Clinical Skills Handbook 2015 MEDN40060 2

8/20/2019 Clinical Skills Handbook 2015 MEDN40060 2

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Clinical Skills Handbook

Clinical Skills PMC Module

MEDN 40060

Dr G Chadwick/Dr AB Mongey

September 2015

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INTRODUCTION TO HISTORY TAKING

It is extremely important that you should do the following each time

before taking a History or performing a Clinical Examination on a

Patient:

1. Introduce oneself to the patient.

2. Ask the patient how he/she would like to be addressed e.g. Mary or Mrs. Smith

3. Explain what you would like to do e.g. ask some questions, perform an

examination etc.

4. Obtain consent for same. – REMEMBER THAT IF THE PATIENT DOES NOT

GIVE HIS/HERCONSENT YOU CANNOT CONTINUE.

5. Ensure patient is comfortable.

Recommended Textbook: Clinical Examination. A systematic guide to

Physical Diagnosis by N.J. Talley and S. O’Connor

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CARDIOVASCULAR WORKSHOP A

Cardiovascular (CVS) History

Enquire re patient’s name and age

Identify the patient’s presenting complaint i.e. reason for coming to see a

physician and take history.

COMMON SYMPTOMS OF CARDIAC DISEASE:

! Chest pain/tightness/heaviness

! Dyspnoea/orthopnoea / paroxysmal nocturnal dyspnoea

! Ankle swelling

! Palpitations

! Syncope

CHEST PAIN

Where?

How long?

How did it occur?

Does it radiate anywhere?

How severe is the pain? - can use a 0-10 scale.

Is it getting better or worse?

Is it intermittent or constantly present?

Does anything bring on the pain?

Does anything make the pain better or worse?

Is there any other symptoms with the pain? Ask about cardiovascular symptoms.

Does the pain interfere with your ability to perform certain functions/activities?Have you ever had the pain previously? If yes, when, where, how often etc.

DYSPNOEA (difficulty with breathing)

When does it occur?

How long has it been occurring?

Does it wake the patient from sleep? = Paroxysmal Nocturnal Dyspnoea

Does it occur when lying supine? = Orthopnoea

How many pillows are needed to prevent the orthopnoea

How severe is the dyspnoea? e.g. does it interfere with talking?

Is it getting better or worse?Is it intermittent or constantly present?

Aims:! To be able to take a cardiovascular history

! To be familiar with common cardiovascular symptoms

! To know the risk factors for coronary artery disease.

! To be familiar with the common causes of chest pain.

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Does anything bring on the dyspnoea? does exertion brings on the dyspnoea, and if so,

how much exertion?

Does anything make the dyspnoea better or worse?

Are there any other symptoms with the dyspnoea? Ask about other cardiovascular

symptoms.

Does the dyspnoea interfere with your ability to perform certain functions/activities?

Have you ever had the dyspnoea previously? If yes, when, where, how often etc.

ANKLE SWELLING

How far up the legs does the swelling extend?

Did it come on suddenly or gradually?


Any precipitating factors, such as standing or sitting for prolonged periods of time?

When is the swelling worse? Does it improve with elevation/overnight?

Are there any other factors associated with the swelling?

PALPITATIONS

When do they occur?

Is the heartbeat slow or fast, regular or irregular?

How long have they been occurring?

How long do they last?

Are they increasing or decreasing in frequency?

Anything that precipitates the palpitations?Anything that relieves the palpitations?

Are there any other factors associated with the palpitations? e.g. dizziness/blackouts/

chest pain

SYNCOPE

When did it occur? What were the circumstances? e.g. rising from a seated position?

How long did it last?

Were there any warning symptoms that preceded the blackout?

Has it occurred previously?

Were there any other factors associated with the blackout? e.g. palpitations/dizziness/chest pain?

See Appendix I for clinical descriptors of cardiac symptoms

Past (Medical & Surgical) History:

! Enquire re previous history of heart disease and if so what type and what therapies

were used to treat it, including angioplasty or coronary artery bypass graft surgery

!Enquire re conditions known to predispose to cardiac disease such as: Diabetes,hyperlipidemia, hypertension, thyroid disease; rheumatic fever,

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Family History:

! Enquire re family history of coronary artery disease/ischaemic heart disease (IHD)

and if so, what age was the family member when he/she developed IHD?

! Enquire re history of Diabetes or hyperlipidemia among family members.

Social History:

! Ask if patient is smoker or non-smoker; if smoker enquire as to how many

cigarettes patient smokes/day & for how long; if non-smoker enquire if patient was

a former smoker.

! Ask is patient drinks alcohol & determine their usual daily/weekly consumption.

! Enquire as to the patient’s occupation and whether the patient can still perform his/

her occupation.

Medications:

Obtain a list of medications that the patient is taking including OTC medications.Enquire if the patient has any medication allergies.

TAKE A HISTORY

Risk Factors for Coronary Artery Disease

1. Previous coronary artery disease

2. Smoking

3. Raised Cholesterol (targets: Total Cholesterol


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CARDIOVASCULAR WORKSHOP B

CVS Examination I

1. EXAMINATION OF THE ARTERIAL PULSE

Arterial pulsation reflects various cardiac events in the cardiac cycle as well as certain

characteristics of the systemic arteries. Information about cardiac status can be

obtained from any artery that is palpable – the radial artery is used most commonly because of its accessibility.

Palpate the radial artery at the wrist just medial to the radius using the forefinger and

middle finger pulps of the examining hand

Characteristics of an Arterial Pulse:

1. Rate:

Count for 15 seconds; multiply by 4 to convert to beats per minute. Count for 60

seconds if pulse is irregular. Normal rate is between 60 and 100 beats/minute.

Bradycardia refers to a rate less then 60 per minute and tachycardia refers to rate

greater than 100 per minute

2. Rhythm:

Check whether the rhythm is regular or irregular. If the rhythm is irregular, check if it

is regularly irregular or irregularly irregular. A regularly irregular pulse may be due to

extrasystoles or due to sinus arrhythmia (pulse increases with each inspiration and

decreases with each expiration). An irregularly irregular pulse that is chaotic with no

pattern occurs in atrial fibrillation.

3. Character & Volume:

These are better assessed with the carotid or brachial artery. A collapsing pulse occurs

in aortic regurgitation and a small volume pulse occurs in aortic stenosis.

Evaluating for Radio-femoral Delay:

While palpating the radial pulse, also palpate the femoral pulse with the fingers of the

other hand (femoral pulse is detected below the inguinal ligament 1/3 of the way up

from the pubic tubercle). Delay between the two pulses suggests coarctation of the

aorta.

Aims:

! To take the arterial pulse accurately & be able to comment on rate, rhythm &

character of same

! To measure blood pressure completely and accurately

! To be familiar with the peripheral signs of cardiac disease

! To assess and measure the JVP

Causes of Bradycardia Causes of Tachycardia

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2. BLOOD PRESSURE MEASUREMENT

Systolic blood pressure is the peak pressure occurring in the artery following

ventricular systole. Diastolic blood pressure is the level to which pressure in the arteryfalls during ventricular diastole. Normal blood pressure is 140/90 or less. An indirect

measurement of blood pressure is obtained with a sphygmomanometer.

The Sphygmomanometer consists of:

a) an armlet or cuff (a rubber bladder covered with inextensible material),

b) a pump (a rubber bulb with valves) which inflates the cuff &

c) a pressure gauge (a mercury or aneroid manometer) which measures the

pressure in the inflated cuff.

Procedure for measuring Blood Pressure

1. Seat the patient with their bare arm resting on a table so the midpoint of the upper

arm is level with the chest

2. Locate the brachial artery on the inner side of the arm just above the antecubital

fossa and medial to the biceps tendon. Place the cuff so the midline of the bladder

is over the arterial pulse and wrap snugly around patient’s bare arm.

3. While palpating the radial pulse, inflate the cuff and note the pressure at which the

pulse disappears and subsequently reappears during deflation. This is the Palpation

Method (of Riva-Rocci) and gives a preliminary estimate of systolic blood

pressure. This preliminary estimation is important to avoid subsequent inaccurate

readings of blood pressure by auscultation in patients with very high or very low

blood pressures.

4. Place the bell of the stethoscope over the brachial artery just above antecubital

fossa but below the edge of the cuff.

5. Inflate the bladder rapidly to about 20mmHg above the estimated systolic blood

pressure. Then partially open the valve and deflate the bladder at a rate of about

2mmHg/sec while listening for the appearance of “Korotkov sounds”.

