Clinical Examinations & Skills

Mubeen Rahman - smr107@ic.ac.uk

Hb (g/dL) 2/3 4/5 6 7/8 9-12 13 14-6 16/7 17 18 19 20/1 22/3 24 25 26-8 29 30 30/1 31 32/3 34-6 History/CVS Resp Lymph GIT & DRE UL & LL Cranial Nerves Opthal/Oto Cerebellar Speech/DDx Trauma/GCS ANT/MMSE GALS/Lumps Thyroid/PVS Breast & Skin Inguinal/Genitalia Musculoskeletal Volume Status Explain Procedure Inject/ABG/Phleb Cannulation/IVI Suturing/PEFR BP/ XRays/ECG PaCO2 Urine Na+ Urine K+ Ur. Protein 1 Hct MCV Platelets WBC Neutrophils Lymphs Eosinophils Basophils Monocytes A/PTT Na+ K+ Ca2+ Mg2+ Creatinine Urea Albumin Proteins Bilirubin ALT/AST Alk P LDH CRP CK PaO2 M13-18 M0.4-.54 76-96 150-400 4-11 40-75% 20-45% 1-6% 0-1% 2-10% 35-45s 135-145 3.5-5 2.12-.65 0.75-1.05 70-150 2.5-6.7 35-50 60-80 <17 3-35 30-35 70-250 <10 25-195 >10.6 75-100 4.7-6 35-45 100-250 14-120 <150 10-14s mmol/L mmol/L mmol/L mmol/L uL/L mmol/L g/L g/L umol/L iu/L iu/L iu/L mg/L iu/L kPa mmHg kPa mmHg mmol/24hrs mmol/24hrs mg/24hrs F11-16 F0.37-.47 fL 109/L 109/L 2-7.5 1.3-3.5

History Taking
Greet, state name/role, confirm patients name and DOB. EXPLANATION & CONSENT (purpose, time available) PRESENTING COMPLAINT (open qs, a brief phrase, in pts own words) HISTORY OF P. COMPLAINT (event narrative, time course, clarify what pt means, use SOCRATES & relevant RoS) PAST MEDICAL HISTORY (illnesses, hospital admissions, THREAD2S2 MJ) DRUG HISTORY (current, recent, herbal, OTC & recreational drugs, ?allergies inc. nature of reaction) FAMILY HISTORY (? affecting blood family (immediate) ?Parents a&w, and if dec., what age and cause. ? Ethnicity SOCIAL HISTORY (occupations, pets, recent travel, sexual history, EtoH what/when, smoking (pys of what), ?abode & w/whom, ADLs, immunisations, place of birth, change in sleep, mental state, effects SYSTEMS REVIEW: CVS - CP, palpitations, claudication, oedema RESP - cough, haemoptysis, sputum, wheeze GIT - Appetite/wt/bowel habits, vomiting, haematemesis, abdo pain, rectal bleeding GUS/O&G - Haemat/dysuria, freq, voiding difficulty, LMP, #of pregnancies, miscarries CNS - Headache, vision, faint, fit, funny turns, weakness, paraesthesia MSK - Joint pain/stiffness, swelling, immobility, rashes, irritation SUMMARY - DDx Ix, Tx, MANAGEMENT PLAN ! SAMPLE: Signs/Symptoms, Allergies, Medications, PMHx, Last Ins & Outs
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Cardiovascular Examination
WIPE (Wash hands, Introduce with name and role, confirming patients name and DOB, position at 45o and expose chest and back) GENERAL INSPECTION - obese, ill, anxiety, distress, malar flush, pain, SOB, cyanosed, pallor, congenital abnormalities (Downs - have Septal Defects, Marfans - Asc. Ao. An, Turners Aortic Coarctation) GENERAL INSPECTION items to do with care IVI diuretics (POed/HF), oxygen, GTN spray, monitor, ciggs. INSPECT HANDS NAILS, FINGERS, PALMS- Clubbing via Schamroths Window (chronic O2, cong. cyan. HD, A.Myxoma, SBEndocarditis), cyanosis, warmth, endocarditis (splinter haemorrhages, Oslers nodes, Janeway lesions), tar stains, koilonychia (IDA), leukonychia (alb), tendon xanthomata, anaemia, palmar erythema (portal HTN) PERFUSION - ?CRT < 2s (CO, vasoconstriction, Art. Obstruct, Raynaulds, Shock). If hands hot + tremor = thyrotoxicosis RADIAL PULSE rate and rhythm RADIAL PULSE SYNCHRONY (left and right) - !coarctation COLLAPSING PULSE - BRACHIAL BLOOD PRESSURE both arms INSPECT EYES pallor, jaundice, (?valve prosthesis), corneal arcus/sinilis, xanthelasma, Graves (proptosis, ptosis, lid retractions => !AF / output HF) INSPECT FACE malar flush (MS)

 INSPECT MOUTH pallor, cyanosis indicates a min of 5g/dL deoxHb (shunting) , glossitis (B Vit), high arch palate, dental caries CAROTID PULSE ?Volume & character. Check opp. side separately. Collapsing rapid up & downstroke = AR Bisferiens = both collapse + plateau Mixed Ao Valve Disease Pulsus alternans alternating strong and weak pulses = Severe LVF Slow Rising (+plateau) = ASten check Brachial Pulse Pulsus paradoxicus vol. on insp by >10mmHg - Tamponade, constrictive pericarditis, asth. JVP ( HEPATOJUGULAR REFLEX) 45 degrees - !RAP eg RVF/fluid overload. a & v waves = HS I & II INSPECT PRAECORDIUM - Scars (CABG, valvotomy), abnormal veins, pacemakers (subcostal), visible apex beat, pulsations, breathing. PALPATE PRAECORDIUM Apex, compare against position of 5th ICS MCL. Laterally displaced or diffuse impulse = LVF/dilated cardiomyopathy PALPATE HEAVES & THRILLS AUSCULTATE PRAECORDIUM time with the carotid pulse, over the valves: Aor, Pul, Tri, Mitral. MANOEUVRES (L. Side - MS, lean forward Ao Incomp.) on expiration. Expiration clarifies right sided murmurs & v.v. ?Duration, Radiation, HS & amplitude S3 = Ken-tuc-ky (MR) S4 = Ten-ess-see (ASten/CHF) ?Radiations: Axilla (MR), Carotid (ASten)
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AS

AR

MR

MS

?Murmurs: LSE RVHypertophy (pulm.HTN), 2nd ICS Dilated PArt (L) or Asc. Ao (R), Ej SM = ASten oroutput state - children/preg EDM = AR (rarely PR) - 2o to Endocarditis Mid DM = MS/AR PSM = MR, merging with S2, occurs in M/TR Machine murmur Patent ductus arteriosus
Murmur Grade Intensity: 1 Just audible 4 Loud & w/ thrill 2 Quiet 5 Very loud 3 Moderately loud 6 Audible w/o Steth

AUSCULTATE CAROTID ARTERY bruits, w/ bell, stop patient breathing PERCUSS/AUSCULTATE CHEST - pleural effs /creps at bases (LVF/CCF) OEDEMA - Check sacrum/ankle -CCF EXTRAS: AUSCULTATE & PALP for AAA + RENAL BRUITS HEPATOMEGALY - congestive disease (RVF), or pulsatile in Tri regurg) SPLENOMEGALY Inf. Endocarditis MSU Dipstick for Haematuria Peripheral Vascular and Resp Exam Assess femoral, popliteal, dorsalis pedis and posterior tibial pulses. ? OPTIC FUNDI (Roths Spots, HTN/DM), ECG + Exercise ECG if inconclusive, Request Echo THANK, OFFER TO HELP PT DRESS

