Ocular Examination

I don’t know about you but I personally don’t like being this close to a random person. Also, this examination reminds me of holding my breath near the optician incase I had bad breathe, even though nine times out of ten they had bad breathe anyway. Regardless, we all need to know how to do this examination, so even if you don’t like it, you’re going to have to power on through and do it.

1. Wash your hands, tell the patient what will happen, check that they are okay with this and check that you have everything you need. (pro tip: it’s an ISCE, you will do)
2. Start by asking them to remove glasses or contact lenses if they normally wear them.
3. Then, inspect the eyes, look for
   1. Proptosis, bulging of the eye balls (tends to happen in thyrotoxicosis).
   2. Ptosis, drooping eyelids, can be caused by neuromuscular issues or conditions such as hypothyroidism.
   3. Look at their conjunctiva, is it red or inflamed? Filled with yellow gunk like in conjunctivitis?
   4. Look at their pupils, inspect for any differences in size, again this can have a neuromuscular cause such as a lesion to the occulomotor nerve.
   5. Test pupillary reflexes, shine the ophthalmoscope at the patient’s pupil and watch that one contract then do it again with a hand between their eyes blocking the light and watch the other pupil contract. Repeat on the other side.
4. Test their visual acuity using the snellen chart, their acuity is measured by the lowest level that they can read perfectly. The snellen chart works by the definition that at 6 metres they should be able to read the line down that has a 6 attached to it, they should be able to read the line with 12 attached to it at 12m as it is twice the size. I wouldn’t worry too much about it though, it’s the type of thing you tend to send people to their optician about. Say you would test visual acuity but you don’t need to do it for year two ISCE’s
5. Now you need to test their visual fields. Grab a white hat pin and do the double H movement to test their visual field, its covered in more detail in the cranial nerves examination.
6. Then test their blind spot using a red hat pin, again this is talked about more in the cranial nerves examination post.
7. Next, we move onto ophthalmoscopy. Make sure the patient is facing away from any light and draw the blinds if you can. Then put the ophthalmoscope on its lowest setting, the white zero, and adjust to what your visual acuity needs numbers wise (this is something you need to figure out when you practice). Use your right hand and right eye to look at the patients right eye. It tends to help to place your other hand on their forehead so you don’t go too close and warn them that you will be invading their personal space.
8. Ask them to look at a distant object over your shoulder and assess their red reflex. Do this by holding the ophthalmoscope about 10cm away from their eye and move it around until you find the reflex. Normally your ophthalmoscope will be on the temporal side just above the horizontal midline. Then staying at this angle, gradually move closer to the patient.
9. Examine the retinal vessels, optic disk, and macula in turn. You may need to practice this a lot as its sometimes hard to keep focus. A pale disk could be due to ischaemia of the optic blood vessels. Flame haemorrhages can be due to high blood pressure. Diabetic patients can have multiple blot haemorrhages showing lots of vascular breakdown and new vessel formation. My point is that a lot can be wrong so either learn it all or get good at describing what you are seeing. 
10. You should slowly move away from the eye now. Then repeat with the other eye. Finally, turn the ophthalmoscope off and thank your patient before washing your hands. Jump on over to your skill.

Well Done and Good Luck!!

References

Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.

Testing the Brain: What Neurological Exams Can Tell Us About Ourselves – Brain Connection [Internet]. Brain Connection. 2018 [cited 29 March 2018]. Available from: https://brainconnection.brainhq.com/2008/08/06/testing-the-brain-what-neurological-exams-can-tell-us-about-ourselves/

Eye Movements – Cranial Nerves [Internet]. Cranial Nerves. 2018 [cited 11 March 2018]. Available from: https://bmc.med.utoronto.ca/cranialnerves/illustrations-by-chapter/eye-movements

Figure 11.1 Anatomy of the human eye. Box 11A(1) Myopia and Other Refractive Errors. – ppt download [Internet]. Slideplayer.com. 2018 [cited 29 March 2018]. Available from: http://slideplayer.com/slide/7698549/

Obstetric Examination

Babies!!! Now this is actually a really cute examination to do, mothers are always happy to talk about their little parasites! In all seriousness, if you’re doing this on a real ward you might want to check with a midwife which patients would be willing to talk to a medical student. If they are going to put the baby up for adoption etc they may not want to talk to you, which is understandable.

