Documentos de Académico
Documentos de Profesional
Documentos de Cultura
CLINICAL EXAMINATION
NEUROLOGIC EXAMINATION
Cranial Nerve Examination
Inspection: scar marks, asymmetry of face, eyes,
pupils, wasting
I ask patient to smell
II PEARL, Funduscopy, VA, pinhole test, visual
fields,
III, IV, VI ptosis; presence of asymmetry of eyes and
pupils; extraocular movements; accommodation
V sensation (ophthalmic, maxillary, and mandibular)
and motor (clench teeth - masseter; open mouth and
push to close pterygoid muscles; if weakened jaw
deviates to affected side); corneal reflex; jaw jerk
(UMN)
VII close eyes and dont let me open them, smile,
wrinkle forehead, puff up cheeks
VIII whisper test; rinne test and weber (256)
IX and X hoarseness; cough; ask to sip water to
check problems with swallowing; Gag reflex and uvula
XI raise shoulder and SCM
XII tongue
TIA Examination
Face: asymmetry of face, ptosis, eyes/pupil of equal
size, redness/swelling; PEARL; ophthalmoplegia;
accommodation; funduscopy
JVP, carotid pulse and bruit
Upper/Lower limb neurologic examination
Neurological Examination of the Upper Limb
Inspection: signs of head injury, facial asymmetry,
ptosis, muscle wasting and fasciculation
Palpate muscles for tenderness, Pronator drift
(UMN/cerebellar lesion), tremors,
Tone
Power (shoulder grasp, biceps and triceps power,
flexion and extension of wrist, grasp, flexion and
extension of fingers; adduction and abduction of
fingers
Reflexes: biceps, triceps, brachioradialis
Sensation
Vibration and Proprioception
Finger-to-nose test and alternating movements
(dysdiadochokinesia)
Neurological Examination of the Lower Limb
Inspection: wasting of muscles, tremors,
fasciculations, surgery marks, deformity
Gait assessment: observe for limping
Walk on heels: L5
Walk on toes: S1
Squatting
Romberg test
Heel-Toe Walking
Palpation for tenderness of muscles
Power (hip flexion and extension, knee flexion and
extension, adduction, abduction, inversion, eversion,
plantar flexion, dorsiflexion)
Reflexes (knee, ankle, babinski, clonus)
Sensation
Vibration and Proprioception
Cerebellar: Heel-to-shin, foot tapping test
2
Hypothyroidism: brittle, dry and coarse,
alopecia, loss of eyebrows, periorbital
edema, facial puffiness, xanthelasma (lipid
deposits over the lower eyelids), swollen
tongue
Other signs (Hypocalcemia):
o Schvostek: twitching of facial muscles upon
tapping of the facial nerve along the angle of
the mandible
o Trousseau: flexion of wrist and MCP joints
upon inflating the BP cuff above systolic.
Chest: gynecomastia in hyperthyroidism; pleural
effusion (hypothyroidism)
CVS: hyperdynamic circulation (arrhythmia and
cardiac failure) and systolic flow murmurs; pericardial
effusion (hypothyroidism)
Myopathy: sit and stand hyperthyroidism
Legs: pretibial myxedema (bilateral firm, elevated,
dermal nodules on the shin, may be of different colors
hyperthyroidism
o
Pleiomorphic Adenoma
Physical examination
General appearance
Vital signs
ENT: Inspection, palpation (site, size, shape, surface,
contour, consistency, compressibility, temperature,
tenderness, transillumination, fixation, fluctuation,
reducible, pulsatile, signs of inflammation, discharge,
ulceration, vascularity), Lymph nodes (submandibular,
submental, anterior and posterior auricular, occipital,
anterior and deep cervical LN), Facial nerve testing:
asymmetry, close eyes and dont allow to open them,
smile, clench teeth, Do check oral cavity using mouth
and torch (dental problem or ulcers of mouth and
tongue); parotid duct:: palpate from inside of the
mouth and check for discharge and salivary stone
Diagnosis and Management
For examiner: We are presented with a middle-aged
man who presents with a long-standing mass on the
face which is suggestive of a parotid enlargement. On
examination, the mass is noted to be wellcircumscribed firm mass without signs of facial nerve
involvement which is highly suggestive of a benign
tumor called pleiomorphic adenoma.
-
c.
History
Can you tell me more about it? When? Is it growing
suddenly or slowly? Painful or not painful? Does it
move when you feel it? It is firm or hard when you feel
it? Any ulceration, infection or bleeding from this site?
