Examinations Flashcards
What should you do at the beginning of every examination
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
Describe the steps in the hand and face part of a cardiovascular examination
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
Describe the steps in the chest part of the cardiovascular examination
(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
Describe the rest of the cardiovascular examination
-inspect back
-auscultate lung bases
-check for sacral oedema
-check for pitting oedema in the ankles
Describe the hand and face steps of a respiratory exam
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
Describe the chest steps in a respiratory exam
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
Describe the back and last steps in the respiratory exam
Repeat all the chest steps but on the back with the patient sitting forwards
-palpate ankles for oedema
Describe the inspection steps of the thyroid exam
-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)
Describe the palpation steps of a thyroid exam
-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
Describe percussion, auscultation and last steps of a thyroid exam
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
Describe the main categories assessed in an upper and lower limb neurological examination
Tone, Power, Reflexes, Coordination, Sensation
Describe the tone and power steps in an upper limb examination
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
Describe the reflex and sensation steps of an upper limb neurological examination
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
Describe the coordination steps of an upper limb neurological examination
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
Describe the face, hand and neck steps of a GI examination
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 (?)
Describe the abdominal palpation steps in the GI examination
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
Describe the percussion and auscultation step of a GI examination
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
Describe the upper limb section of a peripheral vascular examination
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
Describe the abdominal section of a peripheral vascular examination
-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
Describe the lower limb section of a peripheral vascular examination
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
Describe the first and tone parts of a lower limb examination
-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
What should you do at the beginning of every examination
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
Describe the power steps in a lower limb examination
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
Describe the reflex, sensation and coordination steps in a lower limb examination
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
Describe the steps involved in the first part of a cerebellar examination
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
Describe the steps involved in the tone and special tests part of a cerebellar examination
Tone: check tone of upper and lower limbs including shoulder, elbow, wrists and hands, and hip, knee and ankle
Heel to shin test
Dysdiadochokinesis
Describe the steps involved in a diabetic foot exam
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
Describe the look steps in a hip examination
-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
Describe the feel steps in a hip examination
-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
Describe the move steps in a hip examination
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
Describe the special steps in a hip examination
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
Describe the look steps in a knee examination
-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
Describe the feel steps in a knee examination
-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
Describe the move steps in a knee examination
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
Describe the special steps in a knee examination
-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)
Describe the look and feel steps in a spine examination
-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
Describe the movement steps in a spinal examination
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
Describe the last steps in a spinal examination
-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
Describe the look and feel steps in a hand examination
-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
Describe the move steps in a hand examination
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
Describe the special tests in a hand examination
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
Describe the look and feel steps in a shoulder examination
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
Describe the move steps in a shoulder examination
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
Describe the special tests in shoulder examination
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
How do you test CNI?
Olfactory Nerve
-ask the patient if they have had any changes to their sense of smell
-would test with olfactory testing bottles
How do you test CNII
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
How do you test CNIII, IV and VI
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.
How do you test for CN V
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
How do you test CNVII
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
How do you test CNVIII
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
How do you test CNIX and CNX
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
How do you test CNXI
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
How do you test CNXII
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
What are the screening questions for the GALS examination?
- Do you have any pain or stiffness in your muscles, joints or back?
- Do you have any difficulty getting yourself dressed without any help
- Do you have any problem going up and down stairs
Describe the inspection part of a GALS examination
Ask the patient to walk to the end of the room and back
Ask the patient to stand and turn in 90 degree increments
Describe the arm part of a GALs examination
-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
Describe the leg part of a GALS examination
-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
Describe the spine part of the GALS examination
-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
