Long Case Exams Flashcards
1
Q
Please perform an upper limb sensory neurological exam- after 5 minutes I will ask you some questions
A
General Approach
- wash hands
- introduce yourself
- explain what exam entails
- gains consent
- asks about pain
- remarks about whether patient is optimally exposed
General Inspection
- mention posture
- mention environmental aids/devices
- mentions walking aids
- mentions any tremors
Closer Inspection
- mentions any fasciculations
- muscle wasting
- symmetry
- scars
- amputations
- contractures
Soft Touch
- demonstrate on sternum with tap not a stroke
- asks patient to close eyes and tell if they feel the soft touch
- examines each dermatome
Sharp touch
- demonstrates at sternum
- asks patient to close eyes
- assesses each dermatome
Assessment of vibration
- intially tested at sternum with eyes closed
- Test for vibration sensation starting distally - stop when they ‘can feel it’
Questions
- what are your findings on examination?
- What is your differential diagnosis?
2
Q
Perform a Diabetic Foot exam on this patient. When you are done I will ask you a few questions.
A
Initial Approach
- wash hands
- introduce yourself
- explain procedure
- ask for consent
- ask if in any pain
- commont on position and exposure
General Observation
- patient appears well- no apparent pain
- comfortable position
- colour of foot
- orthopaedic shoes
- walking stick
- obvious ulcers
- nails
- cellulitis
- charcots foot
Palpation
- temperature of foot - with back of hands on both sides - start at knees down *if charcots foot, by definition there will be a temperature difference
- capillary refill- normal <2 seconds - perform in 3 toes of each foot
pulses
- Femoral pulse - move along
- popliteal pulse - move along
- posterior tibial - tell them where it is located - midpoint of the line between the medial malleolus and the calcaneous
- dorsalis pedis - located a third of the way from the bisection of the malleoli down the first web-space
Percussion
- monofilament - stocking neuropathy
- explain procedure and ask patient to close eyes
- test on sternum first
- start proximal to distal - start with mid shin and compare sides as you go
- keep asking if it’s the same on both sides - try 5-6 points on the leg *not assessing dermatomes
- Vibration
- test first on sternum
- ask them to close their eyes
- test then on most distal part of big toe
- test on 3 toes
- test on medial malleolus
- reflexes
- feel for tendon first
- knee jerk reflex
- patellar tendon - ask patient to swing legs over bed and lightly bounch hammer off tendon
- ankle reflex
- have them ‘frog leg’ their leg, tap achilles
- Jendrassik maneouvre if they’re having a hard time relaxing - ask them to pull their fingers
- Question
- why are diabetic patients at a higher risk of ‘foot problems’?
- macrovascular ischaemia- due to poor blood perfusion
- microvascular neuropathy - leading to malformation of foot and degeneration of joints
3
Q
please perform an upper limb neurological exam excluding sensation. After 5 minutes I will ask you some questions.
