THE ULTIMATE HIGH YIELD

OSCE
GUIDE
FOR MEDICAL STUDENTS

THE MEDIC PRO

 THE ULTIMATE HIGH YIELD

OSCE
GUIDE
FOR MEDICAL STUDENTS

THE MEDIC PRO

Disclaimer: the content of this book is for informational and educational purposes only, and
does not substitute professional medical advice or consultations with healthcare
professionals. This book is a high yield guide only and may not contain all the necessary
findings for your exam so please use at as a general reference and not as your sole source of
preparation. Credit to the rightful owners for pictures//media used. Please do not share this
book around with those who have not purchased it.

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 CONTENTS
01 CARDIOVASCULAR
HISTORY STATIONS
1. HOW TO TAKE A HAEM HISTORY
PHYSICAL EXAMINATIONS
1. CONGESTIVE HEART FAILURE SDL PROCEDURES
2. RIGHT SIDED HEART FAILURE 1. HOW TO PERFORM VENIPUNCTURE
3. LEFT SIDED HEART FAILURE 2.HOW TO DO INJECTIONS (INTRAMUSCULAR
4. RHEUMATIC HEART DISEASE & SUBCUTANEOUS)
5. LEG PAIN (PERIPHERAL ARTERY DISEASE)
04 GASTROINTESTINAL
HISTORY STATIONS
1. HOW TO TAKE A CVS HISTORY PHYSICAL EXAMINATIONS
2. HYPERTENSION FOLLOW-UP
1. CHRONIC LIVER DISEASE INSPECTION
SDL PROCEDURES 2. CHRONIC LIVER DISEASE EXAMINATION
3. HYDRATION STATUS
1. HOW TO TAKE AN ECG
2. HOW TO READ AN ECG HISTORY STATIONS
1. HOW TO TAKE A GI HISTORY
02 RESPIRATORY
SDL PROCEDURES
1. DIGITAL RECTAL EXAMINATION
PHYSICAL EXAMINATIONS
1. PNEUMOTHORAX 05 RENAL
2. POSTEROLATERAL EXAMINATION
3. LUNG CANCER
4. BRONCHIAL ASTHMA INSPECTION
PHYSICAL EXAMINATIONS
1. CHRONIC KIDNEY DISEASE
HISTORY STATIONS 2. FEVER, DYSURIA & FLANK PAIN
1. HOW TO TAKE A RESPI HISTORY
HISTORY STATIONS
2. ASTHMA FOLLOW-UP
1. HOW TO TAKE A RENAL HISTORY
SDL PROCEDURES
SDL PROCEDURES
1. HOW TO USE A METRED DOSE INHALER
1. URINE DIPSTICK
2. HOW TO USE A PEAK FLOW METER
3. HOW TO READ A CHEST X-RAY
06 ENDOCRINE
03 HAEMATOLOGY
PHYSICAL EXAMINATIONS
1. THYROID EXAMINATION
PHYSICAL EXAMINATIONS
2. HYPERTHYROIDISM
1. CERVICAL LYMPH NODE EXAMINATIONS 3. HYPOTHYROIDISM
2. AXILLARY LYMPH NODE EXAMINATIONS 4. CUSHING SYNDROME

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 CONTENTS
HISTORY STATIONS 7. HAND INJURY (MEDIAN, RADIAL

1. HOW TO TAKE A ENDO HISTORY AND ULNAR NERVES)

2. THYROID FOLLOW-UP 8. OPTIC NERVE (CN2)

3. DIABETES FOLLOW-UP 9. TRIGEMINAL NERVE (CN5)

10. ACCESSORY NERVE (CN11)

SDL PROCEDURES 11. HEARING LOSS (CN8)

1. HOW TO USE A FUNDOSCOPE 12. SQUINT (CN3, 4, 6,) & FACIAL

2. HOW TO USE A GLUCOMETER ASSYMETRY (CN7)

3. HOW TO USE A INSULIN PEN 13. DIFFICULTY SWALLOWING & SPEECH

(CN 9, 10, 12)

08 REPRODUCTIVE HISTORY STATIONS

1. HOW TO TAKE A CNS HISTORY
HISTORY STATIONS
SDL PROCEDURES
1. HOW TO TAKE A REPRO HISTORY
1. HOW TO USE AN OTOSCOPE
SDL PROCEDURES
1. BREAST EXAMINATION
10 SPECIAL STATIONS
2. BIMANUAL PALPATION
3. PAP SMEAR
HISTORY STATIONS
4. ANTENATAL EXAMINATION
1. ALCOHOL HISTORY
2. ASSESS CVS RISKS
07 MUSCULOSKELETAL 3. EMPATHY STATION
4. DRUG INFORMATION GIVING
PHYSICAL EXAMINATIONS
1. SHOULDER EXAMINATION
2. ELBOW EXAMINATION
2. KNEE EXAMINATION
3. HIP EXAMINATION
4. CERVICAL EXAMINATION
5. THORACOLUMBAR EXAMINATION

HISTORY STATIONS
1. HOW TO TAKE AN MSK HISTORY

09 NERVOUS
PHYSICAL EXAMINATIONS
1. UPPER LIMB SENSORY
2. LOWER LIMB SENSORY
3. UPPER LIMB MOTOR
4. LOWER LIMB MOTOR
5. DIABETIC FOOT EXAM
6. CEREBELLAR & COORDINATION
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CARDIOVASCULAR
SYSTEM

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 HIGH YIELD CVS
PE CASES
- PE STATIONS -

CONGESTIVE HEART FAILURE

General Inspection
Patient at 45° angle
Alert, conscious, responsive
Respiratory distress + cyanosis

Inspection
Hands: peripheral cyanosis, clubbing + capillary refill
Pulse: both [radio-radial delay] + single [rate, rhythm, volume]
Mention vitals: BP, RR, temperature
Mouth + lips: for central cyanosis
Pedal edema

JVP
Inspect: scars + vein distension
Pulse: carotid pulse
Measurement: turn to left + observe and comment in cm [4-4.5cm]
Mention: Kussmaul’s sign, hepatojugular reflex and liver examination

Chest Inspection
Chest wall deformities: pectus carinatum + excavatum
Scars
Symmetry

Chest Palpation
Ask if hands are warm enough
Apex beat: comment on position [displacement]
Thrills at 4 regions

Auscultation
Hand on carotid pulse
4 regions: comment on S1 + S2 heard, in sync with the carotid pulse
Additional heart sounds: comment on S3/S4 sounds
Murmurs: mitral stenosis, aortic regurgitation
Lung bases: comment on any crackles
Sacral edema: comment on presence

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 HIGH YIELD CVS
PE CASES
- PE STATIONS -

RIGHT SIDED HEART FAILURE

General Inspection
Patient at 45° angle
Alert, conscious, responsive
Respiratory distress + cyanosis

Inspection
Hands: peripheral cyanosis, clubbing + capillary refill
Pulse: both [radio-radial delay] + single [rate, rhythm, volume]
Mention vitals: BP, RR, temperature
Mouth + lips: for central cyanosis
Pedal edema

JVP
Inspect: scars + vein distension
Carotid pulse: comment on rhythm + volume
Measurement: turn to left + observe and comment in cm [4-4.5cm]
Hepatojugular reflex: comment if JVP sustained > 10s
Kussmaul’s sign: comment on JVP rise upon inspiration
Liver examination: palpation, span, check for pulsatile liver

Chest Inspection
Chest wall deformities: pectus carinatum + excavatum
Scars and chest symmetry

Chest Palpation
Ask if hands are warm enough
Apex beat: comment on position [displacement]
Parasternal heave: breathe in + out and hold and comment on presence
Thrills at 4 regions

Auscultation
Hand on carotid pulse
4 regions: comment on S1 + S2 heard, in sync with the carotid pulse
Additional heart sounds: comment on S3/S4 sounds
Murmurs: mitral stenosis, aortic regurgitation
Lung bases: comment on any crackles
Sacral edema: comment on presence
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 HIGH YIELD CVS
PE CASES
- PE STATIONS -

LEFT SIDED HEART FAILURE

General Inspection
Patient at 45° angle
Alert, conscious, responsive
Respiratory distress + cyanosis

Inspection
Hands: peripheral cyanosis, clubbing + capillary refill
Pulse: both [radio-radial delay] + single [rate, rhythm, volume]
Mention vitals: BP, RR, temperature
Mouth + lips: for central cyanosis
Pedal edema

Chest Inspection
Chest wall deformities: pectus carinatum + excavatum
Scars
Symmetry

Chest Palpation
Ask if hands are warm enough
Apex beat: comment on position + heaving + displacement
Parasternal heave: breathe in + out and hold and comment on presence
Thrills at 4 regions

Auscultation
Hand on carotid pulse
4 regions: comment on S1 + S2 heard, in sync with the carotid pulse
Additional heart sounds: comment on S3
Lung bases: comment on any crackles
Sacral edema: comment on presence

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 HIGH YIELD CVS
PE CASES
- PE STATIONS -

RHEUMATIC HEART DISEASE

General Inspection
Patient at 45° angle
Alert, conscious, responsive
Respiratory distress + cyanosis

Inspection
Hands: splinter hemorrhage, Janeway lesions, Osler’s nodes [press pulp for
pain] and clubbing
Pulse: both [radio-radial delay] + single [rate, rhythm, volume]
Mouth: pharyngitis, dental caries, petechiae in mucosa + cyanosis
Trunk + limbs: erythema marginatum + subcutaneous nodules
Mention: JVP rise

Chest Inspection
Chest wall deformities: pectus carinatum + excavatum
Scars
Symmetry

Chest Palpation
Ask if hands are warm enough
Apex beat: comment on position
Thrills at 4 regions

Auscultation
Hand on carotid pulse
4 regions: comment on S1 + S2 heard, in sync with the carotid pulse
Additional heart sounds: comment on S3/S4
Mitral stenosis: mid-diastolic murmur (low-pitched + rumbling) best heard
at the apex + rolling to the left [bell]
Lung bases: basilar crackles

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 HIGH YIELD CVS
PE CASES
- PE STATIONS -

LEG PAIN (PAD)

General Inspection
Patient at 45° angle
Alert, conscious, responsive
Respiratory distress + cyanosis

Lower Limb Inspection

Look at both limbs
Calf: scars, swelling, muscle wasting, loss of leg hair
Feet: peripheral cyanosis, thickening of nails

Palpation
Palpate both right + left
Ankles: check for pitting edema
Temperature: feel + compare on both
[using dorsum of hands from top to bottom]
Capillary refill: check on both big toes [must be less than 2s]
Pulses: check if palpable + comment on the symmetry of volume

1. Femoral pulse: 1 cm below the mid-inguinal point (between ASIS and

pubic symphysis)
2. Popliteal pulse: knee flexed to 30 degrees, deep in popliteal fossa
3. Posterior tibial pulse: 2 cm below and behind medial malleolus
4. Dorsalis pedis pulse: Lateral to tendon of extensor hallucis longus in the
middle of dorsum of foot

Mention Only
Auscultation of pulses using Doppler ultrasound
Measuring BP around ankle to calculate ABI
Berger’s test

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 HOW TO TAKE
A CVS HISTORY
- HX STATIONS -

INTRODUCTION
Hi, I’m _____ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

HOPI
Ask about onset + triggers

Ask SOCRATES

Ask associated CVS symptoms: chest pain + shortness of breath + ankle

swelling + palpitations

Ask head to toe symptoms: [very quickly] Dizziness

Headache
Blurred vision
Ask about systemic symptoms:
Flu-like symptoms
- Weight changes: how many kg + over how long Difficulty swallowing
- Appetite changes: increased or decreased Cough
Nausea/vomiting
- Urinary changes
Chest pain
- Bowel changes Back pain
Ask about progression + previous episodes Abdominal pain
Skin changes
Leg swelling
PAST MEDICAL HISTORY
Now I'm going to ask you a few questions about your general health.
Do you have any long-standing medical conditions: high BP, high
cholesterol or diabetes [ask all 3]

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies?

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FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents?
- Death: ask age at death + cause [I'm so sorry to hear that]
- Disease or condition: ask if they are seeking treatment

Do you have any siblings? [ask about any conditions]

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.
Are you currently working: ask about occupation + stress

Do you live alone or with someone: ask about health of partner/ kids if any

Ask if they have anyone at home to help them [only if symptoms are serious]

Can you describe your diet: what kind of diet + high intake of fried, fatty or
salty food

Do you exercise regularly: what kind + how often

Have you travelled anywhere recently: duration of flight + where [if relevant]

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: what kind + how often [do CAGE if relevant]

Do you consume any recreational drugs: name + oral/IV

ClOSING
That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

Worry: It's a good thing you came in today and we will take it one step at a
time alright?

Scared about death or serious outcome: I understand you are worried

about ______, it can be scary to think about however it's too early to
conclude anything right now, but we will take it one step at a time. I can
ensure you that you are in good hands.

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 HYPERTENSION
FOLLOW-UP
- HX STATIONS -

INTRODUCTION
Hi, I’m _____ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

INITIAL DIAGNOSIS
Ask when + how were you diagnosed with hypertension?

Ask about checkups: frequency + if any were missed

Ask about initial readings: BP readings + if reports are available

COMPLIANCE
Ask about current medications: name + dose + frequency + compliance

Ask about any medication changes: name + reason

Ask about medication side effects/allergies: if yes, ask about the reaction in
specific

CONTROL
Ask about home monitoring: last reading + BP monitor use

Ask about the last time eyes were checked: for hypertensive retinopathy

Ask about lifestyle changes: diet + exercise

Chest pain
Dyspnea (PND+ OP)
COMPLICATIONS Ankle swelling
Palpitations
Ask about any current symptoms

Ask about hypertensive complications Blurred vision

Ask about systemic symptoms Headaches
Dizziness
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 PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.