Any other lumps and bumps in the body? Any weight
loss or change in appetite? Did you notice any
Consent
Inspection: sitting comfortably on the bed and does
not appear to be SOB, conscious and alert, not
cyanosed, not attached to oxygen, no medications, or
IV lines. He does not appear cachectic.
Hands: cyanosis, clubbing, nicotine stains, test
patient's resistance to adduction (brachial plexus
involvement in pancoast/apical lung tumor), press
wrist and note tenderness (hypertrophic pulmonary
osteoarthropathy - results from periosteal
3
inflammation secondary to pancoast tumor), pulse and
RR, wrist extension for 30 mins and look for flapping
tremors for CO retention
-
Chest
Inspection: pectus carinatum/excavatum, deformities,
scars, radiation marks, erythema and signs of
inflammation, tattoos, barrel-shaped chest,
kyphoscoliosis, spine central
Palpation: check chest expansion (breathe in and out
by mouth): upper lobe expansion (equal rising of
clavicles), middle and lower lobe: thumbs should
move at least 5cm, sacral edema, tactile fremitus (with
hands over chest)
Percussion: supraclavicular area
Auscultation: air entry, added sounds, vocal fremitus
Examine anterior chest as well
-
Back:
o
Murmurs:
MS: normal pulse, reduce in volume
MR: pounding pulse
AS: slow-rising pulse
AR: collapse pulse
Systolic murmur at aortic area (DDx)
AS radiate to carotid
Aortic Sclerosis (doesnt radiate)
HOCM functional systolic murmur
Pregnancy
Thyrotoxicosis
Fever
Anemia
Main causes of AS
Increased age
Congenital bicuspid valve
Main causes of MR
Rheumatic fever
MVP/rupture of chordate tendinae
MI
Infective endocarditis
Dilated cardiomyopathy
4
Examination of the Lower Extremities
-
Examination
Inspection:
o Distribution:
Below the femoral vein in the groin
to medial side of the thigh to lower
leg saphenous vein
Back of leg to calf area short
saphenous vein
o Signs of inflammation, cutaneous venous
flares, pigmentation, edema,
lipodermatosclerosis, dermatitis/eczema,
venous ulcers, loss of hair, atrophy of skin,
color change of the skin (deep blue, black,
purple), venous impulse at saphenofemoral
junction
Palpation
o Hard: thrombosis; tender: thrombophlebitis
o Temperature
o cough impulse
Place fingers over line of vein
immediately below the fossa
ovalis (saphenofemoral
junction) ask patient to cough
Management
Refer for Doppler ultrasound for accurate diagnosis
Use supportive stockings (apply in the morning before
standing out of the bed)
Avoid scratching skin over the veins
Sit with legs on a foot stool
Maintain ideal weight
Eat high fiber diet
Treatment options
o Sclerotherapy (use a small volume of
sclerosing agent particularly below the
knee)
o Surgical ligation and stripping remove
obvious varicosities and strip perforators
Complications
Superficial thrombophlebitis
Skin eczema
Skin ulceration
Bleeding
Calcification
Marjolin ulcer (SCC)
5
EXAMINATION OF THE ABDOMEN
Case (Condition 70): You are an intern in the ED and a 50-yearold male having had hematemesis for about 500ml of fresh
blood 2 hours ago accompanied by transient feeling of
lightheadedness and sweating. The patient is alcoholic and
likely to have chronic liver disease on the basis of history that
you have taken.
Task
a.
b.
c.
d.
Physical examination
Is my patient hemodynamically stable
Consent
Exposure: midchest to symphysis pubis
Inspection:
o General appearance: Patient lying
comfortably. Abdomen moving with
respiration. He is not cachectic. There is no
obvious jaundice or pigmentation. He is well
oriented. IV drug marks
o Hands: clubbing, cyanosis, leukonychia,
pallor, CRT, palmar erythema, dupuytren
contractures
o Raise hands flapping tremor/asterixis
(20-30 seconds)
o Arm: Spider nevi, bruising/petechia, scratch
marks, IV drug marks, tattooing or body
piercing
o Face: anemia and jaundice, KayserFleischer rings, parotid gland enlargement,
fetor hepaticus, flushing/congestion of the
face; Mouth: stomatitis, gingivitis,
ulcerations, telangiectasias
o Lymph nodes: cervical, axillary, inguinal
o Chest: spider nevi and gynecomastia
Abdomen
o Inspection: distention, caput medusa, visible
pulsations, visible peristalsis, striae,
bruising, hernia orifices
o Inspect at level of tummy: ask patient to
breathe in and out through the mouth
look for visible masses
o Palpation: Ask if patient has pain anywhere
in the stomach; Relax and breathe in and
out; mass or tenderness on superficial
palpation; deep palpation; palpate liver
o Liver span: from midclavicular line (Normal:
6-12)
o Spleen
o Percussion: shifting dullness for ascites
(percuss from right towards left side)
o Auscultation: bowel sounds and venous
hum (between umbilicus and xiphisternum)
o Testicular atrophy
o Scratch marks in legs and edema;
sensations
o DRE!!!!
