OSCEs Ankle clonus by nikeborome

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									                           OSCEs

Examinations

       Lymph nodes (axillary, cervical, inguinal)
       Skin
       Breast
       Neck
       Thyroid
       Lump/mass (any site)
       CVS
       Peripheral vascular system
       Varicose veins
       Normal heart sounds and murmurs
       Respiratory system
       Normal and added breath sounds – rubs, wheezes
        and crackles
       Alimentary and abdominal system (inc. tests for
        ascites)
       Male external genitalia
       Acute abdomen
       Digital rectal examination
       Mini mental state examination
       Cortical function (speech, language, perception)
       GALS screen
       Cranial nerves
       Peripheral nervous system (inc. UMN, LMN,
        cerebellar and extrapyramidal sings)
       Principles of bone and joint examination
       Joints of the upper limb (shoulder/elbow/wrists/hands)
       Joints of the lower limb (hip/knee/ankles/feet)
       Examination of the spine
       Hernias (inguinal/femoral/umbilical)
       Vision (inc. fundoscopy)
       Hearing (inc. otoscopy)




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Practical procedures

       Insertion of iv cannulae and choosing iv fluids
       Perform venepuncture
       Insert urinary catheter (male and female)
       Suture skin (and principles of LAs)
       Scrubbing and aseptic technique
       Performing subcutaneous injection
       Performing intradermal injection
       Performing intramuscular injection
       Recording temperature
       Measure peak respiratory flow rate (PEFR)
       Administer/demonstrate use of a metered-dose
        inhaler
       Spirometry
       Checking bedside blood sugar measurement and
        perform a glucose tolerance test
       Perform an ECG (3 and 12 lead)
       Measuring blood pressure
       Basic life support (using Resussi-Annie)
       Record baseline measurements – pulse, respiratory
        rate, pulse oximetry
       Insert an NG tube
       (Blood transfusion)
       (Pleural aspiration)
       (ABG sampling)
       (Performing intravenous injection)

Explaining things


Endoscopy       bronchoscopy
                upper GI endoscopy (OGD)
                colonoscopy
                sigmoidoscopy
                (ERCP)




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Radiographic imaging    chest x-ray
                        contrast enema
                        contrast meal
                        IVP

Ultrasound examination imaging of abdomen and pelvis
                       echocardiography
                       use of Doppler to measure blood flow

CT scan

MRI scan

Isotope scan            bone
                        lung
                        thyroid

Other

            Using Glasgow coma scale
            Interpret 12-lead ECG results
            Identify common abnormalities on chest X-ray
            Identify common abnormalities on abdominal X-
             rays – need to print off sBMJ articles as appear
            Writing a prescription/drug chart



                  1. Insertion of an iv cannula


Equipment:

        Intravenous cannula. Sizes:

        Blue 22G        V small
        Pink 20 G       Small
        Green18G        Average



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        Grey 16G         Large
        Brown14G         V large

        Gloves
        Steri wipe and gauze
        Tourniquet
        Saline flush or IV fluid with giving set
        Securing dressing (tegaderm)
        5-10ml syringe and saline flush
        Sharps bin

1. Accumulate your equipment, introduce yourself to the
patient and explain what you are about to do – obtain
consent.

2. Apply a tourniquet to upper arm (preferably of non-
dominant hand) and ask patient to open and close their hand.

3. Select a vein which is palpable and straight - if the cannula
is for long-term use it is best situated away from joints e.g.
lower forearm cephalic vein. Visualise how the cannula will go
along the vein.

5. Put gloves on - swab entry site and wait for alcohol to dry.

4. Take the cannula: remove the sheath, open the wings and
take off the white cap without touching the needle – tell patient
                                                         o
it will scratch. Introduce the needle into the vein at 30 to the
skin, bevel upwards. Once the needle is in the vein there will
be a visible flashback in the barrel of the needle

5. Slide the cannula into the vein over the needle while
removing the needle.

6. Remove the tourniquet before fully removing the needle.
Put white cap on the end of the cannula – you can press on
the vein to stop blood coming out.

7. Dispose of sharp.



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8. Wipe off any blood with gauze and apply tegaderm.

9. Flush the cannula with saline.

10. Attach the giving set of the intravenous fluid to the
cannula, which would previously have been run through to
eliminate any air bubbles – adjust the drip to run slowly (rolling
downwards = slower).

11. Set infusion rate, note time infusion started.


Questions around the topic:

Where is the best site to place venous cannulae?
You would usually use a forearm veins – dorsum of hand
ones are inconvenient for patients, you should stay away from
joints, and foot veins can easily thrombose. You should also
try to site the cannula in the patient‟s non-dominant hand.
However, if the patient‟s arms were needed for, say, dialysis,
this would also have to be taken into account.

In an emergency which cannula would you use and where?
A large-bore (brown) cannula into the antecubital fossa.


                      Choosing an iv fluid


1. Before prescribing, assess the patient‟s blood volume and
general clinical condition (lying and standing pulse and blood
pressure, hydration of the tongue and axilla, and JVP lying at
   o
45 and flat).

2. Check the renal function and electrolytes.

3. If the patient has lost blood, transfuse.




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4. In hypovolaemic shock – give colloid.

5. In metabolic acidosis – consider giving bicarbonate, but
discuss with senior colleague.

6. Serum sodium very high or very low – consider giving
hypo/hyper tonic saline, but not without senior supervision.

7. If none of the above, give an isotonic solution (5% dextrose,
0.9% saline, or dextrose saline).

8. If the patient is volume depleted, give saline. If euvolaemic,
alternate dextrose and saline, or give dextrose saline.

9. Tailor the rate of fluid administration to the patient‟s
measured or expected urinary loss, allowing an extra volume
of about 0.5L per 24h for “insensible” loss, and adjust this rate
upwards or downwards to correct any abnormality of plasma
potassium.

10. Give added potassium (eg. 20mmol/l), adjusted upwards
or downwards to correct any abnormality of plasma
potassium.

11. Watch the patient‟s JVP, BP, arterial pulse, urine output,
and U&Es to monitor effects of therapy.


      2. Taking blood from a patient (venepuncture)

Equipment

    Gloves
    Blood taking device (vacutainers/syringe/butterfly/needle)
    Tourniquet
    Alcohol swab
    Cotton wool ball
    Elastoplast
    Blood forms



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1. Write out the blood forms for the tests required.

2. Accumulate your equipment; vacutainers used in OSCE.

3. Introduce yourself to the patient and explain what you are
going to do and why.

4. Attach the tourniquet to the upper arm of the patient
(preferably non-dominant arm) and ask them to open and
close their hand.

5. Select a vein; usually the antecubital fossa is the best. Also
make sure you are not taking blood from an arm that has an
IV drip running into it.

6. Swab the selected vein with the alcohol swab – wait for it to
dry.

7. Put your gloves on. Warn the patient you are about to start
– hold the skin taut and insert the needle at 30 degrees to the
skin. Insert the bottles into the vacutainers barrel; if you are in
the vein they will fill with blood. If not you will need to adjust
your needle. Fill all the bottles required.

8. Remove tourniquet.

9. Place cotton wool ball over needle and withdraw it from the
skin then the patient should apply pressure for 5 mins.

10. Dispose of sharps.

11. Label bottles with name, hospital number, date of birth
and date of sample - place them with you pre-prepared forms
in a bag to go to the lab.

12. Apply a small plaster to patients arm.




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The chart below shows the colour coding of different bottles
and their usage (need to know).

Tube     Additive      Mode of action         Uses
                                 2+
Purple   EDTA          Forms Ca salts to      Haematology
                       remove Ca2+. Gently
                                              (FBC), blood bank
                       invert bottle after
                       filling to prevent     (cross match).
                       clotting.
           +           Forms Ca2+ salts to
Blue     Na citrate                           Coagulation    tests
                       remove Ca2+. Full
                       bottle needed.
                                              (INR).
Green    Plasma        Anticoagulates with    Chemistries.
                       lithium and heparin
         separating    –            plasma
         tube with     a is separated with
         lithium and   PST gel at bottom
         heparin       of tube.
Yellow   None          Serum      separator   Chemistries,
                       tube (SST) contains
                       gel at bottom to
                                              immunology      and
                       separate blood from    serology.
                       serum             on
                       centrifugion.
Red      None          Blood clots and        Chemistries,
                       serum is separated
                       by centrifugion.
                                              immunology,
                                              serology and some
                                              blood bank
                                              profiles.
           +           Antiglycolytic agent
Grey     Na fluoride                          Glucose levels.
               +       preserves glucose
         and K         for up to 5 days
         oxalate
           +           Forms Ca2+ salts to
Black    Na citrate                           ESR
                       remove Ca2+.


Questions around the topic:

What colour tube would you use for X/what additives does X
colour tube have in it?
See above.

Should you clean the patient’s arm before taking blood?



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There isn‟t really evidence that you need o swab an arm that
is “socially clean” before venepuncture, but most people do it
out of habit.

What is the best way to dispose of sharps from
venepuncture?
Do not re-sheath the needle – place it straight in the sharps
bin after asking the patient to press on cotton where you have
just taken the blood.

What ways other than vacutainers are there to take blood?
There are also butterflies and syringes, but syringes put you
at risk of needle stick injury when filling vacutainers. You can
also obtain blood straight out of a venflon using a syringe.

*see also iv cannulation for tips on which veins not to use.

              3. Insertion of a urinary catheter


*MALE* (urethra=20cm)

Equipment

        Catheter size 14 or 16
        Catheter bag
        Catheterisation pack
        Sterile saline 10ml in syringe
        Lignocaine gel 10ml in syringe
        Water to inflate catheter balloon
        Sterile gloves

1. Confirm the diagnosis and explain to the patient what you
are about to do and why. At all times ensure that the patient
knows what is happening. The patient needs to get into a
supine position with their legs slightly apart.

2. Choose an appropriately sized Foley catheter and check
the capacity of its balloon.



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3. Gather all the materials you will need – sterile pack,
catheter, sterile cleansing lotion, sterile gloves, local
anaesthetic gel with introducer nozzle (e.g. Instillagel), leg
bag, syringe for inflating the balloon.

4. Open the pack onto a trolley. Then open all the other items
onto the sterile field, being careful to avoid contaminating it.

5. Roll up your sleeves (if necessary), wash your hands
carefully and put on sterile gloves.

6. Prepare a sterile paper drape by cutting a hole with
scissors.

7. Grasp the penis gently but firmly with a swab held in your
non-dominant hand. Clean the penis with a single pass of
each lotion-soaked swab, moving from meatus towards the
perineum.

8. Pass the drape over the penis, thereby providing a sterile
field.

9. Gently insert the nozzle of the anaesthetic gel into the
meatus and firmly squeeze the tube. Warn the patient that it
may sting. Gently press the penile urethra to stop the gel
oozing out. Wait several minutes for the anaesthetic to take
effect.

10. Open the catheter‟s inner covering, but ensure that the tip
does not become unsterile. Insert it gently into the meatus and
feed it steadily in (if it gets stuck can try pulling penis down
gently, which straightens the urethra). Position a receiver
under the free end of the catheter. When and only when urine
flows out, it is safe to inflate the balloon with the specified
amount of fluid – pull on it gently to check that the balloon is
inflated.




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11. Attach the catheter to the leg bag, ensuring that the bag‟s
emptying port (if present) is in the „off‟ position. Failure to do
this will lead to urine-soaked clothes.

12. Remove the drape.

13. Ensure that the foreskin (if present) is pulled down over
the glans. Failure to do this may result in a painful
paraphimosis.

14. Clear away all debris. Ensure your patient is comfortable
and that you have written up the necessary instructions for the
ward staff. Note down the volume of urine in the bag (residual
volume).

Some anatomy of the male urethra:
The external orifice at the glans of the penis is the narrowest
part of the male urethra. Within the glans the urethra dilates to
form the fossa terminalis. Near the posterior end of the fossa
a fold of mucous membrane projects into the lumen from the
roof – the membranous part of the urethra is fixed. The
prostatic part of the urethra is the widest and most dilatable
                                     o
part. By holding the penis at 90 to the body, the S-shaped
curve is converted to a J shape. On reaching the membrane
part of the urethra, a slight resistance is felt due to the urethral
sphincter and surrounding rigid perineal membrane – at this
point if you lower the penis towards the thighs the catheter will
pass through more easily.

*FEMALE* (urethra=3.8cm)

Steps 1-6 are as for male catheterisation (see above)

Remember it may be difficult to identify the external urethral
orifice in the female, especially if the tissues are swollen. It is
surprisingly easy to pass a catheter into the vagina instead of
the urethra. Only by seeing urine flow through the catheter
can you be sure that you have performed the procedure
correctly.



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7. Swab the perineum, holding each lotion-soaked swab in
your non-dominant hand and swabbing from urethra towards
anus.

8. Cover the perineum with a fenestrated drape.

9. Identify the external urethral orifice and insert local
anaesthetic gel – warn the patient that it may sting. Wait for
this to take effect.

10. Insert the catheter as in Stage 10 above, but remembering
that the female urethra is much shorter than its male
counterpart.

Steps 11 - 13 are as for male catheterisation (see above).


Questions around the topic:

 What are the indications for catheterisation?
Urinary retention
Urinary incontinence
When the patient is temporarily incapacitated: surgery, severe
illness, trauma, ITU
To monitor urine output: e.g. in the case of acute renal failure
To give intra-vesical chemotherapy
Investigation e.g. micturating cystourethrography

What are the contraindications for catheterisation?
Suspected urethral injury – e.g. perineal bruising, blood at the
meatus
History of urethral stricture or false passages

What are the possible complications of catheterisation?
Pain
Infection
Irritation and possibly stricture if a rubber (not silicone)
catheter is left in place more than 3 weeks



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Why might no urine come out of the catheter?
Catheter tipped blocked with jelly? Flush with saline
Tip may be misplaced
May be no urine in bladder (e.g. patient is in acute renal
failure and suprapubic tenderness misattributed to bladder
distension?)

                          6. Suturing

NB. In the OSCEs you will be asked to do a simple interrupted
suture. You will not be asked to show how to do the LA bit, but
I‟ve included it here because I think you‟re expected to
mention skin prep/LA before you start.

Equipment:

        Suturing kit
        Sterile gloves
        Needle holders
        Toothed forceps
        Scissors
        (Sterile pack)
        (Sterile gloves)
        (5ml syringe, 21G needle and 25G needle)
        (Local anaesthetic)

1. Introduce yourself to the patient, check details and explain
what you are going to do.

2. Open sterile pack and put inner pack on trolley. Wash
hands and then open the inner pack. Ask assistant to open
gloves onto sterile field. Dry hands on sterile towel and put on
gloves.

3. Ask assistant to pour antiseptic solution into the receiver.

4. Request a 5ml syringe, 21G needle to draw up anaesthetic,
and a 25G needle to infiltrate.



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5. Request a suture – eg. A 4/0 synthetic, non-absorbable
monofilament with a curved needle.

6. Ask assistant to open the vial of anaesthetic – eg.
Lignocaine with 1/200 000 adrenaline (to minimise bleeding).
Atttach the 21G needle to the syringe and draw up 5ml of
anaesthetic. Detach the needle without resheathing, discard it
and attach a 25G needle.

7. Clean the skin with antiseptic-soaked cotton wool, held with
forceps.

8. Infiltrate the skin with local anaesthetic, remembering to
draw back on the syringe before injecting. Warn the patient
that it will sting.

9. Give the anaesthetic 5-10 minutes to work – test the skin
with a sharp needle before you start to ensure that the LA has
worked.

**This is the point where the OSCE will begin, so you need o
say, “Before I started suturing I would already have prepared
the skin, set up a sterile field and infiltrated with local
anesthetic. I would have left 5-10 minutes for the LA to work
and checked that the patient could not feel pain with a
needle”.**

10. Select and open a suitable suture, eg. a 4/0 synthetic,
non-absorbable monofilament with a curved needle.

11. Grasp the needle with the tip of the needle holder, two
thirds of the way from the needle‟s point to where the suture is
joined on. With simple interrupted sutures, you want to go in a
halves-quarters-eights pattern.

12. Steadying the skin on one side of the wound edge with
dissecting forceps, take a bite through the full thickness of the
other side of wound edge with the needle – you want to put



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the needle in 1-2mm away from the edge. The needle should
follow the line of its curvature as it passes through the tissue.

13. Grasp the needle as it comes out half way through the
wound and pull it through in a curved way. Remount needle in
the needle holder before taking a corresponding bite on the
other side of the wound – you should aim to come out the
same distance from the wound edge as you went in.

14. Pull the needle through with forceps - do not touch the
needle with your fingers or you may cause a needlestick
injury. Hold it with toothed forceps while repositioning it in the
needle holder.

15. Pull the suture through until only a short free end
protrudes.

16. Tie a reef knot, ensuring that the knot is not too tight. This
goes in a two one way, one the other, then one in the original
direction manner – you must make sure that you are crossing
the straight edge and the loops across each other in a
different direction each time. (see the surgical skills site for
video). The knot should end up slightly to one side of the
wound.

17. Cut both ends of the suture, but not so short that they will
be difficult to identify during removal.

18. Sutures should be 5-10mm apart.

19. Mention that you would also need to consider is the
patient required a tetanus injection and that you would
dispose of sharps after finishing.

Questions around the topic:


How soon can you start suturing after the anaesthetic?



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It can take 5-10 minutes for the LA to work, but you need to
check that the patient cannot feel a sharp needle applied to
the skin before starting.

When should the sutures be removed?
After about 7 days, though scalp wounds heal faster.

What are the possible side effects of the anaesthetic?
    Adrenaline can cause ischaemic tissue necrosis – you
       must never use it on extremities such as the fingers,
       ear lobe or nose. It‟s fine for the trunk or limb.
    A massive dose of iv lignocaine inadvertently given
       intravenously     can     cause       convulsions, CNS
       depression, heart block or acute heart failure. Tthis is
       why you must draw back on the needle before
       injecting to check you aren‟t in a vein.
    Anaphylaxis is a possible problem.

Under what circumstances should a tetanus immunisation be
given?
     If a patient has not received a “booster” dose in the
       last 10 years
     If the wound is contaminated

What anaesthetic must not be used on fingers?
Adrenaline.

             Local anaesthetics (a la Andrew)


*** Patient management ***

BEFORE THE PROCEDURE

Must take a thorough history, checking for contraindications to
LA.

Absolute - known hypersensitivity to LA agents.



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Relative - eg extreme anxiety, needle phobia, porphyria (if
using prilocaine).

Treat the whole patient, not just their lesion. Explain the
proposed action and obtain consent.

DURING THE PROCEDURE

Remember to treat the whole patient. Explain what you are
doing and talk to the patient. Avoid using words like "pain" or
"hurt". Emphasise that you will take time for the LA to work
before starting the procedure.

Establish a rapport. Remain aware of how the patient is
reacting. This will help to identify problems.

Every patient must feel as though you are in full control of the
situation. Perform with confidence. Be slick.


AFTER THE PROCEDURE

Warn patients about post-operative pain when the LA wears
off, how to deal with it.

Give advice about driving after the procedure, and whether
someone should be with them for the first 24 hours. Provide
written information about what to expect, and what to do if
problems arise.

SUMMARY

Be aware of your patient as a whole person. Explain what you
are going to doing in terms that suit each patient's
understanding.

Be familiar with the signs of anaesthetic toxicity and remain
alert to notice and treat it at an early stage.




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Must be able to manage sudden collapse. Ensure fully trained
in resuscitation, suitable well-maintained equipment on hand.

Be aware of Golden Rules - anaesthetic toxicity, the use of
adrenaline, and giving ring blocks.

*** Keeping records ***


It is vital to keep careful records of the admin of LA.

Drugs - drug name, with or without adrenaline, concentration,
amount, expiry date, batch no.
Personnel - who administered the drugs. Who checked the
choice and amount of drug. Who was present.

*** Safe practice ***

IMPORTANT PROBLEMS

Anaphylaxis to LA is rare, but you must be able to treat this
immediately if this occurs. You should be aware of the current
national guidelines on the emergency treatment of
anaphylaxis.

Patients may collapse unexpectedly for reasons unrelated to
the surgery or anaesthesia, eg faints, MIs, epilepsy. The
commonest cause is a simple faint (vasovagal attack). It is
important to diagnose and treat this promptly so as to avoid
overly aggressive resuscitation.

RESUSCITATION

Be prepared if the shit hits the fan (all staff competent in basic
life support, the responsible doctor may need Advanced Life
Support).

SUMMARY




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Major problems caused by LA are rare, but it is vital to plan
what to do if they occur.
You must be vigilant for the signs and symptoms of toxicity.
You and your staff should be up-to-date with your national
guidelines for resuscitation.

*** Golden rules ***

END ARTERIES - Never use LA containing adrenaline when
anaesthetising any part of the body supplied by an end artery
eg fingers, toes, ears, nose or penis (especially not the penis).

TOXICITY - be aware of the signs of systemic toxicity and act
quickly if they occur.

INFECTION - never inject LA through infected skin.

WAIT - always wait long enough for the LA to work before
starting a procedure, especially if you've given a ring block.
Use a clock/watch.

VASCULAR SUPPLY - never give ring blocks to patients with
diabetes, or peripheral vascular disease.

*** Anaesthetic agents ***

SUMMARY

Lidocaine is the most-commonly used agent. It is suitable for
almost all cases of minor surgery. The dose limit depends on
many factors and each patient needs individual assessment.

Adrenaline makes procedures easier by reducing bleeding
(and prolonging life of LA??) but can sometimes be
dangerous. Never use adrenaline with end arteries as this can
cause irreversible ischaemia.

True hypersensitivity is very rare. So-called anaesthetic
reactions require careful elucidation.



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Be aware of the symptoms and signs of toxicity, and take
prompt action if they arise.

CHOICE OF AGENT

LAs may be amides or esters. Amides (eg lidocaine,
bupivacaine, prilocaine) are more stable in solution than the
esters and cause fewer hypersensitivity reactions. Esters
(such as amethocaine and benoxinate) are absorbed more
rapidly from mucous membranes.

Lidocaine - the most suitable agent. It has a rapid onset of
action and its effect lasts for 60-90 minutes. It is effective and
safe provided you understand its limitations.

Bupivacaine and prilocaine - these are longer-acting than
lidocaine. Bupivacaine toxicity is resistant to treatment.
Prilocaine can cause methaemoglobinaemia (--> central
cyanosis).

Others - other LAs exist. Don't use them.

LIDOCAINE PREPARATIONS

Lidocaine solution is available at 3 strengths (0.5%, 1% and
2%). Each strength is also available with adrenaline.

1% is adequate for most purposes.

Lidocaine solution is supplied in single dose vials and multi
dose bottles. Single-dose vials minimise the risk of
contamination.

DOSE LIMIT FOR LIDOCAINE

Dose in one session should not exceed:




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Lidocaine (without adrenaline) - 3mg/kg body weight (ie max
200mg for 70kg man).
Lidocaine (with adrenaline) 1:200,000 - 7mg/kg body weight
max 500mg for a 70kg man.

The maximum safe doses for lidocaine quoted can be
misleading, LA effects depend on a number of factors, ie size
of patient, vascularity of infiltration site, cardiac output, drug
distribution, and metabolism. Dose should be calculated per
patient.

In practice you will only need a few ml of LA for most minor
procedures. Beware of the cumulative effects of injecting
many small lesions in a single session, and never draw up
more than the total safe dose for that patient.


TOXICITY

Toxicity is caused by high circulating levels of drug. This may
be because of a high total dose or the particular distribution.

The use of a vasoconstrictor (adrenaline) delays systemic
restribution by reducing blood flow, effect lasts longer.

Most minor procedures require only small amounts. Moreover,
most minor procedures occur at sites far away from major
blood vessels so inadvertent intravascular injection of
significant quantities of LA or adrenaline is rare.

If you suspect toxicity, don't give any more, be ready with
supportive measures until drug effect subsided.

SYMPTOMS AND SIGNS OF TOXICITY

Be vigilant.

Early signs - CNS - restless, tingling of limbs or around mouth,
confusion



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Late signs - CNS - depression, convulsions, unconsciousness
                Cardioresp - respiratory depression,
arrhythmias, cardiorespiratory arrest.

Cardiac toxicity can be resistant to treatment, particularly
bupivacaine.


*** Adrenaline ***

Makes procedures easier by reducing bleeding (eg on scalp).
Reduces systemic absorption, can use larger volumes without
toxicity.
Blanching of skin shows extent of anaesthetised field.

Don't inject into end-artery territory.

Dose limit for adrenaline - total dose in one episode <500
micrograms.

*** Syringes ***

Use finest available diameter needle. Minimises discomfort.
Ensure LA at room temperature.

*** Needles ***

Needles are colour-coded according to their diameter. Green
(21 gauge, 0.8mm), Blue (23 gauge, 0.6mm), Orange (25
gauge, 0.5mm).

Use big bore needle (eg green) to draw up LA, small bore (eg
blue or smaller) to inject.

*** Infiltration anaesthesia ***

Slowly inject LA around lesion. Use a fan shaped infiltration
for small lesions.
For larger lesions you should use an encircling technique.



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Allow time for LA to work.

CHECKS

LA in date?
Contraindicated?
Calculate maximum dose. Draw up less than this.
Ensure LA nice and warm.
Check if the LA contains adrenaline.
Record that you are using a plain agent if adrenaline
contraindicated.
Get assistant to check. Record their name.

PROCEDURE

Mark the lesion, especially if it is deep or the patient has many
similar lesions.
Ensure that you infiltrate an area that includes and goes
beyond the lesion you will remove especially if you are
excising an ellipse.

A fan shaped infiltration is most suitable for a small lesion
(only make two injections, but with each one, wiggle the
needle around to squirt LA around lesion without withdrawing
it from the skin).
An encircling technique may be more suitable for a large
lesion (make six or so injections).

Ensure that you inject LA deep to the lesion as well as all
around it.
Inject slowly - rapid injection distends tissues, may cause
discomfort
Take time for LA to work


*** Ring block ***




23
A ring of LA is injected proximally at the base of a digit,
producing anaesthesia distally. Understand and visualise
anatomy of the digit and its nerves.

A ring block takes longer to work than LA. Anaesthetize
completely. Wait for it to work. Don't use adrenaline. Not with
patients with DM or peripheral vascular disease. Never inject
through infected skin (cause infection through tissue plains).

Don't use too much fluid. This may cause pressure ischaemia.
1-3ml is usually significant.

1) Raise a bleb over the dorsum of the digit, just distal to the
MTP or MCP, to anaesthetise the dorsal twigs of the digital
nerves.
2) Angle the needle towards the palm or sole and inject about
0.5ml of LA along one side of the digit. Withdraw the needle
partially, and inject a further small quantity just deep to the
skin, to get any superficial nerve twigs.
3) Withdraw completely and inject similarly on the other side
of the digit.

Avoid piercing the skin on the palmar/plantar aspect. Ensure
your finger is not under the digit and at risk of needlestick
injury, if you inadvertently pierce the skin.


                       7. Scrubbing up



See printed sheet for summarised guidelines.

Scrubbing

Prior to scrubbing you should have opened gown and on to
that opened your gloves. Open a disposable scrub brush. You
should also have your mask and hat on and have removed
watch/rings etc.



24
1. Turn on taps, until water is a comfortable temperature. Use
elbow control taps if possible. Don‟t have water pressure too
high, to avoid getting wet, as the water splashes off your
arms, while scrubbing.

2. Position hands upwards, higher than your elbows to
encourage excess water to fall form the elbow into the sink.
Wet hands and forearms, from fingertips to elbows.

3. Using your preferred „scrub solution‟ wash hands and
forearms thoroughly for 1 minute, using the sponge of your
disposable scrub brush. Pay special attention to areas around
the base of the thumb, between the fingers and the wrist
areas, as these are often neglected or missed. Rinse again
from fingertips to elbows.

4. Using your scrub brush, scrub each fingernail in turn on
both hands, with chosen scrub solution. The total time for this
is 1 minute. Rinse nails thoroughly.

5. Next, wash hands up to wrists only, with preferred solution.
Pay special attention to each finger, web spaces, and base of
thumb, palm and back of each hand.

6. Finally rinse thoroughly from fingertips to elbows being
especially careful not to get wet. A wet scrub suit will
subsequently contaminate a sterile gown.

7. Dry both hands, using the towels provided with the sterile
gown. Ensure hand and forearms are dried from fingertips to
elbows.

Gowning

1. Pick up the sterile gown with both hands. Identify yoke of
neck to ensure that the gown is the right way up.




25
2. Step away from the trolley, into an area that is safe to open
the gown without the risk of touching an object or wall and
thus contaminating the gown.

3. With the inside of the gown towards you, open it up by
allowing it to drop downwards gently.

4. Slide hands and arms into the „arm‟ holes of the gown, by
advancing the gown slowly up your arms. Don‟t be tempted to
put the gown onto your shoulders, as contamination of the
sleeves could occur.

5. Do not allow your hands to come beyond the cuffs of the
arms of the gown, if the gloves are going to be donned using
the closed technique. If using the open technique advance
your hands out of the sleeves.

6. An assistant will bring the gown onto your shoulders, by
touching the inside of the gown only. They will also secure the
ties at the back of the gown.

7. Ensure the section at the back of the gown is secured,
using the tapes at found at the side of the gown.

Donning gloves – Closed Method

1. With hands still inside sleeve of sterile gown, place thumb
across palm of hand, with palm facing upwards.

2. Pick up either glove and place it onto upturned palm.
Ensure that the thumb of the glove is placed on top of thumb
of hand and the fingers of the glove are facing up your own
arm towards your body.

3. Hold one side of glove cuff with sleeved hand and the other
side with the free hand.




26
4. Bring glove over top of fingers and push fingers up into the
glove. Using the free hand pull glove down onto your sleeved
hand.

5. Once the glove is fairly secure pull sleeve of gown
downwards towards your body, so your hand advances from
the sleeve of gown into the glove.

6. Position glove until it is comfortable, don‟t allow the cuff of
the gown to protrude from the glove, as this area is not
waterproof.

7. Repeat same procedure for other glove.

Open Method

1. Pick up either glove from packet, by touching only the
inside of the cuff of the glove, which should be folded back
upon itself.

