VS Flashcards
When undertaking general inspection of a patient, list the signs which could indicate underlying gastrointestinal pathology
- Pallor
- Abdominal distension
- Jaundice
- Cachexia
- Obvious morbid obesity
- Hyperpigmentation
- Oedema
- Hernias
What are the 6 F’s of abdominal distension?
- Foetus
- Flatus
- Fluid
- Fulminant mass
- Fat
- Faeces
Name common abdominal scars & operations related to them
> Inguinal - hernia repair
> McBurney’s - appendectomy
> Pfannenstiel - Caesarean section
> Midline laparotomy - Abdominal Aortic Aneurysm Repair
> Subcostal - open cholecystectomy
> Nephrectomy - kidney resection
Describe “asterixis” and what it could indicate in the context of a GI examination
Bilateral flapping tremor elicited by asking patient to extend arms + cock their wrists back
Could indicate hepatic encephalopathy, renal failure…
What are Kayser-Fleischer rings?
Clinical sign of Wilson’s disease
Abnormal copper processing in the liver results in dark circles encircling the iris
Which condition is associated with the formation of hyperpigmented macules in the mouth?
Peutz-Jeghers syndrome
Genetic disorder which results in GI polyps
Which signs found in the mouth would be indicative of gastrointestinal pathology?
- Glossitis: smooth erythematous enlargement of tongue due to iron, B12, or folate deficiency
- Angular stomatitis
- Hyperpigmented macules
- Oral candidiasis
- Aphthous ulceration
What is the location of Virchow’s node and what could enlargement of said node imply?
- Left supraclavicular fossa
- Malignancy, sarcoidosis, infection
Which signs found in the chest could indicate gastrointestinal pathology?
- Spider naevi: cirrhosis; normal in pregnancy
- Gynaecomastia: cirrhosis
- Hair loss: iron deficiency anaemia, malnutrition
What is acanthosis nigricans and, if present, what could it indicate?
Hyperpigmentation and hyperkeratosis of axillary skin
Could indicate type II diabetes or GI malignancy
What do Cullen’s sign and Grey-Turner’s sign indicate?
- Cullen’s sign
Bruising around the umbilicus, late sign of haemorrhagic pancreatitis - Grey-Turner’s sign
Bruising around the flank, late sign of haemorrhagic pancreatitis
What does caput medusae indicate?
Portal hypertension - complication of cirrhosis
Describe the correct order that should be followed when performing an abdominal examination
- Inspection with patient lying flat
- Ask patient if in any pain
- Start palpation away from site of pain (if present)
- Light palpation of all 9 areas
- Deep palpation of all 9 areas
- Use palpation to check for any organomegaly
- Use percussion to check for hepatosplenomegaly, bladder distension or shifting dullness
- Auscultation to check for bowel sounds & bruits
Which factors should be taken into account when assessing for enlargement of the liver?
- Palpation and percussion of the liver should begin at the right iliac fossa
- 1-fingerbreadth enlargement of the liver could be considered normal
- Could be associated with asterixis
- If a liver edge is felt you should exclude lung hyperinflation as a contributor
Which factors should be taken into account when assessing for enlargement of the spleen?
- Palpation and percussion should start at the right iliac fossa
- Massive enlargement can be found in patients with leukaemia
- In a healthy adult it is normal to not be able to palpate the spleen when taking a deep breath in
- Grade 4 enlargement means the spleen goes past the umbilicus
- Very mild enlargement of the spleen usually can’t be detected during an abdominal examination
How long do you have to listen before considering that bowel sounds are absent?
1-3 minutes
Differentiate between normal and abnormal bowel sounds
Normal: borborygmus-type hyperactive bowel sounds
High-pitched: bowel obstruction
Following auscultation, which of the following would you say to the examiner that you would do to complete your GI exam?
- Inspect external genitalia in males: exclude inguino-scrotal herniae
- Inspect hernial orifices in males & females
- Digital rectal examination
Describe the steps that should be followed during a Digital Rectal Examination
- Explain procedure and obtain consent
- Offer chaperone
- Place patient in left lateral decubitus position
- Put on gloves, lubricate 1 index finger
- Inspect perianal area
- Ask patient to press down, insert gloved lubricated index finger
- Examine lateral and posterior rectal walls
- Examine anterior rectal wall/prostate
- Ask patient to squeeze finger to assess anal tone
- Withdraw finger and examine for blood/mucus
Match the following signs with genitourinary pathology
- Palpable bladder
- Positive renal punch sign
- Loin pain and haematuria
- Proteinuria and oedema
- Palpable bladder: urinary retention
- Positive renal punch sign: acute pyelonephritis
- Loin pain and haematuria: renal stone
- Proteinuria and oedema: nephrotic syndrome
Describe the steps required to perform urinalysis
- Don gloves and check patient details on sample
- Check expiry date of urine dipstick
- Check appearance of urine for colour & sediment and smell odour
- Hold stick correct way up and immerse in sample for 2 seconds
- Remove stick and tap stick on rim of sample bottle to remove excess
- Read stick correct way up against side of the chart
- Wait appropriate time to report each finding
- Dispose of stick and gloves appropriately
- Report exact findings
What would you look for when inspecting a patient during a neurological examination?