Do you have any long-standing medical conditions: high BP, high

cholesterol or diabetes [ask all 3]

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies: ask about what happens

FAMILY HISTORY

How are your parents + siblings?

Ask if there is any family history of CVD

SOCIAL HISTORY
Ask about occupation: ask about stress

Ask about their diet: what kind of diet + high intake of fried, fatty or salty
food

Ask about exercise: ask how often

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: how often

ClOSING

That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

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 HOW TO TAKE
AN ECG
- SDL PROCEDURE -

INTRODUCTION
Hi, I’m _______ , a ___ year-medical student. Can I confirm your full name and
age please?

Today I’ve been asked to take an ECG for you, is that okay with you?
[gain consent]

Explain procedure: an ECG is a machine that records the electrical activity

of your heart. It will involve you to remove your upper garments + any
metallic objects, exposing your chest. I’ll place a few stickers and leads on
your chest and limbs. You won't be any pain and I will guide you through
everything.

Ensure privacy: this will be done in a closed + private room, everything is

confidential and a chaperone will be provided if you need

PROCEDURE PREPARATION

Pre-procedure: do you have any questions? Are you in any pain before we
start?

Patient preparation: remove upper garments, socks and shoes. Take off any
metallic objects like jewellery + watches. Keep still and do not move.

LEAD PLACEMENT

PRECORDIAL LEADS:
V1 - 4th intercostal space at right sternal border
V2 - 4th intercostal space at left sternal border
V3 - mid point of V2 + V4
V4 - 5th IC space mid clavicular line
V5 - at level of V4 at anterior axillary line
V6 - at level of V5 mid-axillary line

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LEAD PLACEMENT

LIMB LEADS:

Remember Ride Your Green Bike [for limb leads]

Red: right hand [proximal to wrist]

Yellow: left hand [proximal to wrist]
Green: left leg [proximal to ankle]
Black: right leg [proximal to ankle]

POST-PROCEDURE

Taking the ECG: check the calibration and make sure the patient is
still. Then print out the ECG
Label the ECG: patient's full name + ID + date + time
Remove all equipment from the patient [offer to wipe off the gel]

ClOSING

The procedure is now complete. I will relay this to my senior doctor and we
will get back to you soon.

Thank you for your time.

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 HOW TO READ
AN ECG
- SDL PROCEDURE -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
age please?

Today I’ve been asked to check your ECG, is that okay with you? [consent]

ECG details check and say: full name + date + time

[to confirm the correct ECG]
ECG BASICS
1 SMALL BOX (X-AXIS) = 0.04S
4 ESSENTIALS 1 SMALL BOX (Y-AXIS) = 0.1 mV

1 LARGE BOX (X-AXIS) = 0.2S

2 LARGE BOXES (Y-AXIS) = 1MV
Calibration: usually at speed of 25mm/s

Rhythm: check for a constant RR interval + if P waves are followed

by a QRS complex (lead II)
Types: regular, irregularly irregular, regularly irregular

Heart rate: may be present on the ECG but always double check
Regular HR: (number of large boxes between 2 R waves)/300
Irregular HR: (number of R waves present in 30 large boxes) x 10

Cardiac axis: check lead I and aVF (normally up in both)

LAD: +ve lead I & -ve aVF
RAD: -ve lead I & +ve aVF

COMPONENTS

P wave: check for normal morphology

Height < 2.5 small boxes (lead II) + < 1.5 small boxes (V1)
Width < 3 small boxes

PR interval: check if interval is 3-5 small boxes (lead II)

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COMPONENTS

Q wave: pathological if > 2 small squares deep (lead II, III, aVF)

QRS complex: check is width is 2-3 small boxes (lead II)

ST segment: check lead all leads for any elevation or depression

[check below for interpretation]

T wave: should be up in all leads except aVR & V1

QT interval: should be < 1/2 RR Interval

U wave: check for the presence

ECG COMPONENT SUMMARY

PR INTERVAL
T
P

QT INTERVAL

Q S

QRS
COMPLEX

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RESPIRATORY
SYSTEM

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 HIGH YIELD
RESPI CASES
- PE STATIONS -

PNEUMOTHORAX
General Inspection
Patient at 45° angle
Alert, conscious, responsive
Respiratory distress + cyanosis

Chest Inspection
Chest wall deformities: pectus carinatum + pectus excavatum
Open fractures + bleeding
Symmetry: stand at end of bed and comment on symmetry

Chest Palpation
Warn patient before tracheal deviation +ask for any pain
Tracheal deviation: comment on deviation + paratracheal symmetry
Cricosternal distance: comment on fingers
Apex beat: position + diminished
Chest expansion: 3 areas and comment on movement [normal is at least
5cm]
Percussion: comment on notes + symmetry on both sides

Auscultation
Breath sounds: comment on vesicular breath sounds + symmetry [bell in the
supraclavicular spaces]
Vocal resonance: symmetry + any reduction/absence
Lung bases: comment on crackles

POSTEROLATERAL EXAMINATION

General Inspection
Alert, conscious, responsive
Respiratory distress + cyanosis

Posterior Chest Inspection

Chest wall deformities: scoliosis + kyphosis
Scars (posterior + lateral)
Chest movement
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 HIGH YIELD
RESPI CASES
- PE STATIONS -
Chest Palpation
Hug both arms
Tracheal deviation: comment on deviation + paratracheal symmetry
Cricosternal distance: comment on fingers
Chest expansion: 2 areas [above + below nipples]
Percussion: comment on notes + symmetry

Auscultation
Breathe in + out through mouth
Breath sounds: comment on vesicular breath sounds symmetry +
additional sounds [bell in the supraclavicular spaces]
Vocal resonance: symmetry + any reduction/absence
Lung bases: comment on crackles

LUNG CANCER
General Inspection
Alert, conscious, responsive
Generalized muscle wasting or cachexia

General Inspection
Hands: tobacco stains, wasting of interossei muscles and clubbing
Vitals: pulse, BP, temperature, respiratory rate [mention]
Face: Horner’s syndrome, cyanosis, plethora
Nose: obstructing masses
Mouth + lips: central cyanosis
Neck: distended veins
Mention: cervical lymph node examination
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 HIGH YIELD
RESPI CASES
- PE STATIONS -

Chest Inspection
Inspect from the end of the bed
Chest wall deformities: pectus carinatum + excavatum
Distended vessels
Symmetry of chest movement: from end of bed

Chest Palpation
Warn patient before + ask for any pain
Tracheal deviation: comment on deviation + paratracheal symmetry
Cricosternal distance: comment on fingers
Apex beat: position + diminished
Chest expansion: 3 areas and comment on movement [normal is at least
5cm]
Percussion: comment on notes + symmetry on both sides

Auscultation
Breath sounds: comment on vesicular breath sounds symmetry +
additional sounds [bell only in the supraclavicular spaces]
Vocal resonance: symmetry + any reduction/absence
Lung bases: comment on crackles
Sacral edema: comment on presence

BRONCHIAL ASTHMA INSPECTION

General Inspection
Alert, conscious, responsive
Respiratory distress + cyanosis
Use of accessory muscles for respiration [SCM, trapezius, scalene]

General Inspection
Hands: central cyanosis, fine tremor, flapping tremor
Pulse: comment on rate, rhythm, volume, character [measure for 30s]
Respiratory rate: comment on rate
Vitals: temperature + blood pressure
Nose: nasal polyps and discharge
Mouth: central cyanosis and white patches of candidiasis

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 HOW TO TAKE
A RESPI HISTORY
- OSCE NOTES -

INTRODUCTION
Hi, I’m ______ , a [__] year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought you in today. Everything we discuss today will be kept private
and confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

HOPI
Ask about onset + triggers

Ask SOCRATES

Ask associated RESPI symptoms: chest pain, dyspnea, cough, sputum,

haemoptysis, wheezing

Ask head to toe symptoms: [very quickly] Dizziness

Headache
Ask about systemic symptoms: Blurred vision
Flu-like symptoms
- Weight changes: how many kg + over how long
Difficulty swallowing
- Appetite changes: increased or decreased
Cough
- Urinary changes Nausea/vomiting
- Bowel changes Chest pain
Back pain
Ask about progression + previous episodes
Abdominal pain
Skin changes
PAST MEDICAL HISTORY Leg swelling

Now I'm going to ask you a few questions about your general health.
Do you have any long-standing medical conditions: high BP, high
cholesterol or diabetes [ask all 3]

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies: ask about what happens

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 FAMILY HISTORY

Now I'm going to ask you a few questions about your family.

How are your parents?

- Death: ask age at death + cause [I'm so sorry to hear that]
- Disease or condition: ask if they are seeking treatment

Do you have any siblings? [ask about any conditions]

SOCIAL HISTORY

Now I'm going to ask you about your general lifestyle.

Are you currently working: ask about occupation

Do you live alone or with someone: ask about health of partner/ kids if any

Ask if they have anyone at home to help them [only if symptoms are serious]

Can you describe your diet: what kind of diet

Do you exercise regularly: what kind + how often

Have you travelled anywhere recently: where [if suspecting TB]

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: what kind + how often [do CAGE if relevant]

Do you consume any recreational drugs: name + if taken orally/IV

ClOSING

That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

Worry: It's a good thing you came in today and we will take it one step at a
time alright?
Scared about death or serious outcome: I understand you are worried
about ______, it can be scary to think about however it's too early to
conclude anything right now, but we will take it one step at a time. I can
ensure you that you are in good hands.

MEDICP
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 ASTHMA
FOLLOW-UP
- OSCE NOTES -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought you in today. Everything we discuss today will be kept private
and confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

INITIAL DIAGNOSIS
Ask when + how were you diagnosed with asthma?

Ask about checkups: frequency + if any were missed

COMPLIANCE
Ask about current medications: name + dose + frequency + compliance

Ask about any medication changes: name + reason

Ask about medication side effects/allergies: if yes, ask about the reaction in
specific

CONTROL
Ask about home monitoring: peak flow meter use + last 2 readings

Ask GINA questions:

In the last 4 weeks:

1. Daytime asthma symptoms more than twice a week?
2. Reliever needed for symptoms more than twice a week?
3. Any night waking due to asthma?
Dyspnea
4. Any activity limitation due to asthma? Wheezing
Cough
COMPLICATIONS Sputum

Ask about any current symptoms

White patches
Ask about asthma/inhaler use complications (candidiasis)
Fine tremors
Ask about systemic symptoms MEDICP
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 PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.

Do you have any long-standing medical conditions: high BP, high

cholesterol or diabetes [ask all 3]

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies: ask about what happens

FAMILY HISTORY

How are your parents + siblings?

Ask if there is any family history of asthma/eczema

SOCIAL HISTORY

Ask about living conditions: ask about dust, pets or allergens

Ask about exercise: how often + if it triggers asthma

Ask about lifestyle: if asthma has affected their daily activities + how

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: how often

ClOSING

That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

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 HOW TO USE A
METRED DOSE INHALER
- SDL PROCEDURE -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name
and age please?

You have been started on [name of inhaler], for your asthma.

Today I’ve been asked to teach you how to use your inhaler correctly.

I will walk you through the steps first and at the end I'd like you to repeat
the instructions back to me okay?

Prepare equipment: canister + mouthpiece

GIVING INSTRUCTIONS CANISTER

TEST THE INHALER

Remove the cap and shake well
Point the inhaler away from you + press the canister
Check if a puff of medication comes out
MOUTHPIECE

PREPARATION
Make sure you are sitting upright or standing up
Hold the inhaler upright
Remove the cap + shake the canister
Breathe out slowly - until your lungs are empty
Seal your lips around the mouth piece tightly
Press down on the canister and breathe in slowly
Continue to breathe in for a few seconds - so the medication can settle

AFTER:
If you need another puff, repeat these steps after 30 seconds

CLOSING
Ask the patient to repeat the steps back to you
Ensure they perform the inhaler technique correctly [correct if necessary]

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 IF USING A SPACER / CHAMBER

Test the inhaler like above

PREPARATION
Make sure you are sitting upright or standing up
Hold the inhaler upright
Remove the cap + shake the canister

SPACER
Insert the inhaler into the hole at the end of the spacer
Breathe out slowly - until your lungs are empty
Place the mask around your mouth tightly
Press the canister to release 1 puff into the spacer
Breathe in deeply - in + out several times

AFTER:
Repeat the steps above if you need another puff

INHALER TYPES

BLUE INHALER BROWN INHALER SPACER

Name: salbutamol Name: dexamethasone Function: allows direct

[corticosteroid] deposition of medication
Function: relieves asthma within lungs
attack Function: prevents asthma
attack Uses:
Mechanism: bronchodilator
For children aged 4-5 yrs
Mechanism: anti-inflammatory
Onset: within 2 hours + Adults using
short-acting Onset: within 2-8 days + corticosteroid inhalers
long-acting [prevents side effects]
Adults having difficulties
with inhaler
[provides convenient use]
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 HOW TO USE A
PEAK FLOW METRE
- SDL PROCEDURE -

INTRODUCTION

Hi, I’m ______ , a ___ year-medical student.

Can I confirm your full name and age please?

Today I’ve been asked to teach you how to use a device called a peak flow
meter. This will help you measure your asthma control.

I will walk you through the steps first and at the end I'd like you to repeat
the instructions back to me okay?