2. Advance hand into glove with the aid of your other hand,
remembering to only touch the inside of the glove.

3. Using already gloved hand, pick up the other glove, by only
touching the outside of the glove, at the cuffed area.

4. Advance ungloved hands into glove and with the aid of the
other hand ensure that it is comfortable.

5. Be careful when turning cuff area down that accidental
contamination does not occur.

NB. In the OSCE you will only be expected do the gowning
and gloving part and will probably have to remain scrubbed as
the suturing section is usually straight after.

Questions around the topic:

How long should you scrub up for?



27
3-5 minutes.

What antiseptic agents can you use for scrubbing?
Betadine or chlorhexadine based.

On which parts should you use the scrubbing brush?
On the nails only.

Why should you not use the scrubbing brush everywhere?
You can expose normal commensals, which may be
pathogenic to the patient.


                      Aseptic Technique


Consists of maintenance of a sterile field throughout a
particular procedure.

In clinical procedures there are usually two sterile fields:
The work surface
The patient.

Sterile work surface achieved by:
Ensuring base of work surface is clean (usually a trolley)
Ensuring outer wrap of dressing pack and all required items
are intact and in date.
Ensuring inner part of dressing pack is wrapped in sterile
paper
Ensuring hands are clean and hand washing facilities/alcohol
rub is available

Note: Alcohol rub is a suitable alternative to hand washing if
hands are clean.
It may also be used immediately prior to gloving with sterile
gloves.

Procedure:
Peel apart and remove dressing pack from outer wrap



28
Open pack by handling from corners only. If possible undo
first two paper folds at both sides and then open third fold
away from you. The final fold will present the pack in the
centre of a sterile wrapping (sterile field).

NB Please note that only products that are sterile should be
placed on the sterile work surface.

Equipment must not be touched until hands have been
cleaned and sterile gloves applied.

Preparation of pack:
Add all other sterile goods to sterile work field.
Wash hands/use alcohol rub and apply sterile gloves using
open method of application
Request cleaning solution and any other solutions from
assistant e.g. sterile water/saline; prepare dressing towel;
prepare local anaesthetic for administration if necessary.

Note: If injecting local anaesthetic it may be preferable to
administer it before preparing dressing pack to allow time for it
to work.

Clean hand: dirty hand principle

This method is designed to reduce the possibility of
contamination of the work surface to ensure that the hand that
comes into closest contact with the patient never touches the
work field.

It is achieved by:
 Placing the trolley closest to clean hand (usually dominant
      hand)
 Passing items from clean hand to dirty hand without
      touching fingers/forceps. The clean hand/forceps is
      usually above the dirty hand/forceps when passing swabs
      etc to reduce the possibility of contamination.




29
Clean patient methodically in one direction and discard used
swab in clinical waste bag (yellow).
Use a new swab each time until area and surrounding skin is
thoroughly cleaned.

Choice of antiseptic cleansing agent:

The cleansing agent of choice must take into account
wound/operative site and patient allergies. The most common
solutions used are Iodine or Chlorhexadine based
preparations. Antiseptics with an aqueous base are suitable
for most procedures. Alcohol based solutions are generally
used in specific circumstances, most commonly orthopaedics
where there is little risk of the solution coming into contact
with delicate membranes.



         8. Administering a subcutaneous injection

Use: -           administers drugs just under skin for slow but
                 complete absorption. ie. heparin and insulin.

Equipment: -     2ml syringe
                 23fg needle (blue)
                 drawing up needle
                 alcohol swab
                 equipment tray
                 non-sterile gloves
                 prescribed drug

1. Collect and prepare necessary equipment. Endure sterile
packaging is intact before opening. Draw up prescribed
medication.

2. Check patient‟s details.

3. Introduce self and explain procedure.
4. Wash hand and don a clean non-sterile pair of gloves.



30
5. Uncover injection site (upper arm, upper leg or abdomen)

6. Clean skin with alcohol swab. Allow to dry.

7. Pinch and hold a fold of patients skin.

8. Insert needle in the base of the skin fold at an angle of 20-
30 degrees.

9. Release hold on fold of skin.

10. Aspirate syringe to ensure needle is not placed in blood
vessel.

11. Inject drug very slowly.

12. Withdraw needle quickly.

13. Wipe area with clean swab.

14. Ensure patient has suffered no reaction to administered
drug.

15. Dispose of sharps and remove glove and wash hands.

16. Record on appropriate documentation.


         9. Administering an intradermal injection

Use: - vaccinations, allergy testing

Equipment required: -    1ml syringe (calibrated in 1/100)
                         25fg – 27fg needle (orange)
                         Alcohol swab
                         Non-sterile gloves
                         Prescribed medication
                         Clean swab



31
1-4. As for subcutaneous injection.

5. Select appropriate injection site – ideally lightly pigmented,
thinly keratinised and light covering or no hair. (forearm, upper
arm, shoulder blade or upper chest)

6. Clean area with alcohol swab and allow to dry.

7. Pull and hold skin taut over injection site.

8. Position needle parallel to skin surface with bevel of needle
facing upper most.

9. Insert needle approx 3mm under epidermis. Avoid
penetrating the subcutaneous tissue. Do not aspirate once the
needle is in position.

10. With steady pressure inject medication slowly.

11. Once completed quickly withdraw needle.

12. Wipe area with a clean dry swab, but do not massage
area as this will disperse medication.

13. Remove gloves and wash hands.

14. Complete appropriate documentation.


       10. Administering an intramuscular injection

Use: - For the sustained release effect of drugs when placed
into the muscle i.e. analgesics

Equipment: -     5ml of 10ml syringe
                 21fg needle (green)
                 23fg needle (blue)
                 drawing up needle



32
                 injection tray
                 alcohol swab
                 clean swab
                 small elastoplasts adhesive dressing
                 non-sterile gloves
                 prescribed drug

1-4. As for subcutaneous injection.

5. Choose injection site and clean with alcohol swab. Allow to
dry.

6. Holding needle and syringe like a „dart‟ and at an angle of
90 degrees, quickly jab needle into skin approx 2-3 cm.

7. Once in position aspirate the syringe to ensure that the
needle has not been inserted into a blood vessel. If blood
appears withdraw and replace the needle with a new one to
begin the procedure again. If no blood appears continue with
the procedure.

8. Inject the prescribed drug slowly and firmly.

9. Withdraw the needle rapidly.

10. Apply pressure to area with a clean swab.

11. Dispose of sharps. Remove gloves and wash hands.

12. Document as appropriate.

          Administering an intravenous injection

Use:-   where a very rapid response is required
        where you have had difficulty siting a venous cannula
        certain specific drugs – eg. calcium gluconate.

Equipment:       drug
                 2x 21G needles



33
                 5ml syringe
                 tourniquet

1. Introduce yourself, explain what you are about to do and
obtain consent.

2. Check the vial of the drug you are giving for the name of
the drug and concentration – if necessary, check dose and
administration rate in the BNF.


3. Attach a green (21G) needle to a 5ml syringe.

4. You need to work out the correct volume to draw up to
make a suitable concentration. Eg. if you wanted to give 40g
of a drug and the concentration is 4mg/ml, you would draw up
a little more than 4ml of drug into the syringe.

5. Hold the syringe and needle vertically, with the needle tip
pointing upwards. Tap the syringe so that air bubbles rise to
the top.

6. Gently advance the plunger so that the syringe contains
exactly 4ml and the air has been expelled.

7. Discard the needle and attach a new (21G) needle.

8. Position and tighten a tourniquet and do a venepuncture.

9. Draw a little blood back into the syringe.

10. Once you are satisfied that the needle is well positioned in
the vein, loosen the tourniquet and gently advance the
plunger, making sure that you don‟t accidentally give a bolus if
you don‟t need to.




34
Questions around the topic
What other methods might you use to give a drug
intravenously?
*Infusion from a drip bag – for drugs that have to be given
slowly (eg. cytotoxics)
*Administration by a syringe pump – where steady plasma
concentration needed (eg. insulin/heparin)
*Administration through a central (opposed to venous
cannula) – for drugs that irritate veins (eg.
amiodarone/dopamine)

Give an example of an emergency drug that has to be given
by slow intravenous infusion.
Classic example is calcium gluconate for the acute
management of hypocalcaemia – 10ml of 10% solution over
10 minutes. Others include many anti-dysrhythmics, which
may cause asystole or VF in a bolus.

How quickly could you give an IV bolus of potassium chloride?
This is a trick question! Potassium must never be given as a
bolus as it can cause asystole!!




                11. Recording a temperature

There are four common ward based methods of measuring
temperature: oral, axillary, rectal and tympanic.

Normal Temperature readings:
               o
oral     36 –37 C
               o
axillary 36.4 C
               o
rectal 37.6 C




35
Before all of these do the usual checking name, introducing
self and explaining what you are going to do.

Oral

1. Use a glass mercury filled thermometer. Ensure that it is
clean. Place a plastic protective sheath over the thermometer
or if not available clean with an Isopropyl Alcohol 70% soaked
swab. If using a digital thermometer ensure that it is on.

2. Introduce self and explain what you are going to do.

3. Ensure that it has been at least 10 minutes since the
patient last drank any fluids or smoked a cigarette.

4. Shake the mercury in the glass thermometer down to below
35 degrees.

5. Place thermometer in mouth of patient sublingually, on one
side of midline frenulum.

6. Ensure lips are closed so the thermometer is held securely
in place.

7. Hold in place for 3-4 minutes.

8. Remove thermometer and hold horizontally, turning slowly
until a mercury strip is seen running down the side of the
thermometer.

9. Record the highest temperature reading the mercury has
reached.

10. Clean and replace the thermometer.

11. Document the result.

12. Wash hands.




36
Rectal

1. Ensure that you have a rectal thermometer. The ends are
more bulbous than an oral thermometer and the top is often
coloured blue. The recording scale starts at a lower figure
than the oral thermometer.

2. Wash hands and don a pair of clean non-sterile gloves.

3. Clean the thermometer and apply a protective plastic
sheath.

4. Position the patient on their sides and expose anus.

5. Lubricate and insert the thermometer into the anus no more
than an 2.5 cm (1 inch).

6. Hold in place for at least 4-5 minutes.

7. Remove thermometer.

8. Reposition patient and return bedclothes.

9. Holding the thermometer horizontally and read the mercury
strip on the side of the thermometer.

10. Clean thermometer. Remove gloves wash hands.
Record results on appropriate documentation.

Axillary

1. Clean thermometer and place under the arm of the patient
ensuring the thermometer touches the skin.

2. Close down arm and secure in place for 3-4 minutes.

3. Remove thermometer and holding horizontally read the
temperature recorded from the mercury strip, which can be
seen.



37
4. Clean thermometer.

5. Wash hands

6. Document temperature recorded.

Tympanic

1. Temperature recording digital machines can be used to
record temperature by placing a probe onto the ear canal.

2. Use according to manufactures instructions.

3. Ensure that the probe is clean before use, and clean it after
use.

     12. Measuring PEFR (Peak Expiratory Flow Rate)

Equipment: -    Hand held Peak Flow Meter
                Disposable cardboard mouthpiece

1. Collect together equipment and test.

2. Check patient‟s details to ensure you are dealing with the
correct person.

3. Introduce self and explain procedure.

4. Ensure the device reads zero or is at base level of the
recording meter.

5. Ideally patient should be standing for this procedure. Help
patient to stand if needed.

6. Attach mouthpiece to flow meter.




38
7. Ask patient to place device into mouth with lips enclosed
around end of mouthpiece, hand holding the meter
underneath so they don‟t restrict the movement of the pointer.

8. Patient should inhale deeply and then exhale quickly and
forcibly. (Remember - it is not the amount of breath that is
being measured but the speed in which it is exhaled). Say, “I
want you to take a deep breath and then blow out as hard and
as fast as you can, as though you‟re trying to get all the air out
of your lungs in one go”.

9. This should be repeated 3 times allowing the patient to
recover between each episode.

10. Record the highest reading of the 3.

11. If the patient is on a bronchodilator e.g. salbutamol, you
will need to perform the peak flow measurement after its
administration. This would then give you pre and post peak
flow measurements, which are documented on a peak flow
chart (see over page).


Questions around the topic

What factors affect the peak flow reading?
Gender, build (height), age and disease status.

What pattern might you see in peak flow I someone with
asthma?
There is diurnal variability in the PEFR of someone with
asthma – it is lower in the morning, highest in the middle of
the day and then really low in the evening.

What would you expect a normal PEFR to be?
This greatly depends on the factors above, but broadly
speaking 380-500L/min in women and 520-660L/min for men.




39
How could you use peak flow to distinguish between someone
with asthma and someone with COPD?
You could give a bronchodilator – in COPD there will be little
or no reversibility, but in asthma there will be a marked
improvement in PEFR.

           Teach inhaler technique (using MDIs)


Key points:
-explain how it works
-demonstrate
-ask patient to perform procedure
-give feedback and explain common problems
-ask patient to repeat procedure
-invite questions and check understanding of important points

1. Introduce yourself to patient, check diagnosis and explain
you are going to teach them how to use the inhaler.

2. Explain how the bronchodilator works: “It relaxes the air
passages in your lungs so it‟s easier for you to breathe”.

3. Explain that the bronchodilator solution needs to:
-“Reach as deep into your lungs as possible” and
-“Stay in your lungs long enough to be absorbed”.

4. Talk through the steps of the procedure:
*remove the mouthpiece cover
*shake the canister
*hold the inhaler vertically in your dominant hand with your
index finger over the top and the mouthpiece close to your
mouth.
*breathe right out
*put the mouthpiece in your mouth with your lips tightly round
it
*press firmly down on the body of the inhaler as you start to
breathe in



40
*take in a deep breath slowly so that the spray goes deeply
into your lungs
*hold breath for 10s
*breathe out

5. Silently go through the procedure yourself.

6. Ask the patient to perform the procedure.

7. Correct errors and get them to repeat it until they have
mastered it.

8. Explain common problems:
-difficulty in handling inhaler
-not triggering spray at right moment (usually too late)
-not breathing the spray right down into lungs
-not holding spray in lungs long enough for it to be absorbed

9. Ask patient if they have any questions, comments or
concerns.

10. Test understanding – eg. “What do you think are the most
important points in the explanation I have just given you?”

11. State that if you were teaching the patient to use an
inhaled steroid you would also advise them to wash their
mouth out after use.


Questions around the topic

Why is it so important to teach good inhaler technique?
Even with good technique only 15% of the contents are
inhaled – 85% are deposited on the wall of the pharynx and
swallowed.

What could you do if you were sure that someone wasn’t able
to use their inhalers correctly?



41
Think about giving them a spacer – this is a plastic conical
sphere put between the patient‟s mouth and the inhaler. They
reduce particle velocity so less drug is deposited in the mouth
and reduce the need for coordination between pressing
inhaler and breathing in. They are very useful in children and
the elderly.
Another option is automatically triggered MDIs which only
release the drug as the patient breathes in – however, these
are expensive.

Some of the drugs used in asthma:
Salbutamol - 2 adrenoceptor agonist – short-acting
bronchodilator
Salmeterol - 2 adrenoceptor agonist – long-acting
bronchodilator
Ipratropium bromide – muscarinic antagonist/anticholinergic –
bronchodilator (useful in COPD)
Sodium cromoglycate – anti-inflammatory
Beclomethasone/fluticasone – inhaled corticosteroid (can be
low or high dose)
Prednisolone/methotrexate – oral corticosteroid

What are some of the important points about each type of
drug?
     2 agonists and anti-cholinergics
           - these rapidly control symptoms and can be
              taken as required, within a specified dose
              range
           - the recommended dose shouldn‟t be
              exceeded – if they aren‟t controlling
              symptoms, the patient should contact a
              doctor

        Inhaled steroids
             - these only work if taken regularly and aren‟t
                 effective if taken only during acute attacks
             - they can cause oral thrush in high doses –
                 need to wash mouth out after using them




42
        Salmeterol and cromoglycate
            - they must be taken regularly, as with inhaled
                steroids

                           Spirometry

Spirometry measures the FEV1 and FVC of a patient, which
are dependent on height, age and sex. The instrument used is
basically a box with a tube coming out of it. The technique
involves a maximum inspiration followed by a forced
expiration (for as long as possible). Patients with airflow
limitation may have a very long forced expiratory time.

You need to say to the patient that this test is different to the
peak flow one – “You need to breathe in as mush air as you
can and then breathe out as fast as you can for as long as
you can, until there‟s no air left in your lungs”. Do a Sonia –
“Keep going, keep going, keep going…”.

The FEV1 expressed as a percentage of the FVC is an
excellent measurement of airflow limitation – it is around 75%
in normal subjects.

        In obstructive lung disease there is a decreased ratio
         because the FEV1 falls more than the FVC
        In restrictive lung disease both FEV1 and FVC are
         reduced so you get a normal ratio (it may even be
         increased because of elastic recoil)

In emphysema and asthma, the total lung capacity may
increase, but there is usually a reduction in the FVC. This is
because the small airways cause obstruction to airflow before
the normal RV is reached – this traps air in the lung giving an
increased RV.

Some definitions:

Vital capacity (VC)



43
The change in volume of air in the lungs from a complete
inspiration to the complete expiration. In patients with lung
disease it can be greater than FVC due to air trapping in the
manoeuvre.

Forced Expiratory Volume in the First Second (FEV1)
The maximum volume of air expelled from the lungs in the first
second of forced expiration, starting from full inspiration.

Forced Expiratory Ratio (FER)
This is the FEV1 expressed as a percentage of the vital
capacity – it is sometimes called the FEV1% or the FEV1/VC%
when expressed as a percentage of the VC, or the
FEV1/FVC% when shown as a percentage of the FVC. In
normal subjects it should be over 75% - ie. The subject should
be able to exhale at least three quarters of their vital capacity
in the first second.

Peak Expiratory Flow Rate (PEFR)
The maximum flow that can be sustained for 10milliseconds
on forced expiration starting from full inspiration. It is
measured in L/min using a peak flow meter.

Forced Expiratory Flow (FEF 25-75%)
The overall forced expiratory flow rate of the middle part of the
FVC manoeuvre. It gives an indication of what is happening in
the lower airways and is expressed in L/s. Can be an early
warning sign of disease.

See p. 764 of Kumar and Clark to see some pics of spirometry
readings.

Differentiating between COPD and asthma on spirometry:

        An abnormal FEV1 with little variability in serial PEFR
         (<10%) strongly suggests COPD
        A normal FEV1 excludes the diagnosis
        More than 15% variability in serial PEFR over 24h
         suggests asthma



44
        An FEV1/FVC ratio <75% is diagnostic of obstruction.
         If the ratio is normal and the test was technically
         acceptable, the trace is not obstructive and the
         diagnosis may not be COPD.


              13. Arterial Blood Gas Sampling

Before you start introduce yourself, gain consent and, if the
patient is on oxygen, check its concentration.

     a. Femoral artery

Equipment:
         Arterial blood gas syringe with heparin
         Alcohol swab
         Swab
         1% lignocaine local anaesthetic
         Syringe and blue needle for anaesthetic

1. Lay the patient supine with the groin and leg extended and
slightly abducted.

2. Locate the femoral artery, halfway between the anterior
superior iliac spine and pubic symphysis, 2 cm below the
inguinal ligament.

3. Clean the skin directly over the artery with an
alcohol swab.

4. Raise a bleb of local anaesthetic.
5. Fix the artery between two fingers whilst inserting
heparinised needle and syringe at 90° to skin.

6. Slowly advance the needle till there is free flow into syringe.




45
7. Withdraw needle, and apply pressure for 5 minutes.

8. Cap the syringe and place in ice till analysed.

        b. Radial artery

Equipment: as for femoral artery
1. Before the procedure, perform the Allen test:
Occlude both ulnar and radial arteries digitally and allow the
veins to drain all the blood. Release the ulnar artery while
keeping the radial artery compressed. The hand colour should
return in less than 5 seconds, indicating that there is sufficient
collateral blood flow from the ulnar artery.

2. If the patient fails the Allen test, arterial blood gases from
the radial artery should not be attempted.

3. Place patient in supine position with wrist and thumb
extended.

4. Place a rolled up hand towel under the dorsal surface of the
wrist.

5. Palpate the radial artery

6. Clean the skin proximal to the wrist joint.

7. Raise a small bleb of local anaesthetic at the proposed
entry site with a 25G needle into the skin.

8. Insert the needle of a heparin-coated 2ml syringe at 60-90°
through the skin, ensuring avoidance of air in the syringe.

9. Palpate the radial artery proximally, using it as a guide of
direction to advance needle.

10. The arterial blood pressure will fill the syringe
automatically.



46
11. Withdraw the needle and apply pressure for 5 minutes.
Cap the syringe and place in bag of ice if immediate
analysis not possible.




           14. Bedside blood glucose monitoring


Depending on the hospital, this station can use two methods –
visually read test strips or a meter. Usually it involves using a
bottled solution instead of someone’s blood

Glucose meter method

Equipment: -     Blood glucose meter
                 Test strips
                 Lancet/spring loaded finger prick device
                 Alcohol swab
                 Non-sterile gloves
                 Cotton wool ball
                 Watch

1. Collect equipment and ensure the test strips are in date.
The machine should also be calibrated for use with that
particular batch of strips according to manufacturers
instructions. (This involves matching a code number on the
strip bottle to the code registered on the meter).

2. Check patient‟s details, introduce yourself and explain what
you‟re about to do – obtain consent.

3. Wash hands and don a clean pair of non-sterile gloves -
ensure the patient has also washed their hands or swab
chosen finger with alcohol swab.

5. Turn on the blood glucose meter and calibrate.



47
6. Once the meter is ready for use (as each machine will be
different ensure you have read the manufacturers instructions
for use before you begin), use the lancet prick the patient‟s
finger lateral to the fingertip. (Try and avoid the thumb,
forefinger and fingertips). Don‟t choose a finger that has been
tested recently.

8. Squeeze the finger to obtain a large drop of blood. Apply
the drop of blood to the appropriate area on the test strip.

9. Insert the test strip into the machine according to the
manufactures recommendations. Some may require the blood
to be wiped off before hand others may not.

10. Allow the machine to analyse the blood. In some meters
this can take up to 60 seconds.

11. While waiting, clean the patient‟s fingers.

12. Once the analysis is complete record the results.

13. Dispose for lancet and test strip as appropriate.

14. Remove the gloves and wash hands.

15. Take appropriate actions according to results.

Visually-read strip method

This is exactly as above, but when you‟ve got the blood on the
strip you have to leave it for 60s, wipe and then read the strip
against a visual check card.


Questions around the topic:

Why do you get the patient to wash their hands?



48
To prevent infection (though unlikely) and to remove any
traces of glucose from the fingers.

If the test result was 8.0mmol/l, what significance would you
attach to this?
You can‟t attach any significance to it without knowing
whether the measurement was a fasting glucose or not.
Glucose should really be measured before breakfast or just
before a main meal.

If the fasting blood glucose was 8.0mmol/l, what significance
would you attach to it and what further action should you
take?
This result is compatible with diabetes, but an abnormal finger
prick test must be confirmed by laboratory measurement
before diagnosis, and maybe also an oral glucose tolerance
test.
      Patients may be transiently hyperglycaemic during an
         acute illness such as pneumonia – a fasting BM
         needs to be repeated when the patient is over the
         illness.
      If the patient was diabetic, a fasting glucose of
         8.0mmol/l is moderate, though not „perfect‟ glycaemic
         control. A dietician should advise them on a sugar-
         free diet, notify the GP and arrange an OP follow up.

Some revision re: diagnosis of diabetes:
Fasting glucose   2-hour glucose           Interpretation
     >7.0     or    >11.1                  Diabetes mellitus
>6.1 and <7.0 + >7.8 and <11.1             Impaired glucose tol.
>6.1 and <7.0 +      <7.8                  Impaired fasting glyc.
<6                                         Normal

Most patients do not need an oral glucose tolerance test
(OGTT), but those with IFG on fasting glucose do. Another
indication for OGTT is when you get 2 disconcordant fasting
glucose tests.
In symptomatic individuals, diabetes is confirmed by one of
the following:



49
*Random plasma glucose of >11.1mmol/l
*Fasting plasma glucose >7.0mmol/l
*OGTT 2-hour value of >11.1mmol/l (on follow up of IFG)
NB. Blood glucose is 10% less than that of plasma glucose.

         Performing an oral glucose tolerance test

1. Introduce self to patient, explain what is going to happen
and why you want to do the test - gain consent. OGTT is
reserved for true borderline cases of DM.

2. The patient needs to fast overnight. After the fast, 75g of
glucose is taken in 250-350ml of water.

3. Blood samples are taken in the fasting state and two hours
after the glucose has been given.

4. A specific enzymatic glucose assay must be used.

5. See above for interpretation.




                 15. How to Perform an ECG

1. Explain to the patient what is about to happen

2. Check ECG Machine has paper and is calibrated so paper
speed is 25mm/s and sensitivity is set to 1mV=10 mm

3. Remove the clothing of the patient above the waist, and
position the patient comfortably in the bed
4. Attach the following leads to the following places;
occasionally body hair needs to be removed to ensure good
electrode contact.

Lead I Right Arm
Lead Il Left Arm



50
Lead III Left Leg
AVR      Right Arm
AVL      Left Arm
AVF      Left leg
           th
V1       4 intercostals space to right of sternal edge
           th
V2       4 intercostals space to left of sternal edge
V3       Halfway on a line joining V2 to V4
           th
V4       5 intercostals space midclavicular line
V5       same horizontal level as V4 but in anterior axillary line
V6       same horizontal level as V4 and V5 but in midaxillary
         line




                16. Measuring blood pressure

1. Introduce yourself to the patient with your full name, check
their details and say what you are about to do.

2. Choose an appropriate cuff size for the patient‟s arm – the
bladder should be 1/3 the length of the arm. In practice, 95%
of patients fit the standard cuff size of 20-25cm. Connect the
bladder and pump to the sphyg.



51
3. Ask the patient to roll up their sleeve and rest the arm at the
level of the heart – preferably the patient should be lying
down. The equipment should also be at this level and you
should be at eye level with the sphyg. gauge.

4. Check that the sphygmomanometer is working and set to
zero.

5. Ensure there is no air in the bladder of the cuff. Wrap it
neatly around the upper arm (usually R arm) with the bladder
over the brachial artery but so the cubital fossa is exposed.
Wrap the cuff around quite tightly so it can not fall down the
arm. Ensure tubes are running down the brachial artery and
vein.

6. Inflate the cuff whilst palpating the radial artery to obtain the
systolic pressure by palpation. Inflate 20-30mmHg above
where you cannot feel pulsation. Let the pressure out slowly
until you feel the pulse return.

7. Locate the brachial pulse and place stethoscope over it to
obtain pressure by auscultation. Inflate the cuff back to 20-
30mmHg over the systolic value by palpation. Let the
pressure out slowly (2mmHg/s). Anticlockwise shuts the
pump, clockwise opens it.
                                         st
8. The point at with sound appears (1 Korotkof sound) is the
systolic pressure. Record this to the nearest 2mmHg.

9. Continue to deflate – the point at which the sounds
disappear (fifth Korotkof sound) is the diastolic pressure.
Again record to the nearest 2mmHg. In some normal people
the sounds may not disappear – then use Korotkof fourth
sound (muffling) and record that you have done this.

10. Remove the cuff and thank the patient.




52
11. State that you would go on to measure the blood pressure
again for accuracy and also with the patient standing to check
for a postural drop – if there is a drop of >20mmHg systolic
pressure that is still sustained at 2 minutes then the patient
has postural hypotension.

Questions around the topic:

Why do you put the arm at the same level as the heart?
If it was higher or lower than the heart you would get a falsely
high/low blood pressure (low if arm above heart, high if
below).

Why do you need to choose an appropriate cuff size?
Because if you use a cuff that is too small it has to exert a
greater pressure on the arm and you‟ll get a falsely high
reading.

Why do you check the redial pulse pressure?
To ensure that you don‟t miss an auscultatory gap.

How would you know if someone was hypertensive?
In adults 160/95mmHg or more is the WHO definition of
hypertension. However, as the patient may be nervous the
first time they have BP checked it should be rechecked at the
end of the consultation and again on a separate date for
confirmation. You must also check for signs of retinal
changes, LVH and proteinuria.

What might you conclude if there was a pressure difference
between the two arms?
A difference >20mmHg suggests arterial occlusion, eg.
Dissecting aneurysm or atheroma. A difference of 10mmHg is
found in 25% of healthy people.

Random facts:
*Wide pulse pressure          (160/30mmHg)    suggests    aortic
incompetence



53
*Narrow pulse pressure (95/80mmHg) suggests aortic
stenosis
*patients with AF are difficult to obtain a BP from as they have
a variable pulse.


        17. Basic life support (using Resussi-Annie)

     1. Initial assessment

-Ensure your own safety.
-Tell the examiner you would move the person to safety.
-Gently shake the person‟s shoulders/pinch ear and ask
loudly, “Are you alright?”

If there is no response, shout for help.

     2. Airway maintenance

-Place a hand on forehead and gently tilt head back, keeping
thumb and index finger free to close nose if rescue breathing
is required.
-With fingertips under the point of the chin, lift the chin to open
the airway. If you suspected a spinal injury you could also
open the airway by bringing the jaw forward.

     3. Check breathing

Keeping the airway open, look listen and feel for breathing for
10s.
-look for chest movements
-listen at the mouth for breath sounds
-feel for air on your cheek

If there is no breathing, send a friend for help. If you were on
your own you would call an ambulance at this point unless the
problem is trauma or drowning when you would perform
resuscitation for 1min before calling help.




54
     4. Rescue breathing

Remove any visible obstructions from the person‟s mouth,
such as dislodged dentures (well-fitting dentures can be left in
place).

Give 2 effective rescue breaths, each of which must make the
chest rise and fall.

-ensure head tilt and chin lift
-pinch soft part of nose closed with index finger and thumb of
hand on forehead
-open mouth a little, but maintain chin lift
-blow steadily into mouth for 1.5-2s, watching for chest to rise
as in normal breathing
-maintaining head tilt and chin lift, take mouth away from
person and watch for chest to fall as air comes out
-repeat sequence for second breath

     5. Check circulation

Assess person for signs of circulation – take <10s

-look for movement, including swallowing or breathing
-check carotid pulse

If circulation is present, you need to carry on breathing for the
person and check pulse every minute. If there is no pulse…

     6. Chest compression

-place one hand on top of the other, with the fingers
interlocked and the heel of the lower hand over the middle of
the lower half of the sternum.

