Professional Documents
Culture Documents
Dr G Chadwick/Dr AB Mongey
September 2015
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CARDIOVASCULAR WORKSHOP A
Cardiovascular (CVS) History
Aims:
To be able to take a cardiovascular history
To be familiar with common cardiovascular symptoms
To know the risk factors for coronary artery disease.
To be familiar with the common causes of chest pain.
Enquire re patients name and age
Identify the patients presenting complaint i.e. reason for coming to see a
physician and take history.
COMMON SYMPTOMS OF CARDIAC DISEASE:
Chest pain/tightness/heaviness
Dyspnoea/orthopnoea / paroxysmal nocturnal dyspnoea
Ankle swelling
Palpitations
Syncope
CHEST PAIN
Where?
How long?
How did it occur?
Does it radiate anywhere?
How severe is the pain? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the pain?
Does anything make the pain better or worse?
Is there any other symptoms with the pain? Ask about cardiovascular symptoms.
Does the pain interfere with your ability to perform certain functions/activities?
Have you ever had the pain previously? If yes, when, where, how often etc.
DYSPNOEA (difficulty with breathing)
When does it occur?
How long has it been occurring?
Does it wake the patient from sleep? = Paroxysmal Nocturnal Dyspnoea
Does it occur when lying supine? = Orthopnoea
How many pillows are needed to prevent the orthopnoea
How severe is the dyspnoea? e.g. does it interfere with talking?
Is it getting better or worse?
Is it intermittent or constantly present?
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Does anything bring on the dyspnoea? does exertion brings on the dyspnoea, and if so,
how much exertion?
Does anything make the dyspnoea better or worse?
Are there any other symptoms with the dyspnoea? Ask about other cardiovascular
symptoms.
Does the dyspnoea interfere with your ability to perform certain functions/activities?
Have you ever had the dyspnoea previously? If yes, when, where, how often etc.
ANKLE SWELLING
How far up the legs does the swelling extend?
Did it come on suddenly or gradually?
Is it intermittent or constantly present?
Any precipitating factors, such as standing or sitting for prolonged periods of time?
When is the swelling worse? Does it improve with elevation/overnight?
Are there any other factors associated with the swelling?
PALPITATIONS
When do they occur?
Is the heartbeat slow or fast, regular or irregular?
How long have they been occurring?
How long do they last?
Are they increasing or decreasing in frequency?
Anything that precipitates the palpitations?
Anything that relieves the palpitations?
Are there any other factors associated with the palpitations? e.g. dizziness/blackouts/
chest pain
SYNCOPE
When did it occur? What were the circumstances? e.g. rising from a seated position?
How long did it last?
Were there any warning symptoms that preceded the blackout?
Has it occurred previously?
Were there any other factors associated with the blackout? e.g. palpitations/dizziness/
chest pain?
See Appendix I for clinical descriptors of cardiac symptoms
Family History:
Enquire re family history of coronary artery disease/ischaemic heart disease (IHD)
and if so, what age was the family member when he/she developed IHD?
Enquire re history of Diabetes or hyperlipidemia among family members.
Social History:
Ask if patient is smoker or non-smoker; if smoker enquire as to how many
cigarettes patient smokes/day & for how long; if non-smoker enquire if patient was
a former smoker.
Ask is patient drinks alcohol & determine their usual daily/weekly consumption.
Enquire as to the patients occupation and whether the patient can still perform his/
her occupation.
Medications:
Obtain a list of medications that the patient is taking including OTC medications.
Enquire if the patient has any medication allergies.
TAKE A HISTORY
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CARDIOVASCULAR WORKSHOP B
CVS Examination I
Aims:
To take the arterial pulse accurately & be able to comment on rate, rhythm &
character of same
To measure blood pressure completely and accurately
To be familiar with the peripheral signs of cardiac disease
To assess and measure the JVP
Causes of Tachycardia
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sounds become muffled. In North America it is taken as the point at which sounds
disappear.
7. In practice, blood pressure should be measured on two separate occasions with a
period of a few minutes between. Record the blood pressure readings as follows
Phase I (SBP Palp)
Phase IV V
eg
Features of a JVP:
Visible but not palpable
Diffuse waveform
Increases with expiration; decreases with inspiration
Can be obliterated; fills from above
Abdominojugular reflux test (Hepatojugular reflux) is a means of testing for ventricular
failure. Pressure exerted over the middle of the abdomen or liver for 10 seconds will
increase venous return to the atrium resulting in a transient rise in the JVP. The test is
positive if it remains elevated for the duration of the compression: this is indicative of
right ventricular failure or elevated left atrial pressure.
Abnormalities of JVP:
Causes of elevated JVP:
Giant a waves:
pulmonary hypertension
tricuspid stenosis
Cannon waves:
Absent a waves:
atrial fibrillation
Large v waves:
tricuspid incompetence
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CARDIOVASCULAR WORKSHOP C
CVS Examination II
Aim: To locate the apex beat and listen to the heart sounds
Inspection of praecordium e.g. for scars, pulsations or pacemakers.
Palpation of the heart:
Locate the apex beat and assess its nature
Palpate over the apex and valvular areas for thrills (palpable murmur).
Palpate over the left parasternal area to assess for a heave indicative of right
ventricular enlargment
Apex Beat:
The apex beat is an impulse generated by the systolic contraction of the left ventricle.
It is the most inferior and lateral palpable pulsation. Normally it is located in the 5th
left intercostal space, mid-clavicular line. The apex beat may be displaced laterally
and/or inferiorly when the heart is enlarged. The apex beat may not be palpable in
some patients, such as those with over-inflated lungs. If the apex beat is not palpable
with the patient lying down a further attempt should be made with the patient in an
upright position and if still not palpable with the patient on their left side.
The quality of the pulsation of the apex beat should also be noted e.g. a tapping apex
beat may be felt in mitral stenosis.
Note that the apex beat cannot be localized accurately with the patient in the left
lateral position but information may be obtained regarding its quality.
