Examination

COMMON STATION
SPECIALIST IN PLAB 2 PREPARATION
EXAMINATIONS
In
PLAB 2
Dr Elmira Yaghmaei Dr Hamed Salehi
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Copyrights © 2017 Common Stations PLAB Academy – Dr Hamed Salehi. All Rights Reserved
Table of Contents
1. Abdominal Examination (GI Examination) ............................................................................. 3
2. Thyroid Examination................................................................................................................... 16
3. Unconscious Patient Examination .......................................................................................... 26
4. Meningitis Examination (Headache) ....................................................................................... 33
5. Alcoholic/Diabetic foot Examination ...................................................................................... 39
6. Hip Examination ........................................................................................................................... 51
7. Knee Examination ....................................................................................................................... 60
8. Elbow Examination ..................................................................................................................... 71
9. Whiplash Injury (Cervical Examination) ................................................................................ 80
10. Primary Survey........................................................................................................................... 86
11. Secondary Survey ..................................................................................................................... 98
12. Cranial Nerve II – VII Examination....................................................................................... 102
13. Field of Vision........................................................................................................................... 118
14. Diplopia ...................................................................................................................................... 125
15. Cranial Nerve VIII Examination (Vestibulocochlear) ...................................................... 131
16. Lymphoreticular Examination .............................................................................................. 142
17. Cardiovascular Examination ................................................................................................ 155
18. Respiratory Examination ....................................................................................................... 175
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1. Abdominal Examination
(GI Examination)
Task:
“Mr Clinton is a 45 year old patient who has come to the Accident and Emergency
department complaining of upper abdominal pain.
He has been drinking 40 units of alcohol per week since he was young.
Please perform an abdominal examination on this gentleman and discuss your findings with
the examiner.
Please do not examine the groin area.
Please do not take history.”
Introduction:
This is essentially an examination of the patient’s abdomen; it is also called the
gastrointestinal examination (GI). It is a complex examination which also includes
examination of other parts of the body including the hands, face and neck. The abdominal
examination aims to pick up on any gastrointestinal pathology that may be causing a
patient’s symptoms e.g. abdominal pain or altered bowel habit. This examination is
performed on every patient that is admitted to hospital and regularly in clinics and general
practice.
Like most major examination stations this follows the usual procedure of inspect, palpate,
auscultate (look, feel, listen).
A. Subject Steps:
As with any examination station routine, begin by introducing yourself, obtaining consent to
examine the patient and position them appropriately. It is important to explain what the
examination will entail and what you are going to do.
A.1. Greet the patient
A.2. Introduce yourself
A.3. Clarify identity
A.4. Explain the procedure:
“I am here to examine your tummy. I will be as gentle as possible but if at any point you feel
any discomfort or would prefer me to stop, please let me know and I will stop the
procedure.”
A.5. Exposure:
For this examination the patient should be exposed from xiphisternum to the pubis
symphysis, leaving the chest and legs covered. However, you can simply ask the patient to
undress above waist.
“For the purpose of this examination you need to be exposed/undressed above waist.”
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A.6. Ensure Privacy and Chaperone:
“I will ensure your privacy and I will have a chaperone with me throughout the
examination.”
A.7. Gain consent and co-operation:
“May I proceed?” Or “Is that alright with you?”
A.8. Position:
For this examination the patient should be lying flat on the bed (supine position) with his
head slightly elevated with the help of one pillow to relax the abdominal muscles.
B. General Examination:
B.1. General Inspection:

- Check if the patient appears uncomfortable or is in distress.
- Look for abnormal contours/distension.
- The cough test: While looking at the face, ask the patient to cough. If this causes
abdominal pain, flinching or a protective movement of hands towards the abdomen,
suspect peritonitis.
B.2. Hands:
Inspect the patient’s hands. Provide clear instructions to the patient and minimise the
amount of movements they need to make (don’t have them turning their hands back and
forth multiple times). Particular signs which you should be looking for are:
- Palmar erythema: Reddening of palms – thenar / hypothenar eminences / liver disease /

pregnancy
- Clubbing: Can be a result of inflammatory bowel disease / cirrhosis / coeliac disease
- Koilonychias: Spooning of the nails – chronic iron deficiency
- Leukonychia: Whitened nail bed – hypoalbuminemia / liver failure / enteropathy
- Dupuytren’s contracture: Thickening of palmar fascia, associated with alcohol excess.
If patient has chronic liver disease, this may suggest alcohol is the cause.
- Hepatic flap/Asterixis:
Technique:
1. Ask patient to stretch out arms, with hands dorsiflexed and fingers stretched out
2. Ask to hold their hands in that position for 13 seconds
3. The hands will flap (flex/extend at the wrist) in an irregular fashion if positive
4. This sign can indicate either hepatic encephalopathy (due to liver failure) / uraemia / CO2
retention
- Peripheral cyanosis: Bluish discoloration of nails – indicates oxygen saturation of < 85%
- Radial pulse: Check the rate (count for 10 seconds, multiply by 6), rhythm and volume of
the pulse at the wrist.
It can be a good indication of some conditions such as infection/sepsis.
- Blood pressure
Note: When there is no clock to check pulse rate or you are not provided with a blood
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pressure machine to check BP, you may simply say:
“I can feel the pulse. The rhythm is regular and the volume is adequate. Ideally I would
check the pulse for 1minute. I would also check my patient’s blood pressure.”
B.3. Eyes:
- Conjunctival pallor (anaemia)
Inform the patient that you are going to have a look at his eyes:
“I am going to have a look at your eyes. I will be gently pulling your eyelids down . Is that
okay with you? Could you please look up for me? ”
Or
ask patient to lower an eyelid to allow inspection:
“I am going to have a look at your eyes. Could you please pull both your lower lids down and
look up for me?”
- Conjunctival icterus
“I am going to have a look at your eyes. I will be gently pulling your upper eyelids up. Is that
okay with you? Could you please look down for me? ”
Or
“I am going to have a look at your eyes. Could you please pull both your upper lids up and
look down for me?”
- Sunken eyes (dehydration)

- Xanthelasma: Lipid-laden yellow plaques that occur most commonly near the inner
canthus of the eyelid and signify hyperlipidaemia (PBC, chronic obstruction,
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hypercholesterolemia).
- Corneal arcus: A greyish-white ring (or part of a ring) opacity occurring in the periphery of
the cornea, in middle and old age. It is due to a lipid infiltration of the corneal stroma. With
age the condition progresses to form a complete ring.
B.4. Mouth:
- Central cyanosis: Bluish discoloration of the lips and mucous membranes (inferior aspect
of tongue).
“Could you please open your mouth and roll your tongue back?”
- Angular stomatitis: Inflamed red areas at the corners of the mouth – iron / thiamine / B12
deficiency
- Pigmentation: Peutz-Jeghers syndrome
- Telangiectasia: Osler-Weber-Rendu syndrome
- Mouth ulcers: Look at the buccal mucosa for any obvious ulcers which could be a sign of
Crohn’s disease / coeliac disease
- Tongue (glossitis): Also look at the tongue. If it is red and fat it could be another sign of
anaemia - iron/B12/folate deficiency
- Oral candidiasis
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B.5. Neck:
- Engorged neck veins / JVP: raised in fluid overload (renal dysfunction, liver dysfunction),
tricuspid regurgitation (may cause pulsatile hepatomegaly)
- Lymphadenopathy (Virchow’s node/ Troisier’s sign):
Examine cervical and supraclavicular lymph nodes.
Palpate the left supraclavicular lymph node. A palpable enlarged supraclavicular (Virchow’s)
node is known as Troisier’s sign. This is the node which drains the thoracic duct. This
receives lymph drainage from the entire abdomen as well as the left thorax. Enlargement of
this node may therefore suggest metastatic deposits from a malignancy in any of these
areas (gastric carcinoma).
C. Abdominal Inspection:
Position the patient lying flat, with their arms by their side and legs uncrossed. Comment on
any obvious abnormalities such as scars, masses and pulsations. Also note if there is any
abdominal distension.
“Please put your hands by your side and breathe normally.”

- Abdominal distension: fluid (ascites) / bowel distension / large masses / fat (obesity)
/faeces (constipation) / flatus / fetus (pregnancy)
- Scars: Midline scars (laparotomy) / RIF (appendectomy) / right subcostal (cholecystectomy)
- Visible masses, hernias or pulsation/peristalsis: a central pulsatile and expansive mass
may indicate an abdominal aortic aneurysm (AAA)
- Dilated veins/Caput Medusa: Visible veins suggesting portal hypertension
- Incisional hernias
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- Spider naevi: Indication of liver Cirrhosis
- Striae: either reddish / pink (new) or white / silverfish (chronic) – abdominal distension
- Umbilicus: Centrally placed and inverted is normal
- Skin changes: Redness/sinuses/marks or spots/erythema/swelling
D. Palpation:
Ask if there is any pain and examine this part last. Ensure that your hands are warm and
warn your patient before touching him.
Watch the patient’s face for signs of discomfort.
D.1. Temperature:
Assess each of the four quadrants temperature.
Check the local rise of temperature using the back of your hand. Compare each quadrant of
one side with the other side.
- Comment on your finding: “There is no rise in temperature.”

D.2. Superficial palpation:
Technique:
1. Initial examination should be superficial using one hand.
2. Where you start depends on the patient. If a patient has pain in one particular area, you
should start as far from that area as possible.
3. Squat by the bed so that the patient’s abdomen is at your level.
4. Place the hand flat over each area and flex at the metacarpophalangeal joints (Use your
palm). You should feel whether the abdomen is soft but you should always be looking at the
patient’s face for any signs of pain.
5. Assess each of the four quadrants, in an S shape pattern away from the pain and look for
the following:
Tenderness: Look at the patient’s face whilst palpating for evidence of pain. If this elicits
pain, check for rebound tenderness.
Rebound tenderness: Pain is worsened on releasing the pressure – peritonitis.
Guarding: Involuntary tension in the abdominal muscles – assess if localised or general.
Rigidity
Masses: Large / Superficial masses may be noted on light palpation.
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D.3. Deep palpation:
Assess each of the four quadrants again, but with greater pressure on palpation. You should
still be looking at the patient’s face for them flinching due to pain.
D.3.1. Detect masses:

If any masses are noted, assess location (which quadrant?), size, shape, consistency
(smooth / soft / hard / irregular), mobility (Is it attached to superficial / underlying tissues?)
and pulsatility (A pulsatile mass suggests vascular aetiology – aneurysm).
D.3.2. Organomegaly:
Having performed a general examination of the abdomen, you should now feel for
organomegaly, particularly of the liver, spleen and kidneys. Palpation for the liver and
spleen is similar, both starting in the right iliac fossa.
D.3.2.1. Liver:
Technique:
1. Using the radial border of the index finger aligned with the right costal margin.
2. Start palpation from the right iliac fossa.
3. Press your right hand into the abdomen as you ask the patient to take deep breaths in
and out.
4. Move your hand (without lifting it up, in a step-wise fashion) upwards, towards the right
costal margin (right hypochondrium) until you feel the liver.
5. You should try to time the palpation with the patient’s breathing – in as this presses down
on the liver.
6. A distended liver feels like a light tap on the leading finger when you press down. If the
liver is distended, its distance from the costal margin should be noted.
- Comment on your finding: “I cannot feel the edge of the liver.”
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Murphy’s Signe:
The gallbladder is not usually palpable when healthy. An enlarged gallbladder suggests
obstruction to biliary flow or infection (cholecystitis).
Technique:
1. Place your hand on the right costal margin.
2. Ask the patient to take a deep breath in and gently palpate the right upper quadrant in
the midclavicular line.
3. On inspiration, as the gallbladder is pushed into your hand they may suddenly develop
pain and stop inspiring. This is a positive Murphy’s sign, which is suggestive of Cholecystitis.
4. A similar manoeuvre in the left upper quadrant should not elicit discomfort.
D.3.2.2. Spleen:
The spleen is not usually palpable, therefore if you feel it, it’s at least 3x its normal size.
Technique:
2. Using the radial border of the index finger aligned with the left costal margin, start
palpation from the right iliac fossa and then move your hand upwards towards the left
costal margin (left hypochondrium).
3. While palpating ask the patient to take deep breaths in and out.
4. You should try to time the palpation with the patient’s breathing –in as this presses down
on the spleen.
5. The edge of the spleen which may be felt if distended, is more nodular than the liver.
6. If suspect splenomegaly but cannot detect it, assess patient in the right lateral position
with your left hand pulling forwards from behind the rib cage:
Ask the patient to lie on their right side towards you. Support the rib cage with your left
hand and again ask the patient to take deep breaths in, as you move your right hand up
towards the left hypochondrium.
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- Comment on your finding: “The edge of spleen is not palpable.”
D.3.2.3. Kidneys:
In the majority of people the kidneys are not palpable, but they maybe in thin patients who
have no renal pathology.
Technique:
1. For each kidney, place one hand behind patient at the loin
2. Press down on the abdomen with your other hand and ‘flick’ the kidney up with your
lower hand against your upper hand. (Ballottement of kidney; ballot the kidney between the
two hands).
- Comment on your finding: “Kidneys are not palpable.”
D.3.2.4. Aorta:
You should also palpate for the abdominal aorta to check whether it is expansile, which
could be suggestive of an aneurysm.
Note the aortic pulsation can often be felt in thin patients, but shouldn’t be expansile.
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Technique:
1. Position your palms on either side of the umbilicus
2. Palpate midline just above umbilicus, at the border of the aortic pulsation.
3. Note the movement of your fingers:
Upward movement = pulsatile
Outward movement = expansile (suggestive of AAA)
- Comment on your finding: “Aorta is/ is not palpable and is not expansile.”
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E. Percussion:
Next you should percuss. This can also be used to check for organomegaly or ascites, if it is
suspected.
With the patient lying flat, percuss all four quadrants of the abdomen.
Inform the patient:

“I am going to gently tap over your tummy, is that okay with you?”
E.1. Liver percussion:

- Percussion over the abdomen is usually resonant, over a distended liver it will be dull.
- The purpose of liver percussion is to measure the liver size (liver span).
- Confirm the lower border and define the upper border of the liver.
Technique:
1. Starting in the midclavicular line at about the 2nd intercostal space, lightly percuss and
move down.
2. Percuss inferiorly until dullness denotes the liver's upper border. (It will usually become
dull at level of 5th ICS)
3. Resume percussion from right iliac fossa on the midclavicular line.
4. Percuss superiorly until dullness indicates the liver's lower border.
5. Measure span in centimetres.
- Comment on your finding: “There is no hepatomegaly. Liver span seems to be normal.
Ideally I would measure the liver span with a measuring tape.”
E.2. Spleen percussion:

Percuss from left costal margin (border of spleen) towards mid-axillary line and lower left
ribs for dullness of spleen.
- Comment on your finding: “There is no splenomegaly.”
E.3. Bladder:
Percuss suprapubic region, from above the umbilicus downwards.
Dullness in suprapubic region suggests bladder enlargement.
- Comment on your finding: “The bladder is not enlarged.”
E.4. Ascites:
E.4.1. Shifting dullness:

Percussion can also be used to check for ‘shifting dullness’ – a sign of ascites.
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Technique:
1. Percuss from the centre of the abdomen to the flank until dullness is noted (centrally to
laterally).
2. Keep your finger on the spot at which the percussion note became dull.
3. Ask patient to roll onto the opposite side to which you have detected the dullness
4. Keep the patient on their side for 30 seconds
5. Repeat your percussion in the same spot
6. If fluid was present, this will now have moved by gravity (ascites) and then the area that
was previously dull should now be resonant
7. If the flank is now resonant, percuss back to the midline, which if ascites is present, will
now be dull (i.e. the dullness has shift.
E.4.2. Fluid Thrill:
Technique:
1. Have the patient lying supine.
2. Ask the patient or your assistant to place one or both hands (ulnar surface of hand
downward) in a wedge-like position into the patient's mid abdomen, applying with slight
pressure. This will prevent the transmission of impulse through abdominal wall.
3. The examiner places the fingertips of one hand along one flank, and with the other hand
firmly gives a sharp tap along the opposite flank.
4. Positive test: The examiner is able to detect "a shock wave" of fluid moving against the
fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to
the other by the force of the tap along the opposite flank.
F. Auscultation:
F.1. Bowel sounds:
Inform the patient:
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“I am going to listen to your tummy, is that okay with you?”
Place your stethoscope either side of midline, just below the umbilicus and listen to the
bowel sounds.
F.2. Bruits (Use bell):
F.2.1. Aortic bruit – Listen over aorta by auscultating either side of midline, just above the
umbilicus - AAA
F.2.2. Renal bruit – Listen over renal arteries by auscultating just above the umbilicus,
slightly lateral to the midline.
G. To Complete the Examination:

You may carry out the following if appropriate:
G.1. Ankle oedema

G.2. Check hernial orifices – e.g. if there’s signs of obstruction
G.3. Perform a digital rectal examination (PR) e.g. if there’s a suggestion of UGIB
G.4. Perform an examination of the external genitalia –
“Ideally I would finish my examination by listening to the bowel sounds and testing renal
and aortic bruits. I will check for fluid thrill if needed. If appropriate, I would palpate for
ankle oedema, examine the hernial orifices, perform a PR or examine the external genitalia“
Thank the patient and kindly ask him to dress up.
Thank the chaperone.
Thank the examiner.
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2. Thyroid Examination
Task:
“Mr Pryce is a 25 year old patient who is presented to the outpatient clinic. He is suspected
to have hyperthyroidism.
Please do relevant examination.
Please do not take history.”
Introduction:
The thyroid gland sits at the front of the neck and produces endocrine hormones into the
bloodstream. Sometimes the gland can produce too much (hyperthyroid) or too little
hormone (hypothyroid) which results in a patient needing treatment. There are certain signs
and symptoms that the patient may present with and it is there that you are examining the
patient for in this station.
A. Subject Steps:
Begin this station by greeting and introducing yourself to the patient.

Make sure you clarify his identity, get proper consent and maintain dignity. It is important to
explain what the examination will entail and what you are going to do.
A chaperone will be provided if it is required for this procedure.
A.2.Introduce yourself
“I am here to examine the gland in your neck. I will be as gentle as possible but if at any
point you feel any discomfort or would prefer me to stop, please let me know and I will stop
the procedure.”
A.5. Exposure:
For this examination the patient should be exposed above the chest.
In the exam the patient is usually wearing a V-neck T-shirt which provides adequate
exposure for this station:
“I can see that you are adequately exposed. Thank you for that.”

“However, I will ensure your privacy and I will have a chaperone with me throughout the
examination.”
A.7. Gain consent and co-operation: “May I proceed?”
A.8. Position: Sitting on a chair (with space behind)
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B. General Examination:
B.1. General Inspection (Assess the patient’s demeanour):
- Check if the patient appears hyperactive, anxious, nervous, agitated, fidgety (hyperthyroid)
or slow and lethargic (hypothyroid)
- Comment on your findings: “My patient doesn’t look anxious, nervous or agitated.”
B.2. Hands:
A dysfunctioning thyroid gland may give stigmata of disease in many places, so as always, it
is best to start with the hands.
Inspect the patient’s hands for:
- Sweatiness (hyperthyroid)
- Assess temperature: Warm peripheries if hyperthyroid
- Palmar erythema: Redding of the palms at the thenar / hypothenar eminencies –
hyperthyroidism
- Clubbing (Thyroid Acropachy): Phalangeal bone overgrowth – Graves’ disease
- Tremor:
Technique:
1. Ask the patient to “hold hands out”.
2. Place a piece of paper on the backs of the patient’s outstretched hands and look for
tremor (the paper will quiver).
3. Peripheral tremor can be a sign of hyperthyroidism.
- Radial pulse: Check the rate, rhythm and volume of the pulse at the wrist.
Rate: Tachycardia (hyperthyroidism)
Rhythm: Irregular / Atrial fibrillation (hyperthyroidism)
Volume
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- Blood pressure
“I can feel the pulse. The rate seems to be normal, the rhythm seems to be regular and the
volume is adequate. Ideally I would check the pulse for 1minute. I would also check my
patient’s blood pressure.”
B.3. Eyes:
The ‘normal’ upper eyelid should always cover the upper eye such that the white sclera is
not visible between the lid and the iris. In hyperthyroidism with exophthalmos there is
proptosis as well as lid retraction and ‘lid lag’ may also be detected.
If the patient reports double vision when eye movements are being tested this indicates
ophthalmoplegia of hyperthyroidism.
Inform the patient: “Please sit straight on the chair, with your vision fixed on a distant
object. I am going to take a look at your eyes.”
B.3.1. Look:
- Eye level / Symmetry

- Ptosis
- Lid retraction: Note if the sclera is visible above the iris – seen in Grave’s disease
- Exophthalmos (anterior displacement of the eye out of the orbit):
Look at the patient’s eyes from his both sides:
“I will be looking at your eyes from your sides.”
- Proptosis (hyperthyroidism):
Whilst standing behind the patient (with permission), ask them to tilt their head back
slightly; this will give you a better view to assess any proptosis:
“I will be looking at your eyes from the behind. Could you please look up to the ceiling for
me?”
B.3.2. Lid lag:
Lid lag occurs as a result of the anterior protrusion of the eye from the orbit (exophthalmos)
which is associated with Grave’s disease.
Technique:
1. Hold your finger high and ask the patient to follow it with their eyes (with their head still).
2. Move your finger downwards
3. Observe the upper eyelid as the patient follows your finger downwards
4. If lid lag is present, the upper eyelid will be observed lagging behind the eyes downward
movement (the sclera will be visible above the iris)
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B.3.3. Eye movements / Ophthalmoplegia:
Eye movements can be restricted in Grave’s disease due to abnormal connective tissue
deposition in the orbit and extra-ocular muscles.
Technique:
1. Ask the patient to keep their head still.
2. Ask the patient to follow your finger with their eyes, as you make an ‘H’ shape.
3. Observe for restriction of eye movements and ask the patient to report any double vision
or pain.
C. Thyroid Examination:
C.1. Look:
This step includes inspection of the neck, swallow test and tongue protrusion test.
C.1.1. Inspection of Neck:
Observe it as a whole but pay particular attention to the area of the thyroid gland. You
should look from the front and the sides looking for any obvious abnormalities.
A midline swelling should raise your suspicion of thyroid pathology.
Ask the patient to slightly lift his chin up, inspect the midline of the neck (in the region of the
thyroid) and comment on:
- Obvious swelling, goitres or masses: The normal thyroid gland should not be visible.
- Scars: Previous thyroidectomy scars (collar incision) can easily be missed.
- Skin changes: Erythema
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C1.2. Swallow Test:
This test can help to differentiate between different causes. Goitres, thyroglossal cysts and
in some cases lymph nodes should move up on swallowing (lymph nodes will move very
little).
Technique:
1. Hand the patient a glass of water
2. Ask patient to sip water, hold in his mouth and then swallow
3. Observe the patient as he takes a sip
4. Observe the movement of any mass or swelling as he drinks.
- Comment on your finding: “There is no mass or swelling visible (moving) on deglutition.”
C.1.3. Tongue protrusion Test:

This test can also help to differentiate between different causes.
Thyroid gland masses and lymph nodes will not move. However, Thyroglossal cysts will
move upwards noticeably.
Technique:
1. Ask patient to stick out his tongue.
2. Look for any lump moving up.
- Comment on your findings: “There is no mass or swelling visible on tongue protrusion.”
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C.2. Palpation:
Next you should feel the gland. The approach is from behind (Seek permission from the
patient).
Ensure that your hands are warm and warn your patient before touching him.
C.2.1. Thyroid Palpation:
The approach is from behind so always tell the patient what you will be doing and that you
will be behind them. Warn them again the moment before you actually touch their neck.
You should use both hands at the same time to compare left and right side. Be gentle
because it will probably be uncomfortable for the patient.
Technique:
1. Ask if the patient has any pain in the neck before palpating.
2. Stand behind the patient and ask him to slightly flex his neck (To relax the
sternocleidomastoids)
3. Place your hands either side of the neck
4. Place the 3 middle fingers of either hand along the midline of the neck below the chin.
5. Locate the thyroid notch (The upper edge of the thyroid cartilage / Adam’s apple)
6. Move downwards until you feel a soft tissue which is the cricothyroid membrane.
7. Move downwards until you reach the cricoid cartilage
8. The first 2 rings of the trachea are located below the cricoid cartilage and the thyroid
isthmus overlies this area.
9. Palpate the thyroid isthmus using the pads of your fingers (not the tips)
10. Palpate each lobe of the thyroid in turn. Fix one side with your hand and palpate the
other side using your other hand.
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On palpation, if a lump is noted, assess site, size, shape, symmetry, surface (counter, edge,
colour), consistency (smooth, nodular), surrounding structures, mobility (fixed, tethering),
solitary or multiple, temperature and tenderness.
C.2.2. Swallow Test:

Repeating the swallow test whilst palpating (from behind) allows you to confirm the early
finding, but also attempt to ‘get under’ the lump. If there is a distinct inferior border under
which you can place your hand with the entire lump above it then the goitre is unlikely to
have retrosternal extension.
Technique:
1. Hand the patient a glass of water
2. Ask patient to sip water, hold in his mouth and then swallow
3. Whilst standing behind the patient palpate the gland as the patient is swallowing
4. Feel for symmetrical elevation of the thyroid lobes, Asymmetrical elevation may suggest a
unilateral thyroid mass.
- Comment on your finding: “I cannot feel any mass or swelling moving on deglutition.”
C.2.3. Tongue protrusion Test:

Technique:
1. Ask the patient to protrude their tongue once more.
2. Palpate while the patient sticks out their tongue.
3. If a mass is a thyroglossal cyst, it will rise with this manoeuvre.
- Comment on your finding: “I cannot feel any mass or swelling on tongue protrusion.”
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C.2.4. Lymph Nodes Palpation:
Whilst still behind the patient, take the opportunity to examine the cervical lymph nodes.
Local lymphadenopathy may suggest metastatic spread of a primary thyroid malignancy.
Technique:
1. Gently place the pads of your fingers on each side of the neck. Feel both sides together
for comparison.
2. Start under the chin to feel the submental nodes.
3. Then move along the lower jaw line to feel the submandibular nodes.
4. Then behind and in front of the ears for the post- and pre-auricular nodes.
5. Ask the patient to slightly bend his head downwards and feel for the occipital nodes.
6. Ask the patient to turn his head to the left/right and then feel along the anterior border
of the sternocleidomastoid muscle for the anterior cervical and around to the posterior
border, for the posterior cervical lymph nodes.
7. Ask patient to shrug his shoulder and feel above and below the clavicle for the supra- and
infra-clavicular nodes.
C.2.5. Temperature:
1. Whilst still behind the patient, use the back of your hand
2. Check and compare the local rise of temperature in both lobes.
3. Compare with the side of the neck
- Comment on your findings: “There is no rise in temperature.”
C.2.6. Trachea:
Complete palpation by assessing if the presence of a large thyroid mass has caused the
trachea to deviate from the midline.
Palpation of the trachea can be uncomfortable, so ensure to warn the patient and have a
gentle technique.
Inform the patient: “I am going to gently press over your neck, this may feel a bit
uncomfortable but I will be as gentle as possible.”
23
Technique:
1. Move to the front.
2. Ensure patient’s neck musculature is relaxed. You may ask the patient to bend his chin
slightly downwards.
3. Insert the tip of your index finger into the suprasternal notch, between the heads of the
two clavicles.
4. Then gently apply some pressure to locate the trachea.
5. Check that your fingertip fits easily into both sides.
Note: You may use the 3 finger technique.
- Comment on your Finding: “Trachea is placed centrally.”
D. Percussion:
Retrosternal Dullness may indicate a large thyroid mass, extending posterior to the
manubrium (retrosternal goiter).
1. Start from the sternal notch.
2. Percuss the sternum downwards for dullness of retrosternal extension of a goiter.
- Comment on your findings: “No retrosternal dullness is indicated.”
E. Auscultation:
A Thyroid bruit, would suggest a sign of increased blood flow (vascularity), which may be
heard in hyperthyroidism.
A bruit in a smooth thyroid goiter is suggestive of Grave’s disease.
Technique:
1. Ask patient to hold breath for 10 seconds
2. Then auscultate each lobe of the thyroid for a bruit.
3. This can be done using either the bell or diaphragm.
24
F. To Complete the Examination:
You may carry out the following if appropriate:
F.1. Ankle Reflexes:
- This will be slow relaxing in hypothyroidism and brisk in hyperthyroidism.
- Ask patient to face away from you with knee resting on chair and then test ankle reflexes.
F.2. Pretibial myxedema:
- Brown swelling of the lower leg above the lateral malleoli in Grave’s disease.
- It is most commonly seen on the shins (pretibial areas) and is characterised by swelling and
lumpiness of the lower legs.
- Ask patient to stand up from the chair and look for pretibial myxedema.
F.3. Proximal myopathy:

- Proximal myopathy is associated with hyperthyroidism.
- Ask patient to stand from a sitting position with arms crossed.
- An inability to do this suggests proximal muscle wasting
Thank the patient.

Thank the examiner.
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3. Unconscious Patient Examination
Task:
“Mr Edward has been brought to the accident and emergency department after having a
road traffic accident. He is unconscious. Primary and secondary surveys have been done.
Please assess GCS and perform a neurological examination.”
Introduction:
Assessing the neurologic status of unconscious or comatose patients can be a challenge
because they can’t cooperate actively with your examination. But once you become
proficient in performing this exam, you’ll be able to detect early significant changes in a
patient’s condition.
Procedure:
A. Universal Precautions:
Tell the examiner that you will take all the universal precautions before doing this
examination:
“I assume that I have taken all the universal precautions.”
B. Greet/introduce yourself to the patient:

Even though the patient is unconscious, it is advisable for you to do this step.
Note: Check patient’s identity if he/she has any wrist band.
C. Assess Level of Consciousness (GCS):
The GCS is a neurological scoring system used to assess conscious level following a head
injury or any other cerebral insult likely to cause neurological deterioration.
It is scored out of 15 and is comprised of 3 categories, best eye response scoring 4, best
vocal response scoring 5 and best motor response scoring 6.
Usually, a GCS of 8 or less indicates severe brain insult; the patient may be unable to
maintain an airway and requires intubation, and may need to go to the intensive care unit
for airway monitoring.
- Explain what you are going to do to the patient:

“I am going to assess your Glasgow coma scale now.”
26
1) To assess Eye opening response, ask: “Could you please open your eyes and keep them
open for me?”
Eye Response
4 Spontaneous eye opening

3 Eye opening response to speech
2 Eye opening in response to pain
1 No eye opening
2) To assess Verbal response, ask: “Do you know where you are now?” and record level of
best speech.
Verbal Response:
5 Oriented : The patient knows who he is and where he is
4 Confused : The patient responds to question in a conversational manner but
there is some disorientation and confusion
3 Inappropriate speech : Random or exclamatory articulated speech, but no
conversational exchange
2 Incomprehensible speech: Moaning but no words
1 No response
To assess Motor response, ask: “Could you please raise your right arm for me? Left arm?
Right leg? Left leg?” and record the best response of any limb.
6 Obeying commands: Patient will do what you asked
5 Localizing response to pain: Put pressure on patient’s fingernail bed.
Purposeful movement towards changing painful stimulus is a ‘localizing’
response
4 Withdraws to pain/flexion withdrawal: Patient will flex the arm away from the
painful stimulus
3 Flexor response to pain/abnormal flexion: Nailbed pressure causes abnormal
flexion of both arms
2 Extensor posturing to pain: The stimulus causes arm extension
1 No response to pain
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Note 1: If the patient did not show any motor response, ask: “Could you please stick out
your tongue?”
Note 2: And if no response is indicated, apply painful stimulus by gently squeezing the
patient’s thumb.
Note 3: Make sure that you inform the simulator before applying any pain:
“I am going to squeeze your thumb.”
Break down the GCS, using the given GCS card in the exam and verbalize it to the examiner.
Eye Response:
I scored eye opening:
4 because the eyes were opened spontaneously.
3 because the eyes opened in response to speech.
2 because the eyes opened in response to pain.
1 because the eyes did not open at all.
Verbal Response:
I scored the best verbal response:
5 because patient was oriented.
4 because patient had confused conversation.
3 because patient had inappropriate speech.
2 because patient had incomprehensive speech.
1 because patient had no response.
Motor Response:
I scored the best motor response:
6 because patient obeyed command.
5 because patient showed localizing response to pain.
4 because patient showed withdrawal response (flexion withdrawal) to pain.
3 because patient showed abnormal flexion response to pain.
2 because patient showed abnormal extension response to pain.
1 because patient showed no response to pain.
Note: An overall score is made by summing the score in the 3 areas assessed.
Verbalize your overall GCS score to the examiner.
“My patient has the overall GCS score of …. out of 15.”
D. Neurological Examination:
A full neurological examination includes assessment of both the motor and sensory systems.
However in this station the patient is not conscious, therefore we do not assess the sensory
system.
- Position: Supine position

- Exposure:
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“I am going to examine you now. For the purpose of this examination I need to undress you
fully by cutting all your clothes. I will ensure your privacy and I will have a chaperone with
me throughout my examination.”
D.1. Bulk:
Begin by observing the patients legs and arms, looking for any muscle wasting, fasciculations
or asymmetry.
“Bulk seems to be normal/abnormal. Ideally I will measure the bulk with the help of a
measuring tape. ”
D.2. Tone:
Upper limbs:
- Warn the patient before touching him and warm your hands up.
- Ask patient to “relax/go floppy”.
a. Shoulder tone:
Start proximally at the shoulder, feeling how easy the joint is to move passively.
b. Elbow tone:
- Then move down to the elbow, again assessing each one’s tone in turn.
- Feel for any spasticity or rigidity.
c. Wrist tone:
- Now move to the wrist, again assessing each one’s tone in turn.
29
Lower limbs:
- Ask if they have any pain in feet, legs or hips before assessing for the tone.
a. Leg/Hip tone:
Roll the leg on the bed (from side to side) to see if it moves easily.
b. Knee tone:
- Put your hand behind the knee and raise it quickly.
- The heel should lift slightly from the bed if tone is normal.
c. Ankle tone:
Check for ankle tone by placing the patient’s leg turned outwards on the bed, moving the
ankle joint (plantar flexion/dorsiflexion) a few times to check for the tone.
D.3. Reflexes:
- Check upper, lower and pupillary reflexes.

- For each reflex, test right, then left and compare.
- Decide whether reflexes are absent, diminished, normal or exaggerated.
- Introduce medical hammer:
“This is a medical instrument called hammer. I am going to gently tap it on different parts of
your legs and arms. It will not cause any pain but I will be as gentle as possible. Is that alright
with you?”
Upper Limb Reflexes:

There are three reflexes in the upper limb:
a. The Biceps Reflex (C5, 6) – located in the cubital fossa.
The biceps reflex is tested by supporting the patient’s arm, with it flexed at roughly 60
30
degrees, placing your thumb over the biceps tendon and hitting your thumb with the
tendon hammer. It is vital to get your patient to relax as much as possible and for you to
take the entire weight of their arm.
b. The Triceps Reflex (C7) – The triceps reflex is elicited by resting the patient’s arm across
their chest and hitting the triceps tendon just proximal to the elbow.
c. The Supinator Reflex (C6) – Located 4 inches proximal to base of the thumb.
With their arm rested on their abdomen, locate the supinator tendon as it crosses the
radius, place three fingers on it and hit the fingers. This should give the supinator reflex.
Lower Limb Reflexes:

There are three reflexes in the lower limb:
a. The Knee (Patellar) Reflex (L3, 4):
- The knee reflex is tested by placing the patient’s leg flexed at roughly 60 degrees.
- Place one hand in the popliteal fossa and take the entire weigh of your patient’s leg with
your arm.
Note: It is vital to get your patient to relax as much as possible and for you to take the entire
weight of their leg.
- Then strike on the patella tendon (just below the patella) with the tendon hammer (keep
looking at quadriceps).
b. The ankle Jerk (L5, S1):
- There are several accepted methods to check for the ankle reflex.
- You can ask the patient to slightly bend the knee and then drop it laterally.
- Grasp the foot, dorsiflex and then strike the Achilles tendon (keep looking at calf).
c. The Plantar Reflex (L5, S1, S2):
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Finally, with their leg out straight and resting on the bed, run the orange stick along the
outside of the foot, towards the little toe. This gives the plantar reflex.
- Normal response is the flexion of the great toe with flexion of other toes (downward
movement of the great toe).
- An abnormal reflex would see the great toe extending.
- Babinski’s sign is positive if there is dorsiflexion of the great toe.
This is abnormal (upper motor neuron lesion) if patient age >6 months.
“Ideally I will do plantar reflex with the help of an orange stick.”
Pupillary Reflex:
Ask for a pen torch and throw light on the patient’s eyes to look for pupillary reflex.
E. Head to Toe Examination:
“Ideally I will finish my examination by performing a complete head to toe examination to

look for any injuries.”
- Thank the patient.

- Cover the patient with warm blanket to prevent hypothermia.
- Thank the examiner.
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4. Meningitis Examination (Headache)
Task:
“Mr Edmond has come to the accident and emergency department complaining of severe
headache. Please assess his level of consciousness, perform a relevant examination and
discuss your findings with the examiner.”
Introduction:
Although meningitis has been recognized since antiquity, the clear description of signs of
meningeal irritation is relatively recent. Since outcome in meningitis is dependent on early
treatment--and therefore early diagnosis--familiarity with all the meningeal signs is
desirable.
Procedure:
A. Universal Precautions:
Tell the examiner that you will take all the universal precautions before doing this
examination:
“I assume that I have taken all the universal precautions.”
B. Greet/introduce yourself to the patient

Note: Check patient’s identity if he/she has wristband
C. Patient’s Comfort:
C.1. Offering painkillers:
- Ask the patient:
“Would you like me to give you some painkillers?”
- Verbalize what you are going to do to the examiner:

“I would like to give my patient some painkillers.”
C.2. Dimming the light:
- Ask the patient:
“Would you like me to dim the light for you?”
- Verbalize what you are going to do to the examiner:

“I would like to dim the light.”
Note: If the patient is uncooperative, if he doesn’t remove his hand from his eyes or
answers your questions by mumbling, try to help him remove his hand gently and verbalize:
“Let me help you remove your hand.”
33
D. Assess Level of Consciousness (GCS):
The GCS is a neurological scoring system used to assess conscious level following a head
injury or any other cerebral insult likely to cause neurological deterioration.
It is scored out of 15 and is comprised of 3 categories, best eye response scoring 4, best
vocal response scoring 5 and best motor response scoring 6.
Usually, a GCS of 8 or less indicates severe brain insult; the patient may be unable to
maintain an airway and requires intubation, and may need to go to the intensive care unit
for airway monitoring.
- Explain purpose of visit to the patient:

“I am going to assess your Glasgow coma scale now.”
1. To assess Eye opening response, ask: “Could you please open your eyes and keep them
open for me?”
Eye Response
4 Spontaneous eye opening
3 Eye opening response to speech
2 Eye opening in response to pain
1 No eye opening
2. To assess Verbal response, ask: “Do you know where you are now?” and record level of
best speech.
Verbal Response:
5 Oriented : The patient knows who he is and where he is
4 Confused : The patient responds to question in a conversational manner but
there is some disorientation and confusion
3 Inappropriate speech : Random or exclamatory articulated speech, but no
conversational exchange
2 Incomprehensible speech: Moaning but no words
1 No response
34
3. To assess Motor response, ask: “Could you please raise your right arm for me? Left arm?
Right leg? Left leg?” and record the best response of any limb.
6 Obeying commands: Patient will do what you asked

5 Localizing response to pain: Put pressure on patient’s fingernail bed.
Purposeful movement towards changing painful stimulus is a ‘localizing’
response
4 Withdraws to pain/flexion withdrawal: Patient will flex the arm away from
the painful stimulus
3 Flexor response to pain/abnormal flexion: Nailbed pressure causes abnormal
flexion of both arms
2 Extensor posturing to pain: The stimulus causes arm extension
1 No response to pain
Note 1: If the patient did not show any motor response, ask: “Could you please stick out
your tongue?”
Note 2: And if no response is indicated, apply painful stimulus by gently squeezing the
patient’s thumb.
Note 3: Make sure that you inform the simulator before applying any pain:
“I am going to squeeze your thumb.”
Break down the GCS, using the given GCS card in the exam and verbalize it to the examiner.
Eye Response:
I scored eye opening:
4 because the eyes were opened spontaneously.
3 because the eyes opened in response to speech.
2 because the eyes opened in response to pain.
1 because the eyes did not open at all.
Verbal Response:
I scored the best verbal response:
5 because patient was oriented.
4 because patient had confused conversation.
3 because patient had inappropriate speech.
2 because patient had incomprehensive speech.
1 because patient had no response.
Motor Response:
I scored the best motor response:
6 because patient obeyed command.
5 because patient showed localizing response to pain.
4 because patient showed withdrawal (withdrawal flexion) response to pain.
3 because patient showed abnormal flexion response to pain.
35
2 because patient showed abnormal extension response to pain.
1 because patient showed no response to pain.
Note: An overall score is made by summing the score in the 3 areas assessed.
Verbalize your overall GCS score to the examiner.
“My patient has the overall GCS score of …. out of 15.”
E. Meningeal Signs:
- Position: Supine position
- Inform the patient that you are going to examine him:
“Now I am going to examine you.”
E.1. Neck Stiffness:

- Nuchal rigidity is the inability to flex the neck forward due to rigidity of the neck muscles.
- To assess neck rigidity, ask:

“Could you please try to touch your chest with your chin?”
E.2. Brudzinski’s Neck Sign:
- Brudzinski’s sign is one of the physically demonstrable symptoms of meningitis in which

forced flexion of the neck elicits a reflex flexion of the hips and knees.
- Inform the patient about what you are going to do:

“Let me help you with that. Please bear with me for a moment.”
Technique:
1. Hold the patient’s head with your fingers at the occiput.
2. Try to gently flex his neck, so that his chin touches his chest.
3. Severe neck stiffness causes a patient's hips and knees to flex when the neck is passively
flexed. This indicates a positive Brudzinski’s sign.
36
E.3. Kernig’s Sign:
- Kernig’s sign is a diagnostic sign for meningitis, marked by a loss of the ability of a supine
patient to completely straighten the leg when it is fully flexed at the knee and hip.
- Inform the patient about what you are going to do:

“I am going to lift your leg, is that alright with you?”
Technique:
1. Flex one of the patient’s thighs at the hip and knee, both at 90 degree angles.
2. Use your other hand to extend the leg at the knee joint while the hip is maintained flexed.
3. Severe stiffness of the hamstrings causes pain and an inability to straighten the leg. This
indicates a positive Kernig’s sign.
Note: Positive Kernig’s sign on one side, leads to involuntary flexion in the opposite leg due
to pain.
F. Meningitis Rash:
This condition is marked by a deep red or pink coloured rash on the skin of patients affected
with meningitis. Medical experts believe that it is an alarming symptom of an underlying
infection and should not be ignored.
- Exposure:
“For the purpose of this examination you need to be undressed fully. I will ensure your
privacy and I will have a chaperone with me throughout my examination.”
- Ask the examiner for a pen torch and look for rash over the patient’s chest, armpits and
behind the ears.
37
- If you find a rash, do the Tumbler test to check whether it is a blanching rash or a non-
blanching one.
Glass test:
It is a simple technique to examine the nature of the skin rash. In this procedure, an
ordinary glass tumbler is placed on the rash-affected skin of a patient and rolled for a while.
In case, the bright red spots do not undergo a colour change then such a patient is possibly
affected with meningitis.
- Thank the patient.

- Cover the patient with warm blanket to prevent hypothermia.
G. Management:
Note: If in the question you are asked for the management of the meningitis, tell the
examiner that:
• I will admit my patient.

• I will give my patient analgesia.
• I will isolate my patient.
• I will inform my seniors.
• I will take blood sample for C/S, FBC, U&E, LFT, CRP, Clotting profile and toxicology
screen.
• I will start giving my patient IV Benzyl Penicillin.
• I will arrange for CT brain (to assess intracranial pressure).
• I will arrange for lumbar puncture (for CSF analysis).
• I will trace all the close contacts of the patient and I will seek advice from
microbiology team for prophylactic treatment (e.g. Rifampicin).
38
5. Alcoholic/Diabetic foot Examination
Task:
“Mr Clark has long-standing diabetes mellitus for more than 25 years. He presented to the
outpatient clinic, medicine department.
Please perform a routine examination.”
Introduction:
In diabetes it is important to check distal circulation. Diabetes affects blood vessels, causing
a loss of blood supply that can lead to ischemia and tissue damage.
This is particularly the case in the peripheries. The feet are the most distal tissues from the
heart and so the most likely to be affected first by the pathological changes in diabetes.
A chaperone is required for this procedure.
Subject Steps:
A.2. Introduce yourself
Explain what you would like to do:
“I am here to examine your legs. I will be as gentle as possible but if at any point you feel
procedure.”
A.5. Exposure:
For this examination the patient should be exposed below the waist.
“For the purpose of this examination you need to be undressed below waist. You can keep
your briefs on.”
examination.”
A.7. Gain consent and co-operation: “May I proceed?” Or “Is that alright with you?”
A.8. Position:
In lying position with the couch flat or at 45 degrees.
39
B. Inspection:
Inspect front legs, feet and posterior aspect of the legs thoroughly. This involves asking the
patient to bend the knees and also to lift his legs up.
Note: In the exam you may face a real diabetic patient thus it is important to inspect the
legs carefully and comment on your findings, if any.
Observation of the legs
B.1. Front legs:

Inform the patient about what you are going to do and then inspect the front legs:
“I am going to have a look at your legs, is that alright with you?”
Possible findings:
- Dryness
- Shininess
- Pigmentation
- Hairlessness
- Pallor
- Cellulitis
- Erythema
- Swelling
- Gangrene
- Ulcers
- Skin breaks
- Lesions
B.2. Feet:
Possible findings:
B.2.1. Dorsum:
- Hard Corn
40
B.2.2. Toes:
- Ingrown toe nails
- Discoloration
- Blanching
- Dystrophic
- Paronychia / Onychomycosis
- Amputation
B.2.3. Web spaces:
Inform the patient:
“I am going to have a look between your toes, is that okay?”
- Fungal infection (Tinea Pedis)

- Ulcers
- Cracked
- Soft Corn
B.2.4. Sole:
- Callus formation
- Ulcer
B.2.5. Heel:
Inform the patient:
“Can you please lift your right/left leg up?”
- Pressure sores
B.3. Behind Legs:

- Same as front, comment if there is any abnormality.
- Ask patient to bend the knees, with his feet on the couch.
- Approach from the head end.
“Could you please bend your knees with your feet on the couch?”
C. Palpation:
After completing the inspection, move onto palpating the legs.
- Warm your hands up.
- Inform patient before touching him.
41
C.1. Temperature:
Initially assess the temperature of each leg.
Starting distally, feel with the back of your hand and compare the legs to each other noting
any difference.
- Dorsum of foot; check for cold periphery (e.g. PVD, Ischemia).

