The CExs for Block 2 include examination of:

MSK screening
Knee exam
Shoulder Exam
Hand exam
Spinal Exam of a young man
Hx from an elderly man with 1 month of low back pain
Hx from a patient with recent onset (<6 months) of polyarthralgia
Hx from a patient with suspected RA

The CExs for Block 3 include examination of:

Chest examination
Chest X-Ray
Arterial blood gases
Spirometry

The CExs for Block 4 include examination of:

Anaemia History
Full blood count in Anaemia diagnosis
Lymph node exam

Musculoskeletal Screening Examination

1. Assess and describe gait.
2. Describe spinal posture, using lordosis, kyphosis and scoliosis descriptors.
3. Assess cervical lateral flexion.
4. Assess lumbar function.
5. Inspect and describe the upper limb (skin, nails, muscle bulk etc).
6. Hand grip.
7. Pinch grip.
8. Elbow extension.
9. Shoulder movement (at least abduction or flexion).
10. Inspect and describe the lower limbs (skin, muscle bulk, alignment, joint
swelling etc).
11. Test for effusions of the knee (bulge sign and/or patella tap as appropriate
depending on degree of swelling).
12. Hip internal rotation.
13. Determine which joint regions warrant detailed examination on the basis of the
screening examination.

Musculoskeletal Screening Examination

Examining the GAIT:
Characterise any limp (e.g. Antalgic (modified by pain), Trendelenberg
(modified by hip weakness).
Assess limb alignment when standing and walking.
Examining the SPINE:
Describe the posture while standing, using the terms lordosis, kyphosis
(bends in the sagittal plane) and scoliosis (bends in the coronal plane).
Assess cervical lateral flexion and lumbar flexion.
Examining the LEGS:
Examine the skin (scars, bruising) and muscles (wasting, asymmetry).
Inspect the soles of the feet and the pattern of callus.
Assess metatarso-phalangeal tenderness (lateral compression).
Check for knee swelling and test for effusion when appropriate (bulge sign,
patella tap).
Assess hip internal rotation with the knee flexed to 90°.
Determine, on the basis of the screening examination, which joint regions
warrant detailed examination.
Examine the ARMS:
Inspect the hands (palmar and dorsal aspects) for muscle wasting, skin and
nail changes.
Assess hand grip (coarse motor function) and pinch grip (fine motor
function).
Assess metacarpo-phalangeal joint tenderness (by lateral compression).
Assess elbow extension - both sides simultaneously and compare.
Assess the patient's ability to clasp their hands behind their neck with arms
abducted, and elbows back (shoulder abduction and external rotation).

Examination of the Knee

1. Assess gait.
2. Describe knee alignment.
3. Assess quadriceps bulk and symmetry.
4. Test for effusion.
5. Test for tenderness.
6. Localise tenderness to an anatomical structure. Score ‘correct’ if no tenderness
is present.
7. Assess range of flexion and extension.
8. Assess collateral ligaments.
9. Assess anterior cruciate ligaments.
10. Assess posterior cruciate ligaments.

1. The examination of the knee must include assessments while standing/walking

and lying.
2. Assess alignment of the knee while standing and check for scars and swelling
(popliteal cysts can sometimes be seen more easily than felt). Be able to use the
terms 'varus' and 'valgus' to describe alignment of the knee.
3. Assess gait, preferably without shoes or other supports.
4. With the patient supine (on their back), assess quadriceps muscle bulk and
symmetry. A painful knee will usually lead to wasting in the quadriceps.
5. Determine if there is an effusion (bulge sign, patella tap).
6. If the knee is swollen, determine if the swelling is hard (bone/ cartilage)
or soft (fluid/ synovium).
7. Palpate for tenderness and, if present, attempt to localise this anatomically
(joint line, tendon insertion, bursa etc).
8. Assess the range of flexion and extension.
9. Feel and listen for crepitus.
10. Assess lateral and medial collateral ligaments. Appreciate the effect of
articular cartilage loss on these assessments of stability.
11. Test the anterior cruciate (Lachman's and anterior drawer tests) and
posterior cruciate (posterior sag test) ligaments.
12. Describe the functional limitations associated with the abnormalities found.
13. Suggest likely causes of the abnormal findings (initially into categories,
e.g. degenerative, inflammatory, traumatic; then with respect to specific
diagnoses, e.g. rheumatoid arthritis).

