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Consultation Manual Part 2 - Examination Skills

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Overview of all examinations needed for medical school finals summarised in bullet points. Contains additional information on presenting findings.

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Consultation Manual Part 2 - Examination Skills

  1. 1. Medical Consultation Manual: Part II Examination Skills Christiane Riedinger May 2014
  2. 2. TOC: Examinations ● Cardiovascular ● Respiratory ● Abdominal ● Neurological ○ Screening ○ Lower limb ○ Upper limb ○ Cranial nerves ○ Fundoscopy ○ Cerebellum ○ Language/speech ○ Memory ○ Special tests ○ GCS ○ Brain Death ○ Certification of Death ● Surgical ○ Peripheral Vascular ○ Varicose Veins ○ Hernia ○ Male Genitalia ○ Stoma ○ Breast ○ Neck/thyroid ○ Lump/lymph node ● Skin ● ENT ○ Ear ○ Nose ○ Mouth ● Orthopaedics ○ Hands ○ Shoulder ○ Feet ○ Knee ○ Hip ○ Spine ○ GALS
  3. 3. General Remarks ● Blue INSPECT ● Green PALPATE ● Red MOVE ● Pink SPEECH ● Purple SUMMARY ● THIS IS NOT REPEATED ON EVERY PAGE BUT YOU SHOULD ALWAYS INCLUDE THIS: (vital points!) Every examination starts and ends with…. ○ Introduces self, name and purpose of examination ○ Performs hand hygiene, roll up sleeves etc. ○ Ensures patient comfortable, prepared and happy to proceed ○ Explains process and examination to patient in a professional and considerate manner ○ Mentions obvious findings on general inspection ○ … [examination] ○ Explains that examination is complete and thanks patient ○ Performs hand hygiene ○ Presents findings in a clear and logical manner ○ Makes a reasonable attempt at diagnosis when questioned
  4. 4. CV Examination ● Seehttps://www.youtube.com/watch? v=vreCONlSwZs&index=2&list=PLGESeMFkgqnxC3Yvkgq7_sdfUszaRvlpr for MacLeod’s examination of the cardiovascular system. ● Expose patient’s chest and abdomen ● Inspect patient for ○ SOB ○ Cyanosis ○ Clicking sounds of artificial metallic heart valve ○ Oxygen supply ○ Scars on chest and legs ● Inspect hands for ○ Capillary refill ○ Palmar erythema ○ Clubbing: congenital heart disease, bacterial endocarditis ○ Nail changes ○ Nicotine stains ○ Splinter haemorrhages (vasculitic process) ○ Osler’s nodes (painful immunocomplex depositions) ○ Janeway lesions (microabscesses) ● Assess patient’s pulse: ○ Radial pulse: rate rhythm and volume ○ Check for collapsing pulse - ask for shoulder pain first! ○ Compare both radial pulses for radioradial delay ○ Ask if you should assess radiofemoral delay ○ Assess brachial pulse ○ Assess carotid pulse ● Ask for blood pressure ● Assess JVP with patient at 45*! Perform maneuvre for hepatojugular reflux. ● Inspect face for ○ Pallor ○ Central cyanosis ○ Corneal arcus ○ Xanthelasma ○ Dental caries ○ Comment on presence/absence of mitral facies
  5. 5. CV Examination: ctnd ● Inspect chest and precordium for deformities, scars, pacemakers etc. ● Palpate for heaves and thrills (palpable murmur) ● Examine apex beat. Auscultate for heart rate at apex and comment on any pulse deficit. ● Auscultate using diaphragm and bell ○ Palpate carotid pulse at the same time to ID heart sounds ○ Also auscultate in L axilla and ask patient to turn on L ○ Also auscultate 2nd intercostal space and ask patient to sit up and hold breath in expiration ● Auscultate lung bases at front and back ● Palpate for hepatomegaly and pulsating liver (in tricuspid regurgitation ● Palpate for sacral oedema ● Palpate for ankle oedema ● To complete my examination, I would like to perform urinalysis and fundoscopy, look at the patient’s obs chart (HR, saturations, temperature) and perform a CXR. ● PRESENTATION I’ve just examined this gentleman who [was / was not] comfortable at rest [needed oxygen?] and [had/didn’t have] peripheral stigmata of cardiovascular disease such as clubbing or reduced capillary refill. The patient [did/did not] have any bruises indicating warfarinisation. My most notable finding was [X]. - E.g. a [systolic/diastolic] murmur loudest over the [X], and radiating to the [X], indicating [X]. Associated findings were - Displaced apex beat, quality of apex beat (normal 5th IC space midclavicular line) - Abnormal pulse rate, rhythm (e.g. AF) and character. I found the following risk factors for cardiovascular disease - Xanthoma, xanthelasama indicating hyperlipidaemia - Nicotine stains - Increased BP - Arteriovenous fistula indicating advanced kidney disease - Signs of diabetes mellitus Most important negative findings were - No signs of heart failure: pitting oedema, pulmonary oedema, reduced capillary refill. Pulse rate, rhythm and character normal. No pulse deficit. - No cyanosis - No clubbing, normal heart sounds. In summary, I think the diagnosis is [X] / my differential diagnosis is [X].
  6. 6. Respiratory Examination ● See https://www.youtube.com/watch?v=gr0RlyC1QHw for MacLeod’ s examination of the respiratory system ● Expose patient’s chest and abdomen ● Patient sits reclined on examination bench ● Inspect patient and surroundings for ○ General appearance ○ Breath sounds, SOB ○ Use of accessory muscles ○ Chest deformities ○ Scars ○ Presence of inhalers, oxygen ● Inspect hands for ○ Clubbing: malignancy, chronic resp. disease ○ HPOA ○ Peripheral cyanosis ○ Capillary refill ○ Nicotine stains ○ Wasting ● Ask patient to hold out hands, inspect for CO2 retention flap, tremor ● Check patient’s pulse and respiratory rate ● Ask for blood pressure and mention paradox ● Assess JVP ● Inspect face ○ Pallor ○ Tongue: central cyanosis ● Examine position of trachea and assess for tracheal tug by palpating trachea on inspiration
  7. 7. Respiratory Examination ctnd. ● Examine apex beat ● Inspect chest again ● Assess chest expansion in two areas ● Percuss by comparing both sides ● Assess tactile vocal resonance ● Auscultate by comparing both sides and comment on added sounds. Ask patient to cough and repeat, crackles originating from upper airways will change while those originating from pathology in the bronchioles and lower will not ● Auscultate for whispering pectoriloquy ● Ask patient to sit up and examine from behind ● Palpate cervical and supraclavicular lymph nodes ○ Submental ○ Submandibular ○ Upper, middle and lower cervical nodes ○ Post. triangle along border of trapezius ○ Post. auricular ○ Occipital ○ Scalene nodes (get patient to tilt head towards inspected side) ○ Supraclavicular fossa ● Percuss on the back by comparing both sides ● Assess tactile vocal resonance ● Auscultate by comparing both sides and comment on sounds ● Auscultate for whispering pectoriloquy ● Palpate for sacral oedema ● Palpate for ankle oedema ● Check for signs of DVT, erythema nodosum ●
  8. 8. ● To complete my examination, I would like to test the peak flow, inspect the sputum pot and record oxygen saturations and temperature. ● PRESENTATION I’ve just examined this gentleman who [was / was not] comfortable at rest [needed oxygen?] and [had/didn’t have] stigmata of respiratory disease such as clubbing, hyperexpanded chest, chest deformities, obvious scars etc.. The patient [did/did not] have any cushingoid features indicating steroid therapy. - My most notable finding was [X], e.g. hyperexpanded chest with reduced air entry /diminished breath sounds in all lung fields - Associated findings were [Y], e.g. reduced cricosternal distance - Comment on (in order of relevance to your major findings) - Chest expansion - Percussion note - Whispering pectoriloquy, vocal resonance. - The most important negative findings were [Z] - In summary, I think the diagnosis is [X] / my differential diagnosis is [X]. Respiratory Examination ctnd.
  9. 9. Abdominal Examination ● See https://www.youtube.com/watch?v=jqQ4U_DXKf8 for MacLeod’ s examination of the abdomen ● Expose patient’s chest and abdomen down to the ASIS ● Patient lies flat on examination bench ● Inspect patient for ○ General appearance ○ Jaundice, gynaecomastia, weight ○ SOB ○ Paucity of axillary hair ○ Arms: bruising or scratch marks ○ If for acute abdo: signs of shock or dehydration ● Inspect hands for peripheral stigmata of abdominal disease ○ Clubbing: liver cirrhosis ○ Nail changes: Leukonychia, koilonychia ○ Spider naevi ○ Palmar erythema: chronic liver disease ○ Dupuytren’s ● Get patient to hold out arms with wrists extended: liver flap/asterixis? ● Inspect face ○ Icteric sclerae ○ Spider naevi ○ Tongue ○ Mouth: angular stomatitis, ulcers, teeth, fetor ● Inspect chest for spider naevi and gynaecomastia ● Inspect abdomen for distension, scars ○ Can ask patient to inflate and deflate abdomen
  10. 10. Abdominal Examination: ctnd ● Ask patient if there is any pain or tenderness before proceeding to palpation! ● Palpate abdomen at level of patient superficially, then deeply in all areas while observing the patient’s face. Kinder than testing for rebound tenderness: tender on percussion ● Palpate for hepatomegaly and percuss from above ● Palpate for splenomegaly and percuss for dullness ● Ballotte kidneys (can also palpate renal angle in sitting patient) ● Distinguish ○ Kidney ballotable moves vertically on inspiration resonant to percussion ○ Spleen has a notch moves towards RIF on inspiration dull to percussion ● Check for ascites, e.g. by shifting dullness or transmitted thrill ● Palpate for AAA ● Auscultate for bowel sounds: present, absent, early obstruction = increased, late obstruction = high-pitched tinkling ● Auscultate for renal bruit, hepatic and aneurysmal bruit ● Palpate apex and auscultates heart including axilla ● Patient sits up ● Examine back for scars ● Assess cervical lymph nodes, including Virkow’s node ● Palpate for sacral oedema ● Check for pyoderma gangrenosum and ankle oedema ● To complete my examination, I’d like to examine the hernial orifices, examine the external genitalia and perform a digital rectal examination. (If required, suggest special tests, e.g. Murphy’s test for cholecystitis) ● PRESENTATION
  11. 11. Neuroexam - Screening ● Think about how best to summarise steps to save time ● Gait ● Eyes ○ Eye movements ○ Visual fields ○ Pupils ○ Fundoscopy ● Face ○ Facial sensation V ○ Facial movement VII ○ Tongue movement XII ○ Uvula X ○ Neck flexion XI ● Arms ○ Inspect ○ Patient holds outstretched arms ○ Tone ○ Power ○ Reflexes ● Legs ○ Inspect ○ Tone ○ Power ○ Reflexes ● Sensation: Fingers and Toes ○ Proprioception ○ Vibration ○ Light touch ○ Pain ● Coordination: Arms and legs ● Note ○ If you suspect a stroke always also include a cardiovascular examination! ○ Can screen for hemispheres/1* cortices systematically ■ Frontal (Mental test, reasoning), parietal (e.g. spatial attention) occipital (vision), temporal (memory), speech (receptive vs. expressive dysphasia), initiation of movement (extrapyramidal), movement (motor cortex), sensation (sensory cortex) ○ If you suspect CNS metastasis look for primary! ○ If you investigate dizziness, include an examination of the ears and hearing ○ Watch out for potential psychiatric problems by noting appearance, behaviour, mood, delusions, hallucinations, vegetative symptoms
  12. 12. Neuroexam - Lower Limb ● See https://www.youtube.com/watch?v=pFEs9lg5SVo for MacLeod’s examination of lower limb ● Expose patient’s lower limb appropriately ● Patient sits on examination bench ● Inspect lower limbs for ○ Skin changes ○ Ulceration ○ Muscle wasting - LMN ○ Fasciculation - LMN ○ Ataxia of movements ○ Involuntary movements ○ Comment on any obvious general features ● Inspect gait: Ask patient to walk, turn and walk back ● Patient on examination bench ● Examine tone ○ Roll (internally and externally rotate) extended lower limb, then quickly lift/flex the knee ○ Look for clasp knife reflex (spasticity) - UMN ○ Try to elicit ankle clonus - UMN ○ Look for lead-pipe rigidity - extrapyramidal ○ Look for cogwheeling* - extrapyramidal ● Examine power ○ Start at hips and move distally** ○ Static approach: “Hold leg in this position, don’t let me straighten/bend it” ○ Dynamic approach: “Pull me towards you, push me away/down”
  13. 13. Neuroexam - Lower Limb: ctnd. ● Examine power ctnd. ○ Test 2 movements per joint (required to elicit UMN lesion, 1 would be enough for LMN lesion but not good for exam) ○ Use MRC grading scale to describe findings ● Examine coordination ○ Ask patient to run heel down the opposite shin ● Elicit reflexes, reinforce if necessary (e.g. interlock fingers and pull them apart) ○ Patella - L3/4 ○ Calcaneal tendon - S1 ○ Babinski - UMN ● Assess proprioception ● Assess sensation ○ Fine touch ○ Pin prick ○ Vibration ● To complete my examination, I’d like to .... ● PRESENTATION The most important thing in the neuro exam is to distinguish upper from lower motor neuron lesion. Again, proceed by stating most notable finding, additional features that back up this finding, important negatives, summary of likely diagnosis.
