding, ask if they understand, have any concerns or
questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain

Examination
 Patient preparation: patient sitting upright over edge of bed
 General inspection
 Facies
 Coarse features  acromegaly
 Moon face  Cushing’s
 Thyroid stare hyperthyroidism
 Myxoedema facies ( hypothyroidism, Grave’s disease)
 Peaches and cream complexion (smooth pale yellow skin, and peachy cheeks) 
hypothyroidism
 Goitre (thyroid enlargement) (hyperthyroidism, hypothyroidism)
 Sweating  hyperthyroidism, hypoglycaemia, acromegaly, menopause
 Overweight (hypothyroidism) or underweight ( thyrotoxicosis, hyperthyroidism)
 Appropriate dress for the temperature  hyperthyroidism, hypothyroidism
 Alopecia (loss of hair)  hypothyroidism
 Hirsutism  increased androgens, tumour, PCOS, anorexia
 Galactorrhoea or gynecomastia  prolacinoma

40
  Height /stature  acromegaly
 Skin
 Paleness of skin  hypothyroidism, hypoparathyroidism
 Increased pigmentation  primary adrenal insufficiency, Cushing's syndrome or
acromegaly
 Decreased pigmentation  hypopituitarism, vitiligo
 Measure body weight
 Measure body height
 Nails
 Thyroid acropachy (clubbing and swelling of digits)  Grave’s Disease specifically (Grave’s
triad)
 Onycholysis
 Hands
 Enlarged hands  acromegaly
 Palmar erythema, tremor  hyperthyroidism
 Feel the palms
 Palmar erythema, moist, warm or sweaty  hyperthyroidism
 Dry and cool hypothyroidism
 Radial pulse
 Tachycardia, bounding pulse  hyperthyroidism
 Atrial fibrillation  hyperthyroidism
 Bradycardia  hypothyroidism
 Arms
 Loss of axillary (and pubic) hair  androgen insufficiency, hypogonadism,
adrenal insufficiency
 Blood pressure – lying and standing
 Hypertension  Cushing’s, acromegaly, phaochromocytoma
 Postural hypotension  Addison’s disease
 Trousseau's sign  hypocalcaemia and tetany
 Test for proximal myopathy (chicken manuver)
 Technique: Ask patient to bend their elbows and hold up, push down on
the proximal limbs Troussea's sign
 Proximal myopathy / weakness  hyperthyroidism, hypothyroidism, Cushing’s,
acromegaly
 Axillae
 Loss of axillary hair  hypopituitarism
 Acanthosis nigricans  acromegaly
 Skin tags  acromegaly
 Face
 Facies (as above)
 Enlarged, coarsened facial features  acromegaly
 Hair
 Temporal recession of the scalp hair in women  androgen excess
 Absence of facial hair in men  androgen insufficiency, hypogonadism
 Hirsutism  panhypopituitarism
 Dry, coarse hair  hypothyroidism
 Loss of the outer third of eyebrow  hypothyroidism
 Skin
 Fine-wrinkled hairless skin  panhypopituitarism
 Skin greasiness, acne or facial plethora  Cushing’s
 Dry, waxy skin (waxy skin)  hypothyroidism
 Eyes
 Proptosis, lid retraction, lid lag  hyperthyroidism (all forms)
 Exophthalmos  Grave’s disease specifically (Grave’s triad)
 Puffy eyes‘ hyperthyroidism
 Fundoscopy

41
  Neovascularisation, haemorrhages, cotton-wool spots  diabetes, diabetes
secondary to acromegaly (GH counters insulin)
 Mouth
 Protrusion of the chin and enlargement of the tongue acromegaly
 Buccal pigmentation  Addison’s disease
 Neck
 Midline neck mass
 Goitre (thyroid enlargement)  hyperthyroidism, hypothyroidism
 Thyroglossal cyst (a midline mass that can present at any age)
 Parathyroid glands (very rare)
 Neck webbing  Turner’s syndrome
 Thyroidectomy scar: a ring around the base of the neck  hypothyroidism
 Palpate for supraclavicular fat pads  Cushing’s
 Chest
 Hirsutism, loss of body hair, reduction in breast size  panhypopituitarism
 Gynaecomastia, loss of body hair  panhypopituitarism
 Nipple pigmentation  Addison’s disease
 Abdomen
 Hirsutism, central fat deposition, purple striae  Cushing’s
 External genitalia
 Virilisation or atrophy.
 Lower Limbs
 Ulcers and diabetic changes  diabetes, hypothyroidism
 Pre-tibial myxedema  Grave’s Disease specifically (Grave’s triad)
 Assess reflexes:
 Brisk reflexes hyperthyroidism
 Delayed relaxation phase  hypothyroidism

Investigations
 Hormone evaluation:
 prolactin, GH, IGF1, T3/T4, LH/FSH/testosterone / E2 and progesterone
 urinary free cortisol (metabolites of cortisol in urine), morning serum cortisol
 Anterior pituitary function tests: GnRH stimulation, TRH stimulation and insulin tolerance test
(stimulating GH and ACTH secretion)
 Short synacthen (synthetic ACTH) test [SST]
 Dexamethasone (synthetic glucocorticoid) cortisol supression test (DXST)
 Urinalysis
 MRI Pituitary and visual fields test

42
 Examination - Diabetic
From Student Guidelines and tute prep

Indications
 Diabetes known or suspected  Leg cramps
 High blood glucose  Asymptomatic glycosuria detected on
 Polyuria routine physical examination
 Polydipsia (excessive thirst)  Diabetic ketoacidosis
 Poor healing, ulcers, sores and boils − Coma
 Blurry vision  Identification and control of
 Pins and needles complications of diabetes
 Weakness and fatigue

Contraindications:
 Signs of DKA (air hunger, thirst, dehydration, nausea and vomiting)  give insulin immediately
 Type I diabetic with vomiting, fever or infection, persistent hyperglycaemia  give insulin
immediately

Equipment
1. Stethoscope 5. Opthalmascope
2. Sphygomanometer 6. Monofilament
3. Snellen chart 7. 128MHz tuning fork
4. Red hat pin 8. Tendon hammer

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself
 Confirm the correct patient - ask name, DOB and UR number
 Obtain informed consent
 Rationale / indication
 Involves: look and feel of the face, neck, chest, abdomen and legs, take some measurements,
listen to your heart and examine eyes and reflexes
 Exposure: dress down to underwear; gown available, will cover with gown and expose when
necessary
 Discomfort, risks and complications, can stop at any time
 Importance of proceeding, ask if they understand, have any concerns or questions
 Gain consent
 Offer a chaperone
 Ask if patient has any pain

Examination A) General Examination and Vitals

 General Inspection
 General appearance – well, conscious, comfortable, not in acute distress or discomfort
 Age, weight, body habitus,
 Dehydration ( osmotic diuresis due to glycosuria)
 Fluid overload ( diabetic neuropathy  fluid overload)
 Endocrine facies (e.g. Cushing's syndrome or acromegaly) (→ secondary diabetes)
 Dressings ( concealing leg ulceration)
 Walking aids, white stick for vision, amputations
 Bedside clues: Glucometer,urine sample, diabetic diet chart, glucose chart/diary, medical alert bracelet
or necklace
 Pigmentation (e.g. haemochromatosis-bronze diabetes) (→ secondary diabetes)
 Signs of hypoglycaemia – sweaty, confused and irritable

43
  Signs of DKA: excessive thirst (polydipsia), dehydration, Kussmaul's breathing ('air hunger') (→ lack of
glucose → fat metabolism → excess acetyl-CoA→ acidic ketone bodies → acidosis), nausea, vomiting
and/or abdominal pain, acetone smell on breath, weakness or fatigue, confusion / drowsiness / coma
 Take Vital Signs
 Heart rate
 Tachycardia ( infection, hyperglycemia, dehydration)
 Bradycardia ( B-blocking medication concealing signs)
 Resp. rate
 Tachypnoea ( ketoacidosis)
 Temperature
 High: ( infection due to high blood sugar increasing risk)
 Blood pressure lying
 Hypertension ( diabetic nephropathy and fluid overload and/or cardiovascular disease)
 Blood pressure standing
 Postural hypotension (15-20 drop systolic, >10 diastolic significant) ( diabetic autonomic
neuropathy, dehydration)
 Take Vital Statistics/Measurements
 Height (on bare feet)
 Weight (on firm surface)
 Waist
 Measure directly on skin, halfway between lowest rib and the top of the iliac crest, roughly in line
with umbilicus
 Normal: < 80 cm for female and < 94cm for males is healthy
 Calculate BMI (kg / height squared in m2)
 Normal: 20 – 25 is healthy

Examination B) Upper Body

**Patient preparation: supine at 45 degrees**
 Hands
 pin pricks
 candida of nails
 arthritic deformity (→ affects insulin delivery)
 splinter haemorrhages ( subacute bacterial endocarditis, PVD)
 Feel warmth of hands
 Cold and blue (→ small or large vessel disease / peripheral vascular disease)
 Measure capillary refill
 Poor capillary refill (→ peripheral vascular disease)
 Arm (including axilla flexures)
 Injection sites
 Skin lesions
 Scars for Coronary Artery Bypass Grafting (CABGs)
 Candida infection
 Palpate Injection Sites
 Atrophy or hypertrophy of subcutaneous fat (subtle depression or lumps in the skin at injections
sites) (→ immune reaction due to impure insulin use)
 Reflexes
 Face
 ‘Endocrine facies’ (Cushing’s, acromegaly) (→secondary diabetes)
 Facial asymmetry (→stroke as a complication of diabetes)
 Mouth: candida infection
 Eyes
 Test visual acuity (Snellen chart 6m or 3m)
 Impaired (→ Retinal disease (permanent impairment) hyperglycaemia, water retention
(temporarily impaired))
 Test eye movements (H-pattern)
Ask patient to hold head still, follow red target and report any diplopia. Draw H-pattern.

44
  Asymmetry in movement or reporting of diplopia (→ CNIII mononeuropathy → CNIII
Nerve palsy )
 Fundoscopy
 Silver wiring (hypertension), microaneurysms, haemorrhages, exudates. Proliferation of
vessels  diabetic retinoapthy
 Neck
 Skin rashes ( tinea corporis)
 Acanthosis nigricans (back of neck, folds of neck, axillae, below breasts) (→ insulin resistance)
 Scleroedema diabeticorum (rare, thickened skin over back and neck)
 Thyroid
 Goitre ( more common in diabetics)
 Ask patient to swallow
 Auscultate the carotid arteries
**Patient to hold their breath while you listen**
 Carotid bruits (→ carotid atherosclerosis → vascular disease)

Examination C) Chest and Abdomen

 Chest
 Oedema (diabetic nephropathy or cardiovascular disease  fluid overload
 Stenotomy scar (diabetics have increased risk of IHD)
 Apex beat
 Displaced apex  cardiomegaly secondary to heart disease or fluid overload
 Auscultate for heart sounds (murmurs)
 Optional: Auscultate lung fields (e.g. if febrile and unwell)
 Basal crackles / creps ( chest infection, pleural effusion  heart failure)
**lie patient flat on one pillow**
 Abdomen
 Injection sites (usually lower abdomen and lateral thighs)
 Palpate injection sites (carefully)
 Atrophy or hypertrophy of subcutaneous fat (subtle depression or lumps in the skin at injections
sites) (→ immune reaction due to impure insulin use)
 Palpate for Liver Border
 Hepatomegaly (haemochromotosis  excess iron  pancreas
damage  diabetes)
 Hepatomegaly ( diabetes  fatty infiltration of liver)
 Auscultate
 Aortic bruits/stenosis (above umbilicus)
 Renal bruits (above and to the left and right of umbilicus)

Examination D) Lower Limbs

 Inspection (be sure to lift the leg)
 Acanthosis nigricans (in groin flexure) ( insulin resistance)
 Injection sites
 Charcot’s joints (grossly deformed disorganised joints)
 Muscle wasting
 quadriceps muscle wasting ( femoral nerve mononeuropathy i.e.
“diabetic amyotrophy”)
 Atrophic change (shiny skin, hair loss) ( diabetes, PVD)
 Necrosis, callus, ulceration ( ischaemia and peripheral neuropathy)
 Complicated ulcers: in a pressure area, over a joint, extending down to
Necrobiosis lipoidica: One or
bone more tender yellowish-brown
 Surrounding red flare, exudates that may have a greenish tinge or patches, round, oval or an
irregular shape , which develop
unpleasant odour  active infection slowly on the shins, over several
 Boils, cellulitis or fungal infections ( diabetes, high tissue glucose levels months. Rare unknown cause.
and ischaemia  infection risk)

45
  Toe web spaces
 macerated interdigital skin ( increased risk of tinea corporis)
 Necrobiosis lipoidica diabeticoru (on shins, specific but rare)
 Neurological Assessment

 Ask patient to answer yes when felt. Widespread reduced sensation
then test more proximally until sensation defined.
 6/10 or less  loss of protective sensation
 Stocking distribution of sensation loss  diabetic neuropathy
 Risk of causing ulcer
 2) Dorsal column function (proprioception sense)
 Grasp great toe either side of distal IP.Show patient up and down.
Ask them to close their eyes and detect movement.
 3) Vibration sense
 Demonstrate a) vibration and b) stopped on sternum. Ask patient
to close their eyes and report a) vibration and 2) when it stops.
Start on MCP joint of toe. If unreliable or incorrect, move to
ankle, tibial tubercle and ASIS.
 loss of proprioception  diabetic neuropathy, diabetic
pseubatobes (damage to large nerve fibers)
 4) Reflexes – knee, ankle and plantar
 Reduced or absent reflexes  diabetic neuropathy
 Palpation
 Feel warmth of foot  PVD, diabetic ischaemia
 Capillary refill
 Pulses – dorsalis pedis, posterior tibial, popliteal and femoral
 Auscultation
 Femoral bruits

Investigations
 If unconscious, always treat as a hypoglycaemic event. Give the patient a source of sugar e.g. honey on the
tongue and sides of mouth
 Blood ketones: 0.6mm/L or over may need medical attention. Over 1.5mmol/L requires intensive
intervention)
 Acute symptoms
 Glucometer blood glucose (normal is 3.5-8mm/L, 3.-6 befor emeals, 4-8 after meals)
 Urine Analysis for glycosuria (positives test is >10mmol/L), ketones(ketoacidosis, poorly controlled
diabetes, insufficient insulin, infection, etc), proteinuria (→ diabetic nephropathy), nitrites and/or
blood (→ asymptomatic UTI)
 Blood ketones (over 0.6mm/L concerning. Over 1.5mmol/L requires intensive intervention)
 Measure Hyperglycaemia
 Random plasma glucose (RPG) - without regard to time of last meal
 Fasting plasma glucose (FPG) - before breakfast
 Oral glucose tolerance test (OGTT) - 2 hours after a 75-g oral glucose drink
 Postprandial plasma glucose (PPG) - 2 hours after a meal
 Haemoglobin A1c (A1C) - reflects mean glucose over 2–3 months
 Fructosamine/glycated serum protein - reflects mean glucose over 1–2 weeks.
 Estimated average glucose (eAG)
 Diagnosis of diabetes (if not already)
 Glucose Challenge Test (GCT)
 Oral Glucose Tolerance Test (OGTT) 75gm glucose
load
 DM: Fasting (8 hours) ≥ 7.0, 2hrs post glucose
load: >11.1
 Impaired fasting glycaemia: Fasting 6.1 -6.9, 2hrs
post glucose load: <7.8

46
  Routine Investigations
 Glucometer: blood glucose monitoring, aiming for 4.0 - 6.0 mmol/L pre meal, 4.0 - 8.0 mmol/L post
meal
 Hb-A1c every 3-6months
 Annual investigations
 Lipid profile
 Urinary albumin excretion rate (timed overnight or 24hr) OR early morning microalbumin creatinine
ratio
 Thyroid Function Test (type I due to increased risk)
 Urea, Creatinine and Liver Function Tests.
 Referral: Ophthalmologist (or some optometrists) for assessment of the retina, Endocrinologist, Nephrologist,
Diabetes Educator, Podiatrist, Dietician, Exercise Physiologist, Pharmacist.

Treatment of Hypoglycaemia
 Mild hypoglycaemia is often managed effectively with the self-administration of 15 g of carbohydrate (e.g.,
three 5-g glucose tablets, ½ cup of fruit juice)
 Moderate hypoglycaemia may require larger amounts of carbohydrate (15–30 g).
 Severe hypoglycaemia, requires immediate treatment, with I.V. glucose as the standard treatment
 Glucagon may be used as an effective adjunct, especially in patients who do not respond clinically to
intravenous glucose. Glucagon given via a 1-mg I.M. dose has been found to be most effective in adults.
Following delivery of glucagon, oral glucose should be administered to aid in hepatic glycogen repletion

Treatment of DKA
 1.Insulin therapy
 2.Rehydration
 3.Sodium bicarbonate for acidosis management
 4.Potassium replacement
 5.Treatment of leading causes
 6.Supportive and symptomatic treatment of complications

Treatment to Hyperglycaemic, hyperosmolar non-ketotic coma (HHNC)

 1. Rehydration
 2. Insulin infusion
 3.Treatment of leading causes
 4.Supportive and symptomatic treatment of complications

Complications
 Causing a diabetic ulcer with monofilament

47
Examination – Shoulder
From Student Guidelines

Indications Contraindications (medical emergencies)

 Pain (sudden or de novo)  If they joint looks infected (septic arthritis)
 Injury, trauma, fall this requires immediate referral
 Tendonitis (chronic)  If there are signs of acute impairment of
 Altered gait circulation or sensation in the limb, this is
 Assessment of systemic disease (e.g. RA, a time-critical medical emergency.
OA, fibromyalgia) Examination should not delay initiating
 Arthritis management.
 Gout  If dislocation or fracture is suspected,
 Following a lower limb history suggesting vascular compromise, distal
pulses, sensation and movement distal to
the joint must be assessed
Equipment  If fracture is suspected, passive mvt should
1. Tape measure be performed very carefully. Stop if
2. Goniometer causing pain or crepitus.

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Indications
 Involves: look and feel of your shoulders, perform some movements
 Exposure: both shoulders, will need to undress from waist up but can
keep bra on, offer a gown and draw the curtains
 Importance of proceeding , ask if they understand, have any concerns or
questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain
 Ask the patient if they are left or right handed
AC Separation

Examination – SHOULDER
 Ensure adequate exposure of both shoulders and privacy. Lift bra as
necessary
 Look: Inspection
*with the patient standing, inspect from the front, side and behind*
 General: how patient undresses, pain, posture, how they hold the
shoulder
 Deformities (dislocation of AC joint or GH joint, valgus, valrus),
Glenohumeral dislocation
muscle wasting or asymmetry (deltoid), swelling, scars (athroplasty),
skin (inflammation, erythema, bruising, lacerations, psoriasis,
ulceration, rashes)
 Biceps rupture
 Posteriorly: position, contour and symmetry of the scapula,
supraspinatus and infraspinatus fossa, wasting of infraspinatus or
supraspinatus

48
Bulge of biceps
rupture
  Check hands for Raynaud’s phenomenon
 Feel: Palpation
* look their face while examining* start with normal side* examine painful
area last* use one finger * ask them to report pain *
 Feel temperature  inflammation, infection, septic joint
 Feel bony landmarks: SC joint, clavicle, AC joint, acromion
process, sub-acromion bursae, coracoid process (inferior and Subluxation (partial dislocation) of
medial to the acromion), from the acromion to the spine of the AC joint
scapula
 Tenderness, deformity or crepitus of the bones  fracture,
dislocation
 Tenderness of the joint bursitis, inflammation in and around
joint
 If fracture present, check for pneumothorax (rarely caused by
clavicular fracture)
 Feel muscles of the rotator cuff: around the head of the humerus Biceps tendon in
 Head of humerus (lateral and below acromion)
 Biceps tendon in the intertubercular groove / bicipital
groove (2cm lateral to coracoid, should feel it flick)
 Supraspinatus: Lateral to acromion process as patient extends
shoulder
 Feel for distal pulses if suggestion of vascular compromise eg:
dislocation (medial emergency)
 Test sensation if suggestion of nerve injury eg: axillary nerve in
dislocation (medial emergency)
 Palpate axillary lymph nodes if suspecting infection or neoplastic
disease
 Move
* start with active movement * compare L to R, starting with normal
side*then carefully perform active mvt*
 Apley Scratch Test Screen for Limitation
 Patient first reaches over the opposite shoulder, then reaching behind the neck and
finally reaching under behind the back. This does move the shoulder the most
movements. If the patient reports pain, test specific ranges
 Abduction and adduction
 Adduction: patient moves the arm across the front of the chest (which requires a small
degree of external rotation as well)
 Abduction: Stand behind the patient, place one hand on the inferior pole of the scapula.
Measure the angle of abduction occurring at the GH before mvt of the scapula begins.
Then asses their range with the combination of scapula movement and the GH joint.
 Repeat while pressing down on the abducting shoulder
 Painful resisted abduction and external rotation  rotator cuff disease,
partial/full thickness tear of the tendon, tear or inflammation of teres minor or
infraspinatus
 Flexion / Extension:
 The arm is flexed up as high as possible and swung backwards as far as possible. Assess
for limitation with or without pain and joint crepitus are assessed.
 External rotation
 External rotation (infraspinatus and teres minor): The patient holds their arms at their
sides and flexes their elbow up to 90°, bringing the forearm perpendicular to the torso.
Ask them to turn the forearms out laterally as far as possible.
 Internal rotation
  The patient places their hand behind their back and is asked to touch up as high on the
back as possible with the thumb. Grade by looking at the position of the thumb. Usually
only proceed to Jobe’s empty can test if this internal rotation is limited.
 If positive, Jobe’s test (empty can test)
 Ask patient to hold point thumbs to the floor (as if emptying cans) and lift the
arms up (shoulder flexion 90°ish). This puts them in maximal internal rotation.
Push down on the hands and ask them to resist your downward pressure. Assess
power out of 5.
 Pain or weakness  damage to supraspinatus tendon
 Passive movement range greater than active  tendonitis (minimal force is transmitted into
the tendons during passive movement)
 Passive movement range = active movement range  intra-articular process (arthritis)
 Global painful restriction of the shoulder of unknown aetiology → adhesive capsulitis /
‘frozen shoulder’
 Measure
 Measure angles with tape or goniometer (in rehab or medicolegqal cases)
 Normal: abduction to 90°, adduction to 50°
 Normal: flexion to 180° (GH also contributes 90°), extension to 65°
 Normal: external rotation to 65°, internal rotation to 90°
 Special Tests
 Apley scratch test performed in MOVE
 1) Hawkin’s test for Impingement
 Forward flex the arm to 90° and the elbow the elbow also to 90°. Forcibly
internally rotate the humerus. This rotates the greater tuberosity under
the acromion and impinges the supraspinatus tendon between the
humeral head and the acromion process
 2) Sulcus test for laxity
 Ask the patient to flex the forearm to 90° and hold the the patient’s elbow
(this distracts the joint). Grasp the forearm with your other hand and pull
the humerus inferiorly. We are looking for a sulcus between the acromion
and the humeral head. It will be visible anteriorly or laterally
 3) Apprehension/relocation test for instability
* patient lies on the bed supine *look at the patient’s face*
 This can be performed sitting or supine with the shoulder just off the edge
of the bed, but the body safely centred on the bed. The shoulder abducted
to 90° and elbow is flexed to 90°. The examiner holds the patient's wrist
with one hand. The other hand applies counter pressure at the anterior
humerus to control any forward movement of the humerus (i.e.
anterior dislocation), should any dislocation start to occur. The wrist is
moved towards the patient’s head so that the shoulder is gently
externally rotated. This applies pressure to the shoulder in an anterior
and inferior position. The more abducted, the more unstable the joint
and apprehension will be elicited with this pressure. Ehen discomfort is
reached, apply pressure over the anterior humeral head (relocation) to
relieve the pain.
 Pain or apprehension relieved with relocation  Positive test  anterior shoulder
instability
 Resisted elbow flexion
 The patient flexes the elbow with the forearm supinated and the shoulder in the neutral
position. Resist flexion. Tenderness in the bicipital groove → biceps tendonitis
Investigations
 XRAY: Suspected trauma/fracture/dislocation, calcification of the rotator cuff due to tendonitis,
established arthritis (joint space narrowing), bony changes associated with malignancy, trauma,
congenital
 US: Great for shoulder pathology, quantifying bursitis and tendon injury, depends on US operator skill
 CT: Can be useful, but if cost is no barrier MRI should be used instead as it better visualises the soft
tissues with bone and has less radiation
 Nuclear medicine tests: US preferred for tendon pathologies. Can demonstrate active tendonitis, or
detect hyperplastic bone lesions
 Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis

Complications
 Causing patient more pain/trauma whilst trying to perform an examination
 Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
 Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a medical
emergency
Examination – Elbow
From Student Guidelines

Indications Contraindications (medical emergencies)

 Pain (sudden or de novo)  If they joint looks infected (septic arthritis)
 Injury, trauma, fall this requires immediate referral
 Tendonitis (chronic)  If there are signs of acute impairment of
 Altered gait circulation or sensation in the limb, this is
 Assessment of systemic disease (e.g. RA, a time-critical medical emergency.
OA, fibromyalgia) Examination should not delay initiating
 Arthritis management.
 Gout  Crystal-induced joint diseases (e.g. gout)
 Following a lower limb history require urgent pain relief.
 If dislocation or fracture is suspected,
suggesting vascular compromise, distal
Equipment pulses, sensation and movement distal to
1. Tape measure the joint must be assessed
2. Goniometer  If fracture is suspected, passive mvt should
be performed very carefully. Stop if
causing pain or crepitus.

