How to examine a hydrocoele
(1) Exclude a hernia by asking the patient to cough 2X – visible cough impulse and 2X again –
palpable cough impulse
(2) Examine the cords by examining the neck (at the base of the penis) and trying to get above
the swelling
(3) If non of these are positive then it is not a hernia!!
(4) Since it is a purely localized scrotal swelling examine the swelling just like you would for a
lump [S2CEAT2M + LNs](5) Test for fluctuation in 2 planes
(6) Testis on the side of the hydrocele cannot be felt because it is buried within the hydrocele
and is posteriorly placed
(7) Examine the inguinal lymph nodes – they drain the scrotal skin / and the Paraortic lymph
nodes – they drain the testicles (this is important because testicular CA can give rise to
secondary hydroceles)

Examination of a thyroid swelling
Before you begin: (a) Make sure patient is sitting down (b) Make sure you are facing good
natural lighting (c) Make sure you have a chaperon available (d) Adequately undress patient

Standing in front of patient
1. Check / inspect the anterior neck swelling
2. Ask patient to swallow
3. Stick out tongue
4. Place hand on swelling and ask patient to swallow for tug
5. Check for tracheal deviation

Move to back of patient
6. Place hand on ligamentum nuchae and tilt head of patient forward to relax neck muscles
7. Check for S4CEAT2M
S – Site of swelling
S – Size
S – Shape
S – Surface
C – Consistency
E – Edge
A – Attachment to skin and muscle (push against patient face and check mobility of swelling wrt
opposite sternocleidomastoid muscle)
T – Temperature differential
T – Tenderness
M – Mobility
8. Check to see if swelling extends retrosternally
9. Check for lymph node enlargement
10. Check Navzinger’s sign (tilt head and look for proptosis beyond supercilliary ridge)

Now Move to front of patient
11. Check Gofffrey’s sign (furrowing of forehead as patient looks up)
12. Check for lid retraction / lid lag / opthalmoplegia
13. Check for moistness of palm
14. Check for clubbing
15. Check pulse
16. Check BP
17. Check for fine tremors
18. Check pretibial myxedema
19. Check Achille’s Tendon Reflex

How to examine an inguinal hernia
(1) Ask patient to stand up, face bright natural light and stand on the RIGHT side of the patient
and inspect. Look for the presence of any scars and note the size of the scar (previous wound
infection)
(2) Ask patient to turn head away from you and cough twice – look at each side of the groin with
each cough for a visible cough impulse
(3) Ask patient to cough twice again – now feel for a palpable cough impulse at each side of the
groin
(4) Try and get above the swelling by placing inspecting the cord at the neck (root of the penis)
while gently pulling it laterally
(5) Ask patient to lie down now
(6) Try reducing the swelling by supporting the superficial ring as you press the fundus of the
hernia sac to gently guide swelling back in through the superficial ring. Note: If you run into
problems ask patient to flex his hip to help with the reduction
(7) Examine both testis and the epididymis now one after the other
(8) Examine the urethral meatus for any stricture
(9) Palpate urethra by following the guttering on the ventral surface of the penis up to the
bulbous urethra – feel for any indurations in the urethra!!
(10) Slightly flex the knee of the patient and follow the tendon of the adductor longus muscle to
the pubic bone
(11) Feel for the pubic bone and gently roll your finger upwards to locate the pubic tubercle
(12) Locate the anterior superior iliac spine – palpate along the soft inguinal ligament towards
the bone (the first bony prominence met it the anterior superior iliac spine)
(13) Replace your index finger with your thumb and find the mid‐point of the inguinal ligament
with your free index finger. Move 1.25cm upwards and perpendicularly and 1.25cm medially to
locate a defect (i.e. occlude the deep inguinal ring)
(14) Ask patient to cough and feel for palpable cough impulse
(15) Remove your index finger and look for a visible cough impulse

 

NOTES

Why is it important for the patient to stand up?
(i) We need gravity to help us demonstrate a cough impulse
(ii) Gravity is needed to demonstrate the presence of a hydrocoele
(iii) Gravity is needed to demonstrate the presence of a varicocele
(iv) Finally gravity is needed to demonstrate the presence of a spermatocele

A Herniotomy and Herniorraphy is done to prevent complications such as:
(a) Irreducibility
(b) Obstruction
(c) Strangulation
(d) Trauma

 

Why should you remove the sac?
Herniotomy is the most important procedure done of the two and it is done to prevent
recurrence of the hernia. In children and fit young adults only a herniotomy is done!! During
surgery the hernia sac is TRANSFIXED at its neck to make sure all of the sac is excised.

