Pal Pack 23 by DanPaulli

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									PAL PACK




 Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
                    General Tips for Examinations

Beginning the Examination
      Always introduce yourself to the patient, and gain permission for the examination.
Remember to find out their name. You should then position the patient appropriately (45
degrees for cardiovascular and respiratory, flat for abdominal). Next, you should expose
the relevant part of the patient.

      You should always do a general inspection from the end of the bed. Don’t forget
to look at the surroundings (for sputum pot, central line, walking stick, etc.).

During the Examination
       Try to develop a methodical approach to the examination. Although each system
is slightly different, the standard order is as follows:
                                                    •   Inspect
                                                    •   Palpate
                                                    •   Percuss
                                                    •   Auscultate
        You should avoid causing pain to the patient. You can achieve this by asking
the patient if they have any pain, and by palpating gently to start with. Remember to look
at the patient’s face when you are feeling for tenderness.

Concluding the Examination

       You should always thank the patient, and leave them comfortable, and covered
up again. Don’t forget to wash your hands!




                            Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
                              Respiratory History

Name, Age, Occupation

Presenting Complaint
For each symptom:
1. Onset
2. Duration
3. Course
4. Severity
5. Precipitating Factors
6. Relieving factors
7. Associated features
8. Previous episodes
Six main respiratory symptoms:
1. Cough (character)
2. Sputum (colour, amount)
3. Haemoptysis (colour, amount)
4. Wheeze (diurnal variation?)
5. Chest Pain (site, radiation, character)
6. Shortness of breath (exercise tolerance, orthopnoea)
Night sweats, weight loss

Past Medical History
eg. Tuberculosis, atopy

Social History
Smoking (pack years), pets, stairs

Family History

Drug History
Allergies, inhalers, home oxygen

Systemic Review
Summarise – does the patient have any questions?


                             Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
                           Cardiovascular History

Name, Age, Occupation

Presenting Complaint
Remember the 8 questions you need to ask about each symptom?
4 main cardiovascular symptoms:
1. Chest pain (character, radiation)
2. Shortness of breath (exercise tolerance, orthopnoea, paroxysmal nocturnal dyspnoea,
   pink frothy sputum)
3. Ankle swelling (sacral, diurnal variation)
4. Palpitations (tap out rhythm, dizzy, blackouts)
Main Risk Factors for Ischaemic Heart Disease:
1. Smoking
2. Hypertension
3. Diabetes mellitus
4. Hyperlipidaemia
5. Family history

Past Medical History (may ask under presenting complaint)
eg. angina, myocardial infarction, bypass operation, rheumatic fever, stroke, intermittent
claudication

Social History
Smoking (pack years), alcohol, stairs

Family History
At what age did the relative have illness?

Drug History
Allergies

Systemic Review
Summarise – does the patient have any questions?




                             Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
                          Measuring Blood Pressure
          (see Clinical Examination, 2nd edition, Epstein et al., page 152)

Before We Start….
Why do we measure blood pressure?
What are we measuring? What are we listening for?
What measurement is considered “too high”?
What are the pieces of equipment called?

Introduction
Introduce yourself
Get verbal consent from the patient
Check the sphygmomanometer is on the same level as the heart
Choose the correct cuff size for the patient

Taking the Measurement
Place cuff around arm (2.5cm above antecubital fossa)
Inflate cuff until radial pulse can no longer be felt (estimates systolic pressure)
Deflate cuff completely
Inflate cuff again to a pressure 30mmHg higher than estimated systolic
Palpate brachial artery
Place stethoscope over brachial artery
Deflate cuff at 2-3mmHg per second
Listen for systolic pressure (start of sounds), and diastolic pressure (complete
disappearance of sounds)
Record measurements

Before We Finish…
What is “white coat syndrome?”
If you think a patient’s measurement is artificially high because of the above, what do
you do?
When might you take measurements lying and standing?
When might you take pressures in both arms?
Are there any sphygmomanometers other than the mercury ones?


                              Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
                           Respiratory Examination
           (see Clinical Examination, 2ndedition, Epstein et al., page 113)

Introduction
Introduce yourself, gain permission, check position (45°), expose appropriate area and
look around the bed and at the patient from a distance.

Hands and arm
Look and feel the hands for temperature and colour.
Look at the fingers for clubbing of the nails and nicotine staining.
Check for a CO2 retention flap and feel the radial pulse (rate, rhythm and volume).