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Indications
 Involves: look and feel of your elbows and perform some movements
 Exposure: both upper limbs, can undress from waist up but can keep bra on, offer a gown and
draw the curtains
 Importance of proceeding , ask if they understand, have any
concerns or questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain
 Ask the patient if they are left or right handed

Examination – ELBOW The ‘carrying angle’ – a normal slight

 Ensure adequate exposure of both elbows and privacy. Lift bra as necessary valgus deviation when the arm is fully
extended. This may be lost or exaggerated
 Look: Inspection if the joint has been distorted by disease
*with the patient standing, inspect from the front, side and behind* process such as advanced RA
 General: how patient undresses, pain, posture, how they hold the
elbow (cradling arm  supracondylar fracture)
 Tense, red swollen joint  olecranon bursitis
 Deformities (change in carrying angle, valgus, valrus  RA), abnormal
bone alignment  fracture, dislocation
 Muscle wasting and asymmetry (flexors, extensors) Above: gouty tophi.
 Swelling - localised or generalised Below: RA nodules
 Skin: Rheumatoid nodules ( RA), gouty tophi ( gout), scars,
inflammation, erythema (olecranon bursitis) bruising, lacerations,
psoriasis, ulceration, rashes
 Check hands for Raynaud’s phenomenon
 Feel: Palpation
 * look their face while examining* start with normal side* examine painful area last*
use one finger * ask them to report pain *
 Feel temperature  inflammation, infection, septic joint
 Feel bony landmarks: lateral and medial epicondyles, olecranon tip, elbow
joint line (with elbow flexed)
 Tenderness of the joint bursitis, inflammation in and around joint
 Tender, spongy joint  synovitis
 Tenderness of the epicondyles  epicondylitis (lateral = tennis elbow, Olecranon bursitis
medial = golfer’s elbow)
 Tenderness of the olecranon  olecranon bursitis (may be acute if joint feels tense)
 Hard nodules (classically on extensor aspect)  RA
 Feel for distal pulses if suggestion of vascular compromise eg: dislocation (medial emergency)
 Test sensation if suggestion of nerve injury eg: axillary nerve in dislocation (medial emergency)
 Palpate axillary lymph nodes if suspecting infection or neoplastic disease
 Move
* start with active movement * compare L to R, starting with normal side*then carefully perform
passive mvt and resisted movement*
 Flexion / Extension
 Supination / Pronation
 With elbow flexed at 90 degrees
 Measure
 Measure angles with tape or goniometer (in rehab or medico-legal cases)
 Normal: flexion and extension 0 - 150°
 Special Tests
 Lateral epicondylitis test (EXTENSOR insertion point)
 Ask the patient to pronate forearm and lift (extend) their
wrist against resistance. Wrist extension strains the extensor
muscle insertion point
 Tenderness  lateral epicondylitis (tennis elbow)
 Medial epicondyle (FLEXOR insertion point)
 Ask the patient to supinate forearm and lift (flex) their wrist
against resistance. Wrist flexion strains the flexor uscle
insertion point.
 Tenderness  medial epicondylitis (golfer’s elbow)

Investigations
 XRAY: Suspected trauma/fracture/dislocation (may not be visible), established arthritis (joint space
narrowing), bony changes associated with malignancy, trauma (black fat pads), congenital
 US: Great for quantifying bursitis and tendon injury, depends on US operator skill. US preferred for
tendon pathologies. Can demonstrate active tendonitis, or detect hyperplastic bone lesions
 CT: Can be useful, but if cost is no barrier MRI should be used instead as it better visualises the soft
tissues with bone and has less radiation
 Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis

Complications
 Causing patient more pain/trauma whilst trying to perform an examination
 Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
 Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a medical
emergency
Examination – Hand
From Student Guidelines

Indications Contraindications (medical emergencies)

 To detect and quantify the severity of  If they joint looks infected (septic arthritis)
disease (e.g. RA, OA, fibromyalgia) this requires immediate referral
 Pain / tenderness  If there are signs of acute impairment of
 Limited function / stiffness circulation or sensation in the limb, this is
 Acute injury, trauma, fall a time-critical medical emergency.
 Tendonitis (chronic) Examination should not delay initiating
 Gout management.
 Crystal-induced joint diseases (e.g. gout)
require urgent pain relief.
Equipment  If dislocation or fracture is suspected,
1. Piece of paper suggesting vascular compromise, distal
2. Key pulses, sensation and movement distal to
3. Button the joint must be assessed
4. Buttonhole  If fracture is suspected, passive mvt should
5. Pen be performed very carefully. Stop if
causing pain or crepitus.

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Indications
 Involves: look and feel of your hands, wrists and forearms.
 Exposure: both arms up to the elbow. If they need to remove clothing, say that there is a
gown and the curtains will be closed.
 Importance of proceeding , ask if they understand, have any concerns or questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain
 Ask the patient if they are left or right handed

Examination – HANDS
 Patient preparation: sitting on bed with hands resting pronated (palms down) on a pillow
 Ensure adequate exposure of hands, wrists and forearms, and privacy.
 General inseption
 Signs of systemic diseases (RA, psoriasis, gout, stigmata of scleroderma (beak nose, puckered
lips and small mouth)), systemically well, pain, presence of walking aids, splints, how they
hold the hand, how they uses or do not use their hands when moving or manipulating
 Look: Inspection
 Trauma ( fracture, scaphoid fracture), deformities ( OA, RA), swelling ( OA, RA),
symmetry and distribution/pattern of affected joints
 Stigmata of RA: ulnar deviation of phalanges at MCPs, swan neck deformities (distal IP flexion
with proximal IP hyperextension), Z thumb and boutonniere deformities (the opposite),
 Stigmata of OA: Heberden’s nodes (osteophytes at distal IPs, most common), Bouchard’s
nodes (osteophytes at proximal IPs)
 Muscle wasting or asymmetry (thenar wasting, hypothenar wasting)
 Stigmata of psoriatic arthritis: sausage fingers and onycholysis
  Nodules ( RA), gouty tophi ( gout),
 Skin: scars (carpal tunnel surgery), inflammation, erythema ( RA), bruising, lacerations
(risk of tendon or nerve damage), psoriatic plaques ( PA), ulceration, rashes, onycholysis
( PA)
 Raynaud’s phenomenon ( systemic sclerosis, scleroderma/SLE)
 Check elbows for RA nodules, gouty tophi and for psoriatic plaques

 Feel: Palpation
*always ask permission before feeling or moving a joint* look their face while
examining* start with normal side* examine painful area last* ask them to report pain *
 Feel temperature  inflammatory arthritis (RA), crystalline arthropathy
(gout or psuedogout), septic joint (infection)
 Palpate wrists
**use thumb and index finger of both hands, thumbs on dorsum**
 Tenderness  RA
 Palpate MCP joints, distal IP joints and proximal IP joints
**use thumb and index finger**
 Tenderness and swelling  arthritis, gout
 Synovitis (feels “boggy”) and synovial effusion  septic
joint, inflammatory arthritis (RA, PA), gout, trauma
 Sublaxation (partial dislocation)  RA
 Hard nodules (classically on extensor aspect)  RA
 Osteophytes  OA
 Palpate anatomical snuffbox
 Tenderness  scaphoid fracture
 Palpate thenar and hypothenar eminences Synovitis (soft tissue joint swelling) is seen
 Check capillary refill in inflammatory arthritis i.e. RA and PA
 Feel for radial pulse and ulnar pulse
 Vascular compromise eg: fracture, dislocation  treat as medial emergency
  Move
* in hand examination, start with passive mvt * compare L to R, starting with normal
side* perform active also*
 Passive:
 Wrist flexion an extension
 Normal: 75°
 MCP, PIP and DIP joints
 ↑ mvt / hypermobile  sublaxation (partial dislocation)  RA
 Feel for crepitus and ROM
 Active
 Wrist flexion (prayer position)
 Wrist extension (reverse prayer position)
 Make fist and straighten out (MCP and IP mvts)
 Ill-defined, swollen knuckles  synovitis  RA, PA
 Thumb opposition (oppose thumbs and individual fingers)
 Measure (hand function)
* No hand examination is complete without a practical assessment of hand function!!!*
 Opposition strength (examiner forces open the “OK” sign)
 Grip strength (ask patient to squeeze examiner’s first two fingers)
 Key grip
 Holding and turning a key; undoing and doing up a button; undo a screw-top jar;
write something
 Special Tests
 1) Carpal tunnel syndrome tests:
 Phalen’s test: Patient holds both wrists in forced flexion (the reverse prayer
position) for 30-60 secs. This increases the contents and pressure in the carpal
tunnel. Ask the patient if they feel a burning, tingling or numb sensation over the
thumb, index, middle and ring fingers (positive test  characteristic symptoms
of carpal tunnel syndrome. Note: it’s not sensitive or specific.
 Tinel’s tests: tap over the flexor retinaculum to reproduce
symptoms of carpal tunnel syndrome. This is much less reliable. This
test can also be done for the ulnar at the elbow and the common
peroneal at the knee)
 2) Neurological quick survey: Check the unique sensory islands and muscle uniquely innervated by
the median, ulnar, and radial nerves.
 Median nerve:
 Sensory: lateral tip of index finger
 Motor: hand palm-up, raise thumb to ceiling (abductor pollicis brevis)
 Fromet’s sign test
 Ulnar nerve:
 Sensory: medial (outer) tip of little finger
 Motor: hold piece of paper against resistance (first dorsal interossei / T1).
Best between middle 2 fingers
 Radial nerve: (no muscles in hand)
 Sensory: first dorsal webbed space
 Motor: thumb extension (away in plane of hand) (extensor pollicis longus)
or extension of the wrist
 Diminished or absent sensation in the hand  injuries of the nerves in the axilla,
arm or forearm, nerve root injury (dermatomal distribution).
 If trauma has occurred, specifically test and document sensation, movement and
circulation that may have been affected by the injury.

Investigations
 XRAY: Suspected trauma/fracture/dislocation, arthritis (joint space narrowing), bony changes
associated with malignancy, trauma, congenital
 OA: joint space narrowing, subchondral sclerosis, subchondral cysts and osteophytes
 RA: joint space narrowing, periarticular osteoporosis and erosions
 Serum / blood tests (need to rule out septic arthritis and osteomyelitis)
 Inflammatory markers (CRP, ESR)
 FBE: Hb and WCC
 Serum immunoglobulins
 Synovial fluid aspiration
 Gram stain and culture for septic arthritis:
 Gout crystal arthritis: urate and negative for birefringment crystals
 Pseudogout crystal arthritis: highly positive for birefringment crystals
 Nerve conduction studies if the site of the injury is still unclear.
 MRI: Visualises the soft tissues with bone and has less radiation so better than CT, good for bone,
cartilage and soft tissues. Osteomyelities plus inflammatory changes in adjacent muscle
 US: Cheap and detailed soft tissue imaging, great for quantifying bursitis, tendonitis and tendon injury,
depends on US operator skill
 CT: Can be useful for clarifying bone anatomy, but if cost is no barrier MRI should be used instead
Examination – Hip
From Student Guidelines

Indications Contraindications (medical emergencies)

 Pain  If they joint looks infected (septic arthritis)
 Injury, trauma, fall this requires immediate referral
 Tendonitis (chronic)  If there are signs of acute impairment of
 Altered gait circulation or sensation in the limb, this is
 Assessment of systemic disease (e.g. RA, a time-critical medical emergency.
OA, fibromyalgia) Examination should not delay initiating
 Arthritis management.
 Gout  If dislocation or fracture is suspected,
 Following a lower limb history suggesting vascular compromise, distal
pulses, sensation and movement distal to
the joint must be assessed
Equipment  If fracture is suspected, passive mvt should
1. Tape measure be very careful. Stop if causing pain or
2. Goniometer crepitus.

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Indications
 Involves: look and feel of your legs, move the legs and perform some special tests
 Exposure: whole of both limbs including the hip and lower back, need to take off clothes from
the waist down but can help underwear on, offer a gown and draw the curtains
 Importance of proceeding , ask if they understand, have any concerns or questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain

Examination – HIP
 Ensure adequate exposure of both hips and privacy. Lift underwear as necessary
 Look: Inspection
*with the patient standing, inspect from the front, side and behind*
 General: how patient undresses, pain, walking aids or orthopaedic shoes, posture
 Gait: normal, pain, limp, antalgic limp, weakness, symmetry, tilt, bear weight through both
legs, stiffness, deformity, length or instability, contact of feet with floor
 From front: Alignment (valrus, vlagus), deformities (flexion contractures, short externally
rotated leg), muscle wasting and asymmetry of muscle bulk, oedema, scars (total hip
replacement)
 From side: excessive lumbar lordosis  flexure contracture/ fixed deformity of hip
 From behind: symmetry of the gluteal and hamstring muscle bulk,
symmetry of popliteal creases,
 Trendelenburg’s sign (from behind)
 Place hands on iliac crests and thumb at the PSIS (dimples). Ask
patient to stand on one leg.
 Normal test: Pelvis is level or rises on side of lifted leg
  Positive Trendelenberg sign: Pelvis falls on the side of the lifted leg when patient
stands on the affected leg  positive test
 Ask patient to climb onto bed (observe this also)**
 Feel: Palpation
*the patient should now be supine on the bed; look their face while examining*
If suggestion of vascular compromise eg: dislocation, feel for distal pulses
 ASIS, the anterior aspect of the hip joint (distal to the midpoint of the inguinal ligament)
and the greater trochanter (with index and middle fingers)
 Tenderness  bursitis, inflammation in and around joint
 Measure: estimate distance from each iliac spine to the greater trochanter
 Palpate inguinal lymph nodes if suspecting infection or neoplastic disease
 Move
* start with active movement; if range of movement is limited, carefully test passive mvt * compare L
to R*
 Ensure patient is lying flat and the pelvic brim is perpendicular to the spine.
 Flexion / Extension:
 Normal flexion: 135°, normal extension: few degrees
 Thomas’s Test
 Place hand palm up under patient’s lumbar spine.
 Ask patient to bend the opposite knee and bring it up to their chest (hip
flexion) while keeping the other leg (side with examiners hand under it)
extended. Feel for obliteration of the lumbar lordosis and look at the opposite
leg.
 Normal test: The extended leg remains fully extended
 Positive Thomas test: extended leg rises, measure  flexure contracture of
hip, commonly due to OA
 Internal / External Rotation
 Usually tested in leg flexion in children and in leg extension in adults
 Flexion/children: With hip and knee both flexed at 90°, move foot laterally for IR and
medially for ER
 Extension/adults: Standing at the foot of the bed, hold the patient’s ankle and rotate
the leg inwards (IR) and outwards (ER)
 Normal external: 50-60°, normal internal: 45°
 Abduction/Adduction:
 Lay left forearm across pelvis with hand and elbow on the two ASIS. With right hand,
hold ankle and abduct leg until reach point where ASIS starts to move – this is the
limit of hip abduction, and further movement is occurring in the lumbar spine. Repeat
with adduction by moving the leg across the body
 Normal: abduction 30-40°, normal adduction: 20°
 Extension (optional):
 With patient lying prone, ask patient to lift each leg off the bed
 Passive movement range greater than active  tendonitis (minimal force is transmitted into
the tendons during passive movement)
 Passive movement range = active movement range  intra-articular process (arthritis)
 Measure
*with patient supine, ensure both legs are in same position)
 1) Measure apparent leg length: Umbilicus to medial malleolus (compare left to right)
 Apparent shortening = deformity at the hip, no loss of bone length
 Altered in pelvic tilt e.g. due to flexure deformity, OA
 2) Measure true leg length: ASIS to medial malleolus (compare left to right)
 True leg shortening = loss of bone length
 Altered in hip pathology or shortening of long bones
 Should be within 1cm of opposite leg. Difference of >2cm is significant.
 Special Tests
  Trendelenburg’s sign – completed in INSPECTION
 Thomas’s test – completed in MOVE

Investigations
 XRAYS (most valuable for hip except in infants): congenital, infective, traumatic, neoplastic, traumatic
 US – good for infants due dominant cartilage. Adults – tendon, bursae
 Nuclear Med: Inflammatory, infective, traumatic, metabolic, neoplastic bone lesions
 CT, MRI: MRI is better as there is less radiation, better soft tissue information
 Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis

Complications
 Causing patient more pain/trauma whilst trying to perform an examination
 Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
 Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a medical
emergency
Examination – Knee
From Student Guidelines, videos shown in tutorial and internet

Indications Contraindications (medical emergencies)

 Pain  If they joint looks infected (septic arthritis)
 Injury, trauma, fall this requires immediate referral
 Tendonitis (chronic)  If there are signs of acute impairment of
 Altered gait circulation or sensation in the limb, this is
 Assessment of systemic disease (e.g. RA, a time-critical medical emergency.
OA, fibromyalgia) Examination should not delay initiating
 Arthritis management.
 Gout  If dislocation or fracture is suspected,
 Following a lower limb history suggesting vascular compromise, distal
pulses, sensation and movement distal to
Equipment the joint must be assessed.
1. Tape measure  If fracture is suspected, passive mvt should
2. Goniometer be very careful. Stop if causing pain or
crepitus.

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Indications
 Involves: look and feel of your knees, put the knees through a range of movements and tests
 Exposure: exposure of both knees, need to take off clothes from the waist down but can help
underwear on, offer a gown and draw the curtains
 Importance of proceeding
 Ask if they understand, have any concerns, any questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain

Examination – KNEE
 Ensure adequate exposure of both knees and privacy.
 Look: Inspection
*with the patient standing, inspect from the front, side and behind, then inspect while supine*
 General: how patient undresses, pain, walking aids or orthopaedic shoes, posture
 Gait: normal, alignment of legs, limp, antalgic limp, weakness, symmetry, bear weight through
both legs, stiffness, deformity (valgus, valrus), instability
 Standing: neutral alignment, scars, leg alignment, symmetry of popliteal creases,
oedema (particularly posteriorly), deformities (valgus, valrus), wasting or
asymmetry of muscle bulk (quads, hamstrings, gastrocs), swelling, contracture,
skin (erythema, bruising, lacerations, psoriasis, ulceration)
*Ask patient to climb onto bed (observe this also) and SIT*
 Observe patella tracking
*ask patient to lie supine* Arthroscopic 'port'
 Supine: partial flexion of knee, oedema (localised and generalised), scars can be subtle
inflammation, scars, wasting or asymmetry of muscle bulk (quads)
 Feel: Palpation
*patient supine; look their face while examining*
 Feel temperature of knee  inflammation, infection, septic joint
 Patella tap for large joint effusions
 One hand grasps the lower quadriceps muscle and compresses the suprapatellar bursa
towards the knee. The other hand pushes the patella downwards.
 Positive sign: Patella sinks to touch femur  large joint effusion
 Bulge sign for small joint effusions
 The left hand compresses the suprapatellar pouch (as above) while the fingers of the
right hand are run along the groove beside the patella on one side and then the other.
 Positive sign: A bulging of the opposite groove to the side being compressed due to a
fluid wave  small joint effusion
 Move the patella laterally and medially across the
underlying femoral condyles and palpate the under-
surface of the patella medially and laterally
 Tenderness  Chondromalacia Patella
 Palpate the joint
*have knee slightly flexed*
 Palpate the joint margins, epicondyles, the full length
of the ligaments and insertion of the patella ligament
on the tibial tuberosities.
 Tenderness or palpable abnormality
 Tibial tuberosity tenderness  Osgood Schlatter disease
 Move
* Ask patient to perform active mvt and then perform passive mvt to check for greater range; if range
of movement is limited, carefully test passive mvt* compare L to R, starting with the normal knee*
 Flexion / Extension: Ask patient to flex and extend knee
 Normal flexion: 0 - 140°
 Normal extension: 5-10° off the bed (hold the femur down)
 Passive movement range greater than active  tendonitis (minimal force is
transmitted into the tendons during passive movement)
 Passive movement range = active movement range  intra-articular process (arthritis)
 Measure
 Goniometer rarely used (e.g. in medicolegal cases or when monitoring of an injury or
pathology). Need to ensure legs are in the same position when supine
 Special Tests
**with the patient supine** compare normal to R**
 1) Collateral ligaments (medial and lateral)
 Hold the ankle with the right hand, slightly flex the knee (approx.
30°) and slip the left hand under the femur (just above the knee).
Alternatively, squeeze the foot under the opposite armpit and hold
the knee with both hands (right). Ensure that the knee is not locked
and is slightly flexed (full extension makes the cruciate ligaments
taught and they will provide lateral stability even if the collateral ligaments are
defective; in flexion, lateral stability is only provided by the collateral ligaments).
Medial ligament: apply a valgus force (move the foot outwards, pull femur medially).
Lateral ligament: apply a varus force (move foot inwards, pull femur out). You may also
repeat with the knee locked to test not only the relevant collateral ligament damaged
but also at least one cruciate ligament.
 Significant abduction or adduction  ligament disruption or injury
 Unusually lax ligaments  ‘normal’ for some
 2) Cruciate ligaments (anterior and posterior)
 Anterior and posterior drawer (ACL and PCL): Bend both knees to
90° with the hips flexed to 45° and sit on the foot. Use both hands to
 hold the upper tibia and use the index fingers to ensure the
hamstring tendons are relaxed. When the patient is relaxed, pull the
tibia forwards to test the ACL and backwards to test the PCL. Normal:
a couple of mms of mvt, no anterior movement of the tibia
suggesting the ACL is intact. This is the best test for the PCL
 The Lachman’s test is the best test for the ACL. Flex the knee to 30°
so it’s off the bed . Have one hand on the thigh above the knee and the other on the leg
below the knee. Forcefully lift the tibial towards the ceiling while keeping the femur
still.
 Posterior (PCL): Lift both legs into the air so that both hips and both
knees are flexed to 90°. From the side, ensure the tibial tubercles are
level and for sagging of the tibia posteriorly.
 3) The Menisci (medial and lateral)
 McMurray Test: Flex the knee (to compress both menisci between
condyles. Place one hand on the knee (anteriorly) to feel both joint
lines. The other holds the foot.
 Medial meniscus: Invert the foot / externally rotate the leg and push
the knee upwards and outwards (varus). Gently flex and extend the
knee.
 Lateral meniscus: Evert the foot / internally rotate the foot. Push the
knee in medially (a valgus force, inwards and upwards). Gently flex
and extend.
 Click, pop, crepitus or pain while straightening the knee  meniscal
disruption
 4) Patella apprehension test
 Apply lateral force to the patella as the knee is moved from full
extension to flexion. Ensure that you are looking at the patient for a http://www.youtube.com/
watch?v=ohSzjNj-KCA
look of apprehension.
 Apprehension of the patient or resists flexion  tendency/risk of
patella dislocation.
 5) Apley’s Grind Test
**ask patient to roll onto stomach**
 Ask patient to flex knees to 90°. Grasps the tibia and repeatedly
internally and externally rotates the tibia while pushing it directly
downward into the bed.
 Positive test = Pain

