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Cardiovascular

 Exam  
 
Inspection   Colour,  Breathlessness,  Distress,  Marfan’s,  BMI,  Breathlessness,  
Sweating  
Hands   Clubbing,  Colour,  Cap.  Refill,  Splinter  Haemorrhages,  Temp.,  Tremor,  
xanthelasma,  osler’s  nodes,  Janeway  lesions.  
Wrist   Radial  Pulse  (rate,  rhythm,  character),  radial-­‐radial/femoral  delays.    
Elbow   Brachial  Pulse,  Waterhammer  Pulse.    Ask  for  BP  
Eyes   Pallor,  arcus,  Kaiser  flescher  rings,  xanthelasma,  retinopathy  
Tongue   Central  cyanosis  and  tooth  decay.  
Neck   Carotid  pulse,  bruits  (aortic  stenosis),  JVP  
Chest  look   Deformity,  Scars  
Chest  /  Heart   Feel  Apex  beat,  Heaves,  Thrills,    
Auscultate  4  valve  positions  (mitral,  tricuspid,  pulmonary,  aortic).  
Lean  Pt  on  Left     Auscultate  apex  and  axilla  for  mitral  regurge  
Sit  pt  forward   Auscultate  (diaphragm)  for  aortic  stenosis  
Auscultate  lung  bases  (pul.  oedema)  
Abdo   AAA  
Legs   Femoral  /  popliteal  /  post  tibial  /  dorsalis  pedis  pulses  
Ulcers,  Ankle  oedema  
Extras   Fundoscopy,  BP,  urine  dipstick,  Temp.  
 

Peripheral  Vascular  Exam  


 
Exposure   Abdo  down,  blanket  for  upper/lower  when  not  examining  
Inspect  arms   Scars,  colour,  skin,  digits,  tar  staining  
Palpate  arms   Temperature  (back  of  hands),  cap  refill,  tendon  xanthelasma  
Radial  pulses   Rate,  rhythm,  radio-­‐radial  delay  
(together)  
Brachial  pulses   Radial,  brachial  pulses  
Ask  for  BP   Ask  for  both  arms  if  suspect  different  pulses  
Face   Arcus,  xanthelasma  
Carotids   Pulse  (not  together),  auscultate  for  bruit  
Inspect  chest  &   Scars,  pulsations,  AAA  
abdomen  
Femoral  pulse   Mid-­‐inguinal  point,  femoro-­‐femoral  delay  (common  iliac  obstruction),  
radio-­‐femoral  delay  
Auscultate  for  bruits  (anteromedial  thigh,  middle  1/3)  
Inspect  legs   Scars,  colour,  skin,  digits,  pressure  points,  xanthomata  on  Achilles  
tendon  
Palpate  legs   Temperature  (using  backs  of  hands),  cap  refill  (toes)  
Popliteal  pulse    
Posteior  tibial   Medial  malleolus  
pulse  
Dorsalis  pedis    
Auscultate    
pulses  (carotid  
→  popliteal)  
Buerger’s  test   1)  Raise  both  legs  (straight  &  slowly)  to  45o  or  angle  where  they  
become  pale  (Buerger’s  angle)  
2)  Put  legs  over  edge  of  bed  or  get  pt  to  stand  
Ischaemia  =  20-­‐30o  for  Buerger’s  angle,  slow  re-­‐perfusion  and  then  
reactive  hyperaemia  for  (2)  
Extras   Doppler  ABPI.  
 
 

Respiratory  Exam  
 
Inspection   Cough,  BMI,  Fever,  Distress,  Drugs  
Hands   Clubbing,  colour,  cap.  Refill,  asterixis,  thenar  wastage,  tobacco  staining,  
tremor  
Wrist   Radial  Pulse  (rate,  rhythm,  character)  
Respiratory  rate  
Ask  for  BP,  mention  pulsus  paradoxus  
Eyes   Pallor,  Horner’s  Synd.  
Tongue   Central  cyanosis  
Neck   JVP,  Lymphadenopathy,  Accessory  muscle  use  
Tracheal   Deviates  to  side  of  collapse,  away  from  tension  pneumothorax  
deviation  &  
tug  
Chest  Scars   Surgery?  
Deformity   Pectus  excavatum?  Barrel  chest?  (AP  =  lateral)  
 
