Physical Examinations

Online clinical batch

Dr Kamalika Herath
ARIMGSAS
 Peripheral Vascular disease
• 65 year old man comes with pain in leg during
walking.
• Task
– Hx
– PE relevant
– Dx and Mx
1. Pain
2. Pain questions
-aggravated by walking/climbing stairs
-relieved by rest
-is there pain at rest/when lying down at night
-Does it get better when leg hung down from bed
-does it get better when you lean forward (neurogenic claudication)

3. Associated
- pins and needles
- weakness
-swelling
-fever

4. Ddx
- smoking, HPTN + on beta blocker, Fmhx of heart disease
-prolonged travel
-trauma/injury
-insect bite
-what’s your occupation, do you stand for a long time
• 1.General look
– 65 male sitting down comfortably
– No walking aids near him

2. Gait
- no neuropathic or antalgic gait
- heel and toe walking normal
- Can you do a full squat – no proximal myopathy
• 3. Inspection (lie down)
– Comparing both legs
– No deformity
– No muscle wasting
– No colour change of skin
– Skin not shiny
– No pigmentation or varicosity
– Hair distribution normal
– No discolouration of feet
– No nail changes
– No signs of infections
– No ulcers
– No pressure sore on soles
• 4. Palpation
– No coldness of limb
– CRFT normal
– Pulses – up to femoral normal (get permission before
palpating the femoral like in cvs exam)

5. Auscultate
- Femoral bruit
-Abdominal aorta
-renal bruit
• 6. Special tests
– Buerger’s

Pallor on elevation
Reactive hyperemia on dangling

- SLR
( just to exclude neurogenic claudication- but not critical error if you
miss)

7. I want to conclude my examination with

all peripheral pulses
full cardiovascular examination
full neurology of LL

8. Can I know the ABI (0.3/0.7)

• You have a condition called PVD
• It means that due to certain risk factors there is fat plaque building
up in the leg vessels, which are impeding he blood flow
• 0.7 – the investigation shows that you need an urgent referral to
specialist who will do a doppler USS to check the obstruction
• Lipid levels, start lipid lowering medication and aspirin to help thin
the blood
• Will withhold the beta blocker till seen by specialist
• LSM important – dietician, arrange consultation for smoking
cessation
• Physiotherapist for graded exercises
• 0.3 – the obstruction is very severe, if we don’t send soon there
can be harm to the leg, immediate admission to hospital for
angiography and consult for surgery (stent or graft)
 Scrotal Examination
• 40 yr old with painless lump on right side of scrotum for 3 months
Task
• Take consent
• Perform PE
• Dx and ddx

• Hello John my name is Dr X I have been asked to examine you today.

• During the examination I will have a chaperone with us at all time
• For the examination I will require adequate exposure so I would like to give you
privacy while you take off the gown.
• During my examination I will take a look at your genitals, examining the lump on
the scrotum and examining the penis as well.
• If you have any discomfort at any time, please stop me.
• Is that alright?

• I will wash my hands and wear gloves.

• 1. General look
• 40 yr old John is sitting comfortable no signs of pain or distress.

• Examiner I would like to do inspection on standing as well

• 2. Inspection while standing
• I cannot appreciate any rash bruise or redness in the groin or lower
abdomen.
• Scrotal skin is not inflamed and no rashes
• No swelling
• No visible mass
• No necrotic tissue
• No visible discharge from the urethral meatus
• 3. Palpation
• John I am going to feel the scrotum for the lump now is that ok.
• There is no local rise of temperature
• Palpate with thumb and index finger.
• I am examining the testes and cord I can appreciate there is a mass on the
right testes
• It is 2 cm in size, regular borders, hard/soft/bag of worms consistency
• I can get above the mass, however I cannot determine whether it is
attached to the testes or not.
• (Soft bag of worms – Varicocele)

• ( Cystic – Hydrocele)
• (Firm – Tumor)
• John I am going to retract the foreskin to look for
any bleeding or discharges.
• Now I will do some special tests
• 4. John can you cough please
• Cough impulse is positive in varicocele

• 5. Phren’s test - I am going to elevate the scrotum tell me if

the pain disappears( relieving of pain of scrotum by elevation
positive in epididymoorchitis) – not required here because it
is a painless lump
• 6. Cremateric reflex (contraction of the cremaster muscle that
pulls up the ipsilateral testes) absent in torsion
• 7. Transillumination test – I am going to shine a
torch onto the scrotum to look for any fluid filled
sacs inside.
• Shine the torch close onto the scrotum. Press onto
the scrotal skin. Positive in hydrocele
• 8. Palpate inguinal LN- Now I will examine the
groin area for any lumps

• 9.Thank you John , examiner I want to

conclude my examination with abdominal
examination for and DRE with consent.

