General Examination

Question 1

Process of taking radial pulse (HR)

Answer 1

Medial to the distal radius with the pulps of the forefinger, middle and ring finger of the examining hand. Count the rate over 30 seconds (and record as beats per minute)

Question 2

What are Korotkoff sounds?

Answer 2

K1: pressure at which a sound is first heard over the artery is the systolic blood pressure K2: deflation of the cuff continues the sound increases in intensity K3: then decreased K4: Becomes muffled K5: then disappears (diastole)

Question 3

How to take a blood pressure

Answer 3

Cuff is wrapped around the patient’s upper arm (which should be supported at the level of the heart) and the bladder centred over the brachial artery. This is found in the antecubital fossa immediately medial to the biceps tendon. For an approximate estimation of the systolic blood pressure, the cuff is fully inflated and then deflated slowly (2 mmHg per second) until the radial pulse returns ( palpation method ). Then, for a more accurate estimation of the blood pressure, this manoeuvre is repeated with the stethoscope placed over the brachial artery ( auscultation method ).

Question 4

Why does BP change between arms?

Answer 4

1. Non dominant to dominate hand (more accurate on non dominate) 2. Possible atherosclerosis 3. Normal 10mmHg

Question 5

Blood pressures? AHA

Answer 5

• Optimal blood pressure: <120/80 • High normal blood pressure: 130–139 mmHg systolic; and/or 85–89 mmHg diastolic. • Mild hypertension (grade 1): 140–159 mmHg systolic; and/or 90–99 mmHg diastolic. • Moderate hypertension (grade 2): 160–179 mmHg systolic; and/or 100–109 mmHg diastolic. • Severe hypertension (grade 3): ≥180 mmHg systolic; and/or ≥110 mmHg diastolic. • Isolated systolic hypertension: ≥140 mmHg (diastolic <90 mmHg)

Question 6

Temperature?

Answer 6

Normal: 36.8°C (range 35.6°C to 37.7°C) In mouth or ear; it is about 1°C less and 0.6°C more in rectum. Temperature is normally higher in the afternoon than in the morning.

Question 7

Respiratory Rate? (RR)

Answer 7

• The normal rate is between 12 and 20 breaths per minute for a healthy adult. • An increased rate may be due to lung disease of almost any type, cardiac failure or metabolic disturbances such as acidosis, or psychological conditions such as anxiety.

Question 8

SpO 2 (pulse oximetry)?

Answer 8

1. Placed on earlobe or finger 2. >95% is generally considered normal. 3. <90% is very abnormal and may indicate respiratory failure.

Question 9

Why do we assess the patient?

Answer 9

-Identify systemic conditions not revealed by the patient -Better assess and diagnose the patient’s condition -Better manage surgical complications -Treatment planning and patient management -Prevention or appropriate management of a medical emergency -Improves rapport and trust of the patient

Question 10

Order of general assessment?

Answer 10

1. RFA 2. General appraisal 3. H&N exam, cranial nerves 4. Face 5. Eyes 6. Hydration 7. Hand and Nails 8. Vitals 9. Level of Consciousness: Glasgow Coma Scale, AVPU Score

Question 11

H&N exam in general assessment? E/O

Answer 11

• Overall appearance (colouring, nervous, unwell?) - Asymmetry or deformation (congenital, infective, surgical, malignancy, bells, glands) - Lymphadenopathy -TMJ Analysis (AAOP, Durham et al, 2015): MoM, Trismus, Mouth opening <35mm, -Sinus (tenderness to palpation, unilateral, discharge) -Goitre

Question 12

H&N exam. I/O

Answer 12

-Lips, Labial and BM, Palate, FOM, tongue, tonsils/throat (uvula/airway category (Mallampati Score- intubation), gingiva (keratinized/nonkeratinized). -Dentition -Saliva (quality and quantity) - meds, sjogrens -deviations - Hypoglossal damage, stroke, met, parkinson’s)

Question 13

Neck assessment - Lymphadenopathy in general assessment?

Answer 13

(Weiss 2012) Bimanual Palpation from behind the patient- Submental, Submandibular, Pre & Post-auricular, Anterior and Posterior Triangle, Supraclavicular

Neck Mass Causes: Inflammatory, Neoplastic, Congenital – consider diagnostic sieve and anatomy

1) Inflammatory : Infective – Viral (Mononucleosis) , Bacterial (Salivary Gland- Parotid), or granulomatous disease ( Sarcoidosis) Odontogenic causes Usually in kids, check for fevers, general discomfort
2) Neoplastic: Lipoma, Pleomorphic Adenoma, Neurofibromatosis , Metastatic neck lesions, Salivary Gland Malignancies (Mucoepidermoid, Adenoid cystic carcinoma) 3) Congenital: Epidermoid Cysts/ Dermoid Cysts

Question 14

Lymph drainage (robbins 2002) -Why is there a classification?