  14. 14. Neuroexam - Upper Limb ● See https://www.youtube.com/watch?v=s9xfkbjrxTs for MacLeod’s examination of upper limb ● Expose patient’s arms and shoulders appropriately ● Patient sits on chair ● Inspect for ○ Skin changes ○ Ulceration ○ Muscle wasting - LMN ○ Fasciculation - LMN ○ Ataxia of movements ○ Involuntary movements ○ Comment on any obvious general features ● Ask patient to hold out arms, inspect for ○ Pronator drift (+/i eyes closed) - UMN ○ Tremor ○ Can test rebound phenomenon by tapping onto wrists - cerebellum ● Examine tone ○ Hold elbow and move forearm by holding onto wrist, move both wrist and elbow joint ○ Look for spastic catch: fast supination ○ Look for clasp knife reflex (spasticity) - UMN ○ Look for lead-pipe rigidity - extrapyramidal ○ Look for cogwheeling* - extrapyramidal
  15. 15. Neuroexam - Upper Limb: ctnd. ● Examine power ○ Start at shoulder and move distally** ○ Static approach: “Hold arm in this position, don’t let me straighten/bend it” ○ Dynamic approach: “Pull me towards you, push me away/down” ○ Test 2 movements per joint (required to elicit UMN lesion, 1 would be enough for LMN lesion but not good for exam) ○ Use MRC grading scale to describe findings ● Examine coordination ○ Finger nose test* ○ Dysdiadochokinesis ○ Rapid finger movements ● Elicit reflexes, reinforce if necessary (e.g. clench teeth) ○ Biceps - C5/6 ○ Triceps - C6/7 ○ Supinator (brachioradialis) - C5/6 ○ Fingers** ○ Hoffman’s reflex*** ● Assess proprioception ● Assess sensation ○ Fine touch (dorsal column) ○ Pin prick (spinothalamic) ○ Vibration ● To complete examination, I would like to … ● PRESENTATION
  16. 16. Neuroexam - LL and UL: short version ● Short version - mnemonic: ○ ATP CRP S ○ Appearance ○ Tone ○ Power ○ Coordination ○ Reflexes ○ Proprioception ○ Sensation
  17. 17. Neuro Limb Examination Appendix ● Nerve Root Scheme Upper Limb ○ C5 = shoulder abduction ○ C6 = elbow flexion ○ C7 = wrist extension (+C6 + radial n.) ○ C8 = finger extension/flexion ○ T1 = finger abduction and adduction ○ Axillary nerve = shoulder abduction ○ Musculoskeletal = elbow flexion ○ Radial nerve = elbow extension, wrist extension ○ Ulnar nerve** = finger ab/adduction, thumb adduction ○ Median nerve *** = thumb abduction, inspect thenar eminence (above not complete, just distinctive movements!) ● Nerve Root Scheme Lower Limb ○ L2 = Hip flexion ○ L3 = Knee extension ○ L4 = Foot inversion, dorsiflexion ○ L5 = Hallux dorsiflexion ○ S1 = Foot eversion ○ Femoral nerve = knee extension ○ Sciatic nerve = knee flexion ○ Obturator nerve = hip adduction ○ Tibial (off sciatic) = foot plantarflexion ○ Deep fibular (off sciatic) = foot dorsiflexion Alternative: Complete Levels LL HIP Flexion L2,3 Extension L4,5 KNEE Extension L3,4 Flexion L5,S1 ANKLE Extension (dorsiflexion) L4,5 Flexion (plantarflexion) S1,2 Alternative: Complete Levels UL SHOULDER Flexion C5,6,7 Extension C5,6,7 Abduction C5 Adduction C6,7,8 Lat. rotation C5 Med. rotation C6,7,8 ELBOW Flexion C5,6 Extension C7,8 ARM Supination C6 (radial) Pronation C7,8 (median) WRIST Flexion, Extension C7,8 FINGERS Long flexors, extensors C7,8 Small muscles of hand T1
  18. 18. Neuro Limb Examination Appendix: ctnd. ● Pyramidal weakness - upper limb ○ Weak shoulder abduction but some adduction preserved ○ Weak elbow extension but some flexion ○ Weak wrist extension but some flexion ○ Weak finger extension but some flexion ○ Weak thumb abduction but some adduction ● Pyramidal weakness - lower limb ○ Weak knee flexion but some extension = leg straight ○ Weak foot dorsiflexion but some plantarflexion = foot drops ○ Weak foot eversion but some inversion = foot inverted ● MRC Scale of Power ○ 0 - no changes ○ 1 - flicker of movement ○ 2 - active movement with eliminated gravity ○ 3 - active movement against gravity (but not resistance) ○ 4 - decreased power against resistance ○ 5 - full power For more background info, see neurology revision presentation.
  19. 19. Neuroexam - Cranial Nerves ● General inspection ○ Face ○ Eyes ○ Position of head ○ Hemiparesis or hemiplegia ● I - Olfactory nerve ○ Ask about changes in smell, can they differentiate tea, coffee, fruit? ○ Sniff test ● II - Optic nerve ○ Visual acuity - Snellen or Jaeger charts (finger counting) ○ Visual fields - Confrontation: When is edge/colour of pen seen* ○ Colour vision - Ishihara ○ Pupillary reflexes - comment on size, shape, inequality, light response ■ PERRLA pupils equal, round and reactive to light+accommodation ○ Fundoscopy - retina, vessels, optic nerve and macula ● III, IV and V - Oculomotor, trochlear and abducent nerves ○ Inspect eye ■ Anhidrosis around eye ■ Ptosis, complete or partial ■ Direction of gaze, symmetry of gaze ■ Pupils ■ Nystagmus ○ Ask: is there any double vision? ○ Ocular movements: saccades (look at index finger of each hand), smooth pursuit (H) ○ Pupillary reflexes ○ Comment on nystagmus and/or ptosis ● V - Trigeminal nerve ○ Sensation of face and anterior scalp (face only may be psychogenic?!?) ○ Corneal reflex ○ Muscles of mastication ■ Masseter - clench teeth ■ Pterygoids - open mouth (jaw deviates to the side of the lesion) ○ Jaw jerk - marked jerk = UMN lesion above the cervical cord
  20. 20. Neuroexam - Cranial Nerves: ctnd. ● VII - Facial nerve ○ Assess asymmetry, presence of nasolabial fold ○ Muscles of facial expression ■ Show teeth ■ Screw up face and don’t let examiner open the eyes ■ Raise eyebrows ■ Smile ○ Mention sense of taste in ant. ⅔ of tongue. ● VIII - Vestibulocochlear nerve ○ Whisper into ear while other meatus occluded - establish that patient hears* ○ Rinne’s test for comparison of air vs. bone conduction - cond. still intact? ■ Tuning fork at 510 Hz (C above standard A/440Hz) ■ Place on mastoid process behind each ear and then outside of pinna, ask what was heard louder** ○ Weber’s test to distinguish conductive vs. sensorineural hearing loss ■ Tuning fork at 256 Hz (~H below middle C) on ■ Place on top of head equidistant from hears ■ Can sound be heard? Symmetrical? Which side louder? ○ Vestibular function ■ e.g. Hallpike test, patient sits on bench with legs extended, then lie them down and observe for nystagmus with head at 45* and 20* extension, then turn to other side, observe, sit back up, observe ● IX - Glossopharyngeal nerve ○ Gag reflex (afferent component), abnormal if NOT present unilateral ● X - Vagus nerve ○ Speech (as in phonation) ○ Observe uvula of soft palate (deviates towards unaffected side) ○ Gag reflex (efferent component) ● XI - Accessory nerve ○ Sternocleidomastoid, turn head against resistance at chin, feel opp. side ○ Trapezius, shrug shoulders ● XII - Hypoglossal ○ Inspect tongue for muscle bulk, fasciculations ○ Ask patient to protrude tongue (deviation to affected side) ○ Speech (as in pronunciation of consonants)
  21. 21. Appendix Cranial Nerves ● How to determine visual acuity (>6y and no learning difficulties) ○ Acuity - objective measure of ability to see (ability to resolve two objects, size of image at retina with respect to cells) at distance and nearby (always test both as conditions such as macular degeneration are worse for distance) ○ Pinhole test - detect presence of refractive errors ○ Prerequisites ■ Always before administration of eye drops ■ Always with best spectacles or contact lenses ■ Always start with the right eye ■ Correct any ptosis by lifting eyelid ■ Provide anaesthesia if needed ● SNELLEN acuity => DISTANCE ○ or LogMAR (different letters) ○ can also use LANDOLT rings (w/o letters) ○ tan a = x/u ○ tan 1 = 0.0175 ○ tan 57 = 1 (radian) ○ for small alpha: tan a = x/u [radians] = a ○ therefore a [degrees] = 57* x/u ○ 1* = 60 minutes ~ 300um on the retina (cone = 30s, 2.3um) ○ 6/6 [m] vision in the UK or 200/200 [feet] in the US ○ DISTANCE / SIZE OF THE LETTERS ○ Numerator - Distance ○ Denominator - Size of letters in each line ○ The line with normal vision (20/20, 6/6) the spaces within the letter are 1 minute apart, and are 5min high ● THE BIGGER THE FRACTION THE BETTER THE VISION => 1 is the best ○ Procedure ■ Patient to stand 6m away ■ Occlude one eye completely ■ Start reading from top until no longer seen ■ Up to line 6/6 [m] or 20/20 [feet] is normal: ● Letter 1 minute high, i.e. 1/60* ● That’s 6/6, 20/20 vision = acuity of 1min ■ If not, which row can you read? ● Line 1, 6/60 or 20/200 patient with normal vision could stand 60m away, if just seen from 6m away then acuity of 10min ● Line 5, 6/12 or 20/40, acuity of 2min ■ If no letter read, use pinhole (corrects for refractive errors*), if still not seen, move patient to 3m from the chart, then 1m, then count fingers (report as CF), if that does not work, wave the hand (report as HM hand movements), if still not seen, shine torch into eye (report as PL perception of light), else NPL. If artificial eye, then record AE. ● Test near acuity using NEAR TEST CHART at 0.3m (size N8 = book print)
  22. 22. Appendix Cranial Nerves: ctnd. ● How to evaluate Weber and Rinne’s test ○ ALWAYS combine with examination of external auditory meatus and drum with an auroscope. ○ Conductive hearing loss Problem conducting sound waves from outer ear through tympanic membrane and middle ear to inner ear. ○ Sensorineural hearing loss Problem in the inner ear, vestibulocochlear nerve or auditory processing centres of the brain. 1. Air conduction (AC) impaired in one or both ears 2. Rinne’s test ● Normal (+): hear air conduction louder than bone AC > BC ● If conductive hearing still intact, patient hears a louder sound when the tuning fork is placed on mastoid process, i.e. BC > AC* 3. Weber’s test ● Normal: one hears sound equally well on both sides ● Weber localises to the side of conductive deafness (where the sound will reach the ear via the bone) or away from the side of sensorineural deafness. ○ Examples AC Rinne Weber Results Impaired on R BC > AC on R Localises to R Conductive hearing loss on R Impaired on R No preference Localises to L Sensorineural hearing loss on R Impaired on both sides BC > AC on R Localises to R CHL on R, SNHL on L Impaired on both sides No preference No preference SNHL on both sides