• • Discard gloves.
• John I have examined you and I have found a mass on the left testes
it could be due to
• 1. Hydrocele* (soft cystic mass trans transillumination positive)
fluid filled sac surrounding the whole testicle that is mostly
harmless
• 2. Varicocele* (bag of worms feeling, cough test positive)
collection of dilated veins with defected valves causing dilatation
• 3. Spermatocele fluid filled sac with dead sperm
• 4. Epididymal cyst benign mass in part of testicle called
epididymis
• 5. Tumor* ( fixed hard mass) it could also be due to a nasty
growth
• 6. Epididimoorchitis infection
 Abdomen
• WIPE
• Hemodynamic stability

• 1. General look
• 50 year old male ill-looking
• Lying down in bed

• 2. Hands
• No palmar erythema
• No dupuytren’s contracture
• No koilonychia,leuconychia, clubbing
• 3. Forearm
• No scratch marks, needle marks
• Pulse is of good volume regular
• Examiner I would like to measure the rate and blood pressure
• John put your hands out, there is no flapping tremor
• 4.Face
• John look up no pallor
• Look down no jaundice
• No parotid enlargement (palpate)
• No signs of angular stomatitis
• Open your mouth no glossitis
• No dry mucous membranes
• 5. Neck
• I would like to check the JVP ideally at 45
degree angle

• 6. Chest
• No spider naevi or gynaecomastea
• 7. Abdomen

• Inspection (from side and foot end)

• Abdomen not distended
• Umbilicus is central
• Flanks not full
• No signs of bleeding around umbilicus or flanks
• No engorged vessels
• No scars
• Can you please cough for me – hernial orifices are
intact
• Palpation
• John where is the pain? Can you locate with one finger?
• I will start from opposite to pain
• No tenderness on superficial palpation
• No rigidity or guarding
• John I will press a little bit harder
• No hepatomegaly no splenomegaly
• Kidneys are not ballotable
• Percussion
• There is no dullness on percussion
• Shifting dullness
• Auscultation
• Over the RLQ for bowel sounds
• Renal bruits
• Aortic bruit
• Log roll
• Check for renal angle tenderness
• With consent of patient and presence of
chaperone
• Inspect genitalia and do digital rectal
examination
• 1. 45 year old lady with RUQ pain. She has nausea
vomiting and fever.

• Head to toe
• Abdomen

• John I am going to press here a little bit harder to

check a special sign, please bear with me
• Murphy’s sign +
• Mx
• To confirm admit
• Call my senior
• Arrange adequate pain medication
• All blood investigations
• USS abdomen
• Please don’t eat till specialist sees you
• You will be given IVF and antibiotics might be required
• If it is infection of GB the surgeon might decide to do a
surgery to remove it.
• 2. 25 year old lady with severe RLQ pain. Last LMP 7 weeks ago.

• Introduce
• Hemodynamic stability
• Abdomen

• Move to resuscitation
• Call for help
• Follow DRSABCD protocol
• 2 wide bore IV cannulae
• Blood for initial investigations, including beta HCG
• Pain relief
• Examine once stable
• Abdomen
• Inspection
• Palpation

• Mcburney’s
• Rovsing’s
Since patient is in pain I will not proceed
with psoas and obturator signs
• Percussion
• Auscultation

• With consent of the patient and in presence of

chaperone would like to do full pelvic
examination
• I want to do a full systemic examination
• Jenny I have examined you and the cause of the
tummy pain here could be due to several reasons
• Since you have later periods it can be due to a
pregnancy outside the womb- ectopic
• It could be due the infection of a rudimentary
organ called the appendix
• It can be due to kidney stones
• It could be due to infection of the large intestine
• Admit
• Call obg registrar and surgical reg
• All blood ix beta hcg, blood groping
crossmatching and USS to rule out ectopic
• Most likely undergo a surgery to remove
either appendix or Ectopic
• We will continuously monitor you
• 3. middle aged male with LLQ pain and bloody
diarrhoea
• Head to toe
• Abdomen