Causes of inguinal hernias
(i) Increased intrabdominal pressure from straining, i.e. long standing constipation, chronic
coughing, straining on micturition
(ii) Lifting heavy objects

Predisposing factors
(i) Patent processus vaginalis
(ii) Weakness in the muscle in older patients
(iii) Injury to the ilioinguinal / iliohypogastric nerve during appendicectomy causes a weakness in
the muscle

What causes recurrence of hernias?
(i) Wound infection, i.e. a broad ugly scar shows a pervious wound infection (linear scar =
healthy healing)
(ii) Poor surgical technique
(iii) Persistence of original precipitating factors

PARKINSONS DISEASE ASSESMENT FORMAT

 

PERFORMANCE CHECKLIST

PERFORMANCE/STEPS

NOT DONE

POORLY

DONE

GOOD

VERY

GOOD

EXCELLENT

 

INSPECTION

1

2

3

4

5

 

EXAMINATION FOR FRONTAL LOBE RELEASE SIGNS:

·      GLABELLAR TAP

·      PALMOMENTAL REFLEX

1

2

3

4

5

 

EXAMINATION FOR RIGIDITY

·      TONE IN ALL LIMBS (LEAD PIPE vs COGWHEEL)

1

2

3

4

5

 

EXAMINATION FOR TREMORS

·      REST TREMORS vs ACTION TREMORS (Archemides spiral, Straight line)

1

2

3

4

5

 

EXAMINATION FOR BRADYKINESIA

·      Facial hypomimia

·      Finger tapping amplitude and velocity

·      Micrographia

·      Gait:

·      Slowness of initiation(gait freezing)

·      Festination (short shuffling gait)

·      Turning (multiple steps)

·      Reduces arm swing

 

 

 

1

2

3

4

5

 

EXAMINATION FOR POSTURAL INSTABILITY AND ATTENTION  TO DETAIL

 

1

2

3

4

5

 

COMPOSURE AND COURTESY

 

1

2

3

4

5

 

SUBTOTAL

35 (50%)

·      Presents findings clearly, sequentially and correctly

·      Differential diagnosis (includes most probable cause)

·      Investigations and possible results

·      Management

50%

FINAL GRADE (S/N 1-8)

 

EXAMINERS COMMENTS AND SIGNATURE

 

 

GAS,TROINTESTINAL SYSTEM                                     PERFORMANCE CHECK-LIST

 

PERFORMANCE / STEPS

NOT

DONE

POORLY

DONE

GOOD

VERY

GOOD

EXCELLENT

 

1

GENERAL INSPECTION

Observes, presence of IVs, NG tubes, catheters, bed pans for Maelena etc )

Ill looking, in pain, wasted, drowsy, confused, Abdomen etc.

1

2

3

4

5

2

GENERAL EXAMINATION

Jaundice, anaemia, pedal oedema, hair texture & distribution, gynaecomastia, purpura, Hands: pallor, palmar erythema, dupuytren’s contracture, finger clubbing, flapping tremor (asterixis), Mouth and Face: parotid gland enlargement, buccal

mucosa and palate (ulcers, thrush etc.) Dentition, Tongue. Lymphadenopathy: (Virchow’s and Inguinal nodes)

 

2

 

4

5

3

ABDOMEN — Inspection: spider naevi, scratch marks / scars, distension, umbilicits, hair distribution pattern, peristaltic movements, prominent abdominal veir.s/Striae

1

2

 

4

5

4

ABDOMEN — Palpation/ Bailoiiiig : light palpation , deep palpation, direction of flow in distended abdominal veins, Palpation for the liver, spleen and kidneys, and characterisation of masses present, Hemial orifices

 

2

3

4

5

 

ABDOMEN – Percussion

Fluid thrill, Shifting dullness, Liver span

1

2

 

4

 

6

ABDOMEN Auscultstion

Bowel sound — present/absent/frequency, Liver bruit, Other bruit

 

