MED OSCE COMPLETE

Table of Contents
1.0 NEBULIZER...........................................................................................................................................10
1.1. PROCEDURE:...................................................................................................................................10
1.2. EXTRA INFORMATION:....................................................................................................................11
1.3. FURTHER QUESTIONS:....................................................................................................................11
2.0 PEAK FLOW..........................................................................................................................................12
2.1. PROCEDURE:...................................................................................................................................12
2.2. EXTRA INFORMATION:....................................................................................................................13
2.3. FURTHER QUESTIONS:....................................................................................................................13
3.0 MDI AND SPACER.................................................................................................................................14
3.1. PROCEDURE:...................................................................................................................................14
3.2. EXTRA INFORMATION:....................................................................................................................15
3.3. FURTHER QUESTIONS:....................................................................................................................15
4.0 PEDIATRIC BASIC LIFE SUPPORT AND ADVANCED CARDIAC LIFE SUPPORT.........................................16
4.1. PROCEDURE:...................................................................................................................................16
4.2. EXTRA INFORMATION:....................................................................................................................17
4.3. FURTHER QUESTIONS:....................................................................................................................17
5.0 ADULT BASIC LIFE SUPPORT AND ADVANCED CARDIAC LIFE SUPPORT...............................................18
5.1. PROCEDURE:...................................................................................................................................18
5.2. EXTRA INFORMATION:....................................................................................................................19
5.3. FURTHER QUESTIONS:....................................................................................................................19
6.0 PSYCHIATRIC MENTAL STATE EXAM....................................................................................................20
6.1. PROCEDURE:...................................................................................................................................20
6.2. EXTRA INFORMATION:....................................................................................................................21
6.3. INTERPRETATION:...........................................................................................................................22
6.4. FURTHER QUESTIONS:....................................................................................................................23
6.5. THEORY...........................................................................................................................................23
7.0 PSYCHIATRIC HISTORY.........................................................................................................................23
7.1. GENERAL:........................................................................................................................................23
7.2. STRESSORS:.....................................................................................................................................24
7.3. EFFECTS:.........................................................................................................................................24

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 7.4. SYSTEMIC REVIEW:.........................................................................................................................24
7.5. SUICIDE RISK ASSESSMENT:............................................................................................................24
7.6. HOMICIDE RISK ASSESSMENT:........................................................................................................25
7.7. PAST PSYCHIATRIC AND MEDICAL HISTORY:...................................................................................25
7.8. SUBSTANCE USE:.............................................................................................................................25
7.9. DEPRESSED MOOD HISTORY:..........................................................................................................25
7.10. PYSCHOSIS HISTORY:....................................................................................................................26
7.11. ANXIETY HISTORY:........................................................................................................................26
7.12. DEPRESSED MOOD CLINICAL CLUES:............................................................................................26
7.13. PSYCHOSIS CLINICAL CLUES:.........................................................................................................27
7.14. ANXIETY CLINICAL CLUES:.............................................................................................................27
7.15. TREATMENT IN PSYCHIATRY.........................................................................................................28
7.16. THEORY.........................................................................................................................................28
8.0 RHEUMATOLOGY EXAM......................................................................................................................30
8.1. INTRODUCTION:.............................................................................................................................30
8.2. HISTORY:.........................................................................................................................................30
8.2.1. Pain:.........................................................................................................................................30
8.2.2. Stiffness:..................................................................................................................................30
8.2.3. Timing and factors:..................................................................................................................30
8.2.3. Impairment and effect:............................................................................................................30
8.3. PROCEDURE:...................................................................................................................................30
8.3.1. Inspection:...............................................................................................................................30
8.3.2. Palpation:.................................................................................................................................31
8.3.3. Movement:..............................................................................................................................31
8.3.4. Function:..................................................................................................................................31
8.4. CLOSING:........................................................................................................................................32
8.5. INTERPRETATION:...........................................................................................................................32
8.5.1. Inspection:...............................................................................................................................32
8.5.2. Palpation:.................................................................................................................................32
8.5.3 Movement:...............................................................................................................................32
8.5.4 Function:...................................................................................................................................32
9.0 DERMATOLOGY EXAM.........................................................................................................................33

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 9.1. INTRODUCTION:.............................................................................................................................33
9.2. HISTORY:.........................................................................................................................................33
9.3. PROCEDURE:...................................................................................................................................33
9.3.1. Inspection................................................................................................................................33
9.3.2. Description:..............................................................................................................................33
9.3.3. Palpation:.................................................................................................................................34
9.3.4. Other areas:.............................................................................................................................34
9.4. CLOSING:........................................................................................................................................34
9.5. INTERPRETATION:...........................................................................................................................34
9.5.1. Description:..............................................................................................................................34
9.5.2. Palpation:.................................................................................................................................35
9.5.3. Other areas:.............................................................................................................................35
9.6. CONDITIONS:..................................................................................................................................36
9.6.1. Melanoma:..............................................................................................................................36
9.6.2. Psoriasis:..................................................................................................................................36
9.6.3. Eczema.....................................................................................................................................37
10.0 CARDIOVASCULAR EXAM...................................................................................................................37
10.1. INTRODUCTION:...........................................................................................................................37
10.2. INSPECTION:.................................................................................................................................37
10.2.1. General:.................................................................................................................................37
10.2.2. Hands and Nails:....................................................................................................................37
10.2.3. Pulses:....................................................................................................................................37
10.2.4. Arm:.......................................................................................................................................37
10.2.5. Face:......................................................................................................................................38
10.2.6. Neck:......................................................................................................................................38
10.2.7. Chest:.....................................................................................................................................38
10.3. PALPATION:..................................................................................................................................38
10.4. AUSCULTATION:............................................................................................................................38
10.5. BACK AND EXTRA:.........................................................................................................................39
10.6. CLOSING:.......................................................................................................................................39
10.7. INTERPRETATION:.........................................................................................................................39
11.0 RESPIRATORY EXAM..........................................................................................................................39

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 11.1. INTRODUCTION:...........................................................................................................................39
11.2. INSPECTION:.................................................................................................................................39
11.2.1. General:.................................................................................................................................39
11.2.2. Hands and Nails:....................................................................................................................39
11.2.3. Face:......................................................................................................................................40
11.2.4. Neck:......................................................................................................................................40
11.2.5. Chest:.....................................................................................................................................40
11.3. PALPATION:..................................................................................................................................40
11.4. PERCUSSION:................................................................................................................................40
11.5. AUSCULTATION:............................................................................................................................40
11.6. BACK:............................................................................................................................................40
11.7. CLOSING:.......................................................................................................................................41
11.8. INTERPRETATION:.........................................................................................................................41
12.0 GASTROINTESTINAL EXAM................................................................................................................41
12.1. INTRODUCTION:...........................................................................................................................41
12.2. INSPECTION:.................................................................................................................................41
12.2.1. General:.................................................................................................................................41
12.2.2. Hands, Nails and Arms:..........................................................................................................42
12.2.3. Face and Neck:.......................................................................................................................42
12.2.4. Chest and Back:......................................................................................................................42
12.2.5. Abdomen:..............................................................................................................................42
12.3. PALPATION AND PERCUSSION:.....................................................................................................42
12.3.1. Liver:......................................................................................................................................42
12.3.2. Spleen:...................................................................................................................................42
12.3.3. Kidneys:.................................................................................................................................43
12.3.4 Ascitic Fluid:............................................................................................................................43
12.4. AUSCULTATION:............................................................................................................................43
12.5. EXTRA:..........................................................................................................................................43
12.6. CLOSING:.......................................................................................................................................43
12.7. INTERPRETATION:.........................................................................................................................43
13.0 FUNDUSCOPY....................................................................................................................................43
13.1. INTRODUCTION:...........................................................................................................................44

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 13.2. INSPECTION:.................................................................................................................................44
13.3. OPTIC DISC:...................................................................................................................................44
13.4 PERIPHERIES AND BLOOD VESSELS:...............................................................................................44
13.5. MACULA:......................................................................................................................................44
13.6. CLOSING:.......................................................................................................................................44
13.7. INTERPRETATION:.........................................................................................................................44
14.0 CRANIAL NERVES...............................................................................................................................44
14.1. INTRODUCTION:...........................................................................................................................44
14.2. PROCEDURE:.................................................................................................................................45
14.2.1. Olfactory:...............................................................................................................................45
14.2.2. Optic:.....................................................................................................................................45
14.2.3. Oculomotor, Trochlear, Abducens:........................................................................................45
14.2.4. Trigeminal:.............................................................................................................................46
14.2.5. Facial:.....................................................................................................................................46
14.2.6. Vestibulocochlear:.................................................................................................................47
14.2.7. Glossopharyngeal and Vagus:...............................................................................................47
14.2.8. Accessory:..............................................................................................................................47
14.2.9. Hypoglossal:...........................................................................................................................47
14.3. CLOSING:.......................................................................................................................................48
14.4. INTERPRETATION:.........................................................................................................................48
15.0 LOWER LIMB MOTOR EXAM..............................................................................................................48
15.1. INTRODUCTION:...........................................................................................................................48
15.2. INSPECTION:.................................................................................................................................48
15.2.1. General:.................................................................................................................................48
15.3. TONE:............................................................................................................................................48
15.4. POWER:........................................................................................................................................48
15.5. REFLEXES:.....................................................................................................................................48
15.6. COORDINATION:...........................................................................................................................49
15.7. GAIT:.............................................................................................................................................49
15.8. CLOSING:.......................................................................................................................................49
15.9. INTERPRETATION:.........................................................................................................................49
16.0 LOWER LIMB SENSORY EXAM............................................................................................................49

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 16.1. INTRODUCTION:...........................................................................................................................49
16.2. INSPECTION:.................................................................................................................................49
16.3. FINE TOUCH:.................................................................................................................................49
16.4. CRUDE TOUCH:.............................................................................................................................50
16.5. JOINT POSITION:...........................................................................................................................50
16.6. VIBRATION:...................................................................................................................................50
16.7. TEMPERATURE:.............................................................................................................................50
16.8. EXTRA:..........................................................................................................................................50
16.9. CLOSING:.......................................................................................................................................50
16.10. INTERPRETATION:.......................................................................................................................50
17.0 UPPER LIMB MOTOR EXAM...............................................................................................................51
17.1. INTRODUCTION:...........................................................................................................................51
17.2. INSPECTION:.................................................................................................................................51
17.2.1. General:.................................................................................................................................51
17.3. TONE:............................................................................................................................................51
17.4. POWER:........................................................................................................................................51
17.5. REFLEXES:.....................................................................................................................................51
17.6. COORDINATION:...........................................................................................................................52
17.7. CLOSING:.......................................................................................................................................52
18.0 PEDIATRIC HISTORY...........................................................................................................................52
18.1. INTRODUCTION:...........................................................................................................................52
18.2. PRESENTING COMPLAINT:............................................................................................................52
18.2.1. General questions for each symptom:...................................................................................52
18.2.2. Technique for Presenting Complaint:....................................................................................52
18.3. REVIEW OF SYSTEMS:...................................................................................................................52
18.4. PAST MEDICAL AND SURGICAL HISTORY:.....................................................................................53
18.5. PAST DRUG HISTORY:....................................................................................................................53
18.6. ALLERGIES:....................................................................................................................................53
18.7. BIRTH HISTORY:............................................................................................................................54
18.8. DEVELOPMENT:............................................................................................................................54
18.9. IMMUNIZATION:...........................................................................................................................54
18.10. FEEDING HISTORY:......................................................................................................................54

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 18.11. FAMILY HISTORY:........................................................................................................................54
18.12. SOCIAL HISTORY:.........................................................................................................................54
18.13. SPECIFIC PRESENTING COMPLAINTS:..........................................................................................55
18.13.1. Fever:...................................................................................................................................55
18.13.2 Diarrhea and vomiting:.........................................................................................................55
18.13.3. Seizures:...............................................................................................................................55
18.13.4. Meningitis:...........................................................................................................................56
18.13.5. Nephrotic or Nephritic syndrome:.......................................................................................56
18.13.6. Cough:..................................................................................................................................56
18.13.7. Asthma:................................................................................................................................57
18.13.8. Sickle Cell:............................................................................................................................57
19.0 ADULT HISTORY.................................................................................................................................57
19.1 INTRODUCTION:............................................................................................................................57
19.2. PRESENTING COMPLAINT:............................................................................................................57
19.2.1. General questions for each symptom:...................................................................................57
19.2.2. Technique for Presenting Complaint:....................................................................................57
19.3. GENERAL SYMPTOMS...................................................................................................................57
19.3.1. Weight Loss:..........................................................................................................................57
19.3.2. Tiredness:..............................................................................................................................58
19.4. ACUTE SYMPTOMS.......................................................................................................................58
19.4.1. Collapse:................................................................................................................................58
19.4.2. Acute Chest Pain:...................................................................................................................59
19.4.3. Acute Shortness of Breath:....................................................................................................60
19.4.4. Acute Abdominal Pain:..........................................................................................................61
19.4.5. Acute Headache:....................................................................................................................62
19.5. CARDIORESPIRATORY SYMPTOMS................................................................................................63
19.5.1. Chest Pain:.............................................................................................................................63
19.5.2. Breathlessness:......................................................................................................................64
19.5.3. Cough:....................................................................................................................................65
19.5.4. Hemoptysis:...........................................................................................................................66
19.6. GASTROINTESTINAL AND RENAL SYMPTOMS...............................................................................66
19.6.1. Abdominal Pain:.....................................................................................................................66

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 19.6.2. Change in bowel habit:..........................................................................................................68
19.6.3. Rectal bleeding:.....................................................................................................................68
19.6.4. Hematemesis:........................................................................................................................69
19.6.5. Polyuria:.................................................................................................................................70
19.6.6. Dysuria, frequency and nocturia............................................................................................70
19.7. CEREBRAL SYMPTOMS..................................................................................................................71
19.7.1. Headache...............................................................................................................................71
19.8. MISCELLANEOUS SYMPTOMS.......................................................................................................72
19.8.1. Diabetic:.................................................................................................................................72
19.8.2. Hypertensive:.........................................................................................................................72
19.8.3. Hypercalcemia:......................................................................................................................73
19.9. REVIEW OF SYSTEMS:...................................................................................................................73
19.20. PAST MEDICAL HISTORY:............................................................................................................74
19.21. PAST SURGICAL HISTORY:...........................................................................................................74
19.22. DRUG HISTORY:..........................................................................................................................74
19.23. ALLERGIES:..................................................................................................................................74
19.24. FAMILY HISTORY:........................................................................................................................75
19.25. SOCIAL HISTORY: FLATMESS.......................................................................................................75
19.25.1. Food and Exercise:...............................................................................................................75
19.25.2. Living:...................................................................................................................................75
19.25.3. Abuse:..................................................................................................................................75
19.25.4. Travel:..................................................................................................................................75
19.25.5. Married:...............................................................................................................................75
19.25.6. Effect:...................................................................................................................................75
19.25.7. Sexual and support systems:................................................................................................75
19.26 CLOSING.......................................................................................................................................76
20.0 ADULT COUNSELLING........................................................................................................................76
21.0 CEREBELLAR EXAMINATION..............................................................................................................76
21.0 PEDIATRIC CARDIOVASCULAR EXAM.................................................................................................76
21.1. INTRODUCTION:...........................................................................................................................76
21.2. INSPECTION:.................................................................................................................................76
21.2.1. General:.................................................................................................................................76

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 21.2.2. Hands and Nails:....................................................................................................................76
21.2.3. Pulses:....................................................................................................................................76
21.2.4. Arm:.......................................................................................................................................76
21.2.5. Face:......................................................................................................................................77
21.2.6. Neck:......................................................................................................................................77
21.2.7. Chest:.....................................................................................................................................77
21.3. PALPATION:..................................................................................................................................77
21.4. AUSCULTATION:............................................................................................................................77
21.5. BACK AND EXTRA:.........................................................................................................................78
21.6. CLOSING:.......................................................................................................................................78
21.7. INTERPRETATION:.........................................................................................................................78
22.0 PEDIATRIC GASTROINTESTINAL EXAM...............................................................................................78
22.1. INTRODUCTION:...........................................................................................................................78
22.2. INSPECTION:.................................................................................................................................78
22.2.1. General:.................................................................................................................................78
22.2.2. Hands, Nails and Arms:..........................................................................................................78
22.2.3. Face and Neck:.......................................................................................................................79
22.2.4. Chest and Back:......................................................................................................................79
22.2.5. Abdomen:..............................................................................................................................79
22.3. PALPATION AND PERCUSSION:.....................................................................................................79
22.3.1. Liver:......................................................................................................................................79
22.3.2. Spleen:...................................................................................................................................79
22.3.3. Kidneys:.................................................................................................................................79
22.3.4 Ascitic Fluid:............................................................................................................................80
22.4. AUSCULTATION:............................................................................................................................80
22.5. EXTRA:..........................................................................................................................................80
22.6. CLOSING:.......................................................................................................................................80
22.7. INTERPRETATION:.........................................................................................................................80
23.0 PEDIATRIC LOWER LIMB MOTOR EXAM............................................................................................80
23.1. INTRODUCTION:...........................................................................................................................80
23.2. INSPECTION:.................................................................................................................................80
23.2.1. General:.................................................................................................................................81

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 23.3. TONE:............................................................................................................................................81
23.4. POWER:........................................................................................................................................81
23.5. REFLEXES:.....................................................................................................................................81
23.6. COORDINATION:...........................................................................................................................81
23.7. GAIT:.............................................................................................................................................81
23.8. CLOSING:.......................................................................................................................................81
23.9 INTERPRETATION:..........................................................................................................................82
24.0 PRESENTATION IN HISTORY...............................................................................................................82
25.0 PRESENTATION IN EXAM...................................................................................................................82

1.0 NEBULIZER

1.1. PROCEDURE:
Good day mummy/daddy (handshake). My name is O’Neele Bhola and I am one of the final year
students. Today I would like to demonstrate the set up for a nebulizer. We have our oxygen tank and
gauge, the Christmas tree, the oxygen tubing, the nebulizer cup (respule) with its cover and atomizer,
the various medications which are used in asthma, needles and syringe to pull up the medication,
various sizes of masks and bag of normal saline to top up the medication.

Firstly, I would like to set up the medication. I understand that this is an acute asthmatic attack and
therefore the medication of choice is the Ventolin solution. The other medications here is the atrovent,
which can also be given as nebulized medication, and hydrocortisone, which cannot be given as a
nebulized solution but as an IV drug in children who cannot tolerate oral prednisolone. I would like to
take up 1ml which is 5mg (child over 5) or 0.5ml which is 2.5mg (for child under 5). I use the smaller
needle and 1ml syringe for this. Next I would put this into the respule or nebulizer cup. I make up the
volume in the respule to 3ml using the normal saline which picked up with the bigger 3ml needle and
syringe. Additionally if atrovent was to be added an appropriate dose can be added as well to the
nebulizer before adding the normal saline and then making combined up the volume to three mls.

I then place in my atomizer and connect the threaded cover to the top of the cup. I would next like to
connect the Christmas tree to the gauge on the oxygen followed one end of the oxygen tubing to the
Christmas tree and the next end to the underside of the nebulizer cup. An appropriately sized nebulizer
mask (one with the big holes) will then be attached. I will then ask mummy/daddy to attach the mask
around the child’s face and fix/adjust the whiskers to fit properly. I will turn on the flow of the oxygen
after the mask has been secured. The nebulizer should begin to mist and I would like you
(mummy/daddy) to encourage your child to take deep breaths in and out (tidal breathing) for 10-15
minutes.

