Physical Examdocx

Acute Abdomen examination
Wednesday, 3 May 2017

9:20 AM
APPROACH
▪ Vitals signs - may I know the patient's BP with postural drop? RR with saturation? HR with rhythm?
Temperature?
o If BP low - secure IV line for fluids, draw blood for investigations
o If saturation low - start on O2
▪ Pain questions
o Are you in any pain? Can you point to the site of pain? How severe is it, can you rate it from 1-
10? Don’t worry I will give you painkillers. Do you have any allergies?
▪ I understand that you are in severe pain, what I'm going to do now is to examine you to find out the
reason why you are having this pain. This examination involves me having a look, feel of your
tummy, along with listening to your tummy sounds. I will be touching the painful site towards the
end and I will try to be very gentle, please bear with me. Is that alright with you?
▪ For the purpose of examination, I would like you to please undress yourself from above the waist.
▪ Inspection
o Stand at the foot end of the bed
• On inspection of the foot end of the bed, John seems to be lying comfortably or appears to
be in pain and distress
• There is no unusual effort of breathing, and no noisy breathing
• I cannot appreciate any pallor or color changes
• I can see an IV line attached to the patient, but other than that, I cannot see any adjuncts
around the bed
o Stand at the right side of the bed
• First and foremost is RULE OUT PERITONITIS
▪ The abdomen tends to be moving with respiration (if not moving, sign of
peritonitis)
▪ There is no abdominal distention
▪ There is no discoloration (pancreatitis produces different color signs in the
abdomen)
• There are no surgical scar marks, stomas, or striae
• I'm going to ask you to please cough for me, let me know if that hurts you, and please
point to where it hurts you. (look for signs of generalized and localized peritonitis)
▪ RUQ - gallbladder
▪ LUQ - spleen
▪ RLQ - appendix
▪ LLQ - diverticulitis, small/large bowel obstruction
▪ Now I want to have a look at your hands. Check peripheral circulation - to check if patient is having
internal bleeding or not
o Capillary refill time - check if there is delayed CRT
o Temperature - check if cold/clammy
o Pallor - turn over hands and compare with your own palm
o Pulses - check if present and regular
▪ Face
o Check for conjunctival pallor (anemia)
• I will pull your lid down, please look up
o Check for scleral icterus (jaundice)
• I will pull your lid up, please look down
o Check for mucosal dryness
• Can you please open your mouth and stick your tongue out?
▪ Now I'm going to have a feel of your tummy.
o Palpate superficially, last on the painful site. Before you touch the painful site, say: I
understand you are having severe pain there, I'm just going to touch it very superficially and
gently. Feel for any guarding or rigidity.
o Now I'm going to feel your tummy a bit deeper. DO NOT PALPATE DEEPER IN THE
PAINFUL SITE.
o Check for rebound tenderness. (to elicit localized peritonitis)
https://doc-0s-8c-docs.googleusercontent.com/docs/secures…947883231/*/0B6fqgpF9YByvSE8wY0NvWlF5YlU?e=download 15/1/18, 4Q54 pm

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• I'm going to press deeply on your tummy slightly away from the painful site and then I
will release it quickly, let me know if the quick release cause you any pain.
• Did that quick release after I touched you cause you pain or not?
• Rebound tenderness is done AWAY from the area of pain
o Ideally, I would like to check for organomegaly, but my patient is in pain, I'm just wondering if
I can skip that.
• If you are told to go ahead, feel for liver, feel for spleen, then feel for kidneys
o I'm going to tap on your tummy, please let me know if that's painful for you.
o Auscultate for bowel sounds and aortic bruits
▪ If patient has generalized peritonitis
o Do you feel similar pain all over your tummy? Doctor, I am not going to proceed with my
superficial, deep palpation and checking for organomegaly because my patient is in severe
pain all over.
o I am just going to have a listen of your tummy.
▪ I would like to finish off by doing the examination of the external genitalia checking for hernial
orifices, and digital rectal examination. If it is a female patient, finish off with a pelvic examination
then digital rectal examination.
----------
Case 1: Your next patient is Jenny, 28 years old, who presents to you with sudden onset of severe tummy
pain in her upper abdomen.
TASKS
1. Examiner the patient
2. Tell her the most likely diagnosis with differential diagnoses
Our upper tummy has different structures. This is your food pipe, stomach, organ behind named pancreas,
right upper part liver, gallbladder, and left is spleen. If you are having upper tummy pain, it can be related
to any of this. But in your case, I think that most likely your symptoms is related to a condition called
acute cholecystitis.
-----------
RUQ pain cases in AMC exam:
▪ Cholecystitis - RUQ tenderness, fever, Murphy's sign positive
▪ Cholangitis - RUQ tenderness, fever, Murphy's sign positive, jaundice
Murphy sign: I'm going to keep my hand under your ribs, I will ask you to take a deep breath
in for me, let me know if that hurts you. If gallbladder is inflamed, there will be pain upon
taking the deep breath.
RIF pain
▪ Appendicitis - RIF tenderness, rebound tenderness, Mcburney's point of tenderness, Rovsing's sign
McBurney's - I am drawing an imaginary line from the anterior superior iliac spine to the
umbilicus, and checking for tenderness 2/3 of the way from the umbilicus to the ASIS which
is the McBurney's point.

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LIF pain
▪ LIF tenderness, rebound tenderness, fever, dryness of oral mucosa
-----------
Case 2:
Your next patient is Sara, 25 years old with sudden onset of severe tummy pain. She has been
complaining of some pain in her right iliac fossa for the past 1 week. But today it is very worse. Her urine
pregnancy test is vaguely positive and she has 8 weeks amenorrhea.
TASKS
1. Examine the patient
2. Tell the most likely diagnosis
Differential Diagnoses
▪ Appendicitis
▪ Ectopic pregnancy
▪ Ovarian cyst rupture
▪ PID
▪ Endometriosis
Acute Vertigo (PICA) Lateral Medullary Syndrome

(Wallenberg Syndrome)
Sunday, May 28, 2017
3:02 AM
You are working in a primary care facility attached to a teaching hospital and a 50 year old man is
consulting you about intense dizziness. He is a previous patient who is overweigh, and he is on
medication for control of hypertension and hyperlipidemia. He appears unwell and distressed with slight
drooping of left eyelid. His wife drove him to the hospital.
TASKS
1. PE
2. Diagnosis and management with examiner
APPROACH
▪ Physical Exam
o Is the patient hemodynamically stable? Can I please know the patient's vitals?
o General appearance: lying on the couch, very tightly holding on the bed
o Neurological exam
• Cranial nerves

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▪ CN II
• Visual acuity
• Visual fields (nystagmus on looking to the left)
• Color
• Light reflex
• Afferent CN II
• Efferent CN III
• Accommodation reflex
• Fundoscopy
▪ CN III (Horner's syndrome is present - ptosis, miosis, anhidrosis)
▪ CN V
• Sensory
• Ophthalmic (pain sensations are lost over the left side of the face)
• Maxillary
• Mandibular
• Corneal reflex (absent)
• Afferent CN V
• Efferent CN VII
• Motor
▪ CN VII (all normal)
▪ CN VIII (hearing normal, but vestibular component gone)
▪ The rest of the cranial nerves are normal
o IPTRCS of the upper and lower limb
• On inspection, I cannot see any fasciculation
• Power and tone are normal
• Reflexes are normal
• Coordination also normal
• But pain and temperature sense is lost over the right part of the body
o ENT exam (normal)
o Cardiovascular exam (normal)
▪ Diagnosis and Management

Mary, I am concerned because after my examination, I have found some of the features that are
pointing towards stroke.
What happens in this is the blood supply to the brain decreases or is affected. That is why you are
having vertigo.
We will admit you, we will take a photo of your brain or what we call CT scan, to find out why the
blood supply to your brain is affected. Also I will refer you to the specialist who will assess you
further. If you want, I can also call your family. Do not worry, we are all here to help you.
Ankle/Foot Exam
Thursday, 18 May 2017
3:18 PM
Acute pain
Ankle sprain
Chronic pain
Plantar fasciitis
Plantar fasciitis + Achilles tendon rupture
Mononeuroma
Your next patient is a 17 year old boy who landed on his inverted foot while playing basketball.
TASKS
1. Examine his foot
2. Discuss further management
▪ Our first aim is to rule out syndesmosis instability/fracture or a high ankle sprain. Because if this is
present, the patient needs referral for surgery.

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▪ Next aim is to rule out Achilles tendon rupture.
▪ Third aim is to find out the extent of ankle sprain.

o Three ligaments:
• Posterior talofibular
• Anterior talofibular
• Calcaneofibular
8
Physical Exam
▪ Inspection
o Compare both feet
o Look for any redness, warmth, obvious swelling, obvious deformity
▪ Palpation
o Palpate the normal foot first
o Start 6 cm above the medial malleolus, then palpate the joint line, then lateral malleolus up to 6
cm above the lateral malleolus
o Palpate the base of the 5th metatarsal because it is the most fractured bone in merging injuries
o Palpate for tenderness on the three ligaments
▪ Movement
o Can you please try to move your ankle?
▪ Special tests

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o Find out which tendons are injured
• Anterior drawer test
▪ Tests for the integrity of the anterior talofibular ligament
▪ Positive sign: more than 5mm displacement
• Lateral Talar tilt test

▪ Tests for integrity of anterior talofibular, posterior talofibular, calcaneofibular
▪ Plantar flex and invert: stress the ATF
▪ Neutral and invert: stress the CCF
▪ Dorsiflex and invert: stress the PTF
o Rule out high ankle strain

• Squeeze test
▪ the higher the patient feels pain, the more severe the injury

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o Rule out Achilles tendon rupture
• Thomson's/ Simmond's test
▪ Grasp the calf and squeeze, the foot should plantar flex in normal foot
Management
▪ Low ankle sprain without tendon rupture:
o PRICE: protect, rest, ice, compression, elevation
o Analgesia
o Can wear Camboots (controlled ankle movement boots) - can be an alternate to rest
o Can heal in 2-3 weeks
***massage is contraindicated in first 48 hours because it produces heat, will cause vasodilatation,
increase swelling
▪ Low ankle sprain with tendon rupture
o Refer for surgery
▪ High ankle sprain
o Refer for surgery
Chronic foot pain

4:06 PM
43 year old male comes with complaint of persistent annoying pain in his feet.

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▪ Rheumatoid Arthritis
o Deformities - bunions
o Crowding of toes
o Achilles tendon nodules/rheumatoid nodules
o Nail changes (psoriatic arthritis)
▪ Osteoarthritis (high BMI + foot pain)
o Nodules
▪ Plantar fasciitis
o Early morning pain
o Localized tenderness over the plantar fascia insertion
o Windlass test
▪ Morton's neuroma/Morton's metatarsalgia

o Mulder's click
• Pain in between the 3rd and 4th metatarsal

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Physical Exam
▪ Inspection
o Gait: is the patient demonstrating a normal heel strike/toe off gait?
o Front:
• Symmetry, bunions, scars, swelling, erythema
o Side:
• Foot arches
o Back:
• Foot/ankle symmetry
• Achilles tendon
▪ Palpate
o Temperature, compare between legs
o Pulses
o Achilles tendon
o Work distal to proximal. Start from normal leg.
o Squeeze the metatarsophalangeal joints by compressing the 1st and 5th metatarsals between
your thumb and forefinger. Tenderness suggests inflammation common in early rheumatoid
arthritis
o Feel for Morton's neuroma.
• Mulder's click: simultaneous compression of the transverse arch (hold transverse arch and
squeeze) with palpation of inter-metatarsal space - a painful click is positive Mulder's
click which is diagnostic of interdigital neuroma
o Feel for Plantar fasciitis

• Windlass test: reproduce the pain symptoms upon pushing on the foot while the great toe
is dorsiflexed

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o Do straight leg test to rule out any referred pain
Assessment of a Comatose patient

Monday, 15 May 2017
2:53 PM
A young patient is brought to ED with unconsciousness. His airway is patent and breathing without
difficulty. His blood pressure is table and temperature is 37.5.
TASKS
1. Do one test to check his level of consciousness
2. Examination to see potential cause of unconsciousness
3. Differential diagnosis
4. Investigation you would like to arrange
▪ I want to proceed with the DRSABCDE protocol.

▪ Danger: to make sure that the patient is safe to approach. I will wear glove, goggles, and gowns.
o Pre-eclampsia epilepsy patient, lie down the patient in left lateral position
o Anaphylaxis - bee sting - remove the bee sting with a forceps
▪ Response
▪ Send for help
▪ Airway
▪ Breathing
▪ Circulation
Differential Diagnosis of Coma:

▪ C - CO2 narcosis, respiratory failure, Cnake bite (look for fang marks)
▪ Overdose of drugs (benzodiazepines, opiods, sedatives), alcohol, opioids, tranquilizers,
antidepressants, analgesics, organ failure
o Drugs: look for IV drugs marks, check pupils, check respiratory rate
▪ Metabolic, hypoglycemia, DKA, hypothyroidism, hepatic failure, Addison failure, uremia
o DKA: fruity smell of breath
o Hypothyroidism: non-pitting edema, toad skin, loss of outer third of the eye brows,
o Addison failure: hyperpigmentation
o Uremia: sallow/grey skin, fistula
▪ Apoplexy
o ICH (hematoma, head injury, cerebral tumor/abscess)
o Infratentorial (posterior fossa): cerebellar tumor, brainstem infarct/hemorrhage (fixed dilated
pupil), Wernicke encephalopathy
o Meningism (neck stiffness): SAH, meningitis, non-blanchable rash
o Other: encephalitis, overwhelming infection
o Trauma
Glasgow Coma Scale: EVM 456

Less than 8, intubate!
▪ Eye opening
o Spontaneous 4
o To speech 3
o To pain 2

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o No eye opening 1
▪ Verbal
o Appropriate, coherent 5
o Confused 4
o Inappropriate 3
o Incomprehensible 2
o No verbal output 1
▪ Motor
o Obeys commands 6
o Localizes to pain 5
o Withdraws to pain 4
o Decorticate (flexion) 3
o Decerebrate (extension) 2
o No movement 1
Physical Exam
▪ Hands
o Nicotine staining
o Clubbing
o Palmar erythema for liver disease
o Dupuytren contracture
o Cold sweaty hands for DKA
o Tremors for hypoglycemia
▪ Arms
o IV drug marks
o Fistula for uremia
o Spider nevi for liver disease
o Scratch marks for liver disease
o Toad-like skin for hypothyroidism
o Non-blanchable rash for meningitis
o Sallow/gray skin for uremia
▪ Head
o Any brain trauma or injury
o Loss of outer third of eyebrows
o Pupils
• Fixed dilated pupils for brainstem injury or stroke
• Pinpoint pupils for opioid overdose
• Fundoscopy for increased ICP
o Mouth
• Fetor hepaticus for liver failure
• Fruity smell of the breath
• Oral hyperpigmentation for Addison failure
o Neck
• Neck stiffness
o Chest
• Barrel chest for COPD
• Apex beat
o Abdomen
• Insulin marks in the abdomen
o Legs
• Non-pitting edema
Investigations
▪ Office tests/Bedside tests: BSL, ECG, UDT
▪ Blood: FBE, UEC, TFT, LFT, ABG, Synacthen test
▪ Urine: urine drug screen
▪ Imaging: CT scan or MRI of head
Back examination

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2:05 PM
35 year old male, presents to your GP complaining of back pain, radiating down the back of the thigh
after lifting a heavy object.
TASKS:
1. Do physical examination
2. Most probable diagnosis and management
2 cases in AMC: sciatica or acute mechanical back pain
Positive points in history:

▪ Sciatica: problem in heel toe walking, reflex might be reduced or normal, modified SLR or slump test
may be positive
▪ Mechanical back pain: nothing will be positive, just the back pain
APPROACH
WIPE
Wipe your hands
Introduce yourself
Position the patient
Expose properly
▪ Good Day. I’m Dr.________, I’m the HMO in this hospital. How do you want me to address you?
▪ I understand that you are having some back pain, I am so sorry for that.
▪ Today I’m going to do a physical examination of your back. I’m going to have a look, feel and I’ll ask
you to do some movements. I will also tell the examiner my findings while I’m doing my
examination, please pardon my medical jargons.
▪ I'll be asking you to remove your shirt, your pants, just remain in your undergarments and I'll be
having my examiner to be my chaperone.
▪ Before I start my examination, are you in pain? Where exactly is the pain? Do you need any
painkillers? During the examination if I hurt you or you feel uncomfortable, just let me know so
that I could stop okay?
Physical Examination:
▪ Gait: Can you take few steps for me? Can you walk on your heels and then with your toes?
o The gait is normal and not antalgic with good range of motion of the lower extremities.
o The patient has no problem with heel to toe walking
• Toe walking: S1
• Heel walking: L5
▪ On inspection of the back:
o Both shoulders are at the same level.
o The posture is normal, the back is symmetrical
o There were no scars, no swelling on articular joints.
o No muscle wasting of the paravertebral muscle.
o No wasting of the gluteal muscles. (crouch when you inspect the gluteal muscles)
▪ On inspection from the side:
o Normal curvature of the spine is maintained
o No visible deformity or lateral deviation of the spine.
o There is no excessive lordosis of the spine.
▪ On inspection from the front:
o Both anterior superior iliac spine is at the same level.
o Check power of thigh muscles
• Can you squat down and stand up? I'm just checking if there is any weakness in your
thighs
• Report: There is no proximal myopathy.
o Trendelenburg sign (abductor minimus, medius, psoas muscles)
• I'll be placing my thumbs over your pelvic area, is that alright with you? Can you bring
both of your legs together? I'll hold you and support you, you will not fall.
• Put both thumbs on the ASIS. Start with the more painful side.
▪ If there is pain on the right, lift the right leg.
• Report: The sound side did not sag. The affected area also did not sag.

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▪ On palpation:
o Temperature:
• I'll be having a feel of your back to check the temperature, is that alright with you?
• Alternate feeling top and bottom.
• Report: There is no local rise in temperature.
o Tenderness
• I'll be pressing some joints on your back. Please tell me if there is any soreness.
• Use your thumb to palpate
▪ C7
▪ Along the spine
▪ Paraspinal muscles
▪ Posterior superior iliac spine
▪ Sacroiliac joint
• Report: There were no tenderness on C7, spinous process. No tenderness on paraspinal
line, posterior superior iliac spine and sacroiliac joint.
▪ Movement
o Now I will be testing your back movement. Can you follow after me?
o Report:
• There were no pain on movement of the spine and the ranges of motions are good. OR
• There was restriction on _____ because of pain.
o Movements:
• Flexion
• Extension
• Left Lateral Flexion
• Right Lateral Flexion
• Left Rotation
• Right Rotation
▪ Schober's test: I will be measuring your spine on flexion. Is that alright with you?
o Measure:
• Schober’s test: central of Dimples of Venus (between sacroiliac joints), measure 10 cm
above, 5 cm below
o Can you bend forward and try to touch your toes?
o Report: the Schober’s test is normal with >20 cm measurement of the spine.
• If <20cm: Ankylosing spondylitis

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▪ Can you lie down for me please?
o Can you push away my hands?
• Report: The power are good on knee flexion and extension and ankle plantar flexion and
dorsiflexion.
▪ L3: extension of knee “kick out your leg”
▪ L4: flexion of knee “bend your knee and stop me from straightening it”
▪ L5: dorsiflexion of ankle “point your foot towards your head and don’t let me push it
down”
▪ S1: plantar flexion of ankle “press against my hand with the sole of your foot”
o This is a neuro hammer, I’m going to test your knee and ankle reflex.
• Report: The reflexes were normal.
▪ L3- L4: Knee jerk
▪ S1 : Ankle jerk
o This is a cotton, this is how it feels like. Can you close your eyes and let me know if you can
feel it? Tell me if it is equal on both sides?
o This is a neuro pin, this is how it feels like. Can you close your eyes and let me know if you
can feel it? Tell me if it is equal on both sides?
• Report: The sensations from L1-S1 were all normal.
▪ L1: pocket area
▪ L2: medial thigh
▪ L3: lateral leg to just above the knee
▪ L4: knee to medial malleolus
▪ L5: dorsum of foot (great toe, 2-4 toes)
▪ S1: lateral aspect of ankle (4-5th toes)
▪ Special Tests:
o Straight leg raising test: if <60: passive dorsiflexion
• I will be raising your leg, tell me if it hurts in your back.
• Bring the leg into the pain free zone, then dorsiflex the foot (to make sure that the pain is
not due to hamstring test). Also ask the patient to touch the chin to the chest (maneuver
to stretch the dura)

