Examination Presenting Flashcards
How to present a cardio exam?
- Today I performed an examination on ___ who is a ___ year old M/F.
- On general inspection…
- There were/weren’t peripheral stigmata of cardiac pathology
- The pulse was __ bpm and the rate and rhythm were __.
- On palpation…
- On auscultation…
- Oedema?
- In summary…
How would you complete a cardio exam?
- check femoral pulses and radio/femoral delay
- check blood pressure and LSBP
- ophthalmoscopy
- 12 lead ECG
How to present a resp exam?
- I performed a resp exam on __ who is a __ year old M/F
- On general inspection they appeared…
- There were/weren/t peripheral stigmata of respiratory disease. Tremor?
- The pulse was __ bpm and the rate and rhythm were __
- The resp rate was __
- On palpation, chest expansion was __ and there was no evidence of tracheal or mediastinal shift
- On percussion, all lung fields were…
- On auscultation, vesicular breath sounds were present and there were/weren’t added sounds
- Oedema?
- In summary…
How would you complete a resp exam?
- check sputum pot
- peak flow
How to present an abdo exam?
- Today I performed an abdo exam on…
- On general inspection…
- There were/weren’t peripheral stigmata of GI pathology. Tremor?
- On percussion and palpation, no signs of organomegaly
- On auscultation, bowel sounds…
- Oedema?
- In summary…
To complete an abdo exam?
ISHRUG
Inguinal lymph nodes
Stool sample
Hernial orifices
Rectal exam
Urine analysis
Genital exam
How to present a GALS exam?
- Today I performed a GALS exam on…
- On general inspection…
- Normal appearance in gait, arms, legs and spine?
- Full range of movement in all modalities?
- In summary?
To complete a GALS exam?
Perform a focused examination on any abnormalitites found
How to present a spine exam?
- Today I performed a spine exam on…
- On general inspection…
- Gait was…
- On palpation…
- Full range of movement?
- No abnormalities detected
- Special tests were +ve/-ve?
- In summary…
To complete a spine exam?
- full neuro exam on upper/lower limbs
- abdo/hip exam if lower back pain
- check vascular status
How to present lower MSK (hip/knee/ankle) exam?
- Today I performed a MSK examination on…
- On general inspection…
- Gait was…
- On palpation…
- Full range of movement?
- No abnormalities detected
- Special tests were +ve/-ve?
- In summary…
To complete a lower MSK exam?
- assess joints above and below as well as ipsilateral knee joint
- neurovascular exam on lower limbs
How to present an upper MSK (shoulder/elbow) exam?
- Today I performed a MSK examination on…
- On general inspection…
- On palpation…
- Full range of movement?
- No abnormalities detected
- Special tests were +ve/-ve?
- In summary…
To complete upper MSK exam?
- examine joints above and below
- full neurovascular exam
- ipsilateral joint
How to present a hand exam?
- Today I performed a hand exam on…
- On general inspection…
- On palpation…
- Full range of movement?
- No abnormalities detected
- Sensation was intact?
- Special tests were +ve/-ve?
- In summary…
To complete a hand exam?
- Examine joints above and below
- Full neurovascular upper limb exam
How to present cranial nerves exam?
- Today I performed a CN exam on…
- On general inspection…
- On examination of CN I-XII…
- Special tests were +ve/-ve
To complete my examination?
Perform upper and lower limb neurological exam.
Trigeminal: corneal reflex and jaw jerk
Optic: ophthalmoscopy, colour vision
How to present lower limb neuro exam?
- Today I performed a lower limb neuro exam on…
- On general inspection? No abnormalities in posture, deformities, wasting, fasciculations
- Gait and romberg’s?
- Tone?
- Power?
- Reflexes present/illicited? Plantars?
- Coordination intact?
- Sensation normal in all modalities?
- In summary…
To complete lower limb neuro exam?
- upper limb neuro exam
- CN exam
To complete an upper limb neuro exam?
- lower limb neuro exam
- CN exam
How to present upper limb neuro exam?
- Today I performed a lower limb neuro exam on…
- On general inspection? No abnormalities in posture, deformities, wasting, fasciculations
- Pronator drift?
- Tone?
- Power?
- Reflexes present/illicited?
- Coordination intact?
- Sensation normal in all modalities?
- In summary…
How to present a cerebellar exam?
- Today I examined…
- On general inspection…
- Gait was normal? Ataxia?
- Nystagmus? Speech?
- Normal tone, coordination, reflexes in all limbs?
- To summarise…
To complete cerebellar exam?
- Full neuro exam
- Hearing assessment
How to present a thyroid exam?
- Today I performed a thyroid exam on…
- On general inspection…
- Peripheral stigmata of thyroid pathology?
- Pulse was __ bpm and rate and rhythm were __
- Evidence of tremor?
- Evidence of thyroid eye disease?
6.5. Closer inspection of thyroid normal? If not describe lump… - On palpation, evidence of goitre/swelling?
- On auscultation, evidence of bruit?
- Pretibial Myxoedema?
- In summary…
How to complete thyroid exam?
- fundoscopy
- blood tests for T4/TSH levels
How to present a diabetic foot exam?
- Today I did a diabetic foot exam on…
- On general inspection…
- Gait and footwear?
- Vascular exam normal? Pulses present?
4.5 Ulcers? If so describe… - Sensation/coordination and proprioception in tact? (if not where was it absent up to?)
- Ankle reflex?
- To summarise…
How to complete a diabetic foot exam?
- capillary glucose/HbA1c
- lower limb neuro
- full peripheral vascular exam
How to present peripheral arterial exam?
- Today I performed a peripheral arterial exam on…
- On general inspection…
- 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.
- On auscultation of carotid bruit? On palpation pulse was…
- Abdominal aortic pulse not palpable. On auscultation bruit?
- In lower limbs, was/wasn’t stigmata of disease. All pulses present? Vascular signs?
- Sensation of lower limbs in tact?
- Buergers test?
- To summarise…
How to complete peripheral vascular exam?
- ABPI
- blood pressure
- full cardiovascular exam
