Clinical Examinations & Skills

Mubeen Rahman - smr107@ic.ac.uk

Hb (g/dL) M13-18 F11-16

Hct M0.4-.54 F0.37-.47
2/3 History/CVS MCV 76-96 fL
4/5 Resp Platelets 150-400 109/L
6 Lymph WBC 4-11 109/L
Neutrophils 40-75% 2-7.5
7/8 GIT & DRE
Lymph’s 20-45% 1.3-3.5
9-12 UL & LL Eosinophils 1-6%
13 Cranial Nerves Basophils 0-1%
Monocytes 2-10%
14-6 Opthal/Oto
A/PTT 35-45s 10-14s
16/7 Cerebellar
Na+ 135-145 mmol/L
17 Speech/DDx K+ 3.5-5 mmol/L
18 Trauma/GCS Ca2+ 2.12-.65 mmol/L
Mg2+ 0.75-1.05 mmol/L
19 ANT/MMSE
Creatinine 70-150 uL/L
20/1 GALS/Lumps Urea 2.5-6.7 mmol/L
22/3 Thyroid/PVS Albumin 35-50 g/L
Proteins 60-80 g/L
24 Breast & Skin
Bilirubin <17 umol/L
25 Inguinal/Genitalia ALT/AST 3-35 iu/L
26-8 Musculoskeletal Alk P 30-35 iu/L
LDH 70-250 iu/L
29 Volume Status
CRP <10 mg/L
30 Explain CK 25-195 iu/L
Procedure
PaO2 >10.6 kPa
30/1 Inject/ABG/Phleb 75-100 mmHg
31 Cannulation/IVI PaCO2 4.7-6 kPa
35-45 mmHg
32/3 Suturing/PEFR
Urine Na+ 100-250 mmol/24hrs
34-6 BP/ XRays/ECG Urine K+ 14-120 mmol/24hrs
Ur. Protein <150 mg/24hrs

1
 History Taking
 Greet, state name/role, confirm patient’s
name and DOB. EXPLANATION &
CONSENT (purpose, time available)
 PRESENTING COMPLAINT (open q’s, a
brief phrase, in pt’s own words)
 HISTORY OF P. COMPLAINT (event
narrative, time course, clarify what pt
means, use SOCRATES & relevant RoS)
 PAST MEDICAL HISTORY (illnesses,
hospital admissions, THREAD2S2 MJ)
 DRUG HISTORY (current, recent, herbal,
OTC & recreational drugs, ?allergies inc.
nature of reaction)
 FAMILY HISTORY (? affecting blood family
(immediate) ?Parents a&w, and if dec.,
what age and cause. ? Ethnicity
 SOCIAL HISTORY (occupations, pets,
recent travel, sexual history, EtoH –
what/when, smoking (py’s of what), ?abode
& w/whom, ADL’s, immunisations, place of
birth, change in sleep, mental state, effects
 SYSTEMS REVIEW:
CVS - CP, palpitations, claudication, oedema
RESP - cough, haemoptysis, sputum, wheeze
GIT - Appetite/wt/bowel habits, vomiting,
haematemesis, abdo pain, rectal bleeding
GUS/O&G - Haemat/dysuria, freq, voiding
difficulty, LMP, #of pregnancies, miscarries
CNS - Headache, vision, faint, fit, funny
turns, weakness, paraesthesia
MSK - Joint pain/stiffness, swelling,
immobility, rashes, irritation
 SUMMARY ± - DDx
 Ix, Tx, MANAGEMENT PLAN
! – SAMPLE: Signs/Symptoms, Allergies,
Medications, PMHx, Last Ins & Outs
2
Cardiovascular Examination
 WIPE (Wash hands, Introduce with
name and role, confirming patient’s
name and DOB, position at 45o and
expose chest and back)
 GENERAL INSPECTION - obese, ill,
anxiety, distress, malar flush, pain,
SOB, cyanosed, pallor, congenital
abnormalities (Down’s - ½ have
Septal Defects, Marfan’s - Asc. Ao.
An, Turner’s – Aortic Coarctation)
 GENERAL INSPECTION – items to
do with care – IVI diuretics (POed/HF),
oxygen, GTN spray, monitor, ciggs.
 INSPECT HANDS – NAILS,
FINGERS, PALMS- Clubbing via
Schamroth’s Window (chronic O2,
cong. cyan. HD, A.Myxoma,
SBEndocarditis), cyanosis, warmth,
endocarditis (splinter
haemorrhages, Osler’s nodes,
Janeway lesions), tar stains,
koilonychia (IDA), leukonychia
(alb), tendon xanthomata, anaemia,
palmar erythema (portal HTN)
 PERFUSION - ?CRT < 2s (CO,
vasoconstriction, Art. Obstruct,
Raynauld’s, Shock). If hands hot +
tremor = thyrotoxicosis
 RADIAL PULSE – rate and rhythm
 RADIAL PULSE – SYNCHRONY (left
and right) - !coarctation
 COLLAPSING PULSE - BRACHIAL
 BLOOD PRESSURE – both arms
 INSPECT EYES – pallor, jaundice,
(?valve prosthesis), corneal arcus/sinilis,
xanthelasma, Grave’s (proptosis, ptosis,
lid retractions => !AF / output HF)
 INSPECT FACE – malar flush (MS)
 INSPECT MOUTH – pallor, cyanosis -
indicates a min of 5g/dL deoxHb
(shunting) , glossitis (B Vit), high arch
palate, dental caries
 CAROTID PULSE – ?Volume &
character. Check opp. side separately.
Collapsing – rapid up & downstroke = AR
Bisferiens = both collapse + plateau –
Mixed Ao Valve Disease
Pulsus alternans – alternating strong and
weak pulses = Severe LVF
Slow Rising (+plateau) = ASten – check
Brachial Pulse
Pulsus paradoxicus – vol.  on insp by
>10mmHg - Tamponade, constrictive
pericarditis, asth.
 JVP (± HEPATOJUGULAR REFLEX) –
45 degrees - !RAP eg RVF/fluid overload.
“a” & “v” waves = HS I & II
 INSPECT PRAECORDIUM - Scars
(CABG, valvotomy), abnormal veins,
pacemakers (subcostal), visible apex
beat, pulsations, breathing.
 PALPATE PRAECORDIUM – Apex,
compare against position of 5th ICS MCL.
Laterally displaced or diffuse impulse =
LVF/dilated cardiomyopathy
 PALPATE – HEAVES & THRILLS
 AUSCULTATE PRAECORDIUM
time with the carotid pulse, over the
valves: Aor, Pul, Tri, Mitral.
 MANOEUVRES (L. Side - MS, lean
forward – Ao Incomp.) on expiration.
Expiration clarifies right sided murmurs & v.v.
 ?Duration, Radiation, HS & amplitude
 S3 = Ken-tuc-ky (MR)
 S4 = Ten-ess-see (ASten/CHF)
?Radiations: Axilla (MR), Carotid (ASten)
3
AS AR
MR MS
?Murmurs: LSE – RVHypertophy
(pulm.HTN), 2nd ICS – Dilated PArt (L) or
Asc. Ao (R),
Ej SM = ASten oroutput state - children/preg
EDM = AR (rarely PR) - 2o to Endocarditis
Mid DM = MS/AR
PSM = MR, merging with S2, occurs in M/TR
Machine murmur – Patent ductus arteriosus
Murmur Grade Intensity:
1 Just audible 4 Loud & w/ thrill
2 Quiet 5 Very loud
3 Moderately loud 6 Audible w/o Steth
 AUSCULTATE CAROTID ARTERY –
bruits, w/ bell, stop patient breathing
 PERCUSS/AUSCULTATE CHEST –
- pleural effs /creps at bases (LVF/CCF)
 OEDEMA - Check sacrum/ankle -CCF
 EXTRAS:
 AUSCULTATE & PALP for AAA +
RENAL BRUITS
 HEPATOMEGALY - congestive disease
(RVF), or pulsatile in Tri regurg)
 SPLENOMEGALY – Inf. Endocarditis
 MSU Dipstick for Haematuria
 Peripheral Vascular and Resp Exam
 Assess femoral, popliteal, dorsalis
pedis and posterior tibial pulses. ?
 OPTIC FUNDI (Roth’s Spots,
HTN/DM), ECG + Exercise ECG if
inconclusive, Request Echo
 THANK, OFFER TO HELP PT DRESS
Respiratory Examination
 WIPE - chest (and back) @ 45o
 GENERAL INSPECTION – respiratory
distress, symmetry of movement,
accessory muscles, pursed lips, pallor,
cyanosis, wheeze, breathing pattern,
Medical - Horner’s syndrome (Pancoast’s
tumour ), erythema nodosum (sarcoidosis),
deformity: Kyphoidosis/Lordosis/Scoliosis
Paraphernalia – O2 mask, sputum pot,
flow meter, inhalers, nebuliser, drains.
 HANDS –– Warmth, bounding pulse,
dilated veins (CO2 retention), skin thinning
(Ca), tar stains, peripheral cyanosis,
koilonychia (IDA). Small muscle wasting
(esp. 1st dorsal interossei) – Pancoasts.
Clubbing (large cell Ca, ILD, TB, suppurative
disease, mesothelioma, lung Ca,
bronchiectasis, empyema, Cy Fi) – if +ve look
for pain w/ wrist mvmt (pypertrophic pulm.
osteoarthopathy) - ! lung Ca
 WRISTS – Ask pt to put arms straight
out infront, spread fingers (B2 agonist
tremor). Then cock wrists back for
>30s (CO2 retention flap).
 ASSESS PULSE (RATE + RHYTHM)
while assessing flap – looks slick!
 ASSESS RESPIRATORY RATE
Note: Depth + Effort + Obvious Sounds
 INSPECT EYES - Anaemia (pallor on
underside), miosis, ptosis (drooping
upper eyelid), anhidrosis - Horner’s
syndrome/Pancoast’s tumour.
 INSPECT TONGUE, LIPS, MOUTH -
Tongue – cyanosis (blue tinge
underneath), glossitis. Lips – angular
stomatitis. Mouth – candida infection
(steroid).
4
 EXAMINE NECK - Neck/face
swelling, dilated veins (SVC
obstruction – lung tumour).
 ASSESS JVP - Ask pt to look to left,
illuminate. JVP raised in cor pulmonale,
RVF, Fluid OD
 CAROTID PULSE - bounding pulse in
CO2 retention.
 PALPATE LYMPH NODES – From
behind (submental, submandibular,
supra-clavicular, posterior-auricular,
occipital)
! – Infection, Neoplasm, Sarcoid
 PALPATE TRACHEA - Warn pt first.
Palpate for deviation. T  Fibrosis/
Collapse, T  Pneumo/Effusion.
 CRICOSTERNAL DISTANCE -
Measure finger breadth distance
between cricoid cartilage and
suprasternal notch (~2 fingers, less in
emphysema, COPD = tracheal tug, if
w/systole – Ao. Arch Aneurysm)
 FEEL FOR APEX BEAT
 INSPECT CHEST - Pectus excavatum,
carinatum (rickets), funnel (congenital).
Scars (ant/posterior). Kyphoscoliosis,
barrel chest, radiotherapy tattoo, skin
damage
 CHEST EXPANSION (STERNAL,
LOWER) - 2 hands on sides of chest,
thumbs meet in middle (not touching
skin). Sternal – check upward mvmt.
Lower rib cage – laterally (>5cm).
 Repeat on back at 2 levels.
w/ Effusion, Consolidation, Collapse,
Pneumothorax and Fibrosis
 PERCUSS FRONT - Supraclavicular,
clavicles (directly) then chest wall (2 x
3 positions including axilla).
 Resonance (air) – Pneumo/COPD
Resonance (dull)= fluid, solid i.e.
Large effusion or consolidation

