Examination Flashcards
Hypertension exam - general observations
Cushingoid features - central obesity, buffalo hump, straie, thin skin, bruising, proximal myopathy
Peripheral oedema
Hypertension exam - hands
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
Hypertension exam - eyes
Ophthalmoscope for hypertensive retinopathy
Thyroid eye disease
Hypertension exam - neck
Bruits
JVP / fluid status
Thyroid exam
Hypertension exam - chest and CVS
Observe chest shape
Palpate apex
Listen to heart sounds
Pulmonary oedema
Hypertension exam - abdomen
Renal or adrenal mass
Renal bruits (renal artery stenosis)
Distension
Child abuse - physical indicators that should raise suspicion for child abuse
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
Child abuse - bruising patterns
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
Child abuse - skeletal injuries
Fracture in non-ambulatory child
Metaphyseal fracture
Multiple, bilateral, differently ages rib fractures
Complex skull fractures
Scapular and spinous process fractures
Child abuse - burn patterns
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
Breast exam - Observation sitting up
Shape, contour, symmetry
Visible mass
Skin changes - dimpling, redness, thickness
Nipples - discharge, peau d’orange, rash, ulceration, asymmetry
Breast exam - palpation
4 quadrants / clock face
Lump - consistency, fixed vs mobile, smooth or rough borders, size, location
Nipple - palpate nipple and areola
LNs - axillary, supraclavicular, infraclavicular
Breast exam - metastasis
Liver enlargement
Chest for effusion
Spine for pain
Male - testis for lump
Head and neck exam - inspection of neck
Lump position
Shape
Size
Overlying skin ? tethered ? erythematous
Scalp
Pinna
Face for skin lesions or scars
Head and neck exam - palpation of lump
Shape
Temperature
Tenderness
Surface
Edge
Consistency
Compressibility / reducibility
Translucent
Pulsatile ? bruit
Superficial or deep tethering
LN basin - head and neck
Thyroid
Head and neck exam - which facial nerve and how
Facial nerve
Platysma
Lift eyebrows
Show teeth
Ear nose and throat for neck lump exam
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
DDx for mass at angle of the jaw
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
Hoarse voice examination
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
Hoarse voice investigation
CXR
Laryngoscopy
Bronchoscopy
CT larynx and pharynx
Barium swallow
Thyroid function
CT Brain and other neurological tests
Liver exam - Observation
Scars
Distension
Mass
Jaundice
Tattoos
Track marks from IVDU
Striae
Caput medusa
Liver exam - Hands
Nail changes - clubbing, leukonychia
Palmar erythema
Dupuytren’s
Hepatic flap
Liver exam - arms and neck
Excoriation
Needle marks
Petechiae
Muscle wasting
Virchow’s LN - gastric cancer - left supraclavicular
Liver exam - face
Eyes: Pallor, jaundice, xanthelasma
Mouth: Ulcers, stomatitis, glossitis
Liver exam - chest
Spider naevi
Gynocomastia
Hair distribution
Liver exam - abdomen
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
Liver exam - ankles and finish
Oedema
To complete - genitalia, PR, hernias
Hernia exam - observations
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
Hernia exam - palpation
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.
Hernia exam - percussion and auscultation
Resonance and bowel sounds = likely containing loops of bowel
Indirect inguinal hernia
Through deep ring and out superficial ring
Lateral to inferior epigastric
Into scrotum
Direct inguinal hernia
Through Hesselbach’s triangle (lateral border = inferior epigastric, medial border = rectus, through weakness in conjoint tendon
Medial to inferior epigastric
Femoral hernia
Through femoral canal
Medial to femoral artery and vein
Borders of the inguinal canal
Floor = inguinal ligament
Roof = transversus abdominis and internal oblique muscles
Anterior = external oblique muscle
Posterior border = transversalis fascia laterally and conjoint tendon medially
Vascular exam - Inspection
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
Vascular exam - inspection of ischaemic foot
Colour - purpuric or gangrene
Line of demarcation
Trophic changes e.g. dry skin, scale, nail changes
Vascular exam - palpation
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
Vascular exam - palpation of ischaemic foot
Temperature - cool
Pulses - femoral, popliteal, posterior tibial, dorsalis pedis
Vascular exam - auscultation
Femoral artery bruit
Vascular exam - neuro
Sensation to light touch, pin prick, vibration, position
Reflexes
Vascular exam - special tests
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.
