PHYSICAL EXAMINATION WORKSHOP Dr. Golshan Salehi

PHYSICAL EXAMINATION Dr. Golshan Salehi Apr 2018, ARIMGSAS General Principles

➢ Greet the patient andintroduce yourself ➢ Wash your hands ➢ Permission of patient with explanation of what you have to do ➢ Also seek consent for exposure. Expose the area that needs to be examined ➢ Do not disrobe patient yourself, only help if needed ➢ Remember it as WIPE ➢ It is very important to know the position of examination ➢ Abdominal –lying flat with 1pillow ➢ Respiratory –sitting upright ➢ Cardiovascular –sitting at 45o ➢ Do not forget to first do a general inspection. Useful Recourses

➢ Geeky medics: website and smartphone app ➢ Talley and O’Connor’s Clinical Examination ➢ Notes ❖ And PRACTICE, PRACTICE and PRACTICE! Its never enough Karen’s notes??? Cranial Nerve Examination

You work as HMO in an emergency department when the consultant in charge asks you to take a group of medical students and to demonstrate to them how to examine the cranial nerves. Tasks: Perform an examination of the cranial nerves Give running commentaries to the examiner ➢ WIPE ➢ GA: facial asymmetry, position of eyes, ptosis ➢ Olfactory nerve (I): ➢ Have you noticed any change in your smell? ➢ Please close your eyes and smell this: coffee beans/vanilla essence ➢ One nostril at a time ➢ Optic nerve (II): ➢ Visual acuity: Snellen chart. Please read the lowest line. Covering one eye at the time. ➢ With spectacles ➢ Visual fields (red topped pin): Cover one eye of patient and your opposite eye. Distance should be an arm’s length. Patient should look at examiner’s nose, head still.

➢ Without spectacles ➢ Ask for color of red top pin ➢ Fundoscopy: ask if available. Looking at cornea, lens, retina, optic disk. ➢ Oculomotor (III) + Trochlear (IV) + Abducens (VI) Nerve : ➢ Ptosis, pupils (PEARL) ➢ Eye movement: H shape ➢ Accommodation ➢ Trigeminal nerve (V) ➢Sensation ➢Motor function: ➢ clench your teeth and feel ➢ open mouth and don’let me close it ➢Jaw jerk ➢Corneal reflex: V afferent and VII efferent ➢ Vestibulocochlear nerve (VII) ➢ Facial Nerve (VII) ➢Whisper test ➢Rinne and Weber: 512Hz ➢Facial asymmetry ➢Wrinkle your forehead ➢ Glossopharyngeal (IX) and vagus(X) nerve ➢Close your eyes, don’t let me open them ➢Say AHH, check for uvula and palate ➢Blow out your cheeks ➢Hoarseness and cough ➢Smile ➢Swallow: sip this glass of water ➢Purse your lips ➢ Accessory nerve (XI) ➢Any change in your taste? ➢Shrug your shoulders don’t let mepush them down ➢Do you think you are hearing louder? ➢Look to the other side and push against my hand. ➢ Hypoglossal nerve (XII) ➢Show me your tongue? Bell’s Palsy

➢ A 36-year-old woman, Jennifer, presents to your GP practice, complaining of sudden onset of left sided facial weakness with facial disfigurement, preceded by pain behind the left ear. ➢ Your task are: ➢ Take a brief focusedhistory ➢ Examine the patient ➢ Most likely diagnosis to the patient ➢ HOPC: Since when? Is it the first time? Is it getting worse?

➢ How did it start:Sudden/gradual. ➢ DDx ➢ Did you notice any difficulty in speech or weakness in any of your limbs? ➢ Did you fall? ➢ Have you had any recent infection? ➢ Have you had any recent trauma? ➢ Have you felt any changes in hearing? Hyperacusis ➢ Do you think your taste has changed? ➢ +/- ➢ Are there any lumps in front of the ear? Are you having any pain in the face? Do you feel any blisters on the face or ear? If severe pain-look for Ramsay hunt syndrome. ➢ Have you had any recent ear infection or ear pain? OM ➢ Have you had any pain behind the ear or at the angle of your jaw? - Mastoiditis, parotitis ➢ PMHx, PFHx, PSHx ➢ SADMA ➢ WIPE ➢ GA: distressed/anxious ➢Facial asymmetry: flattening of forehead and nasolabial fold. ➢Palpebral fissure widen on affected side ➢ VS: Normal ➢ Facial Nerve (VII) ➢Wrinkle your forehead ➢ If it spares the forehead: CNS cause ➢Close your eyes, don’t let me open them ➢ Bell’s reflex: on attempted eye closure, the eye tolls upward and inwards on affected side ➢Blow out your cheeks ➢Smile ➢Purse your lips ➢Any change in your taste? ➢Do you think you are hearing louder? ➢Corneal reflex: lost on affected side ➢ Afferent arm: V th CN ➢ Efferent arm: VII th CN ➢ Vestibulocochlear nerve (VII) ➢Whisper test ➢Rinne and Weber: 512Hz ➢ Ear ➢Inspection: signs of inflammation/infection/rash: vesicles -Ramsay Huntsyndrome ➢ Otoscopy: external auditory canal for vesicles/signs of infection o trauma/tympanic membrane/OM ➢ Parotid gland ➢Inspection: signs of inflammation/signs of infection/mass ➢Palpation: mass ➢ Lymph nodes ➢ To conclude my examination ➢CN ➢UL and LL neurological examination ➢Complete eye examination looking for cornealabrasion ➢ Dx –5C’s ➢ Mx ➢ Protect the eye: Artificial tears and eye patch ➢ Steroids: start within 72 hours of symptoms onset ➢ Acyclovir

➢ Physical therapy Parotid Examination

➢ A middle-aged man comes in to your GP clinic with a swelling on the left side of his face just above the angle of his jaw between the mastoid and mandible. A picture of the swelling is provided. ➢ Task ➢History ➢Physical examination ➢Diagnosis and management

➢ DDx ➢Pleomorphic adenoma ➢Carcinoma ➢Pre auricular lymph node ➢Chronic parotitis ➢Abscess Pleomorphic Adenoma

➢ WIPE ➢ GA ➢ Inspection: from picture, describe it – site, size, shape, signs of inflammation or infection ➢ Palpation: site, size, shape, surface, contour, consistency, compressibility, temperature, tenderness, trans illumination in soft, fixation, fluctuation, pulsatile ➢ Facial nerve (VII):motor ➢ Cervical lymph nodes ➢ Bimanual palpation: request gloves, tongue depressor and torch. See if any discharge fromduct Assessment of a Lump

➢ Inspection ➢ Site:can help narrow the differential ➢ Size ➢ Shape: well defined? ➢ Overlying skin changes: erythema / ulceration / punctum ➢ Palpation ➢ Consistency :smooth / rubbery / hard / nodular / irregular ➢ Fluctuance: if fluctuant, this suggests it is a fluid filled lesion – cyst ➢ Borders: well defined/irregular ➢ Pulsatility: suggests vascular origin –e.g. carotid body tumour / aneurysm ➢ Temperature: increased warmth may suggest inflammatory / infective cause ➢ Tenderness ➢ Relation to underlying / overlying tissue – tethering / mobility (ask to turn head) ➢ Auscultation: to assess for bruits –e.g. carotid aneurysm ➢ Special test ➢ Trans-illumination: suggests mass is fluid filled Ear Examination

➢ 34 yo male, came with history of recurrent otitis media, now coming with deafness. ➢ Tasks : ➢ Relevant Hx ➢ Ear Physical Examination ➢ Dx ➢ DDx ➢ Conductive deafness: wax, foreign body, OM, trauma, otosclerosis, cholesteatoma ➢ Sensory deafness ➢ HOPC ➢Since when? On and off ➢ Is it the first time? No it has happened 4 times before ➢ Is it getting worse? Yeah, I feel my hearing is getting worse ➢If pain –SOCRATES ➢ Associated Sx: Fever ➢ ➢ PMHx, PFHx, PSHx ➢Discharge ➢Balance ➢ SADMA ➢Tinnitus: ringing sensation ➢ Medication: antibiotics for ➢Fullness recurrent AOM/gentamycin/furosemide ➢Hearing loss ➢Runny nose, sore throat ➢Trauma: swimming, diving, plane ➢Noise exposure ➢Facial asymmetry ➢ Inspection ➢ Skin changes: signs of infection, signs of inflammation ➢ Discharge ➢ Symmetry ➢ Scars

