Examinations

Question 1

diabetic foot examination

Answer 1

Intro

• Hands wash
• Introduce
• Name and DoB
• Explain examination
• Consent
• Ensure adequate exposure and look at legs from end of the bed

General inspection

• Missing toes
• Look around bed for clues e.g. walking aids
• Limb colour

Close inspection

• Hair loss
• Skin changes
• Redness
• Ulcers
• Joint deformity e.g. Charcot
• Look for hidden ulcers e..g between toes
• Check bottom
• Lift heal up

Palpation

• Feeling down leg for:
  
  • Compare temp
  • Capillary refill time <2s
  • Assess pulses
    
    • Dorsalis pedis
    • Posterior tibial
  • Mono-filament testing (for sensation)
    
    • Show them how it feels first then get them to close their eyes and say which side they feel it on (apply enough pressure so they can feel)
  • Vibration sensation (128Hz tuning fork)
    
    • Provide an example of sensation at central point e.g. sternal angle
  • Proprioception (joint position)
    
    • Move toe up and down and ask the patient which way it is going)
  • Test reflexes
    
    • Lift knee up and ankle out to the side ankle jerk reflex

Walk

• Assess smoothness and symmetry of gait
  
  • Antalgic gait may suggest joint trauma e.g. charcots

Inspect footwear (e.g. uneven soles)

Question 2

thyroid examination

Answer 2

Intro

• Hands wash
• Introduce
• Name and DoB
• Explain examination
• Consent
• Ensure adequate exposure and look at legs from end of the bed

Inspection

• Does the patient appear
  
  • Hyperthyroidism
    
    • Agitate
    • Anxious
    • Fidgety
  • Hypothyroidism
    
    • Tired
• Hands
  
  • Thyroid acropachy
  • Peripheral tremor (lay paper on hands)
  • Turn hands overlook for
    
    • Dry skin (hypo)
    • Palmar erythema and sweat (hyper)
• Pulse
• Face
  
  • sweating- hyper
  • dry ski. and loss of outer third of eyebrow- hypo
• Eyes
  
  • Exophthalmos (graves)
    
    • Inspect for anterior displacement of the eye out of the orbit (look from the side)
  • H test- eye movement
    
    • Restriction of eye movement?
  • Assess for lid lag
  • inspection of neck
    
    • skin changes- erythema
    • scars- thryoidectomy
    • masses- goitre
    • Drink some water and observe movement of any masses when swallowing
    • Stick tongue out
      
      • No movement- thyroid gland mass, lymph node
      • Upward movement- thyroglossal cyst

Palpation of neck

• Ask patient to flex neck slightly forwards and relax
• Begin palpation at thyroid process (adams apple), as you move downward youll reach the superior edge of the cricoid cartilage, below the cricoid cartilage is the isthmus of the thyroid gland, palpate the isthmus and then the thripid lobes separately
• Stick tongue out
• Sip of water and swallow
• Feel for the glands
• Tracheal deiation e.g. large goitre
• Tap opn chest to detecrt any retrosternal dullness e.g. large goitre

Auscultate

• Each lobe of the thyroid listening for thyroid bruit (increased vascularity secondary to graves disease)

Special tests

• Reflexes in arms
  
  • Hyporeflexia associated with hypothyroidism
• Look at shins for pre-tibial myxoedema
• Stand up and cross arms- proximal myopathy (hyper)

Question 3

rheumatology examination overview

Answer 3

GALS: gait, arms, legs, spine

Question 4

The following general principles should be followed during a rheumatology examination:

Answer 4

Step1: Introduction

• Firstly, introduce yourself.
• Explain what you are going to do to the patient.
• Gain verbal consent
• Ask the patient to let you know if you cause them discomfort.

Step 2: Inspection

• Look for:
  
  • Swelling
  • Deformity
  • muscle wasting
  • skin and nail abnormalities e.g. scars, psoriasis

Step 3: Palpation

• Feel for:
  
  • warmth with the back of the hand
  • tenderness -palpate with just enough pressure to blanch your thumb nail
  • swelling -is its soft tissue or bony?
  • Crepitus
  • effusion -can you ballot fluid?

Step 4: Movement

Assess the range of movements -both active and passive

Question 5

rheum exam: Gait

Answer 5

Inspection of the patient when standing can reveal the diagnosis….

