The short cases

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Chapter 6 The short cases

Clinical examination is more art than science. When the art is practised well, the science (investigation) is merely confirmatory.

The authors’ mantra

The short cases require practice over a period of time.

Purpose

The individual short cases are the examiners’ oppor tunity to see how candidates elicit physical signs and therefore give candidates the opportunity to showcase what they do on a daily basis.

Format

Each candidate sees four short cases, two cases with one pair of examiners and two cases with a different pair of examiners. Each of the four examiners will act as the lead for an individual case. For each pair of cases you have 20 minutes, although the time allocated to each case may not be equal, depending on the complexity of cases. As with the long case, bells are used to signal the start and finish of each section. When the bell sounds for the end of the first 20-minute session, you will be redirected to sit outside another room ready for the second session. Following a five-minute break, you will be taken by the second pair of examiners to your other two cases for a further 20 minutes.

The ‘typical’ split of the short cases is one cardio vascular, one neurological, one of either respiratory or abdominal and one other. However, the actual cases used will depend on availability on the day. Therefore, more than one case may be given from the same system. None of the above categories are mandatory and the order of cases varies. At least one short case will be paediatric.

As a guide, for each case approximately seven minutes is usually assigned to the clinical examination before presentation and questions. You will be given the choice of presenting your findings as you go or at the end. Any further discussion will relate only to the case at hand. The focus will be on synthesising findings for a diagnosis or differential diagnosis, including further methods to clarify this. On occasion you may be shown results of relevant investigations that assist in the differential diagnosis, although time constraints will usually prevent this.

Preparation

The majority of short cases will be outpatients with painless, stable, well-documented signs. Most of these patients are well trained and follow instructions easily. Really well trained patients will even anticipate your next move and position themselves accordingly. However, a good ‘hot’ case from the emergency department will not be overlooked. For this reason, your examination technique also has to work for the ‘untrained’ patient — and, as such, it has to work in your everyday work life. Remember, the most effic ient way to examine a system is via the short case tech nique. You should therefore consider practising this tech nique as preparing for all your future patient exam in ations, not simply rehearsing for the fellowship exam.

There is no substitute for practice. Each component of the short case is important and requires preparation and practice. This means becoming familiar with:

• the equipment you will use
• the setting in which you see patients
• the range of patients you will see
• the technique and timing of the clinical examination
• presenting each case
• answering questions on each case.

The only way to look slick and present with ease is to have done it a sufficient number of times so you do not have to think about it.

Become familiar with your chosen location for your equipment, especially pins, cotton wool, tuning fork and tendon hammer for the neurological exami nation. Most candidates prefer to use their own ophthalmoscope and auroscope. By necessity, those provided are often slightly different from the kind normally in use at your workplace. Practising on ‘normal’ volunteers is an excellent way to become familiar with your examination ‘kit’ without having to suffer the embarrassment of disorientation in front of real patients.

Be comfortable doing basic observations. A FACEM should look slick measuring blood pressure, pulse rate, respiratory rate, SaO2 and temperature. Practising these skills will help enormously. Recording them in the notes at work and encouraging others to do likewise will also engender good working relationships with the nursing staff.

When given a patient’s name, use it a few times straight away (as this is also your only time to ask again or be corrected successfully if you get it wrong) and regularly afterwards. This technique is a favourite for salespeople. Calling people by name engages them earlier, makes them relaxed and engenders a sense that you are taking a personal interest in them. Try it, and compare the results with when you don’t do this.

You will be given the choice of presenting your findings as you go or at the end. Most major systems (e.g. cardiovascular) are better suited to a summation at the end as you accumulate diagnostic information along the way. For others where the diagnosis is apparent but several signs need to be demonstrated (e.g. rheumatoid hands or examination of a lump), presenting as you go ensures you do not omit findings.

Top athletes are taught: ‘Train as you intend to compete, because you will always compete as you train.’ Become familiar with examining each system in a maximum of seven minutes. If your ‘normal’ approach varies with each patient and changes in duration, your performance at the examination (competition for marks) will reflect this. Practise individual examinations with someone timing you. This can be done at home with friends or family members who are happy to volunteer: they will soon be able to tell you when you have missed something. A word of warning: if your partner or family members become the ‘subjects’ for your practice, remember that time spent together in this way does not count as ‘quality time’.

Teaming up with physician trainees is a great way to discover medical short cases, and they will also make useful allies as practice examiners and examinees. A number of textbooks include likely medical short cases. However, the specialty of emergency medicine covers much more than general medical cases: you must also search out short cases from other specialty areas in wards, clinics and rooms. Seeing patients in surroundings that are unfamiliar to you is good practice for the exam itself.

The following are some of the more likely conditions with which you should seek experience in addition to those that physician trainees will be seeking, although this list is far from exhaustive:

• Paediatrics: almost any adult condition can be present in children as well. Your interaction with the child and parent will be on display. Children also present with a variety of syndromes, not all of which will have names you are familiar with. Identifying abnormalities is more important than knowing the name. Ensure that you know the normal childhood milestones and how to do a ‘baby check’.
• Surgery: hernias, organomegaly, ulcers, vascular insufficiency, varicose veins, and breast and thyroid examination.
• Orthopaedics: joints, especially the knees.
• Obstetrics: normal pregnancy assessment and features of pre-eclampsia.
• Trauma unit: peripheral nerve injuries including the brachial plexus, and facial injuries with complications (e.g. cranial nerve injury, orbital blow-out fractures).

Practise presenting your cases as succinctly as possible. Remember that some descriptors are patho gnomonic and should be used only if you are confident of the diagnosis. For example, a ‘collapsing pulse’ and a ‘plateau pulse’ are specific for aortic incompetence and aortic stenosis, respectively. Describing the pulse as ‘full volume’ or ‘low volume’ is safer if you are unsure. Practising as both examiner and examinee will allow you to iron out quirks and habits that can be annoying. Using ‘um’ excessively needs to be brought to your attention early, so you can amend your language accordingly. Avoid using terms such as ‘middle-aged’ and ‘gentleman’, which can become points of debate in themselves: ‘man’, ‘woman’, ‘child’ and ‘baby’ are safer terms. If you can practise some sessions with an examiner, they can help with this task. Your DEMT and other FACEMs will also be helpful, as will other trainees preparing for the fellowship exam. Be con structive in your critique of others and encourage them to be likewise. The intention of this practice is to allow you to develop a ‘style’ where you present as a competent colleague. You do not want to be giving a lecture (over-confident) or to look stunned before each question expecting a hidden agenda (under-confident). Constructive critique from and of others will help you to find your way.

Whenever you need to get some fresh air, spend it casually watching people walk in and out of the outpatient clinic and/or main entrance of the hospital (or while shopping or going for a walk). This is espe cially good practice for analysing gait patterns, and you can challenge colleagues on how many people you can diagnose from a distance. You will be surprised how often this can be done!

Anticipate the questions that will be asked and practise your answers. The expected series of questions the examiners will ask are:

• What else would you like to examine?
• Present your findings so far.
• Can you put these findings together?
• What else could it be?
• What supports one differential over another?
• What else could you do to clarify things further?
• Are there any features suggesting a specific aetiology?

Examining a candidate who provides the answers in a logical fashion without being asked is more satisfying than having to drag the answers out of a candidate one at a time. The more competent you are, the higher you will score. Later sections in this chapter include examples of responses that enable you to keep talking until you are stopped.

Some systems are well suited to prepared answers. Cardiovascular examination, for example, has a relatively limited number of diagnoses, and the more common ones should be rehearsed. Well-prepared candidates will anticipate these diagnoses and present their findings in a thorough polished manner before being asked. Being well prepared saves time and enables you to maximise the information you are giving. If, for some reason, you are off track, the exam iners will stop and redirect you.

The final part of your preparation is the ‘dress rehearsal’. Ensure that you practise a couple of each of the major system examinations in your examination outfit. This will confirm that it is comfortable and practical and make you more at ease on the day.

On the day

In the current structure, the short cases are undertaken on the afternoon of the first day, after the long case. There is a lunchbreak for the examiners between the long and short cases, so your break will be at least this long. Typically, you will have a few hours between your sessions. Use the time to relax and eat something that is easy to digest and will not make you sleepy.

At the end of the break, expect to get right down to business. The examiners will be ready, directing you straight to your first case.

Hand-cleaning facilities will be available in each patient area, similar to everyday practice. Good FACEMs wash their hands between patients. Act like a FACEM.

Listen carefully to the introduction, including the patient’s name and what you are being asked to examine. Use the patient’s name as soon as possible, as you have practised. If you do not understand an instruction, ask for clarification.

The issue of whether to present the examination findings as you go or to complete the examination before summarising what you have found is a matter of personal choice. The examiners will allow you to present either way. Regardless of which method you choose, be mindful of the time. The examiners will want to ask questions, so your examination and presentation need to be timed to allow for this. If you elect to present at the end and your examination is slow, the examiners will stop you when they need to ask questions. If you present as you go but spend time presenting irrelevant material, you may run out of time.

After each case, try to clear your mind and be ready to start afresh for the next one. Each case is marked independently from the others so treat them as such. Although it is human nature to mull over past performance, it is not helpful. During the fiveminute break between sessions, collect your thoughts, and ensure that your ‘kit’ is back together and everything is in its correct pocket. The second set of examiners will not know how you performed in the first two cases.

Depending on the number of candidates, after you have completed your four cases you may be quarantined until the last group has finished. Be prepared for this and use it as an opportunity to wind down, as you will be tired after a long day.

Examination approaches

It is the theory that decides what we can observe.

Albert Einstein

The following sections provide a suggested method for approaching commonly encountered cases, along with possible introductions that may be used by your examiners. These descriptions are not exhaustive of the countless number of clinical signs that may be detectable, but they do provide an organised framework that will enable you to detect all abnormal findings.

For comprehensive background material, you will find it invaluable to refer to excellent resources such as:

• Talley N, O’Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis, 5th edn. Elsevier, Sydney, 2006.
• Ryder REJ, Mir MA, Freeman EA. An Aid to the MRCP Short Cases, 3rd edn. Blackwell, Oxford, 2003.
• Harris W, Timms B, Choong R. Examination Paediatrics: A Guide to Paediatric Training, 3rd edn. Elsevier, Sydney, 2006.
• Browse N et al. Browse’s Introduction to the Symptoms and Signs of Surgical Disease, 4th edn. Hodder Arnold, London, 2005.

This chapter does not aim to be a substitute for these educational sources. Rather, it complements these books by reviewing areas of key importance, with particular emphasis on areas that FACEM exam candidates are commonly asked and/or classically struggle with (e.g. neurology).

Examples are also provided of the lay language that may be used when engaging with patients in the exam. This is not meant to be condescending to prospective candidates, but is included as an extension of the requests we sometimes receive from trainees to model how we would succinctly interact with and instruct patients under exam conditions. Ultimately, we recommend using the same approaches you would use in ‘real life’ and encourage you to develop your own efficient but friendly professional banter.

Cardiovascular system examination

The examiner’s introduction is usually nondescript and directs you to examine the whole cardiovascular system:

‘Mr Jones has a cardiac condition. Please examine his cardiovascular system.’

Specific direction indicates key findings the exam iners wish to focus on, maximising your time. Do not be concerned: this gives you more time for a detailed examination. If you are directed to the praecordium, examine the praecordium — do not examine the peripheries. However, you will be able to note the patient’s general appearance and usually JVP while auscultating.

Getting started

Introduce yourself to the patient using the patient’s name, while making a show that you are confirming the patient’s posture at 45 degrees.

Hello, Mr Jones. Can I just check you’re sitting comfortably?

Once the patient is settled, step back sufficiently to be able to scan the whole area, including the bedside table, underneath the trolley and so on for any clues. Note them as you discover them:

I don’t see any evidence of medical therapy such as oxygen. I presume that this is Mr Jones’ walking stick.

Observe the patient’s general appearance, colour (anaemia, plethora, cyanosis), pursed-lip breathing, respiratory rate and obvious scars. The JVP may be visible at a distance. Head bobbing is an uncommon sign of aortic incompetence (AI), but easily missed if not specifically checked for.

Peripheries

Start from the hands checking for anaemia, cyanosis, pulsations in the nail beds (AI) and stigmata of endocarditis (e.g. splinter haemorrhages in the nail beds, digital septic emboli, haemorrhagic Janeway lesions in the palms).

Feel the pulse for rate, rhythm and volume. While checking the pulse, you have more opportunity to check the hands and scan the rest of the patient. If the pulse is particularly good volume, try feeling with your fingers flattened against the radial pulse with the patient’s forearm elevated (tapping pulse of AI).

As you move up the arm, feel the brachial pulse and politely ask the examiners:

Is there a blood pressure available?

Listen carefully to the numbers and remember them. Occasionally you may be directed to measure the patient’s blood pressure yourself. This is neither a good nor a bad thing. You may be asked to do so because the blood pressure is interesting (low pulse pressure in aortic stenosis (AS), high in AI) or because the case allows time for this and the examiners want to see whether you are competent in a basic procedure. Looking off ended when directed to measure the blood pressure or fumbling around indicating that this is something you haven’t done in a long time is not a good way to impress.

Move to the neck, feel the carotid pulse for character and auscultate for bruits:

I’m just going to listen to your neck.

If breathing is noisy, give clear instructions:

Breathe in … Breathe out … Stop … Now breathe normally.

Assess the JVP. If it is not visible, make sure it is not too low (try a hepatojugular response — Mr Jones, is it okay if I just press on your belly briefly?) or too high, in which case the distended vein will become measurable sitting up. Sinus rhythm gives a regular double pulsation. If the patient is in AF, look care fully for cannon waves on top of single pulsations. Large fluctuations (CV waves) are seen with tricuspid incompetence (TI).

Check briefly for conjunctival pallor and central cyanosis (lips and tongue).