-Position yourself vertically above the victim‟s chest and, with
arms straight, press down on the sternum to depress it 4-5cm.
Be sure that fingers do not press on ribs.




55
-Release the pressure, without losing contact between hand
and sternum, and repeat compressions at a rate of
~100/minute; compression and release should take an equal
amount of time.

Rescue breathing and compression need to be combined at a
rate of 2 breaths to 15 compressions if alone. If you have a
companion, you can use a ratio of 1 breath to 5
compressions, working on opposite sides (NB. Do not
compress until the chest has deflated).

Continue until:
    Help arrives
    The victim shows signs of life
    You become exhausted

Summary: see separate sheet.


 19. Record baseline measurements – pulse, respiratory
                  rate, pulse oximetry

Pulse

        Take the radial pulse for 30s and double it or for 15s
         and quadruple it. If you can‟t feel the radial pulse feel
         the carotid. Chart the pulse in bpm.

Respiratory rate

Take this at the same time as the pulse – you can‟t tell the
patient that you are measuring it or they will breathe faster.
Chart the RR in breaths/min.

Oxygen saturation
You need to use a pulse oximeter machine for this. Switch it
on and wait for it to self calibrate. Apply the finger probe to a
finger that does not have nail varnish on and wait for a stable
reading to appear. Chart the reading in % and state on the



56
chart if the reading was on air or on oxygen, and if on oxygen
then what concentration.

See over for an example of a chart that you might be asked to
fill in.



                     41. Reporting an ECG

1. Report the name and age of the patient

2. Date of the ECG

3. Note whether or not the patient was experiencing any chest
pain when the ECG was performed.

4. Record the rate of the ECG. This can be done by dividing
300 by the number of large squares between two QRS
complexes, if the rhythm is irregular divide 900 by the number
of large squares between 4 successive QRS complexes




57
5. Rhythm – check there is a P wave in front of every QRS
complex. Is the rate regular, irregular or irregularly irregular?



6. Look for prolongation of the PR interval



7. Look for extra beats or deflections e.g. that may occur with
a paced rhythm



8. Axis – if the S wave is greater than the R wave in lead I,
there is right Axis deviation. If the S wave is greater than the
R wave in lead II there is left axis deviation



9. Look at the configuration of the QRS complexes



10. Look at the ST intervals to see if they are raised or
depressed.



11. Look at the T wave to see if it is normal, inverted or
peaked



12. Give a summary and diagnosis




A normal 12 lead ECG




58
Some Abnormal ECGs




59
60
61
62
63
               Reporting a Chest Radiograph


1. Make sure the film is correctly orientated on the x-ray box

2. Report the name and age of the patient with the date the
radiograph was taken

3. Report whether the film was taken anteroposterior (AP) or
Posteroanterior (PA). And whether it was taken with patient
erect or not.

4. Check the orientation of the film by seeing if the clavicular
heads are level

5. Check penetration of the film by seeing if you can see the
thoracic vertebral bodies through the mediastinum.

6. Check scapulae are adequately out of the field of view



64
7. Check whether the patient made an adequate inspiratory
effort when the film was taken by counting the number of
anterior ribs to the diaphragm. There should be 6 or more.

8. Check the mediastinum; look for deviation of the tracheal
shadow. Look at the shape of the heart; assess the width of
the cardiac shadow, which should be half diameter of the
chest. This can only be done on PA films NOT on AP.

9. Look at the lung fields – use upper, middle and lower zone
to describe because you would need a lateral view to localise
the fissures.

10. Look at the costophrenic angles

11. Look at the diaphragm

12. Look at the bony structures

13. Look at the skin and subcutaneous tissue shadow

14. If you have found no abnormalities, go over the “review”
areas where you might be likely to miss things – apices,
periphery of the lungs, under and behind the hemidiaphragms,
behind the heart.

14. Summarise your findings and give a diagnosis. If there are
no abnormalities the commentary should include any
problems behind the heart (need a penetrated film), any
bulkiness at the hila (lymph nodes, tumour, vascular –
pulmonary hypertension), presence of both breast shadows in
a female patient, skeleton, soft tissues.


See the additional notes on “Chest X rays made easy”.


           Reporting an Abdominal Radiograph



65
1. Make sure the film is correctly orientated on the x-ray box.

2. Report the name and age of the patient with the date the
radiograph was taken.

3. Report whether the film was taken anteroposterior (AP) or
not (can also be decubitus with patient on his/her side) and
whether the patient was supine or erect.

4. Check that the whole abdomen is visible on the film.

5. Check the film is adequately penetrated by looking for
lumbar spinous processes though lumbar vertebral bodies.

6. Look at the bowel gas patterns (amount and distribution),
checking for dilated large or small bowel. Gastric bubble in
LUQ is normal. Also normally see gas in colon and rectum.
Small bowel should be <3cm diameter, large bowel <5cm
diameter (except caecum which is <9cm). Faecal matter gives
a “mottled” appearance.

7. Look for extraluminal gas - abnormal.

8. Look for calcified structures e.g. aorta, urinary stones.
Check in particular the cartilage of ribs, blood vessels,
pancreas, kidneys, gallbladder area and pelvis.

10. Look at the bony structures.

11. Look at skin and subcutaneous tissues. A usually identify
organs by rim of fat round them. Particularly check for the
kidneys (should be ~3-3.5 vertebral bodies long). What looks
like a mass in the region of the stomach is usually a gastric
pseudotumour caused by gastric fluid lying in the fundus of
the stomach on supine films.

12. Make a final check for any foreign objects.



66
See notes on “Abdominal X rays made easy” for more detail.


Key to densities on AXRs:

Black – gas
White – calcified structures
Grey – soft tissues
Dark grey – fat
Intense white – metallic structures

     44. How to perform a digital rectal examination (DRE)

Equipment:

          Gloves
          Lubricating jelly
          Swabs

1. Ensure that your patient knows what you are going to do
and why. Arrange for a chaperone to be present.

2. Position your patient lying on their left side, with their knees
pulled up towards their chin and their back near the edge of
the couch.

3. Put on gloves and have lubricating jelly and a paper tissue
within easy reach.

4. Lift the patient‟s right buttock with your left hand and
inspect the anus carefully, using a good light.

5. Put a little jelly on the pad of your right index finger.

6. Explain to your patient that they will feel pressure, and
probably a feeling like wanting to empty their bowels.




67
7. Place your finger on the anus. DO NOT FORCE IT IN but
wait patiently until you feel the sphincter relax.

8. Gently pass your finger in, trying to form a mental picture of
the anatomy as you do so. Watch your patient‟s face
throughout the procedure to detect if you are causing pain.

9. Gently insert your whole finger and sweep round the rectum
systematically, feeling for abnormalities in the lumen, the
rectal wall, the perirectal tissues and beyond.

10. To feel the prostate, sink down on one knee and pronate
your wrist. Identify the prostate gland and assess its size,
hardness and whether you can feel the midline sulcus.

11. In a female patient you will usually feel the cervix
anteriorly. This is normal.

12. Remove your finger and examine the glove for traces of
stool, mucus or blood.

13. Wipe any gel from the anus and perineum.

14. Ensure that your patient is comfortable and covered.

              Respiratory system examination


1. Introduce yourself to the patient and explain what you are
                                                            o
going to do. Expose the chest and position the patient at 45 .

2. INSPECTION

     a. From the end of the bed look for:
      Signs of respiratory distress e.g. use of accessory
        muscles, leaning forward
      Symmetry of chest movement
      Cyanosis
      Pursed lip breathing



68
         Other clues of disease including: oxygen mask,
          sputum pot, peak flow meter, inhalers, nebuliser,
          cachetic, walking aids, chest drains, rib cage
          deformity etc.
         Erythema nodosum (sarcoidosis)

You can stand and say, “Could you just take two deep breaths
for me please”, to get a good idea of what they‟re breathing‟s
like before you start.

     b. Hands look for:
      Clubbing (loss of angle, nail bed fluctuation, increased
        curvature both planes)
      Nicotine staining
      Peripheral cyanosis
      Small muscle wasting (esp. 1 dorsal interossei)
                                      st

      Signs of CO2 retention – warm peripheries, dilated
        veins, bounding pulse

     c. Wrists
      If there are signs of clubbing move the patient‟s wrist
        back and forth to see if there is pain (hypertrophic
        pulmonary osteoarthropathy).
      Ask the patient to put their arms straight out in front of
        them and spread their fingers. Look for 2-agonist
        tremor.
      With their arms still extended ask the patient to cock
        their wrists back. Observe for a CO2 retention flap.

     d. Pulse: assess radial pulse and at the same time
        assess respiratory rate and breathing pattern.

     e.   Eyes look for:
         Anaemia (pallor on the under side of the eyelid)
         Ptosis (drooping upper eyelid)
         Miosis (constricted pupil)

     f.   Mouth look for:



69
        Central cyanosis (blue tinge under the tongue)

     g. Neck
      Assess JVP: ask the patient to look over their left
        shoulder, illuminate the area and look carefully for any
        pulsations. Verify that the pulsations are not arterial.
        Check for hepatojugular reflux (apply firm pressure to
        the abdomen and watch for a rise in the position of
        pulsatation). It is raised in cor pulmonale.
      Lymphadenopathy: assess cervical, axillary and supra
        and infra clavicular lymph nodes.

     h. Chest: look for:
      Chest wall deformities (eg. barrel chest)
      Scars: anteriorly and posteriorly.

3. PALPATION

     a. Trachea: palpate for deviation (warn the patient that it
     can be uncomfortable). Upper lobe collapse causes
     tracheal deviation.

     b. Cricosternal distance: measure finger breadth distance
     between cricoid cartilage and suprasternal notch.
     (reduced in emphysema).

     c. Chest expansion: place hands around the 2 sides of
     the chest with the thumbs meeting in the middle (but not
     touching the skin). Note separation of the thumbs on
     inspiration. Do this down the length of the lungs and
     laterally as well as AP and PA. Normal = above 5cm.

4. PERCUSSION

Percuss supraclavicular regions, clavicles (tap them directly,
not your finger), the chest wall in at least 6 positions,
comparing each side (front and back). Don‟t forget the axilla.
Listen for dullness or hyper-resonance.



70
5. AUSCULTATION

     a. Breath sounds: listen in the same positions that you
     percussed, asking the patient to breath in and out through
     their mouth quietly. Assess:
      Whether breath sounds are absent, vesicular (normal)
          or bronchial
      Intensity of breath sounds.
      Ratio of inspiratory vs expiratory breath sounds.
      Added sounds e.g. wheeze (monophonic or
          polyphonic), crackles (fine or course), pleural rub.

     b. Vocal fremitus: Ask the patient to say „99‟ whilst
        auscultating. (more reliable than tactile vocal
        fremitus).

6. State that you would like to see a chest x-ray, carry out lung
function tests (PEFR, spirometry) and review the contents of
any sputum pots. Also look at temperature chart.


Questions around the topic

The examiner can also ask you what signs you might expect
to find in certain respiratory conditions – see p93 of OSCE
book for a good summary.

Also need to know what the different added sounds are –
skills lab has tapes.

You can be asked what the causes of certain signs are – see
the signs list.

                        Breath sounds




71
Vesicular breath sounds
Sound heard over normal lungs. It has a rustling quality and is
heard on inspiration and the first part of expiration.

Reduction is expected in airways obstruction. The “silent
chest” is a sign of severe asthma, and emphysema can also
cause a marked reduction. Generalised reduction in sound
also occurs with a thick chest or obesity.

Anything interspaced between the lung and the chest wall will
reduce the breath sounds – usually unilateral so easily
detected. Describe this as “reduced breath sounds” rather
than “reduced air entry”.

Causes reduced breath sounds: asthma, emphysema,
tumour, thick chest, obesity, pleural thickening, pleural
effusion, pneumothorax, lobar collapse.

Bronchial breathing
This occurs in both inspiration and expiration with a gap in
between. Difficult to describe how it sounds, but pattern
different to vesicular breathing (although many people with
airways obstruction have normal breath sounds that go on into
middle or late expiration). You can mimic the sound by putting
your tongue on the roof of your mouth and breathing through
open mouth.

Bronchial breathing heard when sound generated in the
central airways is transmitted unchanged through lung
substance – ie. When the lung itself is solid as in
consolidation but the air passages remain open. Sound is
conducted normally to the small airways and then modified by
air in alveoli, but solid lug conducts the sounds better straight
to the lung surface and stethoscope.

If the central airways are obstructed by say a tumour, no
transmission of sound will take place and no bronchial
breathing will be heard despite the presence of solid lung. An



72
exception is seen in the upper lobes, where it can be heard
even if there is blockage.

Causes: pneumonia (almost always), lung abscess near the
chest wall, dense fibrosis, effusion (can hear above the
effusion because it may compress lung), over a collapsed
lung if the airway is patent (rare, but can hear in upper lobes).

Wheezes (rhonchi)
These are prolonged musical sounds, largely occurring on
expiration (can be inspiratory though) – due to localised
narrowing of the bronchial tree. Caused by vibration of the
walls of a bronchus near to its point of closure.

Most patients with wheeze have many (=polyphonic wheeze),
each coming from a single, narrowed area. As the lung gets
smaller on expiration, the airways also get smaller, and each
narrowed airways reaches a critical phase when it produces a
wheeze and then stops doing so. So during expiration you
usually get lots of wheezes in sequence and together. A
single wheeze indicates a single narrowing – carcinoma or
foreign body (=monophonic wheeze).

Wheezes are typical of airways narrowing of any cause –
asthma and bronchitis are the most common (smooth muscle
contraction, inflammatory changes and increased bronchial
secretions cause narrowing). Sometimes patient with these
conditions have no wheezes, in which case you can ask them
to take a deep breath in and blow out hard. Occasionally,
wheezing can also be heard in pulmonary oedema.

Don‟t say “bronchospasm” – this is narrowing caused only by
smooth muscle contraction, whereas wheeze is usually
multifactorial.

Wheeze-like breath sounds can disappear in severe asthma
and emphysema because of low rates of airflow – amount of
wheeze does not correlate with severity of disease – PEFR is
a better measurement.



73
Causes: chronic bronchitis, asthma, emphysema, pulmonary
oedema.

Stridor
This is a harsh inspiratory and expiratory noise that can be
imitated by adducting the vocal cords and breathing in and
out. You can usually hear it by putting your ear to the patient‟s
mouth.

Causes: large airway narrowing in the larynx, trachea or main
bronchi.

Crackles (crepitations, rales)
There are two main types of crackles:

(1) “Coarse” crackles occur when there is fluid in the larger
bronchi and a bubbling sound can be heard that clears or
alters as the secretions causing the sound are cleared on
coughing or deep breathing.

(2) “Fine” crackles sound like velcro – they occur on
inspiration and are high-pitched, explosive sounds. The
mechanism for them is though to be: where you have
premature closure of the small airways at the end of
expiration, you need to overcome the surface tension keeping
them closed on the next inspiration to open them. When they
eventually “pop open”, crackles are produced. During
inspiration, larger bronchi open before smaller ones, so
crackles from chronic bronchitis and bronchiectasis occur
early. Conditions largely involving the alveoli (LVF, fibrosis,
pneumonia) tend to produce crackles later on inspiration.

Note whether crackles are localised – this would be expected
in pneumonia and mild bronchiectasis. Pulmonary oedema
and fibrosing alveolitis typically affect both lung bases equally.

Normal people, especially smokers, may have a few basal
crackles – these usually clear with a few deep breaths.



74
Causes: LVF, fibrosing alveolitis, extrinsic allergic alveolitis,
pneumonia, bronchiectasis, chronic bronchitis, asbestosis.

Pleural rub
Caused by the inflamed surfaces of the pleura rubbing
together – it sounds like a creaking noise. You can try to
imitate it by placing one hand over the ear and rubbing the
back of that hand with the fingers of the other.

Pleural rub is usually heard on both inspiration and expiration.
Make sure you‟re not just moving the stethoscope on the
chest if you think you hear it. Coarse crackles can also sound
like rubs – a cough will shift the former.

If there is any pain, ask the patient to show you where it is –
this will often localise the rub.

Causes: pleural inflammation           (pneumonia,   pulmonary
embolism), effusion.


           Gastrointestinal system examination


1. Introduce yourself to the patient, check name and explain
what you are going to do.

2. Positioning - ensure the patient is comfortable, but they
should be lying flat. Classically examine from “nipples to
knees” although in practice only the abdomen is exposed
unless the hernial orifices/genitals are being closely
examined. Remember to examine from the right hand side of
the bed.

3. INSPECTION

a. From the end of the bed look for:


75
        general features of the patient – age, cachexia,
         anorexia, obesity, normal weight.
        drainage devices
        medication
        special diet notices, high energy drinks, fluid charts

b. Hands
     Nails: leukonychia, clubbing
     Palms: palmar erythema, Dupuytren‟s contracture
       (you can usually feel this before you see it)

c. Test for a liver flap (asterixis) by asking the patient to close
their eyes and hold their arms out in front of them, with wrists
up. Look for a flap for about 20secs.

d. Face:
     Eyes: look at sclera for jaundice and under eyes for
        signs of anaemia
     Mouth: ulcers, angular stomatitis, Peutz-Jegher‟s
        spots, dehydration or any kind of coating.
     Subtly smell breath for hepatic fetor (stale urine,
        ammonia), DKA (sweet/acetone smell), halitosis.

e. Neck – feel the cervical lymph nodes, particularly the
supraclavicular Virchow‟s node, which is commonly enlarged
in GI malignancy.

f. Chest
     Spider naevi - >6 is significant 9they are mostly above
         nipple line)
     Gynaecomastia

g. Abdomen: look for the following:
     Distension
     Abdominal movement with respiration (a rigid
       abdomen is a sign of peritonitis) and pulsations
     Swellings or obvious herniae
     Scars



76
        Distended veins, including caput medusa
        Divarication of rectus muscle
        Skin changes (eg. bruising, signs of itching from
         pruritis)

4. GENERAL PALPATION

Ask the patient if they have any pain – if so, leave that area
until last during palpation. Remember to watch the patient‟s
face throughout the examination. Palpate systematically
through the nine quadrants.

a. Superficial palpation
Feeling for three things – tenderness (normal, or rebound),
rigidity, guarding.

b. Deep palpation
Feeling more for masses and deep-seated pain. Any masses
must be described (position, shape, size, surface, fixed,
movement with respiration, tenderness, pulsation).

5. FEEL FOR ORGANS

a. Liver
Feel for the liver edge at inspiration (size, surface, edge,
pulsation). Start in the RIF and proceed to the costal margin –
you can use either fingertips of the side of index finger. After
the edge of the liver has been established, percuss the upper
and lower borders to confirm your findings.

Why examine the upper border? As the capacity of lungs
increase (e.g. in emphysema), the liver is pushed inferiorly,
giving pseduo-hepatomegaly.

b. Spleen
Start in the RIF and feel towards the left hypochrondrium. Can
use lateral tilt to make job easier (ask patient to turn onto their
right side and feel again). The spleen is not usually palpable.
Also percuss for it in the same manner.



77
c. Kidneys
Palpated by “ballotment”. One hand should be placed on the
abdomen, and should remain fixed. The other hand is placed
posteriorly, and is used to flick or bounce the kidney between
your hands. Difficult to feel unless huge kidney, e.g. polycystic
kidney disease.

d. Abdominal aorta
Press down firmly but not too hard with middle and index
fingers together. An abdominal aneurysm will push them
upwards (pulsatile) and outwards (expansile).

6. FURTHER PERCUSSION (AND TESTS FOR ASCITES)

Have already percussed the liver and spleen – you can also
percuss for ascites of necessary, or for bladder distension if
you suspect it.

a. Shifting dullness
No point doing this if patient doesn‟t have a distended
abdomen. Percuss from the umbilicus laterally (with fingers
pointing toward the head) and ascertain the percussion note is
resonant at the umbilicus (gas at the apex) and dull in the
flanks (fluid-dependent). If this is not the case, the patient
doesn‟t have ascites.

Ask the patient to roll towards you (on their right side) whilst
keeping your hand over the left flank where it was dull. Wait 1
minute, and re-percuss. Note should have changed from dull
to resonant.

Roll patient onto their left side. Wait 1 minute. Left flank
should be dull again.

b. Fluid thrill
Flick the abdomen on one side while keeping your hand on
the other to feel any movement transmitted across. If you feel
a thrill, it is due to movement through a fluid. Ask the patient



78
to put the ulnar edge of one of their hands in the centre of the
abdomen to prevent a false positive thrill from fat.

7. AUSCULTATION

a. Listen for bowel sounds – normal, borborygmi (with
increased peristalsis), absent (with ileus or peritonitis),
tinkling=increased (with obstruction). Need to listen for a
minimum of 15s, and a minute to confirm absence.

b. Auscultate in at least three places for bruits – abdominal
aorta, kidneys (for renovascular disease, just above the
umbilicus, just away from the midline) and the liver.

8. Palpate the hernial orifices for inguinal or femoral hernias –
you could say that it would be easier to do this if you got the
patient to stand or cough.

9. Check the ankles for signs of oedema and say you could
also check the sacral area too.

10. State that to complete the exam you would also like to
examine the genitals, do a rectal exam and dipstick the urine.


Questions around the topic

What other condition do you get a flap in?
With respiratory failure as a sign of carbon dioxide retention.

At what level of bilirubin can you detect jaundice?
Twice the upper limit of normal, or over 36μmol/L.

What is the significance of gynaecomastia in an abdominal
exam?
Gynaecomastia is seen in cirrhosis because you get high
circulating oestrogen levels because the liver does not break
down the hormone.



79
           Using the Glasgow Coma Scale (GCS)

Where there is a station with a scenario of a patient with a
reduced level of consciousness, you must always use the
GCS after assessing ABC. You must also be able to calculate
it for the specified case – the minimum score is 3.

Category                               Score

Eye opening
Spontaneous                            4
To speech                              3
To pain                                2
None                                   1

Best verbal response*
Oriented                               5
Confused conversation                  4
Inappropriate speech                   3
Incomprehensible                       2
None                                   1

Best motor response
To verbal command                      6
Localises to pain                      5
Withdrawal flexion to pain             4
Abnormal flexion to pain               3
(decorticate rigidity)
Extension to pain                      2
(Decerebrate rigidity)
None                                   1

*Notes on best verbal response:

Oriented = patient knows who he is, who you are and where
he is, month, year and season.

Confused = patient responds in conversational manner but
some disorientation and confusion



80
Inappropriate speech = random speech, swearing etc.

Interpretation of results:

GCS 8 or less - severe injury
GCS 9-12      - moderate injury
GCS 13-15     - minor injury

50% of patients with a GCS score <5 at 24h die or remain in a
PVS.

Questions around the topic

Under what circumstances might you not be able to assess
GCS accurately?
Examples include when the patient‟s eye is closed by
swelling, when an endotracheal tube or tracheotomy is
present, stroke patients who are aphasic, and when the
patient has no use of one limb – for best motor response you
should usually record the best arm response.

How would you test pain?
You could use either a sternal rub, pressing on the nail bed or
pressing on the supraocular area.




Excising a lesion


     1. Mark a 2mm margin around the lesion. This will
        provide adequate removal if the lesion turns out to be
        malignant.

     2. Design an elliptical incision, which encompasses the
        lesion. Length:width ratio should be 3:1. Ensure that
        the long axis lies parallel to a line of relaxed skin



81
         tension (Langer‟s Lines). Mark the incision with a felt
         pen.
     3. Infiltrate with local anaesthetic.
     4. Holding the scalpel blade at right angles to the skin,
         make a decisive incision along the marked lines.
     5. Ensure that the incision is adequate in all three
         dimensions.
     6. Remove the lesion and send to histology.
     7. Close the wound with interrupted sutures.

                 Cardiovascular History

History of Presenting Complaint

Should specifically ask about:

        Chest pain? – site, character, radiationg, duration,
         precipitating factors, alleviating and aggravating
         factors
        Dyspnoea – exertional, orthopnoea (characteristic
         of heart failure but also get with respiratory
         conditions), paroxysmal nocturnal (HF again),
         exercise tolerance
        Ankle swelling
        Palpitations (“awareness of heart beat”) –
         precipitating factors, character, frequency of onset
        Syncope
        Intermittent claudication – exercise tolerance
        Also sweating, fever, appetite change, nausea or
         vomiting (symptoms of heart failure or digitalis
         toxicity), tiredness (may be due to heart failure or
         ischaemia, or may be a consequence of treatment
         with beta-blockers).


Previous Medical History




82
Important past medical conditions include:

        Hypertension, rheumatic fever, diabetes mellitus,
         previous strokes or MIs
        Arrhythmias, peripheral vascular disease,
         intermittent claudication, renal failure

Previous operations of note include:

        CABGs, angioplasty, pacemaker insertion, any
         vascular surgery.


Drug History

All prescription and OTC medications.

Any allergies should be noted. Establish nature of reaction.


Family History

Any relevant family history. Specifically, DM, MI, CVA,
angina, hypertension, any heridtary disorder.

Enquire about the state of health of the patient‟s father,
mother, siblings and children. If they are dead, ask what
they died of and at what age (carefully!).


Social History

Employment?

Smoking, drinking? How much for how long?




83
            Cardiovascular system examination


*For this one I think you need to check with the examiner if
they want you to include the peripheral pulses (ie. leg pulses
and all the arm ones). I‟ve written that up separately in more
detail*

1. Introduce yourself to the patient and get consent. Put them
                            o
in the correct position – 45 with the chest exposed (women
can keep bra on until need to listen to the heart).

2. Look at the patient‟s general appearance:

*Do they look well, ill, distressed, confused?
*Are they obese?
*Are there any obvious chest/neck scars?
*Do they look breathless or cyanosed?
*Obvious disorders with CVS implications:-
     Marfans syndrome (elongated asymmetrical face,
        high-arched palate, tall, arm span longer than height,
        arachnodactyly) - possible ascending aortic
        aneurysm.
     Down‟s syndrome - up to 50% of children with Down‟s
        have a congenital heart defect (most commonly AV
        septal defect, then ventricular septal defect).
     Turner‟s syndrome (X0) (infantilism, webbed neck,
        short stature, increased carrying angle of arms) - CV
        implications are coarctation of the aorta and other left-
        sided heart defects.

3. Inspect the hands for:

Nails:
*Clubbing
*Splinter haemorrhages




84
Fingers:
*Peripheral cyanosis from cold (vasoconstriction)/arterial
obstruction/low cardiac output
*Tar stains – suggest a smoker

Palms:
*Osler‟s nodes (red, painful, transient swellings on the pulp of
fingers)
*Janeway lesions (small, erythematous macules on the thenar
& hypothenar eminence, blanch under pressure)
*Palmar & tendon xanthomata – yellow lipid deposits

4. Feel the radial pulse: assess rate, rhythm and character
and volume. Feel the pulse on one hand and assess it – then
take the other hand and feel both pulses simultaneously – are
they in sync? (Coarctation of the aorta can cause radial-radial
delay).

Rate: count over 20-30s – <60 = bradycardia (commonest
arrhythmia), >100 = tachycardia. Can also take the respiratory
rate at this point.

     Rhythm:    Normal – remember sinus arrhythmia. Absent
in autonomic neuropathy.
                Regularly irregular – ectopic systolic beats or
second-degree heart block
                Irregularly irregular – atrial fibrillation, multiple
        ectopic beats
                No pattern – probably AF

Character and volume: these are best felt at the carotids, but
also at the brachial artery. However, you need to feel the
radial specifically for a collapsing pulse.

5. Palpate the brachial artery – assess character. The pulse
can be:

Normal




85
Collapsing pulse – lift the patient‟s arm above the head and
put palm over wrist – you can feel the radial artery knocking
against the hand. (Aortic incompetence)

Slow rising pulse – put thumb over brachial artery to feel.
(Aortic stenosis)

Bisferiens pulse (bifid) – the pulse feels as though it has two
peaks. (mixed aortic valve disease)

Pulsus alternans – alternating strong and weak pulses.
(Severe LVF)

Pulsus paradoxicus – volume decreases on inspiration by
>10mmHg. (Cardiac tamponade, constrictive pericarditis,
asthma).

6. Say that you would now like to take the blood pressure over
the brachial artery.

7. Inspect the face:

Eyes:
*Jaundice
*Cataracts
*Corneal arcus, xanthelasma
*Anaemia
*Say you‟d like to use an opthalmoscope to look in the eyes
for changes suggestive of DM/hypertension and Roth‟s spots.

Face:
*Mitral facies – thin face with purple cheeks (“malar flush”)
associated with mitral stenosis.

Tongue:
*Central cyanosis of lips and under tongue (CVS shunting)

8. Feel the character of the carotid pulse using the thumb (not



86
worried about feeling your own pulse as you‟re assessing
character rather than presence).

9. Assess the Jugular Venous Pressure (JVP). Make sure the
                o
patient is at 45 and put a light on the area you‟re looking at.
Look between the heads of the sternomastoid for pulsation
just above the clavicle - remember that you are looking for the
internal not the external vein. You can confirm the venous
nature of the pulse by pressing on the liver area
(hepatojugular reflex). More notes on JVP later.

10. Have another look at the chest to see if there are:

* Scars: median sternotomy may indicate CABG (or maybe
surgery on oesophagus); left lateral thoracotomy scar may
indicate a closed mitral valvotomy

*Masses in left subcostal region, under right or left pectoral
muscle – pacemaker?

*Abnormal breathing pattern.

*Abnormal pulsations.

*Skeletal deformities - kyphoscoliosis, and pectus excavatum
can distort the position of the heart (and thus the apex beat),
and can impair pulmonary function.

11. Palpate the precordium:

*Try to identify the apex beat (difficult) in the midclavicular
line, 5th intercostal space. If you do find it, ask yourself where
it is in relation to where it should be. It may be “tapping” on
your hand (mitral stenosis), “heaving” (LVH) or there may be a
“thrill” (palpable murmur).

*Feel for heaves and thrills over the rest of the precordium in
the mitral area (apex), tricuspid area (L sternal edge, 4th
space), pulmonary area (L sternal edge, 2nd space) and



87
aortic area (R sternal edge, 2nd space). Remember – A Place
To Meet.