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Thank you for your time. Are there any questions?

1.2. EXTRA INFORMATION:

See asthma action plan in 2.0 PEAK FLOW section

1.3. FURTHER QUESTIONS:

1. What is the concentration and dose of Ventolin?
The normal concentration of nebulized Ventolin is 5 mg/ml. The dose in children over 5 years is 5 mg
which would be equal to 1 ml of the Ventolin solution. The dose under 5 years is 2.5 mg which would be
equal to 0.5 ml of the Ventolin solution.

2. What is the concentration and dose of Atrovent?

The normal concentration of nebulized Atrovent is 250 mcg/ml or 500 mcg/ml. The dose in children over
5 years is 500 mcg which would be equal to 2 ml of the Atrovent solution. The dose under 5 years is 250
mcg which would be equal to 1 ml of the Atrovent solution.

3. What are the side effects of Ventolin?

Side effects that can be experienced and are important to tell the mother is nervousness, shaking
(tremor), palpitations. More serious side effects are increased in blood pressure, chest pain and
headache.

4. What are the side effects of Atrovent?

Side effects that can be experienced and are important are dry mouth, cough, headache, nausea,
dizziness and it can also cause a decrease in urine.

5. What is the mechanism of action of Ventolin?

Salbutamol stimulates β2 adrenergic receptors which are predominant receptors in bronchial smooth
muscle of the lung. This causes relaxation the smooth muscles of airways, from trachea to terminal
bronchioles.

6. What is the mechanism of action of Atrovent?

Ipratropium bromide is an anticholinergic agent. It blocks muscarinic cholinergic receptors and results in
decreased contractility of smooth muscle and decreased secretions into the airway.

7. Discuss the GINA guidelines for acute asthmatic attack.

Initial assessment; Determine if mild/moderate, severe or life threatening and/or risk factors for asthma
related death
Mild or moderate; 4-10 puffs by MDI and spacer every 20 mins per hour, prednisolone 1-2mg/kg (max
40), controlled oxygen (O2 sats 94-98), treats as severe if worsening
Severe or life threatening; transfer to acute care facility, give inhaled SABA +/- ipratropium bromide
(Atrovent), oxygen and systemic steroids, if life threatening or worsening consider starting magnesium
sulphate, aminophylline and/or ICU transfer with intubation.

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 8. Differentiate a mild/moderate attack.
Talks in phrases, prefers sitting to lying, not agitated, increased resp rate, no accessory muscle use, pulse
mildly elevated, O2 sats 90-95, PEF >50

9. Differentiate a severe attack

Any one of; PEF <50, resp rate >30, HR >120, cant complete sentences in one breath

10. Differentiate a severe

Any one of; PEF <33, SPO2 <92, Hypoxia, hypercapnia, CHEST (cyanosis, hypotension, exhaustion, silent
chest, tachy or brady arrhythmia)

11. What are risk factors for asthma related death?

Patient unable to distinguish severe asthma, previous severe exacerbation with ICU admission, LOC,
respiratory failure or intubation, prior asthmatic complications (hypercapnia, metabolic acidosis or
pneumothorax), 2-3 ED visits in last year, hospitalization in last month, 2 refills of Ventolin inhaler per
month, severe attacks despite long term steroid use, underlying cardiopulmonary disease

2.0 PEAK FLOW

2.1. PROCEDURE:
Good day mummy/daddy (handshake). My name is O’Neele Bhola and I am one of the final year
students. Today I would like to demonstrate the peak flow to you. What’s your child’s name and how old
are they? This device here is called a peak flow meter. A peak flow meter is a cheap, portable, handheld
device for people with asthma that is used to measure how good and how fast air moves out of your
lungs. When you use this it can tell you how good your asthma is controlled, if your child is having an
asthma attack and if the medications are working if there is an attack.

The peak flow meter itself consists a mouth piece and peak flow meter, which has the end to attach the
mouth piece, the end with the holes for air to exit and the pointer and scale used to get the value of the
peak flow. The mouth piece can be a card board disposable one or a plastic one which is reusable after
washing.

In order to use the peak flow meter properly, firstly you must stand up or sit up with your back straight.
This is the pointer/indicator that slides up and down but it must be put to zero before you use it. After
you put it to zero, take a deep breath in, filling the lungs completely. You then place the mouthpiece in
your mouth; lightly put it in between your teeth and close your lips on it. Blast the air out as hard and as
fast as possible in a single blow and then remove the meter from your mouth. Do you understand
everything so far mummy/daddy?

After that, you record the number that appears on the meter and then repeat the procedure two more
times. You then want to record the HIGHEST of the three readings in an asthma diary. This reading is

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your peak expiratory flow (PEF). This highest reading is now your personal best and this would help you
when using your asthma care plan which I would explain at the soon. You also would like to the take
your peak flow measurement twice a day at the same time in the morning and evening when the
asthma is in good control for two to three weeks to determine the personal best.

Your daily peak flow readings help you recognize early drops in airflow, know when your child's personal
best improves naturally as he or she grows and to tell if he or she is having an asthma attack.

2.2. EXTRA INFORMATION:

The asthma action plan uses the peak flow reading compared to the personal best and tells you what
actions to take. If you don’t understand any part I can repeat for you.

There are three zones; green, yellow and red, just like a traffic light. GREEN ZONE is GOOD ZONE. This is
when the reading on the peak flow is 80% of the personal best, asthma symptoms are present and/or
there is no limitation to your child activity. No extra medications are required and all regular
medications are taken as normal. The YELLOW ZONE is the ALERT ZONE. This is where the peak flow is
between 51-79% of the personal best or the child has symptoms like the moderate cough, wheezing,
shortness of breath, breathing faster than usual (usually >25 per minute) or the symptoms affect normal
activities. This is where the rescue medication is taken in the proper dose and frequency and the peak
flow is rechecked after 15-20 minutes. If there are 2 or more consecutive readings in the yellow zone in
less than 2 days or 48 hours the child has to come in to accident and emergency.

The RED ZONE is the EMERGENCY ZONE. This is when the peak flow is below 50% of the personal best
or there are symptoms of severe asthma. If the child is unable to complete sentences in one breath,
using extra muscles to breathe or unable to perform usual activities, these are symptoms of severe
asthma. The child should come into accident if there was worsening after the rescue medication is given
or the peak flow was in the red zone again 15-20 minutes after the medication was given. If there is any
turning blue of the lips, trouble talking at all or throat tightness then you should call the ambulance.

Thank you for your time. Are there any questions?

2.3. FURTHER QUESTIONS:

1. How would you know assess a child for discharge from hospital?
Improved symptoms not needing short acting beta 2 agonist, peak expiratory flow rate >60-80% of
personal best or predicted best, oxygen saturation maintained above 94% on room air, resources at
home adequate.

2. What is needed at discharge of an asthmatic child

Reliever medication to be continued as needed, a controller medication is started or stepped up, inhaler
technique and adherence should be assessed before step up or started, prednisolone is continued for 3-
5 days in children. There should also be follow up in 2-7 days.

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 3. What would be done at follow up
Reliever medication reduced to as needed, controller continued at higher dose for short term or long
term depending on background of exacerbation, risk factors (modifiable) should be addressed including
technique and inhaler adherence.

Action plan should be followed up including understanding and modification as needed

4. What investigations are required in acute asthmatic exacerbation?

Peak flow rate, arterial blood gas (normal is usually decreases PaCO2 with a normal or slightly decrease
O2), CBC, urea and electrolyte, creatinine, CRP, blood cultures, CXR if diagnosis unsure or atypical.

5. What does TAME stand for in asthma discharge?

Technique for inhaler use
Avoidance of triggers: Allergens, smoke/smoking, dust
Monitor: Peak flow diary (2-4x/day)
Educate: On need for treatment compliance, emergency action plan

3.0 MDI AND SPACER

3.1. PROCEDURE:
Good day mummy/daddy (handshake). My name is O’Neele Bhola and I am one of the final year
students. Today I would like to demonstrate the metered dose inhaler and spacer technique to you.
What’s your child’s name and how old are they? The Inhaler has three parts; the barrel with
mouthpiece, the cap and canister. The canister holds the medication and the mouth piece delivers the
medication. The spacer consists of the mouth piece and cap, the chamber and the back piece with the
whistle.

To prepare to use the inhaler and spacer, first you shake the inhaler. If the inhaler hasn’t been used in a
while then it will need to be primed. You prime it once with a test spray and then it is ready for use. You
then connect the inhaler to the spacer. With your back straight, either sitting or standing, you make a
tight seal round the mouthpiece of the spacer and, deliver one puff into the chamber of the spacer. If
the child cannot make a tight seal then a mask can be attached to the end of the spacer to be placed
over the mouth and nose of the child. The child then takes 10 slow breaths in and out. The whistle o the
end of the spacer tells you if the child is breathing in and out too quickly.

If more than one puff must be given then this is done separately. To give each consecutive puff then the
inhaler is removed from the spacer, shaken once more and then the procedure is repeated.

For care of the inhaler, an extra inhaler should be kept at all times in case the other one has finished. To
see if the canister has finished, it can be placed in a cup of water. If it remains vertical then it is full, if it
is horizontal then it is empty.

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For care of the spacer it can be taken apart and washed. It is washed in a warm soapy solution. No
wiping of the spacer is to be done. This causes friction on the inner tube and causes the medicine to
adhere to the sides of the chamber. It should be air dried. After taking the medication, the mouth should
be washed out. Thank you. Are there any questions?

3.2. EXTRA INFORMATION:

Common side effects of Ventolin inhalers are headache, dizziness, sleep problems (insomnia), cough,
hoarseness, sore throat, runny or stuffy nose, mild nausea, vomiting, and dry mouth but common are
palpitations and tremor.

Possible side effects of steroid inhalers are hoarseness and oral thrush

See Asthma action plan in 2.0 PEAK FLOW

3.3. FURTHER QUESTIONS:

1. What are the GINA guidelines for chronic asthma management?
STEP 1: AS-NEEDED SABA WITH NO CONTROLLER (this is indicated only if symptoms are rare, there is no
night waking due to asthma, no exacerbations in the last year, and normal FEV1).
Other options: regular low dose ICS for patients with exacerbation risks.

STEP 2: REGULAR LOW DOSE ICS plus as-needed SABA

Other options: LTRA are less effective than ICS; ICS/LABA leads to faster improvement in symptoms and
FEV1 than ICS alone but is more expensive and the exacerbation rate is similar

STEP 3: LOW DOSE ICS/LABA either as maintenance treatment plus as-needed SABA, or as
ICS/formoterol maintenance and reliever therapy
For patients with ≥1 EXACERBATION in the last year, low dose BDP/formoterol or BUD/formoterol
maintenance and reliever strategy is more effective than maintenance ICS/LABA with as-needed SABA.
Other options: Medium dose ICS
Children (6–11 years): Medium dose ICS. Other options: low dose ICS/LABA

STEP 4: Low dose ICS/formoterol maintenance and reliever therapy, or medium dose ICS/LABA as
maintenance plus as-needed SABA
Other options: Add-on tiotropium by mist inhaler for patients ≥12 years with a history of exacerbations;
high dose ICS/LABA, but more side-effects and little extra benefit; extra controller, e.g. LTRA or slow-
release theophylline (adults)
Children (6–11 years): Refer for expert assessment and advice.

STEP 5: Refer for expert investigation and add-on treatment

Add-on treatments include tiotropium by mist inhaler for patients with a history of exacerbations (age
≥12 years), omalizumab (anti-IgE) for severe allergic asthma, and mepolizumab (anti-IL5) for severe
eosinophilic asthma (age ≥12 years). Sputum-guided treatment, if available, improves outcomes.

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Other options: Some patients may benefit from low dose OCS but long-term systemic side-effects occur.

4.0 PEDIATRIC BASIC LIFE SUPPORT AND ADVANCED CARDIAC LIFE SUPPORT

4.1. PROCEDURE:
Approach safely; looking to ensure the environment is secure.

Gently stimulate the child using a sternal rub and ask loudly, ‘Are you all right? Can you hear me?’

Optional; If the child responds by answering or moving, leave in that position unless unsafe. Assess
condition and seek help if required. Reassess regularly.

If the child does not respond, call for help. “Help, Help, I need some help inside here nurse. Bring a crash
cart and AED.”

Place hand on forehead and use a chin lift to put child in neutral position. This is for a child under 6
months. For an older child they use the sniffing the morning air position (head tilt and chin lift). From
this position I can make sure the airway is patent and feel, listen and look for sign of respiration. If
breathing is abnormal or absent I would remove any airway obstruction and give 5 initial rescue breaths
with bag and mask (appropriate size pediatric mask) looking for rise and fall of the chest.

Optional; If the child was breathing normally I would turn the child onto his side into the recovery
position. Check for continued normal breathing.

Next I would assess for circulation. In a child under one year I would use the brachial pulse and assess
the pulse for 10 seconds with two fingers on the inner aspect of the arm. For an older child I could use
the carotids for this.

Optional; If I am confident that there are signs of circulation, I continue rescue breaths as required
until child returns to spontaneous circulation. The child is turn to recovery position if breathing
returns but remains unconscious. The child is also reassessed

If there are no signs of circulation, chest compressions are started at rate of 100-120 per minute. 15
chest compressions are delivered followed by 2 rescue breaths. The lower third of the sternum along
the midline is compressed to a thickness of about 4-5cm or two inches. For an infant I would use two
finger, for a toddler I would use one hand (using heel of the hand) and for a teenager I would use two
hands for delivery of my chest compressions. I would repeat this for five cycles.

Optional; If there are two rescuers the encircling technique is used where one give compression whilst
one delivers breaths. Both thumbs are placed on sternum with thumbs pointing to head and other
fingers support back.

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After five cycles of chest compression and breaths, the child is reassessed before restarting the 5 cycles.
Resuscitation is continued until the child shows signs of life (normal breathing, or definite circulation),
further qualified help arrives or I become exhausted.

4.2. EXTRA INFORMATION:

When help does arise the AED shall be attached to the child in tandem with continued CPR. The rhythms
that show up should then be assessed. These rhythms are split in to shockable and non-shockable
rhythms. The non-shockable rhythms are pulseless electrical activity and asystole. The shockable
rhythms are ventricular tachycardia and ventricular fibrillation.

If the rhythm is non-shockable, an IV access is established. The first dose of epinephrine is give via this in
between the cycle. This is 0.1ml/kg of 1 in 10000 is required. This is given every 3-5 minutes once the
rhythm remains unshockable. After each dose of epinephrine, CPR is continued until next dose required
and the rhythm remains non-shockable.

If the rhythm is a shockable rhythm, an IV access is established. Then a shock of 4 J/kg is delivered by the
defibrillator and then CPR restarted. After 2 minutes of uninterrupted CPR, shock once again if the
rhythm is shockable. After the shock, 0.1 ml/kg of 1 in 10000 of epinephrine is given and CPR is
continued. Once again, After 2 minutes of uninterrupted CPR, shock once again if the rhythm is
shockable. After the shock, 5mg/kg of amiodarone is given and CPR is continued. Epinephrine and
amiodarone are given in alternate doses after each shock on the rhythm remained shockable.

If rhythm returns to an organized cardiac rhythm the pulse should be assessed and if present, return to
post-resuscitation care.

If rhythm becomes non-shockable, then treat as non-shockable rhythm.

Reversible causes must also be treated within the procedure.

4.3. FURTHER QUESTIONS:

1. Any other maneuvers can open the airway?
Jaw thrust

2. What are other locations that can be used for assess the pulse?
Femoral pulse

3. Why is the neutral position used in infants?

Occiput is bigger in the infants and therefore the sniffing position would close off their airway. Also their
cricoid cartilage is not fully developed.

4. What are the common reversible causes of cardiac arrest?

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The common causes are hypoxia, hypovolemia, hyper or hypokalemia, hypothermia (not common in our
setting), thrombosis (cardiac and pulmonary), tension pneumothorax, tamponade and toxins.

5. When you see asystole, what other considerations are there and what measures are taken?
The leads are ensured to be placed on the patient; this would cause a flat line
Ensure the AED is tracing from the leads and not the paddles; this would also cause a flat line
Turn up the gain; to ensure that the trace is not a ventricular fibrillation which is a shockable rhythm

5.0 ADULT BASIC LIFE SUPPORT AND ADVANCED CARDIAC LIFE SUPPORT

5.1. PROCEDURE:
Approach safely; looking to ensure the environment is secure.

Gently stimulate the patient using a sternal rub and ask loudly, ‘Are you all right? Can you hear me?’

Optional; If the patient responds by answering or moving, leave in that position unless unsafe. Assess
condition and seek help if required. Reassess regularly.

If the patient does not respond, call for help. “Help, Help, I need some help inside here nurse. Bring a
crash cart and AED.”

Place hand on forehead and use a head tilt and chin lift to put patient in sniffing position. From this
position I can make sure the airway is patent and feel, listen and look for sign of respiration and
simultaneously feel for pulses at the carotids.

If breathing is abnormal or absent and a pulse is present, I would remove any airway obstruction and
give 10-12 breaths per minute or 1 breath every 5-6 seconds. Every 2 minutes of respirations the patient
is reassessed to see if there is absence of pulses or return to spontaneous respiration.

If breathing is abnormal or absent and a pulse is absent, I would begin chest compressions are started at
rate of 100-120 per minute. 15 chest compressions are delivered followed by 2 rescue breaths. The
lower third of the sternum along the midline is compressed to a thickness of about 4-5cm or two inches.
I would use two hands for delivery of my chest compressions.

Optional; If I am confident that there are signs of circulation and spontaneous respirations I would
monitor the patient until the help has arrived.

After the 30 chest compression, I will perform 2 rescue breaths. This is continued for 5 cycles. The
patient is reassessed. The patient is reassessed before restarting the 5 cycles. Resuscitation is continued
until the patient shows signs of life (normal breathing, or definite circulation), further qualified help
arrives or I become exhausted.

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5.2. EXTRA INFORMATION:
When help does arise the AED shall be attached to the patient in tandem with continued CPR. The
rhythms that show up should then be assessed. These rhythms are split in to shockable and non-
shockable rhythms. The non-shockable rhythms are pulseless electrical activity and asystole. The
shockable rhythms are ventricular tachycardia and ventricular fibrillation.

If the rhythm is non-shockable, an IV access is established. The first dose of epinephrine is give via this in
between the cycle. This is 10ml of 1 in 10000 is required (1mg). This is given every 3-5 minutes once the
rhythm remains unshockable. After each dose of epinephrine, CPR is continued until next dose required
and the rhythm remains non-shockable.

If the rhythm is a shockable rhythm, an IV access is established. Then a shock of 200J is delivered by the
biphasic defibrillator and then CPR restarted. After 2 minutes of uninterrupted CPR, shock once again if
the rhythm is shockable. After the shock, 10ml of 1 in 10000 of epinephrine is given and CPR is
continued. Once again, After 2 minutes of uninterrupted CPR, shock once again if the rhythm is
shockable. After the shock, 300 mg (first bolus) of amiodarone is given and CPR is continued.
Epinephrine and amiodarone (second bolus is 150 mg) are given in alternate doses after each shock on
the rhythm remained shockable.

If rhythm returns to an organized cardiac rhythm the pulse should be assessed and if present, return to
post-resuscitation care.

If rhythm becomes non-shockable, then treat as non-shockable rhythm.

Reversible causes must also be treated within the procedure.

5.3. FURTHER QUESTIONS:

1. Any other maneuvers can open the airway?
Jaw thrust, especially

2. What are other locations that can be used for assess the pulse?
Femoral pulse and brachial pulses

3. What are the common reversible causes of cardiac arrest?

The common causes are hypoxia, hypovolemia, hyper or hypokalemia, hypothermia (not common in our
setting), thrombosis (cardiac and pulmonary), tension pneumothorax, tamponade and toxins.

