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Clinical Examination > Examination > Flashcards

Examination Flashcards

1
Q

Hypertension exam - general observations

A

Cushingoid features - central obesity, buffalo hump, straie, thin skin, bruising, proximal myopathy
Peripheral oedema

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2
Q

Hypertension exam - hands

A

Tremor / sweaty (phaeo)
Pulse rate and rhythm (? AF)
Radial-femoral delay (thoracic outlet syndrome, aortic aneurysm, pre-subclavian coarctation, atherosclerosis, PE, tumours)
Radial-radial delay (normal 15ms apart, aortic coarctation, atherosclerosis, thromboembolism)
Vasculitis
Flap (uraemia)
Brisk reflexes

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3
Q

Hypertension exam - eyes

A

Ophthalmoscope for hypertensive retinopathy
Thyroid eye disease

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4
Q

Hypertension exam - neck

A

Bruits
JVP / fluid status
Thyroid exam

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5
Q

Hypertension exam - chest and CVS

A

Observe chest shape
Palpate apex
Listen to heart sounds
Pulmonary oedema

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6
Q

Hypertension exam - abdomen

A

Renal or adrenal mass
Renal bruits (renal artery stenosis)
Distension

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7
Q

Child abuse - physical indicators that should raise suspicion for child abuse

A

Injury pattern inconsistent with history
Multiple injuries / multiple types
Various stages of healing
Poor hygiene
Pathognomonic injuries - loop marks, stocking and glove burns, head trauma - SDH, retinal haemorrhage, skeletal injuries

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8
Q

Child abuse - bruising patterns

A

Multiple areas beyond bony prominences
Ears / facial cheeks / buttocks / palms / soles / necks / genitals
Many stages of healing
Bruises in non-ambulatory child
Pattern - grab / slap / human bite / loop
Oral injury, lingula or labial frenula tears

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9
Q

Child abuse - skeletal injuries

A

Fracture in non-ambulatory child
Metaphyseal fracture
Multiple, bilateral, differently ages rib fractures
Complex skull fractures
Scapular and spinous process fractures

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10
Q

Child abuse - burn patterns

A

Shape of hot object
Stocking and glove demarcation
Cigarette burns
Splash burns not consistent with developmental age
Localised to genitals / buttocks / perineum
Evidence of delayed seeking treatment

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11
Q

Breast exam - Observation sitting up

A

Shape, contour, symmetry
Visible mass
Skin changes - dimpling, redness, thickness
Nipples - discharge, peau d’orange, rash, ulceration, asymmetry

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12
Q

Breast exam - palpation

A

4 quadrants / clock face
Lump - consistency, fixed vs mobile, smooth or rough borders, size, location
Nipple - palpate nipple and areola
LNs - axillary, supraclavicular, infraclavicular

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13
Q

Breast exam - metastasis

A

Liver enlargement
Chest for effusion
Spine for pain
Male - testis for lump

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14
Q

Head and neck exam - inspection of neck

A

Lump position
Shape
Size
Overlying skin ? tethered ? erythematous
Scalp
Pinna
Face for skin lesions or scars

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15
Q

Head and neck exam - palpation of lump

A

Shape
Temperature
Tenderness
Surface
Edge
Consistency
Compressibility / reducibility
Translucent
Pulsatile ? bruit
Superficial or deep tethering
LN basin - head and neck
Thyroid

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16
Q

Head and neck exam - which facial nerve and how

A

Facial nerve
Platysma
Lift eyebrows
Show teeth

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17
Q

Ear nose and throat for neck lump exam

A

Any primary lesions - thyroid, larynx, pharynx, scalp
Oral exam
Duct orifices - base of tongue for sublingual and submandibular, opposite 2nd upper molar tooth for parotid duct

