Examinations

Question 1

What should you do at the beginning of every examination

Answer 1

Wash hands, introduce yourself, identify patient, explain what you are going to do, gain consent

General inspection of patient and their surroundings from end of bed. Note:
-patient demeanour/ whether they appear well at rest
-any walking aids/medications etc

Question 2

Describe the steps in the hand and face part of a cardiovascular examination

Answer 2

Hands:
-general observation eg colour, tar staining
-assess temperature
-assess clubbing
-cap refill time
-measure radial pulse
-assess radio-radial delay
-locate brachial pulse
-assess collapsing pulse (aortic regurg) ASK ABOUT PAIN IN SHOULDER!
-ask the examiner if they would like you to measure BP/say you would measure BP

Face:
-general inspection of face
-check for anaemia
-ask patient to open mouth so you can inspect gums and tongue
-check for JVP by positioning patient at 45 degrees and getting them to turn their head to the left
-hepatojugular reflex may not be required but mention that you would do it
-auscultate the carotids
-feel the carotids

Question 3

Describe the steps in the chest part of the cardiovascular examination

Answer 3

(ask patient to expose their chest)
General Inspection:
-look at patient’s chest for scars, visible cardiac pulsation etc

Palpation:
-heaves
-thrills
-palpate the apex beat

Auscultation (feel carotid pulse while you auscultate)
-listen to all 4 areas with diaphragm
-listen to all 4 areas with bell
-listen to axilla
-ask patient to roll to their left and listen to mitral area with bell. Ask them to exhale and hold while you do this (mitral stenosis)
-ask patient to sit forwards, exhale and hold, and listen to aortic area (aortic regurg)
-listen to carotids while patient holds their breath

Question 4

Describe the rest of the cardiovascular examination

Answer 4

-inspect back
-auscultate lung bases
-check for sacral oedema
-check for pitting oedema in the ankles

Question 5

Describe the hand and face steps of a respiratory exam

Answer 5

Hands:
-general inspect of hands
-assess temperature
-cap refill
-clubbing
-assess fine tremor and flapping tremor
-assess radial pulse

Face:
-assess eyes for anaemia ect
-ask patient to open mouth and inspect gums, tongue and general mouth health
-check JVP
-assess tracheal deviation
-check lymph nodes

Question 6

Describe the chest steps in a respiratory exam

Answer 6

Palpation:
-assess chest expansion
-palpate apex beat
-place hands on chest and ask patient to say 99 (tactile vocal fremitus) may be reduced in effusion or pneumothorax

Percussion:
-percuss both sides and start from the shoulders/clavicles
-make sure to percuss axilla

Auscultation:
-listen to all areas while patient breathes in and out through their mouth
-listen to all areas again while patient says 99
-if you suspect consolidation, get the patient to whisper two two as this will appear louder in areas of consolidation

Question 7

Describe the back and last steps in the respiratory exam

Answer 7

Repeat all the chest steps but on the back with the patient sitting forwards

-palpate ankles for oedema

Question 8

Describe the inspection steps of the thyroid exam

Answer 8

-inspect general appearance of patient
-inspect the hands for temperature, clubbing, sweating, palmar erythema etc
-check for a tremor by asking the patient to put their hands in front of them and placing a piece of paper on their hands
-check the pulse
-check for signs of muscle wastage
-inspect eyes
-ask patient to follow your finger in a H shape
ask patient to follow your finger up and down to look for lid lag
-inspect the neck for masses
-ask the patient to stick their tongue out (mass move up means
thyroglossal cyst)
-inspect tongue
-ask patient to swallow some water (if mass moves then thyroid mass)

Question 9

Describe the palpation steps of a thyroid exam

Answer 9

-palpate trachea
-palpate neck from behind to look for masses
-ask patient to stick tongue out
-ask patient to swallow some water
- if there is a mass, determine size, if it moves or is fixed, if it moves on swallowing and tongue sticking out
-palpate lymph nodes

Question 10

Describe percussion, auscultation and last steps of a thyroid exam

Answer 10

Percuss:
-percuss upper sternum

Auscultation:
-ask patient to hold breath and auscultate over thyroid

Other:
-ask patient to stand from a chair while holding their arms over their chest
-assess ankle reflexed

Question 11

Describe the main categories assessed in an upper and lower limb neurological examination

