Physical Examination Flashcards
What are the basics of the OSCE physical exam?
- Performed on a role player who does NOT have any real signs and will not act them out
- Explain every step as you do it in order to show what you are looking for, what the findings would look like and the potential DDx
- Relevant clinical findings will be provided to you by the examiner as you go, these will not be given to you if you haven’t performed that part of the exam
- Make sure to highlight the aspects of the exam that will differentiate key diagnoses
- it can be helpful to provide an opening statement to summarise differentials and what you will examine for
- The examination is looking at DDx, severity, precipitants (ie allergy) and complications
Upper limb Dermatomes and Myotomes
Upper Limb Dermatomes
C5- lateral shoulder
C6- Thumb
C7- Middle finger
C8- Little finger
T1- medial forearm
Upper Limb MyotomesShoulder abduction- C5
Shoulder adduction- C6/7
Elbow flexion- C5/6
Elbow extension- C7
Wrist flexion- C6/7
Wrist Extension- C7/8
Flinger flexion/Grip strength- C7/8
Finger Extension- C8
Finger Abduction- T1
NEXUS criteria for examining a C-spine? High risk features? low risk features
NEXUS
- No midline tenderness
- Normal level of alertness
- No focal neurological deficits
- No intoxication
- No painful distracting injury
- No imaging required if all 5 -ve and age <60
High risk features
- High velocity (car >100kph), Rollover or ejection
- Age >65
- Extremity paraesthesias
- Bicycle collision
- MBA/motorised vehicle crash
- Fall greater than 0.9m
Low risk features
- Ambulatory
- Sitting in ED
- Delayed neck pain
- No midline tenderness
- Simple rear end collision
Bilateral lower limb weakness exam
DDx
- Guillane-Barre Syndrome!!!
- Acute trauma (including cauda equina)
- Spinal infection
- Tick Paralysis
- Endocrine complication (Diabetes, hyperthyroid etc)
Exam
- General inspection for wasting, dyspnoea and flat facies
- Focussed spinal exam (trauma and infection)
- Abdominal exam particularly for enlarged bladder and PVR
- Lower limb neuro exam targeting sensation, power and reflexes (reduced/absent in GBS)
- Perianal sensation and anal tone (cauda equina)
- Consider upper limb and cranial nerves exam, as well as resp function tests
Investigations
GBS- LP for oligoclonal bands and albuminocytolic dissociation
- Forced vital capactiy (<20ml/kg suggestive of need for ICU
- Blood tests for antibodies and basic biochem
- consider ABG
- Consider viral PCR and stool cultures for caustive agent
What are the differences between upper motor and lower motor neurone disorders on exam?
Foot drop differentials
- Spinal cord vs radiculopathy vs peripheral nerve
- Spinal cord = upper motor neurone signs, dermatomal sensory alteration
- Radiculopathy = lower motor neurone signs and dermatomal sensory alteration
- Peripheral nerve (common or deep peroneal) = LMN and nerve distribution sensory changes
Common peroneal
- Anterior stocking distribution (deep and superfical peroneal), proximal and lateral aspect of lower leg compression or injury
Deep Peroneal
- 1st webspace sensory distribution, usually from anterior lower leg compartment syndrome
What is the approach to the swollen joint/Arthritis?