12. Auscultate the valve areas: (as above) you should listen
with the bell of the stethoscope since most murmurs are low
pitched. Ask yourself:

*Are there any murmurs? If so, are they in systole or diastole,
do they occupy all of the systole or part of it? Does the
murmur radiate? You can also time the murmur with the
carotid artery (pulse=systole), which is difficult.
*What are the heart sounds like? Are they soft or loud? Is the
second heart sound split (normal on inspiration)?
*Are there any added sounds?
*Is there a pericardial rub? (scratching sound in systole and
diastole)

You should time the heart sounds with the carotid pulse. In
addition to auscultating the four main areas with the bell, there
are two more manoeuvres:

1)Turn the patient slightly onto their left side; Ask them to,
“Breathe in, breathe out, hold it there”. Listen with the bell
over the apex for the low-pitched rumbling mid-diastolic
murmur of mitral stenosis (loud 1st heart sound).
2)Sit the patient forward, ask them again to breathe in,
breathe out and hold it. Listen with the diaphragm over the
aortic area and the L sternal edge for the high-pitched blowing
early diastolic murmur of aortic incompetence. Check for
sacral oedema at the same time.

If you think you have heard a murmur, you would also want to
listen in the axilla (mitral regurg) and below L clavicle (ductus
arteriosus, pulmonary valve murmurs).

13. Listen over the carotid artery for radiating murmurs and
bruits.

14. Percuss and auscultate the chest front and back for



88
pleural effusions – listen for crepitations at both bases.

The examiner may not want you to go any further than this,
but the following would complete the exam:

15. Lay the patient flat and palpate the abdomen, feeling
particularly for the liver (may be enlarged –> congestive
disease, or pulsatile -> tricuspid reflux) and any dilation of the
abdominal aorta.

16. Assess the femoral, popliteal, dorsalis pedis and posterior
tibial pulses. In the exam it may be enough to say, “I‟d also
like to feel the…”. Say you‟d also time the femorals with each
other and with the radial (delayed in coarctation of aorta), and
you‟d also look for signs of peripheral vascular disease such
as paleness/coldness/gangrene/varicose veins.

17. Check for ankle oedema - press in either of these places
for a minute. Anything other than impression promptly
disappearing is pitting oedema.

18. Say, “I‟d like to finish my examination by performing an
ECG and doing an exercise test if ECG was inconclusive. I‟d
also like to dipstick the urine.”

                 Some extra notes on pulses


The arterial pulse is felt by compressing an artery against
bone. The pulse rate should be between 60 and 80 beats per
minute when an adult is lying quietly. If it is below 60 you can
say the person is bradycardic, and if it is above 100 you can
say they are tachycardic. Young children have higher pulse
rates and the elderly and very fit may have slower rates.
The character is more important than the rate of pulse, and
you should feel it at the brachial or carotid artery because if it
is irregular not all beats may be transmitted to the radial artery
(eg. in AF you get an apex-radial deficit).




89
Rhythm
In normal subjects the pulse is regular except for a slight
quickening in early inspiration and a slowing in expiration
(sinus arrhythmia). Irregularities of the pulse rhythm are
usually due to premature beats (occasional/repeated
irregularities superimposed on normal rhythm), intermittent
heart block (occasional beats dropped from a normal rhythm)
or AF (irregularly irregular pulse). AF irregularity will persist
through exercise whereas the other two usually disappear on
exercise.

Large-volume pulse
If you can see the carotid pulse in the neck (Corrigan‟s sign),
there may be an aneurysm or a large-volume pulse. This can
be caused by: high output states, aortic regurgitation. Also in
bradycardia (because need large stroke volume).

Small-volume pulse
Seen in cardiac failure, shock, and obstructive vascular or
valvular disease. Also present in tachycardia.

Collapsing pulse
This is a type of large-volume pulse with a brisk rise and fall. It
is found in the elderly when the aorta is rigid, or in high
cardiac output (eg. thyrotoxicosis, anaemia, fever). Aortic
regurgitation or persistent ductus arteriosus can also cause
this.

Slow-rising pulse
A type of small-volume pulse seen in aortic stenosis.

Pulsus paradoxus (paradoxical pulse)
This is more of an exaggeration of normal pattern, where
there is a fall in pulse volume of >10% on inspiration. There is
always a fall, but it‟s usually less then 10%. The reason for the
fall in pressure is that the R heart responds directly to
changes in intrathoracic pressure while the filling of the L
depends on pulmonary intravascular volume. Thus on



90
inspiration there is a reduction in the filling of the L ventricle
and a small drop in pulse volume. At high respiratory rates
this is exaggerated.
Asthma can cause this because there is severe airflow
limitation – there is an increased and sudden –ve intrathoracic
pressure on inspiration and this will enhance the normal fall in
BP.
In patients with cardiac tamponade the fluid in the pericardium
increases the intrapericardial pressure, thereby reducing the
heart‟s filling capacity. The inspiratory increase in R ventricle
occurs at the expense of the L ventricle as they are both
confined to a „fixed‟ pericardium. A similar mechanism occurs
in constrictive pericarditis.

Pulsus alternans (alternating pulse)
Characterised by beats that are alternately weak and string,
but with a regular rhythm. It is a feature of severe myocardial
failure, and is due to the prolonged recovery time of damaged
myocardium – indicates poor prognosis. Noticed on taking BP
because the systolic BP can vary from beat to beat by up to
50mmHg.
It can also occur where there is rapid, abnormal tachycardia –
it‟s often a compensatory mechanism in this case.
You need to distinguish pulsus alternans from bigeminal
pulse, which is where there are premature ectopic beats
following every sinus beat – no regular rhythm.

Pulsus bisferiens
A two-peaked pulse. The first systolic wave is the “percussion”
wave produced by the transmission of the LV pressure in
early systole. The second peak is the “tidal” wave, caused by
recoil of the vascular bed. This normally happens in diastole,
but when the LV empties slowly or is obstructed from
emptying completely, the tidal wave occurs in late systole.
This pulse is found in hypertrophic obstructive myopathy an in
aortic regurg combined with aortic stenosis.




91
                          The JVP

The internal jugular vein is a key factor in assessing the
“input” side of the heart. It has no valves and is a direct
communication with the SVC an R atrium. It is therefore a
good measure of R atrial pressure. You can‟t use the external
jugular because it has valves and also because it passes



92
through many layers of fascia, which may obstruct it.

The normal pressure in the R atrium is equivalent to that
exerted by a column of blood 10-12cm tall. When the patient
sits of stands the vein is collapsed and when they lay flat it is
                                                       o
completely filled. If the patient lies supine at 45 the jugular
venous pulsation should be seen just above the clavicle. (If
you can‟t see it, lay the patient a bit flatter). It is important for
the patient not to tense the sternomastoid muscles because
the JVP lies just beneath them.

When you‟re looking for the JVP, make sure you‟re looking at
the internal not the external jugular, and if you do see
pulsation that it is not coming from an artery (namely the
carotid). You can tell the JVP and the carotid apart by using
the following:


                    Venous
         Arterial

Most rapid movement inward                             Most rapid
movement outward

2 peaks per cycle (in sinus rhythm)                    1 peak per
cycle

Affected when compress abdomen                         Not affected
by compressing abdo.

May displace earlobes when high
       Never displaces earlobes


Once you‟ve identified the JVP you need to assess:

Is the JVP raised or low?




93
*A normal JVP is less than 4cm above the manubriosternal
                            o
angle with the patient at 45 .

*You cannot measure an abnormally low JVP clinically, but
the causes include haemorrhage and other forms of
hypovolaemia.

*In patients where the JVP is very high you may need to sit
them up to be able to see the pulse waveform properly (as
this will decrease the height of the JVP slightly). As a rule of
thumb, if the JVP is above the clavicle when the patient is
sitting up, it must be raised. The causes of a raised JVP are:

Common          Congestive or R sided heart failure
                Tricuspid regurgitation

Less common Cardiac tamponade
            Massive pulmonary embolism

Rare            Superior vena cava obstruction (waveform
not present)
                Constrictive pericarditis
                Tricuspid stenosis
                Excessive transfusion/excessive infusion of
fluids
                Renal disease with salt and water retention

In constrictive pericarditis or cardiac tamponade you get
Kussmaul‟s sign – the JVP increases in inspiration. This is
because the heart is relatively squashed and so when the
diaphragm descends the heart cannot fill as well.

Is the JVP wave normal? (if it is raised this comes into
consideration)

The normal JVP wave consists of three peaks and two
troughs – the peaks are described as a, c and v waves. The
troughs are known as x and y descents.




94
The a wave is produced by atrial systole
The x descent occurs when the atrial contraction finishes
As the pressure falls there is a small transient increase that
produces a positive deflection called the c wave. This is
caused by transmission of the rapidly increasing RV pressure
before the tricuspid valve closes.
The v wave develops as the venous return fills the right atrium
during continued ventricular systole.
The y descent follows the v wave when the tricuspid valve
opens. You can distinguish the a wave from the v wave by
simultaneously palpating the carotid artery – the a wave
occurs immediately before carotid pulsation and the v wave
with it.

Below is the normal waveform:




Common abnormalities:

Large a waves
These are caused by increased resistance to ventricular
filling, as seen in RVH due to pulmonary hypertension or
pulmonary stenosis. They can also be caused by tricuspid
stenosis, but this is rare because patients with TR are usually
in AF so don‟t have a waves.
A very large a wave occurs when the atrium contracts against
a closed tricuspid valve. This is a cannon wave, and they
occur irregularly in complete heart block and ventricular
tachycardia (where there‟s simultaneous atrial and ventricular



95
contraction).

Large v waves
Tricuspid regurgitation causes giant v waves (systolic waves)
because the RV pressure is transmitted directly to the RA and
great veins.

Steep y descent
Diastolic collapse of elevated venous pressure can occur in
RVF but is more marked in constrictive pericarditis and
tricuspid regurgitation. At the end of ventricular systole the
elevated atrial pressure suddenly falls when the tricuspid
valve opens. However, the ventricles are stiff and can not be
distended. The venous pressure therefore rapidly rises again.
The rapid fall and rise is called Friedrich‟s sign.

JVP and diseases:

The most important waveform to know is tricuspid
regurgitation, By far the most common cause of a raised JVP
is congestive cardiac failure (R side involvement). A raised but
non-pulsatile JVP should make you think of SVC obstruction.

Atrial fibrillation: no a waves, disordered pattern

Tricuspid regurgitation: giant v (systolic) waves that are
larger and earlier than normal v waves – can‟t be obliterated
by pressing with finger

Pulmonary hypertension and tricuspid stenosis: large a and
small c wave
(ie. Right ventricular hypertrophy)

Constrictive pericarditis: exaggerated descent (particularly y
wave) corresponding to onset of systole




96
                         Heart sounds



What are heart sounds?

Closure of the heart valves at different stages of the cardiac
cycle gives rise to sounds that are readily audible through a
stethoscope – these are described as “lub-dup”:

1st heart sound = lub = closure of mitral and tricuspid
valves
2nd heart sound = dup = closure of aortic and pulmonary
valves (higher pitched)

Splitting of the second heart sound

In children and young adults the 2nd heart sound splits into
two components during inspiration (lub da-dup) and comes
together again in expiration. This is the result of minor
changes in the stroke volume of L and R ventricles in
respiration. Splitting of the second heart sound in expiration
indicates an abnormality.

During inspiration, venous return to the R side of the heart is
increased, so R ventricular stroke volume is increased and
closure of the pulmonary valve is delayed. At the same time,
pooling of blood in the pulmonary veins reduces filling of the L
ventricle and makes aortic valve closure slightly earlier than in
expiration. The split may be widened by other factors that
delay ventricular contraction, such as RBBB or pulmonary
valve stenosis.

Conversely, anything that delays L ventricular contraction,
such as LBBB or hypertrophic obstructive cardiomyopathy
may so delay the aortic component of the 2nd heart sound
that the normal relationship is reversed an there is increased
splitting of the 2nd heart sound on expiration, with the sounds
coming together on inspiration.



97
Finally, in an atrial septal defect, there is a characteristically
fixed splitting of the 2nd heart sound because the hole in the
intra-atrial septum means that the L and R atrial pressure
remains equal throughout the respiratory cycle.

                First and second heart sounds

Many factors can influence the intensity of the heart sounds,
including hyperdynamic circulation, valve replacements, low
cardiac output, stenosis of valves and atrial fibrillation. The
most common causes of a loud first heart sound are an
increased cardiac output or mitral stenosis. The most common
causes of an abnormally quiet first heart sound are reduced
cardiac output and either a thick chest wall or emphysema.

                Third and fourth heart sounds

These are abnormal heart sounds that are heard in addition to
the normal ones.

The 3rd heart sound is a low-pitched, thudding sound that
occurs in diastole and coincides with the end of the rapid
phase of ventricular filling. 2 causes:
Physiological – in young fit adults under circumstances of
increased cardiac output (athletes/pregnancy). No
pathological significance.
Pathological – severe impairment of the L ventricle, eg. in
dilated cardiac myopathy, after an MI, in massive PE.
Patients with the pathological 3rd heart sound almost always
have a tachycardia and the 1st and 2nd sounds are relatively
quiet – ie. “da-da-boom, da-da-boom”. This called gallop
rhythm.

A 4th heart sound is an extra beat sound that coincides with
atrial contraction. It is usually best heard in patients whose L
atrium is hypertrophied but is NOT heard in mitral stenosis. A
fourth sound sounds like “da-lub-dup, da-lub-dup”.




98
Summary of heart sounds:




Other added heart sounds

Ejection click
This is a high-pitched ringing sound that usually follows very
shortly after the 1st heart sound. It is a feature of aortic or
pulmonary valve stenosis – it‟s probably caused by the
sudden opening of the deformed valve.

Opening snap
This is a diastolic sound heard in mitral stenosis and
associated with the tensing of the diaphragm formed by the
stenosed valve. It is best heard to the L of the sternum and
sounds a bit like the 2nd part of a widely split 2nd heart
sound.



99
Sounds from artificial heart valves
An artificial heart valve usually makes a noise both on
opening and closing. The closing sound is usually louder than
the opening sound, so an aortic prosthesis will have a soft
opening click just after the 1st heart sound and a loud closing
click that contributes to the 2nd heart sound. Conversely, a
mitral valve will give a soft opening click in a similar position to
the opening snap of mitral stenosis and a loud closing click
that contributes to the first heart sound.


                            Murmurs

A murmur is a more or less musical sound occurring at a
specific point in the cardiac cycle and resulting from turbulent
blood flow. The important points in analysing a murmur are
where it occurs in the cardiac cycle, what it sounds like, where
it is best heard, where it radiates to and what happens in
manoeuvres like deep breathing.

Systolic murmurs

3 causes:
*Leakage of blood through a structure that is usually closed
during systole (mitral or tricuspid valves or the interventricular
septum)
*Blood flow through a valve normally open in systole that has
become abnormally narrowed (aortic or pulmonary stenosis)
*Increased blood flow through a normal valve (a flow murmur)

Murmurs due to leakage of blood through an incompetent
mitral or tricuspid valve or interventricular septum defect are
usually of similar intensity throughout systole. They are called
pansystolic murmurs. In mitral prolapse (where the valve is
okay at the start of systole but then becomes incompetent)
you get a mid or late systolic murmur.

Murmurs that are due to blood being forced through a narrow



100
aortic or pulmonary valve or to increased blood flow through a
normal aortic or pulmonary valve tend to start quietly at the
beginning of systole, rise to a crescendo in midsystole and
then become quiet again. These are ejection systolic
murmurs.

Diastolic murmurs

These can be divided into:
Early diastolic murmurs – incompetence of the aortic or
pulmonary valve. Maximal at beginning of diastole when
aortic/pulmonary pressure is highest, and rapidly becomes
quieter as pressure in the great vessel falls. It is described as
a whispered letter „r‟.
Mid-diastolic murmurs – usually caused by blood flow through
a narrowed mitral or tricuspid valve, or to increased flow
through one of these (eg. children with atrial septal defect).

Innocent murmurs

These are murmurs that are not associated with any structural
abnormality or with haemodynamic disturbance. They are
common in children and young adults. They are: always
systolic, always quiet, usually best heard at the L sternal
edge, not associated with ventricular hypertrophy.

Differential of murmurs:

*Mid-systolic

Aortic stenosis
Pulmonary stenosis
Atrial septal defect
L and R outflow tract obstruction

*Pansystolic

Mitral regurgitation
Tricuspid regurgitation



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Ventricular septal defect

*Ejection-systolic

Innocent murmur
Aortic stenosis
Pulmonary stenosis
Hypertrophic cardiomyopathy
Flow murmurs (fever, athlete‟s heart)

*Mid-diastolic

Mitral stenosis
Tricuspid stenosis

*Early-diastolic

Aortic regurgitation
Pulmonary regurgitation

*Combined systolic and diastolic

Patent ductus arteriosus
Aortic stenosis and regurgitation

See also Kate‟s valve disease notes.

          Peripheral vascular system examination


1. Introduce yourself to the patient (you‟ll probably be told
they‟re having pain in their legs), check problem and patient
name, obtain consent.

2. Get the patient lying down to start with – need the lower
arms and all of the legs exposed.




102
3. Inspect from the end of the bed. You are looking for: scars,
obvious ulcers/gangrene etc, how the patient is holding their
limbs, muscle atrophy.

4. Examine the radial pulse‟s rate, rhythm, volume and
character. Assess both radial pulses at once for radial-radial
delay.

5. Feel the brachial pulse both sides.

6. Say that you would like to measure the BP in both arms at
this point.

7. Feel the carotid pulse both sides and also auscultate for
bruits/murmurs.

8. Palpate and auscultate over the abdominal aorta.

9. Inspect the legs fully for: signs of (pre) gangrene; ulceration
(describe if present); skin changes inc. varicose eczema, loss
of hair, pallor, damage from previous ulcers etc; scars from
operations (groin, inner thigh); varicosities.

10. Say if you thought you saw any varicosities you would ask
the patient to stand so you could see them better (increased
venous filling on standing) –see later notes.

11. Ask the patient if they have any tenderness in their legs.

12. Comment on any difference in skin temperature – use the
back of your hand and compare the two legs. Start at the feet
and move up – if it‟s normal in the feet there‟s little point in
going on. Colder in ischaemia (unless there is infection).

13. Look between the toes and at the heels for ischaemic
changes and guttering (= chronic ischaemia of the limb is
associated with onset of extreme pallor of the foot and
emptying – „guttering‟ – of dorsal foot veins with limb
elevation.



103
14. Look for reduced capillary return by compressing a nail
bed on each of the feet.

15. Palpate the arteries of the legs – comment on any
difference in character between the two legs:

Femoral artery – feel both together, auscultate and also time
with the radial artery.
The midpoint of the inguinal ligament, which stretches
between the anterior superior iliac spine and the pubic
symphysis.

Popliteal artery – feel in both flexed and extended positions.
Need to get the patient to relax hamstrings and calf muscles –
flex the patient‟s knee and place the thumbs of both hands on
the tibial tuberosity. Use the pulps of the fingers to palpate the
neurovascular bundle against the posterior surface of the
upper end of the tibia.

Posterior tibial artery – feel.
Midway between the medial malleolus and the heel.

Dorsalis pedis artery – feel.
Felt along a line that extends between the middle of a line
drawn between the two malleoli and the webspace between
the first and second toe (congenitally absent in 10% of
people).

16. Elicit Buerger‟s test – this is used as a rough guide to the
degree of ischaemia in the leg. The leg is elevated passively
     o
to 45 (it becomes pale and blanched in a poor arterial supply
because it can‟t be perfused against gravity). Then ask the
                                o
patient to hang their leg at 90 over the side of the bed – it
becomes cyanosed as the dilated vascular bed fills with
deoxygenated blood. Check the mobility of the patient‟s leg
before doing this.




104
17. Say that you would like to measure the ankle/brachial
pressure index and examine the foot for sensation.


Questions around the topic

How would you measure an ankle-brachial pressure index?
This is a measure of how well perfused the legs/feet are.
Need a hand-held Doppler and a sphygmomanometer.
Measure the brachial blood pressure and record the systolic
pressure. Then put the Doppler over the three pedal arteries
in turn (dorsalis pedis, posterior tibial and perforating
peroneal) whilst inflating the cuff. The pressure at which the
Doppler signal disappears is the systolic pressure of that
artery as it passes under the cuff. Take the highest pedal
artery pressure and work out: foot artery/brachial artery.

In health, ABPI should be 1+ in supine position.
Claudication: <0.8
Critical ischaemia: <0.4

What signs, other than you’ve looked for, might you expect to
find in vascular disease?
Hands: Nicotine stains
         Raynaud‟s syndrome
         Wasting of small muscles of hand (thoracic outlet
syndrome)
         Calcinosis (Scleroderma and the CREST syndrome)

Face: Corneal arcus and xanthelasma
(hypercholesterolaemis)
        Horner‟s syndrome (carotid artery problems)
        Prominent neck veins (axillary/subclavian vein
occlusion)

Abdomen:        Epigastric/umbilical pulsation (AAA)

**Remember the 6 P‟s of acute limb ischaemia**:




105
Pulseless, pallor, perishing cold, parasthesia, paralysis, and
pain and squeezing muscles.
How do you record pulses in notes?
Normal +
Reduced +/-
Absent -
Aneurysmal ++

                        Varicose veins


Most patients with varicose veins do not have any symptoms,
but if present they include discomfort/pain (especially on
standing and in heat), itching ankles, swelling, ulceration,
thrombophlebitis (pain, swelling and redness over the
varicose veins).

If you find a patient with varicose veins whilst doing a
peripheral vascular system exam:

1. Inspect - distribution of VVs; is it long or short saphenous?
Look with the patient standing and laying.

2. Feel the legs for any differences in temperature.

3. Feel the veins for localised tenderness, thickening and
induration (thrombophlebitis), ulcers, oedema around the
ankles.

                         o
4. Elevate the limb to 15 and note the rate of emptying of the
veins.

5. Perform the Trendelenberg test. Encourage the varicose
veins to empty by stroking them in the direction of flow and
raise the leg to remove blood further. Use fingers or a
tourniquet to occlude the saphenofemoral junction. Ask the
patient to stand. Remove the pressure – if the veins fill, there



106
is incompetence (if the incompetency is low down the leg, the
veins may still fill even if you are still occluding the
saphenofemoral junction). The principle of the test is that
varicose veins occur due to retrograde flow of blood through
incompetent valves from deep to superficial veins. If you stop
the backflow, the VVs remain collapsed, but fill when you
release the pressure because backflow can occur again.

6. Perform a tourniquet test. This is for when you think the
incompetency is low down the leg (eg. veins still fill even when
pressure applied to saphenofemoral junction in Trendelenberg
test). The veins are emptied of blood and the tourniquet
applied below the level of a suspected perforator. If there is
incompetence the veins will remain collapsed and will fill in a
retrograde manner when the tourniquet is released.

Questions around the topic


What other investigations might you want to do in a patient
with varicose veins?
Duplex ultrasound
Colour Doppler can identify retrograde flow of blood at
incompetent valves and perforators.

What is a varicose vein?
Varicose veins occur due to retrograde flow of blood through
incompetent valves from deep to superficial veins.

What is the basic anatomy of the long and short saphenous
veins?
Long saphenous vein passes anterior to medial malleolus up
the medial aspect of the calf to behind the knee, then up the
middle aspect of the thigh to join the common femoral vein in
the groin at the saphenofemoral junction. (ie. up medial
aspect of leg)
Short saphenous vein passes behind lateral malleolus and up
posterior aspect of calf. Commonly joins popliteal vein at the



107
saphenopopliteal junction – 2cm above posterior knee crease.
(ie. up back of calf)

How can lower limb venous disease present?
4 types of venous leg disease:
DVT
Varicose veins
Superficial thrombophlebitis
Chronic venous insufficiency and ulceration

The four cardinal symptoms they present with are: Pain,
Swelling, Discolouration, Ulceration

                     Breast examination

1. Introduce yourself, check patient‟s name, gain consent.

2. Ensure privacy and, if appropriate, get a chaperone.

3. Ask the patient to undress to the waist.

4. With the patient sitting comfortably with the arms at the
side, inspect the breasts. Look at size, symmetry and contour.
Also colour (eg, inflammation) and venous pattern.

5. Look at the nipples to see if there are eczematous changes,
Paget‟s disease of the nipple, inversion or Peau d‟orage.

6. Ask the patient to raise her arms above her head
(accentuates asymmetry), and then press them onto her hips
(accentuates contours).

7. Ask the patient to lie down, head supported by one pillow.

8. Ask, “Can you please show me where the lump is? Do you
have any pain in your breasts”.

9. Start examining in the opposite breast, opposite quadrant.
This means that you get used to the patient‟s breasts and they



108
get used to your hand. The arm on the side that you are
examining should be under the patient‟s head. Palpate the
quadrants of the breast systematically, with the flat of the
middle three fingers, starting and ending at the same spot –
you are trying to compress the breast tissue against the chest
wall. Another order of examining is to start in the area where
malignancy is least likely (lower medial) to most likely (upper
lateral). Then examine the tail of Spence (the axillary tail):

10. Whilst examining the nipple area ask, “Do you have any
discharge?”. If yes, ask the patient to elicit it themselves.

11. Repeat steps 9 and 10 for other side. If they have a lump,
you need to assess it (refer to notes on assessing any lump).

14. Ask the patient to sit up and examine the axillae. Take eg
their right arm with your right arm. Examine axilla with other
hand. Say, “Let me take all the weight of your arm”. Examine
all four walls (inc. medial border humerus, lateral chest wall
and all along axillary fold) and roof of axilla. If you find any
nodes you need to report size, shape, consistency, mobility
and tenderness.

15. Examine for lymphadenopathy (submandibular, anterior
posterior cervical chains, supraclavicular, infraclavicular).

16. Tell the patient they can cover up now.

17. Say, “I would also like to examine the spine for mets,
percuss and auscultate for pleural effusions, and feel for a
hard craggy liver edge.”


Questions around the topic

What are the causes of breast lumps?

Benign Fibroadenoma (mobile “breast mouse”)
       Simple cyst



109
        Fat necrosis
        Fibroadenosis (tender, “lumpy” breasts)
        Abscess (painful and tender)

Malignant Glandular
           Areolar
Usually hard and irregular – may be fixed to skin or underlying
chest wall muscle.

Why do you ask the patient to raise their arms and put them
on her hips?
This tightens the suspensory ligaments and exaggerates
abnormalities.

                    Writing up a drug chart


Drug charts vary between hospitals, so when you know where
your OSCE is going to be, go and get one from that hospital.
They are generally fairly self explanatory, but there are a
couple of points to bear in mind:


1. Any prescriptions which are to be given straightaway and
then regularly have to go in the once only box and also the
regular medication box.

2. Remember to write in the dates and then put lines through
when the drug is to be stopped, so it‟s clear that it‟s not to be
given after a certain date.

3. The pharmacy box never needs to be filled in by you – it‟s
for when the pharmacists do their ward rounds.

4. Normal times for drugs to be given tend to be at 6am,
10am, 4pm and 10pm.




110
See prescription charts for sample ways of filling in a
prescription for amoxycillin 500mg three times a day by mouth
for one week.


Abbreviations to use

Route of medication:
IM – intramuscular
SC – subcutaneous
IV – intravenous
O – oral
TOP – topically
Inh – inhalation

Maximum frequency
 o
4 – 4 hourly
OD – once daily
bds – 2x daily
tds – 3x daily
qds – 4x daily

Dose
mg
μg
g
ml
L
T (one tablet)
TT (two tablets)


              Digital rectal examination (DRE)

Equipment:

        Gloves
        Lubricating jelly



111
         Swabs

1. Ensure that your patient knows what you are going to do
and why. Use uncomplicated language – “I need to examine
your back passage using my finger to see if there are nay
problems there. Is that alright?”. Arrange for a chaperone to
be present (they should stand on left of patient to reassure
them).

2. Position your patient lying on their left side, with their knees
pulled up towards their chin and their back near the edge of
the couch.

3. Put on gloves and have lubricating jelly and a paper tissue
within easy reach.

4. Lift the patient‟s right buttock with your left hand and
inspect the anus carefully, using a good light. Look for
haemorrhoids, fissures, skin tags, warts etc.

5. Put a little jelly on the pad of your right index finger.

6. Explain to your patient that they will feel pressure, and
probably a feeling like wanting to empty their bowels.

7. Place your finger on the anus. Do not force it in but wait
patiently until you feel the sphincter relax. Note the tone of the
anal sphincter.

8. Gently pass your finger in, with the pulp facing posteriorly,
trying to form a mental picture of the anatomy as you do so.
Watch your patient‟s face throughout the procedure to detect
if you are causing pain.

9. Gently insert your whole finger and sweep round the rectum
systematically, feeling for abnormalities in the lumen, the
rectal wall, the perirectal tissues and beyond. The normal
rectum feels uniformly smooth and pliable. Note faecal
presence (rectum should normally be empty) and consistency,



112
rectal mucosal condition and whether there are any extra
rectal masses.

10. To feel the prostate, sink down on one knee and pronate
your wrist. Identify the prostate gland and assess its size,
hardness and whether you can feel the midline sulcus.

11. In a female patient you will usually feel the cervix
anteriorly. This is normal.

12. Remove your finger and examine the glove for traces of
stool, mucus or blood. If there is blood, what colour is it?

13. Wipe any gel from the anus and perineum.

14. Ensure that your patient is comfortable and covered.


**The normal prostate has a median sulcus separating the two
lobes. This sulcus may become indistinct in a benign
hypertrophied prostate, and the gland feels firm and smooth
and bulges more than 1cm into the lumen. A carcinomatous
prostate feels hard and irregular and the median sulcus is
obliterated**


                 4. Using an opthalmoscope


1. Make sure you know the parts of the instrument and how it
works. Turn it on and shine it on the back of your hand to
ensure that the correct beam shape is selected and that the
battery is functioning.

2. Set the lens wheel to zero.

3. Explain what you are going to do, that you are going to dim
the lights and that you will be moving close to the patient‟s



113
face. Ask the patient to focus on an object straight in front of
them in the distance.

4. Dim the lights – if necessary, use tropicamide drops 0.5%
to dilate the patient‟s pupil.

4. Hold the instrument in your right hand, with the light beam
shining towards the patient slightly nasally. Steady it against
your right cheek.

