OSCEs Flashcards
Describe cardio exam.
Summary:
- Usual intro, general inspection, 45°
- Inspect hands (1,2,3)
- 1- front (Janeway lesion, osler)
- back (splinter haemorrhage…2- xanthoma, tar staining)
- 3- cap refill, temperature….clubbing
- Arms
- Pulse, radio-radio delay, collapsing pulse
- BP, brachial pulse
- Neck (Carotid pulse, JVP, hepatojugular reflex)
- Face
- eye (pallor, xanthelesma)
- mouth (central cyanosis, angular stomatitis, dentition, high arched palate)
- Chest Inspection (deformity, scars,.. pacemaker, ICD,.. visible pulsation)
- Palpation (apex, heaves thrills)
- Auscultate
- heart (4 regions + lean forward and roll left)
- carotid
- lung bases
- Edema (sacral, pedal edema)
- Further assessment (Peripheral vascular, ECG, …glucose level,urine dipsticks, fundoscopy)
Describe peripheral vascular exam
Summary:
- Usual intro, general inspection
- Upper body (same as cardio):
- Inspect hands (1,2,3)
- 1- front (Janeway lesion, osler)
- back (splinter haemorrhage…2- xanthoma, tar staining)
- 3- cap refill, temperature….clubbing
- Arms
- Pulse, radio-radio delay, collapsing pulse
- BP, brachial pulse
- Neck (Carotid pulse)
- Abdomen (see abdo exam)
- Inspect (visible pulsation)
- Palpation (expansion of aorta)
- Auscultation (aortic bruit)
- Lower limb
- inspection
(cap refill, pallor, temp, muscle wasting, hair loss, ..ulcers, discolouration,
scars, edema, varicose veins, missing toes) - palpation (femoral, popliteal (auscultate), post tib, dorsalis (lateral to EHL))
- motor (wiggle toes)
- sensation (distally to proximally)
- Buerger’s test (2-3mins, angle <20 degress = severe ischemia, reactive hyperaemia)
- Further exam (CV exam, ABI, lower limb neuro)
Describe resp exam.
Summary:
- Usual intro, 45°,
- general inspection (O2, SOB/accessory muscles, cough/stridor/wheezing, scars/deformities)
- Hands (peripheral cyanosis, clubbing, tar staining,
rheumatological changes, temperature
- Arms
- Asterixis (metabolic encephalopathy, in hypercapnia, CCF, liver failure, renal failure)
- Pulse, resp rate
- Head and neck (JVP, central cyanosis, Horners) (miosis, ptosis, anhidrosis (decreased sweating), with or without enophthalmos (inset eyeball)
Chest (anterior and posterior) - Inspection (scars (chest drains), chest deformities, asymmetery) - Palpation (trachea, lung expansion) - Percussion - Auscultation (lungs, vocal fremitus) Additional - Neck LN (CA) - Sacral and pedal edema
Describe abdo exam.
