examination skills masterclass hughes exam skills...staff development programme 2010 5 precordium...

Examination Skills

Masterclass Royal Blackburn Hospital Wednesday 10th March 2010

Dr Richard Hughes

Staff Development Programme 2010

2

Contents

INTRODUCTION

3

CVS EXAMINATION – CRIB SHEET

4

CVS EXAMINATION – DETAILED LIST

7

RESPIRATORY EXAMINATION – CRIB SHEET

12

RESPIRATORY EXAMINATION – DEATILED LIST

14

ABDOMINAL EXAMINATION – CRIB SHEET

19

ABDOMINAL EXAMINATION – DETAILED LIST

21

ACKNOWLEDGEMENTS

27


3

Introduction

This booklet is designed to aid in clinical examination skills.

The aim is to outline a systematic approach to clinical examination that is valid

for both students and doctors sitting post-graduate examinations.

Each section is laid out in a similar manner, with a ‘crib sheet’ that can be used as

an aide memoire followed by a more detailed explanation of the examination

technique.

I hope you find the booklet useful and enjoyable.

Dr Richard Hughes MBChB MRCP MCEM

SpR in Emergency Medicine

Sub-specialty Acute Medicine


4

Cardiovascular Examination – Crib Sheet

• Introduce yourself

• Wash hands

• Position patient supine at 450

• Expose patient above the waste and also below the knees

• General Inspection

o Scars (sternotomy, scars from saphenous vein donation to CABG)

o SOB

• Hands

o Clubbing

o Splinter haemorrhages

o Quincke’s sign

o Osler’s nodes

o Janeway lesions

o Xanthomata on extensor tendons

• Radial pulses (both at same time)

• Brachial pulse

• Check for collapsing pulse

• Eyes

o Anaemia

o Xanthelasmata

o Corneal arcus

• Face

o Malar flush

• Mouth

o Central cyanosis

• JVP and hepatojugular reflex

• Carotid pulse for character

o Slow-rising (aortic stenosis)

o Collapsing (aortic regurgitation)

o Jerky (hypertrophic cardiomyopathy)


5

Precordium

• Inspection

o Scars

o Breathing

o Visible apex

• Palpation

o Apex beat (normally 5th IC space, mid-clavicular line)

o Parasternal heave

o Aortic thrill

Auscultation

• Left-sided heart murmurs are heard best in expiration

• Right sided heart murmurs are heard best in inspiration

• Palpate the carotid whilst listening over precordium to enable timing of

any murmur

• Listen over the four valve areas with the diaphragm to see if any murmurs

are heard:

o Mitral valve - apex

o Tricuspid valve – 4th IC space, left sternal edge

o Pulmonary valve – 2nd IC space, left sternal edge

o Aortic valve – 2nd IC space, right sternal edge

• Go back to apex and listen for:

o Mitral regurgitation

� Pansystolic murmur

� Heard best over apex

� Radiates to axilla (demonstrate this by listening here)

o Mitral stenosis

� Listen with bell

� Mid-diastolic murmur

� Heard best:

• Over apex

• In expiration

• With patient rolled onto left side


6

• Go back to aortic valve region and listen for:

o Aortic stenosis

� Ejection systolic murmur

� Radiates to carotids (demonstrate this by listening here –

also listen for carotid bruits)

o Aortic regurgitation

� Early diastolic murmur

� Heard best:

• In 2nd aortic area (3rd or 4th intercostal space, LSE)

• With patient lent forwards

• In expiration

• Keep patient sat forwards and:

o Listen for crackles at lung bases

o Palpate for sacral oedema

• Lay patient back to 450

• Palpate for ankle oedema

• To complete

o Blood pressure in both arms

o Look at obs chart

o Palpate all peripheral pulses


7

Cardiovascular Examination – Detailed List

General

Compared with the respiratory examination and abdominal examination, there is

probably more variation in the way a ‘textbook’ cardiovascular examination is

conducted.

