Examination Flashcards
4AT
- ALERTNESS
- Normal = 0
- Mild sleepiness for <10 seconds after waking, then normal =
- Clearly abnormal = 4 - AMT4
- Age, DOB, place, current year
- No mistakes = 0
- 1 mistake = 1
- >/=2 mistake/untestable = 2 - ATTENTION
- Months of the year backwards
- >/=7 = 0
- <7 / refuses to start = 1 - Untestable = 2 - ACUTE CHANGE
Evidence of significant change or fluctuation in: alertness, cognition, other mental function
(eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs
- No = 0
- Yes = 4
INTERPRETATION
- >/=4 = possible delirium +/- cognitive impairment
- 1-3 = possible cognitive impairment
- 0 = delirium or severe cognitive impairment unlikely (but delirium still possible if (4) information incomplete)
Frontal Lobe Examination
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Hearing, vision
Questions
1. Change in sense of smell
2. Behaviour (impulsive)
- Lexical Fluency
- Words in one minute beginning with F, not people or places - Similarities
- Table and Chair - Proverbs
- Stitch in time saves nine - Estimates
- Height of an average English man
- Miles between London and Manchester - Luria Test
- Fist, Edge, Palm - Conflicting Instructions
- “Tap twice when I tap once.”
- “Tap once when I tap twice.” - Go-No-Go Test
- “Tap once when I tap once.”
- “Do not tap when I tap twice.” - Prehension Behaviour
- Do not take my hands - Key search
Parietal Lobe Examination
Overview
- WIPE
1. Questions (2)
2. Eyes (3)
3. Hands (3)
4. Copy Instructions (5)
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Hearing, vision
Questions (2)
1. Awareness of physical health conditions (Anosagnosia)
2. Getting lost or confused in new places? (Topographical disorientation)
Eyes (3)
1. Visual fields (Lower-quadrant homonymous hemianopia - damage to optic radiation)
2. Identify Queen on bank note (Prosopagnosia)
3. Identify a pen with eyes closed (Astereoagnosia)
Hands (3)
1. Show me your right finger (Finger Agnosia)
2. Touch your left ear with your right hand (Right-left disorientation)
3. Identify ‘H’ and ‘W’ drawn on palm (Agraphagnosia)
Copy Instructions (5)
1. Serial 7s (Dyscalculia):
2. Copy interlocking pentagons and a cube (Constructional apraxia)
3. Draw a clock face with numbers and the time saying 10 past 5 (Neglect)
4. Write a sentence (Dysgraphia)
5. Turn jacket the right way round (Dressing Apraxia)
Temporal Lobe Examination
Overview
- WIPE
1. Questions
2. Memory (Registration, STM, LTM, Semantic, Recall)
3. Language
4. Visual Recognition
5. Visual Function
Check First
- Wash hands, get consent
- Hearing, vision
Questions
1. Epilepsy
2. Psychosis
Memory
1. Registration:
a. Remember Address - Harry Barnes, 73 Orchard Close, Kingsbridge, Devon
2. Short Term Memory
b. How did you get here today?
c. What did you have for breakfast?
3. Long Term Memory
d. Where did you grow up?
e. What is the name of your primary school?
4. Semantic memory
f. What is the name of the first female UK prime minister?
g. Can you think of any famous landmarks?
