Examinations Flashcards
How do you introduce yourself for any physical examination:
Full name:
Your Role:
Confirm patient name and DOB:
Wash/ alcohol gel hands
Hi My names Poppy I’m a physician associate and I’m going to be completing a …. Examination on you today.
This will involve….
Can I confirm your name and DOB
Wash hands/ sanitize
After confirming patient name and DOB what are the next steps to a physical examination?
Explain the purpose of the consultation
Gain consent to proceed
Adequate expose the patient (access to full upper body)
Position the patient at 45 degrees
Ask if they have any pain prior to proceeding
How do you generally inspect a patient when first walking in?
End of bed - walking aids, Inhalers, GTN Sprays, Medical Equipment
Clinical signs suggestive of pathology - Cyanosis (blue colour/ lack of O2), Pallor (pale), Shortness of breath
Hands:
1) Inspect the hands
Colour
Tar staining
Xanhomata fat building up on the surface of skin
Clubbing
IE Signs
Splinter Haemorrhages
Jane way lesions - PAINLESS lesions on the plantar surfaces of feet and hands, Haemorrhagic lesions caused by septic micro- embolism, Seen in infective endocarditis
Older Nodes- PAINFUL red purple slightly raised lesions - seen in infective endocarditis
2) Assess and compare temperature of the hands
3) Assess capillary refill time - should be less than 2s
Pulses and BP:
Palpate the radial pulse, assessing the heart rate and rhythm
• Assess for radio-radial delay - assess pulse in both wrists to see if occurring at the same time
• Assess for a collapsing pulse - can lift patients arm (primarily aortic regurgitation)
• Palpate the brachial pulse, assessing rate,rhythm, volume and character
• Offer to measure the patient’s blood pressure in both arms
• Auscultate the carotid pulse
• Palpate the carotid pulse
Jugular venous pressure (JVP)
Measure the JVP with the patient positioned correctly
Internal jugular vein (IJV) - using it as an indirect measurement of central venous pressure
• Runs between medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid - making it hard to visualise
• Measure it from the sternal angle to the top of the pulsation point
of the IJV (in healthy normal individuals, this shouldn’t be more than 3cm)
• Elicit hepatojugular reflex if appropriate
• Biphasic
• No palpable pulsation
• Occludable
• Decreases with inspiration
• Lowers when sat up
Face:
Inspect the face for:
Malar flush – seen in mitral stenosis
Inspect the eyes for relevant signs:
Conjunctival pallor
Corneal arcus - when you have a white, blue or gray crescent shape (arc) made of lipid (fatty) deposits that curves around the outer edges of the cornea of the eye
Xanthelasma - harmless, yellow growth that appears on or by the corners of your eyelids next to your nose.
Inspect the mouth for relevant signs:
Central cyanosis - bluish colour of the lips
Angular stomatitis - inflammation causing cracked sores of the mouth
Dental hygiene - infective endocarditis
High arched palate - associated with Marfan syndrome - mitral/aortic valve prolapse and aortic dissection
Chest:
Inspect for scars, chest wall deformities and pulsations/heaves (throbbing)
PALPATION OF THE CHEST
• Palpate the apex beat and assess position – should be 5th intercostal space, mid- clavicular line – LV contracts against chest wall
• Assess for a parasternal heave
AUSCULTATION OF THE CHEST
• Auscultate the mitral, tricuspid, pulmonary and aortic valve with the diaphragm of the stethoscope, whilst palpating the carotid pulse.
• Repeat auscultation of all 4 valves using the bell of the stethoscope.
Aortic valve - 2nd intercostal space right sternal edge
• Pulmonary valve - 2nd intercostal space left sternal edge
• Tricuspid valve - 4th intercostal space lower left sternal edge
• Mitral valve - 5th intercostal space on the apex
AUSCULTATION:
Auscultate the carotid arteries using the diaphragm of the stethoscope whilst the patient holds their breath to identify radiation of an aortic murmur
• Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration to listen for an early diastolic murmur caused by aortic regurgitation
Auscultate the carotid arteries using the diaphragm of the stethoscope whilst the patient holds their breath to identify radiation of an aortic murmur
• Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration to listen for an early diastolic murmur caused by aortic regurgitation
Final Steps:
Inspect the posterior chest wall for any deformities or
scars
• Auscultate the posterior lung fields (back)
• Palpate for sacral oedema (lower back)
• Palpate the patient’s ankles for evidence of pitting oedema
• Inspect the patient’s legs for evidence of saphenous vein harvesting sites
How do you complete your physical 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
• Suggest further assessments and investigations (e.g. peripheral vascular examination, abdominal examination,12-lead ECG, urine dipstick, capillary
As soon as you see the patient at the end of the bed, what are you looking for?
Patient
Are they well? And Alert?
Comfortable/uncomfortable
Colour
Normal, pale, cyanosed
Body habitus (sensitively)
Obvious scaring
Any devices you can see
Any abnormal sounds you can hear
Give a general inspection for Sally, 49 where everything looks normal.
Sally, 49.
General Inspection Example Presentation
Upon general inspection, Sally appears alert and comfortable at rest. She doesn’t appear to be in any distress and there are not any mobility aids, medications or oxygen at the bedside. She has normal colour and body habitus and at this point there are no obvious scars or abnormalities I can see.
Next:
Sally, I’d like to look at your hands if thats okay?
Presenting Hands Example:
Sally i’d just like to look at your hands if that’s okay?
I’m just having a feel of the temperature and they feel warm and well perfused. Next I will be looking at your nails. No signs of any tar staining, peripheral cyanosis or markers for infective endocarditis. Pulps are also clear for any osler nodes. Would you be able to place your fingers together like this? That’s great, so no signs of clubbing. And just checking the wrists for any xanthomata. That is all fine, thank you.
What is pulse pressure and what an it show?
Pulse pressure = the gap between the systolic and diastolic reading.
Example: A systolic of 140 and a diastolic of 90, will give a pulse pressure of 50mmHg
Narrow pulse pressure: <25mmHg difference.
Causes include aortic stenosis, congestive heart failure and cardiac tamponade
Wide pulse pressure: >100mHg difference. Causes include aortic regurgitation and aortic dissection
Chest inspection for deformities:
PECTUS EXCAVATUM
Structural deformity causing a sunken in ● appearance of the anterior thoracic wall
PECTUS CARINATUM
Also known as ‘pigeon chest’, protrusion of sternum and ribs
