Clinical Skill Session

Dr. Myo Hla Myint

 (I) CVS
• General – Face, Oedema etc.
• PR
• BP
• JVP
• Precordium and heart sounds
 PR
Use the larger (brachial, carotid or femoral)
pulses to assess the pulse volume and character
and in hypotensive states according to:
• rate
• rhythm
• volume
• character.
The radial, brachial and carotid pulses.
(A) Locating and palpating the radial pulse.
(B) Feeling for a collapsing radial pulse.
(C) Assessing the brachial pulse with your thumb.
(D) Locating the carotid pulse with your thumb.
(E) Examining the femoral artery, while simultaneously checking for radiofemoral delay.
 Blood pressure

• Korotkoff sounds
• As the pressure is reduced, the sounds muffle
(phase 4) and then disappear (phase 5). Inter-
observer agreement is better for phase 5 and
this is recorded as diastolic BP. Occasionally
muffled sounds persist (phase 4) and do not
disappear; in this case, record phase 4 as the
diastolic pressure
JVP
Figure 6.21 Jugular venous pressure in a healthy subject.
(A) Supine: jugular vein distended, pulsation not visible.
(B) Reclining at 45°: point of transition between distended and collapsed vein can usually be
seen to pulsate just above the clavicle.
(C) Upright: upper part of vein collapsed and transition point obscured
Figure 6.22 Jugular venous pressure.
(A) Inspecting the jugular venous pressure from the side (the internal jugular vein lies deep to the
sternocleidomastoid muscle).
(B) Measuring the height of the JVP.
(C) Form of the venous pulse wave tracing from the internal jugular vein: a = atrial systole; c = closure of the
tricuspid valve; v = peak pressure in right atrium immediately prior to opening of tricuspid valve; a-x = descent,
due to downward displacement of the tricuspid ring during systole; v-y = descent at commencement of
ventricular filling
Figure 6.34 Palpating the heart. (A) Use your hand to palpate the cardiac impulse. (B) Localize the apex beat
with your finger (roll the patient, if necessary, into the left lateral position). (C) Palpate from apex to sternum for
parasternal pulsations
Site for Auscultation
Figure 6.35 Auscultating the heart.
(A) Listen for the murmur of mitral stenosis with the lightly applied bell with the patient in the left lateral position.
(B) Listen for the murmur of aortic regurgitation with the diaphragm with the patient leaning forward.
(II) Respiratory Examination
Tracheal Shift
 Chest Expension

Assessing chest expansion from the front.

(A) Expiration. (B) Inspiration
Sites for percussion.
(A) Anterior and lateral chest wall.
(B) Posterior chest wall.
Auscultation
Diagrammatic representation of breath sounds.
(A) Vesicular.
(B) Bronchial.
Note the gap between inspiration and expiration and change in pitch and the blowing,
tubular quality of bronchial breath sounds
Vocal resonance
 (III) Abdominal examination
• Patient preparation!
• Inspection
• Palpation
• Percussion
• Auscultation
 Abdominal Examination
• Inspection – Scars, visible swelling
• Palpation – Light palpation,
Deep palpation
Mass: site, size, shape, surface, margin,
consistency, mobility, tenderness
Liver, Spleen, Kidneys
• Percussion – Ascites (free fluid)
• Auscultation – Bowel sounds – normal, increased,
decreased
- Bruit
 Regions of the abdomen

RH, right hypochondrium; RF, right flank or lumbar region; RIF, right iliac fossa;
E, epigastrium; UR, umbilical region; H, hypogastrium or suprapubic region;
LH, left hypochondrium; LF, left flank or lumbar region; LIF, left iliac fossa
 (IV) Pelvic examination

• Explain details of the procedure and gain verbal

consent
• Ask the patient to empty her bladder & remove any
sanitary protection.
• Allocate a separate private area for the patient to
undress.
• Chaperone should always be present.
 Pelvic Examination procedure

• Inspection of external genitalia, ask patient to

strain and/or cough
• Speculum examination
• Bimanual examination
 Inspection

• Hair distribution
• Vulval skin
• Labia majora and minora
• Look for discharge, prolapse, ulcers,
warts
• On seperating the labia minora
-inspect urethral orifice
-clitoris normal or enlarged
-on straining – demonstrable stress
incontinence, cystocele, cervical
descent, rectocele
• Look at the perineum for scars/tears
Speculum
 Speculum examination
Inspect for:
• Cervical os – nullip/multip
• Cervix & Vaginal walls –
healty or not
• Discharge
• Warts
• Tumours
• Bleeding
Anatomy for bimanual examination
 Bimanual Examination

Cervix:
• Direction – downwards and
forwards/backwards
• Size
• Consistency
• Mobility
• Tenderness
• Os –open or not
 Bimanual Examination

Uterus
• Direction – AV/RV
• Size
• Consistency
• Mobility
• Tenderness
Adnexae
• Mass present or not – if + describe
Bimanual Examination
Bimanual Examination
(V) VAGINAL EXAMINATION IN OBSTETRICS
A score of 6 or more predicts the likelihood of successful induction of labour.
A score of 5 or less is regarded as being unfavourablefor induction of labour, and use of
artificial rupture of the amniotic sac and/or oxytocin infusion are unlikely to be successful.
 Vaginal Examination In labour
• Cervical dilatation
• Effacement/cervical length
• Membranes +/-
• Liquor – colour, odour, amount
• Presentation
• Position
• Station
• Cord
• Cephalic – moulding, caput succedaneum
Effacement and dilatation of the cervix
Presentation
Position
The Stewart method for
estimation of the degree of
molding of the fetal head.
Caput Succedaneum