Auscultation of Heart:
Listen for heart sounds, added sounds, murmurs, pericardial rub.
The first heart sound occurs at the beginning of systole and is the sound of
the mitral and tricuspid valves closing.
The second heart sound occurs at the end of systole and is the sound of the
aortic and pulmonary valves closing.
Murmurs are generated by turbulent blood flow, which usually results from structural
abnormalities of the heart valves or abnormal communications between the chambers
of the heart.
If a heart valve is stenosed (narrowed) then is will generate a murmur when
the valve is open, e.g. aortic stenosis results in a systolic murmur, mitral
stenosis causes a diastolic murmur.
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Ausculatation of the heart sounds is performed with both the bell and diaphragm of the
stethoscope over the 4 valvular areas to evaluate for murmurs:
Aortic area (Right 2nd intercostal space)
Pulmonary area (Left 2nd intercostal space)
Tricuspid area (Left sternal border, 5th interspace)
Mitral area (Left 4th intercostal space, just medial to the mid-clavicular line)
When a murmur is detected one needs to determine:
its timing i.e. whether it is systolic or diastolic which is determined using the
carotid pulse
its intensity
if/where it radiates to e.g. mitral incompetence murmur radiates to the axilla.
Certain manoeuvres can be used to augment the sound of individual murmurs:
Right sided murmurs become louder during inspiration and left sided murmurs are
louder during expiration.
Ask patient to lean forward and hold breath in expiration, listen at the left sternal
border for Aortic Regurgitation
Ask patient to turn to the left and hold breath in expiration, listen to the mitral area
for Mitral Stenosis murmur.
Please refer to Clinical Examination textbook by N.J. Talley and S OConnor for
further information regarding characteristics of murmurs.
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RESPIRATORY WORKSHOP A
Respiratory History
Aim:
To obtain a complete history for the respiratory system
Enquire re patients name and age
Enquire re patients presenting complaint, and obtain a history of the presenting
complaint
COMMON SYMPTOMS FOR RESPIRATORY DISEASE:
Dyspnoea
Cough
Sputum
Haemoptysis
Wheeze
Chest pain
SPUTUM
How long have you been coughing up sputum?
How much sputum do you cough up per day? e.g. teaspoonful/teacupful etc x times per
day
What colour is the sputum?
Any other factors associated with the production of sputum?
HAEMOPTYSIS (coughing up of blood)
How long have you been coughing up blood?
How much blood do you cough up per day e.g. teaspoonful/teacupful etc x times per
day
What colour is the blood? e.g. bright red or rusty colour etc
Any other factors associated with the production of sputum? e.g. weight loss, night
sweats
Common causes of Haemoptysis: Pneumonia, TB, Malignancy, Pulmonary Infarction
WHEEZE
When does it occur?
How long has it been occurring?
How severe is the wheeze? e.g. does it interfere with talking?
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the wheeze? e.g. exposure to dusts, allergens, exercise etc.
Does anything make the wheeze better or worse?
Are there any other symptoms with the wheeze? Ask about other respiratory symptoms
Have you ever had the wheeze previously? If yes, when, where, how often etc.
CHEST PAIN
Where?
How long?
Does it radiate anywhere?
How severe is the pain? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the pain?
Does anything make the pain better or worse? e.g. does breathing or coughing
aggravate the pain
Are there any other symptoms with the pain? Ask about other respiratory symptoms
Have you ever had the pain previously? If yes, when, where, how often etc.
OTHER SYMPTOMS:
Fever
Hoarseness
Night sweats
Past Medical History:
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Enquire re current, past and childhood illnesses, including Asthma, TB, Chronic
Bronchitis.
Enquire as to any previous surgery.
Family History:
Check for Family history of respiratory disease. Enquire about Asthma, Cystic
Fibrosis, and Emphysema. Also enquire re family history of TB.
Social History:
Enquire re current employment, and previous employment particularly any
exposure to asbestos, dusts, chemicals etc.
Ask patient specifically what they do at work as this may give major clues to
possible diagnosis.
Exposure to dusts, animals and birds may all be relevant.
Improvement in symptoms over the weekend or when patient is away from work,
may suggest an occupational lung disease.
Check re smoking status (in pack years).
Enquire re alcohol intake (can increase risk of TB, and aspiration pneumonias).
Ask about the patients housing.
Any recent travel?
Also enquire about any hobbies (esp keeping budgerigars or pigeons)
Medications:
Enquire if patient is taking any medications including OTC medications and herbal
supplements
Ask about the use of medications such as NSAIDs and beta-blockers which may
worsen asthma
Enquire re allergies
TAKE A HISTORY
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RESPIRATORY WORKSHOP B
Respiratory Examination I
Aim: To carry out a respiratory system examination on a patient Part I
General inspection:
Observe general appearance. Is patient breathless, in distress, or cyanosed?
Determine the rate of patients breathing and note the depth and regularity of the
respirations
Comment on any chest deformities, or asymmetry
Check for use of accessory muscles
Are there any obvious scars? e.g., thoracotomy scar
Inspection & Examination of hands:
Assess hands for colour/ temperature
Check for nicotine staining
Check for clubbing
Test for asterixis (flapping tremor of CO2 retention)
Respiratory causes for Clubbing: Bronchial carcinoma; chronic lung suppuration e.g.
abscess, bronchiectasis, Cystic fibrosis, Interstitial lung disease, mesothelioma
Inspection & Examination of head & neck:
Check sclera for signs of anaemia
Horners syndrome (apical lung cancer)
Inspect mouth for central cyanosis
Palpate the cervical, infraclavicular, and axillary lymph nodes
Trachea:
Palpate for tracheal deviation. Place index and middle finger on either side of
trachea, in suprasternal notch.
The trachea can be displaced towards or away from the side of the lung lesion. What
are the causes of tracheal displacement?