  23. 23. Neuroexam - Fundoscopy ● Can dilate pupils with Guttae (g) (drops) 1% tropicamide (antimuscarinic producing mydriasis) or 2.5/10% phenylephrine hydrochloride for greater dilatation (a1 agonist) ○ Contraindication: risk of angle-closure glaucoma ● Ask patient to sit comfortably, explain procedure ● Inspect eyes ● Draw curtains and/or turn down lights ● Switch on ophthalmoscope, set dioptres to desired setting, set to largest white light (check by shining on the hand) ● Ask patient to focus on point in the distance (to avoid accommodation and pupillary constriction!) ● Observe patient’s R eye with your R eye, then L with L ● Look at the red reflex from ~30cm away ● Gradually move towards the eye until optic disc seen (on nasal side of retina, 15* medial to the macula but in same plane, make sure to adjust focus so you can see sharply) ● Inspect optic disc ○ Inspect disc margins ○ Cup-disc ratio (CDR) = central yellow up / entire size, <0.5 ○ Colour, atrophy if completely yellow or white ○ Pulsation of veins seen in 70% of patients (normal RIP) ● Inspect and trace vessels from disc into periphery ○ Narrowing of arteries? variable “calibre” => atherosclerosis ○ Tortuous dilated veins? => venous occlusion, ischaemia ○ AV nipping? crossing arteriole compresses vein => hypertension ○ Veins are darker and wider than arteries ● Inspect background retina ○ Ask patient to loop up, down right and left to inspect all quadrants ○ Colour (racial diversity) ○ Contour ● Inspect macula and fovea (avascular, temporal to the optic disc) ○ Ask patient to look straight into the light ○ Haemorrhages? Drusen (yellow/white accummulations of yellow/white material)? Laser scars? Exudates? Oedema? ● Potential pathology ○ Papilloedema Swelling of the optic disc, usually bilateral ○ Optic atrophy Loss of optic nerve fibres ○ Glaucoma Widening of optic cup due to increased intraoccular p.* ○ Diabetic retinopathy Microaneurysms, dot and blot haem., hard exudates, Neo-vascularisation, cotton woll spots, dot haemorrhages ○ Hypertensive retinopathy AV nipping, variable calibre, coton wool spots, blot haemorrhages, papilloedema, flame-shaped haem. ○ Black lesions: laser scars, melanoma, choroidal naevus, retinitis pigmentosa
  24. 24. Examination of the Eye ● See other slides for details of examinations mentioned here ● Assess vision (without having dilated the pupils) ○ Visual acuity - Snellen or Jaeger charts ○ Visual fields “Confrontation” - When does pen/colour become visible* ○ Colour vision - Ishihara charts ○ Ocular movements - Always or especially if diplopia ● Intraocular pressure ● Pupillary responses ● Assess external eye systematically from front to back ○ Eyelids - symmetrical, swellings, e.g. “stye”/hordeolum, chalazion ○ Eternal eye ■ Conjunctiva ■ Fornices ■ Cornea - with torch. Opacity, abrasion, ulcer, oedema? ○ Anterior chamber ○ Lens: normal lens means pupil is black ○ Pupils: PERRLA (Pupils equal round and reactive to light and acc.) ○ Vitreous body ● Assess internal eye ○ Red reflex*** ○ Retina ■ Optic disc ■ Macula ■ Posterior pole (typo in book) ■ Peripheral retina ■ Each retinal quadrant in turn ○ Assess position of floaters**, move head to and fro ■ Opacity moves in same direction = behind the lens ■ Opacity moves in the opposite direction = in front ■ Opacity does not move at all = in lens ● Dilate the pupils at appropriate point during systematic examination of the eye
  25. 25. ● Hx with all sub-categories ● RVA and LVA Visual acuity ● Presence/ absence of RAPD Relative afferent pupillary defect ● Ishihara x of y charts seen ● Lids ● Conjunctiva White = normal ● Cornea Clear = normal ● A/C (ant. chamber) D&Q (deep and quiet = normal) ● Lens dense NS (nuclear sclerosis) ● IOP [mmHg in each eye] ● Fundi ○ draw ○ node CDR (cup-disc ratio) ● Impression ● Plan ● Other abbreviations ○ CT Cover test ○ UA Unaided ○ EOM External ocular movements ○ PH Pinhole Standard Recording of Eye-Ex
  26. 26. Neuroexam - Cerebellum ● Remember mnemonic DANISH ○ Dysdiadochokinesia ○ Ataxia ○ Nystagmus ○ Intention tremor ○ Slurred speech / staccato => dysarthria ○ Hypotonia ● Observe gait for ataxia ○ If gait normal repeat with closed eyes, may progress to side of the lesion ● Finger-nose test for intention tremor and dysmetria ● Test for dysdiadochokinesia ● Assess for hypotonia, hyporeflexia ● Assess eye movements and test for nystagmus (max. looking torwards lesion and fast phase towards lesion, oppositve in vestibular cause!) and saccades (overshooting) ● Assess speech for staccato or slurring ○ “West Register Street, Edinburgh” ○ “Baby hippopotamus” ○ “British constitution” ● Ask to perform fundoscopy as demyelination is the commonest cause of cerebellar signs, ask to perform cranial nerve examination (=> DD of brainstem lesion?)
  27. 27. Neuroexam - Language/Speech ● Important to keep in mind: education, mother tongue, premorbid intelligence and that anxiety or depression can affect performance ● Establish the patient can hear you ● In general, ask to perform tasks of increasing difficulty to determine threshold ● Give instructions to assess comprehension => receptive aphasia ○ Close eyes ○ Open eyes ○ Hold up 2 fingers ○ Touch right ear with left hand ○ Take a piece of paper, fold it in half, give it to me with your left hand into my right hand ○ Increase complexity until patient unable to do it ● Can assess reading here => alexia ○ Hold up card with instructions, e.g. “close your eyes” ○ Ask to read a newspaper, afterwards ask to summarise what they have read ● Try to distinguish dysarthria form dysphasia ● Assess free speech => expressive aphasia ○ Ask patient to describe something, e.g. their work or a picture ○ Assess ● Slurring (+ intact comprehension and writing = dysarthria*) ● Fluency, content, choice of words (avoidance of words?) ● Rhythm, grammar ● Assess writing => agraphia ○ Ask to write down what patient sees on the picture ● Assess word finding => agnosia, expr. aphasia ○ Name objects ■ What is this? ■ What do you do with it? ○ List animals ○ List words beginning with S (normal >12 /min) ● Ask if patient is able to repeat words ○ West Register Street, Edinburgh ○ Baby hippopotamus ○ British constitution ○ No ifs, ands or buts ➔ Hearing ➔ Commands => comprehension ➔ Reading ➔ Free speech => expression ➔ Writing ➔ Word finding ➔ Word repetition
  28. 28. Neuroexam - Memory ● Multiple classifications of memory, examination does not reflect elements of a single classification but types of memory that can be easily assessed ● Different types of memory can be tested with the same task ● Implicit memory (memory without conscious awareness of previous experiences) - rarely an early feature of disease ● Explicit memory - affected more often, has many subtypes ● See summary slide in Neurological Revision Presentation ● Orientation ○ Time ○ Place ● Attention / Working memory / Verbal memory ○ Digit span ○ Normal is 7 forwards, 5 backwards ● Episodic memory / retrograde memory Explicit ○ How did you get to the hospital ○ Ask to recall distant life events, autobiographical details ■ Where were you born, go to school ■ When did you get married, have children, start working ● Anterograde memory ○ Digit span 2 - ask to recall numbers from the beginning ○ Alternatively, ask to remember a sentence and ask to recall later ● Semantic memory Explicit ○ Test recognition of words ■ Comol, camel ○ Test understanding of the meaning of words ■ Caterpillar, violin ○ Recall facts ■ How many letters in the alphabet ■ Monarch/prime minister during 1st world war (has to be far enough in the past in order not to be episodic if person alive at that time) ● Non-verbal/visual memory Explicit ○ R non-dominant hemisphere in R handed ○ Show geometrical shape and ask patient to pick it out of number of shapes ● Procedural memory Implicit ○ Ask patient to tie a knot ● Formal Tests ○ MMSE (mini mental state examination, see next slide) x/30 ○ ACE-R Addenbrooke’s cognitive assessment x/100 ○ TYM test, x/50, patient does themselves ○ Professional neuropsychological testing ➔ Time, place ➔ Digit span ➔ Recall life events ➔ Digit span 2 ➔ Recognise words ➔ Understand words ➔ Recall facts ➔ Recall shape ➔ Recall process ➔ Formal testing
  29. 29. Neuroexam - Special Tests ● Dyspraxia ○ Difficulty of performing a motor task despite intact understanding and motor functions, as well as intact extrapyramidal, cerebellar and sensory systems ○ Ask patient to pretend drinking a cup of tea with a saucer ● Constructional apraxia ○ Inability of drawing a geometrical shape ○ Ask patient to draw/copy a geometrical shape ○ Parietal disturbance ● Neglect ○ Ask patient to copy an image or draw a clock? ○ Ask patient to put on their jacket ○ Non-dominant hemisphere parietal lesion ● Attention deficits ○ Assess digit span: repeat forwards and backwards ○ norma: 7 forward, 5 backward ● Orientation ○ Time: day, month, year ○ Place: ward, hospital, town ○ Person: name ● Higher Function ○ calculate: take serial 7 away from 100, double 3s ● Abstract thought ○ Interpret proverbs: what does “people in glass houses shouldn’t throw stones” mean? ○ Ask patient to estimate the weight of an elephant (5t) or the length of a jet (70m)
  30. 30. Neuroexam - GCS 4+5+6 Eye opening ● 4 = Spontaneous ● 3 = To verbal stimulus ● 2 = To pain ● 1 = None Verbal response ○ 5 = Oriented ○ 4 = Confused ○ 3 = Inappropriate words* ○ 2 = Incomprehensible/moaning ○ 1 = None Motor response ○ 6 = Obeys commands ○ 5 = Localises to pain (towards stimulus) ○ 4 = Withdraws from pain ○ 3 = Flexion to pain (decorticate)** ○ 2 = Extension to pain (decerebrate)*** ○ 1 = None
  31. 31. Mental State Examination ● Appearance ○ General health ○ Clothing ○ Skin: tattoos, piercings, injection sites, lacerations ○ Personal hygiene ○ Movements: Dyskinesias, tremors, tics, chorea, gait ● Behaviour ○ Eye contact, rapport ○ Facial expression ○ Manner ○ Signs of anxiety, depression, hallucinations, aggression ○ NON-verbal behaviour ● Speech ○ Tone, rate, volume, quantity, fluency ○ Normal: spontaneous, logical, relevant, coherent ○ Pathological: circumstantial (taking long to get to the point), perseveration (repeating words or topics), neologisms ○ Thought form expressed in speech ■ Implying logical connection or associations in nonsensical statements ■ Thought block, patient’s mind goes blank ■ OHPsychiatry: “Linearity, goal-directedness, associational quality, formal thought disorder” ● Thought content and beliefs ○ “Odd thoughts” ○ Depression Self-denigration, guilt, hopelessness ○ Ruminations Persistent, disabling preoccupations ○ Obsessions ○ Phobias ○ Overvalued ideas Held beyond reason and causing distress ○ Delusions + its subtypes Abnormal beliefs ○ Thoughts of suicide or self-harm ○ Thoughts of harm to others
  32. 32. Mental State Examination ● Mood (“Climate”) ○ Subjective ○ Objective: dysthymic, euthymic, elated/hyperthymic ○ Anxiety and panic symptoms ● Affect (“Weather”) ○ External manifestation of emotions ○ Stable, labile, irritable, perplexed, suspicious ● Perception ○ Have you seen or heard things that other people can’t see? ○ Illusions Misinterpretations of normal perceptions ○ Hallucinations Perceptions in the absence of an external stimulus ○ Pseudo-hallucination Patient retains insight about hallucination ○ Depersonalisation Feeling detached and unreal ○ Derealisation World lifeless ● Cognition ○ Memory Short and long term ○ Orientation Day, date, time ○ Dyspraxia Draw intersecting pentagons ○ Dysphasia Receptive or expressive ○ Executive function ● Insight ○ Patient’s understanding of their condition
  33. 33. Mental Health Risk Assessm. ● Based on ○ Past behaviour ○ Informants ○ Review of case notes ○ Safety of environment of patient interaction ● PATIENT ○ Risk of self-harm ■ Suicidal ideations ■ Preventative factors ■ Predisposing factors ■ Previous episodes of self-harm ■ Hx of support services and willingness to engage with them ■ Depression: thoughts of hopelessness and worthlessness ■ Delusions: Hallucinations inciting self-harm ○ Risk of self-neglect and accidental harm ■ Home safety (household and crime) ■ Overdosing / non-compliance with medication ■ Wandering ■ Self neglect ■ Abuse, access to healthcare ■ Falls ■ Eating ○ Vulnerability to abuse ● OTHERS ○ Acts or threats of violence, arson, sexually inappropriate behaviour ○ Previous containment ○ Compliance with treatment and drug regime ○ Alcohol or drug misuse ○ Behaviour of impulsive nature ○ Stress ○ Delusions and command hallucinations ○ Risk to children ● Also see notes in history section