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o Report: The straight leg raising test is normal.
o Slump test: sit, slump forward, chin to chest, straightened leg, normal first then affected leg,
both legs straightened together then dorsiflexion of affected leg
• Can you sit on the edge of the bed for me? Put your chin to your chest, straighten your leg
while I dorsiflex the affected foot.
o Report: The patient is negative for slump test.
▪ Do you have any trouble with passing urine or stools? If yes, refer for possible cauda equina injury.
o I want to check for saddle anesthesia (S3 - perianal area)
▪ I would like to conclude my examination by doing a full neurological examination of the lower limbs.
Management:
Acute mechanical back pain:
PRICE
Refer to physiotherapist
Painkiller
Review in 2 days time
Red flags: If pain is increasing in intensity, pain is shooting down the leg, any bladder or bowel
incontinence.
Sciatica
Your backbones are stacked on top of each other, and there are nerves that run through these
places. And since you lifted a heavy object, sometimes these bones tend to compress the nerves
surrounding it causing the symptoms that you're having right now.
PRIC
Refer to the orthopedic surgeon
MRI scan
Refer to the physiotherapist
Give painkillers
When you are trying to lift something from the floor, do not bend your back. Bend your knees, and
hold the object close to your body.
Bell Palsy
Monday, 15 May 2017
4:19 PM
Your next patient is a 46 year old man with complaints of sudden sagging of the left side of his face. He is
very concerned about the possibility of stroke.
TASKS

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2. Further management plan
Differential Diagnosis
▪ Bell's palsy (most common cause, but a diagnosis of exclusion)
▪ Stroke
▪ Ramsay Hunt Syndrome (shingles of 7th cranial nerve)
▪ Parotid gland malignancy
▪ Cerebellopontine angle tumor (associated with hearing loss)
▪ Basal skull fractures of the petrous bone
APPROACH
▪ Do full cranial nerve examination
o Examine 7th nerve: see abnormalities
o Examine ears to check for vesicles (RHS)
o Examine mouth to look for vesicles (RHS)
o Hyperacusis is a feature of facial nerve palsy because normally stapedius muscle dampens the
vibrations of the stapes
▪ I would also like to do a neurological examination of the upper and lower limb to check for tone,
power, reflexes to rule out stroke
Bleeding examination
Tuesday, 2 May 2017
9:45 AM
28 year old female presents to your GP clinic with heavy periods.
▪ Medical
o Hypothyroidism
• Puffy face, hoarseness of voice, midline neck swelling (if there is obvious neck swelling,
ask the patient to swallow)
o Bleeding disorder
• Petechiae, purpura, ecchymosis/bruising
o Liver problems
• Jaundice, hepatomegaly, icterus
▪ Gynecological
o Fibroid - benign, growth in your womb composed of muscle cells. Check for masses in the
abdomen, especially in suprapubic area.
• Pelvic examination
▪ Inspection: bleeding, clots/tissue, offensive smell, colour
▪ Speculum: vaginal wall tears
▪ Per vaginal exam: CMT, uterus enlarged up to 8 weeks, irregular,
anteverted/retroverted, mobile, non-tender
o Endometriosis
• Pelvic examination
▪ Inspection
▪ Speculum:
▪ Per vaginal exam: CMT, normal size, retroverted, fixed, tender/non-tender
o Endometrial polyp

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o Endometrial hyperplasia - thickness of the inner lining of the womb
If you have a patient with menorrhagia and you do not find anything in the physical exam, do
a transvaginal ultrasound. If you find there is thickness of the endometrial lining, do a
hysteroscopy and biopsy to find out if it is just hyperplasia or it is cancer.
o Endometrial cancer
o Ovarian cancer
Physical Exam
▪ Good morning, I am Dr Lea, one of the doctors here today. I understand that you are having bleeding
from down there. How are you feeling right now? Do you have pain, dizziness, shortness of breath?
▪ Vital signs
o Check for heart rate, if regular
o Check for BP and postural drop
▪ I would like to transfer the patient to the resuscitation room, secure an IV line, draw blood for blood
tests, and start fluids, and I would like to start my patient on oxygen
▪ Pain - are you feeling any pain at the moment? Would you like me to give you some painkillers?
▪ I'm going to examine you for the heavy bleeding that you are having. This examination involves me
having a look at you, having a feel of your tummy, and then with your consent, I would like to
examine your private areas.
▪ Any patient who is bleeding, check the peripheral circulation of the patient. Ask the patient to lay her
hand flat, then turn over
o Capillary refill time
o Temperature - use the back of the hand to feel, compare both sides. cold/clammy
o Pallor
o Pulses - weak/thready
▪ Arms
o Petechiae, purpura, ecchymosis
▪ Face
o I'm going to pull your lower lid down a bit. Check for conjunctival pallor. Then pull the upper
lid up. Please look down. Check for pallor.
▪ Mouth
o I'm going to assess your voice. What is your occupation? Look for hoarseness of voice.
o Check for mucosal dryness. Check the tongue.
▪ Neck
o Check for midline neck swelling. If you see a swelling, ask patient to swallow to see if the
swelling moves with swallowing or not.
▪ Chest
o Heart auscultation: I am going to listen to your heart. check mitral (apex) --> tricuspid -->
pulmonary --> aortic
o Lungs: turn the stethoscope to the bell side

• Please take a deep breath in and out through your mouth for me
• Check apex of the chest (above clavicles)
• Auscultate the back

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o
▪ Abdomen: ask the patient to lie on his back

o I would like the head end of the bed to be flat. Stand on the right side of the patient
o Ask the patient to remove his shirt, or expose the abdomen area
o Do you have pain anywhere in the tummy at the moment?
o Start superficial palpation from left iliac fossa, to right iliac fossa, to left upper quadrant to
right upper quadrant
o Do deep palpation the same way EXCEPT on the painful side
*IF ACUTE ABDOMEN: I will not proceed with my superficial, deep palpation or check for
organomegaly because my patient is in severe pain
o Can you take deep breaths in and out for me? Once patient inhales, dip your finger to feel the
liver edge as it descends
o Percuss to find the edges of the liver, then measure the span of the liver (Normal: 6-12cm at
the midclavicular line)

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o
▪ Pelvic
o Inspection: bleeding, clots/tissue, offensive smell, colour
o Speculum: vaginal wall tears
o Per vaginal exam: CMT, uterus size, position, mobility, tenderness
▪ Investigations
o Blood test
• FBE, clotting profile, blood group and cross-matching and hold, TFT, LFT
o Imaging
• Transvaginal ultrasound
Breast Examination
11:51 AM
Dr. Kamalika
***
65/F with right sided breast lump. Her mother was diagnosed with breast cancer at 60 years old
TASKS
Do physical examination
Order investigations
Give differentials
22/F with right sided breast lump. Her mother was diagnosed with breast cancer at 60 years old.
TASKS
Order investigations
Give differentials
DDx
Fibroadenoma
Normal variant
Cancer
APPROACH
I have been asked to examine you today. During my examination, we will have a chaperone with us
at all times. For my examination, I will require proper exposure, I will give you privacy until you
change. This examination will involve me having a look, and feel of your breasts and underarms,
and doing some special tests. I will guide you throughout the process. Will that be ok with you?
INSPECTION
My patient is 65 year old Jenny, who is sitting comfortably, with no pain or signs of distress.
Now Jenny, I'm going to have a look at your breasts

Can you keep your arms by your side?

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No asymmetry of the breasts, no visible masses, no skin dimpling, or tethering, no peau d
orange, no discharges or bleeding from the nipples. Nipples are not retracted.
Can you please put your hands above your head and lower them slowly
No visbile lumps over the axilla, no tethering of the nipple or skin, no nipple shifting.
Now please press your hands to your hips
There is no accentuation of dimpling
PALPATION
Patient is still sitting down
I will now have a feel of your nodes on your underarms.
Check on apical, central, pectoral, lateral, posterior, infraclavicular, and supraclavicular

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Now jenny, I will now feel for lumps on your breasts. Can you please lie down? Can you please
raise your arm above your head?
Use 3 pulps of your fingers (index, middle, and ring finger) to palpate
Proximal to distal, on a zigzag pattern, from lateral to medial
I can feel that there is a mass over the right upper outer quadrant, single, firm, 1x2cm,
movable, with regular borders. There are no masses behind the areola or the nipple.
Jenny can you please squeeze your nipple to see if there are discharges?
I want to conclude my examination by doing a full respiratory examination, check for

hepatomegaly, and bone tenderness.
INVESTIGATIONS
I would like to arrange for the following investigations
<35yo - ultrasound scan, biopsy
>35yo - mammogram, biopsy
EXPLANATION
Older female case

Based on my examination, I found that you have a mass over the right breast. It could be due to several
conditions. First, it can be a ormal variant because with age the breast tissue could be less dense causing
this lump. It could also be due to a lumpy breast which is called fibroadenosis. It could be a fibroadenoma
but it is unlikely in your age. Or it could be a nasty growth, given your age and your family history. Don't
worry, you are in good hands, and we will assess you further by doing investigations.
Younger female case

This is most likely a fibroadenoma, which is a non-cancerous breast mass, which is common in the
reproductive age group due to high estrogen
Breast examination
4:02 PM
Dr. Shabana
You are in GP and a 55 year old lady came with complaints of lump in the right breast. Her mom was
diagnosed with breast cancer, and she is concerned about it.

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TASKS
1. Do relevant physical exam with running commentary to the examiner
2. Explain about the possible cause to the patient
3. Discuss further investigations
When I stepped into the room, a middle aged lady was sitting in the chair.
▪ Good morning Mary, I am Dr. ____.

▪ I understand that you are here because you have a lump in your breast. May I know which breast?
Right breast
▪ I know that you are worried about this, but I will do my best to help you with this.
▪ I am going to examine your breast, in the presence of a female chaperone, will that be okay?
▪ For purposes of examination, I would like you to undress yourself completely from above the waist.
▪ During my examination, I would try to be very gentle, but if I hurt you, please tell me.
Wear gloves.
▪ Look
o I would like to examine you in 3 positions, first I would like you to sit down with your hands
at your side, then hands above the head, and lastly hands on your hip and try to lean forward.
o On comparing the breasts on both sides, the breast looks symmetrical. There are no swellings,
scar, erythema, skin changes over the breast such as peau d' orange, puckering of the skin and
dimpling of the skin.
o I cannot see any changes over the areola.
o There is no nipple retraction, cracking of the nipple, eczema of the nipple and discharge.
▪ Feel
o I would like to set the bed at 45 degrees, and I would like you to lie on the bed for me.
o I will warm my hands before I touch you.
o Now I am going to feel for your breast, will that be okay? Can you point to the site where you
felt the lump?
o Start with the normal breast
o If you found a lump:
• site
• Size
• Shape
• Temperature over the lump
• Tenderness
• Consistency
• Fluctuant
• Mobility: take the arm towards the back (shoulder extension to fix the pectoralis muscle)
▪ Explanation
I have examiner your breast and I have found a lump. It can be because of a harmless condition like
a fibroadenoma, but I am a bit concerned that it might be due to a harmful condition like cancer,
given your family history as well. That is why we need to do investigations to confirm your
diagnosis just to be in the safe side. It will involve doing an FNAC or doing a core biopsy to be
done by the specialist.
Cardiovascular examination
Saturday, May 27, 2017
5:16 AM
Young 25 year old Alex comes to your GP centre because his usual GP told him that he had a murmur in
his heart when he was checked 3 months back. He is planning a trip to Bali in next month and concerned
about his heart condition.
TASKS
1. Do relevant cardiovascular examination
2. Tell your finding to the patient
3. Discuss management
Pathologic murmurs, check for:

▪ Fever

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▪ Thyroid
▪ Infective endocarditis
▪ Valvular heart disease
General look:
▪ Is my patient attached to a cardiac monitor?
▪ Is supplemental oxygen given?
▪ Is the patient having respiratory distress?
General Examination (Head to toe)

▪ Head:
o Head nodding - present in aortic regurgitation
▪ Face:
o Malar flush - present in aortic stenosis
▪ Eyes
o Anemia, jaundice, xanthoma, xanthelasma
o Eye signs of thyroid disease: lid lag, lid retraction, exophthalmos
o Fundoscopic exam - Marfan's present with posterior dislocation of the lens
▪ Nose and Ear: check for peripheral cyanosis
o Tip of the nose
o Ear lobes
▪ Lips and tip of the tongue: check for central cyanosis
▪ Mouth:
o Check for high-arching palate
o Ill-fitting dentures
o Any dental work-up - risk factor for infective endocarditis
▪ Neck
o Carotids - anterior border of the sternocleidomastoid, below the angle of the jaw, along the
SCM at the level of the cricoid cartilage
• Auscultate
• Palpate
o JVP - position-dependent
• Just at the level of the sternoclavicular joint, but if it is heightened, measure it
o Thyroid
▪ Hand
o Check for needle marks, tattoos and piercings in the arm and forearm - risk for tricuspid
vegetations
▪ Wrist
o Pulse - rate, rhythm, volume, tension, condition of the arterial wall, radio-radial delay, radio-
femoral delay, collapsing pulse - present in aortic regurgitation
• Pulse is 80 per minute, rhythm is regular, volume is regular, tension is fine, no radio-
radial delay, no radio-femoral delay,
• Collapsing pulse is felt with the palmar proximal part of the phalanges, ask if there is
shoulder pain because you will lift the arm
o Blood pressure
▪ Palm
o Osler nodes
o Janeway lesions
o Anemia, jaundice
▪ Dorsum
o Nail
• Clubbing
▪ Palpate the finger
▪ Fluctuation test
▪ Shamroth window test
• Splinter hemorrhages
• Capillary refill time
• Peripheral cyanosis
▪ Abdomen
o Palpate the liver - right-sided heart failure and congestive heart failure give rise to tender
hepatomegaly
o Check for ascites - shifting dullness
o Auscultation
• Renal artery stenosis bruit
• Abdominal aortic aneurysm

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▪ Legs
o Dependent edema
o Cyanosis
o Signs of peripheral vascular disease - ulcer, gangrene, amputation
Cardiovascular examination proper (precordium examination) - patient should be in a 45 degree

position, lying down
▪ Inspection
• Hand should be placed on both hips so you could inspect all angles
o Bony chest deformity
• Pectus excavatum
• Pectus carinatum
o Bulge
o Visible apical impulse
o Scar
• Infraclavicular scar - pacemaker surgery
o Pleural tap mark - pleural effusion or pulmonary edema
o Hyperdynamic circulation
• Suprasternal pulsations
• Subxiphoid pulsations
▪ Palpation
o Apex - mitral area
• Tricuspid (left lower sternal border)
• Aortic (right upper sternal border, 2nd ICS)
• Pulmonic (left upper sternal border, 2nd ICS)
o Thrill - palpable murmur
o Heave - left parasternal heave - right ventricular hypertrophy
▪ Percussion - area of cardiac dullness
▪ Auscultation
• Auscultate with both bell and diaphragm on all 4 areas
Very important: Left thumb should be on the carotids
If normal, say: I have checked mitral, tricuscpid, pulmonary and aortic, first and second heart
sounds were audible with no murmurs
• Most common murmurs here in Australia is mitral, in developing countries it is aortic
o Ask patient to assume a left lateral position, left hand on the carotids, use the bell of the
stethoscope, left sided murmurs are better heard on expiration, ask patient to hold breath after
expiration, listen for mitral murmurs
o Ask patient to sit down, lean a bit forward, use diaphragm because aortic murmurs are harsh
and high-pitched, ask patient to hold breath on expiration, listen for aortic murmurs
o To accentuate the murmurs, ask patient to do: Valsalva, squatting, or squeeze the hand
• Auscultate the base of the lungs
▪ Office test: bedside ECG
Management
Well John, I haven't found a murmur, but one of my colleagues have heard a murmur, so the best way to
confirm this is to do an ECG and echocardiogram. If it comes back normal, then there's no need to refer
you to the cardiologist. But if something is seen on your ECG or echo, then I will need to refer you to the
specialist.
Doctor can I go for a trip?

Yes, you can go for a trip, but it is advisable and I strongly recommend to confirm it with a cardiologist
and with some investigations before you go.
Cardiovascular examination
Monday, 15 May 2017
2:01 PM
Your next patient in a general practice setting is a 25 year old Mr. Jones, who comes to you for a general
check-up. 1 year back, he was examined by a GP who found a murmur over the precordium.
TASKS
1. Take a relevant history
2. Perform Cardiovascular examination

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3. Discuss necessary investigations with the patient
History for murmur:

▪ Site
▪ Quality - is it soft or harsh?
▪ Intensity
▪ Radiation
▪ Thrill
▪ Timing
**Diastolic murmur is always pathological
**mitral stenosis: diastolic, mitral regurgitation: systolic
Differential Diagnosis for murmur:

▪ Valvular heart disease
▪ Hyperdynamic circulation
o Anemia
o Aortic regurgitation
• Water hammer pulse
• Wide pulse pressure
▪ Infective endocarditis
o Splinter hemorrhages (nails)
o Osler nodes (finger)
o Janeway lesions (palm)
o Roth spots (fundoscopy)
o IV drug use - tricuspid valve
o Poor dental hygiene
▪ Heart failure
o Nails
• Peripheral cyanosis
• Clubbing (schamroth sign)
o Face
• Malar flush
• Highly-arched palate
o Neck
• JVP, carotid bruit, thyroid bruit
o Chest
o Visible pulsations
o Any abnormalities in the chest wall
o Apex beat (5th intercostal space, MCL)
o Thrills (palpable murmurs)
o Heaves (movement of the hand with the heartbeat)
o Percussion - done to outline the border of the heart (cardiac dullness)
o Auscultation
• Start listening to Mitral area (use bell of the stethoscope)
• You can ask the patient to do a left lateral position to better hear the heart sounds
▪ Hyperthyroidism
Physical Examination
▪ Nails
o Peripheral cyanosis
o Clubbing
o Splinter hemorrhages
o Osler nodes and Janeway lesions
▪ Hands/Arms
o Check for tremors of hyperthyroidism
o Signs of IV drug use
o Water hammer pulse (feel the pulse, then raise the arm, the pulse will become feeble/weak)
o Check for radio-radial delay to check for COA (examiner, I would also want to do the radio-
femoral delay)
o Check biceps and triceps reflex (hyperreflexia as feature of hyperthyroidism)
o Check blood pressure for wide pulse pressure
▪ Eyes
o Fundoscopy for Roth spots
o Conjunctival pallor for anemia

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o Eye changes of hyperthyroidism
▪ Face
o Malar flush
▪ Mouth
o Dental hygiene
o Central cyanosis
o Highly-arched palate (Marfan syndrome)
▪ Neck
o JVP
o Carotid and thyroid bruit
▪ Chest
o Lungs: check for adventitious breath sounds
o Visible pulsations
o Any abnormalities in the chest wall
o Apex beat (5th intercostal space, MCL)
o Thrills (palpable murmurs)
o Heaves (movement of the hand with the heartbeat)
o Percussion - done to outline the border of the heart (cardiac dullness)
o Auscultation
• Start listening to Mitral area (use bell of the stethoscope first, then diaphragm)
• Tricuspid, aortic, pulmonic (diaphragm
• You can ask the patient to do a left lateral position to better hear the heart sounds
▪ Legs
o Peripheral edema
Diagnosis and Management

Mark I have listened to your heart. I have not found anything of concern.
Why did my GP before hear a murmur? Do you remember at that time, did you have fever? Most
probably that your GP heard that time is due to fever. They result from minor turbulence in the flow of
blood, which occurs in entirely healthy children and even in adults.
Innocent murmurs are often rather louder, and hence more easily detected, during an illness associated
with a raised temperature (fever). As the heart works harder when the body temperature is high this makes
the turbulence in blood flow increase and the murmur is louder.
Cranial nerve examination

Friday, 28 April 2017
4:49 PM
Your next patient is Mr. George, who has had a motor vehicle accident this morning. He was brought to
the hospital by ambulance. His primary survey is normal. Vital signs are stable at the moment.
TASKS
1. Perform cranial nerve examination
I am going to examine your cranial nerves. These are the nerves that arise from your brain and perform
different functions. During this examination, I will be assessing your vision, sense of smell, the strength
of your facial muscles, and some hearing tests.
a. CN I (Olfactory)
▪ Have you noticed any recent changes in your sense of smell?
▪ Can you please cover your one nostril and close your eyes? Can you identify this? *let patient smell
coffee
▪ Can you cover the other nostril and keep your eyes closed? Can you identify this? *let patient smell
perfume
a. CN II (Optic)
Now I'm going to examine your vision.
▪ Visual acuity
Make sure patient is at 6 feet from the Snellen chart. *patient should be wearing spectacles if
he wears one*
Do you wear any prescription glasses or contact lenses? Can you please wear it for me?