So lets learn what you should do after you have spoken about the mother’s obs and gynae history:

1. Wash your hands!! Like seriously, hand hygiene is a must, especially in flu season. Explain what you are going to do and get consent.
2. Ask the lady to lie on the couch, make it so that she is at about a 30 degree angle, if she lies perfectly flat she will probably pass out from not being able to breathe fully.
3. Next, ask her to expose her belly, she may have to wiggle her trousers down a little to expose the bottom of the bump, you want to see from the xiphisternum to the pubic symphysis.
4. Now, like most things you need to inspect for scars such as a pfannenstiel scar from a past c-section. If someone has had two c-sections in the past they will most likely have to have one this time around. Look for any abnormal colouring or shapes, sometime if the lady is very slim you can see parts of the baby.
5. Then, ask if there is any tenderness and be really gentle in those areas if there is any, keeping an eye on the mother’s face for any signs of pain.
6. Place your hand gently on their belly and feel for the lateral and upper limits of the uterus. Try not to press too hard because you can stimulate myometrial contractions making it hard to feel baby.
7. Facing the mum’s head (standing by her legs), place your hands at the fundus (top) of the uterus, on either side, and feel for the babies head or bottom, this will tell you if they are breach or cephalic. If it’s large and smooth or knobbly then it may be the back or limbs, in that order. If that’s the case, try this again at the lateral side, if their bottom or head is there then the babies lie is transverse.
8. Once you have found the head or bottom, slide your hands down the ladies belly, the fuller smoother side normally contains the back. you should now know how the baby is lying either longitudinal, transverse or oblique. If it is longitudinal or oblique you should also know if the baby is breach or cephalic (vertex), the head is up or down. 
9. Now, stand next to the lady’s head and feel for the presenting part of the baby, the part in their pelvis. You may need them to take a deep breath in so you can feel deeper. If it’s a head you should be able to push it between your hands and feel the hardness.
10. Now, measure the baby by placing the tape measure, face down, from the highest part of the fundus to the pubic symphysis. They say about 1cm for every week the baby has been growing is about average but you get babies bigger and smaller all the time.
11. Now, clean a Pinard stethoscope and use it to listen to the babies heartbeat. The best way to do this is to place it on their anterior shoulder, so a bit behind where their head is, on the side you think the back is, then place your ear on the flatter surface and let go with your hand. You should hear the babies heart beat going very fast don’t worry if it sounds a little distant through your stethoscope, that’s normal.
12. Now thank your lady, clean your equipment and hands and move on to your skill. The terror of babies is nearly over!

References

Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.

ADNAN M, profile V. Fetus in-utero [Internet]. Medicinembbs.blogspot.co.uk. 2018 [cited 28 March 2018]. Available from: http://medicinembbs.blogspot.co.uk/2012/04/fetus-in-utero.html

Neurological (Sensory) Examination

Sensations. The five senses are a big part of being human and it can have devastating consequences when people lose one such as their ability to feel. The diabetic foot examination exists for a reason. Now, that means your ability to test people’s sense of touch is paramount in helping your patients.

1. Okay so you need to wash your hands, clean your tuning fork and introduce yourself. Now would be an excellent time to tell your patient what you are going to do and get consent.
2. Now like the neuromuscular motor examination you are going to test the upper limb then the lower limb. Your patient needs to having their arms and legs on show for this as you need to assess them. They should be reclined on the couch and you should take a moment to do a general inspection from the foot of the bed to see any abnormalities such as Charcot’s foot.
3. Start with light touch, you need to grab some cotton wool and make a wisp from it. Now demonstrate how it will feel on the patients sternum (central so less likely to have any problems with sensation than the peripheries). Then ask them to close their eyes and touch in random patterns over both arms, asking them to say when they feel the cotton wool. Compare each arm and note any differences.
4. After this, use a neurotip to test their response to pain, this shouldn’t hurt them though, its more a pressure than a pain. Again, show them what both the sharp and blunt end of the neurotip feel like on their sternum then get them to close their eyes and test it on their arms, asking for verbal confirmation. Map out any areas of reduced sensation (hypoaesthesia), or increased sensation (hyperaesthesia).
5.  Next, you need to test their ability to detect vibration. Get your tuning fork (remember you want the big one, 128 hz) and show them what it feels like when it is vibrating by placing it on their sternum. Then get them to close their eyes again and place the vibrating tuning fork on the distal interphalangeal joint of the index finger. Move move proximally if they can’t sense that. So to the proximal interphalageal joint then, the next bony prominence and so on until they can feel it.
6. Now, you need to test their proprioception. So, hold their distal interphalageal joint between two fingers and while they are watching move their finger tip up and down. Then get them to close their eyes. You now need to confuse them by moving the joint up and down a bit and then move it up and ask them to identify whether it is up or down. Do this on both hands and move more proximally if they can’t detect if it is up or down correctly.
7. Following on, you now need to do the above (3-6) with their lower limbs. The only real difference is that you will be testing their great toe instead of their index finger.
8. You are done! Wash your hands and clean your tuning fork, thank your patient and move the hell on.

