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Clinical Examinations for PLAB 2

The ‘Teaching’ scenarios

"You should be willing to contribute to the education of students or colleagues,"

and, "If you have responsibilities for teaching you must develop the skills, attitudes
and practices of a competent teacher. You must also make sure that students and
junior colleagues are properly supervised." General Medical Council – ‘Good
Medical Practice’

Contents:

1) Adult Basic Life Support (BLS)

2) Knee examination
3) Breast examination
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Adult Basic life support (BLS)
Scenario: You are an FY2 working in a teaching hospital.

You have been asked to teach a 3rd year medical student basic life support.
A manikin will be provided along with the BLS algorithm.

• Introduce yourself to the student and explain to him that you are one of
the doctors and have come to show him how to perform Basic Life
Support
• Check how much the student already knows about BLS and then teach
him step by step how to perform BLS.
• The key to being a good teacher is to give the information in a manner in
which the student can understand, follow and retain what you have said
– intermittently you should check if the student is actually following you!
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Resuscitation Council (UK) 2015 guidelines

ADULT BLS SEQUENCE

SAFETY/DANGER – check that you, victim and any bystanders are safe

Kneel down next to the patient on his right side.

RESPONSE - Gently shake his shoulders and ask loudly: “Are you all right?"

AIRWAY AND BREATHING - Open the airway

• Turn the victim onto his back – you will have a manikin
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• Place your hand on his forehead and gently tilt his head back; with your
fingertips under the point of the victim's chin, lift the chin to open the
airway

Look, listen and feel for normal breathing for no more than 10 seconds

CALL FOR HELP – 999 or 2222 (cardiac arrest team) - Ask a helper to call if
possible otherwise call them yourself
• Stay with the victim when making the call if possible
• Activate the speaker function on the phone to aid communication with the
ambulance service

Send someone to get an AED if available

If you are on your own, do not leave the victim, start CPR

Start chest compressions

• Place the heel of one hand in the centre of the victim’s chest; (which is
the lower half of the victim’s sternum
• Place the heel of your other hand on top of the first hand
• Interlock the fingers of your hands and ensure that pressure is not applied
over the victim's ribs
• Keep your arms straight
• Do not apply any pressure over the upper abdomen or the bottom end of
the bony sternum
• Position your shoulders vertically above the victim's chest and press
down on the sternum to a depth of 5–6 cm (1/3 of patient’s chest)
• After each compression, release all the pressure on the chest without
losing contact between your hands and the sternum;
• Repeat at a rate of 100–120 min-1
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After 30 compressions open the airway again using head tilt and chin lift
and give 2 rescue breaths

• Pinch the soft part of the nose closed, using the index finger and thumb of
your hand on the forehead
• Allow the mouth to open, but maintain chin lift
• Take a normal breath and place your lips around his mouth, making sure
that you have a good seal
• Blow steadily into the mouth while watching for the chest to rise, taking
about 1 second as in normal breathing; this is an effective rescue breath
• Maintaining head tilt and chin lift, take your mouth away from the victim
and watch for the chest to fall as air comes out
• Take another normal breath and blow into the victim’s mouth once more
to achieve a total of two effective rescue breaths. Do not interrupt
compressions by more than 10 seconds to deliver two breaths. Then
return your hands without delay to the correct position on the sternum
and give a further 30 chest compressions
Continue with chest compressions and rescue breaths in a ratio of 30:2

Do not interrupt resuscitation until:

• Help arrives and asks to take over

• You become exhausted
• The victim is definitely waking up, moving, opening eyes and breathing
normally

ONCE YOU HAVE PERFORMED IT AND TIME PERMITTING ASK THE

MEDICAL STUDENT TO NOW PERFORM IT!

Invite questions!
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Knee Examination
You are an FY2 working in a teaching hospital.

You have been asked to teach a 5th year medical student how to perform a
knee examination.

Remember: any orthopaedic examination follows the sequence of LOOK

à FEEL à MOVE à SPECIAL TESTS

• Introduce yourself to the student and explain to him that you are one of
the doctors and have come to show him how to perform a knee
examination
• Approach the simulated patient, check patient’s ID, explain the procedure
and obtain consent and ask him if he is happy to allow the medical
student to watch him perform a knee exam.

‘I need to examine your knee joint. This will involve me looking, feeling
and moving your knee. I will also be asking you to walk. Are you happy
for me to continue?’ I also have a medical student with me who I will be
teaching the examination to. Will that be oK?
‘Are you in any pain at the moment?’
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• Ensure patient is exposed from the waist down, but can remain in briefs
(ideally wearing shorts)
• Ensure patient is comfortable and ask if he has pain before beginning

Look
- Ask the patient to stand and look at the knees:
• Anteriorly: any obvious swellings, deformities, symmetry, scars,
erythema, quadriceps wasting or bruises
• Laterally: swellings
• Posteriorly: any popliteal swelling (Baker’s cyst, popliteal artery
aneurysm), calf muscle wasting
Note: Varus deformity (bow-legged); valgus deformity (knock-kneed)

Gait
- Ask the patient to walk to the end of the examining room and observe the
gait (smooth and symmetric? Antalgic?)

Feel
- Ask the patient to lie down
- Check for any localised rise in temperature
- Palpate the knee joint (knee should be flexed at 900). Start with the
unaffected knee.