6. Note the pressures at which the sounds appear (phase I), the sounds become

muffled (phase IV) and the sounds disappear (phase V). This is the auscultatory

method of Korotkov. In Europe the diastolic pressure is taken as the point at which

! Physiological e.g. athletes

! Drugs e.g. beta-blockers, digoxin

! Hypothyroidism

! Raised intracranial pressure

! Hypothermia

!

Inferior myocardial infarction

! Hyperdynamic circulation e.g.

exercise, fever, hyperthyroidism,

pregnancy, anaemia

! Drugs e.g. beta-agonists

! Hypovolaemia

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sounds become muffled. In North America it is taken as the point at which sounds

disappear.

7. In practice, blood pressure should be measured on two separate occasions with a

period of a few minutes between. Record the blood pressure readings as follows

Phase I (SBP Palp) eg 140 (138 palp)

Phase IV – V 82 - 78

3. SIGNS OF CARDIAC DISEASE

General inspection:

! Is patient dyspnoeic or cyanosed?

! Nutritional status

Examination of hands:

! Note temperature / colour of hands/ presence of nicotine stains

! Check for clubbing

! Check for splinter haemorrhages( e.g., subacute bacterial endocarditis)

! Check for cyanosis (peripheral)

Clubbing: This is characterized by an increase in the soft tissue of the distal portion ofthe digits. Initially there is increased fluctuance of the nail bed, which feels boggy, and

loss of the angle between the nail bed and the digit. The fingernail needs to be

inspected from the side to determine if there is loss of the angle. Then an increase in the

longitudinal curvature of the fingernail develops. Finally the soft tissue of the distal

portion of the digits (overlying the distal phalanx) becomes enlarged and develops a

“club” like appearance.

Cardiac causes include: Cyanotic congenital heart disease; Infective endocarditis

Examination of head and neck:

!

Check the sclera for anaemia! Check mouth for central cyanosis

! Look for xanthomata

! Locate the carotid pulse and assess

Abdominal Examination:

! Palpate the abdomen for enlarged liver this can be seen with right sided failure.

Peripheral Oedema:

! Check for pitting ankle oedema

Chest Examination:

! Percuss and auscultate the chest to check for pulmonary oedema/pleural effusion

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4. JUGULAR VENOUS PULSE ASSESSMENT

! Position patient at 45° angle

! Ask the patient to turn his/her head to one side, in order to relax the

sternocleidomastoid (SCM) muscle

! Locate the internal jugular vein medial to the clavicular head of the SCM muscle.

! Measure the vertical height from the sternal angle (zero point) to the highest point

of the JVP - the vertical height should not be > than 3cm.

! Assess the character of the JVP wave

Features of a JVP:

! Visible but not palpable

! Diffuse waveform

! Increases with expiration; decreases with inspiration

! Can be obliterated; fills from above

Abdominojugular reflux test (Hepatojugular reflux) is a means of testing for ventricular

failure. Pressure exerted over the middle of the abdomen or liver for 10 seconds will

increase venous return to the atrium resulting in a transient rise in the JVP. The test is positive if it remains elevated for the duration of the compression: this is indicative of

right ventricular failure or elevated left atrial pressure.

Abnormalities of JVP:

Causes of elevated JVP : right ventricular failure;

tricuspid regurgitation;

pericardial tamponade;

superior vena caval obstruction

Giant “a” waves: pulmonary hypertension

tricuspid stenosis

Cannon waves: nodal rhythm (regular rhythm)

complete heart block (irregular rhythm)

Absent “a” waves: atrial fibrillation

Large “v” waves: tricuspid incompetence

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CARDIOVASCULAR WORKSHOP C

CVS Examination II

Aim: To locate the apex beat and listen to the heart sounds

! Inspection of praecordium e.g. for scars, pulsations or pacemakers.

Palpation of the heart:

! Locate the apex beat and assess its nature

! Palpate over the apex and valvular areas for thrills (palpable murmur).

! Palpate over the left parasternal area to assess for a heave – indicative of right

ventricular enlargment

Apex Beat:

The apex beat is an impulse generated by the systolic contraction of the left ventricle.

It is the most inferior and lateral palpable pulsation. Normally it is located in the 5th

left intercostal space, mid-clavicular line. The apex beat may be displaced laterally

and/or inferiorly when the heart is enlarged. The apex beat may not be palpable in

some patients, such as those with over-inflated lungs. If the apex beat is not palpable

with the patient lying down a further attempt should be made with the patient in an

upright position and if still not palpable with the patient on their left side.

The quality of the pulsation of the apex beat should also be noted e.g. a tapping apex

beat may be felt in mitral stenosis.

Note that the apex beat cannot be localized accurately with the patient in the left

lateral position but information may be obtained regarding its quality.

Auscultation of Heart:

Listen for heart sounds, added sounds, murmurs, pericardial rub.

! The first heart sound occurs at the beginning of systole and is the sound of

the mitral and tricuspid valves closing.! The second heart sound occurs at the end of systole and is the sound of the

aortic and pulmonary valves closing.

Murmurs are generated by turbulent blood flow, which usually results from structural

abnormalities of the heart valves or abnormal communications between the chambers

of the heart.

! If a heart valve is stenosed (narrowed) then is will generate a murmur when

the valve is open, e.g. aortic stenosis results in a systolic murmur, mitral

stenosis causes a diastolic murmur.

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! If a valve is incompetent/regurgitant (not closing properly) then the

murmur will occur when the valve is supposed to be closed e.g. mitral

incompetence results in a systolic murmur; aortic incompetence results in a

diastolic murmur.

Ausculatation of the heart sounds is performed with both the bell and diaphragm of the

stethoscope over the 4 valvular areas to evaluate for murmurs:

Aortic area (Right 2nd intercostal space)

Pulmonary area (Left 2nd intercostal space)

Tricuspid area (Left sternal border, 5th interspace)

Mitral area (Left 4th intercostal space, just medial to the mid-clavicular line)

When a murmur is detected one needs to determine:• its timing i.e. whether it is systolic or diastolic which is determined using the

carotid pulse• its intensity • if/where it radiates to e.g. mitral incompetence murmur radiates to the axilla.

Certain manoeuvres can be used to augment the sound of individual murmurs:

! Right sided murmurs become louder during inspiration and left sided murmurs are

louder during expiration.! Ask patient to lean forward and hold breath in expiration, listen at the left sternal

border for Aortic Regurgitation

! Ask patient to turn to the left and hold breath in expiration, listen to the mitral area

for Mitral Stenosis murmur.

Please refer to “Clinical Examination” textbook by N.J. Talley and S O’Connor for

further information regarding characteristics of murmurs.

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RESPIRATORY WORKSHOP A

Respiratory History


Enquire re patients presenting complaint, and obtain a history of the presenting

complaint

COMMON SYMPTOMS FOR RESPIRATORY DISEASE:

! Dyspnoea

! Cough

! Sputum

! Haemoptysis

! Wheeze

! Chest pain

DYSPNOEA (difficulty with breathing)

When does it occur?


Does it wake the patient from sleep?

How severe is the dyspnoea? e.g. does it interfere with talking?



Does anything bring on the dyspnoea? does exposure to dusts, allergens, exercise etc.

bring on the dyspnoea, and if so, how much exertion?

Does anything make the dyspnoea better or worse?

Are there any other symptoms with the dyspnoea? Ask about other respiratory

symptoms

Does the dyspnoea interfere with your ability to perform certain functions/activities?

Have you ever had the dyspnoea previously? If yes, when, where, how often etc.

COUGH

When does it occur?


Is the cough productive of sputum or is it a dry cough?

How severe is the cough? e.g. does it interfere with talking?



Does anything bring on the cough? e.g. exposure to dusts, allergens, exercise etc.

Does anything make the cough better or worse?Are there any other symptoms with the cough? Ask about other respiratory symptoms

Have you ever had the cough previously? If yes, when, where, how often etc.

Aim:! To obtain a complete history for the respiratory system

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SPUTUM

How long have you been coughing up sputum?

How much sputum do you cough up per day? e.g. teaspoonful/teacupful etc x times per

day

What colour is the sputum?

Any other factors associated with the production of sputum?

HAEMOPTYSIS (coughing up of blood)

How long have you been coughing up blood?

How much blood do you cough up per day e.g. teaspoonful/teacupful etc x times per

day

What colour is the blood? e.g. bright red or rusty colour etc

Any other factors associated with the production of sputum? e.g. weight loss, night

sweats

Common causes of Haemoptysis: Pneumonia, TB, Malignancy, Pulmonary Infarction

WHEEZE

When does it occur?


How severe is the wheeze? e.g. does it interfere with talking?



