Spine Examination - Revision Card

WIPER

... Standing...
Look
Sides, behind - asymmetry, wasting, scoliosis, lordosis, kyphosis

Feel
Spinal processes
Paraspinal muscles

Move
Lumbar
- Flexion - fingers in spinous processes
- Extension
- Lateral flexion - arm down sides
Cervical
- Flexion, extension, lateral flexion, rotation

... Sit on couch, arms crossed...
Thoracic
- rotation

... Lying on couch...
Straight leg raise
Dorsiflexion of foot, and big toe
Limb reflexes

Knee Examination - Revision Card

WIPER

... Standing...
Gait

Look
Valgus/varus deformity
Popliteal swellings

... Couch...
Look
Varus/valgus deformity
Muscle wasting
Scars/Swellings/Erythema/Rash
Side - fixed flexion deformity

Feel
Skin temperature
Patellar tap and crossfluctuation (bulge sign)
Knee slightly flexed - joint line and borders of patella, femoral condyles, tibial tuberosity
Popliteal fossa

Move
Flexion and extension - active & passive
With crepitus
Posterior sag (PCL)
Medial and lateral collateral - 15 degrees
Anterior draw test (ACL)

Hip Examination - Revision Card

WIPER

....Standing....

Move

Assess gait - antalgic/Trendelburg

Trendelenberg test

Look
Gluteal muscle bulk

...Couch...
Look
Fixed Flexion deformity
Leg length
- ALL - xiphisternum - MM
- TLL - ASIS - MM
Scars

Feel
Greater trochanter for tenderness

Move
Flexion - knee flexed
Internal rotation
External rotation
Thomas' test - FFD - loss of pelvic tilt

Shoulder Examination - Revision Card

WIPER

Look
Shoulders - front, side, behind
- symmetry, posture, wasting scars

Feel
Temperature
Palpate bony landmarks - SCJ, ACJ, Acromion process, scapula
Joint lines
Surrounding muscles - supraspinatus, infraspinatus, deltoid muscles

Move
Hands behind head (ext rotation)
Hands behind back (int rotation)
Elbow flexed at 90 degrees
- external rotation
Raise arm
- flexion
Hand behind
- extension
Abduct
- 10 to 120 degrees
- passive
Push against wall
- scapular movement

Function
Hands behind head and back

REMS - General Principle

WIPER

Look
Scars
Swellings
Rashes
Muscle wasting

Feel
Temprature
Swellings
Tenderness

Move
Full range of movement - active and passive
Restriction - mild/moderate/severe

Function

Elbow Examination - Revision Card

WIPER

Look
Scars
Swellings
Rashes

Feel (at 90 degrees)
Skin Temperature
Head of radius
Joint line
Medial & lateral epicondyles

Move
Full flexion & extension - compare
Pronation & supination
Crepitus
Function - hand to mouth or nose

Hand Examination - Revision Card

WIPER

Look
Inspect dorsum of hands for muscle wasting, skin and nail changes/swelling
Can you turn your hands over for me?
Check wrist for carpal tunnel release
Put hands on shoulders? - check elbows

Okay - you can put them back on the pillow

Feel
Skin
- Temperature
- Presence of nodules/plaques at elbows
- Tendon thickening

Joints/Bone
Pain in your hands?
- Squeeze MCPs
- Bimanually palpate swollen/painful joints, incluiding wrist

Nerves
- Radial Nerve - pulse, first web-space
Turn your hands over?
- Median Nerve - thenar eminence bulk, lateral index finger sensation
- Ulnar Nerve - hypothenar eminence bulk, medial aspect of medial fingers
*tendon thickening

Move
Wrist flexion and extension (prayer and inverse prayer sign)
Thumb opposition/abduction
Full finger extension and full finger tuck (extensor tendon ramage, joint damae, neuro damage
Finger adduction/abduction

Function
- grip power 
- pincer grip
- pick up small object

Carpel Tunnel Syndrome?
Tinel's Test
Phalen's Test (60s)
Old Synovitis
Thick, rubbery, non-tender
Active synovitis
Thick, rubbery, effusion, warm, swollen, tender

Confirming a Death

Before approaching the patient...
I would ask the nurse for a brief history of the background to the death - find out who discovered him/witnessed it
I am checking that full attempts at reversal of any contributing factors have been made
I would also confirm that the patient was not for resuscitation
I would also like to read the patient's medical notes and drug chart and recent diagnosis and past medical history