Investigations
 XRAYS (most valuable for knee): fractures, arthritis, malignancy
 US – good for infants due dominant cartilage. Adults – tendon, bursae
 Nuclear Med (limited use in knee): Inflammatory, infective, traumatic, metabolic, neoplastic bone
lesions
 CT, MRI: CT can be useful but MRI is better as there is less radiation, shows both bone and soft tissue,
better soft tissue information, and most pathology of the knee occurs in soft tissues
 Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis

Complications
 Causing patient more pain/trauma whilst trying to perform an examination
 Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
 Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a medical
emergency
Examination – Ankle
From Student Guidelines

Indications Contraindications (medical emergencies)

 Pain  If they joint looks infected (septic arthritis)
 Injury, trauma, fall this requires immediate referral
 Tendonitis (chronic)  If there are signs of acute impairment of
 Altered gait circulation or sensation in the limb, this is
 Assessment of systemic disease (e.g. RA, a time-critical medical emergency.
OA, fibromyalgia) Examination should not delay initiating
 Arthritis management.
 Gout  Crystal-induced joint diseases (e.g. gout)
 Following a lower limb history require urgent pain relief.
 If dislocation or fracture is suspected,
Equipment suggesting vascular compromise, distal
1. Tape measure pulses, sensation and movement distal to
2. Goniometer the joint must be assessed.
 If fracture is suspected, passive mvt should
be very careful. Stop if causing pain or
crepitus.

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Indications
 Involves: look and feel of your lower legs, move the ankle
 Exposure: exposure of both ankles and lower legs. Can keep underwear on, offer a gown
and draw the curtains
 Importance of proceeding
 Ask if they understand, have any concerns, any questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain

Examination – ANKLE
 Ensure adequate exposure of both ankles (bare feet) and privacy.
 Look: Inspection
 General: removing shoes and socks, pain, walking aids or
orthopaedic shoes, posture
 Deformity (hallux valgus i.e bunions) or crowding of toes RA,
sausage shaped toesPA, AS), athropathy (joint disease, esp
in toes), muscle wasting or asymmetry, oedema/swelling,
scars, skin (inflammation, erythema, bruising, lacerations,
psoriasis, ulceration), psoriatic nail changes, calluses
(sublaxation)
 Integrity of the arches for flattening
 longitudinal medial arch (from heel to first MT- joint)
 transverse arch (under MT-P joints)
 flattening RA
  Gait: asymmetry or abnormality of mvt, misalignment (over pronation or supination),
ability to bear weight, stiffness, instability

 Feel: Palpation
*normal ankle first* look their face while examining*
 Lateral and medial malleoli oedema
 The joint line
 Squeeze MT-P joints (with 1st and 5th metatarsals between hands)
 Tenderness RA
 Metatarsal heads
 The base of the 5th metatarsal  avulsion fracture
 Medial and lateral ligaments
 Feel temperature of ankle inflammation, infection, septic joint
 Palpate Achilles tendon
 Tenderness  Achilles tendonitis
 RA nodules  RA
 Move
* start with normal side* ask patient to perform mvts first, then perform passive mvts*
It is usually difficult to give an exact range of movements in degrees and describing the
movement as a percentage of the other side or what a normal person can do is usually all that
can be done
 Ankle joint / Talar joint (tibia and fibula with talus)
 Dorsiflexion and plantarflexion
 Measure angle from right angle of ankle.
 Normal: dorsiflexion 20°, plantarflexion 50°
 Subtalar joint (talus with calcaneus)
 Inversion and eversion
 Hold the toes in one hand and the tibia in the
other. Twist the forefoot.
 Normal inversion: 20-30°
 Normal eversion: 5-10°
 Midfoot (multiple joints, mostly talus mvt with
navicular)
 Hold the calcaneus still in one hand (i.e. fix the hindfoot) and hold the distal
metatarsals in the other. Twist the forefoot
 The metatarsals can move dorsally (extension), plantarward (flexion), medially
(adduction), laterally (abduction), rotate in (supination) and rotate out
(pronation).
 Tenderness on movement
 Passive movement range greater than active  tendonitis (minimal force is transmitted
into the tendons during passive movement)
 Passive movement range = active movement range  intra-articular process (arthritis)
 Measure
 Special Tests

Investigations
 In trauma, examine and decide whether you need to perform an XRay of the ankle or the foot
(base of 5th meta-tarsal suspected)
 XRAYS fractures, arthritis, malignancy
 US – good for infants due dominant cartilage. Adults – tendon, bursae
 Nuclear Med (limited use in knee): Inflammatory, infective, traumatic, metabolic, neoplastic
bone lesions
  CT, MRI: CT can be useful but MRI is better as there is less radiation, shows both bone and soft
tissue, better soft tissue information, and most pathology of the knee occurs in soft tissues
 Inflammatory markers (CRP, ESR, WCC): Need to R/O septic arthritis, osteomyelitis

Complications
 Causing patient more pain/trauma whilst trying to perform an examination
 Missing an infected joint (septic arthritis)! Especially in a child. This requires urgent referral
 Disruption to a joint that has compromised the circulation/sensation of the limb. This is also a
medical emergency
Examination – Back
From Student Guidelines

Indications
 Complaints of back pain Equipment
 Suspect back is the source of a 1. Measuring tape
pathology i.e. pain radiating down leg 2. Pen
3. Tendon hammer
Contraindications: none 4. Neurological exam – cotton wool,
 Cord compression, cauda equina neurotip, tuning fork, etc
syndrome or trauma, esp. cervical
spine  medical emergency

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself
 Confirm the correct patient – ask name, DOB and UR number
 Obtain informed consent
 Rationale / indication
 Procedure: look and feel of the back, ask you to perform turning and bending
movements, and perform some special tests.
 Exposure: just be in underwear
 Discomfort, risks and complications
 Importance of proceeding
 Ask if they understand, have any concerns, any questions
 Gain consent
 Ask if the patient has any pain

Examination:
 Patient preparation: patient standing with their back to you
 INSPECTIONs
 overall posture, including scapula position,
 curves of the back (normal curves, pathological curves), scoliosis
 landmarks: waist creases, ASIS alignment
 muscle wasting
 surgical scars - possible surgery to the spine
 PALPATION
 Palpate each spinous process – can do sitting or standing.
 Identify surface landmarks of spine
 C7 is the most prominent of the cervical vertebrae
 T3/T4 is approximately level with the spine of the
scapula
 T7 is approximately level with the inferior angle of the
scapula in neutral position
 T10 may be located by following medially the angle of
the 12th rib to the midline or count down from T7
 L4 spinous process (L4/5 disc) is at or just below the
level of the iliac crests
  Feel for the tone of the erector spinae muscles (lateral to spine)
 spasm in the muscles  area of pain
 PERCUSS **warn patient**
 Percuss each spinous process, facet joints and sacro‐iliac joints.
 MOVE
**watch face during all movements for any signs of pain**
 Feeling for pain or misalignmnt
 Cervical spine **whilst sitting**
 forward flexion “put your chin to your chest” (normal 0 – 80°)
 extension “look up at the ceiling” (normal 0 – 50°)
 lateral flexion “put your ear to your shoulder (normal 0 – 45°)
 rotation “look over your shoulder” (normal to 80° each side)
 Thoracic spine **whilst sitting to keep hips fixed**
 rotation – ask the patient to sit, keep their hips still, cross their arms over their
chest and rotate their shoulders
 flexion – bend forward as far as you can
 extension - arch your shoulders backward and push your abdomen out forwards
 lateral flexion - slowly lower your right hand down towards the floor (repeat with
left)
 Lumbar spine **whilst standing**
 flexion – “bend forward as far as you can” / “try to touch your toes”
 Extension “arch your back and push your tummy out”
 Lateral flexion “ run your hand down the side of your leg towards the floor”
 Functional examination of gait (optional)
 Ask patient to walk to the wall and back. Classically lumbar spinal stenosis causes
pain that is worse with walking
 SPECIAL TESTS
 Schober’s test for forward flexion **standing**
 Assesses whether movement is occurring in the lumbar spine
or the hip joint and is critical for lumbar spine assessment.
Mark the skin in the midline at the level of the dimples of
Venus (i.e. the left and right PSIS) which overlie the sacroiliac
joints. Using a tape measure, draw two marks, one 10cm
above and one 5cm below this.
 Place the end of the tape measure on the upper mark and ask
the patient to ‘touch the toes’.The distance ... should increase
from 15cm to more than 20cm.”
 Distance is less then 20  spine is fixed  ankylosing
spondylitis
 Also may indicate scoliosis
 Straight Leg Raise test **lying supine**
 Ask the patient to one leg straight up (actively) and measure
their range (with the knee extended).
 Then, place one hand under the Achilles tendon and one over
the knee (to keep the knee extended) and gently passively
raise the leg up further. Once leg is raised, internally rotate and dorsiflex. Ask
patient to lift head off bed.
 Ask the patient to report pain or symptoms, where it is and whether this is
normally the site of pain (and not hamstring pain)
 Negative test: no pain or symptoms, this is not sciatica.
  Positive test for sciatica: reproduction of symptoms, significant difference
between sides, or if symptoms are reproduced at the end of range when adding
extra sciatic nerve tension. Record the angle of flexion which produces the pain
 Reflexes
 Lower limb: knee jerk, ankle jerk and plantar reflex.
 Upper limb reflexes should be examined if any pathology of the Cx spine
 Neurological examination:
Indicated where there are confusing signs, pain below the hip/buttocks, decreased
mobility/strength/senses. May be of the upper or lower limb, or for spincter tone
 Tone, power, reflexes (done), coordination, sensation
Examination – Cranial Nerves
From Student Guidelines

Indications
 Injury (sports, MVA)  History suggesting nerve lesion
 History of cerebrovascular disease or  General neurological examination
neuropathy  Complete medical examination
 Known neck pathology (tumour,
infection)

Contraindications: - none

Equipment
1. Bottle scents 6. Cotton wool
2. Snellen chart 7. Neurotip pin
3. Target (e.g. hat pin) 8. Tuning fork
4. Ophthalmoscope 9. Tendon hammer
5. Flashlight

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself
 Confirm the correct patient
 ask name, DOB and UR number
 Obtain informed consent
 Rationale / indication
 Procedure: Involves examining your eyes, hearing, and movements of the
face, tongue and shoulder.
 Exposure: down to upper neck (for shoulder muscles)
 Discomfort, risks and complications
 Importance of proceeding
 Ask if they understand, have any concerns, any questions
 Gain consent
 Ask if the patient has any pain

Examination:
 Patient preparation: ask patient to sit level with you
 General inspection
 Abnormalities of head shape or size (hydrocephaly, acromegaly, Paget’s disease)
 Ptosis, Proptosis, Pupillary inequality (remember a patient will have a glass eye!)
 Deviation of gaze (squint) , head tilt
 Facial asymmetry
 Scars, Cachexia
 Hearing aids, glasses
 Rashes or skin lesions
 CNI (olfactory) nerve:
 Ask if the patient has noticed any problems with their sense of smell/taste
 Inspect for rash, deformity of the nose, ensure both nostrils are clear (oedematous
polyps  non‐neurological anosmia)
 Ask patient to block one nostril and report which scent they can detect as the various
essences are presented (coffee, vanilla and peppermint). Use separate scents for
each nostril
 Anosmia  usually non-neurological (blocked nose, medication related), early
Parkinson’s sign
 CNII (optic) nerve:
 Visual acuity – Snellen’s Chart
 Ask if the patient normally wears glasses or contacts for long distance, ask them
to wear these during the assessment. note both unaided and aided visual acuity
for each eye
 Test each eye separately
 Ask the patient to cover their right eye with their hand (or eye cover) and read as
far down the Snellen chart with their left eye. Repeat on other eye
 Record the smallest line read for each eye and report visual acuity grade (usually
6/x)
 A pass is typically 2 errors or less.
 Report these errors e.g. 6/6 -2
 If the patient is unable to read even the largest letter, grade their acuity as:
 Count fingers
 See hand movement
 Perceive light
 No perception at all
 Visual fields – Confrontational Test
 Explain to the patient that you are testing their eyes against your eyes
 Position the patient and yourself so that you are arms length apart with your
eyes at the same level and directly opposite.
 Ask them to cover one eye, as you cover your opposite eye (on the same side).
 Ask them to fix their gaze on your eye, and explain they are not to look for the
target (red hat pin or moving finger), but to report when it comes into the
periphery of their vision (“tell me when you see then pin out of the corner of your
eye” / tell me when you can see its red).
 Start with the target centrally half way between yourself and the patient and
confirm they can see it clearly.
 Position the target peripherally in each quadrant of the visual field and move it
centrally. This tests peripheral vision in four quadrants in this eye.
 Repeat on the opposite eye
 Report whether there are any gross visual field defects – hemianopia, stroke
 Blind spot: Not expected to be done in OSCEs
 Fundoscopy
 Ask the patient to fix on a distant visual target (over your shoulder)
 Check first for a red reflex from a distance (if absent consider a cataract or an
artificial eye)
 Start with the ophthalmoscope on +20 lens to inspect the cornea and iris, then
rack down the magnification and move closer to the patient to progress from
lens, to vitreous then eventually focus on the fundus. The fundus has two main
landmarks – the optic disc and the macula, and each of these should be
inspected, as well as each quadrant and the vessels
 CNIII (oculomotor) nerve, CNIV (trochlear) nerve, CNVI (abducens) nerve:
 Draw H – Assess motor:
 Ask the patient to keep their head still and follow the target. Ask to report if they
see any double vision. Draw a “H” pattern and look for nystagmus and
symmetrical eye movements
 Light reflex – direct and consensual reflexes in each eye.
 Ask patient to focus on a distance object behind you. Shine light from the side
into the eye being tested. Observe constriction of the pupil of that eye (direct
response). Shine the light a second time and observe constriction of the eye that
is not being tested (consensual response).
 Normal: Both pupils should dilate as the light is removed.
 Swinging-flashlight test (for afferent pupil defect):
 If direct testing suggests a ↓ light reflex, move the torch quickly from eye to eye.,
resting on each eye for 1-2 seconds
 As the torch is swung to the eye with the relative afferent pupillary defect
(RAPD), both eyes will constrict less (therefore appearing to dilate paradoxically)
→ Marcus Gunn sign  optic nerve lesion.
 Accommodation reflex:
 Ask the patient to first fix on a distant object and then focus on the target in front
of them when you say. Bring a target (hair pin or finger) held close to their face.
Say ‘now”
 Normal: The eyes should converge and pupils should constrict symmetrically
 CNV (trigeminal) nerve:
 Sensory – Light touch
 Demonstrate the touch on the chest. Ask patient to close their eyes and say
when they feel the touch on their face. Using a wisp of cotton wool, perform light
touch (touch not stroke) on 3 regions (ophthalmic, maxillary and mandibular)
 Repeat on the opposite side.
 Repeat with warm hand vs cold tuning fork
 Sensory –Facial pain
 Repeat with the neurotip pin  assesses pain
 Report normal sensation of the face
 Motor – Muscles of Mastication
 Ask patient to bite down/clench teeth. Palpate masseter, temporalis and
pterygoid muscles  look for muscle wasting
 Ask patient to open their mouth and resist opening jaw against your hand
(pterygoid)
 Report normal bulk of the muscles of mastication
 Reflexes (2)
 Corneal reflex: using a wisp of cotton wool touched to the cornea . Warn the
patient that you’re testing their blink reflex. Don’t approach within the visual axis
 Jaw jerk: rest your fingers on the jaw. Ask patient to relax jaw. Tap your own
finger with a tendon hammer. Little or no movement is normally elicited, while an
exaggerated jerk suggests pathology
 CNVII (facial) nerve:
 Motor: Facial Muscles
 “Raise your eyebrows”
 “Screw your eyes tightly shut and don’t let me open them”
 “Show me your teeth”
 “Puff out your cheeks” and “don’t let me push the air out”
 Sensory: Anterior tongue
  Ask if any changes in taste anterior 2/3 of tongue (salt, sweet, sour, bitter)
 CNVIII (Acoustic) nerve
 Whisper numbers (gross hearing loss)
 classically ‘68’ and ‘100’ into one ear while blocking hearing in the other by
rubbing your fingers over their opposite ear.
 Weber’s test (sensorineural):
 Rest the stem of the tuning fork on the forehead in the midline. Ask whether the
patient hears one louder than the other.
 Sound localises to the affected ear with conductive loss
 Sound localises to the contralateral ear with sensorineural hearing loss.
 Rinne’s test (conduction):
 Tuning fork stem on the mastoid process and ask the patient to report when the
vibration is inaudible Bring the fork to the external auditory meatus.
 If there is normal conduction the patient will report the sound as louder when
next to their ear.
 If it is not lounder / they can’t hear it, there is reduced air conduction in the
middle ear (and if this the same ear as was louder in the Weber’s test, it confirms
the conduction loss in that ear)
 Balance
 Ask patient to stand up and close eyes. If easy, ask to stand on one foot.
 CNIX (glossopharyngeal) nerve and CNX (Vagus) nerve:
 Inspect tongue in mouth for wasting, fasciculations. Use a torch!
 Ask the patient to say “Ahhh”. Observe for any asymmetry as the uvula is drawn
upwards.
 Deviation = uvula deviates to the strong, functional side as the palate elevates
and pulls the uvula towards it.
 Gag reflex - a spatula is touched to back of the soft palate.
 Glossopharyngeal (afferent)
 Vagus (efferent)
 Palatal incompetence
 Place a cold, flat object under their nostrils and ask the patient to say “pop, pop,
pop”. Incompetence will result in frosting as humid air is expelled from the
nostrils.
 CNXI (accessory) nerve (innervates trapezius):
 Inspect for trapezius atrophy or asymmetry.
 Ask patient to shrug their shoulders and resist resistance (push down on shoulders –
“don’t let me push your shoulders down”)
 Ask patient to turn their head against resistance (“try to turn your head against my
hand”)
 CNXII (hypoglossal) nerve:
 Ask patient to stick out tongue
 Tongue deviation  LMN lesion, deviation toward the affected side

Complications
 Discomfort or harm to the patient (e.g. with corneal or gag reflex)

Investigations
 Imaging: Brain CT or MRI
 NCS (Nerve Conduction Studies) - Stimulate nerves and measure latency, amplitude and
conduction velocity between two point
Examination – Neurological Upper Limb
From Student Guidelines

Indications Contraindications
 Neurological history 
 General neurological exam
 Full medical examination

Equipment
1. Tendon hammer
2. Cotton wool
3. Neurotip
4. 128Hz tuning fork

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself (shake the patient’s hand)
 Confirm the correct patient - ask name, DOB and UR number
 Obtain informed consent
 Rationale / indication
 Procedure: Look, feel and move of the arm and its joints, then test muscle strength,
reflexes and sensation
 Exposure: of the arm and whole girdle shoulder, may need to undress
 Discomfort, risks and complications
 Importance of proceeding, ask if they understand, have any concerns or questions
 Gain consent
 Ask if the patient has any pain

Examination: Upper Limb

Overview: inspection, tone, power, reflex, coordination and sensation
**compare left with right, starting with normal limb first**
 Patient preparation: sit over the edge of the bed
 INSPECTION
 How does the patient undress? Follow commands? How is their coordination?
 Abnormal posture, upper limb flexion (hemiplegia), deformity
 Muscle wasting (deltoid, biceps, thenar, hypothenar, interossei, especially between first
and second digit) asymmetry or flaccidity, include the back
 Abnormal movements - tremor, or fasciculations.
 Resting tremor  Sign of Parkinson’s
 Fasiculations  Sign of LMN lesion
 Skin abnormalities - scars, herpes zoster rash (Shingles), neurofibromas.
 Test for “Arm Drift” or “Pronator drift”: ask the patient to close their eyes and hold out
both arms horizontally and supinated (palms upwards). It is abnormal for either arm to
drift. Note the direction and form of any drift
 Downwards drift  Weakness, UMN lesion
 Upwards drift  Cerebellar Disease
 Drift in both directions  Impaired proprioception
 TONE
 Ask patient to relax. Hold the arm with hands and put shoulder, elbow and wrist through
a range of passive movements at different velocities.
 Grade as hypotonic, normal or hypotonic,
 Hypertonia / spasticity  sign of an UMN lesion.
 Cogwheel rigidity (form of hypertonia)  associated with Parkinson’s disease
  Hypotonia / rigidity:  sign of a LMN lesion.
 POWER (graded 1 [no contraction] to 5 [normal power])
 Also helpful to test against your own power of the same action
Shoulder
 Abduction  C5,C6  lift your arm up, don’t let me push you down
 Adduction  C6,7,8  now try to tuck your arms in, don’t let me bring them up
Elbow
 Flexion  C5,C6  bend elbows up and try pull your arm in”
 Extension  C7,C8  now try to
Wrist
 Flexion  C6,C7  “drop hands, don’t let me push them up”
 Extension  C7, C8  “cock wrists back, don’t let me push them down”
Fingers
 Flexion  C7,C8  patient squeezes two of the examiner’s fingers
 Extension  C7,C8  hold palm, “straighten your fingers, don’t let me bend them”
 Abduction  C8,T1  “spread your fingers, don’t let me push them together”
 Adduction  C8,T1  “put your fingers tight together, don’t let me separate them”

