Physical Examinations

Question 1

Breast Examination

Answer 1

• Consent
• Offer Chaperone
• Wash hands
• Inspection
  
  • Look for asymmetry / dimpling
    
    • Place hands on waist and press hard (tense pectoral muscles), hold fingers in front of chest and pull hard (tense pectoral muscles, raise hands above head (spread breast tissue over chest wall).
• Axillary examination
  
  • Chest wall -> anterior musculature -> posterior musculature -> close arm and check high into axilla
• Palpation of breast
  
  • Lying on back. place arm over head.
    
    • Start at areola, proximal -> distal from 3 O’clock clockwise for 1 revolution.
  • Palpate nipple. Rock fingers over nipple.
  • Ask patient to try to express discharge from nipple.
  • Mound the breast tissue. Push breast tissue together to review for any dimpling of concentrated breast tissue.
  • Repeat palpation for other breast.

Question 2

Eye Examination

Answer 2

Visual Acuity
- Wall-mounted Snellen chart
- Able to use reading glasses
- L -> R -> Both (Read smallest line possible).
Visual Fields
- Nasal and temporal fields by counting fingers in different levels (upper / middle / lower)
Pupillary Light reflex
- Shine light straight ahead into eye
- Reflex Should be in middle of pupil on both sides.
- Check individual eyes for direct and consensual pupillary reflex.

Extraocular muscle function
- General movements + convergence of eyes.

Opthalmoscopy
- Stand at 15 degrees lateral to patient. Have patient fix gaze in distance. Look for red reflex. Adjust diopter as one approaches patient to focus on vasculature of fundus. Look through quadrants. Have patient look directly at light for a quick second to focus on fovea of macula. Then cease examination.

Note; Panoptic opthalmoscope offers 25 degree field of view vs 5 degree field of view of direct opthalmoscope. Also has greater working view between patient and examiner and has a cup to shut out ambient light for the patient during examination.

Question 3

Diabetic Foot Examination

Answer 3

• Consent
• Wash hands
• Ensure adequate exposure

General inspection
- Pallor, erythema, hair loss, skin changes, redness, ulceration, joint deformities, assess in between toes for hidden ulcers or infections.

Feel
- Tenderness, assess pulses
- Monofilament sensation testing
- 128hz tuning fork vibration testing. Test on sternum.
- If abnormal, continue to proprioception and reflexes. Otherwise can continue to gait.
- Reflexes
- Ankle jerk - Over achilles tendon

Gait
- Smoothness and symmetry.

Review footwear for wear marks.

Question 4

Hip Exam

Answer 4

Gait
Footwear
Measure leg length
- ASIS to medial malleolus.
Palpation
- Greater Trochanter

Special Tests
- Trendelenburgs Test. Place hands on iliac crests and ask patient to stand on one foot. +’ve test if iliac crest drops indicating gluteal weakness.
- Thomas’s test. Bring both knees up to chest eliminating lumbar lordosis. Allow individual leg to go back to rest on bed. Inability to straighten leg = fixed flexion deformity.