Assess the distance between the cricoid cartilage and the suprasternal notch for
hyperinflation
Palpation of chest:
Palpate for equal chest expansion, comparing each side. Use measuring tape to
measure chest expansion:- normal is 2 inches or 5 cms.
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Test for tactile fremitus, by placing the flat of the hands on the chest and asking the
patient to say ninety-nine. Compare each side with the other.
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RESPIRATORY WORKSHOP C
Respiratory Examination II
Aim: To carry out a respiratory system examination on a patient Part II
Percussion of the chest:
The principle underlying percussion is that air gives a resonant percussion note and
fluid or solid tissue a dull note.
Technique for Percussion: Place middle finger of non dominant hand on the area of
the chest you want to percuss. Lift the other fingers off the chest wall (so they wont
dampen the vibrations). Hold the middle finger of the percussing hand at a 90 angle
and tap the dorsum of the applied middle finger with the tip of the percussing finger.
Keep the fingers of the percussing hand immobile and move the percussing hand from
the wrist.
Percuss chest. Start at apex of lung, comparing each side. Both anterior and
posterior chest walls should be percussed in addition to the lateral chest walls and
clavicles.
Determine if resonance is normal, increased or decreased. Localize areas of
hyperresonance or dullness to the different lobes of the lungs using your knowledge
of anatomy. Note the character of the dullness e.g stony dull suggests a pleural
effusion.
Auscultation of chest:
Ask patient to take deep breaths. Auscultate chest with diaphragm of stethoscope.
Start at apex, compare each side. Auscultate over the anterior, posterior and lateral
chest walls.
Note whether air entry is normal or reduced.
Note whether the inspiratory:expiratory ratio is normal or if one of the phases are
prolonged.
Note whether breath sounds are vesicular or bronchial.
Are there any adventious sounds?
Breath sounds:
Breath sounds are reduced in pneumothorax, or pleural effusion.
The expiratory phase of the breath sounds is prolonged in airway obstruction (e.g.
asthma).
Normal breath sounds are described as vesicular.
Bronchial breathing occurs when air is passed from the bronchi through fluid filled
alveoli to the chest wall, the classic situation in which this occurs is pneumonia.
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Adventitious sounds are extra sounds in addition to breath sounds- rhonchi are
whistling sounds which occur when air passes through narrowed bronchi e.g., asthma;
crepitations are crackling sounds due to fluid in the alveoli e.g.infection
(bronchopneumonia), pulmonary oedema or alveolitis.
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GI WORKSHOP A
Gastro-Intestinal (GI) History
Aims:
To obtain a complete history for the Gastrointestinal system
Be familiar with the differential diagnosis of abdominal pain
Enquire about the patients name, age and occupation.
Enquire about the patients presenting complaint and the history of the
presenting complaint.
COMMON SYMPTOMS FOR GASTROINTESTINAL DISEASE:
Abdominal Pain
Nausea
Vomiting
Diarrhoea
Constipation
Bleeding per rectum
Abdominal Swelling
Weight loss
Dysphagia
ABDOMINAL PAIN
Where?
How long?
How did it occur?
Does it radiate anywhere?
How severe is the pain? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the pain?
Does anything make the pain better or worse?
Are there any other symptoms with the pain? Ask about GI symptoms
Have you ever had the pain previously? If yes, when, where, how often etc.
NAUSEA
When does it occur?
How long has it been occurring?
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the nausea? e.g taking certain foods or medications
Does anything make the nausea better or worse?
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Are there any other symptoms with the nausea? Ask about other GI symptoms such as
vomiting, diarrhoea etc.
Have you ever had nausea previously? If yes, when, where, how often etc.
VOMITING
When does it occur?
How long has it been occurring?
Is it getting better or worse?
How frequently does it occur?
Does anything bring on the vomiting? e.g taking certain foods or medications
Does anything make the vomiting better or worse?
Are there any other symptoms with the vomiting? Ask about other GI symptoms
Have you ever had vomiting previously? If yes, when, where, how often etc.
How much do you vomit up?
What is the colour and consistency of the vomitus?
Is there any blood with the vomitus (heamatemesis)?
DIARRHOEA
When does it occur?
How long has it been occurring?
Is it getting better or worse?
How frequently does it occur?
Does anything bring on the diarrhoea? e.g taking certain foods or medications
Does anything make the diarrhoea better or worse?
What is the volume of the diarrhoea?
What is the colour and consistency of the diarrhoea?
Is there any blood or mucus with the diarrhoea?
Are there any other symptoms with the diarrhoea? Ask about other GI symptoms
Have you ever had diarrhoea previously? If yes, when, where, how often etc.
CONSTIPATION
How long has it been occurring?
Is it getting better or worse?
How frequently do you have a bowel movement?
What is the consistency of the stool?
Does anything bring on the constipation? e.g taking medications
Does anything help the constipation?
Is there any blood with the stool?
RECTAL BLEEDING
When does it occur?
How long has it been occurring?
How frequently does it occur?
Is it getting more or less frequent?
What is the volume of the blood that is passed?
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ABDOMINAL SWELLING
Did it come on suddenly or gradually?
Is it increasing or decreasing?
Are there any other factors associated with the swelling? e.g. pain
Have you ever had abdominal swelling previously?
WEIGHT LOSS
How much?
Over what time period?
How is your appetite/intake?
DYSPHAGIA (Difficulty in swallowing)
How long has it been occurring?
Can you swallow solids and/or liquids?
Have you lost weight?
Do you have to regurgitate the food?
Is it associated with pain?
Have you ever had heartburn?
Past Medical History:
Current or previous illnesses including history of GI disorders such as peptic
ulcer disease etc.
Enquire re previous surgery.
Family history:
Family history of GI diseases such as cancer of the colon or inflammatory
bowel disease.
Social History:
Enquire re alcohol and cigarette consumption.
Enquire as to present and past employment e.g. potential exposure to hepatitis
B & C.
Enquire re recent travel.
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GI WORKSHOP B
Gastro-Intestinal (GI) Examination
Aim:
General Inspection:
Observe patients general appearance; nutritional status.