Does anything bring on the wheeze? e.g. exposure to dusts, allergens, exercise etc.

Does anything make the wheeze better or worse?Are there any other symptoms with the wheeze? Ask about other respiratory symptoms

Have you ever had the wheeze previously? If yes, when, where, how often etc.

CHEST PAIN

Where?

How long?




Is it intermittent or constantly present?Does anything bring on the pain?

Does anything make the pain better or worse? e.g. does breathing or coughing

aggravate the pain

Are there any other symptoms with the pain? Ask about other respiratory symptoms

Have you ever had the pain previously? If yes, when, where, how often etc.

OTHER SYMPTOMS:

! Fever

! Hoarseness

! Night sweats

Past Medical History:

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! Enquire re current, past and childhood illnesses, including Asthma, TB, Chronic

Bronchitis.

! Enquire as to any previous surgery.

Family History:

! Check for Family history of respiratory disease. Enquire about Asthma, Cystic

Fibrosis, and Emphysema. Also enquire re family history of TB.

Social History:

! Enquire re current employment, and previous employment particularly any

exposure to asbestos, dusts, chemicals etc.

! Ask patient specifically what they do at work as this may give major clues to

possible diagnosis.

! Exposure to dusts, animals and birds may all be relevant.

! Improvement in symptoms over the weekend or when patient is away from work,

may suggest an occupational lung disease.

! Check re smoking status (in pack years).

! Enquire re alcohol intake (can increase risk of TB, and aspiration pneumonias).

! Ask about the patient’s housing.

! Any recent travel?

! Also enquire about any hobbies (esp keeping budgerigars or pigeons)

Medications:

! Enquire if patient is taking any medications including OTC medications and herbal

supplements

! Ask about the use of medications such as NSAIDs and beta-blockers which may

worsen asthma

! Enquire re allergies

TAKE A HISTORY

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RESPIRATORY WORKSHOP B

Respiratory Examination I

Aim: To carry out a respiratory system examination on a patient – Part I

General inspection:

! Observe general appearance. Is patient breathless, in distress, or cyanosed?

! Determine the rate of patient’s breathing and note the depth and regularity of the

respirations

! Comment on any chest deformities, or asymmetry

! Check for use of accessory muscles

! Are there any obvious scars? e.g., thoracotomy scar

Inspection & Examination of hands:

! Assess hands for colour/ temperature

! Check for nicotine staining

! Check for clubbing

! Test for asterixis (flapping tremor of CO2 retention)

Respiratory causes for Clubbing: Bronchial carcinoma; chronic lung suppuration e.g.

abscess, bronchiectasis, Cystic fibrosis, Interstitial lung disease, mesothelioma

Inspection & Examination of head & neck:

! Check sclera for signs of anaemia

! Horner’s syndrome (apical lung cancer)

! Inspect mouth for central cyanosis

! Palpate the cervical, infraclavicular, and axillary lymph nodes

Trachea:

! Palpate for tracheal deviation. Place index and middle finger on either side of

trachea, in suprasternal notch.

The trachea can be displaced towards or away from the side of the lung lesion. What

are the causes of tracheal displacement?

! Assess the distance between the cricoid cartilage and the suprasternal notch for

hyperinflation

Palpation of chest:

! Palpate for equal chest expansion, comparing each side. Use measuring tape to

measure chest expansion:- normal is 2 inches or 5 cms.

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! Test for tactile fremitus, by placing the flat of the hands on the chest and asking the

patient to say ninety-nine. Compare each side with the other.

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RESPIRATORY WORKSHOP C

Respiratory Examination II

Aim: To carry out a respiratory system examination on a patient – Part II

Percussion of the chest:

The principle underlying percussion is that air gives a resonant percussion note and

fluid or solid tissue a dull note.

Technique for Percussion: Place middle finger of non dominant hand on the area of

the chest you want to percuss. Lift the other fingers off the chest wall (so they won’t

dampen the vibrations). Hold the middle finger of the percussing hand at a 90° angleand tap the dorsum of the applied middle finger with the tip of the percussing finger.

Keep the fingers of the percussing hand immobile and move the percussing hand from

the wrist.

! Percuss chest. Start at apex of lung, comparing each side. Both anterior and

posterior chest walls should be percussed in addition to the lateral chest walls and

clavicles.

! Determine if resonance is normal, increased or decreased. Localize areas of

hyperresonance or dullness to the different lobes of the lungs using your knowledge

of anatomy. Note the character of the dullness e.g stony dull suggests a pleuraleffusion.

Auscultation of chest:

! Ask patient to take deep breaths. Auscultate chest with diaphragm of stethoscope.

Start at apex, compare each side. Auscultate over the anterior, posterior and lateral

chest walls.

! Note whether air entry is normal or reduced.

! Note whether the inspiratory:expiratory ratio is normal or if one of the phases are

prolonged.! Note whether breath sounds are vesicular or bronchial.

! Are there any adventious sounds?

Breath sounds:

Breath sounds are reduced in pneumothorax, or pleural effusion.

The expiratory phase of the breath sounds is prolonged in airway obstruction (e.g.

asthma).

Normal breath sounds are described as vesicular.

Bronchial breathing occurs when air is passed from the bronchi through fluid filled

alveoli to the chest wall, the classic situation in which this occurs is pneumonia.

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Adventitious sounds are extra sounds in addition to breath sounds- rhonchi are

whistling sounds which occur when air passes through narrowed bronchi e.g., asthma;

crepitations are crackling sounds due to fluid in the alveoli e.g.infection

(bronchopneumonia), pulmonary oedema or alveolitis.

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GI WORKSHOP A

Gastro-Intestinal (GI) History

Enquire about the patient’s name, age and occupation.

Enquire about the patient’s presenting complaint and the history of the

presenting complaint.

COMMON SYMPTOMS FOR GASTROINTESTINAL DISEASE:

! Abdominal Pain

! Nausea

! Vomiting

! Diarrhoea

! Constipation

! Bleeding per rectum

! Abdominal Swelling

! Weight loss

! Dysphagia

ABDOMINAL PAIN

Where?

How long?

How did it occur?





Does anything bring on the pain?Does anything make the pain better or worse?

Are there any other symptoms with the pain? Ask about GI symptoms

Have you ever had the pain previously? If yes, when, where, how often etc.

NAUSEA

When does it occur?




Does anything bring on the nausea? e.g taking certain foods or medicationsDoes anything make the nausea better or worse?

Aims:

! To obtain a complete history for the Gastrointestinal system

! Be familiar with the differential diagnosis of abdominal pain

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Are there any other symptoms with the nausea? Ask about other GI symptoms such as

vomiting, diarrhoea etc.

Have you ever had nausea previously? If yes, when, where, how often etc.

VOMITING

When does it occur?



How frequently does it occur?

Does anything bring on the vomiting? e.g taking certain foods or medications

Does anything make the vomiting better or worse?

Are there any other symptoms with the vomiting? Ask about other GI symptoms

Have you ever had vomiting previously? If yes, when, where, how often etc.

How much do you vomit up?

What is the colour and consistency of the vomitus?

Is there any blood with the vomitus (heamatemesis)?

DIARRHOEA

When does it occur?



How frequently does it occur?

Does anything bring on the diarrhoea? e.g taking certain foods or medicationsDoes anything make the diarrhoea better or worse?

What is the volume of the diarrhoea?

What is the colour and consistency of the diarrhoea?

Is there any blood or mucus with the diarrhoea?

Are there any other symptoms with the diarrhoea? Ask about other GI symptoms

Have you ever had diarrhoea previously? If yes, when, where, how often etc.

CONSTIPATION


Is it getting better or worse?How frequently do you have a bowel movement?

What is the consistency of the stool?

Does anything bring on the constipation? e.g taking medications

Does anything help the constipation?

Is there any blood with the stool?

RECTAL BLEEDING

When does it occur?


How frequently does it occur?Is it getting more or less frequent?

What is the volume of the blood that is passed?

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What is the colour of the blood? e.g. bright red or dark

Is there any mucus or diarrhoea with the blood?

Are there any other symptoms? Ask about other GI symptoms

Have you ever had rectal bleeding previously? If yes, when, where, how often etc.

Any change in the colour of the stool? E.g. black tarry stool indicates upper GI bleed

ABDOMINAL SWELLING

Did it come on suddenly or gradually?

Is it increasing or decreasing?

Are there any other factors associated with the swelling? e.g. pain

Have you ever had abdominal swelling previously?

WEIGHT LOSS

How much?

Over what time period?

How is your appetite/intake?

