General Instructions

• Always examine the patient from their right.
• Make sure you get consent at the start of the examination, but then you don’t need to keep asking the patient again as you do the rest of the examination! You should still explain what you are going to do, but don’t keep asking them if its ok.
• Remember you are always comparing the two lungs. Practice lots so you know what normal is.
• You may also be asked to palpate the apex beat to see if it has been displaced.
• Always ask the patient to strip to the waist, even women! Check they feel comfortable, women may want to keep a bra on, and always explain what you are doing, so that they don’t think you are just having a grope!
• The middle lobe of the lung can only be auscultated from the axilla and back of the patient.
• About 90% of diagnostic information will be gained from patient history – therefore examination should only ever be used as a subsidiary! Never just dive in and examine someone without knowing the proper history first.
• Always look for a sputum pot!
  • Yellow/green sputum – sign of infection
  • Massive amounts of sputum – most likely bronchiectasis
  • Look for signs of blood – could be infection, could be malignancy
  • You may get very suspicious if they also have a hoarse voice and/or weight loss

Chest Examination

General observation of the patient

Inspection

• check the colour of the patient (e.g. are they cyanosed)
• patient should be sat at 45’ for this examination. If the patient is very breathless in this position, then allow them to sit up straight. Patient comfort is the most important factor.
• see if there are any obvious signs of weight loss
• see if there is any ‘’breathlessness’’ – see if they are already propped up on many cushions (heart failure)
• see if there is any wasting of the accessory muscle of breathing. This may be present if the patient suffers from COPD)
• see if the patient is pursing their lips on breathing.
• look at the patient’s expiratory time. Normally expiratory time is shorter than inspiratory time, however, in lung diseases, often there is very short inspiration followed by prolonged expiration.
• listen if there are any audible breathing sounds (normally there aren’t.)
• check the surroundings, e.g. is there oxygen, inhalers or a nebulizer etc. as these are clues to possible respiratory disorders. Also look for a drip, any medications, sputum pots, nasal specs or masks.

Patient’s Hands

1. Loss of the angle of the nail bed
2. Drumstick-like appearance
3. Boggy nailbed (increased fluctuance)
4. Increased curvature of the nail

• Respiratory causes of clubbing include: Empyema, Bronchiectesis, Non-small cell carcinoma, Lung fibrosis, CF, Abscesses, suppurative diseases – diseases that produce a lots of pus!

• Check for signs of cyanosis
• check for tar staining
• Duypetren’s contracture
• check for asterixis. Ask the patient to hold out their arms and bend their wrists so that their palms are vertical pointing away from them. Wait up to 30 seconds. If there is a flapping tremor (a ‘coarse flap’) this suggests a retention of carbon dioxide.
• Other signs that show CO2 retention include warm sweaty palms (due to vasodilation), and a bounding pulse – always check the pulse!
• Koilonychia – iron deficiency anaemia.
• Leukonychia – white nailsa as a result of hypoalbuminaemia – liver disease
• Beau’s lines – sign of serious illness in the past 3 months (nails take 3 months to grow fully). They are horizontal ridges in the nail – a bit like rings in a tree trunk.
• Splinter haemorrhages (endocarditis) – although they are very commonly caused by trauma (manual labour).
• Fine tremor – there is a fine tremor often present in respiratory patients that is caused by β₂– agonists – i.e. salbutamol.
• Check the BP – or at least say you would check it

Check the pulse!

• Rate – tachy >100 / norm / brady <60
• Rhythm – regular / irregular / regularly irregular / irregularlyirregular
• Character
  • Bounding pulse – anything with hyperdynamic circulation – fluid overload e.g. aortic regurg, thyrotoxicosis
  • Slow rising pulse – put four fingers on the pulse (radial or carotid) and you can feel the pulse hit each of your fingers in turn caused by aortic stenosis. in the normal individual it should hit all fingers at once.

Patients head / neck

• check for cyanosis on the underside of the patient’s tongue.
• check for lesions
• check the eyes – e.g. for anaemia, jaundice, xanthelasma and Horner’s sign – consists of: constricted pupils, a droopy eyelid and reduced sweating – all on the same side of the face – e.g. no sweating on the affected side of the face. This is a common symptom of an upper lung tumour.
  • Sympathetic nerves cause dilation of the pupil
  • Parasympathetic cause constriction. Thus in this case, there is no sympathetic, so the pupil is always constricted – however – as the parasympathetic is still active, you may be able to constrict the pupil even further by shining a light into it – this does not mean that Horner’s is not present!
  • The arrangement of sympathetic nerves in this area – the sympathetic chain! – 1^st order neurons travel from the brain, to the spinal chord between levels C8 and T2. From here, second order neurons pass out of the spinal chord, out over the apex of the lung, and then up alongside the carotid artery, to the superior cervical ganglion. There are then two sets of nerves originating from here. One lot of these 3^rd order neurons goes over the cavernous sinus and to the eye, the other goes along the external carotid and then goes to the sweat glands of the face.
  • A lung tumour can damage the second order neurons over the apex of the lung, resulting in Horner’s Sign
• Arcus – caused very commonly by age, and the least common cause is Wilson’s disease.
• check for angular stomatitis – sign of iron deficiency anaemia and pernicious anaemia
• Check for glossitis – can be a sign of iron deficiency anaemia or pernicious anaemia (b12 deficiency)
• Check under the toungue for central cyanosis
• Smell the breath – check for ketones – smell like pear drops
• Check dental state
• Look for thrush and leukoplakia – signs of immunosupression – thus can be linked with chest infections
• HHT – hereditary haemorrhagic telangactasia
• Purtz-Jager-syndrome (PJS) – freckles on the lips.
• Buccal pigmentation – caused y Addisson’s disease – a brown discolouration.
• Ocronosis – grey pigmentation of the skin around the oropharynx – and theu urine will also turn dark on standing.

• Check for general signs of swelling – this can be caused by SVC obstruction as a result of lung cancer. The cancer can either cause this directly, or can cause a thrombus in this region. The SVC collects blood from the head, neck and arms. When this is blocked there is swelling in the head and neck and engorged veins. There is a loss of the normal JVP pulsations – because the JVP becomes raised and non-pulsatile. The head and neck becomes swollen, but there is enough collateral circulation to spare the arms. There may be visible distended veins on the chest wall.

Neck

JVP

Trachea

Lymph nodes

• lung cancer can spread to the lymph nodes of the neck
• when it does, it usually produces very hard nodes, that form a mass, which is fixed to underlying structures
• nodes associated with lung cancer are most commonly found in the supraclavicular area, particularly between the clavicular heads of SCM.
• Other causes of lymph nodes enlargement tend to cause rubbery (not hard) nodes, and these are not usually tethered to underlying structures.