- Calf; check for raised temperature (e.g. cellulitis, DVT).
C.2. Tenderness:
- Gently palpate the different parts of legs and feet.
- Look at face for any tenderness.
C.3. Pulses:
Assessing the circulation is important to indicate any peripheral vascular disease.
C.3.1. Dorsalis pedis: Feel on the dorsum of the foot, lateral to the extensor tendon of the
great toe.
C.3.2. Posterior tibialis: Felt posterior to the medial malleolus of the tibia.
42
C.3.3. Capillary Refill:
- Warn the patient before touching him:

“I am going to gently press over your toe nail.”
- Check capillary return by compressing the nailbed (for 5 seconds) and then releasing it.
- Normal colour should return within 2 seconds.
- Prolongation suggests PVD.
D. Neurological Examination:
D.1. Sensory:
D.1.1. Fine/Light Touch:
The places to touch the patient should test each of the dermatomes.
Sensation is lost in a glove and stocking pattern consistent with all peripheral neuropathies.
43
Technique:
1. Pick up a cotton wisp.
2. Demonstrate sensation on patient’s sternum first, to ensure they understand what it
should feel like.
3. Make sure the patient’s legs are placed out straight on the bed.
4. Ask the patient to close his eyes.
5. With the patient’s eyes shut, lightly test their feet and legs (one by one) with the cotton
wool.
6. Tell the patient to say ‘yes’ every time he feels the cotton wool as it felt before.
You can instruct the patient in this way:

“I am going to touch different parts of your leg with the help of a cotton wisp. I want you to
close your eyes and say ‘yes’ whenever you can feel me touching you. It’s going to feel like
this (Touch the sternum with cotton wisp).”
7. Start from the sole. Three spots (heel, below the big toe and below the small toe) must be
touched with the cotton wisp in the sole.
8. Then touch the big toe.
9. Then move up to the dorsum of the foot. From this point upwards follow an ‘S’ shape
pattern (ankle, shin and knee).
10. When patient says “yes, I can feel it.”, do not go further.
11. Throw the cotton wisp into the clinical waste bin.
12. Ask patient to open the eyes.
Comment on your finding:
- Loss of fine touch below the ankle level: on both sides/left/right

- Loss of fine touch below the mid-shin on: both sides/left/right
- Loss of fine touch below the knee on: both sides/left/right
- Fine touch is intact on both sides.
44
D.1.2. Pain Sensation (Pin prick):
Pain sensation is lost in a glove and stocking pattern consistent with all peripheral
neuropathies.
Technique:
1. Pick up a neuro-pin and introduce it to the patient.

2. Ask examiner about using blunt or sharp end of neuro-pin.
should feel like.
5. With the patient’s eyes shut, test their feet and legs (one by one) with the neuro-pin.
6. Tell the patient to say ‘yes’ every time he feels the pin as it felt before.

“This a medical instrument called neuro-pin. I am going to touch different parts of your leg
with it. I want you to close your eyes and say ‘yes’ whenever you can feel me touching you.
It’s going to feel like this (Touch the sternum with neuro-pin).”
7. Start from the sole. Three spots (heel, below the big toe and below the small toe) must be
touched with the cotton wisp in the sole.
8. Then touch the big toe.
9. Then move up to the dorsum of the foot. From this point upwards follow an ‘S’ shape
pattern (ankle, shin and knee).
11. Throw the neuro-pin into the sharps bin.

- Loss of pain sensation below the ankle: on both sides/left/right
- Loss of pain sensation below the mid-shin on: both sides/left/right
- Loss of pain sensation below the knee on: both sides/left/right
- Pain sensation is intact on both sides.
45
D.1.3. Vibration Sensation:
Vibration is another part of sensory assessment in diabetic patients and is more sensitive
than touch.
Technique:
1. Pick up a 128Hz tuning fork and introduce it to the patient.
Note: Having the correct tuning fork is extremely important. A 128Hz tuning fork has a
lower pitch and is used for testing vibration.
should feel like.
4. With the patient’s eyes shut, twang the long ends of the tuning fork and place the round
base of the fork on four bony points (leg by leg):
Bony prominences:
a. Ball of big toe
b. Medial malleolus (Ankle)
c. Mid-shin
d. Tibial tuberosity
5. Tell the patient to say ‘yes’ every time he feels the vibration as it felt before.

“This is a medical instrument called tuning fork which is a vibrating instrument. I am going to
vibrate it and place it on different places of your legs. I want you to close your eyes and say
‘yes’ whenever you can feel the vibration. It’s going to feel like this (Touch the sternum with
tuning fork).”

- Loss of vibration sensation below the ankle: on both sides/left/right
- Loss of vibration sensation below the mid-shin on: both sides/left/right
46
- Loss of vibration sensation below the knee on: both sides/left/right
- Vibration sensation is intact on both sides.
D.1.4. Proprioception:
Finally assess the joint position sense known as proprioception.
Technique:
1. Hold the distal phalanx of the great toe on either side so that you can flex the
interphalangeal joint, while stabilizing the rest of the toe.
2. Show the patient that when you hold the joint dorsiflexed, that represents “Up”, whereas
when you hold it flexed that represents “Down”.
3. Ask the patient to close their eyes.
4. Having moved the joint a few times, hold it in one position – up or down.
5. Ask the patient which position the joint is in.
6. Test the great toe first.
Note: Proprioception in big toe must be tested twice.
7. If proprioception is impaired in big toe, then move further to ankle and knee joints.
8. If patient can figure out the joint position, do not move further.
- Loss of proprioception in knee, ankle and big toe joints: on both sides/left/right
- Loss of proprioception in ankle and big toe joints: on both sides/left/right
- Loss of proprioception in big toe joint: on both sides/left/right
- Proprioception is intact on both sides.
D.2. Motor:
D.2.1. Bulk:
Begin by observing the patients legs, looking for any muscle wasting, fasciculations or
asymmetry.
“Bulk seems to be normal/abnormal. Ideally I will measure the bulk with the help of a
measuring tape.”
47
D.2.2. Tone:
- Ask if they have any pain in feet, legs or hips before assessing the tone.
a. Leg/hip tone:
Roll the leg on the bed (from side to side) to see if it moves easily.
b. Knee tone:
- Put your hand behind the knee and raise it quickly.
- The heel should lift slightly from the bed if tone is normal.
c. Ankle tone:
Check for ankle tone by placing the patient’s leg turned outwards on the bed, moving the
ankle joint (plantar flexion/dorsiflexion) a few times to check for the tone.
D.2.3. Power:
- Direct patient to adopt position and follow commands below, while you as the examiner
resist movements as appropriate to grade power.
- Test each muscle group bilaterally before moving on to the next position.
- Again, start at the hip asking the patient to abduct, adduct, flex and extend against your
hand so you can assess how much force they can overcome. Do the same for flexion and
extension at the knee and ankle as well as the toes.
a. Hip flexion: “Keeping your leg straight, can you lift your leg off the bed, don’t let me push
it down.”
b. Hip extension: “And now using your leg, push my hand into the bed.”
c. Hip abduction: Position hands on outer thighs – “Push your legs out to the sides.”
d. Hip adduction: Position hands on inner thighs – “and push your legs together.”
e. Knee flexion: “Bend your knee and bring your heel to your bottom, don’t let me pull it
away”.
f. Knee extension: “Now kick out against me and push me away.”
g. Ankle plantar flexion: With your hand on the underside of the patient’s foot ask them to
“bend your foot down, pushing my hand away.
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h. Ankle dorsiflexion: Put your hand on the dorsum of the foot and ask them to “lift up
your foot, point your toes at the ceiling, don’t let me push your foot down.”
D.2.4. Reflexes:
- Check lower limbs reflexes.

- For each reflex, test right, then left and compare.
- Decide whether reflexes are absent, diminished, normal or exaggerated.
- Introduce medical hammer:

“This is a medical instrument called hammer. I am going to gently tap it on different parts of
your legs. It will not cause any pain but I will be as gentle as possible. Is that alright with
you?”
- There are three reflexes in the lower limb:
a. The Knee (Patellar) Reflex (L3, 4):
- The knee reflex is tested by placing the patient’s leg flexed at roughly 60 degrees.
- Place one hand in the popliteal fossa and take the entire weigh of your patient’s leg with
your arm.
Note: It is vital to get your patient to relax as much as possible and for you to take the entire
weight of their leg.
- Then strike on the patella tendon (just below the patella) with the tendon hammer (keep
looking at quadriceps).
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b. The Ankle Jerk (L5, S1):
- There are several accepted methods to check for the ankle reflex.
- You can ask the patient to slightly bend the knee and then drop it laterally.
- Grasp the foot, dorsiflex and then strike the Achilles tendon (keep looking at calf).
c. The Plantar Reflex (L5, S1, S2):

Finally, with their leg out straight and resting on the bed, run the orange stick along the
outside of the foot, towards the little toe. This gives the plantar reflex.
- Normal response is the flexion of the great toe with flexion of other toes (downward
movement of the great toe).
- An abnormal reflex would see the great toe extending.
- Babinski’s sign is positive if there is dorsiflexion of the great toe.
This is abnormal (upper motor neuron lesion) if patient age >6 months.
“Ideally I will do plantar reflex with the help of an orange stick.”

Thank the examiner.
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6. Hip Examination
Task:
“Mrs Robert has been diagnosed with osteoarthritis. You are SHO in orthopedic department
outpatient clinic. Please do relevant examination of hip and report your findings to the
examiner.”
Introduction:
Hip complaints in adults are often related to pain e.g. arthritis or bursitis.
You should ensure you are able to perform this examination, along with all other joint
examinations, confidently.
The examination of all joints follows the general pattern of “look, feel, and move” as well as
occasionally “special tests”.
Subject Steps:
1. Greet the patient
2. Introduce yourself
3. Clarify identity
4. Explain the procedure:

“I am here to examine your hip joint, this will involve looking, feeling and moving the joint. I
will be as gentle as possible but if at any point you feel any discomfort or would prefer me
to stop, please let me know and I will stop the procedure.”
5. Exposure:
For this examination the patient should be completely exposed.
Note: However in the exam patient is exposed below waist with his briefs on.
- To the examiner: “Ideally I would ask my patient to be fully exposed.”
- To the patient: “Thank you for the adequate exposure.”
6. Ensure Privacy and Chaperone:

examination.”
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7. Gain consent and co-operation: “May I proceed?” Or “Is that alright with you?”
Position:
Standing upright with palms facing forwards and arms by their side (anatomical position)
and then lying flat on the couch.
Procedure:
1. Look:
a. General Inspection:
To begin make the patient to stand in anatomical position. Ensure that you check both hips
from front, the sides and behind.
- “May I please know which side is bothering you?”

- “Have you ever had any knee or hip surgeries previously?”
- “Are you able to stand up?”
- “Could you please stand up for me, with your arms tucked by your side, palms facing me
and your feet together.”
Assess Asymmetry Anteriorly:

Comment on the levels of shoulders, anterior superior iliac spine (ASIS), knees and Medial
Malleoli.
- Comment on your finding: “Shoulders, anterior superior iliac spines (ASIS), knees and
Medial Malleoli are all at the same level.”
Anteriorly, Posteriorly, Sides:

- Deformity
- Redness, Erythema, rashes
- Scars – previous surgery / trauma
- Swelling
- Skin changes
- Sinuses
- Wasting of muscle (Quadriceps / Gluteal muscles) – suggests chronic inflammation /
reduced mobility
- Leg length discrepancy
- Pelvic tilt
- Comment on your findings.
b. Trendelenburg’s Test:
- Inform patient that you are going to touch the hip area.
Technique:
1. With the patient standing, crouch in front of them.
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2. And gently place one of your hands on each anterior superior iliac spine (ASIS), so that
you can monitor the movement of the pelvis.
3. Ask the patient to stand on the affected side. (i.e. patient should raise the unaffected leg
off the floor.)
4. In a negative test, the pelvis remains level or the unsupported side may rise slightly.
5. In a positive test, your hand will drop or the patient falls toward the unaffected side.
- Positive test suggests hip abductor muscle weakness on the leg the patient is standing on.
c. Assess Gait:
Gait is assessed by asking the patient to walk. An abnormal gait may be a sign of hip pain or
proximal muscle weakness.
- Ask patient to walk a few meters, turn and walk back to you:
“Are you able to walk independently?”
“Could you please take a few steps for me?
Assess gait in these aspects:
- Symmetry
- Size of paces
- Arm swing
- Smoothness
- Speed
- Pain
Assess gait and comment on:
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i. Normal gait:
- Comment on your findings: “My patient’s gait seems to be normal, smooth, symmetrical
and with a normal speed.”
ii. Antalgic gait – a limp adopted to avoid pain by reducing weight-bearing time on the
affected side.
- Comment on your findings: “My patient seems to have antalgic gait.”
iii. Trendelenburg gait - The Trendelenburg gait pattern (or gluteus medius lurch) is an
abnormal gait (as with walking) caused by weakness of the abductor muscles of the lower
limb, gluteus medius and gluteus minimus.
With hip disease the abductor muscle group (gluteus medius) becomes weak. With walking
when standing on the affected limb, the abductors cannot hold the pelvis level. This would
result in the patient falling over because the pelvis drops.
To counteract this, the patient actually leans over the affected limb to alter the centre of
gravity.
2. Feel:
- Next ask the patient to lie flat on the bed.
- Warm up your hands.
- Warn the patient before touching him.
a. Assess Temperature:
- Feel the temperature (using the back of your hand); compare it to mid-thigh as well as
comparing both sides.
- It is difficult to detect any changes as the hip is a deep joint.
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Note: Since in the exam the patient is not fully exposed, you are not able to assess the
temperature. However, you should demonstrate and verbalise to the examiner that:
“Ideally I will assess the hip joint temperature.”
b. Tenderness:
- As the hip joint lies deeply there is little to palpate. However in the real life we check for
bony tenderness, palpate the greater trochanter and the head of femur.
i. Bony tenderness:
Place your hand over the anterior superior iliac spine. Move upwards and backwards to
palpate over the iliac crest.
Keep looking at patient’s face to feel for bony tenderness.
Trochanteric Bursitis:
Now drop your hands down to the lateral aspect of the femur and feel the greater
trochanter and the trochanteric bursal region. Any tenderness here could suggest
trochanteric bursitis.
Head of femur:
You can palpate the head of the femur over midpoint of inguinal ligament which is halfway
between ASIS and the pubic symphysis. (Mid-inguinal point)
Note: However in the exam we are not going to palpate the inguinal region.
- To the examiner: “Ideally I would palpate the head of femur.”
3. Measure Leg Length:

Now check both the apparent and true length of the leg:
True leg length discrepancy: is found by measuring from the anterior superior iliac spine
(ASIS) to the medial malleolus, comparing left and right legs.
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- Comment on your finding: “There is no true length discrepancy between right and left
legs.”
Apparent leg length discrepancy: is measured from the xiphisternum or umbilicus to the
medial malleolus, comparing left and right legs.
- Comment on your finding: “There is no apparent length discrepancy between right and left
legs.”
4. Move:
It is important to elicit a range of active movements first so that pain is not inflicted by
passive movements. This involves the patient performing the movement.
Ensure you observe for restricted range of movements and signs of discomfort.
Note: However in the exam due to time restrictions, we will only ask the patient to perform
the movements actively.
Movements to be assessed at the hip are:
Flexion: “Could you please bring your knees towards your chest as much as possible?” Or
“Keeping your leg straight, can you lift your leg off the bed?”
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Extension: Ask the patient to lie face down on the couch and to lift the leg in turn to assess
the range of extension.
Note: However in the exam due to time restrictions we are not going to assess hip
extension.
- To the examiner: “Ideally I will assess the hip extension.”
Abduction: “Could you please bring your right/left leg towards the edge of the couch?”
Adduction: “Can you please lift your left/right leg and rest it on the other leg.”
Internal Rotation: “Bring your heels apart and try to touch your toes together.”
External Rotation: “Bring your heels together and try to move your toes away from each
other.”
- Comment on the range of movements: Full and free, restricted or painful movements
Note: In real life after asking the patient to perform the hip movements actively, we
perform them once again passively.
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Movement Muscle Group Expected Range
Flexion Iliopsoas 140
Rectus Femoris
Quadriceps
Extension Gluteus Maximus 10
Hmastrings
Abduction Gluteus Medius 45
Gluteus Minimus
Adduction Adductors (Longus, brevis, 30
magnus) – Obturator nerve
Internal Rotation Gluteus Medius 40
Gluteus Minimus
External Rotation Pyriformis 40
Gamelli
Quadratus Femoris
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5. Special Tests:
Thomas Test:
- Inform patient that you are going to place your hand under his back.
Technique:
1. Place one of your hands under the lower back (to ensure that the resting lordosis is
removed).
2. Fully flex the unaffected hip with your other hand until the lumbar spine touches the
fingers of the hand under the back. (Lumbar lordosis is now flattened.)
3. Observe the other hip; if it is lifted off the couch as a result of this manoeuvre, there is a
fixed flexion deformity in that hip.
- A positive test suggests a hip flexor muscle contracture.
6. Neurovascular Assessment:
- Palpate for the dorsalis pedis and posterior tibialis arterial pulses.
- Ask the patient to wriggle the toes.
- Thank the patient and kindly ask him to dress up.
- Mention to the examiner that:

“Ideally I would like to examine the full neurovascular status of the lower limb and examine
the joint above and joint below.”
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7. Knee Examination
Task:
“Mr Smith is a 25-year old gentleman who is suffering from pain in his knee. Examine the
knee joints and give your findings to the examiner.”
Introduction:
Knee complaints are very common presentations to A&E, general practice as well as
orthopaedic clinics. Some hospitals even have special “knee” clinics. Common presenting
complaints are pain in the knee, the knee locking or giving way. Common conditions that
cause these symptoms include arthritis, ligament and/or cartilage injuries.
The examination of all joints follows the general pattern of “look, feel, and move” as well as
occasionally “special tests”, in which this station has many.

Subject Steps:
3. Clarify identity

“I am here to examine your knee joint, this will involve looking, feeling and moving the joint.
I will be as gentle as possible but if at any point you feel any discomfort or would prefer me
to stop, please let me know and I will stop the procedure.”
Exposure:
For this examination the patient should be exposed below the waist.
“For the purpose of this examination you need to be undressed below waist. Thank you for
adequate exposure. You can keep your briefs on. ”

examination.”
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Gain consent and co-operation: “May I proceed?” Or “Is that alright with you?”
Position:
Standing upright with palms facing forwards and arms by their side (anatomical position)
and then lying flat on the couch.
Procedure:
1. Look:
To begin make the patient to stand in anatomical position.
Ensure that you check both knees from front, the sides and behind.
- “May I known please which side is bothering you?”

- “Have you ever had any knee or hip surgeries previously?”
- “Are you able to stand up?”
and your feet together.
Assess Asymmetry Anteriorly:
Comment on the levels of shoulders, anterior posterior iliac spine (ASIS), knees and Medial
Malleoli.
- Comment on your finding: “Shoulders, anterior superior iliac spines (ASIS), knees and
Medial Malleoli are all at the same level.”
Anteriorly, Posteriorly, Sides:

- Deformity: Valgus (knock-knees) or varus (bow-legged)
- Redness, Erythema, rashes
- Scars – previous surgery / trauma
- Swelling – effusions / inflammatory arthropathy / septic arthritis / gout
- Popliteal Swelling (Posteriorly) – Baker’s cyst / Popliteal aneurysm
- Sinuses
- Muscle (Quadriceps) wasting – suggests chronic inflammation / reduced mobility
- Leg length discrepancy
- Comment on your findings.
b. Assess Gait:
Gait is assessed by asking the patient to walk. An abnormal gait may be a sign of hip pain or
proximal muscle weakness.
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- Ask patient to walk a few meters, turn and walk back to you:
“Are you able to walk independently?”
“Could you please take a few steps for me?”
Assess gait in these aspects:

- Symmetry
- Size of paces
- Arm swing
- Smoothness
- Speed
- Pain
Assess gait and comment on:
i. Normal gait:
- Comment on your findings: “My patient’s gait seems to be normal, smooth, symmetrical
and with a normal speed.”
Antalgic gait – a limp adopted to avoid pain by reducing weight-bearing time on the
affected side.
- Comment on your findings: “My patient seems to have antalgic gait.”
2. Feel:
- Next ask the patient to lie flat on the bed.

