HISTORY OF BREAST LUMP

Greet the patient, introduce yourself and take permission

Biodata

Presenting complaint with duration

How did the lump start?

How was it noticed?

Progression of the lump—is it increasing in size?

—what is the rate of increase?

Is swelling painful or painless?

Is it related to the menstrual cycle?

Any nipple discharge

Any nipple retraction

Any skin changes over the breast/ulcer

Ask about following – menarche, menopause

age at first delivery

parity

hx of lactation,

use of OCP/hormone replacement therapy

Family history of breast malignancy/disease

Hx of saturated fatty diet

Hx of alcohol

Hx of cigarette smoking

Hx of trauma,

Hx of tuberculosis – chronic cough, contact, drenching night sweats

Complications –Weight loss Anorexia Cough/HemoptysisDyspnea

Jaundice Abdominal swelling Low back pain Paraplegia

Hx of treatment

Review of systems; Past medical/surgical history; Drug/Allergy history

Thank the patient

HISTORY OF ALTERATION IN BOWEL HABIT

Score each step of the history as—Good (3) OR Average(2) OR Poor(1)

Greet patient, introduce yourself and take permission 3 2 1

Biodata 3 2 1

Presenting complaint with duration 3 2 1

How did this complain start—sudden or gradually? 3 2 1

Pattern of change—constipation or diarrhoea 3 2 1

—is there alternating diarrhoea with constipation 3 2 1

Frequency of bowel motion since onset of symptom 3 2 1

Frequency of bowel motion before the present change in bowel habit 3 2 1

How long does the constipation lasts? 3 2 1

Nature of stool 3 2 1

Estimated quantity of stool 3 2 1

Passage of mucus in stool 3 2 1

Passage of blood in stool 3 2 1

Feeling of incomplete emptying of rectum following defaecation 3 2 1

Tenesmus; painful desire to pass stool but nothing comes out 3 2 1

Associated colicky abdominal pain 3 2 1

Associated abdominal distension 3 2 1

Associated vomiting; characterize 3 2 1

Associated abdominal swelling/mass 3 2 1

History of weight loss and anorexia 3 2 1

History of painful micturition 3 2 1

History of frequency 3 2 1

Family history of similar illness 3 2 1

History of treatment so far 3 2 1

Review of systems; Past medical/surgical hx; Drug allergy; Family and social history

Thank the patient

HISTORY OF A CHILD WITH CHRONIC CONSTIPATION SINCE BIRTH

Greet the mum, introduce yourself and take permission

Biodata

Presenting complaint with duration

Ask about delayed passage of meconium

Frequency of bowel motion since birth

Nature of stools

Progression of the constipation—is frequency of bowel motion getting worse

Do they have to stimulate the child before he can pass stool

Hx of abdominal distension

Hx of vomiting

Hx suggestive of abdominal colics

Any previous episodes of diaarrhoeaoccuring with the chronic constipation

Any previous hx of fever

Any hx of failure to thrive—is the child growing well?

Ante natal hx: -hx of fever/rash in mum during first trimester(viraemia)

-hx of use of over the counter drugs

-hx of use of native medicines

-hx of exposure to radiations, petrochemicals

Ask about antenatal ultrasound scan

Hx of delivery and immediate post natal state of the child

Nutrition hx

Immunization hx

Developmental milestones

Family hx; ask about similar condition in the child’s siblings

Thank the mum

ABDOMINAL EXAMINATION OF ACUTE APPENDICITIS PATIENT

Scoring system: Good (3)

Average (2)
Poor (1)
Circle the APPROPRIATE score for each step
DON’T SCORE STEPS THAT WERE NOT CARRIED OUT