5. Recall of Address above
Language
1. Repeat ‘no ifs ands or buts’
2. Read ‘close your eyes’
3. Write a sentence
Visual Recognition
1. Name objects of increasing difficulty (watch / pen / nib)
2. Recognise the queen on a bank note
Visual Functions
1. Visual Fields
2. Draw a clock face with numbers and the time saying 10 past 5 (Neglect)
EPSE
Overview
- WIPE
1. At rest
2. Face
3. Upper Limb Neuro
4. Standing up
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Offer chaperone
- Hearing, vision
Examine at rest
1. Tremor
- Place hands on knees
- Hands out face down
Examine Face
1. Hypomimia
2. Tongue movements
3. Hypersalivation (under tongue)
Upper Limb Neuro
1. Tone - cogwheeling, stiffness
2. Power
3. Co-ordination
Examine Standing up
1. Akathisia
2. Gait - Parkinson gait
Presenting ECGs
Overview
1. Patient Demographics
2. Rhythm & PR
3. Rate
4. Axis
5. QRS Complexes
6. ST & T wave
7. QTc Interval
- Patient Demographics
1a. Patient name, DOB, any symptoms (e.g. chest pain)
1b. ECG date and time and which in series
1c. Check calibration: Paper speed (25mm/s), magnitude (10mm/mV), 2 large squares in height
1d. One small box = 40 ms, one large box = 200 ms
2 Rhythm & PR
> Use rhythm strip
2a. Check Sinus
- mark 4 R waves
2b. PR Interval
- Length = 3-5 small squares (120-200ms)
- 1st degree AV block: PR >5 small squares and regular
- 2nd degree AV block
– Mobitz type 1: PR progressively elongates then drops a QRS
– Mobitz type 2: fixed PR interval with 2:1/3:1/4:1 block- 3rd degree (complete) AV block: complete dissociation between p waves and QRS complexes
- Rate
> Use Rhythm Strip
- Total R waves on ECG x 6 (if ECG is 10 seconds long).
- 60-100ms = normal - Axis
> Use leads I and II
- QRS complexes in leads I and II are normally both predominantly positive
3a. LAD = R waves ‘leaving’: LV hypertrophy/strain, inferior MI
3b. RAD = R waves ‘reaching’: tall & thin body type; RV hypertrophy/ strain - QRS Complexes
5a. Length <3 small squares (120ms)
5b. Increased QRS
– RBBB: QRS in V1 has M (RSR1) pattern and QRS in V6 has W pattern – MarroW
– LBBB: QRS in V1 has W pattern and QRS in V6 has M (RSR1) pattern – WilliaM - ST & T
> Check in all leads
7a. ST Elevation
- ≥1 small square (infarction; pericarditis or tamponade if in every lead)
– Inferior: Lead II, Lead III, Lead aVF
– Lateral: Lead I, Lead aVL, V5, V6
– Anterior: V1, V2, V3, V4
– Septal: V1,V2
6b. T wave
> Check in all leads
- T wave Inversion
– Causes: ischaemia/post-MI; right/left ventricular hypertrophy (right chest or lateral leads respectively); bundle branch block; digoxin treatment
- Morphology
– Tented (hyperkalaemia)
– Flat (hypokalaemia) - QTc Interval
> Use Rhythm Strip
7a. Bazetts Formula = QTc = QT / √RR.
– Max = 440ms (men), 460ms (women)
– >500ms = substantial increase in arrhythmia risk– specifically torsades de pointes, leading to syncope and potentially sudden cardiac death –> stop offending drug and urgent referral to cardiology
7b. Review all meds in BNF
Causes of QTc Prolongation
Electrolyte Abnormalities
- Hypokalaemia, hypocalcaemia, and hypomagnesaemia
Antipsychotics
- Most of themusually in a dose-dependent fashion
- Lurasidone = safe
- Low Risk = clozapine, olanzapine, aripiprazole, risperidone, and sulpiride are considered ‘low’ risk
Antidepressants
- SSRIs (especially citalopram, particularly at higher doses)
- SNRIs, tricyclic antidepressants
Psychotropics
- lithium, methadone
Antiarrhythmics
- Flecainide, amiodarone, sotalol
Antibiotics
- Macrolodies (e.g. erythromycin, clarithromycin), ciprofloxacin
Antimalarials
- Chloroquine
Prolonged QTc Station
Explanation
- ‘this means that the heart is taking too long to recharge itself between heartbeats, and this can cause serious problems’).