• I have examined you and the cause of pain and blood in stools
can be due to a condition called diverticulosis
• It is the outpouching of wall of your bowel due to
constipation, sometimes gets infected
• Admit
• Arrange all ix
• Send stool for microscopy and culture
• You might be put on AB
• 4. Acute abdomen (acute abd for 2
hours,vomit 2 times,alcoholic,back pain last
week)
• Hemodynamic stability
• Abdomen

• Inspection
• Palpation
• Cannot proceed with palpation due to pain
• There is diffused guarding and rigidity all over
the abdomen
• I will check the liver and spleen
• Special tests mcburneys etc …cannot perform
• Auscultate
• I have examined you and there is pain and
rigidity all over the tummy
• Consistent with an acute abdomen
• In which there would be rupture perforation
or obstruction of either organ or intestine
• It is an emergency
• Admit
• Senior
• Erect CXR abd to look for gas under diaphragm
• Blood ix
• Serum amylase lipase BG crossmatch
• NPO
• Iv analgesics
• IVF
• IV AB
 Hydration Assessment
• 30 year old female with vomiting and 4 episodes
of diarrhoea and tummy discomfort. No history
of travel.
• Task :
• 1. Assess her hydration status
• 2. Perform Abdominal examination
• 3. Likely diagnosis

• WIPE
• 1. General look
• 30 year old Jenny lying down on the couch mildly distressed due to pain.

• 2. Hands
• Jenny let me take a look at your hands.
• The palms are cold and clammy, the CRFT is normal, the pulses are regular
and of good volume, examiner I would like to measure the rate (perform),
I would like to measure the blood pressure with postural drop. Jenny I am
going to check the water content of your skin I will pinch the wrist. Skin
turgor is good.
• 3. Eyes
• On inspection of the eyes, they are not
sunken. Can you look up, no signs of anemia,
can you look down, no signs of jaundice.
• 4. Mouth
• I can see there are dry lips, can you open your
mouth, the mucous membranes are dry.
• 5. Chest
• I am going to listen to your heart now, S1 and
S2 heard no murmurs, air entry is equal, I
would like to measure the RR and saturation.
• 6. Abdomen
• On inspection from the side and foot end, the
abdomen is flat, moves with respiration, no visible
masses, umbilicus is central
• Jenny where id the tummy pain, on palpation there is
no tenderness guarding or rigidity of any quadrant, no
signs of organomegaly
• Jenny I am going to check for any fluid, there is no
dullness.
• I will listen to your bowel sounds, there are normal.
• With consent of the patient I would like to look at the
hernia orifices and DRE ( examiner says normal)
• 7. Legs
• The lower limbs are cold and CRFT is normal
• 8. Examiner I would like to measure the temperature,monitor the
urine output with input output chart.

• Jenny most likely you have a condition called gastroenteritis. That is

the infection of the gut mostl likely due to a virus.
• It will settle in a few days but I have found that you are moderately
dehydrated meaning you have lost a lot of water and important
electrolytes from your body.
• Rest assured we will investigate and manage you accordingly.
 Chronic liver disease Examination
• 1. 55 year old man brought to ED with hematemesis 500ml. 6
months previously had similar incident and endoscopy showed
esophageal varices. He continued to drink.
• Task
• Perform PE
• Dx

• 2. 55 year old John came for investigation results. His GGT was
increased. He is a long time alcoholic
• Task
• PE
• Dx, Mx
• For case 1 :
• WIPE
• Examiner can I know the hemodynamic stability
unstable
• I will shift patient to resuss cubicle
• Call for help
• Follow DRSABCD protocol
• Insert 2 wide bore IV cannulae
• Take blood for initial investigations
• Start on IVF NS bolus 20ml/kg
• I will continue once patient is stable
• 1. General look
• Average built man lying down, mildly distressed due to pain
• He is conscious
• No yellowish discolouration of body
• No pigmentation
• 2. Hands
• No clubbing
• No leuconychia, koilonychia
• There is no palmar erythema, no muscle wasting
• No dupuytren’s contractures
• No flapping tremor
• PR regular, good volume
• Examiner I want to check rate and blood pressure

• 3. Forearms
• No scratch marks
• Few spider naevi seen
• 4. Face
• No plethora
• No parotid enlargement
• No anemia
• no jaundice in eyes
• No angular stomatitis or cheilitis
• Open your mouth no gingivitis or glossitis
• No fetor hepaticus
• 5. Cervical LN no enlargement

• 6. Chest
• Few spider naevi present
• No gynaecomastea
• Heart sounds normal
• Air entry equal
• 7. Abdomen
• On inspection of the abdomen from side and foot end, there are no prominent veins, no bruising or
scratch marks, no distension, moves with respiration

• Do you have any pain?