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18
Q

DDx for mass at angle of the jaw

A

Metastatic SCC (parotid neoplasia)
Pleomorphic adenoma (parotid gland)
High grade adenoid cystic carcinoma
Infection e.g. mumps or TB (parotiditis)
Inflammation e.g. Sjogren’s
Lymphoma
Lipoma
Sebaceous cyst
Carotid tumour

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19
Q

Hoarse voice examination

A

Temperature
Demonstrate hoarse voice
Mouth and bimanual inspection and palpation
Cranial nerves - gag, palatal movements, sensation, tongue movements, acccessory
Indirect laryngoscopy
Facies for hypothyroidism
Nose and ears
Neck for lumps, scars, nodes
Thyroid
Chest
General - nutrition, hypothyroidism

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20
Q

Hoarse voice investigation

A

CXR
Laryngoscopy
Bronchoscopy
CT larynx and pharynx
Barium swallow
Thyroid function
CT Brain and other neurological tests

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21
Q

Liver exam - Observation

A

Scars
Distension
Mass
Jaundice
Tattoos
Track marks from IVDU
Striae
Caput medusa

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22
Q

Liver exam - Hands

A

Nail changes - clubbing, leukonychia
Palmar erythema
Dupuytren’s
Hepatic flap

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23
Q

Liver exam - arms and neck

A

Excoriation
Needle marks
Petechiae
Muscle wasting

Virchow’s LN - gastric cancer - left supraclavicular

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24
Q

Liver exam - face

A

Eyes: Pallor, jaundice, xanthelasma
Mouth: Ulcers, stomatitis, glossitis

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25
Q

Liver exam - chest

A

Spider naevi
Gynocomastia
Hair distribution

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26
Q

Liver exam - abdomen

A

Scars, distension
Striae, caput medusa, stoma
Palpate 9 regions superficial and deep
Palpate liver and spleen for enlargement
Ballot kidneys
Feel for AAA - expansile pulsatile mass
Percuss liver, spleen, shifting dullness, bladder
Auscultate: bowel sounds, bruits

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27
Q

Liver exam - ankles and finish

A

Oedema
To complete - genitalia, PR, hernias

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28
Q

Hernia exam - observations

A

General inspection of pt and bedside
Standing first and then lying
Ask them to cough / bear down
Look for swelling / observe inguinal ring and femoral canal
Describe lump - site, size, shape, skin, extension into scrotum
Compare sides

Ask for any pain before starting palpation

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29
Q

Hernia exam - palpation

A

Ask about pain before starting

Support the patient with one hand, and use the other to examine the lump
Consistency
Temperature
Surface
Tender
Fluctuant
Cough impulse
Reducible or irreducible

Note - you can’t palpate above the upper border of a hernia

Once reduced - place fingers over deep inguinal ring - if when coughing, it remains reduced, likely direct, if reappears, then indirect.

30
Q

Hernia exam - percussion and auscultation

A

Resonance and bowel sounds = likely containing loops of bowel

31
Q

Indirect inguinal hernia

A

Through deep ring and out superficial ring
Lateral to inferior epigastric
Into scrotum

32
Q

Direct inguinal hernia

A

Through Hesselbach’s triangle (lateral border = inferior epigastric, medial border = rectus, through weakness in conjoint tendon
Medial to inferior epigastric

33
Q

Femoral hernia

A

Through femoral canal
Medial to femoral artery and vein

34
Q

Borders of the inguinal canal

A

Floor = inguinal ligament
Roof = transversus abdominis and internal oblique muscles
Anterior = external oblique muscle
Posterior border = transversalis fascia laterally and conjoint tendon medially

35
Q

Vascular exam - Inspection

A

Observe subcutaneous veins, note varicosities
Observe intradermal veins
Scars from previous surgery
Oedema (poor venous flow)
Venous eczema and hair loss
Pigmentation and haemosiderin deposition
Lipodermatosclerosis
Ulceration - position, shape, size, edge (sloping, punched out, rolled, undermined), base (healthy, sloughy, avascular, purulent, necrotic, underlying structures visible), depth, discharge, surrounding cellulitis / health of surrounding skin

