I was surprised to learn that someone has read this page.
For that reason I feel that I should do a bit of disclosure. I passed the PACES exam about two years ago on my first attempt. I worked very hard to pass it. I used to come into work an hour early to do the ward round before clinic to free up time for consultant teaching in the afternoon. I was very lucky and I got lots of good consultant teaching. At that time I was an SHO on a good rotation at a small teaching hospital in Scotland.
I am a UK national and I went to medical school in England. That puts anyone at an advantage for the PACES exam as several of the stations involving history taking and ethics are easier if you have attended medical school in Britain.
I attended two PACES courses - a PASTEST course in Manchester which was OK and the Neuropaces course at the Walton Centre in Liverpool which was very good. I would advise candidates to attend a couple of courses.
I saw as many patients with other people watching me as possible. Practice with your colleagues and criticise each other harshly. If you are used to doing a clinical examination under pressure you will be more comfortable in the exam. Some examiners can be pretty nasty.
As a first year SHO I helped out with the PACES exam in my hospital. Some of the examiners from other hospitals were rather harsh. 'I see you have completely failed to examine for a collapsing pulse. Why should you have done that?' was the best line that I overheard.
The best book I found was the blue covered book by Hall. I advise that you read it from cover to cover. There is a smaller pocket book called cases for paces which is good. The old version of Ryder is good for examination routine and pictures. The new, golden covered edition has lots of history taking and ethics cases that are worth reading.
Make sure you practice history taking and ethics before the exam!
I am now a neurology trainee. I'm pretty lucky. I do a fair bit of PACES and medical student teaching when I can. It's all good fun.
Good luck if you are sitting the exam.
Tuesday, 21 April 2009
Monday, 15 January 2007
Examination of the heart – PACES
- Examination of the heart – PACES
Position – approach from right/patient at 45’
Ask permission/introduce self/adjust clothing
Visual survey is patient/does patient have
A. breathless?
B. cyanosed?
C. Pale?
D. Malar flush? Mitral stenosis
E. Franks sign (earlobe creases)?
F. Forceful carotid pulsations (Corrigans sign in AI, forceful pulsation in coarctation of the aorta)
G. Tall, sinuous venous pulsations (CCF, tricuspid incompetence, pulmonary HT, etc)
H. Left thoracotomy scar (mitral stenosis) or midline sternal scar (valve replacement/CABG)
I. Ankle oedema –
J. Finger clubbing (cyanotic congenital heart disease, SBE)
K. Splinter haemorrhages
Pulse – rate & rhythm- Is pulse collapsing? Especially if large volume pulse – make sure you are seen to lift arm – ask if arm is sore before lifting
- Radiofemoral delay (coarctation of the aorta)
- other pulses – brachial & carotid looking for slow rising pulse – especially if low volume pulse
- JVP – if interesting pulsations noted further examine. Corrigans sign (forceful rise and quick fall of pulsations) may be reinforced by collapsing pulse. Can time individual waves against opposite carotid. A large v wave which may oscillate the earlobe suggests tricuspid incompetence – should later demonstrate peripheral oedema and pulsatile liver using bimanual technique (place left palm posteriorly and right hand anteriorly over enlarged liver). If the venous wave comes before the carotid pulsation it is an a wave suggesting pulmonary hypertension (mitral valve disease, cor pulmonale) or pulmonary stenosis (rare)
- Measure height of JVP in CM directly above the sternal angle
- Localise apex beat with respect to mid-clavicular line and ribspaces, initially by visual inspection (ha ha) then by palpation. If apex beat is vigorous you should stand the index finger on it to localise point of maximum impulse (PMI) and assess the extent of its thrust. Impulse graded as just palpable, lifting (diastolic overload, i.e. mitral or aortic incompetence), thrusting (stronger than lifting) or heaving (outflow obstruction)
- Palpation with hand placed from left lower sternal edge to apex will detect a tapping impulse (left atrial ‘knock’ in mitral stenosis) or thrills over the mitral area (mitral valve disease)
- Feel for right ventricular lift (left parasternal heave). Place right palm parasternally over right ventricular area and apply sustained and gentle pressure. If RVH is present you will feel the heel of your hand lifted by the force (pulmonary hypertension)
- Palpate the pulmonary area for palpable second sound (pulmonary hypertension) and aortic area for palpable thrill (aortic stenosis)
- If you feel a strong RV heave recheck for giant a wave (pulmonary HT, pulmonary stenosis) or v wave (tricuspid incompetence, CCF). Palpable thrills over mitral (MS) or pulmonary (PHT) areas should make you think of and check for other complementary signs.