Summary: - Usual intro, supine, - General inspection (comfortable, scars, masses jaundice obvious pallor abdominal distantion)
Hands Inspection
- Clubbing – inflammatory bowel disease / cirrhosis / coeliac disease
- Koilonychia – spooning of the nails – chronic iron deficiency
- Leukonychia – whitened nail bed – hypoalbuminemia (liver failure / enteropathy)
- Palmar erythema – reddening of palms – liver disease / pregnancy
- Dupuytren’s contracture: (Thickening of the palmar fascia, Associated with alcohol excess / family history)
- Hepatic flap (asterixis)
Arms
- Bruising, Petechiae
- Scratch marks (skin scraped off because of cholestatic pruritis)
- Track marks
- Palpate for axillary lymphadenopathy – malignancy / infection
Eyes
- Xanthelasma, Conjunctival pallor, Jaundice
Mouth
- Angular stomatitis – inflamed red areas at the corners of the mouth – iron/B12 deficiency
- Oral candidiasis – white slough on oral mucous membranes – iron deficiency / immunodeficiency
- Mouth ulcers – Crohn’s disease / coeliac disease
- Tongue (glossitis) – smooth swelling of the tongue with associated erythema – iron/B12/folate deficiency
Neck
- Cervical lymph nodes
- Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy
Chest
- Spider naevi – central red spot with reddish extensions (>5 significant) – chronic liver disease
Gynaecomastia – liver cirrhosis / digoxin/ spironolactone
Detailed abdominal inspection:
- Scars, Masses, Pulsation (AAA), stomas, striae, Abdominal distension
- Caput medusae – engorged paraumbilical veins – portal hypertension
- Cullen’s sign – bruising surrounding umbilicus – retroperitoneal bleed (pancreatitis/ruptured AAA)
- Grey-Turner’s sign – bruising in the flanks – retroperitoneal bleed (pancreatitis/ruptured AAA)
- Palpation (9 quadrants,
liver, spleen,
Murphy’s sign, urinary bladder,
aorta, kidneys) - Percussion (9 quadrants, liver span, spleen, shifting dullness)
- Auscultation (bowel sounds, renal bruit, aortic bruits)
- Further exam (PR, hernia orifice, genitourinary)
Normal liver span 6-12cm
Describe cranial nerve exam
Exam Summary:
Positioning/Exposure
- Sitting opposite in a chair, face and neck exposed
General Observation
- Patient is comfortable, alert and awake
- Any walking aids, ask for reading glasses/contacts
Inspection (Face, eyes, scars)
- Face: drooping, asymmetery, facial wasting, fasciculations
- Eyes – ptosis, proptosis, pupillary inequality, deviation of eyes
- Scalp for craniotomy scars
CNI – Olfactory
- Ask for changes in smell/taste (can also be CN VII and IX)
- Can test using strong smelling substances (coffee beans, vanilla, isopropyl alcohol wipes)
– don’t use pungent substances (CNV)
CNII – Optic (3) - Visual acuity – make sure to ask patient to wear reading glasses if present
- Visual fields – remove reading glasses (COVER 1 EYE)
- Visuospatial Neglect
CNII/III – Optic and Oculomotor (3)
- Light reflexes (direct and consensual)
- Test for afferent pupillary defect (shine light from one pupil into the other, look for relaxation – reduced acuity -> reduced direct reflex)
- Accommodation (constriction of both pupils)
CN III/IV/VI – (1) Oculomotor, Trochlear and Abducens - Eye movements (III – superior/inferior/medial rectus, inferior oblique, IV – superior oblique, VI – lateral rectus) – look for nystagmus, ask for double vision
- Check for saccadic movement
- Difficulty holding upward position at midline – myasthenia gravis
CN V – Trigeminal (Ophthalmic, Maxillary and Mandibular divisions) (3+3)
- Light touch sensation in each sensory division (can you feel it? Same on both sides?)
- Pin prick
- Corneal reflex (cotton wool brought in to the side of the cornea)
- Test muscles of mastication (masseters and temporalis muscle – clench jaw)
- Test pterygoids (open mouth, don’t let me close)
- Test the jaw jerk reflex (let your mouth fall, tap with tendon hammer over finger)
CN VII – Facial (4 branches +2)
- Frontalis muscle power (raise eyebrows “don’t let me push down”), Frown (temporal branch)
- Obicularis oculi muscle power (shut your eyes and don’t let me pull them open) (zygomatic branch)
- Obicularis oris (puff out your cheeks) (Buccal)
- Smile showing teeth , Purse lips (whistle) (mandibular)
- Notice any change in taste (ant 2/3 tongue)
- Hearing sounds louder than usual (stapedius paralysis)
CN VIII – Vestibulocochlear
- Hearing screening test
- Webers test – tuning fork 512 in midline on forehead “is it louder in 1 ear)
- Rinne’s test – tuning fork on mastoid, when bone conduction is lost test air conduction (positive Rinne’s test is normal)
CN IX/X – Glossopharyngeal and Vagus (4+)
- Open mouth and inspect the palate and uvula, Say “ahhhh” – check for symmetrical rise of the uvula (will deviate to normal side if abnormal)
- Ask the patient to cough
- Test for ability to swallow
- (optional)Test for gag reflex (sensory IX, motor X) or touch the back of the pharynx w/ a tongue depressor
CN XI – Accessory (2)
- Shrug shoulders, “don’t let me push it down” (trapezius)
- Sternocleidomastoid muscle power – turn head into hand (turn your head to your right and don’t let me stop you)
CN XII – Hypoglossal
- Examine tongue at rest (wasting and fasciculations)
- Protrude the tongue and look for deviation (will deviate towards lesion as tongue muscles push)
Offer - All other neurological examinations
Describe lower limb neuro exam.
