PE

Question 1

Breast and axillary system PE

what do you expect to see for
“Exposure: Shirt and brassiere off”

Answer 1

• bilateral supraclavicular areas
• both breasts AND both nipple areola complexes

Question 2

Breast and axillary system PE

on 1st look, what abnormalities will you be looking for

Answer 2

• overall: scars, visible masses and skin changes
• nipple areola complexes: nipple masses and nipple discharge

Question 3

Breast and axillary system PE

what other positions will you get the patient to do
for your 1st look for abnormalities

Answer 3

• hands over head
  (“Ma’am, do you mind putting your hands over head for me?”)
• hands pushing down on hips
  (“Ma’am, do you mind putting your hands back on your hips and squeeze your hips like you’re angry?”)

Question 4

Breast and axillary system PE

during further examination, what position should the patient be in?

Answer 4

• 45 degrees
• with hands behind head

Question 5

Breast and axillary system PE

during further examination, which side of the patient should you start with?

Answer 5

asymptomatic side

Question 6

Breast and axillary system PE

during further examination, how do you check for lumps in the breast?

Answer 6

with the pulps of 3 fingers,
* either starting from outward and move towards nipple
* or moving from quadrant to quadrant

note:
- start by examining axillary tail FIRST
(which is located around BRA LINE)
- fingers always point OUTWARDS, until that 1 portion where it’s not physically possible to point outwards (for that part only can point inwards)
- if the breats are ptotic (i.e. drooping/sagging), can use 1 hand to lift up inframammary fold of breast (i.e. crease beneath breast)

Question 7

Breast and axillary system PE

what are the things you should comment on if a lump is palpated

Answer 7

1. site
   (quadrant/clock face + distance (in cm) from nipple)
2. size (in cm)
3. surface
   (regular/irregular)
4. consistency
   (soft/firm/hard)

note:
* soft = feels like LIPS
* firm = feels like NOSE
* hard = feels like FOREHEAD

Question 8

Breast and axillary system PE

if lump is present in breast, how do you check whether it’s attached to the chest wall?

Answer 8

hold the lump and ask patient to squeeze down on her hips

when you squeeze down on your hips, your pectoral muscles pop out
-> thus if lump is tethered to the muscles it will bulge out

Question 9

Breast and axillary system PE

what should you do if nipple discharge is seen on inspection?

Answer 9

• milk EACH QUADRANT towards the nipple
  (3 fingers, flat, fingers pointing outwards)
  → to find out which duct it comes from
• note character of discharge
  (milk/pus/blood)

note: each quadrant
= milk 4 times in total,
once at each quadrant

ALSO why is this impt?
* uniductal (one duct) → more concerning for pathology (e.g., intraductal papilloma, carcinoma in situ)
* multiductal (several ducts) → more likely physiological (e.g., hormonal, galactorrhea)

Question 10

Breast and axillary system PE

what position should the patient be in when you examine her axilla?

Answer 10

patient’s elbow (on side being examined)
should be on your ipsilateral hand
(“Ma’am, can you rest all your weight on my hand?”)

Question 11

Breast and axillary system PE

what parts of the axilla should you examine?

Answer 11

• anterior border
• medial border
• posterior border
• lateral border
• apical surface
  (get patient to lower arm (the one you are examining) slightly first)

3 fingers, ROUNDED movements, inspect borders in anti-clockwise direction

Question 12

Breast and axillary system PE

what should you offer the patient at the end of the PE

Answer 12

• examine supraclavicular lymph nodes
• auscultate and percuss chest for pleural effusions
• palpate abdomen for hepatomegaly
• percuss spine for tenderness

for spine, percuss from top to bottom

why is this impt?
* to rule out regional spread (supraclavicular nodes)
* and check for distant metastases (lungs/pleura, liver, bone)

Question 13

Thyroid PE

what should be examined during general inspection

Answer 13

• body habitus
• skin quality
  (sweaty/dry)
• eye signs
• quality of voice
  (hoarse?)

why is this impt?
to check for systemic features of thyroid dysfunction
1. body habitus:
- thin build = HYPERthyroidism
- puffy habitus = HYPOthyroidism
2. skin quality:
- warm, moist and sweaty skin, sometimes pretibial myxedema = HYPERthyroidism
- dry, cold skin = HYPOthyroidism
3. eye signs:
- exophthalmos, lid lag, staring look
= Graves’ (HYPERthyroidism)
4. quality of voice:
- hoarse voice
→ recurrent laryngeal nerve involvement
= e.g. thyroid cancer, large goiter

Question 14

Thyroid PE

if swelling or nodule is seen, what 2 inspections should you do after to distinguish the type of nodule?

