1

Clinical Examinations & Skills

Mubeen Rahman - smr107@ic.ac.uk

2/3 History/CVS

4/5 Resp

6 Lymph

7/8 GIT & DRE

9-12 UL & LL

13 Cranial Nerves

14-6 Opthal/Oto

16/7 Cerebellar

17 Speech/DDx

18 Trauma/GCS

19 ANT/MMSE

20/1 GALS/Lumps

22/3 Thyroid/PVS

24 Breast & Skin

25 Inguinal/Genitalia

26-8 Musculoskeletal

29 Volume Status

30 Explain Procedure

30/1 Inject/ABG/Phleb

31 Cannulation/IVI

32/3 Suturing/PEFR

34-6 BP/ XRays/ECG

Hb (g/dL) M13-18 F11-16

Hct M0.4-.54 F0.37-.47

MCV 76-96 fL

Platelets 150-400 109/L

WBC 4-11 109/L

Neutrophils 40-75% 2-7.5

Lymph’s 20-45% 1.3-3.5

Eosinophils 1-6%

Basophils 0-1%

Monocytes 2-10%

A/PTT 35-45s 10-14s

Na+ 135-145 mmol/L

K+ 3.5-5 mmol/L

Ca2+ 2.12-.65 mmol/L

Mg2+ 0.75-1.05 mmol/L

Creatinine 70-150 uL/L

Urea 2.5-6.7 mmol/L

Albumin 35-50 g/L

Proteins 60-80 g/L

Bilirubin <17 umol/L

ALT/AST 3-35 iu/L

Alk P 30-35 iu/L

LDH 70-250 iu/L

CRP <10 mg/L

CK 25-195 iu/L

PaO2 >10.6 kPa

75-100 mmHg

PaCO2 4.7-6 kPa

35-45 mmHg

Urine Na+ 100-250 mmol/24hrs

Urine K+ 14-120 mmol/24hrs

Ur. Protein <150 mg/24hrs

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History Taking

Greet, state name/role, confirm patient’s

name and DOB. EXPLANATION & CONSENT (purpose, time available)

PRESENTING COMPLAINT (open q’s, a brief phrase, in pt’s own words)

HISTORY OF P. COMPLAINT (event narrative, time course, clarify what pt means, use SOCRATES & relevant RoS)

PAST MEDICAL HISTORY (illnesses, hospital admissions, THREAD2S2 MJ)

DRUG HISTORY (current, recent, herbal, OTC & recreational drugs, ?allergies inc. nature of reaction)

FAMILY HISTORY (? affecting blood family (immediate) ?Parents a&w, and if dec., what age and cause. ? Ethnicity

SOCIAL HISTORY (occupations, pets, recent travel, sexual history, EtoH – what/when, smoking (py’s of what), ?abode & w/whom, ADL’s, immunisations, place of birth, change in sleep, mental state, effects

SYSTEMS REVIEW: CVS - CP, palpitations, claudication, oedema RESP - cough, haemoptysis, sputum, wheeze GIT - Appetite/wt/bowel habits, vomiting, haematemesis, abdo pain, rectal bleeding GUS/O&G - Haemat/dysuria, freq, voiding difficulty, LMP, #of pregnancies, miscarries CNS - Headache, vision, faint, fit, funny turns, weakness, paraesthesia MSK - Joint pain/stiffness, swelling, immobility, rashes, irritation SUMMARY ± - DDx Ix, Tx, MANAGEMENT PLAN

! – SAMPLE: Signs/Symptoms, Allergies, Medications, PMHx, Last Ins & Outs

Cardiovascular Examination

WIPE (Wash hands, Introduce with name and role, confirming patient’s name and DOB, position at 45o

and expose chest and back)

GENERAL INSPECTION - obese, ill, anxiety, distress, malar flush, pain, SOB, cyanosed, pallor, congenital abnormalities (Down’s - ½ have Septal Defects, Marfan’s - Asc. Ao. An, Turner’s – Aortic Coarctation)

GENERAL INSPECTION – items to do with care – IVI diuretics (POed/HF), oxygen, GTN spray, monitor, ciggs.

INSPECT HANDS – NAILS, FINGERS, PALMS- Clubbing via Schamroth’s Window (chronic O2, cong. cyan. HD, A.Myxoma, SBEndocarditis), cyanosis, warmth, endocarditis (splinter haemorrhages, Osler’s nodes, Janeway lesions), tar stains, koilonychia (IDA), leukonychia (alb), tendon xanthomata, anaemia, palmar erythema (portal HTN)

PERFUSION - ?CRT < 2s (CO, vasoconstriction, Art. Obstruct, Raynauld’s, Shock). If hands hot + tremor = thyrotoxicosis

RADIAL PULSE – rate and rhythm RADIAL PULSE – SYNCHRONY (left

and right) - !coarctation COLLAPSING PULSE - BRACHIAL BLOOD PRESSURE – both arms INSPECT EYES – pallor, jaundice,

(?valve prosthesis), corneal arcus/sinilis, xanthelasma, Grave’s (proptosis, ptosis, lid retractions => !AF / output HF)

INSPECT FACE – malar flush (MS)

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Murmur Grade Intensity: 1 Just audible 4 Loud & w/ thrill 2 Quiet 5 Very loud 3 Moderately loud 6 Audible w/o Steth

INSPECT MOUTH – pallor, cyanosis - indicates a min of 5g/dL deoxHb (shunting) , glossitis (B Vit), high arch palate, dental caries

CAROTID PULSE – ?Volume & character. Check opp. side separately.

Collapsing – rapid up & downstroke = AR Bisferiens = both collapse + plateau –

Mixed Ao Valve Disease Pulsus alternans – alternating strong and

weak pulses = Severe LVF Slow Rising (+plateau) = ASten – check

Brachial Pulse Pulsus paradoxicus – vol. on insp by

>10mmHg - Tamponade, constrictive pericarditis, asth.

JVP (± HEPATOJUGULAR REFLEX) –

45 degrees - !RAP eg RVF/fluid overload. “a” & “v” waves = HS I & II

INSPECT PRAECORDIUM - Scars (CABG, valvotomy), abnormal veins, pacemakers (subcostal), visible apex beat, pulsations, breathing.

PALPATE PRAECORDIUM – Apex, compare against position of 5th ICS MCL. Laterally displaced or diffuse impulse = LVF/dilated cardiomyopathy

PALPATE – HEAVES & THRILLS AUSCULTATE PRAECORDIUM

time with the carotid pulse, over the valves: Aor, Pul, Tri, Mitral.

MANOEUVRES (L. Side - MS, lean forward – Ao Incomp.) on expiration.

Expiration clarifies right sided murmurs & v.v. ?Duration, Radiation, HS & amplitude S3 = Ken-tuc-ky (MR) S4 = Ten-ess-see (ASten/CHF)

?Radiations: Axilla (MR), Carotid (ASten)

?Murmurs: LSE – RVHypertophy (pulm.HTN), 2nd ICS – Dilated PArt (L) or Asc. Ao (R), Ej SM = ASten oroutput state - children/preg EDM = AR (rarely PR) - 2o to Endocarditis Mid DM = MS/AR PSM = MR, merging with S2, occurs in M/TR Machine murmur – Patent ductus arteriosus

AUSCULTATE CAROTID ARTERY – bruits, w/ bell, stop patient breathing

PERCUSS/AUSCULTATE CHEST – - pleural effs /creps at bases (LVF/CCF)

OEDEMA - Check sacrum/ankle -CCF EXTRAS: AUSCULTATE & PALP for AAA +

RENAL BRUITS HEPATOMEGALY - congestive disease

(RVF), or pulsatile in Tri regurg) SPLENOMEGALY – Inf. Endocarditis MSU Dipstick for Haematuria Peripheral Vascular and Resp Exam Assess femoral, popliteal, dorsalis

pedis and posterior tibial pulses. ? OPTIC FUNDI (Roth’s Spots,

HTN/DM), ECG + Exercise ECG if inconclusive, Request Echo

THANK, OFFER TO HELP PT DRESS

AS

MR

AR

MS

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Respiratory Examination

WIPE - chest (and back) @ 45o GENERAL INSPECTION – respiratory distress, symmetry of movement, accessory muscles, pursed lips, pallor, cyanosis, wheeze, breathing pattern, Medical - Horner’s syndrome (Pancoast’s tumour ), erythema nodosum (sarcoidosis), deformity: Kyphoidosis/Lordosis/Scoliosis Paraphernalia – O2 mask, sputum pot, flow meter, inhalers, nebuliser, drains. HANDS –– Warmth, bounding pulse, dilated veins (CO2 retention), skin thinning (Ca), tar stains, peripheral cyanosis, koilonychia (IDA). Small muscle wasting (esp. 1st dorsal interossei) – Pancoasts. Clubbing (large cell Ca, ILD, TB, suppurative disease, mesothelioma, lung Ca, bronchiectasis, empyema, Cy Fi) – if +ve look for pain w/ wrist mvmt (pypertrophic pulm. osteoarthopathy) - ! lung Ca WRISTS – Ask pt to put arms straight

out infront, spread fingers (B2 agonist tremor). Then cock wrists back for >30s (CO2 retention flap).

ASSESS PULSE (RATE + RHYTHM) while assessing flap – looks slick!

ASSESS RESPIRATORY RATE Note: Depth + Effort + Obvious Sounds INSPECT EYES - Anaemia (pallor on

underside), miosis, ptosis (drooping upper eyelid), anhidrosis - Horner’s syndrome/Pancoast’s tumour.

INSPECT TONGUE, LIPS, MOUTH - Tongue – cyanosis (blue tinge underneath), glossitis. Lips – angular stomatitis. Mouth – candida infection (steroid).

EXAMINE NECK - Neck/face swelling, dilated veins (SVC obstruction – lung tumour).

ASSESS JVP - Ask pt to look to left, illuminate. JVP raised in cor pulmonale, RVF, Fluid OD

CAROTID PULSE - bounding pulse in CO2 retention.

PALPATE LYMPH NODES – From behind (submental, submandibular, supra-clavicular, posterior-auricular, occipital)

! – Infection, Neoplasm, Sarcoid PALPATE TRACHEA - Warn pt first.