 AUSCULTATE FRONT- Ask pt

to take deep breaths via mouth
(show). Listen w/ diaphragm -
?vesicular, bronchial, what intensity,
added sounds like wheeze,
(mono/poly), crackles, pleural rub
 TACTILE/VOCAL RESONANCE
Ask pt to say ‘99’ when listening to 2
x 3 positions.
 WHISPERING PECTORILOQUY
Ask pt. to say “one” repeatedly,
whisper transmitted in consolidation
 PERCUSS BACK - Do back 2 x 3
positions.
 AUSCULTATE BACK – 2 x 3
POSITIONS
 TACTILE/VOCAL RESONANCE
BACK – 2 x 3 positions
 w/ consolidation
 w/ Pneumothorax and Effusion
 OEDEMA – Sacral and ankle
 EXTRAS:
 CVS Exam, CXR, Peak flow,
Sputum pot sample, ABG

5
Lymph Node Examination
 HEAD & NECK NODES
• VERTICAL NECK: Neck flexion may
relax the strap muscles. Feel for the
superficial cervical nodes along the SCM
body. The posterior cervical nodes run
along the anterior body of trapezius. The
deep cervical chain is difficult to feel, as
they are deep to the long axis of SCM;
explore by palpating firmly through the
muscle.
 INFRACLAVICULAR
 AXILLARY NODES
Take the pt’s L arm with your R hand and
explore with your L hand and vice versa:
• Slightly cup examining hand and palpate
into axilla apex for apical group – small
nodes may only be felt by rotating the
fingertips against the chest wall.
• Feel for the anterior group of nodes
along the posterior border of the anterior
axillary fold, the central group against the
6
lateral chest wall, and the posterior group
along the posterior axillary fold.
• EPITROCHLEAR (ELBOW) - Passively
flex the patient’s relaxed elbow to a right
angle. Support with one hand whilst feeling
in the groove above / posterior to the
medial condyle of the humerus.
 PARA-AORTIC - deep central mass if
enlarged

 INGUINAL & LEG NODES - Supine
• H’al – just below inguinal ligament
• V’al - along the long saphenous vein
 POPLITEAL - Relax the fossa by
passive flexion – explore by wrapping the
hands either side of knee and exploring
with the fingers of both hands.
 SPLEEN & LIVER
 Examine the DRAINAGE AREAS of
any enlarged nodes.
General points to note:
Size: anything >1cm is abnormal
Consistency: hardness suggests Ca,
rubbery consistency points to lymphoma
Tenderness: implies infection
Fixation: suggests malignancy
Overlying skin: tethering is a feature of
malignancy, inflammation suggests infection
Gastroin testinal Ex amination
 WIPE - ‘nipples to knees’ for
abdominal portion, initially 45o, then
supine for abdomen, w/ pillow/s under
head, relaxed, arms by sides, check
patient is comfortable)
 INSPECTION - cachexia, obesity,
normal weight, hydration, pain, pallor,
pruritis (jaundice), distension, scars,
masses, bruising, etc.
Paraphernalia: Drains, stoma feeding
tubes, notices, supplements, catheter.
 HANDS - Palmar erythema,
Dupytren’s Contracture, Clubbing
(IBD, liver cirrhosis, malabsorption).
Koilonychia, Leuconychia (chronic liver
disease, nephrotic syndrome).
Arteriovenous fistulae (lump from
dialysis). Hydration (dehydration
makes skin flaccid), nail pitting,
xanthomata
 WRISTS - Test for asterixis (hep
flap) w/ pt. holding arms out, wrists
cocked >30sec – check pulse here too!
 RADIAL PULSE (AF, Shock)
 EYES – Scleral icterus, pallor, corneal
arcus, xanthelasma, KF rings.
 LIPS - angular stomatitis, cheliosis
(fissuring/crack of lips), herpes labialis,
 GUMS – hypertrophy, gingivitis.
 MUCOSA – ulceration, pigmentation
(Peutz Jegher’s – dark freckles on lips,
face, mucosa, w/ GI obstruction and
polyps), Osler-Weber-Rendu
telangiectasia (capillaries near surface,
alcohol, malignancy).
 TEETH – caries (cavities), dentures.
7
 TONGUE – dry/wet, jaundice,
atrophic, furred & beefy, swollen,
candidiasis, tonsils, palate, etc.
 BREATH – fetor hepaticus (stale
urine, ammonia), alcohol, ketoacidosis
(peardrops), halitosis.
 CERVICAL LYMPH NODES – from
behind
 VIRCHOW’S NODE/TROISIER’S
SIGN (L SUPRACLAVICULAR AREA)
 JVP – raised in hepatic pathologies
 INSPECT CHEST - Gynaecomastia,
Spider Naevi (~>5 pathological in
women, any in men), feeding/tunnelled
lines, body hair distribution
 INSPECT ABDOMEN – Get to level
of patient, lie SUPINE
 INSPECT ABDOMEN – distension,
lumps, caput medusa, bruising,
scratches, visible peristalsis, rigidity
(peritonitis).
 INSPECT ABDOMEN – Ask pt to
cough (pain/hernias), to raise legs
(rectal divarication, hernias).
 ASK PATIENT IF THEY HAVE PAIN
 PALPATION - SUPERFICIAL -
Tender region last. Watch patient’s
face. Visit all 4/9 quadrants. Elicit
tenderness, rigidity, guarding.
 PALPATION – DEEP - deep-seated
pain (rebound?). Any masses
described as lump w/ position, shape,
size, surface, fixed, mvmt w/ resp.,
tenderness, pulsation.
 PALPATION – LIVER (from RIF, w/
deep breaths). Percuss for upper &
lower border using index finger edge -
! psuedohepatomegaly due to
hyperinflated lungs
 PALPATION – SPLEEN (from RIF, w/
deep breaths using fingertips). Percuss.
 PALPATION – KIDNEYS (bimanual
ballotment)
 PALPATION - ABDOMINAL AORTA
- 2 hands (or middle & index finger)
firmly at either side. AAA will push
upwards (pulsatile) and out (expansile)
 PERCUSSION – 4 QUADRANTS
 PERCUSSION – ASCITES
 a. Shifting dullness: Percuss from
umbilicus laterally (w/ fingers pointing
toward head). ?resonant at umbilicus, dull
in flanks. If not, no ascites. Pt. rolls to
RHS whilst keeping your hand over L
flank where it was dull. Wait 1m and re-
percuss. Note should have changed:
dullresonant. Roll pt. onto LHSide.
Wait 1m. Left flank should be dull again.
 b. Fluid thrill: Flick on one side, feel any
mvmt transmitted. Thrill due to mvmt
through fluid. Ask pt. to put ulnar edge of
a hand in centre of abdo to prevent a
false +ve thrill from fat.
 AUSCULTATION – quadrants for
bowel sounds (>15s, >1 min for absent.
Normal, borborygmi (mvmt), absent
(ileus) , tinkling ( e.g. obstruction)
 OEDEMA – check ankles
 AUSCULTATION – AA BRUIT,
RENAL AND LIVER
 EXTRAS: Palpate hernia orifices,
examine the external genitalia, DRE,
urine dipstick:
SG >1.010 = dehydration, <1.007 Normal
Ketones = DM
Albustix = Renal Infec, DM, jaundice, Thy
Nitrites & Leukocytes = UTI
Hb = Glomerular damage/Rhabdomyolysis
8
 Glucose = Diabetes / Nephropathology
 THANK, CHECK COMFORT,
OFFER TO HELP GET DRESSED.
Digital Rectal Examination
 WIPE – nipples to knees, left lateral
position, knees drawn up to chest,
feet clear of perineum, buttocks at
edge of couch. ? CHAPERONE
 PUT ON GLOVES
 ASK ABOUT PAIN/DISCOMFORT
 INSPECTION – skin tags, warts,
haemorrhoids, fistula, fissure,
abcesses, pilonidal sinus, prolapsed
rectal mucosa, skin discolouration,
scratch marks, discharge
 PALPATION – WARN PT FIRST
 PALPATION – lubricate finger, use
pulp of finger on anus, press firmly and
aim towards umbilicus
 PALPATION – rotate around 360°,
feel for masses, mucosal changes,
temperature changes, prostate
 ASSESS ANAL WINK – reflexive
contraction of the anal sphincter on
stroking peri-anal skin (S1-3)
 ASSESS ANAL TONE (ask pt to
squeeze finger)
 REMOVE FINGER GENTLY
 EXAMINE FINGER – evidence of
blood, mucous, stool etc.
 CLEAN UP PT – leave towels for
them to clean themselves
 ASK PT TO GET CLEANED UP
AND DRESSED (do not thank the pt)
 DISPOSE OF GLOVES/WASTE AND
WASH HANDS
 EXPLAIN FINDINGS TO PT
Upper Limbs PNS Examination  COORDINATION – FINGER-NOSE
“I Think People Can’t Resist Penetrative S Games”
 WIPE - 45o or upright, arms/legs fully
exposed)
 INSPECTION – palsies, abnormal
movements, fasciculation, wasting,
tenderness
Hemiplegia – flexed UL, extended LL
T1 palsy – weak finger adduction and
abduction. Sensory loss to medial forearm.
Radial nerve – wrist drop. Sensory loss on
small area of dorsal web of thumb.
Median nerve – Adductor Pollicis Brevis
weakness. Sensory loss thumb, 1st 2 fingers,
palmar surface.
Ulnar nerve – interversion, hypothenar
muscles waste, claw-hand, no finger extension.
Sensory loss, half 4th, all 5th, palmar surface.
Erb-Duchenne (C5-7) - waiter’s tip.
 PRONATOR DRIFT, TREMOR –
parkinsonism, thyrotoxicosis, chorea,
athetosis, spasm
 TONE – wrist, elbow, shoulder etc…
 POWER –Shake hands w/pt.
• Shoulder abd/add’n (C5) “chicken wings”
• Elbow flex/ext (C5 & C6). “boxer”.
• Wrist Flexion/ext – “push fist up/down”
• Finger grip (C8, T1). “squeeze my fingers”
• Finger Abduction (dorsal interossei, ulnar
nerve, T1) “squeeze/spread fingers”. -DAB
• Finger adduction (T1). “paper pull” -PAD
• Fine movements – “fingers to thumbs”
9
– both sides, with your finger at arm’s
length. Cerebellar changes = past
pointing and intention tremor
 COORDINATION –
DYSDIADOKINESIS – both hands
 COORDINATION – FINGERS – play
piano etc
 REFLEXES – biceps, triceps, supinator
with Jendrassik manoeuvre if needed.
 PROPRIOCEPTION – always
demonstrate up/down motion first,
use finger on either side of both toes,
eyes closed, test peripherally first
 SENSATION – LIGHT TOUCH – ask
about numbness, use cotton wool,
eyes closed, test at sternum and start.
 SENSATION – PIN PRICK (PAIN) –
sharp or blunt, test at sternum, go...
 L2 – Medial Thigh, L3 – Knee, L4 –
Floor, L5 – Lat. Side, S1 – Pinkie, S2
– Posterior Thigh
 VIBRATION – 128Hz tuning fork,
tester on sternum first, begin test
distally on bony prominences.
 SENSATION – TEMPERATURE –
(since pain and temperature both
spinothalamic) – dermatomal
distribution, determine if tuning fork is
hot or cold
 FUNCTION – Ask pt. to write their
name
 THANK, COVER, COMFORT.
MRC Power Scale:
5 Normal power
4 +/- Movement against gravity plus resistance
3 Movement against gravity
2 Movement without gravity
1 Palpable contraction w/ no active mvmt
0 No active contraction
10
Lower Limbs PNS Examination  SENSATION – LIGHT TOUCH – ask
 WIPE (45 degrees or upright,
arms/legs fully exposed)
 INSPECTION – palsies, abnormal
movements, fasciculation, wasting,
tenderness
 TONE – rock legs, flick knee
upwards, look for clonus
 POWER:
Hip Adduction/Abduction (L1, 2)
“push your legs against me, pull legs
together...”
Hip flexion (L1, 2) – “leg straight, lift
whole leg off bed, don’t let me push it down”.
Knee flexion (L5, S1, 2) – “heel to you,
bring to bottom, don’t let me pull it away”
Knee extension (L3, 4) – “Now try to
push it down straight again, push me away.”
Plantar flexion (S1) – “Point your toes up
to the ceiling, and press down against me”
Dorsiflexion (L4, 5) – “Now pull up
against me, stop me pushing your toes down”
about numbness, use cotton wool,
eyes closed, test at sternum first.
 SENSATION – PAIN – pin along
dermatomes
 C5 – Lateral arm, C6 – Lateral
forearm +thumb/index, C7 – Middle
F, C8 – Pinkie, T1- Medial Forearm
 SENSATION – VIBRATION – do or
mention, 128Hz tuning fork, tester on
sternum first, test distally first, on
bony prominences
 SENSATION – MENTION
TEMPERATURE (since pain and
temperature both spinothalamic) –
dermatomal distribution, determine if
tuning fork is hot or cold
 GAIT – ROMBERG’S
 GAIT – WALK NORMAL - to point
and back, HEEL-TOE, WALK TIP TOE
 GAIT – CROUCHING AND
STANDING

