OSCE Tutorials 2014 Handout

Content Outline: Implementation:

I. HEENT a) Extend your arm. Move your fingers into the visual
A. Ophthalmology Examination field. Start from the temporal field.
B. Head and Neck Examination b) Ask the patient to tell you when he/she first spots your
C. Ear examination finger
D. Mouth, Nose, & Throat Examination c) Repeat this pattern in upper and lower temporal
II. Cardio & Skin quadrants
A. Cardio Examination d) Do finger counting in one hand. Do it in all four
B. Skin Examination quadrants. Test at least 2 times per quadrant
III. Respiratory e) Perform simultaneous finger counting
A. Posterior Chest Expansion
B. Tactile Fremitus 3. Ocular Motility
C. Posterior Chest Percussion a) Sit facing the patient. Hold finger at eye level 10-14
D. Chest Auscultation inches in front of the patient. Ask the patient to look
E. Egophony & Whispered Pectoriloquy straight ahead.
IV. Abdominal b) Ask the patient to follow your finger as you move
A. General Approach target into 6 cardinal fields and up and down along
B. Inspection midline. Elevate upper lid with finger on your free
C. Auscultation & Percussion hand to observe down gaze
D. Percussion of Liver Size c) Note any nystagmus.
E. Percussion for Ascites
F. Palpation 4. Digital Tonometry
G. Goldflam Test a) Instruct the patient to look down (NOT TO CLOSE
H. Other Special Maneuvers THE EYES). Examiner rests forefingers of both hands
V. Surgical on superior aspect of the patients right globe.
A. Axilla Examination b) May rest other fingers gently on patients forehead
B. Breast Examination c) Examiner gently and alternately depress both
C. Rectal Examination forefingers on the globe while assessing tone
D. Nasogastric Tube Insertion d) Repeat procedure in other eye
E. Male Urethral Catheterization
F. Female Urethral Catheterization
5. Direct Fundoscopy
G. Basic Suturing
a) Darken room. Shine the light at the back of your hands.
H. Two Hand Surgical Knot
Change it to the smallest size, colored yellow.
I. One Hand Surgical Knot
b) Turn lens disc to 0 diopter.
J. Instrument Knot Tying
c) Hold ophthalmoscope in your Right hand to examine
VI. Neurological
Right Eye, vice versa
A. Cranial Nerve Assessment: I, V, VII, IX, X, XI, XII
d) Instruct patient to stare into a distant target
B. Motor Examination
e) Check patients ROR at 15 inches. Approach the patient
C. Sensory Examination
slowly. Steady instrument by resting ulnar border of
D. Reflex Examination
the hand against patients cheek, while the thumb of
E. Cerebellar Examination
free hand raises the upper eyelid
F. Meningeal Examination
f) Dial ophthalmoscope focusing lens to clarify fundus
image.
g) Angle the ophthalmoscope 15 temporal to fixation
I. HEENT EXAMINATION h) Locate optic disc, by following a retinal blood vessel.
A. OPHTHALMOLOGIC EXAMINATION Assess cup to disc ratio.
1. Pupillary Examination h) Examine surrounding of optic disc
a) Dim light, ask the patient to fixate on a distant target i) Examine macular area
b) Shine penlight directly into eye (from side or below) j) Examine other eye
.
directly into the light B. HEAD AND NECK EXAMINATION
c) Observe direct pupillary response 1. Head Examination
d) Repeat procedure a-c in other eye a) Explain the procedure to the patient.
b) Inspect and examine the hair, scalp, skull, and face.
2. Visual Field Examination
c) Check for abnormalities in turgor & color. Check also
Confrontation
for signs of edema & inappropriate facies.
Set-up:
d) Palpate lymph nodes starting from the pre-auricular
a) Position the patient. Occlude the eye not being tested
nodes, all the way upwards and around the ear till the
b) Seat yourself facing the patient at a distance of 1 meter.
subclavicular nodes
Close the eye directly opposite the patient.
c) Ask the patient to fixate on your nose.

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2. Neck Examination
a) Explain the procedure to the patient.
b) Inspect and palpate the cervical lymph nodes.
c) Note any masses or unusual pulsations in the neck.
d) Feel for any deviation of the trachea.
e) Observe sound and effort of the patients breathing.
f) Inspect and palpate the thyroid gland.
Palpation of the Thyroid Gland
Objective: Demonstrate the anterior approach in palpating
the Thyroid gland.
1. Explain the procedure.
2. Inspect the anterior neck area
3. Ask patient to flex neck slightly forward (to relax SCM)
4. Place fingers of both hands on patients neck (index
finger just below cricoid cartilage)
5. Ask patient to swallow
6. Feel for thyroid isthmus and lateral lobes
7. Take note of the following:
a. Size
b. Shape
c. Consistency of gland
C. EAR EXAMINATION
1. Otoscopy
a) Explain the procedure to the patient.
b) Ask the patient which is the affected ear. Do otoscopy
first on the unaffected ear.
c) Use the largest possible speculum. (A larger speculum
will allow you to visualize the tympanic membrane
better.)
d) Using your thumb and index finger pull the ear of the
adult backwards and upwards (if the patient is a child,
pull the pinna backwards and downwards)
e) Insert the speculum 14 to 12 inch into the canal.
f) First find the landmarks.
g) Do the procedure on the affected ear
2. Weber Test
a) Explain the procedure to the patient.
b) Using the base of the tines, strike the thenar eminence.
c) Place the tuning fork in the midline of the head.
(Vertex, glabella, chin or bridge of nose).
d) Ask the patient if the sound is louder on one side or is
heard midline.
3. Rinne Test
a) Explain the procedure to the patient.
b) Using the base of the tines, strike the thenar eminence.
c) Place the vibrating tuning fork near the ear canal then
on the mastoid process.
d) Ask the patient whether the sound is louder when the
tuning fork is by the canal or on the mastoid process
e) If it is Rinne negative and Rinne equal, Rinne
threshold testing must be done
D. MOUTH, NOSE, & THROAT EXAMINATION
1. Oral Cavity and Oropharyngeal Examination
a) Explain the procedure to the patient.
b) Focus head mirror properly.
c) Inspect lips, gingiva, tongue, & sublingual area using
tongue depressor.
d) Depress the anterior two thirds of the tongue and
instructs the patient to say Aah.
e) Visualize the oropharyngeal structures.
2. Anterior Rhinoscopy
a) Explain the procedure to the patient.
b) Focus head mirror properly.
c) Hold nasal speculum properly with the non-dominant
hand.
d) Insert nasal speculum gently.
e) Open the blades of nasal speculum gently.
f)Withdraw nasal speculum with the blades partially
open.
3. Posterior Rhinoscopy
a) Explain the procedure to the patient.
b) Focus head mirror properly.
c) Depress middle third of the tongue.
d) Warm the mirror.
e) Ask the patient to breathe through the nose.
f) Rotate the mirror behind the soft palate.
4. Indirect Laryngoscopy
a) Explain the procedure to the patient.
b) Focus head mirror properly.
c) Instruct the patient to stick out tongue.
d) Hold the tongue using gauze.
e) Instruct the patient to breathe through the mouth.
f) Hold the laryngeal mirror like a pencil.
g) Warm the laryngeal mirror on buccal mucosa or light
source.
h) Introduce the mirror through the side of the mouth.
i) Instruct the patient to say E.
II. CARDIO & SKIN EXAMINATION
A. CARDIO EXAMINATION
1. Inspection
Observe the chest and note deviations such as barrel
chest, obesity, visible thrills, & dynamic precordium
2. BP determination
a) Explain the procedures to the patient
b) Correctly apply the BP bladder over the brachial artery
c) Check the tightness of the cuff. Make sure 2 fingers can
fit between the cuff and the arm.
d) Acquire palpatory BP. Then, manometer is deflated.
e) Reinflate the manometer, take the auscultatory BP
(inflates cuff to 20-30mmHg above the obtained palpatory
BP)
f) Deflate the manometer at around 3 mmHg/beat.
g) Report the acquired BP.
3. Apex Beat
a) Explain the procedure briefly to the subject
b) Expose the anterior chest
c) Inspect the precordium
d) Use the palmar aspect of the hand to look for the most
lateral impulse
e) Use 1 finger to determine the amplitude of the impulse
f) Identify the Apex beat
4. Carotid Pulse
a) Make sure patient is lying down with the head of the
bed elevated to about 30 degrees
b) Inspect neck for carotid pulsations
c) Place left index and middle finger on the right carotid
artery at the lower third of the neck, and feel for
pulsations
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 d) Slowly increase pressure until maximal pulsation is B. TACTILE FREMITUS
felt. Slowly decrease pressure until best sense of arterial
pressure is felt.

5. Auscultation
a) Make sure patient is relaxed in a supine position
b) Use the diaphragm of the stethoscope to listen
throughout the precordium
c) Auscultate the Aortic Region (between the 2nd, 3rd ICS
@ the right sternal border)
d) Auscultate the Pulmonic Region (between the 2nd and
3rd intercostal spaces at the left sternal border)
e) Auscultate the Tricuspid Region (between the 3rd, 4th,
5th, and 6th intercostal spaces at the left sternal border) 1. Use either the ball (the bony part of the palm at the base of
f) Auscultate the Mitral Region (near the apex of the the fingers) or the ulnar surface of your hand
heard between the 5th and 6th intercostal spaces in the 2. Ask the patient to repeat the words ninety-nine or one-
mid-clavicular line) one-one.
3. Identify and locate any areas of increased, decreased, or
6. Jugular Venous Pressure absent fremitus (comparing both sides).
a) Explain briefly what is to be done
b) Patient is positioned on a 30 degree angle or greater. C. POSTERIOR CHEST PERCUSSION
c) Turn the patients head away from himself/herself
d) Locate the internal jugular vein by using tangential
lighting. After which, locate the highest point of pulsation
in the internal jugular vein
e) Place the ruler correctly at the sternal angle
f) Place a rectangular object making a 90 degree angle
with the ruler and make a horizontal line resting on top of
the jugular pulsation
g) Read the vertical distance and report the findings
measured in centimeters.

B. Skin Examination
1. Explain briefly what is to be done
2. Report on the following skin characteristics:
a) Color
b) Turgor
c) Texture
d) Warmth
3. Describe:
a) Primary skin lesions
b) Presence or absence of secondary skin lesions
c) Nail beds (as to color , shape, presence of clubbing or
cyanosis)
d) Color , quantity, distribution of hair
e) Presence of mass, pigmentation, lesions on scalp
III. RESPIRATORY EXAMINATION
A. POSTERIOR CHEST EXPANSION
1. Explain briefly to the subject what is to be done
2. Adequately expose the posterior chest wall. Drape
accordingly.
3. Ask subject to cross arms and hold shoulders
4. Place thumbs at the level of the 10th ribs, with fingers
loosely grasping and parallel to the lateral rib cage.
5. Position hands then slide them medially just enough to raise
a loose fold of skin on each side between the thumb and the
spine.
6. Ask the patient to inhale deeply and exhale slowly.
7. Report physical findings.
1. Explain briefly to the subject what is to be done
2. Adequately expose the posterior chest wall
3. Ask subject to cross arms and hold shoulders
4. Percussion: hyperextend middle finger of non-
dominant hand (pleximeter)
5. Place the distal interphalangeal joint on the surface in
between ribs running parallel to the axis of ICS
6. Avoid surface contact by any other part of the hand
7. Plexor of the dominant hand strikes the pleximeter
8. Report character of sound (normal = resonant)
D. CHEST AUSCULTATION
1. Explain briefly what is to be done
2. Properly apply stethoscope on the chest wall
3. Instruct patient to take deep breaths (inhale-exhale)
with mouth open
4. Listen to the different areas systematically
5. Report on breath sounds
a) Character (bronchial, vesicular, bronchovesicular)
b) Intensity (equal, unequal, decrease or increase in
certain lung fields)
E. EGOPHONY & WHISPERED PECTORILOQUY
1. Explain briefly what is to be done.
2. Properly apply stethoscope on the chest wall
3. Instruct patient to say eee while auscultating different
areas of the thorax (egophony)
4. Instruct patient to whisper ninety-nine/one-two-
three/bluemoon while auscultating different areas of the
thorax (whispered pectoriloquy)

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IV. ABDOMINAL EXAMINATION
A. GENERAL APPROACH
1. Have the patient lie supine on examination table with arms
at side or folded across chest. Put legs up.
2. Stand to the patients right
3. Undrape the abdomen from the symphysis pubis to just
above the xiphoid process. Bring sheet up from below to cover
the patient below the waist, then bring the gown up to the
xiphoid process. Remember, patient privacy is to be respected
at all times.
B. INSPECTION
Systematically inspect all four quadrants and epigastric area,
noting the following:
1. Skin (scars, rashes, lesions, caput, venous dilatation,
spider angiomata see your physical diagnosis text for
descriptions).
2. Contour of the central abdomen (Flat, rounded,
protuberant, distended or scaphoid).
3. Symmetry (or lack thereof due to masses or organ
enlargement causing a focal protuberance).
4. Visible pulsations (Particularly aortic pulsations in the
upper abdomen)
6. Conclude examination by measuring liver edge at the
midclavicular line
E. PERCUSSION FOR ASCITES
1. Introduce self to patient
2. Explain briefly what is to be done on the patient
3. With patient lying supine, expose the abdomen
4. Ask the patient to bend his/her knees and place his/her
hands on the sides or on the chest
5. Test for:
a) Shifting dullness
1) While patient is supine, map the borders of
tympany and dullness on the patients abdomen
2) Ask patient to turn to 1 side and mark borders
again
b) Fluid wave
1) Ask patient or an assistant to press the edges of
both hands firmly down the midline of the abdomen
2) While examiner taps one flank sharply with
his/her fingertips, the other hand feels on the
opposite flank for an impulse transmitted through
the fluid.
6. Cover the patient
7. Thank the patient

C. AUSCULTATION AND PERCUSSION

F. PALPATION
1. Auscultate 4 quadrants with the stethoscope
1. Palpate each quadrant of the abdomen lightly to detect
diaphragm
tenderness, muscular spasm, or rigidity, pulsatile mass
2. Describe character (e.g., high pitched, tinkling, rushes,
(aortic aneurysm)
rumbling) - The term borborygmi (rumbling, gurgling,
2. Palpate each quadrant of the abdomen deeply, noting any
tinkling noises heard on auscultation of the abdomen in
of the following: tenderness, masses, pulsations, palpable
conditions of increased intestinal peristalsis) is sometimes
bowel loops, rushes or movement. Try to examine with the
used.
patients respiratory flow, and be sure to palpate tender
3. Listen in the midepigastrum for abdominal aortic
areas last (and gently).
bruits.
3. Identify the bottom edge of the liver. Begin palpating
4. Listen on the left and right sides of the epigastrium for
below the lower edge identified by percussion, and work
renal artery bruits.
your way superiorly. Scratch test is acceptable. Remember,
5. Listen over the femoral arteries for femoral bruits.
the right lobe of the liver comes down lower than the left
6. Percuss the four quadrants of the abdomen. (This will
lobe.
be painful if the peritoneum is irritated). Describe if it is
4. Palpating the spleen: Normally the spleen is not palpable.
tympanitic or dull.
A good screen is to percuss along the left side of the
7. Percuss over the suprapubic area. (This will be dull if
abdomen. If no dullness is noted, the spleen is unlikely to be
bladder is distended).
enlarged. To confirm your findings, palpate the left upper
quadrant deeply in both the supine position, and with the
D. PERCUSSION OF LIVER SIZE
patient resting on his/her right side.
1. Explain briefly to patient what is to be done
2. With the patient lying supine, expose the abdomen and G. Goldflam Test
ask the patient to bend both knees and place hands on the 1. Explain to patient what is to be done
side. 2. Expose patients back
3. Identify RMCL 3. Put non-dominant hand, palm down over the
4. Percuss to identify the upper border of the liver by costovertebral angle, both left and right (Correct location is
starting from the 2nd ICS proceeding inferiorly until important)
percussion note changes from resonance to dullness 4. Deliver a blow with fist (ulnar surface of fist) upon the
5. Determine the lower edge (2 alternatives: should be able dorsum of hand
to perform at least 1) 5. Note presence or absence of pain
a) Palpation 6. Cover patients back
1) Palpate the abdomen beginning from the level of 7. Thank patient
the iliac crest, asking the patient to take deep breaths
2) Palpation proceeds upwards until lower liver edge
H. OTHER SPECIAL MANEUVERS
is palpated.
1. Murphys Sign:
It is performed by asking the patient to breathe in and
b) Percussion
then gently placing the hand below the costal margin
Begin percussing from the level of the iliac crest
on the right side at the mid-clavicular line (the
proceeding superiorly until percussion note changes
approximate location of the gallbladder). The patient is
from tympany to dullness

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 then instructed to inspire (breathe in). Normally,
during inspiration, the abdominal contents are pushed
downward as the diaphragm moves down (and lungs
expand). If the patient stops breathing in (as the
gallbladder is tender and, in moving downward, comes
in contact with the examiner's fingers) and winces with
a 'catch' in breath, the test is considered positive.
A positive test also requires no pain on performing the
maneuver on the patient's left hand side.
2. Rovsings Sign
Also known as indirect tenderness. The sign is positive
when pressure applied to the left lower quadrant
results in right lower quadrant pain. Positive for
appendicitis.
3. Psoas Sign
Principle: stretch of pelvic musculature (iliopsoas
muscle) will elicit pain. Roll the patient on their left side
and hyperextend the right hip. Pain with extension is a
positive sign.
4. Obturator Sign
Principle: same as psoas sign. The examiner flexes the
patients right hip and internally rotates the right hip.
Pain with internal rotation is a positive sign.
5. Rebound Tenderness
The clinician maintains hand pressure over an area of
tenderness. The clinician then releases the hand
pressure suddenly. Pain denotes a positive test.
V. SURGICAL EXAMINATIONS & PROCEDURES
A. AXILLA EXAMINATION
1. Introduce self to patient
2. Explain briefly to the patient what is to be done
3. Ask permission to expose patient
4. Inspect skin of each axilla (use left hand to palpate right
axilla and vice versa; fingers must lie directly behind
pectoral ms. pointing toward midclavicle)
5. Palpate axillary nodes
a) central axillary
b) pectoral
c) lateral
d) subscapular
6. Ask patient to put on robe
7. Report assessment to patient, say thank you.
B. BREAST EXAMINATION
1. Inspect the breasts in four positions. (Arms at sides, arms
over head, hands pressed against hips, leaning forward).
Note for size and symmetry, contour, and appearance of
the skin.
2. Inspect the nipples. Compare size, shape, and direction
of pointing (e.g. inversion, retraction, and deviation). Also
note any rashes, ulcerations or discharge.
3. Palpate the breasts, including augment4ed breasts. Breast
tissue should be flattened and the patient supine. Palpate a
rectangular area extending from the clavicle to the
inframammary fold or bra line, and from the midsternal line
to the posterior axillary line and well into the axilla for the
tail of Spence. Note consistency, and tenderness, and
nodules.
4. Use vertical strip pattern (currently the best validated
technique) or a circular or wedge pattern. Palpate in small,
concentric circles.
5. For the lateral portion of the breast, ask the patient to roll
onto the opposite hip, place her hand on her forehead, but
keep shoulders pressed against the bed or examining table.
(see image below)
6. For the medial portion of the breast, ask the patient to lie
with her shoulders flat against the bed or examining table,
place her hand at her neck, and lift up her elbow until it is
even with her shoulder.
7. Palpate each nipple. Palpate and inspect along the
incision lines of mastectomy.
C. RECTAL EXAMINATION
You can omit it in examination of adolescent but the risk
of missing an asymptomatic carcinoma in middle-aged
and older persons necessitates performance in the said
age groups.
The examination requires GENTLENESS, SLOW
MOVEMENT OF A FINGER, CALM DEMEANOR, and
an explanation to the patient what he or she may feel.
Procedure:
1. You can use many position for the patient but the side-
lying position is satisfactory and allows good views of the
perianal and sacrococcygeal areas. Ask the patient to lie
on his left side with his buttocks close to the edge of the
table near you. Flex the patients hips and knees
especially the top leg to stabilize the patient position and
visibility.
2. Drape the patient appropriately and adjust the light for
the best view.
3. Glove your hand and spread the buttocks apart.
4. Inspect the sacrococcygeal and perianal areas for
lumps, ulcers, inflammation, rashes, or excoriations.
Palpate any abnormal areas, noting lumps or tenderness.
warts, herpes, syphilitic chancre, and carcinoma. A
perianal abscess produces a painful, tender, indurated,
and reddened mass. Pruritus ani causes swollen,
thickened, fissured skin with excoriations.
5. Examine the anus and rectum. Lubricate your gloved
index finger, explain to the patient what you are about to
do, and tell him that some discomfort will be felt. Ask the
patient to strain and place the pad of your lubricated and
gloved index finger over the anus. As the sphincter
relaxes, gently insert your fingertip into the canal
pointing into the umbilicus.
6. If you feel the sphincter tighten, pause and reassure the
patient. When in a moment the sphincter relaxes, proceed.
Occasionally, severe tenderness prevents you from
further examination. Do not force it and instead, place
your fingers on both sides of the anus, gently spread the
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 orifice, and ask the patient to strain down. Look for a
lesion, especially anal fissure which might cause the
tenderness.
7. If you can proceed without undue discomfort, note:
a) Sphincter tone of the anus. Normally, the muscles
of the anal sphincter close snugly around your finger.
b) Note: Sphincter tightness in anxiety (thats why you
have to make your patient relaxed first before going
on with the procedure), inflammation, or scarring; laxity
in some neurologic diseases.
c) Tenderness, if any
d) Induration
e) Note: Induration may be due to inflammation,
scarring or malignancy.
f) Irregularities or nodules
8. Insert your finger to the rectum as far as possible.
Rotate your hand clockwise to palpate as much as of the
rectal surface on the right side.
9. Rotate your hand counter clockwise to palpate the
surface posteriorly and on the patients left side.
10. Note any nodules, irregularities, or induration. To
bring a possible lesion into reach, take your finger off the
rectal surface, ask the patient to strain down, and palpate
again.
11. Rotate your hand further counter clockwise so that
your finger can examine the posterior surface of the prostate
gland. You can do it by turning your body somewhat
away from the patient. This will make the patient feels
like urinating but ask him he will not do so. Sweep your
finger over the prostate gland, identifying its lateral lobes
and median sulcus between them. Note the size, shape,
and consistency of the prostrate and identify any nodules
or tenderness. Normal prostate is rubbery and nontender.
12. If possible, extend your finger above the prostate to
the region of the seminal vesicles and peritoneal cavity.
Note nodules or tenderness.
13. Gently withdraw your finger, wipe the patients anus
or give him tissues to do it himself. Note the color of any
fecal matter on your glove, and test it for occult blood.
gastrointestinal bleeding and lower gastrointestinal
bleeding, respectively.
14. Give the patient back his clothes, explain that the
procedure is over and thank the patient.
D. NASOGASTRIC TUBE INSERTION
A plastic tube is inserted through the nose, down the back
of the throat, oesophagus and into the stomach.
The bore of the tube (large = 16, medium = 12, small = 10)
is dictated by the tubes intended purpose. For short- or
medium-term nutritional support in those with a defective
swallow, a fine-bore tube is used. Larger bores are used to
drain the stomach contents and decompress intestinal
obstruction.
Contraindications: severe facial trauma and basal skull
fractures.
Complications: aspiration, tissue trauma, electrolyte loss,
tracheal or duodenal intubation, perforation of oesophagus
or stomach.
Procedure:
1. Introduce yourself, confirm the patient's identity, explain
the procedure, and obtain verbal consent.
2. Wash hands thoroughly, put on gloves and plastic apron.
3. Ideally, the patient should be seated upright (often the
head tilted slightly forwards can aid insertion).
4. Examine patient's nose for deformity/obstructions and
decide which nostril to use.
5. Use the tube to measure the distance xiphisternum,
earlobe, tip of nose and note the distance.
6. Lubricate the first 4-8cm of tube. You may also wish to
use local anaesthetic spray on patient's throat if available.
7. Pass the tube into the nostril, and then posteriorly, a short
distance at a time. You will feel it turn the corner at the
nasopharynx and another slight obstruction as it passes into
the oesophagus.
8. If the patient is able, they should be asked to swallow as
the tube passes the pharynx a brief sip of water may help
here.
9. Advance the tube as far as the pre-measured distance.
10. To check for correct placement, you may wish to aspirate
some stomach contents with the syringe and test the fluid's
pH (should be <6).
11. Secure the tube to the patient's nose with some tape, you
may also wish to curl it back over their ear and secure it to
their cheek.
12. Request a CXR and confirm the tube's position (below
diaphragm in the region of the gastric bubble) before using
for feeding.
13. Once the position is confirmed, remove the central
guidewire before use and save this (use a plastic page-file
and file in the nursing notes).
14. Ensure that you record the procedure in the patient's
notes.
Hints
Never force.
pre-freezing the tube can ease its passage.
of air (20-30ml) down the tube using the syringe whilst
listening to the epigastrium with the stethoscope. You should
hear the air entering the stomach. (NB This technique is no
longer considered appropriate in the UK and health care
workers are advised against using it).
E. MALE URETHRAL CATHETERIZATION
A urinary catheter has a balloon near the tip which is
inflated via a sidearm near the other end. Once inside the
bladder, the inflated balloon prevents it falling or being
pulled out.
Procedure:
1. Wash hands thoroughly. Confirm the patient's identity,
explain procedure, and obtain verbal consent.
2. Unwrap all the equipment onto a trolley in an aseptic
fashion and pour saline solution over the cotton balls.
3. Position the patient supine with genitalia exposed. Raise
bed to a comfortable height.
4. Wash hands again and put gloves on. Create a hole in the
centre of the towel and drape over the patient so the penis
can be reached through the hole.
5. From here on, use your non-dominant hand to hold the
penis with some gauze.
6. Clean the penis with the wet cotton balls, working away
from the meatus. Remember to retract the foreskin and
clean beneath.
7. Lift penis to a vertical position, carefully position the
nozzle of the lubricant gel inside the meatus and instill the
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 full 10ml slowly. (If proving problematic, can be aided by
gentle milking action.)
8. Position the kidney bowl between the patient's thighs to
catch spillages later.
9. The catheter will be in a plastic wrapper with a tear-away
portion near the tip. Remove this portion, being careful not
to touch the catheter.
10. Insert the tip of the catheter into the urethral meatus and
advance slowly but firmly by feeding it out of the remaining
wrapper.
11. On passing through the prostate, some resistance may be
felt which, if excessive, may be countered by adjusting the
angle of the penis by pulling it to a horizontal position
between the patient's legs.
12. On entering the bladder, urine should start to drain.
Advance the catheter to the hilt to ensure the balloon is
beyond the urethra.
13. Inflate the balloon with the 10ml of saline via the
catheter side-arm. Warn the patient to alert you to any pain
and watch his face.
14. Remove the syringe and withdraw catheter until
resistance is felt.
15. Attach draining tube and catheter bag.
16. Replace the foreskin, clean and redress the patient as
necessary.
Hints
You may wish to verify the presence of a full bladder with
a bladder-scanner before starting.
Lack of urine drainage may be caused by: blockage of gel,
empty bladder or catheter misplacement.
Attempt to aspirate urine using a catheter-tipped syringe.
Feel for a full bladder. If there is any doubt about the
position of the catheter, remove immediately (deflating
balloon first) and seek senior advice.
Always record the residual volume. This is essential in
cases of urinary retention.
Consider the use of prophylactic antibiotics before the
procedure.
Complications: pain, infection, misplacement and trauma.
Patients with prostate disease can often experience some
mild hematuria following catheterization. Don't worry but
watch carefully and be sure the bleeding doesn't continue
or form into clots.
Beware latex allergy!
F. FEMALE URETHRAL CATHETERIZATION
A urinary catheter has a balloon near the tip which is
inflated via a side-arm near the other end. Once inside the
bladder, the inflated balloon prevents it falling or being
pulled out.
Bear in mind that nurses tend to catheterize females if they
are able so if a doctor is asked to do it, expect the
catheterization to be rather tricky! Always consider
antibiotic prophylaxis.
Procedure:
1. Wash hands thoroughly. Confirm the patient's identity,
explain procedure, and obtain verbal consent.
2. Unwrap all the equipment onto a cleaned (antiseptic)
trolley in an aseptic fashion and pour saline over the cotton
balls.
3. Position the patient supine with knees flexed and hips
abducted with heels together. Raise bed to a comfortable
height.
4. Wash hands again and put gloves on. Lay the towel and
drape over the patient so the genitalia are exposed.
5. From here on, use your non-dominant hand to hold the
labia apart, approaching the patient from the right hand
side, leaning over their ankles so as to reach the genitalia
from below.
6. Clean the genitalia with the wet cotton balls (using each
once only), working in a pubis-anus direction.
7. Carefully position the nozzle of the lubricant gel inside
the meatus and instilling most of the 5ml.
8. Position the bowl between the patient's thighs to catch
spillages.
9. The catheter will be in a plastic wrapper with a tear-away
portion near the tip. Remove this portion, being careful not
to touch the catheter and apply a little lidocaine gel to the
catheter tip.
10. Insert the tip of the catheter into the urethral meatus and
advance slowly but firmly by feeding it out of the remaining
wrapper.
11. On entering the bladder, urine should start to drain.
Advance the catheter fully to ensure the balloon is beyond
the urethra.
12. Inflate the balloon with the 10ml of saline via the
catheter side-arm. Warn the patient to alert you to any pain
and watch her face.
13. Remove the syringe and withdraw catheter until
resistance is felt.
14. Attach draining tube and catheter bag.
15. Clean and redress the patient as necessary.
16. Record the residual urinary volume.
Hints
Some female patients are easier to catheterize in a different
position lying on their side with knees raised (seek
experienced help).
Lack of urine drainage may be caused by: blockage of gel,
empty bladder or catheter misplacement.
Attempt to aspirate urine using a catheter-tipped syringe.
Feel for a full bladder. If there is any doubt about the
position of the catheter, remove immediately (deflating
balloon first) and seek senior advice.
Complications:
o Pain.
o Infection.
o Misplacement and trauma.
Beware latex allergy!
G. BASIC SUTURING
Basic suturing, or stitching, has many practical applications
outside the field of surgery.
Whether you are called upon to suture a central line in place
or are stitching up a laceration, it's a skill you should
practise before you need to use it. Undoubtedly, the best
way to learn is by watching a surgeon and then doing it
yourself.
Procedure:
1. Introduce yourself, confirm the identity of the patient,
explain the procedure, and obtain verbal consent.
2. First assess the wound and decide on the size of the
suture material.
wound closure such as glue, staples and steri-strips. Always
consider the most appropriate means of closing a wound.
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 3. Before suturing, irrigate the wound, and remove any
foreign bodies and any non-viable or infected tissue.
4. Use a needle holder such as toothed forceps where
possible, to minimize the risk of needlestick injury.
5. Hold the needle 2/3 of the way from the needle tip.
6. Lift the skin edge farthest away without pinching or
damaging it.
7. Pierce the skin with the needle at 90.
8. Rotate your wrist to pass the needle into the middle of the
wound.
9. Release the forceps and clasp the needle again as it
protrudes into the wound, rotating it out of the wound.
10. Next press the near side with the closed forceps to evert
the skin edge, and pass the needle through, taking a smooth
semicircular course to exit at 90 to the wound edge.
11. This method ensures a square bite and good eversion of
the wound.
12. Now perform a surgeon's knot. (see text below)
13. Remember to cut the ends of the thread off, leaving a
few mm so that they can be easily removed later.
When removing sutures, clean the wound with antiseptic
solution, use forceps or a blade and pull the suture out
across rather than away from the wound.
The time taken to remove non-absorbable sutures depends
on the location:
o Face: 5-7 days.
o Scalp: 7-10 days.
o Limbs and trunk: 12-14 days.
H. TWO HAND SURGICAL KNOT TYING
This is the surest way of tying a knot particularly when
continuous pressure is needed.
Tying can be done by the non-dominant hand (left).
Usually done when working with short sutures
A young surgeon should learn first to tie the two hand knot.
However, he will find that there are certain advantages in
the one hand knot like he does not have to put down all his
instruments to tie this knot, consequently fewer motions
and less time are required.
Procedure:
1. Grasp the long end of the suture with the flexed middle,
fourth, and little fingers on the left hand. With the other
bringing the short end back between the extended thumb
and index finger of the left hand.
2. Cross the thumb of the left hand over the short end and
under the long end. Continue to hold the ends of the suture
as before.
3. Hook the thumb of the left hand about the long end and
pull it across the short end by extending the thumb. In this
way a loop is created.
4. Bring the short end being held by the right hand forward
over the long end and place it on the palmar surface of the
distal phalanx of the thumb.
5. Grasp the short end of the suture between the thumb and
index finger of the left hand.
6. Bring the short end of the suture through the loop by
advancing the index finger and allowing the thumb to slip
out of the long end. You now have the first half-hitch, with
the index finger through the loop made by the hitch.
7. Since the ends of the suture are crossed at this point it is
necessary to cross your hands to uncross the suture after the
short end is grasped by the right hand.
8. The first half-hitch is set down. Note that the long end
which was on the left side as the knot was begun is now on
the right side. However, the left hand is still grasping the
long end.
9. Begin the second half-hitch by uncrossing the hands, but
continuing to hold the long end with the middle, fourth,
and little finger of the left hand and the short end with the
thumb and index finger of the right hand.
10. Hook the thumb of the left hand under the long end
which is being held by the same hand.
11. Bring the short end in the right hand across the left
thumb to midway between the thumb and index finger thus
producing a loop.
12. Appose the index finger of the left hand against the
thumb.
13. Pass the apposed thumb and index finger through the
loop. Bring down the short end held by the right hand and
place this end between the thumb and index finger of the
left hand.
14. Release the short end from the right hand and bring the
index finger and thumb of the left hand back through the
loop carrying the short end along.
15. Grasp the short end again with the right hand.
16. Set the second hitch in place.
I. ONE HAND SURGICAL KNOT
The knot may be tied with either hand but the more
dominant hand is used and the left hand is used to
tie the knot. With this, you can keep the needle
holder in your right hand, thereby reducing the
number of motions necessary.
Procedure:
1. Grasp the short or free end which is on the right with the
left hand and bring it across to the left under the long end
which is held by the right hand. Hold the short end between
the thumb and index finger of the left hand with the
proximal portion lying on the volar surface of the middle
and ring fingers.
2. Bring the left hand under the long end until the long end
crosses the short end between the index and middle fingers
of the left hand.
3. Flex the middle finger and get it beneath the short end.
4. Catch the short end between the middle and ring fingers
of the left hand. When you have hold of the suture with
these fingers you can release the end which was held by the
thumb and index fingers of the same hand.
5. Withdraw the middle and ring finger through the loop
bringing the short end along with them.
6. Set this half-hitch in place by pulling both ends.
7. Continue to hold the short end between the thumb and
index finger of the left hand. With the right hand, bring the
long end beneath the ring finger of the left hand and up
over the volar surface of the middle fingers of the same
hand.
8. Flex the middle and ring fingers of the left hand and
move them over beneath the short end.
9. Extend the middle and ring finger so that there is one
finger on either side of the short end of the suture.
10. Bring the middle and ring fingers of the left hand
together, grasping the short end of the suture. Release the
hold by the index finger and thumb on the same suture. Pull
the middle and ring fingers from the loop with the
contained short end of the suture.
11. To set the knot down properly you must cross your
hands after pulling the short end through the loop.
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 12. The knot is then set in place with proper traction in the
plane of the loop.
J. INSTRUMENT KNOT TYING
This knot requires the use of a hemostat. This has value
when one end of the suture is short (as, for example, when it
has been accidentally broken), when tying a knot in the
deeper cavity or when using a no touch technique when
working in a joint cavity.
Procedure:
1. The short end can be pulled quite short. Make a loop of
the long end of the suture about the instrument beginning
with the instrument in front of the suture
2. Grasp the short end of the suture by the hemostat which
is through the loop.
3. Pull the suture through the loop and set the knot down
properly using only the instrument for traction. The traction
must be exerted in the plane of the knot. Pull the short end
toward you and the long end away.
4. Start the second hitch by again wrapping the long end
about the instrument, but in this instance do it in the
opposite direction. Begin with the instrument behind the
long end of the suture.
5. After making the loop about the instrument grasp the
short end of the suture with the instrument and pull it
through the loop.
6. After pulling the short end through the loop, set the short
end in place, pulling the short end away from you and the
long end toward you.
VI. NEUROLOGICAL EXAMINATION
A. CRANIAL NERVE ASSESSMENT
1. CN I (Olfactory Nerve) Assessment
a) Test one nostril at a time with eyes closed.
b) Use at least three test substances for testing.
. coffee, vanilla, tobacco
2. CN V: Corneal Reflex (Sensory) Assessment
a) Use a free piece of cotton
b) Bring in a wisp of cotton from the lateral side to touch
the lateral side of the cornea of the adducted eye.
c) Bring the cotton directly in from the side to avoid
entering the field of vision.
3. CN V: Face Sensation V1, V2, V3 (Sensory) Assessment
a) Test for:
1) Pain (toothpick)
2) Temperature: may use any metal object like neuro
hammer or tuning fork; test for cold and warm (rub
the neuro hammer with your hands)
3) Light touch (wisp of cotton)
4) Pressure (may use hand)
b) Compare results on both sides
4. CN V: Masseter & Temporalis ms. (Motor)
a) Ask the patient to close and clench his/her jaw
b) Feel for superficial temporal muscles
c) Compare bulk of the muscle concerned
d) Palpate then grade
5. CN VII: Facial Nerve Assessment
a) Test forehead wrinkling, eyelid closure, mouth
retraction, whistling or puffing out of cheeks, and
wrinkling of skin over the neck (platysma action).
b) Listen to labial articulations. Say lalalalala
6. CN IX (Glossopharyngeal) & X (Vagus) Assessment
a) Check swallowing reflex
b) Check gag reflex (explain)
7. CN XI (Accessory Nerve) Assessment
a) Inspect sternocleidomastoid and trapezius contours
b) Check head movements and shoulder shrugging
8. CN XII (Hypoglossal Nerve) Assessment
Inspect the oral cavity. Note tongue deviation, atrophy
and fasciculations.
B. MOTOR EXAMINATION
Test in a rostrocaudal sequence
Test the range of motion first before testing the strength
1. STRENGTH OF SHOULDER & LATISSIMUS DORSI
a) Shoulder
1) Ask the patient to extend arms forward, to the sides,
and above the head.
2) Inspect from front and back
3) After assessing the range of motion, ask the patient
to abduct arms, then attempt to push downward as
the patient resists it.
b) Latissimus Dorsi
1) Ask the patient to extend arms to both sides
2) Apply upward pressure on both elbows. Ask the
patient to resist.
2. STRENGTH OF UPPER ARM MUSCLES
a) Elbow flexor
1) Patient flexes forearm
2) Examiner puts one hand on shoulder, other hand on
wrist
3) Attempt to straighten patients forearm
b) Elbow extensors
1) Patient flexes forearm
2) Examiners hand on the wrist of the pt., ask the pt to
extend the forearm as you apply resistance
3. STRENGTH OF FOREARM MUSCLES
c) Wrist flexors
1) Ask the patient to make a fist and hold the wrist
flexed against your effort to extend it
2) Attempt to extend the patients wrist by hooking
your finger around the patients fist and flex your own
wrist
b) Wrist extensors
1) Rest the patients forearm flat on his thigh or
tabletop
2) Ask patient to dorsiflex the wrist as you try to press
it down with the butt of your palm on the patients
knuckles
4. STRENGTH OF FINGERS
a) Finger extension
1) Ask the patient to place his/her hand palm down
with fingers hyperextended
2) Turn your hands over (palmside up) then press
against the patients fingers
b) Finger flexion
1) Grab patients wrist with one hand (to steady the
arm)
2) Offer two fingers of your hand for the patient to
hold
3) Instruct the patient to grip on your fingers and ask
him/her not to let your finger get away as you try to
extract your finger from the patients grasp.
Note: functional position of the hand slightly
dorsiflexed optimal hand position to exert the
strongest grip
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5. STRENGTH OF THIGH MUSCLES 2. BICEPS REFLEX
a) Knee extensors a) Have the patient sit.
1) With the knees flexed, instruct the patient to extend b) Ask the patient to rest his/her hands on the knees while
2) Apply resistance forming a 90 degree angle at the elbow.
b) Knee flexors c) The examiners thumb places slight tension on the
1) Knees still flexed in a 90 angle patients biceps tendon (at the area of the antecubital
2) Ask the patient to resist as you try straightening the fossa).
leg d) The examiner strikes his thumbnail a crisp blow.
6. STRENGTH OF ANKLES AND TOES 3. TRICEPS REFLEX
a) Ask the patient to dorsiflex, invert, and evert the feet a) Have the patient sit.
b) Inspect and palpate the legs. Then check for strength b) The examiner dangles the patients forearm over
by manual opposition his/her (examiner) hand at a 90 degree angle.
c) Plantar flexion testing Have the patient walk on the (Alt.) The examiner cradles the patients forearm in
balls of his/her feet. his/her (examiner) hand with the elbow forming a 90
degree angle.
5 Normal Strength c) Strike the triceps tendon (near the bony tip of the
4 Moves joint through full range against resistance greater elbow).
than gravity but examiner can overcome the action (make 4. BRACHIORADIALIS REFLEX
a percentage estimate of strength to compensate for a) Have the patient sit.
broad range of this number)
b) The examiner cradles the patients forearm in one
3 Moves part full range against gravity but not against any
hand, placing the thumb on top of the radius.
resistance
2 Moves part only when positioned to eliminate gravity c) The examiner strikes his/her thumbnail rather than the
1 Only a flicker of contraction of muscle but cannot move joint patients radius.
0 Complete paralysis ** The examiner may cradle both forearms side by side for
accurate comparison of the responses of the two arms.
5. PATELLAR REFLEX (SITTING)
C. SENSORY EXAMINATION a) Have the patient sit with the legs dangling over the
1. PROPRIOCEPTION (DIGITAL POSITION SENSE) edge of the table.
a) Explain briefly what is to be done. b) The examiner observes the degree of pendulousness,
b) Support patient hand or foot and grasp the 4th digit at which usually amounts to three after-swings before the
the sides. leg stops swinging.
c) Wiggle it in the correct manner w/o it touching other
digits straight line.)
2. PROPRIOCEPTION (ROMBERGS POSITION SENSE) c) The examiner places a hand on the patients knee.
a) Explain briefly what is to be done. d) The examiner strikes the patellar tendon a crisp blow.
b) Ask patient to stand with feet together. Then observe The examiner should see and feel the magnitude of the
for swaying. response.
c) Ask patient to close the eyes. Note for increase in 6. ANKLE REFLEX
swaying a) Have the patient sit with legs dangling over the edge of
3. VIBRATION SENSE the table. Have him/her completely relax the leg.
a) Explain briefly what is to be done. b) The examiner dorsiflexes the foot to place slight tension
b) Place the tuning fork in the right positions while on the triceps surae muscle.
assessing for patients ability to detect the vibration. c) The examiner strikes the Achilles tendon.
c) Test with patients eyes open and closed. Methods for eliciting the extensor toe sign
4. STEREOGNOSIS AND TACTILE AGNOSIA Descriptive Eponym Maneuver
a) Explain briefly what is to be done. Name
b) Ask the patient to close his eyes. Plantar toe Babinski Move an object along the lateral
c) Use different objects and ask patient to identify using reflex aspect of the sole
sense of touch. None Chaddock Move an object along the lateral
d) Test both hands. side of the foot
Achilles-toe Schaeffer Squeeze hard on the Achilles
D. REFLEX EXAMINATION reflex tendon
Shin-toe Oppenheim Press your knuckles on the
1. USE OF THE PERCUSSION HAMMER
reflex patients shin and move them
a) Dangle the hammer handle loosely between the thumb
down
and forefinger, allowing it to swing like a pendulum.
b) Simultaneous extension of the elbow added to the wrist Calf-toe Gordon Squeeze the calf muscles
swing adds further velocity to the tip of the hammer, thus reflex momentarily
delivering a crisp blow. Pinprick toe Bing Make multiple light pinpricks on
c) If the velocity of the hammer head is great enough and reflex the dorsolateral surface of the
the wrist and grip loose enough, the hammer head foot
bounces all the way back up and falls backward across
the crevice between your thumb and forefinger, thus
returning to the initial position.

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E. CEREBELLAR EXAMINATION Nealon, T.F. (1994). Fundamental skills in surgery. United
1. ATAXIA Kingdom: Saunders (W.B.) Co Ltd.
a) Ask the patient to stand and walk
b) Observe for a broad-based stance and gait.
c) Tandem walking step along a straight line, placing
the heel of one foot directly in front of the toe of the other.
Most sensitive clinical test for gait ataxia.

2. ARM ATAXIA
Postural tremor and tremor of the arms during the finger-
to-nose test
a) Ask patient to extend the arms straight out in front.
Inspect for:
Wavering incoordination during this volitionally
maintained posture, and for frank rhythmic postural
tremor.
b) After inspecting, instruct patient to place his index
fingers on the tip of his nose.
Observe for frank tremor that increases as the finger
approaches the nose (intention tremor) and when the pt.
fails to precisely place tip of f
c) Have the patient perform this test thrice. If uncertain,
have patient alternately touch his nose, to your finger and
to his for several times
3. DYSDIADOCHOKINESIA
Rapid alternating movement test for dystaxia and
dysmetria
Ask patient to hold out the hand, and to supinate and
pronate them as rapidly as possible.

F. MENINGEAL EXAMINATION
1. BRUDZINSKIS SIGN
a) Explain the procedure to the patient.
b) Ask him/her to lie supine on the examining table.
c) With the patient relaxed the examiner places his/her
hand under the patients occiput and gently attempts to
flex the neck.
(A positive Brudzinskis sign causes flexion and
adduction of the legs as the head is flexed.)
2. KERNIGS SIGN
a) Explain the procedure to the patient.
b) Ask him/her to lie supine with the knees bent on the
examining table.
c) The examiner keeps the patients knees bent while
flexing the limb at the hip.
d) When the patients thigh reaches the vertical position,
very gently straighten the knee.
(A positive Kernigs sign will make the patient
wince in pain, and the reflex hamstring spasm will
prevent further straightening of the knee.)

REFERENCES:
Bickley, L. S., Szilagyi, P. G., & Bates, B. (2007). Bates' guide
to physical examination and history taking. Philadelphia:
Lippincott Williams & Wilkins.
DeMyer, W. (2004). Technique of the Neurologic Examination.
U.S.A.: McGraw-Hill.
Edgerton, M. (1988). The art of surgical technique. Baltimore:
Williams & Wilkins.
Mackay-Wiggan, J. (2012). Suturing Techniques. Medscape.
Retrieved from
http://emedicine.medscape.com/article/1824895-
Copyright 2013 Alpha Sigma Phi and Phi Alpha Sigma
overview#a15.
(Pending SEC registration.

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