• There is no tenderness on superficial palpation no guarding or rigidity

• On deep palpation no hepatomegaly or splenomegaly

• (if tape is there check the liver span)

• John I am going to tap the tummy to see if there is any fluid

• There is no dullness on percussion
• John can you roll to the left
• Tap again, there is no shifting dullness

• Bowel sounds are normal, no aortic bruits

• 8. With the consent of the patient and presence of chaperone I will
check hernia orifices, check for testicular atrophy, DRE for melena

• John I have examined you,

• The cause for the increase in investigation could be due to
viruses,metabolic causes, effect of alcohl on liver
• Most likely I am suspecting it could be due to chronic liver disease due to
the long term intake of alcohol

• I will refer you to a specialist for further investigation and management

which will include
• Full liver profile with viral serology
• Uss/Ct
• You will be managed accordingly
 Facial lump
55 year old man comes to you with facial lump.
• Task :
• Hx (2mins)
• Perform relevant PE
• Dx and Mx
• Hello John my name is Dr. X how can I help you?
• Hx
• When did you notice the lump (over last couple of months)
• Is it increasing in size? (yes)
• Is there any pain? (no)
• Any redness,colour change,discharge or bleeding from the lump? (no)
• Associated sx
• Fever ? (no)
• LOW/LOA (yes)
• Flu-like illness previously? (no)
• Difficulty opening mouth? / Problems chewing / Hearing problems/ Facial
asymmetry
• Pmhx
• SADMA
• I am going to examine your lump now.
• WIPE

• 1. Inspection (look at pic given and describe)

• There is a lump at the angle of the jaw,
• below the ear lobule and tragus,
• size is approximately 2*3 cm,
• overlying skin is intact,
• no redness, bleeding or discharges,
• ear lobes not displaced,
• no pulsation,
• no engorged vessels

• Examiner is there a lump on the other side?

• 2. Palpation
• I am going to feel the lump now to see the
• Size, shape, consistency, mobility, borders
• ( examiner will give either finding of a malignant
variant or benign variant)

• I will feel for other neck lumps – cervical LN normal

• Auscultate the lump for any bruits

• Examiner I want to examine the mouth for intraoral

extension
• 3. Special tests
1. we will check the function of your facial nerve. Follow my
instructions please
- wrinkle your forehead
-Close your eyes, don’t let me open them
-say ‘eeee’
-blow your cheeks
* In malignant case it will be affected
2.CN viii
• Mx :
• I have examined your lump, and most likely it is a lump arising
from the parotid gland,which is a gland contributing to saliva
production.
• It could be a harmless growth,infection
• it wasn’t tender but it is hard and not mobile and the facial
nerve is affected as well, which is why I am concerned that it
can be a nasty growth.

• Refer to specialist for Ix – CT/USS guided FNAC or biopsy to

identify the cells
• Most likely they will perform a surgery to remove the lump
 Breast Examination
• 50 yr old Jenny comes with right breast lump.
Mother diagnosed with breast cancer at the age of
60.
• Task
• Take consent
• Perform PE
• Arrange Ix and give ddx
• Hello Jenny my name is Dr Maria. I have been asked to examine
your breasts today.

• I will have a chaperone with us at all times

• I will need adequate exposure for the examination so I will give you
privacy while you take off the gown.
• During my examination, I will be taking a look at your breasts,
feeling for the lump and I will be examining your armpits for lumps
as well.
• If you feel uncomfortable at any time please stop me,
• Is that alright?

1. General look
• My patient is 50 yr old Jenny she is sitting comfortably no signs of
trauma bruising or bleeding.
• Inspection of the breasts (while sitting)
• Jenny can you keep your arms by your side ;
• With arms by side
• No asymmetry of breasts
• No visible mass
• No engorged vessels
• No skin dimpling/ tethering and colour changes
• No peau de orange skin

• Nipples are not retracted

• No discharge or bleeding from nipples
• No skin changes in the areola

• Can you raise your arms above and behind your head and lower them slowly?
Thank you
• With arms raised above and behind the headlower arms slowly
• No accentuation of tethering of nipples or skin
• No nipple shifting
• No visible masses in the axillae

• Can you press your hands on your hips?