Also, the examination should take on a different emphasis depending on what is

found. For example, if I saw giant 'cV' waves in the JVP, I would:

• Listen carefully over the 4th IC space left sternal edge with the breath held

in inspiration to listen for tricuspid regurgitation

• Feel for pulsatile hepatomegaly

I do neither of theses as part of my routine examination. Therefore, the list

below is not exhaustive, but forms a framework to cover most common ‘PACES-

style’ cardiology patients and forms a good baseline examination to teach

students.

It is clearly important to check the blood pressure as part of a cardiovascular

exam. Some people say “I would now check the blood pressure” as they palpate

the brachial pulse. Some people (like me) leave it until the end. I don’t think it

matters as long as you say you would do it.

There are many, many signs associated with cardiac disease (for example, with

aortic regurgitation). I make no apology for not including them all!

Introduce yourself

Wash hands

Position patient supine at 450

Expose patient above the waste and also below the knees

General Inspection

• Scars

o The saphenous veins are the most commonly used vessels for

coronary artery bypass grafts

o The presence of a midline sternotomy scar in the absence of scars

on the legs should alert the examiner to the likely diagnosis of a

prosthetic valve replacement


8

o Things often aren’t that easy, though, as many patients have a

CABG and valvular replacement at the same time and so will have

both types of scar

• SOB

Hands

• Clubbing

o Congenital cyanotic heart disease

o Subacute bacterial endocarditis

• Splinter haemorrhages

o Infective endocarditis

• Quincke’s sign

o Alternate flushing and paling of the nail bed when pressure is

applied to the tip of the nail. Seen in aortic regurgitation.

• Osler’s nodes

o Small, painful, purplish nodules at finger pulps. Seen in infective

endocarditis.

• Janeway lesions

o Pink palmar macules. Seen in infective endocarditis.

• Xanthomata on extensor tendons

o Familial hypercholesterolaemia

Radial pulses (both at same time)

• Radial-radial delay may be felt with coarctation of the aorta

Brachial pulse

Check for collapsing pulse

• Also called ‘water hammer’ pulse

• With aortic regurgitation

• Best felt by raising patient’s arm and feeling the radial pulse ‘slap’ against

your fingertips or palm

Eyes

• Anaemia

• Xanthelasmata

• Corneal arcus

o White deposit in the cornea near the periphery - indicative of

hypercholesterolemia among those under the age of 60

Face

• Malar flush. This may be a sign of pulmonary hypertension, of which

mitral stenosis is a cause.


9

Mouth

• Central cyanosis. Seen with cyanotic heart disease.

JVP (and hepatojugular reflex)

Waveform

When it occurs What it represents

‘a’ Just before ventricular

systole

Venous distension due to

right atrial contraction

‘c’ (a flicker in the x

descent)

Ventricular systole Closure of tricuspid

valve, whose leaflets

bulge backwards during

ventricular systole

‘x’ Synchronous with

carotid pulse

Tricuspid valve drawing

away from right atrium

as right ventricle empties

‘v’ Not synchronous with

ventricular systole

Venous filling of right

atrium whilst tricuspid

valve still closed

‘y’ Precedes atrial

contraction

Opening of tricuspid

valve

• Abnormalities(list not exhaustive):

o Giant ‘a’ or cannon wave

� Complete heart block

� Atrium contracting against closed ventricle

o Giant ‘cV’ waves

� Tricuspid regurgitation

� ‘x’ descent lost and replaced by very prominent upright

systolic wave representing blood shooting back up into

neck as right ventricle contracts


10

Carotid pulse for character

• Slow-rising (aortic stenosis)

• Collapsing (aortic regurgitation)

• Jerky (hypertrophic cardiomyopathy)

Precordium

• Inspection

o Scars

o Breathing

• Palpation

o Apex beat (normally 5th IC space, mid-clavicular line)

� Tapping apex – mitral stenosis

� Sustained apex beat – aortic stenosis

� Thrusting apex – aortic regurgitation

o Parasternal heave (right ventricular hypertrophy)

o Aortic thrill (aortic stenosis)