Power is graded out of five according to the Medical

Research Council scale. The greatest power is noted, even
if it’s only momentary
0. No muscle contraction visible
1. Flicker of contraction but no movement
2. Joint movement when effect of gravity eliminated
3. Movement against gravity but not against examiner’s
resistance
4. Movement against resistance but weaker than normal
5. Normal power

 REFLEXES
If difficult to elicit a reflex, a reinforcing manoeuvre should be used. This can be getting the
patient to clench their teeth or perform a valsava manoeuvre.
 Described as: absent, reduced, normal, brisk/increased, markedly increased/clonus
 Patient needs to relax limb in a neutral position (e.g. folded on lap on pillow). There are
four to test:
 Biceps (C5,C6) (hand pronated)
 Brachioradialis (C5,C6),
 Triceps (C7,C8),
 Finger Jerk (C8) (hand supinated)  should be no contraction, marked contraction
indicates UMN lesion

 COORDINATION
 Finger‐nose test
 This movement is repeated both briskly and slowly, and the examiner’s finger is mov
ed about to alter the target. Ensure the patient is in their extremes of movement to
(i.e. fully outstretched arm) to reveal subtle tremours.
 gross in‐coordination or intention tremor  cerebellar disease
 past‐pointing  less severe cerebellar disease
 Rapidly alternating movements
 The patient is observed pronating and supinating their hand rapidly.
 Dysdiadochokinesia  Parkinson’s, MS, cerebellar lesion
 Rebound
 The patient is asked to rapidly lift (flex) their arms from their side forward and stop
on your command
  SENSATION
Pain, light touch, vibration, proprioception, temperature if indicated
 Pain (neurotip) followed by light touch (cotton wisp)
Demonstrate on sternum. Ask patient to close eyes and report when
they feel it and whether it feels the same on both sides. If reduced,
repeat testing.
 C5 – shoulder tip
 C6 – lateral aspect forearm, thumb
 C7 – middle finger
 C8 – little finger
 T1 – medial aspect upper arm and elbow
 Temperature (optional)
Note that objects will feel cooler at the periphery compare to
proximally
 Vibration (posterior column)
Demonstrate on sternum. Ask patient to report whether they can feel
vibration and to report when it stops
 Rest the tuning fork on distal IP joints (or another distal bony
prominence)
 If it is not felt, move the form more proximally DIPs  ulnar head
at the wrist  olecranon at the elbow
 Proprioception (posterior column)
 Ask patient to close their eyes. Move the distal IP joint of the little finger up and
down, first demonstrating then asking the patient to report the direction. Hold the
joints on the side (not top and bottom)

Investigations
 NCS (Nerve Conduction Studies) - Stimulate nerves and measure latency, amplitude and
conduction velocity between two points
 Best for testing neuropathy, allows you to pinpoint the site of descreptancy,.
 Decreased amplitude indicates amplitude problems
 Prolonged latency and decreased conduction velocity indicates demyelinating
 Better for extremities rather than proximal nerves where they’re deeper
 Conduction block: there will be a pulse more proximally, but the pulse wave will be flat
more distally. Most common cause is compression or ischaemia (which causes focal
demyelination).
 EMG – fine needle electrode, recording MU action potentials (i.e. when a muscle cell is activated)
 Helps differentiate neuropathic from myopathic, and helps localise conditions.
 EMG allows you to pick out individual muscles and show where the neuropathic changes
are.
 Cerebral spinal fluid (CSF) collection
 Increased CSF gamma globulin levels may be due to diseases such as multiple sclerosis,
neurosyphilis, or Guillain-Barre syndrome.
 Increased glucose in
 X-Ray if impingement (e.g. radiculopathy) is suspected

Complications
 Prick wounds or injuries from neurotip
Examination – Neurological Lower Limb
From Student Guidelines

Indications Contraindications
 Neurological history 
 General neurological exam
 Full medical examination
2. Pin (neurotip) for pain sensation
Equipment 3. Cotton wool
1. Tendon hammer
4. 128 Hz tuning fork

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself (shake the patient’s hand)
 Confirm the correct patient - ask name, DOB and UR number
 Obtain informed consent
 Rationale / indication
 Procedure: Look, feel and move of the whole leg, then test muscle strength, reflexes and
sensation
 Exposure: of the leg and hip girdle, need to take pants off, keep underwear on
 Discomfort, risks and complications
 Importance of proceeding, ask if they understand, have any concerns or questions
 Gain consent
 Ask if the patient has any pain

Examination: Lower Limb

 Patient preparation: sitting or standard to begin
 Overview: inspection, tone, power, reflex, coordination and sensation
 INSPECTION
 How does the patient undress? Follow commands? How is their coordination?
 Walking aids?
 Muscle wasting, compare the left side with the right side.
 Abnormal movements – a tremor, or fasiculations (rippling of skin/twitching).
 Resting tremor  Sign of Parkinson’s
 Fasiculations (minor twitches in the muscle belly)  Sign of LMN lesion
 Skin abnormalities – scars (hip replacement scar), herpes zoster rash (Shingles),
neurofibromas.
 Posture – extension of lower limb (UMN lesion), flaccidity,
 GAIT
 Ask patient to walk across the room and back
 1) normally
 2) heel to toe (cerebellum)
 3) on their toes (S1)
 4) on their heels (L4/L5)
 Trendelenburg’s gait, wide base gait, ataxia, antalgic gait (due to weakness or pain), high
lifting of foot, circumduction gait (increased tone, weak hamstrings), scissoring gait (para-
pyretic)
 Ask the patient to squat down and stand back up
 Proximal muscle weakness  myopathy, myasthenia gravis, LMN lesion, Eaton
Lambert Syndrome, muscular dystrophy
 Romberg Test
 Ask the patient to stand still with their feet touching together. Then ask them to close
their eyes in this stance.
 Unsteadiness with eyes open  cerebellar defect (ataxia)
 Unsteadiness worse with eyes closed  loss of proprioception (sensory ataxia).

 TONE
 Ask patient to relax. Move the knee joint passively; move the ankle joint passively. Do a
fast movement than a slow movement. Distract or ask them to grit their teeth If
necessary. Graded as hypotonic, normal or hypotonic,
 Hypertonia / spasticity  sign of an UMN lesion.
 Lead pipe rigidity (stiff regardless of velocity)
 Cogwheel rigidity (form of hypertonia, variable)  associated with Parkinson’s
disease
 Hypotonia / rigidity:  sign of a LMN lesion.
 Spastic catch (clasp knife effect after moving it quickly)
 Test for Clonus
 With the knee slightly bent, the ankle is sharply dorsiflexed to stretch the Achilles
tendon. If clonus is present the calf muscles will contract repeatedly against your
hand. Count the number of beats and compare for asymmetry.
 Clonus  sign of a UMN lesion.

 POWER (graded 1 [no contraction] to 5 [normal power], tested in midrange of movement)

 Para-paresis (bilateral)  Proximal vs distal
 Hemiparesis (respects midline)  Axial (trunk and proximal
 Pyramidal girdles)
 Myotomal  Fatigable (not routinely tested)
 Pyramidal
 Single nerve

Hip With the legs flat on the bed

 Flexion (psoas, iliacus)
 Extension (G. max)
 Abduction (G. med, G.
min, TFL, sartorius)
 Adduction (adductors)
Knee
 Flexion (BF, SemT, SemM)
 Extension (quads)
Ankle
 PF (gastrocs, plantaris,
soleus)
 DF (TA, EDL, EHL)
Tarsal
 Eversion (FL, FB, EDL)
 Inversion (TP, gastrocs,
FHL)
Toes (usually only great toe)
 Dorsiflexion (EHL)
 plantaflexion (FDL)
 L2,L3  “lift straight leg off the bed, don’t let me push down”
 L5,S1,S2  examiner hold leg up by calf, “try push leg onto the bed”
 L5,S1,S2  “push your legs out against my hands”
 L2,L3,L4  “squeeze your legs together against my hands”
With the knee flexed:
 L5,S1  “pull your heel towards your bottom”
 L3,L4  “straighten your leg”
 S1,S2  “push down against my hand, don’t let me push it up”
 L5,L5  “point foot towards you, don’t let me push it down”
 L5,S1  “Turn soles of feet out, don’t let me pull them in”
 L5,S1  “Turn soles of feet in, don’t let me pull them out”
 L5,S1  “push your toe up against my finger”
 S1,S2  “push your toe down against my finger”
 Power is graded out of five according to the Medical
Research Council scale. The greatest power is noted, even
if it’s only momentary
0. No muscle contraction visible
1. Flicker of contraction but no movement
2. Joint movement when effect of gravity eliminated
3. Movement against gravity but not against examiner’s
resistance
4. Movement against resistance but weaker than normal
5. Normal power

 REFLEXES
If difficult to elicit a reflex, a reinforcing manoeuvre should be used. This can be getting the
patient to clench their teeth or perform a valsava manoeuvre.
 Described as: absent, reduced, normal, brisk/increased, markedly increased/clonus
 There are 3 to elicit:
 Knee Jerk (L3-L4) (knee slightly flexed)
 Ankle Jerk (S1-S2) (manually dorsiflex and rotate first)
 Plantar reflex (L5, S1, S2) (laterally near heel across metatarsal heads)
 Norma: great toe flexes at the MTP joint.
 Extension of the toe “upgoing Plantar”  UMN lesion of corticospinal tract

 COORDINATION
Tests multiple components – vision, cerebellum, motor power, joint integrity
 Toe-Finger test
 The patient uses their great toe to touch the examiner’s finger with their knee bent.
This may demonstrate an intention tremor (tremor increases as target is approached)
 Heel-shin test
 Ask the patient to run their heel up and down the shin of the opposite leg.
 Abnormal  cerebellar lesion
 Foot-tapping test
 The patient is asked to tap their toe rhythmically against the examiner’s hand.

 SENSATION
Pain, light touch, vibration, proprioception, temperature if indicated
 Pain (neurotip) followed by light touch (cotton wisp)
Demonstrate on sternum. Ask patient to close eyes and report
when they feel it and whether it feels the same on both sides. If
reduced, repeat testing.
 L1 – anterior groin area
 L2 – proximal anterior thighL3 – immediately superior to
the knee anteriorly
 L4 – medial calf
 L5 – lateral calf and middle of dorsum foot
 S1 – lateral heel
 S2- posterior midline thigh
 S3 , S4, S5 – concentric rings in ‘saddle area’ around the
anus
 If there is reduced sensation, repeat testing in the
abnormal area.
 Vibration (posterior column)
Demonstrate on sternum. Ask patient to report whether they
can feel vibration and to report when it stops
 Rest the vibrating fork on the great toe.
  If vibration sensation is reduced or absent, it is progressively tested more proximally:
great toe  ankle  patella  anterior superior iliac spine.
 Proprioception (posterior column)
 Ask patient to close their eyes. Move the distal IP joint of the great toe up and down,
first demonstrating then asking the patient to report the direction. Hold the joints on
the side (not top and bottom)
 Common patterns: Distal / glove and stroking, single nerve, dermatomal, hemispheric
 Unusual patterns: Crossed, dissociated (disturbance affects one pathway but spares the
other), suspended (central court syndrome)

Investigations
 NCS (Nerve Conduction Studies) - Stimulate nerves and measure latency, amplitude and
conduction velocity between two points
 Best for testing neuropathy, allows you to pinpoint the site of descreptancy,.
 Decreased amplitude indicates amplitude problems
 Prolonged latency and decreased conduction velocity indicates demyelinating
 Better for extremities rather than proximal nerves where they’re deeper
 Conduction block: there will be a pulse more proximally, but the pulse wave will be flat
more distally. Most common cause is compression or ischaemia (which causes focal
demyelination).
 EMG – fine needle electrode, recording MU action potentials (i.e. when a muscle cell is activated)
 Helps differentiate neuropathic from myopathic, and helps localise conditions.
 EMG allows you to pick out individual muscles and show where the neuropathic changes
are.
 Cerebral spinal fluid (CSF) collection
 Increased CSF gamma globulin levels may be due to diseases such as multiple sclerosis,
neurosyphilis, or Guillain-Barre syndrome.
 Increased glucose in
 X-Ray if impingement (e.g. radiculopathy) is suspected

Complications
 Prick wounds or injuries from neurotip
Examination – Skin
Indications
 Skin lesion
 Symptoms of malignant cancers

Contraindications

Equipment
1. Magnifiers
 Lumino dermlite (polarized illuminated hand-held magnifier)
 Magnifying glass
 Head loup
2. Dermatoscope
3. Wood’s lamp
4. Camera

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Involves: Close look and feel of the lesion and the body for any othe rlesions
 Exposure: Undress down to underwear for exposure of complete skin surface. Close
curtains, cover with sheet and expose when necessary
 Importance of proceeding
 Ask if they understand, have any concerns, any questions
 Gain consent
 Offer a chaperone (especially male doctors)
 Ask if the patient has any pain

Examination Summary:
 Patient preparation: Good lighting, complete skin surface exposed.
 Assess general illness
 Examine the entire surface of the skin
 Examine special sites – scalp, nails, mouth and ask about ano-genital region
 Describe lesion morphology and distribution
 2. Distribution of lesions / full skin examination
 Any pigmented lesions: assess with dermatoscope

Examination:
 Patient preparation: Good lighting, complete skin surface exposed.
 General inspection: is this patient ill
 Generalised redness
 Facial redness with fever
 Widespread distribution of lesions
 multiple bullae or erosions
 palpable (or impalpable) purpure
 multiple skin infarcts
  Examine the entire skin surface
 Ensure you don’t miss any areas: behind the ears, back of the neck under hair,
between the toes, the back and buttocks, genital region, axillae
 Examine all relevant lymph nodes if a suspicious lesion is found.
 Examine special sites – scalp, nails, mouth and ask about ano-genital region
 Examine scalp skin and hair – psoriasis, lice, nits (eggs)
 Examine nails – infection (bacterial or fungal), lifting of nail, psoriasis
 Examine mucosae – dermatosis, lichen planus, Stevens–Johnson syndrome
 Ask about ano-genital region – dermatosis, lichen planus, lichen sclerosis

 Individual lesion morphology

 Look/Appearance
 Height: Flat (macule or patch), elevated (papule, nodule or plaque)
 Fluid: Clear-filled blister (vesicle or bulla), pus-filled (pustule or abscess)
 Accumulation of dermal fluid: smooth elevation (wheal) diffuse swelling of
subcutaneous tissue (angioedema)
 Blood extravasation: pinpoint (petechial), palpable collection (ecchymosis
haematoma)
 Loss of skin surface: part of epidermis (erosion), epidermis and dermis
(ulcer), slit in skin (fissure), loss of skin due to scratching (excoriation)
 Scarring: thicker than skin (hypertrophic scar), thinner than skin (atrophic
scar)
 Crust (a collection of dried serum and cellular debri)
 Touch:
 Stretch surrounding skin
 Rub a lesion (if suspecting mastocytoma)
 Rubbing of mastocytoma  will urticate
 If suspected skin cancer, examine local (regional) lymph nodes
 Distribution of lesions / full skin examination
 Symmetrical:
 Flexure, extensor or intertringinous regions
 Central, peripheral or photosensitive patterns
 Asymmetrical:
 If asymmetrical: Configuration lesions
 Single and random, clustered or dermatomal
 Koebner phenomenon (lesions appear along lines of trauma)
 Annular (ring shaped) or Lines of Blashko

Further Investigations
 Dermatoscopy with oil
 Pigmented lesions
 Skin swab for culture or PCR
 suspected bacteria, viruses (to perform PCR)
 Nail clippings for microscopy and culture
 suspected toe nail fungal disease (onychomycosis, tinea unguium)
 Skin scrapings (transferred to glass slide, 10% KOH added and examined under light
microscope)
 suspected fungal infections (dermatophytosis)
 Microscopy
 Suspected lice in hair, scabies (scrape the burrow/papule),
 Wood’s lamp
  Erythrasma (corynobacterium fluoresces coral pink), vitiligo (depigmentation is
white)
 Skin prick testing
 Suspected type 1 hypersensitivity
 Patch testing
 Suspected type 4 hypersensitivity as in allergic contact dermatitis
 Skin biopsy for histopathology
 If unsure of the clinical assessment, but only AFTER a provisional clinical diagnosis
has been made
 Skin biopsy is often of little value for inflammatory disease
 Biopsy is important to confirm clinical diagnosis in neoplastic skin disease
 Select the correct technique
 Always make a clinical diagnosis before biopsy a pigmented lesion
 Provide pathologist with as much clinical information as possible
 Talk with the histopathologist if the pathology report doesn’t fit the clinical diagnosis
Examination – Ear, Nose, Throat
From Student Guidelines

Indications
 Pain Contraindications
 Discharge 
 Ringing 
 Deafness

Equipment
1. Otoscope with clean earpiece
2. Nasal speculum
3. Tongue depressor
4. Pen light
5. Tuning fork (512 ideal)

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself
 Confirm the correct patient - ask name, DOB and UR number
 Obtain informed consent
 Rationale / indication
 Procedure: Look in your ears, test you hearing and have a look in your nose and mouth
 Exposure: down to the neck
 Discomfort, risks and complications
 Importance of proceeding, ask if they understand,
have any concerns or questions
 Gain consent
 Ask if the patient has any pain
 Offer the patient a chaperone

Part A) The Ear

 Inspection
 Pinna – size, shape and deformit, trauma, lesions,
redness, scars
 External canal – skin lesions (cirrhosis), cerumen (earwax),
crusting, hearing aids, growths
 Presence of discharge (blood, serous, mucopurulent)
 Palpation for tenderness
 Pinna
 Tragus
 Otoscopic examination
Fit clean ear piece to scope. Hold scope like a pen with thumb and res
other fingers against face. Pull pinna gently posteriorly & stabilise head
with other fingers.
 Skin of the cannal
 Wax
 Forgein bodies
 Discharge
 Debris
 Tympanic membrane:
 Colour and transparency The tympanic membrane is gray,
 Fluid semitransparent and ovoid. The
 Sclerosis, inflammation, redness lateral process of the malleus is
 Perforation / continuous contacting the membrane and
the long process of the incus can
be seen behind the tympanic
membrane in the two o'clock
position.
  Scars
 Movement (with air puff)
 Gross hearing test
Whisper random numbers while rustling fingers in opposite ear
 Weber’s Test
Place the vibrating tuning fork in the centre of the forehead. Ask the patient if they can hear the
sound equally in both ears or better on one side
 Sound equally in both ears = Normal hearing
 Louder in one ear = conduction loss in THAT ear or sensorineural loss in the OPPOSITE ear
 Sensorineural hearing loss (unilateral) = louder in unaffected ear
 Conductive hearing loss (unilateral) = louder in affected ear
 Rinne’s test
Place the vibrating tuning fork on the mastoid process to assess bone conduction. Move it to the ear
(air conduction) and ask if they can still hear it, and if it’s louder.
 Patient hears it louder next to ear = normal conductive hearing = positive test
 Patient hears softer next to ear = loss of conductive hearing = negative result

Webers test abnormal  perform Rinne’s test

1) Both ears normal = SN loss in opposite ear
2) Negative Rinne (not louder) in same ear = conductive loss in that ear
3) Negative Rinne (not louder) in opposite ear = both

Part B) The Nose

**Look from above and below**
 Inspection:
 Obvious swelling or deformity (septum deviation best seen inferiorly)
 Scars or abnormal creases across nose or face
 Redness or skin disease
 Discharge or crusting
 Test nasal patency:
Ask patient to block one nose, hold metal speculum under nose and ask them
to sniff.
 Inspect with nasal speculum
 Septum, no deviation
 Inferior turbinates (not swollen, pink and tender)
 Oedema and inflammation
 Polyps (insensitive)
 Foreign body
 Bleeding, spots, crusts
 Palpate paranasal sinuses
 Apply pressure examining for tenderness
 Low medial forehead (frontal)
 Medial orbital walls (maxillary)
 Anterior maxillae (+ maxillary teeth as could be related to dental
infect)
 Illumination (under superior orbit, 30° to face, then inferior orbit)
 Test smell
 Not routinely assessed
  Block one nostril and sniff bottled scent (vanilla, coffee, alcohol wipe)
 Patient report smell then do other nostril

Part C) The Throat

 Inspection
 Trismus (inability to open mouth wide due to variety of causes)
 Condition of tongue
 Use tongue depressor to inspect:
 Back of tongue
 Tonsils
 Uvula
 Soft palate
 Posterior pharyngeal wall
 Swelling, inflammation, exudates
 Symmetrical elevation of soft palate (say ahhhh)
 Hard palate (tilt your their head back)
 Mucosa of buccal region and gingival
 Condition of teeth

Part D) The Neck

**Examine from behind if possible**
 Palpation
 parotid glands (lumps, duct obstruction tumours)
 trachea to larynx from under chin to sterna notch (midline)
 lymph nodes
 Submandibular, anterior triangle and posterior triangle

Further Investigations (often part of an abdominal exam)

 Hearing test / tone audiometry
Complications
 Exacerbating pain
 Examination – Eye
From Student Guidelines and Tutorial in TCP

Indications Contraindications
 Vision loss or deterioration 
 Diplopia
 Optic neuritis Equipment
 Stroke or other causes of field loss 1. Snellen chart
 Changes in vision 2. Eye paddle
3. Flashlight
4. Red hatpin
5. Opthamoscope

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient
 ask name, DOB and UR number, check this matches the request form
 Consent
 Involves: insertion of a tube through the nose, throat and into the stomach
 Exposure: abdomen to have a listen to the chest
 Complications: can insert it into the lungs
 Indications and importance of proceeding
 Ask if they understand, have any concerns, any questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain

Procedure:
 Preparation
 Switch of room lights, should be dim but not dark
 Warn the patient that the bright light can temporarily dazzle them
 Patient shoud be sitting up.
 Test visual acuity – Snellen Chart
 Seat the patient 6m from the Snellen chart
 Allow the patient to wear glasses if they usually wear them, and the results are referred to as
"best corrected vision".
 Examine the right eye first
 Ask the patient to obscure their left eye with an ‘eye paddle’ or card – enough to occlude
vision but not pressed against the eye. This is important to prevent cheating.
 Ask the patient to read from the top of the chart down with their right eye.
 Record the last line completed accurately as the acuity for distance vision for which eye.
 Numerator = number of meters standing away
 Denominator = which line read (60 for top line, 6 for lowest
line)
 Repeat with the opposite (left) eye.
 Near vision test (Hand-help acuity chart)
 Test colour vision
 Use the Ishihara Colour Plates to test colour vision
 Test response to light
  Shine a light in the left eye, looking for constriction of both the left pupil AND the right pupil.
Repeat in the other eye
 Test visual fields
 Sitting an equal distance from the patient, ask them to cover one eye with their hand or an
eye paddle
 Using both hands (an equal distance between yourself and the patient), hold up one-to-two
fingers on each hand.
 Try to hold one hand in a left/temporal field and the other in a right/nasal field and ask the
patient to tell you how many fingers you’re holding up.
 Switch visual fields and repeat.
 Repeat on the other eyes.
 Test extra-ocular movements
 Ask the patient to keep their head still and follow the red dot with their eyes
 Ask them to report any double vision
 Using the red hatpin, draw a H-pattern in the air.
 Observe for full movement of the eyes, any nystagmus, and any reported diplopia
 Perform fundoscopy
 Pupil dilatation (with one drop tropicamide 1% in each eye and wait for 15 minutes) is useful
to acquaint yourself with the normal fundus but may not always be possible, especially in
neurology patients or those with a head injury.
 It is important to get your patient to fixate on a precise area (for example, the corner of the
room or curtain rail). If you are too vague about this they will move their eyes. Instruct the
patient to look at this spot no matter what—even if you get in the way. This spot should be
located so that they are looking slightly away from you when they are examined—that is, to
the left when you examine the right eye and vice versa.
 It is best to examine the patient's left eye with your own left eye and right eye with your own
right eye—this takes practice. Try to keep your other eye open. Certainly, in an examination,
such as for membership of the Royal College of Physicians (MRCP) part 2, you shouldn't close
your other eye while examining the retina.Place your hand on the patient's forehead so that
your fingers are splayed but your thumb is on the upper lid. This is important as you will use
your thumb to hold the patient's lid open and also the joint of your flexed thumb is exactly
where your forehead needs to end up.

