Foundations of Clinical Method Workbook, Term 1

School of Medicine and Dentistry College of Life Sciences and Medicine

YEAR 2 MBChB Foundations of Clinical Method Workbook, Term 1

2013 / 2014 CONTENTS

Introduction...... 2

Alimentary System - Clinical Communication...... 3

Alimentary System - Commonly used terms...... 4

Session 1: Introduction to Clinical Examination of the Alimentary System...... 5

Session 2: Clinical Examination of the Abdomen...... 9

Session 3: Examination of the Alimentary System & Rectal Examination...... 12

Testing for Faecal Occult Blood – FOB Test...... 19

The Head and Neck...... 20

Nervous System...... 28

Exercise 1...... 38

Exercise 2: Cranial Nerves Crossword...... 39

E-Portfolio activities for Year 2, Term 1...... 40

Calgary Cambridge Framework...... 41

Dress Guidance...... 42

How to Handwash...... 43

Hand Rub Procedure...... 44

SEWS Chart...... 45

1 Introduction

In year one of your course we introduced you to the concept of clinical method. Clinical method is the term used to describe the skills and the way in which these skills are used to obtain information from a patient in order to make a diagnosis. The skills are often divided into clinical communication, clinical examination and procedural skills. During year one you began to learn these communication and examination skills and learned about a general history and examination as well as detail on the respiratory and cardiovascular systems. You had the opportunity to learn and practise these skills in the Clinical Skills Centre with the help of simulated and volunteer patients, and also to transfer these skills for the first time to a clinical area when you had your first ward attachments. You therefore had the opportunity to begin to develop the skills which will allow you to take your place in the healthcare team delivering safe, clinically effective and patient centred care.

This year sees the beginning of the Systems II part of the course, during which you will learn further about systems of the body. This term will focus on the alimentary system, the head and neck and the nervous system. There will be clinical communication sessions and examination sessions for each of these systems.

You will also continue to transfer your skills to the workplace with a series of clinical attachments on Thursday mornings. These will run across the whole of Year 2. Specific objectives will be provided on MyMBChB http://www.abdn.ac.uk/mymbchb( ) for these attachments but generally the aim is for you to improve and refine your history and examination skills in the clinical setting and to steadily incorporate new learning as it occurs in the Clinical Skills Centre. We will explain this further in an introductory lecture in week one. Details of this lecture are provided below. Thereafter information about the communication teaching is provided before the workbook sections on examination. This is followed with detail on the e-portfolio activities for this term. Please note that the last day for submission of this work is 13th December 2013.

You should bring this workbook with you to all Foundations of Clinical Method sessions. Guidance for dress expected of medical students and staff for patient contact is provided at the end of this workbook along with details on hand hygiene for your convenience.

Lecture: Overview of the Foundations of the Clinical Method Term 1, Year 2

Leads: Dr Angus Cooper and Dr Rebecca Riddell

Aims: To provide students with a brief review of Year 1 teaching, then Year 2 teaching will be outlined, in the context of Years 1 - 3 of the Foundation of the Clinical Method (Clinical Communication and Physical Examination), and how this fits into teaching on the 5-year programme

Objectives: • Explain the aims of the Foundations of the Clinical Method • Describe the course organisation and an overview of the content of Year 2 • Explain the expectations for student behaviour and attitudes on this course, and the MBChB generally including issues relating to improving patient safety • Present the rationale for the Foundations of the Clinical Method using examples and case studies

Format: This will be a lecture.

2 Clinical Communication

This year you will continue to develop your communication skills in the clinical skills centre to become more effective and efficient at taking patient centred histories. This will be complemented by your ward attachments. We continue to use the Calgary Cambridge framework, introduced in Year 1.

Alimentary System: History Taking & Clinical Communication Practical Sessions

There are two 2 hour tutorials during this system. Simulated patients will be present for the second tutorial.

Aims: To introduce students to alimentary history taking, in the context of the obtaining of a full patient history.

Objectives: • Refresh Year 1 patient centred history taking skills • List the sections in the history format • Learn the essential questions for a gastro-intestinal history • Learn how to best ask about potentially sensitive issues, ensuring the comfort of both student/doctor and patient • Identify and explain factors which are important in how sensitive questions are asked • Learn the importance of, and skills involved in, exploring patient issues that might be physical, psychological or social in nature • Further develop history taking skills

Format: Two sessions are timetabled and small group teaching will be used with time dedicated to skills practice. Additional materials may be posted on MyMBChB nearer the time of the session – please check MyMBChB regularly

Clinical Examination

Alimentary System: Clinical Examination

As with the Foundations of Clinical Method teaching in Year 1, in addition to the relevant communications sessions there will be a series of sessions which will focus on clinical examination. These sessions will further develop your understanding and practice of clinical method. During your ward attachments you will have the opportunity to introduce all that you learn in these sessions into your patient assessment. Three 2-hour clinical examination sessions are timetabled. Please remember that whenever you attend the clinical examination sessions, you are also practising your clinical communication skills!

3 N.B. Please view the ‘Clinical Examination of the Alimentary System’ video on MyMBChB before attending Session 1. MyMBChB→Year 2→Foundations of Clinical Method→Clinical Method Resources

Completing the following exercise will help to improve your knowledge and understanding. If you are not sure how to pronounce the terms, please don’t hesitate to ask the tutors in the Clinical Skills Centre or staff in clinical areas.

What do you understand by the following commonly used terms?

Palmar erythema

Petechiae

Fauces

Spider naevus/ naevi (pl)

Jaundiced/ icteric

Dysphagia

Virchow’s node

Haematemesis

Melaena

Tenderness

Guarding

Ascites

Flatus

Flatulence

Hernia

Hepatomegaly

Splenomegaly

Fetor hepaticus

4 Session 1: Introduction to Clinical Examination of the Alimentary System

Aims: • To view a DVD demonstrating Clinical Examination of the Alimentary System • To perform a peripheral examination relevant to the Alimentary System on a volunteer patient • To understand correct positioning and exposure of a patient for examination of the abdomen • To identify the nine named regions of the abdomen • To perform the initial part of an abdominal examination including inspection, light palpation and deep palpation.

Clinical examination of the Alimentary System – as with all clinical examinations – begins with an overview of the patient’s general condition. Initially you must determine if any form of immediate medical intervention is required. Useful information can be gleaned even before introducing yourself to the patient – a patient with abdominal pathology may look pale and unwell, be in obvious pain or may be clearly jaundiced or have obvious signs of weight loss; any drowsiness or restlessness may indicate hepatic encephalopathy.

• Clean your hands • Introduce yourself to the patient, giving your name and status • Carefully check the patient’s identity (name plus date of birth/ID band) • Explain to the patient why you are there and what the examination will involve • Gain informed consent to continue. • Examine from the patient’s right side

Perform your initial examination with the patient semi-reclined in a comfortable position with arms & upper chest area exposed. (In this session, female patients are not required to remove their underwear e.g. bra). Allow the patient to remove or adjust their own clothing, but offer guidance or assistance as necessary. Watching how the patient removes clothing may give useful clues about their condition e.g. how much pain they are in or how weak /tired/ unwell they are feeling.

General Looks well/unwell? distressed/in pain?; lying still/rolling about the bed? • Bedside equipment? e.g. IV infusion/‘drip’ • Vomit bowl? (check contents) • Nutritional status – does the patient look overweight or underweight? is patient of slight, average or heavy build? (check weight/height/BMI on charts i.e. Nutrition Screening Record). • Signs of dehydration? e.g. eyes sunken into orbits • Measure/check the patient’s temperature, pulse & respiratory rate as all of these may be abnormal in patients with abdominal pathology. Check the SEWS (Scottish Early Warning Scoring) chart at the end of the bed – these charts are used in most acute care areas. (see workbook p.45).

Hands • Inspect the hands for evidence of arthropathy (look for swollen joints which could be a sign of inflammatory bowel disease) • Look for palmar erythema (?‘liver palms’ - marked erythema over hypothenar eminence) • Inspect palmar creases for pallor (?anaemia). Palmar creases are normally pink in fair-skinned patients • Look and feel for Dupuytren’s contracture (?2° to alcohol) • Look at the nails for - leuconychia (?chronic liver disease) - koilonychia (?Fe deficiency) - signs of finger clubbing (?chronic liver disease).

Arms • bruising (?liver dysfunction) • scratch marks (‘pruritus’/itching may indicate chronic cholestasis) • muscle wasting (?inadequate nutrition ?sepsis) • track marks (?intravenous drug user at risk of Hepatitis B and C) • check forearm for loss of skin turgor (?dehydration).

Flapping tremor • Ask patient to hold their arms outstretched with both wrists in full extension and fingers separated. • Hold for at least 15 seconds.

A ‘hepatic flap’ may be elicited in a patient with severe hepatocellular disease (hepatic encephalopathy) N.B. A flapping tremor can also occur in: - severe ventilatory failure and CO2 retention - advanced renal failure with severe metabolic disorder - acute focal brain lesions (parietal or thalamic) and is the result of intermittent failure of the mechanisms in the brain required to maintain posture; the posture of the hands is intermittently dropped and then resumed, resulting in a jerky, flapping tremor.

5 Neck – revision of examination of cervical lymph nodes will be covered in the Head & Neck block. It is important to feel, in particular, for an enlarged left supraclavicular node as part of a full examination of the Alimentary System as this node may become enlarged due to lymphatic spread from an upper gastrointestinal tumour e.g. carcinoma of stomach (Virchow’s node).

Head Ask the patient to look up and then gently pull down the lower lids with your thumbs • look for conjunctival pallor (?anaemia due to gastrointestinal blood loss) • check colour of the sclera - should be white and not yellow (?liver dysfunction) • facial swelling (?parotid gland enlargement 2° to alcohol)

Mouth - examination of the mouth will not to be performed in this session. Practical revision of examination of the mouth (including salivary glands) will be covered in the Head & Neck block later this term. • Inspect the corners of the mouth, looking for angular stomatitis (?Fe, Vit B deficiency). Using a spatula (tongue depressor) and pen torch, inspect: • buccal mucosa for - pigmentation - ulceration (aphthous ulcers are common in inflammatory bowel disease i.e. Crohn’s) - oral candidiasis (thrush) • fauces for signs of infection eg of tonsils • gums for swelling or bleeding (?liver dysfunction) • state of dentition • tongue for ulceration or glossitis – e.g. smooth red tongue (?Fe, folate, B12 deficiency)

While examining the mouth of a patient in hepatic failure you may become aware of a sweet ‘mouldy hay’ smell on the patient’s breath (fetor hepaticus).

Upper chest • spider naevi (more than 5 → ?liver dysfunction) - look on the upper chest, arms and face (i.e. area of drainage of the superior vena cava). • gynaecomastia in male patients (?liver dysfunction → increased oestrogen) • loss of body hair in male patients (?liver dysfunction)

Although the legs will not be examined in today’s teaching session, you should be aware that you may find several clinical signs in the lower limbs associated with pathology of the alimentary system e.g. peripheral oedema due to hypoalbuminaemia/liver failure or erythema nodosum associated with inflammatory bowel disease.

Abdomen

Important!! Before starting to examine the abdomen, it is extremely important to POSITION the patient correctly and to EXPOSE the abdomen adequately.

Reposition the patient for examination of the abdomen: • adjust the height of the bed if necessary • ask the patient to lie supine supported by 1 pillow (check patient does not become short of breath when lying flat) • adjust bed-linen and clothing so that the whole of the abdomen from the xiphisternum to the pubic symphysis is exposed. (Ask the patient to adjust their own clothing, but offer assistance if required, making sure that the patient’s chest and legs are not left uncovered unnecessarily) • patient’s hands placed by sides • legs not crossed

Inspection: • Gentle movement of the abdomen with respiration is generally an indication that the abdomen is relaxed & pain-free (N.B. when peritonitis is present, respiration may be shallow and rapid and the abdomen may not move with respiration).

• Shape of the abdomen – is it a normal, symmetrical shape or is the abdomen generally distended? is there localised swelling or an obvious mass? You may need to view the abdomen from different angles or from the end of the bed to determine any abnormality of abdominal shape. (Remember the 5 Fs – possible causes of abdominal distension: fat, faeces, flatus, fluid or fetus).

Also look for: • visible pulsation (?abdominal aorta) • scars (?surgery or trauma) • a stoma (?ileostomy/colostomy) • distended veins (?portal hypertension ?inferior vena caval obstruction) • striae (?weight gain then loss) • skin colour change (e.g. jaundice) • scratch marks (?chronic cholestasis) • petechiae (pin-head sized red spots cause by bleeding under the skin ?liver dysfunction)

6 Palpation: Successful palpation of the abdomen will only be achieved if your technique is correct. Your examining hand should lie flat on the surface of the abdomen and be in line with your forearm. Adjust the height of the bed or alternatively you may need to sit on a chair beside the bed or even kneel down to examine the patient effectively.