Causes of enlarged lymph nodes

CHEST

Inspection

Palpation

First of all, you should asses the upper part of the chest. Ask the patient to take a deep breath out, then, lay your hands on flat on the upper part of the chest, and ask them to take deep breaths. Yu should feel both sides of the chest moving in and out equally. Remember the ribs of the chest move like bucket handles.
For the lower part of the chest you should use fingertips and the lateral aspect of the chest, and put your thumbs next to eachother in the middle of the chest. Really ‘scoop’ up the chest in your hands. It is easier to feel expansion here than in the upper part and you should see your thumbs move away from eachother as the patient breathes in. You should check that both hands deviate equally.
check both the front and back! – i.e. check for expansion twice; once on the front and once on the back.
when checking on the patient’s front, your hands should go under the patient’s breasts
You should also feel for vocal fremitus. Here you ask the patient to say ‘99’ and feel their chest for resonance. You should use the side of your hand (i.e. down the edge of your little finger) and make ‘v’ shapes on the patient’s chest with your palms facing upwards as you feel both sides of the chest at the same time. It is actually much easier to hear* differences in fremitus that is to feel them. If you ask the patient to whisper ‘one, one, one, one’ and use your stethoscope then you can hear fremitus. If there is consolidation then on the side that there is consolidation you will here ‘one’ very clearly through your stethoscope.
In consolidation, there is a loud-speaker effect of fremitus! – i.e. fremitis is better on the side of consolidation!
Make sure you feel on both the front and the back, and at all the places

• Front – apices, upper lobs, laterally
• Back – upper lobes, lower lobes

When you hear it, it is called whispering pectoriliquae. it is easiest to hear when they whisper (rather than talking).
You can listen for it while they are talking, in which case it is called vocal resonance. You just get them to say ‘99’ in the same way you would when feeling for it. Make sure you listen over:

• The apices
• Upper lobes
• Lateral aspects (under axilla)
• Upper and lower lobes on the back
• These are all basically the same places you would listen for the breath sounds!

Increased vocal fremitus – consolidation
Decreased vocal fremitus – empyema, pneumothorax,pleural effusion
Sound waves travel more freely through solid (i.e. consolidation) than through air. Liquid, or air, or anything that increases the distance between the lung and the chest wall will cause decreased fremitus.
Assessing vocal fremitus is most useful when combined with percussion:

The book also suggests you may want to palpate the precordium and axillary lymph nodes
Precordium
Not always that useful in respiratory exam, but you may be able to palpate:
Rib fractures – this may be highlighted by a very tender area on the chest, and a grinding/crunching sensation called crepitus. Often due to trauma, and may co-exists with pneumothorax / haemothorax. Very rarely you may find a pathological fracture from cancer.
Subcutaneous emphysema – this can cause general swelling of the head and neck, and when palpated, will produce a crackling sensation under the hand.
Apex beat – right lower lobe / right lung collapse can shift the apex beat to the right. Left lower lobe / left lung collapse can displace the beat to the left.
A tension pneumothorax or a large pleural effusion can push the beat away from the side of the pathology.
Axillary lymph nodes – these drain the breasts and the pleurae. The lungs are primarily drained through the lymph nodes of the neck. It is often possible to palpate axillary lymph nodes, although they are unlikely to be pathological if less than 0.5cm. if they are greater in size than 1cm in diameter then they are always pathological.

• If the lump is hard, then this is suspiscious of breast cancer or rarely, mesothelioma.
• if the lump is firm as opposed to hard, then many generalised lymph node pathologies could apply

How to examine

Ask if there are any painful or tender areas. If there are, ask if you can palpate them, and do this gently. Can you elicit tenderness? Does it feel like rib injury?
Palpate any swollen areas that are suggestive of subcutaneous emphysema. Feel for the distinctive crackling
Palpate the apex beat
Examine the axillary lymph nodes. Take the weight of the patients arm on your own shoulder. Make sure you palpate the medial, anterior, lateral and posterior aspects of the axilla. If you feel any lumps, make sure you get a clear feel of size and consistency.

• Do the same at both sides!
• Press on reasonably hard – don’t just wiggle your fingers around, because you will just tickle them!

Percussion

Auscultation

• Wheeze – whistley, noisy breathing
• Crackles – e.g. like a rustling crisp packet
• Rubs – squelching squeaky sound, like walking in fresh snow
• Crepitations – shorter that cracks.

The quality of breath sounds

Vesicular – these are normal breath sounds. They are soft sounding – they sound like rustling leaves. They are caused mainly by the sound of air in the alveoli. This means the intensity of the sound gradually increases as inspiration continues, as more and more air reaches the alveoli. During expiration, vesicular breath sounds fade away, as the alveoli empty, and air is only travelling through the bronchi (which are further away from the stethoscope, and thus harder to hear).
Bronchial breath sounds – these are abnormal breath sounds.

• An example of this is bronchial breathing. Consolidation, fibrosis or collapse can alter the structure of the alveoli. In these instances, the breath sounds are no longer soft and rustling. Instead they become harsh. They can also be heard at different times of the respiratory cycle. They change so that they can be heard throughout inspiration, just stopping near the end (when air is only rushing through the alveoli). There is then a short gap, before air can once again be heard rushing through the bronchi. The sound is harsh, and generally louder than that of vesicular breathing.
• Expiratory sounds tend to be louder and longer than inspiratory sounds – this is the opposite to vesicular breath sounds.
• Detecting areas of bronchial breathing is very difficult
• In COPD and asthma there may be quieter normal breath sounds.
• Mild damage to the alveoli (as in mild fibrosis, consolidation or collapse) can also cause quieter breath sounds
• Pneumothorax and pleural effusion can also cause quiet breath sounds, because they push the lungs further away from the chest wall.
• Occasionally in very thin patients, the vesicular breath sounds are louder than in normal patients
• Over the upper chest it can be particularly difficult to distinguish vesicular from bronchial breath sounds. In fact, in these areas, normal breath sounds that you can hear may infact be bronchial. In these instances, the normal breath sounds are referred to as bronchovesicular.
• Rhonchi – these are long continuous sounds, that sound a bit like snoring. They are caused by obstruction to the airway; often by excess secretion of mucus, mucosal swelling or tumour tissue in the airway. They can be diffuse or localised. They are a common expiratory diffuse finding in COPD, and also found during inspiration in asthma.

• They are nearly always inspiratory
• They may also occur in COPD, bronchiectasis and resolving pneumonia
• Crackles can be described as fine, medium or coarse. Fine crackles are high pitched and squeaky, course are low pitched, and medium are somewhere inbetween.

Wheeze – this is sometimes called ronchi. It is a continuous whistling sound caused by the narrowing of airways. They are usually due to small airways obstruction, such as in COPD and asthma. Wheeze is only usually heard on expiration. This may mean it is heard on inspiration and expiration, but if it is heard only on inspiration, then it is called stridor – and stridor is a very bad prognostic sign (cancer), as is monophonic wheeze (as this is caused by a single blockage to a single airway).