Check for any evidence of jaundice or pigmentation.
Inspection & Examination of hands for the following:
Clubbing
Nail signs e.g. leuconychia which is seen with hypoalbuminaemia
Palmar erythema
Dupuytrenss contracture
Check for liver flap (liver failure)
Inspection & Examination of head, neck and thorax:
Inspect sclera for anaemia, jaundice, iritis
Inspect mouth for ulceration, pigmentation, atrophic glossitis.
Examine the neck for lymphadenopathy
Examine the upper body for gynaecomastia, spider naevi (signs of liver
disease).
Abdominal Examination:
Inspection:
Check for scars of previous surgery
Distension
Striae
Bruising
Pigmentation
Localised masses
Palpation:
Superficial palpation: Begin by examining the region furthest from pain or discomfort.
Examine each of the 9 regions. Check for any tenderness, guarding and any masses.
Deep palpation: Follow by deep palpation. Check for organomegaly and any abnormal
masses.
Palpation of the Liver: Ask patient to breathe in and out. Start in the right lower
quadrant, and feel for the liver edge using the flat of the hand or the fingertips.
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Palpation of the Spleen: As for the liver, start in the right lower quadrant and move
towards the splenic area.
Ballotment of the Kidneys: Position the patient close to the edge of the bed, and ballot
each kidney using deep bimanual palpation.
Palpation of the Aorta: Palate the aorta, at a point midway between the xiphisternum
and the umbilicus, using the thumb and the index finger of the palpating hand.
Percussion:
Percuss the lower and upper borders of the liver (usually found in 4th intercostal
space).
Percuss the spleen.
If abdominal distension, check for shifting dullness (ascites)
Percuss the suprapubic area for dullness (bladder distension)
Auscultation:
Check for bowel sounds
Check for aortic bruit over the abdominal aorta
Check for renal artery bruits (above and lateral to the umbilicus, suggests renal
artery stenosis)
In a real patient situation you would also:
Perform a Rectal examination, check for blood, masses.
Examine the groins (checking hernial orifices with patient standing)
Examine the Genitalia
Abdominal Examination:
Start with inspection:
Observe the abdomen for movement with respiration. - Peritonism is
associated with lack of movement
Distension - What are the causes of abdominal distension?
Check for scars of previous surgery
Any lumps or masses
Palpation:
Superficial palpation: Begin by examining the segment furthest from pain or
discomfort. Examine each of the 9 regions. Check for any tenderness, guarding and
any masses.
If Tenderness is detected check for rebound tenderness which is indicative of
peritonitis in which pain occurs when inflamed peritoneal surfaces are moved
relative to each other.
Deep palpation: Follow by deep palpation. Check for organomegaly and any abnormal
masses. Also check for pulsatile masses such as aortic aneurysm.
For abdominal masses determine the following: site, tenderness, size, surface, edge,
consistency, mobility with movement and respiration, and whether it is pulsatile or not.
If a pulsatile mass is detected check for expansile pulsation which is characteristic of
an aneurysm.
Check for Murphys sign if suspect cholecystitis.
Percussion:
Perform light percussion over areas of tenderness pain that occurs on
percussion suggests underlying peritonism.
Percuss over masses to assess for dullness e.g. ovarian cyst.
Auscultation:
Check for bowel sounds and assess their quality Are they present/absent?
Are they normal/ increased or diminished?
Bowel sounds are absent in peritonitis; absent/reduced in ileus; increased in bowel
obstruction.
Check peripheral pulses if suspect a ruptured/dissecting aortic aneurysm.
See Appendix II for Differential diagnosis of acute abdomen.
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Palpation:
Position
Size
Tenderness
Cough Impulse
Check if the hernia is reducible/irreducible.
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GI WORKSHOP C
Aim:
Palpation:
Begin by gently palpating each testis using the thumb and fingers.
Check for:
Presence of both testes
Size of testis
Tenderness
Swelling
Consistency
Masses
Palpate the epididymis
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Before procedure:
1. Introduce self to patient
2. Explain what you are about to do. Advise that patient may find procedure
uncomfortable but not painful.
3. Obtain consent from patient for same
4. Ensure patient is comfortable. Lie patient on their left hand side, with knees
drawn up to chest.
5. Request patient to remove trousers and underwear.
6. Be aware of the sensitive nature of intimate examinations and try to put patient
at their ease.
7. It may be necessary to request a chaperone. (For the purposes of this exercise a
manikin is provided)
Rectal examination:
Firstly put on a pair of gloves
Separate the buttocks and inspect the anus and skin surrounding the anus.
Check for:
!"external thrombosed piles (tense bluish swellings at anal marginpainful)
#"skin tags
$"rectal prolapse (may only be apparent when patient asked to strain)
%"anal warts (condylomata acuminata), may be confused with skin tags.
&"anal fissure (crack in anal wall, may be too painful to allow rectal
examination). Usually occur posteriorly and in the midline.
'"pruritis ani (may lead to irritation, redness or weeping of surrounding
skin)
("carcinoma of the anus (rare, may be visible as a fungating mass at the
anal margin)
)"excoriation (may occur secondary to chronic diarrhoea)
*"fistula-in-ano may occur in Crohns disease.
During insertion external sphincter tone can be assessed. Tone can also be
assessed by asking patient to squeeze down on finger.
Rotate the finger clockwise and check for masses.
In men the prostate gland can be assessed through the anterior rectal wall. The
normal prostate is firm, rubbery and bi-lobed. A hard nodule may represent
carcinoma of the prostate.
In women the cervix may be palpated through the anterior rectal wall.
Remove the finger and examine the glove for colour of faeces, blood and
mucous. Dispose of gloves appropriately in clinical waste.
Advise patient examination is finished and that may dress self again.