Prepare equipment: peak flow metre + mouthpiece

BASICS

GIVING INSTRUCTIONS FUNCTION: A PEAK FLOW

METRE MEASURES A
PERSON'S MAXIMUM SPEED
OF EXPIRATION AS THEY
BEFORE: BLOW INTO IT
Make sure you are standing up MAIN USE: ASSESS ASTHMA
CONTROL
Attach the mouthpiece to the peak flow metre
Make sure the indicator is at the base of the scale
Hold the peak flow meter horizontally in your hand

DURING:
Take a deep breath in
Blow out as hard + fast as you can

AFTER:
Write down the reading obtained
Repeat this another 2 times for 2 more readings
Note down the highest reading among the 3

CLOSING
Observe the patient + ensure they perform the test correctly
[correct if necessary]
Compare the reading with the normal predicted values of peak flow
(using the chart below)
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 PERSONAL BEST MEASUREMENT

Instruct the patient to identify their personal best peak expiratory flow by
recording the highest number achieved within 2 weeks when he/she
feels relatively well without respiratory symptoms

The personal best is determined under the 3 following conditions:

1. Peak flow rate is measured at least twice a day for 2-3 weeks

2. Peak flow rate should be measured upon awakening and in the late
afternoon or early evening

3. Peak flow rate should be measured 15-20 minutes after use of an

inhaled short-acting beta 2-agonist (inhaler)

Ensure the patient keeps a small notebook to record all measurements

PEAK FLOW & ZONES

based on the
patient's gender,
age and height

Green zone
(80-100% of personal best) signals everything is fine, no asthma symptoms

Yellow zone
(50-80% of personal best) signals caution, may be having asthma episode that
requires increase in dose of medicine, or asthma is generally not controlled.
Doctor may need to change the prescription.

Red Zone
(below 50% of personal best) signals alert, seek medical advice if reading does
not return to yellow or green zone
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 HOW TO READ
A CHEST X-RAY
- SDL PROCEDURE -

INTRODUCTION

Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
age please?

Today I’ve been asked to check your x-ray, is that okay with you? [consent]

X-ray details check and say: full name + date + time [to confirm the x-ray]

RIPE CHECK- IMAGE QUALITY

Rotation: check if the medial aspect of the clavicles are equidistant from
the spinous processes + the spinous processes are vertically orientated
against the vertebral bodies.

Inspiration: check if 5-6 anterior and lung borders are visible

PA/AP view: if there is no label, assume it's PA

Exposure: check if the left hemidiaphragm is visible to the spine + if the

vertebrae is visible behind the heart

TRACHEA

Deviation: check for tracheal deviation

Paratracheal masses: check along the right + left side of the trachea

Carina: check if it’s visible

Right + left bronchus: check if it’s visible

LUNGS
Check right + left lung for:

Fields: check for opacities/consolidations

Apex: check for consolidation or cavities

Hilum: check for presence of lymphadenopathy and symmetry in size

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LUNGS

Diaphragm: ensure the right is higher than the left & if the left is above
gastric bubble

Costophrenic angle: check for sharpness or loss of angle

Pleura: check for thickening + haemothorax/pneumothorax

HEART

Size: ensure the cardiac diameter is < 50% of cardiothoracic diameter

[only in PA view]

Borders: check if right + left borders are well defined

Aortic knuckle + AP window: check for visibility

EXTRA

Soft tissue swellings: haematoma

Bone abnormalities: fractures

Medical gadgets: pacemaker, feeding tube, valves

RIPE SUMMARY & X-RAY SUMMARY

TRACHEA
ROTATION
LUNGS
INSPIRATION
HEART
PA/AP VIEW
EXTRA

EXPOSURE

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HAEMATOLOGY
SYSTEM
 HIGH YIELD
HAEM CASES
- PE STATIONS -

CERVICAL LYMPH NODE EXAMINATION

General Inspection
Patient sitting upright
Bleeding or bruising
Pallor
Cachexia

Neck Inspection
Inform patient you will inspect from behind
Ask if patient has any pain first
Lymphadenopathy
Irregularities

Neck Palpation
Inform patient you will be pressing around neck
Palpate with the pulp of first 3 fingers in a circular motion
Submental - below chin
Submandibular - under the mandible
Tonsillar - angle of the mandible
Parotid - angle of the mandible
Pre-auricular - in front of ears
Post-auricular - behind ears

Do right first then left

Superficial cervical - along the anterior SCM down to the clavicle
Supraclavicular - behind the clavicles
Deep cervical - along the posterior SCM up to to the mastoid process
Occipital - on the occipital protuberance

Lymph Node Findings

Remember SSS-CMTO
Site: state the anatomical location
Size: state in dimensions (cm)
Shape: state regular or irregular.
Consistency: state if it's soft, hard or rubbery.
Tenderness: press + ask the patient for pain
Mobility: check if the lymph node is mobile or tethered
Overlying skin changes: state any changes like erythema

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 HIGH YIELD
HAEM CASES
- PE STATIONS -

AXILLARY LYMPH NODE EXAMINATION

General Inspection
Patient at 45° angle
Bleeding or bruising
Pallor
Cachexia

Axilla Inspection
Ask if patient has any pain first
Scars
Masses
Skin changes

Axilla Palpation
Inform patient you will be pressing around underarms
Palpate with the pulp of first 3 fingers in a circular motion
Do right arm first then left
Anterior nodes - within anterior axillary fold
Central nodes - centre of the axilla, along the wall of the thorax
Posterior nodes - within posterior axillary fold
Lateral - along the border of the humerus
Apical - insert fingers pointing the clavicle to palpate the apex of axilla

Lymph Node Findings

Remember SSS-CMTO
Site: state the anatomical location
Size: state in dimensions (cm)
Shape: state regular or irregular.
Consistency: state if it's soft, hard or rubbery.
Tenderness: press + ask the patient for pain
Mobility: check if the lymph node is mobile or tethered
Overlying skin changes: state any changes like erythema

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 HOW TO TAKE
A HAEM HISTORY
- HX STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

HOPI
Ask about onset + triggers

Ask SOCRATES

Ask about sleep + daily activity

Ask associated HAEM symptoms: fatigue, paleness, dizziness, shortness of

breath, bleeding, bruising, rashes or infections

Ask head to toe symptoms: [very quickly] Headache

Blurred vision
Ask about systemic symptoms: Flu-like symptoms
Difficulty swallowing
- Weight changes: how many kg + over how long
Cough
- Appetite changes: increased or decreased Nausea/vomiting
- Urinary changes Chest pain
- Bowel changes Back pain
Abdominal pain
Ask about progression + previous episodes Skin changes
Leg swelling
PAST MEDICAL HISTORY
Now I'm going to ask you a few questions about your general health.

Do you have any long-standing medical conditions: high BP, high cholesterol
or diabetes [ask all 3]

Are you taking medications: ask for any iron or vitamin B12 supplements or
anti-coagulants

Have you had any recent surgeries or hospitalisations? [bone marrow

transplant, spleen removal or stomach surgery]

Do you have any allergies? HE

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 FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents + siblings (if any)?
Ask for family history of bleeding disorders

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.
Are you currently working: ask about occupation + stress

Do you live alone or with someone: ask about health of partner/kids if any

Do you have anyone at home to help you [only if symptoms are serious]

Can you describe your diet: any vegetarian or vegan diet

Do you exercise regularly: what kind + how often

Have you travelled anywhere recently: duration of flight + where [if relevant]
I'm going to ask you a few sensitive questions.
Do you smoke: how many sticks a day + for how long

Do you drink alcohol: what kind + how often [do CAGE if relevant]

Do you consume any recreational drugs: name + oral/IV

ClOSING
That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

Worry: It's a good thing you came in today and we will take it one step at a
time alright?
Difficult to perform daily activities: I understand it can be difficult especially
with your current symptoms. I would advise you not to overwork yourself
right now and if possible ask for help from your family members with your
daily tasks. Just take it one day at a time and we will be there with you
throughout this journey.

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 HOW TO DO
VENIPUNCTURE
- SDL PROCEDURE -

INTRODUCTION

Hi, I’m _____ , a __ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Explain the procedure: today I’ve been asked to take a blood sample from
you as you have come in for _______. For this procedure will need to expose
your forearm area and I will insert a needle to draw some blood. You may
feel a sharp prick but I’ll try to make it as quick as possible
Warn of complications: you may experience swelling or redness on the
site which is normal, but if you experience any persistent bleeding or
bruising then please come back to us
This will be done in a closed + private room, everything will be kept private
and confidential
Ensure consent: do I have your consent to proceed?
EQUIPMENT
Pre-procedure questions: 1. NEEDLE
6. TAPE

1. Are you on any blood thinning medication?

2. SYRINGE

2. Do you have any bleeding disorders?

3. BLOOD TUBE 7. GLOVES

3. Did you fast before coming here today?

[8 hours fast for plasma glucose + lipid profile only] 4. ALCOHOL SWAB

8. TOURNIQUET

PREPARATION 5. COTTON

Ask the patient to expose forearm area

Gather all your equipment within the kidney dish

Select the correct colour tube and label it with the patients name and ID
Inspect for venipuncture contraindications: AV fistula, lymphedema or
haematoma
Palpate to select a suitable vein

PROCEDURE
Keep talking to the patient as you go

Sanitise your hands and don a pair of gloves

Assemble the syringe + needle [checking their expiry dates]
Apply the tourniquet MEDICP
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PROCEDURE
Keep talking to the patient as you go
Swab the site in a circular motion from in → out
Warn the patient before inserting needle: say "sharp prick"
Insert the needle at 15-30° angle and draw back the syringe
Observe for flashback and draw an adequate amount of blood
Remove the tourniquet using your free hand and gather the gauze
Gently remove the needle + quickly press the cotton on the site
Place the needle into the blood tube [let the syringe empty itself]
Quickly place the piece of tape over the cotton

POST-PROCEDURE
Ensure to dispose everything correctly

Take out the needle from the tube and dispose it in the sharps bin
Gently invert the blood tube 8-10 times
Remove your gloves and dispose them within the clinical waste bin
Throw away plastic waste from the kidney dish into a regular bin
Confirm that the tube is labelled with the patient's name + ID
Inform the patient the sample will be sent to the labratory and they will be
contacted once the results are ready.

IN THE CASE YOU DO NOT GET BLOOD!

Do NOT push the syringe back inside

Remove the tourniquet with your free hand + gather the gauze
Gently remove the needle + quickly press the gauze on the site
Apply the tape onto the gauze and ask the patient to relax
Dispose the needle in the sharps bin + your gloves into the clinical waste bin
Gather a new set of equipment: including a new tube
Repeat the preparation steps as above and try again on the other arm

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 HOW TO DO
INJECTIONS
- SDL PROCEDURE -

INTRODUCTION 6 R'S OF DRUG

ADMINISTRATION
Ensure you have all the following:
1. Gather all necessary equipment R IGHT PERSON
2. Medication chart
3. Medication - correct name + calculate the R IGHT DRUG
correct dose + choose an appropriate site
4. Check the 6 R's of drug administration R IGHT DOSE
Hi, I’m _____ , a __ year-medical student. Can I R IGHT TIME
confirm your full name and the last 4 digits of
your IC please? R IGHT ROUTE
Today I've been asked to give you a [medication]
injection for your [symptom/condition]. R IGHT DOCUMENTATION

I will be giving it to you on your [site]. You may

feel a slight prick but I will make it as quick as EQUIPMENT
possible.
1. 2 NEEDLES
For this injection you will need to expose your 6. TAPE

[site] and this will be done in a closed and

private room and everything will be kept private 2. 1 SYRINGE
and confidential. A chaperone will be provided if
you need. 7. GLOVES
4. 2 ALCOHOL
SWABS
Do I have your consent to proceed?
[ensure consent]
8. FORCEPS

PRE-PROCEDURE 5. COTTON

Ask the patient to expose the site

Pre-procedure questions:
1. Do you have any allergies?
2. Do you have any bleeding disorders?

