RCSI.COM
EDITORS IN CHIEF
Dr. Gozie Offiah
Prof. Gerry McElvaney
Prof. Arnold DK Hill
2 nd E D I T I O N
R C S I U N I V E R S I T Y O F M E D I C I N E A N D H E A LT H S C I E N C E S
RCSI
HANDBOOK OF
CLINICAL SKILLS
ii
iii
RCSI
HANDBOOK
OF CLINICAL
SKILLS
iv
First published in Ireland in August 2021
This edition published in Ireland in September 2022
by RCSI, University of Medicine and Health Sciences
123 St Stephen’s Green, Dublin, D02 YN77, Ireland
ISBN 978-1-9996983-4-8
© RCSI 2022
All rights reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or mechanical, including
photography, recording or any other information storage in a retrieval system
without prior permission from the publishers.
Produced and designed in Dublin, Ireland by RCSI
v
RCSI
HANDBOOK
OF CLINICAL
SKILLS
EDITORS IN CHIEF
Dr. Gozie Offiah
Prof. Gerry McElvaney
Prof. Arnold DK Hill
vi
DISCLAIMER
The information in this book is derived from multiple sources and is the personal opinion of the authors.
It is designed as a guide incorporating the five pillars of clinical skills namely communication skills (history
taking), clinical examination skills, procedural skills and clinical reasoning in the undergraduate setting. The
authors and editors have taken care to ensure that the content of this textbook covers the relevant points to
allow students formulate differential diagnoses and plan further investigations and management of patients
in the clinical environment.
This material is intended to guide students through the process of performing a detailed clinical skills
evaluation including history taking, clinical examination, performing procedural skills and an introduction
to prescribing skills. As such, this clinical skills book should be used in conjunction with the recommended
reading lists and electronic resources made available by RCSI.
Clinical surgery and medicine are ever-changing fields. The editors and authors of the RCSI Clinical Skills
book have made every effort to provide information that is accurate and complete as of the date of
publication. However, in view of the rapid changes occurring in medical science, as well as the possibility of
human error, there may be some technical inaccuracies, typographical or other errors.
The information contained herein is provided “as is” and without warranty of any kind. The contributors to
this book, including the RCSI, disclaim responsibility for any errors or omissions or for results obtained from
the use of information contained herein.
There are QR codes relating to immersive virtual learning challenges and external resources on pages in
this book. These learning challenges cover complex consultation skills. Users will work their way through a
consultation, selecting the questions that they think are most appropriate to ask the patient, and assessing
the patient’s response after each of their selections. You will be briefed about the task at hand at the start
of each challenge. You will also receive feedback at the end of the consultation and an opportunity to then
practice it as much as you would like. These were designed and intended to support for medical students in
the latter stages of their training who are covering these topics as part of their course. Medical students in
the earlier stages of training are not expected to be able to consult at this level.
vii
ACKNOWLEDGEMENTS
SENI O R E D I T O R S
Dr Gozie Offiah, Senior Lecturer & Director of Curriculum, Department of Surgery, RCSI, Dublin.
Prof Gerry McElvaney, Head of School of Medicine, Professor of Medicine, RCSI, Dublin.
Prof. Arnold DK Hill, Dean of Medical Programmes, Professor of Surgery, RCSI, Dublin.
A SSI STAN T E D I T O R S :
Dr Yazan Qaoud, Clinical Tutor, Department of Surgery, RCSI, Dublin.
Dr Amenah Dhannoon, Clinical Tutor, Department of Surgery, RCSI, Dublin.
A U TH O R S :
Mr. Enda Hannan, Clinical Lecturer, Department of Surgery, RCSI, Dublin.
Mr. Anthony Hoban, Clinical Lecturer, Department of Surgery, RCSI, Dublin.
Dr Claire Condron, Senior Lecturer, Department of Simulation, RCSI, Dublin.
Dr. Daniel Creegan, Clinical Tutor, Department of Surgery, RCSI, Dublin.
Dr Hannah Gogarty, Lecturer, Department of Medicine, RCSI, Dublin.
Mr. Eric Clarke, Lecturer, Department of Medical Professionalism, RCSI, Dublin.
Dr. Aisling Lavelle, Education Lead, Irish Hospice Foundation.
SPEC I A L T H A N K S T O T HE CONTR IBUTOR S
Catherine Bruen, Siobhan Murphy, Dr. Melanie Cunningham, Dr. Caroline Delany,
Dr. Dara Cassidy, Dr. Emer O'Brien, Dr. Juliette Duff, Dr. Andrea McCarthy,
Ms. Orla Keegan, Dr. Máirtín Ó Maoláin, Dr. Muirne Spooner, Mr. Colm Power, Mr. Niall Davis,
Mr. Peter Naughton, Mr. Seamus McHugh, Mr. Wail Mohammed, Prof. Brendan McAdam,
Prof. Fidelma Fitzpatrick, Prof. Frank Cunningham, Prof. James Paul O’Neill,
Prof. Mark Sherlock, Prof. Raghu Varadarajan and Prof. Shane O’Neill.
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P R E FA C E
This second edition of the RCSI handbook of Clinical Skills is designed to
guide you through components of history taking, physical examination,
introduction to prescribing and procedural skills both in the classroom and in
the clinical setting. This 2nd edition was modified based on students' feedback
on the 1st edition. The handbook was designed for students in RCSI, University
of Medicine and Health Sciences across Dublin, Bahrain and Malaysia for all
years of the undergraduate programme.
This RCSI handbook of Clinical Skills should serve as a guide and template for
your study and should be used in conjunction with the tutorial and ward based
teaching which you will receive during the course of your programme.
The authors and contributors of the book are RCSI graduates and RCSI
academic staff. We hope that you find it a useful resource in both your
undergraduate training and into your future careers.
Dr. Gozie Offiah
Senior Lecturer & Director of Curriculum - THEP implementation
Department of Surgery
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CONTENTS
ACKNOWLEDGEMENTS
VII
PREFACE
IX
CHAPTER 1: INTRODUCTION
TO THE CALGARY CAMBRIDGE
MODEL
1
Calgary - Cambridge Guide One –
Interviewing the Patient
3
Initiating the session
3
Gathering Information
3
Providing Structure
4
Building Relationship
4
Facilitative Response - Minimal
Encouragements
27
Paraphrasing
27
Open-Ended Questions
27
Non-verbal skills
28
Picking up verbal and non-verbal cues
28
CHAPTER 4: DYING, DEATH
AND BEREAVEMENT
33
When Someone is Dying
36
Encountering Death
42
Grieving When Someone Dies
43
46
51
Why do I Need to Know about Dying?
Closing the Session
(Preliminary Explanation Planning)
5
RCSI Student Experiences
Calgary - Cambridge Guide Two –
Explanation and Planning
6
CHAPTER 5: TIPS FOR
CLINICAL EXAMINATION
35
Providing the Correct Amount and
Type of Information
6
WIPE Mnemonic for Beginning
a Clinical Exam OSCE
Aiding Accurate Recall and Understanding
6
Transmission Based Precautions
53
Hand and Hygiene - 5 moments
56
Equipment Required for Clinical Exam
56
Upon Completion of OSCE
station/ Long Case Clinical Exam
56
Achieving A Shared Understanding:
Incorporating the Patient’s Perspective
7
Planning: Shared Decision Making
7
Closing the Session
7
53
CHAPTER 2: PRINCIPLES
OF HISTORY TAKING
11
Lump Examination
63
SOCRATES
16
Examination of A Skin Lesion
65
Systems Review
16
Lymph Node Examination
66
CHAPTER 3: INTRODUCTION
TO ACTIVE LISTENING
23
CHAPTER 7: CARDIOVASCULAR
AND RESPIRATORY
EXAMINATION
71
History Taking
Listening and its Role during
the Medical Interview
13
25
CHAPTER 6: LUMPS AND SKIN
LESIONS EXAMINATION
61
Acute Chest Pain History
73
25
Cardiovascular Examination
77
What are the Specific Skills
of Active Listening?
26
Commonly Prescribed Medications –
Cardiovascular System
85
Wait Time
26
Effective Pauses
27
The RCSI Three-Column Guide –
Cardiovascular Examination
86
Patient Rapport
xi
Acute Shortness of Breath History
91
Spinal Examination
231
Respiratory Examination
95
Hip Examination
234
Knee Examination
236
Commonly Prescribed Medications –
Respiratory System
100
Ankle and Foot Examination
239
The RCSI Three-Column Guide –
Respiratory Examination
102
Commonly Prescribed Medications –
Rheumatology/MSK and Dermatology
242
The RCSI Three-Column Guide –
Musculoskeletal Examination
244
CHAPTER 11: VASCULAR
EXAMINATION
255
CHAPTER 8: ABDOMINAL
EXAMINATION
109
Gastrointestinal Examination
115
Groin Hernia Examination
125
Stoma Examination
131
Lower Limb Venous Examination
262
Digital Rectal Examination
Abdominal Pain History
111
Lower Limb Arterial Examination
257
135
Diabetic Foot Examination
265
Commonly Prescribed Medications –
Gastrointestinal System
139
The RCSI Three-Column Guide –
Vascular Examination
267
The RCSI Three-Column Guide –
Gastrointestinal Examination
141
CHAPTER 9: NEUROLOGICAL
EXAMINATION ACUTE
HEADACHE HISTORY
153
CHAPTER 12: BREAST &
ENDOCRINE EXAMINATION 279
Thyroid/Neck Lump and Thyroid
Status Examination
Breast Examination
281
286
Collapse History
159
Cushing’s Syndrome Examination
289
Glasgow Coma Scale
163
Acromegaly Examination
292
Mental State
165
Cranial Nerves Examination
167
Commonly Prescribed Medications –
Endocrine System
295
The RCSI Three-Column Guide –
Endocrine Examination
296
The RCSI Three-Column Guide –
Breast Examination
301
Upper Limb Neurological Examination
176
Lower Limb Neurological Examination
181
Cerebellar Examination
185
Extrapyramidal System Examination
188
Hand Neurological Examination
192
Speech Assessment
196
Commonly Prescribed Medications –
Nervous System
198
CHAPTER: 13
RENAL AND GENITOURINARY
EXAMINATION
307
Renal Examination
309
Testicular Examination
311
Commonly Prescribed Medications –
Nephrology, Genitourinary
314
CHAPTER 10: MUSCULOSKELETAL
EXAMINATION
219
REFERENCES
319
Principles of Assessment
221
Hand and Wrist Examination
222
APPENDIX
321
Elbow Examination
226
Shoulder Examination
228
The RCSI Three-Column Guide –
Neurological Examination
200
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1
CHAPTER 1
INTRODUCTION
TO THE CALGARY
CAMBRIDGE
MODEL
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RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
In t ro d u c t io n to t he Ca lga ry Ca mbridge model
CALGA RY - C AM BRID GE GUID E O NE I NTERVIEWIN G T H E PAT IE N T
INITIATING THE SESSION
Establishing initial rapport
1.
Greets patient and obtains patient’s name
2.Introduces self, role and nature of interview; obtains consent if necessary
3.
Demonstrates respect and interest, attends to patient’s physical comfort
Identifying the reason(s) for the consultation
4.
Identifies the patient’s problems or the issues that the patient wishes to address
with appropriate opening question (e.g., “What problems brought you to the
hospital?” or “What would you like to discuss today?”)
5.
Listens attentively to the patient’s opening statement, without interrupting or
directing patient’s response
6.
Confirms list and screens for further problems (e.g., “so that’s headaches and
tiredness; anything else……?”)
7.
Negotiates agenda taking both patient’s and physician’s needs into account
GATHERING INFORMATION
Exploration of patient’s problems
8.
Encourages patient to tell the story of the problem(s) from when first started to
the present in own words (clarifying reason for presenting now)
9.
Uses open and closed questioning technique, appropriately moving from open
to closed
10. Listens attentively, allowing patient to complete statements without interruption
and leaving space for patient to think before answering or go on after pausing
11. Facilitates patient’s responses verbally and non–verbally e.g., use of encouragement, silence, repetition, paraphrasing, interpretation
12. Picks up verbal and non–verbal cues (body language, speech, facial expression,
affect); checks out and acknowledges as appropriate
13. Clarifies patient’s statements that are unclear or need amplification (e.g., “Could
you explain what you mean by light headed”)
14. Periodically summarises to verify own understanding of what the patient has said;
invites patient to correct interpretation or provide further information.
15. Uses concise, easily understood questions and comments, avoids or adequately
explains jargon
16. Establishes dates and sequence of events
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I ntrod u c t io n t o t h e C a l g ar y Camb r id g e mo d e l
Additional skills for understanding the patient’s perspective
17. Actively determines and appropriately explores:
- patient’s ideas (i.e., beliefs re cause)
- patient’s concerns (i.e., worries) regarding each problem
- patient’s expectations (i.e., goals, what help the patient had expected for each problem)
- effects: how each problem affects the patient’s life
18. Encourages patient to express feelings
PROVIDING STRUCTURE
Making organisation overt
19. Summarises at the end of a specific line of inquiry to confirm understanding before moving on to the next section
20. Progresses from one section to another using signposting includes rationale for
next section
Attending to flow
21. Structures interview in logical sequence
22. Attends to timing and keeping interview on task
BUILDING RELATIONSHIP
Using appropriate non-verbal behaviour
23. Demonstrates appropriate non–verbal behaviour
- eye contact, facial expression
- posture, position & movement
- vocal cues e.g., rate, volume, tone
24.If reads, writes notes or uses computer, does in a manner that does not interfere
with dialogue or rapport
25. Demonstrates appropriate confidence
Developing rapport
26. Accepts legitimacy of patient’s views and feelings; is not judgmental
27. Uses empathy to communicate understanding and appreciation of the patient’s
feelings or predicament; overtly acknowledges patient’s views and feelings
28. Provides support: expresses concern, understanding, willingness to help; acknowledges coping efforts and appropriate self care; offers partnership
29. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examination
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
In t ro d u c t io n to t he Ca lga ry Ca mbridge model
Involving the patient
30. Shares thinking with patient to encourage patient’s involvement
(e.g., “What I’m thinking now is”)
31. Explains rationale for questions or parts of physical examination that could appear to be non-sequiturs
32. During physical examination, explains process, asks permission
CLOSING THE SESSION (Preliminary Explanation Planning)
33. Gives any preliminary information in clear well organised manner, avoids or explains jargon
34. Checks patient understanding and acceptance of explanation and plans; ensures
that concerns have been addressed
35. Encourages patient to discuss any additional points and provides opportunity
to do so (eg. “Are there any questions you’d like to ask or anything at all you’d
like to discuss further?”)
36. Summarises session briefly
37. Contracts with patient re next steps for patient and physician
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I ntrod u c t io n t o t h e C a l g ar y Camb r id g e mo d e l
CA LGARY - C AM BRID GE GUIDE T W O –
E XPL ANATIO N AN D P L AN N ING
PROVIDING THE CORRECT AMOUNT
AND TYPE OF INFORMATION
AIMS: to give comprehensive and appropriate information to assess each individual patient’s
information needs to neither restrict or overload
1.
Chunks and checks: gives information in manageable chunks, checks for understanding, uses patient’s response as a guide to how to proceed
2.
Assesses patient’s starting point: asks for patient’s prior knowledge early
on when giving information, discovers extent of patient’s wish for information
3.
Asks patients what other information would be helpful e.g., aetiology, prognosis
4.
Gives explanation at appropriate times: avoids giving advice, information or
reassurance prematurely
AIDING ACCURATE RECALL AND UNDERSTANDING
AIMS: to make information easier for the patient to remember and understand
5.
Organises explanation: divides into discrete sections, develops a logical sequence
6. Uses explicit categorisation or signposting (e.g., “There are three important
things that I would like to discuss. 1st...” “Now, shall we move on to.”)
7.
Uses repetition and summarising to reinforce information
8.
Uses concise, easily understood language avoids or explains jargon
9.
Uses visual methods of conveying information: diagrams, models, written information and instructions
10. Checks patient’s understanding of information given (or plans made): e.g., by
asking patient
ACHIEVING A SHARED UNDERSTANDING:
INCORPORATING THE PATIENT’S PERSPECTIVE
AIMS: to provide explanations and plans that relate to the patient’s perspective to discover
the patient’s thoughts and feelings about information given to encourage an interaction
rather than one-way transmission
11. Relates explanations to patient’s perspective: to previously elicited ideas, concerns and expectations
12. Provides opportunities and encourages patient to contribute: to ask questions,
seek clarification or express doubts; responds appropriately
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
In t ro d u c t io n to t he Ca lga ry Ca mbridge model
13. Picks up and responds to verbal and non-verbal cues e.g.,
patient’s need to contribute information or ask questions,
information overload, distress
VIRTUAL
LEARNING
14. Elicits patient’s beliefs, reactions and feelings re information
given, terms used; acknowledges and addresses where necessary
PLANNING: SHARED DECISION MAKING
AIMS: to allow patients to understand the decision making process to
involve patients in decision making to the level they wish to increase
patients’ commitment to plans made
BREAKING
BAD NEWS
15. Shares own thinking as appropriate: ideas, thought processes,
dilemmas
16. Involves patient:
- offers suggestions and choices rather than directives
- encourages patient to contribute their own ideas, suggestions
VIRTUAL
LEARNING
17. Explores management options
18. Ascertains level of involvement patient wishes in making the
decision at hand
19. Negotiates a mutually acceptable plan
- signposts own position of equipoise or preference regarding
available options
- determines patient’s preferences
DISCLOSURE OF
MEDICAL ERROR
20. Checks with patient
- if accepts plans,
- if concerns have been addressed
CLOSING THE SESSION
Forward planning
VIRTUAL
LEARNING
21. Contracts with patient re next steps for patient and physician
22. Safety nets, explaining possible unexpected outcomes, what to
do if plan is not working, when and how to seek help
Ensuring appropriate point of closure
23. Summarises session briefly and clarifies plan of care
24. Final check that patient agrees and is comfortable with plan and
asks if any corrections, questions or other issues
SEXUAL HEALTH
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CHAPTER 2
PRINCIPLES OF
HISTORY TAKING
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P ri nc i p le s o f H is t o r y Tak in g
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
P rinciples of H istory Ta king
H I STORY TA K IN G
History taking is a core skill in medicine which takes time to develop and polish. Over
the course of your training, you must learn to elicit all relevant information from your
patients in a variety of challenging situations. A well-formed template will aid you
should an assessment become difficult, or if you need to reconfigure your approach
during questioning. There is no single best way to do this and each individual student
must find a technique which suits their own style and is reproducible. The important
practice points are:
Develop and maintain a good rapport with the patient
Elicit a thorough history without omissions
Practice time management
Present these findings succinctly to your clinical supervisor or examiner
The first part of any history taking exercise is a clear and deliberate introduction to the
patient and gaining consent to proceed. For example, one might say ‘Good afternoon
Mr. Smith, my name is John Doe, Professor Hill’s medical student. I’ve been asked
to come and see you to ask some questions, would that be alright with you?’ Take
your time to direct the patient to the appropriate setting which should be set up in
advance of the session and avoid the urge to hurry the interaction. In some instances,
a chaperone may be required and this should be decided beforehand. Introduce your
chaperone in the same manner. Small talk can be appropriate and may put the patient
at ease but this might not always be the case.
Eliciting a history:
Starting with an open-ended question, let the patient tell you what the problem is.
Often they will give you the diagnosis, so it is important to allow the patient some
time to tell their story. Often the patient will not be as concise as you are attempting
to be, this is fine. Once the patient stops spontaneously, it can be useful to provide a
short summary and progress to direct the rest of the history using a mix of open and
closed questioning.
Listen carefully to the patient and observe changes in body language when dealing
with topics of concern for the patient. Where appropriate, acknowledge the difficulties
that the patient may be experiencing, but avoid being patronising. Remember, the
patient will be doing the same to you, and if you are restless or impatient it will be
noted.
Points to consider:
-
Ensure a safe and quiet environment
Pre-arrange all necessary adjuncts to your assessment
Listen diligently; make notes as needed (explain this to the patient)
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P ri nc i p le s o f H is t o r y Tak in g
-
Ensure that the patient has time to elaborate on relevant points
Conduct the history along a systematic approach
Summarise the history and compile the findings in chronological order
Ensure that important information was not missed in error
Thank the patient for their time and proceed as required
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
P rinciples of H istory Ta king
CO M P O NE N T S O F A C L I NI C AL HI STORY
Introduction, consent and confirm the patient details
~ Full name
~ Age and date of birth
Presenting Complaint (PC)
~ Why has the patient presented to hospital or clinic?
~ What is the patient’s chief concern?
History of Presenting Complaint (HxPC) and Risk Factors (RF)
~ Expand on the presenting complaint
~ The mnemonic SOCRATES may be used to further characterize symptoms:
Site / Onset / Character / Radiation / Associated symptoms / Timing / Exacerbating & relieving factors / Severity
~ Detail recent treatments and current management
~ Describe recent similar episodes
~ Patient specific risk factors for disease
Past Medical History (PMHx)
~ Detail all past medical diagnoses and diagnostic tests or investigations
~ Blood transfusions
Past Surgical History (PSHx)
~ Describe previous surgical interventions
~ Post-operative course
~ Planned surgical interventions
Medications and Allergies
~ List any previous drug reactions or allergies and document findings clearly
~ List any prescription or non-prescription medication use
Family Medical History (FMHx)
~ Diseases in first degree relatives
~ Explore diseases in second degree relatives
~ Are any family members undergoing screening for a particular disease?
Social History (SoHx)
~ Occupational history
~ Social supports (marital status, family, housing, access to assistance as required)
Alcohol / Smoking or vaping / Recreational drug use
Systems Review (SR)
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P ri nc i p le s o f H is t o r y Tak in g
SOCRATES
Site:
-
Ask exactly where the symptom is - can the patient point to the region precisely or
is it diffuse?
Onset:
-
When did the symptoms start? Be specific when quantifying time frames.
Character:
-
Ask the patient to elaborate on their understanding of the symptom. If pain is
the PC, is it sharp or dull? Is there burning pain as in some upper gastrointestinal
presentations?
Radiation:
-Is there a pattern of radiation for the presenting symptoms? For example,
paraesthesia may radiate along a dermatome. In some cases, a typical radiation
pattern can point to a diagnosis, e.g., periumbilical pain, which then localises to
the right iliac fossa at McBurney’s point in acute appendicitis.
Associated symptoms:
-
Some conditions will have a predictable list of associated symptoms, e.g., chest
pain from an acute myocardial infarction may be associated with shortness of
breath, palpitations, collapse, etc.
Timing:
-
One should know if the symptoms started rapidly or if they were insidious in
onset. Furthermore, are the symptoms present all of the time or intermittently? It
is important to know if these symptoms are progressing, and if so ,since when? Or
are they settling with time?
Exacerbating and alleviating factors:
-
What, if anything, makes symptoms worse or better? For example, in intermittent
claudication, exercise will make symptoms worse and this will be relieved by a
period of rest.
Severity:
-
This is highly subjective, but a reasonable approach is to use the Visual Analogue
Scale, where a score of 0 is pain free and 10 is the worst pain that the patient has
ever experienced.
SYSTEMS REVIEW
Once a full history has been completed, it is important to ask about symptoms or
dysfunction in other systems. This will reduce the risk of missing important information
relating to the presenting complaint. A systems review can be an extensive series of
questions and many may not be applicable to each patient. Use your judgement to
decide how detailed your questioning needs to be.
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P rinciples of H istory Ta king
S Y S T E M S R E VI E W Q UE S TI ON S
General Questions:
- Unintentional weight loss or weight gain?
- Difficulty sleeping or change in pattern of sleep?
- Feeling well (or poorly) in general? Fatigue?
- Any recent medical evaluations or treatments?
- Fevers, chills, sweats, weight loss?
Cardiovascular System:
- Chest pain or pressure? Does this occur with activity? (Angina)
- Shortness of breath on exertion (Dyspnoea)
- Shortness of breath lying flat? (Orthopnoea)
- Shortness of breath that awakens you from sleep? (Paroxysmal Nocturnal Dyspnoea)
- Lower limb swelling?
- Sudden loss of consciousness? (Syncope)
- Rapid heartbeat or palpitations?
- History of rheumatic fever, high blood pressure, high cholesterol?
Respiratory System:
- Shortness of breath at rest or on exertion?
- Chest pain?
-Is there a cough? Is it productive? Sputum / Haemoptysis?
- Wheezing? When does this happen? (Bronchospasm)
- Have you been told that you snore loudly?
- Do you fall asleep during the day?
- Do you have night sweats?
Gastrointestinal System:
- Have you had mouth ulcers or a sore tongue?
- Dyspepsia? Relieved or exacerbated by eating?
- Difficulty swallowing? Solids or liquids? Is this progressing?
- Is it painful to swallow? (Odynophagia)
- Abdominal pain or distention?
- Nausea or vomiting? Vomiting blood? (Haematemesis)
- Jaundice?
- Change in bowel habit including change in colour / frequency / consistency?
-Is there blood or mucus per rectum?
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P ri nc i p le s o f H is t o r y Tak in g
S Y S T E M S R E VI E W Q UE STI ON S
Renal, Genitourinary and Reproductive Systems:
- Blood in urine? (Haematuria)
- Painful urination? (Dysuria) Urinating at night? (Nocturia)
-Incontinence?
- Urgency, frequency or polyuria?
-Incomplete emptying? Hesitancy? Decreased force of stream? Dribbling?
- Menstrual history for females
- Per vaginam (PV) or Per urethra (PU) discharge?
- Painful intercourse? (Dyspareunia)
- Erectile dysfunction? Changes in libido?
Neurological Assessment:
- Changes in sight, smell, taste, hearing?
- Seizures, fits, collapse?
- Headaches?
- Numbness or paraesthesia?
- Weakness?
- Difficulty with gait?
- Difficulty with speech?
- Bowel or bladder dysfunction?
- New psychiatric symptoms?
Vascular System:
- Changes in skin temperature, colour, hair distribution?
- New or chronic ulcers or slow healing wounds?
-Varicose veins?
- Claudication?
- Rest pain?
- Tissue loss, gangrene?
Musculoskeletal System:
- History of trauma?
- Joint pain, swelling, stiffness? Better or worse with activity?
- Hot, swollen joint with fever?
- Early morning pain or stiffness?
- Muscle aches and pain?
- Low back pain?
- Dry or sore eyes? Red eyes?
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
P rinciples of H istory Ta king
S Y S T E M S R E VI E W Q UE S TI ON S
Breast and Endocrine Systems:
- New palpable breast or axillary lump?
- Skin changes, nipple retraction, nipple discharge?
- Unintentional weight change?
- Fatigue? Low mood?
- Dry or greasy skin or hair?
- Change in smell or vision? Change in voice?
- Polyuria, polydipsia, polyphagia?
Visual System:
- Change in vision or blurriness?
- Double vision? (Diplopia)
- Eye discharge?
- Red eye? Or pain in the eye?
ENT / Head and Neck:
- Pain? Swelling in the neck?
- Sores or non-healing ulcers in/around mouth?
- Change in hearing acuity?
- Ear pain or discharge?
- Nasal discharge? Post nasal drip?
- Change in voice/hoarseness?
- Dental pain or changes in bite?
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CHAPTER 3
INTRODUCTION
TO ACTIVE
LISTENING
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I ntrod u c t io n t o A ct iv e List e n in g
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Introduct ion to Act ive Listening
LI ST ENING AN D IT S RO L E D UR I N G T HE
M E DICAL INT E RV IE W
Since the time of Hippocrates faculty have been instructing students to let patients
tell their own story because listening to the patient‘s account of their illness is the best
source of information to help make an accurate diagnosis. Sir William Osler, the first
Professor of medicine at Johns Hopkins Hospital and considered the father of modern
medicine emphasized the importance of taking a good history by saying
“Listen to your patient, they are telling you the diagnosis,”
PATIENT RAPPORT
Why do we care about creating a good patient-doctor relationship?
Patient satisfaction is directly correlated to the effective listening of physicians and
other healthcare practitioners. When patients are encouraged by their healthcare
providers to complete their statement of concerns they feel more comfortable with
the interaction and the relationship and thus reveal important medical information.
Research suggests that when healthcare providers listen to patients, it can result in
better compliance, enhanced patient satisfaction and physicians are less vulnerable to
malpractice lawsuits as a result. Effective communication as an essential component
of physician-patient interaction is not a new concept, however more recently
effective communication has been framed as an essential competence for medical
professionals.
Often times listening is an underused and not a completely understood skills set. Just
because an individual hears stimuli that does not necessarily mean they are processing
meaning from that stimuli and actually listening.
Active listening is a skill showing that the health care provider is both receptive to and
responsive to the patient. Active listening is the nonverbal demonstration that the
health care provider is paying attention to the patient and to the patient’s story.
Active listening is not “preparing to speak”.
It is not formulating the next question in your mind as the patient speaks.
Active listening includes appropriate eye contact, body posture and gestures;
it encompasses effective note taking, organised pacing of the interview, and
attentive silence to allow the patient time to gather thoughts and respond. It is the
3-dimensional demonstration of engagement with the patient. As such, it cannot be
choreographed ahead of time, and instead must be in constant creation with the
dynamics of the interview.
The underlying message of active listening is “I am here for you.”
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I ntrod u c t io n t o A ct iv e List e n in g
“I can’t promise to solve all your problems but I can promise that you won’t
have to face them alone”
Active listening is not only hearing what people say, but also paying attention to how
it is said, so that further dialogue can be adjusted to elicit the needed responses. This
is a method of listening to understand the intent of the sender and the circumstances
under which the message is given as well as the content of a message. To encourage
active listening it is necessary to stop doing other things and give full attention
to the speaker. This will promote a greater sense of understanding and improved
communication thereby fostering a relationship.
Active listening will
~ Help to gain information
~ Convey to the patient a sense of concern and care.
~ Provide insight into problems the patient has which might impede adherence
~ Provide insight into how the patient may behave in future situations
Active listening allows the patient to speak without interruption and allows the
healthcare provider to
~ Absorb information to respond to the patient’s questions and concerns.
~ Follow the patient’s train of thought.
~ Pay attention to nonverbal cues.
~Validate unspoken feelings.
~Verify the patient understands.
Real listening is something you commit your whole self to.
~ You have to quieten the mind
~ Really paying attention and focusing on what the other person is saying
~ Look for the essence of what the other person is trying to say.
~ Pick up the messages that have a certain urgency
~ Respond to these nuances with further questions.
WHAT ARE THE SPECIFIC SKILLS OF ACTIVE LISTENING?
~ wait-time
~ facilitative response
~ paraphrasing
~ nonverbal skills
~ picking up verbal and non-verbal cues
Wait time
Making the shift from speaking to listening at appropriate moments in the
consultation is not easy. Inadvertently, we often find ourselves preparing our next
question rather than focusing
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Introduct ion to Act ive Listening
attention on what the patient is saying. We may become so involved in formulating
our next question that we divert our own attention from hearing the patient’s message
and fail to give the patient adequate time to respond. In the medical interview, using
wait time effectively allows the patient time to think and to contribute more without
interruption and the doctor to have time to listen, think and respond more flexibly.
Effective Pauses
Silence can be very effective on a number of levels. Most people are not comfortable
with silence and will fill it with talk. You can use silence just before or just after saying
something important.
Facilitative response - Minimal Encouragements
Some healthcare professionals clearly have a greater ability than others to encourage
their patients to say more about a topic, to indicate to patients that they are interested
in what the patient is saying and that they would like them to continue. Along with
nonverbal head nods and the use of facial expression, use verbal encouragers which
signal the patient to continue their story. This is often achieved very efficiently with
minimal or no interruption and yet provides the patient with the necessary confidence
to keep going. Such facilitative comments include:
“uh-huh”, “go on”, “yes”, “I see”
Paraphrasing
A summary in your own words of what you were told demonstrates listening, creates
empathy and establishes rapport because it is evident that you have heard and
understood. Paraphrasing can begin with the words, “let me see if I understand you
correctly, -- are you telling me…” or “Are you saying…” Paraphrasing also clarifies
content, highlights issues and promotes give and take between you and the patient.
Open-ended Questions
Open questions allow the patient to tell the story in their own words – “Can you tell
me about the pain?” The primary use of open-ended questions is to help a patient
start talking. Asking open-ended questions encourages the person to say more
without actually directing the conversation. They are questions that cannot be
answered with a single word such as “yes” or “no”. Using open-ended questions
will get information for you with fewer questions, than those that usually begin with
how, what, when and where. “Why” questions tend to pass judgment and shut down
communication thus “why” questions are not asked directly.
Closed questions allow the doctor to clarify a point or get specific information
–“How many times did you vomit?” Too many closed-end questions give a feeling of
interrogation which makes rapport building difficult.
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I ntrod u c t io n t o A ct iv e List e n in g
Non-verbal skills
Much of our willingness to listen is signalled through our nonverbal behaviour which
immediately gives the patient strong clues as to our level of interest in them and in
their problems. Many individual components are involved in nonverbal communication
including posture, movement, proximity, direction of gaze, eye contact, gestures,
affect, vocal cues (tone, rate, volume of speech), facial expression, touch, physical
appearance, and environmental cues (placement of furniture, lighting, warmth). All
these skills can assist in demonstrating attentiveness to patients and facilitate the
formation of a supportive relationship
Among the most important of all the non-verbal skills is eye contact. It is so easy to
be distracted from your patient by notes or a computer. Poor eye contact can be
misinterpreted by the patient as lack of interest and can inhibit open communication.
Communication research has shown that non-verbal messages tend to override verbal
messages when the two are inconsistent or contradictory. If you provide the verbal
message that you want the patient to tell you all about their problem while at the
same time you speak quickly, look harassed and avoid eye contact, your non-verbal
message will win out and the patient will read that time is at a premium.
The importance of both verbal and nonverbal facilitation skills lies in the message that
they impart to the patient. Facilitation skills are effective in encouraging patients to tell
their story as they directly signal to our patients something about our attitude to them,
our interest in them and their story, and our helpful intentions. Without these skills, the
patient remains uncertain about our interest in what they are saying and our need for
them to continue with their account: it might be clear to us in our minds that we wish
the interview to proceed in a certain way but is our verbal and nonverbal behaviour
skillful enough for the patient to share that understanding?
Picking up verbal and non-verbal cues
Another important listening skill is that of picking up patients’ verbal and non-verbal
cues. This requires both listening and observation. Often patients’ ideas, concerns
and expectations are provided in nonverbal cues and indirect comments rather than
overt statements. These cues often feature very early in the patient’s exposition
of their problems and the doctor needs to look out specifically for them from the
very beginning of the interview. The danger lies in either missing these messages
altogether or assuming we know what they mean without checking them out with the
patient. Patients’ cues and the assumptions we make about them need to be checked
out and acknowledged in the interview.
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CHAPTER 4
DYING,
DEATH AND
BEREAVEMENT
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D y i ng, D e a t h a n d B e re a ve me n t
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Dying, Dea t h a nd Berea vement
D YI N G, DEAT H AN D BE RE AV E M E N T
SECTION 1: WHY DO I NEED TO KNOW ABOUT DYING?
It may seem strange to you at first that we have included a chapter on Dying,
Death and Bereavement in a curriculum which focuses so much on supporting and
preserving life. Death however is a part of life, and you will face it sometimes in your
student and professional career.
When you are on clinical attachments, you will meet patients who are told they have
a life-limiting illness, you will meet people who are dying, and you may also be with
them as they die. You will meet family members who are supporting a loved one at
end of life and people who have been bereaved. You will meet staff who are caring
for people who are dying and staff who are grieving the loss of a patient they had
grown close to. You may grieve yourself when a patient dies, or it may remind you of a
personal loss.
These are things which most other college students will not face, and it is important
for you to consider them now, so that you are better prepared when you come faceto-face with them, as you sometimes will.
While there is of course an overlap, we have tried to divide this chapter into
- When Someone is Dying
- Encountering Death
- Grieving when Someone Dies
- RCSI Student Experiences
We have focussed on a few core skills here, and have also introduced a number of other
important topics which you will meet elsewhere in the curriculum.
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VIRTUAL
LEARNING
SECTION 2: WHEN SOMEONE IS DYING
Over 40% of people in Ireland will die in hospital, so dying is an
expected part of hospital-life. It is something you will get used to over
time, but hopefully not desensitised to. As a medical student and
doctor, it is important to protect yourself, but it is also important not
to lose your ability to empathise.
2.1 Delivering Bad News
DELIVERING
BAD NEWS
This short animation
(5 minutes) introduces you
to the skills you will need
to deliver bad news in an
empathic, but effective way.
or visit bit.ly/3ztgHeb
FURTHER
READING
DELIVERING
BAD NEWS PDF
A useful summary of how to
Deliver Bad News
The reality of dying will likely begin for the patient by hearing ‘bad
news’ from a healthcare professional.
While you will not be delivering bad news to patients as a medical student, this is
clearly an important skill which you will need to learn. You will therefore meet it in
other places in the curriculum also.
The task of Delivering Bad News is broken
here into 5 steps:
1. Prepare yourself
Set aside some time, find a quiet place,
ensure you know all the facts
2. Make a connection
Sit down, introduce yourself, find out what
the person knows and what they would like
to know
3. Warning flag,
then break the news
in clear terms
A warning allows the person to prepare
themselves somewhat, give the news slowly
in chunks, check for understanding, avoid
jargon
4. Acknowledge the
shock, let the person
respond, and address
their concerns
Give them time, allow for silence
5. Plan and follow-up
Share information with relevant members of
the healthcare team, debrief with a colleague
and look after yourself too
or visit bit.ly/3z8Ozwx
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Dying, Dea t h a nd Berea vement
While you should not be delivering bad news as a medical student, the following are
some useful phrases which you could use or adapt when you are practicing this skill
with simulated patients:
• How have you been since I saw you last?
• Tell me, what do you know about the tests you’ve been having?
• Your test results are back and, unfortunately, the news isn’t as good as we’d like
•Do you want to tell me in your own words what you understand from what we
have talked about?
• So just for clarity, let me tell you again what we know about this
•I can see this is a shock for you
•I don’t know if you were expecting to get this news today
• What is your biggest concern right now?
• There are options available to help manage your symptoms and help you live
your life as fully as possible. We can talk about these more when you’ve had a
chance to take-in what I’ve told you
• There isn’t any specific treatment to make your illness go away, but there is a lot
we can offer to help you to cope
How would you like a doctor to deliver bad news to a member of your family?
This is probably worth reminding yourself of from time to time.
VIRTUAL
LEARNING
DISCUSSING
DYING
Discussing dying on Vimeo
or visit bit.ly/3cZocSu
2.2 Talking about Dying and Facing Difficult Questions
The conversation in which bad news is delivered, should of course
not be the only conversation a doctor will have with a patient
about their prognosis, and later their end-of-life care. These are
difficult conversations though, and even experienced doctors can
sometimes struggle to get it right. This short animation (6 minutes)
explores some of the challenges which doctors face when they
discuss dying. It also highlights however the positive outcomes
which can result from good and honest communication.
As a medical student, you should not address dying with a patient unless
you have permission from their medical team to do so, and it is rarely
appropriate without a member of the team present.
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FURTHER
READING
Occasionally however, a patient or family member may ask you a
difficult question for which you are not prepared – ‘Do you think
I’m going to die?’ or ‘Is my Dad dying’? These are indeed difficult
questions, and your response is important.
As a medical student, you should not answer a patient’s difficult
questions. Nor should you however ignore this plea for help or walk
away. So what do you do?
DISCUSSING
DYING: NHS
SCOTLAND PDF
Discussing dying
or visit bit.ly/3PXf1jW
Tips for dealing with difficult questions as a medical student:
• Try not to panic, take a breath and pause
• Don’t shut the person down to avoid the question being asked
•
Inform them however that as a student, you cannot answer
their questions, but that if they wish, you can listen and will then
try to find someone who can help
•If they wish to proceed, don’t rush them
•Give the person your full attention and listen to them, really
listen
• Allow the person to express themselves, allow for silent pauses
• If appropriate, gently probe to find out what is on their mind
• Remember, your job is to listen and to relay the information
•Inform the person again that as a student, you cannot answer
their questions, but that you will find someone appropriate and
will relay their concerns
• Make sure you do inform an appropriate person
Answering difficult questions might make us feel uncomfortable, and unsure about
where the conversation is likely to lead. We may worry about saying the wrong
thing. We often focus on keeping patients happy and comfortable and making them
feel better. Sometimes we may respond with a jovial ‘you’re grand’ or ‘don’t worry’.
Is this the response you would like if you asked a question you wanted a proper
answer to?
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Doctors will have to respond to difficult questions, so it is a skill you will use when
you are a qualified doctor, and will therefore practice as a student with simulated
patients. When a person is concerned about something and they want to talk about
it, they will choose who they speak to, and they will make this choice based on who
they feel will be the best person to have this conversation with. For the patient, the
best person is often a person whom they can trust, who they feel will be most likely to
listen to them and whom they feel will be empathetic. If the result is a closing down of
the conversation, they might choose not to voice their concerns again. It is important
therefore to recognise that if a patient chooses to have a conversation with you about
what is worrying them, then it is because they believe you will help. Your job when you
are a doctor, will be to accept that trust and to explore their concerns with them.
You don’t always have to have the right answers, it is not necessarily about that. It is
about allowing the person to express what it is they are worried about, listening to
them and then providing them with the support they need.
Whilst it is normal to feel uncomfortable when difficult questions are asked, it’s
important not to panic and rush a response, instead gently probe to find out what lies
behind the question:
•
•
•
•
What makes you ask that?
Are you worried about something in particular?
Do you want to talk about what is worrying you?
How can I help?
The key is that conversations are allowed to happen, that the person is allowed to
express themselves and ask for information, and that you as a staff member are willing
to listen to them.
‘Am I dying?’/ ‘Is my Mum dying?’
These are particularly difficult questions for a doctor to hear, listen to and answer.
•Using the responses listed above can help, but sometimes, the person asking
the question is looking for clarity
•Perhaps they have things they need to do, say or sort out, and are looking for
an honest answer so that they can plan for what is important to them
•Often the person will have a sense that they/their loved one is coming to the end
of their life and are looking for another person to listen to them as they express this
•A qualified doctor might respond in the first instance with something like –
‘You are sick enough to die’ or ‘Your mother is sick enough to die’
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2.3 The Journey of Dying
You may not have thought about it before, but the journey towards dying will vary,
depending on the diagnosis. The 4 diagrams below might represent an RTA, a
malignancy, heart failure, and dementia.
Theoretical Trajectories of Dying. Reproduced with permission (Lunney et al., 2002).
While things don’t always happen as expected, you will generally recognise with
experience, where a patient is on their journey. This allows you, the patient and their
family, to plan, have conversations, and put things in place. You will have seen how
important this opportunity is in the animation on Discussing Dying. It highlighted
how the focus will shift from cure to care, and which allows the emphasis to be less on
survival more on fulfilment. This brings us on to the breadth of end-of-life care.
2.4 Approach to Care at End of Life
We should adopt a palliative care approach when supporting patients at the end of
their lives (Ryan et al, 2014). This describes a person-centred, multi-disciplinary approach
to planning and delivering a person’s care. There are a set of core skills which every
clinician should have which will allow them to adopt a palliative care approach, and
these skills will be addressed at various points in the curriculum.
A palliative care approach requires us to consider not only the patient’s physical needs,
but also their psychological, social and spiritual needs. It highlights the importance of
good communication, and the need to optimise a person’s comfort and quality of life.
All healthcare professionals, including medical students, should adopt a palliative care
approach, because ‘dying is everyone’s business’ (The Irish Hospice Foundation, 2022).
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NOTE: It is important to understand, that while a palliative care approach should be taken by all
healthcare professionals who are caring for patients at end-of-life, Palliative Care itself is a medical
specialty which will be addressed by the appropriate teams at various points in the curriculum.
FURTHER
READING
THINK AHEAD
PDF
Think Ahead
or visit bit.ly/3d2AXf3
FURTHER
READING
END OF LIFE
CARE TOOLKIT
PDF
Toolkit for compassionate
end of life care
or visit bit.ly/3By3hQD
2.5 Advance Care Planning and Advance Healthcare
Directives
Advance Care Planning (ACP) is the process of having
meaningful conversations about what is important to a person
and what they would want for their future care. It is a way of
helping a person to understand their illness and how it might
impact them in the future. It is also a way to find out what
matters to the person and what their wishes and preferences
are. The earlier the ACP process is commenced the better. The
Think Ahead form which can be accessed here, is a detailed
tool which can help people and their families to not only think,
but plan ahead.
An Advance Healthcare Directive (AHD), sometimes known
as a ‘living will’, is a statement about the type and extent of
medical or surgical treatment a person would want or not want
in the future, on the assumption that they will not be able to
make that decision at the relevant time. AHDs are important
because they give people the opportunity to express their
wishes now about refusing life-sustaining treatment at a time in
the future when they may not be able to make that decision for
themselves.
These very important matters will be addressed elsewhere in
the curriculum, however some helpful information on end-oflife planning and preparation is included in this document.
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VIRTUAL
LEARNING
DYING IS NOT
AS BAD AS YOU
THINK
‘Dying is not as bad as you
think’ | BBC Ideas - YouTube
or visit bit.ly/3vz8GDj
VIRTUAL
LEARNING
COPING WITH
DEATH AND
BEREAVEMENT
Coping with death and
bereavement as a health
and social care professional
on Vimeo
or visit bit.ly/3BBfHay
SECTION 3: ENCOUNTERING DEATH
As a medical student, you will have the privilege of being present at
the very beginning or the very end of some people’s lives. Research
indicates that as a medical student, your first experiences of the
death of a patient are often the most memorable to you, even if
without a strong connection to a particular patient (Jackson et al.,
2005, Rhodes-Kropf et al., 2005).
3.1 The Final Hours and Minutes
Where possible in a hospital, a patient’s family will be with them
when they die, and it is not a place for outsiders, other than those
who are attending to the patient. There are situations however when
you will be with a patient as they die, so it is helpful to understand
what dying looks like. This short video (4 minutes) will reassure you
that ‘dying is probably not as bad as you were expecting’. It also
highlights the importance of talking about ‘normal human dying’.
Mind Yourself
When you have experienced a difficult situation either as a medical
student or as a doctor – be it responding to a difficult question, or
being with someone as they die – it is always a good idea to debrief
and take a little time for yourself. Similarly, it may be that you can
support a colleague who needs someone to listen to them.
This short animation (4 minutes) outlines the importance of TALKing:
•
•
•
•
Tell someone how you are feeling
Ask for help
Listen to colleagues, and be
Kind to yourself and those you work with
3.2 What is a Good Death?
What would you like for yourself or a loved one at end-of-life? What would be really
important to you? These are not easy things to reflect on, but studies have shown
a remarkable concordance in what people want. In general terms then, what you
would like for yourself, could probably tell you a lot about how to support patients
and their families at this time.
An Irish study (Weafer, 2014) showed that the 3 most important things to
people are; being free from pain or other symptoms, being surrounded
by loved ones, and being afforded privacy and dignity.
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3.3 Practical Considerations and Procedures When Someone Dies
When a patient dies, it is often an overwhelming experience for the grieving family, and
their needs should be considered, even while hospital-life continues for everyone else.
A little time, privacy and kindness will make a big difference to a grieving family and will
be much appreciated, so it is important to hold onto this empathy in the rush to fulfil the
practical and legal duties which follow a patient’s death in hospital.
Customs and procedures at the time of death will vary somewhat between hospitals
depending on their Care After Death policies, but they will include many of the following:
laying-out the person’s body (‘last offices’), returning their belongings to the family,
removing the deceased to the mortuary, spending time in the family room, religious and
cultural rights, certifying the death, post-mortem, informing the coroner etc. Some of
these matters concern the doctor directly, and some are things which a doctor should
understand as patients may ask about them. These important issues will therefore be
addressed elsewhere in the curriculum.
FURTHER
READING
LOSS AND
THE GRIEVING
PROCESS
Loss and the Grieving Process
or visit bit.ly/3zQIkyS
FURTHER
READING
THE ACUTE
HOSPITAL AND
WORKPLACE
GRIEF
SECTION 4: GRIEVING WHEN SOMEONE DIES
4.1 Loss and Grieving
You may already have experienced loss in your personal life, and
as a medical student and doctor, you will also experience death in
your professional life. The concept of the Stages of Grief to which
some people may still refer to, is no longer an accepted model of
grief, and we recognise that people will experience a wide range
of emotions, in no particular order, as they cope with their loss.
Knowing what a ‘normal’ grieving process looks like (wide-ranging
as it is), helps us to identify people who may need some additional
support, or who are experiencing complicated grief.
•This brief interactive course (10 minutes), which includes
a short animation, on Loss and the Grieving Process,
highlights some of the emotions people experience when
they are bereaved, and the processes by which we normally
cope with grief.
•This other brief interactive course (5 minutes), which also
includes a short animation, introduces the concept of
professional grief among staff in an acute hospital setting.
It also highlights the importance of self-care and support
which we have touched-on in Section 3.1.
The Acute Hospital and
Workplace Grief
or visit bit.ly/3btfuvm
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VIRTUAL
LEARNING
4.2 Talking to Someone Who is Bereaved
You should be guided by your medical team when approaching
relatives of patients who have died, and as a medical student, it is
often not appropriate to approach grieving family members.
