4th Semester ICM Practical Protocols

Please demonstrate how to begin to examine the abdomen.
(One can allow some variation in order so long as inspects first and light palp precedes deep palp)
Explains, positions, asks for tenderness-
Inspects (briefly) from foot of bed & adequately exposes – at least to inguinal region
Auscultates
Percussion – 9 areas -
Light palpation – 9 regions (watches pts face)
Deep palpation – 9 areas
Rebound tenderness (gently

This patient is thought to have appendicitis. Please demonstrate how to begin to examine the abdomen.
Explains & positions & asks for tenderness
Inspects,
Auscultates,
Percusses,
Light palp, looks for guarding, rigidity, rebound, McBurney’s
Deep palp.
Rovsing’s, Psoas, Obturator signs

Please demonstrate how to examine for ascites.
Explains to patient:
Positions & inspects (distended, full flanks, everted umbilicus)
Dullness in flanks
Shifting dullness: ( rolls pt. etc)
Fluid wave

This patient has left sided loin pain. Please demonstrate how to examine the kidneys.
Explains & positions patient asks for tenderness:
Inspection of patient for pallor, fetor: (brief)
Inspection of abdomen
Ausculate (bruits)
Percussion of abdomen
Light & deep palpation of abdomen
Bimanual palpation with ballottement & attempted entrapment of kidneys on deep inspiration.
Palpate & percuss (Costo-vertebral angle) for tenderness in renal angle (starts with normal side)

Please demonstrate how to examine this patient’s liver
Explains to patient & asks for tenderness
Positions & inspects
Percusses & identifies upper & lower border & gives liver span in cms
Palpates lower border – (starts in RIF, asks pt to inhale deeply, etc )
Describes liver findings (normal or nodularity, tenderness, consistency)

Please demonstrate how to examine the spleen
Explains , positions patient & asks about tenderness
Inspects,
Percusses (9-11th I C Space / Traube’s space/splenic percussion sign)
Palpates: starts in RIF, watches face, feels on insp, feels laterally enough
Rolls pt over to right, positions correctly and palpates correctly bimanually

Please measure this patient’s blood pressure
Explains, asks routine questions, positions patient, (sitting is preferable),
Inspects arm and locates brachial artery
Checks cuff size, applies cuff correctly, knows how to assemble machine
Checks systole by palpation, Deflates cuff completely,
Inflates 2nd time to 30mm Hg above systolic pressure by palpation, supports arm, releases pressure completely etc
Gives reading rounded to the nearest 2 mm

Please demonstrate how you would examine for DVT
Positions pt and explains,
Inspects & notes oedema, swelling of calf, colour, distended superficial veins varicose veins
Feels temperature - compares with other side
Measures calf diameter in both legs
Palpates, between soleus, popliteal fossa and femoral vein for tenderness
Checks foot pulses and capillary refill

Please examine Harvey and describe the findings
Feels & describes the pulse (radial or brachial & carotid)
Inspects & palpates the precordium (apex, thrills, RV )

Listens in all 4 areas and in neck and axilla & describes S1 & S2 (splitting), & comments on presence or absence of S3 & S4 .Times the pulse from the carotid pulse:
Describes apical findings in detail ( heaving apex, with pre systolic impulse)
Times the pulse from the carotid pulse & Listens in all 4 areas and in neck and axilla & describes S1 & S2, -
Detects S4 - distinguishes from S3

Please examine this patient’s JVP
Explains & positions patient
Inspects neck, identifies ext & int. Jugular pulsation (or site)
Characterizes venous pulse (A & V waves, up to 6 features which distinguish it from the carotid -
Measures w r t sternal angle
Gives pressure in cms from R atrium (and knows normal values)
Demonstrate how to elicit Hepato-jugular reflux

Please demonstrate how to examine the ears
Explains & asks for pain
Inspects,
Palpates ear/mastoid
Checks hearing (both ears)
Tuning fork tests: Rinne/Weber
Otoscopy, describes appearance of drum & EAM -

Examine the parotid gland and the lymph nodes of the head and neck
Explains & positions patient & asks for pain.
Inspection
Palpation of parotids
Palpation of H& N LN groups: (submand. & submental, ant triangle, post triangle, occipital, pre & post auricular, supraclavicular)

Please demonstrate how to examine the thyroid gland and for signs of hyperthyroidism/hypothyroidism
Explains & positions patient & asks for tenderness
Inspects neck- (lighting, swallowing, water) -
Palpates both lobes & isthmus as pt swallows water (from behind is best)
Auscultates
Examines for signs of thyrotoxicosis /hypothyroidism

Please demonstrate how you would examine the breasts on the patient and then the model.
Explains/ requests permission/chaperone
Shows how would position pt to inspect breasts in at least 2 positions
Positions & drape pt to palpate the breasts
Please continue using the model”
Palpates the breasts (starts on R, systematic, squeezes gently nipple)
Locates lump and describes position and character
Change back to patient
Examines axillae of patient bilaterally for LN - (& axillary tail)

Please demonstrate how to examine the pelvis using the patient and the model.
Explains to pt, chaperone, empty bladder (vocab. & manner v imp here)
Positions & drapes pt. (Fowlers or asks to use stirrups)
Change to model
Inspects vulva, for cystocele, discharge, notes odor, etc
Lubricates and examines with “main d’accoucheur” obstetrician’s hand
Assesses uterus size, (bimanually)
Examines fornices (rotates hand), cervical excitation (cervical motion tenderness, “chandelier sign”)
Examines fingers for discharge