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ENDOCRINE WORKSHOP A
Endocrine History
Aims:
To obtain a history for endocrinologic disorders
To be familiar with symptoms for Diabetes Mellitus and Thyroid disease
Weight Change
Polydipsia/Polyuria
Heat/cold intolerance
Change in Bowel habit
Palpitations
Fatigue
Skin/Hair changes
Parasthesias
WEIGHT CHANGE
Has there been a loss or gain in weight/
How much? If patient does not weigh themselves inquire requiring need to increase or
decrease in their clothes size.
Over what time period?
How is your appetite?
Take a dietary history and try and quantify daily caloric intake?
POLYDIPSIA/POLYURIA
Are you drinking more fluids and if so how many glasses per day?
Are you urinating more frequently?
Are you passing bigger volumes of urine?
How long?
HEAT/COLD INTOLERANCE
Are you more sensitive to cold temperatures i.e. feeling cold in environments where
others do not feel cold?
Are you more sensitive to the heat i.e. feeling hot in environments where others do
not?
How long?
Is it getting better or worse?
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When does it occur? e.g. during the daytime or at night. CTS symptoms occur more
frequently at night.
MISCELLANEOUS
Have you had any sweats?
Have you or any of your family members noted any change in your appearance?
Have you noticed any change in your vision?
Any difficulties with attaining/sustaining penile erections?
TAKE A HISTORY
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ENDOCRINE WORKSHOP B
Examination of a Diabetic Patient: Evaluation for Peripheral Vascular
Disease and Peripheral Neuropathy
COMPLICATIONS OF DIABETES MELLITUS
Aim:
Peripheral Neuropathy
Loss of sensation starts at the most distal portion of the extremeties in a symmetrical
pattern. Initially the posterior spinal columns, which carry light touch, vibration and
proprioception, are affected followed by the spinothalamic columns which carry pain
and temperature sensation.
Ask if the patient has noted altered sensation, such as numbness or tingling, in any part
of their body. If the answer is negative, show the patient what each of the following
feel like with their eyes open and them check that they can appreciate them on the
distal phalanx of the index finger and hallux with their eyes closed:
Vibration is tested with a 128 Hz tuning fork on bony prominences
Joint position sense (Proprioception) is tested by asking the patient to identify the
direction of movement of the distal phalanx.
Light touch with your finger tip or by touching (not stroking) the skin with cotton
wool
Pinprick with a neurotip or tooth pick with the patients eyes open asking whether
they can feel that it is sharp and hurts like a pin. Patient is asked to differentiate
between sharp and dull.
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If the patient reports an abnormality map out its extent with light touch or pinprick
testing or compare the two sides and draw it on a body chart.
Special Tests:
Trendelenburgs test:
First elevate leg to 90 to drain the veins. Apply a tourniquet to the upper thigh, and
then ask the patient to stand up. The veins should gradually fill in the next 30 seconds.
Release the tourniquet. If sudden additional filling of the veins occurs, then there is
sapheno-femoral incompetence.
Buergers Test:
Lift the patients legs to 45. Rapid pallor occurs with poor arterial supply. Then ask
the patient to dangle the legs over the side of the couch. Cyanosis occurs with PVD.
Auscultation:
Check for aortic bruit over the abdominal aorta
Check for Femoral bruits.
!35
ENDOCRINE WORKSHOP C
Thyroid Gland Examination; Breast Examination
Aims:
To perform an examination of the thyroid gland on a patient
To perform a breast examination
BREAST EXAMINATION
Inspection
Position the patient sitting up with the chest fully exposed.
Inspect the nipples for abnormalities such as retraction (may indicate underlying
cancer) or a unilateral redness of the nipple (which may be a sign of Pagets disease).
Inspect the skin of the surrounding breast for any dimpling, peau dorange or
unilateral visible veins (which could again suggest a cancer).
Ask the patient to fix her hands on her hips and press against her hips. This causes her
pectoralis muscles to contract and highlights any subtle dimpling or fixation in the
breast tissue.
!36
Next ask the patient to raise her hands above her head. Inspect carefully again for any
asymmetry. This manoeuvre will especially make obvious if one of the nipples is fixed,
as it will not move symmetrical to the other nipple.
Palpation
Position the patient lying down. Palpation is performed with the palmar surface of the
middle three fingers, lying flat against the surface of the breast. Roll the fingers over
the breast tissues while pressing in lightly. Avoid use of the finger tips.
One needs to palpate all 4 quadrants of the breast systematically. One can visualise the
breast as a clock, and palpate each time zone from areola to periphery as one system of
ensuring that you do not miss any section.
Next palpate the axillary tail of the breast, between your thumb and fingers.
Check for lumps behind the nipple and if any fluid can be expressed.
Finally, palpate the axillary and supraclavicular lymph nodes systematically. When
examining the right axillary lymph nodes, rest the patients right arm on your right
forearm. Then use your other hand to palpate the five main groups of lymph nodes:
central, lateral, pectoral/ medial, infraclavicular, subscapular.
Features of a breast lump:
In describing a breast lump, you need to address the following aspects:
Posi%on''
Size'and'shape'
Consistency'(hard'or'so5)'
Tenderness''
Fixed'or'mobile'
Single'or'mul%ple'
!37
MUSCULOSKELETAL WORKSHOP A
Musculoskeletal (MSK) History
Aim: To be able to obtain a locomotor (musculoskeletal) history
Do you have any pain, swelling or stiffness in your muscles, joints or back?
Can you dress yourself completely without any difficulty?
Can you walk up and down stairs without any difficulty?
Joint pain
Joint swelling
Joint stiffness
Muscle pain
Muscle weakness
Difficulty with function such as walking etc.
JOINT PAIN:
Where?
How long?
How did it occur?
Does it radiate anywhere?
How severe is the pain? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the pain?
Does anything make the pain better or worse?
Are there any other symptoms with the pain? Ask about swelling and stiffness
of the joints.
Does the pain interfere with your ability to perform certain functions/activities?
Have you ever had the pain previously? If yes, when, where, how often etc.
!38
SWELLING:
Where is it located?