Other investigations
 Panoptic Ophthalmoscope
 Direct Ophthalmoscope
 Slit Lamp
Procedure – Surgical Handwash
To Do.
Procedure – Vital Signs and Observations
 Patient Questions
 Alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the
exam?
 Never take an BP on an arm with;
 Arterio-venous fistula
 Lymphoedema
 Same side as a mastectomy
 Recent radial harvest for coronary artery graft surgery
 • Avoid an arm with a cannula in-situ
 Heart Rate
Index and middle finger. If the radial can’t be felt, use the carotid pulse
 Rate: 60-100 normal (normal bradycardia, tachycardia)
 Rhythm: regular or irregular, irregularly irregular = AF
 Volume/character: weak, strong or bounding
 Where the pulse was taken
 Radio-radial delay, radiofemoral delay
 Respiration Rate
 Rate: 12-20 normal (normal bradypnoea or tachypnoea)
 Pattern: Regular and unlaboured (no distress, Kussmal)
 Ratio to pulse: 1:4
 Use of accessory muscles
 Blood Pressure
Take towards end to minimise white-coat hypertension. Arm should be level with heart (if too
hair, the BP will be high). Palpate for the brachial artery. Wrap the sphygmo 2.5cm above the
artery. Wait 2 mins before repeating on same arm.
 Normal, hypertension (140/90),
 Manner: Sitting or standing, L or R
 Lying and standing (drop in more than 15 = postural hypotension)
 Left and right (variation of up to 10mmHg is acceptable)
 Stethoscope:
Warm it in your hands before use

 Temperature (Tympanic membrane):

Pull the ear backward to straighten the ear canal for accuracy. Aim the tip of the ear probe
midway between the opposite eye and earlobe. Inaccurate if there is wax obstructing the
tympanic membrane. Not recommended for use in children less than 2 years old because the ear
canal is too narrow to get an accurate reading
 Normal Tympanic: 35.8°C to 38°C

General tips
 In a patient with a possible vascular event, such as a dissecting thoracic aneurysm, take pulses in
all extremities.
 In some patients, it may be difficult to palpate a pulse, for example due to obesity
 Specialists (for example vascular surgeons) may use a Doppler device if necessary to find pulses.
 Never rely on a monitor or any electronic device for the heart rate – you should always check the
pulse manually as well.
 Do not auscultate the heart over clothing
  Blood pressure can be influenced by physical activity, posture, the respiratory cycle, smoking,
caffeine and anxiety.
 It is normal to feel slight variation in the regular pulse. This is due to the effect of inspiration and
expiration on the tone of the vagus nerve. This will be noticed as an regularly irregular pulse.
 Factors that can influence temperature are biological rhythms, hormones, environmental factors,
exercise, eating food and age

Sites used for measuring temperature:

 1. Mouth  7. Oesophageal
 2. Axilla  8. Urinary bladder
 3. Rectum  9. Trachea
 4. Tympanic membrane  10. Pulmonary artery
 5. Skin surface
 6. Femoral

Mercury thermometer : Must shake before use. Slowly being phased out of use in
healthcare. Can be used to measure oral, axillary and rectal temperature
Digital thermometer : Can be used to measure oral, axillary and rectal temperature
Procedure – Basic Life Support
Dangers:
 Eliminate dangers to yourself, then to the victim
 Warn any bystanders of danger
 Protect cervical spine!
 CPR must be on flat, DRY surface

Response
 Commands:
− Can you hear me
− Squeeze my hand, open your eyes
 Actions:
− Squeeze shoulders
− Sternal rub

Send for help

 Call out, call 000
− Keep ambulance on speakerphone
 Direct bystander to call for help
− Need to do 3 things:
 1 Call 000, tell them where we are, victim is unconscious, why, try to stay on
the line
 2 Find a defibrillator
 3 Make sure you come back
 What did I say?
 Q: What is a defibrillator?
− It is a machine that will restart the heart and it’s in a small box
− Shopping or sports centres, hospital or community centre

Airway
 Check airway is CLEAR
− If suspect fluid or vomit in lungs
 Tilt head to side
 Put on left side
 Open airway
− Hold forehead
− Tilt HEAD back
− Chin lift
 If cervical spine injury is suspected:
− Bystander stabilises head
− Jaw thrust to open airway without extending the neck
− Fingers under jaw and lift
− Use thumbs to open mouth
Breathing
 Look
 Feel
 Listen

Compressions:
 Kneel on the patient’s right side
 30 compressions then 2 breaths
− 2 compressions per second
− 100 compressions a minute;
− Count aloud
 Heel of hand on lower half of sternum, middle finger over nipple
 Fingers interlocked over left of chest/heart
 Arms straight, elbow extended
 Compress straight down – do not rock
 Rescue Breaths
− Close nostrils
− Tilt chin further back as you breathe in
− LOOK for lungs inflating and fall of chest
− LISTEN for breathing

Defibrillator
 Use IMMEDIATELY
 Take clothes OFF, DRY person if wet
 Put battery in
 Press green button to turn on
 Put pads on
 Plug in pads
 TELL EVEYRONE TO STAND BACK
 Re-commence compressions until shock is advised
 Begin compressions immediately after shock

Constantly:
 Continue checking for
− Dangers
− Response/breathing

Instructing Others
 CPR
− Do you know CPR?
− Are you willing to perform CPR? / Do you think you can learn it?
− Look where my knees are. Position your knees in the same way so you can lean
− Arms straight, elbows extended, and use your upper body
− Interlace one hand over the other
− Press one 3rd the depth of the chest,
 − Number of compressions, count aloud
− Hard and fast compressions, followed by 2 breaths
− Stop compressions when giving breaths
 Defib
− Open it
− Put the battery in
− press the green button to turn it on
− Unstick the paddels and pass them to me
− Plug the padels in

Special Cases
 Infants
− Use 2 fingers to compress
 Stomach Distended
− do not apply pressure to stomach
 Pregnant
− Put pillow/jumper under right buttock
− Keep shoulders flat
− Pelvic tilt to the left
 Procedure – ECG
Indications
 Chest pain  Electrolyte abnormalities (E.G. k+)
 Shortness of breath (SOB)  Syncope/fainting
 Palpitations  Monitoring of drug effects and toxins
 Chronic or acute heart failure  Routine medical examination e.g.
 Hypertension medical insurance
 Congenital cardiac abnormalities  Baseline ECG e.g. with HT or diabetes

Uses of a 12 Lead ECG

 Guide therapy and risk stratification for patients with Acute Myocardial Infarction
 Diagnosis of cardiac arrhythmias
 Detect electrolyte disturbance (E.g. hyperkalaemia and hypokalaemia)
 Detect conduction abnormalities (E.g. bundle branch block)
 Screening tool for ischaemic heart disease
 Non-cardiac disease (E.g. pulmonary embolus)

Contraindications: none

Ideally, the patient should not have had alcohol, tobacco, caffeine, or performed physical
exercise within 30 minutes of the exam. The exception is when a patient has performed exercise as part
of an exercise stress test)

Equipment
1. Disposable razor and sharps bin (if necessary)
2. Electrodes (disposable or reusable with electrode gel)
3. ECG machine
• Charged or plugged in to AC power
• Adequate paper to print
4. Cables

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself
 Confirm the correct patient
− ask name, DOB and UR number, check this matches the info on the computer
 Obtain informed consent
− Rationale / indication: measure the electrical activity of the heart as it contracts, to detect
any changes which would indicate cardiac disease
− Exposure: exposure of the chest including bra, wrists and ankles
− Procedure: placing sticky electrodes across the chest, wrists and ankles
− Discomfort, risks and complications
− Importance of proceeding
− Ask if they understand, have any concerns, any questions
− Gain consent
 Ask if the patient has any pain
 Ask if the patient allergies to gel or electrodes
 Ask if the patient has any jewellery or metal implants to take it off or turn it off
 Ask if the patient has had any caffeine, cigarettes, alcohol or exercised in the last 30 mins
Procedure/ Activity:
 Patient preparation: patient should be supine on an incline, undressed from waist up and covered
with a gown, all jewellery and metal removed.
− Ask the patient to remove any metal objects e.g.
watches, hearing aids, jewellery (these may affect
the tracing). Other electrical objects should be
switched off.
− Ensure patient is warm and not over-exposed
− If the patient has body hair, you must shave it off
with a disposable razor prior to carrying out the
ECG
 Attach an electrode to the inside of each wrist
 Attach an electrode to the inside of each ankle
 Attach six electrodes across the chest
 Connect the appropriate ECG cables to each electrode
− LA and RA to each wrist
− LL and RL to each ankle
− V1-V6 praecordial lead electrodes from right to left
across chest

 Confirm (i.e. double check) the correct the ECG cable is attached to each electrode.
− ECG cables are colour-coded and labelled with a position
 Ensure lead wires are in straight lines and not crossing over each other (minimise interference on
the tracing)
 Ensure the patient is lying still, comfortable and quiet
− This minimises non-cardiac muscle contraction.
 Check the ECG for any artefacts and stable baseline
 Record the ECG
− The tracing should be made in the following order
− I II III AVR AVL AVF V1 V2 V3 V4 V5 V6
 Machine should be switched off, electrodes removed and the patient allowed to dress.
 Documentation: The tracing should be marked with the following as soon as it is printed:
− Patient name, UR number and DOB
− Date and time recorded
− Any reports of chest pain or discomfort
− Patient position
− Medications taken for pain e.g. GTN
 Examine the ECG tracing immediately
 The patient should be informed of the findings of the ECG
  Cleaning:
− Clean electrode placement sites on patient
− For reusable electrodes, clean away electrode gel with hot soapy water or 70% alcohol
wipes
− ECG cables – cleaned with hot soapy water or 70% alcohol wipes
 Storage:
− ECG should be plugged into AC power when not in use
− Adequate paper should be stored in the ECG machine
 Perform hand hygiene

Report Findings / Systematic analysis

 Patient name, DOB, UR number, time and date of ECG, presence of chest pain
− Relieving and exacerbating factors, relevant medications
 Rate
− 1) HR: Use Lead II - 300/large boxes, 1500/small boxes, R waves in 15 squares x 20
 Rhythm
− 1) Sinus/non sinus (1P wave:1 QRS complex)
− 2) Regular or irregular(compare distances between P and between QRS)
− Any irregular beats
 Axis
− Should be between 0-90 degrees from LEAD I
− Count different between Q and R waves in Leads I and aVF.

 P wave: Atrial depolarisation

− 1) Shape: Small, round and upright
− 2) Size: 3mm/3 small boxes / 0.08-0.12 secs duration, <2.5mm height
− 3) Upright in correct leads (II, V1).
− Sinus rhythm: 1:1 width with each QRS and preceding each QRS
 PR interval: Atria-AV node-Ventricles
− 1) Isoelectric.
− 2) Length: Normal: 5mm / 5 small boxes / 0.12-0.20 secs,
 QRS complex: Ventricular depolarisation
− 1) Length: Normal: less than 3mm / 3 small boxes / 0.12secs duration / 0.08 – 0.11
− Height: Variable, but should increase across V1-V6.
− Pathology
 Large = ventricular hypertrophy
 Pathological Q waves. Should normally be small (<25% of R wave), almost non-
existent in Lead II. <1mm duration.
 ST segment: Depolarisation-Repolarisation
− Normal: 2-3mm / 2-3 small boxes / 0.08-0.12secs, isoelectric
− Pathology:
 Elevation: AMI, LBBB.
 Depression: Ischaemia, ventricular hypertrophy, acute posterior MI, PE
 T wave: Ventricular repolarisation
− 1) Should be upright when QRS is upright. Comment on upright or inversion.
 Should be upright in Lead I, Lead II, V3-V6.
 − Normal: 2-3mm / 2-3 small boxes / 0.08-0.12 secs duration, Height: <5mm in limb leads,
<10mm in praecordial leads, same direction as the QRS it follows
 QT interval: Duration of systole in ventricles
− Should be 7-11mm/0.30-0.46secs, <0.425 sec when corrected for HR
− Varies with heart rate
 Increased = bradycardia
 Decreased = tachycardia
− Long QT: MI, hypocalcaemia, myocarditis, drugs (amiodarone), subarachnoid haemorrhage
 U wave: Atrial Repolarisation
− If present, usually only small
 Any other waves
 Compare with previous ECG if available
 Clinical context of patient
 Provisional Diagnosis
 Reported by

Complications
 Misplacement of leads causes false interpretations
 Interference / confounding of results by tremors, shivering, speaking, movement, etc
Procedure – Venepuncture
Indications
To obtain a sample of venous blood for laboratory testing for monitoring and diagnostic purposes.
 Venepuncture must be necessary - you can’t get the result in some other way
 Bacteriological: blood cultures
 Haematological: LFTs, glucose, cardiac enzymes, INR and PT, ESR, transfusion samples (storage for later use in
patients requiring blood transfusions)
 Biochemical: Urea and electrolytes (U+Es), Ca, Mg, phosphate, etc
 Cytological: FBE
 Note Venesection: removal of blood as treatment of certain diseases

Site of Venepuncture
 SITE: Selecting a suitable site and vein for venepuncture should include an assessment of:
 Age of the patient
 Condition of the veins (location, size) – see below
 Patient’s condition
 Patient preference / dominant hand
 Damage to veins from previous venepuncture
 First preference veins: large, visible, palpable, bouncy veins on non-dominant arm which refill when
released, fixed to surrounding
 VEIN: Place index finger over the vein, press lightly and release. Assess the elasticity and rebound filling (sense
of touch more important than vision)

Contraindications:
Veins and sites to avoid whenever possible include:
 Inflamed, bruised or painful veins
 Broken skin, Cellulitis or Phlebitis at site
 Hard, cord-like, fibrosed or thrombosed veins
 Sclerosed veins ‐ these feel hard and bumpy
 Veins in the lower extremities e.g. the feet, due to risk of embolism and thombophlebitis
 Very small and non-palpable veins
 Veins which have been repeatedly used
 Venous obstruction and lymphangitis of the extremity
 Administration of intravenous fluid distal to the proposed site:
 If this is the only possible site: Cease IV infusion, wait 5-10 mins, conduct venepuncture distal to
cannulation site, ensure results are not diluted.
 Limb being preserved for vascular surgery
 Extremity on same side as a mastectomy
 If patient has had a double mastectomy, DO NOT take blood from the arms!
 Arterio‐venous fistula
 Care in patients with a known coagulopathy (relative contraindication)

Equipment (have enough for 2 attempts):

1. Gloves (non‐sterile)
2. Protective eye wear
3. Sharps disposal container
4. Kidney dish
5. Under pad (aka ‘bluey’)
6. Tourniquet
7. Skin Prep ‐ Alcohol swab (soap and water skin prep if testing for blood alcohol levels)
8. Vacutainer set and/or butterfly needle or needle and syringe
9. Appropriate blood collection tubes
10. Cotton balls
11. Tape
 12. Pathology request slip labelled with patient identification stickers
13. Plastic specimen bag

Introduction / Communication / Consent

 Perform hand hygiene
 Introduce yourself
 Confirm the correct patient
 ask name, DOB and UR number, check this matches the request form
 Obtain informed consent
 Rationale / indication
 Exposure: Between elbow and wrist
 Procedure: insertion of a needle to draw blood
 Discomfort, risks and complications: minor (pain, bruising, skin infection) more serious (blood clot,
nerve injury and sepsis)
 Importance of proceeding
 Ask if they understand, have any concerns, any questions
 Gain consent
 Ask if the patient has any allergies (latex, plasters, apparatus),
 Ask if on any blood thinning medications (e.g. warfarin, aspirin, etc)
 Ask if previously any adverse reactions or any difficulties with previous venepunctures (e.g. fainting)
 Ask if they’ve had any surgeries on this arm/side of chest

Procedure:
 Collect equipment in a kidney dish (you have already performed hand hygiene and can access sterile stock)
 Check the request slip to determine which blood tubes are necessary (check tube information found in
all clinical areas if necessary).
 Where venepuncture is anticipated to be difficult, a 21G needle and 10 or 20mL syringe may be used
 Ensure the sharps bin is within arm’s reach.
 Put on PPE (glasses +/- gown)
 Wash hands using an antiseptic soap solution and water
 Position the patient – ensure the patient is comfortable in a seated or reclined position with arm at or below
heart level
 If history of fainting, perform supine (lie them down)
 Topical subcutaneous anaesthetic is not recommended but may be used for patients with anxiety
 Place a bluey under the arm
 Select appropriate vein/site for venepuncture
 Consider handedness; avoid:, legs, previous IV, bruises
 Absolute contraindications: fistula, mastectomy, skin issues, infections, burns damaged veins
 Feel vein: it should feel round, firm, bouncy, elastic and have rebound filling
 Apply the tourniquet 10cm above the chosen site
 Tighten to prevent venous return. You should be able to slip 1 finger
under the tourniquet. Do not occlude arterial circulation! If a vein is very mobile or skin
 Clean skin with an alcohol swab. Allow 30s to dry! tissue is frail, a 21‐gauge
 Prepare vacuatainer system butterfly needle will assist
with needle stability
 Remove the needle cap and place needle into the holder
 In bacterial bottles, disinfect bung (i.e. the rubber stopper on top of
bottle)
 Fix the vein: place the thumb parallel to the vein; draw the skin taut immediately
below (distally) to the site
 Warn the patient of a sharp scratch
 Insert the needle bevel-up at a 15º angle directly in line with the
course of the vein (See Figure 2).
 Only 2 puncture attempts should be undertaken, if unsuccessful request
assistance (state that you have made two failed attempts and would then
request assistance)
 Insert the blood tube into the Vacutainer® holder and allow filling until the vacuum is exhausted. Repeat for
each blood tube required (the tourniquet helps encourage blood flow)
 Loosen the tourniquet
 Place a cotton ball over the needle insertion site and gently remove the needle.
 Dispose immediately, NEVER recap a needle.
 Apply pressure over the venepuncture site until bleeding ceases (usually 1‐
2 minutes). You may ask the patient to apply firm pressure if they are able
 Apply cotton ball/tape.
 Invert the tubes to ensure blood mixes with heparin
 Label the tubes and fill out the pathology request form
 All blood tubes must be labelled at the patient’s bedside
 Full name, DOB and UR are minimum on bottle labels
 Document the date and time on the pathology request and sign your name
 Provide contact number in case of positive culture
 Put the specimens in the plastic specimen bag with the request form in the front pocket of the bag.
Specimens are sent to the pathology laboratory.
 Make sure patient is feeling alright: in pain, anxious or light headed?
 Wash hands

Complications
 Pain
 Haematoma  loosen tourniquet, remove needle, apply pressure
 Syncope/fainting
 Local irritation
 Infection (local cellulitis or infections)
 Injury to vessels, nerves, ligaments or tendons
 Thrombosis (blood clot)
 Needle stick injury – Hep B and C, HIV, HTLV1, syphilis  flush with water, post-exposure prophylaxis
 Haemolysis of blood in tube
 may affect results e.g. potassium
 Inadequate amount of blood to fill tubes  use paediatric tubes in difficult venepuncture
 Prolonged tourniquet
 Significant increases can be found in total protein, aspartate aminotransferase (AST), total lipids,
cholesterol & iron.
 Affects packed cell volume and other cellular elements

Filling Order:
 Blood tubes must be filled in the following order:
 No additive tubes (eg. Blood cultures)
• Aerobic and anaerobic bottles – need to
sample in both
• Aerobic is followed by anaerobic
 Serum tubes (without gel- citrate and ACD)
 Serum tubes (with gel)
 Coagulation tubes (exact amount stipulated on tube
is required)
 Tubes with other additives (Heparin, EDTA, Glucose,
ESR)
• ethylenediaminetetra-acetic acid (EDTA)
contains K+

Volume required on collection

 Volume
 Pediatrics: 1-5 mL (1-5 mL per bottle)
 Adults: 16-20 mL (8-10 mL per bottle)
 Minimum Volume
  Pediatrics: 0.5 mL per bottle
 Adults: 5 mL per bottle

Reporting
 Positive results may be reported by phone
 Antibiotic cover until specific sensitivity is found.
 Protocols

Troubleshooting
 Can’t feel a distended vein
 A) Ask the patient to clench and unclench a fist a few times and/or B) Place a covered heat pack on the
venepuncture site or place the arm or hand in warm water for 5‐10 minutes
 No blood flows into blood tube
 Confirm needle in correct position
 Advanced needle forward
 Needle is advanced through the vein wall
 Needle needs to be pulled back into vein
 Bevel of the needle is at an incorrect angle
 Angle of the needle needs to be adjusted
 The vein has collapsed
 Slightly tighten tourniquet and ask the patient to gently clench and unclench the fist on that side.
 Haematoma formation
 A hematoma forms under the skin adjacent to the puncture site
 Release the tourniquet immediately and withdraw the needle. Apply firm pressure.
Procedure – Injections
From Student Guidelines

Indications
 No oral form of drug available (vaccinations)
 Faster onset of action
 Higher doses tolerated systemically
 Patient is ‘nil orally’
 Medications altered during ingestion i.e. insulin
 Medications needed for steady or long-term infusion

Contraindications
 Allergies
 Issue with patient or medication confirmation
 Expired medication
 Patient declines

Equipment
1. Gloves 6. Syringe
2. Kidney dish 7. Medication
3. Sharps container 8. Injecting needle
4. Alcohol swab 9. Cotton wool
5. Drawing up needle 10. Medication chart

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient
 ask name, DOB and UR number, check this matches the request form
 Consent
 Have they had this medication or an injection before? Were there any issues? (fainting?)
 Involves: injection of a needle into the arm, buttocks or leg (IM); fat around body (SC)
 Exposure: depends on injection site: buttocks or thigh, belly or arm, etc
 Complications: pain, bruising, arm feeling heavy, local infection, (minor), medication error, nerve
or vessel damage, allergic reaction or more serious infection (major)
 Indications and importance of proceeding:
 Ask if they understand, have any concerns, any questions
 Gain consent
 Offer a chaperone
 Ensure patient privacy
 Ask if the patient has any allergies (medications, anaesthetic, latex, alcohol, tape)
 Ask if the patient has had this medication or an injection before
 Ask the patient which arm is dominant
 Comment that you would need another member of staff to confirm the procedure
 Before a medical student administers ANY drug by ANY route, it must be checked by another
member of staff and delivered only under the direct supervision of a staff member.