AND what are their implications

Answer 14

• movement with swallowing
  ← moves with swallowing
  = thyroid origin
• movement on protrusion of tongue
  ← moves with tongue protrusion
  = thyroglossal duct cyst

movement = swelling/nodule goes upwards

Question 15

if swelling or nodule is seen, how do you check for its extent?

Answer 15

percuss sternum
AND L and R of it
→ check for retrosternal extension

if it has extended, will be DULL instead of resonant

Question 16

Thyroid PE

if swelling or nodule is seen, what should you check at trachea?

AND how to do it

Answer 16

• palpate for position of trachea
  <- bcos a thyroid goiter or large nodule can result in trachea deviation

steps:
1. run MIDDLE finger down from chin to just above sternal notch
2. place INDEX and RING fingers on each side of middle side
(check that index and ring fingers are between sternocleidomastoid muscles)
3. check that index and ring fingers are equidistant from middle finger

Question 17

Thyroid PE

if swelling or nodule is seen, what sign should you check for

Answer 17

Pemberton’s
steps:
1. get patient to raise both arms above their head for 1 min
2. check for facial flushing, distended neck veins, dyspnea, or stridor

why is this impt?
* bcos LARGE THYROID OR RETROSTERNAL GOITER can compress the superior thoracic aperture
* raising the arms further narrows the superior thoracic aperture
→ temporarily obstructing SVC and thus venous return from head and neck
⇒ venous congestion, facial plethora, neck vein distension, and sometimes respiratory symptoms

Question 18

Thyroid PE

which lymph nodes should you palpate

and where are they located

Answer 18

cervical, mainly
1. Submental
2. Submandibular
3. Preauricular
4. Posterior auricular
5. Anterior cervical (3, including supraclavicular)
6. Posterior cervical (2)
7. Occipital

Question 19

Thyroid PE

what should you check for in arms

Answer 19

1. arms for tremors
2. hands for thyroid acropachy (= clubbing),
   onycholysis (= nail separation from nail bed)
   and sweaty palms/dry skin
3. radial pulse for tachycardia or atrial fibrillation
   THEN check for collapsing pulse
   (pulse becomes more exaggerated when arm is lifted)
4. biceps tendon reflex (on both sides)
5. shoulders for power during abduction (on both sides)

can rmb as go down then go back up

• tremors: HYPERthyroidism
• acropachy: Graves’ (HYPERthyroidism)
• onycholysis: HYPERthyroidism
• AF: HYPERthyroidism
• hyperreflexia OR delayed reflex relaxation: HYPER or HYPOthyroidism
• myopathy (= muscle weakness): HYPERthyroidism

Question 20

Thyroid PE

what should you check for in eyes

Answer 20

1. general appearance:
   proptosis/exophthalmos, lid retraction, chemosis
2. lid lag
3. ophthalmoplegia

• proptosis/exophthalmos: forward bulging of the eyeball
• lid retraction: sclera visible above the iris
  ⇒ giving a “staring” look
• chemosis: conjunctival edema (swollen, jelly-like conjunctiva)
• lid lag: upper lid moves more slowly than the globe → sclera seen above iris when looking down
• ophthalmoplegia: restricted eye movements
  ⇒ diplopia

Question 21

Thyroid PE

how do you check for lid lag

Answer 21

• steps:
  1. stand diagonally (45º to the side) from the patient
  2. ask the patient to keep their head still and get them to follow your finger as you draw a “D”
  (the D comes towards you)
• positive finding: a strip of sclera seen above the iris

Question 22

Thyroid PE

how do you check for ophthalmoplegia

Answer 22

• steps:
  1. ask the patient to keep their head still and follow your finger as you draw a big “H” in the air
  2. at each of the 8 points, ask them how many fingers you’re holding up
• positive finding: eye cannot move fully in one or more directions and/or diplopia (= double vision)

8 points of H

Question 23

Thyroid PE

what should you check for in legs

Answer 23

1. pretibial myxedema
2. pedal oedema

Question 24

Thyroid PE

what should you auscultate for (as the last step)?