➢ Mastoid process –mastoiditis ➢ Palpation ➢ Temperature ➢ Tenderness: ➢ Tragus and helix –otitisexterna ➢ Mastoid process –mastoiditis ➢ Otoscopy: hold it in a pen holding method with little finger extended, with opposite hand pull helix upwards and backwards. R hand for R ear. ➢ External: auditory canal for wax, foreign body, inflammation ➢ Internal: assess ear canal tympanic membrane ➢ Colour ➢ Light cone: pointing anteriorly and inferiorly ➢ Perforation ➢ Discharge: pus, bleeding ➢ Abnormal growth -cholesteatoma ➢ CN ➢ VII: motor and ask for change in taste ➢ VIII ➢ Whisper test: 15 cm first and then one arm distance ➢ Weber

➢ Neural deafness – sound is heard louder on the side of the intact ear 512 Hz ➢ Conductive deafness – sound is heard louder on the side of the affected ear ➢ Rinne: AC >BC – Rinne +. Mastoid process first, then external auditory meatus

➢ Neural deafness - AC > BC (both air and bone conduction reduced equally)

➢ Conductive deafness -BC > AC (Rinne’snegative) ➢ Lymph nodes ➢ Conclude ➢ will like to to finish with an audiogram if available ➢ Dx - Cholesteatoma ➢ From the Hx and PE that Iperform most likely you have a condition called cholesteatoma. Have you heard about it? ➢ Condition: its a sack like structure which contains death skin cells, those cells release a substance that can dissolve the surrounding structures, ➢ Cause: might be due to the recurrent AOM that you’ve had ➢ Clinical features: when Iwas looking inside your ear Icould see this extra skin in you tympanic membrane, this is affectingyour hearing ➢ Commonality: it is not an uncommon condition ➢ Complications: Deafness, mastoiditis, erode the bone reaching brain matter, encephalitis, abscess, invasion of blood vessels – thrombosis of sinuses ➢ Mx ➢ This condition needs to betreated ASAP ➢ Referral to ENT ➢ Imaging: CT/MRI ➢ Sx: enucleation of cholesteatoma Upper Limb Neurological Examination

➢ Power: resisted movement ➢ WIPE: sitting on edge of bed ➢ Chicken wings: C5 ➢ GA ➢ Biceps: C6 ➢ Abnormal movements –tremor, fasciculation ➢ Triceps: C7 ➢ Muscle wasting –denervated muscle ➢ Fisting: C8 ➢ Skin –neurofibromatosis/herpes zoster ➢ Abduction of fingers:T1 ➢ Arm drift –upper motor neuron ➢ Reflexes pathology ➢ Biceps: C5,6 ➢ Close eyes and place arms extended ➢ Triceps: C7 and palms upwards ➢ Brachioradialis: C6 ➢ Look for evidence of drifting ➢ Finger jerk: C8 ➢ Tone: Test at wrist and elbow ➢ Coordination ➢ Finger to nose test: ➢ Intention tremor ➢ Past pointing ➢ Alternating movements ➢ Dysdiadochokinesis: cerebellar lesion orParkinson’s ➢ Sensation ➢ Patient’s eyes closed ➢ Touch patient’s sternum with cotton wool/pin-prick , so it will feel like this, please say yes when you feel it and if it’s the same in both sides. ➢ Proprioception ➢ Vibration: 128 Hz, patient’s eyes closed ➢ Confirm in sternum ➢ Tell me when you feel it and tell me when it stops

Lower Limb Neurological Examination

➢ 45 yo male, comes to ED complaining of progressive unsteadiness. Drinks 5 glasses of wine a day. ➢ Task ➢Perform relevant PE ➢DDx

➢ DDx ➢Vertigo ➢Cerebellar ataxia: SOL, stroke ➢Peripheral neuropathy ➢Vitamin deficiency ➢ Power ➢ WIPE: standing first ➢ Hip ➢ GA ➢ Flexion (L2,3) ➢ Gait* ➢ Extension (L5,S1,2) ➢ Walk few steps and turn back ➢ Abduction (L4,5,S1) ➢ Walk on heels (L4,5) ➢ Adduction (L2,3,4) ➢ Walk on toes (S1) ➢ Knee ➢ Squat and stand (L3,4) ➢ Flexion (L5,S1) ➢ Rhomberg’s sign* –proprioception ➢ Extension (L3,4) ➢ Tone ➢ Ankle ➢ Knees and ankles ➢ Plantar flexion(S1,2) ➢ Clonus: ankle ➢ Dorsiflexion (L4,5) ➢ Tarsal joint ➢ Eversion (L5,S1) ➢ Inversion (L5,S1) ➢ Reflexes ➢ Knee jerk (L3,4) ➢ Ankle jerk (S1,2) ➢ Plantar reflex (L5,S1,2): If abnormal –upper motor neuron/generalized seizure/coma ➢ Coordination ➢ Heel shin test ➢ Foot tapping test ➢ Sensation ➢ Cotton wool and prick ➢ Position ➢ Vibration

➢ In this particular case you will conclude with full neurological examination ➢ CN ➢ UL TIA Examination

➢ 56 year old John came to hospital because he suddenly felt inability to move his limbs and weakness in right side of his body. He also felt that he had difficulty talking at that time. The episode was only of short duration and now he is completely fine. His vitals are all stable. He is here to see you in the ED to know about hiscondition. ➢ Task ➢ Perform appropriate physicalexamination ➢ Tell the condition and further management u GA u VS: BP, characterisepulse (AF) ➢ UL and LL neurologic examination ➢ Cranialnerves ➢ Fundoscopy+ EYE exam(if amauorosis fugax) ➢ Carotid bruit ➢ CVS ➢ Admission and Mx plan. Thyroid Examination

➢ Male with lethargy. Blood test done shows low TSH, T4 raised. ➢ Task: ➢ Perform PE ➢ DDs with reason. ➢ Thyroid u WIPE: sitting ➢Inspection : skin changes, scars, masses ➢ GA: agitation, anxiety,fidgety ➢ If mass present: Sip of water and ➢ Hands protrude tongue ➢ Dry skin: hypo ➢Palpation: stand behind the patient ➢ Sweating: hyper ➢ Isthmus and each lobe ➢ Sip of water and protrude tongue ➢ Clubbing ➢ Assess: size, symmetry, consistency, masses, ➢ Palmar erythema palpable thrill ➢ Tremor: coarse or fine tremor (paper) ➢ If mass noted: position, shape, tenderness, consistency, mobility ➢ Pulse: characterise ➢Percussion: retrosternal dullness ➢ Rate ➢Auscultation: bruit in Grave’s ➢ Rhythm: AF ➢ Lymph nodes ➢ Face ➢ Lower limbs ➢ Dry or sweating skin ➢Reflexes ➢ Eyebrows ➢Myxedema ➢ Exophthalmos: front, side and above ➢ Proximal myopathy: ask patient to ➢ Lid lag stand from a sitting position with arms crossed ➢ Eye movement: H shape ➢ Inability – Hyperthyroidism Neck Examination –Cervical Spondylosis

➢ Mid 30, tennis player, office worker, complains of right shoulder and neck pain for 1 week. ➢ Task ➢Hx ➢PEFFE ➢DDx ➢Mx

➢ DDx ➢ Cervical Spondylosis ➢ Trauma ➢ RA ➢ WIPE ➢ Look -Inspection ➢ Front ➢ Side ➢ Back ➢ Feel -Palpation ➢ Temperature ➢ Tenderness ➢ Move: Active and passive ➢ Special tests ➢ Compressiontest ➢ UL Neurological Exam Breast Examination

➢ You are in GP and 55 year old, female came with complaint of lump in right breast. Her mom was diagnosed with breast CA and she is concerned about it. ➢ Tasks ➢Do relevant physical exam with running commentary to examiner ➢Explain about possible causes to pt ➢Discuss what investigations u would like to do ➢ DDx ➢Fibroadenoma ➢Breast cancer ➢Breast cyst ➢Trauma ➢Gynecomastia ➢ WIPE:gloves Chaperone GA +VS ➢ Look: arms by side, arms above head, hands on hip and push inwards ➢ Asymmetry, swelling, masses, scars ➢ Skin changes: erythema, puckering, peau d’orange ➢ Nipple changes: retraction, discharge, scale ➢ Feel: pt in 45 degrees, normal breast first ➢ Spiral method: from nipple outwards + axillarytail ➢ If mass: describe, quadrant, hour, how far away from nipple, size and shape, consistency, overlying skin changes, mobility fluctuance ➢ Ask pt to squeeze nipple to assess discharge ➢ Lymph nodes: Axilla (5 walls), cervical, supraclavicular, infraclavicular Primary Survey of a Trauma Patient – DRSABCDE