 COORDINATION – HEEL-SHIN +
TAP –rub your heel from opp. knee
to foot, then tap my hand w/ foot,
repeat as fast as possible
 REFLEXES – tendon knee reflex, ankle
reflex, Babinski manoeuvre
 PROPRIOCEPTION – always
demonstrate up/down first, use finger
around both sides of the toe, eyes
closed, test peripherally first  THANK, COVER, OFFER,
COMFORT

11
12
Cranial Nerve Examination
 WIPE
 GENERAL INSPECTION – weakness,
myopathy, diplopia, tremor,
asymmetry, strabismus, eye position,
ptosis, pupil size, ARTICULATION
(say “red lorry yellow lorry”)
 CNI: OLFACTORY – ask problems
w/ smell or taste. Mention or do
testing nostrils separately w/ scents.
 CNII: OPTIC :
 CNII/III – PUPIL LIGHT REACTIONS
(direct, consensual, swinging)
 CNII/III ETC – ACCOMMODATION
(far  near)
 CNII – FIELDS (in confrontation, 1m
apart, correct eye covering and
movement, both sides and both eyes)
 CNII – INATTENTION (arms 1m
apart, wiggle fingers (l + r + both))
 CNII – ACUITY (ask about
problems, glasses or lenses)
Snellen chart, mini-chart or print up
close, test each eye separately.
 CNII – COLOUR (Ishihara plates)
 CNII – FUNDOSCOPY
 CNIII, IV, VI – Ask pt to mention
any double vision while keeping head
still.
 CNIII, IV, VI – H SHAPE – look for
nystagmus and saccades
 CNV: TRIGEMINAL – MOTOR
(look for wasting, ask pt to open
mouth, wiggle, clench teeth, palpate
temporalis and masseters)
 CNV – SENSORY (touch w/ cotton
wool, eyes closed, 3 levels comparing
13
sides (could do
pain/pinprick if
problematic))
 CNV/VII –
CORNEAL REFLEX
 CNV–JAW JERK
REFLEX
 CNVII: FACIAL –
MOTOR (look for
wasting, asymmetry.
Ask pt to frown, raise eyebrows,
screw eyes up, then against resistance.
“Show me your teeth, puff out cheeks”
and against resistance. Taste not
usually assessed)
 CNVIII:
VESTIBULOCOCHLEAR
 ACUITY AND BALANCE – ask any
problems w/ your hearing or balance?
 CNVIII- ACUITY (press
tragus/distract opposite ear and
whisper in other ear, both sides)
 CNVIII – RINNE’S (512 or 256Hz)
 CNVIII – WEBER’S (512 or 256Hz)
 CNIX: GLOSSOPHARYNGEAL
– ask any problems w/ your speech,
taste or swallowing?
CNIX/X – look in mouth, watch uvula at
rest and w/ pt saying aahh. Deviation away
from lesion
 CNIX/X – ask pt. to cough, swallow
 CNIX/X – GAG REFLEX (?sip water)
 CNXI – POWER – shrug shoulders
and against resistance, turn neck to
side and against resistance, palpating
opposite sternocleidomastoid
 CNXII: HYPOGLOSSAL –
examine tongue at rest (bulk,
 fasciculation), then on protrusion, - Arteries = light, small | Veins = dark, big
then waggle side to side, la la la etc.  EXAMINE FUNDUS (hard exudates,
Ask pt.to push finger through cheek a-v nipping or crossing, copper-wiring,
 THANK, OFFER HELP, COMFORT blot haemorrhages – hypertension,
soft exudates, flame haemorrhages,
Ophthalmoscopy new vessel formation – diabetes)
 EXAMINE MACULA (“look at the
 WIPE (dim lights, sit facing pt at the light” – vision should be 6/6 here)
same height), EXPLANATION AND  EXAMINE THE FRONT OF THE EYE
CONSENT. ? CHAPERONE - rack through lenses to focus on
 REMOVE PT’S GLASSES/ASK ABOUT different parts of the eye, try +10-12d
CONTACT LENSES  REPEAT PROCEDURE - OTHER EYE
 INSPECTION - ptosis, styes,  THANK PT, SWITCH LIGHTS ON,
squinting, inflammation, exopthalmos. REPLACE GLASSES etc…
 CHECK OPHTHALMOSCOPE (at 0,
don’t use full power light) Fundi Cheat Sheet
 WARN PT ABOUT BRIGHT LIGHT
 REST HAND ON PT’S FOREHEAD – Normal Fundoscopic View:
place thumb supraorbitally.
 START W/ NORMAL SIDE FIRST
 USE OPHTHALMOSCOPE
CORRECTLY (in right hand, use right
eye to look at pts right eye)
 Ask pt. to focus on distant point, level
to you, over your shoulder. Approach
at 15o laterally to their line of vision.
 RED REFLEX (from approx 1m,
look for opacities, or loss of reflex)
 FUNDOSCOPY – FOCUSING -
move as close to the patient as Normal Optic Disk: Pale pink/yellow,
possible, focus on blood vessels by round/slightly oval, with a crisp and well
scrolling through different lenses – defined margin against the retina.
may be easier to focus on iris first. Occasional surrounding ring may be
 FIND OPTIC DISC - use arrow sign present; at the centre is a pale
and follow blood vessels. physiological cup – note the cup-to-disc
ratio. It is 3-4mm nasally from the fovea.
 EXAMINE OPTIC DISC - focus - look
for cupping (glaucoma), papilloedema (
ICP). Check physiologic cup and border.
 VESSELS – inspect all quadrants
14
Abnormalities:
 VITREOUS – Opacities – asteroid
hyalosis, scars, DM – haemorrhages,
fibrous tissue, angiogenesis
 OPTIC DISC:
Papilloedema – Swollen, poorly
demarcated disc. Cx inc. Intracranial space
occupying lesions, tumours, abcess,
haematoma. Malignant HTN, Benign IC
HTN, Central Vein Thrombosis, CO2
Optic Atrophy – Pale disc, clearly
delineated. Pupil reacts consensually but
not directly. Cx. inc. MS, II Compression
(tumour, aneurysm), Glaucoma.
Papillitis – early sign of MS, it is ocular
inflammation restricted to the optic nerve
head.
15
Optic Disk Cupping – 2o to glaucoma
(vessels seem to fall down the disc)
Myelinated nerve fibres – streaky white,
irregular patches w/frayed margins, Benign,
Does not affect vision
 ARTERIOLES & VENULES – Calibre,
light reflex (silver wiring), AV Nipping
 QUADRANTS and MACULA –
Haemorrhages: Dot, Blue, Flame
Microaneurysms , Laser Scars
Exudates: Hard (well defined edges, light
reflex,), Soft (fluffy w/ill defined edges).
Hard exudates may form a ring (circinates)
in DM’s. Cotton Wool Spots
Hypertensive Retinopathy:
GRADE 1- Narrowed retinal arterioles,
increased light reflex – sliver wiring
GRADE II – AV Nipping
GRADE III – Malignant HTN: Flame (less
frequently) blot haemorrhages, cotton
wool exudates.
GRADE IV – Papilloedema e.g. venous
engorgement, elevation of optic disk,
haemorrhages adj. or over disk & blurring
of optic margins. Indicates cerebral
oedema and ICP)! Pre-eclampsia
Otoscopy
 WIPE (sit facing pt at the same ht,
access to both ears)
 EXPLANATION AND CONSENT
 ASK ABOUT PAIN/DISCOMFORT–
warn pt, start w/ normal side.
 CHECK OTOSCOPE ( turn on light,
use clean sterile speculum)
 USE OTOSCOPE CORRECTLY (hold
in R hand for R ear, hold it on its side
like a pencil, always advance under
direct observation)
 PULL PINNA UP AND BACK
(straighten external auditory meatus)
 POSITION OTOSCOPE NEAR
E.A.M. - advance under direct
supervision, up to the first row of
hairs but no further)
 OTOSCOPY – EXAMINE EAM (look
for swelling, redness, discharge, wax,
foreign bodies)
 OTOSCOPY – EXAMINE
TYMPANIC MEMBRANE (look for,
redness, swelling, perforation, bulging,
clear light cone indicates healthy TM)
 OTOSCOPY – EXAMINE BEHIND
TYMPANIC MEMBRANE (look for
bulging, inflammation, obvious
abnormalities)
 W/DRAW OTOSCOPE CAREFULLY
 THANK PT, SUMMARISE FINDINGS
± DIAGNOSIS
Cerebellar Examination
 WIPE, EXPLANATION AND
CONSENT (undress to light
underwear)
16
 INSPECTION (muscle wasting,
trunkal ataxia, fasciculation,
discoordination, slurred speech)
 ASSESS FOR TREMOR (use a piece of
paper to assess fine tremor and
intention tremor)
 GAIT (stride length, arm swing, ataxia,
observe co-ordination of turn. Ask pt
to walk heel-to-toe)
 ROMBERG’S TEST
 SPEECH (ask pt to repeat “baby
hippopotamus” and “british constitution”)
 VISION (?changes, double vision etc)
 ASSESS NYSTAGMUS or SKEW
DEVIATION
 CHECK for DYSDIADOKOKINESIA
 COORDINATION – ARMS
(intention tremor, past pointing, lack
of co-ordination)
 COORDINATION – LEGS (run heel
down shin. toe to hands)
 TONE – ARMS (hypotonia, assess
shoulder, elbow and wrist movement)
 TONE – LEGS (roll leg side to side,
look for toe swing, flick knee up and
watch heel)
 REFLEXES – ARMS (biceps, triceps
and supinator. Look for hypo-reflexia)
 REFLEXES – LEGS (knee and ankle .
look for hypotonia)
 THANK PT, HELP GET DRESSED
Pastries help digest cerebellar disease...
Dysdiadokokinesia Paraneoplastic Synd.
Ataxia Abcess/Atrophy
Nystagmus Stroke and MS
Intention Tremor Trauma
Scanning dysarthria Raised ICP
Hypotonia Infection –EBV,CPox
Ethanol & Poisons
Spinocerebellar Atax
Speech Examination
 INSPECTION – Raynaud’s, CREST,
thyroid, Hemiplegia, or other dx
assoc. w/dysphasia, Nystagmus,
Intention tremor, Parkinsonisms
 QUESTIONS: “What is your Name,
Address, items you had for lunch”
 ARTICULATION: “British Constitution,
Baby Hippopotamus, West Register St.”
 CONDUCTION APHASIA-
Repetition of above...
 SPASTIC DYSARTHRIA:
Cerebellar – Slurred, jerky, Explosive
Psudobulbar Palsy – Indistinct, Suppressed,
w/o modulations, “hot potato, Donald duck”
PD – Monotonous, oaccent/emphasis, slur
Mytonic Dystrophy – Slurred &
Suppressed
Huntingdon’s Chorea – Slurred,
Monotone
 FLACCID DYSARTHRIA – Bulbar
palsy: Nasal w/ decreased modulation,
slurring of labial and lingual consonants
“pa,la”. VII, IX, X, XII Paralysis
 MYOPATHIC DYSARTHRIA – My.
Gravis – Weak hoarse voice w/nasal
quality, pitch unsustained, soft accents.
 VARIEGATED DYSARTHRIA
Thyroid: Low pitch, catarrhal, hoarse,
croaking, guttural voice (sounds like
tongue>mouth).
Amyloidosis: Large tongue
Mx Ulcers – Some speech indistinct
Parotitis/Temporomandibular Arthritis –
Monotonous, suppressed, badly modulated
17
 COMPREHENSION – Don’t gesture:
“Tongue out, Shut your eyes, Touch your
nose”. Good = Expressive, Bad =
Receptive Aphasia
 NOMINAL DYSPHASIA – Display
keys “what is this? Is it a spoon, is it a
pen, is it keys?” Test ability to form
sentences e.g. “Where do you live and
how would you get home from here?”
 OROFACIAL DYSPRAXIA – Test firs
w/o gesture: “Show me your teeth, move
your tongue from side to side”, Rpt.
w/gesture. ?Ideational or ideomotor
dyspraxia (lesions in the operculum)
 AMTS
Differential Diagnosis Screen
V Vascular and Ischaemic
I Inflammatory and Infectious
T Trauma and Surgery
A Acquired inc. Drugs
M Metabolic
I Idiopathic & Iatrogenic
N Neoplasm / Malignancy
C Congenital and Genetic
D Deficiencies
Investigations:
Cultures, Bloods (A/V), Imaging, Functional
tests, Scopic and Biopsies
Treatment: Conservative, Medical, Surgical
Surgical Sieve – causes for lumps etc:
Infection (Acute, Chronic, Acute on Chronic) –
can be viral, bacterial or fungal
Neoplasm – Benign, Malignant (1 or 2o)
Mechanical - Strictures, Obstructions
The TRAUMA Rapid Patient Assessment Tool – DRsAcBCDEEEFG