Praecordium

Inspect for a visible apex beat or heaves and scan for scars (which may be in the axilla). Sternotomy scars without evidence of vein grafting should raise suspicion of surgery for valves or transplant. Internal mammary grafts are associated with multiple vascular clips on CXR. Do not miss a pacemaker or ICD insertion pocket scar.

Feel for the apex beat. If not palpable, reach out to the posterior axilla. If still not palpable, consider that it may be on the other side (dextrocardia). Once located, confirm its position relative to the mid-clavicular line (or anterior/mid-axillary lines if displaced significantly) and whether it is normal, force ful or otherwise.

After feeling for the apex beat, palpate vertically alongside the sternum for thrills or ventricular heaves (using the heel of your palm) and finally feel horizontally across the heart base.

Auscultation starts at the apex beat with the stethoscope diaphragm. Deliberately focus on the first heart sound, then the second (including splitting and change of splitting with respiration; identify mechanical valvular sounds). Specifically listen for a third, fourth and then additional heart sounds. Clicks may be loud and dismissed as extraneous sounds. Listen first for systolic and then diastolic murmurs.

After listening at the apex (mitral area), listen in turn to the lower left sternal edge (tricuspid area), then the left upper sternal edge (pulmonary area) and right upper sternal edge (aortic area). Confirm the timing of any murmur by simultaneously palpating the carotid pulse and listen in the axilla and carotids for radiation. Right heart murmurs are louder with inspiration and the opposite is true for left-sided murmurs, so ask the patient to take some slow, deep breaths while listening for changes with the respiratory cycle.

After listening with the diaphragm to all four areas, change to the bell on the stethoscope. The tone difference of mitral stenosis requires a change in mental focus initially to ‘tune in’: listen with the bell held lightly against the chest over the apex. Do not press firmly as this may obliterate a soft mitral diastolic murmur. Lying on the left side accentuates mitral murmurs. Flatten the bed in anticipation of further examination: Could I please ask you to lie down on your left side? Palpate the apex beat again (it usually moves) and identify mitral murmurs.

Sit the patient up: Can I get you to sit up and lean forward? Feel the parasternal area again for thrills or heaves. An AI murmur is best heard with the diaphragm as the patient leans forward at end expiration: Please take a big breath in… Breathe right out … Stop … Now breathe normally.

If you have heard a clear aortic outflow murmur, you may wish to try isometric exercise at this stage: Make a loose fist with your hands. Squeeze hard when I say so. Listen for the character of the murmur: Squeeze now [listen] … and relax [listen again]. Murmurs associated with HOCM will decrease with isometric exercise, while those associated with aortic valve obstruction will increase. Valsalva has the opposite effect. If you are seriously considering HOCM at this stage (it is more common in exams than in real life), it may be worthwhile going ahead with other manoeuvres such as squatting in a mobile patient (HOCM decreases with squatting down and increases on rising from the squat; aortic valve obstruction is the reverse). Although it is uncommon to demonstrate these manoeuvres, if you do suggest them during dis cussion, you must be prepared to demonstrate them.

When the patient is sitting up, check for sacral oedema and basal crackles. Thoracotomy and valvotomy scars are also best seen from behind.

With the patient supine, check for hepatic enlarge ment and pulsatility. Checking the legs for oedema, deep vein thrombosis and scars from bypass grafting completes the examination.

With practice, you can complete all the above within seven minutes. If not, you will be stopped before you complete your examination.

As you progress through your cardiovascular system examination you will receive ‘clues’. For example:

• The presence of AF makes mitral valve disease more likely, while absence makes it less likely. Low-volume pulses are associated with obstructive lesions, while high-volume pulses are associated with valvular incompetence.
• A high JVP and exaggeration of a pansystolic murmur with inspiration suggest a right-sided lesion. Tricuspid incompetence is likely and therefore a pulsatile liver is to be expected.

If you detect all the peripheral clues, you should have a reasonable indication of the likely diagnosis before you even auscultate. If so, you should be think ing of other features that support or refute your diagnosis or give indications of severity.

Discussion

The examiners will stop you with a clear statement, followed by: ‘What else would you like to examine?’ Respond with:

I would complete my cardiovascular system examination with [whatever you have not done] as well as completing a general examination including [whichever observations have not been done] and a urinalysis looking for …

You will be given results if relevant to the discussion, then asked to ‘present your findings so far’. At this point you can wait for the questions to come one by one or you can anticipate them and keep going until stopped. The examiners will commonly follow with the pattern of asking about possibilities, the likelihood of each possibility, the rationale for and against each, and confirmation for and against each.

The following is an example of how to respond in a manner that demonstrates your knowledge and understanding of the clinical signs and displays your ability to be a ‘real’ FACEM. Read it first with the questions being asked and then again with the questions removed. An excellent candidate will progress through each aspect of questioning without being prompted by the examiners’ questions.

‘Present your findings so far.’

Mr Jones is a well-looking man comfortable at rest and in no distress. He has no peripheral stigmata of disease. His pulse rate is 80 beats per minute, regular, full volume and tapping in nature at the wrist. Blood pressure was given at 160/70, and JVP is normal. Central pulses confirm the full volume. Praecordial examination demonstrates a well-localised apex beat displaced 2 cm lateral to the mid-clavicular line. There is a suggestion of a left ventricular heave with no thrill palpable. Auscultation reveals a mixed murmur heard loudest in the aortic area with radiation to the carotids but also well heard at the apex. Both heart sounds are heard with normal splitting. The diastolic murmur was loudest on sitting forward on exhalation with no appreciable change during the respiratory cycle. There is no evidence of cardiac failure and the liver is not pulsatile.

‘Can you put these findings together?’

The mixed murmur has a number of possible diagnoses. I believe the most likely is mixed aortic valve disease with aortic incompetence as the dominant lesion, given the large pulse pressure and collapsing nature of the pulse.

‘What else could it be?’

A number of other possibilities can account for these murmurs. The diastolic component could be due to mitral stenosis or less commonly tricuspid stenosis or pulmonary incompetence. The systolic component could be due to mitral or tricuspid incompetence, pulmonary stenosis or a pulmonary or aortic flow murmur. VSD or ASD could also cause systolic murmurs, and to-and-fro murmurs can be caused by more complex lesions such as coarctation or anatomical abnormalities including transposition of vessels.

‘What supports one differential over another?’

In this age group, without signs of surgical intervention and in a well patient the likelihood of coarctation is remote. This would be a more common consideration in young children and evidenced by radiofemoral delay. I don’t think the murmurs were louder with inspiration, making right-sided valvular lesions less likely. Mitral valve lesions are best heard at the apex, whereas this murmur was loudest at the base. However, it was well heard at the apex, which may represent an Austin Flint murmur. Of note, Mr Jones is in sinus rhythm. This would be unusual for mitral valve lesions where AF is more likely. Both heart sounds were well heard, which is also against significant mitral incompetence; however, this would still be an important differential diagnosis.

Other conditions such as VSD are possible, but these are usually well localised, mostly systolic only and would not be expected to be associated with such a large pulse pressure. It would be unusual for a diastolic murmur to be present with HOCM and this is also effectively ruled out by the systolic murmur increasing with isometric exercise.

‘What else could you do to clarify things further?’

After completing the physical examination, the key initial investigations will be an ECG and chest X-ray. The ECG will confirm sinus rhythm and may demonstrate left ventricular hypertrophy. The chest X-ray may show valvular calcification, dilation of the left atrium if there is mitral valve disease and I expect it will also reveal enlargement of the left ventricle and absence of cardiac failure.

The definitive investigation is echocardiography. This will confirm the diagnosis, the degree of incompetence or stenosis, the flow gradient, the size of the left ventricle and the ejection fraction and determine whether the aortic valve is tri- or bicuspid.

‘Are there any features suggesting a specific aetiology?’

If you have been following the path of questions above, the bell may have gone by now. If you took the initia tive and led the discussion, the time saved may have created an opportunity to score some bonus marks.

If you are confident of the diagnosis, as an alternative approach to the presentation, you could start by providing your diagnostic assessment and then present the findings that support this condition and exclude the major differential diagnoses. In that case, you can also take a different tack when the examiners stop you and ask ‘what else would you like to examine?’ and make sure you get these responses in from the outset:

Mr Jones has features of aortic incompetence. As well as completing my usual cardiovascular system examination I would like to additionally check for DeMusset’s head-nodding sign and Quinke’s sign of nail-bed capillary pulsation, measure the blood pressure in both arms for evidence of aortic dissection, check for Argyll-Robertson pupils of tertiary syphilis and for a high arched palate and check for increased joint mobility of collagen disorders such as Marfan’s syndrome.

The cardiovascular system examination is particu larly well suited to prepared responses that allow you to demonstrate your knowledge and differential diagnosis. Make sure that you know the features of all the valvular lesions including indications of severity. Do not omit VSD, ASD, HOCM, coarctation of the aorta and congenital malformations. Once you are familiar with the list of differentials for various murmurs and changes in heart sounds, having a discussion or presentation along the lines of the above dialogue will become increasingly easy.

Neurological system examination

Cranial nerves

If no specific direction is given, go through in num erical order. Occasionally, you will be directed to the ‘lower’ cranial nerves, in which case you should start from the end (CN XII) and work backwards. If the examiners wish to focus on a particular area, they will direct you accordingly.

Patients are best positioned sitting with their head at equal height to yours. This can mean sitting on a chair (which may find you crouching down) or on the side of the bed. Introduce yourself to the patient and remember to use the patient’s name. Position the patient appropriately: Mr Jones, could you please sit facing me with your legs over the side of the bed? Let your hands rest in your lap.

Enquire, Mr Jones, are you sore anywhere?, to ensure that you will be able to proceed with your examination in the usual manner. Then take a step back to make the same general observations as with any other system examination. Ptosis from Horner’s syndrome or a third nerve lesion, facial droop with absence of a smile from facial nerve lesions, neck masses and so on are all more obvious when you step back. If there is a clear abnormality, say so.

CN I: olfactory nerve

CN I is rarely tested. Asking the patient, Can you smell normally?, is generally sufficient.

CN II: optic nerve

Acuity

Have your visual acuity chart prepared with the same print on both sides. Make sure that you know the distance specified on the chart (usually an arm’s length). Ask the patient whether they wear glasses and, if they do, check uncorrected vision first, corrected later. Ask the patient to cover one eye and hold the chart in front of the patient. Ask: What is the lowest line you can read? Then check the other eye.

Acuity is recorded as the lowest line the patient can read and includes the number of mistakes. For example, 6/12 – 2 indicates that the patient is able to read the 6/12 line but with two errors. If the patient is unable to read the top line, move forward until they can, recording the distance at which the 60 line becomes visible. If they still can’t read it, check for movement, then light perception.

Visual fields

Face the patient. Hold the hatpin between you and ask, Can you see the pin? Then ask the patient to cover their left eye while you cover or close your right eye. Use the hatpin to come in from each quadrant in turn. Tell the patient: Keep looking straight at me. Tell me when you first see the pin out of the corner of your eye.

Use your own fields as ‘normal’ to identify restric tions in the patient’s fields. Find the blind spot, estimat ing its size. Ask: Tell me when the pin disappears. Once it does, ask: And tell me when it comes back.

Repeat the same process for the other side. Note whether one or both blind spots are abnormally large (consider papilloedema, optic neuritis). Under standing the visual pathway anatomy is crucial to local ising lesions (see Figure 6.1). Table 6.1 illustrates the principal abnormalities that may be encountered.

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Figure 6.1 The visual pathway anatomy

TABLE 6.1 Visual field defects

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Fundi

Ask the examiners, Would you like me to examine the fundi? Occasionally you will be asked to do so. Get used to examining the patient’s right eye with your right eye and the patient’s left eye with your left eye. If you are able to use the ophthalmoscope with either hand, this will reduce the chances of you tilting your head in the path of the patient. Tell the patient: I’m going to look at the back of your eyes now. Could you please look straight at that corner? [pointing with the ophthalmoscope light]

Do not ask the patient to look at a light source or the pupils will constrict. Advise: Blink if you need to, but keep looking there so I don’t have a moving target. If my head gets in the way, try to still keep looking at the same spot.

Once the red reflex is found, move in and examine the optic disc. Follow the vessels out peripherally noting any pathology. Specifically look for haemor rhages, silver wiring and venous pulsation. Check the macula last of all by asking the patient to look at the light.

CN III, IV and VI: oculomotor, trochlear and abducens nerves

• oculomotor = moving the eye
• trochlear = acts via a trochlear attachment
• abducens = abducting

Eye movements tend to confuse those who have forgotten their anatomy (or never learned it in the first place). Understanding anatomy is fundamental to appreciating why the ‘direction of action’ of some muscles is almost the opposite of the direction in which they are tested. Figure 6.2 will refresh your memory. The photographs and diagrams demonstrate the muscles involved when testing eye movements.

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Figure 6.2 Anatomy of the extraocular muscles

(a) Muscles tested with eye movements

(b) Anatomy of extraocular muscles testing eye movements

(c) Anatomy of extraocular muscles in neutral position

The key is to consider the difference between the alignment of the resting visual axis (forward), the line of the orbits (out at an angle) and the angle of pull of the extraocular muscles in relation to these. These align with the eyes deviated ∼45 degrees and this is why we test up and down gaze in this position. The oblique muscles insert posterior to the rotational axis of the globe. Acting on their own as an individual muscle in the resting position, they each abduct the globe. The superior oblique will also cause the eye to look down and internally tort. The inferior oblique has the opposite effects. However, when the eye is adducted, the visual axis is aligned with the direction of pull of the obliques and so their actions are reduced to simply causing the eye to look up (inferior oblique) or down (superior oblique).

The same consideration applies to the superior and inferior rectus muscles — acting as isolated muscles in the neutral position, they each adduct the eye. However, they are tested with the eye abducted (aligning the pull of the muscles with the visual axis) by their ability to move the abducted eye up (superior) or down (inferior).

Once you have mastered this anatomy, practise drawing it and showing/teaching it to junior staff and medical students. A summary of the functions and innervations of the individual extraocular muscles is provided in Table 6.2.