WHAT TO SAY
TO A BEREAVED
PERSON
Dr Susan Delaney on what
to say to a bereaved person
- YouTube
or visit bit.ly/3zwAfhp
You will however meet people who have recently been bereaved,
in both your personal and professional life, and you may struggle
to know what to say. This short video (3 minutes) will give you some
guidance.
Do
Don’t
• Acknowledge the loss
•Care more about the
person than your own
discomfort
•Be aware of how
bereavement affects people
•Encourage the person to
talk if they want to
•Minimise the impact of the loss
(you’ll meet someone else)
•Reassure when what is needed
is permission to share grief
•Limit the time in which
support is given
•Expect someone to be ’back
to normal’ quickly
4.3 The Bereavement Pyramid
Following the public health model, the Bereavement Pyramid is
a framework which illustrates how all people who experience a
bereavement have some level of need (Irish Hospice Foundation, 2022)
•Level 1: ALL bereaved people have a need for compassion and
acknowledgement of the death
•Level 2: SOME people need additional support which is outside
their natural network, such as peer to peer support
•Level 3: SOME people require a more intensive support, such as
counselling
•Level 4: A FEW people require support from a specialist
therapeutic service. Level 4 is what is termed Complicated Grief/
Prolonged Grief Disorder (World Health Organization, 2019)
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Dying, Dea t h a nd Berea vement
Adult Bereavement Care Pyramid
4.4 Death and Bereavement in Society
Modern medicine has brought significant changes to how we live and also where
we die, 44% of Irish people die in hospital, 23% die in residential care and 8% die in
specialist inpatient palliative units (hospices). Only 23% of deaths occur in the person’s
home (Matthews S, 2021), compared to 100 years ago when most people died at
home while being looked after by family and friends.
Conversations about death and dying can be difficult. Doctors, patients, or family
members may find it easier to avoid them altogether and continue treatment (Sallnow
et al., 2022). Hospital staff, just like the general public, may not be very comfortable
talking about dying and death, and are even less comfortable talking to a person
who has been recently bereaved (McKeown et al., 2010). Therefore it is important for
medical students to recognise death as a part of life rather than a traumatic event.
(Smith-Han et al., 2016).
Bereavement and grief affect large numbers of people in our society. It is estimated
that as a consequence of the c30,000 deaths in Ireland each year, between four to ten
people are significantly impacted by each of those deaths (Irish Hospice Foundation,
2017, McLoughlin, 2018). Feelings of grief can manifest at any time and any place
and how others respond and support that grief can either complicate or facilitate the
grieving process (Davidson and Doka, 1999).
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D y i ng, D e a t h a n d B e re a ve me n t
VIRTUAL
LEARNING
SECTION 5: RCSI STUDENT
EXPERIENCES
5.1 Student Voice
MARITA
STAUNTON: RCSI,
SENIOR CYCLE
STUDENT
RCSI student Marita Staunton
talks about volunteering
during the covid pandemic
or visit bit.ly/3vAXkP1
VIRTUAL
LEARNING
ALIYA ALI: RCSI,
SENIOR CYCLE
STUDENT
RCSI student Aliya Ali talks
about volunteering during the
covid pandemic
or visit bit.ly/3Qi0cs8
VIRTUAL
LEARNING
ADRIAN WOON:
RCSI, SENIOR
CYCLE STUDENT
RCSI student Adrian Woon
talks about volunteering
during the covid pandemic
The COVID-19 pandemic has highlighted the importance of endof-life and bereavement care as an integral part of healthcare
provision (Pearce et al., 2021). The significant morbidity and
mortality rates encountered during a short time span by healthcare
professionals (and students) has been challenging (Kaul et al., 2021).
Public health restrictions due to the COVID-19 pandemic have
impacted on all aspects of our lives, particularly so for those who
could not visit and care for their loved ones, this was a significant
loss in itself (Bear et al., 2020).
In March 2020, during the COVID-19 pandemic, a group of RCSI
students volunteered to work with frontline staff in Beaumont and
Connolly hospitals, Dublin. During this time, there were no hospital
visits and RCSI teaching was held online only. Elective surgery and
outpatient appointments were being cancelled and ICU beds were
almost exclusively occupied by COVID-19 patients. Up to then, 128
people had died in Ireland from COVID-19, with 3,447 confirmed
cases. The number of patients infected COVID-19 had put the
Irish health care system under severe pressure. The students who
volunteered as part of this initiative helped to prone position
seriously ill Covid-19 patients. It takes up to 8 people, working as a
team, to do this correctly.
The RCSI student volunteers faced unexpected challenges
and development outside of RCSI’s definition of medical
professionalism.
Some of the student volunteers found themselves experiencing
death and dying during this programme and found this difficult to
cope with. One student remarked how using the support of family
members and other team members helped them to stay resilient.
Their experiences were published (Ali et al., 2021) and in the
videos linked below, three of the volunteers give insights into their
experiences.
We would like to acknowledge our collaboration with Irish Hospice
Foundation and their work in producing this chapter.
or visit bit.ly/3oW9BcU
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Dying, Dea t h a nd Berea vement
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CHAPTER 5
TIPS FOR
CLINICAL
EXAMINATION
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T i ps fo r C l in i ca l E xa m i nat io n
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
T ips for Cl inica l Exa mina t ion
Before you begin:
WIPE mnemonic for beginning a clinical exam OSCE
Wash your hands (and consider need for transmission based precautions*)
Introduce yourself and Identify the patient
Permission (explain what you are going to do and gain consent), Pain (ask if any) and
Position
Expose patient appropriately (& consider if chaperone required) & relevant Equipment
*Transmission Based Precautions
•
Additional precautions to use when Standard Precautions** alone may not be
sufficient to prevent the transmission of certain infectious agents
•The type of transmission-based precaution you use depends on the specific
mode of transmission of the infecting microorganism which can be by contact
(direct with the patient or indirect with the environment/equipment), and/or
droplet, and/or airborne
Transmission
Based Precaution
Example of when to use
1. Contact
•Person with DIARRHOEA likely infectious origin. Example:
C. difficile infection
-Food poisoning (eg Salmonella, Campylobacter, E. coli 0157)
Norovirus / rotavirus infection
•Colonisation/infection with antibiotic resistant pathogens
(MRSA, CPE, VRE)
• Scabies
•Shingles (if one dermatome infected and not covered)
2. Droplet
• Influenza
• COVID- 19 (no aerosol-generating procedures)
• Pertussis (whooping cough)
• Respiratory Syncytial Virus (RSV)
• Mumps
• Rubella
• Diphtheria
•Group A streptococcal infection (for first 24 hours of
antibiotic treatment)
•Meningococcal (Neisseria meningitides) meningitis for first
24 hours of antibiotic treatment)
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T i ps fo r C l in i ca l E xa m i nat io n
3. Airborne
• Tuberculosis
• COVID-19 (aerosol generating procedure)
• MERS, SARS
• Measles
• Chicken pox (varicella)
•Shingles, if patient is immunocompromised or two or more
dermatomes involved (Disseminated herpes zoster)
Images courtesy of: The Infection Prevention and Control Team, Beaumont Hospital
**Standard Precautions: a group of infection prevention and control practices that
you use always, regardless of the patients infectious status. These include hand
hygiene, safe injection practices, management of sharps, management of needle
stick injuries and blood and body fluid exposure.
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T i ps fo r C l in i ca l E xa m i nat io n
Before you examine the patient, remember the 5 moments of hand hygiene
Image courtesy of: The Infection Prevention and Control Team, Beaumont Hospital
Key Point: Always perform a general inspection in a clinical examination OSCE
•
White coat
Upon completion of OSCE station/
Long case clinical exam:
•
Appropriately dressed
•
Equipment required for clinical exam:
•Bare below the elbow (sleeves rolled
up, no wrist watches, rings, etc)
•
Stethoscope
•
Reflex hammer
•
Tuning forks (128Hz & 256Hz)
•
Pen torch
•
Neurotip / monofilament
•
Cotton wool bud
•
Measuring tape
•
Stopwatch
•
Snellen chart
•
Pen & paper
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Thank the patient
•Inform them that they can redress,
or cover them with a blanket if
appropriate
•
Check end of bed notes
•
Wash your hands
•
Offer to present your findings
•
Consider your differentials
T ips for Cl inica l Exa mina t ion
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CHAPTER 6
LUMPS AND
SKIN LESIONS
EXAMINATION
L U M P E X A M I N AT I O N
SKIN LESION
E X A M I N AT I O N
LY M P H N O D E
E X A M I N AT I O N
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Lu mps a nd Skin Lesions Exa mina t ion
L U M P E X A M I N AT I O N
These principles can be used to assess any lump or swelling & apply
to abdominal masses, groin herniae, breast lumps, scrotal lumps, neck
swellings, etc.
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position patient (dependant on location of lump)
Ask patient if in any pain
Ask patient where the area of concern is
Inspection
USE THE 6 Ss OF LUMP INSPECTION: Site, Size, Shape, Symmetry, Skin changes, Scars
DESCRIBING A LUMP ON INSPECTION
Site: Where is it anatomically located
Size: Rough estimate in cm (e.g., 3cm x 2cm)
Shape: Round/oval/irregular
Symmetry: Both symmetry about its own axis & with opposite side of body where relevant
Skin changes: Erythema/ulceration/punctuation
Scars: From previous surgery/trauma
Palpation
USE THE MEMORY AID 3 Teachers around a CAMPFIRE
DESCRIBING A LUMP ON PALPATION
Tenderness: Inflammation
Temperature: Inflammation
Transillumination: Fluid-filled cystic lesion
Consistency: Hard/firm/soft
Appearance: General appearance of the patient
Mobility: Is it fixed/tethered to overlying & underlying structures?
Pulsatile & expansile: Implies arterial lesion
Fluctuant: Attempt to ‘bounce’ lump between your two index fingers (lipomas are
fluctuant)
Irreducible: Attempt to reduce & check for cough impulse if hernia suspected
Regional lymph nodes: Enlarged in inflammation or malignancy
Edges: irregular/infiltrative/well-defined
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L um ps a n d S kin L e s i o n s Ex amin at io n
Palpation of Lymph Nodes
•
Palpate regional lymph nodes (especially if malignancy suspected)
Auscultation
•
Assess for bruit (AV fistula)
Completion
• Examination of relevant systems (e.g., GI system if abdominal mass)
• Assess neurovascular status if lump on limb
•Inquire about change to size, shape, borders, colour, pain or presence of discharge
•Inquire about quality of life & cosmetic concerns
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o
FNAC
oImaging
o
Serial photographs
DIFFERENTIAL DIAGNOSIS FOR A LUMP
Cutaneous
Benign
Seborrhoeic keratosis, Campbell de
Morgan spots, Dermatofibroma
Malignant
BCC, SCC, Melanoma
Subcutaneous
Sebaceous cyst
Fat
Lipoma
Arterial
Aneurysm
Venous
Varicosity
Neurological
Neuroma
Lymphatic
Lymphadenopathy
Muscle
Leiomyoma, rhabdomyoma, sarcoma
Skeletal
Bone tumour, malunited fracture, osteoma
Specific to location
Abdomen/groin/scrotum/neck/breast (see relevant sections)
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E X A M I N AT I O N O F A S K I N L E S I O N
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position patient (dependant on location of lesion)
Ask patient if in any pain
Ask patient where the area of concern is
Inspection
•
•
Comment on 6 Ss as above
Specifically note if any melanoma warning signs:
MELANOMA WARNING SIGNS (ABCDE)
Asymmetry
Borders (irregular)
Colour (mixed pigment)
Diameter (>6mm) and Discharge (bleeding)
Evolution (inquire if any change in size/shape/colour/itching/bleeding
Palpation
•
•
•
•
Feel if elevated above surrounding skin
o
Macule = Flat
o
Papule = Elevated
Tenderness (inflammation)
Temperature (inflammation)
Feel for regional lymphadenopathy
Completion
•Full systemic examination for evidence of metastatic disease if malignancy
suspected
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o
Bloods
o
Biopsy
o
Serial photographs
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L um ps a n d S kin L e s i o n s Ex amin at io n
LY M P H N O D E E X A M I N A T I O N
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position patient (dependant on location)
Ask patient if in any pain
Ask patient if they have noticed any obvious lumps or swellings
Key Point: Remember to always compare both sides throughout entire examination
Inspection
•
•
•
•
General appearance: Comfortable/unwell/distressed
Cachexia
Rigors
Obvious lumps or swellings (Describe using 6 Ss)
Palpation
Ask if any tenderness in each region before you palpate
Describe any lump you feel on palpation as per lump examination
TYPICAL CHARACTERISTICS FOR LYMPHADENOPATHY
Tender & fluctuant: Acute infection
Non-tender & rubbery: Lymphoma or primary malignancy
Non-tender & hard: Metastatic
Head & Neck:
• Examine from behind the patient & use the pads of 1st 3 fingers on each hand
• Under chin (submental) moving to angle of jaw (submandibular)
• Move up jaw to in front (pre-auricular) & behind ear (post-auricular)
• Move to back of head to palpate occipital nodes
• Palpate along anterior border of sternocleidomastoid to palpate anterior cervical chain
• Palpate supraclavicular lymph nodes by asking patient to shrug their shoulder
o Virchow’s node = left supraclavicular fossa (intra-abdominal malignancy)
• Troisier’s sign
•Palpate posterior cervical chain posterior to sternocleidomastoid but anterior to
trapezius
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Lu mps a nd Skin Lesions Exa mina t ion
Axilla:
• Have patient face you
•Take their left arm in your left hand to elevate & examine the axilla with your free right
hand (& vice versa)
• Ensure patient’s arm is relaxed (tell them to let you take all of the weight of their arm)
• Palpate anterior wall, posterior wall, lateral wall, medial wall & apex of axilla
Groin:
• Delineate inguinal ligament by palpating ASIS & pubic tubercle
• Palpate just below the ligament
Further Examination
•
•
Palpate abdomen for hepatosplenomegaly
Examine any areas drained by palpable lymph nodes
o Cervical:
• Head & neck
• Oral cavity
• Larynx
• Pharynx
o Axilla:
• Arm
• Breast
• Abdomen/chest wall
above umbilicus
o Inguinal:
• Leg
• Buttock
• Perineum (scrotum/anal canal)
• Abdominal wall below umbilicus
Completion
• Full systemic examination for evidence of metastatic disease if malignancy suspected
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o Ultrasound
o Biopsy
o CT-TP
DIFFERENTIAL DIAGNOSIS FOR LYMPHADENOPATHY
Infection:
• Bacterial: e.g., tuberculosis, streptococcus, syphilis
• Viral: e.g., mumps, EBV, HIV
• Other: e.g., toxoplasmosis
Autoimmune:
• Sarcoidosis
•
Systemic lupus erythematosus
Malignancy:
• Haematological (lymphoma, CLL)
• Metastatic
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CHAPTER 7
CARDIOVASCULAR
AND RESPIRATORY
EXAMINATION
A C U T E C H E S T PA I N
HISTORY
C A R D I O VA S C U L A R
E X A M I N AT I O N
ACUTE SHORTNESS OF
B R E AT H H I S T O R Y
R E S P I R AT O R Y
E X A M I N AT I O N
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Ca rd iova scula r a nd Respira tory
A C U T E C H E S T PA I N H I S T O RY
Scenario:
You are on call in emergency department and a 45-year-old gentleman presents
with chest pain. Please take his history:
Tips starting out:
•Your aim is to show, through the means of a well structured set of questions, how
much you know about the important features of chest pain, important associated
symptoms and important risk factors for the most common differentials.
•As you move through the history, you can start to formulate a list of differential
diagnoses and further ask specific questions to rule in/rule out various potential
diagnoses.
•Remember to inform the patient when you are moving into a different part of the
history. This is not necessarily for the patient’s benefit but rather to make it easy
for the examiner to follow your train of thought.
Introduction
Hello, my name is Daniel, one of the doctors on call today. If it’s okay with you I’d like
to ask you some questions about what brought you into hospital today. Is that okay?
Opening Questions
•
When did you come into hospital?
•How did you get to the hospital? Did you come via ambulance? Did you decide
yourself to come to the hospital today or were you advised to come by your
general practitioner?
•What was it that made you decide to come to the hospital? (If they said that
their general practitioner advised them to come, then this question should be
replaced with – “What was it that made you attend your general practitioner –
try to avoid asking straight out why the general practitioner thought they should
come to hospital as this may lead to premature closure in terms of differential
diagnosis workup)
You should now be aware that this is an “Acute chest pain history” as the patient has
informed you that they have attended emergency department with chest pain. It is
now time to move into the three parts of your history of presenting complaint.
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C ard i o v a s cu l a r a n d R e sp ir at o r y
History of Presenting complaint Part 1: Presenting Symptom
•If it’s okay with you I’d now like to ask you some more questions about the chest
pain you have been experiencing.
• When did this chest pain start?
• What were you doing at the time it started?
•Has it been there constantly since then or does it come and go? How long does it
last?
•Whereabouts did you feel the chest pain? Can you point with a finger to the exact
location or was it more generalised?
•Did the pain travel anywhere? (Start off this question with an open question and
then be more specific, i.e., ask if the pain travelled to the jaw, left arm, neck or back
– remember you are not just looking for cardiac causes!!!!)
• How would you rate the pain out of 10?
•How would you describe the pain? (again, start with an open question here and
then you can be more specific and ask is the pain felt like a “stabbing sensation” or
more like a “burning sensation” or more like a “pressure sensation”
•Is there anything that made the pain worse? (Again, start this question with an open
ended component and then move into the specifics – It is important to determine if
exercise, breathing, movement, bending, lying down, eating or touching made the
pain worse and you should ask specifically about each of these)
•Is there anything that makes the pain better? Did rest make the pain go away? Did
you take any medications that helped? Does any position result in easing of the pain?
• Have you ever experienced a similar pain before in the past?
Now that you have explored the presenting symptom in detail, it is your job to assess for
associated symptoms. This is the second part of your History of Presenting Complaint.
Remember to tell the patient that you are moving onto a new section so that the
examiner can follow your train of thought.
History of Presenting Complaint Part 2: Associated Symptoms
•Thank you for telling me about what brought you into hospital. It must have been
quite a frightening and distressing experience for you and we are going to do our
best to find out what is causing it. If it’s okay with you I’d now like to ask about
some other symptoms that you may or may not have had.
•Were you finding it difficult to breathe? (remember that if the patient answers yes
to any of these questions about associated symptoms you will need to explore
them in more detail)
•Were you experiencing any palpitations or did you feel your heart was pounding
very fast in your chest?
• Did you have any cough? Were you coughing up any phlegm?
• Did you have a temperature?
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Ca rd iova scula r a nd Respira tory
• Did you feel nauseous or like you wanted to get sick? Did you vomit?
• Have you been able to eat or is your appetite gone?
•Have you noticed any swelling in your legs? Is one leg more swollen than the other?
• Did feel dizzy or like you were going to collapse?
• Are there any other symptoms you had that I haven't asked you about?
Now it is time to move onto the third part of your history of presenting complaint
and explore some risk factors that may help you arrow your differential. Remember
that although some of these questions may also be relevant to other parts of your
history it is important to ask them here to show that you have an idea of the types of
differentials to be considering.
History of Presenting Complaint Part 3: Risk Factors
•Thank you for telling me about all of the symptoms you have been experiencing.
If it’s okay with you I’d now like to ask you some questions about some things
that may have contributed to what’s going on? This will involve me asking some
questions about your day to day life and your past medical history. Is that ok?
•
•
•
•
Risk factors for cardiac cause of chest pain
o
Have you ever had a heart attack before?
o
Do you have a family history of heart attack or stroke?
o
Do you smoke?
o
Have you been told that you have high blood pressure?
o
Have you been told that you have high cholesterol?
o
Do you do much exercise?
o
What is your diet like?
o
Do you have diabetes?
Risk factors for PE
o
Have you ever had a clot in the lung or the leg before?
o
Do you have a family history of blood clots?
o
Have you been on any long journeys recently or any long flights?
o
Have you had any recent surgery?
Risk factors for pneumonia
oIs anyone else at home with you unwell?
o
Have you travelled anywhere recently?
o
Have you had the flu vaccine?
o
Have you had a vaccine called the pneumococcal vaccine?
Risk factors for GI causes
o
Have you ever been told you had an ulcer in your stomach?
o
Have you ever suffered from heart burn?
o
Have you ever had a camera test of the stomach before? What did it show?
By this point you should have a fair idea of a narrowed list of differentials and you can
now move onto the rest of the history.
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C ard i o v a s cu l a r a n d R e sp ir at o r y
Past Medical History/ Past Surgical History
•I’d now like to ask you some ore questions about your past medical history. I know
we have already discussed your high blood pressure and diabetes but do you
have any other conditions?
• Have you had any surgeries before?
Medications
• Do you take any regular medications?
• Do you take any over the counter medications?
•Do you have any allergies to any medications – remember to ask about what
the allergy was and what happened to them (nausea with penicillin is not an
allergy!!!!!!)
Family History:
•I know we have talked about some of your family history but are there any other
conditions that run in the family?
Social history
•
•
•
•
We have already discussed your smoking but what about alcohol?
And I’m sorry for having to ask, but what about any street drugs?
Who is at home with you?
Where do you work?
Systems review
•
As per systems review section of book
Concerns and Expectations
•Thank you very much for giving me all this information. Before we finish can I just
ask if there is anything in particular that you are concerned about?
•And is there anything in particular that you hope to get out of this consultation
today?
Okay, thank you very much. I’m just going to summarise briefly
what I learned today and you can feel free to correct me
if I miss anything.
This QR code relates
to an immersive virtual
learning challenge on
the topic of Shared
Decision Making.
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C A R D I O V A S C U L A R E X A M I N AT I O N
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose patient (ideally to the waist)
Position appropriately (initially sitting at 45o)
Ask the patient if experiencing any pain or discomfort
General Inspection
•
General appearance
o
Unwell / Distressed / Tachypnoeic
o
Nutrition status/cachexia
•
Peripheral equipment
o
Oxygen tubing, peripheral or central lines, drains, indwelling catheters
o
Bedside medications, infusion stands, etc.
•
Colour
o
Pallor / Cyanosis / Malar flush
Nails
•
Clubbing
•
Koilonychia
o
•
Splinter haemorrhage
o
•
Spooning of nails due to iron deficiency anaemia
Small, red infarct in the nail associated with subacute bacterial endocarditis
Capillary refill
o
Normal = 1-2 seconds, increased in congestive heart failure
CLINICAL
EXAMINATION
Question: CV causes of clubbing:
-
Congenital heart disease
-
Cyanotic heart disease
-
Atrial myxoma
-
Axillary artery aneurysm
CARDIOVASCULAR
EXAM
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CAUSES OF CLUBBING
Congenital cyanotic
heart disease
Infective endocarditis
Atrial myxoma
Familial
IBD
Interstitial lung disease
(e.g., fibrosing alveolitis, IPF)
Idiopathic
Cirrhosis
Malignancy (bronchial ca,
Coeliac disease Thyroid
mesothelioma)
acropachy
GI lymphoma
Suppurative lung disease
(bronchiectasis , CF,
abscess, empyema)
STAGES OF CLUBBING
1. Increased fluctuance & bogginess of nailbed
2. Loss of normal <165o angle between nail and cuticle
3.Increased curvature of nail
4. ‘Drumsticking’ of distal digit
5. Hypertrophic osteoarthropathy: Shiny, striated appearance
Schamroth’s Sign: The absence of a normal diamond-shaped ‘window’ when
fingernails of the same finger on opposite hands are placed against each other, nail
to nail. If this window is absent, the test is positive and clubbing is present
Hands
• Peripheral cyanosis
• Tar stained fingers from smoking
•Xanthomata
o
Yellow deposits associated with type II hyperlipidaemia
• Osler nodes (Rare)
oPainful, red, raised lesions found on the hands and are associated with
infective endocarditis
• Janeway lesions (Rare)
oNon-tender, small, erythematous macular or nodular lesions on the palms
that are indicative of infective endocarditis
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Ca rd iova scula r a nd Respira tory
PULSE CHARACTER
ASSOCIATED CARDIAC PATHOLOGY
Small volume
Weak pulse
Aortic stenosis
Collapsing
Aortic regurgitation
Patent ductus arteriosus
Peripheral AV fistula
Severely arteriosclerotic aorta
Plateau
Aortic stenosis
Anacrotic
Notched wave on upstroke
Aortic stenosis
Bisferiens
A double beat pulse
Obstructive cardiomyopathy and aortic
regurgitation
Pulsus Paradoxus
(> 10mmHg drop in SBP with inspiration)
Cardiac tamponade
Arms
•
Blood pressure
Face / Eyes / Mouth
• Central cyanosis
• Conjunctival pallor
•Xanthelasma
o
Intracutaneous yellow cholesterol deposits around eyes
• High arched palate
o
Marfan’s syndrome
• Dentition
o
Diseased teeth can be a source of organisms causing infective endocarditis
• Corneal arcus
o
Hyperlipidaemia
Neck
•
•
Carotid pulse
o
Found medial to the sternocleidomastoid muscle (SCM)
o
Better for characterizing pulse character and volume
JVP (Patient at 45° incline)
o
Indirect measurement of central venous pressure
o
Internal jugular vein runs directly into the right atrium
o
Height above the sternal angle in centimetres is the venous pressure in cm of H20
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Figure 1. JVP WAVEFORM
a) Right atrial (RA) contraction
c) Right ventricle (RV) contraction and tricuspid valve closure
x) RA relaxation
v) RA filling
y) Tricuspid valve opening and RV filling
JVP VERSUS CAROTID PULSE
Carotid pulsations
Jugular venous pulsations
Single pulse
Double pulse for each heart beat
(a-wave & v-wave)
Rapid inward movement
Rapid outward movement
Pulse persists with pressure at the root
of the neck
Obliteration of pulse with pressure
Not affected by respiration
JVP falls on inspiration
No change with posture
May be obliterated in standing
No hepato-jugular reflux
Increases with abdominal pressure
Palpable
Non-palpable
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
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Figure 2. JUGULAR VESSELS
Internal Jugular vein
Sternocleidomastoid
External Jugular vein
Clavicle
Praecordium
•Inspect the praecordium for scars and any abnormal pulsations
•
Observe the shape of the chest
o
Barrel chest
o
Pectus carinatum
o
Pectus excavatum
•
Is there a pacemaker or defibrillator box?
•
Palpate the apex beat
o
The lowest and most lateral position where the heartbeat can be palpated
oMeasure this location by counting rib spaces from the angle of Louis (second
intercostal space)
o
Describe the lateral position from the mid-clavicular line
•
Palpate the praecordium for palpable murmurs (thrills) using a flat palm
o
Thrills that coincide with the apex beat are systolic
o
Palpable thrills are signs of significant murmurs
•
Palpate for a parasternal heave
–The heel of the hand is lifted from the chest in systole with severe RV or LA
enlargement
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APEX BEAT ABNORMALITIES
Apex beat character
Associated cardiac pathology
Small volume or feeble
Dilated cardiomyopathy
Strong or forceful
Hypertrophy
Thrusting
Hypervolaemia, left to right shunt, MV
or AV incompetence, cardiomyopathy
Sustained
Aortic stenosis, severe hypertension
Tapping
Mitral stenosis
Asynchronous
Left ventricular aneurysm
Impalpable
Obese, hyper-inflated chest from COPD
Auscultation
•There are 4 main areas of the heart to listen over. Listed below, you will find the
best place to hear valve sounds. They are not valvular surface markings.
MITRAL
5th ICS Mid-clavicular line on Left
TRICUSPID
4th ICS Lateral sternum on Left
AORTIC
2nd ICS Lateral sternum on Right
PULMONARY
2nd ICS Lateral sternum on Left
•
Listen for normal heart sounds
o
First and second
–
S1: Beginning of systole - MV and TV closing
–
S2: End of systole & created by the AV and PV closing
•
Listen for abnormal heart sounds
o
Third or fourth heart sounds
– S3: low pitched, mid diastolic - Gallop rhythm
• Sign of left ventricular failure
• Normal in pregnancy
– S4: Late diastolic - Gallop rhythm
• Associated with hypertension
• Always absent in atrial fibrillation
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
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•
Listen for additional heart sounds
o
Opening snap
– High-pitched sound associated with mitral stenosis after S2
– Sudden opening of the valve followed by murmur
– Heard using bell over left lower sternal edge
o
Ejection systolic click
– Early systolic high-pitched sound
– Aortic or pulmonary stenosis with mobile valve
– Heard over AV or PV
o
o
Metallic heart valves
Pleural or pericardial rub
SYSTOLIC MURMURS
Timing
Pathology
Maximal intensity
Pansystolic
Mitral regurgitation
Tricuspid regurgitation
VSD
Apex to LEFT axilla
LEFT lower sternal edge
Ejection systolic
Aortic stenosis
Pulmonary stenosis
HOCM
ASD
Aortic area
Pulmonary area
LEFT lower sternal edge
Late systolic
Mitral valve prolapse
Apex
Timing
Pathology
Maximal intensity
Early diastolic
Aortic regurgitation
Pulmonary regurgitation
LEFT lower sternal edge
Mid-diastolic and
pre-systolic
Mitral stenosis
Tricuspid stenosis
Apex
RIGHT lower sternal edge
Continuous
PDA
AV fistula
Below left clavicle
Left sternal edge
DIASTOLIC MURMURS
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GRADING MURMURS
1/6 – Very soft, unlikely to hear unless known to be present
2/6 – Soft but audible with experience
3/6 – Moderate without thrill
4/6 – Loud with palpable thrill
5/6 – Very loud and easily palpable thrill
6/6 – May be audible without stethoscope
Dynamic manoeuvres
•
Aortic regurgitation
oAsk the patient to hold their breath and lean forward - the murmur should
get louder
o
Breath holding makes mitral stenosis quieter
• Mitral stenosis
o
Lying on the left side will increase mitral stenosis
•Valsalva manoeuvre
o
Decreases left ventricular outflow and increases a HOCM murmur
Completion
•
Auscultate the lung fields
o
Crepitations from pulmonary overload
• Assess the peripheral pulses
• Assess for signs of peripheral oedema
o
Sacrum and lower limbs
• Palpate the abdomen
o
Assess for signs of hepatomegaly from right heart congestion
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations, if indicated:
o
ECG
o
ECHO (TTE vs TOE)
o
Cardiac MRI
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COMMONLY PRESCRIBED MEDICATIONS – CARDIOVASCULAR SYSTEM
Drug type
Common indications
Examples
Alpha blockers
Hypertension
Doxazosin
Angiotensin
converting enzyme
(ACE) inhibitors
Hypertension, heart
failure, coronary artery
disease
Ramipril, perindopril
Angiotensin neprilysin
inhibitors (ARNI)
Heart failure
Sacubitril/valsartan
Angiotensin receptor
blockers (ARB)
Hypertension
Losartan, candesartan
Anticoagulants
Atrial fibrillation, VTE,
mechanical valve
replacement*
Vitamin K antagonist e.g.,
Warfarin
Factor Xa inhibitors e.g.,
Rivaroxaban, apixaban
Direct thrombin inhibitors
e.g., dabigatran
Low molecular weight heparin
e.g., enoxaparin
Unfractionated heparin
*Warfarin only
Antiarrhythmics
Arrhythmias
Amiodarone, flecainide,
adenosine
Antiplatelets
Coronary artery disease,
peripheral vascular disease
Aspirin, prasugrel, ticagrelor,
clopidogrel
Beta blockers
Arrhythmia, coronary
artery disease
Bisoprolol, metoprolol
Calcium channel
blockers
Hypertension, arrhythmia,
angina
Amlodipine, verapamil,
diltiazem
Diuretics
Heart failure
Furosemide, bumetanide,
spironolactone,
hydrochlorothiazide
Inotropes
Shock, cardiac arrest,
acute decompensated
heart failure
Dopamine, adrenaline,
dobutamine, noradrenaline
Nitrates
Angina, hypertension,
heart failure
Glyceryl trinitrate, isosorbide
mononitrate
Statins
Hypercholesterolaemia
Atorvastatin, rosuvastatin
• Please note these do not constitute exhaustive list of medications or indications. Reference texts and/or
drug formularies should always be consulted for comprehensive medication and prescribing information.
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THE RCSI THREE-COLUMN OSCE GUIDE
Cardiology Examination excluding the Praecordium
“This is a cardiology station. You have 5 minutes to perform a cardiology examination excluding the
praecordium. I will then ask you to present your findings and answer a question”.
Examination
Expected/Normal Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and
consent
• Introduces self with name and
level, explains what he/she will
be doing and obtains consent
for same
Hi my name is X. I’m a third
year medical student at RCSI.
What’s your name? Nice to
meet you. I’ve been asked to
examine your cardiovascular
system today. That will involve
examining your hands, face,
neck, and your legs. Would
that be ok?
Position and exposure
• Patient positioned at a 45
degree angle and undressed to
the waist
Mr/Mrs A is appropriately
positioned and exposed for
this examination.
Enquires about pain
• Prior to examining
Are you in any pain?
GENERAL INSPECTION
Performed from the end of the
bed
o Inspects for
o Equipment
o Patient
‘On general inspection Mr/
Mrs A appears well; there
are no peripheral stigmata of
cardiovascular disease and no
equipment around the bed.’
Equipment
o O2 delivery, IV access, ECG
monitor, catheter bag, mobility aids
Patient
o Appears unwell, tachypnoea,
cachexia, chest asymmetry, midline
sternotomy scar, pacemaker, ICD’
‘On closer inspection of the
hands there were no stigmata
of cardiovascular disease. ‘
• Clubbing- ‘There is grade X
clubbing.’
o Grade 1: Fluctuation & softening
of nail bed
o Grade 2: Loss of the <165° angle
between the nailbed and fold
o Grade 3: Increased convexity
nail fold
o Grade 4: Thickening of distal
finger
• Stigmata of infective endocarditis
o Osler nodes, Janeway lesions,
splinter haemorrhages
• Other
o Palmar crease pallor, tendon
xanthomata, peripheral cyanosis
or tar staining present
HANDS
o Inspects for
o Clubbing
o S
tigmata of infective
endocarditis
o Palmer crease pallor
o Xanthomata
o Peripheral cyanosis
o Tar staining
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
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Examination
Expected/Normal Comments
Potential/Abnormal Comments
‘On palpation of the pulse,
its rate was ‘X’bpm, and was
of a regular rhythm, with a
normal character. There was
no collapsing pulse and no
evidence of radio-radio delay
or radio-femoral delay.’
‘On palpation of the pulse it is…
• Tachy/bradycardic at a rate of X
• Regular irregular or irregularly
irregular rhythm
‘On closer inspection of the
face, there are no stigmata
of cardiovascular disease.’
Face
• Malar flush (Mitral Stenosis)
Eyes
• Conjunctival pallor (Anaemia)
• Corneal arcus or xanthelasma
(Chol)
• Scleral icterus (haemolytic anaemia
from metallic valve)
Mouth
• High-arched palate (Marfan’s)
• Poor dentition (Source for IE)
• Peripheral/central cyanosis
(Cyanotic heart disease)
‘On examination of the
carotid arteries, they are of
normal volume & character.
The JVP is not raised at a
distance of 5cm from the
sternal notch.’
Carotid artery
o Audible bruit
JVP
o Raised at a distance of ‘X’cm
PULSE & BLOOD PRESSURE
Pulse
• Palpates with 2 fingers &
comments on rate, rhythm &
character.
Delays
• Palpates for radio-radio delay
• Offers to do radio-femoral delay.
Collapsing pulse
• Palpates pulse with two fingers,
grasping muscular part of
forearm and then raising the
patient’s arm vertically upwards
(asks about shoulder pain
before lifting), feels for tapping
impulse at the wrist on raising
Blood pressure
• Offers to perform blood
pressure
‘There is…
• Radio-radio delay
o Aortic dissection
• Radio-femoral delay
o Coarctation of the aorta
• Collapsing pulse
o Aortic Regurgitation
HEAD
Face
• Skin changes
Eyes
• Examines by pulling down/up
eyelids looking at conjunctiva/
sclera
Mouth
• Looks inside mouth with torch
and at roof of mouth
NECK
Carotid artery
•P
alpates & auscultates both
arteries
JVP
•E
xamines at 45°, head turned
to left slightly. Measures from
the sternal notch. Demonstrate
all features;
o Visible but not palpable
o M
ore prominent inward
movement than artery
o C
omplex, double wave form
o Decreases on inspiration
o Fills from above
o A
ssesses for hepatojugular
reflux
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Examination
Expected/Normal Comments
Potential/Abnormal Comments
LUNGS, ABDOMEN, SACRUM & LOWER LIMBS
Lungs
• Auscultates lung bases
Abdomen
• Liver- With patient lying flat,
start palpation in RIF and move
hand on expiration towards
right costal margin
• Spleen- palpates towards
left costal margin from
RIF, can place other hand
posterolaterally under left
lower ribs to help identifying
enlarged spleen
Sacrum
• Palpates for pitting oedema
Lower Limbs
• Palpates for pitting oedema
behind medial malleolus of
tibia and distal shaft of the tibia
for at least 15 seconds.
‘On examination of lung
bases there is normal vesicular
breath sounds, with no
added sounds and there is no
evidence of organomegaly or
peripheral oedema.’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Lungs
o Bibasal inspiratory crepitations
(pulmonary oedema with CCF)
Abdomen
o Hepatomegaly, pulsatile liver (TR)
or splenomegaly
Sacrum
o Presence of oedema – describes to
what level oedema is present and
whether it is pitting or
Lower limbs
o Presence of oedema – describes to
what level oedema is present and
whether it is pitting or
o Vein harvesting scars on legs
Ca rd iova scula r a nd Respira tory
THE RCSI THREE-COLUMN OSCE GUIDE
Cardiology Examination of the Praecordium
"This is a cardiology station. You have 5 minutes to inspect, palpate and auscultate the praecordium.
I will then ask you to present your findings and answer a question."
Examination
Expected/Normal Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and
consent
• Introduces self with name and
level, explains what he/she will
be doing and obtains consent
for same
Hi my name is X. I’m a third
year medical student at RCSI.
What’s your name? Nice to
meet you. I’ve been asked to
examine your cardiovascular
system today. That will involve
examining your hands, face,
neck, and your legs. Would
that be ok?
Position and exposure
• Patient positioned at a 45
degree angle and undressed to
the waist
Mr/Mrs A is appropriately
positioned and exposed for
this examination.
Enquires about pain
• Prior to examining
Are you in any pain?
GENERAL INSPECTION
Performed from the end of the
bed
o Inspects for
o Equipment
o Patient
‘On general inspection Mr/
Mrs A appears well; there
are no peripheral stigmata of
cardiovascular disease and no
equipment around the bed.’
Equipment
o O2 delivery, IV access, ECG
monitor, catheter bag, mobility aids
Patient
o Appears unwell, tachypnoea,
cachexia, chest asymmetry, midline
sternotomy scar, pacemaker, ICD’
‘On closer inspection of the
praecordium there are no
stigmata of cardiovascular
disease.'
Scars
• Describes site, length, orientation,
colour
o Sternotomy (CABG/valve surgery)
o Thoracotomy (mitral valvotomy)
o PPM/ICD & underlying mass
Skeletal abnormalities
o Pectus Excavatum, Kyphoscoliosis
Visible apex beat
CLOSER INSPECTION
Performed from right hand side
of the bed
o Inspects for
o Scars
o Pacemaker/ICD box
o Skeletal abnormalities
o Visible apex beat
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Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On palpation the apex
beat was palpable in the
5th intercostal space, midclavicular line. There was no
heave and no thrills. ‘
• Apex beat- ‘The apex beat was
impalpable/displaced to _location_’
• Parasternal heave- ‘A parasternal
heave was present’
• Thrills- ‘There was a palpable thrill
felt over the Aortic/Pulm/Tricus/
Mitral area’
PALPATION
• Apex beat- begins in axilla,
moves medially, counts down
spaces
• Parasternal heave- uses heel of
hand or fingers placed to left of
sternum
• Thrills- uses flat of hand to
palate over apex, left sternum
& base of heart
AUSCULTATION
• Auscultates all 4 valve positions
with diaphragm- mitral (apex
beat), tricuspid (5thLICS),
pulmonary (2ndLICS), aortic
(2ndRICS)
• Auscultates with bell at apex
• Times to pulse
DYNAMIC MANOEUVRES
• Mitral Stenosis- Listens over
mitral area using bell with
patient in left lateral position
• Aortic Regurgitation- Leans
patient forward in full
expiration, listens at lower left
sternal border with diaphragm
• Mitral Regurgitation- Listens
in axilla
‘On auscultation there is
normal first and second
heart sounds with no added
sounds.’
Murmur Descriptions
‘On auscultation there was…’
• A (pan/ejection)systolic/ (early/mid)
diastolic murmur
• Loudest at the Aortic/Pulmonary /
Tricuspid/Mitral area
• Radiating to the axilla/carotids
• Louder on inspiration/expiration
• Grade x/6
Valve replacement
‘On auscultation there was…’
• An audible (metallic) click
o Click before the carotid pulse
=MVR
o Click after the carotid pulse= AVR
CAROTIDS
• Aortic Stenosis- Listens to
carotid
'There is no carotid bruit.’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
‘There is a carotid bruit on the L/R/
bilaterally.’
Ca rd iova scula r a nd Respira tory
A C U T E S H O R T N E S S O F B R E AT H
HISTORY
Scenario: You are on call in emergency department and Mary, a 78 year old lady
presents with a 2 day history of worsening Shortness of breath. Please take a history
Tips starting out
•When taking an acute history it is important to avoid premature closure.
Premature closure is when you hone in on a particular diagnosis too early, either
because of your own personal biases or because of something a patient says. An
acute history taking session is all about being able to show the examiner that you
can consider a full set of differential diagnoses. Chronic histories, which you will
learn later on, are different and focus instead on particular conditions and your
knowledge of the diagnosis, presentation and management of said condition.
Introduction:
•Hello, my name is Daniel, one of the doctors on call today. Is it okay with you if I
ask you some questions about what has brought you into hospital today?
Opening Questions
• When did you come into hospital
•How did you come into hospital? Did you come via ambulance or did you come in
by yourself?
•Did you decide to come to emergency department by yourself or were you
referred by your general practitioner?
•What was it that made you come to emergency department? (If they said that
their general practitioner referred them to emergency department then ask what
it was that made them go to the general practitioner in the first place)
You will now be aware that the patient presented because of shortness of breath.
Now it is time to start down your acute shortness of breath proforma starting off
with a detailed exploration of this presenting symptom, before delving deeper into
associated symptoms and risk factors
History of Presenting Complaint Part 1: Presenting Symptom
• How long have you been feeling short of breath for?
• Did it come on suddenly or gradually?
•Is there any particular time of the day that the shortness of breath is worse?
•Is there anything in particular that brings the shortness of breath on?
•Is there anything in particular that makes the shortness of breath improve?
•Is it only there with exercise or is it there at rest too?
• Do you get short of breath getting dressed or doing household chores?
• Have you experienced anything like this before in the past?
• How is it affecting your day to day life?
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History of Presenting Complaint Part 2: Associated symptoms
•Thanks for telling me about your shortness of breath. I’m sure it has been very
frightening for you and we will do our best to get to the bottom of it for you today?
•If it’s okay with you now I’d like to ask you some questions about other symptoms
that you may have experienced along with the shortness of breath?
• Have you had any chest pain?
• Do you get a pain in the chest when you take a deep breath?
•Have you noticed any swelling in the legs? Have you noticed that one leg is more
swollen than the other?
• Have you found yourself waking up in the middle of the night short of breath?
•Do you get short of breath lying flat? How many pillows do you sleep on at night?
Has this number increased recently?
• Have you noticed any cough? Have you been coughing up any phlegm?
•Have you noticed any temperatures or chills? Have you checked your temperature
at home?
• Have you noticed any change in your voice or any hoarseness?
• Have you noticed any pain in the throat?
• Have you noticed any swelling in the neck area?
•Have you or anyone closed to you noticed any change in your colour? Has anyone
commented on a change in colour of your lips at any point?
• Have you coughed up any blood?
•Have you noticed that you have been sweating a lot at night, so much so that you
have had to change the sheets on the bed or your pyjamas over night?
• Have you noticed any weight loss?
• Are there any other symptoms that you have had that I haven't asked you about?
Now that you have explored the presenting and associated symptoms it is time to
move onto risk factors, to help narrow your differential. Remember to sign post with
the patient so that the examiner can follow your train of thought.
History of Presenting Complaint Part 3 – Risk factors
•
•
Risk factors for cardiac cause
oDo you smoke? (needless to say this is also a risk factor for all the other causes
too!!)
o Do you have high blood pressure?
oHave you ever had a heart attack or been told that you have some blockages in
your heart arteries?
o Do you have high cholesterol?
o Do you have a family history of heart disease or heart attacks?
Risk factors for infectious cause
oIs there anyone else at home unwell at the moment? Anyone with flu like
symptoms?
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Ca rd iova scula r a nd Respira tory
•
•
o Have you travelled anywhere recently?
oIs there anyone else at home unwell at the moment? Anyone with flu like
symptoms?
o Have you travelled anywhere recently?
o Have you had all your vaccines?
oDo you ever have difficulty swallowing or have you ever been told to use
thickener in your food or drink to make it easier to swallow?
o Do you ever find yourself coughing a lot when you drink or eat?
Risk factors for lung malignancy?
o Do you have a family history of lung cancer?
o Have you been exposed to chemicals, fumes or smoke in your place or work?
Risk factors for PE?
o Have you ever had a clot in the lung or in one of the legs?
o Has anyone in your family ever had a clot in the lung or one of the legs?
o Have you had any recent surgery or spent a lot of time in bed recently?
o Have you been on any long journeys recently?
Now you are ready to move onto the rest of your history and hopefully you have
already earned yourself most of the marks
Past medical History/past Surgical History
•We have already talked about some of your past medical history but do you have
any other medical problems or do you attend your general practitioner regularly
for anything?
•Have you ever had any surgeries?
Family History
•I know you have already told me about how your dad sadly passed away from lung
cancer and again I really am very sorry to hear that. Are there any other conditions
that run in the family?
Medications:
•
•
•
Do you take any regular medications
Do you take any over the counter medications
Do you have any allergies?
Social History:
•Thanks for telling me already about your smoking history. Is it okay if I ask if you
drink alcohol? How much do you drink? How often? What drinks do you drink?
• Who is at home with you?
• Do you have a stairs at home?
• Do you have any home help?
• Do you do your own shopping and cook your own meals?
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•
•
Do you have a bathroom downstairs?
Where did you used to work?
Systems review
•
See appropriate section of book
Concerns and Expectations
•Before we finish I’d just like to ask you if you have any particular concerns or
worries that you would like me to address?
•Any can I just ask was there anything in particular that you hoped to get out of
today’s consultation?
Finish
•I’m now going to, with your permission, just go through a brief summary of what
I have learned from you today. Please do let me know if I have gotten anything
wrong or made any mistakes.
This QR code relates
to an immersive virtual
learning challenge on
the topic of Smoking
Cessation and Health
Behavioural Change.
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Ca rd iova scula r a nd Respira tory
This QR code relates
to an immersive virtual
learning challenge on
the topic of Paediatric
Asthma.
This QR code relates
to an immersive virtual
learning challenge on
the topic of Covid 19.