Shoulder Examination
1. Inspect both shoulders.
2. Palpate for tenderness over appropriate areas.
3. Assess range of adduction and abduction.
4. Assess range of flexion and extension.
5. Assess range of internal and external rotation.
6. Assess range of passive movements.
7. Performs test for rotator cuff impingement.
8. Performs test for anterior instability.

1. There are two components to shoulder movement, glenohumeral movement and

scapulothoracic movement.
2. Compare both shoulders, simultaneously or consecutively.
3. Inspect the shoulder, look from the front, back and the side. Look for
postural asymmetry, swelling, muscle wasting and scars.
4. Palpation:
I. Examine for different sites of tenderness. It is important to
understand the underlying anatomy to know where to palpate.
II. Examine the sternoclavicular and acromioclavicular joints and the
humeral head.
III. Biceps tendon is best palpated in the bicipital groove with the arm
abducted to about 40 degrees and externally rotated. Palpate distally from the
anterolateral corner of the acromion.
IV. The supraspinatus and infraspinatus tendon insertions can be felt over
the greater tuberosity, just below the acromion.
V. The glenohumeral joint is below the tip of the coracoid process.
5. Active movements: They can be done together or consecutively, and will depend
on how easy it is for the patient to move both arms at the same time.
When examining active shoulder movements, first demonstrate the movement to
the patient.
I. Flexion: Elevate a straight arm forward as far as possible, about 180°.
II. Extension: Extend a straight arm backwards, about 60°.
III. Abduction: The palm of the hand faces forward and the straight arm is
elevated sideways in the plane of the body. The normal range is 160° to 180°. About
120° of this movement takes place at the glenohumeral joint, and the remainder is
scapulothoracic.
IV. External and internal rotation: These are tested with the arm abducted
to 90° and the elbow at 90°. Both internal and external rotation can be assessed
easily. However, if abduction is limited this should be done with the elbow by the
side. There will be some restriction of internal rotation by the trunk. Most of
external rotation on adduction takes place at the glenohumeral joint.
V. Adduction is tested by asking the patient to move the arm in front of
the body and is about 50°.
6. Passive movements: Both shoulders should be examined. The arms should be
abducted, adducted, internal and external rotation, flexion and extension. It is
important to compare both the active and passive movements.
7. Normal passive movements and restricted active movements suggests that there
is a rupture of the tendon.
8. There are three other important tests that are used in assessing the
shoulder.
9. The “apprehension test” is used to assess where there is anterior instability
of the shoulder joint. This often occurs after dislocation where there has been
significant damage to the joint capsule.
This can be done standing, sitting or with the patient lying in a supine
position. The arm is abducted to 90° and the elbow flexed to 90°. The arm is then
externally rotated at the shoulder. A positive test is when the patient becomes
apprehensive or nervous, and resists further movement.
If direct manual pressure on the front of the shoulder relieves the
apprehension, the so called relocation sign, this is further evidence of anterior
instability.
10. The test for impingement is used to determine whether there is any rotator
cuff impingement between the greater tuberosity and the subacromial arch. This
occurs when there is damage to, or inflammation of the rotator cuff. The patient is
sitting and the arm is flexed to 90° at the shoulder. One hand steadies the
scapula. The arm is flexed to 90° at the elbow and internally rotated. This pushes
the supraspinatus tendon against the acromion and coracoacromial ligament.
11. Restriction of external rotation in adduction (i.e. with the arm by the side,
palm of the hand forward, elbow bent to 90°) signifies glenohumeral pathology as
opposed to subacromial pathology.

Hand Examination
1. Observe hands - obtain good exposure.
2. Check for hand asymmetry/ deformities.
3. Note finger nails and skin for rashes.
4. Ask patient about tender areas in hands.
5. Gently palpate wrist and finger joints for swelling and tenderness.
6. Determine if joint swelling is soft or hard.
7. Test wrist and finger movements actively and passively.
8. Examine hand function (e.g. turning key/ undoing buttons).

