Examinations - This is a summary of notes I have put together to help me revise for the clinical PDF

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This is a summary of notes I have put together to help me revise for the clinical exams....

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Examinations and history taking Abdominal examination https://www.youtube.com/watch?v=PYAnF6GJY2I Introduction (WIPERQ) - Wash hands - Introduce yourself + confirm patient details - Position patient correctly - Expose patient - R(?) - Questions, in any pain etc General inspection - Bedside table e.g. feeding tubes, stoma, drains - Patient’s appearance e.g. agitated, pain, confusion - Body habitus e.g. obese/cachexic - Jaundice e.g. cirrhosis/hepatitis - Pallor (suggests anaemia e.g. upper GI bleeding) - Scars (midline - laprotomy, RIF - appendectomy, right subcostal cholecystectomy) - Abdominal distension e.g. ascites, masses, bowel distension - Masses e.g. organomegaly/malignancy - Main are JAMSB (jaundice, abdominal distension, masses, scars, body habitus) Inspection - Hands - Clubbing - inflammatory bowel disease (IBD e.g. Crohn’s), Coeliac disease, cirrhosis - Koilonychia - spooning of nails (chronic iron deficiency) - Leukonychia - whitening of nailbed (hypoalbumenia - liver failure/enteropathy) - Palmar erythema - reddening of palms (liver disease/pregnancy) - Dupuytren’s contracture (thickened fascia, excess alcohol)

- Hepatic flap - hold out arm fully extended and dorsiflexed, 15 seconds, flap if hepatic encelopathy - Arms - Bruising (abnormal coagulation - secondary to liver failure) - Petechiae (reddish/purplish/brownish spots on arm) - Track marks (IV drug use e.g. HIV/hepatitis) - Excoriations (pruritis due to cholestasis) - Axilla - Lymphadenopathy (malignancy/infection) - Hair loss (malnourishment) - Acanthosis nigricans (hyperpigmentation - GI adenocarcinoma/obesity) - Eyes - Xanthelasma (yellow rings around eyes - hyperlipidaemia) - Conjuctival pallor (anaemia) - Jaundice (esp in sclera) - Mouth - Angular stomata (iron/B12 deficiency) - Oral candiadidis (iron/B12 deficiency) - Ulcers (Crohn’s/coeliac disease) - Tongue glossitis - B12/folate/iron deficiency - Neck - Cervical lymph nodes - lymphodema (infection/metastatic malignancy) - Virchow’s node - left supraclavicular fossa (gastric malignancy) - Chest - Gynecomastia - liver cirrhosis, spironolactone/digioxin - Loss of hair - malnourishment/iron deficiency anaemia - Spider naevi - >5 is of concern, chronic liver disease Detailed inspection - Scars - midline (laprotomy)/RIF (appendectomy)/right subcostal (cholecystectomy) - Masses - organomegaly / malignancy

- Pulsations - central pulsatile and expanding mass suggests AAA (abdominal aortic aneurysm) - Cullen’s sign - bruising around umbilical region (retroperitoneal bleeding/ ruptured AAA) - Grey-Turner’s sign - bruising around flanks (“) - Caput medusae - distended paraumbilical veins (portal hypertension) - Striae - white/silver (old) pink/red (new) - Abdominal distension (5Fs) - fat (obesity), fluid (ascites), flatus, faeces (constipation), fetus (pregnancy) - Stomas - colostomy (LIF), ileostomy (RIF), urostomy (RIF and some urine)

Palpation - Ask about areas of pain but examine them last, kneel to level of patient, observe face for any discomfort - Examine each of the 9 quadrants - Light palpation - tenderness, rebound tenderness (tenderness only comes on when releasing pressure e.g. peritonitis), guarding (involuntary tension in abdominal muscles), masses