R E S P I R AT O R Y E X A M I N AT I O N
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose the patient (ideally to the waist)
Position appropriately (initially sitting at 45 degrees)
Ask the patient if any pain or discomfort
General Inspection
•
CLINICAL
EXAMINATION
RESPIRATORY
EXAM
General appearance
oUnwell / Distressed / Tachypnoeic / Drowsiness
or confusion / Tripod position
oPursed lip breathing / Accessory muscle use / Wheezing / Stridor / Hoarseness
o Respiratory rate
o Cheyne-Stokes respiration
– Alternating hyperventilation and apnoea
o Rapid shallow respiration – “Door stop respiration”
–Interstitial lung disease
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•
•
•
Peripheral equipment
oOxygen tubing, peripheral or central lines, drains, sputum pot, incentive
spirometer, bedside medications, infusion stands
Nutrition status/cachexia
Colour
o Pallor / Cyanosis
Nails
•
Clubbing:
Examination Question: Respiratory causes of clubbing:
Interstitial lung disease (IPF, Fibrosing alveolitis, Asbestosis)
Malignancy (Lung cancer, Mesothelioma)
Suppurative lung disease (Bronchiectasis, CF, Empyema)
Hands
•
•
•
•
Peripheral cyanosis
Tar stained fingers from smoking
Signs of Hypercapnia
o Warm hands / coarse tremor / dilated veins on dorsum of hand
Wasting of small muscles of the hand
o Apical lung tumour affecting the brachial plexus
Wrists & Arms
•
•
Radial pulse
o Rate & Rhythm
o Character & Volume
– Pulsus paradoxus in severe asthma
Blood pressure
Face & Neck
• Central cyanosis
• Pursed lip breathing
• Coughing
•Distended neck vessels – impulsatile, associated with facial swelling in SVC
obstruction
Closer inspection of the chest
•
Sit the patient up comfortably
•
Look for scars from previous thoracic surgery
•
Look for thickened or erythematous skin post radiotherapy
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Ca rd iova scula r a nd Respira tory
•Inspect the shape of the chest from the front and back
o Smaller on one side
– Fibrosis
– Collapse
– Pneumonectomy
o Rotation
– Scoliosis
– Kyphosis
o Pectus excavatum: Sunken sternum
o Pectus carinatum: ‘Pigeon chest’
o Barrel chest
–Obstructive airway disease – chest seems fixed and doesn’t move on inspiration
Palpate the chest
•
•
Sit the patient up comfortably
Check the position of the trachea
TRACHEAL DEVIATION
Pulled toward pathology
Pushed away from pathology
Atelectasis
Large pneumothorax
Pneumonectomy or agenesis of lung
Massive pleural effusion
Fibrosis
Mass (neck, thyroid, lung)
Expansion of the chest
•Place your hands on the posterior chest with fingers extending around the chest
wall - thumbs should almost meet in the midline
•As the patient inhales, the thumbs should move apart symmetrically. Normal > 5cm
Vocal fremitus
•Palpate the chest wall with the ulnar border of your hand and ask the patient to
say ‘ninety-nine’ or ‘blue balloons’ out loud
o Consolidation increases the resonance felt in your hand
Percussion
• Place your left hand on the chest wall with your middle finger in line with patient’s ribs
•Use the pad of your middle finger on the right to strike the middle finger on the
left hand
• Compare left to right / include the apex and axilla
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•
A dull note suggests consolidation
o A stony dull note suggests an effusion
o A resonant note suggests air-filled viscus
o A hyper-resonant note suggests pneumothorax
Auscultation
•Using the diaphragm of your stethoscope, auscultate the chest anteriorly and
posteriorly comparing left with right; include the apices and axillae
• Listen for the quality of the breath sounds
o Normal:
– Louder and longer on inspiration
– There should be no audible gap between inspiration and expiration
o Bronchial sounds:
– Due to air turbulence
– Found in areas of consolidation
– Gap between inspiration and expiration
– Expiratory sound has a higher pitch
o Added sounds:
–
Wheeze
• Local – Tumour / Foreign body
• Diffuse – Asthma / COPD
–
Friction rub
• Due to pleural irritation
• Constant grating sound
–
Crackle
Fine crackles
Associated with interstitial lung disease
Medium crackles
Associated with LV failure and COPD
Coarse crackles
Associated with pools of retained secretions
–Vocal resonance
• Ask the patient to repeat ‘ninety-nine’ aloud as you listen over the areas
auscultated previously
• In consolidated regions, the numbers are more clearly heard
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Ca rd iova scula r a nd Respira tory
Completion
• Consider cardiovascular examination if relevant
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations, if indicated:
o PFTs
o Sputum sample
o Bronchoscopy
Chest signs in respiratory disease
Pathology
Percussion
note
Breath sounds Added
sounds
Chest wall
movement
Consolidation
Dull
Decreased
bronchial
Crackles
Reduced over
affected area
Atelectasis
Dull
Absent or
reduced
Absent
Reduced over
affected area
Pneumothorax
Resonant
Absent
Absent
Reduced
Asthma
Normal
Normal or
reduced
Wheeze
Symmetric reduction
Pleural effusion
Stony dull
Absent if large
Friction rub
Reduced over
affected area
Fibrosis
Normal
Normal
Fine crackles Small reduction
symmetrically
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COMMONLY PRESCRIBED MEDICATIONS – RESPIRATORY SYSTEM
Drug type
Common indications
Examples
Short acting inhaled
beta agonists (SABA)
Asthma, COPD
Salbutamol
Long acting inhaled
beta agonists (LABA)
Asthma, COPD
Formoterol, salmeterol,
indacaterol
Inhaled corticosteroids
(ICS)
Asthma, COPD
Beclometasone, budesonide
Inhaled anticholinergics
(antimuscarinics)
Asthma, COPD
Ipratropium bromide (SAMA),
tiotropium, umeclidinium
(LAMA)
Phosphodiesterase-4
inhibitor (PDE-4)
COPD
Roflumilast
Methylxanthines
Asthma, COPD
Theophylline, aminophylline
Glucocorticoids
Asthma, COPD
Prednisolone (PO)
hydrocortisone (IV)
Inhaled antibiotics
Cystic fibrosis, non-CF
bronchiectasis
Tobramycin, azithromycin
CFTR modulation
therapies
Cystic fibrosis
Ivacaftor/tezacaftor/elexacaftor
Ivacaftor/lumacaftor
Antihistamines
Allergic rhinitis, asthma
Cetirizine, chlorphenamine,
loratidine
Mucolytics
COPD, cystic fibrosis,
non-CF bronchiectasis
Carbocysteine, dornase alfa
Leukotriene receptor
antagonist
Asthma, allergic rhinitis
Montelukast
Pyridones
Interstitial lung disease
Pirfenidone
Kinase inhibitors
Idiopathic pulmonary
fibrosis
Nintedanib
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Ca rd iova scula r a nd Respira tory
Drug type
Common indications
Examples
Antimicrobials
commonly used
Pneumonia, infective
exacerbation of chronic
lung diseases e.g.,
COPD, bronchiectasis
Amoxicillin, clarithromycin,
doxycycline, amoxicillin/
clavulanic acid, piperacillin/
tazobactam, cefuroxime,
levofloxacin, aztreonam
Influenza
Fungal infection
Tuberculosis
Oseltamavir
Voriconazole, amphotericin B
Rifampicin, isoniazid,
pyrazinamide, ethambutol
*Please note these do not constitute exhaustive list of medications or indications. Reference texts and/or
drug formularies should always be consulted for comprehensive medication and prescribing information.
PROCEDURAL
SKILL
PEAK FLOW
PROCEDURAL
SKILL
02 DEVICES
PROCEDURAL
SKILL
ABG
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THE RCSI THREE-COLUMN OSCE GUIDE
Respiratory Examination - Anterior chest
“This is a respiratory station. You have 5 minutes to examine the hands and the anterior chest. I will
then ask you to present your findings and answer a question”.
Examination
Expected/Normal Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and
consent
• Introduces self with name and
level, explains what he/she will
be doing and obtains consent
for same
Hi my name is X. I’m a third
year medical student at RCSI.
What’s your name? Nice to
meet you. I’ve been asked to
examine your chest today. That
will involve looking at your
chest and listening to your
lungs. Would that be ok?
Position and exposure
• Patient position sitting up in bed
or sitting at bedside and exposed
to waist.
Mr/Mrs A is appropriately
positioned and exposed for
this examination.
Enquires about pain
• Prior to examining
Are you in any pain?
GENERAL INSPECTION
Performed from the end of the bed
o Comments on
o Equipment
o Patient
‘On general inspection Mr/
Mrs A appears well, with
no evidence of respiratory
distress and no equipment
around the bed.’
Equipment
o O2 delivery, IV access, catheter
bag, mobility aids, nebs, inhalers,
peak flow meter, chest drain,
tracheostomy
Patient
o Appears unwell, tachypnoea,
dyspnoea, cachexia, chest
asymmetry, use of accessory
muscles, cyanosis, stridor, cough,
wheeze, Pemberton’s sign
'On examination of the
hands, there are no signs of
respiratory disease, and the
respiratory and heart rates
are within normal limits.’
• ‘There is grade X clubbing.’
Grade 1: Fluctuation & softening
of nail bed
Grade 2: Loss of the <165° angle
between the nailbed and fold
Grade 3: Increased convexity nail
fold
Grade 4: Thickening of distal finger
o Cyanosis, tar staining, wasting of
small muscles, asterixis/tremor
o The respiratory/heart rate is
increased/decreased to X bpm.
HANDS
o Systematic inspection of the
hands
o Checks for Tremor/Asterixis
o Extends
the arms, spreads the
fingers, dorsiflexs the wrist
and observes for “flapping”
tremor at the wrist. If not
immediately apparent, may
ask patient to keep arms
straight while examiner gently
hyperextend patient’s wrist
with sweeping motion.
o Checks Pulse, Resp Rate & offers
BP check
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Ca rd iova scula r a nd Respira tory
FACE AND NECK
• Eyes
• Central cyanosis
o A
sks patient to lift tongue
to roof of mouth and looks
underneath
• JVP
o E
xamines at 45°, head turned
to left. Measures from the
sternal notch.
• Tracheal deviation & tug
o P
alpates anterior inferior
neck just above jugular
notch by gently pressing
fingertips between the lateral
tracheal wall and medial
sternocleidomastoid.
o Watches for tug during
inspiration
• Offers to assess for Pemberton’s
‘On examination of the face,
there is no evidence of
respiratory disease.’
‘JVP is not visible.’
‘The trachea is central with
no evidence of tracheal tug.’
• Eyes
o Horner’s, chemosis, pallor
• Central cyanosis
o Present
• JVP
o Raised at a distance of ‘X’cm
• Trachea
o Displaced to R/L
– Ipsilateral- collapse, fibrosis
– Contralateral-mass, effusion,
pneumothorax
o Tracheal tug present
• Pemberton’s
o Present
CLOSER INSPECTION OF ANTERIOR CHEST
Comments on
• Scars
• Skeletal abnormalities
• Signs of respiratory distress
• Symmetry of chest wall
movement
‘On closer inspection of the
chest, there are no signs of
respiratory disease.
Scars
• Sternotomy (CABG/valve surgery)
• Thoracotomy (lobe/
pneumonectomy)
• Radiotherapy tattoos
Skeletal abnormalities
• Pectus Excavatum/Carinatum
• Kyphoscoliosis
• Barrel Chest – Increased AP diameter
‘On palpation, the apex
beat is palpable in the
5th intercostal space,
mid clavicular line. Chest
expansion is symmetrical
and greater than 5cm.Tactile
fremitus is normal.’
Apex beat
• The apex beat is displaced to X
‘Percussion note is resonant
bilaterally in all lung zones’
‘The percussion note is D/SD/HR in
X zone’
• D- Dull – consolidation
• SD- Stony dull - effusion
• HR- Hyperresonant – COPD,
pneumothorax
PALPATION
Apex beat
• Begins in axilla, moves medially,
counts down spaces
Chest expansion
•O
n anterior chest with both
thumbs placed lightly on chest
wall, asks patient to inspire deeply
and observes distance & symmetry
Tactile fremitus
• Places ulnar aspect of hand
in intercostal spaces and asks
patient to say ‘99’ at each point,
compares sides
Chest expansion
• Chest expansion is symmetrical/
asymmetrical to X cm
Tactile fremitus
• Tactile fremitus increased
PERCUSSION
•P
ercusses clavicles directly with
middle finger
• Percusses in supra-clavicular
fossa and all lung zones & axilla
& compares sides – uses middle
finger of right hand to strike middle
phalanx of left middle finger.
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Examination
Expected/Normal
Comments
Potential/Abnormal Comments
AUSCULTATION
• Listens with bell in supraclavicular
fossa and compares sides
• Listens with diaphragm in all
other lung zones including axilla
and comparing sides
• Performs vocal resonance
bilaterally by asking patient
to say ‘99’ and listening with
stethoscope
‘On auscultation of the
anterior chest, there is
normal vesicular breathing,
with no added breath
sounds.'
• Intensity of breath sound – reduced
• Quality of breath sound – bronchial
• Added sounds (clarify whether
inspiratory or expiratory) – wheeze,
fine/coarse crepitations, pleural rub
• Vocal fremitus – increased (e.g.,
consolidation)
THE RCSI THREE-COLUMN OSCE GUIDE
Respiratory Examination - Posterior chest
“This is a respiratory station. You have 5 minutes to examine the hands and the posterior chest. I will
then ask you to present your findings and answer a question”.
Examination
Expected/Normal Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and
consent
• Introduces self with name and
level, explains what he/she will
be doing and obtains consent
for same
Hi my name is X. I’m a third
year medical student at RCSI.
What’s your name? Nice to
meet you. I’ve been asked
to examine your chest today.
That will involve looking at
your chest and listening to
your lungs. Would that be ok?
Position and exposure
• Patient positioned at a 45 degree
angle and undressed to the waist
Mr/Mrs A is appropriately
positioned and exposed for
this examination.
Enquires about pain
• Prior to examining
Are you in any pain?
GENERAL INSPECTION
Performed from the end of the bed
o Inspects for
o Equipment
o Patient
‘On general inspection Mr/
Mrs A appears well, with
no evidence of respiratory
distress and no equipment
around the bed.’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Equipment
o O2 delivery, IV access, catheter bag,
mobility aids, nebulisers, inhalers,
peak flow meter, chest drain,
tracheostomy
Patient
o Appears unwell, tachypnoea,
dyspnoea, cachexia, chest
asymmetry, use of accessory muscles,
cyanosis, stridor, cough, wheeze
Ca rd iova scula r a nd Respira tory
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On examination of the
hands, there are no signs
of respiratory disease,
respiratory and heart rate
and within normal limits.’
o Clubbing, cyanosis, tar staining,
wasting of small muscles, asterixis/
tremor
o Abnormal RR, HR, BP
HANDS
• Systematic inspection of the
hands
• Checks for Tremor/Asterixis
• Check Pulse, Respiratory Rate
& BP
CLOSER INSPECTION OF POSTERIOR CHEST
Performed from behind the patient
• Inspects for
o Scars
o Skeletal abnormalities
o Chest wall movements
‘On closer inspection of
the posterior chest wall,
there are no scars, skeletal
abnormalities or other
stigmata of respiratory
disease.‘
Scars
• Thoracotomy, drain sites
Skeletal abnormalities
• Kyphoscoliosis
Chest wall movements
• Asymmetry, increased AP diameter
‘Chest expansion was
symmetrical and greater than
5cm. Tactile fremitus was
normal.’
Chest expansion
• Chest expansion is symmetrical/
asymmetrical to X cm
Tactile fremitus
• Tactile fremitus increased
‘Percussion note is resonant
bilaterally in all lung zones’
‘The percussion note is D/SD/HR in
X zone.’
• D- Dull – consolidation
• SD- Stony dull - effusion
• HR- Hyperresonant – COPD,
pneumothorax
‘On auscultation of the
posterior chest, there is
normal vesicular breathing,
with no added breath
sounds.'
• Intensity of breath sound – reduced
• Quality of breath sound – bronchial
• Added sounds (clarify whether
inspiratory or expiratory) – wheeze,
fine/coarse crepitations, pleural rub
• Vocal fremitus - increased (eg,
consolidation)
PALPATION
Chest expansion
•O
n anterior chest with both
thumbs placed lightly on chest
wall, asks patient to inspire
deeply and observes distance &
symmetry
Tactile fremitus
•P
laces ulnar aspect of hand
in intercostal spaces and asks
patient to say ‘99’ at each point,
compares sides
PERCUSSION
•A
sks patient to move arms
forward so that scapulae move
anteriorly
•P
ercusses clavicles directly with
middle finger
•P
ercusses all lung areas including
axillae & compares sides - uses
mid`dle finger of right hand to
strike middle phalanx of left
middle finger.
AUSCULTATION
• L istens with diaphragm in all lung
areas including apex and axilla
•C
ompares both sides
•P
erforms vocal resonance by
asking patient to say “99” while
listening with stethoscope &
compares sides
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109
CHAPTER 8
ABDOMINAL
EXAMINATION
A B D O M I N A L PA I N
HISTORY
GASTROINTESTINAL
E X A M I N AT I O N
GROIN HERNIA
E X A M I N AT I O N
STOMA
E X A M I N AT I O N
D I G I TA L R E C TA L
E X A M I N AT I O N
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RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abdomina l Exa mina t ion
A B D O M I N A L PA I N H I S T O RY
Scenario: This is Paul, a 30 year old female who presents with generalised abdominal
pain. Please take a history
Tips starting out
•Abdominal pain is a common presenting symptoms and is therefore common in
exams.
•The associated symptoms and risk factors are different depending on
whereabouts the pain in the abdomen is. In this case I have discussed the
questions that you must ask about abdominal pain in general and then I have
divided the associated symptoms and the risk factors based on the location of the
abdominal pain.
Introduction:
•Hello, my name is Daniel, one of the doctors on call today. If it’s okay with you I’s
like to ask you some questions about what brought you into hospital today?
Opening Questions
•
•
•
When did you come to emergency department?
Did you come via ambulance or did you come by yourself?
What was it that made you come to emergency department?
History of Presenting Complaint Part 1 – presenting Symptom
•If it’s okay with you I’d like to ask you some more questions about the pain in your
abdomen. Is that okay?
•Whereabouts is the pain (the location of the pain will determine which associated
symptoms and which risk factors you will ask about but it will not change the
course of questioning in this particular section)
• Can you point with one finger where it is or is it more generalised?
• Was it always in this position or has it changed?
• How bad was the pain out of 10?
• Did it come on suddenly or gradually?
•Is the pain still there now?
•Is it constant or does it come and go? (If it comes and goes you must ask how
long it lasts and how often it comes)
• What were you doing when it came on?
•Is there anything that made the pain worse?
• Did any particular position make the pain worse?
•Is there anything in particular that made the pain better?
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•Does the pain make you want to stay really still or does it make you want to constantly
move around? (This is a useful question to help differentiate between colickly pain such
as with renal calculi that makes one want to roll around and peritonitic pain such as
with appendicitis that makes one want to stay very still)
•Did you come over any speed ramps on the way to the hospital? How did these affect
the pain?
• Have you ever had pain like this before in the past.
History of Presenting Complaint Part 2 – Associated Symptoms
•Thank you for telling me about your pain. I know it must have been awful for you and
we will do our best to get to the bottom of it.
• Questions for RUQ pain
oHave you noticed any change in the colour of your urine? Have you noticed
that it has gotten any darker?
oHave you noticed any change in the colour of your stool? Have you noticed
that it is a lighter?
oIs the pain brought on by a fatty meal?
oHave you or has anyone else noticed a change in the colour of the skin or eyes?
Have they reported that you looked a little bit yellow?
oHave you had any vomiting? What was in the vomit? What colour was it? Was
there any blood?
o What is your appetite like?
o Have you noticed any diarrhoea?
o Have you had any high temperatures?
• Questions for epigastric pain?
o Have you experienced any heartburn?
o Do you get a lot of burping after eating?
o Do you vomit after eating?
o Have you noticed any acid taste in your mouth?
o Have you vomited up any blood?
oHave you noticed that you have had very dark stool that almost looks like tar?
Have you noticed an unusual smell to the stool?
oHave you noticed that your stool tends to float in the toilet water and that it is
difficult to flush?
• Questions for LIF pain
o Have you had constipation recently?
oIs there any blood in the stool?
o Have you had any temperatures?
• Questions for flank pain?
o Have you noticed any blood in the urine?
o Have you been urinating more frequently than usual?
o Have you noticed any pain in your back?
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abdomina l Exa mina t ion
•
•
•
oIs it painful when you urinate?
o Have you had any temperatures?
Questions for RIF pain
oDo you feel like eating? What is your favourite food? If I gave this to you now
would you be able to eat it?
o Have you had any temperatures?
Questions for all females
oIs there any chance you could be pregnant?
oWhen was your last menstrual period? Are your periods regular? Have you
noticed any changes recently?
o Have you noticed any abnormal bleeding between your periods?
o Have you noticed any discharge from the vagina?
oIs the pain related to the stage of your menstrual cycle?
General Questions for all sites
o Have you had any vomiting or diarrhoea
oHave you noticed any blood in the stool (if there has been blood in the stool
it is important to try and quantify it. It is also important to ask if it is bright red
blood or dark blood, if there are any clots and if it comes before the stool, after
the stool or mixed in with the stool or if it is just on the toilet paper on wiping)
oHave you had any constipation? When was the last time the bowels opened?
Are you passing wind?
o Have you noticed any swelling of the abdomen?
o Have you had any high temperatures?
History of Presenting complaint Part 3: risk factors
•If its okay with you Id now like to ask you some questions about some things that may
give us a clue as to what caused this?
• Questions for RUQ pain
o Have you ever been told you had gallstones?
o Have you ever had your gallbladder removed?
o Do you have a family history of gallstones?
• Questions for Epigastric Pain
o Do you drink alcohol?
o Have you ever been told that you have an ulcer in the stomach?
oDo you take pain killers such as neurofen or other anti-inflammatory
medications often?
o Do you take aspirin?
oHave you ever had a camera test down into the stomach? Do you know if they
found anything?
o Have you ever been told that you have liver disease or liver failure?
o Do You take steroids often?
o Have you been told that you have a very high level of fat in the blood?
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•
Questions for LIF pain
o Have you ever been told that you have a condition called diverticulosis?
oHave you ever had a camera test into the back passage? Do you know if they
found anything?
oDo you have a history of inflammatory Bowel Disease or do you have a family
history of it?
o Have you ever been told that you have Irritable Bowel Syndrome?
• Questions for flank pain
o Have you ever been told that you had kidney stones?
o Have you a family history of kidney stones?
o Do you suffer from urinary tract infections?
o Have you ever been told that you had an abnormality in the kidneys?
oHave you ever been told that you have very high level of calcium in the blood
or that you have an issue with your parathyroid glands in the neck?
• RIF pain
o Have you ever had your appendix taken out
• Females
o Have you ever had cysts on the ovaries
o Have you had recent unprotected intercourse?
oIs there any chance you could be pregnant?
You can now move onto the rest of your history
Past Medical History/Past surgical history
•
•
Do you have any other medical problems that we haven't talked about?
Have you ever had any surgeries before in the past?
Medications
•
•
•
Do you take any regular medications?
Do you take any over the counter medications?
Do you have any allergies to any medications?
Family history
•I know we have discussed some of your family history already but are there any
other conditions that run in the family?
Social history
•
•
•
•
Do you smoke?
Do you drink alcohol?
Who is at home with you?
What do you work as?
Systems review
•
See appropriate section of book for details on how to do a systems review.
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abdomina l Exa mina t ion
Concerns And Expectations
• Before we finish I’d just like to ask if there is anything in particular that is worrying you?
•And can I ask if there is anything in particular that you were hoping to get out of this
visit today?
Finish
•Now, if it’s okay with you, I’m just going to go through a brief summary of what I have
learned today. Please do let me know if I make any errors or leave anything out.
G A S T R O I N T E S T I N A L E X A M I N AT I O N
Introduction:
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose patient (ideally nipples to knees)
oXiphisternum to pubic symphysis is appropriate in most
circumstances
Position appropriately (initially supine at 45o)
o Lie flat when proceeding to abdomen
Ask patient if in any pain
CLINICAL
EXAMINATION
GI EXAM
General Inspection
•
•
•
•
General appearance
o Unwell/distressed/in pain?
Peripheral equipment
o O2, lines, drains, catheter, meds, vomit bag/sick bowl and parenteral nutrition
Nutrition status/cachexia
Colour/jaundice
o Typically clinically apparent if serum bilirubin >35μmol/L
Nails
•
•
•
•
Clubbing
o GI Causes: IBD, cirrhosis, lymphoma, coeliac disease
Koilonychia
o Spooning of nails due to iron-deficiency anaemia (e.g., GI bleed)
Leuconychia
o White discolouration due to hypoalbuminaemia (e.g., CLD)
Capillary refill
o Normal = 1-2 sec
o Reduced in shock/dehydration
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Hands
•
•
•
Tendon xanthomata
o Hyperlipidaemia (Cholestasis, PBC)
Palmar erythema
o CLD, pregnancy, hyperthyroidism, RA
Dupuytren’s contracture
o CLD, DM, labour/trauma, familial, phenytoin, Peyronie’s disease
Wrists
•
•
Hepatic asterixis/Liver flap
oHepatic encephalopathy: due to delivery of toxins usually metabolised by liver
to brain
o Asterixis also in resp & renal failure
Radial pulse
o Assess circulatory status (e.g., tachycardia in septic shock)
Arms
•
•
•
Bruising
o CLD (thrombocytopaenia, coagulopathy, falls)
Excoriations
o Pruritus from obstructive jaundice
Tattoos/IVDU marks
o Risk of Hepatitis B & C
Face
•
•
Cushingoid appearance
o Moon face, acne, hirsuitism, plethora
o C2H5OH excess causing alcoholic pseudo-Cushing’s
Parotid enlargement/sialadenosis
o C2H5OH excess
Eyes
•
•
•
Scleral icterus (Jaundice)
Conjunctival pallor (Anaemia)
Corneal arcus
o Congenital, chronic cholestasis, hyperlipidaemia, >50yrs
•Xanthelasma
oFleshy, yellow, subcutaneous deposits around eye/eyelids in hyperlipidaemia
(cholestasis, PBC)
• Kayser-Fleischer rings
o Copper deposits in Wilson’s disease
o Need slit lamp to see
• Episcleritis/Conjunctivitis (IBD)
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Abdomina l Exa mina t ion
Mouth
•
•
•
•
•
•
•
Angular stomatitis (Iron/B12 deficiency, Crohn’s, dentures)
Glossitis (B12 deficiency)
Aphthous ulcers (Crohn’s, Behcet’s disease, HSV)
Oral candidiasis (immunodeficiency)
Fetor hepaticus
o Musty/sweet breath odour: mercaptan accumulation in hepatic failure
Pigmentation
o Peutz-Jegher’s syndrome, Addison’s disease
Telangiectasia
o Osler-Weber-Rendu syndrome
Neck
•
•
Lymphadenopathy
oParticularly left supraclavicular (Virchow’s node, metastatic invasion seen in
gastric ca - Trosier’s sign)
JVP
o May be raised in CLD caused by right heart failure
Chest
•
•
•
Gynaecomastia (CLD, testicular failure, etc)
Loss of chest hair in males (CLD)
Spider naevi
o Dilated blood vessels found in distribution of SVC
o Refill centrally after compression
o 5+ suggest CLD
CAUSES OF GYNAECOMASTIA
Physiological: Idiopathic, pubertal, neonatal, old age
Testicular Failure: Klinefelter’s syndrome, viral orchitis, testicular trauma, dialysis
Excess Oestrogen: Oestrogen-secreting tumour, CLD, hyperthyroidism
Pharmacological: Cimetidine, digoxin, spironolactone, steroids, cannabis
Abdomen
•
Lie flat with one pillow & arms by sides to relax abdominal wall muscles
Inspection
•
Abdominal distension (6 Fs)
o Fat, Fluid, Flatus, Faeces, Foetus, Flippin’ big tumour
• Caput medusa (dilated veins from umbilicus outwards)
o Portal HTN
• Scars (previous surgery)
• Hernia (ask patient to cough)
•Visible pulsation/peristalsis
• Abdomen moving with respiration
o Absence implies peritonitis
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Figure 3. COMMON SURGICAL SCARS
1
2
3
4
5
11
12
8
6
9
7
1
2
3
4
10
Mercedes (upper GI surgery)
Rooftop (liver transplant)
Kocher’s (open cholecystectomy)
Midline laparotomy
5
Right paramedian laparotomy
6
Left paramedian laparotomy
7
8
9
Lanz (open appendicectomy)
Gridiron (open appendicectomy)
Groin (inguinal hernia)
10 Pfannenstiel (Caesarean section)
11 Nephrectomy
12
Laparoscopy (appendicectomy, cholecystectomy, other)
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Abdomina l Exa mina t ion
Figure 4. SURGICAL SCAR LOCATIONS
Carotid endarterectomy
(or ENT surgery/lymph
node clearance)
Thyroidectomy
/parathyroidectomy
Pacemaker incision
(pacemaker, ICD,
deep brain stimulation)
Midline sternotomy
(CABG, valvuloplasty,
cardiac surgery)
Subcostal/Kocher
(open cholecystectomy)
Midline
(most abdominal surgery)
Open nephrectomy
Rooftop
(gastrectomy, oesophagectomy,
bilateral adrenalectomy,
liver resection/transplant)
Paramedian Incision
Transverse Incision
McBurney
(appendicectomy)
Rutherford Morisson
(renal transplant)
Lanz
(appendicectomy)
Pfannenstiel
(lower section Caesarean
section)
9781032074955 | RCSI HANDBOOK OF CLINICAL SURGERY FOR FINALS, Ed. 5 | Offiah & Hill,
Copyright (© 2021) by CRC Press.
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Palpation
•
•
•
•
Down on one knee, ask if any pain in abdomen
Keep watching face of patient as you palpate
Start furthest point away from tender area
All 9 areas of the abdomen
o Name each area as you palpate it
• Light palpation: Feeling for tenderness, guarding, superficial lumps/masses
•
Deep palpation: 2-handed technique to better assess for deep masses (describe
as per lump examination)
9 Abdominal Regions
Right
Hypochondrium
Epigastric
Region
Left
Hypochondrium
Right Lumbar
Umbilical
Region
Left Lumbar
Right Iliac Fossa
Hypogastrium
Left Iliac Fossa
SIGNS OF PERITONITIS ON PALPATION
Guarding: Voluntary contraction of abdominal wall musculature to avoid pain
(peritonitis)
Rigidity: Involuntary contraction of abdominal wall musculature in response to
underlying inflammation (peritonitis)
Rebound tenderness: Pain on removal of pressure after applying pressure to
abdominal wall (peritonitis)
CAUSES OF EPIGASTRIC MASS
Skin/soft tissue: Cyst, lipoma, sarcoma
GI: Epigastric hernia, gastric ca, pancreatic ca, pancreatic pseudocyst
Other: AAA, lymphadenopathy
CAUSES OF ILIAC FOSSA MASS
Skin/soft tissue: Cyst, lipoma, sarcoma
GI:
-RIF: Appendix mass, Crohn’s disease, Caecal ca
-LIF: Colorectal ca, diverticular mass, faecal loading
Testicular: Undescended testis, ectopic testis
Gynaecological: Ovarian tumour/cyst/fibroid
Urology: Transplanted kidney
Vascular: Iliac aneurysm, lymphadenopathy
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Liver:
•
•
•
•
•
•
•
•
•
Using radial border of hand
Start in RIF & work up towards right costal margin
Ask patient to take deep breaths in & out
Feel for liver edge during inspiration
o Liver edge will strike fingers as it descends
Advance hand up during expiration
Take note of point at which liver is felt
Percuss down along the mid-clavicular line to find upper border of liver
o Percuss down from axilla in female patient
Record size of liver in cm
o Normal liver span = 6-12cm
Note character of liver: e.g., smooth, craggy, tender
CAUSES OF HEPATOMEGALY
Physiological:
Riedel’s lobe
Hyperexpanded chest
C2H5OH:
Alcoholic liver disease
Fatty liver
Infective:
Viral (hepatitis, EBV, CMV) Bacterial (TB,
abscess)
Protozoa (Malaria, Schistosomiasis)
Metabolic:
Amyloid Sarcoid
Hereditary haemochromatosis Wilson’s
disease
Malignant:
Primary HCC
Metastatic deposits
Lymphoma
Leukaemia
Congestive:
RHF
Tricuspid regurgitation Budd-Chiari
Syndrome
FEATURES OF AN ENLARGED LIVER
Smooth: Venous congestion, fatty infiltration
Nodular: Metastasis, cysts
Pulsatile: Tricuspid regurgitation
Tender: Hepatitis, RHF (capsular pain)
Bruit: HCC, AVM, TIPSS
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Gallbladder:
Key Point: Courvoisier’s Law: in the
•Palpate at mid-clavicular line below right patient with painless jaundice and
costal margin
an enlarged gallbladder (or RUQ
• Ask patient to inspire
mass), the cause is unlikely to be
•
Murphy’s sign positive if patient
gallstones and is thought to be due
winces & catches breath as inflamed
to an obstructing pancreatic or biliary
gallbladder strikes your hand
malignancy until proven otherwise
Spleen:
• Using radial border of hand
• Start in RIF & work up towards left costal margin
• Ask patient to take deep breaths in & out
•If not felt, ask patient to roll onto right side and apply pressure gently to left lower
posterior ribs, then repeat technique as above
o Encourages enlarged spleen to move out from behind ribs
• Spleen is enlarged if palpable (typically 1½-2 times enlarged to be palpable
CAUSES OF SPLENOMEGALY
Mnemonic CHINA
Congestion: portal hypertension
Haematological: haemolytic anaemia, sickle cell disease
Infection: malaria, EBV, CMV, HIV
Neoplasm: CML, myelofibrosis, lymphoma
Autoimmune: RA (if low WCC: Felty’s syndrome), sarcoidosis, amyloidosis
CAUSES OF MASSIVE SPLENOMEGALY
3 Ms:
Malaria
Myelofibrosis
CML
Kidneys:
• Feel bilaterally for loin masses or tenderness
• Ballot bimanually in turn
DIFFERENTIATING BETWEEN SPLENOMEGALY AND ENLARGED LEFT KIDNEY
Spleen
Kidney
-Cannot ‘get above’ it
-Dull percussion note
-Moves down and out on respiration
-Palpable notch on medial side
-Cannot be balloted
-Can ‘get above’ it
-Resonant percussion note
-Will not move on respiration
-No palpable notch
-Can be balloted
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CAUSES OF ENLARGED KIDNEYS
Unilateral
Bilateral
-Cannot ‘get above’ it
-Dull percussion note
-Moves down and out on respiration
-Palpable notch on medial side
-Cannot be balloted
-Can ‘get above’ it
-Resonant percussion note
-Will not move on respiration
-No palpable notch
-Can be balloted
Abdominal Aortic Aneurysm:
• Palpate deeply with two hands roughly 3cm lateral (left) & superior to umbilicus
• Feel for expansile, pulsatile mass
Percussion
• Quickly percuss all 9 areas
o Percussion tenderness = peritonitis
o Tympanic = ?bowel obstruction
Shifting Dullness: Usually ≥1.5L ascites present if shifting dullness
•
•
•
•
Percuss away from midline towards left flank
o Not to the right, as hepatic dullness may interfere
Hold finger at point where dullness is first detected
Roll patient towards you, wait 30s & percuss again at this point
If now resonant, test is positive (due to fluid movement)
Fluid Thrill:
•Ask patient to place ulnar border of hand over umbilicus, down the centre of the
abdomen
• Place your left hand on left side of abdomen
• ‘Flick’ the skin at right side
• A fluid thrill felt by left hand implies tense ascites
CAUSES OF ASCITES
Transudate (protein<30g/L)
Exudate (protein>30g/L)
-CLD
-RHF
-Fluid overload
-Hypoalbuminaemia
-Constrictive pericarditis
-Nephrotic syndrome
-Infection: SBP, TB
-Inflammation: Pancreatitis
-Malignancy: gastric, colonic, pancreatic,
liver (primary/metastases), ovarian,
lymphoma
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CAUSES OF ENLARGED KIDNEYS
-Portal HTN
-Hypoalbuminaemia
-H2O & Na+ retention secondary to RAAS activation
Auscultation
•
•
•
•
Bowel sounds (just below umbilicus, ideally for 1 min)
o Comment if present/absent, active/sluggish/tinkling
o Absent? Ileus
o Tinkling? Obstruction
Renal bruit (superior & lateral to umbilicus)
o Renal artery stenosis
Liver bruit if enlarged liver felt
o HCC, AV malformation, TIPSS
Aortic bruit
o AAA
Legs
•
Peripheral oedema (CLD)
•
Erythema nodosum (IBD)
•
Pyoderma gangrenosum (IBD, RA)
EXTRAINTESTINAL MANIFESTATIONS OF IBD
Mnemonic: A PIE SAC
Arthritis, Ankylosing spondylitis
Pyoderma gangrenosum, Perianal skin tags (Crohn’s) I for eyes (iritis, uveitis,
episcleritis, conjunctivitis) Erythema nodosum
Sclerosing choloangitis (PSC in UC), Sacroilitis Aphthous ulcers (Crohn’s)
Clubbing, Cholelithiasis, renal Calculi
Completion:
•Examine hernia orifices, external genitalia (testicular atrophy in CLD), palpate for
inguinal lymphadenopathy
• Perform DRE
• Review observation chart & fluid balance chart
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
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G R O I N H E R N I A E X A M I N AT I O N
Definition of a hernia: the abnormal protrusion of part of or a whole viscus through an
opening in the wall of its containing cavity into a space where it is not normally found
Introduction
•
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Ask for chaperone (this is an intimate examination)
Expose patient (fully from the waist down)
o Use sheets where appropriate to protect patient dignity
Position appropriately
o Supine & swelling obvious? Examine supine
o Supine & swelling not obvious? Examine standing
o Already standing? Examine standing
Ask patient if they have noticed any lump and to show you where it is
Ask patient if in any pain
Inspection
•
•
•
Clearly inspect both sides
Ask patient to cough (look for visible cough impulse)
6 Ss as per lump exam:
DESCRIBING A GROIN LUMP ON INSPECTION
Remember 6 Ss of describing a lump on inspection
Site: e.g., left groin
Size: Rough estimate based on gross appearance
Shape: Round/oval/irregular
Symmetry: e.g., unilateral/bilateral hernia
Skin changes: Erythema?
Scars: Previous surgery
•
Relevant scars in hernia exam:
o Incision in groin crease: previous open repair
o Umbilical scar: previous laparoscopic hernia repair
o Laparotomy: possibly emergency surgery due to acute complication of hernia
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COMPLICATIONS OF GROIN HERNIAS
- Incarceration: a hernia which cannot be reduced to normal position
- Strangulation: compromise of the blood supply to the contents of the hernia
which can lead to necrosis, perforation & peritonitis
- Obstruction: mechanical & functional obstruction of bowel contents in hernia
(colicky abdominal pain, constipation, vomiting, distension)
Palpation
•Put on gloves, get down on one knee, ask if any pain, keep looking at patient’s
face for discomfort
• Palpate normal side first for palpable swelling & cough impulse
• Move onto affected side
DESCRIBING A GROIN LUMP ON PALPATION
Remember mnemonic for describing a lump on palpation:
3 Teachers around a CAMPFIRE
Tenderness: Inflammation
Temperature: Inflammation
Transillumination: Fluid-filled cystic lesion
Consistency: Hard/firm/soft
Appearance: General appearance of the patient
Mobility: Is it fixed/tethered to overlying & underlying structures?
Pulsatile & expansile: Implies arterial lesion
Fluctuant: Attempt to ‘bounce’ lump between your two index fingers (lipomas are
fluctuant)
Irreducible: Attempt to reduce & check for cough impulse if hernia suspected
Regional lymph nodes: Enlarged in inflammation or malignancy
Edges: irregular/infiltrative/well-defined
•
•
•
Tenderness & warmth imply strangulated hernia
Absent cough impulse? Either incarcerated hernia or lump is not a hernia at all
Try to locate lower edge of swelling (may extend into scrotum)
Locate pubic tubercle:
Remember:
Inguinal hernia: above & medial to pubic tubercle
Femoral hernia: below & lateral to pubic tubercle
Palpate scrotum:
•
•
Extension of groin swelling to scrotum in indirect inguinal hernia
Attempt to ‘get above’ scrotal swelling (not possible if hernia)
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Abdomina l Exa mina t ion
Reduction
• Ask patient if they can ‘push the lump back inside’
• Try yourself with permission if they cannot (wear gloves)
• Lie down flat if not possible standing (reduces intra-abdo pressure)
•Irreducible? Incarcerated hernia
o Consider strangulation/obstruction
Deep Ring Test:
•
•
•
•
•
Proceed with this if hernia is reducible
Reduce hernia
Locate deep ring at midpoint of inguinal ligament
o Halfway between ASIS & PT
Occlude deep ring with 2 fingers while hernia reduced
Ask patient to cough
o Hernia does not reappear = Indirect
o Hernia reappears = Direct
Key Point: Midpoint of Inguinal Ligament vs Mid-Inguinal Point:
Midpoint of inguinal ligament: landmark of deep inguinal ring
• Halfway between ASIS & pubic tubercle
Midinguinal point: landmark of femoral pulse
• Halfway between ASIS & Pubic Symphysis (PulSe)
DO NOT CONFUSE THESE LANDMARKS
Auscultation
•
Auscultate over lump for bowel sounds
o Hernia typically contains bowel or omentum
o Tinkling bowel sounds in obstruction
Completion
• Examine contralateral groin & scrotum if not done
• Examine for inguinal lymphadenopathy
• Offer to examine standing if examined supine
•Offer to perform full abdominal exam to assess for acute complication (such as
obstruction) and look for causes of raised intra-abdominal pressure
o Hepatomegaly, splenomegaly, APKD, bladder distension, ascites
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
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ADDITIONAL NOTES
Figure 5. BORDERS OF THE INGUINAL CANAL: the inguinal canal is an
oblique passage through the lower anterior abdominal wall which conveys:
- the spermatic cord in males
- the round ligament of uterus in females
External oblique
Internal oblique
Transversus abdominis
Ilioinguinal nerve
Testicular artery
Conjoint tendon
Pampiniform plexus
of veins
Vas deferens
3 fascia of spermatic cord:
Internal spermatic
Cremasteric
External spermatic
9781032074955 | RCSI HANDBOOK OF CLINICAL SURGERY FOR FINALS, Ed. 5 | Offiah & Hill,
Copyright (© 2021) by CRC Press.
INGUINAL HERNIAS
Indirect
Direct
- Protrude through deep inguinal ring
- M
ay pass through superficial ring &
extend into scrotum (inguino-scrotal
hernia)
- Due to patent processus vaginalis
- More common in younger patients
- Protrude through posterior wall of the
inguinal canal
- Do not pass through the deep ring to
superficial ring into scrotum
- Acquired weakness in transversalis
fascia
- More common in older patients
Pantaloon hernia: Direct & indirect hernia together
HASSELBACH'S TRIANGLE
Lateral: Inferior epigastric vessels
Medial: Lateral border of rectus muscle (linea semilunaris)
Inferior: Inguinal ligament
Direct hernias occur within Hasselbach’s triangle (Medial to inferior epigastric vessels)
Indirect hernias occur outside of Hasselbach’s triangle (Lateral to inferior epigastric vessels)
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TYPES OF INGUINAL HERNIA REPAIR
Open
- Mesh repair: Lichenstein
- Suture repair: Shouldice (higher recurrence rate)
Laparoscopic
- TEPP: Total extraperitoneal procedure
- TAP: Transabdominal procedure
DIFFERENTIAL DIAGNOSIS FOR GROIN LUMP
Above inguinal ligament:
- Inguinal hernia
- Testicular maldescent
Below inguinal ligament:
- Femoral hernia
- Testicular maldescent
- Saphena varix
- Femoral artery aneurysm
Any groin lump:
- Lipoma
- Sebaceous cyst
- Lymph node
CONTENTS OF SPERMATIC CORD
3 arteries: Testicular artery, cremasteric artery, artery to vas deferens
3 nerves: Genital branch of genitofemoral nerve, ilioinguinal nerve, autonomic nerves
3 others: Vas deferens, pampiniform plexus of veins, lymphatics
3 coverings: External spermatic fascia, cremasteric fascia, internal spermatic fascia
A NOTE ON FEMORAL HERNIAS
• Protrusion of abdominal cavity contents through femoral canal
• More common in women than men
•Despite this, inguinal hernias are still more common in women than femoral hernias
• High risk of strangulation (40%) due to narrow neck
• Cough impulse often absent
FEMORAL CANAL
Borders of Femoral Canal
Anterior: Inguinal Ligament
Posterior: Lacunar Ligament
Lateral: Femoral Vein
Medial: Pectineal Ligament
Contents of Femoral Canal Lymph node
(Cloquet’s gland) Fat
MANAGEMENT OF FEMORAL HERNIAS
• No role for conservative MGT due to high strangulation risk
• Asymptomatic & reducible? Lockwood’s repair (Low approach)
•Symptomatic or strangulated? McEvedy’s repair (high approach) +/- laparotomy
if necrotic bowel
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Figure 6. FEMORAL TRIANGLE
Floor:
lliopoas
Pectineus
Superior: Inguinal Ligament
Great Saphenous Vein
Lateral: Medial
Border of Sartorius
Medial: Medial Border of
Adductor Longus
Femoral Nerve
Femoral Artery
Femoral Vein
Deep Inguinal Lymph Nodes
CONTENTS OF THE FEMORAL TRIANGLE
Mnemonic NAVEL (lateral to medial)
Nerve: Femoral Nerve
Artery: Femoral Artery
Vein: Femoral Vein (GSV branches from here at SFJ)
Empty space: Femoral Canal
Lymph nodes: Deep Inguinal Lymph nodes
Risk Factors for Hernia Development
• Family history
• Weak abdominal wall musculature
o Increasing age (direct inguinal hernia)
o Surgery (incisional hernia)
• Raised intra-abdominal pressure (CHOP)
o COPD/Chronic cough, constipation
o Heavy lifting
o Obesity, organomegaly
o Pregnancy, prostatism
Other Types of Hernias
Para-umbilical: Acquired defect in linea alba, typically above umbilicus (rarely below)
• Often irreducible with high strangulation risk
• Therefore always repaired (Mayo repair)
Umbilical: Congenital abnormality with herniation of abdominal contents through
umbilicus
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Epigastric: Through linea alba in epigastrium
• Moderate risk of strangulation: Usually repaired
Spigelian: Through linea semilunaris at outer border of rectus sheath
• High strangulation risk: Always repaired
Incisional: Can occur at any site of surgery, but especially in midline surgery
• Usually asymptomatic with low strangulation risk
• Repair if symptomatic, incarceration or cosmetic issue
Richter’s: Only part of the bowel wall herniates resulting in strangulation without
obstruction
• More common in femoral hernias, due to a more narrow neck
S T O M A E X A M I N AT I O N
Definition of a stoma: an iatrogenic opening which connects a hollow organ to the
outside world with a bag to collect its contents
INDICATIONS FOR STOMA FORMATION
- Resection of diseased portion of bowel: Hartmann’s procedure, APR,
panproctocolectomy
- Feeding: Gastrostomy/Jejunostomy
- Diversion: Protect distant bowel (anastomosis/fistula/abscess)
- Decompression: To relieve distal obstruction (loop colostomy)
- Lavage: Temporary stoma for on table lavage prior to bowel resection
CLASSIFICATION OF STOMAS
-
Anatomy: ileostomy, colostomy, urostomy
Temporary v Permanent
End v Loop
COMPLICATIONS OF STOMAS
(Mnemonic RIB SPINE)
Retraction
Ischaemia
Bleeding
-
Stenosis/obstruction, Skin excoriation (ileostomy), Stone formation (gallstones,
renal stones)
Prolapse, Parastomal hernia, Psychosocial disturbance
Infection
Nutritional deficiency/dehydration (high output), Necrosis
Electrolyte disturbance (hypokalaemia)
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Introduction
•
•
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose patient (ideally nipples to knees)
o Xiphisternum to pubic symphysis appropriate here
Position appropriately (Lie flat)
Ask patient if in any pain
Ask patient if any problems with stoma
Offer to remove bag
Inspection
Mnemonic for inspection of stoma: Small Bags Should Lay More Snugly On
Committed Patients
•
•
•
•
•
•
•
•
Site:
o RIF: Usually ileostomy
o LIF: Usually colostomy
Bag content (feel bag):
o Fluid: Ileostomy
o Solid: Colostomy
o Urine: Urostomy
Spout:
o Present? Ileostomy
o No spout & flushed to skin: colostomy
Lumen:
o Single lumen: End stoma
o Double lumen: Loop stoma
Mucosa:
o Healthy/unhealthy/inflamed/ulcerated
Scars:
o Previous procedure
o Laparotomy? Laparoscopy?
Old sites:
o Previous stoma sites
Complications:
o Anatomical: Prolapse, retraction, stenosis, parastomal hernia
– Ask patient to cough
o Dermatological: skin discomfort & excoriation
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abdomina l Exa mina t ion
– Seen typically in ileostomy as enzymes & bile salts in small bowel content
irritate skin
o Metabolic: High output stoma, electrolyte imbalance
– Ask to see fluid balance chart and recent U&E results to assess for these
o Vascular: Haemorrhage, ischaemia, gangrene
o Psychological: Depression/anxiety
o Other: Associated gallstone disease
• Perineum:
o Anus absent in APR
Palpation
• Down on one knee, ask if any pain in abdomen or stoma
• Keep watching patient’s face as you palpate
• Stoma bag
o Feel contents (solid/liquid)
• Lumen
o Insert gloved finger to assess patency
• Parastomal hernia
o Palpate & ask patient to cough to assess for cough impulse
Auscultation
• Bowel sounds (just below umbilicus, ideally for 1 min)
o Absent? Ileus
o Tinkling? Obstruction
Completion
• Offer to perform full GI examination
• Ask to see stoma output chart & bedside vitals
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
HOW TO DETERMINE IF AN END COLOSTOMY IS TEMPORARY OR PERMANENT
Ask the patient if they still have a back passage or not
-
Yes: Temporary end colostomy; e.g., Hartmann’s procedure or Anterior Resection
No: Permanent end colostomy; APR for low rectal tumour
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ADDITIONAL NOTES
OVERVIEW OF STOMAS
Type of Stoma
Colostomy
-Usually LIF
-Hard stool
-No spout
Ileostomy
-Usually RIF
-Liquid content
-Spout present
Possible Procedure
End Colostomy
Single lumen
+/- mucous fistula
Permanent: Abdomino-perineal
resection (APR)
Temporary: Hartmanns, Anterior
resection
•Mucous fistula may be present in
Hartmann’s
Loop Colostomy
2 lumens
To defunction
• Relieve distal obstruction
• Protect new distal anastomosis
End Ileostomy
Single lumen
+/- mucous fistula
Permanent: Panproctocolectomy (UC,
FAP)
Temporary: Emergency subtotal
colectomy
•Mucous fistula may be present in
subtotal colectomy
Loop Ileostomy
2 lumens
Urostomy
To defunction
•
•
Relieve distal obstruction
Protect new distal anastomosis
Following cystectomy (with ileal conduit)
INDICATIONS FOR COMMON COLORECTAL PROCEDURES
Procedure
Indication
Right hemicolectomy
Extended right hemicolectomy
Left hemicolectomy
Sigmoid colectomy
Anterior resection
Abdomino-perineal resection (APR)
Panproctocolectomy
Caecal & ascending colon tumours
Transverse colon tumours
Descending colon tumours
Sigmoid colon tumour, diverticular disease
Low sigmoid or high rectal tumour
Low rectal tumour Ulcerative colitis, FAP
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abdomina l Exa mina t ion
COMMON DEFINITIONS
Hartmann’s Procedure: Removal of the sigmoid colon with closure of the rectal
stump and formation of a potentially reversible end colostomy
Panproctocolectomy: Removal of the entire colon, rectum and anus, forming a
permanent end colostomy
Abdominoperineal resection: Removal of the lower rectum and anus with
formation of a permanent end colostomy
D I G I TA L R E C TA L E X A M I N AT I O N
“Put your finger in it or put your foot in it.”