Select the Injection Type

 The site for the injection depends on the medication type and the amount to be injected
 The only difference is size of syringe, gauge and length of needle used to deliver different amounts
Procedure:
 Patient preparation: pitting comfortably
 Collect equipment
 Confirm patient (with another member of staff) again
 Patient’s name, DOB and UR number on wrist
 Allergies
 Confirm medication (with another member of staff)
 Right patient
 Right drug
 Right dose drawn
 Right route
 Right time
 Don gloves
 Draw up the medication

A) Intramuscular
 2-5mls, 23G-25G long 25mm needle
 Depends on muscle bulk, age and site, choose smallest possibl
 If 25G inject very slowly
 Delivers: Vaccines, analgesia, adrenaline, anti-emetics, antibiotics, antipsychotics (rapid systemic action,
large drug doses)
 Sites:
 Deltoid (2 fingers below acromion, centre of arm). Hep B, tetanus (vaccines)
 Ventrogluteal (index on ASIS, middle on iliac crest, between v’s of fingers)
 Dorsogluteal (superior-lateral quadrant of buttocks) safer than gluteal
 Vastus lateralis (anterolateral thigh, hand’s breadth down from greater trochanter and a hand’s
breadth from the knee): preferred for children <12months as larger than the arm
 Deltoid and ventrogluteal sites are the preferred sites for adults.
 Deltoid: good for bedbound patients (better circulation) and small injections
 Gluteal: good for thin patients, patients with muscle wasting
 Volumes
 Up to 5mls in the thigh (average adult)
 2mls in the thigh (small adult or child)
 Up to 2mls in the arm
 Procedure
 The limb should be positioned to rest the specific muscle. Ask the patient to RELAX
 Assess the thickness of the subcutaneous layer
 Pull the skin to flatten the subcutaneous layer (also prevents back-leak of medication)
 Insert needle at 90° (if patient or muscle is small, grasp the muscle and inject at 45°)
 Aspirate to check for blood. If you aspirate blood, remove and get a new syringe of medication and
a new needle
 SLOWLY inject medication over 5 seconds. There is not a lot of pain when you insert the needle
into the muscles but there will be pain from tissue distension as you inject.

B) Subcutaneous
 Less than 1ml, 25G shorter 16mm needle
 Delivers: Insulin, heparin, clexane (low molecular weight heparin) and some immunisations. (for frequent
injections and slow, controlled absorption)
 Procedure:
 Pinch a wad of skin at a fatty site
 Place needle on skin for 3 seconds at 45°-90°
 Push needle through skin
 Release pinched skin
 Hold barrel with dominant hand and aspirate needle to check for blood
  If you aspirate blood, remove and get a new syringe of medication and a new needle
 Inject medication

C) Intradermal
 Less than 0.1mls, 25G shorter 16mm needle
 Delivers: allergy testing, tuberculin testing, or local anaesthetics.
 Procedure:
 Use an alcohol swab to cleanse the skin. This is not necessary if the skin is clean
 Hold skin taught with index and thumb of non-dominant hand
 Insert needle bevel up at 10-15°
 Bevel should only just be in skin, no further
 No need to aspirate (there are no significant blood vessels in the area)
 Inject until bleb/wheel appears

Completion and Documentation

 Apply pressure with cotton wool
 Withdraw needle
 Do not touch or massage the site (this may increase systemic absorption).
 Perform hand hygeine
 Inform the patient the procedure is complete
 Ensure the patient feels well and stays sitting for a period of time
 Educate the patient: stay sitting, inform if feeling unwell, feeling pain or unexpected reactions
 Fill out the medication on the chart:
 What medication was given
 Dose given
 Route delivered
 Time given
 Sign and print your name.
 Document in the medical history all of the above

Complications
 Medication error  Ecchymosis (bruising – esp with
 Pain anticoagulants)
 Local irritation  Injury to nerves (esp. sciatic) and vessels
 Infection (local and systemic)  Scar tissue (esp in diabetics)
 Haematoma  Anaphylaxis/allergic reaction
Procedure – ABGs
From Student Guidelines and two videos on DSO

Indications
 Establish changes in acid-base homeostasis
 To diagnose acidosis or alkalosis
 Suspicion of hypoxemia and hyper(hypo)capnia
 Establish severity of condition e.g. respiratory failure, metabolic acidosis in sepsis
 Diagnosis e.g. respiratory failure
 Manage ICU patients and guide therapy (e.g. o2 administration, ventilation, alkali treatment)
 Monitor patients during cardiopulmonary surgery, cardiopulmonary exercise testing or sleep
studies
 Determine prognosis of critically ill patients

Contraindications
 Bleeding tendency e.g. coagulation  AV fistula, synthetic graft (femoral
therapy artery)
 Overlying infection or burn at site  Same side as mastectomy
 Absent collateral circulation (Allen’s test)  Severe atherosclerosis at site
 Reynaud’s disease

Equipment
1. Gloves 7. Pre-package ABG syringe with heparin
2. Gown ball, a 22G needle and cap for transport
3. Protective eye wear (face shield, glasses) 8. 2 sterile gauze swabs / cotton wool
4. Specimen bag with ice (gives 1 hr for 9. Tape
reading) 10. Patient’s label
5. Sharps bin 11. Patient’s request slip
6. Antiseptic swab

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient
 ask name, DOB and UR number, check this matches the request form
 Consent
 Indications
 Involves: taking blood sample from the wrist to access respiratory status and acid-base
balance
 Complications: painful, bleeding and bruising (minor), more serious like nerve damage,
infection of the blood or clot (emboli, major)
 Importance of proceeding
 Ask if they understand, have any concerns or questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain, or is allergic to any tapes or plasters
 Ask if the patient has any allergies (latex, alcohol, tape, plasters, local anaesthetics),
 Ask if on any blood thinning medications (e.g. warfarin, aspirin, etc)
 Ask if previously any adverse reactions or any difficulties with previous blood taking (e.g. fainting)
  Ask if they’ve had any surgeries on this arm/side of chest
Procedure
 Collect equipment (hands have been wasted
 Prepare to test ABGs - either:
 Have transport a bag of ice ready, or
 Be aware of the location of the blood gas machine
 Before putting on gloves: Test for collateral (ulnar) blood supply with Allen’s Test:
 Arteries commonly sampled: Radialbrachialfemoral
 Elevate hand and make a fist for 30 seconds
 Apply pressure over the ulnar and radial arteries
 Open hand whilst still elevated. The hand should be pale.
 Release ulnar pressure. Colour should return to the hand within in 7 seconds
 This means the ulnar artery is patent and it is safe to cannulate the radial artery
 If test is negative: test other hand, then brachial artery is used
 Ensure sharps bin is within arm’s reach
 Palpate the pulse
 Put on PPE (including gloves)
 Patient positioning:
 With the palm facing up, the patient’s hand should be bent back slightly (or a small rolled
towel placed under the wrist) to bring the radial artery to the surface.
 Overextending the wrist should be avoided as this might occlude the pulse.
 Ensure the patient is comfortable
 Cleanse the skin with the alcohol swab.
 Palpate for the pulse with your index and middle fingers being careful not to touch the site of
injection.
 After locating the strongest pulse sensation, slightly anchor the artery with your index and middle
fingers.
 Hold the syringe at 45° angle or less (how you hold a pencil or dart) with the bevel of the needle
facing up
 Insert the needle (bevel up) under the skin surface and advance slowly until you see a flash of
blood
 Stop and maintain this position until you have collected 2 to 4cc of blood. You should not need to
aspirate; the arterial pressure will ensure auto-filling of the syringe.
 Trouble shooting
 Only in the event that you are using a small gauge needle (e.g. 25 gauge),or the patient is
hypotensive, should you aspirate the syringe.
 If you push the needle too far: withdraw it slowly until blood flows into the syringe
 If you fail, try to re‐direct the needle without coming out of the skin.
 When complete, withdraw the needle and apply firm pressure with the gauze for 5mins
 Check the site for bleeding, oozing, or seepage of blood. If present, apply pressure until all
bleeding has stooped.
 Long compression times are necessary for patients on anticoagulation therapy or with
bleeding disorders
 You can ask the patient to do this, if the importance of firm pressure is stressed
 You may need to apply a cotton ball with tape to the puncture site (only after you have
compressed the site for 5 minutes and ensured bleeding has stopped.)
 Remove the needle from the syringe. Do NOT recap the needle. Place the needle in the sharps bin
 If there is an air cube present, put the needle into it to expel any air and thendetach the
needle and cube as a unit.
 Hold the syringe upright and gently tap the syringe. Expel any air bubbles from the blood gas
syringe (they may alter the blood gas results)
  Cap the syringe
 Place the syringe in the bag of ice
 Fill out the pathology request form
 Full name, DOB and UR are minimum on bottle labels
 Document the date and time on the pathology request and sign your name
 Provide contact number for results
 Put the specimens in the plastic specimen bag with the request
 Attach the laboratory request slip to the bag, and have the sample transported to the laboratory
immediately
 If you are going to analyse the sample, you should do so as soon as possible.
 The results are usually available for interpretation within 5 minutes

Complications
 Painful
 Bleeding (haematoma)
 Bruising
 Arterial occlusion – thrombus /dissection
 Infection (local or septic)
 Embolism
 Nerve damage
Procedure - Nebuliser, Oximetry and Oxygen
To Do!
Procedure - Asthma Education
Explanation of Asthma
 Asthma results from hypersensitivity of the lungs to harmless triggers in the air, such as allergens, pollens,
smoke, cold air and many other things.
 Often worse at night or early morning, may be seasonal, and brought on by triggers (allergic & irritant).
 When people who are affected breathe in a trigger, the airways:
 start to spasm (smooth muscle constriction)
 become inflamed and swell (oedema of bronchial mucosa)
 and start secreting mucus (secretions of mucous glands)
 All of these effects cause the airways to become narrow, making it difficult to get air in and out. This is what
we call an asthma attack or an acute episode
 Its characterised by cough, wheeze, and difficulty breathing (only 1 or all 3).
 However, asthma is considered a reversible obstructive airway disease, because with the proper prevention
and treatment, we can relax the airways and

How Asthma is Managed

 Asthma is managed with two types of medications
 Preventers: these are taken every day to treat the inflammation, swelling and mucus
 Relievers: are taken when you’re having an asthma attack o quickly reverse the spasming.
 Their correct use makes a big difference to how effective the medications are.
 Be sure to also check the use-by date and to store them in a cool, dry area.
 1) ‘Reliever’ - metered dose inhaler (MDI) (Salbutamol, Ventolin)
 Shake the canister
 Take the lid off
 Place it in the mouth without biting it, make a good seal
 Try to breathe mouth to empty the lungs
 Begin taking a breath in and as you do, press the top and continue to breathe in deeply
 Hold your breath for 10 seconds, and then breathe out gently
 DEMONSTRATE
 Storage and care: need to clean them once a week by taking the metal canister, separate the cap and
the plastic holder and run them under water.
 2) ‘Reliever’ medication (Turbuhaler)
 Remove the protective cover
 First check how many doses are left on the side
 You need to load it and the device must be upright while you do this. Turn the screw forward and
back to load the chamber with medication. You will hear a click
 Again, empty the lungs and keeping the devise upright you need to breathe in hard and fast to deliver
the medication to the lungs
 Hold your breath for 10 seconds, and then breathe out gently
 DEMONSTRATE
 Storage and care: need to wipe the mouthpiece with a tissue after each use.
 Pros and Cons of each reliever:
 The first requires coordination and there’s no indicator of doses which are left, so you need to keep
track of how often you’re using it.
 The second requires you to breathe in hard, which can be difficult if you’re having an attack.
 1) Preventer medication – Accuhaler
 Has both medications combined into one (the oral steroids and the long acting B-agonist)
 Check how many doses are left. Put your thumb in the slot and pull it back to open it.
 Load the medication into the device by pulling the lever back
 Again, empty your lungs ans suck in the medication, hold your breathe for 10 seconds and then
breathe normally.
 Once finished, wipe with a tissue and close.
 Important to wash your mouth out after using any inhalers with the steroids in them as this can cause oral
thrush. What we recommend is that you use it before brushing your teeth.
Explain the Asthma Management Plan
 Explain the need for action plan and its constant review
 Explain the idea of early treatment preventing deterioration e.g. before exercise
 Signs of deterioration – acute symptoms, interval symptoms, changes in peak flow
 Management plan includes maintenance
 Medication instructions (below)
 Emergency treatment and when to call ambulance
 Use 12 doses of the reliever, one puff at a time.
 The same or more effective than the nebuliser
 If that doesn’t relieve it, call an ambulance.

Explain the use of a spacer

 Reasons for use
 The use of a spacer is recommended because it means that you don’t need to coordinate the breath
with the delivery of medication.
 Most importantly, it ensures more of the medication reaches deep into the lungs instead of getting
stuck in the mouth.
 Use a valved spacer for adults and older children, a spacer with an attached face-mask or mouthpiece for
children aged 2–4 years and a large-volume spacer for children aged 5 years and over.

 There is a small volume spacer and a larger one.
 Instructions
 Screw the two pieces together if a large spacer
 Remember to shake the inhaler first.
 Take the cap off one end and insert the inhaler into the other.
 With one spray, take 4 normal breaths. Repeat for additional sprays
 DEMOSNTRATE
 To clean, wash it in warm, soapy water once a month and left it AIR DRY. Don’t use any other cleaning
products or rub it dry. This can cause static which will cause the medication to stick to the sides.

Explain the use of a peak flow meter

 The peak flow meter is a home-use device that is used to measure peak expiratory flow rate (PEFR) i.e. how
fast you can breathe during the first second for foreceful breathing.
 Uses:
 It indicates the degree of airflow obstruction that is occurring, so peak flow will be affected if your
asthma is active or not being well controlled
 The patient can detect when they’re not well, self-monitor their asthma control and know whether a
review of the management plan is needed
 It is not used to diagnose or treat asthma!
 Who should use it
 People with moderate to severe persistent asthma
 When symptoms are intermittent
 Symptoms are related to occupational triggers (i.e. peak flow meter is portable and can be used at
work to detect changes in PEFR)
 The diagnosis is uncertain
 When monitoring treatment response
 Peak flow monitoring is often not recommended for children under 12 years, and should never be
used in children under 7
 Instructions
 Patient should be upright or standing
 Hold the meter from underneath, taking care not to cover the dial
 Put the dial at 0
 Hold the meter straight and horizontal
 Take a deep breath in and make a firm seal around the mouthpiece
 Breathe as hard and fast as you can
  Do this three times and take the best or average of 3 readings
 DEMONSTRATE
 PATIENT TO DEMONSTRATE
 Use an asthma diary to record your daily peak flow meter readings (morning and night), any attacks and
medication use.
 Monitoring (when reccoemnded) is usually done in addition to reviewing asthma symptoms and
frequency of reliever medication use.

 A "normal" peak flow rate is based on a person's age, height, sex and race. A standardized "normal" may be
obtained from a chart comparing the patient with a population without breathing problems.
 Approximation is: PEFR (L/min) = [Height (cm) - 80] x 5:
 Indications for Short-term monitoring (2-8 weeks)
 To help to identify asthma triggers
 To monitor response to a new treatment or a change in dose (up or down)
 To calculate the "trigger point" for a written asthma action plan.
 Indications for Long-term monitoring (daily)
 For people with asthma who have frequent exacerbations (flare-ups)
 For people with moderate to severe asthma who have little warning of exacerbations
 For people with asthma who are anxious or tend to over-treat minor events
 For people with asthma who are ‘poor perceivers' of airway narrowing.
Procedure – Digital Rectal Exam
From Student Guidelines

Indications Contraindications
 Screening for rectal or prostate cancer, or Refer to a specialist when:
prostate enlargement
 Diagnosis of rectal abnormalities
 As part of a complete physical examination
in men
 Patient request a DRE and PSA (discuss first)
 Following an abdominal exam
 Rectal bleeding (e.g. in stool)(haemorrhoids,
cancer)
 Anal discomfort (pain, itching, burning,
stinging, fissures, haemorrhoids)
 Change in bowel function (colorectal
carcinoma, +faecal occult)
 Change in urinary function (BPH – hesitancy,
FUN, poor stream, dribbling)
 Faecal incontinence (anal sphincter tone,
prostate, chronic constipation causing
overflow incontinence)
 Check anal tone (spinal cord compression)
 General symptoms of cancer (LOW, malaise)
 Following a GU/sexual history
 As part of a gynaecological exam in women
 Patient declines examination (absolute)
 Anal fissures present or suspected (painful,
may further open)
 Prolapsed and thrombosed haemorrhoids
(painful)
 Paediatric patients
 Active inflammation of the bowel: CD, UC,
diverticulitis
 Recent surgery, trauma, radiotherapy in the
area
 Immunocompromised (e.g. chemotherapy)
or at risk of increased bleeding
 Recent history of abuse
 Spinal patients: may cause autonomic
dysreflexia
 Recent AMI
 Valvular heart disease, prosthetic valves:
may require antibiotic prophylaxis.
 Latex allergy

Equipment
1. Gloves (2 pairs)
2. Lubricant
3. Bluey
4. Tissues

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number

 Ask if they have any allergies (e.g. to latex)

 Check if the patient needs to empty bowels first
 Ask if he has any pain

Examination
 Patient preparation: left lateral position (on left side, facing wall with knees drawn up towards chest)
 If the patient has difficulty climbing onto the table, examine standing and leaning over the couch
 Put on gloves (ensure fingernails are short)
 Place bluey under patient’s buttocks
 Consistently communicate with the patient about what you’re doing
 Monitor the patient’s responses and consistently ask if you are causing any discomfort
 Use non-dominant hand to lift the patient’s upper (right) buttocks.
 Inspect the anus and perianal area
 Thrombosed external haemorrhoids (piles)
 Skin Tags
  Rectal Prolapse
 Anal Fissure
 Fistula-in-ano
 Condylomata Acuminata (anal warts)
 Carcinoma of the anus
 Pruritus ani
 Excoriation
 Ask the patient to bear down to check for:
 Haemorroids
 Prolapse
 Anal incontinence
 Lubricate the tip of your index finger of your dominant hand
 Reassure the patient that they will feel uncomfortable (like they need to pass a bowel movement) but this
is normal and they will not actually pass anything.
 Draw the patient’s right buttock up with the left hand and place the pad of the right index finger against the
anus, with the finger pointing in the direction of the patient’s front.
 Ask the patient to breathe deeply through their mouth (to assist reflex sphincter relaxation).
 Wait for reflex sphincter relaxation, and gently press on the anus until the anal sphincter gives and gently
insert the finger into the rectum, pointing the finger now in the direction of the patient’s head.
 Do not proceed if insertion is difficult. This may be due merely to apprehension or a tight
sphincter. A tight sphincter can be due to anal stricture, fibrosis of anal muscles and anal
carcinoma. You will cause resistance and severe pain if you force the finger in.
 If due to apprehension, when you feel resistance on advancing your finger, stop moving forward,
hold your finger in place and wait, with the patient breathing slowly, until the sphincter is felt to
relax, then advance.
 If the patient has an anal fissure, the anal sphincter goes into spasm which cannot be overcome by
relaxation, patience or gentleness. Search the anal area for a tear. A DRE can sometimes only be
performed under a general anaesthetic
 Examine the posterior wall: Use the pulp of the index finger to sweep around the rectal wall from 2
(relative to the patient’s spine) clockwise to 10 o’clock at 3 different levels
 The walls of the rectum should be smooth and uninterrupted. Feel for masses (polyps, cancers)
and ulcers.
 Each level feels 1-2cm. This way, the first 7-8cm of rectal wall should be felt.
 Posteriorly, you are able to feel the hollow of the sacrum and the coccyx
 Examination of the anterior wall: clockwise from 10 o’clock (relative to the patient’s spine) to 2 o’clock at 3
different levels. Kneel down if necessary.
 In the male, this is where you will feel the prostate. When you palpate the prostate, the patient
may feel that they are going to pass urine, but reassure them that they will not.
 CONSITENCY: A rubbery, smooth, firm, bi-lobed mass with a groove (median sulcus) running down
the centre.
 MOBILITY: The lobes should be symmetrical and smooth, with no nodules or irregularities.
 SIZE: With age, the prostate becomes firmer, increases in size, and loses the groove.
 In the female, the cervix can usually be felt through the anterior rectal wall, feeling like a smooth
lump
 Finally, return your hand to the initial position and ask the patient to bear down so that, when you sweep
with your examining finger, you can feel an extra centimetre of the rectal walls
 Note any masses or ulcers
 Asses the consistency, mobility and size of the prostate (or cervix)
 Note the consistency of the rectal contents (It is not uncommon to feel faeces in the rectum)
 Ask the patient to clench your finger to assess external sphincter tone
 The normal muscle tone should grip the finger firmly.
 Relaxed or weakened anal sphincter may be due to torn or lacerated anal muscles or atony of the
muscles from neurological lesions.
 Ask the patient to relax and breathe deeply.
 Remove the finger
  Look at the glove for finger for colour, blood, mucus or pus. Save it for faecal occult blood testing if
indicated.
 The gland should be bi-lobed, soft and the surface should be smooth.
 If pathological, the gland can be enlarged, firm, nodular or craggy.

