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Examinations Flashcards

1
Q

A-E assessment

A

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

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2
Q

Cardiovascular examination- Process

A
  1. Introduction, explanation, consent, position (45degrees)
  2. General inspection
    • GTN spray, breathlessness, obvious chest pain,
      sweating, nausea/vomiting, cachexia
    • Associated conditions: Down’s syndrome, Marfan’s
      syndrome, Turner’s syndrome
  3. 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
  4. Inspect face
    • Eyes: xanthalasma, corneal arcus, jaundice?
    • Mouth: Central cyanosis, petechiae, tooth decay
    • General: pallor, malar flush
  5. Inspect neck
    • Carotid pulse (character/ volume)
    • Raised JVP
  6. Inspect chest
    • Pacemakers, scars (sternotomy, thoracotomy),
      chest drains
  7. Palpate chest
    • Apex beat
    • Heaves
    • Thrills
  8. Auscultate chest
    • Heart sounds: murmurs? added sounds?
  9. Auscultate lung bases
  10. Assess ankle and sacral oedema
  11. Offer:
    • Blood pressure measurement
    • Abdominal exam
    • Peripheral vascular examination
    • Appropriate test e.g. ECG, troponin, CXR, CT….
  12. Summarise and conclude
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3
Q

Cardiovascular exam - Pathology (GENERAL INSPECTION)

A
  • 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
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4
Q

Causes of collapsing pulse

A

Aortic regurgitation, patent ductus arteriosus

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5
Q

Cardiovascular examination - Pathology (CHEST INSPECTION)

A

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.

  1. Anterolateral thoracotomy
    - Used in a variety of operations for cardiac, pulmonary,
    and oesophageal pathology.
  2. Axillary thoracotomy
    - A muscle sparing approach to the thoracic cavity
    - Used for pneumonectomy and pneumothorax
    operations.
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6
Q

Causes of irregular pulses, radial-radial delay and radio-femoral delay

A

Irregular pulse = Atrial fibrillation

Radial-radial delay = Large arterial occlusion (atherosclerotic plaque or aneurysm)

Radio-femoral delay = Coarctation of the aorta

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7
Q

Causes of clubbing

A

Cardiovascular causes: Cyanotic congenital heart disease, infective endocarditis

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8
Q

Causes of tar staining

A

Tar staining = Current/ previous Smoker

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9
Q

Description and causes of janeway lesions/oslers nodes

A

Janeway lesions (non-painful erythematous lesions on the palm of the hands) = infective endocarditis

Oslers nodes (painful erythematous lumps on fingertips) = Infective endocarditis

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10
Q

Cause of cold peripheries and prolonged capillary refill time

A

Cold peripheries = reduced oxygenation

Prolonged capillary refill time = Hypovolaemia, hypoxia

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11
Q

Causes of koilonychia

A

Koilonychia = anaemia (Fe deficiency)

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12
Q

Causes of splinter haemorrhages

A

Splinter haemorrhages = infective endocarditis, anaemia (Fe deficiency)

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13
Q

Causes of displaced apex beat

A

Displaced laterally + thrusting quality = volume overload e.g. mitral or aortic regurgitation

Impalpable apex beat (DOPEE) = Dextrocardia, obesity, pneumothorax, emphysema, effusion

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14
Q

How to palpate parasternal heaves and what causes them?

A

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

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15
Q

How to palpate thrills?

A

Thrills should be felt for over the apex, left sternal edge and the base of the heart

They indicate a murmur.

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16
Q

Cause of xanthelasma and corneal arcus

A

Hyperlipidaemia

17
Q

Causes of central cyanosis

A

Hypoxia

18
Q

How can jaundice indicate a cardiovascular condition?

A

Jaundice = Prosthetic heart valve induced haemolysis

19
Q

Description and cause of Petechiae

A

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

20
Q

Description and cause of malar flush

A

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)

21
Q

Causes of variants of the carotid pulse (slow rising, collapsing, small volume, pulsus alternans)

A

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

22
Q

Causes of a raised JVP

A 
Right ventricular failure
Tricuspid stenosis/regurgitation
Pericardial effusion
Constrictive pericarditis
SVC obstruction 
Fluid overload
23
Q

Causes of a raised JVP

A 
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

24
Q

Respiratory Examination - Process

A
  1. Introduction
  2. General inspection
    [inhalers, nebulisers, oxygen, accessory muscles]
  3. Hands
    [Clubbing, fine tremor, course tremor, tar staining,
    pulse]
  4. Face and neck
    [Central cyanosis, xanthalasma, corneal arcus,
    ulceration in the mouth, JVP]
  5. Chest inspection
    [Equal expansion, scars, respiratory rate]
  6. Chest palpation
    [Trachea position, apex beat, chest expansion]
  7. Chest percussion
  8. Chest auscultation
    [Chest and axilla]
  9. Posterior inspection, palpation, percussion and
    auscultation
  10. Lymphadenopathy
  11. Ankle oedema
  12. Conclusion and summary
25
Q