Damage to the tracts of the spinal cord that do sensation such as the spinothalamic tract can cause these losses in sensation. However, it could be a problem at either the brain or peripheral end so it is important to map out any loss of sensation.

References

Epstein O. Clinical examination. Edinburgh: Mosby; 2008.

Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.

[Internet]. Cjon.ons.org. 2018 [cited 28 March 2018]. Available from: https://cjon.ons.org/cjon/17/1/supplement/current-methods-assessment-and-management-taxane-related-neuropathy/html/full

Neurological (Motor) Examination

Now, neurological examinations are long things so you may want to take a moment to get snacks, I need to get provisions before even attempting to type this all out and I don’t have to practice any of it. Anyway, neurological examinations can be split into motor and sensory, as you can see from the title, this is the motor one. I’m pretty sure that this is part of your cranial nerves competency in year 2 as well so practice lots. Good luck!!

1. Get some sort of explanation going, consent your patient,wash your hands, clean your equipment (tendon hammer) and begin.
2. You need to see the patients upper and lower limbs so you need them to expose those areas, they normally will already have done so for the ISCEs.
3. Ask them to stand up and inspect their limbs for muscle wasting or hypertrophy. Note any deformities or asymmetry such as clawing of the hands, things like the hand of benediction. Muscle wasting occurs early in lower motor neurone lesions whilst upper motor neurone lesions are only linked to it through disuse so it takes longer. Sports players may have muscle hypertrophy and this may be asymmetrical if they favour a dominate hand in something such as tennis.
4. Get the patient to walk away from you and then back towards you whilst you inspect their gait. Look for symmetry in their movements and smoothness. A limp may be due to pain or weakness in that limb. ask them to repeat with heel to toe and tip toe gaits. Then ask them do Romberg’s test, stand with their eyes closed and see if they lose balance. Ask them to sit on the examination couch and inspect them again from the end of the couch as above.
5. You want to test all the upper body first while they are sitting down, this can be in a chair but it’s easier if they are sitting on the edge of the coach or properly on it with the back fully up.
6. Begin with tone. Start by asking about any painful joints, if they have any make sure to be careful when inspecting these. Then get them to go all ‘floppy’, as relaxed as they would be if they had just had a full body massage.
7. Passively move each joint in every direction it goes both slowly and quickly. Build up the speed and identify whether the joint contracts (clonus) it will do so in upper motor neurone lesions and is associated with spastic hypertonia, resistance to movement.
8. Rigidity is a hypertonia normally found in Parkinson’s,  (cog-wheel rigidity) which is best seen in slow movements.  You need to make sure that you isolate the joint you are moving so you are only testing the tone of that specific joint. For example, hold the patients elbow still whilst testing the wrist.
9. Then test the power of their joints. You should start by assessing for pronator drift, get them to close their eyes and outstretch their arms, if their wrist begins to pronate then they have an upper motor neurone weakness, their ability to supinate is weaker than that to pronate.
10. Then, ask the patient to do the following movements without resistance (see that they can do them against gravity) then with you providing resistance. Remember to isolate the muscle you are testing.
    1. Finger abduction/adduction
    2. Finger flexion/ extension
    3. Thumb abduction/adduction
    4. Wrist extension/flexion
    5. Elbow extension/ flexion
    6. Shoulder abduction/ adduction
11. Onwards to reflexes! Upper limb reflexes are biceps, triceps, supinator and fingers.  Remember you want to hit the tendon not the bone or muscle. Hold the tendon hammer right at the end and allow the weight of the hammer to control the strength of the blow, we’re not trying to break some little old ladies’ bones here. Compare each tendon to the other arm in turn. Get them to clench their teeth if you can’t get the reflex.
    1. Biceps jerk, feel for the biceps tendon, get them to flex their arm if you can’t find it easily. Then placing the arm at about 45 degrees bent, hold your thumb over the tendon and hit your thumb. Watch their elbow flex.
    2. Triceps jerk, bend the arm to around 90 degrees, and hit the triceps tendon. It’s just above the elbow joint, you can feel it when they extend their arm. You don’t need to cover this one with your thumb. Watch their elbow extend.
    3. Supinator jerk, on the lateral part of your dorsal arm is your supinator tendon.  It’s about three fingers proximal to your wrist. Place our thumb over it with the patients hand fully relaxed and hit your thumb. Watch their wrist supinate.
    4. Finger jerk, place your index and middle finger across the patients proximal phalanges and hit your fingers. Watch for their fingers flexing.
12. Then you need to test coordination. Get them to do the finger nose test, touch their finger to yours (which you will hold out in front of them) and then to their nose and back again, going as quickly as they can. Also, ask them to clap their hands normally and then back to back, doing their repetitively as quick as they can.
13. Now onto the lower limbs. You want them laying on the couch with their back at about 45 degrees for this.
14. The lower limbs has a wiggle, wiggle, drop, drop method for testing tone. Wiggle the thighs from side to side, then lift the knees up and drop them. Before you drop the knee glance at the foot, if it’s moved off the couch then they likely have increased tone. Then test the ankle and foot as you did with the wrist earlier. Assess for clonus on the ankle, move it gradually quicker and quicker and notice if it contracts.
15. Then assess power of the following movements. Assess against gravity and then against resistance. Remember to isolate the joint.
    1. Hip flexion/extension
    2. Hip abduction/adduction
    3. Knee Flexion/extension
    4. Ankle dorsiflexion/plantar flexion
    5. Ankle eversion/inversion
    6. Great toe extension
16. Then you need to test reflexes. The lower limb ones are; the knee, ankle and plantar reflexes.
    1. Knee jerk, get the patient to sit on the edge of the couch with their legs hanging over the edge. Hit their knee just below the patella and watch the leg extend and swings forward.
    2. Ankle jerk, whilst they are still sitting on the edge, get them to place one ankle over the other knee. Pull their foot into dorsiflexion and hit the achilles tendon. Repeat on the other limb. You should feel the foot plantar flex.
    3. Plantar reflex, using a blunt object such as the end of a pen or the end of the tendon hammer covered with your thumb, run along the plantar surface of the foot, moving up from the heel towards the little toe then across to the big toe. Their foot should move away from it, if they move towards it this may indicate an upper motor neurone lesion.
17. Lastly, coordination of the lower limbs can be tested by getting the patient to rub their heel along the top of their opposite shin, they should be encouraged to do this as quickly as possible.
18. Wash your hands, clean your stuff and thank your patient.

