Physical exam: Special cases

Question 1

Diabetic foot

Answer 1

1. Inspection
   
   • Ask px to remove both socks. Offer help.
   • Describe where are you looking: the base of the foot, sides, in-between toes, etc.
     
     • If any ulcer: location, shape, size, “margins not elevated”, “no active bleeding or oozing”
     • “No other ulcers in the same foot” / check other foot / in-between toes and nails.
   • “No pigmentation around the medial and lateral malleoli”
   • SEADS: Quadriceps wasting/ swollen joints
   • “No signs of arterial insufficiency:no hair loss/ no shiny tight skin/ no hypertrophic nails”
2. Palpation
   
   • Temperature
   • Capillary refill (< 3”)
   • Pulses: dorsalis pedis / posterior tibial /popliteal / (to examiner) I would like to check the femoral arteries
3. Abdomen:
   
   • Drape the patient / I would like to examine your abdomen / can you please uncover your abdomen
   • Listen for bruits (aortic / renal / iliac)
4. Neurology
   
   • Light touch (Both, from distal to proximal): “Here is a piece of cotton, this is how it feels, CAN YOU PLEASE CLOSE YOUR EYES and tell me when you feel it touching you?”

If light touch is NOT ok, then:

• Light touch sensation is absent distal to the level of … cm above ankle
• Proprioception: “I will move your toe, close your eyes please, tell me is it up or down”. Then move to the next joint. Start with head of metatarsal, medial malleolus, tibial tuberosity, …
• Vibration: tuning fork, “here is the sensation you will feel, tell me when it stops”. intact / decreased / absent
• Monofilament test: to distinguish between the light touch and pressure sensation / 10 points on the foot (9 on the sole, and one on the dorsum above the big toe meta-tarso phalangeal joint)
• Ankle reflex; if you have time: knee reflex and Babinski

5. Special
   
   • I would like to arrange for ankle/brachial index

Question 2

Peripheral Arterial Disease

Answer 2

1. Inspection
   
   • Ask px to remove both socks. Offer help.
   • SEADS
   • “No signs of arterial insufficiency:no hair loss/ no shiny tight skin/ no hypertrophic nails”
2. Palpation
   
   • Temperature
   • Capillary refill (< 3”)
   • Pulses: dorsalis pedis / posterior tibial /popliteal / (to examiner) I would like to check the femoral arteries
     
     • Grade amplitude: 0 (absent), 1 (weaker), 2 (normal), 3 (bounding, aortic insuff)
3. Abdomen:
   
   • Drape the patient / I would like to examine your abdomen / can you please uncover your abdomen
   • Listen for bruits (aortic / renal / iliac)
4. Neurology
   
   • Light touch (Both, from distal to proximal): “Here is a piece of cotton, this is how it feels, CAN YOU PLEASE CLOSE YOUR EYES and tell me when you feel it touching you?”

If light touch is NOT ok, then more tests.
Sensitivity is tested following dermatomes, and you go up to until the px feels.

5. Special:
   -Burger test: I would like to raise your legs, for 1-2 minutes, if you feel any pain / numbness / tingling please let me know, check the color of the foot. Then
   dangle the feet and check the colour -> “no pallor on elevation, Burger test is negative”.
   -I would like to arrange for ankle/brachial index
   -Allan’s test: For radial and ulnar (compression of one at a time)

Question 3

Cardiac examination

Answer 3

Intro: Can you please lie down?

1. HR and BP (lying down): Get systolic by pulse, then increase 30 mmHG, then auscultate
2. Sit up and relax for 2 minutes:
   
   • Orientation
   • Mouth for dehydration
   • Eyes for pallor
   • Lung’s base auscultation
   • Sacral edema
   • Lower limb edema
3. HR and BP (sitting up): “No difference”
4. General:
   
   • Radial pulse bilaterally
   • Hands: Refill/clubbing/T
   • Fundoscopic
5. Neck: Carotid /JVP
6. Heart:
   
   • Inspection: Symmetrical/PMI
   • Palpation: Apex, heaves, thrills
   • Auscultation:
     
     • Areas A-P-T-M: “Normal S1, S2. No murmurs”
     • Look for S3, S4 at the apex (with the bell)
     • Aortic insufficiency murmur
   • Listen to lung bases
7. Abdominal exam: Pulsation/bruits (aortic/renal/iliac)
8. Lower limbs exam: Inspection / Palpation (temperature/pulsation) LL BP

Question 4

Secondary HTN (young man with HTN)

Answer 4

Intro: Can you please lie down?
1. Vitals:
-There is systolic and diastolic HTN
-I want to rule out orthostatic hypotension
(pheochromocytoma)
-I would like to compare UL and LL (coarctation of
aorta )
-No tachycardia (pheochromocytoma /
hyperthyroidism )
2. General:
-Orientation (Brain edema)
-Truncal obesity / cervical fat pad / moon face (Cushing)
-Check for proximal ms weakness (Cushing )
-Check the eyes from the side for proptosis,
lid lag test (hyperthyroidism )

