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Clinical Skills > General Examination > Flashcards

General Examination Flashcards

1
Q

What are the body parts examined in a general examination?

A

Hands
Arms
Head and Neck
Face
Legs
Feet

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2
Q

What aspects are assessed in the initial assessment?

A

Records
Appearance
Conscious level/behavior
Environment

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3
Q

What is the NEWS2 chart?

A

A chart that monitors vital signs

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4
Q

What are the vital signs monitored by a NEWS2 chart?

A

Pulse rate
Temperature
Respiratory rate
Oxygen saturation (pulse oximetry)
Blood pressure
Conscious level

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5
Q

When does a NEWS2 chart indicate clinical deterioration?

A

A NEWS2 score of 5 or 6 is considered a key threshold that may indicate clinical deterioration and should prompt an urgent response by a clinician.

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6
Q

What are you looking for when examining appearance?

A

Signs of distress (pain, fast breathing, distressing cough)
Signs of abnormalities (Sweating, pallor, plethora, jaundice, pigmentation, rashes)
Body habitus (weight, height, deformaties)
A community alarm or medical alert bracelet/necklace
Fraility

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7
Q

What is a community alarm?

A

A community alarm is fitted to a home telephone and the resident is given an emergency button to wear around their neck or wrist

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8
Q

What is a medic alert bracelet?

A

The purpose of medical ID (alert) jewellery—identification necklaces and bracelets with medical information inscribed on them—is to provide emergency health workers with information about any conditions you may have.

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9
Q

How can you determine how alert a patient is?

A

AVPU scale

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10
Q

Things to look for when assessing alertness

A

Pain?
Engaging normally?
Confused?

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11
Q

What are examples of important things to note when assessing the environment?

A

Oxygen mask
Vomit bowl or sputum pot
Medication devices - inhaler, nebuliser, GTN spray
Nasal tube
Intravenous infusion
Monitoring devices
Hearing aids
Smoking devices
Mobility equipment - walking sticks, crutches, wheel chair

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12
Q

What does the AVPU scale stand for?

A

Alert
Responds to verbal stimuli
Responds to pain stimuli
Unresponsive to stimuli

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13
Q

What are examples of important things to note when assessing the environment?

A

Oxygen mask
Vomit bowl or sputum pot
Medication devices - inhaler, nebuliser, GTN spray
Nasal tube
Intravenous infusion
Monitoring devices
Hearing aids
Smoking devices
Mobility equipment - walking sticks, crutches, wheelchair

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14
Q

What is the normal range of body temperature?

A

36 - 37.5 degrees C

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15
Q

What is considered hypothermia?

A

Body temp <35 degrees C

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16
Q

What is the most common way to measure body temperature?

A

Aural/tympanic/ear

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17
Q

What is the second most common way to take the temperature?

A

Non-contact - forehead

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18
Q

What is a normal reading for oxygen saturation?

A

> 96%

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19
Q

What can read to false (high or low) readings of oxygen saturations?

A

Cold extremities
Nail varnish
Different skin tones

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20
Q

What condition can cause false high oxygen saturation readings and how can you spot it?

A

Carboxyhaemoglibin - formed during carbon monoxide exposure as seen in smoke inhalation

Patients can have a rosy complexion but can be grossly oxygen deprived due to carbon monoxide’s higher binding affinity for haemoglobin preventing normal levels of oxygen carriage in the blood.

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21
Q

What two values make up arterial blood pressure?

A

Systolic blood pressure
Diastolic blood pressure

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22
Q

What does systolic blood pressure represent?

A

The peak pressure within the arterial system following ventricular contraction

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23
Q

What does diastolic blood pressure represent?

A

The residual pressure within the arterial system before the next contraction.

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24
Q

How much of a difference in blood pressure in each arm is considered normal?

A

10mmHg

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25
Q

Normal blood pressure reading

A

120/80

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26
Q

What should be avoided when taking blood pressure?

A

It is best to avoid obtaining a blood pressure in the same arm in which an arteriovenous fistula (a surgically formed link between the arterial and venous systems used to aid haemodialysis treatment) is present, or where lymphedema (persistent, non-gravity related swelling) exists.