If you are struggling for time leave out the power against gravity bit and only do it if they can’t move their limb against resistance.

You are done!!!!! Now, go and practice hitting people with a hammer! Have fun and use this as a reminder to never do DIY.

References

Epstein O. Clinical examination. Edinburgh: Mosby; 2008.

Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.

Lab 33: Equilibrium. – ppt video online download [Internet]. Slideplayer.com. 2018 [cited 28 March 2018]. Available from: http://slideplayer.com/slide/4577602/

Limbs: reflexes and sensation [Internet]. Clinical Gate. 2018 [cited 28 March 2018]. Available from: https://clinicalgate.com/limbs-reflexes-and-sensation/

Plantar reflex / Babinski sign | Bloomsbury Educational Ltd [Internet]. Clinicalexams.co.uk. 2018 [cited 28 March 2018]. Available from: http://www.clinicalexams.co.uk/plantar-reflex-babinski-sign/

ENT Examination

Ear. Nose. Throat. The place of most gunky childhood illnesses. Yuck. As gross a concept as that is, it’s important to learn all of this exam because you’ll see it a lot. Just go to GP land for a day, you’ll get at least one patient who will need some form of an ENT examination, especially in the winter. It’s not really surprising that the ear, nose and throat get so many connected illnesses given how anatomically close they are. I mean who really ever gets a sore throat without their ears hurting every time they swallow? Anyway, let’s move on.

