Examinations Flashcards
1
Q
diabetic foot examination
A
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)
2
Q
thyroid examination
A
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
- Hyperthyroidism
- 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
- Exophthalmos (graves)
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)
3
Q
rheumatology examination overview
A
GALS: gait, arms, legs, spine
4
Q
The following general principles should be followed during a rheumatology examination:
A
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
5
Q
rheum exam: Gait
A
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.
6
Q
rheum exam: Arms and hands
A
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.
7
Q
special tests of the hand : motor
A
- 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
8
Q
other special tests of the hand
A
tinels
phalens
9
Q
Tinel’s test
A
- 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
10
Q
phalens test
A
- 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
11
Q
Clinical features of median nerve palsy
A
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).
12
Q
Clinical features of ulnar nerve palsy
A
- 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.
13
Q
GALS quick screening test for MSK disorder
A
14
Q
example GALS
A
15
Q
more detailed GALS
A