TABLE 6.2 Extraocular muscles

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Extraocular muscles

With the hatpin (or ophthalmoscope) still in hand from testing CN II, now is the time to test eye movements. Using an ophthalmoscope has the advan tages of producing a light for the patient to focus on, a light reflection that highlights minor deviation between the eyes and a ready light source for testing pupil light responses, and keeps it poised if you have not examined the fundi and the examiners wish to direct you that way. Alternatively, use your torch. Do not shine the light directly at the patient’s eyes as this ‘blinds’ them and causes pupil constriction. Aim for the mid forehead level so you can see the light is still on. You can use your finger instead of the pin but it looks less ‘slick’ and, unless you hold it perfectly vertically, the patient may report diplopic images ‘at an angle’ when they are not.

If there is ptosis, you may need to hold the upper lids open. Even without ptosis, this does make abnormality of eye movement more obvious and so is a good technique to practise. Tell the patient: Keep looking at the pin [or light]. Tell me if you see double.

Move the pin from one side to the other holding it at each side (medial and lateral recti). Check for correct movement and nystagmus. The light reflection in the pupils is a sensitive test of misalignment if the patient fails to report diplopia.

Next move the pin out to one side and test up (and hold it to confirm both sides have moved) and down (holding and checking again). Referring back to our anatomy discussion, this is testing the various obliques and recti. Move the pin to the other side. Repeat the up and then down movements.

If diplopia occurs, enquire about the orientation of the images: Are they side by side or at an angle or above each other? The direction of gaze where the diplopia occurs or is maximal indicates the muscle involved. If there is any doubt which eye is the cause, cover one eye and ask: When I cover this eye, does the inside or outside one disappear? The outer image is always from the eye with the palsy.

If a disorder of gaze is observed, test each eye individually with the other covered. This is important for several reasons. First, it allows you to concentrate on one eye, reducing confusion as you try to remember the anatomy of both eyes at the same time. Second, it confirms which eye has the abnormality. Finally, it reveals disorders of conjugate gaze that may be con fus ed with medial and lateral recti palsies in particular.

Pupils

Examine the following:

• Size: check equality and estimate size in millimetres. Your acuity chart may have pupil size on it.
• Shape: irregular pupils may be due to trauma (including surgery), adhesions from past iritis or neurosyphilis.
• Light response: instruct the patient to look straight at you while you shine the light from the side. Swing the light in from the side so it does not obstruct your view. Do it twice for each side. The first time look for constriction of that pupil (direct reflex). Pause long enough to watch it dilate again. The second time, observe constriction of the other pupil (consensual reflex). Finish by ‘swinging’ the light between the patient’s eyes, observing the contraction of each as light is shone in it. Afferent pupil defects will become obvious only when this is done.
• Accommodation: hold your pin/ophthalmoscope at an arm’s stretch away from the patient. Tell them to keep looking at the light (or pin). As you bring it in, watch for convergent gaze and pupil constriction accompanying it.

Disorders

Common causes of disorders of eye movement include trauma and multiple sclerosis. Consider also CNS lesions including tumours, vascular malformations and brain stem strokes. A variety of neuromuscular disorders, as well as lesions of CN III and the sym pathetic nervous system can cause ptosis.

• Nystagmus: this is expected in normal individuals on extreme lateral gaze where it is brief. Only test lateral gaze to 45 degrees. Where one direction of nystagmus is faster, it is named in that direction. Learn a list of causes for horizontal and rotary nystagmus. Find a colleague who is very short-sighted and practise testing ocular movements on them without their glasses/contact lenses. Rotatory nystagmus should be expected.
• Horner’s syndrome: sympathetic innervation of part of the levator palpebrae superioris (raiser of the upper lid) causes ptosis, which is usually incomplete. Ocular movements are preserved, which differentiates this from a lesion of CN III. Look for the other features resulting from sympathetic loss on that side of the face: a constricted pupil (miosis), lack of sweating (anhidrosis) and sunken eye (enophthalmos). If present, follow the anatomical path of the sympathetic fibres backwards along the arteries (ophthalmic, carotids), root of neck/apex of lung (stellate ganglion) and back to the origin from T1. Proximal lesions will have the full complex, whereas orbital lesions will lack facial anhidrosis. Lesions of the lateral spinal cord (syringomyelia), brain stem (lateral medullary syndrome) or cerebral cortex will have other neurological features.
• CN VI: isolated lesions can cause a failure of abduction of the affected eye. Palsies of this nerve are not uncommon as CN VI has the longest intracranial course and is therefore subject to compression at multiple locations. Its crossed origin may lead to false localising signs with a diversity of conditions causing raised intracranial pressure.
• CN IV: isolated lesions of CN IV are uncommon but possible. The superior oblique has little influence on the resting eye and hence there is usually no obvious palsy on initial inspection. It becomes apparent with an inability for the adducted eye to look down.
• CN III: the upper eyelid and most of the extraocular muscles are supplied by CN III. Lesions may be complete or partial. In the resting position a complete lesion causes a prominent ptosis with the eye being pulled by the unopposed actions of CN IV (down and out) and CN VI (out). Partial lesions can be clarified by ‘adding together’ individual muscle defects.
• CN III and IV: an interesting challenge is to determine the presence of a CN IV nerve defect in the presence of a complete CN III defect. Remember that the adducted eye looking up tests CN IV, but a lesion of CN III makes adduction impossible! The solution: simply ask the patient to look to the other side. Although adduction is not possible, the superior oblique, acting on its own, will internally tort the eye. Inward rotation of the eye on attempted adduction confirms that CN IV is intact. Knowledge of anatomy is a wonderful thing!
• Internuclear ophthalmoplegia (INO): lesions of the medial longitudinal fasciculus cause an inability of adduction on the side of the lesion and nystagmus in the abducting eye. This is often bilateral and is almost always caused by multiple sclerosis. INO simulates medial recti palsies when both eyes are tested together. However, the astute clinician will test each eye individually while the other is closed, confirming the medial recti function (normal adduction) is intact and the condition is limited to a disorder of conjugate gaze — not a cranial nerve or extraocular muscle lesion. Bizarre defects of all three nerves may be seen in Wernicke’s encephalopathy, a syndrome caused by thiamine deficiency. It is characterised by a triad of ataxia, ophthalmoplegia and impaired short-term memory. A true unilateral INO has been described in this condition.

Bilateral defects in lateral gaze during conjugate eye movement (with nystagmus of the adducting eye) are most often associated with excess alcohol consumption and represent another form of INO. Normal abduction when testing eyes individually differentiates INO from bilateral CN VI lesions.

• Argyll-Robertson pupil: the pupil reaction associated with neurosyphilis is due to a defect in the Edinger-Westphal nucleus near the nucleus for CN III and results from dissociation of the accommodation and light reflexes. The easiest way to remember the lesion is with the aide memoir: just like contracting the syphilis, the pupil accommodates nicely but does not react well to light!

Holmes-Adie syndrome: this is due to a defect in the parasympathetic pathway. The parasympathetic fibres originate in the Edinger-Westphal nucleus near the origin of CN III and travel in the periphery of the optic nerve. They leave the nerve prior to reaching the globe and are distributed within the orbit via the ciliary ganglion. Interference with the parasympathetic pathway results in a dilated pupil, with reduced or absent light and accommodation reflexes. It may also be associated with other features, including decreased tendon reflexes.

Because of their peripheral location in the optic nerve, pressure on the nerve will often cause loss of parasympathetic function (dilated pupil) prior to visual defects. This is a classic finding with com pression from a berry aneurysm.

Of note, lesions of the visual pathway posterior to the Edinger-Westphal nucleus will have intact pupil reflexes.

• Marcus-Gunn pupil: disorders of the visual pathway anterior to the chiasm (afferent defects) can be caused by retinal or optic nerve lesions. Light perception is not relayed and so no light reflex occurs. However, a consensual response mediated via the parasympathetic fibres will cause constriction if the lesion is retinal or involves the optic nerve distal to the point at which the parasympathetic fibres depart the optic nerve. The good eye has both light reflexes; the one with the afferent defect only a consensual response. When a light is shone in the eye with the afferent defect, neither the ipsilateral pupil nor the contralateral pupil will constrict. However, the pupil will constrict from light in the other eye. ‘Swinging’ the light from one side to the other will cause constriction of both pupils when light is shone in the ‘good’ eye, but no constriction when shone in the eye with the afferent defect. As the light is swung from side to side, the ‘good’ pupil constricts relative to the one with the afferent defect. In particular, the side with the afferent defect will appear to dilate while the light is shone in it as it recovers from the constriction triggered by the previous consensual response.

CN V: trigeminal nerve

Named for the three sensory branches, it has a motor component as well.

Sensation

Begin by testing light touch. As you dab (not stroke) cotton wool on an area expected to have normal sensation, such as the upper sternum, explain: This is a piece of cotton wool. Can you feel this? Close your eyes. Say ‘yes’ when you feel me touch you.

Test the mid forehead on each side (V1), over the infraorbital region (V2) and the jaw below the outer border of the mouth (V3). These are roughly in a line that also coincides with the foraminal openings.

Test pin-prick sensation next. As you dab the pin against the same ‘test’ area as before, explain: This is a specially blunted pin that won’t hurt your skin. Is this sharp? Then, as you dab the blunted side, tell the patient: This is dull. Explain: Close your eyes. Say ‘sharp’ or ‘dull’ as I touch you.

Test as for light touch. If a ‘dull’ response is consistently obtained or no response is obtained, go back over that area. For areas that are abnormal, ensure that you have tested ‘sharp’ and ‘dull’ to ensure the patient isn’t simply saying ‘sharp’ or ‘dull’ to everything.

Motor

CN V supplies the muscles of mastication: masseter, temporalis and the pterygoids. It also supplies the tensor tympani and tensor palatini muscles, which are not normally tested. However, keep this in mind because defects of CN V will be associated with sensitivity to noise. This can be enquired about when the examiners ask what else you would do. It also explains why people clench their teeth and tighten their facial muscles (CN VII supplies stapedius) in response to loud noises.

Ask the patient to clench their teeth, and palpate the masseter and temporalis on each side. Get the patient to open their mouth, which will cause deviation to the side of weakness by the stronger pterygoids on the ‘good’ side. Finally, ask the patient to push against your hand while your hand is on the lateral jaw to test the pterygoids, confirming the side of weakness.

Taste

Although not often part of the examination, taste is easily tested with a salt sachet from the kitchen. Tear off the corner, dab the sachet on each side of the anterior two-thirds and posterior third of the tongue. Recall from your growing confidence with anatomy that taste sensation is derived from CN VII but the fibres travel with CN V after the chorda tympani join it shortly after exiting the skull in front of the ear. Innervation of the tongue is summarised in Table 6.3.

TABLE 6.3 Innervation of the tongue

Anterior two-thirds Posterior one-third
Touch V3 IX
Taste VII (superior salivary nucleus via chorda tympani) IX/X (inferior salivary nucleus)
Motor XII XII

Corneal reflex

The afferent limb is CN V; efferent is CN VII. Testing this reflex can be unpleasant if not necessary for the case, so before proceeding ask the examiners: Would you like me to examine the corneal reflex? Twist a corner of cotton wool and tell the patient: I’m just going to gently touch the corner of your eye. Use it to dab the lateral cornea, taking care not to enter the visual axis and to avoid touching the lids, both of which also cause the patient to blink. If there is no response, ask whether the patient is able to feel the cotton wool.

CN VII: facial nerve

Central causes (upper motor neuron lesions) are most commonly CVAs. Peripheral causes (lower motor neuron lesions) are typically Bell’s palsy, trauma-related or part of a wider neuromuscular condition. Facial muscles are most easily tested ‘top to bottom’ with instructions such as:

• Raise your eyebrows. The frontalis muscle is innervated bilaterally at the upper motor neuron level. Paralysis of one side indicates a lower motor neuron cause. Central lesions are usually not associated with weakness of the frontalis.
• Screw your eyes up tightly. If the eyes do not close, you may see the globe roll upwards (Bell’s phenomena).
• Don’t let me open your eyes. Normal strength prevents you from opening the eyes with upward pressure.
• Open your eyes and smile.
• Purse your lips. or Try to whistle.
• Puff out your cheeks. Tap the cheeks to see whether they are weaker on one side or whether air escapes from the mouth.

Taste can be tested if not done earlier.

CN VIII: auditory nerve

Hearing can be tested grossly by the ability to hear fingers rubbed or lightly flicked near each ear.

More sophisticated testing requires a tuning fork: 256 Hz is preferable but not essential.

• Rinne’s test: prime the tuning fork by pulling it between gripped fingers. Do not bang it against your hand or other object, as this can set up odd harmonics. Hold it in front of one of the patient’s ears and ask: Can you hear that? Place it over the mastoid and repeat the query. Move it back and forth and clarify: Which is loudest, in front or behind? Normally, air conduction is greater than bone. Bone is louder when there is a conductive loss on that side.
• Weber’s test: place the primed tuning fork in the middle of the patient’s forehead. Ask: Do you hear that better on one side or in the middle? The sound will be heard on the side of a conductive hearing loss or on the opposite side to a sensorineural loss. Try humming yourself and occluding one ear to confirm the way a conductive deficit localises (to that side).

The combination of Rinné’s and Weber’s tests should enable you to decide the side and type of deficit of hearing loss.

CN IX and X: glossopharyngeal and vagus nerves

• glossopharyngeal = tongue and pharynx
• vagus = ‘wandering’, as the nerve does throughout the trunk

These nerves are tested together by palatal move ments, gag reflex and sensation (touch and taste) to the posterior third of the tongue.

Ask the patient to open their mouth, and then shine a light inside. With a tongue depressor in hand ask the patient to say ‘ahh’. Weakness is like a puppet with a string broken: the affected side does not elevate as well or at all.

Testing light touch on the posterior third of the tongue and gag reflex on either side can be done with the tongue depressor touching either side of the posterior tongue and tonsillar beds accordingly. However, this is unpleasant if function is intact. Practise the technique during your practice sessions, but on the day ask the examiners: Would you like me to test the gag and posterior sensation?