Exam Summary: Look, Tone, Power, Reflexes, Light Touch, Pain, Vibration, Proprioception, Coordination
Positioning/Exposure
- supine, legs and thighs entirely exposed
General Observation
- …
Inspection
- SWIFT (Scars, Wasting of muscle, Involuntary movement, Fasiculations, Tremor)
- Posture (UMN hemiplegia – lower limb extension)
Tone
- Test in the knees and ankles, flex and extend the knee at varying speeds
- Test for clonus in the ankles, move the ankle around to ensure relaxation and then sharply dorsiflex
Power
- Test hip flexion/extension/abduction/adduction,
- knee flexion/extension,
- ankle dorsi/plantar flexion
- Toe up and down
Reflexes
- Knee jerk
- Ankle jerk
- Plantar reflex
Light Touch (L2-S1) - Test individual dermatomes, compare left and right and ask if they are the same
Pain
- Offer to do pain (sharp dull differentiation) in all dermatomes
Vibration
- Test on the MTP head or more proximally if there is loss of vibration sense distally
Proprioception
- Test using the big toe, knees and hips if necessary
Coordination
- Heel-shin test
- Foot-tapping – tap foot against your hand as fast as they can- dysdiadochokinesis
Gait
Heel 2 toe
Heel (L5)
Toe (S1)
Squat and stand
Rombergs
- Examine stance and posture – asymmetry
- Ask to walk a few steps and turn around – foot drop, circumduction, symmetry of hips, shuffling/Parkinsonian gait, wide based cerebellar gait , antalgic gait (spending most time on 1 foot in stance phase)
- Tandem gait (heel to toe) – cerebellar ataxia
- Walking on the toes - S1 lesion
- Walking on heels L4/5 lesion causing footdrop
- Squat and stand (proximal myopathy (L3/4)
- Romberg’s
Offer - All other neurological examinations
- MSK lower limb examinations (knee, hip)
Describe hand and wrist exam.
Exam Summary: Look, Feel, Move
Positioning/Exposure
- Sitting opposite, expose the joint above (elbow) and below (N/A), remove all jewellery
General Observation
- Observe posture deformities
Inspection
- Examine the joint from all angles
- Nail changes –discolouration, pitting and ridging (psoriatic arthritis), vasculitic rash near nails (rheumatoid arthritis), splinter haemorrhages (infective endocarditis or systemic lupus erythematosus)
- Joint deformity – ulnar deviation, Z thumb, swan neck, Boutonniere’s deformities (rheumatoid arthritis), Bouchard’s nodes on PIP, Heberden’s nodes on DIP (osteoarthritis)
- Joint changes – swelling, erythema
- Wrists and elbows – rheumatoid nodules and gouty tophi (palpate for changes aswell)
- Skin changes – erythema, atrophy, scars, rashes (psoriatic rash – scaly erythematous plaques on extensor surfaces)
- Muscle wasting – thenar eminence, hypothenar eminence (carpel tunnel syndrome)
Palpation
- Ask for tenderness
- Check temperature of joints
- Palpate wrists, anatomical snuffbox, MCP, PIP and DIP feeling for swelling, sublaxation and checking for tenderness, LF Bony swelling (hard and immobile – osteoarthritis), boggy swelling (soft and spongy – synovitis), fluctuant swelling (effusion)
- Squuze MCPs
- Test for wrist crepitus
Move + Special test: 3 + Passive
- Test active movements first – gross screening tests of hand, wrist and arm movements
- Finger flex/ext, abd/add, grip, pincer grip, Thumb abduction (palms and thumb pointing ceiling), dexterity (undo button, write name, take off/put on watch)
- Prayer position (wrist extension), Reverse prayer (wrist flexion + carpal tunnel syndrome)
- pronate hands, form a fist (finger flexion), release fist quickly (finger extension + trigger finger),
- If there is time, check all passive movements, if no time, only do passive movements if a problem was found on active movement
Offer
- Elbow and Shoulder examinations
- UL neurological examinations
Describe shoulder exam.