  34. 34. Neuroexam - Brain Death ● Death = irreversible loss of brainstem function. ● UK brain death criteria ○ Existence of irreversible brain damage ○ Exclusion of potentially reversible causes such as ■ Depressant drugs ■ Hypothermia ■ Metabolic or endocrine disturbances ■ Reversible causes of apnoea ○ Coma, apnoea and the absence of brainstem reflexes formally demonstrated by two doctors, one of them a consultant, together and 2 occasions ● Testing brainstem reflexes ○ Pupil response to light ○ Corneal reflex - blinking to touch of cornea with cotton wool ○ Oculovestibular reflexes - eye movements when instilling ice-cold water into external auditory meatus ○ Stimulation of cranial nerve sensory territories (response to pain), e.g. motor response to supra-orbital pressure ○ Gag or cough reflex - palate or bronchial stimulation ○ Apnoea test - is there a respiratory response to acidaemic respiratory stimulus upon reduction of ventilation rate without hypoxia (pCO2 > 6kPa and pH <7.4)
  35. 35. Diagnosis of Deathby CNS criteria ● Death = Irreversible loss of brainstem function (forebrain cannot again function normally, inability to maintain homeostatic functions). ● Previously = simultaneous onset of ○ Apnoea ○ Unconsciousness ○ Absence of circulation. ● Death can be diagnosed after 5 minutes of observed asystole (has caused irreversible damage to brainstem), as determined by ○ Absence of of central pulse ○ Absence of heart sounds ○ +/- absence of activity on continuous ECG or echocardiogram (if measured) ● Approach ○ Obtain brief history of the circumstances of death from the nurse ○ Confirm patient’s identity by using notes and patient bracelet ○ Response to voice ○ Response to pain sternal rub / supraorbital pressure ○ Pupillary reflexes (30s each) fixed and dilated, possibly dry ○ Observe central pulse for 1min carotid on both sides (or femoral) ○ Auscultate for heart sounds at aortic, pulmonic, tricuspid and mitral areas) for 1min (each?) ○ Observe and auscultate (anterior and lateral chest) for respiratory effort for 30s/1min on each side ○ Check for presence of pacemaker ○ Note: bowel sounds may still be present ○ Protect the patient’s dignity by covering him/her with a sheet ● Declare time of death in notes when criteria are met ○ Asked to verify death: ■ No response to pain ■ Pupils fixed and dilated ■ No carotid pulse for 60 seconds ■ No audible heart sounds for 60 seconds ■ No audible breath sounds for 60 seconds ■ Death declared at [TIME] on [DATE] ■ No pacemaker palpable ■ Can write rest in peace RIP ○ Sign, Name, position, bleep number
  36. 36. Peripheral Vascular Exam ● Expose ● Ask about pain ● Inspection ○ SOB ○ Signs of abnormal perfusion Pallor, cyanosis, mottling, diabetic shin spots ○ Signs of previous surgery Scars (also of CABG on chest!), amputations ○ Legs Ulcers, gangrene, bandages, inspect between toes and heels for ischaemic changes ○ Abdomen Mottling, dilated veins, distension, note weight ○ Face Corneal arcus, xanthelasma, Horner’s, prominent veins, facial swelling ○ Neck ● Hands ○ Inspect Nicotine stains, xanthoma, calcinosis, purple fingertips, pits and scars, muscle wasting ○ Palpate temperature, cap refill! ○ Palpate pulses on hands and arms: Radial, brachial, BP, radioradial delay, capillary refill Suggest taking BP, especially when radial pulses difficult to palpate, <15mm diff. ● Continue palpating pulses ○ Neck Bilat. carotid + auscultation, held breath after inspiration ● Abdomen ○ Assess epigastric/umbilical pulsation midline above the umbilicus ○ Auscultate for bruit over aorta, renal arteries, splenic artery ● Continue palpating pulses ○ Legs Palpate for temperature: legs, compare both feet Capillary refill, compare both sides Femoral, popliteal, dorsalis pedis*, post. tibial, radiofemoral delay Auscultate above the femoral artery. Is the femoral pulse aneurysmal? I would also like to record the ankle brachial pressure index ABPI Suggest to perform a Doppler of the peripheral arteries of the leg
  37. 37. Peripheral Vascular Exam ctnd. ● Buerger’s test ○ Would you like me to perform Buerger’s test? ○ Raise feet to 45*/50% for 2-3min, does pallor develop? ○ Then sit up and hang foot off bed, observe return of blood, reactive hyperaemia** after ~2min? ○ Would you like me to repeat the Buerger’s test on the other side? ● To complete my examination, I would like to carry out a cardiovascular examination, a full neurological examination of the lower limbs (=> sensation) and perform urinalysis. I’d also like to acquire the ABPI and an ECG, as well as a Duplex scan of the lower limb. ● PRESENTATION ○ EXAMPLE: I have just examined this [X]’s peripheral arterial system, noting pale (+/- mottled), cold peripheries with reduced capillary refill time, indicating poor arterial perfusion. I noted the popliteal and posterior tibial pulses were absent. Burger’s test was positive indicating reactive hyperaemia. There were no signs of of ulceration or previously healed ulcers, and no sign of an abdominal aneurysms or arterial bruits on auscultation. ● Useful investigations: ○ FBC, U&E, clotting, lipid profile, glucose ○ ECG, CXR, US, angiogram ● Management of PVD ○ Conservative: stop smoking, diet, exercise ○ Medical: reduce risk factors such as hypertension, hypercholesterolaemia, diabetes ○ Interventional: balloon arthroplasty ○ Surgical: bypass grafting
  38. 38. Peripheral Vascular Exam Appendix ● ABPI ○ Determine systolic BP with Doppler US on both arms, posterior tibial and dorsalis pedis pulses ○ Calculate ABPI = highest lower limb reading / highes upper limb reading ○ ABPI ~ 1 = normal (Normal DVT prophylaxis) ○ 0.5 < ABPI < 0.9 = claudication (DVT prophylaxis = low pressure stockings) ○ ABPI < 0.5 = critical ischaemia (DVT prophylaxis just elevation) ● Fontaine Classification of PVD ○ 1 asymptomatic ○ 2 intermittent claudication ○ 3 pain at rest ○ 4 critical ischaemia, ulceration, gangrene ● Surgical procedures of reperfusion ○ Aortobifemoral graft ○ Cross-over graft from contralateral iliac/femoral artery ○ Femoropopliteal graft ○ Using long saphenous vein (for FP graft) or artificial polytetraflouroethylene (Dacron) graft ● DD of pulsating mass ○ Aneurysm ○ Ectatic (tortuous) artery, especially in carotid ○ Mass adjacent to artery, e.g. carotid body tumour, pancreatic cancer ○ True expansile pulsation of aneurysm is revealed on bimanual palpation rather than simple conduction of the pulse, if in doubt suggest US ● DD of ulcers ○ Venous 80% Above medial malleolus, + skin pigmentation from stasis ○ Arterial 10% Painful, + stigmata of peripheral vascular disease, absent pulses ○ Mixed 5-10% Both above features ○ Neuropathic Intact vasculature + loss of sensation, unless + periph.v (T2DM) ○ Traumatic ○ Systemic, e.g. RA ○ Neoplastic, e.g. skin CA
  39. 39. Varicose Veins ● Ask if patient in pain ● Inspect legs while patient while on bench and then again standing up ○ Distribution of veins ○ Ulcers ○ Eczema ○ Venous stars, spider veins ○ Lipodermatosclerosis ○ Atrophy blanche ○ Pitting oedema If present check JVP ○ Scars from previous stripping (incision) or radiofrequency ablation (depressed area) ○ Comment on whether origin from long, short saphenous or perforators! ● Palpate ○ For temperature with back of hand (if cold arterial disease may be co-existent), also palpate course of vein. ○ For tenderness, firm areas, pitting oedema (if you find oedema => check JVP) ■ Do not forget gaiter area!! (=areas where skin changes and venous stasis are most likely to occur, where most prominent perforator veins are likely to be found: Lower third of the medial aspect of the leg, immediately above the medial malleolus) ○ Also palpate veins for tenderness and associated oedema ■ Perform direction test where one empties a short section of a vein, by sliding a finger across, then compress vein at two sites and let go of the higher site, watch if it refills. If yes => incompetence. ● Feel for leg pulses ○ Femoral ○ Popliteal ○ Dorsalis pedis ○ Tibialis posterior ● Test cough impulse: ○ Find saphenofemoral junction (2-4cm inferolateral to pubic tubercle, or medial of 1/2way point between ASIS and pubic tubercle) and ask patient to cough. ○ If impulse felt presence of saphena varix. ■ Disappears on lying flat ■ Seen as visible lump in the groin, palpate to distinguish from lymph node
  40. 40. Varicose Veins: ctnd. ● The 'tap test': put finger lightly onto saphenofemoral junction*, then tap on varicose vein lower down the leg. If they are in continuity (i.e.: the valves are incompetent) then you will feel thrilling from the vein to the junction. Thrills are normally interrupted by competent valves, if incompetent, then tapping sends a palpable shock wave up the vein. ● Trendelenburg test, used to assess the competence of SFJ: ○ Lie the patient down, elevate the leg and drain venous blood from the varicose vein ○ Place two fingers on the SFJ (or ask patient to do instead) ○ Ask patient to stand, keeping fingers in place ■ If the veins do not refill until the pressure is removed = “can control refill” → SFJ is incompetent ■ If the veins do refill → SFJ may or may not be incompetent, presence of distal incompetent perforators ■ If the superficial veins fill more rapidly while pressure is applied then there is valvular incompetence below the level where pressure is applied. The veins fill via backflow from the deep veins. ○ Then release fingers ■ Slow refilling: 3-5s (normal), SFJ ■ If there is rapid filling after the pressure is relieved then the communicating veins are competent but the superficial veins are incompetent. ● Tourniquet test ○ Ask patient to lie down and lift up leg ○ Drain venous blood from the varicose vein ○ Apply a tourniquet mid-thigh, and later below the knee ○ Ask patient to stand up ○ Look for refill of the varicose vein – normal is a few seconds ○ If no refill → long saphenous varicose vein incompetent valve. This is confirmed by taking off tourniquet: if a incompetent valve is there, will have a sudden gush filling from above when remove tourniquet. ○ If there is refill → incompetence is lower down the leg. So re-apply tourniquet e.g.: under knee. No refill of varicose vein means that there is short saphenous varicose vein incompetence. If it does refill → perforating vein incompetence lower down the leg ● Perthe’s test (can offer to perform) Note: This is a painful and rarely used test. ○ Place tourniquet at SFJ / high up in the thigh to control superficial reflux. Ask patient to tiptoe. If varicosities improve then there is an incompetent perforator (the three locations where the superficial veins join the deep system) and the deep venous system is functional. Note: The faulty valve is located wherever you occlude the perforators and this controls the refilling of the superficial veins. Confirm with ultrasound.
