Physical Examination EXAM FORMAT

Clavicular Fracture

• Bicycle fall or some other activity and fall• PE, Xray, Immediate and long term Mx

• Immediate Mx:• Sling- learn how to put the sling on• PRICE- painkillers, rest, ice• Elevation when you sleep• Physio• Early mobilisation of wrist and fingers• Review at 2 week• Red flag → swelling, numbness, colour change, tingling → come to the hospital

• WIPE

• Painkiller

• General appearance • Distressed pain, protective posture• At respiratory distress

• Inspection• Bruise• Step deformity• Asymmetry of shoulder• Pallor in hand

• Palpation• Temp- local rise of temperature at clavicle

site• Decrease in hand- cold and clammy

• CRT• Pulse• Tenderness

• Sternoclavicular joint

• Clavicle• Acromioclavicular • Coracoid• Head of humerus• acromion

• Movement • Cannot assess movement since patient is in

pain but asked finger and wrist which he moved

• Neurological examination (dermatome wise)• Movement → Check C8 and T1→ check

grab and spread your hands• Sensory → Dermatome – cotton

• Key point→ r/o pneumothorax • Just do auscultation

Shoulder examination

• WIPE

• Painkiller

• GA- distressed, protective posture

• Inspection• Front- Clavicle is well aligned, no step deformity, no scar

or swelling, No obliteration of the deltopectoral groove• Side- no exaggerated cervical lordosis and thoracic

kyphosis• Back- no scoliosis, no paramuscles wasting, the spine

appears to be central in alignment, and spine of scapula and borders of scapula. No obvious deformity.

• palpation• Temp• Tenderness- no pain over sternoclavicular joint, clavicle,

AC joint then to coracoid process, joint line, head of humerus, greater tuberosity then deltoid and biceps and Back- over spinous process, paraspinous muscles, trapezius, supra and infraspinatous and borders of scapula

• Sensation over the deltoid

• Movements – always normal side first• Active

• Flexion • Extension• Abduction and adduction• Internal and external

• Power

• Special test:• Empty can test- press down on the shoulder after pouring

it down → Rotator cuff injury• Positive in pain

• Full can test – thumb up and press down →• Neer test- internal rotation of arm and we passively raise

the arm→ there will be pain → supraspinatus impringement

• Apprehension Test

Shoulder Conditions Special Test

Impingement syndrome Painful Arc, Neer’s sign,

Hawkins’s test

Rotator cuff tear test Drop arm test, Empty can test

Shoulder instability Apprehension test

Special tests:

• Impingement of supraspinatus muscle• Active supraspinatus movement restricted• Passive supraspinatus movement +• Power of abduction –• Empty can –• Neer test +

• Injury of supraspinatus muscle• Active supraspinatus movement restricted• Passive supraspinatus movement +• Power of abduction –• Empty can +• Neer test -

Gynecomastia

• 25 year old boy presents to you with breast enlargement • Boy is a bodybuilder• He is using Nandrolone (anabolic steroids)

• Task• PE

• DDx• Breast cancer• Pseudo gynecomastia• Liver d/s• Hyperthyroidism• Prolactinoma• Testicular cancer• Normal in obesity and puberty

• General appearance • Jaundice, dressed according to weather,

Anxious face• BMI

• Nails→ leukonychia, onycolysis, clubbing

• Fingers → thyroid acropachy

• Palm → Dupuytrens contracture• Palmar erythema• Moist sweaty hands

• Tremor → flapping Tx

• PR with rhythm and BP

• Hair thinning or loss

• Eye changes• Exophthalmos • Lid lag • movement – lig lag and ophthalmoplegia• In prolactinoma → visual field – Bitemporal

hemianopia• Fundoscopy

• Neck – Thyroid

• Breast examination: with consent and chaperon• Inspection in Neutral, waist and push hands

behind the head, push back and lean forward• Palpation → Im feeling for the normal disk

like tissue• Mass → site, size, border, surface and

consistency, mobility and tenderness. Hold the mass and ask the patient to squeeze the chest muscles

• Ask the patient to squeeze the nipple- for discharge

• LNs → axillary and clavicle

• Chest → Spider nevi

• Abdomen → liver size → they might ask you to skip• Pelvic exam → Testicular swelling

