Examinations Flashcards
A-E assessment
Airway
= Is is patent? Is it obstructed? Are they able to talk?
= If obstructed then attempt to remove obstruction
= If unable to maintain airway, intubate
Breathing
= Inspect chest, calculate respiratory rate
= Palpate: chest expansion, trachea position
= Percuss chest
= Auscultate chest
= Oxygen sats
= Give oxygen if required
= Differential diagnoses?
Circulation
= Pulse
= Capillary refill time
= Blood pressure
= Urine output
= Give fluids if required
= ECG monitoring?
Disability = Temperature = Blood glucose = AVPU or GCS = Pupils
Exposure
= Examine full body of the patient
Cardiovascular examination- Process
- Introduction, explanation, consent, position (45degrees)
- General inspection
- GTN spray, breathlessness, obvious chest pain,
sweating, nausea/vomiting, cachexia - Associated conditions: Down’s syndrome, Marfan’s
syndrome, Turner’s syndrome
- GTN spray, breathlessness, obvious chest pain,
- Inspect hands
- Collapsing pulse
- Radial pulse (regular rate/ rhythm?)
- Radial-radial delay?
- Clubbing, tar staining, Janeway lesions, Oslers
nodes, warmth, capillary refill time, splinter
haemorrhages, koilonychia
- Inspect face
- Eyes: xanthalasma, corneal arcus, jaundice?
- Mouth: Central cyanosis, petechiae, tooth decay
- General: pallor, malar flush
- Inspect neck
- Carotid pulse (character/ volume)
- Raised JVP
- Inspect chest
- Pacemakers, scars (sternotomy, thoracotomy),
chest drains
- Pacemakers, scars (sternotomy, thoracotomy),
- Palpate chest
- Apex beat
- Heaves
- Thrills
- Auscultate chest
- Heart sounds: murmurs? added sounds?
- Auscultate lung bases
- Assess ankle and sacral oedema
- Offer:
- Blood pressure measurement
- Abdominal exam
- Peripheral vascular examination
- Appropriate test e.g. ECG, troponin, CXR, CT….
- Summarise and conclude
Cardiovascular exam - Pathology (GENERAL INSPECTION)
- GTN spray = Diagnosed angina or previous ACS
- Breathlessness = ACS, respiratory, MSK
- Obvious chest pain = ACS, Angina,
- Sweating, nausea/vomiting = ACS
- Cachexia (muscle wasting) = Malignancy, severe heart
failure - Marfan’s syndrome = Aortic regurgitation (association)
- Down’s syndrome = Congenital heart disease
(association) - Turner’s syndrome = Coarctation of the aorta
Causes of collapsing pulse
Aortic regurgitation, patent ductus arteriosus
Cardiovascular examination - Pathology (CHEST INSPECTION)
Median Sternotomy:
- Predominately used for open heart surgery, such as
valve replacements, CABG, or cardiac transplant.
- The incision is made from the substernal notch to
around the xiphoid process, before cutting directly
through the sternum to enter the thoracic cavity.
Pacemaker incision:
- 4-5cm incision is made in the left infraclavicular region.
Thoracotomy:
- Used to access the pleural space of the thorax. The three main subtypes are the posterolateral incision, anterolateral incision, and axillary incision.
1) Posterolateral thoracotomy
- Gold standard for access to the thorax.
- Used for pulmonary resections (pneumonectomy or
lobectomy), chest wall resection, or oesophageal
surgery.
- Anterolateral thoracotomy
- Used in a variety of operations for cardiac, pulmonary,
and oesophageal pathology. - Axillary thoracotomy
- A muscle sparing approach to the thoracic cavity
- Used for pneumonectomy and pneumothorax
operations.