- Look for any other abnormalities on ECG (arrhythmia)
Drug History
- Compliance
- Overdose
- OTC medication
- Antipsychotics, Antidepressants, psychotropics
- Antiarrhythmics
- Antibiotics
Bazetts Formula
- QTc = QT / √RR.
– Max = 440ms (men), 460ms (women)
– >500ms = substantial increase in arrhythmia risk– specifically torsades de pointes, leading to syncope and potentially sudden cardiac death –> stop offending drug and urgent referral to cardiology and A&E
Risk Factors
- Age, gender
Cranial Nerve Examination
Overview
- WIPE
- CNI-XII
- Close
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Offer chaperone
- Hearing, vision
CNI - Olfactory
1. Smell
CNII - Optic
1. Visual Acuity - Snellen Chart
2. Neglect - moving fingers
3. Visual Fields
4. Pupil Response - direct / consensual
5. Accommodation
6. Fundoscopy
CN III, IV & VI - Occulomotor, Trochlear & Abducens
1. Ptosis
2. ‘H’ Eye movements
CN V - Trigeminal
1. Sensation: Ophthalmic, Maxillary, Mandibular
2. Motor: Mouth opening and jaw clench
CV VII - Facial
1. Facial symmetry
2. Sensory: Sense of taste
3. Motor: Raise eyebrow, screw up eyes, puff out cheeks, show teeth
CNVIII - Vestibulocochlear
1. Whisper test
Hearing Tests w/ 512 Hz
2. Weber’s - midline L vs R
3. Rinne’s - Mastoid process vs outside ear canal
CNIX - Glossopharyngeal
1. Uvula - visualise and say Aah
CNX - Vagus
1. Cough
2. Swallow
CNXI - Accessory
1. SCM wasting
2. Shrug shoulders
3. Turn head L + R
CNXII - Hypoglossal
1. Tongue inspection
2. Tongue movements
Close
1. Extra Tests - Colour vision (Ishihara plates), otoscopy, formal test of smell
Lower Limb Neuro Exam
Overview
- WIPE
1. History
2. Inspection
3. Tone
4. Power
5. Co-ordination
6. Sensation
7. Reflexes
8. Gait
9. Close
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Offer chaperone
- Hearing, vision
History
1. LL weakness
2. Trauma
3. Numbness
4. Head Injury
Inspection
1. Walking aides
2. Scars, tremors, fasciculations
Tone
1. Hips
2. Knees
3. Ankles
Power
1. Hip Flexion and Extension
2. Knee Flexion and Extension
3. Ankle Flexion and Extension
4. Hoover’s Sign (hand under affected limb whilst raising other)
Co-ordination
1. Heel-shin test
Sensation
1. Light touch (cotton wool)
2. Vibration (128 Hz tuning fork)
3. Pain (pin prick)
4. Proprioception (thumb up-down)
Reflexes
1. Knee Reflex
2. Ankle Reflex
3. Plantar Reflex
Gait
1. Normal Walking
2. Heel-toe walking
Close
1. Extra examination: ULN, CN, vascular status
Upper Limb Neuro Exam
Overview
- WIPE
1. History
2. Inspection
3. Tone
4. Power
5. Co-ordination
6. Sensation
7. Reflexes
8. Close
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Offer chaperone
- Hearing, vision
History
1. UL weakness
2. Trauma
3. Numbness
4. Head Injury
Inspection
1. Walking aides
2. Scars, tremors, fasciculations
Tone
1. Shoulder
2. Elbow
3. Wrists - cogwheeling
Power
1. Shoulder abduction and adduction
2. Elbow Flexion and Extension
3. Wrist Flexion and Extension
4. Finger Extension and abduction
5. Power grip
6. Precision Grip - thumb and index finger
Co-ordination
1. Finger - nose test
2. Dysdiadokinesis
Sensation
1. Light touch (cotton wool)
2. Vibration (128 Hz tuning fork)
3. Pain (pin prick)
4. Proprioception (thumb up-down)
Reflexes
