IMU OSCE Students Notes ZhenZhe.

2018 IMU-FPEPII

International Medical University

Medical Sciences

Semester 5

First Professional Examination Part II

Domain 2/ First Criteria

Objective Structured Clinical Examination (OSCE)

Clinical Examination Notes (Student)

Instructions for using this document:

This document is NOT an official document from IMU for your OSCE in Bukit Jalil.
This document can only serve as a guide for your OSCE practises, and not your only source to prepare for OSCE.
The author would like to apologise beforehand for any typos that may have been missed and not corrected.
Please refer to clinical examination textbooks for more details of significance of each physical sign. Do not perform every single component
of the examinations during OSCE. Read the scenarios carefully, choose the appropriate and relevant examination depending on the case
scenario. Bear in mind that to obtain a high score and good grade in OSCE, it is not just about fulfilling the checklist. You overall
performance and your communication with the patients play a huge role as well.
Please don t bring this to CSSC during teaching and learning sessions.
The case scenarios provided in this document are only for practising purposes. The mark schemes do not represent the actual examiner
guide used in the real OSCE, and hence can only be used for reference purposes.
Please do NOT send this document to anyone else without permission. If you have it, it is for you.

Acknowledgement
The author of this document would like to thank the lecturers in CSSC for their teachings, which made the completion of this document possible
The author would also love to thank his personal copy of clinical textbooks, and the Internet for all the useful information and images

This copy of document belongs to:

Name

Intake

Student ID

Contact Number

ALL THE BEST FOR YOUR SEMESTER 5 OSCE!

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IMU OSCE Students Notes ZhenZhe.2018 IMU-FPEPII

CONTENT
Cardiovascular System
General
Specific
Peripheral
ECG
Respiratory System
General
Specific
Peak Flow Meter
Meter Dose Inhaler
Chest X-ray
Haematological System
General
Cervical Lymph Nodes
Axillary Lymph Nodes
Examination of Lumps and Bumps
Venepuncture
Gastrointestinal System
General
Specific
Digital Rectal Examination
Renal System
General for CKD
Specific
Relevant Chest Examination for CKD
Urine Dipstick
Urinary Catheterisation (I shall pray for you)
Endocrine System
Fundoscopic Examination
Glucometer
Thyroid Gland Examination
Assessment of Thyroid Status
Specific Endocrine Disorders Examination
Reproductive System
Antenatal Examination (Abdomen)
Pap Smear and Pelvic Bimanual Palpation
Breast Examination
Musculoskeletal System
GALS Screening
Shoulder Examination
Elbow Examination
Wrist and Hand Examination
Hip Examination
Knee Examination
Ankle Examination
Cervical Spine Examination
Thoracolumbar Spine Examination
Nervous System
Glasgow Coma Scale
Mini Mental State Examination
Upper Limb Sensory Examination
Lower Limb Sensory Examination
Diabetic Foot Examination
Upper Limb Motor Examination
Lower Limb Motor Examination
Examination of Specific Peripheral Nerves
Cerebellar Function Examination
Cranial Nerves Examination
Semester 5 Clinical Block
Intramuscular Injection
Subcutaneous Injection
Using Insulin Pen

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IMU OSCE Students Notes ZhenZhe.2018 IMU-FPEPII
Cardiovascular System

General Examination
*better to have patient lying at 45 degrees
General Inspection
Check the following:
Is the patient alert, responsive, conscious?
Any chest pain or respiratory distress?
Any muscle wasting?
General skin colour? Any cyanosis?

Hands
Check the following during the examination Relevance
Temperature and moisture of hands upon contact Can be cold and clammy for heart failure or cardiogenic
shock
Inspect for presence of tendon xanthomata on the dorsum Hyperlipidaemia
(tendon xanthomata can be found on extensor surfaces such as elbow)
Look for any digital clubbing b checking nailbed angle b placing patient s Cyanotic congenital heart disease
hand horizontal to eye level Infective endocarditis with seeding of emboli
Inspect nail colour Blue nails indicate peripheral cyanosis of circulatory
cause
Inspect nails for any splinter haemorrhage Vasculitis, with or without infective endocarditis
Look for tobacco stains (NOT nicotine stains) on finger tips and in between Smoking is a risk factor for CVS diseases
fingers
Check capillary refill. Press on finger tips on both hands for 10 seconds, Evaluate circulation. Normal refill is within 2 seconds
then let go one by one (DO NOT let go both at the same time)
Look for any pallor in the palmar creases Microangiopathic haemolytic anaemia
Look for Osler nodes on finger pulps. Compress all phalanges at onceto Infective endocarditis
confirm if lesions seen
Look for Janeway lesions on palm Infective endocarditis
Vitals (mention)
Evaluate patient s pulse (radial pulse)
Comment on rate, rhythm, volume, any radio-radial delay, collapsing pulse or any other abnormal characters depending on case
scenario. See below:
Collapsing pulse
First, ensure the patient has no shoulder pain
Palpate the radial pulse with your hand wrapped around the wrist
Raise the arm above the head briskly
Feel for a tapping impulse through the muscle bulk of the arm as blood empties from the arm very quickly in diastole, resulting
in the palpable sensation
This is associated with increased stroke volume of the left ventricle and decrease in the peripheral resistance leading to the
widened pulse pressure of aortic regurgitation.
Other causes of widened pulse pressure such as high output cardiac failure, pregnancy etc.
Measure blood pressure
Measure respiratory rate, and temperature

Eyes
Look for any xanthelasmata around the eyes Hyperlipidaemia
Look for any arcus cornealis in the eye Somewhat increased risk of cardiovascular disease,
however highly non-specific
Look for any mitral facies (rosy cheeks with bluish tinge) Mitral stenosis and pulmonary hypertension
Mouth
Look for any high arched palate Marfan syndrome
Look for any cyanosis in tongue and lips Central cyanosis
Check for any dental caries Source of infective endocarditis
Look for any petechiae in mucosa of mouth (labial, buccal) Infective endocarditis
Neck
Inspect for any neck vein distention Congestive heart failure, superior vena cava syndrome
Assess carotid pulse Provides information about aortic pulse waveform
Jugular venous pressure measurement (Mention)
Abdomen
Mention liver examination as a part of examination for right heart failure. Check for pulsatile liver.
Legs
Any pitting oedema? Congestive heart failure, right heart failure
Press at bony areas starting just proximal to medial malleolus for several
seconds and let go
Check for any thickening of Achilles tendon Dyslipidaemia
Inspect for signs of peripheral vascular disease (seen later)
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Specific Examination (Heart)
*patient MUST be lying at 45 degrees
General Inspection (DO NOT waste too much time here)
Check the following:
Is the patient alert, responsive, conscious?
Any chest pain or respiratory distress?
General skin colour? Any cyanosis?

Inspect
Check the following:
Is the chest symmetrical?
Any chest all deformities? Such as pectus e cavatum and pectus carinatum (just give one, don t aste time)
An scars in the anterior and lateral chest? (don t have to name the scars, don t aste time)
Any visible pulsation? Is the apex-beat visible?
Any distended vessels? (mention only if relevant such as superior vena cava syndrome)

Palpation (ask for any chest pain, and whether hands are warm enough)
Palpate the apex beat.
First, feel with the flat of the hand on the chest just below the nipple, then localise using one finger. Demarcate the apex beat
in relation to intercostal spaces, and midclavicular line.
For position within intercostal spaces, start with the sternal angle, and move laterally to the second rib, then move downwards.
To dra the midclavicular line, identif sternoclavicular joint, and acromioclavicular joint, then find the midpoint, and dra a
straight line down towards the mid-inguinal point.

Check for any heaving of apex beat (left ventricular hypertrophy), or displaced apex beat (inferiorly and laterally in left ventricular
dilation)
Place heel of right hand over left parasternal area to feel for any parasternal heave when patient holds breath after expiration
(parasternal heave indicates right ventricular hypertrophy)
Palpate for thrills over the 4 valve areas on the chest (apply same principle to auscultation)
Thrills are palpable murmurs

Jugular Venous Pressure (JVP)

To measure JVP:
Patient must be lying at 45 degrees, and tilt his head to the left side to expose the right side of the neck
Look for the internal jugular vein pulsation. Use torch to increase visibility. Start with the space between the two heads of SCM
just above the clavicle. If really not present, try searching along the border of SCM as JVP may be elevated.
Once the internal jugular venous pulsation is identified (see below), place a ruler perpendicular to the floor over the sternal
angle, and place another ruler perpendicular to the first ruler to the pulsation identified. Ensure that the 0 mark of the first ruler
facing the sternal angle. Normal JVP is less than 4/5/4.5 cm above sternal angle (elevated in right heart failure and pericardial
effusion). If to be commented in terms of cmH2O, add 5 cmH2O (difference in height between right atrium and sternal angle)

Differentiating jugular venous pulse from carotid pulse:

multiphasic - the JVP "beats" twice (in quick succession) in the cardiac cycle. There are two waves in the JVP. The first beat
represents that atrial contraction (termed a) and second beat represents venous filling of the right atrium against a closed
tricuspid valve (termed v). The carotid artery only has one beat in the cardiac cycle.
non-palpable - the JVP cannot be palpated. If one feels a pulse in the neck, it is generally the common carotid artery.
occludable - the JVP can be stopped by occluding the internal jugular vein by lightly pressing against the root of the neck. It
will fill from above.
varies with head-up-tilt (HUT) - the JVP varies with the angle of neck. If a person is standing, his JVP appears to be lower
on the neck (or may not be seen at all because it is below the sternal angle). The carotid pulse's location does not vary with
HUT.
varies with respiration - the JVP usually decreases with deep inspiration. Physiologically, this is a consequence of the Frank
Starling mechanism as inspiration decreases the thoracic pressure and increases blood movement into the heart (venous
return), which a healthy heart moves into the pulmonary circulation.
Jugular venous pulse is a rapid inward movement, carotid pulse is a rapid outward movement

Also check the following:

K a (paradoxical increase in JVP on inspiration) Pericardial effusion, cardiac tamponade, restrictive pericarditis

Hepatojugular reflux Positive test result indicates right ventricular failure

Apply pressure to the liver The mechanism for this phenomenon has not been clearly
Observe the JVP for a rise elucidated. Impaired right ventricular compliance may lead to an
In healthy individuals, this should last no longer than 1-2 abnormal response to the increased preload caused by
cardiac cycles (it should then fall) increased venous return and the raised diaphragm caused by
If the rise in JVP is sustained (for more than 10 seconds) abdominal compression and elevated intra-abdominal pressure.
and equal to or greater than 4cm this is a positive result
A positive hepatojugular reflux sign is suggestive of right-
sided heart failure and/or tricuspid regurgitation

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Auscultation
Using the diaphragm, listen over the four valve areas of heart, while placing hand over carotid pulse to identify S1 and S2
(because e can t differentiate just b auscultation hen a murmur is present). Spend 5-10 seconds at each region.
Comment on whether S1 and S2 can be heard clearly, any additional heart sound (S3, S4) and any murmurs?
S3 indicates residual volume in ventricle (e.g. left ventricular failure)
S4 indicates ventricular hypertrophy (e.g. aortic stenosis, systemic hypertension)

Components of reporting a murmur:

Timing which phase of the cardiac cycle?
Duration e.g. pan-systolic? Mid-systolic? Early diastolic? Late diastolic?
Pitch and character
Intensity
Location
Any radiation

Pericardial friction rub

An extra heart sound of to-and-fro character, typically with three components, ONE systolic and TWO diastolic. It resembles the
sound of squeaky leather and often is described as grating, scratching, or rasping. The sound seems very close to the ear and may
seem louder than or may even mask the other heart sounds. The sound usually is best heard between the apex and sternum but
may be widespread.

With fingers on carotid pulse, ask patient to lie towards his left. Listen over mitral area using bell to pick up any low-pitched diastolic
murmur of mitral stenosis when patient holds his breath after expiration

With fingers on carotid pulse, ask patient to sit up and lean forward, use diaphragm to listen over aortic area to pick up any systolic
murmur of aortic stenosis, or early diastolic murmur of aortic regurgitation when patient holds breath after expiration
*left sided murmurs are louder on expiration, right sided murmurs are louder on inspiration
*aortic regurgitation murmur can be heard at lower left sternal border as well

Listen using diaphragm over carotid area for carotid bruit

Listen over lung bases from the back to check for any pulmonary oedema. Ask patient to breathe in and out while listening
Pulmonary oedema presents as mid-inspiratory, medium crackles

Auscultation Areas of the Heart; palpation for thrills

Pericardial friction rub VS pleural friction rub

Pericardial friction rub Pleural friction rub
Pericardial friction rub may have one, two, or three audible ordinarily has two audible components
components
pericardial rub can be heard even after cessation of breathing a pleural rub can only be heard during inspiration and expiration
Pain due to pericardial rub is always central in location. Pleural rub creates pain mostly on the lateral part of the chest wall
The intensity of pleural rub is increased on pressing the diaphragm of the stethoscope over the affected area, whereas there is no such
change in case of a pericardial rub

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Examination of Peripheral Vascular System
*A = arteries, V = veins

General inspection is NOT quite relevant here

Arms
Inspect for any: A
Muscle wasting (especially small muscles of hand)
Discolouration
Tobacco stains
Ulcers
Scars from healed ulcers in secondary Raynaud phenomenon
Assess radial and brachial pulses (rate, rhythm, VOLUME, character) A
Mention blood pressure measurement for BOTH arms to compare both sides A

Abdomen
Inspect for obvious pulsation A
Palpate for abdominal aortic pulse A
Place non-dominant hand on abdomen above umbilicus slightly left of midline
Rest dominant hand on top of non-dominant hand
Upper hand applies pressure while lower hand feels the aortic pulsation

Gauge the width of pulsation if prominent which may suggest AAA

Patient lies supine with knees flexed to relax abdominal muscles
Place both hands palms do n on patient s abdomen ith inde fingers on each side of aorta. Move both index fingers
laterally until pulsation cannot be felt
AAA is suspected if diameter is more than 3cm
Auscultate over abdominal aorta for bruit A

Lower Limbs
Inspect for any:
Scars (from healed ulcers) AV
Muscle wasting A
Ulcers AV
Pigmentation, or discoloration (Any pallor in the extremities? Or any peripheral cyanosis as seen in toe nails?) AV
Distended veins or varicosities V
Loss of leg hair A
Thickening of nails A
V
Obvious swelling

Arterial ulcer Venous ulcer

Past medical history Peripheral arterial disease, cardiovascular Deep vein thrombosis, or suggestive of occult
and cerebrovascular disease DVT such as leg swelling after childbirth, hip/
knee replacement or long bone fracture
Risk factors Smoking, diabetes mellitus, Thrombophilia, family history and previous
hypercholesterolemia and hypertension DVT
Pain Severe pain except in diabetics with 1/3 have pain but not usually severe,
neuropathy; improves on dependency improves with elevating the leg
Site Pressure area (malleoli, heel, fifth metatarsal Gaiter areas, usually medial to long
base, metatarsal heads and toes) saphenous vein, 20% lateral to short
saphenous vein
Margin Regular, indolent, punched-out Irregular, often with neoepithelium (whiter
than mature skin)
base Green or necrotic black, with no granulation Pink and granulating under green slough
Surrounding skin No venous skin changes Lipodermatosclerosis always present
Veins Empty with guttering on elevation Full and usually varicosed
Swelling and oedema Absent Usually present
Temperature Cold Warm
Pulses Absent or very weak Present, but may be difficult to feel
Feel and compare temperature on both sides using dorsum of hands (cold in arterial disease, warm in venous disease) AV
Check for capillary refill in big toe nails A
Palpate along the course of superficial veins by estimation for any tenderness V
*great saphenous vein exits foot anterior to medial malleolus and travels on more medial aspect of leg before emptying into
femoral vein
*Short saphenous vein exits foot posterior to lateral malleolus and travels on more lateral aspect of leg before emptying into
popliteal vein

Test venous filling by occluding dorsal venous arch and release to check for venous refilling V
If distended veins are seen, check for direction of flow of blood in vein using the two-finger method (see below)

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Check ankles for any pitting oedema V

Check pulses for symmetry of volumes starting from the most proximal pulse (some lecturers may recommend distal) A
Femoral pulse 1 cm below the mid-inguinal point (between ASIS and pubic A
symphysis)
Popliteal pulse With knee flexed to 30 degrees, deep in popliteal fossa A
between heads of gastrocnemius
Posterior tibial pulse 2 cm below and behind medial malleolus A
Dorsalis pedis pulse Lateral to tendon of extensor hallucis longus in the middle of A
dorsum of foot
Mention auscultation of pulses using Doppler ultrasound A
Mention measuring blood pressure around ankle to calculate ankle-brachial index (ABI) A
Mention performing B e e e A
Let patient lie supine in the bed for at least 5 minutes
Lift leg to be examined up to 45 degrees for 1 minute and observe any colour change in foot (pallor with guttering/
emptying of superficial veins in peripheral vascular disease)
Ask patient to sit up with legs hanging down. Observe for 2 minutes for reactive hyperaemia. Loss of pallor and
spreading redness (reactive hyperaemia on dependency) is a positive test result.

Electrocardiogram (ECG)
Part 1: Taking an ECG

Introduction
Explaining the procedure:
To measure electrical activity of heart
Exposure (removing shirt) privacy, chaperone
Applying some gel and attaching some wires but painless
The possible need of removing chest hair
Remove all metallic objects attached such as wallet, keys etc.

Attaching Limb Leads

Red limb lead at right forearm proximal to wrist
Yellow limb lead at left forearm proximal to wrist
Green limb lead at left lower leg proximal to ankle
Black limb lead at right lower leg proximal to ankle
*however, if the real leads are provided, check the labels on the leads, as the colour representation may be different (happened in
Batu Pahat Hospital)

Attaching the Chest Leads (V1 V6)

V1 at right 4th intercostal space at right sternal border
V2 at left 4th intercostal space at left sternal border
V4 at left 5th intercostal space at left mid-clavicular line
V3 at midpoint between V2 and V4
V5 at the left anterior axillary line, at the same horizontal level as V4
V6 at left mid axillary line, at the same horizontal level as V5

Check the calibration of the ECG machine, ask patient to sta still and don t move, and print out the ECG strip
Label the ECG strip with patient s details (name, ID), time and date the ECG is taken.
Remove all equipment from patient, and offer to wipe the gel off for the patient

Part 2: Reading an ECG (for Preclinical Phase Level)

Check patient s details, time and date the ECG as taken to ensure ou have the right patient s ECG
Check the calibration of ECG. 10mm = 1mV, speed of 25mm/ sec (standard calibration)
Check rhythm of ECG using lead II (the longest). Was the heart beating regularly?

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Check heart rate. Heart rate is most likely already printed out on the strip. Double check the heart rate by calculating using rough
estimation.
If heart rate is regular, calculate number of large boxes in between R waves, and divide 300 by that number to get the heart
rate.
If heart rate is irregular, calculate number of R waves present in 30 large boxes (1 large box is 0.2s, hence 30 large boxes
represent 6 seconds). Multiply that number by 10 to get the heart rate (number of R waves within 60 seconds)
Bradycardia if less than or equal to 50 bpm, tachycardia if more than 100 bpm
Evaluate cardiac axis by looking at leads I, II and III
Evaluate P wave (check for any P waves with abnormal appearance which may indicate atrial arrhythmia)
Evaluate PR interval normally between 0.12 and 0.22s (3-5 small boxes). Is PR interval prolonged or shortened?
Evaluate QRS complex normal width is roughly one small box. Check for any broadening of QRS, abnormal QRS, peaked R wave.
Any pathological Q waves? Pathological Q wave is more than 1mm wide, more than 2mm deep and more than 25% of height of the
following R wave
Sum of depths of R and S wave should be less than 35mm. More than that may indicate ventricular hypertrophy
Evaluate ST segment. Any depression or elevation?
Evaluate T wave. Normal T wave is upright in all except aVR lead, and less than 50% of height of QRS. Any inverted or peaked T
wave?
Evaluate QT interval if suspect prolongation
Check for presence of any U wave

Examples of Case Scenarios for Practice (number of asterisk indicates predicted difficulty level)
Case 1**

Mr A, a 60-year-old man with longstanding uncontrolled hypertension complains of orthopnoea and paroxysmal nocturnal dyspnoea.

Examine the patient and check for signs of left heart failure.
At the sixth minute, the examiner will ask you one question.

Mock examiner may refer to the following mark scheme to grade his/ her peers
*kindl a k o kip/ omi hen come acro he ord men ion in he mark cheme

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Ensure patient lying at 45 degrees (3 marks deducted from total score if not performed) /1
General inspection for respiratory distress and cyanosis -
Examine hands for peripheral cyanosis and capillary refill /2
Mention vitals (pulse, blood pressure, breathing rate) /1
Examine lips and tongue for central cyanosis /1
Inspect chest wall for deformities, visible pulsation, scars /1
Palpation of apex beat, with accurate demarcation /1
Comment on whether heaving is felt, and whether there is displacement of apex beat /2
Check for thrills at all four regions /1
Auscultate the four regions, with reference to carotid pulsation. /2
Comment on S1, S2, and whether S3 and 4 can be heard
OMIT specific left sided murmurs and carotid bruit -
Auscultate lung bases for pulmonary oedema /2
QUESTION: Describe the auscultation finding if pulmonary oedema is present. /2
Ans: medium, mid-inspiratory crackles at the lung bases
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 22 marks

Case 2***
Mr B, who was diagnosed with pulmonary emphysema more than 10 years ago, developed swelling at the ankles.

Examine the patient to look for signs of right heart failure.

At the sixth minute, the examiner will ask you one question.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Ensure patient lying at 45 degrees (3 marks deducted from total score if not performed) /1
General inspection for respiratory distress and cyanosis -
Examine hands for peripheral cyanosis and capillary refill /2
Mention vitals (pulse, blood pressure, breathing rate) /1
Inspect chest wall for deformities, visible pulsation, scars /1
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Palpation of apex beat, with accurate demarcation /1
Check for thrills at all four regions -
Check for parasternal heave /2
Auscultate the four regions, with reference to carotid pulsation. /2
Comment on S1, S2, and whether S3 and 4 can be heard, or whether a tricuspid regurgitation murmur can be heard
Measure JVP. /3
Confirm venous pulse by palpation or occlusion method
Ruler placement perpendicular to floor and to each other on sternal angle
Comment using correct unit. Cm water
Mention palpation of liver for pulsatile liver /2
Mention checking for Kussmaul s sign (bonus)
Mention performing abdominojugular/ hepatojugular reflux
Mention percussion of chest for pleural effusion
Check for pitting ankle oedema. (correct technique gives the 2nd mark) /2
QUESTION: Apart from pulmonary emphysema, give another cause of right heart failure /1
Ans: any chronic lung diseases such as fibrosis, bronchiectasis, chronic bronchitis, pulmonary embolism, or left heart failure
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 22 (+ 2) marks

Challenging Tasks that bab c e in OSCE*****

Case 1
A 30-year-old woman who had a recent long-distance flight experience presents with sudden chest pain and breathlessness. Perform relevant
physical examination on this patient to evaluate the possibility of pulmonary embolism.
(pulmonary embolism cannot be diagnosed from physical examination)

Ans: Look for signs of right heart failure (acute cor pulmonale) + signs of deep vein thrombosis (DVT)

Case 2
A 30-year-old man who had undergone dental surgery not long ago, complains of fever, chest pain and palpitation.

Perform relevant examination on this patient to look for signs of Infective Endocarditis. You do NOT need to examine his mouth.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Ensure patient lying at 45 degrees (3 marks deducted from total score if not performed) /1
General inspection for pain and respiratory distress -
Examine hands for capillary refill, janeway lesions, osler nodes, splinter haemorrhage, skin rash /3
Mention vitals (pulse, blood pressure, breathing rate) /1
Inspect chest wall for deformities, visible pulsation, scars /1
Palpation of apex beat, with accurate demarcation /1
Check for thrills at all four regions /1
Check for parasternal heave -
Auscultate the four regions, with reference to carotid pulsation. /4
Comment on S1, S2, and whether S3 and 4 can be heard, or whether any regurgitation murmur can be heard
Comment on whether pericardial friction rub can be heard
Mention auscultate for aortic and mitral valve murmurs
Omit JVP measurement -
Auscultate lung bases for any pulmonary oedema -
Mention examination of the spleen for any splenomegaly +2
marks
Mention fundoscopy to look for any Roth spot +2
marks
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 18 (+ 4) marks

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Respiratory System

General Examination
*better have patient lying at 45 degrees
General Inspection
Check the following:
Is the patient alert, responsive, conscious?
Any chest pain or respiratory distress?
General skin colour and appearance? Any cyanosis?
Any general muscle wasting, cachexic appearance? (Lung malignancy)
Any medical gadgets around the patient?
Hands
Check the following during the examination of hands Relevance
Check for digital clubbing Hypertrophic pulmonary osteoarthropathy
Lung cancer
Look for tobacco stains Smoking is a risk factor for many pulmonary diseases
Check colour of finger nails Peripheral cyanosis
Check for wasting of interossei muscles Lung cancer and T1 nerve root infiltration (interossei
muscle is innervated by ulnar nerve)
Check for fine tremors. Ask patient to stretch out upper limbs horizontally Salbutamol use in asthmatic and COPD patients
and place a piece of paper on both hands and observe
Check for flapping tremors. Ask patient to extend elbow and wrist. Apply Hypercapnia in type 2 respiratory failure loss of postural
slight pressure over the palms to further extend wrist and observe tone control
Pulse, temperature, respiratory rate (all the vitals) Tachycardia due to salbutamol use etc.

Face
Check for any signs of Horner s s ndrome: partial ptosis, enophthalmos Sympathetic ganglion invasion by lung cancer
(from the side of patient), anhidrosis, miosis
Look for any cyanosis or plethora Superior vena cava syndrome in lung cancer
Palpate for any paranasal sinus tenderness. Frontal, ethmoidal and Sinusitis
maxillary sinuses
Examine the nose with a torch. Upper respiratory tract lesions
Look for any flaring of alae nasi, nasal septum deviation, presence of Turbinate hypertrophy may occur in chronic sinusitis
polyp, foreign body or any other obstructing masses (such as turbinate
hypertrophy) to assess patency of nasal cavity, discharge, bleeding etc.

Mouth
Look for cyanosis in mouth and lips Central cyanosis
Inspect tonsils for any swelling or exudate, and pharyngeal wall for Erythema, swelling, exudates
erythema
Check for any white, curd-like patches on tongue Candidiasis in corticosteroid usage for asthma
Neck
Inspect neck for scars, distended veins Pulmonary hypertension and Cor pulmonale
Look for use of accessory muscles of respiration (SCM, scalene muscles, Respiratory distress
platysma, trapezius)
Check for any tracheal deviation (WARN patient beforehand) Tension pneumothorax (contralateral deviation)
Place 2nd and 4th finger over the sternoclavicular joint on either side, Lung atelectasis (ipsilateral deviation)
use finger to palpate for thyroid cartilage and cricoid cartilage and
the trachea downwards
Gently press the suprasternal notch to continue palpating the
trachea and check for deviation
Check for symmetry of paratracheal spaces on both sides
Mention palpation of cervical lymph nodes Metastases in malignancies of respiratory tract
Tuberculosis
Mention measurement of JVP Cor pulmonale and raised JVP
Only check for ankle pitting oedema if suspecting cor pulmonale Cor pulmonale (right heart failure due to lung pathology)

Specific Examination (Lungs)

Anterolateral Chest Examination
* Patient must be lying at 45 degrees
General Inspection (d e d c e)
Is the patient alert, responsive, conscious?
Any chest pain or respiratory distress? Any use of accessory muscle of respiration?
General skin colour and appearance? Any cyanosis?
Any general muscle wasting, cachexic appearance? (Lung malignancy)
Any noisy breathing? Stridor or wheezing? Go near to the patient, and ask patient to breathe in and out
Any abnormal breathing pattern such as Chyne-Strokes breathing or Kussmaul s breathing

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Inspection of Chest
Stand at the edge of the bed, ask patient to breathe in and out deeply. Observe the rise and fall of the chest, symmetry and any
paradoxical chest or abdominal movement during breathing
Paradoxical sternal movement suggests trauma or multiple rib fractures.
Paradoxical abdominal movement, in which the abdomen moves out with expiration, can be a sign of a paralyzed diaphragm,
respiratory failure, or fatigue during an exacerbation of COPD.
Intermittent paradoxical abdominal movement may be caused by muscle fatigue from respiratory pump failure
Epigastric depression with inspiration suggests large pericardial effusion or a paralyzed diaphragm
Bulging interspaces on inspiration suggests a tension pneumothorax, a large pleural effusion, emphysema
Estimate the ratio anteroposterior (AP) to lateral diameter of chest. Ratio exceeding 5:7 may indicate hyperinflated barrel chest
Look for chest wall deformities (pectus excavatum and carinatum), scars, distended prominent vessels which can occur in Superior
Vena Cava Syndrome, visible pulsations etc.
Palpation
Check for any tracheal deviation (WARN patient beforehand)
Place 2nd and 4th finger over the sternoclavicular joint on either side, use finger to palpate for thyroid cartilage and cricoid
cartilage and the trachea downwards
Gently press the suprasternal notch using index finger to continue palpating the trachea and check for any deviation
Check for symmetry of paratracheal spaces on both sides by gently pressing on them and compare
Measure distance between suprasternal notch and cricoid cartilage. (Less than 3-4 fingers breadths suggest lung hyperinflation)
Locate and demarcate apex beat
Apex beat can be diminished in hyperinflated lungs, and may be displaced in severe tension pneumothorax or lung collapse causing
mediastinal shift
Perform and check chest expansion
Place hands firml on the chest all, e tend fingers around the sides of patient s chest. Thumbs should almost meet in the
midline and hover just off the chest to allow free movement
Ask patient to breathe in deeply. Thumbs should move symmetrically apart by at least 5 cm.
Chest expansion may be reduced in cases such as pleural effusion, lung collapse, pneumothorax, pulmonary fibrosis (reduced
unilaterally), COPD and diffuse lung fibrosis (reduced bilaterally)
Hoover s sign in pulmonar emph sema: in ard movement of lo er rib during inspiration, impl ing flat but functional diaphragm
Check for symmetry of tactile-vocal fremitus (tactile fremitus). Place ulnar edge of hands on chest of each side and ask patient to
sa 99 . Tactile fremitus is increased in lung consolidation in pneumonia

Percussion
Percuss the supraclavicular spaces, then 2 areas above and 1 area below nipple along midclavicular line, and 1 each above and
below nipple on lateral chest wall
Resonant for normal lungs
Hyper-resonant with decreased liver dullness in COPD and asthma (bilaterally), pneumothorax on the affected side
Dull in pneumonia (consolidation), lung collapse and severe diffuse pulmonary fibrosis
Stony dull in pleural effusion

Auscultation
Ask patient to breathe in and out deeply, and only move from one region to another when patient has fully exhaled. Follow the
regions used in percussion.
Was it vesicular breath sound? Or bronchial breath sound? (lung consolidation)
Are the breath sounds equal on both sides of the chest?
Any rhonchi (low pitch), wheezing (high pitch) or any other additional breath sound such as crackles or pleural friction rub?