Respiratory Examination
WIPE - chest (and back) @ 45o GENERAL INSPECTION respiratory distress, symmetry of movement, accessory muscles, pursed lips, pallor, cyanosis, wheeze, breathing pattern, Medical - Horners syndrome (Pancoasts tumour ), erythema nodosum (sarcoidosis), deformity: Kyphoidosis/Lordosis/Scoliosis Paraphernalia O2 mask, sputum pot, flow meter, inhalers, nebuliser, drains. HANDS Warmth, bounding pulse, dilated veins (CO2 retention), skin thinning (Ca), tar stains, peripheral cyanosis, koilonychia (IDA). Small muscle wasting (esp. 1st dorsal interossei) Pancoasts. Clubbing (large cell Ca, ILD, TB, suppurative disease, mesothelioma, lung Ca, bronchiectasis, empyema, Cy Fi) if +ve look for pain w/ wrist mvmt (pypertrophic pulm. osteoarthopathy) - ! lung Ca WRISTS Ask pt to put arms straight out infront, spread fingers (B2 agonist tremor). Then cock wrists back for >30s (CO2 retention flap). ASSESS PULSE (RATE + RHYTHM) while assessing flap looks slick! ASSESS RESPIRATORY RATE Note: Depth + Effort + Obvious Sounds INSPECT EYES - Anaemia (pallor on underside), miosis, ptosis (drooping upper eyelid), anhidrosis - Horners syndrome/Pancoasts tumour. INSPECT TONGUE, LIPS, MOUTH Tongue cyanosis (blue tinge underneath), glossitis. Lips angular stomatitis. Mouth candida infection (steroid).
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EXAMINE NECK - Neck/face swelling, dilated veins (SVC obstruction lung tumour). ASSESS JVP - Ask pt to look to left, illuminate. JVP raised in cor pulmonale, RVF, Fluid OD CAROTID PULSE - bounding pulse in CO2 retention. PALPATE LYMPH NODES From behind (submental, submandibular, supra-clavicular, posterior-auricular, occipital) ! Infection, Neoplasm, Sarcoid PALPATE TRACHEA - Warn pt first. Palpate for deviation. T Fibrosis/ Collapse, T Pneumo/Effusion. CRICOSTERNAL DISTANCE Measure finger breadth distance between cricoid cartilage and suprasternal notch (~2 fingers, less in emphysema, COPD = tracheal tug, if w/systole Ao. Arch Aneurysm) FEEL FOR APEX BEAT INSPECT CHEST - Pectus excavatum, carinatum (rickets), funnel (congenital). Scars (ant/posterior). Kyphoscoliosis, barrel chest, radiotherapy tattoo, skin damage CHEST EXPANSION (STERNAL, LOWER) - 2 hands on sides of chest, thumbs meet in middle (not touching skin). Sternal check upward mvmt. Lower rib cage laterally (>5cm). Repeat on back at 2 levels. w/ Effusion, Consolidation, Collapse, Pneumothorax and Fibrosis PERCUSS FRONT - Supraclavicular, clavicles (directly) then chest wall (2 x 3 positions including axilla).

Resonance (air) Pneumo/COPD Resonance (dull)= fluid, solid i.e. Large effusion or consolidation AUSCULTATE FRONT- Ask pt to take deep breaths via mouth (show). Listen w/ diaphragm ?vesicular, bronchial, what intensity, added sounds like wheeze, (mono/poly), crackles, pleural rub TACTILE/VOCAL RESONANCE Ask pt to say 99 when listening to 2 x 3 positions. WHISPERING PECTORILOQUY Ask pt. to say one repeatedly, whisper transmitted in consolidation PERCUSS BACK - Do back 2 x 3 positions. AUSCULTATE BACK 2 x 3 POSITIONS TACTILE/VOCAL RESONANCE BACK 2 x 3 positions w/ consolidation w/ Pneumothorax and Effusion OEDEMA Sacral and ankle EXTRAS: CVS Exam, CXR, Peak flow, Sputum pot sample, ABG

Lymph Node Examination

HEAD & NECK NODES

lateral chest wall, and the posterior group along the posterior axillary fold. EPITROCHLEAR (ELBOW) - Passively flex the patients relaxed elbow to a right angle. Support with one hand whilst feeling in the groove above / posterior to the medial condyle of the humerus. PARA-AORTIC - deep central mass if enlarged INGUINAL & LEG NODES - Supine Hal just below inguinal ligament Val - along the long saphenous vein

VERTICAL NECK: Neck flexion may relax the strap muscles. Feel for the superficial cervical nodes along the SCM body. The posterior cervical nodes run along the anterior body of trapezius. The deep cervical chain is difficult to feel, as they are deep to the long axis of SCM; explore by palpating firmly through the muscle. INFRACLAVICULAR AXILLARY NODES Take the pts L arm with your R hand and explore with your L hand and vice versa: POPLITEAL - Relax the fossa by passive flexion explore by wrapping the hands either side of knee and exploring with the fingers of both hands. SPLEEN & LIVER Examine the DRAINAGE AREAS of any enlarged nodes. General points to note: Slightly cup examining hand and palpate into axilla apex for apical group small nodes may only be felt by rotating the fingertips against the chest wall. Feel for the anterior group of nodes along the posterior border of the anterior axillary fold, the central group against the
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Size: anything >1cm is abnormal Consistency: hardness suggests Ca, rubbery consistency points to lymphoma Tenderness: implies infection Fixation: suggests malignancy Overlying skin: tethering is a feature of malignancy, inflammation suggests infection

Gastroin testinal Ex amination

WIPE - nipples to knees for abdominal portion, initially 45o, then supine for abdomen, w/ pillow/s under head, relaxed, arms by sides, check patient is comfortable) INSPECTION - cachexia, obesity, normal weight, hydration, pain, pallor, pruritis (jaundice), distension, scars, masses, bruising, etc. Paraphernalia: Drains, stoma feeding tubes, notices, supplements, catheter. HANDS - Palmar erythema, Dupytrens Contracture, Clubbing (IBD, liver cirrhosis, malabsorption). Koilonychia, Leuconychia (chronic liver disease, nephrotic syndrome). Arteriovenous fistulae (lump from dialysis). Hydration (dehydration makes skin flaccid), nail pitting, xanthomata WRISTS - Test for asterixis (hep flap) w/ pt. holding arms out, wrists cocked >30sec check pulse here too! RADIAL PULSE (AF, Shock) EYES Scleral icterus, pallor, corneal arcus, xanthelasma, KF rings. LIPS - angular stomatitis, cheliosis (fissuring/crack of lips), herpes labialis, GUMS hypertrophy, gingivitis. MUCOSA ulceration, pigmentation (Peutz Jeghers dark freckles on lips, face, mucosa, w/ GI obstruction and polyps), Osler-Weber-Rendu telangiectasia (capillaries near surface, alcohol, malignancy). TEETH caries (cavities), dentures.

TONGUE dry/wet, jaundice, atrophic, furred & beefy, swollen, candidiasis, tonsils, palate, etc. BREATH fetor hepaticus (stale urine, ammonia), alcohol, ketoacidosis (peardrops), halitosis. CERVICAL LYMPH NODES from behind VIRCHOWS NODE/TROISIERS SIGN (L SUPRACLAVICULAR AREA) JVP raised in hepatic pathologies INSPECT CHEST - Gynaecomastia, Spider Naevi (~>5 pathological in women, any in men), feeding/tunnelled lines, body hair distribution INSPECT ABDOMEN Get to level of patient, lie SUPINE INSPECT ABDOMEN distension, lumps, caput medusa, bruising, scratches, visible peristalsis, rigidity (peritonitis). INSPECT ABDOMEN Ask pt to cough (pain/hernias), to raise legs (rectal divarication, hernias). ASK PATIENT IF THEY HAVE PAIN PALPATION - SUPERFICIAL Tender region last. Watch patients face. Visit all 4/9 quadrants. Elicit tenderness, rigidity, guarding. PALPATION DEEP - deep-seated pain (rebound?). Any masses described as lump w/ position, shape, size, surface, fixed, mvmt w/ resp., tenderness, pulsation. PALPATION LIVER (from RIF, w/ deep breaths). Percuss for upper & lower border using index finger edge ! psuedohepatomegaly due to hyperinflated lungs
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 PALPATION SPLEEN (from RIF, w/ deep breaths using fingertips). Percuss. PALPATION KIDNEYS (bimanual ballotment) PALPATION - ABDOMINAL AORTA - 2 hands (or middle & index finger) firmly at either side. AAA will push upwards (pulsatile) and out (expansile) PERCUSSION 4 QUADRANTS PERCUSSION ASCITES a. Shifting dullness: Percuss from umbilicus laterally (w/ fingers pointing toward head). ?resonant at umbilicus, dull in flanks. If not, no ascites. Pt. rolls to RHS whilst keeping your hand over L flank where it was dull. Wait 1m and repercuss. Note should have changed: dullresonant. Roll pt. onto LHSide. Wait 1m. Left flank should be dull again. b. Fluid thrill: Flick on one side, feel any mvmt transmitted. Thrill due to mvmt through fluid. Ask pt. to put ulnar edge of a hand in centre of abdo to prevent a false +ve thrill from fat. AUSCULTATION quadrants for bowel sounds (>15s, >1 min for absent. Normal, borborygmi (mvmt), absent (ileus) , tinkling ( e.g. obstruction) OEDEMA check ankles AUSCULTATION AA BRUIT, RENAL AND LIVER EXTRAS: Palpate hernia orifices, examine the external genitalia, DRE, urine dipstick: SG >1.010 = dehydration, <1.007 Normal Ketones = DM Albustix = Renal Infec, DM, jaundice, Thy Nitrites & Leukocytes = UTI Hb = Glomerular damage/Rhabdomyolysis
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Glucose = Diabetes / Nephropathology THANK, CHECK COMFORT, OFFER TO HELP GET DRESSED.