Positioning/Exposure - Standing with top exposed
General Observation - Observe for aids – arm sling
- Observe patient removing clothing – check for pain and limitation in movement
- Any obvious deformities/malalignments
Inspection
- Skin changes – erythema, rash, scarring)
- Muscle changes – wasting/disuse atrophy
- Alignment – symmetry (shoulder and scapula)
- Joint – swelling
Palpation
- Ask for tenderness
- temperature
- sternoclavicular joint , acromioclavicular joint, coracoid process, humerus
- border of the scapula
Move, (6 movments + scapular during abduction+
Passive)
- flexion, extension, abduction, adduction,
- external rotation and internal rotation (hands up back)
- Assess scapular movement during abduction (abduct while hand on scapula)
- Passive movement
Special Tests(5)
- Anterior Apprehension test
- Supraspinatus – abduct arm at side against resistance at 0 degrees
- Supraspinatus – painful arc assessment – raise patients arm and ask them to lower slowly (pain between 60-120O suggest impingement)
- Infraspinatus and teres minor – arm forward and elbow flexed, externally rotate against resistance
- Subscapularis – hand behind back palm outwards, push out against resistance
Offer - Neck and elbow examinations
Describe knee exam.
Positioning/Exposure
- Lying supine, exposed from the joint above (hip) to the joint below (ankle)
General Observation
- Observe for aids – mobility aids
- Observe for any obvious deformities/malalignments
Inspection
- Skin changes - erythema, rash, scars
- Muscle wasting
- Swelling, deformities (valgus/varus)
Palpation
- Ask for tenderness
- Palpate quadriceps for wasting
- joint temperature
- Patellar tap
- bulge test (sweep medial side upward, then lateral side downward to see a bulge)
- Raise knee to 90O and palpate along the patella, tibial tuberosity, head of the fibula and along the joint line (tenderness and bony swelling)
- Palpate the popliteal fossa – Bakers cyst
- MEASURE quadriceps bulk (20cm above tibial tuberosity)
Move
- Active movements first – knee flexion/extension
- Passive movements – flexion (feel for crepitus), extension
Special Tests
- Anterior/posterior drawer test (ACL/PCL)
- Medial and lateral collateral ligaments
- McMurray’s test (medial and lat menisci)
Gait - Can be done at the start
- Stand the patient and reinspect for deformities
- Speed/symmetry
- Heel strike/toe off
- Abnormal gaits – antalgic, leg length discrepancy
Offer - Neurological exam, exam hip and feet
Describe hip exam.
Positioning/Exposure
- Exposure of the pelvis and hips (underwear appropriate)
- Standing initially for inspection and gait, supine for the rest of the exam
General Observation - ..
Inspection -
Skin changes – erythema, rash, scars
- Muscle wasting ( quadriceps, gluteal wasting)
- Alignment – asymmetry, pelvic tilt, leg length discrepancy, scoliosis
- Joint changes – swelling , popliteal swelling
Gait
- Speed/symmetry
- Heel strike/toe off
- Abnormal gaits – antalgic, leg length discrepancy
- Trendelenburg’s sign
Palpation
- Ask the patient to lie supine
- Measure leg length (true leg length ASIS medial malleolus, apparent leg length umbilicus medial malleolus)
- Ask for tenderness
- Assess temperature
- Palpate ASIS, greater trochanter
Move
- Active movement – hip flexion
- Passive movement – hip flexion, internal/external rotation, abduction/adduction
- Ask patient to lie prone – active and passive hip extension (keep hand on the sacroiliac joint)
Special Tests
- Thomas’s test (can be done during hip flexion) – one hand on patient’s back (ensure lordosis is gone), bring both legs up to chest, and relax one leg (inability to fully extend =fixed flexed deformity)
Offer - Neurological examination of the lower limb, examine the spine and the knee
Describe neck and back exam.