A
Initial Approach
- wash hands
- introduce yourself
- explain procedure
- gain consent
- asks about pain
- remarks on whether patient is optimally exposed
General Inspection
- mention posture
- mention environmental or walking aids/devices
- mention any tremors/involuntary movements
Closer Inspection
- Mentions fasciculations
- mentions muscle wasting
- mentions symmetry
- mentions scars
- mentions amputations
- mentions contractures
Tone
- ask patient to ‘shake hand’ and let their arm go limp - move their arm around in all directions assessing tone
- compares both arms
Power
- start at shoulders ‘try to lift arms like a chicken against my hands’
- push arms like a chicken against my hands
- Test elbows
- Test wrists
- Test fingers
- compare sides
- Give grade out of 5
Coordination
- ask patient to touch their nose, then your finger- patient’s arm should be near full extension
Reflexes
- use reinforcements (Jendrassik manouvre if indicated)
- Biceps reflex - place your thumb on the biceps tendon - strike your thumbnail
- Triceps reflex - have them extend arm to feel it- then tap it directly
- Brachioradialis tendon - on thumb side of forearm - place your thumb down before tapping it
Questions
- what are your findings on examination - systemic description of findings
- What is your differential diagnosis
- clinical symptoms of a disease
4
Q
please perform a lower limb neurological examination exclusing sensation - after 5 minutes I will ask you some questions
A
General approach
- wash hands
- introduce self to patient
- explain procedure
- gain consent
- ask if in any pain
- remak on whether patient is optimally exposed/ positioned
General inspection
- mentions posture
- mentions any environmental aids/devices
- mentions orthopaedic shoes
- mentions walking aids
- mentions any tremors
Closer Inspection
- mentions fasciculations
- muscle wasting
- symmetry
- scars
- amputations
- contractures
GAIT analysis
- ask patient to walk from one side of room to other
- ask them to walk ‘heel toe’ from one side of room to other
Tone and clonus
- perform leg roll
- lift knee and let drop - does heel remain in contact with bed
- ankle clonus while leg is ‘frog legged out
- compare like with like as you go
power
- isolate muscle groups
- hip flexors
- quads
- hamstrings
- anterior tibial
- gastrocnaemius
- toes
Coordination
- ask patient to graze their heel up and down the opposite shin - ask them to repeat on other side
Reflexes
- test patellar reflex - have them swing legs over the side
- test ankle reflex - frog leg patient
- use Jendrassik manouvre if indicated
- check babinski sign
Questions
- what are your findings on examination
- what is differential diagnosis
5
Q
please perform a lower limb sensory neurological examination. After 5 minutes I will ask you some questions
A
Initial Approach
- Wash hands
- introduce yourself to patient
- explain procedure
- gain consent
- ask if in any pain
- comment on exposure and positioning
General Inspection
- posture
- environmental aids/devices
- orthaopedic shoes
- amputations
- contractures
Closer Inspection
- mentions fasciculations
- muscle wasting
- symmetry
- scars
Soft Touch
- initially test soft touch on sternum - do not stroke - only tap
- ask patient to close their eyes
- test dermatomes down the leg
Sharp touch
- demonstrate on sternum -
- ask patient to close eyes
- test down dermatomes on leg
Vibration
- demonstrate on sternum
- ask patient to close eyes
- begin distally and ascend to find sensory level
Proprioception
- tell patient what youre testing - and give demonstration of up and down on toe
- ask patient to close eyes
- hold toe by the sides of it
- ask patient to tell you if it’s up or down
Questions
- what are your findings
- what is your differential diagnosis
6
Q
please examine this patient;s cranial nerves 2 through 6. After 5 minutes I will ask you some questions
A
Initial approach
- wash hands
- introduce yourself to patient
- explains procedure
- gain consent
- ask if in any pain
- comment on positioning/exposure
General inspection
- comment on posture
- comment on focal neurological signs like facial droop
- comment on muscle bulk
- comment on scars, rashes or ptosis
- comment on any obvious abnormalities
- mention symmetry
Cranial nerve 2