Light palpation: Palpation is performed with the palmar surface of all the fingers of the right hand and all movement should be fromthe metacarpophalangeal (MCP) joints.

• Ask the patient if there are any painful or tender areas of the abdomen BEFORE you begin palpation. • Ensure your hands are as warm as possible – successful palpation requires the muscles of the abdominal wall to be relaxed; cold hands upset patients and will cause abdominal muscles to contract. • Start palpation away from the site of any pain • Watch the patient’s facial response while performing your examination. • Start with light palpation over the whole of the abdomen, exerting light pressure in each of the 9 regions in turn

RUQ = right upper quadrant E = epigastrium LUQ = left upper quadrant LH = left hypochondrium LLQ = left lower quadrant LF = left flank RLQ = right lower quadrant LIF= left iliac fossa H = hypogastrium RIF = right iliac fossa RF = right flank RH = right hypochondrium U = umbilical region

• Palpate for superficial masses which may be located either within the abdominal wall (e.g. a lipoma or sebaceous cyst) or within the abdominal cavity. • Feel for any areas of tenderness (pain elicited by palpation) which may be caused by inflammation of the parietal peritoneum. • Feel for any areas of increased muscle tension – guarding. Abdominal discomfort may cause reflex contraction of abdominal muscles which you might be able to detect with your hand. Involuntary guarding may be a sign of peritoneal inflammation but voluntary guarding can frequently be caused by anxiety.

Rebound tenderness is caused when compression of the abdominal wall is rapidly released. If there is doubt about the presence of significant peritoneal inflammation it is more acceptable to percuss over the area or to ask the patient to give a cough, rather than rapidly releasing the examining hand which may cause the patient unnecessarily severe pain.

Rigidity - Persistent involuntary contraction of abdominal muscles (known as rigidity) indicates peritonitis and is always associated with abdominal pain with tenderness on palpation.

After completing light palpation, move on to deep palpation of the 9 regions of the abdomen

Deep palpation: This may be rather uncomfortable even in healthy individuals and it is useful to ask the volunteer patient to comment on the comfort of the examination and to ask how the firmness of your deep palpation compares with that of the tutor.

Palpate for • abdominal masses (if any masses are felt, they need to be examined in detail – see workbook p.8) • areas of tenderness or pain on deep palpation (you may find an area which was not tender to light palpation but is tender to deep palpation).

Examination for major organs:

In normality, you may feel: - the pulsation of the abdominal aorta in the epigastrium (remember to palpate gently in this area – review ‘Locating Arterial Pulses’ in Year 1, Term 2 FCM workbook clinical examination of cardiovascular examination.) - the caecum in the right lower quadrant (may feel or hear a ‘squelch’) - the descending & sigmoid colon on the left side (containing varying amounts of faeces prior to evacuation) and you may just feel - the liver edge at the right costal margin

After completing both light and deep general palpation, you should then examine specifically for the major abdominal organs i.e. liver, spleen & kidneys.

7 Examination for major organs:

Liver Upper border: 5th right intercostal space on full expiration. Lower border: at costal margin in MCL on full inspiration. • Begin by placing your hand in the patient’s right iliac fossa, with the radial edge of your right hand parallel to the right costal margin. • Press firmly over the abdomen, inwards & upwards. • If you hold this position and ask the patient to take a deep breath in through the mouth, when the liver descends during inspiration you might feel the edge of the liver ‘nudging’ your index finger. • If no liver edge is felt, reposition your hand 2-3cms closer to the costal margin while the patient is breathing out, and again feel for a liver edge on deep inspiration. • Continue to move your hand in a stepwise manner, until you reach the right costal margin, keeping your hand still during inspiration. When you hand is placed at the costal margin, you may just feel the edge of a normal liver.

N.B. Remember, it is unlikely that your volunteer patient will have a readily palpable liver edge; using correct examination technique is the purpose of this part of the session.

Spleen The spleen is located between the 9th & 11th ribs on the left side of the abdomen, posterior to the mid-axillary line. Like the liver, it moves with respiration but the spleen only becomes palpable when at least twice its normal size.

• Begin palpating with your right hand in the right iliac fossa and press gently but firmly inwards & upwards towards the left costal margin as the patient breathes deeply in and out • Reposition your hand in a stepwise manner diagonally across the abdomen while the patient is breathing out. • A greatly enlarged spleen will bump against your fingers towards the end of deep inspiration. If the spleen is sufficiently enlarged you may feel the splenic ‘notch’.

Bimanual palpation may be used to examine the spleen: As you move your right hand step-wise towards the left costal margin, press the left lower ribs posteriorly with your left hand on deep inspiration.

N.B. Remember that you are very unlikely to be able to feel the spleen in your volunteer patient – using correct examination technique is the purpose of this part of the session.

Kidneys The kidneys are retroperitoneal organs; lie in the ‘renal’ angle formed (posteriorly) by 12th rib and lateral margin of vertebral column; extend from level of T12 – L3; right kidney is 2-3cm lower than the left. To examine for kidneys • use deep bimanual palpation • place one hand on the abdomen and the other hand behind the loin area • ask the patient to take a deep breath in and then, as they breathe out, press your hands as close together as possible. If you keep your hands in this position, when the patient takes another deep breath in, the kidney will move downwards and may become palpable on deep inspiration.

N.B. You are very unlikely to feel a normal kidney – using correct examination technique is the purpose of this part of the session. You may very occasionally be able to palpate the lower pole of the right kidney in very slim patients (a normal kidney should feel smooth and firm).

Technique of ballottement: You are NOT expected to routinely employ this technique of kidney examination at this stage of your training. ‘Ballotter’ literally means ‘to shake about’ or ‘to toss or roll around’. When a kidney is ‘ballotted’, it can be felt to bump against the anterior hand when the fingers of the posterior hand flex abruptly and press the renal angle sharply - if you cannot feel anything which you think might be a kidney on initial examination, there will be nothing to ballotte!

Examining an Abdominal Mass If an abdominal mass is detected you will need to be able to describe the following features: • Site • Size • Shape • Surface (smooth/craggy) • Edge/outline (regular/irregular) • Tenderness to palpation • Consistency (hard/soft) • Mobility • Pulsatile? • Fluctuant? • Is it possible to get above the mass?

8 Session 2: Clinical Examination of the Abdomen

Aims: • To perform abdominal examination on a volunteer patient, including inspection, palpation, percussion and auscultation • To learn how to elicit the sign of ‘shifting dullness’ • To learn how to elicit a ‘fluid thrill’ • To learn how to elicit a ‘gastric splash’

Examination of the Abdomen:

Think! PATIENT POSITIONING & ADEQUATE EXPOSURE

• Ask the patient to lie supine supported by 1 pillow - adjust the backrest and pillows as necessary and remember to check that the patient does not become breathless when lying flat • Adjust bed-linen and clothing so that the whole of the abdomen from the xiphisternum to the pubic symphysis is exposed. Ask the patient to adjust their own clothing, but offer assistance as required, making sure that the patient’s chest and legs are not left uncovered unnecessarily. • Adjust the height of the bed if necessary • Patient’s hands placed by sides • Legs not crossed

Inspection of the abdomen: • Gentle movement of the abdomen with respiration is generally an indication that the abdomen is relaxed & pain-free (N.B. when peritonitis is present, respiration may be shallow and rapid and the abdomen may not move with respiration).

• Also look for: - visible pulsation (?abdominal aorta) - scars (?surgery or trauma) - a stoma (?ileostomy/colostomy) - distended veins (?portal hypertension ?inferior vena caval obstruction) - striae (?weight gain then loss) - skin colour change (e.g. jaundice) - scratch marks (?chronic cholestasis) - petechiae (pin-head sized red spots cause by bleeding under the skin ?liver dysfunction)

Palpation: Successful palpation of the abdomen will only be achieved if your technique is correct. Your examining hand should lie flat on the surface of the abdomen and be in line with your forearm. Adjust the height of the bed, or alternatively you may need to sit on a chair beside the bed or even kneel down to examine the patient effectively.

Palpation is performed with the palmar surface of all the fingers of the right hand and all movement should be fromthe metacarpophalangeal (MCP) joints.

Light palpation: • Ask the patient if there are any painful or tender areas of the abdomen BEFORE you begin palpation. • Ensure your hands are as warm as possible – successful palpation requires the muscles of the abdominal wall to be relaxed; cold hands upset patients and will cause abdominal muscles to contract. • Start palpation away from the site of any pain • Watch the patient’s facial response while performing your examination. • Start with light palpation over the whole of the abdomen, exerting light pressure in each of the 9 regions in turn • Palpate for superficial masses which may be located either within the abdominal wall (e.g. a lipoma or sebaceous cyst) or within the abdominal cavity. • Feel for any areas of tenderness (pain elicited by palpation) which may be caused by inflammation of the parietal peritoneum. • Feel for any areas of increased muscle tension – guarding. Abdominal discomfort may cause reflex contraction of abdominal muscles which you might be able to detect with your hand. Involuntary guarding may be a sign of peritoneal inflammation but voluntary guarding can frequently be caused by anxiety.

Rebound tenderness is caused when compression of the abdominal wall is rapidly released. If there is doubt about the presence of significant peritoneal inflammation it is more acceptable topercuss over the area or to ask the patient to give a cough, rather than rapidly releasing the examining hand which may cause the patient unnecessarily severe pain.

9 Rigidity - Persistent involuntary contraction of abdominal muscles (known as rigidity) indicates peritonitis and is always associated with abdominal pain with tenderness on palpation.

After completing light palpation, move on to deep palpation of the 9 regions of the abdomen

Palpate for • abdominal masses (if any masses are felt, they need to be examined in detail – see workbook p.7) • areas of tenderness or pain on deep palpation (you may find an area which was not tender to light palpation but is tender to deep palpation).

In normality, you may feel: - the pulsation of the abdominal aorta in the epigastrium (remember to palpate gently in this area – review ‘Locating Arterial Pulses’ in Year 1, Term 2 FCM Workbook Clinical Examination of Cardiovascular System.) - the caecum in the right lower quadrant (may feel or hear a ‘squelch’) - the descending & sigmoid colon on the left side (containing varying amounts of faeces prior to evacuation) and you may just feel - the liver edge at the right costal margin

After completing both light and deep general palpation, you should then examine specifically for the major abdominal organs i.e. liver, spleen & kidneys.

Examination for major organs:

Liver • Begin by placing your hand in the patient’s right iliac fossa, with the radial edge of your right hand parallel to the right costal margin. • Press gently but firmly over the abdomen, inwards & upwards towards the right costal margin. • If you hold this position and ask the patient to take a deep breath in through the mouth, you may feel the edge of the liver ‘nudging’ your index finger when the liver descends during inspiration. • If no liver edge is felt reposition your hand 2-3cms closer to the costal margin, while the patient is breathing out and again feel for a liver edge on deep inspiration. (NB. Remember that your volunteer patient may not have a palpable liver). • Continue to move your hand in a stepwise manner, until you reach the costal margin, remembering to keep your hand still during inspiration. • Percussion may be used to confirm the level of the lower edge of the liver. • Begin percussing from the right iliac fossa (the percussion note here should be resonant as there is underlying gas-filled bowel) • Percuss towards the right costal margin in a stepwise manner • Percussion note will become dull when the lower edge of the liver is reached.

[If the liver is palpable below the costal margin, you can confirm whether the liver is actually enlarged (and has not just been pushed downwards e.g. by hyperinflated lungs) by locating the upper border of the liver by percussion. The percussion note over the chest in the mid-clavicular line at the level of the 2nd right rib should be resonant, but on percussing downwards the note will become slightly duller when the upper border of the liver is reached - normally in the 5th or 6th intercostal space on full inspiration.]

N.B. Remember, it is unlikely that your volunteer patient will have a readily palpable liver edge; using correct examination technique is the purpose of this part of the session.

Spleen The spleen is located between the 9th & 11th ribs on the left side of the abdomen, posterior to the mid-axillary line. Like the liver it moves with respiration, but the spleen only becomes palpable when at least twice its normal size.

• Begin palpating with your right hand in the right iliac fossa and press gently but firmly inwards & upwards towards the left costal margin as the patient breathes deeply in and out • Reposition your hand in a stepwise manner, diagonally across the abdomen while the patient is breathing out. • A greatly enlarged spleen will bump against your fingers towards the end of deep inspiration and if the spleen is sufficiently enlarged you may be able to feel the splenic ‘notch’.