Abdominal examination - process

A
  1. Introduction
  2. General inspection
    [Abdominal distention, pain, jaundice, ]
  3. Hands and arms
    [Dupytrens contracture, palmar erythema, finger clubbing, leuchonychia, koilonychia, purpura, radial pulse, fistulae, injection marks]
  4. Face and neck
    [Xanthelasma, jaundice, pallor, ulcers, pigmentation, telangiectasia, stomatitis, glossitis, poor dentition, gingivitis, candidiasis, tonsillar infections, odours, JVP]
  5. Chest inspection
    [Spider naevi, gunaecomastia, loss of axillary hair]
  6. Abdominal inspection
    [Movement, distension, scars, hernias, dilated veins, scratch marks, pulsations, striae, grey turner’s sign, Cullen’s sign]
  7. Abdominal palpation
    [Superficial, deep, hepatomegaly, splenomegaly, ballot the kidneys, aorta, murphy’s sign]
  8. Abdominal percussion
    [Liver, spleen, bladder, flanks]
  9. Abdominal auscultation
    [Renal bruits, bowel sounds, aorta bruits]
  10. Renal tenderness
  11. Lymphadenopathy
  12. Ankle oedema
  13. Conclusion and summary
26
Q

Cranial nerve examination - Process

A

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

27
Q

Hydration status examination - Process

A
  1. Introduction
  2. General inspection
    [Breathlessness, Catheters, IV fluids, drains,
    vomit/sputum bowels]
  3. Inspect Hands
    [Capillary refill time, skin turgor, temperature, pulse,
    blood pressure, collapsing pulse]
  4. Inspect face
    [Sunken eyes, dry mouth, JVP, carotid pulse]
  5. Inspect and palpate chest
    [Skin turgor, capillary refill time, apex beat]
  6. Auscultate chest
    [Heart sounds, lung bases]
  7. Inspect abdomen
    [Ascites]
  8. Inspect legs
    [Peripheral oedema]
  9. Conclusion
28
Q

Reticuloendothelial examination - process

A
  1. Introduction
  2. General inspection
  3. Cervical lymphadenopathy
  4. Axillary lymphadenopathy
  5. Inguinal lymphadenopathy
  6. Palpate and Percuss liver
  7. Palpate and percuss spleen
  8. Conclusion
29
Q

Diabetic foot examination - process

A
  1. Introduction
  2. General inspection
    • surroundings (drains, drugs, drips, drinks)
    • patient
    • shoes
    • swelling
    • bones/joints
  3. Palpation
    • temperature
    • capillary refill
    • pulses
    • monofilament
    • vibration
30
Q

Describe a Venous ulcer

Site, depth, edges, base, colour, pain, characteristics

A 
Site = Gaiter region
Depth = Superficial
Edges = Sloping
Base = Granulating
Colour = Pink
Pain = Moderate 
Other = varicosities, venous eczema, haemosiderin deposits, lipodermatosclerosis
31
Q

Describe an ischaemic ulcer

A 
Site = Sole
Depth = Deep
Edges = Punched out
Base = Sloughy and pale
Colour = Pale
Pain = Painful
Other = Loss of pulses
32
Q

Describe a neuropathic ulcer

A 
Site = Sole
Depth = Deep
Edges = Punched out
Base = Sloughy and bloody
Colour = Red
Pain = No pain
Other = Neuro loss
33
Q

Neurological examination (upper limb) = Process

A
  1. Introduction
  2. General inspection
    = Walking aids
3. Inspection of the upper limbs
    = Muscle fasciculations
    = Posture, asymmetry
    = Size and shape of muscles
    = Scars or bruising
  1. Assess tone
  2. 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]
  3. 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
  1. Conclusion
34
Q

Neurolongical exam - lower limb -Process

A
  1. Introduction
  2. General inspection
    = Walking aids
3. Inspection of the lower limbs
    = Muscle fasciculations
    = Posture, asymmetry
    = Size and shape of muscles
    = Scars or bruising
  1. Assess tone
  2. 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
  1. Conclusion
35
Q

Thyroid examination - process

A
  1. Introduction
  2. General inspection
  3. Inspect hands + measure pulse
  4. Inspect face and eyes
  5. Inspect neck
  6. Palpate neck and thyroid
  7. Cervical lymphadenopathy
  8. Percuss sternum
  9. Auscultate over thyroid gland
  10. Inspect lower limbs - pre-tibial myxedema
  11. Assess reflexes
  12. Ask patient to stand from a chair without assistance
  13. Conclusion
36
Q

Thyroid exam - Pathology for hyper and hypothyroidism

A
  1. Introduction
  2. General inspection
    HYPER = heat intolerance, sweating, agitation, tremor, weight loss,
    HYPO = cold intolerance, shivering, lethargy/drowsy, puffiness/general oedema, weight gain
  3. 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
  4. Inspect face and eyes
    HYPER = hair loss, Exophthalmos, Lid lag, Lid retraction, opthalmoplegia
    HYPO = Puffiness, hair loss, loss of lateral eyebrows, dry skin
  5. Inspect neck
    HYPER = goitre (GRAVES, MULTINODULAR)
    HYPO = goitre (HASHIMOTO’S)
  6. Palpate neck and thyroid
    HYPER = goitre (GRAVES, MULTINODULAR)
    HYPO = goitre (HASHIMOTO’S)
  7. Cervical lymphadenopathy
  8. Percuss sternum
    HYPER = Retrosternal goitre
  9. Auscultate over thyroid gland
    HYPER= thyroid bruits
  10. Inspect lower limbs - pre-tibial myxedema
    HYPER = Pre-tibial myxedema
  11. Assess reflexes
    HYPER = Brisk reflexes
    HYPO = Slow relaxing reflexes
  12. Ask patient to stand from a chair without assistance
    HYPER = Proximal myopathy
  13. Conclusion

OSCE (8 decks)

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