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COMMON STATION SPECIALIST IN PLAB 2 PREPARATION EXAMINATIONS In PLAB 2 Dr Elmira Yaghmaei Dr Hamed Salehi 1 Copyrights © 2017 Common Stations PLAB Academy – Dr Hamed Salehi. All Rights Reserved Table of Contents 1. Abdominal Examination (GI Examination) ............................................................................. 3 2. Thyroid Examination ................................................................................................................... 16 3. Unconscious Patient Examination .......................................................................................... 26 4. Meningitis Examination (Headache) ....................................................................................... 33 5. Alcoholic/Diabetic foot Examination ...................................................................................... 39 6. Hip Examination ........................................................................................................................... 51 7. Knee Examination ....................................................................................................................... 60 8. Elbow Examination ..................................................................................................................... 71 9. Whiplash Injury (Cervical Examination) ................................................................................ 80 10. Primary Survey........................................................................................................................... 86 11. Secondary Survey ..................................................................................................................... 98 12. Cranial Nerve II – VII Examination ....................................................................................... 102 13. Field of Vision ........................................................................................................................... 118 14. Diplopia ...................................................................................................................................... 125 15. Cranial Nerve VIII Examination (Vestibulocochlear) ...................................................... 131 16. Lymphoreticular Examination .............................................................................................. 142 17. Cardiovascular Examination ................................................................................................ 155 18. Respiratory Examination ....................................................................................................... 175 2 Copyrights © 2017 Common Stations PLAB Academy – Dr Hamed Salehi. All Rights Reserved 1. Abdominal Examination (GI Examination) Task: “Mr Clinton is a 45 year old patient who has come to the Accident and Emergency department complaining of upper abdominal pain. He has been drinking 40 units of alcohol per week since he was young. Please perform an abdominal examination on this gentleman and discuss your findings with the examiner. Please do not examine the groin area. Please do not take history.” Introduction: This is essentially an examination of the patient’s abdomen; it is also called the gastrointestinal examination (GI). It is a complex examination which also includes examination of other parts of the body including the hands, face and neck. The abdominal examination aims to pick up on any gastrointestinal pathology that may be causing a patient’s symptoms e.g. abdominal pain or altered bowel habit. This examination is performed on every patient that is admitted to hospital and regularly in clinics and general practice. Like most major examination stations this follows the usual procedure of inspect, palpate, auscultate (look, feel, listen). A. Subject Steps: As with any examination station routine, begin by introducing yourself, obtaining consent to examine the patient and position them appropriately. It is important to explain what the examination will entail and what you are going to do. A.1. Greet the patient A.2. Introduce yourself A.3. Clarify identity A.4. Explain the procedure: “I am here to examine your tummy. I will be as gentle as possible but if at any point you feel any discomfort or would prefer me to stop, please let me know and I will stop the procedure.” A.5. Exposure: For this examination the patient should be exposed from xiphisternum to the pubis symphysis, leaving the chest and legs covered. However, you can simply ask the patient to undress above waist. “For the purpose of this examination you need to be exposed/undressed above waist.” 