Brief examinations Flashcards
Lower limb neuro?
1) Introduction.
2) Inspection (front side back).
3) Romberg’s test.
4) Gait assessment.
5) Tone part 1 (isolate each joint).
6) Tone part 2 (knee drop, hip roll, ankle clonus).
7) Power (Hip, knee, ankle, big toe).
8) Reflex (Knee, achilles, Babinski).
9) Coordination (Ankle-shin test).
10) Sensation (Soft touch, pin prick, temperature, vibration, proprioception).
11) Conclusion.
Upper limb neuro?
1) Introduction.
2) Inspection (Front side and back - including scapula).
3) Tone (Wrist, elbow and shoulder).
4) Power (Thumb, fingers, wrist, elbow and shoulder).
5) Reflexes (Brachioradialis, biceps and triceps).
6) Coordination (Opposition, nose-to-finger, pronator drift, nose with eyes closed, dysdiadochokinesis).
7) Sensation (Soft touch, pin prick, temperature, vibration, two point distinction, proprioception).
8) Conclusion.
Cardio?
1) Introduction.
2) General inspection.
3) Inspection of hands.
4) Palpation of hands (temp + cap refill).
5) Palpation of radial pulse (radio-radial delay? HR?)
6) Palpate the brachial pulse.
7) Collapsing pulse.
8)Carotid pulse.
9) JVP.
10) Hepatojugular reflex.
11) Face inspection (eyes and mouth).
12) Chest inspection.
13) Chest palpation (Apex, thrills and heaves).
14) Auscultation of valves.
15) Special auscultations (Sit forwards and hold breath in on tricuspid, left axilla, apex roll onto side, carotids).
17) Back (Auscultate lung bases, examine for sacral oedema).
18) Palpate for hepatomegaly.
16) Ascites.
17) Ankle oedema.
18) Conclusion.
19) Also like: 12 lead ECG, both arms BP, lying and standing BP, screen for hypertensive retinopathy, radio-femoral delay.
GALS?
1) Introduction.
2) Qs: Pain/stiffness anywhere? Dress/redress? Climb up AND down stairs?
3) General inspection (front side back).
4) Assess gait.
5) Spine assessment (Touch toes, touch shoulders with head).
6) Upper limb assessment (Hands behind head and elbows back, hands in front with elbows extended - inspect and assess pronation/supination, MCP squeeze, fist, opposition, finger squeeze).
7) Lower limb assessment (Flex/extend knee and feel for crepitus, patellar tap, internal/external hip rotation, foot inspection, MTP squeeze).
8) Conclusion.
GI?
1) Introduction.
2) General inspection.
3) Inspection of the hands.
4) Palpation of hands (temperature and palmar thickening).
5) Flapping tremor.
6) Radial pulse.
7) Forearms inspection (pruritus).
8) JVP.
9) Inspect face (eyes and mouth).
10) Palpate lymph nodes.
11) Inspect chest wall.
12) Inspect back
13) Inspect abdomen.
14) General palpation of abdomen.
15) Specific organ palpation (Spleen, liver - Murphy’s sign, kidneys, aorta, bladder).
16) Percuss abdomen (liver, spleen, bladder).
17) Shifting dullness.
18) Auscultate (bowels, aorta, renal arteries).
19) Conclusion.
20) ISHRUG (Inguinal nodes, stool sample, hernial orifices, rectal exam, urinalysis, genitalia exam).
Cranial nerves?
1) Introduction.
2) General inspection (especially face and eyes).
CN I: Smell test (isolate each nostril).
CN II: Schnellen chart, peripheral vision, finger waggle, accomodation, light reflex.
CN III, IV and VI: H test (any double vision?).
CN V: Sensation forehead cheekbone and chin, clench teeth and open mouth wide, jaw jerk.
CN VII: Scrunch face, smile and show teeth, puff out cheeks, raise eyebrows, purse lips.
CN VIII: Whisper number in each ear. If abnormal, then tuning fork in centre of patients head - which side is louder (Weber’s)? Tuning fork against bone behind ear, then next to ear canal - which is louder (Rinne’s test)?
