FOCP Flashcards
Hand examination
Look: When inspecting, assess if changes are symmetrical, involve mainly PIP/DIP, MCP/wrist
Palms down
□ swelling/deformity/muscle wasting/scars/thinning skin and bruising (steroid use)/ rashes
□ Nail changes (psoriatic, nail fold vasculitis)
Palms up
□ When asking the patient to turn their hands over, do they have difficulty with this movement?
□ Muscle wasting, particularly over thenar and hypothenar eminences, palmar erythema, ?carpal tunnel release scar
Ask the patient to lift their hands up and show you their elbows - ?psoriatic plaques at the elbows, ?Rheumatoid nodules
Feel :
Ask about pain
Palms up:
□ Radial pulse
□ Palpate Hypo-/thenar eminences bulk and assess for any tendon thickening
□ Median and ulna nerve sensation (eyes closed and assess sensation over thenar and hypothenar eminence and the index and little finger)
Palms down:
□ Temperature – forearm, wrist, MCP joints
□ Radial nerve – sensation over 1st web space
□ Squeeze MCP joints and watch face for pain
□ Bimanually palpate and MCP/PIP/DIP joints that appear swollen/painful - ?synovitis (‘rubbery’ feel, swollen, tender, warm)
□ ?any bony swelling – squaring of 1st MCP, Heberden’s/Bouchard’s
□ Bimanually palpate wrists
□ Run your hand up the extensor surface of the forearm to the elbow - ? Rh nodules.
Move:
Active:
□ Ask patient to straighten their fingers
□ Ask patient to make a fist
□ Assess wrist extension/flexion by asking the patient to make a prayer sign and inverted prayer sign
Passive:
□ Assess finger extension and flexion; wrist flexion and extension
Power:
□ Median nerve – test power of thumb abduction
□ Ulna nerve – test finger abduction
□ Radial nerve – test power of finger extension
Special Tests
If there is evidence of median nerve entrapment:
Phalen’s manouevre
□ Wrist held in forced flexion 60 seconds. Paraesthesiae/ pain/ numbness may indicate median nerve compression
Tinel’s sign
□ Percuss over nerve – if paraesthesiae occurs, suggests nerve entrapment
Function:
□ Ask patient to grip your 2 fingers (power grip)
□ Ask patient to pinch your finger using their thumb and index finger (pincer grip)
□ Ask patient to pick up small object e.g. coin/pen/undo shirt button
L
Diabetic foot examination
Inspection (feet & legs) • Hair loss • Muscle wasting • Scars & previous operations • Ulceration & fungal infections (inc plantar surface and between toes) • Nails (fungal infections) • Charcot joint Palpation • Temperature • Capillary Return • Peripheral pulses (dorsalis pedis, posterior tibial, popliteal, femoral) Sensation • Light touch using 10g monofilament • Vibration sensation with tuning folk placed on distal joints (as neuro exam) Proprioception • As in neuro exam Reflexes • Ankle reflex General observation • Gait • Inspect footwear General Questions • Previous vascular interventions • Edinburgh Claudication Questionnaire • Previous history of foot ulceration
Shoulder examination
Look for: Symmetry, posture, muscle wasting, scars
Feel
□ Temperature over front of shoulder
□ Palpate bony landmarks – start at sternocalvicular joint, clavicle, acromioclavicular, acromion process and around the scapula.
□ Palpate joint line
□ Palpate muscle bulk – supra+infraspinatus, deltoids
Move
Active movements:
□ Internal and external rotation
□ Flexion and extension
□ Adduction and abduction (? Painful arc)
Passive movements:
□ Repeat the above movements whilst assessing for crepitations
□ When assessing abduction, stand behind the patient to assess any excessive scapula movement
Function
□ Hands behind head and back (as high as possible)
Peripheral vascular examination
Inspection
• nails and hands
• face and neck (corneal arcus and xanthelasma, Horner’s syndrome, hoarseness of voice, prominent veins in neck, shoulder and anterior chest
Upper limbs COMPARE BOTH LIMBS
• Temperature
• CRT
• Palpate radial & brachial pulses
• Perform BP
• Palpate carotid pulses and auscultate for bruit
Abdomen
• Inspect for epigastric/umbilical pulsation, mottling, weight loss
• Palpate for AAA (flat)
• Auscultate for renal bruit
Lower limbs- COMPARE BOTH LIMBS
• Inspect -colour, scars, between toes and heels
• Temperature
• CRT
• Palpate
-Dorsalis pedis pulse-feel in middle of dorsum of foot just lateral to tendon of extensor hallucis longus
-Posterior tibial pulse-feel 2 cm below and 2cm behind the medial malleolus using pads of your fingers
-Popliteal pulse-flex knee 30 degrees, thumb in front of knee and fingers 2 cm below knee crease press firmly
-Femoral pulse-tell patient what you are going to do- use pad of index and middle finger over artery
• Check for radio-femoral delay
• Auscultate for femoral bruits
• Buergers test
• ABPI
Breast examination
Inspection
Patient should be sitting or standing
Inspect both breasts both from the side and the front
Hands relaxed on thighs
Hands on waist and push inwards
Hands behind head
Palpation
Lie patient down with head on pillow
Hand on same side as breast to be examined place behind head
Examines all areas of the breast including the underside of breast and axillary tail in a systematic manner either
Spiral
Clock face
Palpates over the nipple
If there is any discharge present, attempt to, or asks patient to express any discharge from the nipple.