Investigations
 PSA (in combination with DRE can indicate the risk of prostate cancer) – needs to be done before the DRE
 Faecal occult blood test
 Referral to urologist or gastroenterologist (esp if a mass is felt)

Patient Education


Complications
 Patient feels uncomfortable or assaulted (legal ramifications) due to inadequate information, poor consent
process, or perceived unnecessary or vigorous contact – communicate at all times!
 Exacerbation of pain or discomfort with the procedure or with palpation
 Anal trauma
 Re-opening of an anal fissure
 Tenesmus (urge to defacate)
 Considerations for this sensitive area

Abnormal Findings
 Sphincter: Loss of tone, patulous: ?Cauda equina syndrome
 Contents: Hard, impacted, foreign body present
 Rectal wall: Pelvic masses in women
 Mucous membrane: irregular, mass present (cancer)
 Prostate (normally 2.5cm long)
 Smooth, large , firm and non-tender (Benign enlargement)
 Hard, irregular nodule or fixed hard mass (Cancer, chronic prostatitis)
 Large, boggy and tender (Acute prostatitis)
 Stools:
 Bloody: (Haemorrhoids, bleeding rectal lesion)
 Black: (Upper GI bleed, iron, some antacids)
Procedure - Urinalysis
From Student Guidelines and tute prep

Indications  Pregnancy
 Genitourinary symptoms  As part of a general examination
 Renal symptoms  Screening or diagnosis of pathology
 Gastrointestinal history
 Diabetes history Contraindications: none

Equipment
1. Gloves
2. Yellow-top sterile urinary pathology specimen container
3. Urinalysis dipstick strip
4. Watch
5. If necessary:
 Urine pregnancy test (beta HCG)

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number
 Consent
 Indication: identify markers in the urine of infection or disease, for screening or to aid diagnosis
 Involves: taking mid-stream urine sample and bringing it back to me to be tested here.
 Exposure: go to a cubicle to produce the sample in a container in private
 Complications: none, can contaminate the sample and need to repeat it.
 Importance of proceeding and reassurance
 Ask if they understand, have any concerns or questions
 Gain consent – if performing pregnancy test, specifically request consent
 Ask if they have any pain

Procedure
 Check the strips you are about to test for their use-by date and the correct colour for the untested strip
 Strips left exposed to the atmosphere may have discoloured and be inaccurate.
 Check the time different parts of the strip are to be red (usually 30s and 1min)
 Cleanse the area around the urinary opening with clean water
 Instruct the patient on sample collection (preferably first specimen in the morning and mid-stream in case
you need to send the specimen off for further testing):
 Midstream: Clean the tip of the penis or vulval area with water or sterile towelette. Retract the foreskin or part
the labia with your fingers and hold the open sterile container with the other. Do not touch inside the jar. Let
the first part of the urine stream go into the toilet. Collect the middle part of the stream in the sterile jar.
Return the sample for testing immediately or put it in the fridge if there will be a delay.
 Put on gloves
 Assess the urine’s COLOUR, TRANSPARANCY and SMELL
 Normal fresh urine is clear, pale to dark yellow or amber in colour and clear.
 Normally the odour is ‘urinoid’.
 Presence of absence of any visible strands, crystals, blood clots
 Note the time
 Remove a dipstick strip, being sure to re-seal the jar
 Dip the strip in to the urine
 If performing a beta HCG, follow the directions for the particular test kit you are using (times and
procedures vary from kit to kit)
 At the appropriate time, compare the colour change on each segment of the strip to the colour chart
provided (usually on the side of the container)
  Different parts of the strip are read at different times (some at 30sec, some at 1 minute)
 The dipstick should be ‘read’ at the allotted times – often if the stick is left for an extended period
of time, some of the test blocks will be positive. This is not accurate after the designated time.
 At the appropriate time, read the urine BHCG test.
 Re-seal the urine sample
 Dispose of the dipstick
 Document findings and interpret results:
 pH: Low (acidic) = acidosis, high protein diet, acidic fruits, high (alkaline) = alkalosis, vegetarian diet
 Specific gravity (urine concentration): Low = hydration, inability to concentrate (generalised renal
impairment or nephrogenic diabetes insipidus); High: dehydration
 Protein: nephrotic syndrome, glomerular nephritis, renovascular, glomerular or tubulo-interstitial
renal disease, overflow of abnormal proteins in diseases such as multiple myeloma.
 Blood: menstrual, UTI, nephritic syndrome, renal stones, renal carcinoma, glomerular nephritis
 Nitrites: bacteria (a negative test doesn’t rule out UTI because not all produce nitrites and some
take time to develop)
 Leukocytes(pyuria): whole or lysed WBCs (if negative, infection is unlikely, however patients can still
have a UTI without pyuria), contamination (vagina, foreski), URTI or pneumonia,
 Glucose: diabetes mellitus,
 Ketones: DKA or starvation
 Bile, bilirubin and urobilinogen: conjugated bilirubin = liver disease, bile duct obstruction, high
urobilinogen = haemolytic disease or hepatocellular disease

Investigations
 Urine microscopy, culture and sensitivity (MCS) if UTI suspected to confirm
 Determines the responsible organism and its antibiotic sensitivities, which is important if the infection does not
respond to treatment

Complications
 False-positive readings
Procedure – Nasogastric Tube
From Student Guidelines, Tute Prep Answers and Associated Video

Indications
 To introduce fluids, nutritional support and medication administration, radioactive materials or
activated charcoal into the stomach (cases of anorexia, dehydration in infants, drug overdose, etc)
 To decompress the gastrointestinal tract (GIT), by aspiration of gastric contents (fluid, air, blood).
 E.g. Bowel obstruction and associated vomiting
 E.g. Ileus (common after surgery) and associated vomiting
 E.g. Severe pancreatitis and associated vomiting and ileus
 To assist in the clinical diagnosis through analysis of substances found in gastric contents.
 To removal gastric contents to facilitate endoscopic visualisation of the mucosa

Contraindications
 Head trauma, maxillofacial injury, facial traumaor anterior fossa skull fracture. There is the risk of
intracranial penetration by inserting a NG tube blindly through the nose. This has the potential of
passing through the cribriform plate, thus causing penetration of the brain by the NGT.
 A nostril with any type of obstruction (previous broken nose with limited space to pass NGT), polyps
etc.
 History of oesophageal stricture, oesophageal varices, alkali ingestion, as these pose a risk of
oesophageal perforation.
 Comatose patients and unconscious patients have the potential of vomiting during NGT insertion.
Intubation/airway protection is the first priority and the airway must be secured prior to NGT
insertion. This is due to the risk of aspiration if NGT is inserted, triggering gag reflex and vomiting,
which can result in aspiration if the patient is unable to protect their airway (loss of coughing reflex).
 Caution should be utilized when passing a NG tube in a patient with suspected cervical spine injury.
Manual stabilization of the head is required during the procedure to prevent further Cx injury.
Excessive manipulation or movement by the patient during placement including coughing or gagging
may potentiate cervical injury.
 Orogastric tubes are not as well tolerated by conscious patients but are associated with less
complications, for example, sinusitis and nasal erosion and are suitable for intubated or unconscious
patients

Equipment
1. Gloves 9. Cup of water with straw
2. Gown 10. Catheter-tip (Toomey) syringe
3. Protective eye wear (face shield or glasses) 11. Stethoscope
4. Bluey 12. pH stick
5. Kidney dish/basin 13. Non-allergenic tape
6. Topical anaesthetic 14. Safety pin
7. NG tube (appropriate size) 15. Drainage bag if required
8. Water soluble lubricant

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient
 ask name, DOB and UR number, check this matches the request form
 Consent
 Involves: insertion of a tube through the nose, throat and into the stomach
 Exposure: abdomen to have a listen to the chest
 Complications: uncomfortable, gagging, can insert it into the lungs
  Indications and importance of proceeding
 Ask if they understand, have any concerns, any questions
 Gain consent
 Offer a chaperone
 Ask if the patient has any pain

Procedure:
 Ensure correct patient, privacy and that informed consent has been obtained
 Collect equipment (hands have been washed, can access sterile stock)
 Patient preparation:
 If patient awake: sit patient in an upright position
 If unconscious: intubate first and lie patient in the left lying position if possible
 Ask patient if they’ve ever had any nasal polyps or issues with their oesophagus
 Determine which nostril should be used
 Inspect the nostrils for polyps
 Have the patient blow through one nostril at a time to assess their patency
 Place bluey on patient’s chest
 Provide the patient with a basin/kidney dish to minimise contact with aspirated gastric content.
 Apply topic anaesthetic to the nasal cavity and/or the oral cavity
 Determine NGT length
 First, measure distance from the tip of the nose to the lobe of the ear
 From the lobe of the ear, measure to the xiphisternum.
 Mark the summative length with a pen or piece of tape.
 Insert the NG tube
 Position patient upright in the sniffing position – neck flexed, head extended
 Lubricate the first 5 cm of the NG tube liberally.
 Gently insert tube along floor of the nose in a posterior direction parallel to the floor
 When it is evident that the NGT is in the oropharynx (reached the back of the throat) the
patient will start to gag.
 At this time encourage the patient to facilitate the tube passage by swallowing. Sips of water
will assist in swallowing (if they can’t drink, ask patient to mimic the action of swallowing).
 Continue to insert tube, trying to coordinate tube advancement with swallowing
 Once the tube is past the larynx, guide it to the predetermined length.
 Ensure that the patient is not in respiratory distress
 Ask if the patient is okay, can they breath and speak. If they cannot, remove the tube immediately
 Confirm the tube is in the correct position with the following techniques
 1) Push 30cc/ml of air down the NGT whilst listening over epigastrium with a stethoscope. If
successful, you should be able to hear the air entering the stomach with “a whooshing”
sound.
 2) Use the syringe to then aspirate gastric content. Test it on litmus paper (acidic)
 3) If unsure, place the open end of the NGT in to a cup of water. Persistent bubbling may
indicate the NGT has passed through the larynx.
 4) If any substances will be added, order a chest XRay to confirm position. The radio-opaque
tip of the NGT should travel below and sit below the diaphragm in the stomach area.
 If unable to positively confirm the NGT has been placed in the correct position  remove and
reattempt
 Once correct position confirmed, secure the NGT
 Ensure the skin of the nose is clean.
 Take a strip of tape and tear it horizontally for one half of its length
 Placing the fill end of tape from the bridge to the tip of the nose and the two tails wrapped in
opposite directions around the tube itself.
 Tincture of benzoin can help keep the tapes secure to the nose if patient sweats a lot.
 Clamp or connect the NG tube as desired.
  To deter the NG tube from dangling and possible dislodgment:
 Curve and tape the tube to the patient’s cheek to prevent unnecessary tugging on the nostrils.
Attach the tube to the patient’s gown. (Do not tape to the patient’s forehead as this will put
pressure on the nares.)
 Wrap a small piece of tape around the tube near the connection creating a tab.
 Loop a rubber band in a slip knot near the connection and pin to the patient’s gown.
 Give clear instructions written and verbal about suction, aspiration and recording of observations

Complications
 Nasal irritation, sinusitis, epistaxis, rhinorrhoea, sore throat, skin erosion or oesophagotracheal fistula.
 Oesophageal perforation, trachea-oesophageal fistula
 Tracheal/bronchial/airway intubation  remove tube immediately
 Respiratory difficulty and distress
 Hypoxia, cyanosis, or respiratory arrest due to accidental tracheal intubation.
 Aspiration pneumonia secondary to vomiting, aspiration or introduction of agents into lungs
 Pneumothorax
 Note: These may well be less marked if the patient has decreased conscious state as they may
not cough in response to tracheal intubation.
 Intracranial placement e.g. through cribriform plate (look for change in consciousness, neurological
signs)
Procedure - Pelvic Exam and Pap Smear
From Student Guidelines, videos on DSO

Indications Contraindications
 Pap smear or other swab Most require consideration of the patient’s context
 Pregnancy and whether to perform carefully or to not perform
 GU symptoms  Patient declines examination (absolute)
 STI symptoms (dysuria, discharge)  Vaginismus
 Following a sexual history  Female circumcision (some forms)
 Screening in women who are sexual active or  Pain (relative)
who have a new sexual partner  Paediatric case
 Past sexual abuse

Equipment
1. Gloves  Pencil
 Use nitrile gloves if allergic to latex  Spatula
2. Bluey  Cytobrush
3. Small pillow (to elevate pelvis)  Slide
4. Light  Spray
5. Lubricant  Container
6. Speculum (of correct size)  Liquid preparation vial (Thinprep)
7. Sponge older forceps 11. Tissues
8. Gauze squares 12. Sanitary pad (if bleeding occurs)
9. Swabs (if necessary)
10. Smear test (if necessary)

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient - ask name, DOB and UR number

 Ask if they have any allergies (e.g. to latex)

 Check if the patient would like to empty her bladder first
 Ask if she has any pain

Examination
 Patient preparation: Supine at 30° with frog legs (pull heels together towards buttocks and flop knees
out)
 This allows the examiner to maintain eye contact and relax abdomen
 Alternatively, bend knees with feet 20cm.
 Put on gloves
 Place bluey under patient’s buttocks
 Consistently communicate with the patient about what you’re doing
 Monitor the patient’s responses and consistently ask if you are causing any discomfort

Examination A) Inspection of external genitalia

Labia majora and perineum, separate the labia majora with one hand to inspect the labia minora, vaginal
opening, urethra and clitoris
 Skin lesions (Herpes), Bartholian cysts ( idiopathic, gonococcal infection), discharge from urethra
or vagina
 Ask the patient to bear down / strain to asses for weakness or damage to pelvic floor muscular tone
 Prolapse of bladder through anterior vaginal wall  cystocele
 Prolapse of rectum through posterior vaginal wall rectocele
  If there is a cystocele or rectocele is present, consider using a Sims speculum
 Ask the patient to cough to asses for prolapse and leakage of urine
 Leakage of urine  stress incontinence

Examination B) Speculum Examination of Internal genitalia

(if required, this is when the smear test and any swabs are taken).
 Test the speculum: ensure that it opens, closes and locks easily
 Warm the speculum under a tap (to minimise contraction of muscles due to cold)
 Place a small amount of lubricant on the outside of the blades. Smear it along the blades.
 With the speculum closed but not locked, hold it in your dominant hand
 Use the non-dominant hand to spread the labia apart with the thumb and index
 Pause with the speculum in gentle contact while the patient relaxes the vaginal sphincter.
 Do not force the speculum against the initial reflexive contraction
 Insert the speculum into the vagina in a posterior (sacral) direction.
 This can be done horizontally, vertically or a combination of the two (e.g. 11 to 5 o’clock’),
with the handle facing up, to the left or down.
 Method of insertion depends on the examiner’s preference, the size of the patient and
elevation of the pelvis
 Do not force the speculum against resistance.
 Ask the patient to breathe slowly through their mouth to overcome resistance.
 Advance the speculum along the length of the vaginal canal along the path of least resistance (.e. the
uterus may be retroverted)
 If there is significant resistance or the patient is too uncomfortable, stop and remove the
speculum. Ask whether they wish you to attempt again, or whether it is too uncomfortable/
too difficult and should be deferred
 Warn the patient this may feel uncomfortable as you exert pressure on the vagina.
 Open the speculum by slowly squeezing the handles.
 View the cervix. Manipulate the angle of the speculum by small increments so that the cervix is
completely in view.
 Inspect the appearance of the cervix
 Colour
 Growths
 Bleeding
 Discharge
 Greenish-yellow purulent  trichomonas
 A thick, white, adherent, "cottage cheese-like"  candida infection
 Thin, "fishy smelling" gray discharge  bacterial vaginosis
 Lock the speculum in place using the locking screw bolt.
 Perform any tests or swabs at this point (while hands are free)
 Unlock the bolt, hold the handles down to keep it open and rotate the open speculum to inspect the
vaginal walls.
 To withdraw the speculum, ease the pressure on the handle and allow the blades to close as you
withdraw the speculum. This is probably easiest with the blades vertical
 Be careful not to close the blades over the cervix.

 If you can’t find the cervix with the speculum:

  Tell the patient that you need to alter the examination to find the cervix. Reassure them that
“sometimes a normal cervix can be pointing in a different direction and be difficult to
locate.”
 Look laterally as you carefully withdraw the speculum (having it in too far is a common error)
 Take the speculum out completely, perform a digital examination to locate the cervix
 Title the patient’s pelvis upwards using a pillow or placing their fists under their buttocks
 Consider a longer / different sized speculum, or adjusting the angle.
 If lax vaginal walls are obscuring your view consider using the sponge holder forceps to
retract them. Another GP ‘tip’ is to snip the tip off a condom and cover the speculum with
the condom so that it forms a sheath over the speculum that holds the walls back – this
works well, but must be carefully explained to the patient to avoid any misunderstanding of
the use of a condom during the examination.
 Consider involving a peer or superior. Manipulating the speculum in search of the cervix can
be uncomfortable, and in general, three attempts is probably enough before you consider
calling for help.

Procedure: Pap Smear

 The speculum should still be in place with the cervix visualised
 If the cervix is partially obscured by mucous, wipe this away first using gauze swabs in the sponge
holder forceps. Alternatively use a long, large cotton tip stick.
 Label the glass slide (with a diamond pencil) before obtaining the smear with: the patient’s full name,
DOB, UR number, the date and the doctor’s name.
 Use a diamond pencil on plain glass slides or a pencil on frosted end slides.
 Two specimens must be taken separately
 Using a wooden spatula with a long lip: from the endocervix around the cervical os
 Using a cytobrush: into the cervical os to obtain a cervical specimen from the endocervical
canal.
 ** During pregnancy it is advised you only use the spatula**
 Rotate each brush by 360° to collect cells.
 Smear cells from the wooden spatula moderately thinly on to one half of a single clean, dry glass slide.
Smear cells from the cytobrush on the other half.
 Fix immediately by (Cytospray) spray fixing or immersing in 96% alcohol.
 Shake the can well and hold upright. Spray several times at least 25cm from the slide. Leave
it to dry
 The smears dry within seconds! If this happens before fixation, the specimen will be
substandard for cytological examination.
 If taking 2 smears, it is best to fix the first before obtaining the second.
 If also sending a liquid phase cytology test (liquid cytology), after wiping it on the slide, ‘rinse’ the
spatula and cytobrush in the specific liquid before discarding them.
 Yellow top containers or clear plastic slide carriers are used to transport the slides to the laboratory.

Procedure: Vaginal Swabs

 If swabs are to be taken (eg for Chlamydia/gonorrhoea/vaginosis/herpes) these should be taken after
the Pap smear.
 Confirm that you are using an appropriate swab for the organisms you are checking for.
 Swabs vary from laboratory to laboratory as well as each organism.
 Usually three samples are taken “Triple swabs”
 Gonorrhoea - endocervical swab , roll the swab across a glass slide and insert swab into tube
containing charcoal transport medium.
 Chlamydia – endocervical swab, insert the second plastic swab 1-2 cm into the endocervical
canal, rotate for 5-10 secs, break off swab into chlamydia transport medium with the
urethral swab
 Herpes Simplex Virus - high vaginal swab in "Stuarts medium"
 Vaginal tests for bacterial vaginosis, candidiasis, trichomoniasis and inflammation – sample of
secretions with a cotton swab, running the swab along the left lateral wall of the vagina. Roll the swab
across the glass slide. Insert the swab into a tube containing charcoal transport medium
  Saline microscopy should be performed to look for candidal buds or hyphae (show picture 1), motile
trichomonads , epithelial cells studded with adherent coccobacilli (clue cells suggesting bacterial
vaginosis; show picture 3), and polymorphonuclear cells. (See "Microscopy" above).
 Vaginal culture: microscopic examination and, if necessary, culture for Candida.
 Cervical culture: can assist in detecting trichomonas. Using culture on Diamond's medium or one of
the rapid diagnostic tests for Trichomonas should also be performed if pH is >4.5 and there is purulent
discharge.

Examination C) Bimanual Examination of the Uterus, Ovaries and Tubes and the inguinal lymph nodes
 Stand at the patient’s right side
 Lubricate the index and middle finger of your dominant hand
 Use the finger and thumb of your other non-dominant hand to separate the labia
 Enter with the index and middle finger on a vertical axis, tucking the ring and little fingers into your
palm.
 Keep any pressure posteriorly, as pressure anteriorly on the urethra is very uncomfortable.
 Once you have entered, turn the hand clockwise so that the fingers are facing palm-up on the
horizontal axis.
 Attempt to feel the cervix: With the internal hand, feel the cervix above your fingers and push up on
(”tip”) the cervix. When you push on the cervix, it moves the anteverted uterus (66% of women) and
you can feel it between your hands.
 Once you find it, place your left hand on the patient’s abdomen at the suprapubic region (ensure it’s
not lubricated) and try to feel the uterus tip your external hand.
 You cannot always feel the uterus. It depends on the size of the patient (more difficult in
obese women), the tightness of the abdominal muscles, the mobility of the pelvic organs, the
angle of the uterus (retroverted uteri not felt as easily this way) and the size of the uterus.
 In a non-pregnant woman, it should be the size of a pear.
 If you feel it, it suggests enlargement due to pregnancy or fibrosis.
 To feel a retroverted uterus, slide your fingers behind the cervix so you’re in the posterior
fornix and press the abdominal wall.
 Attempt to feel the adnexae (collective name for ovaries and tubes): move the vaginal fingers into
the right fornix and move the abdominal hand over to the patient’s right iliac fossa. Again, gently try
to tip the ovaries.
 The ovary is not usually felt between the hands unless it is enlarged, or the patient is very
slim.
 Abnormalities in the adnexae: ovarian mass, PCOS, malignancy endometrioma, tubo-
ovarian abscess, fallopian mass (ectopic, hydrosalpinx, fibroma), non-gynaecological
problems (appendix, diverticular abscess)
 Repeat in the left adnexa.
 Remove the hand and \check the glove for the presence of blood or discharge.
 Offer some tissues to the patient so that she can wipe herself
 Check the inguinal lymph nodes.