1. Explain what the hell you are going to do, it is always helpful to practice this in advance, it’s surprisingly difficult at times to not use medical jargon. Get consent, wash your hands and breathe, panicking doesn’t solve anything.
2. Next, inspect their nose, look for any deformities or redness/swelling. If appropriate look in their nostrils for any polyps, you can do so using the otoscope. Place a new speculum on the otoscope and use it to inspect the inferior turbinates, holding it just in the nostril. An allergic rhinitis would cause the mucosa to turn pale and atrophy.  You should NOT do so with a child. Sinusitis rarely causes facial swelling but it would be painful for the patient if you press around the inflamed paranasal sinuses.
3. Then, move on to the ears, it’s best to start by looking at the external aspect of the ear. Note any abnormalities such as a haematoma from something like a rugby injury (look at the ears of a few rugby players and you will know what to look for). Also look at the colour and size. The tops of ears get a lot of sun exposure and so can be a big sight for skin cancer, especially in men, purely because they don’t tend to have as much hair covering their ears. Deformities of congenital origin can be linked to sensorineural hearing difficulties.
4. Now, for the otoscope, change the speculum before you begin. You want to hold the otoscope with the same hand as the side of the face you are on, right ear, right hand. With your other hand take hold their pinna and check it’s not painful for you to gently pull on it, if it isn’t then gently pull it up and back. Place your otoscope in their ear, resting the side of your hand on their face, this stops you hurting them if they move suddenly. Look through the otoscope at the inside of their ear canal, look for discharge, wax buildup or any wounds. Then inspect their tympanic membrane, you should see a cone of light on a grey pearlescent membrane, it looks sort of like the tambourines in primary school did, if you had them. A white scar could indicate previous perforation. You may also be able to see fluid behind the drum due to otitis media.
5. Finally, on to the throat. Ask your patient to open their mouth as wide as they can and say ah. Shine a light into their mouth, such as a pen torch, if you can see the back of their throat then that is fine, if not grab a tongue depressor and use it to press their tongue down and out of the way. Inspect the throat for any swellings or signs of infection. White patches could be caused by something such as a candida infection due to inhaler use or the development of AIDS.

You’re finally finished, dispose of all the equipment you used in the appropriate bins and get ready for the skill. It’s ideal to wash your hands and take a second to think about what you need to do next, remember panic gets you nowhere.

References

Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.

Ear Examination – Oxford Medical Education [Internet]. Oxford Medical Education. 2018 [cited 19 March 2018]. Available from: http://www.oxfordmedicaleducation.com/clinical-examinations/ear-examination/

GALS Examination

Gait, arms, legs and spine, legs and spine. Ah the nostalgia, when the entirety of your anatomical knowledge could be condensed into one song. Wait…it still can…

Anyway, all jokes aside this is clinical skills not some surface anatomy quiz so don’t panic. GALS is a screening tool for neurological, musculoskeletal and functional problems. It’s not perfect but it is quick and detects if you need to examine anything in more detail.

Let’s start:

1. Introduce yourself, maybe have a nice chat about the weather, you know normal British things to do to ease the tension. Wash your hands, get consent and check if they want a chaperone.

– You need to ask screening questions for this one, if they answer negatively to all three they probably don’t have anything significant that the GALS examination will pick up on, whilst you can mention this to the examiner in the ISCE, it’s a good idea to do the rest of the examination regardless.

– Do you have any pain or stiffness in your muscles, joints or back?

– Do you have any difficulty dressing yourself?

– Do you have any difficulty walking up or down stairs?

They also need to be in either lose shorts or their underwear so if you can find a way to politely ask this it will help you in the future. In the exam they will most likely be wearing the stuff they need to be for the GALS screen, the CSRC staff are good at organising that.

2. You should start by inspecting them like you would in an MSK examination, look for any redness, swelling or scars, asking them to rotate by 90 degrees three times until you have inspected them entirely. Then ask them to walk from one side of the room to the other, looking for smoothness in their gait, good balances and symmetry. Ask them to walk again but this time away from you with heel to toe (tightrope) walking and back to you on their tiptoes if they can. Things such as pain can affect the gait, this would form an antalgic gait. A limp can also be caused by differences in the leg lengths.

3. Arms, you’re basically testing that they can do everything with the right range of movement and power you would expect for the individual in question.

– Start by looking at their hands and feeling along their joints for things such as rheumatoid arthritis or just plain osteoarthritis.

– Now, ask them to clench their hands and then straighten them. This will look at most of the movements of their hands. Look at the dorsal hand to check all the fingers are fully extended. Then ask them to squeeze your finger, this will test the power of their flexion.

– Next, ask them to touch each of their finger tips to their thumbs. This should be coordinated. Neurological deficits can make this difficult for the patient and they may have to look at their hands to do it right. This could suggest they have a problem with proprioception.