Positioning/Exposure - Start standing and exposed to underpants (just top off may be acceptable)
General Observation - Walking/mobility aids
Inspection
(Spine curvature, Shoulder, neck and hip symmetry) - Inspect the spine from every angle
- Anterior – shoulder and neck symmetry, hip symmetry
- Lateral – normal cervical lordosis, thoracic kyphosis and lumbar lordosis (loss of any of these)
- Posterior – scars, wasting, scoliosis (bend to assess functional or anatomical)
Palpation
- Palpate spinous processes – alignment and pain
- Palpate sacroiliac joints – tenderness
- Palpate paraspinal muscles – spasm/tenderness
Move
- Cervical spine movements – flexion, extension, rotation, lateral flexion
- Lumbar spine movements – touch toes, lean back, lumbar lateral flexion
- Thoracic spine movements – rotation (must be done while sitting, arms crossed and hips stabilised by hands)
Special Tests
- Schober’s test – mark 5cm below and 10cm above the PSIS level, bend and measure (normal >20 cm)
- Sciatic nerve stretch tests – strait leg raise and dorsiflex the foot, “any pain?”
- Femoral nerve stretch test – lying on tummy, raise leg, bend knee, “any pain?”
Offer - Neurological assessment on upper and lower limbs
Describe haem exam.
Exam Summary:
(Hands, arms, head and neck
Spine and chest
Abdomen, legs)
Positioning/Exposure
- Sitting initially, and then lying supine, will require to take top and bottoms off (expose as you go)
General Observation:
- surroundings, not in respiratory distress,
- pallor
- bruising (petechiae, purpura, ecchymoses)
- jaundice (hemolysis)
- scratch marks (in some lymphoma and MPNs)
- rashes (lymphoma)
Nails: - koilonychia (dry, brittle spoon nails, Fe deficiency/fungal infection) - ??digital infarcts, - ??splinter haemorrhages Hands: - palmar crease pallor (anaemia) - wasting - arthropathy (tophi, RA)
Arms: - bruising, scratch marks - pulse (tachycardia in anemia) - epitrochlear nodes (flex elbow to 90 degree and palpate just anterior and proximal to the medial epicondyle) (infection, NHL or rarely syphilis) - axillary lymph nodes . pectoral . subscapularis . lateral (brachial) . central . apical (subclavicular)
Face: - eye: conjunctival pallor, jaundice Mouth: - gum bleeding - ulceration, infection and haemorrhage of buccal and pharyngeal mucosa - palatine tonsils - artophic glossitis (anemia) - angular stomatitis (may be affected in non-Hodgkin’s)
Head and Neck LNs
- submantle, submandibular
- pre-/post-auricular, occipital
- jugular chain (ant. SCM)
- posterior triangle nodes
- supraclavicular (shrug)
Spine and Chest
- spine tenderness: fist percussion
(one palm on spine, other hand fist percuss)
- sternum and clavicles; with heel of hand
- shoulders: push together
Abdomen (supine):
- hepatomegaly
- splenomegaly
. Traube space percussion (arms abducted slightly, precuss medial to lateral at a couple of levels)
. Castell spot (lowest ICS, MCL, full inspiration!)
- inguinal lymph nodes (along the inguinal ligament: drains pelvic, and along femoral vessels: drains lower limb)
Legs:
- bruising, scratch mark
- leg ulcers (hemolytic anemia, thrombotic thrombocytopenic purpura, Felty’s syndrome)
Additional:
- lower limb neurological exam (B12 deficiency)
- fundoscopy (engorged retinal vessels and papilledema) (increased blood viscosity from macroglobulinemia, MPN or chronic granulocytic leukaemia)
- urinanalysis (hematuria, bile)
- rectal and pelvic exam (blood loss)
Describe the thyroid exam.