DYSPHAGIA (Difficulty in swallowing)


Can you swallow solids and/or liquids?

Have you lost weight?

Do you have to regurgitate the food?

Is it associated with pain?

Have you ever had heartburn?


!

Current or previous illnesses including history of GI disorders such as pepticulcer disease etc.

! Enquire re previous surgery.

Family history:

! Family history of GI diseases such as cancer of the colon or inflammatory

bowel disease.

Social History:

! Enquire re alcohol and cigarette consumption.

!Enquire as to present and past employment e.g. potential exposure to hepatitisB & C.

! Enquire re recent travel.

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Medications/ Drug history:

! Enquire as to present and previously prescribed medications.

! Nonsteroidal anti-inflammatory medications may cause upper GI bleeding.

! Liver disease can occur with medications such as paracetamol, tetracyclines

etc.

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GI WORKSHOP B

Gastro-Intestinal (GI) Examination

General Inspection:

Observe patients general appearance; nutritional status.

Check for any evidence of jaundice or pigmentation.

Inspection & Examination of hands for the following:

Clubbing

Nail signs e.g. leuconychia which is seen with hypoalbuminaemia

Palmar erythema

Dupuytrens’s contracture

Check for liver flap (liver failure)

Inspection & Examination of head, neck and thorax:

! Inspect sclera for anaemia, jaundice, iritis

! Inspect mouth for ulceration, pigmentation, atrophic glossitis.

! Examine the neck for lymphadenopathy

! Examine the upper body for gynaecomastia, spider naevi (signs of liver

disease).


Inspection:

! Check for scars of previous surgery

! Distension

! Striae

! Bruising

! Pigmentation

! Localised masses

Palpation:

Superficial palpation: Begin by examining the region furthest from pain or discomfort.

Examine each of the 9 regions. Check for any tenderness, guarding and any masses.

Deep palpation: Follow by deep palpation. Check for organomegaly and any abnormal

masses.

Palpation of the Liver : Ask patient to breathe in and out. Start in the right lower

quadrant, and feel for the liver edge using the flat of the hand or the fingertips.

Aim: To perform an examination of the Gastro-Intestinal system

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Palpation of the Spleen: As for the liver, start in the right lower quadrant and move

towards the splenic area.

Ballotment of the Kidneys: Position the patient close to the edge of the bed, and ballot

each kidney using deep bimanual palpation.

Palpation of the Aorta: Palate the aorta, at a point midway between the xiphisternum

and the umbilicus, using the thumb and the index finger of the palpating hand.

Percussion:

! Percuss the lower and upper borders of the liver (usually found in 4 th intercostal

space).

! Percuss the spleen.

! If abdominal distension, check for shifting dullness (ascites)

! Percuss the suprapubic area for dullness (bladder distension)

Auscultation:

! Check for bowel sounds

! Check for aortic bruit over the abdominal aorta

! Check for renal artery bruits (above and lateral to the umbilicus, suggests renal

artery stenosis)

In a real patient situation you would also:

! Perform a Rectal examination, check for blood, masses.

! Examine the groins (checking hernial orifices with patient standing)

! Examine the Genitalia

Acute Abdomen Assessment

In patients presenting with an acute abdomen, it is vital to determine whether

they will need urgent surgery or not.

General Inspection:

! Observe patients general appearance. Is the patient distressed? Is patient in

obvious pain?! Assess patient’s vital signs, and recheck frequently.- is the patient tachycardic,

hypotensive, sweating?

Aims:! To examine a patient presenting with an acute abdomen

! To become familiar with the differential diagnosis of an acute abdomen.

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Start with inspection:

! Observe the abdomen for movement with respiration. - Peritonism is

associated with lack of movement

! Distension - What are the causes of abdominal distension?

! Check for scars of previous surgery

! Any lumps or masses

Palpation:

Superficial palpation: Begin by examining the segment furthest from pain or

discomfort. Examine each of the 9 regions. Check for any tenderness, guarding and

any masses.

! If Tenderness is detected check for rebound tenderness which is indicative of

peritonitis in which pain occurs when inflamed peritoneal surfaces are moved

relative to each other.

Deep palpation: Follow by deep palpation. Check for organomegaly and any abnormal

masses. Also check for pulsatile masses such as aortic aneurysm.

For abdominal masses determine the following: site, tenderness, size, surface, edge,

consistency, mobility with movement and respiration, and whether it is pulsatile or not.If a pulsatile mass is detected check for expansile pulsation which is characteristic of

an aneurysm.

Check for Murphy’s sign if suspect cholecystitis.

Percussion:

! Perform light percussion over areas of tenderness – pain that occurs on

percussion suggests underlying peritonism.

! Percuss over masses to assess for dullness e.g. ovarian cyst.

Auscultation:

Check for bowel sounds and assess their quality -

! Are they present/absent?

! Are they normal/ increased or diminished?

Bowel sounds are absent in peritonitis; absent/reduced in ileus; increased in bowel

obstruction.

Check peripheral pulses if suspect a ruptured/dissecting aortic aneurysm.

See Appendix II for Differential diagnosis of acute abdomen.

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Examination for a Hernia:

Groin Hernias are divided into Inguinal and Femoral. Typically a groin hernia presents

as a lump in the groin region that appears with standing or activities which raise intra-

abdominal pressure. Examination should occur with the patient in the standing

followed by the supine position.

Inspection:

! Location of the swelling/lump

! Scars

! Assess for cough impulse

Palpation:

! Position

! Size

! Tenderness

! Cough Impulse

!

Check if the hernia is reducible/irreducible.

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GI WORKSHOP C

GU (Genito-Urinary) Examination, Rectal Examination

It is essential to wear gloves when performing an examination of the male genitalia.

Inspection of the Male Genitalia for:

! Ulceration – including the Glans Penis

! Other lesions such as warts

! Urethral discharge

! Scrotal oedema and/or erythema

! Check that left testis hangs lower than the right

Palpation:

Begin by gently palpating each testis using the thumb and fingers.

Check for:

! Presence of both testes

! Size of testis

! Tenderness

! Swelling

! Consistency

! Masses

! Palpate the epididymis

Features of a Scrotal Mass:

In describing a scrotal mass, you need to address the following features:

! Position

! Size

! Tenderness

! Fixed or mobile

! Is it translucent?

! Is it possible to get above the mass? – if not it is most likely an inguino-scrotal

hernia

!

Does it fell like a bag of worms? (varicoele)

Aim: To perform an examination of the Male Genitalia

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Rectal Examination and Insertion of Urinary Catheter

Before procedure:

1. Introduce self to patient

2. Explain what you are about to do. Advise that patient may find procedure

uncomfortable but not painful.3. Obtain consent from patient for same

4. Ensure patient is comfortable. Lie patient on their left hand side, with knees

drawn up to chest.

5. Request patient to remove trousers and underwear.

6. Be aware of the sensitive nature of intimate examinations and try to put patient

at their ease.

7. It may be necessary to request a chaperone. (For the purposes of this exercise a

manikin is provided)

Rectal examination:! Firstly put on a pair of gloves

! Separate the buttocks and inspect the anus and skin surrounding the anus.

! Check for:

!"external thrombosed piles (tense bluish swellings at anal margin-

painful)

#"skin tags

$"rectal prolapse (may only be apparent when patient asked to strain)

%"anal warts (condylomata acuminata), may be confused with skin tags.

&"anal fissure (crack in anal wall, may be too painful to allow rectal

examination). Usually occur posteriorly and in the midline.'" pruritis ani (may lead to irritation, redness or weeping of surrounding

skin)

("carcinoma of the anus (rare, may be visible as a fungating mass at the

anal margin)

)"excoriation (may occur secondary to chronic diarrhoea)

*"fistula-in-ano may occur in Crohn’s disease.

! Next lubricate index finger of examining hand.

! Ask patient to breathe in and out quietly through the mouth.

! Place index finger over anus, as if pointing in the direction of the genitalia! Insert lubricated finger into the anus and slowly advance into the rectum.

Aims:

! To perform a rectal examination on a manikin

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! During insertion external sphincter tone can be assessed. Tone can also be

assessed by asking patient to squeeze down on finger.

! Rotate the finger clockwise and check for masses.

! In men the prostate gland can be assessed through the anterior rectal wall. The

normal prostate is firm, rubbery and bi-lobed. A hard nodule may represent

carcinoma of the prostate.

! In women the cervix may be palpated through the anterior rectal wall.

! Remove the finger and examine the glove for colour of faeces, blood and

mucous. Dispose of gloves appropriately in clinical waste.

! Advise patient examination is finished and that may dress self again.

