COURSE: INTERMEDIATE CLERKSHIP
CODE: BCM 320
The course has 3 parts (Modules):
1. Pediatric History and Physical examination
2. Surgical History and Physical examination
3. Obstetrics / Gynaecology History and Physical examination
Each module is divided into units (Systems).
Each unit has several topics
LESSON 1
PEDIATRIC HISTORY & PHYSICAL EXAM
(CHILDREN ARE NOT JUST LITTLE ADULTS)
PAEDIATRIC HISTORY
Taking a Paediatric History should be thorough and systemic. It is a rewarding
experience to work with the child and their family to develop trust and rapport to
have subsequent comfortable examination.
Learning Objectives:
1. To understand the differences between pediatric and adult patient history.
2. To understand that the child age has an impact on obtaining an appropriate
medical history.
3. To understand all the ramifications of the parent as informant in pediatric Hx
taking.
4. To understand and appropriately use open-ended and directed questions.
5. To develop an awareness of appropriate clinical settings for proper Hx
taking.
Competencies:
To obtain an accurate and complete history of a pediatric patient in different
age groups thus:
i.
Less than 1 year
ii.
Between 1 and 5 years
iii. More than 5 years
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The child’s age is key in determining what will need to be asked in regards to the
nature and presentation of illnesses, developmental, behavioral problems and the
organization of subsequent management.
Differences between Pediatric and Adult History:
i. Content Differences
a. Prenatal and birth history
b. Developmental history
c. Social history of family - environmental risks
d. Immunization history
ii. Parent as Historian (informant)
a. Parent’s interpretation of signs, symptoms
1. Children above the age of 4 may be able to provide their own history
2. Reliability of parents’ observations varies
3. Adjust questioning: “When did you first notice Kiprotich was limping”? instead
of “When did Kiprotich’s hip pain start”?
b. Observation of parent-child interactions
1. Distractions to parents may interfere with Hx taking
2. Quality of relationship
c. Parental behaviors/emotions are important
1. Parental guilt - nonjudgmental/reassurance
2. The irate parent: causes
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LESSON 2
PAEDIATRICS HX TAKING
Requirements of Paediatrics Hx taking
i.
ii.
Informant(in young child)
Interpreter (if necessary)
Procedure of Paediatrics Hx taking
1. Establish rapport with the informant and the child.
- Usually greeting the child and making positive remarks will easy the
child.
- Greet the parents or carers and the siblings ( if present)
- Check the child’s first name and gender. It helps build rapport by asking
how the child prefers to be addressed.
- Introduce yourself and your role
- Gain consent to take the history
- Initially keep a comfortable distance (establish eye contact and rapport
with family).
- Children generally feel initially more comfortable & secure in parent’s
arms or lap
- Observe how the child plays/interacts with others.
- Make sure you address questions to the child, when appropriate
(Depending on age, you might get useful history)
- Talk to parents/carers and the child/ adolescent separately (start with the
parent): introduce the idea through normalization eg – “It is my usual
practice to…”
2. Personal Identification
- Age, sex, race, and other important identifying information about patient
- Identifying the informant and relationship to patient and reliability
3. The presenting complaint / Chief complaint
- Is a brief statement of primary problem (including duration) that caused
family to seek medical attention
- Start open – eg “So, “What’s brought you in today?” allow them to
recount in their own words and pace.
4. History of Present complaint / Illness
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- Is a concise chronological account of the illness, including any previous
treatment with full description of symptoms (both pertinent positives &
negatives).
- They belong here if they relate to the differential diagnosis for the chief
complaint
- Have the following questions answered :
o When did the current problem start? What was it like?
o Any change if any? (When and how)?
o Any medical attention before? If so, what investigations
/treatments?
o Previous episodes?
o Relieving or aggravating factors?
o Any photos or video evidence in your phone? (eg rash or seizure
episode).
5. Review of systems
- This involves performing a brief screen for symptoms in other body
systems.
- This may help to pick any missed symptoms which may be relevant to
the diagnosis.
- Weight: recent changes, weight at birth
- Skin & Lymph: rashes, adenopathy, lumps, bruising & bleeding,
pigmentation changes
- HEENT: History of injury, headaches or infection / surgery?,
concussions, unusual head shape, strabismus, conjunctivitis, visual
problems: Visual acuity/glasses, History of injury or surgery, hearing,
earache, ear infections, draining ears, throat infections, cold and sore
throats, tonsillitis, mouth breathing, noisy breathing (stridor), snoring,
apnea, oral thrush, epistaxis, caries
- Cardiac/Heart: cyanosis and dyspnea, chest pain, fainting episodes,
exercise tolerance, squatting, chest pain, palpitations, History of
rheumatic fever
- Respiratory: breathing problems, wheezing, chronic cough, sputum,
hemoptysis, TB
- GIT –Stool color and character, diarrhoea/constipation, vomiting,
hematemesis, jaundice, abdominal pain, colic, appetite , rectal bleeding
- Genitourinary – Dysuria, frequency, hematuria, discharge, abdominal
pains, quality of urinary stream, polyuria, previous infections, facial
edema, wetting/accidents, toilet training
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- Musculoskeletal – Joint/limb pains or swelling, other functional
abnormalities, fevers, scoliosis, myalgia or weakness, injuries, gait
changes
- Skin & Allergy – General rashes, birthmarks or unusual marks, urticaria,
hay fever, allergic rhinitis, asthma, eczema, drug reactions
- Pubertal development - Secondary sexual characteristics, Age of
menarche, menses and menstrual problems, sexual activity
Continue:
(i)
To periodically summarise as you move through the rest of the history
(ii) Signposting (explaining to the patient/parent/carer): What you have
covered & What you plan to cover next eg “Ok, so we’ve talked about
the symptoms.”“Now I’d like to discuss any previous medical history.”