• Bow legs are due to medial compartment arthritis usually OA as the medial compartment takes most load.
• Knock knees are much less common, and are indicative of both compartments being involved in inflammatory arthritis.
• Flat feet may be idiopathic, but are a feature of joint hypermobility syndromes and of inflammatory arthritis.
• If the forefoot is widened, with irregular gaps between toes which do not sit on the ground, this is likely to be inflammatory arthritis.

Question 6

rheum exam: Arms and hands

Answer 6

Examination of the hands is the regional examination most frequently carried out by rheumatologists as both rheumatoid arthritis and osteoarthritis commonly involve these joints. As the joints are superficial they are easy to examine.
It is also important to be confident with neurological examination of the hands as numbness is a common symptom.

Question 7

special tests of the hand : motor

Answer 7

• As the patients to carry out the following movements against resistance
  
  • Wrist/finger extension-radial nerve
  • Finger abduction of the index finger- ulnar nerve
  • Thumb abduction- median nerve

Question 8

other special tests of the hand

Answer 8

tinels

phalens

Question 9

Tinel’s test

Answer 9

• Carpal tunnel syndrome (any type of arthritis can predispose)
• Tap over the carpal tunnel with you index and middle fingers for 30-60 seconds
  
  • If pt develops tingling in the thumb and radial two and a half fingers, this suggest median nerve irritation

Question 10

phalens test

Answer 10

• Ask patient to hold their wrist in complete and forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds.
• If patients symptoms develop then the test is positive

Question 11

Clinical features of median nerve palsy

Answer 11

These depend on the where in its course the nerve is damaged.

• The wrist is the most common site, leading to CTS with numbness of the hand in a median nerve distribution but with sparing of the palm due to an intact palmar cutaneous branch.
  
  • In CTS there may be weakness of thumb opposition and abduction. Ask the patient to move their thumb upwards away from the palm of the hand (abduction) and to touch the little finger with the thumb (opposition).
  • Thenar eminence wasting is a late feature.
• If the nerve is damaged in the arm, a key feature may be loss of sensation over the palm, and also weak finger flexion but preservation of flexion of the ring and little finger DIPJs (ulnar nerve).

Question 12

Clinical features of ulnar nerve palsy

Answer 12

• These include numbness over hypothenar eminence and in the ulnar nerve distribution of hand.
• Paralysis of flexor carpi ulnaris causes weak wrist flexion and adduction.
• Paralysis of medial two parts of flexor digitorum profundus causes weak flexion of ring and little finger DIPJs.
• Paralysis of most of the intrinsic muscles of the hand results in weak MCPJ flexion and IPJ extension of ring and little fingers, loss of finger abduction and adduction, and loss of opposition of little finger.
• To test adductor pollicis, ask the patient to grip a piece of card between the thumb and the side of the index finger (Froment’s test).
• In ulnar nerve palsy, the IPJ and MCPJ of the thumb will flex as the patient tries to grip the card. Test adduction by asking the patient to grip the card between the little and ring fingers whilst holding the fingers extended. Test the first dorsal interosseus muscle by asking the patient to abduct the extended index finger against resistance.
• “CLAW HAND” deformity may be present at rest, and on attempted finger extension the patient cannot extend the IPJs of their ring or little fingers.
  
  • The “claw hand deformity is due to fixed flexion of the IPJs and hyperextension of the MCPJs of the ring and little fingers due to unopposed median nerve function. The clawed appearance is most pronounced when the nerve is injured at the wrist, for example by compression in Guyon’s canal, as the function of flexor digitorum profundus will be preserved.

Question 13

GALS quick screening test for MSK disorder

Answer 13

Question 14

example GALS

Answer 14

Question 15

more detailed GALS

Answer 15

Question 16

abdominal examination

Answer 16

Abdominal examination

Introduction

• Wash your hands
• Introduce name and role
• Confirm patient. Name and DoB
• Adjust bed to 45 degrees
• Adequately expose patients abdomen

General inspection

• Clinical signs
  
  • Age
    
    • Younger- IBD
    • Older- chronic liver disease and malignancy
  • Confusion
    
    • End stage liver disease- hepatic encephalopathy
  • Pain
  • Obvious scars- surgery
  • Abdominal distention
    
    • Ascites
    • Underlying bowel obstruction
    • organomegaly
  • Pallor
    
    • Anaemia (GI bleeding or mal)
  • Jaundice
    
    • High bilirubin
      
      • Acute hepatitis
      • Liver cirrhosis
      • Cholangitis
      • Pancreatic cancer
  • Hyperpigmentation
    