Case- Alcohol cerebellar degeneration

• You are a HMO in ED, 40 year old John presents with unsteady gait for past 3 hours. He went to a pub last night and drank alcohol in excess and this morning when he got out of bed, he felt very wobbly on his feet. Your task is to:

• perform physical examination• most likely DDX

DDx.• Alcohol induced Cerebellar

degeneration• Strokes/TIA• A/c sensory Neuropathy• Vit B12 def• Brain tumors • Meiners disease

Alcohol Cerebellar degeneration PE

• Findings

• WIPE

• General Inspection- patient comfortable and not in distress

• Gait• Ask are you able to bear your weight, do you need

walking aid.• Can you please walk a few steps please

• Ataxic gait – it’s a broad based drunken gait

• Walk in a straight line with your heels and toes touching – tandem gait

• Romberg's sign • If they lose balance with open eyes → cerebellar +• If they lose balance with closed eyes → sensory

• Lower limb • ITPRSC• Inspection – wasting and fasciculation + SWIFT

• Tone• Power – they will say skip• Reflex-

• Knee (do it in sitting)→ pendula reflex

• Sensation - dermatomal• Coordination → heel to shin test

• Upper limb• Finger to nose → pass pointing and intentional

tremor• Dysdiadokokinesia• Rebound phenomenon (cerebellar)

• Face• Eye → Nystagmus (vertical)• Speech- British constitution or hippopotamus →

look for slurring on speech

AMC Cases

Alcohol Cerebellar Degeneration Peripheral Neuropathy- DM Peripheral Neuropathy- Alcohol

Gait → Drunken gait

Romberg’s → +

Coordination

Motor

Gait → Normal

Romberg’s → -

Sensory

Gait → Normal

Romberg’s → -/+

Sensory

Coordination

Sensory

Cranial Nerves

Motor

Coordination

Cranial Nerves

Motor

Cranial Nerves

Diabetic Neuropathy

• A middle age woman presented to you with burning and tingling sensation of feet and leg calf pain. She is known history of diabetes.Tasks-do sensory neurological examination (may be relevant or Lower limb exam as well)-dx and ddx to patient

• DDx:• Diabetic sensory Neuropathy• Alcohol sensory neuropathy• Vit B12 deficiency• Uremia• Liver disease

• WIPE

• Gait + rombergs

• Inspection:• Ulcers – between the toes aswell• Swelling and redness

• Palpation• Temperature• capillary refill time • dorsalis and posterior tibial pulses

• Sensation• Cotton wool – fine • Toothpick- pain

• For both fine and pain first check the dermatome and then sensory level

• Vibration- 128Hz• Base of the first ‘toe• Medial malleolus• Tibial tuberosity• ASIS

• Proprioception- joint position

• Monofilament• Always normal in exam

• Reflex• Achilles and ankle

• I would like to complete my examination by doing

Tone, power and coordination-upper limb neuro exam-cranial nerve exam-cerebellar signs

• rewash hands and thanks the patient and the examiner

• Glove or stove Appearance → Diabetic neuropathy

Alcohol neuropathy

• Case 1/GP, middle aged man came because having tingling and pain on his legs. He is a chronic alcoholic and consumes ? drinks ? years. • Tasks:• -Perform lower limb neurological examination, tell the findings to the examiner

(7min)• -Tell the diagnosis/differential diagnosis

• Case 2/ 50 year old man comes to your GP as having problem with his gait. He is chronic alcohol drinker, known history of hypertension. Lab value given abnormal GGT and normal B12 and HBA1Ctasksexamination of lower limbexplain Dx and DDx to patient with reasons

DDs:

• DDx:• Diabetic sensory Neuropathy

• Alcohol sensory neuropathy

• Vit B12 deficiency

• Uremia

• Liver disease

• WIPE

• Gait + tandem + rombergs + heel and toes

• Inspection:• Ulcers – between the toes aswell• Swelling and redness• SWIFT

• Palpation• Temperature• capillary refill time • dorsalis and posterior tibial pulses

