Clinical Examination Tutorial
1. Mrs. Smith has just separated from her husband, comes to see you with
suspicion that her 2 year-old daughter might be sexually abused by her
new partner. The child doesn‟t want to go back to her father‟s house. Task : Management
The main thing to do is doing nothing! Shouldn‟t contaminate the history by
asking the child questions or do physical examination. These things need to be
done by expert (Gatehouse Centre)
Ask general questions to the child, not sexual abused questions and do general
PE, including find the evidence of possible child abused.
- Would you like to stay with your dad? If not, why don‟t you like your dad?
Contact child protection or human service department.
I understand that it‟s very upsetting to you. This thing is beyond my
responsibility, I‟d refer your child to Gatehouse centre. People there are expert in child sexual abuse, they will take sample from you child and find evidence to
prove your suspicion. They will take care of your concern and I‟ll follow up you with the Gatehouse centre after everything is done.
Should I contact the police?
Not necessary now, the Gatehouse centre will take care of that and if need to,
they‟ll arrange for you.
If the child doesn‟t want to stay with her father and cannot isolate her from her
step-father ? can admit the child for protection. Anyway, the first thing is refer
to Gatehouse centre and they have their guideline for this.
If it‟s a child abuse case, GP or HMO can do PE and record on the chart ? bruise, anal excoriation.
2. You are a local GP, 150 km from the nearest Paediatric Centre. The lady
brings her daughter, 9, who has been diagnosed with DM type1 for 18
months. You‟ve been asked to continue Mx for her. No further Hx. Task: Talk to the mother about your management
a. Check BS record book
b. Check HbA1C every 3 months
c. Check the injection site
d. Check blood pressure
e. Check Urine sugar
f. Ensure follow up with endocrinologist, dietician and children diabetic clinic
at least once a year
g. Other issues:
-Eating ? don‟t skip meal
-Review school report
Ask mum if she‟s coping alright
Eye, heart and kidney complications: annual review from 10 or 12 years old
3. Father of a 3 wk old child comes to you as child is vomiting profusely since
last 2 days. No diarrhea. The father says „vomit went everywhere‟. The baby is
on breast milk and feeds well. O/E: baby looks well, hydration good, v/s is
given (all normal). Giant peristaltic waves seen on the abdomen. No mass felt.
Task: Explain to the father what the problem is.
No further history to be taken
If can ask questions: Questions to ask:
- Is there any bile in vomitus?
- How far is the vomiting?
- Is the child febrile? ? meningitis, UTI
- Gastro-esophageal reflux symptoms
- Time of vomiting after feeding
Congenital pyloric stenosis
? 2-8 weeks after birth
? As stomach becomes bigger, the vomiting is more severe and more
Complication of pyloric stenosis
I‟d like to do investigation to confirm my diagnosis.
- U/S to see severity of the stenosis
- U&E to see dehydration and electrolyte imbalance
Your child has a condition called “pyloric stenosis”, (draw a diagram) this part of
the stomach has a thickened wall and slows down the food.
The treatment is a simple operation (pyloromyotomy) to make this site bigger
and the successful rate is high. Your child will grow normally and everything
will be normal. We need to refer your child to the surgeon as soon as possible.
Does he have to have an operation now?
The surgeon will assess his condition and decide whether he should have an operation now or later. The time of the operation depends on surgical team.
? Admit the child
? IV (might need NSS + KCl)
? Consult surgery
4. Mr. Graham a 50 yr old man comes to ED, complaining of pain in his
lumbar region for 3 days. He believes it may be spinal in origin. The
pain became so severe 2 hours ago and was not settling. The nurse gave
him some pain reliever and you are called to see him.
Task: Take a history
Tell the examiner what investigation you want to do.
Explain the condition and management to the patient
Pain occurred 3 times before for about 1 week. Father has stone but not sure where. His water work is smelly, thick color, no stone passing. He drinks occasionally and smokes 5-10/day for 20 years.
Full ward test: Protein + RBC
Blood U&E, Cr, uric acid – normal
Plain KUB: calcification 1 cm at lower 1/3 of the ureter with some
U/S: Kidney size is normal, no stone, no dilated calyx.
Questions to ask:
- Pain: site, size, radiation, relieved by, aggravated by, associated symptoms. - Any temperature
- Trauma or lifting
- 1st episode?
- History of sciatica
- Major health problem, any stone before, job – sitting all the time
- Fluid intake
- PH, FH, Medication, Allergy, operation
- 85% of stones are radio-opaque
- Urine full ward test ? if +ve then MSU microscopy
- Blood test is not really necessary
- Plain KUB
- Renal U/S to see kidney function, anatomy, size, dilatation - Abdomen CT scan if can‟t see stone from above tests
? Rib fracture
? Gallstones if right side
? Pyelonephritis if fever
We got the result of your test & found a stone there (draw a diagram), that‟s why
you feel pain. This stone moves and irritates the ureter so there is RBC in the
It‟s 1 cm, and too big to pass out by itself so I need to admit you and have either
open surgery or laparoscopic surgery. I need to talk to the surgical urologist to
consider taking it out.