3 Copyrights © 2017 Common Stations PLAB Academy – Dr Hamed Salehi. All Rights Reserved A.6. Ensure Privacy and Chaperone: “I will ensure your privacy and I will have a chaperone with me throughout the examination.” A.7. Gain consent and co-operation: “May I proceed?” Or “Is that alright with you?” A.8. Position: For this examination the patient should be lying flat on the bed (supine position) with his head slightly elevated with the help of one pillow to relax the abdominal muscles. B. General Examination: B.1. General Inspection: - Check if the patient appears uncomfortable or is in distress. - Look for abnormal contours/distension. - The cough test: While looking at the face, ask the patient to cough. If this causes abdominal pain, flinching or a protective movement of hands towards the abdomen, suspect peritonitis. B.2. Hands: Inspect the patient’s hands. Provide clear instructions to the patient and minimise the amount of movements they need to make (don’t have them turning their hands back and forth multiple times). Particular signs which you should be looking for are: - Palmar erythema: Reddening of palms – thenar / hypothenar eminences / liver disease / pregnancy - Clubbing: Can be a result of inflammatory bowel disease / cirrhosis / coeliac disease - Koilonychias: Spooning of the nails – chronic iron deficiency - Leukonychia: Whitened nail bed – hypoalbuminemia / liver failure / enteropathy - Dupuytren’s contracture: Thickening of palmar fascia, associated with alcohol excess. If patient has chronic liver disease, this may suggest alcohol is the cause. - Hepatic flap/Asterixis: Technique: 1. Ask patient to stretch out arms, with hands dorsiflexed and fingers stretched out 2. Ask to hold their hands in that position for 13 seconds 3. The hands will flap (flex/extend at the wrist) in an irregular fashion if positive 4. This sign can indicate either hepatic encephalopathy (due to liver failure) / uraemia / CO2 retention - Peripheral cyanosis: Bluish discoloration of nails – indicates oxygen saturation of < 85% - Radial pulse: Check the rate (count for 10 seconds, multiply by 6), rhythm and volume of the pulse at the wrist. It can be a good indication of some conditions such as infection/sepsis. - Blood pressure Note: When there is no clock to check pulse rate or you are not provided with a blood 4 Copyrights © 2017 Common Stations PLAB Academy – Dr Hamed Salehi. All Rights Reserved pressure machine to check BP, you may simply say: “I can feel the pulse. The rhythm is regular and the volume is adequate. Ideally I would check the pulse for 1minute. I would also check my patient’s blood pressure.” B.3. Eyes: - Conjunctival pallor (anaemia) Inform the patient that you are going to have a look at his eyes: “I am going to have a look at your eyes. I will be gently pulling your eyelids down . Is that okay with you? Could you please look up for me? ” Or ask patient to lower an eyelid to allow inspection: “I am going to have a look at your eyes. Could you please pull both your lower lids down and look up for me?” - Conjunctival icterus “I am going to have a look at your eyes. I will be gently pulling your upper eyelids up. Is that okay with you? Could you please look down for me? ” Or “I am going to have a look at your eyes. Could you please pull both your upper lids up and look down for me?” - Sunken eyes (dehydration) - Xanthelasma: Lipid-laden yellow plaques that occur most commonly near the inner canthus of the eyelid and signify hyperlipidaemia (PBC, chronic obstruction, 5 Copyrights © 2017 Common Stations PLAB Academy – Dr Hamed Salehi. All Rights Reserved hypercholesterolemia). - Corneal arcus: A greyish-white ring (or part of a ring) opacity occurring in the periphery of the cornea, in middle and old age. It is due to a lipid infiltration of the corneal stroma. With age the condition progresses to form a complete ring. B.4. Mouth: - Central cyanosis: Bluish discoloration of the lips and mucous membranes (inferior aspect of tongue). “Could you please open your mouth and roll your tongue back?” - Angular stomatitis: Inflamed red areas at the corners of the mouth – iron / thiamine / B12 deficiency - Pigmentation: Peutz-Jeghers syndrome - Telangiectasia: Osler-Weber-Rendu syndrome - Mouth ulcers: Look at the buccal mucosa for any obvious ulcers which could be a sign of Crohn’s disease / coeliac disease - Tongue (glossitis): Also look at the tongue. If it is red and fat it could be another sign of anaemia - iron/B12/folate deficiency - Oral candidiasis 6 Copyrights © 2017 Common Stations PLAB Academy – Dr Hamed Salehi. All Rights Reserved B.5. Neck: - Engorged neck veins / JVP: raised in fluid overload (renal dysfunction, liver dysfunction), tricuspid regurgitation (may cause pulsatile hepatomegaly) - Lymphadenopathy (Virchow’s node/ Troisier’s sign): Examine cervical and supraclavicular lymph nodes. Palpate the left supraclavicular lymph node. A palpable enlarged
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