Palpate for deviation. T Fibrosis/ Collapse, T Pneumo/Effusion.

CRICOSTERNAL DISTANCE - Measure finger breadth distance between cricoid cartilage and suprasternal notch (~2 fingers, less in emphysema, COPD = tracheal tug, if w/systole – Ao. Arch Aneurysm)

FEEL FOR APEX BEAT INSPECT CHEST - Pectus excavatum,

carinatum (rickets), funnel (congenital). Scars (ant/posterior). Kyphoscoliosis, barrel chest, radiotherapy tattoo, skin damage

CHEST EXPANSION (STERNAL, LOWER) - 2 hands on sides of chest, thumbs meet in middle (not touching skin). Sternal – check upward mvmt. Lower rib cage – laterally (>5cm).

Repeat on back at 2 levels. w/ Effusion, Consolidation, Collapse, Pneumothorax and Fibrosis PERCUSS FRONT - Supraclavicular,

clavicles (directly) then chest wall (2 x 3 positions including axilla).

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Resonance (air) – Pneumo/COPD Resonance (dull)= fluid, solid i.e. Large effusion or consolidation

AUSCULTATE FRONT- Ask pt to take deep breaths via mouth (show). Listen w/ diaphragm - ?vesicular, bronchial, what intensity, added sounds like wheeze, (mono/poly), crackles, pleural rub TACTILE/VOCAL RESONANCE Ask pt to say ‘99’ when listening to 2 x 3 positions. WHISPERING PECTORILOQUY Ask pt. to say “one” repeatedly, whisper transmitted in consolidation PERCUSS BACK - Do back 2 x 3

positions. AUSCULTATE BACK – 2 x 3

POSITIONS TACTILE/VOCAL RESONANCE

BACK – 2 x 3 positions w/ consolidation w/ Pneumothorax and Effusion OEDEMA – Sacral and ankle EXTRAS: CVS Exam, CXR, Peak flow,

Sputum pot sample, ABG

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Lymph Node Examination

HEAD & NECK NODES

• VERTICAL NECK: Neck flexion may relax the strap muscles. Feel for the superficial cervical nodes along the SCM body. The posterior cervical nodes run along the anterior body of trapezius. The deep cervical chain is difficult to feel, as they are deep to the long axis of SCM; explore by palpating firmly through the muscle. INFRACLAVICULAR AXILLARY NODES Take the pt’s L arm with your R hand and explore with your L hand and vice versa:

• Slightly cup examining hand and palpate into axilla apex for apical group – small nodes may only be felt by rotating the fingertips against the chest wall. • Feel for the anterior group of nodes along the posterior border of the anterior axillary fold, the central group against the

lateral chest wall, and the posterior group along the posterior axillary fold. • EPITROCHLEAR (ELBOW) - Passively flex the patient’s relaxed elbow to a right angle. Support with one hand whilst feeling in the groove above / posterior to the medial condyle of the humerus. PARA-AORTIC - deep central mass if

enlarged INGUINAL & LEG NODES - Supine

• H’al – just below inguinal ligament • V’al - along the long saphenous vein

POPLITEAL - Relax the fossa by passive flexion – explore by wrapping the hands either side of knee and exploring with the fingers of both hands. SPLEEN & LIVER Examine the DRAINAGE AREAS of

any enlarged nodes.

General points to note:

Size: anything >1cm is abnormal Consistency: hardness suggests Ca, rubbery consistency points to lymphoma Tenderness: implies infection Fixation: suggests malignancy Overlying skin: tethering is a feature of malignancy, inflammation suggests infection

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Gastrointestinal Examination

WIPE - ‘nipples to knees’ for abdominal portion, initially 45o, then supine for abdomen, w/ pillow/s under head, relaxed, arms by sides, check patient is comfortable)

INSPECTION - cachexia, obesity, normal weight, hydration, pain, pallor, pruritis (jaundice), distension, scars, masses, bruising, etc.

Paraphernalia: Drains, stoma feeding tubes, notices, supplements, catheter. HANDS - Palmar erythema,

Dupytren’s Contracture, Clubbing (IBD, liver cirrhosis, malabsorption). Koilonychia, Leuconychia (chronic liver disease, nephrotic syndrome). Arteriovenous fistulae (lump from dialysis). Hydration (dehydration makes skin flaccid), nail pitting, xanthomata

WRISTS - Test for asterixis (hep flap) w/ pt. holding arms out, wrists cocked >30sec – check pulse here too!

RADIAL PULSE (AF, Shock) EYES – Scleral icterus, pallor, corneal

arcus, xanthelasma, KF rings. LIPS - angular stomatitis, cheliosis

(fissuring/crack of lips), herpes labialis, GUMS – hypertrophy, gingivitis. MUCOSA – ulceration, pigmentation

(Peutz Jegher’s – dark freckles on lips, face, mucosa, w/ GI obstruction and polyps), Osler-Weber-Rendu telangiectasia (capillaries near surface, alcohol, malignancy).

TEETH – caries (cavities), dentures.

TONGUE – dry/wet, jaundice, atrophic, furred & beefy, swollen, candidiasis, tonsils, palate, etc.

BREATH – fetor hepaticus (stale urine, ammonia), alcohol, ketoacidosis (peardrops), halitosis.

CERVICAL LYMPH NODES – from behind

VIRCHOW’S NODE/TROISIER’S SIGN (L SUPRACLAVICULAR AREA)

JVP – raised in hepatic pathologies INSPECT CHEST - Gynaecomastia,

Spider Naevi (~>5 pathological in women, any in men), feeding/tunnelled lines, body hair distribution

INSPECT ABDOMEN – Get to level of patient, lie SUPINE

INSPECT ABDOMEN – distension, lumps, caput medusa, bruising, scratches, visible peristalsis, rigidity (peritonitis).

INSPECT ABDOMEN – Ask pt to cough (pain/hernias), to raise legs (rectal divarication, hernias).

ASK PATIENT IF THEY HAVE PAIN PALPATION - SUPERFICIAL -

Tender region last. Watch patient’s face. Visit all 4/9 quadrants. Elicit tenderness, rigidity, guarding.

PALPATION – DEEP - deep-seated pain (rebound?). Any masses described as lump w/ position, shape, size, surface, fixed, mvmt w/ resp., tenderness, pulsation.

PALPATION – LIVER (from RIF, w/ deep breaths). Percuss for upper & lower border using index finger edge - ! psuedohepatomegaly due to hyperinflated lungs

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PALPATION – SPLEEN (from RIF, w/ deep breaths using fingertips). Percuss.

PALPATION – KIDNEYS (bimanual ballotment)

PALPATION - ABDOMINAL AORTA - 2 hands (or middle & index finger) firmly at either side. AAA will push upwards (pulsatile) and out (expansile)

PERCUSSION – 4 QUADRANTS PERCUSSION – ASCITES a. Shifting dullness

b.

: Percuss from umbilicus laterally (w/ fingers pointing toward head). ?resonant at umbilicus, dull in flanks. If not, no ascites. Pt. rolls to RHS whilst keeping your hand over L flank where it was dull. Wait 1m and re-percuss. Note should have changed: dullresonant. Roll pt. onto LHSide. Wait 1m. Left flank should be dull again.

Fluid thrill:

AUSCULTATION – quadrants for bowel sounds (>15s, >1 min for absent. Normal, borborygmi (mvmt), absent (ileus) , tinkling ( e.g. obstruction)

Flick on one side, feel any mvmt transmitted. Thrill due to mvmt through fluid. Ask pt. to put ulnar edge of a hand in centre of abdo to prevent a false +ve thrill from fat.

OEDEMA – check ankles AUSCULTATION – AA BRUIT,

RENAL AND LIVER EXTRAS: Palpate hernia orifices,

examine the external genitalia, DRE, urine dipstick:

SG >1.010 = dehydration, <1.007 Normal Ketones = DM Albustix = Renal Infec, DM, jaundice, Thy Nitrites & Leukocytes = UTI Hb = Glomerular damage/Rhabdomyolysis

Glucose = Diabetes / Nephropathology THANK, CHECK COMFORT,

OFFER TO HELP GET DRESSED.

Digital Rectal Examination

WIPE – nipples to knees, left lateral position, knees drawn up to chest, feet clear of perineum, buttocks at edge of couch. ? CHAPERONE

PUT ON GLOVES ASK ABOUT PAIN/DISCOMFORT INSPECTION – skin tags, warts,

haemorrhoids, fistula, fissure, abcesses, pilonidal sinus, prolapsed rectal mucosa, skin discolouration, scratch marks, discharge

PALPATION – WARN PT FIRST PALPATION – lubricate finger, use

pulp of finger on anus, press firmly and aim towards umbilicus

PALPATION – rotate around 360°, feel for masses, mucosal changes, temperature changes, prostate

ASSESS ANAL WINK – reflexive contraction of the anal sphincter on stroking peri-anal skin (S1-3)

ASSESS ANAL TONE (ask pt to squeeze finger)

REMOVE FINGER GENTLY EXAMINE FINGER – evidence of

blood, mucous, stool etc. CLEAN UP PT – leave towels for

them to clean themselves ASK PT TO GET CLEANED UP

AND DRESSED (do not thank the pt) DISPOSE OF GLOVES/WASTE AND

WASH HANDS EXPLAIN FINDINGS TO PT

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MRC Power Scale: 5 Normal power 4 +/- Movement against gravity plus resistance 3 Movement against gravity 2 Movement without gravity 1 Palpable contraction w/ no active mvmt 0 No active contraction

Upper Limbs PNS Examination

“I Think People Can’t Resist Penetrative S Games”

WIPE - 45o or upright, arms/legs fully exposed)

INSPECTION – palsies, abnormal movements, fasciculation, wasting, tenderness

Hemiplegia – flexed UL, extended LL T1 palsy – weak finger adduction and abduction. Sensory loss to medial forearm. Radial nerve – wrist drop. Sensory loss on small area of dorsal web of thumb. Median nerve – Adductor Pollicis Brevis weakness. Sensory loss thumb, 1st 2 fingers, palmar surface. Ulnar nerve – interversion, hypothenar muscles waste, claw-hand, no finger extension. Sensory loss, half 4th, all 5th, palmar surface. Erb-Duchenne (C5-7) - waiter’s tip. PRONATOR DRIFT, TREMOR –

parkinsonism, thyrotoxicosis, chorea, athetosis, spasm

TONE – wrist, elbow, shoulder etc… POWER –Shake hands w/pt.