• The pitch and duration of the wheeze is related to the severity of the pathology. The loudness of the wheeze is not related to the severity of the underlying pathology.
• Rarely, heart failure can cause bronchospasm which results in a wheeze.

Friction rub – this is the sound of the two layers of pleura rubbing together as the lungs expand and contract. The main causes are pneumonia, pulmonary infarct and malignancy. Usually these causes lead to inflammation, and it is the inflammation that causes the actual rub.

• Rub is often very localised
• Often the patient complains of pain in the region of the sound – in which case the patient has pleurisy.
• In contrast to crackles, rub only tends to be heard in expiration.

Definitions

Nebulizer

Clubbing

Causes of clubbing

Chest deformities

• Pectus excavatum – funnel chest – a depress sternum – often congenital, but can also be linked to congential diseases, such as marfan’s syndrome. It is generally just cosmetic, but can have a minor effect on lung function. very rarely it can cause breathlessness.
• Pectus carinatum – pigeon chest – a prominent sternum – often develops during childhood in patients with Rickets or severe chest disease. It is thought that it may be due to strong contractions of the diaphragm while the ribcage is still pliable. Just cosmetic, very little effect on lung function (although there may be underlying disease remember)
• Kyphscoliosis – this is spinal deformity, resulting in increased A-P and lateral curvature of the spine. It affects 1 in 1000, and 1 in 10 000 severely. The patient will look like they have abnormal posture.It is mostly idiopathic, and first noticed in childhood. It can be quite severe (as well as being cosmetic) and often causes breathlessness in middle age.
• Thoracoplasty – This was a surgical treatment used in the past to treat TB. It involved removal of several ribs, and thus the affected side can appear very deformed. It reduced lung capacity, which can cause breathlessness in old age (particularly in smokers).

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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• Wash hands
• Check patient name/DOB/hospital number
• Introduce- “My name is…”
• Consent
• “Is it ok if I have a look and feel of your head, neck, chest and hands?”
• Chaperone
• Confidentiality
• Position – 45
• Exposure – Chest

• General: Comfortable at rest? Look around bedside for Oxygen, Nebulisers, Medication
• Hands: Clubbing, Tar staining, Peripheral cyanosis, Flapping tremor, Pulse- character &rate
• Mouth: Central cyanosis
• Neck: JVP, Lymph Nodes
• Chest: Scars, Deformities, Use of accessory muscles, Resp rate

• Tracheal Deviation
  • Warn the patient this may be uncomfortable.
  • Best Technique:Single finger in sternal notch
• Chest Expansion 
• Vocal Fremitus is rarely helpful

• Chest: Start at the apices above the clavicle, include the 3 lung zones (Upper/ Mid/ Lower) and the axilla
• Compare right to left

• Upper/ Mid/ Lower Zones
• Normal sounds should be vesicular
• Listen for added sounds eg. Wheezes, crackles, rubs.
• Assess Vocal Resonance

• Repeat Inspection/ Palpation/ Percussion / Auscultation on the patients back

• At the end check the patients leg and sacrum for peripheral oedema

• “To complete my examination I would like to request further investigations including full bloods/CXR/PEFR/Spirometry/Lung function tests” Adapt this appropriately to the patient you are examining.
• Thank patient
• Cover up and check comfortable

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A swollen, tender, warm, red calf can be indicative of several conditions, one of which is Deep Vein Thrombosis (DVT).

Other differentials could include include cellulitis, muscle injury, achilles tendon rupture, phlegmasia and varicose eczema. Examining a swollen leg is a common OSCE station.

Introduction

• Introduce yourself
• Check you have the right patient
• Explain what you are going to do
• Gain consent
• Wash hands! 

Inspection

• Look around the bed for any mobility aids
• Look for signs of pregnancy
• Look for signs of any recent surgery or trauma
• Look for GTN spray (atherosclerotic disease – increase risk factor)
• Look for breathlessness – may be present if there is a secondary PE

Inspection of the legs

• Look for any obvious redness and swelling
• Look for varicose veins
• Look for missing digits
• Look for ulcers

Palpation

• Check the temperature of the legs at 3 different places. Compare the legs each time
• Check pulses
• Check for pitting oedema
• Check for tenderness – squeeze the patient’s leg around the ankle. Tell them what you are going to do first! Ask them if there is any pain, and look at their face! Repeat with the other leg
• Measure the diameter of the leg with a tape measure! Choose a point on the calf, and measure the same point on each leg. Usually this is 10cm below the tibial tuberosity.
• If there is a difference between the legs of >3cm then this is significant for DVT

Auscultation

• Listen at the lung bases – if PE is present, then there may be reduced breath sounds at the lung bases

Finishing off

Thank the patient, and tell them they can now cover up
Mention any further investigations:

• Well’s score – if this is low, do a D-dimer
• Bloods – U +E’s, clotting, FBC
• Duplex scanning – USS + Doppler
• Venogram

References

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General inspection

Get the child to take their top off
Look around the bed for:

• Medications
• Drip
• Special dietary requirements
• Stool sample pot

Look at the patient for:

• Obvious signs of illness

Abdomen:

• The 5 ‘Fs’ (only 4 apply in children! – Fat, faeces, flatus, fluid (+ fetus)
• Scars
• Bruising
• Stoma
• Mass / discolouration (e.g. in Pancreatitis:)
  • Grey-Truner’s sign – discolouration in the flank
  • Cullen’s sign – discolouration around the umbilicus
• Obvious movements e.g.: Pyloric stenosis – sometimes you can see a peristaltic movement from left to right, particularly after a feed

Hands

• Leukonychia – white nails – hypoalbuminaemia (liver failure)
• Koilonychia – spoon shaped nails – iron deficiency anaemia
• Polished nails – sign of scratching – rash (e.g. jaundice)
• Clubbing – Crohn’s, UC, coeliac’s
• Beau’s lines – horizontal white lines – caused by any acute severe illness – grow out in 12 weeks
• Asterixis – high levels of urea – liver failure
• Dupytrens contracture – idiopathic / liver failure
• Bruising – liver failure / vitamin K deficiency (in neonates)

Face

• Ulceration – Crohn’s
• Angular stomatitis – iron deficiency anaemia
• Gum hypertrophy – leukaemia, scurvy, anti-epileptics (phenytoin)
• Glossitis – big red smooth tongue – iron deficiency anaemia / B12 deficiency
• Candida – immunodeficiency (AIDs, leukaemia)
• Freckling around the mouth – Putz-Jehger’s syndrome – associated with polyps in the bowel. High risk of cancer / obstruction

Eyes

• Yellow sclera – jaundice
• Pale conjunctiva – anaemia
• Keyser-Fleischer rings – Wilson’s disease (mean age of presentation 6-20)
• Xanthelasma – Hyperlipidaemia (can be inherited in an autosomal dominant fashion but unlikely to present in children)
• Corneal arcus – cholesterol deposits