Answer 11

Tone, Power, Reflexes, Coordination, Sensation

Question 12

Describe the tone and power steps in an upper limb examination

Answer 12

Tone: assess passive movement of shoulder, elbow and wrist on both sides and compare as you go.
Power: assess shoulder, elbow and wrist again. Assess only one side at a time.
-Shoulder abduction= elbows out to side and push down
-Shoulder adduction= elbows out to side and push up
-elbow flexion= hands like a boxer and pull away
-elbow extension= hands like a boxer and push towards patient
-wrist extension= make a fist and cock wrists up, try and push them down
-wrist flexion= make a fist and flex wrists down, try and push them up
-finger extension= hold fingers out and press down
-finger abduction= splay fingers out and try and press them in
-thumb abduction= palm up, point thumb up to the ceiling and push down

Question 13

Describe the reflex and sensation steps of an upper limb neurological examination

Answer 13

Reflex:
-biceps, triceps and supinator reflexes

Sensation: (patient must have eyes closed and you must first demonstrate the feeling on their sternum)
-use cotton wool for light tough sensation (dorsal columns and spinothalamic tracts)
-use the sharp end of a neuro tip for pin prick sensation (spinothalamic tracts)
-use a tuning fork for vibration sensation (dorsal columns) and start at the thumb. Only move proximally if they have reduced sensation in the thumb

Proprioception: dorsal columns
-demonstrate up and down to the patient
-ask them to close their eyes
-ask them which direction you are moving their thumb in

Question 14

Describe the coordination steps of an upper limb neurological examination

Answer 14

Finger to nose test:
-ask patient to touch their nose and then your outstretched finger as fast as they can
-if patients struggle to do this, may indicate underlying cerebellar pathology

Dysdiadochokinesia:
-flipping hand up and down on other hand

Question 15

Describe the face, hand and neck steps of a GI examination

Answer 15

Hands:
-inspect hands and nails for pallor, erythema, spoon shaped nails, dupuytren’s contracture
-check for finger clubbing
-check for flapping tremor
-check temperature

Face:
-ask to pull down eyelids and look up for signs of anaemia, jaundice etc
-look for xanthelasma
-ask patient to open mouth to check for ulcers, general dental hygiene, glossitis etc

Neck:
-palpate for lymphadenopathy
-check JVP (?)

Question 16

Describe the abdominal palpation steps in the GI examination

Answer 16

Ask if they are in any pain first!!!

General Inspection:
-general look at stomach and abdomen for scars, swelling, distention, stretch marks

Light palpation:
-lightly palpate 9 areas while patient breathes normally and watch their face as you do this

Deep Palpation:
-deeply palpate the 9 areas while patient breathes normally and watch their face as you do. If one area is painful, palpate last

Liver Palpation:
-ask patient to take deep breaths in
-start in right iliac fossa and move superiorly towards the ribs

Gallbladder Palpation:
-palpate at right costal margin
-ask patient to take a deep breath in

Spleen palpation:
-start in right iliac fossa
-ask patients to take deep breaths in
-move towards left costal margin

Aorta palpation:
-use both hands and perform deep palpation just below the umbilicus

Bladder palpation:
-gentle palpation of bladder

Question 17

Describe the percussion and auscultation step of a GI examination

Answer 17

Percuss liver:
-using same direction as palpation

Percuss spleen:
-using same direction as palpation

Percuss bladder:
-percuss down from umbilicus

assess shifting dullness if indicated

Listen to bowel sounds in at least two areas

Auscultate the aorta

Question 18

Describe the upper limb section of a peripheral vascular examination

Answer 18

General inspection:
-inspect and compare both limps outstretched for pallor, cyanosis, tar staining, gangrene etc
-check temperature of both
-check cap refill time of both
-check the radial pulses
-measure radio-radial delay
-perform Allen’s test
-check the brachial pulses
-offer to check BP

Question 19

Describe the abdominal section of a peripheral vascular examination

Answer 19

-auscultate the carotid artery while asking the patient to hold their breath
-palpate the carotid artery
-inspect the abdomen
-palpate the aorta
-auscultate the aorta
-auscultate the renal arteries

Question 20

Describe the lower limb section of a peripheral vascular examination

Answer 20

General inspection:
-inspect and compare both lower limbs for cyanosis, pallor, ulcers, hair loss, scars, paralysis etc

-check temperature
-check cap refill time
-palpate femoral pulse
-palpate popliteal pulses
- palpate posterior tibial pulse
-palpate dorsalis pedis pulse
-assess sensation by using a bit of cotton wool and moving from distal to proximal, comparing each side as you go