– Now, ask them to make the prayer position, palms together and wrists extended, then the reverse prayer position, dorsal aspects together and wrists flexed. This will test wrist flexion and extension. Rheumatoid arthritis can affect this and cause the joints to immobilise, it can also be painful if they have carpal tunnel syndrome.

– Ask your patient to flex and extend their elbows as fully as they can. Then pronate and supinate their wrists followed by putting their hands behind their head and pushing their elbows back, this will test external rotation. Then ask them to play their hands behind their back and push their elbows forward.

4. Next is the legs part.

– Look at the joints and palpate each knee, feeling for warmth (inflammation) and swelling. You should do a patella tap here to check for an effusion or fluid (see the knee MSK examination for more details).

– Next, passively flex both knees and hips with your hand on the patients knee, feeling for crepitus there and in their hip joint. This can be due to osteoarthritis which has led to   bones scrapping on bone as the cartilage has worn away over time.

– Rotate their hip internally and externally, looking for any pain or fear, this may be due to past dislocations.

– Look at their feet for any abnormalities, gently squeeze the metatarsal heads to check for tenderness (squeeze the whole foot at the level of the heads).

– You can do the Thomas test to check for fixed flexion (if you can’t remember how to do it it’s in the hip MSK examination post).

5. Spines.

– Inspect the spine from the back and side of the patient, look for symmetry and normal muscle bulk without atrophy. Inspect their hip to see if they are level. A lack of symmetry could be due to scoliosis or osteoporosis resulting in spinal fractures. Palpate along the C7 (big spiky one when the neck is flexed) to the L5 vertebrae feeling for any pain or swelling.

– Ask your patient to bend down and touch their toes if they seem to have enough balance to safely do so. If they can put their hands flat of the floor they may have hypermobility. Before they bend down place your hand on their lumbar spine with a finger on two different vertebrae. As they bend your fingers should move away and then as they stand back up they should come back together. Ask them to bend backwards as much as they can to test spinal extension.

– Next, get them to twist their torso whilst keeping their hips and feet still, you can place your hands lightly on their hips to ensure they are not moving them.

– Finally, ask them to flex and extend their neck, and them laterally flex it, to touch their ear to their shoulder.

6. You’re done!!! One of the things to watch out for when doing this examination is that some people may be hyper-mobile and are likely to dislocate their joints easier than other people. You should be careful to not force them out of normal ranges when doing passive movements. Conditions such as Marfan’s and Ehlers-Danilo’s can also cause this.

References

Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.

WSIAT | Symptoms in the Opposite or Uninjured Leg [Internet]. Wsiat.on.ca. 2018 [cited 19 March 2018]. Available from: http://www.wsiat.on.ca/english/mlo/symptoms_leg.htm

Woodward T, Best T. The Painful Shoulder: Part I. Clinical Evaluation. [Internet]. Aafp.org. 2018 [cited 19 March 2018]. Available from: https://www.aafp.org/afp/2000/0515/p3079.html

Rheumatology: Ch 9 [Internet]. Nle.nottingham.ac.uk. 2018 [cited 19 March 2018]. Available from: http://www.nle.nottingham.ac.uk/websites/rheumatology/chapter9.html

Breast Examination

Okay so the breast examination, there’s so many ways to do this, quadrants, clocks, spirals etc. I’m going to talk you through one way because I refuse to type out every single way, I don’t have that much free time. Anyway, remember all that dignity and respect stuff, especially when it comes to real people’s breasts. Even thought that is not the case for your ISCEs, you should act like they are real.

Now, repetitive rant over, let’s begin.

1. Wash your hands and talk to your patient and possible chaperone etc. Please remember to get consent!

2. Ask your patient to undress her top half and lie with her hands on her thighs, relaxed. Now you should inspect her, standing at the end if the bed, look for asymmetry, swelling, skin changes (peau d’orange) and nipple changes (inverted?).

3. Then ask the patient to place their hands firmly on their hips and inspect all the above again. Following this, ask her to place her hands behind her head and inspect again and finally get her to push her torso forward, this should exacerbate any skin dimpling.

4. Now, you should have a pillow behind her head but if you don’t already then pop one there now. Ask her to pop one hand behind her head, this is the side you will be examining. When you are done repeat everything on the other side, with her switching which arm is behind her head.

– Look at the breast as a clock face, mentally draw the hour numbers. Then using the palmar surface of the first three fingers of your hand palpate each hour segment of the breast moving in from the outside towards the nipple, pressing the breast tissue against the chest wall. Other methods are seen below.

