Physical Examination Flashcards
Pseudo-parkinsonism
Incidence: 20%
RFs: more common in older women
Onset: gradual onset after a few weeks
Symptoms: akinesia, rigidity and tremor
Management: reduce dose, change to 2nd gen
Acute dystonia
Incidence: 10%
RFs: young men, antipsychotic naive
Onset: few hours
Symptoms: oculogyric crisis, torticollis, grimacing, trismus, exaggerated posturing
Management: IM procyclidine 5-10mg
Akithisia
Incidence: 25-50%
RFs: rapid increase in antipsychotic dose
Onset: most commonly after day 5
Symptoms: irritability and restlessness
Management: procyclidine or propranolol
Tardive dyskinesia
Incidence: 5% at 1 year, 20% of chronic Rx
Risk factors: elderly women, organic brain disease, long exposure to antipsychotics, affective disorder, Hx of EPSEs
Symptoms: lip smacking, chewing, tongue protrusion, pelvic thrusting
Management: change to 2nd gen, vitamin E, tetrabenzine
Cerebellar Exam
Inspect
Arms: Tone, dysdiadochokinesia, Finger to nose
Head: speech - repeat british constitution and baby hippopotamus
Nystagmus: eye movements
Legs: Reflexes, heel to shin test
Gait - straight line and heel to toe walk
Rombergs: Stand still, feet together, arms at side, close eye - +ve if unsteady when closed eyes
Thyroid Exam
Relevant hx: energy, weight/appetite, mood, temp. intolerance, bowels, libido, skin/hair appearnce, changes in cycle.
Inspect including: exopthalmos (side and above), skin changes, hair loss, weight changes.
Hands - sweating, onycholysis, thyroid acropachy.
Pulse
Look for tremor.
Eye movements: H
Lid Lag: follow finger quickly from top to bottom.
Inspect neck
Ask to swallow.
Palpate gland from behind.
Ask to swallow
Cervical lymph nodes.
Auscultate thyroid.
Reflexs
Proximal myopathy - stand from chair arms crossed.
Pretibial myxoedmea
Signs CHF (legs/auscultate lung bases.
EPSE Exam
Hands on knees - look for tremor.
Then hands out facing down - place paper if available on hands.
Tone, power, co-ordination + cogwheeling.
Hypomimia- ask pt to open mouth looking for abnormal tongue movements + pooling of saliva.
Stand - no obvious akathesia. Ask to hold hands out at side, then let arms fall freely
Gait
Fundoscopy
History: onset, duration, severity, progression, associated symptoms, triggers.
La Belle Indifference: lack of concern.
Assess secondary gains, mood, risk.
Focus on distant obect.
Use right eye for right eye.
Check red reflex
Follow red reflex into eye towards nasal.
Assess optic disc and retinal vessels
Assess macula by asking to look directly at light.
Describe to patient what looking for
Snellen chart, ishihara plates, refelxes to complete.
Cardiology Exam
45 degress
Inspection:
Inspect including around bed
Hands + wrists - cap refil, clubbing, radial pusle 15 secs, radio-radial delay, collapsing pulse.
Face - malar flush, conjuntival palor, mouth - arch or poor dentiotion.
Neck: JVP relax left, lean. Palpate carotids 1 at a time.
Scars.
anterior chest: Apex beat, heaves/thrills.
4 valve locations.
MS: Roll onto left and auscultate apex.
MR: Axilla using diaphragm.
AS: Carotids in full expiration
AR: Forward, full expiration L parasternal 3rd intercostal.
Percuss for pleural effusions + ausculatate for creps
Ankle oedema.
Offer ECG< Fundoscopy, peripheral pulses, BP
Respiratory Exam
Inspection: cyanosis, inability to speak full sentences, acessoary muscles, scars, asymmetry, cough
Palpate:
Trachea, apex beat, cervical lymph nodes.
Chest expansion
Percussion
Auscultation
Vocal resonance (99).
Scaral oedema, peripheral oedema.
Abdominal Exam
Inpsect:
Appropriate comments to patient not examiner - ‘you appear to be in a lot of pain’.
Distention, mass, dressing, scar, track marks, excoriation, gynaecomastic, nail changes.
Palpate - light palapation 9 regions. Deep palpation 9 regions.
Tenderness , rebound, guarding, masses.
Liver + spleed + kidneys + Abdomianl aorta.
Percuss liver, spleen, shifting dullness.
Aucultate bowel sounds + aortic + renal bruits.
If hepatic encephalopathy:
Add eye movements, past pointing,
Lower limb reflexes and gait
PNS Exam
Wash hands
Confirms details
Consent
Offers chaperone
Inspect
Tone
Power
Reflexes
Co-ordinatiion
Sensation (light, vibration, proprioception, pain).
Gait
CNS Exam
I: Smell change
II: Snellen chart, neglect, fields, Pupils, fundoscopy
III IV VI: H movement
V: 3 x sensation + power of mandible + jaw clenching
VII: Facial asymmetry + eyebrows, screw eyes, frown, bear teeth, puff cheeks + ?taste problems
VIII: Whisper in each ear. Webers + RInne’s
IX: Uvula, not gag reflex
X: Cough + Swallow
XI: Shrug, turn head L+R, SCM muslce
XII: Tounge out, side to side.
ECG interpretation
Rhythm
Rate
Axis (I and aVF positive/positive normal, P/N left (II neg) N/P right) R > S +ve
QRS less than 120 (3 squares)
QTc (Bazett formula QT/square root RR interval) >440 men >460 women
ST&T
PR 120-200 (3-5 small)
Small = 40ms. Big = 200ms. 5 big = 1 second
V1-2 septal, 3-4anterior, 5-6 lateral (I aVL)
II, III, Avf inferior
Frontal Lobe Assessment
PAVL Go Key Reflex
P: Personality and smell - ?any changes, has anyone else noticed?