Causes of irregular pulses, radial-radial delay and radio-femoral delay
Irregular pulse = Atrial fibrillation
Radial-radial delay = Large arterial occlusion (atherosclerotic plaque or aneurysm)
Radio-femoral delay = Coarctation of the aorta
Causes of clubbing
Cardiovascular causes: Cyanotic congenital heart disease, infective endocarditis
Causes of tar staining
Tar staining = Current/ previous Smoker
Description and causes of janeway lesions/oslers nodes
Janeway lesions (non-painful erythematous lesions on the palm of the hands) = infective endocarditis
Oslers nodes (painful erythematous lumps on fingertips) = Infective endocarditis
Cause of cold peripheries and prolonged capillary refill time
Cold peripheries = reduced oxygenation
Prolonged capillary refill time = Hypovolaemia, hypoxia
Causes of koilonychia
Koilonychia = anaemia (Fe deficiency)
Causes of splinter haemorrhages
Splinter haemorrhages = infective endocarditis, anaemia (Fe deficiency)
Causes of displaced apex beat
Displaced laterally + thrusting quality = volume overload e.g. mitral or aortic regurgitation
Impalpable apex beat (DOPEE) = Dextrocardia, obesity, pneumothorax, emphysema, effusion
How to palpate parasternal heaves and what causes them?
Should be felt with the heel of the hand resting on the left of the sternum .
Indicates right ventricular enlargement or severe left ventricular enlargement
How to palpate thrills?
Thrills should be felt for over the apex, left sternal edge and the base of the heart
They indicate a murmur.
Cause of xanthelasma and corneal arcus
Hyperlipidaemia
Causes of central cyanosis
Hypoxia
How can jaundice indicate a cardiovascular condition?
Jaundice = Prosthetic heart valve induced haemolysis
Description and cause of Petechiae
Petechiae are pinpoint, round spots that appear on the skin as a result of bleeding. The bleeding causes the petechiae to appear red, brown or purple. Petechiae usually appear in clusters. Petechiae appear when capillaries bleed and leak.
Petechiae may have an infective cause e.g. Infective endocarditis
Description and cause of malar flush
Malar flush is a plum-red discolouration of the high cheeks classically associated with mitral stenosis due to the resulting CO2 retention and its vasodilatory effects
Dilatation of the malar capillaries associated with pulmonary hypertension and low cardiac output (mitral stenosis)
Causes of variants of the carotid pulse (slow rising, collapsing, small volume, pulsus alternans)
Carotid pulse (character/ volume)
- Slow rising = aortic stenosis
- Collapsing = Aortic regurgitation, PDA
- Small volume = aortic stenosis, pericardial effusion
- Pulsus alternans (alternating weak and strong) =
distressed left ventricle
Causes of a raised JVP
Right ventricular failure Tricuspid stenosis/regurgitation Pericardial effusion Constrictive pericarditis SVC obstruction Fluid overload
Causes of a raised JVP
Right ventricular failure Tricuspid stenosis/regurgitation Pericardial effusion Constrictive pericarditis SVC obstruction Fluid overload
HOLT - Heart failure, Obstruction of the vena cava, Lymph node enlargement, Thoracic pressure increase
Respiratory Examination - Process
- Introduction
- General inspection
[inhalers, nebulisers, oxygen, accessory muscles] - Hands
[Clubbing, fine tremor, course tremor, tar staining,
pulse] - Face and neck
[Central cyanosis, xanthalasma, corneal arcus,
ulceration in the mouth, JVP] - Chest inspection
[Equal expansion, scars, respiratory rate] - Chest palpation
[Trachea position, apex beat, chest expansion] - Chest percussion
- Chest auscultation
[Chest and axilla] - Posterior inspection, palpation, percussion and
auscultation - Lymphadenopathy
- Ankle oedema
- Conclusion and summary
Abdominal examination - process
- Introduction
- General inspection
[Abdominal distention, pain, jaundice, ] - Hands and arms
[Dupytrens contracture, palmar erythema, finger clubbing, leuchonychia, koilonychia, purpura, radial pulse, fistulae, injection marks] - Face and neck
[Xanthelasma, jaundice, pallor, ulcers, pigmentation, telangiectasia, stomatitis, glossitis, poor dentition, gingivitis, candidiasis, tonsillar infections, odours, JVP] - Chest inspection
[Spider naevi, gunaecomastia, loss of axillary hair] - Abdominal inspection
[Movement, distension, scars, hernias, dilated veins, scratch marks, pulsations, striae, grey turner’s sign, Cullen’s sign] - Abdominal palpation
[Superficial, deep, hepatomegaly, splenomegaly, ballot the kidneys, aorta, murphy’s sign] - Abdominal percussion
[Liver, spleen, bladder, flanks] - Abdominal auscultation
[Renal bruits, bowel sounds, aorta bruits] - Renal tenderness
- Lymphadenopathy
- Ankle oedema
- Conclusion and summary
Cranial nerve examination - Process
Introduction
General inspection
[Bell’s palsy, herpes zoster virus, position of head, glasses, hearing aid]
Cranial nerve I [Olfactory]
= Have you noticed a change in sense of smell or taste recently?