27
Q

What should be used to take blood pressure if bilateral arteriovenous fistulas or lymphedema exist?

A

A lower extremity blood pressure

28
Q

When should blood pressure measurements be delayed?

A

One should delay obtaining a blood pressure is if the patient has smoked, exercised, or had caffeinated products or other stimulants prior to the measurement.

29
Q

How does smoking impact blood pressure?

A

Smoking 30 minutes before the procedure can transiently elevate the blood pressure.

30
Q

How does exercising impact blood pressure?

A

Exercising before measuring the blood pressure can lower the reading.

31
Q

How can caffeine impact blood pressure?

A

Caffeine or other exogenous adrenergic stimulants taken before the measurement can acutely raise the blood pressure reading.

32
Q

Why is blood pressure measured by palpation?

A

Up to 20% of elderly hypertensive patient have an ‘auscultatory gap’.

An auscultatory gap is a period of diminished or absent Korotkoff sounds during the manual measurement of blood pressure.

The improper interpretation of this gap may lead to blood pressure monitoring errors:

  • underestimation of systolic blood pressure
  • overestimation of diastolic blood pressure
33
Q

Examination of the hands

A

This involves both inspection and palpation. Inspect the dorsal and then palmar aspects of both hands noting changes in the skin, nails, soft tissues (muscle wasting) tendons and joints.

34
Q

How can you assess the clubbing of the fingers?

A

Check for loss of Shamroth’s window (ask the patient to hold two fingers back to back. Normally
there should be a diamond-shaped window centred over the nail beds, this is lost in
clubbing)

35
Q

What do you do after checking for clubbing?

A

Feel the temperature of the hands, then move on to inspect the fingernails.

36
Q

What do pale nail beds indicate?

A

The nail bed can appear excessively pale during vasoconstriction as occurs in shock or anaemia or take on a blueish tinge in cyanosis (inadequate oxygenation of the blood).

37
Q

What is the normal capillary refill time of the nails?

A

Normal less than or equal to 2 seconds (up to 4 seconds in the elderly).

38
Q

How do you assess the capillary refill time of the nails?

A

Press on the nail bed for 5 seconds, release and then observe the refill time

39
Q

How do you assess the joints?

A

Shapes - deformities or swollen areas
Ask the patient to make a fist - to check for pain-free, full movement, of all joints

40
Q

What is muscle wasting of the hands?

A

Muscle atrophy is the wasting or thinning of muscle mass.

41
Q

What does muscle wasting of the hands indicate?

A

Neurological disease

42
Q

What is palmar erythema and what does it indicate?

A

Bright red warm hands

Carbon dioxide retention and hyperthyroidism
Can also be found in pregnancy

43
Q

What can a tremor represent?

A

Neurological disease

44
Q

What are the two tremours to test for?

A

Fine
Flapping

45
Q

How do you assess tremours?

A

Fine (lie hands flat)
Flapping - This is done by asking the patient to extend the arms and to extend the wrists (bend the hands backwards at the wrists).

The arms must be kept extended for at least 15 seconds for this type of tremor to become evident and gentle exaggeration of the position by the clinician by pushing the hands further back can sometimes elicit a response.

46
Q

How to assess pulse rate?

A

Beats per min

When taking the pulse, it is acceptable to save time by carefully counting for 15 seconds and multiplying by 4.

47
Q

How is respiratory rate measured?

A

The respiratory rate is the number of breaths per minute (a breath in and out is one breath)

It will only be accurate when counted over a full minute, and as patients often tend to alter their respiratory rate when they know it is being counted, it is often counted surreptitiously while the patient still thinks that the pulse is being taken.

Only vital signs under voluntary control

48
Q

How do you examine the arms?

A

Inspect both arms for evidence of:
* Joint deformity
* Bruising/pigmentation/rashes/skin lesions
* Scars or wounds
* Venous damage due to intravenous drug use (often called track marks) or medical intervention
* Assess skin turgor on forearm to determine hydration status

49
Q

What are you looking for during the overall examination of the face?

A

Symmetry
Colour
Hair distribution

50
Q

What are you looking for during the overall examination of the face?

A

Symmetry
Colour
Hair distribution

51
Q

How do you examine the eyes?