 

 

4

 

7

PERINEUM: Offers to perform genital examination & rectal examination and overall attention to sequence

 

2

3

4

5

8

Composure and Courtesy

 

2

3

4

5

 

SUBTOTAL

40 [50%]

9

Presents findings clearly, sequentially and correctly 10 marks Differential diagnosis(includes most probable cause) 20 marks Investigations and possible results                           10 marks

Management                                                        10 marks

 

 

FINAL GRADE(S/N 1-9)

 

Examiners Comments and Eaaminers Signature:

 

HISTORY ASSESSMENT FORMAT

PERFORMANCE CHECK-LIST

PERFORMANCE / STEPS

NOT DONE

POORLY DONE

GOOD

VERY GOOD

EXCELLENT

 

ESTABLISHMENT OF RAPPORT

Introduction, Reassurance of confidentiality

1

2

3

4

5

 

PRESENTING COMPLAINT(S) & CHRONOLOGY

1

2

3

4

5

 

HISTORY OF PRESENTING COMPLAINT

1

2

3

4

5

 

DIRECT QUESTIONING

1

2

3

4

 

5

 

SYSTEMS INQUIRY

1

2

3

4

 

 

PAST MEDICAL HISTORY

1

2

3

4

5

 

DRUG AND ALLERGY HISTORY

1

2

3

4

5

 

FAMILY HISTORYfBASIC O&G HISTORY in

females

1

2

3

4

5

 

SOCIAL HISTORY

Marital and sexual history, Recreational drugs, alcohol and smoking, Travel, Hobbies, pets, housing, Assessment of related risks

1

2

3

4

5

 

Overall Attention To Sequence Composure and

Courtesy

1

2

3

4

5

 

SUBTOTAL

50 [50%]

 

Presents findings clearly, sequentially and correctly 10marks Differential diagnosis(includes most probable cause)20 marks Investigations and possible results                       10 marks

Management                                                  10 marks

50%

 

FINAL GRADE(’¥OTAL S/N 1-11)

 

 

Examiners Comments and Signature:

 

 

 

 

GENERAL EXAMINATION

 

PERFORMANCE CiJECKLIST

S/N

PERFORMANCE STEPS

NOT DONE

POORLY DONE

GOOD

VERY GOOD

EXCELLENT

 

GENERAL APPEARANCE & MENTAL STATUS

Appearance, wellness, dyspnoea, orientation in TPP, coma scale

1

2

3

4

5

2

NUTRITIONAL STATUS, SKIN, GENERAL OEDEMA

Fluffy/silky hair, cachexia, small for age, facial puffiness,

anasarca, periorbital and sacral oedema

1

2

3

4

5

 

HANDS EXAMINATION, METABOLIC FLAP

Checks palms, fingers, nails, dorsum — pallor, clubbing, muscle wastin,°, 1* ”p*r , I:err.or, foeis pulse?

1

2

3

4

 

5

4

HEAD AN@NECK

Pallor, jaundice, cyanosis, temperature, hydration, neck swellings and thyroid examination

1

2

3

4

5

5

LYMPHADENOPATHY

Checks lymphadenopathy or offers to check it — cervical (sits pafient up), axillary, epitrochlear, inguinal LNs

1

2

3

4

5

6

LEGS EXAMINATION

Appearance, tenderness, warmth, toes & web spaces,

measurement of leg circumference, pitting oedema

1

2

3

4

5

7

Composure & courtesy

1

2

3

4

5      ‘

 

SUBTOTAL

 

8

Presents findings clearly, sequentially and correctly 10 marks Differential diagnosis(includes most probable cause) 20marks Investigations and possible results  ’                     lllmarks

Management                                                     10 marks

50%

 

FINAL GRADE (Total S/N 1-8)

 

 

 

Examiners Comments and Examiners Signature:

NEUROLOGICAL EXAMINATION OF THE

LOWER LIMBS

PERFORMANCE CHECK-LIST

 

PERFORMANCE / STEPS

 

NOT

DONE

POORLY

DONE

GOOD

VERY

GOOD

EXCELLENT

 

 

Inspection of Lower Limbs

Anatomical positon of limbs/Habit, muscle wasting, urinary catheters etc.