- Auscultation – only leave heart if you have a strong expectation of being able to demonstrate interesting and relevant sign (e.g. pulsatile liver to strengthen diagnosis of tricuspid incompetence). Time the first sound with either the apex beat if palpable or by feeling the carotid pulse. Listen to expected murmurs in best positions. Mitral diastolic murmurs (MS) are best heard by turning the patient onto the left side. Diastolic murmur of atrial incompetence is best heard by asking patient to lean forward with breath held after expiration (with diaphragm of chest piece ready in position). For low pitched sounds (mid diastolic murmur of mitral stenosis, heart sounds) use the bell but do not press too hard! High pitched early diastolic murmur of aortic incompetence is easily missed so specifically listen for it.
- Sacral oedema/ankle oedema
- Listen to lung bases – routine although not often relevant in cardiovascular station. More relevant in breathless patient, aortic stenosis with displaced PMI, signs of left heart failure (orthopnoea, pulsus alternans, gallop rhythm)
- Palpate liver – esp if large v wave and pansystolic murmur over tricuspid area. May demonstrate pulsatile liver by placing left hand posteriorly and right hand anteriorly over enlarged liver.
- Offer to measure blood pressure - most relevant in aortic stenosis (narrow pulse pressure) and aortic incompetence (wide pulse pressure)
Examination of the pulse – PACES
- Ask permission
- Approach from right side
- Face – malar flush (myxoedema, mitral stenosis), thyroid disease
- Neck – Corrigan’s pulse(vigourous arterial pulses seen in neck), raised JVP, thyroidectomy scar, goitre
- Chest – thoracotomy scar
- General survey – ascities, clubbing, pretibial myxoedema, ankle oedema,etc
- RADIAL pulse
- rate – 15 seconds
- Rhythmn – slow atrial fibrillation (concentrate on length of pauses) – pauses vary from beat to beat in slow AF
- Character – assess at radial, brachial and carotid. Can be normal, collapsing, slow rising or jerky. Collapsing palpate radial and lift patients hand above head. Palpate brachial with other hand. If waterhammer pulse is present you feel a flick running along all four fingers while you may feel a flick at the brachial. Sensation of sharp knock – present in haemodynamically significant aortic incompetence and patent ductus arteriososis. Less pronounced collapsing pulse can be felt in moderate AI, PDA, thyrotoxicosis, fever, pregnancy, moderate severe mitral incompetence, anaemia, atherosclerosis. Slow-rising pulse – palpate brachial pulse with thumb. Bisferiens pulse – combination of plateau and collapsing effects.
- Carotid –Confirmation of slow-rising and collapsing pulse
- Radio-radial delay - ?fallots with blacklock shunt
- Radiofemoral delay - coarctation of the aorta
- all other peripheral pulses
- additional diagnostic clues
Monday, 4 December 2006
Examination of the peripheral nervous system
The motor system
· Inspection & palpation of muscle groups
· Assessment of tone
· Testing of power
· Elicitation of deep tendon reflexes & plantar responses
· Testing of co-ordination
Inspection & palpation
· Normal variety in muscle bulk & power
· Lower limb musculature symmetrical
· Upper limb musculature more developed in dominant side
· Muscle wasting - Assess distribution. Focal or diffuse. Proximal or distal. Involving peripheral nerve or spinal segment.
· Fasiculations - subcutaneous twitches overlying muscle bellies when muscles are at rest. LMN disease. Brief contraction of single motor units.
· Myoclonus - Sudden, shock-like muscle contraction involving one or more muscle of a whole limb. Focal or diffuse and occur singly or repetitively.
· Choreiform movements - irregular, jerky, semipurposeful. Huntington’s chorea.
· Tics
· Tremor
· Dystonic movements - slow & writhing. Often lead to sustained abnormal contracture & limb posturing
· Pronator drift – ask patient to close eyes and hold out arms with hands supinated. If UMN lesion is present hand will drift into pronation..
Tone
· Ask patient to relax and ‘go floppy’
· Passively flex & extend each joint in turn. Start slowly then more rapidly.
· Upper limbs - test shoulder, elbow joint & wrist joint
· Lower limb - Internal & external rotation of resting leg. Briskly raise knee off leg and watch to see if ankle is also raised.
· Knee clonus - Push patella sharply towards foot and palpate for further jerks.
· Ankle clonus - Support flexed knee with one hand in popliteal fossa so ankle gently rests on the bed. Using other had briskly dorsiflex the foot and sustain the pressure
· Sustained clonus is a sign of UMN damage
Power
· Power is relative to the patient
· Examine muscle groups against contralateral group
· Isometric testing - Patient contracts muscle group & maintains position as examiner tries to overpower group being tested.
· Isotonic testing - Ask patient to put a joint through a range of movement while trying to stop the movement
MRC scale for muscle power
0 - No muscle contraction visible
1 - Muscle contraction visible, but no movement of joint
2 - Joint movement when effect of gravity eliminated
3- Movement sufficient to overcome effect of gravity
4- Movement overcomes gravity plus added resistance
5- Normal power
Deep tendon reflexes
· Biceps jerk - C5, C6
· Triceps jerk - C6, C7
· Supinator jerk - C5, C6
· Knee jerk - L3,L4. Legs must not be in contact
· Ankle jerk - S1
· If difficult have patient grit teeth or pull against hands
Plantar response L5/S1
· Normal - normal plantar flexion of big toe and other toes.