1. Physical examination of any joint involves "look", "feel" and "move".

2. Observe the hands (volar and dorsal aspects) with good exposure. Resting the
hands on a pillow is both comfortable and provides a contrasting background.
3. During observation, you should look for muscle wasting in the hands and for
any evidence of joint swelling or deformities. Side-to-side asymmetry is a good
clue that there is underlying pathology.
4. Check the fingernails for pitting which is seen in psoriasis and examine the
skin of the hands and forearms for erythema (redness) and rashes. Psoriasis is
commonly seen on the extensor surface of the elbows
5. Ask the patient which joints are tender prior to examining them.
6. Gently palpate joints individually to determine the type of swelling. Soft
swellings are likely to be due to fluid or synovium. Hard swellings may be bone or
due to tophi (present in gout).
7. Examine hand function. Various tests may be used including grip, ability to
use a key or undo buttons. These are crucial to patient independence

Spinal Examination of a Young Man (see note 1 below)

1. With adequate exposure of the subject, describe the standing posture using the
descriptors: lordosis, kyphosis and scoliosis.
2. Assess the range of spinal movement, including: • Lumbar: flexion
Thoracolumbar: rotation and lateral flexion
Cervical: lateral flexion, flexion, extension and rotation
3. Assess spinal tenderness and differentiate from widespread tenderness not
restricted to the spine.
4. Show an understanding of the difference between hip flexion and lumbar flexion
when assessing ability to bend forward.
5. Assess hip joint movement.
6. Assess sacroiliac joint irritability.

Spinal Examination of a Young Man (see note 1 below)

1. The approach used depends on the presenting symptoms and the history. This
exercise relates to the assessment of a man aged 18-35 years with back pain of
greater than 12 months duration in the absence of neurological symptoms. Male sex
is specified because inflammatory spondylo-arthropathies are much more likely to
present in young men than young women.
2. Patient should be examined wearing the underpants or brief shorts only.
3. When assessing spinal posture, ask the patient to stand straight with his
feet placed symmetrically.
4. Check for preservation of the normal cervical lordosis, thoracic kyphosis and
lumbar lordosis.
5. Comment on any abnormal curve. Asymmetry of the chest wall often indicates
the presence of a rotational scoliosis.
6. If scoliosis is present in the lumbar region, check for pelvic tilt and leg
length inequality.
7. Does the scoliosis reduce with flexion (pressure) or not (fixed)?
8. In inflammatory back disease, sacroiliac and hip joint involvement are common
and should be looked for.
9. Assessment of tenderness should progress from palpation to firm percussion
(using your fist onto the back of your other hand to transmit force to the patient)
before determining that it is not present.
10. Bending forward involves lumbar flexion and hip flexion. Schober's test
allows quantification of lumbar flexion. With the patient standing erect, marks are
placed 10cm above and 5cm below the L4/5 level. The patient then bends maximally
forward and the distance between the two marks is re-measured. The distance should
increase by at least 5cm (i.e. 15cm - 20cm).
11. Extra-articular features of inflammatory spondylo-arthropathy include
psoriasis, iritis, aortic incompetence and apical pulmonary fibrosis. Assessment
for these features is not expected at the undergraduate level.

History from an elderly man with 1 month of low back pain

1. Uses open-ended questions to obtain history of symptoms.

2. Determines the onset, duration and location of back pain.
3. Asks if the pain is present during the night.
4. Asks if the pain interferes with activities of daily living.
5. Asks if there is a history of constitutional symptoms (e.g. fever, weight loss).
6. Asks if he has experienced recent difficulties with his urinary stream.
7. Does he have risk factors for infection (e.g. recent surgery)?
8. Is there a history of osteoporosis or of risk factors for osteoporosis?
9. Are there neurological deficits (e.g. lower limb weakness and/or paraesthesias)?
10. Inquire about response of pain to analgesics and/or anti¬inflammatory drugs.