4. When you see asystole, what other considerations are there and what measures are taken?
The leads are ensured to be placed on the patient; this would cause a flat line
Ensure the AED is tracing from the leads and not the paddles; this would also cause a flat line
Turn up the gain; to ensure that the trace is not a ventricular fibrillation which is a shockable rhythm

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 5. What should done after giving the epinephrine?
A flush should be done with normal saline between the dose and the arm raised vertically.

6.0 PSYCHIATRIC MENTAL STATE EXAM

6.1. PROCEDURE:
Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final year students.
Today I would like to ask you a few questions so I can perform a mental state exam. Is that alright? Some
of these questions are personal and I assure you this is all confidential. What’s your full name and age
please? It is nice to meet you. Where do you live? What occupation do you do currently?

Mnemonic; Gain Assessment of Subject Behavior, Make Preparation To Describe Cognition

Meaning; General appearance, Attitude, Speech, Behavior, Mood, Perceptual disturbance, Thought
Form, Delusions or Thought Content, Cognition (Judgement and insight)

Observe general appearance; dress (appropriate or dirty), grooming (unkempt or disheveled), posture
(stooped), appropriately (religious wear, promiscuously, oddly)

Observe attitude; cooperative, hostile, evasive, irritable, anxious, tremulous, defensive, seductive,
indifferent, distressed. You seem irritated/anxious/defensive, can you tell me about that?

Observe speech; rate (normal, fast or slow), spontaneity (pressure, reluctant), loudness (loud, soft),
amount (poverty of speech, pressured speech, talkative), prosody and pitch (monotonous, variable)

Observe; behavior (involuntary, catalepsy, posturing, psychomotor retardation or agitation, restlessness,

grimacing). Do you think you feel very energetic or active right now? Do you feel less energetic right
now? I notice you have a little tremor, can you tell me about this? I notice you are tapping your foot, can
you tell me about this?

Mood (subjective); How would you describe your mood right now? Are you sad right now? Are you
happy right now? Do you feel angered right now? Do you feel agitated right now? Do you feel euthymic
right now? Do you feel hopeless right now? Do you feel like dying right now?

Observe mood (objective); Facial expression, posture, motor activity and eye contact are used to
determine if the affect is congruent with mood or if it is flat, restricted, depressed, inappropriate or
labile)

Perceptual disturbances; Do you have any hallucinations right now? Are you seeing anything that isn’t
here right now? Or hearing any noises right now? Hearing people talking when they are not there? Are
you getting any weird smells? Are you getting weird feelings under your skin? Are you getting any weird
tastes in your mouth?

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Thought form; flight of ideas, retardation of thinking, perseveration, loosening of association,
circumstantial thinking, concrete thinking, thought block. Observation of the person’s speech till this
point would have revealed thought disorder. If none are present this is reported as no formal thought
disorder.

Thought content; Are there any thoughts currently on your mind? Can you describe these thoughts?
What are you thinking about at this moment? Do you feel like people are trying to hurt you? Do you
have feeling people are out to get you? Do you believe like you have extra abilities or you are more
special than everybody? Is there anything special or extraordinary about you? Do you have any
superpowers?

Do you think thoughts can be put into your head? Do you believe people can hear your thoughts? Do
you believe thoughts can be taken from your head? Do you believe that you can be controlled through
your thoughts?

Are you ever having any thoughts of killing yourself? Are you having any thoughts of hurting yourself? If
you were left alone to go home, would you hurt yourself? Are you having any feelings to hurt anyone
right now?

Are there any thought that trouble you? Are there any persistent thoughts in your head? Are there any
thoughts that make you afraid? Are there any thoughts that make you feel uneasy and want to do any
actions, like cleaning, counting, washing your hands, clicking a switch?

Judgement; If you were walking down the road and you saw a burning building what would you do? If
you saw a child walking in front of a moving vehicle, what would you do?

Insight; In your opinion, do you believe there is anything wrong with you? Do you think that you have a
mental problem? Are you aware that you will need medications? Would you be willing to take
medications?

This is the end of the mental state exam but I would like to ask you a few more questions to help me
come up with possible diagnoses.

6.2. EXTRA INFORMATION:

How long have you been experiencing these symptoms? Have you ever had any periods with symptoms
of depression? Have you had any previous symptoms of mania? Have you had any previous symptoms of
anxiety? Have you had any previous symptoms of psychosis?

Have you been using any medication? Do you use any alcohol, marijuana, cigarettes or any illegal or
recreational drugs? If so how frequent do you use them? Do you get any symptoms when you do or do
not use them?

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Do you have any medical conditions like seizure disorder, cancer, infections? Have you ever been
diagnosed or treated for any psychiatric condition?

Have you ever tried to commit suicide before?

How have these symptoms been affecting your family, friends, work and yourself?

This is the end of the examination. Thank you.

Rationale: The main point of these follow-up questions is to rule out a medical condition and a
substance use as a cause for the symptoms. The duration of the symptoms can also refine the
diagnosis a bit more.

6.3. INTERPRETATION:
General Appearance; unkempt and disheveled in cognitive disorder, withdrawal or stooped posture in
depressive disorder, inappropriate in manic disorder or psychotic disorder

Attitude; suspicious in paranoia, seductive in mania, apathetic in conversion disorder

Speech; pressured speech in mania, paucity of speech in depression, uneven or slurred speech in
cognitive disorder, monotonous in depression

Behavior (motoric); Fixed posturing and odd behavior in psychotic disorder, hyperactive in stimulant use
or mania, psychomotor retardation in depression, tremors are seen in anxiety or medication use,
minimal eye contact in depression and psychosis. Scanning of the room in anxious or psychotic states

Mood (subjective); suicidal feeling in depression, elation in mania, anxious in anxiety disorder

Mood (objective); change of affect in schizophrenia, flat affect in cognitive disorder, restricted affect in
depression

Perceptual disturbance; visual hallucination in schizophrenia or mania, olfactory hallucination in

temporal lobe epilepsy, tactile hallucination in drug use, delirium tremens and withdrawal, auditory
hallucination in psychosis or drug use

Thought Form; loosening of association in schizophrenia, tangential thinking in mania, flight of ideas in
mania

Thought Content; delusions present (mood congruent or not), Incongruent delusion in psychosis,
Congruent delusion in depressive disorder or manic disorder. Presence of homicidal or suicidal thoughts
adds to need for hospitalization and admission.

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Judgement; impaired in brain disease, schizophrenia, intoxication

Insight; impaired in delirium, dementia, psychosis. Poor insight also affects treatment.

6.4. FURTHER QUESTIONS:

1. What are the important depressive symptoms?
Depressed mood, anhedonia (loss of interest), changes in sleep, decreased energy, hopelessness,
suicidal ideation

2. What are the important manic symptoms?

Increased energy, decreased need for sleep, increased goal directed behavior,

3. What are the important psychotic symptoms?

Hallucinations, delusions, negative symptoms, disorganized behavior

4. What are the important anxiety symptoms?

Worry, anxious, fear, obsession, compulsion, avoidance behavior, palpitations, tremors, impending
doom, shortness of breath, increased awareness, chest tightness, stress, nightmares

6.5. THEORY
1. What are the examination findings in schizophrenia?
Possible examination findings are a disheveled appearance, flat affect, disorganized thought process,
intact procedural memory and orientation, auditory hallucinations, paranoid delusions, ideas of
reference, and lack of insight into their disease

2. What features constitute poor prognosis in schizophrenia?

Poor prognostic factors include early onset, poor social support, negative symptoms, family history,
gradual onset, male gender, many relapses, poor premorbid functioning (social isolation, etc.) and
comorbid substance use.

7.0 PSYCHIATRIC HISTORY

7.1. GENERAL:
Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final year students.
Today I would like to ask you some questions. Is that alright? Some of these questions are personal and I
assure you this is all confidential. What’s your full name and age please? It is nice to meet you. Where
do you live? What occupation do you do currently?

Can you tell me a little bit about the symptoms you have been experiencing? Did you come in
voluntarily? Who brought you in/referred you to here?

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When did it begin? Did it begin suddenly or progressively? Did it worsen or get better? How did it
begin/continue/progress? How frequent has this been happening? What makes it better? What makes it
worse? Is there anything associated with this like a person, a place, an activity or a time of day? Have
you been taking any treatment for this right now? If yes, what, how much, when, are you compliant and
does it work?

Can you tell me a bit about how you were before you began experiencing these changes? What was
your personality like before this?

How has your sleep been? Have you been sleeping more or less? Have you been having night time
awakenings? Have you been having any day time somnolence? Have you been having nightmares? How
long has this been happening? Did something trigger this? Is it getting better or worse?

How has your energy been? Have you been having increased or decreased energy? How long has this
been happening? Did something trigger this? Is it getting better or worse?

How has your concentration been? Has there been increased or decreased concentration? How long has
this been happening? Did something trigger this? Is it getting better or worse?

Do you have any thoughts of hurting yourself? Do you think that you want to die? Are there any
thoughts about hurting anyone? Do you want to hurt anybody?

7.2. STRESSORS:
Has there anything major currently going on in your life? Is anything currently stressing you out? Are
there any problems that you are currently dealing with? Have there been any problems at home, with
your friends, at school or at work? Have you had any personal issues that are unresolved?

7.3. EFFECTS:
How have these symptoms been affecting you personally? What has been the effect on your social
activities? Do you feel withdrawn, good or lonely because of this? How has it affected you occupation?
Has there been any effect academically or functionally?

7.4. SYSTEMIC REVIEW:

Depression; sleep, interest, guilt, energy, concentration, appetite, psychomotor retardation, suicidal
ideation (hopeless, helpless, worthless)

Manic; distractible, irritable, insomnia, grandiosity, flight of ideas, agitation, activity, speedy thoughts,
speech, thoughtlessness, homicidal thoughts

Anxiety; dizziness, palpitations, numbness, chest tightness, sweating, shaking, intense fear, impending
doom, obsessions, compulsions or repetitive acts, nightmares, flash backs, avoidance, awareness,
shortness of breath

Psychotic; hallucinations, delusions, catatonic, negative symptoms (anhedonia, affect, alogia, avolition,
attention), bizarre behavior

7.5. SUICIDE RISK ASSESSMENT:

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Current Episode:
- Before; events leading up, planning, suicide note, perceived lethality, effort to follow through
- During; method and perceived lethality, when and where, how discovered, substance use
- After; feelings now, regret, hopelessness, change of mind, future feelings

Future risk: age, positive for depressive symptoms with suicidal ideation and hopelessness,
comorbidities, past suicide attempts or self-harm, current drug or alcohol use, stressor, unemployment,
poor social support

7.6. HOMICIDE RISK ASSESSMENT:

Future Risk; male sex, younger age, history of violence, substance use, persecutory delusions, command
hallucinations, access to weapons, impulsivity, cruelty to animals or people, non-compliance with
treatment, lack of compassion/empathy, intention to harm, lack of concern over consequences.

7.7. PAST PSYCHIATRIC AND MEDICAL HISTORY:

Have you ever been diagnosed with a psychiatric problem? Have you ever seen a psychiatrist? Have you
ever been admitted to a mental hospital? Do you have any medical conditions? Do you have any
diabetes, hypertension, epilepsy, HIV, infections or cancer? Have you had any trauma to the head
before? Have you had any hospitalizations before?

7.8. SUBSTANCE USE:

Quantify Use; Are you currently on any medications; prescription, over the counter or herbal? What are
the doses and the frequency of this? Are you compliant on these medications?

Do you use any cigarettes and how much? Do you use any recreational drugs; alcohol, marijuana,
cocaine, LSD, ecstasy? How much and how often do you use this? When was the first time you used this
drug or substance? When is the last time you used this? What generally happens on a day when you
don’t drink?

CAGE questions; Have you ever tried to cut down your use? Have you ever felt angry when someone has
told you about your use? Have you ever felt guilty about using this substance? Have you ever had to use
this drug to get rid of the shakes?

Determine if use disorder; Have you had increased the amount you use this substance to get the same
effect to this? Do you have any symptoms when you don’t use this substance? Do you get cravings, have
inappropriate use (e.g. on the job, while driving etc.) or does this have effects on daily living?

7.9. DEPRESSED MOOD HISTORY:

Depressive symptoms; mood, anhedonia, sleep change, energy decrease

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Manic symptoms; distractible, irritable, insomnia, grandiose delusion, flight of ideas, anxious, decreased
need for sleep, speed of thoughts, thoughtless

Associations; anxiety symptoms, psychotic features, worry, stressors

Risks; Suicidal Risk and homicidal Risk

7.10. PYSCHOSIS HISTORY:

Hallucinations; visual, tactile, olfactory, gustatory

Auditory hallucinations; male/female, familiar voice, real or pseudo hallucination, 1 st person/2nd

person/3rd person, content of hallucinations (command hallucination)

Delusions; grandiose, persecutory, reference, thought control/broadcast, insertion, withdrawal,

blocking, eromantie, perception, challenge the delusion

Assess risk to self and risk to others

Differentials; history of mood symptoms, concomitant drug use or medical conditions

Physical symptoms; constitutional symptoms, morning headache, fever, nausea, vomiting

Organic disease; drugs, withdrawal, fatigue TLE, SOL, hypoxia, SLE, HIV, neurosyphillis

7.11. ANXIETY HISTORY:

Attack details; timing, onset, duration, episodes, triggers, effect on life, frequency and avoidance
symptoms.

Somatic symptoms; palpitations, breathlessness, sweating, dizziness

Past history; previous attacks

Associations; depressive symptoms, stressors, worry, avoidance

Differentials; obsessions, compulsions, nightmares, flashbacks, hyperarousal, impending doom, history

of traumatic event

Organic disease; hyperthyroidism, acute coronary syndromes, arrhythmia, drug use

7.12. DEPRESSED MOOD CLINICAL CLUES:

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Depression; criteria met for mood episodes, symptoms of depression presence, absence of manic
symptoms, if psychotic features then mood congruent, not prominent and present only within mood
episodes. Hopelessness and suicidal ideation are big features.

Bipolar disorder; History suggestive of manic episodes as well as depressive episodes

Adjustment disorder; triggered by stressful life event, stress, upset, anxiety, hopelessness, does not
meet criteria for depressive disorder.

Organic disorders; Hypothyroidism, drug side effects, intracranial lesion

7.13. PSYCHOSIS CLINICAL CLUES:

Schizophrenia; 1st rank symptoms usually present, hallucinations (3 rd person auditory, running
commentary), delusion (thought, control or perception), Positive symptoms and negative symptoms
present.

Delusional Disorder; Non-bizarre delusions, absence of other psychiatric symptoms, do not impair
functioning

Bipolar Disorder; Normal mood interspersed with manic and depressive episodes

Schizoaffective; Features of bipolar and psychosis in the same episode

Psychotic Depression; Depression association with psychotic features like hallucination and delusion

Puerperal psychosis; severe mental illness starting after child birth

Delirium; reduced level of consciousness, fluctuating, diurnal variation, infective symptoms

Dementia; long history of progressive memory loss, other deficits in language, comprehension and
thinking and inhibition

Organic disorder; Drugs use, alcohol use or withdrawal, temporal lobe epilepsy, space occupying lesion,
hypoxia, Huntington’s, lupus, neurosyphillis

7.14. ANXIETY CLINICAL CLUES:

Generalized anxiety disorder; anxiety and worry on most days, generalized about everything, long term
problem

Panic Disorder; definitive panic attacks with periods in between asymptomatic, feeling of impending
doom during attack, attacks are unexpected, spends time worrying about another attack (>1 mo)

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Phobic disorder; intense fear triggered by predictable stimulus, common stimuli are agoraphobia,
isolated phobia and social phobia, avoidance behavior, reaction is out of proportion to acceptable
response.

PTSD; cause is a stressful or traumatic life event, intense anxiety with flashback, insomnia, nightmares,
avoidance and emotional detachment, time period greater than 1 month (acute stress disorder is less
than one month)

OCD; obsessive thoughts that are persistent and intrusive and distress the patient, compulsions which
cause relief to the patient of the obsessions, rituals (counting, checking, cleaning)

Depression; possesses criteria to meet depressive disorder with clear mood episodes.

Organic disease; Acute coronary syndromes, arrhythmia and hyperthyroidism

7.15. TREATMENT IN PSYCHIATRY

7.16. THEORY
1. What is a delusion?
Delusions are fixed, false beliefs that remain despite evidence to the contrary and cannot be accounted
for by the cultural background of the individual. They can be categorized as either bizarre or non-bizarre.
A non-bizarre delusion is a false belief that is plausible but is not true. A bizarre delusion is a false belief
that is impossible.

2. What is an illusion
An illusion is a misinterpretation of an existing sensory stimulus (such as mistaking a shadow for a cat).

3. What is a hallucination?
A hallucination is a sensory perception without an actual external stimulus.

4. Discuss the different hallucinations.

Auditory: Most commonly exhibited by schizophrenic patients.
Visual: Occurs but less common in schizophrenia. This may accompany drug intoxication, drug and
alcohol withdrawal, or delirium.
Olfactory: Usually an aura associated with epilepsy.
Tactile: Usually secondary to drug use or alcohol withdrawal.

5. What are medical conditions that can mimic psychosis?

Cerebrovascular disease, Multiple sclerosis, Alzheimer’s, Huntington’s, tertiary syphilis, AIDS,
encephalitis, Addison’s disease, Cushing’s disease, B12 deficiency, lupus, porphyria, temporal arteritis.

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 6. What are substances that can mimic psychosis?
Known drug causes include corticosteroids, antiparkinsonian agents, anticonvulsants, anti-cholinergics,
anti-hypertensives, NSAIDs, digitalis, methylphenidate, and chemotherapeutic agents. Substances such
as alcohol, cocaine, hallucinogens (LSD, Ecstasy), cannabis, benzodiazepines, barbiturates, inhalants, and
phencyclidine (PCP) can cause psychosis, either in intoxication or withdrawal

7. Differentiate psychotic disorders.

In schizophrenia, symptoms must be present for at least six months. Symptoms present for less than one
month, but more than one day, constitutes a brief psychotic disorder. They grey area between
schizophrenia and brief psychotic disorder constitutes schizophreniform disorder.

8. What is schizoaffective disorder?

Criteria met for mood or manic episodes at the same time where criterion for schizophrenia is met.

9. What are the differences between mania and hypomania?

A manic episode lasts at least 7 days whereas a hypomanic episode lasts at least 4 days. Mania causes
impairment, usually warrants hospitalization and may have psychotic features. The hypomanic episodes
are absent of psychotic features, need for hospitalization and impairment.

10. What are medical conditions that mimic mood episodes?

Depressive; Cerebrovascular disease, endocrinopathies, Parkinson’s, viruses, carcinoid syndrome,
cancer, lupus and other collagen vascular diseases
Manic; Hyperthyroidism, temporal lobe epilepsy, multiple sclerosis, neoplasms, HIV infection

11. What are medications that mimic mood episodes?

Depressive; alcohol, anti-hypertensives, barbiturates, corticosteroids, hypnotics or sedatives,
anticonvulsants, anti-psychotics, diuretics, withdrawal from substance use
Manic; antidepressants, sympathomimetics, dopamine, corticosteroids, levodopa, bronchodilators,
cocaine, amphetamines

12. What is the criterion for persistent depressive disorder?

This comprises symptoms for 2 years and never asymptomatic for more than 2 months. Patient never
meets criteria for major depressive disorder

13. What are the lengths of depressive and manic episodes?

In a depressive episode the patient must be symptomatic for 2 weeks but a manic episode is symptoms
for one week.