Auscultation

• Left-sided heart murmurs are heard best in expiration

• Right sided heart murmurs are heard best in inspiration

• Palpate the carotid whilst listening over precordium to enable timing of

any murmur

• Listen over the four valve areas with the diaphragm to see if any murmurs

are heard:

o Mitral valve - apex

o Tricuspid valve – 4th IC space, left sternal edge

o Pulmonary valve – 2nd IC space, left sternal edge

o Aortic valve – 2nd IC space, right sternal edge

• Go back to apex and listen for:

o Mitral regurgitation

� Pansystolic murmur

� Heard best over apex

� Radiates to axilla (demonstrate this by listening here)

o Mitral stenosis

� Listen with bell

� Mid-diastolic murmur

� Heard best:

• Over apex

• In expiration


11

• With patient rolled onto left side

• Go back to aortic valve region and listen for:

o Aortic stenosis

� Ejection systolic murmur

� Radiates to carotids (demonstrate this by listening here –

also listen for carotid bruits)

o Aortic regurgitation

� Early diastolic murmur

� Heard best:

• In 2nd aortic area (3rd or 4th intercostal space, LSE)

• With patient lent forwards

• In expiration

Keep patient sat forwards and:

• Listen for crackles at lung bases

• Palpate for sacral oedema

Lay patient back to 450

Palpate for ankle oedema

To complete

• Blood pressure in both arms

• Look at obs chart

• Palpate all peripheral pulses


12

Respiratory Examination – Crib Sheet

• Introduce yourself and ask permission

• Wash hands

• Position patient supine at 450

• General inspection from end of bed

o ‘Wide-angle lens’

� Inhalers

� Oxygen

� PEFR

� Nebulisers

� Sputum pot (look in it)

o Patient

� Respiratory distress?

� Accessory muscle use?

� Cyanosis?

� Chest shape

• Hands

o Clubbing

o Peripheral cyanosis

o Tar staining

o Fine tremor (β-agonist)

o Coarse tremor (CO2 retention)

• Pulse

• Respiratory rate

• Eyes

o Anaemia

o Horner’s syndrome

• Mouth

o Central cyanosis

o Inspect JVP

• Check for mediastinal shift

o Palpate trachea

o Palpate apex beat

• Sit patient forwards

• Palpate head and neck lymph nodes


13

• Posterior chest

o Chest expansion

o Percussion

o Auscultation

o One of:

� Vocal resonance

� Tactile vocal fremitus

� Whispering pectoriloquy

• Lie patient back to 450

• Anterior chest

o Chest expansion

o Percussion

o Auscultation

o One of:

� Vocal resonance

� Tactile vocal fremitus

� Whispering pectoriloquy

• Palpate for ankle oedema

• To complete:

o Check oxygen sats

o Measure peak flow


14

Respiratory Examination – Detailed List

General

There is always debate about whether the examiner should examine the front of

the chest before the back of the chest or vice versa. I don’t think it really matters,

as long as the whole of one side is done before the whole of the other, to avoid

sitting the patient backwards and forwards repeatedly. Personally, I prefer to

examine the posterior chest first, as you are more likely to find clinical signs at

the back.

Vocal resonance, tactile vocal fremitus and whispering pectoriloquy can be used

to help differentiate between consolidation and pleural effusion. Sound /

vibration is increased through an area of consolidation and decreased if there is

a pleural effusion between the lung and the stethoscope / hand. I do not think

there is a need to use all three as part of a routine examination – I think one is

adequate. I use vocal resonance.

Introduce yourself and ask permission

Wash hands

Position patient supine at 450

General inspection from end of bed

This is especially important for the respiratory examination, as many useful

things can be picked up from simple careful observation.

• ‘Wide-angle lens’

You are looking around for clues as to what the underlying diagnosis may be.

Look for:

o Inhalers

o Oxygen

o PEFR or PEFR chart

o Nebulisers

o Sputum pot (look in it)

• Patient

o Respiratory distress? Accessory muscle use? Cyanosis?

o Chest shape

� ‘Big chest’ with large anteroposterior diameter, little lateral

expansion, lifting of rib cage on inspiration – suggests

hyperinflation. Likely underlying COPD.