• Press hands on the hips
• No accentuation of skin dimpling
• Jenny now I am going to feel for any lumps in
the armpits. Is that alright?
Relax your arm :
• Palpation of LN while sitting
• Axillary LN ( Apical, central, anterior(pectoral),
lateral, posterior(subscapular), infra clavicular,
supraclavicular) not enlarged
• I will feel for any neck lumps as well
• Cervical group
• (not enlarged)
• Jenny now I am going to feel for the lump, can you
please lie down and put your hand above and behind
your head?
• Palpation of breasts while lying down and with hand
above and behind the head (normal side first)
• Palpate each quadrant with pulp of 3 fingers
• ( Describe Lump- size shape consistency
mobility fixed or not single or multiple)
• I can appreciate that there is a mass in the left
upper quadrant, approximately 1*2 cm, firm
in consistency, non-tender, not mobile , no
other masses palpable
•
•
• I am going to feel for any lumps at the nipple
• Palpate areola and behind nipple for lumps –
cannot appreciate any lumps
• Jenny can you please squeeze the nipple; I
want to check for any blood or discharge.
• Thank you Jenny.
• Examiner I want to conclude my examination
by checking for bone tenderness, full
respiratory system and checking for
hepatomegaly.
• Jenny I have felt a lump in the left breast. There could
be several causes for it:
• Breast cyst, fluid filled sacs that are mostly harmless
and is due to hormonal changes in periods
• Fibroadenosis that is a lumpy breast most often found
in reproductive age group and related to periods
• Fibro adenoma* benign breast lump common in young
females due to high oestrogen levels and prolonged
OCP use.
• Fat necrosis fat tissue injury following trauma
• Normal variant due to aging of breast tissue
• However, since it is firm in consistency and given your
family history I am concerned that it can be a nasty
growth Breast CA *
• I would like to arrange some investigations for
you
• Known as the triple test
• Consists of the full physical examination,
• USS (if <35) or Mammogram (if >35)
• FNAC +- biopsy that is taking some cells from the
lump to examine under the microscope.
• Based on the findings you will be managed
accordingly.
 Baby check
• You are a GP , mother of 10 day old baby
presented to clinic for routine check up. Baby
weight, height and head circumference at
birth given and weight and height today given
with some weight gain.
• Task :
– Hx 2 mins
– Perform neonatal examination
– Summarize your findings to mother
• Hello Jenny I am Dr X, how is everything?
• Congratulations
• Is this your 1st baby
• Do you enjoy motherhood
• Do you have enough support

• How is the baby?

• Is he breastfed?
• Poo and pee?
• Any fever, loose stools, crying during pee, yellow discolouration?

• BINDS hx
• Birth, NVD/ csec? Term/preterm?
• Any resuscitation required?
• Heel prick test done?
• Initial immunizations given ?
• Who else is at home?
• Medications given?
• Jenny I am going to examine John now, I will
look at him from head to toe and I will be
gentle as I can. For this I require proper
exposure can you please take his clothes off,
keep the nappy on.

• 1. Gen look
– 10 day old baby boy
– In flexed normal posture
– Skin is pink
– No visible rashes
– No Jaundice
• 2. Head
– On palpation no cephalohematomas
– Anterior fontanelle not bulging or depressed
– The head circumference is 33 cm (perform with tape)

• Face
No dysmorphic features
No epicanthic folds flat nasal bridge
No no micrognathia

Ears normal no extra auricles tags or sinuses

No cleft lip

No masses at the neck

• 3. Arms
– Both arms symmetrical
– No additional digits
– PR regular, good volume
– No radio radial delay
– No radio femoral delay
– Examiner I would like to measure blood pressure in all 4 limbs

• 4. Chest
– No deformities of the chest
– Both nipples at the same level
– No engorged veins
– No palpable thrills in 4 areas
– S1 S2 heard in all 4 regions, no added sounds, no murmurs
– No chest retrations
– Air entry is bilaterally equal
• 5. Abdomen
– Abdomen not distended
– Umbilical stump looks healthy
– On palpation no masses
– On deep palpation no hepatomegaly or
splenomegaly