- Deep palpation - location, size, shape, consistency, mobility (attached to superficial/deep underlying tissue), pulsatility (pulses suggests vascular aetiology) - Palpating liver - pass the radial part of flat side of right hand (by index finger) over the liver, ask patient to take a deep breath, you should feel liver slide under, if it doesnt repeat but 1-2cm higher. Feel regularity of the edge of the liver, how far it extends below the costal margin - Palpating the gallbladder - healthy gallbladder should not be palpable, place hand over right costal margin in the mid-clavicular line (9th rib tip) and ask patient to take a deep breath. Enlarged gallbladder - due to obstruction to biliary flow - will be palpable. - If when palpating on deep breath, you are able to feel the gallbladder, and the patient feels pain - but no discomfort when you repeat on the left - this is a positive Murphy’s sign. - Palpating the spleen - can only be palpated when 3x its original size, place hand over RIF in the same direction as left costal margin, ask patient to take a deep breath, if enlarged should be able to feel the spleen pass over - Palpating the kidneys - place right hand in right costal margin in the right flank, use left hand in this location at the back, ask patient to take a deep breath, you may be able to feel the lower pole of kidney descend inferiorly. Repeat on left side. - Palpating the aorta - use both hands at the midline just above the umbilicus on the border of the aortic pulsation, note the movement of fingers, upwards movement is pulsatile yet outwards movement is expansile (suggests AAA) - Palpate bladder Percussion - Percuss liver - from RIF upwards, and then from right side of chest downwards - Percuss the spleen - from RIF up to left hypochondrium

- Percuss the bladder - suprapubic region; differentiating between suprapubic masses (bladder mass - dull sound, bowel - resonant sound) Shifting dullness - Percuss from centre of abdomen towards each flank - Note the point at which it becomes dull - Ask the patient to roll over on the opposite side - Then the point which was dull should now sound resonant - if there was fluid present (ascites) - Go back to the midline - this point in the midline will now sound dull if ascites is present Auscultations - Normal sound = gurgling, abnormal sound = tinkling (suggests bowel obstruction) - No sound suggests ileum/peritonitis - Bruits: aortic bruits - auscultate just above the umbilical area (AAA), renal bruits - auscultate just above the umbilical region but slightly lateral to the midline Further assessments - Hernias - External genitalia - Digital rectal examination Wash hands Thank patient Summarise findings

GI history taking ● Opening consultation ● Presenting complaint ● Presenting symptoms - For each symptom presented, ask about: onset (when/sudden/gradual), course (are symptoms worsening/getting better/fluctuating), duration (days/weeks/months/years), severity, intermittent/continuous, precipitating and alleviating factors, previous episodes ● Upper GI symptoms - Mouth - pains/ulcers/growths - Dysphagia - onset/progression/solids and/or liquids - Odonyphagia - pain on swallowing/oral candiadidis ● Nausea and vomiting - Frequency and volume - Projectile vomit - suggests obstruction - What does the vomit look like? Undigested food (pharyngeal pouch/achalasia/oesophageal stricture); non-bilious vomit (pyloric obstruction e.g. stenosis); bilious vomit (lower GI obstruction) - Haematemesis - fresh red blood (Mallory-Weiss tear/oesophageal rupture), coffee ground (bleeding peptic/duodenal ulcer) - Anorexia/weight loss - how much weight has been lost, since when ● Abdominal pain - depends on location: RIF (appendicitis), LIF (diverticulutis), flank (pylonephritis), epigastric (gastritis/oesophagitis), right upper quadrant (cholecystitis/hepatitis), suprapubic (cystitis) ● Use SOCRATES to find out about pain - site, onset, character (dull/sharp), radiation, alleviating factors, timing, exacerbating factors, severity ● Bloating (abdominal distension) - fat/flatus/faeces/foetus/fluid ● Altered bowel habits - Diarrhoea - consistency (Bristol stool chart), mucuous (IBD/IBS), blood, malena, urgency, recent antibiotics, recent suspect use, laxative use

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- Constipation - Colour of stool - malaena (peptic/duodenal ulcer, malignancy), pale/steatorrhoea (gallbladder stones/lower GI malignancy), fresh red blood (haemorrhoids, anal fissure) Jaundice - infectious (hep B/C), malignancy, alcoholic liver disease, autoimmune, congenital (Gilbert’s syndrome) Ideas, concerns, expectations Summarise findings Signposting Past medical history - GI diseases, other medical conditions, surgical history, any recent hospital admissions Travel history - local food, contact with dirty water, insect bites Drug history - GI medications, over the counter medication, regular medication, contraception (RIF pain could be ectopic preg) Family history - GI diseases, hereditary causes (e.g. HNPCC / FAP) Social history - alcohol, smoking, drugs, diet (e.g. fibre, gluten, fatty foods), who they live with Systemic enquiry - cardiovascular, resp, GI, urinary, CNS, musculoskeletal, dermatology Closing the consultation