Task
a.
b.
Focused examination
Diagnosis and management
a.
b.
c.
Examination
Is my patient hemodynamically stable
General appearance: lying on bed, unwell and in pain.
offer painkiller (morphine 2.5mg IV + metoclopramide)
Vital signs (BP with postural drop)
Inspection:
o Abdomen not moving with respiration
o General inspection of abdomen: scars,
distention, jaundice, pigmentation
Palpation:
o Where do you feel the pain?
o Superficial palpation tenderness
o Guarding, boardlike rigidity, rebound
tenderness on deep palpation
Auscultation: Bowel sounds
Hernia orifices
DRE
Investigations
FBE, ESR/CRP, blood group and crossmatching
U&CE, LFTs, BSL,
Amylase and lipase
Erect CXR (free gas under diaphragm) and Xray of
abdomen (supine and upright)
Differential Diagnosis
Perforated viscus
Acute pancreatitis
Mesenteric ischemia
Acute cholecystitis
AMI
If female: Ectopic pregnancy, ovarian cyst
rupture/torsion; PID; miscarriage
Management
Admit and call surgical registrar because it is an acute
abdomen most likely due to peptic ulcer
Pass 2 IV line and start fluids for full resuscitation
Pass NGT to decompress stomach
NPO
Insert indwelling catheter to monitor I&O
Start IV antibiotics
Surgery (Exploratory laparotomy)
6
Examination of an Inguinal Hernia
Case: You are a GP and your next patient is a 40-year-old
laborer. 2 weeks ago, he felt pain in his right groin after heavy
lifting at work and a week later, noticed a lump in the groin
which was not there before.
Task
a.
b.
Differential Diangosis
Hernia
Lymph node
Undescended testes
Lipmoma
Hydrocele
Saphenovarix
Aneurysm
Neuroma
Examination
Consent
Do you have any pain in this area?
On standing:
o Inspection: site of swelling (whether medial
or lateral to pubic tubercle), size, shape,
color of underlying skin, and contour, signs
of inflammation. scar marks
o
o
o
-
On lying:
o Check if swelling is reducible then check for
cough impulse; borders, temperature,
tenderness; palpate testes, epididymis and
spermatic cord
o Determine whether femoral or inguinal:
Femoral: if it lies 4 cm below and
4 cm lateral to pubic tubercle
Direct inguinal: above pubic
tubercle and inguinal ligament; 1
cm above pubic tubercle; lies
medial to the inferior epigastric
vessel; sac lies behind spermatic
cord
Indirect inguinal: above pubic
tubercle; lateral side of inferior
epigastric vessel; sac lies within
the spermatic cord so it can
descend to the testes
o
Management
Keep an ideal weight
Adjust diet to avoid constipation
Avoid activities that increase intra-abdominal pressure
(heavy lifting, straining and coughing)
Avoid smoking
Referral for surgical consultation. Done usually by
laparoscopic surgery
Complications: infection, bleeding, anesthesia
complications, swelling, damage to nearby organs
(inferior epigastric vessels or inguinal nerves),
recurrence
MUSCULOSKELETAL EXAMINATION OF THE BACK
Examination of Low back
Case: A patient presented to your GP clinic complaining of back
pain.
Task
a.
7
-
L2
L3
L4
L5
S1
8
-
Other features of RA
Skin: rheumatoid nodules
Head: scleritis in eyes
Lungs: nodules, fibrosis, Caplan syndrome
(pneumoconiosis)
Heart: pericarditis
Abdomen: splenomegaly
Hematologic: neutropenia (felty syndrome = RA +
neutropenia + splenomegaly), anemia
Osteoarthritis
Usually carpometacarpophalangeal and DIP
MUSCULOSKELETAL EXAMINATION OF THE LOWER
EXTREMITY
Task
a.
b.