Percussion may be used to confirm the extent of splenic enlargement. • Begin percussing from the right iliac fossa where the percussion note should be resonant as there is underlying gas-filled bowel). • Progress diagonally across the abdomen towards the left costal margin. • If an enlarged spleen extends below the costal margin, the percussion note will become dull.

10 N.B. Remember that you are very unlikely to be able to feel the spleen in your volunteer patient – using correct examination technique is the purpose of this part of the session

Kidneys The kidneys are retroperitoneal organs, lie in the ‘renal’ angle formed (posteriorly) by 12th rib and lateral margin of vertebral column; extend from level of T12 – L3; the right kidney lies 2-3cms lower than the left.

To examine for kidneys • use deep bimanual palpation • place one hand on the abdomen and the other hand behind the loin area • ask the patient to take a deep breath in and then, as they breathe out, press your hands as close together as possible. If you keep your hands in this position, when the patient takes another deep breath in, the kidney will move downwards and may become palpable on deep inspiration.

Taking into account the patient’s history and your findings on examination, you may suspect that any abdominal distension is caused by fluid. There are two commonly used methods of demonstrating the presence of ‘free’ fluid (ascites) in the peritoneal cavity:

1. Shifting Dullness • With the patient lying supine, start percussing from the centre of the abdomen out towards the left flank, listening for any change in percussion note from resonant (centrally) to dull (in the flank). • Note the point at which the percussion note becomes dull, and keep your hand positioned over this point. • Now ask the patient to roll towards you onto their right side (still keeping your left hand in place). • After allowing time for any fluid to sink, percuss over the area where your hand is still positioned. • If the dull percussion note has changed to become resonant, you have demonstrated that the dullness has “shifted” - and as you percuss down towards the right flank you will find that there will be a new level of dullness to percussion. • Eliciting the sign of shifting dullness confirms the presence of >1.5 litres of fluid.

2. Fluid Thrill • If a patient has a grossly distended abdomen (caused by a very large volume of ascitic fluid) you may be able to demonstrate a fluid thrill.

With the patient lying supine: • Ask an assistant (or possibly, the patient) to place a hand on the midline of the abdomen (to prevent any impulse being transmitted via the skin and subcutaneous fat). • If you ‘flick’ one side of the abdominal wall, an impulse or ‘fluid thrill’ can be detected with your other hand placed on the other side of the abdomen if ascites is present.

Auscultation

Bowel sounds In normality, bowel sounds occur intermittently and may be heard all over the abdomen. • Place the diaphragm of the stethoscope in, for example, the left lower quadrant of the abdomen and note if bowel sounds are present or absent. • If you hear bowel sounds in one area of the abdomen then there is no need to listen in other areas. • Bowel sounds are very variable and you may hear very active, loud gurgling bowel sounds (sometimes even without a stethoscope) or only occasional soft sounds, but this is not usually an indicator of pathology. Activity of bowel sounds depends on numerous factors including timing of the last meal, when defaecation last occurred and patient anxiety. • High-pitched ‘tinkling’ bowel sounds may indicate intestinal obstruction • Only report bowels sounds as ‘absent’ if you have listened for at least 2 minutes and you hear absolutely no bowel sounds in any area. Absence of bowel sounds indicates complete lack of peristalsis in the bowel.

Gastric splash The significance of a gastric splash must be interpreted in the light of the medical history. It is normal to hear a gastric splash if the patient has eaten or taken a drink within 4 hours of examination. If a splashing sound is detected when the patient has not taken anything orally in the 4 hours prior to examination this may indicate gastric outflow obstruction. • Hold the stethoscope diaphragm over the epigastrium with both thumbs, gently grasping both sides of the abdomen with outstretched hands, and shake the abdomen gently from side to side. • Listen for a splashing noise (a ‘gastric splash’) once you have stopped shaking the abdomen • You can often hear a gastric splash without using a stethoscope.

11 Arterial bruits Using a stethoscope, listen over: - abdominal aorta in the epigastrium (?atherosclerosis → aneurysm) - renal arteries, if renal artery stenosis is suspected. Listen on both sides of the midline above and just lateral to the umbilicus. - liver (bruits uncommon e.g hepatocellular cancer) - spleen (bruits uncommon e.g. splenic A-V fistula)

Rubs – listen over the liver and spleen (a rub indicates inflammation of the capsule surrounding the organ)

• Conclude the examination by thanking the patient and helping to make them more comfortable • Clean your hands.

N.B. A full abdominal examination includes examination of the groins (for lymphadenopathy), hernial orifices, male genitalia and a digital rectal examination. None of these examinations will normally be undertaken on volunteer patients. As an undergraduate you should not perform these examinations on ward patients unless you have discussed it with, and are supervised by, a qualified clinician.

In the Urinary System block there will be an opportunity to examine testicular models and to view a video demonstration of examination of the hernial orifices. In future years, during surgical ward and out-patient clinic attachments, you are likely to have an opportunity to examine patients with inguinal and femoral hernias.

Session 3: Examination of the alimentary system & Rectal Examination

Aims: • To practise examination of the alimentary system with volunteer patients • To view a demonstration video of a digital rectal examination • To view a PowerPoint presentation showing examples of perianal conditions • To perform a digital rectal examination on a training model • To perform a test for faecal occult blood (FOB test)

CLINICAL EXAMINATION OF THE ALIMENTARY SYSTEM

Begin with an overview of the patient’s general condition. Does the patient need any form of immediate medical intervention? Useful information can be gleaned even before introducing yourself to the patient – a patient with abdominal pathology may look pale and unwell, be in obvious pain or may be clearly jaundiced or have obvious signs of weight loss; any drowsiness or restlessness may indicate hepatic encephalopathy.

General • Looks well/unwell? distressed/in pain?; lying still/rolling about the bed? • Bedside equipment e.g. IV infusion/‘drip’? • Vomit bowl (check contents)? • Nutritional status – does the patient look overweight or underweight? is patient of slight, average or heavy build? (check weight/height/BMI on charts i.e. Nutrition Screening Record). • Signs of dehydration? e.g. eyes sunken into orbits • Measure/check the patient’s temperature, pulse & respiratory rate as all of these may be abnormal in patients with abdominal pathology. Look at the SEWS (Scottish Early Warning Scoring) chart at the end of the bed – these charts are used in most acute care areas. (see workbook p.45).

12 Hands • Inspect the hands for evidence of arthropathy (look for swollen joints which could be a sign of inflammatory bowel disease) • Look for palmar erythema (?‘liver palms’ - marked erythema over hypothenar eminence) • Inspect palmar creases for pallor (?anaemia). Palmar creases are normally pink in fair-skinned patients • Look and feel for Dupuytren’s contracture (?2° to alcohol) • Look at the nails for - leuconychia (?chronic liver disease) - koilonychia (?Fe deficiency) - signs of fingerclubbing (?chronic liver disease).

Flapping tremor • Ask patient to hold their arms outstretched with both wrists in full extension and fingers separated. • Hold for at least 15 seconds.

Neck – revision of examination of cervical lymph nodes will be covered in the Head & Neck block. It is important to feel, in particular, for an enlarged left supraclavicular node as part of a full examination of the Alimentary System as this node may become enlarged due to lymphatic spread from an upper gastrointestinal tumour e.g. carcinoma of stomach (Virchow’s node).

Mouth - examination of the mouth will not to be performed in this session. Practical revision of examination of the mouth (including salivary glands) will be covered in the Head & Neck block later this term. Inspect the corners of the mouth, looking for angular stomatitis (?Fe, Vit B deficiency). Using a spatula (tongue depressor) and pen torch, inspect: buccal mucosa for - pigmentation - ulceration (aphthous ulcers are common in inflammatory bowel disease i.e. Crohn’s) - oral candidiasis (thrush) fauces for signs of infection e.g. of tonsils gums for swelling or bleeding (?liver dysfunction) state of dentition tongue for ulceration or glossitis – e.g. smooth red tongue (?Fe, folate, B12 deficiency)

While examining the mouth of a patient in hepatic failure you may become aware of a sweet ‘mouldy hay’ smell on the patient’s breath (fetor hepaticus).

Upper chest • spider naevi (more than 5 > ?liver dysfunction) - look on the upper chest, arms and face (i.e. area of drainage of the superior vena cava). • gynaecomastia in male patients (?liver dysfunction > increased oestrogen) • loss of body hair in male patients (?liver dysfunction)

13 Abdomen

Important!! Before starting to examine the abdomen, it is extremely important to POSITION the patient correctly and to EXPOSE the abdomen adequately.

Inspection of abdomen: • Gentle movement of the abdomen with respiration is generally an indication that the abdomen is relaxed & pain-free (N.B. when peritonitis is present, respiration may be shallow and rapid and the abdomen may not move with respiration).

• Also look for: - visible pulsations (?abdominal aorta) - scars (?surgery or trauma) - a stoma (?ileostomy/colostomy) - distended veins (?portal hypertension ?inferior vena caval obstruction) - striae (?weight gain then loss) - skin colour change (e.g. jaundice) - scratch marks (?chronic cholestasis) - petechiae (pin-head sized red spots cause by bleeding under the skin ?liver dysfunction)

Palpation is performed with the palmar surface of all the fingers of the right hand and all movement should be fromthe metacarpophalangeal (MCP) joints.

Rebound tenderness is caused when compression of the abdominal wall is rapidly released. If there is doubt about the presence of significant peritoneal inflammation it is more acceptable topercuss over the area or to ask the patient to give a cough, rather than rapidly releasing the examining hand which may cause the patient unnecessarily severe pain.

Rigidity - Persistent involuntary contraction of abdominal muscles (known as rigidity) indicates peritonitis and is always associated with abdominal pain with tenderness on palpation.

After completing light palpation, move on to deep palpation of the 9 regions of the abdomen

14 Palpate for • abdominal masses (if any masses are felt, they need to be examined in detail – see workbook p.8) • areas of tenderness or pain on deep palpation (you may find an area which was not tender to light palpation but is tender to deep palpation).

After completing both light and deep general palpation, you should then examine specifically for the major abdominal organs i.e. liver, spleen & kidneys.

Examination for major organs:

N.B. Remember, it is unlikely that your volunteer patient will have a readily palpable liver edge; using correct examination technique is the purpose of this part of the session.

Percussion may be used to confirm the extent of splenic enlargement. • Begin percussing from the right iliac fossa (where the percussion note should be resonant as there is underlying gas-filled bowel). • Progress diagonally across the abdomen towards the left costal margin. • If an enlarged spleen extends below the costal margin, the percussion note will become dull.

N.B. Remember that you are very unlikely to be able to feel the spleen in your volunteer patient – using correct examination technique is the purpose of this part of the session

15 Taking into account the patient’s history and your findings on examination, you may suspect that any abdominal distension is caused by fluid. There are two commonly used methods of demonstrating the presence of ‘free’ fluid (ascites) in the peritoneal cavity:

2. Fluid Thrill • If a patient has a grossly distended abdomen (caused by a very large volume of ascitic fluid) you may be able to demonstrate a fluid thrill.

• With the patient lying supine: • Ask an assistant (or possibly, the patient) to place a hand on the midline of the abdomen (to prevent any impulse being transmitted via the skin and subcutaneous fat). • If you ‘flick’ one side of the abdominal wall, an impulse or ‘fluid thrill’ can be detected with your other hand placed on the other side of the abdomen if ascites is present.

Auscultation:

Arterial bruits Using a stethoscope, listen over: - abdominal aorta in the epigastrium (?atherosclerosis > aneurysm) - renal arteries, if renal artery stenosis is suspected. Listen on both sides of the midline above and just lateral to the umbilicus. - liver (bruits uncommon e.g hepatocellular cancer) - spleen (bruits uncommon e.g. splenic A-V fistula)

Rubs – listen over the liver and spleen (a rub indicates inflammation of the capsule surrounding the organ) • Conclude the examination by thanking the patient and helping to make them more comfortable • Clean your hands.