It might be the previous stone that you had, fortunately, we found it early and
kidney is not affected yet. To prevent further attacks, I suggest you to drink
plenty of water.
Can I leave it there?
If left there ? causes pain and affects your health and renal function: such as
If < 4 or 5 mm ? may pass, ask patient to pass urine using mesh to collect stone.
If pass, plain KUB to see again.
? Endoscopy (cystoscopy with basket) if < 5 mm and < 5 cm from cysto-
? Shock wave lithotripsy
? Open surgery
5. Magi, a 32 yr old woman, comes to see you complaining of feeling
anxious and irritable 1 week before her period, resulting in her getting
mood change from happy to miserable in a short time which leads to
getting short tempered with work colleagues and family members.
Task: Take further relevant history
Manage the condition
The symptoms started a few years ago, no drinking and no smoking. Her period
is regular and she had tubal ligation many years ago.
Questions to ask:
- Pills, contraception, pap smear
- Surgery ? ? tubal ligation - Menstrual history
- Life style: job, marriage problem?
Premenstrual syndrome caused by hormonal change and busy life-style.
? Pamphlet about PMS
? Simple change in diet:
o ? Fluid and vegetable
o ? Caffeine
? Relaxation technique
? Talk to husband and bring him next time, I can explain your condition to him.
? Try to have a good nights sleep
? Go for a walk st day of ? Keep diary for 3 months (1 week before period and disappear in the 1bleeding is confirmed PMS)
nd? Vitamin B6 50-100 mg everyday for 3 months then only 2 half of the cycle or
st? Evening Primrose oil 400 mg on day 12 until 1 day of bleeding for 6 months.
? OCP: No need in this case as she had tubal ligation. It‟s good for control of
symptoms and contraception at the same time, SE > benefit for her.
? Mefenamic acid (Ponstan)
? If severe PMS and failed other methods ? can give anti-depressant (last
Am I having early premenopause?
No, you are not as your period is quite regular. This is PMS.
6. A midwife calls you to see a 38 yr old G6P4 woman, who has been in
labor for 12 hours. You rush to her room and find that the third stage of
labor has just been completed but she has had per vaginal loss of about
1.5 liter of blood.
Task: Give your Diagnosis
Manage the case
CALL FOR HELP
2 IV cannula
FBE, GM 4-6 units, U&E, coagulation and LFT
When she‟s stable, find the source of bleeding
1. Look at placenta ? complete?
2. Uterine palpation to see if uterus contracted, if the bladder is full ? empty
and do another uterine palpation then
3. Bimanual uterine massage.
4. IV syntocinon then check uterus and check placenta. If still bleeding, go to
5. EUA (Examination under GA) by Sim‟s speculum if no tear, then
6. Intrauterine prostaglandin
7. If any laceration ? stitch and watch for bleeding.
Steps for uterine atony
? Uterine massage and/or bimanual massage
? IV syntocinon or ergotamine
? Intrauterine prostaglandin if no asthma
? Internal iliac artery ligation
? Hysterectomy for life-saving
- Primary if 500 ml until 24 hour PP
- Secondary from 24 hour PP to 6 weeks
Most common causes of PPH
? Uterine atony
? Grandmulti para
? Retained placenta
? Prolonged labor
? Precipitating labor
7. Michael a 25 yr old man presents with deep laceration at the wrist. The
wrist is covered with a bandage. You are not allowed to take it off.
Task: Examine the wrist
Mention your findings to the examiner
I‟m going to examine your hand, is that alright with you? Do you feel pain now?
If you feel pain at anytime, please let me know & I‟ll stop immediately.
Please put both hands on the pillow.
? Capillary refill < 2 seconds (after finishing, tell the examiner
that capillary refill is less than 2 seconds both hands.)
? I‟m looking for ulnar deformity
? Squeeze, spread fingers (adduct and abduct)
? Formet‟s test for ulnar nerve injury
? Median nerve:
? Touch the pen with thumb
? Ring for opposition
? Sensory: close your eyes please then do from abnormal to normal site.
? Tendon: MP joints
Check with Talley & O‟ Conner book
8. Mr. James a 45 yr old man comes to see you requesting a blood pressure
Task: Take a brief history
Explain to the examiner how to measure the blood pressure
What investigation will you order
Questions to ask:
- Risk of HT
- Signs and symptoms of HT ? headache, blurred vision
- Allergy, FH of HT, stroke
- Occupation, diet, BW, exercise
- Hx of cholesterol, DM, HT, smoking, alcohol, liver & kidney disease - PH of any operation
How to measure BP?