  41. 41. Varicose Veins: ctnd. ● Auscultate over a large group of veins (if present may indicate an underlying arteriovenous malformation) ○ Patient up ○ Ask them to rapidly stand up and down on their toes – filling of the veins indicated deep venous incompetence. ● To complete my examination, I would like to assess the neurovascular status of the limb and examine the abdomen and chest for signs and causes of increased abdominal pressure. I would also like to perform a duplex US. ● PRESENTATION On examination, I noted the presence of multiple dilated tortuous veins in the [X] leg, in the distribution of the [X] saphenous vein [and precise location]. On inspection, there was [or wasn’t] evidence of venous stasis, erythema, haemosiderin deposition and oedema. There was tenderness and increased temperature on palpation. The [X] test indicated that the incompetent vein was located at [X]. There was [no] evidence of associated complications such as venous ulceration, thrombophlebitis or right heart failure as indicated by a raised JVP. ● Summary ○ Ask about pain ○ Inspect ○ Palpate for temperature and palpate veins ○ Leg pulses ○ Cough impulse ○ Tap test ○ Trendelenburg test ○ Tourniquet test ○ Auscultate
  42. 42. ● Vein anatomy ○ Deep system higher pressure than superficial ○ Backflow prevented by valves ○ If valves incompetent then superficial veins dilate => varicose veins ○ Visual diagnosis ■ Long saphenous: medial ■ Short saphenous: popliteal fossa, then lateral ■ Calf perforators: less visible varicosities but associated pigmentation and lipodermatosclerosis. ○ Common sites (remember variation common!) ■ Saphenofemoral junction (long saph + femoral) in groin 4cm inferolateral to pubic tubercle ■ Short saphenous popliteal vein junction in popliteal fossa Appendix Varicose Veins ○ Perforating veins on medial calf ■ lower, middle and upper (above medial malleolus and 1 and 2 handbreadth above) of continuation of long saphenous vein ■ Medial thigh perforator at long saphenous vein ● Incompetent valve in vein results in backflow of venous blood from cranial to caudal and a column of blood standing in this vein. ● Reasoning of occlusion testing of varicose veins: ○ = you occlude a vein at a particular level, e.g. SFJ, saphenous vein, below knee etc. ○ If this occlusion at this level prevents rapid refilling (all veins will refill slowly via the arterial side, rapid refill is what you are looking for), then it is the occluded structure that is incompetent, or any structure lying above it. ○ If vein still refills, then the incompetent structure lies below the level occluded ● Note that pelvic masses, malignancies and pregnancy can first present with varicose veins => always examine abdomen! ● Treatment ○ “High tie”, tie off SFJ, may not work long term ○ Stripping of veins ○ Avulsion, i.e. tear out vein ○ “Whitely procedure”, obliterate veins ○ Laser and microwave catheters ○ Injection of sclerosing agents Picture from Grey’s Anatomy, 40th edition
  43. 43. Diabetic Review Station ● Diabetic foot examination = peripheral vascular and neurological exam, Dr Clark recommends both should be complete (but don’t to sharp touch/pinprick!) ● Ask patient: any pain? (Btw pain at night is indicative of neuropathies) ● Inspection ○ Look at patient from end of the bed ■ SOB, central cyanosis ■ Signs of hyperlipidaemia: xanthelasmata, xanthoma ■ Look at abdomen: Signs of previous insulin injections (lipidodystrophy) or kidney transplant (hockeystick incision in IF)? ■ Visual aids? Blind patient? ○ Look at surroundings: walking aids, diabetic footwear ○ Look at legs ■ Abnormal perfusion: pallor, cyanosis, mottling, diabetic shin spots/dermopathy, hair loss ■ Previous surgery: scars, amputations ■ Joint abnormalities: charcot joints, pressure ulcers ■ Ulcers, gangrene, bandages (ask to look underneath), diabetic dermopathy / shin spots, necrobiosis lipoidica diabeticorum (indicates poor control), granuloma annulare, candidiasis ■ Feet and toes ● Wedge resection of toe? => need to count toes ● Inspect between toes ● Inspect heels + soles of feet for ischaemic changes ● Look at calluses from altered weight bearing +/- infection ● Palpate ○ Temperature ○ PULSES! ■ On leg: dorsalis pedis, posterior tibial, popliteal, femoral ■ Abdominal aortic aneurysm ■ If time: apex beat, carotid, radial, brachial, radioradial and radio-femoral delay ● Auscultate ○ Femoral artery ○ Abdominal aorta ○ Renal arteries ○ If time: carotid artery ● Ask for BP, mention ABPI and Burger’s test
  44. 44. Diabetic Review Station: ctnd. ● Check reflexes ○ Patella tendon (L3/4) ○ Calcaneal tendon (S1/2) ● Assess sensation ○ Run hands up patient’s leg from distal to proximal ■ Can you feel this? ■ Does it feel the same? ○ Test vibration from distal to proximal ○ Test proprioception ○ Test fine touch with monofilament by dermatome: show it’s bendy so patient does not think it’s a needle ○ Mention that pinprick is another option for assessment of sharp sensation / pain ○ If there is marked glove and stocking neuropathy on the lower limbs, also check the upper limbs ● Can check motor ○ Assess lower limb power for myopathy, proceed proximal to distal ○ If no time: ask patient to get up from chair ● To complete my examination, I would like to ○ Carry out a full peripheral vascular and cardiovascular examination, determine the ABPI, perform fundoscopy and urinalysis and obtain and ECG. ● PRESENTATION ○ Distinguish vasculopath vs. neuropathic patient. Or both? ○ EXAMPLE: I have just examined this patient who was comfortable at rest, and who is using diabetic footwear and a walking aid. I noticed several stigmata of diabetes mellitus, such as diabetic dermopathy and bandages covering multiple [arteria/venous/pressure] ulcers, as well as abdominal lipodystrophy indicating subcutaneous insulin injections. I also noted an arteriovenous fistula indicating end- stage renal disease and/or a hockey-stick incision indicating a previous renal transplant. My most notable findings were ■ A peripheral neuropathy in a glove and stocking distribution to the height of [X], with additional loss of vibrational sense +/- loss of proprioception. Reflexes were [X] and there was/was not an associated myopathy. ■ Absence of pulses in the distal limb such as dorsalis pedis and posterior tibial with associated pallor, cold temperature and reduced capillary refill time indicating peripheral vascular disease. ■ Both neuropathic and vasculopathic features!
  45. 45. Diabetic Review Station: ctnd. ● Further investigations ○ Annual diabetic review = surveillance of complications ■ Review the patient’s home blood glucose charts ■ Full Hx including hypo awareness ■ BP (manage more stringently than in other patients, esp. if kidney involvement) ■ Urinalysis for haematuria, proteinuria, special test strips for microalbuminuria including the albumin-creatinine ratio, best done using morning urine (if so consider ACE-i), exclude infection if ve ■ HbA1c - assess ■ U&Es ■ Annual retinal photography ■ Cardiovascular risk factors ● Lipid profile (consider statins and aspirin for prevention) ■ ECG if considered necessary ■ Carry out ABPI if suspected peripheral vascular disease ● Types of diabetic foot problems ○ Ischaemia => peripheral vascular disease and claudication ○ Peripheral neuropathy => glove and stocking neuropathy (symmetrical sensory polyneuropathy), pressure ulcers, charcot joints ○ Mononeuritis multiplex ○ Autonomic neuropathy: test postural drop in BP, ECG for sinus bradycardia, cystometry, pupils, sexual dysfunction ○ Amyotrophy, motor neuropathy ● Why do patients develop these complications? ○ Pathological causes ■ High glucose concentration results in glucotoxicity, i.e. non-enzymatic glycation of components of the vascular system and formation of advanced glycation end-products (AGE) resulting in production of reactive oxygen species (ROS) causing cellular damage ■ => diabetic microangiopathies which affect kidney and retina, procoagulant effects, activation of PKC leading to neovascularisation, oxidative stress causing neurotoxicity, potentiation of atherosclerosis. ○ Practical causes ■ Diabetic control not good due to lack of compliance in treatment, either regarding diet, medication or lifestyle (smoking), resulting in sustained hyperglycaemia ■ Diabetic control can never be as good as in the physiological case (unless perhaps using an insulin pump which can achieve better control due to possibility of smaller increments of units of insulin administration) resulting in transient hyperglycaemia
  46. 46. Diabetic Review Station: ctnd. ● Management of diabetic foot ○ Regular assessments ○ Patient education ■ Avoid walking barefoot ■ Test temperature of bathwater with elbow before entering ○ Nail care and medical chiropody ○ Diabetic footwear ○ Medical: paracetamol for pain, TCA and gabapentin for neuropathic pain, pain ladder, opiates if severe, bisphosphonates for charcot joint ● Diabetic Retinopathy ○ Causes: leaky vessels (e.g. due to aneurysms or microangiopathy) causing bleeding and exudates, narrowed or occluded vessels causing ischaemia and proliferation/angiogenesis which then causes more bleeding, leakage. Bleeding can cause vitreous haemorrhage and retinal detachment. ○ NATIONAL SCREENING COMMITTEE CLASSIFICATION ■ R0 = no DR ■ R1 = mild non-prolif. or pre-prolif microaneurysms, haemorrhage ■ R2 = moderate-severe non-prolif or pre-prolif hard exudat., CWS, beading, IRMA ■ R3 = proliferative, pre-retinal fibrosis and tractional retinal detachment ■ M0 = no maculopathy ■ M1 = diabetic maculopathy ○ Background retinopathy (non-proliferative) ■ Microaneurysms ■ Haemorrhages ■ Hard (lipid) exudates ○ Pre-proliferative retinopathies ■ IRMA intraretinal macrovascular abnormalities ■ Cotton wool spots (CWS) ■ Venous beading ■ Haemorrhage ○ Proliferative retinopathy ■ New vessels at disc (NVD) ■ New vessels elsewhere (NVE) ○ Maculopathy => reduces visual acuity ■ Microaneurysms ■ Haemorrhage ■ Exudates ■ Oedema ○ Also: cataract, rubeosis iridis = neovascularisation on iris, can cause glaucoma ● Comparison with hypertensive retinopathy ○ Arteriolosclerosis and narrowing ○ Flame haemorrhages due to capillary damage - superficial ○ Dot haemorrhages due to leakage ○ Blot haemorrhages due to ruptured aneurysms - deep ○ Cotton wool spots = swollen axonal endings ○ Exudates due to vascular leakage ○ Optic disc swelling ○ Arterior macroaneurysms, microaneurysms ● Treatment of diabetic retinopathy ○ BP and glycaemic control ○ Lipid modification ○ Smoking cessation ○ Diagnose proliferative disease with fundus fluorescein angiography FFA ○ Intraocular ranibizumab for proliferative disease ○ Interventional: Panretinal photocoagulation (PRP, converts NVD to NVE), macular laser therapy, vitrectomy.
  47. 47. Hernia Examination ● Patient should be stood up, preferably on a step, with legs exposed. ● Ask about pain ● Inspect ○ Swellings on either side of the groin ○ Asymmetries/swellings within the scrotum ○ Groin creases for sinuses/fistulae/erythema/obvious swellings ● Palpate ○ HERNIA ■ Palpate from the side, see if you can get below lump. Does it extend to scrotum? ■ Describe the lump and surrounding skin (see lumps/bumps examination sheet) ● A hernia below and lateral to the inguinal ligament is a femoral hernia. ● A hernia above and medial to the inguinal ligament is an inguinal hernia. ● If this is not obvious, see where hernia emerges from upon coughing after reducing it and placing finger on pubic tubercle. ■ Always also palpate other side! ■ Test for cough impulse bilaterally ○ SCROTUM - offer to examine! ■ Testicle ■ Cord ■ Masses ● Can you get above the mass? ● Is it separate from the testicle? ● Does it transilluminate? Is it tender? ● Describe, as for any lump/bump ■ Perform the cremasteric reflex by transversely stroking the inner thigh with the index finger, and watch the ipsilateral testicle ascend within the scrotum. ● Ask patient to sit down ● Percuss and ausculate for bowel sounds over hernia ● Reduce hernia ○ Ask the patient to reduce the hernia him/herself. If unable to, try to reduce it yourself, using the flat of the hand and moving towards the opposite shoulder. You may need to apply some pressure, but note the patient’s level of discomfort as you do this. ○ For Inguinal Herniae: ■ Press firmly over the internal inguinal ring, holding the hernia reduced. ○ Cough test ■ Ask the patient to cough while palpating both sides. ■ Is it controlled? ● Yes = INDIRECT inguinal hernia ● No = DIRECT inguinal hernia ■ Does “normal side” present with hernia while abnormal side controlled? Reduction of one may make a smaller hernia on the contralateral side appear due to increased abdominal pressure. ■ Release the pressure & let the patient cough again. Hernia will re-appear.
  48. 48. Hernia Examinationctnd. ● To complete my examination, I would like to perform: ■ An abdominal examination, ■ a contralateral groin examination and an ■ examination of the external genitalia. ● PRESENTATION ■ “This patient has a [X] cm smooth lump in the [X] groin exhibiting a cough reflex with no upper border (i.e. you cannot get above it) and producing audible bowel sounds. The lump is [reducible/irreducible/strangulated] and emerges [X] to the pubic tubercle, suggesting that it is a [X] hernia. Pressure on the deep inguinal ring [controls] the emergence of the hernia, suggesting that it is [an indirect inguinal hernia]. There [are/are no] signs of complications such as tenderness and erythema, strangulation or signs of bowel obstruction."