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Can you cover your one eye with the palm of your hand. Try to read the lowest and smallest
line for me? Thank you very much. Can you cover your other eye? Can you read the same
line in the opposite direction?"
▪ Visual field
If patient is wearing prescription glasses, ask the patient to remove it.
Sit in front of the patient at the same level. Tell the patient "Focus on my nose. Do not move
your head and neck. Cover your one eye. (you and the patient should be covering the same
side eye)
Now I'm going to bring my finger from the sides to the centre, each time you start to see my
finger, say "yes".
▪ Colour vision
▪ Fundoscopy
I'm going to perform fundoscopy and I am going to look at the back of the eye.
During my examination I might really get close to you, is that alright with you?
During this examination, I want you to focus on the wall behind me, you can blink if you
need to.
To examiner: Doctor, ideally I would like to dim the lights, and dilate the pupils after ruling
out glaucoma.
First examine the red reflex. Shine the light into the pupil.
I'm looking for any blurring of the optic disc margins suggestive of papilledema, pallor of the
optic disc present in optic neuritis, cherry red spots present in central retinal occlusion and
amaurosis fugax, AV nicking which is typical of hypertension, and cotton wool spots and dot
blot haemorrhages present in both hypertension and diabetes.
a. CN III, IV, VI
▪ Light reflex
• "I am going to shine some bright light into your eyes. It might be a little of discomfort,
please bear with me."
• Stand in front, shine the light from the side to the center
▪ Accommodation reflex
• "Please focus on the wall behind me, then focus on my finger (put finger in front of the
nose)"
▪ Ophthalmoplegia (positive finding in the exam)
• "Are you experiencing any double vision at all? I am going to examine your eyes, and if
during my examination, you experience any double vision during examination, please
let me know."
• Do eye movements. Do an "H" sign. Start from center, go the side, then up down, center,
then side up down center.
• Stand in front of the patient. "Focus on my finger, and follow the movements of my
finger with your eyes. Do not move your head and neck.
• Check for upgaze diplopia (muscle involved are inferior rectus +/- inferior oblique, nerve
involved is 3rd CN) - orbital floor fracture
b. CN V
▪ Motor
• "Can you please clench your teeth for me?" *put your hands on cheeks of the patient.
Check for masseter and temporalis muscles.
• "Open your jaw, I'll try to close it, don't let me do it." Push from the head and the jaw.
• "Close your jaw, I'll try to open it, don't let me do it. "Pull the jaw"
• "Turn your head to the right, I'll try to turn it back, don't let me do it. Turn your head to
the left, I'll try to turn it back, don't let me do it."
▪ Sensory
• "I'm going to check some sensations in your face. It's going to feel like this, each time you
start to feel this say yes, tell me if it feels the same or different."
• "Close your eyes." check with the cotton then check with toothpick.
• Both sides of forehead, both sides of cheek bone, both sides of mandible
c. CN VII
▪ "Can you look up?"
▪ "Can you frown for me?"
▪ "Close your eyes, I'll try to open it, don't let me do it."
▪ "Blow your cheek, I'll try to pop it, don't let me do it."
▪ "Smile for me, and show me your teeth"
▪ "Have you noticed any recent changes in your sense of taste?" (anterior 2/3 of tongue)
▪ "Do the sounds which you hear feels louder than usual?" (nerve to stapedius)
a. CN VIII

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a. CN IX & X
Use a torch and tongue depressor, depress the tongue and check the uvula.
Ask the patient to cough.
I am going to assess your speech. I am going to ask you some questions, please answer them. What
is your occupation? (check for hoarseness)
a. CN XI
Can you shrug your shoulders?
a. CN XII
Stick your tongue out for me. There is no wasting, fasciculations of the tongue.
Assess tongue movements. Move your tongue to the right and left.
Can you press your tongue towards your cheek? I will press against it, don't let me do it.
Diabetic foot examination

4:56 PM
65 year old male patient, a known diabetic for 20 years, on medications. Now he is complaining of
numbness and tingling of his right foot.
TASK
1. Perform a foot examination
Materials:
▪ 128 Hz tuning fork
▪ Knee hammer
▪ Monofilament
o Position is 45 degrees
o Expose lower legs and feet
▪ Inspection (stay at the foot end)

o The patient doesn’t have missing limbs or toes.
o Check colour: pale, cyanoses, erythematous
o Skin is not dry, shiny. There is no hair loss. (present in peripheral vascular disease)
o There is no eczema or hemosiderin staining.
o There are no ulcers. (either a venous or arterial ulcer; in diabetes it is an arterial ulcer)
o Arterial ulcer: painful, deep punched out ulcer (associated with Diabetes and peripheral
vascular disease)
o Check at medial malleolus, lateral malleolus, in between the toes, heel (raise the leg and
look underneath)
o There is no swelling, edema.
o There is no deformity of joints caused by neuropathy (Charcot arthropathy)
▪ Palpation
o There is no local rise in temperature. There is no coldness. (hot: cellulitis; cold: peripheral
vascular disease)
o Check capillary refill time. (if CRT is prolonged, that suggests PVD)
o Check dorsalis pedis and posterior tibial pulses.
o Ask the patient to dorsiflex the big toe. The extensor hallucis longus tendon becomes
prominent. Lateral to the tendon will be the dorsalis pedis artery. Palpate with 3 fingers.
o Posterior and inferior to the medial malleolus is the posterior tibialis artery.
▪ Sensation
o I'll be checking for sensation. This is a monofilament. This will not hurt. I will be very gentle.
o Please close your eyes. I will be touching various places on your feet. Please tell me which
side I am checking by saying left or right.
o Check with monofilament. (Pressure should be enough that it bends) 5 places should be
checked.
o Plantar side:
▪ Tip of big toe
▪ Metatarsal head of 1st toe

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▪ Metatarsal head of 2nd toe
▪ Metatarsal head of 3rd toe
▪ Metatarsal head of 5th toe
▪ Vibration - use 128 Hz tuning fork
o This is a tuning fork, this is how it feels when it's buzzing and this is how it feels when it stops.
Place it over the sternum of the patient.
o Now please close your eyes.
o Place tuning fork on the proximal phalanx of the big toe.
o If patient is not able to feel when it stops, go one joint up, until the knee.
o Tell me when you can feel the buzzing, and when it stops.
▪ Proprioception
o Now I am going to do proprioception. That is your joint position sense.
o Perform on the big toe only.
o This is down, this is up, and this is neutral position.
o I would like you to close your eyes and tell me if it is up, down or neutral position.
o If it is affected, go a joint above.
▪ Reflexes
o Ankle jerk (will be lost in advanced peripheral neuropathy)
o This is a knee hammer. It will not hurt. I will be very gentle.
o I would like you to flex your knee.
▪ Gait
o Can you please get up and take a few steps for me.
o Check if symmetrical, able to maintain balance, and arm swing
o If you don't mind, I'll quickly have a look at your footwear.
o Check if shoes are of correct size. Check if there is asymmetrical soles. Check if there is
a hole in the shoes.
o Thank the patient. Wash your hands.
▪ I would like to conclude my examination by doing a full neurological examination of the lower limbs,
check the blood glucose level. I would like to advise on good foot care and provide some reading
materials about foot care.
Ear examination
Tuesday, 2 May 2017
11:38 AM
Our ear is divided into three parts: outer ear, middle ear, inner ear.
This is your outer ear, composed of the ear canal and ear drum. The middle ear, you have 3 small bones,
the ear drum and the eustachian tube.
Inner ear contains apparatus for balancing and a nerve. When we hear, sound waves passes through the
ear canal, causes vibration of the ear drum. Vibrations of the ear drum stimulates the movement of the
three bones in the middle ear, which then stimulates the nerve and send hearing messages to your brain.
Conductive hearing loss - problem in the mechanical transmission of sound due to:
▪ Outer ear: ear wax, foreign body, inflammation of the ear canal
▪ Middle ear:
o Middle ear infection (Otitis media) which causes bulging of the ear drum and eventually
perforation
o Perforation due to trauma
o Otosclerosis - abnormal growth of the bone in the middle ear
o Cholesteatoma - abnormal growth of the skin the middle ear

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Sensorineural hearing loss - problems in the inner ear
▪ Inspection
o Swelling, scar marks, erythema, redness, auricular deformity
▪ Palpation
o Palpate the pre-auricular, post-auricular, tragus and pinna. Look for tenderness, swelling,
nodules, firmness.
▪ Hearing test - May I ask which side is the better ear?
o Whisper test
• Stand at 1 arm's distance. Start with the better ear then move to poor ear.
• I'm going by examining your better ear first. I'd like you to cover your normal ear for me.
I will whisper into your better ear, and I would like you to please repeat what I say.
• Repeat with the poor ear.
o Tuning fork tests

• Rinne Test: bigger size, smaller number (128 Hz) is used for vibration
▪ I'm going to place the tuning fork here over your bone behind your ear then you are
going to hear some buzzing sound, once it stops, let me know.
▪ Once it stops, put the tuning fork next to the ear, then ask, Can you hear it now?
▪ Normal finding: AC > BC or Rinne positive
▪ Abnormal finding: AC < BC or Rinne negative --> Conductive hearing loss
• Weber Test: smaller size, bigger number (512 Hz) is used for hearing
▪ Centralized - normal finding
▪ Lateralized
• Conductive hearing loss - sound localized to poor ear
• Sensorineural hearing loss - sound localized to better ear
▪ Otoscopy
o Have the patient sit comfortably with head tilted slightly away from you. Use largest speculum
that is comfortable.
o Grasp auricle and pull up, out, and back to straighten canal
o Hold instrument up, insert speculum gently down (hold the speculum with the same hand as
the side you are examining, right hand right ear, left hand left ear)

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o Inspect ear canal: cerumen, colour, lesions, foreign body
o Inspect tympanic membrane: landmarks, colour, perforations
• Colour/shape-pearly grey, shiny, translucent, with no bulging or retraction
• Consistency - smooth
• Landmarks
• Cone shaped light reflection of the otoscope light is seen at 5:00 in the right ear and at
7:00 in the left ear
• Short process, malleus and umbo clearly visible
▪ Management
Most likely, you are having conductive hearing loss. It can be caused by a number of reasons such as wax,
foreign body, inflammation of the canal or hole formation in the ear drum due to an infection in the ear
called otitis media, or one of the bones in the middle ear becomes hard called otosclerosis, or when
sometimes there is an abnormal growth of skin inside the middle ear because of longstanding infection
called cholesteatoma.
Eye examination
Tuesday, 2 May 2017
12:51 PM
Your next patient is Mr. Anthony, 58 years old, comes to see you in your GP practice with sudden loss of
vision lasting 60 seconds on his right eye. He has a positive history of Diabetes Mellitus for the past 15
years, and hypertension for the past 20 years.
TASKS
1. Examine patient
2. Tell your most likely diagnosis and differential diagnoses
▪ Transient loss of vision
o Migraine
o TIA
▪ Permanent loss of vision
When our heart pumps, the blood is carried from the heart through one of the blood vessels in the neck to
the blood vessels to the eyes. Sometimes, there is narrowing of this blood vessel in the neck, which we
call as carotid stenosis. This narrowing is caused by fatty plaque formation in the blood vessel. If this
plaque is dislodged from the blood vessel in the neck, it may enter the blood vessels in the eye and cause
sudden loss of vision which is brief, because later on the clot is dislodged again. And because you have
diabetes and high blood pressure for a long time, it predisposed you to having this condition.
However, there are other possibilities. This sort of presentation may also be a warning sign of migraine.

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But at this point, it is very important to rule out a condition such as mini stroke or medically transient
ischemic attack. For this reason, we need to send you to the hospital, admit you and you will be seen by
the specialist who will do further investigations such as basic blood tests such as full blood count, liver
markers, inflammatory markers and imaging such as ultrasound of the neck or carotid doppler ultrasound,
ECG and echo to look at the heart, and a CT scan to look at the brain, to rule out this condition. But
before you go to the hospital, I will start you aspirin.
▪ I am going to examine your eyes to find out the reason why you had this sudden brief loss of vision.
This examination involves me examining your eyes, listening to one of the blood vessels in your
neck, and examination of heart and neurological system. Is that alright with you?
▪ Eyes
o Inspection
• I cannot see any ectropion, intropion.
• I would like to wear my gloves and I would like to evert the upper lids. Look for
follicles/scarring suggestive of trachoma
• Subconjunctival hemorrhages
• Periorbital swelling or redness
o Palpation
• Ask the patient, do you have pain in your eyes?
• Can you please close your eyes? Press on the eyeball to look for retroorbital tenderness
o Cranial nerves
• CN II
▪ Visual acuity
▪ Visual fields
▪ Colour vision
• CN III, IV, VI
▪ Light reflex
▪ ophthalmoplegia
• Fundoscopy perform last

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▪ Papilledema
optic disc is elevated and its surface is covered by cotton wool spots (damaged
axons) and flame hemorrhages (damaged vessels).
Cause by four I's: increased intracranial pressure (papilledema), infarction,
inflammation, infiltration (by cancer)
▪ AV nicking -
Chronic hypertension stiffens and thickens arteries. At AV crossing points
(arrow) arteries indent and displace veins.
▪ Cotton wool spots

Caused by microinfarcts. Exploded ganglion cell axons extrude their axoplasm
into retina. Long DDx: hypertension, diabetes, HIV, severe anemia or
thrombocytopenia, hypercoagulable states, connective tissue disorders, viruses,
and others.

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▪ Carotid bruit
o Take a deep breath in and hold it.
o Listen through the bell in the carotid area.
o Repeat for the other side
▪ I would like to finish off by doing a cardiac and neurological examination
Elbow examination
Monday, 24 April 2017
12:16 PM
Case: Lateral epicondylitis

Pain on the outer side of the elbow
▪ Introduction: Hello, I’m Dr. Lea, I'm one of the doctors who will be looking after you today. (wash
hands simultaneously)
▪ Background: from my case notes, I understand you are having some pain on your shoulder. I'm really
sorry for that. How are you feeling right now? [If she answers yes I am feeling pain, ask "How
severe is your pain?" "Can you tell me the site of the pain?"
▪ *NEVER DO DEEP PALPATION OF THE SITE OF PAIN
▪ *Palpate other sites first before palpating the site of pain
▪ *Before touching it, say "I understand this site is painful, but I am just going to touch it very gently, is
that okay?"
▪ *Offer painkillers, ask about allergies to painkillers; say to examiner: Doctor, I would like to give
painkillers to the patient
▪ Explain: Now I am going to examine you to find out the reason why you are having this pain. And this
examine basically involves me having a look at your elbow, feeling your elbow and doing some
movements with your elbow.
▪ Consent: Is that alright with you?
▪ Handwash: Done with the introduction.
LOOK
▪ On inspection from the front, I can see the normal carrying angle
There is no scar, swelling, erythema, deformity, muscle wasting
▪ On inspection from the side, there is no fixed-flexion deformity
▪ On inspection from the back
o There is no olecranon bursitis
o There is no rheumatoid nodule
o There is no psoriatic patch
FEEL
▪ I'm just going to have a feel of temperature
Front, side, back, on both sides - no rise in temperature
▪ Tenderness
o Medial epicondyle
o Lateral epicondyle
o Olecranon process
o Elbow joint line
o There is no tenderness over the forearm

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MOVE
Only do active movements
▪ Flexion
▪ Extension
▪ Pronation
▪ Supination
SPECIAL TESTS
Make a fist for me, cog your wrist up. *put your hands against the dorsum.* Push up against my hand.
Grab my fingers, squeeze it, I'll try to take my fingers, resist it.
I found out that the condition you're having is called lateral epicondylitis. Have you heard of this? Don't
worry I will explain it to you.
Lateral epicondylitis is also called as tennis elbow because it's commonly seen in tennis players because
of overuse of their elbow. Normally the forearm muscles are attached of the elbow by means of a
structure which is known as tendon. If this tendon gets inflamed, we call it lateral epicondylitis. And the
reason why it is inflamed is due to the overuse.
Facial Trauma
Friday, 28 April 2017
9:44 AM
You're an HMO in the ED, your next patient is Mr. George who has had a motor vehicle accident this
morning. The primary survey has already been done and is normal. Vital signs have been assesses, also
normal. He presents to you with a bruise on his left cheek.
TASKS
1. Relevant focused examination
2. Most likely diagnosis and immediate management to the patient
APPROACH
▪ Hello George, I am Dr. Lea, one of the doctors here at the ED.
▪ From my notes, I understand you had this accident, I am really sorry about that. What I am going to do
today is I am going to examine you to find out if you acquired any injuries after the accident that
you had. Before I proceed, I would like to know if you had any pain? On a scale of 1 to 10, how
bad is it? Do you want me to give you painkillers? Do you have any allergies?
▪ This examination involves having a look at your head and neck and feeling your head and neck and
checking for your facial expressions. Is that alright with you?
▪ Inspection
o "On inspection on the front, I cannot appreciate any stigmata of skull base fracture like raccoon
eye, battle sign, rhinorrhea and otorrhea, no exophthalmos, enophthalmos, hypoglobus. I
cannot see any nasal bone fracture. Do you mind if I pull up your nose up a little bit? There is
no septal hematoma. Can you open your mouth or does it hurt when you open your mouth?
Alright can you please open your mouth? *shine a torch in the mouth* I can see the upper
and lower dental arch, there is no missing tooth. Can you please roll up your tongue for me?
There is no sublingual hematoma."
• Rule out a skull base fracture/basilar fracture
▪ Raccoon eye - periorbital hematoma
▪ Battle sign - hematoma at posterior auricular area (check behind the ears)
▪ Rhinorrhea and otorrhea - clear fluid trickling down nose and ears
• Rule out orbital fractures
▪ Blowout fractures - exophthalmos, enophthalmos, hypoglobus
▪ Raccoon eye
• Rule out nasal fracture
▪ Septal hematoma - "do you mind if I pull your nose up a little bit?"
▪ Zygomatic complex fracture/ maxillary bone fracture - ask the patient if he can open
his mouth, or does it hurt when you open your mouth?
▪ Mandibular bone fracture - if maxillary bone fracture has been ruled out, ask the
patient to open mouth, then look at upper dental and lower dental arch, any
missing tooth
▪ Sublingual hematoma - "can you please roll your tongue up for me?"
▪ Palpation

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o "I'm just going to stand at your back and have a feel of your head. Any pain in there? I cannot
feel any depression, any bulging, or any crepitations. No midline tenderness in the cervical
and thoracic spine. No tenderness at the paraspinal muscles, infraspinatus, supraspinatus and
spine of scapula. I'm just going to have a feel of your face. There are no tenderness in the
orbital, nasal, maxillary and mandible. There is symmetry of the maxillary bone."
o Stand at the back of the patient
o Palpate starting with occipital lobe, then parietal, then temporal and frontal. Assess for any
depression, bulging, crepitation, fracture.
o Check for midline tenderness from cervical to thoracic spine
o Check for tenderness at the paraspinal muscles, infraspinatus, supraspinatus and spine of
scapula
o "I'm going to have a feel of your face." Palpate around the orbit, nasal area, maxillary,
mandible
o Check the symmetry of the maxillary bone *thumbs on the temporal area, 1st finger in the
maxillary bone*
▪ Movements
o Neck range of motion
o Cranial nerves
• CN II (optic)
▪ Visual acuity (only perform this, but mention the other parameters) make sure
patient is at 6 feet from the Snellen chart. *patient should be wearing spectacles
if he wears one* "Do you wear any prescription glasses or contact lenses? Can
you please wear it for me? Can you cover your one eye with the palm of your
hand. Try to read the lowest and smallest line for me? Thank you very much. Can
you cover your other eye? Can you read the same line in the opposite direction?"
"I would like to perform complete 2nd cranial nerve examination by checking for
visual field, color vision and fundoscopy."
▪ Visual field
▪ Color vision
▪ fundoscopy
• CN III, IV, VI
▪ Light reflex
• "I am going to shine some bright light into your eyes. It might be a little of
discomfort, please bear with me."
• Stand in front, shine the light from the side to the center
• "Please focus on the wall behind me, then focus on my finger (put finger in
front of the nose)"
▪ Ophthalmoplegia (positive finding in the exam)
• "Are you experiencing any double vision at all? I am going to examine your
eyes, and if during my examination, you experience any double vision
during examination, please let me know."
• Do eye movements. Do an "H" sign. Start from center, go the side, then up
down, center, then side up down center.
• Stand in front of the patient. "Focus on my finger, and follow the
movements of my finger with your eyes. Do not move your head and
neck.
• Check for upgaze diplopia (muscle involved are inferior rectus +/- inferior
oblique, nerve involved is 3rd CN) - orbital floor fracture
• CN V
▪ Motor
• "Can you please clench your teeth for me?" *put your hands on cheeks of the
patient. Check for masseter and temporalis muscles.
• "Open your jaw, I'll try to close it, don't let me do it." Push from the head and
the jaw.
• "Close your jaw, I'll try to open it, don't let me do it. "Pull the jaw"
• "Turn your head to the right, I'll try to turn it back, don't let me do it. Turn
your head to the left, I'll try to turn it back, don't let me do it."
▪ Sensory
• "I'm going to check some sensations in your face. It's going to feel like this,
each time you start to feel this say yes, tell me if it feels the same or
different."
• "Close your eyes." check with the cotton then check with toothpick.
• Both sides of forehead, both sides of cheek bone, both sides of mandible
• CN VII
▪ "Can you look up?"

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▪ "Can you frown for me?"
▪ "Close your eyes, I'll try to open it, don't let me do it."
▪ "Blow your cheek, I'll try to pop it, don't let me do it."
▪ "Smile for me, and show me your teeth"
▪ "Have you noticed any recent changes in your sense of taste?" (anterior 2/3 of
tongue)
▪ "Do the sounds which you hear feels louder than usual?" (nerve to stapedius)
Positive findings: bruising on the left side of the cheek, ophthalmoplegia.