At the patient's side...
Draw the curtain around the model to ensure privacy
I am confirming the patient's identity by checking the wristband with the name and hospital number
I am exposing the patient adequately, and inspecting
I am looking to see if there is any increased muscle tone (rigor mortis)
I am commenting on the absence of respiratory movements
I am looking at the colour and lack of physical movement

Response...
I am seeing whether the patient is responsive to pain eg trapezius squeeze, sternal rub, pressure on orbits

Eyes...
I am inspecting the eyes with a pen torch to see if the pupils are fixed and dilated
Checking for a light response, direct and consensual reflex and noting their absence
I am inspecting the fundi with an ophthalmoscope to see if there is segmentation of the retinal blood columns (only present in 30%),  also looking for tracking/rail roading of the retinal veins

Pulses...
I am  palpaing the major pulses - confirm that no pulses can be palpated - check on both sides for a minute
I am palpating the carotid pulse on either side
I am palpating both femoral pulses on either side

Precordium...
Look for pacemaker scar
I am auscultating the praecordium for heart sounds for 1 minute, and commenting on their absence.
I am auscultating the chest for any breath sounds for 3 minutes,  and commenting on their absence.

Finishing Off...
I am washing my hands
I am documenting in the notes my findings, and the date and time of death
e.g.
Pupils fixed and dilated
No spont resp effort
No response to deep stimuli
Absent heart and breath sounds for 3mins
Time of death: 0000
Date of death 12/12/12

NOTE pt has pacemaker - therefore cannot cremate

Plan

a) fill out death certificate/contact coroner

b) contact family

c) arrange for patient to be moved to morgue

d) contact GP

Signature and date
Printing it with designation and bleep number
I am asking the nurses to contact the deceased's next of kin

NB!!

Conditions that can mimic death
- hypothermia
- hypoglycaemia
- alcohol/drug overdose
- adrenaline use at cardiac arrest can cause dilated pupils
- rigor mortis does not appear until 3hrs after death

GALS Examination - Revision Card

WIPER

GAIT
Observe gait (3)
Observe patient in anatomical position (8)

SPINE
Inspect spine (3)
Assess lateral flexion of neck (1)
Assess lumbar spine movement (2)

ARMS
Observe shoulder movement (3)
Observe back of hands and wrists (2)
Observe palms (2)
Assess power grip & grip strength (4)
Assess fine precision pinch (1)
Squeeze MCPs (1)

LEGS
Assess full flexion and extension (3)
Assess internal rotation of hip (1)
Patellar tap (1)
Inspect feet (3)
Squeeze MTPs (1)

GALS Examination

- Screening examination
- Examines Gait, Arms, Legs and Spine
... but we usually examine them in the order of Gait, Spine, Arms, Legs, for simplicity.
... however, 'GSAL' is less catchy.

WIPER

"Hi, my name is Anamika Basu, I'm a final year student.

- Is it alright if I do a quick examination of your joints and general movement?

- For this examination we need to have in your underwear, is that okay?

- And we'll need to have you standing up at the start of it."

GAIT

"Can you walk a few steps away from me, turn around and walk back to me?"

I'm observing the patient's gait for symmetry, smoothness and the ability to turn quickly.

"Can you stand like this (imitate anatomical position)?"

I'm looking from 

- behind, from the sides, and from the front,

all the time assessing for 

- the bulk and symmetry of the shoulder, gluteal, quadriceps and calf muscles,

- limb alignment,

- alignment of the spine,

- level of iliac crests,

- ability to extend elbows and knees,

- any popliteal swelling,

- and any abnormalities of feet.

SPINE

As the patient is standing, I am also inspecting the spine

- behind for scoliosis

- and from the side to observe any lordosis or kyphosis

"Can you tilt you head to each side, with the ear towards the shoulder?"

I'm assessing the lateral flexion of the neck

"Can you bend down to touch your toes, as much as you can?"

I'm assessing functional movement

"Okay, now I'm just placing two fingers on your back. Can you straighten up for me?"

I placed my fingers on the lumbar vertebrae to see if they move apart on flexion and back together on extension. This also helps to distinguish the patient's movement from compensatory hip flexion.

ARMS

"Would you like to sit on the couch?

- Can you put you hands behind your head?"

I'm assessing

- shoulder abduction,

- external rotation

- and elbow flexion

"Okay, relax, now can you put you hands out like this, with the palm face down, and fingers outstretched?"

I'm looking for any 

- joint swelling

- or deformity

"Can you turn your hands over?"

I'm assessing the palms for

- muscle bulk

- and any abnormalities

"Can you make a fist for me?"