Abnormal breath sounds

Bronchial breath sounds have hollow blowing quality, audible throughout expiration and often has a gap between inspiration
and expiration. Expiration sound has higher intensity and pitch than inspiratory sounds. Present due to turbulence in large
airways are heard without being filtered by alveoli (consolidation increases transmission of sounds)
Wheezes are caused by continuous oscillation of opposing airway walls, have musical quality, often louder on expiration, and
are due to small airway obstruction. Rhonchi are low-pitched wheezes due to larger bronchi obstruction
Crackles are interrupted non-musical sounds due to collapse of peripheral airways on expiration. On inspiration, air rapidly
enters distal airways causing alveoli and small bronchi to open abruptly, producing the crackles

Different causes of crackles

Early inspiratory Small airway disease such as bronchiolitis
Middle inspiratory Pulmonary oedema
Late inspiratory Pulmonary fibrosis (fine)
Pulmonary oedema (medium)
Bronchiectasis and lung abscess (coarse)
Biphasic Bronchiectasis (coarse)
Check for vocal resonance, b asking patient to sa 99 hen placing stethoscope on the same regions. Are they equal on both
sides? Any reduction or absence of vocal resonance on any side?
If there is increased vocal resonance, ask patient to whisper 99 while you listen. In a normal lung, high-pitched sounds are
attenuated.
Vocal resonance may be increased in consolidation, decreased in pleural effusion and absent in tension pneumothorax

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Pericardial friction rub VS pleural friction rub
Pericardial friction rub Pleural friction rub
Pericardial friction rub may have one, two, or three audible ordinarily has two audible components
components
pericardial rub can be heard even after cessation of breathing a pleural rub can only be heard during inspiration and expiration
Pain due to pericardial rub is always central in location. Pleural rub creates pain mostly on the lateral part of the chest wall
The intensity of pleural rub is increased on pressing the diaphragm of the stethoscope over the affected area, whereas there is no such
change in case of a pericardial rub

Posterolateral Chest Examination (just apply similar principles)

Inspect posterior chest for any deformities such as scoliosis, kyphosis which can compromise lung capacity
Ask patient to fold arms across shoulder or hug their knees to protrude scapula on both sides, when performing tactile-vocal femitus
Check 3 different areas on both sides of posterior chest. Remember to check lateral chest wall
Auscultate lung bases to check for any crackles

Peak Flow Meter

*there might be slight differences in performing and giving instructions to patients to monitor at home

Before e begin .
Predicted Values for Peak Expiratory Flow (PEF) using EU scale

The scale on the right is used to predict normal PEF values for patients based on
gender, age and height.
It is useful for health professionals to have a guide as to what peak flow could be
expected from each individual, if they didn't have asthma.
It is used for quick reference and serves as a guide to determine patient s normal
expected PEF values.
Patient s personal best peak flo ma be used as reference for long-term
monitoring

Personal Best Peak Flow Rate

The patient s individual personal best peak flow rate must be re-evaluated to account for
both growth and disease progression. Peak flow rate measurement should be periodically
correlated with office spirometry.
The patient is instructed to identify his or her personal best peak expiratory flow by recording
the highest number achieved within 2 weeks when he or she feels relatively well without
respiratory symptoms. Details of measurement are as follows:
Peak flow rate is measured at least twice a day for 2-3 weeks
Peak flow rate should be measured upon awakening and in the late afternoon or early evening
Peak flow rate should be measured 15-20 minutes after use of an inhaled short-acting beta 2 -agonist

Scenario 1: Giving Instructions to Patient to Do the Test

Explaining the purpose of the procedure

To quickly check their lung/ breathing function, or to check their asthma control etc.
Prepare equipment
Peak flow meter, mouthpiece

Giving Instructions (inform patient that they must )

Sit or stand upright while carrying out the test
Fit the mouthpiece firmly around the peak flow meter (if it is just a one-time measurement we can just fixate it for the patient)
Ensure that the indicator at the base of the numbered scale
Hold the indicator horizontally/ parallel to the ground, and such that the hand holding the peak flow meter does not obstruct the
movement of the indicator
Take in a deep breath
Place the mouthpiece in the mouth and seal lips around the mouthpiece. Ensure that tongue does not block the (lumen of) tube.
Blow out as hard and as fast as they can
Write down the reading obtained. Repeat another 2 times to get another 2 readings
Note the highest reading among the 3

Observe patient and ensure they perform the test correctly. Correct patient when necessary
Compare the reading with the normal predicted values of peak flow (using the chart above)

Scenario 2: Instructing Patient to Monitor at Home

*sequence may vary according to individuals
Explain the purpose of monitoring and introducing the test to monitor, show the equipment to the patient
Give instructions to patients on how to perform a peak flow meter test as shown above
Ask patient to demonstrate once, and observe and ensure that they do it correctly
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Remind patient to repeat another 2 times each time they do the test, and take the highest reading
Instruct patient to identify his or her personal best peak expiratory flow by recording the highest number achieved within 2 weeks
when he or she feels relatively well without respiratory symptoms
The personal best is determined under the following conditions:
Peak flow rate is measured at least twice a day for 2-3 weeks
Peak flow rate should be measured upon awakening and in the late afternoon or early evening
Peak flow rate should be measured 15-20 minutes after use of an inhaled short-acting beta 2 -agonist (inhaler)
*remind patient they have to obtain 3 readings each time they do the test, but only take the highest reading
Instruct patient to have a small notebook to record the highest reading every time the test is done at home
Inform patient about the Peak Flow Zone System
Green zone (80-100% of personal best) signals everything is fine, no asthma symptoms
Yellow zone (50-80% of personal best) signals caution, may be having asthma episode that requires increase in dose of
medicine, or asthma is generally not controlled. Doctor may need to change the prescription
Red zone (below 50% of personal best) signals alert, seek medical advice if reading does not return to yellow or green zone

Meter Dose Inhalers

I c a e .
Sit upright or stand up
Remove cap from mouthpiece of inhaler
Shake the inhaler
Tilt head backwards slightly and breathe out
Seal your mouth on mouthpiece, press down on canister as you breathe in slowly
Breathe in slowly for 3-5 seconds
Hold your breath for 10 seconds to allow medication to settle
If another puff is required, repeat the above steps after 1 minute/ 60 seconds

If spacer/ chamber is used,

Repeat step 1 to 3, then insert the inhaler into the hole at the end of the spacer
Press on the canister to spray 1 puff of medication into the spacer
Place the mask over your face tightly and breathe in slowly and deeply
Hold your breath for 10 seconds.
If another puff is required, repeat after 1 minute/ 60 seconds

Reading a Chest X-Ray

Fundamental
Check the following systemically
Name, date and If orientation is not mentioned, assume PA
orientation of film
Lung fields Equally translucent? Any opacities?
Lung apices Any masses, cavitation or consolidation above and behind the clavicles?
Trachea Position (is it central or deviated?), check for any paratracheal masses and retrosternal goitre
Heart Normal cardiac silhouette is less than half of the internal transthoracic diameter (cardiothoracic ratio)
Any widening of mediastinum?
Hilum Compare shape and density. Normal should be concave laterally convexity suggests lymphadenopathy
Diaphragm Right hemidiaphragm is normally higher than left side. Anterior end of right 6th rib should cross mid-
diaphragm, if not, hyperinflated lung
Costophrenic angle Any loss of costophrenic angle suggesting effusion or pleura thickening?
Soft tissue Look around chest wall for any soft tissue masses or subcutaneous emphysema
Bones Check for any fractures and metastatic deposits of lung cancer in ribs, clavicles, and vertebrae

Slightly More Detailed (with ABCDE approach adapted from Geeky Medics)

Details of the film Patient details (name, ID), date and time the X-ray was taken
Image Quality Rotation
RIPE The medial aspect of each clavicle should be equidistant from the spinous processes
The spinous processes should also be in vertically orientated against the vertebral bodies.
Inspiration
5-6 anterior ribs, the lung apices, both costophrenic angles and lateral rib edges should be visible
Projection
AP vs PA film
If there is no label, then assume it s a PA. Also, if the scapulae are not projected ithin the chest, it s PA.
Exposure
Left hemidiaphragm visible to the spine and vertebrae visible behind heart

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Airway (A) Trachea: Is the trachea significantly deviated?
The trachea is normally located centrally or just slightly off to the right
If the trachea is deviated, look for anything that could be pushing or pulling at the trachea.
Also inspect for any paratracheal masses/lymphadenopathy
Pushing of trachea e.g. large pleural effusion / tension pneumothorax
Pulling of trachea e.g. consolidation with lobar collapse

Carina and bronchus

The carina is located at the point at which the trachea divides into the left and right main bronchus.
On a good quality CXR this division should be visible and is an important landmark when assessing
nasogastric tube placement, as the NG tube should dissect the carina if it is correctly placed (i.e. not in
the airway).
The right main bronchus is generally wider, shorter and more vertical than the left main bronchus. As a
result, it is more common for inhaled foreign objects to become lodged here (as the route is more direct).
Depending on the quality of the CXR you may be able to see the main bronchi branching into further
subdivisions of bronchi which supply each of lobe.

Hilar Structures
The hilar consist of the main pulmonary vasculature and the major bronchi.
Each hilar also has a collection of l mph nodes hich aren t usuall visible in health individuals.
The left hilum is often positioned slightly higher than the right, but there is a wide degree of variability
between individuals.
The hilar are usually the same size, so asymmetry should raise suspicion of pathology
The hilar point is also a very important landmark; anatomically it is where the descending pulmonary
artery intersects the superior pulmonary vein. When this is lost, think of a lesion here (e.g. lung tumour
or enlarged lymph nodes).
Hilar enlargement can be caused by a number of different pathologies:
Bilateral symmetrical enlargement is typically associated with sarcoidosis.
Unilateral / asymmetrical enlargement may be due to underlying malignancy.

Breathing (B) Lungs

Inspect the lungs:
When looking at a CXR we divide each of the lungs into 3 zones, each occupying 1/3 of the height of
the lung.
These zones do not equate to lung lobes (e.g. the left lung has 3 zones but only 2 lobes).
Inspect each of the zones of the lung first ensuring that lung markings occupy the entire zone.
Compare each zone between lungs, paying close attention for any asymmetry (some asymmetry is
normal and caused by the presence of various anatomical structures e.g. the heart).
Some lung pathology causes symmetrical changes in the lung fields, which can make it more difficult to
recognise, so it s important to keep this in mind (e.g. pulmonar oedema).
Increased airspace shadowing in a given area of the lung field may suggest pathology (e.g. consolidation /
malignant lesion).
The complete absence of lung markings within a segment of the lung field should raise suspicion of
pneumothorax.

Pleura
Inspect the pleura:
The pleura is not normally visible in healthy individuals, unless there is an abnormality such as pleural
thickening.
Inspect the borders of each of the lungs to ensure lung markings extend all the way to the edges of the
lung fields (if there appears to be an area lacking lung marking with decreased density this may suggest
the presence of a pneumothorax).
Fluid (hydrothorax) or blood (haemothorax) can also accumulate in the pleural space, causing an area
of increased opacity or a combination of both a pneumothorax and fluid (hydropneumothorax).
If a pneumothorax is suspected, you should reassess the trachea for evidence of deviation away from the
pneumothorax which would be in keeping with a tension pneumothorax. This is a medical emergency requiring
immediate intervention. If a tension pneumothorax is suspected clinically (shortness of breath and tracheal
deviation) then immediate intervention should be performed without waiting for imaging as this condition will
result in death if left untreated.
Pleural thickening can be caused by mesothelioma.

Cardiac (C) Assessing heart size

In a healthy individual the heart should occupy no more than 50% of the thoracic width (e.g. a
cardiothoracic ratio of <0.5).
This rule only applies to PA chest x-rays (as AP films exaggerate heart size), so you should not draw
any conclusions about heart size from an AP film.
If the heart occupies more than 50% of the thoracic width (on a PA CXR) then this suggests abnormal
enlargement (cardiomegaly)

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Assessing heart borders
Inspect the borders of the heart which should be well defined in healthy individuals:
The right atrium makes up most of the right heart border.
The left ventricle makes up most of the left heart border.

The heart borders may become difficult to distinguish from the lung fields as a result of various pathological
processes (e.g. consolidation) which cause increased opacity of the lung tissue.
Loss of definition of the right heart border is associated with right middle lobe consolidation
Loss of definition of the left heart border is associated with lingular consolidation

Diaphragm (D) Diaphragm

The right hemi-diaphragm is in most cases higher than the left in healthy individuals (as a result of the
underlying liver). The stomach underlies the left hemi-diaphragm and is best identified by the gastric
bubble located within it.
The diaphragm should be indistinguishable from the underlying liver in healthy individuals on an erect
CXR, however if free gas is present (often as a result of bowel perforation), air accumulates under the
diaphragm causing it to lift and become visibly separate from the liver. If you see free gas under the
diaphragm you should seek urgent senior review, as further imaging (e.g. CT abdomen) will likely be
required to identify the source of free gas.

Costophrenic angles
The costophrenic angles are formed from the dome of each hemi-diaphragm and the lateral chest wall.
In a healthy individual the costo-phrenic angles should be clearly visible on a normal CXR as a well-
defined acute angle.

Loss of this acute angle (sometimes referred to as costophrenic blunting) can suggest the presence of fluid
or consolidation in the area. Costophrenic blunting can also occur secondary to lung hyperinflation (seen in
diseases such as COPD) as a result of diaphragmatic flattening and subsequent loss of the acute angle.

Everything else Mediastinal contours

LOL (E) The mediastinum contains the heart, great vessels, lymphoid tissue and a number of potential spaces where
pathology can occur. The e act boundaries of the mediastinum aren t particularl visible on a CXR, however
there are some important structures that you should assess.

Aortic knuckle:
Left lateral edge of the aorta as it arches back over the left main bronchus.
Loss of definition of the aortic knuckles contours can be caused by an aneurysm.

Aorto-pulmonary window:
The aorto-pulmonary window is a space located between the arch of the aorta and the pulmonary arteries.
This space can be lost as a result of mediastinal lymphadenopathy (e.g. malignancy).

Bones
Inspect the visible skeletal structures looking for any abnormalities (e.g. fractures / lytic lesions).

Soft tissue
Inspect the soft tissues for any obvious abnormalities (e.g. large haematoma).

Tube/ Valves/ Lines etc.

Tubes nasogastric tubes are something ou ll often be asked to assess on a chest x-ray to confirm it
is safe for feeding
Lines (e.g. central line / ECG cables).
Artificial valves (e.g. aortic valve replacement).
Pacemaker (often located below the left clavicle).

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Examples of Case Scenarios for Practice

Case 1***
Mr C, a 30-year-old man who just had a minor car accident, presented with breathlessness, chest pain and cough.

Perform a relevant anterior chest examination on this patient and report your findings. You may omit tactile fremitus.
At the sixth minute, the examiner will ask you one question.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Ensure patient lying at 45 degrees (3 marks deducted from total score if not performed) /1
General inspection for respiratory distress, cyanosis, etc. -
Inspect chest wall for deformities, open fractures, erythema, prominent pulsation, bleeding, AP: lateral diameter ratio etc. /2
Inspect chest wall movement during inspiratory and expiratory phase
Palpate apex beat with accurate demarcation. Commenting that apex beat is not displaced or diminished /2
Perform chest expansion for at least 2 different areas. (correct technique gives the 2nd mark) /2
Omit tactile-vocal fremitus -
Check for tracheal deviation. (correct technique gives the 2nd and 3rd mark) /3
Percussion of chest wall at appropriate areas of the anterior and lateral chest using accurate technique. Commenting on the /3
percussion notes at all regions
Auscultate for breathing sounds, and accurate commenting /2
Auscultate for vocal resonance, and accurate commenting. A de e a e 99 /2
QUESTION: Give 3 possible physical findings if the patient has tension pneumothorax /1
Ans: displaced apex beat, tracheal deviation away (from affected side), hyper-resonant percussion notes on affected
side, absent or reduced breath sounds, absent vocal resonance
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 24 marks

Case 2****
Mr D, a 26-year-old man who had a long history of bronchial asthma came to the clinic for his regular follow-up.

Perform a relevant general physical examination on this patient and report your findings.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Allow patient to lie at 45 degrees. /1
General inspection for any respiratory distress, cyanosis, use of accessory muscle of respiration /2
Examine hands for cyanosis, fine tremor, and flapping tremor /3
Measure pulse rate (allow student to measure for 30 seconds). Comment on rate, rhythm, volume and any abnormal character /2
Measure breathing rate (must measure for 1 minute), with comments on respiratory rate /2
Mention temperature and blood pressure measurement /1
Nose examination with use of torch. Demonstrate checking for nasal polyps and discharge in allergic rhinitis /2
Omit paranasal sinuses palpation -
Inspect lips and tongue for any central cyanosis, and any white patches of candidiasis /2
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 21 marks

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Haematological System

General Examination for Haematological Disorders

General Inspection
Check the following during general inspection, or when you are Relevance
examining specific parts of the body:
Describe the build and nourishment of the patient Haematological malignancies such as leukaemia,
lymphoma or malnutrition anaemia
Does the patient have any petechiae and ecchymoses? Thrombocytopenia
Any skin pigmentation? Lymphoma
Any skin rashes? Lymphoma
Any ulceration of skin? Neutropenia
Any generalised cyanosis? Polycythaemia
Any plethora? Polycythaemia
Does the patient have generalised jaundice? Haemolytic anaemia
Any scratch marks? Basophilia in Myeloproliferative disorders
Hands
Check palmar creases for any pallor Anaemia
Inspect nails for any koilonychia (spoon nails) Iron deficient anaemia
Mention examining the joints in the hands for any swelling, inflammation Secondary gout due to myeloproliferative disorders,
(arthritis) drug treatment, haemophilia for hemarthroses (more for
knee)
Check by palpating for epitrochlear node swelling Lymphoma, HIV

Mention axillary lymph nodes examination Malignancies (especially breast cancer)

Mention vitals (pulse, respiratory rate, temperature, blood pressure) Fever in leukaemia, Hodgkin lymphoma, infectious
mononucleosis
Mention tourniquet test (extra) Thrombocytopenia, dengue fever
A blood pressure cuff is applied and inflated to the midpoint between
the systolic and diastolic blood pressures for five minutes. The test is
positive if there are more than 10 to 20 petechiae per square inch

Face
Check for any pallor in conjunctiva, and any jaundice in sclera of eyes Anaemia, haemolytic anaemia
Check for any conjunctival suffusion/ excessive redness Polycythaemia
Inspect for facial flushing and malar rash SLE (malar rash), dengue (facial flushing)
Mouth
Check for any angular stomatitis at the corners of mouth Nutrient deficiency anaemia
Inspect gums for any hypertrophy Monocytic leukaemia
Inspect mucosa of mouth for any ulceration, infection, bleeding, petechiae Bone marrow failure and pancytopenia
Check for any redness in the pharyngeal wall for sign of pharyngitis, and Infectious mononucleosis
any tonsillar enlargement in tonsillitis
Inspect the tongue for presence of lingual papillae. Loss of papillae Nutrient deficiency anaemia
indicates glossitis

Neck
Mention cervical lymph node examination Infectious mononucleosis and malignancies
Palpate for any tenderness in spine, sternum, clavicles, shoulders Multiple myeloma, leukaemia
Abdomen
Mention examination of inguinal nodes Malignancies
Mention liver and spleen examination Extramedullary haematopoiesis
Leukaemia and lymphoma
Legs
Inspect legs for any signs of vasculitis rashes etc. Henoch Schonlein purpura over thighs
Inspect lower limbs for any bruising Thrombocytopenia
Check for any skin pigmentation Lymphoma
Examine knee joint for swelling Haemophilia and hemarthroses
Check for any ulceration Neutropenia
Mention nerve examination for peripheral neuropathy Vitamin B12 deficiency anaemia

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Cervical Lymph Nodes Examination

Overview of Significance of Cervical Lymph Nodes

The examination
Ensure the neck is exposed sufficiently, inspect the neck for any visible nodes from front, sides and behind
Have the patient to relax the neck by slightly flexing forward (optional for lymph nodes, but must for thyroid examination)
Palpate each groups of cervical lymph nodes using the pulps of 3 fingers, with gentle rolling movement
Start under the chin with submental lymph nodes, followed by submandibular, preauricular, posterior auricular, (upper cervical lymph
nodes at the angle of jaw) and occipital lymph nodes. Palpate both sides at the same time.
Identify the SCM which demarcates the posterior border of the anterior triangle. Palpate upper cervical lymph nodes (some call it
tonsillar/ jugulodigastric lymph nodes), which are most commonly enlarged in URTI. Move downwards along the SCM to feel the
superficial anterior lymph nodes. Palpate one side entirely before moving on to the other side
Warn the patient that you are about to go a bit deeper this time. Have the patient to turn the head to the opposite side against your
resistance to reveal the SCM, hook 3 fingers onto the SCM, have the patient to face the front once again, and palpate along the
groove for any enlarged deep anterior lymph nodes. Palpate one side entirely before moving on to the other side
Palpate posterior lymph nodes in the posterior triangle, followed by supraclavicular lymph nodes
If a mass/ swelling is felt, describe the swelling (see later)

Axillary Lymph Nodes Examination

To make things easy and prevent us from falling into an awkward situation, have patient to rest his/ her arm of the side to be
examined on your shoulder, and use your hand of the opposite side to palpate for any enlarged axillary lymph nodes.
For e ample, hen e amining the patient s right a illa, have patient to rest his/ her right arm on our shoulder as ou palpate
using your left hand.

Groups of Axillary Lymph Nodes

Central nodes Located high in the axilla, at the centre in the adipose fat
Anterior/ pectoral nodes Located along the inferolateral border of pectoralis major, within the anterior axillary fold
Posterior/ subscapular nodes Located deep within the posterior axillary fold
Lateral nodes Felt against the upper humerus
Apical nodes Located at the apex of axilla at the lateral border of first rib
When palpating, insert fingers deep and pointing towards the direction of the clavicle

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Examination of Lumps and Bumps
General Principles (adapted from Oxford Medical Education)

Site Anatomical location

Usually expressed in terms of distance from a bony prominence (e.g. 2cm superior to the angle of the right
mandible) or a well-demarcated site (e.g. left antecubital fossa)
Size o Size can be estimated but ideally should be measured using a tape measure or ruler
o Size should be stated in at least two dimensions (e.g. 1cm x 1cm), and three where possible
Shape o The lump should be considered in three dimensions when describing its shape
o Descriptions should be made in geometrical terms where possible (e.g. spherical, oval, round etc.)
Margin o Palpate around the lump, or look around the skin lesion. Is the margin well- or poorly defined?
Surface o Appearance
(appearance and Is it smooth or rough; flat or raised; regular or irregular?
colour) Is there any evidence of ulceration (skin breakdown) or necrosis (blackened, usually secondary to
ischaemia)?
Normal skin often overlies deep lumps, while superficial swellings are more likely to result in a change
in the overlying skin
o
o Colour
The lump may be the colour of the overlying skin or may appear red and inflamed
Certain lumps are abnormally pigmented (e.g. melanoma)
Temperature Is the lump warm upon palpation?
Tenderness Warn patient beforehand!
Consistency o This clinical feature describes a spectrum between hard and soft and can be considered under three
categories: hard, firm (rubbery or spongy) or soft
Hard lumps suggest the possibility of cancer
Fluid-filled lumps may be tense (and thus quite hard), rubbery or spongy
Soft lumps are more likely to be benign (e.g. lipoma)
o In terms of comparisons: hard is like your chin, firm is like your nose, soft is like your ear-lobe

Pulsatility o Note whether the lump is pulsatile, suggesting a vascular origin

o Try to determine whether the pulsation originates from the lump itself or whether it is transmitted from a nearby
vessel
o Intrinsic pulsation is indicated by a swelling that is pulsatile and expansile (e.g. an abdominal aortic aneurysm)
Compressibilityo Compressibility
and reducibility o Lumps that can be emptied by pressure but reappear spontaneously on release of pressure are
compressible (e.g. varicose veins)
o
o Reducibility
o Lumps which disappear with pressure and do not return spontaneously (e.g. inguinal hernias) are reducible
o Before attempting to compress or reduce a lump be sure to ask the patient if the area is tender
o It is often helpful to ask the patient to demonstrate reducibility themselves (particularly true of hernias)

Fluctuation o To test for fluctuation put your fingers (thumb and index finger) on either side of the lump, opposite each
other. Press with one finger and feel whether the lump bounces against your other finger
o This indicates a fluid- or fat-filled lump

Mobility o Observe first whether the lump moves spontaneously, on respiration or with muscular contraction
o Certain lumps have a characteristic mobility (e.g. fibroadenoma). The mobility of other swellings may vary
depending on anatomic site and other factors
o
o Lesions that lie superficial to a muscle group should be tested for mobility with the underlying muscles
both relaxed and contracted
o If a previously mobile lump becomes fixed on contraction of the underlying muscles it is likely that the lesion
has infiltrated the muscle layer
o
o Mobility can also be reduced by e e , which reflects an inflammatory or neoplastic process (e.g. in
breast cancer)
o Tethering can be demonstrated by gently moving the lump in two planes, looking carefully for wrinkling or
pulling of the skin

o
Transillumination Using a pen torch, shine a light across the lump ideally in a dark room
o A swelling containing clear fluid will glow when this test is performed, such as in:
Simple cyst
Hydrocele
o It is important to note, however, that lipomas (fat-filled lumps) will also transilluminate
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Percussion Of limited value
o Gas-filled swellings (such as any involving the bowel) are resonant to percussion, while dullness to percussion
is a feature of fluid-filled lesions and solid structures (e.g. retrosternal thyroid mass)
Auscultation o Typical findings include bruits/ murmurs over vascular lesions or areas with an abnormally increased blood
supply (e.g. enlarged thyroid) and bowel sounds heard over an inguinal hernia
o Also check neighbouring lymph nodes which drain the site of the lump
Regional lymph
nodes o Systemic infection and malignancies

Venepuncture

Confirm patient name and ID

Explain the purpose of procedure (e.g. to measure blood sugar level, to check blood platelet count, liver function etc.)
*please take note that if patient is here to have their fasting venous plasma glucose measured, ensure that patient has already fasted
for at least 8 hours
Explain the process briefly (using needle and syringe to draw blood from the arm, which can cause a bit of pain)
Warn patient about potential complications such as bleeding and bruising, and action to be taken when they persist

Wash hands, prepare and assemble all equipment are present in kidney dish on the trolley. These include preparing syringe with
needle, cotton, tape, alcohol swab, and placing the tube of the correct colour, Bring the equipment closer to patient, by pulling the
trolle to the patient s side if there is no table. DO NOT place the kidney dish on the couch/ bed.

Inspect patient s arm for an contraindications for venepuncture. These include:

AV fistula, signs of infection, inflammation, hematoma, lymphedema etc.

Appl tourniquet, and ask patient to make a fist, and tap on patient s arm gentl to make the veins more prominent
Select a suitable vein by palpating the vein to determine its size and volume, and identify the direction of vein
Wear gloves, and disinfect the area to be punctured in an outward circular motion
Hold the cotton using your left hand, and inform patient before inserting needle. Draw blood slowly, and ensure the amount of blood
drawn is sufficient to meet the indicator level of the test tube when you transfer the blood into the test tube.
Remove tourniquet, remove needle and compress using cotton which you are already holding in your left hand, ask patient to press
firmly on the cotton
Transfer blood into the tube, meanwhile check whether patient has stopped bleeding, apply tape onto cotton
Take out needle from the tube, and dispose it into the sharp bin immediately
Shake the tube 10 times

Remove gloves, ash hands and label tube ith patient s name, ID, date and time of the blood sample being taken
Inform patient that blood sample will be sent to the laboratory, and they will be informed when the results are ready

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Examples of Case Scenarios for Practice
Case 1****

Mr E, a 20-year-old man is suspected of having acute leukaemia.

Perform a relevant physical examination on this patient and report your findings.

Note: students are expected to look for signs of pancytopenia, and examine the spleen for splenomegaly
Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1
General inspection: is the patient ill or cachexic? Rapid breathing? Etc. -
Hands and arms: check for any pallor in palmar creases, petechiae /2
Mention vitals: pulse, blood pressure, temperature, breathing rate /1
Eyes: check for any pallor in conjunctiva /1
Mouth: check for any gum hypertrophy, check mucosa for any ulceration, petechiae, bleeding etc., check pharyngeal wall for any /2
signs of infection
Mention lymph nodes examination /2
Mention palpation for any bony tenderness Bonus
1 mark
Perform spleen examination to check for splenomegaly (palpation and percussion) /4
Mention liver examination /1
Lower limbs: check for any ulceration and petechiae /1
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 20 (+ 1) marks

Case 2**
Mr F, a 55-year-old diabetic man, came to have his fasting venous plasma glucose level measured.

Perform venepuncture to obtain blood sample from Mr F.

Case 3****
Ms G, a 45-year-old lady who had undergone mastectomy for her left breast due to breast cancer, noticed a lump in her right breast.

Examine her right breast and her right axillary lymph nodes, and report your findings.

C a e Ta a bab c e OSCE*****
Case

A 20-year-old man who complains of high fever and joint pain is suspected of having dengue fever.

Perform relevant examination on this patient and report your findings.