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ENDOCRINE WORKSHOP A

Endocrine History

Enquire about the patient’s name, age and occupation.

Enquire about the patient’s presenting complaint and the history of the

presenting complaint.

COMMON SYMPTOMS FOR ENDOCRINE DISORDERS

! Weight Change

! Polydipsia/Polyuria

! Heat/cold intolerance

! Change in Bowel habit

! Palpitations

! Fatigue

! Skin/Hair changes

!

Parasthesias

WEIGHT CHANGE

Has there been a loss or gain in weight/

How much? If patient does not weigh themselves inquire requiring need to increase or

decrease in their clothes size.

Over what time period?

How is your appetite?

Take a dietary history and try and quantify daily caloric intake?

POLYDIPSIA/POLYURIAAre you drinking more fluids and if so how many glasses per day?

Are you urinating more frequently?

Are you passing bigger volumes of urine?

How long?

HEAT/COLD INTOLERANCE

Are you more sensitive to cold temperatures i.e. feeling cold in environments where

others do not feel cold?

Are you more sensitive to the heat i.e. feeling hot in environments where others do

not?How long?


Aims:

! To obtain a history for endocrinologic disorders

! To be familiar with symptoms for Diabetes Mellitus and Thyroid disease

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CHANGE IN BOWEL HABIT

Have you noticed a change in the frequency of passing a bowel movement and if so

what is the difference? i.e. increased/decreased

Has the consistency of your stool changed? i.e. more loose or harder

How long?


PALPITATIONS

When do they occur?

Is the heartbeat slow or fast, regular or irregular?

How long have they been occurring?

How long do they last?

Are they increasing or decreasing in frequency?

Anything that precipitates the palpitations?

Anything that relieves the palpitaions?

Are there any other factors associated with the palpitations? e.g. dizziness/blackouts/

chest pain

FATIGUE/LETHARGYHow long?

How severe? e.g. does it interfere with social activities or ability to work

How much sleep do you get?


SKIN CHANGES

What type of changes?

Any bruising or skin fragility?

Has your skin become drier?

Has the colour of your skin changed? e.g become more tanned (hyperpigmented)Have you had any increase in hair growth?

Have you noticed any hair loss? If so where?

PARAESTHESIAS/NUMBNESS

Peripheral neuropathy occurs as a complication of Diabetes Mellitus and carpal

tunnel syndrome(CTS) with hypothyroidism

Where?

How long?

How severe? -

Is it getting better or worse?Is it intermittent or constantly present?

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When does it occur? e.g. during the daytime or at night. CTS symptoms occur more

frequently at night.

MISCELLANEOUS

Have you had any sweats?

Have you or any of your family members noted any change in your appearance?

Have you noticed any change in your vision?

Any difficulties with attaining/sustaining penile erections?


! Current or previous illnesses including history of endocrine disorders including

gestational diabetes.

! Enquire re previous surgery including thyroidectomy, or abdominal surgery.

! Obtain a detailed menstrual history.

Family history:

! Family history of endocrine diseases such as diabetes mellitus, thyroid

disorders, osteoporosis, parental hip fractures.

Social History:

!

Enquire re alcohol and cigarette consumption.! Possible exposure to radiation.

Medications/ Drug history:

! Enquire as to present and previously prescribed medications in particular the

use of glucocorticoidsteroids, thiazides.

TAKE A HISTORY

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ENDOCRINE WORKSHOP B

Examination of a Diabetic Patient: Evaluation for Peripheral Vascular

Disease and Peripheral Neuropathy

COMPLICATIONS OF DIABETES MELLITUS

Examination for Diabetic complications:

! General inspection: Comment on signs of obesity! Examine upper limbs for nail changes, eg fungal infection, and injection sites.

! Perform Fundoscopy looking for retinopathy.

! Check mouth for signs of thrush

! Check skin for injection sites, scars, ulcers, necrobiosis etc.

! Check for quadriceps muscle wasting.

! Check for peripheral neuropathy.

! Examine the legs for vascular abnormalities.

Peripheral Neuropathy

Loss of sensation starts at the most distal portion of the extremeties in a symmetrical

pattern. Initially the posterior spinal columns, which carry light touch, vibration and

proprioception, are affected followed by the spinothalamic columns which carry pain

and temperature sensation.

Ask if the patient has noted altered sensation, such as numbness or tingling, in any part

of their body. If the answer is negative, show the patient what each of the following

feel like with their eyes open and them check that they can appreciate them on the

distal phalanx of the index finger and hallux with their eyes closed:

Vibration is tested with a 128 Hz tuning fork on bony prominences

Joint position sense (Proprioception) is tested by asking the patient to identify the

direction of movement of the distal phalanx.

Light touch with your finger tip or by touching (not stroking) the skin with cotton

wool

Pinprick with a neurotip or tooth pick with the patient’s eyes open asking whether

they can feel that it is sharp and hurts like a pin. Patient is asked to differentiate between sharp and dull.

Aim: To assess a patient for complications of Diabetes Mellitus

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If the patient reports an abnormality map out its extent with light touch or pinprick

testing or compare the two sides and draw it on a body chart.

Peripheral Vascular Disease

Examination of Arterial Pulse

Arterial pulsation reflects various cardiac events in the cardiac cycle as well as certain

characteristics of the systemic arteries. Information about cardiac events can be

obtained from any artery whose pulsation can be felt on the surface – the radial artery

is used most commonly because of its accessibility.

In order to assess the peripheral arterial system, several pulses must be examined –

radial, brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis. Palpation

of arteries should always be light and done with the palmar aspect of the fingers.

Inspection:

1. Inspect for skin changes, e.g. pallor, pigmentation, varicose eczema in the gaiter

area, loss of hair.

2. Look for signs of gangrene: black toes, amputated toes etc.3. Check for scars e.g. from previous varicose vein surgery or bypass surgery

4. Look for signs of ulceration: describe the site, size, shape, edge, & surrounding

skin of ulcer.

Venous ulcers more commonly occur above the medial malleolus, are usually

shallow, and painless, and may be associated with varicose veins, and varicose

eczema.

Arterial ulcers are painful, have a punched out appearance, and may be

associated with pallor and hair loss.

5. Check for varicose veins, with the patient standing.

6. Check for any limb oedema.

Palpation:

Firstly check skin temperature, with the back of your hand, and compare both legs.

Next check for capillary refill. Select a nail bed and compress it for several seconds. It

should take less than 2 seconds for the normal red colour to return.

Palpate for any varicose veins. Tenderness on palpation may suggest thrombophlebitis.

If oedema is present determine if it is pitting or non pitting.

Non pitting oedema may be suggestive of chronic venous insufficiency.

Next examine for peripheral pulses:! Femoral: At the inguinal ligament.

! Popliteal: In the popliteal space with knee flexed and foot resting on the bed.

Aim: To perform a peripheral vascular system examination

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! Posterior Tibial: Behind the medial malleolus

! Dorsalis Pedis: Lateral to the extensor tendon of the big toe.

Special Tests:

Trendelenburg’s test:

First elevate leg to 90° to drain the veins. Apply a tourniquet to the upper thigh, and

then ask the patient to stand up. The veins should gradually fill in the next 30 seconds.

Release the tourniquet. If sudden additional filling of the veins occurs, then there is

sapheno-femoral incompetence.

Buerger’s Test:

Lift the patient’s legs to 45°. Rapid pallor occurs with poor arterial supply. Then ask

the patient to dangle the legs over the side of the couch. Cyanosis occurs with PVD.

Auscultation:

! Check for aortic bruit over the abdominal aorta

! Check for Femoral bruits.

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ENDOCRINE WORKSHOP C

Thyroid Gland Examination; Breast Examination

Thyroid Gland Examination:

!Expose the neck fully, and comment if any thyroid swelling

! Give the patient a glass of water and ask patient to swallow. Comment on your

observations.

! Examine the neck from behind. Comment on size, shape, consistency,

tenderness, and nodularity of the thyroid.

! Palpate thyroid movement on swallowing. Is the gland mobile or fixed?

! Examine for any lymph gland swelling.

! Move to the front and palpate again – note if trachea is deviated.

! Listen for any bruits.

Signs of Thyroid Disease! Examine the eyes. Check for exophthalmos (Grave’s disease); lid lag; lid

retraction.

! Check for proximal muscle weakness.

! Check reflexes – delayed relaxation is a sign of hypothyroidism.

! Pulse – rate; rhythm.

! Check for tremor, palmar erythema, sweating (hyperthyroidism).

BREAST EXAMINATION

InspectionPosition the patient sitting up with the chest fully exposed.