· Positive Babinski sign - dorsiflexion
Clonus
· Rhythmical repetitive plantar flexion and dorsiflexion
· Loss of supraspinal inhibition
· Sharp muscle stretching causing oscillation within circuit of the reflex arc
· Normal – a few beats
· Pathology – asymmetrical or sustained
Hoffman reflex
· Lesion at level of C5/6 – supinator jerk
· Inversion of supinator jerk – flexion of the fingers
· Supinator/biceps often lost
· Can be elicited by ‘flicking’ one finger – all other fingers should flex
· Similar to Babinski
Co-ordination
· Finger-nose test
· Rapid alternating movements
· Heel shin test.
The sensory system
· Proprioception
· Light touch
· Pin prick
· Vibration
· Temperature
· Two point discrimination
· Aim to determine if any modalities are impaired and to determine the site of any lesion
Examination system
· Touch - cotton wool, tissue paper or light touch
· Pain - pin
· Deep pain - squeeze muscle bellies
· Temperature - cool object - tuning fork
· Joint position sense - Start distal. Show patients movements and name them. Close eyes. Avoid guessing.
· Vibration sense - tuning fork
· Two point discrimination
· Inspection & palpation of muscle groups
· Assessment of tone
· Testing of power
· Elicitation of deep tendon reflexes & plantar responses
· Testing of co-ordination
Inspection & palpation
· Normal variety in muscle bulk & power
· Lower limb musculature symmetrical
· Upper limb musculature more developed in dominant side
· Muscle wasting - Assess distribution. Focal or diffuse. Proximal or distal. Involving peripheral nerve or spinal segment.
· Fasiculations - subcutaneous twitches overlying muscle bellies when muscles are at rest. LMN disease. Brief contraction of single motor units.
· Myoclonus - Sudden, shock-like muscle contraction involving one or more muscle of a whole limb. Focal or diffuse and occur singly or repetitively.
· Choreiform movements - irregular, jerky, semipurposeful. Huntington’s chorea.
· Tics
· Tremor
· Dystonic movements - slow & writhing. Often lead to sustained abnormal contracture & limb posturing
· Pronator drift – ask patient to close eyes and hold out arms with hands supinated. If UMN lesion is present hand will drift into pronation..
Tone
· Ask patient to relax and ‘go floppy’
· Passively flex & extend each joint in turn. Start slowly then more rapidly.
· Upper limbs - test shoulder, elbow joint & wrist joint
· Lower limb - Internal & external rotation of resting leg. Briskly raise knee off leg and watch to see if ankle is also raised.
· Knee clonus - Push patella sharply towards foot and palpate for further jerks.
· Ankle clonus - Support flexed knee with one hand in popliteal fossa so ankle gently rests on the bed. Using other had briskly dorsiflex the foot and sustain the pressure
· Sustained clonus is a sign of UMN damage
Power
· Power is relative to the patient
· Examine muscle groups against contralateral group
· Isometric testing - Patient contracts muscle group & maintains position as examiner tries to overpower group being tested.
· Isotonic testing - Ask patient to put a joint through a range of movement while trying to stop the movement
MRC scale for muscle power
0 - No muscle contraction visible
1 - Muscle contraction visible, but no movement of joint
2 - Joint movement when effect of gravity eliminated
3- Movement sufficient to overcome effect of gravity
4- Movement overcomes gravity plus added resistance
5- Normal power
Deep tendon reflexes
· Biceps jerk - C5, C6
· Triceps jerk - C6, C7
· Supinator jerk - C5, C6
· Knee jerk - L3,L4. Legs must not be in contact
· Ankle jerk - S1
· If difficult have patient grit teeth or pull against hands
Plantar response L5/S1
· Normal - normal plantar flexion of big toe and other toes.
· Positive Babinski sign - dorsiflexion
Clonus
· Rhythmical repetitive plantar flexion and dorsiflexion
· Loss of supraspinal inhibition
· Sharp muscle stretching causing oscillation within circuit of the reflex arc
· Normal – a few beats
· Pathology – asymmetrical or sustained
Hoffman reflex
· Lesion at level of C5/6 – supinator jerk
· Inversion of supinator jerk – flexion of the fingers
· Supinator/biceps often lost
· Can be elicited by ‘flicking’ one finger – all other fingers should flex
· Similar to Babinski
Co-ordination
· Finger-nose test
· Rapid alternating movements
· Heel shin test.
The sensory system
· Proprioception
· Light touch
· Pin prick
· Vibration
· Temperature
· Two point discrimination
· Aim to determine if any modalities are impaired and to determine the site of any lesion
Examination system
· Touch - cotton wool, tissue paper or light touch
· Pain - pin
· Deep pain - squeeze muscle bellies
· Temperature - cool object - tuning fork
· Joint position sense - Start distal. Show patients movements and name them. Close eyes. Avoid guessing.