-Buerger’s test: raise patient’s feet 90degrees for 1-2 mins and then have them hang their legs over the side of the bed. In normal people, the legs should stay pink even when elevated

Question 21

Describe the first and tone parts of a lower limb examination

Answer 21

-Assess the patient’s gait by first asking them to walk to the end of the room and back, and then ask them to do heel to toe walking
-Romberg’s test- ask patient to stand with feet together and arms by their side and ask them to close their eyes

Tone:
-roll legs from side to side
-lift and drop knee onto bed
-test ankle clonus

Question 22

What should you do at the beginning of every examination

Answer 22

Wash hands, introduce yourself, identify patient, explain what you are going to do, gain consent

General inspection of patient and their surroundings from end of bed. Note:
-patient demeanour/ whether they appear well at rest
-any walking aids/medications etc

Question 23

Describe the power steps in a lower limb examination

Answer 23

Power:

-hip flexion: ask patient to lift leg up and then push down
-hip extension: ask them to push your hand into the bed while you push down
-ask them to push their thighs together
-ask them to push their thighs apart
-knee flexion: ask them to bend their knee and stop you straightening their leg
-knee extension: ask them to bend their knee and try and straighten their leg
-ankle plantarflexion: ask them to push down against your hand as if they are trying to straighten their feet
-ankle dorsiflexion: ask them to pull their feet away from you towards their body
-big toe extension: ask them to pull their big toe towards their body while you try and straighten it

Question 24

Describe the reflex, sensation and coordination steps in a lower limb examination

Answer 24

Reflexes: assess knee jerk, ankle jerk and plantar reflexes

Sensation:
-test light touch and pink prick sensation
-test vibration sensation starting at interphalangeal joint of the patient’s big toe
-test proprioception using the big toe

Coordination:
-heel to shin assessment

Question 25

Describe the steps involved in the first part of a cerebellar examination

Answer 25

Gait: normal walking and heel to toe gait Romberg's test- ask patient to stand with their feet together and arms by their sides and close their eyes Speech: repeat 'British constitution' and 'baby hippopotamus' Eyes: -check for nystagmus by asking the patient to follow your finger with their eyes while you trace a H pattern -check for impaired smooth pursuit by asking the patient to look at your nose and then your outstretched hand, and back

Question 26

Describe the steps involved in the tone and special tests part of a cerebellar examination

Answer 26

Tone: check tone of upper and lower limbs including shoulder, elbow, wrists and hands, and hip, knee and ankle Heel to shin test Dysdiadochokinesis

Question 27

Describe the steps involved in a diabetic foot exam

Answer 27

Inspection: inspection of foot and lower limbs for gangrene, ulcers, hair loss, cyanosis. scars, missing limbs, pallor etc Palpation: -palpate each joint assessing for discomfort -assess temperature -cap refill -check posterior tibial pulse and dorsalis pedis pulse Sensation: use -monofilament to check sensation on base of patient's foot - proprioception -vibration sensation ankle jerk reflex gait check patient's footwear

Question 28

Describe the look steps in a hip examination

Answer 28

-ask the patient to stand and turn in 90-degree increments and inspect each aspect of the joint -ask the patient to walk to the end of the room and back -ask the patient to lay on the bed -inspect hips and joints for abnormalities

Question 29

Describe the feel steps in a hip examination

Answer 29

-feel and compare the temperature of each hip -palpate the greater trochanter of each leg -measure apparent leg length from umbilicus down to malleolus -measure true leg length from anterior superior iliac spine down to malleolus

Question 30

Describe the move steps in a hip examination

Answer 30

Active movement: -hip flexion = bring knee to chest -hip extension: straighten leg out Passive movement: -hip flexion= bring the knee to the chest -internal and external rotation: bring knee towards chest and rotate in and out -abduction and adduction= keep patient's leg straight and move in and out. Hold the opposite hip to the one you are moving when performing this manoeuvre -hip extension= ask the patient to roll onto their front and lift the leg up while keeping it straight

Question 31

Describe the special steps in a hip examination

Answer 31

Thomas' Test: Assess for a fixed flexion deformity of the contralateral hip by flexing the ipsilateral hip fully. -patient to lie on bed -place hand under lumbar spine -flex hip, bringing knee to chest -look for hip raising off the bed, this is a positive sign of fixed flexion deformity Trendelenburg's Test: assesses abductor muscle strength of the hip -ask patient to stand on one leg -hip should rise on the leg that is being raised -if the pelvis drops on the side that isn't being raised