Greet patient, establish rapport, take permission 3 2 1

Positioning 3 2 1
Exposure 3 2 1
Inspection – Over whole anterior abdomen 3 2 1
Squat by right side of bed 3 2 1
Squat by foot of bed 3 2 1
Inspect Hernia orifices while the patient coughs 3 2 1
Ask for any area of pain in the abdomen—POINTING SIGN 3 2 1
Start light palpation AWAY from the site of pain 3 2 1
Light palpation systematically region by region 3 2 1
Demonstrate tenderness at the Right Iliac Fossa 3 2 1
Demonstrate Rebound Tenderness 3 2 1
Demonstrate Rovsing sign 3 2 1
Demonstrate psoas sign 3 2 1
Demonstrate obturator sign 3 2 1
Deep palpation – digging motions region by region 3 2 1
Palpation for organs – liver 3 2 1
- spleen 3 2 1
- both kidneys 3 2 1
Percussion – check for shifting dullness 3 2 1
Auscultation – first demonstrate Mc Burney’s point 3 2 1
-then listen for Bowel sound using DIAPHRAGM of stethoscope
3 2 1
Rectal Examination—Score 3 for making attempt
Thank the patient 3 2 1
For General Attitude toward the patient 3 2 1
For Orderliness – IPPA(+3)

SCORE -5 FOR LACK OF ORDERLINESS

ABDOMINAL EXAMINATION IN GASTRIC OUTLET OBSTRUCTION
PATIENT

Scoring system: Good(3)

Fair(2)
Poor(1)
Circle the APPROPRIATE score for each step
DON’T SCORE STEPS THAT WERE NOT CARRIED OUT

Greet patient, establish rapport, take permission 3 2 1

Positioning 3 2 1
Exposure 3 2 1
Inspection – Over whole anterior abdomen 3 2 1
Squat by right side of bed 3 2 1
Squat by foot of bed 3 2 1
Inspect Hernia orifices while the patient coughs 3 2 1
Ask for any area of pain in the abdomen 3 2 1
Start light palpation AWAY from the site of pain 3 2 1
Do Light palpation systematically region by region 3 2 1
Deep palpation – digging motions region by region 3 2 1
Palpate for STOMACH 3 2 1
Do SUCCUSSION SPLASH 3 2 1
Palpation for organs – liver 3 2 1
- spleen 3 2 1
- both kidneys 3 2 1
Percussion – check for shifting dullness 3 2 1
Auscultation – first demonstrate Mc Burney’s point 3 2 1
-then listen for Bowel sound using DIAPHRAGM of stethoscope
3 2 1
Rectal Examination— score 3 if candidate make the effort
Thank the patient 3 2 1
For General Attitude toward the patient 3 2 1
For Orderliness – IPPA(+3)
HISTORY OF HEAMATURIA
Score each step of the history as—Good (3) OR Average(2) OR Poor(1)

Greet the patient; introduce yourself; take permission 3 2 1

Biodata 3 2 1
Presenting complaint and duration 3 2 1
Mode of onset 3 2 1
Character of Haematuria – painful/painless 3 2 1
total, initial, terminal 3 2 1
passage of clots 3 2 1
Associations – Dysuria 3 2 1
- Abdominal pain ; characterize if present 3 2 1
Irritative symptoms: -urgency 3 2 1
- frequency 3 2 1
- nocturia 3 2 1
- urge incontinence 3 2 1
Obstructive symptoms -Hesitancy 3 2 1
-Straining 3 2 1
-Poor stream 3 2 1
-Intermittency 3 2 1
-Incomplete voiding 3 2 1
-Acute Retention 3 2 1
Associated Abdominal mass 3 2 1

Previous history of urethritis 3 2 1

Previous history of urethral instrumentation 3 2 1
History of trauma 3 2 1
History of Drug use eg Rifampicin 3 2 1
History of bleeding disorder 3 2 1
Lived in a riverine area/bath in a stream 3 2 1
Smoking cigarette 3 2 1
Industrial worker (paint, petrochemicals etc) 3 2 1
Weight loss, 3 2 1
Anorexia 3 2 1
Low back pain, 3 2 1
Bone pains 3 2 1
History of treatment 3 2 1
Review of system 3 2 1
Past medical/surgical history/drug Hx 3 2 1
Family social history – Alcohol 3 2 1
Thank the patient 3 2 1
For General Attitude toward the patient 3 2 1

SCORE -5 FOR DISORDERED HISTORY TAKING

COUNSELLING FOR A COUPLE—THE HUSBAND SPINAL
INJURED (COMPLETE C4 TRAUMATIC PARAPLEGIA)

Describe the type of injury the patient has suffered to the couple using

simple anatomy of the cervical spine

Describe to the couple the two main types of spinal cord injuries and

their likely outcomes:

Complete injury with no likelihood of walking again

Incomplete cord injury in which there is a chance of walking again

What is the patient’s type of injury and its likely prognosis?