Digital Rectal Examination

WIPE nipples to knees, left lateral position, knees drawn up to chest, feet clear of perineum, buttocks at edge of couch. ? CHAPERONE PUT ON GLOVES ASK ABOUT PAIN/DISCOMFORT INSPECTION skin tags, warts, haemorrhoids, fistula, fissure, abcesses, pilonidal sinus, prolapsed rectal mucosa, skin discolouration, scratch marks, discharge PALPATION WARN PT FIRST PALPATION lubricate finger, use pulp of finger on anus, press firmly and aim towards umbilicus PALPATION rotate around 360, feel for masses, mucosal changes, temperature changes, prostate ASSESS ANAL WINK reflexive contraction of the anal sphincter on stroking peri-anal skin (S1-3) ASSESS ANAL TONE (ask pt to squeeze finger) REMOVE FINGER GENTLY EXAMINE FINGER evidence of blood, mucous, stool etc. CLEAN UP PT leave towels for them to clean themselves ASK PT TO GET CLEANED UP AND DRESSED (do not thank the pt) DISPOSE OF GLOVES/WASTE AND WASH HANDS EXPLAIN FINDINGS TO PT

Upper Limbs PNS Examination COORDINATION FINGER-NOSE

I Think People Cant Resist Penetrative S Games

WIPE - 45o or upright, arms/legs fully exposed) INSPECTION palsies, abnormal movements, fasciculation, wasting, tenderness Hemiplegia flexed UL, extended LL T1 palsy weak finger adduction and abduction. Sensory loss to medial forearm. Radial nerve wrist drop. Sensory loss on small area of dorsal web of thumb. Median nerve Adductor Pollicis Brevis weakness. Sensory loss thumb, 1st 2 fingers, palmar surface. Ulnar nerve interversion, hypothenar muscles waste, claw-hand, no finger extension. Sensory loss, half 4th, all 5th, palmar surface. Erb-Duchenne (C5-7) - waiters tip. PRONATOR DRIFT, TREMOR parkinsonism, thyrotoxicosis, chorea, athetosis, spasm TONE wrist, elbow, shoulder etc POWER Shake hands w/pt. Shoulder abd/addn (C5) chicken wings Elbow flex/ext (C5 & C6). boxer. Wrist Flexion/ext push fist up/down Finger grip (C8, T1). squeeze my fingers Finger Abduction (dorsal interossei, ulnar nerve, T1) squeeze/spread fingers. -DAB Finger adduction (T1). paper pull -PAD Fine movements fingers to thumbs

both sides, with your finger at arms length. Cerebellar changes = past pointing and intention tremor COORDINATION DYSDIADOKINESIS both hands COORDINATION FINGERS play piano etc REFLEXES biceps, triceps, supinator with Jendrassik manoeuvre if needed. PROPRIOCEPTION always demonstrate up/down motion first, use finger on either side of both toes, eyes closed, test peripherally first SENSATION LIGHT TOUCH ask about numbness, use cotton wool, eyes closed, test at sternum and start. SENSATION PIN PRICK (PAIN) sharp or blunt, test at sternum, go... L2 Medial Thigh, L3 Knee, L4 Floor, L5 Lat. Side, S1 Pinkie, S2 Posterior Thigh VIBRATION 128Hz tuning fork, tester on sternum first, begin test distally on bony prominences. SENSATION TEMPERATURE (since pain and temperature both spinothalamic) dermatomal distribution, determine if tuning fork is hot or cold FUNCTION Ask pt. to write their name THANK, COVER, COMFORT.
MRC Power Scale: 5 Normal power 4 +/- Movement against gravity plus resistance 3 Movement against gravity 2 Movement without gravity 1 Palpable contraction w/ no active mvmt 0 No active contraction

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Lower Limbs PNS Examination SENSATION LIGHT TOUCH ask

WIPE (45 degrees or upright, arms/legs fully exposed) INSPECTION palsies, abnormal movements, fasciculation, wasting, tenderness TONE rock legs, flick knee upwards, look for clonus POWER: Hip Adduction/Abduction (L1, 2) push your legs against me, pull legs together... Hip flexion (L1, 2) leg straight, lift whole leg off bed, dont let me push it down. Knee flexion (L5, S1, 2) heel to you, bring to bottom, dont let me pull it away Knee extension (L3, 4) Now try to push it down straight again, push me away. Plantar flexion (S1) Point your toes up to the ceiling, and press down against me Dorsiflexion (L4, 5) Now pull up against me, stop me pushing your toes down COORDINATION HEEL-SHIN + TAP rub your heel from opp. knee to foot, then tap my hand w/ foot, repeat as fast as possible REFLEXES tendon knee reflex, ankle reflex, Babinski manoeuvre PROPRIOCEPTION always demonstrate up/down first, use finger around both sides of the toe, eyes closed, test peripherally first

about numbness, use cotton wool, eyes closed, test at sternum first. SENSATION PAIN pin along dermatomes C5 Lateral arm, C6 Lateral forearm +thumb/index, C7 Middle F, C8 Pinkie, T1- Medial Forearm SENSATION VIBRATION do or mention, 128Hz tuning fork, tester on sternum first, test distally first, on bony prominences SENSATION MENTION TEMPERATURE (since pain and temperature both spinothalamic) dermatomal distribution, determine if tuning fork is hot or cold GAIT ROMBERGS GAIT WALK NORMAL - to point and back, HEEL-TOE, WALK TIP TOE GAIT CROUCHING AND STANDING

THANK, COVER, OFFER, COMFORT

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Cranial Nerve Examination

WIPE GENERAL INSPECTION weakness, myopathy, diplopia, tremor, asymmetry, strabismus, eye position, ptosis, pupil size, ARTICULATION (say red lorry yellow lorry) CNI: OLFACTORY ask problems w/ smell or taste. Mention or do testing nostrils separately w/ scents. CNII: OPTIC : CNII/III PUPIL LIGHT REACTIONS (direct, consensual, swinging) CNII/III ETC ACCOMMODATION (far near) CNII FIELDS (in confrontation, 1m apart, correct eye covering and movement, both sides and both eyes) CNII INATTENTION (arms 1m apart, wiggle fingers (l + r + both)) CNII ACUITY (ask about problems, glasses or lenses) Snellen chart, mini-chart or print up close, test each eye separately. CNII COLOUR (Ishihara plates) CNII FUNDOSCOPY CNIII, IV, VI Ask pt to mention any double vision while keeping head still. CNIII, IV, VI H SHAPE look for nystagmus and saccades CNV: TRIGEMINAL MOTOR (look for wasting, ask pt to open mouth, wiggle, clench teeth, palpate temporalis and masseters) CNV SENSORY (touch w/ cotton wool, eyes closed, 3 levels comparing
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sides (could do pain/pinprick if problematic)) CNV/VII CORNEAL REFLEX CNVJAW JERK REFLEX CNVII: FACIAL MOTOR (look for wasting, asymmetry. Ask pt to frown, raise eyebrows, screw eyes up, then against resistance. Show me your teeth, puff out cheeks and against resistance. Taste not usually assessed) CNVIII: VESTIBULOCOCHLEAR ACUITY AND BALANCE ask any problems w/ your hearing or balance? CNVIII- ACUITY (press tragus/distract opposite ear and whisper in other ear, both sides) CNVIII RINNES (512 or 256Hz) CNVIII WEBERS (512 or 256Hz)

CNIX: GLOSSOPHARYNGEAL ask any problems w/ your speech, taste or swallowing? CNIX/X look in mouth, watch uvula at rest and w/ pt saying aahh. Deviation away from lesion CNIX/X ask pt. to cough, swallow CNIX/X GAG REFLEX (?sip water) CNXI POWER shrug shoulders and against resistance, turn neck to side and against resistance, palpating opposite sternocleidomastoid CNXII: HYPOGLOSSAL examine tongue at rest (bulk,

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

Ophthalmoscopy
WIPE (dim lights, sit facing pt at the same height), EXPLANATION AND CONSENT. ? CHAPERONE REMOVE PTS GLASSES/ASK ABOUT CONTACT LENSES INSPECTION - ptosis, styes, squinting, inflammation, exopthalmos. CHECK OPHTHALMOSCOPE (at 0, dont use full power light) WARN PT ABOUT BRIGHT LIGHT REST HAND ON PTS FOREHEAD place thumb supraorbitally. START W/ NORMAL SIDE FIRST USE OPHTHALMOSCOPE CORRECTLY (in right hand, use right eye to look at pts right eye) Ask pt. to focus on distant point, level to you, over your shoulder. Approach at 15o laterally to their line of vision. RED REFLEX (from approx 1m, look for opacities, or loss of reflex) FUNDOSCOPY FOCUSING move as close to the patient as possible, focus on blood vessels by scrolling through different lenses may be easier to focus on iris first. FIND OPTIC DISC - use arrow sign and follow blood vessels. EXAMINE OPTIC DISC - focus - look for cupping (glaucoma), papilloedema ( ICP). Check physiologic cup and border. VESSELS inspect all quadrants
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- Arteries = light, small | Veins = dark, big EXAMINE FUNDUS (hard exudates, a-v nipping or crossing, copper-wiring, blot haemorrhages hypertension, soft exudates, flame haemorrhages, new vessel formation diabetes) EXAMINE MACULA (look at the light vision should be 6/6 here) EXAMINE THE FRONT OF THE EYE - rack through lenses to focus on different parts of the eye, try +10-12d REPEAT PROCEDURE - OTHER EYE THANK PT, SWITCH LIGHTS ON, REPLACE GLASSES etc