Equipment provided: sphygmomanometer

*take note of the physical signs of dengue fever and dengue haemorrhagic fever
Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1
General inspection: does the patient appear to be very ill? Sweating? -
Hands and arms: inspect for maculopapular or macular rash, petechiae /2
Vitals: Measure blood pressure, and mention the other vitals such as temperature, pulse and breathing rate /3
Mention tourniquet test +2
A blood pressure cuff is applied and inflated to the midpoint between the systolic and diastolic blood pressures for five minutes. marks
The test is positive if there are more than 10 to 20 petechiae per square inch

Inspect face for facial flushing, a sensitive indicator of dengue fever /1

Inspect trunk and abdomen for maculopapular or macular rash, petechiae /1
Mention chest examination for pleural effusion (dengue haemorrhagic fever) +2
marks
Examine liver for hepatomegaly: palpation and percussion of liver. Omit the rest of the abdominal examination /3
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 16 (+ 4) marks

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Gastrointestinal System

General Examination

General Inspection
Check the following during general inspection, or when you are Relevance
examining specific parts of the body:
How is the mental state of the patient? Is the patient alert, conscious and Hepatic encephalopathy
responsive?
Describe the build and nourishment of the patient. Any wasting? Malabsorption syndromes and malnutrition
Malignancies
Cirrhosis
Chronic alcoholics
Does the patient have any generalised jaundice? Liver or hepatobiliary tract problem
Does the patient have any generalised skin pigmentation? Haemochromatosis
Does the patient have any acanthosis nigricans? Malignancies
Acanthosis nigricans
caused by factors that stimulate epidermal
keratinocyte and dermal fibroblast proliferation.
In the benign form of acanthosis nigricans, the
factor is probably insulin or an insulin-like growth
factor (IGF) that incites the epidermal cell
propagation. This occurs during
hyperinsulinemia and insulin resistance
In malignant acanthosis nigricans, the
stimulating factor is hypothesized to be a
substance secreted either by the tumour or in
response to the tumour. Transforming growth
factor (TGF) alpha is structurally similar to
epidermal growth factor and is a likely candidate

Hands
Check patient s hands for an palmar erythema Stigmata of chronic liver disease
Any pallor in the palmar creases? Chronic GI blood loss such as peptic ulcer disease
Malabsorption of iron or vitamin B12
Check hands for any Dupu tren s contracture Chronic alcoholism, a risk factor for liver and pancreas
D e c ac e diseases
fibrosing disorder that results in slowly progressive thickening and shorting
of the palmar fascia and leads to debilitating digital contractures,
particularly of the metacarpophalangeal (MCP) joints or the proximal
interphalangeal (PIP) joints. This condition usually affects the fourth and
fifth digits (the ring and small fingers)
Inspect nails for any leukonychia Hypoalbuminemia
Inspect nails for any koilonychia Iron deficiency anaemia due to GI blood loss or
hypochlorhydria in atrophic gastritis
Inspect nails for any Beau lines (deep grooved lines) Malnutrition
occur when the nail matrix is injured, and the growth of the nail is slowed
Inspect nails for any Muehrcke s lines Hypoalbuminemia
paired, white, transverse lines that signify an abnormality in the
vascular bed of the nail.
A localized oedematous state in the nail bed may exert pressure on
the underlying vasculature, thereby decreasing the normal
erythema typically seen through the nail plate
Check for any digital clubbing Cirrhosis and pulmonary shunting
Inflammatory bowel disease
Celiac disease
Check for any flapping tremor, asterixis Hepatic encephalopathy
Vitals as usual

Arms
Any bruising or petechiae in the arms? Obstructive jaundice
Fat malabsorption (vitamin K)
Reduced production of coagulating factors from
liver
Petechiae due to bone marrow suppression
from alcohol
Hypersplenism in portal hypertension increases
blood cells sequestration, including platelets
Any muscle wasting? See above in general inspection
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Any signs of scratch marks? Pruritus in obstructive jaundice
Any tendon xanthoma in extensor surfaces such as elbow? Hypercholesterolemia
Trunk
Look for any spider naevi in upper trunk and proximal arm Chronic liver disease
Does the male patient appear to have gynaecomastia? Or loss of axillary Chronic liver disease (liver unable to metabolise
hair oestrogen and androgens, and peripheral tissue such
as adipose convert androgen into oestrogen.
Mention supraclavicular node, especially Virchow node on left side GI malignancy
Eyes
Check sclera for any jaundice, and conjunctiva for any pallor Scleral icterus for hyperbilirubinemia, pallor for anaemia
Inspect eyes for any Bitot s spot Vitamin A deficiency due to fat malabsorption

Xanthelasmata Cholestasis
Uveitis Extra-intestinal manifestation of IBD

Mouth
Palpate cheeks to check for any parotid enlargement Alcoholism
Appreciate any abnormal breath smell from the mouth Fetor hepaticus, alcohol smell
Inspect for any angular stomatitis Nutrient deficiency anaemia
Examine tongue for any leukoplakia, erythroplakia, candidiasis, glossitis Glossitis seen in nutritional deficiency anaemia
Examine mucosa for any ulcers Aphthous ulcers of unknown reason, or IBD

Look for jaundice in the lingual frenulum Hyperbilirubinemia

Legs
Check for any ankle oedema Hypoalbuminemia in chronic liver disease and chronic
protein loss in malabsorption

Specific Examination (Abdominal Organs)

In IMU, the examination sequence for the abdomen is Inspection, Palpation, Percussion and Auscultation. In many other universities, they
were taught to perform auscultation first, as palpation may disrupt the intestinal contents, affecting auscultation later.
Kidney and bladder examination is explained later in the Renal System chapter.
The sequence stated below can vary from individual to individual.
*Patient must be lying flat on the bed. Ask patient if he/she wants to empty bladder first
General Inspection (spend as little as time as possible)
How is the mental state of the patient? Is the patient alert, conscious and responsive?
Describe the build and nourishment of the patient. Any wasting?
Does the patient have any generalised jaundice?
Does the patient have any generalised skin pigmentation?
Does the patient have any acanthosis nigricans?
Does the patient have any abnormal breath smell? Such as alcohol or fetor hepaticus?
Is the patient in any pain or distress? (Acute abdomen)

Inspection of the Abdomen

Ensure there is sufficient exposure - from xiphoid process of sternum up to pubic symphysis
Inspect shape of abdomen by looking at the abdomen at eye level. Is the abdomen flat, scaphoid, round/ distended?
Observe movement of abdomen with inspiration and expiration. Any prominent masses in abdomen, which manifests with
asymmetrical movement, revealed with breathing?
Look at the umbilicus. Is it inverted or everted?
Any local swellings which may indicate hernia?
Any scars or stoma in the abdomen?
Any prominent veins in the abdomen (caput medusae)? If present, elicit direction of venous flow

Any prominent pulsation in the abdomen? Abdominal aortic aneurysm

Any visible peristalsis? Pyloric obstruction due to peptic ulceration or tumour can cause visible peristalsis across upper
abdomen from left to right (stomach)
Any striae or stretch marks?

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IMU OSCE Students Notes ZhenZhe.2018 IMU-FPEPII
General Abdominal Palpation (Ask for any pain, and ensure that hands are warm)
Palpate the 9 regions of abdomen in a systematic manner. Al a s atch patient s facial e pression for an signs of discomfort
during palpation
Palpation technique: all hand movements occur at metacarpophalangeal joints, NOT the interphalangeal joints, and hand
should be moulded to the shape of the abdomen. For palpation of edges of organs or masses, lateral surface of the index
finger is the most sensitive part of the hand
Begin with superficial palpation, followed by deep palpation

Assess abdominal muscle tone by light dipping movements with fingers

Comment on whether tenderness was present, any palpable masses, and any guarding or rigidity of the abdomen
Guarding of abdomen (when resistance to palpation occurs due to contraction of abdominal muscles) may result from tenderness of
anxiety, and is voluntary.
Rigidity is constant involuntary reflex contraction of abdominal muscles, always associated with tenderness and indicates peritoneal
irritation or inflammation (peritonitis)
Guarding can often be overcome by having the patient purposely relax the muscles; but rigidity cannot be

General Abdominal Percussion

Percuss the four quadrants of abdomen. Comment on whether the percussion notes are tympanic, or any dullness noted.
McB e ( ec c 1)
Location: On a straight line joining ASIS and umbilicus, McBurney point is at the junction of medial 2/3 and lateral 1/3 on this line
Tenderness at McBurne s point is a sign of acute appendicitis

Examination of the Liver (Hepatomegaly)

Liver Palpation
Begin by placing hand at right iliac fossa
Ask patient to take deep breaths. As patient inhales, palpate for liver lower border using the lateral border of the index finger
as mentioned previously. With each breath, move your hand progressively up (1cm at a time) form right iliac fossa towards
right hypochondriac region until reaching costal margin or until edge of liver is felt.
If edge of liver is felt, comment on whether there is tenderness, any pulsations felt (pulsatile liver in right heart failure), size,
surface, consistency. Also feel for nodules or irregularities
Optional: measure distance between costal margin and lower edge of liver along midclavicular line. This is NOT the liver span

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There seems to be 2 ways of palpating the liver as described

in different videos and textbooks.

Liver Percussion for Liver Span

Starting at right iliac fossa in midclavicular line, lightly percuss upwards costal margin. Mark area of dullness. If no dullness
appreciated, use costal margin as lower border
Percuss downwards in the chest along right midclavicular line until dullness is heard. Mark level of dullness
Measure distance between these 2 points, which is the liver span
Normal liver span is between 6-12cm in the midclavicular line

Murphy sign (specific sign 2)

Can be checked during liver palpation
Firmly press hand in right upper quadrant just below costal margin along midclavicular line
Ask patient to take in a deep breath
Tenderness may indicate acute cholecystitis
Descent of diaphragm caused by inspiration induces pain as the tender gallbladder is pressed against our hand

Examination of the Spleen (Splenomegaly)

Spleen Palpation
Place hand over right iliac fossa or just below umbilicus. Keep hand stationary and ask patient to take
in deep breaths. Feel for any splenic edge as it descends on inspiration
Move hand diagonally upwards towards left hypochondriac region. Synchronise palpation when
patient takes in deep breaths
Ask patient to roll towards you onto his right side, palpate using right hand while using left hand to
press for ard on patient s left lo er ribs from behind to help to push the spleen anteriorl .

Enlarged spleen Enlarged kidney

Upper border can t be felt Upper border can be felt
Notch present No notch
Not ballotable Ballotable
Moves inferio-medially on inspiration Moves inferiorly on inspiration
May enlarge towards umbilicus Enlarges inferiorly lateral to umbilicus
Dullness to percussion Resonant percussion note due to overlying bowel gas
Spleen Percussion
While patient is still l ing on his right side, percuss in the Traube s space, hich is bounded b left si th rib superiorl , left anterior
axillary line and left costal margin inferiorly

Ascites 1: Fluid Thrill

Ask patient to place ulnar edge of his/ her hand in the midline of the abdomen to prevent transmission of impulse across the
surface of abdominal wall
Place your left hand flat against one side of the abdomen
Flick your right finger on the opposite side of the abdomen
Feel for any ripple on your left hand
Ascites 2: Shifting Dullness
Percuss from the middle of abdomen at the umbilicus towards the flank until a dull note is obtained
Keep finger in place and ask patient to turn towards or away from you (depending on your own style). Pause for 10 seconds.
Percuss again in the flank. Ascites is suggested if this area becomes resonant
Confirmed by obtaining a dull note when percussing back towards the umbilicus

Auscultation of the Abdomen

Bowel Sounds place stethoscope (diaphragm) to the right of the umbilicus and do not move it. Listen for up to 2 minutes before
concluding that bo el sounds are absent. Stop auscultating as soon as bo el sounds can be appreciated. DO NOT count the rate
of bowel sounds/ movement
Absence of bowel sounds implies paralytic ileus or peritonitis
In intestinal obstruction, bowel sounds have increased frequency and volume, and have high pitch
Arterial Bruit
Listen above umbilicus for abdominal aortic bruit
Listen 2-3 cm above and lateral to umbilicus for bruit in renal artery stenosis
Listen 2-3 cm below and lateral to umbilicus for bruit in iliac artery stenosis
Mention femoral artery bruit below inguinal ligament at junction of medial 1/3 and lateral 2/3
Bruit suggest atheromatous or aneurysmal aorta or superior mesenteric artery stenosis. Listen if suspecting ischaemic bowel disease
Listen over liver for bruit
Hepatic bruit is indicative of alcoholic hepatitis, primary or metastatic cancer

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Digital Rectal Examination
*examination procedure for a male patient is explained as it involves prostate examination

Explain the purpose of examination, and how it will be done

Mention that you will be examining back passage using finger, you will be wearing gloves and using lubricant. Patient must remove
lower garment including underwear and lie in a certain position for the examination. Chaperone and privacy ensured.
For better communication skills with patient, reassure patient that it will only take a short while, and the examination is important
based on specific indication for that patient, if he/ she seems reluctant to do the examination.
Ask if patient would like to empty bladder first
Give instructions to patient on lying position. Patient should lie close to the right edge of the bed, turn body to the left and lie on left
side, bend and hug knees or bring knees to chest
Wash hands and wear gloves
Inspect perianal and perineal area for rectal prolapse, haemorrhoids, skin tags, excoriation, discharge, anal fissure.
Ask patient to cough or strain to check for any haemorrhoid and rectal prolapse
Apply lubricant to index finger
Ensure patient is ready and relaxed, and ask patient to inform if they feel pain during the examination
Introduce finger at 6o clock position and wait for patient to relax. Always look at patient s facial e pression to check for tenderness
Assess anal sphincter tone by asking patient to squeeze against your finger
Inform patient before inserting finger. Rotate 360 in clock ise and anticlockwise, and feel wall of rectum (normally smooth and
pliable). Check for any polyp, obstructing faecal matter, thickening, irregularities and tenderness of the rectal wall.
For male patients, examine the prostate gland. Turn finger towards anterior, and feel for median sulcus and two lobes. Report on
presence of median sulcus, smoothness or presence of any irregularities, consistency and any tenderness in prostate gland (normally
smooth and rubbery)
Inform patient before gently withdrawing finger. Inspect gloves for any blood, mucus and faecal matter
Thank patient and offer tissue to clean up, and offer toilet visit if patient has urge to defecate. Remove gloves and dispose
appropriately.

Examples of Case Scenarios for Practice

Case 1***
Mr H, a 60-year-old man complains of abdominal pain and bloody stools in the past 24 hours.

Tasks:
1. Examine the abdomen and report your findings
2. Perform a digital rectal examination on this patient.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

General inspection: is the patient in pain or distress? -
Inspection of abdomen /2
Sufficient exposure (1 mark)
Shape of abdomen; noting any distension, and position of umbilicus
Movement during respiration
Scars or stoma
Prominent peristalsis or pulsation
Palpation of abdomen /4
9 regions with sufficient exposure (0/ 1 mark if exposure is insufficient)
Superficial and deep palpation (correct palpation technique)
Observing patient s facial e pression during palpation
Comment on any tenderness, masses felt and guarding/ rigidity (1 mark)
Percussion of abdomen at 4 quadrants with comment /1
Demonstrate McBurney point /1
Omit liver and spleen examination -
Remind student that kidney and bladder examination is not relevant here -
Auscultation of abdomen for bowel sounds, and bruit at the abdominal aorta (mesenteric artery stenosis) /2
Accurate positioning of patient for DRE /2
Use of gloves and lubricant (Minus 10 marks if gloves not used lol) /1
Inspecting perianal area /1
Checking for haemorrhoid and rectal prolapse upon straining /1
Examination of rectal wall with comment /1
Prostate examination /1
Inspecting gloves after removing finger from patient s rectum for an blood, mucus and faecal matter /2
Overall assessment on organisation, confidence, and communication skills with patient (including offering patient to empty bladder /6
before examination, and reassuring patient during DRE)
Total = 26 marks

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Case 2***

Mr I, a 50-year-old man who has had heavy alcohol intake for the past 20 years, complains of yellowing of eyes, nausea, and fatigue.

Perform a relevant general physical examination on this patient and report your findings.

*students are expected to look for signs of chronic liver disease

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1
General inspection: mental state, build and nourishment, general skin colour (any jaundice?) /2
Hands: palmar erythema, Dupu tren s contracture, beau lines, Muehrcke s lines, digital clubbing, flapping tremor /4
Arms: petechiae or bruising, tendon xanthoma /1
Mention vitals /1
Eyes: jaundice in sclera, xanthelasmata (dyslipidaemia) /2
Mouth: jaundice in lingual frenulum, smell of alcohol in breath, fetor hepaticus, palpate for any parotid gland enlargement /2
Chest: gynaecomastia, spider naevi /2
Inspect abdomen: caput medusae /1
Legs: petechiae, ankle oedema /1
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 22 marks

Case 3****

Mr I, the 50-year-old man from the previous case, is now suspected of having chronic liver disease.

Examine his abdomen and report your findings. You do not need to check for ascites.

*students are expected to perform general abdominal examination (inspection, palpation, percussion), check for hepatosplenomegaly,
and finally auscultate the abdomen (hepatic bruit)

Case 4****

Mr J, a 30-year-old man who just came back from India, and had no history of blood transfusion and intravenous drug use, is suspected of
having acute hepatitis.

Perform relevant examination on this patient and report your findings.

*this is a case of a suspected Acute Hepatitis, NOT chronic hepatitis

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1
General inspection: mental state, general skin colour (any jaundice?) /1
Mention vitals (pulse, temperature, breathing rate, blood pressure) /1
Eyes: jaundice in sclera /2
Mouth: yellow discolouration in lingual frenulum /1
Inspect abdomen, paying extra attention to right hypochondrium/ right upper quadrant /2
Palpation of the 9 regions of the abdomen /2
9 regions with sufficient exposure (0/ 1 mark if exposure is insufficient)
Superficial and deep palpation (correct palpation technique)
Observing patient s facial e pression during palpation
Comment on any tenderness, masses felt and guarding/ rigidity (1 mark)
Percussion of abdomen -
Liver palpation with correct technique and accurate comment /4
Liver percussion /4
Start from right iliac fossa
Percuss along midclavicular line up to dullness or costal margin
Percuss from upper chest down to dullness
Measure liver span using measuring tape/ ruler
Auscultation -
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 23 marks

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Renal System

General Examination (mainly for CKD)

General Inspection
Check the following during general inspection, or when you are Relevance
examining specific parts of the body:
How is the mental state of the patient? Is the patient alert, conscious and Uremic encephalopathy
responsive?
Describe the build and nourishment of the patient. Any wasting? Chronic kidney disease, RCC
Is the patient in respiratory distress? Fluid overload in CKD
Does the patient have uremic fetor? Uraemia in CKD
Does the patient have sallow complexion? (often yellow) Chronic kidney disease
Any medical equipment such as urinary catheter? Urinary retention, distended bladder etc.

Hands
Any pallor in the palmar creases? Anaemia in CKD
Any deformities of gouty tophi at small joints of hands? Chronic hyperuricemia and chronic gout
Check nails for any Muehrcke s lines Hypoalbuminemia due to proteinuria
Check nails for any Beau lines Multiple causes
Any half and half nails? the proximal portion is white (edema and anemia) and
the distal portion is dark. These nails imply either renal
or liver disease
Check whether patient has flapping tremor Uraemia
Check whether capillary refill is within 2 seconds. May be increased in Hypotension may occur in patients with AV fistula for
hypotension haemodialysis in the same side of upper limb, which
may indicate steal syndrome
Check for any evidence of carpal tunnel syndrome such as Tinel s sign, Longstanding CKD or haemodialysis
sensory in tips of lateral 3 fingers, Phalen test, and thenar muscle wasting
Vitals as usual Kussmaul s breathing in metabolic acidosis in CKD
Arms
Inspect arm for any scars and AV fistula. If fistula is present, palpate for Haemodialysis
thrills which indicates functioning fistula
Note any bruising in the arm Uraemia and platelet dysfunction
Note any skin pigmentation Excretion failure. Sign of advanced CKD
Note any scratch marks Uraemia and hyperphosphatemia
Mention checking for any peripheral neuropathy, myopathy and bone CKD, diabetes mellitus
tenderness

Head and Neck

Check for any conjunctival pallor Anaemia in CKD
Inspect for any periorbital oedema Hypoalbuminemia due to proteinuria
Uremic fetor Uraemia
Ulcers in mouth CKD and increased risk of infection
Mention ophthalmoscopy/ fundoscopy to examine eyes Hypertensive and diabetic retinopathy
Look at neck and supraclavicular fossa for any haemodialysis catheters
or scars of old placement sites

Lower Limbs
Check for any ankle oedema Hypoalbuminemia, fluid overload
Mention checking for any peripheral neuropathy

Specific Examination (Kidneys and Urinary Bladder)

Abdominal Examination
General Inspection (spend as little as time as possible)
How is the mental state of the patient? Is the patient alert, conscious and responsive?
Describe the build and nourishment of the patient. Any wasting?
Does the patient have any sallow appearance?
Does the patient have any abnormal breath smell such as uremic fetor?
Is the patient in any respiratory distress?

Perform general abdominal examination as usual

Inspection
Palpation of 9 regions - pay extra attention to left and right hypochondriac and lumbar region (enlarged kidneys), and
suprapubic/ hypogastric area (enlarged bladder), comment whether any masses felt at these regions
Percussion of 4 quadrants
(Leave auscultation for later)

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Kidney and Bladder Examination
Bimanual Palpation of Kidneys to detect lesser degrees of kidney enlargement
Place left hand belo patient s back belo the lo er ribs and right hand anteriorl over the upper
quadrant just lateral to the rectus muscle
Firmly, but gently push hands together as patient breathes out.
Ask patient to breathe in deeply, and feel for the lower pole of kidney moving down between your
hands. If lower pole of kidney can be felt, gently push the kidney back and forwards between two
hands to demonstrate its mobility (balloting)
If kidney is palpable, assess its size surface and consistency
Renal Punch
Ask patient to sit up, palpate renal angle between spine and 12th rib
posteriorly firmly but gently
Firmly strike the renal angle once with the ulnar aspect of closed fist over
dorsum of another hand after warning patient.
Note any discomfort to the patient

Palpation of Urinary Bladder (?)

According to the old CSSC manual, there is a part where you palpate the bladder if a mass felt at the suprapubic region is suspected
to be the bladder, and to feel the upper border of the bladder. However, this is NOT seen in Macleod s.
Percussion of Urinary Bladder
Percuss over a resonant area in the abdomen in the midline, then downwards towards the pubic symphysis. Change to dull
percussion note indicates upper border of bladder.
Repeat using a diagonal axis on both left and right side
Comment on whether the bladder appears to be distended
Auscultation
Auscultate for any bruit arising from renal artery stenosis - Listen 2-3 cm above and lateral to umbilicus

Relevant Chest Examination for CKD

Cardiovascular System
Measure pulse and blood pressure.
Pulsus paradoxus may be present in uremic pericarditis-cardiac tamponade

Pulsus paradoxus
Pulsus paradoxus is an abnormally large decrease (more than 10mmHg) in stroke volume, systolic blood
pressure and pulse wave amplitude during inspiration
Normally during inspiration, a person's s stolic blood pressure decreases b 10 mmHg and pulse slightly increases. This is
because the decrease in intra-thoracic pressure and stretching of the lungs during inhalation expands the compliant pulmonary
vasculature so that blood pools in the lungs and decreases pulmonary venous return to the left atrium. Also, the increased
systemic venous return to the right side of the heart expands the right heart and directly compromises filling of the left side of
the heart by slightly bulging the septum to the left, reducing maximum volume. Reduced left-heart filling leads to a reduced
stroke volume which manifests as a decrease in systolic blood pressure, leading to a faster heart rate due to the baroreceptor
reflex, which stimulates sympathetic outflow to the heart.
Under normal physiologic conditions the large pressure gradient between the right and left ventricles prevents the septum from
bulging dramatically into the left ventricle during inspiration. However, such bulging does occur during cardiac tamponade
where pressure equalizes between all of the chambers of the heart. Following a zero-sum game principle, as the right ventricle
receives more volume it can push the septum into the left ventricle reducing its volume in turn. This additional loss of volume
of the left ventricle that only occurs with equalization of the pressures (as in tamponade) allows for the further reduction in
volume, so cardiac output is reduced, leading to a further decline in BP.
A third mechanism may additionally contribute. The large negative intra-thoracic pressure increases the pressure across the
wall of the left ventricle (increased transmural pressure, equivalent to [pressure within ventricle] - [pressure outside of
ventricle]). This pressure gradient, resisting the contraction of the left ventricle, causes an increase in afterload. This results in
a decrease in stroke volume, contributing to the decreased pulse pressure and increased heart rate as described above.
Pulsus paradoxus occurs not only with severe cardiac tamponade, but also with asthma, obstructive sleep apnoea and croup.
The mechanism, at least with severe tamponade, is likely very similar to those of hypertrophic and restrictive cardiomyopathies
(diastolic dysfunction), where a decrease in Left Ventricular (LV) filling corresponds to an increasingly reduced stroke volume.
In other words, with these cardiomyopathies, as LV filling decreases, ejection fraction decreases directly, yet non-linearly and
with a negative concavity (negative first and second derivatives). Similarly, with tamponade, the degree of diastolic dysfunction
is inversely proportional to the LV end-diastolic volume. So, during inspiration, since LV filling is lesser relative to that during
expiration, the diastolic dysfunction is also proportionally greater, so the systolic pressure drops >10 mmHg. This mechanism
is also likely with pericarditis, where diastolic function is chastened.

Measure jugular venous pressure (JVP), which can be raised in

cardiac tamponade due to severe uremic pericarditis
fluid overload (with normal waves of JVP)

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Palpate apex beat, which may be displaced in fluid overload causing ventricular dilation
Auscultate for
Mid-s stolic flo murmur/ innocent murmurs
S3 or S4
Pericardial friction rub
Check for pitting oedema
Respiratory System
Measure respiratory rate
Percuss chest to detect pleural effusions, which may be due to fluid overload or hypoalbuminemia
Auscultate for bilateral basal lung crepitation (pulmonary oedema)

Urine Dipstick Test

Obtain urine sample (mid-stream, clean catch specimen)

Instructions to collect urine sample (if the task states to do so)
For female patients,
You may be given a special clean-catch kit that contains sterile wipes.
Sit on the toilet with your legs spread apart. Use two fingers to spread open your labia.
Use the first wipe to clean the inner folds of the labia. Wipe from the front to the back.
Use a second wipe to clean over the opening where urine comes out (urethra), just above the opening of the vagina.
To collect the urine sample:
Keeping your labia spread open, urinate a small amount into the toilet bowl, then stop the flow of urine.
Hold the urine cup a few inches (or a few centimetres) from the urethra and urinate until the cup is about half full.
You may finish urinating into the toilet bowl.

For male patients,

Clean the head of the penis with a sterile wipe. If you are not circumcised, you will need to pull back (retract) the foreskin first.
Urinate a small amount into the toilet bowl, and then stop the flow of urine.
Then collect a sample of urine into the clean or sterile cup, until it is half full.
You may finish urinating into the toilet bowl.

Check patient s identit on the urine specimen bottle

Inspect urine for any obvious abnormalities (cloudiness, redness, salt particles etc.)
Check urine test strip s e pir date stated on the outside of the container
Place 2 layers of tissue papers on the table, open the test strip container, take one out by holding the reagent-free end, and close
the container immediately
Compare the colours of the strip taken out with the colours shown on the strip. Check whether initial colours of the strip to be used
is normal
Wash hands and wear gloves
Open the cap of the urine specimen bottle, immerse the strip completely into the urine, and remove immediately. Check the strip
container for reacting time for each reagent
Remove the strip from the urine and place it on the tissue
Wait for maximum reacting time (2 minutes if not mistaken), then compare with the reference colour panels on the strip container
Document results and dispose all waste into clinical waste bin

Urinary Catheterisation
Let us pray that it will not come out for Semester 5 OSCE
The following steps are taken straight from the CSSC old manual

For male patient,

Introduce yourself to patient (full name and role), explain the purpose of the procedure, explain steps of the procedure, privacy
ensured, obtain consent
Lie patient supine with his legs slightly separated - check for distended urinary bladder by abdominal palpation and percussion.
Wear your mask and open the sterile set using aseptic technique.
Arrange equipment and pour cleansing lotion.
Place protective sheet under patient.
Wash hands and put on sterile gloves.
Place a collecting vessel (e.g. kidne dish) in bet een the patient s legs.
Clean the penis thoroughly; retract the prepuce and clean the urethral meatus, scrotum and suprapubic area.
Drape so that only the penis is exposed.
Hold the penis upright with gentle traction; squeeze anaesthetic and/or lubricant jelly into the urethra and occlude it with pressure
from a gauze.

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Introduce the tip of the urinary catheter into the urethra using non-touch technique, and advance the catheter slowly until the end
arm of the catheter is up to the meatus.
Check that urine is flowing from the catheter and allow the urine to drain.
Pinch and withdraw the catheter when the flow ceases while patient takes a deep breath. Dry the genitalia
If the catheter is to be left in situ:
Inflate the bulb of the Fole s catheter ith the required amount of sterile water.
Gently pull on the catheter until resistance is felt.
Connect the catheter to the connector head of the urine bag.
Secure the connections.
Anchor catheter at the inner thigh with adhesive tape.
Stabilize the catheter, tubing and bag.
Record volume and colour of urine in the bag; send urine sample for analysis if warranted.
Remember to reposition the prepuce/ foreskin.
Clean the penis and scrotal region.
Dispose all used disposable plastic materials and gloves into the medical waste bin, clear trolley and finally wash hands.
If the catheter is not left in situ, record the volume and colour of urine drained; send urine sample for analysis if warranted

For female patient,

Introduce yourself to patient (full name and role), explain the purpose of the procedure, explain steps of the procedure, privacy
ensured, obtain consent
Lie patient supine with his legs slightly separated - check for distended urinary bladder by abdominal palpation and percussion.
Wear your mask and open the sterile set using aseptic technique.
Arrange equipment and pour cleansing lotion.
Place protective sheet under patient.
Position the patient with her thighs apart and knees flexed.
Wash hands and put on sterile gloves.
Lubricate tip of the urinary catheter and place it in a kidney dish.
Drape the patient, then clean the genitalia thoroughly.
With one hand still separating the labia majora, place the kidney dish in bet een the patient s thighs.
Introduce the tip of the urinary catheter into the urethra while the patient takes a deep breath, and advance the catheter approximately
5 to 7.5 cm into the urethra (adult).
Check that urine is flowing from the catheter and allow the urine to drain.
Pinch and withdraw the catheter when the flow ceases while patient takes a deep breath. Dry the genitalia
If the catheter is to be left in situ:
Inflate the bulb of the Fole s catheter ith the required amount of sterile water.
Gently pull on the catheter until resistance is felt.
Connect the catheter to the connector head of the urine bag.
Secure the connections.
Anchor catheter at the inner thigh with adhesive tape.
Stabilize the catheter, tubing and bag.
Record volume and colour of urine in the bag; send urine sample for analysis if warranted.

Clean the genital area

Dispose all used disposable plastic materials and gloves into the medical
waste bin, clear trolley and finally wash hands.
If the catheter is not left in situ, record the volume and colour of urine drained;
send urine sample for analysis if warranted

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Examples of Case Scenarios for Practice
Case 1****
Ms K, a 55-year-old diabetic lady, presented with dysuria, fever and flank pain.

Perform relevant abdominal examination on her and report your findings.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

General inspection: does the patient appear to be very ill? -
Inspection of abdomen for any masses in hypochondriac regions, and other things such as movement of abdomen during /2
respiration etc.
Palpation of the 9 regions of abdomen, superficial and deep with correct technique and sufficient exposure /3
Bimanual palpation with balloting of both kidneys with correct technique /4
Place left hand belo patient s back belo the lo er ribs and right hand anteriorl over the upper quadrant just lateral to
the rectus muscle (correct area of placement of hands)
Firmly, but gently push hands together as patient breathes out.
Ask patient to breathe in deeply, and feel for the lower pole of kidney moving down between two hands.
Gently push the kidney back and forwards between two hands to demonstrate its mobility
Identifying renal angle, and perform renal punch /3
Percussion of 4 quadrants in the abdomen /1
Omit bladder percussion /1
Omit renal artery stenosis auscultation -
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 20 marks

Case 2***
Mr L, a 68-year-old man, who was diagnosed with Benign Prostatic Hyperplasia some time ago, presented with acute urinary retention.

Examine his abdomen and report your findings.

Ans: general abdominal examination + focused palpation of suprapubic region for distended bladder + percussion of bladder

Case 3***
Mr M, a 60-year-old man, who has had longstanding hypertension and diabetes mellitus, is currently having reduced urine output, shortness
and breath and noticed swelling of ankles.