I'm assessing

- power grip,

- hand and wrist function

- and range of movement in fingers

"Can you squeeze my fingers for me?"

I'm assessing grip strength

"Can you bring each finger in turn to meet the thumb?"

I'm assessing fine precision pinch, which has functional importance

"Do you have any pain in your hands?"

I'm gently squeezing across the MCP joints to check for tenderness, which might suggest inflammatory joint disease, remembering to look at the patient's face for discomfort.

LEGS

"Can you lie down on the couch for me? Are you comfortable? Do you have any pain in your legs? I'm just going to have a feel of your knee joints."

I'm assessing for 

- full flexion and extension of the knees

- and feeling for ant crepitus 

- x2

I'm flexing the hip and knee to 90 degrees, holding the knee and ankle. This is to assess the

- internal rotation of each hip in flexion

- x2

"I'm going to tap on your knee."

I'm performing a patella tap on each knee to check for patellar effusion

This involves me sliding down my hand down the thigh and push over the suprapatellar pouch, forcing any effusion behind the patella. Keeping the pressure on that hand, I use the first two fingers of my other hand to push the patella down gently. If the patellar bounces and 'taps' this is positive for the present of an effusion.
- x2

I'm inspecting the feet for

- swelling,

- deformity

- and calloses on the soles

"Is there any pain in your toes?"

I am squeezing across the MTP joints to check for tenderness

GALS is written down a column with two additional columns headed appearance and movement.

A tick is given for normal findings, and a cross for abnormal ones, with extra notes noting the details.

Hydration

Assessing hydration in a patient

A popular OSCE question. Which makes it surprising that it's always such a surprise, maybe because - Surprise! - we've never been taught it.

Situations where assessing the fluid status is important eg dehydration:-
-Vomiting
-Sepsis
-Bowel obstruction
-Bleeding
-Recent Surgery
-Diarrhoea
-Fever

Causes of fluid overload:-
-Right heart failure
-Constrictive pericarditis
-Hypoalbuminaemia

Anyhoo - how to assess someone's hydration status, whether dehydrated or fluid overloaded:

General Inspection
I'm looking at the environment to see if there are any important clues into the patient's fluid status. This includes
-fluid restriction,
-drugs
-drips
-lines
-catheter bags,
-or nutritional supplements.

I am then looking at the patient to see if there is any obvious signs of them being
-dehydrated
-or fluid overloaded, e.g. oedema.

Hands
Starting with the hands I am
-feeling them
-and testing the capillary refill to see if there are signs of peripheral shutdown.
Dehydration would be indicated if the cap refill was prolonged.
Normal <2s.

Wrist
I am palpating the
-pulse.
Both dehydration and fluid overload would cause a tachycardic pulse.

Arm
I am testing
-the blood pressure,
-both sitting and standing.
If there was a decrease in the pressures this could indicate dehydration.

Wait 3 minutes between sitting and standing.
Fall in >20mmHg Systolic or >10mmHg Diastolic = Postural Hypotension

Neck
I am looking at the patient's neck to assess
-the JVP, as its height is an indicator of intravascular volume.
Normal = 2cm above sternal angle

If it is diminished, this indicates dehydration.
If it is raised it can indicate fluid overload.

Face
I am looking at
-the eyes, to see if there are sunken orbits. This can indicate moderate to severe dehydration.
I am also looking in
-the mouth to see if there is a lack of moisture, which indicates dehydration.

Chest
Looking at the chest, I am assessing
-the skin turgor by pinching a fold of skin at the sternum (this could also be done on the forearm) for a few moments and then releasing it.

If the skin resumes its place quickly the skin turgor is normal, but if takes a longer amount of time the skin turgor is reduced, and this indicates dehydration.
NB This test, however, is of less use in the elderly when there is loss of skin elasticity.

Oedema
I am checking
-the sacral region
-and legs for signs of oedema, and therefore fluid overload.

Auscultation
I am listening to
-the lungs for the presence of fine inspiratory basal crackles, which could indicate pulmonary oedema
-additional heart sounds to indicate a hyperdynamic state

And to finish off...
I'd like to check the patient's
-temperature
- obs chart (temperature, BP, O2 sats, pulse, RR)
-urine output/catheterise
- fluid balance chart
Inputs (IV fluids, oral intake)
Outputs (urine, stool, drains, stoma bags etc) - vomiting? diarrhoea?
- drug chart – is patient on any diuretics?
- notes - recent surgery?
- further Ix i.e. U&Es, FBC, central line monitoring

Cardiovascular Examination - The Script

WIPER

Washes hands.

