Short cases

Question 1

Steps of CV short case

Answer 1

Inspection
- Growth - Short ?Noonan or turners or T21. Tall marfans
- Scars (thoracotomy or sternotomy, drain scars/pacing wires), groin incisions for catheter
- Cyanotic?
- Development
Hands
- Clubbing?
- Peripheral cyanosis
- Peripheral cap refill
- Any stigmata of endocarditis (Janeway lesions, oslers nodes or splinter haemmhorages)
Wrist
- Radial pulse, radial-radial delay (coA)
- Offer to check for radial-femoral delay (to maintain report I will come back to this)
Arms
- Blood pressure
- Water-hammer (collapsing) pulse (AR)
Neck
- Check JVP at 45 degrees if >5yo
- Carotid pulse
- Scars ?central line
Eyes
- Pallor
- Scleral icterus
Mouth
- Cyanosis? (They appear cyanotic but I would like to confirm this with oxygen saturation’s)
- Dentition comment (relevant for IE)
Chest
- Inspection
- Scars
- Symmetry
- Pectus excavatum (Scooped in) or carinatum (pigeon)
- Palpation
- Heaves (palpate over sternum; palms on chest, indicates massive ventriclar hypertrophy)
- Thrills (supracalvicularly, suprasternally then over each valve) - if thrill palpable then murmur is a grade 4
- Apex beat (both sides)
- Auscultation
- Listen in all 4 valve spots with Bell and diaphragm
- Listen for radiation in axilla and carotid and on the back between the scapula (coarctation or peripheral pulmonary stenosis) and supraclavicular
- Maneuvers
- Inspiration - increases R sided murmurs
- Expiration - increases L sided murmurs
- Sitting up vs lying down (benign murmurs will disappear)
- Rolling to left
- Valvsalva manoeuvres (blow on your thumb)
Lungs
- Listen for creps
Abdomen
- Hepatomegaly and/or ?pulsatile liver (tricuspid regurgitation)
- Sacral oedema and peripheral oedema

Question 2

Steps to respiratory exam

Answer 2

1. Hand hygiene
2. Introduce self and say hello
3. General inspection
   
   1. Unwell/well, any resp distress?
   2. Growth:
      
      1. General comment
      2. Plot on chart
      3. Self-reported tanner staging
   3. Vital signs
      
      1. HR and RR - offer to take
      2. Sats (does he appear cyanosed?) and temp (ask for these)
   4. Iatrogenic
      
      1. Supplemental O2?
      2. Sputum
      3. Inhaler
      4. PT devices/gait aid
      5. Glucometers
      6. Lines
   5. Dysmorphism
      
      1. Cushingoid?
   6. Exposure
      
      1. Shirt off ideally
   7. Pain and positioning
      
      1. Sitting upright
      2. Able to move around patient
4. Peripheries -> arm -> face -> chest
   
   1. Resp effort
      
      1. Signs of distress (s/c or ic recessions or tracheal tug)
      2. Resp cycle (exp > insp = obstructive conditions)
      3. Noises - Stridor/wheeze
   2. Cough (moist/dry) - ask them to ‘huff’ and cough
      
      1. Moist - PCD and CF or other non CF bronchiectasis
   3. Hands
      
      1. Clubbing
      2. Pallor/anaemia
      3. Pulse and RR
      4. Fingerprick from BSL
      5. ASterixis
   4. Arms
      
      1. Muscle bulk and fat stores
      2. IV access scars
   5. Eyes
      
      1. Pallor
      2. Jaundice/scleral icterus
   6. Ears
      
      1. ?grommets (chronic ear infections/otorrhoea with PCD)
   7. Nose
      
      1. Polyps or deviated septum
   8. Sinus palpation ?pain
   9. Mouth
      
      1. Central cyanosis
      2. Palate ?previous repair
      3. Tonsils (present/enlarged/absent?)
   10. Neck
       
       1. Trachea ?deviation
       2. Lymph nodes
5. Chest
   
   1. Inspection
      
      1. Resp distress
      2. Shape (Chest wall deformities or asymmetry)
         
         1. Pectus excavatum?
         2. Also examine back - ?scoliosis
      3. Scars
         
   2. Palpation
      
      1. Chest expansion
      2. Apex beat (brief)
      3. Vocal fremitus (palpation whilst patient says ’99’)
   3. Percussion
      
      1. Start at clavicles and all way out to axilla
   4. Auscultation (with vocal resonance)
      
      • Brief Cardiac exam
        - Apex beat (if not already done) ?dextrocardia with PCD ?pulm HTN
        Other (be guided by your differential diagnosis; eg CF - constipation, nasal polyps, PEG, evidence of liver disease or diabetes)
      • Abdomen
        - Inspection (PEG, insulin sites, scars)
        - Palpation (organomegaly, situs inversus, constipation)
        - Percuss (for ascites, only if suspicion)
      • ENT
        - Hearing
        - Look in ears and nose