Indications for DRE:
Assessment of prostate
Rectal bleeding
Change of bowel habit
Constipation which has not responded to treatment
Urinary or faecal incontinence
Assessment of anal tone (suspected spinal cord pathology/cauda equina)
Introduction
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
o Explain that there may be some discomfort
o Ask them to alert you if painful or if they wish to stop
• Ensure chaperone present
• Expose patient (bare between hips & knees)
• Position appropriately
o Left lateral position, knees to the chest, buttocks at the edge of the bed
• Ask patient if in any pain
• Put on non-sterile gloves & apron
• Ensure lubricating jelly available
• Ensure good lighting
•Use blankets where possible to protect patient dignity, ensure doors locked and
curtains drawn to prevent interruption
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Abdom i n a l E xa m i n a t io n
Inspection
• Keep talking to the patient and explain what you are doing as you proceed
•Gently part buttocks to expose anus and natal cleft
Look for:
• Skin excoriation
o Stool leakage/sphincter dysfunction
• Rash (?STI)
• Skin tags/perianal warts (?STI)
• Pilonidal sinus (in natal cleft)
• Fissures (Usually posterior midline)
oIf fissure is present, doing a DRE will be extremely painful and may be
contraindicated
• Fistulae (may be manifestation of IBD)
• Swellings/lumps protruding from anus
Palpation
• Haemorrhoids (check if thrombosed)
• Tumour/polyp
• Prolapsed rectum
•Before starting palpation, have the patient bear down to assess for the leakage of
any blood, mucus or faeces from the anal area
• Warn patient that you are starting internal examination
• Lubricate gloved index finger
• Insert finger into the rectum pointing posteriorly
•
Note whether the rectum is empty or loaded with faeces
o Soft v impacted stool
•
Assess anal tone (“Can you squeeze my finger?”)
o Poor/absent tone suggests neurological pathology
•
Palpate rectal walls
oSweep finger around the rectal walls from posterior starting position to anterior
position, both anticlockwise and clockwise, ensuring all 360o checked
o Note site & size of any abnormality
– Record site on clock face with 12 o’clock being anterior
– e.g., 2cm irregular mass at 6 o’clock
•Palpate the prostate anteriorly in males (the cervix may be palpable in females
anteriorly)
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abdomina l Exa mina t ion
Key Point: When palpating the prostate during DRE:
o Note size, symmetry & texture
o Normal prostate approximately walnut sized
o Should be symmetrical with palpable midline sulcus
o Normal: Smooth, walnut-sized
o Malignant: Craggy, enlarged
o BPH: Smooth, enlarged
o Prostatitis: Boggy texture
•
Remove finger & examine faecal material on glove
o Fresh red blood
o Melaena
o Mucus
• Use faecal material on FOB kit
• Clean anus with gauze at the end of examination
•Immediately dispose of gloves & cover patient to protect their dignity
Completion
• Offer to perform full GI examination
•If malignancy suspected, offer to perform systemic exam to assess for metastatic
disease
• Thank patient, help them dress & wash hands
• Summarise your findings
• Suggested further investigations:
o FBC & haematinics
o FOB
o CEA
o Colonoscopy
o CT TAP
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ADDITIONAL NOTES
CAUSES OF GI BLEEDING
Upper GI Bleed:
Lower GI Bleed:
Oesophageal:
-Varices
Malignancy
Ulcer
Oesophagitis
Mallory-Weiss tear
Gastric:
-Varices
Malignancy
Ulcer
Gastritis
Dieulafoy’s lesion
Duodenal:
Ulcer
Malignancy
Aorto-enteric fistula
-
-
-
Colorectal cancer
Colorectal polyps
Diverticular disease
Colitis
• Inflammatory
• Ischaemic
• Infective
• Radiation
Angiodysplasia
Anal pathology
• Haemorrhoids
• Fissure
Bleeding diathesis/coagulopathy
Risk Factors for Colorectal Cancer
• Family history
• Previous history of polyps or CRC
•IBD
• Diet rich in meat/fat & poor in fibre
• Polyposis syndromes (FAP, HNPCC, juvenile polyposis)
• Lynch Syndrome (Hereditary non-polyposis colorectal cancer)
• Sedentary lifestyle
• Obesity
• Smoking
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abdomina l Exa mina t ion
COMMONLY PRESCRIBED MEDICATIONS – GASTROINTESTINAL SYSTEM
Drug type
Common indications
Examples
Antacids
Indigestion,
gastrooesophageal
reflux
Sodium alginate, calcium
carbonate, magnesium
carbonate
Proton pump inhibitors
GORD, PUD, ZollingerEllison syndrome, triple
therapy
Pantoprazole, lansoprazole,
omeprazole
Antiemetics
Nausea, vomiting,
vertigo, gastroparesis
Domperidone,
metoclopramide, cyclizine,
prochlorperazine, ondansetron
Antispasmodics
Irritable bowel
syndrome
Anti-diarrhoeals
Diarrhoea
Loperamide
Laxatives
Constipation
Isphaghula husk (fybogel),
lactulose*, bisacodyl, docusate
*hepatic
encephalopathy
Pancreatic enzymes
Exocrine pancreatic
insufficiency
Pancreatin (Creon)
Vasopressin analogue
Oesophageal varices
Terlipressin
Somatostatin analogue
Oesophageal varices
Octreotide
Anti-inflammatory
drugs
Inflammatory bowel
disease
Corticosteroids e.g.,
prednisolone (PO/PR),
hydrocortisone (IV)
Aminosalicylates e.g.,
Mesalazine
Immunomodulators
Inflammatory bowel
disease
Mercaptopurine (6-MP),
azathioprine, methotrexate
Biologics
(immunosuppressants)
Inflammatory bowel
disease
Infliximab, adalimumab,
vedolizumab
Beta blockers
Chronic liver disease
(varices prevention)
Propranolol, carvedilol
Diuretics
Ascites
Spironolactone, furosemide
Bile acids
Primary biliary
cholangitis (prevent/
delay liver damage)
Ursodeoxycholic acid
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Drug type
Common indications
Examples
Bile acid sequestrants
Primary biliary
cholangitis (pruritis)
Cholestyramine
Antimicrobials
commonly used:
Cholecystitis
Amoxicillin/clavulanic acid,
metronidazole, cefuroxime,
ciprofloxacin
Peritonitis/biliary/
intraabdominal
infections
Spontaneous bacterial
peritonitis
Cirrhosis (prevention of
encephalopathy)
Viral hepatitis
Amoxicillin/clavulanic acid,
gentamicin, metronidazole,
piperacillin/tazobactam,
aztreonam
Ceftriaxone
Rifaximin
Entecavir, tenofovir (Hep B)
Sofosbuvir, ledipasvir (Hep C)
*Please note these do not constitute exhaustive list of medications or indications.
Reference texts and/or drug formularies should always be consulted for
comprehensive medication and prescribing information.
PROCEDURAL
SKILLS
NASO GASTRIC
TUBE INSERTION
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abdomina l Exa mina t ion
THE RCSI THREE-COLUMN OSCE GUIDE
Gastrointestinal Examination - Features of Liver disease
“This is a medical station. You have 5 minutes to complete an examination to assess this patient for
features of liver disease. I will then ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and
consent
• Introduces self with name and
level, explains what he/she will
be doing and obtains consent
for same
Hi my name is X. I’m
a third year medical
student at RCSI.
What’s your name?
Nice to meet you.
I’ve been asked
to examine your
abdomen today.
That will involve me
looking at, feeling
and listening to your
abdomen. Would that
be ok?
Position and exposure
•P
atient positioned at 180
degrees, undressed to the waist,
with hands placed at the sides
Mr/Mrs A is
appropriately
positioned and
exposed for this
examination.
Enquires about pain
• Prior to examining
‘Are you in any pain?’
Abbreviation key (NB: these
abbreviations are not necessarily
medically acceptable abbreviations
and have been abbreviated for the
purposes of this document only):
RHC = right hypochondrium
EPG = epigastrium
LHC = left hypochondrium
RF = right flank
LF = left flank
UMB = umbilicus
RIF = right iliac fossa
LIF = left iliac fossa
SPC = suprapubic
AA = abdominal aorta
GENERAL INSPECTION
Performed from the end of the
bed
oInspects for
o Equipment
o Patient
‘On general
inspection Mr/Mrs A
appears well, there
are no peripheral
stigmata of liver
disease, and no
equipment around
the bed.’
Equipment
• IV access, emesis bowl, NG tube, PEG
tube, medications, aids/devices, O2
delivery
Patient
• Appears unwell/in pain/pale/jaundice
• BMI e.g., cachexia, muscle wasting
• Obvious wounds, scars, dressings,
catheters, stomas, herniae, masses,
pulsations etc.
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Abdom i n a l E xa m i n a t io n
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On inspection of the
hands, arms and face
there are no signs of
liver disease‘
Hands
oClubbing (IBD, Cirrhosis, Coeliac
disease)
o Leuconychia (Hypoalbuminaemia)
o Koilonychia (Iron deficiency anaemia)
oPalmer erythema (Cirrhosis)/crease
pallor (anaemia)
oDupytren’s contracture (Excess
alcohol)
oHepatic flap (Hepatic
encephalopathy or uraemia)
Arms
•Pigmentation changes(Jaundice)
•
Scratch marks (Cholestasis)
Eyes
•
Conjunctival pallor (Anaemia)
•
Scleral icterus (Liver disease)
•
Xanthelasma (Hyperlipidaemia)
Mouth
•Angular stomatitis (Iron/B12
deficiency)
•Mouth (Aphthous) ulcers (Crohn’s/
Coeliac disease)
•
Candidiasis (Immunodeficiency)
•Tongue glossitis (Iron/B12/Folate
deficiency)
HANDS & ARMS & FACE
Performed from the right hand side
of the bed
oInspects hands for
o Clubbing
o Leuconychia
o Koilonychia
oPalmer erythema/crease pallor
o Dupytren’s Contracture
o Hepatic flap
oAsks patient to fully extend
arms + wrists and then s
Observes for downward
movement of the hands for
10-15 seconds.
oInspects arms for
o Pigmentation changes
o Scratch marks
oInspects the eyes for
o Conjunctival pallor
o Scleral icterus
oXanthelasma
oInspects the mouth for
o Angular stomatitis
o Mouth (Aphthous) ulcers
o Candidiasis
o Tongue glossitis
CHEST & ABDOMINAL INSPECTION
Performed from the right hand side
of the bed
oInspects the chest for
o Spider Naevi
o Gynaecomastia
•Inspects Abdomen for
o Shape
o Scars/wounds/dressings
oMasses
Ecchymosis
‘On inspection of the
chest and abdomen
there are no stigmata
of liver disease’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Chest
•
Spider Naevi (Chronic liver disease)
•
Gynaecomastia (Liver Cirrhosis)
Abdomen
•
Shape
o Scaphoid / Distended
o Scars/wounds/dressings
oMercedes Benz/RUQ (Liver
transplant)
o Midline laparotomy
oLapraroscopic port sites/abdominal
paracentesis scars
oPfannensteil, Kocher, McBurney/
Lanz
o Paramedian, transverse etc
o Masses (Site, size, shape, colour)
o Ecchymosis
•
From LMWH injections
Abdomina l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On palpation the
abdomen was soft and
non- tender. ‘
Light palpation
•There is tenderness in the RIF/LIF/
SPC/RF/LF/UMB/LHC/RHC/EPG
with (no) guarding/rigidity.
•Or The abdomen is diffusely rigid
with tenderness and guarding
throughout.
Deep palpation
•There is palpable mass in RHC/EPG/
LHC/RF/LF/UMB/RIF/SPC/LIF. It is
smooth/irregular, tender/non-tender,
fluctuant/non fluctuant, mobile/
immobile, approx Xcm and (shape).
Liver
•The liver edge is palpable, displaced
to X (haemochromatosis, fatty
liver, CCF, malignancy, lymphoma,
myeloproliferative..)
Spleen
•The spleen is palpable, displaced to
X (portal hypertension, malaria, CML,
1° lymphoma..)
Kidney
•The L/R kidney is palpable (PCKD),
moves with/out respiration, can/
not get above it, smooth/irregular
borders, mobile/non-mobile.
PALPATION
• Kneels & watches face for pain
• Names all 9 areas on palpation
Light palpation
• Uses
1 hand, palm flat, flexes at
MCPs
Deep palpation
• Uses
2 hands, palm flat, flexes at
MCPs
Liver
• Asks
patient to breathe in on
palpation
• Starts
from RIF moving towards
RHC using radial border of index
finger.
• Moves
hand at end of expiration
Spleen
• Asks
patient to breathe in on
palpation starting from RIF
moving towards LHC.
• Moves
hand at end of expiration
Kidneys
• 1
hand anterior on abdomen, 1
hand posterior at renal angle,
both palms flat.
• Asks
patient to expire while
flexing MCPs of posterior hand
and keeping gentle pressure with
the anterior hand.
• Performs
on both sides.
‘There were no
palpable masses or
organomegaly.’
PERCUSSION
Audible percussion notes from the
end of bed
Liver
• Begins from RIF moving superiorly
to costal margin. Asks patient
to mark dull note. Palpates out
2nd IC space from sternal angle
and percusses intercostal spaces.
Measures approx. size with hand.
Spleen
• Begins from RIF to most inferior
intercostal space left anterior
axillary line
Shifting dullness
• Begins percussion from umbilical
area to left flank. If there is a dull
percussion note, marks spot,
asks patient to roll on their side
towards them, waits 30 secs and
percusses same position
The liver span was
approximately 1015cms. This is a normal
liver width.’
Liver
•The liver was enlarged, with an
approximate width of (estimate size
Xcm i.e., >15cms)
‘I was unable to percuss
the spleen as the
spleen is not enlarged.’
Spleen
•The spleen was enlarged, with an
approximate distension of Xcm
‘There was no evidence
of shifting dullness’.
Shifting dullness
•There was evidence of shifting
dullness and therefore free fluid in
the abdomen.
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Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘Bowel sounds are
present and normal.’
Bowel Sounds
• On auscultation there was high pitched,
tinkering/ increased /no bowel sounds
AUSCULTATION
Bowel Sounds
• A
uscultates over the ileocecal
valve using diaphragm of
stethoscope for up to 1 minute
LOWER LIMB EXAMINATION
• U
ses thumbs to apply pressure
bilaterally to bony points, starting
at dorsum of feet, then medial
malleolus, tibia etc, removing
thumb after ~2 secs to observe
for pitting
‘There was no oedema
present.’
Oedema
• Pitting oedema is present on the R/L to
the level of ¬_X_ (eg. mid shin)
CONCLUSION
• T
hanks patient
‘Thank you Sir/Madam (to patient).’
THE RCSI THREE-COLUMN OSCE GUIDE
Gastrointestinal Examination - Abdominal exam
“This is a surgical station. You have 5 minutes to complete an abdominal examination. I will then ask
you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level,
explains what he/she will be doing
and obtains consent for same
Hi my name is X. I’m
a third year medical
student at RCSI. What’s
your name? Nice to
meet you. I’ve been
asked to examine your
abdomen today. That
will involve me looking
at, feeling and listening
to your abdomen.
Would that be ok?
Position and exposure
• P
atient positioned at 180 degrees
and undressed to the waist
Mr/Mrs A is
appropriately
positioned and
exposed for this
examination.
Enquires about pain
• Prior to examining
‘Are you in any pain?’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abbreviation key (NB: these
abbreviations are not necessarily
medically acceptable abbreviations
and have been abbreviated for the
purposes of this document only):
RHC = right hypochondrium
EPG = epigastrium
LHC = left hypochondrium
RF = right flank
LF = left flank
UMB = umbilicus
RIF = right iliac fossa
LIF = left iliac fossa
SPC = suprapubic
AA = abdominal aorta
Abdomina l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On general inspection
Mr/Mrs A appears
well, there are no
peripheral stigmata
of gastrointestinal
disease and no
equipment around the
bed.’
Equipment
• O2 delivery, IV access, aids/devices,
sick bowl, medications, NG tube
Patient
• Appears unwell/in pain/pale/jaundice
• BMi e.g., cachexia, muscle wasting
• Obvious wounds, scars, dressings,
stomas, herniae, masses, pulsations etc
‘On closer inspection
of the abdomen
there are no stigmata
of gastrointestinal
disease.’
• Shape
oScaphoid / Distended (fat, foetus,
fluid, flatus, faeces)
o Scars
o Midline laparotomy
o Lapraroscopic port sites
o Pfannensteil (C-section)
o Kocher (Cholecystectomy)
o McBurney/Lanz (Appendix)
oParamedian, transverse, oblique etc
o Distended veins/caput medusa
o Striae
oVisible peristalsis, pulsations
o Lumps (Site, size, shape, colour)
o Stoma (Site, spout, content )
‘On palpation the
abdomen was soft and
non- tender.‘
Light palpation
• There is tenderness in the RIF/LIF/
SPC/RF/LF/UMB/LHC/RHC/EPG with
(no) guarding/rigidity.
• Or The abdomen is diffusely rigid
with tenderness and guarding
throughout.
Deep palpation
• There is palpable mass in RHC/EPG/
LHC/RF/LF/UMB/RIF/SPC/LIF. It is
smooth/irregular, tender/non-tender,
fluctuant/non fluctuant, mobile/
immobile, approx Xcm and (shape).
Liver
• The liver edge is palpable,displaced
to X
Spleen
• The spleen is palpable, displaced to X
Kidney
• The L/R kidney is palpable, moves
with/without respiration, can/cannot
get above it, smooth/irregular
borders, mobile/non-mobile.
Abdominal Aorta
• ‘The abdominal aorta is pulsatile and
expansile to approx. Xcm’.
GENERAL INSPECTION
Performed from the end of the bed
oInspects for
o Equipment
o Patient
CLOSER INSPECTION
Performed from the right hand side of
the bed
• Inspects for
o Scars/wounds/dressings
o Distention
o Masses / Stoma
o Hernia (ask patient to cough)
o Pulsations
o Ecchymosis
PALPATION
• Kneels & watches face for pain
• Names all 9 areas on palpation
Light palpation
• Uses 1 hand, palm flat, flexes at MCPs
Deep palpation
• Uses 2 hands, palm flat, flexes at MCPs
Liver
• Asks patient to breathe in on palpation
• Starts from RIF moving towards RHC
using radial border of index finger.
• Moves hand at end of expiration
Spleen
• Asks patient to breathe in on palpation
starting from RIF moving towards LHC.
• Moves hand at end of expiration
Kidneys
• 1 hand anterior on abdomen, 1 hand
posterior at renal angle, both palms flat.
• Asks patient to expire while flexing
MCPs of posterior hand and keeping
gentle pressure with the anterior hand.
• Performs on both sides.
Abdominal aorta
• Palpates using lateral borders of both
hands above and left of the umbilicus.
• Places hands 5 cm either side of midline,
then slowly moves hands together.
‘There were no
palpable masses or
organomegaly. ‘
‘The abdominal aorta
was impalpable/
pulsatile and not
expansile.’
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Abdom i n a l E xa m i n a t io n
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
PERCUSSION
Audible percussion notes from the end ‘The liver span was
approximately
of bed
10-15cms. This is a
Liver
• B
egins from RIF moving superiorly to normal liver width.’
costal margin. Asks patient to mark
dull note. Palpates out 2nd IC space ‘I was unable to
percuss the spleen
from sternal angle and percusses
intercostal spaces. Measures approx. as the spleen is not
enlarged.‘
size with hand.
Spleen
‘There was no
• B
egins from RIF to most inferior
evidence of shifting
intercostal space left anterior axillary
dullness’.
line
Shifting dullness
• B
egins percussion from umbilical
area to left flank. If there is a dull
percussion note, marks spot, asks
patient to roll on their side towards
them, waits 30secs and percusses
same position.
Liver
• The liver was enlarged, with an
approximate width of (estimate size
Xcm i.e., >15cms)
Spleen
• The spleen was enlarged, with an
approximate distension of Xcm
Shifting dullness
• There was evidence of shifting
dullness and therefore free fluid in the
abdomen.
AUSCULTATION
‘Bowel sounds are
Bowel Sounds
present and normal.’
• Auscultates over the ileocecal valve
using diaphragm of stethoscope up
‘There are no renal
to 1 minute
bruits.’
Renal bruits
• 3cm superior and lateral to umbilicus
using bell of stethoscope on both sides
Bowel Sounds
• On auscultation there was high
pitched, tinkering/ increased /no
bowel sounds
Renal Bruits
• On auscultation there was a right/left/
bilateral renal bruit/s’
ADDITIONAL TESTS
Murphy’s sign
• A
sks patient to breathe out fully
then places hand below right costal
margin in mid clavicular line. Asks
patient to take a deep breath in &
watches patient -?stops to ‘catch’
their breath due to pain.
Rebound tenderness
• C
ompresses abdomen slowly during
palpation and quickly releases. Watches
patient -?pain felt on releasing.
Rosving’s sign
• P
ain felt in RIF during palpation of LIF.
‘Murphy’s sign is
negative.’
‘There is no rebound
tenderness.’
‘Rosving’s sign is
negative.‘
Murphy’s sign
• Murphy’s sign is positive.
oIndicative of cholecystitis.
Rebound tenderness
• T
here was rebound tenderness over X.
oIndicative of peritonitis.
Rosving’s sign
• Rosving’s sign is positive.
oIndicative of acute appendicitis.
CONCLUSION
• Thanks patient
• Offers to examine hernial orifices,
Digital Rectal Examination and Urine
Dipstick
‘Thank you Sir/Madam (to patient).’
‘To conclude my examination ideally I would check the hernial
orifices, perform a DRE and do a urine dipstick’
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Abdomina l Exa mina t ion
THE RCSI THREE-COLUMN OSCE GUIDE
Gastrointestinal Examination - Abdominal and hernia exam
“This is a surgical station. You have 5 minutes to complete an abdominal examination and examine for
herniae. I will then ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level,
explains what he/she will be doing
and obtains consent for same
Hi my name is X. I’m
a third year medical
student at RCSI. What’s
your name? Nice to
meet you. I’ve been
asked to examine your
abdomen today. That
will involve me having a
look, feel and listen to
your abdomen. Would
that be ok?
Position and exposure
• P
atient positioned at 180 degrees
and undressed to the waist
Mr/Mrs A is
appropriately
positioned and
exposed for this
examination.
Enquires about pain
• Prior to examining
Are you in any pain?
Abbreviation key (NB: these
abbreviations are not necessarily
medically acceptable abbreviations and
have been abbreviated for the purposes
of this document only):
RHC = right hypochondrium
EPG = epigastrium
LHC = left hypochondrium
RF = right flank
LF = left flank
UMB = umbilicus
RIF = right iliac fossa
LIF = left iliac fossa
SPC = suprapubic
GENERAL INSPECTION
Performed from the end of the bed
oInspects for
o Patient
o Equipment
oAsks patient to cough and
comments on presence or
absence of swelling
On general inspection
Mr/Mrs A appears
well, there are no
peripheral stigmata of
gastrointestinal disease
and no equipment
around the bed.
Equipment
• O2 delivery, IV access, aids/devices, sick
bowl, medications, NG tube
Patient
• Appears unwell/in pain/pale/jaundice
• BMi e.g., cachexia, muscle wasting
• Obvious herniae, wounds, dressings,
scars, stomas, masses, pulsations etc
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Examination
Expected/Normal
Comments
Potential/Abnormal Comments
On closer inspection
of the abdomen
there are no stigmata
of gastrointestinal
disease.
• Shape
oScaphoid / Distended (fat, foetus,
fluid, flatus, faeces)
o Scars
o Midline laparotomy
o Lapraroscopic port sites
o Pfannensteil (C-section)
o Kocher (Cholecystectomy)
o McBurney/Lanz (Appendix)
o Paramedian, transverse, oblique etc
o Distended veins/caput medusa
o Striae
oVisible peristalsis, pulsations
o Lumps (Site, size, shape, colour)
o Stoma (Site, spout, content )
On palpation the
abdomen was soft and
non- tender.
Light palpation
• There is tenderness in the RIF/LIF/
SPC/RF/LF/UMB/LHC/RHC/EPG with
(no) guarding/rigidity.
• Or The abdomen is diffusely rigid with
tenderness and guarding throughout.
Deep palpation
• There is palpable mass in RHC/EPG/
LHC/RF/LF/UMB/RIF/SPC/LIF. It is
smooth/irregular, tender/non-tender,
fluctuant/non fluctuant, mobile/
immobile, approx Xcm and (shape).
n/a
• There is a mass in the RIF/LIF/SPC/LF
/RF/UMB/RHC/EPI/LHC.
• It is approximately (X)cm by (X)cm
and bulges outwards on coughing,
• It has a regular/ irregular outline
• It is/is not situated behind any scars.
• There are (no) signs of overlying
erythema/excoriation/skin changes.
CLOSER INSPECTION
Performed from the right side of the
bed
o
o
o
o
o
o
o
Comments on
Scars/wounds/dressings
Distention
Masses / Stoma
Hernia (ask patient to cough)
Pulsations
Ecchymosis
PALPATION
• Kneels & watches face for pain
• Names all 9 areas on palpation
Light palpation
•U
ses 1 hand, palm flat, flexes at
MCPs
Deep palpation
•U
ses 2 hands, palm flat, flexes at
MCPs
HERNIA INSPECTION
Inspects for
o Site
o Size
o Shape
o Regularity
o Relationship to scars
o Overlying skin changes
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Abdomina l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
n/a
‘On palpation...
• The mass is
o Firm/soft
o Tender/ non-tender
o Approx (X)cm by (X)cm.
• There is a positive/negative cough
reflex
• The hernia self-reduces when the
patient lies down/can be reduced.
• While occluding the deep ring and
asking the patient to cough the hernia
reappears/does not reappear.
On palpation of the
scrotum there is no
evidence of scrotal
extension of the
hernia.
• On examination of the scrotum, there
is thickening around the spermatic
cord suggestive of scrotal extension
of the hernia which is most consistent
with the presence of an indirect
inguinal hernia.
• The lump is transillumnable/not.
Bowel sounds are
present and normal.
Bowel Sounds
• On auscultation there was high
pitched, tinkering/ increased /no
bowel sounds
Renal Bruits
• On auscultation there was a right/left/
bilateral renal bruit/s
HERNIA PALPATION
• E
xamines hernia lying flat & standing
• F
eels for cough impulse
• A
ssess for self-reducibility
• If not self-reducible asks patient if
they can reduce it and if they are not
able to then comments that would
ideally attempt to reduce it.
• C
orrectly localizes deep ring (half
an inch above midpoint of inguinal
ligament. Midpoint of inguinal
ligament identified as halfway
between the pubic tubercle and
ASIS), occludes deep ring and
assesses whether hernia is direct or
indirect.
SCROTAL EXAM
• If cannot get below lower border of
hernia, candidate assess for scrotal
extension
• If a mass is found in the scrotum,
offers to trans-illuminate
AUSCULTATION
Bowel Sounds
• A
uscultates over the ileocecal valve
using diaphragm up to 1 minute
Renal bruits
• 3
cm superior and lateral to umbilicus
using bell of stethoscope on both
sides
There are no renal
bruits.
CONCLUSION
• Thanks patient
• Digital Rectal Examination
• Urine Dipstick
Thank you Sir/Madam (to patient).
To conclude my examination ideally I would perform a DRE and
do a urine dipstick
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153
CHAPTER 9
NEUROLOGICAL
EXAMINATION
ACUTE HEADACHE HISTORY
COLLAPSE HISTORY
GLASGOW COMA SCALE MENTAL
STATE
CRANIAL NERVE EXAMINATION
U PPER LIMB NEUROLOGICAL
EXAMINATION
L OWER LIMB NEUROLOGICAL
EXAMINATION
CEREBELLAR EXAMINATION
E XTRA PYRAMIDAL SYSTEM
EXAMINATION
HAND NEUROLOGICAL
EXAMINATION
SPEECH EXAMINATION
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Neurologica l Exa mina t ion
ACUTE HEADACHE HISTORY
Scenario: You are on call in emergency department and you are asked to see James
who is a 35 year old male with a headache. Please take a history.
Tips Starting out
•This is an acute history and so should follow the format and page layout of an
acute history at the start of this book.
•Your aim is to show the examiner, through the means of a well-structured
interview, that you know how to explore headache as a symptom and that you are
aware of the potential differentials.
•It is vitally important that you show, through your questions that you are
considering the most emergent diagnoses which in this case would likely be
Subarachnoid Haemorrhage and Meningitis.
Introduction:
Hello, my name is Daniel, one of the doctors on call today. If it’s okay with you I would like
to ask you a few questions about what brought you into hospital today. Is that alright?
Opening Questions;
• When did you arrive in the emergency department?
• Did you come via ambulance or did you com yourself?
•Did you decided to come yourself or did your general practitioner refer you?
What was it that made you decide to come to emergency department?
Now you should be aware that this is an acute case as the patient has just presented
with a symptoms and he has told you that he came because he had a headache so
you can follow your “Acute Headache” proforma, which, given its frequency in exams,
should be well prepared.
History of Presenting Complaint Part 1: Presenting Symptom
• To start off, I’d like to ask you some questions about your headache. Is that okay?
• When did the headache start?
• What were you doing when it started?
• Did it come on suddenly or gradually?
• Has it been persistent since then or did it come and go?
• Has it been getting steadily worse since then or has it stayed the same?
•How bad is it out of 10? Would you describe it as the worst headache you have
ever had?
• Have you ever had a headache like this before? What is different about this one?
•Is there anything that makes the headache worse? Is it worse when you are lying
down? Is it worse in the mornings?
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•Is there anything that makes the headache better? Have you tried any medications
that have helped? Which ones?
• How would you describe the headache?
• Whereabouts is it? Did it start in this position or has it moved?
• Does the pain move anywhere? Does it shoot down the neck or behind the eye?
Now that you have explored the presenting symptom in detail you can move onto the
second part of the history of presenting complaint which is “Associated symptoms”.
Remember that if the patient answers “yes” to any of these questions you will need
to explore that symptom in detail. You can find the appropriate questions for that
symptom in the corresponding section of the book.
History of Presenting Complaint Part 2: Associated Symptoms
•Thank you for telling me about what brought you into hospital. If it’s okay with you
I’d now like to ask you about some other symptoms that you may or may not have
had also. Is that okay with you?
• Have you noticed any rash anywhere?
•Do you have any pain or stiffness in your neck? Do you have any difficulty with
moving your neck?
• Have you felt nauseous or like you want to get sick? Have you vomited?
•Have you found yourself avoiding bright lights as it was irritating your eyes? Do
you feel more comfortable in a dark room?
•Have you noticed or has anyone you know noticed that you have been more
drowsy recently?
•Have you or has anyone you know reported that you have been somewhat confused?
• Have you had any temperatures?
• Have you noticed any issues or changes with your vision?
• Have you had any sore throat or cough or flu like symptoms?
• Have you had any pain in the ear or behind the ear?
•Have you had any changes in your hearing? Have you been experiencing a ringing
sensation in either ear?
•Did you noticed any strange symptoms just before the headache came on, for
example a strange taste, noise or flashing lights?
• Have you noticed any loss of power in any of your limbs?
• Have you noticed any numbness or tingling anywhere?
You may not have time to go through all of these symptoms particularly if the patients
tells you that they have in fact experienced them as this will require further exploration
but it is important to try and get the main points across. Remember running out of time
is not necessarily a problem, once you have been progressing through the history in a
logical manner, without unnecessary repetition and without irrelevant questioning.
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History of Presenting complaint Part 3: Risk Factors
•Thank you for telling me about all of those symptoms. It sounds like it has been a
very rough few days for you and I hope we can make things somewhat better for
you very soon. If it’s okay with you now, can I ask you a few questions about some
things that may have contributed to causing this headache?
• Migraine risk factors
o Have you ever suffered from migraine before?
o Do you have a family history of migraine
• Meningitis Risk factors
oHave you been in contact with anyone who has been unwell or that has had
similar symptoms
o Did you get all your relevant vaccines as a child
o Have you ever been told that you had a weak immune system?
•Intracranial haemorrhage risk factors
o Have you had any injury to the head recently?
oHave you ever been told that you had an abnormality in the brain called an
aneurysm? Or have you been told that you have an aneurysm anywhere else in
the body?
oHas anyone in your family ever been told that they have an aneurysm or a
swelling in one of the bloods vessels in the brain?
o Has anyone in your family ever had a bleed in the brain?
oHave you ever been told that you had a condition called “Polycystic Kidney
disease”?
• Other headache risk factors
o Have you been very stressed recently?
o Do you drink enough fluids during the day?
oDo you find that you get headaches at certain points in your menstrual cycle
(obviously this question is only relevant to pre-menopausal women…asking this
question to a man would be unlikely to earn you extra marks!!!)
By this stage you should have an idea as to whether or not the headache is something to
worry about or whether it is less of a concern. Indeed, acuity is a very pertinent feature with
sudden acute headaches generally of greater danger. You can now move on to the rest of
your history, which as per usual should take significantly less time as you have already dealt
with the key important features in your history of presenting complaint, arguably the most
important part of the history, certainly when considering allocation of marks in exams.
Past medical History/Past Surgical History.
•Thank you for telling me all these important features. Id now like to ask you about
some other parts of your past medical history
•Do you have any other medical problems that we haven’t discussed? Do you see
you general practitioner regularly for anything?
• Have you had any surgeries?
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Medications
•
•
•
Do you take any medications regularly? Which ones?
Do you take any over the counter medications?
Do you have any allergies to any medications?
Family History:
•We have already discussed some of the conditions that seem to run in your family
but are there any other conditions that you know of?
Social History
•Do you smoke? How much? For how long have you been smoking. (It is well worth
your while learning how to calculate pack years of smoking)
•Do you drink? How much do you drink? How often? What do you drink? (It is
also well worth you while learning how to calculate units of alcohol consumed)
(If a patient tells you that they do drink alcohol and it appears that they drink to
excess, it would be important to screen with some questions for alcohol misuse
or dependence disorder – the CAGE Questionnaire is useful in this regard and is
worth memorising – It can be found in the appropriate section of this book)
• Who is at home with you?
•Where do you work?
Systems Review
•See appropriate section of book for systems review questions
Concerns and Expectations
•Before we finish is there anything in particular that is concerning you or that you
are worried about?
•Could I ask if there was anything in particular that you were hoping to get out of
this consultation, just so we are both on the same page.
Finish
Now, if it’s okay with you I’m just going to briefly summarise
what I have learned from you today. Please do correct
me if I get anything wrong.
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COLLAPSE HISTORY
Scenario: You are on call in emergency department and you are referred a 40 year
old male who has collapse in the supermarket this am. Please take his history
Tips Starting out
•Although a collapse history does follow the general proforma of an acute history it
does have some original features that are worth taking note of. The most pertinent
of these is that instead of the usual SOCRATES questions associated with the
presenting symptom, a collapse history necessitates asking questions about three
timepoints, namely, before the event, during the event and after the event.
•It is essential that you let the examiner know that you would like to get a collateral
history. So at some point during the history it is important that you ask the patient
if anyone witnessed the event and if you have their permission to talk to them.
•Although it may seem obvious, students often confuse collapse with
unconsciousness. It is possible to collapse and remain conscious!! You must
establish the facts around this early on.
Introduction:
•Hello, my name is Daniel, one of the doctors on call today. Is it okay with you if I
ask you some questions about what brought you into hospital today.
Opening Questions
•
•
•
When did you come to the hospital?
Did you come via ambulance or did someone bring you?
What was it that made you come to the hospital today?
We will assume that the patient has now informed you that they were brought to
hospital via ambulance after collapsing while shopping in his local supermarket. You
will notice that there are only two sections to the history of presenting complaint and
not three. This is because we include associated symptoms and presenting symptom
together under three headings.
History of Presenting Complaint Part 1 and 2: Presenting Symptom and
associated symptoms
•
Before the fall
o Can you remember what you were doing at the time that you fell?
oWere you sitting or standing? (If they were standing you need to ask how
long they had been standing for and whether they were walking or standing
stationary and for how long)
o Did you have any symptoms before you collapse?
o Did you have any chest pain?
o Did you have any shortness of breath?
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•
•
o Did you experience any dizziness?
o Did you have any change in your vision?
o Did you feel nauseous?
o Did you notice any ringing in your ears
oDid you have any strange symptoms like strange visions of flashing lights, a
strange taste or strange sounds?
o Did you notice any weakness in your arms or legs?
o Did you notice any numbness or tingling in any part of your body?
o When was the last time you had had something to eat or drink?
oWas there anything on the ground that you remember tripping over. (not
everything is complex – he may just have tripped over his shoelace!!!)
During the fall
o Do you remember the collapse itself?
o Did you fall forwards or backwards?
o Did you lose consciousness? Do you know for how long?
o Did you hit your head?
o Do you remember if you put your hands out to protect yourself?
oDo you know what part of your body you landed on? Did you sustain any
injuries?
oIs there anyone else that saw the episode? Have they told you anything about
it? Is it okay with you if I talk to them when we have finished?
oDid the witness say that they noticed any jerking movements or shaking?
How did they describe this? How long did it go on for? Did it just stop
spontaneously?
o Do you know if you bit your tongue?
After the event
o What is the first thing you remember after you came around?
oyou confused? Did you know where you were and what had happened? How
long did it take you to get back to normal?
oWere you able to get up off the ground yourself or did you need assistance?
(If they needed assistance it is important to determine why they needed
assistance – was it because of pain, weakness or confusion?
o Were you able to call for help yourself?
o Did you have any pain anywhere?
o Were you able to walk?
o Did you have any headache?
o Did you fell nauseous?
Now that you have gone through the key time points of the event you can move onto
risk factors to help you in your search for a cause of the collapse. You can divide your
risk factors based on body system.
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History of Presenting Complaint Part 2: risk factors
•
•
•
•
Risk factors for cardiac causes?
oHave you any history of heart disease?
oHave you ever been told that you have a slow heart beat or a fast heart beat or
an irregular heart beat?
oHave you ever been told that there is an issue with the flow of electricity in your
heart?
oDo you have a family history of heart disease?
oI know this can sometimes be distressing question but is there any history of
sudden death in your family?
oHave you ever had an ultrasound of the heart? Were you told that you had any
issues with the valves in your heart?
o Have you ever had a heart attack?
o Do you smoke?
o Do you have high blood pressure?
o Do you have diabetes?
o Do you have high cholesterol?
o Do you take any medications?
o Do you take any recreational drugs?
Risk factors for Neurologic cause?
o Have you ever had a seizure before?
o Do you have a family history of seizures?
o Have you ever had an injury to the brain or head before?
o Have you ever been told you might have epilepsy?
o Have you ever had a stoke before?
o Do you have a history of stroke in the family?
Risk factors for more benign causes?
o Do you have a history of fainting?
oDo you ever feel dizzy when you stand up to quickly or if you stand in the same
spot for too long?
o Do you drink enough fluids during the day?
Risk factors for Endocrine Causes
o Have you ever had issues with low or high blood pressure?
oHave you ever been told that you have a low level of steroid or cortisol
production in the body?
o Have you ever had low blood sugars levels before?
o Do you have a family history of diabetes or any issues with the pancreas?
Now that you have explored the details of the event and risk factors for some
underlying causes you can move on to the rest of the history.
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Past Medical History/Past surgical history
•
•
Do you have any other medical problems that we haven't talked about?
Have you ever had any surgeries before in the past?
Medications
•
•
•
Do you take any regular medications?
Do you take any over the counter medications?
Do you have any allergies to any medications?
Family history
•I know we have discussed some of your family history already but are there any
other conditions that run in the family?
Social history
•
•
•
•
Do you smoke?
Do you drink alcohol?
Who is at home with you?
What do you work as?
Systems review
•See appropriate section of book for details on how to do a systems review.
Concerns And Expectations
•Before we finish I’d just like to ask if there is anything in particular that is
worrying you?
•And can I ask if there is anything in particular that you were hoping to get out of
this visit today?
Finish
Now, if it’s okay with you, I’m just going to go through a brief summary of
what I have learned today. Please do let me know if I make any errors or leave
anything out.
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GLASGOW COMA SCALE
Frequently assessed. Often a pass/fail question.