  49. 49. Hernia Examination: Appendix ● DD of lump in the groin ○ Hernial orifices ■ Inguinal hernia ■ Femoral hernia ○ Testicular apparatus ■ Undescended testicle ■ Encysted hydrocoele of the cord (can get above it) ■ Ectopic testis ■ Lipoma of the cord ○ Local structures ■ Lymphadenopathy of inguinal lymph node(s) below the inguinal ligament due to infection, lymphoma, neoplasm ■ Saphena varix, i.e. dilated varicose vein at the sapheno-femoral junction (inferior to femoral canal), disappears on lying flat ■ Femoral artery aneurysm (pulsatile) ■ Abscess in psoas sheath ■ Lipoma ● Reasons for hernia being irreducible ○ Adhesions ○ Size of contents greater than the neck ● Features of strangulation ○ Severe pain in hernia ○ Colicky abdominal pain and tinkling bowel sounds from obstruction ○ No cough impulse ● Local anatomy ○ Midpoint of the inguinal ligament (½ between ASIS and pubic tubercle): deep ring of inguinal canal ○ Mid-inguinal point (½ between ASIS and pubic symphysis): location of the femoral artery ○ VAN: femoral vein, artery, nerve, from medial to lateral ○ Indirect hernia, emerges laterally to the inferior epigastric artery ○ Hence a direct hernia emerges medially to the inferior epigastric artery. through a weakpoint termed Hesselbach’ s triangle, med. to inf. epig. a. and lat. to rectus abdominus) ○ Structures entering deep ring: vas, 3 arteries (artery to vas, testicular artery, cremasteric artery), veins (cremasteric vein, testicular vein), genital branch of genitofemoral nerve, sympathetics, obliterated processus vaginalis ○ Structures joining in the inguinal canal: internal spermatic fascia, cremasteric fascia, cremaster, ilioinguinal nerve ○ Structure joining on exiting the superficial ring: external spermatic fascia ○ Layers of the testes (outside - in): skin, dartos, Colle’s fascia, external spermatic fascia, cremasteric fascia, internal spermatic fascia, tunica vaginalis, testis. ○ The femoral triangle is a subfascial space of the upper thigh bordered laterally by the sartorius muscle, medially by the adductor longus muscle and superiorly by the inguinal ligament, which continues as the sharp-edged lacunar ligament medially. It contains the femoral nerve laterally, the femoral artery and femoral vein more medially, as well as the femoral canal, which contains lymph nodes (Cloquet’s node) and fat and passes lymphatics from superficial to deep. The femoral artery, vein and canal are embedded within the femoral sheath in three compartments. The femoral sheath is a tunnel-like continuation of the fasciae lining the abdomen. ○ A weakness in the femoral canal can result in viscus passing through where it is at particular risk of strangulation due to the sharp edges of the lacunar ligament.
  50. 50. Examination of the Male Genitalia ● Can you get above lump? (if not = hernia) ● Is the lump part of the testis? ● Does lump transilluminate? (if not => more likely to be CA) ● Is there tenderness? ● Solid lump suggests malignancy ● Hydrocoele testes usually not palpable and excellent transillumination ● Epidydimal cyst DD (also transilluminates, palpable separately to testes) ○ Spermatocoele (indistinguishable clinically) ○ Solid lumps following epididymitis ○ Varicocoele ○ Hydrocoele ○ Testicular tumour ● Epidydimal cyst treatment ○ Sclerotherapy ○ Surgical removal ○ Aspiration not useful ● Varicocoele, palpable as “bag of worms, more prominent upon standing. Ass. with infertility due to raised T?. Cause: reflux from L gonadal vein, renal CA. Mx conservatively or surgically or embolisastion XY
  51. 51. Stoma Examination ● Inspect patient ○ Surroundings ○ General conditions ○ Stigmata of abdominal disease ○ Hydration status (ileostomies can result in significant fluid losses) ○ Abdomen: scars? => type of stoma? hernias? esp. parastomal ● Examine Stoma ○ Site ■ RUQ => transverse colostomy flush spout ■ RLQ => ileostomy raised spout ■ LUQ => usually not put here, if so then LLQ types ■ LLQ => end, loop, double-barreled colostomies ○ Number of openings and calibre ■ 1 => end, loop ■ 2 => double-barreled loop, 2 separate stomas ■ Urostomy < ileostomy < colostomy ○ Contents of stoma bag ■ Liquid stool => ileostomy ■ Solid stool => colostomy ■ Urine => urostomy, “ileal conduit” ○ Spout ■ Integrity of intestinal/mucosal and surrounding skin ■ Evidence of prolapse, retraction and other complications ○ Palpate stoma and the lumen(/ina) ● Mention to examine perineum and anus to determine what type of stoma
  52. 52. Appendix Stoma Examination ● Stoma Artificial connection between conduit and outside ● Types of stoma ○ Loop Loop of colon brought up, temp. secured with rod ○ Double barrelled Loop colostomy with two holes and double stoma ○ End Proximal end brought up ○ Mucous fistula Bringing up of distal bowel end ○ Paul Mikulicz Double-barreled with two separate stomas ○ Ileostomy Raised stout with prominent mucosal folds ○ Colostomy Flat ”flush” stout ○ Permanent vs. defunctioning to protect distal bowel, e.g. to allow anastomosis to heal ○ Urostomy/ileal conduit After total cystectomy, attach ureters to detached section of the ileum with or without valve. ○ Gastro-jejunostomy Type of gastric bypass ○ Percutaneous endoscopic gastrostomy To allow tube-feeding ● Types of bowel resection ○ (Ensure good blood supply to cut ends, usually resect all that is supplied by the vessels supplying the part to be removed) ○ Proctocolectomy Removal of colon, rectum and anus ○ Total colectomy with ileostomy and mucous fistula of the rectum (unless oversewn) or later creation of ileal reservoir (ileoanal pouch) ○ Right, left hemicolectomy, transverse hemicolectomy, extended right hemicolectomy (incl. transverse colon) ○ Sigmoid colectomy ○ Hartmann’s Resection of sigmoid with temporary end colostomy that is later rejoined ○ Anterior resection Partial removal of rectum with anastomosis +/- temporal (ileal) stoma ○ AP resection (Abdominoperineal) Removal of the rectum and anus and permanent end colostomy, performed with two incisions. ○ Total anorectal reconstruction Create electrically stimulated or artificial mechanical sphincter after AP excision of the rectum ● Complications ○ Early ■ Haemorrhage ■ Ischaemia ■ Retraction ■ Obstruction ■ Side-effects of high output => e.g. hypokalaemia ○ Later ■ Psychological problems ■ Dermatitis ■ Obstruction ■ Prolapse, intussusception, stenosis, fistulae ■ Parastomal hernia ● Indications ○ Diversion of contents ○ Exteriorisation of bowel without distal end ○ Decompressing and/or relieving obstruction ○ Lavage ○ Feeding
  53. 53. Breast Examination ● Ask if patient would like chaperone, ask about pain ● Be “polite but ruthless” in terms of exposure for inspection ● Patient sits at side of bed ● General observation ○ General appearance - cachexia, pallor, SOB ○ Signs of previous surgery - wide local excision, mastectomy, reconstruction ○ Signs of previous radiotherapy - radiotherapy marks, scarring, depigmentation ○ Signs of infection - redness, erythema, abscess ○ Signs of malignancy - skin dimpling, peau d’orange, nipple retraction, ... ○ Nipples ■ Discharge, e.g. lactation, blood (duct ectasia, intraductal papilloma) ■ Rash (e.g. in Paget’s, DCIS underlying nipple, peau d’orange) ■ Inversion of nipples ■ Accessory nipples ○ Supraclavicular area and axilla - swellings, nodes, veins, muscle wasting ● Inspect breasts ○ Ask if pain when moving arms ○ Watch breasts as arms behind head – invasion of lig. of Astley Cooper* arms behind back – invasion of pec major / chest wall ○ Tethering or fixation during these movements indicates T4 disease. ○ Ask about discharge and if present ask patient to demonstrate it ● Continue with patient lying flat with hands behind the head ● Cover patient and expose body only those parts needed. Start on NORMAL side! ● Check inframammary fold with back of hand ○ I am now examining under the breast ○ Most common finding: intertrigo – chronic thrush under breast ● Palpate 5 areas of the breast and axilla and nodes ○ Axilla: if examining L, hold pt’s L hand with your L hand and palpate with your R and vice versa. Ask patient to lift arm up, place your hand in axilla, support pt’s arm with your arm, then roll fingers down axilla in all directions: post, ant, sup, inf. Whenever you feel a lump, note if it is fixed or not. ○ Palpate with flat fingers, don’t prod (even the mannequin!) , move all around breast ○ Upper outer quadrant ○ Upper inner quadrant ○ Lower inner quadrant ○ Lower outer quadrant ○ Alveolar complex ○ Remaining lymph nodes: infraclavicular, supraclavicular, neck ● Cover patient
  54. 54. Breast Examination: Appendix ● Palpate for an enlarged liver ● Ausculate the lung bases ● To complete my examination, I’d like to perform a full abdominal and respiratory examination and complete the triple assessment by performing a mammogram and fine needle aspiration. I’d also like to send off any discharge for cytology and acquire a chest X- ray. ● PRESENTATION ○ I have just examined [X]. On inspection, I noted [X]. My most notable finding was a tender/non-tender [X cm] lump in the [X] quadrant of the [X] breast. It had a [X] surface and a [X] edge, is mobile/immobile and not/attached to [X]. There are [X] palpable in the axilla [continue describing size, consistency and mobility if found]. There are [X] nodes palpable in the supraclavicular fossa / other sites. My differential diagnosis is [X] based on the age of the patient, the most likely diagnosis is [X].