➢ 13 yo girl, fell of a horse about half an hour ago. Now she's brought in to rural hospital from where the nurse is calling you. You are an HMO in a tertiary hospital. ➢ Task ➢ Answer the nurse’s questions ➢ Manage the case ➢ Goals of primarysurvey ➢ Seek and treat lifethreats ➢ Expedite delivery of the patients to the appropriate inpatient service ➢ Minimize mortality ➢ Talk to the patient. Any verbal response strongly suggests that for the moment at least their ABCDE’s are okay! ➢ Once identified, deal with a problem BEFORE moving on in your assessment. ➢ After any intervention, return to the start of the primary survey. ➢ D –Danger: ➢ Look for danger to patient and you (is my patient safe to approach?) ➢ Say “my patient is safe to approach” ➢ R – Response: ➢ Stabilize the patient’s neck by holding with both hands around the patient’s neck ➢ Ask patient: ➢ Can you open your eye please? ➢ Can you open your mouth please (also check airway is patent or not?) ➢ Do you have any pain around your body? ➢ Ask examiner to come and hold the patient’s neck and PUT NECK COLLAR if provided!! ➢ S- Seek for help: (HMO is the one who has to call AMBULANCE) ➢ A – Airway maintenance with cervical spine protection: ➢ Protect C-spine: don’t put collar first because you wont be able to assess airway. ➢ One person to manually keep c-spine aligned until you finish assessing airway. ➢ Patency ➢ Is the patient talking to you? ➢ Secretion, blood, fluid →suction ➢ Foreign body →forceps ➢ Escalate from simple to advanced techniques as required. ➢ Employ simple airway maneuvers: Jaw thrust and chin lift. Head tilt inappropriate with cervical spine control ➢ Use airway adjuncts: oropharyngeal or nasopharyngeal airway → Intubation ➢ Once airway is safe →Collar ➢ B – Breathing and ventilation: Look, feel, listen of chest movement and air entry ➢ RR and SpO2 ➢ Inspection: External signs oftrauma, asymmetrical chest movements ➢ Careful palpation over entire chest wall may reveal unsuspected injury e.g. crepitus / surgical emphysema. ➢ Percussion –often difficult in a noisy trauma bay ➢ Auscultation – listening for air entry bilaterally, gauge adequacy and assess for added sounds ➢ Trachea – palpate to see if deviated, although true tracheal deviation due to a tension pneumothorax is pre-terminal and it is unlikely to be the only sign ➢ May be appropriate to log roll at this stage if concerned about a posterior chest injury. ➢ C – Circulation and haemorrhage control ➢ Check BP, pulse and capillary return ➢ Systematically look for evidence of bleeding. Fast scan if available. ➢ If hypotensive: ➢ IV line 2 large wide bore needle on both sides → take blood samples for BLD GROUP AND CROSSMATCH, FBE, ➢ U&E (Na+/K+ especially), TOXICOLOGY SCREENING, LFTs,BSL

➢ Normal saline stat dose (20ml/kg – ran as fast as possible) ➢ Intraosseous line: if IV not available ➢ Attach ECG and check for any abnormalities ➢ Hemorrhage control ➢ Most external bleeding can be at least temporarily controlled with direct pressure, tourniquets or by tying off vessels. ➢ D –Disability

➢Assess GCS ➢ <8 –intubation (if no one to incubate, call for “air ambulance”) ➢ COWS: ➢ Can you hear me? ➢ Open your eyes ➢ What’s your name? ➢ Squeeze my hand

➢ AVPU score (P and U need incubation) ➢ A – alert ➢ V –verbal response ➢ P –pain stimulus response ➢ U – unresponsive ➢Check pupil (reactive or not) ➢Glucose ➢ E –Exposure and environmental control –2ary Survey: completelyundress the patient but avoid hypothermia Unconscious patient

➢ Young patient was found unconscious by a flat mate. Flat mate is unable to provide more details about the patient as he just moved in. Primary survey was done, patient is HDN stable, c-spineis clear. ➢ Task ➢ Determine level of unconsciousness, GCS ➢ Identify the cause

➢ DDx ➢ CNS: meningitis, trauma, massive stroke affecting both hemispheres, post ictal status, SAH, tumour. ➢ Endocrine: hypoglycemia, Addison’s, myxedema coma ➢ Drug overdose ➢ WIPE: Introduce yourself and tell the pt what are you going to do. ➢ GA ➢ Assess alertness -AVPU ➢ GCS: you will assess the three component while your doing AVPU

AMC score is usually 9 or 10 - Motor: 4 or 5/6 - Verbal: 3 - Eyes: 2 ➢ Now head to toes approach looking for cause ➢ Head: sings of trauma, deformities, crepitation, battle sign ➢ Eyes: pupillary reflex, pupil size and symmetry, raccoon eyes ➢ Ears: tympanic membrane, CSF ➢ Nose: nasal septum fracture,CSF ➢ Mouth: tongue bites, vomit, smell: alcohol, uremic or DKA ➢ Neck: trachea, neckrigidity ➢ Chest: inspection, auscultation and percussion ➢ Abdomen: insulin injection marks,palpation ➢ Pelvis: compress pelvis, genitals ➢ Upper limbs: IV drugs injection marks,bites ➢ Lower limbs: signs of trauma,Babinski ➢ Log roll: with 3 pplto assess spine Respiratory Examination

➢ WIPE: sitting up ➢ GA: RR, dyspnoea, cyanosis, characteristics of COPD – pursed lip breathing / use of accessory muscles, hoarseness, stridor ➢ Hands ➢ Clubbing –chronic lung pathologies ➢ Wasting / weakness - Compression and infiltration by a peripheral lung tumor of a lower trunk of the T1 nerve root ➢ Pulse -Tachycardia and pulsus paradoxus: asthma ➢ Hypertrophic pulmonary osteoarthropathy –carcinoma /fibroma ➢ Flapping tremor –CO2 retention ➢ Face: Horner’s, cyanosis, pharynx,sinuses ➢ Neck: Tracheal displacement/tug, lymphnodes ➢ Chest: ask pt to sit up on the edge and examine from the back ➢ Inspection: shape, symmetry scars, movement of chest wall from top. ➢ Palpation ➢ Chest expansion: lower lobes show best ➢ Rib tenderness ➢ Tactile Fremitus ➢ Percussion ➢ Symmetrical areas in the posterior and axillary regions ➢ Supraclavicular area and percussion on clavicle as well ➢ For posterior percussion the patient has to be asked to move the elbows forwards across the chest ➢ Auscultation ➢ Using diaphragm auscultate areas in the back symmetrically ➢ Also auscultate high into the axillae and using the bell auscultate above the clavicle as well ➢ Vocal resonance ➢ Ask the patient to say ‘ninety-nine’ while you listen over each part of the chest ➢ Now ask patient to turn around and perform in the same order and auscultate heart. Peak Expiratory Flow

➢ Ensure the PEFR meter is set to zero ➢ Sit up straight or stand ➢ Take a deep breath (as deep as you can possibly manage) ➢ Place your mouth around the mouthpiece of the PEFR meter, ensuring a tight seal with your lips ➢Make sure proper technique ➢ Exhale as hard and as fast as you can ➢ Note the PEFRreading ➢ Repeat this process a further 2 times ➢ The highest reading of the 3 should be taken as the overall result CVS Examination

➢ You are in GP, 30 year old man came for check up before he increase his health insurance. He was told by his previous GP one year ago that there was abnormal heart sound murmur in hisheart. ➢ Tasks ➢ Do relevant PE excluding abdomen and lower limbs ➢ Explain findings to pt ➢ Discuss about Mx ➢ DDx ➢ Physiologic ➢ Infective endocarditis ➢ Anemia ➢ Hyperthyroidism ➢ Valvular disease ➢ WIPE: pt in 45 degrees ➢ Auscultation: one hand incarotid ➢ GA: dyspnoea, cyanosis, IV line,ECG ➢ S1, S2 in four areas ➢ Murmur ➢ Hands: cyanosis, pallor, clubbing, splinter hemorrhage, Osler’snodes, ➢ Mitral: L lat, radiation to axilla Janeway lesions ➢ Aortic: lean forward, insp, radiation to carotid ➢ Arms: characterize pulse, radio- ➢ Back: Base oflungs, edema radial/femoral delay, BP u Abdomen ➢ Head: malarflush, eyes, cyanosis in ➢ Hepato/splenomegaly tongue, lips, palate ➢ Ascites ➢ Neck: JVP and HJ reflux, carotid bruit ➢ Aorta: fell and listen ➢ Chest ➢ Renal bruit ➢ Inspection: deformities, scars, apex beat ➢ LL: pulse, CRT, PVD, edema ➢ Palpation: apex beat, thrill , heave(L)

Chronic LiverDisease

➢ Your next patient in the ED is a 56-year-old mas who has been BIBA with a history of collapse and hematemesis. He is known to drink, but has never been to hospital before. When the ambulance arrived he was lying on the floor of his room with blood oozing from his mouth, BP 100/50, P 92 reg, RR 16, SaO2 94 on RA,GCS 12 (eye 3, verbal 4, motor 5). An IV cannula was placed, crystalloid fluids administered and the patient is stable now. ➢ Task ➢ Perform PE ➢ Discuss the most likely Dx and Mx with examiner Chronic LiverDisease Hands to toe approach

