1
Q
How do you summarise a cardio exam?
A
- hands symmetrically warm, CRT normal
- no peripheral stigmata of CV disease
- pulse was _bpm and normal rate and rhythm
- assessment of JVP showed no abnormalities
- no scars or chest wall abnormalities, apex beat palpable 5th int cos space in mid clav line
- on palpation there were no heaves or thrills
- on auscultation, 1st and 2nd heart sounds were present with no added sounds
2
Q
How do you complete a cardio exam?
A
- check for femoral pulses and radio-femoral delay
- check blood pressure in both arms
- check lying and standing BP in one arm
- perform fundoscopy
- 12 lead ECG
3
Q
How do you summarise a resp exam?
A
- pulse was _ bpm and of normal rate and rhythm, resp rate was …
- hands were symmetrically warm
- no evidence of tremor or asterixis
- Closer inspection of chest: no scars or chest wall deformities
- on palpation there was symmetrical chest expansion and no evidence of mediastinal shift
- on percussion, all lung fields were resonant
- on auscultation, vesicular breath sounds were present and there were no added sounds
4
Q
How do you complete a resp exam?
A
- take a sputum sample (check for volume, consistency, colour and odour)
- assess peak flow
- check O2 sats
5
Q
How do you summarise a GI exam?
A
- abdomen was soft and non-tender
- no evidence of organomegaly
- bowel sounds were present and normal
6
Q
How do you complete a GI exam?
A
Examine:
- inguinal lymph nodes
- stool sample
- hernial orifices (femoral and inguinal)
- rectal examination
- urinalysis
- external genitalia(males)
7
Q
How do you summarise a GALS exam?
A
- normal appearance in gait, arms, legs and spine
- full range of movement in all modalities tested
- if any abnormalities found, perform a regional exam of the MSK system
8
Q
How do you summarise a spine exam?
A
- no abnormalities detected
- normal gait
- on palpation, no tenderness
- full range of movement throughout the spine
- special tests were -ve
9
Q
How do you complete a spine exam?
A
- full neuro exam of upper and lower limbs
- hip and shoulder exam
- in lower back pain, perform abdo and hip exam and consider rectal exam
- examine peripheral pulses
10
Q
How do you summarise a diabetic foot exam?
A
- gait was normal
- neurovascular assessment of both feet were normal
- sensation was intact in both feet
11
Q
How do you complete a diabetic foot exam?
A
- bedside capillary blood glucose
- ankle brachial pressure index
12
Q
How do you summarise a thyroid exam?
A
- pulse was _bpm and of normal rate and rhythm
- no evidence of tremor
- no evidence of thyroid eye disease
- on palpation, no evidence of goitre or swelling
- on percussion, no evidence of retrosternal goitre
- on auscultation, no evidence of bruits
13
Q
How do you complete a thyroid exam?
A
- perform fundoscopy
- conduct blood tests (T4 and TSH)
14
Q
How do you summarise an upper limb neuro exam?
A
- no abnormalities in posture, deformities, muscle wasting or fasciculations
- pronator drift was -ve
- tone was normal throughout
- power was 5/5 in all muscle groups
- reflexes were normal and present bilaterally
- coordination was intact
- sensation was normal in all modalities tested
15
Q
How do you complete an upper limb neuro exam?
A
- examine cranial nerves
- carry out lower limb neurovascular exam
16
Q
How do you summarise a hand exam?
A
- On palpation, no tenderness
- Full range of movement in all modalities tested
- Sensation was intact
- Special tests were –ve
17
Q
How do you complete a hand exam?
A
- neurovascular exam of upper limbs
- examination of elbow and shoulder joints
18
Q
How do you summarise cranial nerve exam?
A
- on general inspection, they appeared well at rest
- on examination of cranial nerves I-XII, there were no abnormalities detected
- special tests were negative
19
Q
How do you summarise a knee exam?
A
- Normal gait and joint appearance
- On palpation, there was no tenderness
- Full range of movement in all modalities tested
- Special tests were –ve
20
Q
How do you complete a knee exam?
A
- neurovascular exam of both lower limbs
- examine hip and ankle
- McMurray’s test if indicated
21
Q
How do you summarise a shoulder exam?
A
- On palpation, no tenderness
- normal shoulder joint appearance
- Full range of movement in all modalities tested
- Special tests were –ve
22
Q
How do you complete a shoulder exam?
A
- neurovascular upper limb exam
- examine cervical spine and elbow
23
Q
How do you summarise a hip exam?
A
- Normal gait
- Normal hip joint appearance
- On palpation, there was no tenderness
- no evidence of pelvic tilt or fixed flexion deformity
- Full range of movement in all modalities tested
- Special tests were –ve
24
Q
How do you complete a hip exam?
A
- neurovascular exam of lower limbs
- examine lumbar spine and knee joint
25
How do you summarise a lower limb neuro exam?
- There were no abnormalities in posture, deformities, muscle wasting or fasciculation’s detected
- Gait was normal
- Rombergs test was -ve
- Tone was normal throughout
- Power was 5/5 in all muscle groups bilaterally
- Reflexes were normal and present at knee and ankles bilaterally
- Plantars were downgoing bilaterally
Coordination was intact
- Sensation was normal in all modalities tested
26
How do you complete a lower limb neuro exam
- neurovascular exam of upper limbs
- cranial nerves exam
27
How do you summarise a cerebellar exam?
- gait was normal
- no evidence of nystagmus
- assessment of limbs showed normal tone, reflexes and coordination
28
How do you complete a cerebellar exam?
- full neuro exam of cranial nerves and upper and lower limbs
29
How do you summarise a varicose veins exam?
- venous eczema and (size - 3x3cm) shallow/deep ulcer noted on (area)
- several visible varicose veins
- no evidence of phlebitis
- pulses were normal throughout in both lower limbs
- findings are consistent with peripheral venous disease
30
How do you complete a varicose veins exam?
- doppler ultrasound
- venous duplex scanning
- ABPI measurement
- abdo exam
- peripheral arterial exam
31
How do you summarise a peripheral vascular exam?
- No stigmata of peripheral arterial disease
- Pulses were present bilaterally in upper and lower limbs and had normal rate, rhythm and character
- The pulse was ___bpm
- Abdominal aortic pulse was not palpable
- Sensation of the lower limb was intact
- Buerger's test was negative
32
How do you complete a peripheral vascular exam?
- measure BP
- measure ABPI
- cardio exam
Phase 2b
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