Did it come on suddenly or gradually?
Is it intermittent or constantly present?
Any precipitating factors, such as injuries?
Are there any associated factors, such as pain, redness, warmth?
When is the swelling worse? Does it improve with elevation/overnight
STIFFNESS:
Which part of the body is affected?
When does it occur? Is it worse in the morning or in the evening?
How long does it last?
Need to determine if the Musculoskeletal symptoms are likely secondary to a problem
resulting from a joint disorder Arthritis
Questions to ask if the problem may be related to Arthritis
Does the problem arise from a joint?
Is the condition acute or chronic?
Is it an Inflammatory or Non-Inflammatory form of arthropathy?
What is the number of joints involved?
Monoarticular: only one joint involved
Pauciarticular: 2- 4 joints involved
Polyarticular: > 4 joints involved
Axial: predominant involvement of the spine
What is the pattern of affected joints?
What is the impact of the condition on the patients life?
Need to assess both physical and psychologic impact
Past Medical History:
Enquire about any previous episodes of similar symptoms
Enquire about any other illnesses
Ask about any prior injuries or surgeries
Family History:
Ask if any family member suffers from joint or muscle problems
Social History:
Ask about current and previous employment
Ask if symptoms interfere with patients ability to work or take care of
themselves
Ask about use of alcohol
Medications:
Ask if patient has taken any medication(s) for the problem
Obtain a complete list of all the medications that the patient is taking currently
Ask about medication allergies
!39
Systems Review:
Obtain a complete review of systems - in particular, any rashes, hair loss,
dryness of eyes or mouth, change of colour of digits upon exposure to cold
ambient temperatures, fevers, fatigue or change in weight.
!40
MUSCULOSKELETAL WORKSHOP B
Musculoskeletal (MSK) Examination Upper Extremity
GENERAL PRINCIPLES OF JOINT EXAMINATION: Look; Feel; Move.
LOOK:
FEEL:
Scars
Swelling
Rashes
Muscle wasting
is it sore
Temperature
Swelling
Tenderness
MOVE:
FUNCTION:
Functional assessment of joint
Bimanually palpate the MCP, PIP and DIP joints and note any swelling,
tenderness or warmth.
Check for tenderness and squaring of the 1st CMC joint.
Bimanually palpate the wrists.
Ask the patient to straighten their fingers fully and note inability to do so.
Ask the patient to make a full fist can s/he tuck their fingers into the palm? If
not move the fingers passively to determine if the problem is with the joints of
the tendons.
Asses wrist flexion and extension actively (prayer sign) and passively.
Assess grip strength.
Assess fine precision pinch by asking patient to pick up a small object.
EXAMINATION OF THE ELBOW
Look for scars, swellings, redness, muscle wasting, nodules or rashes.
Look from the front for the carrying angle and from the side for flexion
deformity.
Assess skin tenperature
While holding the elbow at 90, palpate over the head of radius and joint line
with your thumb for tenderness, swelling or warmth.
Palpate the medial and lateral epicondyles and olecranon process for tenderness.
Assess full flexion and extension actively and passively.
Assess pronation and supination, both actively and passively, in addition to
feeling for crepitus.
Assess function e.g. hand to nose or mouth.
EXAMINATION OF THE SHOULDER
Inspect the shoulder from in front, from the side and from behind checking for
symmetry, muscle wasting, scars etc.
Assess skin temperature over the front of the shoulder.
Palpate the bony landmarks (SC joint, AC joint, acromion process and around
the scapula) and surrounding muscles
Palpate the anterior and posterior joint line and bicipital groove.
Assess movement and function: hands behind head, hands behind back. How far
up the spine can s/he reach?
Assess movements of the shoulders, both actively and passively.
Observe scapular movement while patient is abducting the arm.
Movements of the shoulder:
Abduction: Request patient to raise arms above head, making the palms touch
(180)
Adduction: Request patient to move arm across front of chest (50)
Flexion: Request patient to raise arm forwards (180)
!42
Extension: Request patient to move arm backwards, with elbow bent (65)
Internal rotation: Request patient to turn arm in towards chest wall (90)
External rotation: Request patient to rotate arm laterally as far as possible (60)
with elbow at 90.
See Appendix III for further shoulder examination techniques.
!43
MUSCULOSKELETAL WORKSHOP C
Musculoskeletal (MSK) Examination Lower Extremity and Spine
Aims:
To perform a musculoskeletal examination of the lower extremity &
spine
With the knee flexed to 90 palpate the joint line, patellar tendon and tibial
tuberosity for tenderness and swelling.
Feel behind the knee for a popliteal (Bakers) cyst.
Perform the patellar tap to assess for an effusion.
Assess for the bulge sign (cross fluctuance)
Assess full flexion and extension, both actively and passively, and note range of
movement. Feel for crepitus.
Assess the stability of the collateral ligaments by flexing the knee to 15 and
alternately stressing the joint line on each side.
Assess the stability of the cruciate ligaments using the anterior and posterior
draw tests. Initially look from the side of the knee to check for a posterior sag or
step-back of the tibia which suggests PCL damage.
!45
Assess movement of the cervical spine: flexion (chin to chest), extension (look
at the ceiling), rotation (look over each shoulder) and lateral flexion (ear to
shoulder).
Assess movement of the lumbar spine: flexion, extension, and lateral flexion
use the Schobers test to measure forward flexion.
Schobers test: With patient standing erect make a mark over midpoint between the
posterior superior iliac spines and another 10 cm higher; ask patient to bend forward
and re-measure between the 2 points: an increase of 5 cm is normal
With the patient sitting on the couch and arms crossed in front:
Assess thoracic rotation (with your hands on the patients shoulders to guide the
movement)
With the patient lying on the couch:
Perform straight leg raising (SLR) test: flex hip with knee straight until limit is
reached; then dorsiflex the ankle: -if positive, the leg pain is aggravated (this
confirms stretching of the sciatic nerve).