• Sensation• Cotton wool – fine • Toothpick- pain

• For both fine and pain first check the dermatome and then sensory level

• Vibration- 128Hz• Base of the first ‘toe• Medial malleolus• Tibial tuberosity

• ASIS

• Proprioception- joint position• Monofilament

• Always normal in exam

• Reflex• Achilles and ankle

• Coordination• Lower limb

• Heel shin test • Finger toe test

• I would like to complete my examination by doing-Tone, power and coordination

-upper limb neuro exam-cranial nerve exam-cerebellar signs-chronic liver disease signs

PVD

• 45 year old man presents with Right leg pain, worse on waking and better on rest

• Task• Perform lower limb examination

• WIPE

• Painkiller

• General appearance

• Gait – antalgic gait, arm swing

• Inspection• Hair loss• Colour change – pallor or hyperpigmentation• Ulcers• Shiny skin• Rash, swelling, deformity

• Palpation• Temp• CRT• Pulse- Dorsalis Pedis, post tibial absent• Tenderness

• Foot and knee

• Movement • General movement of toes and feet and knee

• Special Test• Beurgers test→ looking for pale, sit on edge of bed

• Hyperemia

• Bruit → femoral, Aortic and renal

Case 3- PVD + DM

• DM pt presents to you with pain in right leg walking uphill & night better at rest

• Task• Lower limb examination

• WIPE

• Painkiller

• General appearance

• Gait – antalgic gait, arm swing

• Inspection• Hair loss• Colour change – pallor or hyperpigmentation• Ulcers• Shiny skin• +general stuff• Ulcers – between the toes aswell• Swelling and redness

• Palpation• Temp• CRT• Pulse- Dorsalis Pedis, post tibial absent• Tenderness

• Foot and knee

• Reflex• Achilles and ankle

• Movement • General movement of toes and feet and knee

• Sensation• Cotton wool – fine • Toothpick- pain

• For both fine and pain first check the dermatome and then sensory level

• Vibration- 128Hz• Base of the first ‘toe• Medial malleolus• Tibial tuberosity• ASIS

• Proprioception- joint position• Monofilament

• Always normal in exam

• Special Test• Beurgers test→ looking for pale, sit on edge of bed

• Hyperemia

• Bruit → femoral, Aortic and renal

Case

• You are a GP and your next patient is Mr. David → 55 yr old male, presents to your clinic with c/o pins and needles on his right foot for past 1 day. He is a strawberry picker by profession. He doesn’t have any significant past medical history.

• Task:• Perform physical examination• Tell the pt about your most likely Dx and DDx

• Foot drop → common peroneal nerve palsy – aka strawberry pickers palsy

Foot Drop• General- Mr Jones seems to be likely comfortably, doesn’t appear to

have any obvious pain or distress and no Protective posture

• Check the gait• Are you able to bare your weight?• Would you be able to take a few steps for me?

• In foot drop there are two types of gait – dragging gait or high stepping gait?

• Romberg’s sign – to differentiate between sensory ataxia and peripheral neuropathy.

• Look (Please lie down on the bed)• SWIFT → Swelling, Wasting of muscles, Involuntary movements,

fasciculations and Tremors.• I cannot appreciate any stigmata of peripheral vascular disease.

• Ulcers

• Skin color changes

• Loss of hairs

• Shiny skin

• Feel• Temperature

• Using one hand, compare the temperature of patients both feet, comment on it.

• There is no cold or clammy feet.

• Tenderness• Check the forefoot, midfoot and hindfoot of both sides

• Circulation • Check the Capillary refill time of both feet

• Check the pulse- dorsalis pedis and posterior tibial.

• Sensation • TIP → tibial nerve – Inversion and Plantar flexion

• Sensation of tibial nerve is checked on the sole of the foot

• Superficial peroneal nerve – eversion • Lateral and dorsal aspect of foot

• Deep peroneal nerve – dorsal flexion• Sensation over the first web space between toe and 2nd toe

• Movements Of the Ankle• Point them up – dorsiflexion• Point them down – Plantar flexion • Move your feet away – eversion• Bring them together – Inversion

• Special Test:• Fibula Tap Test:

• Tap the groove of knee over the lateral aspect and ask if theres a shooting pain the feet.