A: Abstraction - PCoS
Proverb interpretation: Too many cooks spoil the broth?
A stitch in time saves nine?
Cognitives: How many Camels in Denmark? How high is a double decker bus?
Similarities: Train & Bicycle, Watch & Ruler.
V: Verbal Fluency - Letter fluency - name as many animals in one minute.
L: Luria - Fist Edge Palm - 5 x for normal.
Key: imagine paper is a field, show me how you would find a key if it were lost in the field.
Go-no-go Test: First: When I tap once, you tap twice, when I tap twice you tap once.
Second: When I tap once, you tap once.
When I tap twice, you do not .
Reflexes: Graps (stroke palm), pout when stick to lips, Palmomental (stroking thenar eminence -> contraction of mentalis muscle).
MMSE cognitive examination
ORARLP
Orientation -
Year, Season, Date, Day, Month
Where are we now? Country, County, Town, Hospital, Floor?
Registration -
name 3 apple, table, key
Attention - Spell WORLD backwords.
Recall - tell me those three words?
Language (NIPES) -
N (name): Name two objects (e.g pen, watch).
I (ifs): No if’s ands or buts - repeat
P (procedure): 3 Stage command - place indext finger of right hand on your nose and then left ear.
E (close eyes): Read and obey - Close your eye
S (sentence): Write a sentence
Pentagons: copy this picture - intersecting pentagons
Pariental Lobe Assessment
Dominant:
Receptive dysphasia (should be obvious)
Acalculia - 4+7
Agraphia - Write a sentence
R-L disorientation - Touch R ear with L hand
Finger agnosia: show me your R index finger
Ideomotor apraxia: Brushing hair
Astereognoia: Close eyes, object (pen/coin) in palm, ask them to tell you.
Agraphagnosia: Eyes closed - trace H on palm tell me what letter.
Non-dominant:
Topographical disorientation - Ask if confused lost new places.
Constructional apraxia: Intersecting pentagons.
Anosagnoia: ask patient if they have deficit
Neglect: Wiggle R then L then both fingers - which is wiggling.
Parietal - routine
CDOIV
Finger / Finger / 7s - 3 commands
Sentence / Clock / Pentagons - 3 drawing tasks
Dressing / Health / Getting lost - 3 OAP questions
Object (eyes close) / Trace a letter / face (bank note) - 3 identify questions
Visual Fields
Temporal Lobe Assessment
Dominant:
Language:
Receptive aphasia - repeat words.
Verbal retention: Harry Barnes, 73 Orchard Close, Kingsbridge, Devon. Ask to repeat.
Alexia: Read a couple of sentences
Agraphia: Write a couple of sentences
Anomia: Objects in room, increasing order of difficulty: pen bottle watch nib.
Check retention.
Non-dominant:
Draw abstract shape - ask to copy
Hemisomatagnosia 0 are all 4 limbs working well?
Prosopagnoaia (any difficulty recognising faces or Benton facial).
Musical recognition?
Non verbal retention (repeat drawing).
Both:
Semantic memory (facts):
Current prime minister?
What happened to JFK?
Which City Eiffel Tower?
River that runs through London?
Autobiographical memory:
What did you have breakfast?
How did you get here?
Where were you born?
What was your first school?
Visual Fields (upper quadrantanopia).
Epilepsy: ?ever had
Psychosis: Strange beliefs/voices.
Temporal - routine
EMLV
Extra - psychosis / epilepsy
Memory (RSLSR)
- Registration/Working - Harry Barnes, 73 Orchard Close, Kingsbridge, Devon (or your own)
- Short - Breakfast, get here
- Long - Where born, first school
- Semantic - First female PM, famous landmarks
- Recall
Language (overlaps with NIPES)
- Read -
- Write -
- Repeat - ifs and buts
Vision - OFF Clock
- Objects
- Faces
- Fields
Clock face
Korsakoffs exam
Orientation time (year, season, month, date, day)
Orientation place (country, county town/village, building, ward)
Enquire about memory
RSLSR
STM (breakfast)
LTM (name of first school)
/Autobiographical (where married?)
Semantic (river in London)
recall
Procedural (ride a bike?)
Working: digit span forward star with 3 digits (normal 6+-1)
Digit span backwards (5+-1)
Confabulation: tell me what you did today? (Note will need collateral)
Cerebellar exam
If wernikes
Orientation
Fields/neglect
Cerebellar exam
Anorexia exam
Inspect arms to face
Cardio exam
Palpate liver
Assess for shifting dullness
SUSS
Sensation peripherally (not dermatome)
Offer bloods ecg full neuro exam obs
Lithium tox exam
Orientation
Inspect
Tremor
Eye movements
Mouth (dry)
Upper: Tone Power Coordination
Lower: reflexes
Abdominal palpate and auscultate
Serotonin syndrome or nms exam
Bloods ecg obs med changes
Orientation
Hands
Tremor
Pulse (full obs)
Inspect eyes/reflexes to light
Eye movements
Mouth (dry)
Upper: Tone + power
Lower: tone clonus and reflexes
Abdominal: sounds
Hyperprolactinaemia exam
Hands and feet (big)
visual fields (bitemporal hemianopia)
Thyroid exam
Chest examine - galactorrhoea and gynaecomastia
(Thyroid exam plus looking at chest, feet, fields).
Offer CNS exam for palsy