1. Use open-ended questions. Try not to avoid artificially constraining the

patient's symptoms to a given pattern early in the process.
2. Obtain a detailed history of the onset of back pain. You should try and
determine specifics: when did the pain start, how sudden and severe was the pain at
onset?
3. How constant is the pain and is it present at night? This is more likely to
be due to a serious underlying condition.
4. Is thee limitation of function so as to interfere with activities of daily
life?
5. Consider underlying disorders such as infection or malignancy. These may be
suggested by fever or weight loss. Prostate cancer commonly metastasises to the
vertebrae.
6. Consider osteoporotic fractures and ask about risk factors.
7. Neurological deficits suggest nerve route entrapment. The commonest roots
involved are L5 and S1. These are associated with pain radiating down the leg and
are referred to as "sciatica".
8. Most patients with back pain have some relief with simple analgesics or non-
steroidal anti¬inflammatory drugs. Failure to respond to these is a "red flag" to
alert you to the possibility of more serious underlying pathology

History from a patient with recent onset (<6 months) of polyarthralgia

1. Onset of symptoms.
2. Distribution of joints involved.
3. Features of inflammation: swelling, pain, heat.
4. Early morning stiffness.
5. Systemic features: fatigue, weight loss, fever.
6. Extra-articular features: rash, eyes, mucosal ulceration, respiratory, etc.
7. Medications or other treatments used, and effectiveness.
8. Functional assessment (effect of activities of daily living).
9. Family history of arthritis (attempt to clarify what type).

1. Enquire about the onset of symptoms.

Have they been insidious or sudden in onset?
Are they associated with systemic features such as fever or weight loss?
2. Establish the pattern of affected joints:
 Small joint and symmetrical: Systemic Lupus Erythematosus (SLE) or Rheumatoid
Arthritis.
Asymmetrical and affecting small and large joints: psoriatic arthritis.
Asymmetrical and affecting the lower limbs: reactive arthritis.
Dactylitis (sausage-like digits): psoriatic and reactive arthritis.
3. Duration of early morning stiffness is often of greater diagnostic use than
severity. Early morning awakening and improvement of symptoms with activity also
reflect inflammatory joint disease.
4. Some combinations of extra-articular features can suggest particular
inflammatory disorders: iritis, inflammatory back pain and asymmetrical lower limb
arthritis suggest inflammatry spondylo-arthropathy. Raynaud's syndrome, malar rash,
serositis and proteinuria suggest systemic lupus erythematosus. A scaly rash and
dactylitis with nail pitting suggest psoriatic arthritis.
5. Enquire about medications that have been used for symptom relief. A marked
response to NSAID's or prednisone supports an inflammatory cause.

History from a patient with suspected Rheumatoid Arthritis

1. Uses open-ended questions to obtain history of symptoms.

2. Determines the onset, duration and location of joint pain.
3. Asks about the presence and duration of morning joint stiffness.
4. Asks about the presence of joint swelling.
5. Establishes the pattern of joint symptoms - is there symmetrical involvement?
6. Is there limitation of daily function (e.g. use of hands)?
7. Asks whether there is a family history of rheumatoid arthritis.
8. Asks for symptoms to suggest extra-curricular involvement (e.g. nodules over
pressure areas, dryness of eyes and mouth, weight loss).
9. Enquire about response of joint symptoms to analgesics and/or anti-inflammatory
drugs.

1. Try to obtain a detailed history of the onset of joint symptoms. You should
establish which joints are effective and how sudden was the onset.
2. How long have the symptoms been present? In rheumatoid arthritis, at least 6
weeks is required for the diagnosis.
3. Morning joint stiffness typically exceeds 60 minutes in active rheumatoid
arthritis.
4. Ask about presence of joint swelling (soft tissue) as well as joint pain.
5. Rheumatoid arthritis is a systemic disease, so it is important to check for
evidence of extra- articular involvement. These include the development of
rheumatoid nodules over traumatised surfaces (olecranon, calcaneal tuberosity,
matacarpo-phalangeal joints) and sicca symptoms (reduced tear and saliva
production).
6. In general, patients with rheumatoid arthritis have some relief of symptoms
with non-steroidal anti-inflammatory drugs.

Interpretation of Arterial Blood Gases

1. Identify the patient and date of the Arterial Blood Gas (ABG)
2. Identify the Fraction of Inspired Oxygen (FiO2)
3. Determine if the pH is normal (7.35-7.45); low (<7.35) indicating acidosis; or
high (>7.45) indicating alkalosis
4. Determine if the PaCO2 is normal (35-45 mmHg); low (<35) indicating hypocapnia;
or high (>45) indicating hypercapnia
5. Determine whether the PaCO2 is appropriate, or inappropriate for the pH
6. Determine if the PaO2 is low (<80 mmHg.) indicating hypoxaemia
7. Identification of Type I or Type II respiratory failure
8. Calculate the Alveolar-arterial (A-a) gradient