- Choose any side of the arm
- Choose correct size of the cuff
- Apply cuff 2 cm above cubital fossa
- Palpate radial and brachial pulse
- start to inflate the cuff while feeling the radial pulse, until can‟t feel the pulse
- Start to deflate the cuff freely, put stethoscope under the cuff, hear the sound
as well as feel the pulse again.
- Check another side
- Do both lying and standing
9. A 65 yr old lady presents with recurrent pain in her abdomen arising
especially in the morning.
Task: Take a history
Ask the examiner about the finding
Ix and DDx
Questions to ask:
- Risk factors (Fat, forty, fertile, female)
? Have you ever been diagnosed high cholesterol?
? Any blood disease?
? Pregnant, HRT?
? Gastric surgery before? - Pain question, aggravated by fatty food?
- Fever, jaundice, N/V
- Urine color
- Previous episode
- chest pain, cough
- bowel motion, dysphagia, haemetemesis
- GA, V/S
- Abdomen: full examination
- U/S ? stone, dilatation, thickening of the wall? - CXR to r/o pneumonia
- Abdominal X-ray to r/o bowel obstruction
- ERCP if obstructive jaundice
? Acute cholecystitis
? Acute pancreatitis
? Pneumonia RLL
? Acute cholangitis (if fever)
? Irritable bowel syndrome
10. Ms. Brown brought her 3 yr old daughter, complaining of pain in the
right ear. She looked unwell. O/E Temp 38.6 C, mildly inflamed throat,
tympanic membrane is red and inflamed.
Task: Ask the relevant questions for diagnosis
Manage the case
Questions to ask:
- Flu symptoms
- Has she had this before?
st 24 hour; wait to see in 24 or 48 hours, it 25% is viral infection especially in the 1may settle down. If she complains more pain, fever and can‟t eat ? bring her
- Mention options about antibiotic to give now or later and check ear drum. If
give, Amoxicillin for 5 days
- Increase fluid intake
- Panadol regularly for fever and pain
- F/U in 24 hours
Ear infection ? ABO is the issue to consider
11. Mr. Smith a 65 yr old man with a history of benign prostatic
hypertrophy, now on the list for transurethral resection of prostate
Task: Consent him for TURP
Answer the patient‟s questions
Explain about TURP
- Put pencil-like instrument with camera at the finger chip like head from
- Spinal anesthesia, not GA
- Blood in urine
- Might have catheterization for 1-2 days, after taking it out might feel a little
bit of pain. Make sure to drink more water and pain relief might help. - Rest 1-2 weeks
? No driving 2-3 weeks
? No sex 6 weeks
Side effects of TURP
- Retrograde ejaculation ? need to spin urine for sperm and then IVF (TURP
does not affect fertility while complete excision does.)
- bleeding, infection
- Anesthesia complication
Chance of recurrence: 20% in 5 years
12. Ms. Herald brought her 4 days baby (Bill) because she noticed that he is
looking yellowish in color. He was a term infant, delivered at hospital
by normal vaginal delivery after a normal pregnancy. He weighed 3,500
gm at birth. O/E you find mild jaundice on the face and upper trunk
only. The urine and stool are normal, no other abnormalities were
Task: Explain the condition to the patient
Answer questions patient may ask
Questions to ask:
- Is the baby breast or bottle fed? (breast fed)
rd- When did the jaundice start? (3 day of life)
- Is the baby feeding well? (yes)
Explain to the mother
This is physiological jaundice caused by
? RBC in newborn has shorter life span than adult (70 days compared to 120
ndrd? Haemoglobin ? due to hemolysis in the 2 -3 day
? Hepatic-bilirubin metabolism is not mature (less efficient)
? Absence of gut flora impedes elimination of bile pigment
These causes happen in nearly everybody. Keep feeding baby and this jaundice
will disappear in 2 weeks. It‟s very rare that it will affect the baby. No need for treatment.
If fever, ? feeding, irritability ? bring him back
Should I stop breast feeding?
No, you should even feed more frequently.
Does he need phototherapy?
Not at the moment
Breast feeding jaundice (24 hr-2 week)
Breast milk contains certain substance that affect conjugated bilirubin (prevent
conjugation). That‟s why baby turns yellow. Keep breast feeding more regularly
and baby‟s body will adjust to this and jaundice will disappear in few days. It‟s
quite common condition in this age.
Jaundice in the 1st 24 hours
- G-6-PD deficiency
- Rh, ABO incompatibility
- Congenital infection (TORCH)
More than 2 weeks - Prolonged physiological jaundice
- Unconjugated: (cause kernicterus)
? Breast feeding