Expansion   Equal  R/L?  
↓  =  PE,  consolidation,  fibrosis,  pneumothorax  or  collapse  
Percussion   ↑  in  pneumothorax,  ↓  in  all  else  
TVF   ↑  TVF  =  consolidation,  fibrosis,  top  of  effusion  
Auscultation     Crackle→oedema  or  fibrosis  (fine)  or  bronchiectasis/pneumonia  (coarse).  
Rub→  pleura  infarct  /  inflammation  (pneumonia)  
Wheeze  →  obstruction.  
Bronchial  Breathing→  consolidation,  fibrosis,  top  of  effusion.  
Breathing  sound  ↓    =  consolidation,  obesity,  over  Pleural  Effusion,  
pneumothorax.  
Ankle   Oedema  
Extras   Peak  flow,  O2  sats,  spirometry,  Temp.,  sputum  pot  
 

Abdominal  Exam  
 
Inspection   Drugs,  regimen,  hydration,  musculature,  fever,  SOB,  jaundice,  distress  
Hands   Clubbing,  koilonychia  (↓  Fe2+  anaemia),  leukonychia,  palmar  erythema,  
Dupuytren’s  contracture,  asterixis,  Spider  naevi  (all  else  is  Liver  failure)  
Face   Spider  naevi,  Jaundice,  parotid  swelling  (ETOH)  
Eye   Jaundice,  pallor  
Mouth   Angular  stomatitis  (thrush,  ↓  Fe2+),  glossitis  (↓  Fe/folate/B12),  ulcers  
(Crohn’s),  thrush.  
Neck   Lymphadenopathy  –  remember  Virchow’s!  
Chest  insp.   Spider  naevi,  gynecomastia,  Caput  medusae  
Abdo  insp.   Scars,  distension  
Palpation   Check  for  pain  1st  
6  areas  -­‐  Superficial  &  deep.    Liver,  spleen  (hameolytic  anaemias,  infection),  
kidneys  balloting  (UTI),  bladder.  
Auscultation   Bowel  sounds,  aortic  and  renal  artery  bruits.  
Percussion   Inc.  ascites  
Groin   Hernia,  lymph  nodes  
Leg   Oedema,  gangrene  
Extra   PR  exam,  Inguinal  orifice,  ext.  Genitalia,  urinalysis  
Review  jaundice,  anaemia,  cyanosis,  clubbing,  lymphadenopathy.  
 
Upper  Peripheral  Neuro    
 
Appearance   Pronator  drift  
Tremor,  wasting,  fasciculation  
Tone   Shake  hands  while  supporting  elbow:  
 
Power   Pt  birdwings  →  push  down  
Support  elbow:  “stop  me  pulling/pushing  your  hand”  
Pt  fist  and  Support  forearm:  “stop  me  pushing  up/down/  sides”  
Ask  pt  to  turn  palms  up,  thumbs  up  →  try  to  push  thumbs  down  
Paper  snatch  
Co-­‐ordination   Finger  (moving)  to  nose,  piano,  dysdiadochokinesis  
Reflexes   Biceps  (indirect),  triceps  (direct),  Supinator  (indirect)  
Sensation   Cotton  wool  and  neurotip  (to  sternum  first  for  reference)  
Vibration  fork  →  thumb  carpal/metacarpal  
Proprioception:    hold  digit  at  sides  and  move  up/down  
 

Lower  Peripheral  Neuro  


 
Appearance   Gait,  Romberg’s  test,  tremor,  wasting,  fasciculation  
Tone   Roll  legs:    assess  ankle  tone  
                 Lift  knee  quickly  →  heel  lifts  of  bed?  
Ankle  clonus  (>5  =  pathology)  
Power   Pt  lift  leg  →  stop  me  pressing  down  
Pt  bend  knee  →  “stop  me  pulling  your  foot  away  /  pushing  toward”  
Support  shins,  Pt  cocks  feet  back  →  “stop  me  pushing  your  feet  up  /  down    
/  sideways”  
Co-­‐ordination   Heel  slide  on  shins  
Reflexes   Knee  on  lift,  achilles  on  stretch  
Babinski  check  using  orange  stick  (⊕=↑,  normal  =  ↓)  
Sensation   Cotton  wool  and  neurotip  (to  sternum  first  for  reference)  
Vibration  fork  →  ball  of  foot  
Proprioception:    hold  digit  at  sides  and  move  up/down  
 