· Vibration sense - tuning fork
· Two point discrimination
Examination of the abdomen
General points
Approach from right hand side
Ask if patient can lie flat
Lie patient flat on one pillow
Exposure - ideally nipple to knee but realistically only lower garments to about halfway between iliac crest and synthesis pubis
1 - Visual survey
Look for
Pallor
Pigmentation
Jaundice
Spider naevi
Xanthelasma
Parotid swelling
Gynaecomastia
Scratch marks
Tattoos
Abdominal distension
Distended abdominal veins
An abdominal swelling or herniae
Surgical scars
Decreased body hair
2 - Comment on pigmentation
3 - Examine the hands
Dupuytren’s contracture
Clubbing
Leuconychia - white discolouration of the nails
Palmar erythema
Flapping tremor
4 - Pull down lower eyelid
Anaemia
Icterus in sclerae
Xanthelasma
Guttering between eyeball & lower lid is best place to look for pallor or discolouration
5 - inspect mouth
Cyanosis of lips - cirrhosis of liver
Swollen lips - Crohn’s
Telengiectasis - Osler-Weber-Rendu
Patches of pigmentation - Peutz-Jeghers
Mouth ulcers - Crohn’s disease
6 - Lymph nodes & JVP
Palpate neck & supraclavicular fossae for Cervical lymph nodes
If you find lymph nodes palpate axillae & groin for evidence of generalised lymphadenopathy - lymphoma, chronic lymphocytic leukemia
JVP may be enlarged in portal hypertension
7 - gynaecomastua
Palpate for glandular tissue in obese patients
8 - Spider naevi
Distribution of superior vena cava
May be seen on hands, arms, face & back
9 - Scratch marks
Anywhere on body - may be sign of hyperbilirubinaemia or uraemia
10 - Body hair distribution
More in men
Reduced chest hair and axillae hair
Think about facial hair
Examine pubic hair later
11 - Observe the abdomen
Three sections - epigastric, suprapubic & umbilical
Pulsations
Generalised distension - ascities
Swelling in one particular area
Scars or fistulae - ?previous surgery for Crohn’s
Distended abdominal veins - flowing away from umbilicus in portal hypertension. Upwards from groin in IVC obstruction
12 - Palpation
Ensure hands are flat at side of patient
Talk to patient to encourage them to relax
Ask patient if he has any tenderness & tell him to tell you if you hurt him.
1. Systematically examine whole abdomen with light palpation. Use pulps of fingers & gentle flexion of MCP joints with hand flat on abdominal wall
2. Deeper palpation
3. Internal organs. For liver & spleen start in right iliac fossa. Work up to right hypochondrium for liver. Work diagonally across abdomen to left hypochondrium for spleen. Organs felt best against radial border of index finger & pulps of index & middle finger. Organs descend on inspiration so gently press & move hand up to meet them at this time.
4. Kidneys are found by bimanual palpation in each lateral region
Palpation of internal organs is difficult if ascities is present. In such cases press quickly, flexing at wrist joint to displace fluid & palpate the enlarged organ.
Mass in left hypochondrium - spleen or kidney. Kidney - can get above it, can separate it form the costal edge, can bimanually palpate & it has resonant percussion note.
Deep palpation in flanks for ascending & descending colon.
Gentle palpation for aortic aneurysm in midline of abdomen.
Palpate for inguinal lymph nodes
Check hernial orifices
Note pubic hair thickness/distribution
Causes of an enlarged liver - 3C’s
· Cancer
· C2H5OH - alcohol
· Congestive cardiac failure
13 - percussion
Start at nipple moving down
Locate upper edge of liver & spleen
Left lower lateral chest wall may become dull to percussion before enlarged spleen is palpable
Lower palpable edges of both organs. Start percussing in right iliac fossa moving towards appropriate area moving from resonant to dull areas
14 - Shifting dullness
Check flanks for stony dullness - no need to continue with procedure of demonstrating shifting dullness if this is not present
Ask patient with ascities to turn on side - this shifts dullness from upper to lower flank
15 - Auscultation
Of little use in exam situation
Very important as part of full routine
Bowel sounds
Renal artery bruits
Listen for other sounds such as rub over spleen or kidney or a venous hum
16 - External genitalia
Not usually requires in exam but state that you would
Small testes - chronic liver disease
17 - Rectal examination
Abdominal examination is incomplete without rectal exam
I would also like to…
Rigid sigmoidoscopy
Dipstick urine for protein, blood, etc
Approach from right hand side
Ask if patient can lie flat
Lie patient flat on one pillow
Exposure - ideally nipple to knee but realistically only lower garments to about halfway between iliac crest and synthesis pubis
1 - Visual survey
Look for
Pallor
Pigmentation
Jaundice
Spider naevi
Xanthelasma
Parotid swelling
Gynaecomastia
Scratch marks
Tattoos
Abdominal distension
Distended abdominal veins
An abdominal swelling or herniae
Surgical scars
Decreased body hair
2 - Comment on pigmentation
3 - Examine the hands