Rectal examination ● Introduce yourself - WIPERQ, explain nature of examination (finger into back passage, uncomfortable, but not painful, and will only last a short while), gain consent and request chaperone if needed ● Gather equipment - gloves, apron, lubricant and paper towels ● Preparation - put on apron and gloves, ask patient to remove underwear, give blanket cover, leave room and give them time, ask them to sit in left lateral position, knees to chest. ● Inspection - separate buttocks and look for: - Skin excoriations (sphincter dysfunction/incontinence) - Haemorrhoids (thrombosed?) - Skin tags

- Rashes - Anal fissures (posteriorly in the midline) - Fistulae/abscesses (perianal Crohn’s disease) - External bleeding (GI pathology/anal pathology such as squamous cell anal cancer) ● Palpation - Tell them you’re going to insert finger, then insert finger into anal canal - Palpate prostate anteriorly - note the size symmetry and texture, should be walnut sized and symmetrical, with palpable midline sulcus, tip of the nose texture. - Abnormal prostate may have asymmetry, with boggy texture (fluid filled - associated with prostatis), midline sulcus may not be palpable anymore - may be smooth (benign prostatic hypertrophy) or irregular (malignancy) - Rotate finger 360deg to feel the rectum - note any masses/irregularities, and any stool (soft/compact) - Assess anal tone by asking the patient to squeeze your finger - Withdraw finger - inspect for blood (fresh red/melena), inspect for stool/mucus - Clean patient with paper towels, cover them with the sheet provided, allow them to get dressed (leave room) - Dispose of clinical waste - Wash hands ● Complete examination - thank patient + summarise findings ● Further investigations could include: full abdominal examination, abdominal X-ray, bloods, faecal occult blood, flexible sigmoidoscopy/colonoscopy, CT abdomen/pelvis Hip examination ● Look, feel and move Look

● General inspection - Front: scarring, quadriceps wasting, pelvic tilt, foot deformity - Side: lumbar lordosis, knee flexion, foot arches - Behind: scoliosis, gluteal bulk, pelvic tilt ● Observe gait - smoothness, turning, speed - Note any antalgic gait/Trendenenberg gait - Assess patient’s footwear Feel ● Feel tissues overlying hips - tenderness indicates infection/inflammation ● Feel greater trochanter - tenderness suggests trochanteric bursititis ● Measure apparent leg length - umbilicus to tip of medial malleolus ● Measure true leg length - ASIS to tip of medial malleolus Move ● Active movements - active flexion ‘bring your knee to your chest’ normal ROM is 120° ● Passive movements - Flexion - Internal rotation - rotate foot laterally, normal ROM is 40° - External rotation - rotate foot medially, normal ROM is 45° - Abduction - stabilise contralateral iliac crest, use other hand to abduct the hip until the pelvis tilts, normal ROM is 45° - Adduction - stabilise contralateral iliac crest, use other hand to adduct the hip until the pelvis tilts, normal ROM is 40° ● Position patient prone to test for hip extension - lift one leg at a time, normal ROM is 10-20° Special tests ● Thomas’ test - Place one hand under the patient’s spine, passively flex unaffected leg as much as you are able to, lumbar lordosis should flatten, contralateral leg should remain flat - If contralateral leg lifts off the bed, this is a positive sign, indicates fixed leg flexion deformity in the affected hip

● Trendelenberg’s sign - Place hands on both iliac crests - Ask patient to lift each leg for 30 seconds - Iliac crest on the side where leg is raised should lift upwards too - If it falls down, this is a positive sign, which indicates weak hip abductors in contralateral side To complete the examination ● Thank patient, wash hands, summarise findings ● Further assessments - full neurovascular examination of both legs, examine joint above and below (lumbar spine/knee), imaging - X-ray, CT, MRI Cardiovascular examination https://www.youtube.com/watch?v=XU_xeUMJ3Zc&feature=youtu.be&fbcli d=IwAR21zREnWGoecSzojr7KkAjFtnZx7ZRu6S25p_yEn-C1jdlDwj_t4yOK Xd8 https://geekymedics.com/wp-content/uploads/2013/04/Cardiovascular-Exa mination-OSCE-Mark-Scheme.pdf ● Introduction - Wash hands - Introduce yourself, confirm patient details, explain the examination, gain consent - Position the patient 45deg with chest exposed + ask if they are in pain ● General inspection - bedside table, general pallor, chest (scars), legs ● Hands - *Clubbing - Schamroth’s window, sign of infective endocarditis and cyanotic congenital heart disease - *Temperature - cold suggests reduced cardiac output - *Capillary refill time (...