Question 32

Describe the look steps in a knee examination

Answer 32

-ask patient to stand and turn in 90-degree increments and closely inspect the knee -ask the patient to walk to the end of the room and back to inspect gait -ask patient to lie on bed -inspect knees when lying down -ask to inspect bottom of patient's footwear

Question 33

Describe the feel steps in a knee examination

Answer 33

-feel and compare the temperature of the knee joints -palpate the knee joint with the leg out straight -perform patella tap -perform bulge test -palpate the knee joint when the knee is flexed at 90 degrees

Question 34

Describe the move steps in a knee examination

Answer 34

Active Movement: -flexion= ask them to bend their knee as much as possible -extension= ask patient to flatten their leg as much as possible Passive Movement: (hold patient's knee) -flexion= bring ankle towards bottom, bending the knee -hyperextension= lay leg flat and left leg up

Question 35

Describe the special steps in a knee examination

Answer 35

-posterior sag test= position patient with knee bent and foot flat on bed. Inspect from the side. -anterior draw test -lateral/medial collateral test (the awkward twisty one)

Question 36

Describe the look and feel steps in a spine examination

Answer 36

-general inspection -ask the patient to stand and turn in 90-degree increments while you inspect the spine -assess the patient's gait by asking them to walk to the end of the examination room and back -palpate each of the spinal processes and sacroiliac joints -palpate the paraspinal muscles noting any tenderness or muscular spasms

Question 37

Describe the movement steps in a spinal examination

Answer 37

Assess active movement first and if abnormalities are noted, repeat the movements passively Cervical Spine: -flexion: touch chin to chest -extension: ask patient to look at ceiling -lateral flexion: touch ear to shoulder on each side rotation: turn head side to side Lumbar Spine: -flexion: touch toes while keeping legs straight -extension: lean back as far as comfortable -lateral flexion: slide left hand down left leg and right hand down right leg while keeping legs straight Thoracic Spine: -rotation: ask patient to cross arms of chest and twist from side to side while seated

Question 38

Describe the last steps in a spinal examination

Answer 38

-modified Schober's Test= measure 10cm above and 5cm below the posterior superior iliac spines and then ask the patient to bend over. Should be a 5cm or more increase in the distance between the 2 points -lateral flexion= ask patient to stand with feet apart and measure distance from finger tips to the floor. Ask the patient to lean to the side and remeasure the distance- >10cm difference

Question 39

Describe the look and feel steps in a hand examination

Answer 39

-closely inspect both sides of both hands -inspect the elbows for psoriatic plaques -feel temperature of both hands -feel snuffbox, hypothenar and thenar bulk -check for palm thickening -check radial and ulnar pulses -perform allen's test -palpate each joint/hand/wrist -palpate along ulnar border -check median and ulnar nerve sensation

Question 40

Describe the move steps in a hand examination

Answer 40

finger flexion/extension: make a fist and then straighten finger adduction/abduction: ask the patient to extend and spread their fingers and then back to normal wrist: prayer sign and reverse prayer sign thumbs: palms up towards ceiling and stick thumbs up Against Resistance: -stop you pushing fingers down -stop you pushing fingers together -stop you pushing thumb down power grip: stop you pulling a pen out of their fingers lateral pinch grip: ask patient to hold pen normally

Question 41

Describe the special tests in a hand examination

Answer 41

These are both for the median nerve --> Tinel's Test: tap over median nerve area (tap over wrist) Phalen's Test: ask patient to put hands in the prayer position for 1 minute and report and pain or tingling Ulnar --> ask patient to cross fingers and hold a piece of paper between finger and thumb Radial --> test wrist and finger dorsiflexion against resistance

Question 42

Describe the look and feel steps in a shoulder examination

Answer 42

Look: general inspection and then ask the patient to turn in 90 degree increments and closely inspect the shoulder Feel: -assess temperature of both joints -palpate muscle bulk of joints and surrounding areas

Question 43

Describe the move steps in a shoulder examination

Answer 43

Screening movements: ask patient to put hands behind head and then hands behind shoulder Active Movements: -lift arms up in front of them and then towards the ceiling -move arms behind back as far as they will go -raise arms out to their sides until their hands touch above their heads -ask patient to keep arms straight and cross them across their body -ask them to bend their elbows and flex their elbows out to the side -ask them to put their hand behind their back and reach as far as possible up their back Passive Movements: -repeat all the above movements passively

Question 44

Describe the special tests in shoulder examination

Answer 44

Resisted active internal rotation: place hand behind back and lift off and then resist Acromio-clavicular joint pathology: scarf test Empty can test (supraspinatus assessment): ask patient to put hands out in front of them and then "tip can up" so thumb points down towards floor and then push down whilst patient resists Painful Arc: passively raise patient's arm to ceiling and then ask them to lower their arm again Resisted active external rotation: have patient bend elbow at 90 and push outwards against your hand

Question 45

How do you test CNI?