Abdomen

• Palpate all 9 areas
• Look at the patients face for signs of pain as you palpate
• Abdo pain in children
  • Many causes!
  • Classical signs of appendicitis may / may not be present if there is appendicitis.
  • Pain tends to be less localised than in adults
• Superficial palpation first
• Then deep palpation
  • Faeces?
  • Other masses?
• Size / placement of the liver
  • In children it is likely to be up to 2 fingers palpable. This is normal, and prevalence of this decreases with age
  • Technique same as adult
• Size / placement of the spleen
  • Same technique as adult
  • Tipping for the spleen – ask the patient to lie on their right hand side, and bring their left knee towards their chest. Put their left hand on your left shoulder, and ask them to take a deep breath in, as you feel under the costal margin. You might just feel the edge of the spleen.
• Traube’s note – percussion at the 9^th intercostals space at the mid-axillary line – normally resonant, but in splenic enlargement, becomes dull
  • Ballot for the kidneys
  • Gallbaldder – not usually palpable. If painful and palpable, then not gallstones!

Percussion

• Size of the liver
• Shifting dullness

Auscultation

Listen 2cm above the umbilicus

• Should be able to hear any renal artery bruits if present
• Should be able to hear bowel sounds
• Normal bowel sounds – aka borborygmi occur at least every 2-3 minutes
• High pitched, tinkling bowel sounds – obstruction
• Absent bowel sounds – peritonitis

Causes of Hepatomegaly in children

• Herpes infection including CMV and EBV
• Leukaemia
• Lymphoma
• Congestive cardiac failure – possibly due to congenital heart defects
• Infection –toxins / sepsis
• Drugs –eg. Anti-tuberculosis drugs
• Hepatitis
• Metabolic disorders
• TORCH infections – these are usually referred to as infections of the pregnant mother which can cause congenital defects: Toxoplasmosis, Other (syphilis, Hepatitis B, HIV), Rubella, Cytomegalovirus, Herpes

Causes of splenomegaly in children

• TORCH Infections
• Sepsis
• Haemolytic anaemias (rare)
• Juvenile Rheumatoid arthritis (rare)

Finishing off

• Check external genitalia  / hernia orifices– e.g. testicular atrophy in liver disease, hernias
• Do a PR – lumps, constipation, bleeding, lesions – Rarely performed in children, but may be indicated in some cases
• Ankle oedema – liver failure
• Urine dipstick – renal failure, diabetes, infection
• COVER UP THE PATIENT AND THANK THEM!

References

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• You will probably have to adapt the exam accordingly! Generally, you could put the children into three categories depending on their age: 0-6months, 6-24 months and 2 years+

Is the child awake and alert? Are they running around? Do they seem generally ill or distressed? Who is with them? Are they sat on their parents knee?
Are there any medications around?

• Oxygen – if so, check at the wall how much, and by what method is it being administed (e.g mask, nasal specs)
• Fluids – what fluids?
• Inhalers?
• Cannula
• Central line (e.g. in F to provide IV antibiotics)

Any audible cough, wheeze, breathing difficulties?

• Fat/skinny
• Rashes, scars?

Hands

• Clubbing – sign of CF
• Tremor – from B2 agonists
• Check capillary refill
• Feel temperature of hands / cyanosis
• Check radial/brachial pulse
  • Radial is often difficult to feel in children
  • Check the respiratory rate at the same time

Face

Nose

• Snotty / red
• Nasal polyps (CF)

Ears

• TAKE TEMPERATURE
• Always look inside! In an infected ear, it is likely to be red and tender. Check the tympanic membranes. S their a fluid level? Is it damadged? In infection Wax is less likely, as the high temperature often melts it, so if your view is obstructed by wax, it might not be a bad sign

Mouth and Throat

• Look at the lips and under the tongue for signs of cyanosis
• Using a torch, look at the back of the throat for signs of infection
• Using a tongue depressor is down to personal preference. Some practitioners do not recommend it as you could injure the child, particularly the soft palate, and many children don’t like it.
• Tonsilitis may cause white pus to exude from the tonsils
• Infections in the larynx and below will generally not have any throat signs. Some textbooks even advise not to look in the throat in croup – as the presence of the tongue depressor can exaggerate the condition.

Neck

Lymph nodes – examine the lymph nodes of the neck in the same way as in an adult.
Trachea

• Is it central? – in OSCE just say you would check – unpleasant and will upset the child!
• Tracheal Tug – This is where the trachea is pulled posteriorly and superiorly during inspiration, and results from recruitment of accessory muscles in laboured breathing

Chest

Any scars – surgery –e.g. Meconium Ileus in CF
Rahses
Hickman line
Recession

• Subcostal
• Intercostal
• Harrison’s Sulcus – two symmetrical sulci, horizontal, at the lower margin of the anterior thorax, at the attachment of the diaphragm. A sign of prolonged respiratory distress in children. Most commonly present in children with asthma who have required an increased respiratory effort over several months. Also present in Rickets where there is insufficient calcium to allow for bone mineralisation, and the soft ribs are distorted by the pull of the diaphragm.
• Does it look like there is hyper expansion?
• Check the respiratory rate 

Palpation

• Chest Expansion – in young children, only need to check one, usually on the front. In older children, with a larger thorax, you should check 4 times – twice on the front, and twice on the back – at the top, right under the axilla, and at the bottom of the thorax.
• Measure chest expansion with tape measure – measure at full inspiration and full expiration. (not often performed in practice – but say you would do it)
• Heart – feel the location of the apex beat, checking for displacement

Percussion

• Difficult and will probably not yield great results in very small children (under 2). Should be performed in older children. Same technique as adult 

Auscultation

• Same technique as adult – just make sure you compare sides and listen to all lobes, including under the axilla and to the apices above the clavicle.

Finishing off

Feel for the liver. If the liver is lower than expected, it may be displaced by hyper expanded lungs. Normal liver position:

• Age 0-6 months – 1-2 fingers below rib cage
• Age 6-24 months – 0-1 finger below rib cage
• Age 2+ – usually not palpable (but remember, palpable liver is often still normal)

Do a peak flow test
Check O2 sats
If not already done, you might want to strip off the child to check for rashes (meningitis / septicaemia)
Remember to look in the ears and throat if you missed it out earlier!

Common Findings of Respiratory Exam in children

References

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• introduce yourself
• wash your hands
• check you’ve got the right patient

Inspection

• Is the patient in any pain?
• Check around the bed
  • Mobility aids
  • O2
  • Cigarettes
  • Medication
• Look for any general signs – e.g. heart failure, cyanosis, pallor

Hands

• Tar staining
• Palmar xanthomas
• Capillary return – Press for at least 2-3 seconds – then check the return appears within 2 seconds
• Radial pulse – comment on the rate, rhythm and character. Also check for radio-radial delay – this is a sign of co-arctation of the aorta.
• Do the blood pressure in BOTH arms

Face

• Eyes – look for xanthelasma, arcus and conjunctival pallor
• Mouth – look for central cyanosis and angular stomatitis
• Caroitd pulse – check it and comment on the character!