Cranial nerve II [Optic] = Inspect eyes closely = Double vision? = Difficulty walking down the stairs when walking? = Visual acuity (snellen chart) = Visual field (occlude one eye and chest quadrants] = Fundoscopy = Light reflexes (direct and consensual) = Accommodation reflex =Eye movements
Cranial nerve II [Occulomotor]
= Light reflexes
= Accommodation reflex
= Eye movements
Cranial nerve IV [Trochlear]
= Eye movements
Cranial nerve V [Trigeminal]
= Cutaneous facial sensation (neuropin and light touch)
= Temporalis and masseter wasting and power
= Protraction
= Side-side movement
= Open jaw against resistance
= Jaw jerk
Cranial nerve VI [Abducens]
= Eye movements
Cranial nerve VII [Facial] = Inspect for mouth dropping, nasolabial fold = Muscle power = Corneal reflex (CN V and VII) = Change in taste
Cranial nerve VIII [Vestibulocochlear] = Hearing aid? = Inspect ears = Auroscopy = Whisper test = Weber and Rinne's test = Vertigo?
Cranial nerve IX [Glossopharyngeal] and X [Vagus] = Inspect palate pharynx = Observe uvula = Observe speaking and coughing = Gag reflex
Cranial nerve XI [Accessory nerve]
= Sternocleidomastroid - head movement against resistance
= Trapezius - shrugs shoulder
Cranial nerve XII [Hypoglossal] = Inspect tongue = Movement of tongue = Power of tongue = Tongue twister
Conclusion
Hydration status examination - Process
- Introduction
- General inspection
[Breathlessness, Catheters, IV fluids, drains,
vomit/sputum bowels] - Inspect Hands
[Capillary refill time, skin turgor, temperature, pulse,
blood pressure, collapsing pulse] - Inspect face
[Sunken eyes, dry mouth, JVP, carotid pulse] - Inspect and palpate chest
[Skin turgor, capillary refill time, apex beat] - Auscultate chest
[Heart sounds, lung bases] - Inspect abdomen
[Ascites] - Inspect legs
[Peripheral oedema] - Conclusion
Reticuloendothelial examination - process
- Introduction
- General inspection
- Cervical lymphadenopathy
- Axillary lymphadenopathy
- Inguinal lymphadenopathy
- Palpate and Percuss liver
- Palpate and percuss spleen
- Conclusion
Diabetic foot examination - process
- Introduction
- General inspection
- surroundings (drains, drugs, drips, drinks)
- patient
- shoes
- swelling
- bones/joints
- Palpation
- temperature
- capillary refill
- pulses
- monofilament
- vibration
Describe a Venous ulcer
Site, depth, edges, base, colour, pain, characteristics
Site = Gaiter region Depth = Superficial Edges = Sloping Base = Granulating Colour = Pink Pain = Moderate Other = varicosities, venous eczema, haemosiderin deposits, lipodermatosclerosis
Describe an ischaemic ulcer
Site = Sole Depth = Deep Edges = Punched out Base = Sloughy and pale Colour = Pale Pain = Painful Other = Loss of pulses
Describe a neuropathic ulcer
Site = Sole Depth = Deep Edges = Punched out Base = Sloughy and bloody Colour = Red Pain = No pain Other = Neuro loss
Neurological examination (upper limb) = Process
- Introduction
- General inspection
= Walking aids
3. Inspection of the upper limbs
= Muscle fasciculations