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LESSON 3 (Unit ct)
6. Past Medical/Surgical History
- Major medical/ surgical illnesses: diagnoses, operations and dates.
- Accidents & injuries: Trauma-fractures, lacerations
- Current medications & Known allergies (not just drugs)
7. Peri-natal History / Pregnancy and Birth History
Peri- natal period is the period immediately before and after birth (20/28 wks
to 1/4wks after birth).
Pre-natal Period
- Any illnesses/drugs during that period(bleeding, trauma, hypertension,
fevers, infectious illnesses, medications, drugs, alcohol, smoking, rupture
of membranes)
- T.T immunization
- Antenatal profile
- P.V. bleeding
- Nutrition & Attitudes towards pregnancy/Parenthood.
Natal Period
- Labour: Length & Nature (normal, prolonged, fetal distress; term,
preterm or post mature)
- Delivery: type/where (SVD, assisted or C/S; hospital/home)
- Baby: colour(pink/blue),cried and weight.
- Problems: Mother/baby; Immediate; Resuscitation, Incubation, Feeding
or breathing.
Post-Natal
- 1st wk events: transfusion, convulsions, infections, cyanosis, jaundice.
- Dietary Hx: Breast feeding/bottle, Weaned-when/on what. On what now
and who feeds.
- Neonatal period - Apgar scores, breathing problems, use of oxygen, need
for intensive care, hyperbilirubinemia, Jaundice? birth injuries, feeding
problems
- Immunization: BCG scar, check Road to health Card; ? reasons for
missed immunizations.
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- Growth and development: Physical growth, Milestones ages(smiling,
rolling, sitting alone, crawling, walking, running, 1st word, toilet training,
etc; see developmental charts), Social development Hx(Sleep Hx, speech,
discipline, schooling- present grade, specific problems, interaction with
peers, personality & sexuality: Behavior - enuresis, temper tantrums,
thumb sucking, pica, nightmares etc)
8. Personal Social Economical History
It involves clarifying the details of the child’s family and community:
1. Living situation, conditions and environment.
2. Economic status and occupation of parents.
3. Composition and habits of parents/family.
Thus ask of the following:
Individuals living with the child
Housing
Parental/Carer occupation
Parental habits: smoking status
Relationships/marital status
The child’s preferred play or leisure activities? Are they happy at
home/school?
Impact of this illness on the family (especially if chronic or ongoing)?
i.
ii.
iii.
iv.
v.
vi.
vii.
9. Family History
This will help in assessing the child’s risk of developing certain diseases thus:
1. Illnesses - cardiac disease, hypertension, stroke, diabetes, tuberculosis,
cancer,
abnormal bleeding, allergy and asthma, epilepsy.
2. Mental retardation, congenital anomalies, chromosomal problems,
growth problems, consanguinity (blood relationship), ethnic
background.
i.
ii.
iii.
Enquire about child’s position in family.
Do any conditions run through the family? If so, who has been affected
(over several generations)
Have any family members (family tree/blood relatives or genogram) or
friends had similar problems or any serious disorder?
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iv.
Deaths in the family – cause and age, especially if in infancy or childhood.
LESSON 4
PAEDIATRIC PHYSICAL EXAMINATION
Objectives
1. To perform a full systematic physical examination of a child.
2. To understand the difference in the general approach of physical examination in
child compared to that in adult patient, and how it varies with age.
3. To observe and demonstrate physical findings unique to the pediatric
population.
Requirements
1. Privacy (esp. in older children)
2. Comfort
3. Adequate light
4. Instruments for measuring height, length & weight
5. Thermometer
6. Otoscope
7. Torch
8. Sphygmomanometer
9. Tongue depressor
10.Watch with second hand
11.Ruler
12.Tape measure
13.Stethoscope
14.Patella hammer
15.Tuning fork
Procedure of Paediatrics Physical Examination
1. Explain the procedure to the child/informant
2. Be honest. If something is going to hurt, tell them that in a calm fashion
3. Be systematic:
i. General examination,
ii. Vital signs then
iii. Systemic examination (RS, CVS, Abd, CNS, MSS).
4. Examination of older children is same as of adults but take the following
consideration:
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1.
2.
3.
4.
Do anxious uncomfortable procedures last
Establish rapport and gain the child’s confidence
Examine young children on their parent’s lap
Observe behavior of child and informant towards each
other
5. Observe child’s face for dysmorphic features e.g. Down’s
syndrome, cretinism, nutritional status, level of
consciousness, toxic or distressed, cooperation, cyanosis,
pallor, jaundice, dehydration
6. Observe the head for shape, size, bossing & fontanels
5. Anthropometric data: Wt., length/height, mid-upper arm
circumference(MUAC)
6. Vital signs:
Normals differ from adults, and vary according to age
i. Temperature sites: Tympanic vs. oral vs. axillary vs. rectal
ii. Heart rate: Auscultate or palpate; apical or femoral; Palpate antecubital or
radial pulse in older child.
iii. Respiratory rate: Observe for a minute not 15 seconds since infants
normally have periodic breathing. Rate/Min; < 2months- ≤ 60, 2 to24
months- ≤ 50, 2 to 5 yrs ≤ 40.
iv. Blood pressure: Use appropriate size cuff (2/3 width of upper arm)
v. Growth parameters: Plot on appropriate growth curve; Weight,
Height/length & OFC (Occipital Frontal Circumference)
7. Systemic examination: NB: Awake not a sleeping child, when using the
stethoscope, place it first on the informant for reassurance, warm it by
rubbing.