� ‘Small chest’ – possible fibrotic lung disease

� Pectus excavatum (‘funnel chest’) – common congenital

abnormality. Can occur on its own or with Marfan’s

syndrome


15

� Pectus carinatum (‘pigeon chest’) – can occur congenitally

or during adolescent growth spurt. Can occur in isolation or

as part of genetically inherited syndromes

Hands

• Clubbing. Causes:

o Bronchial carcinoma

o Chronic pulmonary infection:

� Empyema

� Bronchiectasis

� Lung abscess

� Cystic fibrosis

o Idiopathic pulmonary fibrosis

o Asbestosis

• Peripheral cyanosis

• Tar staining

• Fine tremor (β-agonist use)

• Coarse tremor (CO2 retention) – ‘asterixis’

Pulse

Respiratory rate

• Do this whilst palpating pulse so that patient is not aware that you are

counting their respiratory rate (may cause them to become

subconsciously tachypnoeic!)

Eyes

• Anaemia

• Horner’s syndrome – four potential features:

o Miosis

o Partial ptosis

o Anhydrosis on affected side of face

o Apparent enopthalmus

o Usual cause is Pancoast’s tumour – tumour of thoracic inlet

infiltrates sympathetic chain and T1 nerve root

Mouth

• Central cyanosis

Inspect JVP

Check for mediastinal shift

• Palpate trachea

• Palpate apex beat

• Mediastinum moves away from affected side in tension pneumothorax

• Mediastinum moves towards affected side in lung collapse or focal

fibrosis


16

Sit patient forwards

Palpate head and neck lymph nodes

No hard and fast rules as to which should be examined. Could do all. Must do the

ones in bold:

• Submental

• Submandibular

• Tonsillar

• Pre-auricular

• Post auricular

• Occipital

• Cervical

• Supraclavicular

• Axillary

Posterior chest

• Chest expansion

o Use ‘bucket handle’ approach with fingers in intercostal spaces

either side of chest and thumbs floating in midline – allows ribs to

move outwards

• Percussion - compare sides

o Stony dullness

� Effusion

o Dullness

� Consolidation

� Collapse

o Resonant

� Normal

o Hyper-resonant

� Tension pneumothorax


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• Auscultation

o Compare sides

o Breath sounds can be normal or bronchial

o The volume can be normal or reduced

o There may be added breath sounds

Sounds What they sound like When they

are heard

Breath sounds

Normal (vesicular) Louder and longer in

inspiration than expiration

No gap between inspiratory

and expiratory sounds

Normally

Bronchial Hollow, blowing

Resemble sound when

stethoscope applied to neck

(but quieter)

Over an area

of

consolidation

Added sounds

Crackles Early and

mid-

inspiratory

Tend to be coarse

If clear on coughing and occur

in expiration are probably

result of airway secretions

Pneumonia

Bronchiectasis

Late

inspiratory

Tend to be fine Pulmonary

fibrosis

Pulmonary

oedema (may

be coarse)

Wheeze Expiratory

Polyphonic

COPD

Asthma

Pleural rub Scratching or grating sound on

deep inspiration, like leaves

underfoot or snow underfoot

Pulmonary

embolism

Pneumonia

• One of:

o Vocal resonance– say “99”

o Tactile vocal fremitus – say “99”

o Whispering pectoriloquy – whisper “99”

• Lie patient back to 450


18

Anterior chest

• Chest expansion

• Percussion

• Auscultation

• One of:

o Vocal resonance

o Tactile vocal fremitus

o Whispering pectoriloquy

Palpate for ankle oedema

To complete:

• Check oxygen sats

• Measure peak flow


19

Abdominal examination – Crib Sheet

• Introduce yourself, ask permission

• Wash hands

• Position patient

o Supine

o 1 pillow

o Exposed from xiphisternum to pubic symphysis

• Inspection from end of bed

o Jaundice

o Pigmentation

o Spider naevi

o Excoriations

o Abdominal distension

o Distended abdominal veins

• Hands

o Clubbing

o Koilonychia, leuconychia

o Palmar erythema

o Dupuytren’s contracture

o Asterixis

• Check radial pulse

• Eyes

o Anaemia

o Icteric sclera

o Xanthelasmata

• Mouth

o Apthous ulcers

o Telengiectasia

o Glossitis

o Angular stomatitis

• Palpate for supraclavicular lymphadenopathy

• Inspect for gynaecomastia (if male)

