SUMMARISING + FURTHER INVESTIGATIONS Flashcards
CARDIOVASCULAR EXAM
how would you summarise?
Today I performed a cardiac examination on ____ who is a ____ year old male/female.
On general inspection, he/she appeared comfortable at rest + did not report any pain
There was no peripheral stigmata of cardiac pathology
The pulse was ___bpm + was of normal rate and rhythm
On palpation, there were no heaves or thrills
On auscultation, 1st and 2nd heart sounds were present with no added sounds
In summary, this was a normal cardiac examination
CARDIOVASCULAR EXAM
what further investigations would you require?
Check for femoral pulses and radial femoral delay
BP both arms
BP lying + standing
Fundoscopy
12-lead ECG
CXR
RESPIRATORY EXAM
how would you summarise?
I performed a respiratory examination on ___ who is a ___ year old male/female.
On general inspection, he/she appeared comfortable at rest + not using their accessory respiratory muscles at rest.
On examination, there were no peripheral stigmata of respiratory pathology.
The pulse was ___bpm and was of normal rate and rhythm.
The respiratory rate was _____
There was no evidence of tremor.
On palpation, there was symmetrical chest expansion and no evidence of mediastinal shift or hyperinflation.
On percussion, all lung fields were resonant.
On auscultation, vesicular breath sounds were present and there were no added sounds.
In summary, this was a normal respiratory examination.
RESPIRATORY EXAM
what further tests would you require?
Check the sputum pot (volume, consistency, colour, odour)
Assess peak flow
Spirometry
CXR
BP lying and standing
Oxygen saturations
LOWER LIMB NEURO
how would you summarise?
I performed a lower limb neurological examination on ___ who is a ___ year old male/female
On general inspection, he/she appeared comfortable at rest
There were no abnormalities in posture, there was no muscle wasting or fasciculations
Gait was normal with both dorsiflexion and plantarflexion intact.
Romberg’s test was negative
Tone was normal throughout.
Power was 5/5 in all muscle groups bilaterally.
Reflexes were normal and present at knee and ankles bilaterally
Plantars were down going bilaterally
Coordination was intact
Sensation was normal in all modalities tested
In summary, this was a normal lower limb neurological examination
LOWER LIMB NEURO
what further investigations do you require?
Examine cranial nerves
Upper limb neurological examination
Pinprick + temperature
CT/MRI
UPPER/LOWER LIMB NEURO
how do you judge power?
MRC scale
5 = normal power
4 = active movement against gravity + resistance
3 = active movement against gravity
2 = active movement with gravity eliminated
1= flicker or trace of contraction
0 = no contraction
UPPER LIMB NEURO
how would you summarise?
I performed an upper limb neurological examination on ___ who is a ___ years old male/female
On general inspection, he/she appeared well at rest
There were no abnormalities in posture, there was no muscle wasting or fasciculations
Pronator drift was negative
Tone was normal throughout
Power was 5/5 in all muscle groups bilaterally
Reflexes were normal and present (at supinators, biceps and triceps bilaterally)
Coordination was intact
Sensation was normal in all modalities tested
In summary, this was a normal upper limb neurological examination
UPPER LIMB NEURO
what further investigations are required?
Examine cranial nerves
Lower limb neurological examination
Pinprick + temperature
CT/MRI
CRANIAL NERVES
how would you summarise?
I performed a cranial nerve examination on ___ who is a ___ year old male/female
On general inspection, he/she appeared well at rest
On examination of cranial nerves I-XII, there were no abnormalities detected
Special tests were negative
In summary, this is a normal cranial nerve exam
CRANIAL NERVE
what further tests are required?
Perform an upper and lower limb neurological examination
Corneal reflex
Fundoscopy
Jaw jerk
Gag reflex
Testing of abnormal nerves
CEREBELLAR EXAM
how would you summarise?
Today i performed a cerebellar exam on ___, who is a _____ year old male/female.
On general inspection, he/she appeared well at rest.
On examination, Romberg’s test was negative.
There was no evidence of ataxic gait or truncal ataxia.
Coordination was normal.
There was no evidence of nystagmus or tremor.
Tone was normal throughout.
In summary, this was a normal cerebellar examination.
CEREBELLAR
what further tests are required?
Cranial nerve examination
Upper + lower limb neuro examination
Head CT scan
ABDOMINAL EXAM
how would you summarise?
Today I performed an abdominal examination on ___ who is a ___ year old male/female
On general inspection, he/she appeared comfortable at rest and reported no pain.
On examination, there was no peripheral stigmata of gastrointestinal pathology.
There was no tremor of asteristick nature.
The abdomen was soft and non-tender with no evidence of organomegaly
Bowel sounds were present and normal
In summary, this was a normal abdominal examination.
ABDOMINAL EXAM
what further investigations are required?
To complete my examination, I would:
(ISHRUG)
Inguinal lymph nodes
Stool sample
Hernial orifices (femoral and inguinal)
Rectal examination
Urinalysis
Genital exam
DIABETIC FOOT EXAM
how would you summarise?
Today I performed a diabetic foot examination on ___ who is a ___ year old male/female
On general inspection, the patient appeared comfortable at rest
There were no abnormalities detected.
Gait was normal.
Neurovascular assessment of both feet were normal.
Sensation was intact in both feet.
if it was lost, you say where it was lost up to e.g. ‘light touch sensation was absent from the feet to the knees’
In summary, this was a normal diabetic foot examination
DIABETIC FOOT
what further tests are required?
Fundoscopy
Blood pressure
HbA1c
Pinprick and temperature
ABPI
GALS
how would you summarise?
