Physical Examination Flashcards
What do you look for in the inspection stage of the CVS exam?
- are they lying comfortably in bed
- is there obvious pedal oedema
- is there cyanosis
- are they young? - could have congenital heart disease
What do you examine for in your CVS examination?
Hands
- are they warm/cool? (suggesting reduced CO)
- is there clubbing
- is there systemic disease (arthritis/peripheral cyanosis)
Radial pulses
- rate
- assess for collapsing pulse
- request or take a BP
Eyes
- xanthelasma or corneal arucs
- conjunctival pallor suggestive of anaemia?
Face
- malar flush may represent pulmonary hypertension secondary to mitral valve disease
- look for central cyanosis at mouth
Neck
- assess JVP with patient at 45°
- normal height is 4cm above manubriosternal angle
- feel carotid pulse assessing volume and character
Chest
- look for scars from previous surgery
- signs of a pacemaker?
- palpate apex beat - check placement and character
Feet
- pedal oedema
- peripheral pulses
What do you auscultate for in the CVS exam?
- auscultate over the apex, pulmonary, tricuspid and aortic regions
- left lateral position in expiration with bell of stethoscope for mitral stenosis
- sitting forwards in expiration for aortic regurgitation
- listen over carotid arteries for bruits or murmur radiation
- listen over lung bases for pulmonary oedema
How do you differentiate between the JVP and carotid pulse?
The JVP is biphasic and easily occluded by gentle pressure.
It also displays a positive hepatojugular reflex.
What are the signs and symptoms of aortic stenosis?
Signs
- narrow pulse pressure
- slow rising pulse
- soft second heart sound
- left ventricular failure
Symptoms
- snycope
- chest pain
- heart failure
Where is aortic stenosis best heard?
Systolic, crescendo-decrescendo murmur, heard loudest in upper right sternal border (2nd right intercostal space) radiating to carotids bilaterally.
What are the causes of aortic regurgitation?
- rheumatic heart disease
- ankylosing spondylitis
- marfan’s syndrome
- infective endocarditis
What are signs of pulmonary hypertension?
- loud pulmonary component of the 2nd heart sound
- Graham Steel murmur of pulmonary regurgitation
- right ventricular heave
- tricuspid regurgitation - giant V waves in the JVP
What do you look for in examination of the respiratory system?
Hands
- nicotine stains
- clubbing
- peripheral cyanosis
- CO2 retention flap
Radial pulses
- rate/character
Eyes
- Horner’s syndrome (ptosis, miosis, anhydrosis) secondary to an invading malignacy
Face
- check for central cyanosis or pursed lip breathing
Speech
- hoarse voice may indicate recurrent laryngeal nerve involvement as a result of malignancy
Neck
- assess JVP with patient at 45°
- raised and pulsatile in cor pulmonale
- look at trachea, check for tug or deviation
Chest
- note the shape of the chest ?hyperinflated ?use of accessory muscles
- look for scars from prev surgery
- check expansion front and behind
What do you do in percussion of the chest?
Percuss looking for areas of hyper-resonance and areas of dullness.
Compare sides.
What do you do in auscultation of the chest?
- Auscultate listening for quality and character of breath sounds and any added sounds.
- Crackles may be course (secretions in larger airways eg pneumonia) or fine (small airway disease eg pulmonary oedema, fibrosing alveolitis).
- Wheeze may be polyphonic (asthma/COPD) or monophonic (single large airway obstruction).
- Tactile and vocal resonance will determine whether dullness is due to a pleural effusion (reduced transmission) or consolidation (enhanced transmission).
- repeat on back
- remember to check for lymphadenopathy
HOw do you look for pulmonary hypertension in the abdomen?
Pulsatile hepatomegaly
What other tests would you ask for in the respiratory exam?Spiro
Spirometry
Pulse oximetry
Consider ABG and CXR
What are the causes of COPD?
- smoking
- occupational exposure (eg coal workers’ lung)
- alpha 1 antitrypsin deficiency
When should LTOT be prescribed?
- when the pO2 is consistently at or < 7.3 kPa (55mm Hg)
- or if pO2 is 7.3 - 8 kPa with presence of polycythaemia or evidence of pulmonary HTN
What are the common pathogens in CAP?
- streptococcus pneumoniae (most common)
- haemophilus influenzae
- mycoplasma pneumoniae
What is atelectasis?
Absence of gas from a segment of lung parenchyma.
As the partial pressure of dissolved gas in the blood is less than the atmosphere, there’s uptake of gas from obstructed, non-ventilated alveoli resulting in alveolar collapse.
What are the cranial nerves?
Oh oh oh to touch and feel very good velvet, AH!
- Olfactory
- Optic
- Oculomotor
- Trochlear
- Trigeminal
- Abducens
- Facial
- Vestibulocochlear
- Glossopharyngeal
- Vagus
- Accessory
- Hypoglossal
How would you perform a cranial nerve examination?
- Olfactory
- have you noticed any loss of smell?
- Optic
- any problems with vision?