You may experience swelling or redness on the site which is normal, but if
you experience any persistent bleeding or bruising then please come back to
us [warn of any complications]

PREPARATION

Sanitise your hands and don a pair of gloves

Assemble the syringe + needle
[checking both their expiry dates]

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PREPARATION
Check the medication expiry date first
Swab the tip of the medication bottle

Poke the needle in to the medication and press down on syringe

Flip the medication bottle upside down
[making sure the bevel is immersed fully]
Draw slightly more than the desired volume [tap syringe if air bubbles form]
Flip the medication back and remove the needle

CHANGING NEEDLES
Use the forceps to twist and remove the current needle
Discard the needle into the sharps bin
Connect a new needle onto the syringe
Push a tiny drop of medication out until the exact volume is reached
[while the needle cap is still on]

INTRAMUSCULAR INJECTION
Say 3, 2, 1 before injecting the site
Swab the injection site - in a circular motion from in to out
Use your free hand to stretch the skin taut [only before injecting]
Hold the needle like a pencil and inject at a 90° angle
Use your free hand to aspirate a small amount to check for blood
If no blood is drawn press down on the syringe to inject fully
Remove the needle + apply pressure with cotton [do not rub the site]

SUBCUTANEOUS INJECTION
Say 3, 2, 1 before injecting the site

Swab the injection site - in a circular motion from in to out

Use your free hand to pinch the skin taut [only before injecting]
Hold the needle and inject at a 45° angle
Once you fully inject all the medication, wait 5-10 seconds
Remove the needle + apply pressure with cotton + apply tape
[do not rub the site]
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 POST-PROCEDURE
Keep talking to the patient as you go
Discard the needle into the sharps bin
Discard the plastic waste into the regular bin
Remove your gloves and discard into the clinical waste bin
Sanitise your hands and inform the patient the injection is complete
Document the injection: date + time of the injection and sign

VOLUME OF MEDICATION EQUATION

Volume (ml) = dose required x volume of the medication
medication dose

SITES FOR INTRAMUSCULAR INJECTIONS

1. DORSOGLUTEAL:
Locate greater trochanter + PSIS
Connect a line between these 2 points
Injection site is in the upper outer quadrant

2. VENTROGLUTEAL
Use right hand (if its the left buttock) to locate greater
trochanter
Align index finger pointing to ASIS
Inject between index + middle finger

3. DELTOID
Locate the acromion process
Inject 3 fingertips below the acromion (adults)

4. VASTUS LATERALIS
Identify the greater trochanter + lateral femoral
condyle
Locate the middle third of thigh
Inject into the anterolateral aspect

SITES FOR SUBCUTANEOUS INJECTIONS

1. LATERAL ASPECT OF UPPER ARM

2. 2-3 INCHES FROM THE UMBILICUS

3. ANTERIOR ASPECT OF THE THIGH

4. THE UPPER BACK
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GASTROINTESTINAL
SYSTEM

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 HIGH YIELD
GI CASES
- PE STATIONS -

CHRONIC LIVER DISEASE (INSPECTION)

General Inspection
Ask if the patient wants to empty bladder first
Alert, conscious, responsive
Generalised jaundice, mental state, build

Hands Inspection
Palms: palmar erythema and dupuytren's contracture
Nails: Muehrcke’s lines, beau lines, clubbing
Tests: flapping tremors
Vitals (mention)

palmar erythema dupuytren's contracture Muehrcke’s lines beau lines clubbing

kayser-fleischer rings
Arms Inspection
Petechiae
Tendon xanthoma

Eyes Inspection
Scleral jaundice spider naevi

Kayser Fleischer rings

Mouth Inspection
Jaundice of the lingual frenulum
Smell of alcohol
Fetor hepaticus lingual frenulum
Parotid gland enlargement

Chest Inspection
Spider naevi
Gynaecomastia
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 HIGH YIELD
GI CASES
- PE STATIONS -

CHRONIC LIVER DISEASE (EXAMINATION)

caput medusae
General Inspection
Ask if the patient wants to empty bladder first
Alert, conscious, responsive

Abdominal Inspection
Caput medusae ascites

Ascites
Scars
Masses
Visible pulsations
Abdominal Examination
Make sure your hands are warm
Ensure sufficient exposure from xiphoid process to pubic symphysis
Ask for any pain and always watch the patient's face
Superficial palpation: comment on tenderness, rebound tenderness,
guarding, rigidity and any palpable masses felt
Deep palpation: comment on masses [site, size, shape, mobility,
consistency and tenderness]
Percussion of 4 abdominal quadrants: comment on tympanic or dull

Liver Examination
Palpation: comment on if the liver edge is felt [note the size, surface,
consistency, tenderness and pulsations]
Percussion: comment on the liver span [normal is 6-12 cm]

Spleen Examination
Palpation: comment on if the any splenic edge [normally not felt]
Percussion: not any change from resonant to dull [indicates splenomegaly]

Ascites
Fluid thrill: comment on if it's present
Shifting dullness: note any change from dull to resonant

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 HIGH YIELD
GI CASES
- PE STATIONS -

Auscultation
Hepatic bruit: using bell

Legs
Petechiae
Ankle edema

HYDRATION STATUS

Inspection skin turgor

Alert, conscious, responsive

Disorientated or lethargic
Any medical gadgets present

General Inspection
Hands: temperature, capillary refill, skin turgor
(pinch the skin) sunken eyes

Face: sunken appearance, decreased tear production

Mouth: dry mucous membranes

Vitals (Must Do)

Pulse: comment on the rate + rhythm
BP: state the reading
Respiratory rate: normal is 15-20
Temperature

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 HOW TO TAKE
A GI HISTORY
- HX STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

HOPI
Ask about onset + triggers

Ask SOCRATES

Ask associated GI symptoms: abdominal pain, nausea/vomiting, diarrhea,

constipation, bloody stool, jaundice

Ask for vomit only: before/after meal and content (bile or blood)
Ask for diarrhea only: frequency and content (water, blood, mucus or pus)

Ask head to toe symptoms: [very quickly]

Dizziness
Headache
Ask about systemic symptoms:
Blurred vision
- Weight changes: how many kg + over how long Flu-like symptoms
Difficulty swallowing
- Appetite changes: increased or decreased
Cough
- Urinary changes Nausea/vomiting
- Bowel changes Chest pain
Back pain
Ask about progression + previous episodes Abdominal pain
Skin changes
Leg swelling
PAST MEDICAL HISTORY
Now I'm going to ask you a few questions about your general health.
Do you have any long-standing medical conditions: high BP, high
cholesterol or diabetes [ask all 3]

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

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FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents?
Is there any family history of cancer?

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.
Are you currently working: ask about occupation + stress

Can you describe your diet: what kind of diet + high intake of fried, fatty or
salty food

Do you exercise regularly: what kind + how often

Have you travelled anywhere recently: duration of flight + where [if relevant]

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: what kind + how often [do CAGE if relevant]

Do you consume any recreational drugs: name + oral/IV

ClOSING
That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

Worry: It's a good thing you came in today and we will take it one step at a
time alright?

Scared about death or serious outcome: I understand you are worried

about ______, it can be scary to think about however it's too early to
conclude anything right now, but we will take it one step at a time. I can
ensure you that you are in good hands.

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 DIGITAL RECTAL
EXAMINATION
- SDL PROCEDURE -

SPECIFIC INTRODUCTION
Hi, I’m ______ , a __ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today I’ve been asked to examine your back passage
Explain the procedure: for this you will need to remove your lower
garments including your underwear. I will examine your back passage
using my finger to examine for any irregularities. It will not painful but may
feel uncomfortable. This will be done in a closed and private room,
everything is private and confidential, and a chaperone will be provided.
Consent: do I have your consent to proceed?
Pre-procedure questions: would you like to go to the toilet first?
Specific position: could you please remove your lower garments and
underwear and please lie the ride side of the bed, turn to your left and hug
both of your knees?

INSPECTION
Ensure the patient is comfortable
Perianal area: haemorrhoids skin tags, discharge and anal fissures
Prolapse: ask the patient to cough + comment on any hemorrhoids + rectal
prolapse

PALPATION
Ask the patient to relax and and ask for any pain at each place
Anal sphincter tone: ask the patient to squeeze your finger and comment
on the tone [finger is at the 6 o'clock position]
Rectal wall: comment on polyps, irregularities, masses and tenderness
[normally smooth and pliable]
Prostate: comment on tenderness, consistency and irregularities on the
median sulcus and 2 lobes [normally smooth and rubbery]
Gloves: comment on any blood, mucus or fecal matter
[after you have removed your finger]

CLOSING
The examination is now over, here is some tissue for you to clean up
I will relay all the information to my senior doctor and we will get back to you
soon with the results, thank you.
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RENAL SYSTEM

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 HIGH YIELD
RENAL CASES
- PE STATIONS -

CHRONIC KIDNEY DISEASE (INSPECTION)

General Inspection uremic fetor

Patient at 45° angle

Alert, conscious, responsive
Build and nourishment
Respiratory distress
Uremic fetor
Medical gadgets: urinary catheter
thenar muscle wasting

Hands Inspection
Palms: pallor of the palmar creases
Nails: half and half nails, beau lines and Muercke's
lines
Tests: flapping tremors
Signs of carpal tunnel syndrome: thenar muscle
wasting, Tine's sign and Phalen's sign
pallor of palmar creases
Vitals (must): pulse, RR, BP and temperature

Arms Inspection
Bruising
Skin pigmentation
Scratch marks

Eyes Inspection
Conjunctival pallor

Legs Inspection
Petechiae
Ankle edema
Check for peripheral neuropathy: mention sensory and motor exam

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 HIGH YIELD
RENAL CASES
- PE STATIONS -

KIDNEY EXAM - FEVER, DYSURIA & FLANK PAIN

General Inspection
Patient lying flat
Alert, conscious, responsive

Abdomen Inspection
Ensure sufficient exposure from xiphoid process to
pubic symphysis
Shape: flat, round or distended
Visible masses or pulsations
Umbilicus: inverted or everted

Abdominal Palpation
Make sure your hands are warm
Ask for any pain and always watch the patient's face
Superficial palpation: comment on tenderness,
rebound tenderness, guarding, rigidity and any
palpable masses felt
Deep palpation: comment on masses [site, size,
shape, mobility, consistency and tenderness]
Percussion of 4 abdominal quadrants: comment on
tympanic or dull

Kidney Palpation
Make sure your hands are warm
Ask for any pain and always watch the patient's face
Balloting: comment on size, surface and consistency [if palpable]

Auscultation
Renal artery stenosis: 2-3cm above and lateral to the umbilicus and
comment on any bruits

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 HOW TO TAKE A
RENAL HISTORY
- HX STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

HOPI
Ask about onset + triggers

Ask SOCRATES

Ask associated RENAL symptoms: loin pain, dysuria, urinary changes [volume,
colour, blood, smell, cloudy, frothy, sediment]

Ask head to toe symptoms: [very quickly]

Dizziness
Ask about systemic symptoms: Headache
Blurred vision
- Weight changes: how many kg + over how long Flu-like symptoms
Difficulty swallowing
- Appetite changes: increased or decreased Cough
- Urinary changes Nausea/vomiting
- Bowel changes Chest pain
Back pain
Ask about progression + previous episodes Abdominal pain
Skin changes
Leg swelling
PAST MEDICAL HISTORY
Now I'm going to ask you a few questions about your general health.
Do you have any long-standing medical conditions: high BP, high cholesterol or
diabetes [ask all 3]

Have you had any past urinary stones or UTIs?

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies? MEDICP
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FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents?
Is there any family history of cancer?

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.

Are you currently working: ask about occupation + stress

Can you describe your diet: what kind of diet + high intake of fried, fatty or
salty food

Do you exercise regularly: what kind + how often

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: what kind + how often [do CAGE if relevant]

Do you consume any recreational drugs: name + oral/IV

ClOSING
That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

Worry: It's a good thing you came in today and we will take it one step at a
time alright?

Scared about death or serious outcome: I understand you are worried

about ______, it can be scary to think about however it's too early to
conclude anything right now, but we will take it one step at a time. I can
ensure you that you are in good hands.

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 HOW TO USE A
URINE DIPSTICK
- SDL PROCEDURE -

INTRODUCTION

Hi, I’m ______ , a __ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today I’ve been asked to test your urine with a urine dipstick.
This will be done in a closed and private room and everything is private and
confidential.
Consent: do I have your consent to proceed?

PREPARATION - FEMALES

Explain the procedure: I will teach you how to collect a clean urine sample.
You'll be given a clean-catch kit with sterile wipes. First sit on the toilet bowl
with your legs apart. Use 2 fingers to spread your labia open. Use the first
wipe to clean the inner folds and the second wipe to clean the urethra.

Urinate into the toilet bowl first then stop, then collect urine into the cup
until it is half full. You can finish urinating into the toilet bowl afterwards

PREPARATION - MALES

Explain the procedure: I will teach you how to collect a clean urine sample.
You'll be given a clean-catch kit with sterile wipes. Use a wipe to clean the
head of your penis (pull back foreskin if you are not circumcised)

Urinate into the toilet bowl first then stop, then collect urine into the cup
until it is half full. You can finish urinating into the toilet bowl afterwards

PROCEDURE

Check the patient's identity on the urine bottle

Inspect the urine for any obvious abnormalities: cloudiness, redness and salt
particles

Check urine test strip expiry date

Place 2 sheets of tissue paper on the table, open the test strip container and
take one out [close the containter immediately]

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PROCEDURE
Compare the colours of the strip taken out with the colours shown on the
bottle. Check whether initial colours of the strip to be used is normal
Wash your hands and wear gloves

Open the cap of the urine specimen bottle, immerse the strip completely into
the urine, and remove immediately. Check the strip container for reacting
time for each reagent

Remove the strip from the urine and place it on the tissue

Wait for 2 minutes and then compare it with the reference colour panels on
the strip container
Document results and dispose all waste into clinical waste bin

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ENDOCRINE
SYSTEM

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 HIGH YIELD
ENDO CASES
- PE STATIONS -

THYROID EXAMINATION
General Inspection
Patient sitting upright goitre

Alert, conscious, responsive

Generalised or local swellings
Redness
Scars
Distended veins
Ask the patient to protrude tongue and swallow
distended veins
water: comment on the presence of thyroglossal cyst

Neck Palpation
Inform patient you will palpate from behind
Thyroid gland: palpate both lobes + isthmus and
comment on the size, shape, consistency, tenderness,
mobility and thrills [normally firm + smooth]
Ask patient to swallow water: feel for any masses thyroglossal cyst

From front: palpate both lobes and isthmus

Tracheal deviation: comment on position
Mention: cervical lymph node exam (if suspecting
cancer)
Percussion
Upper manubrium: comment on the note

Auscultation
Right and left lobe: comment on any bruits

HYPERTHYROIDISM - STATUS
General Inspection
Patient sitting upright
Alert, conscious, responsive
Well-nourished
Emotion: anxious or irritable
Appearance: increased sweating, staring appearance
and neck swelling
Weight loss HE
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 HIGH YIELD
ENDO CASES
- PE STATIONS -