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- Feel the temperature (using the back of hand); compare it to mid-thigh or mid-calf as well
as comparing both sides.
- Increased temperature may suggest inflammation / infection.
b. Tenderness:
Note: Keep looking at patient’s face for tenderness.
Technique:
Bent position:
a. Patella (Knee cap):
1. Flex the knee slightly.
2. Begin by palpating the patella at its superior patellar pole where the quadriceps muscle
group inserts, noting for areas of tenderness.
3. Progress down in a diamond shape and palpate the borders of patella for any tenderness.
(Medial and lateral patellar borders)
4. Move down to the base of the patella (inferior pole of patella).
Note: Palpate the medial and lateral patellar borders one at a time.
b. Popliteal fossa:
With the patient prone, palpate the popliteal fossa for the presence of a cyst, most
commonly found on the medial aspect of the fossa under the medial head of the
gastrocnemius and semimembranosus tendon (Baker's cyst).
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c. Medial and lateral joint lines:
Joint line tenderness indicates medial or lateral meniscal injury.
1. Knees slightly flexed.
2. Find joint space along lateral and medial margins.
3. Palpate along medial then lateral margins.
Note: Palpate the medial and lateral joint lines one at a time.
Straightened position:
a. Anterior tibial tuberosity (insertion of patellar tendon):

1. Extend the knee.
2. Palpate the tibial tuberosity where the patellar tendon is attached to the tibia which is
the point of insertion of the patellar tendon.
- The tibial tuberosity is normally a smooth and rounded protrusion.
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b. Patellar tendon:
Palpate the length of the patellar tendon from its insertion at the tibial tuberosity to the
inferior aspect of the patella. The patellar tendon normally feels broad and rope like.
c. Sweep Test:
The sweep test is used to assess for joint small effusion in the knee area. Joint effusion is
the presence of increased intra-articular fluid.
Technique:
1. The patient lying in supine position and has the knee in full extension and relaxed.
2. Puts your hand beneath the medial tibiofemoral joint line.
3. Then stroke your hand upwards and towards the suprapatellar bursa for 2-3 times in a
sweeping motion in an attempt moving the effusion from the inside of the joint capsule to
the suprapatellar pouch.
4. Then stroke downwards on the lateral aspect of the knee (thigh), just superior to the
suprapatellar bursa towards the lateral joint line.
5. If the test is positive you’ll detect a small wave or bulge on the medial aspect of the knee,
just inferior to the patella within a few seconds.
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d. Patellar Tap Test:
Tap the patella to see if there is any large effusion deep to the patella.
Technique:
1. For this test, have the patient supine, with knees extended.
2. Empty the suprapatellar pouch (milk fluid down out of the suprapatellar pouch) by sliding
your left hand down the thigh to the patella.
3. Keep your left hand in position and use your right hand’s index and middle fingers to
sharply tap patella.
4. If a tap is elicited, this is a positive test (Patella sinks, striking femur then comes back up).
e. Grind Test:
The purpose of this test is to detect the presence of patellofemoral joint disorder.
A positive sign on this test is pain in the patellofemoral joint. (Patellofemoral osteoarthritis)
Technique:
1. Patient is positioned in supine with the involved knee extended.
2. Place the web space of your hand superior to the patella while applying pressure (pushing
patella against femur).
3. Ask the patient to gently and gradually contract the quadriceps muscle.
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3. Move:
It is important to elicit a range of active movements first so that pain is not inflicted by
passive movements. This involves the patient performing the movement.
Ensure you observe for restricted range of movements and signs of discomfort.
Note: However in the exam due to time restrictions, we will only ask the patient to perform
the movements actively.
Movements to be assessed at the knee are:

Knee flexion: “Bend your knee and bring your heel as close to your bottom as you can
manage.”
Knee extension: “Straighten your leg out as best as you are able to.”
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Hyperextension (Passively): Lift foot when patient relaxed and look for hyperextension.
Hyperextension
- Comment on the range of movements: Full and free, restricted or painful movements.
4. Special Tests:
a. Stress Test (Collateral Ligaments):
Technique:
1. Hold patient’s leg, with the knee flexed at 15 to 30 degrees.
2. Place lateral stress (valgus test) on the knee for medial collateral ligament (MCL) - pulling
tibia a bit away from the midline.
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3. Place medial stress (varus test) on the knee for lateral collateral ligament (LCL) - pulling
tibia a bit towards midline.
4. Keep looking at patient’s face for tenderness. Pain suggests collateral ligament injury
Note: In real patient in addition to pain, widening of knee joint in medial side indicates MCL
and widening of knee joint in lateral side indicates LCL.
b. McMurray’s Test:
1. Flex the patient’s knee to 90 degrees.

2. Hold over the knee with one hand and the sole with the other hand.
3. Extend the knee while heel facing medially for medial meniscal injury.
4. Extend the knee while heel facing laterally for lateral meniscal injury.
5. Pain or a click suggests a positive test, confirming meniscal injury.
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c. Drawer’s Test:
1. Flex the knee to 90 degrees.
2. Sit on the patient’s foot to keep it stable.
3. Keep your thumbs on the lateral sides of tibial tuberosity
4. Push the leg for posterior cruciate ligament (PCL) injury.
5. Pull the leg for anterior cruciate ligament (ACL) injury.
6. Normally no movement should be seen.
7. Excessive movement suggests cruciate ligament injury.
- Palpate popliteal, dorsalis pedis and posterior tibial pulses.

- Ask the patient to wriggle the toes
- Mention to the examiner that:

“Ideally I would like to examine the full neurovascular status of the lower limb and examine
the joint above and joint below.”
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8. Elbow Examination
Task:
“Mr Blake is a 43-year old man who has come to your clinic complaining of pain in his elbow
for one month.
Please perform a relevant examination, report your findings to the examiner and discuss
management with the patient.”
Introduction:
Elbow complaints are often related to pain e.g. epicondylitis (tennis and golfer’s elbow),
fractures and bursitis, although can also be skin related with regards to other medical
conditions e.g. psoriasis and rheumatoid arthritis. Occasionally elbow problems can also
cause ulnar nerve entrapment.
The examination of all joints follows the general pattern of “look, feel, and move” and
occasionally some “special tests”.

71
Subject Steps:
3. Clarify identity

“I am here to examine your elbow joint, this will involve having a look and feel of the joint,
in addition to assessing the joint movement. I will be as gentle as possible but if at any point
you feel any discomfort or would prefer me to stop, please let me know and I will stop the
procedure.”
5. Exposure:
For this examination the patient should be exposed from the waist up.
Note: However in the exam patient’s arms are adequately exposed.

- To the examiner: “Ideally I would ask my patient to be exposed from the waist up.”
- To the patient: “Thank you for the adequate exposure.”
examination.”
Position:
Standing upright with palms facing forwards and arms by their side. (anatomical position)
Procedure:
1. Look:
Begin with observation of the joint. Make the patient to stand in anatomical position.
Ensure that you check both elbows from front, the sides and behind.
- “May I known please which side is bothering you?”

(forwards) and your feet together.”
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Anteriorly:
- Deformity: Carrying angle (normally 5-15 degrees): “Carrying angle is equal on both sides.”
- Redness, rashes,
- Scars – Suggestive of previous injury / surgery
- Swelling / Erythema of the joint - may suggest acute injury / inflammatory arthritis /
infection
- Fullness in cubital fossa
- Wasting of muscle (Biceps)
Sides:
- Fixed flexion deformity – often post traumatic
- Olecranon bursitis – the swelling overlying the olecranon is often most noticeable from this
angle
- Scars, swelling, erythema
Posteriorly:
- Deformity
- Fullness of olecranon fossa
- Scars
- Rheumatoid nodules – firm lumps on the elbow / olecranon – indicate systemic
rheumatoid disease
- Psoriatic plaques – well defined pink / red elevated lesions with silvery scale
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2. Feel:
- Feel the elbow, assess the joint temperature (using the back of your hand); ideally
compare to the joint above or the joint below.
- A particularly warm joint may indicate inflammatory arthritis or infection.
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b. Palpation:
- Palpate the joint lines, including the medial and lateral epicondyles (from front) and
olecranon (from back) for any localised tenderness. (Diamond palpation)
- Keep looking at patient’s face for tenderness.
3. Move:
The movements at the elbow joint are all fairly easy to describe and assess. These are
flexion, extension, pronation and supination.
Flexion: “Could you please try to touch your shoulders with your hands?”
Extension: Ask the patient to extend the elbows completely.
Pronation: “Please tuck your elbows by your side and turn your palms down, to face the
floor.”
Supination: “Please tuck your elbows by your side and turn your palms up, to face the
ceiling.”
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4. Special Tests:
Finally you should check for tennis elbow and golfer’s elbow.
a. Medial Epicondylitis – “Golfer’s Elbow”:

- Ask the patient to actively flex the elbow to 90 degrees, with forearm pronated and wrist
fully extended.
- Support patient’s elbow with your hand.
- Ask the patient to flex wrist while you are applying resistance.
- Localised pain over the medial epicondyle suggests a diagnosis of medial epicondylitis.
Golfer’s Elbow:
Golfer's elbow is a condition that causes pain where the tendons of your forearm muscles
attach to the bony bump on the inside of your elbow. The pain might spread into your
forearm and wrist.
It's not limited to golfers. Tennis players and others who repeatedly use their wrists or
clench their fingers also can develop golfer's elbow.
Golfer's elbow, also known as medial epicondylitis, is caused by damage to the muscles and
tendons that control wrist and fingers. The damage is typically related to excess or repeated
stress — especially forceful wrist and finger motions. Improper lifting, throwing or hitting, as
well as too little warm-up or poor conditioning, also can contribute to golfer's elbow.
Many activities can lead to golfer's elbow, including:
Golf: Gripping or swinging clubs incorrectly or too forcefully can take a toll on your muscles
and tendons.
Racket sports: Excessive topspin can hurt your elbow. Using a racket that's too small or
heavy also can lead to injury.
Throwing sports: Improper pitching technique in baseball or softball can be another culprit.
Football, archery and javelin throwing also can cause golfer's elbow.
Weight training: Lifting weights using improper technique, such as curling the wrists during
a biceps exercise, can overload the elbow muscles and tendons.
In addition, any activity that requires repeatedly bending and straightening your elbow can
cause golfer's elbow. This includes painting, raking, hammering, chopping wood, using a
computer, doing assembly-line work and cooking. A day or two of yard work or cooking for
company usually won't cause golfer's elbow, though. The activity generally needs to be
done for more than an hour a day on many days to cause a problem.
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b. Lateral Epicondylitis – “Tennis Elbow”:
- Ask the patient to actively flex the elbow to 90 degrees, with forearm pronated and wrist
fully flexed.
- Support patient’s elbow with your hand.
- Ask the patient to extend wrist while you are applying resistance.
- Localised pain over the lateral epicondyle suggests a diagnosis of lateral epicondylitis.
Tennis Elbow:
Tennis elbow is a painful condition that occurs when tendons in your elbow are overworked,
usually by repetitive motions of the wrist and arm.
The pain of tennis elbow occurs primarily where the tendons of your forearm muscles
attach to a bony bump on the outside of your elbow. Pain can also spread into your forearm
and wrist.
Tennis elbow is an overuse and muscle strain injury. The cause is repeated contraction of
the forearm muscles that you use to straighten and raise your hand and wrist. The repeated
motions and stress to the tissue may result in a series of tiny tears in the tendons that
attach the forearm muscles to the bony prominence at the outside of your elbow.
As the name suggests, playing tennis — especially repeated use of the backhand stroke with
poor technique — is one possible cause of tennis elbow. However, many other common arm
motions can cause tennis elbow, including:
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• Using plumbing tools
• Painting
• Driving screws
• Cutting up cooking ingredients, particularly meat
- Check for Radial pulse
- Ask patient to wriggle fingers.
- To the examiner: “To complete my examination I would examine the joint above and joint
below, and also do a full neurovascular exam distal to the joint”
Management:
The sooner you begin treatment, the sooner you'll be able to return to your usual activities.
• Rest: Avoid activities that aggravate your elbow pain until the pain is gone. If you
return to activity too soon, you may make it worse.
• Ice the affected area: Apply ice packs to your elbow for 15 to 20 minutes at a time,
three to four times a day for several days. To protect your skin, wrap the ice packs in
a thin towel.
• Take an over-the-counter pain reliever: Try ibuprofen (Advil, Motrin IB, others),
naproxen sodium (Aleve, others) or acetaminophen (Tylenol, others).
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Use a brace: Your doctor might recommend that you wear a counter force brace on your
affected arm, which might reduce tendon and muscle strain.
Physiotherapy (Stretch and strengthen the affected area): Your doctor may suggest
stretching and strengthening exercises. Physical or occupational therapy can be helpful, too.
A type of strengthening (eccentric) that lengthens the tendon of the wrist extensor muscles
has been shown to be particularly effective in treating chronic tendon irritation.
Corticosteroid injection
Surgery is seldom necessary. But if your signs and symptoms don't respond to conservative
treatment in six to 12 months, surgery may be an option. A new procedure involves
minimally invasive, ultrasound-guided removal of scar tissue in the region of the tendon
pain.
Most people will get better with rest, ice and pain relievers. Depending on the severity of
your condition, the pain may linger for months to years — even if you take it easy and
follow instructions on exercising your arm. Sometimes the pain returns or becomes chronic.
Note: In the exam you can simply say to the patient:

“Based on examination you have a condition called medial/lateral epicondylitis which is
caused by overuse and damage to the tendons of your forearm muscles that attach to the
bony bump on the inside/outside of your elbow.
The most important thing you can do is rest your injured arm and stop doing the activities
that caused the problem until the pain is gone.
Holding a cold compress, such as ice pack, against your elbow for a few minutes several
times a day can help ease the pain.
However if the pain persists you can take some over the counter painkillers such as
ibuprofen. Your doctor might recommend that you wear a counter force brace on your
affected arm, which might reduce tendon and muscle strain. Physiotherapy can be helpful,
too.
If the pain does not relieve after sometime, we may consider injection to your forearm.
Invasive treatments, such as surgery, will usually only be considered in severe and persistent
cases, where non-surgical approaches have not been effective.”
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9. Whiplash Injury (Cervical Examination)
Task:
“Mr Holmes is a 30-year old man who met a road traffic accident yesterday. He presented to
the hospital today, complaining of pain and stiffness in his neck.
Take a brief history and perform the relevant examination.”
Introduction:
An acute whiplash injury follows sudden or excessive hyperextension, hyperflexion, or
rotation of the neck and causes neck pain and other symptoms. Whiplash injury is common
in road traffic accidents, and may also be caused by sports injuries, falls or assaults.
Whiplash can be a serious injury and you may not experience symptoms right away.
Symptoms may be mild at first and gradually worsen. Furthermore, symptoms can
sometimes develop days, weeks, or even months after the initial injury. The main symptom
of whiplash is neck or upper back pain. You may also experience other symptoms, such as:
• Shoulder and/or arm pain

• Tenderness and/or stiffness
• Numbness and/or tingling
• Headaches
• Dizziness
• Nausea
• Blurred vision
Differentials:
1) Whiplash injury
2) Radiculopathy (Root compression)
3) Stable fracture of the cervical vertebra
Procedure:
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1. Greet and introduce yourself to the patient.
2. Typical Diagnostic Questions:
- To the patient:
D: “Could you please tell me what happened?”
P: “Doctor, I met a road traffic accident yesterday.”
D: “So what brought you to the hospital today?”
P: “My neck is painful.”
D: “I am so sorry to hear that. Please keep your head still and try not to move your head and
neck.”
D: “Where in the neck you have this pain?”
P: “Back of my neck.”
D: “When did the pain start (To rule out stable fracture)?”
P: “Since this morning.”
D: “Does the pain travel to other parts of your body?”
P: “No.”
D: “Apart from this pain, are you experiencing anything else?”
P: “My neck is stiff.”
D: “Since when?”
P: “Since today.”
D: “Are you experiencing any numbness, tingling or weakness in your hands (To rule out
root compression)?”
D: “Yes/No.”
D: “Have you ever had any problems in your neck before?”
P: “No.”
3. Physical Examination:
a. Exposure:
“I am going to examine you now. I can see that you are adequately exposed, thank you for
that (patient wearing short sleeves). I will be as gentle as possible but if at any point you feel
procedure. Is that alright with you?”
b. Inspection of the neck:
Inspect the neck entirely. Make sure you check behind the neck and comment on:
- Deformity
- Bruises
- Swelling
- Wounds
- To the examiner: “There are no deformities, bruises, swelling or wounds around the neck.”
c. Palpation:
- warm up your hands before touching the patient.
- Patient seated with you standing behind (with permission).
“I am going to gently press over the back of your neck with my thumb. Please say ‘yes’ if it
hurts and ‘no’ if it doesn’t. Please do not move your head or neck.”
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Spine: Use your thumb to palpate over the cervical spine, up to 3rd thoracic vertebra (T3)
for bony injury tenderness.
Para-spinal area: Use both of your thumbs to palpate over both the para-spinal areas in a
zigzag/climbing pattern.
4. Neurological Examination of the upper limbs:

a. Sensory:
I. Fine touch:
Technique:
should feel like.
3. Ask the patient to close the eyes.
4. Test light touch, according to the dermatomes by lightly touching both upper limbs with a
piece of cotton wool whilst patient’s eyes are closed.
6. Ask the patient to open his eyes.
- To the patient: “I am going to touch different parts of your hands/arms with the help of a
cotton wisp. I want you to close your eyes and say ‘yes’ whenever you can feel me touching
you. It’s going to feel like this (Touch the sternum with cotton wisp).”
7 Points:
C8 – Small finger
C7 – Middle finger
C6 – Thumb
C6 / T1 – Forearm
C5 / T2 – Arm
- Comment on your finding: “Fine touch is intact on both sides.”
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II. Pain sensation:
1. Pick up a neuro-pin and introduce it to the patient.

2. Ask examiner about using blunt or sharp end of neuro-pin.
should feel like.
4. Ask the patient to close the eyes.
5. Test pain sensation, according to the same dermatomes by touching both upper limbs
with a neuro-pin whilst patient’s eyes are closed.
6. Throw the neuro-pin into the sharps bin.
- To the patient: “This a medical instrument called neuro-pin. I am going to touch different
parts of your hands/arms with it. I want you to close your eyes and say ‘yes’ whenever you
can feel me touching you. It’s going to feel like this (Touch the sternum with neuro-pin).”
- Comment on your finding: “Pain sensation is intact on both sides.”
b. Motor:
C5 – Shoulder abduction
C6 – Elbow flexion
C7 – Elbow extension
C8 – Wrist extension
T1 – Finger abduction
- Comment on your finding: “There is no motor deficits.”
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c. Reflexes:
Check all three reflexes in the upper limb:
• The Biceps Reflex

• The Triceps Reflex
• The Supinator Reflex
- Comment on your Findings: “All reflexes are normal.”
5. Radiological Examination:
- Tell the examiner: “I would like to stabilise his neck and send him for an X-Ray of his neck.”
- Examiner: “Assume the X-Ray is normal.”
- To the examiner: “Since the X-Ray is fine, I will proceed with the cervical spine
movements.”
6. Movements:
Cervical spine movements which are assessed are:
- Lateral flexion
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- Rotation
- Flexion
- Extension
There are some easy commands for checking these:
- Could you please place your right ear on your shoulder?
- Could you please place your left ear on your shoulder?
- Could you please turn your head to the left?
- Could you please turn your head to the right?
- Could you please put your chin on your chest?

- Could you please put your head back to look at the ceiling?
- Comment on your finding: “Movements are restricted.” (Whichever direction)
- To the examiner: “My diagnosis is whiplash injury.”

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10. Primary Survey
Task:
“Mr Nick is a 28-year old man who has met with a RTA (Road traffic accident) and has been
brought to the Accident and Emergency department. His blood pressure is 110/70 mmHg
and his pulse rate is 110 beats/min.
Please perform a primary survey/initial assessment on this patient.”
Introduction:
Patients are assessed, and their treatment priorities are established, based on their injuries,
vital signs, and the injury mechanisms.
In severely injured patients, logical and sequential treatment priorities must be established
based on overall patient assessment.
The patient’s vital functions must be assessed quickly and efficiently. Management consists
of a rapid primary survey, resuscitation of vital functions, a more detailed secondary survey,
and, finally, the initiation of definitive care.
This process constitutes the ABCDEs of trauma care and identifies life-threatening
conditions by adhering to the following sequence:
Airway maintenance with cervical spine protection

Breathing and ventilation
Circulation with haemorrhage control
Disability: Neurologic status
Exposure/Environment control: Completely undress the patient, but prevent hypothermia.
A quick assessment of the A, B, C, and D in a trauma patient can be conducted by identifying

oneself, asking the patient for his or her name, and asking what happened.
An appropriate response suggests that there is no major airway compromise (ability to
speak clearly), breathing is not severely compromised (ability to generate air movement to
permit speech), and there is no major decrease in level of consciousness (alert enough to
describe what happened). Failure to respond to these questions suggests abnormalities in A,
B, or C that warrant urgent assessment and management.
During the primary survey, life-threatening conditions are identified in a prioritized
sequence based on the effects of the injuries on the patient’s physiology because it is
frequently not possible to initially identify the specific anatomic injuries.
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Procedure:
1. Universal Precautions
Tell your examiner that you will take all the universal precautions before doing this
examination:
“I assume that I have taken all the universal precautions and that the trauma team is with
me.”
2. Airway
I. If the patient is not collared, immobilize the head from behind with both hands, before
talking to the patient.
This should be the initial approach to all casualties with head, neck or shoulder pain.
Note: However in the exam, most of the time the patient is already collared and you do not
need to do the manual in line immobilization. If so carry on with the second step of checking
response.
II. Greet and introduce yourself to the patient:
“Hello Mr Nick, are you alright?”

“I am Dr……, one of the doctors in emergency department.”
Note: In the exam patient will respond.
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- Verbalize to the examiner:
“Since my patient is speaking, he is conscious and his airway is patent.”
III. Apply Neck Collar:
Triple Immobilization:
- Patients deemed at risk of cervical spine injury should have their neck immobilized.
- Cervical spine immobilization should be maintained until full risk assessment (cervical
spine X-rays and/or CT scan) indicates it is safe to remove immobilization.
- The neck should be triple immobilized using:

a. A correctly sized, rigid cervical collar
b. Blocks or sandbags placed on either side of the head (e.g. rolled up towels or bags of
fluid)
c. Tape or straps over chin and forehead
Ask the patient to not move his head and neck while you are applying the collar.
“Mr Nick, please do not move your head, I am going to apply a neck collar for you.”
Note: However in the exam, most of the time the patient is already collared and you do not
need to apply it. Apply the neck collar only if it is not already placed.
- Verbalize to the examiner that:
“In real life, I would do triple immobilization. I will give my patient high flow oxygen. I would
request one of my team members to connect all the monitors and I will arrange for all the
primary series of X-Rays. (Chest, pelvic – AP, cervical spine - lateral)”
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IV. Exposure:
“Mr Nick, I am going to examine you now. For that I need to undress you fully by cutting all
your clothes. I will ensure your privacy and I will have a chaperone with me throughout my
examination. Is that alright with you?”
3. Breathing:
I. Determine the rate and depth of respiration:

From the foot end comment on rate and depth:
“My patient is not breathless. Ideally I will check the respiratory rate.”
II. Neck:
- Inform the patient: “Mr Nick, I will gently remove your collar, please do not move your
head and neck. Okay?”
Gently remove the anterior part of the collar and comment on:
a. Engorged neck veins / JVP: Look for pulsation behind the sternocleidomastoid.
- Comment on your finding: “JVP in my patient has not raised. There are no engorged neck
veins”
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b. Tracheal shift:
Assess if the trachea is central or is deviated from the midline.
gentle technique.
- Inform the patient: “I am going to gently press over your neck, this may feel a bit
Technique:
two clavicles.
3. Check that your fingertip fits easily into both sides. If it is deviated, it may suggest
pneumothorax.
- Comment on your Finding: “Trachea is placed centrally / there is no tracheal shift.”
III. Chest:
a. Inspection:
From the bedside comment on:

- Chest wall movements (unilateral or bilateral chest wall movements)
- Use of accessory muscles
- Any signs of injury including:
Open wounds / Penetrating injuries
Bruises (especially around the heart)
Evidence of rib fractures / Flail chest / Chest deformities
- Comment on your finding: “Chest movements are bilaterally symmetrical. There is no use
of accessory muscles and no signs of injury.”
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b. Palpation/Chest expansion:
- Feel for chest expansion. Normally this should be at least 5 centimetres.
- If one of your thumbs moves less, this suggests reduced expansion on that side.
- Reduced expansion can be caused by lung collapse, pneumothorax, etc.
Technique:
1. Place your hands firmly on the chest wall inferior to the nipples.
2. Warp your fingers around either side of the chest and bring your thumbs together in the
middle, so that they touch (anchor with the fingers and leave the thumbs free-floating).
3. Ask the patient to take a deep breath in and out.
4. Observe movement of your thumbs and note the distance your thumbs move apart, they
should move apart equally.
Normally this should be at least 5 centimetres.
- Comment on your finding: “Chest expansion is equal on both sides.”
c. Percussion:
- Perform percussion on both sides, comparing similar areas on both sides and feel for any
dullness, resonance on percussion.
Note: In the exam percuss 2 points on the anterior chest wall and one point on lateral chest
wall, comparing right and left.
- Inform the patient: “I am going to gently tap over your chest, is that okay with you?”
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Technique:
1. Place your non-dominant hand on the chest wall.
2. Your middle finger should overlie the area you want to percuss.
3. With your dominant hand’s middle finger, strike middle phalanx of non-dominant hand’s
middle finger.
4. The striking finger should be removed quickly, otherwise you may muffle resulting
percussion note.
5. All movements should come from your wrist joint, and your middle finger should remain
partially flexed.
- Comment on your finding: “There is no hyper-resonance or dullness on percussion.