Inspect the nipples for abnormalities such as retraction (may indicate underlying

cancer) or a unilateral redness of the nipple (which may be a sign of Paget’s disease).

Inspect the skin of the surrounding breast for any dimpling, ‘peau d’orange’ or

unilateral visible veins (which could again suggest a cancer).

Ask the patient to fix her hands on her hips and press against her hips. This causes her

pectoralis muscles to contract and highlights any subtle dimpling or fixation in the

breast tissue.

Aims:

! To perform an examination of the thyroid gland on a patient

! To perform a breast examination

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Next ask the patient to raise her hands above her head. Inspect carefully again for any

asymmetry. This manoeuvre will especially make obvious if one of the nipples is fixed,

as it will not move symmetrical to the other nipple.

PalpationPosition the patient lying down. Palpation is performed with the palmar surface of the

middle three fingers, lying flat against the surface of the breast. Roll the fingers over

the breast tissues while pressing in lightly. Avoid use of the finger tips.

One needs to palpate all 4 quadrants of the breast systematically. One can visualise the

breast as a clock, and palpate each time zone from areola to periphery as one system of

ensuring that you do not miss any section.

Next palpate the axillary tail of the breast, between your thumb and fingers.

Check for lumps behind the nipple and if any fluid can be expressed.

Finally, palpate the axillary and supraclavicular lymph nodes systematically. When

examining the right axillary lymph nodes, rest the patient’s right arm on your right

forearm. Then use your other hand to palpate the five main groups of lymph nodes:

central, lateral, pectoral/ medial, infraclavicular, subscapular.

Features of a breast lump:

In describing a breast lump, you need to address the following aspects:

! !"#$%"&

! ($)* +&, #-+.*

! /"$#0*&12 3-+4, "4 #"56

! 7*&,*4&*##

! 8$9*, "4 :";$


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MUSCULOSKELETAL WORKSHOP A

Musculoskeletal (MSK) History

Aim: To be able to obtain a locomotor (musculoskeletal) history


Enquire as to why the patient has come to see the doctor and what is his/her major

complaint

Screening Questions (GALS questionnaire) for MSK disease:

• Do you have any pain, swelling or stiffness in your muscles, joints or back?

• Can you dress yourself completely without any difficulty?• Can you walk up and down stairs without any difficulty?

If all negative patient is unlikely to have a musculoskeletal problem.

If positive need to obtain a more detailed history.

COMMON MUSCULOSKELETAL SYMPTOMS:

! Joint pain

! Joint swelling

! Joint stiffness

! Muscle pain

! Muscle weakness

! Difficulty with function such as walking etc.

JOINT PAIN:

• Where?

• How long?

• How did it occur?

• Does it radiate anywhere?

• How severe is the pain? - can use a 0-10 scale.

• Is it getting better or worse?

• Is it intermittent or constantly present?

• Does anything bring on the pain?

• Does anything make the pain better or worse?

• Are there any other symptoms with the pain? Ask about swelling and stiffness

of the joints.

• Does the pain interfere with your ability to perform certain functions/activities?

• Have you ever had the pain previously? If yes, when, where, how often etc.

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SWELLING:

• Where is it located?

• Did it come on suddenly or gradually?

• Is it intermittent or constantly present?

• Any precipitating factors, such as injuries?

• Are there any associated factors, such as pain, redness, warmth?

• When is the swelling worse? Does it improve with elevation/overnight

STIFFNESS:

• Which part of the body is affected?

• When does it occur? Is it worse in the morning or in the evening?

• How long does it last?

Need to determine if the Musculoskeletal symptoms are likely secondary to a problem

resulting from a joint disorder – “Arthritis”

Questions to ask if the problem may be related to Arthritis

• Does the problem arise from a joint?

• Is the condition acute or chronic?

• Is it an Inflammatory or Non-Inflammatory form of arthropathy?

• What is the number of joints involved?

• Monoarticular: only one joint involved

• Pauciarticular: 2- 4 joints involved

• Polyarticular: > 4 joints involved

• Axial: predominant involvement of the spine• What is the pattern of affected joints?

• What is the impact of the condition on the patient’s life?

Need to assess both physical and psychologic impact


! Enquire about any previous episodes of similar symptoms

! Enquire about any other illnesses

! Ask about any prior injuries or surgeries

Family History:! Ask if any family member suffers from joint or muscle problems

Social History:

! Ask about current and previous employment

! Ask if symptoms interfere with patient’s ability to work or take care of

themselves

! Ask about use of alcohol

Medications:

!Ask if patient has taken any medication(s) for the problem

! Obtain a complete list of all the medications that the patient is taking currently

! Ask about medication allergies

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Systems Review:

! Obtain a complete review of systems - in particular, any rashes, hair loss,

dryness of eyes or mouth, change of colour of digits upon exposure to cold

ambient temperatures, fevers, fatigue or change in weight.

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MUSCULOSKELETAL WORKSHOP B

Musculoskeletal (MSK) Examination – Upper Extremity

GENERAL PRINCIPLES OF JOINT EXAMINATION: Look; Feel; Move.

LOOK: • Scars• Swelling• Rashes• Muscle wasting

FEEL: • Temperature•

Swelling• Tenderness

MOVE: • Range of Movement – Active and Passive

FUNCTION: • Functional assessment of joint

Examination of the Upper Extremity

EXAMINATION OF THE HAND AND WRIST

! Inspect the backs of the hands for muscle wasting, scars, deformity or swelling.

Decide if the changes are symmetrical or asymmetrical and which joints or other

structures are mainly involved.! Look for skin and nail changes

! Ask patient to turn their hands over and note any pain or difficulty in doing so.

! Inspect the palms for signs of muscle wasting as seen with some neuropathies

and for swelling of the tendon sheaths.

! Check wrist for carpal tunnel release scar.

! Feel for radial pulse, tendon thickening, and bulk of thenar and hypothenar

eminences.

! Assess skin temperature at the patient’s forearm, wrist and MCP joints using the

back of your hand. Is there any difference?

!Squeeze MCP joints to assess for tenderness (watch the patient’s face forevidence of discomfort )

Aim: To perform a musculoskeletal examination of the upper extremity

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! Bimanually palpate the MCP, PIP and DIP joints and note any swelling,

tenderness or warmth.

! Check for tenderness and squaring of the 1st CMC joint.

! Bimanually palpate the wrists.

! Ask the patient to straighten their fingers fully and note inability to do so.

! Ask the patient to make a full fist – can s/he tuck their fingers into the palm? If

not move the fingers passively to determine if the problem is with the joints of

the tendons.

! Asses wrist flexion and extension actively (prayer sign) and passively.

! Assess grip strength.

! Assess fine precision pinch by asking patient to pick up a small object.

EXAMINATION OF THE ELBOW

! Look for scars, swellings, redness, muscle wasting, nodules or rashes.

! Look from the front for the carrying angle and from the side for flexion

deformity.

! Assess skin tenperature

! While holding the elbow at 90º, palpate over the head of radius and joint line

with your thumb for tenderness, swelling or warmth.

! Palpate the medial and lateral epicondyles and olecranon process for tenderness.

! Assess full flexion and extension – actively and passively.

!

Assess pronation and supination, both actively and passively, in addition tofeeling for crepitus.

! Assess function – e.g. hand to nose or mouth.

EXAMINATION OF THE SHOULDER

! Inspect the shoulder from in front, from the side and from behind checking for

symmetry, muscle wasting, scars etc.

! Assess skin temperature over the front of the shoulder.

! Palpate the bony landmarks (SC joint, AC joint, acromion process and around

the scapula) and surrounding muscles! Palpate the anterior and posterior joint line and bicipital groove.

! Assess movement and function: hands behind head, hands behind back. How far

up the spine can s/he reach?

! Assess movements of the shoulders, both actively and passively.

! Observe scapular movement while patient is abducting the arm.

Movements of the shoulder:

! Abduction: Request patient to raise arms above head, making the palms touch

(180°)

! Adduction: Request patient to move arm across front of chest (50°)

! Flexion: Request patient to raise arm forwards (180°)

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! Extension: Request patient to move arm backwards, with elbow bent (65°)

! Internal rotation: Request patient to turn arm in towards chest wall (90°)

! External rotation: Request patient to rotate arm laterally as far as possible (60°)

with elbow at 90°.

See Appendix III for further shoulder examination techniques.

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MUSCULOSKELETAL WORKSHOP C

Musculoskeletal (MSK) Examination – Lower Extremity and Spine

EXAMINATION OF THE HIP

With the patient standing:

! Observe the patient’s gait. Does s/he have an antalgic (painful) or Trendelberg

(commonly manifested as “waddling”) gait?