Perform relevant general physical examination to look for signs of chronic kidney disease and report your findings.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

General inspection: mental state, build and nourishment, check for any sallow appearance, any respiratory distress, any uremic /3
fetor
Hands: palmar creases pallor, beau lines, Muehrcke s lines, half-and-half nails, flapping tremor, gouty tophi, mention carpal tunnel /4
syndrome
Arms: petechiae or bruising, pigmentation, scratch marks /2
Mention vitals /1
Eyes: conjunctival pallor /2
Legs: petechiae, ankle oedema, mention checking for peripheral neuropathy /2
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 20 marks

Case 4****
Ms N, has visited the GP clinic that you are attached to due to dysuria, urgency and vaginal discharge.

1. Give instructions to this patient to collect a midstream, clean-catch urine sample

2. Perform a urine dipstick test on the provided urine sample

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Challenging Task that probably w come out in OSCE*****
Case
Mr M, a 60-year-old man, who has had longstanding hypertension and diabetes mellitus, is currently having reduced urine output, shortness
and breath and noticed swelling in ankles.

Perform relevant chest examination for Mr M to look for signs of fluid overload.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

General inspection: mental state, build and nourishment, check for any sallow appearance, any respiratory distress, any uremic /2
fetor, any cyanosis
Chest inspection /1
Apex beat palpation with demarcation /2
Measure JVP using correct technique /3
Chest percussion (either anterior or posterior chest) to check for pleural effusion +2
marks
Auscultate for heart sounds, hether additional heart sounds and flo murmur are present, ith reference to carotid arter /2
pulsation
Auscultate lung bases for any crepitation due to pulmonary oedema /2
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 18 (+ 2) marks

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Endocrine System

Fundoscopic Examination
*commonly used to check for hypertensive and diabetic retinopathy, and to check for papilledema in cases of increased intracranial pressure
*also performed after the neurological assessment of the eye (CN2,3,4,6)

Steps for the Examination

Introduce yourself to patient (full name and role), explain the purpose of the procedure, explain steps of the procedure, privacy
ensured, obtain consent
Explain to patient about the procedure, whereby you will be using the ophthalmoscope to examine the eyes. The room lights will be
dimmed. You ill need to shine a light into the patient s e es and advise patient to inform if light beam gets too bright or uncomfortable.

First, look at the external appearance of the eye observe for any swelling, redness, scars, discharge
Darken the room, switch on the ophthalmoscope light and turn the lens disc until you use see the large round beam of white light.
Shine the light on the back of your hand to check the type of light, its desired brightness and the electrical charge of the
ophthalmoscope.

Turn the lens disc to the 0 diopter. (A diopter is a unit that measures the power of a lens to converge or diverge light). Keep your
finger on the edge of the lens disc so you can turn the disc to focus the lens when you examine the fundus.
Instruct patient to focus their gaze on a distant object to help prevent constriction of pupils from accommodation. Tell patient to blink
and breath normally.
Hold the ophthalmoscope on your right hand and use your right eye to examine the patient s right e e, hold it in our left hand and
use our left e e to e amine the patient s left e e. This keeps ou from bumping into the patient s nose and gives ou more mobility
and closer range for visualizing the fundus.

Hold the ophthalmoscope firmly braced against the medial aspect of your bony orbit with handle tilted laterally at about a 20-degree
slant from vertical. Make sure you can see clearly through the aperture.
Place yourself about 30cm away from patient and an angle of 15 degrees lateral to patient s line of vision. Shine the light beam on
the pupil and look for an orange glow in the pupil - red reflex. Note any opacities interrupting the red reflex.

Keeping the light beam focused on the red reflex, move in with the ophthalmoscope on the 15- degree angle toward the pupil until
ou are ver close to it, almost touching the patient s e e lashes.
Inform patient about coming closer to them. You may also need to lower the brightness of the light beam if the examination is too
uncomfortable for the patient.
First locate the optic disc. Look for the round yellowish- orange structure. If you do not see it at first, follow a blood vessel centrally
until you do. You can tell which direction is central by noting the angle at which the vessels branch and vessels becomes larger when
approaching the disc.
Now focus on the optic disc. If you have no refractive error, the retina should focus on 0 dioptres. If you are myopic (near-sighted),
rotate the lens disc counter-clockwise to the minus dioptres (red) and if you are hyperopic (far sighted), move the disc clockwise to
plus dioptres (green). Use the same method if the patient has refractive error.
Inspect the optic disc: Note the sharpness or clarity of the disc outline or margins, colour of the disc and cup-disc ratio. Detect
papilledema (swelling of the optic discs and anterior bulging of the physiologic cup).

Inspect the retina (nasal and temporal), including arteries and veins as they extend periphery and the macula. Arteries are light red
and smaller with brighter light reflex. Vein is dark red, larger with absent light reflex. Identify any lesions like haemorrhages, exudates,
new vessels, cotton wool spots and photocoagulation scars. Note their shape, size, colour and distribution.

Inspect the fovea and surrounding macula by directing your light beam laterally or by asking the patient to look directly into the light.
Look for any similar lesions.
Examine the other eye.
Report your findings

Using a Glucometer

Preparing patient Explain to patient about the procedure (requires a small prick to draw a bit of blood) and the importance in
monitoring blood sugar level
Prepare all equipment glucometer, test strip (check expiry date), lancet, alcohol swab and cotton
Wash hands. Warm patient s hands
Place a test strip in the machine. The machine will be activated when blood is placed on the test strip
Ensure that patient s hand is dr . Wipe the area to be pricked ith the alcohol s ab and ait for it to dr
Prick the patient s fingertip using the lancet after choosing the needle si e
Collect the drip of blood onto the test strip which has already been placed in the machine
Wait for glucometer to show reading. Meanwhile blot the puncture site with cotton
Record patient s blood glucose reading
Disposal of waste (sharps and clinical waste) and hand washing after the procedure

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Neck Examination of Thyroid Gland (ada ed Ta e )
*have the patient sit with neck slightly flexed and neck muscles relaxed. Ensure sufficient exposure of neck and upper chest including clavicles
Inspection of the Neck
Normal thyroid gland may be just visible below the cricoid cartilage in a thin young person, and usually only the isthmus is
visible as a diffuse central swelling.
Look at the front and sides of the neck to check for any localised of generalised swelling of the thyroid gland in the neck. An
outward bulge suggests goitre (80% euthyroid, 10% hyperthyroid, 10% hypothyroid)
If swelling is present, comment on site, size, shape and symmetry
Check for scars (may be thyroidectomy scars), prominent distended veins and redness of overlying skin. Dilated veins over
the upper part of the chest wall, often accompanied by raised filling level/ filling of external jugular vein in the upper chest,
suggest retrosternal extension of the goitre causing thoracic inlet obstruction. Rarely, redness of overlying skin occurs in cases
of suppurative thyroiditis
Ask patient to protrude tongue, only thyroglossal cyst will rise.
Ask patient to swallow some water, and observe the neck swelling if present. Check if the swelling moves upwards with
swallowing. Only goitre and thyroglossal cyst will rise during swallowing due to attachment to larynx. Thyroid and trachea rise
about 2 cm as the patient swallows, pause for half a second then descend. Some non-thyroid masses can rise slightly during
swallowing but move up less than trachea, and fall again without pausing.

Palpation
Palpate the thyroid gland from behind. Ensure patient s neck is slightly flexed to relax the SCM
Place both hands with the pulps of the fingers over the gland just below the cricoid cartilage. Feel both lobes and the isthmus.
Feel one side at a time; use one hand to steady the gland and the other to palpate
Comment on the following:
size, shape (uniform or irregular)
consistency (soft, firm, rubbery? stony hard which suggests carcinoma, calcification in a cyst and fibrosis),
tenderness (which occurs in subacute lymphocytic thyroiditis etc.),
mobility (skin tethering suggests carcinoma),
thrills (when the gland is usually metabolically active)
Ask patient to swallow water. Meanwhile feel over the gland as it moves upwards.
Move to the front to palpate for localised swellings which are more easily defined from the front. Note the position of the
trachea, which may be displaced by retrosternal gland.
Also mention examining cervical lymph nodes for any swelling, and trachea for any deviation depending on case
scenario
Percussion
Percuss the upper part of manubrium and comment on the percussion note. Change from resonant to dull note indicates a possible
retrosternal goitre, however this is not a reliable sign
Auscultation
Listen over each lobe for any bruit, which is a sign of increased blood supply that may occur in hyperthyroidism, or occasionally
from the use of anti-thyroid drugs
Differentials - may be carotid bruit (but this is louder over the carotid artery itself)
It there is a goitre, apply mild compression to the lateral lobes and listen for any stridor

Pe be to test for thoracic inlet obstruction due to retrosternal goitre or other masses
Ask patient to lift both arms up as highly as possible
Wait for a while, and search the face for signs of congestion (plethora) and cyanosis, associated respiratory distress and
inspiratory stridor.
Look at the neck veins for distention which indicates venous congestion.
Ask patient to take a deep breath in through mouth and listen for stridor

Assessment of Thyroid Status

H = Hyper, L = Hypo

*if you are suspecting hyperthyroidism based on the case, look for signs of hyperthyroidism
If patient s th roid status is completel unkno n and ou are clueless, check for all

General inspection
Observe patient s nutritional status. Is the patient well nourished? HL
Does the patient appear calm, or anxious, restless and irritable? H
Does the patient appear disinterested, and sluggish? L
Does patient show any signs of weight loss or weight gain? HL
Does the patient have increased sweating? H
Does the patient have staring appearance which may indicate exophthalmos? H
Does the patient show enlargement of thyroid gland in the neck? HL

Hands
Upon contact, are the palms warm and sweaty (hyper), or cool and dry (hypo)? HL

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Any palmar erythema? H
Any pallor in the palmar creases? L
Any thyroid acropachy, and onycholysis? H
Check for any fine tremor by placing paper on outstretched fingers H
Check for signs of carpal tunnel s ndrome (Tinel s sign, Phalen test, and sensor of lateral 3 fingers, muscle wasting of thenar L
muscles)
Assess pulse. Any tachycardia and irregular rhythm (atrial fibrillation), or bradycardia? HL

Head and Face

Check patient s hair. An hair thinning and brittle hair (hyper), or dry coarse hair associated with alopecia (hypo) HL
Any coarse skin? L
Any loss of outer third of eyebrows? L
Any periorbital oedema? L
Inspect eyes for puffy eyelids, lid retraction, exophthalmos from the side of the patient, complications of proptosis such as H
conjunctival chemosis (oedema of conjunctiva and injection of sclera), conjunctivitis, corneal ulceration
Test for any lid lag H
Inform patient to keep head still and follow your fingers with his eyes
Hold finger high and ask patient to follow your finger as it descends from upper to lower part of visual field
If lid lag is present, the descent of the upper lid lags of the eyeball, and there is increased visibility of sclera during eye
movement
Test for ophthalmoplegia, weakness of ocular muscles, complication of proptosis, through H test H
Stand at patient s opposite at roughl one arm s length distance
Move fingers in H shape, and instruct patient to follow using eyes without moving their head
Check eyeball movement, and whether patient experiences any diplopia

Check patient s mouth for an macroglossia L

Check if patient has slow and coarse speech with hoarseness of voice L

Upper Limbs
Check proximal myopathy (just once will do) by asking patient to abduct shoulder against resistance HL
Check biceps reflex (just one reflex will do. Brisk reflex in hyper, delayed relaxation in hypo HL
Lower limbs
Check proximal myopathy by asking patient to cross their arms and stand up from sitting position without supporting using HL
arms and hands
Check knee reflex HL
Check for any pretibial myxoedema (infiltrative dermopathy in Graves disease) H
Check for any pitting oedema at the ankles L
Chest
Mention checking for any pericardial and pleural effusion L
If it is a case of a longstanding hyperthyroidism, mention check for signs of congestive heart failure H

Specific Examination for Acromegaly

Face (check the following)

Coarsening of features
Thick greasy skin
Enlargement of nose
Prognathism (protrusion of mandible) and separation of lower teeth

Limbs
Check for soft tissue enlargement and complications arising from it such as carpal tunnel syndrome
Eyes
Assess visual field for any bitemporal hemianopia
Measure blood pressure as hypertension is common

Specific Examination for Hypopituitarism

Inspection (check for the following)

Extreme skin pallor due to combination of mild anaemia AND melanocyte stimulating hormone deficiency
Absent axillary hair caused by deficiency of adrenal androgens
Reduced or absent secondary sexual hair caused by deficiency of gonadotrophins
Testicular atrophy, or secondary breast atrophy
Hypophysectomy scar (transfrontal ones will be apparent, but not transphenoidal)

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IMU OSCE Students Notes ZhenZhe.2018 IMU-FPEPII
Eye Examination
Check for optic nerve function, any visual field defect, bitemporal hemianopia due to optic chiasm compression (refer to Nervous
System Module)
Check for any cranial nerve 3, 4, 6 defects due to tumour compressing cavernous sinus

Reflex
Check for any hung-up reflexes (delayed relaxation) by using ankle jerk for example. This is also seen in hypothyroidism

S ec c E a a C Syndrome

Hands
Assess skinfold thickness on the dorsum of hands using calipers. Normal skinfold should be thicker than 1.8mm
Check vitals hypertension
Have the patient to stand up
Have patient undress to underwear and inspect from front, back and sides. Note for any moonlike facies and central obesity.
Limbs appear thin despite sometimes very gross truncal obesity (mostly intraabdominal rather than subcutaneous fat)
Inspect for any bruising. Bruising is due to loss of perivascular supporting tissue in protein catabolism
Check for any excessive pigmentation on extensor surfaces as MSH and ACTH share the same precursor molecule
Check for proximal myopathy (Refer to Thyroid)
Inspect the back for buffalo hump, which is due to fat deposition over interscapular area
Palpate for bony tenderness of the vertebral bodies due to crush fractures from osteoporosis (cortisol has anti-vitamin D effect
and promotes negative calcium balance by increasing urinary calcium excretion, disrupting bone matrix)
Face and neck
Check for any facial plethora
Check for moonlike facies if not checked previously
Inspect for any acne and hirsutism
Examine visual fields for any signs of pituitary tumour
Abdomen
Check for any purple striae, which is due to weakening and disruption of collagen fibres in the dermis causing exposure of
vascular subcutaneous tissue
Palpate for any adrenal masses over the renal area (rare)
Palpate liver for any hepatomegaly which is due to fat deposition or rarely adrenal carcinoma deposit

S ec c E a a Add Disease

General Inspection
Look for signs of weight loss
Skin
Examine the entire skin surface for abnormal or excessive pigmentation, especially in sun-exposed areas and areas subjected to
trauma and pressure such as skin creases, buccal mucosa and recent scars
This is due to MSH in primary adrenal insufficiency
Blood pressure
Measure blood pressure, and test for any postural hypotension
Testing for Postural Hypotension
Positive test result: drop of more than 20mmHg in systolic pressure and/ or drop of more than 10mmHg in diastolic pressure within
2-3 minutes of standing up after lying flat for 5 minutes

General Endocrine Examination (adapted from Macleod)

*probabl on t come out in OSCE

Check the following Relevance

Does the patient appear to be restless and agitated, or slow and Hyperthyroidism and hypothyroidism
lethargic?
Measure height and weight to calculate BMI Central obesit in Cushing s s ndrome
Check for any thoracic kyphosis Osteoporotic vertebral collapse in Cushing s s ndrome
Inspect face and eyes for any staring appearance, moonlike facies, Cushing s s ndrome and h perth roidism
exophthalmos etc.
Inspect mouth for overgrowth of chin and tongue (acromegaly and Acromegal , h poth roidism, Addison s disease
macroglossia in h poth roidism) and for buccal pigmentation (Addison s)
Examination of hands
Handshake with patient Acromegaly
Any palmar erythema and sweating? Hyperthyroidism
Any soft tissue overgrowth? Acromegaly
Any palmar crease pallor, or pigmentation? H poth roidism, Addison s disease
Any thenar muscle wasting due to Carpal tunnel syndrome? Hypothyroidism

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IMU OSCE Students Notes ZhenZhe.2018 IMU-FPEPII
Examination of skin
Any abnormal pallor? Hypopituitarism
Any skin pigmentation? Addison s disease
Any plethora? Cushing s s ndrome
Inspect axilla and groin for acanthosis nigricans Insulin resistance and type II diabetes mellitus
Check whether patient has normal body hair (quality and amount) Hirsutism in PCOS, adrenal carcinoma
Loss of axillary and pubic hair in hypopituitarism
Assess pulse rate, rhythm and volume Tachycardia and atrial fibrillation in hyperthyroidism
Blood pressure measurement H pertension in Cushing s s ndrome,
phaeochromoc toma, Conn s s ndrome or primar
hyperaldosteronism
Postural hypotension in adrenal insufficiency
Examination of eyes
Any exophthalmos? Puffy eyelids? Lid retraction? Conjunctival Hyperthyroidism
chemosis?
Any periorbital oedema? Hypothyroidism
Assess visual acuity and field Pituitary tumour
Perform ophthalmoscopy Diabetes mellitus
Check for any macroglossia Hypothyroidism
Examine the neck for any goitre Thyroid disorders
Inspect for any gynaecomastia, and galactorrhoea (gently massage the Prolactinoma
tissue towards the nipple to see if milk is expressed)
Examination of abdomen
Any purple striae? Cushing s s ndrome
Any palpable mass? Adrenal tumour (however be careful if suspecting
phaeochromocytoma as palpation can cause
hypertensive paroxysm)
Inspect legs for any pretibial myxoedema Hyperthyroidism
Check for any proximal myopathy in upper or lower limbs Thyroid disorders
Check reflexes Thyroid disorders
Examine feet for signs of diabetic neuropathy, ischemia Diabetes mellitus

Specific Examination for Diabetes Mellitus

Refer to Nervous System Module for Diabetic Foot Examination

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IMU OSCE Students Notes ZhenZhe.2018 IMU-FPEPII
Examples of Case Scenarios for Practice

Case 1****
Ms O, noticed a progressive uniform swelling in her anterior neck.

Examine this patient to assess her thyroid status.

Ans: Check for both hyperthyroidism and hypothyroidism

Case 2***
Mr P, who has a strong family history of Graves disease, came in complaining of restlessness, palpitation and excessive sweating.

Perform relevant examination to assess his thyroid status.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

General inspection: nutritional status, weight loss; any restlessness, agitated or excessive sweating, swelling in the neck /2
Hands: temperature and moisture of palm, palmar erythema, onycholysis, thyroid acropachy, fine tremor /4
Mention assessment of pulse for atrial fibrillation /2
Head and face: any hair changes? Inspect Eyes: exophthalmos, lid retraction, puffy eyelids, conjunctival chemosis etc. /3
Test for lid lag and ophthalmoplegia /4
Check for proximal myopathy and reflex (one each) /2
Inspect lower limbs for any pretibial myxoedema /2
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 25 marks

Case 3****
Mr Q, who has a strong family history of thyroid cancer, notices a painless swelling on his neck.

Examine his neck and report your findings. You do NOT need to examine the trachea.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Inspection of neck. Check for any surgical scars, prominent distended veins and redness of overlying skin etc. Ask patient to /4
protrude tongue and swallow some water.
Palpation of thyroid gland at its correct location, ith patient s neck slightl fle ed to rela neck muscles /3
Ask patient to swallow water during palpation /1
Omit percussion -
Palpation of lymph nodes in the neck: anterior superficial and deep and posterior cervical lymph nodes /3
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 17 marks

C a e Ta a P bab W C e OSCE
Case*****
Mr R, has experienced visual field defect and notices purple striae in his abdomen

E amine this patient to look for signs of Cushing s disease.

At the 6th minute, the examiner will ask you one question.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

General inspection for obvious features of Cushing s s ndrome -
Measure blood pressure /2
Check for any bruising, acne, buffalo hump, excessive pigmentation of skin, moonlike facies, facial plethora, hirsutism (women) /4
Examine eyes (visual field) to check for any bitemporal hemianopia /3
Check for any proximal myopathy (upper or lower limbs) /2
QUESTION: Give 2 causes of Cushing s s ndrome /2
Ans: Exogenous steroid use, Pituitary tumour, adrenal tumour, ectopic ACTH release
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 19 marks

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Reproductive System

Antenatal Examination (Booking Visits)

*examination sequence may differ
*before examination, measure height and weight to calculate BMI, and ask patient to empty her bladder
*have the patient to lie flat on a pillow, abdomen exposed from xiphisternum to pubic symphysis

General inspection (spend minimum time)

Is the patient in any pain or distress?
Measure blood pressure
Inspection of Abdomen
Note for any scars, particularly from previous caesarean section, linea nigra, striae gravidarum
Note swelling of uterus arising from pelvis
Note for any other swellings
Note for any obvious foetal movements

Pa a Abd e (a a b e e a e e e )
After telling patient to inform you about any tenderness, lightly palpate the 9 regions of abdomen as you would in
gastrointestinal system, by using the flat of your hand
Pay extra attention to the uterine swelling, and gently flex your fingers to palpate the upper and lateral edges of the firm mass
Note for uterine consistency, any tenderness or guarding outside the uterus, and any uterine contraction
Estimate whether liquor is sufficient and normal (based on experience) by assessing how far from the surface the foetal parts
are. If can only be felt on deep palpation, there is large amount of fluid (probably polyhydramnios)
*Palpate lightly to avoid triggering myometrial contractions which make foetal parts difficult to feel. Avoid any deep palpation of any
tender areas of uterus
For the 3 manoeuvres, ensure that you palpate deep enough. Foetal parts cannot be felt without adequate pressure
Fundal Grip
Face the patient s head, and place both hands on either side of the fundus and feel the foetal parts
Attempt to ballot the foetus, and check whether the foetal part at the fundal end is ballotable or not
Lateral Grip
Feel both sides of uterus one at a time. To feel for the left side of abdomen, use left hand to gently push and firmly secure the
right side, and feel the left side gently using your right hand. Repeat for the other side.
The side which is fuller suggests the foetal back is on that side.
Pelvic Grip
No face the patient s legs, place hands on either side of the uterus, ith left hand on patient s left side, and feel the lower
part of the uterus by applying firm pressure towards the midline, to try and identify the presenting foetal part.
Ballot the foetal part (e.g. head) by pushing it gently from one side to the other and feel it moving between fingers. Note the
consistency.

Head vs Buttock of Foetus

Head Buttock
Hard, round and globular Firm, broader
Ballotable Non-ballotable

After the above 3 manoeuvres, determine foetus lie and presentation:

Lie
Lie is the relationship of the long axis of the foetus to the long axis of the uterus
Longitudinal lie: the head or the buttocks/feet (breech) of the foetus may be palpable over or in the pelvic inlet.
Oblique lie: when the long axis of the foetus is at an angle of 45° to the long axis of the uterus.
Transverse lie: the foetus lies at right angles to the mother.

Presentation
refers to the part of the foetus that occupies the lower pole of the uterus.
determine whether the presentation is cephalic (head), breech (buttocks or feet) or shoulder. At term, 95% of babies present
by the head

Measurement of Symphysial-Fundal Height (after 20 weeks)

SFH represents the distance between the fundus of the uterus to the (superior border of the) pubic symphysis
To locate the fundus of the uterus, palpate the highest point of the uterus (the fundus) by using the ulnar border of the left
hand and moving it downwards from below the xiphisternum until the fundus is located.

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To locate the pubic symphysis, palpate downwards in the midline starting from a few centimetres above the pubic hair margin.
Fix the measuring tape at the highest point on the fundus (not always in the midline), and measure to the top of the pubic
symphysis. To avoid bias, place the centimetre side of the tape downwards. Lift the tape and read the measurement on the
other side (in cm)
Station and Engagement in late pregnancy or labour
Station and engagement tells us how far descended the foetal head is within the pelvic cavity. The station of the head is
described in fifths above the pelvic brim. The head is engaged when the greatest transverse diameter (biparietal diameter)
has passed through the inlet of the true pelvis.
The estimated number of fifths of foetal head palpable through the abdominal wall indicates the station. Generally, if it is less
than three-fifths palpable, then the bab s head is probabl engaged.
To determine the station of the foetus during OSCE, place fingers above the pubic symphysis and identify the number of
fingers used to palpate the head of foetus. Convert this to the number of fifths of foetal head above pelvic brim

Auscultation of Foetal Heart

Palpate the anterior shoulder of the foetus once the lie and presentation of the foetus has been determined. A shallow groove
palpable between the presenting part and rest of the foetus helps to identify the anterior shoulder.
Facing the mother s feet, place the Pinard stethoscope over this area.
Put the left year against the ear piece and press against the maternal abdomen gentle to keep it in place.
Hands off the stethoscope.
Count the fetal heart rate for 1 minute/30 seconds.
Report the rate and rhythm of the foetal heart sounds.
Normal foetal heart rate is between 110 160 beats/minute.
Pinard stethoscope is not useful before 28 weeks.
Electronic hand-held Doppler is useful as early as 14 weeks.

General Guide for Intimate Examinations (such as DRE and Pap Smear)
*please read for better patient communication and empathy

Explain why the examination is necessary and allow much opportunity for patients to ask questions
Explain what the examination will involve, in a way the patient can understand and have a clear idea of what to expect, including any
potential pain or discomfort.
Obtain the patient s permission before the e amination and be prepared to discontinue if the patient asks ou to
Record the permission that has been obtained (consent form)
Keep discussions relevant and avoid unnecessary personalized comments
Ensure a chaperone is present with you during the examination.
Give the patient privacy to undress and dress and use drapes to maintain the patient s dignit . Do not assist the patient in removing
clothing unless you have clarified with them that your assistance is required.

Pap Smear and Pelvic Bimanual Palpation

*This document only describes the procedure of liquid-based cytology
Recommendation for Pap Smear Screening by American Cancer Society
All woman should begin cervical cancer screening at age 21.
Women between the ages of 21 and 29 should have a pap smear test every 3 years. They should not be tested for HPV unless it is
needed after an abnormal pap smear test.
Women between the ages of 30 and 65 should have a pap smear test and HPV test every 5 years. This is a preferred approach but having
a pap smear test alone every 3 years is also acceptable.
Women over the age of 65 who have had regular screenings with normal results should not be screened for cervical cancer. Women who
have been diagnosed with cervical pre-cancer should continue to be screened.
Women who had their uterus and cervix removed in a hysterectomy and have no history of cervical cancer or pre-cancer should not be
screened.
Women who have had the HPV vaccine should still follow the screening recommendations for their age group.
Women who are at elevated risk for cervical cancer may need to be screened more often.

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Steps for the Procedure
*al a s check patient s face for signs of discomfort
Introduce yourself, explain purpose of procedure (for early detection of cervical cancer)
Explain briefly how the procedure will be carried out:
The patient needs to undress from waist downwards and underwear removed.
A small instrument is inserted into the private part to take some cells from the entrance of the womb and will be smeared to a
glass for testing.
The procedure may be slightly uncomfortable.
The patient may also notice some spotting after the procedure.
Ensure privacy, confidentiality and presence of female chaperone, and obtain consent
Ask patient:
When was the first day of her last period? (pap smear best done during midcycle)
Did she practise douching, use any vaginal medication and was she involved in sexual intercourse in the past 24 hours?

Position patient with adequate exposure:

Position the patient into a lithotomy position. The patient rests supine with the knees drawn up and separated or in stirrups, with the
buttocks to the edge of the table.

Label the specimen container ith patient s details, and fill up the c tolog form
Adjust lighting for better visualisation of vulva and vagina
Wash hands, wear gloves and prepare equipment: speculum, normal saline, swabs/ gauze and broom
Drape sterile to el under patient s buttocks
Inspect external genitalia for any abnormalities, such as bleeding / discharge, rashes, skin lesions, ulcers, swelling, mass or growth.
Have the patient strain to look for prolapse of vaginal walls and involuntary leakage of urine.
Wet the speculum with normal saline. No need to clean the external genitalia using swabs
Hold the speculum with the right-hand index finger hooked on the top blade.
Part and hold the lips of the labia minora apart with the left hand, insert the speculum with its blades closed into the introitus with the
widest part dimension of the instrument in the transverse position as the vagina is widest in this direction.
Alternately, place gently the left index finger inside the introitus and press it downwards. When the muscles relax, place the left
middle finger inside the introitus to separate the labia minora widely and insert the speculum with blades closed in the horizontal
position into the vaginal canal.

Insert the speculum forward and downward until it nearly touches the cervix.
Open the blade slowly and gently to completely visualize the cervix.

Lock the speculum in place once you have the cervix clearly in view. If unable to visualize the cervix, just move the speculum forward
and backward and sweep it up so that blades can encircle the whole cervix.

Inspect the cervix. Note any gross cervical lesions such as erosions, ulcers, growths or mass. Observe the size and shape of the
cervical os. If there is discharge or mucus, take swab for microscopic examination and culture and sensitivity if indicated.

Insert the centre of the plastic broom into the cervical os and rotate the broom 5 times through 360 degrees in a clockwise direction
Remove the broom:
For SurePath: Insert the broom into the larger opening of the vial. Rotate the broom 90° to use the inner edge of the insert to pull off
the broom into the vial.

For ThinPrep: Rinse the broom by pushing it into the bottom of the vial 10 times, forcing the bristles apart. Then, swirl the broom
vigorously to release more material.

Place the cap on the vial and tighten firmly

Unlock the speculum and remove it slowly while inspecting the vaginal wall. Leave the blades open all the way while inspecting the
vaginal wall. Ensure that the cervix or vaginal tissue are not trapped between the blades as you remove. Allow the speculum to close
by itself as it is almost out of the vagina (by weight of the right index finger hooked around the upper blade)

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Bimanual Palpation (a a c ec a e c )
Lubricate the index and middle fingers of your right hand.
Using the thumb and index finger of the left hand, separate the labia minor and gently open the introitus.
Gently insert the fingers into the vaginal canal. If the patient is tense, introduce the index finger initially and when the vaginal muscles
relax, insert the middle finger. Other fingers must be held outside the vaginal orifice and ensure that the thumb and other fingers to
be tucked in the palm of your hand.

Assess the vagina in transit until the cervix is located. Feel the vaginal mucosa and note any ulcers or growth.
Palpate the cervix and feel its consistency and whether there are any growths or polyps felt (if not visualized before).

Uterus
To examine the uterus, place the left hand over the suprapubic area. Gently press downwards at the pubic symphysis,
examining the pelvic organs between both hands.
Push your fingers into the posterior fornix and lift the uterus while pushing down your hand left hand towards the uterus,
palpating the uterus between both hands (see below). Note its size, shape, position, consistency, regularity and tenderness.
This may be felt well when the uterus is anteverted
If the uterus cannot be felt at this point, there may be a possibility that the uterus is retroverted. Confirm this by palpating the
posterior fornix to feel the uterus or running the fingers along the posterior vaginal wall to feel the uterus.

Use your vaginal fingers to push the cervix back and upwards, and feel the fundus with your
abdominal hand.

Then move your vaginal fingers into the anterior fornix and palpate the anterior surface of the uterus,
holding it in position with your abdominal hand.

To feel the adnexal masses, place the left hand over the right iliac fossa and apply gentle pressure downwards, sweeping the
pelvic organ downwards. In the same time, place the fingers of the right hand into the right laternal fornix and elevate the
fingers upwards to palpate the mass between both hands
The same step is repeated on the left iliac fossa.
If a mass is felt, describe the location, size, surface, consistency and tenderness.