8. Chest/Respiratory examination: Do inspection, palpation, percussion &
auscultation
a). Inspection
- Check for:
i. Any abnormalities: Chest wall configuration (Barrel/Pigeon
chest)
ii. Pattern of breathing: Abdominal breathing & Period breathing
(normal in infants) (pause < 15 seconds)
- Respiratory rate: Use of accessory muscles: retraction /flaring
b). Palpation
- Vocal fremitus is of no clinical value in children (In adults: repeat the
word ’ninety–nine’; Decreased in effusion, pneumo but increased in consolidation)
c). Percussion
Useful in older but not young children
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-
Use plexor without preximeter (direct)
d). Auscultation
Gives important clues to lungs & pleura conditions
Breath sounds and additional noises can be difficult to interpret in
the very young
Crepitations (fine crackling noises on inspiration) can occur
in normal babies
Persistent & bilateral crepitations in a distressed child: bronchiolitis or left
heart failure.
Rales (intermittent noises during inspiration & expiration); indicate liquid
debris in
larger airways and may be transmitted from the back of the throat.
Rhonchi (persistent harsh noises added on to breath sounds) rare in children;
suggest persistent obstruction.
Bronchial breathing (continuous noises that extend the breath sounds)
heard over upper back; transmitted from the main airway.
- Stridor: harsh noise which originates in the upper airways - occurs during
inspiration.
- Wheezing: occurs when mid-airways are narrowed, eg asthma (bilateral),
airway obstruction (unilateral). It is usually expiratory.
- Auscultate for: Equality of breath sounds; Check for Rales, wheezes,
rhochi
9. Cardio-vascular system examination:
Inspection
- Check for symmetry of the chest
- Check for any chest wall abnormalities eg scoliosis, kyphosis
- Look for any abnormal pulsation on the precordium
Palpation
- Warm up your hands
- Lay your whole hand flat all over the chest to get the general impression
of the cardiac activity
- Palpate the precordium for apex beat (site and nature), thrills & heaves
- Below 7 yr of age the apex beat is at the 4th IC and slightly to left of the
MC line
- While below 2 yr its difficult to feel the apex
- NB; Thrills are palpable murmurs/vibrations while heaves are forceful
sustained lifting/tabbing over the precordium
- Apex beat is the lowermost outermost point of maximum cardiac impulse
Percussion
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- Has limited value because of the greater accuracy of the radiological
examinations
- However it can assist in detection of;
i. Percardial effusion
ii. Aortic aneurysm (dullness to the sternum)
iii. Cardiomegaly
Auscultation
Auscultate for the presence & characteristics of the following sounds:
i.
Heart rate and rhythm
ii.
Heart sounds
iii. Murmurs
iv.
Additional sounds (eg pericardial rub)
- The characteristics of the abnormal sounds include: site, timing, intensity,
character/pitch, radiation and relation to respiration, posture and
exercises
10.Abdominal Examination:
Inspection
- Observe for swellings and movements
- Infants and children upto 3yr, usually have protuberant abdomens
- Becomes more scaphoid as child matures
- Observe Umbilicus (infection, hernias) and abdominal wall for Muscular
integrity (diasthasis recti)
Auscultation
- As in adults
Percussion
- As in adults
Palpation
- If possible watch the child's face for tenderness while you palpate
- Avoid tender area until end of exam
- Check for Rebound, guarding
- Liver, spleen, kidneys: May be palpable in normal newborn(determine
their sizes & positions)
- Note position, size, surface and texture of any enlarged organ
- Upto 4 yrs, liver is palpable 2cm BCM(below the costal margin)
- Use ballottement to examine abd. Of a crying child
- ENT ; examine last , with special positioning
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LESSON 5
RESUSCITATION OF THE NEWBORN
Introduction
-
Neonatal resuscitation need cannot always be anticipated/predicted.
So equipment/staff must always be ready.
10% of newborns require resuscitation.
Less than 1% require extensive resuscitative.
Hence newborn resuscitation is a critical skill.
Aim of the resuscitation is to prevent death/neurodevelopmental sequelae
Objective
- To be able to perform acute management of the newborn with asphyxia
neonatorum.
Indications
- Mild asphyxia
- Moderate asphyxia
- Severe asphyxia
Requirements
- Heater
- Light source
- Stethoscope
Procedure/Method
- The requirements and procedure will depend on the severity of the
asphyxia.
