System examination stations

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to examine your cardiovascular system. This will involve looking at your hands and face, examining your chest and looking at your legs. Is this ok with you?”

“Would you like a chaperone present?”

“Please expose only the area we need to examine; I will help you keep covered.”

“I will ensure the bed is at 45 degrees”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me why you have come to hospital?”

General inspection

“I am looking at the…”

Patient’s

• comfort level; respiratory distress
• body habitus
• dysmorphic features
• scars (sternotomy or pacemaker)

Environment

• oxygen
• GTN spray
• walking aids

Hands and other observations

“I am feeling for…”

• warmth
• clamminess
• the pulse (rate; rhythm; quality)

“I am looking for…”

• clubbing
• tar staining
• peripheral cyanosis
• features of endocarditis (e.g. Janeway lesions)
• signs of aortic regurgitation (e.g. head bobbing)

Other observations

• Blood Pressure
• Respiratory Rate
• Oxygen saturations
• Temperature
• Blood glucose

Neck

“I am looking for…”

• Carotid pulse (one side at a time; never compress both carotids together): "I am going to feel the pulses in your neck in turn to assess their quality"
• Jugular venous pressure:
  • "I will start with the bed at about 45 degrees and adjust it to see the venous pulsation clearly.
  • Please turn your head to the left and relax head on the pillow.
  • If helpful, and with your permission, I will apply gentle sustained abdominal pressure while watching the neck veins (abdominojugular reflux).
  • I am measuring the vertical height of the venous pulsation above the sternal angle, in centimetres, and recording your position."

Face

“I am looking for evidence of…”

• Corneal arcus and xanthelasma
• Conjunctival pallor (please look up I will gently lower your bottom eye lids)
• Central cyanosis
• Angular stomatitis of lips

Precordium

Inspection: “I have already commented on.”

"I am palpating…”

• the central capillary refill time
• the apex beat: identify its actual position; normally near the fifth intercostal space in the midclavicular line
• each valve area for heaves and thrills of palpable murmurs

No percussion

"I am auscultating the…”

• carotids for bruit or radiation of aortic stenosis
• all the heart valves with bell and diaphragm
• for murmurs (including maneuvers to assess for murmurs as indicated by findings)

Additional

“Please can you…”

• lean forward so I can listen to your lungs and press on your lower back to assess for oedema
• lie flat so I can assess for hepatomegaly
• lift your trousers above your knees so I can look for peripheral oedema

Close

“Thank you. That is the end of the examination.”

“Do you need any help getting dressed?”

“In summary my working differential diagnosis is…”

"To complete my examination (scenario dependent) I would like to:

• Examine peripheral pulses: including checking for radio-femoral/radio-radio delay; ankle-brachial pressure index
• Obtain an
  • ECG
  • chest x-ray,
  • lying/standing blood pressure
  • urinalysis
  • blood tests (state which ones)

“Does that sound reasonable to you? Do you have any questions or concerns?”

Further reading

• Geeky Medics — Cardiovascular examination 2
• Oxford Medical Education — Cardiovascular exam detailed
• Geeky Medics — Heart murmurs
• Geeky Medics — JVP assessment
• Geeky Medics — Record ecg
• Geeky Medics — How to read an ecg
• Stanford — JVP measurement

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to examine your respiratory system. This will involve looking at your hands and face, examining your chest and looking at your legs. Is this ok with you?”

“Would you like a chaperone present?”

“Please expose only the area we need to examine; I will help you keep covered.”

“I will ensure the bed is at 45 degrees”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

"Can you briefly tell me why you have come to hospital?

General inspection

“I am looking at the…”

Patient’s

• comfort level
• body habitus
• scars from chest drains/aspiration
• chest wall deformity
• respiratory distress and shortness of breath
• cyanosis

Environment

• oxygen
• inhalers/nebulisers
• sputum pots

Hands and other observations

“I am feeling for…”

• warmth
• clamminess
• the pulse (rate; rhythm; quality)

“I am looking for…”

• clubbing
• tar staining
• peripheral cyanosis
• wasting (Pancoast's tumour)
• CO₂ retention tremor

Other observations

• Blood Pressure
• Respiratory Rate
• Oxygen saturations
• Temperature
• Blood glucose

Neck

“I am looking for…”

• Jugular venous pressure:
  • "I will start with the bed at about 45 degrees and adjust it to see the venous pulsation clearly.
  • Please turn your head to the left and relax head on the pillow.
  • If helpful, and with your permission, I will apply gentle sustained abdominal pressure while watching the neck veins (abdominojugular reflux).
  • I am measuring the vertical height of the venous pulsation above the sternal angle, in centimetres, and recording your position."
• Lymph nodes: I need to feel for any glands in your neck. I will stand behind you and feel along your jaw; in front of then behind your ears; down your neck and along your collar bones.
• Trachea position: I need to feel in the space between your collar bones assessing that your windpipe is central.