14. What is the criterion for cyclothymia?

This comprises numerous periods with hypomanic symptoms (but not a full hypomanic episode) and
periods with depressive symptoms (but not full MDE) for at least 2 years with the person never having
been symptom free for >2 months during those 2 years.

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 15. What is the difference between Bipolar 1 and Bipolar 2?
Bipolar 1 has had manic episodes with or without depressive episodes but Bipolar 2 has had depressive
episodes and hypomanic episodes.

8.0 RHEUMATOLOGY EXAM

8.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to ask you a few questions and examine your hands. Will that be okay?
Can I have you name and age? Are you in any pain today? If you feel any pain, I would like you to let me
know? I would like you to expose your hands and arms up to the elbows and I would like you to place
you hand on a pillow on your lap.

8.2. HISTORY:
First I would like to ask you a few questions.

8.2.1. Pain:
Have you been having any pain in your hands? When as the first time you had this pain? What is the
timing of this pain? What joint are involved in the pain? If you had to rate the pain from 1 to 10 with ten
being the worse pain, how bad is the pain?

8.2.2. Stiffness:
Do you have any stiffness in the joints as well? How much days per week do you get this stiffness? How
long does the stiffness last?

8.2.3. Timing and factors:

Is it worse in the morning, later in the evening or after periods of inactivity? Does anything make it
better or worse? If you had to say how severe this is, how bad is this joint problem?

8.2.3. Impairment and effect:

Do you have any skin rashes or any bowel disease? How is it affecting your daily activities e.g. bathing,
cooking, chores, work, typing etc. What about picking small objects, buttoning buttons and writing?

8.3. PROCEDURE:

8.3.1. Inspection:
On general inspection the patient’s hands begin with inspection of the nail. Look for nail changes like
pitting or onycholysis. Look for loss of the nail bed angle, excessive fluctuance of the nail bed and loss
schamroth’s window. These indicate that there is clubbing present.

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Assess the fingers for scars, and swellings at the joint such as effusions, Heberden’s or Bouchard’s
nodules. Effusions are fluid like boggy swellings whereas Heberden’s and Bouchard’s are bony swellings.
Heberden’s are found at the distal interphalangeal joint whereas Bouchard’s are found at the proximal
interphalangeal joint. Assess the fingers for deformities. Flexion at the distal interphalangeal joint and
extension at the proximal interphalangeal joint is consistent with the swan neck deformity. Extension at
the distal interphalangeal joint with flexion at the proximal interphalangeal joint is consistent with
boutoniere deformity. The Z thumb is characteristically seen as extension at the first interphalangeal
joint with flexion at the metacarpophalangeal joint.

Assess the metacarpophalangeal joints now for ulnar deviation and swelling. Ulnar deviation makes the
phalanges point or deviate laterally.

Assess the wrist now for wasting of the interossei muscles as well as subluxation at the wrist. Go to feel
at the dorsum of the arm up to the elbow as well to look for rheumatoid nodules.

Allow the patient to turn over their hands. Assess the palms for scars, dupuytren’s contractures, palmar
erythema and then the wasting of the thenar and hypothenar eminences. The scars can be a carpal
tunnel release. Dupuytren’s contracture is thickening of the palmar fascia causing passive flexion of the
4th and 5th finger when pulled on.

Comment on any visible skin rashes especially on the extensor surfaces, face. Look for any gouty tophi
especially on ear.

8.3.2. Palpation:
Feel the temperature on both hands. Feel across each of the joints singly including the MCPS, the wrist
and the thumb interphalangeal joints. Generally squeeze all 4 distal interphalangeal joints and proximal
phalangeal joints at the same time. If any pain or abnormality is detected then they are squeezed
individually.

8.3.3. Movement:
Assess active movement. Allow the patient to make a fist, extend fingers, abduct fingers, adduct fingers,
perform the prayer and reverse prayer sign.

Assess passive range of movement. Hold the patient by the wrist with your opposite hand and then
mold their fingers into a fist using your own fingers. Circumduction of the wrist is also done. Stiffness
must be assessed and also the presence of crepitus.

8.3.4. Function:
Assess function of the joint. Make the patient form an “ok” sign which each finger in turn with the
thumb and allow them to resist you separating them. Next make the patient squeeze on your fingers in a
grip and resist you trying to remove them.

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Assess fine motor. Make the patient button a button, pick up a coin, pretend to play a piano or sign their
name.

8.4. CLOSING:
Thank you for your time. The exam is now finished. To finish I would like to examine the other joint
groups in the upper and lower limb to gain a better understanding of the pattern of joint involvement. I
would also like to complete a full history and examine any other systems that would have likely
involvement.

8.5. INTERPRETATION:

8.5.1. Inspection:
On nail inspection, pitting and onycholysis are signs of psoriasis and this finding, in the presence of joint
pain increases the suspicion of psoriatic arthritis. Finger clubbing is present in systemic pathology.

On inspection of the fingers, scars on the fingers give mean previous surgery or trauma. Previous surgery
to the finger can cause osteoarthritis and previous trauma to the finger can cause earl osteoarthritis.
Surgeries can also be done to the fingers for osteoarthritis as well as rheumatoid arthritis. Swan neck,
boutonierre and Z-thumb deformity are classic findings in rheumatoid arthritis and joint effusions can be
present. Heberden’s and Bouchard’s nodes are pathognomonic of osteoarthritis. Wasting of the
interosseous muscles is consistent with ulnar nerve palsy.

On inspection of the metacarpophalangeal joints, ulnar deviation and subluxation are caused by
rheumatoid arthritis. Subluxation of the wrist is seen in rheumatoid arthritis as well. Wasting of the
thenar or hypothenar eminences are associated with median and ulnar nerve palsies respectively.
Palmar erythema in this context is caused by rheumatoid arthritis or can be incidental and associated
with another condition such as pregnancy, liver disease and hyperthyroidism. Previous scars for
dupuytren’s contracture and carpal tunnel release can be evident from surgical scars to the palm.

Rheumatoid nodules are seen in rheumatoid arthritis, rash can indicate inflammatory bowel disease or
psoriatic arthritis.

8.5.2. Palpation:
Warmth of the hand indicates an inflammatory etiology. Swelling and tenderness in a joint would
indicate infection or a synovitis. Joint effusion can be seen in rheumatoid arthritis.

8.5.3 Movement:
Active range of movement allows to as the amount of impairment. Pain on passive movement can also
indicate an inflammatory etiology.

8.5.4 Function:

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This also allows for assessment of impairment. If patient is unable to perform the these activities then it
should be interpreted as impairment.

9.0 DERMATOLOGY EXAM

9.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to ask you a few questions and examine your skin. Will that be okay?
Can I have you name and age? Are you in any pain today? If you feel any pain, I would like you to let me
know? I would like you to expose the area that is affected.

9.2. HISTORY:
First I would like to ask you a few questions.

9.2.1. General:
Tell me about the problem you have been having with your skin. Is this your first episode? When did it
start? Where did it start? How does it look? What color is it? Has it changed in appearance since it first
appeared? Did it stay there or did it spread? What other location is it? Does it involve the hair, ear, lips
and eyes or legs? Is it itchy or painful? Does it have any discharge? Has anything made it better, like
moisturizer, any creams or any topical agents? Has anything made it worse, like sunlight, drying of the
skin, stress or medications? Are there any things that trigger it, like sunlight, dryness of skin, medications
or stress? Have you tried any medications for it? Have you seen a doctor for this before?

9.2.2. Associations:
Has there been any joint pain? Has there been any hair loss? Do you have any history of asthma, allergic
rhinitis (itching nose or eyes) or eczema? Does anybody in your family have any skin problems? Have
you had any recent travel, any recent illnesses or stressful events in your life? How has the rash been
affecting you personally? Has it affected you socially and occupationally? Has it affected you family as
well?

9.3. PROCEDURE:

9.3.1. Inspection
Start by examining the general area of the skin. State the site(s) of the lesion as well as the number, the
pattern and distribution. The site would be in terms of the body part on which the rash is located. The
distribution can be widespread, generalized and localized. It can be flexural, extensor, photosensitive or
dermatomal. The proximity of the rash to sites of trauma is important as well as in relation to pressure
areas. The pattern can be discrete, confluent (merging lesions), linear, target, annular or discoid).

9.3.2. Description:
Describe the lesions in terms of size, shape, color and associated secondary changes. The morphology
and the margins can be examined last. For size and shape, the lesion can be a macule or patch, a papule

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or plaque, a vesicle or bullae, a pustule, an abscess or a wheal. Color can be erythematous, purpuric,
hyper-pigmented, hypo-pigmented or de-pigmented. Secondary changes are crusting, lichenification,
scaling, excoriation or scarring. Excoriation is loss of epidermal surface following trauma. Lichenification
is roughening of the skin with accentuation of skin markings. Scaling is flaking of the skin. Crusting is the
roughening of dried serum, blood and cellular debris that has eroded through epidermis. A scar is new
fibrous tissue forming at wound bed that can be hypertrophic, atrophic or keloid.

If the lesion is pigmented then symmetry, borders, number of colors seen and size must be commented
on. Pigmented lesions can be asymmetric, with irregular borders, differently pigmented or large in size
(>6 mm).

9.3.3. Palpation:
The lesions must be palpated. The surface must be assessed along with the consistency and the mobility.
Tenderness is elicited and temperature of the lesions must be assessed.

9.3.4. Other areas:

Proceed to check the fingers and nails, elbows, upper back, scalp and behind ears, mucous membranes
and mouth and shins. Examine the joints on the hands. On the fingers, look for nail pitting, onycholysis,
subungual hyperkeratosis. On all the other locations, look for more rash involvement. Check the scalp
for alopecia. Check the mouth for aphthous ulcers.

9.4. CLOSING:
Thank you for your time. The exam is now finished. To finish I would like to take a full clinical history,
examine any other relevant organ systems and take a skin biopsy.

9.5. INTERPRETATION:

9.5.1. Description:
Size and Shape:
- Differentials for a macular rash or hyper-pigmented lesion include post-inflammatory hyper-
pigmentation, café-au-lait spots, melasma, pigmented basal cell carcinoma

- Differentials for a papular rash include, scabies, acne vulgaris, rosacea, psoriasis, urticaria, lichen
planus and pyogenic granuloma

- Differentials for a maculopapular eruption include rubella, roseola, erythema infectiosum,

meningococcal, secondary syphilis, leptospirosis, systemic lupus erythematosus, sarcoidosis,
Kawasaki disease, graft vs host disease,

- Differentials for a nodular rash include erythema nodosum, acne vulgaris,.

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 - Differentials for a pustular lesion include acne vulgaris, acne rosacea, pyogenic infection,
folliculitis, secondary syphilis, pustular psoriasis, candida and dermatophyte infection.

- Differential for a vesicular or bullous rash include burns and chemical agents, infections such as
impetigo, toxic epidermal necrolysis, herpes, varicella, syphilis, hand foot mouth, Stevens
Johnson syndrome, pemphigoid, insect bite.

- Differentials for an oral ulcer include herpes simplex, herpes zoster, IHV, TB syphilis, angular
stomatitis, EM/SJS/TEN, Behcet’s, lupus, chemotherapy, radiation and sickle cell disease.

- Differentials for a skin ulcer include syphilis, TB, vasculitis, pyoderma gangrenosum, sickle cells,
squamous cell carcinoma, necrobiosis lipoidica and basal cell carcinoma

Color:
- Differential for erythema include cellulitis, erythema multiforme, erythema nodosum, urticaria,
erysipelas and angioedema

- Differentials for purpuric and petechial lesions include thrombocytopenia, disseminated

intravascular coagulation, immune thrombocytopenic purpura, marrow failure, vasculitis, drug
reactions, steroids and infection such as malaria, tuberculosis, Rocky Mountain spotted fever,
gonococcus, meningococcus and HIV.

- Differentials for hypo-pigmented or depigmented rashes include vitiligo, albinism, post-

inflammatory hypo-melanosis, tinea versicolor, psoriasis, melanoma, secondary syphilis.

Secondary changes:
- Differential for lichenification and excoriation secondary to pruritus include infestations like
scabies and lice, infection like bacteria, fungus or viral (zoster), urticaria, dermatitis
herpetiformis, bullous pemphigoid and lichen planus.

Pigmented lesions:
- Any asymmetric, irregularly bordered lesions, showing varying pigmentation and greater than 6
mm are suspicious for melanoma.

9.5.2. Palpation:
- Differentials for tenderness and temperature include abscess, impetigo, cellulitis, furuncle,
carbuncle, and necrotizing fasciitis.

9.5.3. Other areas:

- Differentials for scarring alopecia include physical trauma like burns and chemicals,

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 - Differentials for non-scarring alopecia include aging, drugs, seborrheic dermatitis, psoriasis,
tinea capitis, lupus, secondary syphilis and alopecia areata.

- Joint pain is associated with lupus, psoriasis and inflammatory bowel disease

- Nail pitting, onycholysis, subungual hyperkeratosis are associated with psoriasis

9.6. CONDITIONS:

9.6.1. Melanoma:

Description: Asymmetrically pigmented plaque/tumor with irregular borders and variably pigmented. It
is a single lesion with size >6mm and has a recent change in appearance, size and/or character.

Risk Factors: Sunlight, fair skinned, increased age, immunosuppression

Treatment: excision with secondary margin excision depending on depth +/- lymphadenectomy +/-
chemotherapy

9.6.2. Psoriasis:

Description: Symmetrical well defined erythematous plaques with silvery scales located on extensor
surface

Other sites: scalp, behind ears, navel, sacrum, flexural surfaces if inverse (axilla, groin and sub-
mammary)

Triggers: stress, infections, Koebner phenomenon, lithium, beta-blockers, anti-malarials, alcohol,

smoking

Other findings: Pitting, Onycholysis, Subungual hyperkeratosis, Psoriatic arthritis

Variants: Guttate, Plaque, Pustular, Erythrodermic, Inverse

Management: Education (avoid triggers), soap susbtitutes, emolientss, topicals (vitamin D analogues,
steroids, tar for inpatients, retinoids, UV phototherapy

Biological Therapy: methotrexate, ciclosporin, acetretin

Non-Biological Therapy: Infliximab, etanercept

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9.6.3. Eczema

Description: Itchy, poor demarcated papule and vesicles +/- lichenification

Sites: eyes, cheeks, elbows, knees

Complications: Infection with staph aureus or HSV

Types: irritant contact dermatitis, allergic contact dermatitis, seborrheic dermatitis

Management: education (avoid triggers), soap substitute, emollients, topical steroids

ca10.0 CARDIOVASCULAR EXAM

10.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to examine your chest and heart. Will that be okay? Can I have you
name and age? Are you in any pain today? If you feel any pain, I would like you to let me know? I would
like you to take off your jersey to expose the chest and the bed is placed at 45 degrees for this exam.

10.2. INSPECTION:

10.2.1. General:
Observe if the patient is in distress and look for oxygen therapy, fluids or any other medications at the
bedside like glyceryl tri-nitrate. Look for scars, active precordium and chest wall deformities. Check for
pedal edema (maybe sanitize hand again after).

10.2.2. Hands and Nails:

Assess for temperature on the front of the hands and look for lesions such as Osler’s nodes and Janeway
lesions. Turn over the hands and look for peripheral cyanosis, capillary refill time, splinter hemorrhages
and clubbing. For clubbing, look for loss of the nail bed angle first, then for excessive nail bed fluctuance
and then for schamroth’s window.

10.2.3. Pulses:
Assess the radial pulse for 15 seconds, assessing the rate rhythm, volume and character. Assess for
radio-radial delay and radio-femoral delay.

10.2.4. Arm:
Ask the patient if they have any pain in their shoulder. Tell them to relax their arm and don’t help you
lifting it at all. Press the radial pulse with the proximal segment of your fingers, firstly till you barely feel
it and then until it cannot be felt. Raise the arm up and see if the pulse strengthens and if you can now
feel it. Put the arm back down and see if the pulse now disappears.

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Ask for the blood pressure. Assess the pulse pressure.

10.2.5. Face:
Assess the mucous membranes and the sclera, looking for jaundice, conjunctival pallor and dryness of
the mucous membranes.

Look for central cyanosis in the mouth and assess the dentition to see if it is adequate or poor. Look for
a high arched palate.

10.2.6. Neck:
Assess the jugular venous pulse by turning the neck slightly to the right. Look for the double pulsation on
the left side of the neck. Ask if the patient has pain in the belly and then press on the right upper
quadrant. Watch for a rise on the jugular venous pulse and a fall as the pressure on the liver is released.
Look for tracheal deviation.

10.2.7. Chest:
Inspect for any scars; midline, inframammary or laterally. Look closer for active precordium and look for
any signs of a pacemaker.

10.3. PALPATION:
Palpate for dextrocardia and localize the apex beat; palpate the sternal angle, count the intercostal
spaces down and check the distance of the apex beat from the mid clavicular line. Feel for thrills over all
the valves and look for a parasternal heave.

10.4. AUSCULTATION:
Place your hand on the carotid to time the murmur

Place the bell at the apex and, with the patient in the left lateral position, make the patient breathe in,
out, and then holding in expiration. Listen for the murmur of mitral stenosis.

Place the diaphragm at the apex and make the patient breathe in, out and then holding in expiration.
Listen for the murmur of mitral regurgitation. Listen for radiation to the axilla.

Place the diaphragm at the tricuspid area and make the patient breathe in and then holding in
inspiration. Listen for the murmurs of aortic regurgitation, ventricular septal defect and tricuspid
regurgitation.

Place the diaphragm at the pulmonary area and make the patient breathe in and then holding in
inspiration. Listen for the murmurs of pulmonary stenosis or atrial septal defect.

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Place the diaphragm at the aortic area and make the patient breathe in, out and then holding in
expiration. Listen for the murmur of aortic stenosis. Listen for radiation to the axilla.

Make the patient sit up and lean over. Place the diaphragm at the apex and make the patient breathe in,
out and then holding in expiration. Listen and then move to the tricuspid area and listen for the murmur
of aortic regurgitation. See if it heard best in the aortic area or the tricuspid area.

Auscultate the carotids for radiation of aortic stenosis to the carotids.

10.5. BACK AND EXTRA:

Palpate the carotids for a low volume and slow rising carotid pulse if aortic stenosis is present.

Auscultate the back at the bases of the lungs for basal crepitation and feel for sacral edema. Tell the
patient you are going to feel on their lower back before you do so for sacral edema.

Place the bed flat and then inform the patient you will check for enlargement of the liver.

10.6. CLOSING:
Thank you for your time. The exam is now finished. You can cover back up. To finish I would like perform
a 12 lead ECG.

10.7. INTERPRETATION:

11.0 RESPIRATORY EXAM

11.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to examine your chest and lungs. Will that be okay? Can I have you
name and age? Are you in any pain today? If you feel any pain, I would like you to let me know? I would
like you to take off your jersey to expose the chest and the bed is placed at 45 degrees for this exam.

11.2. INSPECTION:

11.2.1. General:
Observe if the patient is in distress and look for oxygen therapy, fluids or any other medications at the
bedside like inhaler, nebulizer mask and sputum pot. Look for scars, audible breathing, nasal flaring, use
of accessory muscles and chest wall deformities.

11.2.2. Hands and Nails:

Assess the palm of the hands and look for pallor, peripheral cyanosis, clubbing. For clubbing, look for
loss of the nail bed angle first, then for excessive nail bed fluctuance and then for schamroth’s window.