Answer 45

Olfactory Nerve -ask the patient if they have had any changes to their sense of smell -would test with olfactory testing bottles

Question 46

How do you test CNII

Answer 46

Optic Nerve light reflexes: shine pen torch into patient's eye from the side and look for constriction in direct pupil and contralateral pupil Visual acuity: ask the patient to cover one eye and ask them how many fingers you are holding up Visual fields: cover one eye and ask the patient to cover their own eye directly opposite this, with the patient directly staring into the opposite eye. Bring your finger in diagonally and ask the patient to tell you when they can see your finger. Repeat in all 4 quadrants Inattention: hold your fingers up to the side and ask the patient which finger, if any or both you are wiggling Accommodation: ask the patient to focus on a point in the distance and the bring your finger up in front of them and ask them to focus on your finger. The pupils should both contract

Question 47

How do you test CNIII, IV and VI

Answer 47

Oculomotor, trochlear and abducens Ask the patient to keep their head still and follow your finger with their eyes in a H shape. Ask if their experience double vision.

Question 48

How do you test for CN V

Answer 48

Trigeminal test sensation using a bit of cotton wool in each of the dermatomes of the trigeminal nerve- ask the patient to tell you when they feel you touching their face and if it feels the same on both sides Ask the patient to clench their jaw and feel the jaw and muscles ask the patient to open their mouth against resistance test the jaw jerk reflex

Question 49

How do you test CNVII

Answer 49

Facial Ask the patient to: -screw up their eyes and not let you open them -puff out their cheeks -raise their eyebrows -purse their lips

Question 50

How do you test CNVIII

Answer 50

Vestibulocochlear Cover one of the patient's ears and whisper a number in the other Rinne's Test: vibrating tuning fork held on mastoid behind ear until no sound is heard and then moved in front of ear. It should louder in front of ear. If it is louder on mastoid, this indicates conductive hearing loss Weber's test: vibrating tuning fork placed on centre of forehead and should be heard equally in both ears. In conductive hearing loss, sound is heard louder in abnormal

Question 51

How do you test CNIX and CNX

Answer 51

Glossopharyngeal and vagus Ask the patient to open their mouth and inspect, ask them to say aah (glossopharyngeal) Ask whether the patient has had any difficulty swallowing Ask the patient to cough Do not need to test gag reflex

Question 52

How do you test CNXI

Answer 52

Accessory nerve Test trapezius by asking the patient to shrug their shoulders against resistance test sternomastoid by asking the patient to turn their head against resistance

Question 53

How do you test CNXII

Answer 53

Hypoglossal Ask the patient to open their mouth and observe their tongue at rest for fasciculation Ask them to stick their tongue out Ask the patient to push their tongue into the cheek of their mouth and resist your finger

Question 54

What are the screening questions for the GALS examination?

Answer 54

1. Do you have any pain or stiffness in your muscles, joints or back? 2. Do you have any difficulty getting yourself dressed without any help 3. Do you have any problem going up and down stairs

Question 55

Describe the inspection part of a GALS examination

Answer 55

Ask the patient to walk to the end of the room and back Ask the patient to stand and turn in 90 degree increments

Question 56

Describe the arm part of a GALs examination

Answer 56

-ask them to put their hands behind their head -ask them to put their hands out in front of them with their palms facing downwards -ask them to turn their palms up to face the ceiling -ask them to make a fist -ask them to grip your fingers -ask them to touch each finger in turn to their thumb -squeeze across the MCP joints and observe for discomfort

Question 57

Describe the leg part of a GALS examination

Answer 57

-passive knee flexion -passive knee extension by keeping the leg straight and lifting the ankle slightly -passive internal rotation of the hip -squeeze the MTP joints and observe any discomfort -patellar tap

Question 58

Describe the spine part of the GALS examination

Answer 58

-lateral flexion of cervical spine by asking them to touch their shoulder with their ear -lumbar flexion by placing fingers on lumbar vertebrae and asking the patient to bend forwards, fingers should move apart