! Look for gluteal muscle bulk.

! Perform the Trendelenberg test: Ask the patient to alternately stand on each

leg alone; in an abnormal test the pelvis on the contralateral side will dip. This

test is used to assess proximal muscle strength.

With the patient lying on the couch:

! Look for flexion deformity and leg length disparity.

! Check for scars.

! Palpate over the greater trochanter for tenderness (sign of trochanteric bursitis).

! Assess abduction and adduction.

! With the hip at 90° assess full hip flexion, internal and external rotation.

! Perform Thomas’ test: with one hand under the patient’s back to ensure that

lumbar lordosis is removed fully flex the hip and observe the other leg. If it lifts

off the couch then there is a fixed flexion deformity in that hip.

EXAMINATION OF THE KNEE

With the patient standing:! Assess the patient’s gait.

! Look for varus/valgus deformity and popliteal swellings.


! Look, from the end of the couch, for symmetry, alignment, varus (lower leg

deviated medially)/valgus (lower leg deviated laterally) deformity, muscle

wasting, scars, rash and swelling.

! Look from the side for fixed flexion deformity.

! Assess skin temperature, comparing one side with the other.

!With the knee slightly flexed palpate the borders of the patella for tenderness.Swelling.

Aims:

! To perform a musculoskeletal examination of the lower extremity &

spine

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! With the knee flexed to 90° palpate the joint line, patellar tendon and tibial

tuberosity for tenderness and swelling.

! Feel behind the knee for a popliteal (Baker’s) cyst.

! Perform the patellar tap to assess for an effusion.

! Assess for the “bulge sign” (cross fluctuance)

! Assess full flexion and extension, both actively and passively, and note range of

movement. Feel for crepitus.

! Assess the stability of the collateral ligaments by flexing the knee to 15° and

alternately stressing the joint line on each side.

! Assess the stability of the cruciate ligaments using the anterior and posterior

draw tests. Initially look from the side of the knee to check for a posterior sag or

step-back of the tibia which suggests PCL damage.

EXAMINATION OF THE FOOT AND ANKLE


! Assess the patient’s gait cycle (heel strike, stance, toe-off)

! Look at the forefoot for toe alignment,

midfoot (foot arch) for foot arch position &

hindfoot for Achilles tendon thickening/swelling and alignment.


! Look at dorsal and plantar surfaces of the foot for symmetry, rashes, nail

changes, clawing and alignment of the toes, swelling and callus formation.! Assess skin temperature over the forefoot and ankle.

! Squeeze the MTP joints and observe the patient’s face for any discomfort.

! Palpate the midfoot, ankle joint line and subtalar joint for tenderness, swelling

and warmth.

! Assess both active and passive movement at the:

ankle/tibiotalar (dorsi- and plantar flexion),

subtalar (inversion and eversion),

mid-tarsal (inversion and eversion with immobilisation of the heel) &

1st MTP (dorsi- and plantar flexion) joints.

!Look at the patient’s footwear for abnormal wear

EXAMINATION OF THE SPINE


! Inspect from the side and from behind for muscle wasting, asymmetry or

scoliosis of the spine.

! Palpate the spinous processes, paraspinal muscles and sacroiliac joints for

tenderness.

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! Assess movement of the cervical spine: flexion (chin to chest ), extension (look

at the ceiling), rotation (look over each shoulder ) and lateral flexion (ear to

shoulder).

! Assess movement of the lumbar spine: flexion, extension, and lateral flexion –

use the Schober’s test to measure forward flexion.

Schober’s test: With patient standing erect make a mark over midpoint between the

posterior superior iliac spines and another 10 cm higher; ask patient to bend forward

and re-measure between the 2 points: an increase of ! 5 cm is normal

With the patient sitting on the couch and arms crossed in front:

! Assess thoracic rotation (with your hands on the patient’s shoulders to guide the

movement )


! Perform straight leg raising (SLR) test: flex hip with knee straight until limit is

reached; then dorsiflex the ankle: -if positive, the leg pain is aggravated (this

confirms stretching of the sciatic nerve).

! Asses limb reflexes and strength of the dorsi-flexors of the big toe.

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NEUROLOGY WORKSHOP A

Neurology History

Enquire re patient’s name, age & occupation

Enquire about the patient’s presenting complaint and the history of the presenting

complaint

Common symptoms are as follows:

! Headache.

! Weakness of the face, trunk or limbs! Paraesthesia (tingling/pins and needles) or numbness

! Disturbance of vision

! Disturbance of hearing

! Disturbance of speech.

! Disturbance of sphincter control (bladder or bowel)

! Ataxia (loss of coordination)

! Gait disturbance

! Difficulties with cognition and/or memory

! Tremor or involuntary movements.

HEADACHE

Where?

How long?

What type of pain? e.g. throbbing, sharp, dull etc.

What were you doing when it started it?


How severe is the headache? - can use a 0-10 scale.



Does anything bring on the headache?

Does anything make the headache better or worse?

Are there any other symptoms with the headache? Ask about other neurologic

symptoms

Have you had headaches previously? If yes, when, how often etc.

WEAKNESS

Where?

How long?

How did it occur? e.g did it come on suddenly or gradually

How severe is the weakness?


Aim: To obtain a neurological history

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Does it interfere with your ability to perform certain functions and if so what?

Are there any other symptoms with the weakness? Ask about other neurologic

symptoms

Have you ever had any weakness previously? If yes, when, which part of the body etc.

PARAESTHESIAS/NUMBNESS

Where?

How long?

How severe? -



When does it occur? e.g. during the daytime or at night

Does anything bring on the paraesthesias/numbness? e.g such as certain movements

Are there any other symptoms? Ask about other neurologic symptoms

Have you ever had the parathesias/numbness previously? If yes, when, where, how

long did it last etc.

DISTURBANCE OF VISION

What type of disturbance? e.g. loss of vision, blurring of vision, double vision etc.

Does it involve one or both eyes?

How long?

How severe? E.g. is it total or partial

What were you doing when it began?Is it getting better or worse?


Are there any other symptoms? Ask about other neurologic symptoms.

Have you ever had the disturbance of vision previously? If yes, when, where, how long

did it last etc.

DISTURBANCE OF HEARING

What type of disturbance?

Does it involve one or both ears?How long?

How severe? E.g. is it total or partial

What were you doing when it began?




Have you ever had difficulties previously? If yes, when, where, how long did it last etc.

DISTURBANCE OF SPEECHWhat type of disturbance? e.g. is it difficulty in finding or saying the words?

How long?

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Have you ever had the speech difficulty previously? If yes, when, where, how long did

it last etc.

DISTURBANCE OF SPHINCTER CONTROL

What type of disturbance? i.e bowel or bladder or both

How long?

How severe? e.g. is it total or partial




Are there any other symptoms? Ask about other neurologic symptoms and back pain

Have you ever had problems with incontinence previously? If yes, when, where, how

long did it last etc.

ATAXIA


Which part of the body is involved?

How long?How severe? e.g. is it total or partial





Does it interfere with your ability to perform certain functions and if so what?

Have you ever had similar symptoms previously? If yes, when, where, how long did

they last etc.

GAIT DISTURBANCE


How long?

How severe? e.g. can you walk independently



Are there any other symptoms? Ask about other neurologic symptoms including

vertigo, numbness, weakness etc.


they last etc.

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DIFFICULTIES WITH COGNITION OR MEMORY

What type of difficulties?

How long?


Are there any other symptoms? Ask about other neurologic symptoms.


they last etc.

Obtain a collateral history (information from a family member/friend) if possible.

Past (Medical & Surgical) History:

! Enquire re previous diagnosis of neurological disease or other diseases that may

predispose to neurologic disorder

! Enquire re previous surgery.

Family History:

! Enquire re family history of neurological disease/ medical conditions.

Social History:

! Enquire about smoking history

!

Ask if patient drinks alcohol & what their usual weekly consumption is.! Enquire as to the patient’s occupation.

! Enquire about patient’s ability to function e.g. doing activities of daily living etc.

Medications:

! Ask patient what medications they are on, including prescribed and OTC

medications

Allergies:

! Enquire if the patient has any medication allergies

Systems Review:

! Systematic review of symptoms involving body systems.

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NEUROLOGY WORKSHOP B

Cranial Nerves Examination

Aims: To perform a mini-mental state examination

To carry out an examination of the cranial nerves

HIGHER FUNCTIONS

Ask if the patient is left or right handed. Establish if the patient is alert and able to give

a clear history. If relevant, test for dysphasia, examine the mental state and perform the

Mini Mental State Examination (see Appendix V).