- assess visual acuity - both eyes with and without glasses if present - ask them to read clock if snellen chart not available
- “I would like to assess using fundoscopy”
- test visual fields - sit close to the patient and ask them to cover one eye - you cover same eye and compare your visual field to their own
Cranial nerve 2 + 3
- assess pupillary light reflex - have them make a wall between their eyes and test coordination between pupils
Cranial nerve 3 + 4+ 6
- assess eye movement using H
- ask patient to tell you if they see double or if it’s painful
- report any nystagmus
Cranial nerve 5
- assess sensory of trigeminal nerve
- test soft-touch against sternum
- test all three divisions - opthalmic, maxillary, mandibular
- comment on muscle wasting
- assess strength of bit opening and closing - feel for pterygoid function
- offer to do jaw jerk and corneal reflex
Questions
- what are your findings
- what is your differential
7
Q
please examine this patient’s cranial nerves from 7-12. After 5 minutes I will ask you some questions
A
Initial Approach
- wash hands
- introduce self
- explain the exam
- gain consent
- ask if in any pain
- comment on positioning/exposure
General/Close Inspection
- comment on posture
- comment on focal neurological signs
- comment on muscle bulk
- comment on scars, rashes, and ptosis
- mention symmetry
Cranial nerve 7
- raise eyebrows
- close eyes tightlyl - don’t let me open them
- puff out cheeks - don’t let me push them in
- purse your lips
- show me all of your teeth
- ask patient about taste (anterior 2/3)
Cranial nerve 8
- assess hearing with whisper test
- Rinne’s test - tests for sensorineural deafness
- with tuning fork vibrating place it on mastoid process and ask patient if they hear it-
- ask the patient to tell you when they stop hearing it
- take tuning fork away from mastoid process and place outside of hear without touching patient
- normal Rinne’s test - the patient will be able to hear it after it’s removed from mastoid = neurosensory hearing is more acute than conduction
- Weber’s test - tests for conduction deafness
- hit tuning fork
- place tuning fork on forehead
- ask if it is louder on one side or the other or if its the same in both
- If it’s louder in one ear = bad ear- conduction deafnes
Cranial nerve 9
- offer to perform gag reflex
Cranial nerve 10
- inspect the uvula - ask patient to open mouth and say “ahh”
- comment on any deviation
Cranial Nerve 11
- test sternocleidomastoid
- test trapezius
Cranial nerve 12
- assess patient’s tongue, strength, and deviation protrusion
- observe any muscle wasting and fasciculations
Questions
- what are your findings on examination
- what is your differential
8
Q
Please examine this patient’s hands from a rheumatoid perspective. After 4 minutes I will ask you a question
A
Initial approach
- wash hands
- introduce yourself to patient
- explain exam to patient
- gain consent
- ask if in any pain
- place hands on pillow
- expose arms above the elbows
General Inspection
- mentions patients overall status
- mention any devices, medications etc
Closer Inspection
- Z thumb
- swan neck deformity
- boutonniere
- ulnar deviation of fingers
- radial deviation at wrist
- sublaxation
- checks elbows for nodules
- erythema
- scars
- swellings
- thenar eminence wasting
- absence of features
Palpate
- check for warmth
- test for tenderness
- test for swelling
- palpate each individual joint
- squeeze test
assess active movement
- prayer sign
- opposite prayer sign
- make a fist
- thumb opposition
Check function of joints and small muscles
- check function of fingers - pick up a coin and turn a key
9
Q
Perform a Hip exam.
A
Initial Approach
- wash hands
- introduce self
- explain procedure
- gain consent
- ask patient if in any pain
- comment on position and exposure
General Observation
- walking aids
- assymetry
- casts
- displacement of hip
Closer Inspection - look have them stand up
- scars - look at underwear/under clothing
- erythema
- swelling
- deformity
- muscle bulk
Gait observation
- tendelenburg gait
- perform trendelenburgs test
Feel - patient lie down
- bony prominences - ASIS, pubic tubercle, greater trochanter- check for pain
- Feel for temperature
- feel for muscle bulk or wasting
- measure quadriceps and compare
- measure for true and apparent limb length
- true = ASIS to medial maelloelus