• Shoulder abd/add’n (C5) “chicken wings”

• Elbow flex/ext (C5 & C6). “boxer”.

• Wrist Flexion/ext – “push fist up/down”

• Finger grip (C8, T1). “squeeze my fingers”

• Finger Abduction (dorsal interossei, ulnar nerve, T1) “squeeze/spread fingers”. -DAB

• Finger adduction (T1). “paper pull” -PAD

• Fine movements – “fingers to thumbs”

COORDINATION – FINGER-NOSE – both sides, with your finger at arm’s length. Cerebellar changes = past pointing and intention tremor

COORDINATION – DYSDIADOKINESIS – both hands

COORDINATION – FINGERS – play piano etc

REFLEXES – biceps, triceps, supinator with Jendrassik manoeuvre if needed.

PROPRIOCEPTION – always demonstrate up/down motion first, use finger on either side of both toes, eyes closed, test peripherally first

SENSATION – LIGHT TOUCH – ask about numbness, use cotton wool, eyes closed, test at sternum and start.

SENSATION – PIN PRICK (PAIN) – sharp or blunt, test at sternum, go...

L2 – Medial Thigh, L3 – Knee, L4 – Floor, L5 – Lat. Side, S1 – Pinkie, S2 – Posterior Thigh

VIBRATION – 128Hz tuning fork, tester on sternum first, begin test distally on bony prominences.

SENSATION – TEMPERATURE – (since pain and temperature both spinothalamic) – dermatomal distribution, determine if tuning fork is hot or cold

FUNCTION – Ask pt. to write their name

THANK, COVER, COMFORT.

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Lower Limbs PNS Examination

WIPE (45 degrees or upright, arms/legs fully exposed)

INSPECTION – palsies, abnormal movements, fasciculation, wasting, tenderness

TONE – rock legs, flick knee upwards, look for clonus

POWER:

Hip Adduction/Abduction (L1, 2) “push your legs against me, pull legs together...” Hip flexion (L1, 2) – “leg straight, lift whole leg off bed, don’t let me push it down”.

Knee flexion (L5, S1, 2) – “heel to you, bring to bottom, don’t let me pull it away”

Knee extension (L3, 4) – “Now try to push it down straight again, push me away.”

Plantar flexion (S1) – “Point your toes up to the ceiling, and press down against me”

Dorsiflexion (L4, 5) – “Now pull up against me, stop me pushing your toes down”

COORDINATION – HEEL-SHIN + TAP –rub your heel from opp. knee to foot, then tap my hand w/ foot, repeat as fast as possible

REFLEXES – tendon knee reflex, ankle reflex, Babinski manoeuvre

PROPRIOCEPTION – always demonstrate up/down first, use finger around both sides of the toe, eyes closed, test peripherally first

SENSATION – LIGHT TOUCH – ask about numbness, use cotton wool, eyes closed, test at sternum first.

SENSATION – PAIN – pin along dermatomes

C5 – Lateral arm, C6 – Lateral forearm +thumb/index, C7 – Middle F, C8 – Pinkie, T1- Medial Forearm

SENSATION – VIBRATION – do or mention, 128Hz tuning fork, tester on sternum first, test distally first, on bony prominences

SENSATION – MENTION TEMPERATURE (since pain and temperature both spinothalamic) – dermatomal distribution, determine if tuning fork is hot or cold

GAIT – ROMBERG’S GAIT – WALK NORMAL - to point

and back, HEEL-TOE, WALK TIP TOE GAIT – CROUCHING AND

STANDING

THANK, COVER, OFFER, COMFORT

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Cranial Nerve Examination

WIPE GENERAL INSPECTION – weakness,

myopathy, diplopia, tremor, asymmetry, strabismus, eye position, ptosis, pupil size, ARTICULATION (say “red lorry yellow lorry”)

CNI: OLFACTORY – ask problems w/ smell or taste. Mention or do testing nostrils separately w/ scents.

CNII: OPTIC : CNII/III – PUPIL LIGHT REACTIONS

(direct, consensual, swinging) CNII/III ETC – ACCOMMODATION

(far near) CNII – FIELDS (in confrontation, 1m

apart, correct eye covering and movement, both sides and both eyes)

CNII – INATTENTION (arms 1m apart, wiggle fingers (l + r + both))

CNII – ACUITY (ask about problems, glasses or lenses) Snellen chart, mini-chart or print up close, test each eye separately.

CNII – COLOUR (Ishihara plates) CNII – FUNDOSCOPY CNIII, IV, VI – Ask pt to mention

any double vision while keeping head still.

CNIII, IV, VI – H SHAPE – look for nystagmus and saccades

CNV: TRIGEMINAL – MOTOR (look for wasting, ask pt to open mouth, wiggle, clench teeth, palpate temporalis and masseters)

CNV – SENSORY (touch w/ cotton wool, eyes closed, 3 levels comparing

sides (could do pain/pinprick if problematic))

CNV/VII –CORNEAL REFLEX

CNV–JAW JERK REFLEX

CNVII: FACIAL – MOTOR (look for wasting, asymmetry. Ask pt to frown, raise eyebrows, screw eyes up, then against resistance. “Show me your teeth, puff out cheeks” and against resistance. Taste not usually assessed)

CNVIII: VESTIBULOCOCHLEAR

ACUITY AND BALANCE – ask any problems w/ your hearing or balance?

CNVIII- ACUITY (press tragus/distract opposite ear and whisper in other ear, both sides)

CNVIII – RINNE’S (512 or 256Hz) CNVIII – WEBER’S (512 or 256Hz)

CNIX: GLOSSOPHARYNGEAL

– ask any problems w/ your speech, taste or swallowing?

CNIX/X – look in mouth, watch uvula at rest and w/ pt saying aahh. Deviation away from lesion CNIX/X – ask pt. to cough, swallow CNIX/X – GAG REFLEX (?sip water) CNXI – POWER – shrug shoulders

and against resistance, turn neck to side and against resistance, palpating opposite sternocleidomastoid

CNXII: HYPOGLOSSAL – examine tongue at rest (bulk,

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fasciculation), then on protrusion, then waggle side to side, la la la etc. Ask pt.to push finger through cheek

THANK, OFFER HELP, COMFORT

Ophthalmoscopy WIPE (dim lights, sit facing pt at the

same height), EXPLANATION AND CONSENT. ? CHAPERONE

REMOVE PT’S GLASSES/ASK ABOUT CONTACT LENSES

INSPECTION - ptosis, styes, squinting, inflammation, exopthalmos.

CHECK OPHTHALMOSCOPE (at 0, don’t use full power light)

WARN PT ABOUT BRIGHT LIGHT REST HAND ON PT’S FOREHEAD –

place thumb supraorbitally. START W/ NORMAL SIDE FIRST USE OPHTHALMOSCOPE

CORRECTLY (in right hand, use right eye to look at pts right eye)

Ask pt. to focus on distant point, level to you, over your shoulder. Approach at 15o laterally to their line of vision.

RED REFLEX (from approx 1m, look for opacities, or loss of reflex)

FUNDOSCOPY – FOCUSING -move as close to the patient as possible, focus on blood vessels by scrolling through different lenses – may be easier to focus on iris first.

FIND OPTIC DISC - use arrow sign and follow blood vessels.

EXAMINE OPTIC DISC - focus - look for cupping (glaucoma), papilloedema ( ICP). Check physiologic cup and border.

VESSELS – inspect all quadrants

- Arteries = light, small | Veins = dark, big EXAMINE FUNDUS (hard exudates,

a-v nipping or crossing, copper-wiring, blot haemorrhages – hypertension, soft exudates, flame haemorrhages, new vessel formation – diabetes)

EXAMINE MACULA (“look at the light” – vision should be 6/6 here)

EXAMINE THE FRONT OF THE EYE - rack through lenses to focus on different parts of the eye, try +10-12d

REPEAT PROCEDURE - OTHER EYE THANK PT, SWITCH LIGHTS ON,

REPLACE GLASSES etc… Fundi Cheat Sheet Normal Fundoscopic View: Normal Optic Disk: Pale pink/yellow, round/slightly oval, with a crisp and well defined margin against the retina. Occasional surrounding ring may be present; at the centre is a pale physiological cup – note the cup-to-disc ratio. It is 3-4mm nasally from the fovea.

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Abnormalities: VITREOUS – Opacities – asteroid

hyalosis, scars, DM – haemorrhages, fibrous tissue, angiogenesis

OPTIC DISC: Papilloedema – Swollen, poorly demarcated disc. Cx inc. Intracranial space occupying lesions, tumours, abcess, haematoma. Malignant HTN, Benign IC HTN, Central Vein Thrombosis, CO2

Optic Atrophy – Pale disc, clearly delineated. Pupil reacts consensually but not directly. Cx. inc. MS, II Compression (tumour, aneurysm), Glaucoma.

Papillitis – early sign of MS, it is ocular inflammation restricted to the optic nerve head.