- Fasciculations
- Tremor
- Muscle wasting
- Posture
How would you assess for lower limb tone during a neurological examination?
- Rotate foot at ankle then sudden extension
- Lift leg at knee then drop to bed
- Roll leg
Which movements would you perform to assess lower limb power during a neurological examination?
- Dorsi/plantarflex the foot against resistance: ankle power
- Invert foot at ankle: mid-foot power
- Move heel towards bottom against resistance: knee flexion
- Lift straight leg off bed against resistance: hip flexion
- Push raised upper leg down: hip extension
- Leg straightened at knee against resistance: knee extension
Differentiate between upper and lower motor neuron signs
- UMN
Increased/brisk reflexes
Increased tone
Clonus - LMN
Decreased/absent reflexes
Decreased tone
Atrophy/muscle wasting
How would you elicit the plantar reflex? What does this indicate?
- Stroke the lateral side of the foot with the point of the tendon hammer
- Watch for the first movement of the toes
- Normal response is plantar flexion
Extension: positive Babinski sign, pyramidal pathology
How would you elicit an ankle reflex?
- Place patient’s foot and ankle at 90º
- Strike Achilles tendon with tendon hammer
- Watch for reflex & compare sides
How would you assess upper limb tone?
- Quick pronation
- Rotate elbow and wrist at the same time, vary speed
- Rotate wrist for cogwheel rigidity (Parkinson’s)
How would you test power in the upper limbs?
- With arms out and elbows bent slightly resist elbows being bent fully: elbow extension
- Holding the forearm with wrist facing down ask patient to bend their wrist down against resistance: wrist flexion
- Holding forearm ask patient to cock wrists back against resistance: wrist extension
- With palms facing up & thumbs pointing upwards, resist thumb being bent down: thumb abduction
- Ask patient to spread fingers and resist you closing them: finger abduction
- With arms held to the side & elbow flexed to sternum, ask patient to resist arms being pushed down: shoulder abduction
- Ask patient to grip 2 of your fingers: flexion at MCP joints
How would you test for upper limb reflexes?
- Biceps: biceps tendon in antecubital fossa
- Triceps: tendon proximal to elbow
- Supinator: tendon at base of wrist on radial side
- Jendrassik reinforcement manoeuver: to strengthen reflex ask patient to clench their teeth
Unilateral headache with associated photophobia and nausea would indicate:
Migraine
Shuffling gait, tremor and cogwheel rigidity would indicate:
Parkinson’s disease
Describe the scale used to assess muscle power
MRC Scale
5 - normal power
4 - movement overcomes gravity and added resistance
3 - movement overcomes gravity but not added resistance
2 - moves but not against gravity
1 - muscle contraction visible but no movement of joint
0 - no muscle contraction observed
How would you test movements of the cervical spine?
- Extension: ask patient to tilt head back as far as possible
- Forward flexion: ask patient to put chin to their chest
- Lateral flexion: ask patient to put their ear to each shoulder
- Rotation: ask patient to look over each shoulder
How would you test movements of the thoracic and lumbar spine?
- Thoracic
Rotation: sitting down with arms crossed turn to right and left - Lumbar
Forward flexion: bend down and touch toes
Extension: lean back as far as possible
Lateral flexion: run hand down lateral side of each leg
What is straight leg raising (SLR)?
Test for sciatica (nerve entrapment, lumbar disc prolapse)
Raise leg straight off bed and dorsiflex foot - elicits pain in sciatica
Positive SLR - Lasegue’s sign
Relieved by flexion of the knee
What observations should be made during inspection of the hip?
- Swelling
- Muscle wasting
- Scars
- Leg shortening
Name the points of measurement used for
A) True leg length
B) Apparent leg length
A) Anterior superior iliac spine - medial malleolus
B) Xiphisternum - medial malleolus
What is Thomas’ Test?
Special test used in REMS of the hip
Used to detect a fixed flexion deformity in the contralateral hip
Place hand under patient’s lumbar spine and flex the hip (spine will be flattened against bed)
In cases of fixed flexion deformity, affected leg will lift off bed/bend at knee
Which special tests are used in REMS of the knee?