- APGAR Score at 1 minute after birth is used to classify the severity of
asphyxia thus (8 to 10 No asphyxia, mild-moderate asphyxia 5 to 7,
severe asphyxia 0 to 4)
1. Suction material (machine, tubes)
2. Oxygenation materials (face mask, ambubag, laryngoscope, endotracheal tube)
3. I.V. line materials (syringes, needles, brannulas, strapping, swabs, solusets, drip
stand)
4. Umbilical cord materials (cord clamps, umbilical catheters)
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5. Drugs (Vit k, sodium bicarbonate, 10, 25 & 50% glucose, adrenaline,
hydrocortisone)
Cardiac message
- Place 2 fingers midway between the nipple and sternum of the baby
- Apply gentle pressure(1.5 – 2 cm) X 120/minute
- Concurrently ventilate the baby(X 2 in every 5 compressions of the
sternum)
- Release pressure immediately
- CT monitoring of femoral pulse
- Absent or very low pulse; give adrenaline
Intubation
- With severe asphyxia, immediately intubate the trachea and begin
assisted ventilation.
- Few infants require immediate intubation.
- The majority of infants can be managed via a face mask.
- Recommend positive inspiratory pressure (PIP) is 30cm H2O for a term
baby and 20-25cm for a preterm baby.
- Place the Pt. in neutral position
- Introduce the endotracheal tube
- Confirm correct insertion by : i. Rise and fall of chest ii. Chest
auscultation
(Stomach distension indicate oesophageal intubation)
NB: Newborns who do not require resuscitation can be identified by these 3
characteristics:



Term gestation?
Crying or breathing?
Good muscle tone?
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LESSON 6
SURGICAL HISTORY & PHYSICAL EXAMINATION
SURGICAL HISTORY TAKING
Objectives
- To provide a positive professional relationship.
- To establish concerns about the patient’s past medical / surgical
- To avail information necessary for making a diagnosis.
- To provide information necessary for the patient’s management
Requirements
i. Informant (Relative, Friend, Police, Good Samaritan) if severely
injured/unconscious or child
ii. Previous records/Referral note PRN
Procedure
Step 01 Personal Identification
- Greet the patient by name
- Introduce yourself and explain that you are a medical student
- Seek for consent to speak to Pt. / them
- Ensure that the patient is comfortable
Step 02 - Presenting Complaint (PC): CC
- Is what the patient tells you is wrong eg chest pain
- Is usually the reason for the patient’s visit
- It is stated in patient’s own words &
- In chronological order
- Most surgical CC are related to injury, swelling, wound or signs of
luminal obstruction
- Most Common Complaints In Surgery Are " Pain & Swelling "
- CC aids in diagnosis & treatment (should be prioritized)
Step 03 - History of Presenting Complaint (HPC)
- It elaborates on the chief complaint in detail
- Symptoms can be elaborated in terms of:
i. Mode & cause of onset
ii. Course & Duration of disease
iii. Relation to constitutional factors
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iv. Special character & Effects on nearby structures
- Treatment taken
- Negative answers are also more valuable to exclude the disease
- Gain as much information you can about the specific complaint eg for
chest pain ask:(Site, Onset, Character, Radiation, Association, Time
course, Exacerbators & Severity ): SOCRATES
Step 04 - Review of Systems (ROS)
- It gives information about the other systems which are not covered in
your HPC.
- Eg if CC is chest pain (CVS) then other systems to review are:
i. Respiratory
ii. GI
iii. Neurology
iv. Genitourinary
v. Musculoskeletal
vi. Psychiatry
Step 05 - Past Medical/Surgical History (PMH)
- It gathers information about a patient’s other medical problems (if any).
Step 06 –Personal, Social and Economic History (PSEH)
- Find out what medications the patient is taking (including dosage &
freq.)
- Find out more about the patient’s background (smoking and alcohol)
- Use of any illegal substances eg cannabis, cocaine, etc.
- Find out who lives with the patient.
- History of any allergies.
Step 06 - Family History (FH)
- Get information about any family history of e.g diabetes or cardiac
history.
- Any genetic conditions within the family eg polycystic kidney disease.
Step 07 - Summary of History
- Reviewing what the patient has told you
- Repeat back the important points (Pt. to correct
misunderstandings/errors)
- Address patient’s expectations/hopes from the consultation: ICE [I]deas,
[C]oncerns and [E]xpectations.
Step 8 - Patient Questions / Feedback
- Respond to the patient’s questions if any
- But never give any false information
- The questions aren’t necessarily testing your knowledge
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Step 9
- Thank Pt./them for their time and
- Say that one of the doctors looking after them will be coming to see them
soon.
LESSON 7
SURGICAL PHYSICAL EXAMINATION
1. FEMALE BREAST AND AXILLA EXAMINATION
Embryology/Physiology Facts about Breast & Axilla
- Both originate from ventral buds of ectoderm(5th to 6th Wk fetal
development)
- The buds are bilateral ridges extending from axilla to inguinal("milk line"
)
- Accessory nipples and breast tissue are found along the line in adults.
- Breasts development is identical in males and females in utero till
puberty onset
- The adult breast is roughly conical: contains 15 to 20 lobes; lobules
- The breast is divided into quadrants (or comparison to a clock face)
- The upper outer quadrant of the breast
i. Contains a greater volume of tissue than elsewhere
ii. Is also the most common location for a breast malignancy to
arise
iii. It extends superior-laterally toward the axilla and shoulder.
iv. This portion of the breast is called the axillary tail of Spence
v. 90% of the breast drain into axillary lymph nodes(10%
thoracic nodes)
vi. Lymph drainage pathways are usually the 1st site of breast
Ca spread
Objective
- To be able to perform adequate physical examination of female breast
- To be able to diagnosis and do surveillance of benign and malignant
breast diseases.