Repeats in entirety on the opposite side
Lymph nodes
Axillary – chest wall, anterior, posterior
Supraclavicular lymph nodes
Checks both sides
Hip examination
□ Look:
o Observe with the patient standing, muscle bulk (esp gluteal muscle bulk) – Note, this may be done later when assessing gait if patient already on couch.
o Observe with patient lying flat on couch (scars, redness, swelling, flexion deformity and muscle wasting)
o Measure true leg length (ASIS to ipsilateral medial malleolus) - 2cm discrepancy between legs is significant
□ Feel: Palpate greater trochanters for pain
□ Move: With the knee flexed, assess full hip flexion/ extension
o Internal/ external rotation (with the knee flexed at 90 degrees)
Special Tests
□ Thomas’ Test
o Patient lies flat on the examination table and doctor places hand under the lumbar spine (removing lumbar lordosis).
o Fully flex one hip, bringing the knee towards the patient’s chest and observe the CONTRALAERAL hip (this is the side that is being tested for a fixed flexion deformity). The test is positive (i.e. a fixed flexion deformity is present) if the contralateral hip to the one being moved, lifts from the couch).
□ Trendelenburg’s Test: Patient stands on one leg. In a normal test, the pelvis will stay level (or even rise). Weakness of abductor muscles is demonstrated if the side contralateral to the side you are testing droops (the side that you are testing is the side that they are standing on).
o Examiner holds hands out for support
□ Function:
□ Assess patient’s gait (note ensure that you inspect gluteal muscle bulk if not done previously)
Endocrine examination
General observation
• Lethargy/ disinterested ↓
• Dry coarse hair↓
• Alopecia ↑
• Dry skin ↓
• ‘Peaches & cream’ complexion ↓
• Hoarse/Deep voice ↓
• Agitated/Fidgety ↑
• Sweaty ↑
• Pre –tibial myxedema ↑ (Graves)
• Kyphosis ? osteoporotic fracture ↑
Hands
• Palmar erythema ↑
• Thyroid acropathy ↑ (Graves)
• Onycholysis ↑ ↓
• Tremor ↑ (out stretched arms, palms upwards – single sheet of paper to assess fine tremor)
• Pulse (brady ↓ tachy ↑ AF ↑) – rate, volume, rhythm
Face
• Lid lag ↑
• Proptosis ↑
• Oedema around the eyes ↑ ↓
• Loss of outer part of eyebrows ↓
• Tongue – smooth, ? associated B12 def ↓
• Buccal mucosa pigmentation -? Addision’s disease
Neck Inspection
• Scars from previous surgery
• Asymmetry & swelling
• Observe on swallowing (water)
Neck Palpation (from behind)
Ask prior to examination: if any pain is present in the neck
• Place hands on the front of patients neck with index fingers just touching
• Feel for abnormalities whilst patient swallows (water)
• Note the site, shape, size, edges, consistency, attachments transillumination & inflammation of any swelling/ goitre
• Feel for thrill & pulsation
• Lymph nodes
• View from behind & above and assess for exopthalmos, dysthyroid eye disease
Percussion
• Percuss sternum for dullness (retrosternal goitre) and across clavicles if appropriate
Auscultation
• Auscultate over swelling with diaphragm and listen for bruit
Reflexes
• Ankle reflex (slow relaxation ↓) (brisk - ↑)
Test for proximal myopathy
• Patient to hold arms out – try and push them down
• Ask patient to stand up from chair (with arms folded across the chest)
Cardiovascular examination
• Inspects nails and hands, CRT Feels for -radial pulse for rate / rhythm -collapsing pulse -radial-radial delay - radial –femoral delay (or states intention) • Records BP • Examines face/ eyes (Malar flush, pallor, jaundice, xanthelasma, corneal arcus • Examines mouth • Assess JVP • Feels carotid pulse • Inspects precordium (scars, deformity) • Palpates apex beat • Palpates for heaves & thrills • Auscultates over aortic, pulmonary, tricuspid and mitral areas with diaphragm & bell* (intensity, splitting, added sounds or murmurs) • Times with carotid pulse • Auscultates in axillae area • Auscultates over the carotid arteries Manoeuvres • Moves patient onto left side and listens over mitral area (expiration, with bell) • Sits patient forward and listens at both right and left sternal edge (expiration, bell) Listen to a few beats first before accentuating the sound using expiration • Auscultates lung bases • Feels for sacral oedema Feels for ankle oedema, calf tenderness,
GALS examination
Screening questions:
□Do you have any pain or stiffness in your muscles joints or back?