  55. 55. Breast Examination ● Components of triple assessment: ○ Clinical Hx/Ex => done ○ Radiological Mammography and US ○ Pathological Fine needle aspiration => cytology and core biopsy ○ MRI if younger patient or discrepancy between clinical assessment and mammography or when planning breast conserving surgery ● Note main DD has 4 choices (Mannequin does not have an inflammatory lesion and has 2 lumps to palpate, the nature of the benign diagnosis depends on age of patient) ○ Inflammatory lesion ■ Usually painful and non-cyclical ○ Fibrocystic lesion ■ Women >30 ■ Changes with cycle ○ Benign neoplasm, e.g. fibroadenoma ■ Women <30! ■ Changes with cycle ○ Malignant lesion ■ Painless lump ■ More likely in upper outer quadrant? ● DD of breast discharge ○ Ask if spontaneous or on squeezing ○ Orange watery fluid from single duct Intraductal papilloma ○ Bright red blood from single duct Papilloma or malignancy ○ White or green discharge from multiple ducts Benign ○ Bilateral milky discharge Galactorrhoea ● Note on axillary nodes ○ 25% of palpable node will not contain metastases ○ 25% of nodes containing metastases are not palpable
  56. 56. Neck/Thyroid Examination ● Note: This an attempt to combine general neck and medical/surgical thyroid examination ● Patient sits on chair ● Inspect ○ General ■ Appearance and weight ■ Signs of autoimmune disease, e.g. vitiligo ■ Signs of hyperthyroidism ● Eye signs ○ Exophthalmos, lid retraction, lid lag, ophthalmoplegia**, chemosis* ○ Periorbital oedema ● Tremor ● Myxoedema ■ Signs of hypothyroidism ● Coarse facial features ● Dry skin, pallor ● Loss lateral eyebrows ● Hair loss ○ Goitre or other lump on neck, comment on symmetry ○ Scars on the neck ○ Facial nerve palsy ● Hands Can start with hands if thyroid exam unless examiner says proceed to the neck, if neck exam then proceed to the neck immediately ○ Temperature and sweating ○ Palmar erythema ○ Nails ○ Thyroid acropachy - subperiosteal new bone formation on hands ○ Carpal tunnel syndrome (hypo) ○ Tremor ○ Palpate Pulse ● Observe neck while patient is ○ Protruding the tongue ■ Does potential lump move? => Thyroglossal cyst will move ■ Observe for lingual thyroid ■ Shine light into mouth to observe for lingual thyroid ○ Swallows while drinking a glass of water ■ Ask patient to drink and swallow when asked ■ Does potential lump move? => Goitre will move ■ Is inferior border of potential lump visible during swallowing? ● Ask about pain and dysphagia => involvement of oesophagus
  57. 57. Neck/Thyroid Examination: ctnd. ● Assess hoarseness: Ask patient to count from 1-10 => recurrent pharyngeal nerve ● Palpate neck from behind ○ Palpate the triangles of the neck (demonstrate/talk through subdivisions, not just ant+post!) ○ Lymph nodes and salivary glands ■ Sub-mental ■ Sub-mandibular ■ Pre- and post. auricular ● If swelling of parotid gland, palpate inside of mouth to see if deep lump ● Offer to check facial nerve function if suspected parotid lump ● Note what lymph nodes are also present around the gland => DD ■ Ant. and post. cervical chain ■ Occipital ○ Thyroid ■ Both lobes and isthmus ■ Comment on size, shape and consistency, symmetry mobility, tenderness ○ Ask patient to swallow again and feel thyroid/lump during swallowing ○ Supra- and infraclavicular regions ○ Palpate for position of the trachea ● Percuss over sternum to assess retrosternal extension of thyroid/lump (dullness) ● Auscultate over thyroid and lump for bruits indicating increased vascularity ● Assess eyes and eye movements ○ Check for proptosis (ideally from above) ○ Check eye movements ○ Check for lid lag (proptosis and lid lag = exophthalmos) ● Assess legs ○ Palpate shins for pretibial myxoedema (above lateral malleoli) ○ Check reflexes! (Look for slow relaxation if hypo and brisk if hyperthyroid) ○ If you suspect thyroid disease, also assess for presence of myopathy, e.g. by asking patient to stand up from chair ● Assess for thoracic inlet syndrome ○ JVP ○ Offer Pemberton’s test ● Offer to test sensation and neck movements (if you know dermatomes and innervation)
  58. 58. Neck/Thyroid Examination: ctnd. ● To complete my examination, I would like to perform a ○ neurological, ○ cardiovascular and ○ respiratory examination and ○ carry out an ultrasound of the thyroid. ● PRESENTATION: ○ I have just examined [X]. My most notable finding was a [X] cm lump [X]cm from the midline in the [X] triangle / or a diffusely enlarged thyroid gland. The lump was [consistency, i.e. nodular vs smooth; borders, mobility, transillumination]. It did/did not extend retrosternally or was/was not associated with a bruit. There was/wasn’t any associated lymphadenopathy. ● In neck: distinguish single nodule, multinodular, diffuse enlargement of thyroid
  59. 59. Neck Appendix: Anatomy ● Triangles of the neck ○ Anterior Borders: Midline, mandible, sternocleidomastoid ■ Sub-mental/suprahyoid ■ Muscular/inf. carotid ■ Sub-mandibular Carotid/sup. carotid ○ Posterior Borders: Sternocleidomastoid, clavicle, trapezius ■ Occipital ■ Supra-clavicular ● Brachial plexus surface anatomy ○ Erb’s point: Location of upper trunk of brachioplexus 2-3cm superior to clavicle ○ Also (don’t know if that refers to the same location) post. border of middle of sternocleidomastoid muscle where cutaneous branches of cervical plexus emerge ● Lymph node drainage ○ Oral cavity => submental ○ Oropharynx => upper neck ○ Larynx => middle neck ○ Hypopharynx, thyroid => lower neck ○ Post. nasal space, scalp, thyroid => post triangle Most likely to be node, consider CA if older
  60. 60. Neck Appendix: DD ● Describing the features of a lump: she cuts the fish 3x + PER ○ Site, size, surface ○ Colour, contour, consistency, compressibility ○ Tenderness, temperature, transillumination ○ Fluid-filled, fixed (tethering vs. fixation), fields (lymphatic drainage) ○ Pulsatile ○ Expansile ○ Reducible + DEPTH ○ In neck: distinguish single nodule, multinodular, diffuse enlargement of thyroid ● DD of neck lumps categorised by features or locations ○ In general, consider origin from ■ Lymph nodes ■ Salivary glands ■ Endocrine = thyroid ■ Embryological!!!!! ■ Vascular: lymphangioma/cystic hygroma ■ Neurological ■ Infectious => abscess, dental abscess ■ Neoplastic => carotid body tumour, lymphoma ○ Move on swallowing ■ Thyroid ■ Thyroglossal cyst - embryological remnant of thyroglossal duct MIDLINE! ○ Does not move on swallowing ■ Salivary gland, e.g. in submandibular triangle. ■ Branchial cyst (sup. carotid or submandibular), cystic hygroma / lymphangioma (base of post. triangle), usually 20-30y old but still be suspicious about CA ○ Moves when tongue protruded Thyroglossal cyst - hard, spherical, often submental ○ Midline ■ Thyroglossal cyst ■ Thyroid isthmus nodule ■ Tooth abscess ○ Anterior triangle ■ Lymph node ■ Salivary glands ■ Branchial cyst - failure of obliteration of 2nd branchial cleft Can also call it lateral cervical cyst as actual embryological origin now unclear! Can also be 1st branchial arch which would be located near the angle of the jaw. Ant to upper Sternocl.mst. so submandibular/sup. carotid triangle, smooth, cystic (filled with pus-like material high in cholesterol => xtals under microscope!), does not transilluminate, 2-3% bilateral. Can distend later in life even though present from birth. Branchial sinus is an opening at ant. border of lower sternocleidomastoid between int+ext carotid arteries (if into tonsillar fossa then branchial fistula)
  61. 61. Neck Appendix: ctnd. ● Anterior triangle ctnd. ■ Cold abscess ■ Carotid body tumour - chemodectoma or paraganglioma Bilateral in 5-10% of patients, pulsating, 10% malignant, 5% spread. May be familial, syndromic: MENII, von Hippel-Lindau, NF type I. Examine cranial nerves (IV upwards) or consider post-op. complication if scar “Goblet sign” on angiography: splaying on part of the carotid bifurcation! If syndromic exclude phaeochromocytoma. TRANSMITS THE CAROTID PULSATION OR HAS BRUIT +/- cr. n. palsies Hard to palpate just near hyoid bone. Note hyoid moves when tongue protrudes but not much on swallowing. Called “Potato tumours” due to consistency. Clinically very hard to distinguish from enlarged lymph node! ■ Carotid aneurysm ■ Laryngocele - air-filled space communicating with the larynx, made worse by blowing. ○ Posterior triangle ■ Lymph node ■ Pharyngeal pouch - embryological remnant ■ Cystic hygroma/lymphangioma - swelling of jugular lymph sac, base of post. triangle, transilluminates, most common on the L Examine mouth, larynx and trachea and hypopharynx as can obstruct! ■ Cervical rib ■ Subclavian artery aneurysm ■ Reconsider branchial cyst even if ant. triangle more likely ○ Skin ■ Sebaceous cyst ■ Dermoid cyst ■ Abscess ■ Lipoma ○ Babies after birth trauma ■ Sternocleidomastoid tumour: head turned away from swelling but tilted towards the lesion ● Thyroid lumps ○ Thyroid lumps are common ○ Benign lumps common ○ Malignant lumps rare (<1% of solitary nodules) ○ Clinical criteria that make lump more likely to be neoplastic ■ Solitary (solitary => neoplasm, benign or malignant) ■ Nodules in young people ■ Nodules in men ■ Hx of radiation treatment ■ “cold nodule” has 10% chance of malignancy ○ More likely to be benign ■ Multiple nodules ■ “hot nodules” = take up radioactive Iodine
  62. 62. Neck Appendix: ctnd. ● Thyroid lumps ctnd. ○ Diffusely swollen ■ Grave’s ■ Hashimoto’s ■ Multinodular goitre, but nodules not palpable. Note: nodular means endocrine impairment more likely ■ Subacute thyroiditis ○ Multiple nodules in thyroid ■ Multinodular goitre (likely in exams) ■ Multiple cysts ■ Multiple adenomas ○ Solitary nodule in thyroid ■ Cyst ■ Tumour ● Benign or malignant ● 1* v. 2* ■ Dominant single nodule in multinodular goitre ● Salivary gland lumps ○ Consider if: ■ Diffuse, bilateral, changes in overlying skin, pain, +facial nerve palsy, involvement of the oral cavity, palpable stones, associated systemic conditions ○ Parotitis (+pain) or sialadenitis ○ 80% of salivary gland tumours are in the parotid and 80% of p. tumours are benign, 50% of submandibular tumours benign ○ Parotid tumour ■ Pleomorphic/mixed adenoma (benign, commonest, may recur) ■ Adenolymphoma/Warthin’s tumour ■ Adenoid cystic carcinoma = malignant +/- VII palsy, hard on palpation, mucoepidermoid, 2* tumour ○ Salivary calculus(sialolithiasis) causing local swelling ■ Confirm with sialogram = contrast in salivary duct + plain X-ray
  63. 63. Neck Appendix: Scars Incisions for radical neck dissection A Congenital sinus B Carotid tumour/branchial cyst B1 Congenital sinus lower segment C Oesophageal diverticulum D Scalenotomy, phrenic nerve crush E Submental abscess drainage F Thyroglossal cyst/sinus excision G Cricothyreotomy I Thyroidectomy J Cervical abscess drainage K Int/ext. carotid exposure L Common carotid exposure M Brachial plexus/subclavian a exp. Further investigations ● FBC - lymphocytes to rule out lymphoma, AOCD ● TFTs - thyroid abnormalities, +/- thyroid autoantibodies ● LFTs - liver mets? ● U&Es - Ca2+ of malignancy ● CRP/ESR - inflammation, lymphoma ● If suspect medullary carcinoma: electrophoresis for calcitonin amyloidosis ● Other special: somatostatin, 5-HT, VIP levels, red gene => if present prophylactic thyroidectomy. ● Thyroid US with US-guided FNA of lump (FHY1-5 classification?) ● Thyroid radioisotope scan to identify hot nodules ● Transnasal laryngoscopy ● (Hemithyroidectomy if in doubt for histological analysis) ● Sialogram ● MRI/CT endoscopy ● Arteriography of carotid bifurcation ● PET ● Node: Always FNA NOT excision biopsy as usually not curative on its own if node
  64. 64. Lump Examination ● Note: This attempts to combine examination of a lump with that of lymph nodes ● Patient sits on chair ● Inspect ○ General inspection ■ Number of lumps ■ Previous scars ■ Signs of infection: fever, erythema, oedema, lymphangiitis ○ Lump/node ■ Site, lymphatic drainage ■ Size ■ Depth ■ Colour ■ Pulsatility ■ Expansibility ■ Reducibility ■ If node: matted or discrete ● Palpate ○ Surface: incl. skin overlying lump ○ Contour ○ Consistency ○ Tenderness ○ Temperature ○ Palpate lymph nodes at drainage site of lump! ○ If you suspect it is a lymph node, palpate sites of nodes ■ Cervical nodes ■ Axillary nodes ■ Epitrochlear nodes: superomedial to med. epichondyle of humerus ■ With patient lying flat ● Inguinal nodes ● Popliteal nodes
  65. 65. Lump Examination: ctnd. ● Move ○ Fixation ○ Tense underlying muscle to see if tethered to it ● Transillumination ● Percussion ● Auscultation ● If suspecting it’s a lymph node: ○ Assess other lymph nodes for general lymphadenopathy ○ Assess abdomen with patient lying flat ■ Hepatomegaly ■ Splenomegaly ■ Assess area of lymphatic drainage leading to the enlarged lymph nodes in question, e.g. limbs, scrotum, abdomen ● If you suspect parotid lump, look and feel inside mouth and test facial nerve function. ● To complete my examination, I’d like to: ○ Assess the neurovascular status: dermatome, myotome, blood supply ○ Other ● PRESENTATION
  66. 66. Skin Examination ● Arrange for chaperone! ● Ask if patient in pain. ● Equipment ruler, magnifying glass, dermatoscope ● General inspection ○ Skin type and pigmentation ○ Hair growth pattern and pigmentation ○ Symmetry of condition ○ Sun damage pattern ● Examine lesion pointed out by patient ○ Size, size, surface ○ Colour, contour, consistency ○ Tenderness, temperature, transillumination ○ Pulsatility ○ Expansile ○ Reducibility ○ Palpate superficially and deeper (between finger and thumb) ○ Palpate lymph nodes draining the region ● Scalp ○ Feel ○ Inspect by parting the hair ○ Look for edge of the rash ○ Hair ■ Baldness ■ Excess hair ■ Unusual thickness or twistiness ■ Distribution ○ Scarring ● Hands ○ Wrists (=> scabies) ○ Fingers ○ Nails ● Arms, axillae, neck ○ Flexures: axillae, antecubital fossae ○ Elbows (=> psoriasis)
  67. 67. Skin Examination: ctnd. ● Face ○ Sun damage ○ Any sign of skin cancer ○ Hair growth (including eyelashes and eyebrows) ○ Mucosal surfaces of eyes ○ Mouth and lips ○ Look into mouth, inspect tongue and inside cheeks, looking for mucosal involvement ● Ears ○ External pinnae ■ Inspect for ● Solar damage ● Scaliness (=> seborrhoeic dermatitis) ● Tender areas with ridges (=> chondrodermatitis) ○ External auditory meatus ■ Psoriasis, eczema ● Trunk ○ Chest ○ Nipples ○ Abdomen and umbilicus ○ Back ○ Buttocks ○ Flexures (=> intertrigo) ● Genitalia, perineum, groins, peri-anal skin ● Legs ○ Flexures ○ Knees (=> psoriasis) ○ Lower legs (=> varicose veins) ○ Ankles (=> venous eczema) ● Feet ○ Soles (=> pustular psoriasis) ○ Toe webs (=> fungal infection) ○ Toenails
  68. 68. Skin Examination: ctnd. ● Note the distribution of all lesions identified ● Can do scratch test (or ask the patient to), if profuse silver scale => psoriasis ● To complete my examination, I would like to examine any skin lesions with a dermatoscope, analyse any skin scrapings or nail clippings for fungi, send of skin swabs for microscopy, culture and sensitivity. ○ In the case of atypical naevi, can mention respiratory examination. ○ In the case of psoriasis, can mention joint examination. ○ In the case of NF1, can mention fundoscopy, visual acuity (optic glioma) and head CT/MRI (optic glioma, sphenoidal dysplasia), BP and 24h urine collection for catecholamines (phaeochromocytoma) ● PRESENTATION: Describe the lesions ○ Number ○ Size ○ Distribution ○ Arrangement ○ Type (macule, papule, nodule, vesicle, bulla, rash) ○ Colour ○ Pigmentation ○ Morphology ■ Shape ■ Pattern ■ Symmetry ■ Surface ■ Edges/Border ○ Consistency ○ Summarise, likely diagnosis ○ Prepare presentation for neurofibromatosis type 1.