16 Digital Rectal Examination (Examination ‘per rectum’ or ‘PR’)

• Prior to a rectal examination, the patient will usually have undergone an abdominal examination. As an undergraduate, you must not take the decision to perform an intimate examination such as rectal examination on any patient unless supervised by an appropriate tutor. • Training models are available for use in the Clinical Skills Centre, as rectal examination will not usually be undertaken with volunteer patients. • It is important to give the patient a clear explanation of why a rectal examination is necessary, as this may not be at all obvious to the patient. • Advise the patient that they may find rectal examination uncomfortable and, in some cases, that it may be painful. Reassure the patient that if severe pain is experienced, you will stop the examination. • It is also advisable to tell the patient that rectal examination may promote a feeling of rectal fullness which may stimulate a desire to open the bowels – reassure the patient that this is very unlikely to happen. • Having explained to the patient what the examination involves, you must ask for permission to proceed (informed consent). • It is advisable to check current GMC guidance on intimate examinations and the use of chaperones. Wherever possible, you should offer the patient the opportunity of having a chaperone present during a rectal examination. This applies regardless of whether you are the same sex as the patient. • It is important to spend some time positioning the patient correctly, bearing in mind that an elderly patient or one with reduced mobility may require significant assistance. • Ideally, the patient should lie on their left side with hips and knees flexed and with the heels out of the way. Ensure the buttocks are positioned at the edge of the bed. • Good illumination and careful positioning will enable you to have a clear view of the perianal area. • Make sure you have all the necessary equipment ready to use and within easy reach. • Show respect for the patient by ensuring that only the area being examined is exposed. • The patient should be examined from the right side of the bed. • Put on gloves and place disposable towels under the patient and make sure there is adequate lighting. • Gently separate the buttocks to inspect the perianal area. • Look at the shape of the anus and observe whether it is open or closed – asking the patient to strain down may reveal abnormal descent of the anus or rectal prolapse. • Lubricant must first be applied to the examining finger: When examining a patient, water-soluble gel is used, but when using the rectal examination trainers, ONLY silicone oil may be used. • Let the patient know when you are about to start the rectal examination (placing your left hand over the patient’s hip area may help the patient feel less isolated). • First place the pulp of the index finger on the anal margin and wait until the anal sphincter begins to relax and insert the tip of the finger into the anal canal. • Gently push the finger through the anal canal and then assess anal tone by asking the patient to squeeze your finger with the anal muscles. • Move the finger further into the rectum, following the sacral curve posteriorly. • Gently sweep the finger through 180o exploring the posterior and then both posterolateral walls of the rectum in turn. • Rotate the wrist to palpate the anterior wall and then both anterolateral rectal walls in turn (you may find it easier to adopt a crouching position) • In men, the prostate gland will be palpable through the anterior wall of the rectum. (Detailed teaching on examination of the prostate will be covered in the Urinary system block) • In women, you may feel the cervix or a vaginal tampon through the anterior rectal wall. • Note the absence or presence of faeces in the rectum and note the stool consistency. • Carefully examine any palpable abnormalities within the rectum (i.e. irregularity in the rectal wall or a mass within the lumen of the rectum) and once you have completed a thorough examination, slowly withdraw your finger, feeling for any irregularities within the anal canal • Examine your gloved finger for stool colour and for any blood, mucus and pus.

17 • Inform the patient that you have finished the examination and wipe any excess gel from the perianal area and cover the patient appropriately. • After removing and disposing of the gloves in clinical waste, clean your hands and allow the patient to use the tissues and to dress in privacy. • It is professional to refrain from answering questions or delivering information while the patient is undressed and still lying on their side. • Document your findings in the patient’s medical records and also document details of any information given to the patient about your findings.

The Scottish Bowel Cancer Screening Programme

All men and women aged between 50 and 74 receive a Faecal Occult Blood (FOB) test kit in the post every three years. The test is partially completed at home and then returned to the national Bowel Screening Centre for Scotland based in King’s Cross Hospital, Dundee.

The centre completes all the returned FOB tests and then notifies: • all participants of their results • all GP surgeries of their patients’ positive FOB results • all NHS Boards of positive results requiring further investigations.

If initial FOB test is positive this is repeated. If still positive, patients are offered colonoscopy where appropriate. If a patient has a coexisting condition, such as inflammatory bowel disease, their case is discussed with their Gastroenterologist before proceeding to colonoscopy.

It is NOT advisable to perform an FOB test on a sample acquired on digital rectal examination as false positive results may occur. FOB testing is not now usually carried out routinely in the ward or community/GP setting as the FOB test is very sensitive with a high false positive rate - even vigorous teeth brushing or eating red meat can turn the test positive! General FOB testing is therefore no longer recommended but the FOB test is, nevertheless, a simple procedure with which you require to be familiar.

18 Testing for Faecal Occult Blood – FOB Test

1. Prepare Equipment: 4. Add reagent to develop test:

• ‘Hema-screen’ slide test (check expiry date) • Lift small flap on other side of slide test to • Applicator reveal reverse side of windows • Reagent/developer • Place 2 drops of reagent onto each window • Gloves and wait • Faecal specimen 30-60 secs • Clinical waste bag • Place 1 drop of reagent onto control strip at bottom of test slide and wait 30 secs.

2. Prepare for FOB test: 5. Check control area & read result: • Write patient’s name/date of birth on slide • Check control strip after 30 secs: test - should be no colour change on NEG- • Put on gloves NEG-NEG strip • Observe faecal specimen for colour i.e. (still pinkish/red) - abnormally pale? - BLUE colour should appear on - black and tarry (?melaena) POS+POS+POS strip - dark red/bright red (?frank blood) • Read result in 30-60 secs: 3. Perform FOB test: - NO colour change = FOB – ve - BLUE colouration = FOB +ve • *Use applicator to: - Smear small amount of stool in window I - Smear small amount of stool from different area of specimen in window II

• Press cover closed *N.B. In the teaching session you should apply a sample from two different specimens

6. Waste Disposal:

• Dispose of test slide, applicator and specimen in clinical waste bag • Remove gloves and dispose of in clinical waste bag • Clean your hands

19 THE HEAD and NECK

Preparation for the Examination Session Macleod’s Clinical Examination is your core text for these examination sessions. You will find it very helpful to have studied the relevant sections (found in the chapters on:- general examination, endocrine system and ear, nose and throat) before the practical examination sessions and to have revisited the Year One Workbook (general examination) and to have viewed the video on Head and Neck Examination on MyMBChB.

Aim The aim of the session is to give you the opportunity to learn how to examine the head and neck.

Objectives By the end of the session you will have learnt • How to examine the face and scalp • How to undertake an ENT examination • Particularly to examine the - lymph nodes of the neck - salivary glands - thyroid gland • How to use an auriscope • How to conduct simple hearing tests • Recognise certain head and neck clinical features Definition For this session we have defined the head and neck as that area above the clavicles. We will not be covering the formal examination of the cranial nerves, the detailed examination of the eyes or the measurement of the JVP – these are all covered in other clinical teaching sessions (revisit Year One CVS for JVP and Cranial Nerves and Fundoscopy will be covered in the Neurological Session that follows). Detailed vestibular function tests are not included.

For clarity during these sessions we will describe the examination of each area in turn following the standard approach of inspection and palpation with auscultation where appropriate (percussion is omitted) and will demonstrate the simple hearing tests

History Unlike other clinical examinations that you have learnt which have focused on a system, examination of the head and neck may be required across a whole range of systems. The importance of an adequate history is an essential pre-requisite. While many of the problems will fall into the province of the Ear, Nose and Throat (ENT) speciality, the head and neck links to many other areas of medical practice noting particularly the Endocrine and Nervous systems. Equipment The equipment you will require is detailed below (for work in the Clinical Skills Centre all equipment needed for the examination will be provided – if you have a stethoscope please bring this with you to the clinical examination sessions).

1. Gloves 2. Torch 3. Tongue depressors 4. Auriscope and specula 5. Tuning fork

Examination Make sure you are prepared - appropriate dress for a clinical area clean hands (washed / alcohol gel) Ensure the patient is prepared - that you have introduced yourself you have checked the patient details you have explained the examination to the patient you have answered any questions the patient may have you have gained consent from the patient you have explained how you will give the results of the examination and answer questions

The description that follows is a complete examination – In clinical practice some parts of the examination might only be undertaken if the history points to a potential problem in that area.

The patient should be seated at a comfortable height and the head and neck should be exposed.

20 Start with a general examination and then move to specific areas of the head and neck

Initial Assessment Looking for any potentially life threatening conditions that may require immediate intervention General physiological checks Respiratory check (rate, mouth / nose, effort) Pulse check ( rate, rhythm) Check fingers (cyanosis, clubbing, tar staining) Check small muscles for wasting Examination of the hands Check palms (warmth, anaemia, palmar creases {Addison’s disease}) Check for tremor (fine {hyperthyroidism}, flapping) Shape of hands – large, thickened (acromegaly) Examination of arms Looking for any sign of muscle wasting, injection sites, oedema Vitiligo (may be associated with autoimmune diseases {diabetes mellitus, thyroid or adrenal disorders})

Head and Neck Examination – start with a general inspection of the whole area above the clavicles

General Examination of the Head and Neck INSPECTION General inspection Look all round the head and neck checking for • Expression • Shape of face and skull • Symmetry • Scars • Swellings (pulsations) • Skin (e.g. rashes, acne, blisters, vitiligo) • Hair (distribution, loss) • Movements (weakness) Eyes Lid lag, proptosis, eye movements, ptosis Check the sclera for jaundice or anaemia

Now move to consider each of the areas of the head and neck in turn. These include:

• The Bones of the Skull, Face and Cervical Spine • The Neck, Lymph Nodes and Salivary Glands • Nose • Mouth and Throat • Ears

Specific Examination of the Head and Neck The Bones of the Skull, Face and Cervical Spine Remember to ask the patient if they have any pain in the face, head or neck INSPECTION Skull and Face The general symmetry if not already studied should be observed looking particularly for features of endocrine upsets or bony changes suggestive of underlying disease or genetic syndromes PALPATION Skull • Feel the bones of the skull – frontal, temporal, occipital • Run your fingers along the nuchal lines • Palpate each mastoid process • Run your fingers around each orbital margin (notice any irregularity and the orbital notch) • Check for tenderness along the temporal artery on each side Facial bones and Temporo- • Feel the bones of the face and the mandible Mandibular (T-M) Joint • Place your Index and middle fingers over the T-M joint (just in front of the tragus) and ask the patient to open and close their mouth and then move the jaw sideways – observe movement of the joint (be gentle as even in normality this might be tender) Cervical Spine • Ask the patient to move their head – flexion, extension, rotation and lateral movements (note any movements that cause pain, limitation of movement or are not equal on both sides) • Palpate the spinal processes of the cervical vertebrae and the paraspinal muscles (looking for midline tenderness or lateral tenderness)

21 Specific Examination of the Head and Neck The Neck, Lymph Nodes and Salivary Glands INSPECTION Neck Fullness, goitre, swellings - mid line or unilateral, torticollis, signs of SVC (superior vena cava) obstruction Lymph nodes or Salivary Looking for any obvious swellings under the jaw, at the angle of the jaw or in the anterior or Glands posterior triangles PALPATION Lymph nodes This description of lymph nodes follows your learning in Year 1 – General Examination – please read the section at the end of this module to assist and develop your understanding of the clinical descriptions you may meet in clinical practice particularly in ENT practice.

Standing behind the patient palpate the lymph nodes in the following areas comparing sides (looking for any palpable nodes – if found assess for tenderness, consistency, size, tethering or Matting). Be prepared to ask the patient to tilt their head to improve or assist palpation

• Pre-auricular • Post-auricular • Occipital • Tonsillar • Superior cervical chain • Posterior cervical chain • Deep cervical chain • Supraclavicular (check particularly on the left side-Virchow’s nodes) • Scalene • Submandibular • Submental Salivary glands While there are three pairs of salivary glands only two are easily palpated

• Parotid gland – two parts - lies at the angle of the jaw with the superficial part overlying the masseter muscle – palpate at the angle of the jaw and over the masseter and the “tail” of parotid below the earlobe just behind the angle of jaw • Submandibular gland – palpate under the mandible and feel towards the midline. (consider bi-manual palpation inside mouth – see below when you examine the mouth) Neck From the front of the patient, check the position of the trachea and then the hyoid bone, thyroid and cricoid cartilages Move behind the patient to examine the neck in greater detail – ensure the patient knows what will happen with this part of the examination. Palpate the lateral aspects and the whole of the front of the neck, looking for any swellings

Determine if the swelling is:

• Cystic (compressible) • Vascular (pulsatile) • Nodular (hard)

For all swellings note the position (described as Midline or Lateral) – for lateral, consider if in the Anterior or Posterior Triangle; if in the midline, at the front of the neck

• Ask the patient to swallow (offer a sip of water to facilitate swallowing) if the swelling moves upwards on swallowing then it is the thyroid • Ask the patient to put out their tongue and note any movement – thyroglossal cysts move upwards (thyroglossal duct attachments) AUSCULTATION Carotid artery Listen over the carotid artery - listening for a carotid artery bruit (not a transmitted heart valve murmur) – use the diaphragm and ask the patient to hold his / her breath – in carotid artery stenosis a bruit may be heard Thyroid Listen over an enlarged thyroid – use the diaphragm of the stethoscope and ask the patient to hold his /her breath – listen over both lobes of the thyroid – In Graves’ disease a soft bruit may be heard