    • Haemochromatosis
  • Oedema
    
    • Liver cirrhosis
  • Cachexia
    
    • Ongoing muscle loss not entirely reversed with nutritional supplementation underlying malignancy and advanced liver failure
  • Hernias (umbilical/ incisional hernia)
    
    • Ask patient to cough
• Objects and equipment
  
  • Stoma bags
  • Surgical drains
  • Feeding tubes
  • Other medical equipment
  • Mobility aids
  • Vital signs
  • Fluid balance
  • Prescriptions

Hands

• Inspection
  
  • Palms
    
    • Pallor- anaemia
    • Palmar erythema- redness involving heel of hand-c hronic liver disease
    • Dupuytrens contracture
  • Nail signs
    
    • Koilonychia- iron deficiency anaemia (malabsorption in crohns)
    • Leukonychia- hypalbuminaemia ( ESLD)
  • Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed- Schamroths window
    
    • IBD
    • Coeliac disease
    • Liver cirrhosis
    • Lymphoma
  • Asterixis- liver flap
    
    • Due to hepatic encephalopathy- hyperammonaemia
    • Can be CO2 retention in type 2 resp failure
• Palpation
  
  • Temp
    
    • Cool hand ssuggests poor peripheral perfusion
  • Radial pulse- rate and rhythm
  • Dupuytrens contracture
    
    • Thickening of the palmar fascia
      
      • Excessive alcohol
      • Age
      • Male
      • diabetes

Arms and axillae

• Arms
  
  • Bruising- clotting abnormality secondary to liver disease
  • Excoriations- relieving pruritis
  • Needle track marks- IVDU
• Axillae
  
  • Acanthosis nigricans
    
    • Hyperpigmentation and thickening of thr axillary skin
      
      • Insulin resistance
      • GI malignancy
  • Hair loss
    
    • Iron def anaemia
    • malnutrition

Face

• Eyes
  
  • Conjunctival pallor- anaemia
  • Jaundice
  • Corneal arcus- hypocholesteraemia
  • Xanthelasma- yellow, raised cholesterol rich deposits around eye- hypercholesterolaemia
  • Kayser-Fleischer rings- dark ring encircles the iris- Wilsons copper desists
  • Perilimbal injection- anterior uveitis IBD
• Mouth
  
  • Angular stomatitis- iron def anaemia
  • Glossitis- iron B12 and folate def
  • Oral candidiasis – immunosuppression, steroids
  • Aphthous ulceration- iron B12 and folate def, crohns
  • Hyperpigmented macules- Peutz-Jeghers syndrome- polyps in GI tract inherited condition

Neck

• Palpate for lymphadenopathy
  
  • Virchow’s lymph nodes – left supraclavicular fossa- metastatic intrabdominal malignancy
  • Right supraclavicular fossa

Chest

• Inspect
  
  • Spider naevi- increased circulating oestrogen- liver cirrhosis ( damage to the liver impairs its capacity to metabolize and inactivate estrogens)
  • Gynaecomastia- increased circulating oestrogen- liver cirrhosis
  • Hair loss- also caused by increased levels of circulating oestrogen

Abdominal

• Inspect
  
  • Scars
  • Abdominal distension (The six fs)
    
    • Fat
    • Fluid
    • Flatus
    • Faeces
    • Fetus
    • Fulminant mass
  • Caput medusae- portal hypertension (liver cirrhosis)
  • Striae
    
    • caused by tearing during the rapid growth or overstretching of skin (e.g. ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy)
  • Hernias
  • Cullens’ signs
    
    • Bruising around the umbilicus – haemorrhagic pancreatitis
  • Grey-turners sign
    
    • Bruising around the flank- haemorrhagic pancreatitis
  • Stomas
    
    • Location
    • Contents
    • Consistency of stool
    • Spout
• Palpate (make sure patient is lying flat, ask patient if any abdominal pain, kneel beside patient)
  
  • Light palpation of 9 regions
    
    • Tenderness
    • Rebound tenderness
    • Present when the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain. This is a non-specific, unreliable clinical sign that can, in some cases, be associated with peritonitis (e.g. appendicitis).
    • Guarding- involuntary tension in abdominal muscles that occurs on palpation- peritonitits
    • Rovsings sign
      
      • palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa. This sign was historically said to be indicative of appendicitis, but it is not reliable and at best indicates peritoneal inflammation of any cause affecting the left and/or right iliac fossa.
    • Masses e.g. hernias
  • Deep palpation- feeling for masses
    