CN XI: accessory nerve

The accessory (to the vagus) nerve provides motor supply to the trapezius and sternocleidomastoid.

Ask the patient to turn their head to one side and hold it there as you push against them and feel the sternocleidomastoid muscle on the other side. Then test the other side.

CN XII: hypoglossal nerve

• hypoglossal = below the tongue

The muscles on either side of the tongue push it out. Weakness causes deviation to the abnormal side. Lower motor neuron lesions may be associated with fasciculations. Ask the patient to push out their tongue as far as they can. If there is no obvious deviation, ask them to push it to the left, then to the right.

Cerebellum

Common introductions include:

‘Mr Jones has some difficulties with coordination [or gait]. Please examine this and anything else you find relevant.’

Less commonly, the lead may refer to speech or balance. A common mnemonic for features to demon strate is DASHING:

Dysdiadochokinesis
Ataxia
Slurred speech
Heel–shin
Intention tremor
Nystagmus
Gait (wide-based, positive Romberg sign).

Minimal postural changes to the patient make the exam ination appear much more professional. There fore, it is best to not demonstrate these signs in the order of the mnemonic but rather to use the mnemonic to ensure that they are all part of the examination.

Verbal response gives you a rapid assessment of speech. Problems with ataxia and tremor may be obvious from the outset. If you are confident with the signs from the early stages, you may wish to present these and then indicate as you go what you are going to do and outline your findings. With this approach, the examiners, the patient and you all become more relaxed. A sufficiently trained patient may even start the motions when you describe what is coming next!

The following approach is suggested:

• Unless there is some obvious reason not to walk the patient, go for gold from the outset. Ask: Is it okay for Mr Jones to walk? If the answer is yes, proceed with the ‘gait’ examination. A wide-based, ‘drunken’ ataxic gait gives you a warm feeling inside knowing you are on the right track. When combined with the highstepping, foot-slapping features of sensory deficit, you have almost diagnosed alcohol as a cause. However, do not assume that this is the only diagnosis as there are many causes of cerebellar dysfunction. Now would be a good time to describe exactly what you have just seen (or not seen, if this has excluded significant cerebellar dysfunction).

Get the patient to sit on the bed with their legs dangling over the side.

• If slurred speech has not been identified, use the ‘purple, turtle, lilac’ approach (see the section ‘Speech’ later in the chapter).
• If nystagmus has not already been witnessed, demonstrate it on lateral gaze bilaterally.

Dysdiadochokinesis is a sophisticated test. Remember the meaning of the word: dys- (abnor mality of), -diado- (alternating), -chokinesis (rapid movement). Make your instructions brief while demonstrating: Tap the back of your hand like this [demonstrating with palm down], now like this [using dorsal surface] and now back and forth like this as fast as you can. Okay, now let’s do the same again with the other hand.

Because you test both sides, there is no need to say left or right initially and, if the patient has a ‘good’ side, they will generally use that side (or their dominant one) first. This minimises ‘practise’. If there is a difference between sides ask: Are you left- or right-handed?

• Intention tremor (and past pointing) is best demonstrated by ‘finger–nose’ testing. Hold your finger in front of the patient’s nose far but enough away that the patient needs to extend their arm most of the way to reach it: this maximises any tremor present. Now ask: Touch my finger … Now your nose … Keep going back and forth.

Past pointing is maximal on the first cycle or two. After a few circuits when the patient has become comfortable, move your finger at the time they touch their nose to further demonstrate tremor and localisation difficulties. Then repeat: Okay, now the other hand … Touch my finger … Now your nose … Keep going back and forth.

By now you have demonstrated most cerebellar signs but still have a couple left . It may be time to start the discussion regarding synthesising your findings or, if you’ve already put it together, to start talking about possible causes. If you have been presenting your findings as you go, turn to the examiners and ask: Would you like me to continue with reflexes and heel–shin? If you have not been presenting your findings, the examiners may stop you at this point. When asked, ‘What else would you do?’, the answer in this case is completed with, I would complete my examination by confirming other features of cerebellar dysfunction that I have not yet completed such as pendular reflexes and heel–shin testing. This lets the examiners know there is more and gives them the option of proceeding or, being happy that your slick examination so far would only be continued, moving on to see how deep your differential diagnosis/causes list is. Otherwise, continue with your examination as follows:

• Pendular reflexes are pathognomonic for cerebellar disorders. Only use this term if you are happy with this diagnosis. Have the patient sit with their legs over the end of the bed, not touching the floor, and with their knees sufficiently off the bed to allow their legs to swing unimpeded. Tap the patella reflex without touching or holding the leg. In good cases, the leg will swing like a pendulum for several beats instead of the normal reaction of stopping after one. You will need to have seen this in practice to be convinced.
• The final section is the heel–shin test. If the patient is unable to walk, start in the supine position with this test (and complete the other components in the supine position, finishing with sitting the patient up for reflexes only if the patient is able). As always, instructions must be succinct and supplemented with a demonstration: Put your heel on your knee, run it down to your foot … Lift it high in the air back up to your knee … Do it again … . and once more … Now the other side.

A good patient will already be trained, but a good technique will train any patient! If the patient has trouble following instructions, hold their foot and take it through the motions for the first circuit or two.

Discussion

There are many causes of cerebellar signs, with alcohol the most common in society. Learn a list of causes and be familiar with particular features of any you mention. Inherited disorders such as Friedreich’s ataxia (autosomal recessive) are more common in examinations, particularly as they also have a number of other neurological signs (upper motor neuron signs with absent ankle jerks, optic atrophy, peripheral neuropathy), physical signs (pes cavus, cocked toes, kyphoscoliosis) and seemingly unrelated conditions (cardiomyopathy, diabetes mellitus). This creates a veritable ‘field day’ should you notice the other physical signs before the examiners ask the inevitable ‘What else would you like to examine’ and ‘What else could it be?’ Beware of diagnosing cerebellar pathology in patients with limb weakness, as any cause of paresis will impair the patient’s ability to complete many of the tests.

Upper limbs

A variety of introductions can be used, usually non-descript such as:

‘Mr Jones has some difficulties with [or weakness in or numbness in] his left arm. Please examine his upper limbs.’

Alternatively, you may just be asked to examine the limbs or perform a neurological examination of the peripheries. The examiners will endeavour to make it very clear what they want you to examine. If you have any doubt at all, ask. The examiners will not let you proceed along the wrong path.

Upper limb neurological conditions may be related to trauma (including axillary injuries with scars not immediately obvious), generalised neurological disorders, myopathies or neuromuscular disorders forming part of a named complex. Conditions such as motor neuron disease, muscular dystrophies and peripheral neuropathies can all be found in neurology outpatient clinics and frequently are used for undergraduate and postgraduate examinations. Spend some time in the neurology clinics!

Essential anatomical knowledge includes myotomes, dermatomes, peripheral nerve distributions, and the brachial plexus and spinal cord pathways. The sympathetic trunk may also be involved with lower brachial plexus injuries.

Mastering the anatomy will enable you to differ entiate between neuromuscular disorders, spinal lesions, brachial plexus injuries and peripheral nerve lesions. Learn the patterns of each. A useful starting point is to learn the features of a cord hemisection (Brown-Séquard), including which pathways are ipsilateral or contralateral (depending on the level the fibres cross). Table 6.4 shows a cross-section of the spinal cord demonstrating the principal pathways, while Figure 6.3 presents a coronal representation of the major spinal cord pathways. Note that a lesion affecting one side of the spinal cord (Brown-Séquard syndrome) will result in paralysis and loss of proprio ception and vibration sensation on the same side as the lesion, and loss of pain and temperature on the opposite side of the lesion. Once you have mastered the anatomy, learn the features of median, radial and ulna nerve lesions both proximal and distal.

TABLE 6.4 Spinal cord anatomy

image

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Figure 6.3 Coronal representation of major spinal cord pathways

Getting started

Patients are best positioned sitting with their head at an equal height to yours. Introduce yourself to the patient by shaking hands (which may demonstrate weakness or increased tone), and position the patient: Mr Jones, could you please sit facing me with your legs over the side of the bed? Let your hands rest in your lap.

In addition to positioning the patient, this may demonstrate any gross abnormality such as paresis as they ‘assume the position’. Enquire, Mr Jones, are you sore anywhere?, to ensure you will be able to proceed with your examination in the usual manner.

Take a step back and observe the surrounds and the patient from a distance. Look for symmetry, wasting, tremor, fasciculations and abnormal posturing. After you have focused on the upper limbs, quickly scan the rest of the patient, including face and lower limbs. Occasionally you will be rewarded with a pattern that ‘puts it all together’. For example, a patient whose arm is held in the ‘tip taking position’ and who has a wasted shoulder, tracheostomy scar and bicycle helmet but no other protective cycling gear can give you the diagnosis of upper brachial plexus injury (Erb-Duchenne palsy), most likely from trauma (traction), and associated with prolonged ventilation (tracheostomy) and head injury with poorly controlled epilepsy. If you can make this sort of diagnosis from the initial observation, you can also predict what you are likely to find.

After your inspection from a distance have a brief, closer look at the front and back of the patient’s arms, neck and axilla (lift the arm) for any scars.

Motor examination

Power is best assessed starting proximally and working distally.

Rapid assessment

The following gives a rapid global assessment:

Mr Jones, hold your arms out in front of you.

Turn your palms up to the ceiling.

Close your eyes and keep your arms there. [A drift will occur in the side with weakness.]

Open your eyes and rest your hands back in your lap.

Observe for fasciculations. Lightly flick the arm and forearm muscles if there is any evidence of fasciculation to highlight this to the examiners.

Tone

Check each arm for tone by holding the patient’s hand in the ‘handshake’ position and gently ‘shaking’ the limb. If tone is increased, try to determine whether it is uniform or more pronounced proximally or distally.

Power

The technique is to get the patient to move if they can and then to push against you resisting. If power is limited, you may need to orientate the joint involved so that gravity is eliminated. For each joint, position the patient and then test power with the instruction, Push against me, as you hold your hand at the end of the ‘lever’ so you have maximal ability to resist their movement. For some movements the instruction, Stop me moving you, will work better. Practise each and see which works best for you. Table 6.5 contains mixed examples of these instructions. Grade each muscle group as per Table 6.6.

TABLE 6.5 Examination of upper limb myotomes

Myotome Examination technique
Shoulder abduction (C5, 6) Mr Jones, lift your arms out to the side like chicken wings [demonstrate]
Push against me [with your hands on top of the elbows]
Shoulder adduction (C6, 7, 8) Bring your arms in to your side
Push against me[with your hands on the medial aspect of the elbow]
Elbow flexion (C5, 6) Pull your hands up to your shoulders [position the palms in full supination]
Stop me moving you [pull outwards on each arm in turn]
Elbow extension (C7, 8) Push against me [with your hands on the back of each hand in turn]
Wrist flexion (C6, 7) Bend your wrists down [demonstrating yourself with the arms held forward, fully prone with fingers clenched into a loose fist]
Stop me moving you
Wrist extension (C7, 8) Now bend them up
Stop me moving you
Finger extension (C7, 8) Straighten your fingers
Stop me moving you
Finger flexion (C7, 8) Grip my finger [offer only one finger to grip; two or more can be crushed. Attempt to slide your finger out]

TABLE 6.6 Grading muscle power

Power Description
0 Nothing
1 Flicker
2 Movement but unable to overcome gravity
3 Able to overcome gravity, not resistance
4 Able to overcome some resistance, not normal strength
5 Normal

Reflexes

Make sure the patient’s arms are relaxed by asking the patient to rest them in their lap again. For the biceps (C5, 6) and supinator (C5, 6) jerks, a more consistent result is obtained by placing your thumb against the biceps tendon and your finger over the brachioradialis muscles and tapping your digit rather than tapping the patient directly. The triceps (C7, 8) reflex is best elicited by tapping the tendon directly.

If the reflexes are brisk, you can demonstrate this firstly by tapping more softly with the hammer and then directly with your index finger. You may also choose to demonstrate a finger jerk by flicking the DIP joint of the middle finger (Hoffman or finger flexion reflex). If this is also positive, you may be able to elicit clonus of the elbow and/or wrist joints.

If the reflexes are difficult to obtain, they can be ‘reinforced’ by getting the patient to clench their teeth just before you tap each one out.

Specific tests of the peripheral nerves in the hand

• Ulnar nerve: testing for finger abduction (C8, T1) — slide your eye chart between the patient’s fingers, advising: Keep your fingers straight. Bring them together. Stop me sliding this out. Testing for Froment’s sign, slide your eye chart between the patient’s thumb and index finger, advising: Grip this between the tips of your thumb and finger. Stop me sliding it out. If the patient has to resort to ‘pad-to-pad’ pinch (thumb flexion from the flexor pollicis muscle), this sign is positive (due to weakness of the adductor pollicis muscle supplied by the ulnar nerve).
• Median nerve: the mnemonic LOAF describes the small muscles in the hand innervated by the median nerve:
Lumbricals (usually two lateral)
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis.

With the patient’s hand still supinated from testing Froment’s sign, hold your finger directly above the patient’s thumb and instruct them to touch your finger. Failure to abduct indicates a deficit (weakness of the abductor pollicis brevis muscle). Placing a coin on the table and asking the patient to pick it up tests both median nerve sensation and motor function (flexion, opposition).

• The radial nerve has no motor innervations in the hand.

Shoulder

If the signs are confined to the shoulder region, examine the patient from behind, specifically testing all movements of the shoulder (abduction, adduction, internal and external rotation, flexion, extension), and palpating the supra and infraspinatus muscles. Test for winging of the scapula (serratus anterior muscles) by asking the patient to push forward with outstretched hands and palpate the rhomboids when the patient attempts to pull the shoulder blades together at the back. From the front, inspect and palpate the sternal and clavicular heads of the pectoralis major muscle while pulling on a ‘monkey grip’. After testing abduc tion, test sensation over the deltoid for evidence of axillary nerve deficit.