36
Q

Vascular exam - inspection of ischaemic foot

A

Colour - purpuric or gangrene
Line of demarcation
Trophic changes e.g. dry skin, scale, nail changes

37
Q

Vascular exam - palpation

A

Cough impulse at saphenofemoral junction
Feel length of veins
Lie patient down
- Palpate ulcers - ? hot compared to limb, tender, relationship to surrounding structures
- Feel for perforators
- TAP TEST = tapping over SFJ and feeling percussion travelling down leg into region of varicosities

38
Q

Vascular exam - palpation of ischaemic foot

A

Temperature - cool
Pulses - femoral, popliteal, posterior tibial, dorsalis pedis

39
Q

Vascular exam - auscultation

A

Femoral artery bruit

40
Q

Vascular exam - neuro

A

Sensation to light touch, pin prick, vibration, position
Reflexes

41
Q

Vascular exam - special tests

A

Tourniquet test - Brodie-Trendelenburg test
- To assess valvular incompetence if varicose veins are present
- Empty superficial veins - lift leg + milk + apply tourniquet at level below and stand
- High up > if veins refill the incompetence below the SFJ (2.5cm below and lateral to PT)
- Above knee (adductor canal perforators)
- Below knee (saphenopopliteal junction)

Buergers test: Elevate leg and watch soles to see at what angle pallor develops (<20 degrees indicates ischaemia). Then lower leg and observe over time to return to pink colour - longer if ischaemic and then develops reactive hyperaemia

Venous refill: Elevate for 3mins then lower leg - should see venous refill within 30s

Perthes test: to assess patency of deep venous system prior to varicose vein surgery. TOurniquet at level of SFJ and ask patient to mobilise - if superficial veins collapse then deep veins patent.

42
Q

Vascular exam - general

A

Femoral and inguinal LNs
Regional pulses
Abdomen for masses
Testes for masses, varicosity
PR / PV for pelvic masses

43
Q

Vascular - investigations

A

FBC, U&E, ESR, CRP
Wound swab
ABPI
Doppler
BSL HbA1c

44
Q

Varicose veins management

A

Stripping
SF / SP ligation
Tie perforators
Injection sclerotherapy

45
Q

Vascular ulcer descriptions - flat sloping edge

A

Healing ulcer
Usually shallow
Typical of a venous ulcer

46
Q

Vascular ulcer descriptions - Punched out

A

Vertical edge, rapid depth and sloughing of the full thickness skin without attempt at repair
Typical of neuropathic / vasculitis ulcers. Historically syphilitic ulcers - now rare

47
Q

Vascular ulcer descriptions - undermined edge

A

occur when infection supervenes in subcutaneous tissue - eg pressure sores

48
Q

Vascular ulcer descriptions - rolled edge

A

Develops when there is slow growth of tissue at the edge of the ulcer. Almost pathognomonic of BCC

49
Q

Vascular ulcer descriptions - everted / heaped edge

A

Develops when tissue at the edge of the ulcer is growing quickly and spillign over normal skin. Usually SCC.

50
Q

Shoulder exam - inspection

A

Scars
Swelling
Skin changes
Muscle wasting - supraspinatus, infraspinatus, deltoid
Deformity
Scoliosis

51
Q

Shoulder exam - feel

A

Start at medial clavicle, along to ACJ, biceps tendon, deltoid, scapula spine, infra-supra fossa
Distally - sensation - axillary, median, radial, ulna
Pulses

52
Q

Shoulder exam - move

A

Active - ab, ad, ext, flex, internal and external rotation
Hands behind head
Passive - ? improvement ? crepitus
Power

53
Q

Shoulder exam - special tests

A

Empty can = supraspinatus
Painful arc
Lift off = subscap
External rotation = infraspinatus and teres minor