➢WIPE ➢ Vitals: request examiner for VS, move to resus, IV cannula, blood group, crossmatch and hold. ➢GA ➢Hands: Palmar erythema, Dupuytren’s contracture, leukonychia, clubbing ➢Hepatic flap ➢Pulse, BP ➢Scratch marks and IV drugsmarks ➢Face: jaundice ➢ Eyes: jaundice, anemia, Kayser-Fleischer rings(Wilson’s) ➢ Parotid enlargement ➢ Mouth: fetor haepaticus, mouth for signs of vit def ➢Neck: JVP and hepatoyugular reflux ➢Spider nevi and gynecomastia ➢S1, S2 Chronic Liver Disease –Abdomen Hands to toeapproach

➢ Inspection: scars, collateral circulation,distention, visible peristalsis, masses ➢ Palpation: Requires a relaxed patient and warm hands of the examiner! ➢ Starting the examination away from the painful or tender area. ➢ Look at patients face throughout the examination for signs of discomfort ➢ Superficial palpation: tenderness, lumps, guarding (voluntary resistance to palpation), rigidity (involuntary contraction of abdominal muscles). ➢ Deep palpation: masses ➢ Rebound tenderness ➢ Hepatomegaly (liver span) and Splenomegaly ➢ Percussion: shifting dullness ➢ Auscultation: bowel sounds and hepatic bruit Chronic LiverDisease Hands to toe approach

➢ Hernial orifices ➢ I will like to complete my examinationby ➢ Genitalia: testicular atrophy ➢ DRE for melena ➢ Lower limbs: edema, bruising, scratching Acute Abdomen

➢ You are an HMO in the ED. Middle age lady complaining of upper abdominal pain, nausea and fever (38.9) for few hours. +/- jaundice. ➢ Task ➢Perform abdominal PE ➢Explain most likely Dx and DDx to thepatient. ➢ DDx ➢Cholecystitis ➢Cholangitis: fever +abdominal pain + jaundice = Charcot’s triad ➢Hepatitis ➢Pancreatitis ➢Kidney stone ➢Right lower lobe pneumonia ➢WIPE ➢VS: ask examiner for HDN stability – move to ressus if necessary, 2 IV cannulas, blood sample and hold ➢ u OFFER PAIN KILLERS –THEY ARE MAGIC ➢ Allergic to anymedication? ➢GA: pain, protective posture ➢Inspection ➢Palpation ➢ Ask where is the pain–start from opposite side ➢ Superficial: if elicit pain, apologize and stop palpation ➢ Guarding and rigidity ➢ Deep: ➢ Don’t perform but tell the examiner what would you look for ➢ Special tests: engage the patient with you, depending on most probable Dx, perform special test. It will elicit pain so apologize again ➢ Rebound tenderness ➢ Murphy sign: + ➢ Mc Burney’s point, Rovsing’s, Psoas ➢ Renal angle tenderness ➢Percussion: don’t perform ➢Auscultation ➢Genitalia andDRE: with patient’s consent ➢Office test: UDT and BSL

Scaphoid Fracture Examination

➢ 10 yo boy had a fall from skateboard. A hand x ray was done yesterday which was normal, GP diagnosed a wrist sprain and sent him home. Today he is coming back due to persistent pain. ➢ Task ➢ Perform physical examination ➢ Diagnosis. ➢ Another important investigation. ➢ WIPE ➢ Inspection ➢ Signs of inflammation ➢ Signs of trauma ➢ Deformities ➢ Palpation ➢ Temperature ➢ Tenderness: around thumb area ➢ CRT ➢ Pulse ➢ Movement: active and passive ➢ Thumb will be restricted ➢ Special tests ➢ Compression test ➢ Snuff box tenderness ➢ Dx –5Cs ➢ Clinical diagnosis ➢ X ray can be normal ➢ Mx ➢ Pain killers ➢ Registrar ➢ Scaphoid cast –cup holdingmethod ➢ Review in two weeks with xray ➢ If pain and/or abnormal x ray → further investigations and leave cast for at least 2 more weeks ➢ If pain –and x ray normal → removecast ➢ Red flags Cubital/Carpal Tunnel Syndrome

➢ 40 yo male, come to your GP clinic complaining of pins and needles in his hand for the last 6 months. Gradually getting worse, not responding to NSAIDs. ➢ Task ➢ PE with running commentary to the examiner ➢ Explain Dx to the patient with reasons ➢ DDx ➢Cervical spondylosis ➢Thoracic outlet mass –Pancoast Tumor ➢Elbow entrapment –Cubital tunnel syndrome ➢Wrist entrapment –Carpal tunnel syndrome ➢ WIPE ➢ Move –UL Neurological exam ➢ GA ➢ Power: from distally to proximally ➢ Inspection: from neck tohand ➢ Card holdingtest: Ulnar ➢ Pen test:Median ➢ Asymmetry, deformity ➢ Rest as usual ➢ Signs of inflammation or infection ➢ Sensation ➢ Signs of trauma ➢ Dermatomes: if neck pain ➢ Muscle wasting ➢ Median (C6or C7) ➢ Palpation: from neck tohand ➢ Ulnar (C8): if lost

➢ Temperature ➢ Below elbow loss and below wrist lost– ➢ Cubital tunnel syndrome ➢ Tenderness ➢ Below elbow intact and below wrist lost – ➢ CRT Guyon’s canal syndrome

➢ Pulse ➢ Reflexes ➢ Special tests ➢ Neck compression test ➢ Ulnar nerve entrapment ➢ Tap test ➢ Median nerve entrapment ➢ Tinnel ➢ Phallen De Quervain Tenosynovitis

➢ A 45 year old waiter, John, comes to you for a flu injection and he mentions that he has increasing difficulties with his job carrying heavy trays, his right hand does not seem to be strong enough anymore and he wonders if you can help him with that as well as with the flu injection. ➢ Task ➢ History ➢ Focused Physical Examination (restricted thumb movements, + Finkelstein test)c. ➢ Diagnosis and Management ➢ History ➢ HOPC: ➢ Since when? started1 week ➢ Is it the first time? Yes ➢ Is it getting worse? Yes SOCRATES

➢ Thumb area, radial border ➢ Gets worse while carrying trays and dishwashing ➢ +ve findings: ➢ Trauma? No ➢ Repetitive movement ➢ Weakness? Yes, I’m droppingthings lately ➢ Anywhere else in thebody? ➢ Rash ➢ Occupation: waiter ➢ PMHx, PFHx, PSHx ➢ SADMA ➢ PE ➢ Inspection ➢ Signs of inflammation: localised swelling in the area of the radial styloid ➢ Signs of trauma ➢ Deformities ➢ Palpation ➢ Temperature ➢ Tenderness: over and just proximal to radial styloid ➢ CRT ➢ Pulse ➢ Movement: active and passive ➢ Restriction of movements of the thumb ➢ Special test –Finkelstein’s test ➢ Dx –5 C’s ➢ You have a condition called de Quervain tenosynovitis which is the inflammation of the sheath covering tendons that supplies muscle of the thumb. ➢ Mx ➢ At this stage, it is very important for you to rest your hand especially from offending activities. ➢ You can use ice packs if there is any swelling. ➢ Iwill give you NSAIDs for 2-3 weeks and we will use splints to avoid further movement. ➢ If after 2-3 weeks, there is still pain, then we can inject steroids into the sheath. ➢ Last resort: Surgery –release the tendons Hand Cut Examination –FullCut

➢ 35 yo male comes to your GP clinic because of cut in the wrist. Picture of cutis given. ➢ PE of hand with running commentary to the examiner. ➢ Don’t remove gauze. ➢ Inspection ➢ Symmetry ➢ Gauze on wrist, soaked or not with blood ➢ Deformity ➢ Normal flexed position: lost, hand is hyperextended ➢ Skin colour: pink/pale ➢ Muscle wasting ➢ Signs of trauma ➢ Palpation ➢ Temperature: cold/warm ➢ Tenderness: above and below the bandage ➢ CRT! –vascular indemnity ➢ Pulse: radial and ulnar ideally, depending where the bandage is ➢Movement ➢ Extension wrist : preserved –radial nerve ➢ Flexion wrist: lost –tendon cut ➢ Flexor carpi radialis ➢ Flexor carpi ulnaris ➢ Palmaris longus ➢ Flexion MCF: lost –nerve cut ➢ Lumbricalis ➢ Median (2nd and 3rd) and ulnar (4th and 5th) nerve ➢ Flexion PIP: lost –tendon cut ➢ Flexor digitorum superficialis ➢ Flexion DIP: lost –tendon cut ➢ Flexor digitorum profundus ➢ Abduction/adduction of fingers: lost - nerve cut ➢ Interossei ➢ Ulnar nerve ➢ Flexion MCF thumb: lost - nerve cut ➢ Flexor pollicis brevis ➢ Median nerve ➢ Flexion IP thumb: lost –tendon cut ➢ Flexor pollicis longus ➢ Abduction/adduction thumb: lost ➢ Median and ulnar nerve ➢ Sensation ➢ Palm ➢ C6 –median: lost ➢ C8 –ulnar: lost ➢ Dorsum: preserved ➢ Motor ➢ Pen test: patient cant do it – Median nerve ➢ Card holding test: patient cant do it – Ulnar nerve Elbow Examination -Medial and Lateral Epicondylitis