– You are feeling for any lumps or differences in texture, especially between the two breast. Remember the breast is from the clavicle to the upper abdomen and from the midline to the border of the lat dorsi, don’t forget the auxiliary tail.

– If you find a mass then you should define it, where it is, how large in diameter it is, its consistency and if it’s mobile. You can check mobility by holding the mass between your fingers and asking the patient to flex her pectoral muscles with her hands behind her head. If it moves with her muscle it’s connected and possibly infiltrated the muscle, suggesting malignancy.

– Next you need to palpate the nipple, its normal decency to ask the patient to squeeze it gently themselves to try to express any discharge. If there is some note it’s colour and consistency.

5. Now pop on some gloves as you need to palpate the axillary lymph nodes, feel each of the four sides for any masses. This can be pretty uncomfortable so warn the patient prior to beginning. Mention you would do all regional ones such as supraclavicular etc. but don’t worry about actually doing so.

6. You are done! The most likely thing you’re looking for in this case is breast cancer or some kind of infection, normally due to breast-feeding. Evil babies.

References

Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.

bugswong with Keywords: peau, orange [Internet]. Bugswong.smugmug.com. 2018 [cited 14 March 2018]. Available from: https://bugswong.smugmug.com/keyword/peau;orange/

Breast exam – Women Health Info Blog [Internet]. Women Health Info Blog. 2018 [cited 14 March 2018]. Available from: https://www.women-info.com/en/breast-exam/

GenitourinaryExamination – Female

Now for the second genitourinary examination, the female one. I can’t talk for everyone but people tend to be more relaxed around people of their own gender so if you aren’t the same gender as your patient, try to get your chaperone to be so. Besides from remembering to be respectful and checking the patient is alright every few minutes (even if it’s a plastic model) you should be okay, this is a pretty short examination.

1. First things first, talk your patient through what’s going to happen, check they’re cool with that, wash your hands, don some gloves and possibly an apron (hey, these clothes are lasting you the whole ISCE) and ask if they want a chaperone. It’s probably a good idea to check you have the right person but here’s hoping you asked that before taking the history.

2. You need to politely ask the patient to pop their clothes of, try to be precise with what they need off, people tend not to think when they’re faced with embarrassing situations. Ask the lady to sit with her feet up to her bottom then let her legs fall open.

3. Okay so like most thing we start by looking, inspect the vaginal opening, look out for cliteromegaly which could be associated with hyperandrogenism. Also inspect pubic hair distribution and look for evidence of folliculitis or STIs. A raised mass in one of the labia could be a Bartholin’s gland that has swollen due to blockage, they’re normally rather painful.

4. Ask the patient to cough and then strain, noting any prolapse or incontinence. This could be due to weakened pelvic floor muscles post childbirth or due to ageing.

5. It’s often best to do a speculum examination prior to the bimanual one especially if you have to take a swab as it reduces the likelihood of the lubrication jelly mixing with the sample. Start by either lubricating the speculum or running it in water. Then gently spread the labia and insert the speculum, holding it so the blades are closed and vertical. Once it is fully inserted you should rotate the speculum 90 degrees (normally so the handle is pointing down) and open it. You should be able to see the cervix, if not try reinserting it at a different angle. Observe the cervix looking for any redness (possible signs of CIN) or discharge. You can ask the patient to cough again to look for uterine prolapse. As you close and remove the speculum turn it so you can look at the vaginal walls. Now tell the patient you will be moving on to the bimanual examination.

6. Get a tissue ready for your patient to us afterwards (trust me you don’t want to be manically trying to do this afterwards). Then apply lubrication jelly to your middle and index fingers. Warn your patient you are going to insert them, then do so, feeling for the walls of the vagina, noting any crevices or masses.

7. Next, feel for the cervix. The cervix should be donut shaped and have fornix around it. Move your fingers into the posterior fornix and place your other hand on the women’s lower abdomen. Push the uterus up, with your fingers and push down with you hand and you should be able to feel it between the two. Feel the size of it and notice if it brings the patient any discomfort. Endometriosis can cause painful nodules in the posterior fornix and fixation of the uterus.

8. Move your fingers into one of the lateral fornix and move the hand on the patients abdomen to slightly above and lateral to the umbilicus on the side of your fingers. Using the same technique as before assess the adnexal masses (ovaries). Remember to check the other side as well.