Fundi Cheat Sheet

Normal Fundoscopic View:

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

Abnormalities: VITREOUS Opacities asteroid hyalosis, scars, DM haemorrhages, fibrous tissue, angiogenesis OPTIC DISC: Papilloedema Swollen, poorly demarcated disc. Cx inc. Intracranial space occupying lesions, tumours, abcess, haematoma. Malignant HTN, Benign IC HTN, Central Vein Thrombosis, CO2

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

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

Myelinated nerve fibres streaky white, irregular patches w/frayed margins, Benign, Does not affect vision ARTERIOLES & VENULES Calibre, light reflex (silver wiring), AV Nipping QUADRANTS and MACULA Haemorrhages: Dot, Blue, Flame Microaneurysms , Laser Scars Exudates: Hard (well defined edges, light reflex,), Soft (fluffy w/ill defined edges). Hard exudates may form a ring (circinates) in DMs. Cotton Wool Spots Hypertensive Retinopathy: GRADE 1- Narrowed retinal arterioles, increased light reflex sliver wiring GRADE II AV Nipping GRADE III Malignant HTN: Flame (less frequently) blot haemorrhages, cotton wool exudates. GRADE IV Papilloedema e.g. venous engorgement, elevation of optic disk, haemorrhages adj. or over disk & blurring of optic margins. Indicates cerebral oedema and ICP)! Pre-eclampsia
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Papillitis early sign of MS, it is ocular inflammation restricted to the optic nerve head.

Otoscopy
WIPE (sit facing pt at the same ht, access to both ears) EXPLANATION AND CONSENT ASK ABOUT PAIN/DISCOMFORT warn pt, start w/ normal side. CHECK OTOSCOPE ( turn on light, use clean sterile speculum) USE OTOSCOPE CORRECTLY (hold in R hand for R ear, hold it on its side like a pencil, always advance under direct observation) PULL PINNA UP AND BACK (straighten external auditory meatus) POSITION OTOSCOPE NEAR E.A.M. - advance under direct supervision, up to the first row of hairs but no further) OTOSCOPY EXAMINE EAM (look for swelling, redness, discharge, wax, foreign bodies) OTOSCOPY EXAMINE TYMPANIC MEMBRANE (look for, redness, swelling, perforation, bulging, clear light cone indicates healthy TM) OTOSCOPY EXAMINE BEHIND TYMPANIC MEMBRANE (look for bulging, inflammation, obvious abnormalities) W/DRAW OTOSCOPE CAREFULLY THANK PT, SUMMARISE FINDINGS DIAGNOSIS

INSPECTION (muscle wasting, trunkal ataxia, fasciculation, discoordination, slurred speech) ASSESS FOR TREMOR (use a piece of paper to assess fine tremor and intention tremor) GAIT (stride length, arm swing, ataxia, observe co-ordination of turn. Ask pt to walk heel-to-toe) ROMBERGS TEST SPEECH (ask pt to repeat baby hippopotamus and british constitution) VISION (?changes, double vision etc) ASSESS NYSTAGMUS or SKEW DEVIATION CHECK for DYSDIADOKOKINESIA COORDINATION ARMS (intention tremor, past pointing, lack of co-ordination) COORDINATION LEGS (run heel down shin. toe to hands) TONE ARMS (hypotonia, assess shoulder, elbow and wrist movement) TONE LEGS (roll leg side to side, look for toe swing, flick knee up and watch heel) REFLEXES ARMS (biceps, triceps and supinator. Look for hypo-reflexia) REFLEXES LEGS (knee and ankle . look for hypotonia) THANK PT, HELP GET DRESSED Pastries help digest cerebellar disease...
Dysdiadokokinesia Ataxia Nystagmus Intention Tremor Scanning dysarthria Hypotonia Paraneoplastic Synd. Abcess/Atrophy Stroke and MS Trauma Raised ICP Infection EBV,CPox Ethanol & Poisons Spinocerebellar Atax

Cerebellar Examination
WIPE, EXPLANATION AND CONSENT (undress to light underwear)
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Speech Examination
INSPECTION Raynauds, CREST, thyroid, Hemiplegia, or other dx assoc. w/dysphasia, Nystagmus, Intention tremor, Parkinsonisms QUESTIONS: What is your Name, Address, items you had for lunch ARTICULATION: British Constitution, Baby Hippopotamus, West Register St. CONDUCTION APHASIARepetition of above... SPASTIC DYSARTHRIA: Cerebellar Slurred, jerky, Explosive Psudobulbar Palsy Indistinct, Suppressed, w/o modulations, hot potato, Donald duck PD Monotonous, oaccent/emphasis, slur Mytonic Dystrophy Slurred & Suppressed Huntingdons Chorea Slurred, Monotone FLACCID DYSARTHRIA Bulbar palsy: Nasal w/ decreased modulation, slurring of labial and lingual consonants pa,la. VII, IX, X, XII Paralysis MYOPATHIC DYSARTHRIA My. Gravis Weak hoarse voice w/nasal quality, pitch unsustained, soft accents. VARIEGATED DYSARTHRIA Thyroid: Low pitch, catarrhal, hoarse, croaking, guttural voice (sounds like tongue>mouth). Amyloidosis: Large tongue Mx Ulcers Some speech indistinct Parotitis/Temporomandibular Arthritis Monotonous, suppressed, badly modulated

COMPREHENSION Dont gesture: Tongue out, Shut your eyes, Touch your nose. Good = Expressive, Bad = Receptive Aphasia NOMINAL DYSPHASIA Display keys what is this? Is it a spoon, is it a pen, is it keys? Test ability to form sentences e.g. Where do you live and how would you get home from here? OROFACIAL DYSPRAXIA Test firs w/o gesture: Show me your teeth, move your tongue from side to side, Rpt. w/gesture. ?Ideational or ideomotor dyspraxia (lesions in the operculum) AMTS

Differential Diagnosis Screen

V I T A M I N C D Vascular and Ischaemic Inflammatory and Infectious Trauma and Surgery Acquired inc. Drugs Metabolic Idiopathic & Iatrogenic Neoplasm / Malignancy Congenital and Genetic Deficiencies

Investigations: Cultures, Bloods (A/V), Imaging, Functional tests, Scopic and Biopsies Treatment: Conservative, Medical, Surgical Surgical Sieve causes for lumps etc: Infection (Acute, Chronic, Acute on Chronic) can be viral, bacterial or fungal Neoplasm Benign, Malignant (1 or 2o) Mechanical - Strictures, Obstructions
17

The TRAUMA Rapid Patient Assessment Tool DRsAcBCDEEEFG

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

Glasgow Coma Scale

E Y E V E R B A L M O T O R

4 3 5 4

Spontaneous (alert) 2 In response to pain In response to any speech 1 Absent Orientated pt knows who he is, where he is and why, the year, season, month Confused patient responds in a conversational manner, but there is some disorientation and confusion. 3 Inappropriate speech random/articulated speech, no conversational exchange 2 Incomprehensible speech moaning but no words 1 None 6 Obeying command pt does simple things you ask (beware grasp reflex) 5 Localizing response to pain elicit pain w/ fingernail bed pressure (w/ pencil), parasternal rub, pressing on supraocular/supraorbital area. Purposeful movements towards changing painful stimuli is a localizing response 4 Withdraws to pain pulls limb away from painful stimulus 3 Flexor response to pain pressure on nail bed causes abnormal flexion of limbs decorticate posture/rigidity 2 Extensor posturing to pain stimulus causes limb extension (adduction, internal rotation of shoulder, pronation of forearm) decerebrate posture/rigidity 1 No response to pain SCORE = BEST E/V/M : GCS 8 severe injury | 9-12 moderate | 13-15 minor
18

Abbreviated Mental Test

Warn patient not to worry or be concerned about their answers. EMPOWER PATIENT TO ASK IF THEY DONT UNDERSTAND, BE POLITE SPEAK CLEARLY, NON-PATRONISING 1. Age 2. DoB 3. Time (TO NEAREST HOUR) 4. Year (allowing for Dec/Jan) 10a. I would like you to remember this address: 42 WEST STREET. Please repeat it back. - get the patient to repeat it back instantly. 5. Where are you (name of institution)? 6. Recognition of two people e.g. porter, doctor, family member 7. Dates of WWII or other substitutes (WWI 1914-18, WWII 1939-45) 8. Name of present monarch/prime minister. 9. Count backwards from 20 to 1 dont stop them prematurely 10b. Please repeat back to me the address I asked you to remember. ADD SCORE UP (OUT OF 10 POINTS) & INFORM EXAMINER OF THE SCORE INTERPRET (8+ normal, 7 borderline, 6 or less is cut-off to separate normal elderly persons from those confused or demented w/ a correct assignment of 81.5%)

Mini Mental State Examination - 30 p oi n t sc al e

Orientation Registration Attention & calculation Recall Language

1. What is the year, season, date, month, day (1 pt. each)? 2. Where are we? Country, county, town, hospital, floor (1 pt. each) 3. Name 3 objects, taking 1s to say each. Then ask the pt. to repeat them. (1 pt. each) Repeat the q. until the pt. learns all 3. 4. Serial sevens (1 pt. each). Stop after 5 answers. Alternatively spell world backwards. 5. Ask for the names of the 3 objects asked in Q3 (1 pt. each). 6. Pt. to ID a pencil & a watch. Have pt. name them for you (1 pt. each). 7. Have the pt. repeat no ifs, ands or buts (1 pt.) 8. Have the pt. follow the 3-stage command Take the paper in your R hand, fold paper in half, put paper on the floor. (3 pt.s) 9. Have the pt. read and obey the following: Close your eyes (in large letters). (1 pt.) 10. Have the pt. write a sentence of their choice it must have a subject and an object and make sense. Ignore grammatical errors. (1 pt.) 11. Have pt. draw 2 intersecting pentagons give 1 pt. if all the angles are preserved & if the intersecting sides form a quadrangle.