Quadriceps tendon à Borders of the patella à patellar tendon à tibial

tuberosity à head of the fibula à lateral joint line à medial joint line à
popliteal fossa

- Patellar tap test (large effusions) – empty the suprapatellar pouch by sliding
your hand down the thigh towards the patella. Keeping that hand in position,
press down with the index/middle fingers of your other hand on the patella (a
tapping sound suggests an effusion).
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- Milking (sweep) test (small effusions) – milk any fluid out of the medial
aspect of the joint using a sweeping motion. Then see if you can milk it back
again, looking for a bulge or ripple on the medial side.

- Measure quadriceps bulk

Move (active and passive)

Active

- Flexion – “move your heel as close to your bottom as you can”

- Extension – “straighten out your leg as much as you can”

Passive

(Ask patient to relax legs as much as possible)

Look for crepitus, restricted ROM and pain

Hyperextension – elevate both legs by the heels and observe for any
hyperextension (>100 suggests laxity of PCL)

- Anterior drawer test (anterior cruciate ligament): flex the knee to 900 and
sit on the patient’s foot. Wrap your fingers around the proximal tibia with
your fingers behind the leg and the thumbs positioned over the tibial
tuberosity. Pull forward on the tibia. (There should be no movement;
movement suggest ACL injury)
- Lachman’s test: have the knee flexed and rest it on your leg to ensure the
muscles are relaxed. Hold the thigh with your left hand and grasp hold of the
lower leg with right hand. Pull forwards to look for any movement
(movement suggests injury to ACL)

- Posterior drawer test (posterior cruciate ligament): in the same position

push backwards on the tibia. (there should be no movement; movement
suggests PCL injury)
- Lateral stress test (varus stress test): hold the knee flexed at about 300 in
one hand and the ankle in the other. Apply lateral stress to the knee, whilst
applying force to the ankle in the opposite direction.
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- Medial stress test (valgus stress test): apply medial stress to the knee,
whilst applying force to the ankle in the opposite direction.
- McMurrays test (meniscal injury): no longer recommended by NICE! The
examiner will stop you from performing this test.

• Thank the patient for his co-operation and ask if he needs any help getting
dressed.

After completion state that ideally you would assess neurovascular status of
lower limbs and exam joints above and below. Order any tests you deem
necessary e.g. X-ray
Invite questions to the student!
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Breast Examination
You are an FY2 working in a teaching hospital.

You have been asked to teach a 3rd year medical student how to perform a
breast examination.

• Introduce yourself to the student and explain to him that you are one of
the doctors and have come to show him how to perform a breast
examination
• Approach the simulated patient, check patient’s ID, explain the procedure
and obtain consent and ask him if he is happy to allow the medical
student to watch him perform a breast exam.

• Introduce yourself to the patient, confirm patient’s ID, and explain the
examination (‘I have been asked to perform a breast examination on you
today. This will first involve me having a look at your breasts and then
having a feel of the breast tissue. I will then examine the glands of your
neck and armpit. Does that sound OK?) And ask for consent (‘are you
happy for me to go ahead?’)
• Offer chaperone and ensure privacy and comfort
• Exposure: undress from the waist up and put on a front opening gown.
• Note: if the patient has been referred or has concerns of a lump, ask
where the lump is.

Inspection

Patient should be sitting on the examining couch with her legs over the side
arms by the sides and hands on thighs

Look for:
- Asymmetry
- Swellings or masses (note size, location and shape)
- Skin changes e.g. dimpling (peau d’orange), erythema
- Nipple changes e.g. retraction, ulceration, discharge or bleeding
- Scars e.g. lumpectomy, mastectomy
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- Ask the patient to squeeze the nipple to express any discharge (do not do
this yourself!)

Ask the patient to adopt the following positions (accentuate any lumps by
tensing pectoralis major):
1. Hands on hips and push inwards
2. Arms above and behind the head – inspect axillae for any masses as well
as inspecting under the breasts
3. Lean forwards (hands are kept behind the head)

Palpation
- Patient must be lying down on the examining couch – 450
- Examine the asymptomatic breast first
- Ask the patient to place the arm of the side being examined behind her
head
- Use the flat of your fingers to compress the breast tissue against the
chest wall, feeling for any masses – start at the nipple and work
outwards in a circular motion
Note: if you find a mass, continue examining the remaining breast tissue and
then return to it once completed

- Palpate the axillary tail of Spence

- Palpate the periareolar region using your thumb
- Repeat palpation of the other breast

Examining a breast lump

1. Site of the lump e.g. upper outer quadrant of right breast
2. Size (in cm)
3. Shape e.g. irregular
4. Consistency e.g. rubbery (fibroadenoma), firm, smooth
5. tenderness
6. Mobility
7. Attachment to overlying skin
8. Attachment to underlying structures e.g. pectoralis major (ask the patient to
tense their muscle)
9. Overlying skin changes
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10. Fluctuance – hold the mass by its sides then apply pressure with another
finger to the centre of the mass

If the mass is fluid filled (e.g. cyst) then you should feel the sides bulging
outwards

Lymph node assessment

Standing position
• Palpate the axillary lymph nodes. Stand opposite the patient. When
examining the left axillary group ask the patient to place his left arm on
your left shoulder and you also place your left arm on the patient’s left
shoulder for support. With your right hand begin examining the axillary
group:
o Apical (palpate against glenohumeral joint)
o Anterior (palpate against pectoralis major)
o Central (palpate against lateral chest wall)
o Posterior (palpate against latissimus dorsi)
o Medial (palpate against humerus)
• Repeat for the right axillary group

Thank the patient, allow the patient to get re-dressed and invite any questions
from the medical student