Abdomen

• Look for obvious pulsations and masses
• Look for scars
• Check the AA – is it pulsatile (normal) or expansile (abnormal). The aorta bifurcates at approximately the level of the umbilicus

Leg inspection

• Swelling
• Discoloration
• Scars
• Dressings
• Pallor
• Missing hair / nails / toes
• Ulcers
• Dry skin
• Just have a good look and feel of the legs and toes. Make sure you look between the toes and lift up the feet.
• Compare the temperature with the back of your hand – do this at 3 separate places on each leg

Leg palpation

• Temperature – compare both legs using the back of your hand. Compare in several different places
• Sensation – ask the patient to close their eyes, and then touch them in a couple of different places on their feet. Ask them to say where/when they feel it
• Capillary refill – same as for the hands
• Pulses – check that these are normal / absent / reduced – comment on what you find
  • Dorsalis pedis
  • Posterior tibial
  • Popliteal – take the weight of the patients legt with both hands and feel into the popliteal fossa
  • Femoral

• Lift up the legs for 30s to 1 min, and see if they go pale
• If they do, then ask the patient to then sit up and drop the leg over the side of the bench. If the leg then turns red/purple then this is a positive test and the patients has reflex hyperaemia which is present when there is poor peripheral circulation
• Reflex hyperaemia occurs when there is dilation of the peripheral blood vessels when the leg is raised in response to the fall in bp. Then when the leg is lowered, the massively dilated blood vessels suddenly fill causing the leg to go a red/purple colour

Auscultation

• Renal bruit
• Femoral bruit
• Aortic bruit
• Carotid bruit

To finish

• Thank the patient
• Aks if they have any questions
• Allow them to re-dress in private
• Mention any further possible tests:
  • FBC – anaemia
  • U+E’s – renal failure
  • Blood sugar – diabetes

References

Read more about our sources

The post Peripheral Vascular Exam appeared first on almostadoctor.

• Introduce yourself to the patient and explain the procedure. Use a chaperone.
• Ask the patient to expose her abdomen. You need to expose her down to the hairline to be able to fell properly later on.
• Wash your hands

• Inspection
• Palpation
• Percussion
• Auscultation

Inspection

• Scars – e.g. caesarean scar (Pfannenestiel scar)
• Linea Nigra – a dark coloured line on the skin running downwards from the umbilicus. It is present in about 75% of all pregnancies, and usually about 1cm wide. It usually appears in the second trimester, and will regress after birth, although it may never disappear completely. It may recur after sun exposure.  It is thought to be the result of excess melanin production (hyperpigmentation) as a result of the high oestrogen levels in pregnancy.
• Striae Gravidarum – stretch marks
• Fetal movements – are any visible?
• Comment on the size / shape / appearance of the abdomen – e.g. this is a uniformly distended abdomen, consistent with pregnancy

Palpation

Fundal height

• Palpate the fundus. It is usually relatively easy to feel. There are several ways of feeling; some like to use a’ chopping’ action – using the lateral aspect of the little finger, but it is probably more accurate just to have a good feel with the palms, using both your hands.
• Now find the upper board of the pubic symphysis, and measure the distance between this and the top of the fundus. It is best practice to measure ‘blind’ – with the scale on the blank side of the tape so you do not inadvertently bias your reading.
• The uterus cannot normally be palpated until 12 weeks. At 16 weeks it lies roughly ½ way between the pubis symphysis and the umbilicus. At 36 weeks, the fundus may be under the ribs, particularly in primigravida. After 36 weeks, the fundal height may be slightly lower, as the head may have descended into the pelvis.

Assessing the fetus

For a pregnancy of >32 weeks gestation you should asses the lie and presentation, and feel the head.
Lie – this is the position of the long axis of the fetus in relation to the mother. Palpating the abdomen try to feel the baby’s back and limbs. The back will feel like smooth curve, whilst the limbs will feel irregular and usually indistinct.

• Longitudinal lie – the spine of the fetus is perpendicular to (or in line with)  the mothers
• Transverse – the spine isat 90’ to the mothers. Usually it is inferior and the limbs superior. Associated with breech presentation, and will usually need to be delivered by caesarean.
• Oblique – describes a lie where the spine is not perpendicular not at 90’ to the mothers.

Presentation

This is determined by the fetal lie and the presenting part

• Cephalic – the lie is usually normal (although could be
• Breech –refers to when the buttocks / feet present first
• Other presentations
• Shoulder presentation – common in transverse lie
• Face presentation
• Brow presentation
• Breech presentation is still described as longitudinal lie (e.g. – see image). Breech occurs in 3-4% of all pregnancies.

Position

This describes the position of the fetal head in relation to the pelvis, e.g.:

• Left occipito-Anterior (LOA) – i.e. the fetal occiput is on the mother’s left/anterior
• Right occipito anterior (ROA)
• Occipito anterior (OT)
• Left occipito transverse (LOT) – the fetal occiput is on the mother left
• Right occipituo transverse (ROT)
• Direct Occipito Posterior (OP) – the fetal occiput is at the mothers back
• Left Occipito Posterior (LOP) – the fetal occiput is pointing diagonally backwards to the left
• Right Occipito Posterior (ROP)
• Breech positions – Right sacrum posterior (RSP) – the fetal sacrum is pointing diagonally backwards to the mother’s right

Engagement

• The whole head is palpable – “the head is 5/5^ths palpable”
• The jaw only is palpable – 1/5^th palpable
• In primigravida, the head normally engages by the 37^th week. In subsequent pregnancies, it usually does not engage until labour.
• The head is ‘engaged’ when the widest part has passed through the pelvic brim – thus roughly equal to 2 or 3/5^ths palpable.

Percussion

• Oligohydramnios – low volume of amniotic fluid. A normal fetus will drink amniotic fluid, and urinate back into the fluid, keeping the volume stable. Reduced volume could be the result of a fetal kidney problem.
• Polyhydramnios – high volume of amniotic fluid. Associated with maternal diabetes (of any type: e.g. type I, type II, gestational).

Auscultation

• Is the rate normal?
• Is it regular?
• Pinard stethoscopes only enable you to hear the fetal heartbeat from 24 weeks.

Doppler fetal monitor (aka Sonicaid) – more commonly used in clinical practice than the Pinard, as it allows the mother to hear the hearbeat as well. Can come up in the OSCE so make sure you know how it use it. Basically, just put some of the gel over the shoulder area of the fetus, then put the probe on the gel, and turn it on.