• SLR: ( you need to ask what type of pain)• In sciatica- (shooting type of pain)

• Local back pain (low back pain)

DDx

• Common peroneal nerve palsy

• DM and alcoholic neuropathy

• Vitamin B12 neuropathy

• Peripheral neuropathy

• Mononeuropathy → sciatica

• polyneuropathy

Dx:

• After examining you, what you might have is most likely common peroneal nerve palsy aka strawberry picker palsy.

• There is a main nerve at the back called sciatic nerve which runs down to the lower back to the buttocks to the back of the thigh and at the level of the knee it divides into 2 branches- common peroneal and deep peroneal nerve. I think in your case it is the common peroneal nerve that is compressed at the level of the knee. Because you are a strawberry picker, you squat to pick the strawberries which can cause compression of the nerve at the level of the knee.

• The other possible causes could be injury to the main sciatic nerve but in that case you should have shooting pain from back, buttock and all the way to the feet.

• It can be peripheral neuropathy- which is a damage of multiple smaller nerves at the feet due to alcohol, B12 or Dm. but that usually involves both feet and is normally a long standing problem.

Bell palsy Case 1

• young man woke up in the morning with the asymmetrical face. He is worried about having stroke.Tasks-physical examination of facial nerve-other relevant examinations to rule out the causes of his symptoms-tell the patient the most likely Dx and DDx with reasons

Case 2

• 40 year old man present with facial asymmetry• Perform relevant CN examination

DD

• Stroke/TIA

• CPA tumour

• Ramsey hunt

• Parotid Cancer

• Bells palsy

• Trauma

• Cholesteatoma

• Inspection-face: asymmetry, nasolabial fold, drooping of the corner of mouth)-eyes: drooping, ptosis-ears: rash or vesicles-parotid gland: visible lump or swelling

Note/ in the exam, there might be widening of palpebral fissures, smoothing of nasolabial fold, drooping of left or right sided corner of mouth.

• facial nerve examination• taste and hyperacusis

do you have any change in your taste or hearing?• wrinkle forehead

can you look up as to wrinkle your forehead and do not let me push them down?

• close eyes tightlycan you close your eyes tightly and do not let me open them?

• puff out cheekcan you puff out your cheeks and do not let me push them together?

• show me your teethcan you show me your teeth please?

Note/ in the exam, the examiner will give you the

findings on pictures and all lower and upper side of the face will be affected to know there is lower motor neuron palsy. For example: loss of wrinkles, failure of eye closure and rolling up of eye under the upper eyelid, failure to blow out cheeks, and deviated mouth to one side.

• Palpation• Head to face – signs of trauma/tenderness• Fundoscopy• assess ear with otoscope Examiner will say normal• feel the parotid gland: lump and tenderness.

Examiner will say normal• feel for lymph nodes.

• Trigeminal nerve- clench your teeth and palpate the temporalis and masseter

• Sensory: ophthal, mandibular and maxillary• Motor: jaw • Reflex: corneal and jaw

• complete exam with Ideally Hearing test and other cranial nerve examination and UL/LL neurology.

• From Hx and PEFE, Ive found that Facial nerve is not functioning, this nerve is responsible for the movements of your facial muscles and facial expression. There are many causes that can affect the facial nerve such as DDs….. And idiopathic facial nerve palsy or bells palsy. I can see that it must be scary for you but Let me assure you that it is a common condition and not serious. In Most cases, this condition will usually resolve spontaneously without any complications.

Case

• You are HMO in ED and your next pt is Michael 45 man presents with MVA this afternoon, his primary survey has been done A,B,C → Normal, Vitals stable. Afebrile → he c/o pain on his left cheek which is bruised.