= Posture, asymmetry
= Size and shape of muscles
= Scars or bruising
- Assess tone
- Assess power
= Shoulder abduction [Deltoid C5/6]
= Elbow flexion [Biceps C5/6]
= Elbow extension [Triceps C7/8]
= Wrist extension [Radial and ulnar extensors C6/7/8]
= Wrist flexion [Radial and ulnar flexors C6/7/8]
= Finger flexion [Long and short finger flexors C8]
= Finger abduction/adduction [Intrinsic muscles T1]
= Thumb abduction [Abdctor pollicis brevis T1] - Assess reflexes
= Biceps [C5]
= Brachioradialis [C6]
= Triceps [C7]
7. Assess sensation
= Light touch
= Pinprick
= Vibration
= Proprioception
8. Assess co-ordination = Dysdiadochokinesia (flip hand around quickly) = Finger-to-nose test (tremor) = Finger-to-thumb test = Pronator drift = Cerebellar drift
- Conclusion
Neurolongical exam - lower limb -Process
- Introduction
- General inspection
= Walking aids
3. Inspection of the lower limbs
= Muscle fasciculations
= Posture, asymmetry
= Size and shape of muscles
= Scars or bruising
- Assess tone
- Assess power
= Hip flexion [Iliopsoas L1/2]
= Hip adduction [Adductors L2/3]
= Knee extension [Quadriceps L3/4]
= Ankle dorsiflexion [Tibialis anterior L4]
= Ankle plantarflexion [Gastrocnemius S1/2]
= Great toe dorsiflexion [Extensor hallucis longus L5]
6. Assess reflexes
= Knee jerk [L3/4]
= Ankle jerk [S1]
= Clonus
= Plantar's response (Babinski's sign)
7. Assess sensation
= Light touch
= Pinprick
= Vibration
= Proprioception
8. Assess co-ordination = Heel-shin = Gait = Heel-to-toe = Romberg's test
- Conclusion
Thyroid examination - process
- Introduction
- General inspection
- Inspect hands + measure pulse
- Inspect face and eyes
- Inspect neck
- Palpate neck and thyroid
- Cervical lymphadenopathy
- Percuss sternum
- Auscultate over thyroid gland
- Inspect lower limbs - pre-tibial myxedema
- Assess reflexes
- Ask patient to stand from a chair without assistance
- Conclusion
Thyroid exam - Pathology for hyper and hypothyroidism
- Introduction
- General inspection
HYPER = heat intolerance, sweating, agitation, tremor, weight loss,
HYPO = cold intolerance, shivering, lethargy/drowsy, puffiness/general oedema, weight gain - Inspect hands + measure pulse
HYPER = warm and sweaty hands, palmar erythema, thyroid acropachy (clubbing = GRAVES), tachycardia, irregular pulse i.e. AF
HYPO = cold dry skin, bradycardia - Inspect face and eyes
HYPER = hair loss, Exophthalmos, Lid lag, Lid retraction, opthalmoplegia
HYPO = Puffiness, hair loss, loss of lateral eyebrows, dry skin - Inspect neck
HYPER = goitre (GRAVES, MULTINODULAR)
HYPO = goitre (HASHIMOTO’S) - Palpate neck and thyroid
HYPER = goitre (GRAVES, MULTINODULAR)
HYPO = goitre (HASHIMOTO’S) - Cervical lymphadenopathy
- Percuss sternum
HYPER = Retrosternal goitre - Auscultate over thyroid gland
HYPER= thyroid bruits - Inspect lower limbs - pre-tibial myxedema
HYPER = Pre-tibial myxedema - Assess reflexes
HYPER = Brisk reflexes
HYPO = Slow relaxing reflexes - Ask patient to stand from a chair without assistance
HYPER = Proximal myopathy - Conclusion
