Examinations - Jon Flashcards
1
Q
Describe your gastrointestinal examination
A
- General inspection:
- Comfortable at rest versus distressed patient
- Obvious jaundice, anaemia, cachexia, mental state
- Hands:
- Pulse rate, capillary refill
- Palmer erythema, pallor, Dupuytren’s
- Hepatic flap
- Arms:
- Brusing, wasting, spider naevi, scratch marks
- Face:
- Scleral jaundice, pallor of the conjunctiva, xanthalesma, optic rings
- Dental condition, stomatitis, chelitis, geographic tongue
- JVP, note any neck swellings
- Chest
- Gyanecomastia, spider naevi, body hair
- Abdomen - ask about tenderness:
- Inspect
- Scars, distension, caput medusae, striae, bruising, pigmentation
- Palpate
- Masses, organomegaly
- Liver, spleen, kidneys (comment on whether palpable or not)
- Percuss
- Liver size
- Ascites; if present check for shifting dullness
- Inspect
- Groin:
- Check for hernias - stand up if concerns
- Testes, lymph nodes
- Legs:
- Bruising, oedema, wasting
- Other:
- Rectal exam, cardiovascular exam, vitals for trend etc.
2
Q
Describe your examination of an abdomen
A
- Inspection:
- Scars, distension, prominent veins, striae, bruising, visible swellings
- Palpation - check for tenderness
- Percuss then palpate
- Liver palpable?
- Spleen palpable?
- Kidneys ballotable?
- Acites present?
- Groin
- Check for hernias standing and lying
- External genitalia exam
- Digital rectal exam and proctosigmoidoscopy
3
Q
Describe your examination of a patient with known portal hypertension
A
- General Inspection:
- Jaundice, anaemia, cachexia
- Hands:
- Palmer erythema, Dupuytren’s, pallor of the palmer creases, clubbing
- Asterixis (abnormal urea metabolism impairs midbrain function)
- Radial pulse
- Arms:
- Striae, scratch marks, bruising spider naevi
- Face:
- Jaundice, flushing, optical rings, lips and tongue for cyanosis
- JVP
- Chest:
- Gynaecomastia, loss of hair, spider naevia
- Abdomen:
- Inspect:
- Caput medusae, ascites/distension, scars
- Palpate - ask for tenderness:
- Hepatomegaly, splenomegaly
- Liver edge character
- Percussion:
- Liver span
- Ascites
- Inspect:
- Groins:
- Hernias, hydrocoele
- Rectal exam and proctosigmoidoscopy
4
Q
Describe your peripheral vascular exam
(directed at lower limbs)
A
- General Inspection
- Comfortable at rest, anaemia, prostheses
- Inspection of legs:
- Stigmata of arterial disease:
- Loss of hair, digital ulcers, amputations, trophic nail changes
- Stigmata of venous disease:
- Haemosiderin, LDS, oedema, venous ulcers, varicosities
- Stigmata of diabetic foot:
- Altered morphology, diabetic ulcers, dry, cracked skin
- Surgical scars; GSV harvest, stripping, stab phlebectomy
- Check between toes
- Stigmata of arterial disease:
- Palpation
- Warmth, dryness, capillary refil time
- Pulses; femoral, popliteal, PT, DP
- Focused neurology:
- Sensation; gross and monofilament awareness
- Power; gross
- Proprioception and vibration
- Special tests:
- Arterial
- ABPI, Beurger’s angle (follow by drop)
- Venous
- Trendelenberg; occlude the SFJ and check for quick refill; this test is rarely performed and adds little to management.
- Diabetic
- HbA1c, high ABPIs; toe pressures
- Duplex USS, CTA, MRA, Angiograms
- Arterial
5
Q
Describe your head and neck exam
A
- General Inspection:
- Comfortable versus distressed; audible breathing?
- Appropriately dressed for weather?
- Agitated or somnolent?
- Body habitus
- Hands:
- Tremor, diaphoresis, pulse rate, dry hands, thyroid acropachy (clubbing)
- Onycholysis
-
Inspect from the front:
- Eyes:
- Exopthalmos, lid lag, chemosis, diplopia, Horner’s
- Mouth:
- Lingual thyroid
- Consider bimanual oral exam; palpate ducts
- Assess dentition
- Face:
- Facial plethora
- Neck:
- Inspect:
- Scars, swelling, skin changes, asymmetry, sinuses
- Poke out tongue
- Ask to swallow water
- Skin for lesions (melanoma, SCC, BCC, lipomata)
- Inspect:
- Eyes:
- Move behind:
- Palpate - ask for tenderness
- Masses, lymph node levels
- Thyroid - ask to swallow
- Palpate - ask for tenderness
- Percuss
- Retrosternal thyroid
- Ausculate for carotid bruit or thyroid bruit
-
Special tests:
- Large goitre:
- Pemberton’s
- Retrosternal dullness
- Hyperthyroidism:
- Tendon reflexes
- Pre-tibial myxoedema
- Voice check; high pitch and range
- Nasoendoscopy
- Parotid:
- Facial nerve
- Transilluminate thyroglossal cyst
- Large goitre:
6
Q
Describe your examination of an inguinal hernia
A
- Patient standing initially (if practical)
- Inspect:
- Scars in the groin and abdomen
- Site and size of the hernia
- Extension into scrotum
- Abdominal distension
- Palpate - Check for tenderness:
- Assess extent; into scrotum?
- Assess reducibility
- Inguinal or femoral?