Hands Inspection
Temperature: warm and sweaty exophthalmos

Palms: erythema
Dorsal: thyroid acropachy and onycholysis
Fine tremors
Pulse: tachycardia
Face Inspection
Hair: dry and course with alopecia
Eyes: exophthalmos, puffy eyelids and lid retraction thyroid acropachy

[check from the side of the patient]

Eye Tests
Lid lag: comment on increasedvisibility of the sclera
during eye movement
Eyes: exophthalmos, puffy eyelids and lidretraction

pretibial myxoedema
Face Inspection
Hair: dry and course with alopecia
Opthalmoplegia: do the H test and ask the patient for
any double vision
Upper Limbs
Proximal myopathy: comment if patient can resist
movement
Biceps reflex: comment on any brisk reflex

Lower Limbs
Inspection: pretibial myxoedema
Knee reflex: comment on any hyperreflexia
Proximal myopathy: comment on ability

HYPOTHYROIDISM - STATUS
General Inspection
Patient sitting upright
Alert, conscious, responsive
Well-nourished
Emotion: disinterested and sluggish
Appearance: neck swelling
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 HIGH YIELD
ENDO CASES
- PE STATIONS -
Hands Inspection
Temperature: cool and dry
Palms: pallor loss of eyebrow hair

Signs of carpal tunnel syndrome: wasting of thenar

muscles, Phalen's sign and Tinel's sign
Pulse: bradycardia
Face Inspection
Hair: thin and brittle
Skin: coarse macroglossia
Eyes: loss of outer 1/3 of eyebrow and periorbital edema
Mouth: macroglossia and slow/coarse speech
Upper Limbs
Proximal myopathy: comment if patient can resist
movement
Biceps reflex: comment on any delayed relaxation
pitting edema

Lower Limbs
Inspection: pitting edema
Knee reflex: comment on any hyperreflexia
Proximal myopathy: comment on ability to resist

CUSHING SYNDROME
General Inspection
Patient sitting upright
Alert, conscious, responsive
Thoracic kyphosis
Buffalo hump
Specific Inspection
Skin: plethora, excessive pigmentation and bruising
Face: moon like facies, acne and hirsutism (women only)
Specific Tests
Eyes: peripheral visual field test and comment on any bitemporal hemianopia
Proximal myopathy: comment on ability to resist
BP: check for hypertension
Abdomen Examination
Inspection: purple striae
Superficial and deep palpation: comment on any adrenal masses
Liver palpation: check for hepatomegaly
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 HOW TO TAKE AN
ENDO HISTORY
- HX STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

HOPI
Ask about onset + triggers

Ask SOCRATES

Ask associated ENDO symptoms: fatigue, heat/cold intolerance, neck

swelling, thirst, menstrual change, hirsutism, weakness

Ask head to toe symptoms: [very quickly] Dizziness

Headache
Ask about systemic symptoms: Blurred vision
Flu-like symptoms
- Weight changes: how many kg + over how long Difficulty swallowing
- Appetite changes: increased or decreased Cough
Nausea/vomiting
- Urinary changes
Chest pain
- Bowel changes Back pain
Abdominal pain
Ask about progression + previous episodes Skin changes
Leg swelling

PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.
Do you have any long-standing medical conditions: high BP, high cholesterol or
diabetes [ask all 3]

Have you had any past urinary stones or UTIs?

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies? MEDICP

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FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents?
Is there any family history of diabetes or thyroid disease?

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.

Are you currently working: ask about occupation + stress

Can you describe your diet: what kind of diet + high intake of fried, fatty or
salty food

Do you exercise regularly: what kind + how often

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: what kind + how often [do CAGE if relevant]

Do you consume any recreational drugs: name + oral/IV

ClOSING
That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

Worry: It's a good thing you came in today and we will take it one step at a
time alright?

Scared about death or serious outcome: I understand you are worried

about ______, it can be scary to think about however it's too early to
conclude anything right now, but we will take it one step at a time. I can
ensure you that you are in good hands.

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 DIABETES
FOLLOW-UP
- HX STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent? [consent]

What brings you to the clinic today?

INITIAL DIAGNOSIS
Ask when + how were you diagnosed with diabetes?

Ask about checkups: frequency and if any were missed

Ask about initial readings: BGL readings + HbA1C reading

COMPLIANCE
Ask about current medications: name + dose + frequency + compliance

Ask about any medication changes: name + reason

Ask about medication side effects/allergies: if yes, ask about the reaction in
specific

CONTROL
Ask about home monitoring: last reading + glucometer use

Ask about the last time eyes were checked: for diabetic retinopathy

Ask about any lifestyle changes: diet + exercise

Hyperglycemia Hypoglycaemia
COMPLICATIONS Polyuria
Dizziness
Sweating
Hyperphagia Hunger
Ask about any current symptoms Fatigue Weakness
Palpitations

Ask about diabetic complications

Blurred vision
Ask about systemic symptoms Foot ulcers
Tingling/numbness
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 PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.
Do you have any other long-standing medical conditions?

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies: ask about what happens

FAMILY HISTORY

How are your parents + siblings?

Ask if there is any family history of diabetes

SOCIAL HISTORY
Ask about occupation: ask about stress

Ask about their diet: what kind of diet + high intake of sugary food and drinks,
processed foods

Ask about exercise: ask how often

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: how often

ClOSING

That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

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 THYROID
FOLLOW-UP
- HX STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

INITIAL DIAGNOSIS
Ask when + how were you diagnosed with thyroid disease?

Ask about checkups: frequency + if any were missed

Ask about initial readings: thyroid blood tests

COMPLIANCE
Ask about current medications: name + dose + frequency + compliance

Ask about any medication changes: name + reason

Ask about medication side effects/allergies: if yes, ask about the reaction in
specific

CONTROL
Ask about last readings [if any]

Ask about lifestyle changes: diet + exercise

COMPLICATIONS

Ask about any current symptoms

Ask about hyper/hypothyroid complications

Ask about systemic symptoms

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 PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.

Do you have any long-standing medical conditions: high BP, high

cholesterol or diabetes [ask all 3]

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies: ask about what happens

FAMILY HISTORY

How are your parents + siblings?

Ask if there is any family history of thyroid disorders

SOCIAL HISTORY

Ask about occupation: ask about stress

Ask about their diet: what kind of diet

Ask about exercise: ask how often

I'm going to ask you a few sensitive questions

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: how often

ClOSING

That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

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 HOW TO USE A
FUNDOSCOPE
- SDL STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today I’ve been asked by my senior doctor to check your eyes. Everything
done today will be kept private and confidential.

Do I have your consent to proceed? [consent]

Explain procedure: today I will examine your eyes using an opthalmoscope.

The room lights will be dimmed. I will need to shine light into your eyes so
please do let me know if at any point this gets uncomfortable.

PRE-PROCEDURE
Ask the patient to sit on a chair directly opposite you
Eyes inspection: swelling, redness, scars and discharge

Darken the room and turn on the ophthalmoscope and turn the lens disc
until you see the round beam of white light

Shine the light on the back of your hand to check the type of light, its desired
brightness and the electrical charge of the ophthalmoscope

Turn the lens disc to 0 diopter

Ask the patient to focus on a distant object and that they may blink and
breathe normally.

PROCEDURE
To inspect the right eye: hold the opthalmoscope in your right hand and use
your right eye to examine

Hold the opthalmoscope 30cm away from the patient at an angle of 15

degrees lateral to the patients line of vision

Shine the light beam into the pupil and look for an orange glow in the pupil
(red reflex) - comment on any opacities blocking the red reflex
Keep the light focussed on the red reflex and slowly move closely to the
patient until you are almost touching their eyelashes [inform the patient]

Locate the optic disc: round yellowish-orange structure

Inspect the optic disc: comment on the sharpness and clarity of the disc
outline, colour of the disc and the cup-disc ratio

Comment on any papilledema MEDICP

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PROCEDURE

Inspect the retina: comment on any haemorrhages, exudates, new vessels,

cotton wool spots and photocoagulation scars [note their shape, size, colour
and distribution if any]
Inspect the fovea and surrounding macula: comment on any similar
abnormal lesions seen

Repeat these steps for the left eye and report your findings

CLOSING

The examination is now complete, thank you for your time.

I will relay all the findings to my senior doctor and we will get back to you with
the results.

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 HOW TO USE A
GLUCOMETER
- SDL STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today I’ve been asked by my senior doctor to teach you how to use a
glucometer, which monitors your blood sugar. Everything done today will be
kept private and confidential.

Do I have your consent to proceed? [consent]

Explain procedure: today I will walk you through how to use the glucometer
device correctly. At the end of the interview, I will ask you to repeat the steps
back to me to make sure you understand.

PROCEDURE EQUIPMENT

1. GLUCOMETER 3. LANCET
Prepare all the equipment as shown

Make sure to check the expiry date of the test strip

5. COTTON

Wash your hands and don a pair of gloves

2. TEST STRIP

Place 1 test strip into the glucometer 4. ALCOHOL SWAB

[this will activate the device]

Clean the patient's finger using an alcohol

[use the left index finger if the patient is right-handed]
Prick the patient's fingertip using the lancet

Press against the finger to draw a drip of blood onto the edge of the test strip

Wait for the glucometer to show the reading

While you wait, press the cotton on the puncture site

Record the blood glucose reading

Dispose the lancet into the sharps bin and all other waste into the clinical
waste bin

CLOSING
Ask the patient to repeat the steps and check their understanding

Inform the patient to keep a record of all the readings in a book and to
dispose lancets correctly [by recapping the needle]
Thank the patient for their time
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 HOW TO USE AN
INSULIN PEN
- SDL STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today I’ve been asked by my senior doctor to teach you how to use an insulin
pen. Everything done today will be kept private and confidential.

Do I have your consent to proceed? [consent]

Explain procedure: today I will walk you through how to use an insulin pen
correctly. At the end of the interview, I will ask you to repeat the steps back to
me to make sure you understand.

PREPARATION
Remove the pen cover

If using an intermediate acting insulin pen, inform

the patient to gently roll the pen between the palms
for 15 seconds to mix

Pull the paper tab off the pen needle

Screw the needle onto the insulin end of the pen

Remove the outer needle cover

Remove the inner needle cover to expose the needle

Prime the pen: turn the dose selector knob to 1 unit, hold the pen upwards
and press the dose knob completely and watch for a drop of insulin to come
out - ensure the dial returns back to zero after this

PROCEDURE
Set your dose: turn the dose knob to choose your insulin dose
[double check it is correct]

Select an injection site: either abdomen, upper thigh or back of the upper arms

Clean the injection site with an alcohol swab first

Inject the insulin: hold the pen with your fingers curled around it and your
thumb above the dose knob
Gently pinch up the skin with your free hand

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PROCEDURE

Quickly insert the needle at a 90° angle and press the dose knob

Leave the needle in place for 5-10 seconds to prevent any leakages
Pull the needle straight out of the skin [do not massage the area]

CLOSING
Inform the patient it is normal to see a drop of blood/small bruise at the site
Place the outer needle cover over the needle and twist to unscrew the needle
from the pen

Make sure to throw away the needle in the sharps bin

Place the outer needle cover back onto the pen

Ask the patient to repeat the steps and check their understanding
Thank the patient for their time

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REPRODUCTIVE
SYSTEM

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 HOW TO TAKE A
REPRO HISTORY
- HX STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

HOPI
Ask about onset + triggers

Ask SOCRATES

Ask associated REPRO symptoms: menstrual change, abdominal pain,

vaginal discharge, breast changes, breast/testicular lumps, infertility

Ask head to toe symptoms: [very quickly] Dizziness

Headache
Ask about systemic symptoms: Blurred vision
Flu-like symptoms
- Weight changes: how many kg + over how long Difficulty swallowing
- Appetite changes: increased or decreased Cough
Nausea/vomiting
- Urinary changes
Chest pain
- Bowel changes Back pain
Abdominal pain
Ask about progression + previous episodes Skin changes
Leg swelling

PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.
Do you have any long-standing medical conditions: high BP, high cholesterol or
diabetes [ask all 3]

Have you had any history of STDs or bleeding problems?

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies? MEDICP
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MENSTRUAL HISTORY *
* Only ask if there are any menses changes
At what age did you get your period?
When was you last menstrual period?
Are your cycles usually regular and how long do they last?
How many pads do you usually use?
Do you have an bleeding between cycles?
Do you have any postmenopausal bleeding? [ask only if menopausal]
Do you experience menstrual cramps? Do you use pain killers?
Have you done any recent pap smears, vaginal or breast examinations?

SEXUAL HISTORY *
* Ask when the patient has abdominal pain and vaginal discharge
Now I will be asking you some sensitive questions.
Are you currently in a relationship?
Are you sexually active?
Have you had any other partners? Are they male or female?
How often do you have sexual intercourse? When was the last time?
Have you experienced any pain during sexual intercourse, erectile dysfunction
(if male) or and post-coital bleeding?
Do you use contraception - if so which type?
Have you had any previous STDs?

FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents?
Is there any family history of cancer?

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.

Are you currently working: ask about occupation + stress

Can you describe your diet: what kind of diet + high intake of fried, fatty or
salty food

Do you exercise regularly: what kind + how often

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MENSTRUAL HISTORY *
* Only ask if there are any menses changes
At what age did you get your period?
When was you last menstrual period?
Are your cycles usually regular and how long do they last?
How many pads do you usually use?
Do you have an bleeding between cycles?
Do you have any postmenopausal bleeding? [ask only if menopausal]
Do you experience menstrual cramps? Do you use pain killers?
Have you done any recent pap smears, vaginal or breast examinations?