Explanation: George, after examining you, I found out that you are having a condition called orbital floor
fracture. Do you have any idea what it is? Please don’t worry, I will explain to you. Our eyeball is
surrounded by a bone which is called the orbital bone. Sometimes, this bone can get fractured especially
after such accidents as in your case.
When this bone is fractured, there is some entrapment of some muscles of your eyeball which can give
you this double vision.
Immediate management: I need to call my senior and the specialist to come and have a look at you. Most
likely there is a need to do a CT scan of your facial bones to confirm entrapment or not, and then you will
be managed accordingly.
Foot Drop/Common Peroneal Nerve Entrapment

9:24 AM
Dr. Kamalika
***
45 year old man, a strawberry picker, with pins and needles sensations on his foot.
TASKS
Present differential diagnosis to the examiner and to the patient
***
APPROACH
WIPER
I'm sorry to hear that you are having discomfort in your leg. I will do my best to examine you and
find out the cause of the discomfort that you're having. This will involve me having a look, and feel
of your legs, and also doing some special tests. Don't worry, I will guide you throughout the
process. Will that be alright for you?
Before we begin, are you having any pain at the moment? *give pain killers*
INSPECTION
Sitting - inspection
The patient is sitting comfortably, no asymmetry of the face or posture. No tremors or
involuntary movements.
Can you please stand?
Standing: Front, Side, Back

Front: There are no deformities, no fasciculations, neurocutaneous skin manifestations.
Side: normal curvature tone is preserrved, no obvious bruises, redness, or obvious injuries to
side of the leg
Back: no bruises, no deformities, or rashes, or signs of obvious trauma
GAIT
Can you please take 5 steps for me, then turn and come back here again?
The patient has a high-stepping gait,
Now can you please walk on your toes? How about walking on your heels?
Patient is unable to walk on the heel of the right foot, but he is able to walk on the toes
Can you please walk like this (demonstrate tandem gait)

Unable to do full tandem gait on the right foot
Now can you please lie down?

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TONE
Tone of the hip is fine, no rigidity
Tone of the knees are fine
Tone of the ankle joint is fine as well.
POWER
I will check the power, please push against my hand
Bend your knees please, push against my hand.
Now please push your feet against my hand.
Dorsiflexion and eversion of right foot is lost
REFLEXES
This is a neuro hammer, I will be gently tapping your ankle.
SENSATION
This is a cotton wool, it will feel this way. Now I will put this in different parts of your thigh, leg,
and foot, and ask you to please close your eyes. please say yes if you feel it, and tell me if there is a
difference in how you feel it on one side compared to the other.
There is no sensation over the webs pace between first and second toe
SPECIAL TEST
SLR
Please raise your leg. Do you feel any pain when you raise your leg?
TAPPING THE FIBULAR HEAD

Tap on the fibular head (lateral part of the proximal leg) == > pain over the dorsum of the foot ==
positive for common peroneal nerve entrapment
I would like to conclude my examination by doing a full back neurological examination.

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***
EXPLANATION
The walking problem you nave is a foot drop, most likely affecting the common peroneal nerve. It
is a long nerve at the head of the small leg bone (fibula). It twists as it goes down. In your case, I
suspect it got compressed or trapped there, which can be seen after prolonged squatting, sitting
cross-legged, and in sports injuries. However, this foot drop can also be due to muscle problems
like muscular dystrophy or due to disorders in the brain and spinal cord like stroke or multiple
sclerosis.
Hand exam: Knife cut to the wrist

4:24 PM
35 year old female patient, presenting with a cut over the left wrist. Dressing is applied, painkillers given.
TASK
1. Perform relevant physical examination.
▪ Good afternoon, I am Dr. _____.

I've been tasked to assess your hand to find out the extent of your injury.
▪ I’m going to have a look, feel and I’ll ask you to do some movements. Is that alright with you?
▪ I will be giving a running commentary of my examination findings to my examiner, I am so sorry,
please excuse my medical jargon.
▪ Can you please put your hand on this pillow?
Physical examination:
▪ Inspection
o On comparing both hands, I can appreciate a bandage over the left wrist. It is not soaked in
blood.
o The normal flexed position of the affected hand is lost and the hand seems to be extended or in
hyperextended position.
o Check the skin colour: comment if it is normal or pale.
o I cannot appreciate any cut in the right hand. No obvious swelling, redness, deformity,
bleeding, bruising is seen.
▪ Palpation
o I'll just be checking for temperature. I'll be very gentle, on your cut area.
• There is no localized rise in temperature.
o Now I'll be feeling for tenderness.
• Start proximally, going distally to the hand
• Start on unaffected hand then affected hand. Stop palpating the affected area if it is
painful.
• I am very sorry, I will not continue palpating your affected hand.
o Now I'll be pressing over your nails to check your capillary refill time.
• Press for 5 seconds, then release
• CRT is less than 2 seconds, is normal.
• Do on other side.
o Now I will check the pulses. I will not do it in the affected side as you are having pain on that
side.
• Examiner, may I have a wrist watch so I can count the pulse for a full minute
• I will start with the radial pulse, then check the ulnar pulse.
▪ Pulse is 80, with regular rhythm.
• I cannot palpate for radial and ulnar in right wrist because of the cut.
▪ Movement
o Now I would like you to follow my movements.
• Can you do like this? - Wrist flexion and extension
▪ I can appreciate wrist flexion and extension of the left hand
▪ Patient is unable to do wrist flexion and extension on the right side so I am
suspecting injury to flexor carpi ulnaris, flexor carpi radialis and palmaris longus.
• Can you bend your fingers for me?
▪ Patient is able to do finger flexion on the left side but unable to do it on the right
side so I am suspecting injury of the lumbrical muscles which is supplied by the

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median and ulnar nerves.
• Stabilize the finger joints
▪ Can you flex your finger, checking for movement at the PIP joint
▪ Patient is able to move the finger at the proximal interphalangeal joint on the left
side, but unable on the right side so I am suspecting an injury to the flexor
digitorum superficialis
▪ Can you flex your finger, checking for movement at the DIP joint
▪ Patient is able to move the finger at the proximal interphalangeal joint on the left
side but unable to do on the right side so I am suspecting an injury to the flexor
digitorum profundus.
• Ask the patient to abduct and adduct the fingers
▪ Patient is able to do abduction and adduction of the fingers on the left hand, but
unable to do on the right side so I am suspecting an injury to the interosseus
muscles which is supplied by the ulnar nerve.
• Ask to do thumb movements
▪ Do flexion, extension, abduction, adduction and opposition of the thumb
▪ Patient is able to do all thumb movements on the left hand, but unable to do on the
right side, so I am suspecting injury to the median and ulnar nerves.
▪ Pen touch
o Now I am going to the pen touch test to check for abductor strength of the median nerve.
o Can you please move against the resistance?
o Patient is not able to do pen touch on the affected side, so I am suspecting injury to the median
nerve
▪ Card holding
o Now I am going to do the card holding test. This is done to check the strength of the adductor
muscles.
o Please hold the paper in between your thumbs, I will try take it, please don't let me do it.
o Patient is not able to perform the card holding test on the right side, so I am suspecting injury
to the ulnar nerve.
▪ Sensation
▪ 4 areas
o 2 palmar
• Median nerve: thumb
• Ulnar nerve: 4th finger
o 2 dorsal
• Radial nerve: snuff box area
• Dorsal cutaneous branch of ulnar nerve: below the MCP of 4th finger
▪ I would like to conclude my examination by performing a whole neurovascular examination of the
hand.
Management
Because patient is unable to perform flexion of wrist and flexion of MCP, PIP, DIP and flexion,
extension, adduction and abduction of the fingers and the thumb on the right side, I am suspecting
injury to the flexor carpi ulnaris, flexor carpi radialis, palmaris longus, flexor digitorum
superficialis and flexor digitorum profundus which is supplied by the median and ulnar nerve.
I will have to refer you to the hand surgeon as I have found a nerve involvement and tendon
injuries.
Hand exam: Scaphoid fracture

2:10 PM
• Most common bone to be fractured in the wrist

• The problem with this bone is that it is often missed on the initial x-ray
o If you have doubts, just treat it as a fracture
• Cast for 10 days
• Follow-up after 10 days then do a repeat x-ray
▪ If positive for fracture, just keep the cast for 4 more weeks
▪ If negative for fracture, but with thumb pain and tenderness, do an MRI
• Has poor blood supply
o Non-union

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o Avascular necrosis
• Usual mechanism of fracture is a fall on an outstretched hand
-------------
28 years old Mark comes to you with a history of fall on his outstretched hand. He is having pain on his
right wrist. You saw him last week, and at that time you had ordered an x-ray of his right wrist which
turned out to be normal. Today, he is here because the pain is not getting better.
TASKS:
2. Tell the reason why he is having pain in his hand
3. Order further relevant investigations
Differential Diagnosis:
▪ Scaphoid fracture
▪ Fracture of the radial-styloid process
▪ Osteoarthritis or fracture of the first carpo-metacarpal joint
▪ De Quervain's tenosynovitis
APPROACH
▪ I understand from my notes that you had a fall recently. I am really sorry about that. How are you
feeling at the moment? Any pain?
▪ How severe is your pain at the moment? Do you need pain killers? Any allergies?
▪ Please excuse me for a moment, I would just like to talk to my examiner.
▪ Examiner, I would like to give my patient some painkillers.
▪ Good Day. I’m Dr.________, I’m the HMO in this hospital. How do you want me to address you?
▪ Today I’m going to do a physical examination of your hand to find out the reason why you are having
pain in your wrist. I’m going to have a look, feel and I’ll ask you to do some movements. Is that
alright with you?
▪ Can you expose your hand up to your mid upper arm while I wash my hand.
▪ During the examination if I hurt you or you feel uncomfortable, just let me know so that I could stop.
▪ Can put your hands over this pillow?
▪ Inspection:
o Dorsal
• On inspection, comparing both hands, there were no erythema, scars, swelling of the
snuffbox and joints.
• No wasting of interossei muscle or small muscles of the hand.
• No Heberden and Bouchard’s nodes.
▪ MCP: RA
▪ DIP: OA
• I cannot see any stigmata of rheumatoid arthritis. There were no ulnar deviation, no z
deformity, no boutonniere and swan neck deformity.
• There were no sausage shaped phalanges and no nail pitting psoriatic arthritis.
o Palmar: Can you turn over your hands for me?
• Comparing both hands, there were no wasting of thenar and hypothenar muscles.
• No claw hand seen.
o Elbow: Can you show me your elbow? On inspection there were no psoriatic patches and there
were no rheumatoid nodules palpated. (over olecranon)
▪ Palpation:
o Can you please point to the site of pain? I'm sorry, I will be touching that side towards the end,
I will be starting on the non-painful part.
o On palpation, the temperature, CRT and radial and ulnar pluses were normal.
o There were no hypothenar and thenar wasting. No nodules palpated.
o Can you open your hand and then close it?
• There was no thickening of the tendon.
o Can you turn over your hand for me?
• There were no tenderness and swelling of the ulnar, radial styloid, metacarpophalngeal
and proximal interphalangeal joints.
• The sensation for radial(dorsum of the hand in the web space between thumb and index),
ulnar (palmar, on the tip of little finger) and median nerve (palmar, on the tip of the 3rd
finger) were all normal.
▪ Move:

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o Can you bend your wrist upwards (extension) and downwards (flexion)?
o Can you move your wrist outwards (ulnar deviation), and inwards (radial deviation)
o Can you bend your fingers for me? (flexion)
o Can you open it again? (extension)
o Can you separate your fingers? (abduction) and bring it back? (adduction)
o Can you follow my thumb movements? (thumb away from palm:extension; thumb pointed
upwards:abduction; thumb towards the pinky:flexion; thumb against the palm:adduction)
o Now, I’m going to move it, please relax your hands for me.
o There were no limitation of movement on active and passive flexion and extension of the wrist,
flexion and extension of the MCP joints and flexion, extension, abduction, adduction and
opposition of the thumb.
▪ Special test:
o Axial compression test (Scaphoid fracture)
o MCP joint Stability test: passive movement of MCP joints
o Long flexor tendons test: bend DIP and PIP joints
o Phalen’s (CTS)
o Tinel’s (CTS)
o Finkelstein’s test (De Quervain’s Tenosynovitis)
▪ Function test:
o Grip Strength
o Key grip
o Opposition strength
o Write with a pen
▪ To complete my examination, I would like to examine the elbow joints and do a neurovascular
examination of the upper limb
▪ Explanation
You have fracture of one of the small bones of the wrist called scaphoid fracture. This may have
happened because you've had a fall in an outstretched hand. The problem with this fracture is, the x-
ray may miss the finding the fracture during the first week from the injury. Therefore, when we
clinically suspect this fracture as in your case, we try to limit the movement in the affect hand to
prevent the fracture from getting worse. Medically this is called as immobilization. We are now
going to apply a cast for you now, and you need to wear this for a minimum of 10 days, and I will
review you again and arrange another x-ray during your review.
Further investigations: I would like to do an MRI scan because this bone is having a poor blood
supply, and there is a big risk of complications if the blood supply to this bone is decreased delivery
of oxygen and nutrients to the bone, and the bone cells may die which is a condition called
avascular necrosis.

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Headache examination
11:38 AM
Your next patient is 48 years old Mr. John, who presents to your GP clinic with headache.
TASKS
2. Tell him the most likely diagnosis and differential diagnosis.
Types of headache
▪ Tension
o Localized tenderness over the head
▪ Migraine
o May have visible pulsations in the temporal area
▪ Cluster
o Lacrimation, drooping of eyes, runny nose
Causes
1. Infections
o Viral - URTI (rhinitis, sinusitis, common cold and flu)
o Bacterial - meninggococcemia, meningitis
Examination
▪ Nose - check the nasal mucosa
o Pallor, swollen, boggy
▪ Mouth
o Pharyngeal erythema
o Swelling and exudates in the tonsils
o Check for deviation of uvula (Quinsy/peritonsillar abscess displaces the uvula)
• If any of these findings is positive, take a swab
o Check for white-coated tongue (bacterial infection)
• If positive, take scrapings of the tongue
▪ Ear
o I would like to look into the ear with the otoscope to see if there is bulging of the typmanic
membrane
▪ Sinuses
o Check frontal and maxillary sinuses
o If positive, do a transillumination test
• Ask the patient to open mouth, throw light towards the maxillary sinus
▪ If sinuses are intact, you can see the light in the sinuses
1. Vision problems
2. Space occupying lesion in the brain
o BP is high
o Fundoscopy for papilledema
3. Subarachnoid hemorhage

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o Neck stiffness
o GCS
o Neurological signs
4. Temporal arteritis
o Thick, tender, temporal artery
o Rule out polymyalgia rheumatica
• Hip and shoulder weakness/pain
o Rule out vision problems
Examination
▪ Vital signs focusing on temperature and blood pressure
o High BP, do fundoscopy to rule out papilledema
▪ I'm going to examine you to find out why you're having this pain. This examination involves me
having a look and feeling your head, and doing some other tests. Is that okay with you?
▪ Inspection
o During my examination, I might ask you to expose some parts of your body relevant to my
examination.
o On inspection I cannot see any rash, but I might need to expose him properly later on to check
for any rash. (meninggococcemia)
o Stigmata of cluster headache: red watery eyes, runny nose, droopy eyelids
o I cannot see any visible pulsations in the head
o I cannot see any swelling, redness or thickening of the temporal artery (temporal arteritis)
▪ Palpation: I'm going to have a feel of your head
o Palpate occipital, parietal, temporal, frontal
o Palpate midline tenderness over the cervical spine (cervical spondylosis) and thoracic
tenderness
▪ Sinuses
o Check frontal and maxillary sinuses
o If positive, do a transillumination test
• Ask the patient to open mouth, throw light towards the maxillary sinus
▪ If sinuses are intact, you can see the light in the sinuses
▪ Nose - check the nasal mucosa
o Pallor, swollen, boggy
▪ Mouth
o Pharyngeal erythema
o Swelling and exudates in the tonsils
o Check for deviation of uvula (Quinsy/peritonsillar abscess displaces the uvula)
• If any of these findings is positive, take a swab
o Check for white-coated tongue (bacterial infection)
• If positive, take scrapings of the tongue
▪ Ear
o I would like to look into the ear with the otoscope to see if there is bulging of the tympanic
membrane
▪ Eyes
o Do full eye exam
▪ I would like to ask my patient to lie on the bed. I would like to check for neck stiffness. And I would
like to do a complete neurological examination [upper and lower limb motor and sensory
examination, and all the cranial nerves]
Positive examination findings: visible pulsations over the affected temporal area
After examining you, I found out that you have some visible pulsations on one side of your head. It can
be seen in migraine, however at this point, I am more concerned about a more serious condition which is
temporal arteritis, which is the inflammation of a blood vessel on one side of your head, that is why we
would do some investigations such as routine blood tests and inflammatory markers, and I will refer you
to a specialist who will probably do some imaging to confirm the diagnosis.
Hip examination
Tuesday, 23 May 2017
9:36 AM
Kevin aged 58 years presents to your surgery in a busy Friday afternoon for his repeat scripts of Coversyl.

Page 44 of 94
He is a builder by occupation. While you are writing his script, he mentions that he has been getting pain
in his right groin and right hip region on and off for the last couple of months. This pain interferes with
his work, particularly climbing up and down ladders and carrying heavy timber loads. The area
surrounding gets swollen sometimes on busy days at work. He reports playing a lot of sports in his youth
but no prior surgery. He is worried about his future as a builder.
TASKS
1. Perform appropriate physical examination
2. Explain the condition to the patient.
APPROACH
▪ General appearance
o Holding a protective posture
o Pain expression on the face
▪ Gait: Trendelendburg sign/Lurking gait

o Which hip hurts? Right hip
Hold both ASIS
o Could you please stand on your left leg, lift your right leg backwards
o The sound side will sag
▪ Look (front, side, back)

1 meter from the patient, kneel down so that you're eye level with the hip
o I am looking from the front and I am comparing both the hips
• Both the ASIS are in the same level
• Both the inguinal creases are symmetrical
• There is no redness/erythema, no visible swelling, no visible scar
o I am looking from the side
• The lumbar curvature looks normal (normal lordosis)
▪ There is no fixed flexion deformity
▪ There is no hyperextension deformity
o I am looking from the back
• Both the PSIS are on the same level
• No wasting of the gluteal muscles
• No scars
Ask the patient to go to the cough, and lie down.

