70 Station 27 Male genitalia examination
• Palpate the inguinal nodes in the inguinal crease. Remember that only the penis and scrotum
drain to the inguinal nodes, as the testicles drain to the para-aortic lymph nodes.
• Ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
• Consider a rectal examination to examine the prostate.
• Consider an ultrasound scan if you detect a bulky or painful mass in the scrotum or cannot
Conditions most likely to come up in a male genitalia examination station
• collection of fluid in the tunica vaginalis
• presents as unilateral (or less commonly bilateral)
• epididymal cysts may be multiple and bilateral.
• unlike in a hydrocoele, the testis is palpable quite
• dilated veins along the spermatic
• almost invariably left-sided.
• ‘bag of worms’ upon palpation.
• there may be a cough impulse.
• likely to disappear upon lying down.
Direct inguinal hernia (see Station 24)
Specifications: A male anatomical model in lieu of a patient.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the procedure and obtain his consent.
• Position him flat on the couch with legs apart and groin exposed.
• A catheterisation pack • A 12–16 french Foley catheter
• Saline solution • A catheter bag
• Two pairs of sterile gloves • A 10 ml syringe containing sterile water
• A 10 ml pre-filled syringe • Adhesive tape
• Gather the equipment (a male catheter is longer than a female one).
• Check the expiry date of the catheter.
and pour saline solution into the receiver.
• If pre-filled syringes are not provided with the pack, draw up 10 ml sterile water and 10 ml
lignocaine gel into separate syringes.
• Drape the patient. Some recommend tearing an appropriately sized hole into the drape and
• Place a collecting vessel in the patient’s entre-jambes/crotch.
• With your non-dominant hand, hold the penis with a sterile swab.
• With your dominant hand, retract the foreskin and clean the area around the urethral meatus
• Instil 10 ml of lignocaine gel into the urethra. Hold the urethral meatus closed.
• Indicate that the anaesthetic needs about 5 minutes to work.
• Change into a new pair of sterile gloves.
• Hold the penis so that it is vertical.
continually ensuring that this does not cause the patient any pain.
• Gently retract the catheter until a resistance is felt.
• Tape the catheter to the thigh.
72 Station 28 Male catheterisation
• Ensure that the patient is comfortable.
• Record the date and time of catheterisation, type and size of catheter used, and volume of urine
Indications for catheterisation:
• hygienic care of bedridden patients.
• collection of a specimen of uncontaminated urine.
• imaging of the urinary tract.
• previous failure to catheterise.
• paraphimosis (from failure to reposition the foreskin).
• urethral perforation and creation of false passages.
Specifications: A female anatomical model in lieu of a patient.
• Introduce yourself to the patient.
• Confirm her name and date of birth.
• Explain the procedure and obtain her consent.
• Ask her to undress from the waist down and place a sheet over her.
• Two pairs of sterile gloves • A 10 ml pre-filled syringe containing 2% lignocaine gel
• A catheterisation pack (Instillagel)®
• Saline solution • A 10 ml syringe containing sterile water
• A 12–16 french Foley catheter • A catheter bag
and pour antiseptic solution into the receiver.
• If pre-filled syringes are not provided with the pack, draw up 10 ml sterile water and 10 ml
lignocaine into separate syringes.
• Put on a pair of sterile gloves.
• Ask the patient to remove hersheet and lie flat on the couch, bringing her heelsto her buttocks
and then letting her knees flop out.
• Place a collecting vessel in the patient’s entre-jambes/crotch.
• Use your non-dominant hand to separate the labia minora.
• Clean the area around the urethral meatus with saline-soaked swabs.
• Coat the end of the catheter with lignocaine gel and instil 5 ml of lignocaine into the urethra.
• Indicate that the anaesthetic needs about 5 minutes to work.
• Change into a new pair of sterile gloves.
• Holding the catheter by its sleeve, gently and progressively insert it into the urethra.
continually ensuring that this does not cause the patient any pain.
• Gently retract the catheter until a resistance is felt.
• Tape the catheter to the thigh.
74 Station 29 Female catheterisation
• Ensure that the patient is comfortable.
• Record the date and time of catheterisation, type and size of catheter used, volume of water
used to inflate the balloon, and volume of urine in the catheter bag.
Figure 21. Preparing to insert the
‘I’m very brave generally’, he went on in a low voice: ‘only today I happen to have a headache’.
Lewis Carroll, Through the Looking Glass
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain that you are going to ask him some questions to uncover the nature of his headaches,
• Ensure that he is comfortable.
Presenting complaint and history of presenting complaint
Rule out head injury before enquiring about the pain:
• Site. Ask the patient to point to the site of the pain.
• Character, for example, sharp, dull, throbbing, band-like constriction.
– visual disturbances such as double vision and fortification spectra
– neurological deficit (weakness, numbness, ‘pins and needles’)
• Exacerbating and relieving factors; for example, activity, stress, eye strain, caffeine, alcohol,
dehydration, hunger, certain foods, coughing/sneezing).
• Severity. Ask the patient to rate the pain on a scale of 1 to 10, and determine the effect that it
76 Station 30 History of headaches
• Current, past, and childhood illnesses.
• Ask specifically about headache, migraine, hypertension, cardiovascular disease, and travel
• Prescribed medication. Ask specifically about withdrawal from NSAIDs, opioids, glyceryl
trinitrate, and calcium channel blockers.
• Over-the-counter medication.
• Parents, siblings, and children.
• Ask about migraine and travel sickness.
• Employment, past and present.
• Mood. Depression is a common cause of headaches.
• Alcohol use. Alcohol is a common cause of headaches.