Requirements
 Examining table
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

Flash light
Ruler/tape measure
Indications
- These will be both in symptomatic and asymptomatic patients
- Breast complains: pain, skin changes, discharge, lumps, gross changes in
size/shape
- Routine: 25 and 40 years old for breast cancer every 1 to 3 years
Contraindications
- Lack of patient’s cooperation
- Lack of patient’s consent
- Patient’s anxiety
Procedure
Preparation
-
Patient undressed down to the waist.
cover the patient's lower half for comfort
courteous and gentle approach toward the patient
A same-sex chaperone to accompany the examiner
NB
- Physical breast examination can be divided into three components:
 Inspection,
 Palpation and
 Lymph node exam.
Procedure
Carefully explain what you are going to do - and why
Introduce yourself
Inspection
Is best done while the Pt is in the following 4 sitting positions:
i.
Arms hanging at sides
ii.
Arm over the head
iii. Arms at hips
iv.
Leaning forward
Inspect each breast (and compare them) for: Size, Symmetry, Contour,
Colour/texture, Lesions; Nipple – Size, Retraction, Discharge, Ulcerations; Areola
– Pigmentation / development
Palpation
Is done in 2 positions consecutively thus:
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i.
Sitting
ii.
Supine
Ask patient to first point out her findings eg lump, lesion before you start palpating
Systematically palpate breast, axilla and supraclavicular/infraclavicular regions
Always start with the normal breast
There are 3 commonly accepted breast palpation techniques thus:
i.
Vertical zigzag palpation
ii.
Concentric circular palpation
iii. Quadrant palpation
Be calm, patient and not in hurry
Its often not easy to evaluate 2nd & 3rd quadrants in sitting position (re-do in
supine)
Palpation will not be complete till you palpate for:
i.
Breast tissue
ii.
Areola
iii. Nipple
iv.
Tail of Spence & axilla
v.
Lymph nodes
vi.
Repeat in supine position
* “Read of the various manoeuvres”
NB:
When palpating the breasts, it is important to pay attention to the following
features of any identified masses:
1. Shape: the most common benign lesions, like a cyst or a fibroadenoma, have
very regular borders while cancerous nodules tend almost always to be
irregular in shape
2. Consistency: a mass that feels rock hard or otherwise very firm is probably
malignant, while a rubbery or elastic consistency is typical of a benign lesion
3. Relation to the skin: a lesion that is very fixed to skin is usually malignant
4. Changes over time: rapid changes of a lesion over weeks to months raise
suspicion for cancer
5. Tenderness: cancerous nodules tend to be nontender, while benign lesions
are often particularly tender. A mass that changes in tenderness during the
menstrual cycle is most likely benign
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LESSON 8
2. EXAMINATION OF THE BACK
Objective
1. To able to perform inspection, percussion and palpation of the back
2. To be able to test for the movements of the back
3. To be able to carry out several provocation tests of the back
4. To be able to carry out several functional tests of the back
This examination is done while:
i.
Standing
ii.
Lying down
Procedure
While standing:
Inspection:
- Examine the patient symmetry
- Examine the patient posture: Is there any curve? Determine whether its :
i.
Postural/Compensatory ( Ask pt to lean forward with arms
crossed over the chest and hands on opposite shoulders; it
will disappear while structural appears greater)
ii.
Structural/fixed
iii. Curveture in obese person(Difficult to detect; you will feel it
when pt leans forward and you ran finger down his back)
- Inspect for: Kyphosis (posterior curvature of the spine) Lordosis (anterior
curvature of the spine).Scoliosis (lateral curvature of the spine).
Palpation:
- Palpate the paraspinal muscles for atrophy, tension, and pain.
- Palpate the spinal column for any deformities and point tenderness.
Percussion
- Percuss with finger or percussion hammer
- Percuss each vertebra systematically
- Pain with percussion is a sign of infection or fracture
Measurement of movements
- Check for:
i.
Flexion
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ii.
iii.
iv.
Extension
Lateral bend &
Rotation
Flexion
- Pt to slowly bend forward and try to touch the toes (An increase ≥ 10cm
between C7 to S1)
Extension
- Pt. to lean backwards as far as possible( Normal is 300 to vertical)
Lateral bend
- Pt to lean to the Lt then to the Rt as far as possible(angle of 350 normal)
Rotation
- Pt. seated on the couch with popliteal spaces resting on couch edge(angle
of 450 normal)
While lying down:
Do the following
i. Measure length of lower limbs(if there was scoliosis)
ii. Exclude hip deformities
iii. Perform straight leg test
iv. Perform the pump handle test
Straight leg test
- Pt. supine
- Raise up the foot and note the point of pain
- Exclude compensatory lordosis
- Repeat the raising and the pain point, dorsiflex the foot
- Positive test if increased test(Irritation of sciatica)
Read and make notes on (Assignment):
1. Pump handle test
2. Aird’s test
3. Magnuson’s test
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3. PELVIS AND HIP JOINT EXAMINATION
Objective
1. To perform an adequate physical examination of the pelvis and hip joint
2. To inspect the pelvis and hip joint
3. To perform the movement tests of joint of hip
4. To perform the measuring techniques of the limb length
5. To perform the function tests for various disorders of the hip joint
Requirements
i. Measuring tape or piece of string
ii. Skin marker
iii. Small wooden block or thin books
Procedure
- The examination of the pelvis and the hip joint will involve inspection
and palpation
- Check on what side is the Pt bearing most of his wt.