Gently withdraw the fingers and inspect the glove for evidence of blood, discharge or pus.
Offer patient wipes to clean up and thank patient

Breast Examination by Medical Professional

*refer to Haematology Module for details of lump examination and describing a lump

Introduce yourself. Explain that examination involves exposure, touching breasts, check for any lumps etc.
Inspection of Breasts
The four positions for inspecting the breasts:
Ask patient to rest her hands on her thighs to relax pectoral muscles
Ask patient to press her hands firmly on her hips to contract the pectoral muscles
Ask patient to raise her arms above her head
Ask patient to lean forward to expose the whole breast and exacerbate skin dimpling

Check the breasts for any asymmetry and local swellings

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Look for any skin changes:
Erythema (mastitis)
Engorged veins (fibroadenoma, sarcoma)
Skin dimpling (breast cancer)
Peau d orange (classical sign of cancer from blockage of subcuticular lymphatics leading to oedema of skin which deepens
mouths of sweat glands and hair follicles)
Nodules (often metastatic)
Ulceration and fungation (advanced carcinoma)

Inspect nipple for any changes:

Symmetry in size and shape
Retractions/ cracks/ fissures
Ulcers
Rash
Discharge
Number of nipples present

Palpation of the Breasts

Ask patient to lie down flat or at 45 degrees on a pillow, with her hand under her head on the side to be examined

Hold our hand flat to patient s skin and palpate breast tissue using palmar surface of middle 3 fingers. Compress breast tissue
firmly against chest wall
View breast as a clock face. Examine in a clockwise direction from outside towards the nipple.
Gently elevate the breast with your hand to uncover dimpling overlying a tumour which may not be obvious on inspection
Examine the axillary tail between finger and thumb as it extends towards the axilla
Palpate the areola
Palpate the nipple by holding it between index finger and thumb. Massage the breast towards the nipple, and gently squeeze
the nipple after warning patient to uncover any discharge. Note colour and consistency of any discharge, along with number
and position of affected ducts
If a mass is felt, note the following characteristics:
Site/ Size/ Shape
Surface
Margin
Consistency
Fluctuation
Mobility
Tenderness
Fixity (to the skin, to the breast tissue, to the underlying muscle and chest wall)

Fixity
Fixity to the skin could be tethered or fixed. Tethered means the malignant growth has infiltrated the fibrous septae called
Cooper s ligament and will be puckering (contract into wrinkles or small folds) but the lump can still be moved
independently to the skin. Fixed to the skin is when the growth has infiltrated the skin. Here the skin cannot be pinched.
Fixity to the underlying muscle or chest wall to test this, place the patient s hands on her hips and hold the mass
between your thumb and forefinger. Ask her contract and relax the pectoral muscles by pushing into her hips.
Note whether the mass moves with the contraction of the pectoral muscles and separates when the muscle is relaxed.
If so, the mass is fixed to the muscles. If the mass does not move at all, means it has infiltrated the chest wall.

Palpation of Related Structures

Examine the axillary lymph nodes
Examine the cervical lymph nodes including supraclavicular lymph nodes
Comment if palpable mass is felt (Describe lump)

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Breast Self-E a a ( bab c e OSCE)
*Giving advice and instructions to patients
*I am only putting it here for fun

Instructions to be given to patients:

Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.
Here's what you should look for:

Breasts that are their usual size, shape, and color

Breasts that are evenly shaped without visible distortion or swelling
If you see any of the following changes, bring them to your doctor's attention:
Dimpling, puckering, or bulging of the skin
A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out)
Redness, soreness, rash, or swelling

Step 2: Now, raise your arms and look for the same changes.
Step 3: While you're at the mirror, look for any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow
fluid or blood).

Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your
right breast. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular
motion, about the size of a quarter.
Cover the entire breast from top to bottom, side to side from your collarbone to the top of your abdomen, and from your armpit to
your cleavage.
Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you
reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn.
This up-and-down approach seems to work best for most women. Be sure to feel all the tissue from the front to the back of your
breasts: for the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use
firm pressure for the deep tissue in the back. When you've reached the deep tissue, you should be able to feel down to your ribcage.

Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when
their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements
described in step 4.

Examples of Case Scenarios for Practice

Case 1****
Mrs S, a 30-year-old pregnant woman has begun to show signs of labour.

Equipment provided: sphygmomanometer

Tasks:
1. Measure her blood pressure
2. Examine her abdomen

Case 2****
Mrs T, a 50-year-old woman who had undergone total mastectomy of her left breast, noticed a lump on her right breast.

Examine her right breast and the relevant lymph nodes.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /2

Ensure privacy, chaperone, reassuring patient
Inspect right breast from the 4 positions /4
Comment on any asymmetry, gross swelling or dimpling, skin changes and nipple changes seen
Palpate the right breast using middle 3 fingers in a clockwise direction from outside towards nipple /6
Evaluate the swelling based on its size, shape, consistency and fluctuation, mobility and fixity, tenderness, overlying skin changes
Examine the nipple
Examine the tail of Spence
Examine the axillary lymph nodes on the right side /2
Examine the supraclavicular lymph nodes on the right side /1
Examine the other cervical lymph nodes /2
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 26 marks

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Musculoskeletal System

General Principles of Joint Examination

Look, Feel, Move, Special Tests and Function
Exposure: should include proximal and distal joint to the examined area
Some things to LOOK for
General appearance (symmetry)
Swellings
Erythema or change in colour
Deformity (compare with opposite side)
Muscle bulk
Scars (may be small, such as arthroscopy scars, or unobtrusive such as old and faded scars or in skin crease)
Attitude of the limbs, whether in symmetrical attitude or whether held in abnormal attitude on 1 side or both sides (attitude
normal position)
Draining sinuses

Some things to FEEL for

Temperature
Effusion and other swellings
Tenderness on anatomical structures - around site of tenderness identified by patient, over bony landmarks, along the joint
line (if accessible), at the attachments of muscles and ligaments
Crepitus during movement

Movements at Joints

When commenting on large joint movement, ensure that you mention active or passive, what movement, L or R side, and the angle from
neutral position (e.g. ranging from 0 to 80 degrees), and whether there is any pain experienced during each movement

Relevant Examination
If the OSCE task doesn t specif , and ask to perform relevant e amination of the certain bod part, remember Neurovascular structures
nearby
Perform neurological assessments (refer to Nervous System) and assess pulses (refer to Cardiovascular System)
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GALS Screening - Gait, Arms, Legs, and Spine (less likely to come out in OSCE)
*Sequence of examination may vary, everything is good as long as all aspects are being covered
*The following list is adapted from Macleod and the old CSSC manual

Screening Questions GALS

Any pain or stiffness in any muscle, joint or spine?
Are you able to dress and undress yourself? (upper limb function)
Are you able to walk up and down the stairs? (lower limb function)
Gait
Ask patient to walk for a certain distance, turn around and walk back G
Observe gait symmetry, stride length, smoothness, and ease of turning,
Normal heel strike, stance, toe-off, swing through pattern of gait
From Patie Bac
Inspect A, L, S
Shoulder muscle bulk and symmetry
Spine, whether there is scoliosis
Level of iliac crests
Hamstring bulk and symmetry
Calf bulk and symmetry
Achilles tendon swelling
Hind foot swelling or deformity
Palpate shoulder muscles for tenderness (supraspinatus is the first to be affected) A
Put hands on patient s hips, and ask patient to turn left and right (upper thoracic movement) S
F Pa e S de
Inspect
Normal spinal curves (cervical lordosis, thoracic kyphosis, lumbar lordosis) S
Hip or knee deformity (eg. Fixed flexion deformity of knee) L
Ask patients to bend and touch toes, place fingers on 2 adjacent lumbar vertebrae and ask patient to straighten up, check S
both fingers move together)
F Pa e Front
Inspect from anatomical position
Deltoid bulk and symmetry A
Full elbow extension bilaterally A
Normal carrying angle A
Quads bulk and symmetry L
Knee swelling or deformity L
Foot arches L
Midfoot and forefoot deformity L
Ask patient to open his mouth, and move jaw to both sides TM
Ask patient to slide hands down the leg (lateral flexion of the spine) S
Bend the neck and move head towards shoulder (cervical lateral flexion) S
Look up and down (cervical flexion and extension) S
Put both hands at the back of the head (shoulder abduction, external rotation, elbow flexion) A
With elbo s at the side and fle ed to 90 , pronate and supinate the arm A
Bend elbow and place both hands on shoulder (elbow flexion) A

Hands
Elbows ben 90 a d ea a ed
Inspect wrist and fingers (back of the hand) for swelling and deformities, and interossei wasting A
Squee e patient s metatarsal heads for tenderness A
Straighten arms and hands horizontally, and make a fist, and open hands flat (flexion and extension of all fingers) A

Eb be 90 a d ea a ed
Inspect palms for tendon sheath swelling, thenar and hypothenar wasting A
Prayer and reverse prayer (wrist flexion and extension) A
Squeeze 2 fingers of ours (power grip) A
Check pincer grip (ask patient to make OK sign and ask patient to not let us break open the ring) A
Check thumb opposition with all fingers for both hands A

With Patient Lying Supine

Place left hand below the back at the lumbar region, flex both hips passively and check for straightening of lumbar lordosis L
Put one leg down (check for fixed flexion deformity). L
Ask patient to actively flex one knee at a time while placing hand on knee to feel for crepitus. L
Ensure hip and knee are bent to 90 , check internal and e ternal rotation of hips L
Straighten both legs and perform patella tap to check for knee effusion L
Inspect foot, check sole for ulcers (abnormal load bearing) L
Squeeze metatarsal heads to check for tenderness L

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Shoulder Examination
*have patient to sit during Look, and stand during Feel and Move, and expose the shoulder completely
*sequence may vary slightly
Look
Examine from the front, the back and in the axilla for the following:
Any deformities such as loss of normal rounded contour? Are the shoulder levels equal on both sides? Check for any obvious
deformities of the anterior glenohumeral and complete acromioclavicular joint dislocation. Shoulder contour in posterior
glenohumeral dislocation may only appear abnormal when you stand above the seated patient and look down on the shoulder
swelling
Any swelling?
Any muscle wasting, especially deltoid, supraspinatus and infraspinatus? Wasting of supraspinatus and infraspinatus indicates
a chronic tear of their tendons
Size and position of scapula, e.g. is it elevated or depressed? Are both scapula symmetrical? Any obvious winging of the
scapula?
Other things to look for depending on case scenarios: open wounds, bleeding, bruising (e.g. if it is a case of a trauma or fall)
Feel
Use 2 fingers and palpate for tenderness, swelling, deformity in:
Sternoclavicular joint
Clavicle
Acromio-clavicular joint
Acromion
Head of humerus
Greater and lesser tuberosity of humerus.
Biceps tendon in the bicipital groove
Coracoid process (roughly 2 cm below and medial to the acromion)
Spine, medial border and inferior end of the scapula
Locating the biceps tendon in the bicipital groove
Stand behind the patient, place fingers slightly inferior to acromion process on the greater tuberosity, and externally rotate the
arm to feel fingers sliding into the bicipital groove
Tenderness upon palpation in the bicipital groove may indicate bicipital tendinitis. To confirm, ask patient to supinate forearm
and flex at the elbow joint against resistance. Pain will occur in bicipital tendinitis
Gently palpate shoulder muscles for any tenderness, especially supraspinatus which is usually first affected in a shoulder pathology
Extend the shoulder to bring the supraspinatus anterior to the acromion process, and palpate the supraspinatus tendon

Move
Active Movements
Instruct the patient to perform the following and observe:
Abduction (normally 0-180 degrees) bring one arm away from the side as far as possible, meanwhile you palpate the inferior
pole of the scapula between thumb and index finger to detect scapular rotation (can determine how much movement occurs
at glenohumeral joint). Then have patient to bring the arm down slowly while you watch the scapula movement for symmetry
and smoothness.
If glenohumeral joint is excessively stiff, movement of scapula over chest wall will predominate

True abduction of the arm, which takes the humerus from parallel to the spine
to perpendicular; and upward rotation of the scapula, which raises the humerus
above the shoulders until it points straight upwards

Adduction (normally 0-50 degrees) bring one arm at a time across the chest to opposite shoulder
Flexion and extension (Flexion normally 0-180 degrees, extension normally 0-60 degrees) bring both arms forward and to
the back as much as they can
External rotation (normally 0-90 degrees) tug elbows to the side, and swing both arms outwards
Internal rotation (normally 0-70 degrees) place hand (thumbs up) behind back and move thumb up along spine, note the
level of spinous process that the patient can reach (estimation e.g. jugular notch at T2, sternal angle at T4/T5)

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For all movements except internal rotation, comment on the range of movement with reference to the neutral/ anatomical position,
whether it is symmetrical on both sides and any associated pain (NOT tenderness).
E.g. active abduction of the left shoulder joint ranges from 0 to 170 degrees, however reduced on the right shoulder joint to only 140
degrees, or, active abduction of both shoulder joints is symmetrical ranging from 0 degrees to 160 degrees

Passive Movements (usually to evaluate reduced movements to check for any associated pain, AND crepitus)
Always inform patient to relax all muscles to be examined before passive movements, and let you move the joint for them
Stabilise the shoulder joint while performing the following movements for the patient:
Abduction abduct patient s arms one side at a time (lol)
Adduction stand at patient s side, rest patient s forearm on our forearm of the same side, and bring it across to the opposite
side of the chest
Flexion and extension of shoulder joint
External rotation from patient s back, hold patient s rists, tug their elbows to their sides, and move their arms outwards
Internal rotation ith the elbo s bent, place the patient s forearm at his back, and tr to lift the forearm and hand off the back
and see if it is possible to be performed without causing pain
Resisted Movements
To assess resisted movements, ensure that the joint is in the position of partial or full movement to be assessed
Initiating abduction ask patient to start abducting arm out from his side against your resistance. This tests supraspinatus
which initiates abduction (pain on forced abduction at 60 degrees suggests supraspinatus tendinitis)
Abduction ask patient to abduct arm out from his side, parallel to floor (elbows bent) and resist while
you push down on the humerus. This tests the deltoid muscle
Adduction ask patient to adduct arm partially, and resists your movement as you try to move the
arm out of the adducted position
External rotation ask patient to externally rotate against your resistance with elbows tugged to their
sides
External rotation (isolating infraspinatus and teres minor) test again with shoulder flexed at 30
degrees. Pain suggests tendinitis
Internal rotation place patient s arm at his back, ith elbo s bent, ask patient tr to lift his hand off his back against our force.
This tests subscapularis muscle
Special Tests (Preclinical Phase)
Painful arc test (impingement)
Passivel abduct the patient s arm full , and ask patient to lo er it do n slo l and inform whenever pain is felt and disappears
Pain occurring between 60 and 120 degrees of abduction occurs in painful arc
If the patient cannot initiate abduction, place hand over scapula to confirm that there is no scapular movement
Passively abduct the internally rotated arm to 30-45 degrees, and ask patient to continue to abduct the arm.
Pain on active movement especially against resistance, suggests impingement
Winging of Scapula
Ask patient to lean and place both hands on a wall. Look for any scapular winging, which suggests paralysis or weakness of serratus
anterior supplied by long thoracic nerve
Function
Have the patient to perform the following and observe:
Dress and undress
Get their hands to the back of the head, and between shoulder blades

Elbow Examination

Look
Have patient to stand in the anatomical position with both elbows extended and placed at the sides
Check the elbows for the following:
What is the patient s carr ing angle of elbo s in anatomical position? Normal is about 11-13 degrees
Look around the elbow joint for any swelling, bruising, scars
Check for any rash, tophi, rheumatoid nodules (on the proximal extensor surface of forearm)
Feel
Palpate bony landmarks: lateral and medial epicondyles, and olecranon tip. Focal tenderness over the epicondyles may
indicate epicondylitis (see below)
With elbow fully extended, feel for sponginess on either side of olecranon, and ask for tenderness. Synovitis feel spongy or
boggy when elbow is fully extended
Feel and compare temperature at both joints
Feel for any firm swellings in the elbow which may indicate bursitis
Move
Active Movements
Assess flexion-extension arc by asking patient to touch his shoulder on the same side and then straighten the elbow as far as
possible. (Normally 0-145 degrees).
Assess pronation and supination by asking patient to put his elbows by the side of the body and flex them to 90 degrees, and ask
him to turn hands upwards (supination) and downwards (pronation)

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Passive Movements
With one hand at the elbow, perform flexion and extension of the elbow joint and check for any pain and crepitus
Resisted Movements
Stabilise the elbow joint and ask patient to flex and extend his elbow against your resistance
Have the patient to put elbows by the side of his body, flexed to 90 degrees in the mid-prone position. Hold the patient s hands as if
you are handshaking, and ask patient to resist while you attempt to pronate and supinate the forearm
Special Tests
Lateral epicondylitis (tennis elbow)
Ask patient to fle elbo to 90 , pronate and fle hand and rist. Support patient s elbo and ask patient to e tend wrist against
resistance. Pain is produced at lateral epicondyle and may be referred down the extensor aspect of the arm if lateral epicondylitis is
present.
G e eb ( edial epicondylitis)
Fle elbo to 90 , supinate hand. Support patient s elbo and ask patient to fle rist against resistance. Pain is produced at the
medial epicondyle and may be referred down the flexor aspect of the arm if medial epicondylitis is present

Wrist and Hand Examination (more unlikely, but not impossible to come out in OSCE)
*have the patient to rest his hands on a pillow, or just a flat table will do
Look
Inspect the hands for any:
Colour changes such as erythema
Swelling of metacarpophalangeal (MCP) joints causing loss of indentation between knuckles, when all joints are fully flexed
Deformity (ulnar deviation, s an neck, boutonniere s deformit etc.)
Nodes and nodules
Extra-articular signs:
Small muscle wasting of interossei
Nail changes such as pitting nails (psoriasis), onycholysis (loosening of nail from nail bed) in psoriatic arthritis, splinter
haemorrhages in vasculitis
Feel
Feel for any swellings. Hard swellings are bony, soft swellings suggest synovitis
Using thumb and index finger of both hands, palpate above and below the interphalangeal (IP) joints to detect sponginess.
Sponginess suggests synovitis
Squeeze gently across the MCP joints to check for any tenderness or bogginess
Palpate the flexor tendon sheaths in the hands and fingers to detect local swellings or tenderness. If swelling detected, ask
patient to fle and then e tend the finger to see if there is triggering or locking (stenosing tenosynovitis)
Feel for crepitus later during active movements
Press on the anatomical snuffbox for any tenderness. Tenderness suggests scaphoid fracture
Move
Active Movements
Wrist flexion and extension ask patient to flex and extend the wrist (demonstrate for patient)
Wrist abduction ( radial deviation ) and adduction ( ulnar deviation )
Fingers flexion and extension ask patient to make a fist
and extend fingers fully.
Lack of full extension may indicate tendon rupture
Feel for crepitus by placing index finger across the fully
extended fingers and ask patient to open and close fingers
Thumb flexion and abduction demonstrate for the patient
Fingers abduction and adduction
Thumb opposition with other fingers
Remember to comment on the movements
Passive Movements
Wrist extension (normally 0-90 degrees) ask patient to put palms of his hands together and extend wrist fully (prayer sign)
Wrist flexion (normally 0-90 degrees) ask patient to put backs of his hands together and flex wrist fully (reverse prayer sign)
Move each finger through flexion and extension and notice any triggering or locking
Trigger Finger
One of the most common causes of hand pain and disability, the flexor tendon causes painful popping or snapping as the patient
flexes and extends the digit. The patient may present with a digit locked in a particular position, most often flexion, which may require
gentle, passive manipulation into full extension
Resisted Movements
Support the distal forearm and ask patient to flex and extend the wrist against your resistance
Check for thumb abduction against resistance
Check for finger abduction and adduction against resistance
Function
Assess power grip. Insert inde and middle finger into patient s palm and ask him to squee e as hard as possible. Attempt to
pull out your fingers to assess the strength of patient s grip
Assess pincer grip (assesses anterior interosseous nerve function). Ask patient to make an OK sign, hile ou attempt to
break open the ring formed b the patent s thumb and inde finger

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Assess key grip. Ask patient to press onto a blanket/ paper between thumb and the rest of the knuckle, while you attempt o
pull out the paper/ blanker from the patient s grip
Assess patient s manual dexterity by asking patient to perform thumb opposition at a high speed

Wrist and Hand with a Wound (examine the following structures)

Specific Muscles and Tendons
Flexor digitorum profundus ask patient to flex distal interphalangeal (DIP) joint while you hold the PIP joint in extension
Flexor digitorum superficialis hold the other fingers fully extended to eliminate action of flexor digitorum profundus which can
also flex PIP, and ask patient to flex the PIP joint
Extensor digitorum ask patient to extend fingers with wrist in neutral position
Flexor and extensor pollicis longus hold proximal phalanx of thumb firmly, and ask patient to flex and extend the IP joint

A flexor digitorum profundus

B flexor digitorum superficialis
C extensor digitorum
D flexor pollicis longus
E extensor pollicis longus

Specific Nerves
Use the Pa e -scissors-stone-OK sign. Ask patient to:
Fully extend wrist and fingers (paper). Radial nerve is responsible for wrist and finger extension
Make the scissors sign. Ulnar nerve supplies hypothenar muscles, interossei, medial two lumbricals, adductor pollicis, flexor
carpi ulnaris and ulnar half of flexor digitorum profundus
Clench fist fully (stone). Median nerve supplies thenar muscles that abduct and oppose the thumb, lateral two lumbricals, flexor
digitorum profundus 2&3, flexor digitorum superficialis, flexor carpi radialis, palmaris longus and pronator teres.
Make the OK sign to check for anterior interosseous nerve function. This nerve is a terminal branch of median nerve suppl ing
flexor pollicis longus, index finger flexor digitorum profundus, and pronator quadratus. Making OK sign depends on both flexor
pollicis longus and index finger flexor digitorum profundus functioning.
Refer to Nervous System for more details on examinations of specific peripheral nerve function
Specific tests for Carpal Tunnel Syndrome and Median Nerve (see this again in Nervous System chapter)
Check sensation over thumb, index and middle fingers and lateral half of ring finger
Check for any wasting in thenar eminence muscles
Test thumb abduction ith patient s held palm up on a flat surface, and ask patient to move thumb verticall against our
resistance (abductor pollicis brevis)
Test opposition by checking pincer grip
Perform Phalen test
The patient is asked to hold their wrist in complete and forced flexion (pushing the dorsal surfaces
of both hands together) for 30 60 seconds.
The lumbricals attach in part to the flexor digitorum profundus tendons. As the wrist flexes, the flexor
digitorum profundus contracts in a proximal direction, drawing the lumbricals along with it. In some
individuals, the lumbricals can be "dragged" into the carpal tunnel with flexor digitorum profundus
contraction. As such, Phalen's manoeuvre can moderately increase the pressure in the carpal tunnel
via this mass effect, pinching the median nerve between the proximal edge of the transverse carpal
ligament and the anterior border of the distal end of the radius. By compressing the median nerve within the carpal tunnel,
characteristic symptoms(such as burning, tingling or numb sensation over the thumb, index, middle and ring fingers) conveys
a positive test result and suggests carpal tunnel syndrome.
Perform Reverse Phalen test
This test is performed by having the patient maintain full wrist and finger extension for two
minutes. The reverse Phalen's test significantly increases pressure in the carpal tunnel within
10 seconds of the change in wrist posture and the carpal tunnel pressure has the tendency to
increase throughout the test's duration. In contrast, the change in carpal tunnel pressure noted
in the standard Phalen's test is modest and plateaus after 20 to 30 seconds
The extended wrist posture significantly changes the pressure within the carpal tunnel and may
be more useful as a provocative examination manoeuvre. Reverse Phalen's manoeuvre results
in a significantly higher intracarpal canal hydrostatic pressure as compared to a traditional
Phalen's. This is thought to add to the sensitivity of conventional screening methods
Check for any T e performed by lightly tapping (percussing) over the nerve to elicit a
sensation of tingling or "pins and needles" in the distribution of the nerve

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Brief Introduction to Gait
For assessment of gait, we would ask patient to walk to the end of the room, turn around and walk back while we observe
Inspect the s mmetr of the patient s gait. Is the stride length equal on both sides?
Inspect the smoothness of the patient s gait during heel strike, toe-off
When the patient reaches the end of the room, are they able to turn quickly without any issues?
Is each step of normal height? Increased stepping height is noted in foot drop
Is there any evidence of pain (antalgic gait)?

Some Gait Abnormalities

Antalgic gait An antalgic gait is a gait that develops as a way to avoid pain while walking. It is a form of gait abnormality where the
stance phase of gait is abnormally shortened relative to the swing phase. It can be a good indication of pain with
weight-bearing. Example of causes: osteoarthritis
Hemiplegic gait The patient stands with unilateral weakness on the affected side, arm flexed, adducted and internally rotated. Leg on
same side is in extension with plantar flexion of the foot and toes. When walking, the patient will hold his or her arm to
one side and drags his or her affected leg in a semicircle (circumduction) due to weakness of distal muscles (foot drop)
and extensor hypertonia in lower limb. This is most commonly seen in stroke. With mild hemiparesis, loss of normal
arm swing and slight circumduction may be the only abnormalities.
Diplegic gait Patients have involvement on both sides with spasticity in lower extremities worse than upper extremities. The patient
walks with an abnormally narrow base, dragging both legs and scraping the toes. This gait is seen in bilateral
periventricular lesions, such as those seen in cerebral palsy. There is also characteristic extreme tightness of hip
adductors which can cause legs to cross the midline referred to as a scissors gait. In countries with adequate medical
care, patients with cerebral palsy may have hip adductor release surgery to minimize scissoring.
Neuropathic gait Seen in patients with foot drop (weakness of foot dorsiflexion), the cause of this gait is due to an attempt to lift the leg
(Steppage gait, high enough during walking so that the foot does not drag on the floor. If unilateral, causes include peroneal nerve
Equine Gait)/ palsy and L5 radiculopathy. If bilateral, causes include amyotrophic lateral sclerosis, Charcot-Marie-Tooth disease and
High stepping other peripheral neuropathies including those associated with uncontrolled diabetes.
gait
Trendelenburg Hip girdle muscles are responsible for keeping the pelvis level when walking. If you have weakness on one side, this
gait will lead to a drop in the pelvis on the contralateral side of the pelvis while walking (Trendelenburg sign and gait).
With bilateral weakness, you will have dropping of the pelvis on both sides during walking leading to waddling. This
Myopathic/ gait is seen in patient with myopathies, such as muscular dystrophy.
waddling gait
Hyperkinetic gait This gait is seen with certain basal ganglia disorders including Sydenham's chorea, Huntington's Disease and other
forms of chorea, athetosis or dystonia. The patient will display irregular, jerky, involuntary movements in all
extremities. Walking may accentuate their baseline movement disorder.
Ataxic Most commonly seen in cerebellar disease, this gait is described as clumsy, staggering movements with a wide-based
(cerebellar) gait gait. While standing still, the patient's body may swagger back and forth and from side to side, known as titubation.
Patients will not be able to walk from heel to toe or in a straight line. The gait of acute alcohol intoxication will resemble
the gait of cerebellar disease. Patients with more truncal instability are more likely to have midline cerebellar disease
at the vermis.
Parkinsonian gait In this gait, the patient will have rigidity and bradykinesia. He or she will be stooped with the head and neck forward,
with flexion at the knees. The whole upper extremity is also in flexion with the fingers usually extended. The patient
walks with slow little steps known at marche a petits pas (walk of little steps). Patient may also have difficulty initiating
steps. The patient may show an involuntary inclination to take accelerating steps, known as festination. This gait is
seen in Parkinson's disease or any other condition causing parkinsonism, such as side effects from drugs.
Sensory gait As our feet touch the ground, we receive proprioceptive information to tell us their location. The sensory ataxic gait
occurs when there is loss of this proprioceptive input. In an effort to know when the feet land and their location, the
patient will slam the foot hard onto the ground in order to sense it. A key to this gait involves its exacerbation when
patients cannot see their feet (i.e. in the dark). This gait is also sometimes referred to as a stomping gait since patients
may lift their legs very high to hit the ground hard. This gait can be seen in disorders of the dorsal columns (B12
deficiency or tabes dorsalis) or in diseases affecting the peripheral nerves (uncontrolled diabetes). In its severe form,
this gait can cause an ataxia that resembles the cerebellar ataxic gait.
Scissor gait Primarily associated with spastic cerebral palsy. Hypertonia in the legs, hips and pelvis means these areas become
flexed to various degrees, giving the appearance of crouching, while tight adductors produce extreme adduction,
presented by knees and thighs hitting, or sometimes even crossing, in a scissors-like movement while the opposing
muscles, the abductors, become comparatively weak from lack of use

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Hip Examination
*ensure sufficient exposure. Ideally, patient should remove all clothes except the underwear or wear only loose shorts
Look
Gait
Start b assessing patient s gait. Ask patient to alk for a distance, turn around and alk back. Then ask patient to stand for a while
as you will be further examining him in his standing position
Inspect the s mmetr of the patient s gait. Is the stride length equal on both sides?
Inspect the smoothness of the patient s gait during heel strike, toe-off
When the patient reaches the end of the room, are they able to turn quickly without any issues?
Is each step of normal height? Increased stepping height is noted in foot drop
Is there any evidence of pain (antalgic gait)?
Inspection (have the patient to stand)
From the front:
Is the stance straight?
Are the shoulders parallel to the ground and symmetrically over the pelvis (which may mask a hip deformity or true shortening
of leg)
Any obvious deformity in the hips, knees, ankles and foot?
Any muscle wasting or spasm in the quadriceps femoris?
From the side:
Any increased or stoop lumbar lordosis? Both may result from a flexion contracture
From behind:
Is the spine straight or curved (scoliosis)?
Any gluteal atrophy? Ask patient to roll up his shorts
Look around for any scars, sinuses, dressings, or skin changes around the hip.