Follow EVM method:
• E = Eyes (score of 1-4)
• V = Voice (score of 1-5)
• M = Motor (score of 1-6)
EYE OPENING RESPONSE (E)
1
Does not open eyes
2
Opens eyes in response to painful stimulus
3
Opens eyes in response to voice
4
Opens eyes spontaneously
BEST VERBAL RESPONSE (V)
1
Makes no sound
2
Incomprehensible sounds (moaning but no words)
3
Inappropriate words (not in coherent sentences)
4
Confused (responds to questions coherently but is disorientated)
5
Orientated to time, place & person
BEST MOTOR RESPONSE (M)
1
No response
2
Extension to painful stimuli (decerebrate response)
3
Abnormal flexion to painful stimuli (decorticate response)
4
Flexion/Withdrawal from pain
5
Localises to painful stimuli
6
Obeys command
REMEMBER: GCS scale runs from 3-15
THERE IS NO SUCH THING AS A GCS OF 0  THE LOWEST GCS POSSIBLE IS 3
THIS BOOK HAS A GCS OF 3
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INTERPRETATION
Severe brain injury
GCS 8 or less
Moderate brain injury
GCS 9-12
Minor brain injury
GCS 13+
Key Point: At a GCS of 8 or less, the patient will not be able to protect their
airway and requires anaesthetic input with a view to intubation
Memory Aid for Causes of Acute Confusional State/Delirium
Mnemonic: I WATCH DEATH
•Infection
o Ecephalitis, meningitis, UTI, pneumonia
•
Withdrawal
o Alcohol, benzodiazepines, barbiturates
•
Acute metabolic disorder
o Electrolyte imbalance, hepatic or renal failure
•
Trauma
o Head injury, post-operative
•
CNS pathology
o Stroke, haemorrhage, tumour, seizure, Parkinson’s
•
Hypoxia
o Anaemia, cardiac failure, pulmonary embolus
•
Deficiencies
oVitamin B12, folic acid, thiamine
•
Endocrine disorders
o Thyroid, glucose, parathyroid, adrenal
•
Acute vascular
o Shock, vasculitis, hypertensive encephalopathy
•
Toxins
o Substance abuse, medication (alcohol, anaesthetics, anticholinergics, narcotics)
•
Heavy metals
o Arsenic, lead, mercury poisoning
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M E N TA L S TAT E
Abbreviated Mental Test Score (AMTS)
•
This is a rapid tool for assessing cognitive state and should be memorised
•
The maximum score is 10
•
A score of <8 implies presence of cognitive impairment
•
Further & more formal testing is required to confirm this
•
Each question gets an all or nothing score
o For example, in counting, if any number missed, the patient gets a 0 for this
ABBREVIATED MENTAL TEST SCORE (1 POINT EACH)
- Age of the patient
- Current time (to the nearest hour)
- Recall a 3-part address (e.g., 20 West Street)
- Current year
- Current location (name of hospital or town)
- Recognise 2 people (e.g., relatives, carers, doctors, nurses)
- Date of birth
- Years of second world war (or question of historical relevance)
- Name of current prime minister
- Count backwards from 20 to 1
Mini-Mental State Examination (MMSE)
•
•
•
A more detailed test than ATMS
Score out of 30
Usually performed with the help of a proforma but is worth memorising
ORIENTATION (10 POINTS)
Time (maximum 5 points)
Place (maximum 5 points)
What is the:
• Year? (1 point)
• Season? (1 point)
• Month? (1 point)
• Date? (1 point)
• Day of the week? (1 point)
Where are we now?:
• Country? (1 point)
• Town? (1 point)
• Street? (1 point)
• Hospital/building? (1 point)
• Floor? (1 point)
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REGISTRATION (3 POINTS)
• Slowly name 3 everyday objects (e.g., apple, table, penny)
• Ask patient to repeat these 3 objects back to you (1 point each)
•Repeat the objects up to 6 times until they are learned (record how many times
this takes)
ATTENTION & CALCULATION (5 POINTS)
•Ask the patient to spell WORLD backwards (1 point for each letter in the correct
position)
OR
•Ask the patient to count backwards from 100 in sevens: 100, 93, 86, 79, 72, 65
(1 point for each correct answer)
RECALL (3 POINTS)
•Ask the patient to recall the 3 items named earlier (1 point each)
LANGUAGE (9 POINTS)
•Ask the patient to name 2 objects you point to, e.g., pencil & watch (1 point each)
• Ask the patient to repeat “No ifs, ands or buts” (1 point, 1 attempt only)
• Follow a 3-stage command (1 point each):
o Pick up a piece of paper with their left hand
o Fold it in half
o Put it on the floor
•Write ‘CLOSE YOUR EYES’ on a piece of paper & ask the patient to read out
the instruction & follow the command (1 point)
•Ask the patient to write a short sentence, which must include a subject, a verb &
make sense, although spelling & punctuation are not taken into account (1 point)
•Show the patient a picture of two intersecting pentagons forming a quadrangle
(see below) & ask them to copy this (1 point)
INTERPRETATION OF MMSE
25-30
Normal
18-24
Moderate
impairment
<17
Severe impairment
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C R A N I A L N E R V E S E X A M I N AT I O N
Introduction
• Wash hands
• Introduce yourself & confirm patient details
• Explain examination & gain consent
• Consider chaperone
•Expose & position (sitting, 1-2m opposite you with your heads at roughly the
same level)
General Inspection
•
•
•
•
•
•
•
Ptosis
Strabismus
Asymmetry
Facial palsies/weakness
Swelling
Scars (e.g., craniotomy)
Speech abnormalities (assess throughout examination)
CNI: Olfactory Nerve
•
•
Ask patient if they have noticed any change in sense of smell or taste
o Taste perception can be diminished with olfactory loss
o Bilateral disease necessary to produce significant symptoms
Test with scented bottles if indicated (rarely done in practice)
CAUSES OF OLFACTORY NERVE PALSY
•Trauma
• Frontal lobe tumour
• Meningitis
CNII: Optic Nerve
Mnemonic AFRO: Acuity, Fields, Reflexes, Ophthalmoscope
A: Visual Acuity:
• Ask if any problem with vision recently
• Check if the patient wears glasses/contact lenses before proceeding
• Ask patient to read a written sentence, covering each eye in turn
•Formally assess visual acuity with Snellen chart (please see user instructions on the
back of the chart)
• Check colour vision with Ishihara charts
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F: Visual Fields:
•Ask patient to look at your nose and ask if they can see your whole face for crude
assessment of visual fields
•Ask patient to cover one eye with their hand while you close your opposite eye
with your own hand
oe.g., patient covers their right eye with their right hand while you close your left
eye with your left hand
•Ask patient to look at your nose and to tell you when they see your finger or white
hat pin
• Move hat pin or wiggling finger from corners of all 4 visual fields to centre
o Top right, bottom right, top left, bottom left: to centre
• Note where patient’s visual fields differ from your own
• Repeat on opposite side
• When this is done, test for inattention (often as a result of stroke)
o Ask patient to look at your nose with both eyes open
o Wiggle both your index fingers in the peripheries bilaterally
o Vary between both, one or neither
o Ask patient to point at which side moves or say neither or both
R: Pupillary Reflexes: (motor component by CNII, sensory component by CNIII)
• Direct & consensual light reflex:
o Ask patient to stare at a point on the wall
o
Shine pen torch into one eye (warn them that you are going to shine a torch
into their eyes) from side
o Both pupils should constrict
– Direct light reflex: Constriction of pupil in which light was shone
– Consensual light reflex: Constriction of other pupil
• Swinging light test:
o Swinging torch from eye to eye should induce immediate bilateral constriction
o Signifies normal direct & consensual light reflex
oThe following occurs in relative afferent pupillary defect (RAPD)/Marcus Gunn
pupil:
–Light on normal eye causes normal direct & consensual reflex (afferent fibres
in this eye are unaffected)
–Light on affected eye causes slow direct & consensual reflex (afferent fibres
in this eye are affected)
–With a RAPD, the issue is decreased optic nerve sensation to light. So it will
only affect the direct response, not consensual, as only the CNII sensory
input is deficient
O: Ophthalmoscopy: Indicate that you would like to examine fundus with an
ophthalmoscope
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Figure 7: INTERPRETATION OF VISUAL FIELD DEFECTS
ORBIT
LEFT
Optic nerve
1
2
Optic chiasm
3
Optic tract
Temporal
pathway
LEFT
RIGHT
Parietal
pathway
4
RIGHT
1
Right monocular vision loss
2
Bitemporal hemianopia
3
Left homonymous hemianopia
4
Left homonymous
superior quadrantanopia
5
Left homonymous
inferior quadrantanopia
6
Left homonymous hemianopia
with macular sparing
5
Optical lobe
6
CAUSES OF COMMON VISUAL FIELD DEFECTS
Monocular vision loss
•
•
MS
Giant cell arteritis
Bitemporal hemianopia
•
Optic chiasm compression
o Pituitary adenoma
o Internal carotid artery aneurysm
Homonymous hemianopia
•
Lesions behind the optic chiasm
o Tumour
o Abscess
o Stroke
CN III, IV & VI: Oculomotor, Trochlear & Abducens Nerves
Eye Movements:
• Inspect briefly for ptosis or abnormal eye position (e.g., CNIII palsy)
•Ask patient to keep their head still (offer to stabilise chin with your hand) & follow
your finger with their eyes only
• Ask them to inform you of any double vision before you commence movement
• Move finger or hat pin in a H position roughly 1m from patient’s face
•Inspect for obvious nystagmus or ophthalmoplegia as you do so
• If there is nystagmus, note direction of fast beat & move finger quickly to elicit
o Nystagmus on extreme lateral gaze is a normal variant
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•If diplopia is reported: Ask if images are horizontal or vertical to each other
o Ask patient to cover each eye in turn & report which image disappears
o Looking up: Upper image from affected eye
o Looking down: Lower image from affected eye
o Looking laterally: Lateral image from affected eye
Accommodation:
• Hold your finger in front of patient’s face
•Ask patient to look at far away point (e.g., wall), then to focus on your finger on
command
• Check for appropriate pupillary constriction during convergence
FEATURES OF THIRD NERVE PALSY
•
•
•
•
Eye deviated ‘down and out’
Ptosis (drooping of eyelid)
Dilated pupil if complete
o Non-traumatic pupil sparing palsies referred to as ‘medical third nerve palsy’
oThis is because in diabetic CNIII palsy the pial vessels supplying
parasympathetic fibres are unaffected by diabetic microangiopathy
Those affecting pupil called ‘surgical third nerve palsy’
CAUSES OF THIRD NERVE PALSY
•
•
•
•
•
•
•
•
Diabetes mellitus (usually pupil-sparing)
Temporal arteritis
SLE
MS
Cavernous sinus thrombosis
Amyloid
Posterior communicating artery aneurysm (painful 3rd nerve palsy)
Tumour
CAUSES OF PTOSIS
Unilateral
Bilateral
•
Third nerve palsy
•
Myasthenia gravis
•
Horner’s syndrome
•
Myotonic dystrophy
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Figure 8. EXTRAOCULAR MUSCLES
SR
IO
LR
MR
IR
SO
NOSE
CNIII suppIies:
• Superior rectus (SR); Elevates eye
• Inferior rectus (IR): Depresses eye
• Medial rectus (MR): Adducts eye
• Inferior oblique (IO): Elevates adducted eye
CNIV supplies:
• Superior oblique (SO): Depresses adducted eye
CNVI supplies:
• Lateral rectus (LR): Abducts eye
MEMORY AID FOR EXTRAOCULAR MUSCLES NOT SUPPLIED BY CNIII:
SO4 LR6
CAUSES OF CNIV PALSY
CAUSES OF CNVI PALSY
•
•
•Skull fracture involving petrous
temporal bone
• Nasopharyngeal cancer
• Raised ICP (false localising sign)
o 1st nerve compressed in raised ICP
Uncommon in isolation
Usually as a result of orbit trauma
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MANIFESTATION OF CNIV PALSY
MANIFESTATIONS OF CNVI PALSY
• Superior oblique paralysed
•Diplopia on downward & inward
gaze
• Lateral rectus paralysed
•Inability to look laterally
•Eye deviated medially due to
unopposed action of medial rectus
CNV: Trigeminal Nerve
Sensory Component:
•Ask patient to close eyes & say ‘yes’ when they feel you touching their face (& if it
feels the same on both sides): Test sternum first for control
•Assess light touch & sharp touch bilaterally at 3 sensory branches of trigeminal
nerve (move from side to side)
o Ophthalmic branch: Forehead
o Maxillary branch: Over zygoma
oMandibular branch: Chin lateral to midline
Motor Component:
•Ask patient to clench jaw & palpate muscle contraction above angle of the jaw
(Masseter muscle)
•Ask patient to open jaw against resistance (Pterygoid muscle); Jaw deviates
towards side of weakness
Reflexes:
•
Jaw jerk reflex
o Ask patient to slightly open their mouth
o Place your finger on their chin & gently strike with tendon hammer
o Exaggerated opening of mouth in response implies UMN lesion
Corneal reflex
oTraditionally tested by gently touching cornea with cotton bud & eliciting
involuntary blinking
oCan be indirectly tested by testing sensation inside orifice of nostril with cotton bud
–Branch of trigeminal which results in corneal reflex also provides nostril
sensation
•
CAUSES OF TRIGEMINAL NERVE PALSY
•
•
•
Trigeminal neuralgia
Acoustic neuroma
Herpes zoster virus
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CNVII: Facial Nerve
Facial Tone:
• Look for obvious asymmetry
o Reduced forehead wrinkling (LMN lesion only)
o Drooping of corner of mouth
o Flattening of nasolabial fold
Motor Component:
•Ask patient to raise eyebrows, close eyes shut tightly (try to pull them open), puff
out cheeks, show you their teeth
oCheck for Bell’s sign: Upward & outward rolling of eye on attempted eye closure
(facial nerve palsy)
Sensory Component:
• Chorda tympani (supplies taste to anterior 2/3 tongue) – ask if any change in taste
• Nerve to stapedius (ask if any trouble with loud noises)
CAUSES OF FACIAL NERVE PALSY
UMN (forehead spared)
LMN (forehead affected)
• Stroke
• MS
• Meningitis
•Space-occupying lesion (acoustic
neuroma, glioma)
• Bell’s palsy (55%)
•Trauma (parotidectomy, blunt/
penetrating)
•Ramsay Hunt (HZV – shingles of CNVII)
• Malignant parotid tumour
• Sarcoid (often bilateral)
Bell’s Reflex: Upwards gaze on attempted eye closure (sign of facial nerve palsy)
CNVIII: Vestibulocochlear Nerve
Hearing (cochlear branch):
•Cover one ear and whisper ‘another’ in alternate ear, asking the patient to repeat
it, then do the same on opposite side
•Rinne test: Place vibrating 256Hz or 512Hz tuning fork against mastoid bone (sound
no. 1) until the vibration is no longer heard, then place tuning fork close to (but not
touching) the external auditory meatus (sound no. 2)
o Ask which sound was louder
o Air conduction should always be louder than bone conduction
• Weber test: Place vibrating tuning fork in centre of forehead
o Ask if sound is louder in left ear, right ear, or equal
o Should be heard equally in both ears
Balance & posture (vestibular branch):
• Offer to demonstrate Doll’s eye reflex
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INTERPRETATION OF RINNE & WEBER TESTS
Rinne Test
Weber without
lateralisation
Weber’s lateralises
left
Weber lateralises
right
Air>bone (both
ears)
Normal
Sensorineural loss on
right
Sensorineural loss on
left
Bone>air (left
ear)
N/A
Conductive loss on left
Combined loss on left
Bone>air (right
ear)
N/A
Combined loss on right Conductive loss on
right
Bone>air (both
ears)
Conductive loss Combined loss on right Combined loss on left
& conductive loss on
in both ears
& conductive loss on
right
left
CAUSES OF HEARING LOSS
Conductive
Sensorineural
•Otitis externa, chronic otitis
media
• Wax, foreign bodies
• Trauma
• Syndromes (e.g., Marfan’s)
• Osteopetrosis
• Paget’s disease
•Genetic (Usher’s, Klippel-Feil syndrome)
• Measles, mumps, rubella
• Prematurity
• Meningitis
• Vitamin B deficiency
• Multiple sclerosis
•Drug-induced (Furosemide, Gentamicin)
CNIX & X Glossopharyngeal & Vagus Nerves
•
•
•
•
•
Take note of patient’s speech quality
Shine pen torch in mouth & ask patient to say ‘ahhh’
Look for movement of soft palate & uvula (should elevate equally)
Uvula will deviate away from side of weakness
Offer to test gag reflex at this point
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BULBAR PALSY
PSEUDOBULBAR PALSY
Lesion
Bilateral LMN lesion of CNIX,
X & XII
Bilateral UMN lesion of CNIX,
X & XII
Causes
•
•
•
•
•
Motor neurone disease*
Syringobulbia
Guillain-Barre syndrome
Poliomyelitis
Diphtheria
• Motor neurone disease*
• Multiple sclerosis
•Bilateral CVA affecting
internal capsule
• High brainstem tumours
• Head injury
Features
• Gag reflex: Absent
•Tongue: Flaccid, wasted,
fasciculating
• Palate movement: Absent
• Jaw jerk: Absent/normal
• Speech: Nasal
• Emotions: Normal
•Other: Signs of
underlying cause (e.g.,
limb fasciculations)
• Gag reflex: Hyperreflexive
•Tongue: Spastic,
contracted
• Palate movement: Absent
• Jaw jerk: Increased
•Speech: Spastic,
monotonous, slurred,
high pitched, ‘Donald
duck’ dysarthria (trying to
squeeze words out from
tight lips)
• Emotions: Labile
•Other: May have UMN
limb features
*Can cause either
CNXI: Spinal Accessory Nerve
•Ask patient to turn their head left & right against your hands
(Sternocleidomastoids)
o Sternocleidomastoids laterally rotate head to contralateral side
• Ask patient to shrug shoulders against your hands (Trapezius)
CNXII: Hypoglossal Nerve
• Take note of appearance of tongue
oNormal? Flaccid, wasted & fasciculating? (bulbar palsy) Spastic & contracted?
(pseudobulbar palsy)
• Ask patient to stick tongue out
o Will deviate toward side of weakness
•Ask to move tongue from side to side & push it inside of mouth against resistance
Completion
• Offer to perform full neurological examination
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
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•
•
Summarise your findings
Further investigations:
o Bloods (out rule renal, liver or thyroid dysfunction)
o Lumbar puncture: MS (oligoclonal bands), meningitis (WCC, organisms)
o Imaging: CT/MRI brain
o EEG: Epileptiform activity
CONDITIONS WHICH CAN AFFECT ANY CRANIAL NERVE
•
•
•
•
•
•
•
•
Diabetes mellitus
Stroke
MS
Tumour
Sarcoid
Vasculitis (e.g., polyarteritis nodosa)
Systemic Lupus Erythematosus (SLE)
Syphilis
UPPER LIMB NEUROLOGICAL
E X A M I N AT I O N
UPPER/LOWER LIMB NEURO EXAMINATION MEMORY AID
“IS THIS PHYSICIAN REALLY SO CRUEL?”
Inspection
Tone
Power
Reflexes
Sensation
Coordination
Introduction:
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose (top off)
Position (supine at 45o)
Ask if any pain/tingling/weakness in arms or hands
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CLINICAL
EXAMINATION
UPPER LIMB
NEUROLOGICAL
EXAM
Neurologica l Exa mina t ion
General Inspection
•
•
•
•
Symmetry, muscle wasting, fasciculations
Scars, neurocutaneous lesions
Equipment (e.g., walking aids)
Abnormal posture:
'UMN Lesion' posture: Shoulder adducted, elbow flexed, wrist flexed & pronated,
lower limb held in fixed extension
o Erb’s palsy/Klumpke’s paralysis
o Spine: kyphosis, lordosis, scoliosis
•
Pronator drift:
o Ask patient to stretch arms out in front of them with their palms facing ceiling
o Ask patient to close eyes & keep hands in same position
oIf hand drifts downwards & pronates? Positive test on that side (implies subtle
UMN disorder)
Tone
•Hold patient hand in handshake position while supporting their arm at their elbow
& instruct them to let their arm go floppy
•Move shoulder, elbow & wrist joints simultaneously to assess for hypertonia/
hypotonia
• Pronate/supinate forearm to detect ‘Supinator catch’ – early sign of hypertonia
• Assess for ‘clasp-knife’ hypertonia (UMN lesion)
oIncreased tension in extensor of joint when passively flexed, which rapidly gives
way on further pressure
Power
•
Ask if patient right or left handed (can affect power)
•
Assess one arm at a time & compare with opposite side
•
Immobilise muscles above muscle group being assessed
•
Grade power out of 5
•
Say aloud what movement, root & nerve you are testing to the examiner
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MOVEMENT
ROOT
NERVE
Shoulder abduction
C5
Axillary
Elbow flexion
C5/C6
Musculocutaneous
Elbow extension
C7
Radial
Wrist extension
C6
Radial
Finger extension
C7
Radial
Finger flexion
C8
Median & ulnar
Thumb abduction
T1
Median
Finger abduction
T1
Ulnar
GRADING OF POWER
5
Full power against resistance
4
Power against some resistance
3
Able to move against gravity but unable to move against resistance
2
Movement possible if gravity eliminated
1
Flicker of contraction possible
0
No movement
Reflexes
• Ask patient to relax & close their eyes
• Can be instructed to clench teeth prior to striking as a reinforcing manoeuvre
•
Biceps jerk (C5/C6): Shoulder adducted, elbow flexed across the patient’s body,
arm resting on pillow, with your thumb on biceps tendon
o Strike thumb with reflex hammer
•
Triceps jerk (C7): Support patient arm at elbow & strike triceps tendon directly
with reflex hammer
• Supinator jerk (C5/C6): Position as for biceps jerk with forearm slightly pronated
o Strike with tendon hammer on radial border 5cm above wrist
GRADING OF REFLEXES
0
Absent
+1
Somewhat diminished, low normal
+2
Normal
+3
Brisker than average, possibly not indicative of disease
+4
Very brisk, hyperactive, with clonus
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Sensation
Vibration:
•Test vibration on sternum first so patient knows what sensation they are expected
to feel
• Ask patient to close eyes & tell you if they feel vibration (& tell you when it stops)
• Progress superiorly until positive response elicited
•Place vibrating 128Hz tuning fork at middle finger DIPJ, radial styloid, olecranon &
shoulder tip in turn until positive response elicited
• Repeat on opposite side
Light touch & sharp touch:
• Test using cotton wool & neurotip/monofilament
• Ask patient to close eyes & demonstrate sensation on sternum
•Instruct patient to say yes when they feel it touching their skin
• Move from side to side (ask do they feel the same on both sides)
AREA
ROOT
Above shoulder tip
C4
Regimental badge area
C5
Tip of thumb
C6
Tip of middle finger
C7
Tip of little finger
C8
Medial mid-forearm
T1
•Suspect peripheral neuropathy? Assess for sensory level by dragging cotton wool
up arm beginning at tip of middle finger
o Instruct patient to inform you if/when they feel change of sensation
oRepeat on opposite side
Proprioception:
• Immobilise middle finger at middle phalanx with one hand
•Grasp distal phalanx at sides with free hand (avoid holding pulp which allows
touch to be used)
•Ask patient to close eyes & tell them if finger pointing up, down, or if they are unsure
o Demonstrate to patient upwards & downwards movement before you begin
• Randomly move fingertip up or down 4 times & ask them to tell you position
• Repeat on opposite side
•If unable to identify direction of movements accurately, move to proximal joints
(e.g., wrist, elbow, shoulder) until intact
Temperature:
• Can be assessed with cold & warm metal tubes but rarely performed
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2-point discrimination:
•Inform examiner that you would assess this with a 2-point compass point on each
dermatome & check if patient feels sensation at 1 or 2 points
oRecord distance between 2 points at which 2 point discrimination is present
Coordination
•
•
•
Finger-nose test:
oAsk patient to touch your finger with their outstretched finger & then their own
nose repeatedly
– May elicit intention tremor, dysmetria & past-pointing (cerebellar ataxia)
– Repeat on opposite side
Hand slapping test:
oAsk patient to tap one hand on the other, alternating between palmar & dorsal
sides of moving hand
– Assesses for dysdiadochokinesis (cerebellar ataxia)
– Repeat on opposite side
Ask patient to hold hands out & pretend to play a piano
o Difficult in UMN & Parkinson’s
Completion
• Offer to perform full neurological examination
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o Bloods
o Lumbar puncture if suspect MS/meningitis
o EEG, EMG, nerve conduction studies
o Brain imaging (CT/MR brain) – Space-occupying lesions, stroke, MS
o Spine imaging (XR, MRI)
ADDITIONAL NOTES
DIFFERENTIATING UMN & LMN PRESENTATIONS
UMN
LMN
Tone
Increased (Spastic)
Normal/reduced
Power
Reduced
Reduced
Reflexes
Brisk
Reduced/absent
Plantars
Up
Down
Coordination
Reduced
Normal
Fasciculation
Absent
Present
Clonus
Yes
No
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LOWER LIMB NEUROLOGICAL
E X A M I N AT I O N
CLINICAL
EXAMINATION
Introduction:
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose (top off)
Position (supine at 45o)
Ask if any pain/tingling/weakness in arms or hands
LOWER LIMB
NEUROLOGICAL
EXAM
General Inspection
•
•
Symmetry, muscle wasting, fasciculations
Abnormal posture:
‘UMN lesion’ posture: hip & knee extended, foot plantarflexed & inverted
•
•
o Foot drop
o Spine: Kyphosis, lordosis, scoliosis
Scars/soft tissue damage due to sensory neuropathy (inspect feet clearly)
Assess gait (ask patient to walk to one end of room, turn around & walk back)
Romberg’s test:
• Stand patient up, feet together, arms by side & facing you
• Hold your hands near patient’s shoulders in case support needed
• Ask patient to close eyes
• Test is positive if patient sways/falls with eyes closed
o Tests for sensory ataxia due to loss of proprioception
• Test can be performed at end of examination but is easily forgotten
Tone
•
•
•
Instruct patient to let their leg go floppy & rock their leg from side to side
Briskly pull upwards from behind knee (indicates hypertonia)
Briskly pull each foot into dorsiflexion to assess for clonus (UMN lesion)
Power
• Assess one leg at a time & compare with opposite side
•Immobilise muscles above muscle group being assessed
• Say aloud what movement, root & nerve you are testing to the examiner
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Movement
Root
Nerve
Hip flexion
L1/L2
Femoral
Hip extension (push heel into bed)
L5/S1
Gluteal
Knee flexion
L5/S1
Sciatic
Knee extension
L3/L4
Femoral
Ankle dorsiflexion
L4
Peroneal
Big toe extension
L5
Peroneal
Ankle plantarflexion
S1
Tibial
Reflexes
• Ask patient to relax & close their eyes
•Can be instructed to clench teeth prior to striking as a reinforcing manoeuvre or
lock fingers together and pull hard (Jandressik’s manoeuvre)
• Knee jerk(L3/L4): Sitting over edge of bed
o Strike infrapatellar tendon with reflex hammer (palpate tendon first)
•
Ankle jerk(S1): Abduct & externally rotate hip, flex knee & use hand to slightly
plantarflex foot
o Strike Achilles tendon with hammer
• Babinski response:
o Run pointed tip of reflex hammer up lateral side of plantar surface of foot
– Plantarflexion of big toe is normal
–Dorsiflexion of big toe is indicative of UMN lesion (positive Babinski response)
o Assess for clonus
Sensation
Light touch & sharp touch:
• Test using cotton wool & neurotip
• Ask patient to close eyes & demonstrate sensation on sternum
•Instruct patient to say yes when they feel it touching their skin
• Move from side to side (ask do they feel the same on both sides)
Area
Root
Antero-medial mid-thigh
L2
Medial aspect of thigh just above knee
L3
Medial malleolus
L4
Dorsal 1 web spacer
L5
Lateral aspect of heel
S1
st
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Neurologica l Exa mina t ion
•Suspect peripheral neuropathy? Assess for sensory level by dragging cotton wool
up leg beginning at tip of 1st hallux
o Instruct patient to inform you if/when they feel change of sensation
o Repeat on opposite side
Proprioception:
•Immobilise forefoot with one hand
•Grasp distal hallux at sides with free hand (avoid holding pulp which allows touch
to be used)
• Ask patient to close eyes & tell them if toe pointing up, down, or if they are unsure
o Demonstrate to patient upwards & downwards movement before you begin
• Randomly move hallux up or down 4 times & ask them to tell you position
• Repeat on opposite side
•If unable to identify direction of movements accurately, move to proximal joints
(e.g., ankle, knee, hip) until intact
Vibration:
• Test vibration on sternum first
• Ask patient to close eyes & tell you if they feel vibration (& tell you when it stops)
• Progress superiorly until positive response elicited
•Place vibrating 128Hz tuning fork at tip of hallux, medial malleolus, tibial
tuberosity & ASIS in turn until positive response elicited
• Repeat on opposite side
Temperature:
• Can be assessed with cold & warm metal tubes but rarely performed
2-point discrimination:
•Inform examiner that you would assess this with a 2-point compass point on each
dermatome & check if patient feels sensation at 1 or 2 points
o Record distance between 2 points at which 2-point discrimination is present
Coordination
•
•
Heel-shin test:
oAsk patient to run their heel down front of shin, lift off the leg & return it to
knee repeatedly
o Replicate in contralateral leg
o Intention tremor & dysmetria in cerebellar ataxia
Foot tap test and toe-finger test also done for coordination
Special Tests
•
•
Perform Romberg’s test if not already done
Straight leg raise
o Patient lying supine
o Ask them to inform you if any pain
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o Hold ankle & flex hip with leg straight
o Should be possible to 90o without pain
oPain radiating from back to posterior leg is positive test for L5/S1 nerve root
compression
•
Femoral stretch test
o Patient lying prone on front
o Ask them to inform you if any pain
o Hold thigh & ankle
o Extend hip while keeping leg straight
oPain radiating down from back to anterior leg is positive test for L1-L4 nerve
root compression (likely L4)
Completion
• Offer to perform full neurological examination
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o Bloods
o Lumbar puncture if suspect MS/meningitis
o EEG, EMG, nerve conduction studies
o Brain imaging (CT/MR brain) – Space-occupying lesions, stroke, MS
o Spine imaging (XR, MRI)
SENSORY MODALITIES OF THE SPINAL CORD
Anterolateral
spinothalamic tracts
Pain, temperature & crude touch
Dorsal columns
Vibration, conscious proprioception, fine touch & 2-point
discrimination
Spinocerebellar tracts
Muscle stretch & unconscious proprioception
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Neurologica l Exa mina t ion
C E R E B E L L A R E X A M I N AT I O N
MEMORY AID FOR FEATURES OF CEREBELLAR DISEASE
Mnemonic DANISH
Dysdiadochokinesis
Ataxia (truncal & limb)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/Heel-shin test
Introduction:
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose (ideally down to shorts/underwear) & position (supine at 45o)
General Inspection
•
•
Bruising & scars from recurrent falls, walking aids at bedside
Symmetry, muscle wasting, fasciculations (LMN lesion)
Head
•
•
Nystagmus
o Hold head still & ask patient to follow finger with their eyes only
o Move finger quickly up, down, left & right
o Observe for nystagmus
Speech:
o Ask patient to read something aloud (staccato speech)
o Ask patient to say ‘baby hippopotamus’ (slurred speech)
Upper limb assessment
•
Assess tone & power as per upper limb neurological examination
o Hypotonia is a feature of cerebellar disease
o Reduced power may give impression of impaired coordination
Coordination:
• Rebound phenomenon:
oAsk patient to hold arms out straight in front with palms facing down & eyes
closed
o Instruct them to keep arms in this position
o Push each arm down in turn & release
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o Observe for arm bouncing up beyond original position
o Overshooting is a feature of dysmetria
•Finger-nose test (as per upper limb neurological examination) for dysmetria,
intention tremor & past-pointing
•Hand slapping test (as per upper limb neurological examination) for
dysdiadochokinesis
Lower limb assessment
•
Assess tone & power as per lower limb neurological examination
o Hypotonia is a feature of cerebellar disease
o Reduced power may give impression of impaired coordination
Coordination:
• Foot tapping test
o Ask patient to tap foot off floor as rapidly as possible
o Difficulty & slowness = Dysdiadochokinesis
•Heel-shin test (as per lower limb neurological examination) for intention tremor &
dysmetria
Posture
•Assess stability while sitting (cross arms in front & sit still) and standing (feet
together & arms by sides)
o Look for truncal ataxia
•Perform Romberg’s test (as per lower limb neurological examination) to assess for
sensory (rather than cerebellar) ataxia
Gait
•
•
•
Observe gait as patient walks across room, turns around & comes back
Features of cerebellar gait
o Broad-based gait
o Unsteady with veering laterally
o Irregular steps
Walk heel to toe (v. difficult with cerebellar ataxia)
Completion
• Offer to perform full neurological examination
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o MRI to visualise posterior fossa
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Neurologica l Exa mina t ion
ADDITIONAL NOTES
CAUSES OF CEREBELLAR DISEASE
Mnemonic PASTRIES
Posterior cranial fossa tumour
Alcohol (& Wernicke’s encephalopathy)*
Sclerosis (Multiple sclerosis)
Trauma Rare
Inherited (e.g., Friedreich’s ataxia, Arnold-Chiari malformation) Epilepsy medications
(carbamazepine, phenytoin toxicity)
Stroke
*Alcohol-induced cerebellar disease typically spares the upper limbs
LOCALISATION OF CEREBELLAR LESION
Vermis lesion (central)
Cerebellar hemisphere lesion
•Truncal ataxia (little/no limb ataxia)
• Staggering gait
• Slurred, staccato speech
•Ipsilateral limb ataxia
• Nystagmus
•Unsteady gait (veering towards side
of lesion)
NB: A cerebellar lesion may involve both vermis & hemispheres, and be impossible
to localise clinically
Signs of Cerebellar Limb Ataxia
•
•
•
•
Dysdiadochokinesis: Inability to perform rapid, alternating movements
Dysmetria: Lack of coordination of movement typified by overshooting/
undershooting intended position of limb
Intention tremor: Tremor which increases as extremity approaches endpoint of
deliberate, visually-guided movement
Past-pointing: Overshooting a point attempted to reach with patient’s finger
NYSTAGMUS & OPHTHALMOPLEGIA
Nystagmus: Rapid involuntary movement of the eyes
Causes:
• Congenital
• Brainstem disorder
o MS, stroke, tumour
• Cerebellar disease (see above list)
•Vestibular dysfunction
• Labyrinthitis, Meniere’s disease, CNVIII lesion
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Ophthalmoplegia: Paralysis of extraocular muscles responsible for eye movements
Causes:
• Myasthenia Gravis
• Cranial nerve III/IV/VI palsy
• Graves’ disease
• Wernicke’s encephalopathy
• Progressive supranuclear palsy (usually downward gaze)
Wernicke’s encephalopathy
•
•
Neurological symptoms due to thiamine (Vitamin B1) deficiency
Often due to C2H5OH abuse
Classic triad:
o Ophthalmoplegia
o Ataxia
o Confusion
• Wernicke’s encephalopathy is an acute syndrome
•Korsakoff’s psychosis is chronic neurological dysfunction due to Wernicke’s
encephalopathy
EXTRAPYRAMIDAL SYSTEM
E X A M I N AT I O N
MEMORY AID FOR CORE FEATURES OF PARKINSONISM
Mnemonic TRAP
Mnemonic TRAP
Tremor Rigidity
Akinesia (or bradykinesia, more accurately)
Postural instability
Introduction:
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position (supine at 45O)
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Neurologica l Exa mina t ion
General Inspection
•
•
•
•
Facial hypomimia (expressionless, ‘mask-like’ face)
Slow blink rate
Loss of facial micromovements
Flexed extrapyramidal posture
o Cannot lie flat (head held off pillow)
o ‘Simian’ posture on standing: hunched over with arms held in front of body
– Known as a ‘hands over hernia’ posture
Tremor
•
•
•
Ask patient to rest hands onto pillow on lap
Observe for resting tremor
o ‘Pill rolling’, coarse (3-5Hz) tremor
o Exacerbated by distraction (tapping other hand on knee)
o Improved by concentration
o Look for unilateral/asymmetrical distribution
oAsk patient to hold hands out in front with fingers spread: Parkinsonian tremor
improves (true resting tremor)
Assess for other potential causes for tremor:
o Does it worsen when hands are held up? Postural tremor
o Flapping tremor/asterixis? Seen in hepatic/respiratory/renal failure
o Titubation (nodding movement of head)? Benign essential tremor
Rigidity
•
•
•
•
Assess for tone in upper limb as per upper limb neurological examination
Check for ‘lead pipe’ rigidity at elbow
oIncreased tone causing sustained resistance to passive movement throughout
whole motion without fluctuation
o Ask patient to tap knee with other hand while continuing to flex/extend elbow
–Contralateral synkinesis (performing action with opposite limb increases
rigidity)
Check for ‘cogwheel’ rigidity at wrist
o Combination of lead pipe rigidity & tremor
o Jerky resistance to passive movement as muscles tense & relax
Repeat with opposite arm
Akinesia (bradykinesia)
•
•
Ask patient to touch thumb to each finger in turn as quickly as they can
Ask patient to hold out hands & pretend to play piano
o Look for slowness in the above actions
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Postural instability
•Ask patient to stand up from chair, walk to opposite end of room, turn around &
walk back towards you
Observe for features of parkinsonian gait:
o Simian/flexed forward posture
o Hesitancy/Freezing (difficulty initiating movements & turning)
o Shuffling
o Lack of arm swing
o Small, hurried steps
o Festination (quickening & shortening of normal strides)
o Retropulsion (loss of balance in a posterior direction)
Function assessment
Speech:
• Ask patient to state full name, date of birth & address
• Listen for quiet, slow, monotonous speech
Writing:
• Ask patient to write name & address
• Look for micrographia
Global function assessment:
• Ask patient to
o Open a button on their shirt
o Pretend to turn taps
o Pretend to turn a key
Special tests
Glabellar tap: (Offer to perform this but you will rarely be required to)
• Ask patient to stare at point on wall
• Tap forehead between patient’s eyes with your index finger WITH PERMISSION
•Failure to suppress blinking response after first 3-4 taps: suggestive of Parkinson’s
disease
Completion
•
Offer to assess for evidence of Parkinson’s plus syndromes
oFull neurological examination (cerebellar & pyramidal signs of multi-system
atrophy)
o Assess eye movements (for evidence of progressive supranuclear palsy)
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
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Neurologica l Exa mina t ion
•
•
Summarise your findings
Suggested further investigations:
o Postural BP (autonomic neuropathy of multi-system atrophy)
o CT brain (vascular/lewy body dementia)
ADDITIONAL NOTES
Causes of Parkinsonism
•Idiopathic Parkinson’s disease
• Multiple cerebral infarcts
• Parkinson’s-plus syndromes
•
•
•
•
o Multi-system atrophy (autonomic features, cerebellar & pyramidal features)
o Progressive supranuclear palsy (ocular features, such as vertical gaze palsy)
oVascular parkinsonism (worse in legs than arms, pyramidal signs, prominent gait
abnormality)
oLewy body dementia (early dementia with fluctuating cognition & visual
hallucinations)
Post-encephalopathy
Drug-induced e.g., neuroleptics, prochlorperazine, metoclopramide
Toxin-induced e.g., MPTP, manganese, copper (Wilson’s disease)
Trauma (Dementia pugilistica/punch-drunk syndrome)
Management of Parkinson’s Disease
Social:
• Home adaptation with occupational therapy input
Medical:
• Levodopa
• Dopamine agonists (ropinirole, pergolide, apomorphine, bromocriptine)
• MAO-B inhibitors (safinamide, selegiline, rasagiline)
• Anticholinergics (orphenadrine, procyclidine)
Surgical:
• Basal ganglia ablation
• Deep brain stimulation
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TREMOR: RHYTHMIC INVOLUNTARY OSCILLATION OF LIMBS, TRUNK, HEAD
OR TONGUE (3 TYPES)
1. Resting tremor:
•
Worst at rest
•
Usually slow (3-5Hz)
•
‘Pill rolling’ of thumb over finger
•
e.g., Parkinsonism
2. Postural tremor:
•
Worst with arms outstretched
•
Causes:
o
Exaggerated physiological tremor (e.g., anxiety, hyperthyroidism, alcohol,
β2 agonists)
–
Usually rapid (8-12Hz) & symmetrical
–
Non-progressive
–
MGT: Rx underlying cause, β-blockers, gabapentin
o Benign essential tremor (often familial)
–
Usually slower (4-7Hz), mild asymmetry common
–
Progressive
–Improves with alcohol
–
MGT: β-blockers, gabapentin
3. Intention tremor:
• Worst on movement
• Seen in cerebellar disease
• Associated with dysdiadochokinesis, past-pointing & dysmetria
HAND NEUROLOGICAL
E X A M I N AT I O N
NERVE
MOTOR INNERVATION
Median Mnemonic LOAF
• Lateral 2 lumbricals
• Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis
SENSORY INNERVATION
• Lateral palm
• Thumb & lateral 2½ fingers
Ulnar
• S
mall muscles of the hand except • Medial hand (palm & dorsum)
LOAF muscles
• Medial 1 ½ fingers
Radial
• Extensors (fingers, wrist & elbow)
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• Lateral dorsum of hand (no fingers)
Neurologica l Exa mina t ion
Exam Tip:
Neurological assessment of the hand consists of examining median nerve, ulnar
nerve & radial nerve. You may be asked to examine all 3 at once or a nerve
individually. Even if asked to assess only one nerve (for example: in carpel tunnel
exam), it would be wise to do some cursory testing of the other nerves.
Introduction:
• Wash hands
• Introduce yourself & confirm patient details
• Explain examination & gain consent
• Consider chaperone
•Expose & position (sleeves rolled up to beyond elbows, hands resting on pillow
with palms facing up)
• Ask patient if any pain in hands/arms
Exam Tip:
REMEMBER TO ALWAYS COMPARE BOTH SIDES THROUGHOUT ENTIRE
EXAMINATION
Inspection
•
•
•
Muscle wasting:
o Thenar eminence (median)
o Hypothenar eminence (ulnar)
–Check thenar & hypothenar eminence by asking patient to put hands in
‘begging’ position
o Interossei - check back of hand for intermetacarpal guttering (ulnar)
Deformity:
o Ape hand (median)
–Wasting of thenar eminence
–Inability to oppose or flex thumb
o Partial claw hand (ulnar)
–Weak medial lumbricals – clawing of little & ring fingers
–Lateral lumbricals unaffected (innervated by median)
o Wrist drop (radial)
Scars:
o Carpal tunnel decompression scar (median)
o Elbow scar/deformity (ulnar)
o Upper arm deformity from previous humeral shaft # (radial)
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Power
•
•
•
Median:
oThumb abduction: palms facing upwards, point thumbs straight up towards
ceiling, tell patient to resist you pushing down
o Thumb opposition: touch each finger with thumb
Ulnar:
o Finger abduction:
– Hold digits 3-5 between your thumb & fingers
– Abduct patient’s index finger for them
–Tell them to not let you push their index finger back in as you attempt to
push index finger back towards 3rd finger
Radial:
o Wrist extension
o Finger extension
oThumb extension: with hand vertical & thumb pointing up towards ceiling
(instruct patient to not let you push it down)
Sensation
•
Median: Lateral side of index finger
•
Ulnar: Medial side of little finger
•
Radial: Anatomical snuffbox
Special tests
•
•
Median nerve:
oTinel’s test: Repeatedly tap over median aspect of ventral wrist - over the carpal
tunnel
– Positive test = pain & worsening of carpal tunnel symptoms
o Phalen’s test: Hands held together in flexion (‘reverse prayer’ sign) for 1 min
– Positive test = paraesthesia/tingling worsens
Ulnar nerve:
oFroment’s sign: Ask patient to hold paper between straight thumb & index
finger as you pull away
–Positive test = flexed DIPJ of thumb (long thumb flexors used to
compensate for weak adductor pollicis)
Function assessment
•
Test pincer grip
•
Ask patient to squeeze your fingers tightly
•
Prayer sign
•Everyday tasks (undo button, write sentence, pretend to turn taps, pretend to turn
key in door)
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Neurologica l Exa mina t ion
Completion
•
•
•
•
Offer to assess vascular status of hand
o Radial pulse
o Ulnar pulse
o Allen’s test
Thank patient & wash hands
Summarise your findings
Suggested further investigations:
o Nerve conduction studies
ADDITIONAL NOTES
CAUSES OF CARPAL TUNNEL SYNDROME
Mnemonic MEDIAN TRAP
Myxoedema
Ethanol (alcohol)
Diabetes mellitus
Idiopathic
Amyloidosis
Neoplasm
Trauma
Rheumatoid arthritis
Acromegaly Pregnancy
COMMON MECHANISMS OF INJURY
Median
Carpal tunnel syndrome
Ulnar
Elbow trauma
Radial
Humeral shaft #
Saturday night palsy*
*Where the radial nerve is compressed against the humerus (such as by falling asleep with arm hanging over
back of armchair)
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SPEECH ASSESSMENT
Introduction:
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position (sitting in chair)
General
•
•
Ask some simple questions:
o “What is your name?”
o “How old are you?”
o “What is your address?”
o “How did you get here today?”
Establish if this is dysarthria or dysphasia, then move to that part of exam
Dysarthria
•
•
•
•
Ask patient to repeat difficult phrases:
o “British constitution”
o “West Register Street”
o “Red lorry, yellow lorry” (lingual sounds – using tongue)
o “Baby hippopotamus” (labial sounds – using lip)
o “We see three grey geese”
Ask patient to repeat these sounds:
o “Pa” (labial)
o “Ka” (lingual)
o “Ta” (palate)
Ask patient to count to 30 (fatigability in myasthenia gravis)
Test cranial nerves IX, X & XII as per cranial nerves exam
o Assess for bulbar/pseudobulbar palsy
Dysphasia
•
•
•
Ask patient to obey these commands (receptive)
Ask patient to say as many words as they can in 60s (<12 is abnormal)
Name objects (nominal):
o Watch
o Pen
o Tie
o Table
o Chair
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Neurologica l Exa mina t ion
•
•
–If unable to name, give them possibilities/options
– “Is it a pen, comb or cup?”
Ask patient to obey commands (receptive):
o “Stick out your tongue”
o “Point to ceiling”
o “Close your eyes”
More complicated command now (receptive):
o “Pick up the paper, fold it in half and put it on the floor”
Completion
•
•
•
Offer to perform full neurological history & examination
Thank patient & wash hands
Summarise your findings
ADDITIONAL NOTES
COMMON SPEECH ABNORMALITIES
Dysarthria
Inability to articulate words correctly
• Bulbar palsy: Flaccid
• Pseudobulbar palsy: Spastic
• Cerebellar: slurred, staccato speech
• Myasthenia gravis: weak, quiet & fatigable
Dysphasia
•Expressive (Broca’s area lesion – frontal lobe, dominant
hemisphere): Comprehends but unable to express
•Receptive (Wernicke’s area lesion – temporal lobe,
dominant hemisphere): Difficulty comprehending
questions
•Global (damage to both areas): Unable to express or
comprehend
• Nominal: Unable to name objects
Dysphonia
Impairment in ability to produce voice
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COMMONLY PRESCRIBED MEDICATIONS – NERVOUS SYSTEM
Drug type
Common indications
Examples
Antiplatelets
TIA, stroke
Aspirin
Anticoagulants
Prevention of stroke in
atrial fibrillation
Vitamin K antagonist e.g., Warfarin
Factor Xa inhibitors e.g.,
Rivaroxaban, apixaban
Direct thrombin inhibitors e.g.,
dabigatran
Benzodiazepines
Anti-epileptic
drugs
Seizures, status
epilepticus, anxiety
Diazepam, midazolam, lorazepam,
alprazolam
Acute MS relapse
Methylprednisolone
Epilepsy/seizure
disorder
Levetiracetam, phenytoin, sodium
valproate, carbamazepine,
lamotrigine, topiramate, gabapentin
(some have other
indications e.g.,
migraine, neuropathic
pain, bipolar disorder,
depression)
Benzothiazoles
Motor neurone disease
Riluzole
MS disease
modifying therapy
Relapsing remitting MS
Interferon beta, alemtuzumab,
natalizumab, dimethyl fumarate,
fingolimod, teriflunomide
Skeletal muscle
relaxants
Spasticity
Baclofen, tizanidine
5-HT agonists
Migraine
Sumatriptan
Anti-Parkinson
agents
Parkinson’s disease
Levodopa, ropinirole, entacapone,
rasagiline, biperiden, amantidine
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Neurologica l Exa mina t ion
COMMONLY PRESCRIBED MEDICATIONS – NERVOUS SYSTEM
Drug type
Common indications
Examples
Acetylcholinesterase Myasthenia gravis
inhibitors
Alzheimer’s dementia
Pyridostigmine
NMDA receptor
antagonists
Alzheimer’s dementia
Memantine
Antidepressants
Depression/anxiety
Escitalopram, venlafaxine,
mirtazapine, amitryptiline,
Antipsychotics
Psychotic disorders,
schizophrenia, acute
confusional states
Olanzapine, risperidone, quetiapine,
haloperidol, clozapine,
Mood stabilisers
Bipolar disorder
Lithium, carbamazepine, sodium
valproate, lamotrigine
Antimicrobials
commonly used
CNS infection
Antibiotics: Ceftriazone, vancomycin,
amoxicillin
Donepezil, rivastigmine
Antiviral: aciclovir
• Please note these do not constitute exhaustive list of medications or indications. Reference texts and/or
drug formularies should always be consulted for comprehensive medication and prescribing information.
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THE RCSI THREE-COLUMN OSCE GUIDE
Neurological Examination - Cranial nerves 2-6
“This is a neurology station. You have 5 minutes to examine cranial nerves two to six. I will then ask you
to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level, explains
what he/she will be doing and obtains
consent for same
‘Hi my name is X. I’m
a third year medical
student at RCSI. What’s
your name? Nice to meet
you. I’ve been asked
to examine your face
today. That will involve
examining your vision
and eye movements
and checking sensation
in your face. Would that
be ok?’
Position and exposure
• P
atient seated
‘Mr/Mrs A is
appropriately positioned
and exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Are you in any pain?’
GENERAL INSPECTION & CLOSER INSPECTION
Performed from end, then right side of bed
o Inspects for
o Patient eg. facial asymmetry
o Equipment such as glasses
‘On general inspection
Mr/Mrs A appears
well. There is no facial
asymmetry and Mr/Mrs
A is not wearing glasses.’
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• Glasses, enucleation
• Facial asymmetry, wasting
• Craniotomy/facial scars
• Ptosis, Proptosis, Anisocoria
Neurologica l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
‘Visual Acuity is normal in
both eyes’
Visual Acuity
• Vision is reduced –
hypermetropia, myopia,
absent.
• Quantify visual deficit – can
see fingers, light etc.
CRANIAL NERVE II
Visual Acuity
• Assesses with Snellen chart.
• If unable to read chart, proceeds to finger
counting, then light perception.
Visual Fields
• C
onfrontational testing
o A
sks patient to cover one eye at time with
hand
o Examiner
seated directly across from
patient
o A
sks patient to direct gaze to
corresponding eye of examiner
o Examiner
holds up number of fingers
peripherally, equidistant between
themselves and patient
o Target
starts outside visual field then
moves slowly to more central position until
patient confirms visualization of the target
o Asks
patient to correctly identify the
number of fingers
o All
4 quadrants (upper and lower, temporal
and nasal) tested
• O
ffers to perform fundoscopy, assess colour
vision and assess blind spot.
‘On confrontational
testing, visual fields are
intact in all 4 quadrants of
both eyes’
Visual fields
• Bitemporal hemianopia
o Optic chiasm lesion,
pituitary tumour
• Unilateral field loss
o Optic nerve lesion,
tumour/vascular
• Homonymous hemianopia
o Optic tract to occipital
cortex, vascular/tumour
• Inferior/superior
quadrantanopia
‘Both pupils are equal
and reactive to light.
Pupillary constriction
in response to
accommodation was
normal and there was no
evidence of RAPD.’
• P
upils are unequal in size –
Right pupil is X mm & Left
pupil is Y mm
Direct & Consensual light
reflex
• N
o /sluggish response to
direct or consensual light
testing
CRANIAL NERVES II&III
• C
omments on pupil size and symmetry
Direct & Consensual light reflex
• W
ith a pocket torch shines light from side
into one of pupils to assess reaction to light
(direct).
• O
bserves reaction of other pupil (cons)
RAPD
• S
winging light test – moves torch from
pupil to pupil in arc, observes for normal
constriction of both pupils
Accommodation
• A
sks patient to look into distance, then to
focus on finger held near patient’s nose.
Observes for constriction of both pupils
RAPD
• R
APD present (MarcusGunn)
Accommodation
• A
ccommodation impaired/
absent (lesions of ipsilateral
optic nerve, ipsilateral
CN3 parasympathetics,
pupillary constrictor muscle,
or bilateral lesions of the
pathways from optic tracts to
visual cortex.)
(Argyll Robertson pupil–
accommodation response
present, light response absent)
RCSI
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N euro l o g i ca l E xa m i n a t i o n
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
‘There is full range of
eye movements in the
horizontal and vertical
planes. There was no
nystagmus elicited’
Eye movements
• CN3 palsy-dilated pupil,
ptosis, eye “down & out”.
• CN4 palsy- unable to look
down when eye adducted
• CN6 palsy – failure of
abduction
CRANIAL NERVES III, IV & VI
Eye Movements
• P
erforms assessment of eye movements of
both eyes in complete “H” pattern
• A
sks patient to report pain or diplopia
Nystagmus
• A
ssesses for nystagmus in vertical and
horizontal plane in ‘+’ pattern
Nystagmus
• Towards lesion=cerebellar.
• Away from lesion =
vestibular.
• INO = nystagmus in
abducting eye
CRANIAL NERVE V
Sensory Division
• A
ssesses sensation in all 3 branches of CNV
and compares both sides. (Touches with
cotton wool – not strokes)
Motor Division
• Inspects & palpates masseter and
temporalis muscles for wasting/ asymmetry
• Asks patient to clench teeth and assess
strength of masseter muscles
• Asks patient to keep mouth open as
examiner push against chin – Pterygoid
‘Sensation was intact
and symmetrical in
all branches of the
Trigeminal nerve.
There is no evidence
of abnormality with the
muscles of mastication.’
Reflexes
Offers to perform jaw jerk & corneal reflex
Sensory Division
• Asymmetry in sensation
• Loss of sensation in
Ophthalmic/ Maxillary/
Mandibular/All branches
of the Trigeminal Nerve
unilaterally / bilaterally.
Motor Division
• Wasting of muscles of
mastication
• Weakness of Masseter,
Temporalis, Pterygoid
• Deviation of the jaw to left/
right
Reflexes
• Exaggerated / absent jaw
jerk
• Absent corneal reflex
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Neurologica l Exa mina t ion
THE RCSI THREE-COLUMN OSCE GUIDE
Neurological Examination - Cranial nerves 7-12
“This is a neurology station. You have 5 minutes to examine cranial nerves seven to twelve. I will then
ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level, explains
what he/she will be doing and obtains
consent for same
‘Hi my name is X. I’m a
third year medical student
at RCSI. What’s your name?
Nice to meet you. I’ve
been asked to examine
the nerves in your face.
This involves assessing the
movements of your face,
your hearing and tongue
movements. Would that
be ok?’
Position and exposure
•
Patient seated
•
Arms and shoulders exposed
‘Mr/Mrs A is appropriately
positioned and exposed
for this examination.’
Enquires about pain prior to examining
‘Are you in any pain?’
GENERAL INSPECTION
Performed from the end of the bed
o Comments on
o Patient
o Equipment
On general inspection
Mr/Mrs A appears well,
with normal posture, no
peripheral stigmata of
neurological disease and
no equipment around the
bed.’
• Glasses, enucleation,
hearing aids
• Facial asymmetry, wasting
• Craniotomy/facial scars
• Ptosis, Proptosis, Anisocoria
‘On examination of the
facial nerve, there is no
obvious asymmetry of
the face and there is
no normal power in all
branches of the nerve.