    • Location
    • Size and shape
    • Consistency
    • Mobility
    • Pulsatility
  • Palpate the liver
    
    • Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger).
    • Ask the patient to take a deep breath and as they begin to do this palpate the abdomen. Feel for a step as the liver edge passes below your hand during inspiration (a palpable liver edge this low in the abdomen suggests gross hepatomegaly).
    • Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the right costal margin.
    • As you get close to the costal margin (typically 1-2 cm below it) the liver edge may become palpable in healthy individuals.
    • Causes of hepatomegaly
      
      • Hepatitis (infective and non-infective)
      • Hepatocellular carcinoma
      • Hepatic metastases
      • Wilson’s disease
      • Haemochromatosis
      • Leukaemia
      • Myeloma
      • Glandular fever
      • Primary biliary cirrhosis
      • Tricuspid regurgitation
      • Haemolytic anaemia
• Palpate the gallbladder (Murphy’s sign)
  
  • Position your fingers at the right costal margin in the mid-clavicular line at the liver’s edge.
  • Ask the patient to take a deep breath.
  • If the patient suddenly stops mid-breath due to pain, this suggests the presence of cholecystitis (known as “Murphy’s sign positive”).
• Palpate spleen
  
  • Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger).
  • Ask the patient to take a deep breath and as they begin to do this palpate the abdomen with your fingers aligned with the left costal margin. Feel for a step as the splenic edge passes below your hand during inspiration (the splenic notch may be noted).
  • Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the left costal margin.
    
    • In healthy individuals, you should not be able to palpate the spleen. A palpable spleen at the edge of the left costal margin would suggest splenomegaly (for the spleen to be palpable at this location it would need to be approximately three times its normal size).
    • Causes of splenomegaly
      
      • Portal hypertension secondary to liver cirrhosis
      • Haemolytic anaemia
      • Congestive heart failure
      • Splenic metastases
      • Glandular fever
• Ballot the kidneys
  
  • Place your left hand behind the patient’s back, below the ribs and underneath the right flank.
  • Then place your right hand on the anterior abdominal wall just below the right costal margin in the right flank.
  • Push your fingers together, pressing upwards with your left hand and downwards with your right hand.
  • Ask the patient to take a deep breath and as they do this feel for the lower pole of the kidney moving down between your fingers. This bimanual method of kidney palpation is known as balloting.
  • If a kidney is ballotable, describe its size and consistency.
  • Repeat this process on the opposite side to ballot the left kidney
    
    • In healthy individuals, the kidneys are not usually ballotable, however, in patients with a low body mass index, the inferior pole can sometimes be palpated during inspiration.
• Palpate the aorta
• Palpate the bladder
  
  • Palpate suprapubic area
• Percussion
  
  • Percuss the liver
    
    • Percuss upwards 1-2 cm at a time from the right iliac fossa (the same position used to begin palpation) towards the right costal margin until the percussion note changes from resonant to dull indicating the location of the lower liver border
    • Continue to percuss upwards 1-2 cm at a time until the percussion note changes from dull to resonant indicating the location of the upper liver border.
    • Use the knowledge of the upper and lower border of the liver to determine its approximate size.
• Percuss the spleen
  
  • Percuss upwards 1-2 cm at a time from the right iliac fossa (the same position used to begin palpation) towards the left costal margin until the percussion note changes from resonant to dull indicating the location of the spleen (in the absence of splenomegaly the spleen should not be identifiable using percussion)
  • Percuss the bladder
    
    • Percuss downwards in the midline from the umbilical region towards the pubic symphysis. A distended bladder will be dull to percussion allowing you to approximate the bladder’s upper border.
• Assess shifting dullness – ascites
  
  • Percuss from the umbilical region to the patient’s left flank. If dullness is noted, this may suggest the presence of ascitic fluid in the flank.
  • Whilst keeping your fingers over the area at which the percussion note became dull, ask the patient to roll onto their right side (towards you for stability)
  • Keep the patient on their right side for 30 seconds and then repeat percussion over the same area.
  • If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).
• Auscultate
  
  • Assess bowel sounds
    
    • Normal- gargling
    • Tinkling- bowel obstruction
    • Absent- ileus
  • Listen for bruits
    
    • Aortic
    • Renal
  • Legs
    
    • Pedal oedema (hypoalbinaemia - liver cirrhosis)

To complete the examination…

• Explain to the patient that the examination is now finished.
• Thank the patient for their time.
• Dispose of PPE appropriately and wash your hands.
• Summarise your findings