PHYSICAL EXAMINATION Dr. Golshan Salehi Apr 2018, ARIMGSAS General Principles ➢ Greet the patient andintroduce yourself ➢ Wash your hands ➢ Permission of patient with explanation of what you have to do ➢ Also seek consent for exposure. Expose the area that needs to be examined ➢ Do not disrobe patient yourself, only help if needed ➢ Remember it as WIPE ➢ It is very important to know the position of examination ➢ Abdominal –lying flat with 1pillow ➢ Respiratory –sitting upright ➢ Cardiovascular –sitting at 45o ➢ Do not forget to first do a general inspection. Useful Recourses ➢ Geeky medics: website and smartphone app ➢ Talley and O’Connor’s Clinical Examination ➢ Notes ❖ And PRACTICE, PRACTICE and PRACTICE! Its never enough Karen’s notes??? Cranial Nerve Examination You work as HMO in an emergency department when the consultant in charge asks you to take a group of medical students and to demonstrate to them how to examine the cranial nerves. Tasks: Perform an examination of the cranial nerves Give running commentaries to the examiner ➢ WIPE ➢ GA: facial asymmetry, position of eyes, ptosis ➢ Olfactory nerve (I): ➢ Have you noticed any change in your smell? ➢ Please close your eyes and smell this: coffee beans/vanilla essence ➢ One nostril at a time ➢ Optic nerve (II): ➢ Visual acuity: Snellen chart. Please read the lowest line. Covering one eye at the time. ➢ With spectacles ➢ Visual fields (red topped pin): Cover one eye of patient and your opposite eye. Distance should be an arm’s length. Patient should look at examiner’s nose, head still. ➢ Without spectacles ➢ Ask for color of red top pin ➢ Fundoscopy: ask if available. Looking at cornea, lens, retina, optic disk. ➢ Oculomotor (III) + Trochlear (IV) + Abducens (VI) Nerve : ➢ Ptosis, pupils (PEARL) ➢ Eye movement: H shape ➢ Accommodation ➢ Trigeminal nerve (V) ➢Sensation ➢Motor function: ➢ clench your teeth and feel ➢ open mouth and don’let me close it ➢Jaw jerk ➢Corneal reflex: V afferent and VII efferent ➢ Vestibulocochlear nerve (VII) ➢ Facial Nerve (VII) ➢Whisper test ➢Rinne and Weber: 512Hz ➢Facial asymmetry ➢Wrinkle your forehead ➢ Glossopharyngeal (IX) and vagus(X) nerve ➢Close your eyes, don’t let me open them ➢Say AHH, check for uvula and palate ➢Blow out your cheeks ➢Hoarseness and cough ➢Smile ➢Swallow: sip this glass of water ➢Purse your lips ➢ Accessory nerve (XI) ➢Any change in your taste? ➢Shrug your shoulders don’t let mepush them down ➢Do you think you are hearing louder? ➢Look to the other side and push against my hand. ➢ Hypoglossal nerve (XII) ➢Show me your tongue? Bell’s Palsy ➢ A 36-year-old woman, Jennifer, presents to your GP practice, complaining of sudden onset of left sided facial weakness with facial disfigurement, preceded by pain behind the left ear. ➢ Your task are: ➢ Take a brief focusedhistory ➢ Examine the patient ➢ Most likely diagnosis to the patient ➢ HOPC: Since when? Is it the first time? Is it getting worse? ➢ How did it start:Sudden/gradual. ➢ DDx ➢ Did you notice any difficulty in speech or weakness in any of your limbs? ➢ Did you fall? ➢ Have you had any recent infection? ➢ Have you had any recent trauma? ➢ Have you felt any changes in hearing? Hyperacusis ➢ Do you think your taste has changed? ➢ +/- ➢ Are there any lumps in front of the ear? Are you having any pain in the face? Do you feel any blisters on the face or ear? If severe pain-look for Ramsay hunt syndrome. ➢ Have you had any recent ear infection or ear pain? OM ➢ Have you had any pain behind the ear or at the angle of your jaw? - Mastoiditis, parotitis ➢ PMHx, PFHx, PSHx ➢ SADMA ➢ WIPE ➢ GA: distressed/anxious ➢Facial asymmetry: flattening of forehead and nasolabial fold. ➢Palpebral fissure widen on affected side ➢ VS: Normal ➢ Facial Nerve (VII) ➢Wrinkle your forehead ➢ If it spares the forehead: CNS cause ➢Close your eyes, don’t let me open them ➢ Bell’s reflex: on attempted eye closure, the eye tolls upward and inwards on affected side ➢Blow out your cheeks ➢Smile ➢Purse your lips ➢Any change in your taste? ➢Do you think you are hearing louder? ➢Corneal reflex: lost on affected side ➢ Afferent arm: V th CN ➢ Efferent arm: VII th CN ➢ Vestibulocochlear nerve (VII) ➢Whisper test ➢Rinne and Weber: 512Hz ➢ Ear ➢Inspection: signs of inflammation/infection/rash: vesicles -Ramsay Huntsyndrome ➢ Otoscopy: external auditory canal for vesicles/signs of infection o trauma/tympanic membrane/OM ➢ Parotid gland ➢Inspection: signs of inflammation/signs of infection/mass ➢Palpation: mass ➢ Lymph nodes ➢ To conclude my examination ➢CN ➢UL and LL neurological examination ➢Complete eye examination looking for cornealabrasion ➢ Dx –5C’s ➢ Mx ➢ Protect the eye: Artificial tears and eye patch ➢ Steroids: start within 72 hours of symptoms onset ➢ Acyclovir ➢ Physical therapy