The patient does not
reports a change in
hearing or taste’
Inspection
• R/L facial droop, asymmetry,
loss of nasolabial fold, vesicles
on pinna
Motor
• UMN lesion – Ipsilateral
mouth droop, eye droop, loss
of nasolabial fold, sparing of
forehead and brow muscles
• LMN lesion - Ipsilateral
mouth droop, eye droop,
loss of nasolabial fold, loss of
forehead & brow movements
Sensory
• Taste change anterior 2/3
tongue, vesicles of RamsayHunt - pinna, hyperacusis
CRANIAL NERVE VII
Inspection
• F
or facial droop, asymmetry, loss of
nasolabial fold, vesicles on pinna
Motor
• Temporal- Asks patient to look up and
wrinkle forehead, while pushing forehead
• Z
ygomatic -Asks patient to close eyes tightly
then attempts to force open
• Buccal- Asks patient to blow out cheeks
• M
andibular- Asks patient to show teeth
• C
ervical- Asks patient to tense neck
Sensory
• A
sk about hyperacusis and taste change
RCSI
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N euro l o g i ca l E xa m i n a t i o n
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
‘On examination of the
vestibulocochlear nerve,
there is no evidence of a
hearing impairment.’
Hearing Issue
• Hearing reduced in left /
right ear
CRANIAL NERVE VIII
Establishes if hearing issue
• Asks patient if any problem with hearing
• C
overs one ear and whispers a number into
other ear.
Rinne’s
• B
ase of 512Hz (or 256Hz) tuning fork at
mastoid process until vibration no longer
heard, then fork placed at auditory meatus
and patient asked if sound still heard
Rinne’s
• Vibration note is not
audible at external auditory
meatus, Rinne’s test is
negative (conduction
deafness)
Weber’s
• Sound is heard louder
in the normal earsensorineural deafness
• Sound is heard louder
in the abnormal earconduction deafness
Weber’s
• 5
12Hz (or 256Hz) Tuning fork vibrating in
middle of forehead and asks patient in
which ear sound is louder
CRANIAL NERVE IX & X
• Inspects palate and uvula
• A
sks patient to say “ah”, checks for uvular
deviation
• O
ffers to assess gag reflex
• A
sks about abnormal taste posterior tongue
‘On inspection of the 9th
and 10th cranial nerve, the
uvula is central.’
• Uvular deviation away from
abnormal side
• Absent / exaggerated gag
reflex
• Abnormal taste posterior
tongue
‘On assessment of the
11th cranial nerve, there is
normal symmetry, muscle
bulk and movements of
the sternocleidomastoid
and trapezius muscles.’
Trapezius
• Loss of muscle bulk
• Weakness/reduced power
‘On examination of
the 12th cranial nerve,
there is no wasting or
fasciculations of the
tongue and no deviation
on protrusion.’
• Tongue fasciculations,
wasting – LMN lesion
• Deviation of the tongue
towards the weaker or
affected side
CRANIAL NERVE XI
Trapezius
• Asks patient to shrug shoulders, feels the
bulk of the trapezius muscles and attempt
to push the shoulders down.
Sternomastoids
• Asks patient to turn head against resistance,
feels bulk of sternomastoids opposite side.
Sternomastoids
• Loss of muscle bulk
• Weakness/reduced power
CRANIAL NERVE XII
• Inspects tongue at rest in floor of mouth for
wasting and fasciculations
• Asks patient to stick out tongue, looking for
deviation
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Neurologica l Exa mina t ion
THE RCSI THREE-COLUMN OSCE GUIDE
Neurological Examination - motor examination upper limbs
“This is a neurology station. You have 5 minutes to complete a motor examination of this patient’s
upper limbs. I will then ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level, explains what
he/she will be doing and obtains consent for same
‘Hi my name is X.
I’m a third year
medical student at
RCSI. What’s your
name? Nice to
meet you. I’ve been
asked to examine
your arms today.
That will involve
looking at your
arms, moving them
around, checking
the power, then
testing your coordination and your
reflexes. Would that
be ok?’
Position and exposure
• Patient seated
• Arms and shoulders exposed
‘Mr/Mrs A is
appropriately
positioned and
exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Are you in any
pain?’
GENERAL INSPECTION
Performed from the end of the bed
oInspects for
o Patient
o Equipment
‘On general
inspection Mr/Mrs
A appears well, with
normal posture, no
peripheral stigmata
of neurological
disease and no
equipment around
the bed.’
• Patient
oPosture (hemiplegic
posturing), involuntary
movements, focal
neurological signs
• Equipment
oWalking aids, assistive
devices
RCSI
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Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
‘On closer
inspection of the
upper limbs there
are no stigmata
of neurological
disease. ‘
• Neurocutaneous stigmata
o Scars, ulcers, rashes
• Asymmetry
• Muscles
oWasting/hypertrophy, R/L
_x_
• Abnormal movements
• Fasciculations, myoclonic
‘There is no
evidence of
drifting’
‘There was drifting present on
the left/right.’
CLOSER INSPECTION
Performed from right hand side of bed
• Inspects for
o Symmetry
o Muscles
o Abnormal movements
DRIFT
• Asks the patient to
o hold out both hand, arms extended
o eyes closed
• Watches for drifting
• Upper motor neuron lesion
– the drifting of the limb is
due to muscle weakness.
The drifting downwards
starts distally with the
fingers and spreads
proximally.
• Cerebellar disease – the
drift is due to hypotonia
and is usually upwards.
• Loss of proprioception –
the drift is due to loss of
joint position sense and can
be in any direction.
TONE
• T
akes hand as if to shake while holding forearm.
• P
ronates and supinates forearm.
• R
olls hand at wrist.
• H
olds forearm and elbow and moves arm through
full range of flexion and extension at elbow.
‘Tone is normal
bilaterally’
‘Tone is increased/decreased
on the right/left side at the
shoulder/elbow/wrist’
• Tone increased hypertonic, as in an upper
motor neuron lesion.
• Tone decreased hypotonic, as in a lower
motor neuron lesion
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Neurologica l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
POWER
‘Power is 5/5
Shoulder
throughout.’
Abduction - With the elbows flexed ask the patient to
abduct the arms. The patient should resist the examiner
pushing them down.
Adduction - The patient should adduct the arms with the
elbows flexed. The patient should resist the examiner
separating them.
Elbow
Flexion - Ask the patient to bend the elbows and not to
let you straighten it.
Extension - With the elbow bent ask the patient to
straighten the elbow and not to let you bend it.
Wrist
Flexion - Ask the patient to flex the wrist and not to let
you straighten it.
Extension - Ask the patient to extend the wrist and not to
let you bend it.
Fingers
Flexion - The patient squeezes two of the examiner’s
fingers.
Extension - The patient should straighten the fingers and
not allow the examiner to push them down.
Abduction - The patient should spread the fingers and
not allow the examiner to push them together.
Adduction - Place a piece of paper between the patient’s
fingers and they should stop examiner pulling it out.
‘Power is reduced to x/5 on left/
right _joint_ _movement(s)_’
CO-ORDINATION
Rebound
• Asks the patient to lift rapidly the arms from the sides
and then stop.
Finger-nose test
• Asks the patient to touch their nose with their index
finger and then to touch the examiner’s outstretched
finger at nearly full extension.
• Test should be done several times with the patient’s
eyes open and then closed.
Dysdiadochokinesis
• Asks the patient to pronate and supinate their
hand on the dorsum of the other hand as rapidly as
possible.
‘Co-ordination is
normal.’
Finger Nose Test
1] Intention tremor [cerebellar
disease].
2] Past-pointing [cerebellar
disease]
Dysdiadochokinesis
Slow and clumsy movement
[cerebellar disease]
‘Reflexes are
present bilaterally,
and of normal
character’
‘The biceps/triceps/
brachioradialis reflex/all reflexes
on the right/left was/were…..’
• Absent (0)
• Reduced (+)
• Normal (++)
• Exaggerated (+++)
• Exaggerated with clonus
(++++)
REFLEXES
• Ensures patient is resting comfortably
• Uses whole length of hammer & allows hammer to
swing through arc
• Compares like with like
• Biceps, Triceps & Brachioradialis
• Uses reinforcement (Jendrassik manoeuvre) if needed
RCSI
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N euro l o g i ca l E xa m i n a t i o n
THE RCSI THREE-COLUMN OSCE GUIDE
Neurological Examination - sensory examination upper limbs
“This is a neurology station. You have 5 minutes to complete a sensory examination of this patient’s
upper limbs. I will then ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level, explains
what he/she will be doing and obtains
consent for same
‘Hi my name is X. I’m
a third year medical
student at RCSI. What’s
your name? Nice to meet
you. I’ve been asked
to examine your arms
today. That will involve
checking the sensation of
the arms using different
equipment. Would that
be ok?’
Position and exposure
• Patient seated
• Arms and shoulders exposed
‘Mr/Mrs A is
appropriately positioned
and exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Are you in any pain?’
GENERAL INSPECTION
Performed from the end of the bed
oInspects for
o Patient
o Equipment
On general inspection
Mr/Mrs A appears well,
with normal posture, no
peripheral stigmata of
neurological disease and
no equipment around
the bed.’
• Patient
o Posture (hemiplegic
posturing), involuntary
movements, focal
neurological signs
• Equipment
o Walking aids, assistive
devices
‘On closer inspection
of the upper limbs
there are no stigmata
of neurological disease,
such as asymmetry or
abnormal movements‘
• Neurocutaneous stigmata
o Scars, ulcers, rashes
• Asymmetry
• Muscles
o Wasting/hypertrophy,
R/L _x_
• Abnormal movements
o Fasciculations, myoclonic
jerks, dystonia, chorea,
athetosis, ballism, tics
CLOSER INSPECTION
Performed from right had side of the bed
• Inspects for
o Neurocutaneous stigmata
o Symmetry
o Muscles
o Abnormal movements
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Neurologica l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
‘Soft touch is normal
bilaterally.’
‘Sensation is reduced/absent
on the right/left/both arms
in the ‘X’ dermatome when
assessing soft touch’
SOFT TOUCH
• U
ses cotton wool
• D
emonstrates at sternum
• P
roceeds to assess each dermatome on both
upper limbs, patient’s eyes closed
C5 – Deltoid patch
C6 – tip of thumb
C7 – tip of middle finger
C8 – tip of little finger
T1 – medial aspect of forearm/elbow
• P
atient to say yes when feels touch
• S
tudent to ask if there is a difference in sensation
between the arms or from the sternum
Or
‘Sensation is reduced/
absent in a non-dermatomal
distribution on the right/left/
both arms when assessing
soft touch’
SHARP TOUCH
'Sharp touch is normal
• U
ses neurotip
bilaterally.’
• D
emonstrates at sternum
• P
roceeds to assess each dermatome on both
upper limbs, patient’s eyes closed
• P
atient to say yes when feels touch
• S
tudent to ask if difference in sensation
between the arms or versus sternum
• If sensation is impaired, assesses for nondermatomal distribution Starts at fingers, moves proximally at 5cm
intervals, crossing dermatomes, assesses if
impaired sensation persists as dermatomes are
crossed, attempts to map out dullness by moving
vertical/ horizontally to normal area
‘Sensation is reduced/absent
on the right/left/both arms
in the ‘X’ dermatome when
assessing sharp touch’
Or
‘Sensation is reduced/
absent in a non-dermatomal
distribution on the right/left/
both arms when assessing
sharp touch’
VIBRATION
• B
ase of vibrating tuning fork placed on
'Vibration sense is normal
sternum and questions if vibration/buzzing can bilaterally.’
be felt by patient
• A
sks patient to close eyes and tell examiner
when vibration/buzzing stops
• P
roceeds to test along the arms and ask if
vibration/buzzing felt and when stops
• S
tarts at the base of thumb and if abnormal
proceeds to ulnar head at wrist, olecranon at
elbow, acromion at shoulder
‘Vibration sense is impaired
or lost to the level of thumb/
wrist/elbow/shoulder, on the
left/right/both arms.’
PROPRIOCEPTION
• G
rasps distal phalanx thumb from sides
• F
lexes and extends the distal phalanx of
thumb, demonstrating which position is up &
down to patient
• A
sks patient to close their eyes
• R
epeats flexion/extension and asks patient
position (Up or down?)
• If abnormal proceeds to test as follows:
o Wrists: flexion/extension
o Elbow: flexion/extension
‘Proprioception is normal
bilaterally.’
‘Proprioception is impaired
to the level of the finger/
wrist/elbow, on the left/right/
both arms.’
RCSI
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N euro l o g i ca l E xa m i n a t i o n
THE RCSI THREE-COLUMN OSCE GUIDE
Neurological Examination - Motor examination Lower limbs
“This is a neurology station. You have 5 minutes to complete a motor examination of this patient’s lower
limbs. I will then ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level, explains
what he/she will be doing and obtains
consent for same
Hi my name is X. I’m
a third year medical
student at RCSI. What’s
your name? Nice to meet
you. I’ve been asked to
examine your legs today.
That will involve looking
at your legs, moving
them around, checking
the power, then testing
your co-ordination and
your reflexes. Would that
be ok?’
Position and exposure
• Patient at 45 degree angle
• Legs exposed from mid-thigh
‘Mr/Mrs A is
appropriately positioned
and exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Are you in any pain?’
GENERAL INSPECTION
Performed from the end of the bed
oInspects for
o Patient
o Equipment
‘On general inspection
Mr/Mrs A appears well,
with normal posture, no
peripheral stigmata of
neurological disease and
no equipment around
the bed.’
o Patient
o Abnormal posture/
movements, focal neuro
• Equipment
o Walking aids, assistive
devices
‘On closer inspection
of the lower limbs there
are no stigmata of
neurological disease,
such as asymmetry or
abnormal movements‘
• Asymmetry
• Muscles
o Wasting/hypertrophy,
R/L _x_
• Abnormal movements
o Fasciculations, myoclonic
jerks, dystonia, chorea,
athetosis, ballism, tics
CLOSER INSPECTION
Performed from right hand side of bed
• Inspects for
o Neurocutaneous stigmata
o Symmetry
o Muscles
o Abnormal movements
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Neurologica l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
TONE
• Encourages patient to relax
• P
laces hands above and below the patient’s
knee and rocks the leg back and forth,
observing the foot
• P
laces hands under the knee and passively
flexes/extends knee joint
• C
heck for ankle clonus
oHolds leg, rolls ankle then sharply
dorsiflexes foot, holds & observes
‘Tone is normal bilaterally,
with no evidence of ankle
clonus.’
‘Tone is increased/decreased
on the right/left side at the
hip/knee/ankle’
• Tone increased hypertonic +/- clonus, as
in an upper motor neuron
lesion.
• Tone decreased hypotonic, as in a lower
motor neuron lesion
POWER
• A
ttempt to isolate the joints
• C
ompares like with like
Hip
Flexion – Asks the patient to raise straight leg,
resisting movement by pushing down above the
patient’s knee.
Extension – Asks the patient to maintain their
leg in extension flat on bed and not allow
examiner to pull the leg up.
Abduction – Asks the patient to move the leg
to the side, from the midline, and not allow the
examiner to push it back in.
Adduction – Asks the patient to keep the legs
together and not allow the examiner to separate
them
Knee (isolates by placing hand on hip/thigh)
Flexion – Asks the patient to bend the knee and
not allow it to be straightened
Extension – With the knee bent, asks the patient
to straighten it and not allow it to be bent
further
Ankle (isolates by placing hand on distal leg)
Plantarflexion – Asks the patient to planterflex
foot against resistance
Dorsiflexion – Asks the patient to dorsiflex the
foot against resistance
Inversion – Asks the patient to invert the foot
against resistance
Eversion – With the foot in complete
plantarflexion, asks the patient to evert the foot
against resistance
Toes (isolates by holding foot)
Plantarflexion – Asks the patient to plantar flex
the big toe against resistance
Dorsiflexion – Asks the patient to bring the big
toe up against resistance
‘Power is 5/5 throughout.’
‘Power is reduced to
x/5 on left/right _joint_
_movement(s)_’
0/5 Complete paralysis
1/5 Flicker of contraction
2/5 Movement possible
without gravity
3/5 Movement possible with
gravity
4/5 Movement possible with
gravity & resistance
5/5 Normal power
RCSI
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N euro l o g i ca l E xa m i n a t i o n
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
‘Co-ordination is normal
bilaterally.’
Co-ordination was impaired
on the right/left side’
CO-ORDINATION
Compares like with like
Toe-finger test
• A
sks patient to raise the foot with knee bent
and touch finger with their big toe.
Heel-shin test
• A
sks patient to place their heel on the
opposite knee and then slide the heel down
the front of the shin to the ankle.
• T
hen lift the heel off the leg and place it back
on the knee.
• R
epeat the movement a number of times and
then on the opposite side.
Foot-tapping test
• A
sks the patient to tap the sole of the foot
quickly on the examiner’s hand
Toe finger test
1] Intention tremor
[cerebellar disease].
Heel-shin test
1] Slow and clumsy
movement [cerebellar
disease]
2] Missing the target
[cerebellar disease]
Foot-tapping test
1] Loss of rhythmicity/
dysdiadochokinesis
[cerebellar disease]
REFLEXES
• Ensures patient is resting comfortably
• U
ses whole length of hammer & allows
hammer to swing
• C
ompares like with like
• A
nkle & knee reflexes
• U
ses reinforcement (Jendrassik manoeuvre) if
needed
• P
lantar reflex assessed with a blunt object
along the lateral border of foot
‘Reflexes are present
bilaterally, and of normal
character, with both
plantar reflexes down
going’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
‘The ankle/knee reflex/all
reflexes on the right/left
was/were…..’
• Absent (0)
• Reduced (+)
• Normal (++)
• Exaggerated (+++)
• Exaggerated with clonus
(++++)
Plantar reflex on the right/
left/both were upgoing
(Babinski response)
indicating UMN lesion
Neurologica l Exa mina t ion
THE RCSI THREE-COLUMN OSCE GUIDE
Neurological Examination - Sensory examination lower limbs
“This is a neurology station. You have 5 minutes to complete a sensory examination of this patient’s
lower limbs. I will then ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal
Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level, explains what
he/she will be doing and obtains consent for same
‘Hi my name is X.
I’m a third year
medical student
at RCSI. What’s
your name? Nice
to meet you. I’ve
been asked to
examine your legs
today. That will
involve checking
the sensation of the
legs using different
equipment. Would
that be ok?’
Position and exposure
• Patient at 45 degree angle
• Legs exposed from mid-thigh
‘Mr/Mrs A is
appropriately
positioned and
exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Are you in any
pain?’
GENERAL INSPECTION
Performed from the end of the bed
o Inspects for
o Patient
o Equipment
‘On general
inspection Mr/Mrs
A appears well, with
normal posture, no
peripheral stigmata
of neurological
disease and no
equipment around
the bed.’
• Patient
oPosture (hemiplegic
posturing), involuntary
movements, focal
neurological signs
• Equipment
oWalking aids, assistive
devices
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N euro l o g i ca l E xa m i n a t i o n
Examination
Expected/
Normal
Comments
Potential/Abnormal
Comments
‘On closer
inspection of the
lower limbs there
are no stigmata
of neurological
disease.
• Neurocutaneous stigmata
o Scars, ulcers, rashes
• Asymmetry
• Muscles
o Wasting/hypertrophy,
R/L _x_
• Abnormal movements
o Fasciculations, myoclonic
jerks, dystonia, chorea,
athetosis, ballism, tics
‘Soft touch is
normal bilaterally.’
‘Sensation is reduced/absent
on the right/left/both legs
in the ‘X’ dermatome when
assessing soft touch’
CLOSER INSPECTION
Performed from right had side of the bed
• Inspects for
o Neurocutaneous stigmata
o Symmetry
o Muscles
o Abnormal movements
SOFT TOUCH
• Uses cotton wool
• Demonstrates at sternum
• P
roceeds to assess each dermatome on both lower
limb, patient’s eyes closed
• P
atient to tell student when they feel something by
saying yes
• S
tudent to ask if difference in sensation between
the legs or versus sternum
Or
‘Sensation is reduced/
absent in a non-dermatomal
distribution on the right/left/
both legs when assessing soft
touch’
SHARP TOUCH
• Uses cotton wool
• Demonstrates at sternum
• P
roceeds to assess each dermatome on both lower
limb, patient’s eyes closed
L1 – upper anterior groin area
L2 – upper anterior thigh
L3 – area around the front of the knee
L4 – medial aspect of leg
L5 – lateral aspect of leg and medial side of the
dorsum of the foot
S1 – heel of the foot
• Patient to say yes when feels touch
• S
tudent to ask if difference in sensation between
the legs or versus sternum
• If sensation is impaired, assesses for nondermatomal distribution Starts at toes, moves proximally at 5cm intervals,
crossing dermatomes, assesses if impaired sensation
persists as dermatomes are crossed, attempts to
map out dullness by moving vertical/ horizontally to
normal area
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‘Sharp touch is
normal bilaterally.’
‘Sensation is reduced/absent
on the right/left/both legs
in the ‘X’ dermatome when
assessing sharp touch’
Or
‘Sensation is reduced/
absent in a non-dermatomal
distribution on the right/left/
both legs when assessing
sharp touch’
Neurologica l Exa mina t ion
Examination
Expected/
Normal
Comments
Potential/Abnormal
Comments
‘Vibration sense is
normal bilaterally.’
‘Vibration sense is impaired or
lost to the level of toe/ankle/
knee/hip, on the left/right/
both legs.’
‘Proprioception is
normal bilaterally.’
‘Proprioception is impaired
to the level of the toe/ankle/
knee, on the left/right/both
legs.’
VIBRATION
• Uses 128Hz tuning fork
• B
ase of vibrating tuning fork placed on sternum
and questions if vibration/buzzing can be felt by
patient
• A
sks patient to close eyes and tell examiner when
vibration/buzzing stops
• P
roceeds to test along the legs and ask if vibration/
buzzing felt and when stops
• S
tarts at the base of the 1st toe along the medial
aspect and if abnormal proceeds to lateral
malleolus, tibial tuberosity, ASIS, costal margin
PROPRIOCEPTION
• Grasps distal phalanx hallux from sides
• F
lexes and extends the distal phalanx of the 1st
toe, demonstrating which position is up & down
to patient
• Asks patient to close their eyes
• R
epeats flexion/extension and asks patient
position (Up or down?)
• If abnormal proceeds to test as follows:
o Ankle: plantar/dorsiflexion
o Knee: flexion/extension
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219
CHAPTER 10
MUSCULOSKELETAL
EXAMINATION
PRINCIPLES OF ASSESSMENT
HAND AND WRIST
E X A M I N AT I O N
E L B O W E X A M I N AT I O N
S H O U L D E R E X A M I N AT I O N
S P I N A L E X A M I N AT I O N
H I P E X A M I N AT I O N
K N E E E X A M I N AT I O N
ANKLE AND FOOT
E X A M I N AT I O N
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Musculoskeleta l Exa mina t ion
PRINCIPLES OF ASSESSMENT
It is important to listen carefully to your examiner when asked to perform an assessment
of a limb. Is the question to assess the limb from a rheumatological, neurological,
trauma or combined perspective?
In day-to-day practice, it is wise to examine any limb from all perspectives, as pathology
in one aspect of a limb’s physiology may adversely affect function in any other system.
This would include a complete rheumatology/orthopaedic (specifically offer to examine
the joint above and below), neurological and vascular assessment. For this reason, it
is imperative to understand the instructions given in an examination situation, as a full
assessment would be difficult to perform in the time allowed in exam conditions.
This chapter will look at examination from a rheumatological and orthopaedic
perspective. The vascular and neurological examination of the limbs and spine can be
found in the associated chapters in this handbook.
RHEUMATOLOGY HISTORY – PRESENTING SYMPTOMS
Major Symptoms:
Associated Symptoms
Joints
• Pain
• Swelling
• Stiffness - Morning
• Loss of function
• Deformity
Eyes
• Dry eyes
• R
ed eyes
Back Pain
Muscle Pain
• Atrophy
Mouth - Xerostomia
Raynaud’s Phenomenon Rashes and
ulcers
Note: The rheumatological system can be examined using the GALS method
Gait / Arms / Legs / Spine
Gait
• Are there mobility aids or adaptations in use?
•Assess for signs of an antalgic (painful) gait, both in the mechanics of the gait and
in the expression of the patient
• Observe the patient transferring from sitting to standing
o Are there difficulties in reaching standing?
o Is there a need for mobility aids?
o Does the patient bias a particular side?
• Ask the patient to walk to the end of the room and back to you. Take note of:
o Stance
o Stride length
o Smoothness of swing phase
o Heel strike and Arm swing
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H A N D A N D W R I S T E X A M I N AT I O N
Introduction
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position the patient appropriately
oThe patient should sit on the edge of a bed, hands resting, palms down, on a
pillow or on a table
o You should be able to see to the elbow bilaterally
Examination
•
•
Always remember to LOOK, FEEL & MOVE the affected region
Compare right with left
LOOK:
• Redness or erythema over a joint suggesting inflammation
o Arthritis or infection
• Swelling
o Effusions from fluid in the joint capsule
o Inflammation of the synovium
o Bony swelling
– Heberden’s nodes at the base of the DIP
– Bouchard’s nodes on the PIP
• Deformity
o Deviation of the joint from its normal biomechanical axis
– E.g., Ulnar deviation of the wrist in Rheumatoid arthritis
– Swan neck or Z-thumb
• Subluxation or dislocation
oThe articular surfaces of the joint become displaced (subluxation) prior to
losing contact (dislocation)
• Scarring
o Previous surgery to the joint
• Atrophy
oWasting of the associated musculature
• Nail and Skin changes
o Look for rashes such as psoriasis or vasculitis
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
PSORIASIS:
VASCULITIS:
Psoriasis arthropathy - Sausage fingers
Linear haemorrhages
Nail Changes:
Purpritic rashes
•
•
•
•
• Non-blanching
•Non-tender
Pitting
Oncholysis
Hyperkeratosis and ridging
Discolouration
Both associated with RA
FEEL:
• U
sing both hands feel for the patient’s wrists for calor and tumor associated with
effusions and infection
• P
alpate the both the dorsal and ventral surfaces for synovitis
• T
henar and hypothenar eminence
o Wasting is noted in ulnar/median nerve lesions
• Palmar thickening
o Dupuytren’s contracture
– Familial
– Alcohol excess
– Occupational exposure to vibration or excessive grip
• Palpate the radial & ulnar pulse
o Is there adequate supply to the hand?
• Palpate the joints of the hand
o Assess for tenderness / irregularities / warmth
• Palpate the anatomical snuffbox
MOVE:
It is important to note that active movements assessing joint, muscle, tendon, and
nerves; passive movements assessing joint mostly; resisted movements assessing
muscle, tendon, and nerves
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ASSESSING ACTIVE RANGE OF MOVEMENT (AROM)
Wrist extension
- Put palms of your hands together and bring your elbows as high as they will go
Wrist flexion
- Put backs of your hands together and bring your elbows down to the floor
Radial deviation
- Place your palms on the table, keeping your arm still and point your middle
finger towards the midline
Ulnar deviation
- Place your palms on the table, keeping your arm still and point your middle
finger away from the midline
Finger flexion and adduction
- Make a fist
Finger extension and abduction
- Open your fist and splay your fingers
- Trigger finger from sclerosing tenosynovitis will limit extension
Thumb movements
- Flexion / extension / opposition / abduction / adduction / circumduction
•
Now assess Passive ROM (PROM), feeling for:
o Crepitus
o End feel
– Boggy - Synovial inflammation
– Hard - Bone on bone contact e.g., Rheumatoid or Osteoarthritis
– Soft - Muscle on muscle
– None - Subluxation or dislocation
Functional assessment
•Resist movement in the movements listed above and grade muscle power
using the Oxford Scale (0-5)
• Assess grip strength by asking the patient to squeeze 2 of your fingers
•Assess Pincer strength by asking the patient to oppose the thumb and little
finger and resisting you pulling them apart
•Assess Opposition strength by asking the patient to oppose the thumb and
little finger and resisting you pulling them apart
•Ask the patient to perform a functional task e.g., pick up a pen and write a
sentence or open a button
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
OXFORD GRADING OF POWER
5
Full power against resistance
4
Power against some resistance
3
Able to move against gravity but unable to move against resistance
2
Movement possible if gravity eliminated
1
Flicker of contraction possible
0
No movement
Special tests
•
Perform Finkelstein’s test
o Tuck the thumb into a closed fist and quickly bring the wrist into ulnar deviation
– Pain in the tendons of the thumb suggest DeQuervain’s tenosynovitis
Completion
•
Suggest a neurovascular assessment of the hand and wrist
•
Examine the elbow
•
Thank the patient
•
Summarise your findings
Typical ROM
WRIST
THUMB
Flexion / Extension
0 - 75° / 0 - 75°
Flexion / Extension
0 - 75° / 0 - 75°
Radial deviation
0 - 20°
Radial deviation
0 - 20°
Ulnar deviation
0 - 35°
Ulnar deviation
0 - 35°
Pronation
0 - 75°
Pronation
0 - 75°
Supination
0 - 80°
Supination
0 - 80°
FINGERS
MPJ Flexion
0 - 90°
MPJ Hyperextension
0 - 45°
PIP Flexion
0 - 100°
DIP Flexion
0 - 80°
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E L B O W E X A M I N AT I O N
Introduction
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position the patient appropriately
o The patient should sit on the edge of a bed
o You should be able to see the entire upper limb bilaterally
Examination
•
•
Always remember to LOOK, FEEL & MOVE the affected region
Compare right with left
LOOK:
•Ask the patient to stand with their arms hanging by their side. Inspect the limb
and elbow from the front, from the side and from behind. A normal carrying angle
is 5 - 15°
• Redness or erythema over a joint suggesting inflammation
o Arthritis or infection
o Psoriatic plaques
– Well defined pink, scaly lesions
• Swelling
o Bursitis
o Effusions from fluid in the joint capsule
o Rheumatoid nodules
– Typically posterior on the olecranon
• Deformity
o Fixed flexion deformity of the biceps
• Scarring
o Previous surgery to the joint
• Atrophy or hypertrophy of the associated musculature
FEEL:
•Using both hands feel for the patient’s elbow for calor and tumor associated with
effusions and infection.
• Palpate both the bony prominences in the joint for tenderness
o Medial and lateral epicondyles
o Olecranon
• Palpate the joint lines
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
MOVE:
•Assess active range of movement (AROM) first, the patient may stand or sit for this
exam
ASSESSING AROM OF ELBOW
Elbow extension (0 - 140°)
- Straighten your arms
Elbow flexion (0°)
- Bring your palms to your shoulders
Forearm Pronation (0 - 75°)
- Place your hands out, palms down
Forearm Supination (0 - 80°)
- Turn your palms upwards
Now assess Passive ROM (PROM), feeling for:
o Crepitus
o End feel
– Boggy - Synovial inflammation
– Hard - Bone on bone contact e.g., Rheumatoid or Osteoarthritis
– Soft - Muscle on muscle
– None - Subluxation or dislocation
•Assess power and grade according to the Oxford rating system as in the wrist and
hand examination.
•
SPECIAL TESTS
•
•
Assess for medial and lateral epicondylitis
o MEDIAL (Golfer’s Elbow)
–Passively extend the elbow, supinate the forearm and extend the wrist and
fingers
– Positive: Reproduction of pain
o LATERAL (Tennis Elbow)
–Passively extend the elbow, pronate the forearm and flex the wrist and
fingers while palpating the lateral epicondyle
– Positive: Reproduction of pain
Assess for ligamentous laxity
o VARUS stress test – Lateral collateral ligament
– Stabilize the upper arm, elbow in 20° flexion and humerus in medial rotation
– Apply a VARUS / Adduction force to the forearm
– Positive: Excessive laxity / pain
o VALGUS stress test – Medial collateral ligament
– Stabilize the upper arm, elbow in 20° flexion and humerus in lateral rotation
– Apply a VALGUS / Abduction force to the forearm
– Positive: Excessive laxity / pain
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Completion
•
•
•
Suggest a full neurovascular assessment of the upper limb
Thank the patient
Summarise your findings
S H O U L D E R E X A M I N AT I O N
Introduction
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position the patient appropriately
o The patient should sit on the edge of a bed or stand if comfortable
o The patient should be exposed to the waist
Examination
•
•
Always remember to LOOK, FEEL & MOVE the affected region
Compare right with left
LOOK:
•Ask the patient to stand with their arms hanging by their side - inspect the limb
from the front, from the side and from behind
o Ask the patient to lean against a wall and assess for winging of the scapula
– Winging suggests damage to long thoracic nerve
• Redness or erythema
• Swelling
o Only very large effusions will be seen
• Deformity
o Sulcus sign
o Bony asymmetry
• Scarring
• Atrophy or hypertrophy of the associated musculature
FEEL:
•Using your hands, feel the patient’s shoulder for calor and tumor associated with
effusions and infection
• Palpate the bony prominences in shoulder girdle for tenderness
o Start medially at the SC joint
o Palpate along the clavicle to the AC joint and on to the acromion
o Palpate the spine of the scapula
o Finish by assessing the glenohumeral joint
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
•
•
Assess the muscles of the girdle for tenderness
Palpate the axilla for masses or tenderness
MOVE:
• Assess active range of movement (AROM) first
ASSESSING AROM OF SHOULDER
Shoulder extension (0 - 60°)
- Bend your arm at your elbow and push backwards
Shoulder flexion (0 - 160°)
- Bring your arm forwards and over your head as far as possible
Shoulder abduction (0 - 170°)
- Bring your hand out from your side and over your head if possible
Shoulder adduction (0 - 45°)
- Place your arm in front of yourself and bring your hand across your midline
Shoulder internal rotation (0 - 70°)
- Abduct your arm to 90°, bend your elbow 90°. Point your hand as far to the
floor as possible
Shoulder external rotation (0 - 90°)
- Abduct your arm to 90°, bend your elbow 90°. Point your hand as far behind
you as possible
•
Now assess passive ROM (PROM), feeling for:
o Crepitus
o End feel
– Boggy - Synovial inflammation
– Hard - Bone on bone contact e.g., Rheumatoid or Osteoarthritis
– Soft - Muscle on muscle
– None - Subluxation or dislocation
Functional assessment
•Resist movement in the movements listed above and grade muscle power using
the Oxford Scale (0-5)
• Ask the patient to perform a functional task:
oPut your hand behind your head as if brushing your hair and see how far you
can reach along your spine
o Put your hands behind your back and reach upwards as far as possible
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OXFORD GRADING OF POWER
5
Full power against resistance
4
Power against some resistance
3
Able to move against gravity but unable to move against resistance
2
Movement possible if gravity eliminated
1
Flicker of contraction possible
0
No movement
SPECIAL TESTS
Apprehension test – Anterior shoulder instability
o Place the patient supine. Abduct the shoulder gently to 90°
o Gently add lateral rotation
o Positive: Apprehension
• Sulcus sign – Inferior shoulder instability
o Patient standing or sitting with their arm by their side
o Grip the elbow at the condyles and pull distally
o Positive: Sulcus appears under the acromion / pain / apprehension
• Hawkins-Kennedy Impingement test – Impingement of supraspinatus tendon
o Patient sitting. Shoulder to 90° forward flexion
o Flex the elbow to 90°
o Gently add passive medial rotation
o Positive: Reproduction of symptoms
• Scarf test – AC Joint pathology
o Place the arm to be examined across the chest to the contralateral shoulder
oThe examiner then pushes the arm into further adduction, mimicking throwing
a scarf over the shoulder
o Positive: Pain over the AC joint
• Speeds test – Bicep tendon pathology
oSitting or standing, ask the patient to flex their shoulder with the elbow extended
and the forearm supinated
o The examiner then resists shoulder flexion
o Positive: Pain in the bicipital groove
• Empty can test – Supraspinatus tendon or subscapular nerve pathology
oSitting or standing, flex the shoulder to 90°, abduct to 30° and point the
patient’s thumbs downwards
o Resist further abduction of the shoulder
o Positive: Pain or weakness
•
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
•
Lift off test (Gerber’s) – Subscapularis dysfunction
o Place the dorsum of the hand against the mid-lumbar region
oThe patient is asked to lift the hand from the back against resistance (from the
examiner)
o Positive: Inability to lift the hand from the back
Completion
• Suggest a full neurovascular assessment of the upper limb
•Thank the patient and assist dressing if requested or required, ensuring consent
for assistance has been obtained
• Summarise your findings
S P I N A L E X A M I N AT I O N
Introduction
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position the patient appropriately
o The patient should stand if comfortable
o The patient should be exposed to the waist and wearing shorts if possible
Examination
•
Always remember to LOOK, FEEL & MOVE the affected region
LOOK:
• Are there mobility aids or adaptations in use? Front
• Look at the patient’s posture
• Look for symmetry in the clavicles and shoulders
Side
• Assess for cervical lordosis / thoracic kyphosis / lumbar lordosis
o Normal thoracic kyphosis is 20-45°
Behind
• Scarring from previous surgery
• Scoliosis
o Lateral curvature of the spine, C or S-shaped
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CAUSES OF SCOLIOSIS
Congenital
Neuromuscular or myopathic
•Spina Bifida / Cerebral palsy / muscular dystrophy / neurofibromatosis / spinal
muscle atrophy / Marfans / Ehlers-Danlos
Degenerative scoliosis
• Trauma / previous surgery
Idiopathic scoliosis
•Infantile affected at birth or < 3 years
• Juvenile 3-9 years
• Adolescent 10-18 years old
• Adult > 18 years
FEEL:
•Feel along the length of the spine. Palpating the spinous processes to assess for
pain.
Ask regularly if they are experiencing pain
• Palpate the sacroiliac joints
• Palpate the paraspinal muscles - assess for wasting or spasm
MOVE:
• Assess active range of movement (AROM)
AROM OF CERVICAL SPINE – PATIENT SITTING OR STANDING
Flexion (0 - 80°)
- Touch your chin into your chest
Extension (0 - 50°)
- Tilt your head up toward the sky
Lateral flexion (0 - 45°)
- Bring your ear to your shoulder
Rotation (0 - 80°)
- Turn your head to the left as far as it can go. Repeat to the other side
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
AROM OF THORACIC SPINE – PATIENT SITTING ON EDGE OF BED
Rotation (0 - 40° each side)
- Cross arms over the chest and ask the patient to turn to one side as far as
they can
- Compare to the other side
AROM OF LUMBAR SPINE – PATIENT STANDING
Flexion (0 - 60°)
- Touch your toes keeping your knees straight
Extension (10 - 20°)
- Lean back as far as you can
Lateral flexion (0 - 30° to each side)
- Slide your hand down the side of your leg as far as possible, keeping your legs
straight - repeat for both sides
Rotation (0 - 80°)
- Turn your head to the left as far as it can go - repeat to the other side
SPECIAL TESTS
•
•
Schober’s test – Assesses ROM in the lumbar spine
o Identify the PSIS - mark the skin 5cm below and 10cm above the PSIS
o Ask the patient to touch their toes
o Measure the distance between the 2 marks which should increase to >20cm
o If < 20cm, consider pathology such as Ankylosing spondylitis
Straight leg raise – Sciatic stretch test (Patient supine on the bed)
o Holding the ankle and keeping the knee straight, passively flex the hip
o Once maximum ROM is reached, dorsiflex the foot
o Positive: Pain in the posterior thigh or buttock indicates compression on the
sciatic nerve
Completion
• Suggest a full neurovascular assessment of all limbs
•Thank the patient and assist with dressing if requested or required, ensuring
consent for assistance has been obtained
• Summarise your findings
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H I P E X A M I N AT I O N
Introduction:
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position the patient appropriately
o The patient should be wearing shorts
Examination
•Always remember to LOOK, FEEL & MOVE the affected region
LOOK:
• Are there mobility aids or adaptations in use?
Front
• Look at the patient’s posture / Scars / Muscle wasting
Side
• Assess for lumbar lordosis
Behind
• Assess for scoliosis / gluteal wasting / pelvic tilt
Gait
•Assess for signs of an antalgic (painful) gait, both in the mechanics of the gait and
in the expression of the patient
• Observe the patient transferring from sitting to standing
o Are there difficulties in reaching standing?
o Is there a need for mobility aids?
o Does the patient bias a particular side?
• Ask the patient to walk to the end of the room and back to you. Take note of:
o Stance
o Stride length
o Smoothness of swing phase
o Heel strike
o Arm swing
o Trendelenburg gait
Trendelenburg pattern: an abnormal gait due to weakness in gluteus medius
and minimus, as caused by a superior gluteal nerve lesion.
FEEL:
•Using your hands feel for the patient’s hip for calor and tumor associated with
inflammation and infection
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
•
•
Palpate the bony prominences (greater trochanter) for tenderness
Measure leg length
o Apparent leg length – From the umbilicus to the medial malleolus bilaterally
o True leg length – ASIS to the tip of the medial malleolus
MOVE:
• Assess active range of movement (AROM)
AROM OF HIP – PATIENT LYING ON BED
Flexion (0 - 120°)
- Flex the knee to 90° and bring the hip towards the patient’s chest
Extension (5 - 20°)
- The patient can lie on their side and push their leg backward
Abduction (0 - 40°)
- Lying supine, bring the leg away from the midline with the knee extended
Adduction (0 - 25°)
- Lying supine, bring the leg across the midline with the knee extended
Internal rotation at 90° flexion (0 - 45°)
- Lying supine, hip flexed to 90°, invert the knee
External rotation at 90° flexion (0 - 45°)
- Lying supine, hip flexed to 90°, evert the knee
•
Now assess for passive ROM (PROM), feeling for:
o Crepitus
o End feel
– Boggy - Synovial inflammation
– Hard - Bone on bone contact e.g., Rheumatoid or Osteoarthritis
– Soft - Muscle on muscle
– None - Subluxation or dislocation
SPECIAL TESTS
•
Thomas’ test – Assesses for fixed flexion deformity in the hips
oPlace the patient supine and place a hand or rolled towel under the lumbar
spine to limit movement
o Passively, fully flex a hip
oObserve the other hip, if it lifts from the bed it suggests a fixed flexion
deformity of that hip
Completion
• Suggest a full neurovascular assessment of the limb
•Thank the patient and assist dressing if requested or required, ensuring consent
for assistance has been obtained
• Summarise your findings
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K N E E E X A M I N AT I O N
Introduction:
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position the patient appropriately
o The patient should be wearing shorts
Examination
•
Always remember to LOOK, FEEL & MOVE the affected region
LOOK:
• Are there mobility aids or adaptations in use? Front
• Look at the patient’s posture / Scars / Quadriceps wasting
•Valgus or Varus deformity
Side
• Assess for hyperextension / Scars
Behind
• Assess for Baker’s cyst / popliteal aneurysm / scars
Gait
•Assess for signs of an antalgic (painful) gait, both in the mechanics of the gait and
in the expression of the patient
• Observe the patient transferring from sitting to standing
o Are there difficulties in reaching standing?
o Is there a need for mobility aids?
o Does the patient bias a particular side?
• Ask the patient to walk to the end of the room and back to you. Take note of:
o Stance
o Stride length
o Smoothness of swing phase
o Heel strike
o Arm swing
o Trendelenburg gait
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
FEEL:
•Using your hands, feel the patient’s knee for calor and tumor associated with
inflammation and infection
• Palpate the bony prominences and joint for tenderness
• Palpate the quadriceps tendon and the patella
o Ensure that the tendon is intact
o Check for crepitus in the patellofemoral joint
• Palpate the tibial tuberosity
o Osgood-Schlatter disease
• Palpate the collateral ligaments for pain
• Examine the popliteal fossa for a Baker’s cyst or popliteal aneurysm
• Measure the circumference of the quadriceps 20cm above the tibial tuberosity
o Compare right with left
• Patellar tap - Assess for large effusions
oEmpty the suprapatellar pouch by sliding your hand from the thigh over the
patella
oKeep your hand in position below the patella and use your other hand to press
down on the patella.
oIf there is an effusion you will feel a distinct tap as the patella touches the femur
• Sweep test - Assess for small effusions
oEmpty the suprapatellar pouch and the medial side of the joint by wiping
upward
o Wipe downwards on the lateral aspect of the joint
o Look for a bulge in the medial aspect of the joint
– The presence of a bulge on the medial side of the joint suggests an effusion
MOVE:
• Assess active range of movement (AROM)
Knee - Patient should lie on a bed
AROM OF KNEE – PATIENT LYING ON BED
Flexion (0 - 140°)
- Flex the knee by bringing the heel towards the backside
Extension (0 - (-10)°)
- Straighten the knees as best as possible
•
Now assess Passive ROM (PROM), feeling for:
o Crepitus
o End feel
– Boggy - Synovial inflammation
– Hard - Bone on bone contact e.g., Rheumatoid or Osteoarthritis
– Soft - Muscle on muscle
– None - Subluxation or dislocation
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Functional assessment
•Resist movement in the movements listed above and grade muscle power using
the Oxford Scale (0-5)
OXFORD GRADING OF POWER
5
Full power against resistance
4
Power against some resistance
3
Able to move against gravity but unable to move against resistance
2
Movement possible if gravity eliminated
1
Flicker of contraction possible
0
No movement
SPECIAL TESTS
•
Anterior and Posterior Drawer
o Flex the patient’s knee to 90°
oInspect for evidence of posterior sag as this can give a false positive anterior
drawer sign
oWrap your hands around the proximal tibia with your fingers around the back
of the knee, thumbs over the tibial tuberosity
o Pull the tibia anteriorly, sharply
– Significant movement suggests anterior cruciate laxity / rupture
o Push the tibia posteriorly
– Significant movement suggests posterior cruciate laxity / rupture
•
Lateral collateral ligament
o Knee flexed to 15°
o Hold the patient’s ankle between your elbow and side
o Place one hand along the medial aspect of the knee
o Place the other hand on the ankle
oPush steadily outward with the hand holding the ankle whilst supplying an
opposite force with the left
oIf the LCL is damaged, your hand may detect the lateral side of the joint
opening up or pain may be reproduced on the lateral aspect of the joint
•
Medial collateral ligament
o Knee flexed to 15°
o Hold the patient’s ankle between your elbow and side
o Place one hand along the lateral aspect of the knee
o Place the other hand on the ankle
oPush steadily inward with the hand holding the ankle whilst supplying an
opposite force with the other hand
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
oIf the MCL is damaged, your hand may detect the medial side of the joint
opening up or pain may be reproduced upon the medial aspect of the joint
•
McMurray’s Test
o Hold the knee fully flexed
o Place one hand over the knee joint and the other on the sole of that foot
oApply a valgus stress to the knee whilst the other hand rotates the leg
externally and extends the knee
o Pain and/or an audible click can indicate a torn medial meniscus
o The lateral meniscus is examined by repeating this process from full flexion
oApply a varus stress to the knee and medial rotation to the tibia prior to
extending the knee
Completion
•
Suggest a full neurovascular assessment of the limb
•Thank the patient and assist dressing if requested or required, ensuring consent
for assistance has been obtained
•
Summarise your findings
A N K L E A N D F O O T E X A M I N AT I O N
Introduction
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose & position the patient appropriately (from the knee down)
Examination
•
Always remember to LOOK, FEEL & MOVE the affected region
LOOK:
• Are there mobility aids or adaptations in use? Front
• Look at the patient’s posture
•Valgus or Varus deformity at the ankle
• Look for hallux valgus
o Bunions at the 1st MCP joint
• Look for calluses
o Indicates abnormal loading in the foot
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M us c u l o s k e l e t a l E xa m i nat io n
Side
• Clawing of the toes
• Look at the longitudinal arch of the foot
Behind
• Assess for Baker’s cyst / popliteal aneurysm / scars / calf muscle bulk
•Integrity of the Achilles tendon and symmetry of muscle bulk
•Valgus or Varus deformity at the ankle
Gait
•Assess for signs of an antalgic (painful) gait, both in the mechanics of the gait and
in the expression of the patient
• Observe the patient transferring from sitting to standing
o Are there difficulties in reaching standing?
o Is there a need for mobility aids?
o Does the patient bias a particular side?
• Ask the patient to walk to the end of the room and back to you. Take note of:
o Stance
o Stride length
o Smoothness of swing phase
o Heel strike
o Is there excessive flexion at the knee
–Increasing ground clearance in foot drop
FEEL:
•Using your hands feel for the patient’s ankle and foot for calor and tumor
associated with inflammation and infection
• Palpate the bony prominences and joint for tenderness
• Palpate the Achilles tendon
o Ensure that the tendon is intact
• Palpate the posterior tibial pulse and the dorsalis pedis pulse
• Palpate the collateral ligaments for pain
• Measure the circumference of the calf muscle 10cm below the tibial tuberosity
o Compare right with left
MOVE:
• Assess active range of movement (AROM)
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
AROM OF ANKLE AND FOOT – PATIENT LYING ON BED
Dorsiflexion (0 – 20°)
- Pull your toe towards your head
Plantarflexion (0 – 50°)
- Point your toes away from yourself as far as possible
Inversion (0 – 25°)
• Turn the sole of your foot towards the midline
Eversion (0 – 35°)
• Turn the sole of your foot away from the midline
Toe flexion and extension
• Assessed by asking the patient to curl their toes and straighten them
Toe Abduction and Adduction
• Spread your toes as far as you can, then actively squeeze them closed
•
•
Now assess Passive ROM (PROM), feeling for:
o Crepitus
o End feel
–
Boggy - Synovial inflammation
–
Hard - Bone on bone contact e.g., Rheumatoid or Osteoarthritis
–
Soft - Muscle on muscle
–
None - Subluxation or dislocation
The interphalangeal joints should be tested individually
o Is there a flexion deformity? Is there pain?