-Asses the radial pulse bilaterally
-Hands: capillary refill / temperature / skin dry or wet
(thyroid ). Stretch your hands please ! fine tremors
(hyperthyroidism )
-Fundoscopic examination: disc edema / retinal hemorrhage
3. Neck:
*Thyroid:
-“No masses”
-Palpate
-Percuss the retro-sternal thyroid dullness
*JVP
4. Chest
-Palpate the apex
-Look for S3, S4 at the apex (with the bell)
-Listen to lung bases
5. Abdominal: Inspection, auscultation, palpation
6. Lower limbs: Edema, femoral/radial delay
7. Brief neuro: Knee or ankle reflex

Question 5

Tremor

Answer 5

1. VS: “ I would like to R/O orthostatic hypotension”
2. Inspection:
   *Tremors:
   Right hand tremors, not obvious on the left hand
   -Count from 10 to 1 please -> tremors ↑ with mental activity -> consistent with Parkinson disease, and r/o anxiety
   -Stretch your hand please / no fine tremors. R/o
   hyperthyroidism
   -No flapping tremors -> r/o liver failure
   -Finger to nose / no intentional tremors -> r/o
   cerebellar disease
   -Patient tremors consistent with Parkinson disease,
   resting tremors, beads rolling, and limited to right
   hand
   *Face: “(No) limited facial expression, decreased eye blinking, drooling”
3. Palpation and rigidity (wrists and elbows)
   -Parkinsonism: Cog wheeling, lead pipe rigidity
   -Stroke: Clasp knife spasticity
4. Standing/walking postural instability:
   -Would you please stand up! Do you need help;
   patient finds difficulty in standing up
   -Can you walk few steps for me please:
   Comment
   -Stooped posture
   -Shuffling (festinating) gait
   -Decreased arm swinging
   -Patient turns in blocks
5. Special tests:
   -Rapid alternating movements (hand supination &
   pronation / oppose thumb to fingers) ->
   dysdiadochokinesia
   -Can you please repeat “British constitution” ->
   monotonous
   -Can you write a sentence for me -> micrographia
   -Can you draw a spiral parallel to this (draw spiral on
   paper)
6. “I would like to perform a Mini-mental status”

Learn Treatment!
*Pharmacologic
-Mainstay of treatment: Sinemet (levodopa / carbidopa).
-Levodopa related fluctuation: delayed onset of response (affected by mealtime), end-of-dose deterioration (i.e. “wearing-off”), random oscillations
of on-off symptoms
-Major complication of levodopa therapy is dyskinesias
-Treatment of early PD: DA agonists, amantadine, MAOI
-Adjuncts: DA agonists, MAOI, anticholinergics (especially if prominent tremors), COMT inhibitors
*Surgical: thalamotomy, pallidotomy, deep brain stimulation (thalamic, pallidal, subthalamic), embryonic dopaminergic stem cell transplantation

Question 6

Volume Status Assessment

Answer 6

1. Inspection
   * General appearance - observing from the end of the bed and commenting on distress /fluid restriction warning/vomit bowls/IV lines/monitoring devices/catheter bag
   * Hands (cool/ capillary refill/peripheral cyanosis, skin turgor)
   * Pulses (radial pulse comment on RRCV, radio-radio delay, radio-femoral delay.
   First, ask for shoulder pain or limitation, check for collapsing pulse)
   * Measure BP (appropriate technique). Measure BP
   by auscultation check sitting and standing for in 1 minute for postural changes and in all four limbs (usually not done in exam settings).
2. Orientation:
3. Impact
   * Face: (sunken eyes/ pallor/ lips for central/peripheral cyanosis/mouth- Furrowed tongue/ underneath the tongue for dryness)
   * Neck
   -Hepato-jugular reflex
   -JVP (height and waveform, Kussmaul sign, palpate carotid pulse (character and volume)
   * Chest: (deformities/ asymmetry/ scars/ pacemaker/ sternotomy/thoracotomy)
   -Palpation: apex beat (locations and character); for tenderness PMI/ feel for thrills/heaves
   -Auscultation: in all areas plus LLD/ with the bell Apex-LLSB / axillary area and comment on S1, S2, S3, S4.
   -sitting and leaning forward Expiration held (AR) aortic area
   -carotid pulses with the bell (lower bed to 30 degree angle DO NOT before auscultating to check if there is a bruits- never both at once)
   -Base of lungs
   -Percussion: Dullness
   * Abdomen:
   -Inspect the abdomen (bulging flanks, fluid wave).
   -Auscultate for bowl sounds.
   -Percussion: 1. Liver 2. Spleen 3. Ascitis: shifting dullness 4. Suprapubic for bladder.
   -Palpate: Palpate for the liver, ballot the kidneys and
   palpate the bladder.
   * Lower limbs: Edema (sacral, leg pitting)

Question 7

Peripheral artery disease: Common concerning symptoms

Answer 7

• Abdominal, flank, or back pain
• Pain in the arms or legs
• Intermittent claudication
• Cold, numbness or pallor in legs
• Hair loss in extremities
• Swelling in calves, legs, or feet
• Color change in fingertips or toes in cold weather
• Swelling with redness or tenderness

Question 8

Peripheral artery disease: Symptoms to ask

Answer 8

• Abdominal, flank, or back pain
• Unusual constipation or distention
• Urinary retention
• Difficulty voiding
• Renal colic

Warning signs:

• Claudication
• Non-healing wounds
• Abdominal pain after meals (food fear)