• Genitals
• Jenny can I examine his genitalia, can you please
remove the nappy.
• Bilateral testes palpable in scrotum
• Meatus is normal
• (Female- No labial fusion ambiguous genitalia)
• 7. Legs
– Legs are symmetrical
– No additional digits

• 8. Back
• Jenny I will turn the baby over to check the back
• No spinal deformities or spina bifida
• Anus is intact
 9. Hip examination
– I am going to do some special tests to check for hip
instability
– The groin creases are symmetrical

– Barlow
• Flexion
• Adduction
• Push back

- Ortolani
- Flexion
- Abduction
- Pull forward
• 10. Neurology
– Will check the nerve function
– Tone is not floppy or hypertonic
– Rooting reflex positive
– Grasp reflex present
– Jenny I will gently drop his head to check his nerve
function, don’t worry I will support him – Moro
reflex is normal
• 11. Fundoscope and Otoscope
– I am going to look at his eyes and ears with this
instrument
– Looking for the red reflex
– No discharges from the ear
• Jenny I have examined John and everything is good.
• His heart is good , the basic nerve functions are
good, there is no problem with his breathing, and
hips are stable.
• The height weight and the size of his head is
appropriate as well.
• You can take him home now, if he has fever, difficulty
in breathing, loose stools etc please come to me or
go to ED.
Rash DDX hematology examination
• 27 year old lady presented with non pruritic, non blanching,
maculopapular rash in lower limbs. Had viral URTI one week
back.
• Task

• PE with running commentary to examiner

• Dx ddx
• WIPE

• 1. General look
• 27 year old lady sitting comfortably, no rashes except in
lower limbs

• Rash:

• There is a wide spread rash o the shin of the LL, red

maculopapular, non blanching and non pruritic, there is
no bleeding discharge or vesicles visible.
• 2. Hands
• No splinter hemorrhages
• No clubbing
• No koilonychia leuchonychia
• Pulses are good volume and regular
• CRFT is normal
• Examiner I would like to check the BP
• 3. Forearm
• No needle marks no scratch marks
• Epitrochlear LN normal
• Jenny relax your arms I am going to check for
lumps in armpit

• Apical
• Central(medial
• Anterior(pectoral)
• Lateral
• Posterior (subscapular)
• Infraclavicular and supraclavicular
• https://www.youtube.com/watch?v=-
dmrXVye7lA
• 4. Face
• No frontal bossing
• No anemia and jaundice
• No cheilitis stomatitis
• Open mouth no gum bleeding/gum hypertrophy
• No mucosal pigmentation
• I am going to check the back of our throat, no
tonsillar enlargement or congestion
• 5. Neck
• All LN of cervical group normal

• Jenny can you lie down I will bend your neck

to chin, no neck stiffness
• 6. Chest

• Heart sounds normal

• Air entry equal
• I will tap on the collar bone, no bone tenderness

• 7. Abdomen
• Do you have any pain?
• No tenderness on superficial palpation
• No organomegaly

• 8. I want to check the inguinal LN (examiner will say

skip)
• 9. Leg
• No edema no signs of infection

• 10. I would like to conclude my examination by

checking temperature, complete skin survey
to look for bruising or bleeding
• Jenny I have examined you and I am suspecting a condition called
ITP
• We have three cell lines in the body one is RBC, WBC, platelets.
• Platelets are responsible for preventing bleeding
• Following the viral infection, the virus has reacted with the platelets
making it to decrease, causing bleeding giving this rash
• There are other causes for the rash like
• IMN
• HSP
• Meningococcemia
• HIV
• leukemia
 Rash in upper arm
• 40 year old John presented to you with rash in upper left arm. Following gardening
Task
• 1. Hx 2 min
• 2. Perform PE
• 3. Ddx
• Hello John my name is dr maria how can I help you today – dr I have a rash
• Tell me about the rash, since how long
• What is the colour?
• Is it only there or anywhere else
• Is there any pain or swelling ?
• Is it itching bleeding or any dishcarges?

• Is there any associated fever, vomiting, sob?

• Did you have any trauma/injury ?

• Any insect bite,
• Contact with branch of tree,leaves
• Iv cannulation recently
• Any surgical procedures
• Any prolonged work like painting?