9. Remove your hands and use the tissue to clean the patient, leaving it there for them to clean themselves with before getting dressed. Clean/dispose of all your equipment and wash your hands. Thank your patient and move on to your skill, unless that was a cervical swab which should have been done in step 5 or a high vaginal swab which should have been done just before you put in the speculum.

You are finished! Take a 5 minute break, check your phone and then move on to something completely different, don’t let it all get mixed up in your mind.

References

Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.

Cold F, Health E, Disease H, Management P, Conditions S, Problems S et al. Pelvic Exam With Speculum [Internet]. WebMD. 2018 [cited 12 March 2018]. Available from: https://www.webmd.com/women/pelvic-examination-with-speculum

PHQ-9

Depression is something you’ll see a lot in your lifetime, you can probably see it right now if you look around you, goodness knows ISCEs cause quite a bit of it. You can either give your patients this as a questionnaire for them to fill out and be incredibly upfront about it or you can ask the questions as part of the history taking process. Try both ways and pick whichever way works best for you, just remember that regardless you will need to have a score at the end of it.

The main point of a consultation with someone who has depression is tackling the fact that they don’t really want to be there, most of the time they have been dragged or have come in for something else. You should probably either acknowledge that verbally or at least in the way you conduct the consultation, they’re probably not going to answer open questions with that much information. Just stay calm and get used to practicing these difficult consultations with each other, use the actors when you have them.

These are the questions of the PHQ-9, I don’t really have much to say about them, they’re a screening tool that helps GP’s diagnose when they only have 10 minutes to do so. That’s probably less time than you have so cheer up, maybe don’t put on too big a smile and practise, practise, practise.

Genitourinary Examination – Male

Now, as awkward as I imagine the first few of these you actually do are going to be, you need to know how to do them. Thankfully, if you have it in the exam, it’ll be on a plastic model. Genitourinary examinations tend to be pretty short and a lot of it is just looking and making sure everything looks normal, even if normal has a bit of a range. So just try to make it seem as calm and routine as you can, remember even if you feel slightly awkward they will be feeling horrifically more so. Let’s start.

1. First wash your hands and pop on some gloves. Consent your patient and ask if they want a chaperone etc.

2. Ask them to undress, it’s normally helpful to ask them to do so whilst you are washing your hands, saves time and gives them some modesty, you can hand them/tell them about the blanket to cover up.

3. Now you need to take a look, inspect the groin area for any swellings, if your notice any, palpate them and see if they are reducible or not then ask the patient to cough and see if they increase in size. This checks if it is a hernia. It’s also useful in the future to see where it is to indicate whether it’s an inguinal or femoral hernia. Additionally, inspect for any redness, ulcers or rashes. They may have dermatitis or folliculitis if they shave their pubic hair or swelling from an underlying lymphatic problem.

4. Next, take a look at the penis. Look at the position of the urethral opening, see if they have hypospadias or epispadias, urethral openings along the shaft of the penis. Retract the prepuce (foreskin) and inspect the glans for red patches, vesicles or discharge indicating an STI. Always ensure you bring the prepuce forward after this to avoid paraphimosis (where the foreskin acts like a tourniquet around the glans stopping some of the blood flow).

5. Then the scrotum, look again for any redness or warts etc indicating an STI, remember to check the posterior side as well. Palpate the scrotum gently using both hands. Feel the entirety of the testis to check for lumps and palpate along the spermatic cord which should include the vas deferens, a structure that feels like a piece of string.

6. If you can feel a swelling try to get above it, if you can it’s a scrotal swelling, if not it may be a hernia, likely an inguinal one. Ask the patient to stand up and it should move down if it is a hernia. Ask them to cough and if that also makes the swelling expand then it’s likely an abdominal hernia. If it’s a scrotal swelling you can shine a pen torch on it. If it transilluminates then it’s most likely a fluid filled cyst such as a hydrocoele or an epididymal cyst.

7. Clean up everything and ask them to get dressed, it’s all done. Don’t forget to wash your hands!

That’s all for the male genitourinary examination, like I said, it’s a short one so you’ll be done and out of that examination room in no time!

References

Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.

Epstein O. Clinical examination. Edinburgh: Mosby; 2008.

What’s the difference between a hernia, a sports hernia, and an inguinal hernia? [Internet]. San Diego Running & Sports Injury Clinic. 2018 [cited 10 March 2018]. Available from: https://www.sdri.net/2014/04/21/whats-the-difference-between-a-hernia-and-a-sports-hernia/