Cranial  Nerves  
 
1,  Olfactory   “Have  you  noticed  any  change  in  your  sense  of  smell?”  
2,  Optic   Acuity  (colour  vision  -­‐  Ishihara)  
Fields  
Reflexes  (light  direct/consensual  and  accommodation)    
Ophthalmoscope  (red  reflex,  colour,  contour,  cupping)  
3,  4,  6  Oculomotor,   Eye  movements  (nystagmus),  ptosis,  pupillary  size  &  shape  
trochlear,  abducent   Ask  for  double  vision  
5  Trigeminal   Motor  –  “clench  teeth”  &  feel  masseter/temporalis  
Sensory  –  sharp/soft  on  both  sides  in  all  3  CN5  areas  
Mention  reflexes:  corneal  and  jaw  jerk  
7,  Facial   “Screw  your  eyes  up,  show  me  your  teeth,  blow  out  your  
cheeks”  
Mention:  taste  ant  2/3  tongue,  hyperacusis  
8,  Vestibulocochlear   Hearing  –  Whisper  test,  auroscopy,  Weber,  Rhinnes  
9,  10,   Gag  reflex,  “say  ahhh”  →  uvular  deviation  
Glossopharyngeal/vagus   Ask  about  swallowing,  hoarse  voice  
11,  Accessory   Shrug  shoulders  &  turn  head  against  resistance  (palpate  
opposite  SCM)  
12,  Hypoglossal   Stick  tongue  out,  wiggle  it  around  
 
 
 

Groin  
 
Exposure   Move  trousers  below  curvature  of  bottom  
Inspection   Scars,  hernia  
Cough  &  watch    
Palpate   1) ASIS,/pubic-­‐tubercle-­‐midpoint,  1  finger  on  deep  
ring,  1  on  inguinal  ligament  (superficial  ring)  –  
patient  to  cough  
2) Same  position  but  with  pressure  on  deep  ring  –  
patient  to  cough  again  
3) Feel  for  superficial  inguinal  lymph  nodes  
4) Femoral  pulse  
5) Femoral  canal  –  patient  to  cough  again  
6) Listen  to  femoral  artery  (aneurysm)  
Stand  patient  up  &   Varicocele,  contralateral  hernia  
re-­‐examine  for  
hernia/ext  genitalia  
 

Breast  
 
Inspection   Asymmetry,  skin  change  
Raise  arms  &  watch   Asymmetry  of  movement  
Palpate  (lying  flat)   Examine  normal  first  
Use  flats  of  fingers,  4  quadrants  +  nipple,  then  axillary  tail  
(with  hand  behind  head)  
Palpate  axilla   Lift  patient’s  arm  &  move  back  down  after  in  axilla  
Supra/infraclavicular    
fossa  palpation  
Hands  on  hips  to  test    
mass  movement  if  
located  
 

Thyroid  
 
Inspection  (from  front)   BMI  estimate,  scars,  lumps,  tremor/restless/agitated,  
eyes,  hair  &  eyebrows,  stand  from  chair  without  hands  
Palpate  thyroid   (Find  thyroid  notch,  move  down  to  just  below  cricoid,  
then  lateral)  
Ask  to  stick  out  tongue  (thyroglossal  cyst)  
Ask  to  swallow  (thyroid)  
Uniformly  enlarged,  solitary  or  multinodular?  
Percuss  upper  sternum   Mediastinal  extension  
Ausc  for  thyroid  bruit   Graves  disease  
Lymph  nodes   Ant  cervical,  supraclavicular,  post  cervical,  
(explain  process)   submandibular,  submental,  pre-­‐auricular,  post-­‐auricular,  
  occipital  [Hard  =  malignant,  tender  =  infection,  rubbery  =  
lymphoma]  
Eyes  (in  Graves’)   Exophthalmos,  lid  retraction,  lid  lag,  opthalmoplegia,  
chemosis  (conjunctival  oedema)  
Palpate  parotid   Plus  look  in  mouth  &  examine  facial  nerve  if  lump,  plus  
ask  pt  to  open  jaw  to  assess  if  attached  
Hands   Temperature,  palmar  erythema,  thyroid  acropachy,  
tremor,  pulse  (AF,  tachy),  vitiligo  
Palpate  other  lumps  (e.g.   Describe:  site,  size,  shape,  consistency,  fluctuance,  
shins–pre  tibial   transilluminance,  temperature,  tenderness,  tethering,  
myodema)   pulsatility,  spread  (LNs)  
Check  reflexes   Hypothyroidism  