Investigations
 Pap smear (as above): cells are transferred directly to slide for viewing
 Liquid-based cytology (as above): sample cells are placed in liquid solution for transport to the lab,
whereby they are extracted for cytologic analysis.
 Vaginal swabs
 Urinalysis (esp for chlamydia and gonorrhoea if they have discharge)
 Urine PCR (screening for STIs)

Patient Education
 Pap smear testing is recommended in Australia every 2 years for every woman who has ever been
sexually active from the age of 18 until 70. If sexual activity starts after 18, Pap smears should
commence 2 years after sexual activity. ‘Sexual activity’ includes lesbian sexual activity.
 Pelvic examination is an important part of assessment of a pregnant woman
Complications
 Patient feels uncomfortable or assaulted (legal ramifications) due to inadequate information, poor
consent process, or perceived unnecessary or vigorous contact – communicate at all times!
 Exacerbation of pain or discomfort with the procedure or with palpation
Procedure – IV Cannulation
From Student Guidelines

Indications (delivery)
 Administration of drug therapy (especially low-bioavailable drugs or when patient can’t eat)
 Fluid replacement and maintaining fluid-electrolyte balance
 Blood transfusion or transfusion of blood products
 Unconscious patient (resuscitation)

Contraindications
 cubital fossa veins
 joint areas e.g. wrist, knee – as for cubital fossa veins (bending will kink the tube)
 veins of the legs & feet in adults ( increased risk of DVT and phlebitis)
 previous intravenous sites (e.g. for venepuncture)
 bruised areas
 the patient’s dominant arm, if possible
 never use the following sites except in an immediate life threatening situation
 a fistula or arteriovenous shunt
 arm on the side of a mastectomy, or axillary resection (usually performed for breast
cancer)
 scarred or injured areas e.g. burns
 veins damaged by infiltration or phlebitis
 infected areas ( sepsis)
 areas infiltrated by dermatological conditions
 sclerotic or thrombosed veins

Selecting and Preparing a Vein

 Examine both arms
 Inspect and palpate for problems, e.g. tortuous veins, sclerosed knotty veins (these veins feel like
solid cords). Veins should feel round, firm, elastic and well filled
 Warm skin if necessary (e.g. with a warm towel or warm pack)
 Place arm dependent if increased venous filling is necessary
 Ensure cannula length corresponds to the length of straight vein
 Identify previous history of cannulation and modify approach if indicated – “It took the anaesthetist 4
attempts” is usually a significant history

Equipment
1. Gloves  Syringe (5 ml)
2. Apron  Non‐bevelled drawing up needle
3. Glasses  Sterile sodium chloride (NaCLl)
4. Sharps container 0.9% solution (saline)
5. ‘Bluey’ 12. Transparent bi-occlusive dressing
6. Tourniquet 13. Micropore® silk tape
7. Antiseptic solution 14. Scissors
 0.5 ‐ 1% Chlorhexidine with 70% 15. Additional
isopropyl alcohol  EMLA Local anaesthetic (e.g. 1%
 Use an aqueous based alternative lignocaine) or anaesthetic cream
if there is a known allergy to  3‐way tap or triflow
alcohol  Short extension tube
8. IV cannula (correct length/diameter)  Blood collection tubes and
9. Cannula ‘bung’ or valve ‘vacutainer’ adaptor
10. Gauze  Giving set (if setting up an IV
11. Flush infusion)
  Prescribed IV fluid  Splint and bandage (for children)

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient
 ask name, DOB and UR number, check this matches the request form
 Consent
 Involves: insertion of a needle with a cannula, a small rigid tube, into a vein, It might sting
when I insert the needle but after the cannula shouldn’t hurt
 Exposure: between wrist and elbow typically
 Complications: minor, such as inflammation, bruising, swelling, infection of the skin or more
serious such as nerve damage or infection of the blood (sepsis)
 Indications and importance of proceeding: rare, critical to guide treatment
 Ask if they understand, have any concerns, any questions
 Gain consent
 Offer a chaperone
 Discuss analgesia
 Ask if the patient has any allergies (latex, alcohol, tape, local anaesthetics),
 Ask if on any blood thinning medications (e.g. warfarin, aspirin, etc)
 Ask if previously any adverse reactions or any difficulties with previous cannula (e.g. fainting)
 Ask if they’ve had any surgeries on this arm/side of chest

Procedure:
Note: student guidelines say to wash hands and put on gloves, before choosing the vein and applying
tourniquet.
 Collect equipment (hand hygiene has already been performed and you may access sterile stock)
 Ensure the sharps bin is within arm’s reach.
 Put on PPE – glasses +/- gown
 Wash hands
 Position the patient: ensure the patient is comfortable with the arm resting on a pillow
 Place a bluey under the arm
 Apply the tourniquet
 Place arm dependent if increased venous filling is necessary
 Select a vein:
 Consider handedness; avoid: joints, legs, previous IV, bruises
 Absolute contraindications: fistula, mastectomy, skin issues, infections, burns damaged veins
 Feel vein: it should feel round, firm, bouncy, elastic and have rebound filling
 Put non-sterile gloves on
 Clean skin with antiseptic solution. Using a circular motion working from inside out for approximately
5cms, swab skin. Allow 30s to dry!
 chlorhexidine in alcohol or Persist Plus swab stick for skin disinfection
 Use an aqueous based alternative if there is a known allergy to alcohol
 Clip hair if necessary.
 While waiting, use the syringe to draw up the saline flush. Replace into the syringe’s sterile packet.
 Inspect the cannula for any obvious defects
 Rotate the cannula on the needle to release it
  Fix the vein by holding the skin taught with other hand
 With the cannula bevel-up and pointing in the direction of the blood flow (up the arm), insert the
cannula at a 20-30°
 Stop when blood is seen in the flashback chamber.
 Lower the angle of insertion almost to skin level.
 Advance the cannula itself a few mms off the needle into the vein, and then stop again.
 Do not advance against resistance.
 Lower the cannula until it is almost flush with the skin and gradually advance the cannula until it has
entered the vein to the hub
 lf blood tests are required, attach Vacutainer System@ to end of cannula, release your non-dominant
hand and insert tubes into Vacutainer System@ until required quantity of blood acquired
 Release the tourniquet
 Apply fingertip pressure at the distal end of the cannula tip to prevent flow of blood onto the patient
and sheet
 Hold the introducer and discard it immediately into an appropriate sharps container.
 Attach a bung /extension tubing/IV giving set (as required)
 Flush the cannula and line with 5 mls Normal Saline (prevents clotting).
 Cover skin and cannula hub with transparent dressing.
 Write the insertion date/time sticker on transparent dressing
 Secure further as required e.g. tape the tubing to the skin, splint arm, bandage etc
 Document the procedure in the relevant medical record (date, time, site and operator)
 Cannula should be removed within 48hrs to minimise risk of infection. This is your
responsibility.
 Ensure patient is comfortable. Clean up any splashes. Check daily for infections.
 Wash hands

Cannula should be removed within 48hrs to minimise risk of infection. This is your responsibility.

Complications
 Leaving the cannula in for more than 48hrs
 Check daily for infections.
 Cannula should be removed within 48hrs to minimise risk of infection. This is your
responsibility.
 Remove immediately if they are no longer needed for treatment
 Thrombophlebitis (inflammation of the vein associated with thrombosis/clot)
 Infiltration (extravasation of fluid into the tissues either because of damage to the vein or
dislodgement of the cannula)
 Haematoma (a localized collection of blood outside the blood vessels, usually in the tissue)
 Nerve, tendon or ligament damage
 Infection
 Local cellulitis
 Systemic Infection (sepsis)
 Catheter‐related Bloodstream Infection (CRBSI)
 Infective Endocarditis (sometimes requiring valve replacement)
 Osteomyelitis (metastatic infection to bone)
 Sepsis
 Local reactions/allergy
 Emboli – air, catheter fragment
 DEATH
Procedure – Suturing
From Student Guidelines

Indications
 Almost all types of wounds
 Most traumatic wounds
 Stabilisation of external lines and tubes (central venous lines, chest tubes, surgical drains)

Contraindications
 Unqualified to suture
 Other injuries that have priority (e.g. threat to airway, internal organ damage with penetrating trauma)
 Underlying structures requiring attention – nerves, tendons, named arteries, joint capsules internal organs,
compound fractures
 Contamination requiring formal cleaning in operating theatre
 Large skin defects – where skin needed for primary closure has been lost (e.g. motorbike accident) and
grafting will be required
 Extended interval between injury and repair – there is a maximum time (“golden period” over which a
wound may be safely closed
 Allergy to local anaesthetic/latex
 Adrenaline should not be injected near end-arteries such as in fingers, toes, nose or penis

Alternative Techniques
Wound staples are often used on lacerations of the scalp or extremities and offer the advantage of rapid placement
but do not allow the meticulous wound-edge approximation afforded by suturing.
Tissue adhesives and wound tapes ( steri-trips, Dermabond) are often used for smaller or superficial lacerations but
are not suitable alone for lacerations subject to significant tension.

Assessing a Wound for Suturing

 Many wounds will heal by themselves
 Caution: always assess whether suturing should be performed by you as a junior doctor
 Am I qualified: junior doctors should show all wounds to the ED consultant for approval. It may need to be
referred to the plastic surgeon.
 Co-operation of the patient: are they cooperative or do they need a general anaesthetic?
 Site and tissue apposition: does apposition need perfect alignment to ensure good cosmetics (e.g.
vermillion border of the lip; on the face of a child; complex facial laceration on an adult)? Is the laceration
complex? It is in close proximity to a vital structure where scarring would limit functional ability or
cosmetics (e.g. injury of the lip; across a joint; on the genitalia; involving the eyelid; involving a tendon
underneath; injury involving a chainsaw)
 Infection: What is the infection risk, is the wound still in the “golden period”, how should this be managed.
This includes age, state of health and conditions impacting on wound healing and susceptibility to
infection. If there is a substantial risk that closure of a particular wound might result in infection, the
decision to close or to leave the wound open can be postponed and the condition of the wound after 3- 5
days will determine the best strategy. Wounds left unsutured after cleaning appear to have a higher
resistance to infection than do closed wounds.
 Foreign bodies: Potential for foreign bodies to be embedded in the wound
 Resection of dead tissue: some traumatic wounds have tissue that is isolated from its blood supply. Tthe
body can manage a small amount of dead tissue in the healing process, but a large necrotic load will delay
healing, promote abscess formation or act as a focus for local inflammation and infection. Any tissue that
looks non-viable should be carefully resected, and decisions about what to excise come with experience
and teaching in the clinical years.

Equipment
Many hospitals stock pre-packaged suture trays that contain most of the necessary equipment
1. Light
2. ‘Bluey’ (to protect work surface/patient clothing)
 3. Glasses
4. Gown +/- mask if risk of splatter
5. Gloves (non- powdered)
6. Sharps container
7. Skin cleansing agent (chlorhexidine, providence iodine)
8. Sterile gauze
9. Drawing up needle
10. 25G needle (anaesthetic)
11. Local anaesthetic (+/- adrenaline 5mcg/ml)
12. 5- or 10-mL syringe
13. Saline (irrigation)
14. 30- to 60-mL syringe with splash guard for irrigation
15. Sterile bowl
16. Sterile drape
17. Suturing
 Suture needle and material
 Needle holder
 Toothed forceps (Adson Brown)
 Dissecting forceps
 Scalpel (with blade and handle)
 Suture scissors
18. Dressing to go over closed wound

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient
 ask name, DOB and UR number, check this matches the request form
 Consent
 Involves: injection of anaesthetic and stitching the skin together, explain that they will feel
pressure but not pain
 Exposure: of the wound
 Complications: infection, haematoma
 Indications and importance of proceeding: faster healing, better cosmetics, less discomfort.
 Ask if they understand, have any concerns e.g. fears, any questions
 Gain consent
 Advise the patient to tell you if they feel pain, nausea or dizziness
 Offer a chaperone or family to stay
 Ensure patient privacy
 Ask if the patient has any allergies (latex, alcohol, tape, local anaesthetics)
 Ask if they are up to date with their tetanus immunisations

Procedure: (LACERATE)
Look, Anaesthetic, Cleaning, Equipment, Repair, Assess results and complications, Tetanus status and Education
 Assess whether suturing should be performed (see above)
 Position patient: supine and at level for suturing either standing or sitting
 Perform and document a thorough neurovascular and functional examination of structures distal to the
wound
 Position light
 Put on PPE – glasses, gown and gloves
 Prepare equipment
 Cover the wound with cleansing disinfectant solution (chlorhexidine, Betadine).
 Give this time to be effective (2-5 minutes)
 Prepare anaesthetic
 Use a drawing up needle to draw up anaesthetic lignocaine (‘lidocaine’) in a syringe
 Put a 25G needle onto the syringe
  Inject local anaesthetic:
 Puncture the skin superficially into the dermis at a 45° angle
 Aspirate back on the syringe to check that you are not in a blood vessel
 Inject 1–2 ml of anaethetic). A small "bleb" will appear, allowing you to push the needle in further
and deeper.
 Continue to inject the local anaesthetic along the line of the cut or where you will suture,
aspirating as you go
 Allow the anaesthetic time to work
 Scrub a wide area of skin surface surrounding the wound with an antiseptic solution (standard 10%
povidone-iodine or chlorhexidine gluconate (Hibiclens) solution)
 This will remove contaminants that might be carried into the wound by instruments, suture
material, dressings, or the clinician’s gloved hand.
 It is important to remove all particulate matter; any material left in the dermis may become
impregnated in the healed tissue and result in a disfiguring “tattoo” effect.
 Irrigate the wound profusely with saline solution, via a 30- to 60-mL syringe and splash guard until all
visible, loose particular matter has been removed.
 Vigorous irrigation is required to remove bacteria and particulate matter.
 Minimum recommended volumes of irrigation fluid vary with the size of the wound and the
potential for contamination; there is no standard volume per length of wound.
 Disinfect the skin surface adjacent to the wound (NOT the wound itself) with a standard 10% povidone-
iodine or chlorhexidine gluconate (Hibiclens) solution.
 Paint the solution widely on the skin surrounding the wound but do not allow it to seep into the
interior of the wound itself as it can damage the tissue.
 Place a single fenestrated over the wound site with the window over the wound
 Use a metal probe or forceps to explore the entire depth and the full extent of every wound under direct
visualization with good lighting in an
 Attempt to locate: hidden foreign bodies, particles, bone fragments
 Identify any injuries to underlying structures that may require repair.
 Debride dead tissue i.e. tissue embedded with foreign matter, bacteria, or tissue that otherwise impairs the
ability of the wound to resist infection and prolongs the period of inflammation.
 Debridement of devitalized tissue is vital.
 Dead tissue will not heal and acts as a resevour for infection.
 Suture (see technique below)
 Dressing:
 Wipe away blood and cover the wound with a non-adherent dressing
 Splint if over a joints e.g. fingers, hands, wrists, extensor surface of elbow, posterior legs, plantar
surface of feet, extremities when skin grafts have been applies
 Elevate injured extremities is important in all injuries
Technique
 General tips
 The total number of sutures will vary by laceration. Enough sutures should be placed so that the
wound edges are fully approximated.
 The spacing between sutures should generally be equal to the bite width of each suture.
 Avoid placing an excessive number of sutures as this may increase the risk of infection, increase
scarring and unnecessarily injure delicate tissues.
 As you progress with the repair and the wound edges become approximated, you can drive the
needle through both sides of the laceration in a single pass, again using a gentle supination of the
wrist.
 Wounds under considerable tension may need more sutures closer together.
 Often if there is significant tension an alternative approach to wound closure (such as additional deep
internal sutures), or specialist consultation is advisable as wounds closed under tension often fail to heal or
heal with a poor cosmetic result.

Tips for suturing -

 Do not put your fingers through the ring holes of the driver while suturing; this interferes with proper
technique. You may put your fingers into the holes when opening the driver and while tying knots.
  Pull the knot closed just enough to approximate the wound edges. Remember that the wound edges will
swell over the next several days and the knots will become tighter. Knots that are pulled too tightly may
lead to wound edge ischemia and could increase the likelihood of infection or unsightly scar.
 While it is tempting to use the fingers to grasp the needle tip to pull the needle through the skin, this
practice risks a needle stick. Reposition the needle holder or use forceps to disengage the needle from the
laceration.
 An excessive number of throws in a knot weakens the suture at the knot. If the clinician uses square knots
(or a surgeon’s knot on the initial throw, followed by square knots) that lie down flat and are tied securely,
knots will rarely unravel.

Suture Removal
 Face - ↓ tram tracking of scar, can remove alternate suture early
 3 – 5 days
 follow with papertape or steristrips
 Limbs
 7 – 14 days
 Trunk/Back
 10 – 14/21 days
 Delayed healing w DM and chronic CS use = 14 – 21 days

Complications
 Breakage
 Scaring
 Adverse reactions
 Infection
Procedure – Plastering
To Do
Procedure – Catheterisation
From Student Guidelines, tute prep and two videos

Indications – By Purpose
Should only be used when non-invasive means are not appropriate or fail. Use non-invasive methods first
 Diagnostic
 Obtain sterile urine sample for testing
 Monitor urine output (during surgery, critically ill, AKI)
 Deliver contrast media for imaging
 Measuring post-urination residual volumes
 Therapeutic
 Drain bladder (e.g. urinary retention)
 Care of bedridden patients
 Instillation of medication
 Bladder irrigation (flushing when patient has haematuria, to remove blood and clots)

Indications – By Duration
 1. Intermittent catheterisation
 Collection of sterile urine sample.
 Provide relief of discomfort from bladder distension.
 Decompression of the bladder.
 Measure residual urine.
 Management of patients with spinal cord injury, neuromuscular degeneration, or incompetent
bladders.
 2. Short-term indwelling catheterisation
 Post-surgery and in critically ill patients to monitor urinary output.
 Instil medication for local intravesical therapy.
 Prevention of urethral obstruction from blood clots with continuous or intermittent bladder
irrigations Instillation of medication into the bladder.
 Instilling contrast media for imaging procedures,
 Surgical procedures involving pelvic or abdominal surgery repair of the bladder, urethra, and
surrounding structures.
 Urinary obstruction (e.g. enlarged prostate), acute urinary retention.
 3. Long-term indwelling catheterisation
 Refractory bladder outlet obstruction
 Neurogenic bladder with urinary retention.
 Prolonged and chronic urinary retention.
 To promote healing of perineal ulcers where urine may cause further skin breakdown.

Contraindications
 ABSOLUTE: Urethral injury, confirmed or suspected, usually in the setting of pelvic fracture
 Suggested by blood at meatus, gross heamaturia, perianal hematoma and high riding prostate
gland
 If suspected, perform a genital and rectal exam, and retrograde urethrography
 ABSOLUTE: Spinal cord injury (SCI)
 Urethral stricture
 Recent urethral or bladder surgery
 Increased infection risk
 Aggressive, combative or uncooperative patient
 Routine incontinence – use non-invasive methods (pads, intermittent catheterisation, penile-sheath
catheters)
 Equipment
1. Apron  Male: 16Fr or 18Fr (more rigid, easier
2. Glasses to insert past prostate)
3. Light  Females: 12fr. 14Fr (up to 16Fr.)
4. Towel 13. 10 ml syringe with luer lock tip.
5. ‘Bluey’ 14. 10mL sterile water
6. Bin 15. Urine collection
7. Sterile catheter pack (with sterile field,  Closed bladder drainage unit, e.g.,
sterile gloves, forceps, swabs and sterile leg bag with tap and leg straps
fenestrated drape) OR
8. Sterile gloves  Jug for urine (for larger volumes)
9. Skin cleansing lotion (aqueous chlorhexidine OR
0.1% or sterile water)  Specimen jar, request form and
10. Kidney bowl labels for pathology specimens
11. Lubricant (Lubafax, Lignocaine Gel, pre- 16. Catheter straps (Cathstrap) or Tape
packed 10ml syringe containing lignocaine (alternative means of strapping catheter to
gel 2% with chlorhexidine 0.05%) leg).
12. Catheter x2

Introduction / Communication / Consent

 Hand hygiene
 Introduce self
 Confirm the correct patient
 ask name, DOB and UR number, check this matches the request form
 Consent
 Involves: insertion of a tube into the urethra in the genital area, up into the bladder.
 Exposure: genitals, close the curtains, cover and expose when necessary
 Complications: uncomfortable, UTIs, injury,
 Indications and importance of proceeding: painful, increase infection risk,
 Ask if they understand, have any concerns, any questions
 Gain consent
 Offer a chaperone
 Ensure patient privacy
 Assess whether they have a pelvic injury or spinal cord injury, any health issues with urethra or previous bladder
surgeries
 Ask if patient has
 Ask if the patient has any allergies (latex, alcohol, tape, local anaesthetics)

Procedure:
 Collect equipment (hand hygiene has already been performed and you may access sterile stock)
 Put on PPE – glasses and gown
 Place the towel and bluey under the patient’s buttocks
 Patient preparation: Ask the patient to lie in supine position. Females should have their knees bent, hips flexed,
knees apart and feet resting apart up on bed.
 If needed, raise pelvis with pillow, blanket or inverted bedpan.
 Turn on and position light
 Perform hand hygiene (2)
 Open urinary catheter pack to generate sterile field
 Open sterile equipment onto the sterile field –
 Sterile gloves
 Cleaning solution (into tray)
 Lubricant (into tray)
 Syringe
 Catheter
 Sterile water – have standing ready, put under the sterile field, or pour into sterile tray
 Perform hand hygiene (3)
  Don sterile gloves
 Don blue sterile gloves from the catheter pack
 Use your non dominant (left) hand to open the labia majora / retract the foreskin. This hand is non-sterile.
 Cleanse the skin using the yellow tweezers, cotton wool/swabs and cleansing solution (aqueous chlorhexidine 0.1%
or sterile water),
 Females: labia minora and meatus area from front to back.
 Males: meatus and around the glans penis.
 Remove blue gloves
 Place fenestrate drape over the perineum / penis
 Place the kidney dish near perineum / penis
 User sterile syringe to draw up sterile water
 Open plastic covering of catheter (at the perforation) to expose the tip of the catheter
 Check inflation of the catheter balloon (while still in the packet)
 Lubricate
 Females: Lubricate catheter tip. Use non-dominant hand to open and pull up labia majora.
 Males: Use a sterile swab in the non-dominant hand around the penis to retract the foreskin. Instil
lignocaine gel 2% with chlorhexidine into the urethra
 Insert:
 Females: Gently insert the catheter into the clean urethra in a slightly upward direction until urine drains.
 Male: extend the penis vertically and insert catheter along the urethra. Hold penis either side - do not exert
pressure on the underside of the penis as this may block the urethra. Insert the catheter until resistance felt
(external sphincter at ~18cm), and then lower the penis to horizontal position.
 As insertion proceeds slowly withdraw the plastic covering; do not entirely withdraw as this can catch the first urine.
 Insert catheter a little further into the bladder to ensure the balloon is clear of the bladder neck.
 If any contamination of the catheter occurs during insertion, use another sterile catheter.
 Urine should flow if you have inserted the catheter correctly into the bladder (most of the time)
 No urine flow: obstructed catheter (clot), wrong site or empty bladder.
 If no urine, flush the catheter with saline and urine or saline should return
 ONLY once there is urine flow, inflate the balloon with sterile water with amount denoted on the catheter.
 Never inflate the balloon until urine has been visualized and is draining.
 If there is not urine flow and you are not sure you have the catheter in the correct position (in the bladder)
do not inflate the balloon. This prevents trauma to the urethra.
 Cease inflation immediately if the patient experiences pain or discomfort.
 Gently pull the catheter so that the balloon is sitting up against the bladder orifice.
 Males: The prepuce (foreskin) MUST be returned to its normal position after the catheter is inserted.
 Attach sterile drainage bag to catheter. Ensure there is urine flowing into the drainage bag
 Catheter is secured to the medial thigh with tape or the catheter strap (catrap).
 Attach leg bag to thigh or calf with bag straps. It should be in a dependant position e.g. below the bed.
 Ensure patient is comfortable. Clean up any splashes.
 Wash hands
 Removal
 Warn patient
 Deflate the balloon
 Gentle remove
 Throw into clinical waste

Documentation
 Time and date of catheterisation.
 Reinsertion date
 Amount and character of the urine obtained.
 Catheter – brand, size, balloon size and amount of sterile water
 Residual urine amount.
 Any difficulties with insertion.
Complications
The best way to prevent complications is to avoid catheterisation whenever possible.
 Females”.
 Most common: infection and trauma to urethra and bladder
 Traumatic injury may cause strictures, narrowing, and scarring of the urethra.
 Within 48 hours, up to 85% of catheters may be colonized with bacteria, which may lead to bacteriuria.
 Male:
 UTIs are common (3-10% of patients per day of catheterisation). Although many infections are limited to
asymptomatic bacteriuria, in some instances, pyelonephritis, bacteremia, and urosepsis develop. The
potential for serious illness or death is real, since nosocomial urinary tract infections have been shown to
extend hospital stays by three days and to triple the mortality rate in catheterised patients. Patients at
increased risk for catheter-related infections include the elderly, persons with diabetes, and those with
underlying renal insufficiency or advanced, life-threatening illnesses
 Trauma to the urethra and bladder.
 Paraphimosis (trapping of foreskin under glans penis, can become medical emergency)
 Occasionally, it may not be possible to deflate the retention balloon, owing to obstruction of the secondary
lumen or malfunction of the valve.
 Non-deflation of the balloon
 Autonomic Dysreflexia – a hypertensive crisis which can be triggered by catheterisation in persons with complete or
incomplete (SCI) at or above the T6 level with catastrophic hypertensive complications. If AD is untreated the blood
pressure may rise to extreme levels that may result in brain haemorrhage or seizures

Risk Minimisation
 The best way to prevent complications is to avoid catheterisation whenever possible.
 Diligent preparation and meticulous attention to proper sterile technique
 Continually review need for catheter
 Removal of the catheter as early as clinically possible, and vigilance are mandatory.
 The routine use of prophylactic antibiotics is not beneficial and encourages the proliferation of resistant species.
However, antibiotic treatment should be considered for patients at high risk for infection and for those undergoing
certain invasive procedures, such as transurethral resection of the prostate and renal transplantation.