Answer 14

Benninger et al, 2011, A Head and Neck Lymph Node Classification Using an Anatomical Grid System While Maintaining Clinical Relevance that Aim to unify anatomical and clinical systems -surgical landmarks and patters on cancer metastasis -IA, IB, IIA, IIB, III, IV, V, VI

Question 15

Lymph drainage -IA (anterior triangle)

Answer 15

Submental (IA): -Drainage: FOM, anterior tongue, ant mandibular ridge, lower lip -Boundaries: ant digastric, body of the hyoid, synthesis of the mandible

Question 16

Lymph drainage - IB (anterior triangle)

Answer 16

Submandibular (IB): -Drainage: Ant nasal cavity, soft tissue of mid face, submandibular gland -Boundaries: body of the mandible, stylohyoid, ant/post belly of digastric

Question 17

Lymph drainage - IIA/IIB

Answer 17

Upper Jugular (IIA, IIB): -Drainage: Oral cavity, nasal cavity, nasopharynx, oropharynx hypopharynx, larynx, parotid gland Boundaries: Base of skull, inf body of hyoid, stylohyoid, spinal accessory and SCM

Question 18

Lymph drainage - III

Answer 18

Middle Jugular (III): -Drainage: Oropharynx, Nasopharynx, oral cavity, larynx -

Boundaries: inf hyoid, cricord cartliage, sternohyoid m, SCM

Question 19

Lymph Drainage - IV

Answer 19

Lower Jugular (IV): -Drainage: Hypopharynx, thyroid, cervical oesophagus

-Boundaries:inf cricoid cartliage, clavicle, SCM, sternhyoid m

Question 20

Lymph Drainage - VA/B

Answer 20

Post Triangle (VA, VB): -Drainage: Naso/oro pharynx, Cutaneous structures of posterior scalp and neck

-Boundaries: SCM/Trap m. inf cricoid cartlage

Question 21

Lymph Drainage - VI

Answer 21

Ant Triangle (VI): -Drainage: Thyroid Gland, glottic, subglottic larynx, apex of piriform sinus, cervical oesophagus

-boundaries: hyoid bone, suprasterbal, CCA

Question 22

Cranial Nerve Examination - I Olfactory

Answer 22

Smell test with different bottles, ask patient if they notice change in smell

Question 23

Cranial Nerve Examination - II Optic

Answer 23

Visual Acuity (Snellen Chart). Visual Fields (Hat-pin). Each eye tested separately -Visual Acuity Pt to be 6 m from the chart, Normal if line marked 6 can be read properly Ask pt to read the smallest line possible -Visual Fields: Hat pin in clinician’s hand, moving side top and bottom Any dis-appearance would indicate pathology on various regions within the optic nerve

Question 24

Cranial Nerve Examination - III Occulomotor - IV Trochlear - VI Abducens

Answer 24

Check for Ptosis, Nystagmus, Strabismus Diplopia: Ask patient to follow finger in H pattern- check pain, diplopia (double vision), restriction of movement, ptosis -Light Reflex: With torch shine light from the side into one of the pupils- check for constriction, the other pupil will also constrict due to consensual response -Accomodation: Ask pt to look into the distance than onto an object your holding- 30 cm away – should see constriction of both pupils - Accommodation: Check constriction of pupils when asked to focus on a hat-pin 30 cm away III- Sympathetic innervation – pupil dilation- mydriasis III – Parasympathetic innervation – constriction – miosis CN II, III (Superior Rectus, Inferior Rectus, Inf Oblique, Medial Rectus) - Pupillary Reflex with light, Size and Symmetry of pupils CN IV- Superior Oblique CN VI - Lateral rectus

Question 25

Cranial Nerve Examination - V Trigeminal

Answer 25

Corneal Reflex, Facial reflex, Masseter Reflex; Motor Function: Ask patient to clench, move jaw laterally, open against resistance (check muscles of mastication) - V1 Lightly touch cornea with soft cottonwool medially from the side- check sensation(VI) and for blinking (Facial) Check facial reflex of all three branches with pin on face Motor Function: Ask pt to push and pull jaw against force Masseter Reflex: Let mouth open and relxed, tap jaw with tendon hammer – should slightly close

Question 26

Cranial Nerve Examination - VII Facial

Answer 26

Facial Asymmetry: Raise eyebrows, puff cheeks, smile CN VII: Ask pt to raise eybrows, puff cheeks, smile. Causes of damage: Vascular, Scwanoma, MS

Question 27

Cranial Nerve Examination - VIII Vestibulocochlear

Answer 27

Hearing: Cover one ear, and whisper in the other ear, If unclear : Rinne’s/Weber’s Test Vestibular: Head Impulse Thrust Test (HIT)

Question 28

Cranial Nerve Examination -IX and X (Glossopharyngeal and Vagus)

Answer 28

Ask the pt to say ‘Ah’ using tongue depressor, check soft palate rise symmetrically Uvula deviation to aside – unilateral Xth nerve palsy Ask pt to cough, swallow Gag Reflex by touching back of the pharynx (IX)

Question 29

Cranial Nerve Examination -XI Accessory

Answer 29

Shrug shoulders and turn head R- L against resistance

Question 30

Cranial Nerve Examination - XII Hypoglossal

Answer 30

Inspect tongue wasting, fasciculations, asymmetry. Lateral movement and protrusion

Question 31

Patient colouring (Pallor) in the general assessment?