- apparent = umbillicus to medial malleolus
Movement
- active movement
- bring knee up to chest
- keep legs straight and lift slightly off bed have them make circles with leg
- passive movement
- lift knee up towards chin
- move leg out to side
- hip at 90 degress and knee at 90, then rotate in and then out
Special Tests
- trendelenburgs test
- thomas test - put hand behind lumbar spine and have them lift leg up with knee bent - if back can’t flatter, the other leg will come off the table
Conclusion
- would like to perform X rays
- would like to exam lumbar spine and knee
- assess distal pulses and perform neurological exams
10
Q
Perform a knee examination
A
Initial Approach
- wash hands
- introduce yourself to patient
- explain procedure to patient
- gain consent
- ask if any pain
- comment on the positioning/exposure
General Inspection
- walking aids
- have patient stand if they can
- gait analysis
- comment on any knee deformities - Varus or Valgus
Closer Inspection
- scars
- erythema
- swelling
- deformity
- muscle bulk
Palpation
- bony prominences - for tenderness
- joint lines - for tenderness
- medial and lateral joint lines while knee bent
- patella and posterior knee while knee extended
- feel for heat
- muscle bulk - 20cm up from tibial tuberosity
- check for effusion - patellar tap test
- milk effusion from froximal to distal
- tap patella of distal femoral condylar surface
Movement
- active
- bring heel up to bum and back out again
- push knee right down towards the table
- straight leg raise
- Passive
- flexion
- extension
Special Tests
- patellar apprehension test
- test patellar tendon moving medial/lateral
- valgus and varus stresses to knee
- test lateral collateral and medial collateral ligaments
- anterior and posterior drawer test - test ACL and PCL
- grasp proximal tibia and pull anteriorly or posteriorly
- posterior sag test - test PCL
- knees bent, feet flat on bed- inspect for posterior sag
- lachman’s test - test ACL
- grasp proximal tibia and distal thigh - tibia is pulled forward to assess degree of anterior motion and thigh is pushes towards table - should hear a click
Conclusion
- would like to perform X rays
- would like to examine joint above and below
11
Q
Perform a thyroid exam on this patient
A
Initial Approach
- wash hands
- introduce yourself to patient
- explain procedure
- gain consent
- ask if in any pain
- comment on positioning and exposure
General Inspection
- flushed
- tremour
- anxious/sweating
- normal body habitus
Closer Inspection
- hands= swelling/clubbing, palmar erythema, fine tremor - test with piece of paper
- Check pulse
- Face = eyebrows, look from above and from the side for exopthalmos and lid lag
- eye - ask them to follow finger - look for double vision or pain
- neck -
- lift chin and look for scars, goitre
- ask them to sip some water - thyroid should move when swallowing
palpation
- palpate gently - assess all lobes - push thyroid over to one side to assess lobe
- describe any masses - size, feel
- goitre - are there palpable nodules? enlarged?
- ask them to swallow while you palpate
- lymph nodes - submental, submandibular, pre-auricular, post auricular, cervical chain, supraclavicular - don’t piano key
- tracheal deviation
Auscultation
- take a deep breath and hold - listen for bruits
Percussion
- tap the manubrium - if there was thyroid extension it would be dull on percussion
Special tests
- pembertons test - put arms in air and look for stridor or flushing
Additional tests
- look for pretibial myxoedema and reflexes
12
Q
Perform an orthopaedic examination of the shoulder
A
Initial Approach
- wash hands
- introduce yourself to patient
- explain procedure
- ask for consent
- ask if in any pain
- comment on position and exposure
General Inspection
- alert, breathing,
- comfortable at rest
- no obvious deformity or ‘squaring’ of the shoulder
- muscle wasting
- splints
- amputations
- casts
Closer Inspection
- scars
- redness
- inflammation
Feel shoulder
- feel one shoulder first - she may have you move on and not have to do the other
- palpate the
- sternum
- clavicle
- sternoclavicular joint
- acromium
- humerous head
- coracoid process
- scapula
- Check temperature
Move
- active
- check all shoulder movements
- if they can’t move it, ask “is it because of pain or weakness”?