I performed a GALS examination on ___ who is a ___ year old male/female
On general inspection, he/she appeared comfortable at rest
Normal appearance in gait, arms, legs and spine
Full range of movement in all modalities tested
In summary, this was a normal GALS examination
GALS
what further investigations would be required?
If any abnormalities were found, I would perform a regional examination of the MSK system
THYROID EXAM
how would you summarise?
Today I performed a thyroid examination on ___ who is a ___ year old male/female.
On general inspection, he/she appeared well at rest.
No peripheral stigmata of thyroid pathology
The pulse was of normal rate and rhythm and was ___bpm
There was no evidence of tremor
There was evidence of thyroid eye disease, goitre or any other swelling.
On percussion, there was no evidence of retrosternal goitre.
On auscultation, there was no evidence of bruits.
In summary, this was a normal thyroid examination
THYROID EXAM
what are the further tests?
Perform fundoscopy
Free T3 + T4
TSH
Thyroid ultrasound
ECG
HAND EXAM
how would you summarise?
I performed a hand examination on ___ who is a ___ year old male/female
On general inspection, he/she appeared comfortable at rest
No abnormalities detected
On palpation there was no tenderness
There was range of movement in all modalities tested
Sensation was intact
Special tests were negative
In summary, this was a normal hand examination
HAND EXAM
what further investigations are required?
Fully examine the ipsilateral elbow if the patient has pain or restricted movement at the wrist joint
HIP
how would you summarise?
Today I performed a hip examination on ___ who is a ___ year old male/female
On general inspection, he/she appeared comfortable at rest
No abnormalities were detected
Gait was normal
On palpation, there was no tenderness
Full range of movement in all modalities tested
Special tests were negative
In summary, this was a normal hip examination
HIP
what further tests are required?
Examine lumbar spine and ipsilateral knee joint
Perform a neurological and vascular examination of the lower limb
Femoral pulses
KNEE
how would you summarise?
I performed a knee examination on ___ who is a ___ year old male/female
On general inspection, he/she appeared comfortable at rest
No abnormalities were detected.
Gait was normal
On palpation, there was no tenderness
Full range of movement in all modalities tested
Special tests were all negative
In summary, this was a normal knee examination
KNEE
what further investigations are required?
Examine the ipsilateral hip and ankle. When examining the ankle, I would use the ‘look, feel, move’ approach
Assess the neurological and vascular status of the limb
SHOULDER EXAM
how would you summarise?
I performed a shoulder examination on ___ who is a ___ year old male/female
On general inspection, he/she appeared comfortable at rest
No abnormalities detected
On palpation, there was no tenderness
There was full range of movement in all modalities tested
Special tests were all negative
In summary, this was a normal shoulder examination
SHOULDER
what further tests should be done?
Examine the cervical spine and elbow using ‘look, feel, move’
Assess the neurological and vascular status of the limb
VARICOSE VEINS
how would you summarise?
today I examined ______ a ______ year old male/female
They appeared comfortable at rest and there were no objects around the bed of relevance
On examination _______ was present.
Pulses were present throughout both lower limbs.
In summary these findings are consistent with peripheral vascular disease.
VARICOSE VEINS
what are the further investigations?
- doppler USS
- venous duplex scan
- ankle brachial pressure index (ABPI)
- peripheral arterial exam
- abdominal exam
ANKLE AND FOOT
how would you summarise?
Today I examined ______, a ______ year old male/female
On general inspection they appeared comfortable at rest.
There were no peripheral stigmata of MSK disease
Ankles and feet appeared normal on inspection and the gait was unremarkable
The range of movement throughout the ankles and the feet was normal
In summary this is a normal ankle and foot exam
ANKLE AND FOOT
what are the further investigations?
- neurovascular exam of both lower limbs
- exam of knee and hip joint
- further imaging (x-ray or MRI)
LYMPHORETICULAR EXAM
how would you summarise?
Today I examined _____, a ______ year old male/female.
On general inspection the patient appeared comfortable at rest
There was no evidence of cachexia, pallor, rashes, bruising or bleeding
Assessment of the cervical and axillary lymph noes did not reveal any evidence of lymphadenopathy
adbominal examination was unremarkable with no evidence of hepatosplenomegaly
In summary this is a normal lymphoreticular examination
LYMPHORETICULAR EXAM
what are the further assessments?
- FBC
- biopsy
- further imaging
- examination of any relevant organs
SPINE
how would you summarise?
Today I examined ______ a ______ year old male/female
On general inspection they appeared comfortable at rest
There were no peripheral stigmata of MSK disease
There were no objects or equipment around the bed of relevance
Assessment of the spine revealed normal alignment
There was no tenderness on palpation
The range of motion of the cervical, thoracic and lumbar spine was normal
In summary these finding are consistent with a normal examination of the spine
SPINE
what are the further investigations?
- neurovascular exam of upper and lower limbs
- exam of hip and shoulder joints
- further imaging`
DVT
how would you summarise?
today i examined ______ a _____ year old male/female
on general inspection the patient appeared comfortable at rest
There were no objects or obvious risk factors associated with DVT
on peripheral examination of the hands there were no identifiable risk factors for thromboembolic disease and no acute signs of PE
Gross inspection of the legs revealed no obvious erythema, swelling or signs of venous insufficiency
Palpation = no warmth, tenderness along the distribution of the deep veins. Calf circumference was normal and equal
In summary there are no clinical findings indicating a DVT
DVT
what are the further investigations?
- cardiovascular exam
- ABPI
- peripheral arterial exam
- peripheral vascular exam