SEXUAL HISTORY *
* Ask when the patient has abdominal pain and vaginal discharge
Now I will be asking you some sensitive questions.
Are you currently in a relationship?
Are you sexually active?
Have you had any other partners? Are they male or female?
How often do you have sexual intercourse? When was the last time?
Have you experienced any pain during sexual intercourse, erectile dysfunction
(if male) or and post-coital bleeding?
Do you use contraception - if so which type?
Have you had any previous STDs?

FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents?
Is there any family history of cancer?

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.

Are you currently working: ask about occupation + stress

Can you describe your diet: what kind of diet + high intake of fried, fatty or
salty food

Do you exercise regularly: what kind + how often

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 HOW TO PERFORM
A BREAST EXAM
- SDL STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today I’ve been asked by my senior doctor to examine your breasts.

Explain procedure: you will need to remove your upper garments including
your bra. It will involve me looking at your breasts and feeling around them to
check for irregularities. It will not be painful but may feel uncomfortable.

This will be done in a closed and private room, everything is private and
confidential, and a female chaperone will be provided.

Do I have your consent to proceed? [consent]

MOVEMENTS
Ask the patient if they are in any pain first then ask them to
get undressed
Ask the patient to stand up

Ask them to perform the 4 following movements as shown:

1. Place your hands by your sides
2. Place your hands firmly on your hips
3. Keep your hands on your hips and bend forward
4. Place your hands above your head
Comment on: breast symmetry and any local prominent
swellings

PALPATION
Ask the patient to lie flat on the bed and lift up the hand of
the inspecting side
Inspect both breasts: comment on breast and nipple
symmetry, size and shape

Individual breast inspection: comment on any skin changes,

nipple changes or any peau d'orange appearance

Palpation: breast tissue, nipples and axillary tails in a circular

motion from in to out and squeeze the nipples to check for
any discharge

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LYMPH NODES

For any lump felt: comment on the site, size, shape, consistency, tenderness,
mobility, temperature and fluctuation

Examine axillary lymph nodes: comment on any lumps and comment as

above [see lymph node examination]

Examine clavicular lymph nodes (infraclavicular and supraclavicular):

comment on any lumps felt

Examine cervical lymph nodes: comment on any lumps [see cervical lymph
node examination]

CLOSING
The examination is now complete. You may now get dressed.
I will relay all the findings to my senior doctor, thank you for your time

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 HOW TO DO A
BIMANUAL
PALPATION
- SDL STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today you have come in for a pap smear

Explain procedure: for this procedure you will need to undress from your waist
downwards including your underwear. I will insert 2 fingers up your vagina
which allows me to assess the parts of your vaginal area. This will not be
painful but may feel uncomfortable.

This will be done in a closed and private room, everything is private and
confidential, and a female chaperone will be provided.

Do I have your consent to proceed? [consent]

Pre-exam questions:
1. When was the first day of your last menstrual period?
2. Do you want to go to the toilet before we start?

INSPECTION
Ask the patient to undress and lie supine with the knees bent and separated
Inspect external genitalia: comment on any bleeding, discharge, ulcers or
masses

Inspect vaginal prolapse: ask the patient to cough and comment on any
prolapse and any involuntary leakage of urine

PALPATION
Ask the patient for any pain throughout the exam
Palpate the vaginal mucosa: normally is narrow, soft and the urethra is
palpable, comment on any signs of masses or tenderness

Palpate the cervix: normally small, firm smooth, comment on any signs of
masses or tenderness

Palpate the uterus: normally small, firm, smooth and anteverted, comment on
any signs of masses or tenderness
Palpate right and left adnexa: comment on any palpable ovaries and masses

Check the gloves after removal: comment on any blood, discharge and pus

CLOSING
The examination is now complete, here are some wipes for you to clean up
Thank you for your time, we will get back to you soon with the results
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 HOW TO DO A
PAP SMEAR
- SDL STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today you have come in for a pap smear

Explain procedure: for this procedure you will need to undress from your waist
downwards including your underwear. I will be inserting a plastic device
(speculum) which allows me to inspect your vagina and cervix. Then I will take
a sample of cells using a small brush. This will not be painful but may feel
uncomfortable.
This will be done in a closed and private room, everything is private and
confidential, and a female chaperone will be provided.

Do I have your consent to proceed? [consent]

Pre-exam questions:
1. When was the first day of your last menstrual period?
2. Do you use any vaginal medication?
3. Do you practice douching? EQUIPMENT
4. Have you had sexual intercourse in the past 24 hours?
1. SPECULUM 4. BRUSH

PREPARATION
Ask the patient to undress and lie supine with the knees
2. LUBRICANT 5. GLOVES
bent and separated
Prepare your equipment as shown on the right
3. SAMPLE POT

Adjust the lighting and label the tube first

Wash your hands and don a pair of gloves

Drape a sterile towel under the patient

INSPECTION
Inspect the external genitalia: comment on any bleeding, discharge, ulcers or
masses

Vaginal prolapse: ask the patient to cough and comment on any prolapse and
involuntary leakage of urine

PROCEDURE
Prepare the speculum: apply an adequate amount of lubricant on the outside
of the speculum

Hold the speculum with the right-hand index finger hooked on the top blade.
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PROCEDURE
Part and hold the lips of the labia minora apart using your left hand

Insert the speculum (blades closed and unscrewed) into the vaginal canal in
the transverse position [warn the patient]
Keep inserting the speculum and as it approaches the cervix turn the
speculum upside down slowly (so the handles are at the top)

Press the handles together to open the blades and screw it tightly to keep it
stable
Inspect the cervix: normally it is small and pink, comment on the appearance,
size and shape of the cervical os and any bleeding, discharge or masses

Now insert the broom straight inside until it touches the cervical os [make
sure not to touch the sides of the speculum]

Rotate the the broom 5 times in a clockwise motion

Remove the brush carefully and place it into the sample pot [usually you
insert the tip of the broom into a smaller compartment of the pot to detach it
from the stick]

Close the cap of the sample pot tightly

POST-PROCEDURE
Unlock the speculum and remove it slowly while inspecting the vaginal wall

Allow the speculum to close by itself as you remove it out of the vagina

Proceed to cover the patient

Dispose your gloves and equipment into the clinical waste bin

Wash your hands

CLOSING
Inform the patient the examination is now complete and they may get
dressed

Offer them tissue to clean up

Inform them that you will get back to them with the results

Thank the patient for their time

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 HOW TO DO AN
ANTENATAL EXAM
- SDL STATIONS -

INTRODUCTION

Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today you have come in for your antenatal check-up

Explain procedure: for this examination you will need to lift your upper
garments. I will be looking at your tummy, feeling around to determine your
baby's position and taking a few measurements as well. This will not be
painful but may feel uncomfortable.

This will be done in a closed and private room, everything is private and
confidential.

Do I have your consent to proceed? [consent]

Pre-exam questions:
1. Do you need to go to the toilet first?
2. Do you have any pain anywhere?

PREPARATION
Ask the patient to expose tummy area and lie flat, resting on the pillow
Calculate BMI: measure the patient's height and weight (BMI = weight/height²)

Measure the patient's blood pressure: comment on the reading

INSPECTION
Ensure the patient is comfortable
Inspect for scars: comment on linea niagra, striae gravidum and any C-section
scar

Inspect for any abnormal swellings and fetal movements

PALPATION
Ask for any pain before starting and always observe the patient
Light palpation (9 regions): comment on uterine consistency, tenderness,
guarding and uterine contractions

Fundal grip: check if the part is ballotable [buttock is firm, broad and non-
ballotable]

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 PALPATION
Ask for any pain before starting and always observe the patient
Lateral grip: check which side is more full [baby's back]

Pelvic grip: check if the part is ballotable [head is ballotable,

hard, round and globular]
Comment on the fetal lie and presentation

MEASUREMENTS
Note this can only be done after 20 weeks
Fundal-symphysial height: palpate the fungus and pubic
symphysis then place a measuring tape over [comment the
height in cm]

Station and engagement: comment in fifths of the fetal head

through the abdomen [less than 3/5 is engaged]

Auscultation: place the Pinard stethoscope at the baby's

anterior shoulder, listen with your ears (hands off) and count
the heart rate for 30 seconds [comment on the rate and
rhythm]

CLOSING
The examination is now complete, I will relay all the information to my senior
doctor

Thank you for your time

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MUSCULOSKELETAL
SYSTEM

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 HIGH YIELD
MSK CASES
- PE STATIONS -

SHOULDER EXAMINATION

General Inspection SWIFT INSPECTION

Patient standing up
S CARS OR SWELLING
SWIFT inspection
Medical gadgets WASTING OF MUSCLES
I NVOLUNTARY MOVEMENTS
Shoulder Inspection
Anterior: bruising, assymetry of shoudler F ASICULATIONS
girlde and swelling
T REMORS
Lateral (right + left): scars and deltoid wasting
Posterior: scars, asymmetry (trapezius,
supraspinatus and infraspinatus) and scoliosis

Shoulder Palpation MOVEMENTS

Temperature: comment on both shoulders ABDUCTION (0-180°)
Palpation: comment on tenderness, swellings ADDUCTION (0-50°)
and bony irregularities FLEXION (0-180°)
EXTENSION (0-60°)
Shoulder Movement EXTERNAL ROTATION (0-90°)
Do one side at a time INTERNAL ROTATION (0-70°)
For all movements include: type of motion +
right/left shoulder
Active movements: comment on movement +
exact angle
Passive movements: ask for pain each time +
exact angle + any pain or crepitus
Resisted movements: comment if patient can
resist + any pain

Special Tests
Painful arc test: comment on passive abduction range + any pain during
60-120° active movement
Winging of scapula: comment on appearance of any scapular winging
Empty can test: comment on any tenderness on 90° elevation and internal
rotation upon resistance

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 HIGH YIELD
MSK CASES
- PE STATIONS -

ELBOW EXAMINATION

General Inspection
SWIFT INSPECTION
Patient standing up
SWIFT inspection S CARS OR SWELLING
Medical gadgets
WASTING OF MUSCLES
Elbow Inspection I NVOLUNTARY MOVEMENTS
Carrying angle: comment on the angle
[normal = 11-13°]
F ASICULATIONS
Anterior: swelling, bruising, scars rheumatoid T REMORS
nodules
Posterior: rash, tophi or deformities
Elbow Palpation
MOVEMENTS
Temperature: comment on both shoulders
Palpate lateral and medial epicondyles and FLEXION-EXTENSION ARC
(0-145°)
olecranon: comment on any swellings or
PRONATION
tenderness
SUPINATION
Shoulder Movement
Do one side at a time
For all movements include: type of motion +
right/left elbow
Active movements: comment on movement
+ exact angle
Passive movements: ask for pain each time +
exact angle + any pain or crepitus
Resisted movements: comment if patient
can resist + any pain

Special Tests
Lateral epicondylitis test ask the patient to flex the elbow to 90° and
pronate their hand, ask them to extend their wrist while you apply
resistance downwards [comment on any pain elicited on the extensor
surface of the forearm]
Medial epicondylitis: ask the patient to flex the elbow to 90°, supinate their
hand and ask them to flex their wrist while you apply resistance upwards
[comment on any pain elicited on the flexor surface of the forearm]
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 HIGH YIELD
MSK CASES
- PE STATIONS -

HIP EXAMINATION

General Inspection
SWIFT INSPECTION
Patient standing up
SWIFT S CARS OR SWELLING
Medical gadgets
WASTING OF MUSCLES
GAIT I NVOLUNTARY MOVEMENTS
Cycle: heel-strike and toe-off
F ASICULATIONS
Limping
Ease of turning T REMORS
Trendelenburg's sign: comment if positive
[do both sides]
MOVEMENTS
Hip Inspection
FLEXION (0-120°)
Anterior: scars, bruising, swelling
ABDUCTION (0-45°)
Lateral (right + left): flexion deformities
Posterior: scars, muscle wasting and scoliosis ADDUCTION (0-25°)
EXTENSION (10-20°)
EXTERNAL ROTATION (0-45°)
Hip Palpation
INTERNAL ROTATION (0-45°)
Patient lying flat
Temperature: comment on both hips
Palpation: comment on tenderness, swellings or bony irregularities
Leg length: measure apparent length (umbilicus medial malleolus) and
true length ( ASIS medial malleolus)

Hip Movement
Do one side at a time
For all movements include: type of motion + right/left hip
Active movements: comment on movement + exact angle
Thomas' test (special test): check for the presence of fixed flexion deformity
Passive movements: ask for pain each time + exact angle + any pain or
crepitus
Resisted movements: comment if patient can resist + any pain

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 HIGH YIELD
MSK CASES
- PE STATIONS -

KNEE EXAMINATION

General Inspection
SWIFT INSPECTION
Patient standing up
SWIFT inspection S CARS OR SWELLING
Medical gadgets
WASTING OF MUSCLES
Knee Inspection I NVOLUNTARY MOVEMENTS
Anterior: scars, bruising, swelling and
deformities (genu valgum or genu varum)
F ASICULATIONS
Lateral (right + left): knee hyperextension and T REMORS
fixed flexion deformity
Posterior: scars, muscle wasting and popliteal
swellings MOVEMENTS
GAIT FLEXION (0-140°)
Symmetry EXTENSION (0°)
Smoothness: comment on heel strike + toe-
off phase
Limping
Ease of turning