Impingement tests
- Neer’s (passive flexion)
- Hawkins-Kennedy - 90 degrees flexed shoulder, elbow, then passive medial rotation

Instability = apprehension test - arm abducted elbow flexed 90/90, and push shoulder joint forward

54
Q

Elbow exam - special tests

A

Lateral and medial stress testing

Tennis elbow - lateral epicondylitis - pain with resisted wrist extension

Golfers elbow - medial epicondylitis - pain with resisted wrist flexion

55
Q

Hip exam - special tests

A

Trendelenburg (when standing) - weakness of hip abductors

Thomas test - hand under lower back, lift one leg, if other hip flexes / knee bends - fixed flexion deformity

56
Q

Knee exam - special tests

A

MCL / LCL
ACL / PCL - anterior and posterior drawer test
Lachmans tests
Meniscal grind
Patella apprehension test

57
Q

Carpal tunnel exam - look

A

Wasting
Scars
Skin changes

58
Q

Carpal tunnel exam - feel

A

Muscle bulk
Sensation - medial nerve (index) compared to ulna (little) and radial (dorsal)

59
Q

Carpal tunnel exam - move

A

Median nerve muscles
Abductor pollicis brevis
Opponens
Compare sides

60
Q

Carpal tunnel exam - special tests

A

Tinel’s = percussion over carpal tunnel
Phalen’s = flex wrist and hold for one minute
Positive if symptoms are reproducible

61
Q

Hand exam - look

A

Skin changes or infection
Swellings
Lacerations
Normal cascade of fingers
Abnormal positioning of fingers / hand
Scars

62
Q

Hand exam - palpate

A

All areas / joints for tenderness and fluctuance

Perfusion of each digit:
Cap refill
Colour
Turgor

63
Q

Hand exam - move

A

Form fist for gross assessment of function
FPL
FDP
FDS
Extensors (lag or droop)

64
Q

Hand exam - nerves

A

Sensation

Then finish with LA injection and re-examine movement and explore wound

65
Q

What does median nerve supply?
AIN branch?
Palmar branch?
Muscular recurrent branch?

A

MN - Pronator teres, FCR, Palmaris longus

AIN - FDP IF MF, FPL, PQ

Palmar branch (before carpal tunnel) - skin over thenar muscles

Muscular recurrent branch (after flexor retinaculum) - thenar muscles

66
Q

What does the ulnar nerve supply?
Give off?

A

Supplies FDP RF LF, FCU

Gives off:
Dorsal branch - sensation to dorsal surface of RF and LF
Superficial palmar branch - palmar surface of LF and RF and hypothenar eminence
Deep branch of hand - motor to 3 hypothenar eminence muscle, all interossei, add pollicis, 2 ulnar lumbricals

67
Q

Brachial plexus exam - observation

A

Postures
- Upper lesion - arm adducted and internally rotated at shoulder, pronated and extended at elbow
- Lower lesion - deficit of small muscles - claw hand, unopposed wrist extensors, hyperextension of MCP and flexion of IPJs due to loss of hand intrinsic muscles

Open injury
Muscle wasting
Horner’s syndrome and serratus anterior / scapula winging (proximal lesion - preganglionic involving sympathetic trunk)

68
Q

Brachial plexus - tone and power

A

C5 - deltoid shoulder abduction
C6 - elbow flexion
C7 - Elbow extension and wrist flexion
C8 - Finger flexion
T1 - finger abduction

Reflexes
Distal pulses (often have an associated arterial injury)

69
Q

Elbow exam - observe

A

Swelling
Deformity
Scars
Skin changes

70
Q

Elbow exam - feel

A

Medial condyle, medial joint line
Ulnar nerve
Biceps tendon
Lateral epicondyle, lateral joint line
Radio-capitellar joint - palpate while supinating and pronating
Olecranon

71
Q

Elbow exam - move

A

Active flexion, extension, supination, pronation
Compare sides

Clinical Examination (4 decks)

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