□Can you dress yourself completely without any difficulty?
□Can you walk up & down the stairs without any difficulty?
Gait
□Asks the patient to walk a few steps, turn and walk back
Spine
□Inspect from behind examine shoulders, spine, gluteal bulk, level iliac crests, popliteal, calf muscles & hind foot
□Inspect from the side- cervical, thoracic & lumbar spine and knee flexion/hyperextension
□Ask patient to touch their toes and assess lumbar flexion with 2-3 fingers
□Inspect from the front –shoulders, elbows, quads, knees & forefoot
□Ask the patient to perform lateral flexion of the neck
□Assess TMJ (open jaw, move from side to side)
Arms
□ Assess shoulder abduction & external rotation (hands behind their head)
□ Inspect the wrists and hands – muscle bulk etc.
□ Assess power grip (squeeze examiners fingers)
□ Fine precision pinch (each digit)
□ Squeeze metacarpal joints 9one hand a time)
Legs
With patient lying on the bed:
□ Assess passive full knee flexion and internal rotation of hip in flexion (feel for crepitus)
□ Patella tap
□ Exam the soles of the feet
□ Squeeze the metacarpals joints
L
Upper motor examination
Inspection
General Inspection of patient’s appearance, demeanor, apparent discomfort.
Exposure from waist up or vest top; compare R to L
Look for Deformity, asymmetry, wasting, hypertrophy, abnormal movements: fasciculation; tremor; dystonia; Chorea (athetosis)
Tone
Shake forearm and watch hand flopping;
Hold hands, support elbow and put wrist, elbow shoulder through ROM including:
flexion
extension
pronation
supination.
Feel for rigidity, flaccidity and cogwheeling.
Power
Ask patient to perform the movement and apply resistance. Compare R to L.
Shoulder: abduction, adduction (C5 C6)
Elbow: flexion , extension (C5 C6 C7)
Wrist: extension C7 Radial
Finger:
extension- fingers straight, C7 Radial,
Adduction & Abduction - paper test palmer interossei –ulnar nerve and splayed fingers dorsal interossei –ulnar nerve
Thumb: Abduction - palms up thumb up - Abductor pollicis brevis - median nerve. Ring test (opposition) -thumb to little finger
Reflexes:Biceps C5-6, Triceps C6-7, Brachioradialis C5-6
Coordination
Rapid alternating hand movements
Finger-nose test
Function: Pick up coin/button up shirt, Drink glass of water
Elbow examination
Look
Patient standing in anatomical position:
□ Look from the front for the carrying angle
□ Look from the side for flexion deformity
□ Scars, swelling, rash (e.g. psoriasis), nodules, bursitis
Feel
□ Temperature of back of elbow joint and forearm
With the elbow held flexed at 90 degrees:
□ Palpate the olecronon process, head of radius, joint line. Evidence of synovitis?
□ Palpate the lateral and medial epicondyles (tenderness/bursitis)
Move
Active:
□ Full flexion, extension, pronation and supination
Passive movements – one hand on back of elbow joint to feel for crepitus during the movements:
□ Repeat the above movements
Fucntion:
□ Ask the patient to put their hand to their mouth
Sensory examination
Inspection
Exposure – vest top and shorts
Compare R to L observe front and back, looking for deformity, asymmetry, wasting or hypertrophy
Light (fine) touch
Using a wisp of cotton wool
Perform control by lightly touching (NOT stroking) the skin of the sternum.