A

It is usually easiest to examine the pupils first; look for any loss of symmetry in shape or size.

Following this ask the patient to look up and gently pull down on the lower lids to examine the conjunctiva and the sclera.

52
Q

Signs in the face

A

Exopthalmos – protrusion of the eyes in the orbits (sockets) may suggest Graves’ disease (which affects the thyroid as well as the eyes).

Acromegalic facies – very coarse facial features in an adult may suggest acromegaly (adult growth hormone excess) as a diagnosis.

Malar Flush – a characteristic reddening of the cheeks sometimes seen in mitral stenosis, a heart valve condition.
Ptosis – drooping of the eyelids can be a sign of Myaesthenia Gravis, a condition that leads to problems with muscle contraction

Jaundice - often first seen as a yellow discolouration of the normally white (sclera) of the eye, but as jaundice progresses and serum bilirubin increases, the skin and mucous membranes may also acquire a yellow hue.

53
Q

Examination of the mouth

A

To clearly examine the mouth you will need to use your pen torch to give you good light.

You may also need to learn to use the wooden spatula (tongue depressor) to help you see the back of the tongue and the throat (pharynx).

Asking the patient to keep their tongue in their mouth and to say ‘Ah’ often helps you see the back of the throat without using the spatula.

Look for evidence of ulceration, abnormal pigmentation or changes to the tonsils.

54
Q

Signs of central cyanosis in the mouth

A

When all the skin and/or lips have a blue tint.
It is usually a sign of low levels of oxygen in the blood.

55
Q

Signs of the mouth

A

Angular stomatitis - fissuring at the angles of the mouth which may indicate an iron deficiency

Thrush (candidiasis) – fungal infection apparent as a white, adherent layer on the tongue or cheeks, suggesting immunosuppression.

Gingival Hypertrophy - (gum margin swelling) may indicate disease or be a side-effect of certain drugs such as phenytoin sodium (a drug used for epilepsy)

56
Q

Lymph nodes that need to be examined

A
  • Supraclavicular
  • Deep anterior cervical chain including the tonsillar node
  • Submandibular and submental lymph nodes
  • Pre and post auricular lymph nodes
  • Lymph nodes of the posterior triangle of the neck and occipital lymph nodes.
57
Q

Examination of the upper anterior area of chest

A

Inspect the skin on the anterior chest for any skin lesions and inspect to obtain an impression of the overall chest shape.

58
Q

Examination of the legs

A

Begin by inspecting the legs and comparing the two sides for the health of the skin (including colour) and the presence of any swelling.

Smooth skin and loss of hair can be signs of poor arterial circulation or in more severe cases there may be ulceration or infection.

Palpate gently. Are the legs warm or cool? Is there a difference between the sides? If you consider there is swelling present assess for oedema.

59
Q

How to assess pitting oedema?

A

Pressing the skin firmly for up to 15 seconds and then removing your finger or thumb and seeing if there is an indentation left.

60
Q

What is a pitting oedema?

A

A collection of excess fluid in the interstitial space and is usually most marked at the most dependant part of the body (due to gravity).

In an ambulant patient this will be the ankles but bed-bound patients will likely display pitting oedema in the sacral (lower back) region.

61
Q

What is pitting oedema a sign of?

A

Pitting edema is commonly caused by poor circulation or the retention of excess fluids.

62
Q

How do you examine the feet

A

Compare both sides and look at the overall shape of the feet for deformities.

Look for joint swelling.

Capillary refill time can be checked on the nail- beds of the toes as well as on the fingers (but this is less commonly done in adults as there may be problems due to chronic poor vascular disease in older patients).

Remember to look at the soles of the feet.

63
Q

Lower limb signs

A

Varicose veins – visibly distended veins (more prominent on standing due to additional effects of gravity) caused by incompetent valves in the long veins of the leg.

Stasis eczema – a common condition appearing as itchy, dry, flaky, reddened skin affecting the lower leg.

Hallux Valgus – Deviation of the great toe laterally (in valgus), usually acquired), often associated with a bunion over the metacarpophalangeal joint (where the toe meets the foot) of the great toe

Clinical Skills (6 decks)

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