Back pain examination
Look
- Deformity (both back and side)
- Loss of lumbar lordosis, obvious scoliosis
- Previous surgeries
- Erythema, swelling, bruising
Feel
- Central spine for tenderness
- Paraspinal for muscle spasm and tenderness
- Bogginess/deformity
- Push on bilateral ASIS to move the SI joints, illicits SI pain if the issue
Move
- All active
- Bend forward to touch toes
- Bend side to side
- Bend backwards
- Sit down (stabilises the hips) and test lateral rotation
Special tests
- Lower limb neuro exam
- Straight leg raise (lying down, lift straightened leg to point of pain then stop, compare to other side)
- Lasgues test (with straight leg raised, dorsiflex the ankle, should increase pain/symptoms, suggestive of neurological cause ie disc herniation)
General Investigations
- Xrays/CT/MRI
General Management
- Analgesia
Lower limb neuro examination
Mnemonic
Dr GIT PiSR CC
General
- Diagnostic facies
- Urinary catheter, scars legs
- Deformity/scars/tenderness to back (brief lower back exam)
Inspection
- Gait assessment
- Wasting, fasciculations, tremor
- Muscle bulk/tenderness (? myopathy or myositis)
- Palpate the bladder for fullness
- Posture, mobility aids, meds
Tone/Clonus
- Hyper/hypotonia
- Knee and ankle clonus
Power
- Hip/knee/ankle/foot
- see myotomes slide
- Tip toe walking (S1/2)
- Walk on heels (ankle dorsiflexion ie foot drop from peroneal nerve injury or L5)
Sensation
- L1 above inguinal crease, L2 below inguinal crease lateral thigh, L3 front of knee, L4 medial calf, L5 lateral calf, S1 posterior calf, S2 posterior leg
- Perianal sensation
- Vibration/proprioception of the big toe (hold tuning fork over medial aspect of IP joint
- Light touch
- Tenderness
Co-ordination
- Heel/shin
- Foot tapping
- Toe to finger
- Walk heel-toe (exacerbates ataxia, cerebellar but also other issues)
- Rombergs test (falling indicates issues with proprioception or vestibular function, NOT an assessment of cerebellar function)
Reflexes
- Knee (L3/4)
- Ankle (S1/2)
- Plantar (upgoing = UMN, corticospinal tract or brain)
Special tests
- Anal reflex
End of exam
- Summarise findings
- “to complete my exam I would…”
- Further exam and tests
General investigations
- Xray/CT/MRI as indicated
- Inflammatory markers
General Managment
- Analgesia
- Specialist involvement
Upper limb neuro examination
General Appearance
- Vital signs
- Weight (cancer, TB etc)
- Lethargic, unkempt etc
Inspection
- Wasting, oedema
- Position arm is held
- Claw hand (lower brachial plexus and isolated ulnar nerve)
- Waiters tip (erbs, upper brachial plexus)
Tone/Clonus
- Fasciculations (LMN)
- Cogwheel rigidity
Power
- See myotome slide
Sensation
- C3 lateral neck, C4 tip of shoulder, C5 lateral upper arm, C6 lateral lower arm and thumb, C7 middle finger, C8 little finger and medial arm, T1 medial upper arm
- Light sensation (dorsal columns)
- vibration 128mHz fork over medial aspect of the IP joint of thumb and proprioception at IP joint of thumb (dorsal columns)
- Course sensation with pin prick or ice (spinothalamic)
Co-ordination
- Pronator drift (if +ve suggests contralateral corticospinal tract lesion)
- Finger-nose test (cerebellar lesions)
- Dysdiadochokinesis (cerebellar pathology)
Reflexes
- Triceps (C7/8)
- Brachoradialis C5/6
- Biceps C5/6
Special tests
- Froments sign (ulnar nerve, flexion of 1st IPJ when trying to pinch)
- OK sign (anterior interosseous)
Differentials
- UMN in brain
- UMN spinal cord
- Neuromuscular junction (GBS etc)
- LMN in nerve root
- LMN individual nerves
After exam
- “to complete my examination I would…”