22 Specific Examination of the Head and Neck The Nose INSPECTION Nose • Look at the nose from in front, the side and from above the patient, observe the nasal pyramid, notice any discharge • Elevate the tip of the nose to inspect the nasal vestibule PALPATION Nose • Palpate the nasal cartilage and bones • Ask the patient to block one nostril and assess the air flow in the other nostril (reverse the nostril tested) • Feel for tenderness over the paranasal sinuses (maxillary, ethmoidal, frontal)

Specific Examination of the Head and Neck The Mouth and Throat INSPECTION Mouth • Lips (cyanosis, angular stomatitis, other lesions e.g. BCC) (use a torch and tongue • Open mouth – inspect inside, dentition, floor of mouth, hard and soft palate, inside of cheeks, depressor) parotid duct opening (2nd upper molar) • Look at the oropharynx, uvula, tonsillar folds and tonsils Tongue • Dorsal surface, both lateral borders (dryness, wasting) • Ask the patient to touch roof of mouth with the tongue, look at the underside of the tongue and floor of the mouth, frenulum, submandibular duct and opening Bite • Ask patient to gently bite teeth together PALPATION Mouth Explain the examination to the patient - With gloves on, ask the patient to open his / her mouth. (consider if dentures need removing)

Palpate • Along the floor of the mouth (under the tongue) • Submandibular gland (under tongue) • The inside of the cheeks • The tongue

Looking for cystic swellings, irregular roughened areas (suggestive of malignancy), or possible stones in the parotid duct

Specific Examination of the Head and Neck The Ears INSPECTION Ears • The pinna (outer ear) note any nodules or other lesions • Note if the pinna is pushed forward (mastoiditis) • External auditory meatus (note any discharges) • Behind the pinna • Mastoid process (bruising or Battle’s sign) PALPATION Ears Press in front of meatus or pull gently on the pinna (if either cause discomfort consider that there may be infection in the canal and care required with auroscope) Mastoid Process Palpate gently over each mastoid process – looking for tenderness

23 Examination of the Head and Neck – use of the auriscope and hearing tests Auriscope Use of the auriscope Explore how the auriscope works (the handle is the same for the ophthalmoscope) • The handle – rechargeable or batteries • On/off switch and rheostat • The head piece - the lens – bulb - front • The range of specula

• ensure the patient is seated • choose the largest appropriate speculum • hold the auriscope as shown • ask the patient to slightly turn head away from examiner • inspect the outer ear and the meatus • gently pull the pinna upwards and backwards (in an adult) • rest your little finger on the patient’s cheek for support • inspect the auditory canal • repeat for the other ear • visualise the tympanic membrane and identify the surface landmarks

Hearing Tests Whispering test • Stand behind the patient • About 15cm from the ear you are to test, whisper to see if the patient can hear you and they repeat the word you have whispered – this is to check that the patient is able to comply with the test • Mask the hearing in the other ear by gently rubbing the tragus of that ear • Whisper a series of sounds – both numbers and letters and ask the patient to repeat what they have heard • Increase the distance to about one arms length or 60 cm (this is about normal hearing) • Test the other ear in the same way Rinne’s test • To compare Air Conduction (AC) to Bone Conduction (BC) in each ear. • Using a 512 Hz tuning fork make it vibrate • Hold it about 5cm from the external auditory meatus – ask the patient if they can hear the sound • Immediately place the base of the tuning fork on the base of the mastoid process and check that the patient can hear the sound • Ask the patient which was louder - AC or BC – you may have to repeat the test to confirm the result – (normality AC>BC) • Repeat for the other ear • The test is positive if AC>BC • The test is negative if BC>AC = a Conductive Deafness • In unilateral neural deafness a false negative may occur (sound being transmitted through the bone to the good ear) but the whispering test should have demonstrated a unilateral deafness Weber’s test • Make the tuning fork vibrate • Place the base of the tuning fork in the midline – either on the vertex or the middle of the forehead • Ask the patient if the sound is louder in one ear or the other • In normality or if the hearing loss is symmetrical the sound is heard equally • If there is a conductive deafness on one side the sound will be heard loudest in that ear • If there is a sensori-neural hearing loss the sound will be referred to the good (unaffected) ear By undertaking the three hearing checks you should be able to differentiate between conductive and sensori-neural deafness

However if may be necessary to undertake an audiometric assessment and also tympanometry (to test middle ear compli- ance/pressure)

24 Clinical Notes to accompany examination of the head and neck Examination of the head and neck may provide a pointer to underlying pathological processes. By studying the appearance and expression of the patient a range of underlying conditions may become evident. More detailed examination and investigations can then lead to a definitive diagnosis.

Many of these conditions have very typical appearances and medical text books contain coloured pictures which should be viewed – we have not reproduced the pictures here. Search engines on the internet will also provide examples and explanations of the conditions – you are invited to search these out.

Examples of such underlying conditions may include (there are many more)

Thyrotoxicosis Down’s syndrome Familial hypercholesterolaemia Hypothyroidism Pierre Robin syndrome Mitral valve disease Cushing’s syndrome Acromegaly Mumps Addison’s disease Dehydration Facial fractures Parkinsonism Turner’s syndrome Cranial nerve lesions (UMN / LMN) Steroid use Stroke Bells palsy Genetic conditions Cleft lip Myasthenia gravis Systemic Lupus Erythematosus

Examination of the head and neck may reveal signs which are linked to other systems.

These are examples of some of the signs you will learn about and some of the possible underlying causes

Sign System Possible underlying condition Raised JVP CVS Consider, is there increased pressure in the right atrium or superior vena caval obstruction, – heart failure, pericardial tamponade, cardiomyopathy, constrictive pericarditis, fluid overload, tricuspid valvular disease Central cyanosis CVS Increase in circulating deoxygenated haemoglobin resulting from ventilatory RS (failure to oxygenate the blood or circulatory problems (sluggish circulation) Haemopoeitic system with increased oxygen uptake by the cells of the body or a right to left shunt (ventilation / perfusion mismatch in the lungs or congenital heart problem). Blood disorders such as methaemoglobinaemia or polycythaemia Nystagmus CVS Congenital, vestibular, cerebral, stroke, drugs, poisons, cerebellar lesions Eye muscle imbalance Facio-maxillary Trauma to the orbit, congenital, damage to the cranial nerves III, IV, VI, stroke CNS Ophthalmology

The details of cranial nerve examination will be covered in the Nervous System Module. While not covered in this session some of the cranial nerves might be tested when undertaking a full ENT assessment. Revisit this section when you have learnt how to examine the cranial nerves.

The cranial nerves assessed in an ENT examination include:

Cranial Nerve Function considered or to be assessed I Olfactory Sense of smell - difficult to test V Trigeminal Sensory and motor divisions VII Facial Muscles of expression – UMN and LMN; taste anterior 2/3 of tongue VIII Auditory Vestibular and acoustic parts IX Glossopharyngeal Movement of the pharynx and gag reflex X Vagus Act of swallowing and movements of pharynx XII Hypoglossal Movement of the tongue or presence of fasciculation or wasting

* Glossopharyngeal nerve only innervates stylopharyngeus muscle. This motor function is almost impossible to test separately from Vagus which innervates almost all of the other muscles of the pharynx & palate

25 The Cervical Lymph Nodes

During your introduction to the General Examination you learnt to examine the lymph nodes in the neck. These were described in the Year One, Term One Workbook on page 15. They were given the names of the anatomical sites where you find them. This provided a very sound introduction.

The clinical importance of lymph nodes comes from an understanding of the areas of the body that drain through these lymph nodes and consequently if you find an enlarged or palpable node you can identify the site of the body where the primary pathology may be found, whether that is infective or malignant. More general disease states may reveal themselves when a number of groups of lymph nodes are enlarged.

Moving from the lymph node sites you need to know the drainage areas – these are illustrated in the following diagram: In clinical practice the way that lymph nodes in the neck are grouped for descriptive purposes are based on the drainage areas. This descriptive methodology is particularly relevant in the specialty of ENT / Head and Neck Surgery. You will find these descriptions used during your ENT blocks with particular reference to cancers of the head and neck.

The language used describes a system of “levels” for the cervical nodes and are best illustrated in the following diagrams:

Levels I to V lie on the While levels VI and VII lie lateral side of the neck on the front of the neck

26 Glossary of Terms used in the Workbook

Acne Acne vulgaris (or acne) is a common skin disease, affecting mostly skin with the densest population of sebaceous follicles; these areas include the face, the upper part of the chest, and the back. Acromegaly Acromegaly most commonly affects adults in middle age. The disease is hard to diagnose in the early stages and is frequently missed for many years, until changes in external features, especially of the face, become noticeable. Addison’s Disease The symptoms of Addison’s disease develop insidiously. Most people with primary Addison’s have darkening (hyperpigmentation) of the skin, including areas not exposed to the sun; characteristic sites are skin creases (e.g. of the hands), nipple, and the inside of the cheek (buccal mucosa), also old scars may darken. Angular stomatitis Stomatitis is an inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, throat, and roof or floor of the mouth. Severe iron deficiency anaemia can lead to stomatitis – angular stomatitis is inflammation at the corners of the mouth Battle’s Sign Battle’s sign consists of bruising over the mastoid process, as a result of extravasation of blood along the path of the posterior auricular artery. Battle’s sign is an indication of a fracture of the base of the posterior portion of the skull, and may suggest underlying brain trauma. Another common bruising sign of a skull injury is raccoon eyes, the purplish discoloration around the eyes following fracture of the frontal portion of the skull base. BCC (basal cell carcinoma) Basal cell carcinoma is the most common type of skin cancer. It rarely metastasises or kills, but it is still considered malignant because it can cause significant local destruction and disfigurement by invading surrounding tissues. In 80 % of all cases, basal cell cancers are found on the head and neck. Goitre A goitre is a swelling in the thyroid gland, which can lead to a swelling of the neck or larynx. Goitre usually occurs when the thyroid gland is not functioning properly Graves’ Disease Graves’ disease is an autoimmune disease where the thyroid is overactive, producing an excessive amount of thyroid hormones The resulting state of hyperthyroidism can cause a dramatic constellation of neuropsychological and physical signs and symptoms.

Graves’ disease is the most common cause of hyperthyroidism in children and adolescents, and usually presents itself during early adolescence. Lid lag Lid lag sign is the immobility or lagging of the upper eyelid on downward rotation of the eye, indicating exophthalmic goitre (Graves’ Disease). Mastoid Process The mastoid process is a conical prominence projecting from the undersurface of the mastoid portion of the temporal bone. It is located just behind the external acoustic meatus, and lateral to the styloid process. Its size and form vary somewhat; it is larger in the male than in the female. Mastoiditis Mastoiditis is an infection of mastoid process, the portion of the temporal bone of the skull that is behind the ear which contains open, air-containing spaces. It is usually caused by untreated acute otitis media (middle ear infection). If untreated, the infection can spread to surrounding structures, including the brain, causing serious complications. The pinna will appear pushed forward Nuchal Lines The nuchal lines are four curved lines on the external surface of the occipital bone – two on each side (right and left) superior and inferior Parotid Gland The parotid gland is the largest of the salivary glands. It is found wrapped around the mandibular ramus, and it secretes saliva through Stensen’s duct into the oral cavity, to facilitate mastication and swallowing.

Proptosis Proptosis is the forward displacement of the eye seen in association with Graves’ Disease, a form of hyperthyroidism. Thought to be due to fatty deposits behind the eye pushing the eye forward Ptosis Ptosis is a drooping of the upper eyelid. The drooping may be worse after being awake longer, when the individual’s muscles are tired. Submandibular Gland The paired submandibular glands (submaxillary glands) are salivary glands located beneath the floor of the mouth. In humans, they account for 70% of the salivary volume and weigh about 15 grams. Supra-orbital notch The Supra-orbital notch is a small groove at superior and medial margin of the orbit in the frontal bone. The supraorbital nerve passes through this notch Torticollis Torticollis, or wryneck: Stiff neck associated with muscle spasm, classically causing lateral flexion contracture of the cervical spine musculature. Condition in which the head is tilted to one side. Vitiligo Vitiligo is a chronic disorder that causes depigmentation of patches of skin. The cause of vitiligo is unknown, but research suggests that it may arise from autoimmune, genetic, oxidative stress, neural, or viral causes.

27 Nervous System

Nervous System: History Taking & Clinical Communication Practical Session

There is one tutorial in this system. A simulated patient will be present for this session to help you develop your skills with history taking from a third person.

Aims: To introduce students to nervous system history-taking, in the context of the obtaining of a full patient history.