➢ 34 yo female, comes to your GP clinic complaining of pain in the elbow for the past 9 months. Gradually getting worse and affecting her activities. ➢ Task ➢ History (2 min) ➢ PE ➢ Explain Dx ➢ Mx ➢ DDx ➢ Lateral and medial epicondylitis ➢ Traum ➢ Bursiti ➢ RA/OA ➢ History ➢ HOPC –SOCRATES ➢ Site ➢ Onset ➢ Character ➢ Radiation ➢ Alleviating and aggravating factors ➢ Timing ➢ Evolution ➢ Severity ➢ Associated symptoms: stiffness, pain in any other joint, signs of inflammation ➢ Precipitating factor ➢ Trauma ➢ Fall ➢ Occupation ➢ Sports ➢ PMHx, PFHx, Sx ➢ SADMA ➢ WIPE ➢ GA ➢ Inspection: asymmetry, deformities, signs of trauma, signs of inflammation or infection ➢ Palpation ➢ Temperature ➢ Tenderness: medial and lateral epicondyle, joint line, olecranon ➢ CRT ➢ Pulses ➢ Effusion ➢ Move (4): active and passive ➢ Flexion – extension ➢ Supination – pronation ➢ Special test ➢ Wrist extension against resistance –Lateral epicondylitis ➢ Wrist flexion against resistance –Medial epicondylitis ➢ Dx ➢ From Hx and PE most likely you have a condition called medial/lateral epicondylitis. Have you heard about it? Its is also known as golfers or tennis player elbow. ➢ 5C –DRAW! ➢ Condition ➢ Causes ➢ Commonality ➢ Clinical features ➢ Complications ➢ Mx ➢ Pain killers ➢ Rest ➢ Ice ➢ Braces ➢ Physio: after subsiding pain ➢ Dumbbell exercises:Medial/Lateral ➢ Avoid repetitive movements Shoulder Examination

➢ AMC recalls ➢ Impingement → Empty can test ➢ Dislocation: anterior is the most common. Young patient with history of trauma during sports. → Apprehension test ➢ NEVER FORGET TO CHECK AXILLARY NERVE INJURY! ➢ Frozen shoulder: elderly patient, usually with diabetes ➢ You are an HMO in the hospital ED. Your next patient is James who dislocated his right shoulder while playing competitive basketball 6 months ago. It was typical anterior dislocation which was complicated by nerve injury and treated by closed reduction, several weeks of immobilization followed by physiotherapy and gym program. Today James has returned to the ED as he likes to resume playing basketball from the next week.

➢ 55 year old lady came to your GP clinic with complaints of shoulder pain on the right mainly. She used to be in good health otherwise. She used to play tennis previously but these days she cannot play anymore due to painful movement of the right shoulder.

➢ 28 year old Matt arrives your GP practice due to pain in his right shoulder following a rugby game he played 2 days ago. Now movement of the shoulder is painful. He is otherwise healthy.

➢ Task ➢ Perform physical examination ➢ Diagnosis and management ➢ WIPE: Standing ➢ Inspection: front, side and back ➢Signs of trauma ➢Deformity: dislocation ➢Signs of inflammation ➢Muscle wasting ➢ Palpation: from sternoclavicular joint around to scapula ➢ Move (6): Active and passive ➢Flexion and extension ➢Abduction and adduction ➢Internal and external rotation ➢ Special tests ➢Apprehension test: shoulder dislocation ➢Impingement test: painful arch and empty can test ➢Appley scratch test ➢ Axillary nerve examination: power and sensation ➢ I will like to finish my examinationwith ➢1 joint above and 1 joint below ➢Full UL neurological examination Obstetric Examination

➢ WIPE: patient supine 15-30 degrees ➢ GA ➢ VS ➢ Hands: pulse rate, CRT, Peripheraloedema ➢ Face: pallor, jaundice, melasma, oedema ➢ Inspection: ➢Shape of the abdomen ➢Fetal movements ➢Surgical scars ➢Cutaneous signs of pregnancy: linea nigra, striae gravidarum, striae albicans ➢ Fetal lie: longitudinal/oblique/transverse ➢ Place your hands either side of the mother’s uterus (facing the mother) ➢ Apply gentle pressure to the sides of the uterus ➢ One side should feel more full in nature (this is likely the fetal back) ➢ On the opposite side you may be able to feel the fetal limbs ➢ Presentation ➢ Ensure you are facing the mother to observe for signs of discomfort ➢ Warn the mother this may feel a little uncomfortable ➢ Place your hands either side of the lower pole of the uterus(just above pubic symphysis) ➢ Apply firm pressure angled medially, feeling for the presenting part: ➢ A hard round presenting part is suggestive of a cephalic presentation (head first) ➢ A broader, softer, less defined presenting part is suggestive of a breech presentation ➢ Fundal height ➢ Measure the distance between the fundus and pubic symphysis. ➢ This is only accurate after 20 weeks gestation. ➢ 12 weeks gestation –pubic symphysis ➢ 20 weeks –umbilicus ➢ 36 weeks –xiphoid process ofthe sternum ➢ Begin palpation just inferior to thexiphisternum ➢ Palpate using the ulnar border of the left hand ➢ Locate the fundus of the uterus (firm feeling at upper border of the bump) ➢ Now locate the upper border of the pubic symphysis ➢ Measure the distance between the two in cm using a tape measure ➢ This distance should correlate with the gestational age in weeks (+/- 2cm) ➢ To avoid bias, it’s best to place the tape measure facing down, only turning to view numbers once inposition. ➢ Engagement ➢ In late pregnancy the level of engagement should be assessed. ➢ Engagement refers more than 50% of the presenting part (usually the head) having descended into thepelvis. ➢ The level of engagement varies and for this purpose the fetal head is divided into fifths: ➢ If you are able to feel the entire head in the abdomen, it is five fifths palpable (not engaged) ➢ If you are not able to feel the head at all abdominally, it is zero fifths palpable (fully engaged) ➢ FHR ➢ Pinard stethoscope/Doppler US ➢ BP ➢ Conclude with ➢ Urinalysis ➢ Wight and height Scrotal Examination

➢ Young patient with non tender lump on the right testis for the last 3 months ➢ Task ➢ Perform PE on manikin and patient ➢ DDx with reasons ➢ WIPE ➢ Position: lying down and standing at the end of the examination ➢ Ask for gloves ➢ Involve a chaperone ➢ Inspection ➢ General inspection: genital region and surrounding area ➢ Skin changes: rash/bruising/swelling/erythema/hair loss ➢ Scars: specially in the inguinalregion ➢ Masses ➢ Scrotum and perineum: ➢ Ask the patient to hold their penis out of the way to allow easier inspection of the scrotum ➢ Inspect the scrotum from the front, sides and back by lifting the scrotum ➢ Skin changes –rash / ulcers / erythema (e.g. cellulitis / fungal infection) ➢ Scars – may provide clues as to previous operations (e.g. vasectomy or testicular fixation) ➢ Masses –note any obvious lumps, these will require examinationlater ➢ Swelling –unilateral or bilateral? / associated with erythema? ➢ Bruising ➢ Necrotic looking tissue – Fournier’s gangrene is a diagnosis not to be missed and is often first noted on the perineum ➢ Palpation: ➢ Penis: retract foreskin to check phimosis, adhesions, signs of inflection or inflammation ➢ Testicles: Ask the patient to report any pain or discomfort during the examination ➢ Each testicle individually, start on the normal side. ➢ Use thumbs and index fingers, gentle rubbing motion between thumb and index finger to methodically examine the whole body of the testicle ➢ If you are unable to locate a testicle, palpate along the path of the inguinal ligament for an undescended testicle ➢ If mass +

➢ Size/Shape

➢ Borders

➢ Consistency: hard/soft/bag of worms

➢ Is soft - Transillumination

➢ Are you able to get above the mass? – no: inguinal scrotal hernia

➢ Separated or attached to the testicle?