T e de e b sign before letting patient lie down

Stand in front of the patient, place hands at both iliac crests and ask patient to stand on one leg for 30 seconds
Watch and feel iliac crests to see if it moves up or down
Normally, iliac crest on the side with the foot off the ground should rise. Test is abnormal if the hemipelvis falls below the horizontal.
It is caused by gluteal weakness or inhibition from hip pain e.g. osteoarthritis or structural abnormality of the hip joint.
Shortening/ leg length discrepancy
Ask patient to lie supine and stretch both legs out as far as possible equally to eliminate any soft-tissue contracture/ abnormal
posture
Square the pelvis placing the e aminer s forearm across the two anterior superior iliac spines and noting that the line between
the two anterior superior iliac spines is perpendicular to the axis of the body; or that both limbs are in the same position relative
to the pelvis by going to the foot of the bed and placing the two limbs in symmetrical position
Measure with tape from umbilicus to medial malleolus on both legs. This is the apparent length
Measure again from anterior superior iliac spine (ASIS) to medial malleolus on both legs. This is the true length
Compare and determine whether there is any apparent or true leg shortening
Apparent shortening
present if the affected leg appears shortened, usually because of an adduction or flexion deformity at the hip
True shortening some of the causes include:
Fractures, e.g. at the femur neck
Total hip arthroplasty
Septic arthritis
Unreduced hip dislocation
Loss of articular cartilage (long-term arthritis, joint infection)
Feel (patient is now lying supine on the couch)
Palpate the greater trochanter of the femur. Tenderness suggests trochanteric bursitis
Palpate the anterior superior iliac spines
Mention palpating lesser trochanter and ischial tuberosity, which may be tender in sport injuries due to strains of iliopsoas and
hamstring insertions respectively.
Move
Active Movements (relatively insignificant)
Hip flexion ask patient to bring his knee to his chest as far as possible. Repeat for the other side
Passive Movements (patient lying supine)
Flexion (normally 0-120 degrees) place one hand under patient s back against the sacrum to eliminate the lumbar spine
fle ion, and fle patient s hips one b one. From this point onwards, you may take the opportunity to perform T a e
here (see below)
Abduction and adduction (Abduction normally 0-45 degrees; adduction normally 0-25 degrees) stabilise the hip that is not
examined by pressing across ASISs, when performing abduction and adduction of hip joint. For adduction, ask patient to hang
the side of the leg that is not examined off the couch/ bed, before adducting the hip joint, to prevent the side that is not
examined from blocking the way lol, but perform it this way is NOT compulsory
External and internal rotation (both normally 0-45 degrees) with leg in full extension, roll it on the couch and gauge the range
of rotation. Then, flex the knee at 90 degrees, and move foot medially to check external rotation, and laterally to check internal
rotation

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Comment on the movements as usual

As for hip extension, patient must lie prone, hence checked later (see below)

Resisted Movements (patient lying supine)

Check resisted flexion, external and internal rotation.
Check resisted abduction and adduction after the 4 movements above. Have the patient to lie
on his side when doing so. Any pain upon resisted movements?

Passive Movements (patient lying prone)

Hip extension (normally 0-20 degrees) place left hand over pelvis to detect/ prevent any movement. Lift each leg to assess range
of movement.
Resisted Movements (patient lying prone)
Check resisted hip extension

T a e (patient has to lie supine)

This test measures fixed flexion deformity (incomplete extension) which may be masked by compensatory movement at the lumbar
spine or pelvis and increasing lumbar lordosis in an attempt to fully extend the hip joint
While patient is lying supine, place left hand palm upwards under the lumbar spine
Passively flex both legs (hips and knees) as far as possible
Keep the non-tested hip maximally flexed, and by feeling with your left hand confirm that the lordotic curve of lumbar spine
remains eliminated
Ask patient to extend the tested hip. Incomplete extension in this position indicates fixed flexion deformity of the hip
A positive Thomas test indicates flexion contracture of the iliopsoas muscle, which can be seen in osteoarthritis etc.

Knee Examination

Look
Gait
Start b assessing patient s gait. Ask patient to alk for a distance, turn around and alk back. Then ask patient to stand for a while
as you will be further examining him in his standing position.
Inspect the s mmetr of the patient s gait. Is the stride length equal on both sides?
Inspect the smoothness of the patient s gait during heel strike, toe-off
When the patient reaches the end of the room, are they able to turn quickly without any issues?
Is each step of normal height? Increased stepping height is noted in foot drop
Is there any evidence of pain (antalgic gait)?

Inspection
Have the patient to stand in the anatomical position, and check for the following:
Any scars, sinuses, erythema or rashes around the knees? Any bleeding or bruising?
Any nodules seen at both knee joints?
Any deformities such as genu valgum or genu varum?
Any muscle wasting in the quadriceps (which is almost invariable with inflammation or chronic pain and develops within days)
Any flexion deformity of the knee can be seen? If patient stands or lies with a knee flexed, it can be caused by hip, knee or
combined
Any obvious swelling in the knees? Enlarged prepatellar bursa, effusion etc. Does the swelling extend beyond the joint
margins? (infection, major injury, rarely tumour)
Any swelling in the popliteal fossa? Baker s c st hich is due to bursa enlargement in the popliteal fossa
Have the patient lie supine
Check again for any fixed flexion deformity of knee
Check for any leg length discrepancy (refer to Hip Examination)
Feel
Compare temperature on both knees using dorsum of hands
With knees flexed slightly, palpate along the borders of the patella, the nearby bony areas (femur and tibia tuberosity) joint line
(articulation between femur and tibia) to check for any tenderness, swelling or effusion
With knees extended and quadriceps relaxed, palpate on both sides of quadriceps to feel for any sponginess (synovitis)

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Patellar tap
With patient s knee e tended, empt the suprapatellar pouch b sliding our left hand do n the thigh until ou reach the upper
edge of the patella
Keep your left hand there, press down quickly and firmly using fingertips of right hand over the patella
In a moderate-sized effusion you will feel a tapping sensation as the patella strikes the femur. You may also feel a fluid impulse in
your left hand

Bulge or ripple test

E tend patient s knee and ensure that quadriceps are relaxed, empty suprapatellar bursa by sliding your hand down the high
until you reach the upper edge of the patella
Empty the medial compartment of the joint by firmly stroking the medial side of knee caudally with palm of your hand
Firmly stroke the lateral side of the knee joint using the dorsum of your hand, and observe
Test is positive if bulge of fluid appears on the medial side of the knee. This test is useful for detecting lesser amounts of fluid

Move
Active Movements
Flexion and extension (Flexion normally 0-140 degrees) with patient lying supine, ask him to flex his knee up to chest and
then extend leg back down to lie on the couch
You ma feel for crepitus in active or passive movements. Just don t forget to do so
Extension ask patient to lift leg, keeping it straight. If knee cannot be kept fully extended, an extensor lag is present, indicating
quadriceps weakness or other abnormality of extensor apparatus
Comment on movements as usual
Passive Movements
Repeat flexion and extension for the patient
Check for an h pere tension of knee joint. Lift both of patient s legs b the feet. Hyperextension or genu recurvatum is present
if knee extends beyond the neutral position. Up to 10 degrees is normal
Resisted Movements
Assess knee flexion and extension against your resistance. Stabilise the knee joint, by asking patient to rest the knee on your
left hand to eliminate hip joint movement
Special Tests
Collateral ligament testing
With patient s knee full e tended, hold the ankle between your elbow and side of body
Use both hands to apply valgus and varus stress to the knee
Valgus (lateral) force to assess medial collateral ligament
Varus (medial) force to assess lateral collateral ligament
While one hand is applying force, use thumb of another hand to feel the corresponding joint line and assess the degree to
which the joint space opens. Major opening of the joint indicates collateral and cruciate injury

Based on the diagram, for the right leg,

Apply valgus force using left hand (forcing leg into valgus deformity)
Check degree of joint space using with right thumb
This assesses medial collateral ligament

Apply varus force using right hand (sort of forcing leg into varus deformity)
Check degree of joint space opening using the left thumb
This assesses the lateral collateral ligament

If knee is stable, repeat with knee flexed to 30 degrees to assess minor collateral laxity. In this position, the cruciate ligaments
are not taut
Comment: any laxity in any of the ligaments tested? Any tenderness?
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Cruciate ligament (Anterior and posterior drawer test)
Fle the patient s knee to 90 degrees, and maintain its position b sitting ith our thigh trapping patient s foot
Ensure that hamstring muscles are relaxed, and look for posterior sag (posterior sublaxation of tibia on femur) which can cause
false-positive anterior drawer sign which should not be interpreted as anterior cruciate ligament laxity
Anterior drawer test
With your hands behind the upper tibia and both thumbs over the tibia tuberosity, pull the tibia anteriorly
Significant movement as compared with the opposite knee indicates that anterior cruciate ligament is lax. Movement exceeding 1.5
cm suggests anterior cruciate ligament rupture. There is often an associated ligament injury
Posterior drawer test
Push backwards on the tibia this time. Posterior movement of tibia suggests posterior cruciate ligament laxity

Patella apprehension test (not taught in CSSC)

With patient s knee full e tended, push the patella laterally and flex the knee slowly. If patient actively resists flexion, it suggests
previous patellar dislocation or instability

Meniscal provocation test for any meniscus tear (not taught in CSSC)
Medial meniscus
Passively flex the knee to the maximum
Externally rotate the foot and abduct the upper leg at the hip, keeping the foot towards the midline, creating a varus stress at
the knee
Extend knee smoothly. In medial meniscus tears, a click or clunk may be felt or heard, accompanied by discomfort
Lateral meniscus
Passively flex the knee to the maximum
Internally rotate the foot and adduct the upper leg at the hip, creating a valgus stress at the knee
Extend knee smoothly. In medial meniscus tears, a click or clunk may be felt or heard, accompanied by discomfort
Function
Squat test
Ask patient to squat, keeping feet and heels flat on the ground
If patient cannot do this, there is incomplete knee flexion on the affected side, which may be caused by a tear of the posterior horn
of the menisci

Ankle Examination
Introduction to Ankle Ligaments
Medial Ligaments Lateral Ligaments

Surface Location of the Ankle Ligaments

Medial Ankle Ligament/ Deltoid ligament Lateral 2 Calcaneo-fibular ligament

Lateral 1 Anterior talofibular ligament (ATFL) Lateral 3 Posterior talofibular ligament

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Examination Sequence
Look
Gait
Start b assessing patient s gait. Ask patient to alk for a distance, turn around and alk back. Then ask patient to stand for a while
as you will be further examining him in his standing position.
Inspect the s mmetr of the patient s gait. Is the stride length equal on both sides?
Inspect the smoothness of the patient s gait during heel strike, toe-off
When the patient reaches the end of the room, are they able to turn quickly without any issues?
Is each step of normal height? Increased stepping height is noted in foot drop
Is there any evidence of pain (antalgic gait)?
Any hallux rigidus loss of movements at the MTP joint?
Hallux rigidus
most common arthritic condition of the foot and second only to hallux valgus (bunion) as a
condition associated with the big toe
Most patients present with a complaint of pain in the big toe joint while active, especially
when pushing off to walk. Others note swelling and stiffness around the big toe joint or an
inability to bend the toe up or down. A bump, like a bunion or bone spur, can develop on top
of the big toe joint and be aggravated by rubbing against the inside of a shoe.
The true cause of hallux rigidus is not known. However, several risks factors have been identified and include an
abnormally long or elevated first foot bone (metatarsal), differences in foot anatomy, prior traumatic injury to the big toe
and family history. Most of these risk factors cause damage to the surfaces of the bone and lead to wear and tear of the
joint, which in turn leads to arthritis.
Inspection
Have the patient to stand in the anatomical position, and check for the following:
From behind: Is the heel properly aligned? Or is there any valgus or Varus deformity?
From the side: is the longitudinal medial arch preserved? Or is there any flattening (pes planus) or exaggeration (pes cavus)
of foot arches? If arch is flattened, ask patient to stand on tiptoe. This restores the arch in a mobile deformity. But not in a
structural one
Any splay foot can be seen? A splay foot has widening at level of the metatarsal heads, often associated with MTP joint
synovitis

With the patient lying supine now, continue looking for the following:
Are there any scars, sinuses, swelling (s elling of the entire digit, sausage toe or dact litis, is characteristic of psoriatic
arthropathy), bruising, callosities (area of thickened skin at site of repeated pressure), nail changes such as pitting nails,
onycholysis etc., oedema, deformities and abnormal position such as fixed plantar flexion or foot drop in foot and ankle?
Observe toes for any deformities
Feel
Feel for any local tenderness and heat in the foot and ankle
Palpate the following:
Bony landmarks tibia and fibula, ankle (malleoli, base of 5th metatarsal)
Lateral ankle Ligaments (refer to the diagram above)
Medial ankle deltoid ligament (refer to the diagram above)
Extensor tendons of the leg anteriorly
Peroneal tendons of the leg laterally
Flexor tendons behind medial malleolus
Joint lines
Achilles tendon
Either side of Achilles tendon for any effusion
Press on metatarsal heads for any tenderness (tenderness with sponginess suggests synovitis due to rheumatoid
arthritis)
Lateral ligament, particularly AFTL is commonly damaged in sport injuries

Move (Do not forget to feel for any crepitus during movements)
Active Movements
Instruct patient to relax his foot first, and then perform these actions:
Ankle dorsiflexion and plantar flexion (Dorsiflexion normally 0-15 degrees; plantar flexion normally 0-45 degrees) by bending
the foot towards himself and away from himself (demonstrate using your hand)
Inversion and eversion of foot by curving foot inwards and outwards respectively

Passive Movements
Instruct patient to relax his foot, and you perform these actions for the patient, and ask for any pain during movements
Ankle dorsiflexion and plantar flexion grip the heel with the cup of your left hand from below, with thumb and index finger on
both malleoli, put foot through the arc of movement. If dorsiflexion is restricted, assess the contribution of gastrocnemius which

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functions across both ankle and knee joints by measuring ankle dorsiflexion with the knee flexed and extended. If more
dorsiflexion is possible with knee flexed (plantar flexion of gastrocnemius is eliminated in this position), this suggests
gastrocnemius muscle contracture.
Inversion and eversion isolate the subtalar joint by placing foot into dorsiflexion. Move heel into inversion and eversion
Examine the combined mid-tarsal joints by fixing the heel with your left and, and moving the forefoot with your right hand into
dorsiflexion, plantar flexion, abduction, adduction, supination and pronation

Resisted Movements
Dorsiflexion and plantar flexion. Support the ankle joint by placing left hand over the distal tibia and fibula
Inversion and eversion. Place the foot into inversion position, and ask patient to resist as you attempt to make it straight, to
check resisted inversion. Do the same to check resisted eversion

Achilles Tendon
Ask patient to kneel with both knees on a chair
Palpate gastrocnemius and Achilles tendon for any tenderness and soft tissue swelling
Achilles tendon rupture is often palpable as a discrete gap in the tendon above 5 cm above the calcaneal insertion
T e
With the patient kneeling with both knees on a chair, squeeze the calf just distal to the level of maximum circumference or thickness
and check response of foot
If Achilles tendon is intact, plantar flexion of foot will occur

Function (?)
Test patient s abilit to tip toe 2-3 times

Cervical Spine Examination

*ensure sufficient exposure (entire neck and upper thorax)
Look
Observe posture of head and neck from the front, side and back. Note for any abnormality or deformity such as loss of lordosis
(usually due to muscle spasm)
Look for other general abnormalities as mentioned in the beginning of this chapter

Feel
Feel the midline spinous processes from the occiput to T1 (T1 spinous process is usually the most prominent one)
Feel the paraspinal soft tissues
Feel supraclavicular fossae for cervical ribs and any enlarged lymph nodes
Mention feeling the anterior neck structures, including trachea and thyroid gland
Note for any tenderness in the spine, trapezius, interscapular and paraspinal muscles and soft tissues

Move
Active Movements (mainly)
Forward flexion (normally 0 to 80 degrees) ask patient to look down and place chin on the chest
Extension (normally 0 to 50 degrees) ask patient to look upwards as far back as possible
Lateral flexion (normally 0 to 45 degrees) ask patient to put his ear on to the shoulder, and repeat for the other side
Lateral rotation (normally 0 to 80 degrees) ask patient to look over his left and right shoulder
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Passive Movements are only performed gently if active movements are reduced. Establish if the end of the range has a sudden or
a gradual resistance, and whether it is pain or stiffness that restricts the movement. Pain or paraesthesia in the arm on passive neck
movement suggests nerve root involvement.
But for OSCE, you most likely do not need to perform passive movements, but you can mention that you would check as described
above if active movements of the simulated patient are reduced

Mention that you would perform a full neurological assessment of both upper and lower limbs (refer to Nervous System Module) as
a part of the examination in a cervical spine injury

Thoracolumbar Spine Examination

Look
Gait
Start b assessing patient s gait. Ask patient to alk for a distance, turn around and alk back. Then ask patient to stand for a while
as you will be further examining him in his standing position.
Inspect the s mmetr of the patient s gait. Is the stride length equal on both sides?
Inspect the smoothness of the patient s gait during heel strike, toe-off
When the patient reaches the end of the room, are they able to turn quickly without any issues?
Is each step of normal height? Increased stepping height is noted in foot drop
Is there any evidence of pain (antalgic gait)?
Have the patient to stand with the back fully exposed, and check for the following;
Any obvious deformity such as increased or decreased lordosis, scoliosis, soft tissue abnormalities like a hairy patch, or lipoma
that may overlie a congenital abnormality?
Any muscle spasm can be seen?
Compare shoulder and pelvis levels are they equal on both sides?
Check for other abnormalities such as draining sinuses, scars, bruising etc.
Inspect for an muscle asting in the lo er limbs (don t forget gluteal atroph hich is revealed onl ith sufficient e posure)
due to denervation
Feel
You may choose to palpate when the patient is standing, or when he is lying prone (depending on your choice, modify the sequence
of your examination)
With the patient standing, use your index and middle finger to palpate the spinous processes and paraspinal tissues. Begin with T1
spinous process is usually the most obvious one. Note the overall alignment and check for any local tenderness

After warning the patient, lightly percuss the spine with your closed fist (like how you would perform Renal punch) and note for any
tenderness
Move
Active Movements only
Forward flexion ask patient to try to bend forward and touch his toes with his leg straight. Note how far down his legs he can
reach. E.g. forward flexion of the patient is up to ankle level, or 5 cm above the ground.
Extension (normally 0 to 10-20 degrees) ask the patient to straighten up. Stand by to support the patient in case he falls,
and ask patient to lean back as far as possible
Lateral flexion ask patient to slide hand down the side of his body, touching the outside/ lateral side of his legs, as far a
possible while keeping both legs straight. Note the level, e.g. lateral flexion on the left side is up to the knee level
Thoracic spine lateral rotation stand at the patient s back, firml hold the patient s hips, and ask patient to turn his bod to
the left and right.

Sc be e
Mark the skin in the midline at the level of the posterior iliac spines (which corresponds to L5), which overlies the sacroiliac
joints. Assume this is point A
Use a measuring tape to draw one mark 10 cm above (assuming point B) and another mark 5 cm below point A (assuming
point C)
Place the end of the measuring tape on the upper mark (point B), and ask patient to touch his toes. Measure distance between
B and C, which should increase to more than 20 cm in a normal person

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Root Compression Tests
The clinical presentations of lumbosacral radiculopathy vary according the level of nerve root or roots
involved. The most frequent are the L5 and S1 radiculopathies. All lumbosacral nerve roots exit the
spinal canal at the neural foramina below their respective vertebrae. As an example, the L5 nerve
roots exit via the neural foramina at the L5/S1 disc space level. Thus, posterolateral disc herniation
of the L4/L5disc usually compresses the L5 nerve root, while posterolateral disc herniation of
the L5/S1 disc typically compresses the S1 nerve root

Straight-leg raise (let patient lie supine)

Tests L4, L5, S1 nerve root tension (due to L3/4, L4/5, L5/S1 disc prolapse respectively)
With the patient lying supine, lift the foot to flex the hip passively, keeping the knee straight
Measure angle between couch and flexed leg to determine any limitation (normal 80-90 hip flexion) caused by thigh or leg
pain
If a limit is reached, raise the leg to just less than this level, and dorsiflex the foot to test for nerve root tension
If the patient experiences sciatic pain when the straight leg is at an angle of between 30 and 70 degrees or when the foot is
dorsiflexed, the test is positive

Tibia nerve stretch (IMU Semester 5 OSCE does not seem to include this)
Tests L4-L5, S1-S3
With patient lying supine, flex hip to 90 degrees
Extend the knee
Press on either of the hamstring tendons, and then over the tibia in the middle of the popliteal fossa
Test is positive if pain occurs when the nerve is pressed but not the hamstring tendons

Femoral nerve stretch

Tests L2-L4
With the patient lying prone (ask patient to lie on his tummy), flex the knee to 90 degrees, and extend the hip.
Positive result if pain is felt in the back or front of thigh

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Examples of Case Scenarios for Practice
Case 1***
Mr U, a 23-year-old man who is an active tennis player, fell during a friendly match with his friend, and experienced pain in the right ankle.

Examine his ankles and report your findings. You do not need to check for resisted movements

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Assess patient s gait for an abnormalities. Comment on gait s mmetr , stride length, normal phases of gait, smoothness of gait, /3
and the ease of turning
Inspect the ankles for any swelling, bruises, erythema, deformity /2
Palpation of structures of ankles, notably the bony areas (lateral and medial malleolus), lateral ligaments, medial ligaments, muscle /4
tendons, metatarsal heads, joint line. Start with left ankle. Patient please scream in pain when lateral ligaments on right ankle
are palpated
Active and passive movements of ankle joint: Dorsiflexion, plantar flexion, foot inversion and eversion, with appropriate instructions /4
and comments on movements Patient please show discomfort during movements, especially during inversion
Omit Thomson s test /1
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 20 marks

Case 2****
Mr V, a 45-year-old man complains of low back pain.

Examine his lumbar spine, including the specific tests to check for any nerve root compressions.
At the 6th minute, the examiner will ask you one question.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Assess patient s gait for any abnormalities. Comment on gait symmetry, stride length, normal phases of gait, smoothness of gait, /3
and ease of turning
Look for the follo ing from the patient s back: levels of shoulder and pelvis, an deformities such as scoliosis, an loss or increased /3
lumbar lordosis viewed from the side, any muscle spasms, scars, bruises, sinuses etc. and any loss of muscle bulk in lower limbs
Palpate the spinous processes in the lumbar spine, and paraspinal muscle. Ask patient for tenderness /3
Active movements of lumbar spine with patient standing upright, with appropriate instructions and comments on movement: /3
Forward flexion, extension, lateral flexion
Have patient lie supine, and perform straight leg raise test correctly. Patient please complain of pain /3
Omit tibia nerve stretch /1
Have patient lie prone, and perform femoral nerve stretch correctly /3
QUESTION: What are the nerve roots being checked in straight leg raise test? /2
Ans: L4, L5, S1

If student did not perform straight leg raise test,

QUESTION: What are the tests you would perform to check for any nerve root compression?
Ans: Femoral nerve stretch, and straight leg raise test
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 27 marks

Case 3***
Mr W, a 28-year-old man complains of pain in his right elbow.

Examine his elbows and report your findings. At the 6th minute, the examiner will ask you one question.

Appropriate introduction, confirming patient s identit , explaining and obtaining consent /1

Inspect the elbows for any deformity, abnormal carrying angle, scars, swelling, bruising, erythema, nodules, sinuses etc. /2
Palpate epicondyles, olecranon and the spaces between epicondyle and olecranon. Start with left elbow /2
Assess active, passive and resisted movements of elbow flexion and extension, and /4
Active and resisted pronation and supination, with appropriate comments on movements
Check for any medial epicondylitis /2
Check for any lateral epicondylitis. Patient please complain of pain when extend wrist against resistance /2
QUESTION: What is the patient most likely having?
Ans: Lateral epicondylitis
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 18 marks

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Case 4****
Mr X, a 23-year-old football player, complains of left knee pain after playing a match with his friends.

Examine his knees and report your findings. You do not need to perform patellar tap and patellar apprehension test.

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Assess patient s gait. Comment on gait s mmetr , stride length, normal phases of gait cycle, smoothness of gait, and ease of /3
turning. Patient please demonstrate antalgic gait with avoidance of weight bearing on the left side
Comment that antalgic gait is seen
Inspect patient s knees ith patient standing ith his permission, for an deformities, bruising, scars, s elling /2
Palpate both knees starting with the right knee. Palpate along joint line for any tenderness, compare temperature on both sides /2
Perform bulge test correctly /2
Active, passive and restricted movements of knee flexion and extension. Mention checking for any hyperextension /4
Test medial and lateral collateral ligament. Patient please show discomfort when testing medial collateral ligament. /2
Comment
Test anterior and posterior cruciate ligament. Check for posterior sag before testing /3
Perform meniscus provocation, medial and lateral. Patient please complain of pain when testing medial meniscus. Comment /3
Omit Squat test -
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 27 marks

Case 5****
Mr Y, a 35-year-old man experienced neck soreness after a minor car accident.

Tasks:
1. Examine his cervical spine.
2. Perform a motor examination of his upper limbs. You do not need to check all the reflexes of upper limbs.

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Nervous System

Glasgow Coma Scale

The 4 steps in assessing Glasgow Coma Scale of a patient: Check, Observe, Stimulate and Rate
Check is to identify factors that might not allow certain aspects to be tested, e.g. periorbital swelling that prevents eye opening, or
intubation that does not allow speaking. If that is the case, record Not Testable - NT
Stimulation can be central, or peripheral (fingertip pinch). Central preferred over peripheral stimuli, as peripheral stimuli can provoke
reflex without signals reaching higher centres.

EYE OPENING
Criterion and examination Rate Score
Eyes already opened before applying stimulus Spontaneous 4
After greeting the patient, introduce ourselves and instruct patient to open eyes (shout if necessary) Sound 3
After fingertip stimulus (pressing nail tip with increasing intensity for 10 seconds) Pressure 2
No opening at all after stimulus None 1
If patient has any factor that prevents eye opening Not Testable NT
VERBAL RESPONSE
Ask patient their name, where they are, and which month is it now, which are answered correctly Oriented 5
Able to speak and phrase sentences, but incorrect answers Confused 4
Does not talk sensibly, but words can be heard Words 3
Moans and groans Sounds 2
No audible response without interfering factor None 1
If patient has any factor that prevents speaking Not Testable NT
MOTOR RESPONSE
Ask patient to hold our hand and grasp tightly or open their mouth and stick out their tongue if patient Obeys 2-step 6
can t move their hand because of spinal cord injury. Patient does it correctly command
Give peripheral stimulus (finger pinch) and central stimulus (trapezius pinch, then by applying pressure Localising 5
on supraorbital notch, if trapezius pinch does not work, on increasing intensity for 10 seconds). If
patient brings hand to above clavicle in attempt to remove stimulus applied.
Rapid elbow flexion and arm moves away from body Normal flexion 4
Slow elbow flexion with arm moving across chest, forearm rotates, thumb clenched Abnormal flexion 3
Elbow extension Extension 2
No movement at all None 1
If patient has paralysis or any other limiting factor Not Testable NT

Score Interpretation
Total score = Eye + Verbal + Motor
GCS < 5: 80% die or remain vegetative
GCS > 11: 90% complete recovery

Mini Mental State Examination

Another method: Abbreviated Mental Test Score (AMTS)

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Dermatomes

Sensory in Upper Limbs

*Equipment required for full sensory examination: cotton wool, wooden stick, 128Hz tuning fork
*inform patient they must remove upper garment or at least roll up their sleeves of their shirt completely
General Inspection
How is the mental state of the patient? Is the patient alert, conscious and responsive? Any abnormal gross movements?