Ask the patient to close their eyes and say “Yes” when sensation is felt.
Apply cotton wool in a systematic but unpredictable pattern working around the limbs covering all dermatomes.
Compares sides for symmetry.
Maps out any areas of reduced or absent fine touch sensation
Superficial pain (mediator for superficial pain):
Uses Neurotip
Performs control of sharp and blunt on the sternum
Asks the patient to close their eyes and to say “sharp”, “blunt”.
Apply the neurotip in a systematic but unpredictable pattern working around the limb covering all dermatomes.
Compares sides for symmetry.
Map out any areas of absent pin prick sensation.
Disposes of neurotip into sharps bin.
You are testing sharp
Temperature
Not routinely tested but asks patient if any changes noted.
Vibration
use a 128Hz tuning fork
Performs control by placing the vibrating tuning fork on sternum
Asks the patient to close their eyes.
Applies the vibrating tuning fork to a distal bony prominence (first DIP or first IP joint) and asks the patient if they can feel the vibration. Progress proximally, if deemed necessary.
Compare sides.
Proprioception (joint position sense)
Stabilises the IP joint of middle finger and then big toe
Holds the lateral aspects of the distal phalanx with the first and second fingers of dominant hand.
Demonstrate up and down
Ask the patient to close eyes and say “up” or “down” as they move the phalanx.
Compares both sides.
Perform Romberg’s test
Lower limb only.
Lower motor examination
Close inspection Compare R to L observe front and back for Deformity, asymmetry, wasting or hypertrophy Look for abnormal movements: fasciculation; tremor; dystonia; chorea (athetosis) Tone Leg rolling Lift knee briskly Ankle clonus Power Ask patient to perform the movement and hold it as you attempt to displace it. Compare R to L. Hip; flexion, extension Knee: flexion, extension Ankle: dorsiflexion, plantarflexion, Big toe: extension Reflexes Knee (L3-4) Ankle (S1) Plantar/Babinski reflex (S1) Coordination Heel-shin test Function Gait
Cranial nerve examination
Inspect
Look for muscle wasting, scars, rashes, asymmetry,
Sensory
Test light touch and superficial pain bilaterally, with cotton wool and neurotip in all 3 divisions of the V nerve.
Test at central point first.
Avoid angle of jaw
Motor
Test bulk of temporalis and masseter with teeth clenched. Tests power against resistance with jaw open and side to side. Looks for any deviation
Jaw Jerk Reflex
States they would do corneal reflex
Inspect
Looks for asymmetry, involuntary movements, eye closure
Motor
Instructs patient to do following movements
Wrinkle forehead or look up above their head
bare teeth
Test power
close eye tightly (and stop me opening them)
blow out cheeks (and stop me pushing them in)
Mentions/asks about taste anterior 2/3rds of tongue
Asks patient to:
Speak(British Constitution) listening for dysarthria or dysphonia
Say “Aahh” and observe movement of uvula/palate
Blow out cheeks and feel/listen for air escaping form the nose
Cough
Mention gag reflex and swallow test
Inspect sternocleidomastoid and trapezius for muscle wasting from front and behind
Motor
Shrugs shoulders and apply resistance
Turn head from side to side and apply resistance
Compares sides
Inspect
Tongue for wasting, fasciculation’s.
Asks patient to protrude tongue looking for deviation
Asks patient to wiggle tongue from side to side
Motor
Test power asking patient to push tongue into cheek-cheek and apply resistance
Gastrointestinal examintion
Inspects hands Looks for asterixis (flap) Takes Pulse, CRT, blood pressure JVP Lymph nodes, Virchow’s node (Troisier’s sign) Inspection of the face Eyes:- jaundice, anaemia Mouth:- Ulcers, Dehydration, angular stomatitis, glossitis Lie patient Flat Close inspection of the abdomen Inspect for herniae on coughing Palpation At level of abdomen, eyes on patient’s face Elicit area of pain (examine last) Light and deep palpation all 9 areas Percussion/rebound tenderness Palpates – liver, spleen, aorta Ballots Kidneys Percussion:Liver, Spleen, Shifting Dullness; Bladder if history indicates Auscultation: Bowel sounds, Aortic Bruits, Renal Bruits Iliopsoas sign Feels for ankle oedema Conclude examination States intent to check hernial orifices, do a digital rectal examination and examine the external genitalia