Objectives: Learn the essential questions for a nervous system history • Consider the circumstances when taking a history from a third party is required, and why this is useful • Introduce a simple, structured method for assessing if a patient is confused • Consider some of the issues involved in taking a history from a third party • Learn how to take a history from a third party • Further develop specific history taking skills

Format: Small group teaching will be used for this session with time dedicated to skills practice.

There will be two interactive sessions focusing on key issues relating to speech called ‘Let’s talk about speech’. These will be integrated with examination skills.

Additional materials may be posted on MyMBChB nearer the time of the session – please check MyMBChB regularly.

CLINICAL EXAMINATION OF THE NERVOUS SYSTEM

Introduction

The nervous system is fascinating! By building on progressive layers of anatomy, physiology and clinical skills you will be able to enjoy searching for clues in the labyrinth of information and experience many “Eureka” moments.

Not all will make sense immediately but connections will accumulate as you progress your reading and with every patient with whom you come into contact. In this workbook we have detailed the order of examination most commonly followed in clinical practice. This is the order that you will be taught the examination. You will have the opportunity to practise each part of the examination with volunteer patients in the Clinical Skills Centre before incorporating this into your history taking and examination in the wards.

Preparation for Examination Tutorials ‘Macleod’s Clinical Examination’ is your core text for these tutorials. You will find it very helpful to read the appropriate chapter before you come to any clinical examination sessions. For the nervous system, Chapter 11 and 12 (in the 13th edition of this text) are particularly useful. To further help you learn about clinical examination a number of videos and power point presentations have been produced. The videos for the examination of the nervous system (located on the MyMBChB website) should be viewed before you attend the Clinical Examination sessions. There are exercises you should complete before you come to each teaching session. These are detailed with the information provided in this workbook for each session.

Two speech seminars will be conducted as part of the nervous system block in the first and third weeks.

Order of examination

We will provide an explanation and demonstration of clinical examination of the nervous system. In practice, neurological examination is guided by the patient’s history. It is less likely an abnormality will be found on examination if there are no relevant symptoms. Therefore, often we can perform a fairly rapid screening examination to check everything is normal; but then we can also examine some functions in more detail when the need arises.

The order often followed for examination is as follows:

1. Higher functions: conscious level and mental state examination 2. Cranial nerves 3. Upper limbs 4. Lower limbs including Gait

28 Higher Functions Examination of the nervous system begins on your first contact with a patient and continues throughout history taking. All of the following can give you useful clues to the patient’s cognitive function and possible presence of neurological disease.

• Facial expression • General demeanour • Dress & posture • Gait

Speech

This is considered first because it may interfere with history taking; affect your ability to assess higher functions as well as the patient’s ability to perform many parts of the examination. An optional handout which is being developed is available for those interested in focusing on his area.

While introducing yourself and identifying the patient, determine whether there is any obvious physical barrier to communication. This could be due to deafness, inability to understand or to find or forms words at a central (cerebral) level, i.e. aphasia, the inability to produce voice sounds (e.g. whispering) due to problems of air flow or the vocal cords (aphonia) or the ability to modify the sounds produce by the vocal cords using the tongue palate and lips (dysarthria). You will further consider hearing, dysphonia and dysarthria in relation to the cranial nerves.

Assessment of conscious level and mental state examination:

Conscious level

AVPU You should remind yourself of the AVPU assessment of conscious level from the Year 1 First Aid course. AVPU is used not only in first aid settings, but also as part of the ongoing monitoring of acutely ill patients in hospital. You may have noticed it is included on the charts used to monitor patient progress at the end of the beds in wards or in the Clinical Skills Centre known as SEWS (Scottish Early Warning system).

Glasgow Coma Scale A more detailed and reliable method of assessing and recording conscious level than the AVPU scale is the Glasgow Coma Scale (GCS). The GCS is the internationally recognised way of recording conscious level and its components are detailed below.

Glasgow Coma Scale (GCS) Score Eye opening Spontaneous 4 To Speech 3 To Pain 2 No response 1 Verbal response Orientated 5 Confused: talks in sentences but disorientated 4 Verbalizes: words not sentences 3 Vocalises; sounds (groans or grunts) not words 2 No vocalization 1 Motor response Obeys commands 6 Localizes pain e.g. brings hand up beyond chin to supra-orbital pain 5 Flexion withdrawal to pain: no localization to supra-orbital pain but flexes elbow to nail bed pressure 4 Abnormal flexion to pain 3 Extension to pain: extends elbow to nailbed pressure 2 No response 1

The GCS is the total score, and is calculated by adding the scores of the three components. However it is more useful to quote a score for each component when stating and recording the GCS score

29 Mental state examination

Mini Mental Function Test (MMFT) Question Score 1. How old are you? 0 points – Incorrect;1 point - Correct 2. What is the time? 0 points – Incorrect;1 point - Correct 3. Remember the following address (e.g. 42 West Street, Fraserburgh). 4. What year is this? 0 points – Incorrect;1 point - Correct 5. What is the name of the place where we are now? 0 points – Incorrect;1 point - Correct 6. Identification of two persons (doctor, nurse etc.)? 0 points – Incorrect;1 point - Correct 7. What is your date of birth? 0 points – Incorrect;1 point - Correct 8. What were the dates of the Second World War? 0 points – Incorrect;1 point - Correct 9. What is the name of the present monarch? 0 points – Incorrect;1 point - Correct 10.Count backwards from 20 to 1 0 points – Any errors;1 point - All Correct 3. Repeat the address I asked you to remember 0 points – Incorrect;1 point - Correct Normal score 8+ Mild to moderate cognitive disorder 4-7 Moderate to severe cognitive disorder <4

2. Examination of the Cranial Nerves

There are 12 cranial nerves to examine 10 of which (III to XII) arise from the brainstem. This examination is best performed facing the patient who is seated. To be able to understand clinical examination of the cranial nerves you should revise your anatomy teaching on this area.

You will find a fairly rapid cranial nerve screening examination described below and demonstrated at the end of the video on MyMBChB. When doing this examination if you find an abnormality you may need to spend more time looking at that area in more detail. Further detail is available in Macleod’s Clinical Examination.

Cranial Nerves worksheet Olfactory nerve Conveys the sense of smell Test each nostril separately using a strong smelling substance like soap (I) or coffee. (Not routinely performed - ask about any changes in sense of smell - if present, unilateral of bilateral?) Optic nerve (II) Conveys vision Visual acuity Pupillary responses (Reflex - Afferent =II & Efferent= III) Visual fields Fundoscopy (see examination of the eyes on page 31 for further detail) Oculomotor nerve Innervates the superior, medial Inspect size and shape of pupil (III) and inferior rectus muscles, Eye movement test – usually cranial nerves III, IV & VI are all tested the inferior oblique and levator together by performing this. (see examination of the eyes on page 31 palpebrae superioris muscles. for further detail) Also parasympathetic innervation of constrictor pupillae. Trochlear nerve Innervates the superior oblique Eye movements – usually cranial nerves III, IV & VI are all tested (IV) muscle of the eye together by performing this. (see examination of the eyes on page 31 for further detail) Trigeminal nerve Supplies sensation to the face and Sensation: Using a piece of cotton wool and sharp end of a neuro tip (V) motor function to the muscles of touch the ophthalmic (V1), maxillary (V2) and mandibular (V3) areas. mastication. Also corneal reflex for 1V

Motor (V3): Ask the patient to clench their teeth while you palpate for the bulk of the masseter muscle and jaw opening against resistance to test pterygoids muscles. Jaw jerk reflex: afferent V3 & efferent V3 Abducens nerve Innervates the lateral rectus Eye movements – usually cranial nerves III, IV & VI are all tested (VI) muscle of the eye together by performing this. (see examination of the eyes on page 31 for further detail) Facial nerve (VII) Supplies the muscles of facial Motor: Inspect the face for any asymmetry. Look at facial movement, expression. asking the patient to wrinkle their forehead then screw up their eyes, and smile. If you demonstrate the same movements with your own face it helps to explain what you want the patient to do.

(Also the associated (Taste to anterior 2/3 of tongue Sensation: testing taste sensation is rarely performed component of CNVII in & secretomotor to submandibular the chorda tympani) & sublingual salivary glands) 30 Vestibulocochlear The vestibular nerve is concerned Vestibular: check for nystagmus. Other bedside tests of vestibular nerve (VIII) with equilibrium and balance. The function. You may carry out the Unterberger test and tutors may cochlear nerve is for hearing. demonstrate the Dix-Hallpike manoeuvre. Balance may also be observed when testing gait.

Hearing: rub your fingers together close to each ear and ask if this is heard. For a more sensitive test you can say a number close to one ear, starting with a whisper and then if necessary raising the volume of your voice until the number is heard. You should mask hearing in the other ear by gently rubbing your finger over the patient’s tragus. Further detail on how to extend your examination if you detect any evidence of hearing loss is described on page 32. Glossopharyngeal Glossopharyngeal nerve mainly 1. Ask the patient to open the mouth, and say “Aah”. Look to see if nerve (IX) & Vagus carries sensation from the the palate moves symmetrically. Normally both sides of the palate nerve (X) are pharynx & tonsils, and sensation elevate and the uvula should remain central. closely related & taste from the posterior 1/3 of 2. You can also ask the patient to cough and hear if this sounds normal. anatomically and the tongue. Only stylopharyngeus 3. The gag reflex .To elicit the gag reflex touch the side ofthe can be considered muscles are innervated by IX, so throat, in the region of the fauces, on either side, and look for together it is not possible to test motor reflex contraction of the pharyngeal muscles. This reflex may be function of IX separately from X. unpleasant and should not be performed on every patient. Hence the gag reflex is used to test IX

Vagus nerve carries sensation and innervates the upper pharyngeal and laryngeal muscles.

Accessory nerve Innervates the upper trapezius To test the accessory nerve, ask the patient to shrug their shoulders and (XI) and sternocleidomastoid muscles look at contraction of the upper trapezius muscle.

To test the sternocleidomastoid muscles ask the patient to turn their head to one side, so that you can see the muscle contract and assess its bulk. Hypoglossal nerve Innervates the muscles of the Ask the patient to open their mouth. Look at the tongue at rest. (XII) tongue Then ask the patient to stick out their tongue and a move it quickly from side to side.

This is then a good opportunity to test speech, particularly if you haven’t heard the patient speak already.

Eye examination

Visual acuity. The crudest test of visual acuity is asking if the patient can see equally well with each eye. More sensitive testing can be undertaken by asking the patient to read newspaper print with each eye in turn. Ask patient to read the document with each eye separately.

The best method however is to use a Snellen chart at 6 meters distance.

Visual fields. Whereas visual acuity examines central vision, testing the visual fields examines peripheral vision. There are different ways of testing the visual fields depending on the specific abnormality you’re looking for and how much time is available. Visual fields are best assessed by comparing the patient’s fields with your own.

Sit at same level as patient, about 1m apart. Ask patient to cover an eye and you cover your corresponding eye. Test each quadrant in turn by asking the patient to say yes when they can see your finger moving. Bring your finger from the furthest periphery toward the central vision. Repeat for the other eye.

Visual perception (i.e. test for visual inattention) Sit facing the patient and ask the patient to look at your face and point to the hand that is moving. Extend both arms and move your right fingers, then left fingers then both fingers together. The patient should be able to see on each side when fingers are moved only on one side at a time. When fingers on both sides are moved together the normal patient sees both while someone with right-sided inattention would only notice the finger on the left moving.

Fundoscopy. Fundoscopy will be taught during your fourth nervous system clinical examination skills session (see page 37).

Pupillary responses. (Tests cranial nerves II & III) Look at the pupils. Note shape and assess symmetry. The pupillary response to light is tested by moving a bright pen torch from the side of the head to shine on to the pupil while the patient fixes on a distant point. Look for constriction of the pupil

31 • in the side the light is shining (ipsilateral), the direct response. • in the opposite side (contralateral) from where the light is shining, the indirect response.

Now repeat on the other side.

You can also examine the pupillary response to accommodation observing that the pupils constrict as the eyes converge. This may be done at the same time as testing the eye movements.

Pupillary reflexes will be harder to see under bright ambient lighting - a darkened room will be better for this. Pupillary responses may be sluggish in the elderly.

Eye Movements (Tests cranial nerves III, IV & VI). Inspect eyes looking for pupil abnormality or presence of proptosis.

Ask the patient to follow your finger as it moves in a slow ‘H’. While doing this, ask the patient to tell you when there is any double vision. Look for nystagmus, particularly at the extremes of eye movement.

The corneal reflex (Tests cranial nerves V & VII). Ask the patient to look up and with a wisp of cotton wool touch the cornea. Look for a blink response which should be bilateral.