Inspection and Palpation of Upper Limbs (d e d c e e e)

Check both upper limbs for any:
Asymmetry and deformities in upper limbs?
Muscle wasting? Do not forget about smaller muscles in hands such as thenar and hypothenar eminence, interossei etc.
Palpate both sides and compare bulk
Muscle spasms?
Fasciculations?
Tremors?
Involuntary movements? Such as chorea

Light Touch Sensation

Touch the patient s sternum or forehead with the wisp of cotton wool to confirm they can feel it (use the sternum or forehead
as a reference point), and inform that this is what they can expect to feel later
Ask the patient to say yes when they can feel the cotton wool touching their arms and hands
Using the wisp of cotton wool, gently touch the skin (do not stroke)
Assess each of the dermatomes of the upper limbs. Progress at irregular intervals so that patient
cannot predict the next time you will touch his skin
Compare left to right, by asking the patient if it feels the same on both sides
Recommended locations to check each dermatome
C5 Upper outer arm where deltoid bulk is located
C6 Thumb (palmar surface)
C7 Middle finger (palmar surface)
C8 Little finger (palmar surface)
T1 Inner forearm
T2 Upper inner arm near the axilla

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Pin-prick/ Pain Sensation
Repeat the previous assessment steps, but this time using the sharp end of a wooden stick. Progress at irregular intervals so
that patient cannot predict the next time you will touch his skin
If loss of sensation is noted distally, test for glove distribution of sensory loss (peripheral neuropathy) by moving distal to
proximal.
You may check temperature sensation using a cold metallic object such as a cold tuning fork and ask if patient if it feels cold. But in
OSCE you most likely on t be performing that
Vibration Sensation
Ask the patient to close their eyes
Tap a 128 Hz tuning fork
Place onto the patient s sternum/ forehead and confirm the can feel it buzzing. Inform that that this is what they can expect
to feel later
Place onto the distal interphalangeal joint of the forefinger and ask them if they can feel it buzzing
Once the patient sa s the can feel, confirm b asking patient to sa stop or no more as ou stop the tuning fork
If vibration sensation is impaired, continue to assess the bony prominence of more proximal joints (interphalangeal joint of
thumb - carpometacarpal joint of thumb - styloid process of ulna elbow shoulder such as acromion)

Proprioception
Hold the distal phalanx of the thumb or index finger by its sides
Demonstrate movement of the finger up ards and do n ards to the patient, as they watch
Then ask the patient to close their eyes and state if you are moving the finger up or down
If the patient is unable to correctly identify direction of movement, move to a more proximal joint (finger >
wrist > elbow > shoulder)

Two-point discrimination (check if equipment is provided)

Tested with 2 sharp points, and is assumed to reflect how finely innervated an area of skin is
May use callipers or simply a reshaped paperclip to do the testing
May alternate randomly between touching the patient with one point or with two points on the area being tested
The patient is asked to report whether one or two points was felt.
The smallest distance between two points that still results in the perception of two distinct stimuli is recorded as the patient's
two-point threshold
Normal result: on the palms, it is 8 to 12 mm
If there is time and equipment, assess cortical sensations
Stereognosis
Ask patient to close eyes, and identify a familiar object, such as coin or key, placed in their hand. Repeat using another object
Graphesthesia
Ask patient to close eyes, and identify a letter or number written on their palm. Repeat using another number or letter
Sensory inattention (only test if sensory pathways are otherwise intact)
Ask patient to close their eyes, apply touch stimuli on both arms together, and separately, in a random manner. Check if patient can
identify whether stimuli is applied on his left, right or both sides correctly

Sensory in Lower Limbs

General Inspection
How is the mental state of the patient? Is the patient alert, conscious and responsive? Any abnormal gross movements?
Inspection and Palpation of Lower Limbs (d e d c e e e)
Check both lower limbs for any:
Asymmetry and deformities in lower limbs?
Muscle wasting? Palpate both sides and compare bulk
Muscle spasms?
Fasciculations?
Tremors?
Involuntary movements? Such as chorea
You will most likely check the gait in Motor System Examination unless the task specifies otherwise
R be Te (always stand close to patient to support in case he falls)
Ask patient to stand with feet close together, arms by the side, eyes opened. Check for significant swaying or tendency to fall.
If patient sways with eyes opened, the patient may be having cerebellar ataxia
Ask patient to close eyes, and assure that you will support in case he falls. Check again for significant swaying or tendency to
fall (ideally wait for up to 1 minute).
Positive, or sensory ataxia is present, if significant imbalance or worsened balance with eyes closed

Light Touch Sensation (have patient to lie supine)

Touch the patient s sternum or forehead with the wisp of cotton wool to confirm they can feel it (use the sternum or forehead
as a reference point), and inform that this is what they can expect to feel later
Ask the patient to say yes when they can feel the cotton wool touching their arms and hands
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Using the wisp of cotton wool, gently touch the skin (do not stroke)
Assess each of the dermatomes of the upper limbs. Progress at irregular intervals so that patient
cannot predict the next time you will touch his skin
Compare left to right, by asking the patient if it feels the same on both sides
Recommended locations to check each dermatome
L2 Extreme high medial thigh
L3 At the knee near to the patella (slightly proximal)
L4 Medial side of the lower leg
L5 Lateral side of the lower leg or dorsum of foot
S1 5th toe or lateral malleolus
S2 Medial side of the popliteal fossa, or ischial tuberosity (lol)
S3 Medial side of the posterior thigh
Pin-prick/ Pain Sensation
Repeat the previous assessment steps, but this time using the sharp end of a wooden stick. Progress at irregular intervals so
that patient cannot predict the next time you will touch his skin
If sensation is reduced peripherally, assess from a distal point and move proximally to identify stocking sensory loss
(peripheral neuropathy). If necessary, keep going all the way up the leg and truck until normal sensation is felt. This may reveal
a sensor level , which is suggestive of a spinal lesion (e.g. if there is abnormal sensation up to the level of the umbilicus, this
suggests a spinal lesion at around T10)
You may check temperature sensation using a cold metallic object such as a cold tuning fork and ask if patient if it feels cold. But in
OSCE you most likely on t be performing that
Vibration Sensation
Ask the patient to close their eyes
Tap a 128 Hz tuning fork
Place onto the patient s sternum/ forehead and confirm the can feel it buzzing. Inform that that
this is what they can expect to feel later
Place onto the distal phalanx of the great toe
Once the patient sa s the can feel, confirm b asking patient to sa stop or no more as ou stop
the tuning fork
If sensation is impaired, continue to assess more proximally along bony areas e.g. proximal
phalanx, followed by malleolus, along tibia etc.
Proprioception
Hold the distal phalanx of the great toe by its sides
Demonstrate movement of the toe up ards and do n ards to the patient (whilst they watch)
Then ask patient to close their eyes and tell you if you are moving the toe up or down
If the patient is unable to correctly identify direction of movement, move to proximal joints (big toe >
ankle > knee > hip)

Diabetic Foot Examination

*always follow the task in OSCE
Gait
Observe gait for any asymmetry, especially any foot drop (high stepping gait). If foot drop suspected, ask patient to try to walk on his
heels. Loss of ankle dorsiflexion makes walking on heels impossible. You may evaluate power of ankle dorsiflexion later
Inspection
Look for any hair loss, nail dystrophy
Examine skin for any excessive callus, fungal infections, ulcers
Ask patient to stand and assess foot arches (may be excessive in neuropathy or collapsed)
Look for any deformation of joints in feet
Any muscle wasting? Palpate both sides and compare bulk
Palpation
Feel and compare temperature of both feet using dorsum of hands
Examine the peripheral pulses, especially the dorsalis pedis and posterior tibial pulses. If absent, mention Doppler ultrasound
and measurement of ABI. You ma also mention Buerger s test to check for an peripheral arterial patholog
Sensory Examination
Test for peripheral neuropathy from distal to proximal, NOT following the dermatomes. Use the nylon monofilament which
buckles at a force of 10 g to apply a standard reproducible stimulus, if not, use cotton wool
Check light touch, pain, and vibration depending on the equipment provided during OSCE. Also check proprioception

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Motor Examination (only perform if suspecting foot-drop, and motor deficits usually occur in advanced diabetic neuropathy)
Assess power of ankle dorsiflexion. Foot drop may be present in diabetic neuropathy
Check for presence of ankle jerk reflex. May be lost in advanced neuropathy

Comparing UMNL and LMNL

Upper Motor Neuron Lesion Lower Motor Neuron Lesion

Inspection No fasciculation or significant wasting (may be some Wasting and fasciculation of muscles
disuse atrophy or contractures)
Pronator drift May be present May be some drift/ movement of arm(s) if weak or de-
afferented, but not pronator
Tone Increased (spasticity) +/- ankle clonus Decreased (hypotonia) or normal
Power Classicall a p ramidal pattern of eakness Different patterns of weakness, depending on cause
(extensors weaker than flexors in arms, and vice e.g. classically a proximal weakness in muscle disease,
versa in legs) a distal weakness in peripheral neuropathy
Reflexes Exaggerated or brisk (hyper-reflexia) Reduced or absent (hyporeflexia or areflexia)
Plantar reflexes Upgoing/extensor (Babinski positive) Normal (downgoing/ flexor)

See below for Myotomes

Motor System in Upper Limbs

*follow the recommended sequence below
General Inspection
How is the mental state of the patient? Is the patient alert, conscious and responsive? Any abnormal gross movements?
Inspection and Palpation of Upper Limbs
Check both upper limbs for any:
Asymmetry and deformities in upper limbs?
Muscle wasting? Do not forget about smaller muscles in hands such as thenar and hypothenar eminence, interossei etc.
Palpate both sides and compare bulk
Muscle spasms?
Fasciculations?
Tremors?
Involuntary movements?
Dystonia sustained muscle contractions leading to twisting, repetitive movements and sometimes tremors. It may be
focal, e.g. torticollis (twisted neck) or global
Athetosis slow writhing movements more similar to dystonia than chorea
chorea brief random purposeless movement which may affect various parts of the body but commonly the arms
Ballism violent flinging movements sometimes affecting only one side of the body (hemiballismus)
Pronator Drift (not taught in CSSC)
Ask the patient to close their eyes and place arms outstretched forwards with palms facing up.
Observe the hands and arms for signs of pronation.
If they are unable to maintain the position the result is positive. Closing the eyes accentuates the effect, because the brain is
deprived of visual information about the position of the body and must rely on proprioception. Tapping on the palm of the
outstretched hands can accentuate the effect.
This is a test of upper motor neuron disease.
If a forearm pronates, with or without downward motion, then the person is said to have pronator drift on that side reflecting a
contra-lateral pyramidal tract lesion. In the presence of an upper motor neuron lesion, the supinator muscles in the upper
limb are weaker than the pronator muscles, and as a result, the arm drifts downward and the palm turns toward the floor. A
lesion in the ipsilateral cerebellum or ipsilateral dorsal column usually produces a drift upward, along with slow pronation of
the wrist and elbow.
Tone
Ask patient to sit at the edge of the bed, and to rela and go flopp . Enquire about an painful
joints or limitations of movements before proceeding
Passively move each joint tested through as full a range as possible, both slowly and quickly in
all anatomically possible directions. Be unpredictable with these movements in both speed and
direction, to prevent patient from actively moving with you, as you only want to test passive tone
Hold the patient s hands as if ou are shaking hands, use another hand to support his elbo .
Assess tone at wrist and elbow
Activation (only performed if tone is increased)
A technique used to exaggerate subtle increase in tone, and is particularly useful for assessing extrapyramidal tone increase.
Ask patient to describe circles in the air with the contralateral limb wile assessing tone. However, a transient increase in tone
with this manoeuvre is normal
Clonus (check for any ankle clonus in lower limb motor examination if tone is increased)
Power
Principles
Do not test every muscle movement in most patients

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Ask about pain which may interfere with testing
Test upper limb power with patient sitting on the edge of the couch
Ask patient to perform a movement before ou provide an opposing force, as ou ould like to first test patient s abilit to
overcome gravity (grade 3). Then apply opposing force (at correct locations, e.g. to test power of hip flexion, press on the thigh
NOT the legs), while you tell the patient to not let you oppose, or ask patient to push/ pull against your force (grade 5/5)
Check for grade 2 movements, by eliminating gravity for patient (e.g. performing movements horizontally with vertical support)
if patient is unable to overcome gravity.
Differentiation between grade 4 and 5 can be quite subjective

Grading of Power
Grade 0 Complete paralysis with no contractions seen
Grade 1 Flicker or trace of contraction
Grade 2 Active movement through full range of motion, but possible only if gravity is eliminated
Grade 3 Active movement through full range of motion, and against gravity but not against resistance
Grade 4 Active movement through full range of motion, and against some or moderate resistance
Grade 5 Normal power. Active movement through full range of motion, and against full resistance, or
even overcome resistance

Macleod s has included a lot more things to check po er, such as asking patient to lift arms above head, asking patient to pla the
piano to check fine movements, and testing truncal strength b asking patient to sit up from l ing position ithout using arms. You
may choose to perform these if you have enough time during OSCE
Recommended movements to be tested for power
Movement Muscle Nerve/ root
Shoulder abduction Deltoid Axillary nerve C5
Elbow flexion Biceps Musculocutaneous nerve C5, C6
Brachioradialis Radial nerve C6
Elbow extension Triceps Radial nerve C7
Wrist extension Extensor carpi radialis longus Posterior interosseous nerve (radial) C6
Finger extension Extensor digitorum Posterior interosseous nerve (radial) C7
Finger flexion Flexor digitorum profundus Anterior interosseous nerve (median) C8
and ulnar nerve (C8) for flexor digitorum
profundus 4 and 5
Finger abduction vertically (just between First dorsal interosseous Ulnar nerve T1
index and middle finger instead of all fingers)
Thumb abduction Abductor pollicis brevis Median nerve T1

Note: to check for po er of finger fle ion and e tension, hold the patient s hands at the wrist and carpals, proximal to the MCP joint,
and ask patient to push fingers down and up against your palm. Something like that:

To check thumb abduction, ask patient to move thumb verticall against our resistance ith patient s held palm up on a flat surface

Ask patient to squee e our fingers ith his hand as ou ould to check po er grip . According to Macleod video, this is to test grip
power, but according to Macleod book, this tests patient s abilit to follo commands instead of po er. It is NOT compulsory to do
this during OSCE
Checking for Dyspraxia (only check this if you really have time in OSCE)
Dyspraxia - difficulty in performing motor task despite understanding
Ask patient to pretend drinking a cup of tea and observe. Difficulty in performing a motor task may be a sign of motor weakness,
cerebellar, sensory or extrapyramidal impairment

Deep Tendon Reflexes

Principle Reflexes
Ensure that both limbs are positioned identically with the same amount of stretch when checking reflexes on each side
Compare each reflex with the other side, check for symmetry of responses
Use reinforcement whenever a reflex appears to be absent. For reflexes in the upper limb, ask patient to clench the teeth or
make a fist with contralateral hand. Patient should relax in between repeated attempts. Strike the tendon immediately after
giving the command to the patient
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Check the biceps reflex (C5/ C6)
Have the patient to relax and rest his right arm on your right arm (ask patient to let you
carry the weight of his arm)
Use your right thumb to palpate and locate the biceps brachii tendon in the antecubital
fossa
Keep your right thumb on the tendon, as you strike the tendon hammer onto your right
thumb using your left hand
Observe for reflex contraction of the biceps and/ or jerk of the forearm

Check the triceps reflex (C7)

Support patient s forearm at his elbo
While the forearm is hanging loose at a right angle to the arm, use tendon hammer to strike
the triceps tendon
Observe for reflex contraction of the triceps and/ or extension of forearm

Check the brachioradialis/ supinator reflex (C6/ C7)

Strike the brachioradialis tendon (at its insertion at the base of the wrist into the radial
styloid process (radial side of wrist around 4 inches proximal to base of thumb))
directly with a reflex hammer when the patient's arm is relaxing
The reflex should cause slight wrist extension and/or radial deviation, supination and
slight elbow flexion

Comment on patient s refle response: normal? Increased or brisk? Diminished? Absent?

Present only with reinforcement?

H a Re e
Place our right inde finger under the DIP joint of patient s middle finger, and left hand to hold pro imal and middle phalanges
Use our right thumb to flick patient s middle finger do n ards
Look for any pathological refle fle ion of patient s thumb
Hoffmann's reflex is often erroneously called 'the Babinski's sign of the upper limb'. However, the two reflexes are quite different, and
should not be equated with each other.
A positive Babinski sign is considered a pathological sign of upper motor neuron disease except for infants, in whom it is normal.
Whereas, a positive Hoffmann's sign can be present in an entirely normal patient. A positive Hoffman's sign in the normal patients is
more commonly found in those who are naturally hyper-reflexive (e.g. 3+ reflexes). A positive Hoffmann's sign is a worrisome finding
of a disease process if its presence is asymmetrical, or has an acute onset, and it reflects hypertonia, but not a useful sign in insolation

Finger Jerk
Place our middle and inde fingers across palmar surface of patient s pro imal phalanges
Tap your own fingers with the tendon hammer
Watch for fle ion of patient s fingers

Motor System in Lower Limbs

General Inspection
How is the mental state of the patient? Is the patient alert, conscious and responsive? Any abnormal gross movements?
Gait
Ask the patient to walk to the end of the room and back
Assess posture, arm swing, stride length, base, speed, symmetry, balance and for any abnormal movements
Listen for any slapping sound of a foot drop gait

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Ask patient to walk first on tip toes, then on the heels. Ankle dorsiflexion weakness (foot drop) is much more common than
plantar flexion weakness, and foot drop makes walking on heels difficult or impossible
Inspection and Palpation of Lower Limbs
With patient lying supine, check both lower limbs for any:
Asymmetry and deformities in lower limbs?
Muscle wasting? Palpate both sides and compare bulk
Muscle spasms?
Fasciculations?
Tremors?
Involuntary movements?
Dystonia sustained muscle contractions leading to twisting, repetitive movements and sometimes tremors. It may be
focal, e.g. torticollis (twisted neck) or global
Athetosis brief random purposeless movement which may affect various parts of the body but commonly the arms
Ballism violent flinging movements sometimes affecting only one side of the body (hemiballismus)

Tone
Ask patient to fully relax both legs
Leg roll roll the patient s leg and watch the foot. It should flop independently of the leg

Leg lift briskly lift leg off the bed at the knee joint and observe movement of the heel, then drop the leg
The heel should remain in contact with the bed, but increased tone may cause it to lift off the bed due to failure of relaxation

Ankle Clonus (check if tone is increased)

Support patient s legs, ith both knee and ankle resting in 90 degrees fle ion
Briskly dorsiflex and partially evert the foot, sustaining the pressure. Clonus is felt as repeated beats of dorsiflexion/ plantar
flexion
Spasticity is velocity-dependent resistance to passive movements, and is detected with quick movements, feature of UMNL.
It is usually accompanied by weakness, hyperreflexia, an extensor plantar response and sometimes clonus. In mild forms, it
is detected at the beginning or end of passive movement. In severe cases, it limits the range of movement and may be
associated with contracture.
Rigidity is a sustained resistance throughout the range of movement and is most easily detected when the limb is moved
slo l . In parkinsonism, it is described as lead pipe rigidit . In the presence of a parkinsonian tremor, there ma be regular
disruption of movement giving it a jerky feel (cogwheel rigidity).
Clonus is a rhythmic series of contractions evoked by sudden stretch of muscle and tendon. Unsustained clonus (<6 beats)
may be physiological. When sustained, it indicates UMNL and is accompanied by spasticity.

Power
Principles
Do not test every muscle movement in most patients
Ask about pain which may interfere with testing
Test lower limb power with patient lying supine
Ask patient to perform a movement before ou provide an opposing force, as ou ould like to first test patient s abilit to
overcome gravity (grade 3). Then apply resistance (at correct locations, e.g. to test power of hip flexion, press on the thigh
NOT the legs)
Check for grade 2 movements, by eliminating gravity for patient (e.g. performing movements horizontally with vertical support)
if patient is unable to overcome gravity.
Differentiation between grade 4 and 5 can be quite subjective
Grading of Power
Grade 0 Complete paralysis with no contractions seen
Grade 1 Flicker or trace of contraction
Grade 2 Active movement through full range of motion, but possible only if gravity is eliminated
Grade 3 Active movement through full range of motion, and against gravity but not against resistance
Grade 4 Active movement through full range of motion, and against some or moderate resistance
Grade 5 Normal power. Active movement through full range of motion, and against full resistance, or
even overcome resistance

Recommended movements to be tested for power

Movement Muscle Nerve/ root
Hip flexion Iliopsoas Iliofemoral nerve L1, L2
Hip extension (patient lies prone) Gluteus maximus Sciatic nerve L5, S1

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Knee flexion Hamstrings Sciatic nerve S1
Knee extension (can check in prone position) Quadriceps Femoral nerve L3, L4
Ankle dorsiflexion Tibialis anterior Deep peroneal nerve L4, L5
Ankle plantar flexion Gastrocnemius and soleus Tibial nerve S1, S2
Dorsiflexion of great toe Extensor hallucis longus Deep peroneal nerve L5
Ankle eversion Peronei Superficial peroneal nerve L5, S1
Ankle inversion Tibialis posterior Tibial nerve L4, L5
When assessing power of hip flexion, remember to stabilise the pelvis, and press on the thighs, not legs.
When assessing power of knee flexion and extension, stabilise the knee joint, by asking patient to rest the knee on your left
hand to eliminate hip joint movement
Always stabilise joint to eliminate all other joint movements

Deep Tendon Reflexes

Use reinforcement whenever a reflex appears to be absent. For reflexes in the lower limb, ask patients to
interlock fingers and pull one hand against the other on your command, immediately before you strike the
tendon (Jendrassik s manoeuvre)

Check knee reflex (L3/ L4)

Patient s heel ma or ma not be rested on the couch, as long as the leg is full rela ed
Palpate for the patella, and strike at the patella where the tendons of the quadriceps insert
After the tap of a hammer, the leg is normally extended once and comes to rest. The absence
or decrease of this reflex is problematic, and known as Westphal's sign. This reflex may be
diminished or absent in lower motor neuron lesions and during sleep. On the other hand,
multiple oscillation of the leg (pendular reflex) following the tap may be a sign of cerebellar
diseases. Exaggerated (brisk) deep tendon reflexes such as this can be found in upper motor
neuron lesions, hyperthyroidism, anxiety or nervousness.
Check ankle reflex (L5/ S1)
Have the patient s ankle to be tested to cross over the contralateral leg.
Ask patient to relax completely.
Passively dorsiflex the foot slightly, and strike the Achilles tendon

Superficial Reflexes
Plantar reflex (S1)
The lateral side of the sole of the foot is rubbed with a blunt instrument or device (usually the sharp end of
tendon hammer, but used obliquely) so as not to cause pain, discomfort, or injury to the skin; the instrument
is run from the heel along a curve to the toes (metatarsal pads)
Watch both the first movement of the great toe and the other leg flexor muscles. Normal response is flexion
of the great toe with flexion of other toes

A true Babinski sign:

Involves activation of the extensor hallucis longus tendon (not involvement of the entire foot, which is a
common withdrawal response to an unpleasant stimulus)
Coincides with contraction of other leg flexor muscles
Is reproducible

You do NOT need to check for other superficial reflexes under this examination, but I will just put these here for your
information:
Abdominal Reflexes (T8-T12)
Patient should be lying supine and relaxed
Stroke the upper and lower quadrants of the abdomen in a medial direction
Normal response is the contraction of underlying muscle, with umbilicus moving laterally or up
or down depending on the quadrant tested

Cremasteric Reflex (L1-L2) in males only

Usually checked to differentiate testicular torsion from acute epididymitis
Abduct and e ternall rotate the patient s thigh
Stroke the uper medial aspect of the thigh
Normally testis of the side stimulated will rise briskly
Lost in testicular torsion

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Examination of Specific Peripheral Nerves ( bab c e OSCE)

Median Nerve
May be compressed as it passes between flexor retinaculum and carpal bones at wrist (carpal
tunnel syndrome); most common entrapment neuropathy which initially produces sensory
symptoms
Look for any wasting in thenar eminence
Test for any altered sensation over hand involving thumb, index and middle finger and
lateral half of ring finger
Test thumb abduction ith patient s hand held palm up on a flat surface, and ask patient
to move thumb vertically against your resistance (abductor pollicis brevis)
Test opposition by asking patient to touch thumb and ring together while you attempt to
pull them apart (opponens pollicis)
For carpal tunnel syndrome,
Perform Phalen test
The patient is asked to hold their wrist in complete and forced flexion (pushing the dorsal surfaces of both hands together) for
30 60 seconds.
Perform Reverse Phalen test
This test is performed by having the patient maintain full wrist and finger extension for two minutes.
Check for any T e performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins
and needles" in the distribution of the nerve

Radial Nerve
May be compressed as it runs through the axilla, or injured in fractures of humerus. Typically cause wrist drop
Inspect for any wrist drop
Test for any weakness of arm and forearm extensors
Look for any sensory loss over dorsum of hand and any loss of triceps tendon reflex

Ulnar Nerve
Most commonly affected at elbow by external compression or injury such as elbow dislocation
Inspect for any wasting of interossei, which manifests as dorsal guttering
Test for an eakness of finger abduction ith patient s fingers on a flat surface, and
ask him to spread the fingers against your resistance
Test adduction b placing a card bet een patient s fingers and pulling it out using our
own fingers
Assess for any sensory loss on ulnar side of hand

Common Peroneal Nerve

Typically presents with foot drop. May be damaged in fibular head fractures, or compressed particularly in immobile patients or
because of repetitive squatting or kneeling
Test for any weakness of ankle dorsiflexion and eversion. Inversion will be preserved
Test for any sensory loss over dorsum of foot

Lateral cutaneous nerve of thigh

May be compressed as it passes through inguinal ligament
Test for any disturbed sensation over lateral aspect of thigh

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Cerebellar and Coordination Examination
*examination sequence may vary. The sequence below was rearranged to make things easier for the patient
General Inspection
How is the mental state of the patient? Is the patient alert, conscious and responsive?
Any abnormal gross movements?
Observe the posture of the patient. In cerebellar disease, head is often rotated and flexed, and shoulder on the lesion side is
lower
Gait
Ask the patient to walk to the end of the room and back
Assess posture, arm swing, stride length, base, speed, symmetry, balance and for any abnormal movements
Any broad-based gait can be seen?
Tandem gait
Assess tandem gait by asking patient to walk heel to toe in a straight line. Demonstrate for the patient and ask him to copy
and follow.
This emphasises any gait ataxia
Cerebellar dysfunction leads to broad-based, unsteady/ ataxic gait which makes walking heel to toe in a straight line impossible

Stance
Ask patient to stand with his bare feet close together and eyes open. Check if the patient sways. Swaying, lurching and inability to
stand with feet together with the eyes open suggest a cerebellar ataxia

R be e
Ask patient to close their eyes but be prepared to steady/ catch the patient. Repeatedly falling is a positive result (sensory ataxia)

Truncal ataxia
Asks patient to sit on edge of bed and cross arms across, observes for unsteadiness of trunk. Those having midline cerebellar
lesions tend to fall.
Check for any Dysarthria (let the patient sit at edge of bed)
Listen to patient s spontaneous speech
Ask patient to say, British constitution
Note patient s volume, rhythm and clarity
Cerebellar dysarthria may be slow and slurred (staccato speech)
Check for any Nystagmus
Perform the H test
Hold your finger at an arm s length away from and in front of patient
Ask patient to look at your finger and follow it with his eyes without moving your head
Move your finger steadily in a H shape. Ensure that the H is large enough that the eyeball can undergo full range of movements
Observe patient s eyes carefully for any nystagmus

If nystagmus is present, note:

position that it occurs
direction where it is most marked
whether it is horizontal, vertical, rotatory or multidirectional
whether there are fast and slow phases (jerk) or equal oscillations about a midway point (pendular)

Nystagmus
Peripheral vestibular nystagmus often has horizontal, vertical and rotatory components, and is usually associated with vertigo.
Central vestibular nystagmus is usually unidirectional, does not alter with direction of gaze or with visual fixation, and vertigo
is less prominent. Common causes include cerebrovascular disease and multiple sclerosis
Vertical nystagmus is uncommon and indicates brainstem damage. Upbeat nystagmus, with the fast phase on looking
upwards, occurs with upper brainstem lesions in multiple sclerosis, infraction and Wernicke s encephalopathy (which occurs
in vitamin B1 deficiency). Downbeat nystagmus may result from lesions around cranio-cervical junction, phenytoin or lithium
intoxication. Demyelination of the medial longitudinal fasciculus within brainstem can cause ataxic nystagmus, where the
oscillations are more marked in the abducting eye than in the adducting eye, which is often associated with internuclear
ophthalmoplegia with reduced adduction (refer to PBL Multiple Sclerosis)

Limb Coordination
While the patient is still sitting at the edge of the bed, check the coordination in his upper limbs

Finger-to-nose test
Hold your finger just within the patient s arm s reach. You should make the patient use
her arm fully outstretched
Ask the patient to touch her nose with the tip of her index finger and then touch your
finger tip
Ask her to repeat movement between nose and your finger (the target finger) as quickly
as possible

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To make the test more sensitive, change the position of your finger, however timing is crucial. Move your finger just as the
patient s finger is about to leave her nose to prevent false-positive ataxia
Note for any intention tremor, and past-pointing/ dysmetria

Rapid alternating movements

To check for any dysdiadochokinesia (dys = bad; diadochos = succeeding; kinesia = movement), demonstrate repeatedly
patting the palm of your hand with the palm and back your other hand as quickly and regularly as possible
Ask patient to copy your actions
Ask patient to repeat with opposite hand
Note for any slow, disorganised, and irregular movements

For coordination in lower limbs, have the patient to lie supine

Heel-to-shin test
With patient lying supine, ask him to place his heel on his opposite knee, and then slide his heel up
and down the shin between ankle and knee

Tone
Now that the patient is lying supine, assess the patient s tone in both upper limbs and lower limbs like how you did for the motor
examination. Note for any hypotonia in cerebellar diseases

Knee Jerk Reflex

Check knee jerk reflex to look for any pendular reflex (oscillation of legs in knee jerk reflex) which can occur in cerebellar diseases

Examination of Cranial Nerves

*RECAP on functions of cranial nerves if ou can t recall
CN 1 (Olfactory Nerve)
Testing of smell is of limited clinical value, and rarely performed. In OSCE, just ask patient if they experienced changes in smell
Hyposmia or anosmia may result from ENT diseases, damage to olfactory filament after head injury or local compression or
invasion by basal skull tumours
Disturbance in smell may also occur in pre-s mptomatic stages of Parkinson s and Al heimer s diseases
Hypogeusia/ ageusia (loss of taste) may occur together

CN 2 (Optic Nerve)
In OSCE, examination of function of optic nerve will be only part of the E a a eE e
Inspection of Eyes (not specific to optic nerve examination)
Check the following:
Is the head position normal? Longstanding paralytic squint often causes abnormal head posture with head turned or tilted to
minimise the diplopia
Position of eyelids when looking straight and on eye movement (any lid retraction etc.)
Proptosis, or for ard bulging of the e eball (check from patient s sides)
Periorbital appearance
Any dry eyes or excessive tearing
Eyelid margin for any narrow palpebral fissure which suggests ptosis
Conjunctiva for any redness or chemosis (oedema) of white of eye
Sclera for any redness or other colour changes
Resting appearance of pupils if visible any miosis or mydriasis can be seen? Compare shape and symmetry
Any strabismus can be seen?
Any nystagmus can be seen?

Visual Acuity (pupil and lens function)

Ask patient to put on their distance glasses if they use them (best corrected vision)
Ensure good ambient lighting
Place a Snellen chart 6 metres away from the patient
Ask patient to cover one eye at a time, and read out the entire row which contains the smallest
letters that he can see. If patient reads the entire row correctly, ensure that patient really cannot
read the row below. If patient does not read the entire row correctly, go to the row just above
and ask patient to read out the letters that you point, then go back to the row that the patient
chose to read from
Repeat with the other eye

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Snellen visual acuity is expressed as 6 (the distance at which the chart is read) over the number corresponding to the lowest line
read. This indicates the distance at which someone with normal vision should be able to read that line. For example, a Snellen visual
acuity of 6/60 indicates that at 6 metres patient can only see letters that they should be able to read 60 metres away. A (perfectly)
normal vision is 6/6.

If patient cannot see the top line/ letter of the chart at 6 metres, bring them forward till they can see,
and record that vision. E.g. 1/60 means they can see the top letter at 1 metre, when normal people
should be able to see it from 60 metres away
If patient still cannot see the top line/ letter at distance of 1 metre, check whether they can count
fingers, see hand movements, or just see light
Repeat the process above for near vision, with patient wearing any reading glasses (best corrected
vision). Hold the near vision test card at about 14 inches/ 35 cm from patient s e es, and ask patient
to read the smallest line seen

Common Refractive Errors:

Hypermetropia (long-sightedness): rays of light from a distant object are focused behind the retina
Myopia (short-sightedness): rays from a distant object are focused in front of the retina
Presbyopia (impaired power of accommodation for near objects) occurs as the lens ages and is less able to change its
curvature
Astigmatism is when the cornea is irregularly curved, preventing light rays being brought to a common focus on the retina

Colour Vision
Mention using Ishihara chart to assess patient s colour vision

Macular Function (if Amsler grid is provided)

Use Amsler grid to record visual defects
Ask patient to cover one eye, hold the grid at comfortable reading distance, fix on
the central black spot with tested eye, and keep eye still and look at grid using the
sides of his vision.
Ask patient to outline with a finger the areas where the lines are broken, distorted
or missing

Visual Fields
Sensory inattention
Test both eyes together. Both you and patient keep both eyes opened. Ensure one arm length distance between you and
patient
Placed hands in upper outer quadrant within both patient and your visual field, with index finger and middle finger pointing out
Wiggle one or two fingers at randomly, and each time ask patient whether he sees 1 or 2 fingers wiggling, and which side he
sees fingers wiggling.
Repeat by testing the lower outer quadrant of the patient s visual field
Note whether patient reports seeing only one side move, and which side or quadrant is affected

Peripheral visual field

Test each eye separately. Ensure one arm length distance between you and patient
Ask patient to cover one e e and look directl into our opposite e e. Shut our e e that is opposite the patient s covered e e
Test each quadrant separately with a wiggling finger. Hold the target equidistant between you and the patient
Start peripherally and move your wiggling finger diagonal towards the centre of vision until patient detects it
Repeat for all other quadrants
Compare the patient s visual field ith ours. Comment on any loss or
reduced visual field of the patient, on which side and which quadrant.