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Ask the person to stretch out the hand and spread the fingers to look for fine tremor, and then to pull
the wrist back and look for any flapping tremor.

11.2.3. Face:
Assess the mucous membranes looking for conjunctival pallor and dryness of the mucous membranes.

Look for central cyanosis in the mouth.

11.2.4. Neck:
Say that you would check the jugular venous pulse at the neck. Look for tracheal deviation.

11.2.5. Chest:
Inspect for any scars; midline, inframammary or laterally. Look chest wall deformities.

11.3. PALPATION:
Assess chest expansion for lateral and AP expansion. Get to the level of the patient to assess for AP
expansion. Look for a hyper-inflated chest and decreased chest expansion either symmetrically or
asymmetrically.

Palpate for dextrocardia and localize the apex beat; palpate the sternal angle, count the intercostal
spaces down and check the distance of the apex beat from the mid clavicular line.

Place the ulnar border of the hand at four points along the mid-clavicular line bilaterally as well as two
points in the axillary region/ lateral chest wall. Make the patient say “99” each time you do so. Look for
increase or decrease in tactile vocal fremitus in the lung zones.

11.4. PERCUSSION:
Percuss the anterior chest wall at four points along the mid-clavicular line bilaterally as well as two
points in the axillary region/ lateral chest wall. Look for hyper-resonance or dullness to percussion in the
lung zones.

11.5. AUSCULTATION:
Place the diaphragm of the stethoscope on the anterior chest wall at four points along the mid-clavicular
line bilaterally as well as two points in the axillary region/ lateral chest wall. Let the patient say “99”
each time you do so. Listen for increased or decreased vocal resonance in the lung zones.
Place the diaphragm of the stethoscope on the anterior chest wall at four points along the mid-clavicular
line bilaterally as well as two points in the axillary region/ lateral chest wall. Auscultate zones as the
patient breathes in and out. Assess air entry and inspiratory and expiratory phases of breathing. Listen
for the quality of breath sounds, crackles, wheeze, stridor or absence of breath sounds.

11.6. BACK:

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Assess chest expansion for lateral expansion. Look for a hyper-inflated chest and decreased chest
expansion either symmetrically or asymmetrically.

The points on the back for the zones of the lung are supra-scapularly, lateral to scapula and infra-
scapularly along the middle of the hemi-thorax.

Place the ulnar border of the hand at the three points along the posterior chest wall. Make the patient
say “99” each time you do so. Look for increase or decrease in tactile vocal fremitus in the lung zones.

Percuss at the three points along the posterior chest wall. Look for hyper-resonance or dullness to
percussion in the lung zones.

Make the patient place their hands on their shoulders.

Place the diaphragm of the stethoscope on the three points along the posterior chest wall. Let the
patient say “99” each time you do so. Listen for increased or decreased vocal resonance in the lung
zones.

Place the diaphragm of the stethoscope on the three points along the posterior chest wall. Auscultate
zones as the patient breathes in and out. Assess air entry and inspiratory and expiratory phases of
breathing. Listen for the quality of breath sounds, crackles, wheeze, stridor or absence of breath sounds.

11.7. CLOSING:
Thank you for your time. The exam is now finished. You can cover back up. To finish I would like perform
a chest radiograph, arterial blood gas and sputum.

11.8. INTERPRETATION:

12.0 GASTROINTESTINAL EXAM

12.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to examine your belly. Will that be okay? Can I have you name and
age? Are you in any pain today? If you feel any pain, I would like you to let me know? I would like you to
take off your jersey to expose the belly the top of the groin and the bed is placed at flat for this exam.

12.2. INSPECTION:

12.2.1. General:
Observe if the patient is in distress and look for oxygen therapy, fluids, catheters, central lines and
drains. Comment on body habitus of the patient. Look for scars, distention, discolorations or visible

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masses. Comment on the rise and fall of the abdomen and the status of the umbilicus. Check for pedal
edema (maybe sanitize hand again after).

12.2.2. Hands, Nails and Arms:

Assess for temperature on the palm of the hands and look for lesions such as palmar erythema or
dupuytren’s contracture. Turn over the hands and look for koilonychias, leuconychia and clubbing. For
clubbing, look for loss of the nail bed angle first, then for excessive nail bed fluctuance and then for
schamroth’s window. Assess the arms for excoriations, needle marks, AV fistulae and purpura.

12.2.3. Face and Neck:

Assess the face for a cushingoid appearance as well as any parotid enlargement

Assess the mucous membranes and the sclera, looking for jaundice, conjunctival pallor and dryness of
the mucous membranes. Comment on the presence of any scleritis or episcleritis seen

Look for angular stomatitis, oral candidiasis, aphthous ulcer and glossitis in the mouth.

Feel for the Virchow’s node and cervical lymph nodes.

12.2.4. Chest and Back:

Assess for gynecomastia and check for spider nevi on the chest and back.

12.2.5. Abdomen:
Inspect for any scars; midline, gridiron, lanz, groin incisions or laparoscopy ports. Look for caput medusa
or prominent veins on the abdomen.

12.3. PALPATION AND PERCUSSION:

Ask the person if they are having any pain in the abdomen. If so, then clarify where the pain is located.
Start palpation in the furthest quadrant and palpate there last.

Kneel and palpate all 9 quadrants lightly and then deeply, looking at the patient’s face as you do so.
Assess for tenderness, rebound tenderness, masses and guarding.

12.3.1. Liver:
From right iliac fossa to the right subcostal margin, in line with nipple, ask patient to breathe in and out
when you say to and push in as they breathe in. Feel for a palpable liver.

From right iliac fossa to the right subcostal margin, in line with nipple, percuss for the liver. The dullness
should correspond with the lower border of the liver. From the infra-clavicular area, percuss between
the ribs down towards the nipple area. The dullness corresponds to the upper border.

12.3.2. Spleen:

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From right iliac fossa to left hypochondriac region, ask the patient to breathe in and out when you say to
and push in as they breathe in. Feel for a palpable splenic notch. If the spleen is not felt the patient rolls
towards you and the left hypochondriac is palpated again.

From right iliac fossa to left hypochondriac region, percuss for the spleen. Feel for a palpable splenic
notch. If the spleen is not felt the patient rolls towards you and the left hypochondriac is palpated again.

12.3.3. Kidneys:
Press on top of the flank with one hand and palpate the back with the other hand to ballot the kidneys.

12.3.4 Ascitic Fluid:

Assess for a fluid thrill. Ask the patient to rest the ulnar border of their hand at the midline of their
abdomen and press down. Flick one side of the abdomen and feel for a transmission of the impulse to
the next side.

Assess for shifting dullness. Percuss from the midline to the periphery, looking for a change in resonance
t dull. Keeping a finger at the point where the sound became dull, make the patient turn towards you.
Percuss once more to see if the area is now more tympanitic or exhibits a loss in the dullness at that
point.

12.4. AUSCULTATION:
The points of auscultation over the abdomen are 1/3 the distance from the umbilicus to the anterior
superior iliac spine, either side of the umbilicus, above the umbilicus and the costal margins in the right
and left upper quadrants. The ileocecal valve is auscultated between the umbilicus and anterior superior
iliac spines. Renal bruits can be heard on either side of the umbilicus and the aortic bruits can be heard
just superior to the umbilicus. Hepatic hum and splenic rub can be heard at the costal margin at mid
clavicular lines on left and right respectively

12.5. EXTRA:
Place your hands simultaneously over the right and left inguinal area, occluding the deep ring. Ask the
patient to cough. Assess if hernia is present on either side or both sides. Place hands over umbilicus and
ask patient to cough one more time. Assess if inguinal hernia present.

12.6. CLOSING:
Thank you for your time. The exam is now finished. You can cover back up. To finish I would like examine
external genitalia, perform a digital rectal exam and acquire a stool sample.

12.7. INTERPRETATION:

13.0 FUNDUSCOPY

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13.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to ask you examine your eyes. Will that be okay? Can I have you name
and age? This exam would involve me shining a light into your eye so I can look at the back of the eye.
You must not look into the light unless I tell you to and it is okay to blink. Are you in any pain today? If
you feel any pain, I would like you to let me know. Firstly, I would like you to pick a spot ahead and focus
on it while I perform the exam.

13.2. INSPECTION:
Inspect the outer eye. Look for any scars, discharge, swelling, ulcers, abrasions, signs of cataract or signs
of inflammation. Approach the patient at 15 degrees laterally and look for the red reflex in both eyes
bilaterally. Comment on its presence bilaterally or unilaterally as well as its completeness.

13.3. OPTIC DISC:

Move in towards the eye on that side and enter at 15 degrees at the level of the patient Adjust the lens
for the refractive error as you go in to focus on the images. Rotate the focus dial in one direction. If the
vessel becomes more blurred then rotate in the other direction until it becomes sharp. Follow at blood
vessels seen back to the optic disk.

When the disc is found, observe its appearance. Consciously note the ‘3 Cs’ of the disc. These are color
contour and cup. Look for a normal pink color or a pale color of the disc. Look for the cup and assess the
cup to disc ratio. Assess the contour, looking to see if it is well defined or if the edges are blurred.

13.4 PERIPHERIES AND BLOOD VESSELS:

Follow the supero-temporal arcade vessels away from the disc and then back towards the disc. Repeat
for the infero-temporal, supero-nasal, and infero-nasal vessels. While following these vessels, look for
signs of retinopathy, extra vessels, pigmentation or exudates. Do not forget to look around the vessels
for laser scars.

13.5. MACULA:
Tell the patient to look into the light. Look at the macula.

13.6. CLOSING:
This is the end of the examination. Thank you. To finish I would like to check the patient’s visual acuity
and perform a slit lamp examination.

13.7. INTERPRETATION:

14.0 CRANIAL NERVES

14.1. INTRODUCTION:

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Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to ask you a examine some of the nerves in your face, neck and back.
Will that be okay? Can I have you name and age? Are you in any pain today? If you feel any pain, I would
like you to let me know? I would like you to expose the area that is affected.

14.2. PROCEDURE:

14.2.1. Olfactory:

Smell:
Ask if they have noticed a change in sense of smell.

14.2.2. Optic:

Visual Acuity:
Ask if the patient wears contact lenses or glasses. Ask if there has been any visual difficulty recently. This
is done using a Snellen’s chart kept at 6m or 20ft from the patient. The patient covers one eye at a time.

Color vision:
This is assessed using the Ishihara plates

Visual Fields:
Ask the patient to look at your nose. Enquire if they can see your entire face. Make them then cover
their left eye. The patient must then look into your left eye with their right eye and you should cover
your right eye. This is done at an arm’s length. Hold a colored pin between yourself and the patient as
far as your hand can reach. Ensure that the pin is in the periphery of your both visual field. Slowly move
the pin from the extremity, where the pin cannot be seen, to the point where it can be just seen and
then towards the center of the visual field. The pin is move from all the four corners of the visual field
towards the center. Compare the patient’s visual field to your own.

Pupillary reflexes:
Ask the patient to focus on a spot on the wall. Inform that you are going to briefly shine a light into their
eye. Assess the direct reflex from the eye the light is shone in to and the consensual reflex of the eye it is
not being shone in to. Repeat for the next eye. Perform the swinging torch for inappropriate dilation of
the eye when light is shone in to the eye.

Fundus:
The patient’s fundus should ideally be examined to assess optic nerve function.

14.2.3. Oculomotor, Trochlear, Abducens:

Eye movement:

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Assess if ptosis is seen in either eyes or any abnormalities of position. Inform the patient to keep their
head still and to follow your finger with their eyes. Move finger in an “H” type pattern. Ask the patient if
they saw double vision at any point. If diplopia is seen, then clarify if the split images are side by side or
one over the other. Additionally, tell them to cover one eye and see which image disappears.

Accommodation:
Inform the patient to keep looking at your finger. Move your finger from half a meter towards the
patient’s nose. Assess pupil constriction.

14.2.4. Trigeminal:

Sensory:
Ask the patient to close their eyes. Explain that you are going to test sensation with a neuro-tip and a
wisp of cotton and they should say “yes” when they feel the sensation. Enquire if sensation was equal on
both sides. The ophthalmic division is above the eye brows, the maxillary division is above the zygoma
and mandibular division is at the chin on either side of the midline

Motor:
Palpate the temporalis muscle as well as the masseter when the jaw is clenched on both sides. The
masseter is palpated above the angle of the jaw.

Reflexes:
Inform that corneal reflexes are assessed directly by touching the cotton wisp on the cornea to invoke
the blink or by testing the sensation inside the nostril which is innervated by the same branch of the
trigeminal but the corneal reflex would be omitted because of the discomfort to the patient.
A jaw jerk is then done by making the patient hang their mouth open, placing your thumb on their chin
and then striking your thumb with a tendon hammer.

14.2.5. Facial:

Facial Tone:
Look for signs of reduced facial tone like absent wrinkling of the forehead, drooping at the corneal of the
mouth or flattening of the nasolabial fold.

Motor:
Tell the patient to raise their eyebrows and wrinkle their forehead. Ask them to close their eyes and not
let you open them. Ask the patient to puff out their cheeks while you press against them. Ask the patient
to smile and show teeth and gums.

Sensory:
Test taste on the anterior two thirds of the tongue or ask the patient if they have been having any
change in taste. Ask the patient if they have been having any problems with loud noises.

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14.2.6. Vestibulocochlear:

Hearing Test:
Rub the tragus or occlude the external auditory meatus of one ear. Whisper some words into the
opposite ear and have the patient repeat.

Rinne Test:
Assess each ear in turn. Using a 512 Hz tuning fork, strike it and place vibrating fork on mastoid process
and then strike it once more and place the vibrating fork in line with the meatus. Ask which noise was
louder.

Weber Test:
Place the vibrating fork on the center of the forehead and ask the patient if the sound is louder on either
side or if it is central or equal on both sides.

14.2.7. Glossopharyngeal and Vagus:

Soft palate and uvula:

Test the patient to open their mouth and say “Ahhh”. Look at the movement of the uvula and assess for
unilateral deviation. Inform that the gag reflex is a part of assessment of these nerves but it is omitted
because of the discomfort to the patient.

Extra:
Ask the patient to swallow and then to cough.

14.2.8. Accessory:

Motor:
Ask the patient to shrug their shoulders against resistance to test the trapezius. Ask the patient to turn
their head against resistance to test the sternocleidomastoid on the opposite side and repeat on the
next side.

14.2.9. Hypoglossal:

Appearance:
Assess to see if the tongue normal, flaccid, wasted and fasciculating or spastic and contracted.

Movement:
Ask the patient to stick out the tongue and assess for deviation to one side. Ask the patient to press the
tongue against the side of the cheek to assess power in the tongue. Repeat this on the next cheek.

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14.3. CLOSING:
Thank you for your time. The exam is now finished.

14.4. INTERPRETATION:

15.0 LOWER LIMB MOTOR EXAM

15.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to examine your legs. Will that be okay? Can I have you name and age?
Are you in any pain today? If you feel any pain, I would like you to let me know? I would like you to take
off your pants and socks to expose the complete lower limb (fit the bed cover as a diaper for this) and
the bed is placed at flat for this exam.

15.2. INSPECTION:

15.2.1. General:
Inspect the patient. Comment on general appearance. Look at the hands grossly for any asymmetry or
posturing. Look at the legs for any gross deformity, any visible scars, and masses. Look for scissoring or
frog leg positioning of the lower limbs. Lift the foot and look at the posterior aspect as well. Move to the
side of the bed and feel for muscle bulk. Look for spontaneous or induced fasciculations bilaterally.

15.3. TONE:
Perform the log roll, looking for signs of hypertonia or hypotonia. Pull up quickly on both legs at the
knee separately to look for hypertonia. Elicit clonus by holding knee at 90 degrees and rapidly
dorsiflexion of the ankle.

Assess passively the tone in all the muscle groups. These include flexion and extension at the hip,
abduction and adduction at the hip, circumduction at the hip, extension and flexion at the knee, plantar
flexion and dorsiflexion at ankle and inversion and eversion at ankle with flexion of the big toe
additionally.

15.4. POWER:
Assess power out of five for each muscle group bilateral. Allow the patient to raise each leg against
gravity and then allow them to push and pull against resistance. Perform hip extension with the patient
on their belly. Use this opportunity to inspect the lower back. Perform hip abdduction and adduction
against resistance. Perform a push and pull against resistance at the knee. Perform a plantar flexion and
dorsiflexion at the ankle against resistance. Rate the power put of five using the MRC scale for power.

15.5. REFLEXES:

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Ask the patient to relax and close their eyes. Assess the tendon reflex at the knee and ankle. Perform the
plantar reflexes by rubbing the orange stick under the lateral feet to elicit up going or down going
plantar.

15.6. COORDINATION:
Perform the heel to shin test to assess coordination

15.7. GAIT:
Ask the patient if they are able to stand. Forst make the patient get off the bed without using their
hands. Allow the patient to perform a normal walk and a tight rope walk assessing for abnormalities of
gait.

15.8. CLOSING:
This is the end of the exam. You can get back on the bed and redress yourself. To finish I would like to
perform a sensory exam of the lower limb to find a sensory level as well as check for anal and urinary
incontinence. As necessary, a full neurological examination of the upper limb and cranial nerves is done.
Further studies would include nerve conduction studies and electromyography.

15.9. INTERPRETATION:

16.0 LOWER LIMB SENSORY EXAM

16.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to examine the sensation in your legs. Will that be okay? Can I have
you name and age? Are you in any pain today? If you feel any pain, I would like you to let me know? I
would like you to take off your pants and socks to expose the complete lower limb (fit the bed cover as a
diaper for this) and the bed is placed at flat for this exam.

16.2. INSPECTION:
Generally inspect the feet. Look for loss of hair, discoloration and any visible ulcers. Also check between
the web spaces for arterial ulcer and at the base of the ankle and foot for neuropathic ulcer. Comment
on any gross deformities of the foot.

16.3. FINE TOUCH:

The dermatomes in the leg should all be checked. L1 is the anteromedial mid-thigh, L2 is medial thigh
above knee, L3 is the medial leg above the medial malleolus, L4 is the lateral leg above the lateral
malleolus, S1 is the lateral forefoot and S2 is behind the knee.

With a cotton wisp, it is tested on the patient's sternum. Ask them how it feels. Repeat this with their
eyes closed at each dermatome from distal to proximal. Ask the patient to tell you when they feel it
every time, if all felt the same and if it was the same bilaterally.

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16.4. CRUDE TOUCH:
The dermatomes in the leg should all be checked. L1 is the anteromedial mid-thigh, L2 is medial thigh
above knee, L3 is the medial leg above the medial malleolus, L4 is the lateral leg above the lateral
malleolus, S1 is the lateral forefoot and S2 is behind the knee.

With a monofilament, it is tested on the patient's sternum. Ask them how it feels. Repeat this with their
eyes closed at each dermatome from distal to proximal. Ask the patient to tell you when they feel it
every time, if all felt the same and if it was the same bilaterally.

Check for glove and stocking distribution by sticking the lower leg from distal to proximal with the
monofilament. Ask the patient if all felt the same or some less than the other.

16.5. JOINT POSITION:

First use the big toe and immobilize the forefoot with one hand and hold the sides of the distal toe.
Show the patient first which direction is up and which is down. Repeat this with their eyes closed and
see if they can sense the direction. If absent then move to the ankle, then the knee and then hip.
Perform this on both sides

16.6. VIBRATION:
Vibrate the 128 Hz tuning fork on the patient chest and ask them how it feels. Tell the to inform you if
they feel the same vibration with there eyes closed on their toes. Perform this with the tuning fork
vibration first on the pulp of the big toe, then the medial malleolus, then then tibial tuberosity and then
the anterior superior iliac spine. There is no need to continue proximally if the vibration sense is
retained distally. Perform this on both sides.