1. As with all investigations: Check the name of the patient and the date on
which the investigation was performed
2. Patients may or may not be receiving supplemental oxygen therapy at the time
they have arterial blood gas (ABG) analysis performed. It is important to know
this, as an increased fraction of inspired oxygen (FiO2) will influence the
interpretation of ABG results. (Note: FiO2 for room air is 0.21)
3. ABG pH is a measure of the blood’s acid/base status. Normal pH is 7.35 -
7.45. A value of less than 7.35 is considered acidic, while a value above 7.45 is
alkaline.
4. The partial pressure of Carbon Dioxide (PaCO2) directly influences the
acid/base balance of blood. A PaCO2 of less than 35 mmHg is low (hypocapnia), while
a value above 45 mmHg is high (hypercapnia). An elevated PaCO2 is the hallmark of
Type II respiratory failure.
5. As pH and PaCO2 are intricately related, it is important to make an
assessment of whether the PaCO2 is in keeping with the observed pH. For example, if
the pH is low (acidotic), a low PaCO2 suggests that the patient is trying to blow
CO2 off in an attempt to increase the blood pH. This would be an appropriate
response to acidosis, and suggests that the primary problem is a metabolic cause
(so called "metabolic acidosis”). Alternatively, in the setting of a low pH
(acidosis), a high PaCO2 is an inappropriate response, and likely to be the cause
of the acidosis (so called "respiratory acidosis”).
6. An assessment of the partial pressure of oxygen (PaO2) is necessary. This is
affected by the partial pressure of inspired oxygen. A patient who has a PaO2 of
less than 80 mmHg has arterial hypoxaemia. This is the hallmark of Type I
respiratory failure.
7. Effective gas exchange is characterised by the relationship between oxygen
and carbon dioxide. An imbalance in this relationship indicates an abnormality of
gas exchange. This information can be obtained by calculating the Alveolar-arterial
(A-a) oxygen gradient. This value can be calculated for a patient breathing room
air at sea level by the using the following equation:
A-a gradient =150- pO2 - (1.25*pCO2)
While the A-a gradient normally increases with age, a value of greater than
20 is considered to be abnormal, and suggests either ventilation/perfusion mismatch
or impaired gas diffusion. It is a valuable tool to help differentiate hypoxaemia
caused by primary lung diseases from things such as respiratory depression and
hypoventilation due to neurological disease or drug over dosage.

Chest exam

1. Inspect the patient noting respiratory distress, nutritional state.

2. Measure the respiratory and pulse rates.
3. Examine the hands for clubbing or peripheral cyanosis.
4. Look at the tongue for central cyanosis.
5. Check the position of the trachea and look for dilated neck veins.
6. Examine for lymphadenopathy in the neck and supraclavicular fossae.
7. Inspect the chest for scars or deformity.
8. Assess chest expansion.
9. Percuss the chest (side to side, front and back and front).
10. Auscultate the chest (side to side, back to front, axillae, back, front).
11. Ask the patient to cough.
12. Inspect the sputum cup and temperature chart.

1. You should position the patient so that you have good access and they are
comfortable. You should note if they appear breathless, are using accessory muscles
of respiration to breathe or are notably obese or cachectic.
2. The respiratory and pulse rates give you a useful guide to physiological
stress. Increased respiratory rates at rest reflect severe compromise of the
system.
3. Cyanosis reflects deoxygenated haemoglobin. Peripheral cyanosis may reflect
slow peripheral circulation with increased oxygen extraction or poor central
oxygenation. Cyanosis of the tongue and oral mucosa reflects poor gas exchange.
Clubbing is an increase in tissue at the nail base so that the angle is lost.
4. The trachea will deviate to the side of a collapsed lung. It can be palpated
with a finger in the sternal notch. Dilated neck veins may be seen with obstruction
of the vena cava by tumour or in right sided heart failure.
5. Palpable lymph nodes in the supra clavicular fossae may represent spread of
lung malignancy to regional nodes.
6. Signs of previous chest surgery should alert you to items not covered in your
history. Thoracotomy scars on the back follow the line of the ribs and can be
surprisingly difficult to see.
7. Hyper expansion of the chest is often associated with chronic airways
disease. Reduced expansion is seen in people with fibrotic lung disease.
8. Chest percussion if is performed by laying your non-dominant hand on the
chest and striking the middle finger with your dominant index finger. It is most
useful for revealing effusions (fluid in the pleural space) and should be performed
from side to side looking for a marked distance difference in the level at which
the note becomes dull.
9. Auscultation can reveal a variety of changes. You should ask the patient to
breathe through there their open mouth and compare the sounds from side to side.
Asymmetry is likely to reflect pathology. The upper lobes are best heard
anteriorly. Some pathologies (pulmonary fibrosis and tuberculosis) favour the upper
lobes.
10. A cough will tell you whether the patient is producing sputum, has normal
vocal cord innervation or has wheeze. Leave it until last in case it sets off a
chain of coughing.
11. The sputum cup will reveal evidence of infection (green or yellow copious
sputum) or bleeding (TB or malignancy). The temperature chart provides information
about infection.