Features:
Inflammation of bursitis or tendinopathy of the gluteus
medius tendon
Common in patients on sports or gardening, increased
weight/BMI
Pain around lateral aspect of hip traveling down the
leg
Trendelenburg test may be positive
Female >45-50
Tenderness of the greater trochanter and/or pain
on abduction
Treatment: NSAIDS, RICE, strengthening exercises,
injection therapy
Differential Diagnosis
Avascular necrosis of femoral head
Osteoarthritis of the hip
Lumbar spine radiculopathy
Iliopsoas tendinitis (flexors of the hip) pain on
stretching of the hip flexor or resisted hip flexion
Examination
Expose from waist down
Assess gait (limping), walk on heels (L5) then toes
(S1); squat and stand;
Trendelenberg test (checks abductors of the hip
gluteus medius): leg which the patient is standing
is the one being tested SOUND/NORMAL side is
going to SAG
o Tests gluteus medius muscles
o Problem in hip joint (severe OA)
o Shortening of neck of femur due to fracture
o SCFE (kids)
Inspection: both hips straight, swelling, deformity,
signs of inflammation, wasting of the muscles, flexion
deformity (side), back (spine is centered, wasting,
deformity)
b.
Features
Most common form of hip disorder
Intrinsic disorder of articular cartilage or to secondary
OA
Risk factors: previous trauma, DDH, septic arthritis,
acetabular dysplasia, SCFE, past inflammatory
arthritis
M=F, usually bilateral; insidious; worse with activity,
relieved by rest and then nocturnal and after resting;
stiffness, limp and deformity; referred pain to groin,
medial aspect of thigh, buttock or knee
PE: antalgic gait, gluteal and quadriceps wasting, first
hip movements lost: IR and extension, fixed flexion
deformity, hip held in flexion and ER (atfirst) IR,
extension, abduction, adduction, flexion, ER
Treatment:
o Weight loss
o Relative rest
o Crutches for acute pain
o Analgesia
o Walking stick
o Physiotherapy
o Physical therapy (isometric exercise)
o Surgery: with severe pain or disability
unresponsive to conservative measures;
total hip replacement (old); femoral
osteotomy (younger patients); hip
resurfacing (<60 years; >90% achieve good
results; last 15-20 years)
Differential Diagnosis
Osteoarthritis
Avascular necrosis
b.
c.
a.
b.
c.
Differential Diagnosis
Adductor tendinitis
Iliopsoas problems
Stress fracture of femoral neck
Osteitis pubis (chronic pain) inflammation of
periosteal bone of symphysis pubis; pain on lower
tummy/pubic bone; point tenderness in symphisis
pubis;
Hernia (Sport inguinal-femoral)
Referred pain from lumbosacral spine
Osteoarthritis of the hip joint
Urologic disorders
Features
Acute groin pain with history of twisting injury and
popping/snapping
Pain inner thigh
10
-
History
-
Task
Palpation
Temperature (of knee is 1 degree lesser than body),
Pulses (while seated popliteal, dorsalis pedis,
posterior tibial), sensation (pain and light touch),
reflexes,
Passive movement
Knees flexed: palate quadriceps, suprapatellar
pouches, patella, patellar tendon, shin of tibia, lateral
malleolus and fibula, head of the fibula, and joint line,
iliotibial band, knee hip joint, adductor muscle,
gastrocnemius, Achilles tendon
Patellar tap test and bulge test (mild effusion
effusion
Valgus and Varus stress test (+ if more than 10
degrees)
Anterior and posterior drawser (+ if more than 10
degrees)
Menisci
o Apleys Grinding test
o External rotation, valgus and flexion or
internal rotation, varus and extension
Patellar apprehension test (impending subluxation or
dislocation of patella)
a.
b.
Inspection:
Landmarks
Patella
Tibial tuberosity
Popliteal fossa
Quadriceps femoris
Suprapatellar pouch
Medial and lateral pouches Peripatellar pouches
(obliterates when there is effusion)
Anserine bursa
Fractures, muscle wasting, scars (longitudinal
TKR, keyhole) , effusion, erythema, neurocutaneous
stigmata
Anterior plane: varus or valgus deformity
Lateral: hyperextension or flexion abnormalities
Posterior: swelling or baker cyst
Observe gait: normal gait, limping, fixed flexion
deformity
Squat and stand up (power and ROM full flexion
and extension)
11
Lower Leg Examination of a Patient with Diabetes Mellitus
(Diabetic Foot)
Case: Your next patient is a 55-year-old female with longstanding diabetes.
Task
a.