Face

“I am looking…”

• at your eyes for Horner’s syndrome (ptosis; miosis; ask about anhidrosis)
• for central cyanosis
• for nasal patency (please occlude each nostril in turn and breathe in and out. Does it feel equal?)

Chest

“I will examine the front, sides and back of your chest, comparing the two sides.”

• Inspect: look for scars, bruising, deformity and the pattern of breathing.
• Palpate: assess expansion, comparing sides. Check for relevant chest-wall tenderness and dependent oedema.
• Percuss: compare corresponding areas on the two sides.
• Auscultate: compare breath sounds and listen for added sounds. For vocal resonance, ask the patient to say “ninety-nine” while listening through the stethoscope.

Tactile vocal fremitus is felt with the hands; vocal resonance is heard through the stethoscope. Choose tests that help answer the clinical question.

Stanford — pulmonary examination

Close

“Thank you. That is the end of the examination.”

“Do you need any help getting dressed?”

“In summary my working differential diagnosis is…”

"To complete my examination (scenario dependent) I would like to:

• Obtain a
  • peak flow
  • chest x-ray,
  • blood gas when indicated by respiratory failure or concern about ventilation or acid–base disturbance; choose arterial sampling when oxygenation needs direct assessment
  • sputum sample
  • blood tests (state which ones)

“Does that sound reasonable to you? Do you have any questions or concerns?”

Further reading

• Geeky Medics — Respiratory examination 2
• Oxford Medical Education — Examination of the respiratory system detailed
• Oxford Medical Education — Respiratory examination 2
• Geeky Medics — Peak expiratory flow rate
• Oxford Medical Education — Abg
• Geeky Medics — Abg interpretation
• Geeky Medics — Chest x ray interpretation a methodical approach
• Radiology Masterclass — Chest pathology end
• Stanford — pulmonary examination

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to examine your gastrointestinal system. This will involve looking at your hands and face and chest, then examining your abdomen. Is this ok with you?”

“Would you like a chaperone present?”

“Please expose only the area we need to examine; I will help you keep covered.”

“I will help you lie comfortably, and ask you to lie flat for the abdominal examination if you can.”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me why you have come to hospital?”

General inspection

“I am looking at the…”

Patient’s

• comfort level
• jaundice
• abdominal distension
• abdominal drains or scars
• spider naevi; caput medusa and gynaecomastia
• anasarca

Environment

• drains

Hands and other observations

“I am feeling for…”

• warmth
• clamminess
• the pulse (rate; rhythm; quality)

“I am looking for…”

• clubbing
• leukonychia
• palmar erythema
• Dupuytren’s contractures
• liver flap

Other observations

• Blood Pressure
• Respiratory Rate
• Oxygen saturations
• Temperature
• Blood glucose

Face

“I am looking for evidence of…”

• conjunctival pallor ("Please look up I will gently lower your bottom eye lids.")
• angular stomatitis of lips
• oral ulcers (Please open your mouth and stick out your tongue.")
• lymph nodes (“I need to feel your neck for any swellings. I will stand behind you to do this.”)

• Virchow’s node can be found in the left supraclavicular fossa and may be a sign of intra-abdominal malignancy

Abdomen

“Now I need to examine your abdomen. Are you ok to lie flat? If at any time you are in pain or want me to stop let me know.”

“I will examine the patient from their right side; at their level; looking at the patient for any signs of discomfort.”

Inspection

• Closer inspection (don't forget the left flank)

Palpation

• Ask where it hurts, begin away from pain and palpate gently, then more deeply if appropriate, assessing tenderness, guarding, rigidity and masses
• Organs: liver; spleen; kidney; bladder
• Aorta

Percussion

• Organs: liver; spleen; bladder
• Ascites (shifting dullness)

Auscultation

• Bowel sounds
• Femoral bruits

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings and working differential diagnosis. Explain the next steps and invite questions.

• Examine lymph nodes and hernial orifices when relevant. Offer rectal, genital or pelvic examination only when clinically indicated, with separate explanation, consent and chaperone discussion.
• Choose investigations for the scenario: for example urinalysis, relevant blood tests and appropriate imaging. State what each test will help establish.

Further reading

• Geeky Medics — Abdominal exam
• Geeky Medics — PR exam
• Radiology Masterclass — Anatomy introduction

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to examine the nerves that supply the upper limbs. This will involve me assessing your strength; sensation; coordination and reflexes in both your arms. Is this ok with you?”

“Would you like a chaperone present?”

“I will help you sit or lie comfortably with your arms supported.”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me what the problem is?”

“Which hand do you write with?”

“Any trauma?”

“Any hobbies?”

“Are you currently working?”

General inspection

“I am looking at the…”

Patient for (standing; front; back; sides)

• wasting
• fasciculation
• posturing
• scars

Environment

• slings
• splints

Tone

“I am going to hold each of your hands and do some movements with them to assess your tone…” (Flexion; extension; supination and pronation at the elbow)

“I am assessing whether tone is increased, reduced or normal.”

Power

“I need to assess your strength by asking you to make some movements against resistance.”

Compare sides, test proximal and distal groups, and document power on the MRC 0–5 scale, including pain or other limitations. Muscles have overlapping root supplies; these are useful key movements, not a complete map of each muscle’s innervation.

Key movement	Clinical root anchor
Elbow flexion	C5
Wrist extension	C6
Elbow extension	C7
Finger flexion (distal phalanx of middle finger)	C8
Little-finger abduction	T1

Also assess shoulder abduction, wrist flexion, finger extension and relevant thumb movements. Specify the movement and peripheral nerve being assessed; thumb extension, opposition and finger abduction are not all simply “T1”.

ASIA: key muscles and neurological assessment

Sensation

“I need to test how well you can feel areas on your skin…”

• Can you feel here? (on upper chest)
• Bring your arms straight by your side with your palms facing forward (‘anatomical’ position).
• Please can you close your eyes and tell me when you feel something.

“I will compare sensation on both sides, test relevant dermatomes and peripheral nerve territories, and map any abnormality using:”

• Light touch (cotton wool)
• Sharp/dull (neurotip)
• Vibration sense (128Hz tuning fork): start on a distal bony prominence and move proximally
• Proprioception (joint position sense)
• Temperature

Reflexes

“Let your arm relax while I check the reflexes with this tendon hammer.”

• Support the limb and compare sides: biceps C5–C6, brachioradialis C5–C6 and triceps mainly C7.
• Describe whether reflexes are absent, reduced, normal or brisk, and use reinforcement if needed without contracting the muscle being tested.

Stanford Medicine 25 — tendon reflexes

Coordination

“Please touch your nose and then my finger, and repeat on the other side.”

• Assess finger–nose testing with eyes open for dysmetria and intention tremor.
• Test rapid alternating hand movements for dysdiadochokinesia.
• Assess pronator drift with the arms extended forwards, palms upwards and eyes closed; look for pronation and downward drift.

University of Utah — motor examination

Close

“Thank you. That is the end of the examination”

“Do you need any help getting dressed?”

“In summary I found/did not find…”

"To complete my examination I would like to do a peripheral vascular and neck examination."(scenario dependent)

“Does that sound reasonable to you? Do you have any questions or concerns?”

Further reading

• Geeky Medics — Upper limb neuro exam
• TeachMePhysiology — upper motor neurones
• TeachMePhysiology — lower motor neurones
• Geeky Medics — Cerebellar examination
• Geeky Medics — ascending spinal tracts
• Geeky Medics — descending tracts
• Geeky Medics — Dermatomes and myotomes
• Geeky Medics — Power grading: MRC
• NCBI Clinical Methods — Assessing reflexes
• ASIA — neurological assessment resources
• Stanford — reflexes

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to examine the nerves that supply the lower limbs. This will involve me assessing your strength; sensation; coordination and reflexes. Is this ok with you?”

“Would you like a chaperone present?”

“Are you ok to change into shorts?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me what the problem is?”

“Any trauma?”

“Any hobbies?”

“Are you currently working?”

General inspection

“I am looking at the…”

Patient for (standing: front; back; sides)

• gross deformity (varus/valgus)
• wasting
• fasciculations
• I will also assess:
  • gait (broad based; shuffling; antalgic)
  • hip extension

Environment

• walking aids (crutches; wheelchair; splints)

Tone

“Please lie back comfortably and let your legs relax while I move them gently.”

• With the patient supine and relaxed, compare resistance to passive movement at the hips, knees and ankles. Check for pain or restrictions before moving the joints.
• Leg rolling and lifting the knee while watching the heel can help assess tone; interpret the response with the rest of the examination.
• To assess ankle clonus when indicated, support the leg, briskly dorsiflex the foot and maintain gentle dorsiflexion. Record the beats and whether clonus is sustained.

Power

“I need to assess your strength by asking you to make some movements against resistance.”

Compare sides, test proximal and distal groups, and document power on the MRC 0–5 scale, including pain or other limitations. Muscles have overlapping root supplies; these are useful key movements, not a complete map of each muscle’s innervation.

Key movement	Clinical root anchor
Hip flexion	L2
Knee extension	L3
Ankle dorsiflexion — bring the foot up	L4
Great-toe extension — lift the big toe	L5
Ankle plantarflexion — push the foot down	S1

Add hip extension, knee flexion, ankle inversion and eversion, and toe flexion as the presentation requires. Interpret the pattern together with sensation and reflexes.

ASIA: key muscles and neurological assessment

Sensation

“I need to test how well you can feel areas on your skin…”

Demonstrate sensation elsewhere first.

Legs in ‘anatomical’ position'

“I will compare sensation on both sides, test relevant dermatomes and peripheral nerve territories, and map any abnormality using:”

• Light touch (cotton wool)
• Sharp/dull (neurotip)
• Vibration sense (128Hz tuning fork): start on a distal bony prominence and move proximally
• Proprioception (joint position sense)
• Temperature

Reflexes

“Let your legs relax while I check the knee and ankle reflexes.”

• Compare knee reflexes L2–L4 (mainly L4) and ankle reflexes S1–S2 (mainly S1). Use reinforcement when needed.
• For the plantar response, use a blunt stimulus along the lateral sole from heel towards the forefoot, then medially. Record flexor, extensor or absent responses; an extensor great toe in an adult suggests corticospinal tract dysfunction. Distinguish this from withdrawal.

Stanford Medicine 25 — reflexes

Coordination

“I need to assess your co-ordination…”

• Can you put the heel of one foot below your knee and run your foot up and down your shin with eyes open; additional testing with eyes closed may help assess sensory contribution (repeat on other side).

Close

“Thank you. That is the end of the examination”

“Do you need any help getting dressed?”

“In summary I found/did not find…”

“To complete my examination (scenario dependent) I would like to do peripheral vascular, abdominal and hip examination.”

“Does that sound reasonable to you? Do you have any questions or concerns?”

Further reading

• Geeky Medics — Lower limb neurological exam
• Geeky Medics — Gait abnormalities
• TeachMePhysiology — upper motor neurones
• TeachMePhysiology — lower motor neurones
• Geeky Medics — Cerebellar examination
• Geeky Medics — ascending spinal tracts
• Geeky Medics — descending tracts
• Geeky Medics — Dermatomes and myotomes
• Geeky Medics — Power grading: MRC
• NCBI Clinical Methods — Assessing reflexes
• ASIA — neurological assessment resources
• Stanford — reflexes

Use the station brief

Focus on the requested nerves and symptoms. Corneal and gag reflexes are not routine tests in an otherwise standard conscious-patient station; explain any clinical indication and seek consent before an uncomfortable test.

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to examine your cranial nerves. These are the nerves in your head that supply the face. It will involve me assessing smell, vision, hearing and getting you to do some movements with your face. Is this ok with you?”

“Would you mind sitting in a chair facing me?”

“Would you like a chaperone present?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me why you've come to hospital today?”

General inspection

“I am looking at the…”

Patient for

• facial asymmetry
• rashes
• ptosis
• unequal pupils
• scars

” will now examine each nerve in turn…”

Environment

• glasses
• hearing aids

Cranial Nerve Examination

You may want to clarify aspects of the required examination with the examiner. Follow the station instructions and the clinical indication

Olfactory: Cranial Nerve I

“Have you noticed any change in your sense of smell?”

Examiner: "would you like me to formally examine this?"

Optic: Cranial Nerve II

Visual acuity

• "If you normally wear glasses please put them on, if haven’t got them with you, use pin hole.
• I will use this Snellen chart to assess acuity.
• Use the distance specified for this chart (six metres for a standard Snellen chart).
• Close one eye, read the lowest line possible, then change side."

Record acuity for each eye as the testing distance over the smallest line read, for example 6/9; record correction and pinhole results

Visual fields

• Please cover one eye. I will cover the opposite and we will look at each in turn
• I will sit opposite you. Please look at my nose; I will bring my finger in from the side, say yes when you see my finger and if you see it disappear at any time (assess all four quadrants in each eye)

Examiner: "Would you like me to formally assess blind spot (red hat pin) or for neglect?”

Colour vision

Examiner: "Would you like me to assess colour vision using Ishihara chart?“

Pupils

"I am looking at the pupils for:

• size
• shape
• regularity
• ptosis
• normal lie

Pupillary reflexes (ask pt to focus on point in distance),

I am assessing for the following pupilliary reflexes:

• Direct
• Consensual
• Swinging-light reflex to assess for a relative afferent pupillary defect

“Depending on the findings and station brief, I would consider…”

• fundoscopy
• slit lamp examination when an ocular problem is suspected
• eversion of lids if FB concern.
• Examiner: "Would you like me to do this?"

Eye movements: Cranial Nerves III, IV, VI

• "Please keep your head still and follow my finger with you eyes.
• Tell if you have any pain or double or blurred vision.
• I am looking for nystagmus and ptosis."

Trigeminal: Cranial Nerve V

Motor

“Please can you clench and relax your teeth?”

“I am feeling over the:”

• Masseter
• Temporalis

Sensory

"Can you feel me touch you (dull, sharp, light etc)"…

• ophthalmic
• maxillary
• mandibular divisions?

“Does it feel the same on both sides?”

Reflexes

Examiner: "would you like me to assess…"

• Corneal reflex
• Jaw jerk

Facial: Cranial Nerve VII

Motor (muscles of facial expression)

• "Show me teeth; puff your cheeks out; purse your lips.
• Close your eyes tight; don’t let me open them.
• Raise your eyebrows and wrinkle your forehead

Sensory

Altered:

• hearing (hyperacusis)
• taste

Vestibulocochlear: Cranial Nerve VIII

Cochlear: hearing

• Ask about hearing change and tinnitus; inspect the ears and perform otoscopy when indicated.
• Assess each ear separately with an appropriate hearing screen. Rinne compares air and bone conduction; Weber assesses lateralisation, using a 512 Hz tuning fork. Interpret with the history and otoscopy.

Vestibular: balance

• For brief, position-triggered vertigo, consider Dix–Hallpike testing when appropriate and safe.
• HINTS is for an acute vestibular syndrome with ongoing symptoms and nystagmus, performed by a clinician trained and experienced in its use. It is not a general test for every dizzy patient or for brief positional symptoms.
• Central or uncertain findings require urgent assessment through the stroke pathway. If trained HINTS assessment is unavailable and BPPV or postural hypotension does not explain acute vestibular syndrome, NICE recommends immediate referral.

NICE NG127 — dizziness and vertigo · SAEM GRACE-3

Glossopharyngeal: Cranial Nerve IX

Ask about swallowing difficulty and any relevant change in taste. Assess IX and X together through the history, voice and palatal movement.

If clinically indicated, the afferent (sensory) limb of the gag reflex is mainly IX; the efferent (motor) limb is X. Do not describe the afferent limb as a motor test or use the gag reflex alone to decide whether swallowing is safe.

Vagus: Cranial Nerve X

“Please open your mouth and say “ah”.”

Listen for a hoarse or nasal voice and inspect palatal elevation and symmetry. Ask about dysphagia. The efferent (motor) limb of the gag reflex is X; test it only when clinically indicated and explain the procedure.

University of Utah — cranial nerve examination

Accessory: Cranial Nerve XI

Motor

• "Can you shrug your shoulders?" (assessing trapezius strength)
• "Turn your head into my hand?" (assessing sternocleidomastoid on both sides)

Hypoglossal: Cranial Nerve XII

Motor

• "Can you stick out your tongue?" (assessing for fasciculation and wasting)
• "Can you push your tongue into your cheek and don’t let me push it in." (assess each side)

Close

“Thank you. That is the end of the examination”

“In summary I found/did not find…”

“To complete my examination (scenario dependent) I would like to…”

“Does that sound reasonable to you? Do you have any questions or concerns?”

Further reading

• Geeky Medics — Cranial nerve exam
• Geeky Medics — Visual pathway and visual field defects
• Geeky Medics — Optic nerve
• NICE CKS — Bells palsy
• NICE CKS — Hearing loss in adults
• Geeky Medics — Hearing assessment and otoscopy
• Geeky Medics — Sudden sensorineural hearing loss
• Oxford Medical Education — Rinnes and weber tests
• Geeky Medics — BPPV
• Geeky Medics — Dix-Hallpike and Epley
• Geeky Medics — HINTS exam
• NICE — recognition and referral of neurological conditions
• SAEM — GRACE-3 dizziness guideline
• University of Utah — cranial nerve examination

Prioritise vision and urgency. Check visual acuity early, before drops where practical. Suspected penetrating injury requires protection from pressure and urgent ophthalmology advice; do not perform tonometry or manipulate the eye. Chemical exposure requires immediate irrigation rather than waiting to complete a routine examination.

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to examine your eyes. This will involve me looking at them directly and with a light source; testing your vision; eye movements, and reflexes. Is that ok with you?”

“Would you like a chaperone present?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me what the problem is?

“Any trauma or injury?”

“Do you wear glasses or contact lenses normally? Have you got them with you?”

General inspection

Face the patient

“In terms of general inspection I am looking at the…”

• External eye appearances: ptosis; proptosis; squint; head tilt; pupil symmetry
• Lids; lashes; lacrimal gland and duct: swelling of lids; position (ectropion/entropion); blepharitis; blepharospasm; follicles; crusting/pus
• Cornea; conjunctiva; sclera: Cornea (white/hazy); sclera (injection – diffuse/local)
• Foreign bodies: Examiner: "would you like me to evert eyelids, fluorescein and assess using the slit lamp?"

Pupils

• Appearance: size; shape; symmetry
• Reflexes
  • Direct
  • Consensual
  • Swinging light test (RAPD – Marcus Gunn pupil)
• Accommodation: please focus on something in the background; now looking at my finger (pupils constrict on focusing from far to near objects)
• Squint: cover/uncover test

Visual acuity

"If you normally wear glasses please put them on. If haven’t got them with you I will use a pin hole.” (If vision improves this suggests a refractive error)

“I will examine each eye in turn…”

Far vision

• "I will use this Snellen chart to assess acuity
• Use the distance specified for this chart (six metres for a standard Snellen chart)
• Close one eye, read lowest line possible, then change side

Record acuity for each eye as the testing distance over the smallest line read, for example 6/9; record correction and pinhole results

Near vision

If near acuity is indicated, use a near-vision chart at its specified distance, with appropriate near correction and lighting. Test each eye separately and record the chart result and test distance.

Colour vision

Examiner: would you like me to assess colour vision using the Ishihara plates?

Visual fields

“Please cover one eye. I will cover the opposite and we will look at each in turn…”

“I will sit opposite you. Please look at my nose, I will bring my finger in from the side, say yes when you see my finger and if you see it disappear at any time (assess all four quadrants in each eye)…”

Examiner: "would you like me to formally assess blind spot (red hat pin) or for neglect?”

Eye movements

“Follow my finger with your eyes keeping your head still. Tell me if you get any pain or double vision."

Examiner: "I am looking for nystagmus and ptosis."

Fundoscopy

Examine in a dim room. Record pupil size and responses first. Dilating drops may improve the view, but require an appropriate indication, contraindication check and local protocol; do not present dilation as automatic in every ED eye examination. Explain transient blur and advise against driving until vision is normal.

• Look for the red reflex, then examine the optic disc, vessels, background retina and macula.
• Describe disc margins, colour and cup-to-disc ratio in context; a ratio of 0.3 is not a universal boundary between normal and abnormal.
• Report what you can actually see. Sudden visual loss, severe pain, a field defect or significant trauma needs urgent specialist assessment.

Stanford — fundoscopy · RCOphth — urgent eye symptoms

Close

“Thank you. That is the end of the examination. I will explain what I have found and the next steps.”

Select further tests for the presentation: slit-lamp examination, intraocular pressure measurement when appropriate and safe, or a fuller cranial nerve examination. Avoid pressure measurement or manipulation when an open-globe injury is suspected.

Assess for giant cell arteritis when the history and findings suggest it. Sudden visual loss or another sight-threatening presentation requires urgent specialist assessment rather than a routine completion checklist.

AAO EyeWiki — measuring visual acuity

Further reading

• Geeky Medics — Examination of the eyes and vision
• Geeky Medics — Fundoscopy
• RCOphth — eye health and urgent symptoms
• Geeky Medics — eyelid disorders
• Geeky Medics — painless red eye
• Geeky Medics — painful red eye
• Geeky Medics — acute angle closure glaucoma
• Geeky Medics — retinal detachment
• Geeky Medics — painless sudden visual loss
• Geeky Medics — orbital and periorbital cellulitis
• Geeky Medics — eye drops
• AAO EyeWiki — measuring visual acuity

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to examine you to assess whether your thyroid may be causing any of your symptoms. This will involve me: examining your hands; face; neck; legs and reflexes. Is this ok with you?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me why you have come to hospital?”

General inspection

“I am looking at the patient for signs of…”

• Flushing
• Loss of outer ⅓ eyebrow
• Tremor

• Obvious eye signs
• Neck swelling or scars around the neck
• Body habitus

Hands and other observations

“I am feeling for…”

• warmth
• clamminess
• the pulse (rate; rhythm; quality)

“I am looking for…”

• Tremor (hold hands out)
• Nail changes (onycholysis; thyroid acropachy)
• Palmar erythema
• Thick coarse skin

Other observations

• BP
• Resp Rate
• Sats
• Temperature
• Blood glucose

Face

“I am looking for…”

• Eyebrow: loss of outer ⅓
• Eye signs:
  • lid retraction
  • Lid lag on downwards gaze ("Please look down for me")
  • Proptosis ("I will assess by looking from the side and down”)
• Eye movements: "Please follow my finger with your eyes and tell me if you get any double vision."

Neck

Inspection

“I am looking at the neck from the front and side for masses/swellings or scars”

Palpation

“I need to feel your neck:“

• Trachea central?
• Masses: size; shape; nodule; diffuse
• "Please can you take a sip of water and swallow" (thyroid swellings usually rise on swallowing)
• "Please can you stick out your tongue" (thyroglossal cysts will move on sticking the tongue out)
• I am just going to feel for any other lumps in the neck (Lymph nodes)

Percussion

"I am going to tap along your breast bone (retrosternal dullness may support suspicion but does not establish or exclude retrosternal extension)

Auscultation

"I am just going to listen to the neck" (assessing for bruits)

Lower limb reflexes

“Lastly I would like to…”

• Look at your shins for any evidence of pretibial myxoedema
• Test your reflexes

Close

“Thank you. That is the end of the examination”

“In summary my working differential diagnosis is…”

“To complete my examination I would like to do the following investigations/tests…”

“Does that sound reasonable to you? Do you have any questions or concerns?”

Further reading

• Geeky Medics — Thyroid status examination
• NICE CKS — Thyroid lump
• NICE CKS — Neck lump
• Geeky Medics — Neck lump examination osce guide
• NICE CKS — assessment of a neck lump
• NICE CKS — Hyperthyroidism
• Geeky Medics — Thyrotoxicosis and hyperthyroidism
• NICE CKS — Hypothyroidism
• Geeky Medics — Thyroid function tests
• NICE NG145 — thyroid disease

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

I have been asked to conduct an examination of your peripheral vascular system. This means assessing the blood supply to your limbs; doing some tests to assess the supply; feeling your pulses and also an abdominal examination. You will need to have your legs exposed up to your groin. Would this be ok with you?

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

"Can you briefly tell me why you have come to hospital?

General inspection

“I am looking at the patient for signs of…”

• habitus (obese or cachetic)
• scars
• distended abdomen
• expansile abdominal mass

Legs

Inspection

• skin colour
• chronic changes e.g. hair loss; ulcers
• oedema: unilateral; bilateral; extent
• scars
• varicose or dilated veins
• infection
• gangrene
• Toes: web spaces and heels

Palpation

• Temperature (dorsum hand long leg)
• Tenderness
• Capillary refill
• Pulses: dorsalis pedis; posterior tibial; popliteal; femoral – compare left to right
• Oedema: pitting vs non pitting
• Circumference
• Sensation; reduced or hyperaesthesia

Move

“Can you wiggle your toes for me?”

Special tests

• Use Doppler when pulses are difficult to feel, and document the arterial signals.
• Buerger’s test may demonstrate elevation pallor and dependent rubor. It is an adjunct to the assessment, not a stand-alone exclusion test.

Ankle–brachial pressure index (ABPI)

With the person resting supine, measure systolic pressures in both arms and at the ankle arteries using appropriate cuffs and Doppler. For each leg, divide its highest ankle pressure by the highest arm pressure.

Result	Interpretation in context
Below 0.9	Supports peripheral arterial disease.
Below 0.5	Suggests severe disease.
Around 1.0–1.4	Usually within the normal range.
Above 1.4	May indicate non-compressible, calcified vessels.

Borderline values and symptoms need further assessment. A normal or high ABPI does not exclude PAD in a person with diabetes. A suddenly painful, cold, pale, weak or numb limb needs urgent vascular assessment; do not delay referral for a routine ABPI.

NICE CG147 — PAD assessment · Stanford — ABPI

Close

“Thank you. That is the end of the examination”

“To complete my examination I would like to do a…”

• CVS examination (including listening for carotid bruits)
• Abdominal exam (including listening for femoral bruits)
• Abdominal US

“In summary my working differential diagnosis is…”

“To complete my examination I would like to do the following investigations/tests…”

“Does that sound reasonable to you? Do you have any questions or concerns?”

Further reading

• Geeky Medics — Peripheral vascular exam
• NICE CKS — Peripheral arterial disease
• RCEMLearning — Acute limb ischaemia
• NICE NG156 — abdominal aortic aneurysm
• RCEMLearning — Aortic dissection
• Geeky Medics — Varicose veins
• NICE CG147 — peripheral arterial disease

Acute testicular pain: consider torsion promptly and obtain urgent surgical/urological review when suspected. No isolated examination sign safely excludes it; investigations must not delay urgent treatment.

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to conduct an examination of your genitourinary system. This will involve me examining your abdomen, groin, scrotum and penis. I will explain each step. Is that all right with you?”

“I can arrange a trained chaperone and explain their role. What would help you feel comfortable?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

“I will close the curtains to ensure privacy and wait outside to allow you to undress from the waist. There is a blanket you can use to cover yourself.“

Brief history

“Can you briefly tell me why you have come to hospital?”

General inspection

“I am looking at the patient for signs of…”

• pain
• gait (if seen walking)

Abdominal examination

“Now I need to examine your abdomen. Are you ok to lie flat? If at any time you are in pain or want me to stop let me know…”

At patients level, keep looking at the patient

Inspection

• Closer inspection, particularly left flank

Palpation

• Ask where it hurts, start away from the pain and palpate gently, then more deeply if appropriate, for tenderness, guarding and masses
• Organs: liver; spleen; kidney; bladder
• Aorta

Percussion

• Organs: liver; spleen; bladder
• Ascites (shifting dullness)

Auscultation

• Bowel sounds
• Femoral bruits

Testicular/penile examination

“I now need to examine your testicles and penis. Are you happy for me to continue?..”

Testes/scrotum

Inspection

• colour
• swelling
• transillumination

Palpation

• size; shape; consistency; mass
• epididymis
• Assess testicular lie, tenderness and swelling. Prehn’s sign is unreliable for excluding torsion.
• cremasteric reflex (its presence does not rule out torsion)

Penis

• erythema
• vesicles
• ulcers
• urethral discharge: select appropriate STI samples and urine testing according to the history and local protocol

Close

“Thank you. That is the end of the examination”

“In summary my working differential diagnosis is…”

“To complete my examination I would like to do the following investigations/tests…”

“Does that sound reasonable to you? Do you have any questions or concerns?”

Further reading

• NICE CKS — Scrotal pain and swelling
• Geeky Medics — Testicular examination
• NICE CKS — Balanitis
• Geeky Medics — A man with penile swelling
• NICE CKS — UTI: men
• Geeky Medics — Urinalysis
• SAEM — testicular torsion

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“Would you like a chaperone present?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

“I will close the curtains to ensure privacy and wait outside to allow you to undress from the waist. There is a blanket you can use to cover yourself.“

Brief history

Will be scenario dependent. Often the examination is required to remove a retained foreign body (tampon or condom).

“Can you briefly tell me why you have come to hospital?”

“Based on what you have told me you are concerned about retained tampon/condom. Is that correct?”

“Can you tell about: when this happened; and brief gynae history (focus on symptoms; sexual activity; current contraception).”

Plan

Base the examination on the symptoms and likely diagnosis. Explain each proposed part, including possible discomfort, and agree consent. Offer a trained chaperone and accommodate the patient’s preferences where possible; explain that they can stop at any time.

“A speculum would help me look for the retained object. I will explain each step, and we can stop whenever you need. Do you have any concerns before we begin?”

A bimanual examination is a separate, indication-dependent assessment; it is not automatically required before removing a visible retained tampon or condom.

Preparation/Procedure

Prepare

• Assess observations, pain, bleeding, pregnancy possibility and urgent illness first. Examine the abdomen as indicated.
• Prepare an appropriately sized speculum, suitable lubricant, a good light, gloves and appropriate equipment for the planned procedure. Arrange assistance if required.
• Provide privacy, a cover and a comfortable supported position. Agree how the patient will signal that they want to stop.

External and speculum examination

Inspect the external genitalia for relevant lesions, inflammation, discharge or trauma. With renewed permission, gently insert the speculum, open when appropriately positioned and visualise the cervix and vaginal walls. Take indicated samples. Remove a clearly visualised foreign body using suitable forceps only when trained and confident; stop and seek help if removal is difficult or painful. Check for remaining material and remove the speculum carefully, avoiding tissue entrapment.

Bimanual examination, when indicated

Explain and obtain consent separately. Using a gloved, lubricated hand with abdominal palpation, assess cervical motion tenderness, the uterus and adnexa as appropriate. Interpret findings with the history; a reassuring examination does not exclude ectopic pregnancy or other urgent pathology.

“Thank you. I will give you privacy to get dressed, then we can discuss the findings and next steps.”

Discussion

• Retained condom: consider pregnancy testing, emergency contraception and STI assessment according to timing and risk.
• Retained tampon: provide advice about fever, rash, vomiting, diarrhoea, dizziness or feeling very unwell; suspected toxic shock requires urgent assessment.
• Pregnancy-related bleeding or suspected tissue: assess haemodynamic stability, pain and pregnancy location; consider ectopic pregnancy. Arrange urgent gynaecology input for significant bleeding, instability or uncertainty. Agree early pregnancy follow-up and explicit safety-netting when discharge is appropriate.

NICE NG126 — ectopic pregnancy and miscarriage · GMC — intimate examinations

Close

“Do you have any further questions or concerns?”

Further reading

• Geeky Medics — PV exam
• Geeky Medics — Speculum exam
• Geeky Medics — Taking swabs
• NICE CKS — Contraception emergency
• Geeky Medics — Methods of contraception
• Stanford — pelvic examination
• GMC — intimate examinations
• NICE NG126 — ectopic pregnancy and miscarriage

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

"Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

"Are you comfortable? Do you need any pain relief?”

“I have been asked to see you because of a rash, is that correct? I will need to examine this rash, and also look at your mouth, scalp and eyes.”

“Would you like a chaperone present?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Briefly tell me about this rash.”

• Recent medications
• Change in cosmetics/cleaning products
• Illnesses
• Foreign travel
• Systemic symptoms

General inspection

“In terms of general inspection I am assessing…”

Patient’s appearance

• level of comfort
• location of rash: symmetrical or extremities

Observations

• BP
• Resp Rate
• Sats
• Temperature
• Blood glucose

Closer inspection

Describe site and distribution, number, size, shape, colour, surface and lesion type (for example macule, papule, plaque, vesicle or pustule). Assess blanching where relevant. Look for mucosal involvement, tenderness, warmth and systemic illness, taking skin tone into account.

Inspect hair, scalp, eyes, mouth and lymph nodes as indicated. Explain any need to examine other areas and obtain consent. The history mnemonic in Chapter 3 supports the history; it does not replace a morphological description.

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the appearance, distribution, relevant history and working diagnosis. Choose treatment for that diagnosis and its severity, rather than automatically prescribing steroids for dryness, antihistamines for itch or antibiotics for an “infected” rash.

For suspected secondary bacterial infection of eczema in someone who is not systemically unwell, NICE advises against routinely offering topical or oral antibiotics. Systemic illness, rapidly progressive pain, blistering or mucosal involvement needs prompt assessment for a serious cause.

NICE NG190 — infected eczema and antibiotics

Further reading

• Geeky Medics — Examining skin lesions
• NICE CKS — Skin lump
• Geeky Medics — Dermatological emergencies
• DermNet — DermnetNZ
• NICE NG190 — infected eczema