Optic Disk Cupping – 2o to glaucoma (vessels seem to fall down the disc)

Myelinated nerve fibres – streaky white, irregular patches w/frayed margins, Benign, Does not affect vision ARTERIOLES & VENULES – Calibre,

light reflex (silver wiring), AV Nipping QUADRANTS and MACULA – Haemorrhages: Dot, Blue, Flame Microaneurysms , Laser Scars Exudates: Hard (well defined edges, light reflex,), Soft (fluffy w/ill defined edges). Hard exudates may form a ring (circinates) in DM’s. Cotton Wool Spots Hypertensive Retinopathy: GRADE 1- Narrowed retinal arterioles, increased light reflex – sliver wiring GRADE II – AV Nipping GRADE III – Malignant HTN: Flame (less frequently) blot haemorrhages, cotton wool exudates. GRADE IV – Papilloedema e.g. venous engorgement, elevation of optic disk, haemorrhages adj. or over disk & blurring of optic margins. Indicates cerebral oedema and ICP)! Pre-eclampsia

16

Otoscopy

WIPE (sit facing pt at the same ht, access to both ears)

EXPLANATION AND CONSENT ASK ABOUT PAIN/DISCOMFORT–

warn pt, start w/ normal side. CHECK OTOSCOPE ( turn on light,

use clean sterile speculum) USE OTOSCOPE CORRECTLY (hold

in R hand for R ear, hold it on its side like a pencil, always advance under direct observation)

PULL PINNA UP AND BACK (straighten external auditory meatus)

POSITION OTOSCOPE NEAR E.A.M. - advance under direct supervision, up to the first row of hairs but no further)

OTOSCOPY – EXAMINE EAM (look for swelling, redness, discharge, wax, foreign bodies)

OTOSCOPY – EXAMINE TYMPANIC MEMBRANE (look for, redness, swelling, perforation, bulging, clear light cone indicates healthy TM)

OTOSCOPY – EXAMINE BEHIND TYMPANIC MEMBRANE (look for bulging, inflammation, obvious abnormalities)

W/DRAW OTOSCOPE CAREFULLY THANK PT, SUMMARISE FINDINGS

± DIAGNOSIS Cerebellar Examination

WIPE, EXPLANATION AND CONSENT (undress to light underwear)

INSPECTION (muscle wasting, trunkal ataxia, fasciculation, discoordination, slurred speech)

ASSESS FOR TREMOR (use a piece of paper to assess fine tremor and intention tremor)

GAIT (stride length, arm swing, ataxia, observe co-ordination of turn. Ask pt to walk heel-to-toe)

ROMBERG’S TEST SPEECH (ask pt to repeat “baby

hippopotamus” and “british constitution”) VISION (?changes, double vision etc) ASSESS NYSTAGMUS or SKEW

DEVIATION CHECK for DYSDIADOKOKINESIA COORDINATION – ARMS

(intention tremor, past pointing, lack of co-ordination)

COORDINATION – LEGS (run heel down shin. toe to hands)

TONE – ARMS (hypotonia, assess shoulder, elbow and wrist movement)

TONE – LEGS (roll leg side to side, look for toe swing, flick knee up and watch heel)

REFLEXES – ARMS (biceps, triceps and supinator. Look for hypo-reflexia)

REFLEXES – LEGS (knee and ankle . look for hypotonia)

THANK PT, HELP GET DRESSED Pastries help digest cerebellar disease... Dysdiadokokinesia Paraneoplastic Synd. Ataxia Abcess/Atrophy Nystagmus Stroke and MS Intention Tremor Trauma Scanning dysarthria Raised ICP Hypotonia Infection –EBV,CPox Ethanol & Poisons Spinocerebellar Atax

17

Speech Examination

INSPECTION – Raynaud’s, CREST, thyroid, Hemiplegia, or other dx assoc. w/dysphasia, Nystagmus, Intention tremor, Parkinsonisms

QUESTIONS: “What is your Name, Address, items you had for lunch”

ARTICULATION: “British Constitution, Baby Hippopotamus, West Register St.”

CONDUCTION APHASIA- Repetition of above...

SPASTIC DYSARTHRIA: Cerebellar – Slurred, jerky, Explosive Psudobulbar Palsy – Indistinct, Suppressed, w/o modulations, “hot potato, Donald duck” PD – Monotonous, oaccent/emphasis, slur Mytonic Dystrophy – Slurred & Suppressed Huntingdon’s Chorea – Slurred, Monotone FLACCID DYSARTHRIA – Bulbar palsy: Nasal w/ decreased modulation, slurring of labial and lingual consonants “pa,la”. VII, IX, X, XII Paralysis MYOPATHIC DYSARTHRIA – My.

Gravis – Weak hoarse voice w/nasal quality, pitch unsustained, soft accents.

VARIEGATED DYSARTHRIA

Thyroid: Low pitch, catarrhal, hoarse, croaking, guttural voice (sounds like tongue>mouth). Amyloidosis: Large tongue Mx Ulcers – Some speech indistinct Parotitis/Temporomandibular Arthritis – Monotonous, suppressed, badly modulated

COMPREHENSION – Don’t gesture: “Tongue out, Shut your eyes, Touch your nose”. Good = Expressive, Bad = Receptive Aphasia

NOMINAL DYSPHASIA – Display keys “what is this? Is it a spoon, is it a pen, is it keys?” Test ability to form sentences e.g. “Where do you live and how would you get home from here?”

OROFACIAL DYSPRAXIA – Test firs w/o gesture: “Show me your teeth, move your tongue from side to side”, Rpt. w/gesture. ?Ideational or ideomotor dyspraxia (lesions in the operculum)

AMTS

Differential Diagnosis Screen

V Vascular and Ischaemic I Inflammatory and Infectious T Trauma and Surgery A Acquired inc. Drugs M Metabolic I Idiopathic & Iatrogenic N Neoplasm / Malignancy C Congenital and Genetic D Deficiencies Investigations: Cultures, Bloods (A/V), Imaging, Functional tests, Scopic and Biopsies Treatment: Conservative, Medical, Surgical Surgical Sieve – causes for lumps etc: Infection (Acute, Chronic, Acute on Chronic) – can be viral, bacterial or fungal Neoplasm – Benign, Malignant (1 or 2o) Mechanical - Strictures, Obstructions

18

The TRAUMA Rapid Patient Assessment Tool – DRsAcBCDEEEFG Danger – to yourself/pt. Think of a SAFE response Response (AVPU) – Call from afar, shout “open your eyes” in both ears, pinch trapezius! shout for help if unresponsive / needed... Airway - ?Patent, controlled, clear, trachea central. Consider adjuncts & O2 (Note SpO2) c-Spine – immobilise with collar, sizing appropriately, Breathing (ATOMFC)– Asthma/Allergies (bronchospasm/silent chest – Tx Anaphylaxis) Tension (surgical emphysema/deviation), Open (Sucking), Massive Haem’x (dullness) - Tx drain/tape up, Flail Chest (crepitus), Cardiac Tamponade (muffled sounds) Tx - decompress Circulation – Stop Haemorrhage. Check Pulses, mark (X) and BP, 14G cannula in ACFossa Disability – Get GCS, ?Fractures, CNS deficits – sensory and motor. Consider Analgesia Expose, Examine, Environment – 2o Survey w/appropriate thermoregulation. ?Extricate Fluids & Electrolytes, Foetus – Bolus Challenge, check chemistry & resus, check if pregnant Glucose, Get Obs – Pupils, HR, CRT, RR, BP, GCS, Temp, Blood Glucose, ECG Form a Revised Trauma Score, get two sets of Obs if needed and GO! Glasgow Coma Scale

4 Spontaneous (alert) 3 In response to any speech

2 In response to pain 1 Absent

5 Orientated – pt knows who he is, where he is and why, the year, season, month 4 Confused – patient responds in a conversational manner, but there is some

disorientation and confusion. 3 Inappropriate speech – random/articulated speech, no conversational exchange 2 Incomprehensible speech – moaning but no words 1 None 6 Obeying command – pt does simple things you ask (beware grasp reflex) 5 Localizing response to pain – elicit pain w/ fingernail bed pressure (w/ pencil),

parasternal rub, pressing on supraocular/supraorbital area. Purposeful movements towards changing painful stimuli is a ‘localizing’ response

4 Withdraws to pain – pulls limb away from painful stimulus 3 Flexor response to pain – pressure on nail bed causes abnormal flexion of limbs

– decorticate posture/rigidity 2 Extensor posturing to pain – stimulus causes limb extension (adduction, internal

rotation of shoulder, pronation of forearm) – decerebrate posture/rigidity 1 No response to pain SCORE = BEST E/V/M : GCS ≤8 severe injury | 9-12 moderate | 13-15 minor

EY E V E R BA L M O T O R

19

Abbreviated Mental Test

Warn patient not to worry or be concerned about their answers. EMPOWER PATIENT TO ASK IF THEY DON’T UNDERSTAND, BE POLITE SPEAK CLEARLY, NON-PATRONISING 1. Age 2. DoB 3. Time (TO NEAREST HOUR) 4. Year (allowing for Dec/Jan)10a. “I would like you to remember this address: 42 WEST STREET. Please repeat it back.” - get the patient to repeat it back instantly. 5. Where are you (name of institution)? 6. Recognition of two people e.g. porter, doctor, family member 7. Dates of WWII or other substitutes (WWI – 1914-18, WWII – 1939-45) 8. Name of present monarch/prime minister. 9. Count backwards from 20 to 1 – don’t stop them prematurely 10b. “Please repeat back to me the address I asked you to remember.” ADD SCORE UP (OUT OF 10 POINTS) & INFORM EXAMINER OF THE SCORE INTERPRET (8+ normal, 7 borderline, 6 or less is cut-off to separate normal elderly

persons from those confused or demented w/ a correct assignment of 81.5%)

Mini Mental State Examination - 30 point scale

Interpreting Scores: 25-30 = Normal, 21-24 = Mild, 10-20 = Moderate, ≥9 = Severe

Orientation

1. What is the year, season, date, month, day (1 pt. each)? 2. Where are we? Country, county, town, hospital, floor (1 pt. each)

Registration 3. Name 3 objects, taking 1s to say each. Then ask the pt. to repeat them. (1 pt. each) Repeat the q. until the pt. learns all 3.

Attention & calculation

4. Serial sevens (1 pt. each). Stop after 5 answers. Alternatively spell “world” backwards.

Recall 5. Ask for the names of the 3 objects asked in Q3 (1 pt. each). Language 6. Pt. to ID a pencil & a watch. Have pt. name them for you (1 pt. each).

7. Have the pt. repeat “no ifs, ands or buts” (1 pt.) 8. Have the pt. follow the 3-stage command “Take the paper in your R hand, fold paper in half, put paper on the floor”. (3 pt.s) 9. Have the pt. read and obey the following: “Close your eyes” (in large letters). (1 pt.) 10. Have the pt. write a sentence of their choice – it must have a subject and an object and make sense. Ignore grammatical errors. (1 pt.) 11. Have pt. draw 2 intersecting pentagons – give 1 pt. if all the angles are preserved & if the intersecting sides form a quadrangle.