5. Shine the light into your patient‟s right eye, looking for a red
reflex from the back of the retina.

6. Move slowly towards the patient, and stop just clear of the
eyelashes. Adjust the lens wheel as necessary, according to
their refraction and yours, so you can see the lashes very
clearly.

7. Then try to focus on the fundus by adjusting the lens wheel
further so you can see the retinal veins. If the patient is short
sighted, a (minus-concave) lens is needed – if they are long
signed a (plus-convex) one.

8. Identify the retina (pink background with blood vessels) and
follow each of the arteries (superior, inferior, nasal and
temporal) and accompanying veins. Identify the optic disc,
where they all converge – examine it as though it were a
clock, with the disc itself at the centre (should be 1.5mm
diameter). You will have to keep adjusting the focus. Report in
turn: the optic disc‟s size, shape and colour; the blood vessels
(arteries narrower and brighter than veins) (pulsation of retinal
veins is normal in normal ICP; it caeses in raised ICP); the
fundus for exudates and haemorrhages.

9. Look at the macula by asking the patient to look directly at
the light.

10. Change the instrument to your left hand and left eye and
repeat the process with the patient‟s left eye.



114
                 Examine the eyes (vision)


*Don‟t focus just on using the opthalmoscope!

The exam needs to be broken into a number of steps
according to the cranial nerves (II, III, IV, VI).

1. Introduce yourself to the patient and check their name –
explain each step of what you are about to do as you do it.

2. Inspect the patient. Look at the face and head for abnormal
head posture, asymmetry or facial dysmorphia. Then look
more closely at the eye: patient may be wearing glasses
(dark if eye pain), people with double vision often close one
eye, when central vision I lost, people may not make eye
contact.

3. Test for visual acuity. Test each eye separately (by
covering the other eye with a hand) using a Snellen chart (at
6m), near vision chart or a magazine/newspaper with the
patient wearing and not wearing glasses/contact lenses.
Visual loss can be graded at the bedside by asking if the
patient can read ordinary typeface/newspaper headlines/can
count fingers/can see handwriting/can distinguish between
light and dark.

4. Test the visual fields. Test by confrontation – stand
opposite the patient at the same level and ask the patient to
cover one eye – you cover the opposite eye. Then, using
fingers in each of the four quadrants, compare what the
patient can see with what you can see. Then same for the
other eye. You have to sort of wiggle your finger towards the
eye, but if available red or white headed pins are meant to be
used. Say, “I‟m going to move my finger like this… the I need
you to cover one eye, and I want you to tell me as soon as
you see my finger”.



115
You can also check for central field defects by moving a test
object across the visual field. Lastly, test for visual inattention
by using bilateral simultaneous stimulation.
You and the patient must keep looking straight ahead through
all these steps.

5. Test colour vision. Use Ishihara plates 75cm from face, one
eye at a time.

6. Detailed inspection of eye. Ask the patient to look up, look
down etc.

7. Test for the accommodation reflex. Ask the patient to look
at an object in the far distance and then quickly at your finger
close to their nose (20-30cm). You are looking for:
convergence/slight ptosis/meiosis.

The next two steps need to be carried out in a dimly lit room:

8. Test for the light reflex. Test for direct and indirect papillary
reflexes using a pen torch. Examine and comment on shape,
size and irregularity of the pupil using the other eye to
compare. You should shine the light in from the side and
below to avoid an accommodation response – use the light on
the opthalmoscope.
Direct light reflex: shine light into eye, pupil constricts.
Consensual light reflex: shine light into R eye, L pupil
constricts.

9. Use the opthalmoscope. See earlier for details of how to
use.

10. Test the eye movements. This tests the III, IV and VI
cranial nerves together. Look for and comment on strabismus
(squint) either convergent or divergent. Fix the head with one
hand and ask the patient to follow your finger with their eyes.
Use the H pattern for individual muscles.




116
11. During the above, ask about diplopia at any stage. The
rules of diplopia are:
-diplopia is maximum when looking in the direction of the
impaired muscle
-the false image is less distinct than the true image
-the false image is displaced furthest in the direction of action
of the impaired muscle

12. Look for nystagmus (normal on extreme gaze) whilst
assessing the eye movements. Nystagmus is named
according to the direction of fast movement:
-always maximum when looking in the direction of fast
movement
-fast movement TOWARDS central lesion (eg. cerebellum)
-fast movement AWAY peripheral lesion (eg. vestibular
apparatus)



Extensions to the station could include:

-visual acuity problem – monocular blindness, MS
-visual field loss – esp. homonymous hemianopia in stroke
-abnormalities on opthalmoscope inc. cataracts, retinopathy,
optic atrophy (need to do MRI if see this), Papilloedema,
hypertensive retinopathy, nystagmus, oculomotor palsies
(esp. VI).

Questions around the topic

How is visual acuity recorded?
The visual acuity is expressed as the ratio of the distance
between the patient and the card (usually 6m) and the figure
on the chart immediately above the smallest visible line. An
acuity of 6/18 therefore means that, at 6m from the chart, the
patient is able to read down to only the 18m line. Make sure
the patient wears glasses if they contain a distance correction.
If the glasses are not available, reading through a pinhole will
correct for any myopia.



117
If the patient is unable to read the 60m line at 6m, they can
redo the test at 3m. The visual acuity for that eye will be
recorded as 3/?. A visual acuity of less than 1/60 can be
tested using fingers or light perception.

Are there any contraindications for mydriatics such as
tropicamide?
They shouldn‟t be used in patient‟s with glaucoma.

What might fundoscopy be able to show?
Diabetic retinopathy (cotton wool spots/hard
exudates/microaneurysms/haemorrhages)
Hypetensive retinopathy (as for diabetes)
Retinal artery/vein occlusion
Cholesterol emboli and deposits
Drusen (hyaline bodies)
Glaucoma
Papilloedema
Optic atrophy
Myelinated nerve fibres (congenital)

If there was no red reflex, what might this mean?
There is something blocking the light from being reflected off
the retina, such as a cataract.


               Using an otoscope/auroscope


1. Introduce yourself to the patient, check their details and
gain consent.

2. Attach a clean otoscope funnel (use the largest that will fit
in the patient‟s ear) to the instrument and ensure that the
battery and light source are functioning.

3. Explain to the patient what you are about to do.




118
4. Look at the outer ear for any redness or secretions or any
evidence of ear surgery/hearing aid fittings.

3. Ask, “Do you have any pain in your ear?”. To examine the
patient‟s right ear, hold the instrument in your right hand
between your index finger and thumb and end pointing
parallel to patient‟s face. Gently pull the patient‟s pinna
upwards and backwards to straighten the external auditory
meatus.

4. Insert the otoscope gently into the ear canal. Observe the
external auditory canal, then identify the tympanic membrane
and note its characteristics. Identify the ossicles beyond it
(see wall charts in the Skills Lab and pics from textbook).

5. If there is suspected infection in one ear only, remember to
change the funnel before going on to repeat the process in
the other ear.

Refer to the picture of the normal anatomy of the tympanic
membrane for how to describe it – normal would be
something like, “The tympanic membrane looks to be
completely intact, and there is no redness, swelling or
grommets. I can‟t see any fluid behind the membrane. The
cone of light is present and I can see the handle of the
malleus. Everything appears to be normal”.

                        Test hearing


1. Introduce self to the patient and check who they are.
Explain what you are about to do. Ask them which ear they
think the problem is in.

2. Test for deafness by rubbing fingers next to each ear. Then
use a quiet whisper (repeat numbers) whilst covering the
other ear, and ask the patient to repeat the number (2 in each
ear).




119
3. Using the tuning fork, ping it and hold it next to each of the
patient‟s ears in turn – check they can hear it and ask them
which ear it is louder in.

4. Perform Rinne‟s test. Ideally the tuning fork should be 512
Hz (high pitched – low pitched is used to test vibration). Ask
the patient to tell you in which position the noise is louder.
Strike the tuning fork and place it firmly on the bone behind
the ear (mastoid process). Then place it parallel to the ear,
with the tines vibrating towards the ear canal. For a Rinne‟s
positive (normal) test, the second sound should be louder (air
conduction > bone conduction). If the middle ear mechanism
is damaged then BC>AC.

5. Perform Weber‟s test. Strike the tuning fork and place it in
the middle of the forehead. It should be heard in the middle. In
sensorineural deafness Weber‟s is AWAY from the affected
side. In conductive deafness it is TOWARDS (ie. you need to
use Rinne‟s to distinguish between a sensorineural deafness
in the L ear and a conductive deafness in the R ear if the
patient hears it louder on the R).

6. Use the auroscope - see earlier for how to do this. Need to
be able to recognise perforation, otitis media, grommets.




                 Cranial nerves examination



1. Introduce yourself to the patient, check name and gain
consent – “I would like to see how the nerves in your head
and neck are working. Is that okay?”

2. CN I: Olfactory nerve (not often tested)




120
Ask, “Have you noticed any changes in your sense of smell or
taste recently?” Most common way of testing smell is to use
squeeze bottles with a nozzle that can be inserted into each
nostril in turn.


3. CN II: Optic nerve (see the vision notes for how to do
components)


Ask the patient how many fingers you are holding up in front
of them, one eye at a time. Test visual acuity using Snellen
chart, colour vision with plates, visual fields and also do
fundoscopy.

4. CN III, IV and VI: Oculomotor, trochlear and abducens
nerves


Look at the eyelids and pupils closely. Then do papillary light
response, including swinging light test (A unilateral depression
of the light response may be obvious but a defect of the
afferent pupillary pathway is best appreciated by swinging the
torch from one eye to the other. As the torch swings from,
say, the right eye to the left, the pupil of the latter, which has
just started to dilate because of the loss of its consensual
reaction, immediately constricts.)
Lastly, test for nystagmus and all the eye movements by
placing your hand on the patient‟s head to keep it still and
asking him/her to follow your finger as you make an H shape.

5. CN V: Trigeminal nerve


Sensory:
a. Touch cotton wool to the patient‟s sternum – “I‟m going to
touch you on the face like this. Can you please say “yes”
every time you feel me touch you. Can you just close your



121
eyes for me?” Test light touch by touching the appropriate
areas of the face with a wisp of cotton wool.
Then test pinprick sensation at the same sites. Distribution is
forehead and down front of nose, sides of nose and under
eyes, down sides of head and over jaw and chin.

b. Corneal reflex – ask the patient to look up to the ceiling
(exposing the lower cornea) and touch the lower eye from the
side with a point of cotton wool. The patient should blink. (This
is quite unpleasant so you may not want to do it in the exam)

Motor:
The Trigeminal nerve supplies the muscles of mastication
(temporalis, masseters and pterygoids)

a. Look for muscle wasting before testing the muscles of
mastication.

b. Ask the patient to clench their teeth – palpate the jaw whilst
they do so.

c. Wiggle jaw from side to side – pterygoids.

d. Jaw jerk – ask the patient to lack their jaw open slightly –
place your index finger the point of the jaw. With the patella
hammer gently strike your finger in a downward motion. In a
+ve jaw jerk the muscles contract and the mouth will close.



6. CN VII: Facial nerve

Predominantly motor – look for, and comment on, any facial
asymmetry.

Upper face – furrow the brow, elevate the eyebrows, screw up
the eyes against you trying to open them.



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Lower face – blow out cheeks, whistle, show teeth.

7. CN VIII: Vestibulocochlear nerve

See separate notes. Do hearing by asking the patient if they
can hear your fingers rubbing together and whispered
numbers, Rinne‟s and Weber‟s and you might also want to
check vestibular function (by throwing them over the end of
the couch – but possibly not in the exam).

8. CN IX: Glossopharyngeal nerve

Traditionally this is tested by doing a gag reflex:
To carry out, press the end of on orange stick first onto one
tonsillar fossa then the other. Besides confirming that the
palate rises in the midline, ask the patient if the sensation is
comparable on the two sides. In the presence of a
glossopharygeal lesion, the gag reflex is depressed or absent
on that side.

However, this is really unpleasant and a better way of
assessing it is to ask the patient to swallow (tests X as well).
Do it in front of and from behind the patient.

9. CN X: Vagus nerve


Ask the patient to open mouth and say “aaaah”. With a
torch/tongue depressor, observe the uvula to see if it is pulled
to one side.

10. CN XI: Accessory nerve


The spinal component of the accessory nerve can be tested
by examining trapezius and sternomastoid.




123
Trapezius - ask the patient to shrug their shoulders, first
without and then with resistance.

Sternomastoid - can be tested by asking the patient to turn
their head to each side against resistance – feel the opposite
side of the neck whilst they do so.

11. CN XII: Hypoglossal nerve

a. Ask patient to open their mouth - inspect the tongue as it
lies in the base of the oral cavity using a pen torch.
Fasciculation imparts a shimmering motion to the surface of
the tongue. Involuntary movements include a coarse tremor,
in PD, and complex unpredictable movements, such as in HD.
As the tongue wastes, it becomes thinner and more wrinkled.

b. Ask the patient to poke their tongue out and look to see if it
points to one side (towards weakness).
   Peripheral Nervous System examination – upper limb


**In summary this goes inspect, tone, power, coordination,
reflexes, sensation (touch, pain, vibration, proprioception,
temperature).**

1. Introduce yourself to the patient, check name and gain
consent – “I would like to see how the nerves and muscles in
your arms are working. Would that be okay? Do you have any
pain in your arms at all?”.
                                                               o
2. You can do the examination with the patient lying at 45 or
sitting up, whichever is more comfy – you need to remember
to compare sides at every step, remembering that what
seems like hyporeflexia might actually be normal but the other
side is hyperreflexia

3. INSPECTION




124
You are looking for:

    a. Palsies:
    * Hemiplegia – flexed upper limb, extended lower limb
    * T1 palsy – weak finger adduction and abduction.
Sensory loss to medial forearm.
    * Radial nerve palsy – wrist drop. Sensory loss on small
area of dorsal web of thumb.
    * Median nerve palsy – adductor pollicis brevis weakness.
    Sensory loss thumb, first two fingers, palmar surface.
    * Ulnar nerve palsy – interversion, hypothenar muscles
    wasted, claw-hand, cannot extend fingers. Sensory loss,
    half fourth, all fifth fingers, palmar surface.
    * Erb-Duchenne  waiter‟s tip.

    b. Abnormal movements:
    * Tremor – Parkinsonian (coarse rhythmical tremor at rest,
    lessens on movement), thyrotoxicosis (a fine tremor of the
    outstretched hands)
    * Chorea – abrupt, involuntary, repetitive, semi-purposeful
movements
    * Athetosis – slow, continuous writhing movement of a
limb
    * Spasm – exaggerated, involuntary muscle contraction

    c. Muscle Wasting:
    * Symmetrical – e.g. DMD
    * Asymmetrical – e.g. poliomyelitis
    * Proximal – e.g. limb-girdle muscular dystrophy (Guillain-
Barre syndrome?)
    * Distal – e.g. peripheral neuropathy
    * Generalized – e.g. MND
    * Localized – e.g. with joint disease

      d. Fasciculations = irregular involuntary contractions of
         small bundles of muscle fibres, not perceived by the
         patient. This is a type of denervation, eg. with MND. It
         is caused by the death of anterior horn cells.



125
      e. Does the patient appear to be using both arms? Be
      suspicious if they are holding one arm up with the other or
      holding one arm across themselves for support (UMN
      lesions typically).

4. Test for pronator drift – ask the patient to stretch their arms
out in front of them, palms facing up and close their eyes.
Look for the palm turning downwards. Also tap the arms down
gently – they should return to their resting position (if they
overswing there may be a cerebellar problem.




5. TONE

Ask the patient to relax their limb as much as they can and
say, “I‟d like to shake hands with you in a funny way”. Hold the
arm at the wrist and move it across the shoulder and elbow
joints, once fast, once slow spasticity is best brought out by
rapid movement, extra-pyramidal lesions are best brought out
by slow movement.

6. POWER

Here you can test both sides at once:

         Shoulder abduction (C5) “I want you to shrug up your
          shoulder like this… And don’t let me push them
          down”.
         Elbow flexion (C5 & C6). “Hold up your arms like this
          and pull towards yourself and pull me towards you”.
         Elbow extension (C7). “Keep your arms there but
          push me away now”.
         Finger grip (C8, T1). “If I put two fingers in front of
          you, can you make a fist and squeeze as hard as you
          can”.



126
         Finger spread (dorsal interossei, ulnar nerve,
          T1)”spread your fingers out for me – now stop me
          pushing them back together. Now squeeze your
          fingers together (put your fingers each side of hand)
          and try to spread them out again”.
         Finger adduction with paper (T1). “Now I’m going to
          put this piece of paper between your fingers. Can you
          squeeze it there whilst I try to pull it away?”
         Fine movements – “Can you touch each of your
          fingers to your thumb please? Thank you”

Power at main joints cannot normally be overcome by
permissible force. Use grading system:

5 – Normal power
4 – Movement against gravity plus resistance
3 – Movement against gravity
2 – Movement without gravity
1 – Palpable contraction with no active movement
0 – No active contraction

7. CO-ORDINATION

*Intention tremor – “Touch your nose, then my finger” from
about 30cm, then move finger around.

*Dysdiadochokinesia (inability to execute rapid alternating
movements)- “Put one palm one the other like this… Then
turn it over… and again… and keep doing that as fast as you
can.”

*Nystagmus – “Please can you follow my finger with your
eyes”. Put one hand on forehead and with other make an H
shape.

8. REFLEXES

Ask the patient to completely relax with their arms hands
clasped gently on abdomen – “I‟d like to look at your reflexes



127
now. It might be a strange sensation, but it shouldn‟t be
uncomfortable”.

*Biceps tendon (C5-C6) – hit with two fingers over it.
*Triceps tendon (C7-C8) – hit straight onto the tendon.
*Supinator (distal end of radius) (C7-C8) – tap with two fingers
over it – get the patient to sort of hang their hands down.

If you have trouble eliciting reflexes, can ask patient to tense
e.g. clench teeth, buttocks, pull hands apart, etc –
REINFORCEMENT.

Reflexes can be graded as below:
0      Absent
+/-    Present only with reinforcement
+      Just present
++     Brisk normal
+++    Exaggerated response

9. SENSATION

Light touch
Ideally use cotton wool – touch it to the sternum first. “I‟m
going to touch you with this piece of cotton wool. This is what
it should feel like. Now I‟m going to touch it to your arms and I
want you to say “yes” every time you feel it. Let me know if it
feels numb or unusual. Is that clear?” “Can you just close your
eyes for me? Thank you”
Touch to dermatomes of T2-C4 (start peripherally) on both
sides.

Pain
You can use a broken in half tongue depressor for this, but
ideally neurological pins. Touch pin to sternum. “Now I‟d like
to test how well you can feel sharp touch. This is what it
should feel like. Like before, please tell me when you feel me
touching you and if it feels strange or numb.”
Touch in same areas. (If you want to localise a lesion, it‟s
easier with pain than fine touch.)



128
Vibration
Use a 128Hz tuning fork (the large one) and remember to hold
it in the middle not on the prongs. Put on sternum initially so
the patient knows what vibration feels like. “I‟m going to place
this on some points on your arms. Please tell me when you
feel it and when it stops buzzing”. Place on bony prominences
– distal phalanx, distal radius, elbow and touch to stop it. If
you suspect that they are feeling the cold not the vibration, get
them to close their eyes and put the tuning fork on them when
it isn‟t vibrating.

Proprioception
There are two ways of doing this:

a. Hold distal to the joint you‟re testing and make small
movements in a random, not alternate fashion. Ask if moving
joint up or down. Should nearly always be right. “I‟m now
going to move your finger (DIP) – this is up and this is down.
Now close your eyes and tell me if you feel your finger move
up or down”.

b. Tell patient to hold hands outstretched, fingers facing in
towards eachother. “Close your eyes and try to touch the tip of
your right middle finger to the little finger on your left hand.”

9. Say that you would like to examine the PNS in the legs and
also observe the patient walking if possible.




129
  Peripheral Nervous System examination – lower limb


**In summary this also goes inspect, tone, power,
coordination, reflexes, sensation (touch, pain, vibration,
proprioception, temperature).**

1. Introduce yourself to the patient, check name and gain
consent – “I would like to see how the nerves and muscles in
your legs are working. Would that be okay? Do you have any
pain in your legs at all?”.
                                                              o
2. You can do the examination with the patient lying at 45 or
sitting up, whichever is more comfy – you need to remember
to compare sides at every step, remembering that what
seems like hyporeflexia might actually be normal but the other
side is hyperreflexia.

3. INSPECTION

You are looking for: palsies, abnormal movements, muscle
wasting, fasciculations and how comfortable the patient‟s legs
look at rest. Also look around for walking aids.

4. TONE

Say, “Can you just let your legs go all floppy – I‟m just going to
move them around”. Bend the knees and the ankles. Roll the
legs to check the hips.

5. POWER

          * Hip flexion (L1, 2) – “Keeping your leg straight, can
you lift your leg off the bed?
                                  Now don’t let me push it down”.
          * Knee flexion (L5, S1, 2) – “Now bring your heel
towards you. Bring it in towards your



130
                                      bottom, don’t let me pull it
                               away”
         * Knee extension (L3, 4) – “Now try to push it down
straight again, push me away.”
         * Plantar flexion (S1) – “Point your toes up to the
ceiling, and press down against me”
         * Dorsifliexion (L4, 5) – “Now pull up against me, stop
me pushing your toes down”

Only severe weakness will be detected as legs are stronger
than arms. Hip weakness is easily missed. Might be more
useful to ask patient to do functional tasks, raise their weight
from a chair (also in other areas, undo buttons, pour a glass of
water…)

6. CO-ORDINATION

Say, “I‟m going to move your leg and I‟d like you to copy the
movement when I‟ve finished”. Take heel of one leg, place on
shin of other and move it down. Take off at ankle and put back
just under knee (heel-shin test).

7. REFLEXES

         Tendon knee reflex – “I‟m going to take the weight of
          your leg – let it go all floppy please”. Raise knees
          with one arm, tap with other (probably from right side
          of bed, lift with left, tap with right). Compare both
          knees.

         Ankle reflex. “Bend your leg like a frog”. Pull the foot
          so it‟s at right angles with the calf. Then tap Achilles
          tendon. Often absent in the elderly.

         Clonus – if a brisk reflex is detected, check for clonus.
          A sharp, sustained dorsiflexion of the foot may result
          in the foot “beating” for many seconds. Clonus
          confirms an increased tendon jerk and suggests a
          UMN lesion. A few symmetrical beats may be normal.



131
          Do not do in OSCE as you’ll probably break their
          ankle!!

         Plantar reflexes – scratch up the lateral side of their
          foot with end of tendon hammer. “I‟m going to stroke
          the site of your foot with this… It won‟t hurt, but you
          might not like the sensation”. Plantar flexion is normal.
          Dorsiflexion, or extension, is abnormal in those over 6
          months of age. Irritating to decide if normal or not; use
          first movement of toes.

8. SENSATION

This is done in the same way to the upper limb. (bony
prominences for vibration are ankle and knee, do the big toe
for proprioception).

9. GAIT

Get the patient to walk a short way down the ward. Ask them
to do a heel-tie walk to check for ataxia. Next ask them to
stand still and shut their eyes – stand behind them to catch
them if they fall. Romberg‟s is essentially a test of position
sense. Any falling is positive. Hysterics may fall sideways but
stop before they fall. +ve = posterior column problem.

 “Are you alright to walk? Could you walk to that (defined)
point, and back? Thank you. Can you now do it with your heel
touching your toe, like this (demonstrate), like you were
walking on a tightrope? Thank you. Can you now walk on you
heels? And now on your toes? Can you now stand with your
feet together and your arms outstretched? Could you now
close your eyes?


                        Gait disturbance


Parkinson’s disease



132
Flexed posture, loss of arm swing when walking, small steps,
lean forward, difficulty in stopping and changing direction to
command.

Hemiparesis (stroke)
Arm may be flexed and adducted across body (no arm swing).
Leg is extended with circumduction when the patient has to
swing the leg around (cannot flex the knee – foot would catch
on floor if leg brought straight through).

Cerebellar disease
Wide-based posture (sway with eyes open). Needs to hold on
to something to walk.

Foot drop (lateral popliteal palsy)
High-stepping gait on that side to prevent the foot catching as
person brings leg through. Foot drop can be observed (lesser
degrees brought out by asking patient to stand on heels).

Peripheral neuropathy
High stepping „stomping‟ gait as patient is unaware of position
of feet. Very careful as they walk.

Arthritis
Painful gait (antalgic). Does not want to weight bear through
affected joint. Quickly steps through to transfer weight through
other leg.

           Lesions that may produce PNS signs


Lower motor neurone lesion
All arrows go down. Wasting, fasciculation (because of
increased sensitivity of receptors to ACh), hypotonia, less
power, absent reflexes, may or may not have sensory loss.
Summary: muscle weakness, depressed reflexes,
fasciculation, wasting, flaccidity.




133
Upper motor neurone lesion
All arrows up. No wasting. Hands drift down. Overswing when
outstretched arms tapped. Clumsy “piano playing”. Hypertonia
– spastic flexion of upper limbs, extension of lower limbs,
clasp knife rigidity. Diminished power. Increased reflexes,
maybe with clonus. Positive Babinski's sign. Maybe sphincter
disturbance. Spastic gait.
The effects of an UMN lesion are typically seen on one side of
the body, contralateral to the lesion.
Summary: muscle weakness, increased reflexes, extensor
plantar response, spasticity.

Cerebellar dysfunction
No wasting, hypotonia with overswing, intention tremor,
dysdiadochokinesia, ataxic gait (deviates to side of lesion if
only in one hemisphere, unsteadiness if midcerebellar),
nystagmus, scanning or staccato speech (dysarthria = defect
of pronunciation, though content is normal. Eg. say “baby
hippopotamus”), incoordination not improved by sight (cf a
sensory deficit).
Examination of cerebellum: articulation, check for nystagmus,
finger-nose and heel-shin tests, gait. The cerebellum is
supplied by the cerebellar arteries, which arise from the
basilar and vertebral arteries.
Causes of cerebellar lesions: infarcts, haemorrhage, tumours
(usually metastatic), MS, alcohol related, hypothyroidism.

Extrapyrimidal dysfunction (e.g. PD)
Flexed posture of body, neck, arms, legs (creep). Involuntary
movements. Expressionless, impassive faces, staring eyes.
Pill-rolling resting tremor. Delay in initiating movements
(akinesia, bradykinesia). Tone – lead pipe rigidity, possibly
cog-wheel with tremor. Normal power, sensation. Speech
slurred. Gait – shuffling small steps, possibly with difficulty
starting, stopping. Assess bradykinesia by asking the patient
to „polish‟ one hand with the other – the movement will fade
away.
Multiple Sclerosis (MS)



134
Evidence of “different lesions in space and time” from history
and exam. Different sites of white matter lesions shown by
optic neuritis, nystagmus (vestibular or cerebellar tracts), brisk
jaw jerk (pyramidal lesion above CN5), cerebellar signs in
arms/gait, UMN signs in arms/legs (pyramidal lesion, left or
right), transverse myelitis with sensory lesion, urine retention
or sensory perception loss (both loss of sensory tracts).
                Examination of a lump (any site)


S: site, size, shape, sounds
C: colour, consistency, contour
T: tethering, transillumination, temperature
P: pulsation, pain


1. Introduce yourself to the patient, check their name and gain
consent, “I understand that you‟ve found a lump on your…
Would it be alright if I examine it? Please could you show me
exactly where it is?”

2. Inspect the mass carefully. Note site, size, shape and
changes in the overlying skin.

3. Lay hand on the mass to see what the temperature of the
skin and the lump itself is.

4. Gently palpate the lump to elicit any tenderness. This will
also allow you to accurately define the size and shape of the
mass. Record finding diagrammatically.

5. Keep your hand on the lump for a few seconds to check for
pulsation. If you feel it, decide whether it is referred pulsation
or whether it is fro the mass itself (2 fingers either side,
upwards and outwards means it‟s from the mass itself).

6. Assess consistency (cystic, solid, hard, soft, fluctuant),
surface texture and the margins of the mass.




135
7. Attempt to pick up a fold of skin over the swelling to assess
skin fixation, and assess the mobility of the skin on the
contralateral side.

8. Determine fixation to deeper structures by attempting to
move the swelling in different planes relative to the
surrounding tissues. Contract the muscles around it to see if it
is attached to them.

9. Look for fluctuation by compressing the swelling suddenly
with one finger, using another finger to determine if a bulge is
created – confirm the presence of fluctuation in 2 planes.

10. Auscultate for vascular bruits and other sounds.

11. Test for transillumination – darken the surroundings and
press the lit end of a pen torch onto one side of the swelling. A
cystic swelling will light up if the fluid is translucent, provided
covering tissues are not too thick.

12. Examine neighbouring lymph nodes. These may be
enlarged due to spread of Ca or inflammation from infection.


“Sudden” finding of a lump by a patient does not necessarily
imply that it has only recently developed. Important to ask if
there has been any change in size or other characteristics
since it was first detected, and whether there are any
associated features such as pain, tenderness or colour
changes. History of preceding events may also be of
diagnostic help. Sometimes physical examination will reveal a
lump of which the patient is unaware.

                      Examining a hernia

Examination of the hernial orifices should be part of all
abdominal examinations. The three main types of hernia are
femoral, inguinal and umbilical.




136
Examination of femoral and inguinal herniae (inguinal
more common 4:1)

1. Introduce yourself to the patient, check name and gain
consent. “I understand that you‟ve found a swelling in your
groin. Would it be alright if I examine it?”

2. Expose the patient from abdomen to mid-thigh. “Can you
show me where the swelling is?”

3. Inspect:
      Ask the patient to turn their head to one side and
        cough. Look at both inguinal canals for an expansile
        impulse. If a swelling is visible, note whether it
        extends into the scrotum and whether it is above or
        below the groin crease.
      If no impulse is apparent, then place your hands over
        the inguinal canals, in line with the inguinal ligament.
        Ask the patient to give a loud cough and feel for an
        expansile impulse. This may be best done with the
        patient standing.
      Look for any scars from previous hernia operations or
        any skin changes over the hernia.

4. If there is a scrotal swelling, try to “get above it”. If you can,
it can‟t be a hernia and there‟s no point in doing the rest of this
exam – go to examination of scrotum and lumps.