Danger – to yourself/pt. Think of a SAFE response

Response (AVPU) – Call from afar, shout “open your eyes” in both ears, pinch trapezius!
shout for help if unresponsive / needed...
Airway - ?Patent, controlled, clear, trachea central. Consider adjuncts & O2 (Note SpO2)
c-Spine – immobilise with collar, sizing appropriately,
Breathing (ATOMFC)– Asthma/Allergies (bronchospasm/silent chest – Tx Anaphylaxis)
Tension (surgical emphysema/deviation), Open (Sucking), Massive Haem’x (dullness) - Tx
drain/tape up, Flail Chest (crepitus), Cardiac Tamponade (muffled sounds) Tx - decompress
Circulation – Stop Haemorrhage. Check Pulses, mark (X) and BP, 14G cannula in ACFossa
Disability – Get GCS, ?Fractures, CNS deficits – sensory and motor. Consider Analgesia
Expose, Examine, Environment – 2o Survey w/appropriate thermoregulation. ?Extricate
Fluids & Electrolytes, Foetus – Bolus Challenge, check chemistry & resus, check if pregnant
Glucose, Get Obs – Pupils, HR, CRT, RR, BP, GCS, Temp, Blood Glucose, ECG
Form a Revised Trauma Score, get two sets of Obs if needed and GO!

Glasgow Coma Scale

E
Y 4 Spontaneous (alert) 2 In response to pain
E 3 In response to any speech 1 Absent
V 5 Orientated – pt knows who he is, where he is and why, the year, season, month
E 4 Confused – patient responds in a conversational manner, but there is some
R disorientation and confusion.
B 3 Inappropriate speech – random/articulated speech, no conversational exchange
A
2 Incomprehensible speech – moaning but no words
L
1 None
6 Obeying command – pt does simple things you ask (beware grasp reflex)
M
O 5 Localizing response to pain – elicit pain w/ fingernail bed pressure (w/ pencil),
T
parasternal rub, pressing on supraocular/supraorbital area. Purposeful
movements towards changing painful stimuli is a ‘localizing’ response
O
R 4 Withdraws to pain – pulls limb away from painful stimulus
3 Flexor response to pain – pressure on nail bed causes abnormal flexion of limbs
– decorticate posture/rigidity
2 Extensor posturing to pain – stimulus causes limb extension (adduction, internal
rotation of shoulder, pronation of forearm) – decerebrate posture/rigidity
1 No response to pain
SCORE = BEST E/V/M : GCS ≤8 severe injury | 9-12 moderate | 13-15 minor

18
 Abbreviated Mental Test

 Warn patient not to worry or be concerned about their answers. 

 EMPOWER PATIENT TO ASK IF THEY DON’T UNDERSTAND, BE POLITE
 SPEAK CLEARLY, NON-PATRONISING
1. Age 2. DoB 3. Time (TO NEAREST HOUR) 4. Year (allowing for Dec/Jan)
10a. “I would like you to remember this address: 42 WEST STREET. Please repeat it back.” - get
the patient to repeat it back instantly.
5. Where are you (name of institution)?
6. Recognition of two people e.g. porter, doctor, family member
7. Dates of WWII or other substitutes (WWI – 1914-18, WWII – 1939-45)
8. Name of present monarch/prime minister.
9. Count backwards from 20 to 1 – don’t stop them prematurely
10b. “Please repeat back to me the address I asked you to remember.”
 ADD SCORE UP (OUT OF 10 POINTS) & INFORM EXAMINER OF THE SCORE
 INTERPRET (8+ normal, 7 borderline, 6 or less is cut-off to separate normal elderly
persons from those confused or demented w/ a correct assignment of 81.5%)

Mini Mental State Examination - 30 p oi n t sc al e

Orientation 1. What is the year, season, date, month, day (1 pt. each)?
2. Where are we? Country, county, town, hospital, floor (1 pt. each)
Registration 3. Name 3 objects, taking 1s to say each. Then ask the pt. to repeat them.
(1 pt. each) Repeat the q. until the pt. learns all 3.
Attention & 4. Serial sevens (1 pt. each). Stop after 5 answers. Alternatively spell
calculation “world” backwards.
Recall 5. Ask for the names of the 3 objects asked in Q3 (1 pt. each).
Language 6. Pt. to ID a pencil & a watch. Have pt. name them for you (1 pt. each).
7. Have the pt. repeat “no ifs, ands or buts” (1 pt.)
8. Have the pt. follow the 3-stage command “Take the paper in your R hand,
fold paper in half, put paper on the floor”. (3 pt.s)
9. Have the pt. read and obey the following: “Close your eyes” (in large
letters). (1 pt.)
10. Have the pt. write a sentence of their choice – it must have a subject
and an object and make sense. Ignore grammatical errors. (1 pt.)
11. Have pt. draw 2 intersecting pentagons – give 1 pt. if all the angles are
preserved & if the intersecting sides form a quadrangle.