• Inspect for spider naevi


20

• Examine the abdomen

o Inspect

� Swelling

� Distended veins (? Caput medusa)

� Scars

o Palpation – look at patient’s face whilst doing this to check for

pain

� All 9 areas of abdomen, starting away from tenderness

� Superficial initially followed by deep

� Palpate for liver, starting in RIF

� Palpate for spleen, starting in RIF

� Bimanual palpation for each kidney

o Percussion

� Liver

� Spleen

� Flank dullness +/- shifting dullness

o Auscultation

� Bowel sounds

� Renal artery bruits

o To complete - offer

� External genitalia

� Hernial orifices

� PR examination

� Generalized lymphadenopathy (esp. if organomegaly)

� Urine dipstick


21

Abdominal examination – Detailed List

General

Some doctors, for patient comfort, begin with the patient positioned supine at

450 for the first part of the examination (hands, face etc). They then lay the

patient flat with one pillow for the ‘abdominal’ part of the examination.

Personally, I lay the patient flat with one pillow from the beginning – I think

either technique is acceptable.

Classically, optimal patient exposure is described as ‘nipples to knees’. This is

clearly inappropriate for the examination setting, and I believe xiphisternum to

pubic symphisis is adequate exposure.

Palpating the abdomen is easier and more comfortable for the patient if the

examiner is sat on a chair next to the bed.

The terms ‘jaundice’ and ‘icterus’ are interchangeable. Icterus is a more ‘medical’

word.

Introduce yourself, ask permission

Wash hands

Position patient

• Supine

• 1 pillow

• Exposed from xiphisternum to pubic symphysis

Inspection from end of bed

The following things can be looked for as part of a ‘visual survey’:

• Jaundice

Yellowing of the skin / sclera can be seen when serum bilirubin is above twice

the normal level (normal level 3-17µmol/l). Causes:

o Pre-hepatic: Usually haemolysis

o Hepatic: Gilbert’s syndrome / other enzymopathies

Acute liver disease (viral, drugs, alcohol)

Chronic Liver Disease

o Post-hepatic: Cholelithiasis

Ca pancreas

Cholangiocarcinoma

Drugs


22

• Pigmentation

o ‘Slate-grey’ or ‘dusky’ pigmentation with haemochromatosis.

• Spider naevi

o A central arteriole that radiates to numerous smaller vessels - said

to look like spider’s legs.

o Blanch when pressure applied and then refill from the centre

o In area supplied by SVC

o Traditionally attributed to excess oestrogen

o 5 or more are probably abnormal

o Sign of chronic liver disease

• Excoriations

o Associated with jaundice

• Abdominal distension

• Distended abdominal veins

o Flow always towards head – suggests IVC obstruction

o Flow away from umbilicus (‘Caput Medusae’) – portal

hypertension

Hands

• Clubbing – causes:

o Cirrhosis

o Crohn’s

o Ulcerative Colitis

• Koilonychia – spoon-shaped nails – iron-deficiency anaemia.

• Leuconychia – nail beds opacify leaving only a rim of pink nail at the

distal end (i.e. gives appearance of white nails). Seen with

hypoalbuminaemia

• Palmar erythema– causes:

o Chronic liver disease

o Pregnancy

o Thyrotoxicosis

o Rheumatoid Disease

o Polycythaemia

o Chronic leukaemia

• Dupuytren’s contracture

Visible and palpable thickening of palmar fascia – causes flexion deformity of one

or more fingers. Causes:


23

o Alcohol dependence

o Anticonvulsant therapy

o Diabetes

o Retroperitoneal fibrosis

o Manual workers

o Idiopathic familial

o Named after Baron Dupuytren (1777-1835) – Napoleon’s Surgeon

o Famous sufferers

� Margaret Thatcher

� JM Barrie – his contracture thought to have been

inspiration for Captain Hook

� Papal Benediction sign may have started with a Pope with

the condition

• Asterixis

o Jerky, irregular flapping at MCP joints and wrist.

o Seen commonly with:

� Hepatic encephalopathy

� CO2 retention

Check radial pulse

Eyes

• Anaemia?