Knee Palpation
Patient lying flat
Temperature: comment on both knees
Patella palpation: comment on tenderness, swellings or effusion
Quadriceps: comment on tenderness
Patellar tap (special test): comment on tapping or fluid impulse in effusion
Bulge test (special test): comment on any bulge in effusion

Knee Movement
Do one side at a time
For all movements include: type of motion + right/left knee
Active movements: comment on movement + exact angle
Passive movements: ask for pain each time + exact angle + any pain or
crepitus
Resisted movements: comment if patient can resist + any pain
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 HIGH YIELD
MSK CASES
- PE STATIONS -

KNEE EXAMINATION

Special Tests
LCL + MCL test: comment on laxity and tenderness
Anterior draw test (ACL): comment on laxity
[movement should not exceed 1.5cm]
Posterior draw test: comment on laxity

CERVICAL EXAMINATION
SWIFT INSPECTION
General Inspection
S CARS OR SWELLING
Patient standing up and upper garments removed
SWIFT and medical gadgets WASTING OF MUSCLES
Anterior: head and neck postire and shoulder I NVOLUNTARY MOVEMENTS
symmetry
F ASICULATIONS
Lateral inspection: cervical lordosis
Posterior: scars, muscle wasting and scoliosis T REMORS

Palpation
Spinous processes: comment on tenderness, MOVEMENTS
alignment, and irregularities FORWARDS FLEXION (0-80°)
Sacroiliac joint: comment on tenderness EXTENSION (0-50°)
Paraspinal muscles: comment on LATERAL FLEXION (0-45°)
tenderness and spasms
LATERAL ROTATION (0-80°)
Mention: supraclavicular fossa, trachea and
thyroid gland scars, bruising, swelling

Movement
For all movements include: type of motion + right/left side
Active movements: comment on movement + side + exact angle
Passive movements: only mention if active movements are reduced
Mention: full upper and lower limb sensory and motor examination

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 HIGH YIELD
MSK CASES
- PE STATIONS -

THORACOLUMBAR EXAMINATION
GAIT
Patient standing up and upper garments removed
Cycle: comment on symmetry, smoothness, ease of turning, heel-strike
and toe-off
Type: comment on the presence of antalgic gait
Inspection
Lateral inspection: thoracic kyphosis and lumbar MOVEMENTS
lordosis FORWARD FLEXION (NOTE
Posterior: scars, muscle wasting and scoliosis HOW FAR DOWN THEIR LEGS
THEY CAN REACH)
Palpation
EXTENSION (10-20°)
Ask for pain during palpation
Spinous processes: comment on tenderness, LATERAL FLEXION (NOTE THE

alignment and irregularities LEVEL THEY REACH)

Sacroiliac joint: comment on tenderness THORACIC LATERAL ROTATION

Paraspinal muscles: comment on tenderness (10-20°)

and spasms
Movement
For all movements include: type of motion + right/left side
Active movements: comment on movement + side + exact angle
Passive movements: only mention if active movements are reduced
Mention: full upper and lower limb sensory and motor examination

Special Tests
Schober's test: mark PSIS (10cm above and 5cm below it) bend
comment on the distance when bent [normal: more than 20cm]
Straight leg raise test: ask for pain at the back of leg/thigh when raised
[positive if there is pain elicited between 30-70° - L4, L5, S1 injury]
Femoral nerve test: ask for pain at the front of the thigh with the knee
flexed to 90° and the hip extended [indicates L2 and L4 injury]

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 HOW TO TAKE AN
MSK HISTORY
- HX STATIONS -

INTRODUCTION
Hi, I’m [your name] , a ___ year-medical student. Can I confirm your full
name and the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

HOPI
Ask about onset + triggers

Ask SOCRATES

Ask associated MSK symptoms: stiffness [duration], crackling, bone

deformities, swelling/redness/warmth, fractures, trauma [overuse]
Ask head to toe symptoms: [very quickly] Dizziness
Headache
Ask about systemic symptoms: Blurred vision
Flu-like symptoms
- Weight changes: how many kg + over how long Difficulty swallowing
- Appetite changes: increased or decreased Cough
Nausea/vomiting
- Urinary changes
Chest pain
- Bowel changes Back pain
Abdominal pain
Ask about progression + previous episodes Skin changes
Leg swelling

PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.
Do you have any long-standing medical conditions?

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies?

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FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents?
Is there any family history of cancer?

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.

Are you currently working: ask about occupation + stress

Can you describe your diet: what kind of diet + any high intake of red meat

Do you exercise regularly: do your symptoms improve or worsen with

exercise?

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: what kind + how often [do CAGE if relevant]

Do you consume any recreational drugs: name + oral/IV

ClOSING
That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

Worry: It's a good thing you came in today and we will take it one step at a
time alright?

Scared about death or serious outcome: I understand you are worried

about ______, it can be scary to think about however it's too early to
conclude anything right now, but we will take it one step at a time. I can
ensure you that you are in good hands.

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NERVOUS SYSTEM

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 HIGH YIELD
CNS CASES
- PE STATIONS -

UPPER LIMB SENSORY

General Inspection
Patient at 45° angle
Alert, conscious, responsive
Abnormal gross movements
SWIFT (upper limbs)

Sensations
Patient at 45° angle and with eyes closed
Light touch: cotton wool [comment if they feel sensation + if its the same
on both sides]
Pin prick: wooden stick [comment if they feel sensation + if its the same
on both sides]
Vibration sensation: 128 Hz fork [intact if they can feel it and tell when it
stops]
Proprioception: test if they can feel the distal thumb moving up or down
[test 3 times]
2 point discrimination: check if the patient can feel 1 or 2 points

Cortical Sensations
Identify 2 objects with eyes closed [both hands]
Grapthesthesia: draw 37 on hand [both hands]

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 HIGH YIELD
CNS CASES
- PE STATIONS -

LOWER LIMB SENSORY

General Inspection
Alert, conscious, responsive
Abnormal gross movements
SWIFT (upper limbs)

Romberg's Test
Patient standing up
Cerebellar ataxia: check for swaying with eyes open
Sensory ataxia: check for ataxia with eyes closed

Sensations
Patient lying flat
Light touch: cotton wool [comment if they feel sensation + if its the same
on both sides]
Pin prick: wooden stick [comment if they feel sensation + if its the same
on both sides]
Vibration sensation: 128 Hz fork [intact if they can feel it and tell when it
stops]
Proprioception: test if they can feel the distal thumb moving up or down
[test 3 times]

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 HIGH YIELD
CNS CASES
- PE STATIONS -

UPPER LIMB MOTOR

General Inspection
Alert, conscious, responsive
Abnormal gross movements
SWIFT (upper limbs)

Tone
Patient sitting up
Ask for any pain first
Comment on tone: check for any hypotonia/hypertonia
Power
1. Ask the patient to do the active movement first
2. Then ask them to resist your motion
3. Grade each motion out of 5

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 HIGH YIELD
CNS CASES
- PE STATIONS -

UPPER LIMB MOTOR

Deep Tendon Reflexes

Check for any hypotonia and hypertonia
Biceps reflex
Triceps reflex
Supinator reflex

LOWER LIMB MOTOR

General Inspection
Alert, conscious, responsive
Abnormal gross movements
SWIFT (upper limbs)

GAIT
Ask patient to walk to end of the room + walk back
Comment on cycle: arm swing, stride length, base, speed and symmetry
Tip-toes + heel to heel walk: comment on any foot drop or plantar flexion
weakness

Romberg's Test
Cerebellar ataxia: check for swaying with eyes open
Sensory ataxia: check for ataxia with eyes closed

Tone
Patient lying down
Leg roll + lift: comment on tone
Clonus: comment on sustained jerky movements

Power
1. Ask the patient to do the active movement first
2. Then ask them to resist your motion
3. Grade each motion out of 5

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 HIGH YIELD
CNS CASES
- PE STATIONS -

LOWER LIMB MOTOR

Deep Tendon Reflexes

Check for any hypotonia and hypertonia
Ankle reflex
Babinski reflex
Knee reflex

DIABETIC FOOT EXAM

GAIT
Ask patient to walk to end of the room + walk back
Comment on cycle: arm swing, stride length, base, speed and symmetry
Comment on any high-stepping gait

General Inspection
Spread the toes to inspect
External: comment on any hair loss and nail dystrophy
Skin: comment on any ulcers, fungal infections and excessive callus
Deformation: comment if any are present in joints

Palpation
Make sure to do both legs
Temperature: comment on both legs
Capillary refill: comment on the time
Pulses: comment on strength between right and left feet
[posterior tibial and dorsalis pedis]
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 HIGH YIELD
CNS CASES
- PE STATIONS -

DIABETIC FOOT EXAM

Sensory Exam
Always use the sternum as a reference + ask the patient
to close their eyes
Monofilament test: small nylon strand [comment if
they feel sensation on right or left]
Light touch: cotton wool [comment if they feel
sensation + if its the same on both sides]
Pin prick: wooden stick [comment if they feel sensation
+ if its the same on both sides]
Vibration sensation: 128 Hz fork at the DIP [comment if
intact if they can feel it and tell when it stops] [only
move proximally if sensation is not felt at the DIP:
MCP medial malleolus tibia]
Proprioception: test 3 times if they can feel the distal
thumb moving up or down [comment on if there is
intact proprioception]

Motor Exam (only in case of foot drop)

Spread the toes to inspect
Dorsiflexion: comment on power grade
Ankle reflex: comment on contraction of
gastrocnemius and associated plantar flexion

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 HIGH YIELD
CNS CASES
- PE STATIONS -

CEREBELLAR & COORDINATION EXAM

General Inspection
Alert, conscious, responsive
Abnormal gross movements
Abnormal posture

GAIT
Ask patient to walk to end of the room + walk back
Cycle: comment on posture, arm swing, stride length and any broad based
gait
Heel to toe: comment on any tandem gait
Romberg's Test
Cerebellar ataxia: patient standing up with feet close together and eyes
open [check for any swaying]
Sensory ataxia: patient standing up with feet close together and eyes
closed [check for any swaying]
Truncal ataxia: patient sitting up on the edge of the bed with arms crossed
and eyes open [check for any swaying]

Sitting Up Tests
Ask patient to sit up on the bed
H test: comment on any nystagmus
Finger to nose test: comment on any intention tremor and past pointing
Dysarthria: ask patient to say 'British Constituition' [comment on the
volume, rhythm and clarity of speech]
Rapid alternating movements: ask patient to place one hand over the other
and clap front and backwards quickly and do this for both hands [comment
on any slow, disorganised or irregular movements]
Upper limb tone: comment on any hypotonia
Knee jerk: comment on any pendular reflex

Lying Down Tests

Ask patient to lie down flat on the bed
Lower limb tone: comment on any hypotonia
Heel to shin test: ask the patient to rub the left leg up and down with the
right leg 3 times, and repeat for the other leg [comment on any loss of
coordination]
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 HIGH YIELD
CNS CASES
- PE STATIONS -

HAND INJURY (MEDIAN, RADIAL AND ULNAR)

Median Nerve
Ask the patient to place their hands out in front of you
Inspection: comment on any wasting of the thenar eminence
Sensory: touch the right + left index on the palmar aspect [comment on any
altered sensation]
Motor: ask the patient to resist thumb abduction and opposition [comment
on the ability to resist]
Special test: Phalen's test, reverse Phalen's test and Tinel's test [comment
on any signs of carpal tunnel syndrome]

Radial Nerve
Ask the patient to place their hands out in front of you
Inspection: comment on any wrist drop
Sensory: touch the anatomical snuffbox on on right + left [comment on any
altered sensation]
Motor: ask the patient to resist wrist extension and finger extension
[comment on the ability to resist]

Ulnar Nerve
Ask the patient to place their hands out in front of you
Inspection: comment on any wasting of the interossei muscles
Sensory: touch the pinky on the palmar and dorsal aspect of right + left
hand [comment on any altered sensation]
Motor: ask the patient to resist finger abduction [comment on the ability to
resist]

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 HIGH YIELD
CNS CASES
- PE STATIONS -

OPTIC NERVE (CRANIAL NERVE 2)

Introduction
Ask the patient to sit on a chair
Explain the purpose: today we will test your eyes and vision
Inspection: comment on the pupil size and alignment

Visual Acuity
Ask if patient wears glasses usually (if yes, ask them to wear)
Snellen chart at 6m away: ask the patient if they can see the top line (if no
keep moving forward until they can - move the chart to 3m away 1m
away count the number of fingers see light]
Full snellen chart: ask the patient to cover one eye and read as far down as
they can: comment on acuity [distance/lowest row read correctly] - normal
is 6/6

Macular Function
Ask the patient to place their hands out in front of you
Amsler grid (if provided): ask the patient to cover one eye and stare at the
black spot [comment on where the patient sees distorted lines or broken
lines are seen]

Colour Vision
Ishihara chart: comment on any colour blindness

Visual Fields
Sensory inattention: ask the patient to look at your eyes and to point which
fingers are moving, testing in the 4 quadrants [comment on any affected
quadrant]
Peripheral vision: ask the patient to cover 1 eye (and you cover your
opposite eye) and tell them to say 'yes' to when they see the finger moving
[comment on which side and which quadrant is affected if any]

Accomodation Reflex
Ask patient to look at the wall + move a pen from a distance to close to
them [comment on convergence and constriction of the pupils]

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 HIGH YIELD
CNS CASES
- PE STATIONS -

OPTIC NERVE (CRANIAL NERVE 2)