Positioning/Exposure
- Sitting opposite, expose the neck and upper chest (unbutton top few buttons)
General Observation
- Environment – medications (thyroxine, amiodarone)
- Clothes appropriate for weather
- Agitated/anxious hyperthyroidism
- Generalised myxoedematous swelling (hypothyroidism)
Hands
- Tremor – test by placing arms out and put a piece of paper over (hyperthyroidism)
- Nail signs –clubbing – Grave’s disease, onycholysis (hyperthyroidism – sympathetic overactivity)
- Sweatiness (hyperthyroidism)
- Temperature – increased (hyperthyroidism)
- Palmar erythema (hyperthyroidism), or pallor/clammy hands w/ peripheral cyanosis (hypothyroidism)
- Hyperkeratinaemia (carrot skin – hypothyroidism, reduced heaptic metabolism, cant break down carotene)
Arms
- Pulse – increased (sinus tachycardia, atrial fibrillation if severe, hyperthyroidism), sinus bradycardia (hypothyroidism)
Eyes
- Lid retraction (sclera visible above iris)
- lid lag (hyperthyroidism) (finger horizontal, up then move down) (Lid lag is the static situation in which the upper eyelid is higher than normal with the globe in downgaze)
- Exopthalmos (Grave’s disease) – look from the side/above
- H test
Mouth
- Exclude oropharyngeal cancer
- Tongue swelling (hypothyroidism)
Neck - Inspection
- Neck swelling
- Scarring
- Discolouration
- Redness
- Dilated veins
- Swallow (thyroid moves up during swallowing)
- Poke tongue (thyroid does not move, thyroglossal cysts moves)
Neck – Palpation
- Palpate from behind, swallow again
- Surface anatomy (quite low in the neck – thyroid cartilage, cricoid cartilage, isthmus is under the cricoid cartilage)
- Size
- Shape
- Consistency – soft (normal), firm (simple goitre), rubbery firm (Hashimoto’s), stony hard (cancer, calcification, cyst)
- Tenderness (thyroiditis)
- Mobility – carcinoma may tether the gland
- Palpate all the head and neck lymph nodes +supraclavicular
- Tracheal deviation – if one lobe is enlarged
- Percuss clavicle sternum (retrosternal extension)
Neck – Auscultation
- Bruits (increased blood supply, hyperthyroidism) -> Ddx carotid bruit, venous hum (can obliterate)
Special Tests
- Reflex tests (biceps) (hyperT—hyperreflexia)
- Look for Pretibial myxoedema (Grave’s)
- Stand up with arms crossed (proximal weakness in hyperT)
Describe the UG exam.
Positioning/Exposure
- Start the patient sitting at 45O on the bed if possible, will eventually expose abdomen and legs
General Observation
- Hyperventilation (metabolic acidosis)
- Signs of uraemia – hiccuping, sallow complexion, uraemic fetor
- Asterixis – terminal chronic renal failure
Hands
- Nail changes – leukonychia (hypoalbuminaemia – nephrotic syndrome)
- Palmar crease pallor
Arms
- Skin changes – bruising, scratch marks
- AV fistula – palpate for a thrill
- Blood pressure
Face
- Eye signs – conjunctival pallor and scleral icterus (rare)
- Skin changes – rash (SLE)
- Mouth – fetor, ulcers
Neck
- JVP
- Previous vascath for haemodialysis
Abdomen
- Inspect for catheter
- Scars – nephrectomy posteriorly, transplantation anteriorly
- Palpate for enlarged kidneys – palpate and balloting, make sure to check L/R iliac fossa for transplanted kidney
- Percuss for ascites
- Auscultation for renal bruits
Legs -
Skin changes – bruising
- Peripheral oedema
Offer
- Cardiac and respiratory exams (signs of CCF and pulmonary oedema in kidney failure)
- Per rectal exam for prostatism
- Urinalysis
Describe cerebellar exam
Cerebellar exam - Nystagmus - Speech - Intention tremor - Past pointing - Rebound dysmetria - Dysdiadochokinesis - Heel shin - Toe pointing - Pendular reflexes - Hypotonia - Posture/balance (Rhomberg) - Gait (Tandem)
Inguinal exam
Take a deep breath,hold, and bear down
Cough
Put fingers on above and below inguinal ligament
9 things in gynecological exam.