Asses limb reflexes and strength of the dorsi-flexors of the big toe.
!46
NEUROLOGY WORKSHOP A
Neurology History
Aim: To obtain a neurological history
Enquire re patients name, age & occupation
Enquire about the patients presenting complaint and the history of the presenting
complaint
Headache.
Weakness of the face, trunk or limbs
Paraesthesia (tingling/pins and needles) or numbness
Disturbance of vision
Disturbance of hearing
Disturbance of speech.
Disturbance of sphincter control (bladder or bowel)
Ataxia (loss of coordination)
Gait disturbance
Difficulties with cognition and/or memory
Tremor or involuntary movements.
HEADACHE
Where?
How long?
What type of pain? e.g. throbbing, sharp, dull etc.
What were you doing when it started it?
Does it radiate anywhere?
How severe is the headache? - can use a 0-10 scale.
Is it getting better or worse?
Is it intermittent or constantly present?
Does anything bring on the headache?
Does anything make the headache better or worse?
Are there any other symptoms with the headache? Ask about other neurologic
symptoms
Have you had headaches previously? If yes, when, how often etc.
WEAKNESS
Where?
How long?
How did it occur? e.g did it come on suddenly or gradually
How severe is the weakness?
Is it getting better or worse?
!47
PARAESTHESIAS/NUMBNESS
Where?
How long?
How severe? Is it getting better or worse?
Is it intermittent or constantly present?
When does it occur? e.g. during the daytime or at night
Does anything bring on the paraesthesias/numbness? e.g such as certain movements
Are there any other symptoms? Ask about other neurologic symptoms
Have you ever had the parathesias/numbness previously? If yes, when, where, how
long did it last etc.
DISTURBANCE OF VISION
What type of disturbance? e.g. loss of vision, blurring of vision, double vision etc.
Does it involve one or both eyes?
How long?
How severe? E.g. is it total or partial
What were you doing when it began?
Is it getting better or worse?
Is it intermittent or constantly present?
Are there any other symptoms? Ask about other neurologic symptoms.
Have you ever had the disturbance of vision previously? If yes, when, where, how long
did it last etc.
DISTURBANCE OF HEARING
What type of disturbance?
Does it involve one or both ears?
How long?
How severe? E.g. is it total or partial
What were you doing when it began?
Is it getting better or worse?
Is it intermittent or constantly present?
Are there any other symptoms? Ask about other neurologic symptoms
Have you ever had difficulties previously? If yes, when, where, how long did it last etc.
DISTURBANCE OF SPEECH
What type of disturbance? e.g. is it difficulty in finding or saying the words?
How long?
!48
ATAXIA
What type of disturbance?
Which part of the body is involved?
How long?
How severe? e.g. is it total or partial
What were you doing when it began?
Is it getting better or worse?
Is it intermittent or constantly present?
Are there any other symptoms? Ask about other neurologic symptoms
Does it interfere with your ability to perform certain functions and if so what?
Have you ever had similar symptoms previously? If yes, when, where, how long did
they last etc.
GAIT DISTURBANCE
What type of disturbance?
How long?
How severe? e.g. can you walk independently
What were you doing when it began?
Is it getting better or worse?
Are there any other symptoms? Ask about other neurologic symptoms including
vertigo, numbness, weakness etc.
Have you ever had similar symptoms previously? If yes, when, where, how long did
they last etc.
!49
!50
NEUROLOGY WORKSHOP B
Cranial Nerves Examination
Aims: To perform a mini-mental state examination
To carry out an examination of the cranial nerves
HIGHER FUNCTIONS
Ask if the patient is left or right handed. Establish if the patient is alert and able to give
a clear history. If relevant, test for dysphasia, examine the mental state and perform the
Mini Mental State Examination (see Appendix V).
of media opacities. View fundus at an appropriate distance from the patient and focus
the ophthalmoscope.
!52
Examination of the vestibular nerve includes testing stance and gait, see below, and for
nystagmus, see above.
Cranial Nerve IX Glossopharyngeal nerve:
Not necessary.
!53
General appearance
Stance and gait
Higher functions
Cranial nerves
Motor system
Sensory system
Inspection
Tone
Power
Coordination
Sensation
!54
Reflexes
Tone:
Tone is an assessment of the freedom of movement of a joint when moved passively,
and is described as being normal, reduced (hypotonia), or increased (hypertonia).
Power:
Power is tested by comparing the examiners strength against the patients full
resistance. Power can be graded as follows:
Grade
Paralysis
Flicker
Normal Power
!55
Tone
Test wrist pronation-supination for a pronator catch in spasticity. Test for rigidity by
slow rotation of the stabilised wrist.
!56
Power
Test the following muscle groups in order, comparing each side as you progress. Each
movement should be tested in isolation: thus to test elbow flexion you must fix the
upper arm with your free hand.
Movement
S t a r t i n g Note
position
Shoulder abduction
900 abduction
Elbow flexion
900 flexion
Elbow extension
900 flexion
Wrist extension
Full extension
Grip
Full abduction
Test in isolation
Full abduction
Reflexes
You will recall from physiology that when a muscle is stretched receptors will fire, and
a spinal reflex will cause the muscle to contract in response. This is the principle
behind eliciting tendon reflexes. When you strike a tendon correctly, with a tendon
hammer the attached muscle is stretched and will reflexly contract in response.
Test Biceps, Supinator (=brachioradialis) and Triceps Reflexes.
If the reflexes are absent, use reinforcement.
Co-ordination
The cerebellum controls coordination of muscle movements. The following tests can
be used to test coordination in the limbs:
Finger nose test:
Ask the patient to touch the tip of your stationary finger, at full stretch, accurately and
gently, and then the tip of their own nose with first one and then the other index finger.
Intention tremor increases as the target is approached and past pointing is overshooting
of the target. Note this test is performed with the subjects eyes open. Asking the
patient to touch his nose with the eyes closed is a test for proprioception.