• Task:• Perform Pex: on Mr. Micheal

• Tell the pt about your most likely diagnosis and initial Mx Plan

• Positive Finding:• Bruising on the left cheek

• Tenderness on left cheek

• Up gaze Diplopia (vertical diplopia)

Orbital floor fracture• Inspection:

• On inspection I can appreciate bruising on left cheek but apart from that I cannot appreciate any:

1. Stigmata of basillar skull fracture

• Raccoon eye

• Rhinorrhea

• Otorrhea

• battle sign

2. Stigmata of Orbital floor fracture

• Exophthalmos

• Enophthalmos

• Hypo Globus

• Periorbital edema/ hematoma/bruising

• Subconjunctival hemorrhages

3. Nasal fracture

• Obvious nasal deformity

• Nasal septal hematoma

4. Maxillary/ Zygomatic complex fracture

• On chewing → pain over maxillary bone

• On chewing → pain of TMJ – TMJ dysfunction

5. Mandibular fracture

• Upper dental arch/lower dental arch →missing tooth

• Sublingual hematoma

• On inspection from the back, the spine appears to be central in alignment, and I can clearly appreciate the spine of scapula and borders of scapula. No obvious deformity.

• Ideally I would like to expose the back and look for alignment of the back

• Palpation:

Stand at the back:• Check the maxillary bone alignment and symmetry(stand at the back and place both

index fingers over the maxillary bone)

• Feel for tenderness of the back → no tenderness over cervical and thoracic spine

• Procedure: Stand at the back of the patient and use your thumb to feel for the back spines

• Feel for paraspinal tenderness, feel for trapezius and supraspinatus and infraspinatus

• Theres no tenderness over the spine and borders of scapula

Stand at the front:• I know you have pain over the left cheek, ill touch the painful area at the very end and

ill warn you before I touch the painful area and ill be very gentle.

• Start feeling the orbital bone, nasal bone and maxillary bone of the normal side.

• Similarly feel the other area (touch the painful area last) → nasal bone, maxillary bone and finally orbital bone (I'm about to touch the painful area, please bare with me)

• Movements: ( can you please copy my movement)• Flexion – touch your chin to the neck

• Extension- ask the patient to look straight

• Hyperextension- ask the patient to look up

• Left and right rotation- rotate your head left and right

• Left and right lateral flexion- tilt your head to left and right

• Check the eye movements: Draw the H sign and ask the patient if he have double vision or pain in all areas.

• Ideally I’d like to finish my examination by doing a complete CN examination (but mainly focusing on 2,3,4,6, 5th, 7th and 8th). I’d like to do a complete secondary survey.

• After examining you, I think the most likely condition you are suffering from is called orbital floor fracture.

• Have you ever heard of this before- No• Don’t worry I’ll explain it for you• Theres a bone surrounding the eye called the orbital bone- in your case, there can be a

fracture of this bone. That’s why you are having this double vision (up gaze diplopia). • This is a surgical emergency → need surgery within 24 hrs otherwise it will cause permanent damage.

• Another possibility is that because of the trauma, there is excessive swelling of the soft tissue around the eye which is compressing one of the muscles (inferior rectus muscle) which is causing double vision.• False entrapment ( too much swelling) → conservative management

• I need to admit you to hospital. There is a need to do a CT scan of your facial bones to confirm the diagnosis. I’ll also get my senior to come and review you. If needed we’ll also call the specialist to come and see you.

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

Parotid

History:• Can you tell me more about it? When? Is it growing suddenly or slowly?

Painful or not painful? Does it move when you feel it? It is firm or hard when you feel it? Any ulceration, infection or bleeding from this site? (lump x 5 years noticed when he was shaving; slowly growing, not painful, came in due to cosmetic reasons).

• Any other lumps and bumps in the body? Any weight loss or change in appetite?

• Facial Nerve: Did you notice any asymmetry of the face? Any disturbance in function of your face? Any change in taste sensation? Any problems with swallowing, hearing or breathing? Hoarseness?

• Do you have any pain or swelling in the gum while chewing? How is your general health?

• PMHx of cancer or radiation therapy? FHx of cancer, SADMA? + smoker x1/2 pack.

Physical examination:• General appearance

• Vital signs (fever may point towards parotitis)

• Look:• I can appreciate a lump on the right side, it is present in the preauricular area at the level of the angle of the jaw. Roughly its

around 2-3 cm in size. Shape- spherical. Overlying skin appears to be normal. And I cannot appreciate any punctum.