Sensory examination

Start initially with testing each dermatome, and test peripheral nerves subsequently. To recall the dermatomes, remind yourself of the brachial plexus arising from C5, C6, C7, C8, T1. The middle of these is also the supply for the middle finger (C7). If you hold your left hand up with fingers extended and touch your index finger to your thumb you make the number ‘6’, reminding you C6 supplies that side of the hand and forearm. C8 supplies the other side and C5 and T1 supply the lateral and medial arm, respectively.

• C5 — lateral arm
• C6 — lateral wrist
• C7 — middle finger
• C8 — medial wrist
• T1 — medial arm

Instruct the patient to hold their arms in the anatomical position to bring the dermatomes into alignment for testing. Tell them, Turn your hands out like this, while demonstrating the anatomical position. Test light touch and pin-prick sensation as outlined in the cranial nerve section above.

Specific tests of the peripheral nerves in the hand

There is a large amount of overlap between the periph eral nerves. These areas are most consistently supplied by the following nerves, allowing you to limit your examination to the hand:

• ulnar nerve: ulna aspect of little finger
• median nerve: pad at tip of index finger
• radial nerve: on the dorsal surface, between the MCP joints of the thumb and index finger.

Vibration

Select your 128-Hz tuning fork and prime it as described earlier. Press it against the patient’s sternum and ask: Can you feel that buzz? Once confirmed, begin testing by pressing on bony points starting distal — if negative, move proximally, and if normal, move on to position sense testing (see below). Begin with the dorsum of the thumb MCP joint. Tell the patient to close their eyes as you prime the tuning fork, then ask: Tell me when you feel the buzz. Once confirmed, ask: Tell me when it stops. Stop the tuning fork with your fingers after a brief interval to confirm what the patient is telling you. If necessary, test the ulna styloid and then the ulna olecranon.

Position sense

This is tested by holding either side of a joint, not top and bottom, as differences in light touch between the top and bottom ‘give the game away’. Tell the patient, Close your eyes. Begin with a finger. Advise, This is up, followed by This is down, as you demonstrate the movement. Then ask: Tell me which way I move it. Lift up or down. If there is no answer, prompt with: Where is it now? If proprioception is impaired at the fingers, repeat the procedure at the wrist and then elbow until a normal response is obtained.

Discussion

If there are multiple findings as you progress, it may be best to present them as you discover them. This approach ensures that you do not miss reporting any findings later. Presenting in the same logical sequence that you examined is an alternative (e.g. inspection, tone, power, reflexes, sensation). If you are confident with your findings, you should anticipate and consider your responses to the ‘usual’ questions.

‘What else would you like to examine?’

You would like to complete the neurological exami nation including the lower limbs and whatever else seems relevant (e.g. cranial nerves, cerebellar function) as dictated by your findings. Looking at the base of the neck and lifting the arm to see the axilla are essential to identify scars from surgery or trauma and other lesions that may be the causes of the condition you have identified. If you are assured of the findings, you may suggest further examination that would confirm your diagnosis or provide other signs of causes or complications.

‘Present your findings so far’

Only present relevant positives and negatives. If you have an overarching assessment (e.g. proximal myopathy, lower brachial plexus injury, distal ulnar nerve deficit) then start with this and support your assess ment with the findings. If you have been presenting as you go, this question will not be asked.

‘Can you put these findings together?’

Think whether it is possible to explain the findings with a single diagnosis. Sometimes there is more than one condition present, and some neurological con ditions remain undiagnosed! The focus of this exam in ation is more on your ability to examine and syn thesise information than to come up with a specific (and particularly so if rare) diagnosis. Consider, however, whether the lesion is central (often bilateral, increased tone, increased reflexes, limited to motor or sensory modality loss or cerebellar signs) or peripheral (fasciculations, reduced tone, depressed or absent reflexes). If mixed motor and sensory lesions, consider whether it fits a cord level or peripheral nerve distribution.

‘What else could it be?’ and ‘What supports one differential over another?’

Have a differential diagnosis list prepared for the var ious conditions.

‘What else could you do to clarify the diagnosis further?’

Imaging is the most common answer. Plain films, CT and MRI may be indicated, depending on the likely lesion and location.

‘Are there any features suggesting a specific aetiology?’

By this stage the question has most likely already been addressed.

Lower limbs

This examination and its introduction are similar to that for an upper limb neurological examination. A variety of introductions can be used, usually non-descript such as:

‘Mr Jones has some difficulties with [or weakness in or numbness in] his left leg. Please examine his lower limbs.’

Alternatively, you may just be asked to ‘examine the legs’. If the introduction is, ‘Mr Jones has difficulty walking’, it is reasonable to ask to test this first. Most of the conditions affecting the upper limbs can also present in the lower limbs.

In addition, spinal cord lesions and complications from polio are more frequent in the lower limbs. Specific to the lower limbs are conditions associated with neural tube defects. You must ensure you look at the patient’s back at some stage — the earlier the better.

As with the upper limbs, essential anatomical knowledge is fundamental. This includes myotomes, dermatomes, peripheral nerve distribution, and the lumbosacral plexus and spinal cord pathways.

Getting started

Begin in the same way as for the upper limb exami nation. The patient can either be supine or sitting with their legs over the side of the bed as for the upper limb examination. Practise both techniques, as some patients are not able to sit safely. Regardless of position, the patient’s legs must be fully exposed, with modesty protected by underwear, a towel or both. Enquire, Mr Jones, are you sore anywhere?, to ensure you will be able to proceed with your examination in the usual manner.

Take a step back and observe the surrounds and the patient from a distance. Look for symmetry, wasting, tremor, fasciculations and abnormal posturing. After you have focused on the lower limbs, quickly scan the rest of the patient including their face and upper limbs.

After your inspection from a distance have a brief, closer look at the front of the legs, the back of the legs and the patient’s back for any scars.

Motor examination

If possible, begin by asking: May I see Mr Jones walk? If your request is permitted, proceed with the gait examination. At the end of the gait examination, test ability to squat and rise (proximal myopathy). The detailed neurological examination can then follow. If your request is declined, proceed as follows.

Tone

With the patient supine, check each lower limb by ensuring it is relaxed and then briskly lift the knee slightly off the bed and observe how the leg follows. If tone is increased, try to determine whether it is uniform or more pronounced proximally or distally. For the sitting patient, test tone on each side by lifting the leg from below the knee in a similar fashion.

Power

Use the same technique as for the upper limbs, which is outlined in Table 6.7.

TABLE 6.7 Examination of lower limb myotomes

Myotome Examination technique
Hip flexion (L2, L3) Push against me [with your hands on the distal thigh]
Hip extension (L5, S1, S2) Stop me moving you [as you attempt to lift from behind the distal thigh]
Hip abduction (L4, L5, S1) Push against me [with your hands on the proximal outer thigh]
Hip adduction (L2, L3, L4) Stop me moving you [as you resist with your hands on the medial thigh]
Knee flexion (L5, S1) If supine, test with the knees bent up to 90 degrees
Push against me [as you resist with your hands underneath the leg]
Knee extension (L3, L4) If supine, test with the knees bent up to 90 degrees
Stop me moving you [as you push with your hands on the front of the leg below the knee]
Ankle dorsiflexion (L4, L5) If supine, test after extending the knee
Pull up against my hand [as you press on the front of the foot]
Ankle plantar flexion (S1, S2) If supine, test after extending the knee
Press down on my hand [as you press up on the sole of the foot]

Reflexes

If the patient is supine, rest both knees on your arm to ensure they are relaxed, then tap over the patella tendon (knee L3, L4). Turn the leg out into a ‘frog’ position for the ankle jerk (S1, S2). It is helpful to cross the limb being tested to the other side so that the ankle is resting over the distal shin of the opposite leg. This makes it easier to access the tendon. Test the plantar response (S1) by running the blunt end of your pen or a key up the lateral aspect of the sole of the foot. Do not use sharp instruments that could cause pain and/or leave marks.

If the reflexes are brisk, demonstrate this as des cribed for the upper limbs. Attempt to elicit clonus of the ankle and/or knee joints by brisk then sustained upward pressure on the soles and by downward pres sure on the patella, respectively.

Similarly, if the reflexes are difficult to obtain, getting the patient to clench their teeth or make a ‘monkey grip’ and pull just before you tap each one out can ‘reinforce’ them.

Sensory examination

Start initially with testing each dermatome. Testing peripheral nerves is usually limited to foot sensation for the plantar nerves and differentiation between the superficial and deep branches of the common peroneal (tibial) nerve. The deep branch supplies the dorsal webspace between the hallux and second toe. Test light touch and pin-prick as recommended in the cranial nerve examination. Test the ‘middle’ of each dermatome in turn:

• L1 — groin
• L2 — anterior thigh
• L3 — over patella
• L4 — medial leg
• L5 — lateral leg, most of the dorsum of the foot
• S1 — lateral aspect of the dorsum and sole of the foot (‘we stand on S1’)
• S2 — back of leg
• S3, 4, 5 — form concentric rings verging on the anus (discuss with the examiner before testing these).

Vibration

Select your 128-Hz tuning fork, and prime and intro duce it as described earlier. Begin with the dorsum of the hallux MCP. Test (if necessary) the lateral malleolus of the ankle, tibial tuberosity and finally the anterior superior iliac spine.

Position sense

Use the hallux. If proprioception is impaired, repeat the procedure at the ankle and then the knee until a normal response is obtained.

Discussion

If there are multiple findings as you go, it may be best to present them as you discover them. This approach ensures you do not miss reporting any finding later. If you are confident with your findings, you should anticipate and consider your responses to the ‘usual’ questions.

‘What else would you like to examine?’

You would like to complete the neurological examina tion including the upper limbs and whatever else seems relevant (e.g. cranial nerves, cerebellar function) as dictated by your findings, including looking at the back if not already done. If you are confident of the findings you may suggest further examination that would confirm your diagnosis or provide other signs of causes or complications.

‘Present your findings so far’

Only present relevant positives and negatives. If you have an overarching assessment (e.g. proximal myopathy, common peroneal (tibial) nerve deficit), then start with this and support your assessment with the findings. If you have been presenting as you go, this question will not be asked.

‘Can you put these findings together?’

Think whether it is possible to explain the findings with a single diagnosis. Sometimes there is more than one condition present and again some neuro log ical conditions remain undiagnosed! If operations have been performed involving tendon transfers, it may be extremely difficult to synthesise the findings. The focus of this examination is more on your ability to examine and synthesise information. Consider, as with the upper limb examination, whether the lesion is central or peripheral. If mixed motor and sensory lesions, consider whether it fits a cord level or peripheral nerve distribution.

‘What else could it be?’ and ‘What supports one differential over another?’

Have a differential diagnosis list prepared for the various conditions.

‘What else could you do to clarify things further?’

Imaging is again the most common response. Plain films, CT and MRI may be indicated depending on the likely lesion and location.

‘Are there any features suggesting a specific aetiology?’

By this stage the question has most likely already been addressed.

Gait

A slick examination of gait is done with a single ‘lap’. Walking the patient up and back several times is exhausting and time-consuming, looks disorgan ised and gives no more information than a single lap with efficient purpose. Do it once, do it right, and move on.

The patient should be bare footed with their legs fully displayed while preserving modesty. The patient’s pyjama bottoms can stay on provided they are not in danger of tripping the patient, but will have to come off or up when examining the legs for a neurological examination.

Although the patient will generally be well trained by the time they see you, you should develop a technique that works for the uninitiated. Try it out in your everyday practice. The fewer words in your instructions, the better.

Mr Jones, could you please stand beside the bed?

Stand beside the patient. Identify a good place you can walk to in a straight line with room to walk alongside the patient all the way. Place one hand around and close to but not touching the patient’s far shoulder to demonstrate that you can catch the patient if they become unstable.

Walk with me towards that corner [or whatever your chosen destination is].

After a few steps are taken, before you reach the half-way mark and without stopping, instruct: Now one foot in front of the other, heel to toe. [demonstrating yourself while giving the instruction].

Now stop. Turn around. Let’s walk back.

As the first step is taken, instruct: On your toes if you can [for two or three steps] and now on your heels, which should then bring you back to the bedside.

Good. Now stand just in front of the bed and face me.

Ensure that the patient is close to but not touching the bed. This way they cannot fall backwards and you can safely demonstrate signs in front of them.

Put your arms by your sides and your heels together.

Observe whether the patient is able to stand un aided. If able, place a hand on either side of the patient’s shoulders, near but not touching, to reassure both patient and the examiners and ask the patient to close their eyes. There is no need to give the patient a push as some medical students are taught. If the patient is unable to remain stable (positive Romberg test), this will be apparent within a few seconds. A positive Romberg test indicates impaired coordination. It is not a test of cerebellar function, although is often present in cerebellar disorders.

Learn to recognise the common patterns: the ‘drunken gait’ of cerebellar dysfunction; the high-stepping, foot-slapping gait of peripheral sensory loss (often caused by alcohol); antalgic gait (painful lesions); paretic gait (hemiparesis); the swing of a foot drop; and the shuffling Parkinsonian gait.

Parkinson’s disease

You may be told the diagnosis or asked to assess gait or speech. When you introduce yourself and step back to observe the patient from a distance, you may notice a walking frame as well as these typical features:

• expressionless face
• absent blinking
• head bobbing (titubation)
• dribbling from the corner of the mouth
• paucity of limb movement
• resting, pill-rolling tremor.

Ask the patient to state their full name and the day’s date. The slow, quiet, monotonous voice is characteristic.

Test gait if permitted (most likely) or if directed. The slow, shuffling gait is characteristic, along with difficulty starting and freezing. Asking the patient to turn around suddenly and to stop and start highlights these.