• Diet: tea and coffee, cheese and yoghurt, chocolate.
• Ask the patient if there is anything he might like to add that you have forgotten to ask about.
• Ask him if he has any questions or concerns.
• Summarise your findings and offer a differential diagnosis.
Station 30 History of headaches 77
Conditions most likely to come up in a history of headaches station
• constant pressure, ‘as if the head were being
• pain typically last 4–6 hours but this is highly
• may be precipitated by stress, eye strain,
sleep deprivation, bad posture, irregular meal
Cluster headaches (‘suicide headaches’):
• excruciating unilateral headache that is of
• located in the periorbital or temple area, may
radiate to the neck or shoulder.
• associated with autonomic symptoms such as
ptosis, conjunctival injection, lacrimation.
• each headache lasts from 15 minutes to 3
• headaches most often occur in ‘clusters’: once
or more every day, often at the same time of
day, for a period of several weeks.
• unilateral, dull, throbbing headache lasting
• may be aggravated by activity.
• associated with nausea, vomiting,
• about half experience prodromal symptoms
such as altered mood, irritability, or fatigue
several hours or days before the headache.
• about one-third experience an aura,
commonly consisting of visual disturbances or
neurological symptoms, before or along with
• frequency of headaches varies considerably,
but average is about 1–3 a month.
• unilateral pain in the temporal region.
• associated with scalp tenderness, jaw
claudication, blurred vision, and tinnitus.
• three times more common in females.
• mean age of onset is 70 years.
• urgent treatment is required to prevent
• occipital headaches associated with cervical
• cervical pain may radiate to the base of the
skull, shoulder, or hand and fingers.
• may be associated with weakness, numbness,
or pins and needles in the arms and hands.
• severe and bilateral headache.
• may be associated with high fever, neck
stiffness, photophobia, phonophobia, altered
• thunderclap headache (‘like being kicked in
the head’) that is of very rapid onset.
• may be associated with vomiting, altered
mental status, neck stiffness, photophobia,
visual disturbances, seizures.
• dull, throbbing headache associated with
vomiting, ocular palsies, visual disturbances,
• may be worse in the morning and may wake
• aggravated by coughing and head
• dull and constant headache or facial pain
• may be associated with flu-like symptoms and
• may be aggravated by bending over or lying
• intense unilateral facial pain (‘like stabbing
electric shocks’) lasting from seconds to
• may occur several times a day.
• triggered by common activities such as
eating, talking, shaving, and tooth-brushing.
• may be associated with a trigger area on the
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain that you are going to ask him some questions to uncover the cause of his collapse, and
• Ensure that he is comfortable.
Presenting complaint and history of presenting complaint
Think about the common causes of a funny turn, as these should inform your line of questioning.
• Whether the patient remembers falling.
• If the fall was witnessed and if a collateral history is available.
• The circumstances of the fall:
– had the patient just arisen from bed? (postural hypotension)
– had the patient just suffered an intense emotion? (vasovagal syncope)
– had the patient been coughing or straining? (situational syncope)
– had the patient been turning or extending his neck? (carotid sinus syncope)
– had the patient been exercising? (arrhythmia)
– did the patient have any palpitations, chest pain, or shortness of breath? (arrhythmia)
• Any loss of consciousness and its duration.
• Prodromal symptoms such as aura, change in mood, strange feeling in the gut, sensation of
• Fitting, frothing at the mouth, tongue biting, incontinence.
• Headache or confusion, or amnesia upon recovery.
• Injuries sustained, especially head injury.
• Over-the-counter medication.
• Recent changes in medication.
Station 31 History of ‘funny turns’ 79
• Parents, siblings, and children.
• Ask specifically about epilepsy and heart problems.
• Employment, past and present.
• Effect of falls on patient’s life.
• Ask the patient if there is anything he might add that you have forgotten to ask about.
• Ask him if he has any questions or concerns.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a history of ‘funny turns’ station
• loss of consciousness lasting from a few
seconds to a few minutes is preceded by
nausea, sweatiness, dizziness or tightness
• provoked by stressful, anxiety-provoking,
or painful situations (vasovagal syncope),
by coughing or straining (situational
syncope), or by applying pressure upon
the carotid sinus, for example, by wearing
a tight collar, turning the head, or shaving
• loss of consciousness preceded by
dizziness, light-headedness, confusion, or
• provoked by postural change.
• causes include hypovolaemia (e.g.
dehydration, bleeding, diuretics,
vasodilators), drugs (e.g. tricyclic
antidepressants, antipsychotics, alpha
blockers), and certain medical conditions
(e.g. diabetes, Addison’s disease).
80 Station 31 History of ‘funny turns’
• may be either a bradycardia or
• may be provoked by exertion.
• may be associated with palpitations, chest
pain, shortness of breath, fatigue.
• history of heart disease/risk factors for
heart disease are very likely.
• patient should be hospitalised and
placed on a cardiac monitor to rule out
ventricular tachycardia, which can result
• less commonly, cardiac syncope can be
caused by an obstructive cardiac lesion
such as aortic or mitral stenosis.
Generalised tonic-clonic seizure:
• sudden loss of consciousness
accompanied by fitting, frothing at the
mouth, tongue biting, incontinence.
• seizure lasts for about 2 minutes.
• seizure is followed by confusion and
• seizure may be preceded by an aura
which may involve déjà vu, dizziness,
unusual emotions, altered sense
perceptions, or other symptoms.
• most frequent symptoms include loss of
vision, aphasia, unilateral hemiparesis,
• symptoms last for a few seconds to a few
minutes and never for more than 24 hours
• loss of consciousness can occur, although
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