➢ Cough impulse? Yes: hernia/varicocele

➢ Palpation: ➢Epididymis - epididymitis ➢Spermatic Cord: masses and tenderness ➢ Special tests ➢Prehn’s test: ➢ if pain relieved -Epididymitis ➢ If pain gets worse –Testicular torsion ➢Cremaster reflex: medial thigh ➢ Loss of reflex -Testicular torsion ➢ Patient standing: look and feel for varicocele or hernia

Hip Examination

➢ Kevin aged 58 years presents to your surgery in a busy Friday afternoon for his repeat scripts of coversyl. He is a builder by occupation. While you are writing his script, he mentions that he has been getting pain in , particularly climbing up and down ladders and carrying heavy timber loads. The area surrounding gets swollen sometimes on busy days at work. He reports playing a lot of sports in his youth but no prior surgery. He is worried about his future as a builder. ➢ Task: ➢ Perform appropriate physical examination(6 mins) ➢ Explain the condition tothe patient ➢ DDx ➢ OA(Rheumatoid arthritis as D/D) ➢ OA with adductor tendinitis ➢ Bursitis(not this year yet) ➢ WIPE: Standing ➢ Gait ➢Antalgic gait ➢Trendelenburg gait ➢ Trendelenburg test: normal side sags ➢Patient standing, candidate siting down with hands in patient’s hips ➢Patient’s hands on your elbows forsupport ➢ Measurements ➢Apparent leg length: umbilicus to the tip of medial malleolus ➢True leg length: ASIS to the tip of medialmalleolus ➢ Look: ➢Front: scars, tilt, quadriceps ➢Side: lordosis ➢Back: scoliosis, gluteal wasting ➢ Palpation: temperature, tenderness, greater trochanter, bonyprominences ➢ Movements: (6) passive and active ➢Flexion/Extension ➢Abduction/Adduction ➢Internal/ External rotation ➢ Special tests(3) ➢ Thomas test: +ve in fixed flexiondeformity ➢ Place hand under patient’s spine to identify lordosis ➢ Actively flex both legs (hips/knees) as far as you are able to. ➢ Your hand should detect that the lumbar lordosis is now flattened. ➢ Ask patient to fully extend the hip you are assessing: Incomplete extension suggests a fixed flexion deformity at the hip joint. ➢ Repeat the test to assess the contralateral hip joint. ➢ Adductor squeeze test: +ve in adductor tendinitis ➢ Flex both knees to 90 ➢ Place fist in between the knees ➢ Ask patient to squeeze the knee ➢ FABER test: Flexion, ABduction, and External Rotation ➢ Assess pathologies at the hip, lumbar spine and sacroiliac region. ➢ Patient in supine positon ➢ Leg tested is places in a figure of 4 ➢ Stabilize opposite hip and depress ipsilateral knee ➢ +ve: sacroiliac joint, groin pain – hip disorder Knee Examination

➢ You are in GP, 18 year old girl who is hockey player (not professional) present with right knee pain for 2 months which is worse on climbing up and down stairs and less pain on flatfloor. ➢ Tasks ➢ Ask further history ➢ PE findings from examiner ➢ Management with patient ➢ AMC recalls ➢ Chondromalacia patellae ➢ Patellar tendinitis ➢ Patellar subluxation ➢ WIPE: standing ➢ Gait: Antalgic gait ➢ Inspection: front, side and back ➢ Scars –previous surgery ➢ Signs of trauma ➢ Signs of inflammation ➢ Signs of infection ➢ Asymmetry / leg length discrepancy ➢ Valgus or varus deformity ➢ Quadriceps wasting – suggests chronic inflammation / reduced mobility ➢ Baker’s cyst –from the back ➢ Palpation: temperature, tenderness, CRT, wasting,effusion ➢ Around patella ➢ Tibial tuberosity ➢ Head of fibula ➢ Joint line ➢ Popliteal fossa: Baker's cyst ➢ Movement (2): active and passive ➢ Special tests (5) ➢ Patellar tap: large effusion ➢ Sweep test- bulge test: small effusion ➢ Patellar Apprehension test –patellar subluxation ➢ Clarke’s test –chondromalacia patellae ➢ Patellar tilt test –Patellar tendinitis ➢ Ligaments test (4) ➢ Anterior drawer : Anterior cruciate ligament ➢ Posterior drawer: Posterior cruciate ligament ➢ Lateral collateral: Varus stress test ➢ Medial collateral: Valgus stress test ➢ Meniscus ➢ Appley grinding test: patient prone Peripheral Vascular Disease Examination

➢ WIPE: lying down ➢ Inspection ➢ Signs of cardiovascular disease: cigarette smoking/hyperlipidemia ➢ Color of skin ➢ Look at leg / toes / between toes / feet / musculature / presence or absence of ulcers ➢ Trophic changes -loss of skin, hair, gangrene ➢ Ulcers ➢ Arterial: Ischemic ulcers - found in least well-perfused areas and over pressure points ➢ Look at heel for neuropathic ulcers ➢ Venous ulcers atgaiter area ➢ Palpation: temperature, CRT, characterise pulses ➢ Femoral pulse: halfway between the anterior superior iliac spine and pubic symphysis ➢ ALWAYS ASK FOR PERMISSION ➢ Popliteal pulse: compression against posterior aspect of the tibia ➢ Posterior tibial midway between medial malleolus and heel ➢ Dorsalis pedis: lateral to extensor hallucis longustendon ➢ Say you would check for AAA ➢ Auscultation ➢ Bruit: femoral/renal/aorta ➢ Special tests ➢ Buerger’s test: Lift leg above level of the heart. At some point the perfusion drops and leg becomes white: Buerger'sangle. ➢ Normal leg can remain perfused at angle >90'If angle <20' indicates severe ischemia ➢ Drop leg over side of bed causes diseased leg to become purple-red =reactive hyperemia ➢ Ankle brachial pressure indexes ➢ SBP in arm andSBP in leg (with Doppler) ➢ ABPI = ankle/brachial SBP Peripheral Neuropathy Examination

➢ 52 yo male with history of long standing poorly controlled diabetes. Complaining of burning sensation in both feet. ➢ Task ➢ Perform LL examination with running commentary to the examiner ➢ Explain most likely Dx to patient

➢ DDx ➢ Diabetic neuropathy ➢ Alcoholic neuropathy ➢ Vitamin deficiency

➢ Nerve entrapment ➢ WIPE ➢ GA ➢ Gait: normally, heels (L5), toes (S1),tandem ➢ High stepping gait: indicates loss ofproprioception ➢ Examine footwear ➢ Inspection: lying down, including heels and between toes ➢Abnormal movement, fasciculation, muscle wasting ➢Skin changes, shiny, dry, hair distribution ➢Deformity ➢Trauma, ulcers or signs of infection ➢ Palpation: temperature, tenderness, CRT, pulses,edema ➢ LL Neurological examination ➢Tone ➢Power: hip (4), knee (2), ankle (4) ➢Reflexes ➢Coordination ➢ Finger – nose ➢ Heel – shin ➢ LL Neurological examination ➢ Sensation: ➢ Cotton wool and pin → globe and stocking sensation loss ➢ Dermatome distribution ➢ Now, distal to proximal ➢ Vibration (128Hz), the biggest one on the table) in bony prominences ➢ Position ➢ Monofilament ➢ To finish myexamination ➢ Fundoscopy:DM ➢ Stigmata of CLD ➢ Office test: CBG and UD Ankle and FootExamination

➢ Cyclist, lady, 30yo, pain worse in morning, pain worse cycling (long stem) ➢ Task ➢ Foot exam (6 minutes) ➢ DDx with reason Plantar Fasciitis and Morton’s Neuroma

➢ WIPE ➢ General appearance ➢ Gait: Always assess gait when PE from lower back distally is involved ➢ Straight, toes and heels ➢ Look -Inspection: foots outside the edge of the bed ➢ Feel –Palpation: Pulse, temperature, tenderness, CRT ➢ Move: Active and passive ➢ Special tests ➢ Windlass test: Plantar fasciitis ➢ Squeeze test: Morton’s neuroma ➢ Thompson test: Ruptured Achilles tendon Plantar Fasciitis and Morton’s Neuroma