• Palpation:• Temperature comparing the surrounding• Tenderness- feel and ask• Swelling→ (3x3, irregular, firm, non-tender, rounded/bosselated, well-circumscribed, no punctum, redness, discharge or scar

marks) “She Cuts The Fish PERfectly”:• Site, Size, Shape (round, regular, irregular), Surroundings, Surface• Contour (well defined, irregular), Consistency (soft, firm, hard), Colour, Compressibility• Tenderness, Temperature, Transillumination• Fluctuation (fluid filled cyst), Fixity (mobile against underlying structures or against the skin)• Pulsation• Expansile• Reducible

• Lymph nodes (submandibular, sub-mental, anterior and posterior auricular, occipital, anterior and deep cervical LN).

• Facial nerve testing: asymmetry, close eyes and don’t allow to open them, smile.

• Do check oral cavity using torch (dental problem or ulcers of mouth and tongue).

Differential Diagnosis:• Benign Parotid tumour: pleomorphic adenoma, Warthin’s tumor

• Malignant Parotid tumour: carcinoma

• Metastasis from primary growth

• Parotid abscess, Chronic parotitis

• Dental abscess

• Lipoma

• Pre-auricular adenoma

• Skin (moved when the skin is moved)- Sebaceous cyst, Epidermoid cyst,

• Subcutaneous (skin moved over the lump)- Neurofibroma, Lipoma.

• Muscle or tendon (limited lump mobility) - Nerve- pressing on the lump causing pain.

Diagnosis and Management:• Mark, from history and examination, I am not suspecting anything

serious till now. I am thinking about an overgrown salivary gland near your jaw i.e. parotid gland and the condition I am suspecting is pleomorphic adenoma of the parotid gland. Let me assure that it is a benign swelling and to further confirm it, I will refer you to the surgeon.

• He will do a CT scan or MRI to see the overall dimension and tissue invasion and FNAC to determine whether the tumor is benign or malignant.

CASE 5-

• You are a GP, about to see a 56 year old male who had sudden painless loss of vision for few min yesterday while watching TV. Now this morning he has come to see you. He is all good now. He is diagnosed pt. of DM and HTN and has been taking medication for the same for a long time for this. You are required to-

• 1. Perform relevant PE with instrument provided inside.

• 2. Tell the possible causes to pt.

DDx-

• Mostly, Amaurosis fugax as transient vision loss.

• Could also be HTN neuropathy

• DM neuropathy.

• Optic neuritis.

• Temporal arteritis.

• CRVO

• CRAO

• Glaucoma

Eye examination

• GA• Vitals • Focused eye examination

• Look• Obvious deformity• Cord like structure at temporal region• Eye lids- ectropion or entropion, ptosis • Eye- swelling, injection, redness and any

discharge• Pupil- size and shape (compare both

sides)• Corneal scratch mark, abrasion, ulcer

• CNs 2 → visual acuity followed by pinhole test, visual field and colour vision

• 3,4,6→ PALE→ Pupil size, accommodation, Eye movements and light reflex

• Fundoscopy (at the last of eye)• Palpation

• Eye pressure- with finger plump

• Check for carotid bruit.• Check for temporal tenderness.• Do CVS examination (Check only for

heart sounds to rule out murmurs)• Complete PE by doing full neuro

examination.

EAR case- pain and hearing loss

• 3 cases – Wax, AOM and cholesteatoma• 2 min Hx• PE• Dx/DD

• Pain• WIPE• Pain killers• Inspection

• Asymmetry of the ear• Affected ear- discharge, bleeding, abnormality of ext ear

• Mastoid engorgement

• Palpation• Temp• Tenderness → tragus, helix, anterior helix and lobar

• Ext ear

• Mastoid

• Motion tenderness

• Otoscopy• Wax- yellowish ball• Cholesteatoma → whitish discharge

• AOM• Red bulging TM

• Perforation no discharge

• Keypoints• AOM → look for cervical LNs• Cholesteatoma→ 7th nerve palsy

• Hearing test• Whisper test

• 2 distances- close and one hand

• Rinnes (512)• Ring the tuning fork like holding

• Good explanation about the test

• When you start hearing it- let me know

• When you stop hearing it let me know

• Then I will move it in front of your ear and if you hear it, let me know

• Webers (512)• SNHL → to opposite

• CHL → to affected ear

Ear pain DD

• AOM

• COM

• Otitis externa

• Otosclerosis

• Wax

• Cholesteatoma

• Meiners disease

• Acoustic neuroma

Ear Hx taking

• Open ended

• Pain Qs

• Painkillers

• Since? First time? On and off?