Propulsion and retropulsion (inability to stop shuffling once ‘pushed’) are classical signs, but are high risk just to demonstrate during a stressful exam. Mention that these features would be expected and give the examiners the opportunity to decline: I anticipate Mr Jones would demonstrate propulsion and retropulsion. Would you like me to demon strate these? This may give you points without risking unintentionally pushing Mr Jones over in your exam-fuelled enthusiasm! Should the examiners think both Mr Jones and you are up to it, they will permit it.

After gait is assessed, demonstrate the remaining features:

• tone: ‘lead pipe’ or ‘cog wheel’ rigidity on wrist pronation/supination
• tremor: maximal at rest; disappears on finger–nose testing
• dysdiadochokinesis: will be present
• facial features and speech: comment on these if not already done
• glabellar tap: continuous blinking on tapping the forehead with your finger while ensuring your finger is not visible to the patient
• micrographia: writing will be small when the patient is asked to write a sentence.

Finish by testing for frontal lobe signs and progress to higher mental functions if time permits.

Speech

Disorders of speech can reflect difficulty with the mech anical movement (dysarthria) or content (dysphasia). Dysarthrias usually imply cranial nerve palsy, cere bellar dysfunction or some other mechanical disorder resulting from neuromuscular dysfunction, trauma or mass lesions. Dysphasias (or aphasia if no response) can be expressive, reflected as difficulties in naming objects (nominal dysphasia) or problems with per ception (understanding instructions). Dysphasias are typically cortical in origin and may be associated with other neurological signs and symptoms, some of which may form a named syndrome. Some are more common and/or interesting than others and hence are more likely to come to your ED or turn up in the exam.

For example, Gerstmann’s syndrome (dominant parietal lobe disorder) is a combination of:

Acalculia (difficulties with simple arithmetic)
Agraphia (writing difficulty)
Left–right disorientation
Finger agnosia (unable to name fingers).

These features may be recalled using the mnemonic AALF. If present, examine the visual fields for a right inferior quadrantanopia.

Getting started

Begin by asking the patient their full name and the day’s date. This should give an indication of whether you are dealing with a dysarthria, a dysphasia or a disorder such as cerebellar dysfunction or Parkinson’s disease.

Dysarthrias

Ask the patient to say ‘purple, turtle, lilac’. Difficulties in saying individual words localise to the structure starting with the same letter: purple = pharynx; turtle = tongue; and lilac = larynx. Once a disorder is identified, progress to testing of the lower cranial nerves and cerebellum.

Dysphasias (or aphasia if no response)

Determine whether this is receptive, expressive, nominal or some other variety. Having already asked the patient to say ‘purple, turtle, lilac’, you will know whether there is a problem with reception. Present the patient with a pen. Ask: What is this? If there is no response (aphasia) or the wrong but a related word is given, progress to: What do you do with it? A fluent response with incorrect, often totally unrelated content suggests receptive dysphasia. Expressive dysphasia will be apparent if the patient seems to understand the question but struggles to structure a fluent response. These individuals will subsequently be able to follow written instructions such as ‘write your name’ or ‘close your eyes’. Nominal dysphasia will be detected by asking the patient to name a part of the pen, such as the nib or lid: they will be unable to do this.

Higher mental functions

‘Mr Jones has difficulty with memory, please test his higher mental functions.’

If the introduction includes any specific features, this may provide clues regarding further examination after higher mental functions have been assessed.

Introduce yourself, shaking the patient’s hand. Ask about hand dominance and use your standard start of: Mr Jones, could you please state your full name and the date today. This tests orientation and may indicate a speech disorder or give other clues how to proceed. If nothing is forthcoming to direct you specifically, test speech, memory and then the cortical lobes in turn.

Memory

Test short-term memory by asking the patient to recall three objects. Pick simple ones that everyone would know, such as cutlery and crockery items. Test immediate recall. Test long-term memory with general knowledge. ‘Who is the Prime Minister?’ sometimes produces interesting responses! At the end of the session do not forget to prompt for recall of the objects you asked the patient to remember.

Parietal lobe

Test the patient’s ability to do up and undo buttons and ask them to demonstrate for you how they use a key, to look for apraxia.

Ask the patient to write their name in full. Follow by asking them to draw a clock, marking in the numbers and putting the hands at ‘20 past 8’. If they have difficulty with the clock, ask them to draw a house and then mark in a door, windows and a chimney. Observe for visual inattention.

Draw a five-point star and ask the patient to copy it to assess constructional apraxia. When doing this in clinical practice, label your and the patient’s artwork so that those reading the notes later can assess your star-drawing ability as well as the patient’s!

Test for nominal aphasia and all the features of Gerstmann’s syndrome. Assess for sensory inattention by touching one of the patient’s hands, then the other. They should identify you have done this; however, when both hands are simultaneously touched the patient will be unable to detect that you have done this on the affected side.

Evaluate the patient’s ability to recognise num bers drawn on their palms (graphaesthesia) or identify objects with palpation with the eyes closed (stereognosis).

Frontal lobe

Practise your frontal lobe reflex testing on babies during your paediatric sessions:

• palmar mental reflex: contraction of ipsilateral mentalis muscle pulling the corner of the mouth down when the palm is firmly stroked
• pout: when the lips are tapped
• rooting: the mouth draws towards a finger stroked on the side of the mouth
• grasp: the patient will grasp and not let go of a finger stroked across the palm.

Asking the patient to explain a proverb such as ‘a rolling stone gathers no moss’ or ‘people who live in glass houses shouldn’t throw stones’ tests abstract thinking. Proverbs are culturally specific so, if the patient does not understand these, ask whether they know any others. As you do this more often you will learn new ones. An associated expressive dysphasia may also make this difficult.

Finish by asking the patient to recall your three objects again to test five-minute recall.

Discussion

Wherever possible, try to find a unifying diagnosis or anatomical location of a lesion. When asked what you would like to do further, this will guide you. In most cases further neurological testing will be indicated, including visual fields, cranial nerves and limbs.

Respiratory system examination

Respiratory cases are in plentiful supply as most chronic respiratory conditions induce signs that do not go away (unless they are surgically removed or replaced with a transplant). As with the abdominal examination (in the next section), it is difficult to give anything other than a nondescript introduction without giving a localising clue. For the sake of brevity you will usually just be introduced and asked:

‘Please examine Mr Jones’ chest [or respiratory system].’

The prevalence of chronic respiratory disease in child hood makes a paediatric respiratory short case even more likely than a cardiac or neurological one.

Getting started

As always, introduce yourself to the patient and step back to survey the scene. The respiratory examination is one where there may well be clues waiting for you on the bedside table or scattered elsewhere: a walking frame, wheelchair, oxygen cylinder or oxygen on the patient, sputum mug, metered-dose inhaler and peak-flow meter are just some of the possible clues. If there is a sputum mug, ask to look inside it. If you have been doing short cases properly, you will have looked into quite a few of these and realised why examination of the sputum mug is part of the standard ‘respiratory’ ward round. If there is no mug present, you must ask if one is available. The contents will help you incredibly.

The respiratory examination is also one where much information can be obtained before laying hands on the patient. After positioning the patient in your pre ferred way (see below), the following approach is recom mended, even if your instruction is to examine the chest. The examiners will move you on if they really do not want you to assess general function.

Mr Jones, could you please put your arms out straight in front of you with your wrists bent back like this?

While the patient is poised and you are waiting to see whether asterixis (CO2 retention) develops, you can check the patient’s general appearance, count the respiratory rate, check for pursed-lip breathing and use of accessory muscles, and determine whether this level of exertion has any effect on the patient during the time it takes to count the respiratory rate.

Thank you, Mr Jones. You can put your arms down now. When you’re ready, please take a deep breath in and blow it out for as long and hard as you can.

Encourage them to keep going if it is prolonged and/or if effort appears to be less than full. In some patients this will precipitate a coughing episode, which further clarifies their condition and physiological reserve. If a cough has not been induced already, ask for one now. Have a tissue ready in case it is productive, in which case you now have sputum to examine.

Some candidates prefer to examine the patient sitting in bed normally, some prefer the patient to have their legs over the side or end, some examine the patient initially from behind and some prefer to have the patient seated in a chair. A chair may not always be available, so we encourage you to become familiar with examination on the bed as well. Use whichever works best for you, but become comfortable with alternatives in case the patient is unable to swing their legs over the side of the bed or sit in a chair.

Peripheries

Once again, the respiratory examination has great potential for peripheral stigmata. As well as signs already tested, clubbing can be caused by any malignant or chronic inflammatory pulmonary condition. The hallmarks are increased nail-bed sponginess and loss of the angle at the nail base — not just curvature of the nail, which can be a normal finding. Look for tar staining from smoking (check both hands), evidence of anaemia, cyanosis (which could be peripheral or central) and muscle wasting associated with chronic respiratory disease or malignancy (either cachexia or an apical tumour invading the lower roots of the brachial plexus).

Inspect the face for Horner’s syndrome, anaemia or cyanosis (central). The voice may be harsh from smoking, hoarse from a recurrent laryngeal nerve injury or palsy, or oesophageal if a laryngectomy has been performed. The face and neck may also show the typical facies and buffalo hump from steroid excess.

Chest

The peripheral examination, although rewarding, does tend to take up some time. A substantial portion of the seven minutes may have passed before you get to the chest. For this reason, we recommend you maximise your time by examining first those areas that are likely to produce results.

Moving down from the face, check for cervical nodes, supraclavicular masses or nodes, the trachea for midline shift , whether the apex beat is palpable or displaced and whether there are any obvious scars on the front (e.g. from chest drains or thoracotomies). This gives information regarding upper and lower mediastinal shift , which, when combined with evidence or absence of surgery, indicates possible contractions, lobectomy or pneumonectomy.

At this point, you will gain more information from examining the back than the front, so proceed to the back. Some candidates instruct the patient to touch their elbows together to move the scapula laterally. In reality, this has little effect on the examination finding and is uncomfortable for the patient. Practise this technique if you find it aids your examination findings or become comfortable letting the patient adopt a position of ease, which usually involves placing their hands on their legs and splinting, a manoeuvre that also causes the scapula to move laterally but without discomfort. Inspect for scars again. Most surgical incisions are more prominent from behind and may not even be visible from in front.

Check expansion of the upper, mid and lower zones. Upper lobe expansion may best be assessed by looking over the patient’s shoulders at the front of the chest, rather than from encircling the hands around the chest wall and observing their movement with breathing.

Percuss down both sides, remembering to check the axillae. Dullness should be described as ‘stony’ only in the presence of definite signs of a pleural effusion. Tactile fremitus is rarely contributory and not essential.

Check breath sounds carefully: Mr Jones, take some breaths in and out through your mouth. They don’t have to be too deep, but must be through your mouth. If necessary, you can instruct them to take larger breaths if breath sounds are still hard to hear. Bronchial breath sounds are equal in volume during inspiration and expiration with a pause in-between. Bronchial breath sounds result from solid material connecting larger airways with the lung periphery (consolidation, fibrosis including surgical scars, solid tumours). Tracheal breath sounds are ‘bronchial’ in nature.

Listen for adventitial sounds. Crackles that clear with coughing indicate exudative lesions with material that can be ‘moved’ (e.g. bronchitis, bronchiectasis). Non-clearing crackles indicate fixed obstructions (e.g. fibrosis, non-exudative alveolitis). Wheezes result from narrowed medium and small airways and are commonly seen with asthma, obstructive air ways disease and acute bronchitis. They may be expiratory and/or inspiratory. Inspiratory stridor is due to extrapulmonary obstruction (larynx, trachea). Expiratory stridor is due to intrapulmonary large airway obstruction.

Rubs result from pleural friction. The sound is classically described as like wet ships’ ropes stretching. Check out a nearby harbour if in doubt. Rubs are generally heard at the point of pleural separation due to fluid. Every patient with a pleural effusion will have a rub near its apex if you examine closely enough.

Vocal resonance is tested by auscultating while the patient speaks: Mr Jones, say ‘ninety nine’ [or ‘one’] every time I touch your chest. Listen carefully in all areas including the axillae. Vocal resonance is increased by the same sound-conducting lesions that are associated with bronchial breathing, but may occur in the absence of bronchial breathing if larger airways are not involved.

Whispering pectoriloquey is the ability to hear a whispered ‘ninety nine’ (or ‘one’) clearly on auscultation. It is an eloquent sign resulting from the same circumstances that produce increased vocal resonance and bronchial breath sounds.

After examining the patient’s back carefully, you are likely to have found most, if not all, the physical signs present. With practice, ensuring you listen once, listen carefully and move on, you will be able to complete the entire examination within seven minutes. If you have practised well and time permits, repeat the above sequence on the front of the chest. Mostly this will serve to reinforce the signs you have already elucidated, giving you time to ‘put it all together’.

Discussion

The most common opening from the examiners will be as follows.

‘What else would you like to examine?’

As well as going on to complete your peripheral examination (if you were confined to examining the chest), you would complete those components of the examination above that have not been done, take a set of observations paying particular attention to SaO2 (this will usually be given when asked) and then proceed on to a full general examination. You may wish to do a Pemberton’s test if a superior vena caval obstruction is possible (e.g. probable pulmonary malignancy). The detail you focus on will most often include a cardiovascular examination for evidence of cor pulmonale and can be directed towards specific conditions you have identified.

‘Present your findings so far’ and ‘Can you put these findings together?’

Remember the patient’s general appearance, your findings around the bed and evidence gathered from the peripheral examination. If you are able to produce an overarching diagnosis and feel comfortable justifying it, now would be the time to say so and then back it up. Stick to relevant positive and negatives rather than a blow-by-blow description of the detailed examination.

‘What else could it be?’ and ‘What supports one differential over another?’

Use your pre-prepared and memorised lists of causes for clubbing, mediastinal shift, dullness to percussion, crackles that clear or not, bronchial breathing and so on to differentiate between exudative, ‘solid’ and ‘liquid’ conditions. If you are unsure, going through this rationally with the examiners demonstrates your clinical acumen, which is what the examination is all about.

‘What else could you do to clarify things further?’ and ‘Are there any features suggesting a specific aetiology?’