5. Having determined that there is a swelling present, you
need to decide if it is femoral or inguinal:
     Locate the pubic tubercle (small bony prominence
        2cm from the midline on the pubic crest).
     If the hernial sac passes medial to and above an
        index finger placed on the pubic tubercle then the
        hernia must be inguinal in site.
     If the hernial sac passes lateral to and below an
        index finger placed on the pubic tubercle then the
        hernia must be femoral in site.



137
6. Ask, “Is there any tenderness over the swelling? I‟d like to
feel it now”.

7. Feel the hernia to try and identify:
     Temperature, tenderness, size, shape,
         transillumination, consistency and cough impulse.
     What are the contents of the sac? Bowel tends to
         gurgle and is soft and compressible. Omentum is
         firmer and doughy.
     Is the hernia reducible? Best decided lying down. Ask
         the patient if it is reducible and if so get him to reduce
         it himself to prove this. It is more painful is the
         examiner reduces it himself. Try doing it yourself
         gently if the patient can‟t do it.
     Is the hernia direct or indirect? Again best done lying
         down. Inspect the direction of impulse. A direct hernia
         tends to bulge through the posterior wall of the
         inguinal canal, whilst in an indirect hernia the impulse
         can often be seen to travel obliquely down the
         inguinal canal. Also if you place on finger just above
         the mid-inguinal point (over the deep inguinal ring), if
         the hernia is controlled by this finger then it must be
         an indirect inguinal hernia.

8. Percuss the hernia – it may be very resonant if there are
loops of bowel in it.

9. Auscultate the hernia – bowel sounds are heard if there are
viable loops of gut – they are absent in strangulation.

10. Examine the other side of the abdomen, then say that
you‟d like to perform a complete abdominal examination.

Umbilical hernia

These are common in infants under 2 years (most heal
spontaneously). Children of African descent have a high



138
incidence of umbilical hernias, which usually require surgical
correction.

If the umbilicus is everted than an umbilical hernias may be
present. This can be confirmed by feeling an expansile
impulse on palpitation of the swelling when the patient
coughs. You basically have to examine these as you‟d
examine any lump.



Questions around the topic

What is a hernia?
A hernia is a protrusion of part of or the whole of a viscus
through a defect that may be normal or abnormal (congenital
or acquired), in the wall that contains it.

What types of hernia can you get?
Inguinal, femoral, umbilical, incisional, hiatus and, rarely,
obturator, lumbar, Spigelian (through a defect in the lateral
border of the rectus sheath).

What is the differential diagnosis of an inguinal hernia?
(commoner in men)
Femoral hernia (below the groin crease, below and lateral to
pubic tubercle)
Large hydrocoele of cord/tunica vaginalis (may mimic
irreducible hernia but you can probably
                                             get above it
Communicating hydrocoele (transilluminates and is fluctuant)
Large cyst of the epididymis
Undescended or ectopic testis (there with be an empty
scrotum)
Lipoma of the cord.

Differential diagnosis of a femoral hernia? (commoner in
women)



139
Inguinal hernia
Lipoma in femoral triangle
Aneurysm of femoral artery (expansile pulsatation will be
present)
Enlarged inguinal lymph node (look for generalised
lymphadenopathy and examine drainage
                                areas)
Saphena varix (thin and blue, easily compressible, usually
obvious varicosity of the long sap)

What is the difference between a direct and an indirect
inguinal hernia?
An indirect inguinal hernia forms when bowel or omentum
protrudes through a lax internal inguinal ring and finds its way
into the inguinal canal. Bowel may force its way through the
external ring and may slip into the scrotum.
A direct inguinal hernia develops through a weakness in the
posterior wall of the inguinal canal. These herniae seldom
force their way into the scrotum and, once reduced, their
reappearance is not controlled by pressure over the internal
inguinal ring.

See anatomy notes.

               Examination of male genitalia


This usually follows an abdominal examination.


1. Introduce yourself and explain that you would like to
examine the patient‟s penis and testes and that the
examination will be quick and gentle. Get a chaperone.

2. Position patient correctly: examine the patient in the supine
position with the scrotum drawn forward to lie on top of the
thighs – you may have to ask the patient to stand later if the
diagnosis is unclear with the patient lying down. You can
cover them from thighs down.



140
3. Say that you would already have checked the distribution of
facial, axillary and abdominal hair and checked to see if
gynaecomastia was present.

4. Put on some gloves.

5. Inspection

         Inspect all sides of the scrotum (left testis lies lower
          than the right) and note pubic hair distribution (loss of
          axillary hair in hypogonadism).
         Do a general inspection looking for ulcers and
          lesions/inflammation/skin changes around the penis
          and scrotum.
         Gently retract the foreskin of the penis (should be
          painless) and look for ulcers and urethral discharge –
          ask the patient to express any discharge themselves
          (state that any discharge would be sent for
          microscopic examination and culture). Examine the
          external urethral meatus – use your forefinger and
          thumb to squeeze the meatus open gently; this should
          expose healthy, pink mucosa.

6. Palpitation

         Ask if the scrotum is painful, and ensure that your
          hands are warm (temperature affects scrotal
          appearance). Make sure you look at the patient‟s face
          to ensure you aren‟t causing discomfort.
         Ask the patient if they have a lump – if so, where is it?
          Start on the opposite testis to get a feel for normal
          (most testicular disorders are unilateral)
         Palpate the spermatic cord (vas deferens) between
          finger and thumb from inguinal ring to testes (normally
          smooth and non-tender). Also feel for undescended
          testis here.



141
         Palpate the testis, noting the consistency and size
          (should be pliant, soft, rubbery consistency) – there
          shouldn‟t be much tenderness.
         Palpate the epididymis, which is felt as an elongated
          smooth structure along the posterolateral surface of
          the testicle (normally smooth and is broadest
          superiorly at its head).
         If measuring beads are available then measure
          testicular size.
         Examine the other side.
         Palpate inguinal regions for lymphadenopathy.

7. If a mass is found…

         Assess any mass according to how you would assess
          any lump.
         Is the swelling on the scrotum or in the scrotum?
         If it is in the scrotum then can you „get above it?‟ (If
          not, it is likely to be an inguinal hernia)
         If the upper boarder is palpable, then decide if the
          mass is cystic or solid. If the mass is cystic, if you
          steady it between thumb and fingers of one hand and
          then use the other hand to invaginate the mass in a
          second plane, it will fluctuate between thumb and
          fingers with pressure change.
         If the mass is solid, is it smooth or craggy and is it
          painful?
         Is the mass within the testes or separate from it?
         Transilluminate the mass: shine a bright light at the
          back of the mass and note if light is transmitted (cystic
          masses spread a red glow into the scrotum).
         If a varicocoele is present then it will feel like a „bag of
          worms‟ that is separate from the testis. It is best to
          examine them in the standing position. Ask the patient
          to cough while you palpate the varicoele (a
          characteristic feature is transmission of the raised
          intra-abdominal pressure to the varicoele which is felt
          as a cough impulse).



142
8. It may help to ask the patient to stand up so you can
inspect the mass further, especially if you suspect a hernia.

9. Thank the patient and cover them with a blanket if
appropriate.




                  Abnormalities of the penis




Prepuce (foreskin)
The prepuce may be too tight to retract over the glans
(=phimosis). If the prepuce is tight but retracts and catches
behind the glans, oedema and swelling may occur, preventing
the return of the foreskin (=paraphimosis). If left untreated, the
swelling and congestion can result in gangrene (yuck!).


Glans
Hypospadias is a developmental abnormality where the
urethral meatus appears on the inferior (ventral) surface of the
        o                         o
glans 1 hypospadias), penis (2 hypospadias) or even the
perineum (tertiary hypospadias). Inflammation of the gland is
termed balanitis. If there is inflammation of the glans and
prepuce, the term balanoposthitis is used. Genital (herpetic)
warts may be seen on the glans.




143
Urethral discharge
This is one of the commonest genital disorders in men, and is
caused by urethral inflammation (urethritis). The cause of the
discharge can‟t be confidently predicted from appearance,
though gonorrhoea tends to cause a profuse purulent
discharge. Nongonococcal urethritis can be caused by
urethral infection or be associated with Reiter‟s syndrome
(triad of urethritis, seronegative arthritis and conjunctivitis).



Penile ulcers
Ulceration of the glans or (rarely) the shaft of the penis may
occur in a number of disorders. The most common cause is
herpetic ulceration. Characteristic painless vesicles occur 4-5
days after sexual contact. The vesicles often rupture, causing
painful superficial erosions with a characteristic erythematous
halo. The confluence of these erosions may cause discreet
ulcers that can suddenly become infected. The urethral meats
may be affected, causing dysuria. If there is a possible history
of venereal disease, consider syphilis and in the tropics
consider chancroid, lymphogranuloma venereum and
granuloma inguinale. Infrequently, drug reactions can cause
penile ulceration. Squamous cell carcinoma can present as an
ulcer of the penis or scrotum.
            Abnormalities of the scrotum


General
If one half of the scrotum appears smooth and poorly
developed, consider an undescended testis (cryptorchidism).
This appearance of the scrotum helps to distinguish a
maldescent from a retractile testis, in which the testis has




144
descended but retracts vigorously towards the external
inguinal ring. The retracted testis will be difficult to palpate.
The scrotal skin may be red and inflamed – commonest cause
is candidiasis. Small yellowish scrotal lumps or nodules are
common and usually represent sebaceous cysts.

Absent testis
Failure of descent, surgical removal (torsion, tumour),
retraction. If it‟s undescended you should be able to find it
around the inguinal canal.

Cystic swelling
Cystic accumulations are caused by entrapment of fluid in the
tunica vaginalis (a hydrocoele) or an accumulation of fluid in
an epididymal cyst. They are              typically fluctuant and
transilluminate, causing a bright red glow through the scrotum,
though transillumination may be lost of the cyst has a
thickened wall or is filled with blood.
*Epdidymal cyst – felt as a distinct swelling behind the
adjoining testis (because the epididymis is behind the body of
the testis)
*Hydrocoele – surrounds and envelops the testis, which
becomes impalpable as a discreet organ.

Varicocoele
These occur in 5-8% of normal adult males and are almost
always L sided. They result from a varicosity of the veins of
the pampiniform plexus, a leash of vessels surrounding the
spermatic cord. Most varicocoeles don‟t cause symptoms and
are discovered incidentally, but patients can rarely present
with scrotal swelling, discomfort or infertility. Examine the
patient in a standing position and ask them to cough – it feels



145
like a „bag of worms‟. The varicocoele usually empties when
the patient lies supine.

Solid swellings
Use same method as with cystic swelling to distinguish
between a testicular and an epididymal mass. Diffuse, acutely
painful swelling usually occurs in acute inflammatory condition
such as orchitis or torsion of the testis. These are
emergencies.
Solid masses may be smooth or craggy, tender or painless,
but carcinoma must always be the first differential (most
common Ca in young men). Other solid masses include
tuberculomas and syphilitic gummas.

Torsion of the testis
This is most common in 11-30 year olds and presents with
severe scrotal pain that radiates to the inguinal region and
lower abdomen. On examination, the scrotal skin overlying the
affected testis may be reddened, with the affected testis lying
higher than the unaffected one. The testis may be very tender
and the spermatic cord is thickened and sensitive to palpation.


Scrotal oedema
Usually occurs when there is a diffuse oedema (eg. in severe
congestive heart failure) or Hypoproteinaemia as in nephritic
syndrome. The scrotal tissue becomes stretched and taut,
with pitting of the skin.

Testis tumours
Commonest malignancies in young men. May be seminomas
(30-40yrs), teratomas (20-30yrs), tumours of Sertoli or Leydig
cells. Contralateral tumour found in 1 in 20 cases.




146
Presentation is a painless testis lump. NB. In pure seminoma
you don‟t get a raised AFP. Treatment is orchidectomy.


                    Neck examination


1. Introduce yourself to the patient, check name and gain
consent.

2. Place the patient so that you can get behind them and to
the sides of them.

3. Go to the level of the neck and look from the front and the
sides for any physical abnormalities such as lumps or skin
lesions.

4. Examine the thyroid gland, which includes trying to find out
what any lumps in that region are. See separate notes.
Always check that the patient doesn‟t have any tenderness in
their neck before starting.

5. Examine the lymph glands:
     Inspect for any visible lymphadenopathy
     Palpate one side at a time, using the fingers of one
       hand then compare with the contralateral side
     Assess site, size and consistency of any palpable
       gland and also if it‟s tender or not. Determine if the
       gland is fixed to any surrounding structures.

Cervical nodes are examined with the patient sitting – feel for
the submental, submandibular, preauricular, tonsillar,
supraclavicular and deep cervical glands in anterior triangle of
neck. Do so from behind. From the front of the patient,
examine the posterior triangles, up the back of the neck to the
posterior auricular and occipital nodes. See lymph gland
examination for how to do it.




147
6. Look in the mouth:
     Check the salivary glands – the opening of the parotid
        duct can be seen on the buccal mucosa as a small
        papilla opposite the 2nd upper molar tooth. Openings
        of submandibular salivary gland ducts are under the
        tongue, either side of the frenulum (they can be
        affected by mumps)
     Ask the patient to poke their tongue out and observe
        the neck for lump movement –you‟re looking for a
        thyroglossal cyst.
     Say that you‟ like to test the gag reflex, but don‟t do it!

7. Assess the trachea to see if it is in the midline.

Say you’d also like to do the following:

8. Test the movements of the neck: to examine cervical spine
- see separate guide.

9. Palpate the carotid arteries separately. Listen for bruits.

10. Assess the JVP.

11. Say that if you thought a swelling was a thyroid swelling
you‟d like to go on to examine the thyroid function.



                   Thyroid examination


When you‟re asked to examine the thyroid, you need to check
whether the examiner wants you to examine the thyroid gland
itself or the thyroid function. Use notes on hypo/hyper
thyroidism to ascertain what you‟re looking for in different
states. Resuming you‟ve been told that any swelling on the
neck is thyroid related…




148
1. Introduce yourself to the patient, check name and gain
consent.

2. Position the patient so you can move around them.

3. Observe the patient: are                they   anxious/fidgety,
slow/lethargic, thin/fat, look cold/hot?

4. Examine the hands:
     Temperature of skin
     Quality of skin – dry/greasy
     Feel the radial pulse
     Look for tremor by asking the patient to stick their
       hands out in front of them – put a piece of paper on
       top

5. Examine the eyes:
     Look for exopthalmos from the side and behind (if
       you‟re tall enough)
     Test for lid lag

6. Ask patient to say their name – you‟re checking for
hoarseness/dysphasia.

7. Examine the thyroid itself:

a. Inspection
Look at the thyroid area from the front and the side for any
obvious swellings. Is any swelling localised (one lobe) or
diffuse? Are there any scars suggesting previous surgery?
Are the veins distended (obstruction of thoracic inlet by
retrosternal goitre)?

b. Get a glass of water. Stand at the font of the patient and get
them to swallow, and then do the same from the side.

c. Get the patient to poke their tongue out and feel/observe
the mass – you‟re checking for a thyroglossal cyst.



149
d. Palpate the thyroid from the front (quickly). Check that
there‟s no tenderness before starting.

e. Tell the patient that you‟d like to examine the neck from
behind:
     Stand behind the patient and examine the thyroid –
         try to move the patient‟s own skin over it rather than
         pressing your fingers in, and feel right down to the
         sternal notch. Press it from one side to the other.
     Confirm that any swelling is thyroid related by getting
         the patient to swallow whilst you palpate the thyroid in
         the sternal notch.
     You then need to ascertain the following about the
         swelling: tenderness, size and shape of goitre,
         single/multiple swelling, smooth/nodular surface, and
         consistency.

f. Still from behind the patient, feel the cervical lymph nodes.

g. Palpate the trachea from the front – if you can feel it, check
to see if it is in the midline, if you can‟t then it may be
obstructed by the thyroid, so you need to try and ascertain the
size of the thyroid.

h. Check for a retrosternal goitre by getting the patient to
swallow – if you can keep your fingers between the thyroid
cartilage and the sternal notch when they swallow, there‟s no
retrosternal goitre. Another method is to percuss the
manubrium sterni – this is normally resonant.

i. Auscultate the thyroid – there may be a bruit in a toxic
goitre.

8. Say that you‟d like to assess the ankle reflexes (delayed
relaxation in hypothyroidism; all reflexes are, but it‟s shown
best here).




150
               Lymph node examination

Head and neck nodes
Start by examining the nodes encircling the lower face and
neck. Sit the patient forward. You can examine these nodes
from the front or the back, and both d=sides can be examined
simultaneously. Palpate the nodes in sequence:
     submental group in the midline behind the tip of the
         mandible
     submandibular nodes midway and along the inner
         surface of the inferior margin of the mandible
     tonsillar node at the angle of the jaw
     pre-auricular nodes immediately in front of the ear
     post-auricular nodes over the mastoid process
     occipital nodes at the base of the skull posteriorly
     vertical neck nodes. It may be helpful to flex the neck
         slightly to relax the strap muscles. Feel for the
         superficial cervical nodes along the body of the
         sternocleidomastoid. The posterior cervical nodes run
         along the anterior body of trapezius. The deep
         cervical chain is difficult to feel, as they are deep to
         the long axis of sternocleidomasoid; explore for these
         nodes by palpating firmly through the muscle.
     supraclavicular nodes - lie in the area bound by the
         clavicle inferiorly and the lateral borer of
         sternocleidomastoid medially.
     infraclavicular nodes – lie just beneath the clavicle


Axillary nodes
The axillary nodes can be palpated from the front with the
patient either lying or sitting. Take the patient‟s L arm with
your R hand and explore with your L hand and vice versa.
     Slightly cup your examining hand and palpate into the
         apex of the axilla for the apical group of nodes – small
         nodes may only be felt by rotating the fingertips
         against the chest wall.



151
         Feel for the anterior group of nodes along the
          posterior border of the anterior axillary fold, the
          central group against the lateral chest wall, and the
          posterior group along the posterior axillary fold.
         Check for supra and infra clavicular nodes and also
          the epitrochlear nodes.


Epitrochlear nodes
Passively flex the patient‟s relaxed elbow to a right angle.
Support this position with one hand whilst feeling with your
fingers for the epitrochlear nodes, which lie in a groove above
and posterior to the medial condyle of the humerus.


Para-aortic nodes
A deep central mass can be due to enlarged para-aortic
nodes.



                     Inguinal and leg nodes
Examine these nodes with the patient lying down. The
superficial nodes run in two chains:
     Palpate horizontal chain – runs just below the line of
         the inguinal ligament
     Palpate vertical chain – runs along the long
         saphenous vein
Relax the popliteal fossa by passive flexion – explore the
fossa for enlarged popliteal nodes by wrapping the hands
around either side of the knee and exploring the fossa with the
fingers of both hands.


***Remember to palpate the spleen and liver as part of the
lymphatic system, and examine the drainage areas of any
enlarged nodes. Assess any lumps as usual***




152
General points to note:
Size: anything >1cm is abnormal
Consistency: hardness suggests Ca, rubbery consistency
points to lymphoma
Tenderness: implies infection
Fixation: suggests malignancy
Overlying skin: tethering is a feature of malignancy,
inflammation suggests infection

                       The GALS screen


Introduce yourself and explain that you would like to examine
the patient‟s joints.

Questions

         Do you have any pain or stiffness in any of your
          muscles, joints or back?
         Can you dress yourself completely without any
          difficulty?
         Can you walk up and down the stairs without any
          difficulty?

Ask them to undress down to underwear
It is best to examine gait, spine, arms then legs for practical
purposes

Gait

Ask the patient to walk to the other side of the room , turn and
walk back.
     Observe whether they swing their arms and move
        their legs symmetrically.
     Does the patient avoid weight bearing on one leg?




153
Spine

         Inspect the patient standing from the front, side and
          behind.
         Ask the patient to touch their toes while keeping their
          knees straight (lumbar flexion). Place 2 of your fingers
          over adjacent spinous processes in the lumbar region
          and as the patient bends your fingers should move
          apart. (NB patients with a rigid spine may be able to
          touch their toes if they have supple hips).
         Ask the patient to „put their ear to their shoulder‟ on
          each side in turn (lateral cervical flexion)

Arms

         Inspect the patient‟s arms extended by their side in
          the anatomical position. Inspect the arms for obvious
          deformities e.g. swelling or deformity.
         Keeping their elbows by their side (to fix them), with
          their elbows flexed to 90º ask the patient to turn their
          palms towards the ceiling and then down to the floor
          (pronation and supination).
         Ask the patient to hold out their hands and inspect for
          any skin or nail changes or joint deformity.
      
                                  nd   th
          Squeeze across the 2 – 5 MCP joints (while
          watching the patient‟s face) and note any pain.
         Ask the patient to make a tight fist (check the fingers
          flex fully into the palms).
         Ask the patient to touch finger to thumb in turn (fine
          movement).
         Ask them to put their hands behind their head and
          bring their elbows backwards (abduction and external
          rotation of the shoulder and flexion of the elbow)


Legs

With the patient standing:



154
         Inspect from the front, side and from behind.

Ask the patient to lie down on the couch:

         Expose both legs and inspect them close up. Look for
          flexion deformity at the hip or knee.
         Feel the temperature of the knee with the back of your
          hand, comparing both sides.
         Carry out the bulge test: using your middle and index
          finger, sweep along the medial aspect of the knee,
          thus forcing any fluid to the lateral side. Then sweep
          along the lateral side of the knee and see if a bulge
          appears on the medial side as the fluid moves back.
         Ask the patient to move their heal towards their
          bottom (active knee and hip flexion)
         Passively flex the hip and with the knee flexed,
          passively test internal rotation at the hip.
         Extend the knee, keeping one hand on the patella to
          feel for crepitus.
         Ask the patient to extend, flex, invert and evert the
          ankle.
      
                                  nd   th
          Squeeze across the 2 –5 MTP joints, noting any
          pain.

If abnormalities are found, a more detailed examination of the
abnormal joint should be performed. In general:

         Look for swelling or deformity
         Feel to assess whether swelling is soft (soft tissue or
          fluid) or bony. If it is soft, is it warm or cold?
         Move the joint to assess its range of movement and
          instablility.

If the problem is unilateral compare with the normal side.




155
      Principles of bone and joint examination


The general rule for all these things is:
*Expose the whole area
*Inspect (scars/swelling/deformity/inflammation/wasting)
*Palpate (temperature/tenderness/crepitus/swelling and type
of swelling)
*Move (active and passive)
Always compare sides.


Bone

Whichever structure is being examined, ensure that it is
completely exposed and that the patient is comfortably
positioned. Determine whether there is any abnormal
angularity. Is there limb shortening? Look for tenderness by
gently palpating those parts of the bone close to the skin
surface.



Joints (i) Inspection


                          Swelling
Causes of joint swelling include effusions, thickening of the
synovial tissues and of the bony margins of the joint.
Differentiate between these by palpation. If you suspect joint
swelling, compare it with the joint of the opposite limb.
Particularly note of the swelling appears to be from the joint
itself or from adjacent structures.




156
                          Deformity
This results from either misalignment of the bones forming the
joint, or from alteration of the relationship between the
articular surfaces. If misalignment exists, you can get:
      Deviation of the part distal to the joint away from the
          midline = valgus deformity (eg. “knocked knees” or
          genu valgum)
      Deviation towards the midline = varus deformity (eg.
          “bow legged” or genu varum)
If there is deformity, you need to assess whether it is fixed or
mobile. Partial loss of the articular surfaces is subluxation,
complete loss is dislocation. These are usually traumatic, but
can be seen in inflammatory joint disease (especially RhA).

                         Skin changes
Palpate the skin over a joint to assess its temperature and
also look for redness.


           Changes of adjacent structures
Usually this is muscle wasting. Assess the muscle bulk above
and below the affected joint, making a comparison with the
opposite limb if that is spared. Wasting of quadriceps is
particularly conspicuous in disease of the knee joint.

        (ii) Palpation

Use the “two intertwined Cs” method so you are palpating all
sides of the joint at once.


                              Swelling
Determine the consistency of any swelling – is it soft or hard,
and where is the swelling – certain sites are particularly



157
susceptible to certain changes. A hard swelling suggests OA
whilst a boggy. spongy swelling suggests synovial thickening
in RhA. An effusion is fluctuant – the fluid can be displaced
from one part of the joint to another. Swelling can also occur
adjacent to the joint, and again you need to determine
consistency – soft fluctuant swellings suggest enlarged
bursae, harder swellings occur in RhA and gout.

                         Tenderness
Carefully palpate the joint margin and adjacent bony surfaces,
together with the surrounding ligaments and tendons. Is the
tenderness within the joint or outside it, and is it localised or
generalised? In an acutely inflamed joint, all the edges will be
tender. If there is derangement of a single knee cartilage,
tenderness will be confined to the margin of that cartilage. In
degenerative joint disease, you may find tenderness in
structures adjacent to the joint. Tenderness close to the joint
may reflect primary pathology in bone (eg. osteomyelitis) or in
the tendon sheath (eg. De Quervain‟s tenosynovitis).

Temperature
Assess temperature with fingertips in small joints and with the
back of the hand for larger ones. Use either the contralateral
joint or above and below the upper and lower joint margins for
comparison.

        (iii) Movement

You need to determine the range of movements, whether the
movement is limited by pain, and whether there is instability.
To define the range of movement, start with the joints in the
neutral position (= the limbs extended with the feet dorsiflexed
     o
to 90 , the upper limbs midway between pronation and
                                     o
supination with the arms flexed to 90 at the elbows). For
accurate measurement you would need a goniometer.
Movement of a joint can be active (induced by patient) or
passive (induced by examiner). You usually use active



158
movement for spine and passive for limbs. Restriction of
active compared with passive movement is usually due to
muscle weakness.
From the neutral position, record the degrees of flexion and
extension. If extension does not normally occur at a joint but is
present, record degrees of hyperextension. For the ankle and
wrist, extension is referred to as dorsiflexion and flexion as
plantar flexion and palmar flexion. In a ball and socket joint,
you need to record the degrees of flexion, extension,
adduction, abduction, and internal and external rotation.
The range of movement varies between individuals – an
excessive range may be constitutional or pathological.
Carefully note if pain occurs during joint movement.
                 Examination of the shoulder


The shoulder is made up of multiple parts that cannot be
tested in isolation. The capsule and rotator cuff muscles
stabilise the shoulder joint. It is a shallow joint so it and the
surrounding structures are susceptible to injury.

Inspection

         Ask the patient to remove their top; asking the patient
          to undress may allow assessment of functional
          impairment.
         Inspect from: in front, side and behind with the patient
          standing
         Observe for asymmetry, muscle wasting (especially
          the deltoid), abnormal posture, swelling, scars,
          bruising, deformity and the level of the shoulders, also
          inspect the axilla.

Palpitation

Ask if the shoulder is painful before you examine it and stand
in front of the patient face to face.




159
Palpate the follow in the order (while observing the patient‟s
face):
     Sternoclavicular joint
     Clavicle
     Acromioclavicular joint
     Acromial process
     Head of the humerus
     Coracoid process
     Spine of the scapular (from behind)
Feel for swelling and crepitus.

Measure

         Assess deltoid bulk by measuring the circumference
          at the top of both arms.

Movements

Movements should be tested actively. Stand with the patient
face to face with you and ask them to copy the movements
you make. Ask patient to let you know if there is any pain.

         Flexion: flex the elbow to 90° then move the arm
          upwards until the fist points backwards.
         Extension: flex the elbow to 90° then move the arm as
          far backwards as possible.
         Abduction: with the elbow fully extended, move the
          arm away from the body until the fingertips point to
          the ceiling
         Adduction: with the elbow fully extended, bring the
          arm across the trunk
         External and internal rotation: with the elbow fixed at
          90°, pinned into the side, move the forearm in an arc
          like motion, thus separating the hands (external
          rotation) and bringing them together (internal
          rotation).




160
      During abduction and adduction fix the scapular, so that
      you can take account of any movement here. (Movement
      of the scapula can give false impression of movement at
      the shoulders).

         Test all the movements passively. Ask the patient to
          relax and move the arm test the movements of the
          shoulder.

Function

             Ask the patient to put their hands behind their
              head and push their elbows as far back as
              possible.
             Ask the patient to scratch the centre of their back
              as far up as possible.

Special tests

         Ask the patient to push against the wall with flat palms
          and observe the scapulae for winging (caused by
          muscle weakness)
         Ask the patient to abduct the shoulder against the
          force of your hands (painful in supraspinatus
          tendonitis)
         Ask the patient to shrug their shoulders against the
          force of your hands (assesses CN XI)
         Test the sensation over the „regimental badge area‟
          on the skin over the deltoid (assesses axillary nerve
          sensory function).
         Test the circulation in the upper limb (as injury to the
          shoulder can compromise blood supply) – palpate the
          radial and brachial arteries.

Perform a neurological examination

Disorders




161
         Pain from the glenohumeral joint radiates to the front
          and side of the upper arm
         Pain over the top of the shoulder suggests
          acromioclavicular joint disease; confirmed by point
          tenderness over the joint.
         In glenohumeral joint disease such as adhesive
          capsulitis and RA, passive and active movements are
          equally restricted.
         In disease of the rotator cuff e.g. calcific tendonitis,
          there is restricted active movement but passive
          movement remains full.
         Painful arc syndrome – pain on shoulder elevation.
         Remember that pain felt at the shoulder does not
          necessarily arise from the shoulder.



                Examination of the elbow


The patient should be standing, or seated without obstruction
to the elbow movements.

Inspection


         Muscle wasting, deformity, swelling, skin changes,
          bruising, scars
         Is the patient holding their elbow normally?

Palpation

Check to see if the shoulder is painful before you start
pushing around.
    Feel for any areas of local tenderness, particularly
       over the lateral and medial epicondyles
    Feel any swellings and define their nature



162
         Check skin temperature

Movements


Test active movements first – ask the patient to copy any
movements you make:
    Flexion: bring the elbow up so it‟s parallel with the
        upper arm.
    Extension: with arm straight, try to bring forearm back
        behind to become parallel with upper arm (shouldn‟t
        be able to move it much at all)
    Pronation: flex elbow to 90 , thumb up, and turn palm
                                   o

        down
    Supination: flex elbow to 90 , thumb up, and turn
                                     o

        palm up

Then test passive movements – feel for crepitus and note
whether any movements are painful.