EXAMINATION OF THE CRANIAL NERVES

Cranial Nerve I – Olfactory nerve: (need containers with coffee or peppermint )

Ask if the patient can appreciate taste and smell. Further testing is not necessary unless

the patient complains of abnormal taste or smell or there is a special reason to test

olfaction. If testing is needed check that the airway is clear and test each nostril with a

basic smell, such as peppermint or coffee.

Cranial Nerve II - Optic nerve: (need 3- or 6-metre Snellen chart and pinhole)

Visual acuity

Ask patient if they are aware of reduced vision in either eye. Test visual acuity wearing

distance glasses, if worn, in each eye separately with Snellen chart. Use 3-metre chart

at 3 metres or 6-metre chart at 6 metres, which produce equivalent results.

If visual acuity less than 6/6 use a pinhole. Record visual acuity right (VAR) X/60

with/without aid of pinhole/glasses and visual acuity left (VAL) Y/60 with/without aid

of pinhole/glasses.

Visual fields (need 7 mm red pin)

Ask patient if they are aware of a field defect in either eye. Establish that the small red

pin target (7 mm) is visible with each eye. Test extent of visual field by testing each

eye from each quadrant asking the patient to state as soon as they can see the pinhead

at all (regardless of colour).

Fundoscopy (need ophthalmoscope and darkened room)

Use the ophthalmoscope to examine the fundus of each eye separately with the other

eye fixating in the distance. Hold ophthalmoscope correctly (examining right eye with

ophthalmoscope in right hand and using right eye and examining left eye with

ophthalmoscope in left hand and using left eye unless good reason not to be able to do

so). The index finger should be on the focussing wheel. Assess red reflex for presence

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of media opacities. View fundus at an appropriate distance from the patient and focus

the ophthalmoscope.

Cranial nerves III, IV and VI – Oculomotor, trochlear and abducent nerves:

(need torch)

Inspect for ptosis (drooping eyelid), pupil size, strabismus (squint), proptosis.

Test for pupil light reaction and accommodation in each eye separately.

Look for nystagmus within a 30o range.

Cranial Nerve V – Trigeminal Nerve: (need cotton wool, pin or neurotip, tendon

hammer)

Ask if the patient has any numbness or altered sensation in the face.

Test light touch in each of the three divisions of the trigeminal nerve.

If an abnormality is found determine its extent with a pin.

Test the corneal reflex with a wisp of cotton wool, touching cornea not sclera. Avoid

touching eyelashes and eliciting a ‘threat’ reaction.

Motor division: Ask patient to clench teeth, open and the close mouth against

resistance. Test for jaw jerk also.

Cranial Nerve VII – Facial nerve:

Look for facial asymmetry.

Test frontalis – ask patient to wrinkle the forehead/raise their eyebrows.

Test orbicularis oculi – ask patient to close eyes tightly: look for burying of the

eyelashes.Test orbicularis oris – the patient is asked to show their teeth.

Ask patient to blow out their cheeks.

Ask about taste.

Cranial Nerve VIII – Auditory and vestibular nerves: (need 256 or 512 Hz tuning

fork and auroscope)

Ask if the patient has a problem with their hearing. Test by first speaking and then

whispering numbers at three feet with masking of the non-tested ear using a piece of

paper held over the non-test ear and scratching it when speaking or whispering.If hearing loss is reported (history or examination) first perform the Weber test. Strike

a 256 or 512 Hz tuning fork on your knee and apply it firmly to the patient’s forehead.

Ask whether they hear it more on one side or the other or equally. The tuning fork

lateralises to the side of greater conductive loss or the side with the better cochlea in

sensori-neural hearing loss. Then perform the Rinne test with the same tuning fork.

First apply the tuning fork firmly to the mastoid process and then hold it in front of the

external auditory meatus. Ask the patient which is louder. Patients with normal middle

ear function hear better by air than bone conduction.

Examine the external auditory meatus and tympanic membrane with an auroscope.

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Examination of the vestibular nerve includes testing stance and gait, see below, and for

nystagmus, see above.

Cranial Nerve IX – Glossopharyngeal nerve:

Not necessary.

Cranial Nerve X – Vagus nerve: (need torch, tongue depressor )

Ask about difficulty swallowing. Test articulation (for dysarthria), coughing and

elevation of the soft palate on saying Aah! If any of these are abnormal test gag reflex

by touching the posterior pharyngeal wall on each side with an orange stick and

comparing the responses.

Cranial Nerve XI – Spinal- Accessory nerve:

Test sternocleidomastoid examined with the head tilted to the opposite side and with

resistance against the tester’s hand placed at the angle of the jaw. The muscle belly is

visible and may be palpated. Neck flexion is a useful screening test but not sufficient.

Test trapezius by asking the patient to shrug the shoulders and palpating the muscles,

with shoulders elevated.

Cranial Nerve XII – Hypoglossal nerve: (need torch)Observe the tongue rest in the floor of the mouth for wasting and fasciculation.

Observe protrusion of the tongue and note deviation.

Observe tongue movements for slowness seen in UMN lesions.

After the workshop you should familiarise yourself with the features of the various

cranial nerve palsies, eg 3rd nerve palsy, 6 th nerve palsy etc.

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NEUROLOGY WORKSHOPS C AND D

Peripheral Neurologic Examination I and II

Aim: To perform an examination of the peripheral nervous system

ORDER FOR EXAMINATION OF THE NERVOUS SYSTEM

The conventional order for describing the examination is:

! General appearance

! Stance and gait

!

Higher functions! Cranial nerves

! Motor system

! Sensory system

STANCE AND GAIT

Ask the patient to rise from a chair without using their hands and stand still with their

feet together.

Ask the patient to stand on their toes and then their heels, steadying the patient bygently holding their hands.

Watch the patient walk across the room turn round and come back to you looking for:• Whether the gait is normal or abnormal• Painful gait• Unsteadiness• Foot drop• Hemiparetic gait• Spastic gait• Stooped posture, slowness and loss of arm swinging•

Others: marche á petit pas, Waddling gait

If, and only if, the patient is steady, test heel-toe walking

The upper and lower limbs are examined separately. The examination of the upper or

lower limbs is divided into six parts:

! Inspection

! Tone

!

Power! Coordination

! Sensation

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! Reflexes

Tone:

Tone is an assessment of the freedom of movement of a joint when moved passively,

and is described as being normal, reduced (hypotonia), or increased (hypertonia).

Power:

Power is tested by comparing the examiner’s strength against the patient’s full

resistance. Power can be graded as follows:

EXAMINATION OF THE MOTOR SYSTEM

UPPER LIMBS

The patient should be seated with the upper limbs exposed to show the shoulders and

their arms outstretched and the hands supinated and then pronated.

Observation

Look for:• Any obvious abnormality• Skin changes (including scars, ulcers, café au lait patches, neurofibromas)• Deformity (including joint swelling, asymmetry)• Wasting (especially first dorsal interosseous, abductor pollicis brevis, shoulder

muscles)• Involuntary movements (fasciculation, tremor, dystonia, chorea, myoclonus).

Grade 0 Paralysis

1 Flicker

2 Movement when gravity excluded

3 Movement against gravity

4 Movement against some resistance

5 Normal Power

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Tone

Test wrist pronation-supination for a pronator catch in spasticity. Test for rigidity by

slow rotation of the stabilised wrist.

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Power

Test the following muscle groups in order, comparing each side as you progress. Each

movement should be tested in isolation: thus to test elbow flexion you must fix the

upper arm with your free hand.

Reflexes

You will recall from physiology that when a muscle is stretched receptors will fire, and

a spinal reflex will cause the muscle to contract in response. This is the principle behind eliciting tendon reflexes. When you strike a tendon correctly, with a tendon

hammer the attached muscle is stretched and will reflexly contract in response.

Test Biceps, Supinator (=brachioradialis) and Triceps Reflexes.

If the reflexes are absent, use reinforcement.

Co-ordination

The cerebellum controls coordination of muscle movements. The following tests can

be used to test coordination in the limbs:

Finger nose test:

Ask the patient to touch the tip of your stationary finger, at full stretch, accurately and

gently, and then the tip of their own nose with first one and then the other index finger.

Intention tremor increases as the target is approached and past pointing is overshooting

of the target. Note this test is performed with the subject’s eyes open. Asking the

patient to touch his nose with the eyes close

Clinical Skills Handbook 2015 MEDN40060 2

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Transcript of Clinical Skills Handbook 2015 MEDN40060 2