▪ Feel (temperature, tenderness)
o I am checking the temperature of both hips, comparing on the upper half and lower half of the
body
• There is no elevation of temperature
o I will press on different parts of the hip, tell me if the area I am holding is painful
Start on the non-painful hip
• ASIS
• Iliac crest
• Greater trochanter
• Adductor tendinitis
• Symphysis pubis (ask permission before palpating midline bony landmarks)
• Pubic tubercle
Ask patient to turn laterally
• PSIS
• Sacroiliac joint
• Ischial spine
▪ Move
o Active
• Flexion: Could you please bring your knee towards your chest?
• Extension (partial): Could you please put it down in neutral position?
• Abduction: Could you please bring this left towards me?
• Adduction: Could you please cross it over to the other leg?
• *External rotation: rotate hip outwards
• *Internal rotation: rotate hip inwards
o Passive
Place your hand on the hip joint, feel for crepitations

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• Flexion
• Extension
• Abduction
• Adduction
All ranges of motion of the left hip are full with no pain
Extension and flexion of the right hip is painful with limitation of movement
I will not continue with adduction as the patient feels pain
All ranges of movement of the right hip were restricted because of pain
▪ Measurement
o Apparent leg length
• Measure from umbilicus to the medial malleolus of both legs. Check for discrepancy
between the legs
Both the apparent leg lengths are equal
Unequal in osteoarthritis
o True leg length
• Measure from ASIS to the medial malleolus of both legs. Check for discrepancy between
the legs
Unequal in fractured femur
▪ Special test
o Thomas test
• Elicit whether there is fixed flexion deformity of the hip
• Ask patient to flex hip
• Press on the knee towards the abdomen
• The contralateral leg will go up if there is fixed flexion deformity because the lumbar
curvature cannot flatten out
o FABER test (Flexion, Abduction, External rotation)
• Can you please do a figure of 4 with your legs
• Press knee down, press over the opposite hip
• Where do you feel the pain?
▪ Midline in front: symphysis pubisitis
▪ Hip: osteoarthritis of the hip
▪ Back: sacroileitis
o Squeeze test
• Could you please squeeze my fist in between your thighs?
• Patient will feel pain in the midline
▪ Adductor tendons are inflamed = adductor tendinitis
▪ Examine one joint above and one joint below the hip joint
o I would like to check one joint above which is the spine and one joint below which is the knee
▪ Examine whole lower limb neurological
o I would like to do a full neurological exam of the lower limb
Osteoarthritis Adductor Tendinitis Trochanteric bursitis

Pain Yes Yes +/-
Trendelenburg Yes +/- +/-
gait
Look normal normal Redness in the Inflamed
area in the trochanteric
area
Temperature normal normal Increased temperature
Tenderness May get tenderness if you Tenderness on medial Tenderness on greater
press on the hip joint thigh trochanter
Move All ROM are painful and Adduction is painful and All normal OR abduction
restricted in the affected restricted is painful and restricted
side
Measurement Discrepancy between normal Normal
apparent leg lengths
Thomas test normal normal Normal
FABER yes no No
Squeeze test no yes no
Reporting:

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▪ Osteoarthritis
John thank you very much for letting me do the physical exam. I am sorry if I caused you pain at
any moment.
I had a look at your hip, it looked fine, however, while you walked you were walking with a limp
which is not normal.
I also felt your hip, some areas were painful, and you were not able to move it freely in all
directions.
In the measurement, there is nothing to worry about.
I did a special test as well, one called FABER test was positive
Considering the physical examination findings, you most likely have osteoarthritis affecting the
right hip. Do you know what it is?
This is your hip bone and this is your thigh bone. The hip bone and thigh bone has a joint, which is
a ball and socket joint. This is the ball and this is the socket.
You have a problem with the lining of the joint, it's a bit irritated and eroded due to weight bearing
and repetitive movements. It is also called a wear and tear injury.
That is what I am considering but my other differentials in my mind are adductor tendinitis which is
a problem in the medial group of muscles of the thigh, and trochanteric bursitis which lateral side of
the hip
▪
Hypertension Exam
5:32 PM
A 30 year old male comes in to your GP clinic with BP measured to be 160/90. He had further 2 readings
and revealed his BP to still be elevated. He is generally well but smokes 20 cigarettes per day for the last
10 years.
TASKS
1. Perform physical examination
2. Advise further management
**very important to check: kidney, thyroid, acromegaly, cushing

Our aim is to look for:
▪ Causes of secondary hypertension (TRACKPADS)
o Thyrotoxicosis: tremors in the hands, nail changes, bulging eyes, thyroid bruits, gynecomastia,
pretibial myxdema
o Reno-vascular:
• RTA - renal artery bruits - check with bell of stethoscope
• Fibromuscular dysplasia
• Reflux nephropathy
• Polycystic kidney disease
o Aorta
• COA - radio-radial/radio-femoral delay
o Cushing syndrome - moon-shaped face, striaes in the arms and neck
o Kidney (chronic kidney disease - glomerulonephritis, nephropathy (do urine albumin creatine
ratio: baseline test) - sodium retention, PCKD)
o Pheochromocytoma
o Aldosteronism (Conn)
o Drugs (OCP, NSAIDs, steroids, alcohol), DM
o Sleep apnea, smoking
▪ End-organ damage
o Eyes: fundoscopy
o Neck: carotid bruits (carotid stenosis)
o Chest: displacement of apex beat (left ventricular hypertrophy d/t long-standing hypertension)
o Abdomen: abdominal artery bruit (aortic aneurysm)
o Legs: weak peripheral pulses (peripheral artery disease)
In all physical examination, our first comment should be general appearance. Then comment on BMI.
▪ Hands:
o Check for clubbing

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o Check for tremors of hyperthyroidism
o Check for radio-radial delay to check for COA (examiner, I would also want to do the radio-
femoral delay)
o Check for striae of Cushing disease in the volar aspect of the forearm
o Check biceps and triceps reflex (hyperreflexia as feature of hyperthyroidism)
▪ Face
o Look for moon facies of Cushing disease
▪ Eyes
o Fundoscopy to check for retinopathy
o Look for bulging eyes (hyperthyroidism)
▪ Throat
o Check the tongue and throat inlet (OSA) (Malampati score)
▪ Neck
o Check neck circumference (OSA)
o Check for carotid bruit
• I want to listen to some vessels in your neck. It might be uncomfortable, please bear with
me.
• Can you please look to the other side?
• Feel for the carotid artery, then place the stethoscope over the pulse.
• Kindly hold your breath for a while, while I listen.
o Check for thyroid bruit
• Can you look straight?
• Place stethoscope over the thyroid
▪ Chest
o Gynecomastia in hyperthyroidism
o Displaced apex beat as sign of LVH
o Murmurs
▪ Abdomen
o Abdominal striae of Cushing
o Abdominal aortic bruit
• 2 cm above the umbilicus
o Renal artery bruit
• 2 cm lateral to the site of abdominal aortic bruit
o Ballotable kidney
▪ Legs
o Pretibial myxedema
o Check pulses for peripheral vascular disease
o Reflexes of the lower limb
Investigations: FBE with hemoglobin, UEC for renal function, blood lipid level, blood sugar level,
routine microscopic examination of urine, 12L ECG, insulin-like growth factor, 24 hour dexamethasone
suppression test
If the investigations come back normal, most likely you have essential hypertension. You need to do
lifestyle modifications first. (regular exercise 30 minutes a day, 5 days a week, 150 minutes per week
total, no salt, low fat, avoid oily food, do not smoke) If lifestyle modifications do not work, refer to
cardiologist to start medications.
Hypertension-CV risk assessment

Monday, 1 May 2017
1:58 PM
You are a GP, 26/F, presented to you because on her last visit to the blood bank, her blood pressure was
150/100. she has been asked to see the GP. The practice nurse checked her BP at 3 different times, and at
all times her BP was the same. PE did not reveal any abnormality.
TASKS
1. History
2. Explain differentials
3. Explain most probable dx and management to the patient

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▪ Primary Hypertension
▪ Secondary Hypertension
▪ Kidney Causes
▪ Adrenal - pheochromocytoma
▪ Cushing's
▪ Conn Syndrome
▪ Contraceptive pills
▪ Steroids
Hypertension: check 3x
MNEMONIC: CAUSES OF HYPERTENSION

T - hyperThyroidism - weather preferences, recent weight change (weight loss), change in bowel
habits (diarrhea in hyperthyroidism)
R - Renal artery stenosis - can cause blood in urine, back pain. Vague symptoms and nothing
specific
A - coarctation of the Aorta - can rule out on physical exams (RR and RF delays), disparity of BP
on all 4 extremities
C - Cushing's - features: weight gain, Moon facies, purple striae, acne, hyperpigmentation,
hirsutism, atrophic skin with telangiectasia
K - all Kidney disorders - change in color, frequency, any family history of kidney diseases
(Polycystic kidney disease -- Occasional headaches -- ANEURYSMS in PCKD)
P - Pheochromocytoma - sweating, headaches, palpitations, nervousness
A - primary hyperAldosteronism - CONN'S SYNDROME - generalized muscle weakness,
D - drugs: OCP, Steroids, alcohol, recreational drugs (cocaine), smoking, NSAIDs
OCP - how long have they've been using it?
S - obstructive SLEEP apnea - tiredness, even in the morning, snoring, weight changes
UREMIA - scratch marks

ACROMEGALY
Routine investigations
First line:
FBE, ESR, UEC, RFTs, TFTs,
Primary hyperaldosteronism - Na+ increase, K+ decrease
Renal ultrasound
12L ECG - how hypertension has affected the heart (enlarged in chronic hypertension)
Lipid profile
2nd line investigations

Cortisol levels - Cushing's
Catecholamine & VMA - pheochromocytoma
Renin-aldosterone ratio (high aldosterone, low renin = ratio will go down in primary
hyperaldosteronism)
2d echo
MANAGEMENT OF HYPERTENSION
First diagnosis of hypertension: do lifestyle modifications for 6 months. If still persists, start anti-
hypertensives

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Diet - dietician.
Regular exercise
Smoking, Alcohol cessation
Sleep hygiene
BP aim: </= 140/90
OSA - sleep study. Then give CPAP
If hypertension with peripheral organ damage = ANTI-HYPERTENSIVES
If lifestyle medication fails,

Start with a single anti-hypertensive, lowest dose.
Do regular monitoring of BP at home
Once the BP doesn’t go down (after 4-6 weeks), increase dose
If still not work (4-6 weeks), add on another med OR change med
Usually, start them on ACE inhibitors or ARBs

ACEi - CONTRAINDICATED IN bilateral renal artery stenosis and asthma
Patients >/= 65yrs = start on diuretics alone
Unintentional weight loss: >10% of body weight within 2 MONTHS?
PE
Ga: is he conscious or oriented? PICCLED BMI
Any Cushingoid facies? Moon facies, central obesity
Frontal bossing? Big hands? = ACROMEGALY
Hands: clubbing, tremors, bruising, dry coarse skin, excess sweating of the palms
PULSE: equal on both sides? Any RR or RF delays?
Femoral bruits
BP: any postural variation, BP on all extremities
EYES: lid retraction, exophthalmos, any generalized condition or facial discoloration of the face?
Fundoscopy
FUNDOSCOP CHANGES
Y
Grade 1 Narrowing,
Silver wiring
Grade 2 AV nicking
Grade 3 Cotton wool spots, flame shaped hemorrhage
Grade 4 Papilledema
MOUTH: HIGH ARCH PALATE

Neck: Carotid and thyroid bruits
Chest/CVS: apex beat, Basal crepitations and sacral edema
Abdomen: scars, distention, Any invisible masses or pulsations = AAA
Palpations = pulsative, organomegaly, renal angle tenderness
Auscultation: aortic bruit, renal bruit,
Lower limb: Edema, peripheral pulses, sign of peripheral vascular disease
Office tests: UDS, ECG, BSL
Any signs of pregnancy

Do a urine pregnancy test with consent
OCP induced hypertension:

Stop OCPs immediately wherever you find there's a high BP. Check again after 2-3
days. Choose another form of contraception
AUSTRALIAN CARDIOVASCULAR RISK ASSESSMENT

Age, sex
Diabetic or not
Current BP
Cholesterol levels - total cholesterol: HDL ratio

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Smoker or non-smoker
ALREADY HIGH RISK (>15% risk of CVD within the next 5yrs)
Diabetes AND age >60
DM with microalbuminuria (>20mcg/min, or urinary albumin:creatinine ratio >2.5mg/mmol
(MALES), >3.5mg/mmol for females)
Moderate or severe CKD, persistent proteinuria or eGFR <45ml/min/1.73m2
Diagnosis of familial hypercholesterolemia
BP>/= 180/110
Serum total cholesterol >7.5mmol/L
Aboriginal and Torres straight islander aged >74
Moderate Risk: 10-15% risk of CVD in the next 5yrs

Low Risk: Less than 10% of CVD within the next 5 years
Male
Cholesterol levels 7.7 (N<4)
Smoker/Nonsmoker = SMOKER
BP 160/90
Age 40
HDL normal
LDL high
Blood sugar levels normal
==> NOT ASSESSED BECAUSE HE IS 40 YO,
35-45YO only for aboriginal people
57 years old = orange = HIGH RISK!
55/F diabetic, non-smoker

BP 140/90
TC:HDL ratio is 6
==> yellow = HIGH RISK!
https://www.heartfoundation.org.au/images/uploads/publications/Absolute-CVD-Risk-Quick-Reference-
Guide.pdf
Lifestyle mod ==> 3-6mos ==> meds

If there is fam history
****
CASE FROM KAREN:
Hyperlipidemia/Cardio Vascular Risk assessment

Case: Your next patient in GP practice is a 45-year-old man, for whom you arranged some investigations
last week. Cholesterol is 7.5, HDL is 1.2, LDL is high triglyceride is high. This person’s father had MI
one year back had bypass. Mother has HTN.
Task
a. Take history (The patient has sedentary life style, works in the computer, lack of exercise, un
healthy diet, a bit overweight, father underwent cardiac surgery, mother has HTN, job is also stressful.)
b. Explain the results
c. Manage the case
Risk Factors for CVD:

- Hypertension
- Smoking
- High cholesterol
- Diabetes
- Obesity
- Sedentary life stress
- Stress/Type A personality
- Alcohol excess
- Poor dietary habits
- Family history of MI, HTN, DM
- Male
- Age

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Biochemical:
- Normal: Cholesterol <4mmol/L
- LDH <2.5
- HDL >1mmol/L
- Triglyceride <1.5
When to start statins:

- If patient is having existing coronary artery disease if cholesterol > 4mmol/L
- If patient is having one of the risk factors: DM, familial hypercholesterolemia, HTN, PVD, If family
history of 1st relative <60yo with CHD if cholesterol is more than >6.5 or if cholesterol >5.5 with HDL
<1.
- If the pt is a male 35-75yo or it’s a post-menopausal women >75yo cholesterol is >7.5 or the TG >4
- If cholesterol is more than >9
History:
- Alright, John good to see you again. Your results are here. I need to ask you some questions
- Ask the examiner “If the risk assessment chart is available to do the cardiac vascular risk
assessment?”
- Alright John, your blood report showed you have got high cholesterol in your blood, you also have
high bad lipids in your blood. LDL and TG are the bad lipids. The good lipids, HDL, is low. When you
have bad lipids they all come together and block the blood vessels leading to Heart and PVD and strokes.
You have hyperlipidemia also high risk for DM, also lead to HTN.
- We will start with the life style modification. It’s important to do some exercise 30min of exercise 5
days a week. Would you be able to do that?
- Diet: Eat healthy. “Red light theory. Avoid the red meat. Whatever is green eat unlimited, yellow eat
in a limit, whatever is red avoid it. Don’t eat too much junk food. Its imp to maintain a healthy weight. I
understand you job is stress, take it easy do some relaxation exercises spend some time with friends and
family in the weekends to reduce your stress. If you are smoking quit smoking. Drink alcohol within the
safe limits. Assess if the patient needs statin. Before we start on the statin we need to do LFTs and CK
test.
- Regularly monitor his BP, fasting BSL, review them often.
- Reading material. Review him again. Referral no at this stage
Hypocalcemia Examination
3:27 PM
35 year old lady Jane presents to you with some tingling sensation and severe burning pain in both her
hands. She had been diagnosed with hypothyroidism for the past 7 years and she has recently had a
surgery for goiter (thyroidectomy), she has been feeling like this since after the surgery.
TASKS
1. Perform PE
2. Advise patient
Differential Diagnosis:
▪ Hypocalcemia due to removal/injury to parathyroid glands
▪ Carpal tunnel syndrome - median nerve compression
▪ Ulnar nerve neuropathy
▪ Cervical radiculopathy
▪ From the neck: neck pain, shoulder pain, hand pain
▪ From the elbow: wrist pain only
***
Median nerve: C5-T1
Hypocalcemia: pins and needles, paresthesia noted, sensation is intact, no nerve damage is noted
APPROACH
• Look
• Feel
o Temperature
o Tenderness

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o Pulse
o Circulation
o Sensation with cotton and pin
• Sensations will be intact. Just a burning pain will be felt
• Move
o Median
o Ulnar
o Radial
• Special Tests
o Carpal tunnel syndrome
• Phalen's:
• Tinel's: tap on the middle of the wrist. Do you feel any shock-like pain, pins and needles
sensation over this area?
▪
o Froment's sign
o Ulnar nerve entrapment
• Tinel: ulnar styloid side
o Chvosteks' sign
o Trosseau's sign
• To complete my examination, I would like to examine the elbow joints and do a full neurovascular
examination of the upper limb.
• Explanation
I have examined you for all the nerve injuries, and I have found out that all your nerves are intact.
However sometimes, these symptoms may also be due to low levels of calcium in your blood. In
your case, you had this surgery and you had your thyroid gland removed. It is a common
complication after this kind of surgery to have low levels of another hormone in the body called as
parathyroid hormone which is responsible for regulating the calcium levels in the body. In your
case, I suspect that you have had this complication and that is why you are having these symptoms.
Informed Consent - amputation, blood transfusion

Sunday, May 28, 2017
5:21 AM
How to obtain a informed consent for procedure:
Make sure that the person is well-oriented to time, place and person.
▪ Tell about the diagnosis
o Explain about the condition
▪ Tell about the proposed procedure

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▪ Tell about the risk of procedure
▪ Tell about the risk of not having the procedure
▪ Tell about the alternative (if available)
▪ Build rapport first. Ask how the patient is. Is he having any pain. Is he ready for the procedure.
--------------
26 year old male, just recently had a motor vehicle accident. His left leg is crushed. The specialist has
assessed the patient and they are thinking about the possibility of a below the knee amputation.
TASKS
1. Explain the proposed management
2. Get the consent from the patient
Build rapport: I am sorry with what has happened to you. The specialist has told me about your condition,
are you having any pain today?
Check orientation: Do you know the date today? Do you know where you are? Do you know who you
are?
Unfortunately with the condition that you have, we might have to manage it operatively. I am so sorry, we
may consider the possibility of cutting your leg.
Do you want me to call someone to be with you?
To save your life, we might have to cut your leg so that the infection will not spread to the rest of your
body. Also, if we don't do it now, we might have to cut more than what we have to cut now.
We can try to treat the leg, connect the nerves and blood vessels, but the chances of infection and blood
loss and complications will be more.
I know it is a very tough situation for you, but we also have a good prosthetic department who could
provide an artificial limb for you. But at the end of the day, the decision is yours.
I will come to you again, you can discuss with your family members. If you want to ask any more
questions, I will be here to answer them.
Why did you not get consent?

The patient might be emotional and in shock.
The patient might be under the influence of morphine.
--------------
A 28 week pregnant lady (Jehovah's witness) comes to you with a severe antepartum hemorrhage. The
patient was resuscitated and they have diagnosed grade 4 placenta previa. The specialist has decided to
give blood transfusion and he requested you to talk with the patient.
Unfortunately Mary, we have found that you are having a condition called placenta previa. As you have
lost a lot of blood, the specialist has advised to give you blood transfusion. I am here to take your consent
for this procedure.
Mary as you have lost a lot of blood, it can be dangerous for you as well as your baby. Mary also this
procedure can have some risks like spread of infection, but for you this can be life-saving. If we don't give
this, your body might go into shock and that will be very bad for you.
In that case, we can just give you IV fluids.
Did you get the consent?

The patient was a Jehovah's witness, so it is against her religion so she has refused it completely.
I have checked the orientation, the patient is oriented.
I have explained the condition well, I have explained the risks of the procedure and the risks of not having
the procedure, but she still prefers to do the alternatives.
If the baby needs to have blood transfusion, can we give?

YES. After delivery, we can give. Because patients CANNOT deny life-saving procedure to the child.
(In Australia, the fetus has NO rights. So we have to wait until the baby is born)
Knee Examination
10:53 AM

Page 54 of 94
PHYSICAL EXAM OF THE KNEE
1. Look
a. Scar
b. Swelling (suprapatellar fullness (bursae)
c. Redness
d. Rash
e. Bruising
f. Muscle atrophy
g. Deformity (flexion and extension; genu varum - bowlegs, genu valgum - knock knees)
8
Flexion deformity Extension deformity
a. Gait (antalgic if with pain)
b. Look for popliteal cyst on the back of the knee (baker's cyst)
1. Feel
a. Assess temperature with the back of the hand, above the knee, on the knee, below the knee
b. Tenderness
i. Patella
ii. medial joint line
iii. lateral joint line
iiii. popliteal region
v. head of fibula - from head of fibula palpate all the way down to lateral malleolus looking
for tenderness then go to medial malleolus then follow the shin and palpate all the way
to the tibial tubercle (in Osgood Schlatter, tibial tubercle is tender)
vi. Quadriceps tenderness
vii. ASIS to lateral part of patella - Iliotibial band tenderness
c. Palpate pulses
1. Move
a. Active movement
i. Flexion - can you slide your foot towards your bottom
ii. Extension - can you stretch your leg out
b. Passive movement - look for crepitation (sign of chondromalacia patellae/patellofemoral pain
syndrome/jogger's knee - the ITB is really tight. The patella lies in the femoral groove
normally. Since ITB is really tight, it pulls the patella to the side. The undersurface of the
patella gets early arthritic changes because it gets scratched under the lateral femoral condyle)
1. Special tests
a. Patellar tap

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a. Patellar bulge
a. Patellar apprehension
a. Anterior drawer test

Page 56 of 94
a. Posterior drawer test
>
a. Valgus stress test
a. Varus stress test
a. Apley's grinding tests

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a. Clark's test/patellofemoral test
a. Patellar tilt test
Knee examination
6:12 AM
19 year old boy came to your GP center with complain of pain in his right knee. He has been involved in
net-ball game for long and was preparing for an upcoming game. His medical history is unremarkable. He
is apparently healthy. He had no trauma to the knee.
TASKS
1. Perform physical examination
2. Tell the condition
3. Manage the case
Cases
▪ Chondromalacia patella
▪ Patellar tendonitis
▪ Patellar subluxation
General look
▪ Any distress
▪ Protective posture
Gait +/- Squat down
▪ Could you walk a few steps for me? Does it hurt when you walk?