Interpreting Scores: 25-30 = Normal, 21-24 = Mild, 10-20 = Moderate, ≥9 = Severe

19
GALS Screen  INSPECT FROM FRONT -
“HANDS BEHIND HEAD AND FORCE
 WIPE, EXPLANATION AND ELBOWS BACK” (symmetrical full range
CONSENT (undressed to light of pain free movement)
underwear)  ARMS DOWN AND PALMS
 PRIVACY AND CHAPERONE FORWARD (deltoids, elbow extension,
 ASK THREE SIMPLE SCREENING normal quads, knees, foot arches, varus,
QUESTIONS: valgus deformities)
“Pain/stiffness in muscles, joints, back?”  “HANDS OUT IN FRONT, PALMS
“Can you dress completely w/out any DOWN” (PRONATION)
difficulty?”  “TURN YOUR HANDS OVER”
“Can you walk up and down stairs w/out (SUPINATOR), PALMS (elbows fixed,
any difficulty?” radioulnar joint movement, symmetry,
swelling wasting deformity, skin/nails)
 INSPECT GAIT – “walk to the wall
and back” – symmetry, smooth, arm  “MAKE A TIGHT FIST/SQUEEZE MY
swing, no pelvic tilt, stride length, quick FINGERS”
turn, Parkinson’s, Trendelenberg,  “ANY PAIN WHEN I SQUEEZE YOUR
antalgic, high-stepping gaits FINGERS?” (Watch patient’s face, 2nd-5th
 INSPECT GAIT – “WALK HEEL TO MCP)
TOE” (cerebellar disorders)  “TOUCH TIPS OF FINGERS TO
 ROMBERG’S TEST THUMB IN TURN”
 INSPECT FROM BEHIND -  ASK PT TO LIE ON COUCH (45
“STAND W/ BACK TO ME” (check DEGREES) – TELL ME IF ANY
shoulder, paraspinal bulk, buttons, DISCOMFORT
scoliosis, leg muscle bulk, iliac crests  HIP AND KNEE FLEXION (feel for
level, calf muscles, Achilles tendons) crepitus at the knee)
 PALPATE SUPRASPINATUS BULK,  HIP INTERNAL ROTATION
PINCH TRAPEZIUS (Hyperalgesia)  KNEE – TEMPERATURE AND
 INSPECT FROM SIDE (knee PATELLA TAP. ?EFFUSION
position, lordosis, kyphosis)  ANKLE MOVEMENT (FLEX,
 PLACE TWO FINGERS ON BACK, EXTEND, INVERT, EVERT)
TOUCH TOES, LEG STRAIGHT -  SQUEEZE MTP JOINTS
FLEXION AND EXTENSION (lumbar  INSPECT SOLES
expansion)  STATE/DO – IF ABNORMALITIES
 INSPECT FROM FRONT – “OPEN FOUND A MORE DETAILED
MOUTH, MOVE JAW SIDE TO SIDE” – EXAMINATION PERFORMED
TMJ movement  THANK, HELP, CHECK PT
 INSPECT FROM FRONT – NECK
MOVEMENTS (all 3 planes)

20
 Lumps and Bumps Examination
 Pulsation, Pain
 Mobility
 Site, Size, Shape, Surface, Surrounding Tissues, Sounds
 Colour, Contour, Consistency
 Edge
 Numbers
 Temperature, Tethering, Transluminenscence, Tenderness - !
1. WIPE “I understand that you’ve found a
lump on your… Would it be alright if I
examine it? Please could you show me exactly
where it is?”
2. Inspect mass carefully. Note site, size,
shape & changes in overlying skin.
3. Lay hand on mass to see what the
temperature of the skin and the lump itself
is.
4. Gently palpate the lump to elicit any
tenderness. This will also allow you to
accurately define the size and shape of the
mass. Record finding diagrammatically.
5. Keep hand on lump for a moment to
check for pulsation. If +ve, decide if
referred pulsation or from mass itself (2
fingers either side, upwards and outwards
= from the mass itself).
6. Assess consistency (cystic, solid, hard,
soft, fluctuant), surface texture and
margins.
7. Attempt to pick up a fold of skin over
the swelling to assess skin fixation, and
assess the mobility of the skin on the
contralateral side.
8. Determine fixation to deeper
structures by attempting to move swelling
in different planes relative to surrounding
tissues. Contract the muscles around it to
21
see if it is attached to them. ? tethered to
fat or bone in >2 planes
9. Look for fluctuation by compressing
the swelling suddenly with one finger,
using another finger to determine if a
bulge is created – confirm the presence of
fluctuation in 2 planes.
10. Auscultate for vascular bruits and
other sounds.
11. Test for transillumination – A cystic
swelling will light up if the fluid is
translucent, provided covering tissues are
not too thick.
12. Examine neighbouring lymph nodes.
These may be enlarged due to spread of
Ca or inflammation from infection.
 “Sudden” finding of a lump by a pt. does
not necessarily imply that it has only
recently developed. Important to ask if
there has been any change in size or other
characteristics since it was first detected,
and whether there are any associated
features such as pain, tenderness or
colour changes. History of preceding
events may also be of diagnostic help.
Sometimes physical examination will reveal
a lump of which the pt. is unaware.
Thyroid Examinatio n
 WIPE, EXPLANATION, CONSENT,
CHAPERONE
 POSITION, EXPOSURE, COMFORT
(sitting, expose neck to clavicles)
 CHECK IF PATIENT HAS ANY
TENDERNESS
 SYMPTOMS – pressure symptoms, like
dyspnoea or dysphagia, hoarseness of
voice (e.g. recurrent laryngeal nerve
infiltration by cancer),
hyperthyroid/hypothyroid symptoms.
 GENERAL INSPECTION -
anxious/fidgety/thin/wasting hands, face,
shoulders/hot(hyper);
slow/lethargic/fat/cold (hypo)
 VOICE - hoarseness/dysphasia (hypo) –
ask patient to say their name.
 HANDS - toxic signs – moist, hot,
sweaty, tremor w/ fingers spread
(hyper); dry/cold (hypo); thyroid
acropachy (like clubbing but in
association w/ Grave’s disease)
 PULSE – tachycardia, atrial fibrillation
(hyper); bradycardia (hypo)
 EYES (front and sides) - exopthalmos –
lower cornea and sclera visible in
Grave’s disease (due to ↑orbital fat,
oedema, cellular infiltration) Lid lag (ask
patient to follow your finger up and
down) and lid retraction (spasm of the
smooth muscle in the upper eyelid
reveals upper border corneoscleral
junction) – both hyper. Also look for
diplopia/opthalmoplegia.
 INSPECT MOUTH – LIPS, MUCOSA,
TONGUE, THROAT
 INSPECT NECK (FRONT, SIDES) –
asymmetry, punctum ,erythema,
22
eczema, scars, goitre, discharge,
pulsations, distend veins
 ASK PATIENT TO POKE TONGUE
OUT – WATCH FOR
THYROGLOSSAL CYST
 ASK PATIENT TO TAKE WATER,
HOLD, SWALLOW (FRONT, SIDE)
(GOITRE)
 PALPATE – FROM BEHIND – GET
PATIENT TO SWALLOW (ascertain
tenderness, size, shape, single/multiple
swellings, smooth/nodular, consistency)
 EXAMINE CERVICAL LYMPH NODES
 WARN PATIENT BEFORE TRACHEAL
PALPATION
 PALPATE TRACHEA FOR
DEVIATION, CRICOSTERNAL
DISTANCE
 PERCUSS STERNUM/SWALLOW
 AUSCULTATE THYROID – ASK
PATIENT TO HOLD BREATH
 LIMBS - proximal myopathy (stand from
a chair w/out using hands a sensitive
indicator of hypo/hyper). Pretibial
myxoedema (puffiness on shins,
Grave’s).
 SAY YOU’D LIKE TO – EXAMINE
REFLEXES - assess the reflexes
(delayed, slow-relaxing in
hypothyroidism).
 SAY YOU’D LIKE TO – EXAMINE
FOR OTHER - Pericardial effusion,
carpal tunnel, and ascites are features of
hypothyroid.
 SAY YOU’D LIKE TO – EXAMINE
FOR THYROID FUNCTION - If goitre
is suspected
 THANK, CHECK COMFORT
Peripheral Vascular System
Examination
 WIPE, EXPLANATION, CONSENT,
CHAPERONE (lying w/ legs & arms
exposed)
 GENERAL INSPECTION – Scars,
ulcers, gangrene, amputations, wasting,
CRT
 RADIAL PULSES (Rate, Rhythm, Radio
Radial delay)
 BRACHIAL PULSES
 BLOOD PRESSURE – both arms
 CAROTID PULSE (auscultate, palpate)
?Aneurysms, bruits, narrowing
 ABDOMINAL VESSELS (palpate &
auscultate for AAA, check renal bruits)
 INSPECT LEGS – gangrene, ulcers, skin
change, (pallor/red), varicose eczema,
hair loss, scars, varicosities, disuse
atrophy, and swelling.
 INSPECT FEET – between toes, heels,
look for ulcers and discolouration.
 ASK PATIENT for ?leg tenderness
 LEG TEMPERATURE – compare w/back
of hands (skin colder in ischaemic unless
infection)
 CAPILLARY REFILL (nailbed on each
foot - <2s)
 FEMORAL ARTERY (palpate,
Auscultate, compare, ?radio-femoral
delay)
 POPLITEAL ARTERY
(+FLEX/EXTENDED, SFA BRUITS)
 POSTERIOR TIBIAL ARTERY (midway
between medial malleoulus and heel)
 DORSALIS PEDIS ARTERY (slightly
ever leg, feel along a line extending
between middle of a line drawn
23
between two malleoli and webspace
between 1st + 2nd toes)
 EXTRA – BURGER’S TEST - (Check
pain/mobility first) – elevate leg to
~>45º, look for ischaemia (leg goes
white), hang leg off bed at 90º, watch
for reactive hyperaemia
 EXTRA – TRENDELENBERG TEST –
Describe location of SFJ (5cm below
and medial to femoral pulse), Occlude
w/ tourniquet, elevate leg to empty
veins, ask pt to stand and watch for
rapid filling of veins
 EXTRAS:
 TEST FOOT SENSATION
 ABPI - Arterial Brachial Pressure Index
 THANK, COVER, OFFER COMFORT
 ABPI should be 1+ in supine position.
 Claudication: <0.8
 Critical ischaemia: <0.4.
 Remember the 6 P’s of acute limb
ischaemia:
Pulseless, pallor, perishingly cold,
paraesthesia, paralysis and pain (and
squeezing muscles!)
How do you record pulses? Normal +
Decreased +/- , Absent - , Aneurysmal ++
Breast Examination  COVER PT, CHECK COMFORT (don’t
thank pt)
 WIPE @ 45o, EXPLAIN, CONSENT,  EXTRAS:
PRIVACY AND CHAPERONE  Examine liver for mets (if lump +ve)
 ASK PT - ?PAIN, DISCOMFORT,  AUSCULTATE FOR PLEURAL
DISCHARGE (!pt elicits), LUMPS EFFUSIONS/EXAMINE THE SPINE
 GENERAL INSPECTION –cachexia,  MAMMOGRAPHY OR USS (<35yrs)
swollen arms, size, shape, asymmetry, Record findings as follows:
contour, colour, venous pattern, local
swelling, nipple changes (inversion,
Paget’s (unilateral), eczema (bilateral)),
Peau d’orange (sweat glands/Cooper’s
ligaments)
 INSPECTION POSITION – relaxed w/
arms by sides (relaxes pectorals)
 INSPECTION POSITION – arms raised Skin Examination
above head (tightens suspensory
ligaments, skin puckering) 1. WIPE & Ensure good illumination
 INSPECTION POSITION – hands (preferably natural light).
pressed firmly on hips (tenses pectorals) 4. Measure Lesion Dimensions - helpful
 INSPECTION POSITION – learning assessing progression and regression.
forward 5. Attempt to transilluminate fluid swellings.
 Pt @ 45º, check comfort, arms behind
6. Assess skin colour and variations.
head. Start with normal breast first.
7. Describe the primary morphology of a
 PALPATE BREASTS up and down (2
localised skin lesion:
SIDES) – use palmar surface of fingers,
work around breast in a systematic way • Macule, Patch, Papule, Plaque, Wheal,
Vesicle, Nodule, , Petechia or ecchymosis,
 PALPATE AREOLA REGION (2 SIDES)
Bulla, Telangiectasia, spider naevus
 PALPATE AXILLARY TAIL (2 SIDES)
8. Describe the secondary characteristics:
 DEFINE ANY MASSES AND
• Superficial erosion, Ulceration, Crusting,
DETERMINE TETHERING (hands
Scaling, , Fissuring, Lichenification, Atrophy,
pushed on hips before and after testing Excoriation, Scarring or keloid,
movement)
9. Describe the distribution of a more
 SIT PATIENT UP AND REST widespread rash or colour change
APPROPRIATE ARM ON YOUR ARM
10. Assess temperature of the affected area.
 PALPATE AXILLA (medial, lateral,
posterior, anterior, apex) 11. General Exam, looking for evidence of
systemic disease.
 PALPATE cervical, supra/infraclavicular
lymph nodes