- assess acuity - reading vision chart one eye at a time
- assess visual fields
- check direct and consensual light reflexes and look for relative afferent pupillary defect
- Oculomotor
- check eye movements all four directions
- Trochlear
- supplies superior oblique muscle which, when the eye is fully adducted, moves the eye down
- Trigeminal
- test opthalmic, maxillary and mandibular branches with light touch to the face and check motor function by asking them to clench teeth while you look for wasting of masseter muscles
- Abducens
- supplies lateral rectus, which adducts the eye
- Facial
- raise your eyebrows
- close your eyes tightly
- show your teeth
- puff out your cheeks
- Vestibulocochlear
- ask about hearing/balance problems
- Rinne’s test
- compare sound conduction through air and bone by ringing fork near auditory canal and then against mastoid process
- positive if sound is loudest when in the air (non pathological state)
- Weber’s test
- tuning fork in middle of forehead - sound should be equal in both ears
- in sensorineural deafness - sound is not detected by affected ear
- in conductive deafness sound is loudest in the affected ear
- Glossopharyngeal
- mainly sensory nerve providing sensation to pharynx
- Vagus
- open mouth and say “ahh!”
- look for movement of the uvula, in pathological states it moves to the opposite side fo the lesion
- Accessory
- innervates sternomastoid and trapezius
- shrug shoulders and turn head against resistance
- Hypoglossal
- Intrinsic muscles of tongue
- stick out tongue - deviation is to the side of the lesion
What additional tests would you perform after a cranial nerve exam?
Formal visual acuity, colour vision, audiometry, fundoscopy and peripheral nervous system examination.
What is the light reflex?
- light falls on retina
- generates electrical impulses that travel via the optic nerve then optic tract to lateral geniculate ganglion
- then fibres pass to Edinger-Westphal nuclei and oculomotor nuclei in the periaqueductal grey matter of the midbrain
- signal continues in parasympathetic fibres that entwine oculomotor nerves and stimulate the ciliary ganglion, ciliary nerves and finally pupillary sphincter muscle of each eye
What are the signs of a complete 3rd nerve palsy?
- unopposed sympathetic innervation (dilated pupil, loss of accommodation reflex)
- unopposed superior oblique and lateral rectus muscles (down and out)
- ipsilaeral ptosis (loss of levator palpebrae superioris)
What are the signs of optic nerve damage?
- Decreased visual acuity
- optic atrophy
- a relative afferent pupillary defect (RAPD)
- decreased colour vision
- central scotoma (blind spot)
A damaged nerve will atrophy, resulting in reduced acuity and a big central blind spot. The swinging torch test is looking for an RAPD as less light is detected by an atrophic optic nerve, resulting in pupillary dilatation when the light shines on the affected pupil
Which nerves supply the superior oblique and lateral rectus muscles?
Trochlear and abducens nerves, respectively.
What is Horner’s syndrome?
Interruption of the sympathetic chain and may occur anywhere from it’s origin in the hypothalamus to the postganglionic fibres.
Most commonly affects sympathetic outflow from C8/T1 to the superior cervical ganglion and includes pathologies such as cervical lymphadenopathy, thyroid masses and neck surgery complications.
Signs are:
- miosis ipsilateral to site of lesion
- partial ptosis due to loss of sympathetic nerve supply to levator palpebrae muscle
- anhydrosis of ipsilateral face
- enophthalmos due to paralysis of eyelid tarsus muscles
What do you need to ask for in an obstetric preop assessment?
- brief obstetric Hx - covering previous pregnancies and modes of delivery
- problems during pregnancy
- routine anaesthetic Hx - prev surgeries/GAs and any complications thereof
- general health and PMH
- any clotting abnormalities or anticoagulant therapy
- obtain full drug Hx including allergies
- ask about GORD + ability to take NSAIDs
- ask about dentition and problems with MO or neck ROM
- check airway
- check IV access by looking for good veins
- if high BMI say you’d d/w senior anaesthetist (?US back)
- feel pulse, take BP, look for anaemia/peripheral oedema
- check obs chart + height/weight
- check blood tests (Hb/renal impairment/coagulopathy)
What are the advantages of regional anaesthesia over GA for C-section?
- minimal risk of aspiration
- lower risk of anaphylaxis
- more alert neonate promoting early bonding and breastfeeding
- improved postop analgesia
- earlier mobilisation
- both mother + partner awake at time of surgery
What are the CI to epidural during labour?
- maternal refusal
- allergy to LA
- local infection
- uncorrected hypovolaemia
- coagulopathy
What is placenta previa?
The placenta implants between fetus and cervical os
What is placenta accreta ?
Abnormal implantation of placenta.
Placenta increta - placenta grows into myometrium
Placenta percreta - placenta grows through myometrium to uterine serosa and surrounding structures.
They’re at risk of major haemorrhage, esp. if placenta is anterior as likely to be divided by surgeon.
What is pre-eclampsia?
A multisystem disease that remains a major cause of maternal death worldwide. Pathophysiology not fully understood but thought that failure of placentation occurs early in pregnancy leading to vascular endothelial cell damage and dysfunction. This causes release of vasoactive substances that promote generalised vasoconstriction and reduced organ perfusion.
Hypertension and proteinuria (>0.3 g/L) that develops after 20 weeks gestation in previously normotensive woman.
Oedema isn’t in the definition but will often be clinically evident.
What are the 6P’s of an ischaemic limb?
Pale
Pulseless
Painful
Paralysed
Paraesthetic (numb)
Perishing cold
