Chapter 6 – System examination stations

“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 or a drink?”

“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 can you take your top off?”

“I will ensure the bed is at 45 degrees” 

“I will talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

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

“I am looking at the…”

“I am looking for…”

• Carotid pulse: “I am going to feel the pulses in your neck in turn to assess their quality”
• Jugular venous pressure:
  • “I will ensure you are at 45 degrees.
  • Please turn your head to the left and relax head on the pillow.
  • I am going to press on the upper right side of your abdomen to elicit the hepato-jugular reflex.
  • I am measuring the number of centimetres it is from the sternal angle.”

“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

Inspection: “I have already commented on.”

“I am palpating…”

• the central capilliary refill time
• the apex beat – 5^th intercostal space; 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)

“Please can you…”

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

“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?”

“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 or a drink?”

“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 can you take your top off?”

“I will ensure the bed is at 45 degrees” 

“I will talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

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

“I am looking at the…”

“I am looking for…”

• Jugular venous pressure:
  • “I will ensure you are at 45 degrees.
  • Please turn your head to the left and relax head on the pillow.
  • I am going to press on the upper right side of your abdomen to elicit the hepato-jugular reflex.
  • I am measuring the number of centimetres it is from the sternal angle.”
• 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.

“I am looking…”

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

“I am looking at the front, sides and then back of the chest…”

“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,
  • arterial blood gas (if low oxygen saturations)
  • sputum sample
  • blood tests (state which ones) 

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

“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 or a drink?”

“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 can you take your top off?”

“I will ensure the bed is at 45 degrees” 

“I will talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

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

“I am looking at the…”

“I am looking for evidence of…”

• conjunctival pallor (“Please look up I will gently lower your bottom eye lids.”)
• cngular stomatitis of lips 
• cral 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.”)

“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.”

“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 the the axilla; groin;  the hernial orifices; perform a rectal examination and testicular exam (male patients)
• Obtain a
  • urinalysis
  • chest x-ray/abdominal x-ray/CT scan
  • blood tests (state which ones) 

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

“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 or a drink?”

“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 ensure the bed is at 45 degrees” 

“I will talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

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

“Which hand do you write with?”

“Any trauma?”

“Any hobbies?”

“Are you currently working?”

“I am looking at the…”

“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.”

“I need to assess how strong you are by asking you to do some movements…”

Test the different muscle groups

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

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

“I will assess the different modalities of all dermatomes 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

“I need to assess your reflexes, I will use the tendon hammer to assess them…”

“Try and relax your arm, I am going to…”

• tap in the crook of your elbow (biceps: C5-6)) 
• tap on your lower arm just above your wrist on the side where the thumb is (brachioradialis: C6-7)
• to support your arm by interlocking my fingers with yours allowing your elbow to hang down, and tap just above the elbow (triceps: C7-C8)

“I need to assess your co-ordination…”

• With your index finger can you touch your nose and then my finger? Keep going back and forth and try to keep following my finger. I will keep my finger still. Please continue with your eyes closed (finger-nose).
• Close your eyes and extend your arms up to the ceiling, palms up and keep them there (pronator drift).
• Can you place your hand into your palm and then move your hand back to front as quickly as you can. Please repeat on the other side (dysdiadochokinesia).

“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?”

“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 or a drink?”

“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 talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

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

“Any trauma?”

“Any hobbies?”

“Are you currently working?”

“I am looking at the…”

“Please sit on the couch with legs out in front of you, I am going to move your legs to look at the tone. I will…”

• roll your legs then ankles (independently) side to side.
• briskly lift your knees up (from underneath) (whole distal leg rises suggests hypertonia).
• briskly lift your ankle up (ankle dorsiflexion) to look for clonus (greater than 5 beats is abnormal).

“I need to assess how strong you are in your legs…”

Test the different muscle groups

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

Demonstrate sensation elsewhere first.

Legs in ‘anatomical’ position’

“I will assess the different modalities of all dermatomes 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

“I need to assess your reflexes, I will use the tendon hammer to assess them…”

“Try and relax your arm, I am going to…”

• tap just below your knee (patella reflex: L3/4).
• to move rotate your foot out and tap the back of your heel (ankle reflex: S1/2).
• tickle the bottom of your feet (plantar response) (Extension = Babinski’s sign = upper motor neurone lesion).

“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, and then closed (repeat on other side).

“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?”

“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 or a drink?”

“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 talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

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

“I am looking at the…”

You may want to clarify aspects of the required exmaintion with the examiner. These are hughlighted in blue

“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?”

“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 or a drink?”

“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 talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

“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?”

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?”

• 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

“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
• Please stand here at a distance of six metres from the chart
• Close one eye, read lowest line possible, then change side

Visual acuity(V/A) = 6/number of line achieved

Near vision  

Examiner: would you like me to assess near vision by asking the patient to read a sentence from a book?

Colour vision                                                                                            

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

“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 6 quadrants)…”

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

“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.”

“I would do this in a dark room, having dilated the pupils with a short acting drop like 1% tropicamide. I will have informed the patient that they cannot drive until their vision is back to normal.”                 

I am examining the:

• Red reflex                                                                                                                                 
• Retina (start lateral, find a vessel and move in), paying particular attention to:
  • Optic disc (normal cup/disc ratio 0.3)                                                                                      
  • Retinal vessels (tortuous; nipping; neovascularisation; haemorrhage) 
  • Macula (“Please look into my light” -cherry red = CRAO, drusen = mac degen

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

“To complete my examination I would like to…”

• perform a slit lamp exam, 
• check intraoccular pressures,
• a full cranial nerve examination,
• assess for risk factors for GCA and investigate as needed

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

“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 or a drink?”

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

“I will talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

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

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

“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.”

“Lastly I would like to…”

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

“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?”

“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 or a drink?”

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 talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

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

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

“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?”

“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 or a drink?”

“I have been asked to conduct an examination of your genitourinary system. This will involve me examining your abdomen; groin; scrotum and penis”

“We will have a chaperone present?”

“I will talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

“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.“

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

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

“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

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

Testes/scrotum

Penis

• erythema
• vesicles
• ulcers
• discharge (if present -swab; urine dip and send for microscop, culture and sensitivity)

“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?”

“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 or a drink?”

“Would you like a chaperone present?”

“I will talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

“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.“

Will be scenario dependant. Often the examination is required to remove a retained foreign body (tampn 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).”

Will be scenario dependant.

“I think what we need to do is try to remove…”

“This will involve me examining your abdomen for any pain and then an internal examination, which will involve my firstly the placing two fingers in your vagina and pressing on your abdomen to assess whether there is any tenderness, followed by the use a speculum to help visualise and remove…”

“Have you understood what I have said, or is there anything you want to clarify or go over again?”

“I will ensure you are in a private room and a female chaperone will be present.”

“If at any time you want to stop or you are in pain please let me know.”

“Do you wish to continue with the 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…”

Wash hands and put on gloves and apron

“Well done, it has been removed. Are you ok?”

“I will give you some privacy to get changed and then there are a couple of things we need to discuss.”

Will depend on the scenario:

• Retained condom: discussion around: STI screens; emergency contraception.
• Retained tampon: requires safety netting around toxic shock syndrome.
• Retained clot/products in suspected miscarriage:
  • Fit for discharge: arranging early pregnancy unit follow up and safety net.
  • Needs admission/further treatment: manage haemorrhage and urgent referral.

“Do you have any further questions or concerns?”

“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 or a drink?”

“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 talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

“Briefly tell me about this rash.”

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

“I will need to examine your rash…”

• Describe characteristics of rash using SOCRATES (see Chapter 3)
• Examines: hair; eyes; mouth; lymph nodes
• If appropriate comment on the need to examine the genitalia

“Thank you very much the examination is now over.”

“Would you like any help getting changed?”

“In summary my working differential diagnosis is…

“I think we should try, e.g.

• Dry: emollient: weak steroids 
• Itchy: antihistamines 
• Infected: topical fusidic acid; flucloxacillin 

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