- Other exams and investigations
General Investigations
- Imaging
- Nerve conduction studies
General Management
- Analgesia
- Physio
- Referral to appropriate specialty
Cardiovascular Exam
Start the exam with patient sitting on examination bed at 45 degrees
General Appearance
- Dyspnoea, cyanosis, grey
- In obvious pain
- Facies (turners, marfans, Down)
- Rheumatic disorders
- Chest/radial/leg scars
- Xanthelasma, arcus cornea, scleral icterus and jaundice
- Dentition, high arched palate
- Malar flush (mitral/Pulm stenosis)
Hands/Arms
- Radial-radial and radiofemoral delay
- Nature of pulse (jerky in HOCM, collapsing, puls
- Bilateral BPs, arm/leg BP’s
- Clubbing
- Oslers/Janeway lesions, splinter haemorrhage
- Xanthomata
Neck
- Sitting at 45 degrees
- JVP and waves
- Hepatojugular reflux
- Carotid bruit/referred murmur
Praecordium and Back
- Scars chest and back
- Deformity
- Thrills, heaves, apex beat position
- Percuss for effusions
- Auscultate for rales
- Sacral oedema
Auscultation
- Heart sounds (loud vs quiet, fixed splitting, increased splitting)
- Added sounds (S3 and S4, gallop rhythm)
- Pericardial rub
Murmurs
- In the 4 principal areas
- Increasing SVR will make L) sided murmurs louder (except HOCM and MVP) and R) sided softer
- Opposite with decreased SVR
- Inhalation/Valsalva = R) sided louder and L) sided quieter
- Exhalation = L) sided louder and R) sided quieter
Peripheral
- Abdo exam for ascites, aorta, enlarged/pulsatile/tender liver
- Legs for oedema, PVD, clubbing toes
Post exam
- Summarise
- Further exams (ie PVD, resp)
- ECG, CXR, blood pressures
MOST COMMON MURMURS
HOCM
- Harsh crescendo-decrescendo systolic murmur
- Heard best at the apex and lower left sternal border
- gets louder when SVR low (sudden standing, inhalation or valsalva maneuvre)
- Gets quieter when SVR increased (squatting, passive leg raise and sustained hand grip)
Aortic Stenosis
- Ejection systolic murmur radiating into the neck
- No major change with maneuvres
Aortic Regurgitation
- Pandiastolic murmur
- Collapsing pulse on raising hand
- Widened pulse pressure
Mitral regurgitation
- Holosystolic murmur
- Radiates to the axilla
MVP
- Click sound with diastolic murmur
- Like HOCM louder when SVR low and quieter when SVR high
Respiratory exam?
Always do a friendly greeting, introduce self and ask patient to undress for examination in culturally sensitive way
General
- Vital signs, weight/cachexia
- Sputum sample if present
- Cough type, always ask the patient to cough!
- Rate/depth respiration
- Dyspnoea, pursed lips breathing, body position (ie tripod)
- Accessory muscle use
Hands
- Clubbing, nicotine staining
- Cyanosis peripherally on hands and centrally around lips
- Wasting, weakness, HPOA
- Flapping tremor aka Asterixis (CO2 narcosis)
- Pulse (tachy, pulsus paradoxus)
Face/Neck
- Icterus, anaemia, Horners
- Central cyanosis in mouth
- Hoarse voice (RLN palsy)
- Tracheal deviation
- Lymph nodes neck/axilla
RFT’s
- Forced expiratory time at bedside
- FVC at bedside
Back
- Scars, shape, radiotherapy
- Expansion
- Percussion
- Auscultate (vocal fremitus, breath sounds, adventitial sounds, wheeze and stridor)
Chest
- Auscultate/percuss
- Vocal fremitus (increased with consolidation, reduced with effusion)
- Cardiovascular exam!
- Pembertons sign
General Investigations
- Respiratory function tests
- CXR/CT scan/VQ
- ABG
- ECG
Abdominal exam?
Always do a friendly greeting, introduce self and ask patient to undress for examination in culturally sensitive way
General
- Jaundice
- Mental state/GCS
- Pigmentation, xanthomata
Hands/Arms
- Hepatic flap!