Now the patient is discharged, what advice do you give?

-Home modification: Removal of staircase

Live downstairs

-Prevention of bed sores and UTI—self catheterization

Counsel on return to work; change of work

Counsel on sexual performance

THYROID EXAMINATION MARKING SCHEME

Establish rapport with the patent 0.5

INSPECTON (IN FRONT)

Inspect the swelling – location / symmetry 0.25

Inspect the face—exophthalmos/ proptosis 0.25

Movement with swallowing 0.5

Movement with tongue protrusion 0.5

PALPATION (In front)

Differential warmth 0.5

Tenderness 0.5

Fixity to the skin 0.5

Centrality of the trachea 1

PALPATION (from behind)

Confirmation of movement with swallowing 0.5

Movement with tongue protrusion 0.5

Check for retrosternal extension

Get below the mass on swallowing 0.5

Percuss over the sternum 0.5

Ascertain the position (plane of location) of the swelling by tensing the

sternocleidomastoid/ strap muscles 0.5

Check consistency/ nodularity / edge of the mass (one side at a time ) 1

Measure the mass 1

Examine for cervical lymphadenopath ( note the motion for each group examined) 1

AUSCULATON Examine for bruit 0.5

METASTASIS TO THE SCALP -Palpate the scalp for nodules 0.5

EYE SGNS- Lid retraction on initial inspection-no mark

-Nafziger’s sign (early phase of exophthalmos) 0.5

-lid lag (exam from patient right side) 0.5

 -eye movements/ field of vision (side of patient) 1

NB: eye movement should include convergence.

(patient should be asked for double vision in aspect of the visual field).

OTHERS:

- Check the palms. 1 mark

- Examine the pulse for rhythm 1 mark
- Check the blood pressure. 0.5 marks
- Auscultate the apex beat. 0.5 marks
- Examine for tremors (this can be done before checking the palms and
pulses). 1 mark
- Inspect the skin for pretibial myxoedema. 0.5 mark
- Do the ankle jerk. 1 mark
- Check for proximal myopathies – upper limb
- lower limb
HYDROCEPHALUS
Examination With Running Commentary
 Inspect the head/ face/ eyes; note
• Assess the general appearance of the child
• Large head
• Craniofacial disproportion
• Fontanelles- are they bulging
• Look out for VP shunt catheter or scar of surgery
• Distended veins
• Sunset appearance of the eyes
• Assess Neck Control

 Palpate the head

• Occipitofrontal circumference
• Palpate fontanelle- is it tense, widened
• Palpate sutures – diasthesis, splayed cranial sutures

 Illuminate the eyes with pen-torch

• Pupillary reaction to light
• Light fixation
• Visual tracking
• Rule out blindness

 Examine the back

• Inspect for any midline mass
• If present characterize as in Spina bifida

 Examine long tract

• Muscle tone
• Muscle power
• Sensation
• Reflexes
EXAMINATION OF A MASS
Scoring system: Good (3)
Average (2)
Poor (1)
Circle the APPROPRIATE score for each step
DON’T SCORE STEPS THAT WERE NOT CARRIED OUT

Greet the patient, introduce yourself and take permission 3 2 1

Inspect both upper limbs 3 2 1
Inspect the observed mass 3 2 1
Palpate – differential temperature 3 2 1
Tenderness 3 2 1
Size – measure in 2 or 3 dimensions 3 2 1
Surface 3 2 1
Edge 3 2 1
Consistency 3 2 1
Fluctuancy 3 2 1
Transillumination 3 2 1
Mobility in TWO planes—perpendicular 3 2 1
Skin attachment 3 2 1
Attachment to underlying muscle 3 2 1
Regional lymph nodes 3 2 1
Thank the patient 3 2 1
For General Attitude towards the patient 3 2 1
SCORE -5 FOR LACK OF ORDERLINESS