Gynaecological Examination
- 9 Things you want to ascertain from obstetric examination
- Fetal Movements
- # “Has the baby been moving normally?” [normally important – fetal movements vary greatly]
- $ Usually ~18-20w multiparous, 15-17w nulliparous
- # Reduce after 36w [space issues] – may report this – should still be investigated
- # May involve maternal kick chart
- Fundal Height
- # Measure in cms – tape measure from pubic symphysis to uterine fundus
- # Serial measurement to ensure uterus [and containing baby] are continually growing – may be
- confounded by increasing engagement especially late T3 when baby moving down
- Lie # lie of long axis of baby compared with long axis of mother
- $ Longitudinal – long axis of baby aligns with long axis of mum
- $ Oblique – head in one of iliac fossas – most common cause = full bladder
- $ Transverse (0.5%) – horizontal – presenting part may be arm or shoulder
- Position # Direction fetus is facing – express using which direction denominator (usually occiput) is facing
- – not as important antenatally
- # Useful in funding best place to assess fetal heartbeat (anterior shoulder)
- # Important in labor ! baby’s orientation
- $ Downward (occiput inferior and anterior)
- $ Upward (occiput inferior and posterior)
- $ Frank breech (buttocks inferior)
- $ Complete breech – feet first
- $ Transverse – up/down but also right or left
- Presenting Part
- # Can usually be palpated 26w+
- # Cephallic – further subdivided
- $ Attitude – also can be used to
- describe how presenting –
- dependent on flexion of baby’s
- head – flexion best – smallest
- diameter
- # Breech (4%) – also subdivided into
- what is presenting first
- $ Complete, extended (frank),
- knee, footling, shoulder
- Engagement # How far into pelvic inlet (from symphysis to sacral prominence) the widest diameter of baby has
- gone.
- # Measure in finger breadths (fraction out of 5)
- # Shows if head will fit into pelvis – can affect fundal height (decrease)
- # Head palpated bimanually
- $ Place hands on imaginary line drawn between ASISs – point fingers inferiorly and medially
- $ “ballot” fetal head between fingers
- $ Usually can be palpated 37w+
- Amniotic Fluid Volume
- # Oligo- or polyhydramnios
- # “Ballot” amnion between hands ! how tense?
- # If you detect any abnormality or are not sure ! U/S can assess deepest pool of fluid
- Uterine irritability
- # Ability to initiate Braxton-Hicks contraction by merely palpating abdomen
- # Examined similarly to amniotic fluid volume except fingers spread during palpation to increase
- sensitivity of touch to feel contractions
- # Often abnormal finding ! IUGR
- Fetal Heart # Detection of fetal heart beat using Doppler device/Pinar stethoscope
- # Least important piece of info ! movements much more important
- # Should sound like horse galloping – faster than maternal HR
- # Not “whooshing” ! that’s placental blood flow
- # Palpate maternal radial pulse to ensure you are hearing fetus not mum
- # Decelerates when: squeezing of cord, hypoxia, pressure on head during labour
- # Usually found near anterior shoulde
Paeds Hx?
HOPC
- eating/diet
- playing
- stool/ wet nappies
- fever
- sick contact
Developmental history / milestones
Immunisation
PMH:
- antenatal
- birth
- neonatal
HEADSS assessment?
HEADSS Assessment: (routinely asked for teeangers)
- Home
- Education
- Activities
- Drugs
- Sex
- Suicide
Cage assessment?
Alcohol
o CAGE: yes= 1 point. 2 points= you may have a problem
Have you ever thought you needed to CUT DOWN on your alcohol consumption
Have you ever been ANNOYED at people who express concern about your alcohol consumption
Have you ever felt bad or GUILTY about your drinking
Do you need a drink or an EYE-OPENER in the morning to steady your nerves or relieve a hangover
Driving assessment?