• Pmhx like diabetes

• SADMA
• John I am going to examine you now, during my examination I will
be taking a look at your arm, feeling around the area, examining
lumps at the neck and armpit. If you feel any discomfort please stop
me. In order for me to do the examination I need proper exposure,
can you please take off the gown. Thank you.
• Wash hands

• 1. Inspection
• I’m comparing both arms, there is a linear rash red in colour
extending from the cubital fossa to the axilla,
• I cannot appreciate any surrounding swelling, erythema,bleeding or
discharge,
• There are no scratch marks or iv canulation marks on the hands.
• John I am going to feel this area, there is no local rise of
temperature, on palpation there is mild tenderness, no cord
like structure felt. The pulses are regular (perform) and of
good volume, the CRFT is normal, examiner would like to
check the BP from the opposite arm(skip)

• I would like to check the temperature from the tympanic

membrane (perform) –normal.
• I am checking for any lump near the cubital fossa-
epitrochlear LN

• Relax your arm I will check the armpit for lumps- axillary LN
not palpable
• Cervical LN group not palpable either

• I am going to listen to your lungs for any added sounds-

breath sounds equal, no crackles.

• Thank you John

• Axillary LN

• https://www.youtube.com/watch?v=-
dmrXVye7lA
• John the rash could be due to infection of the soft
tissue, it could be due an insect bite, irritation of the
skin by a leaf or branch, infection of the blood tunes,
pooling of blood/clot within the blood tube.

• Ddx
• Cellulitis
• DVt
• Thrombophlebitis
• Contact dermatitis
• Insect bite
 Gynaecomastea
• Young man complaining of breast
enlargement. Gym, uses anabolic steroids
• Task
– Perform relevant examination
– dx
• 1. General look
– Average body built man
– No moon facies
– No buffalo hump
– No jaundice
– No voice changes
• 2. Hands
– Not moist and sweaty
– No signs of CLD
– Pulses regular, I want to check rate and blood pressure

3. Face
No plethora
No icterus
I want to check visual field and also fundoscopy

4. Neck
No visible lump
I want to examine for thyroid enlargement
• 4. Chest
Inspection in 3 positions (like in breast exam)
• No visible lumps
• No enlargement (examiner will say +)
• No skin tethering, dimpling
• Nipples normal
Palpation
no disc like breast tissue(glandular tissue) palpable (examiner
says +)
No lumps in any quadrants

5. Axillary LN (might say skip)

• With consent of patient and presence of chaperone I want to
check for hepatomegaly and testicular atrophy

• Most likely you have a condition called gynaecomastea which

means enlargement of breast tissue in males.
• There are many causes as liver problems, thyroid problems,
masses in certain part of brain, but most likely in your case I
suspect it is due to the side effect of the steroids that you are
using.

• We will arrange investigations and manage accordingly

 Pancoast Tumor
• 55 yr old came after FNAC of right neck lump. Chronic smoker
for a long time.Has noticed some weakness of right hand
• Task
• perform focused upper limb neurology
• Perform focused examination to find the cause of the mass
• Explain dx to pt
• 1. General look
– Sitting comfortably
– Plaster on right side neck
– No obvious wasting

2. Hand neurology
Inspection
no thenar hypothenar wasting
no nicotine stains
PR regular
I want to check BP

Tone is good
Power (C8 and T1 reduced)
Reflexes normal

Sensations (skip)

Can you touch my finger then nose

(examiner says rest of neurology insignificant)

• 3. Respiratory exam
Inspection
no barrel chest
no increased work of breathing
Palpation
chest expansion is normal
vocal fremitus (skip)
trachea midline
Percussion
no dullness at apex
Auscultation (examiner says normal)
• 4. Eyes
– I am going to check your eyes now
– (pic given  there’s ptosis and miosis of right eye
• I want to conclude my examination by doing full CN ,
local eye exam and neurology

Most likely the nasty growth you have is Pancoast tumor

It is a tumor at the top of the right lung
Your long standing smoking can be a reason for this
This mass is compressing against the nerve supply to the
hand which is why you have the weakness