  69. 69. Skin Lesions Appendix ● General morphologies of skin lesions ○ Macular Flat <1cm macule < patch ○ Patchy Macular >1cm papule < plaque ○ Papular Raised < 5mm vesicle < nodule ○ Wheal Oedematous papule, white with red border ○ Maculopapular Flat and raised, may be confluent (measles) ○ Nodular Raised and >5mm ○ Cyst Epithelial-lined fluid filled cavity (nodule) ○ Plaque Raised and >2cm (or diameter > thickness) ○ Vesicle Visibly fluid filled <5mm ○ Bulla Visibly fluid filled >5mm ○ Pustule Pus filled ● Surface morphologies of skin lesions ○ Scaly With thickened keratin ○ Desquamated Loss of epithelial cells, can be in combination with scaly ○ Crusty With accumulated dried exudate ○ Horn-like Elevated projection of keratin ○ Lichenification Epidermal thickening ○ Ulcerated Skin loss ○ Eczematous Epidermal breakage ○ Eroded Break in the epidermis not extending to dermis ○ Excoriated Superficial ulceration from scratching ○ Macerated Surface softening due to wetting ○ Purpuric, petechial Subdermal bleeding ● ABC of Melanoma ○ Asymmetrical shape ○ Border irregularity ○ Colour irregularity ○ Diameter >7 mm ○ Evolution of lesion (e.g. change in size and/or shape) ○ Symptoms, e.g. bleeding, itching
  70. 70. Skin Lesions Appendix ctnd. ● DD of skin lesion ○ Pigmented lesions ■ Benign naevus ■ Malignant melanoma ■ Basal cell carcinoma ■ Squamous cell carcinoma ■ Bowen’s disease (SCC in situ) ■ Kaposi sarcoma ○ Benign skin lumps ■ Keloid scars ■ Lipoma ■ Neurofibroma ■ Sebaceous cyst ■ Carbuncle ■ Hydratenitis suppurativa ■ Papillomas ■ Vascular malformations ● Cherry angiomas ● Port wine stains ● Strawberry naevi ● Cavernous haemangiomas ● Venous lakes ● Glomus tumours ● Pyogenic granulomas ○ Always consider in skin lumps ■ Superficial lumps ● Sebaceous cyst Central punctum, round, soft, fluctuant ● Lipoma Soft, mobile, painless, smooth, demarcated in layer where you would expect fat, may be fixed to muscle, especially over scapula, may be fluctuant if fat liquid in warm skin, Dercum’s if many ● Abscess Pain, swelling, erythema ● Dermoid cyst At sites of embryological fusion, e.g.near eyebrow of child, under tongue, at midline. ■ Lymph node Firm, mobile, can be tender ● If glass eye and enlarged liver: consider melanoma in choroid of eye
  71. 71. Ear ● Ask patient if hearing impaired or pain ● Start with the unaffected ear ● Inspect ○ Inspect pinna and periauricular area, incl. behind ear and skin for sun-related changes ○ Congenital abnormalities: accessory auricle, preauricular sinuses, microtia ○ Surgical incisions ○ Ear canal ■ Hold auroscope by placing fingers between auroscope and the patient’s face using your L hand when inspecting the L ear, touch patient’s face with your little finger to give stability and prevent injury to the patient’s ear canal ■ Straighten by pulling ear posteriosuperiorly and insert otoscope carefully into external auditory meatus ■ Wax, discharge, swellings? ■ Foreign body ■ Ear drum ■ Tympanic membrane ● Light reflex ● Integrity ● Observe all quadrants of the membrane, as well as the attic area ● Handle of malleus, parse tensa, parse flaccida ● Presence of grommet ■ Signs of infection ■ Bony swellings: exostoses (more common in surfers due to cold!) and osteomas ● Assess hearing ○ Whisper into ear while other meatus occluded - establish that patient hears ○ Rinne’s test for comparison of air vs. bone conduction - cond. still intact? ■ Tuning fork at 510 Hz (C above standard A/440Hz) ■ Place on mastoid process behind each ear and then outside of pinna, ask what was heard louder ○ Weber’s test to distinguish conductive vs. sensorineural hearing loss ■ Tuning fork at 256 Hz (~H below middle C) on ■ Place on top of head equidistant from hears ■ Can sound be heard? Symmetrical? Which side louder? ● Assess vestibular function ○ Rhomberg test - Patient stands with arms outstretched to the side, closes eyes: does patient fall over towards one side? If so, the labyrinthine system on that side is affected. ○ Hallpike test - First explain procedure, then: Patient sits on bench with legs extended, then lie them down and turn the head to the side (45* and 20* extension), observe for nystagmus. Then turn to other side, observe, sit back up, observe. Rotational / torsional nystagmus: benign paroxysmal positional vertigo. ○ Unterberger test - Patient attempts to walk with high knees on the spot with arms outstretched. Does patient actually walk forward or turn? Suggests labyrinthine lesion.
  72. 72. Nose ● lnspect the bony and cartilaginous parts of the nose from the front by covering the top and lower halves, respectively, to detect deviation ● Place metal object (e.g. tongue depressor) under nose and watch for mist development (=> intact nasal flow) ● Ask patient to sniff to demonstrate potential collapse of the nasal ala ● Assess symmetry of the entrance to the nasal cavity (gently push up tip of nose with the thumb) ● Inspect the inside with an otoscope (or use torch light) ○ Presence of polyps? ○ Septal deviation? ○ Septal perforation? ● If there is discharge, suggest to take a swab ● Assess sensation around the distribution of the maxillary division of the trigeminal nerve ● Assess or inquire about sense of smell
  73. 73. Mouth + Throat ● Inspect oral cavity ○ Buccal mucosa ○ Parotid duct orifice (opposite 2nd upper molars in cheek) ○ Teeth ○ Gingiva ○ Hard palate ○ Soft palate ○ Uvula ● Inspect teeth and gums ● Inspect vestibule, i.e. area between teeth and cheek, opening of parotid duct next to 2nd upper molar ● Inspect tongue ○ Ask patient to stick tongue out and move right and left ○ Ask patient to lift tongue to inspect floor of oral cavity and submandibular duct orifices (lat. to frenulum) ● Inspect oropharynx ○ Post. pharyngeal wall ○ Palatine tonsils ○ Openings of salivary ducts and glands ● Ask patient to say “Ahh” and inspect for asymmetry of movement of the soft palate ● Check sensation and power in the lips (Vb,c/VII, tongue (Vc/XII), palate (Vb/X) ● Palpate regional lymph nodes
  74. 74. Examination of the Hand ● See https://www.youtube.com/watch?v=bovmH1-gT68 for McLeod’s hand examination. ● Ask about pain ● Expose up to above elbows and place hands on pillow ● Inspect ○ Signs of rheumatoid/autoimmune disease ■ Nodules Look at elbows, then proceed distally ■ Psoriatic plaques ■ Sclerodactily ■ Deformities such as swan neck or boutonniere ○ Skin ■ Atrophy/thinning, papery texture ■ Hair loss ■ Purpura ■ Nodules ■ Rashes ■ Scars overlying joints ○ Nails ■ Pitting / psoriatic nail changes ■ Onycholysis ■ Vasculitis ○ Soft tissues ■ Swelling of wrist or metacarpal heads ■ Muscles: wasting of dorsal interossei, eminences ○ Bones ■ Deformities/abnormalities: ulnar/radial deviation, boutonniere, swan neck, Z thumb, Bouchard and Heberden’s nodes ■ Alignment problems, subluxation ■ Proximal to distal ○ Comment out loud on positive and most notable negative signs ● Palpate ○ Is arthritis currently active? ○ Temperature of joints with back of hand ○ Palpate over wrist joint, again from proximal to distal: wrist, metacarpophalangeal, interphalangeal. Any tenderness? ○ Distal radius and ulna, palms of the hands for contractures ○ Piano key sign: how mobile is head of ulna? ○ Metacarpal squeeze ○ Assess passive movements of joints ○ Describe swelling: “Boggy, fluctuant, bony”
  75. 75. Examination of the Hand: ctnd. ● Active movement ○ Perform pincer grip with four fingers against the thumb ○ Fist in supination ○ Pronate fist ○ Extend little finger (RA in wrist: risk of tendon rupture, extensor digiti mini goes first) ○ Extend all fingers ○ Put palms together ○ Prayer sign ○ Inverse prayer sign ● Assessing function (movement against resistance) ○ Test grip strength of the fists ○ Ask if able to write or do up buttons ○ Patient performs pincer grip with intext finger against resistance ○ Patient forms hook with four fingers, resist ○ Patient holds on to paper as if holding a key, resist removal ○ Patient abducts fingers against resistance ● Special tests ○ Offer Tinel’s and Phalen’s test ● Neurovascular assessment ○ Radial and ulnar pulses ○ Offer Allen’s test ○ Test ulnar, median and radial nerve sensation at autonomous points (combine with next point) ○ Check dermatomal sensation (mainly C6-8, can do C5 and T1 in antecubital fossa) ○ Test for glove and stocking distribution peripheral neuropathy ○ If time - quick motor screen ■ Extend wrist? Radial nerve => C6 ■ Hook? C8 ■ Keep fingers apart against resistance? Ulnar n. => T1 ■ Hold onto card between index and thumb? Ulnar n. => T1 ■ Point thumbs up in supination, against resistance (abductor pollicis brevis) Median => T1
  76. 76. Examination of the Hand: ctnd. ● To complete my examination, I’d like to inspect the scalp (you may also decide to include this in the examination), umbilicus and natal cleft for signs of psoriasis and perform a full respiratory examination. ○ If OA, mention examination of other joints ○ If Dupuytren’s, mention abdominal examination for liver signs and possibly dipstick for glycosuria. ● PRESENTATION ○ I have just examined [X]’s hands and noted [X] on inspection. ■ If RA: My most notable findings were multiple joint deformities such as Boutonniere/Swan neck deformities and ulnar deviation of the metacapophalangeal joints, consistent with RA. The absence/presence of erythema, joint effusions and/or joint tenderness indicates that the disease is currently [not] active. ■ If OA: My most notable findings were Bouchard’s and Heberden’s nodes present at the interphalangeal joints of [X] fingers, as well as thumb quaring, indicating osteoarthritis. [Rest of positive findings...] ○ Finish by mentioning most important negatives, such as mobility, vascular and neurological findings. Comment on functional impairment in every case.
  77. 77. Hand Appendix ● Autonomous areas of innervation of the hand Radial: web of thumb (pad of thumb = C6), median: pad of middle finger (C7), ulnar: pad of little finger (C8)
  78. 78. Elbow ● Expose ● Ask about pain ● Inspect ○ Skin - scars, swelling, redness, extensor surfaces => psoriasis? ○ Muscles - symmetry, wasting ○ Bones - deformity (cubitus varus, valgus), alignment ● Palpate ○ Nodules ○ Effusions ○ Swellings ○ Temperature ○ Bony prominences: olecranon, medial and lateral epicondyles ○ Bursae - bursitis? ● Move ○ Active: flexion, extension, supination, pronation ○ Passive: flexion, extension, supination, pronation ○ Can test against resistance ○ Test lateral epidondylitis (CEO) ■ Passively flex => pain? ■ Extend against resistance => pain? ○ Test for medial epicondylitis (CFO) ■ Passively extend wrist => pain? ■ Flex wrist against resistance => pain? ● Assess vascular status ○ Pulses ○ Capillary refill ● Assess neurological status ○ Power ○ Reflexes ○ Sensation ● Special tests ○ Speed’s test ○ Joergensen’s test

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