• Despite what the midwives might tell you – there is no relationship between fetal heart rate and fetal gender!
• Enables you to hear heart sounds from 10-12 weeks

Finishing off

• Take the BP – checking for pre-eclampsia
• Urine dipstick – checking for
  • Protein – pre-eclampsia
  • Leukocytes – infection
  • glucose (even ketones) – diabetes
• Record mother’s weight – normal pregnancy has weight gain of about 24lbs

Presenting

• Inspection – was there anything visible?
• Lie (e.g. longitudinal)
• Presentation (e.g. cephalic or breech)
• Position (e.g. LOP)
• Fetal heart rate – e.g. was heard – roughly xxxbpm, and regular

References

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The post Pregnant Abdomen Exam appeared first on almostadoctor.

• Some doctors suggest the optimum time for neonatal exam is between 24-48 hours. This allows the foramen ovale time to close (and thus eliminates this physiological murmur) and allows time for neonatal jaundice to present.
• However, usually in practice, the exam in performed <24h after birth.

• The routine examination of the newborn has a poor sensitivity for picking up congenital abnormalities.
• There is no proven benefit of having two doctors perform the examination to spot abnormalities

Serious Congenital abnormalities

1. Congenital heart disease
2. Developmental dysplasia of the hip
3. Talipes
4. Down’s Syndrome
5. Cleft lip and palate
6. Urogenital abnormalities
7. Spina bifida / anencephaly

Congenital abnormalities that spontaneously resolve

• Peripheral cyanosis – particularly hands and feet – will usually resolve within 24 hours
• Traumatic cyanosis –can result from the umbilical cord around the baby’s neck, or a face/brow presentation. Typically causes a blue face, and there may also be petechiae on the head and neck. If there are any signs of cyanosis, you should perform pulse oximetry.
• Distorted head shape / swollen eye lids –normal side effects of delivery
• Subconjunctival haemorrhages
• Cysts – in the gums and floor of the mouth
• Breast enlargement / milk production –can occur in either sex and is completely normal
• Vaginal discharge / blood –a small prolapse is also normal
• Capillary Haemangioma (“stork bites”) – pink macules on upper eyelid, forehead and neck, due to capillary distension. Should fade within first year of life. Those on the neck will become covered with hair. May persist into adulthood on the neck, but are not visible due to hair.
• Urtricaria (“hives”) – rash – dark red raised area, with white papules at the centre. Can be at any site, but most common on the trunk.
• Epstein’s Pearls –harmless small white cysts along the midline of the palate. Resolve within weeks.
• Milia –small white pimples on the face
• Mongolian Blue Spots –look a bit like bruises. Dark/blue patches, usually around the base of the spine. Typically in Asian and African babies. Will fades over the first few years of life.
• Umbilical Hernia –particularly common in African babies. Will resolve by age 2-3.
• Positional talipes –the foot (or feet) remain internally rotated as if in the fetal position, but can be passively externally rotated and have a full range of movement.
• True talipes equinovarus (club foot)– more serious. Again can involve one foot or both (50% of cases bilateral). Quite common (1 in 1000), and 2x as common in boys. Can usually be treated with physiotherapy, or in more serious cases, casts and splints. Surgery is rarely needed. It is generally caused by short/tight tendons, and thus in casts/splints, the tendons are gradually stretched, usually over a period of weeks or months.
• Differentiating – in ture talipes equinovarus, it is now possible to dorsiflex the foot such that the dorsal surface of the foot touches the shin. In positional talipes, this is possible.

Other Abnormalities

• Strawberry Naevus – not present at birth usually, but develops in the first few weeks of life. They are more common in premature babies. Looks a bit like a red strawberry. They tend to grow for 3-9 months, and then gradually recede. No treatment is needed, except for some rare instances, where it may obstruct vision or with the airway. Thrombocytopaenia can be present with large lesions.
• Naevus flammeus – aka Port wine stain – this is usually present at birth, and grows as the child grows. Caused by abnormal capillaries in the skin (dermis layer). If it is particularly disfiguring laser treatment is available.

Pre-examination checklist

• Name
• DOB
• Gestational age
• Birthweight – Including birthweight centile
• Delivery type
• Feeding / urinating / bowel movements (meconium passed?)
• Any parental concerns?

Examination

General Inspection

• If there is apparent cyanosis check the tongue as the most accurate indicator of central cyanosis. If present, central cyanosis requires immediate action!
• If pale, check hematocrit for polycythaemia or anaemia
• Hypotonia may be due to Down’s

Is the baby responsive?

Head

Measure head circumference – using a paper tape measure. this provides a rough estimate of brain size. You should plot your recordings on the growth chart.
Palpate the fontanel and sutures

• Fontanel size is extremely variable.
• Raised fontanel in crying is normal
• If fontanel is raised when baby is not crying, raised ICP may be the cause. Cranial ultrasound is recommended in this instance.
• A tense fontanel is also a late sign of meningitis, but often note seen
• Sagittal suture is often separated
• Coronal suture may be ‘over-riding’
• It is normal for the skull bones to have been moved during birth
• Should NOT be fused

Face

Check symmetry, e.g. of eyes, ears, nose
An unusual looking face could be the result of a congenital syndrome. There are hundreds! Seek expert help. Particularly common is:
Down’s Syndrome:

• Oblique eye fissures with epicanthic skin folds
• Flat nasal bridge
• Light coloured spot in peripheral iris (Brushfield spots)
• Protruding tongue (due to small oral cavity)
• Short neck

Eyes

• Check Red reflex with ophthalmoscope:
• Retinoblastoma
• Cataracts – 50% of cases are identified in this manner. Congenital cataracts can affect development of normal vision.
• Corneal Opacity

Ears – tops of the eras should be level with the eyes. If the ears are lower down (‘low set’) then this is a possible sign of Down’s syndrome.
Palate –use your finger and a torch! A tongue depressor may damage to baby’s palate.

• Make sure you check posteriorly to exclude posterior cleft lip and palate. Also at the back of the palate theri may be an indentation from a submucous cleft.
• Natal teeth are sometimes present. If they are lose, they should be removed to avoid aspiration.

Chest

Breathing and chest wall movement – have a general inspection, looking for signs of respiratory distress

•  RR – 30-60 is normal

Auscultate the heart

• HR – 110-160 is normal. May drop to 85 during sleep.

Congenital heart disease

• 50% of all murmurs in newborns will be ‘innocent’. An innocent murmur is usually; Mid systolic and Radiates to the back/axilla
• Difficult to detect if it is innocent or not in many cases
• If in doubt, get an echo
• Communicate with parents. Tell them if the baby has an unusual feeding or other difficulties to bring them back straight away

Abdomen

• Liver – usually 1-2 fingers below the costal margin
• Spleen – usually palpable
• Kidneys – may be palpable – particularly on the left
• Bladder – palpable bladder could be a sign of urinary outflow obstruction. This is particularly true in boys, in whom it is possible to have a congenital urethral valve. This requires urgent ultrasound. If the valve is the cause, this can cause urinary retention and subsequent pylonephritis and serious kidney damage (reflux nephropathy).
• Any other masses – are often renal, but still need investigation!
• Umbilicus – check for hernia (usually benign) and infection
• Usually abdomen is soft

Genitailia and Anus

• Testes – confirm they are present!
• Vagina – a small prolapse is normal
• Doubt over the sex? – if there is ambiguous genitalia – DON’T GUESS THE SEX! – discuss this with the parents, and inform them you will need to conduct some tests.
• Anus – present? Patent?