Formal respiratory function testing and a chest X-ray should be included in almost every answer. Further examination or investigation will help with the ‘complications’ and ‘cause’. If all goes well, these final questions will have already been dealt with.

You may be shown a chest X-ray if it is either interesting or confirms your findings. Time constraints usually prevent this, although briefly being shown an image confirming your diagnosis of ‘right middle lobe consolidation’ is a nice way to finish off a respiratory short case.

Abdominal examination

It is difficult to begin with any introduction other than:

‘This is Mr Jones. Please examine his abdomen [or gastrointestinal system].’

Any other introduction tends to give you too big a clue. If you are asked to examine the gastrointestinal system, start with a general and peripheral exami nation. If you are directed to the abdomen, focus on this, although a brief general examination is likely to be permitted. You will be stopped if you are taking too long to get to the abdomen. After completing the abdominal examination, you may wish to keep examining until you are interrupted, returning to the peripheries and performing a directed examination that is relevant to your major findings.

Getting started

Introduce yourself to the patient with a handshake, ensure that the patient is supine and comfortable, and enquire about any painful areas. You can now do this in your sleep (and may do). Take your well-practised step back. The surroundings may not offer many clues, but significant organomegaly is often visible on simple inspection from the other side of the room. In fact, it is often more easily appreciated from this distance.

Scan the patient for features of alcoholic liver disease or the cachexia of malignancy. Haemochromatosis (‘bronzed diabetes’) is more obviously abnormal pigmentation when viewed from a step back. Consider the degree of ‘tan’ relative to the local climate and time of year. Anaemia and/or jaundice may be apparent. If there is evidence of liver disease, ask the patient to hold their hands out with their wrists extended and check for asterixis (‘liver flap’ associated with hepatic failure).

Peripheries

Check the patient’s hands for clubbing (malignancy, primary biliary cirrhosis, inflammatory bowel disease), anaemia, palmar erythema, Dupuytren’s contractures and abnormal pigmentation of the palmar creases. The skin of the arm and trunk may show bruising, spider naevi or scratch marks indicating pruritus (consider obstructive jaundice).

Examine the sclera for anaemia or jaundice. The eyes may demonstrate Kayser-Fleisher rings indicating Wilson’s disease. These signs are subtle and best appreciated after having seen them before (in clinics). Check for perioral pigmentation associated with Peutz-Jegher syndrome. Assess dental hygiene and look for glossitis and any other intra-oral abnormality.

On the way past the chest towards the abdomen, pause briefly to look for gynaecomastia and more spider naevi if you have not found the requisite five to be classified as abnormal. Demonstrate that they blanch then refill from the centre.

Abdomen

Continue inspection of the abdomen for scars, striae, a caput medusa and the generalised distension of ascites. It is easier to report these now as they are obvious, you may not have said anything for a while and this keeps the examiners ‘tuned in’, as well as ensuring you do not forget to present them later.

Crouch down to look horizontally across the abdomen. Ask the patient to take some breaths in and out. Significant organomegaly or other masses not appreciated previously may become obvious.

If possible, have warm hands (even if they are a bit clammy!). Remember whether any area was indicated as being tender and modify your palpation accordingly. Begin with light palpation of all four quadrants and lightly run your fingers across the abdomen. Peritoneal deposits are best appreciated by this manoeuvre and are easily missed with deeper palpation. After light palpation, deeper palpation will delineate any mass or organomegaly.

Specifically examine the liver, spleen and kidneys. Begin palpation of the liver in the lower quadrants, moving up with each breath until an edge is felt advancing against your hand. Follow the edge left and right as far as you can, evaluating texture, smoothness and edge for the portion palpable below the costal margin. Percuss out the upper margin and estimate the span, thus excluding simple ptosis.

Begin palpation of the spleen in the right lower quadrant. It should enlarge along the axis of the tenth rib towards the umbilicus, come down with respiration and have a notch. If the spleen is not palpable, position the patient on their right side and palpate again with one hand behind the patient’s left lower ribs pulling the spleen forward. A spleen in a child is normally tippable. In an adult the normal anterior limit is the mid-axillary line: it must be twice normal size before becoming palpable.

If a mass is felt in the left flank, test for ballotment and percuss over it. Unlike the spleen, the kidney does not move with respiration and should ballot. In addition, the splenic flexure of the colon and/or stomach will create resonance to percussion over a kidney but not the spleen. An upper margin of the spleen will not be palpable, but you may be able to ‘get above’ a kidney. None of the signs differentiating between spleen and kidney are absolute, with the possible exception of the presence of a notch, making an ‘overall’ assessment of a left flank mass a matter of clinical judgement, not just a single feature. Ballot for a right-sided kidney with the patient supine, and percuss over any mass found.

After checking for organomegaly and defining any other masses that are palpable, test for ascites by the presence of a fluid thrill and shifting dullness. Both require the margin of dullness (fluid edge) to be determined initially in the supine position. Make a mental note of the position, but do not mark it — the examiners do not want evidence for subsequent candidates! A fluid thrill can be elicited by placing one hand over a flank ensuring it is over presumed fluid but not an organ. Tap the other side in the same position (fluid but not organ) with a finger. With fluid present, a percussion wave can be felt easily. This test can be made more sensitive by placing a hand in the middle of the abdomen to ‘stabilise’ it — however, this is not necessary and would require you to have a third hand or have one of the examiners leaning over the patient with you. Shifting dullness is elicited by rolling the patient onto their side after percussing the edge of the ascites and waiting preferably for a few minutes (although rarely does more than ∼20 seconds pass) before percussing again to find the edge has moved posteriorly. Rolling the patient away from you makes it easier when subsequently percussing, as you will not have to lean over the patient.

Discussion

The examiners will usually stop you after you have examined the abdomen unless you have been particu larly timely. If so, carry on as if the ‘usual’ questions were being asked.

‘What else would you like to examine?’

You would like to examine the hernial orifices and testicles (in males) for size and abnormal lesions, complete a rectal examination including evaluation of the prostate (in males) and check for a rectal ‘shelf ’. You would like to check a urinalysis for bilirubin and evidence of infection, take a set of observations and then proceed to a full general examination. In particular, you would like to examine for evidence indicating conditions, causes and complications of what you have found so far. For example, an isolated, irregular firm hepatomegaly in a cachectic individual is metastatic disease until proven otherwise. Your further examination would therefore be focused on those organs that produce hepatic metastases (e.g. bowel, lung, kidneys, thyroid, prostate, melanoma).

‘Present your findings so far’ and ‘Can you put these findings together?’

If you have an overarching diagnosis, present it first and then justify it. If not, give a systematic presentation of relative positives and negatives.

‘What else could it be?’

You should have a pre-prepared list of causes of massive, moderate and mild hepatomegaly, splenomegaly and hepatosplenomegaly, as well as unilateral and bilateral kidney enlargement. The priority listing should take into account the individual patient rather than just regurgitating the ‘list’.

‘What supports one differential over another?’

As an example, this could relate to how the causes of a mass may be differentiated, particularly spleen versus liver.

‘What else could you do to clarify things further?’ and ‘Are there any features suggesting a specific aetiology?’

Specific investigations may be needed (e.g. investigations to determine the cause of suspected obstructive jaundice would include LFTs including direct bilirubin, ultrasound of the liver and bile ducts, and a CT scan of the abdomen).

‘Other’ examinations

An almost endless variety of cases can be presented in the short cases. As well as those listed here, you should be familiar with assessment of hernias, ulcers, peripheral vascular disease, varicose veins, aortic and popliteal aneurysms and so on. Spend time in general and subspecialty surgical clinics!

Knee (orthopaedic)

Of the joints, the knee is the most likely to appear as a short case, although the general technique applies to other regions. Degenerative arthritis and ligamentous instability are the most likely conditions to be encountered. It is unlikely that you will be permitted to walk the patient at the beginning of the examination, although this should be requested. If granted, any functional deficit will be readily apparent. The general ‘orthopaedic’ approach should be adopted: look, feel, move, X-ray.

Look

Assuming you are not permitted to walk the patient, begin with the patient supine and their legs fully exposed, preserving modesty. Check for symmetry between the limbs, inspecting for wasting of the quadriceps, protuberances, effusions and skin lesions. In tense effusions, the knee will be held in the ‘position of ease’ flexed at 45 degrees. Scars may indicate corrective surgery or result from trauma.

Feel

After checking there is no pain, assess for heat by gentle palpation. Feel the joint margin for warmth and thickened synovium (a difficult sign to appreciate). Check for an effusion by ‘milking’ the suprapatella recess from the mid-thigh down to the patella. In the presence of an effusion, the patella can then be ‘tapped’ against the distal femur.

Move

Place one hand over the patella with your thumb and fingers extending over the medial and lateral joint margins. Gently flex the knee as far as the patient will permit. The hand on the patella and joint will appreciate crepitus in each of the three ‘compartments’ during this range of movement. Estimate (or measure) the degrees of flexion. Gently extend the knee, palpating for crepitus again until maximum extension is reached. ‘Locking’ is an inability to reach full extension. The most common causes are torn menisci, with the torn section folded over, or some other form of intra-articular foreign body. The normal knee will rest extended slightly beyond 180 degrees.

• Collateral ligaments are tested by flexing the patient’s knee to ∼30 degrees, placing one hand behind the knee to ensure the hamstrings are relaxed and then applying gentle varus and valgus stress.
• Cruciate ligaments are tested by flexing both the patient’s knees to 90 degrees. Initially observe for any difference in the position of the tibia. Relative posterior movement indicates laxity or disruption of the posterior cruciate ligament. Fix one foot with your body, usually by sitting on it. Place one or both of your hands around the patient’s knee with your thumb(s) on the tibial tuberosity and fingers posterior resting against the hamstrings, ensuring they are relaxed. Now attempt to ‘draw’ the tibia forward (anterior cruciate test) or backwards (posterior cruciate test). Compare with the other side to ensure that an anterior ‘draw’ sign was not simply a correction of a posteriorly displaced tibia back to normal.
• Menisci are tested by flexing the patient’s knee fully and then extending while the foot is everted and then inverted (McMurray’s test). Each manoeuvre tests the anterior and posterior horns of each meniscus at various points during the movement. The menisci can also be tested in the prone position with the knee flexed at 90 degrees. The leg is ‘ground’ down upon the distal femur. This test (Appley’s grinding test) is rarely contributory to the clinical examination in ED.

X-ray

Radiographic imaging is the final stage of assessment of a joint. Features of osteoarthritis and rheumatoid arthritis should be well known. If a knee is presented as a short case, there should be time to examine and comment on plain films.

Rheumatoid hands

The most likely ‘hand’ to be presented, other than one with a neurological finding, is the rheumatoid hand. If specifically directed to the hand (the most likely scenario), do not start with a general examination. You will gain some appreciation of the overall status of the patient as you proceed, and can include this at the end of your examination if presenting as you go (or at the start if you prefer to present later). Our advice is to present your findings as you go, as it is easy to omit certain findings if you are trying to remember too much. Develop a system to take you through each component of the pathology in a systematic fashion that ‘scans’ the hands, wrists and forearms.

Have the patient sitting on the edge of the bed or in a chair with the hands resting palm down on a pillow. It will be highly likely that a pillow will be beside the patient for this very purpose.

Look

Briefly scan the patient as you take a step back to observe in your usual fashion. If this is clearly a rheu ma toid hand, let the examiners know you know the diagnosis: Mr Jones has a symmetrical, deforming polyarthropathy of the wrists and hands. You can now all relax as you provide the detail.

Comment first on the deformities of position. Ulnar wrist deviation and various combinations of DIP and PIP joint deformation forming ‘Z’ thumbs (shaped like the letter), ‘boutonnière’ (fingers that make the shape of a buttonhole when opposed) and ‘swan neck’ (fingers) deformities should be noted for each finger. Note subluxation of MCP joints.

Next, comment on any obvious joint irregularities. Subluxation of wrist and MCP joints with swelling of the PIP joints is to be expected in rheumatoid arth ritis. Swelling predominantly in the DIP joints is more in keeping with osteoarthritis. Gout can produce tophi, which may extrude.

Note wasting, particularly of the thenar and inter os seous muscles.

Examine the skin starting at the finger tips and moving proximally. Thin, shiny skin may be caused by the condition (e.g. scleroderma) or steroids used to treat it. Bruising, evidence of infection and scars are important. Scars over joints may represent replacements that have corrected the previous deformity.

Spend some time on the nails. Clubbing is uncommon but you may find evidence of anaemia, pitting (psoriatic arthropathy), ridging, curling and other deformities. Infarcts beneath or around the nails may indicate active vasculitis or be telangiectases associated with CREST syndrome.

Ask the patient to turn their hands over. Observe again for scars, redness, wasting and evidence of anaemia.

Feel

Feel each joint in the digits and wrists in turn. Note instability, swelling and warmth. Palpate the tendons for thickening.

Move

Test the range of movement in each joint. Begin by asking the patient to clench and open their hands a few times. Restricted movement and tendon entrapment (trigger fingers) will be obvious. If so, it may not be necessary to examine in finer detail.

Examine further

Unlike the ‘orthopaedic’ examination where you proceed to X-ray the joint next, the medical physician further evaluates the extent of disease. Initially evaluate the hands further by testing functional ability. Have a container with a key and coin inside that can be seen (these are useful in neurological testing). Assess the patient’s ability to open the container and demonstrate the use of the key.

Continue with the examination beyond the request ed area by moving up the arm. Feel for rheumatoid nodules (ulna surface) and look for rash. Indicate that you would go on to examine all the other limb joints (say this convincingly, because you may be taken up on the offer if time permits) and then proceed to a full physical examination.

The list of articular and extra-articular manifes tations of rheumatoid arthritis is long. Mention the ones that are common and commonly potentially deadly from the emergency medicine perspective (reduced neck mobility with atlantoaxial instability may be fatal in over-judicious attempts at intubation). Presenting from the perspective of a FACEM instead of a general physician will count well in your favour.