Percussion note is resonant.”
d. Auscultation:
- Ask patient to take steady breaths in and out through mouth and listen with diaphragm,
comparing right and left.
- Auscultate the anterior chest wall, alternating between each side of the chest wall (to
compare).
- Do not forget the lateral chest wall.
- In each area assess the quality and amplitude of breath sounds whilst noting any added
sounds.
- Listen for:
1. Sounds of obstruction (stridor) and air escaping.
2. Breath sounds and symmetry of air entry.
3. Heart sounds.
Note: In the exam auscultate 2 points on the anterior chest wall and one point on lateral
chest wall, comparing right and left.
- Inform the patient: “I am going to listen to your chest. Can you please take deep breaths in
and out for me?”
- Comment on your findings: “Ideally I will listen for heart sounds. Respiratory sounds are
audible. There is no absent or diminished breath sounds.”
- To the examiner: “I assume the chest is fine.”
4. Circulation:
I. External Bleeding: Look for any signs of external hemorrhage or any blood on the floor.
- Comment on your finding: “There are no signs of external bleeding.”
II. Conjunctival Pallor:
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- Inform the patient and check the conjunctiva:
“I am going to have a look at your eyes. I will be gently pulling your eyelids down. Is that
- Comment on your finding: “There is no pallor.”
III. Cold and pale peripheries:

Evaluate skin color and feel for the peripheries to see if they are cool.
- Comment on your finding: “The peripheries are not cold.”
IV. Vital signs (BP, Pulse rate and Capillary refill time):
Make sure you insert two large-bore cannula that blood samples have been sent for FBC,
U&E, blood sugar, clotting and cross-match 4 units.
Note: Vital signs are either mentioned in the question or you may have to ask the examiner
for them (BP and Pulse).
- Ask for vitals: “May I know his/her vitals, please?”
To the examiner:
“My patient’s blood pressure is….mmHg and his pulse is…...
I will place two large bore IV cannulas.
I will take a blood samples and send it for all the routine blood testing (FBC, U&E, ABG, LFT,
blood sugar, toxicology screen, clotting screen) including grouping and cross-matching 4
units of blood.”
Initial Fluid Therapy:

Warmed isotonic electrolyte solution such as lactated Ringer’s and normal saline are used
for initial resuscitation.
An initial, warmed fluid bolus is given. The usual dose is 1 to 2 L for adults. Absolute volumes
of resuscitation fluids should be based on patient response.
To the examiner: “I will start resuscitation with warmed crystalloid solution.”
5. Internal Bleeding
I. Abdomen: Look for any signs of internal bleeding.
a. Inspection:
- From the foot end:
Look for abnormal contours/distension.
- Comment on your finding: “The abdomen is not distended.”
- From the bedside comment on:

- Abrasions
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- Contusions
- Lacerations
- Penetrating wounds
- Bruises
- Swelling
b. Palpation:
- Ensure that your hands are warm and warn your patient before touching him.
- Watch the patient’s face for signs of discomfort.
- Assess each of the four quadrants, in an S shape pattern and look for the following:
Tenderness: Look at the patient’s face whilst palpating for evidence of pain.
Rebound tenderness: Pain is worsened on releasing the pressure – peritonitis.
Guarding: Involuntary tension in the abdominal muscles – assess if localised or general.
Rigidity
c. Percussion:
With the patient lying flat, percuss all four quadrants of the abdomen.
However in the exam you may only percuss the flank area to check for dullness.
- Inform the patient:
“I am going to gently tap over your tummy, is that okay with you?”
d. Auscultation:
Auscultation of the abdomen may be difficult in a noisy emergency department, but it can
be used to confirm the presence or absence of bowel sounds.
- Place your stethoscope either side of midline, just below the umbilicus and listen to the
bowel sounds.
- Listen for sluggish or absent bowel sounds.
- Inform the patient: “I am going to listen to your tummy, is that okay with you?”
- Place your stethoscope below the umbilicus for a few seconds just to demonstrate that
you are checking for the bowel sounds.
- Comment on your finding: “I could not hear the bowel sounds. Ideally I would listen for 2
minutes.”
- To the examiner: “I assume the abdomen is fine.”
II. Pelvis:
a. Inspection:
Look for:
- Pelvic deformity / Limb length discrepancy / Rotational deformity of the leg without
obvious fracture
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- Scrotal (perineal) hematoma
- Blood at the external urethral meatus
- Bruising, swelling or laceration of the perineum, vagina, rectum or buttocks (Suggestive of
an open pelvic fracture.)
- Tell the examiner:

“Ideally I’d like to expose my patient completely to check for any pelvic deformities, bruises,
swelling, lacerations, scrotal (perineal) hematoma or blood in the external urethral meatus.”
b. Palpation:
Compression Distraction Maneuver:

Mechanical instability of the pelvic ring may be tested by manual manipulation of the pelvis.
This procedure should be performed only once during the physical examination, as testing
for pelvic instability can result in further hemorrhage.
Note: In patients with shock and physical exam findings suggestive of pelvic fracture
including evidence of ruptured urethra (high-riding prostate, scrotal hematoma, blood at
the urethral meatus), limb length discrepancy or a rotational deformity of leg, manual
manipulation of pelvis can be detrimental as it may dislodge a blood clot that has already
formed.
- Inform the patient: “I am going to gently press over your hips, please let me know of it
hurts. Is that alright?”
Technique:
Because the unstable pelvis is able to rotate externally, the pelvis can be closed by manually
pushing on the iliac crests at the level of the anterior superior iliac spine.
Motion can be felt if the iliac crests are grasped and the unstable hemipelvis is pushed
/rotated inward (internally) and then outward (externally).
Note: Compression distraction manoeuvre is positive if patient shows any signs of

tenderness, which indicates Pelvic fracture.
1. Patient is lying in anatomical position.

2. Approach from right side.
3. Apply thumb of each hand to appropriate anterior superior iliac spine (ASIS) and fingers
to get firm hold.
4. Then rotate wrist inward to see if pelvis "Closes".
5. Then try to move outward with wrists simultaneously, to "Open".
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- To the examiner if the compression distraction manoeuvre is positive:
“Since compression distraction manoeuvre is positive, I am suspecting pelvic fracture.
I have already resuscitated my patient.
I will stabilize the pelvis by applying a pelvic binder.
I will also arrange to transfer my patient to a trauma centre for definitive management.”
Note: A pelvic binder or other device can apply sufficient stability for the unstable pelvis at
the level of the greater trochanters. These temporary methods are suitable to gain early
pelvic stabilization. The binders are only a temporary procedure.
Definitive care of patients with hemodynamic abnormalities demands the cooperative
efforts of a team that includes a trauma surgeon, an interventional radiologist if available,
and an orthopaedic surgeon.
Angiographic embolization is often the best option for definitive management of patients
with ongoing haemorrhage related to pelvic fractures.
- To the examiner if the compression distraction manoeuvre is negative:

“I assume the pelvis is fine.”
III. Thigh:
a. Inspection:
Look for:
- Swelling
- Deformities
- Bruising
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- Wounds
b. Palpation: Distal pulses (Dorsalis pedis)
c. Movements:
- Comment on your finding: “I can see a swelling on the right/left thigh, I am suspecting
fracture of femur.
I have already resuscitated my patient.
I will stabilize the fracture by applying Thomas splint.
I will also inform the orthopaedic team for further management.”
If spring test is negative and there is no swelling on the thigh, ask the patient if he has any
pain in his thighs and if he is able to lift his leg up. If he has pain in his thigh the diagnosis is
femur fracture.
If spring test is positive and there is no swelling on the thigh, do not ask him to lift his leg.
Just palpate over the lower part of the thigh for any signs of tenderness.
“I assume the thighs are fine.”
6. Disability (Neurological Evaluation):

A rapid neurologic evaluation is performed at the end of the primary survey. This neurologic
evaluation establishes the patient’s level of consciousness (using the GCS), pupillary size and
reaction, lateralizing signs and spinal cord injury level.
“Since the patient is speaking, he is fully conscious. Ideally I will check his pupils.”
7. Exposure / Environmental Control:
Thank the patient. Cover him with warm blanket to prevent hypothermia.
8. Adjuncts to Physical Examination:

- Monitor the patient’s exhaled CO2 with an appropriate monitoring device.
- Attach an ECG Monitor to the patient.
- Insert urinary and gastric catheter unless contraindicated and monitor patient’s output of
urine.
- Other studies include FAST, DPL and X-ray if necessary.
Note: However, at the beginning you have already mentioned that you have connected all
the monitors and you have arranged for all the primary series of x-rays.
- To the examiner: “Ideally I will insert an NG tube and a suprapubic urinary catheter. Once
my patient is stable I will proceed to the secondary survey.”
Thank the examiner.
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11. Secondary Survey
Task:
“Mr Wade is a 28-year old man who has fallen from the ladder 3 hours ago. He has been
brought to the Accident and Emergency department. His pulse rate is 90 beats/min and his
blood pressure is 110/70 mmHg. Primary survey has been done. Neck injury has been ruled
out. Please do the secondary survey.”
Introduction:
The secondary survey does not begin until the primary survey (ABCDEs) is completed,
resuscitative efforts are underway and the normalization of vital functions has been
demonstrated.
The secondary survey is a head-to-toe evaluation of the trauma patient, that is, a complete
history and physical examination, including reassessment of all vital signs. Each region of the
body is completely examined.
Procedure:
1. Universal Precautions:
Tell your examiner that you will take all the universal precautions before doing this
examination:
“I assume that I have taken all the universal precautions and that the trauma team is with
me.”
Note: If in the question, the patient’s vitals are not stable say:
“I will re-do the primary survey. I will give my patient IV fluids to stabilize him. Once he is stable, I
will proceed with the secondary survey.”
2. History:
Every medical assessment includes a history of the mechanism of injury. The PAMPLE
history is a useful mnemonic for this purpose:
- Pain
- Allergies
- Medical illness/Medications currently used
- Past illness/Pregnancy
- Last meal
- Events/Environment related to the injury
-To the patient:

D: “Hello, I am doctor… one of the doctors working in this department.
I understand that you fell from a ladder today, is that right?”
P: “Yes, doctor.”
D: “I am so sorry to hear that. Do you have any pain anywhere in your body? Where?”
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P: “Yes, everywhere doctor/ in my leg.”
D: “Do you have any medical illness?”
P: “No, doctor.”
D: “Are you taking any medications regularly?”
D: “Are you allergic to anything?”
3. Exposure:
“Mr Wade, I am going to examine you now. For that I need to undress you fully by cutting all
your clothes. I will ensure your privacy and I will have a chaperone with me. I will be as
gentle as possible but if at any point you feel any discomfort or would prefer me to stop,
please let me know and I will stop the procedure. Is that alright with you?”
4. Vitals:
- To the examiner: “I will keep an eye on my patient’s vital signs throughout my
examination.”
5. Examination:
If there is a swelling on his thigh, suspect femur fracture. Examine thigh first, give your
diagnosis and management and then proceed to the head to toe examination.
Thigh:
a. Inspection:
Inspect the lower limbs for evidence of blunt and penetrating injury, including:
- Contusions
- Lacerations
- Deformities
- Wounds
- Bruises
- swelling
- Comment on your finding: “I can see a swelling on the right/left thigh.”
b. Distal Pulse: Assess the dorsalis pedis for presence, absence and equality.
c. Sensation: If there is no cotton wisp available in the exam, use your finger to check for
sensation.
- To the patient: “Please close your eyes and say yes whenever you can feel me touching
you.”
d. Movements: “Can you please wriggle your toes?”
Diagnosis to the examiner:
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“I am suspecting closed femur shaft fracture.”
Management:
1. I will resuscitate my patient if needed– Oxygen, IV fluids, blood testing
2. I will give him analgesics – IV Morphine
3. I will stabilize/immobilise the fracture by applying Thomas splint.
4. I will arrange for X-Ray of femur (AP and lateral) including the hip and knee joints.
5. I will also arrange to transfer my patient to a trauma centre for definitive management.”
If there is a bandage suspect open femur shaft fracture. Management same as above, plus:
6. I will open the bandage, assess and clean the wound
7. I will give antibiotics if needed.
8. I will administer tetanus immunization.
6. Head to toe Examination:

Check for:
Skull/Forehead: Wounds, lacerations, bleeding, swelling, bruises

Ears: Foreign body, bleeding, CSF leakage (otorrhra) and battle’s sign
Eyes: Foreign body, hematoma, periorbital contusion, subconjunctival haemorrhage,
raccoon eyes, ideally do fundoscopy and pupillary reflex.
Nose: Foreign body, bleeding, CSF leakage (rhinorrhea)
Mouth: Foreign body, dentures, missing, broken or loose teeth, mucosal lacerations
Maxilla/Mandible: Any fractures
Neck: Swelling, tracheal position, lacerations, engorged veins, bruises
Chest:
1. Inspection: Chest movements, open wounds, bruises, deformities, flail chest
2. Palpation: Chest expansion
3. Percussion: Hyper-resonance or dullness
4. Auscultation: Absent or diminished breath sounds, muffled heart sounds
Abdomen:
1. Inspection: Abdominal distension, bruises, swelling, open wounds
2. Palpation: Tenderness, rigidity, guarding
3. Percussion: Flank dullness
4. Auscultation: Absent or sluggish bowel sounds
Pelvis:
1. Inspection: Bruises, swelling, open wounds, deformities, scrotal hematoma and external
urethral meatus bleeding.
2. Palpation: Tenderness, spring test
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Un-injured limbs:
1. Inspection: Bruises, deformities, puncture marks
2. Distal pulses
3. Sensation
4. Movements: Ask the patient to lift his uninjured limbs, wriggle toes
“I assume other limbs are normal.”
“Ideally I will finish my head to toe examination. I would do a complete neurological

examination. I would log-roll the patient to examine his back for any spinal injuries or
tenderness.
I will do a per-rectal examination.
I will rule out any neck injuries and remove his collar (if neck injuries have not been ruled
out). I will cover my patient with a warm blanket to prevent hypothermia.”
Thank the patient.

Thank the examiner.
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12. Cranial Nerve II – VII Examination
Task:
“Mr Wade is a 48-year who has presented to the hospital. Please examine this man’s cranial
nerves and then present your findings.”
Introduction:
There are 12 pairs of nerves that come from the brain, one for each side of the brain. One or
more of the nerves can be affected depending on what is the cause. Common conditions
include space occupying lesions (tumours or aneurysm), myasthenia gravis and multiple
sclerosis, although there are many more.
In this station you are only asked to test cranial nerves II to VII which involves a number of
steps.
Optic Nerve (II)
Oculomotor (III)
Trochlear Nerve (IV)
Trigeminal Nerve (V)
Abducent Nerve (VI)
Facial Nerve (VII)
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Subject Steps:
3. Clarify identity

“I am here to examine the nerves in your face. If at any point you feel any discomfort or
would prefer me to stop, please let me know and I will stop the procedure.”
Position:
- Sit directly opposite and on the same level as the patient, at a distance of around 1 meter.
- Sit straight, neither you nor the patient should be leaning backward or forward.
Procedure:
1. General Inspection:
- Inform the patient: “Please sit straight on the chair, with your vision fixed on a distant
object. I am going to take a look at your face and eyes.”
Inspect for:
- Eye level / Symmetry (Eye position III, IV, VI)
- Ptosis (CN III)
- Redness
- Lid retraction: Note if the sclera is visible above the iris
- Discharge
- Forehead wrinkles (CN VII)
- Nasolabial folds (CN VII)
- Angles of mouth (CN VII)
- Temporalis/Masseter (mastication muscles) muscle wasting (CN V)
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me?”
- To the examiner: “On inspection both eyes are at the same level and are symmetrical.
There is no ptosis, redness, lid retraction or discharge from the eyes. There is no
exophthalmos or proptosis.”
2. Visual Acuity (CN II):
Ideally the acuity is easily tested with Snellen charts. If the patient normally wears glasses or
contact lenses, then this test should be assessed both with and without their vision aids.
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Colour vision is tested using Ishihara plates, which identify patients who are colour blind.
However, in the exam, visual acuity is assessed using the “Finger Counting” method which is
the ability of the patient to count fingers at a given distance.
Note: If the patient normally wears glasses or contact lenses, then this test should be
assessed with glasses kept on.
- Ask the patient: “Do you wear glasses?”

Technique:
1. Ask the patient to cover his right/left eye: “Could you please cover your right/left eye for
me?”
2. Hold your hand in the middle.
3. Show random number of fingers (two times for each eye).
4. And ask the patient to tell you how many fingers he can see: “Could you please tell me
how many fingers you are able to see?”
5. Test each eye separately in turn.
To the examiner:
“Ideally I will check the visual acuity using Snellen chart. I would also like to test colour vison
using Ishihara plates.”
3. Visual Fields (CN II):
A. Peripheral Visual Field (X Test):

Commonly the visual field for each eye can be divided crudely into four quadrants:
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- Upper Temporal
- Lower Temporal
- Upper Nasal
- Lower Nasal
Using a white hat pin test each eye’s peripheral field of vision and confirm it with own fields
or formally via perimetry testing:
Technique:
1. Introduce the white head pin to the patient.
2. Sit directly opposite and on the same level as the patient, at a distance of around 1 meter.
3. Ask the patient to cover one eye with their hand. If the patient covers their left eye, you
should also cover your own left eye i.e. the contralateral eye, with your hand as well.
4. Then ask the patient to fix their gaze on your nose, keeping their head still.
5. Hold the white head pin in the upper outer quadrant of his visual field, maintain an
equidistance between yourself and the patient.
6. Slowly bring the white pin inwards, towards the centre of your visual field (keeping it at
mid-distance between you and the patient) until the patient sees it.
7. Ask the patient to identify the point at which he first sees the pin.
- To the patient: “This is medical instrument called white head pin. I am going to draw an
imaginary X with this pin and I want you to say ‘yes’ when you first see it.
Could you please cover your right/left eye for me? I will be doing the same. Please keep
looking at my nose and do not move your head or neck.”
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8. Do this in a diagonal direction in each of the 4 quadrants only. (Draw an imaginary X)
Note: This will involve you swapping your hands to keep the same eye covered.
9. Repeat the test again for the other eye and compare with your visual field.
- If you are able to see the white head pin, but the patient cannot, this would suggest a
reduced visual field.
B. Central Field of Vision (Blind Spot):

The beginning of the optic nerve in the retina is called the optic disc. Since there are no
photoreceptors (cones and rods) in the optic disc, this area of the retina cannot respond to
light stimulation. As a result, it is known as the “blind spot,” and everybody has one in each
eye.
Using a Red hat pin mark out the patient’s blind spot:
Technique:
1. Introduce the red head pin to the patient.
5. Hold the red head pin mid-distance between your open eyes.
6. Check if the patient can see it as red:
“This is a medical instrument called pin. Could you please tell me what colour it is?”
7. Now move the pin slowly from the centre towards the periphery in a horizontal line.
8. Get the patient to tell you when it “disappears” and when it “reappears”.
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9. Then bring the pin back to the blind spot.
10. This time move it slowly upwards and downwards till the pin disappears.
This will map their natural ‘blind spot.
11. Map his blind spots on each eye to your own.
- To the patient: “Can you see this red pin? I am going to move it in front of your eyes and I
want you to tell me when it disappears and reappears.
- Verbalize your findings to the examiner:

a. If his blind spot matches yours, say:
“My patient’s blind spot matches mine.”
b. And if it doesn’t:
“My patient’s blind spot is inconclusive.”
4. Pupillary Reflexes (CN II, III):
- Check pupils for size, shape, symmetry and reaction to light (direct and consensual) for any
relative afferent pupillary defects.
- Visual reflexes comprise ‘Direct’ and ‘Consensual’ reflexes.
Technique:
1. Ask patient to place one hand vertically along his nose, between his eyes to block any
light from entering the eye which is not being tested, and focus on a distant point in the
room.
2. Inform the patient: “Please look straight ahead, I am going to shine a bright light into your
eyes.”
3. Direct pupillary reflex:
Shine light into the pupil (one eye) and observe constriction of that pupil.
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Note: Sluggish or lack of constriction may suggest pathology – optic nerve/brain stem
pathology, drugs.
4. Consensual pupillary reflex:

Again shine a light into the pupil, but this time observe the contralateral pupil.
A normal consensual response involves the contralateral pupil constricting.
Note: Lack of a normal consensual response may suggest: Damage to one or both optic
nerves/damage to the Edinger Westphal Nucleus.
5. This should be tested on both sides and check that the pupils on both sides constrict.
5. Accommodation (CN II, III):

The accommodation reflex is a reflex action of the eye, in response to focusing on a near
object, then looking at distant object, comprising coordinated changes in vergence, lens
shape and pupil size (accommodation).
Technique:
1. Place your finger approximately 15cm in front of the patient’s eyes.
2. Ask the patient to focus on a distant object (clock on a wall/light switch).
3. Then ask him to switch from looking at the distant object to your nearby finger.
4. Observe the Pupils, you should see constriction and convergence bilaterally.
- To the examiner: “Accommodation reflex is intact with my patient.”