- Passive
- do all the same movements for them
- feel for crepitus and stopping of the joint
- offer to do other arm - probably won’t have to
Special Tests
- painful arch - passive up, active down - look for subachromial pain
- scarf test - check for arthritis in head of humerus
- jobbs test - arm abducted and at 45 degress from body, thumb down, have them press up against hand - test for impingement
- Lift off test - arms behind back and press against hand - tests subscapularis
- teres minor/infraspinatus = press out againt hand with extension at elbow
Compound movements
- hands behind head
- two hands both behind back
- cross-directional grab hands behind back
13
Q
Perform a cardiac exam on this person
A
- Initial Approach
wash hands
introduce self
explain procedure
gain consent
ask patient if in any pain
comment on position and exposure
- General Inspection
- walking aids
- devices
- obvious haemodynamic instability (color, oedema, consciousness)
- appearance of respiratory distress
- Hand Inspection
- clubbing
- splinter haemorrhages
- tar staining
- xanthomata (hypercholesterolaemia)
- peripheral cyanosis
- feel pulse (rate, rhythm, character, volume)
- check for collapsing pulse as well
- Blood pressure
- Examine head and neck
- xanthelasma
- corneal arcus (hyperlipidaemia)- or common in older age group
- scleral icterus (yellowing)
- Malar flush (SLE)
- poor dentition
- cyanosis of lips (peripheral)
- cyanosis of tongue (Central)
- Palpate carotid artery
- auscultate carotid arteries for bruits
- examines jugular venous pulsation
- performs hepatojugular reflux
- examines sacrum and lower limbs for peripheral oedema
- Examines Praecordium
- presence/absence of visible apex beat, sternotomy scars and pacemakers
- Palpation of praecordium
- apex beat - demonstrate position
- palpates aortic and pulmonary areas for heaves and thrills
- checks for parasternal heave
- Auscultation
- four valve positions - using both diaphragm and bell
- times pulse
- dynamic manoevers
- moves to left lateral for mitral
- leans forward for aortic
- Inspiration/expiration
- Auscultation of carotids for bruits
14
Q
Perform a GI exam
A
- Initial Approach
- wash hands
- introduce yourself
- explain procedure
- get consent
- ask if in any pain
- General Inspection
- any aids, IV, catheters
- any breathing devices
- any obvious scars or stomas
- any obvious hernias
- cachexia? distension?
- Closer inspection
- caput medusae
- spider naevi
- massess
- pulsations
- scars
- catheters
- Hand inspection
- cyanosis
- koilinykia (spoon nails) - sign of anaemia
- clubbing - signs of lung disease, congenital heart disease, malabsorption, cirrhosis, graves disease
- asterixis - CO2 retention
- palmar erythema (liver cirrhosis and pregnancy)
- wrist
- pulse and respiratory rate
- face
- xanthalasma
- corneal icterus
- conjunctival pallor
- angular stomatitis
- mouth ulcers
- poor dentition
- candida infection
- Palpate
- palpate all 9 areas soft then hard (right hypochondrium, epigastric, left hypochondrium, right flank, umbilius, left flank, right iliac fossa, suprapubic, left iliac fossa) - watch face as you do it - with light tough lift up quickly to assess for rebound tenderness
- palpate the liver
- ballot the kidneys
- palpate the spleen
- Percuss
- percuss for liver borders
- percuss for spleen
- Auscultate
- bowel sounds
- renal bruits
- If hernia present
- mention location of hernia, scars, overlying skin changes, cough impulse, ask patient to lift head off the bed for palpation, attempt reduction of hernia
- Conclude: would like to check for hernias and perform a DRE
15
Q
Perform a respiratory exam focussing on the posterior chest
A
- Initial Approach
- Wash hands
- introduce yourself
- explain procedure
- gain consent
- ask if in any pain
- General inspection
- observes environment
- mention haemodynamic and respiratory stability
- mentions resp rate
- any aids/devices
- use of accessory muscles
- Inspection of hands
- clubbing
- cyanosis
- tar staining
- wasting of small muscles
- asterixis
- Inspection of posterior chest
- scars
- symmetry
- deformities
- scoliosis
- kyphosis
- Palpation of posterior chest
- chest expansion
- tactile fremitus
- Percussion of posterior chest
- apex and axilla are percussed
- auscultation
- apex and axill are auscultated - listens throughout breathing cycle
*
- apex and axill are auscultated - listens throughout breathing cycle