- Any asymmetry
- Look for scars and wasting of the gluteal and the thigh muscles.
- Test for the following movements:
1. Flexion: Knee bent. Opposite thigh remains in neutral position.
Flex the knee as the hip flexes
2. Abduction: measured from a line that forms an angle of 90° with a
line joining the anterior superior iliac spines
3. Adduction (measured in the same manner)
4. Rotation in flexion with knee and hip both flexed at 90 degrees the
ankle is abducted.
5. Rotation in extension with knee and hip both flexed at 90 degrees
the ankle is adducted.
6. Extension: attempt to extend the hip with the patient lying in the
lateral or prone position.
Thomas test for tight hip flexors both performed by the provider holding the
unaffected leg to the chest and leaving the affected leg on the table. If the affected
leg cannot lie flat on the table it is a positive test.
Normal range of motion
 Internal rotation - 40°
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




External rotation - 45°
Flexion - 125°
Extension - 10-40°
Abduction - 45°
Adduction - 30°
LESSON 9
ADDITIONAL EXAMINATION OF THE HIP JOINT
 1. Test for flexion deformity.
- Place your left hand flat between the lumbar spine of the Pt. and the
couch
- Flex the normal hip fully till the lumbar lordosis is abolished
- If there is a flexion deformity on the opposite side, the leg on that side
will move into a flexed position
- This is then a positive “Thomas's test”
2. Trendelenburg test. Observe the patient from behind and ask him or her to stand on one
leg. In health, the pelvis tilts upwards on the side with the leg raised. When the
weightbearing hip is abnormal, owing to pain or subluxation, the pelvis sags downwards
due to weakness of the hip abductors on the affected side.
3. Measurement of 'true' and 'apparent' shortening. The length of the legs is measured from
the anterior superior iliac spine to the medial malleolus on the same side. Any difference
is termed 'true' shortening and may result from disease of either the hip joint or the neck
of the femur on the shorter side. 'Apparent' shortening is due to tilting of the pelvis and
can be measured by comparing the lengths of the two legs, measured from the umbilicus,
provided there is no true shortening of one leg. Apparent shortening is usually due to an
abduction deformity of the hip.
4. KNEE JOINT EXAMINATION
Objective
1. To adequately inspect the knee and the lower extremity
2. To be able to perform movement tests of the joint
3. To be able to perform tests for the pathological disorders of the knee
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Requirements
- The examination couch
- A tape measurer
Procedure
- Wash hands
- Introduce yourself
- Confirm patient details – name/DOB
- Explain examination: “Today I need to examine your knee joint, this will
involve looking, feeling and moving the joint.”
- Gain consent
- Expose patient’s legs
- Ask if patient currently has any pain
Inspection
Anteriorly
- Scars – previous surgery / trauma
- Swellings – effusions / inflammatory
- Symmetry/Asymmetry/leg length discrepancy
- Deformity ( eg Valgus or varus)
- Quadriceps wasting ( due to reduced mobility / arthritis / nerve injury)
Posteriorly
- Scars
- Asymmetry
- Popliteal swellings (Popliteal aneurysm/cyst)
Inspect the lateral aspect of the knee.
Palpation
- Patient supine on the bed.
- Assess and compare knee joint temperature
- Assess muscle tone
- Assess and qualify swelling (consistency and attachments to bone,
subcutaneous layers, or skin)
- Quadriceps tendon for tenderness (may suggest tendonitis)
- Patella – palpate medial &lateral patella facets and tendon
Assess for joint effusion
- Joint effusion can be caused by:
 Ligament rupture,
 Septic arthritis,
 Inflammatory arthritis and
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 Osteoarthritis
Patellar tap
Is done in large joint effusions
Empty the suprapatellar pouch by sliding your left hand down the thigh
to the patella.
Keep your left hand in position
With your right hand fingertips, press downwards on the patella with a
sharp jerky movement
- If there is fluid present you will feel a distinct tap as the patella bumps
against the femur
Sweep test
Useful for detecting small joint effusions
Patient supine
Leg relaxed and straight.
Swipe fluid from the medial part of the knee into the suprapatellar pouch.
Hold the fluid in the suprapatellar pouch with one hand on the medial side.
Swipe down from the suprapatellar pouch on the lateral side with the other
hand.
The appearance of a bulge or ripple on the medial side of the joint
suggests the presence of an effusion.
LESSON 10
5. LOCAL EXAMINATION
Objective
1. To be able to perform an adequate local examination
2. To be able to visualize local physical signs
3. To be able to adequately interpret local signs for diagnosis
purposes
Definition: Is the examination of a certain specific area of the body with the aim of
finding out the cause of deviation from the normal.
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- These areas include:
i. Local physical examination
ii. Lump/Swelling
iii. Wound
iv. Fracture
Procedure
Local physical Examination Procedure
- The sequence may include inspection, palpation, percussion &
auscultation.