Pupil Reflex
Place hand between the eyes and make sure to do on both eyes
1st shine (direct): ask the patient to look at the wall with the hand between
both eyes and shine the light within the pupil [comment on pupil
constriction]
2nd shine (consensual): comment on constriction of the opposite pupil
Swinging light test: swing the light from left and right + comment on pupil
reaction [optic nerve lesion affects direct reflex and occulomotor nerve
lesion affects both]

Mention
Ask if patient wears glasses usually (if yes, ask them to wear)
Fundoscopy: to complete the examination
H test: to assess occular movements
Lid lag test: to assess for any thyroid disorder

TRIGEMINAL NERVE (CRANIAL NERVE 5)

Sensory Exam
Use the sternum as a reference point
Light touch: comment if there is intact sensation and felt equally on both
sides in V1, V2, V3
Pin-prick: comment if there is intact sensation and felt equally on both
sides in V1, V2, V3

Motor Exam
Ask if patient wears glasses usually (if yes, ask them to wear)
Inspection: comment on wasting of mastication muscles (temporalis)
Jaw deviation and massaters: ask patient to clench jaw and comment on
the muscle bulk felt
Jaw jerk: tap the chin with mouth slightly open using a tendon hammer
and comment on brisk closure

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 HIGH YIELD
CNS CASES
- PE STATIONS -

ACCESSORY NERVE (CRANIAL NERVE 11)

Inspection and Palpation

SCM: comment on any wasting and hypertrophy
Trapezius: feel and comment on wasting or asymmetry

Movemement
Trapezius: ask patient to shrug and resist your movement [comment on
power]
SCM: ask the patient to turn right/left and resist your movement [comment
on power]

HEARING LOSS (CRANIAL NERVE 8)

Inspection
Inspect both ears
Hearing aid
Ear: skin erythema, swelling and discharge
Mastoid: swelling and erythema

Whisper Test
Stand at arms length behind patient and cover 1 ear
Introduction: say you will whisper words from behind the patient and they
must repeat what they hear (give them an example first)
Whisper a number on the right side while occluding the left ear (then
repeat for the left ear)
Comment on the patient's ability to hear the correct word on both sides

Weber's Test - 1st

Ask if patient hears vibration [512Hz tuning fork] equally on both sides on
forehead: [if yes do Rinne's in both ears, if no do Rinne's on
lateralised side]

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 HIGH YIELD
CNS CASES
- PE STATIONS -

HEARING LOSS (CRANIAL NERVE 8)

Rinne's Test
Ask the patient to close their eyes
Both ears: place the tuning fork at the
mastoid and ask the patient when they no
longer hear it then move the fork in
front of their ear [positive Rinne's if they can
still hear it]
Lateralised ear: do this on the affected ear
only

Result
Conductive hearing loss: if Rinne's negative
Sensorineural hearing loss: if Rinne's positive
(air conduction > bone condition)

SQUINT (CN3, 4, 6) FACIAL ASYMMETRY (CN7)

CN3, 4, 6
Inspection: strabismus, head turns or tilt
H test: comment on any double vision + nystagmus
If there is double vision: comment on the position seen
If there is nystagmus: position, direction, presence of
fast/slow/equal oscillatory phases

CN7
Inspection: loss of forehead wrinkle, loss of nasolabial fold,
mouth drooping and fasciculations
Sensory: ask for any recent changes in taste
Motor:
1. Raise your eyebrows: check for symmetrical wrinkling
2. Smile and show your teeth
3. Close your eyes tightly: try to open patient's eyes
4. Blow out your checks and keep your mouth tightly shut: try
to push their cheeks if air leaks out of the mouth

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 HIGH YIELD
CNS CASES
- PE STATIONS -

DIFFICULTY SWALLOWING AND SPEECH

(CN 9, 10, 12)

CN9 and 10
Mouth examination: say 'Ah!' [comment on palate elevation symmetry and
any deviation of the uvual
Patient's speech: ask 'how are you doing?' [comment on any hoarseness of
voice}
Puff cheeks: listen for any escaping air
Cough: comment on cough strength and any bovine cough
Swallow test: comment on any absence of swallowing, cough or change in
voice

CN12
Inspection: ask the patient to protrude tongue [check for wasting,
fasciculation or any involuntary movements + any tongue deviation]
Tongue movements: ask the patient to move their tongue side to side and
press against their cheek
Speech: ask patient to say 'yellow lorry'
Swallow test: comment on any absence of swallowing, cough or change in
voice

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 HOW TO TAKE A
CNS HISTORY
- HX STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

HOPI
Ask about onset + triggers

Ask SOCRATES

Ask associated CNS symptoms: headache, dizziness, vision problems, hearing

loss, tingling/numbness, weakness, seizures, stiff neck, falls

Ask head to toe symptoms: [very quickly] Dizziness

Headache
Ask about systemic symptoms: Blurred vision
Flu-like symptoms
- Weight changes: how many kg + over how long Difficulty swallowing
- Appetite changes: increased or decreased Cough
Nausea/vomiting
- Urinary changes
Chest pain
- Bowel changes Back pain
Abdominal pain
Ask about progression + previous episodes Skin changes
Leg swelling

PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.
Do you have any long-standing medical conditions?

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies?

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FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents?
Is there any family history of cancer?

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.

Are you currently working: ask about occupation + stress

Can you describe your diet?

Do you exercise regularly?

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: what kind + how often [do CAGE if relevant]

Do you consume any recreational drugs: name + oral/IV

ClOSING
That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

Worry: It's a good thing you came in today and we will take it one step at a
time alright?

Scared about death or serious outcome: I understand you are worried

about ______, it can be scary to think about however it's too early to
conclude anything right now, but we will take it one step at a time. I can
ensure you that you are in good hands.

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 HOW TO USE AN
OTOSCOPE
- SDL STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?
Today I’ve been asked by my senior doctor to examine your ears using an
otoscope. Everything done today will be kept private and confidential.

Do I have your consent to proceed? [consent]

Explain procedure: today I will examine your ears using a device called an
otoscope. I will place this into your ear and look for any abnormalities. At any
point you feel uncomfortable do let me know.

PREPARATION
Ask the patient for any pain before starting
Inspection of the pinna and mastoid: comment on any swelling, erythema
and deformities

Palpation of the pinna and mastoid: check for any tenderness

Choose a suitable sized otoscope speculum that can fit comfortably in the
patient's external auditory meatus and attach it to the otoscope

Check the otoscope works and is emtting light

To examine the right ear: use your right hand to hold the otoscope
horizontally like a pen

PROCEDURE
Gently pull the ear upwards and backwards when inserting the otoscope

Slowly enter the ear and stop once you see the tympanic membrane

Inspect the external auditory canal: inflammation, abrasions or skin lesions

Inspect for any ear wax - as this may obstruct your view of the tympanic
membrane
Look for the tympanic membrane: grey structure with the hand of malleus in
the middle and a cone of light at the 4-5 o'clock position (right ear) and 7-8
o'clock position (left ear)

Inspect the tympanic membrane: colour, swelling, bulging, abnormal growth,

loss/blurring of the cone of light and the presence of a grommet

CLOSING
Repeat the steps for the left ear and inform the patient once you are done

Thank the patient for their time HE

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SPECIAL STATIONS

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 HOW TO TAKE
AN ALCOHOL HISTORY
- HX STATIONS -

INTRODUCTION
Hi, I’m ______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

MOTIVATIONAL INTERVIEW

Would you mind to tell me more about your drinking habit?

How can I help you with your drinking?

What make you think that you want to change?

What happens if you do not change?

What are the good things if you change?

What do you want to do in order to change?

HOPI

How can I help you with your drinking?

Ask about onset: When did you start drinking?

Ask about types of alcohol consumed

Ask about amount of alcohol consumed

Ask about frequency of drinking in a week

Ask about progression of drinking: Do you drink more now?

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 CAGE QUESTIONS

C: Cutting down Agitation

Tremor
Have you tried cutting down on your drinking? Nausea
How long can you stay off alcohol?
When you tried to stop drinking, did you experience any
symptoms?
A: Annoyed
Have you ever felt annoyed by criticism of your drinking habits?
G: Guilty
Do you ever feel guilty about drinking?

E: Eye Opener
Have you ever had a drink first thing in the morning?

EFFECTS OF ALCOHOL

Health Impact: ask Psychosocial impact: Hang-over effects: ask

about symptoms of ask about about symptoms that
alcoholism psychological occur after a drinking
symptoms + social episode
Headache impacts
Dizziness Tremors
Memory loss Depression Nausea
Blurred vision Anxiety Insomnia
Abdomen pain Insomnia Headache
Palpitation Work/Family Vomiting
Pallor /Financial problems Sweating
Mood changes
Muscle weakness

PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.

Do you have any long-standing medical conditions: PUD, liver disease, or

vomiting blood?

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies: ask about what happens

FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
Ask about any family history of alcohol abuse
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SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.

Are you currently working: ask about occupation + finances

Can you describe your diet: what kind of diet + high intake of fried, fatty or
salty food

Do you exercise regularly: what kind + how often

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you consume any recreational drugs: name + oral/IV

ClOSING
That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

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 ASSESS PATIENT RISK
FOR CVS DISEASE
- HX STATIONS -

INTRODUCTION
Hi, I’m _______ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

INITIAL DIAGNOSIS
Do you have any known CVS diseases?

Ask when + how were you diagnosed?

Ask about checkups: frequency + if any were missed

Ask about initial readings: BP reading + lipid profile + blood glucose level

COMPLIANCE
Ask about current medications: name + dose + frequency + compliance

Ask about any medication changes: name + reason

Ask about medication side effects/allergies: if yes, ask about the reaction in
specific

CONTROL
Ask about home monitoring: BP monitoring or glucometer reading

Ask about lifestyle changes: diet + exercise

COMPLICATIONS
Chest pain
Ask about any current symptoms
Shortness of breath
Ask about CVS disease complications Ankle swelling
Palpitations
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PAST MEDICAL HISTORY

Now I'm going to ask you a few questions about your general health.
Do you have any other long-standing medical conditions?

Are you taking medication for this: name + dose + compliance

Have you had any recent surgeries or hospitalisations?

Do you have any allergies?

FAMILY HISTORY
Now I'm going to ask you a few questions about your family.
How are your parents?
- Death: ask age at death + cause [I'm so sorry to hear that]
- Disease or condition: ask if they are seeking treatment

Do you have any siblings? [ask about any conditions]

SOCIAL HISTORY
Now I'm going to ask you about your general lifestyle.
Are you currently working: ask about occupation + stress

Do you live alone or with someone: ask about health of partner/ kids if any

Can you describe your diet: what kind of diet + high intake of fried, fatty or
salty food

Do you exercise regularly: what kind + how often

I'm going to ask you a few sensitive questions.

Do you smoke: how many sticks a day + for how long

Do you drink alcohol: what kind + how often [do CAGE if relevant]

Do you consume any recreational drugs: name + oral/IV

ClOSING
That's all the questions I have for you today. I will relay this to my senior
doctor and we will get back to you soon.

Do you have any concerns or questions you'd like to share?

Worry: It's a good thing you came in today and we will take it one step at a
time alright?

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 EMPATHY
STATION
- HX STATIONS -

INTRODUCTION
Hi, I’m [your name] , a ___ year-medical student. Can I confirm your full
name and the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have your consent to proceed? [consent]

What brings you to the clinic today?

EMOTIONAL
Ask them open-ended questions: how are you doing today?

Ask how this condition has affected emotional health

Ask about stress levels

Address each emotion stated by the patient and provide reassurance

FAMILY
Ask about how this condition has affected patient's relationship with:

1. Partner
2. Children
3. Parents
4. Siblings

RELATIONSHIPS
Ask about how this condition has affected patient's relationships with friends
and coworkers

Enquire regarding patient's support system

FINANCE
Ask how this condition has affected the patient's financial life

Provide advice and suggestions to patient regarding poor financial

situations: "you could try enquiring with the financial department at the
hospital for specific insurance plans and financial aid'

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SOCIAL

Ask patient if the condition has affected their daily life activities

Ask patient if the condition has affected their ability to work

ClOSING
That's all the questions I have for you today. Thank you for sharing all of this
with me, I wish you all the best.
Do you have any concerns or questions you'd like to share?

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 DRUG INFORMATION
GIVING
- HX STATIONS -

INTRODUCTION
Hi, I’m _____ , a ___ year-medical student. Can I confirm your full name and
the last 4 digits of your IC please?

Today I’ve been asked by my senior doctor to ask you a few questions about
what brought in today. Everything we discuss today will be kept private and
confidential.

Do I have you consent to proceed? [consent]

What brings you to the clinic today?

PATIENT'S PRE-KNOWLEDGE

Do you know why you have been prescribed this medication?

Do you know what illness you have?

When did you first get this disease?

Do you know what this medication is?

Have you taken this medication before?

GENERAL HISTORY TAKING

Ask the patient if they understand the condition: explain in layman terms

Screen for common symptoms of the diagnosed condition and associated

symptoms

Ask patient about other long-standing medical conditions

Briefly explore diet, alcohol intake and smoking habits

Ask patient about drug allergies + other medications

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DRUG INFORMATION
State the name of the medication

Explain the action of medication: describe this very simply

Explain how to take the medication: dose and frequency

Advise patient what to do when you miss dosages

ADDITIONAL INFORMATION
Explain how to store the medication
Describe some side effects

Describe the overdose effects

Explain the contraindications (CI)

Advice on compliance and potential complications if they are non-compliant

ClOSING

Ask the patient to repeat how to take the medication [ensure they understood
correctly]

Ask the patient if they have any concerns or questions

Thank the patient for their time

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 MEDICP
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