Dupuytren’s contracture
Clubbing
Leuconychia - white discolouration of the nails
Palmar erythema
Flapping tremor
4 - Pull down lower eyelid
Anaemia
Icterus in sclerae
Xanthelasma
Guttering between eyeball & lower lid is best place to look for pallor or discolouration
5 - inspect mouth
Cyanosis of lips - cirrhosis of liver
Swollen lips - Crohn’s
Telengiectasis - Osler-Weber-Rendu
Patches of pigmentation - Peutz-Jeghers
Mouth ulcers - Crohn’s disease
6 - Lymph nodes & JVP
Palpate neck & supraclavicular fossae for Cervical lymph nodes
If you find lymph nodes palpate axillae & groin for evidence of generalised lymphadenopathy - lymphoma, chronic lymphocytic leukemia
JVP may be enlarged in portal hypertension
7 - gynaecomastua
Palpate for glandular tissue in obese patients
8 - Spider naevi
Distribution of superior vena cava
May be seen on hands, arms, face & back
9 - Scratch marks
Anywhere on body - may be sign of hyperbilirubinaemia or uraemia
10 - Body hair distribution
More in men
Reduced chest hair and axillae hair
Think about facial hair
Examine pubic hair later
11 - Observe the abdomen
Three sections - epigastric, suprapubic & umbilical
Pulsations
Generalised distension - ascities
Swelling in one particular area
Scars or fistulae - ?previous surgery for Crohn’s
Distended abdominal veins - flowing away from umbilicus in portal hypertension. Upwards from groin in IVC obstruction
12 - Palpation
Ensure hands are flat at side of patient
Talk to patient to encourage them to relax
Ask patient if he has any tenderness & tell him to tell you if you hurt him.
1. Systematically examine whole abdomen with light palpation. Use pulps of fingers & gentle flexion of MCP joints with hand flat on abdominal wall
2. Deeper palpation
3. Internal organs. For liver & spleen start in right iliac fossa. Work up to right hypochondrium for liver. Work diagonally across abdomen to left hypochondrium for spleen. Organs felt best against radial border of index finger & pulps of index & middle finger. Organs descend on inspiration so gently press & move hand up to meet them at this time.
4. Kidneys are found by bimanual palpation in each lateral region
Palpation of internal organs is difficult if ascities is present. In such cases press quickly, flexing at wrist joint to displace fluid & palpate the enlarged organ.
Mass in left hypochondrium - spleen or kidney. Kidney - can get above it, can separate it form the costal edge, can bimanually palpate & it has resonant percussion note.
Deep palpation in flanks for ascending & descending colon.
Gentle palpation for aortic aneurysm in midline of abdomen.
Palpate for inguinal lymph nodes
Check hernial orifices
Note pubic hair thickness/distribution
Causes of an enlarged liver - 3C’s
· Cancer
· C2H5OH - alcohol
· Congestive cardiac failure
13 - percussion
Start at nipple moving down
Locate upper edge of liver & spleen
Left lower lateral chest wall may become dull to percussion before enlarged spleen is palpable
Lower palpable edges of both organs. Start percussing in right iliac fossa moving towards appropriate area moving from resonant to dull areas
14 - Shifting dullness
Check flanks for stony dullness - no need to continue with procedure of demonstrating shifting dullness if this is not present
Ask patient with ascities to turn on side - this shifts dullness from upper to lower flank
15 - Auscultation
Of little use in exam situation
Very important as part of full routine
Bowel sounds
Renal artery bruits
Listen for other sounds such as rub over spleen or kidney or a venous hum
16 - External genitalia
Not usually requires in exam but state that you would
Small testes - chronic liver disease
17 - Rectal examination
Abdominal examination is incomplete without rectal exam
I would also like to…
Rigid sigmoidoscopy
Dipstick urine for protein, blood, etc
Examination of the respiratory system
General points
Introduce self to patient
Ask for permission to examine
Have patient reclining at 45o
Have patients chest bare
1 - Inspect from end of bed
General appearance - evidence of weight loss
Severe kyphoscoliosis
Ankylosing spondylitis may be missed when patient is lying down
Breathlessness - at rest or while removing clothes. Use of accessory muscles for breathing. Accessory muscle useage suggests chronic small airways disease, pleural effusion or pneumothorax.
Pursing of lips (chronic small airways obstruction)
Central cyanosis - (cor pulmonale, fibrosing alveolitis, bronchiectasis) Central cyanosis may be difficult to recognise. It is always preferable to look at the oral mucous membranes
Indrawing of intercostal muscles or supraclavicular fossae (hyperinflation or indrawing of the lower ribs on inspiration (due to low, flat diaphragms in emphysema). Localised indrawing of intercostal muscles suggests bronchial obstruction
Scars thoracotomy or radiotherapy field markings
2 - Listen while observing
Expiration - prolonged & difficult. Chronic airways disease.