Note: Check accommodation if the reaction to the light is poor.
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6. Ocular Movements (H Test/ CN III, IV and VI):
The Oculomotor nerve (CN III), Trochlear nerve (CN IV) and Abducent nerve (CN VI) are
involved in movements of the eye.
Technique:
1. Ask patient to keep his head perfectly still, with both eyes open.
Note: It is important the patient does not move his head.
2. As your patient to follow your finger.
3. Moving your finger through the various axis of eye movement, you should draw an
imaginary ‘H’ in front of the patient.
4. Watch the movements of both eyes while doing it.
5. Ask if patient experiences any double vision or if vision is blurred at any point.
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IIIrd Nerve Palsy
• Ptosis
• Large pupil
• Eye down and out
IVth Nerve Palsy
• Diplopia on looking down and in (often noticed on descending
stairs) - head tilting compensates for this (ocular torticollis).
VIth Nerve Palsy

• Horizontal diplopia on looking out
7.
Nystagmus (CN III, IV, and VI):
Nystagmus is involuntary, often jerky, eye oscillations. Horizontal nystagmus is often due to
a vestibular lesion (acute: nystagmus away from lesion; chronic: towards lesion), or
cerebellar lesion (unilateral lesions cause nystagmus towards the affected side).
If it is more in whichever eye is abducting, MS may be the cause (inter-nuclear
ophthalmoplegia). If also deafness/tinnitus, suspect a peripheral cause (e.g. 8th nerve
lesion, barotrauma, Meniere’s).
If it varies with head position, suspect benign positional vertigo. If it is up-and-down, ask a
neurologist to review – upbeat nystagmus classically occurs with lesions in the midbrain or
at the base of the 4th ventricle, downbeat nystagmus is foramen magnum lesions.
Technique:
1. To test for nystagmus, ask the patient to focus on the tip of your finger, keeping his head
still:
“Keeping your head still, please follow the movements of my finger with your eyes.”
2. Hold your finger at the left lateral edge of their visual field, and move it rapidly (in a
horizontal line) to the right lateral edge of their visual field and hold it there.
3. Carry out the reverse (right to left) movement and look for any abnormal eye
movements.
4. Repeat the procedure in a vertical direction and look for any abnormal eye movements.
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“No vertical or horizontal nystagmus is seen in my patient.
8. Red Reflex:
“Ideally I will also check my patient’s red reflex”
9. Trigeminal Nerve (CN V) Examination:
The Trigeminal nerve is involved in sensory supply to the face and motor supply to the
muscles of mastication. There are three sensory branches of the trigeminal nerve:
ophthalmic, maxillary and mandibular.
A. Sensory Examination of Trigeminal Nerve:

Sensation of face
Technique:
should feel like.
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3. Ask the patient to close his eyes and to say ‘yes’ whenever he can feel you touching his
face:
“I am going to touch different parts of your face with cotton wisp. I want you to close your
eyes and say ‘yes’ whenever you can feel me touching you. It’s going to feel like this (Touch
the sternum with cotton wisp).”
4. Test light touch by lightly touching the face with a piece of cotton wool in three places on
both sides of the face whilst patient’s eyes are closed:
- On the forehead – Ophthalmic branch

- On the cheek – Maxillary branch
- Around the jawline – Mandibular branch
5. Compare left to right for each branch.

B. Motor Examination of Trigeminal Nerve:
a. Palpation:
To test the motor supply:

- Ask the patient to clench their teeth together, place your hands on both sides of patient’s
face and feel for the bulk and contraction of the masseter and temporalis muscles under
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your fingers:
“Could you please clench your teeth?”
- Ask the patient to then open their mouth whilst you apply resistance under the jaw. Try to
push their jaw up and note any deviation:
“Could you please open your mouth against my hand?”
b. Reflexes:
Jaw Jerk Reflex:
Technique:
1. Ask patient to open mouth loosely.
2. Place your index finger horizontally across the chin.
3. Tap the tendon hammer onto your finger held onto a relaxed jaw.
- Normal = Slight closure of the jaw
- Abnormal = Brisk, complete closure of the jaw – UMN lesion
Corneal Reflex:
Technique:
1.Explain procedure and gain consent.
2. Depress lower eyelid.
3. Ask patient to look upwards.
4. Touch edge of cornea using a wisp of cotton wool.
- Normal response = Direct and consensual blinking
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- To the examiner: “Ideally I would test corneal and jaw jerk reflexes.”
10. Facial Nerve (CN VII):
The facial nerve is one of the key cranial nerves with a complex range of functions.
Although at first glance it is a motor nerve to facial expression, which begins as a trunk and
emerges from the parotid gland as five branches, it has taste and parasympathetic fibres
that relay in complicated ways.
A. Motor Examination of Facial Nerve:

The Facial nerve supplies motor branches to the muscles of facial expression. This nerve is
therefore tested by asking the patient to crease up their forehead (raise their eyebrows),
close their eyes and keep them closed against resistance, puff out their cheeks and reveal
their teeth.
Ask the patient to perform the following facial movements:
1. Raised eyebrows: “Raise your eyebrows as if you’re surprised”- (Temporal) / Observe for
asymmetry.
2. Close eyes: “Scrunch up your eyes and don’t let me open them.” - (Zygomatic) / Assess
power
3. Baring teeth: “Show me your teeth. / Can you do a big smile for me?” - (Mandibular) /
Note any asymmetry.
4. Blown out cheeks: “Blow out your cheeks and don’t let me deflate them.” - Assess power
5. Purse lips: “Can you attempt to whistle for me?” - Note any asymmetry
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- Ask patient to relax between tests.
- Verbalize your findings:
“Facial symmetry is normal. I assume the facial nerve is normal.”
B. Sensory Examination of Facial Nerve:

Taste:
The four primary tastes are bitter, sweet, sour, and salty. Screen for disorders of sweet or
salty taste with salt and sugar. With the patient's eyes closed and tongue protruded, take a
tongue blade and smear a small amount of salt or sugar on the lateral surface and side of
the tongue. Instruct the patient to tell you the identity of the substance. Rinse the mouth
thoroughly and repeat the test on the other side, using a different substance.
Note: In the exam you may simply ask the patient: “Did you have breakfast today? How was
the taste? Was it the same as before?”
To complete the examination:
“To complete my examination, I would perform further testing of any nerves that had
abnormal results. I would carry out a full neurological examination of the upper/lower
limbs. I should also consider testing taste sensation on the anterior two thirds of the
tongue.”
Thank the patient.

Thank the examiner.
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13. Field of Vision
Task:
“Mrs Smith is a 60-year old lady presenting to your clinic complaining of trouble in her
vision. Please examine the visual field of this patient.”
Introduction:
A visual field test is a method of measuring an individual's entire scope of vision, that is their
central and peripheral (side) vision. Visual field testing actually maps the visual fields of each
eye individually. The visual field test is a subjective examination, requiring the patient to
understand the testing instructions, fully cooperate, and complete the entire test in order to
provide useful information.
Subject Steps:
3. Clarify identity

“I am here to examine your eyes to assess why you are having problems in your vision. If at
any point you feel any discomfort or would prefer me to stop, please let me know and I will
stop the procedure.”
6. Position:
Sit directly opposite and on the same level as the patient, at a distance of around 1 meter.
Sit straight, neither you nor the patient should be leaning backward or forward.
Procedure:
1. Visual Acuity (CN II):
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119
Technique:
me?”
To the examiner:
2. Visual Fields (CN II):
A. Peripheral Visual Field (X Test):
Commonly the visual field for each eye can be divided crudely into four quadrants:
- Upper Temporal
- Lower Temporal
- Upper Nasal
- Lower Nasal
A normal full visual field with the four quadrants named and the approximate size of each
quadrant described. The large black dot represents the centre of the field or fixation.
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Using a white hat pin test each eye’s peripheral field of vision and confirm it with own fields
or formally via perimetry testing:
Technique:
1. Introduce the white head pin to the patient.
5. Hold the white head pin in the upper outer quadrant of his visual field, maintain an
equidistance between yourself and the patient.
6. Slowly bring the white pin inwards, towards the centre of your visual field (keeping it at
mid-distance between you and the patient) until the patient sees it.
7. Ask the patient to identify the point at which he first sees the pin.
- To the patient: “This is medical instrument called white head pin. I am going to draw an
imaginary X with this pin and I want you to say ‘yes’ when you first see it.
8. Do this in a diagonal direction in each of the 4 quadrants only. (Draw an imaginary X)
Note: This will involve you swapping your hands to keep the same eye covered.
9. Repeat the test again for the other eye and compare with your visual field.
- If you are able to see the white head pin, but the patient cannot, this would suggest a
reduced visual field.
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B. Central Field of Vision (Blind Spot):
The beginning of the optic nerve in the retina is called the optic disc. Since there are no
photoreceptors (cones and rods) in the optic disc, this area of the retina cannot respond to
light stimulation. As a result, it is known as the “blind spot,” and everybody has one in each
eye.
Using a Red hat pin mark out the patient’s blind spot:
Technique:
1. Introduce the red head pin to the patient.
5. Hold the red head pin mid-distance between your open eyes.
6. Check if the patient can see it as red:
“This is medical instrument called pin. Could you please tell me what colour it is?” Or “Can
you see this red pin?”
7. Now move the pin slowly from the centre towards the periphery in a horizontal line.
8. Get the patient to tell you when it “disappears” and when it “reappears”.
9. Then bring the pin back to the blind spot.
10. This time move it slowly upwards and downwards till the pin disappears.
This will map their natural ‘blind spot.
11. Map his blind spots on each eye to your own.
- To the patient: “Can you see this red pin? I am going to move it in front of your eyes and I
want you to tell me when it disappears and reappears.
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a. If his blind spot matches yours, say:
“My patient’s blind spot matches mine.”
b. And if it doesn’t:
“My patient’s blind spot is inconclusive.”
Technique:
room.
eyes.”
pathology, drugs.

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Technique:
Thank the patient.

Thank the examiner.
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14. Diplopia
Task:
“Mr Wade is a 48-year old man presenting to your clinic complaining of double vision.
Please perform a relevant eye examination to assess the cause of his double vision and
present your findings to the examiner.”
Introduction:
Diplopia is a common complaint in medical practice. It may be monocular or binocular. An
understanding of the anatomy of the eye, external ocular muscles and their innervation is
essential to approach diagnosis of the cause.

Make sure you clarify patient’s identity, get proper consent and maintain dignity. It is
important to explain what the examination will entail and what you are going to do.
Subject Steps:
3. Clarify identity

“I am here to examine your eyes to assess why you are having double vision. If at any point
you feel any discomfort or would prefer me to stop, please let me know and I will stop the
procedure.”
6. Position:
- Sit directly opposite and on the same level as the patient, at a distance of around 1 meter.
- Sit straight, neither you nor the patient should be leaning backward or forward.
Procedure:
- Inform the patient: “Please sit straight on the chair, with your vision fixed on a distant
object. I am going to take a look at your eyes.”
Inspect both eyes for:

- Eye level / Symmetry (Eye position III, IV, VI)
- Ptosis (CN III)
- Redness
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- Lid retraction: Note if the sclera is visible above the iris
- Discharge
me?”
- To the examiner: “On inspection both eyes are at the same level and are symmetrical.
There is no ptosis, redness, lid retraction or discharge from the eyes. There is no
exophthalmos or proptosis.”
2. Visual Acuity (CN III):

126
Technique:
me?”
To the examiner:
Technique:
room.
eyes.”
pathology, drugs.
127

Technique:
128
5. Ocular Movements (H Test/ CN III, IV and VI):
The Oculomotor nerve (CN III), Trochlear nerve (CN IV) and Abducent nerve (CN VI) are
involved in movements of the eye.
Technique:
1. Ask patient to keep his head perfectly still, with both eyes open.
Note: It is important the patient does not move his head.
2. As your patient to follow your finger.
3. Moving your finger through the various axis of eye movement, you should draw an
imaginary ‘H’ in front of the patient.
4. Watch the movements of both eyes while doing it.
5. Ask if patient experiences any double vision or if vision is blurred at any point.
6. Binocular/Monocular Cover Test:
Does covering either eye make the diplopia disappear?

This test helps to rule out monocular diplopia, which persists in one eye even if the other
eye is covered.
- To the examiner: “I will confirm my diagnosis with diplopia cover test.”
a. Monocular double vision: It affects one eye only and continues when the unaffected eye
is covered.
It can be caused by abnormalities of the lens, cornea or retina, which result in splitting of
the image.
b. Binocular double vision: This occurs when the images produced by the two eyes do not
absolutely match, so that the images produced are misaligned relative to one another. The
diplopia disappears when one eye is covered.
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7. Nystagmus (CN III, IV, and VI):
Nystagmus is involuntary, often jerky, eye oscillations.
Technique:
still:
2. Hold your finger at the left lateral edge of their visual field, and move it rapidly (in a
horizontal line) to the right lateral edge of their visual field and hold it there.
3. Carry out the reverse (right to left) movement and look for any abnormal eye
movements.

“No vertical or horizontal nystagmus is seen in my patient. Ideally I will also check my
patient’s red reflex”
8. Red Reflex:
“Ideally I would check my patient’s red reflex.”
Thank the patient.

Thank the examiner.
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15. Cranial Nerve VIII Examination
(Vestibulocochlear)
Task:
“Mr Reilly is a 52-year old man who has come to your clinic complaining of dizziness and
hearing difficulties. Please examine this man’s 8th cranial nerve and present your findings to
the examiner.”
Introduction:
There are 12 pairs of nerves that come from the brain, one for each side of the brain. One or
more of the nerves can be affected depending on what is the cause. Common conditions
include space occupying lesions (tumours or aneurysm), myasthenia gravis and multiple
sclerosis, although there are many more.
However, in this station you are only asked to test cranial nerve VIII which involves a
number of steps.
The Vestibulocochlear nerve (CN VIII) provides innervation to the hearing apparatus of the
ear and can be used to differentiate conductive and sensorineural hearing loss using Rinne
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and Weber tests.

Subject Steps:
3. Clarify identity
“I am here to examine your ears and assess why you are having balance and hearing
problems. If at any point you feel any discomfort or would prefer me to stop, please let me
know and I will stop the procedure.”
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Position:
Ask patient to sit and look straight.
Procedure:
Move to both sides of your patient and inspect the front and back of both ears (Pre-auricular, pinna
and post-auricular areas) for:
- Discharge
- Redness
- Scars
- Swelling
- Battle sign
- Foreign body
- Wax
- To the examiner: “On inspection there are no scars, swelling, redness, discharge or battle sign over
the pre-auricular, auricular and post-auricular areas. No foreign body or wax can be seen in the
ears.”
2. Palpation:
A. Temperature:
- Warn your patient before touching him.
- Warm your hands up and then check the local rise of temperature using the dorsum of
your hand.
- Compare both ears with each other.
- To the examiner: “There is no change in temperature.”
B. Tenderness:
Keep looking at the patient’s face for any tenderness. Palpate these areas to elicit pain:
i. Palpate the pre-auricular area with the pulp of your fingers.
ii. Palpate the auricular area with thumb and index fingers.
iii. Palpate the post-auricular area with thumb.
iv. Note whether the mastoid is boggy/swollen or firm.
C. Tragus Test:
In case of an ear infection, pressing the tragus will tell you quickly. If it feels inflamed or if it
hurts, there is an infection in there somewhere.
After warning the patient, gently press over the tragus for any tenderness or fluctuance.
- Tragus test positive: Is a contraindication to otoscopy.
- Tragus test negative: You can proceed with the otoscopy examination.
- To the examiner: “The tragus test is negative. Ideally I proceed to otoscopy examination.”
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3. Auditory Acuity:
Auditory acuity is the clarity or clearness of hearing, a measure of how well a person hears.
It is measured in order to determine a person’s need for a hearing aid.
The ability of patient to hear can be assessed crudely.
Technique:
1. Inform the patient that you are going to his back.
2. Stand behind the patient.
4. Place your fingers a few centimetres from either ear.
5. Rub the fingertips of first one hand.
6. Ask the patient if he can hear it.
7. Now rub the fingertips of your other hand.
8. Ask the patient if he can hear it.
9. Make note of any obvious differences in hearing.
4. Gross Hearing Testing:
i. Ask the patient if they have noticed any change in their hearing recently.
ii. Inform the patient that you are going to his back. Assess each ear individually, standing
behind the patient.
iii. Explain to the patient that you’re going to say a word or number and you’d like them to
repeat it back to you.
iv. Mask the ear not being tested by rubbing the tragus.
v. With your mouth approximately 15cm from the ear, whisper a number or word.
vi. Ask the patient to repeat the number or word back to you.
vii. If the patient repeats the correct word or number, repeat the test at an arm’s length
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from the ear (normal hearing allows whispers to be perceived at 60cm).
viii. Assess the other ear in the same way.
Note: In the exam, you will not have enough time to perform the gross hearing test.
5. Hearing Tests (Tuning Fork Tests):
No single test is diagnostic, but tuning fork tests do give useful information.
Having the correct tuning fork is extremely important. A 512Hz tuning fork gives the highest
frequency and is used specifically to test the hearing. However, a 256Hz can also be used if
this is not available.
Other tuning forks such as the 128Hz have a lower pitch, which is used for testing vibration
and is not part of the ear examination.
In an exam you may be asked to identify the correct tuning fork and then use it to conduct
special hearing tests. As a general rule the 512Hz is the smaller of the tuning forks but
please take the time to get to know which one is which.
A. Rinne’s Test:
This test is designed to assess conductive hearing loss. It does this by comparing the sound
transmission of bone conduction and air conduction.
Technique:
1. Pick up a 512Hz tuning fork and introduce it to the patient.
2. Explain what you are going to do to your patient.
“This is a medical instrument called tuning fork which is a buzzing instrument. I am going to
buzz it and place it behind and in front of your ear. I want you to tell me if the sound is
louder in front of your ear or behind it. Is that alright with you?”
3. Twang the long ends of the tuning fork.
4. Place the round base of the fork on the bony mastoid process behind the patient’s ear to
evaluate bone conduction.
5. And then in front of the ear, next to the ear so that the prongs and auditory canal lie on
the same line, to assess air conduction.
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6. Ask where he hears it loudest.
7. Do it on both ears.
8. The patient should inform you from which location the sound is louder.
A normal patient will find the second position louder.
Interpretation of Rinne’s Test:
1. Rinne’s positive: Normal Hearing or Sensorineural Deafness.
Air conduction is greater than bone conduction / AC > BC
(Louder in front of ear than on mastoid process)
2. Rinne’s Negative: Conductive Deafness.
Bone conduction is greater than air conduction / BC > AC
(Louder on mastoid process than in front of ear)
B. Weber’s Test:
The Weber's test serves two purposes.
It can determine the type of deafness i.e. sensorineural or conductive.

If it is sensorineural loss it can identify which ears cochlear has a better function.
Technique:
1. Start the test by explaining what you are going to do:
“Now I am going to buzz it again and place it on your forehead. I want you to tell me that in
which ear you hear the sound loudest, left, right or in the middle. Is that alright with you?”
2. Twang the long ends of the tuning fork.
3. Place the round base of the fork on the middle of patient’s forehead.
4. Ask if one side is louder than the other.
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Interpretation of Weber’s Test:
Sound localizes to the affected ear with conductive loss, to the contralateral ear in SNHL,
and to the midline if both ears are normal (or if bilateral sensorineural loss):
1. Normal (Or Symmetrical loss): Sound heard in the middle, equally in both ears (Or patient
is not able to hear at all).
2. Sensorineural Deafness: Sound loudest in the less affected ear.
Rinne’s test is positive on both sides. Weber’s test lateralizes to one side. Sensorineural
deafness is opposite to where Weber’s lateralizes.
Conductive
Deafness
• Wax (remove, e.g. by syringing with warm water after softening with
olive oil drops)
• Otosclerosis
• Otitis media
• Glue ear
Chronic
Sensorineural
Deafness
• Often due to accumulated environmental noise toxicity
• Presbyacusis
• Inherited disorders
Sudden
Sensorineural
Deafness
• Gentamicin/ other toxin
• Noise exposure
• Mumps
• Aucostic neuroma
• MS
• Stroke
• Vasculitis
• TB
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3. Conductive Deafness (Rinne’s negative): Sound loudest in affected ear.
Rinne’s test is positive on one side and negative on the other side. Weber’s test lateralizes
to the side which Rinne’s test is negative.
6. Nystagmus (CN III, IV, and VI):
Nystagmus is involuntary, often jerky, eye oscillations. Horizontal nystagmus is often due to
a vestibular lesion (acute: nystagmus away from lesion; chronic: towards lesion), or
cerebellar lesion (unilateral lesions cause nystagmus towards the affected side).
If it is more in whichever eye is abducting, MS may be the cause (inter-nuclear
ophthalmoplegia). If also deafness/tinnitus, suspect a peripheral cause (e.g. 8th nerve
lesion, barotrauma, Meniere’s).
If it varies with head position, suspect benign positional vertigo. If it is up-and-down, ask a
neurologist to review – upbeat nystagmus classically occurs with lesions in the midbrain or
at the base of the 4th ventricle, downbeat nystagmus is foramen magnum lesions.
Technique:
still:
2. Hold your finger at the left lateral edge of their visual field, and move it rapidly (in a horizontal
line) to the right lateral edge of their visual field and hold it there.
3. Carry out the reverse (right to left) movement and look for any abnormal eye movements.