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

19

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

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

20

Lumps and Bumps Examination

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

1. WIPE I understand that youve found a lump on your Would it be alright if I examine it? Please could you show me exactly where it is? 2. Inspect mass carefully. Note site, size, shape & changes in overlying skin. 3. Lay hand on mass to see what the temperature of the skin and the lump itself is. 4. Gently palpate the lump to elicit any tenderness. This will also allow you to accurately define the size and shape of the mass. Record finding diagrammatically. 5. Keep hand on lump for a moment to check for pulsation. If +ve, decide if referred pulsation or from mass itself (2 fingers either side, upwards and outwards = from the mass itself). 6. Assess consistency (cystic, solid, hard, soft, fluctuant), surface texture and margins. 7. Attempt to pick up a fold of skin over the swelling to assess skin fixation, and assess the mobility of the skin on the contralateral side. 8. Determine fixation to deeper structures by attempting to move swelling in different planes relative to surrounding tissues. Contract the muscles around it to
21

Thyroid Examinatio n
WIPE, EXPLANATION, CONSENT, CHAPERONE POSITION, EXPOSURE, COMFORT (sitting, expose neck to clavicles) CHECK IF PATIENT HAS ANY TENDERNESS SYMPTOMS pressure symptoms, like dyspnoea or dysphagia, hoarseness of voice (e.g. recurrent laryngeal nerve infiltration by cancer), hyperthyroid/hypothyroid symptoms. GENERAL INSPECTION anxious/fidgety/thin/wasting hands, face, shoulders/hot(hyper); slow/lethargic/fat/cold (hypo) VOICE - hoarseness/dysphasia (hypo) ask patient to say their name. HANDS - toxic signs moist, hot, sweaty, tremor w/ fingers spread (hyper); dry/cold (hypo); thyroid acropachy (like clubbing but in association w/ Graves disease) PULSE tachycardia, atrial fibrillation (hyper); bradycardia (hypo) EYES (front and sides) - exopthalmos lower cornea and sclera visible in Graves disease (due to orbital fat, oedema, cellular infiltration) Lid lag (ask patient to follow your finger up and down) and lid retraction (spasm of the smooth muscle in the upper eyelid reveals upper border corneoscleral junction) both hyper. Also look for diplopia/opthalmoplegia. INSPECT MOUTH LIPS, MUCOSA, TONGUE, THROAT INSPECT NECK (FRONT, SIDES) asymmetry, punctum ,erythema,

eczema, scars, goitre, discharge, pulsations, distend veins ASK PATIENT TO POKE TONGUE OUT WATCH FOR THYROGLOSSAL CYST ASK PATIENT TO TAKE WATER, HOLD, SWALLOW (FRONT, SIDE) (GOITRE) PALPATE FROM BEHIND GET PATIENT TO SWALLOW (ascertain tenderness, size, shape, single/multiple swellings, smooth/nodular, consistency) EXAMINE CERVICAL LYMPH NODES WARN PATIENT BEFORE TRACHEAL PALPATION PALPATE TRACHEA FOR DEVIATION, CRICOSTERNAL DISTANCE PERCUSS STERNUM/SWALLOW AUSCULTATE THYROID ASK PATIENT TO HOLD BREATH LIMBS - proximal myopathy (stand from a chair w/out using hands a sensitive indicator of hypo/hyper). Pretibial myxoedema (puffiness on shins, Graves). SAY YOUD LIKE TO EXAMINE REFLEXES - assess the reflexes (delayed, slow-relaxing in hypothyroidism). SAY YOUD LIKE TO EXAMINE FOR OTHER - Pericardial effusion, carpal tunnel, and ascites are features of hypothyroid. SAY YOUD LIKE TO EXAMINE FOR THYROID FUNCTION - If goitre is suspected THANK, CHECK COMFORT

22

Peripheral Vascular System Examination

WIPE, EXPLANATION, CONSENT, CHAPERONE (lying w/ legs & arms exposed) GENERAL INSPECTION Scars, ulcers, gangrene, amputations, wasting, CRT RADIAL PULSES (Rate, Rhythm, Radio Radial delay) BRACHIAL PULSES BLOOD PRESSURE both arms CAROTID PULSE (auscultate, palpate) ?Aneurysms, bruits, narrowing ABDOMINAL VESSELS (palpate & auscultate for AAA, check renal bruits) INSPECT LEGS gangrene, ulcers, skin change, (pallor/red), varicose eczema, hair loss, scars, varicosities, disuse atrophy, and swelling. INSPECT FEET between toes, heels, look for ulcers and discolouration. ASK PATIENT for ?leg tenderness LEG TEMPERATURE compare w/back of hands (skin colder in ischaemic unless infection) CAPILLARY REFILL (nailbed on each foot - <2s) FEMORAL ARTERY (palpate, Auscultate, compare, ?radio-femoral delay) POPLITEAL ARTERY (+FLEX/EXTENDED, SFA BRUITS) POSTERIOR TIBIAL ARTERY (midway between medial malleoulus and heel) DORSALIS PEDIS ARTERY (slightly ever leg, feel along a line extending between middle of a line drawn

between two malleoli and webspace between 1st + 2nd toes) EXTRA BURGERS TEST - (Check pain/mobility first) elevate leg to ~>45, look for ischaemia (leg goes white), hang leg off bed at 90, watch for reactive hyperaemia EXTRA TRENDELENBERG TEST Describe location of SFJ (5cm below and medial to femoral pulse), Occlude w/ tourniquet, elevate leg to empty veins, ask pt to stand and watch for rapid filling of veins EXTRAS: TEST FOOT SENSATION ABPI - Arterial Brachial Pressure Index THANK, COVER, OFFER COMFORT

ABPI should be 1+ in supine position. Claudication: <0.8 Critical ischaemia: <0.4. Remember the 6 Ps of acute limb ischaemia: Pulseless, pallor, perishingly cold, paraesthesia, paralysis and pain (and squeezing muscles!) How do you record pulses? Normal + Decreased +/- , Absent - , Aneurysmal ++

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Breast Examination
WIPE @ 45o, EXPLAIN, CONSENT, PRIVACY AND CHAPERONE ASK PT - ?PAIN, DISCOMFORT, DISCHARGE (!pt elicits), LUMPS GENERAL INSPECTION cachexia, swollen arms, size, shape, asymmetry, contour, colour, venous pattern, local swelling, nipple changes (inversion, Pagets (unilateral), eczema (bilateral)), Peau dorange (sweat glands/Coopers ligaments) INSPECTION POSITION relaxed w/ arms by sides (relaxes pectorals) INSPECTION POSITION arms raised above head (tightens suspensory ligaments, skin puckering) INSPECTION POSITION hands pressed firmly on hips (tenses pectorals) INSPECTION POSITION learning forward Pt @ 45, check comfort, arms behind head. Start with normal breast first. PALPATE BREASTS up and down (2 SIDES) use palmar surface of fingers, work around breast in a systematic way PALPATE AREOLA REGION (2 SIDES) PALPATE AXILLARY TAIL (2 SIDES) DEFINE ANY MASSES AND DETERMINE TETHERING (hands pushed on hips before and after testing movement) SIT PATIENT UP AND REST APPROPRIATE ARM ON YOUR ARM PALPATE AXILLA (medial, lateral, posterior, anterior, apex) PALPATE cervical, supra/infraclavicular lymph nodes

COVER PT, CHECK COMFORT (dont thank pt) EXTRAS: Examine liver for mets (if lump +ve) AUSCULTATE FOR PLEURAL EFFUSIONS/EXAMINE THE SPINE MAMMOGRAPHY OR USS (<35yrs) Record findings as follows:

Skin Examination
1. WIPE & Ensure good illumination (preferably natural light). 4. Measure Lesion Dimensions - helpful assessing progression and regression. 5. Attempt to transilluminate fluid swellings. 6. Assess skin colour and variations. 7. Describe the primary morphology of a localised skin lesion: Macule, Patch, Papule, Plaque, Wheal, Vesicle, Nodule, , Petechia or ecchymosis, Bulla, Telangiectasia, spider naevus 8. Describe the secondary characteristics: Superficial erosion, Ulceration, Crusting, Scaling, , Fissuring, Lichenification, Atrophy, Excoriation, Scarring or keloid, 9. Describe the distribution of a more widespread rash or colour change 10. Assess temperature of the affected area. 11. General Exam, looking for evidence of systemic disease.