Perform a neurological examination


                            Disorders

         Fixed flexion deformities are common in patients with
          inflammatory arthritis, whereas hyperextension
                       o
          (beyond –10 is seen in patients with hypermobility).
         Common “lumps” to be found at the elbow are a
          swollen olecranon bursa, rheumatoid nodules and
          sometimes gout.
         You can also get lateral epicondylitis (tennis elbow) –
          pain on extending wrist against resistance when arm
          straight – and medial epicondylitis (golfer‟s elbow) –
          pain on flexing wrist against resistance when arm
          straight.




163
Examination of the wrist and hand


This goes: assess pain, inspect both surfaces, palpate
individual joints, examine the mobility of joints, assess grip
and pinch strength.

Ensure that the patient is comfortable and that you can get all
around the wrist and hand. Ask about any pain in the joints.

Inpection


Remember to examine both dorsal and palmar surfaces for:
         Muscle wasting
         Swelling (note distribution)
         Skin changes, including scars/wounds, rashes, nail
          changes, vasculitic lesions, colour changes
          (erythema, cyanosis, palmar erythema)

Palpation

         Feel for skin temperature and examine pulses
         Feel for any areas of local tenderness, and note the
          nature of any swelling – use the two C‟s technique.
          Need to examine: DIPs, PIPs, IP of thumb, MCPs,
          CMC of thumb, radiocarpal joint, distal radioulnar
          joint.

Movements

As usual, start with active and then passive movements. Note
whether movements are painful.
     Wrist dorsiflexion: cock wrists back (put hands like
       you‟re praying)
     Wrist palmarflexion: make hands point downwards,
       back to back



164
         Wrist radial and ulnar deviation: hold just above wrist
          and ask patient to move hand to R/L
         Gross hand function: make a fist, make your hand stiff
          and straight, make a pinch, open your hand as wide
          as you can, power grip
         Finger flexion and extension (see other notes)
         Finger abduction and adduction: squeeze fingers
          together, spread them apart
         Thumb abduction, adduction, opposition and flexion,
          including precision pinch (pencil) and key pinch.

Perform a neurological examination

               Disorders of hand/wrist movement
       If active range restricted but passive normal, the
        cause is loss of muscle or tendon function.
     If the passive range is restricted, the cause can be
        stiff joints or tight intrinsic muscles.
Hand deformities in RhA include: bulging synovium of MCP
and PIP joints, wasting of dorsal interossei, ulnar deviation,
swan neck/boutonniere deformities, Z-thumb, dorsal
subluxation of the ulnar head, vasculitic lesions on fingertips,
median nerve compression, extensor tendon rupture, palmar
erythema.

                   Examination of the spine


Observe the patient as they walk into the room: observe the
way they walk, the posture, how they hold their neck and how
they sit.

Introduce yourself and explain that you would like to examine
their spine. Ask the patient to remove their top.

Inspection




165
         Inspect the patient sitting and standing, from behind,
          in front and from the side.
         Note abnormal kyphosis, lordosis (increased or
          absent) or a scoliosis (deviation from the midline).
         Ask the patient to stand with their back to the wall.
          Normally you should see the following in contact with
          the wall: occiput, shoulder, buttocks, and heels. If not
          then there is an abnormality.

Palpation

Feel for the following bony landmarks:

         Vertebra prominens at C7 - T1 junction.
         Spinous processes from C6 inferiorly to sacrum
         Facet joints (lie 1cm lateral to spinous processes).
         Sacroiliac joints (beneath Dimples of Venus at S2)
         Palpate the paraspinal muscles.

Percuss the spine gently with the side of your closed fist. This
may elicit local tenderness in those with metastases or
infection in the bone.

Measure

Schober‟s test:
    Identify the Dimples of Venus
    Measure and mark a point 10cm superior to the mid-
       point between the dimples and one 5cm inferior.
    Ask the patient to touch their toes (flexion of the
       lumbar spine)
    The distance between the 2 points should be
       measures when the spine is flexed maximally. The
       distance should increase to >21cm if normal.

Rib excursion:



166
         Measure the chest diameter with the patient in full
          expiration and full inspiration and note the difference
          between the two.

Movements

All movements are tested actively as passive movements are
not feasible.

Cervical:
     Flexion (chin on chest)
     Extension (look up at the ceiling)
     Lateral flexion (put your ear onto each shoulder in
        turn)
     Lateral rotation (look over each shoulder in turn)
When assessing lateral flexion and rotation hold the shoulders
to ensure that the cervical spine moves not the shoulders.

                       Thoracic and lumbar:
         Flexion (touch your toes)
         Extension (lean backwards)
         Lateral flexion (slide your hands down the side of your
          leg on both sides)
         Lateral rotation (twist at the waist, to both left and
          right. Stabilise the pelvis with your hand or perform
          the examination with the patient seated).

Special Tests

         Straight leg test (test for nerve root irritation): with
          the patient supine, fix the patient‟s pelvis across the
          ASIS. Ask the lift their leg keeping it straight (flexing
          the hip with the knee extended).
         Stretch Test (for sciatic nerve irritation): With the
          limit of straight leg raising reached, allow the leg to
          lower slightly. Then dorsiflex the foot (push the toes
          towards the head) quickly. If this causes severe pain,



167
          pins and needles or numbness then the test is
          positive.
         Irritation of upper lumbar nerve roots: ask the
          patient to turn over (prone position and place a pillow
          under the pelvis and abdomen (flexes the lumbar
          spine). Passively flex the knee and holding the foot,
          gently extend the hip. If this provokes spasm of the
          quadriceps and the patient complains of sensory
          disturbance over the front of the thigh then the test is
          positive.

In addition it is advisable to do a neurological examination
alongside an examination of the spine.

Some notes on back disorders


Causes of back pain:
    Muscle of ligamentous strain
    Degenerative intervertebral disc
    Spondylolisthesis
    Arthritis (OA/RhA/AnkSpond)
    Bone infection (Pyogenic/TB)
    Trauma
    Tumour
    Osteochondritis
    Metabolic bone disease

               Prolapsed intervertebral disc
A prolapsed disc is most likely to occur in the cervical (C5/6)
or the lumbar (L5/S1) region. Once nerve root irritation occurs,
likely symptoms include local and referred pain, with sensory
and motor symptoms in associated limbs. Use dermatomal
distribution to work out where the problem is.




168
                 Ankylosing spondylitis
The patient, usually male, complains of spinal pain and
stiffness, the latter improving on exercise. The sacro-iliac
joints are affected initially. Increasing loss of spinal mobility
can lead to a thoracic kyphosis combined with loss of the
lumbar lordosis.

                     Rheumatoid arthritis
Commonly involves the upper cervical spine – synovitis
affecting the cruciate ligament allows posterior subluxation of
the odontoid peg. Compression of the upper cervical cord can
produce tetraparesis.

                      Spinal tumours
Usually metastatic from prostate, breast, lung or kidney.
Initially, there is severe rest pain, sometimes with a referred
component caused by spinal root compression. Later, focal
neurological signs appear.

TB
Commonly involves thoracic and lumbar spine – get vertebral
collapse with gibbus formation and paraspinal abscess. Also
back pain, deformity, and spinal cord compression.




                    Examination of the hip

Inspection

You probably won‟t be able to see a lot, because the hip joint
is overlaid with muscle. Comment on any muscle wasting,
particularly of the quadriceps (hip flexor). Also loo at the leg



169
as a whole – a shortened, externally rotated leg indicated hip
fracture/dislocation.

Palpation

Comment on any tenderness/swelling.

Movement

Have the patient lying on their back – expose the legs, but
make sure they‟ll remain covered when you are testing
abduction and adduction. Test active then passive movement

         Flexion: flex the knee (so you don‟t do a straight leg
          raise), move the thigh towards the patient‟s chest.
          Make sure the pelvis doesn‟t rise from the bed.
         Rotation: have the knee and the hip flexed to about
          90o. One hand holds the knee, the other the foot.
          Move the foot medially (tests external rotation) then
          laterally (tests internal rotation).
         Abduction: grasp the heel of the leg with one hand –
          the other should fix the pelvis by pressing over the
          anterior superior iliac spine on the opposite side.
          Move the leg outwards as far as possible.
         Adduction: move the leg medially.
         Extension: have the patient turn over onto their
          stomach. Place one hand over the sacroiliac joint –
          the other hand elevates the leg.

Special tests

1. Measure the leg length. The true length is measured from
the anterior superior iliac crest on that side to the medial
malleolus. The apparent length is from the umbilicus to the
medial malleolus. A difference in true leg length (R compared
to L) indicates hip disease on the shorter side. Apparent
difference in leg length is due to tilting of the pelvis.




170
2. Thomas test. Tests for fixed flexion and fixed adduction of
hip – where you can‟t make the iliac crests be positioned in
the same horizontal plane at right angles to the spine. The
flexion deformity of the hip can be concealed when the patient
lies flat by a compensatory lumbar lordosis. To check for this,
flex the opposite hip to its maximum, thereby eliminating the
lordosis. If a flexion deformity exists, the affected leg will flex
at the hip.

Ask the patient to walk and observe the gait.

Perform a neurological exam


                    Examination of the knee

Remember to examine both knees even if only one seems
abnormal.

Inspection:

With the patient standing:

         Inspect the knees from in front, the side and behind.
          In particular look for the presence of varus or valgus
          deformity
         Ask the patient to walk to the other side of the room,
          turn and come back and inspect their gait.

With the patient supine:

         Inspect the knees for scars, small volumes of fluid,
          cysts and muscle state.
         Ask the patient to bend their knee and note the
          presence of a tibial sag (seen in posterior cruciate
          ligament damage.).

Palpation




171
         Temperature: compare the 2 sides with the dorsum of
          your hand.
         Palpate the quadriceps tendon, patella and patella
          ligament for any abnormality.
         Palpate the joint line. The patient may need to bend
          their knee to confirm location of the joint line.
         Palpate the patello-femoral joint, including beneath
          the patella.
         Palpate the popliteal fossa for presence of a cyst or
          popliteal aneurysm.
         Palpate for fluid effusions using the bulge test (little
          fluid) or the patella tap test (for larger fluid volume)

         Bulge test: using your middle and index finger,
          sweep along the medial aspect of the knee, thus
          forcing any fluid to the lateral side. Then sweep along
          the lateral side of the knee and see if a bulge appears
          on the medial side as the fluid moves back.
         Patella tap test: Using thumb and index finger to
          „milk‟ fluid from above the knee. Using index and
          middle fingers of the other hand push (not tap) the
          patella down firmly. If fluid is present, the patella will
          bounce off the lateral femoral condyle behind. This is
          felt as a tap.

                            Measure

         Using a tape measure, obtain a circumference (in cm)
          of both the legs around the bulk of the quadriceps
          muscle.

Movements

Assess movements actively then passively.

         Flexion: ask the patient to bend their leg at the knee.
         Extension: ask the patient to straighten their leg.



172
         Hyperextension: lift the leg off the bed and gently
          push the knee downwards from above to see if it will
          extend any further.
         Place you hand over the patella when assessing
          passive movement to feel for crepitus.

Special tests

      1. Testing lateral/medial collateral ligaments:
       The knee needs to be flexed at 30°.
         Support the medial aspect of the thigh and push
         medially on the lateral aspect of the lower leg. This
         tests the lateral collateral.
       Support the lateral aspect of the thigh and push
         laterally on the medial aspect of the lower leg. This
         tests the medial collateral.
       Excessive movement may indicate ligament damage.
      2. Testing anterior/posterior cruciate ligaments:
       With the patient supine, ask them to flex their knee to
         90°
       After checking there is no pain in the foot, sit on the
         foot to stabilise the lower leg
       With both hands, wrap the fingers around the back of
         the knee, keeping the thumbs in front over the patella.
         Position the thumbs so they point directly to the
         ceiling.
       Pull the leg forward to test anterior cruciate and push
         backwards to test posterior cruciate.
       Excessive movement may indicate ligament damage.
      3. Testing the menisci (Apley‟s grinding test):
       Get the patient to turn onto their front (prone), and flex
         the knee to 90°
       Use your left hand to stabilise the lower leg behind
         the knee and with the right hand, grip the heel of the
         foot.
       Twist the foot in a grinding movement. The test may
         cause pain if the meniscus is damaged.




173
In addition

         Peripheral pulse: popliteal, posterior tibial and dorsalis
          pedis should be tested
         Sensation below the knee.

NB the knee is an important source of referred hip pain, so in
theory all knee examinations should be accompanied by an
examination of the hip.




                 Examination of ankle and foot


                           Inspection

With the patient standing:
     Appearance of the foot – is there any obvious
        deformity such as hindfoot pronation/calluses/hallux
        vulgaris/hammer toe/pes planus
     Get patient to stand on tiptoe – painful and difficult in
        Achilles tendinitis, almost impossible if Achilles
        tendon ruptured
     Look at patient walking to assess gait

With the patient supine:
     Look for scars, swelling, deformity, colour change,
        callosities

                            Palpation

Feel for any swelling and decide if it is synovial, bone or
oedema.




174
                         Movement

Active then passive.
     Ankle dorsiflexion and plantarflexion: move foot
         upwards and downwards.
     Subtalar inversion and eversion: stabilise calf with
         one hand, invert and evert foot with other.
     Midtarsal movements: stabilise the ankle with one
         hand then plantarflex and dorsiflex the foot with the
         other.
     Movements of the MTP and IP joints

         Perform neurological examination

Feel for the posterior tibial and dorsalis pedis pulses


**Motor weakness resulting from lesions of nerves of lower
limb:**

Femoral – knee extensors
Obturator – hip adductors
Sciatic – knee flexors/hamstrings
Posterior tibial – ankle and toe plantarflexors
Deep peroneal – ankle and toe dorsiflexors
    Superficial peroneal – ankle evertors (foot drop)


            Mini mental state examination

There are abbreviated versions of this and also a larger, thirty
point score. We need to know the abbreviated version:

1. Introduce yourself to the patient and explain what you are
going to do.



175
2. Perform mini mental tests:

         How old are you?
         What is the time to the nearest hour?
         Where are you?
         I‟d like you to remember the following address “42
          West Street”. Can you please repeat that to me now?
         What year is it?
         Recognition of two people – doctor, nurse etc.
         What is your date of birth?
         Years of Second World War
         Name of monarch
         Count backwards from 20 to 1

Then ask the to repeat the address you gave them earlier.

3. Grade the cognitive function according to a scale: 0-3
severe impairment, 4-7 moderate impairment, 8-10 normal.



MMSE test of 30 point scale


                          Orientation
1. What is the year, season, date, month, day (1 point each)?
2. Where are we? Country, county, town, hospital, floor (1
point each)

                          Registration
3. Name 3 objects, taking 1s to say each. Then ask the
patient to repeat them. (1 point each) Repeat the question
until the patient learns all 3.




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                  Attention & calculation
4. Serial sevens (1 point each). Stop after 5 answers.
Alternatively spell “world” backwards.


                            Recall
5. Ask for the names of the 3 objects asked in Q3 (1 point
each).


                          Language
6. Point to a pencil and a watch. Have the patient name them
for you (1 point each).
7. Have the patient repeat “no ifs, ands or buts” (1 point)
8. Have the patient follow the 3-stage command “Take the
paper in your right hand, fold the paper in half, put the paper
on the floor”. (3 points)
9. Have the patient read and obey the following: “Close your
eyes” (in large letters). (1 point)
10. Have the patient write a sentence of his/her choice – it
must have a subject and an object and make sense. Ignore
grammatical errors. (1 point)
11. Have the patient draw 2 intersecting pentagons – give 1
point if all the angles are preserved and if the intersecting
sides form a quadrangle.

         Higher cortical function examination


This is really complicated and I don‟t think we have to know it
– it said in the Los to know about assessing speech, language
and perception.




177
1. Introduce yourself to the patient, check name and gain
consent. The examination starts as soon as they enter the
room, as you need to assess speech, if there is an alteration
in mood, if there is disturbance in comprehension, and
whether there appears to be evidence of self-neglect.

2. Orientation (assess using mini mental state exam)

3. Memory

         Immediate recall: Use digit repetition (a normal
          response still requires attention and comprehension).
          Start with 2-3 fingers at 1s intervals; normal people
          can remember 5-7 digit sequences. Next do reverse
          repetition of numbers (not solely dependent on
          memory) – normal is 5-7 numbers.

          Recent memory (new learning ability): Ask about
           interpretation of recent events (take into account
           intelligence/culture). Next ask them to repeat three
           objects – a name, an address, a flower. Get them to
           repeat immediately then ask them ten minutes later
           (should get all 3).
      Visual memory can be tested by displaying drawings for a
      5s period, then asking the patient to reproduce the design
      10s later. You can grade them from 0-3 (most people get
      2-3). Visuo-spatial disorders may also affect ability to do
      this.

         Remote memory: Ask the patient about schooling,
          childhood, work history, marriage and, if relevant,
          ages of children (need verification by a relative) – RM
          is spared in people with minor degrees of brain
          damage but lost in dementia.

4. Intelligence



178
         Level of information: ask the patient to give an
          account of recent events and their understanding of
          them.

         Calculation: give a simple addition, subtraction,
          multiplication and division. Assess results and take
          account of patient‟s education.

         Proverb interpretation: assesses both general
          knowledge and capacity for abstract thinking. Read
          proverbs of increasing complexity – “A bird in the
          hand is worth two in the bush” followed by “People in
          glass houses should not throw stones”. You get
          concrete responses in demented individuals – can‟t
          see beyond immediate implications (eg. the glass
                                    nd
          would get broken in the 2 proverb).

         Constructional ability: ask the patient to copy designs
          of increasing complexity. When assessing the
          drawings, look for evidence of unilateral neglect.

5. Geographical orientation

Ask patient to draw an outline of their native country and place
on it some cities – do they have an overall defect of
geographical location, or one based on neglect of half the
visual field?


6. Speech

Determine the patients handedness – don‟t ask which hand
they write with (some people are taught to be R handed) – ask
which hand they hold a knife in or use a brush with. Check
family history of handedness.




179
         Dysarthria: defect of articulation without disturbance
          of language function. Patients have normal speech
          content and if they can write, script will be free of
          dysphasic errors.

         Dysphonia: a defect of speech volume; usually it‟s a
          result of a disorder limiting the movement of muscles
          of respiration or the vocal cords.

         Aphasia: defect of language function in which there is
          either abnormal comprehension or abnormal
          production of speech, or both. Aphasic speech lacks
          grammatical content, displays word-finding difficulty
          and contains word substitutions (paraphasias).
          Paraphasias can be whole word substitution (bread
          for table), syllable subs (speed for feed) or complete
          nonsense words (=neologisms, eg. tersh).

7. Comprehension

         Repetition: ask the patient to repeat simple words,
          then give sentences of increasing complexity.
          Patients often have particular difficulty with “no ifs
          ands or buts”.

         Naming: a naming defect is found in nearly all
          dysphasic patients. Point to a succession of items,
          and name the patient to name each one. Eg. Watch
          and parts of watch.

         Reading: take account of educational background.
          Ask the patient to read aloud, then test
          comprehension by asking questions requiring yes/no
          answers.

         Writing: agraphia is an inevitable accompaniment of
          aphasia. Ask the patient to write single words,
          spontaneously and then in response to dictation.



180
          Check word content and see if the writing is crammed
          to one side (unilateral neglect).

         Praxis: apraxia is a disorder of skilled movement not
          attributable to weakness, incoordination, sensory loss
          or a failure of comprehension. The problem with
          movement may be confined to the limbs, the trunk, or
          even to the face. A defect for a single task is
          ideomotor apraxia. Ideational apraxia is failure to
          perform a more complex sequence of skilled activity.
      Start by asking the patient to carry out a particular task –
      “Pretend to use a screwdriver”. If they can‟t do it, do it
      yourself and ask them to copy you. If there‟s still no
      response, give them the object and ask them to use it.
      These three tasks are in descending order of difficulty.
      Other instructions could be “pretend to whistle”, “salute”
      and “show how you would use your toothbrush”. For
      whole body movements, ask them to go through a
      sequence – eg. take cap off toothpaste, squeeze
      toothpaste onto brush…

         Right-left orientation: some patients have a problem
          with right-left orientation. Test with simple tasks, eg.
          show me your right hand and gradually increase
          complexity, eg. put your left hand on your right ear.
          Dysphasic patients can have trouble understanding
          your commands.

         Agnosia: patients with visual agnosia are unable to
          recognise objects they see, despite intact visual
          pathways and speech capacity. Show objects to the
          patient, asking them to name each one, then allow the
          patient to manipulate the object to see if this improves
          recognition. Other forms of agnosia include the ability
          to name and recognise individual fingers (finger
          agnosia) and colours (colour agnosia).

**The thirty point MMSE can replace many of these tests, as it
takes too long to do everything!!**



181
See p. 304+ in CE for notes on disorders.


                      Blood transfusion


1. Introduce yourself, explain what you would like to do and
obtain consent. This should include an explanation of the
alternatives to transfusion.

2. Record in the case notes:
     The indication for transfusion
     That the patient consented to the transfusion after
        explanation of the reasons, risks and benefits
     The name of the person who ordered the blood
        (legibly)

3. Select the product (whole blood or red cells) and quantity
(as a rule of thumb, 1 unit of red cells will raise the plasma
haemoglobin by 10g/l).

4. Order the product in writing (and by telephone in
emergency). The request form should include:
     Patient‟s identity number, full name and date of birth
     Quantity of blood, and when needed
     Legible signature

5. Take blood:
     Check the patient‟s identity verbally and from her/his
        identity bracelet
     Take 10ml of blood in a tube without anticoagulant
     Immediately after taking blood, label the tube with full
        identification details at the bedside.

6. Ensure the blood reaches the lab promptly, where blood will
be:
     Grouped for ABO and rhesus systems



182
         Tested for IgG antibodies that can damage red cells
               o
          at 37 C
         Cross-matched (red cells of an appropriate group will
          be selected and tested for compatibility with the
          patient‟s serum)

7. Prescribe the amount of blood, and duration of the infusion,
and arrange for it to be delivered.
     Blood is stored at 4 C after cross matching. The
                             o

        infusion must start within 30mins of removing it from
        the refrigerator, and be completed within 5h.

8. Check identity:
     2 people must do this, one a qualified health
       professional
     The patient‟s identity must be checked with the
       patient and also from the ID band, lab report and
       blood bottle
     The cell type, donation number and expiry date
       should be checked

9. Infuse the blood; this must be through a blood
administration set, with an integral filter.

10. Observe:
     Temperature and pulse at time 0. 15min, 30min and
       then hourly

11. Record the details of the transfusion into the notes:
     No. of units, and their group
     Any adverse events

12. Record the transfusion on the patient‟s fluid chart.




183
Questions around the topic

What are the indications for blood transfusion?
1. Moderate to severe acute blood loss
2. In the normovolaemic patient:
      Severe (Hb<80g/l) symptomatic anaemia, particularly
         if causing cardiovascular compromise
      Less severe anaemia if there is a risk that the patient
         may lose blood acutely
      Marrow failure causing symptomatic anaemia, eg. in a
         myeloproliferative disease

What are the possible complications of blood transfusion?
1. Transfusion reaction:
     Blood given to wrong patient
     Reactions due to red cell antibodies other than ABO
        and Rh D
     Non-haemolytic febrile transfusion reactions (eg. due
        to white cell antibodies)
     Allergic or anaphylactic reaction

2. Metabolic (rare and usually in massive transfusion):
     Hypocalcaemia (caused by citrate anticoagulant)
     Hyperkalaemia (esp. with older cells, which lyse more
       easily)
     Hypothermia (with large volumes of cold blood)

3. Infection:
      Viral – HIV, Hep B, Hep C, CMV
      Bacterial – if blood were kept at room temperature
         long enough for bacterial contamination (theoretical)

4. Cardiovascular:
     Fluid overload can cause heart failure.

How would you minimise the cardiovascular risks from
transfusion?



184
*Give red cells rather than whole blood to minimise the
volume load
*Give an intravenous loop diuretic (Frusemide) at the start of
the transfusion
*Close observation for signs of volume overload

What would you do if, thirty minutes after transfusion, the
patient became restless and flushed, and developed a
temperature, skin rash and headache?
This is characteristic of a haemolytic transfusion reaction,
which is a medical emergency.
*Stop the transfusion, replace the giving set and keep the line
open with 0.9% saline.
*Check patient‟s identity against the blood bottle to see if
she/he has received the wrong patient‟s blood
*Take blood for: blood culture, FBC, coagulation screen and
repeat cross-match, U&Es
*Return blood pack and giving set to lab
*Call for senior help


                    Pleural aspiration

1. Introduce yourself to the patient, explain what you would
like to do and obtain consent.

2. Assemble equipment: sterile pack, gloves, antiseptic
solution, 2 or 5ml syringe for local anaesthetic, 20ml syringe
to aspirate fluid, orange (25G) and green (21G) needles, vial
of local anaesthetic, plain sterile tubes and tubes for specific
tests (eg. cytology, glucose).

3. Ask the patient to sit upright and lean forwards with their
arms crossed in front of them, or ask them to lean back and
put arms above head. The patient should have something firm
to lean against. His position gives you good access to the
lower thorax posteriorly.




185
4. Ensure that the patient is relatively comfortable and
maintain dialogue with them throughout the procedure.

5. Percuss the relevant lower thorax posteriorly and identify
the area of dullness caused by the effusion – delineate the
area affected.

6. Palpate the margins of the two ribs that form the interspace
below the top of the area.

7. Wash your hands and wear gloves – use sterile technique.

8. Clean the skin with antiseptic solution, using cotton wool
held with forceps.

9. Draw up local anaesthetic and infiltrate the skin with orange
needle. Introduce the needle about 10cm lateral to the
midline, just above the lower of the two ribs (the
neurovascular bundle runs along the lower border of the ribs.

10. Infiltrate down to pleura with the green needle, always
aspirating before injecting the anaesthetic solution. You may
feel the pleura “give” as you advance the needle, at which
point pleural fluid may flush back into the syringe.

11. Attach a green needle to the 20ml syringe and introduce it
perpendicular to the skin, just above the rib which form the
lower margin of the interspace, following the track of the local
anaesthetic. Penetrate the parietal pleura and aspirate 20ml
fluid.

12. Withdraw the needle and cover the entry site with a dry
gauze dressing.

13. Send the aspirated fluid in appropriately labelled sterile
containers to the lab.


What if no fluid was coming out?



186
         You chose too high an interspace
         The pleura are thickened by fibrosis or tumour
          infiltration
         The pleural fluid is viscid – it may be fibrinous or
          purulent (empyema)

You would:
      Repeat the procedure one interspace down
      Use a larger needle if you suspected there was viscid
         fluid
Ask a radiologist to do an USS, check it is fluid, and direct you
to a better position if you are still having no success.

                    Inserting an NG tube


1. Introduce yourself, explain what you would like to do and
obtain consent.

2. Ask the patient to sit on a chair or on the edge of the bed,
with the neck slightly flexed.

3. Wash your hands and put on gloves.

4. Measure the distance from the tip of the patient‟s nose to
the ear lobe and from the ear lobe to the xiphisternum and
mark that distance on the tube with tape.

5. Place the NG tube, gauze, tube of KY jelly, Xylocaine spray
and a glass of water with a straw on a clean surface next to
the patient.

6. Spray the nostril with Xylocaine.

7. Squirt jelly onto the gauze and lubricate the end section of
the tube.




187
8. Pass the tube into the patient‟s nostril and along the floor of
the nose into the nasopharynx.

9. When the patient is aware of the tube in the back of the
throat, ask them to tilt their head forward and take sips of the
water through a straw.

10. Each time the patient swallows, advance the tube a few
cm (so that the epiglottis is closed whenever the tube is
advanced).

11. If the patient coughs violently, draw back a few cm.

12. Talk to the patient encouragingly throughout the
procedure.

13. Once the tube is in the oesophagus, it should be possible
to advance it quite rapidly into the stomach.

14. Check that the tube is in the correct position by injecting a
small volume of air into it from a syringe and listening with a
stethoscope (wide-bore tube) or by x-raying the patient (fine-
bore tube).

15. Tape the tube to the patient‟s nose.


What are the indications for putting in a Ryle’s tube
(wide-bore tube)?

         To empty the stomach (after GI surgery, in intestinal
          obstruction, after trauma or in serious illness where
          there is serious risk of aspiration)
         To aspirate stomach contents for diagnostic purposes
          (to assess the progress of upper GI bleeding, after
          some forms of poisoning)

You should use a fine-bore tube if you want to give
medications enterally because it is:



188
       Softer and much less uncomfortable
       Less likely to cause oesophageal inflammation and
        stricture
Able to stay in a longer time (> 1 week)
                     Skin examination

1. Introduce yourself to the patient, explain what you‟d like to
do and gain consent.

2. Expose the patient to allow examination of the whole area
of skin you want to look at.

3. Ensure good illumination (preferably natural light).

4. Measure dimensions of skin lesions (especially helpful
when assessing progression and regression).

5. Attempt to transilluminate large swellings (fluid filled).

6. Assess skin colour and variations.

7. Describe the primary morphology of a localised skin lesion:
     Macule
     Patch
     Papule
     Plaque
     Wheal
     Vesicle
     Nodule
     Petechia or ecchymosis
     Bulla
     Telangiectasia, spider naevus

8. Describe the secondary characteristics:
     Superficial erosion
     Ulceration
     Crusting



189
         Scaling
         Fissuring
         Lichenification
         Atrophy
         Excoriation
         Scarring or keloid

9. Describe the distribution of a more widespread rash or
colour change

10. Assess the temperature of the affected area.

11. Perform a general examination, looking for evidence of
systemic disease.

                       Acute abdomen


Acute abdomen = conditions which present with clinical
features of short duration (<10 days) which might indicate a
progressive intra-abdominal condition that is life threatening or
capable of causing severe morbidity. From an examination of
the acute abdomen you want to be able to classify patients as:
         Operation necessary
         Operation not immediately necessary – seek further
          information
         No operation necessary

Structured data sheets can be used to make sure that data is
complete. These include all the signs that you should be
looking for.




190
191
Rovsing’s sign = for acute appendicitis. This is pain more in
the RIF than in the LIF when the LIF is pressed.