Answer 31

Flushed, Pale, Cyanotic etc: - Sympathetic Response (Stress/ Anxiety) - Deep lying venous system or Opaque Skin - Anaemia - Shock

Question 32

What is shock?

Answer 32

Shock is defined as reduction of cardiac output where oxygen demands of tissues are not being met Signs: Pallor, cool and clammy skin, hypotension

Question 33

What do we check about eyes in the general assessment?

Answer 33

1. Check for pupil size (dilation due to sympathetic stimulation), shape, reaction to light and accommodation. asymmetry 2. Check stare/gaze 3. Eye colouring - sclera: red/hemorrhage, blue/osteogenesis imperfecta

Question 34

How to check Hydration in general assessment?

Answer 34

A dehydrated patient has a risk of postural hypotension > Syncope Appropriate levels of hydration is key Total Body Water: 70 Kg male – 40L Signs: - Sunken orbits - Lethargy - Dry mucous membranes (intra-orally) - Reduced skin turgor (Mod – severe dehydration) - Dry axillae (Not practical in the dental setting) - Check BP sitting, then again at standing- Postural hypotension?

Question 35

How do we check Hands for in general exam?

Answer 35

Look, Feel, Move, Assess -Colour, shape, Joints, movement Abnormal Colour: - Pallor of palmar surfaces (Anaemia) - Vitiligo- Autoimmune Adrenal Failure - Yellow Tar Staining – Chronic cigarette smoking Movement: - Neurological issues, arthritis Joints -normal range of motion, nodules

Question 36

How do we check Nails in the general exam?

Answer 36

1. Abnormal Shape of nails -Clubbing (IE, Chronic IBD, Lung cancer, Cyanotic heart disease) 2. Abnormal Architecture -Splinter Haemorrhages (IE), Koilonychia (Iron deficiency, Raynaud’s Phenomenon) -Onycholysis (Thyrotoxicosis) 3. Abnormal Colour - Cyanosis (Blue Nails), Polycythaemia (Reddish- Blue Nails)

Question 37

HR methods?

Answer 37

1) Carotid - Ant border SCM with slight posterior displacement - Level of thyroid cartilage - Easily palpated, even when others are weak 2) Radial Artery - Just medial to the radius, check 30 secs

Question 38

HR abnormalities overview?

Answer 38

Normal Ranges: 60- 100 Bpm Tachycardia (>100) – Fever, pain, stress, exercise, Hyperthyroidism, Cardiac (Valvular/ Vascular pathology) Bradycardia (<60) – MI, Hypothyroidism, AF, Hypoglycaemia Rhythm: - Irregularly Irregular: AF - Regularly Irregular: Sinus Arrythmia - Check for 1 min

Question 39

What is sepsis?

Answer 39

Life threatening systemic organ dysfunction in response to infection Bacteraemia> SIRS (Systemic Inflammatory Response Syndrome) > Multiple Organ Dysfunction Syndrome > Death Mortality rate: 25-30%

Question 40

What are the 4 SIRS?

Answer 40

SIRS If >2 features of the 4: 1. Pyrexia (>38.3) 2. Tachycardia (>90 beats/ min) 3. Tachypnoea (>20 breaths per min) 4. High WBC

Question 41

Treatment for Sepsis?

Answer 41

Treatment Guidelines: Sepsis 6 by UK Sepsis Trust – 50% reduction in mortality rate – www.sepsistrust.org 1- Administer Oxygen 2- Take blood cultures Give IV Ab’s Give IV Fluids Check serial lactases Urine Output

Question 42

What is pyrexia?

Answer 42

Temperature change - can result in death, sign of febrile -Hyperpyrexia – Defines as > 41.6 Deg C -Hypothermia – Defined as < 35 Deg C

Question 43

BMI?

Answer 43

Body Mass Index ->30 obese -25-30 Over Weight -19-25 Normal -<19 Underweight -Look for changes

Question 44

What is the Glasgow Coma Scale (GCS) ?

Answer 44

-Objective description of impaired consciousness Inter-examiner variability -Complex -Useful to track consciousness over a time period Based on Eye opening, Verbal response, Best motor response. -Indications: Work up for medical emergency Trauma Neurological deficit (Nuttall AGL et al 2018)

Question 45

What is the APVU scale?

Answer 45

• Simpler score than GCS - American College of Surgeons - 4 broad scores - No formal training/ equipment required - Easily utilised at bed side A: Alert V: Responsive to Verbal Stimulation P: Responsive to Painful Stimulation U: Unresponsive (Nutall AGL et al, 2018)

Question 46

What are sago charts used for?

Answer 46

Standard Adult Observation Chart -Yellow; Use clinical Judgement - Frequent review (less than 8 hourly) -Red; Rule Based Approach - Mandatory escaulation