• Icteric sclera?

• Xanthelesmata – associated with primary biliary cirrhosis

Mouth

• Ulcers - causes

o Trauma

o Drugs

o Apthous ulcers

o Herpes simplex

o GI disease – inflammatory bowel disease, celiac

o Rheumatological disease – Behcet’s disease, Reiter’s syndrome

o Erythema multiforme

• Telengiectasia

o Chronic liver disease

o Hereditary hemorrhagic telengiectasia

• Pigmented lips

o Peutz-Jeghers syndrome

• Angular stomatitis

o Iron deficiency

o Vitamin B deficiency


24

o Folate deficiency

• Glossitis

o Iron deficiency

o Vitamin B deficiency (esp. B12)

• Gum hypertrophy

o Phenytoin, nifedipine, OCP, cyclosporin

o Pregnancy

o Scurvy

o Gingivitis

Palpate for supraclavicular lymphadenopathy

• Virchow’s node (gastric carcinoma)

Inspect for gynaecomastia (if male)

Inspect for spider naevi

• 5 or more probably abnormal

Examine the abdomen

• Inspect

o Swelling

o Distended veins (? Caput medusae)

o Scars

• Palpation

o All 9 areas of abdomen, starting away from tenderness

o Superficial initially followed by deep

• Lumbar area also referred to as

flank or loin

• Hypogastric area also referred to as

suprapubic area


25

o Palpate for liver, starting in RIF

o Common causes of hepatomegaly – the three ‘C’s

� Cirrhosis (early)

� Cancer – liver often hard, nodular edge

� Cardiac (right-sided heart failure) – liver firm, smooth,

tender edge; may be pulsatile if tricuspid regurgitation

present

o Palpate for spleen, starting in RIF

o Causes of splenomegaly (similar to causes of

hepatosplenomegaly, but an important additional causes are

infective endocarditis and Felty’s syndrome (Rheumatoid

arthritis and hypersplenism)

o Causes of hepatosplenomegaly

� Cirrhosis with portal hypertension

� Lymphoproliferative disorders

• CLL

• ALL

• Myeloma

• Lymphoma

• Waldenstrom’s macroglobulinaemia

� Myeloprolifertive disorders

• CML

• Myelofibrosis

• Polycythaemia Rubra Vera

• Essential thrombocythaemia

� Infection / infiltration

• Glandular fever

• Brucellosis

• Leptospirosis

• Sarcoid

• Amyloidosis

• Glycogen storage disorders

o Bimanual palpation for each kidney

� Causes of a palpable kidney

• Polycystic kidney disease

• Renal cell cancer

• Renal transplant

• Hydronephrosis


26

Distinguishing a large left kidney from a large spleen

Spleen Kidney

Upper border Not palpable Palpable (you can ‘get

above it’)

Medial notch Yes

No

Movement with

inspiration

Downwards and medially Downwards only

Ballotable No Yes (because of

retroperitoneal position)

Percussion Dull over spleen Often resonant over

kidney

• Percussion

o Liver

o Spleen

o Flank dullness +/- shifting dullness

o Causes of ascites:

� Chronic liver disease

� Malignancy

� Right / biventricular heart failure

� Nephrotic syndrome

• Auscultation

o Bowel sounds

o Renal artery bruits

To complete

Offer:

• External genitalia

• Hernial orifices

• PR examination

• Generalized lymphadenopathy (esp. if organomegaly)

• Urine dipstick


27

Acknowledgements

The two main texts consulted for reference whilst producing this booklet were:

1. Tim Hall. ‘ PACES for the MRCP’. Churchill Livingstone.

2. Epstein, Perkin, de Bono, Cookson. ‘Clinical Examination – Second

Edition’. Mosby.

Special thanks to the following people:

• Dr Katherine Bowering (SpR in Gastroenterology)

• Dr Richard Lee (Consultant in Gastroenterology)

examination skills masterclass hughes exam skills...staff development programme 2010 5 precordium...

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