24
Inguinal Hernia Examination  FINISH – Percuss & Ausc. for BSS & gas
 Check other side, and abdo exam.
 WIPE, EXPLAIN, CONSENT,
PRIVACY AND CHAPERONE Indirect Direct
- “stand up”, examine both regions Origin Via Int. Ring, Via posterior
lateral to wall of inguinal
 INSPECTION:
inferior canal, medial to
Inguinal – bulges into the corner of the epigastric inferior
mons veneris, above the groin crease vessels epigastric
Femoral – bulges into medial end of groin vessels.
crease. Check for Scrotal Involvement. Mech. May be Acquired, rare
 PALPATION – FRONT: Examine congenital in childhood
Scrotum & Contents. If you can get Strangulation Common Rare
above it, it’s oHernia. N.B. Infant Scrotum Ext. Often Rare
hydrocele extends up the cord. Reduces on Not readily Spontaneous
 PALPATION – SIDE: Stand at side of lying
hernia. Place a hand in the small of pt’s Recurs post Uncommon Common
back to support, and examining hand surgery
on the lump w/fingers and arm roughly
parallel to inguinal ligament. External Genitalia Examination
 LUMP EXAM – MSCENT
 COUGH IMPULSE – compress lump  WIPE – Gloves and Standing. Kneel by
firmly w/fingers. “cough”. Mvmt of side
swelling w/o expansion or increased  INSPECTION–Lift up and look at
tension is not a cough impulse. !as everything.
absence may be due to adhesions.  INSPECTION – PENIS – Size, Shape,
 REDUCIBILITY – Use flat of hand from Skin Colour, Foreskin, Discharge,
below the lump, lifting the lower end Scaling/Scabbing around distal edge
upward and backwards. Press firmly to  PALPATION – Texture, assess dorsal
relieve tension. Squeeze towards the vein. Retract prepuce to examine skin on
deep inguinal ring. Reduces to: inner aspect, glans and external urethral
Above & medial to the PT –Inguinal. meatus. ?Discharge
Below & lateral to PT - Femoral  INSPECTION – SCROTUM & SKIN
 IN/DIRECT – No correlation w/surgical ? Reddened, Tethered, Fixed. Check posterior
findings. If controlled w/direct pressure aspect. ? Size, Shape, Symmetry.
over internal ring = direct. If not,  PALPATION – SCROTUM – support
indirect. with hand, feel testis & other lumps b/w
 RELEASE & WATCH: index & thumb. ?2 testes. Position &
Indirect = Slide obliquely through canal. nature of testis, epididymitides & cords.
Direct = Project directly forward  LUMPS – can you get above it? If not
then an inguinoscrotal hernia.
25
Transilluminable – Hydro/Spermatocele
? Expansile Cough Impulse, Separate from
testis, Cystic or solid?
Separate Cystic: Epididymal cyst/Spermatocele
Separate Solid: epidiymitis
Testicular Cystic: Hydrocele
Testicular Solid: Tumour, Orchitis, Granuloma,
gumma
Bag of Worms: Varicocele
 LYMPH – Penis, Scrotum, Inguinals.
Covering of testis & cord. Internal
common iliac. Body of testis.
Hand Examination
 WIPE – White Pillow w/elbow exposed
 INSPECTION – FACE:
Systemic sclerosis (expressionless,
telengeictasis), Cushingoid (Steroids in RA),
Exopthalmos (Thyroid)
 ELBOWS – “Place hands on shoulders” –
look for psoriasis/rheumatoid nodules
 INSPECT HANDS – Conditions inc:
-Phalangeal -Boutonniere’s/Z Thumb,
Triggering, Swan Neck
-MCP –Volar sublux, ulnar deviation
-Wrist –Disruption, Ulnar Sublux
-Elbow – Rheumatoid Nodules
-Gout: Asymmetrical swelling, tendon tophi
-Sys. Sclerosis: Sclerodactyly w/finger tapering,
fingertip gangrene, calcified nodule, tight skin
-Psoriasis: Nail pitting, Scaly rash, terminal
interphalangeal arthopathy
 INSPECT HANDS:
Nails: Onycholysis, Fold Infarcts (RA)
Skin Colour: Icterus, erythema, pigmentation
Consistency: tight/shiny, paper thin, purpura
26
Lesions: Vasculitis, Neurofibromata, Telang.
Muscles: Thenar Eminence Waste (Median
N Lesion), General Wastage w/ thenar
sparing (Ulnar N Lesion), Generalised (T1
lesion), Fasciculation – MND, Syringomyelia,
Charcot-Marie-Tooth, old polio
 PALPATION – joints for temp,
tenderness (active disease). Look for:
Dupuytren’s, nodules, calcinosis, xanthomata.
OAnodes: Heberden’s = DIPs,
Bouchard’s = PIPs (varus knee deformity,
Trendelenburg +ve)
 SENSATION - ?Numbness (worse
nocte- Carpal Tunnel)
Median - Index pulp, !thenar eminence, flex.
aspects of radial 3½ digits upto ext. Nail beds.
Changes with Carpel Tunnel Syndrome.
Ulnar – Pinkie pulp, ! palmar/dorsal side of
ulnar 1and ½ fingers
Radial – dorsum of 1st Intermetacarpal space
 PROPRIOCEPTION & VIBRATION
 TONE – flex/ext joints
 MOTOR:
“Open/close hands quickly” – Myotonic
Dystrophy
“Squeeze my fingers” – C8/T1
Radial – “fingers out straight, stop me bending
them” (C7) !Wrist Drop
Ulnar – DAB & PAD tests !Claw Hand –
(hyperextended metacarpophalangeal joints)
Median – APB & OP, !Thenar Eminence
waste and weak pincer grip
 FUNCTION – “undo a button, hold pen,
pick up paper”
 PULSES
Elbow Examination
 WIPE – Stand, check affected
 INSPECTION – front/back/sides,
?carrying angle
 PALPATION – for temp, tenderness
 PALP – lat/medial epicondyles,
olecranon process, radial head.
 MOTION – ACTIVE Ext, Flex,
Supination, Pronation, then PASSIVE
 MOTION – RESIST – Flex, Ext,
Sup/Pronation
 FUNCTION – Eating, Brushing hair
 SPECIAL TESTS - ?Tennis, ?Golfers
Shoulder Examination
 WIPE – Standing, check affected
 INSPECTION – ? front/back/sides
Symmetry, Scars, Swelling, Muscle Bulk
 PALPATION – for temp, tenderness
 PALPATION – SCJ, clavicle, ACJ,
Acromium, Scapula, Medial Border,
Inferior Angle, Lateral Border,
Acromium + other side.
 PALP = Effusions – Joint lines & humeral
head
 PALP – Supraspinatus, Trap, Infra,
 MOTION – Good first– ACTIVE:
Abduction, Flex, Ext. External Rotation
(together), Int. Rtn, Arm across chest.
Repeat PASSIVELY – palp. @ joints for
creps.
 MOTION – Resisted – Int/Ext Rtn,
Abduction (s.spinatus, then pec. Major
and lat. Dorsi, then deltoid@90o,
trapezius @ 120o), flex/ext, biceps ext,
empty can test (SSPinatus).
27
Cervical Spine and Neck
 WIPE – Stand
 INSPECTION – front/back/sides –
?Symmetry, height of shoulders, Scars,
Swelling, Muscle bulk/waste, erythema,
ease of wt. Bearing, shape, bruises
 PALPATION - for temp, tenderness
 PALP – Soft tissues – Trap, SSPinatus,
Rhomboids, ISpinatus, Lat. Dorsi,
spinous processes.
 MOTION – ACTIVE – Rotate L/R, Flex,
Ext, Side Flex (L/R), rpt. PASSIVE
 MOTION – RESIST – Flexion (C1), Ext
(C2), Side Flex (C3), Shoulder girdle
Elevation (C4), Shoulder Adduction
(C5), Elbow Flex (C6), Ext (C7), Thumb
Ext (C8).
 SENSATION – Dermatomes
 REFLEXES – biceps, triceps and BR.
Lumbar Spine Examination
 WIPE – Stand, check affected
 EXAMINE – front/back/sides
 INSPECTION – ?Symmetry, height of
shoulders, Scars, Swelling, Muscle
bulk/waste, erythema, ease of wt.
Bearing, shape
 LIE PRONE
 PALPATION – for temp, tenderness
 PALP – bony landmarks along spine,
spinous processes, iliac crests,
paraspinal muscle, SI joints.
 STAND
 MOTION – Place hand at lumbar spine
Flexion forwards – “run hands along leg from
knee – bend forward”
Extension – “hands on hips and lean back”
Side Flex – “slide hand along one side to knee”
 LIE SUPINE
 MOTION – MYTOTOMES RESIST –
check myotomes
-Hip Flexion (L2), Extension (L3)
-Foot Dorsiflexion (L4)
-Resist Hallux Extension (L5)
-Resist foot Inversion (S1)
- Resist Plantar Flexion (S2)
 SENSATION – Dermatomes, !thigh
 REFLEXES – Knee (L3/4), Ankle Jerk
(S1/2), Babinski
 MOTION – Straight leg, raise w/ foot
dorsiflexion – enquire if pain worsens.
Hip Examination
 WIPE – Stand
 INSPECTION – front/back/sides, bulk,
deformity, scars, colour, gait
 Trendelenburg Test
 LIE SUPINE
 PALPATION – for temp
 DEEP PALP – G. Trocanter,
 CHECK LEG LENGTH :
True: ASIS to Medial Malleolus
Apparent: Umbilicus to Medial Malleolus
 MOTION – Flex/Ext, Int/Ext Rtn,
Abd/Adduction. Rpt PASSIVE w/ hand
on joint. Rpt RESISTED
 THOMAS’ TEST – hand under back and
flex knee to hip
 LIE PRONE
 Active ext, Passive ext.
Knee Examination
 WIPE – Supine + Expose Quads
28
 EXAMINE – Baker’s Cyst, Valgus
(knock-kneed), Varus (bow-legged),
antalgic gait
 INSPECTION – Masses, Scars, Lesions,
Trauma, Swelling (?Medial Fossa
Oedema)
 INSP – Muscle bulk & Symmetry, esp.
atrophy of medial aspect of quads –
vastus medialis, Patella displacement.
 PALPATION – for temp
above/on/below patella
 PALPATION – joint line tenderness:
flex knee & palpate joint line w/ thumb
 PALP = Effusions – Patellar Tap,
Ballotment, Bulge Sign
 MOTION – FULL R.O.M = 0-135o
 ? Crepitus
 ACL – Ant. Draw and Lachman
 PCL, MCL and LCL
 McMurray Test – rotate leg and extend
knee
 Med Meniscus -ext Rtn w/lat force -mel
 Lat Meniscus – int Rtn w/medial force
Ankle and Foot Examination
 WIPE – Stand, check affected
 INSPECTION – front/back/sides,
?Symmetry, varus/valgus, shape, gait
 Check footwear
 LIE SUPINE
 PALPATION – for temp, tenderness
 PULSES – Dorsalis Pedis, Post. Tibialis
 BONY PALP – Med/lat malleoli, joint
line, calcaneum, plantar fascia insertion,
fascia, medial longitudinal arch, 1&5th
MPJs
 MOTION – ACTIVE – Dorsi/Plantar Hypervolaemia:
flexion, Inversion, Eversion – PASSIVE Intravascular:
inc. toe flex/ext.
High BP, Raised JVP, HS III, Pulm. Oedema
 RESIST – dor/plant. flex, ever/inversion,
Extravascular:
toe flex/ext.
Oedema, 3rd Space Fluid -Pleural, Peritoneal
 ANKLE DRAW TEST – checking ant.
talo-fibula ligament
Hypovolaemia Class:
 REFLEXES – Ankle & Babinski
 LIE SUPINE 1 2 3 4
 Palp. Muscle bulk, Ach. tendon, temp, %loss <15 15-30 30-40 >40
 SIMMONDS TEST – Achilles Tendon Vol (l) <3/4 750- 1500- >2000
integrity 1500 2000
Sys N N  
Volume Status Assessment Dia N   
HR N 100- 120 120+
 Skin Turgor 120 Thread V.Thready
 Mucous Membranes – Dry? RR N >20 >20
 Pulse & BP : Resting , postural drop Urine >30 20-30 10-20 0-10
(BP) , ! autonomic neuropathy ml/m