Please demonstrate how to perform the rectal exam using the patient and the model.
Explains & asks about tenderness etc
Positions & drapes patient appropriately – (use left lateral or knee-elbow position)
Change to model
Inspects anus, asks pt to bear down, looks for fistulae –
Introduces finger appropriately, (use water for lubrication on model)
Feels all walls of rectum
Examines and describes prostate
Withdraws finger and examines material on the finger (test for occult blood)

Please demonstrate how to examine the knee.
Explains & positions and inspects
Palpates (heat, tenderness, swelling etc)
Checks for effusion – Bulge or balloon, patellar tap
ROM (passive/active)
Cruciates (Drawer, Lachman’s)
Collaterals -
Menisci - McMurray’s

Please demonstrate how to examine the spine
Explains and positions
Inspects for posture (kyphosis, scoliosis, muscle spasm)
Palpation, tenderness of spinous processes, and paravertebral muscles
ROM (thoracic – rotation, lumbar, flexion (ant, laterally) extension
Straight leg raising (SLR) -
Reflexes (KJ, AJ) –
Starts to test power

Please demonstrate how to examine the (right/left) shoulder joint
Explains, positions, inspects (deformity, erythema)
Palpates: generally for heat, tenderness and SC joint, AC joint, coracoid process, greater tubercle, and biceps tendon (names structures)
ROM (active/passive, flexion/extension, abduction/adduction, internal/external rotation)
Rotator cuff tests:
Supraspinatus: abduction or empty beer can test
Infraspinatus: external rotation
Subscapularis: Gerber’s push-off test

Please demonstrate how to examine this patient’s arms neurologically starting with the motor system
Explains, & inspects (asks for numbness etc, notes flexion deformity, wasting etc)
Tone
Power (grades power /5)
Reflexes (inc. Hoffman’s)
Start sensation with light touch (dermatomes)

Please demonstrate how to examine cerebellar function.
Explains, inspects,
Eye movements – nystagmus
Arms movements: Finger nose (dysmetria, intention tremor, both sides)
Dysdiadochokinesia
Lower limb: heel-shin, foot tapping
Speech
Gait: wide based, drift, heel-toe walking.

Please examine this patient’s extra-ocular muscles
(Best to examine each eye separately)
Explain & position pt,
H test: each eye separately (identifying each muscle being tested)
H test: both eyes at the same time asking for diplopeia
Examines for nystagmus, examines for convergence
Cover/uncover test

Please examine the patient’s facial nerve & trigeminal nerves
Inspect & explains (notes symmetry.)
Examines facial movements (brow, eye closure, teeth, puffing cheeks)
Sensory exam of face
(N.B. Corneal reflex would be unpleasant for pt, but student should describe)
Muscles of mastication

Please demonstrate how to perform fundoscopy on this patient
Explains and asks for discomfort. Positions self and pt, darkens room.
Asks about refractive error in pt , glasses/contact lens
Can operate ophthalmoscope, ask pt to fixate on target.
Describes red reflex. Etc. Attempts to focus using diff lenses, and examines diff areas of retina
Examines left eye with left eye and right with right

Please demonstrate how to examine this patient’s legs neurologically, starting with the motor system
Explains, & inspects (wasting etc.)
Tone, (hips & knees)
Power, (restrict to hips & knees in view of time, grades power /5)
Reflexes (inc Babinski – gently!)
Starts sensation with light touch (dermatomes)

Please demonstrate how to examine the sensory system in the patient’s legs
Explain & inspect - Light touch (dermatomes) -
Temperature or sharp/dull (uses disposable toothpick etc, not a reusable needle)
Vibration sense, proprioception, Romberg’s

Please examine the MEDIAN nerves.
Explains, inspects – thenar eminence, clawing of index finger.
Palpates wrist
Tinel’s & Phalen’s
Power of opposition/ abduction /flexion
Sensation over median distribution

Please demonstrate how to examine for Parkinsonism
Inspection: notes facies, posture, paucity of movement, rest tremor
Assesses tone in upper limb and leg: cog-wheeling:
Asks patient to walk, & turn quickly:
Assesses glabellar tap –
Comment on speech.

Please examine this patient’s pupillary reflexes
Explain & position pt, dim light
Direct and indirect in both eyes
Accommodation reflexes & explains Argyll- Robertson pupil
Marcus Gunn pupil (swinging flashlight test)

Please examine the visual fields of the patient
Explains and positions pt
Both techniques -
Screening – perimetry coming from behind -
Confrontation - One eye at a time, covers his own eye on same side and compares, checks temporal and nasal fields, checks each quadrant
Checks for extinction =inattention

Please examine the eyes & assess the visual acuity of the patient
Explains & positions pt. Inspects and examines the eye
Asks pt about spectacles/ contact lenses and instructs pt to put them on
Asks if can identify letters (ie literate)
Uses reading chart correctly. Separate eyes, distance, instructions clear)
Reports acuity correctly according to card used– (Jaeger, dist equivalent)

This patient is complaining of breathlessness, and may have:…..
Please demonstrate how to examine the respiratory system
Explains & positions Inspects, (cyanosis, clubbing, resp rate, chest shape & expansion
Trachea
(Student may examine from the back at this point)
Expansion, TVF, Percussion Auscultation, Speech (bronchophony etc)
43: lobar pneumonia. 44: pleural effusion, 45: pneumothorax, 46: asthma 47: COPD

Please examine the patient for generalized lymphadenopathy
Inspects and palpates the head & neck (including tonsils,& supraclavicular)
infra-clavicular
axillary,
trochlear,
inguino-femoral
popliteal sites.
Examine for lymphedema