Murphy’s sign = for gallstones. Lay 2 fingers over the RUQ.
Ask the patient to breathe in. This causes pain and arrest of
inspiration as the inflamed GB impinges on your fingers. It is
only +ve if the same test in the LUQ doesn‟t cause pain.

Guarding = Reflex contraction of the abdominal muscle –
press gently on the abdomen and it will change from being
soft to rigid under your fingers. It signifies local or general
peritoneal inflammation, but to get it the inflamed visceral
peritoneum must be in contact with the abdominal wall.

Rebound tenderness = when you press in one someone‟s
stomach it hurts, but as you take the pressure off, there is a
momentary increase in pain. It signifies local peritoneal
inflammation, which manifests as pain as the peritoneum
rebounds after being gently displaced.

Rigidity = this occurs when you have generalised peritonitis.
The muscles are held rigid and the abdomen is “board like”. It
may not move with respiration.



                 Explaining tests to patients


                       1. Explain: ERCP

                    Introduce yourself




192
Start by explaining who you are and checking the details of
the patients and what they‟ve got wrong with them – “So
Mrs…, I understand that you‟ve got X and you‟re going to be
having an ERCP. I‟m going to explain what‟s involved and try
to answer any questions that you might have”.

What is ERCP?

ERCP stands for Endoscopic Retrograde Cholangio-
Pancreatography.
It is an X-ray examination of the pancreatic and bile ducts,
which are injected with a dye before hand to make them show
up. The bile ducts drain bile from the liver while the pancreatic
duct drains pancreatic juice from the pancreas. Both open into
the first part of the small intestine (the duodenum).

When is ERCP used?

The purpose of the examination is to detect any diseases or
irregularities in the bile or pancreatic ducts.
      Location, and in some cases removal, of gallstones
         stuck in the bile duct. It is also possible to reveal
         cancer, infections and cirrhosis of the liver.
      To investigate jaundice where the patient goes yellow
         as the result of a blockage to the bile ducts.
      To investigate otherwise unexplained abdominal pain.
Apart from its diagnostic uses, ERCP can also be used to
relieve jaundice by removing gallstones from the bile ducts or
by placing a plastic tube (stent) across a narrowing in the
lower bile duct.

How is ERCP performed?

An ERCP is carried out in a hospital X-ray department.
Because the stomach needs to be empty to allow the
endoscope to pass safely through, the patient has to fast for
six hours.
After explaining the procedure, the endoscopist will spray the
back of the throat with a local anaesthetic spray similar to that



193
used by dentists which makes the throat feel numb and it may
be difficult to swallow.

A sedative drug is injected into the hand or arm. This is not a
full anaesthetic but it does make the person being examined
feel very sleepy.

A special endoscope is placed in the mouth and the patient is
asked to swallow it. It is rather like swallowing a large piece of
food.

Although the patient is not usually aware of the procedure
after this point, the endoscope is threaded through to the
duodenum. Once there, a thin tube will be passed from the
endoscope through a small hole in the wall of the duodenum
into the ducts that lead to the gall bladder and the pancreas.
The dye is injected into the duct and the X-ray pictures are
taken; the endoscopist will then study X-ray pictures.

If there is a stone in the bile duct, this will be removed by
enlarging the lower end of the duct and dragging the stone
out. If there is a narrowing in the bile duct, a plastic tube
(stent) will be inserted to allow the bile to drain freely into the
duodenum.

After the procedure, the patent will feel sleepy for a few hours.
If a stone has been removed or a stent inserted they may
need to stay in hospital overnight. You must not drive a car,
operate machinery or drink alcohol until the next day.

Is ERCP dangerous?

Diagnostic ERCP is perfectly safe. In very rare cases, patients
may be allergic to the X-ray contrast dye. There is also a
slight risk of inflammation of the pancreas (pancreatitis), which
occurs in about 1 per cent of examinations.

Therapeutic ERCP - when it is used for treatment - is the
equivalent of a surgical operation and although it is still safe,



194
about 3 per cent of patients may suffer complications. The
major ones are infection, bleeding and pancreatitis. Most
people recover completely with medical treatment.

In pregnant women, the liquid dyes could damage the baby.
Patients suffering from liver, heart or kidney diseases should
consult a specialist before taking the test.

        Ask the patient if they have any further
                          questions




      2. Explain: Upper GI endoscopy (OGD/gastroscopy)

What is gastroscopy?

Gastroscopy is an examination of the inside of the gullet,
stomach and duodenum. It is performed by using a thin,
flexible fibre-optic instrument (thinner than your little finger, a
bit like a stethoscope tube) which is passed through the
mouth and allows the doctor to see whether there is any
damage to the lining of the oesophagus (gullet) or stomach,
and whether there are any ulcers in the stomach or duodenum
(the first bend of the small intestine). Sometimes the doctor
will take a small biopsy – a sample of tissue for analysis in the
laboratory. The tissue is removed painlessly through the
endoscope, using tiny forceps.

How is a gastroscopy performed?

Preparation: to allow a clear view, the stomach must be
empty. You will be asked not to have anything to eat or drink
for at least 6 hours before the test. When you come to the
department, a doctor will explain the test to you and will
usually ask you to sign a consent form. This is to ensure that



195
you understand the test and its implications. Make sure you
tell a doctor or nurse if you have any allergies or bad
reactions. They will also want to know about any previous
endoscopy that you have had. You may be asked to put on a
hopsital gown and remove false teeth – these will be kept safe
until after the examination.

During the test: the endoscopist will spray the back of the
throat with a local anaesthetic. This is similar to the
anaesthetic used by dentists. It numbs the throat and may
make it difficult to swallow. When sedation is used, it is not a
full anaesthetic and you will feel sleepy but still be conscious
and aware. A nurse will lay you on your left side and the
endoscopist will put a plastic mouthpiece between your teeth
to keep your mouth open. They will then gently place the end
of the instrument into the mouth and ask you to swallow it,
which feels like swallowing a large piece of food.
The endoscopist may need to put some air into the stomach
to perform the examination effectively and this can cause
discomfort or even a need to belch. This is perfectly normal.
The endoscopist will closely examine the lining of the gullet,
stomach and duodenum to identify the cause of the
symptoms. It will take about 10 to 15 minutes.

After the test: you will be left to rest for 30 minutes. You can
only drink or eat after your swallow reflex is back to normal
after the spray anaesthetic, which usually takes more than an
hour. The back of your throat may feel sore for the rest of the
day, and you may feel a little bloated – if you have been
sedated you must not drink alcohol, drive or operate
machinery until the next day.

What is gastroscopy used for?

         The doctor can study the mucous membrane of the
          stomach from the top to the bottom, and see irritation,
          wounds, or tumours.
         Taking samples or photographs of the mucous
          membrane. The most modern gastroscopes can also



196
          show the areas in the stomach on a TV screen, so
          that the mucous membrane can be studied
          thoroughly. This can be recorded on a videotape, and
          used for later comparison.
         Diagnosis of peptic ulcer, investigation of
          haematemesis, malena, dyspepsia, dysphagia,
          biopsies for celiac disease.

Why doesn't my doctor just send me for an X-ray?

This is a good point. Barium meals were used for many years
for the diagnosis of indigestion symptoms. However, the small
disadvantages of gastroscopy - special units, day-case
admission and the need for sedation - are far outweighed by
the increased accuracy of diagnosis and the ability to take
biopsies at gastroscopy. As a result relatively few barium
meals are performed nowadays.

When will I get the test result?

In many cases the doctor will be able to tell you the
results straight after the test or, if you have been
sedated, as soon as you are fully awake. However, if a
biopsy has been taken, the results may be several
days. It is a good idea to have someone with you, as
when people have been sedated, they often forget
everything that has been said to them. Details of the
results should be discussed with your GP or hospital
specialist – whoever sent you for the test.

Is gastroscopy safe?

All procedures carry some risk but outpatient diagnostic
gastroscopy is very safe. Minor complications (bleeding) are
uncommon and major complications (perforation) are very
rare.




197
Do you have any further questions, or was anything
unclear?




                   3. Explain: Colonoscopy

What is colonoscopy?

This procedure will involve examination of the colon, or large
bowel, using a long, flexible viewing instrument with a camera
and a light on it, called a colonoscope. The colonoscope is
about the thickness of your index finger and is passed through
the anus, or back passage, into the colon, and the doctor can
then use the camera on the end to get a clear view of the
bowel and whether any disease is present. Sometimes a
biopsy, a small sample of tissue, may be taken painlessly
using small forceps through the colonoscope, and can be sent
to the laboratory. It is also possible to remove polyps during
the test – these are abnormal projections of tissue, a bit like
warts.

What is colonoscopy used for?

         Colonoscopy enables the doctor to examine the lining
          of the bowel all the way through the colon and is,
          therefore, used to investigate bleeding, changes in
          bowel movements, abdominal pain and abnormalities
          revealed by other examinations such as barium
          enema, which require confirmation or biopsy.
         It can detect inflammation, ulceration, polyps,
          diverticula and tumours.
         It can also be used for therapy, including polypectomy
          using diathermy snare, diathermy to angiodysplasia
          and treatment of volvulus.

What happens during the examination?




198
On the day before the examination, you will be given a
laxative to ensure the bowel is empty, and you must drink lots
of clear fluids the day before the test to clean the bowel
further. Nothing to eat or drink is allowed for 6 hours before
the procedure.

Colonoscopy is done on an outpatient basis and takes about
20 to 40 minutes. You will have the opportunity to talk to a
doctor about the procedure before it is done, and you will
have to sign a consent form.

You will be asked to lie on your side during the examination.
You will probably be given a sedative injection, which will
make you feel sleepy and relaxed throughout the test. The
colonoscope will be lubricated with some jelly and gently
inserted into the bowel through the back passage. Some air
may be blown gently into the bowel to improve the view of the
bowel lining. This can give you some wind-like pains, but they
don‟t last long. You may also get a sensation like wanting to
go to the toilet, but as the bowel is empty there‟s no danger of
this happening. You might also pass wind but you shouldn‟t
feel embarrassed about this as the staff understand what is
causing it.

Afterwards, you will be allowed to doze until the effects of the
sedation wear off before going home. If a larger piece of
tissue, such as a polyp, has been removed, it may be
necessary to stay in the hospital for a few hours for
observation for possible bleeding. Patients will not be able to
drive home because of the sedation.

Is colonoscopy safe?

Slight risk of complications including perforation and bleeding.
Mortality rate of 0.02%.

When will I get the results of the test?




199
If no biopsy has been taken, the doctor can tell you the results
straight away. However, it is a good idea to have a friend or
relative with you, because if you have been sedated, you may
not remember what you are told. If a biopsy has been taken,
the results will be a few days. You can discuss the results with
your GP or consultant, whoever referred you.

Are there any questions that you would like to ask, or was
there anything that was unclear?




                 4. Explain: Sigmoidoscopy

What is sigmoidoscopy?

Sigmoidoscopy is an examination used to look inside the
lower part of the intestine. Many people feel embarrassed by
it, but it is a necessary way to check for problems in the large
intestine or the rectum, and there is no need to be
embarrassed. A tube, which may be flexible or rigid, is
inserted into the anus and the rectum and colon can be
viewed through it.

What happens before the examination?

On the day of the examination an enema or suppository is
used to soften the stools that need to be evacuated from the
lower part of the intestine.
The patient needs to lie down, usually on their side with their
knees brought up to their elbows. This makes it relatively easy
for the doctor to perform the examination through the rectum.

What happens during the examination?

After the doctor has examined the rectum by inserting a finger
(digital rectal examination), the sigmoidoscope (a metal or
plastic tube) is inserted. Air is blown through the tube, which is



200
also fitted with a light source and a very small camera. The
sigmoidoscope is pushed very slowly 18-22cm inside the
intestine, then gently pulled back out while the doctor carefully
studies the mucous membrane for any abnormalities such as
inflammation or tumours. The examination itself won‟t hurt, but
to see clearly the doctor needs to blow some air into your
rectum – this can give you a feeling of wanting to go to the
toilet, or a slight colicky pain. Biopsy samples of suspicious-
looking tissue can also be taken and studied later under a
microscope.

Since it is difficult to study the lower part of the intestine
(rectum) with the lengthy sigmoidoscope a proctoscope is
used instead. This is only 7-10cm long, and can be inserted
immediately after the sigmoidoscope is removed, allowing the
doctor to study the rectum.

Is it necessary to stay in hospital?

The examination can be performed without anaesthetic as an
outpatient treatment and rarely lasts more than 10-15
minutes. After the examination the patient can go home right
away.



                  5. Explain: Bronchoscopy


Introduce yourself to the patient. Explain: you need to have
a test called a „bronchoscopy‟ to help find the cause of your
symptoms.

What is a bronchoscopy?

A bronchoscopy involves passing a long flexible tube, about
the width of a thin pencil, with a light on the end through the
nose, down the windpipe and into the airways in the lungs.
This allows the doctor to look at the windpipe and the airways



201
directly to check if there is any disease present. A small
specimen, called a biopsy, may need to be taken during the
procedure; this involves painless removal of a small amount of
tissue by tiny forceps threaded down the tube.

      What happens during the bronchoscopy?

You will be asked not to eat or drink for at least 4-6 hours
before the test.
On the day of the test the doctor will explain the test to you
and ask you to sign a consent form to ensure that you
understand the test.
You may be given an injection before the test to make you
sleepy - the doctor will spray local anaesthetic into your nose
and through your mouth to the back of the throat. This may
taste a bit bitter. The spray will make the test more
comfortable.
The tube will be passed through your nose and as the tube is
passed more local anaesthetic may be spayed through the
bronchoscope to numb the voice box. This may make you
cough but as the anaesthetic takes effect your throat will
relax.
The test usually takes about 15-20 minutes and afterwards, if
you are still sleepy from the sedation, then you will be left to
recover in the ward.
Because you throat is numb it is not safe to eat or drink
straight away in case it is inhaled - swallowing should return to
normal in about 3 hours. If you are going home the next day it
is essential that you do not drive, operate machinery or drink
alcohol. The following day you should be able resume your
normal activities.

Is bronchoscopy safe?

Bronchoscopy is very safe, and provides useful information
about what might be the problem. After the test you might
have a slight nosebleed and if you have had a biopsy then
you may find streaks of blood in your phlegm. This will pass in



202
about 24hrs and is nothing to worry about. Any soreness will
also ease in a day or two.




                   6. Explain: (Chest) X-ray

                    What is an X-ray?

X-rays are a form of electromagnetic radiation – they have
high energy and short wavelength and are able to pass
through tissue. On their passage through the body, the denser
tissues, such as the bones, will block more of the rays than
will the less dense tissues, such as the lung.
A special type of photographic film is used to record X-ray
pictures. The X-rays are converted into light and the more
energy that has reached the recording system, the darker that
region of the film will be. This is why the bones on an X-ray
image appear whiter (less energy passes through) than the
lungs (more energy passes through).
The machines used to take X-ray pictures produce X-rays with
energies of around 120,000 electron volts. The X-rays used
for cancer treatment are much more powerful, with energies of
between 2 million and 20 million electron volts.


What happens during an X-ray test?

Chest X-ray is one of the most frequently carried out medical
examinations, and is usually used to look at the heart or the
lung. It is a quick, simple and painless procedure.
The X-ray stand folds a film in a large, flat cassette positioned
at chest level. You stand in between the film and the X-ray
machine. You have to place your hands on your hips and
move your elbows forward, so your shoulderblades don‟t
obscure your lungs. A lead apron will be worn to protect the
lower part of your body. Then you take a deep breath while



203
the radiographer presses a button, that passes the X-rays
through you for a fraction of a second, creating a picture on
the film.

Is X-ray radiation dangerous?

It is one of the ironies of radiological practice that X-rays can
both cause cancer and be used to treat it. Nowadays, with the
use of very small doses of radiation to produce high quality X-
ray images, the risk of cancer after properly supervised X-ray
examinations is extremely small; so small as to be of no
consequence to any individual.

Because staff in the X-ray department work with X-rays all the
time they would, if they stayed beside every patient, over the
course of time, be exposed to quite a high dose of radiation.
This is why they go behind a screen when the X-ray beam is
switched on. The cumulative effect would be significant for
them in a way that it is not significant for an individual patient.

Radiation can cause damage to a foetus, which is why, as far
as possible, the use of X-rays during pregnancy is kept to the
absolute minimum. Any woman who suspects that she is
pregnant, and who has been referred for an X-ray
examination, should make sure that the radiographers and
doctors caring for her know about her condition.




                      7. Explain: CT scan

What is a CT scanner?

A CT (computerised tomography) scanner is a special kind of
X-ray machine. Instead of sending out a single X-ray through
your body as with ordinary X-rays, several beams are sent
simultaneously from different angles.




204
How does a CT scanner work?

The X-rays from the beams are detected after they have
passed through the body and their strength is measured.
Beams that have passed through less dense tissue such as
the lungs will be stronger, whereas beams that have passed
through denser tissue such as bone will be weaker. A
computer can use this information to work out the relative
density of the tissues examined. Each set of measurements
made by the scanner is, in effect, a cross-section through the
body. The computer processes the results, displaying them as
a two-dimensional picture shown on a monitor. The technique
of CT scanning was developed by the British inventor Sir
Geoffrey Hounsfield, who was awarded the Nobel Prize for his
work.

What is the CT scanner used for?

The CT scanner was originally designed to take pictures of
the brain. Now it is much more advanced and is used for
taking pictures of virtually any part of the body. The scanner is
particularly good at testing for bleeding in the brain, for
aneurysms (when the wall of an artery swells up), brain
tumours and brain damage. It can also find tumours and
abscesses throughout the body and is used to assess types of
lung disease. In addition, the CT scanner is used to look at
internal injuries such as a torn kidney, spleen or liver; or bony
injury, particularly in the spine. CT scanning can also be used
to guide biopsies and therapeutic pain procedures.

How is a CT scan prepared for?

If the patient is receiving an abdomen scan, for example, they
will be asked not to eat for six hours before the test. They will
be given a drink containing gastrografin, an aniseed flavoured
X-ray dye, 45 minutes before the procedure. This makes the
intestines easier to see on the pictures. Sometimes a liquid X-
ray dye is injected into the veins during the test. This also
makes it easier to see the organs, blood vessels or, for



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example, a tumour. The injection might be a little
uncomfortable, and some people also experience a feeling of
warmth in their arm.

How is a CT scan carried out?

The scanner looks like a large doughnut. During the scan the
patient lies on a bed, with the body part under examination
placed in the round tunnel or opening of the scanner. The bed
then moves slowly backwards and forwards to allow the
scanner to take pictures of the body, although it does not
touch the patient. The length of the test depends on the
number of pictures and the different angles taken.

Does a CT scan hurt?

The examination does not hurt but some people find it
uncomfortable to lie in the tunnel. As there is little room inside
the tunnel, people who suffer from severe claustrophobia
sometimes have problems with CT scans. Let the doctors and
radiographers know if this might be a problem. Other people
get slightly nervous because of the whirring noise the machine
makes noise while working.

Is a CT scan dangerous?

Far more X-rays are involved in a CT scan than in ordinary X-
rays, so doctors do not recommend CT scans without a good
medical reason. Some patients may experience side effects
due to allergic reactions to the liquid dye injected into the
veins. In very rare cases, this dye has been known to damage
already weakened kidneys. It is important to let the X-ray
doctors or technicians know if you have any allergies, asthma
or kidney trouble, prior to having the X-ray dye injected.



                     8. Explain: MRI scan




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What is an MRI scan?

MRI (magnetic resonance imaging) is a fairly new technique
that has been used since the beginning of the 1980s. The MRI
scan uses magnetic and radio waves, meaning that there is
no exposure to X-rays or any other damaging forms of
radiation.

How does an MRI scanner work?

The patient lies inside a large, cylinder-shaped magnet. Radio
waves 10,000-30,000 times stronger than the magnetic field
of the earth are then sent through the body. This affects the
body's atoms, forcing the nuclei into a different position. As
they move back into place they send out radio waves of their
own. The scanner picks up these signals and a computer
turns them into a picture. These pictures are based on the
location and strength of the incoming signals.

Our body consists mainly of water, and water contains
hydrogen atoms. For this reason, the nucleus of the hydrogen
atom is often used to create an MRI scan in the manner
described above.

What does an MRI scan show?

Using an MRI scanner, it is possible to make pictures of
almost all the tissue in the body. The tissue that has the least
hydrogen atoms (such as bones) turns out dark, while the
tissue that has many hydrogen atoms (such as fatty tissue)
looks much brighter. By changing the timing of the radiowave
pulses it is possible to gain information about the different
types of tissues that are present. An MRI scan is also able to
provide clear pictures of parts of the body that are surrounded
by bone tissue, so the technique is useful when examining the
brain and spinal cord.

Because the MRI scan gives very detailed pictures it is the
best technique when it comes to finding tumours (benign or



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malignant abnormal growths) in the brain. If a tumour is
present the scan can also be used to find out if it has spread
into nearby brain tissue.

The technique also allows us to focus on other details in the
brain. For example, it makes it possible to see the strands of
abnormal tissue that occur if someone has multiple sclerosis
and it is possible to see changes occurring when there is
bleeding in the brain, or find out if the brain tissue has
suffered lack of oxygen after a stroke.

The MRI scan is also able to show both the heart and the
large blood vessels in the surrounding tissue. This makes it
possible to detect heart defects that have been building up
since birth, as well as changes in the thickness of the muscles
around the heart following a heart attack. The method can
also be used to examine the joints, spine and sometimes the
soft parts of your body such as the liver, kidneys and spleen.

How does an MRI scan differ from a CT scan?

With an MRI scan it is possible to take pictures from almost
every angle, whereas a CT scan only shows pictures
horizontally. There is no ionizing radiation (X-rays) involved in
producing an MRI scan. MRI scans are generally more
detailed, too. The difference between normal and abnormal
tissue is often clearer on the MRI scan than on the CT scan.

How is an MRI scan performed?

The scan is usually done as an outpatient procedure, which
means that the patient can go home after the test. During the
scan it is important to lie completely still. For this reason it
might be necessary to give a child an anaesthetic before they
are tested.

Since you are exposed to a powerful magnetic field during the
MRI scan, it is important not to wear jewellery or any other
metal objects. It is also important for the patient to inform



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medical staff if they use electrical appliances, such as a
hearing aid or pacemaker, or have any metal in their body
such as surgical clips, but orthopaedic metalware such as
artificial hips or bone screws is not normally a problem.

Is an MRI scan dangerous?

There are no known dangers or side effects connected to an
MRI scan. The test is not painful; you cannot feel it. Since
radiation is not used, the procedure can be repeated without
problems. There is a small theoretical risk to the foetus in the
first 12 weeks of pregnancy, and therefore scans are not
performed on pregnant women during this time.

Because patients have to lie inside a large cylinder while the
scans are being made some people get claustrophobic during
the test. Patients who are afraid this might happen should talk
to the doctor beforehand, who may give them some
medication to help them relax.

The machine also makes a banging noise while it is working,
which might be unpleasant.



 9. Explain: Ultrasound scan (pelvic, echo and Doppler)

What are ultrasound scans?

Ultrasound scans are images of the internal organs created
from sound waves. The images are produced when the sound
waves are directed into the body then reflected back to a
scanner that measures them. The procedure is painless and
very safe.

What are ultrasound scans used for?

Ultrasound scanning is used to help monitor and diagnose
conditions in many parts of the body, including the kidneys,



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the liver and the heart. It is often used to examine conditions
affecting the organs in a woman's pelvis - the uterus,
Fallopian tubes and ovaries. Ultrasound scanning is not
dangerous and has no side effects, so it is safe to use during
pregnancy.
      In pregnancy - to observe the foetus at 16-18 weeks,
         but can be done at any stage. It can tell the expected
         size and delivery date of the baby, multiple
         pregnancies, or gross abnormalities such as spina
         bifida, as well as the position of the placenta. It is also
         used during amniocentesis and in chorionic villus
         sampling.
      Echocardiography – a type of ultrasound technique
         used to look at the heart; useful in congenital heart
         disease and disorders of heart valves.
      Lliver – can diagnose cysts, cirrhosis, abscesses or
         tumours
      Gallstones
      During needle biopsy can help guide the needle
      Doppler ultrasound: a modified type of ultrasound
         which exploits the doppler effect; the change in pitch
         that accompanies the moving of a sound source
         relative to the detector. Used to investigate moving
         objects, eg. blood flow, fetal heart beat. It is also used
         in angiodynography, in which the rate of blood flow
         through blood vessels is assessed. It can detect the
         narrowing of vessels or turbulence on blood flow.

How does an ultrasound work?

If you are having a pelvic ultrasound, your bladder needs to
be full, so you will be asked to drink plenty of fluids when you
arrive at hospital – this is so other organs can be localised.
You will also have a conducting gel rubbed onto the area that
is going to be scanned. The ultrasound scanner (transducer)
looks like a small paint roller. As it moves back and forth over
the body, it sends sound waves through the skin and muscles.
These waves are then bounced back to the transducer at



210
different rates according to the density of what they hit – the
difference in what is bounced back is turned into an image
that appears on a TV screen. The scan can also be copied
onto paper or X-ray film.

How is an ultrasound scan performed?

The way the ultrasound scan is performed depends on the
purpose of the examination. The scanner can be used
externally on the skin, or through the natural openings of the
body, such as the vagina.

For example, if the kidneys or liver are being examined the
patient will be told to lie on their back or side on an
examination table. Some special gel is spread over the skin,
enabling the scan to define the organs as clearly as possible.

However, if a woman's pelvic organs are under examination, a
transvaginal scan would provide a better picture. A small
probe is gently inserted into the vagina up to the cervix to get
the best image. It should not cause more than a slight
discomfort.

The scan lasts for about 15 minutes at the most and you can
watch it on a TV scan whilst it‟s being done.

Does an ultrasound scan hurt?

An ultrasound scan does not hurt but the gel used for the
examination can feel a bit cold.

Where are ultrasound scans performed?

The examination has traditionally taken place in hospital, with
patients being referred by their GP or midwife. However,
ultrasound is available in a small but growing number of
doctors' surgeries.




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              10. Explain: Barium procedures

This is a group of procedures used to detect and follow the
progress of some diseases in the GI tract. Powdered barium
sulphate mixed with water is passes into the part of the tract
to be examined and x-ray pictures of the area are taken.
Barium is a metallic element which is opaque to x-rays and so
provides an image of the tract on film.

Disorders that can be detected:
     Narrowing or inflammation of the oesophagus
     Disorders of swallowing mechanism
     Hiatus hernia
     Stomach and duodenal ulcers and tumours
     IBD
     Diverticular disease
     Crohns
     Coeliac disease
     Tumours or polyps in the colon

Procedure
Fluorescent screen is connected to the x-ray machine,
enabling the radiologist to follow the progress of the barium
through the GI tract and to see any abnormalities outlined by
barium. Permanent records of the examination are provided
by x-ray photographs or video recordings.

Different types of examination are carried out to investigate
different parts of the GI tract:

Barium swallow meal and follow through – used to investigate
disorders of upper GI tract.
Barium swallow – oesophagus
Barium meal – lower oesophagus, stomach and duodenum
Barium follow through – small intestine

Barium swallow



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Patient usually take in enough air with the barium to facilitate
contrast imaging. If a double contrast barium meal is needed
then necessary carbonated barium with gas producing tablets
or granules. Barium swallow and meal take about 10 minutes
to perform, 10 minutes to follow through.

Barium swallow and intestinal follow through
No food or drink is permitted for 6-9 hours prior. At
examination, patient is given a drink of barium with a
flavoured liquid or bread soaked in barium if swallowing
problem is being investigated. The radiographer then takes x-
rays. For a swallow, the patient is standing, for a meal the
patient lies on the table, and for a follow through the patient
lies on their side and x-ray pictures are taken progressively as
it travels through the small intestine.

Barium small-bowel enema
No food or drink for 9 hours before. At exam, the patient lays
down and the radiographer passes a fine tube through the
stomach and duodenum and into the small intestine. Barium is
then passed down the tube.

Barium enema
For successful examination, the bowel needs to be empty and
clean since faeces can obscure or simulate a polyp or tumour.
Intake of food and drink must therefore be restricted for a few
days prior to exam and laxatives are given. The patient lays
ion the x-ray table face down. Radiographer inserts barium
into the intestine through a tube inserted into the rectum.



        11. Explain: Intravenous pyelography (IVP)

This is also known as intravenous urography (IVU) and
excretion urography. It is a valuable test for diagnosing renal
disease. Carefully timed x-rays are taken of the kidneys and
the full length of the abdomen following a slow intravenous
injection of an organic iodine-containing contrast medium.



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Films taken at the end of injection show opacification of the
parenchyma, allowing definition of size and renal outline. The
kidneys are normally smooth in outline, so any irregularity will
show up, as will the size of the kidney.

The application of a compression band to the abdomen,
designed partially to obstruct ureteral emptying, helps
distension of the upper tracts. Special attention is paid to size,
shape and disposition of the calyces and pelvis for evidence
of anatomical abnormality such as calyceal clubbing,
abnormal dilation, cavitation or filling defects.

After 10-20 minutes, the compression bands are removed and
full-length films are obtained before and after voiding to study
emptying of the upper tract, urethers and bladder.

Complications: reactions to the contrast media (anaphylactic,
convulsions), but non-ionic contrast media has reduced these.
Patients with history of allergy to iodine, those who have had
previous contrast reaction, those with multiple allergies, and
asthmatics should receive 60mg prednisolone the day before
and on the day of the test. Contrast media may also be
nephrotoxic.




            12. Explain: Radioisotope scanning

                            Lungs
Perfusion scan: human albumin labelled with technetium-99m
is injected intravenously. The particles are of such a size that
they impact in pulmonary capillaries, where they remain for a
few hours. A gamma camera is then used to detect the
position of the particles – the resultant pattern indicates the
distribution of pulmonary blood flow; cold areas occur where
there is defective blood flow – eg. PE.




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Ventilation-perfusion scan: xenon-133 gas is inhaled into the
lung and its distribution is detected at the same time. On using
the two scans, a pulmonary embolus can be seen to cause a
striking diminution of perfusion relative to ventilation. Other
lung diseases (eg. asthma or pneumonia) impair both
ventilation and perfusion.



Bone

DEXA scanning.



Thyroid

Use radio-iodine to assess uptake.




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