- McMurray’s test: meniscal tear
- Lachman’s test: ACL damage
- Anterior (ACL damage) and posterior drawer (PCL damage) tests
- Lateral collateral ligament assessment (varum stress test)
- Medial collateral ligament assessment (valgus stress test)
What is the Trendelenberg test?
- Assesses weakness in hip abductors (gluteal muscles)
- Ask patient to stand on one leg at a time
- Pelvis level falling on non-weight-bearing side - positive Trendelenberg sign
What would you look for during inspection of the knee?
- Deformity
- Swelling
- Scars
- Erythema
- Muscle wasting
- Symmetry
- Varus/valgus
What is a Baker’s cyst?
Fluid in the popliteal fossa
How would you assess for the presence of fluid in the knee?
- Patellar tap: large effusion
Slide one hand down thigh to push fluid out of the suprapatellar pouch
Push firmly on patella
Positive: patella bounces and taps off femur - Cross-fluctutation test: small effusion
Push fluid up medial aspect of knee (into joint cavity and suprapatellar pouch)
Stroke down later aspect - watch for a small bulge of fluid in medial aspect of knee
What could tenderness over the tibial tuberosity signify?
Osgood-Schlatter disease
Which pulses would you assess in the foot?
- Posterior tibial
- Dorsalis pedis
What are the features of finger clubbing, and which cardiac conditions can cause it?
Distortion of nailbed angle (flattened)
Loss of Schamroth’s window
Increased fluctuation of nailbed
Rounded fingertips
Cardiac conditions:
- Infective endocarditis
- Congenital cyanotic heart disease
During a cardiovascular examination, which signs would you be looking for during general inspection?
- Cyanosis
- Pallor
- Shortness of breath
- Oedema
Which signs would you be looking for in a patient’s hands during a cardiovascular examination?
Infective endocarditis:
- Splinter haemorrhages
- Janeway lesions
- Osler’s nodes
- Finger clubbing
- Palmar pallor
- Peripheral cyanosis
- Capillary refill time
- Tendon xanthomata (familial hypercholesterolemia)
- Tar staining: smoking
How would you assess a patient’s pulse?
- Rate: normal is 60-100bpm, <60bpm is sinus bradycardia
- Rhythm: regular, regularly irregular (e.g. 2nd degree heart block), irregularly irregular (atrial fibrillation)
- Volume: strong (anaemia, fever, hyperthyroidism); weak (shock)
- Character: collapsing (aortic regurgitation), slow-rising (aortic stenosis)
Lift arm up and check pulse (ask if shoulder pain first)
Condition of the vessel wall should also be felt e.g. hardened in haemodialysis
What is the JVP and how is it measured & accentuated?
- JVP or jugular venous pressure is an estimate of the pressure in the superior vena cava (estimate of right atrial pressure or central venous pressure)
- Located between 2 heads of sternocleidomastoid, ask patient to tilt head 45º
- Measured from manubriosternal joint
- Accentuated by pressing on liver (hepatojugular reflux)
- Rise of >4cm is positive JVP
- Causes: heart failure, heart block, valvular disease
Which signs would you be looking for in a patient’s eyes during a cardiovascular examination?
- Xanthelasma: familial hypercholesterolaemia
- Corneal arcus: familial hypercholesterolaemia (non-pathological in older people)
- Conjunctival pallor: could indicate anaemia
What is malar flush and what does it indicate?
Malar flush is a plum-red discolouration of the cheeks indicating mitral stenosis
Which mouth signs can be linked to cardiovascular disease?
- Central cyanosis (tongue)
- Peripheral cyanosis (around lips)
- High arched palate: Marfan’s syndrome
- Angular stomatitis
- State of dentition: important in endocarditis
Name surgeries which match the following scars
- Sternotomy
- Left thoracotomy
- Posterolateral thoracotomy
- Left subclavicular
- Clamshell incision
- Left mid-axillary
- Sternotomy: CABG or open valve surgery
- Left thoracotomy: coarctation repair
- Posterolateral thoracotomy: lung surgery e.g. lobectomy
- Left subclavicular: pacemaker insertion
- Clamshell incision: transplant or trauma
- Left mid-axillary: subcutaneous cardioverter defibrillator
Describe the steps involved in palpation during a cardiovascular examination
- Palpate apex beat
Furtherst lateral and inferior point of pulsation
Should be 5th intercostal space left midaxillary line
If displaced could indicate cardiac enlargement - Feel for palpable murmurs (thrills) over each valve
- Feel for heaves (can suggest hypertrophy)
Right-sided heave: left parasternal border, hand will lift off chest
Left-sided heave: forceful pulsation with hand placed over cardiac apex
Which side of the stethoscope is preferred to listen to mitral stenosis?