20

GALS Screen

WIPE, EXPLANATION AND CONSENT (undressed to light underwear) PRIVACY AND CHAPERONE ASK THREE SIMPLE SCREENING QUESTIONS: “Pain/stiffness in muscles, joints, back?” “Can you dress completely w/out any difficulty?” “Can you walk up and down stairs w/out any difficulty?” INSPECT GAIT – “walk to the wall and back” – symmetry, smooth, arm swing, no pelvic tilt, stride length, quick turn, Parkinson’s, Trendelenberg, antalgic, high-stepping gaits INSPECT GAIT – “WALK HEEL TO TOE” (cerebellar disorders) ROMBERG’S TEST INSPECT FROM BEHIND - “STAND W/ BACK TO ME” (check shoulder, paraspinal bulk, buttons, scoliosis, leg muscle bulk, iliac crests level, calf muscles, Achilles tendons) PALPATE SUPRASPINATUS BULK, PINCH TRAPEZIUS (Hyperalgesia) INSPECT FROM SIDE (knee position, lordosis, kyphosis) PLACE TWO FINGERS ON BACK, TOUCH TOES, LEG STRAIGHT - FLEXION AND EXTENSION (lumbar expansion) INSPECT FROM FRONT – “OPEN MOUTH, MOVE JAW SIDE TO SIDE” – TMJ movement INSPECT FROM FRONT – NECK MOVEMENTS (all 3 planes)

INSPECT FROM FRONT - “HANDS BEHIND HEAD AND FORCE ELBOWS BACK” (symmetrical full range of pain free movement) ARMS DOWN AND PALMS FORWARD (deltoids, elbow extension, normal quads, knees, foot arches, varus, valgus deformities) “HANDS OUT IN FRONT, PALMS DOWN” (PRONATION) “TURN YOUR HANDS OVER” (SUPINATOR), PALMS (elbows fixed, radioulnar joint movement, symmetry, swelling wasting deformity, skin/nails) “MAKE A TIGHT FIST/SQUEEZE MY FINGERS” “ANY PAIN WHEN I SQUEEZE YOUR FINGERS?” (Watch patient’s face, 2nd-5th MCP) “TOUCH TIPS OF FINGERS TO THUMB IN TURN” ASK PT TO LIE ON COUCH (45 DEGREES) – TELL ME IF ANY DISCOMFORT HIP AND KNEE FLEXION (feel for crepitus at the knee) HIP INTERNAL ROTATION KNEE – TEMPERATURE AND PATELLA TAP. ?EFFUSION ANKLE MOVEMENT (FLEX, EXTEND, INVERT, EVERT) SQUEEZE MTP JOINTS INSPECT SOLES STATE/DO – IF ABNORMALITIES FOUND A MORE DETAILED EXAMINATION PERFORMED THANK, HELP, CHECK PT

21

Lumps and Bumps Examination

Pulsation, Pain Mobility Site, Size, Shape, Surface, Surrounding Tissues, Sounds Colour, Contour, Consistency Edge Numbers Temperature, Tethering, Transluminenscence, Tenderness - ! 1. WIPE “I understand that you’ve found a lump on your… Would it be alright if I examine it? Please could you show me exactly where it is?” 2. Inspect mass carefully. Note site, size, shape & changes in overlying skin. 3. Lay hand on mass to see what the temperature of the skin and the lump itself is. 4. Gently palpate the lump to elicit any tenderness. This will also allow you to accurately define the size and shape of the mass. Record finding diagrammatically. 5. Keep hand on lump for a moment to check for pulsation. If +ve, decide if referred pulsation or from mass itself (2 fingers either side, upwards and outwards = from the mass itself). 6. Assess consistency (cystic, solid, hard, soft, fluctuant), surface texture and margins. 7. Attempt to pick up a fold of skin over the swelling to assess skin fixation, and assess the mobility of the skin on the contralateral side. 8. Determine fixation to deeper structures by attempting to move swelling in different planes relative to surrounding tissues. Contract the muscles around it to

see if it is attached to them. ? tethered to fat or bone in >2 planes 9. Look for fluctuation by compressing the swelling suddenly with one finger, using another finger to determine if a bulge is created – confirm the presence of fluctuation in 2 planes. 10. Auscultate for vascular bruits and other sounds. 11. Test for transillumination – A cystic swelling will light up if the fluid is translucent, provided covering tissues are not too thick. 12. Examine neighbouring lymph nodes. These may be enlarged due to spread of Ca or inflammation from infection. “Sudden” finding of a lump by a pt. does not necessarily imply that it has only recently developed. Important to ask if there has been any change in size or other characteristics since it was first detected, and whether there are any associated features such as pain, tenderness or colour changes. History of preceding events may also be of diagnostic help. Sometimes physical examination will reveal a lump of which the pt. is unaware.

22

Thyroid Examination

WIPE, EXPLANATION, CONSENT, CHAPERONE

POSITION, EXPOSURE, COMFORT (sitting, expose neck to clavicles)

CHECK IF PATIENT HAS ANY TENDERNESS

SYMPTOMS – pressure symptoms, like dyspnoea or dysphagia, hoarseness of voice (e.g. recurrent laryngeal nerve infiltration by cancer), hyperthyroid/hypothyroid symptoms.

GENERAL INSPECTION - anxious/fidgety/thin/wasting hands, face, shoulders/hot(hyper); slow/lethargic/fat/cold (hypo)

VOICE - hoarseness/dysphasia (hypo) – ask patient to say their name.

HANDS - toxic signs – moist, hot, sweaty, tremor w/ fingers spread (hyper); dry/cold (hypo); thyroid acropachy (like clubbing but in association w/ Grave’s disease)

PULSE – tachycardia, atrial fibrillation (hyper); bradycardia (hypo)

EYES (front and sides) - exopthalmos –lower cornea and sclera visible in Grave’s disease (due to ↑orbital fat, oedema, cellular infiltration) Lid lag (ask patient to follow your finger up and down) and lid retraction (spasm of the smooth muscle in the upper eyelid reveals upper border corneoscleral junction) – both hyper. Also look for diplopia/opthalmoplegia.

INSPECT MOUTH – LIPS, MUCOSA, TONGUE, THROAT

INSPECT NECK (FRONT, SIDES) – asymmetry, punctum ,erythema,

eczema, scars, goitre, discharge, pulsations, distend veins

ASK PATIENT TO POKE TONGUE OUT – WATCH FOR THYROGLOSSAL CYST

ASK PATIENT TO TAKE WATER, HOLD, SWALLOW (FRONT, SIDE) (GOITRE)

PALPATE – FROM BEHIND – GET PATIENT TO SWALLOW (ascertain tenderness, size, shape, single/multiple swellings, smooth/nodular, consistency)

EXAMINE CERVICAL LYMPH NODES WARN PATIENT BEFORE TRACHEAL

PALPATION PALPATE TRACHEA FOR

DEVIATION, CRICOSTERNAL DISTANCE

PERCUSS STERNUM/SWALLOW AUSCULTATE THYROID – ASK

PATIENT TO HOLD BREATH LIMBS - proximal myopathy (stand from

a chair w/out using hands a sensitive indicator of hypo/hyper). Pretibial myxoedema (puffiness on shins, Grave’s).

SAY YOU’D LIKE TO – EXAMINE REFLEXES - assess the reflexes (delayed, slow-relaxing in hypothyroidism).

SAY YOU’D LIKE TO – EXAMINE FOR OTHER - Pericardial effusion, carpal tunnel, and ascites are features of hypothyroid.

SAY YOU’D LIKE TO – EXAMINE FOR THYROID FUNCTION - If goitre is suspected

THANK, CHECK COMFORT

23

Peripheral Vascular System Examination

WIPE, EXPLANATION, CONSENT, CHAPERONE (lying w/ legs & arms exposed)

GENERAL INSPECTION – Scars, ulcers, gangrene, amputations, wasting, CRT

RADIAL PULSES (Rate, Rhythm, Radio Radial delay)

BRACHIAL PULSES BLOOD PRESSURE – both arms CAROTID PULSE (auscultate, palpate)

?Aneurysms, bruits, narrowing ABDOMINAL VESSELS (palpate &

auscultate for AAA, check renal bruits) INSPECT LEGS – gangrene, ulcers, skin

change, (pallor/red), varicose eczema, hair loss, scars, varicosities, disuse atrophy, and swelling.

INSPECT FEET – between toes, heels, look for ulcers and discolouration.

ASK PATIENT for ?leg tenderness LEG TEMPERATURE – compare w/back

of hands (skin colder in ischaemic unless infection)

CAPILLARY REFILL (nailbed on each foot - <2s)

FEMORAL ARTERY (palpate, Auscultate, compare, ?radio-femoral delay)

POPLITEAL ARTERY (+FLEX/EXTENDED, SFA BRUITS)

POSTERIOR TIBIAL ARTERY (midway between medial malleoulus and heel)

DORSALIS PEDIS ARTERY (slightly ever leg, feel along a line extending between middle of a line drawn

between two malleoli and webspace between 1st + 2nd toes)

EXTRA – BURGER’S TEST - (Check pain/mobility first) – elevate leg to ~>45º, look for ischaemia (leg goes white), hang leg off bed at 90º, watch for reactive hyperaemia

EXTRA – TRENDELENBERG TEST – Describe location of SFJ (5cm below and medial to femoral pulse), Occlude w/ tourniquet, elevate leg to empty veins, ask pt to stand and watch for rapid filling of veins

EXTRAS: TEST FOOT SENSATION ABPI - Arterial Brachial Pressure Index THANK, COVER, OFFER COMFORT

ABPI should be 1+ in supine position. Claudication: <0.8 Critical ischaemia: <0.4. Remember the 6 P’s of acute limb

ischaemia: Pulseless, pallor, perishingly cold, paraesthesia, paralysis and pain (and squeezing muscles!)

How do you record pulses? Normal + Decreased +/- , Absent - , Aneurysmal ++

24

Breast Examination WIPE @ 45o, EXPLAIN, CONSENT,

PRIVACY AND CHAPERONE ASK PT - ?PAIN, DISCOMFORT,

DISCHARGE (!pt elicits), LUMPS GENERAL INSPECTION –cachexia,

swollen arms, size, shape, asymmetry, contour, colour, venous pattern, local swelling, nipple changes (inversion, Paget’s (unilateral), eczema (bilateral)), Peau d’orange (sweat glands/Cooper’s ligaments)

INSPECTION POSITION – relaxed w/ arms by sides (relaxes pectorals)

INSPECTION POSITION – arms raised above head (tightens suspensory ligaments, skin puckering)

INSPECTION POSITION – hands pressed firmly on hips (tenses pectorals)

INSPECTION POSITION – learning forward

Pt @ 45º, check comfort, arms behind head. Start with normal breast first.