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▪ I found that the patient is walking at a normal pace, with normal arm swing, no antalgic posture, no
pain during walking
Look
• Bend down when looking
Front: I am looking from the front, comparing both knees, I can see that:
o Quadriceps: quadriceps muscles are not wasted
o Suprapatellar pouch: both are not bulged
o Peripatellar pouches: both are not bulged
o There is no genu varum or genu valgus deformity
o There is no scar of previous surgery
o The patellar tendon area does not have erythema
o The rest of the area is normal
Side
o No fixed flexion deformity (osteoarthritis)
o No hyperextension deformity (females who often wear high-heels)
Back
o Hamstring: no wasting
o Calf muscles: no wasting
o Popliteal fossa: baker's cyst
Feel: ask patient to lie down
▪ Temperature
o Compare with upper half and lower half of the body
▪ Tenderness
o Can start with good side, or can do both together
▪ Bony landmarks
o ASIS
o Lateral joint margin
o Medial joint margin
o Patella
o Patellar tendon
o Tibial tuberosity (long-standing patellar tendinitis giving rise to apophysial tendinitis)
o Shin
o Medial malleolus and lateral malleolus
o Bend the knee a little bit, and feel the joint line (between femur and tibia)
o Popliteal fossa for any Baker cyst
Move
▪ Active (range of movement, pain during movement)
o Extension and flexion
▪ Passive (crepitations)
• Put one hand on the knee joint
Special test
1. Patellar tap (large effusion)
2. Swipe test/Bulge test (small effusion)
3. Patellar tilt test (patellar tendinitis)
4. Clark test (chondromalacia patellae/Patello-femoral test)
5. Apprehension test (subluxation of patella)
6. Anterior drawer test (ACL)
7. Posterior drawer test (PCL)
Varus test (MCL)
8. Valgus test (LCL)
9. Apley Grind test/McMurray test (Meniscus)
To complete my examination, I would like to examine one joint above which is the hip joint, and one joint
below which is the ankle joint. And I would like to do a full neurological examination of the lower limb.
MVA - Cranial nerve exam

7:56 AM
28 years old Jennifer was involved in a MVA. She was beside the driver and got hit in her head only. Rest

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of the body received no injury as she recalled the even. Primary survey was done and the patient is stable
at the moment.
TASKS
1. PE
2. Diagnosis and management
Physical Exam
▪ CN I
▪ Do you have difficulty with the nose? Any runny or clogged nose?
▪ Check one nostril at a time.
▪ CN II
▪ Acuity: use a Snellen chart (do a binocular vision first, then uniocular vision next)
▪ If patient is wearing glasses, leave the glasses on
▪ Field
• Use the pin with red tips
• Distance between you and patient is 1 meter
▪ Do confrontation test
▪ Ask the patient to remove the glasses
▪ Check binocular vision then uniocular vision
▪ Tell patient to look straight into your eyes
▪ Move your hands from the periphery to center, on all sides
▪ Color
▪ Reflex
▪ Light: direct and consensual
▪ Accommodation
▪ Ask the patient to look at your pen
▪ Pen start at 2 feet, then move closer until 6 inches away from the patient's eyes
▪ Fundoscopy
▪ CN III, IV, VI
▪ Do an H pattern
▪ Tell patient do not move the head, but move the eyes
▪ Ask if the patient sees double (diplopia)
▪ Report which gaze the patient has diplopia
▪ Differentials for diplopia
• Any of CN III, IV, VI injury
• Any of the 6 EOM muscle injury
• Orbital floor fracture
▪ Specialist will do CT scan to find out what the problem is
▪ CN V (ophthalmic, maxillary, mandibular branches)
▪ Motor
▪ Temporalis
▪ Masseter
▪ Pterygoids
▪ Sensory
▪ Light touch (cotton wool)
▪ Crude touch (blunt end of pin)
▪ Corneal reflex (CN V (afferent) and VII (efferent))
▪ Touch at the sclerocorneal junction at the lateral part, the eye blinks
▪ Jaw jerk reflex
▪ Open a mouth a little bit, put first finger under the lower lip, tap
▪ CN VII
▪ Sensory
▪ Taste sensation of the anterior 2/3 of the tongue
▪ Motor
▪ Stapedius
▪ Wrinkle
▪ Open Eyes
▪ Buccinator
▪ Oris
▪ Smile
▪ CN VIII
▪ Hearing
▪ Whisper (just a screening test)
▪ Disturb the other ear either by rubbing your fingers, occluding the ear or rubbing the
hair
▪ Do near and far

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▪ Rinne
▪ Bang the tuning fork in the thenar region of the palm
▪ Hold tuning fork in the holding region
▪ Bone conduction: Temporal bone or the mastoid
▪ Air conduction: hold the tuning fork 2 inches away from the external acoustic
meatus, and in a perpendicular position to the ear
▪ Check bone conduction then air conduction
▪ Weber
▪ Balance - Caloric test
Management
▪ Admission
▪ I have not found anything wrong with your physical examination
▪ We still need to do some investigations like CT or MRI, but I will discuss with my senior about this
▪ Red flags
▪ Wound care
Neonatal Examination
Sunday, 14 May 2017
1:42 PM
You are the covering night resident in a suburban hospital when you are called to the delivery room to
assess an newborn baby.
TASKS
1. Focused history
2. Examine the baby and give running commentaries
3. Explain your findings to the mother
Positive points in the history: First child, normal pregnancy, and uncomplicated vaginal delivery on
term. Spontaneous crying and breathing. APGAR score of 8 at 1 minute and 10 at 5 minutes.
Positive points in the PE/Investigations:
APPROACH
▪ History
o Good morning, I am Dr. ____, one of the resident doctors here, how are you today?
Congratulations Mrs, X, how is the baby? Is your baby boy or girl? Have you named him? Is
it your first baby?
o How are you coping with your baby? Any problem or complication during or after labor? Is
the baby preterm or full term? How was the birth? Normal or caesarean? Did your baby need
any help after birth with breathing?
o Good to know as forceps deliveries can cause facial bruising, C-sections can occasionally cute
the baby's skin.
o How are you feeding your baby? Breast or bottle? If breastfeeding, ask her: how is it going
/baby latching okay?
o If bottle feeding, ask her "which milk are you giving your baby is taking? Don’t criticize if
mom has not opted to breast feed, this is an individual decision.
▪ Physical Exam
o Can you please give John to me? Oh wow, beautiful! Can I just look at his body to look if there
are any abnormalities?
o Remove the baby's clothes yourself.
o Hands:
• Nails: I can't appreciate any hypoplastic nails (present in fetal alcohol syndrome),
clubbing or cyanosis.
• There is no syndactyly or polydactyly.
• Down syndrome: I do not see any single palmar crease
• Check the tone of the arms
o Shoulders
• Shoulders are symmetrical, at normal level
o Head:
• There are no bulging or sunken fontanelles

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• Suture lines are intact
• I can't see any abnormal swelling in the head (cephalhematoma or caput succedanum)
• Can I have a tape please? I want to measure the head circumference.
o Eyes
• Down syndrome: no epicanthal folds, no Mongolian eyes, upslanting palpebral fissure
• Can I have a fundoscope please? Check ROR reflex: rule out retinoblastoma and
galactosemia
• There are no squints
▪ Corneal light reflex test (Hirschberg test) is a good screening test, but it is not very
sensitive in detecting small deviations. The child looks at a light and the light
reflection (reflex) from the pupil observed; normally, the reflex appears
symmetric (i.e., in the same location on each pupil). The light reflex for an
exotropic eye is nasal to the pupillary center, whereas the reflex for an esotropic
eye is temporal to the pupillary center.
o Nose
• There is no nasal flaring or hypoplastic nose (fetal alcohol syndrome)
o Philtrum
• Philtrum is seen. (absent philtrum in fetal alcohol syndrome)
o Mouth
• No cleft lip
o Ears
• No downset ears (down syndrome)
• No ear tags, no ear sinuses
• Can I have an otoscope please? I want to look inside the ears to look at tympanic
membrane
o Neck
• Tracheal position
• Swelling in the neck
• No
o Chest
• No pectus excavatum
o Abdomen
• No exomphalos, gastroschisis, umbilical hernia
• No organomegaly
o Hips
• No asymmetrical hip creases
• No click or clank in the hip
o Legs
• Check tone of legs (cerebral palsy)
o Feet
• There is no clubfoot or talipes equinovarus
• There is no increased space between 1st and 2nd toe (sandal sign: Down syndrome)
o Back
• No tuft of hair or swelling on the back (spina bifida)
• Remove diaper to check for imperforate anus
• Turn baby around and check genitals, check for hernial orifices
• If male: no hypospadia and epispadia, no penile chordee, no undescended testes
• If female: no ambiguous genitalia (CAH)
o Mouth
• Can I have gloves please?
• Put your finger in baby's mouth to check for rooting and sucking reflex
Neurological Examination
2:49 PM
Is composed of:
▪ Cranial nerve exam
▪ Upper limb neurological exam
▪ Lower limb neurological exam

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IPTRCS
▪ Inspection
▪ Upper limb: fasciculations (acute), muscle wasting (chronic)
▪ Power
▪ Tone
▪ Ask patient to keep their arms or legs relaxed
▪ Reflexes
▪ Ask patient to keep their arms or legs relaxed
▪ Coordination (Cerebellar function)
▪ Upper limb: Finger-nose test: see intentional tremors, past-pointing; Alternate hands:
dysdiadochokinesis
▪ Lower limb:
▪ Heel-shin test: slide your heel on your shin down, then up
▪ Toe-finger test: ask patient to tap their toe on your finger
▪ Toe tap: ask patient to tap your hand with their toes
▪ Sensory
▪ Dermatomes
▪ "Tit for T4"
▪ Pocket area L2
▪ Knee for L4 (until medial malleolus)
▪ Dorsum of foot L5
▪ Lateral lower leg and foot S1
OA/RA
9:37 AM
Dr. Kamalika
***
65/F jenny, pain and stiffness of the hands

TASKS
Perform examination
Explain the diagnosis and give differentials
***
Approach

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Hello jenny, I am Dr. I understand that you have some pain and stiffness of the hand joints. Today I
was asked to examine you. I will be feeling your joints, I will carry out some special tests as well. If
you have any pain, please stop me. Are you in any pain at the moment? *give pain killer*
Ask for pain
INSPECTION
My patient jenny, is Sitting comfortably, in no obvious pain
There will be a pillow under your desk.
Jenny please place your hands on the pillow (palms down)
On inspection, both wrists are symmetrical. No gross deviations or deformity
RA: ulnar deviation
I can appreciate that there is diffuse swelling over the joints

There are no nodules on the joints
Rheumatoid nodules:
Osteoarthritis nodes:
bouchard - proximal interphalangeal joints
heberden's nodes - distal interphalangeal joints
Now jenny please turn your hand on the other way (palms up)
No palm erythema, no thenar and hypothenar muscle wasting
No pitting or nail changes of psoriasis
Jenny can you lift your arms up (INSPECT ELBOWS)
No nodules or rashes present on the elbows and forearms
FEEL/PALPATION
I am going to feel for your hand now
TEMPERATURE
No local rise of temperature
PULSES and CRT = you can miss this
TENDERNESS
Check the wrist
ALL HAND JOINTS
MOVEMENTS (active)

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Wrist flexion, Wrist extension, ulnar and radial deviation
Abduction and adduction of fingers
Keep the pen over the palm, make patient hold the pen over the palm
Flexion of PIPJ and distal PIPJ
Thumb movements: flexion, extension, adduction, abduction, opposition
REPORT: Movements of the hand is slow
SPECIAL TESTS
THENAR TAP (R/O CARPAL TUNNEL SYNDROME):
FINKLESTEIN TEST: Can you put your thumb inside your hand and make a fist: then you
bend it.
DE QUERVEIN'S TENOSYNOVITIS: INFLAMMATION OF EXTENSOR
POLLICIS LONGUS

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I will check your practical function
They have a key on the table.
Jenny, pretend that my fist is a lock, and please use the key to open this lock?
Patient will struggle on this action
I will check for the power of your hands (C8-T1)

Please take my fingers and squeeze it the best you can and don't let my fingers go.
I want to conclude my examination by performing a full neurological examination of the hand
Jenny I can see that there is limitation of movements along with pain and stiffness of your hand
joints. It could be due to Osteoarthritis which is a degenerative condition with ageing due to
repetitive wear and tear of the hand joints. It can also be due to rheumatoid arthritis, which is an
autoimmune condition which means that the body's factors are fighting its own skin and joints. It
can also be due to other connective tissue disorders, or due to psoriatic arthritis.
Obstetrical Examination
Sunday, 14 May 2017
3:47 PM
Fetal lie - relationship of maternal spine and fetal spine

Fetal presentation - don't do ECV in a pregnant patient in labor with breech presentation
Fundal height
Fetal heart rate
Head engagement = for greater than 36 weeks AOG
38 weeks AOG lady come to you for check-up.

FUNDUS BIG
Multiple pregnancy
TORCH
Do you have any pets at home?
Are you eating raw food/meat?
Case: 36 weeks pregnant, patient does not feel any fetal movements
DDx for decreased fetal movements
Intrauterine fetal death = rule out by fetal heart rate
Fetal Heart rate positive
Mother not concentrating/busy somewhere
Sleeping baby
As baby grows, he has less room to move around
Head engagement - sinking of the head into the pelvis
Still do CTG for the patient
High floating head: Engagement not occurred at 36 weeks in a primigravida

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Peripheral Vascular Disease Examination
Sunday, 14 May 2017
4:04 PM
55/M comes to see you with complaint of leg pain while walking uphill. He smokes 20 sticks a day since
the last 20 years. Currently on Atenolol 100mg for high blood pressure.
TASKS
Focused history
Examine the patient
Discuss diagnosis and management with the patient
APPROACH
HISTORY
Most important points to ask: Chest pain? Shortness of breath?
HOPC
LEG PAIN = focused questions: SOCRATES
If there's pain for a prolonged period, ALWAYS ask this: How does this pain
affect your lifestyle?
**EXERTIONAL LEG PAIN
PHYSICAL EXAMINATION
GA: BMI
VITALS: BP
WIPER
Can you please take a few steps for me?
Inspection
Compare legs, scars, check for ulcers in between the toes (arterial ulcers), shiny legs
and loss of hairs,
Palpation
Temperature
Pulses
Dorsalis pedis
Posterior Tibial
Popliteal Pulses
Tenderness
Sensation: normal unless there is diabetic peripheral neuropathy. Charcot joint
problems
Special test
Buerger's test: see if patient has hypoxia in the leg
Normal person = if you raise their legs, their legs won't turn pale.
Raise legs slowly at 45 degrees, wait for 10-15 seconds and check if there is
pallor of the legs.
Then let the patient sit down, and the feet should not touch the ground. Then look
for REACTIVE HYPEREMIA
Induced hypoxia when you lifted the legs. This will then lead to have a
vasodilatory reflex reaction after, causing the feet to have reactive
hyperemia (extra flushed extremity).
Ankle brachial index

Systolic bp of the ankle arteries / systolic bp of the brachial arteries
Use doppler probe in the ankle systolic BP measurement

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ABI: 0.7
MANAGEMENT
Some of the vessels in your legs are narrowed down, that is why they cannot give wnough blood
supply when you walk. At this stage you need to have lifestyle modification. I noticed that you have
been smoking 20 sticks a day, and this can be a reason for that. I can help you to recover from this
and we can arrange another consultation for that. You need to eat a healthy diet, cut down on your
alcohol by only taking 2 standard drinks a day, and do as much physical activities as you can.
I will also do a color doppler ultrasound for you to visualize your vessels in your leg. We will work
as a team, I will refer you to a vascular surgeon who can assess you further.
The medication that you are taking for your bp (beta blocker) is not good for your condition. I will
switch you into another antihypertensive medication (ACEi).
***
Male patient with history of DM presents with intermittent claudication
Do both Peripheral vascular disease and Diabetic Foot examinations.
Pleural Effusion
8:28 AM
A 63 year old Mrs. Leah Young presents to the emergency department with pleuritic right lower chest
pain and shortness of breath, getting worse over the last 6 days. She had a laparoscopic operation for a
diverticular abscess in her sigmoid colon 6 weeks ago with rather protracted recovery. She is a non-
smoker and she does not complain of cough, sputum production or blood. On examination she appears
moderately unwell, her pulse is 110, BP 110/60, T 37.8 There is dullness on percussion on the right side
of the lower chest with reduced breath sounds. You ordered a chest x-ray and she is back with her x-rays
to see you. There is no need for further history, you have already examined the patient and provided
analgesics.
TASKS
1. Read the patients x-ray and tell her the findings
2. Explain your management plan to the patient
Differential Diagnosis of Pleural Effusion

▪ Pleural effusion secondary to either postoperative pneumonia or pulmonary embolism/infarction.
▪ Empyema from a subdiaphragmatic abscess secondary to the previous diverticular abscess
▪ Malignant effusion
▪ Less likely due to post-operative atelectasis
▪ Infective (e.g. tuberculosis)
▪ Any of the other above causes depending on type of pleural effusion
X-ray Interpretation

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This is your x-ray. We are looking at your chest from the back (PA view).
We are seeing your full chest, part of your neck above and part of your tummy below and also your
shoulder joints at the sides.
White area are your ribs and bones. Black is air, so your lungs are normally filled with air. And gray areas
are your soft tissues, vessels, muscles.
Your ribs and bones are fine. Trachea is in midline, which means your lungs are not shifted.
Heart doesn’t look enlarged, cardiac silhouette is normal, no cardiomegaly or enlargement of the heart.
Your lungs though, on comparing both lung fields, you will see that the right side has less black areas than
the left side.
On the lower area of the right side there is a white part, I cannot tell you right now what exactly is there
but something is there. It can be collection of fluid or what we call a pleural effusion. It can also be due to
an infection in the lung, and can be an effusion from the pneumonia. This fluid can be infected, so it can
be a collection of pus called empyema.
You also got a surgery in the tummy, and that might be a contaminated surgery in the tummy, so a
subdiagphragmatic abscess or accumulation of infected fluid between the diaphragm and the liver is also
a possibility.
You also had your surgery 6 weeks back, and right now it looks like a bad recovery since you have not
been ambulatory, your heart rate is fast, your breathing is fast, and you're running a temperature, and you
have signs of pleural effusion, one of the blood vessels might have been clogged or what we call
pulmonary embolism.
Management
Admit
Call ED registrar to come and have a look
Run investigations immediately: FBE with white cell count for infection, ESR CRP for infection, blood
culture
I have only done a front view, but I need a lateral view, and if I don’t see anything on the lateral view, I
would do ultrasound to know if the white area is fluid or solid. If it is fluid, we could do a pleural tap and
send the fluid for cytology, microscopy and culture and sensitivity. If still we find nothing in the
ultrasound, CT may be done but I will discuss with the specialist first. Ultrasound of abdomen, look at
tummy to look for any pus collection anywhere.
I am still unable to tell you what the course will be since that would depend on what we will find out with
the investigations.
But meanwhile, I will provide you with management to give you some relief. If with low saturation, give
oxygen. If with pain, give painkillers. If with low BP, give fluids.
Depending on the situation, investigations will come and I will review it to guide us in our next step in
management. If we see infection, we will give you antibiotics. If we find something in the tummy, we
will involve the surgeon who will drain the pus.
If you have a clot in the vessel, we will do a D-dimer, V/Q scan, Doppler U/S lower limbs and perhaps
CTPA, and involve the vascular surgeon who may start you on low molecular weight heparin, or if
surgical management, removal of the clot by embolectomy.
Rash Differentials Physical Exam

12:29 PM
45/M rash in the upper arm, noted after gardening.