CXR interpretation

1. Identify the patient and date of the chest X-ray

2. Identify the trachea and whether the X-ray is centred or oblique.
3. Identify the aortic arch and hilar shadows.
4. Identify the major chambers contributing to the cardiac silhouette. Left atrium.
5. Assess the cardiothoracic ratio.
6. Identify the upper, middle and lower lobes.
7. Identify vessels and bronchi in the lung fields.
8. Identify the diaphragms and costophrenic angles.

1. You need to know that the X-ray is of the correct person and how it relates
to the current illness. Check the labelling and the date of the X-ray.
2. Technical issues can alter your interpretation of an X-ray. The X-ray should
be straight on rather than oblique. This can be checked by looking at the
relationship of the clavicular heads to the lateral borders of the vertebra behind
them. You should also know whether the X-ray has been shot Posterior to Anterior
(usual) or Anterior to Posterior (X-ray in bed) as the latter produces a larger
heart shadow. The depth of inspiration alters the appearance of an X-ray; the
anterior sixth rib should be at the level of the diaphragm. Poor inspiratory effort
leads to difficulty interpreting shadows in the lung fields.
3. Air filled structures will appear dark (air is radiolucent) while fluid
filled structures (heart and great vessels) will appear light.
4. The hilar of the lungs are formed by the pulmonary arteries and the main
bronchi.
5. The major anatomic structures down the left border of the mediastinal are the
aortic arch, the pulmonary artery and the left ventricle. The major structures
forming the right border of the heart are the left atrium then the right atrium.
The right ventricle is in front of the left and contributes to the inferior border
of the heart.
6. The cardio cardio-thoracic ratio is calculated by comparing the maximum
transverse diameter of the heart to the transverse diameter of the lung fields
measured at the costophrenic angles. An increase implies enlargement of the heart.
7. The right lung is divided into three lobes which are arranged in order down
the thorax (upper, middle and lower). The left lung has an upper and a lower lobe.
The lingula of the left upper lobe overlies the heart and is best seen on the
lateral film.
8. The right and left hemi- diaphragms lie above the liver and stomach
respectively. The gastric bubble (gas in the stomach) usually identifies the
latter. The costophrenic angles should be sharp and loss of this angle implies that
there is fluid in the pleural space.

Performing and Interpreting Spirometry

1. Positions the patient in an appropriate upright position.

2. Sets up the spirometer correctly.
3. Provides clear instructions to the patient on the use of the spirometer and
demonstrates the technique:
Rapid & forceful expiration
Ensure lips are tightly sealed around mouthpiece
Initial maximal deep inspiration
4. Sustained & prolonged expiration (“until lungs are empty”).
5. Asks the patient to perform spirometry.
6. Provides encouragement/ feedback to the patient whilst.
7. He or she is performing the spirometric manoeuvre.
8. Repeats at least 3 times, and chooses best result.
9. Analyses the result and determines if it is normal or abnormal.
10. If the spirometry is abnormal defines whether the pattern is Obstructive or
Restrictive.