GALS  
 
Screen  Qs   Pain,  stairs,  dressing  /  buttons,  gout/arthritis  
Gait   Smoothness,  speed,  stride,  symmetry,  swing,  turn  
Spine  (back)   Assess  shoulders,  paraspinals,  glutes.  Scoliosis,  Baker’s  cysts,  ankle  
deviation  
Palpate  supraspinatus  →  fibromyalgia?  
Spine  (side)   Lordosis,  kyphosis  
Fingers  on  spinous  processes  →  bend  over  slowly  
Spine  (front)   Assess  musculature  
Ear  →  shoulder:  normal  lateral  cervical  flexion?  
Arms   Out  Straighten,  then  elbows  bent  at  side.  
(pronated)   Wrist  /  finger  deformity  (Heberden’s=distal  interphalangeal,  
Bouchard’s=proximal)  
Thenar  wastage  
Pitted  nails  →  psoriasis  
Metacarpal  squeeze:  pain?  =  Synovitis  
Arms   Painful  /abnormal  supination?  
(supinated)   Fist  strength?  
Pincer  co-­‐ordination  and  strength  
Wrists   Elbows  out  and  fingers  pointed  up  (extension),  then  down  (flexion)  
Shoulder   Hands  behind  head  (elbows  out),  then  up  behind  back  
Legs   Asymmetry  of  muscles.    Scars,  swelling,  
Knee  effusion  –  patellar  tap.  
Active  then  passive  (feel  for  crepitus)  flexion  and  extension  
Hips   Check  rotation  on  knee  flexion  
Feet   Metatarsal  squeeze,  callous  check.  
 

Shoulder  
 
Inspection   Front,  side,  back  (including  neck)  
Muscle  wasting,  scars,  swelling  
Palpate  joints  for  muscle   Sternoclavicular  
bulk  &  tenderness   Acromioclavicular  
Glenohumeral  
Palpate  back  of  neck  in    
midline  
Flexion  of  joint   Stand  behind  patient  &  ask  to  raise  arms  
Active  &  passive  (if  active  not  complete)  
Abduction   Stand  behind  pt  &  guide  raising  of  arms  
Abduct  arms  at  about  30o  (active  &  passive)  
External  rotation   Stand  behind  &  position  joints:  
Elbows  tight  to  sides  (elbow  joint  at  90o  facing  forward)  
Guide  patients  arms  to  externally  rotate  as  far  as  poss  
Internal  rotation   Either:  
Shoulder  &  elbow  at  90o,  hands  pointing  towards  ceiling  
Ask  to  move  wrists  forward  (internal  rotation)  as  far  as  
possible  
Or:  
If  unable  to  lift  arm  to  position  above,  ask  to  put  thumb  
behind  their  back  and  see  how  high  they  can  get  it  
Compare  each  side  
Special  tests:   Arms  abducted  to  90o,  wrist  internally  rotated  
Supraspinatus   Patient  to  resist  pushing  down  
Subscapularis   Hand  over  umbilicus  
Patient  to  try  to  slap  their  tummy  against  resistance  
Infraspinatus   Elbows  at  sides  at  90o  (hands  pointing  forwards)  
Patient  to  resist  dr  pushing  in  
Teres  minor   Shoulder  &  elbow  at  90o  (hands  pointing  to  ceiling)  
Dr  pushes  wrists  forward  &  patient  to  resist  
Dislocation  tests   Apprehension  test:  
Shoulder  &  elbow  at  90o  (hand  pointing  up)  
Dr  pushes  humeral  head  from  behind  &  pt  becomes  very  
apprehensive  &  tense  (positive  test)  
Relocation  test:  
Patient  on  bed  in  same  position  as  above  
Joint  pushed  posteriorly  &  patient  is  more  comfortable  
 