Functional assessment
•Resist movement in the movements listed above and grade muscle power using
the Oxford Scale (0-5)
Special Tests
•
Thompson test
o Does this patient have an intact Achilles tendon?
o Patient positioned prone with feet and ankle joint hanging off the bed.
o Squeeze calf and look for ankle plantarflexion
o Plantarflexion = intact Achilles
•
Anterior Drawer test
oDoes this patient have an attenuated or incompetent anterior talofibular
ligament?
o Stabilize distal tibia and internally rotate the foot slightly
o Apply an anteriorly directed force to the calcaneus
o Anterior translation of the foot occurs with ligamentous laxity
o Compare to the contralateral side
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M us c u l o s k e l e t a l E xa m i nat io n
Completion
• Consider a full neurovascular assessment of the limb
•Thank the patient and assist dressing if requested or required, ensuring consent
for assistance has been obtained
• Summarise your findings
COMMONLY PRESCRIBED MEDICATIONS – RHEUMATOLOGY/MSK AND
DERMATOLOGY
Drug type
Common indications
Examples
Non-steroidal antiinflammatories
Osteoarthritis,
rheumatoid
arthritis, gout,
spondylarthropathies
Ibuprofen, diclofenac, celecoxib,
naproxen
Analgesics
Osteoarthritis,
rheumatoid arthritis,
gout
Paracetamol, codeine, tramadol.
e.g., oxycodone, morphine
Corticosteroids
Rheumatoid
arthritis, polymyalgia
rheumatica, vasculitis,
gout, connective tissue
disease
Prednisolone, methylprednisolone,
hydrocortisone
Conventional
disease modifying
anti-rheumatic
drugs (DMARDs)
Rheumatoid arthritis,
psoriatic arthritis,
systemic lupus
erythematosus (SLE)
Methotrexate, sulfasalazine,
hydroxychloroquine, azathioprine,
cyclophosphamide
(some may be used
in dermatology e.g.,
psoriasis, severe
eczema)
Biologic DMARDs
Rheumatoid arthritis,
psoriatic arthritis,
spondylarthropathies,
vasculitis
(some may be used
in dermatology e.g.,
psoriasis, severe
eczema)
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
TNF-α inhibitors e.g., adalimumab,
infliximab, etanercept
B-Cell Inhibitors e.g., rituximab
Interleukin inhibitors e.g.,
toclizumab
Selective co-stimulation modulators
e.g., abatacept
Musculoskeleta l Exa mina t ion
Drug type
Common indications
Examples
Xanthine oxidase
inhibitors
Gout (chronic)
Allopurinol, febuxostat
Anti-gout agents
Gout (acute)
Colchicine
Calcium channel
blockers
Raynaud syndrome
Nifedipine
Topical
corticosteroids
Eczema/atopic
dermatitis, psoriasis
Hydrocortisone, betamethasone
Topical vitamin D
analogues
Psoriasis
Calcipotriol
Topical coal tar
Psoriasis, eczema,
seborrheic dermatitis
Coal tar
Topical calcineurin
inhibitors
Psoriasis, eczema
Tacrolimus
Antimicrobials
commonly used:
Cellulitis
Flucloxacillin, clindamycin,
cefuroxime, vancomycin
Herpes zoster
Septic arthritis/
osteomyelitis*
*may vary depending
on cultures
Aciclovir, valaciclovir
Flucloxacillin, cefuroxime,
vancomycin
• Please note these do not constitute exhaustive list of medications or indications. Reference texts and/or
drug formularies should always be consulted for comprehensive medication and prescribing information.
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M us c u l o s k e l e t a l E xa m i nat io n
THE RCSI THREE-COLUMN OSCE GUIDE
Musculoskeletal shoulder examination
“This is a surgical station. You have 5 minutes to complete a musculoskeletal shoulder examination. I will
then ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level,
explains what he/she will be doing and
obtains consent for same
'Hi my name is X. I’m
a third year medical
student at RCSI.
What’s your name?
Nice to meet you.
I’ve been asked to
examine your right/left
shoulder today. That
will involve inspecting
shoulder and asking
you to perform specific
movements. Please let
me know if you get any
pain at any time.”
Position and exposure
• Have the patient standing with the
shoulders and torso exposed
‘Mr/Mrs A is
appropriately
positioned and
exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Do you have any pain
in your shoulder?’
GENERAL INSPECTION
o P
erformed from the end of the bed,
with patient standing
o Comments on
o Any aids/splints/casts/slings
o Obvious deformity
‘On general inspection
Mr/Mrs A
Appears well and
comfortable without
any aids. He/she does
not appear to have
any deformity of the
shoulder.”
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Equipment
o Walking stick/frame/wheelchair
Patient
o Arm in sling/ cast/splints
o Holding arm due to pain
Musculoskeleta l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On closer inspection
there are no scars/
swelling/erythema, no
muscle wasting, no
winging of the scapula
or obvious deformity.’
Scars
o Arthroscopy – 3 small scars
around shoulder – anterior,
anterolateral and posterior
positioning
CLOSER INSPECTION
Comments on
o Scars
o Erythema
o Swelling
o Deformity
o Muscle bulk
o S
capula winging – patient performs a
wall push up and examiner observes
from behind
o Alignment
o Anterior (delto-pectoral) –
longitudinal scar – Arthroplasty,
ORIF
o Lateral positioning (latera)l scar –
rotator cuff repair
Other
o Effusion/erythema – noticeable
swelling, redness of joint
o Winging of the scapula –
protrusion of scapula in abnormal
position
o Muscle wasting – deltoid/rotator
cuff
o Clavicle deformity – tenting of
skin over clavicle, bony deformity
along clavicle
o AC joint dislocation – clavicle
separated from acromion, clavicle
superior to acromion
o SC joint dislocation – dislocation
medial end of clavicle, prominent
tender bump
o Asymmetry
PALPATION
• B
ony prominences: SC joint, clavicle, AC
joint, spine of scapula, coracoid process,
humerus
• T
emperature
• p
ain
• C
hecks for effusion/swelling – examiner
should compare patient’s shoulders to
check if obvious swelling or on palpation
around bony prominences
• Deformity
• C
omparison to other shoulder
‘On palpation of the
shoulder joint there
is no bone or joint
line tenderness, no
deformity or muscle
wasting,
temperature is normal
and no large effusion’
• Pain over bony prominences
• Joint tenderness – AC joint
• Crepitus
• Muscle wasting of rotator cuff/
biceps/triceps
• Swelling
• Warm joint – compared to other
shoulder using back of handtemperature increase
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M us c u l o s k e l e t a l E xa m i nat io n
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On assessment of
passive and active
motion of the shoulder
it is normal throughout
and all special tests are
negative.”
• Frozen shoulder – stiff and painful
shoulder
• Rotator cuff pathology e.g
impingement – pain on resisted
motion of abduction and lateral
rotation, painful empty can test,
painful abduction, painful overhead
activity
• AC joint osteoarthritis – Scarf
test positive, pain with resisted
movements.
• Shoulder instability – positive Sulcus
test/ apprehension test
• Subscapularis tear/scapular
instability – positive lift off test
MOVE AND SPECIAL TESTS
•A
ctive and passive movement
o Flexion- move arm anteriorly away from
body
o Extension- move arm posteriorly
o Abduction – move arm laterally
o Adduction- move arm medially, across the
body
o Lateral/external rotation – flex elbow to
90 degrees, keep arm at side and move
forearm laterally
o Medial/internal rotation – flex elbow to
90 degrees, keep arm at side and move
forearm medially/across body
• Check for pain throughout arc – check
which of active passive movements cause
pain
• Jobe’s test (Empty can test) – abduction
of shoulder to 90 degrees, horizontally
adduct to 30 degrees and internal rotation
of arm (emptying imaginary can). Examiner
attempts to resist further abduction.
• Scarf Test – examiner places patients hand
on opposite shoulder as if positioning a
scarf
• Lift off test – in maximal internal rotation of
shoulder – resist lift off of hand from back.
• Apley’s scratch test – examiner asks patients
to reach overhead and reach behind neck
to touch opposite scapula, examiner then
asks patient to put hand on lower back and
reach upwards as far as possible towards
opposite scapula.
• Apprehension test – examiner puts patients
arm in 90 degrees abduction, slowly
laterally rotate arm checking for signs of
pain
• Instability test (Sulcus test) – examiner
applies gentle downward traction at
patients elbow joint
CONCLUDING REMARKS
• Imaging – X-ray (further exam with CT/
MRI if needed)
• Examination of joint above & below
• Offer to assess distal pulses & perform
neurological exam
• Washes hands
• Thanks patient
‘To conclude this
exam I would
perform a upper limb
neurological exam and
assess the radial pulse.
I would also examine
the C-spine and elbow
joint, and order an AP
& lateral x-ray of the
shoulder joint’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Musculoskeleta l Exa mina t ion
THE RCSI THREE-COLUMN OSCE GUIDE
Musculoskeletal hip examination
“This is a surgical station. You have 5 minutes to complete a musculoskeletal hip examination. I will then
ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level,
explains what he/she will be doing
and obtains consent for same
Hi my name is X. I’m
a third year medical
student at RCSI. What’s
your name? Nice to
meet you. I’ve been
asked to examine your
hip today. That will
involve inspecting your
gait while walking, and
then examining your leg
including moving it while
lying on the table.’
Position and exposure
• Patient positioned lying flat on the
examination bed and lower limb
exposed, i.e., in shorts
‘Mr/Mrs A is
appropriately positioned
and exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Do you have any pain in
your hip, groin, back or
knee?’
LOOK
• Performed from the end of the bed,
with patient standing and while
walking
o Comments on
o Any walking aids
o Asymmetry
o Varus – oblique displacement of the
joint towards the midline
o Valgus - oblique displacement of the
joint away from the midline
oT
rendelenburg Gait – waddling or
lurching gait
oT
rendelenburg Test – With patient
standing palpate both ASIS. Ask the
patient to stand on one leg and then
the other. Assess for pelvic
‘On general inspection
Mr/Mrs A Appears well,
has a normal gait, does
not appear to have any
walking aids.’
Equipment
o Walking stick/frame/wheelchair
Patient
o Varus/valgus stance
o Abnormal gait: Trendelenburg
Gait – lurching gait
o Positive Trendelenburg Test –
pelvis drops to the contralateral
side during stance on the affected
side
o Unwilling to stand/walk
“The patient walks with the
assistance of a crutch and walks with
a Trendelenburg gait”
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M us c u l o s k e l e t a l E xa m i nat io n
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On closer inspection
there are no scars/
swelling/erythema or a
fixed flexion deformity of
the hip.’
Scars
o Hip arthroscopy – three small
scars over the lateral aspect of the
proximal thigh
o Arthroplasty Scar – longitudinal scar
over the lateral aspect of the hip
Other
o Fixed flexion deformity – unable to
fully extend knee
o Muscle wasting – gluteal and
quadriceps muscles
“The patient has a scar on the lateral
aspect of the hip. It appears to be well
healed. There is wasting of the gluteal
muscles.”
‘On palpation there is
no bony tenderness, no
increased temperature,
and no limb length
discrepancy‘
•P
ain over bony prominences
– ASIS, pubic tubercle, greater
trochanter
•M
uscle wasting - gluteal muscles
and quadriceps
• L imb length discrepancy - True
= ASIS to Medial Malleolus.
Apparent = Umbillicus to Medial
Malleolus
CLOSER INSPECTION: LOOK
Comments on
o
Scars
o
Erythema
o
Swelling
o
Deformity
o
Muscle bulk
FEEL
• Bony prominences: ASIS, pubic
tubercle, greater trochanter
• Feels for temperature
• Feels for muscle bulk or wasting
• Measures for true and apparent
limb length: True = ASIS to Medial
Malleolus. Apparent = Umbillicus to
Medial Malleolus
“There is tenderness over the
greater trochanter on palpation.”
MOVE
• Hip Flexion – bring knee towards
chest
• Hip Extension – move thigh
posteriorly
• Internal Rotation – positions thigh
and leg at right angles the ankle is
abducted
• External Rotation - positions thigh
and leg at right angles the ankle is
adducted
• Hip Abduction – move lower limb
laterally
• Hip Adduction – move lower limb
medially
• Thomas Test – placed hand under
lumbar spine. Asks patient to hold
unaffected knee to the chest and
leave the affected leg on the table
‘On assessment of the
movement of the hip
I cannot appreciate a
decreased or restricted
range of motion actively,
passively or against
resistance. There was
no evidence of a fixed
flexion deformity.’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
• Osteoarthritis – painful movements
particularly on internal and external
rotation
• Labral tear – pain on hip extension.
May have associated clicking.
• Avascular necrosis - painful
movements particularly on internal
and external rotation
• Hip Fracture – leg shortened and
externally rotated.
• Fixed Flexion Deformity – hold
unaffected to the chest and leave
the affected leg on the table. If
affected leg cannot lie flat this is a
positive test.
“There is decreased range of motion
in the right hip compared to the left
hip. There is restriction of internal and
external rotation of the right hip.”
Musculoskeleta l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘To conclude this exam
I would perform a lower
limb neurological exam
and assess the dorsalis
pedis and posterior tibial
pulses.
I would also examine the
lumbar spine and knee
joints. I would like an AP
& lateral x-ray of the hip
joint.’
• Osteoarthritis – painful movements
particularly on internal and external
rotation
• Labral tear – pain on hip extension.
May have associated clicking.
• Avascular necrosis - painful
movements particularly on internal
and external rotation
• Hip Fracture – leg shortened and
externally rotated.
• Fixed Flexion Deformity – hold
unaffected to the chest and leave
the affected leg on the table. If
affected leg cannot lie flat this is a
positive test.
CONCLUDING REMARKS
• X-rays in two planes including the
joint above and below
• Examination of lumbar spine and
knee
• Offer to assess distal pulses &
perform neurological exam
• Washes hands
• Thanks patient
“There is decreased range of motion
in the right hip compared to the left
hip. There is restriction of internal and
external rotation of the right hip.”
THE RCSI THREE-COLUMN OSCE GUIDE
Musculoskeletal knee examination
“This is a surgical station. You have 5 minutes to complete a musculoskeletal knee examination. I will
then ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level,
explains what he/she will be doing
and obtains consent for same
‘Hi my name is X. I’m
a third year medical
student at RCSI. What’s
your name? Nice to meet
you. I’ve been asked to
examine your knee today.
That will involve inspecting
your gait while walking,
the position of your knees
while standing, and then
examining your leg while
lying on the table.’
Position and exposure
• Patient positioned at a 45 degree
angle and lower limb exposed, i.e.,
in shorts
‘Mr/Mrs A is
appropriately positioned
and exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Do you have any pain in
your knee, hip or ankle?’
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M us c u l o s k e l e t a l E xa m i nat io n
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On general inspection
Mr/Mrs A
Appears well, has a
normal gait, does not
appear to have any
walking aids. She does
not have any varus/valgus
abnormality of the knees.’
Equipment
o Walking stick/frame/wheelchair
Patient
o Varus or valgus stance
o Pes planus or pes cavus – flat feet
or high arched feet
o Abnormal gait: antalgic
(decreased stance phase on
effected side), Trendelenburg gait
(lurching gait), drop foot (high
stepping gait)
o Unwilling to stand/walk
GENERAL INSPECTION
• Performed from the end of the bed,
with patient standing and while
walking
o Comments on
o Any walking aids
o Gait
o Varus – oblique displacement of the
joint towards the midline
o Valgus - oblique displacement of the
joint away from the midline
“The patient uses a crutch to assist
with mobilizing, has an antalgic gait
and has a valgus stance.”
CLOSER INSPECTION
Comments on
o Scars
o Erythema
o Swelling
o Deformity – varus or valgus
o Muscle bulk
‘On closer inspection
there are no scars/
swelling/erythema, fixed
flexion deformity of the
knee’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Scars
o Arthroscopy – two small scars
inferiomedially and inferiolaterally
o Total knee replacement –
longitudinal scar over the anterior
aspect of the knee joint
o ORIF of femur tibial plateau
Other
o Effusion – noted swelling around
the knee
o Bakers cyst – noted swelling
posteriorly
o Fixed flexion deformity- unable to
fully extend knee
o Patella Alta/baja – high riding
patella / low set patella
o Muscle wasting - quadriceps
“The patient has a scar over the
anterior aspect of their right knee.
The scar is x cm in length and is
well healed. There is wasting of the
quadriceps muscles on the right side.”
Musculoskeleta l Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On palpation of the knee
joint there is no bone or
joint line tenderness and
no large effusion’
• Bony prominences – tibial
tuberosity
• Joint line tenderness – medial and
lateral joint lines
• Posterior knee: bakers cyst or
popliteal artery aneurysm
• Crepitus
• Muscle wasting of quadriceps/
patellar tendon rupture
“There is medial joint line tenderness
and there is a joint effusion.”
‘On assessment of the
ligaments of the knee
I have found the ACL,
PCL, LCL, and MCL all
to be intact. There is no
obvious meniscal injury
and I cannot elicit signs
of a previous patella
dislocation’
• ACL – positive Lachman’s Test and
positive anterior drawer test
• PCL – Posterior sag noted on
inspection & positive posterior
drawer test
• LCL – Pain on application of varus
stress to knee
• MCL – Pain on application of
valgus stress to knee
• Meniscal tear – positive McMurray
Test
• Patella Apprehension Test – the
patient shows signs of discomfort
when a lateral force is applied to
the patella
PALPATION
• Bony prominences
• Joint lines – medial and lateral joint
lines
• Feels for heat
• Checks for effusion- patellar tap test –
milks effusion from proximal to distal.
Taps patella of distal femoral condylar
surface
SPECIAL TESTS
• Patella apprehension test – lateral
force applied to patella with the
examiners thumb
• Valgus & varus stresses to knee
• Anterior & posterior drawer test –
hips flexed to 45° and knees flexed
to 90 with feet flat n the bed. Grasp
proximal tibia below joint line. Tibia is
drawn anteriorly or posteriorly
• Posterior sag test - – hips flexed to 45°
and knees flexed to 90° with feet flat
on the bed. The candidate inspects
for posterior sag.
• Lachman’s test – knee is flexed to 30.
The examiner grasps the proximal
tibia and distal thigh. The tibia is
pulled forward to assess degree of
anterior motion.
•M
cMurray’s test – hand placed along
the joint line with the knee in flexion.
The examiners second hand holds the
sole of the foot. A varus stress is applied
to the knee while the knee is being
extended and internally rotated. This
tests the lateral meniscus. The opposite
is performed for the medial meniscus.
“There is increased forward
motion of the tibia on the femur on
performing the Lachman Test. This
may indicate an ACL injury.”
CONCLUDING REMARKS
• X-rays
• Examination of joint above & below
• Offer to assess distal pulses & perform
neurological exam
• Washes hands
• Thanks patient
‘To conclude this exam
I would perform a lower
limb neurological exam
and assess the dorsalis
pedis and posterior tibial
pulses. I would also
examine the hip and
ankle joints, and order an
AP & lateral x-ray of the
knee joint’
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255
CHAPTER 11
VASCULAR
EXAMINATION
LOWER LIMB ARTERIAL
E X A M I N AT I O N
LOWER LIMB VENOUS
S Y S T E M E X A M I N AT I O N
DIABETIC FOOT
E X A M I N AT I O N
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Va scula r Exa mina t ion
LOWER LIMB ARTERIAL
E X A M I N AT I O N
PERIPHERAL ARTERIAL DISEASE
•
•
•
CLINICAL
EXAMINATION
Narrowing of arteries to structures other than brain & heart
Underlying pathology typically atherosclerosis
Most commonly lower limb
INTERMITTENT CLAUDICATION
•
•
•
•
Crampy muscular pain
Brought on by exercise
Relieved by rest
Due to imbalance between tissue oxygen supply & demand
LOWER LIMB
ARTERIAL
EXAMINATION
CRITICAL LIMB ISCHAEMIA
•
•
Rest pain
Tissue loss (ulcers/gangrene/necrosis)
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose patient (legs exposed & shirt open/off)
Position appropriately (supine at 45o)
Ask patient if in any pain in legs/feet
General Inspection
•
•
•
•
•
•
•
•
General appearance
o Comfortable/unwell/distressed
Bedside signs
o O2, drips, drains, catheter, cigarettes, medications, aids/prosthesis
Obvious scars
Cyanosis/pallor of limbs
Hanging leg over side of bed
o Classical feature of critical limb ischaemia
Pulsatile mass in abdomen
Tar staining of fingers (smoking is no. 1 risk factor)
Body habitus?
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Vas c ul a r E x a m i n a t io n
Inspection
•
Colour
o Pallor (implies ischaemia)
o Mottling (typically in acute ischaemia)
o Redness with dependency (chronic PVD)
o Black areas (necrosis/gangrene)
–Is gangrene wet/dry?
• Peripheral oedema
o Chronic venous insufficiency, DVT, post-op
• Trophic changes
o Shiny skin
o Hair loss
o Loss of subcutaneous tissue
o Onychogryphosis
• Ulcers (See ulcer description box)
o Carefully examine pressure points
– Lateral foot
– First metatarsal
– Heel
– Malleoli
– Toes
•Venous guttering
o Indentations where superficial veins should be in arterial insufficiency
• Scars
o Fem-pop bypass or Fem-distal bypass
o GSV harvesting
o Abdominal scars (AAA repair/Aorto-bifemoral graft)
• Muscle wasting/asymmetry
• Missing toes/limbs (previous amputation)
• Ask patient to wiggle their toes (gross motor assessment)
Palpation
• Ask about pain before beginning with palpation
Temperature:
• Use back of hand, comparing sides, with one hand only, working proximal to distal
• Cool suggests arterial disease
Capillary Refill:
• Normal = 1-2 seconds
• Prolonged in PVD/ischaemia
•Rapid capillary refill may occur due to dependent pooling of venous blood in
chronically ischaemic limb
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Va scula r Exa mina t ion
Pulses:
• Start proximally and work distal
•Compare like with like and comment on rate, rhythm, character (thready/
bounding) & symmetry
LOWER LIMB PULSES*
Pulse
Landmark
Femoral pulse
•
•
Popliteal pulse
• Flex knee to 45o (ask about pain in knee first)
• Place thumbs on tibial tuberosity
•Curl your fingers into popliteal fossa to compress popliteal
artery against tibia to feel pulsation
• Deepest structure in popliteal fossa
• Frequently impalpable
• DO NOT SAY YOU CAN FEEL IT IF YOU CANNOT
• Easily palpable? May be popliteal aneurysm
Posterior Tibial
pulse
•Halfway between medial malleolus & calcaneus at Achilles
tendon insertion point (Pimenta’s point)
Dorsalis Pedis
pulse
• Draw invisible line from medial to lateral malleolus
• Find midpoint of this line
• Drop a line from here to 1st web space
• Divide this new line into thirds
•Palpate lateral to extensor hallucis longus in middle third of
this line (ask patient to extend toe to make EHL obvious)
• Between bases of 1st & 2nd metatarsals
Mid-inguinal point (halfway between ASIS & pubic symphysis)
Also auscultate for bruit (implies stenosis)
*Offer to use handheld Doppler ultrasound probe if you cannot palpate pulses
Special Tests
•
Buerger’s Test
o Lie patient supine
o Ask about pain in hips/legs
o Start with normal side
o Elevate leg slowly while watching plantar surface of foot
o Note point at which pallor occurs (also observe for venous guttering)
o Record angle between leg and the bed (Buerger’s angle)
– Normal: no pallor even at 90 degrees
– <20 degrees = Severe PAD
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oOnce Buerger’s angle has been reached, ask the patient to hang their legs over
side of bed
oObserve for reactive hyperaemia
–Leg turns red due to arteriolar dilatation (in an effort to remove metabolic waste)
Abdominal Aortic Aneurysm
•Inspect the abdomen for any obvious pulsation
• Palpate deeply with two hands roughly 3cm lateral (left) & superior to umbilicus
Completion
o Feel for expansile, pulsatile mass
– Upward movement = Pulsatile
– Outward movement = Expansile
– Auscultate for bruits
• Offer to perform:
o Cardiovascular exam (evidence of coronary artery disease)
o Varicose vein exam (mixed arteriovenous disease)
o Lower limb neurological exam (paraesthesia in acute limb ischaemia)
• Measure ABPI
• Check bedside vitals
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o Doppler USS
o CT/MR angiogram
o Digital subtraction angiogram
o USS abdomen if AAA suspected
ADDITIONAL NOTES
Ankle Brachial Pressure Index
•
•
Division of systolic blood pressure at ankle by systolic blood pressure at arm
Lower BP in leg compared to arm indicates peripheral arterial disease
ABPI VALUE
>1.1
INTERPRETATION
Abnormal vessel hardening due to calcium deposits in diabetic patient
0.9-1.1
Normal value
0.5-0.9
Intermittent claudication
<0.5*
Rest pain
<0.3*
Gangrene & ulceration
*Critical limb ischaemia
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Va scula r Exa mina t ion
Key point: Features of Critical Limb Ischaemia (6 Ps)
Pain
Pallor
Pulseless
Perishingly cold
Paraesthesia
Paralysis
FONTAINE CLASSIFICATION OF PERIPHERAL ARTERIAL DISEASE
I
Asymptomatic
II
III
Intermittent claudication
• IIA: >200m
•IIB: <200m
Rest pain
IV
Tissue loss
ARTERIAL VERSUS VENOUS ULCERS
Arterial
Venous
Site
Pressure points
Medial gaiter region
Size
Small
Large
Shape
Regular
Irregular
Surroundings Features of peripheral arterial disease
(see lower limb arterial exam)
Features of chronic venous
insufficiency (see varicose
veins exam)
Edges
‘Punched out’
Sloped
Exudate
Low
High
Depth
Deep, underlying structures visible
Superficial, shallow
Base
Necrotic
Granulation tissue
Pain
Yes
Minimal unless infection
Mnemonic for describing an ulcer: BBEDDSS
• Basics (Site, size, shape)
• Base
• Edges
• Depth
• Discharge
• Surroundings
• Sore (Pain)
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Figure 9: LOWER LIMB ARTERIAL SUPPLY
Inguinal ligament
Popliteal trifurcation
Internal
iliac
Common
iliac
External
iliac
Common
femoral
Superficial
femoral
Popliteal
Profunda
femoral
Anterior
tibial
Posterior
tibial
Peroneal
RISK FACTORS FOR PERIPHERAL VASCULAR DISEASE
•
•
•
•
Non-modifiable: Age >50, male gender, family history
Smoking (most important)
‘Deadly triad’ of hypertension, hyperlipidaemia & diabetes mellitus
Other vascular disease
o Coronary artery disease/Angina
o Cerebrovascular disease/TIA
o Carotid artery disease
Repair Indications for AAA
• Symptomatic
• Diameter >5.5cm
•Increase in diameter by 1cm/year
• Rupture
LOWER LIMB VENOUS SYSTEM
E X A M I N AT I O N
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose patient (legs exposed in shorts/underwear)
Position appropriately (standing)
Ask patient if in any pain in legs/feet
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Dorsalis
pedis
Va scula r Exa mina t ion
Inspection
•Varicose veins
o Great saphenous vein: medial lower leg & thigh
o Short saphenous vein: posterior lower leg
• Saphena varix
o Blue lump in groin
o Obvious when standing, often disappears when supine
o Represents dilated SFJ
• Features of chronic venous insufficiency
o Peripheral oedema
oVenous eczema
o Haemosiderin deposits
–Haemosiderin released from breakdown of RBCs released into surrounding
tissues due to venous HTN
–Causes brown staining of skin
–Particularly in medial gaiter area
o Lipodermatosclerosis
–Scarred subcutaneous tissue
–‘Inverted champagne bottle’ appearance
o Atrophie blanche
–Small smooth white areas on skin
o Ulceration
–Medial gaiter area
• Scars
o Groin crease (previous SFJ ligation)
o Popliteal fossa (previous SPJ ligation)
o Scars from stab avulsions
Palpation
•
•
•
•
•
Assess for pitting oedema
Lipodermatosclerosis
o Thick, fibrotic skin
Palpate varicose veins
o Tenderness & warmth imply superficial thrombophlebitis
Calf tenderness
o DVT
SFJ (3cm below and lateral to pubic tubercle) – feel for:
o Saphena varix (feels like under filled balloon that empties with pressure)
o Cough impulse (implies incompetence at SFJ)
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Percussion
Tap test
• Place fingers of one hand at lower limit of varicose vein
• Tap upper limit with other hand
• Percussion impulse indicates incompetent intervening valves
Auscultation
•
Listen for bruits over varicose veins
o Implies AV malformation
Special tests
These tests are time consuming, so offer them to the examiner before proceeding
•
•
•
Tourniquet test
o Lie patient flat
o Perform straight leg raise & place heel on your shoulder
o ‘Milk’ veins empty by massaging blood back towards the groin
o Apply tourniquet around upper thigh
o Get patient to stand up
o Observe legs for refilling of veins and then release tourniquet
oInterpretation:
– Rapid refilling on standing before tourniquet release?
• Incompetence below level of SFJ
– No refilling on standing & rapid refilling on tourniquet release?
• SFJ incompetence
Trendelenburg test
oAs with Tourniquet test, except using fingers to occlude SFJ instead of placing
tourniquet around upper thigh
Perthes’ test
o Place tourniquet around elevated leg so veins below are empty (as above)
o Ask patient to stand up & down on tip-toe 10 times
o Filling of superficial veins & pain in legs indicates deep venous occlusion
o NB: this is not routinely done due to risk of dislodging a DVT
Completion
•Offer to examine the following to assess for masses that could cause intravenous
obstruction:
o Abdomen
o Rectum
o Pelvis in females
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Va scula r Exa mina t ion
• Arterial exam & ABPIs (ulcers may be multifactorial)
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o Doppler USS to identify point of incompetence
D I A B E T I C F O O T E X A M I N AT I O N
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose patient (legs exposed)
Position appropriately (supine at 45o)
Ask patient if in any pain in legs/feet
Key Point: Inspect legs & feet thoroughly, lifting up legs to see underneath &
looking between toes
•
Colour
o Pallor/cyanosis
o Erythema
• Skin
• Nails
o Dry/shiny/hair loss (arterial disease)
o Eczema/haemosiderin deposits (venous disease)
o Dystrophy, onchogryphosis
• Ulcers
o Describe using BBEDDSS mnemonic for ulcers
• Swelling
o Oedema/DVT
• Calluses
o May indicate inadequately fitting shoes
•Venous guttering
• Deformity caused by neuropathy (Charcot foot)
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Vas c ul a r E x a m i n a t io n
•
•
Shoes (inspect footwear)
o Pattern of wear (asymmetrical wearing from gait abnormality)
o Ensure correct size
o Look inside for holes/material that could cause foot injury
Gait
Palpation (Arteriopathy)
Perform these as per lower limb arterial examination
• Temperature
• Capillary refill time
• Pulses (posterior tibial & dorsalis pedis)
Neurological Assessment (Neuropathy)
Monofilament sensation:
• Ask patient to close eyes & demonstrate sensation on sternum
•Instruct patient to say yes when they feel it touching their skin
• Place monofilament on hallux & metatarsal heads 1 - 5
• Press firmly so that monofilament bends & hold in place for 1-2s
• Avoid calluses/scars, which will have reduced sensation
Vibration:
• Ask patient to close eyes & tell you if they feel vibration (& tell you when it stops)
• Place vibrating 128Hz tuning fork on distal phalanx of big toe
• Assess more proximally if sensation impaired (e.g., proximal phalanx)
Proprioception:
• Assess as per lower limb neurological examination
Ankle Jerk Reflex:
• Assess as per lower limb neurological examination
Completion
• Offer to perform full neurovascular examination
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o ABPI
o Doppler USS
o Capillary blood glucose
o HBA1c
o MRI (osteomyelitis)
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Va scula r Exa mina t ion
FEATURES OF DIABETIC FOOT*
Peripheral neuropathy:
• Accidental injury & tissue damage
• Charcot joint development
Autonomic neuropathy:
• Reduced sweating
• Leads to dry, cracked skin
• Route for infection
Arterial disease:
• Large vessel disease
• Small vessel disease
Key Point: Peripheral neuropathy, autonomic neuropathy and arterial disease all
contribute to ulcer formation
THE RCSI THREE-COLUMN OSCE GUIDE
Vascular Examination - Lower limbs
“This is a surgical station. You have 5 minutes to examine this patient’s lower limbs. I will then ask you
to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent
• Introduces self with name and level,
explains what he/she will be doing
and obtains consent for same
‘Hi my name is X. I’m
a third year medical
student at RCSI. What’s
your name? Nice to meet
you. I’ve been asked to
examine your legs today.
This will involve me having
a look at your legs, feeling
for any swellings, checking
for pulses and then
measuring your legs. Is
that ok with you?
Position and exposure
• Patient seated
• Legs exposed
‘Mr/Mrs A is
appropriately positioned
and exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Are you in any pain?’
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Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On general inspection
Mr/Mrs A appears well,
with normal colour
and body habitus, no
peripheral stigmata of
vascular disease and no
equipment around the
bed.’
• Patient
o Obvious amputations
oThere is a below knee/above
knee amputation on the L/R
o R/L, 1st/2nd/3rd/4th/5th toe
oColour asymmetry –
erythema,pallor
o Obvious swellings/masses
oObvious ulcer, ischaemia,
gangrene
• Equipment
oIV drips
o Walking aids
o Prostheses
‘On closer inspection of
the lower limbs there are
no stigmata of vascular
disease or signs of lower
limb pathology’
• Scars
oThere is a Xcm scar that
appears new/well healed on
_location_
• Skin changes
oErythema ~XxXcm(Cellulitis,
DVT..)
oVenous disease (Varicosities,
venous stars, oedema,
eczema…)
oArterial disease (Gangrene, hair
loss, livedo reticularis, distorted
nails…)
• Swellings
o Popliteal fossa (Baker’s Cyst)
oCalf swelling (DVT, haematoma,
muscle strain/tear, ruptured
Baker’s cyst, cellulitis)
• Ulcers
oThere is an ulcer on the med/
lat/ant /post aspect of the L/R
foot/leg.
oIt is approximately X x X cm in
size
oIt has a punched out
appearance with well-defined
borders/irregular inward sloping
borders.
oSurrounded by pale shiny skin/
by erythema with haemosiderin.
oThe base is clean/shallow with
granulation tissue, with a small/
large amount of slough.
o There is/is no active ooze.
GENERAL INSPECTION
Performed from the end of the bed
o Comments on
o Patient
o Equipment
CLOSER INSPECTION
Performed from right hand side of bed
Inspects fully with patient standing and
lying
• Inspects for
o Scars
o Skin changes
o Swellings
o Ulcers
• Also inspects
o Under heels
o Posterior surface of legs
o Between toes
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Va scula r Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
PALPATION
Temperature
• Compares both sides using dorsal
aspect of fingers of same hand
Tenderness
• Squeezes near ankle, then ascends
posterior calves, watching face for pain
Oedema
• Uses thumbs to apply pressure
bilaterally to bony points, starting at
dorsum of feet, then medial malleolus,
tibia etc, removing thumb after ~2 secs
to observe for pitting
Masses
• Uses bimanual technique to palpate any
masses for size, shape, temperature,
tenderness, mobility, regularity
‘Temperature is equal
bilaterally, with no tender
areas and no oedema.’
Temperature
• Temperature was reduced/increased
over the _X_ (e.g., right calf)
Tenderness
• There was tenderness to palpation
of the R/L calf/popliteal fossa
Oedema
• Pitting oedema is present on the R/L
to the level of ¬_X_ (eg. mid shin)
Masses
• There is palpable mass in _X_ (e.g.,
popliteal fossa- Baker’s Cyst)
• It is smooth/irregular, tender/nontender, fluctuant/non fluctuant,
mobile/ immobile, approx. Xcm
and _shape_
PULSES
• Uses index and middle finger to
palpate, comparing both sides
• Femoral: halfway between ASIS and
pubic symphysis
• Popliteal: Deep within lower part
of popliteal fossa. Feels with both
hands with thumbs anchored on tibial
tuberosity
• Posterior tibial: 2cm posterior and
inferior to the medial malleolus
• Dorsalis pedis: Imaginary line from
medial to lateral malleolus, bisect this
line and extend perpendicular line
down to the first webspace. 1/3 of the
way down this line lateral to tendon of
flexor hallucis longus.
‘Pulses are present and
equal bilaterally.’
• Dorsalis pedis/posterior tibial/
popliteal/ femoral pulse was
impalpable on the left/right. If
pulses impalpable they should
be assessed with a Doppler
ultrasound.
‘Leg circumference is
equal bilaterally. ‘
Leg Circumference
• There is a leg circumference
discrepancy of >3cm on the right/
left leg, with the left calf measuring
Xcm and the right measuring Xcm
ADDITIONAL TESTS
Leg Circumference
• Measures leg circumference 10cm
below tibial tuberosity (<3cm not
significant)
CONCLUSION
• Thanks patient
• Summarises and suggest further
examinations and investigations
oFBC, U&Es, coagulation blood
tests, D-Dimer if suspected
DVT (calculate WELLS score) US
Doppler, Duplex US, Venogram
‘To complete my
examination I
would perform a full
cardiovascular and
respiratory exam’
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THE RCSI THREE-COLUMN OSCE GUIDE
Vascular Examination - Lower limbs (Arterial)
“This is a vascular station. You have 5 minutes to examine this patient’s lower limbs from an arterial
point of view. I will then ask you to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• C
leans hands with alcohol gel
Introduction, explanation and
consent
• Introduces self with name
and level, explains what he/
she will be doing and obtains
consent for same
Hi my name is X.
I’m a third year
medical student at
RCSI. What’s your
name? Nice to
meet you. I’ve been
asked to examine
your legs today.
This will involve me
having a look for any
abnormalities and
feeling for the pulses.
Is that ok with you?
Position and exposure
• Patient seated
• A
rms and shoulders exposed
• Shirt off
• Trousers off
‘Mr/Mrs A is
appropriately
positioned and
exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Are you in any
pain?’
GENERAL INSPECTION
Performed from the end of the
bed
o Inspects for
o P
atient features
o E
quipment
‘On general
inspection Mr/Mrs A
appears well, with no
peripheral stigmata
of vascular disease
and no equipment
around the bed.’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
• Patient
o Obvious amputations
o There is a below knee/above knee
amputation on the L/R
o R/L, 1st/2nd/3rd/4th/5th toe
o Midline sternotomy scar
o Obvious ulcers
o Cyanosis
o Pallor
o Colour asymmetry
o Obvious ischaemia or gangrene
• Equipment
o IV drips
o Walking aids
o prostheses
Va scula r Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On closer
inspection of the
lower limbs there
are no stigmata of
peripheral arterial
disease
• Scars
o ‘There is a longitudinal scar on the…’
o P
osterior aspect of the right/left leg consistent
with short saphenous vein harvesting.
o Medial
aspect of the right/left leg consistent
with long saphenous vein harvesting.
o Medial
surface of the leg extending from the
groin down to the medial malleolus consistent
with fem-pop bypass grafting.
• Skin changes
o P
allor/cyanosis
o M
uscle wasting
o G
angrene
o H
air loss
o L ivedo reticularis
o D
istorted nails
• Ulcers
o There
is an ulcer on the medial/lateral/anterior/
posterior aspect of the left/right foot.
o It is approximately X x X cm in size
o It has a punched out appearance with welldefined borders.
o It is symmetrical with regular borders.
o It is surrounded by pale shiny skin
o The
base is clean with a small amount of slough.
o M
inimal granulation tissue evident.
o T
here is/is no active ooze.
‘Temperature is
equal bilaterally
and capillary refill
is normal (≤2
seconds).’
• ‘Temperature was reduced over the right/left
foot/leg.’
• Capillary refill was delayed
Femoral, popliteal,
posterior tibial,
dorsalis pedis pulses
are present and
equal bilaterally.’
• Dorsalis pedis/posterior tibial/popliteal/ femoral
pulse was impalpable on the left/right.’
CLOSER INSPECTION
Performed from right hand side
of bed
• Inspects for
o Scars
o Skin changes
o Ulcers
• Also inspects
o Under heels
o Posterior surface of legs
o Between toes
PALPATION
Temperature
• C
ompares both sides using
dorsal aspect of fingers of
same hand
• Checks capillary refill
PULSES
• Popliteal: Deep within lower
part of popliteal fossa. Feels
with both hands with thumbs
anchored on tibial tuberosity
• Posterior tibial: 2cm posterior
and inferior to the medial
malleolus
• Dorsalis pedis: Imaginary
line from medial to lateral
maleolus, bisect this line and
extend perpendicular line
down to the first webspace.
1/3 of the way down this line
lateral to tendon of flexor
hallucis longus.
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SPECIAL TESTS
• B
uerger’s Test
o R
aises leg to 450 to assess if
pallor occurs (or to whatever
angle pallor first occurs at)
then sits patient over edge
of bed and observes for
reactive hyperaemia
‘Buerger’s test was
normal (no pallor
detected).’
‘Buerger’s angle was noted to be X degrees.
There was reactive hyperaemia on the right/left
foot when the legs were hung over the edge of
the bed.’
ADDITIONAL TESTS
• Offers to perform a venous
examination and perform
ABIs.
‘‘To complete my
examination I would
examine the venous
system and perform
ABIs.’’
THE RCSI THREE- COLUMN OSCE GUIDE
Vascular Examination - Lower limbs (Venous)
“This is a vascular station. You have 5 minutes to examine this patient’s lower limbs from a venous point
of view. I will then ask you to present your findings and answer a question”.
Examination
INTRODUCTION
Expected/Normal
Comments
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and
consent
• Introduces self with name
and level, explains what he/
she will be doing and obtains
consent for same
‘Hi my name is X.
I’m a third year
medical student at
RCSI. What’s your
name? Nice to
meet you. I’ve been
asked to examine
your legs today.
This will involve me
having a look for any
abnormalities and
doing some special
tests. Is that ok with
you?
Position and exposure
• Patient seated
• Arms and shoulders exposed
‘Mr/Mrs A is
appropriately
positioned and
exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Are you in any
pain?’
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Potential/Abnormal Comments
Va scula r Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On general
inspection Mr/Mrs A
appears well, with no
peripheral stigmata
of vascular disease
and no equipment
around the bed.’
• Patient
o Obvious ulcers
o Colour asymmetry
o Swelling
o Varicose veins
‘On closer
inspection of the
lower limbs there
are no stigmata of
peripheral venous
disease.’
• Scars
o There is a longitudinal scar along the medial/
posterior /lateral/anterior surface of the right/
left leg/groin. It measures approximately Xcm
and appears well healed/new.
GENERAL INSPECTION
Performed from the end of the
bed
o Comments on
o Patient
o Equipment
• Equipment
o IV drips
o Walking aids
o prostheses
CLOSER INSPECTION
Performed from right hand side
of bed
• Inspects for
o Scars
o Skin changes
o Ulcers
• Also inspects
o Under heels
o Posterior surface of legs
o Between toes
• Skin changes
o Varicosities
o Venous stars
o Oedema (pitting)
o Venous eczema
o Lipodermatosclerosis /haemosiderin
deposition
o Atrophy blanche
• Ulcers
o There is an ulcer on the med/lat/ant /post
surface of the right/left leg.
o It is approximately Xcm/. It has irregular
inward sloping borders.
o The base is shallow with granulation tissue
and a small amount/large amount of slough.
o The surrounding skin is erythematous with
some haemosiderin deposition.
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Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘’On palpation,
temperature was
equal and normal
bilaterally. Capillary
refill was <2 seconds
which is within
normal limits. There
was no saphena varix
palpable and no
cough impulse.’’
• The temperature of the distal right leg/left leg
below the knee was reduced compared to the
left/right leg.
‘Trendelenburg test
was unremarkable.’
'Trendelenburg test indicated the presence
of perforator incompetence/saphenofemoral
junction incompetence as the varices filled
on standing/did not fill on standing with the
tourniquet in situ.’
PALPATION
• Temperature
o P
alpates on both sides
using dorsal aspect of
fingers of same hand
• A
ssesses capillary refill
bilaterally
o Pushes on the tip of the
great toe or the nail bed
until blanching occurs. Then
releases and notes times for
the red colour return.
• C
ough impulse of saphena
varix
o P
alpates at SFJ (2-4cm
inferio-lateral to the pubic
tubercle) and asks patient
to cough
• P
alpates for calf tenderness
• P
alpates for Oedema
o Uses thumbs to apply
pressure bilaterally to
bony points, starting
at dorsum of feet, then
medial malleolus, tibia etc,
removing thumb after ~2
secs to observe for pitting
• Capillary refill was prolonged on the right/left to
X seconds.
• The cough impulse was positive
• There was calf tenderness on the right/left on
palpation.
• There was unilateral/bilateral pitting oedema up
to the ______.
SPECIAL TESTS
• Trendelenburg Test
o F
lexes hip
o Raises leg
o M
anually empties varicose
veins
o Applies tourniquet to upper
thigh
o A
sks patient to stand and
observes for filling of
superficial veins
• No filling on standing = sapheno-femoral
junction incompetence
• Filling on standing = perforator incompetence
CONCLUSION
• Thanks patient
• S
ummarises and suggest
further examinations and
investigations
FBC, U&Es, coagulation blood
tests, D-Dimer if suspected
DVT (calculate WELLS score) US
Doppler, Duplex US, Venogram
‘‘To complete my
examination I would
examine the arterial
system”
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CHAPTER 12
BREAST AND
ENDOCRINE
EXAMINATION
THYROID/NECK LUMP
& T H Y R O I D S TAT U S
E X A M I N AT I O N
B R E A S T E X A M I N AT I O N
CUSHING’S SYNDROME
E X A M I N AT I O N
A C R O M E G A LY
E X A M I N AT I O N
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THYROID/NECK LUMP AND
T H Y R O I D S TAT U S E X A M I N AT I O N
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose patient (entire neck – unbutton/remove top to ensure adequate exposure)
Position patient (sitting up in a chair)
Ask patient if in any pain
THYROID STATUS EXAMINATION
General Inspection
•
•
•
•
•
General appearance
o Comfortable/unwell/distressed/in pain
Clinically hyperthyroid/hypothyroid/euthyroid?
oHypothyroid: Raised BMI, warmly dressed, thin hair, pale, dry skin, myxoedema
facies
o Hyperthyroid: Thin, restless, tremulous, flushed, sweaty
Any signs of thyroid eye disease
Obvious neck lumps
Scars
THYROID HAND SIGNS
Sign (6 Ps)
Hyperthyroidism
Hypothyroidism
AcroPachy (clubbing)
Present in Graves’ disease
Absent
Palms
Hot & sweaty
Cold & dry
Palmar erythema
Present
Absent
Paper (rest on top of hands
to detect fine resting tremor)
Present
Absent
Pulse
Tachycardia & Atrial fibrillation
Bradycardia
Paraesthesia (CTS features
Absent
Present
•
Reflexes (knee & biceps)
o Hyperthyroidism: Brisk
o Hypothyroidism: Delayed
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•
•
Proximal myopathy
o Present in hyperthyroidism
o Test shoulder abduction
o Test pelvic girdle strength by asking patient to stand up from seated position
Oedema
o Hypothyroidism: Generalised non-pitting oedema
Face
•
•
•
•
Rash
o Graves’ disease: Pretibial myxoedema
Facial appearance
o Hypothyroidism: ‘Peaches & cream’ complexion, rounded face
o Hyperthyroidism: Flushed, gaunt face
Hair
Eyes
THYROID EYE SIGNS
Sign
Interpretation
Loss of outer 1/3 of eyebrow
Hypothyroidism
Periorbital puffiness & sunken eyes
Hypothyroidism
Exophthlamos (look from above head)
Graves’ disease
Ophthalmoplegia
Graves’ disease
(Follow finger with eyes in H pattern)
Lid retraction
Hyperthyroidism
Lid lag
Hyperthyroidism
•
Technique for demonstrating lid lag:
o Hold finger high & ask patient to follow it with their eyes (head still)
o Move finger downwards
o Observe ‘lagging’ of upper eyelid in moving down as eye moves down
– Sclera will be visible above iris
•Voice
o Hypothyroidism: Deep voice
o Hoarse voice may reflect recurrent laryngeal nerve injury post-thyroid surgery
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THYROID/NECK LUMP EXAMINATION
Inspection
•Inspect from front, sides & above
• 6 Ss as per any lump exam
DESCRIBING A NECK LUMP ON INSPECTION
Remember the 6 Ss of lump inspection
Site: midline, anterior triangle or posterior triangle
Size: Roughly estimate diameter in cm
Shape: Round/oval/irregular
Symmetry:
• Graves’ is symmetrical
• Multinodular goitre/uninodular goitre are asymmetrical
Skin changes: Erythema (abscess/infection)
Scars: Collar incision from previous thyroidectomy
•
•
Distended neck veins (SVC obstruction)
o Check Pembertons for retrosternal goitre
Ask patient to:
o Swallow water (goitre moves upwards)
o Stick tongue out (thyroglossal cyst moves upwards)
Palpation
•Place 1st 3 fingers of each hand along midline of neck below chin & locate upper
edge of thyroid cartilage (Adam’s apple) & move inferiorly until you reach cricoid
cartilage
•1st 2 rings of trachea located below cricoid cartilage – thyroid isthmus overlies this
area
• Palpate thyroid isthmus using pulps of your fingers
• Move fingers out laterally & palpate each thyroid lobe in turn
• Attempt to find lower extent (can you get below it?)