PALPATE BREASTS up and down (2 SIDES) – use palmar surface of fingers, work around breast in a systematic way

PALPATE AREOLA REGION (2 SIDES) PALPATE AXILLARY TAIL (2 SIDES) DEFINE ANY MASSES AND

DETERMINE TETHERING (hands pushed on hips before and after testing movement)

SIT PATIENT UP AND REST APPROPRIATE ARM ON YOUR ARM

PALPATE AXILLA (medial, lateral, posterior, anterior, apex)

PALPATE cervical, supra/infraclavicular lymph nodes

COVER PT, CHECK COMFORT (don’t thank pt)

EXTRAS: Examine liver for mets (if lump +ve) AUSCULTATE FOR PLEURAL

EFFUSIONS/EXAMINE THE SPINE MAMMOGRAPHY OR USS (<35yrs)

Record findings as follows:

Skin Examination 1. WIPE & Ensure good illumination (preferably natural light).

4. Measure Lesion Dimensions - helpful assessing progression and regression.

5. Attempt to transilluminate fluid swellings.

6. Assess skin colour and variations.

7. Describe the primary morphology of a localised skin lesion:

• Macule, Patch, Papule, Plaque, Wheal, Vesicle, Nodule, , Petechia or ecchymosis, Bulla, Telangiectasia, spider naevus 8. Describe the secondary characteristics:

• Superficial erosion, Ulceration, Crusting, Scaling, , Fissuring, Lichenification, Atrophy, Excoriation, Scarring or keloid, 9. Describe the distribution of a more widespread rash or colour change

10. Assess temperature of the affected area.

11. General Exam, looking for evidence of systemic disease.

25

Inguinal Hernia Examination WIPE, EXPLAIN, CONSENT,

PRIVACY AND CHAPERONE - “stand up”, examine both regions INSPECTION: Inguinal – bulges into the corner of the mons veneris, above the groin crease Femoral – bulges into medial end of groin crease. Check for Scrotal Involvement. PALPATION – FRONT: Examine

Scrotum & Contents. If you can get above it, it’s oHernia. N.B. Infant hydrocele extends up the cord.

PALPATION – SIDE: Stand at side of hernia. Place a hand in the small of pt’s back to support, and examining hand on the lump w/fingers and arm roughly parallel to inguinal ligament.

LUMP EXAM – MSCENT COUGH IMPULSE – compress lump

firmly w/fingers. “cough”. Mvmt of swelling w/o expansion or increased tension is not a cough impulse. !as absence may be due to adhesions.

REDUCIBILITY – Use flat of hand from below the lump, lifting the lower end upward and backwards. Press firmly to relieve tension. Squeeze towards the deep inguinal ring. Reduces to:

Above & medial to the PT –Inguinal. Below & lateral to PT - Femoral IN/DIRECT – No correlation w/surgical

findings. If controlled w/direct pressure over internal ring = direct. If not, indirect.

RELEASE & WATCH: Indirect = Slide obliquely through canal. Direct = Project directly forward

FINISH – Percuss & Ausc. for BSS & gas Check other side, and abdo exam.

External Genitalia Examination WIPE – Gloves and Standing. Kneel by

side INSPECTION–Lift up and look at

everything. INSPECTION – PENIS – Size, Shape,

Skin Colour, Foreskin, Discharge, Scaling/Scabbing around distal edge

PALPATION – Texture, assess dorsal vein. Retract prepuce to examine skin on inner aspect, glans and external urethral meatus. ?Discharge INSPECTION – SCROTUM & SKIN

? Reddened, Tethered, Fixed. Check posterior aspect. ? Size, Shape, Symmetry. PALPATION – SCROTUM – support

with hand, feel testis & other lumps b/w index & thumb. ?2 testes. Position & nature of testis, epididymitides & cords.

LUMPS – can you get above it? If not then an inguinoscrotal hernia.

Indirect Direct Origin Via Int. Ring,

lateral to inferior epigastric vessels

Via posterior wall of inguinal canal, medial to inferior epigastric vessels.

Mech. May be congenital

Acquired, rare in childhood

Strangulation Common Rare

Scrotum Ext. Often Rare

Reduces on lying

Not readily Spontaneous

Recurs post surgery

Uncommon Common

26

Transilluminable – Hydro/Spermatocele ? Expansile Cough Impulse, Separate from testis, Cystic or solid? Separate Cystic: Epididymal cyst/Spermatocele Separate Solid: epidiymitis Testicular Cystic: Hydrocele Testicular Solid: Tumour, Orchitis, Granuloma, gumma Bag of Worms: Varicocele LYMPH – Penis, Scrotum, Inguinals.

Covering of testis & cord. Internal common iliac. Body of testis.

Hand Examination

WIPE – White Pillow w/elbow exposed INSPECTION – FACE: Systemic sclerosis (expressionless, telengeictasis), Cushingoid (Steroids in RA), Exopthalmos (Thyroid) ELBOWS – “Place hands on shoulders” –

look for psoriasis/rheumatoid nodules INSPECT HANDS – Conditions inc: -Phalangeal -Boutonniere’s/Z Thumb, Triggering, Swan Neck -MCP –Volar sublux, ulnar deviation -Wrist –Disruption, Ulnar Sublux -Elbow – Rheumatoid Nodules -Gout: Asymmetrical swelling, tendon tophi -Sys. Sclerosis: Sclerodactyly w/finger tapering, fingertip gangrene, calcified nodule, tight skin -Psoriasis: Nail pitting, Scaly rash, terminal interphalangeal arthopathy INSPECT HANDS: Nails: Onycholysis, Fold Infarcts (RA) Skin Colour: Icterus, erythema, pigmentation Consistency: tight/shiny, paper thin, purpura

Lesions: Vasculitis, Neurofibromata, Telang. Muscles: Thenar Eminence Waste (Median N Lesion), General Wastage w/ thenar sparing (Ulnar N Lesion), Generalised (T1 lesion), Fasciculation – MND, Syringomyelia, Charcot-Marie-Tooth, old polio PALPATION – joints for temp,

tenderness (active disease). Look for: Dupuytren’s, nodules, calcinosis, xanthomata. OAnodes: Heberden’s = DIPs, Bouchard’s = PIPs (varus knee deformity, Trendelenburg +ve) SENSATION - ?Numbness (worse

nocte- Carpal Tunnel) Median - Index pulp, !thenar eminence, flex. aspects of radial 3½ digits upto ext. Nail beds. Changes with Carpel Tunnel Syndrome. Ulnar – Pinkie pulp, ! palmar/dorsal side of ulnar 1and ½ fingers Radial PROPRIOCEPTION & VIBRATION

– dorsum of 1st Intermetacarpal space

TONE – flex/ext joints MOTOR:

“Open/close hands quickly” – Myotonic Dystrophy “Squeeze my fingers” – C8/T1 Radial – “fingers out straight, stop me bending them” (C7) !Wrist Drop Ulnar – DAB & PAD tests !Claw Hand –(hyperextended metacarpophalangeal joints) Median

FUNCTION – “undo a button, hold pen, pick up paper”

– APB & OP, !Thenar Eminence waste and weak pincer grip

PULSES

27

Elbow Examination

WIPE – Stand, check affected INSPECTION – front/back/sides,

?carrying angle PALPATION – for temp, tenderness PALP – lat/medial epicondyles,

olecranon process, radial head. MOTION – ACTIVE Ext, Flex,

Supination, Pronation, then PASSIVE MOTION – RESIST – Flex, Ext,

Sup/Pronation FUNCTION – Eating, Brushing hair SPECIAL TESTS - ?Tennis, ?Golfers Shoulder Examination

WIPE – Standing, check affected INSPECTION – ? front/back/sides

Symmetry, Scars, Swelling, Muscle Bulk PALPATION – for temp, tenderness PALPATION – SCJ, clavicle, ACJ,

Acromium, Scapula, Medial Border, Inferior Angle, Lateral Border, Acromium + other side.

PALP = Effusions – Joint lines & humeral head

PALP – Supraspinatus, Trap, Infra, MOTION – Good first– ACTIVE:

Abduction, Flex, Ext. External Rotation (together), Int. Rtn, Arm across chest. Repeat PASSIVELY – palp. @ joints for creps.

MOTION – Resisted – Int/Ext Rtn, Abduction (s.spinatus, then pec. Major and lat. Dorsi, then deltoid@90o, trapezius @ 120o), flex/ext, biceps ext, empty can test (SSPinatus).

Cervical Spine and Neck

WIPE – Stand INSPECTION – front/back/sides –

?Symmetry, height of shoulders, Scars, Swelling, Muscle bulk/waste, erythema, ease of wt. Bearing, shape, bruises

PALPATION - for temp, tenderness PALP – Soft tissues – Trap, SSPinatus,

Rhomboids, ISpinatus, Lat. Dorsi, spinous processes.

MOTION – ACTIVE – Rotate L/R, Flex, Ext, Side Flex (L/R), rpt. PASSIVE

MOTION – RESIST – Flexion (C1), Ext (C2), Side Flex (C3), Shoulder girdle Elevation (C4), Shoulder Adduction (C5), Elbow Flex (C6), Ext (C7), Thumb Ext (C8).

SENSATION – Dermatomes REFLEXES – biceps, triceps and BR. Lumbar Spine Examination

WIPE – Stand, check affected EXAMINE – front/back/sides INSPECTION – ?Symmetry, height of

shoulders, Scars, Swelling, Muscle bulk/waste, erythema, ease of wt. Bearing, shape

LIE PRONE PALPATION – for temp, tenderness PALP – bony landmarks along spine,

spinous processes, iliac crests, paraspinal muscle, SI joints.