Driving
- Risk factors
a. Medical history
i. Stroke, Postural hypotension, syncope episodes - Paresis of right side especially
ii. Hypertension – medications, glaucoma
iii. DM – insulin coma, hypo coma, retinopathy, neuropathy (can’t feel pedals)
iv. Ankylosing Spondylitis, neck problems preventing from turning head
v. RA , OA causing ROM restriction
b. Medications
i. Opioid analgesics
ii. Beta blockers
c. Driving
i. Automatic/Manual
ii. Special modifications
iii. Accelerate/brake- slow?
iv. Accidents/Offences
Cardiovascular Cause:
- Cardiac arrest – 6 months private commercial (Private vs commercial driver)
- Syncope – 4 week private 3 months commercial
- MI – 2 weeks private, 4 weeks commercial
Diabetes:
- Avoid hypos, don’t drive when blood glucose <5mmol/L
- Self-monitoring before and 2 hours of driving
- Carry adequate glucose in the vehicle in case of a hypo
- End organ complications shouldn’t hold a license, same with insulin reliant
o Conditional license after 2 years of review with minimal hypos or complications, well controlled
Hearing:
- No restriction for private drivers, but commercial drivers must have >40dB in the better ear (conditional license granted with hearing aid)
MSK Conditions:
- Must be able to do all movements associated with driving, otherwise not adequate
Neurological:
- Diagnosis of dementia shouldn’t drive,
- Seizures – by default cannot drive for 12 hours, but special conditions may apply
o First seizure – no further seizures for at leats 6 months
o Epilepsy – treated for 6 months and no seizures, follows medical advice
o Safe seizures – must be conscious and ability to control vehicle, no other type of seizures for 2 ears
o Sleep only seizures – no seizures while awake
- Benign paroxysmal vertigo – not fit for licence is there is severe episodes in upright posture, can regain after 3 months of no symptoms
- Meniere’s disease – not fit if episode in preceding 2 years, but is okay for condoitonal if there is sufficient warning of attack to stop safely
- Unfit for driving if psychiatric behaviour likely to impair driving
- Unfit for driving if significant OSA
- Unfit for driving if substance abuse
- Unfit for driving if less that 6/12 but can be corrected
OG history?
HOPC +Pregnancy symptoms:
Nausea/vomiting – if severe may suggest hyperemesis gravidarum
Abdominal pain – may suggest the need for imaging
Vaginal bleeding – fresh red blood / clots / tissue
Pain during sex
Headache/visual changes/swelling – pre-eclampsia
Dysuria/urinary frequency – urinary tract infection
Back pain
Fatigue – may suggest anaemia
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Ideas, Concerns and Expectations
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History of the current pregnancy
- home testing kit / hCG blood test / ultrasound scan
- Last menstrual period (LMP) – first day of the LMP
- contraception? – are they still? (e.g. COCP / implant / coil)
- Estimated date of delivery (EDD) – estimated by scan or via dates (LMP + 9 months + 7 days)
- folic acid during the first trimester
- scans or tests?
- Growth of the fetus – within normal limits?
- Placental location – placenta praevia may alter delivery plans
- Fetal movements – usually experienced at around 18-20 weeks gestation
- Labour pains – more relevant in the third trimester
- Planned method of delivery – vaginal / C-section
- Medical illness during pregnancy – if so are they taking any medications?
Obstetrics History: - Gravidity/Parity o Gravidity = number of conception o Parity = number >20 weeks o Live births Mode of delivery Complications APGAR score (activity, pulse, grimace, appearance, respiratory rate) o Miscarriages – gestational age, spontaneous/procedure o Ectopic o Termination (reason) - Expected date of confinement o Dating ultrasound o Last menstrual period + 1 week, - 3 months + 1 year - Symptoms - Surgery - Social Factors – stressors, support, financial security, safety, smoking/alcohol/drugs
Menstrual History:
- Menarche
- Dysmenorrhoea
- Menorrhagia
- Vaginal discharge
- Flow – number of pads/tampons
- Clots
- Symptoms – cramps, mood swings
- Contraception
- Vaccination
- Iron deficiency anaemia screen
Sexual History: - Age of first sexual encounter - Currently sexually active o How many partners in last 3 months, 12 months, ever o Types of partners – men, women, both - Practices – oral, genital, anal - Protection/contraception - Past history of STDs/testing/pap smears - Past history of pregnancy