- Check contralateral side
- Check umbilicus and surgical scars on abdomen
- Ask patient to lie down
- Re-palpate
- If irreducible; can you get above it?
- Transilluminate with pen torch
- Examine testicles
- Assess relationship to femoral pulse and tap GSV if concerns re saphena varix.
7
Q
Describe your clinical assessment of nutrition
A
- General inspection:
- BMI estimation - unreliable in acute setting
- Gestalt appearance of weight loss
- Hands:
- Radial pulse, CRT
- Wasting in the thenar and intrinsic muscle groups
- Grip strength
- Arms:
- Deltoid and triceps bulk
- Face
- Skeletal emergence
- Jaundice of the sclera
- Pallor of the conjunctive
- Stomatitis, angular cheilitis (zinc deficiency)
- Abdomen
- Scaphoid abdomen
- Distension with Kwashiokor
- Surgical scars; especially bariatric or oncological surgery
- Check drains and outputs
- Legs
- Quadriceps bulk; scalloping with wasting
- Calves bulk
- Oedema
- Special tests:
- Anthropometric measurements
- Objective grip strength
- CPEX testing
- Malnutrition Universal Screening Tool
8
Q
Describe your examination of the hands
(Carpal Tunnel, Dupuytren’s, Ulnar Palsy etc)
A
- Look:
- Wasting, asymmetry, scars, positional change, skin changes
- Feel - check for tenderness:
- CRT
- Assess gross sensation of the autonomous zones
- Radial - 1st dorsal web space
- Ulnar - Outer border 5th finger
- Median - Outer border of Index finger
- Move:
- Assess median nerve (L.O.A.F.):
- Opponens pollicus - ring with thumb and little finger; pull apart
- Abductor pollicus - lift thumb to sky with flat hand
- Assess ulnar nerve:
- Palmer interossei - Adduct fingers against examiner finger
- Dorsal interossei - Abduct fingers apart
- Assess radial nerve:
- Extend fingers against resistance
- Extend wrist against resistance
- Assess median nerve (L.O.A.F.):
- Special tests:
- Froment’s sign - paper retained within 1st webspace - Ulnar
- Elbow flexion for cubital tunnel syndrome
- Tinnel’s and Phalens for carpel tunnel syndrome
- Specific functional grips; key, hammer, pinch
9
Q
Describe your examination of the cranial nerves
A
- Olfactory
- Ask if there’s been a change in the sense of smell
- Formally, vials of smelling salts
- Optic
- Ask about changes in visual acuity
- Snellen chart for formal assessment
- Visual fields with moving fingers in each quadrant
- Occulomotor, Trochlear, and Abducens
- H-pattern for diplopia
- Test accomodation at same time
- Trigeminal
- Sensation of the face in V1, V2, V3 zones
- Corneal reflex
- Facial
- Puff cheeks, grimace, smile, shut eyes against resistance
- Vestibulocochlear
- Hearing grossly assessed with distracting sound in other ear
- Rinne’s and Weber’s with hearing loss
- Glossopharyngeal
- Swallow, assess uvula deviation, gag reflex
- Vagus
- Talk and swallow (crossover with CN IX)
- Spinal accessory
- Shrug shoulders
- Deviate head from midline against resistance
- Hypoglossal
- Point out tongue
10
Q
Describe your parotid examination
A
- Inspection:
- Look for wasting, asymmetry, scars, masses, and FACIAL NERVE palsy
- Ask the patient to oopen their mouth for oral cavity inspection
- Palpate:
- Assess any lump of the parotid with S.C.T.N.M.
- Bimanual oral examiation; gloves, ducts, SMG, and parotid via buccal raphe
- Palpate the cervical lymph node basins I-VI
- Facial Nerve:
- Assess the facial nerve
- Temporal - Frontalis wriknles forehead
- Zygomatic - Orbicularis occuli closes eyes
- Buccal - Buccinator blows out cheeks
- Marginal mandibular - Levator angularis oris draws smile
- Cervical - Grimace tenses platysma
- Assess the facial nerve
11
Q
“Examine this patient’s neck”
A
- Inspect:
- Scars, swelling, skin changes, asymmetry, sinuses
- Poke out tongue
- Ask to swallow a sip of water
- Note the size and location of any possible thyroid lesion
- Move behind:
- Palpate after asking about areas of tenderness
- Masses
- Lymph node levels
- Ask to swallow while palpating
- If large goitre:
- Can you get below it?
- Check for retrosternal dullness
- Special tests:
- Pemberton’s sign (for >30 sec)
- Stigmata of hyperthyroidism:
- Tendon reflexes
- Pre-tibial myxoedema
- Voice check; high pitch and range
- Nasoendoscopy
- Transilluminate a thyroglossal cyst
12
Q
Describe the Trendelenberg and Perthes’ Tests
A
Primarily of historical interest as the information gleaned from these tests is more reliably found on duplex USS
Trendelenberg:
- The patient’s leg is emptied of venous blood with elevation with the patient supine
- The SFJ is occluded with the examiner’s hand with firm pressure
- The patient is asked to stand and the varicosities are inspected
- The test is positive if the varicosities fill quickly with release of the SFJ pressure; ie the SFJ is incompetent
Perthes’
- Repeat the Trendelenberg test and allow the varicosities to fill, re-occlude the SFJ
- Ask the patient to stand up and down on their toes several times; this activates the muscle pump and if the perforators are competent then the varicosities should empty (normal test result).
13
Q
A