Introduces self.
&
Asks Permission to examine the patient.

"Hi, my name is __________, I'm a final year medical student. Would it be alright for me to listen to your heart? Thank you."

Expose
&
Reposition

"I would like to have the patient at 45 degrees and exposed from the waist up. 
 Is it alright if I put you at 45 degrees? And are you fine to be undressed from the waist up? Thank you so much."

General Inspection


Bedside - 
"I'm looking around the bed for any 
- ECG leads,
- O2 therapy, 
- or medication, for example, GTN spray."

The Patient -
"I'm looking at the patient to see 
- if they look ill,
- are they SOB at rest,
- is there any cyanosis?
- Are they overweight or cachectic?
- Is there any obvious genetic syndrome, for example, Marfan's?"

Hands -
"Do you have any pain in your hands at all? May I have a look and feel of them?
I'm initially assessing for 
- the temperature 
- and hydration - are the hands particularly sweaty or clammy?
At the nails I'm testing 
- the cap refill 
- and looking for splinter haemorrhages.
At the sides of the fingers I'll inspect for
- signs of clubbing
- or tar staining.
I am then looking at the palms and finger pulps for 
- Janeway lesions 
- or Osler's nodes."

Wrist -
"At the patient's wrist 
- I'm feeling the radial pulse to assess its rate and rhythm."

Upper Arm  - 
"At the antecubital fossa 
- I'm palpating the brachial pulse, to assess rate, rhythm and character. 
- I would at this point also like to take the patient's blood pressure.
Do you have any pain in your arm or shoulder? If it's alright, I'm just going to pull your arm up, relax - it shouldn't hurt.
- I'm testing for the presence of a collapsing pulse."

Neck -
"I'm just to feel your neck now.
- At the neck I am palpating the carotid pulse to assess the rate, rhythm and character.
Can you look to your left, and rest your head against the pillow/my hand?
- I'm assessing the JVP to see if it's raised, and moves with respiration.

Eyes -
"Can you look at the ceiling for me? I'm just going to pull down your lower lid, if you don't mind.
I'm looking at the 
- sclera to assess for any sign of jaundice, 
- and I'm looking to see any paleness of the conjunctiva.
And look straight ahead now.
I'm looking at the 
- iris for corneal arcus.
- I am looking around eyes for xanthelasma."

Cheeks -
"I am looking at the cheeks for mitral facies."

Mouth -
"Can you open your mouth for me?
I am looking at 
- the lips for peripheral cyanosis
- I am looking at the soft palate
- and assessing the dentition.
Can you raise your tongue to the roof of your mouth?
I am looking 
- under the tongue for signs of central cyanosis.
You can relax your mouth now."

CHEST


Inspection - 
"I'm looking at the chest for 
- any scars, 
- pacemakers, 
- abnormal chest movements or shapes, 
- and whether there are any visible pulsations.
- I can also check their leg to see if I suspect vein graft surgery."

Palpation -
"Do you have pain in your chest? If it's fine I'm just going to have a feel of your chest. Can you lean to the left for me?
- I am palpating the apex beat.
- I am also palpating for the presence of heaves or thrills."

Auscultation -
"I'm just going to have a listen now - you can breathe normally.
- I am listening at the 4 areas, with both the bell and the diaphragm of the stethoscope.
Can you breathe in for me and hold your breath. Ok, thank you, now can you breathe out for me and hold your breath. Now breath normally. Can you sit up and lean forward for me? Can you lean towards you left-hand side for me?
If there is an abnormal sound I am assessing 
- the time, 
- the site and radiation (either at the carotids or the axilla), 
- the loudness and pitch, 
- and the relationship to respiration and posture.
Can you hold your breath for me?
- I am also listening at the carotids for any evidence of bruits.
You can breath normally now.
Can you lean forward for me?
- I am listening for evidence of basal crackles.
- I am also checking for sacral oedema.
Ok, you can lean back on the bed and relax. Thank you very much _______, I'm all done - do you need any help putting your clothes back on?

To finish off the exam I'd like to examine
- the peripheral pulses, 
- palpate the lower limbs for peripheral oedema,
- record an ECG, 
- do a urine dipstick
- and if relevant - check the legs for scars from vein grafts, and examine the abdomen, particularly the liver if I suspect right heart failure.
Thank you again."

The ''And finally..." can be remembered handily by
DOPE as in "the person who writes this blog is dope... and for some reason I'm using slang from the 90s."

Dipstick
Oedema
Peripheral Pulses
ECG

I thank you.
Take a bow. Take a bow.