Vascular exam - general
Femoral and inguinal LNs
Regional pulses
Abdomen for masses
Testes for masses, varicosity
PR / PV for pelvic masses
Vascular - investigations
FBC, U&E, ESR, CRP
Wound swab
ABPI
Doppler
BSL HbA1c
Varicose veins management
Stripping
SF / SP ligation
Tie perforators
Injection sclerotherapy
Vascular ulcer descriptions - flat sloping edge
Healing ulcer
Usually shallow
Typical of a venous ulcer
Vascular ulcer descriptions - Punched out
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
Vascular ulcer descriptions - undermined edge
occur when infection supervenes in subcutaneous tissue - eg pressure sores
Vascular ulcer descriptions - rolled edge
Develops when there is slow growth of tissue at the edge of the ulcer. Almost pathognomonic of BCC
Vascular ulcer descriptions - everted / heaped edge
Develops when tissue at the edge of the ulcer is growing quickly and spillign over normal skin. Usually SCC.
Shoulder exam - inspection
Scars
Swelling
Skin changes
Muscle wasting - supraspinatus, infraspinatus, deltoid
Deformity
Scoliosis
Shoulder exam - feel
Start at medial clavicle, along to ACJ, biceps tendon, deltoid, scapula spine, infra-supra fossa
Distally - sensation - axillary, median, radial, ulna
Pulses
Shoulder exam - move
Active - ab, ad, ext, flex, internal and external rotation
Hands behind head
Passive - ? improvement ? crepitus
Power
Shoulder exam - special tests
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
Elbow exam - special tests
Lateral and medial stress testing
Tennis elbow - lateral epicondylitis - pain with resisted wrist extension
Golfers elbow - medial epicondylitis - pain with resisted wrist flexion
Hip exam - special tests
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
Knee exam - special tests
MCL / LCL
ACL / PCL - anterior and posterior drawer test
Lachmans tests
Meniscal grind
Patella apprehension test
Carpal tunnel exam - look
Wasting
Scars
Skin changes
Carpal tunnel exam - feel
Muscle bulk
Sensation - medial nerve (index) compared to ulna (little) and radial (dorsal)
Carpal tunnel exam - move
Median nerve muscles
Abductor pollicis brevis
Opponens
Compare sides
Carpal tunnel exam - special tests
Tinel’s = percussion over carpal tunnel
Phalen’s = flex wrist and hold for one minute
Positive if symptoms are reproducible
Hand exam - look
Skin changes or infection
Swellings
Lacerations
Normal cascade of fingers
Abnormal positioning of fingers / hand
Scars
Hand exam - palpate
All areas / joints for tenderness and fluctuance
Perfusion of each digit:
Cap refill
Colour
Turgor
Hand exam - move
Form fist for gross assessment of function
FPL
FDP
FDS
Extensors (lag or droop)
Hand exam - nerves
Sensation
Then finish with LA injection and re-examine movement and explore wound
What does median nerve supply?
AIN branch?
Palmar branch?
Muscular recurrent branch?
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
What does the ulnar nerve supply?
Give off?
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
Brachial plexus exam - observation
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)
Brachial plexus - tone and power
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)
Elbow exam - observe
Swelling
Deformity
Scars
Skin changes
Elbow exam - feel
Medial condyle, medial joint line
Ulnar nerve
Biceps tendon
Lateral epicondyle, lateral joint line
Radio-capitellar joint - palpate while supinating and pronating
Olecranon
Elbow exam - move
Active flexion, extension, supination, pronation
Compare sides