Central visual field (if you are provided with a red hatpin)
Test each eye separately using a red hatpin
Shut our e e that is opposite the patient s covered e e
Ask the patient to cover one eye and look directly at your open eye
Hold the hatpin in the centre of the visual field, as close to fixation as possible
Ask the patient hat colour the hatpin is. A pale or pink response implies colour desaturation,
usually because of a lesion affecting the optic nerve
Compare the four quadrants of the visual field centrally; each time ask about colour desaturation

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Accommodation Reflex (CN2, 3)
With patient s vision fi ed on a distant point, present our inde finger about 15 cm in front of the patient s e es
Ask patient to focus on it (convergence) as ou move our finger to ards patient s nose (don t touch his nose la)
A normal accommodation reflex response: eyeballs convergence, pupillary constriction and increased convexity

Pupillary Light Reflex (CN2, 3)

Ask patient to fix his eyes on a distant object straight ahead. Ask patient to place his ulnar border of hand in between his eyes
Bring a bright torchlight (please use the yellow light for patient comfort) from the side to shine on the pupil.
Look for constriction of that pupil (direct light reflex)
Repeat and look for constriction of the opposite pupil (consensual light reflex)
Record pupil size in mm and note for any asymmetry or irregularity

Swinging-flashlight test
To identify a relative afferent pupillary defect.
For an adequate test, vision must not be entirely lost. In dim room light, the examiner notes the size of the pupils. The patient
is asked to gaze into the distance, and the examiner swings the beam of a penlight back and forth from one pupil to the other,
and observes the size of pupils and reaction in the eye that is lit.
Interpretation
Normally, each illuminated pupil promptly becomes constricted. The opposite pupil also constricts consensually.
When ocular disease, such as cataract, impairs vision, the pupils respond normally.
When the optic nerve is damaged, the sensory (afferent) stimulus sent to the midbrain is reduced. The pupil, responding
less vigorously, dilates from its prior constricted state when the light is moved away from the unaffected eye and towards
the affected eye. This response is a relative afferent pupillary defect

As a part of the examination of the eye, you would also check for the following which are not part of CN2 examination:
Ocular movements through H test (CN 3,4,6 and Thyroid)
Lid Lag (Thyroid)
Mention completing eye examination with fundoscopy (Refer to Endocrine System Module)

CN 3, 4, and 6 (Oculomotor, Trochlear and Abducens Nerve)

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Please take note of how the H test works:
Look at the right eye, where RIO is labelled. The function of RIO,
the right interior oblique, is tested hen the patient s e eball is
elevated when ADDUCTED, although it is stated in the table
above that the inferior oblique ABDUCTS and elevates the
eyeball.
This is because when the eyeball is adducted first before being
elevated (when you carry out the H test), the superior rectus,
which elevates and adducts eyeball at the same time, will not be
the main muscle acting, as the eyeball was ALREADY adducted,
hence the inferior oblique, which is also capable of elevating
eyeball even when eyeball is already adducted (as it is able to
abduct the eyeball), will be the main acting muscle.
The same principle applies to RSR, RSO and RIR.

Inspection (specific for CN 3, 4, and 6)

Look for any strabismus, and head turns or tilts in the direction of any underacting ocular muscles
H Test
Hold your finger at an arm s length away from and in front of patient
Ask patient to look at your finger and follow it with his eyes without moving your head
Move your finger steadily in a H shape. Ensure that the H is large enough that the eyeball can undergo full range of movements
Observe patient s eyes carefully for any nystagmus (not relevant to CN3,4,6 dysfunction, but you would also check)
Ask patient to inform you whenever he sees more than 1 finger, and note the position of eye/ the H where he sees double
vision (diplopia)
If nystagmus is present, note:
position that it occurs
direction where it is most marked
whether it is horizontal, vertical, rotatory or multidirectional
whether there are fast and slow phases (jerk) or equal oscillations about a midway point (pendular)

CN 5 (Trigeminal Nerve)
Sensory

Ophthalmic nerve (V1): sensory

Maxillary nerve (V2): sensory
Mandibular nerve (V3): sensory and motor

Use principles of sensory examination: Use the sternum as a reference point for the cotton wool or wooden stick and inform
patient that this is what they can expect to feel
Ask patient to close eyes, and sa es each time he feels ou lightl touch them using a cotton ool tip. Do this in areas of
V1, V2, and V3. Remember that angle of jaw is not served by the trigeminal nerve. Remember to progress at irregular interval
Repeat using a wooden stick to check pain sensation
Compare both sides
Perform nasal tickle test if equipment and time is provided. Use a isp of cotton ool to tickle the inside of each nostril and
ask patient to compare, whether the unpleasant sensation is easily appreciated
Corneal reflex (inform patient first if you are performing)
Gently depress the lower eyelid, instruct patient to look upwards, lightly touch the lateral edge of cornea with a wisp of damp
cotton wool. Check for direct and consensual blinking.

Unilateral loss of sensation in one or more branches of facial nerve may result from direct injury in facial fractures (especially
V2) and local invasion by cancer. Lesions in cavernous sinus (e.g. cavernous sinus thrombosis) often causes V1 or V2
cutaneous sensory loss, and loss of corneal reflex, and involvement of CN3,4,6
Trigeminal neuralgia, often due to neurovascular compression, causes severe pain typically in distribution of V2 and V3
Reactivation of herpes varicella zoster virus typically affects either a thoracic dermatome or V1
Motor (mastication)
Inspect for wasting of muscles of mastication (most apparent in temporalis)
Ask patient to clench teeth as you feel the masseters, estimating the bulk and compare both sides
Repeat for temporalis
Place your hand under the jaw to provide resistance, ask the patient to open his jaw. Note any
deviation
Jaw jerk
Ask patient to let his mouth hang loosely open
Place your forefinger in the midline between lower lip and chin

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Strike your finger gently with tendon hammer in a downwards direction. Noting any reflex closing of the jaw. An absent,
or just present reflex is normal
Brisk jaw jerk can be seen in pseudobulbar palsy (UMNL)

CN 7 (Facial Nerve)
Inspection of Face
Inspect face for any asymmetry. Check for any loss of wrinkles over forehead, any loss of nasolabial fold on any side, and
compare angles of mouth on both sides (any drooping?)
Watch for any spontaneous or involuntary movements (fasciculations?)

Sensory
Ask patient if he noticed any changes in taste sensation or loss of taste (chorda tympani nerve and taste in anterior 2/3 of tongue)

Motor
Ask patients to do several facial expressions to check the facial muscles:
Ask him to raise his eyebrows and observe for symmetrical wrinkling of forehead
Ask him to smile and show his teeth
Ask patient to close eyes tightly against resistance as you attempt to open his eyes
Ask patient to blow out his cheeks. Ask patient to keep his mouth shut tightly as you press lightly to check if air leaks out of
mouth

In unilateral lo er motor neurone lesion of CN7, there is eakness in both upper and lo er facial muscles. Bell s pals is a
common condition presenting with acute LMNL of CN7
In unilateral CN7 upper motor neurone lesion, there is relative sparing of upper face due to bilateral cortical innervation of
upper facial muscles. Nasolabial fold may be flattened, drooping of mouth corner may be present, but eye closure is usually
preserved.
Bilateral facial nerve palsies are less common, but may occur in Lyme disease, Guillain Barre syndrome, sarcoidosis and HIV.

CN 8 (Vestibulocochlear Nerve)
In OSCE, examination of function of vestibulocochlear nerve ma onl be part of Ear E amination
If conductive hearing loss is suspected, perform the neurological testing of hearing to identify the type of hearing loss, before doing
otoscopy to identify the cause/ source of the hearing loss
Inspection of Ear
Inspect the pinna/ external ear including the posterior part of pinna for any skin erythema, swelling, discharge, deformities, scars etc.
Inspect the mastoid area for any swelling and erythema

Palpation
Palpate the mastoid area and ask patient for any tenderness (mastoiditis)
Gently pull the pinna and check for any pain before performing otoscopy

Otoscopy
Use the largest otoscope speculum that can fit comfortabl in the patient s e ternal auditor meatus, and attach it to the
otoscope firmly. Ensure that the otoscope is functioning and emitting light
Examine the normal ear first. Use your right hand to hold the otoscope when examining the right ear, and use left hand for left
ear
While examining the right ear, use your left hand to gently pull the upwards and backwards to straighten the cartilaginous
external auditory meatus. Hold the otoscope as if you are holding a pen, and rest the ulnar border of your hand on the patient s

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cheek firmly but gently, and insert the earpiece slowly, gently and not too deeply, and stop once you can see the tympanic
membrane
Through the viewing window, inspect the wall and lumen of the external auditory canal for evidence of inflammation, abrasions,
and skin lesions such as vesicles of herpes zoster. Blood and discharge may be visible as well. While inspecting the wall,
minimise your wrist movements to prevent causing pain to the patient
Note presence of ear wax which may obstruct view of tympanic membrane
Look for the grey tympanic membrane with the handle of the malleus in the middle and a cone
of light at 4 5 o clock position on the right (and 7 8 o clock position on the left).
Inspect the tympanic membrane for:
Loss or blurring of the cone of light early evidence of otitis media
Colour erythema of otitis media, dark red of hemotympanum
Swelling/bulging presence of fluid/pus/blood
Defects perforation of the tympanic membrane
Abnormal growth cholesteatoma
Presence of a grommet (trans-tympanic tube for drainage of fluid/pus in chronic otitis media)
Repeat for the left ear but use your left hand to hold the otoscope, and right hand to pull the pinna.

Hearing Tests
Whisper test
Inform patient that you will be whispering some words into his ears, and ask him to repeat what you said
Stand behind patient, ith our mouth at about 15 cm a a from patient s ear that ou are testing. Have patient to cover the
other ear that is not tested
Whisper some words from where you are. Use combination of multisyllable numbers and words. Ensure that patient really
understands how the test works by speaking using normal voice and ask patient to repeat. Inform patient that you will be now
whispering instead
Repeat for the other ear
Repeat the test at one arm s length from patient s ear
R e e ( se 512 Hz tuning fork)
2 methods:
First method: Inform patient that you will be placing the vibrating tuning fork on his (1) at the back of his ear (tell him that this
is the First Sound), and then (2) 2 cm next to his ear (this is the Second Sound), and tell you when the sound stops (as you
force stop the tuning fork after the 2nd sound)
Ask patient to close his eyes, as you place the vibrating tuning fork on the base of the mastoid process and ask patient if he
can really hear the tuning fork. Next, place the tuning fork next to the ear. Ask patient if the First Sound or Second Sound is
louder. Normal result (Rinne positive) is when the Second Sound (Air conduction) is louder than First Sound (Bone conduction)
Second method: Ask patient to close his eyes, as you place the vibrating tuning fork on the base of the mastoid process and
ask patient if he can really hear the tuning fork Ask patient to tell you when the sound on the mastoid process stops, as you
immediately place it next to his ear, ask again if he can still hear the tuning fork, and force stop to confirm that patient can hear
the sound. Rinne positive if patient can still hear the tuning fork next to his ear after sound at mastoid process has disappeared.
Comment on whether Rinne positive or Rinne negative in both ears
Webe e (use 512 Hz tuning fork)
Place the vibrating tuning fork in the middle of patient s forehead and ask if patient hears the sound equally on both sides, or whether
the sound is louder on any side. Comment whether there is any lateralisation

Vestibular Function Tests

Testing for nystagmus (H test)
Hold your finger at an arm s length away from and in front of patient
Ask patient to look at your finger and follow it with his eyes without moving your head
Move your finger steadily in a H shape. Ensure that the H is large enough that the eyeball can undergo full range of movement
Observe patient s eyes carefully for any nystagmus
If nystagmus is present, note the following:
Whether the nystagmus is horizontal, vertical or rotatory
Which direction of gaze cause the most marked nystagmus
In which direction the fast phase of jerk nystagmus occurs
Whether the jerk nystagmus changes direction when direction of gaze changes
If nystagmus is more obvious in one eye than the other

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Mention performing the Dix-Hallpike positional test (not taught in CSSC)
Ask patient to sit upright, close to the edge of the couch. Warn patient about what you are going to do:
Turn patient s head 45 degrees to one side (lateral
rotation)
Rapidly lower the patient, so that the head is now
30 degrees below the horizontal. Ask patient to
keep their eyes open even if they feel dizzy
Watch the eyes carefully for any nystagmus.
Repeat the test by turning the head laterally 45
degrees to the other side

Me e U e be e e
Ask patient to march on the spot with his eyes closed. The patient will rotate to the side of a damaged labyrinth
Mention performing Fistula test
Repeatedly compress the tragus (projection of ear immediately in front of ear canal) against external auditory meatus to occlude the
meatus. If this produces a sense of imbalance or vertigo with nystagmus, it suggests an abnormal communication between middle
ear and vestibular apparatus, such as erosion due to cholesteatoma

CN 9 and 10 (Glossopharyngeal and Vagus Nerve)

Listen to patient s speech (b asking patient ho he is doing, casual talk) and assess patient s speech for d sarthria, or dysphonia
such as hoarseness of voice
Mouth examination: Ask patient to sa Ah as ou observe movements of soft palate and uvula
Normally, both sides of palate elevate symmetrically, and uvula remains in midline
Unilateral CN 10 damage causes ipsilateral reduction in elevation of soft palate, and deviation of uvula away from the affected sid
Ask patient to puff out his cheeks with lips tightly sealed. Listen for any air escaping from the nose. For the cheeks to puff out, the
palate must elevate and occlude the nasopharynx. If palatal movement is weak, air will escape audibly through the nose
Ask patient to cough. Assess the strength of cough. Any bovine cough can be heard?
DO NOT test pharyngeal sensation and pharyngeal gag reflex. Instead, in a fully conscious patient, perform the Swallow Test:
Administer 3 teaspoons of water in a row and ask patient to swallow. Observe for any absence of swallowing, cough or delayed
cough, or change in voice quality after each teaspoon.
If there are no abnormalities, watch for the same reactions as patient swallows a glass of water

CN 11 (Accessory Nerve)
Look and Feel
From the patient s front, inspect the sternocleidomastoid (SCM) muscle for an asting or h pertroph . Palpate to assess bulk
Stand behind patient to inspect trapezius muscle for any wasting or asymmetry

Movements
Ask patient to shrug their shoulders, then apply downward pressure with your hands, ask patient to resist. Assess the power of
trapezius

To test the power of left SCM, ask patient to turn the head to the RIGHT, while you provide resistance with hand placed on right side
of patient s chin. Test the po er of right SCM b reversing the step above

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CN 12 (Hypoglossal Nerve)
Inspect the patient s tongue for an asting, fasciculation or involuntar movements
Ask patient to stick out his tongue, and look for any involuntary movement and deviation. Unilateral lower motor neurone of
CN 12 lesion causes tongue muscle wasting on the affected side, and deviation to the affected side on protrusion
Ask patient to move his tongue quickly from side to side
Test power by asking patient to press tongue against the inside of each cheek while you press from the outside. Ask patient
to resist and do not let you push his tongue inwards
Ask patient to sa , Yello Lorr as ou assess speech
Perform s allo test as described above. Refer to CN 9 and 10

E a a Me ea I a ( bab c e OSCE)
*position patient supine with no pillow
*e pose and full e tend both patient s legs

Neck Stiffness
Support patient s head with your fingers at the occiput, and ulnar border of your hands against paraspinal muscles of patient s
neck
Flex patient s head gently until his chin touches his chest
Ask patient to hold that position for 10 seconds. If neck stiffness is present, neck cannot be passively flexed, and spasm can
be felt in neck muscles
Flexion of knees in response to neck flexion is Brud inski s sign

Ke
Fle one of patient s legs at hip and knee, ith our left hand placed over medial hamstrings
Use your right hand to extend knee while the hip is maintained in flexion
Look at the other leg for any reflex flexion
Kernig s sign is positive hen e tension is resisted b spasm in hamstrings

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Examples of Case Scenarios for Practice
Case 1****
Mr Z is a 65-year-old man who had suffered from intracranial haemorrhage 5 days ago.

Tasks:
1. Assess the patient using the Glasgow Coma Scale and record your findings using the chart provided
2. Measure the patient s pulse rate and blood pressure
Equipment provided: Glasgow Coma Scale chart, and sphygmomanometer

Case 2***
Mr AA, a 50-year-old man complains of weakness in both his lower limbs for 1 week

Perform a relevant neurological examination for both of his lower limbs and report your findings.

Ans: perform motor examination of lower limbs

Case 3***
Mr BB, a 50-year-old man complains of numbness over his right leg for 1 week.

Perform a relevant neurological examination for both of his lower limbs and report your findings.
Equipment provided: 128 and 512 Hz tuning fork, cotton wool

Ans: perform sensory examination of lower limbs

Case 4****
Ms CC, a 50-year-old lady complains of hearing loss.

Examine her ear, assess her hearing function and report your findings.
At the 6th minute, the examiner will ask you one question.
Equipment provided: Otoscope, earpieces, 128 and 512 Hz tuning fork

Appropriate introduction, confirming patient s identit , e plaining and obtaining consent /1

Inspect external ear for any abnormalities. Inspect the back of the pinna and mastoid area as well /3
Perform Rinne s test for both ears with clear instructions given to patient. Patient please say that Bone Conduction > Air /4
Conduction for both ears. Comment that Rinne negative for both ears
Perform Weber s test. Patient please say that left side is louder than right side. Comment that Weber lateralises left /3
Perform otoscope with correct handling of equipment, pulling the pinna correctly, inserting not too deeply, inspect auditory canal /5
and tympanic membrane, any excessive ear wax. May start with whichever ear student likes
QUESTION: Based on the results from the Rinne s and Weber s test, interpret our findings and state the t pe of hearing defect /2
that the patient is having
Ans: Conductive hearing loss in left ear, and combined conductive and sensorineural loss in right ear
Conductive hearing loss in both ears will only get 1 mark
Overall assessment on organisation, confidence, and communication skills with patient /5
Total = 23 marks

Case 5****
Mr DD, a 70-year-old man who has longstanding diabetes mellitus, complains of numbness in his foot.

Perform relevant examination for his feet, and report your findings
Equipment provided: Tuning fork 128 and 512 Hz, cotton wool

C a e Ta a bab c e OSCE*****
Task
Ms EE, a 45-year-old lady who was diagnosed with Hashimoto thyroiditis some time ago, complains of weight gain, cold intolerance and
numbness in her left hand.

Examine both her hands to check for signs of carpal tunnel syndrome.

Ans: carpal tunnel syndrome is an example of median nerve entrapment, refer to Median Nerve examination

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Semester 5 Clinical Block

Intramuscular Injection

Purpose
Promote rapid absorption of medication
Facilitate the instillation of a larger volume than in the subcutaneous layer of tissue (up to 5 millilitres)
For patients ho are uncooperative or can t take medication orall , and for drugs that are altered b digestive juices

Injection Sites
Deltoid Locate the lateral side of the humerus from two to three fingerwidths below the
acromion process in adults or one fingerwidth below the acromion process in children.

Dorsogluteal (upper outer quadrant) Locate greater trochanter to identify dorsogluteal site.
Locate posterosuperior iliac spine
Draw imaginary line between these 2 points
Inject medication directly into the upper outer quadrant at 90 degrees

Ventrogluteal Place palm of left hand on right greater trochanter so that index finger points towards
ASIS
Spread first and second fingers to form a V, injection site is the middle of the V

Vastus lateralis Identify greater trochanter

Place hand at lateral femoral condyle. Injection site is middle third of anterior lateral
aspect

Example of Calculation of Volume of Medication Administered

Calculate the volume to be drawn up if a patient requires 25mg of Diclofenac Sodium (Voltaren) injection and each ampoule contains 75mg/
3mls.
Strength Required X Volume = Volume to be
Stock Strength administered
25mg/ 75mg X 3mls = 1m

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Steps for the Procedure

Pre-performance Phase
Assemble equipment and check the order
Medication
Medication chart
Sterile syringe (3-5mls)
Sterile needle
Latex Gloves
Alcohol swabs
Injection tray/ Kidney dish
Sharps container
Clinical waste bin
Follow the 6 R right patient, right drug, right dose, right route, right time and right documentation to ensure correct
administration of drug
Explain the procedure (inject site, purpose of medication, sufficient exposure) and gain verbal consent to encourage
cooperation and to alleviate apprehension and anxiety
Wash hands to prevent transmission of microorganism
Don a pair of disposable gloves.

Preparing the Syringe and Needle

Check the expiry date of the syringe and needle.
Remove the syringe from the packaging taking care not to touch the nozzle to prevent contamination.
Remove the needle from its packaging.
Attach the needle to the syringe

Drawing out the medication

First, check if the medication has expired.
Never use medication that is cloudy or discolored. If unsure, consult the pharmacist.
For single dose ampoules, ensure that all the medication is at the bottom of the ampoule to avoid inadequate dosage of
medication.
Wrap an alcohol swab or gauze around the ampoules neck and snap off the top, directing the force away from your body.
Remove the needle cap from the needle by pulling it straight off.
Withdra the medication keeping the needle s bevel tip belo the level of the solution.
Check that the correct amount of medication has been drawn out.
Do not recap the needle.
Pull back the plunger slightly and use forceps to discard the needle and change to a new needle.
Tap the syringe to clear air from it.
Push the plunger slowly until a small droplet of medication is noted at the bevel.
For single dose or multi-dose vials, reconstitute the powdered drugs according to instruction.
Make sure all crystals have been dissolved in the solution.
Warm the vial by rolling it in between your palm to help the drug dissolve faster.
Wipe the top of the vial of medication with an alcohol swab.
Remove the needle cap from the needle.
Pull back on the syringe plunger to draw up an amount of air equal to the amount of medication needed
Holding the vial of medication in an upright position, insert the needle straight into the center of the rubber stopper in the vial.
Then push the plunger to discard all the air into the vial.
With the needle in the vial, turn the vial upside down and hold it in one hand. The tip of the needle should be in the solution.
Pull the plunger back in a slow, continuous motion until you have drawn into the syringe the amount of medication needed.
If air bubbles have formed in the syringe, dislodge them by gently tapping the syringe with your free hand while continuing to
hold the syringe and vial in the inverted position. Bubbles should rise to the top of the syringe, and then you can push them
back into the vial by moving the plunger.
Double check to make sure you have the correct amount of medication in the syringe.
Do not recap the needle.
Pull back the plunger slightly and discard needle using forceps. Change to a new needle.
Push the plunger slowly until a small droplet of medication is noted at the bevel.

Performance Phase
Provide privacy and expose the injection site. Ensure you have a chaperone
Ensure that you remain gloved to reduce contact with blood.
Locate the injection site.
Prepare the injection site by cleaning the area with an alcohol swab using friction in a circular motion.
Wait for a few seconds until the alcohol has dried.
Remove the needle cap from the needle by pulling it straight off and hold the syringe as you would hold a pencil using your
dominant hand.
Spread the skin at the injection site using your non-dominant hand to minimize discomfort. *grasp muscle for small size
patients.

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Insert the needle using a quick smooth motion at a 90 degrees angle. A quick injection is less painful. The 90 degrees angle
facilitates entry into the muscle tissue.
As soon as the needle is in place, move the non-dominant hand to hold the lower end of the syringe.
Slide the dominant hand to the top of the barrel.
Aspirate by slowly pulling back on the plunger and observing for blood. This is to determine whether the needle is in a
blood vessel. Discard the needle and inject another site if blood is aspirated. Discomfort and possibly a serious reaction may
occur if drug intended for intramuscular use is injected into a blood vessel.
If no blood is aspirated, inject the solution slowly. This helps to reduce discomfort by allowing time for the solution to disperse
into the tissue.
Slide back the dominant hand to the lower end of the barrel.
Use the non-dominant hand to spread the skin at the injection site.
Remove the needle quickly in the same direction as on insertion because slow removal of needle pulls the tissue and may
cause discomfort.

Post-performance Phase
Apply gentle pressure on the injection site. Do not massage the injection site. You may note a drop of blood but there is no
cause for concern.
To avoid needle prick injury, NEVER recap used needles. Discard them in the sharps bin.
Cover the patient and assist to a comfortable position.
Remove gloves and wash your hands
Document the administration accurately to prevent medication error
Evaluate the patient s response to the medication ithin an appropriate time frame usually between 15 to 30 minutes after
injection.
Record in the medication chart.

Subcutaneous Injection

Principle
The medication is injected beneath the epidermis into the fat and connective tissue underlying
the dermis, where is less blood flow and therefore a slower absorption rate.

Sites for subcutaneous injection

1. Lateral aspects of the upper arm
2. Umbilical region of abdomen (inject 2-3 inches from umbilicus)
3. The anterior aspect of the thigh
4. The upper back
5. The Posterior lateral of thigh
** For repeated injections rotates sites
***Avoid sites of abnormal subcutaneous tissue such as areas with burn scars,
birthmarks, inflamed tissue or scars.

Steps for the Procedure

Pre-performance Phase
Assemble equipment and check the order
A medication chart
The prescription drug. (This may be a pre-filled syringe where the medication has already been prepared and is ready
for administration)
A tray or receiver
A syringe of appropriate size (0.5-2mls) if not the pre-filled medication
A 25 - 27-gauge needle
Disposable glove
Alcohol swab
A sharp Bin
Clinical Waste Bin
Follo the 6 R s right patient, right drug, right dose, right route, right time and right documentation to ensure correct
administration of drug
Explain the procedure and gain verbal consent to encourage cooperation and to alleviate apprehension and anxiety
Wash hands to prevent transmission of microorganism
Don a pair of disposable gloves.
Preparing the Syringe and Needle
Check the expiry date of the syringe and needle.
Remove the syringe from the packaging taking care not to touch the nozzle to prevent contamination.
Remove the needle from its packaging.
Attach the needle to the syringe.
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Drawing out the medication
First, check if the medication has expired.
Never use medication that is cloudy or discolored. If unsure, consult the pharmacist.
Wipe the top of the vial of medication with an alcohol swab.
Remove the needle cap from the needle.
Pull back on the syringe plunger to draw up an amount of air equal to the amount of medication needed.
Holding the vial of medication in an upright position, insert the needle straight into the center of the rubber stopper in the vial.
Then push the plunger to discard all the air into the vial.
With the needle in the vial, turn the vial upside down and hold it in one hand.
The tip of the needle should be in the solution.
Pull the plunger back in a slow, continuous motion until you have drawn into the syringe the amount of medication needed.
If air bubbles have formed in the syringe, dislodge them by gently tapping the syringe with your free hand while continuing to
hold the syringe and vial in the inverted position.
Bubbles should rise to the top of the syringe, and then you can push them back into the vial by moving the plunger.
Double check to make sure you have the correct amount of medication in the syringe.
Remove the needle from the vial. DO NOT recap the needle.
Pull back the plunger slightly and discard needle using forceps. Change to a new needle.
Push the plunger slowly until a small droplet of medication is noted at the bevel

Performance Phase
Provide privacy and expose the injection site. Ensure you have a chaperone.
Ensure that you remain gloved to reduce contact with blood.
Locate the injection site.
Prepare the injection site by cleaning the area with an alcohol swab using friction in a circular motion.
Wait for a few seconds until the alcohol has dried.
Remove the needle cap from the needle by pulling it straight off and hold the syringe slanting using your dominant hand.
Pinch the skin at the injection site using your non dominant hand to lift the adipose tissue from the underlying muscle to prevent
the solution from being injected into the muscle.
Insert the needle smoothly into the SC skin at angle of 45 degree.
It is not necessary to draw back on the plunger to ensure the needle is not in the vein as it is unlikely that a blood vessel
will be pierced.
Inject the solution by pushing carefully and slowly on the plunger. Wait briefly before withdrawing the needle to help prevent
backtracking.
Use the swab to wipe any fine capillary blood that might be leaking away and apply gentle pressure on the injection site. Do
not massage the area.
Do not recap the needle as this may cause a needle stick injury. Discard the syringe and needle immediately into the sharps
container to prevent any injury.

Post-performance Phase
Cover the patient and assist to a comfortable position.
Remove gloves and wash your hands.
Document the administration accurately to prevent medication error.
Evaluate the patient s response to the medication ithin an appropriate time frame usuall bet een 15 to 30 minutes after
injection.
Record in the medication chart.

Using an Insulin Pen

Steps for the Procedure

Preparing the Insulin Pen

Remove pen cover or cap.
If using milky-white (intermediate-acting) insulin, gently roll pen between palms 15 seconds to mix.

Get the needle ready

A. Pull paper tab off pen needle. Pen needles are available in many sizes
B. Screw needle onto insulin end of pen.
C. Remove outer needle cover.
D. Remove inner needle cover to expose the needle. Throw inner needle cover in trash.

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Get the pen ready
A. Prime the pen and clear air from needle. This adjusts the pen and needle for good accuracy when
it's time to measure your insulin dose. Turn the dose selector knob at end of the pen to 1 or 2 units
(watch dose markings change with turning of knob).
B. Hold the pen with needle pointing upward. Press dose knob up completely while watching for
insulin drop or stream to appear. Repeat, if necessary, until insulin is seen at needle tip. The dial
should be back at zero after completing the priming step.

Dial Insulin Dose

Turn dose knob to "dial in" your insulin dose. (You can dial backward, too.) The pen will allow you
to receive only the amount that you have set. Double-check the dose window to assure your proper
dose

Select an injection site

The abdomen is the preferred place for many types of insulin--between the bottom of the ribs and pubic line, avoiding 2-3 inches
surrounding the umbilicus. The top of the thighs and back of upper arms (if you are flexible) may also be used.

Inject the Insulin

A. Curl fingers around the upper end of the pen to hold secure. Poise thumb, in air, above dose
knob.
B. Gently pinch up skin with your free hand.
C. Quickly insert the needle at a 90-degree angle. Release the pinch.
D. Use your thumb to press down on the dose knob until it stops (the dose window will be back
at zero). Leave the needle in place for 5-10 seconds to help prevent insulin from leaking out of
the injection spot (see package insert to learn timing recommendation for your pen).
Pull the needle straight out of the skin. It is normal to sometimes see a small drop of blood or
bruise. You may lightly pat the site with a tissue or cotton ball, but do not massage the area.

Preparing for future use

Place outer needle cover over needle and twist to unscrew needle from pen. Throw used needle away in the yellow sharp bin box.
Put the outer needle cover back on the pen.

END OF DOCUMENT

IMU-Group12 NOT FOR SALE ME2/15

IMU OSCE Students Notes ZhenZhe.2018 IMU-FPEPII

FINAL CHECK BEFORE GOING FOR OSCE (Clinical Examination)

International Medical University (IMU)
First Professional Examination Part II
OSCE Clinical Examination
Cardiovascular System
General
Specific
Peripheral
ECG
Respiratory System
General
Specific
Peak Flow Meter
Meter Dose Inhaler
Chest X-ray
Haematological System
General
Cervical Lymph Nodes
Axillary Lymph Nodes
Examination of Lumps and Bumps
Venepuncture
Gastrointestinal System
General
Specific
Digital Rectal Examination
Renal System
General for CKD
Specific
Relevant Chest Examination for CKD
Urine Dipstick
Urinary Catheterisation (I shall pray for you)
Endocrine System
Fundoscopic Examination
Glucometer
Thyroid Gland Examination
Assessment of Thyroid Status
Specific Endocrine Disorders Examination
Reproductive System
Antenatal Examination (Abdomen)
Pap Smear and Pelvic Bimanual Palpation
Breast Examination
Musculoskeletal System
GALS Screening
Shoulder Examination
Elbow Examination
Wrist and Hand Examination
Hip Examination
Knee Examination
Ankle Examination
Cervical Spine Examination
Thoracolumbar Spine Examination
Nervous System
Glasgow Coma Scale
Mini Mental State Examination
Upper Limb Sensory Examination
Lower Limb Sensory Examination
Diabetic Foot Examination
Upper Limb Motor Examination
Lower Limb Motor Examination
Examination of Specific Peripheral Nerves
Cerebellar Function Examination
Cranial Nerves Examination
Semester 5 Clinical Block
Intramuscular Injection
Subcutaneous Injection
Using Insulin Pen

ALL THE BEST FOR YOUR SEMESTER 5 OSCE!

IMU-Group12 NOT FOR SALE ME2/15