24

Inguinal Hernia Examination

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

WIPE, EXPLAIN, CONSENT, Indirect Direct PRIVACY AND CHAPERONE Origin Via Int. Ring, Via posterior - stand up, examine both regions lateral to wall of inguinal INSPECTION: inferior canal, medial to Inguinal bulges into the corner of the epigastric inferior mons veneris, above the groin crease epigastric vessels vessels. Femoral bulges into medial end of groin Mech. May be Acquired, rare crease. Check for Scrotal Involvement. congenital in childhood PALPATION FRONT: Examine Strangulation Common Rare Scrotum & Contents. If you can get Scrotum Ext. Often Rare above it, its oHernia. N.B. Infant Reduces on Not readily Spontaneous hydrocele extends up the cord. lying PALPATION SIDE: Stand at side of Recurs post Uncommon Common hernia. Place a hand in the small of pts surgery back to support, and examining hand on the lump w/fingers and arm roughly parallel to inguinal ligament. External Genitalia Examination LUMP EXAM MSCENT WIPE Gloves and Standing. Kneel by COUGH IMPULSE compress lump side firmly w/fingers. cough. Mvmt of INSPECTIONLift up and look at swelling w/o expansion or increased everything. tension is not a cough impulse. !as absence may be due to adhesions. INSPECTION PENIS Size, Shape, Skin Colour, Foreskin, Discharge, REDUCIBILITY Use flat of hand from Scaling/Scabbing around distal edge below the lump, lifting the lower end upward and backwards. Press firmly to PALPATION Texture, assess dorsal relieve tension. Squeeze towards the vein. Retract prepuce to examine skin on deep inguinal ring. Reduces to: inner aspect, glans and external urethral meatus. ?Discharge Above & medial to the PT Inguinal. INSPECTION SCROTUM & SKIN Below & lateral to PT - Femoral ? Reddened, Tethered, Fixed. Check posterior IN/DIRECT No correlation w/surgical aspect. ? Size, Shape, Symmetry. findings. If controlled w/direct pressure PALPATION SCROTUM support over internal ring = direct. If not, with hand, feel testis & other lumps b/w indirect. index & thumb. ?2 testes. Position & RELEASE & WATCH: nature of testis, epididymitides & cords. Indirect = Slide obliquely through canal. LUMPS can you get above it? If not Direct = Project directly forward then an inguinoscrotal hernia.
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Transilluminable Hydro/Spermatocele ? Expansile Cough Impulse, Separate from testis, Cystic or solid? Separate Cystic: Epididymal cyst/Spermatocele Separate Solid: epidiymitis Testicular Cystic: Hydrocele Testicular Solid: Tumour, Orchitis, Granuloma, gumma Bag of Worms: Varicocele LYMPH Penis, Scrotum, Inguinals. Covering of testis & cord. Internal common iliac. Body of testis.

Lesions: Vasculitis, Neurofibromata, Telang. Muscles: Thenar Eminence Waste (Median N Lesion), General Wastage w/ thenar sparing (Ulnar N Lesion), Generalised (T1 lesion), Fasciculation MND, Syringomyelia, Charcot-Marie-Tooth, old polio PALPATION joints for temp, tenderness (active disease). Look for: Dupuytrens, nodules, calcinosis, xanthomata. OAnodes: Heberdens = DIPs, Bouchards = PIPs (varus knee deformity, Trendelenburg +ve) SENSATION - ?Numbness (worse nocte- Carpal Tunnel) Median - Index pulp, !thenar eminence, flex. aspects of radial 3 digits upto ext. Nail beds. Changes with Carpel Tunnel Syndrome. Ulnar Pinkie pulp, ! palmar/dorsal side of ulnar 1and fingers Radial dorsum of 1st Intermetacarpal space PROPRIOCEPTION & VIBRATION TONE flex/ext joints MOTOR: Open/close hands quickly Myotonic Dystrophy Squeeze my fingers C8/T1 Radial fingers out straight, stop me bending them (C7) !Wrist Drop Ulnar DAB & PAD tests !Claw Hand (hyperextended metacarpophalangeal joints) Median APB & OP, !Thenar Eminence waste and weak pincer grip FUNCTION undo a button, hold pen, pick up paper PULSES
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Hand Examination
WIPE White Pillow w/elbow exposed INSPECTION FACE: Systemic sclerosis (expressionless, telengeictasis), Cushingoid (Steroids in RA), Exopthalmos (Thyroid) ELBOWS Place hands on shoulders look for psoriasis/rheumatoid nodules INSPECT HANDS Conditions inc: -Phalangeal -Boutonnieres/Z Thumb, Triggering, Swan Neck -MCP Volar sublux, ulnar deviation -Wrist Disruption, Ulnar Sublux -Elbow Rheumatoid Nodules -Gout: Asymmetrical swelling, tendon tophi -Sys. Sclerosis: Sclerodactyly w/finger tapering, fingertip gangrene, calcified nodule, tight skin -Psoriasis: Nail pitting, Scaly rash, terminal interphalangeal arthopathy INSPECT HANDS: Nails: Onycholysis, Fold Infarcts (RA) Skin Colour: Icterus, erythema, pigmentation Consistency: tight/shiny, paper thin, purpura

Elbow Examination
WIPE Stand, check affected INSPECTION front/back/sides, ?carrying angle PALPATION for temp, tenderness PALP lat/medial epicondyles, olecranon process, radial head. MOTION ACTIVE Ext, Flex, Supination, Pronation, then PASSIVE MOTION RESIST Flex, Ext, Sup/Pronation FUNCTION Eating, Brushing hair SPECIAL TESTS - ?Tennis, ?Golfers

Cervical Spine and Neck

WIPE Stand INSPECTION front/back/sides ?Symmetry, height of shoulders, Scars, Swelling, Muscle bulk/waste, erythema, ease of wt. Bearing, shape, bruises PALPATION - for temp, tenderness PALP Soft tissues Trap, SSPinatus, Rhomboids, ISpinatus, Lat. Dorsi, spinous processes. MOTION ACTIVE Rotate L/R, Flex, Ext, Side Flex (L/R), rpt. PASSIVE MOTION RESIST Flexion (C1), Ext (C2), Side Flex (C3), Shoulder girdle Elevation (C4), Shoulder Adduction (C5), Elbow Flex (C6), Ext (C7), Thumb Ext (C8). SENSATION Dermatomes REFLEXES biceps, triceps and BR.

Shoulder Examination
WIPE Standing, check affected INSPECTION ? front/back/sides Symmetry, Scars, Swelling, Muscle Bulk PALPATION for temp, tenderness PALPATION SCJ, clavicle, ACJ, Acromium, Scapula, Medial Border, Inferior Angle, Lateral Border, Acromium + other side. PALP = Effusions Joint lines & humeral head PALP Supraspinatus, Trap, Infra, MOTION Good first ACTIVE: Abduction, Flex, Ext. External Rotation (together), Int. Rtn, Arm across chest. Repeat PASSIVELY palp. @ joints for creps. MOTION Resisted Int/Ext Rtn, Abduction (s.spinatus, then pec. Major and lat. Dorsi, then deltoid@90o, trapezius @ 120o), flex/ext, biceps ext, empty can test (SSPinatus).

Lumbar Spine Examination

WIPE Stand, check affected EXAMINE front/back/sides INSPECTION ?Symmetry, height of shoulders, Scars, Swelling, Muscle bulk/waste, erythema, ease of wt. Bearing, shape LIE PRONE PALPATION for temp, tenderness PALP bony landmarks along spine, spinous processes, iliac crests, paraspinal muscle, SI joints. STAND MOTION Place hand at lumbar spine Flexion forwards run hands along leg from knee bend forward Extension hands on hips and lean back
27

Side Flex slide hand along one side to knee LIE SUPINE MOTION MYTOTOMES RESIST check myotomes -Hip Flexion (L2), Extension (L3) -Foot Dorsiflexion (L4) -Resist Hallux Extension (L5) -Resist foot Inversion (S1) - Resist Plantar Flexion (S2) SENSATION Dermatomes, !thigh REFLEXES Knee (L3/4), Ankle Jerk (S1/2), Babinski MOTION Straight leg, raise w/ foot dorsiflexion enquire if pain worsens.

Hip Examination
WIPE Stand INSPECTION front/back/sides, bulk, deformity, scars, colour, gait Trendelenburg Test LIE SUPINE PALPATION for temp DEEP PALP G. Trocanter, CHECK LEG LENGTH : True: ASIS to Medial Malleolus Apparent: Umbilicus to Medial Malleolus MOTION Flex/Ext, Int/Ext Rtn, Abd/Adduction. Rpt PASSIVE w/ hand on joint. Rpt RESISTED THOMAS TEST hand under back and flex knee to hip LIE PRONE Active ext, Passive ext.