1

2

3

4

5 

2

Examination of Muscle Bulk, fasciculatîon and Tone

1

2

34

5

 

 

Examination for Muscle Powër (MRC grade)

(Individual muscle groups vs. Overall limb)

1

2

3

4

5 

 

Deep tendon Reflexes of Lower limbs Knee, ankle and

Plantars) CIonus-Ankle& Knee

1

2

3

 

4

5

 

 

Sensory Examination in Lower Limbs

(Dermatomal approach)

Pain and Temperature pathway (Lateral)Vibration and Proprioception pathway(Posterior) Light Touch pathway(Anterior)

1

2

3

4

5

 

6

Examines the Back for Gibbus and Overall Attention To

Sequence

1

2

3

4

5

 

7

Composure and Courtesy

1

2

3

4

5

 

 

SUBTOTAL

 

 

 

8

Presents findings clearly, sequentially and correctly 10marks Differential diagnosis(includes most probable cause) 20 marks Investigations and possibleresults                       10 marks

   Management                                                 10 marks

50%

 

 

FINAL GRADE (S/N 1-8)

 

 

                                                             

 

Examiners Commente and Examiners Signature:

 

 

NEUROLOGIC EXAMINATION:

CEREBELLUM

PERFORMANCE CHECK-LIST

PERFORMANCE / STEPS

NOT

DONE

POORLY

DONE

GOOD

VERY GOOD

EXCELLENT

INSPECTION

Posture of limbs

Abnormal movements (tremors, chorea etc.) Gross deformity of limbs (contractures etc.) Gross wasting / hypenrophy (muscles)Fasciculation ’s (spontaneous / induced)

1

2

345

Examination for Nystagmus

(gaze evoked& spontaneous)

1

2

34

5

E xainination for Scanning epeecH and Dysarthria

1

2

3

45

COORDINATION and DYSMETRIA

 

•               Intention tremors

 Dvsdiadochokinesis                                                        

1

2

3

4

5

Lower Limb COORDINATION

•        Heel to Shin Test

1

2

345

DEEP TENDON REFLEX

•        ELLICITS PENDULAR KNEW TERM

1

2

3

4

5

GAIT ASSESSMENT

•             Broad based cerebellar Ataxia

•              Postural Tremor (Tremor of proximal muscuJature when weight bearing or fixedposture is attempted)

1

2

345

Composure and courtesy

1

2

3

4

5

SUBTOTAL

40 {50%J

Presents findings clearly, sequentially and correctly 10 marks

Differential did8 ‘l °• iS(ifl cludes most probable cause) 20marks Investigations and possible results                         10marfis

 Management                                                       10 marks

50 %

FINAL GRADE (S/N 1-9)

 

Examiners Comments (examiner must justify penalties):

 

Examiners Signature:

RESPIRATORY SYSTEM EXAMINATION

PEFORMANCE CHECK-LIST

S/N

PERFORMANCE / STEPS

NOT DONE

POORLY DONE

GOOD

VERY GOOD

EXCELLENT

1

A. INSPECTION

1.       Shape and symmetry of Chest, Scarification marks, Signs

of Respiratory Distress, Respiratory rate

2.      Patient environment: Looks out for presence of Sputum Bowl, IV lines in situ, Chest Tube in situ, Urethral catheter

1

2

3

4

5

 

B. GENERAL EXAMINATION

Digital clubbing, Finger staining, Weight Loss,Pedal Oedema, Lyrnphadenopathy

1

2

3

4

5

3

PALPATION

Trachea Position, Areas of Tenderness, Chest expansion,

Tactile vocal fremitus

1

2

3

4

5

4

PERCUSSION

Hand and finger positioning

Finger alignment along intercostal spaces (horizontal)

Symmetrical progression of percussion

& Lung zone coverage (DULL, STONY DULL, RESONANT,

” ““”’. RESONANT)

1

2

3

4

5

 

AtISCULTATlON

Symmetrical progression of auscultation

Degree of LUNG Zone coverage

Breath Sounds, Vocal fremitus, added sounds

1

2

3

4

5

 

Repeat examination posteriorly or ask to examine posteriorly Overall Attention To Sequence of examination

1

2

3

4

5

7

Composure and Courtesy

1

2

3

4

5

 

SUBTOTAL

35 |50%]