TASKS
Take history for 2 minutes
Explain the differentials
DDX
CELLULITIS
THROMBOPHLEBITIS
LYMPHANGITIS
DVT
CONTACT DERMATITIS
INSECT BITE
TRAUMA
APPROACH
HISTORY

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Ask about the rash
Duration, one or both sides, is there pain, is there swelling, is it itchy, is there any discharge,
any fever, anything that makes it worse or better
DDx questions
Do you feel any cord-like structure on the rash - thrombophlebitis
Any insect bite/wound over that area? - cellulitis
Any IV cannulation recently? Use IV drugs?
Prolonged repetitive work using your arms (painter) - DVT
SADMA
PMH
FH
PHYSICAL EXAMINATION
Im going to examine you now, during my examination I require exposure so please take off your
gown. I will be examining your upper arm and I will be checking for lumps in the neck and your
underarms. I will listen to your lungs as well.
Wash hands
INSPECTION
Comparing btoh arms, there is a rash over the left arm, extending from the cubital fossa to the
axillary area. There is no surrounding erythema, no swelling, no bleeding, or discharges, no scratch
marks or IV cannulation marks noted.
PALPATION
TEMPERATURE
No local rise of temperature noted
TENDERNESS
No tenderness noted, and no cord-like structure palpable
BLANCHABLE RASH OR NOT using glass test- blanchable goes away,
Rash is blancing/non-blanching
PULSES non blanch-able no change
Radial and brachial (if palpated)
Capillary Refill Time
Check temperature - perform this, oral temperature
PALPATE LYMPH NODES Text

Check for enlargement and tenderness
Epitrochlear: palpate proximal to distal
Axillary LN

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Cervical LN
AUSCULTATION
Listen to the lungs to check for reduced sounds or added sounds (r/o DVT/ pulmo embo)
DIFFERENTIALS
Based on my examination, your rash can be due to several causes. It can be a local infection of the
skin, called cellulitis, given that you have been gardening and you might have a previous wound
there that became infected while you were gardening. It can also be an irritation of the skin by an
irritant called contact dermatitis, or it can also be a clot in the blood tubes (DVT) due to your
repetitive movements using your arms while gardening, or it can also be any infection of the blood
tubes or your lymph vessels.
Respiratory Exam
Monday, 15 May 2017
4:58 PM
A 44 year old patient had come to you with cough.
TASKS
1. Examine the respiratory system.
2. Give running commentary to the examiner.
Differential Diagnoses:
▪ Asthma/COPD
▪ Lung cancer
▪ OLD/ILD
▪ Pneumonia
▪ Foreign body
▪ Cardiogenic cough
APPROACH
▪ Hands
o Nicotine stain
o Clubbing
o Flapping tremors (CO2 narcosis)
o Wrist tenderness (lung cancer can cause hypertrophic pulmonary osteoarthropathy)
▪ Face
oEyes: conjunctival pallor, ptosis/constricted pupil (responsive to light) , enophthalmos
(Horner's syndrome - Pancoast tumor)
o Nose: swelling, polyps, deviated nasal septum
o Mouth
• Central cyanosis
• Dental hygiene: broken tooth or rotten tooth stump may predispose to lung abscess or
pneumonia
• SOB - they will struggle with this - there is no hoarseness
▪ Neck
o Tracheal tug - sign of respiratory distress

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o Tracheal position
o Cervical lymphadenopathy: check while standing behind the patient
▪ Chest
o Shape of chest
o Upper lobe expansion - check for symmetrical elevation of the clavicles
o Lower lobe expansion
o Tactile fremitus
o Percussion - start from supraclavicular fossa
o Vocal fremitus
Investigations: spirometry
Rusty nail in feet

2:04 PM
You are a GP seeing a 72 year old male who stepped over a rusty nail yesterday. The patient recently
migrated from Turkey to Australia. He has a history of COPD. There is a wound on the left foot that is
clean and dressed.
TASKS
1. Further history
2. Discuss preventive aspects of General Practice
Positive points in the history: All day working in the fields

APPROACH
▪ History
o Does my patient understand English or do I need to arrange for interpretation services?
▪ Preventive aspects of General Practice
o Vaccinations
• Tetanus
▪ Patient does not remember his vaccination status: TT + TIG
▪ Guide to tetanus prophylaxis in wound management:
History of tetanus Time since Type of DTPa, DTPa- TIG
vaccination last dose wound combinations, dT,
dTpa, as
appropriate
> 3 doses < 5 years Clean minor No No
wounds
> 3 doses < 5 years All other No No
wounds
> 3 doses 5 - 10 years Clean minor No No
wounds
> 3 doses 5 - 10 years All other Yes No
wounds
> 3 doses >10 years Clean minor Yes No
wounds
> 3 doses >10 years All other Yes No
wounds
> 3 doses or >10 years Clean minor Yes No
uncertain wounds
> 3 doses or >10 years All other Yes Yes
uncertain wounds
• Flu vaccine
▪ Annually
• Pneumococcal
▪ Every 5 years
• Zostavax (shingles vaccine)
o SNAP: way of healthy living

• Smoking cessation, be Slim, be Stress-free

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• Nutrition (Healthy balanced diet)
• Avoid alcohol
• Physical activity
▪ 30 minutes a day, 5 days a week
o Protective gear
• Mark, whenever you work in the fields, you should wear proper protective gear
o Sun exposure
• Slip-Slop-Slap-Wrap
▪ Mark, since you are always working in the fields and under the sun, to prevent skin
cancer, avoid excessive sun exposure by slipping on protective clothing, slop on
sun screen, and slap on a hat, wrap on proper goggles/sunglasses and avoid going
out in the sun during peak hours. There is also an app called a sun smart app,
which tells you what is the best time to go out in the sun.
o FOBT
• Have you got your poo tested at any time?
o AUSDRISK scale
• Screening scale for Diabetes for age 45 years above
Scrotal Examination
Monday, May 29, 2017
8:11 AM
Dr. Dilpreet
▪ Make sure you wear gloves and you ask for a chaperone
▪ Inspection
o Penis: Is there any visible chordee, phimosis, paraphimosis, ulcers and discharge in the
foreskin, meatal stenosis, hypospadias
o Scrotum: no obvious swelling, scar, redness, rash, bruising, bell clapper deformity (if the testes
is horizontal and elevated, it is indicative of testicular torsion) or blue dot sign (torsion of the
testicular appendix), no obvious varicocele, no obvious Fornier's gangrene
▪ Palpation
o Anterior border, posterior border, medial surface, lateral surface, superior pole, inferior pole
o Make sure that the epididymis is in the posterior border, upper pole
• Epididymis has head, body, and tail
o The ideal way to palpate the testis is to hold it with your thumb and middle finger, and palpate
with the first finger and thumb all surfaces
o There are no obvious masses, nodules, cysts, lesions
o Palpate the epididymis: there are no masses, nodules, cysts in the head, body and tail
o Palpate the spermatic cord: no masses, cysts, nodules, and no bag of worm appearance
o Palpate the superficial and deep inguinal ring
• Ask the patient to cough to check for any bulge on coughing
o Palpate the lymph nodes
▪ Special Test
o Cough impulse - check if there is any mass coming out of the testis
o Prehen sign - elevate the testes, and see if the patient's pain is resolved. If it is resolved it is
epididymoorchitis, if it is worse it is testicular torsion
o Cremasteric sign - stroke the medial border of the thigh on the same side, the testis on the same
side moves up. If it is preserved, is it NOT testicular torsion
o Transillumination - if you can transilluminate, it can be a hydrocele or epididymal cyst
▪ Lump Exam 4S 4C FTR
o Site, size, shape, surface, color, contour, consistency, compressibility, fixity and fluctuation,
transillumination, reducibility
o Getting above the swelling: if you are not able to get above the swelling, it means it is an
hernia (it comes from the abdomen)
Scrotal Examination

Page 73 of 94
11:34 AM
Dr. Kamalika
***
40/M with a non-tender lump on the right side of the testis for 3 months.
TASKS
Take consent
Perform physical examination
Give diagnosis and differentials
DDx
Varicocele
Hydrocele
Firm mass = cancer
Epididymoorchitis
spermatocele
**
APPROACH
WIPER
CONSENT
I understand you have a lump in your right testis. I have been asked to examine you. During
my examination, I will have a chaperone with me at all times. For my examination, I will
require proper exposure, I will give you privacy until you change. I will be taking a look at
your genitalia, I will be feeling for any lumps, and doing some special tests. If you are
uncomfortable at any point, please stop me. is that alright for you?
WASH HANDS + WEAR THE GLOVES
INSPECTION
My patient is a 40 year old male sitting comfortably with no signs of pain.
Now please lie down John
On inspection, there are no signs of trauma, bleeding or redness on the lower abdomen and groin
area
There is no obvious lump on the scrotum. No necrotic tissue noted. There are no discharges from
the urethral meatus.
Examiner I would like to inspect on the standing position as well (r/o varicocele)
There are is no engorgement of the scrotum on the standing position.
PALPATION
John I'm going to feel for a lump now, is that alright?
No local rise of temperature over the scrotal sac
John I'm going to retract the foreskin

There are no discharges or bleeding
Palpation proper: palpate from the bottom of the scrotal sac, traveling to the cord and inguinal area

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I cannot feel any mass on the testis, I cannot appreciate if the testis and the epididymis are
separated, no thickening of the cord noted.
Testicular cancer = I can feel a mass over the right testis, firm, approximately 2x2cm, with
regular boarders. I can get above the mass (NOT in continuation of the cord). I cannot say if it
is fully fixed to the testis or not.
Hydrocele = cystic consistency
Varicocele = bag of worms consistency
SPECIAL TESTS
COUGH TEST
Can you please cough?
POSITIVE IF THE SCROTUM ENGORGES
Varicocele = positive
Hernia = positive
PHREN'S TEST
Elevate the testis = pain disappears = positive
Positive in epididymoorchitis
TRANSILLUMINATION TEST
Torch is shine from the back
INGUINAL LYMPH NODES

Palpate if present, if tender or not
I want to end my examination by doing a full abdominal examination and digital rectal examination
EXPLAIN
John I have examined you, and most likely this looks like a hydrocele. Have you heard about it? It
is a fluid filled sac. Or it could also be a varicocele, which is a collection of veins with defective
valves causing dilatation and engorgement of your scrotum. It can also be due to a spermatocele,
which is also a fluid filled sac with dead sperm, or it can also be due to some nasty growth, or
infection.
Shoulder Examination
9:13 AM
▪ Introduction: Hello, I’m Dr. Lea, I'm one of the doctors who will be looking after you today. (wash
hands simultaneously)

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▪ Background: from my case notes, I understand you are having some pain on your shoulder. I'm really
sorry for that. How are you feeling right now? [If she answers yes I am feeling pain, ask "How
severe is your pain?" "Can you tell me the site of the pain?"
*NEVER DO DEEP PALPATION OF THE SITE OF PAIN
*Palpate other sites first before palpating the site of pain
*Before touching it, say "I understand this site is painful, but I am just going to touch it very gently,
is that okay?"
*Offer painkillers, ask about allergies to painkillers; say to examiner: Doctor, I would like to give
painkillers to the patient
▪ Explain: Now I am going to examine you to find out the reason why you are having this pain. And this
examine basically involves me having a look at your shoulder, feeling your shoulder and doing
some movements with your shoulder.
▪ Consent: Is that alright with you?
▪ Handwash: Done with the introduction.
LOOK
▪ On inspection from the front, both the shoulders are well-aligned and symmetrical.
I cannot see any obvious:
o Swelling
o scar marks
o redness or erythema
o any obvious deformity
o muscle wasting: look specifically at the bulk of deltoid muscle
▪ Side: check the spine
I cannot see any:
o Cervical lordosis
o Thoracic kyphosis
▪ Back: check the spine
I cannot see any:
o Scoliosis
o Paraspinal muscle wasting
o Spine of scapula
o Wasting of supraspinatus and infraspinatus muscle
o *you may check if there is winging of the scapula: Can you push against the wall for me?
▪ Lift the arm up to look at the axilla of the patient
o There is no swelling and erythema
o Deltopectoral groove is intact (if there is inflammation or swelling, the groove will disappear
FEEL
▪ *Palpate with 1st and 2nd fingers
▪ *Make sure you have warmed your hands
▪ Temperature: Check temperature with back of hand, compare both sides
"There is no rise in temperature"
▪ Tenderness: Can you point the site of pain for me? *check the site of tenderness towards the end
*Palpate from the sternoclavicular joint, going to the midclavicular, then to the acromioclavicular
joint, the to the coracoid process, then shoulder joint line, then deltoid muscle (2cm below and
medial to the acromioclavicular joint is the coracoid process)
o There is no tenderness over the sternoclavicular joint
o There is no midclavicular deformity.
o There is no tenderness over the acromioclavicular joint
o There is no tenderness over the coracoid process
o There is no tenderness along the shoulder joint line
o There is tenderness over the deltoid muscle

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▪ Check midline tenderness of the spine
▪ Check paraspinal muscles
▪ Check spine of scapula
▪ Check supraspinatus and infraspinatus muscle
MOVE
▪ Active
"I would like you to please copy my movements. "
o Flexion
o Extension
o Abduction
o Adduction
o External rotation
o Internal rotation
"Full range of active movements is achieved."
▪ Passive: "I would like you to leave your arms relaxed and floppy for me. Let me perform the
movements."
▪ Power
o Shoulder flexion: can you flex your arm 90 degrees? push forward against my hand?
o Shoulder extension: can you push backward against my hand?
o Abduction: can you do chicken wings for me? Can you push up against my hand?
o Adduction: can you push down against my hand?
o Internal rotation: can you put your hand against your back? Can you push out against my
hand?
o External rotation: can you flex your arm 90 degrees? Can you push out against my hand?
SPECIAL TESTS
▪ Rotator cuff (4 muscles: supraspinatus, infraspinatus, teres minor, subscapularis)
Cases:
o Supraspinatus injury: abduction is impaired above the shoulder height on active motion, power
of abduction is impaired, BUT full range of motion on passive motion
o Impingement of tendon: abduction is impaired above the shoulder height on active motion,
power of abduction is impaired, BUT full range of motion on passive motion
o Differentiate supraspinatus injury from impingement injury by doing special tests
• To confirm rotator cuff injury: Empty can test

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• To diagnose impingement: Neer test
▪ Anterior shoulder dislocation

o Shoulder apprehension test: pretend throwing a ball for me
EXPLANATION:
Mark, after examining you, I found out that the condition you are having is rotator cuff injury. I'm sorry to
use a medical term. I will try to explain it to you. What happens is that, our arm bone is attached to the
shoulder blade by means of some muscles which are present around the shoulder join in the form of cuff.
These muscles are called rotator cuff muscles. In your case, I'm suspecting there is injury to one of the
muscles of the rotator cuff. We need to confirm this by doing an ultrasound or MRI (but start with
ultrasound first).
Frozen shoulder: patient will not move his shoulder at all. +ve tenderness, no active movement, no
passive movement, no power.
After examining you, I found out that the condition you are having is called as frozen shoulder. I'm sorry
to use a medical term. Do you have any idea what it is? I will try to explain it to you. What happens in
this condition is there is stiffness of your shoulder joint because of which you are unable to perform any
movements. (diagnosis is clinical)
C8/T1 (ulnar nerve) weakness

10:51 AM
Your next patient is 45 years old, Mr. Jack, who presents to your GP clinic with some pain in the neck,
pain in the shoulder, and pins and needles in the right hand .
TASKS
2. Tell him the most likely diagnosis
LOOK
▪ On inspection from the front, both the shoulders are well-aligned and symmetrical.
I cannot see any obvious:
o Swelling
o scar marks
o redness or erythema
o any obvious deformity
o muscle wasting: look specifically at the bulk of deltoid muscle
▪ Side: check the spine
I cannot see any:
o Cervical lordosis
o Thoracic kyphosis
▪ Back: check the spine
I cannot see any:
o Scoliosis
o Paraspinal muscle wasting

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o Spine of scapula
o Wasting of supraspinatus and infraspinatus muscle
o *you may check if there is winging of the scapula: Can you push against the wall for me?
▪ Lift the arm up to look at the axilla of the patient
o There is no swelling and erythema
o Deltopectoral groove is intact (if there is inflammation or swelling, the groove will disappear
FEEL
▪ *Palpate with 1st and 2nd fingers
▪ *Make sure you have warmed your hands
▪ Temperature: Check temperature with back of hand, compare both sides
"There is no rise in temperature"
▪ Tenderness: Can you point the site of pain for me? *check the site of tenderness towards the end
*Palpate from the sternoclavicular joint, going to the midclavicular, then to the acromioclavicular
joint, the to the coracoid process, then shoulder joint line, then deltoid muscle (2cm below and
medial to the acromioclavicular joint is the coracoid process)
o There is no tenderness over the sternoclavicular joint
o There is no midclavicular deformity.
o There is no tenderness over the acromioclavicular joint
o There is no tenderness over the coracoid process
o There is no tenderness along the shoulder joint line
o There is tenderness over the deltoid muscle
▪ Check midline tenderness of the spine
▪ Check paraspinal muscles
▪ Check spine of scapula
▪ Check supraspinatus and infraspinatus muscle
MOVE
▪ Active
o Shoulder
"I would like you to please copy my movements. "
• Flexion
• Extension
• Abduction
• Adduction
• External rotation
• Internal rotation
"Full range of active movements is achieved."
o Neck
• Flexion: touch your chin to your chest
• Extension: look normally
• Hyperextension: look up
• Look to the right, look to the left
• Tilt your head to the right, tilt your head to the left
▪ Power - check it dermatome-wise
o Shoulder
• Abduction (C5)
• Adduction (C5)
o Elbow
• Flexion (C5)
• Extension (C7)
o Wrist
• Extension (C6)
o Grip (C8) - patient is unable to have a good grip on the right side
o Finger abduction (T1) - on the right side, patient cannot spread his hands fully
REFLEXES
o Biceps (C5, C6)
Make the patient sit down. Stay on the right of the patient. Place hand on a begging position,
put 1 finger on the biceps tendon, then strike your finger.
Watch for contraction of the biceps muscle.

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o Brachioradialis (C5, C6)
o Triceps (C7, C8)

Let me bear the weight of your arm. Identify the tendon. Directly strike the tendon.
SENSATION
▪ Light touch - use cotton
▪ Crude touch - use pin
▪ "Normally you would feel it like this, can you feel this?"
▪ "Each time you feel this, please say "yes", and tell me if it feels the same or differently from one side
to the other."
o Clavicular area (C3/C4)
o Deltoid (C5)
o Dorsum of hand web space (C6)
o Middle finger tip (C7)
o Tip of little finger (C8) - there is loss of sensation on the tip of the little finger
o Medial side of forearm (T1) - there is loss of sensation on the medial side of the forearm
o Medial side of arm (T2)
SPECIAL TESTS
Case: C8/T1 weakness
Causes:
Cervical spondylosis (level of neck)
Cubital tunnel syndrome (level of elbow)
Guyon canal (level of wrist)
▪ Spurling test

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"Can you look up and tilt your head towards the side that is painful. I'm going to exert downward
pressure. "
Positive: when the pain arising in the neck radiates in the direction of the corresponding
dermatome ipsilaterally
After examining you, I found out that the neck pain, shoulder pain, and the weakness in your hands is
because of some nerve damage. So what happens is, there are some nerves which arise from the back of
the neck, pass through your shoulder, and all the way down your hands. I think one of the nerves is
damaged there, we call it C8/T1 weakness. Why is this happening? It's because of a condition called
cervical spondylosis. I'm sorry for the medical term, have you heard of this condition? I will explain it to
you.
Our back is made up of small bones, in between each bone, a disc is present to prevent the friction
between the bones. Sometimes, this disc bulges out and causes compression of the nerves which causes
the pain that you are experiencing.
Swelling examination
Sunday, 14 May 2017
4:41 PM
Whenever you get any swelling, we have to ask some features from the examiner to make us differentiate
what type of swelling it is.
Ask about:
▪ Site, size, shape, surrounding, surface, single/multiple
▪ Contour, consistency, color, compressibility, cough impulse (hernias)
▪ Tenderness, temperature, transillumination
▪ Fluctuation (fluid-filled cyst), fixity (mobile against underlying structures or against the skin), Fields
(draining lymph glands for this area)
▪ Pulsation, percussion
▪ Expansile (if we put our hand over the swelling, feel for expansion)
▪ Reducible
CASES:
▪ Parotid swelling
▪ Post-viral lymphadenitis
▪ Testicular swelling
▪ Breast lump
▪ Thyroid
CASE: POST-VIRAL LYMPHADENITIS

Jenny a school teacher brings his 5 year old boy with a complaint that he has some swelling in his neck.
She is afraid that his son is having Hodgkin's lymphoma as his cousin is recently been diagnosed with
Hodgkin's lymphoma, and he also has this swelling in the neck.
TASKS
1. Focused history
2. PE from examiner
3. Further management
Positive points in the history: swelling in the neck 2 weeks back, flu 3 weeks back, no decrease in
activity
APPROACH
▪ History
o First reassure the patient. "Jenny you look stressed. I am here to help you."
▪ Physical Exam
o Ask the swelling questions
o Look for any other swelling in the body
o Look for bruises in the skin

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I will review him regularly, anytime that you feel that he is not feeling well, you can come back to
me, but these swellings usually resolve on its own.
If rubbery swelling: Hodgkin's lymphoma = breaking bad news
Parotid Swelling:
A middle aged man comes in to your GP clinic with a swelling on the left side of his face just above the
angle of his jaw between the mastoid and mandible. A picture of the swelling is provided.
TASKS
1. Focused history
2. PE from examiner
3. Diagnosis and management
Positive points in the history:

Positive points in the PE/Investigations:
APPROACH
▪ History
o How long has it been there? Is it changing? Is it painful? Is it affecting your lifestyle?
o Have you noticed any weight loss? Any night sweats? Fever?
▪ Physical Exam
o General appearance
o Vital signs
o ENT: swelling characteristics
• If facial nerve involved: malignant, if not: benign. Don’t forget to check facial nerve.
Mark, I am not suspecting anything serious till now. I am thinking about an overgrown salivary
gland near your jaw that is your parotid gland, and the condition I am suspecting is pleomorphic
adenoma of the parotid gland. Let me assure you that it is a benign swelling and to further confirm
it, I will refer you to the surgeon. He will do a CT scan or MRI to see the overall dimension and
tissue invasion and FNAC to determine whether the tumor is benign or malignant.
Temporal Arteritis
12:18 PM
55/F with headache and difficulty chewing

TASKS
Give diagnosis and differentials
APPROACH
WIPER
GENERAL LOOK
55 year old patient sitting comfortably with no obvious signs of pain or distress
INSPECTION
GAIT
Jenny can you please take a few steps for me
No neuropathic or antalgic gait
Please sit down
HEAD AND FACE
No asymmetry of the face, no ptosis or lacrimation of the eyes, no obvious signs of injury like
bruises, or swelling no rashes
Take a torch and shine a light on the nose: no discharges no deviation of the septum
MOUTH: can you please open your mouth
No dental caries

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I would like to check the throat for tonsillar enlargement
EARS:
No discharges from the ears
No redness of the mastoid process
TEMPORAL AREA
No tortuous veins over the temporal area
NECK (back)
Normal curvature of the cervical spine is preserved
PALPATION
TENDERNESS
HEAD: no tenderness
FOREHEAD AND TEMPORAL AREAS: there is tenderness over the right temporal regiion
TEMPOROMANDIBULAR JOINT: no tenderness
Can you open and close your mouth?