You have all our support we will arrange further

investigations and manage you accordingly
 Ear examination
• 30 year old with ear pain and discharge.
• Task
• Hx
• Pe
• Dx and mx
• Hx
• Which ear
• Is there any pain
• Pain qs
• Discharge CCOV
• Associated fever, hearing loss+ (which ear? Better in noisy env+),
facial asymmetry
• Causes –
• recent and recurrent infections+
• Injury/trauma
• swimming/?
• Recent air travel
• smoking?
• WIPE
• Inspection
• Comparing both ears
• Symmetrical
• Helix tragus lobule normal
• No discharge
• No tags or sinuses
• No engorgement of the mastoid process
• Palpate
• No local rise of temperature in mastoid
• No tenderness of the helix, tragus, lobule

• John I am going to examine the inside of the ear with

this instrument. it is a little bit uncomfortable I will
be gentle
• I am looking at the external canal for any
deformity,discharge,wax
• Tympanic membrane colour,perforation,scarring,bulging
• Look at tip of otoscope, discard
• Hearing tests
• 1.whisper
• 2.Rinne (BC>AC)
• Facial nerve
• Cervical LN
• Most likely cholesteotoma
• It is an abnormal skin sac behind your ear
membrane with collection of debris and dead
cells
• It is due to repeated ear infections
• If we don’t treat the particles can erode the
bone and enter the brain
• Refer to ENT surgeon for CT scan
• Remove the sac
• Clean ear and instill AB
• Do formal hearing test
• If bone erosion,reconstructive surgery later
• Unilateral conductive deafness –
cholesteotoma
• Bilateral conductive deafness – otosceloris
• Sensorineural deafness – acoutic neuroma
• ( rinne normal, weber lateralizes to normal
ear)
Digital Rectal Examination
• Middle aged man who is having chest pain on
activity, heart racing, pain radiating to arm
and shoulder and had episodes of bright
blood in the stool.
• Task
– Gain consent
– Perform abdominal examination
– Perform DRE
– Explain most likely dx
1. Gen look
• Middle aged man, in distress due to pain

2. Inspection
3. Palpation – no tenderness
4. Percussion
5. Auscultation – BS +
• John I am going to check your back passage
now. We will have chaperone with us.
• (wear gloves, lubricate index finger)
• John can you turn over to your left, bend the
right knee to your chest
• John I am going to remove the sheet now, is
that alright
• Inspection of the perianal region
• I am going to feel the back passage with
finger,it might be bit uncomfortable, take
deep breaths with your mouth open
• I am feeling for any masses in the rectum,
mucosa is smooth,mobile not fixed
• Remover finger-no blood in the glove
• Thank you john (cover the mannikin)
• I could not find any abnormalities during the examination.
• Since you have chest pain, it could be due to angina , that is
loss of blood supply to heart muscle. It could be caused by
block of vessels by fat plaques. But it can also be caused
due to bleeding resulting in anemia.
• it also could be because of mesenteric ischemia where part
of blood supply to the gut is cut off
• The bleeding from the back passage could have been due
to mesenteric ischemia, or bleeding from high up in tummy
ulcers
• It could be due to growths like polyps or nasty growth
• And also bleeding could be due to hemmaroids, that is
dilation of cushion at the rectum
Pelvic examination
• 60 year old lay with feeling of lump down
below.
• Task
– hx
– Perform PE
– dx
• Hx
– Lump coming out or not
– Back pain?
– Any incontinence of urine
– Any bleeding rashes or ulcers on bulge

Associated fever/painful urination

Long standing cough/constipation/ obstetric
history/menopausal sx/HRT
Pmhx – had hysterectomy
• Pelvic examination
– Inspection of vulva and vagina (no bleeding lump
discharges rashes)
– Speculum
• https://www.youtube.com/watch?v=5EIqLqpjWiQ
• Examiner is there a cervix (says no)
• Jenny can you bear down – is there any vault prolapse-yes
• is there any bleeding rashes on it-no

- Bimanual
- https://www.youtube.com/watch?v=Z-O_JYtyQqE&t=195s
• Most likely vaginal vault prolapse
• The vaginal canal has been held in place following
the surgery with rope like structures
• Due to low estrogen in menopause, bad obstetric hx
cause weakened pelvic floor and inadequate repair
following surgery
• 26 year old with post coital bleeding
PE
dx

Speculum : red ring around the cervix

Most likely dx is cervical ectropion
It is the change of cells at the opening of womb (os)
from flat cells(squamous) to tall cells(columnar) can be
seen in teenagers,in pregnancy,owomen on prolonged
ocp. Mostly harmless, do pap smear and follow up with
2 yr pap smears.