Test for dysdiadochokinesis:
Ask the subject to pronate and supinate one hand on the dorsum of the other as quickly
as possible. Difficulty with this test is called dysdiadochokinesis and is a sign of
cerebellar dysfunction.
!57
Bradykinesia
Test fine finger movements to detect bradykinesia if parkinsonism is suspected.
LOWER LIMB
Then ask the patient to recline on a couch undressed to shorts if possible
!58
Observation
Look for:
Power
Test the following muscle groups in order, comparing each side as you progress:
Movement
Starting position
Note
Hip flexion
Knee straight
Hip extension
Lying flat
Knee flexion
900 flexion
Knee extension
900 flexion
Ankle dorsiflexion
Full dorsiflexion
Full dorsiflexion
Co-ordination
Ask the patient to lift the heel high and then carefully place it on the knee of the other
limb and run it down the shin once. This test is difficult to interpret if hip flexion is
weak.
Reflexes
Examine the knee and ankle reflexes (with the joints at 900) and (with an orange stick)
the plantar responses. If the reflexes are absent, use reinforcement.
!59
If the patient reports an abnormality map out its extent with light touch or pinprick
testing or compare the two sides and draw it on a body chart.
Pain and temperature sensation are carried in the lateral spinothalamic columns.
Light touch, vibration and proprioception are carried in the posterior spinal columns.
!60
APPENDIX I
Common causes of Chest pain:
Angina / myocardial infarction
Pericarditis
Pneumothorax
Pneumonia
Pulmonary embolism
GORD
Oesophageal spasm
Costochondritis
Some Characteristics of Chest pain:
Angina is commonly described as a heaviness, tightness or choking sensation.
Angina most commonly presents as retro-sternal /central chest tightness which
may radiate up to the jaw or down the arms. It typically occurs with exertion but
may occur at rest also. It is also relieved by nitrates.
Pain secondary to pericarditis may be relieved by sitting forward.
2. Dyspnoea
Typically occurs on exertion due to failure of left ventricular output to increase
with exercise.
Paroxysmal Nocturnal Dyspnoea wakes patient from sleep with sudden shortness
of breath due to sudden failure of left ventricular output.
3. Ankle Swelling
Ankle oedema due to cardiac causes is usually symmetrical, worse in the
evenings and improves during the night
Can be due to bi-ventricular failure or right ventricular failure 2 to lung disease
Other causes include hypoalbuminaemia, e.g. nephrotic syndrome and cirrhosis
Non-pitting oedema may be due to hypothyroidism or lymphoedema
Unilateral lower limb oedema may be caused by DVT or compression of large
veins by tumour / lymph nodes
4. Palpitations
Term is imprecise; Usually refers to awareness of heartbeat
Examples:
missed beat followed by heavy beat = probable APC / VPC
sudden onset = probable cardiac arrhythmia
gradual onset = probable sinus tachycardia
completely irregular rhythm = atrial fibrillation
5. Syncope / Dizziness
Syncope refers to transient loss of consciousness due to cerebral anoxia
Examples:
!61
APPENDIX II
Differential Diagnosis for Acute Abdomen
Severe abdominal pain, with generalised rigidity:
Perforated peptic ulcer
Perforated bowel
Ruptured AAA
Severe pancreatitis
Tenderness/rigidity right hypochondrium:
Acute cholecystitis
Acute pyelonephritis
Perforated DU
Subphrenic abscess
Hepatitis
Cholangitis
Right sided pneumonia
Tenderness/rigidity left hypochondrium:
Pancreatitis
Diverticulitis
Acute pyelonephritis
Ruptured spleen
Left sided pneumonia
Tenderness/rigidity in RIF
Appendicitis
Salpingitis
Ruptured ectopic pregnancy
Crohns disease
Psoas abscess
Tenderness/rigidity in LIF
Sigmoid diverticulitis
Salpingitis
Ruptured Ectopic Pregnancy
Crohns disease
Epigastric area:
!62
Myocardial Infarct
PUD
Acute cholecystitis
APPENDIX III
Examination of the Shoulder
Bicipital Tendinitis
Tenderness over the bicipital tendon - tender area will migrate with bicipital
groove as arm is abducted & externally rotated.
Speeds Test: pain in the bicipital groove with forward flexion of the shoulder
about 30 against resistance with elbow extended and arm fully supinated
Yergasons test: pain in the bicipital groove with resisted supination of the
pronated forearm with the elbow at 90 and shoulder adducted.
Neer or passive painful arc test - passive flexion of the glenohumeral joint
while preventing shrugging
Hawkins test - with the patients shoulder stabilized with one hand and with
the patients elbow flexed at 90 the clinician internally rotates the shoulder
with the other hand
Yocums test - the hand of the affected side is placed on the shoulder of the
patients unaffected shoulder; the elbow is then raised without elevation of the
shoulder
!63
APPENDIX IV
Aid to examination of motor function
MOVEMENT
MUSCLE
UMN
Shoulder Abd.
deltoid
Elbow Flex
cutaneous
biceps
C5/6
musculo-
Brachio-radialis
C6
radial
radial
++
ROOT
REFLEX
C5
NERVE
axillary
Elbow Ext.
triceps
C7
ECRL
C6
Finger Ext.
EDC
C7
(+)
PIN
Finger Flex
C8
AIN
1st DI
radial
ulnar
++
APB
++
T1
ulnar
T1
median
L1/2
femoral
Hip Flex.
iliopsoas
Hip Add.
adductors
L2/3
Hip Ext.
gluteus max.
L5/S1
sciatic
Knee Flex.
hamstrings
S1
sciatic
Knee Ext.
quadriceps
Ankle dorsiflex.
peroneal
tib. ant.
Ankle eversion
sup.peroneal
peroneii
L5/S1
Ankle plantarflex.
gastroc./soleus S1/S2
++
L3/4
++
L4
!64
++
obturator
femoral
deep
tibial
EHL
L5
!65
deep
APPENDIX V
!66