The afferent part of this reflex, sensation, is via the fifth cranial nerve and the efferent part, motor response, is via the seventh cranial nerve.

Some people find the corneal reflex unpleasant and you don’t have to do it on everyone.

Testing hearing

Use the whisper or finger rubbing test first to detect any hearing loss. If you detect any hearing loss you should proceed to define the type of deafness by means of the tuning fork tests using the short, 512 Hz tuning fork.

Weber’s test: place the vibrating tuning fork against the middle of the forehead and ask whether the sound is heard louder in either ear or centrally.

It is normal for it to be heard centrally, or all over. If heard louder in the ear with hearing loss this suggests conductive deafness; If less loud in the ear with hearing loss this suggests sensorineural deafness.

Rinne’s test: place the end of a vibrating tuning fork against the mastoid bone and ask the patient to compare with the same fork held a few centimetres from the external auditory meatus to assess which sounds louder. By doing this you are asking the patient to compare bone conduction and air conduction. Air conduction should normally be louder but in someone with conductive hearing loss it may be the other way round.

You may wish to consider the Rinne & Webber’s test as describe in Head and Neck section to standardise and consolidate your learning of the tests (see page 24).

3 & 4. Examination of the upper and lower limbs and gait

Generally we examine the motor system and the sensory system in both the upper and lower limbs. We will consider examination of the upper limbs first. Often motor examination of the upper limbs is followed by motor examination of the lower limbs and then sensation is tested starting distally. However you may choose to assess the arms first (both motor and sensation) followed by the legs.

Worksheet for assessing neurological function of the limbs and gait For limb examination the usual order is observation, tone, power, coordination, reflexes and sensation, followed by observation of the gait. The Upper limbs Observation We are looking particularly for muscle atrophy which usually suggests muscle Look for: denervation as found in a lower motor neurone lesion (LMNL) but can also be due • Muscle atrophy to disuse such as occurs in a long standing upper motor neurone lesion (UMNL). • Fasciculations • Skeletal deformity Occasionally muscle fasciculations can be seen as an additional sign of denervation. • Scars However we may also see skeletal deformity scars from previous surgery and • Tremor involuntary movements such as tremor or other abnormal movements. If a tremor • Involuntary movements is seen it should be described by the speed and amplitude of the tremor and when it is maximal e.g. at rest or with active movement.

32 Two commonly found tremors are: • Physiological – fine – anxiety, hyperthyroidism, alcohol excess & some drugs. • Parkinsonian – slow, coarse, worse at rest, mostly upper limbs & usually asymmetrical.

Look for any other involuntary movements such as: • Dystonia – sustained muscles contractions which are twisting & repetitive • Chorea & athetosis – writhing movements • Ballismus – violent flinging movements • Ticks: repetitive stereotyped – these can be suppressed by the patient unlike those described above. Tone This is the resistance felt by the examiner when moving a joint though its range Assess Tone: of motion. The tone can be normal, increased or decreased. It is helpful to • Normal compare the two sides. • Hypotonic • Decreased = hypotonia • Hypertonic • Increased = hypertonia

The two main types of hypertonia are: • Spasticity - a velocity-dependent resistance to passive movement. A feature of UMNL and usually accompanied by weakness, hyper-reflexia, extensor plantar response & sometimes clonus (see below). • Rigidity – Sustained resistance even with slow movement. May be throughout movement (lead-pipe rigidity) or have a jerky feel (cog-wheel rigidity) in presence of Parkinson’s Disease or other extrapyramidal conditions. Before undertaking passive movement of the limbs it is a good idea to check that this is not likely to cause pain. If pain is a problem proceed with more care. Assuming there is no pain, ask the patient to relax, and test tone by performing passive movement of elbow flexion extension, forearm pronation & supination and wrist flexion & extension.

Sometimes it is hard to be sure whether the patient is completely relaxed; passive movements that are sudden and unpredictable, but still gentle, are probably the best ways to eliminate voluntary muscle contraction.

Power We will test Assess Power • shoulder abduction • Shoulder • elbow flexion and extension • Elbow • wrist flexion and extension • Wrist • finger flexion and extension • Finger • the intrinsic muscles of the hand (When testing the intrinsic hand muscles it • Intrinsic muscles of is useful to test separately finger abduction supplied by the ulnar nerve and hand thumb abduction supplied by the median nerve)

With each movement tested it is possible to grade power on the Medical Research Grade power on MRC scale Council (MRC) scale from zero to 5, where zero is no movement and five is full power (see on page 36) • Ask the patient (see video demonstration on MyMBChB)to put their elbows up in the air and to push up hard against you with the arms flexed at the elbow, to “pull towards you” to “push me away” with their arms in this same position. • Ask the patient to make a fist and to cock it back (extend) Then ask the patient to bend the fist down (flex). • Ask the patient to put their fingers straight. Keep them there as you try to flex them. (i.e. test finger extensor muscles) • Ask the patient to squeeze your fingers. • Then spread your fingers wide apart and keep them there as you try to push the patient’s fingers together (i.e. test finger abductor muscles Innervated by Ulnar nerve) • Then ask the patient turn their hand over (supinated) and push their thumb up in the air against your finger.(i.e. test short thumb abductor, pollicis brevis muscle. Innervated by– Median nerve)

33 Co-ordination First ask the patient to hold their arms stretched out in front of them and look Test Co-ordination: for any postural tremor or dystonia. • Arms outstretched • Finger-nose test Then ask the patient to do the finger-nose test • Rapid alternating hand • Ask the patient to put their hands out in front and testing both sides, but one movements at a time ask the patient with their index finger to touch your finger (held up in front of the patient at arm’s length), then to touch their own nose, and then your finger again. The patient should be instructed to do this backwards and forwards as quick as they can.

Next we can test rapid alternating hand movements. • Ask the patient to hold their left hand still and tap it rapidly with the right hand. Then to tap and turn the hand over rapidly (pronated and supinated). This should be repeated with the other side. Reflexes It takes practise to learn to assess reflexes reliably. It is best to use a long Test Reflexes: handled tendon hammer with a weighted head. Hold the handle at the far end • Biceps and then let the weighted head fall onto the target. You are aiming to give a • Supinator muscle stretch stimulus which then triggers a reflex muscle contraction. • Triceps

We need to test three reflexes in each upper limb: Record in case notes • Biceps (C5): place your thumb or index finger over the biceps tendon and as +, ++, +++, - or ± then strike your own thumb or finger. (see page 36) • Supinator (C6): place your thumb or index finger over a point 3-4 cm above the distal end of the radius and then strike your own thumb or finger. • Triceps (C6,C7): strike the muscle directly about 2 cm above the olecranon.

You should compare both sides. If you cannot elicit a tendon reflex directly it is a good idea to try reinforcement.

To do this, ask the patient to clench their teeth or squeeze the opposite hand just as you are striking with the tendon hammer. We can record each tendon reflex as absent, present with reinforcement, present, brisk or exaggerated. Sensation This can be very time consuming, but may be informative. If there are no sensory Test Sensation: symptoms then you are unlikely to find relevant sensory signs. • Pinprick • Vibration Test pinprick sensation using a neuro tip, for example over dorsum of each finger • Joint position sense the medial and lateral forearm and medial and lateral aspect of the arm.

Test vibration sense starting distally, using the large 128 Hz tuning fork on a bony landmark such as the distal end of the radius. If the buzzing cannot be felt distally then you can move proximally (e.g. to the olecranon).

Test joint position sense (otherwise known as proprioception) by asking the patient to close their eyes and making small movements of one of the patient’s fingers. Ask the patient to tell you if the movement is up or down. It is a good idea to explain first what you’re going to do. If you make quite large movements to start with, this will confirm that the patient has understood your instructions. Then the movements can become much smaller to test the proprioception which is normally very sensitive and tiny movements can usually be detected accurately. The Lower limbs Observation As with the upper limbs, we are looking for muscle atrophy. Occasionally Look for: muscle fasciculations can be seen as a sign of denervation or we may see other • Muscle atrophy abnormalities such as skeletal deformity, scars from previous surgery, peripheral • Fasciculations oedema, evidence of peripheral vascular disease and so forth. • Skeletal defomity • Scars • Tremor • Involuntary movements Assessing for Again check with the patient before starting that this is not likely to cause Assess Tone tone discomfort. Where pain is a problem proceed carefully. Assuming the patient is • Normal not in pain, with the patient lying supine, ask them to relax, and test tone by • Hypotonic performing passive movement of hip rotation, and both hip and knee flexion, • Hypertonic comparing the two sides. The knee lift and drop method is particularly sensitive for detecting spasticity. This is demonstrated in the video on MyMBChB and there are diagrams on page 289 of the 12th edition of Mcleod’s Clinical Examination.

Clonus can be tested at the ankle. To test for ankle clonus, perform a sudden, Assess for Clonus but fairly small, movement of ankle dorsiflexion; if this sets off brisk rhythmic calf contractions, that is ankle clonus. A few beats of clonus can be normal, but sustained clonus is definitely abnormal.

34 Power We will test Assess Power • hip flexion and extension • Hip • knee flexion and extension • Knee • ankle dorsiflexion and plantarflexion. • Ankle • Sometimes we test ankle inversion and eversion, and big toe extension. Grade power on MRC scale With each movement tested it is possible to grade power on the Medical Research Council (MRC) scale from zero to 5, where zero is no movement and five is full power (see on page 32)

• Please lift your foot in the air (i.e. test power relative to gravity) • Push your thigh up against my hand and push down (power against resistance) • Repeat on the other side • Then ask the patient to bend one knee and to then pull their heel towards their bottom and then to straighten the knee (“push me away”). • Repeat on the other side • Ask the patient to dorsiflex their foot and then to push their foot down against your hand • Repeat on the other side

N.B. We can also reassess lower limb power when testing gait. Co-ordination This is done using the heel-shin test. Ask the patient to take the heel of one leg Test Co-ordination: and to put it on the knee of the other leg and then to run the heel down your • Heel shin test shin towards the ankle and back again. “Move your heel as quickly as you can”. Repeat on the other side.

N.B. It may be difficult to judge the degree of in coordination if spasticity or weakness is also present. Also it is important to assess lower limb coordination by examining gait. Reflexes We need to test two tendon reflexes in each lower limb: Test Reflexes: • knee reflex (L3, L4): place your left forearm under both knees and then • Knee gently lift the legs off the bed (if legs are heavy relative to your strength, • Ankle lift only one leg at a time - tutors will demonstrate this); you should do the lifting and the patient’s heels should stay resting on the surface. Then strike Record in case notes as the patellar ligament, just below the lowest point of the patella. +, ++, +++, - or ± • ankle reflex (S1): (see page 32)

1. For the right ankle reflex get the patient to flex their right kneeand externally rotate the right hip. Then hold the right foot with your left hand in such a way that you that you have a clear view of the calf muscle. Strike the Achilles tendon and look for calf muscle contraction. Then perform the same manoeuvre on the left. You will need to put your left arm in a slightly awkward position in order to hold the foot while not obstructing your view of the left calf.

2. Alternatively, you can test the ankle reflexes with the both legs flat on the bed by placing your left hand over the sole of the foot and then hitting your own fingers. This is a good way of eliciting brisk ankle reflexes and a good way of comparing the two sides. However it is less sensitive than the first method shown and you cannot conclude that an ankle reflex is absent if you have only used this method.

You should not record a reflex as absent unless you have tried to use reinforcement. As with the upper limbs, we can record each tendon reflex as absent, present with reinforcement, present, brisk or exaggerated. Assess Plantar response The plantar response is often tested at this time. This is done with a small, reasonably hard but blunt, object such as the blunt end of a Neurotip. With this, stroke the lateral side of the sole of the foot firmly starting near the heel and working up towards the ball of the foot and if necessary across the ball of the foot towards the base of the big toe. You are looking for the first movement of the big toe. Where it moves downwards, this is a flexor response, which is normal. If it moves upwards, this is an extensor response which is abnormal.

However sometimes people with ticklish feet demonstrate a brisk, voluntary withdrawal movement which can make a normal response look abnormal!

35 Sensation Test pinprick sensation over the dorsum of each foot, then medial and lateral Test Sensation: shin, and perhaps anterior and posterior thigh. If you find an area of reduced • Pinprick pinprick you need to try and map out its edges to see if it conforms, for example, • Vibration to a specific nerve or root distribution. When trying to map out area of pin prick • Joint position sense loss, move from a blunt area to a sharp area. It is much easier for a patient to • Romberg’s test detect a change to sharp than to blunt. You can also test for a sensory level by using pinprick and moving upwards over the trunk.

Test both sides to detect the level on each side of the body.