16.7. TEMPERATURE:
These are not usually done, but, explain that this would be done with two test tubes carrying warm
water and ice respectively to test for hot and cold sensation. Say it is done on both sides.

16.8. EXTRA:
Assess the person with the Rhomberg's Test. Make the patient stand up with feet facing you and placed
together. Make the patient close their eyes. Look for any unsteadiness.

16.9. CLOSING:
This is the end of the exam. You can get back on the bed and redress yourself. To finish I would like to
perform a motor exam of the lower limb as well as check for anal and urinary incontinence. Also as
necessary full neurological examination of the upper limb and cranial nerves would be required. Further
studies would include nerve conduction studies and electromyography

16.10. INTERPRETATION:

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17.0 UPPER LIMB MOTOR EXAM

17.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to examine your arms. Will that be okay? Can I have you name and
age? Are you in any pain today? If you feel any pain, I would like you to let me know? I would like you to
take off your jersey or expose up to the elbows at least in order to expose the complete upper limb and
the patient is seated for this exam.

17.2. INSPECTION:

17.2.1. General:
Inspect the patient. Comment on general appearance. Look at the hands grossly for any asymmetry or
posturing. Look at the arms for any gross deformity, any visible scars, and masses. Look for visible
evidence of nerve palsy like clawing of the fingers, consistent with a Klumpke paralysis or findings
consistent with an Erb’s palsy. Look for any induced or spontaneous fasciculations. Look at the front and
the back of the hands looking for any wasting of the thenar/hypothenar eminences and interosseous
muscles. Look to see if there is any wrist drop.

17.3. TONE:
Assess passively the tone in all the muscle groups. These include flexion and extension at the elbow,
abduction and addiction at the wrist, circumduction at the wrist, extension and flexion at the wrist,
abduction and adduction of the thumb, circumduction of the thumb and pronation and supination of the
forearm.

Elicit clonus by rapidly extending the wrist back.

17.4. POWER:
Assess power out of five for each muscle group bilateral. Perform extension and flexion of the elbow
against resistance with the patient in the boxer position. Perform flexion and extension at the wrist
against resistance with the patient in the motorcycle position. Perform thumb extension and flexion
against resistance.

Assess function of the joint. Make the patient form an “ok” sign which each finger in turn with the
thumb and allow them to resist you separating them. Next make the patient squeeze on your fingers in a
grip and resist you trying to remove them.

Rate the power put of five using the MRC scale for power.

17.5. REFLEXES:
Ask the patient to relax and close their eyes. Assess the tendon reflex at the bicep, the supinator and
then the triceps.

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17.6. COORDINATION:
Perform the finger to nose test to assess for past pointing or dysmetria. Perform the rapidly alternating
movements of the hand to assess for discoordination or dysdiadochokinesia.

17.7. CLOSING:
This is the end of the exam. You can redress yourself. To finish I would like to perform a sensory exam of
the lower limb to find a sensory level as well as check for anal and urinary incontinence. As necessary, a
full neurological examination of the upper limb and cranial nerves is done. Further studies would include
nerve conduction studies and electromyography.

18.0 PEDIATRIC HISTORY

18.1. INTRODUCTION:
Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final year students. I
understand that your child has been ill and I would like to ask you some questions. Is that alright?
What’s your child’s full name and age please? And what is your name and age? It is nice to meet you.
Where do you live?

18.2. PRESENTING COMPLAINT:

Can you tell me a little bit about the symptoms your child has been experiencing?

18.2.1. General questions for each symptom:

When did it begin? Did it begin suddenly or progressively? Did it worsen or get better? How did it
begin/continue/progress? How frequent has this been happening? What makes it better? What makes it
worse? Is there anything associated with any other symptoms? Have you been taking any treatment for
this right now? If yes, what, how much, when, are you compliant and does it work? When was the last
dose?

18.2.2. Technique for Presenting Complaint:

Go through each symptom according to the site, onset, character, radiation, associations, timing,
exacerbating and alleviating factors and severity. Use only the parameters that apply. Ensure to go
through all the associations of the symptoms. Ensure to get the full evolution of each symptom and the
treatment for each symptom.

18.3. REVIEW OF SYSTEMS:

General: Has he/she been experiencing any fevers, chills, night seats or weight loss? Is there any visible
rash?

Cardiorespiratory: Has he/she been having any chest pain, racing of the heart, difficulty breathing while
lying down, waking in the night with shortness of breath, or general shortness of breath? Has he/she

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been having any cyanosis, squatting, exercise tolerance or tiredness? Have you been having any cough,
wheeze, sputum, snoring, apnea or coughing up of blood?

Gastrointestinal: Have you been having any change in weight or appetite? DO you think that the child is
growing well or not gaining weight? Have you had any nausea/vomiting, indigestion/heartburn or
abdominal pain? Have you had any change in bowel habits, diarrhea, constipation or any blood or mucus
in the stool? Has he/she been having any jaundice or yellowing of the eyes?

Neurological: Have you been having any fits, falls, and loss of consciousness or dizziness? Have you been
having vision or hearing problems, memory loss, neck stiffness or photophobia?

Urologic: Have you been having increased or decreased urine, any urgency to go pee or any excessive
urination at night or day? Have you had any painful urine or passing of blood? Have you had any
incontinence? Has there been any discharge? IS the child toilet trained?

Rheumatologic: Have you had any pain, stiffness or swelling of your joints? Have there been any
deformities or walking problems?

Pubertal: Have there been any strong body odor, hair growth or deepening of the voice? Has the child
reached menarche? Is the child sexually active?

Allergy: Has there been any hives, wheezing, itchy eyes, itchy nose or sensitive skin?

18.4. PAST MEDICAL AND SURGICAL HISTORY:

Has he/she had any medical illnesses such as any sickle cell disease, asthma, seizures, congenital heart
disease, thalassemia or infections? If yes, when was this, what symptoms were experienced and what
treatment was administered?

Has the child had any hospitalizations? If yes, when was this, what symptoms were experienced and
what treatment was administered? Are there any sick contacts?

Has the child had ay surgeries before?

18.5. PAST DRUG HISTORY:

Is he/she on any medications; either prescription, non-prescription of herbal remedies? If yes, what is
the name, what is the dose, why is it needed, how frequently is it taken, when was the last dose and are
they compliant?

18.6. ALLERGIES:
Are there any known drugs or food allergies? What happens when exposed to the allergen? Is it any
reaction such as urticaria, angioedema or pruritus?

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18.7. BIRTH HISTORY:
Was it planned or unplanned? How many obstetric ultrasounds? When were supplements (iron and
folate) started? Were there any medications used during pregnancy? What were the results of the
booking bloods (ABO, Rhesus, HIV, VDRL)? Where was antenatal care done? Did you attend all your
visits?

Were there any problems in pregnancy like bleeding, hypertension, diabetes, infections, alcohol, drugs
and prolonged rupture of membranes? Did the baby go full term? What type of delivery was it? Were
there any complications of delivery like fetal distress, use of forceps or prolonged delivery?

What were the baby’s birth weight and Apgar score? Were there any neonatal problems like jaundice,
need for oxygenation and infection?

18.8. DEVELOPMENT:
Do you have any worries about vision, hearing, or development? What is the child doing no with hands
and legs? What is the child saying now with words or talking? What does the child do interactively?
What school does the child attend? What class is the child in? Are there any complaints for the teacher?
How is the child doing in school academically? Does the child have any tantrum, pica or bed wetting?

18.9. IMMUNIZATION:
Have they had all their immunizations? Ask to see their immunization card? When was last
immunization? For sickle cell patients less than 3 ask about pneumococcal vaccination.

18.10. FEEDING HISTORY:

How long was child breast fed for? How long was the child bottle fed for? At what age did the child start
eating from the family pot? Describe the food groups that the child eats? Describe a typical meal plan
for me?

18.11. FAMILY HISTORY:

Can I have the name and age of both parents? Can I have their occupation? Can I have their highest level
of education? Are the parents married? Any medical conditions run in the family? Did anyone get and
diabetes or hypertension at a young age? Does anyone have cancer, seizures, sickle cell or thalassemia?
Has anyone in the family died of a young age?

18.12. SOCIAL HISTORY:

How much persons live in the house? Where does the child sleep? Does the child have the basic
amenities like running water and electricity? Is there proper garbage disposal? Are there any big bushes,
dirty waters, pest like rats, roaches and mosquitoes or any pets? Has there been any travel? Is the child
happy at home? Does anyone smoke or use alcohol in house? How has the sickness been affecting the
family? How has it affected your child? Has the family been supportive?

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18.13. SPECIFIC PRESENTING COMPLAINTS:

18.13.1. Fever:
General: When did the fever begin? Did you measure it with a thermometer? Where did you measure
it? What are the characteristics: intermittent or constant? Is there any particular pattern? Are then any
associated factors like chills, rigors, excessive sweating or seizures? Did anything make it better like tepid
sponging, fan therapy or Panadol? Was any other treatments given? Did it work and for how long?
When was the last dose given? Were there any other symptoms to suggest infection like runny nose,
cough, diarrhea, bulging fontanelles, tugging at the ears, diarrhea, drooling, wheeze, stridor, joint
swelling?

18.13.2 Diarrhea and vomiting:

Vomiting: How did the vomiting develop? What were the contents? What was the color? What was the
frequency? Was there persistent vomiting even though there was no intake? What was the volume of
vomit? Is the vomiting after a bout of coughing (post-tussive vomiting)

Diarrhea: How did the diarrhea develop? What was the frequency? What is the consistency? Was there
any blood or mucus? What was the color? Was it pale? Does it have any foul smell? Is there any
associated pain, urgency of history of diarrhea and/or constipation? Are there any outbreaks at school,
travel history or sick contacts? Has there been any recent antibiotic use?

Hydration status:
What is the volumes and frequency of input and output? Has there been a change in diapers changes? Is
there any lethargy, irritability, sunken eyes or decreased skin turgor?

Vomiting Differentials: gastroenteritis, bowel obstruction, appendicitis, torsion, poisoning, infection

(meningitis), space occupying lesion, ketoacidosis

Diarrhea Differentials: gastroenteritis, poisoning, bowel obstruction, appendicitis, traveller’s diarrhea,

toddler diarrhea, infectious diarrhea

18.13.3. Seizures:

Characteristics: Was he/she shaking all over (generalized)? Did it start in one place then become
generalized (Jacksonian March)? Did it start in one place and stay at that place (Focal)? How long did it
last? What was the child doing at the time it happened? Was it a twitch in one muscle, violent shaking,
and sudden stiffness? Does the child have any moments of decreased awareness or staring?

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Associations: Was there any fever, frothing, eye rolling, tongue biting, incontinence or
unresponsiveness? Was the child dehydrated? How was the child’s urine and fluid intake? Was there
any vomiting? Has the child had any weird eating habits with weird materials (pica)

If a neonates, was there any lip smacking or cycling movements?

If an older child, was there any prodrome like aura (smell, flashing lights)?

Was there any post-ictal drowsiness, weakness or paresis? Is there any parental seizures? Has the child
had any febrile seizures before? Has any siblings had a history of febrile seizures?

Differentials: febrile seizure, new onset epilepsy, space occupying lesion, metabolic derangement,
poisoning

18.13.4. Meningitis:

In older children: Are there any problems with bright lights? Are there any neck pains? Are there any
headaches?

In younger children: Are there any bulging fontanelles, irritability or lethargy?

Both: Are there any rashes about the body? Has the child had any vomiting, high fever, decreased level
of consciousness or seizures?

18.13.5. Nephrotic or Nephritic syndrome:

General: Is there any swelling of the eyes (peri-orbital), swelling of the legs (pedal edema) or swelling of
the scrotum or vulva (scrotal/vulval edema? Where were the eyes swollen? Was it only in the morning
and went away later? Was it either eyes swollen or both? Was there a discharge? Was there any
associated erythema? Was the vision affected? Was any itchiness present? Is it better/worse during the
day?
Is anywhere else swollen (feet and scrotum)? Is their urine frothy (points to proteinuria)? Has there
been any blood in the urine or dark urine? Was there any rash on the legs or any throat infection? Has
the child had any recent viral illness? Has there been any diarrhea or bloody diarrhea?

Differential: minimal change disease, focal segmental disease, post-streptococcal glomerulonephritis,

IgA nephropathy

18.13.6. Cough:
General: Was it a wet (productive), dry (non-productive), “barking” or a “whooping” cough? What is the
timing: throughout the day & night/at night alone? Are there any triggers? Triggers: cold, dust, illness,

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animal dander, pollen, smoke, exercise or temperature changes? Are there any associated factors: runny
nose, sneezing, wheezing? Is there any history of runny nose, itchy eyes and nose, eczema or asthma?

Differential: asthma (nocturnal cough), bronchiolitis, sinusitis, pneumonia

18.13.7. Asthma:

18.13.8. Sickle Cell:

19.0 ADULT HISTORY

19.1 INTRODUCTION:
Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final year students. I
understand that you are not feeling well today and I would like to ask you some questions concerning
that. Is that alright? What’s your full name and age please? It is nice to meet you. Where do you live?
What is you occupation?

19.2. PRESENTING COMPLAINT:

Can you tell me a little bit about the symptoms your child has been experiencing?

19.2.1. General questions for each symptom:

When did it begin? Did it begin suddenly or progressively? Did it worsen or get better? How did it
begin/continue/progress? How frequent has this been happening? What makes it better? What makes it
worse? Is there anything associated with any other symptoms? Have you been taking any treatment for
this right now? If yes, what, how much, when, are you compliant and does it work? When was the last
dose?

19.2.2. Technique for Presenting Complaint:

Go through each symptom according to the site, onset, character, radiation, associations, timing,
exacerbating and alleviating factors and severity. Use only the parameters that apply. Ensure to go
through all the associations of the symptoms. Ensure to get the full evolution of each symptom and the
treatment for each symptom.

19.3. GENERAL SYMPTOMS

19.3.1. Weight Loss:

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General: How much weight loss and how long? Have you had any associated symptoms? Are any
gastrointestinal symptoms present?

Do an entire systemic review if unsure

Malignancy: Breast lump, hemoptysis (lung), horner’s syndrome features, paraneoplastic syndromes,
prostatic symptoms, change inbowel habits, jaundice, post-menopausal bleed, hematuria

Colon cancer: Elderly, PR bleed, change in bowel habit

IBD: Diarrheas, steatorrhea, abdominal pain, extra-intestinal features

Thyrotoxicosis: Diarrhea, heat intolerance, irritability restlessness, tremor, oligo/amenorrhea

Other considerations: Diet change, substance use, organ failure, diabetes type 1, chronic disease,
chronic infection like TB, HIV/AIDS

19.3.2. Tiredness:

General: When did it start, was it gradual or acute? What is the duration? How did it progress? Is it
intermittent or continuous? Describe what they mean by tiredness. Describe your sleep pattern. How
does this affect you? Do you have any symptoms of anemia? Do you have symptoms of hypothyroidism?

Do an entire systemic review if unsure

Anemia: Breathlessness, chest pain, palpitations, dizziness, headaches, syncope

Hypothyroidism: Constipation, cold intolerance, weight gain

Diabetes: Polydipsia, polyuria, weight loss, visual disturbance

Depression: Low mood, anhedonia, poor sleep, lack of energy, poor concentration, hopelessness,
suicidal ideation, excessive guilt

Other considerations: Post viral fatigue, organ failure, drug use, malignancy, chronic disease, Addison’s
disease

19.4. ACUTE SYMPTOMS

19.4.1. Collapse:

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Generalized seizure: sudden loss of consciousness, limb stiffening and then jerking, incontinence, tongue
biting, preceding aura, confusion or drowsiness when consciousness regained, inattentive and staring if
absence seizure, all muscles relax and drop if atonic seizure, involuntary flexion if myoclonic, stiffening if
tonic seizure

TIA/stroke: sudden onset neurological deficits, weakness, slurred speech, risk factors like diabetes,
hypertension, vascular disease, atrial fibrillation.

Vasovagal syncope: occurs in response to emotion, fear or prolonged standing, preceded by nausea,
pallor, sweating and the period of LOC was relatively short.

Situational syncope: loss of consciousness while coughing, during micturition or defecation

Other neurogenic considerations: brain bleed, raised intracranial pressure

Postural hypotension: dizziness and loss of consciousness on standing from lying down, recent start on
anti-hypertensive

Aortic stenosis: collapse on exertion, breathlessness on exertion, history of angina

Arrhythmia: falls after palpitations, positive cardiac or family history of sudden death, can oocur during
exercise or lying

Other cardiogenic considerations: HOCM, carotid sinus hypersensitivity, vertebrobasilar insufficiency

Other differentials: drug overdose or toxicity, alcohol intoxication, mechanical fall, anemia,
hypoglycemia, leg weakness, anxiety

19.4.2. Acute Chest Pain:

Acute coronary syndrome: crushing central chest pain, radiates to neck of left arm, nausea, vomiting,
shortness of breath, sweatiness, cardiovascular risk factors

Aortic dissection: tearing chest pain of very sudden onset, radiates to back, pain in other sites such as
arms, legs, neck and head, dizziness, shortness of breath, may have syncope

Pericarditis: retrosternal chest pain, pleuritic chest pain, relieved on sitting forward, may radiate to
trapezius, neck or shoulder, viral prodrome

Myocarditis: chest pain, palpitations, fever, fatigue, dyspnea

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Other cardiogenic differentials: stable angina, tamponade, mitral valve prolapse, pulmonary
hypertension, aortic stenosis, arrhythmia

Pulmonary embolism: pleuritic chest pain, dyspnea, hemoptysis, risk factors for a thromboembolism
such as calf pain or deep vein thrombosis, recent surgery, recent fracture, pregnancy, long haul flight,
known cancer, thrombophilia, hypercoagulable state, nephrotic syndrome

Pneumonia: fever, shortness of breath, productive cough, pleuritic chest pain, confusion, ask about
history of chest infection and antibiotic use, hospital stays, immunocompromised state

Pneumothorax: sudden onset chest pain, shortness of breath, risk factors such as Marfan’s, COPD or
asthma

Pleurisy: pleuritic chest pain, dry cough, fever, dyspnea

Other respiratory differentials: lung cancer

Musculoskeletal: sharp chest pain, worse on inspiration or movement, can point to pain, exacerbated by
pressure over chest wall

Costochondritis: costo-sternal joint pain, worse with coughing, twisting or physical activity

GERD: retrosternal burning chest pain, related to meals, lying, straining, chronic cough

Anxiety or panic attack: tight chest pain, shortness of breath, sweating, dizziness, palpitations, feeling of
impending doom, anxious personality, symptoms of generalized anxiety

Esophageal spasm: intermittent crushing substernal pain, relieved by glyceryl tri-nitrate, associated with
dysphagia

19.4.3. Acute Shortness of Breath:

Pulmonary embolism: pleuritic chest pain, dyspnea, hemoptysis, risk factors for a thromboembolism
such as calf pain or deep vein thrombosis, recent surgery, recent fracture, pregnancy, long haul flight,
known cancer, thrombophilia, hypercoagulable state, nephrotic syndrome

Pneumonia: fever, shortness of breath, productive cough, pleuritic chest pain, confusion, ask about
history of chest infection and antibiotic use, hospital stays, immunocompromised state

Pneumothorax: sudden onset chest pain, shortness of breath, risk factors such as Marfan’s, COPD or
asthma

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Acute asthma exacerbation: dyspnea, wheeze, history of asthma, ask about triggers, smoking,
compliance on medications, previous hospitalizations, ICU admissions, intubations, magnesium sulphate
use, cyanosis on previous attack, night time coughing frequency, therapy up until that point

COPD exacerbation: dyspnea, wheeze, change in sputum, known COPD, lifelong smoker, ask about
triggers, smoking, compliance on medications, previous hospitalizations, ICU admissions, intubations,
previous antibiotic use, exacerbations per year, long term or home oxygen use, check for symptoms of
cancer such as weight loss and hemoptysis as well as paraneoplastic or Horner’s syndromes

Other respiratory considerations: extrinsic allergic alveolitis, laryngitis, bronchitis, pneumonitis

Acute coronary syndrome: crushing central chest pain, radiates to neck of left arm, nausea, vomiting,
shortness of breath, sweatiness, cardiovascular risk factors

Acute left/right ventricular failure: shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, pink
frothy sputum, peripheral edema, cardiac history

Other cardiogenic considerations: cardiomyopathy, myocarditis, acute valvular disease, pulmonary

hypertension

Anxiety or panic attack: tight chest pain, shortness of breath, sweating, dizziness, palpitations, feeling of
impending doom, anxious personality, symptoms of generalized anxiety

Other considerations: diabetic ketoacidosis, foreign body, anaphylaxis

19.4.4. Acute Abdominal Pain:

Peritonitis: severe generalized abdominal pain with fever, nausea and vomiting, causes of peptic ulcer
disease, risk factors for gall bladder disease, symptoms of appendicitis, ruptured aneurysm symptoms,
risk factors for ectopic with sign of rupture, spontaneous bacterial peritonitis associated with abdominal
distention (ascites)

Ruptured aortic aneurysm: elderly, severe generalized pain, back pain, decreased level of consciousness,
syncope, reduced GCS, collapse

Appendicitis: young patient, peri umbilical pain and then moves to right iliac fossa, anorexia, nausea and
fever.