1. As spirometry is an effort dependent test, it is important to position the

patient correctly. This involves sitting the patient upright (in a chair, or on the
edge of the bed), and ensuring that they are relaxed and comfortable. Ideally
spirometry is best performed with a nose clip to prevent nasal flow.
2. As there are many different types of spirometer, it is important that you are
familiar with the commonly used models. This involves an understanding of how to
"reset” and "prime” the device so that accurate measurements can be obtained.
3. It is very important that the patient understands how to perform the
spirometry manoeuvre. Without this understanding it is impossible to obtain
meaningful measurements of lung function. This involves the patient holding the
spirometer correctly, and being familiar with the mouthpiece & which end to blow
into. The person supervising the spirometry should explain & demonstrate how the
inspiratory and expiratory manoeuvres are performed. This involves the subject
making a maximal inspiratory effort to fill the lungs "as deeply” as possible. The
subject should then place their lips around the mouthpiece of the spirometer,
ensuring there is a good seal. The subject is then instructed to breathe out "as
hard and as fast as possible, for as long as possible”.
4. Once the subject is familiar with the technique, they should be asked to
perform the manoeuvre several times under supervision. It is important that the
person supervising the spirometry provides feedback and encouragement during the
testing. This involves asking the subject to take as deep a breath as possible, and
then exhale "blow-out” for as "long and hard” as possible. During supervision it is
important to identify any potential sources of error, such as a slow start, mouth
or nose leak, poor effort, or premature test termination (minimum of 6 seconds).
5. Traditionally, spirometry is repeated at least three times, with the best
effort being used for analysis.
6. If the quality of the test is considered satisfactory, spirometry should be
analysed to determine if it is normal or abnormal. If the Forced Expiratory Volume
in one second (FEV1) is reduced to less than 80% of predicted, then the spirometry
is considered to be abnormal. If this is the case, and the FEV1/ FVC ratio is less
than 70% then the spirometry is considered obstructive. If the FEV1 is reduced (as
stated), and the FEV1/FVC ratio is greater than 85% then the spirometry is
considered to be restrictive. If the FEV1 is reduced (as stated), and the FEV1/FVC
ratio is between 70% and 85%, then the spirometry is non¬specifically abnormal.

Taking a History from a Patient with Anaemia

1. Introduce yourself and explain the purpose of the exercise.

2. Determine the severity of the anaemia: asymptomatic or symptoms.
3. Establish the duration of the anaemia or the symptoms: ask for the last blood
count or the last known “normal” blood count.
4. Ask about blood loss: menstrual history, malaena or fresh blood in stools, blood
in the urine, nose bleeds.
5. Ask about diet: red meat, leafy vegetables, milk and other dairy intake.
6. Symptoms of malabsorption: weight loss, diarrhoea, abdominal pain or bloating.
7. History of chronic disease: renal disease,rheumatoid arthritis, chronic
infection, malignancy.
8. Symptoms of red cell haemolysis: jaundice or dark urine.
9. Family history of anaemia: thalassaemia or sickle cell anaemia.
10. Drug history: NSAIDs, chemotherapy, drugs associated with haemolysis.

1. Anaemia is most often recognized by an abnormal screening FBC performed in an

asymptomatic individual. As anaemia worsens symptoms will appear and progress from
non-specific tiredness through shortness of breath to postural hypotension,
ischaemic chest pain and frank cardiac failure with ankle swelling.
2. Acute anaemia is nearly always due to blood loss or haemolysis.
3. The three major classes of anaemia are:
Marrow production defects
Red cell maturation defects
Decreased red cell survival
4. The majority of anaemias are hypo-proliferative in nature and result from
iron deficiency, chronic inflammation and marrow damage. Iron deficiency may
commonly be due to occult loss from the gastro-intestinal tract or overt menstrual
loss with inadequate dietary iron intake.
5. Maturation defects can result from nuclear defects (e.g. vitamin B12 or
folate deficiency or drug toxicity) or cytoplasmic defects (abnormalities in globin
or haem synthesis).
6. Haemolytic anaemia is dramatic but uncommon. It is often an immune mediated
process and may be triggered by some drugs (cephalosporin, levodopa, quinine)

Full blood count in Anaemia diagnosis

1. Identify the patient and date of full blood count.

2. Haemoglobin - comment on whether in the normal range.
3. Mean cell volume - comment on whether in normal range, define the terms
microcytic and macrocytic.
4. Mean cell haemoglobin - comment on whether in normal range. Interpret high and
low values.
5. Reticulocyte count. Comment on its relevance.
6. White cell count - comment on whether in normal range.
7. White cell differentiation - comment if normal or abnormal.
8. Platelet count-comment on whether in normal range.
9. Be able to comment on changes in FBC parameters (Hb, MCV) over time.