CN IX and X: Hoarse voice? Swallowing difficulty? Cough? “Aaahhh” (look at uvula symmetry).
CN XI: Shrug shoulders, turn head against resistance.
CN XII: Stick tongue out, tongue against cheek walls.
Peripheral vascular?
1) Introduction.
2) General inspection
2) Inspection of hands
3) Palpation of hands (temp and cap refill).
4) Ulner and radial pulse (allens test? Radio-radial delay? Radio-femoral delay?).
5) Brachial pulse.
6) BP in both arms (State you would do this in the OSCE).
7) Carotid pulses (one at a time).
8) Inspect the face.
9) Inspect the abdomen.
8) Inspect lower limbs (legs and feet).
9) Dorsalis pedis pulse.
10) Ball-joint pulse.
11) Popliteal pulse.
12) Femoral pulse.
13) Aortic pulse (Not in OSCE).
14) Sensation (light touch) in toes.
15) Cap refill of toes.
16) Auscultate pulses (carotids, subclavians, aortic, femorals).
17) Buerger’s test (elevate legs to 45 for approx. 2 mins. Then let patient hang legs off bed. Observe for colour changes).
18) ABPI calculation.
19) Would like to conduct a full neurological assessment of the upper/lower limbs.
20) Conclusion.
Cerebellar Exam?
1) Introduction (Also neck pain/headaches).
DANISH:
1) Dysdiadochokinesis.
2) Ataxia (Gait + heel-toe test).
3) Nystagmus (H test). ALSO TEST DYSMETRIC SACCADES.
4) Intention tremor (finger nose test). ALSO DO REBOUND PHENOMENON.
5) Speech test (“British constitution”, “C,C,C”, “L,L,L”
6) Hypotonia (Tone of upper limbs + either biceps or patellar reflex) AND Heel-shin test.
Hand examination?
1) Introduction.
2) Place hands on pillow + ask about pain.
3) LOOK (hands, wrists and elbows).
4) FEEL - JOINTS (Wrist, MCP squeeze, anatomical snuffbox, every joint on the fingers and thumb, palm).
5) FEEL - NEURO (Sensation in snuffbox, palmar thumb, palmar ring finger and palmar pinky).
6) FEEL - PULSE (Ulner, radial, Allen’s test).
7) MOVE (Active - only do passive if there is limited ROM):
- Make a fist, then relax.
- Spread fingers then bring back together.
- Palms up and extend thumb to celling.
- Palms horizontal and move thumb towards celling.
- Opposition.
- Hands out in front palms downwards. Test ab/adduction.
- Prayer.
- Reverse prayer.
8) FUNCTION TESTS:
- Squeeze fingers.
- Pick up a coin/key.
- Ask if they can do up/undo buttons.
9) SPECIAL TESTS:
- Tap on the carpal tunnel (Tinnel’s).
- Reverse prayer and hold (Phalen’s).
- Paper between thumb and forefinger.
- Cross fingers.
10) Conclusion.
Shoulder exam?
1) Introduction (ask about shoulder pain+ remove top).
2) Ask the patient if they can wash their own hair, and dress/undress themselves without difficulty.
2) LOOK (front side and back).
3) FEEL (Temp, sternoclavicular joint, clavicle, shoulder, rotator cuff, scapula, traps, spine).
4) MOVE (Active)
- Compounds first (hands behind head, hands behind back - also do lift off test for rotator cuff).
- Flexion, extension, abduction, adduction, internal and external rotation (painful arc = rotator cuff injury).
5) MOVE (Passive).
- All movements passively whilst feeling for crepitus.
6) Special tests
- Test abduction power between 0 and 20 degrees.
- External rotation against resistance.
- Scarf test (adduction).
7) Examine the cervical spine and elbow, and assess the neurovascular state of the limb (State this in the OSCE).
Respiratory?
1) Introduction.
2) General inspection.
3) Inspect hands.
4) Palpate hands (temperature).
5) Flapping tremor test.
6) Palpate radial pulse.
7) Palpate carotid pulse.
8) JVP.
9) Inspect face.
10) Palpate lymph nodes.
11) Palpate trachea.
12) Cricosternal distance.