 JVP CRT N Pale Pale Cold &

Clammy
 Oedema, Effusion, Ascites
Appear N Pale Pale Ash
Daily Weight, Urine Output & [conc]
Mental A Anger As 2 +/- As 3 +/-
State Angst Drowsy confusion/
Pitting Oedema Scale: LOC
1-Mild - slight indentation, no perceptible
swelling of the leg Explaining Procedures
2- Moderate, indentation subsides rapidly
3- Deep, indentation remains for a short  WIPE (greets, states name and role,
time, leg looks swollen confirms patient’s name and DOB)
4- Very deep, indentation lasts a long time,  EXPLANATION AND CONSENT
leg is very swollen (purpose, time available)
 EXISTING KNOWLEDGE (ask what pt
knows about procedure, ever had it before
Hypovolaemia:
or know of anyone who has)
Intravascular:
 TELL THE PT YOU CAN FIND OUT
Cool, clammy, peripheral cyanosis, CRT, ANY INFO THAT YOU DON’T KNOW
weak & rapid pulse, BP, postural drop
Extravascular:
Tissue Turgor, Dry Mucous Membranes
29
(e.g. specific concerns about times etc these
are covered in the appt. letters, and they
can ring the hospital to confirm details)
 ENCOURAGE QUESTIONS (tell them
to ask any q’s, or interrupt if they don’t
understand)
 ELICIT WORRIES/CONCERNS (
particularly about pain/embarrassment)
 EXPLAIN WHAT THE PROCEDURE IS
(why they are having it, what will happen)
 EXPLAIN WHY THEY’RE HAVING IT
(if you know why/if they specifically ask)
 EXPLAIN WHAT WILL HAPPEN
BEFORE THE PROCEDURE (where they
will have to go, will they need to bring
someone, any preparations such as laxatives,
food restrictions, medication changes,
reassure them about the discomfort,
embarrassment)
 ASK ABOUT ANY MEDICATIONS
(esp. about anti-coagulants and insulin, tell
them to consult their GP or specialist
before they stop taking etc)
 EXPLAIN WHAT WILL HAPPEN
DURING THE PROCEDURE (how long it
will take, sedation, analgesia, biopsies,
monitoring, who will be present, how long
till results)
 ASK ABOUT PREVIOUS ALLERGIES
(particularly to analgesia or sedatives, what
happens etc…)
 EXPLAIN ABOUT THE RESULTS
(when they will get them, from who, what
they might show)
 EXPLAIN WHAT WILL HAPPEN
AFTER THE PROCEDURE (getting home,
length of stay, sedations effects, when they
can go back to work, what they can / can’t
do, food restrictions)
30
 EXPLAIN CAREFULLY ABOUT RISKS
AND SIDE-EFFECTS (reassure about
radiation does, sedative reactions,
pain/bleeding from biopsies, what is normal
or abnormal)
 CHECK THE PATIENTS
UNDERSTANDING
 ASK IF THEY HAVE FURTHER Q’S
 ASK AGAIN ABOUT CONCERNS
(e.g. if anything you have said worries them)
 THANK AND REASSURE PT
Injections
 WIPE, GLOVES, SET UP EQUIPMENT
 CHECK DRUGS (expiry date, correct
drug, seals intact, correct dilutant etc)
 CLEAN SITE (alco swab, allow to dry)
 CORRECT NEEDLE AND SYRINGE –
Intradermal – 1ml syringe, 25G/orange
needle, Subcutaneous – 2ml syringe,
23G/blue needle, Intramuscular – 5ml
syringe, 23G/blue needle
 INSERT NEEDLE – WARN PT FIRST
(“sharp scratch”)
 INSERT NEEDLE CORRECTLY –
Intradermal – parallel to skin, approx3mm
deep, Subcutaneous – pinch skin, 20-30°
angle, Intramuscular - 90° angle, 2-3cm deep
 ASPIRATE ( do not for intradermal)
 INJECT SLOWLY
 REMOVE NEEDLE (apply pressure,
clean if necessary, do not apply pressure
to intradermal injections)
 DISPOSE OF SHARPS/WASTE
 OBSERVE FOR ADRs
 THANK PT, COMFORT, REASSURE
 RECORD IN NOTES
Infusions
 WIPE, GLOVES, SET UP EQUIPMENT
 CHECK FLUID BAG (check expiry
date, correct fluid/drug, seals intact etc)
 CHECK CANNULA (flush cannula,
ensure it is still in place/clean)
 PREPARE BAG / GIVING SET
 INSERT SPIKE INTO BAG (ensure a
level surface, beware puncturing bag,
beware sharps injury from spike)
 RUN FLUID THROUGH (no air
bubbles, fill chamber, ensure fluid runs
out the end, turn off before connecting)
 CONNECT CANNULA & GIVING
SET (tube screwed in place/ secure)
 START FLUID
 SET INFUSION RATE (as a rough
guide, 20 drips per ml for crystalloid, 15
drips per ml for blood/colloid)
 DISPOSE OF SHARPS/WASTE
 THANK PT, REASSURE, ASK ABOUT
QUESTIONS
 RECORD DETAILS (document fluid,
time started, time finished, volume,
duration of infusion etc)
Arterial Blood Gas Sampling
 WIPE, ?On O2/Air, record conc. , flow rate.
Equipment: ABG syringe w/Heparin, Alcohol
swab, Swab, 1% lignocaine local anaesthetic,
Syringe and blue needle for anaesthetic
Femoral artery
 Lay pt supine w/ groin and leg extended
and slightly abducted.
31
 Locate femoral artery, halfway b/w the
ASIS & pubic symphysis, 2 cm below the
inguinal ligament.
 Clean skin over artery w/ alcohol swab.
 Raise a bleb of local anaesthetic.
 Fix the artery between two fingers
whilst inserting heparinised needle and
syringe at 90° to skin.
 Slowly advance the needle till there is
free flow into syringe.
 Radial artery
 Before procedure, perform the Allen
test: Occlude both ulnar & radial
arteries digitally, allowing venous
drainage. Release ulnar artery while
keeping radial artery compressed. Hand
colour should return in <5s, indicating
there is sufficient collateral blood flow
from the ulnar artery.
 If the patient fails, radial ABG should
not be attempted.
 Pt supine w wrist & thumb extended.
 Place a rolled up hand towel under the
dorsal surface of the wrist.
 Palpate the radial artery
 Clean skin proximal to the wrist joint.
 Raise a small bleb of local anaesthetic at
the proposed entry site with a 25G
needle into the skin.
 Insert the needle of a heparin-coated
2ml syringe at 60-90° through the skin,
ensuring avoidance of air in the syringe.
 Palpate the radial artery proximally,
using it as a guide of direction to
advance needle.
 The arterial blood pressure will fill the
syringe automatically.
 Withdraw the needle and apply
pressure for 5 minutes. Cap the syringe
and place in bag of ice if immediate
analysis not possible.
Venepuncture  FILL VACUTAINERS/SYRINGES
 REMOVE TOURNIQUET
 WIPE  W/DRAW NEEDLE (place a swab over
 CHECK CORRECT BLOOD FORMS the area first) + APPLY PRESSURE
(ensure form matches pt, check what  DRESS THE WOUND (gauze or
samples are needed) plasters, ?allergies before using plasters)
 GLOVES, SET UP EQUIPMENT  DISPOSE OF WASTE/SHARPS
 CHECK WHICH ARM - ask about  THANK PT, REASSURE, COMFORT
surgeries, mastectomies etc,
 LABEL BOTTLES CORRECTLY/SEND
?preference
TO LAB
 APPLY TOURNIQUET (place arm
below the level of their heart, and make
fists repeatedly) Suturing
 FIND AN APPROPRIATE VEIN
 WIPE – easy wound access, good
(bifurcations are tethered, always go
lighting
above bifurcation, palpate vein well)
 PREPARE EQUIPMENT (sterile trolley,
 CLEAN THE SITE (alco swab, dry)
anaesthetic, sterile instruments etc)
 INSERT NEEDLE – WARN PT FIRST
 PUT ON STERILE GLOVES (open
(“sharp scratch”)
method)
 INSERT NEEDLE CORRECTLY (30°
 CLEAN WOUND – pick out debris,
angle, until flashback is seen or until you
irrigate w/ normal saline, arrange x-ray
feel the vein ‘give’)

Order of Draw:

Note – colours
of tubes depend
on supplier!