Face
Look in the eyes for pallor (anaemia).
Look in the mouth for central cyanosis.

Neck
Look for the Jugular Venous Pulse (JVP).
Feel for lymphadenopathy.
Feel for the trachea – is it central or deviated?

Chest
Examine the front of the chest and then repeat the steps on the back.

      Inspection
      Look for asymmetry or deformity of the chest.
      Look for scars e.g. sternotomy, thoracotomy.
      Look at the movement of the chest and note whether the patient is using accessory
      muscles.
      Count the respiratory rate.
      Palpation
      Feel for the apex beat - normally the 5th intercostal space, midclavicular line.
      Check chest expansion - upper and lower.
      Tactile Vocal Fremitus (TVF)




                              Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
Percussion
Percuss the chest comparing side to side and listening for changes in resonance.
Don’t forget the axillae!
Auscultation
Auscultate all areas of the chest.
Listen for vesicular (normal) or bronchial breath sounds.
Are there any added sounds e.g.wheeze, crackles or rubs?
Test for Vocal Resonance




                        Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
                        Cardiovascular Examination
           (see Clinical Examination, 2nd edition, Epstein et al., page 149)

Introduction
Introduce yourself, gain permission, check position (45°), expose appropriate area and
look around the bed and at the patient from a distance.

Hands
Look and feel the hands for temperature and colour.
Look at the nails for clubbing and splinter haemorrhages.

Arm
Feel for either the radial or the brachial pulse.
Note the rate, rhythm and volume.
Take the Blood Pressure.

Face
Look at the eyes for pallor (anaemia), arcus and xanthelasma.
Look in the mouth for central cyanosis.

Neck
Feel for the carotid pulse – you can comment on character.
Look for the Jugular Venous Pulse (JVP).

Chest
      Inspection
      Look for asymmetry or deformity of the chest.
      Look for scars e.g. sternotomy, thoracotomy.
      Palpation
      Feel for the apex beat – normally in the 5th intercostal space, midclavicular line.
      Feel for heaves and thrills.
      Percussion
      There is no percussion in the cardiovascular examination.




                              Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
      Auscultation
      Listen in the 4 areas:
      Mitral (apex)
      Tricuspid (left lower sternal edge)
      Aortic (2nd intercostal space at the right sternal edge)
      Pulmonary (2nd intercostal space at the left sternal edge)
      Listen for heart sounds and feel the carotid pulse at the same time.
      Listen for murmurs and added sounds.
      Listen at the lung bases.

Finishing Off
Feel for sacral and ankle oedema.
Feel for an abdominal aortic aneurysm.
Feel for the peripheral pulses - femoral, popliteal, posterior tibial and dorsalis pedis




                               Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
                           Abdominal Examination
          (see Clinical Examination, 2nd edition, Epstein et al., page 192)

Introduction
Introduce yourself, gain permission, check position (flat), expose appropriate area and
look around the bed and at the patient from a distance.

Hands
Look and feel for Dupuytren’s contracture.
Look at the nails for clubbing, leuconychia and koilonychia.
Check for a liver flap and feel the radial pulse.

Face
Look in the eyes for pallor (anaemia) and jaundice.
Look in the mouth for ulcers, candida and signs of anaemia (angular stomatitis and
glossitis).

Neck
Look for the Jugular Venous Pulse (JVP).
Feel for lymphadenopathy, particularly Virchow’s node in the left supraclavicular fossa.

Chest
Look for gynaecomastia and spider naevi.

Abdomen
      Inspection
      Look for scars, stoma, distension, bruising, striae and caput medusae.
      Palpation
      Initially perform light palpation for tenderness, rigidity and guarding.
      Look for rebound tenderness.
      Next perform deep palpation for any masses.
      Palpate for the organs - liver, spleen and kidneys.
      Feel for an abdominal aortic aneurysm.




                              Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
      Percussion
      Percuss for the position of the liver and the spleen.
      Percuss for shifting dullness.
      Auscultation
      Listen for bowel sounds.
      Listen for renal bruits.

Finishing Off
Examine the hernial orifices and the external genitalia.
Do a rectal examination.
Check for ankle oedema.




                              Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
                      Musculoskeletal Examination
                                     GALS screen
      The GALS screen is a quick screening examination to pick up problems in the
musculoskeletal system. You are checking for changes in appearance (swelling,
deformity, abnormal posture) and movement (restricted movement, pain – look at
patient’s face). Remember to:
                                    • Get the patient to copy you.
                                             •   Compare one side with the other.