➢ DDx ➢ Trauma ➢ Nerve entrapment ➢ Morton’s Neuroma Ankle Sprain

➢ 23 year old John came to your GP clinic with an injury in his Rt ankle while playing footy. He said he felt a twisting on his Rt ankle while he was tackling a movement with the opponent. He is concerned because he had an upcoming final game shortly in2 weeks. ➢ Tasks ➢ Take short focused history( 2minutes) ➢ Examine the ankle ➢ Tell the condition ➢ Outline management ➢ WIPE ➢ Gait ➢ Inspection: pt lying down, signs of inflammation, signs of trauma, deformity, scars ➢ Palpation: temperature, pulse, CRT, Ottawa ankle rules – define the need of and ankle xray ➢ Bone tenderness along the distal 6 cm of the posterior edge of the tibia ➢ Bone tenderness along the distal 6 cm of the posterior edge of the ➢ Bone tenderness at the base of the fifth metatarsal ➢ Bone tenderness atthe navicular bone ➢ An inability to bear weight both immediately and in the emergency department for four steps ➢ Move: 4movements ➢ Special Tests ➢ Special tests ➢ Talar Tilt test ➢ Anterior drawer ➢ Squeeze test ➢ Thompson test

➢ Neurovascular assessment!! ➢ Pulses: dorsalis pedis and posterior tibialis ➢ CRT ➢ Sensation ➢ Sole: Tibial nerve ➢ Dorsum

➢ Deep peroneal nerve

➢ Superficial peroneal nerve Back Examination

➢ You are working in GP practice and your next patient is a gardener who presents to your surgery with disabling left sided back pain for last 24 hours. He tried lifting a heavy rock and now finds himself really uneasy to move his back. ➢ Task ➢ Perform physical examination ➢ Diagnosis ➢ Management

➢ AMC recalls ➢ Acute mechanical low back pain ➢ Sciatica with IV disc prolapsed ➢ GA: protective or antialgicposture ➢ Gait: straight, heels, toes ➢ Inspection: back andside ➢ Posture, asymmetry, scars ➢ Deformity: scoliosis, loss of lumbar lordosis (ankylosingspondylosis) ➢ Signs of trauma ➢ Signs of inflammation or infection ➢ Palpation ➢ Temperature ➢ Tenderness: spine, para spinal muscles, PSIS, sacroiliac joint, tip of coxis ➢ Every time you're going to palpate or inspect private/sensitive areas ask for permission ➢ Move (6): ask the patient to copy your movements, is always easier than explaining it. ➢ Flexion, extension, lateral flexion and rotation –activeis enough ➢ Measurement ➢ Schober test: use the logic ➢ If you measure 10 cm distally, where are you going to make the mark? ➢ Special test (2) ➢ SLR: positive if <60 degrees ➢ Thomas test ➢ Lower limb neurological examination ➢ Power: L5, S1 ➢ Sensation: L5, S1 ➢ Reflexes ➢ I will like to conclude my examinationwith ➢ Complete neurological examination ➢ 1 joint above, 1 joint bellow ➢ DRE: tone – discard cauda equina syndrome together with saddle sensation ➢ Management ➢ Reassurance ➢ No need for referral, unless cauda equina syndrome – not a recall ➢ No need forimages ➢ Review in 48 hours ➢ Give red flags –if +ve–referral ➢ Review in 7 days ➢ Pain killers ➢ Rest for a short period of time, don’t tell them to stay in bed ➢ Reading material Pelvic Examination

➢ 27 yo lady with single episode of painless post coital bleeding. No dyspareunia. On OCPs. The menstrual history is unremarkable. PAP smear was performed 3 months ago and was normal. ➢ Task ➢Perform pelvic examination, tell what you are looking for in each step. ➢Most likely diagnosis with reasons ➢ DDx ➢Cervical Ca –PAP normal ➢Cervical polyp ➢Cervical ectropion ➢Trauma ➢ WIPE ➢Gain consent ➢ Supine, modified lithotomy position: Bring your hips towards your bottom and then let your knees fall to thesides ➢ Chaperone ➢ Ask chances of pregnancy? ➢ Would you like to empty your bladder before the examination? ➢ GA ➢ Abdominal examination: as usual ➢ Inspection of vulva ➢Ulcers ➢Scars ➢Discharge or bleeding ➢Atrophy: post menopausal ➢Masses ➢Vaginal prolapse: ask patient to cough ➢ Speculum examination ➢ Warn the patient you are about to insert the speculum ➢ Use your left hand (index finger and thumb) to separate the labia ➢ Gently insert the speculum sideways (blades closed, angled downwards and backwards) ➢ Once inserted, rotate the speculum back 90 degrees (so that the handle is facing upwards) ➢ Open the speculum blades until an optimal view of the cervix is achieved ➢ Tighten locking nut to fix the position of the blades ➢ Vaginal prolapse: ask patient tocough ➢ Inspect the cervix ➢ External os –open/closed ➢ Cervical erosions –ectropion + ➢ Masses ➢ Ulcers –e.g. genital herpes ➢ Discharge –e.g. bacterial vaginosis ➢ PAP smear –perform if endocervical brush isavailable ➢ Bimanual examination ➢Entering the vagina ➢ Lubricate gloved fingers ➢ Separate labia using the thumb and index fingers of your non-dominant hand ➢ Gently insert the gloved index and middle finger of dominant hand ➢ Enter the vagina with palm facing laterally and the rotate 90 degrees so that it faces upwards ➢ Asses vagina: walls for any irregularities ormasses ➢ Asses the cervix: position, consistency, os, cervicalexcitation (PID) ➢ Assess the fornices: gently palpate the fornices either side of the cervix for any masses ➢Uterus ➢ Place your non-dominant hand 4cm above the pubis symphysis ➢ Place your dominant hand’s fingers into the posterior fornix ➢ Push upwards with the internal fingers whilst simultaneously palpating the lower abdomen with your non- dominant hand. You should be able to feel the uterus between your hands.

➢ Size –approximately orange sized in an average female

➢ Shape –may be distorted bymasses such as fibroids ➢ Position –anteverted vs retroverted

➢ Surface characteristics –smooth vs nodular

➢ Any tenderness during palpation? ➢ Bimanual examination ➢ Ovaries and uterine tubes ➢ Place your internal fingers into the left lateral fornix ➢ Place your external fingers onto the left iliac fossa ➢ Perform deep palpation of the left iliac fossa whilst whilst moving your internal fingers upwards and laterally (towards the left) ➢ Feel for any palpable masses, noting their size and shape(ovarian cyst / ovarian tumor/ fibroid) ➢ Repeat adnexal assessment on the other side of the patient ➢ To complete my examination ➢ Urinalysis, including β-HCG ➢ Vaginal swabs ➢ Imaging if necessary Headache Examination

➢ 65 yo male, complaining of headache, pain while chewing and shoulder pain. ➢ Task ➢Perform relevant PE ➢Most likely Dx and DDx ➢ DDx: ➢Temporal arteritis ➢Migraine ➢Tension headache ➢Space occupying lesion ➢Sinusitis ➢Ear or dental infection ➢ GA ➢ VS ➢ Scalp ➢Palpate temporal artery ➢ Eye: external and internalwith ophthalmoscope ➢SOL ➢ Ears: external and internal withotoscope ➢ Nose: ask for torch ➢ Throat ➢ Sinuses: palpate ➢ TMJ: palpate ➢ Neck rigidity ➢ Proximal myopathy ➢Chicken wings again resistance ➢Squat ➢ Neurological examination ➢CN ➢U and L Limb examination Hematological Examination

➢ 22 year old Jonathan comes to your GP clinic with Sore throat. He came back for test results which you ordered before and found positive Monospot test, vitals are normal, His blood examination shows elevated Lymphocytes and decreased platelets (40,000). ➢ Task: PE, Dx to patient, Mx

➢ 41 year old Johnson came to your GP clinic for review of his blood result which came back as RBC count 9 ( N 12-16), WBC count 3( N 4- 11),Platelet 110( N 150-400). His PBF shows Blast cell. He is afebrile at the moment with no apparent distress.