“No vertical or horizontal nystagmus is seen in my patient.”
7. Romberg’s Test:
Romberg's test or the Romberg manoeuvre is a test used in an exam of neurological

function, and also as a test for drunken driving.
It is an appropriate tool to diagnose sensory ataxia, a gait disturbance caused by abnormal
proprioception involving information about the location of the joints.
It is also proven to be sensitive and accurate means of measuring the degree of
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disequilibrium caused by the central vertigo, peripheral vertigo and head trauma.
Whilst Romberg’s test does not directly test for cerebellar ataxia, it helps to differentiate
cerebellar ataxia from sensory ataxia. In cerebellar ataxia the patient is likely to be unsteady
on their feet even with the eyes open.
Technique:
1. Ask the patient to stand unaided with his two feet together. The arms are held next to the
body (arms by their side) or crossed in front of the body.
2. Ask the patient to first stand quietly with eyes open.
“Are you able to stand up? Could you please stand up for me? With your feet together and
your arms by your side. Don’t worry I’ll support you.”
3. Then ask the patient to close his eyes: “Can you please close your eyes for me?”
4. The patient tries to maintain his balance. Be ready to support him.
Note 1: For safety, it is essential that you stand close to the patient to prevent potential
injury if the patient begins to sway or fall.
Note2: When the patient closes his eyes, he should not orient himself by light, sense or
sound, as this could influence the test result and cause a false positive outcome.
5. If the patient sway/ lose balance the test is positive and indicates posterior column
disease/ sensory ataxia.
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Interpretation:
1) The Romberg test is positive when the patient is unable to maintain balance with their
eyes closed.
Losing balance can be defined as increased body sway, placing one foot in the direction of
the fall, or even falling.
A positive Romberg test indicates Sensory Ataxia.
2) If there is a more severe proprioceptive or vestibular lesion, or if there is a midline
cerebellar lesion causing truncal instability, the patient will be unable to maintain this
position even with their eyes open.
This indicates Cerebellar Ataxia.
8. Marching Test / Unterberger’s Test:
The Unterberger's test, is a test used in otolaryngology to help assess whether a patient has
a vestibular pathology. It is a simple means of identifying which labyrinth may be
dysfunctional in a peripheral vertigo.
Unterberger, described the tendency of vestibular stimulation to turn the patient in the
earth’s vertical axis when walking. His test identifies that the direction of turning in patients
with unilateral vestibular deficits coincides with the direction of past-pointing and falling—
that is, in the direction of the slow component of nystagmus.
Technique:
1. Ask the patient to stand with their arms extended and thumbs raised.
3. Ask the patient to walk in place (march on the spot for about 50 steps) while his arms are
outstretched and eyes are closed.
4. The angle of rotation as well as forwards and backwards movements is then recorded.
Note: There is, however, a pronounced variability in the rotation angle from one subject to
another and in the same subject on repeated testing, and the outcome should only be used
in the context of the rest of the vestibular test battery.
5. Patients with lesions in their brains or damage to the labyrinth of the ear can start to
rotate or twist. They tend to move in the direction of the damage.
Interpretation:
A positive test is identified by rotational movement of the patient towards the side of the
lesion which indicates a labyrinthine lesion on that side.
1. Normal: Patient remains in the same position.

2. Vestibular lesion: Patient will turn toward the side of the lesion.
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9. To complete the examination:
A. Caloric Test:
In medicine, the caloric reflex test (sometimes termed 'vestibularcaloric stimulation') is
a test of the vestibulo-ocular reflex that involves irrigating cold or warm water or air into the
external auditory canal.
B. Dix-Hallpike Test:
The Dix–Hallpike test or Nylen–Barany test, is a diagnostic manoeuvre used to
identify benign paroxysmal positional vertigo (BPPV).
“Ideally I would complete my examination by doing Dix-Hallpike and Caloric tests.”

Thank the patient.
Thank the examiner.
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16. Lymphoreticular Examination
Task:
“Mr Baker, a 32-year old man, presents to the hospital after being diagnosed with CLL.
Please perform a relevant examination for lymphadenopathy.”
Introduction:
Reticulo-Endothelial is a medical way of saying “Examine the lymph nodes, liver and spleen”.
Conditions which cause enlarged lymph nodes or hepatosplenomegaly are usually the
haematological malignancies such as lymphoid and myeloid leukemia’s.
Whilst the name of the station may sound daunting, it is actually a fairly basic station.
Subject Steps:
3. Clarify identity
“I am here to examine the lumps and bumps in your body. I will be as gentle as possible but
if at any point you feel any discomfort or would prefer me to stop, please let me know and I
will stop the procedure.”
5. Exposure:
For this examination the patient should be fully exposed.
- To the patient: “Ideally for the purpose of this examination you need to be fully exposed
but you can keep your briefs on.”
examination.”
Position:
Three different positions are involved in lympho-reticular examination: Sitting on a chair (to
check for cervical and head lymph nodes), standing (to check for axillary lymph nodes) and
lying down (liver and spleen palpation). You will guide your patient as the examination
proceeds.
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Procedure:
As you have been given a fairly directed instruction, there is little observation to be done. As
the station however revolved around examination of parts of the immune system, it may
look good to start with a brief general inspection.
1. General Inspection (Sitting on chair position):
a. Hands:
Inspect for:
- Clubbing
- Palmar erythema
- Pallor
- Palmar sweating.
- Pulse (Regular pulse/adequate volume)
- Blood pressure
- To the examiner: “Ideally I will check my patient’s pulse and blood pressure.”
b. Eyes:
Inspect for pallor.
- To the patient: “Could you please pull your lower eyelids down?”
c. Oral Cavity / Mouth:
Using a pen torch ask the patient to open his mouth and protrude his tongue.
Note: However in the exam there is no pen torch available.
Inspect for:
- Central cyanosis
- Tonsillar hypertrophy
- Tonsillectomy
Then ask: “Could you please clench your teeth” and look for:
- Gum bleeding
- Gum hypertrophy
d. Adenoids:
- To the examiner: “Ideally I will do a posterior rhinoscopy to check the adenoids.”
2. Palpation (Sitting on chair position):

Begin with an examination of the lymph nodes which are arranged in various groups. This
should be done with the patient sitting and you standing behind them.
Warm your hands up and ensure that the patient is warned before touching him.
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Technique:
1. Inform the patient that you are going to his back.
2. Warm your hand up.
3. Warn the patient before touching him.
4. Gently place the pads of your fingers on each side of the neck. Feel both sides together
for comparison.
5. Start under the chin to feel the submental nodes.
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6. Then move along the lower jaw line to feel the submandibular nodes.
7. Then behind and in front of the ears for the post-auricular and pre-auricular nodes.
8. Ask the patient to slightly bend his head downwards and feel for the occipital nodes.
- To the patient: “Could you please slightly bend your head?”
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9. Ask the patient to turn his head to the left/right and then feel along the anterior border
of the sternocleidomastoid muscle for the anterior cervical and around to the posterior
border, for the posterior cervical lymph nodes.
- To the patient: “Could you please turn your head to the left/right?” Or “Can you please
look left/right?”
- Comment on your findings: “No enlargement of submental, submandibular, pre-auricular,

post-auricular and occipital group of lymph nodes.”
10. Ask patient to shrug his shoulder and feel above and below the clavicle for the supra-
clavicular and infra-clavicular nodes.
- To the patient: “Could you please shrug your shoulder for me?”
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- Comment on your findings: “No enlargement of supraclavicular and infraclavicular lymph
nodes.”
3. Axillary Lymph Nodes Palpation (Standing position):

The overall 3D shape of the axilla looks slightly like a pyramid. The borders consist of four
sides and a base with an opening at the apex.
Borders:
1. Apex: Also known as the axillary inlet, this is formed by lateral border of the first rib,
superior border of scapula, and the posterior border of the clavicle.
2. Lateral wall: Formed by intertubercular groove of the humerus.
3. Medial wall: Consists of the serratus anterior and the thoracic wall (ribs and intercostal
muscles).
4. Anterior wall: Contains the pectoralis major and the underlying pectoralis minor and the
subclavius muscles.
5. Posterior wall: Formed by the subscapularis, teres major and latissimus dorsi.
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Lymph Nodes:
The majority of the upper lymph nodes are located in the axilla. They can be divided
anatomically into 5 groups:
1. Anterior (Pectoral): 3-5 nodes, located in the medial wall of the axilla. They receive lymph
primarily from the anterior thoracic wall, including most of the breast.
2. Posterior (Subscapular): 6-7 nodes, located along the posterior axillary fold and
subscapular blood vessels. They receive lymph from the posterior thoracic wall and scapular
region.
3. Lateral (Humeral): 4-6 nodes, located in the lateral wall of the axilla, posterior to the
axillary vein. They receive the majority of lymph drained from the upper limb.
4. Medial (Central): 3-4 large nodes, located near the base of the axilla (deep to pectoralis
minor, close to the 2nd part of the axillary artery). They receive lymph via efferent vessels
from the pectoral, subscapular and humeral axillary lymph node groups.
5. Apical: Located in the apex of the axilla, close to the axillary vein and 1st part of the
axillary artery. They receive lymph from efferent vessels of the central axillary lymph nodes,
therefore from all axillary lymph node groups. The apical axillary nodes also receive lymph
from those lymphatic vessels accompanying the cephalic vein.
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Examine both axillae for any enlarged lymph nodes in Standing Position.
Palpate the axilla with your free hand, ensuring to cover all areas of the axilla (Medical,
lateral, anterior and posterior walls - Apex of the axilla)
Technique:
1. Inform the patient about what you are going to do and kindly ask him to stand up.
- To the patient: “I am going to examine the nodes in your arm pit. Can you please stand up
for me?”
2. Support the patient’s arm on the side being examined with your shoulder of the same
side.
For example if you are examining the right axilla, use your right arm to support the patient’s.
(Vice versa for left)
- To the patient: “Could you please rest/put your right hand on my right shoulder? I am
going to do the same.”
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3. Put your right hand on her right shoulder and examine the right axilla with your left hand,
ensuring that you feel all groups of axillary lymph nodes (anterior, medial) as well as feeling
into the apex of the axilla. (Apical)
Note: Another way to palpate the axillary group of lymph nodes is to ask the patient to hold
your right biceps while you support the weight of his right arm at their elbow with your right
hand as shown in the picture below. (Vice versa for left)
4. Repeat this on the other side.

5. Note any lymphadenopathy. (Malignancy / infection)
6. Ask the patient to cross her hands in front, then go to her back (with permission):
- To the patient: “Could you please cross your hands in front of you? I need to go to your
back, is that okay with you?”
7. Examine the lateral and posterior group of lymph nodes.
8. Note any lymphadenopathy. (Malignancy / infection)
4. Epitrochlear Lymph Nodes:
Epitrochlear nodes are found on the inside of the upper arm, just above the elbow. These
are rarely the site of pathology and thus not routinely examined. If there is clinical evidence
of an infection distal to the elbow, it makes sense to feel for these nodes as they part of the
drainage pathway.
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Technique:
1. Ask the patient to bend his elbow. (90 degrees)
- To the patient: “Could you please ben your right/left elbow?”
2. To examine the right group of Epitrochlear lymph nodes, hold the patient’s right wrist
with your left hand. (Vice versa for left)
3. Now hold their right elbow in your right palm (cup the patient’s elbow in your hand).
4. Use your thumb (fingers) to lightly palpate the groove between medial epicondyle and
olecranon for the lymph nodes.
5. Liver Palpation (Lying down position):

Next you should move onto examine the liver and spleen. Palpation for the liver and spleen
is similar, both standing in the right iliac fossa.
Technique:
1. Ask the patient to lie down on the couch.
4. Using the radial border of the index finger aligned with the right costal margin.
5. Start palpation from the right iliac fossa.
6. Press your right hand into the abdomen as you ask the patient to take deep breaths in
and out.
7. Move your hand (without lifting it up, in a step-wise fashion) upwards, towards the right
costal margin (right hypochondrium) until you feel the liver.
8. You should try to time the palpation with the patient’s breathing – in as this presses down
on the liver.
9. A distended liver feels like a light tap on the leading finger when you press down. If the
liver is distended, its distance from the costal margin should be noted.
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- Comment on your finding: “I cannot feel the edge of the liver.”
6. Spleen Palpation (Lying down position):

The spleen is not usually palpable, therefore if you feel it, it’s at least 3x its normal size.
Technique:
4. Using the radial border of the index finger aligned with the left costal margin, start
palpation from the right iliac fossa and then move your hand upwards towards the left
costal margin (left hypochondrium).
5. While palpating ask the patient to take deep breaths in and out.
6. You should try to time the palpation with the patient’s breathing –in as this presses down
on the spleen.
7. The edge of the spleen which may be felt if distended, is more nodular than the liver.
8. If suspect splenomegaly but cannot detect it, assess patient in the right lateral position
with your left hand pulling forwards from behind the rib cage:
Ask the patient to lie on their right side towards you. Support the rib cage with your left
hand and again ask the patient to take deep breaths in, as you move your right hand up
towards the left hypochondrium.
- Comment on your finding: “The edge of spleen is not palpable.”
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7. Para-aortic Lymph Nodes:
Para-aortic lymph nodes are located around abdominal aorta.
- To the examiner: “Ideally I would arrange for a CT scan to check for para-aortic and
mediastinal group of lymph nodes.”
8. Inguinal and Femoral Lymph Nodes (Lying down position):
Technique:
1. Cover the genitals.
2. Abduct the hip slightly.
3. Begin by simply looking at the groin region. Make note of any swelling which might
represent adenopathy or a femoral hernia.
4. Roll your fingers horizontally over the inguinal ligament and vertically over the femoral
artery to palpate horizontal and vertical groups of superficial inguinal nodes as well as for
femoral adenopathy.
- You should mention to the examiner at this point you would also like to check the inguinal
lymph nodes for completion, although you won’t be expected to perform this.
- To the examiner: “Ideally I will check the inguinal lymph nodes.”
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9. Popliteal Lymph Nodes (Lying down position):
Move down to the level of the knee to feel for the popliteal lymph nodes.
Technique:
1. Flex knee slightly.
2. Place your hands around the knee and push the tips of your fingers into the popliteal
fossa.
3. Gently palpate the popliteal fossa to feel for popliteal lymph nodes.

Thank the examiner.
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17. Cardiovascular Examination
Task:
“A 50-year old patient who has presented to the hospital. Please perform a CVS examination
and look for signs of heart failure.
His blood pressure is 120/80 mmHg and his pulse is 75.”
Introduction:
This is essentially an examination of the patient’s heart; however it is a complex
examination which also includes examination of other parts of the body including the hands,
face and neck.
The CVS examination aims to pick up on any cardiovascular pathology that may be causing a
patient’s symptoms e.g. chest pain, breathlessness, heart failure.
percuss and auscultate (look, feel, tap, listen).
Subject Steps:
3. Clarify identity
“I am here to examine your heart. I will be as gentle as possible but if at any point you feel
procedure.”
5. Exposure:
“For the purpose of this examination you need to be exposed above waist.”
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examination.”
8. Position:
For this examination the patient should be on the bed with their trunk at 45 degrees. (If the
couch is not at 45 degrees, please inform the examiner.)
1. General Examination:
I. General Inspection:
Make a general observation of the patient.
You should note whether the patient looks uncomfortable or is in distress (Shortness of
breath).
A. Hands:
forth multiple times).
Initially note how warm they feel as this gives an indication of how well perfused they are.
Particular signs which you should be looking for are:
Hands out with palms facing upwards:
- Temperature: Cool peripheries may suggest poor cardiac output / hypovolemia.
- Palmar erythema / pallor
- Palmar sweating / Clammy: Can be associated with acute coronary syndromes.
- Janeway lesions: Non-tender maculopapular erythematous palm pulp lesions – bacterial
endocarditis.
- Osler’s nodes: Tender red nodules on finger pulps / Thenar eminence – infective
endocarditis.
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Hands out with palms facing downwards:
- Clubbing: Finger clubbing has a number of causes including infective endocarditis and
cyanotic congenital heart disease.
Technique:
Ask patient to place the nails of their index fingers back to back.
In a healthy individual you should be able to observe a small diamond shaped window
(Schamroth’s window). When finger clubbing is present, this window is lost.
Note: In the exam, due to time limit, you may only inspect the fingers with the palms facing
downwards to look for clubbing. Both techniques are accepted.
- Splinter haemorrhages: reddish/brown streaks on the nail bed – bacterial endocarditis.
- Tobacco-stained fingers / Tar staining: History of smoking – increased risk of COPD/lung

cancer.
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- Tendon xanthomata: Skin lesions associated with severe hypercholesterolemia and
elevated LDL levels. They are most commonly found on dorsal aspects of the fingers.
- Radio-radial delay: Palpate both radial pulses (bilaterally) simultaneously. They should
occur at the same time in a healthy adult.
A delay may suggest aortic coarctation or dissection or it could be from aortic arch
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aneurysm.
- Collapsing pulse:
Technique:
1. First ensure the patient has no shoulder pain.
2. Palpate the radial pulse with your hand wrapped around the wrist.
3. Raise the arm above the head briskly.
4. You should feel a tapping impulse through the muscle bulk of the arm as the blood
empties from the arm very quickly in diastole, resulting in the palpable sensation.
This is a Waterhammer pulse and can occur in normal physiological states

(fever/pregnancy), or in cardiac lesions (e.g. AR / PDA) or high output states (e.g. anaemia /
AV fistula / thyrotoxicosis)
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- Brachial pulse:
- Just medial to tendinous insertion of biceps
- Waveform character.
- Assess volume and character of the pulse.
- Blood pressure:
- Hyper of hypotensive?
- Pulse pressure (wide = aortic regurgitation / narrow = aortic stenosis)
Systolic BP is the pressure at which the pulse is first heard as on cuff deflation (Korotkov
sounds); the diastolic is when the heart sounds disappear or become muffled (e.g. in the
young).
The pulse pressure is the difference between systolic and diastolic pressures. It is narrow in
aortic stenosis and hypovolaemia, and wide in aortic regurgitation and septic shock.
- Radio-femoral delay: Palpate ipsilateral pulses simultaneously. This is a subtle sign and is
not often seen. Normally the radial and femoral pulses will be felt at the same time as they
are roughly the same distance from the heart. If there is a delay between them, then it is
known as radial-femoral delay.
(Coarctation of aorta)
- To the examiner: “I can feel the pulse. The rhythm is regular and the volume is adequate.
Ideally I would check the pulse for 1minute and I will check the radio-radial delay. Ideally I
would also check my patient’s blood pressure and radio-femoral delay.”
Note: However in the exam, usually the pulse has been mentioned in the question. In that
case you do not need to check the pulse again.
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B. Face:
Eyes:
- Conjunctival pallor (Anaemia):
Or
look up for me?”
- Conjunctival icterus:
Or
- Xanthelasma: Lipid-laden yellow plaques that occur most commonly near the inner
canthus of the eyelid and signify hyperlipidaemia.
- Corneal arcus: A greyish-white ring (or part of a ring) opacity occurring in the periphery of
the cornea, in middle and old age. It is due to a lipid infiltration of the corneal stroma. With
age the condition progresses to form a complete ring.
Cheeks:
- Malar flush: Suggestive of mitral stenosis, low cardiac output
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Mouth:
- Central cyanosis: Bluish discoloration of the lips and mucous membranes (inferior aspect
of tongue).
- To the patient: “Could you please open your mouth and roll your tongue back?”
- Tongue (glossitis): Also look at the tongue. If it is red and fat it could be another sign of
anaemia
- Angular stomatitis: Inflamed red areas at the corners of the mouth
- Oral hygiene
C. Neck:
Move to the patient’s neck to assess their jugular venous pressure.
- Jugular Venous Pressure (JVP) / Engorged neck veins:
The internal jugular vein acts as a capricious manometer of right atrial pressure.
Observe 2 features: the height (jugular venous pressure, JVP) and the waveform of the
pulse.
Raised JVP may indicate: Fluid overload / Right ventricular failure / Tricuspid regurgitation.
Technique:
1. Positioning is very important, ensure the patient is positioned at 45 degrees.
2. Ask the patient to relax and to turn his head slightly away from you (to the left):
“Could you please turn your head to the left?”
3. Observe the neck for JVP; look for pulsation behind the sternocleidomastoid (located in
line with the sternocleidomastoid).
- Comment on your finding: “JVP in my patient has not raised.”
- Hepatojugular Reflux: If the JVP is not seen, assess hepatojugular reflux.
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Having warned the patient that it may cause discomfort, press down on the liver. This will
cause the JVP to rise further. If you decide the pulsation is due to the JVP, note its vertical
height above the sternal angle.
A positive hepatojugular reflux sign is suggestive of right sided heart failure / tricuspid
regurgitation.
Note: In the exam due to time limit, we are not going to assess hepatojugular reflex.
- Carotid pulse:
Inspect (visible carotid = Corrigan’s sign of aortic regurgitation), and palpate volume and
character on one side.
Note: Never palpate both simultaneously.
Locate the carotid pulse medial to the sternocleidomastoid and beside the trachea.
- Comment on your finding: “Carotid pulse in my patient has normal character and adequate
volume.”
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- Pedal Oedema:
Note: Ideally pedal oedema must be checked at the end of the CVS examination. However in
the exam due to time limit, you may prefer to examine pedal oedema whilst standing at the
foot of the bed.
- Warn patient before touching him: “I am going to gently press over your legs.”
- Comment on your finding: “There is no peripheral oedema in my patient.”
II. Chest inspection:
Move the examination to the chest, or precordium. Start by inspecting the area, particularly
looking for any obvious pulsation, abnormalities or scars.
- Chest wall movements:

- To the examiner: “Chest wall movements are bilaterally symmetrical.”
- Precordium Bulge:
- To the examiner: “There is no precordium bulge.”
- Scars: Scars from previous thoracic surgeries / median sternotomy (CABG; valve
replacement; congenital heart disease)
- Skin changes: Redness/ marks or spots/erythema/swelling/thickened skin
- Visible pulsations: Forceful apex beat may be visible – hypertension / ventricular
hypertrophy.
III. Palpation:
Ask if there is any pain. Ensure that your hands are warm and make sure you warn your
patient before touching him.
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A. Apex beat (lowermost lateral pulsation):
Palpation of the chest starts by trying to locate the apex beat. Start by doing this with your
entire hand and gradually become more specific until it is felt under one finger and describe
its location anatomically.
Lateral displacement of the apex beat suggests cardiomegaly.
Technique:
1. lay your whole dominant hand flat over the precordium to obtain a general impression of
the cardiac impulse.
2. Try to locate the apex beat by laying your fingers on the chest parallel to the ribs basis.
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3. Describe the position, where the pulse can be felt, by counting intercostal spaces.
Start from the angle of Louise (2nd intercostal space).
This is normally in the 5th intercostal space in the midclavicular line.
Angle of Louis and 2nd intercostal space
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6. You should also note the character of the apex beat.
- Character:
1) Impalpable: Dextrocardia / COPD
2) Heaving: Caused by outflow obstruction, e.g. aortic stenosis or systemic hypertension
3) Thrusting: Caused by volume overload, e.g. mitral or aortic incompetence
4) Tapping: Mitral stenosis, essentially a palpable 1st heart sound
5) Diffuse: LV failure, dilated cardiomyopathy
6) Double impulse
7) Sustained/strong
- Comment on your finding: “Apex beat in my patient is normal.”
Parasternal Heave and Thrills:

Now palpate for any heaves or thrills. A thrill is a palpable murmur whereas a heave is a sign
of left/right ventricular hypertrophy. A thrill is a palpable murmur felt as a vibration beneath
your hand. A heave feels like an abnormally large beating of the heart.
B. Heaves:
i. Place the heel of your hand flat on chest (with your fingers pointing upwards), to left of
sternum.
ii. Ask the patient: “Could you please take a deep breath in, breath out and hold.”
iii. Feel for right ventricular heave with the heel of your hand in the left parasternal position.
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iv. You may repeat this procedure by placing your hand on chest to right of sternum.
v. Ask patient to breath normally.
You will normally feel the movement of respiration, but sometimes you may also feel the
parasternal heave – in which case, your hand will be lifted off the patient’s chest. You have
to press on quite hard!
It is mostly seen in left and right ventricular hypertrophy.
C. Thrills:
These are very rare, and a result of a murmur producing a palpable sensation (transmitted
murmurs).
They feel a bit like a cat purring. A thrill will nearly always indicate a significant lesion. The
most common type is aortic stenosis producing a thrill in the aortic area.
Technique:
Feel for thrills with the pads of the fingers at the apex and the left and right sternal edges. A
thrill is a palpable vibration.
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V. Auscultation:
- While auscultating the heart, palpate carotid pulse at the same time to determine the 1st
heart sound.
- Ask patient to take deep breaths in and out.
- If you hear any abnormal sounds you should describe them by when they occur and the
type of sound they are producing.
Note: Feeling the radial pulse at the same time can give a good indication as to when the
sound occurs as the pulse occurs at systole.
- Auscultate all four areas of precordium:
A. Mitral valve – 5th intercostal space – midclavicular line (apex beat):