Introduction
Introduce yourself, gain permission, check position, expose appropriate area and look
around bed and at the patient from a distance.

History

1. Is there pain or stiffness in muscles, joints, back?
2. Can the pt walk up & down stairs without difficulty?
3. Can they dress & wash themselves without difficulty?


Gait
Look for smoothness and symmetry of movement.
Gross abnormalities, eg. kyphosis, scoliosis.
Specific gait problems, eg. antalgic gait.

Arms
Look at dorsum of hands for swelling, deformity, muscle wasting.
Patient turns hands over. Look again.
Power and precision grips.
Squeeze over metacarpophalangeal joints.
Full extension and flexion at elbow.
Abduction and external rotation of shoulder.

Legs
Look at legs for muscle wasting and asymmetry.
Look at feet for deformities and swelling.



                              Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
Flexion and extension of knees, feel for crepitus.
Internal rotation of hips.
Ankle movements (dorsi/plantar flexion, inversion, eversion)
Squeeze over metatarsophalangeal joints.

Spine
Lateral flexion of neck.
Place fingers on adjacent lumbar vertebrae to check for movement as patient touches
toes.




                             Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
  Principles of Single Joint Examination (using knee as
                         example)
           (see Clinical Examination, 2nd edition, Epstein et al., page 285)

Look
Deformity (eg. valgus, varus)
Scars (eg. replacement, arthroscopy)
Swelling and redness
Muscle wasting (quadriceps)

Feel
Temperature (with back of hand, compare to other knee)
Tenderness (on joint lines – sign of damage to meniscus)
Palpate swelling (bone, synovium, fluid)
Crepitus
Special tests – patellar tap and bulge tests, palpate for Baker’s cyst

Move
Active (patient moves joint) and passive (you move joint)
Full range of movements (flexion and extension at knee)
Special tests – collateral and cruciate ligaments

Function
Walking, rising from crouched position




                              Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
                             Neurological Examination
            (See Clinical Examination, 2ndedition, Epstein et al., page 309)

Introduction
Introduce yourself, gain permission, check position, expose appropriate area and look
around the bed and at the patient from a distance.

The Cranial Nerves
1. Olfactory
             ask about changes in smell/taste
2. Optic
             a) acuity and colour vision
             b) fundoscopy
             c) fields
             d) pupils – light and accommodation
3, 4 & 6.    Oculomotor, Trochlear & Abducens
             eye movements ? diplopia (nystagmus?)
5. Trigeminal
             a) Sensory – touch in each of the 3 areas near the midline
             b) Motor – muscles of mastication
             c) Corneal reflex and jaw jerk
7. Facial
             raise eyebrows, screw up eyes, blow out cheeks, show your teeth!
8. Vestibulocochlear
             a) rub fingers together or whisper numbers
             b) Rinne’s and Weber’s tests
9 & 10. Glossopharyngeal and Vagus
             a) gag reflex
             b) on saying“ahh” does uvula rise
             (normal) or deviate (abnormal)?
11. Accessory
             shrug shoulders, rotate head against resistance and feel
             sternocleidomastoid


                               Kate Chatten, Mary Howman, Gillian Marks and Tom Smith
12. Hypoglossal
             a) inspect for wasting
             b) stick tongue out and move from side to side

The Limbs
Examine the arms, then the legs
Inspection            wasting, fasciculation
Tone                  normal or increased? eg. clasp-knife, cog-wheel rigidity
Power                 test all muscle groups
                      record as MRC grade 0-5
Coordination          finger to nose
                      test pronation/supination
                      heel-knee-shin test
Reflexes              biceps, triceps, supinator, knee, ankle
                      record as 0/+/++/+++
                      plantar reflex
                      reinforcement
                      clonus
Sensation             light touch, pain, temperature, joint position, vibration
Gait                  Romberg’s test
                      nature of gait eg. wide-based?
What differences would you expect to find between lower and upper motor neurone
lesions? (see bottom of page!)1




1
  UMN – spasticity, increased reflexes, no wasting, extensor plantars, hemi/quadra/para-plegia
LMN – wasting, fasciculation, absent reflexes, pattern depends on cause eg. Peripheral neuropathy,
radiculopathy


                                 Kate Chatten, Mary Howman, Gillian Marks and Tom Smith

								
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