No crepitations over the TMJ
EWING's sign: check for the maxillary sinusitis

Press over the maxillary sinus (bilateral) and ask the patient to bear down
There are no signs of maxillary sinusitis
NECK (BACK): no paraspinal tenderness
MOVEMENTS
NECK MOVEMENTS
FULL EYE EXAMINATION

VISUAL ACUITY
VISUAL FIELDS
DIRECT AND INDIRECT LIGHT REFLEX
FUNDOSCOPY
I'm going to end my examination by doing a full neurologic upper and lower limb examination, and full
cranial nerve examination as well, otoscopy to check the ear, and tonometry and fluorescein staining to
check the eye, check for blood pressure
EXPLANATION
Most likely I am suspecting a condition called temporal arteritis. It is an autoimmune disorder, where
factors of the body fight against its own tissues causing inflammation of the vessels. It can also be due to
migraine, tension headache, referred pain from the ear and the teeth, it could be a bleeding inside the
brain, or it could also be a nasty growth.
Thyroid Exam

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Saturday, 20 May 2017
3:25 PM
Inspection
▪ Comment on BMI
▪ The patient dressed appropriately to the weather
▪ Ask patient to cross hands on his chest, then ask him to stand and walk
▪ There is no proximal muscle weakness of the shoulder and pelvic girdle
▪ In the nails, patient has no thyroid acropathy (onycholysis)
▪ There are no sweaty palms.
▪ Ask patient to stretch arms, place paper on top of the hand, bend towards the level of the paper to
check for tremors
▪ There are no postural or kinetic tremors
▪ Take their pulse
▪ It is a good volume and regular pulse
▪ Take blood pressure on both arms, both sitting and standing to check for postural drop
▪ Look at eyebrows, especially outer third of eyebrows, for whitish discoloration or loss of hair
(madarosis) - hypothyroidism
▪ Look for malar flush (common in hypothyroidism)
▪ Look for eye signs
▪ Lid retraction
▪ Lid lag
• Would you mind following the tip of my pen?
• Move pen from eye level to the level of the tummy.
▪ Staring look/ infrequent blinking
▪ Ophthalmoplegia
• Do "H" and ask if there is double vision
▪ Look for absence of forehead corrugations
▪ Exophthalmos
• Go behind the patient and look if the eyes are bulging beyond the supraorbital margins
(Naffzigger's sign)
▪ Would you mind taking a sip?
▪ Thyroid is moving with swallowing
▪ Would you mind bringing your tongue out?
▪ There is no movement of the thyroid with tongue protrusion (thyroglossal cyst)
▪ There are no rash, bruise, swelling, scar, deformity in the anterior neck and around the thyroid
region.
Palpation
▪ Check temperature of thyroid
▪ Temperature is normal on both sides. No obvious increase in the temperature of the thyroid
▪ Would you mind taking a sip?
▪ Palpate the thyroid if it's moving with swallowing
▪ I'm just going to palpate your thyroid, it might feel uncomfortable, please bear with me
▪ Palpate one lobe at a time: Press on one thyroid lobe, and with the other hand, palpate the
other lobe
• There are no nodules, masses, cystic lesions
▪ Go to the lower border of the thyroid
• I can palpate the lower border of the thyroid (retrosternal extension if not able to)
▪ Palpate lymph nodes
▪ Submental
▪ submandibular
▪ Preauricular
▪ Post auricular
▪ Supraclavicular
▪ Anterior cervical
▪ Posterior cervical
Percussion (may or may not do this)

▪ Start with angle of Louis: 2nd ICS then go left and right of it
▪ There is no obvious parasternal dullness (retrosternal extension)
Auscultation (CRITICAL ERROR: NOT listening to a thyroid bruit)

▪ Palpate the carotid just to make sure you are not listening to the carotid. Go medial to the carotids
▪ There are no thyroid bruits heard
▪ Look for pretibial myxedema (Graves' disease)

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▪ Check ankle reflex
▪ Hyporeflexia - hypothyroid
▪ Hyperreflexia - hyperthyroid
▪ Look for Pemberton's sign
▪ Would you mind raising your hands
▪ There is no obvious respiratory distress, no neck vein engorgement. Pemberton sign is
negative.
▪ I would like to finish with UDT, BSL, ECG, fundoscopy and arrange for basic investigations FBE, UEC,
LFT, thyroid ultrasound, radioiodine uptake scan
TIA/Stroke
7:38 AM
56 year old John came to hospital because he suddenly felt inability to move his limbs and weakness in
right side of his body. He also felt that he had difficulty talking at that time. The episode was only of short
duration and now he is completely fine. His vitals are all stable. He is here to see you in the ED to know
about his condition.
TASKS
1. Perform appropriate physical examination
2. Tell the condition and further management
FULL EXAMINATION
▪ General look
▪ Gait
▪ Rhomberg
▪ Upper/Lower limb
▪ Inspection
▪ Bulk
▪ Tone
▪ Power
▪ Reflex
▪ Sensation
▪ Coordination
▪ Clonus
▪ Cranial nerves
▪ Cardiovascular
▪ Carotids
▪ Pulse, BP
▪ Fundoscopy + Eye exam (if eye TIA)
▪ Office test: BSL, UDT, ECG
Cases
▪ Patient with right arm weakness, now normal
o Upper limb neurology + ask the rest
▪ Patient with left arm weakness, now normal
o Upper limb neurology + ask the rest
▪ Patient with right sided weakness, now normal
o Upper and lower limb neurology (do it together)
▪ Patient with right or left lower limb weakness, now normal
o Lower limb neurology + ask the rest
▪ Patient with sudden onset of loss of vision, now normal
• Differentials: central retinal artery occlusion, central retinal vein occlusion, corneal foreign
body/abrasion, acute angle closure glaucoma
o Eye exam + ask the rest
• Eyes are low set or not?
• Lid margin infection: chalazion, stye
• Drooping of the eyelids, are they retracted?
• Eyeball: is there any ptosis (eyeballs are out), proptos- .is (eyeballs are out and
angulated)
• Lashes: Ectropion and entropion
• Conjunctiva: injected or inflamed?

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• Lid eversion - to look at the palpebral part of the conjunctiva
• Cranial nerves II, III, IV, VI
• Fundoscopic examination
• Slit lamp examination with fluorescein dye
• Measure intraocular pressure by tonometer
Management
▪ Admit
▪ Call the neurological registrar
▪ Arrange investigations
▪ FBC, Lipids, BSL, Urine analysis, ECG and echo, Doppler
▪ You are at the highest risk of stroke for the next 24 hours that is why I am admitting you. We will do
continuous monitoring of the vitals. If you again feel any weakness, have difficulty talking, balance
issues, inform us.
▪ You will be in the hospital for 1 -2 days, and your investigation results will be reviewed by specialist.
▪ When you are discharged, you will be given 2 medications: aspirin and a statin.
Tibia/Fibula Fracture
8:15 AM
X-ray Interpretation
I am really sorry that you had an MVA, we had an x-ray done and I have the plates with me.
Have you ever seen an x-ray before? Do not worry, I will explain it one by one.
If you have any questions, just stop me, I will explain it again.
This is an x-ray of your left leg.

This is a front view which means we are looking at your leg from the front.
We are seeing two things, white and black.
White means bones, black means air. Some are grey, these are soft tissues, muscles, skin, we cannot
differentiate.
This is your leg and part of your knee above and part of your ankle below.
There are two bones, the thicker one is the tibia and the thinner one is the fibula.
Here follow my pen, this is the line of the bone, which should be continuous, but here you see there is a
breach in the continuity of the bone or what we call a fracture.
You see that both bones have a break, so both bones have a fracture.
Whenever two bones are broken, we call it a compound fracture.
And you also see that here the bone has been broken into more than two fragments, so we call that a
comminuted fracture.
And also you have a break in your skin, the bone pierced the skin, so we call that an open fracture.
So your complete diagnosis is an open, compound, comminuted fracture of the tibia and fibula.
Physical Exam
• Inspection
o Bandage
• Loose fitting or tight fitting
• Soaked or not
• Oozing from the bandage or not
• Length and breadth
o Toes
• Color change
o Foot
• Position
o Distal area to fracture
• Bleeding
• Bruising
• Cut
• Laceration
• Palpation
o Neurovascular bundle

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• Nerves
▪ Motor
• Tibial: inversion and plantar flexion
• Peroneal: eversion and dorsiflexion
▪ Sensory
• Common peroneal: dorsum of foot
• Tibial: sole of foot
• Blood vessels
▪ Pulse: anterior dorsalis pedis, posterior tibial
• Tendons
Diagnosis and Management

Now you cannot move the leg at all, but I cannot declare if it is due to pain, fracture, compartment
syndrome, but I will move you to the OR so the orthopedic team can see you.
• Admit
• Call ortho
• Splint the leg
• NPO
• IV access and send blood for all routine blood tests
• VERY IMPORTANT: BLOOD GROUP, CROSSMATCHING, HOLD
If it is compartment syndrome, do fasciotomy

No compartment syndrome, do ORIF with nails and screws
Tremor Examination
12:21 PM
Your next patient is a 42 year old John Benzamin, who comes to see you in your GP clinic because he is
worried that he has got Parkinson's disease. He learned about Parkinson's disease from one of his friends
who has the disease, and he is also concerned that he might have it as he has also noticed shakes in his
both hands. He found that a drink or two settles the shakes in most of the time. He did not notice any
other shakes in any other parts of the body. He is otherwise healthy with no apparent complaints. He
doesn’t have any significant medical or surgical illnesses. He does not smoke. He drinks 5-6 cans of beer
almost all days on weekdays and a little more on weekends.
TASKS
1. Perform relevant PE
2. Tell the condition to the patient and management outline
Cases of shakes:
▪ 40-45 years old with difficulty walking and some shakes = Parkinson's (2016)
o Do PE, Diagnosis and Management
o Positive point: short shuffling gait
o Parkinsonism + neuro
▪ 40-45 years old with shakes, drinks alcohol, thinks he has Parkinson's = Benign essential tremor
(2015)
o Do PE and Diagnosis
o Parkinsonism + neuro
▪ 30-35 years old with diagnosis of schizophrenia, on sertraline and risperidone, complains of shakes =
Risperidone-induced tremor (2016)
o Do History, PE, Diagnosis and management
o Key step: confidentiality
o Parkinsonism + neuro examination
▪ Patient with chronic diarrhea with tremor and anxiety features, history of weight loss = thyrotoxicosis
(2015)
o Do PE, diagnosis and management
o Thyroid exam, neurological exam
▪ Patient who drinks 8-10 standard drinks of alcohol with/without forgetfulness, complains of tremor =
alcohol-induced tremors) (2016)
o Do PE, diagnosis and management
o Stigmata of CLD + neuro examination

Page 87 of 94
---------------------
APPROACH
▪ General look
o Patient is sitting comfortable, no anxious look and no visible tremor at the moment, does not
look restless
▪ Gait
No antalgic or limping gait
o
Ask to do a heel-walking
o
Ask to do toe-walking
o
Ask to do tandem walking with heel to toe
o
I did not see any Parkinsonian gait (difficulty in initiating walking, lack of arm swing, stuporous
posture as if they are falling, short and shuffling steps, difficulty stopping, they cannot turn around
but instead make a u-turn)
o Look for Rhomberg sign
• Can you stretch your arms in front?
Cerebellum is intact
• Can you please close your eyes?
Dorsal columns are intact
▪ Parkinsonism examination
o Face: expressionless or masked face
• Glabellar tap: positive if the extrapyramidal system is involved
o Voice: nasal intonation or hypophonia
• Can you please tell me your address?
• No hypophonia and nasal intonation of the voice, no dysarthria as well
o Pulse and blood pressure: postural drop
o Upper and lower limb
• Bradykinesia
• Lead pipe or cogwheel rigidity
• Could you please show me the shakes?
o If there are visible shakes, no need to put a paper
o If there are no coarse shakes visible, put a paper to check for fine tremors
o Hand
• Rapid alternating movements = dydiadochokinesia
▪ In Parkinson's, they do it very slow
▪ In frontal lobe dementia, they can't do it alternately
• Rapid opposition of the thumbs
• Unbutton and button the shirt
• Do rolling movement of the hands forwards and backwards
• Give patient a paper and a pen and ask to write a sentence
▪ In Parkinson's there is micrographia
▪ Neurological examination
o Inspection
• No muscle wasting
o Bulk
• Biceps bulk and forearm bulk
o Tone
• Put hand on the muscle, move the arm and hand
• There is no rigidity
o Power
• Could you please do chicken wings, and please resist my pressure
• Adduction: push it down
• Triceps and Biceps
• Wrist extension and flexion
o Reflex
• Biceps and triceps (tap on the front head of the triceps)
• Look at the muscle NOT the hand
o Sensation
• Light touch (cotton)
o This is a cotton ball, I will touch in different parts of your hand (C5-T1
dermatomes)
o Discard the cotton ball
• Crude touch (blunt end of pin)
• Joint position sense (check on the thumb)
o Fix the proximal interphalangeal joint, only the DIP moves

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• Vibration (128Hz)
o Ball of thumb at PIP
o Olecranon
o Acromioclavicular joint
o Sternoclavicular joint
o Coordination
• Finger to nose test
▪ +/-Alcohol
o Examiner I would like to check for stigmata of chronic disease in this patient
Unsteady Gait - Chronic Alcoholic

10:01 AM
Dr. Kamalika
***
45/M presenting to you with progressive unsteady gait for 3 months. He is a long-term alcoholic
TASKS
Perform PE
Diagnosis and differentials
Approach
WIPER
John I'm sorry to hear that you are having unsteady gait and it must be very distressing for you. I
will do my best to examine you to find out what is causing this. It will involve me having a look at
you, and doing some special tests to check for your nerve function. Don't worry, I will guide you
throughout the examination. Will that be alright for you?
Before we begin, are you having any pain at the moment? *give pain killers if in pain*
INSPECTION
Patient is sitting. General inspection.
My patient is a 45 year old male sitting comfortably. No asymmetry of the face or posture. No
neurocutaneous manifestations, no involuntary movements, no tremors, no fasciculations, no
choreoathetoid movements, and there are no walking aids (wheelchair, etc) present
GAIT
Now can you stand up and take a few steps for me?
Patient has a broad based gait/waddling gait
Can you walk on your heels? And then on your Toes?

Patient is unable to walk on his heels and toes.
Can you walk by touching your heel with your toe like this (demonstrate tandem gait)?
Patient is unable to do tandem gait
Check for Romberg. Can you stand straight with your ankles together? Don't worry I will support
you
Eyes open first -- -can't maintain the balance = CEREBELLAR ATAXIA
No need to do the eyes closed if already positive with the unsteady gait with eyes open

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EYE MOVEMENTS
Now please sit down, I will now check your eye movements. Please follow this tip of my pen with
your eyes, without moving your head. Please tell me if you're having double vision.
"H" movement to check for nystagmus
I cannot appreciate any nystagmus
SPEECH
Can you please repeat this sentence after me: "BRITISH CONSTITUTION"
My patient has a slurred staccato speech
HANDS
TONE
There is no hypotonia
REBOUND PHENOMENON
Can you put your hand out like this? I will now press your hand, and let go
The patient is positive for rebound phenomenon
FINGER-TO-NOSE TEST
Make sure it is a full-arms' length
Can you touch my finger and touch your nose.
There is an intention tremor and there is past pointing

Page 90 of 94
DYSDIADOCHOKINESIA
Can follow my movements (rapid alternating movements)
The patient has dysdiadochokinesia, unable to do rapid alternating movements
John can you please lie down
TONE OF THE LEGS

There is no hypotonia
COORDINATION TESTS
HEEL TO SHIN TEST
Please put your heel to your knee, and slide it down over your leg.
Patient is unable to do the heel to shin test. There is incoordination of movement
TOE TO FINGER
Can you please bring your big toe to my finger?
There is intention tremor present, and there is past pointing on the legs

Page 91 of 94
SENSATION
This is a piece of cotton. You will feel it like this. Now I will put this in different parts of your
thigh, leg, and foot, and ask you to please close your eyes. please say yes if you feel it, and tell me
if there is a difference in how you feel it on one side compared to the other.
L1-S1 sensations are intact
TRUNCAL ATAXIA
(from a lying down position) Now John, please cross your hands on your chest, and then sit up
There is truncal ataxia.
REFLEXES
This is a neurohammer. I will gently tap on your knee.
The patient has a pendulous knee jerk
I will conclude my examination with full cardiovascular system examination, full upper limb and lower
limb neurological exam with cranial nerve examination, and check the fundus for papilledema, full
examinatiion of the thyroid gland, and check for signs of chronic liver disease.
EXPLANATION
Your walking problem is called ataxia, and most likely it is due to some problem in the brain. Since
you have been a long time alcoholic, it can be due to nerve cell damage by alcohol. However, it
could also be due to stroke, masses in the brain, head injury in the past, certain medications that you
may take (phenytoin), and thyroid problems (hypothyroidism).
Varicose veins
11:40 AM
▪ General appearance
o sitting position
o gait = pain on walking
▪ Inspection
Inspect while the patient is standing and when the patient lies down
Comment if the varicosity is present while stand and disappears when the patient lies down
o Varicosity: medial side of the thigh and leg
• Long
• Short saphenous
o Swelling
• Localized
• generalized
o Skin
• Color of the limb - dusky or not
• Texture of the limb - peau d' orange involving the lymphatics
• Shiny skin - fluid accumulation makes the skin tense
• Eczema - secondary bacterial infection -- itchy varicosities can injure the skin due to
chronic irritation
• Pigmentation - no pigmentation, hemosiderin-laden macrophage pigmentation
• Ulcer - venous ulcers on medial side of the leg, arterial ulcers on the lateral side of the
leg, neuropathic ulcers on the soles
• Scars - previous surgeries can be a risk factor
▪ Palpation
o Temperature - feel with back of the hand, should be warm. If cold, arterial disease may co-exist
o Palpate the vein - feel the course of the vein
o Morissey cough impulse test
• Ask patient to stand.
• Use finger to held over patient's saphenofemoral opening [5cm below and medial to
femoral pulse].
• Ask patient to cough.
• If saphenofemoral junction is incompetent, there is presence of fluid thrill.
▪ Percussion
o Schwartz test/tap test

Page 92 of 94
• Place finger at any point along the varicose vein
• Tap the vein proximally (above the finger)
• Incompetent valves allow the transmission of a fluid thrill to the finger below
▪ Auscultation
o Over a large group of veins may indicate a bruit
o Indicates an underlying arteriovenous malformation
▪ Special test
o Brodie Trendelenburg test
• Vein is emptied by elevating the limb and a tourniquet is tied just below the sapheno-
femoral junction (or using thumb, sapheno-femoral junction is occluded)
• Trendelenburg I: Patient is asked to stand quickly. When tourniquet or thumb if released,
rapid filling from above signifies sapheno-femoral incompetence.
• Trendelenburg II: After standing, tourniquet is not release. Filling of blood from below
upwards rapidly can be observed within 30-60 seconds. It signifies perforator
incompetence.
o Perthes test
• The affected lower limb is wrapped with elastic bandage and the patient is asked to walk
around and exercise. Development of severe cramp like pain in the calf signifies DVT.
• Empty the vein, place a tourniquet around the thigh and ask the patient to stand up
• Ask the patient to rapidly stand up and down on their toes -- filling of the veins indicate
deep venous incompetence
• This is a painful and rarely used test
• Detect a DVT or a perforator incompetence

Page 93 of 94
o Modified Perthes
• Do as in Trendelenburg test, allow a small volume of blood in the varicosity, exercise,
shrinks if deep and perforators are fine
o Fegan's test

Page 94 of 94

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Acute Abdomen examination

Wednesday, 3 May 2017

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Acute Vertigo (PICA) Lateral Medullary Syndrome

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▪ Diagnosis and Management

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▪ Third aim is to find out the extent of ankle sprain.

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• Lateral Talar tilt test

o Rule out high ankle strain

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Chronic foot pain

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▪ Morton's neuroma/Morton's metatarsalgia

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o Feel for Plantar fasciitis

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Assessment of a Comatose patient

▪ I want to proceed with the DRSABCDE protocol.

Differential Diagnosis of Coma:

Glasgow Coma Scale: EVM 456

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2 cases in AMC: sciatica or acute mechanical back pain

Positive points in history:

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28 year old female presents to your GP clinic with heavy periods.

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o Lungs: turn the stethoscope to the bell side

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▪ Abdomen: ask the patient to lie on his back

o Do deep palpation the same way EXCEPT on the painful side

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Now Jenny, I'm going to have a look at your breasts

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Now please press your hands to your hips

There is no accentuation of dimpling

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I want to conclude my examination by doing a full respiratory examination, check for

Older female case

Younger female case

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▪ Good morning Mary, I am Dr. ____.

Pathologic murmurs, check for:

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General Examination (Head to toe)

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Cardiovascular examination proper (precordium examination) - patient should be in a 45 degree

Doctor can I go for a trip?

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History for murmur:

Differential Diagnosis for murmur:

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Diagnosis and Management

Cranial nerve examination

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Diabetic foot examination