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