Limbs

• Femoral pulses – check on both sides that they are present. Pulse pressure may be:
  • Increased – patent ductus arteriosus
  • Reduced –co-arctation of the aorta
• Digits – check the baby has the correct number of digits on all limbs. Also check the palmar creases. A single palmar crease  is a sign of Down’s Syndrome
• Muscle Tone – if you haven’t look at it already. You can move the limbs gently, as you might in a neuro exam. As well as observing normal limb movements. You should sit the baby up and observe head control. In a normal neonate, they should be able to support their head very briefly when vertical.
• Palmar crease – a single crease may be a sign of Down’s Syndrome
• Grip –check that the baby is able to grip one of your fingers with their hand. Check both hands.

Spine

DDH – Developmental dysplasia of the Hip

Barlow Test

• With one hand, stabilise the pelvis
• With the other hand, place your middle finger on the greater trochanter of the femur, and your thumb on the medial aspect of the femur. Then, with the hip flexed, try to adduct the hip, and press the hip down onto the mattress.  In a normal hip, there will be no dislocation. In DDH  you will feel posterior displacement of the greater trochanter.

Ortolani Manouvre

• This is the test to try and replace the dislocated femur in the case of a positive Barlow test.
• Abduct the effected hip, and you should feel (and sometimes here) the femur click back into place.
• You can often get ‘clicks’ without displacement of the head of femur, and these are not significant.

• 6x more common in girls
• Seen in children with a family history (20% of cases have FH)
• More common in breech birth (30% are due to breech)
• More common in neuromuscular disorders
• Early recognition reduces morbidity. The affected limb can be splinted.
• If unsure of the diagnosis, you can do USS.
• Normally performed in the examination of the newborn, and again at 6 weeks of age. Some cases are monitored until the child is able to walk.
• More accurately spotted with USS of the hip joint. This is being used increasingly in hospitals in the UK, mainly to confirm the diagnosis after a positive Barlow/Ortalani test. In some instances it is also used ot screen for the condition, but this is expensive and time consuming, Also remember that generally USS procedures are highly operator dependent.

Reflexes

• Morrow Reflex – Support the child with your hand and forearm. Then gently but swiftly, tilt the child backwards. In normal circumstances, the child should outstretch their arms (and legs). This is a positive morrow reflex.
• Rooting reflex – when you gently touch next to the baby’s mouth, the baby will turn their head and try to suckle.
• Grasp reflex – place your finger in the baby’s palm. The baby should grasp with a firm grip
• Stepping reflex – holding upright above the bed, and then gently brush the bed against the baby’s feet / shins. The baby should step. They may also be able to support some of their own weight.

Vitamin K therapy

• Vit K does not cross the placenta very well
• Vit K stores are low at birth
• Breast milk is low in Vit k
• Formula milk is high in vit K, and thus the condition is rarely seen in formular fed babies
• There is little gut flora in neonates – in a normal adult, bacterial flora produces much of the vit K we absorb.
• Anticonvulsant therapy in the mother can impair vitamin K synthesis, and thus these babies are at increased risk of haemorrhagic disease.

Effects of vit K deficiency

• Easy bruising
• Hematemesis
• Melena
• Prolonged bleeding (e.g. of umbilical stump, or after circumscision)
• Intracranial haemorrhage – rare, but serious. ½ of all babies that suffer from intracranial haemorrhage will have serve morbidity or mortality.

Management

• All babies in the UK are given vitamin K therapy to prevent haemorrhagic disease. This is usually in the form of an IM injection shortly after birth.
• This has been controversial, as one small study suggested a link between IM therapy and childhood cancer. This conclusion has not been confirmed by much larger studies. However, as a result, parents have the option of oral vitamin K therapy, which is given as 3 oral doses over the first 4 weeks of life, due to the variable oral absorption of vit K.
• Mothers on anticonvulsant therapy – take prophylactic therapy from 36 weeks gestation, and the baby is given IM vitamin K after birth.

Anticoagulation in Pregnancy

• Women planning a pregnancy are usually advised to swap their medication before trying for a baby
• In other pregnancies, the therapy should be changed as soon as the pregnancy is confirmed
• The greatest teratogenic effect is during the first trimester

References

Read more about our sources

The post Routine Examination of the Newborn (Neonate Exam) appeared first on almostadoctor.

The shoulder is a ball and socket joint with a wide range of movement. The joint is somewhat unusual, in that the “socket” (glenoid) is very shallow, and as-such, much of the stability of the shoulder joint is provided by the rotator cuff muscles and surrounding ligaments and soft tissues, rather than the bony structures. This is what gives the shoulder its unique wide range of movement.

Along with the knee, the shoulder is one of the most commonly presenting joint pathologies. Common shoulder pathologies include rotator cuff injury (usually Supraspinatus – typically associated with a shoulder impingement), AC (acromioclavicular) joint injury, osteoarthritis and shoulder dislocation.

Like all examinations you should have a systematic approach. The most commonly used approach is the Look, feel move approach:

• Look
• Feel
• Move
• Special tests

Explain the examination to the patient, and once you have their consent, wash your hands and ask the patient to expose the shoulders and clavicles bilaterally.

Starting off the examination

Start with the basics:

• Wash hands
• Introduce yourself
• Greet the patient
• Explain the nature of the examination
• Gain consent – which usually involves asking the patient to remove the clothes from the upper half of the body

Inspection (Look)

• Wasting at the side – likely to be deltoid. This could cause the shoulder to become flattened. Often secondary to nerve lesion.
• Wasting at the back – likely to be trapezius

Deformity

• Deformity over the middle of the clavicle – suggests previous fracture
• Deformity over the distal part of the clavicle – may suggest AC joint pathology or subluxation
• Generalised swelling – most likely caused by effusion
• Flex the arm at the elbow – look for ruptured biceps tendon. You will see a large mass of muscle, that can either be near the elbow joint, or anywhere further up the humerus. The “popeye sign”.
• ‘Winged scapula’ – asking the patient to push against a wall can exaggerate this. It is where the scapula is abnormally laterally rotated. It is the result of a lesion of the long thoracic nerve, or of the muscle this nerve supplies – serratus anterior.