1. The commonest presentation of anaemia in our society is asymptomatic

identification on a blood count done for non-specific reasons.
2. You must confirm that the FBC has been performed on a specific person on a
specific date.
3. If the haemoglobin is below the normal range then the subject is anaemic.
4. Disorders of red cells are divided into 3 categories depending on whether the
red cells are:
Microcytic and hypo-chromic (Iron deficiency)
Normocytic and normochromic
Macrocytic (Deficiency of B12 or Folate or a damaged marrow)
5. The reticulocyte count is important in the classification of anaemia. If the
erythropoietin (EPO) and erythroid bone marrow response are normal then red cell
production can increase 2 to 3 times normal within 10 days. If the subject has an
established anaemia, a reticulocyte response of less than 2 to 3 times normal
indicates either inadequacy of either the EPO or bone marrow response.
6. If anaemia is secondary to bone marrow failure (e.g. aplastic anaemia) the
white cell count may be normal or low. If anaemia is secondary to marrow
infiltration (e.g. by leukaemia) then the white cell count may be low, normal or
high.
7. If anaemia is due to marrow fibrosis or infiltration by cancer the white cell
differential will show increased numbers of immature leucocytes. If anaemia is due
to acute leukaemia then the white cell differential will show increased numbers of
immature cells (blasts) and decreased mature leucocytes. If due to a chronic
leukaemia then the differential will show increased numbers of a particular
leucocyte subtype and decrease in other subtypes.
8. The platelet count will be low or normal in aplastic anaemia and in marrow
infiltration by cancer, leukaemia and lymphoma. It should rise in response to blood
loss or stress such as surgery.
9. The platelet count and white cell count may be low in folate and vitamin B12
deficiency. Platelet count and white cell count are not typically low in iron
deficiency but this may occur in up to 10% of cases.

Lymph node examination

1. Introduces self and explains nature of examination.

2. Examine the epitrochlear lymph nodes.
3. Visualise the palatine, lingual and pharyngeal tonsils (Waldeyer's ring) A light
source must be used.
4. Cervical: Examine the submental, submandibular, jugular chain, posterior
triangle, pre-auricular, post auricular and occipital groups from behind the
patient. Must be able to name and localize at least 4 groups.
5. Examine the supraclavicular nodes from in front of the patient.
6. Axillae: Examine the Pectoral (anterior), Lateral (brachial), Subscapular
(posterior) and Apical groups on both sides. Must demonstrate systematic exam of
the walls of the axillae.
7. Inguinal nodes: along the inguinal ligament.
8. Inguinal nodes: along the femoral vessels.

1. Lymph nodes enlarge in a variety of inflammatory, infective and malignant

conditions. In local infections or malignancies the draining nodes are likely to
become involved and examination of the local draining nodes should be part of your
examination of any focal pathology. The examination of lymph nodes as a group is
usually done in patients where you suspect a lymphoproliferative disorder but may
also be part of the examination of an immunocompromised patient.
2. The size and texture of lymph nodes is often helpful in reaching a diagnosis.
Lymph nodes associated with bacterial infection are often tender to the touch.
Lymph nodes in lymphomas are often large and “rubbery” in feel. Small “shotty”
nodes are often a normal finding in the groins and axillae.
3. The initial position of the patient is usually lying flat as with the
gastrointestinal examination but it is acceptable to examine the epitrochlear and
axillary lymph nodes with the patient sitting.
4. The epitrochlear nodes are proximal and slightly anterior to the medial
epicondyle and examined using the thumb by placing the patients elbow into the
corresponding palm of the examiner (right elbow, right hand).
5. The axillae are examined using the opposite hand to the patient's axilla
(right hand, left axilla) and resting the patient's forearm on the examiner's
forearm. The axillae should be examined on the posterior, anterior and medial walls
and also in the apex.
6. The cervical lymph nodes are best examined from behind with the patient
sitting.
7. It is acceptable to examine the epitrochlear and axillary lymph nodes after
examining lymph nodes of the head and neck.
8. The supraclavicular nodes are examined from the front of the patient.
9. Inguinal lymph nodes are examined with the patient lying flat