Inspection:
- May give direction of farther examination & diagnosis
- Expose the area plus surrounding
- Check for swelling, wounds, scars, rashes, veins & colour
Palpation:
- Pt. to identify any paining site
- Assess local temperature with dorsum of your hand
- Palpate the area ( look at face for tenderness sign)
- Check for pitting oedema
- Test for the various varieties of crepitus thus: bone crepitus, joint
crepitus, Tendosynovitis crepitus & Subcutaneous/Emphysema crepitus
Auscultation/Percussion:
- Auscultation apply only in cases of vascular involvements
- Percussion: in eg hydrocephalus or sinusitis
Lump Examination Procedure
- Examine for the origin & attachment of the lump/swelling
- Which can be skin, subcutaneous tissue, muscle, tendon, nerve or bone
Inspection:
- Determine location
- Describe size (pea, fist tennis ball etc.)
- Shape (round, oval)
- Borders (regular/irregular)
*How do you test for the following characters of a swelling?
a. Pulsation
b. Fluctuation
c. Emptying
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d. Mobility
e. Translucency
Wound Examination Procedure
- Wounds vary depending on the cause and intensity of the causative agent
thus:
i.
Blunt agent
ii.
Sharps
iii. Infection
Inspection:
- Check location
- Shape
- Borders
- Edges (buried, steep, slanting, raised, curling outwards)
- Colour
- Discharge
- Smell
Palpation:
- Tenderness
- Temperature
- Tendency to bleed(None, normal or easy to bleed)
- Mobility
- Lymph nodes(draining the area)
Fractures Examination Procedure
- Pt. seated or in couch depending on fracture nature/site
- Expose the site
- Pt. to locate pain site
- Inspect swelling, bruise, deformity, bone protrusion
- Pt. move the limb in all directions
- Compare temperature
- Palpate gently for tenderness
- Examine concern structures(nerves, blood vessels, muscles & tendons)
- Check for crepitus (if indicated)
6. BURNS ASSESSMENT
A burn is defined as an injury caused by thermal, chemical, radiation or electrical energy.
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Procedure
- Assess the extent and depth of burb(s) by:
i.
History
ii.
Physical examination (assess extent)
History
 Establish the circumstances within which the injury occurred
 How did the fire occur/causative agent? (e.g explosion, some agents cause
more extensive damages than what is visible)
 Where did it occur?
 Was it an enclosed space? (e.g. risk of carbon monoxide exposure)
 When was the patient removed from the fire and how long were they
exposed to it?
 What was the temperature?
 Any loss of consciousness during the accident?
 Did the patient fall or jump? (exclude other injuries)
 Pain experienced in relation to the extent of burn?
 Enquire about the patient’s past medical history and tetanus status
Assessing extent
- Total burn surface area (TBSA) can be estimated using Wallace’s Rule of
Nines.
- In this system, the adult body is divided into anatomical regions that
represent 9% (and multiples of 9%) of the TBSA:
 Head and neck: 9% of TBSA
 Each arm: 9% TBSA
 Each leg: 18% TBSA
 Anterior trunk (front of the body) 18% TBSA
 Posterior trunk (back of the body) 18% TBSA
- The surface area of your hand is about 1%
- Children are assessed using the “rule of sevens”
- Depth of the burn can be assessed by:
i.
Inspection (burn location, skin colour, blisters )
ii.
Pin prick test (Ask Pt. to distinguish between sharp&
blunt ends of needle; feels sharp or/& bleeds=superficial
burn, dull=deep burn)
- Assess the chances of occurrence of complications:
i.
Site involved (joints, face, hands, feet)
ii.
Circumferential burn
iii. Perineum involved
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LESSON 11
OBSTETRIC/GYNAECOLOGY
HISTORY & PHYSICAL EXAMINATION
OBSTRETRIC HISTORY TAKING
An obstetric history involves asking questions relevant to a patient’s current and
previous pregnancies.
Objective:
1. To able to take an history of a woman attending clinic or being
admitted while pregnant, during delivery or in the post-partum
period.
2. To able to highlight specific conditions in obstetrics Hx taking
Procedure:
1. Identification
 Introduce yourself (including your name and role)
 Confirm the patient’s details (name and date of birth)
 Explain the need to take a history
 Gain consent
 Ensure the patient is currently comfortable
2. Chief complain
- Use open questioning to elicit the presenting complaint
3. Hx of presenting complains/illness
- Depends on presence of any complains
- Explore further with both open and closed questions.
4. Review of system(as usual)
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5. Obstetric Hx(Parity, Gravidity, LMP, EDD, Gestation by date, Antenatal
profile, Pregnancy related symptoms, pregnancy complication symptoms )
NB:
i. EDD calculation (Naegle’s rule= + 9/12 + 7/7; with regular 28/7
cycle)
ii. Which are the elements of:
a) Antenatal profile = ANC card, lab –Hb,bld gp, RF, VDRL, HIV
Test, Urinalysis, B/S, Stool for O/C current & previous med.,
Radiological exams, foetal movements
b) Pregnancy related symptoms (breast changes, nausea/vomiting,
indigestion/constipation, tiredness, ˃micturation, leg cramps)
c) Symptoms indicative of complications (P/V-discharge/bleeding,
pains-lower abd./Urinary symptoms, headache/visual disturbance/
swelling, Reduced fetal movements, fever & Pruritis)
6. Past Obs Hx/Previous pregnancies: Is about;
(i) Term Pregnancies ˃24/52; Gestation- dates, Mode of delivery;
home/hosp., labour,-SVD, Vacuum or C/S, Gender, Birth
weight/condition/now, Complications; during pregnancy/delivery/postpartum: –PET, HT, DM, PPH, Assisted reproductive therapies (ART),Care
providers –midwife/ obstetrician
(ii) Other Pregnancies: Gestation –early pregnancy (12 weeks or less) or
second trimester (13-24/52), Outcome: termination/miscarriage/causes
(spontaneous, medical/surgical Mx, transfusion), causes of miscarriage /
stillbirth – e.g. parental/fetal &
(iii) Gravidity/Parity: Gravidity is the total number of pregnancies,
regardless of outcome while Parity is the total number of pregnancies
carried over 24 weeks
7. Past Medical History:
Ask questions about past medical/surgical/mental history
Any Hx of medical co-morbidities which can affect women of
childbearing age (Epilepsy, Asthma, HT, CHD, DM, SCD.