EXAMINE Bakers Cyst, Valgus (knock-kneed), Varus (bow-legged), antalgic gait INSPECTION Masses, Scars, Lesions, Trauma, Swelling (?Medial Fossa Oedema) INSP Muscle bulk & Symmetry, esp. atrophy of medial aspect of quads vastus medialis, Patella displacement. PALPATION for temp above/on/below patella PALPATION joint line tenderness: flex knee & palpate joint line w/ thumb PALP = Effusions Patellar Tap, Ballotment, Bulge Sign MOTION FULL R.O.M = 0-135o ? Crepitus ACL Ant. Draw and Lachman PCL, MCL and LCL McMurray Test rotate leg and extend knee Med Meniscus -ext Rtn w/lat force -mel Lat Meniscus int Rtn w/medial force

Ankle and Foot Examination

WIPE Stand, check affected INSPECTION front/back/sides, ?Symmetry, varus/valgus, shape, gait Check footwear LIE SUPINE PALPATION for temp, tenderness PULSES Dorsalis Pedis, Post. Tibialis BONY PALP Med/lat malleoli, joint line, calcaneum, plantar fascia insertion, fascia, medial longitudinal arch, 1&5th MPJs

Knee Examination
WIPE Supine + Expose Quads

28

 MOTION ACTIVE Dorsi/Plantar Hypervolaemia: flexion, Inversion, Eversion PASSIVE Intravascular: inc. toe flex/ext. High BP, Raised JVP, HS III, Pulm. Oedema RESIST dor/plant. flex, ever/inversion, Extravascular: toe flex/ext. Oedema, 3rd Space Fluid -Pleural, Peritoneal ANKLE DRAW TEST checking ant. talo-fibula ligament Hypovolaemia Class: REFLEXES Ankle & Babinski LIE SUPINE 1 2 3 4 Palp. Muscle bulk, Ach. tendon, temp, %loss <15 15-30 30-40 >40 SIMMONDS TEST Achilles Tendon Vol (l) <3/4 7501500>2000 1500 2000 integrity
Sys N N N N >30 N N A 20-30 Pale Pale Anger Angst N 100120 120 Thread >20 10-20 Pale Pale As 2 +/Drowsy 120+ V.Thready >20 0-10 Cold & Clammy Ash As 3 +/confusion/ LOC

Volume Status Assessment

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

Dia HR RR Urine ml/m CRT Appear Mental State

Explaining Procedures
WIPE (greets, states name and role, confirms patients name and DOB) EXPLANATION AND CONSENT (purpose, time available) EXISTING KNOWLEDGE (ask what pt knows about procedure, ever had it before or know of anyone who has) TELL THE PT YOU CAN FIND OUT ANY INFO THAT YOU DONT KNOW

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

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(e.g. specific concerns about times etc these are covered in the appt. letters, and they can ring the hospital to confirm details) ENCOURAGE QUESTIONS (tell them to ask any qs, or interrupt if they dont understand) ELICIT WORRIES/CONCERNS ( particularly about pain/embarrassment) EXPLAIN WHAT THE PROCEDURE IS (why they are having it, what will happen) EXPLAIN WHY THEYRE HAVING IT (if you know why/if they specifically ask) EXPLAIN WHAT WILL HAPPEN BEFORE THE PROCEDURE (where they will have to go, will they need to bring someone, any preparations such as laxatives, food restrictions, medication changes, reassure them about the discomfort, embarrassment) ASK ABOUT ANY MEDICATIONS (esp. about anti-coagulants and insulin, tell them to consult their GP or specialist before they stop taking etc) EXPLAIN WHAT WILL HAPPEN DURING THE PROCEDURE (how long it will take, sedation, analgesia, biopsies, monitoring, who will be present, how long till results) ASK ABOUT PREVIOUS ALLERGIES (particularly to analgesia or sedatives, what happens etc) EXPLAIN ABOUT THE RESULTS (when they will get them, from who, what they might show) EXPLAIN WHAT WILL HAPPEN AFTER THE PROCEDURE (getting home, length of stay, sedations effects, when they can go back to work, what they can / cant do, food restrictions)

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

Injections
WIPE, GLOVES, SET UP EQUIPMENT CHECK DRUGS (expiry date, correct drug, seals intact, correct dilutant etc) CLEAN SITE (alco swab, allow to dry) CORRECT NEEDLE AND SYRINGE Intradermal 1ml syringe, 25G/orange needle, Subcutaneous 2ml syringe, 23G/blue needle, Intramuscular 5ml syringe, 23G/blue needle INSERT NEEDLE WARN PT FIRST (sharp scratch) INSERT NEEDLE CORRECTLY Intradermal parallel to skin, approx3mm deep, Subcutaneous pinch skin, 20-30 angle, Intramuscular - 90 angle, 2-3cm deep ASPIRATE ( do not for intradermal) INJECT SLOWLY REMOVE NEEDLE (apply pressure, clean if necessary, do not apply pressure to intradermal injections) DISPOSE OF SHARPS/WASTE OBSERVE FOR ADRs THANK PT, COMFORT, REASSURE RECORD IN NOTES
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Infusions
WIPE, GLOVES, SET UP EQUIPMENT CHECK FLUID BAG (check expiry date, correct fluid/drug, seals intact etc) CHECK CANNULA (flush cannula, ensure it is still in place/clean) PREPARE BAG / GIVING SET INSERT SPIKE INTO BAG (ensure a level surface, beware puncturing bag, beware sharps injury from spike) RUN FLUID THROUGH (no air bubbles, fill chamber, ensure fluid runs out the end, turn off before connecting) CONNECT CANNULA & GIVING SET (tube screwed in place/ secure) START FLUID SET INFUSION RATE (as a rough guide, 20 drips per ml for crystalloid, 15 drips per ml for blood/colloid) DISPOSE OF SHARPS/WASTE THANK PT, REASSURE, ASK ABOUT QUESTIONS RECORD DETAILS (document fluid, time started, time finished, volume, duration of infusion etc)

Locate femoral artery, halfway b/w the ASIS & pubic symphysis, 2 cm below the inguinal ligament. Clean skin over artery w/ alcohol swab. Raise a bleb of local anaesthetic. Fix the artery between two fingers whilst inserting heparinised needle and syringe at 90 to skin. Slowly advance the needle till there is free flow into syringe. Radial artery Before procedure, perform the Allen test: Occlude both ulnar & radial arteries digitally, allowing venous drainage. Release ulnar artery while keeping radial artery compressed. Hand colour should return in <5s, indicating there is sufficient collateral blood flow from the ulnar artery. If the patient fails, radial ABG should not be attempted. Pt supine w wrist & thumb extended. Place a rolled up hand towel under the dorsal surface of the wrist. Palpate the radial artery Clean skin proximal to the wrist joint. Raise a small bleb of local anaesthetic at the proposed entry site with a 25G needle into the skin. Insert the needle of a heparin-coated 2ml syringe at 60-90 through the skin, ensuring avoidance of air in the syringe. Palpate the radial artery proximally, using it as a guide of direction to advance needle. The arterial blood pressure will fill the syringe automatically. Withdraw the needle and apply pressure for 5 minutes. Cap the syringe and place in bag of ice if immediate analysis not possible.
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Arterial Blood Gas Sampling

WIPE, ?On O2/Air, record conc. , flow rate.
Equipment: ABG syringe w/Heparin, Alcohol swab, Swab, 1% lignocaine local anaesthetic, Syringe and blue needle for anaesthetic

Femoral artery Lay pt supine w/ groin and leg extended and slightly abducted.