• Palpate while patient sticks tongue out (thyroglossal cyst) and drinks water (goitre)
• Check for tracheal deviation (due to large thyroid mass)
• Palpate head & neck lymph nodes as per lymph node examination
oSubmental, submandibular, pre-auricular, post-auricular, occipital, posterior
cervical chain, anterior cervical chain, supraclavicular
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DESCRIBING A NECK LUMP ON PALPATION
3 Teachers around a CAMPFIRE
Tenderness: Inflammation (e.g., abscess/infection)
Temperature: Inflammation (e.g., abscess/infection)
Transillumination: Fluid-filled cystic lesion
Consistency: Hard/firm/soft
• Smooth: Graves’
• Nodular: Determine if uninodular or multinodular goitre
Appearance: General appearance of the patient
Mobility: Is it fixed/tethered to overlying & underlying structures?
Pulsatile & expansile: Implies arterial lesion (e.g., carotid body tumour)
Fluctuant: Fluid-filled lesion (e.g., thyroglossal cyst)
Irreducible: N/A in neck exam
Regional lymph nodes: Enlarged in inflammation or malignancy
Edges: irregular/infiltrative/well-defined
Percussion
•Percuss from roughly the 4th intercostal space in the midline up to the sternal notch
o Dullness implies retrosternal extension of goitre
Auscultation
•
Auscultate each lobe separately for thyroid bruit
o Suggests increased vascularity (Graves’ disease)
Special Tests
•Pemberton’s sign: Assesses for thoracic inlet obstruction secondary to large
retrosternal goitre
o Ask patient to raise arms above head & take deep breath in
o Listen & look for:
– Stridor (tracheal compression)
– Distended neck veins & facial plethora (obstructed venous return)
Completion
• Offer to perform thyroid status examination if not done
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o TFTs & thyroid autoantibodies
o USS
o FNAC
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ADDITIONAL NOTES
DIFFERENTIAL DIAGNOSIS FOR NECK LUMPS
Midline
Anterior triangle
Posterior triangle
Anywhere
Goitre
Thyroglossal cyst
Branchial cyst
Carotid aneurysm
Carotid body tumour
Laryngocoele
Cystic hygroma
Pharyngeal pouch
Cervical rib
Subclavian aneurysm
Lymph node
Lipoma
Sebaceous cyst
DIFFERENTIAL DIAGNOSIS OF GOITRE
1.
2.
3.
4.
Multinodular goitre (MNG)
• Euthyroid = non-toxic MNG
• Hyperthyroid = toxic MNG
Graves’ disease
Solitary nodule (adenoma/carcinoma)
Thyroiditis (Hashimoto’s, subacute, post-partum)
CAUSES OF HYPERTHYROIDISM
•
•
•
•
•
•
Graves’ disease
Toxic MNG
Toxic adenoma
Thyroiditis – Hashimoto’s, subacute, post-partum
Drug-induced – Thyroxine overdose, Amiodarone, Immune checkpoint inhibitors
TSH-secreting pituitary adenoma – Secondary hyperthyroidism
CAUSES OF HYPOTHYROIDISM
•
•
•
•
•
•
•
Iodine deficiency
Primary atrophic hypothyroidism*
Hashimoto’s thyroiditis*
o Can be euthyroid or hypothyroid
o Rare initial period of hyperthyroidism (Hashitoxicosis)
Post-thyroidectomy
Radioiodine treatment
Drug-induced
o Carbimazole, lithium, amiodarone
Subacute thyroiditis, Riedels and de Quervains thyroiditis
o Temporary hypothyroidism after hyperthyroid phase
*Associated with other autoimmune disorders (T1DM, Addison’s disease, Psoriatic arthritis)
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Graves Disease
IgG antibodies bind to TSH receptor antibodies (TRAB)
• Thyroid cells stimulated to produce excessive thyroid hormones
• Thyroid gland hypertrophies & enlarges diffusely
Classical Features:
• Goitre
• Hyperthyroidism
• Eye disease*
o Exophthalmos, ophthalmoplegia, lid lag, lid retraction
• Thyroid acropachy (clubbing)
• Pretibial myxodema
*Exophthalmos & ophthalmoplegia in the context of thyroid disease are unique to
Graves’, whereas lid lag & lid retraction can occur with any cause of hypothyroidism
BREAST EXAMINATION
Introduction
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Ensure chaperone present
Expose patient to the waist
Position appropriately:
o Sitting at side of bed initially
o Lying flat with hands behind head for palpation
•Ask patient if in any pain & if they have noticed any lumps in breast (& to show you
where)
REMEMBER TO ALWAYS COMPARE BOTH SIDES THROUGHOUT
ENTIRE EXAMINATION
Inspection
Clearly examine breasts, axillae (ask patient to raise arms up) & inframammary folds
(ask patient to elevate breasts)
•
Masses
oCompare breasts in the following positions with patient sitting & look for
dimpling:
– Hands by side
– While slowly raising arms straight above head
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– Pushing down on bed
– Pushing hands against hips
o 6 Ss as per lump exam
DESCRIBING A BREAST LUMP ON INSPECTION
Remember 6 Ss of describing a lump on inspection
Site: e.g., upper outer left breast
Size: rough estimate based on gross appearance
Shape: round/oval/irregular
Symmetry: e.g., compare with opposite breast
Skin changes:
• Erythema (abscess/cellulitis/superficial malignancy)
• Puckering/dimpling/tethering (underlying malignancy)
• Peau d’orange (inflammatory breast cancer)
Scars: Previous surgery
•Comment on symmetry, skin appearance & presence/absence of scars even in
absence of lump
• Nipple changes
NIPPLE CHANGES ON BREAST EXAMINATION (6 DS)
•
•
•
•
•
•
Paget’s Disease
Discharge (note amount, colour & blood staining)
Depression (inversion)
Deviation
Displacement
Destruction
Palpation
Patient lying flat with hands behind head
Ask about any pain before you begin
Examine normal side first
•
Use flat of your 1st 3 fingers to compress breast tissue
•
Palpate using “clock face” method
o Imagine breast as a clock face with nipple being centre of clock
oExamine each ‘hour’ of the breast, working from outside & moving in towards
nipple
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DESCRIBING A BREAST LUMP ON PALPATION
Remember mnemonic for describing a lump on palpation:
3 Teachers around a CAMPFIRE
Tenderness: Inflammation (cellulitis/abscess)
Temperature: Inflammation (cellulitis/abscess)
Transillumination: N/A in breast exam
Consistency: Hard/firm/soft
Appearance: General appearance of the patient
Mobility: Is it fixed/tethered to overlying & underlying structures?
Pulsatile & expansile: N/A in breast exam
Fluctuant: Fluid-filled lesion?
Irreducible: N/A in breast exam
Regional lymph nodes: Enlarged in inflammation or malignancy
Edges: irregular/infiltrative/well-defined
•
•
•
•
•
Palpate axillary tail
Palpate nipple
oIf patient reports nipple discharge, ask them to gently squeeze the nipple to
demonstrate
Palpate along inframammary fold
Palpate axillary lymph nodes
oSupport patient arm & feel apex, anterior wall, posterior wall, medial wall &
lateral wall of axilla
Palpate supraclavicular lymph nodes
Assess for surgical complications in post-op patient
•
Push against wall: look for winging of scapula (long thoracic nerve injury)
•
Assess T2 dermatome sensation (intercostobrachial nerve injury)
Completion
•
Offer to examine opposite side if not done
•
Respiratory, abdominal & spine exam for evidence of metastases
•
Encourage self-examination to patient
•
Proceed to complete triple assessment
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
•
Summarise your findings
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DIFFERENTIAL DIAGNOSIS OF A BREAST LUMP
Benign:
• Fibroadenoma
•Intraductal papilloma
• Lipoma
• Breast cyst
• Abscess
Premalignant:
• Ductal carcinoma in-situ (DCIS)
• Lobular carcinoma in-situ (LCIS)
Malignant:
• Invasive ductal carcinoma (80%)
• Invasive lobular carcinoma (10%)
• Other, e.g., inflammatory breast cancer (10%)
Triple Assessment of Breast Lump:
• Clinical examination
• Imaging (US/Mammogram)
• Fine needle aspiration cytology/core biopsy
CUSHING’S SYNDROME EXAMINATION
Cushing’s Syndrome:
•Collection of stereotypical features due to persistently elevated glucocorticoid
levels
Cushing’s Disease: :
•Benign ACTH-secreting pituitary adenoma causing overstimulation of adrenal
cortex (a cause of Cushing’s syndrome)
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose patient (top off)
Position appropriately (supine at 45o)
Ask patient if in any pain
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General Inspection
•
•
•
•
•
Central obesity & peripheral muscle wasting
Intra-scapular fat pad (‘Buffalo hump’)
Hirsuitism
Effects of osteoporosis (e.g., kyphosis)
Bedside signs
o Inhalers, nebulisers, oxygen (COPD/asthma) - may imply steroid use
o Bedside glucometer (secondary diabetes)
Hands & Arms
•
•
•
•
•
Capillary glucose pin-prick marks on pulps of fingers (secondary diabetes)
Skin quality:
o Thin skin
o Striae
o Pigmentation (Cushing’s disease)
o Bruising
o Poor wound healing
Deforming polyarthropathy (RA): may imply steroid use
Offer to test BP (HTN)
Test shoulder abduction (proximal myopathy)
Face
•
•
•
•
•
Facial mooning
Acne
Hirsuitism
Facial plethora
Male pattern alopecia
Eyes
•
•
Test visual fields (bitemporal hemianopia in pituitary adenoma)
Signs of hypertensive or diabetic retinopathy
Mouth
•
•
Oral candidiasis in steroid use
Listen for hoarseness of voice
Neck
•Intrascapular fat pad (Buffalo hump)
• Supraclavicular fat pads
• JVP in cases of Cushing’s syndrome associated cardiomyopathy
Chest & Back
•
Kyphosis
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Abdomen
•
•
•
Purple striae (& other skin changes as listed before)
Central obesity
Lipodystrophy (insulin injections in diabetics)
Legs
•
Proximal myopathy (ask patient to stand from seated position with arms folded)
Completion
•
Screen for complications:
o Capillary blood glucose (DM)
o U&E (hypokalaemia)
o Bone scan (Osteoporosis)
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations (to confirm diagnosis):
o 24hr urinary cortisol
o Low dose dexamethasone suppression test
oOnce Cushing’s syndrome is confirmed then determine if ACTH dependant of
independent by checking serum ACTH
ADDITIONAL NOTES
CAUSES OF CUSHING’S SYNDROME
ACTH-dependent
• Cushing’s disease (pituitary adenoma)
• Ectopic ACTH-producing tumour (e.g., SCLC, Carcinoid tumour)
ACTH-independent
• Iatrogenic steroids
• Adrenal cortex adenoma/carcinoma
Pseudo-Cushing’s
• C2H5OH abuse
SIDE EFFECTS OF CORTICOSTEROIDS*
Mnemonic CUSHINGOID
• Cataracts
• Ulcers
• Skin changes (thin skin, easy bruising, striae, acne)
• Hypertension, hirsuitism
• Immunosuppression, infection
• Necrosis of femoral heads
• Glucose elevation (diabetes mellitus)
• Osteoporosis, obesity
• Impaired wound healing
• Depression & mood changes (psychosis)
*These are also the clinical features of Cushing’s syndrome
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A C R O M E G A LY E X A M I N A T I O N
Introduction
•
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider chaperone
Expose patient (top off)
Position appropriately (supine at 45o)
Ask patient if in any pain
General Inspection
•
•
Height
Proportion
o Increased hand/foot/head size relative to rest of body
Hands
• Large, spade-like hands
• Capillary glucose pin-prick marks on fingers (diabetes)
• Palms: Sweaty, boggy texture
•Signs of carpal tunnel syndrome (assess median nerve as per hand neurological
exam)
Arms
•
•
Offer to check BP (HTN)
Check for axillary skin tags
Face
•
•
•
•
•
•
‘Coarse’ features
Prominent supraorbital ridges
Acne
Enlarged ears & nose
Prognathism (enlarged, protruding mandible – best seen from side)
Husky, low-pitched voice
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B rea st a nd Endocrine Exa mina t ion
Eyes
• Visual fields (bitemporal hemianopia in pituitary adenoma)
•Fundoscopy to assess for diabetic/ hypertensive retinopathy and also optic
atrophy
•Visual acuity
Mouth
•
•
Macroglossia
Widely-spaced teeth (dental splaying)
Neck
•
•
•
Thyroid goitre (due to increased growth hormone)
Raised JVP (cardiomyopathy)
Acanthosis Nigricans
Chest
•
•
•
Multiple skin tags
Acanthosis nigricans
Features of cardiac failure (auscultate lung bases)
Legs
•
Proximal myopathy (ask patient to stand from seated position with arms folded)
Completion
• Offer to perform full cardiovascular exam (cardiomyopathy, HTN)
•Thank patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Further investigations:
oGlucose tolerance test - positive test shows lack of suppression of growth
hormone (occasionally a paradoxical rise)
o IGF-1
o 12-lead ECG, Echocardiogram (cardiomyopathy)
o Capillary blood glucose (diabetes)
o MRI (pituitary adenoma)
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ADDITIONAL NOTES
FEATURES OF ACROMEGALY
Mnemonic HOT ACROMEGALY
• Heart failure, hypertension
• Oedema (not truly oedema but swelling of hands & feet)
• Teeth widely spaced
• Appearance, amenorrhoea
• Carpal tunnel syndrome, coarse skin, coarse voice
• Reek (body odour secondary to sweating)
• Oily skin
• Myopathy
• Eyes (visual field defect, prominent supraorbital ridges)
• Goitre, Gain weight, Galactorrhoea
• Arthropathy
• Large tongue, ears & nose, Loss of libido
• pituitarY adenoma (cause in 98% of cases)
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B rea st a nd Endocrine Exa mina t ion
COMMONLY PRESCRIBED MEDICATIONS – ENDOCRINE SYSTEM
Drug type
Common indications
Examples
Insulins and insulin
analogues
Diabetes mellitus (type 1
and type 2)
Fast acting:
Insulin neutral (actrapid)
Insulin aspart (novorapid)
Long acting:
Insulin glargine (lantus)
Insulin detemir (levemir)
Biguanides
Type 2 diabetes mellitus
Metformin
Sulfonylureas
Type 2 diabetes mellitus
Gliclazide
Meglitinides
Type 2 diabetes mellitus
Repaglinide
Thiazolidinediones
Type 2 diabetes mellitus
Pioglitazone
SGLT-2 inhibitors
Type 2 diabetes mellitus
Empagliflozin
DPP-4 inhibitors
Type 2 diabetes mellitus
Sitagliptin
Alpha glucosidase
inhibitors
Type 2 diabetes mellitus
Acarbose
GLP-1 receptor agonists
Type 2 diabetes mellitus
Liraglutide
Thyroid hormones
Hypothyroidism
Levothyroxine
Antithyroid drugs
Hyperthyroidism
Carbimazole, propylthiouracil
Corticosteroids
Adrenal failure
Hydrocortisone
Mineralocorticoids
Adrenal failure
Fludrocortisone
Aldosterone antagonists
Hyperaldosteronism
Spironolactone
Dopamine receptor
antagonists
Prolactin secreting
pituitary adenoma,
acromegaly
Cabergoline
Somatostatin analogue
Acromegaly
Octreotide
Bisphosphonates
Hypercalcaemia
Zoledronic acid
Polypeptide hormone
Hypercalcaemia
Calcitonin
Vasopressin analogue
Diabetes insipidus
Vasopressin
Antifungal
Hypercortisolaemia
Ketoconazole
• Please note these do not constitute exhaustive list of medications or indications. Reference texts and/or
drug formularies should always be consulted for comprehensive medication and prescribing information.
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RCSI THREE-COLUMN OSCE GUIDE
Endocrine Examination - Neck exam
“This is a surgical station. You have 5 minutes to complete an examination of this patient’s neck. I
will then ask you to present your findings and answer a question”.
Examination
Expected/Normal Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• C
leans hands with alcohol
gel
Introduction, explanation and
consent
• Introduces self with name
and level, explains what
he/she will be doing and
obtains consent for same
‘Hi my name is X. I’m a third
year medical student at RCSI.
What’s your name? Nice to
meet you. I’ve been asked to
examine your thyroid today.
That will involve looking and
feeling for any abnormalities in
the neck. Would that be ok?’
Position and exposure
• Patient seated
• Neck and arms exposed
‘Mr/Mrs A is appropriately
positioned and exposed for
this examination.’
Enquires about pain
• Prior to examining
‘Are you in any pain?’
GENERAL INSPECTION
Performed from the end of
the bed
oInspects for
o Patient
o Equipment
‘On general inspection Mr/
Mrs A appears well, with
normal colour and body
habitus, no peripheral
stigmata of thyroid disease
and no equipment around
the bed.’
• Patient
o Myxoedema
o Tremor
o Sweating
o Obvious neck swelling
o Scars
o BMI
o Colour
• Equipment
oIV drips
o Walking aids
“On closer inspection there
are no obvious swellings,
masses or scars in the neck”
‘On closer inspection there is a mass
which…
• Moves upwards with swallowing
o Thyroid mass
• Moves upwards with tongue protrusion
o Thyroglossal duct cyst
NECK INSPECTION
Performed from both front
and side
• Inspects for
o Scars
o Massess
o Symmetry
• A
ssesses movement of
thyroid +/- masses on
swallowing and tongue
protrusion
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
B rea st a nd Endocrine Exa mina t ion
PALPATION
Performed standing behind
patient
• P
alpates both lobes of
thyroid with both hands
• P
alpates while getting the
patient to swallow and stick
out tongue
• Palpates for cervical and
supraclavicular lymph nodes
“On palpation the thyroid
gland is palpable. It
moves upwards with
swallowing. There are no
masses or asymmetries.
There is no evidence of
lymphadenopathy”
‘On palpation of the thyroid there is
• A mass present in the midline
approximately X x X cm in size which
moved upwards on protrusion of the
tongue. It was firm/soft/fluctuant with
regular well defined borders and was not
tender or warm.
o Thyroglossal duct cyst
• A large swelling in the midline. It is
smooth with regular borders and is
approximately Xcm in diameter. It moves
upward on swallowing and does not
move with protrusion of the tongue. It
is soft/firm/fluctuant and not tender or
warm.
o Goitre
• A small nodule in the anterior neck
just lateral to the midline. It is firm and
approximately X x Xcm in size. It is firm/
soft/fluctuant and has regular borders.
It is not tender or warm and moves
upwards with swallowing.
o Solitary nodule
PERCUSSION
• P
ercusses for retrosternal
extension – should strike
middle phalanx of third
finger with other third finger
“On percussion of the anterior
chest there was no evidence
of any dullness which may
suggest retrosternal extension
of a thyroid goitre”
• ‘’On percussion of the anterior chest
there was evidence of dullness
extending to _location_ which is
suggestive of retrosternal extension of
a goitre”
“On auscultation there were
no audible bruits.’’
• ‘‘On auscultation there was an audible
bruit over the right/left thyroid lobe’’
• ‘Pemberton’s sign is
negative.’
• ‘Pemberton’s sign is positive.’
AUSCULTATION
• A
uscultates both lobes of
thyroid for bruits
ADDITIONAL TESTS
• Pemberton’s
o Asks patient elevate both
arms until they touch sides
of face, observes for facial
congestion and cyanosis, as
well as respiratory distress
after approximately one
minute.
• C
omments that would
examine for features of
hypo/hyperthyroidism and
thyroid eye disease.
• ‘To complete my
examination I would assess
thyroid status and examine
for features of thyroid eye
disease.’
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RCSI THREE-COLUMN OSCE GUIDE
Endocrine Examination - Thyroid status
“This is an Endocrinology station. You have 5 minutes to assess this patient’s Thyroid Status. I will
then ask you to present your findings and answer a question”.
Examination
Expected/Normal Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• C
leans hands with alcohol
gel
For the purpose of this guide
 = associated with hyperthyroidism
 = associated with hypothyroidism
Introduction, explanation and
consent
• Introduces self with name
and level, explains what
he/she will be doing and
obtains consent for same
Hi my name is X. I’m a third
year medical student at RCSI.
What’s your name? Nice to
meet you. I’ve been asked to
examine your thyroid function
today. That will involve
looking and feeling for any
abnormalities in the neck as
well as examining you face,
arms and legs. Would that
be ok?’
Position and exposure
• P
atient seated
• Neck and arms exposed
• L egs bare below the knee
‘Mr/Mrs A is appropriately
positioned and exposed for
this examination.’
Enquires about pain
• Prior to examining
‘Are you in any pain?’
GENERAL INSPECTION
Performed from the end of
the bed
oInspects patient
for signs of hyper- and
hypothyroidism
‘On general inspection Mr/
Mrs A appears well, with
normal colour and body
habitus, no peripheral
stigmata of thyroid disease
and no equipment around
the bed.’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Patient
• Pretibial Myxoedema (Graves)
• Tremor ()
• Sweating ()
• Obvious neck swelling (/)
• Scars
• BMI (Low-/High-)
• Colour
B rea st a nd Endocrine Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
HANDS & ARMS
‘On examination of the hands
• E
xamines for clubbing &
& arms, there are no stigmata
acropachy
of thyroid disease evident.’
• F
eels palmar surfaces for
warmth, erythema and
sweating
• F
eels radial pulse & counts
heart rate
• A
sks patient to hold out
arms, places piece of paper
on hands, observing for fine
tremor.
• A
sks patient to hold arms
above head assessing for
facial plethora-Pemberton’s
o Asks patient elevate both
arms until they touch
sides of face, observes
for facial congestion
and cyanosis, as well as
respiratory distress after
approximately one minute.
•
•
•
•
•
•
•
Grade X clubbing ()
Acropachy ()
Palmar Erythema ()
Sweaty Palms ()
Pulse
o Irregular, tachycardia()
o Bradycardia ()
Fine tremor of hands ()
Pemberton’s sign is positive
o Goitre (/)
EYES
• Assesses for signs of eye
disease by observing the
eye & eyebrows from in
front & above patient.
• Assesses for lid lag by
asking the patient to follow
a finger, moving it along the
arc of a circle from a point
above patient’s head to a
point below their nose
• Assesses extraocular
movements by asking
patient to follow examiner’s
finger in a H pattern asking
if any pain or double vision.
‘On examination of the face,
there is no evidence of thyroid
eye disease.’
Signs of Thyroid Eye Disease
• Loss of outer 1/3 of eyebrow ()
• Periorbital oedema (/)
• Exophthalmos
Signs
• Lid retraction
specific
• Lid lag
to
• Chemosis
Graves
• Eyelid swelling /
erythema
NECK / THYROID GLAND
Performed from both front
and side
• Inspects for
o Scars
o Masses
o Symmetry
• Assesses movement of
thyroid +/- masses on
swallowing and tongue
protrusion
‘On closer inspection there are
no obvious swellings, masses
or scars in the neck’
‘On closer inspection there is a mass
which…
• Moved upwards with swallowing
o Thyroid mass
• Moved upwards with tongue protrusion
o Thyroglossal duct cyst
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Examination
Expected/Normal
Comments
Potential/Abnormal Comments
“On palpation the thyroid
gland is palpable. It
moves upwards with
swallowing. There are no
masses or asymmetries.
There is no evidence of
lymphadenopathy”
‘On palpation of the thyroid there is
• A large swelling in the midline. It is
smooth with regular/irregular borders
and is approximately Xcm in diameter. It
moves upward on swallowing and does
not move with protrusion of the tongue.
It is soft/firm/fluctuant and not tender
or warm.
o Multinodular goitre / dominant
nodule
‘On percussion of the anterior
chest there was no evidence
of dullness which might
suggest retrosternal extension
of a thyroid goitre’
‘’On percussion of the anterior chest
there was evidence of dullness extending
to _location_ which is suggestive of
retrosternal extension of a goitre”
‘On auscultation of the
thyroid, there were no audible
bruits.’
• ‘There a bruit was audible over the right
/ left thyroid lobe.’
‘On examination of the
legs, there are no skin
changes, normal ankle jerks
& no evidence of proximal
myopathy.’
• Pretibial myxoedema ( Graves)
• Proximal myopathy ()
• Hyporeflexia ()
PALPATION
Performed standing behind
patient
• P
alpates both lobes of
thyroid with both hands
• P
alpates while getting the
patient to swallow and stick
out tongue
• P
alpates for cervical and
supraclavicular lymph nodes
PERCUSSION
• P
ercusses for retrosternal
extension – should strike
middle phalanx of third
finger with other third finger
AUSCULTATION
• A
uscultates both lobes for
bruits
LOWER LIMB EXAMINATION
• O
bserves distal legs for
swelling & skin changes
(pretibial myxoedema)
• P
roximal Myopathy – asks
patient to stand from a
seated position with arms
crossed.
• Checks ankle jerks
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B rea st a nd Endocrine Exa mina t ion
RCSI THREE-COLUMN OSCE GUIDE
Breast Examination
“This is a surgical station. You have 5 minutes to complete a breast examination. I will then ask you
to present your findings and answer a question”.
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
INTRODUCTION
Hand hygiene
• C
leans hands with alcohol gel
Introduction, explanation and
consent
• Introduces self with name and
level, explains what he/she will
be doing and obtains consent
for same
• Get a chaperone
‘Hi my name is X. I’m
a third year medical
student at RCSI. What’s
your name? Nice to meet
you. I’ve been asked to
examine your breasts
today.This will involve
me looking and feeling
for any abnormalities.
Is that ok? I’m going to
ask one of the nurses
to chaperone this
examination, is that ok?
Position and exposure
• Patient seated upright
• A
rms and shoulders exposed
down to the waist
‘Mr/Mrs A is
appropriately
positioned and
exposed for this
examination.’
Enquires about pain
• Prior to examining
‘Are you in any pain?’
GENERAL INSPECTION
Performed from the end of the
bed
oInspects for
o Patient
o Equipment
‘On general inspection
Mr/Mrs A appears well,
with normal colour
and body habitus. The
breasts are symmetrical
with no obvious
abnormality from the
end of the bed.’
• Patient
o Mastectomy
o Obvious scars
o Obvious asymmetry
o Large lump
o Cachexia/increased body habitus
• Equipment
o Walking aids
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Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘On closer inspection
both breasts appear
normal and symmetrical
with no obvious
stigmata of breast
disease.’
Skin: ‘There are visible skin changed noted
in the left/right/both breast/s:
• Asymmetry
• Scars
o Mastectomy scars – approx. Xcm in
length, looks well healed/new, with/
without a drain in situ
o Sentinel lymph node scar in R/L axilla
o Reconstruction scars
– Back- Latissimus Dorsi
– Abdomen- DIEP
• Lump/s
o Site, shape, size
• Skin changes
o Peau d’orange
o Skin tethering/dimpling
• Nipple changes
o Retraction
o Paget’s disease of the nipple
CLOSER INSPECTION
Performed from right hand side
of bed
Examines the patient:
• 1: Arms relaxed on legs
• 2
: Sitting down, hands on hips,
pressing downwards (tenses
pectoral muscles)
• 3
: Hands behind head (expose
whole breast and accentuate
dimpling)
• If patient has large breasts uses
back of hand to lift breast and
expose the submammary folds
• Under both arms
Inspects for:
• Asymmetry
• Scars
• Lumps
• Skin changes
• Nipple changes
PALPATION
• Examines both breasts lying
45deg, all four quadrants in a
systematic way
• Palpates axillary tail
• If lump present, comments on
features
o Size, shape, surface, borders,
Consistency, tenderness,
warmth, mobile…
‘On palpation of
both breasts no
abnormalities were
detected. No lumps
were palpable.’
On palpation there was a lump detected
in the:
• Location: left/right upper/lower outer/
inner quadrant.
• Size: (X)cm by (X)cm in size,
• Description: mobile/immobile/tethered
to underlying structures, smooth/irregular,
rubbery/craggy/hard consistency,
discharge/no discharge, tender/non
tender, hot/warm/normal temperature.
LYMPHADENOPATHY
• Palpates axillary lymph nodes
o Anterior
o Posterior
o Medial
o Lateral
o Apical
o Supraclavicular
‘There was no palpable
lymphadenopathy in
either axilla.’
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
‘On palpation lymphadenopathy was
detected in the:
Location: anterior/posterior/medial/lateral/
apical/supraclavicular region of the left/right
axilla.’
B rea st a nd Endocrine Exa mina t ion
Examination
Expected/Normal
Comments
Potential/Abnormal Comments
‘Thank you Madam.
Would you like any help
getting dressed?’
• ‘In conclusion there was a mass palpable
on the upper/lower inner/outer
quadrant of the breast. The mass was
approximately Xcm by Xcm in dimension
and had/had no overlying skin changes
such as tethering/peau d’orange/nipple
retraction/dimpling. There was/was no
axillary lymphadenopathy appreciable.’
• If there was a scar instead of a mass:
location (as above), length of scar, well
healed/new, skin changes/erythema.
CONCLUSION
• Thanks patient
• Triple assessment
o History & Physical exam
o Imaging  US/mammogram
o Biopsy  FNA, core biopsy
In conclusion this was
a normal breast exam.
I would like to follow
up and complete a
triple assessment with
imaging (ultrasound if
<35y and mammogram
if >35y) and tissue
biopsy (either FNA or
core biopsy)
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CHAPTER 13
RENAL AND
GENITOURINARY
EXAMINATION
RENAL
E X A M I N AT I O N
TESTICULAR
E X A M I N AT I O N
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R E N A L E X A M I N AT I O N
Introduction
•
•
•
•
•
•
Wash hands
Introduce yourself & confirm patient details
Explain examination & gain consent
Consider a chaperone
Expose the patient (xiphisternum to the waist)
Position the patient (supine)
General Inspection
•
•
•
•
General appearance
o Unwell / Distressed / Tachypnoeic
o Fluid overload – peripheral oedema
Peripheral equipment
o Oxygen tubing, peripheral or central lines, drains, indwelling catheters
o Bedside medications, infusion stands, etc.
Nutrition status/cachexia
Colour
o Yellow tinge from uraemia
Nails
•
•
Leukonychia
o White transverse lines on the nail
– Hypoalbuminaemia associated with nephrotic syndrome
o Distal nail is brown and the proximal nail is pink
– Associated with renal failure
Capillary refill
Hands and arms
•
•
•
•
Bruising
o Fingertip bruising from blood glucose monitoring
Flapping tremor (asterixis)
o Uraemia
Fistulae
o If found at the wrist= most likely radiocephalic
oIf found at the anterior cubital fossa= may be brachio-basilic or brachiocephalic
o Palpate for thrill
o Auscultate for bruit
Scratch marks
o Uraemic pruritus
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•
•
Blood pressure
o Hypertension in renal pathology
Parathyroid implantation scar
Face / Eyes / Mouth & Neck
•
•
•
•
•
•
Central cyanosis
Periorbital oedema
o Nephrotic syndrome
Conjunctival pallor
o Anaemia due to renal failure
Mouth dryness / ulceration - immunosuppression
Fetor
Check the JVP for signs of fluid overload
Chest
•
•
Heart
o Heart failure
o Pericarditis
Lungs
o Fluid overload
Abdomen Inspection
•
•
•
Scarring from previous abdominal or renal surgery or peritoneal dialysis
Examine the flanks
Fat necrosis / fat hypertrophy
o Insulin injections
Palpation
•
•
•
•
•
•
You should be level with the abdomen, ask if they have any pain
Keep watching patient’s face as you palpate
Start furthest point away from tender area
All 9 areas of the abdomen
Light palpation:
o Feeling for tenderness, guarding, superficial lumps/masses
Deep palpation:
o Assess for deep lumps/masses
Examining the kidneys
• Place one hand on the anterior abdominal wall and the other in the renal angle
• Ask the patient to breathe out, you then gently press up with the posterior hand
• At the same time, palpate down with the anterior hand
•You can flex the MCP joints of the posterior hand as you attempt to feel the
kidney from above
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Re n a l a nd Genitourina ry Exa mina t ion
Percussion
•
•
Assess for ascites
Percuss the 9 regions of the abdomen and the flanks
o The flank should be resonant
Auscultation
•
Assess for renal bruits
o Listen 1cm superior and lateral to the umbilicus bilaterally
Completion
• Offer to perform full gastrointestinal examination
•Thank the patient, help them dress (if requested or required, ensuring consent for
assistance has been obtained) & wash hands
• Summarise your findings
• Suggested further investigations:
o Urinalysis
o Fundoscopy to assess for diabetic or hypertensive changes
T E S T I C U L A R E X A M I N AT I O N
A testicular or scrotal examination may form part of a renal or abdominal examination,
particularly when hernias are suspected. Yet scrotal pain and swelling is a common
stand- alone presentation to the primary and emergency care settings.
If you are asked to perform such an examination, a structured approach is important.
Introduction
• Wash hands
• Introduce yourself & confirm patient details
• Explain examination & gain consent
• Consider a chaperone
• Use gloves
• Expose the patient (umbilicus to below the waist)
•The patient should stand to assess the male external genitalia but can lie supine
for examination
•Stay to the side of the patient and do not examine from directly in front of the
patient
General Inspection
•Inspect the penis from all sides
o Comment on lumps / bumps / swellings or scars
•Inspect the scrotum in the same way
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•
•
o The patient may oblige by moving the penis out of the way
o Comment on the lie of the testicles
– Normal
– Bell clapper deformity (1:125 men) - Transverse lie
Testicle lacks the normal attachment to the tunica vaginalis
– High riding testicle with decreased cremasteric contraction
Concerning for torsion
o Look for discolouration in the scrotal skin
Examination
Palpation
• Using the index finger and thumb, both testicles are examined individually
• Keep watching face of patient as you palpate
•If you cannot palpate a testicle, start palpating along the course of the spermatic
cord through the inguinal canal to check for an undescended testicle
o If the testicle was removed, then this is not necessary
• Examine the epididymis on both sides
• Examine the spermatic cord on both sides
• Examine the inguinal lymph nodes
•
If you notice a lump or mass:
o Can you get above the mass?
–If not, consider a hernia
o Is the mass related to the testicle?
o Is there a cough impulse?
– Consider a hernia / varicocele
o Is the mass transluminable?
DESCRIBING A SCROTAL LUMP ON INSPECTION
REMEMBER THE 6 Ss OF LUMP INSPECTION
Site: Where is it anatomically located
Size: Rough estimate in cm (e.g., 3cm x 2cm)
Shape: Round/oval/irregular
Symmetry: Both symmetry about it’s own axis & with opposite side of body where
relevant
Skin changes: Erythema/ulceration/punctuation
Scars: From previous surgery/trauma
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Re n a l a nd Genitourina ry Exa mina t ion
DESCRIBING A SCROTAL LUMP ON INSPECTION
Remember mnemonic for describing a lump on palpation:
3 Teachers around a CAMPFIRE
Tenderness: Inflammation
Temperature: Inflammation Transillumination: Fluid-filled cystic lesion
Consistency: Hard/firm/soft
Appearance: General appearance of the patient
Mobility: Is it fixed/tethered to overlying & underlying structures?
Pulsatile & expansile: Implies arterial lesion
Fluctuant: Attempt to ‘bounce’ lump between your two index fingers (lipomas are
fluctuant)
Irreducible: Attempt to reduce & check for cough impulse if hernia suspected
Regional lymph nodes: Enlarged in inflammation or malignancy
Edges: irregular/infiltrative/well-defined
Completion
•
•
•
•
Examine the supraclavicular fossae
oTesticular malignancy spreads to the para-aortic nodes which are difficult to
appreciate but the supraclavicular nodes are readily examinable
Perform an abdominal examination
Thank the patient and wash your hands
Summarise your findings
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R enal a n d G e n i t o u r in a ry Ex amin at io n
COMMONLY PRESCRIBED MEDICATIONS – NEPHROLOGY, GENITOURINARY
Drug type
Common indications
Examples
Antihypertensives
(ACEI, ARB, CCB, BB,
Alpha blockers)
Hypertension associated
with renal disease. ACEI
may slow decline in
kidney function
See cardiology chapter
Diuretics
Volume overload in CKD
Furosemide
Erythropoiesis
stimulating agents
Anaemia
Epoetin alfa
Iron supplements
Iron deficiency anaemia
Ferrous fumarate
Phosphate binders
Renal mineral bone
disease
Sevalamer
Vitamin D analogues
Renal mineral bone
disease
Calcitriol
Calcimimetics
Renal mineral bone
disease
Cinacelcet
Hyperkalaemia
management
Hyperkalaemia
Acute: Insulin/dextrose,
calcium gluconate,
salbutamol
Chronic: Calcium resonium
Immunosuppressants
Renal transplant
Tacrolimus, cyclosporine,
mycophenolate mofetil
Antimicrobials
Prevention of
opportunistic infection
post-renal transplant
Co-trimoxazole (antibiotic)
Muscarinic receptor
antagonist
Overactive bladder
Tolterodine, solifenacin
Beta-3 adrenergic
agonist
Overactive bladder
Mirabegron
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Valganciclovir (antiviral)
Fluconazole (antifungal)
Re n a l a nd Genitourina ry Exa mina t ion
Drug type
Common indications
Examples
5-alpha reductase
inhibitors
Benign prostatic
hypertrophy
Finasteride, dutasteride
Alpha blockers
Benign prostatic
hypertrophy
Tamsulosin
Oral contraceptives
Contraception, polycystic
ovarian syndrome,
endometriosis
Ethinylestradiol/
levonorgestrel (COCP)
Urinary tract infection:
Uncomplicated
Nitrofurantoin, trimethoprim
Complicated
Ciprofloxacin, gentamicin,
amoxicillin/clavulanic acid,
cefuroxime
Antimicrobials
commonly used
Desogestrel (POP)
• Please note these do not constitute exhaustive list of medications or indications. Reference texts and/or
drug formularies should always be consulted for comprehensive medication and prescribing information.
PROCEDURAL
SKILL
URINARY
CATHETHERISATION
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References
REFERENCES
Chapter 1 - The Calgary Cambridge model
Kurtz SM, Silverman JD, Draper J (2005) Teaching and Learning Communication Skills in Medicine
2nd Edition. Radcliffe Publishing (Oxford) Silverman JD, Kurtz SM, Draper J (2005) Skills for
Communicating with Patients 2nd Edition. Radcliffe Publishing (Oxford)
Kurtz S, Silverman J, Benson J, Draper J (2003) Marrying Content and Process in Clinical Method
Teaching: Enhancing the Calgary-Cambridge Guides Academic Medicine;78(8):802-809
Chapter 3 - Active Listening
Brenda Comeaux Trahan & Patricia Rockwell (1999) The Effects of Listening Training on Nursing
Home Assistants: Residents' Satisfaction with and Perceptions of Assistants' Listening Behavior,
International Journal of Listening, 13:1, 62-74, DOI: 10.1080/10904018.1999.10499027
Wanzer, M. B., Booth-Butterfield, M., & Gruber, K. (2004). Perceptions of health care providers'
communication: relationships between patient-centered communication and satisfaction. Health
communication, 16(3), 363–383. https://doi.org/10.1207/S15327027HC1603_6
Stewart M. A. (1995). Effective physician-patient communication and health outcomes: a review.
CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne,
152(9), 1423–1433.
Janis Davis, Amy Foley, Nancy Crigger & Michael C. Brannigan (2008) Healthcare and
Listening: A Relationship for Caring, International Journal of Listening,22:2, 168-175, DOI:
10.1080/10904010802174891
Wolvin, A. D., & Coakley , C. G. (1996). Listening. McGraw Hill.
Chapter 4 - Dying, Death and Bereavement
ALI, A., STAUNTON, M., QUINN, A., TREACY, G., KENNELLY, P., HILL, A., SREENAN, S. &
BRENNAN, M. 2021. Exploring medical students’ perceptions of the challenges and benefits of
volunteering in the intensive care unit during the COVID-19 pandemic: a qualitative study. BMJ
open, 11, e055001.
BEAR, L., SIMPSON, N., ANGLAND, M., BHOGAL, J. K., BOWERS, R., CANNELL, F., GARDNER,
K., LOHIYA, A., JAMES, D. & JIVRAJ, N. 2020. 'A good death'during the Covid-19 pandemic in
the UK: a report on key findings and recommendations.
DAVIDSON, J. & DOKA, K. J. 1999. Living with grief: At work, at school, at worship, Psychology Press.
IRISH HOSPICE FOUNDATION. 2022. Adult Bereavement Care Pyramid. A National Framework. [Online]. Dublin: The Irish Hospice Foundation. [Accessed 06/07/2022].
JACKSON, V. A., SULLIVAN, A. M., GADMER, N. M., SELTZER, D., MITCHELL, A. M., LAKOMA,
M. D., ARNOLD, R. M. & BLOCK, S. D. 2005. “It was haunting…”: physicians’ descriptions of
emotionally powerful patient deaths. Academic Medicine, 80, 648-656.
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R efere n ce s
KAUL, V., DE MORAES, A. G., KHATEEB, D., GREENSTEIN, Y., WINTER, G., CHAE, J., STEWART, N. H., QADIR, N. & DANGAYACH, N. S. 2021. Medical education during the
COVID-19 pandemic. Chest, 159, 1949-1960.
LUNNEY, J. R., LYNN, J. & HOGAN, C. 2002. Profiles of older medicare decedents. Journal of the American Geriatrics Society, 50, 1108-1112
https://www.rand.org/pubs/white_papers/WP137.html
MATTHEWS S, P. M., O'BRIEN GREEN S, HURLEY E, JOHNSTON BM, NORMAND C, MAY P. 2021. Dying and death in Ireland: what do we routinely measure, how can we improve?
Dublin: Irish Hospice Foundation.
MCLOUGHLIN, K. 2018. Enhancing adult bereavement care across Ireland: A study. Dublin: The Irish Hospice Foundation.
PEARCE, C., HONEY, J. R., LOVICK, R., CREAMER, N. Z., HENRY, C., LANGFORD, A., STOBERT, M. & BARCLAY, S. 2021. ‘A silent epidemic of grief’: a survey of bereavement care
provision in the UK and Ireland during the COVID-19 pandemic. BMJ open, 11, e046872.
RHODES-KROPF, J., CARMODY, S. S., SELTZER, D., REDINBAUGH, E., GADMER, N., BLOCK, S. D. & ARNOLD, R. M. 2005. “This is just too awful; I just can’t believe I experienced
that…”: medical students’ reactions to their “most memorable” patient death. Academic
Medicine, 80, 634-640.
RYAN K, CONNOLLY M, CHARNLEY K, AINSCOUGH A, CRINION J, HAYDEN C, KEEGAN O, LARKIN P, LYNCH M, MCEVOY D, MCQUILLAN R. Palliative care competence framework 2014. Health Service Executive (HSE); 2014.
SALLNOW, L., SMITH, R., AHMEDZAI, S. H., BHADELIA, A., CHAMBERLAIN, C., CONG, Y., DOBLE, B., DULLIE, L., DURIE, R. & FINKELSTEIN, E. A. 2022. Report of the Lancet
Commission on the Value of Death: bringing death back into life. The Lancet.
SMITH-HAN, K., MARTYN, H., BARRETT, A. & NICHOLSON, H. 2016. “That’s not what you
expect to do as a doctor, you know, you don’t expect your patients to die.” Death as a learning
experience for undergraduate medical students. BMC medical education, 16, 1-8.
THE IRISH HOSPICE FOUNDATION 2022. Statement of Strategy 2020–2025. Dublin: The Irish Hospice Foundation.
WEAFER, J. 2014. Irish attitudes to death, dying and bereavement 2004-2014.
WORLD HEALTH ORGANIZATION. 2019. ICD-11: International classification of diseases [Online]. World Health Organization. [Accessed 04/07/2022].
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Append ix
APPENDIX 1
RCSI CLINICAL SKILLS VIDEOS
PROCEDURAL SKILLS VIDEOS
Peak Flow
https://www.youtube.com/watch?v=B8ydNfWpUlM&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=1
Instruction on the use of an Inhaler
https://www.youtube.com/watch?v=0YSpLgdX54s&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=2
Subcutaneous Injection
https://www.youtube.com/watch?v=xlSM5XoJKKI&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=3
Hand Rub
https://www.youtube.com/watch?v=KrIbcpb8_Ys&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=4
O2 Devices
https://www.youtube.com/watch?v=D57EmedhkYk&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=5
Intravenous Cannulation
https://www.youtube.com/watch?v=jZt3qzQccDE&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=6
ECG
https://www.youtube.com/watch?v=I40QigeTq7g&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=7
ABG
https://www.youtube.com/watch?v=oyDPxI5PnWg&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=8
Blood Cultures
https://www.youtube.com/watch?v=fTiKvRBbMoE&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=9
Urinalysis
https://www.youtube.com/watch?v=r02WmfJ7vR4&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=10
IM Injection
https://www.youtube.com/watch?v=4589ztzwYpY&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=11
Urinary Cathetherisation
https://www.youtube.com/watch?v=2AMJd6VsOZs&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=12
NASO Gastric Insertion
https://www.youtube.com/watch?v=f3__CnUOnKc&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=13
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Appen d ix
Sterile Gloving
https://www.youtube.com/watch?v=5R5jqHyOnwI&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=14
Blood Glucose Testing
https://www.youtube.com/watch?v=S-9ZQXhPKeA&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=15
Taking a set of Vital Signs
https://www.youtube.com/watch?v=GPKc2IzxZ9s&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=16
Pregnancy Test
https://www.youtube.com/watch?v=hXoUwvNSDTQ&list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK&index=17
RCSI Procedural Skills Video
https://www.youtube.com/playlist?list=PLqoRzG2qRs5Ijbt3Ltxib_7QNpk0W5KCK
CLINICAL EXAMINATION VIDEOS
Cardiovascular Exam
https://www.youtube.com/watch?v=-DiPWX9xLVs
Respiratory Exam https://www.youtube.com/watch?v=VWv-BcaFGVs
GI Exam https://www.youtube.com/watch?v=y3rLZw20UsE
PNS Upper Limb Exam
https://www.youtube.com/watch?v=Rc6ACDIu_bY&feature=youtu.be
PNS Lower Limb Exam https://www.youtube.com/watch?v=K7NIxnu4MTM&feature=youtu.be
Cranial Nerve Exam https://www.youtube.com/watch?v=UelA7rPoblo
Vascular exam (PAD, AAA, Ulcers exams)
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=55f905c4-ac19-49a5-af9478d3a07b7051
Mass Hernia Patient
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=150caf00-d239-420a-8d79-ac0900fcb9e2
AAA Patient
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=fb034575-385f-438d-8f16-ac0900fcb084
Divarication Patient
https://rcsi.cloud.panopto.eu/Panopto/Pages/Embed.aspx?id=ee494d53-aa04-4781-9250ac0900fc03a6
Clinical Examination of the Respiratory Examination
https://www.youtube.com/watch?v=4a7VkGMKaO0&list=PLh2OGLKGhHaCMPcmM0WGVhfBalZ8aXDkx&index=3
RCS I H a n d b o o k o f C l i nic al S k il ls 2 nd Ed it io n
Append ix
Clinical Examination of the Cardiovascular System
https://www.youtube.com/watch?v=FQmPzIGe1qI&list=PLh2OGLKGhHaCMPcmM0WGVhfBalZ8aXDkx&index=2
Demonstrating Extraocular Movement
https://vle.rcsi.com/mod/page/view.php?id=287368
Demonstrating Fundoscopic Eye Exam
https://vle.rcsi.com/mod/page/view.php?id=287369
Thyroid Examination
https://vle.rcsi.com/mod/folder/view.php?id=291819
Vascular Exam
https://vle.rcsi.com/mod/folder/view.php?id=291819
Paediatric Neurological Examination in a Child
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=8d7803d9-569a-4ae0-a2c2ac6100ae94da
Paediatric MSKpGALS in a child
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=7e646c22-aea2-423c-85e3ac6100a26277
Surface anatomy video
https://vle.rcsi.com/mod/book/view.php?id=151458
HISTORY TAKING VIDEOS
Flawed Communication
https://www.youtube.com/watch?v=iezthflsFp4
Effective communcation https://www.youtube.com/watch?v=MyKfYCZG-l0
Vascular History
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=c3771cf3-ca96-47c9-a2f10a4d227a007a
GP History Taking Videos
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=129e094b-0f61-4781-acd3ac1000ae97b3
GP History Taking Videos
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=ba459c11-0054-48a0-8f10ac1000ae98d6
OBS/GYN
Post Term Pregnancy Consultation
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=2daa8f5a-e8f8-4aa6-8570ae2200bf8317
Poor Counselling Station
https://rcsi.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=1701571a-8ebd-4aea-8bcd-abcf00e7cf11
PSYCHIATRY
History taking - bipolar affective disoder
https://vle.rcsi.com/mod/book/view.php?id=234464
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Royal College of Surgeons in Ireland
123 St Stephen’s Green, Dublin 2, Ireland
www.rcsi.com
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