1. Biceps jerk
2. Triceps jerk
3. Supinator jerk
Close
1. Extra examination: LLN, CN, vascular status
Cardiovascular Examination
Overview
- WIPE
1. Brief History
2. Inspection
3. Hands
4. Face
5. Neck
6. Anterior Chest
7. Posterior Chest
8. Ankles
9. Close
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Offer chaperone
- Hearing, vision
Brief History
- Chest pain SOCRATES
Inspection
1. General: GTN, oxygen
Hands
1. Look: Clubbing
2. Feel: Temperature CRT, Radial pulse, RR delay, collapsing pulse
Face
1. Malar Flush
2. Conjunctival pallor
3. Open mouth: dentition & high arch palate
Neck
1. JVP
2. Carotids
Anterior Chest
1. Inspect: Scars, Pectus excavatum
2. Palpate: Apex beat, heaves & thrills
3. Auscultation
- 4 locations: Apex, LLSE, UPLE, URSE
- MS: rolled to L side, @ apex w/ bell
- MR: @ axilla w/ diaphragm
- AS: full expiration @ 2nd ICS & carotids
- AR: lean forward, full expiration, L parasternal in 3rd ICS
Posterior Chest
1. Percussion: pleural effusion
2. Auscultate: lung bases for creps
Ankles
1. Palpates: Pedal oedema
Close
1. Extra tests: Fundoscopy, ECG, palpation of peripheral pulses, BP
Thyroid Examination
Overview
- WIPE
1. Brief History
2. Inspection
3. Hands
4. Eyes
5. Thyroid Gland
6. Close
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Offer chaperone
- Hearing, vision
Brief History (Changes in…)
1. Energy levels
2. Weight or appetite
3. Mood
4. Heat / cold intolerance
5. Bowel movement
6. Libido
7. Skin / hair appearance
8. Menstrual cycle
Inspection
1. Dry, flaky skin - hypo
2. Alopecia
3. Obvious weight loss / gain
Hands
1. Sweating / Increased Temp
2. Onycholysis (nail separates from bed)
3. Thyroid acropachy - hyper
4. Pulse - brady/tachy
5. Tremor - paper on stretched out arms
Eyes
1. Eye Movements - ‘H’
2. Lid Lag
3. Exophthalmos
Thyroid Gland
1. Inspection: Swelling, lumps, asymmetry, scars
2. Swallowing: look from side, goitre & cyst will rise
3. Tongue: only cyst will rise
4. Palpate thyroid: swallow, stick out tongue, cervical lymph nodes
5. Auscultate: thyroid bruits
Legs
1. Pretibial myxoedema (bilateral firm elevated dermal nodules and plaques over shins- Graves)
2. Proximal myopathy- stand up with arms crossed- hyper
Close
1. Extra Tests: Reflexes, cardiac failure signs
Fundoscopy
Overview
- WIPE
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Offer chaperone
- Hearing, vision
Brief History:
- ODPI
- SOCRATES
Examination
1. Focus on a distant object
2. Red Reflex
3. Follow red reflex into the eye towards the nasal side
4. Move closer to the patient to assess optic disc - colour, clarity, cup
5. Assess retinal vessels
6. Macula - look directly at light
Additional
1. Snellen Chart
2. Ishihara Plates
3. Light Reflexes - direct, consensual, swinging light, accommodation
Respiratory Examination
Overview
- WIPE
WIPE
- Wash your hands (and don PPE)
- Introduce yourself
- Patient’s name, date of birth and preferred name
- Explain and gain consent
- Offer chaperone
- Hearing, vision
General Inspection
- DIB
- Scars
- Chest wall abnormalities
Hands
- Pulse
- Respiratory Rate
- Clubbing
- Temp
Palpation
- Trachea
- Apex
- Cervical Lymph Nodes
Chest Exam
- Expansion
- Percussion
- Auscultation
- Vocal Resonance
Oedema
- Sacrum
- Legs