8. Family History:
Usually not a substantial part of the obstetric history
But focus on conditions associated with adverse pregnancy outcomes (eg
Inherited genetic conditions; cystic fibrosis, sickle-cell disease,
Type 2 diabetes (in first-degree relative)
9. Personal Social/Economical History
Ask about occupation, diet, drinking/smoking, proximity of
delivery site/transport
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GYNAECOLOGICAL HISTORY TAKING
Definition:
Is the interviewing of the female patients who present with signs and symptoms
related to reproductive system or complications associated with early pregnancy
(1st & 2nd trimesters)
Objectives:
1. To highlight specific considerations during a gynaecological
history.
2. To be able to perform a thorough interview of a female with
gynaecological presentation.
3. To be able to perform the interview within acceptable ethical and
social standards.
PRECEDURE
Personal Identification
 Introduce yourself (including your name and role)
 Confirm the patient’s details (name and date of birth)
 Explain the need to take a history
 Gain consent
 Ensure the patient is comfortable
Chief Complains
- Ask open questioning to elicit the presenting complaint
-
Ensure the complaint is understood as everything else follows on from here
History of presenting Complaint
- It differs slightly depending on the presenting complaint
- Use open questioning to allow the patient to fully elaborate self
- Ask about impact on their daily life, and how it is currently being
managed
- The specific details to elicit from the presenting complaint include
 Type and site of symptoms
 Timing: Onset and duration, Cyclical (are symptoms
associated with menstruation?)
 Intermittent or continuous
 Exacerbating and relieving factors
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 Previous episodes – including any investigations and
treatments
 Other associated symptoms
Review of the systems
Systemic symptoms can be related to gynaecological disease (and vice-versa). Therefore, a full
systems review is needed in the gynaecological history.
Particularly relevant features include urinary symptoms, bowel symptoms, fever (e.g. PID),
fatigue (e.g. menorrhagia associated anaemia), weight loss (e.g. malignancy) and abdominal
distension (malignancy).
Gynaecological History
1. Parity
2. Menstrual Hx (Menarche, LMP, Duration, Cycle, bleeding amount,
dysmenorrhoea)
3. Any irregular bleeding (Inter-menstrual/Post-coital):Pattern,
duration, amount
4. Menopause
5. PV bleeding/discharge (Colour, Consistency, Amount, Smell)
6. Fertility/infertility
7. Sexual Hx (Partners No, Freq/timing, dyspareunia)
8. STI Hx (previous, treatment/protection)
Past medical Hx
 Current or past illnesses
 Hospital admissions
 Past surgeries
Personal/SE Hx









Medical conditions
Gynecological conditions
Malignancies
Occupation
Support network
Smoking
Alcohol
Marital status
Weight:
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o
o




Rapid weight loss can cause oligo/amenorrhoea.
Obesity can cause menstrual changes, and increase the risk of endometrial cancer.
Occupation – some industrial exposures are risk factors for gynaecological disease.
Home situation – who is at home? Are they independent? These are crucial when
planning treatment.
Smoking and alcohol intake
Diet and exercise
Family Hx.
A family history of any of the following is particularly relevant in a gynaecological history:



Breast/ovarian cancer/endometrial cancer – can be familial (e.g BRCA 1/2 gene).
Diabetes – associated with some reproductive abnormalities.
Bleeding disorders – can be associated with menorrhagia.
NB:
Gynaecological Symptoms
Vaginal Bleeding
Abdominal or Pelvic Pain
Vaginal Discharge
Menstrual History (Frequency, Duration, Volume, LMP)
Other Symptoms (Dyspareunia, Vulval itching &/or anogenital skin changes)
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References
9. Bickley LS et al. Bates' Guide to Physical Examination and
History Taking. 11th ed. Philadelphia, PA: Lippincott Williams &
Wilkins.
10.Breast Examination Techniques Jessica A. Henderson; Troy
Ferguson.Author Information Last Update: February 6, 2020. Go
to:
11.Postpartum Biomedical Concerns: Breastfeeding Charles Carter
MD, ... Christine Stabler MD, FAAFP, in Family Medicine
Obstetrics (Third Edition), 2008
12. NICE. Clinical Knowledge Summary. Nausea/vomiting in pregnancy.
Published: June 2017.
13. BMJ. Reduced fetal
movements. 2018; 360 doi: https://doi.org/10.1136/bmj.k570 (Published 06
March 2018)
14.Minesh Mistry, 2017, revision 10,Bulleted Contents
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