Test vibration sense starting distally, over the medial malleolus, using the large 128 Hz tuning fork. If the buzzing cannot be felt distally you can move more proximally, to the tibial tuberosity.

Test joint position sense by making small toe movements with the patient’s eyes closed, asking the patient to tell you if they can detect whether the movement is up or down.

Remember to explain first what you are going to do and then ask the patient to close their eyes.

Occasionally we ask the patient to stand with their eyes closed as a test of lower limb proprioception. This is called Romberg’s test. Gait It is important to see the patient walk. Abnormalities of gait may give us clues Observe patient: about increased tone, weakness and in-coordination. In an outpatient setting • Walking and turning you may have already seen the patient walk into the room. • Walking heal-to-toe • Arise from sitting The simplest thing is to ask the patient to walk up and down briskly and observe • Walking on tiptoe how they manage this. • Walking on heels • Walking with eyes Look for closed • The leg movements • The patient’s posture • The presence of associated movements such as arm swing

To test balance in more detail you can ask the patient to walk heel-to-toe.

To test proximal lower limb weakness you might ask the patient to rise from a chair without using their arms, or to rise from a squatting position. To test distal limb power you might ask the patient to walk on their heels or stand on tip toes.

Asking the patient to walk with their eyes closed will test vestibular function.

Deep tendon reflexes Patterns: Abnormally brisk with an upper motor neurone lesion (UMNL) Diminished with a lower motor neurone lesion (LMNL) Slow relaxation in hypothyroidism Pendular in some cerebellar lesions

In the case notes please record reflex findings as follows:

Increased or exaggerated or brisk +++ Normal ++ Diminished + Absent - Only present with reinforcement ±

Plantar Response (S1-2) Abnormal if there is extension of large toe, sometimes with flexion & abduction of other toes (Babinski response). The response must be reproducible.

Response Interpretation Only large toe extends Abnormal plantar response Large toe extends and other toes abduct Positive Babinski sign No movement of large toe No response Large toe and other toes extend and ankle dorsiflexes Withdrawal response – repeat the exercise more gently to assess

If Babinski response is present it is likely to be UMNL & this is usually accompanied by spasticity, clonus & hyper-reflexia.

36 Power Power varies with age, regularity of exercise and is limited by pain

Medical Research Council (MRC) Scale for power 0 No muscle contraction visible 1 Flicker of contraction but no movement 2 Joint movement when effect of gravity eliminated 3 Movement against gravity but not against examiner’s resistance 4 Movement against resistance but weaker than normal 5 Normal power

How to perform Fundoscopy, using an Ophthalmoscope

• Familiarise yourself with the workings of the ophthalmoscope eg., ON/OFF switch, aperture adjustment • Ensure the light source from the ophthalmoscope is bright • Select size of aperture to match pupil size (but larger light spot will give a wider field of view at fundus) • If neither you nor patient requires glasses, the fundus should be in focus when using lens ‘0’ but fine adjustment may still be necessary (+2 or 3 / - 2 or 3) • If you or your patient needs corrective lenses for clear vision (ie., normally wears glasses) then you will need to turn the lens disc to + or − to bring the fundus into focus • Use concave − lenses for short-sighted patients (turn lens dial anticlockwise) • Use convex + lenses for long-sighted patients (turn lens dial clockwise) • If you know your own lens correction, it may make it easier if you start off by using your own ‘prescription’ on the lens dial. [NB. Using + lenses also enables you to focus on structures which are more superficial than the fundus eg., cornea, anterior chamber, lens, vitreous humour etc]

Examining the Patient

1. Patient’s pupils should, ideally, be dilated either by: - examining in a darkened room - instilling drops to dilate pupils (as postgraduate only) 2. Ensure that you and the patient are in a comfortable position 3. Patient to fix gaze on a named distant object 4. Use your R eye and R hand to examine patient’s R eye; your L eye and L hand for patient’s L eye.

To examine patient’s R eye • Stand/or sit a little to the right of the patient (approx. 15° from midline), allowing patient a clear view of the distant named object • Hold ophthalmoscope vertically in your right hand, brow-piece touching your eyebrow, right Index finger placed on lens dial.

To examine patient’s L eye: • As above, but standing (or sitting) a little to the left of the patient, using your left eye and left hand to view the fundus. • Stand (or sit) a little to the L of the patient, allowing patient a clear view of the distant named object • Hold scope vertically in your L hand, brow-piece touching your eyebrow, L index finger placed on lens dial • Select “0” on lens dial

Stage 1 Observe the Red ‘Reflex’ • Switch on and select lens ‘0’; holding ophthalmoscope up to your eye, direct beam of light into pupil from a distance of approx. 30cms. Presence of the red reflex demonstrates that light is entering the eye and being reflected back from the fundus; absence indicates obstruction to light pathway eg., cataract.

Stage 2 Examine fundus by moving nearer to the patient so that ophthalmoscope is at a distance of approx. 2-4cms from the patient’s eye • Ensure your eye and patient’s eye are on the same level • Always hold the ophthalmoscope with your index finger on the lens dial to make lens adjustment easier. • Adjust lenses to obtain a sharp image of the fundus. Starting with lens ‘0’, focus on the disc or a blood vessel. If image is blurred, turn to +1, then to +2 or +3. If image becomes more blurred, return to ‘0’, then progress through lenses -1 to -2 or -3. If patient wears glasses with thick lenses (ie., “cannot manage without glasses”) you may need to start from +/-5 to +/-10. • Having focused on the fundus, examine: • Optic disc (shape, colour, definition of edges/rim; note appearance of vessels as they cross rim) • Vessels (appearance of arteries, veins ?tortuous, congested) • Retina (colour, ?haemorrhages, ?exudates, ?detachment, ?tears) • Macula (ask patient to look directly at the beam of light)

37 Exercise 1

Examination of a patient’s nervous system is a very rewarding activity as often their clinical signs will indicate the location of the pathology.

In the following examples can you give a diagnosis and anatomical explanation for the signs. The answers for these problems will be provided on the MyMBChB website in the last week of the nervous system block.

Clinical Condition Diagnosis / Anatomical explanation 1. An 80 year old nursing home resident is found collapsed and the GP is called.

Signs: • Weakness of the right side of face and mouth. • Right arm paralysed and right leg weak • Left side normal • Sensation appears intact • Dysphasic

2. A 27 year old man became involved in a fight and was stabbed in the back. He is unable to move his right leg and is taken to the emergency department

Signs: • Right leg weak; flicker of contraction in the quads only (MRC 1), no movement otherwise; left leg normal power (MRC 5). Tendon reflexes brisker on the right than the left. Extensor right plantar response. • Sensation right leg - absent vibration and joint position sense in toes, ankle, knee and hip - normal pain and temperature sensation in leg and arm • Sensation left leg - normal vibration and joint position sense in toes - absent pain and temperature to umbilicus (T10 level) 3. A 43 year old woman presented to her GP after waking up with a ‘droopy’ face

Signs: • unable to wrinkle right forehead • unable to close right eye fully • unable to smile with right side of mouth • left side of face normal 4. A 30 year old woman presents to her GP with deteriorating vision.

Signs: • Normal visual acuity • Reduced colour vision in both eyes. • Visual field examination reveals a bitemporal hemianopia 5. A 56 year old publican, known to be sociable and friendly, presents to his GP with a gradual worsening unsteadiness when walking.

Signs: • difficulty performing finger-nose test and heel- shin test bilaterally • Unsteady gait, especially attempting to walk heel-to-toe. 6. A 21 year old male has been involved in a high speed road traffic accident.

Signs: • unconscious with a GSC of 3. • both his pupils are dilated and non-reactive to light. • heart rate is slow (45 beats per min)) • blood pressure is elevated (190/100).

38 EXERCISE 2

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39 E-PORTFOLIO ACTIVITIES FOR YEAR 2, TERM 1

Select one of the following options and write a short reflective essay. The essay should be between 400-600 words and should be submitted to your e-portfolio by 13th December 2013.

Options

• Describe your experience of a patient interaction which you have found most interesting in this term. What was different about it? What have you learnt that will help you next time you see a patient like this? OR • Discuss a difficulty or a dilemma relating to being a medical student which you have faced or are facing. How did/will you manage it? What have you learnt? OR • Reflect on the role of a healthcare professional you have seen, other than a doctor. Consider how their role relates to your future role as a doctor and the nature of successful teamwork. How well does the team they belong to work together?

40 Calgary Cambridge Framework

Initiating the Session

• preperation • establishing initial rapprt • identifying the reason(s) for the consultation

Gathering Information Providing • exploration of the patient’s problems to discover the: Building the Structure □ biomedical perspective □ the patient’s perspective Relationship □ background information - context • making • using organisation Physical Examination appropriate overt non-verbal behaviour • attending to flow Explanation and Planning • developing • providing the correct amount and type of information rapport • aiding accurate recall and understanding • achieving a shared understanding: incorporating the • involving the patient’s illness framework patient • planning: shared decision making

Closing the Session • ensuring appropriate point of closure • forward planning

41 Dress Guidance for Medical & Physician Assistant Students rev.Aug2011

Always dress and behave in a professional and appropriate manner in clinical areas, whether on hospital wards, in GP surgeries, on home visits or in the Clinical Skills Centre with volunteer and simulated patients. Patients, visitors and carers generally perceive how you dress as an indication of your competence and of the standard of care you deliver.

• Identity badges must be worn at all times in clinical settings. • You must ensure that your face is exposed and fully visible for the purposes of recognition by patients, tutors and other staff. • Showing your face also makes it easier for hearing-‐impaired patients to hear and/or lip read. • An important part of communication is by using facial expression and so any headdress must not cover the face while attending your course. • White coats are not worn by students in Aberdeen and so both you and your clothing must be kept clean and tidy. • Dress modestly to ensure that staff, visitors and, especially, patients are not distracted or offended. • Denim jeans, very short skirts, shorts, tops with low or revealing necklines or any clothing which exposes the midriff or underwear is not appropriate in any clinical setting. • Sleeves must either be short,¾ length or rolledup away from the wrists prior to hand decontamination, examination of patients or when carrying out procedures. • This will enable effective hand decontamination to be carried out and reduce the risk of cross-infection. • Ties, if worn, must be secured (e.g. by means of a clip or tie-tack) or tucked into the front of the shirt so that risk of cross- infection is minimised. • If your ID badge is worn on a neck lanyard, ensure that the badge does not come into contact with patients or their immediate surroundings during clinical examination or procedures. • Similarly, headscarves must be worn in a way which avoids contact with patients and their immediate surroundings. • Footwear must be clean and in good repair and of a material which can be easily cleaned - splashes and spillages are not uncommon in clinical areas. • Open-‐toed foot wear must be avoided for health and safety reasons. • Longer hair must be tied or clipped back at all times in clinical areas. • Hairstyles must not require frequent readjustment. • Constantly having to move your hair out of your eyes/away from your face is not acceptable. • Fingernails must be kept short and scrupulously clean. • Long nails or nails with sharp edges can pierce fragile skin and can puncture latex gloves – cases of mucosal laceration have even occurred during rectal examination! • False finger nails are totally inappropriate in a clinical setting. • Nail varnish must not be worn. • Jewellery must be kept to a reasonable minimum. • Dangling beads and necklaces/long dangling earrings may interfere with some clinical examinations and procedures. • Rings with stones, ridges, sharp edges or crevices must not be worn. • A plain, smooth ‘wedding’ band is usually acceptable in most clinical areas. • Any ring must be small enough to allow the use of gloves, without risk of tearing. • Special care must be taken to wash and dry under the ring when decontaminating hands. • Wrist watches must be removed to allow for effective hand decontamination and must not be worn during patient contact. • You may pin your watch to your clothing or alternatively use a ‘fob’ style watch. • Bracelets, rubber charity bangles and, in particular, the fabric or leather tie-‐on type of bracelet are not appropriate wear in any clinical area.

Always remember that the well‐being and safety of the patient is of paramount importance. If you have a particular reason why you cannot comply with the above guidelines, please contact your Year Co-ordinator who will be happy to discuss the matter with you.

42 9 Rinse hands with water Palm to palm with fingers interlaced Wet hands with water 5 1 9492 v1 12/09 How to Hand wash? 10 with fingers interlocked Backs of fingers to opposing palms all hand surfaces Apply enough soap to cover 2 6 with a single use towel Dry hands thoroughly Duration of the entire procedure: clasped in right palm and vice versa Rotational rubbing of left thumb 11 Rub hands palm to 3 7 off tap Where applicable, use towel to turn 40-60 seconds 12 hand in left palm and vice versa forwards with clasped fingers of right Rotational rubbing, backwards and interlaced fingers and vice versa Right palm over left dorsum with 4 8 Your hands are now safe.

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