• SIQORAA

• do you hear better in crowded & noisy environment?→ conductive questions

• Fever? Discharge (CCVO), Lumps and bumps? → conductive questions

• Swimming? Smoking in house?

• Buzzing or ringing sound? (tinnitus)

• LOW, LOA, lumps and Bumps- Acoustic neuroma

• Medication- gentamicin

Urinary retention → PR examination

• Your next patient in GP practice is a 76 year old man who had one episode of urinary retention 3 days ago. His retention was resolved with catheterization. He has come to see you for further assessment.

• Task• Perform abdominal examination on him.

• Perform DRE on a mannequin.

• Explain your examinations findings to the examiner.

PR examination

• Consent and chaperon

• Patient is in lateral position

• Inspection• Any skin tags• Bleeding• Discharge• Masses• Fissures• Sinus

• DRE- putting on gloves, lignocaine and lubricant.• Palpating the posterior and lateral walls of rectum• 360 degree palpation• Anterior → prostate

• Size, consistency, nodularity, median sulcus

• Squeeze my finger- Anal tone

• Check finger for blood

• WIPES to clear the area

BPH CA prostate

Increased sizeNormal consistencyNo nodularityNormal sulcus

Increased sizeHardNodularity +Obliterated

Cases- Scrotal Lump

• 50 year old male presents with scrotal lump

• Task• PE

• Ix

• DDx

• 25 year old male presents with pain in scrotum (new)

• Task• PE

• DD-• Hydrocele • Inguinoscrotal hernia• Varicocele• Epididymal cyst• Spermatocele• Hematocele• Chymocele• Epididymoorchitis• Testicular CA• Insect bite

• Ix• USG• Tumour markers- AFP, Beta HCG, LDH• STD screen- 1st catch urine and PCR• Urine MCS

Scrotum Examination

Offer chaperon and with consent

• Ask the patient to stand alongside the mannequin

• Inspection (standing)• Comment on the inguinal swellings

• To r/o cancer, inguinoscrotal swelling• Is it inguinal or testicular

• Any obvious testicular swelling• Don’t comment on the symmetry• Any discharge (pus) from testis (sebaceous cyst)• Any erythema• Colour changes• Cough test

• Penile changes• Any ulcer or discharge

• Palpation- wear gloves (lying)• Feel for inguinal area → for inguinal mass

• Start with Normal testis first → comment on testicular structures

• Stabilise one testis and follow along the cord• Temp• Palpate the mass

• Size, borders, consistency (cystic, rubbery, hard)

• Can I differentiate it from the testis?• Can I get above the mass Testis examinationNew case (epididymal orchitis) – palpate the swelling patient will say its painful, then when you palpate you will feel thickened epididymis

• Special Test:• Mass- transillumination• Cremasteric Reflex• check Inguinal LNs• If patient has pain- Prehn’s sign → elevate the

scrotum and ask if the pain is better

Assessment of comatose patient

• Unconscious patient primary survey donetasks-assess glasco coma scale (chart given)-do other relevant examination-tell the most likely diagnosis and four

differential diagnosis to the examiner

Unconscious Pt PE:

Investigations• Bedside

• ECG

• VBG

• FAST

• BSL

• Bloods:• FBC, UEC, LFT, RFT, TFT, CRP, ESR

• Invasive• CT scan

• LP

DDx:

• Differential diagnosis are1-meningitis2-encephalitis3-subarachnoid hemorrhage4-hypoglycemia5-electrolye disturbance6-drug/ alcohol7-trauma8-CVA9-Epilepsy

Respiratory examination peak flow meter

• You are in GP; your next patient is 45-year-old man. He has shortness of breath after recent viral URTI.Tasks - Perform respiratory system examination (3 or 4 minutes)- Teach patient how to do peak flow meter.- Explain what u are testing to pt.