Answer 24

thyroid bruit
⇒ hypervascularity, most commonly seen in Graves’ disease

use BELL of stethoscope
and listen for continuous low-pitched whooshing sound synchronous with the heartbeat

Question 25

# Abdominal PE what position should the patient be in?

Answer 25

supine, with bed **flat**

Question 26

# Abdominal PE what position should you be in when you examine patient for **ascites and bloating** (at the start)

Answer 26

* standing at **foot of bed** * in both standing and **squatting** positions

Question 27

# Abdominal PE what should you check for in arms | and how

Answer 27

1. clubbing (bring patient's hands up so that **nails are at eye level** and inspect for **bulging of nails**) 2. other nail changes (leuconychia, Muehrcke’s lines) (let patient rest their hands on your hand, palms facing down, then inspect) 3. Dupuytren's contracture (get patient to turn their hands such that it is now **palms facing up**, and **run 1 finger along palm lines** to check for thickened, fibrotic cords along the palmar fascia) 3. palmar erythema (let patient rest their hands on your hand, **palms facing up**, and check for **reddening of palms**) 4. asterixis (ask patient to **extend wrists dorsally** (like “stop” sign), for **15 seconds** and observe for **flapping**) ## Footnote why is it impt? * clubbing = liver cirrhosis * leuconychia, Muehrcke's lines = hypo**albumin**emia * **Dupuytren's contracture = chronic alcohol use (and thus ALD)** * palmar erythema = chronic liver disease (hyper**estrogen**emia) * **asterixis = hepatic encephalopathy**

Question 28

# Abdominal PE what should you check for in eyes | and how

Answer 28

1. pallor (pull DOWN eyelids and get patients to look UP) 2. scleral icterus (pull UP eyelids and get patients to look DOWN) ## Footnote why is it impt? * pallor = anaemia (of chronic disease) (e.g. chronic liver disease) * scleral icterus = hyperbilirubinemia, from e.g. hepatitis, cirrhosis, etc

Question 29

# Abdominal PE what should you check for in mouth

Answer 29

* pallor * oral **thrush** (Candidiasis)

Question 30

# Abdominal PE other than eyes and mouth, what else should you check for in the face

Answer 30

examine **parotid** glands for swelling

Question 31

# Abdominal PE what should you auscultate for

Answer 31

* bowel sounds * liver bruit * renal bruit

Question 32

# Abdominal PE what should you offer at the end of the examination | 6

Answer 32

* review vital signs (*duh...*) * examine **cervical** LNs * examine **hernia** orifices * perform per rectal examination * examine external genitalia * do urinalysis

Question 33

# Cardiovascular PE what should you check for in arms

Answer 33

* examine for the following in hands: 1. CLUBBING 2. cyanosis 3. **stigmata of endocarditis** 4. pallor * palpate radial pulse * examine for collapsing pulse * examine for radial-radial delay * offer to examine for radial-femoral delay

Question 34

# Cardiovascular PE what should you check for in eyes

Answer 34

* pallor * scleral icterus * corneal arcus, xanthelasma

Question 35

what should you check for in mouth

Answer 35

* pallor * cyanosis * dental caries * high-arched palate

Question 36

# Cardiovascular PE what should you palpate for

Answer 36

* apex beat * thrills, parasternal heave, palpale P2 * carotid pulses (1 side at a time)

Question 37

# Cardiovascular PE what should you auscultate for

Answer 37

* mitral area * then turn patient to left lateral position and listen to **apex** => MITRAL *stenosis* and *regurgitation* murmurs * tricuspid area * pulmonary area * aortic area => AORTIC *sclerosis* murmur * sit up and ask patient. to lean foward, then listen over the pulmonary area in full inspiration => PULMONARY *stenosis* murmur and listen over the aortic area in full expiration => AORTIC *regurgitation* murmur * **carotid arteries** => AORTIC *stenosis* murmur * lung bases posteriorly

Question 38

# Cardiovascular PE what should you offer at the end of the examination | 5

Answer 38

* review vital signs (*duh...*) * palpate remaining peripheral **pulses** * examine for **hepatomegaly** * performe urine dipstick test * do fundoscopy

Question 39

# Respiratory PE what should you check for in arms

Answer 39

* examine for the following in hands: 1) clubbing 2) nicotine stains 3) cyanosis * examine for asterixis * measure pulse rate (then measure respiratory rate)

Question 40

# Respiratory PE what should you palpate for

Answer 40

* position of trachea * apex beat

Question 41

# Respiratory PE what should you offer at the end of the examination | 4

Answer 41

* review vital signs (*duh...*) * examine **cervical** LNs * review patient's sputum mug * do peak flow measurement

Question 42

what should you offer at the end of the examination (Vascular arterial PE)

Answer 42

* perform full neurological examination of LL * examine carotid and upper limb pulses * auscultate heart and for visceral and peripheral bruit * use doppler to check for pulses and measure ABPI