STAND MOTION – Place hand at lumbar spine Flexion forwards – “run hands along leg from knee – bend forward” Extension – “hands on hips and lean back”

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Side Flex – “slide hand along one side to knee” LIE SUPINE MOTION – MYTOTOMES RESIST –

check myotomes -Hip Flexion (L2), Extension (L3) -Foot Dorsiflexion (L4) -Resist Hallux Extension (L5) -Resist foot Inversion (S1) - Resist Plantar Flexion (S2) SENSATION – Dermatomes, !thigh REFLEXES – Knee (L3/4), Ankle Jerk

(S1/2), Babinski MOTION – Straight leg, raise w/ foot

dorsiflexion – enquire if pain worsens. Hip Examination

WIPE – Stand INSPECTION – front/back/sides, bulk,

deformity, scars, colour, gait Trendelenburg Test LIE SUPINE PALPATION – for temp DEEP PALP – G. Trocanter, CHECK LEG LENGTH : True: ASIS to Medial Malleolus Apparent: Umbilicus to Medial Malleolus MOTION – Flex/Ext, Int/Ext Rtn,

Abd/Adduction. Rpt PASSIVE w/ hand on joint. Rpt RESISTED

THOMAS’ TEST – hand under back and flex knee to hip

LIE PRONE Active ext, Passive ext. Knee Examination

WIPE – Supine + Expose Quads

EXAMINE – Baker’s Cyst, Valgus (knock-kneed), Varus (bow-legged), antalgic gait

INSPECTION – Masses, Scars, Lesions, Trauma, Swelling (?Medial Fossa Oedema)

INSP – Muscle bulk & Symmetry, esp. atrophy of medial aspect of quads – vastus medialis, Patella displacement.

PALPATION – for temp above/on/below patella

PALPATION – joint line tenderness: flex knee & palpate joint line w/ thumb

PALP = Effusions – Patellar Tap, Ballotment, Bulge Sign

MOTION – FULL R.O.M = 0-135o ? Crepitus ACL – Ant. Draw and Lachman PCL, MCL and LCL McMurray Test – rotate leg and extend

knee Med Meniscus -ext Rtn w/lat force -mel Lat Meniscus – int Rtn w/medial force Ankle and Foot Examination

WIPE – Stand, check affected INSPECTION – front/back/sides,

?Symmetry, varus/valgus, shape, gait Check footwear LIE SUPINE PALPATION – for temp, tenderness PULSES – Dorsalis Pedis, Post. Tibialis BONY PALP – Med/lat malleoli, joint

line, calcaneum, plantar fascia insertion, fascia, medial longitudinal arch, 1&5th MPJs

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MOTION – ACTIVE – Dorsi/Plantar flexion, Inversion, Eversion – PASSIVE inc. toe flex/ext.

RESIST – dor/plant. flex, ever/inversion, toe flex/ext.

ANKLE DRAW TEST – checking ant. talo-fibula ligament

REFLEXES – Ankle & Babinski LIE SUPINE Palp. Muscle bulk, Ach. tendon, temp, SIMMONDS TEST – Achilles Tendon

integrity Volume Status Assessment

Skin Turgor Mucous Membranes – Dry? Pulse & BP : Resting , postural drop

(BP) , ! autonomic neuropathy JVP Oedema, Effusion, Ascites Daily Weight, Urine Output & [conc] Pitting Oedema Scale: 1-Mild - slight indentation, no perceptible swelling of the leg 2- Moderate, indentation subsides rapidly 3- Deep, indentation remains for a short time, leg looks swollen 4- Very deep, indentation lasts a long time, leg is very swollen

Hypovolaemia: Intravascular: Cool, clammy, peripheral cyanosis, CRT, weak & rapid pulse, BP, postural drop Extravascular: Tissue Turgor, Dry Mucous Membranes

Hypervolaemia: Intravascular: High BP, Raised JVP, HS III, Pulm. Oedema Extravascular: Oedema, 3rd Space Fluid -Pleural, Peritoneal Hypovolaemia Class:

Explaining Procedures

WIPE (greets, states name and role, confirms patient’s name and DOB) EXPLANATION AND CONSENT (purpose, time available) EXISTING KNOWLEDGE (ask what pt knows about procedure, ever had it before or know of anyone who has) TELL THE PT YOU CAN FIND OUT ANY INFO THAT YOU DON’T KNOW

1 2 3 4 %loss <15 15-30 30-40 >40

Vol (l) <3/4 750-1500

1500-2000

>2000

Sys N N Dia N HR N 100-

120 120 Thread

120+ V.Thready

RR N >20 >20

Urine ml/m

>30 20-30 10-20 0-10

CRT N Pale Pale Cold & Clammy

Appear N Pale Pale Ash

Mental State

A AngerAngst

As 2 +/- Drowsy

As 3 +/- confusion/ LOC

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(e.g. specific concerns about times etc these are covered in the appt. letters, and they can ring the hospital to confirm details) ENCOURAGE QUESTIONS (tell them to ask any q’s, or interrupt if they don’t understand) ELICIT WORRIES/CONCERNS ( particularly about pain/embarrassment) EXPLAIN WHAT THE PROCEDURE IS (why they are having it, what will happen) EXPLAIN WHY THEY’RE HAVING IT (if you know why/if they specifically ask) EXPLAIN WHAT WILL HAPPEN BEFORE THE PROCEDURE (where they will have to go, will they need to bring someone, any preparations such as laxatives, food restrictions, medication changes, reassure them about the discomfort, embarrassment) ASK ABOUT ANY MEDICATIONS (esp. about anti-coagulants and insulin, tell them to consult their GP or specialist before they stop taking etc) EXPLAIN WHAT WILL HAPPEN DURING THE PROCEDURE (how long it will take, sedation, analgesia, biopsies, monitoring, who will be present, how long till results) ASK ABOUT PREVIOUS ALLERGIES (particularly to analgesia or sedatives, what happens etc…) EXPLAIN ABOUT THE RESULTS (when they will get them, from who, what they might show) EXPLAIN WHAT WILL HAPPEN AFTER THE PROCEDURE (getting home, length of stay, sedations effects, when they can go back to work, what they can / can’t do, food restrictions)

EXPLAIN CAREFULLY ABOUT RISKS AND SIDE-EFFECTS (reassure about radiation does, sedative reactions, pain/bleeding from biopsies, what is normal or abnormal) CHECK THE PATIENTS UNDERSTANDING ASK IF THEY HAVE FURTHER Q’S ASK AGAIN ABOUT CONCERNS (e.g. if anything you have said worries them) THANK AND REASSURE PT Injections

WIPE, GLOVES, SET UP EQUIPMENT CHECK DRUGS (expiry date, correct drug, seals intact, correct dilutant etc) CLEAN SITE (alco swab, allow to dry) CORRECT NEEDLE AND SYRINGE –Intradermal – 1ml syringe, 25G/orange needle, Subcutaneous – 2ml syringe, 23G/blue needle, Intramuscular – 5ml syringe, 23G/blue needle INSERT NEEDLE – WARN PT FIRST (“sharp scratch”) INSERT NEEDLE CORRECTLY – Intradermal – parallel to skin, approx3mm deep, Subcutaneous – pinch skin, 20-30° angle, Intramuscular - 90° angle, 2-3cm deep ASPIRATE ( do not for intradermal) INJECT SLOWLY REMOVE NEEDLE (apply pressure,

clean if necessary, do not apply pressure to intradermal injections)

DISPOSE OF SHARPS/WASTE OBSERVE FOR ADRs THANK PT, COMFORT, REASSURE RECORD IN NOTES

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Infusions

WIPE, GLOVES, SET UP EQUIPMENT CHECK FLUID BAG (check expiry

date, correct fluid/drug, seals intact etc) CHECK CANNULA (flush cannula,

ensure it is still in place/clean) PREPARE BAG / GIVING SET INSERT SPIKE INTO BAG (ensure a

level surface, beware puncturing bag, beware sharps injury from spike)

RUN FLUID THROUGH (no air bubbles, fill chamber, ensure fluid runs out the end, turn off before connecting)

CONNECT CANNULA & GIVING SET (tube screwed in place/ secure)

START FLUID SET INFUSION RATE (as a rough

guide, 20 drips per ml for crystalloid, 15 drips per ml for blood/colloid)

DISPOSE OF SHARPS/WASTE THANK PT, REASSURE, ASK ABOUT

QUESTIONS RECORD DETAILS (document fluid,

time started, time finished, volume, duration of infusion etc)

Arterial Blood Gas Sampling

WIPE, ?On O2/Air, record conc. , flow rate.

Equipment: ABG syringe w/Heparin, Alcohol swab, Swab, 1% lignocaine local anaesthetic, Syringe and blue needle for anaesthetic

Femoral artery Lay pt supine w/ groin and leg extended

and slightly abducted.

Locate femoral artery, halfway b/w the ASIS & pubic symphysis, 2 cm below the inguinal ligament.

Clean skin over artery w/ alcohol swab. Raise a bleb of local anaesthetic. Fix the artery between two fingers

whilst inserting heparinised needle and syringe at 90° to skin.

Slowly advance the needle till there is free flow into syringe.

Radial artery Before procedure, perform the Allen

test: Occlude both ulnar & radial arteries digitally, allowing venous drainage. Release ulnar artery while keeping radial artery compressed. Hand colour should return in <5s, indicating there is sufficient collateral blood flow from the ulnar artery.

If the patient fails, radial ABG should not be attempted.

Pt supine w wrist & thumb extended. Place a rolled up hand towel under the

dorsal surface of the wrist. Palpate the radial artery Clean skin proximal to the wrist joint. Raise a small bleb of local anaesthetic at

the proposed entry site with a 25G needle into the skin.

Insert the needle of a heparin-coated 2ml syringe at 60-90° through the skin, ensuring avoidance of air in the syringe.

Palpate the radial artery proximally, using it as a guide of direction to advance needle.

The arterial blood pressure will fill the syringe automatically.

Withdraw the needle and apply pressure for 5 minutes. Cap the syringe and place in bag of ice if immediate analysis not possible.