 

Presents findings clearly, sequentially and correctly 10 marks Differential diagnosis(includes most probablecause) 20 marks Investigations and possibleresults                          10 marks

Management                                                      10 marks

50 %

 

FINAL GRADE (Total S/N 1-8)

 

Examiners Comments and Signature:

 

CARDIOVASCULAR SYSTEM EXAMINATION

PERFORMANCE CHECK-LIST

 

PERFORMANCE / STEPS

NOT

DONE

POORLY

GOOD

VERY GOOD

EXCELLENT

 

GENERAL EXAMINATION

Inspection, Patients general condition: position, dyspnoea, pain,

Anasarca, Head Bobbing

Patient’s environment: presence of IVs, oxygen, Sputum Bowl. Hands: Pallor, Clubbing, Splinter haemorrhages, Capillary refi11time. Janeway lesions / Oslers nodes

Cvanosis. Bipedal Oedema

1

2

3

4

5

2

Examination of the Radial Pulse: Rate, Rhythm, Volume.

Character, Collapsing Synchrony, Vessel wall.

1

2

3

4

5

4

Examination of the Jugular Venous Pressure (JYP)

Palpation of Liver (hepatojugular reflex)

1

2

3

4

5

5

PRECORDIUM — INSPECTION

1

2

3

4

5

6

PRECORDIUM – PALPATION

Location of Apex beat, Tracheal position when Apex is displaced, thrills and heaves

1

2

3

4

5

7

PRECORDIUM – AUSCULTATION

Heart sounds / murmurs.

Manoeuvres to increase intensity of murmurs Auscultation of hung bases

123

4

5

8

Asks to Check blood pressure and overall anention tosequence

I

2

3

4

5

9

Composure and Courtesy

1

2

34

5

 

SUBTOTAL

50%

10

Presents findings clearly, sequentially and correctly 10 marks Differential diagnosis(includes most probable cause) 20 marks Investigations and possible results                          10  marks

Management                                                      10 marks

50%

 

FINAL GRADE(S/N 1-10)

 

Examiners Comments and Signature

 

 

3″ ,4″ and 6″ CRANIAL NERVES ASSESSMENT

FORMAT

PERFORMANCE CHECK-LIST

PERFORMANCE / STEPS

NOT

DONE

POORLY

DONE

AVERAGE

WELL

DONE

EXCELLENT

 

Inspection of face stands at Arm’s length

1

2

3

4

5

 

Examine Frontalis muscle over activity

1

2

345

 

Examination of eye movements in all directions of GAZE- Nvstagmus & Diplopia assessed

1

2

345

 

Test for Eye lid Fatigability

1

2

3

4

5

 

Examines the pupils light reflex ( focusing on efferent arc-

consensual response)

1

2

3

4

5

 

Composure and Courtesy

1

2

345

 

SUBTOTAL

30 (50%)

 

Presents findings clearly, sequentially and correctly        10 marks

Differential diagnosis(includes most probable cause}      20 marLs Investigations’ and possible results                             10 marLs

   Management                                                        10 marLs

50%

 

FINAL GRADE (SfN 1-7)

 

 

 

Examiners Comments Signature:

 

 

FACIAL (7TH) CRANIAL NERVE EXAMINATION

PERFORMANCE CHECK-LIST

PERFORMANCE / STEPS

NOT

DONE

POORLY

DONE

GOOD

VERY GOOD

EXCELLENT

1

Inspection of face

1

2

3

4

5

2

Examination of Frontalis

123

4

5

 

Examination of Orbicularis Oculi

1

2

3

4

5

 

Examination of Buccinators

1

2

3

4

5

 

Examination of Orbicularis Oris

1

2

3

4

5

 

Examination of Platysma

1

2

3

4

5

 

Tests for Hyperacusis

1

2

3

4

5

 

Tests for taste anterior 2/3rds of Tongue

1

2

345

9

 

Composure and Courtesy

1

2

3

4

5

 

SUBTOTAL

45 |50%]

10

Presents findings clearly, sequentially and correctly 10 marks Differential diagnosis(includes most probable cause) 20 marks Investigations and possible results                         10marks

  Management                                                     10 marks

50 %

 

FINAL GRADE (S/NI-10)

 

Examiners Comments and Signature: