Examinations

Question 1

Order of examination for cranial nerves examination

Answer 1

Visual fields

1. Asks patient to look straight into their eyes and asks patient to cover their LEFT eye whilst candidate covers RIGHT eye.
2. Candidate places their finger halfway between them and the patient, and the edge of the candidate’s visual field.
3. Brings finger from the periphery to the centre until the patient can see it, whilst asking the patient to tell them when they can see it.
4. Asks the patient to tell them when the finger stops moving, just to confirm they can see the finger. Tests all 4 quadrants with good technique.
5. Tests the left eye’s visual fields in the same way.
6. Comments that visual acuity can ideally be assessed by a Snellen chart and that colour vision can be tested using Ishihara plates.
7. Comments that pupillary light reflexes and accommodation reflex can be done.
8. Comments that they would also perform ophthalmoscopy/fundoscopy.

Assessing eye movements (CN III, IV, VI)

9. Inspects pupil for obvious abnormalities such as strabismus (squint), ptosis (eyelid drooping), mydriasis (pupil dilation), miosis (pupil constriction).
10. Assesses eye movements – asks patient to keep head straight and follow their finger in an H sign.
11. Asks patient if they experienced double vision or pain during test.

Assessing muscles of facial expression and mastication (CN V, CN VII)

12. Asks patient to clench teeth and feels muscle bulk of temporalis.
13. Asks patient to clench teeth and feels muscle bulk of masseter.
14. Asks patient to open mouth against resistance.
15. Comments that they would also perform jaw jerk and corneal reflexes.
16. Asks patient to raise their eyebrows, commenting on the symmetry of the forehead creases.
17. Asks the patient to close their eyes tightly and resist opening them.
18. Asks the patient to blow out their cheeks, puts pressure on them and watches for any air escaping.
19. Asks patient to give a toothy smile and comment on symmetry.
20. Thanks patient and washes hands

Question 2

When would you stop CPR

Answer 2

1. If victim starts breathing normally.
2. If qualified help arrives.
3. If exhausted.

Question 3

Order of examination for upper limb PNS examination

Answer 3

Inspection
1. Inspects for muscle bulk, fasciculations, tremors, scars, and other skin changes.

Tone

2. Asks patient if they are in any pain before they begin the assessment.
3. Asks patient to try and relax their arm.
4. Adequately assess tone in the arms: holds the patient’s hands and supports the elbow whilst moving the arm through all movements, either individually or as a compound movement.

Power

5. Isolates each joint appropriately and compares both sides each time.
6. Tests shoulder abduction (C5) and adduction (C6, C7).
7. Tests elbow flexion (C5, C6) and extension (C7, C8).
8. Tests wrist flexion (C7) and extension (C7).
9. Tests finger abduction (T1) and adduction (T1) – by asking them to hold a sheet of paper in between fingers.
10. Test thumb abduction.

Reflexes

11. Elicits biceps reflex (C5, C6).
12. Elicits triceps reflex (C7, C8).
13. Elicits supinator reflex (C5, C6).
14. Demonstrates good technique throughout and compares both sides.

Coordination

15. Finger to nose test.
16. Dysdiadochokinesia  Use rapid alternating movement.

Question 4

order of examination for lower limb PNS examination

Answer 4

Inspection
1. Inspects for muscle bulk, fasciculations, tremors, scars, and other skin changes (SWIFT).

Tone

2. Asks the patient if they are in any pain before beginning examination.
3. Asks patient to try and relax their leg.
4. Assesses hip tone – holds the patient’s thigh above the knee and rolls their leg to either side, watching movements of the foot.
5. Assesses quadriceps tone – holds the patient’s knee and quickly raises it from the bed, watching for the heel to raise off the bed.
6. Assesses ankle clonus – holds the foot and lower leg, then rotates the foot at the ankle joint before briskly dorsiflexing the foot, sustaining the pressure.

Power

7. Isolates each joint appropriately and compares both sides each time.
8. Tests hip flexion (L1, L2, L2), extension (L5, S1), abduction (L4, L5, S1) and adduction (L2, L3, L4).
9. Tests knee flexion (L5, S1) and extension (L3, L4).
10. Tests ankle dorsiflexion (L4, L5) and plantarflexion (S1, S2).

Reflexes

11. Elicits the patellar reflex (L3, L4).
12. Elicits the Achilles reflex (S1, S2).
13. Comments they would also do the Babinski reflex.
14. Demonstrates good technique throughout and compares both sides.

Coordination

15. Uses heel down shin test for coordination.
16. Thanks patient, saying examination has concluded.
17. Wash hands.

Question 5

how do you do a cardiovascular examination

Answer 5

Auscultation

1. Auscultates APTM (A: 2nd IC space, right sternal edge; P: 2nd IC space, left sternal edge; T: 4th IC space, left sternal angle; M: 5th IC space mid-clavicular line).
2. Auscultates mitral area with the bell to check for low-pitch diastolic murmur. Bell: Used for lower-frequency sounds.
3. Times heart sounds with the cardiac cycle by palpating the carotid pulse during auscultation.
4. Correctly identifies each valve area and defines them anatomically.

Examine JVP

1. Candidate asks patient to turn their head to their left.
2. Candidate correctly looks for the JVP between the two heads of SCM.
3. Hepatojugular reflux: Asks about pain, applies firm pressure over the liver for about 10 seconds while watching the JVP.
4. Differentiating JVP from carotid: JVP not palpable, double wave form, augmented by hepatojugular reflux.

Height of JVP

1. Describes measuring the vertical height between the manubriosternal joint and the highest point that the JVP is visible, with the patient at 45 degrees.
2. Thanks patient, informing conclusion of examination.
3. Washes hands.

Question 6

How to do a respiratory examination

Answer 6

1. Performs general inspection from foot of bed and comments on bedside cues.
2. Palpates for tracheal deviation.

Chest Expansion

3. Candidate places hands appropriately on the patient’s chest with thumbs free from the skin and meeting in the middle.
4. Asks the patient to take a deep breath and allows thumbs to move apart with the chest.
5. Repeats chest expansion a second time at a lower level of the chest wall.

Vocal Fremitus

6. Places ulnar aspect of each hand on the chest with one on either side.
7. Asks patient to say ‘99’.
8. Repeats the procedure for at least 3 levels in total.

Percussion

9. Percusses lung apices by percussing the clavicles.
10. Percusses a suitable number of levels down the chest wall – at least 4 including the clavicle.
11. Compares one side to the other each time.
12. Percusses in the right axilla.
13. Maintains good percussion technique throughout.
14. Repeat for the back.

Auscultation

15. Auscultates supraclavicular fossae with the bell of stethoscope.
16. Auscultates a further three levels down the chest wall with the diaphragm. Include axilla for both sides.
17. Compares both sides throughout.
18. Maintains good stethoscope technique throughout.
19. Thanks patient, informing conclusion of examination.
20. Washes hands.

Question 7

How to perform an abdominal examination

Answer 7

1. Performs general inspection from the foot of the bed and comments on bedside cues.

Palpation

2. Asks the patient whether they are in any pain before commencing.
3. Performs light palpation at MCP of the nine regions of abdomen.
4. Performs deep palpation of the nine regions of the abdomen.
5. Maintains good palpation technique throughout including:
   a. Kneeling beside patient.
   b. Watching patient’s face for signs of pain.
   c. Flexing at the MCP and applying suitable pressure.
6. Performs rebound test.

Liver

7. Begins palpating for liver in the RIF.
8. Asks patient to take deep breaths, moving up abdomen with each expiration (pressing in upon inspiration) until the right costal margin is reached.
9. Percusses lower border of liver beginning from RIF.
10. Percusses upper border of liver beginning just above the nipple.

Spleen

11. Palpates for the spleen, beginning at the RIF.
12. Asks patient to take deep breaths, moving across abdomen diagonally with each expiration until the left costal margin is reached.
13. Percusses for the spleen beginning at the RIF and moving diagonally towards Traube’s space.

Kidneys

14. Correctly ballots the kidneys using one hand above and below the patient’s flanks in the appropriate position and to a suitable depth.
15. Thanks the patient and informs conclusion of examination.
16. Washes hands.

Question 8

How to do an elbow examination

Answer 8

1. Performs general inspection from foot of bed – SWIFT.

Look
2. Looks for any obvious deformity, scars, bruises, skin changes, muscle wasting or swelling.

Feel

3. Asks if patient is in any pain before beginning.
4. Feels for temperature using backs of their fingers around each elbow, comparing both sides.
5. Palpates the joint line, medial and lateral epicondyles, and olecranon for tenderness.
6. Extends elbow and feels for sponginess either side of olecranon for synovitis.

Move

7. Suitably assess active movement of flexion, extension, supination, and pronation of the elbow joint whilst communicating clearly to the patient.
8. Suitably assess passive movement by holding patient’s hand and supporting elbow with the other hand, carries out flexion, extension, supination, and pronation of the elbow whilst feeling for crepitus at elbow joint.

Function

9. Asks patient to touch their mouth with their hand.
10. Asks patient to pretend to pour a glass of water.
11. Asks patient to act as if they are putting on a jacket.
12. Thanks patient, informing of conclusion of examination.
13. Washes hands.

Question 9

How to do a knee examination

Answer 9

1. Expose patient from waist down.
2. Performs general inspection from end of bed – SWIFT.

Look

3. Asks patient to stand and inspects knee joint from the front, and side looking for obvious scars, swelling (particular Baker’s cyst) and deformities (varus/valgus).
4. Asks patient to walk and watches their gait – particularly looking for antalgic gait.
5. Asks patient to lie back on the couch and performs closer inspection for scars, swellings, erythema, and for muscle wasting in quadriceps.

Feel

6. Feels for temperature by using the backs of their fingers around each knee joint, comparing both sides.
7. Asks patient to flex their knee and feels all around the joint, feeling tibial tuberosity, medial and lateral joint lines, patellofemoral joint. Say what is being felt.
8. Feels the back of the knee in the popliteal fossa for cysts of aneurysms.
9. Performs the patellar tap test for large effusions – begins by milking the suprapatellar pouch presses firmly on the patella commenting that they are feeling for a ‘tap’.
10. Performs the bulge tap test for small effusions – begins by emptying the medial joint recess then strokes the lateral aspect of the joint watching for a bulge on the medial aspect.

Move

11. Suitably assess active movement of flexion and extension of the knee joint whilst communicating clearly to the patient to maximally flex and then maximally strengthen their leg.
12. Suitably assesses passive movement by stabilising the knee joint with one hand and grasping the ankle with the other before moving the leg through maximal flexion and extension.

Special Tests

13. Tests for the integrity of the medial collateral ligament by stabilising the ankle under their arm and applying pressure to the lateral aspect of the knee.
14. Tests for the integrity of the lateral collateral ligament by stabilising the ankle under their arm and applying pressure to the medial aspect of the knee.
15. Tests for the integrity of the anterior cruciate ligament by performing the anterior drawer test: with the patient’s knee flexed to 90deg, stabilises the foot and firmly pulls the tibia forwards.
16. Tests for the integrity of the posterior cruciate ligament by performing the anterior drawer test: with the patient’s knee flexed to 90deg, stabilises the foot and firmly pulls the tibia backwards.
17. Thanks patient, informing conclusion of the examination.
18. Washes hands.