Additional sounds - wheeze or clicks
Noisy breathing - breathlessness
Difficult & noisy inspiration is usually caused by obstruction of the major bronchi - mediastinal masses, retrosternal thyroid, bronchial carcinoma.
More prolonged, noisy, wheezy expiration os due to chronic small airways obstruction- asthma, bronchitis
3 - Observe movement of the chest wall
Upwards - emphysema
Asymmetrical - fibrosis, collapse, pneumonectomy, pleural effusion, pneumothorax
4 - Inspect hands
Clubbing
Tar staining from tobacco
Coal dust tattoos
Signs of rheumatoid arthritis or systemic sclerosis
Cyanosis - if present check for flapping tremor of CO2 retention
5 - Pulse
If bounding check for flapping tremor
6 - Raised venous pressure
Cor pulmonale or fixed distension of the neck veins (SVC obstruction)
7 - Localise the trachea
Place index finger & ring finger on manubrium sternae over the prominent points on each side. Use middle finger to gently feel the tracheal rings to detect either deviation or a tracheal tug
8 - Check for lympthadenopathy
Carcinoma, TB, lymphoma, sarcoidosis
Cervical region & axillae
9 - Localise apex beat
Difficult if chest hyper-inflated
In conjunction with tracheal deviation this will give evidence of mediastinal shift - collapse, fibrosis, pneumonectomy, effusion, scoliosis
10 - Look for asymmetry
Rest one hand lightly on either side of front of chest to see if there is any reduction of movement - effusion, fibrosis, pneumonectomy, collapse, pneumothorax
11 - Expansion
Grip the chest symmetrically with the fingertips in ribspaces on either side and approximate the thumbs to meet in the middle in a straight horizontal line
Note distance between both thumbs & try to express expansion in centimetres
Assess in both supramammary & inframammary regions.
Better practice to use tape measure
Compare both sides at each level
12 - Percuss chest
Start at supraclavicular fossae & over the clavicles
Percuss over axilla
Few clinicians now map out area of cardiac dullness
Healthy people - dullness behind lower left quarter of sternum which is lost together with normal liver dullness
13 - Tactile vocal fremitus
Check both sides at once with ulnar aspects of hand
Ask patient to say 99
14 Auscultation of breath sounds
Start high at apices
Remember to listen in axillae
Cover both lung fields with bell before using diaphragm
Compare corresponding points on opposite side of chest
Ensure patient breathes with mouth open, regularly & deeply but not noisily
Early inspiratory crackles - chronic bronchitis, asthma
Early & mid-inspiratory & recurring in expiration crackles - bronchiectasis (altered by coughing)
Mid/late inspiratory crackles - restrictive lung disease (fibrosing alveolitis) & pulmonary oedema
15 - Vocal resonance
16 -Examine back
Repeat steps 10 - 15
May help to cross arms in front of patient to pull scapulae apart
Palpate cervical lymph nodes from behind
I would also like to…..
Check peak flow, temperature, bedside spirometry
Look for evidence of Horner’s syndrome & wasting of muscles in one hand
Palpate liver/percuss liver for emphysema
Introduce self to patient
Ask for permission to examine
Have patient reclining at 45o
Have patients chest bare
1 - Inspect from end of bed
General appearance - evidence of weight loss
Severe kyphoscoliosis
Ankylosing spondylitis may be missed when patient is lying down
Breathlessness - at rest or while removing clothes. Use of accessory muscles for breathing. Accessory muscle useage suggests chronic small airways disease, pleural effusion or pneumothorax.
Pursing of lips (chronic small airways obstruction)
Central cyanosis - (cor pulmonale, fibrosing alveolitis, bronchiectasis) Central cyanosis may be difficult to recognise. It is always preferable to look at the oral mucous membranes
Indrawing of intercostal muscles or supraclavicular fossae (hyperinflation or indrawing of the lower ribs on inspiration (due to low, flat diaphragms in emphysema). Localised indrawing of intercostal muscles suggests bronchial obstruction
Scars thoracotomy or radiotherapy field markings
2 - Listen while observing
Expiration - prolonged & difficult. Chronic airways disease.
Additional sounds - wheeze or clicks
Noisy breathing - breathlessness
Difficult & noisy inspiration is usually caused by obstruction of the major bronchi - mediastinal masses, retrosternal thyroid, bronchial carcinoma.