➢ 22 yo male, URTI10 days ago, complaining of rash in lower limbs. ➢WIPE ➢GA ➢Skin: If rash present –characterize ➢ Blanching/not blanching ➢ Signs of anemia/infection/bleeding ➢Hands ➢ Color: anemia, jaundice ➢ Nails: clubbing, koilonychia ➢ Signs of endocarditis: Osler nodes, Janewaylesions, splinter hemorrhage ➢Pulse ➢BP ➢Head: ➢ Mass or deposition ➢ Frontal bossing ➢Eyes: anemia, jaundice, subconjunctival hemorrhage, funduscopy ➢Mouth: ➢ Lips: cheilitis, angular stomatitis ➢ Tongue: glossitis, loss of papillae ➢ Gums: bleeding, hypertrophy ➢ Tonsils: signs of infection, enlargement ➢ Lymph nodes: wash hands again after palpating them ➢Cervical ➢Axillary ➢Epithrochlear ➢ Chest: ➢S1, S2 ➢Bony tenderness in sternum ➢ Abdomen ➢Inspection ➢Palpation ➢ Mass ➢ Spleno/hepatomegaly ➢ Paraortic lymph nodes ➢Auscultation ➢ Lower limbs ➢PVD ➢Edema ➢ To conclude my examination ➢Genitalia: deposition ➢DRE

➢ Dx ➢ From Hx and PE most likely you have a condition called Infectious mononucleosis, have you heard about it? ➢5 C’s ➢ Condition: self limited viral infection that affects the glands of your body, including lymph nodes and spleen ➢ Causes: viral infection transmitted by drops –Monospot test +ve ➢ Clinical features ➢ Sore throat ➢ Lymph nodes enlargement ➢ Spleen enlargement ➢ Commonality: its not an uncommoncondition ➢ Complications: spleen rupture ➢ Mx ➢Rest, fluids, proper diet, if fever –Panadol ➢Viral condition – no need for antibiotics, caution with Amoxicillin as it can cause a rash ➢Not necessary to make more investigations ➢Avoid contact sports ➢Red flags –if present come back to ED ➢ Bleeding ➢ Infection: fever, discharge, bleeding – change in colour of poo or wee ➢Reading material ➢Review in 1 week

MVA Examination

➢ 28 years old Jennifer was involved in a MVA. She was beside the driver and got hit in her head only. Rest of the body received no injury as she recalled the event. Primary survey was done and the patient is stable at the moment. She is complaining of blurring ofvision. ➢ Task ➢ Perform focused physical examination ➢ DDx ➢ AMC recalls ➢ No positive findings –everything normal ➢ Raised ICP –fundoscopy ➢ Orbital floor fracture –eye movement ➢ WIPE ➢ GA: patient in pain/distress or comfortably lying in the bed ➢ Inspection ➢ Signs of trauma: Bruise in the cheek (+ve in orbital floor fracture), battle sign, raccoon eyes, facial asymmetry ➢ Deformities ➢ Palpation: from head down ➢ Crepitation ➢ Tenderness ➢ Eye examination ➢ Inspection ➢ Outside: eyelids, eyelashes, conjunctiva, sclera, anterior chamber, pupils ➢ Inside – Ophthalmoscope: cornea, posterior chamber, vitreous, retina, optic disc, vessels ➢ I'm going to put a light in your eye and Iwill get closer to you to have a look inside your eye, please don’t get confronted, ➢ Examiner I will like to dim light –assume it is ➢ Ideally with midriatic eye drops ➢ Examiner will give you a picture–normal or papilloedema ➢ Palpation: orbital margin (+ve in orbital floorfracture) ➢ Fluorescein stain: just mention that you would like to do it ➢ Tonometer: :just mention that you would like to do it ➢ Ears: tympanic membrane, CSF ➢ Nose: nasal septum fracture,CSF ➢ Mouth: broken or loose tooth, tongue bites, vomit, smell: alcohol, uremic or DKA ➢ Cranial nerve examination ➢ II CN ➢ Visualacuity ➢ Visualfields ➢ Pupillary reflexes ➢ III, IV, VI CN ➢ H shape: diplopia in upward gaze (+ve in orbital floor fracture) ➢ Rest of CN: examiner might stop you ➢ UL/ LL neurology Tremor Examination -Parkinson’s

➢ You are an intern and 60 yo patient is worried that he has got Parkinson’s disease as he has also noticed shakes in his both hands. He found that a drink or two settles the shakes in most of the time. He did not notice any other shakes in any other parts of the body. He is otherwise healthy. He doesn't have any significant medical or surgical illnesses. He is does not smoke. He drinks 5-6 cans of beer almost everyday of weekdays and a little more on weekends. ➢ Tasks ➢ Perform focused PE with running commentary to the examiner ➢ Tell the condition to the patient and outline the Mx ➢ DDx ➢ BET ➢ Thyrotoxicosis ➢ Parkinsonism ➢ Drug induced ➢ Alcoholic tremor ➢ CNS ➢ WIPE ➢ General Appearance: anxiety, abnormal movements ➢ Gait ➢ Stand up and go ➢ Festinating gait, big u turn ➢Hands ➢ Type of tremor: Coarse, fine, intention, flapping ➢ Tests: micrographia, piano, “bamba”, opposing, alternating ➢ Palm: sweaty ➢Pulse ➢Tone ➢BP ➢Chicken wings ➢Face: mask face, glabellar tap, ophthalmopathy, hypophonia, drink water ➢Neck: Carotid bruit, JVP and thyroid examination ➢CVS ➢Lower limbs: myxedema and knee jerk ➢Finish with full upper and lower limb NE +CLD stigmata Tremor Examination -Parkinson’s

➢ Woman with cramps, pins and needles in both hands after 2 weeks of thyroidectomy. ➢ Task ➢Perform PE ➢DDx ➢ DDx ➢Hypocalcemia ➢Cubital/Carpal tunnel syndrome ➢Cervical spondylosis ➢DM or alcoholic neuropathy ➢Vit B deficiency, ➢ WIPE ➢ GA: confusion, anxiety, muscle spams, breathing or speech difficulty ➢ VS ➢ Hand: ➢ Inspection: Tremor and muscle spams ➢ Palpation: temperature, tenderness, CRT ➢ Move ➢ Face :twitching or spasms of muscles ➢ Neck ➢ Inspection of wound: signs of inflammation, signs of infection, swelling (hematoma) ➢ Palpation: Lymph nodes and tenderness ➢ CVS: S1, S2 ➢ Special test: ➢ Trousseau sign: occlusion of the brachial artery with BP cuff precipitates carpo-pedal spasm (wrist flexion and fingers drawn together) ➢ Chvostek sign: tapping over parotid (facial nerve) causes twitching in facial muscles ➢ Reflexes: knee and ankle ➢ Iwill complete my examination for performing complete upper limb neurological examination DRE

➢ A middle age man who is having chest pain on activity relived with rest, heart racing, pain radiating to arms and shoulder and had episodes of bright blood in stool. ➢ Task: ➢Talk to him and gain consentfor examination ➢Do abdominal examination ➢Do DRE ➢Explain the most likely diagnosis ➢ DDx ➢Angina secondary to anemia due to GI bleeding ➢Arrhythmia: AF associated with mesenteric ischemia -no abdominal pain present ➢GI bleeding: fissure, hemorrhoids, polyp, diverticulosis, Ca colon/stomach, bleeding disorders, IBD ➢ WIPE ➢ GA ➢ Chaperone ➢ Abdomen: as usual ➢ Patient is in the left lateral position, on the left side with the knees drawn up and back to the examiner ➢ Look: fistulae, tags, rectal prolapse, pruritus ani, excoriation and signs of blood, mucus. ➢ Feel: ➢ Anterior wall of the rectum for prostate gland in the male and for the cervix in the female. ➢ The normal prostate is a firm, rubbery bi lobed mass with a central furrow. ➢ The finger is then rotated clockwise to assess all rectal surfaces, plus finish with assessing the anal tone. Rash in Upper Limb

➢ Middle aged man came with. Rash in forearm. Pic was given similar to the following but there was no lesion in the wrist. ➢ Tasks ➢ Ho for 2 mins ➢ PE ➢ Probable Dx and DDx to the Pt ➢ Ddx ➢ Lymphangitis ➢ Thrombophlebitis: IV drugs/IV cannulas/IV medication ➢ Cellulitis: insect bite, trauma ➢ Contact dermatitis ➢ History ➢ HOPC: Since when? Is it getting worse? Has always been the same color? Is it painful or itchy? Do you have it in any other place of your body? ➢ DDx ➢ Insectbite ➢ Trauma ➢ IVmedication ➢ IV recreational drug ➢ Contact with any chemicals? New soap, clothes? Bush walking? ➢ Fever ➢ PMHx, PSHx,PFHx ➢ SADMA ➢ Physical Examination: of bothlimbs ➢ WIPE ➢ GA: pain, IV cannulasin hands ➢ VS: temperature (ear thermometer), pulse(clock) ➢ Look: describe picture ➢ Morphology of rash: macular/papular/vesicular/crusty/urticarial, color/shape/regular/irregular/areas of inflammation around/edges, signs of infection or discharge ➢ Signs of inflammation ➢ Signs of trauma, insect bite ➢ Feel ➢ Temperature ➢ Tenderness ➢ Consistency/Blanching ➢ CRT ➢ Move ➢ Lymph nodes: epithrochlear and axillary Dehydration Status

➢ You are a HMO. Next patient is 30 yr old lady who has headache and stomach ache. She passed watery brown motions 4 time this morning. She vomited old food once. No significant past medical history. No travel history. No recent antibiotic. Does not have contact history. ➢ Task: ➢ Perform physical examination including dehydration assessment and abdomen, explain to the examiner at every step about your finding ➢ Explain most likely condition to patient and differential diagnoses ➢ GA ➢ Dehydration status ➢ CRT ➢ Skin turgor ➢ Pulse ➢ BP ➢ Oral mucosa ➢ JVP