Bell - low-pitched sounds
Describe accentuation manoeuvres for mitral regurgitation and aortic regurgitation
Aortic regurgitation: ask patient to sit forward and exhale
Mitral regurgitation: ask patient to roll onto left side and exhale
Which heart murmur might radiate to:
a) the carotids
b) the axilla
a) aortic stenosis
b) mitral regurgitation
What could crackles at the lung bases indicate in the context of a cardiovascular examination?
Crackles at the lung bases could indicate pulmonary oedema as a consequence of heart failure
Which signs would you be looking out for during inspection in the context of a respiratory examination?
- Cachexia
- Dyspnoea/tachypnoea
- Cyanosis
- Cough
- Wheeze
- Stridor
Which signs would you be looking for in the hands in the context of a respiratory examination?
- Tar staining: smoking
- Thin skin/bruising: steroid use
- Finger clubbing: lung cancer, cystic fibrosis, pulmonary fibrosis
- Fine tremor: long-term beta 2 agonist use e.g. salbutamol
- Asterixis: respiratory failure due to CO2 retention
- Palmar pallor/erythema
- Peripheral cyanosis
What are the features of Horner’s syndrome?
Invasion of sympathetic chain by pancoast lung tumour leads to:
- Ptosis: drooping eyelid
- Miosis: constricted pupil
- Enophtalmos
- Reduced/increased hemifacial sweating depending on extent of invasion into sympathetic chain
What are the features associated with consolidation?
- Dull percussion note
- Bronchial breathing
- Reduced chest wall movement on affected side
- No mediastinal displacement
- Increased vocal resonance
- Crepitations
What are the features associated with a pneumothorax?
- Normal or hyperresonant percussion note
- Reduced or absent breath sounds
- Mediastinal displacement to contralateral side if large
- Reduced vocal resonance
- Reduced chest wall movement on affected side
What are the features associated with a pleural effusion?
- Stony dull percussion note
- Reduced chest wall movement on affected side
- Reduced vocal resonance
- Reduced breath sounds
- Mediastinal displacement towards opposite side if large
- May be pleural rub
What are the features associated with COPD
- Reduced chest wall movement on both sides
- Normal or hyperresonant percussion note
- Prolonged expiration
- Vocal resonance normal or reduced
- No mediastinal displacement
- Rhonchi and coarse crepitations
What are the features of asthma?
- Normal or hyperresonant percussion note
- Prolonged expiration or absent if severe
- Normal vocal resonance
- Reduced chest wall movement on both sides
- No mediastinal displacement
- Rhonchi
What are the features of lung collapse?
- Reduced chest wall movement on affected side
- Reduced or absent breath sounds
- Reduced or absent vocal resonance
- Mediastinal displacement towards affected side
- Dull percussion note
What is a normal respiratory rate?
12-20 breaths per minute
Which chest abnormality can reduce lung capacity?
Pectus excavatum
Describe the procedure which should be followed when measuring Peak Expiratory Flow Rate (PEFR)
- Hold peak flow meter horizontally
- Patient seated
- Forced maximum expiration
- Best of 3 readings
- Depengs on age, sex, height and ethnicity
Which clinical features might be found in a patient with Chronic Obstructive Pulmonary Disease (COPD), not including findings during auscultation?
- Reduced FEV1
- Increased antero-posterior chest dimension (barrel chest)
- Cough with mucus production (yellow/green)
- Smoking history
- May be associated with alpha 1 antitrypsin deficiency
Which clinical features might be found in a patient with asthma, not including findings during auscultation?
- Dyspnoea upon exertion is common during an exacerbation
- Reduced FEV1 in an attack, significantly improved with bronchodilators
- Associated with eczema
- Nocturnal cough
- At-home monitoring with PEFR
What is Romberg’s test?
Ask patient to stand with arms by their sides & eyes closed
Tests for sensory ataxia - overly reliant on visual input to maintain balance
Positive if patient loses their balance
Describe how palpation should be carried out in the context of a respiratory examination
- Tracheal position (assess for tracheal deviation)
- Cricosternal distance (normally 3-4 finger breadths)
- Apex beat
- Chest expansion (normally 3-5cm)
- Vocal fremitus
When would whispered pectoriloquy be used during a respiratory examination?
To confirm the finding of bronchial breathing over an area of consolidation
Ask patient to say 111 or 99, should sound louder over area of consolidation
What is the normal range for hyperextension of the knee?
< 10º, more indicates hypermobility
What would you be looking for during inspection of the foot?
- Arch (high arch, flat foot)
- Toe clawing
- Hallux valgus
- Callus formation
- Swelling
- Symmetry
- Skin rashes
- Nail changes (psoriasis)