Respiratory examination• WIPE

• General appearance-dyspnea and cyanosis-respiratory distress (signs of COPD)*accessory muscle use*intercostal or subcostal recession*pursed lip breathing

• Hands-Nicotine staining-Cyanosis-clubbing-Muscle wasting-flapping tremor

• Arm-pulse-Blood pressure

• Face-eyes (pallor, horner signs (ptosis, miosis and anhidrosis))-Mouth (central cyanosis, red/ enlarged tonsils) With tongue depressor- No tonsillitis and no exudates, No pharyngitis, Palatal petechiae, Uvula central, not swollen or dry oral mucosa-signs of allergic rhinitis (nasal crease)

• Neck-JVP-Trachea position

• Posterior Chest• Inspection

-chest shape, deformity-scars-chest wall movement if unilateral decrease: collapse, fibrosis, effusion, pneumoniaif bilateral decrease: COPD, severe asthma

• Palpation-chest expansion (should be >=5 cm)-cervical LN

• Percussion (fold the arm and elevate the elbow)-dullness-hyper resonance

• Auscultation-breathing sounds-added sound-vocal resonance

• Anterior chestinspection (the same)palpation (expansion + supraclavicular LN)percussion (over clavicle, upper chest, axilla and laterally (middle lobe)auscultation (upper chest, axilla and laterally)

• Ideally I would like to complete my examination by doing anterior chest, CVS examinations

Summary

• Now summary of what one would do in these short 3-4 minutesRespiratory examination (12 steps) focus on chest only• inspection (front and back then comment together about: Normal shape, No

deformity, No scars or prominent veins and no RDS signs, normal chest movements)• palpate the trachea (central position; not deviated).• palpate chest expansion from the back • percussion from the back.• auscultate breathing and added sounds from back including upper lobe and laterally• auscultate vocal resonance from back (99)• chest expansion from front• vocal fremitus from front• percussion from front.• auscultate breathing and added sounds from front.• auscultate vocal resonance from front.

Explaining Peak flow meter

1. Now I would like to take some peak flow measurement this would involve breathing out through this peak flow meter (show him)this is used to measure how well the air can flow out of the lungs.

2. in term of setting the equipment first ensure that this mouthpiece is inserted in the peak flow meter.

3. Ensure the dial is set to zero

4. please make sure to sit up nice and straight

5. take a nice deep breath in as far as you can

6. ensure that your lips are sealed lightly around the mouthpiece

7. then breath out as fast and hard as you can.

8. then I will take the best of three measurements

9. Is that all clear to you?Now if you could do it t see how is your breathing?

• Explanation Told him we will do this test three times and take the best of 3 as the reading then examiner gave me the normal reading for the patient. assume this is best of 3.

• This is basically to test how much u can blow out and to check patency of ur smaller airways. The results showed normal, which means u have no problem with breathing out. And I also examined ur chest which is also perfect

• The examiner gave me 700 as the normal reading for the patient and when I performed the test on the patient the reading was 800. So I told patient that the normal value according to your weight and age should be around 700 and yours is 800 so it’s really good

Pancoast

• Smoker, 45 year old had a LN in his neck , Bx: SCC, complaining of tingling and numbness in Rt hand• Task

• Perform N/E of upper limb

• Perform relevant P/E

• Dx/DDx

• DDx for Met SCC• Skin cancer

• Oropharngeal tonsil, pharyngeal, laryngeal, esophageal

• Lung cancer

• WIPE• Inspection

• Wasting • Fasciculations

• Tone• Power (check dermatome wise)• Reflexes

• Biceps and triceps

• Sensory• Coordination- finger to nose• Findings:

• C8, T1• Grasp• Cannot spread F• Loss of sensation on median side of hand

• Relevant PE:• Quick check skin for suspicious lesion

(head and neck)• Throat examination- looking for mass

or swelling• Respiratory:

• Inspection• Palpation- AE• Percussion• Auscultation and vocal fremitus• Findings

• Decrease AE, decrease breathing, Dullness, decrease vocal resonance over Rt lower lobe

• secondary pleural effusion

• Horner's syndrome• Photo• Ptosis and myosis