Gallstone disease: right upper quadrant pain, exacerbated by fatty food if biliary colic, continuous and
fever if cholecystitis, jaundice, fever, chills and rigors if cholangitis

Pancreatitis: severe epigastric pain or central pain with radiation to the back, relieved by sitting
forwards, vomiting, rule out causes such as gallstones, alcohol, scorpion stings, surgery and medications

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Diverticulitis: elderly patient with left iliac fossa pain, pyrexia

Renal colic: spasm of loin to groin pain, nausea, vomiting, cannot lie still

Bowel obstruction: vomiting, abdominal pain, nausea, constipation

Other surgical conditions: testicular torsion, volvulus, strangulated hernia, mesenteric adenitis,
adhesions, abscess

Gastritis or peptic ulcer disease: epigastric pain, related to meals, risk factors such as NSAIDs, alcohol,
steroids and spicy foods

Pyelonephritis: fever, chills, rigors, loin pain, urinary frequency and dysuria

Other medical causes: gastroenteritis, constipation, inflammatory bowel disease, sickle cell, DKA,
hypercalcemia, hepatitis

Ectopic: severe unilateral pelvic pain, 8 weeks pregnant or missed period, shoulder tip pain, shortness of
breath and dizziness if ruptured, vaginal bleeding

Ovarian cyst torsion, rupture of hemorrhage: sudden unilateral pelvic pain, light vaginal bleeding, fever
or vomiting

Pelvic inflammatory disease: bilateral pelvic pain, vaginal discharge, dyspareunia, dysmenorrhea, post
coital or intermenstrual bleeding

Other gynecologic considerations: salpingitis, fibroid degeneration, endometriosis

19.4.5. Acute Headache:

Tension headache: bilateral tight band sensation, recurrent, occurs late in day, associated with stress
and dehydration

Cluster headache: restless, short painful attack around one eye, lasts 30 mins to 3 hours, can occurs
once or twice a day for 1-3 months, comes in clusters, can have lacrimation and flushing and nasal
symptoms, restlessness

Migraine: unilateral pulsating headache in trigeminal distribution, last a few hours to a few days, may
have visual aura, photophobia

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Trigeminal neuralgia: paroxysms of stabbing in unilateral trigeminal nerve distribution, face screws up
with the pain, triggers are washing the area, shaving, eating and talking, symptoms of underlying cause
such a tumor or an aneurysm

Meningitis: photophobia, neck stiffness, fever, rash

Temporal arteritis: unilateral throbbing pain, scalp tenderness, jaw claudication, elderly person
experiencing visual problems

Subarachnoid hemorrhage: sudden onset, meningitis symptoms

Raised intracranial pressure: worse in the morning with coughing and bending, vomiting, reduced GCS,
visual disturbance, facial palsy, neurological symptoms

Sinusitis: facial pain exacerbated by leaning forward or coughing, rhinorrhea, nasal congestion

Closed angle glaucoma: long sighted, pain around eye, swollen red eye, visual blurring and halos around
lights

Hypertensive encephalopathy: headache, visual blurring, vomiting

Other considerations: nitrates, caffeine, hormones, drug withdrawal, otitis media

19.5. CARDIORESPIRATORY SYMPTOMS

19.5.1. Chest Pain:

Description: Where is the pain? Can you point to it? When did the pain start? Can you describe the pain?
Was it crushing or stabbing? Was it tearing of burning? Did it move to the head, neck, back, abdomen or
left arm? Was this associated with any other symptoms? How long did it last? How long in between the
pain? How long was it between episodes? Were there any exacerbating and relieving factors? What is
the severity on a scale of 1 to 10?

General: fever, sweats

Cardiorespiratory: palpitations, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, edema,

chest pain, cough, sputum, wheeze, hemoptysis, fever

Angina: cardiac type chest pain, associated with exertion, relieved by rest, relived by nitrates,
cardiovascular risk factors

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Acute coronary syndrome: crushing central chest pain, radiates to neck of left arm, nausea, vomiting,
shortness of breath, sweatiness, cardiovascular risk factors

Aortic dissection: tearing chest pain of very sudden onset, radiates to back, pain in other sites such as
arms, legs, neck and head, dizziness, shortness of breath, may have syncope

Pericarditis: retrosternal chest pain, pleuritic chest pain, relieved on sitting forward, may radiate to
trapezius, neck or shoulder, viral prodrome

Pulmonary embolism: pleuritic chest pain, dyspnea, hemoptysis, risk factors for a thromboembolism
such as calf pain or deep vein thrombosis, recent surgery, recent fracture, pregnancy, long haul flight,
known cancer, thrombophilia, hypercoagulable state, nephrotic syndrome

Pneumothorax: sudden onset chest pain, shortness of breath, risk factors such as Marfan’s, COPD or
asthma

Musculoskeletal: sharp chest pain, worse on inspiration or movement, can point to pain, exacerbated by
pressure over chest wall

GERD: retrosternal burning chest pain, related to meals, lying, straining, chronic cough

Anxiety or panic attack: tight chest pain, shortness of breath, sweating, dizziness, palpitations, feeling of
impending doom, anxious personality, symptoms of generalized anxiety

Other considerations: costochondritis, pleurisy, gastritis, myocarditis

19.5.2. Breathlessness:

Timing: When did it start? Was it acute or gradual? What are the duration of the symptoms? How did it
progress? Was it intermittent or continuous?

Breathlessness: How much can you usually before breathlessness? Do you have shortness of breath on
lying down? Do you wake up at night short of breath? Does it happen seasonally or does it change
between day and night?

General: fever, sweat

Cardiorespiratory: palpitations, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, edema,

chest pain, cough, sputum, wheeze, hemoptysis, fever

Myocardial Infarction: acute shortness of breath associated with nausea, vomiting and sweating,
crushing central chest pain, and cardiovascular risk factors

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Congestive cardiac failure: shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, pink frothy
sputum, peripheral edema, cardiac history

Pulmonary embolism: pleuritic chest pain, dyspnea, hemoptysis, risk factors for a thromboembolism
such as calf pain or deep vein thrombosis, recent surgery, recent fracture, pregnancy, long haul flight,
known cancer, thrombophilia, hypercoagulable state, nephrotic syndrome

Pneumothorax: sudden onset chest pain, shortness of breath, risk factors such as Marfan’s, COPD or
asthma

Pneumonia: fever, shortness of breath, productive cough, pleuritic chest pain, confusion, ask about
history of chest infection and antibiotic use, hospital stays, immunocompromised state

Asthma: intermittent wheeze, diurnal variation, nocturnal

COPD: chronic shortness of breath, chronic sputum production, significant smoking history

Pulmonary fibrosis: progressive shortness of breath over a long period of time, dry cough, associated
medical condition, occupational exposure or medication use.

Other considerations: anemia, hyperventilation in anxiety, pleural effusion, diabetic ketoacidosis, lobar
collapse, bronchiectasis, aortic stenosis, sarcoidosis, TB, extrinsic allergic alveolitis.

19.5.3. Cough:

Timing: When did it start? Was it acute of gradual? How long does it last? How has it progressed? Is it
intermittent or continuous?

Cough: Was it productive of non-productive? Was it triggered by anything? Is it just nocturnally?

Sputum: How much? How often? What color and consistency? Was there any blood present?

Hemoptysis: What volume was it? Was it fresh or altered blood? How frequent was it? Was it mixed in
the sputum and what type of sputum was it?

Pneumonia: fever, shortness of breath, productive cough, pleuritic chest pain, confusion, ask about
history of chest infection and antibiotic use, hospital stays, immunocompromised state

Asthma: intermittent wheeze, diurnal variation, nocturnal

COPD: chronic shortness of breath, chronic sputum production, significant smoking history

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Post-nasal drip: chronic rhinitis, chronic sinusitis, chronic cough to clear throat

Lung tumor: hemoptysis, weight loss, smoking history, paraneoplastic syndromes or Horner’s syndrome

Pulmonary embolism: pleuritic chest pain, dyspnea, hemoptysis, risk factors for a thromboembolism
such as calf pain or deep vein thrombosis, recent surgery, recent fracture, pregnancy, long haul flight,
known cancer, thrombophilia, hypercoagulable state, nephrotic syndrome

Other considerations: GERD, smoking, left ventricular failure, drug induced (ACE-inhibitors),
bronchiectasis, interstitial lung disease, sarcoidosis, TB, cystic fibrosis

19.5.4. Hemoptysis:

Hemoptysis: What volume was it? Was it fresh or altered blood? How frequent was it? Was it mixed in
the sputum and what type of sputum was it?

Timing: When did it start? Was it acute of gradual? How long does it last? How has it progressed? Is it
intermittent or continuous?

Cough: Was it productive of non-productive? Was it triggered by anything? Is it just nocturnally?

Sputum: How much? How often? What color and consistency? Was there any blood present?

Lung tumor: hemoptysis, weight loss, smoking history, paraneoplastic syndromes or Horner’s syndrome

Pulmonary embolism: pleuritic chest pain, dyspnea, hemoptysis, risk factors for a thromboembolism
such as calf pain or deep vein thrombosis, recent surgery, recent fracture, pregnancy, long haul flight,
known cancer, thrombophilia, hypercoagulable state, nephrotic syndrome

Pneumonia: fever, shortness of breath, productive cough, pleuritic chest pain, confusion, ask about
history of chest infection and antibiotic use, hospital stays, immunocompromised state

Other considerations: prolonged coughing, pulmonary edema, bronchiectasis, mitral stenosis, TB,
laryngeal carcinoma, polyarteritis nodosa, Goodpasture’s syndrome, aspergillosis

19.6. GASTROINTESTINAL AND RENAL SYMPTOMS

19.6.1. Abdominal Pain:

Description: Where is the pain? Can you point to it? When did the pain start? Can you describe the pain?
Was it crushing or stabbing? Was it tearing of burning? Did it move to the back, to the RUQ, to the RLQ

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or anywhere in the abdomen? Was this associated with any other symptoms? How long did it last? How
long in between the pain? How long was it between episodes? Were there any exacerbating and
relieving factors? What is the severity on a scale of 1 to 10?

General: fever and chills

Gastrointestinal: weight change, change in appetites, dysphagia, nausea, vomiting, heartburn,

indigestion, change in bowel habit, blood or mucus in the stool

Urological: hematuria, poor and/or intermittent stream, straining, prolonged micturition, incomplete
bladder emptying, dribbling, frequency, urgency, urge incontinence, and nocturia.

Gynecological: menorrhagia, intermenstrual bleeding, post-coital bleeding, post-menopausal bleeding,

vaginal discharge, pelvic pain, dysmenorrhea, dyspareunia, chance of being pregnant

Ruptured aortic aneurysm: elderly, severe generalized pain, back pain, decreased level of consciousness,
syncope, reduced GCS, collapse

Appendicitis: young patient, peri umbilical pain and then moves to right iliac fossa, anorexia, nausea and
fever.

Gallstone disease: right upper quadrant pain, exacerbated by fatty food if biliary colic, continuous and
fever if cholecystitis, jaundice, fever, chills and rigors if cholangitis

Pancreatitis: severe epigastric pain or central pain with radiation to the back, relieved by sitting
forwards, vomiting, rule out causes such as gallstones, alcohol, scorpion stings, surgery and medications

Diverticulitis: elderly patient with left iliac fossa pain, pyrexia

Renal colic: spasm of loin to groin pain, nausea, vomiting, cannot lie still

Bowel obstruction: vomiting, abdominal pain, nausea, constipation

Gastritis or peptic ulcer disease: epigastric pain, related to meals, risk factors such as NSAIDs, alcohol,
steroids and spicy foods

Ectopic: severe unilateral pelvic pain, 8 weeks pregnant or missed period, shoulder tip pain, shortness of
breath and dizziness if ruptured, vaginal bleeding

Pyelonephritis: fever, chills, rigors, loin pain, urinary frequency and dysuria

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Pelvic inflammatory disease: bilateral pelvic pain, vaginal discharge, dyspareunia, dysmenorrhea, post
coital or intermenstrual bleeding

Other medical causes: gastroenteritis, constipation, inflammatory bowel disease, sickle cell, DKA,
hypercalcemia, hepatitis

Other surgical conditions: testicular torsion, volvulus, strangulated hernia, mesenteric adenitis,
adhesions, abscess

Other gynecologic considerations: salpingitis, fibroid degeneration, endometriosis

19.6.2. Change in bowel habit:

Timing: When did it start? Was it acute of gradual? How long does it last? How has it progressed? Is it
intermittent or continuous?

Stool: How much? How often? What were the contents: bile, blood, mucus, melena?

Gastrointestinal: weight change, change in appetites, dysphagia, nausea, vomiting, heartburn,

indigestion, change in bowel habit, blood or mucus in the stool

Colon cancer: elderly, blood in the stool, melena, weight loss

Gastroenteritis: acute diarrhea, nausea and vomiting

IBD: blood in the stool, mucus in the stool, abdominal pain

IBS: fluctuations between constipation and diarrhea, stress associated, anxious personality

Celiac disease: diarrhea, steatorrhea, anemia symptoms, abdominal discomfort

Thyrotoxicosis: diarrhea, het intolerance, irritability, restlessness, tremor, oligomenorrhea or

amenorrhea

Hypothyroidism: constipation, cold intolerance, lethargy, tiredness, menorrhagia

Other considerations: bowel obstruction, diet and lifestyle changes, perianal conditions, drugs (opiates,
iron, antibiotics, antacids), diverticulitis, overflow constipation, lactose intolerance, chronic infection

19.6.3. Rectal bleeding:

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Timing: When did it start? Was it acute of gradual? How long does it last? How has it progressed? Is it
intermittent or continuous?

Stool: How much? How often? What were the contents: bile, blood, mucus, and melena?

Rectal bleeding: Is it fresh, altered or melena? When does it occur?

Gastrointestinal: weight change, change in appetites, dysphagia, nausea, vomiting, heartburn,

indigestion, change in bowel habit, blood or mucus in the stool

Anal fissure: bleeding on defecation, bright red blood on tissue, intense anal pain, constipation history

Hemorrhoids: bleeding on defecation, bright red blood on tissue, constipation history

Diverticular hemorrhage: sudden painless bleed, elderly female

Distal polyp/cancer: change in bowel habits, weight loss, urgency, tenesmus

Inflammatory bowel disease: blood mixed with stool, mucus, diarrhea, abdominal pain

Hemorrhagic infective gastroenteritis: acute diarrhea and vomiting, history of suspicious food intake

Angiodysplasia: elderly

Proximal polyp/cancer: weight loss and anemia

Hemorrhagic peptic ulcer disease: gastritis symptoms, risk factors like NSAID use, alcohol, steroids,
cocaine and spicy foods

Esophageal varices: history of liver disease/alcoholism, hematemesis

19.6.4. Hematemesis:

Timing: When did it start? Was it acute of gradual? How long does it last? How has it progressed? Is it
intermittent or continuous?

Vomit: How much? How often? What were the contents: bile, blood, mucus, feculent?

Gastrointestinal: weight change, change in appetites, dysphagia, nausea, vomiting, heartburn,

indigestion, change in bowel habit, blood or mucus in the stool

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Hemorrhagic peptic ulcer disease: gastritis symptoms, risk factors like NSAID use, alcohol, steroids,
cocaine and spicy foods

Esophageal varices: history of liver disease/alcoholism, hematemesis

Mallory-Weiss tear: multiple vomits before hematemesis, commonly after binge drinking

19.6.5. Polyuria:

Timing: When did it start? Was it acute of gradual? How long does it last? How has it progressed? Is it
intermittent or continuous?

Polyuria: How much is it in volume? How frequent? How much water do you drink per day? What other
symptoms do you have?

General: fever, sweats, rashes, joint pain, joint swelling

Urological: hematuria, poor and/or intermittent stream, straining, prolonged micturition, incomplete
bladder emptying, dribbling, frequency, urgency, urge incontinence, and nocturia.

Diabetes mellitus: polydipsia, polyuria, weight loss, tiredness, visual disturbance

Diabetes insipidus: polydipsia, polyuria

Chronic kidney disease: fatigue, weakness, pruritus, dyspnea, symptoms of anemia

Other considerations: Cushing’s syndrome, psychogenic polydipsia, drugs (diuretics, alcohol, lithium, and
tetracycline)

19.6.6. Dysuria, frequency and nocturia

Timing: When did it start? Was it acute of gradual? How long does it last? How has it progressed? Is it
intermittent or continuous?

Urination: How much is it in volume? How frequent?

General: fever, sweats

Urological: hematuria, poor and/or intermittent stream, straining, prolonged micturition, incomplete
bladder emptying, dribbling, frequency, urgency, urge incontinence, and nocturia.

Cystitis: dysuria and frequency and urgency

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Urethritis: dysuria and discharge

Pyelonephritis: dysuria, loin pain, fever, chills, rigors, vomiting

BPH: poor flow, terminal dribbling, hesitancy, overflow incontinence, elderly male

Other considerations: anxiety, detrusor instability, bladder of urethral calculus, prostatitis, pregnancy,
diuretics

19.7. CEREBRAL SYMPTOMS

19.7.1. Headache

Description: Where is the pain? Can you point to it? When did the pain start? Can you describe the pain?
Was it crushing or stabbing? Was it tearing of burning? Did it move to the anywhere or localise? Was
this associated with any other symptoms? How long did it last? How long in between the pain? How long
was it between episodes? Were there any exacerbating and relieving factors? What is the severity on a
scale of 1 to 10?

