Examination Presenting Flashcards

1
Q

How to present a cardio exam?

A
  1. Today I performed an examination on ___ who is a ___ year old M/F.
  2. On general inspection…
  3. There were/weren’t peripheral stigmata of cardiac pathology
  4. The pulse was __ bpm and the rate and rhythm were __.
  5. On palpation…
  6. On auscultation…
  7. Oedema?
  8. In summary…
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2
Q

How would you complete a cardio exam?

A
  • check femoral pulses and radio/femoral delay
  • check blood pressure and LSBP
  • ophthalmoscopy
  • 12 lead ECG
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3
Q

How to present a resp exam?

A
  1. I performed a resp exam on __ who is a __ year old M/F
  2. On general inspection they appeared…
  3. There were/weren/t peripheral stigmata of respiratory disease. Tremor?
  4. The pulse was __ bpm and the rate and rhythm were __
  5. The resp rate was __
  6. On palpation, chest expansion was __ and there was no evidence of tracheal or mediastinal shift
  7. On percussion, all lung fields were…
  8. On auscultation, vesicular breath sounds were present and there were/weren’t added sounds
  9. Oedema?
  10. In summary…
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4
Q

How would you complete a resp exam?

A
  • check sputum pot
  • peak flow
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5
Q

How to present an abdo exam?

A
  1. Today I performed an abdo exam on…
  2. On general inspection…
  3. There were/weren’t peripheral stigmata of GI pathology. Tremor?
  4. On percussion and palpation, no signs of organomegaly
  5. On auscultation, bowel sounds…
  6. Oedema?
  7. In summary…
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6
Q

To complete an abdo exam?

A

ISHRUG
Inguinal lymph nodes
Stool sample
Hernial orifices
Rectal exam
Urine analysis
Genital exam

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7
Q

How to present a GALS exam?

A
  1. Today I performed a GALS exam on…
  2. On general inspection…
  3. Normal appearance in gait, arms, legs and spine?
  4. Full range of movement in all modalities?
  5. In summary?
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8
Q

To complete a GALS exam?

A

Perform a focused examination on any abnormalitites found

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9
Q

How to present a spine exam?

A
  1. Today I performed a spine exam on…
  2. On general inspection…
  3. Gait was…
  4. On palpation…
  5. Full range of movement?
  6. No abnormalities detected
  7. Special tests were +ve/-ve?
  8. In summary…
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10
Q

To complete a spine exam?

A
  • full neuro exam on upper/lower limbs
  • abdo/hip exam if lower back pain
  • check vascular status
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11
Q

How to present lower MSK (hip/knee/ankle) exam?

A
  1. Today I performed a MSK examination on…
  2. On general inspection…
  3. Gait was…
  4. On palpation…
  5. Full range of movement?
  6. No abnormalities detected
  7. Special tests were +ve/-ve?
  8. In summary…
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12
Q

To complete a lower MSK exam?

A
  • assess joints above and below as well as ipsilateral knee joint
  • neurovascular exam on lower limbs
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13
Q

How to present an upper MSK (shoulder/elbow) exam?

A
  1. Today I performed a MSK examination on…
  2. On general inspection…
  3. On palpation…
  4. Full range of movement?
  5. No abnormalities detected
  6. Special tests were +ve/-ve?
  7. In summary…
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14
Q

To complete upper MSK exam?

A
  • examine joints above and below
  • full neurovascular exam
  • ipsilateral joint
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15
Q

How to present a hand exam?

A
  1. Today I performed a hand exam on…
  2. On general inspection…
  3. On palpation…
  4. Full range of movement?
  5. No abnormalities detected
  6. Sensation was intact?
  7. Special tests were +ve/-ve?
  8. In summary…
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16
Q

To complete a hand exam?

A
  • Examine joints above and below
  • Full neurovascular upper limb exam
17
Q

How to present cranial nerves exam?

A
  1. Today I performed a CN exam on…
  2. On general inspection…
  3. On examination of CN I-XII…
  4. Special tests were +ve/-ve
18
Q

To complete my examination?

A

Perform upper and lower limb neurological exam.

Trigeminal: corneal reflex and jaw jerk
Optic: ophthalmoscopy, colour vision

19
Q

How to present lower limb neuro exam?

A
  1. Today I performed a lower limb neuro exam on…
  2. On general inspection? No abnormalities in posture, deformities, wasting, fasciculations
  3. Gait and romberg’s?
  4. Tone?
  5. Power?
  6. Reflexes present/illicited? Plantars?
  7. Coordination intact?
  8. Sensation normal in all modalities?
  9. In summary…
20
Q

To complete lower limb neuro exam?

A
  • upper limb neuro exam
  • CN exam
21
Q

To complete an upper limb neuro exam?

A
  • lower limb neuro exam
  • CN exam
21
Q

How to present upper limb neuro exam?

A
  1. Today I performed a lower limb neuro exam on…
  2. On general inspection? No abnormalities in posture, deformities, wasting, fasciculations
  3. Pronator drift?
  4. Tone?
  5. Power?
  6. Reflexes present/illicited?
  7. Coordination intact?
  8. Sensation normal in all modalities?
  9. In summary…
22
Q

How to present a cerebellar exam?

A
  1. Today I examined…
  2. On general inspection…
  3. Gait was normal? Ataxia?
  4. Nystagmus? Speech?
  5. Normal tone, coordination, reflexes in all limbs?
  6. To summarise…
23
Q

To complete cerebellar exam?

A
  • Full neuro exam
  • Hearing assessment
24
Q

How to present a thyroid exam?

A
  1. Today I performed a thyroid exam on…
  2. On general inspection…
  3. Peripheral stigmata of thyroid pathology?
  4. Pulse was __ bpm and rate and rhythm were __
  5. Evidence of tremor?
  6. Evidence of thyroid eye disease?
    6.5. Closer inspection of thyroid normal? If not describe lump…
  7. On palpation, evidence of goitre/swelling?
  8. On auscultation, evidence of bruit?
  9. Pretibial Myxoedema?
  10. In summary…
25
Q

How to complete thyroid exam?

A
  • fundoscopy
  • blood tests for T4/TSH levels
26
Q

How to present a diabetic foot exam?

A
  1. Today I did a diabetic foot exam on…
  2. On general inspection…
  3. Gait and footwear?
  4. Vascular exam normal? Pulses present?
    4.5 Ulcers? If so describe…
  5. Sensation/coordination and proprioception in tact? (if not where was it absent up to?)
  6. Ankle reflex?
  7. To summarise…
27
Q

How to complete a diabetic foot exam?

A
  • capillary glucose/HbA1c
  • lower limb neuro
  • full peripheral vascular exam
28
Q

How to present peripheral arterial exam?

A
  1. Today I performed a peripheral arterial exam on…
  2. On general inspection…
  3. In the upper limbs, there were/weren’t stigmata of peripheral arterial disease. All pulses present at __ bpm and rate/rhythm was __. Vascular signs normal.
  4. On auscultation of carotid bruit? On palpation pulse was…
  5. Abdominal aortic pulse not palpable. On auscultation bruit?
  6. In lower limbs, was/wasn’t stigmata of disease. All pulses present? Vascular signs?
  7. Sensation of lower limbs in tact?
  8. Buergers test?
  9. To summarise…
29
Q

How to complete peripheral vascular exam?

A
  • ABPI
  • blood pressure
  • full cardiovascular exam