More prolonged, noisy, wheezy expiration os due to chronic small airways obstruction- asthma, bronchitis
3 - Observe movement of the chest wall
Upwards - emphysema
Asymmetrical - fibrosis, collapse, pneumonectomy, pleural effusion, pneumothorax
4 - Inspect hands
Clubbing
Tar staining from tobacco
Coal dust tattoos
Signs of rheumatoid arthritis or systemic sclerosis
Cyanosis - if present check for flapping tremor of CO2 retention
5 - Pulse
If bounding check for flapping tremor
6 - Raised venous pressure
Cor pulmonale or fixed distension of the neck veins (SVC obstruction)
7 - Localise the trachea
Place index finger & ring finger on manubrium sternae over the prominent points on each side. Use middle finger to gently feel the tracheal rings to detect either deviation or a tracheal tug
8 - Check for lympthadenopathy
Carcinoma, TB, lymphoma, sarcoidosis
Cervical region & axillae
9 - Localise apex beat
Difficult if chest hyper-inflated
In conjunction with tracheal deviation this will give evidence of mediastinal shift - collapse, fibrosis, pneumonectomy, effusion, scoliosis
10 - Look for asymmetry
Rest one hand lightly on either side of front of chest to see if there is any reduction of movement - effusion, fibrosis, pneumonectomy, collapse, pneumothorax
11 - Expansion
Grip the chest symmetrically with the fingertips in ribspaces on either side and approximate the thumbs to meet in the middle in a straight horizontal line
Note distance between both thumbs & try to express expansion in centimetres
Assess in both supramammary & inframammary regions.
Better practice to use tape measure
Compare both sides at each level
12 - Percuss chest
Start at supraclavicular fossae & over the clavicles
Percuss over axilla
Few clinicians now map out area of cardiac dullness
Healthy people - dullness behind lower left quarter of sternum which is lost together with normal liver dullness
13 - Tactile vocal fremitus
Check both sides at once with ulnar aspects of hand
Ask patient to say 99
14 Auscultation of breath sounds
Start high at apices
Remember to listen in axillae
Cover both lung fields with bell before using diaphragm
Compare corresponding points on opposite side of chest
Ensure patient breathes with mouth open, regularly & deeply but not noisily
Early inspiratory crackles - chronic bronchitis, asthma
Early & mid-inspiratory & recurring in expiration crackles - bronchiectasis (altered by coughing)
Mid/late inspiratory crackles - restrictive lung disease (fibrosing alveolitis) & pulmonary oedema
15 - Vocal resonance
16 -Examine back
Repeat steps 10 - 15
May help to cross arms in front of patient to pull scapulae apart
Palpate cervical lymph nodes from behind
I would also like to…..
Check peak flow, temperature, bedside spirometry
Look for evidence of Horner’s syndrome & wasting of muscles in one hand
Palpate liver/percuss liver for emphysema
Examination of the cardiovascular system
General points
Introduce yourself
Approach patient from right hand side
Adjust backrest so patient is at 45o to the mattress
Exposure - ask patient to remove shirt, etc.
While taking history look for any signs
1- Inspect from end of bed
Oxygen
Comfort
Inhalers
2 - Visual survey
Is patient
· Breathless
· Cyanosed
· Pale
· Xanthelasma
· Coronary arcus
· Malar flush (mitral stenosis)
· Examine earlobes for creases
Pulsation’s on neck -
· Forceful carotid pulsation’s (Corrigan’s sign in aortic incompetence, vigorous pulsation in coarctation of the aorta). Look for titubation
· Tall sinous venous pulsation’s - congestive cardiac failure, tricuspid incompetence, pulmonary hypertension
Inspect the chest
· Left thoracotomy scar (mitral stenosis) or midline sternal scar (valve replacement)
Look at feet
· Ankle oedema
3 - Inspect the hands
· Assess warmth, sweating & peripheral cyanosis
· Finger clubbing - cyanotic congenital heart disease, subacute bacterial endocarditis
· Splinter haemorrhages - infective endocarditis
4 - Pulses
· Radial - rate & rhythm
· Assess for collapsing pulse - visibly lift arm up. First ask patient if they have any shoulder pain
· Radio-radial delay
· Radio-femoral delay - coarctation of the aorta
· Brachial pulse - slow rising pulse
· Carotid pulse - slow rising pulse
5 - Neck
· Visual survey may already have found interesting points
· Corrigan’s sign - forceful rise & quick fall of carotid pulsation
· (Time individual waves of venous pulsation against opposite carotid. Don’t actually do this. MRCP stuff)
· JVP may move earlobe - tricuspid incompetence
· JVP - assess height of JVP above sternal edge in centimetres
6 - Apex beat
· Localise mid-clavicular line
· Inspect for pulsation
· Palpate
· Vigorous beat place index finger on it for point of maximum impulse (PMI)
· Impulse - palpable, lifting, thrusting or heaving
7 - Palpation of chest
1. Hand from lower left sternal edge to apex beat tapping impulse or thrills over mitral area if present
2. Press hand gently over left parasternal area sustained gentle pressure. If right ventricular hypertrophy is present you will feel the heel of your hand being lifted by the force
3. Palpate pulmonary area - palpable second sound (pulmonary hypertension)
4. Palpate aortic area palpable thrill (aortic stenosis)
8 - Auscultation
· Time first heart sound with either apex beat or carotid
· Position properly for different murmurs
· Mitral diastolic murmurs (mitral stenosis) turn patient onto left side. Use bell of stethoscope
· Early diastolic murmur of aortic incompetence ask patient to lean forward and hold breath in expiration
· ‘Lean forward for me please. Can you breathe out and hold your breath please.’