- At apex (mitral area), listen with bell and diaphragm.
- Identify 1st and 2nd heart sounds.
- Listen for added sounds and murmurs; with the diaphragm listen for a pansystolic murmur
radiating to the axilla (Mitral Regurgitation).
Further check for Mitral Stenosis:

At apex with bell, ask patient to breathe in, then out and hold it out and listen over the apex
and axilla with the bell of the stethoscope.
A rumbling mid-diastolic murmur here suggests Mitral Stenosis.
169
Note: In the exam due to time limit we do not perform the further check for mitral stenosis.
B. Tricuspid valve – 5th intercostal space – lower left sternal edge:

At lower sternal edge (tricuspid area) and pulmonary area (left of manubrium in the 2nd
intercostal space), if you suspect a right-sided murmur, listen with patient’s breath held in
inspiration.
170
C. Pulmonary valve – 2nd intercostal space – left sternal edge
D. Aortic valve – 2nd intercostal space – right sternal edge
At the right of manubrium in 2nd intercostal space (aortic area), you may hear an ejection
systolic murmur radiating to the carotids which is suggestive of aortic Stenosis.
Further check for Aortic Regurgitation:
Ask the patient to sit up and slightly bend forward. Listen at the lower left sternal edge with
patient held in expiration. An early diastolic murmur suggests aortic regurgitation.
Note: In the exam due to time limit we do not perform the further check for aortic
regurgitation.
Aortic incompetence can be assessed by asking the patient to sit forward, repeat the
171
“breathe in, out and hold” exercise and listen over the aortic area with the diaphragm.
- Comment on your finding:
“On auscultation, first and second heart sounds were present. No extra heart sounds could
be heard.”
E. Carotid Bruit:
Also auscultate for bruits over carotids, particularly if there is inequality between pulses or
absence of a pulse.
- Causes: Atherosclerosis (elderly), vasculitis (young)
Technique:
1. Ask the patient to hold his breath.
2. Auscultate over the carotid arteries (with breath held) for carotid bruit.
- Comment on your finding: “There is no carotid bruit.”
Note: In the exam, due to time restrictions you may skip this step.
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VI. Auscultation Lung Bases (Basal Crepitations/Crackles):
Auscultate lung bases – Crackles may suggest pulmonary oedema / left ventricular failure.
Ask patient to sit over bedside with crossed arms.
Inform the patient that you are going to listen to his chest from the back and obtain
permission.
Auscultate lower back for basal crepitation.
- Comment on your finding: “On auscultation, I could hear normal vesicular sounds which
are symmetrical on left and right sides. There is no basal crepitation or crackles and no
wheeze.”
VII. Sacral Oedema:

Finally you should assess for Sacral Oedema. Whilst the patient is sat forward, feel the
sacrum for oedema (may indicate right ventricular failure).
Use your thumb or the ulnar border of your hand to look for depression.
- Inform the patient:
173
“I am going to touch your lower back. Is that alright with you?”
- Comment on your finding: “There is no sacral oedema.”
VIII. Pedal Oedema: Pedal oedema may indicate right ventricular failure. When the heart
weakens and pumps blood less effectively, fluid can slowly build up, creating leg oedema.
Note: In the exam due to time limit, you may prefer to examine pedal oedema whilst
standing at the foot of the bed as it is a good early clue that there may be further pathology
to be found.
IX. To complete the examination:

A. Abdomen:
Examine the abdomen for:
- Hepatomegaly and ascites in right-sided heart failure
- Pulsatile hepatomegaly with tricuspid regurgitation
- Splenomegaly with infective endocarditis
- Aortic aneurysm
B. Further Steps:
- Check peripheral pulses / Full peripheral vascular examination
- Observation chart for temperature and O2 saturations
- Dip urine: haematuria / proteinuria - Hypertension
- Perform fundoscopy: Roth spots – infective endocarditis / Malignant hypertension –
papilledema)
- If any abnormality indicated, arrange an ECG and an echocardiogram.
- Bedside capillary blood glucose – Diabetes
Thank the patient and ask him to dress up.

Thank the examiner.
174
18. Respiratory Examination
Task:
“Mrs Gordon is a 57-year old lady presenting to your clinic. Please examine her respiratory
system and present your findings.”
Introduction:
This is essentially an examination of the patient’s lungs; however it is a complex
examination which also includes examination of other parts of the body including the hands,
face and neck.
The respiratory examination aims to pick up on any respiratory (breathing) pathology that
may be causing a patient’s symptoms e.g. shortness of breath, cough, wheeze etc. Common
conditions include chest infections, asthma and chronic obstructive pulmonary disease
(COPD).
percuss and auscultate (look, feel, tap, listen).

Subject Steps:
3. Clarify identity

“I am here to examine your lungs. I will be as gentle as possible but if at any point you feel
procedure.”
5. Exposure:
“For the purpose of this examination you need to be exposed above waist.”
examination.”
175
8. Position:
In lying position with the couch at 45 degrees. If the couch is not at 45 degrees, please
inform the examiner: “I would like the couch to be at 45 degrees.”
I. General Examination
A. General Inspection:
Make a general observation of the patient.
Check whether they are comfortable at rest, if they look tachypnoeic or if they are using
accessory muscles (respiratory distress / shortness of breath).
You should also note whether there is any cough, wheeze or stridor.
1. Hands:
forth multiple times).
Hands out with palms facing upwards:
- Temperature: Coldness may indicate peripheral vasoconstriction/poor perfusion
- Palmar erythema / pallor: Hot, pink peripheries may be a sign of carbon dioxide retention.
- Palmar sweating
Hands out with palms facing downwards:
- Clubbing: Finger clubbing has a number of causes including lung cancer, interstitial lung
disease, complicated tuberculosis, bronchiectasis, cystic fibrosis and lung abscess etc.
Technique:
Ask patient to place the nails of their index fingers back to back.
In a healthy individual you should be able to observe a small diamond shaped window
(Schamroth’s window). When finger clubbing is present, this window is lost.
176
Note: In the exam, due to time limit, you may only inspect the fingers with the palms facing
downwards to look for clubbing. Both techniques are accepted.
- Tobacco-stained fingers / Tar staining: History of smoking – increased risk of COPD/lung
cancer
- Fine tremor:
Technique:
1. Ask the patient to stretch out hands and fingers with palms facing downwards
2. The hands will be trembling involuntarily if positive.
3. There may be a fine tremor caused by excessive use of beta-agonists (e.g. salbutamol) or
theophylline bronchodilators
- Comment on your finding: “There is no fine tremor.”
- Flapping tremor (Asterixis)/CO2 retention flap:
Technique:
1. Ask patient to stretch out arms, with hands dorsiflexed and fingers stretched out
2. Ask to hold their hands in that position for 30 seconds.
Note: Ideally flapping tremor should be assessed for thirty seconds. However in the exam
due to time restrictions you may assess it for a few seconds.
3. The hands will flap (flex/extend at the wrist) in an irregular fashion if positive.
4. A coarse flap may be a sign of carbon dioxide retention.
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- Comment on your finding: “My patient has no flapping tremor.”
In chronic CO2 retainers, these patients will have warm peripheries and large volume pulses
due to the actions of CO2 as a vasodilator.
A bounding pulse may indicate carbon dioxide retention.
After you have taken the pulse it is advisable to keep your hands in the same position and
subtly count the patient’s respiration rate. This helps to keep it as natural as possible.
- Blood pressure
Note: When there is no clock to check pulse rate or you are not provided with a blood
pressure machine to check BP, you may simply say:
- To the examiner: “I can feel the pulse. The rhythm is regular and the volume is adequate.
Ideally I would check the pulse for 1minute. Ideally I would also check my patient’s blood
pressure and respiratory rate.”
178
- Pulsus paradoxus: Pulse wave volume decreases with inspiration – asthma, COPD and
pericarditis.
- Signs of systemic disease (systemic sclerosis, rheumatoid arthritis)
- Wasting of intrinsic muscles (T1 lesions, e.g. Pancoast’s tumour)
- Tender wrists (hypertrophic pulmonary osteoarthropathy – cancer)
2. Face:
Move up to the face!
Eyes:
- Conjunctival pallor:
Or
look up for me?”
- Conjunctival icterus:
Or
- Horner’s syndrome: Horner’s syndrome results from an interruption of the sympathetic
nerve supply to the eye, commonly due to a lung cancer at apex of the lung invading the
sympathetic chain. It is characterised by the classic triad of:
i. Miosis (i.e. constricted pupil)
ii. Partial Ptosis
iii. Loss of hemi-facial sweating (i.e. anhidrosis) chain in the neck or brainstem
179
Nose:
- Nasal flaring: Nasal flaring is when the nostrils widen while a person is breathing. It is a
sign that the person is having difficulty breathing. It is most commonly seen in children and
infants; in those cases nasal flaring can indicate respiratory distress.
Mouth:
- Central cyanosis:
Bluish discoloration of the lips and mucous membranes (inferior aspect of tongue).
Ask the patient to stick out their tongue and note its colour checking for anaemia or central
cyanosis. Remember to ask them to raise their tongue up and check underneath:
- To the patient: “Could you please open your mouth and roll your tongue back?”
- Oral Thrush: Check mouth for oral thrush (e.g. secondary to steroids)
- Pursed lip breathing: Pursed lip breathing (PLB) consists of exhaling through tightly
pressed (pursed lips) and inhaling through nose with mouth closed.
3. Neck:
- Jugular Venous Pressure (JVP) / Engorged Neck Veins:
Look for pulsation behind the sternocleidomastoid.
The internal jugular vein acts as a capricious manometer of right atrial pressure.
JVP is raised in cor pulmonale, pulmonary hypertension, fluid overload and is fixed and
raised in superior vena cava obstruction.
Technique:
1. Positioning is very important, ensure the patient is positioned at 45 degrees.
2. Ask the patient to relax and to turn his head slightly away from you (to the left):
“Could you please turn your head to the left?”
3. Observe the neck for JVP; look for pulsation behind the sternocleidomastoid (located in
180
line with the sternocleidomastoid).
- Comment on your finding: “JVP in my patient has not raised.”
- Tracheal Position:
Assess if the trachea is central or is deviated from the midline.
gentle technique.
- Inform the patient: “I am going to gently press over your neck, this may feel a bit
Technique:
two clavicles.
3. Check that your fingertip fits easily into both sides. If it is deviated, it may suggest a
tumour or pneumothorax.
- Comment on your Finding: “Trachea is placed centrally / there is no tracheal shift.”
Tracheal tug: Tracheal tug is an abnormal downward movement of the trachea with
inspiration (severe airflow limitation).
With trachea moving inferiorly, the crico-sternal distance on inspiration will reduce.
The cricosternal distance is the distance between the inferior border of the cricoid cartilage
and the sternum.
181
A reduction in the crico-sternal distance and tracheal tug signify marked chest hyper-
expansion, usually COPD.
Technique:
1. To measure the crico-sternal distance, put the index finger of your right hand on the
patient’s trachea against the inferior edge of the cricoid cartilage.
2. Place subsequent fingers, in the vertical plane, below this into the sternal notch until the
trachea is no longer palpable and the sternum is reached.
3. This is the crico-sternal distance and is normally three finger widths (5cm) or more.
Note: In the exam due to time restrictions we are not going to assess tracheal tug.
- Left Supraclavicular lymph node:

From behind with patient sat forward palpate lymph nodes of head and neck.
Also palpate for the left supraclavicular lymph node (Virchow’s Node). This drains the
thoracic duct so an enlarged node (Troisier’s sign) may suggest metastatic cancer e.g. lung
or abdominal.
Note: In the exam, due to time restrictions we are not going to check the lymph nodes.
- To the examiner: “Ideally I will examine the left supraclavicular lymph node.”
182
II. Chest Inspection:
The examination now moves onto the chest. Take time to observe the chest looking for any
abnormalities. Remember these may be in the axillae or on the back:
- Chest wall movements (Symmetrical/asymmetrical):

- Ask patient to take deep breaths in and out: “Chest wall movements are bilaterally
symmetrical.”
- Scars: Scars from previous thoracic surgeries
- Skin changes: May indicate recent or previous radiotherapy – redness /marks or
spots/erythema/swelling/thickened skin
- Deformities: Barrel chest (COPD)/ flail chest/ pectus excavatum and carinatum
- Dilated superficial veins / visible pulsations: Engorged veins/visible impulse
- Lesions in the chest wall: Possible metastatic tumour nodules and neurofibromas)
III. Palpation:
Ask if there is any pain. Ensure that your hands are warm and make sure you warn your
patient before touching him.
A. Apex beat (lowermost lateral pulsation):

Palpation of the chest starts by trying to locate the apex beat. Start by doing this with your
entire hand and gradually become more specific until it is felt under one finger and describe
its location anatomically.
Once located, count out the ribs to make it clear to the examiner you have located it.
An impalpable apex beat suggests COPD, pleural effusion or dextrocardia.
Technique:
1. lay your whole dominant hand flat over the precordium to obtain a general impression of
the cardiac impulse.
183
2. Try to locate the apex beat by laying your fingers on the chest parallel to the ribs bases.
3. Describe the position, where the pulse can be felt, by counting intercostal spaces.
Start from the angle of Louise (2nd intercostal space).
This is normally in the 5th intercostal space in the midclavicular line.
Angle of Louis and 2nd intercostal space
184
4. You should also note the character of the apex beat.
- Character:
1) Impalpable: Dextrocardia / COPD
2) Heaving: Caused by outflow obstruction, e.g. aortic stenosis or systemic hypertension
3) Thrusting: Caused by volume overload, e.g. mitral or aortic incompetence
4) Tapping: Mitral stenosis, essentially a palpable 1st heart sound
5) Diffuse: LV failure, dilated cardiomyopathy
6) Double impulse
7) Sustained/strong
- To the examiner: “Ideally I will check my patient’s apex beat..”

B. Chest Expansion:
- Feel for chest expansion. Usual chest expansion in an adult is 4-5 centimetres and should
be symmetrical.
- If one of your thumbs moves less, this suggests reduced expansion on that side.
- Reduced expansion can be caused by pulmonary consolidation, lung collapse,
pneumothorax, etc.
Technique:
1. Place your hands firmly on the chest wall inferior to the nipples.
2. Warp your fingers around either side of the chest and bring your thumbs together in the
middle, so that they touch (anchor with the fingers and leave the thumbs free-floating).
3. Ask the patient to take a deep breath in and out.
185
4. Observe movement of your thumbs and note the distance your thumbs move apart, they
should move apart equally.
Normally this should be at least 5 centimetres.
- Comment on your finding: “Chest expansion is equal on both sides.”
C. Tactile vocal fremitus:

Place the medial edge of your hand on the chest and ask the patient to say “99”.
Do this with your hand in the upper, middle and lower areas of both lungs and ask the
patient to say “99” each time they feel your hand.
Tactile vocal fremitus is increased over areas on consolidation and decreased or absent over
areas of effusion or collapse.
Note: In the exam due to time restrictions, we are not going to perform tactile vocal
fremitus.
186
IV. Percussion:
Perform percussion on both sides, comparing similar areas on both sides and feel for any
dullness, resonance on percussion.
Percuss the following areas, comparing right and left:

Supraclavicular – lung apices
Clavicle: Tap on the clavicle directly which gives an indication of the resonance in the apex.
Chest wall – Percuss normally for the entire lung fields. 3 points on the anterior chest wall
(both sides) and one point on lateral chest wall (both sides).
- Inform the patient: “I am going to gently tap over your chest, is that okay with you?”
Technique:
1. Place your non-dominant hand on the chest wall.
2. Your middle finger should overlie the area you want to percuss.
3. With your dominant hand’s middle finger, strike middle phalanx of non-dominant hand’s
middle finger.
4. The striking finger should be removed quickly, otherwise you may muffle resulting
percussion note.
5. All movements should come from your wrist joint, and your middle finger should remain
partially flexed.
- Comment on your finding: “There is no hyper-resonance or dullness on percussion.

Percussion note is resonant.”
Types of percussion note:

a. Resonant – This is a normal finding
b. Dullness – This suggests increased tissue density – consolidation such as in infection, fluid,
tumour, collapse, fibrosis, pleural thickening.
i. Stony dullness suggests the presence of a pleural effusion.
ii. Cardiac dullness usually detectable over the left side.
iii. Liver dullness usually extends up to 5th rib, right mid-clavicular line; below this, resonant
chest is a sign of lung hyper-expansion (e.g. asthma, COPD).
c. Hyper-resonance – The opposite of dullness, suggestive of decreased tissue density – e.g.
pneumothorax, hyperinflation (COPD).
187
V. Auscultation:
- Ask patient to take steady breaths in and out through mouth and listen with diaphragm,
from apices to bases, comparing right and left:
“I am going to listen to your chest. Can you please take deep breaths in and out for me?”
- Auscultate the anterior chest wall, alternating between each side of the chest wall (to
compare). Do not forget the lateral chest wall.
Note: In the exam auscultate 3 points on each side of the anterior chest wall, compare both
sides and one point on lateral chest wall (both sides).
- In each area assess the quality and amplitude of breath sounds whilst noting any added
sounds.
- Listen for any absent, abnormal and reduced breathe sounds, or any added sounds such as
crackles, wheeze, pleural rub or bronchi.
- Comment on your findings: “Respiratory sounds are audible. I can hear normal vesicular
breath sounds. There are no added sounds.
Assess quality:
- Normal (vesicular): breath sounds have a rustling quality.
- Bronchial breathing: Harsh with a gap between inspiration and expiration, occurs where
lung tissue has become firm/solid, e.g. consolidation, localized fibrosis, above a pleural
effusion or large pericardial effusion (Ewart’s sign). May be associated with increased vocal
resonance and whispering pectoriloquy.
Assess volume:
- Diminished breath sounds: Pleural effusion, pleural thickening, pneumothorax, bronchial
obstruction, asthma or COPD.
- Silent chest: In life-threatening asthma severe bronchospasm prevents adequate air entry.
188
Added sounds:
- Wheezes (rhonchi): Caused by air expired through narrowed airways – Asthma, tumour,
OPD.
- Crackles (crepitations): Caused by re-opening, during inspiration, of small airways which
have become occluded during expiration.
May be fine and late in inspiration if coming from distal air spaces (e.g. pulmonary oedema,
fibrosing alveolitis) or coarse and mid-inspiratory if they originate more proximally (e.g.
bronchiectasis).
- Pleural rubs: Caused by movement of visceral pleura over parietal pleura, when both
surfaces roughened, e.g. by inflammatory exudate. Causes include adjacent pneumonia or
pulmonary infarction.
- Pneumothorax click: Produced by shallow left pneumothorax between layers of parietal
pleura overlying heart, heard during cardiac systole.
VI. Vocal resonance:

Ask patient to say “99” repeatedly and auscultate the chest again, on various points in front
and back.
If a marked increase in resonance is heard, repeat with asking patient to whisper “99”; if
clearly heard this is termed ‘whispering pectoriloquy’ and is a sensitive sign for
consolidation.
Increased volume over an area suggests increased tissue density – consolidation / fluid /
tumour.
189
VII. Assess the posterior aspect of the chest:
Repeat inspection, percussion and auscultation on the back of the chest.
VIII. Lymphadenopathy:
Ask patient to sit forwards and palpate the anterior and posterior triangles, supraclavicular
and axillary nodes.
Lymphadenopathy may indicate infective/malignant pathology – TB / lung cancer.
IX. To complete the examination:
- Palpate for sacral and ankle oedema

- Check peripheral pulses, observation chart for temperature and O2 saturations.
- Examine the sputum pot and check PEFR
- Provide supplementary oxygen if indicated
- Request a CXR if abnormalities were noted on examination
- Perform peak flow assessment (if asthmatic)
- Take an arterial blood gas if indicated
- Perform a full cardiovascular examination if indicated
Thank the patient and ask him to dress up.

Thank the examiner.
190

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COMMON STATION

SPECIALIST IN PLAB 2 PREPARATION

Dr Elmira Yaghmaei Dr Hamed Salehi

B.1. General Inspection:

- Palmar erythema: Reddening of palms – thenar / hypothenar eminences / liver disease /

- Sunken eyes (dehydration)

“Please put your hands by your side and breathe normally.”

- Comment on your finding: “There is no rise in temperature.”

D.3.1. Detect masses:

- Comment on your finding: “I cannot feel the edge of the liver.”

Inform the patient:

E.1. Liver percussion:

E.2. Spleen percussion:

- Comment on your finding: “There is no splenomegaly.”

- Comment on your finding: “The bladder is not enlarged.”

E.4.1. Shifting dullness:

E.4.2. Fluid Thrill:

F.1. Bowel sounds:

Inform the patient:

F.2. Bruits (Use bell):

G. To Complete the Examination:

G.1. Ankle oedema

Begin this station by greeting and introducing yourself to the patient.

A.6. Ensure Privacy and Chaperone:

- Eye level / Symmetry

- Comment on your finding: “There is no mass or swelling visible (moving) on deglutition.”

C.1.3. Tongue protrusion Test:

- Comment on your findings: “There is no mass or swelling visible on tongue protrusion.”

C.2.2. Swallow Test:

C.2.3. Tongue protrusion Test:

- Comment on your findings: “There is no rise in temperature.”

- Comment on your findings: “No retrosternal dullness is indicated.”

F.3. Proximal myopathy:

Thank the patient.

“I assume that I have taken all the universal precautions.”

B. Greet/introduce yourself to the patient:

C. Assess Level of Consciousness (GCS):

- Explain what you are going to do to the patient:

4 Spontaneous eye opening

- Position: Supine position

- Check upper, lower and pupillary reflexes.

- Introduce medical hammer:

Upper Limb Reflexes:

Lower Limb Reflexes:

a. The Knee (Patellar) Reflex (L3, 4):

b. The ankle Jerk (L5, S1):

c. The Plantar Reflex (L5, S1, S2):

“Ideally I will do plantar reflex with the help of an orange stick.”

E. Head to Toe Examination:

“Ideally I will finish my examination by performing a complete head to toe examination to

- Thank the patient.

B. Greet/introduce yourself to the patient

- Verbalize what you are going to do to the examiner:

- Verbalize what you are going to do to the examiner:

“Let me help you remove your hand.”

- Explain purpose of visit to the patient:

6 Obeying commands: Patient will do what you asked

E.1. Neck Stiffness:

- To assess neck rigidity, ask: