Years 1&2/GEC CBM 2013-14 Page 1

CLINICAL SKILLS BOOKLET

Years 1&2 and GEC Community Based
Medicine
2013-2014
Introduction

This booklet of clinical skills for Community Based Medicine should be seen as
a set of building blocks for students to add to in their later clinical years.
The emphasis is on using the IPPA (Inspection, Palpation, Percussion and
Auscultation) approach.
The templates are not comprehensive and the students should be encouraged to
integrate their basic knowledge as they go through each system. It is also
important that students should read relevant chapters in a clinical
examination textbook for more detail.
We want students to develop the skill of trying to make sense of information
they gather. Students are all intelligent young people and should be able to
work out what is going on from first principles in many cases. The aim is for
the student to think about what they are doing why so that when they enter
year 3 they can apply basic skills and knowledge to novel situations.






Years 1&2/GEC CBM 2013-14 Page 2

Abdominal Examination
Wash hands

Introduce self to patient and gain consent

Position the patient correctly lying flat for abdominal examination

Expose the abdomen adequately but preserve patient dignity at phase 1 level this would
be ideally from nipple to knee but in practical terms you should expose the abdomen from
the lower part of the sternum to roughly the level of the top of underpants.

Inspection
Be systematic start by looking from the end of couch comment on:

Nutritional status obese/underweight (how might this affect what you can feel?)
Colour jaundice/pallor

Move onto the hands:

Look for finger clubbing (remember why you would be looking for this what might it
mean?)

Move onto the head:

Look at the sclera for jaundice
Look at the tongue does it look normal? Is it smoother than you would expect? Any
mouth ulcers? If so, what might this mean?

Move onto the abdomen itself:

Look for distension, scars, stomas

Palpation
Examine from the right, ask patient if any pain and start away from site of any pain. Consider
if your hands are warm enough.

Mentally divide the abdomen into the 9 regions as per your anatomy teaching. Palpate in
each region superficial first, then deep. Look at the patient to see if they react to pain or
tense their abdominal muscles in response.

Feel for masses.

Palpate for the liver, spleen and kidneys. Always bear in mind the underlying anatomy.

Percussion
Percuss the liver and spleen and any masses found.

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Auscultation
Using the diaphragm of the stethoscope

Listen to the right of the umbilicus for at least 1 minute for bowel sounds and any other
sounds you may hear.

Thank patient.
Summarise your findings

Cardiovascular Examination
Wash hands

Introduce self to patient and gain consent

Position patient approximately 45 degrees to the horizontal

Expose patient adequately you need to be able to see as much of the chest as possible
but preserving patient dignity. At phase 1 level, a female patient would be allowed to leave a
vest top on but you may have to move this as needed during the examination.

Inspection
Be systematic. Start from the end of the couch. Comment on:

Breathlessness and count respiratory rate (over 30 seconds)
Colour pallor, cyanosis
Ankles for oedema

Move onto the hands:

Look for finger clubbing (what in the CV system might cause this?) and peripheral
cyanosis

Move onto the head:

Look for central cyanosis
Observe neck vessels for raised JVP

Palpation examine from the right
Radial pulse describe rate and rhythm
Measure BP
Palpate the apex beat (describe position)
Palpate ankles for pitting oedema (what might cause this?)

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Percussion
Not necessary at this level
Auscultation
Listen with the diaphragm of the stethoscope over the apex, tricuspid, pulmonary and aortic
areas for approximately 10 seconds to assess the heart sounds.
Listen with the bell of the stethoscope over the apex.
Listen with the diaphragm of the stethoscope to the bases of the lungs.
Thank patient.
Summarise your findings.

Respiratory Examination
Wash hands

Introduce self to patient and gain consent

Position patient approximately 45 degrees to the horizontal

Expose patient adequately you need to be able to see as much of the chest as possible
but preserving patient dignitiy. At phase 1 level, a female patient would be allowed to leave a
vest top on but you may have to move this as needed during the examination.

Inspection
Be systematic. Start from the end of the couch. Comment on:

The patients environment (any inhalers or oxygen cylinders nearby?)
Breathlessness and count respiratory rate (over 30 seconds)
Colour normal, cyanosed, pink
Respiratory effort symmetrical movements, pursed lips, audible wheezing,
accessory muscles, recession
Chest - size and shape, any scars remember to look at the front and the back

Move onto the hands:

Look for finger clubbing (what in the respiratory system might cause this?) and tar
staining

Move onto the head:

Look for central cyanosis



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Palpation
Feel chest movements for symmetry and expansion place hands around the front of the
chest from the ribs and ask them to take a deep breath in and out (keep thumbs free of the
sternum and watch the movement of the thumbs).
Feel for the tracheal location
Percussion
Tapping front of chest comparing one side with the other starting at clavicle and working
down over the upper and middle zones
Tapping back of chest comparing one side with the other over the upper and lower zones.
Listening and feeling for difference normal, hyper-resonant, dull, stony dull

Auscultation
Using the diaphragm of your stethoscope

Listen in the same places as you percussed

Listen for breath sounds vesicular, bronchial, absent

Listen for added noises wheeze, crackles

Thank patient.
Summarise your findings.

Blood pressure measurement
(Input by Dr Panting Consultant Cardiologst)
Practice must supply and student should understand the need for regularly serviced
sphygmomanometer.

Meniscus should be zero if disconnected.

Student should understand the necessity to have a bladder cuff 80% of arm circumference.

Patient should rest for three minutes before blood pressure is measured. Explain to the
patient what to expect.

Student should be less than a foot from instrument.

Students should be able to
Identify the brachial artery.
Place a cuff of appropriate size (80% of arm circumference) in the correct place (2cm
above the point of maximum pulsation of the brachial artery) so that the cuff lies over
the artery. It does not matter if the tubes of the sphygmomanometer are directed up
or down the arm.

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Support the patients arm (e.g. on the table) at the correct height so that the cuff is at
the height of the heart.
Inflate the cuff until the brachial pulse is no longer palpable and then 30 mmHg
higher. (This must be done by palpation to avoid erroneous measurement in the
small number of patients with an auscultatory gap).
Place the diaphragm of the stethoscope over the brachial artery and deflate the cuff
slowly, about 2mm per beat or second
Record the blood pressure using the 1
st
(appearance of sounds) and 5
th

(disappearance of sounds) Korotkov sounds.

Blood pressure should be recorded to the nearest 2 mm Hg (please note on a mercury
spyhgmomanometer the reading will always be in even numbers e.g. 128/72mmHg).
The practice should be supplied with a digital mercury sphygmomanometer. Tutors are
however encouraged to show the students other electronic devices too.
Here is a link from the British Hypertension Society with guidelines on how to measure blood
pressure electronically
http://www.bhsoc.org/files/8413/4390/7770/BP_Measurement_Poster_-_Electronic.pdf
(accessed 30.7.2013)

The Year 2/GEC OSCE BP station will use the digital mercury sphygmomanometers.
Students should practise assembling the cuff and sphygmomanometers and be
familiar with the teaching stethoscopes.

Peak Flow Measurement
Students should be able to use a peak flow meter correctly and demonstrate use of a peak
flow meter to patient.
The student should use a peak flow meter in the following way; all steps are essential
stand up
zero the marker
hold peak flow meter horizontal
inhale fully
enclose the mouthpiece fully with the lips
exhale forcibly without delay through the mouth piece (the exhalation should be as
forceful as possible without excessive straining or coughing)
the reading should be noted and the marker zeroed again
at least three readings should be taken or until the reading is no longer going up (i.e.
training effect is achieved fully)
the reading should be compared with a normogram, allowing for age, gender, and height
and or with the students or patient's previous reading

Peripheral pulses

These are many but first year and second year students should be able to identify the radial
and brachial pulses as described. They should know that if they are uncertain whether they

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are feeling their own or the patient's pulse (particularly likely with the more difficult pulses
and in their early clinical career) that they should feel their own radial pulse simultaneously
using their other hand.

When counting, the student should normally do so for thirty seconds and be able then to
comment on:

rate in beats per minute
rhythm: regular [sinus rhythm], irregular [ectopics], irregularly irregular [AF]

Only rate and a basic description of rhythm are requirements for first and second year
students

Presence or absence of peripheral pulses and the rate and rhythm of the pulse are of
importance for the cardiovascular days.

Radial pulse
Palpate the pulse at the wrist using the tips of the fingers of the right hand. Palpate both
pulses. Use first three fingers of one hand placed at approximately 45 degrees while
supporting the patient's wrist with the other hand.

Brachial pulse
This is usually palpated using the thumb of the same hand i.e. the student's left for the
patient's left etc. It lies just medial to the biceps tendon. Technically more correct is to use
the fingers at the medial side of biceps tendon while supporting elbow with other hand.

Carotid
Palpate with the fingers of the right hand. Place fingers or thumb medial to sterno-mastoid.
Do not palpate both at the same time.

The dorsalis pedis and posterior tibial pulses can be difficult to feel.

Dorsalis pedis
Felt just lateral to the extensor hallucis part way along the dorsal surface of the foot.

Posterior tibial
Can be easily felt by standing at the foot of the couch and simultaneously placing the first
two fingers of both hands behind the medial malleoli, one hand being used for each foot.


Additional resources
Please see below a list of resources from the internet which demonstrate some of the skills
described in this booklet. These are to assist you when you practise your clinical skills.
Reading and seeing the skills demonstrated will not enable you to develop these skills you
must practise at every available opportunity.
Blood pressure
http://www.youtube.com/watch?v=Xhhn08FyImw

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Ok but doesnt check for auscultatory gap and no explanation to patient. Also representation of
sounds poor and unsteady release of air from cuff after 80mmHg. Aneroid rather than mercury
spyphg. Use in conjunction with your clinical skills booklet.
http://www.youtube.com/watch?v=P-hAp6DItkA
Demonstrates checking for auscultatory gap although with radial pulse. This is ok if you are
struggling to find the brachial but do justify why you are doing it. Ignore the last couple of minutes of
dancing and chat!
http://www.bhsoc.org//index.php?cID=162 British Hypertension Society website- useful links on
how to measure BP and further examples of BP readings.

Cardiovascular examination
http://www.youtube.com/watch?v=q_Vap7O-VnI
from macleods more detail than required, use in conjunction with your clinical skills booklet
http://www.youtube.com/watch?v=XiM2fnVDg9A
A lot of detail. Again use in conjunction with your clinical skills booklet to pitch at right level for year
2.
http://www.youtube.com/watch?v=-8Hi1PjZam4
Again in more detail than for year 2 but is a mock up of an OSCE station. At the end also includes a
summary of the findings.
Peripheral pulses
http://www.youtube.com/watch?v=k27S5j48IZw
not great and on a model not a real patient not a lot of anatomical detail
http://www.youtube.com/watch?v=QQIiB51IWMU
Posterior tibial and dorsalis pedis. Where he says distal to the medial malleolus we would say
behind or posterior to the medial malleolus.

Respiratory examination
http://www.youtube.com/watch?v=0rEvNtNjOSs
from macleods more detail than required, use in conjunction with your clinical skills booklet
http://www.youtube.com/watch?v=L19PVsD--KA

Years 1&2/GEC CBM 2013-14 Page 9

an OSCE guide by medical students, again use in conjunction with the clinical skills booklet as you do
not need more detail than given in the booklet
http://www.youtube.com/watch?v=WXhvKwEw3qs
a demonstration of percussion technique, some clinicians would have the fingers closer together on
the hand that is touching the patient.
Peak flow measurement
http://www.youtube.com/watch?v=DxBDfqPmaZU
from asthma UK, simple and clear
Abdominal Examination
http://www.youtube.com/watch?v=gRDeZhOj220
ok, a lot of detail. Level of exposure may not be quite accurate
http://www.youtube.com/watch?v=jqQ4U_DXKf8
from macleods more detail than needed, again use in conjunction with your clinical skills booklet
http://www.youtube.com/watch?v=QO8r_xqamyc
an OSCE guide by medical students. Again use in conjunction with your clinical skills booklet to get
the correct level of detail.