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Venepuncture

WIPE CHECK CORRECT BLOOD FORMS

(ensure form matches pt, check what samples are needed)

GLOVES, SET UP EQUIPMENT CHECK WHICH ARM - ask about

surgeries, mastectomies etc, ?preference

APPLY TOURNIQUET (place arm below the level of their heart, and make fists repeatedly)

FIND AN APPROPRIATE VEIN (bifurcations are tethered, always go above bifurcation, palpate vein well)

CLEAN THE SITE (alco swab, dry) INSERT NEEDLE – WARN PT FIRST

(“sharp scratch”) INSERT NEEDLE CORRECTLY (30°

angle, until flashback is seen or until you feel the vein ‘give’)

Order of Draw: Note – colours of tubes depend on supplier!

FILL VACUTAINERS/SYRINGES REMOVE TOURNIQUET W/DRAW NEEDLE (place a swab over

the area first) + APPLY PRESSURE DRESS THE WOUND (gauze or

plasters, ?allergies before using plasters) DISPOSE OF WASTE/SHARPS THANK PT, REASSURE, COMFORT LABEL BOTTLES CORRECTLY/SEND

TO LAB Suturing

WIPE – easy wound access, good lighting

PREPARE EQUIPMENT (sterile trolley, anaesthetic, sterile instruments etc)

PUT ON STERILE GLOVES (open method)

CLEAN WOUND – pick out debris, irrigate w/ normal saline, arrange x-ray

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to check for foreign bodies, clean wound w/ chlorhexadine from inside out, dispose of swabs after use

DRAPE WOUND – CREATE STERILE FIELD (ensure pt or non-sterile equipment does not touch field)

ANAESTHETISE WOUND – use 1% lidocaine, draw from sterile ampoule, after first injection put needle through anaesthetised area, do both wound edges

WAIT FOR ANAESTHETIC TO WORK (3-5 minutes)

CHECK ANAESTHESIA (pt should feel pressure nut not pain, should feel numb)

CHECK VACCINATIONS (ensure pt has up to date tetanus vaccinations etc)

WARN PT BEFORE STARTING CORRECT NEEDLE HANDLING

(never touch the needle, hold needle 2/3 from point w/ needle holders)

PLACING SUTURE (evert wound edge w/ toothed forceps, needle enters at 90° to skin, approx.0.5-1cm deep & 0.5cm from wound edge, come out in centre of wound & repeat for 2nd side)

KNOT TYING (use at least 3 throws, line up knots on one side, cut approx. 1cm from knot)

PLACING 2ND SUTURE (lay sutures approx. 1cm apart, line up knots)

INFORM PT OF SUTURE CARE ( should be removed after 7days at GP or A&E, keep wound dry, showers not baths, avoid getting wound dirty)

DRESS WOUND (clean and dry wound apply a clean dressing and remove drape)

DISPOSE OF SHARPS (all sharps/needles must go in a sharps bin once they have been used)

DISPOSE OF WASTE (all clinical waste, including drapes, swabs and gloves must be placed in the yellow/clinical waste bins)

DOCUMENT PROCEDURE THANK PT, CHECK PT

UNDERSTANDS WOUND CARE AND REMOVAL INSTRUCTIONS

PEFR and Inhalers

WIPE START W/ PEFR ASK PT TO STAND UP PREPARE FLOW METER (attach mouth

piece, reset slide to bottom) DEMONSTRATE OR EXPLAIN

PROCEDURE (deep breath in, seal lips around mouth piece and blow out as hard and fast as possible “like blowing out a candle across the room”)

ASK PT TO REPEAT 3 TIMES (reset slide to 0 every time, allow pt to recover in between)

RECORD THE BEST OF 3 VALUES COMPARE PT TO AGE/HEIGHT

CORRECTED GRAPHS BEFORE AND AFTER

BRONCHODILATORS (if on the drugs)

STATE YOU WILL TEACH THEM HOW TO USE INHALERS

ASK FOR ANY QUESTIONS/EXPLAIN BRONCHODILATORS OR ASTHMA (as necessary)

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DEMONSTRATE OR EXPLAIN PROCEDURE

MDI – CHECK DRUG/EXPIRY DATE REMOVE MOUTH COVER/CHECK

FOR OBSTRUCTIONS SHAKE INHALER HOLD INHALER VERTICALLY EXHALE START BREATHING IN PLACE INHALER IN MOUTH (seal lips

tightly around it) DEPRESS BUTTON AND KEEP

BREATHING IN HOLD BREATH FOR 10s BREATH OUT WATCH PT AND CORRECT ANY

MISTAKES (repeat until they get it right)

EXPLAIN STEROID INHALERS (need to wash mouth out after use to avoid oral candidiasis)

ASK FOR QUESTIONS (explain common mistakes – not triggering in at right time, not breathing in enough, not holding breath long enough)

CHECK UNDERSTANDING THANK PT, REASSURE, COMFORT Blood Pressure Measurement

WIPE - easy access to arm, remove tight clothing from the arm

ASK QUESTIONS (check pt sitting comfortably, ? caffeine, exercise, stress)

PREPARE SPHYGMOMANOMETER (ensure level w/ pt’s heart, select appropriate size cuff)

CHECK ARM (ensure pt has no problems, previous surgery etc w/ the arm you intend to use)

PALPATE BRACHIAL ARTERY (medial to biceps tendon)

PLACE CUFF – over brachial artery, tubes out of the way, high up on arm to allow steth. access, ensure it is tight

PALPATE RADIAL ARTERY WARN PT INFLATION OF CUFF

BEING UNCOMFORTABLE (reassure them that it does no damage and will be over quickly)

INFLATE CUFF UNTIL RADIAL ARTERY DISAPPEARS

DEFLATE CUFF PLACE STETHOSCOPE OVER

BRACHIAL ARTERY REINFLATE CUFF TO 10mmHg

ABOVE THE DISAPPEARANCE OF THE RADIAL ARTERY

DEFLATE CUFF AT 2mmHg/s LISTEN AND RECORD 1ST AND 5TH

KOROTKOFF SOUNDS REPEAT IN BOTH ARMS (>10mmHg

difference indicates aortic dissection) REPEAT STANDING (>10mmHg drop

indicates postural hypotension) THANKS PT, ANSWER QUESTIONS CXR Interpretation

PT DETAILS – Name, Age, DOB, H# RADIOGRAPH DETAILS – Date, Time,

Type of film, Position, Indication ROTATION (=l distance from spinous

processes to medial ends of clavicles) PENETRATION (outline of vertebral

bodies visible behind the heart border)

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INSPIRATION (right hemi-diaphragm level w/ the tip of the 6th anterior rib)

COMMENT ON OBVIOUS ABNORMALITIES (tubes, lines, clips, masses, opacities)

AIRWAY (trachea, hilum, lung apices) BONES (ribs, bony structures, soft

tissues, breast) CARDIAC (cardiac outline, cardio-

diaphragmatic recess, cardiomegaly, L & R heart border, mediastinum)

DIAPHRAGM (costo & cardiophrenic angles, air under diaphragm, gastric bubble, abnormal peaking or flattening, relative positions of hemi diaphragm)

“EVERYTHING IN BETWEEN” FIELDS (contents, pleura - ?thickening) REVIEW AREAS (apices, retrocardiac

area, peripheral lung margins, diaphragm, air in SC tissues)

SUMMARY ± DIAGNOSIS AXR Interpretation

PT DETAILS – Name, Age, DOB, H# RADIOGRAPH DETAILS – Date, Time,

Type of film, Indication ADEQUACY – EXPOSURE

(xiphisternum to pubic symphysis, both flanks)

ADEQUACY – PENETRATION (spinous process visible through vertebral bodies)

INTRALUMINAL GAS – Volume and Distribution

EXTRALUMINAL GAS – Distribution COMMENT ON OBVIOUS

ABNORMALITIES (tubes, lines, clips, masses, opacities)

SYSTEMATIC REVIEW: BONES, BOWEL, BILIARY TREE

(obstructions, stones, dilations) AORTA (calcification, widening) CALCIFICATION (look at gall bladder,

pancreas, kidneys, bladder, arteries) KIDNEYS (calcification, stones, dilation,

distension, position) URETERS (trace ureter from kidney to

bladder, look for stones, dilations, strictures, look at bladder for position, size, stones)

PSOAS MUSCLE SUMMARY ± DIAGNOSIS ECG Interpretation

PT DETAILS – Name, Age, DOB ECG DETAILS – Date, Time, is it part

of a series e.g. MI’s, Indication CALIBRATION (paper speed 25mm/s,

1mV = 10mm vertical deviation) RATE (regular: 300/RR interval,

irregular: number of QRS complexes in rhythm strip x 6)

RHYTHM (reg, reg irreg or irregularly irregular, sinus – P wave before every QRS complex)

AXIS (Normal: QRS deviation in I & II is up.

LAD: QRS in I is up, and down in II (leaving), RAD: QRS in I is down, and up in II (reaching).

LAD : Normal in pregnancy / emphysema Path – L.Ant. Fasc. Block, or Q waves MI RAD: normal in children/dextrocardia Path - L.Post. Fasc. Block or Q waves from high lateral MI

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Leads: Anatomical Relationship Lateral I, aVL, V5/6 Inferior II, III, aVF Anterior V3/4 Septal V1/2 MORPHOLOGY P WAVES ?before every QRS, ?p pulmonale (peaked) - lung disease/RAH or p mitrale (saddle) –MR. ? atrial flutter saw tooth P-R INTERVAL (normally 0.12-0.2s, shorter indicates extra conduction pathways, longer indicates heart block) QRS COMPLEX – WIDTH (normally <0.12s, wide indicates bundle branch block – look at V1 and V6 for ‘WilliaM MarroW signs’ indicating L and RBBB respectively.) QRS COMPLEX – HEIGHT (tall R wave indicates ventricular hypertrophy, V1: right, V2: left) QRS COMPLEX – Q WAVE (normally <0.04s and <2mm, pathological Q wave w/in hours of an MI) QT INTERVAL (corrected for a heart rate of 60 using QTc = QT/√RR interval) QT = [Ca2+] and v.v. ST SEGMENT (should be isoelectric, elevated in MI, depressed in ischemia) - Digoxin ”reverse tick” sloped depression T WAVES (normal inversion in III, aVR and V1) Inverted = Ischaemia, LVH, Digoxin, Pericarditis and BBB Flattened = Ischaemia, K+ Tall / Tented = K+ (Hyperacute = tall w/ broad base & asymmetry = acute MI) U WAVES (can be normal or K+) SUMMARY AND DIAGNOSIS