Venepuncture
WIPE CHECK CORRECT BLOOD FORMS (ensure form matches pt, check what samples are needed) GLOVES, SET UP EQUIPMENT CHECK WHICH ARM - ask about surgeries, mastectomies etc, ?preference APPLY TOURNIQUET (place arm below the level of their heart, and make fists repeatedly) FIND AN APPROPRIATE VEIN (bifurcations are tethered, always go above bifurcation, palpate vein well) CLEAN THE SITE (alco swab, dry) INSERT NEEDLE WARN PT FIRST (sharp scratch) INSERT NEEDLE CORRECTLY (30 angle, until flashback is seen or until you feel the vein give)

FILL VACUTAINERS/SYRINGES REMOVE TOURNIQUET W/DRAW NEEDLE (place a swab over the area first) + APPLY PRESSURE DRESS THE WOUND (gauze or plasters, ?allergies before using plasters) DISPOSE OF WASTE/SHARPS THANK PT, REASSURE, COMFORT LABEL BOTTLES CORRECTLY/SEND TO LAB

Suturing
WIPE easy wound access, good lighting PREPARE EQUIPMENT (sterile trolley, anaesthetic, sterile instruments etc) PUT ON STERILE GLOVES (open method) CLEAN WOUND pick out debris, irrigate w/ normal saline, arrange x-ray

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

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to check for foreign bodies, clean wound w/ chlorhexadine from inside out, dispose of swabs after use DRAPE WOUND CREATE STERILE FIELD (ensure pt or non-sterile equipment does not touch field) ANAESTHETISE WOUND use 1% lidocaine, draw from sterile ampoule, after first injection put needle through anaesthetised area, do both wound edges WAIT FOR ANAESTHETIC TO WORK (3-5 minutes) CHECK ANAESTHESIA (pt should feel pressure nut not pain, should feel numb) CHECK VACCINATIONS (ensure pt has up to date tetanus vaccinations etc) WARN PT BEFORE STARTING CORRECT NEEDLE HANDLING (never touch the needle, hold needle 2/3 from point w/ needle holders) PLACING SUTURE (evert wound edge w/ toothed forceps, needle enters at 90 to skin, approx.0.5-1cm deep & 0.5cm from wound edge, come out in centre of wound & repeat for 2nd side) KNOT TYING (use at least 3 throws, line up knots on one side, cut approx. 1cm from knot) PLACING 2ND SUTURE (lay sutures approx. 1cm apart, line up knots) INFORM PT OF SUTURE CARE ( should be removed after 7days at GP or A&E, keep wound dry, showers not baths, avoid getting wound dirty) DRESS WOUND (clean and dry wound apply a clean dressing and remove drape)

DISPOSE OF SHARPS (all sharps/needles must go in a sharps bin once they have been used) DISPOSE OF WASTE (all clinical waste, including drapes, swabs and gloves must be placed in the yellow/clinical waste bins) DOCUMENT PROCEDURE THANK PT, CHECK PT UNDERSTANDS WOUND CARE AND REMOVAL INSTRUCTIONS

PEFR and Inhalers

WIPE START W/ PEFR ASK PT TO STAND UP PREPARE FLOW METER (attach mouth piece, reset slide to bottom) DEMONSTRATE OR EXPLAIN PROCEDURE (deep breath in, seal lips around mouth piece and blow out as hard and fast as possible like blowing out a candle across the room) ASK PT TO REPEAT 3 TIMES (reset slide to 0 every time, allow pt to recover in between) RECORD THE BEST OF 3 VALUES COMPARE PT TO AGE/HEIGHT CORRECTED GRAPHS BEFORE AND AFTER BRONCHODILATORS (if on the drugs) STATE YOU WILL TEACH THEM HOW TO USE INHALERS ASK FOR ANY QUESTIONS/EXPLAIN BRONCHODILATORS OR ASTHMA (as necessary)

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 DEMONSTRATE OR EXPLAIN PROCEDURE MDI CHECK DRUG/EXPIRY DATE REMOVE MOUTH COVER/CHECK FOR OBSTRUCTIONS SHAKE INHALER HOLD INHALER VERTICALLY EXHALE START BREATHING IN PLACE INHALER IN MOUTH (seal lips tightly around it) DEPRESS BUTTON AND KEEP BREATHING IN HOLD BREATH FOR 10s BREATH OUT WATCH PT AND CORRECT ANY MISTAKES (repeat until they get it right) EXPLAIN STEROID INHALERS (need to wash mouth out after use to avoid oral candidiasis) ASK FOR QUESTIONS (explain common mistakes not triggering in at right time, not breathing in enough, not holding breath long enough) CHECK UNDERSTANDING THANK PT, REASSURE, COMFORT

Blood Pressu re Measurement

WIPE - easy access to arm, remove tight clothing from the arm ASK QUESTIONS (check pt sitting comfortably, ? caffeine, exercise, stress) PREPARE SPHYGMOMANOMETER (ensure level w/ pts heart, select appropriate size cuff)

CHECK ARM (ensure pt has no problems, previous surgery etc w/ the arm you intend to use) PALPATE BRACHIAL ARTERY (medial to biceps tendon) PLACE CUFF over brachial artery, tubes out of the way, high up on arm to allow steth. access, ensure it is tight PALPATE RADIAL ARTERY WARN PT INFLATION OF CUFF BEING UNCOMFORTABLE (reassure them that it does no damage and will be over quickly) INFLATE CUFF UNTIL RADIAL ARTERY DISAPPEARS DEFLATE CUFF PLACE STETHOSCOPE OVER BRACHIAL ARTERY REINFLATE CUFF TO 10mmHg ABOVE THE DISAPPEARANCE OF THE RADIAL ARTERY DEFLATE CUFF AT 2mmHg/s LISTEN AND RECORD 1ST AND 5TH KOROTKOFF SOUNDS REPEAT IN BOTH ARMS (>10mmHg difference indicates aortic dissection) REPEAT STANDING (>10mmHg drop indicates postural hypotension) THANKS PT, ANSWER QUESTIONS

CXR Interpretation
PT DETAILS Name, Age, DOB, H# RADIOGRAPH DETAILS Date, Time, Type of film, Position, Indication ROTATION (=l distance from spinous processes to medial ends of clavicles) PENETRATION (outline of vertebral bodies visible behind the heart border)
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 INSPIRATION (right hemi-diaphragm level w/ the tip of the 6th anterior rib) COMMENT ON OBVIOUS ABNORMALITIES (tubes, lines, clips, masses, opacities) AIRWAY (trachea, hilum, lung apices) BONES (ribs, bony structures, soft tissues, breast) CARDIAC (cardiac outline, cardiodiaphragmatic recess, cardiomegaly, L & R heart border, mediastinum) DIAPHRAGM (costo & cardiophrenic angles, air under diaphragm, gastric bubble, abnormal peaking or flattening, relative positions of hemi diaphragm) EVERYTHING IN BETWEEN FIELDS (contents, pleura - ?thickening) REVIEW AREAS (apices, retrocardiac area, peripheral lung margins, diaphragm, air in SC tissues) SUMMARY DIAGNOSIS

SYSTEMATIC REVIEW: BONES, BOWEL, BILIARY TREE (obstructions, stones, dilations) AORTA (calcification, widening) CALCIFICATION (look at gall bladder, pancreas, kidneys, bladder, arteries) KIDNEYS (calcification, stones, dilation, distension, position) URETERS (trace ureter from kidney to bladder, look for stones, dilations, strictures, look at bladder for position, size, stones) PSOAS MUSCLE SUMMARY DIAGNOSIS

ECG Interpretation
PT DETAILS Name, Age, DOB ECG DETAILS Date, Time, is it part of a series e.g. MIs, Indication CALIBRATION (paper speed 25mm/s, 1mV = 10mm vertical deviation) RATE (regular: 300/RR interval, irregular: number of QRS complexes in rhythm strip x 6) RHYTHM (reg, reg irreg or irregularly irregular, sinus P wave before every QRS complex) AXIS (Normal: QRS deviation in I & II is up. LAD: QRS in I is up, and down in II (leaving), RAD: QRS in I is down, and up in II (reaching). LAD : Normal in pregnancy / emphysema Path L.Ant. Fasc. Block, or Q waves MI RAD: normal in children/dextrocardia Path - L.Post. Fasc. Block or Q waves from high lateral MI
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AXR Interpretation
PT DETAILS Name, Age, DOB, H# RADIOGRAPH DETAILS Date, Time, Type of film, Indication ADEQUACY EXPOSURE (xiphisternum to pubic symphysis, both flanks) ADEQUACY PENETRATION (spinous process visible through vertebral bodies) INTRALUMINAL GAS Volume and Distribution EXTRALUMINAL GAS Distribution COMMENT ON OBVIOUS ABNORMALITIES (tubes, lines, clips, masses, opacities)

Leads: Anatomical Relationship Lateral I, aVL, V5/6 Inferior II, III, aVF Anterior V3/4 Septal V1/2 MORPHOLOGY P WAVES ?before every QRS, ?p pulmonale (peaked) - lung disease/RAH or p mitrale (saddle) MR. ? atrial flutter saw tooth P-R INTERVAL (normally 0.12-0.2s, shorter indicates extra conduction pathways, longer indicates heart block) QRS COMPLEX WIDTH (normally <0.12s, wide indicates bundle branch block look at V1 and V6 for WilliaM MarroW signs indicating L and RBBB respectively.) QRS COMPLEX HEIGHT (tall R wave indicates ventricular hypertrophy, V1: right, V2: left) QRS COMPLEX Q WAVE (normally <0.04s and <2mm, pathological Q wave w/in hours of an MI) QT INTERVAL (corrected for a heart rate of 60 using QTc = QT/RR interval) QT = [Ca2+] and v.v. ST SEGMENT (should be isoelectric, elevated in MI, depressed in ischemia) - Digoxin reverse tick sloped depression T WAVES (normal inversion in III, aVR and V1) Inverted = Ischaemia, LVH, Digoxin, Pericarditis and BBB Flattened = Ischaemia, K+ Tall / Tented = K+ (Hyperacute = tall w/ broad base & asymmetry = acute MI) U WAVES (can be normal or K+) SUMMARY AND DIAGNOSIS
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