- Clubbing, leukonychia
- Dupuytrens contracture (ETOH)
- Palmar erythema
- Bruising, spider naevi
- Wasting, scratching (cholestasis)
Face
- Parotid swelling/itis (alcohol)
- Fetor hepaticus, alcohol on breath
- Scleral icterus/pallor, kaiser-fleischer rings (Wilsons disease)
- Gum bleeding, candida infection
Chest
- Cardiorespiratory exam (pleural effusions, S3 gallop from heart failure etc)
- Cervical/Axillary lymph nodes
- Gynecomastia
Abdomen
- Scars, distension, spider naevi, caput medusae, bruising
- Palpation for pain and organomegaly
- Liver size, tenderness, hard, bumpy, liver bruits, percussion
- Rebound, guarding, percussion tenderness
- Shifting dullness (percuss umbilicus to left side, roll to left, wait 10-30 second, percuss again)
Percussion/Auscultation
- Percuss for size of liver and spleen, as well for bladder distension
- Auscultate for bowel sounds, renal artery and aortic bruits
End of exam
- Consider exam rectum, hernial orifices and genitalia if indicated
Cranial nerves examination
Name mnemonic
Oh Oh Oh To Touch And Feel Virgin Girls Vaginas And Hymen
Function mnemnonic
- S = sensory, M = motor, B= both
1 Some, 2 Say, 3 Marry, 4 Money, 5 But, 6 My, 7 Brother, 8 Says, 9 Big, 10 Brains, 11 Matter, 12 More
General Inspection
- Facial assymmetry
- Speech abnormalities
- strabismus, ptosis
- ticks
CN I (Olfactory)
- Smell coffee, alcohol swab
CN II (Ophthalmic)
- Visual acuity, Ishihara
- Visual lowest line is line that they get 2 or less incorrect letters
- Blind spot with pen/red pin
- Pupil size, shape and symmetry
- RAPD, accommodation, direct and consensual reflexes
- Visual fields
- Visual extinction (wigglng fingers in peripheries, do they ignore the wiggling fingers when distracted?)
CN III (Oculomotor)
CN IV (Trochlear)
CN VI (Abducens)
- H test
- Nystagmus, ophthalmoplegia
- diplopia
- Cover test to exacerbate strabismus
CNV (Trigeminal)
- Light and pin prick sensation
- V1 (supraorbital)
- V2 (infraorbital)
- V3 (angle of mandible)
- Masseter strength and lateral pterygoids (open mouth against resistance)
- Jaw jerk and corneal reflex
CN VII (Facial)
- Sense of taste and hearing
- Raise eyebrows, scrunch up eyes
- Big smile, blow out cheeks
- Pursed lips
CN VIII (Vestibulocochlear)
- Auditory testing (whisper number or rustling of fingers)
- Balance, Rombergs test
- HINTS/Hallpike
Rinnes
- Tuning fork in mastoid, when cant hear move in front of EAM
- If equal or heard louder on bone then suggests conductive loss (rinnes -ve)
- If louder in air then sensorineural or normal, rinnes positive
Webers
- Tuning fork on forehead, which side loudest?
- Conductive loss heard loudest on affected side
- Sensorineural opposite affected side
CN IX (Glossopharyngeal)
CN X (Vagus)
CNXII (Hypoglossal)
- Changes to voice or swallowing
- Assymmetric elevation of soft palate, uvula deviation
- Sip of water (dysphagia) and cough (weak cough with CNX lesion)
- Gag reflex
- tongue fasiculations, wasting or assymmetric movement (CNXII)
CN XI (Accessory)
- Shrug shoulders (trapezius) and turn head against resistance (SCM)
Post exam
- Summarise
- Say you would perform fundoscopy
Multiple cranial nerve involvement differentials?
- Cavernous sinus syndrome
- Large stroke/bleed
- MS
- Myaesthenia Gravis
- Miller-Fisher syndrome (Ataxia, areflexia and ophthalmoplegia)
- Thyroid orbitopathy
- Giant cell arteritis
- Local orbital infection
Vaginal Speculum use
Eye exam
External Observation
- Ptosis
- Proptosis
- Racoon eyes
- Lacerations
- Deformity
- Lesions/rashes (HSV, HZV etc)
Visual Acuity
- A measure of the eyes ability to distinguish shapes and details
- Determine baseline if known
- Snellen chart
- ishihara chart for colour
- Make sure to correct with pinhole or own glasses/lenses
- 6/6 normal, 6/12 bad, 6/3 very good
- 1st number is distance to chart and 2nd number is distance to the chart that a normal eye would have a similar result
Pupils
- Anisocoria
- Deformity
- Reactivity and RAPD
Eye movements
- CN III, IV and VI
- Diplopia
- EOM entrapment in trauma
Intra-Ocular Pressure
- Tonopen etc
- Always check for ruptured globe
- Gonioscopy/applination by ophthalmologist
Further tests and exam
- Slit lamp
- Ophthalmoscopy +/- dilation
- CN exam
- Ocular ultrasound
- CTB +/- angio cow if considering bleed, stroke or aneurysm