32
 to check for foreign bodies, clean
wound w/ chlorhexadine from inside
out, dispose of swabs after use
 DRAPE WOUND – CREATE STERILE
FIELD (ensure pt or non-sterile
equipment does not touch field)
 ANAESTHETISE WOUND – use 1%
lidocaine, draw from sterile ampoule,
after first injection put needle through
anaesthetised area, do both wound
edges
 WAIT FOR ANAESTHETIC TO
WORK (3-5 minutes)
 CHECK ANAESTHESIA (pt should feel
pressure nut not pain, should feel
numb)
 CHECK VACCINATIONS (ensure pt
has up to date tetanus vaccinations etc)
 WARN PT BEFORE STARTING
 CORRECT NEEDLE HANDLING
(never touch the needle, hold needle
2/3 from point w/ needle holders)
 PLACING SUTURE (evert wound edge
w/ toothed forceps, needle enters at
90° to skin, approx.0.5-1cm deep &
0.5cm from wound edge, come out in
centre of wound & repeat for 2nd side)
 KNOT TYING (use at least 3 throws,
line up knots on one side, cut approx.
1cm from knot)
 PLACING 2ND SUTURE (lay sutures
approx. 1cm apart, line up knots)
 INFORM PT OF SUTURE CARE (
should be removed after 7days at GP or
A&E, keep wound dry, showers not
baths, avoid getting wound dirty)
 DRESS WOUND (clean and dry wound
apply a clean dressing and remove
drape)
33
 DISPOSE OF SHARPS (all
sharps/needles must go in a sharps bin
once they have been used)
 DISPOSE OF WASTE (all clinical waste,
including drapes, swabs and gloves must
be placed in the yellow/clinical waste
bins)
 DOCUMENT PROCEDURE
 THANK PT, CHECK PT
UNDERSTANDS WOUND CARE
AND REMOVAL INSTRUCTIONS
PEFR and Inhalers
 WIPE
 START W/ PEFR
 ASK PT TO STAND UP
 PREPARE FLOW METER (attach mouth
piece, reset slide to bottom)
 DEMONSTRATE OR EXPLAIN
PROCEDURE (deep breath in, seal lips
around mouth piece and blow out as
hard and fast as possible “like blowing out
a candle across the room”)
 ASK PT TO REPEAT 3 TIMES (reset
slide to 0 every time, allow pt to
recover in between)
 RECORD THE BEST OF 3 VALUES
 COMPARE PT TO AGE/HEIGHT
CORRECTED GRAPHS
 BEFORE AND AFTER
BRONCHODILATORS (if on the
drugs)
 STATE YOU WILL TEACH THEM
HOW TO USE INHALERS
 ASK FOR ANY QUESTIONS/EXPLAIN
BRONCHODILATORS OR ASTHMA
(as necessary)
 DEMONSTRATE OR EXPLAIN
PROCEDURE
 MDI – CHECK DRUG/EXPIRY DATE
 REMOVE MOUTH COVER/CHECK
FOR OBSTRUCTIONS
 SHAKE INHALER
 HOLD INHALER VERTICALLY
 EXHALE
 START BREATHING IN
 PLACE INHALER IN MOUTH (seal lips
tightly around it)
 DEPRESS BUTTON AND KEEP
BREATHING IN
 HOLD BREATH FOR 10s
 BREATH OUT
 WATCH PT AND CORRECT ANY
MISTAKES (repeat until they get it
right)
 EXPLAIN STEROID INHALERS (need
to wash mouth out after use to avoid
oral candidiasis)
 ASK FOR QUESTIONS (explain
common mistakes – not triggering in at
right time, not breathing in enough, not
holding breath long enough)
 CHECK UNDERSTANDING
 THANK PT, REASSURE, COMFORT
Blood Pressu re Measurement
 WIPE - easy access to arm, remove
tight clothing from the arm
 ASK QUESTIONS (check pt sitting
comfortably, ? caffeine, exercise, stress)
 PREPARE SPHYGMOMANOMETER
(ensure level w/ pt’s heart, select
appropriate size cuff)
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 CHECK ARM (ensure pt has no
problems, previous surgery etc w/ the
arm you intend to use)
 PALPATE BRACHIAL ARTERY (medial
to biceps tendon)
 PLACE CUFF – over brachial artery,
tubes out of the way, high up on arm to
allow steth. access, ensure it is tight
 PALPATE RADIAL ARTERY
 WARN PT INFLATION OF CUFF
BEING UNCOMFORTABLE (reassure
them that it does no damage and will be
over quickly)
 INFLATE CUFF UNTIL RADIAL
ARTERY DISAPPEARS
 DEFLATE CUFF
 PLACE STETHOSCOPE OVER
BRACHIAL ARTERY
 REINFLATE CUFF TO 10mmHg
ABOVE THE DISAPPEARANCE OF
THE RADIAL ARTERY
 DEFLATE CUFF AT 2mmHg/s
 LISTEN AND RECORD 1ST AND 5TH
KOROTKOFF SOUNDS
 REPEAT IN BOTH ARMS (>10mmHg
difference indicates aortic dissection)
 REPEAT STANDING (>10mmHg drop
indicates postural hypotension)
 THANKS PT, ANSWER QUESTIONS
CXR Interpretation
 PT DETAILS – Name, Age, DOB, H#
 RADIOGRAPH DETAILS – Date, Time,
Type of film, Position, Indication
 ROTATION (=l distance from spinous
processes to medial ends of clavicles)
 PENETRATION (outline of vertebral
bodies visible behind the heart border)
 INSPIRATION (right hemi-diaphragm
level w/ the tip of the 6th anterior rib)
 COMMENT ON OBVIOUS
ABNORMALITIES (tubes, lines, clips,
masses, opacities)
 AIRWAY (trachea, hilum, lung apices)
 BONES (ribs, bony structures, soft
tissues, breast)
 CARDIAC (cardiac outline, cardio-
diaphragmatic recess, cardiomegaly, L &
R heart border, mediastinum)
 DIAPHRAGM (costo & cardiophrenic
angles, air under diaphragm, gastric
bubble, abnormal peaking or flattening,
relative positions of hemi diaphragm)
 “EVERYTHING IN BETWEEN”
 FIELDS (contents, pleura - ?thickening)
 REVIEW AREAS (apices, retrocardiac
area, peripheral lung margins,
diaphragm, air in SC tissues)
 SUMMARY ± DIAGNOSIS
AXR Interpretation
 PT DETAILS – Name, Age, DOB, H#
 RADIOGRAPH DETAILS – Date, Time,
Type of film, Indication
 ADEQUACY – EXPOSURE
(xiphisternum to pubic symphysis, both
flanks)
 ADEQUACY – PENETRATION
(spinous process visible through
vertebral bodies)
 INTRALUMINAL GAS – Volume and
Distribution
 EXTRALUMINAL GAS – Distribution
 COMMENT ON OBVIOUS
ABNORMALITIES (tubes, lines, clips,
masses, opacities)
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 SYSTEMATIC REVIEW:
 BONES, BOWEL, BILIARY TREE
(obstructions, stones, dilations)
 AORTA (calcification, widening)
 CALCIFICATION (look at gall bladder,
pancreas, kidneys, bladder, arteries)
 KIDNEYS (calcification, stones, dilation,
distension, position)
 URETERS (trace ureter from kidney to
bladder, look for stones, dilations,
strictures, look at bladder for position,
size, stones)
 PSOAS MUSCLE
 SUMMARY ± DIAGNOSIS
ECG Interpretation
 PT DETAILS – Name, Age, DOB
 ECG DETAILS – Date, Time, is it part
of a series e.g. MI’s, Indication
 CALIBRATION (paper speed 25mm/s,
1mV = 10mm vertical deviation)
 RATE (regular: 300/RR interval,
irregular: number of QRS complexes in
rhythm strip x 6)
 RHYTHM (reg, reg irreg or irregularly
irregular, sinus – P wave before every
QRS complex)
 AXIS (Normal: QRS deviation in I & II
is up.
 LAD: QRS in I is up, and down in II
(leaving), RAD: QRS in I is down, and up
in II (reaching).
LAD : Normal in pregnancy / emphysema
Path – L.Ant. Fasc. Block, or Q waves  MI
RAD: normal in children/dextrocardia
Path - L.Post. Fasc. Block or Q waves from
high lateral MI
 Leads: Anatomical Relationship
Lateral I, aVL, V5/6
Inferior II, III, aVF
Anterior V3/4
Septal V1/2

 MORPHOLOGY
 P WAVES ?before every QRS, ?p
pulmonale (peaked) - lung disease/RAH or p
mitrale (saddle) –MR. ? atrial flutter saw tooth
 P-R INTERVAL (normally 0.12-0.2s,
shorter indicates extra conduction
pathways, longer indicates heart block)
 QRS COMPLEX – WIDTH (normally
<0.12s, wide indicates bundle branch block
– look at V1 and V6 for ‘WilliaM MarroW
signs’ indicating L and RBBB respectively.)
 QRS COMPLEX – HEIGHT (tall R wave
indicates ventricular hypertrophy, V1: right,
V2: left)
 QRS COMPLEX – Q WAVE (normally
<0.04s and <2mm, pathological Q wave w/in
hours of an MI)
 QT INTERVAL (corrected for a heart
rate of 60 using QTc = QT/√RR interval)
 QT = [Ca2+] and v.v.
 ST SEGMENT (should be isoelectric,
elevated in MI, depressed in ischemia)
- Digoxin ”reverse tick” sloped depression
 T WAVES (normal inversion in III, aVR
and V1)
Inverted = Ischaemia, LVH, Digoxin,
Pericarditis and BBB
Flattened = Ischaemia,  K+
Tall / Tented = K+ (Hyperacute = tall w/
broad base & asymmetry = acute MI)
 U WAVES (can be normal or  K+)
 SUMMARY AND DIAGNOSIS

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