· Listen for aortic incompetence with bell.
10 Auscultate neck
· Listen for radiation of murmurs & carotid bruits
11 - Auscultate lung bases
· Looking for inspiratory crepitations. Essential part of routine cardiovascular examination. Not normally in exam but should do in breathless patient, aortic stenosis with displaced PMI or if there are signs of heart failure (orthopnoea, pulsus alternans, gallop rhythm)
12 - Check for peripheral oedema
· Sacral & ankle
13 - Palpate liver
· May be pulsatile in some cases
14 - Measure blood pressure
· Particularly important in patients with aortic stenosis (low systolic & narrow pulse pressure) and aortic incompetence (wide pulse pressure)
I would also like to…..
· Palpate abdomen for abdominal aorta
· Palpate peripheral pulses
· Fundoscopy diabetic or hypertensive retinopathy
· Palpate thyroid
· Dipstick urine for protein, glucose, blood, ketones
Introduce yourself
Approach patient from right hand side
Adjust backrest so patient is at 45o to the mattress
Exposure - ask patient to remove shirt, etc.
While taking history look for any signs
1- Inspect from end of bed
Oxygen
Comfort
Inhalers
2 - Visual survey
Is patient
· Breathless
· Cyanosed
· Pale
· Xanthelasma
· Coronary arcus
· Malar flush (mitral stenosis)
· Examine earlobes for creases
Pulsation’s on neck -
· Forceful carotid pulsation’s (Corrigan’s sign in aortic incompetence, vigorous pulsation in coarctation of the aorta). Look for titubation
· Tall sinous venous pulsation’s - congestive cardiac failure, tricuspid incompetence, pulmonary hypertension
Inspect the chest
· Left thoracotomy scar (mitral stenosis) or midline sternal scar (valve replacement)
Look at feet
· Ankle oedema
3 - Inspect the hands
· Assess warmth, sweating & peripheral cyanosis
· Finger clubbing - cyanotic congenital heart disease, subacute bacterial endocarditis
· Splinter haemorrhages - infective endocarditis
4 - Pulses
· Radial - rate & rhythm
· Assess for collapsing pulse - visibly lift arm up. First ask patient if they have any shoulder pain
· Radio-radial delay
· Radio-femoral delay - coarctation of the aorta
· Brachial pulse - slow rising pulse
· Carotid pulse - slow rising pulse
5 - Neck
· Visual survey may already have found interesting points
· Corrigan’s sign - forceful rise & quick fall of carotid pulsation
· (Time individual waves of venous pulsation against opposite carotid. Don’t actually do this. MRCP stuff)
· JVP may move earlobe - tricuspid incompetence
· JVP - assess height of JVP above sternal edge in centimetres
6 - Apex beat
· Localise mid-clavicular line
· Inspect for pulsation
· Palpate
· Vigorous beat place index finger on it for point of maximum impulse (PMI)
· Impulse - palpable, lifting, thrusting or heaving
7 - Palpation of chest
1. Hand from lower left sternal edge to apex beat tapping impulse or thrills over mitral area if present
2. Press hand gently over left parasternal area sustained gentle pressure. If right ventricular hypertrophy is present you will feel the heel of your hand being lifted by the force
3. Palpate pulmonary area - palpable second sound (pulmonary hypertension)
4. Palpate aortic area palpable thrill (aortic stenosis)
8 - Auscultation
· Time first heart sound with either apex beat or carotid
· Position properly for different murmurs
· Mitral diastolic murmurs (mitral stenosis) turn patient onto left side. Use bell of stethoscope
· Early diastolic murmur of aortic incompetence ask patient to lean forward and hold breath in expiration
· ‘Lean forward for me please. Can you breathe out and hold your breath please.’
· Listen for aortic incompetence with bell.
10 Auscultate neck
· Listen for radiation of murmurs & carotid bruits
11 - Auscultate lung bases
· Looking for inspiratory crepitations. Essential part of routine cardiovascular examination. Not normally in exam but should do in breathless patient, aortic stenosis with displaced PMI or if there are signs of heart failure (orthopnoea, pulsus alternans, gallop rhythm)
12 - Check for peripheral oedema
· Sacral & ankle
13 - Palpate liver
· May be pulsatile in some cases
14 - Measure blood pressure
· Particularly important in patients with aortic stenosis (low systolic & narrow pulse pressure) and aortic incompetence (wide pulse pressure)
I would also like to…..
· Palpate abdomen for abdominal aorta
· Palpate peripheral pulses
· Fundoscopy diabetic or hypertensive retinopathy
· Palpate thyroid
· Dipstick urine for protein, glucose, blood, ketones
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