11) Inspect chest wall (anteriorly and posteriorly).
13) Palpation (chest expansion both anteriorly and posteriorly).
14) Percuss anterior chest wall (go medially to breasts, then inferiorly).
15) Auscultate anterior chest wall AND AXILLA (deep breaths, cough, “99”).
16) Percuss posterior chest wall.
17) Auscultate posterior chest wall (deep breaths, cough and “99”).
18) Feel for sacral oedema.
19) Assess ankles for pitting oedema.
20) Inspect/request sputum sample and peak flow assessment.
21) Conclusion.
Hip exam?
1) Introduction (+pain in legs/spine).
2) LOOK (Anterior lateral posterior)
3) Gait assessment.
4) TRENDELENBURG’S TEST: Stand on one leg - if other hip drops, this is pathological.
5) MEASURE LEG LENGTH (apparent - umbilicus, true - ASIS).
6) FEEL (Temperature lateral thigh and thigh, greater trochanter).
7) MOVE (Active).
- Bring knee to chest (flexion).
- Straighten leg (extension).
- Leg out to side (abduction).
- Cross leg over (adduction).
8) MOVE (Passive).
- All same movements but feel for crepitus/ask about pain.
- Also test internal/external rotation.
9) THOMAS’S TEST: Place hand behind patient’s lumbar spine and ask them to bring their foot close to their bottom. If the other hip lifts off the bed, flexion is limited.
10) State you would also assess the knee and lumbar spine. You would also complete a neurovascular assessment of the joint.
11) Conclusion.
Knee?
- Introduction.
LOOK:
- General inspection (front side back).
- Supine inspection (swelling, scars, wasting etc.)
GAIT ASSESSMENT.
FEEL:
- Temperature from mid thigh to mid tibia.
- Palpate borders of the patella (lateral, medial, superior and inferior).
- Palpate the popliteal fossa.
- Patellar tap.
- Bulge test.
- Bend leg to 90 and palpate the patellar tendon (inferior to the patellar).
MOVE (Active):
- Flex and extend knee.
MOVE (Passive):
- Passively flex and extend patient’s knee whilst feeling for crepitus.
SPECIAL TESTS:
- Anterior/posterior draw (Leg at 90, pull tibia towards you/push tibia away from you. Should not be any significant movement).
- Lateral collateral test. Lift patients leg off the couch, and exert lateral pressure on each side of the knee. Should not be any significant movement.
Complete the exam:
- Neurovascular exam of both lower limbs.
- Review available imaging.
- Full examination of the hip and ankle joints.
Varicose veins and chronic venous insufficiency?
- Introduction.
- Inspect legs (varicosities, eczema, oedema etc.)
- Locate saphenofemoral junction (inspect, palpate and cough, tap and feel if wave transmitted to other varicose veins).
- Trendelenburg (w/ thigh torniquet) test and Perthe’s test (test the deep veins) (NOT NEEDED FOR OSCE).
- Auscultate the SFJ with a Doppler probe while squeezing the thigh. Should only hear one “woosh”, two indicates incompetence of the SFJ.
- Auscultate the saphenopopliteal junction in the popliteal fossa with the Doppler probe whilst squeezing the calf.
- Examine the abdomen.
- Conclude.
Thyroid
- Introduction (patient should sit in chair).
- General inspection.
- Inspect hands.
- Palpate hands (temperature).
- Paper on dorsum of outstretched hands (fine tremor?)
- Radial pulse.
- Inspect forearm (muscle wasting?)
- Inspect eyes.
- H test.
- Check visual acuity and perform fundoscopy.
- Inspect neck for masses.
- Inspect neck while patient swallows a glass of water (if mass moves, indicates thyroid mass).
- Inspect tongue with it stuck out. Look for mass at the back of the tongue, or mass movement as the patient sticks their tongue out.
- Palpate the trachea.
- Palpate the neck from behind. If mass located, do water swallow and tongue protrusion.
- Palpate the lymph nodes.
- Auscultate the thyroid for bruits whilst the patient holds their breath.
- Get patient to stand from chair without using arms.
- Check knee jerk OR biceps reflexes.
- Conclusion.