Palpation (Feel)

• Acromio-clavicular joint – common site of arthritis. To find this part of the joint, move laterally along the clavicle. It is also commonly damaged in injuries that result from a blow to the shoulder – e.g. falling from a bicycle, rugby injuries to other contact sports or falls
• Greater tuberosity – the insertion point of the rotator cuff muscles
• General Palpation – feel (and sometimes you can also hear it!) for any creptius. This is a crunching, grating feeling inside the joint, indicative of degeneration.
• The subacrominal space – specific tenderness hear can help localise an impingement pathology
• Swelling – feel for any generalised swelling. This can be caused by:
  • Effusion
  • Bursitis
  • Dislocation
  • Previous fractures
• Palpation of the dorsal spine and interscapular area – this area is sometimes called a trigger point for fibromyalgia. Palpating this area in individuals with this condition can elicit pain.

Movement

• Abduction and Adduction – 180 degrees is normal
  • Supraspinatus and deltoid. Deltoid assists from 15 to 90 degrees of abduction, but Supraspinatus does the first 15 degrees all by itself.
  • Suprapsinatus is a common cause of restricted abduction
• Flexion – 180 degrees is normal
• Extension – 180 degrees is normal
• Internal rotation – Ask patient to put the their thumb as high up their back as they can reach. You can measure this in relation to the scapula (should be able to reach inferior border) or the level of thoracic vertebra.
• External rotation – Ask the patient to keep their elbows tucked into their abdomen and external rotate their shoulders. External rotation is particularly badly affected in frozen shoulder (adhesive capsulitis), although this condition limits all movements, and is also affected in glena-humeral joint arthritis. Another test of external rotation is to ask the patient to put their hand behind their head.

Assessing individual muscles

Movements against resistance (isometric contractions)

• Supraspinatus (abduction) – Arms flexed and abducted to 30’, with palms pointing laterally, and thumbs pointing downwards. Patient tries to flex arms further against resistant.
• Infraspinatus / teres minor (external rotation) – Elbow tucked into chest well, flexed at 90’. Patient tries to move palms apart (external rotation) against resistance
• Subscapularis (internal rotation) – Elbow tucked into chest well, flexed at 90’. Patient tries to move palms together (internal rotation) against resistance OR
  • The lift off test – patient has hand behind back (“lifts off” their hand form their back) and pushes backwards against resistance

Special Tests

Hawkins-Kennedy Test

Also tests for for shoulder impingement – which is essentially inflammation of the tendons of the rotator cuff – specifically the supraspinatus tendon. Ask the patient to flex their arm to 90’. Then flex the elbow to 90’ so that this forearm is parallel to the floor. Now, press down on the patient’s wrist and at the same time try to forcibly inwardly rotate the shoulder joint. This is a passive movement, so the patient should be relaxed. This basically presses the tendons of the shoulder cuff against the coraco-humeral ligament. you may also want to repeat the test with external rotation to check the tendon of subscapularis.

• Positive test – pain is elicited. Particularly if the pain is greater, the greater the degree of internal rotation
• Negative test – no pain

The test is not specific enough to give an exact diagnosis – but may help to confirm the diagnosis when there is a strong degree of clinical suspicion.

Scarf Test aka cross-arm test

Apprehension Test

Ask the patient to externally rotate and abduct the shoulder, whilst also flexing the elbow:

• You can double-check your findings. If you repeat the test, but instead, push the patient’s arm backwards, this should releive/not elicit any pain. This is known as the relocation manouvre.
• This tests for shoulder instability / anterior dislocation of the shoulder

The post Shoulder Examination appeared first on almostadoctor.

• Pain
• Swelling
• Abdominal pain (torsion of testes)

1. Usual stuff – wash hands, check right patient, introduce yourself, explain, get a chpaerone
2. Normally, would do full abdominal exam, and check the hernia orifices (check for lumps and bumps in the groin).
3. Get the patient to lie flat, ask for any pain
4. Check the distribution of pubic hair (any gynaecomastia? Liver failure?), skin (scars, swelling, discolouration)
5. Testicles should generally be at the same height, and be the same size, often the left is slightly lower than the right.
6. Check the penis – is it twisted, lumpy, has warts (STI?), smegma – smelly white lumpy stuff under the foreskin – may indicate poor hygiene.  Look for phimosis and paraphimosis, ulcers and skanka. Make sure you look behind the foreskin!
7. Palpation

Are both testes present?! Feel for roughly same size and shape. If they are not both present – it could be due to surgical removal, failure to descend, or retraction.
Are there any lumps? Gently roll the testicles between your fingers. Lumps:

• Can’t get above it – probably an indirect inguinal hernia. Explain a bit about direct and indirect hernias. How do you differentiate 1) indirect and direct inguinal hernias. 2) femoral and inguinal hernias.
• Varicocele – basically big squidgy veins at the back of the testicle – bag of worms
• Testicular cancer – a hard lump on the testes.
• Orchitis – caused by infection – big swollen testes.
• Epididymitis – swollen epididymis – infection – this can lead on to cause orchitis.
• Hydrocele – this will make the testes very large! – it is a collection of fluid around the testicle in the tunica vaginalis– it will make the testicle very difficult to feel.  – this will transluminate to a red colour!

Check the lymph nodes – the ones to check are inguinal for scrotal pathology, and para-aortic for testicular pathology.

If Masses felt need to describe them!

• Site
• Size
• Shape
• Skin colour changes
• Transilluminate
• (hydrocele –red light)
• Tethering
• Temperature
• Tender
• Thrill
• Colour
• Consistency
• Contours
• Cough Impulse- (positive if hernia or varicocele)

1. Can you get above it?

2. Is it separate or part of the testes?

3. Is it cystic or solid?

3. • Testicular and Solid – tumour, orchitis, granuloma, gumma (characteristic tissue nodule found in the tertiary stage of syphilis).
   • Testicular and cystic – hydrocele
   • Separate and solid – epididymitis or orchitis

• Separate and cystic – epidymal cyst

• Palpate lymph nodes
• Do a full abdominal examination, checking hernial orifices
• Get patient to stand up (varicoceles collapse on lying flat)
• Summarize what you have found and other investigations you would like to do if suspected tumour…blood tests, USS, CXR (can get lung mets), CT staging (Royal Marsden’s systems – 4 stages)

• Age 20-30 more likely to be a teratoma
• Age 30-40 more likely to be a seminoma
• Tumour markers for testicular cancer are alpha feto protein( AFP), HCG and LDH.
• Risk factors; undescended testicles
• Treatment is surgery and radiotherapy (Seminoma is especially radio sensitive)

• Aneurysm of femoral artery
• Vein
• Cysts
• Lymphadenopathy
• Undescended testicle
• Hernia

• Common is under 20
• Severe, sudden pain, testicular or abdominal
• Sometimes vomiting
• Testes may contract, lie high up and transverse
• Needs urgent surgical exploration – orchidectomy (removal of testes) or bilateral orchidopexy (stitch testes to tunica vaginalis)

At end always inform patient that the examination is over with and THANK THEM!

The post Testicular Exam appeared first on almostadoctor.