X-ray

Now you can proceed to radiology of the joints. Make sue that you know how to differentiate rheumatoid from osteoarthritis on X-ray. Usually, but not always, there will be insufficient time to view X-rays.

Thyroid

This may be introduced as ‘Mr Jones has a neck mass’ or simply ‘Examine Mr Jones’ neck’.

Inspection

Stepping back and examining the patient may reveal an obvious goitre and the facies of hypothyroidism (thick skin, rosy cheeks, loss of outer third of eyebrow) or hyperthyroidism (exophthalmos). Observe for scars of previous surgery or prominent veins over the head from obstruction. When greeting the patient, ask whether their neck is tender and listen to their voice for evidence of recurrent laryngeal nerve palsy. Offer the patient a glass of water to swallow and observe upward movement of the thyroid gland.

Examination

If examining the patient from in front, place the thumb of one hand over one side of the thyroid while palpating with the other. If you prefer to examine from the back, gently palpate one side at a time. Assess symmetry of enlargement, nodularity, tenderness and any discrete lesions within the gland. Test a swallow again only if there is doubt this is a thyroid gland.

Check for extension of the thyroid into surrounding tissue (check carotid pulsation and the trachea for the midline position) ensuring the lower border can be palpated. It is possible to have accessory glands not connected to the main body given the course travelled by the gland in its embryological journey from the tongue through the neck. Check for surrounding lymph nodes. Listen for a bruit over the gland and the carotids (infiltration). The final part of examining the gland itself is to check for retrosternal extension. Do this by percussing over the sternum and then testing for Pemberton’s sign (superior vena caval obstruction) by raising the patient’s hands above their head.

After examining the thyroid itself, move on to the remaining Cs. If there is evidence of surgery that raises the possibility of inadvertent parathyroid removal, mention that you would like to check for signs of thyroid dysfunction and evidence of hypocalcaemia. If you have ‘spotted’ supporting evidence towards hypo- or hyperthyroidism, mention this specifically and direct your examination accordingly.

Hypocalcaemia may be detectable clinically by the presence of Chvostek’s sign (tapping the facial nerve as it passes through the parotid gland causing focal facial muscle twitching) and Trousseau’s sign (pumping a sphygmomanometer above systolic pressure causes the hand to spasm in the position of the ‘obstetrician’s hand’ — main d’acchoucheur).

Hyperthyroidism will be evident by proptosis, lid lag and retraction, dry eyes and a variety of ophthal moplegias if eye disease is associated (e.g. Grave’s disease). Clubbing may be present along with an exaggerated physiological tremor, sweatiness, tachycardia, dysrhythmias and, in severe cases, cardiac failure. Moving down the body, check for proximal myopathy, pretibial myxoedema (thickened plaques over the tibia) and finally reflexes that are heightened.

Hypothyroidism is classically associated with loss of hair from the outer third of the eyebrow, xanthelasma and a slow, hoarse voice. Hair thinning and obesity are common. Examination of the peripheries may indicate anaemia and peripheral oedema. In the wrist this may lead to a positive Tinel’s sign of carpal tunnel syndrome. The pulse is slow and low volume. Proximal myopathy is less common than with hyperthyroidism and the reflexes are ‘hung up’. The ankle jerks demonstrate this best with a normal contraction but delayed relaxation phase. In severe cases, percussion myotonia will be present — tapping the calf muscles causes local contraction producing a hollow, which is then slow to relax and resolve.

For both hypo- and hyperthyroidism, proceed on to a full general examination starting with the neuro logical and cardiovascular systems.

Breasts

Breast examination may be part of a search for a source of a metastatic lesion or a paraneoplastic neuro logical condition. If there is only one breast, exam ination will focus on draining nodes from the removed side and then a thorough examination of the remaining breast.

Begin with the patient’s arms by their side and relaxed in a semi-recumbent position. Inspect for asymmetry of the breast or nipple, dimpling of skin (peau d’orange), nipple discharge and pigmentation. Axillary nodes may be visible in this position.

Instruct the patient to place one hand behind their neck. This flattens out the breast, brings it to a consist ent anatomical position and exposes the axilla for examination of draining lymph nodes. The movement may unmask tethering of deeper structures.

Examination

Warm your hands first. Using the flat of your hand systematically ‘roll’ your hand over each quadrant, ensuring complete coverage of the breast. Repeat this by placing one hand under the breast while the examining hand systematically covers the breast again. Specifically examine beneath the nipple and for discharge that can be extruded without undue pressure. Finish by examining the axilla in all sections for lymph nodes. Repeat for the other side.

If one breast has been removed, check the arm for evidence of lymphoedema. If a mastectomy has been performed or any lesion palpated, enquire about bony pain, check for rib tenderness, gently percuss over the length of the spine and examine for hepatomegaly, pleural effusions, superior vena caval compression and neurologic deficits suggesting brain metastases.

Lumps

Most ‘lumps’ can be addressed with a simple pattern, such as:

• site, size, shape
• colour, consistency, contour
• mobility, transillumination, draining nodes.

Practise this pattern on all lesions you see.

Pregnancy

Routine assessment of a pregnant patient, especially in the third trimester, should be within the scope of practice for a FACEM. Pregnancy is common, but some complications are commonly deadly. Remember:

• prior to 20 weeks = fetus
• after 20 weeks = baby.

Definitely introduce yourself with a smile. Adding ‘congratulations’ as part of your ‘thanks for partici pating’ doesn’t hurt — and you might get a smile back! Check the patient is comfortable and mention the preferred position is wedged to the left (whether already on the left or not). Note the patient’s general appearance, skin colour (including skin pigmentation), and respiratory rate and effort.

Pregnancy-focused examination

• Features of pre-eclampsia:

• ask for a blood pressure; anticipate being asked to measure it
• look for evidence of oedema — ask whether rings still fit, check ankles and look for periorbital swelling
• mention you would check the urine for protein.

• Estimate of gestation:

• the fundal height is above the pelvic brim at 12 weeks, level with the umbilicus at 20 weeks and up to the costal margin (maximum height) at 38 weeks but drops 2–4 cm as the baby’s head engages at term
• a ‘rule of thumb’ is that the fundal height in centimetres above the symphysis is approximately equal to the number of weeks.

• Lie:

• head and/or back may be palpable
• ask where kicks are felt and/or comment if you feel kicks
• exclude a breech position and identify whether the head is engaged if late pregnancy
• consider multiple pregnancy if ‘too many’ parts are palpable.

• Assessment of baby:

• check movement, kicks
• check heart rate — use a Pinnard; if not heard, Doppler may help
• formal ultrasound confirms single pregnancy, size, morphology, activity, placental lie and adequacy; can plot against normal references and estimate date of delivery; serial examinations confirm appropriate progress.

Neonate/baby check

‘Routine’ baby checks are performed on every new born and therefore should be within the scope of practice for a FACEM. The neonate must be naked.

From the end of the bed

Look for:

• size (average weight at term is 3.5 kg)
• activity
• respiratory rate (40/min is normal), effort, recessions and sounds
• general colour — peripheral or central cyanosis, jaundice
• evidence of birth trauma — caput, scalp abrasions
• gross dysmorphic features — check specifically for features of Trisomy 21 (e.g. flat facies, epicanthic folds, tongue protrusion, brachydactyly with single palmar crease)
• skin

• dry (post-term)
• papular lesions post-birth — common and innocuous
• haemangiomas
• ‘Mongolian blue spot’ over sacrum with spina bifida

• breast enlargement — innocuous

Head-to-toe examination

Check:

• head — shape; ask for circumference and plot on percentile chart
• fontanelles — present, not tense; anterior diamond and posterior triangular shape
• face — features symmetrical
• palate — for defects (cleft)
• neck — for lesions (e.g. cysts)
• abdomen — liver easily palpable; tippable spleen is normal; otherwise, same basic procedure as in an adult
• external genitalia (male) — testicles usually but not always palpable
• anus — should be perforate (ask about passage of stool)
• hips — stable, not dislocated or able to be dislocated (this is an essential part of the examination)
• all limbs and digits — specifically check hands and feet for a simian crease, short inward curved little finger (Trisomy 21)
• heart sounds/murmurs/rate (normal newborn = ∼140/min)
• bilateral breath sounds.

Neurological assessment

Limb or facial paresis should be obvious by now. Check:

• tone

• normal to have limbs flexed at rest and when held
• floppiness raises suspicions of Trisomy 21

• normal reflexes

• grasping
• rooting
• upgoing plantar response
• ‘reflex’ walking
• startle (Moro) — warn parent beforehand!

The absence of reflexes or persistence of reflexes beyond a few months and/or abnormal tone are all indications of CNS pathology.

Paediatrics

Examining children takes practice. Gaining the con fidence of the parent and child requires you to not give the impression of being rushed, uncomfortable or overly concerned. For older children, it is possible to interact mostly with the child. The younger the child, the more interaction will be required with the parent as well.

There is no substitute for practice, so examine children until it becomes routine. In younger children and babies in particular, there is a risk that they can become distressed and unsettled without warning. If you are presented with a baby or small child who is sleeping, go for the money up-front by examining the component where a crying, uncooperative child is likely to make the examination difficult. For example, you may choose first to listen to the posterior chest and then anterior for a respiratory or cardiac examination, rather than starting from the peripheries in the ‘usual’ approach for an adult.

If you do choose to use toys to placate/distract children, choose wisely. Make sure they are child-safe and do not cause noise that will make your examina tion more difficult. Even if the child does not squeeze the toy, the parent might if the child seems to like the sound! Unless toys are washable and you have time to get them back, you should anticipate making them a gift. In normal practice you have time to get them back. Don’t count on it in the exam: have spares.

Although most of the conditions found in adults can also be found in children, some are quite different. Children are more likely to have congenital conditions and ‘syndromes’ with particular patterns of signs. It is not important that you know all of these, apart from the more common ones such as Trisomy 21. Time spent inspecting the child from a distance is time well spent. Obvious dysmorphic features, scars, respiratory rate, skin colour, activity and size are all important. Ensure that you have an examination approach for examining children of all ages. In more ways than not, this will be analogous to the systematic exam in ation of an adult. Examination Paediatrics (by W Harris, Elsevier, Sydney) is an invaluable resource for assisting you to develop thorough, age-appropriate approaches. Recall that a sign of any chronic disorder in children, includ ing respiratory and cardiac failure, is failure to thrive.

Ask to plot the child’s height and weight against percentile charts, including previous values if known. In most cases you will be given this information, although it is not unreasonable for the examiners to ask you how you think the child appears for their age. Make sure that you know the age-appropriate normal weight by whichever formula works for you (e.g. 9 + (age × 2) kg). Become familiar with estimating weights by guessing the weights of children in ED or on the wards (or family and friends) and then checking their actual weights. Knowing how old a child should be when they reach your mid-thigh, hip and shoulder assists estimates of height.

For younger children in particular, you may be asked to assess developmental status. Knowledge of normal verbal and motor milestones is essential (see Table 6.8), while noting there is a large variation in normal: you should not be overly focused on a single milestone if the others appear to be normal.

TABLE 6.8 Normal developmental milestones to age 3

Age Milestone Terminology
4 weeks Fixes and follows through 180 degrees Neonate — up to 28 days
6 weeks Smiles Infant — 28 days to 1 year
2 months Holds head erect when held upright
3 months Head turns to sound
4 months Rolls over from front to back
5 months Reaches and holds with one hand
6 months Transfers between hands
7 months Sits
9 months Crawls; stands with support
12 months Speaks single words Toddler — 1 to 3 years
13 months Walks
15 months Holds cup and drinks
18 months Builds tower of 3 cubes
2 years Speaks 2–3-word sentences
3 years Can use fork and spoon Preschooler — 3 to 5 years

When discussing the possible diagnosis or differential diagnosis in children, ensure your responses are age-specific. For example, cardiac murmurs in children may be pulmonary flow murmurs or due to congenital heart disease. Disorders such as aortic dissection are exceedingly uncommon. Respiratory conditions such as cystic fibrosis are frequent (especially in exams). Abdominal organomegaly may be from storage disorders and not alcohol excess. Organ transplants are common, so make sure you look for scars if there are peripheral signs of disease (e.g. clubbing) but a relative lack or absence of central signs. The ‘cause’ may have been removed and replaced with a normal heart and/or lung!

Time spent in paediatric outpatient clinics or rooms should give you experience of most of the condi tions likely to appear in the examination and how to examine them. It will also give you the opportunity to observe the experts interacting with children and assist in developing your own techniques.

Table 6.9, while not exhaustive, lists some of the conditions you should be familiar with. Similar to the adult cases, paediatric patients may commonly be introduced as having a symptom or sign (e.g. difficulty breathing or walking) that warrants examination to facilitate reaching a likely diagnosis or differential diagnosis. Alternatively, you may be asked to examine a specific system (e.g. cardiovascular) or body region (e.g. a joint or whole limb).

TABLE 6.9 Paediatric short cases

Congenital heart disease
The dysmorphic and syndromic child (e.g. Trisomy 21, Turner’s syndrome)
Neurologic disorders (e.g. cerebral palsy, spina bifida, neurofibromatosis, hydrocephalus)
Neuromuscular disorders (e.g. Duchenne muscular dystrophy, scoliosis)
Developmental assessment
Metabolic disorders (e.g. cystic fibrosis, diabetes mellitus)

Jaundice
Chronic liver disease
Failure to thrive
Obesity
Oedema
Haemophilia
Limping or specific joint examination
Rashes (e.g. seborrhoeic dermatitis, eczema, psoriasis)
Acute disorders (if child is well enough) (e.g. asthma, bronchiolitis, Kawasaki disorder)

Key points

• Take opportunities each day at work to practise your short case technique.
• Spend time with other disciplines’ trainees doing short cases together.
• Commence practice early. It is unwise to leave preparation for the short cases until after the written exam.
• Prepare an examination ‘kit’ for the exam, be familiar with using everything in it and be able to find it easily during the exam.
• Be prepared for and attempt to pre-empt likely questions during your presentation to the examiners.

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