Parotid Examination ➢ A middle-aged man comes in to your GP clinic with a swelling on the left side of his face just above the angle of his jaw between the mastoid and mandible. A picture of the swelling is provided. ➢ Task ➢History ➢Physical examination ➢Diagnosis and management ➢ DDx ➢Pleomorphic adenoma ➢Carcinoma ➢Pre auricular lymph node ➢Chronic parotitis ➢Abscess Pleomorphic Adenoma ➢ WIPE ➢ GA ➢ Inspection: from picture, describe it – site, size, shape, signs of inflammation or infection ➢ Palpation: site, size, shape, surface, contour, consistency, compressibility, temperature, tenderness, trans illumination in soft, fixation, fluctuation, pulsatile ➢ Facial nerve (VII):motor ➢ Cervical lymph nodes ➢ Bimanual palpation: request gloves, tongue depressor and torch. See if any discharge fromduct Assessment of a Lump ➢ Inspection ➢ Site:can help narrow the differential ➢ Size ➢ Shape: well defined? ➢ Overlying skin changes: erythema / ulceration / punctum ➢ Palpation ➢ Consistency :smooth / rubbery / hard / nodular / irregular ➢ Fluctuance: if fluctuant, this suggests it is a fluid filled lesion – cyst ➢ Borders: well defined/irregular ➢ Pulsatility: suggests vascular origin –e.g. carotid body tumour / aneurysm ➢ Temperature: increased warmth may suggest inflammatory / infective cause ➢ Tenderness ➢ Relation to underlying / overlying tissue – tethering / mobility (ask to turn head) ➢ Auscultation: to assess for bruits –e.g. carotid aneurysm ➢ Special test ➢ Trans-illumination: suggests mass is fluid filled Ear Examination ➢ 34 yo male, came with history of recurrent otitis media, now coming with deafness. ➢ Tasks : ➢ Relevant Hx ➢ Ear Physical Examination ➢ Dx ➢ DDx ➢ Conductive deafness: wax, foreign body, OM, trauma, otosclerosis, cholesteatoma ➢ Sensory deafness ➢ HOPC ➢Since when? On and off ➢ Is it the first time? No it has happened 4 times before ➢ Is it getting worse? Yeah, I feel my hearing is getting worse ➢If pain –SOCRATES ➢ Associated Sx: Fever ➢ ➢ PMHx, PFHx, PSHx ➢Discharge ➢Balance ➢ SADMA ➢Tinnitus: ringing sensation ➢ Medication: antibiotics for ➢Fullness recurrent AOM/gentamycin/furosemide ➢Hearing loss ➢Runny nose, sore throat ➢Trauma: swimming, diving, plane ➢Noise exposure ➢Facial asymmetry ➢ Inspection ➢ Skin changes: signs of infection, signs of inflammation ➢ Discharge ➢ Symmetry ➢ Scars ➢ Mastoid process –mastoiditis ➢ Palpation ➢ Temperature ➢ Tenderness: ➢ Tragus and helix –otitisexterna ➢ Mastoid process –mastoiditis ➢ Otoscopy: hold it in a pen holding method with little finger extended, with opposite hand pull helix upwards and backwards. R hand for R ear. ➢ External: auditory canal for wax, foreign body, inflammation ➢ Internal: assess ear canal tympanic membrane ➢ Colour ➢ Light cone: pointing anteriorly and inferiorly ➢ Perforation ➢ Discharge: pus, bleeding ➢ Abnormal growth -cholesteatoma ➢ CN ➢ VII: motor and ask for change in taste ➢ VIII ➢ Whisper test: 15 cm first and then one arm distance ➢ Weber ➢ Neural deafness – sound is heard louder on the side of the intact ear 512 Hz ➢ Conductive deafness – sound is heard louder on the side of the affected ear ➢ Rinne: AC >BC – Rinne +. Mastoid process first, then external auditory meatus ➢ Neural deafness - AC > BC (both air and bone conduction reduced equally) ➢ Conductive deafness -BC > AC (Rinne’snegative) ➢ Lymph nodes ➢ Conclude ➢ will like to to finish with an audiogram if available ➢ Dx - Cholesteatoma ➢ From the Hx and PE that Iperform most likely you have a condition called cholesteatoma. Have you heard about it? ➢ Condition: its a sack like structure which contains death skin cells, those cells release a substance that can dissolve the surrounding structures, ➢ Cause: might be due to the recurrent AOM that you’ve had ➢ Clinical features: when Iwas looking inside your ear Icould see this extra skin in you tympanic membrane, this is affectingyour hearing ➢ Commonality: it is not an uncommon condition ➢ Complications: Deafness, mastoiditis, erode the bone reaching brain matter, encephalitis, abscess, invasion of blood vessels – thrombosis of sinuses ➢ Mx ➢ This condition needs to betreated ASAP ➢ Referral to ENT ➢ Imaging: CT/MRI ➢ Sx: enucleation of cholesteatoma Upper Limb Neurological Examination ➢ Power: resisted movement ➢ WIPE: sitting on edge of bed ➢ Chicken wings: C5 ➢ GA ➢ Biceps: C6 ➢ Abnormal movements –tremor, fasciculation ➢ Triceps: C7 ➢ Muscle wasting –denervated muscle ➢ Fisting: C8 ➢ Skin –neurofibromatosis/herpes zoster ➢ Abduction of fingers:T1 ➢ Arm drift –upper motor neuron ➢ Reflexes pathology ➢ Biceps: C5,6 ➢ Close eyes and place arms extended ➢ Triceps: C7 and palms upwards ➢ Brachioradialis: C6 ➢ Look for evidence of drifting ➢ Finger jerk: C8 ➢ Tone: Test at wrist and elbow ➢ Coordination ➢