Red flags: meningism (rash, fever, neck stiffness), temporal arteritis (visual problems, scalp tenderness
and jaw claudication), closed angel glaucoma (visual problems, red eye, halos around lights)

General: fever, rash, bruising

Neurological: fits, falls, loss of consciousness, vision and hearing problems, memory loss, neck stiffness,
photophobia, weakness, wasting, incontinence, pain, numbness, tingling

Tension headache: bilateral tight band sensation, recurrent, occurs late in day, associated with stress
and dehydration

Cluster headache: restless, short painful attack around one eye, lasts 30 mins to 3 hours, can occurs
once or twice a day for 1-3 months, comes in clusters, can have lacrimation and flushing and nasal
symptoms, restlessness

Migraine: unilateral pulsating headache in trigeminal distribution, last a few hours to a few days, may
have visual aura, photophobia

Trigeminal neuralgia: paroxysms of stabbing in unilateral trigeminal nerve distribution, face screws up
with the pain, triggers are washing the area, shaving, eating and talking, symptoms of underlying cause
such a tumor or an aneurysm

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Meningitis: photophobia, neck stiffness, fever, rash

Temporal arteritis: unilateral throbbing pain, scalp tenderness, jaw claudication, elderly person
experiencing visual problems

Subarachnoid hemorrhage: sudden onset, meningitis symptoms

Raised intracranial pressure: worse in the morning with coughing and bending, vomiting, reduced GCS,
visual disturbance, facial palsy, neurological symptoms

Sinusitis: facial pain exacerbated by leaning forward or coughing, rhinorrhea, nasal congestion

Closed angle glaucoma: long sighted, pain around eye, swollen red eye, visual blurring and halos around
lights

Hypertensive encephalopathy: headache, visual blurring, vomiting

Other considerations: nitrates, caffeine, hormones, drug withdrawal, otitis media

19.8. MISCELLANEOUS SYMPTOMS

19.8.1. Diabetic:

Hyperglycemia: Polydipsia, headaches, trouble concentrating, blurred vision, frequent peeing, fatigue
(weak, tired feeling), weight loss

Hypoglycemia: Palpitations, tremor, nervousness or anxiety, diaphoresis, chills, irritability or impatience,

confusion, including delirium, lightheadedness or dizziness, hunger and nausea

HHS or DKA: Fever, drowsiness, confusion, hallucinations, shortness of breath, dyspnea, vision loss,
convulsions

Complications: stroke or transient ischemic attack, angina, myocardial infarction, intermittent

claudication, rest pain, ulcers, foot infection, blurred vision, difficulty seeing, haziness of vision, diplopia,
poor night vision, frothy urine, tingling, numbness, weakness, paresthesia, neuropathic pain, impotence

Social history: smoking and alcohol, control, monitoring, episodes of hypoglycemia, episodes of
hyperglycemia, support system, effect on family and on self, diet and exercise

Risk factors: Blood pressure, Hyperlipidemia, Smoking, Family history

19.8.2. Hypertensive:

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Hypertension: Severe headache, fatigue or confusion, vision problems, chest pain, dyspnea, palpitations,
hematuria

Hypotension: Fatigue, lightheadedness, dizziness, nausea, clammy skin, depression, loss of

consciousness, blurry vision

Complications: stroke or transient ischemic attack, angina, myocardial infarction, intermittent

claudication, rest pain, ulcers, foot infection, blurred vision, difficulty seeing, haziness of vision, diplopia,
poor night vision, frothy urine, tingling, numbness, weakness, paresthesia, neuropathic pain, impotence

Social history: smoking and alcohol, control, monitoring, support system, effect on family and on self,
diet and exercise

Risk factors: Blood sugar, Hyperlipidemia, Smoking, Family history

Secondary causes: pheochromocytoma (tremors and palpitations), conn’s syndrome (muscle weakness
and muscle cramps), thyrotoxicosis (heat intolerance), PCKD (hematuria), cushing’s syndrome (fatigue,
weight gain)

19.8.3. Hypercalcemia:

Musculoskeletal: Bone pain

Cerebral: Lethargy, weakness, confusion, coma

Renal: polyuria, nocturia, dehydration, renal stones, renal failure

Gastrointestinal: constipation, nausea, anorexia, pancreatitis, gastric ulcer

19.9. REVIEW OF SYSTEMS:

General: Have you been experiencing any fevers, chills, night seats or weight loss? Have you had any
skin rashes and bruising? Has there been any snoring, day time somnolence or apnea while sleeping?

Cardiorespiratory: Have you been having any chest pain, racing of the heart, difficulty breathing while
lying down, waking in the night with shortness of breath, or general shortness of breath/ Have you been
having any cough, wheeze, sputum or coughing up of blood? How far can you walk before you are short
of breath?

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Gastrointestinal: Have you been having any change in weight or appetite? Have you had any
nausea/vomiting, indigestion/heartburn or abdominal pain? Have you had any change in bowel habits or
any blood or mucus in the stool? Has there been any dysphagia? Do you have any oral ulcer?

Neurological: Have you been having any fits, falls, and loss of consciousness or dizziness? Have you been
having vision or hearing problems, memory loss, neck stiffness or photophobia? Has there been any
weakness, numbness or any tingling sensations in the limbs? Has there been any red eye or eye pain?

Urologic: Have you been having increased or decreased urine, any urgency to go pee or any excessive
urination at night or day? Have you had any painful urine or passing of blood? Have you had any
incontinence? Has there been any hesitancy, poor flow, dribbling or incomplete bladder emptying?

Rheumatologic: Have you had any pain, stiffness or swelling of your joints? Has there been any skin
problems, hair loss, dryness of eyes and mouth?

19.20. PAST MEDICAL HISTORY:

Do you have any medical conditions such as hypertension, diabetes, heart disease, epilepsy, asthma,
blood disorders or cancer?

Have you had any recent hospitalization? If yes, what were the symptoms, what was the diagnosis and
what treatments were you given?

Are you in any clinics currently? If yes, what is the reason and are you currently on any therapies in that
regard?

If relevant:
Have you had any previous myocardial infarction or stroke? Have you had any previous chest infections?
Have you had any diarrheal illnesses?

19.21. PAST SURGICAL HISTORY:

Have you had any surgeries before? If yes, what are the dates, the operation and were there any
complications?

Have you had any coronary bypass done, any cardiac catheterization or valvular replacements?

19.22. DRUG HISTORY:

Are you on any medications; either prescription, non-prescription of herbal remedies? If yes, what is the
name, what is the dose, why is it needed, how frequently is it taken, when was the last dose and are you
compliant?

19.23. ALLERGIES:

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Are there any known drugs or food allergies? What happens when exposed to the allergen? Is it any
reaction such as urticaria, angioedema or pruritus? Any history of anaphylactic shock?

19.24. FAMILY HISTORY:

Are your parents alive? What are their ages? If they are not alive, what age did they die and how? Is
there any history hypertension, diabetes or heart disease in the family? Are there any cancers in the
family like colon, breast, prostate or ovarian? Are there any histories of seizure, blood disorders or
asthma? Is there any kidney disease or liver disease in the family? Any history of sudden death

19.25. SOCIAL HISTORY: FLATMESS

19.25.1. Food and Exercise:

Describe the food groups that the you eat? Describe a typical meal plan for me? Have you ever been to a
dietitian? Can you describe typical beverages that your drink including water? Are you currently on any
exercise plan or part of a gym? Do you get any periods of exercise otherwise? Can you describe a typical
day? What about your sleep hygiene? Does your relative ever say you have bad snoring or sleep apnea?
Do you have any daytime somnolence or fatigue?

19.25.2. Living:
Are there amenities at home like running water or electricity? Are there problems with garbage
disposal? Are there any problems with rats, flooding, mosquitoes, cockroaches or high bushes?

19.25.3. Abuse:
Do you smoke? How much years have you been using? How much have you used per day or week? Have
you ever tried to stop? Do you use alcohol? How much years have you been using? How much have you
used per day or week? Have you ever tried to stop? Have you ever used any marijuana, cocaine or any
recreational drugs?

19.25.4. Travel:
Has there been any recent travel or anyone coming from a foreign country?

19.25.5. Married:
Are you currently married, divorced or widowed?

19.25.6. Effect:
Who lives with you at home? Who helps out around the house? How has this medical problem been
affecting you and your family financially, emotionally and otherwise? Has your family been supporting
you? How has this condition been affecting your daily activities?

19.25.7. Sexual and support systems:

Sexual history is not usually relevant. Religion and other coping mechanisms can be explored if relevant.

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Sexual history involves assessment of all partners (male or female) and type of sex. Use of barrier
protection is important. The genitourinary system should be screened for ulcers, wart, discharge and
urinary symptoms etc. A medical history of testing for STI and sexual related disease should be done as
well.

19.26 CLOSING
This is the end. In closing, I would just like to ask if you have any questions for me. Do you have any
ideas or concerns about the symptoms or conditions that you have? Thank you for your time.

20.0 ADULT COUNSELLING

21.0 CEREBELLAR EXAMINATION

21.0 PEDIATRIC CARDIOVASCULAR EXAM

21.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to examine your child’s chest and heart. Will that be okay? Can I have
your child’s name and age? Is your child in any pain today? I would like to take off the jersey to expose
the chest and the bed is placed at 45 degrees for this exam.

21.2. INSPECTION:

21.2.1. General:
Observe if the patient is in distress and look for oxygen therapy, fluids or any other medications at the
bedside. Look for any signs of dysmorphism. Look for scars, active precordium and chest wall
deformities. Check for pedal edema (maybe sanitize hand again after.

21.2.2. Hands and Nails:

Assess for temperature on the front of the hands and look for lesions such as Osler’s nodes and Janeway
lesions. Turn over the hands and look for peripheral cyanosis, capillary refill time, splinter hemorrhages
and clubbing. For clubbing, look for loss of the nail bed angle first, then for excessive nail bed fluctuance
and then for schamroth’s window.

21.2.3. Pulses:
Assess the radial pulse for 15 seconds, assessing the rate rhythm, volume and character. Assess for
radio-radial delay and radio-femoral delay.

21.2.4. Arm:

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Ask the patient if they have any pain in their shoulder. Tell them to relax their arm and don’t help you
lifting it at all. Press the radial pulse with the proximal segment of your fingers, firstly till you barely feel
it and then until it cannot be felt. Raise the arm up and see if the pulse strengthens and if you can now
feel it. Put the arm back down and see if the pulse now disappears.

Ask for the blood pressure. Assess the pulse pressure.

21.2.5. Face:
Assess the mucous membranes and the sclera, looking for jaundice, conjunctival pallor and dryness of
the mucous membranes.

Look for central cyanosis in the mouth and assess the dentition to see if it is adequate or poor. Look for
a high arched palate.

21.2.6. Neck:
Look for tracheal deviation.

21.2.7. Chest:
Inspect for any scars; midline, inframammary or laterally. Look closer for active precordium and look for
any signs of a pacemaker.

21.3. PALPATION:
Palpate for dextrocardia and localize the apex beat; palpate the sternal angle, count the intercostal
spaces down and check the distance of the apex beat from the mid clavicular line. Feel for thrills over all
the valves and look for a parasternal heave.

21.4. AUSCULTATION:
Place your hand on the carotid or brachial artery to time the murmur

Place the bell at the apex and, with the patient in the left lateral position. Listen for the murmur of
mitral stenosis.

Place the diaphragm at the apex. Listen for the murmur of mitral regurgitation. Listen for radiation to
the axilla.

Place the diaphragm at the tricuspid. Listen for the murmurs of aortic regurgitation, ventricular septal
defect and tricuspid regurgitation.

Place the diaphragm at the pulmonary area. Listen for the murmurs of pulmonary stenosis or atrial
septal defect.

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Place the diaphragm at the aortic area. Listen for the murmur of aortic stenosis. Listen for radiation to
the carotids.

Make the patient sit up and lean over. Place the diaphragm at the apex and make the patient breathe in,
out and then holding in expiration. Listen and then move to the tricuspid area and listen for the murmur
of aortic regurgitation. Listen for radiation to the axilla.

Auscultate the carotids for radiation of aortic stenosis to the carotids.

21.5. BACK AND EXTRA:

Palpate the carotids for a low volume and slow rising carotid pulse if aortic stenosis is present.

Auscultate the back at the bases of the lungs for basal crepitation and feel for sacral edema. Tell the
patient you are going to feel on their lower back before you do so for sacral edema.

Place the bed flat and then inform the patient you will check for enlargement of the liver.

21.6. CLOSING:
Thank you for your time. The exam is now finished. You can cover back up. To finish I would like perform
a 12 lead ECG.

21.7. INTERPRETATION:

22.0 PEDIATRIC GASTROINTESTINAL EXAM

22.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to examine your child’s belly. Will that be okay? Can I have your child’s
name and age? Is your child in any pain today? I would like to take off the jersey to expose the belly and
the bed is placed flat for this exam.

22.2. INSPECTION:

22.2.1. General:
Observe if the patient is in distress and look for oxygen therapy, fluids, catheters, central lines and
drains. Examine for dysmorphism. Comment on body habitus of the patient. Look for scars, distention,
discolorations or visible masses. Comment on the rise and fall of the abdomen and the status of the
umbilicus. Check for pedal edema (maybe sanitize hand again after).

22.2.2. Hands, Nails and Arms:

Assess for temperature on the palm of the hands and look for lesions such as palmar erythema or
dupuytren’s contracture. Turn over the hands and look for koilonychias, leuconychia and clubbing. For

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clubbing, look for loss of the nail bed angle first, then for excessive nail bed fluctuance and then for
schamroth’s window. Assess the arms for excoriations, needle marks, AV fistulae and purpura.

22.2.3. Face and Neck:

Assess the mucous membranes and the sclera, looking for jaundice, conjunctival pallor and dryness of
the mucous membranes. Comment on the presence of any scleritis or episcleritis seen

Look for angular stomatitis, oral candidiasis, aphthous ulcer and glossitis in the mouth.

Feel for the Virchow’s node and cervical lymph nodes.

22.2.4. Chest and Back:

Assess for gynecomastia and check for spider nevi on the chest and back.

22.2.5. Abdomen:
Inspect for any scars; midline, gridiron, lanz, groin incisions or laparoscopy ports. Look for caput medusa
or prominent veins on the abdomen.

22.3. PALPATION AND PERCUSSION:

Ask the person if they are having any pain in the abdomen. If so, then clarify where the pain is located.
Start palpation in the furthest quadrant and palpate there last.

Kneel and palpate all 9 quadrants lightly and then deeply, looking at the patient’s face as you do so.
Assess for tenderness, rebound tenderness, masses and guarding.

22.3.1. Liver:
From right iliac fossa to the right subcostal margin, in line with nipple, ask patient to breathe in and out
when you say to and push in as they breathe in. Feel for a palpable liver.

From right iliac fossa to the right subcostal margin, in line with nipple, percuss for the liver. The dullness
should correspond with the lower border of the liver. From the infra-clavicular area, percuss between
the ribs down towards the nipple area. The dullness corresponds to the upper border.

22.3.2. Spleen:
From right iliac fossa to left hypochondriac region, ask the patient to breathe in and out when you say to
and push in as they breathe in. Feel for a palpable splenic notch. If the spleen is not felt the patient rolls
towards you and the left hypochondriac is palpated again.

From right iliac fossa to left hypochondriac region, percuss for the spleen. Feel for a palpable splenic
notch. If the spleen is not felt the patient rolls towards you and the left hypochondriac is palpated again.

22.3.3. Kidneys:

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Press on top of the flank with one hand and palpate the back with the other hand to ballot the kidneys.

22.3.4 Ascitic Fluid:

Assess for a fluid thrill. Ask the patient to rest the ulnar border of their hand at the midline of their
abdomen and press down. Flick one side of the abdomen and feel for a transmission of the impulse to
the next side.

Assess for shifting dullness. Percuss from the midline to the periphery, looking for a change in resonant
to dull. Keeping a finger at the point where the sound became dull, make the patient turn towards you.
Percuss once more to see if the area is now more tympanitic or exhibits a loss in the dullness at that
point.

22.4. AUSCULTATION:
The points of auscultation over the abdomen are 1/3 the distance from the umbilicus to the anterior
superior iliac spine, either side of the umbilicus, above the umbilicus and the costal margins in the right
and left upper quadrants. The ileocecal valve is auscultated between the umbilicus and anterior superior
iliac spines. Renal bruits can be heard on either side of the umbilicus and the aortic bruits can be heard
just superior to the umbilicus. Hepatic hum and splenic rub can be heard at the costal margin at mid
clavicular lines on left and right respectively

22.5. EXTRA:
Place your hands simultaneously over the right and left inguinal area, occluding the deep ring. Ask the
patient to cough. Assess if hernia is present on either side or both sides. Place hands over umbilicus and
ask patient to cough one more time. Assess if inguinal hernia present.

22.6. CLOSING:
Thank you for your time. The exam is now finished. You can cover back up. To finish I would like examine
external genitalia and acquire a stool sample.

22.7. INTERPRETATION:

23.0 PEDIATRIC LOWER LIMB MOTOR EXAM

23.1. INTRODUCTION:
Sanitize hands. Good day sir or miss (handshake). My name is O’Neele Bhola and I am one of the final
year students. Today I would like to examine your child’s lower legs. Will that be okay? Can I have your
child’s name and age? Is your child in any pain today? I would like to take the child’s pants and socks to
expose the complete lower limb (fit the bed cover as a diaper for this) and the bed is placed at flat for
this exam.

23.2. INSPECTION:

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23.2.1. General:
Inspect the patient. Comment on general appearance. Look for dysmorphism. Look at the hands grossly
for any asymmetry or posturing. Look at the legs for any gross deformity, any visible scars, and masses.
Look for scissoring or frog leg positioning of the lower limbs. Lift the foot and look at the posterior
aspect as well. Move to the side of the bed and feel for muscle bulk. Look for spontaneous or induced
fasciculations bilaterally.

23.3. TONE:
Perform the log roll, looking for signs of hypertonia or hypotonia. Pull up quickly on both legs at the
knee separately to look for hypertonia. Elicit clonus by holding knee at 90 degrees and rapidly
dorsiflexion of the ankle.

Assess passively the tone in all the muscle groups. These include flexion and extension at the hip,
abduction and addiction at the hip, circumduction at the hip, extension and flexion at the knee, plantar
flexion and dorsiflexion at ankle and inversion and eversion at ankle with flexion of the big toe
additionally.

23.4. POWER:
Assess power out of five for each muscle group bilateral. Allow the patient to raise each leg against
gravity and then allow them to push and pull against resistance. Perform hip extension with the patient
on their belly. Use this opportunity to inspect the lower back. Perform hip abdduction and adduction
against resistance. Perform a push and pull against resistance at the knee. Perform a plantar flexion and
dorsiflexion at the ankle against resistance. Rate the power put of five using the MRC scale for power.

23.5. REFLEXES:
Ask the patient to relax and close their eyes. Assess the tendon reflex at the knee and ankle. Perform the
plantar reflexes by rubbing the orange stick under the lateral feet to elicit up going or down going
plantar.

23.6. COORDINATION:
Perform the heel to shin test to assess coordination

23.7. GAIT:
Ask the patient if they are able to stand. Forst make the patient get off the bed without using their
hands. Allow the patient to perform a normal walk and a tight rope walk assessing for abnormalities of
gait.

23.8. CLOSING:
This is the end of the exam. You can get back on the bed and redress yourself. To finish I would like to
perform a sensory exam of the lower limb to find a sensory level as well as check for anal and urinary

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incontinence. As necessary, a full neurological examination of the upper limb and cranial nerves is done.
Further studies would include nerve conduction studies and electromyography.

23.9 INTERPRETATION:

24.0 PRESENTATION IN HISTORY

25.0 PRESENTATION IN EXAM

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