Hands  
 
Ask  about  pain  and  use   Ask  about  manual  dexterity  –  buttons?  
pillow,  don’t  shake  
hand  
Nails    
Observe  and  feel   Psoriatic  pitting,    Swelling  of  MCP/PIP  (RA  →  
Fingers   synovitis,  feels  soft),  swan  neck/boutonnieres  
deformities  (?),  thumb  z  deformity  (?),  Passive  flexion  
→  Trigger  Finger  (Stenosing  tendovaginitis  –  nodes  on  
tendon).    
IP  Osteophytes:  Proximal=  Bouchard’s,  
Distal=Heberden’s  (both  OA)  
Ulnar  deviation,  Tophus  (gout)    
Pincer  grip   Coordination  and  power  
MCP   Squeeze  and  feel  for  crepitus  on  flexion,  lost  inter  
MCP  gap  (RA  swelling)  
Pt  makes  fist  and  hide  nails  
Follow  finger  tendons   Nodules  
Palm   Erythema  (RA),  thenar  wastage  (carpal  TS),    
Wrist   RA  swelling  and  all  movement  axes  
Prayer  and  inverse   Normally  90°  both  ways  
prayer  movements  
Elbow   RA  nodules  and  gout  tophi  
 

Hip  
 
Gait   Tredelenburg  (pelvic  side  drops  on  raised  foot),  Antalgic  
(OA  →  shortened  stance  phase)  
Smoothness,  speed,  stride,  swing,  symmetry,  turn    
Ask  to  lie  flat   Also  reposition  bed  to  suitable  height  
Inspect  from  end  of  bed   Deformities,  scars,  muscle  wasting/fasciculations,  
pigmentation,  creases,  swelling,  limb  rotation  
Circulation  check   Dorsalis  pedis  
Posterior  tibial  
Popliteal  (if  none  of  above  found)  
Palpate  groin,  greater   Painful  greater  trochanter  (trochanteric  bursitis)  
trochanter,  iliac  crest  
Abduction  &  adduction   Fixate  opposite  ASIS  &  move  legs  passively  ab  &  adduction  
Rotation  (45°  each   Flex  knee  &  hip  &  move  foot  around  
direction)  
Thomas’  test   Get  patient  to  hold  knees  into  chest  &  feel  obliteration  of  
lumbar  lordosis  curvature  →  extend  each  leg  →  Fixed  
flexion  deformity?  
Turn  Pt  over   Extension  to  20°  
Measurement  of  leg   True  length  =  ASIS  to  medial  malleolus  (Perthe’s  disease,  
length   avascular  necrosis,  OA,  RA,  hip  dislocation  all  →shortening)  
Apparent  length  =  xiphisternum  to  medial  malleolus  (fixed  
hip  adduction  deformity  via  OA/RA)  
 

Knee  
 
Get  patient  to  stand  &  walk  up   Gait  abnormality,  leg  alignment  (valgus  =  knock  
&  down   knee,  varus  =  bow  leg),  recurvatum/hyperextension  
Ask  pt  to  sit  on  couch  (45o  ok)   Feel  knee  Temp.  
Inspect  quads  10cm  above   Wastage,  fasciculation  
patella  (insertion)  
Effusion   Patellar  tap  
(and  RA  nodes,  psoriatic   Milk  medial  gutter  inferiorly  
plaques)   Milk  lateral  gutter  superiorly  
Watch  for  accumulation  of  fluid  medial  to  patella  
Request  Active  flexion   To  see  range  of  painless  movement  
Passive  Flex  to  90o  &  feel  for   Feel  for  crepitus  during  flexion  
joint  line  tenderness  
Request  Patellar   Flex  knee  and  press  patella  laterally:    dislocation  →  
apprehension  test   instability  →  pain  
Extend  knee  fully   Check  range  of  extension  
Medial  &  lateral  collaterals   Hold  ankle  underarm,  hand  on  either  side  of  knee.  
Perform  initially  on  straight  leg,  then  30°  
Medial  Meniscus   Flex  knee,  externally  rotate  foot  and  abduct  thigh  →  
varus  stress  
Lateral  Meniscus   Flex  knee,  internally  rotate  foot  and  adduct  thigh  
Flexion  range   130-­‐140o  normal  
Look  at  profile  of  flexed  knee   Sagging  of  tibia  (Posterior  cruciate  injury)  
Anterior  draw  test   Anterior  cruciate  rupture  
Lackman’s  test  (more   20°  flexed  knee,  one  hand  supporting  lower  thigh,  
sensitive)   other  proximal  leg.    Draw  leg  anterior  (Anterior  
cruciate  rupture)  
Clark’s  test   Patellofemoral  ligament,  gentle  pressure  
Peripheral  pulses   Posterior  tibial,  dorsalis  pedis  
Extras   Also  state  you  would  perform  hip  and  ankle  exams.  
FBC,  ESR/CRP,  Xrays