CMS100 PRACTICAL EXAM.docx

CMS100 PRACTICAL EXAM – STUDY GUIDE Before the exam: Long hair is tied back Nails are short Introduces self by name and role (naturopathic student clinician) Explains the exam Asks explicitly for consent During the exam:  Communicates about initiating physical contact and as appropriate throughout t...

CMS100 PRACTICAL EXAM – STUDY GUIDE Before the exam: Long hair is tied back Nails are short Introduces self by name and role (naturopathic student clinician) Explains the exam Asks explicitly for consent During the exam:  Communicates about initiating physical contact and as appropriate throughout the exam Does not use medical terminology while speaking with the patient Maintains professionalism throughout the exam (does not break character/demeanor, avoids slang/colloquial/inappropriate/derogatory language, utilizes respectful, inclusive communication) After the exam: Verbally concludes the exam with the patient Test Draping How-to Normal results Abnormalities Heart rate none Patient sitting down with back supported, feet on floor Sit down next to patient with hand on their shoulder/back Apply light pressure along the radial artery with the index and middle finger Count rate for 30 seconds and multiply by 2 Normal range is 60-90 bpm The normal pulse rhythm is regular, meaning that the frequency of the pulsation felt by your fingers follows an even tempo with equal intervals between pulsations. Bradycardia is a heart rate less than 50bpm Tachycardia is a heart rate greater than 100bpm Irregular pulses are felt in heart arrhythmias Irregularly irregular pulse: there is no pattern to the irregularity (aka. chaotic rhythm).  Irregularly irregular pulse rhythm is highly specific to atrial fibrillation Regularly irregular pulse: the pattern of missed beats or variation is predictable (e.g. 3 regular beats then one missed beat called a Pause, which is associated with premature contractions) Respiration rate none Patient sitting down with back supported, feet on floor Sit down next to patient with hand on their shoulder/back Count respirations for 30 seconds and multiple by 2 Observe rate, rhythm depth and effort of breathing At rest the normal respiratory rate in adults is between 12-20 cycles per minute Tachypnea: An increase in respiratory rate which occurs with central nervous system stimulation and as compensation for respiration problems occurs with exertion, fear, cardiac insufficiency, pain, pulmonary embolism, acute respiratory distress from infections, pleurisy anemia and hyperthyroidism Bradypnea: Decreased respiratory rate  Occurs with hypothyroidism, respiratory failure, medication and drug use, or brain injuries Kussmaul Breathing (Hyperpnea): respirations are a deep, sighing respiratory pattern occurs due to increased tidal volume with or without an increased respiratory rate and is a form of hyperventilation that can be seen with any disorder that causes significant acidosis such as uncontrolled diabetes, and toxic ingestion particularly alcohol. Cheyne-Stokes breathing: A pattern of crescendo-decrescendo respirations followed by a period of apnea occurs in patients with heart failure, usually while asleep Blood pressure (brachial) none Patient sitting in chair with back supported, feet on floor, should rest atleast 5 min before Ask patient if they have had caffeine or smoked 30 min prior Find brachial pulse on left arm, place cuff 2.5-3cm proximal from cubital fossa, place stethoscope distal to cuff, rest patient arm on table or hold at level of heart Estimate systolic pressure by palpating radial artery, inflate cuff, and note when radial pulse disappears Deflate cuff and have patient pump their fist in the air 10 times Place bell/diaphragm of stethoscope on brachial artery, inflate cuff 20 mm Hg higher than first reading, slowly release pressure in cuff Systolic pressure is when sounds first become audible, diastolic pressure when sounds disappear Normal is >90 mmHg for systolic and >60 mmHg for diastolic Hypotension = low blood pressure (<90/60 mmHg) Signs: Fatigue, shortness of breath Can be seen in bacteremia, pneumonia, and myocardial infarction Hypertension = high blood pressure (>130/80 mmHg) Present in Heart attack, stroke, hypertensive renal failure, and retinopathy Differences in pressure of more than 6-10mm Hg between the arms Subclavian Steal Syndrome Aortic Dissection Differences in pressure between arms and legs Chronic ischemia of the lower extremities Coarctation of the aorta Skin examination of a lower limb drape should go in between legs (triangle draping) Patient lies supine and prone on table Examine the entire leg, as well as the foot, including the web spaces between the toes, the dorsal and plantar aspects of the foot, and the toenails GENERAL Note skin (incl toenails) colour, moisture, temperature, texture, areas of irritation, bleeding, tenderness, consistency, scaling Pull the lower lids down to observe the conjunctival rim (as part of an assessment of pallor in mucous membranes) if indicated skin color: look for changes in pigmentation, redness, pallor, cyanosis and yellowing of the skin pallor is seen on the fingernails, lips, and mucous membranes particularly of the mouth and palpebral conjunctiva. In dark skinned individuals inspecting the palms and soles for pallor might also be useful central cyanosis is best identified in the lips, oral mucosa, and tongue. Be aware the darker skinned individuals have melanin in their lips that may simulate cyanosis Cyanosis of the nails, hands and feet can be central or peripheral in origin Jaundice (yellow colouring of skin) can be observed in the sclera, palpebral conjunctiva, lips, hard palate, undersurface of the tongue, tympanic membrane, and skin Moisture: look for dryness, sweating and oiliness Temperature: use the backs of your hands to assess the temperature of the skin on the arms and legs. Note the temperature on any red areas. Texture: palpate the skin for any roughness or smoothness Mobility and turgor: lift a fold of skin on the dorsum of the hand, sub-clavicular fossa or anterior thigh for 3 seconds so that it is tented and then release; observe its ability to change shape and return to normal ABCDE for melanoma A: Asymmetry B: Border – irregular C: Colour variation D: Diameter > 6mm (E): Evolution/change - as part of your history/examination macule, a flat, nonpalpable circumscribed area (up to 1 cm) of color change that's brown, red, white, or tan patch, a flat, nonpalpable lesion with changes in skin color, 1 cm or larger papule, an elevated, palpable, firm, circumscribed lesion up to 1 cm plaque, an elevated, flat-topped, firm, rough, superficial lesion 1 cm or larger, often formed by coalescence of papules nodule, an elevated, firm, circumscribed, palpable area larger than 0.5 cm; it's typically deeper and firmer than a papule cyst, a nodule filled with an expressible liquid or semisolid material vesicle, a palpable, elevated, circumscribed, superficial, fluid-filled blister up to 1 cm bulla, a vesicle 1 cm or larger, filled with serous fluid pustule, which is elevated and superficial, similar to a vesicle, but is filled with pus wheal, a relatively transient, elevated, irregularly shaped area of localized skin edema. Most wheals are red, pale pink, or white. scale, a thin flake of dead exfoliated epidermis crust, the dried residue of skin exudates such as serum, pus, or blood lichenification, visible and palpable thickening of the epidermis and roughening of the skin with increased visibility of the normal skin furrows (often from chronic rubbing) excoriation, linear or punctuate loss of epidermis, usually due to scratching. Conjunctival rim pallor absent – pale then red Conjunctival rim pallor present, entire lid is pale Heart auscultation Bikini draping Patient lying supine Aortic (A) - located in the 2nd intercostal space on the right sternal border  Pulmonic (P) - located in the 2nd intercostal space on the left sternal border Erb’s point (E; no specific valve) - located in the 3rd intercostal space on the left sternal border. It is useful for a quick and general assessment of the heart as all heart sounds are audible here (pathological and physiological). It is also used to compare heart rate to radial pulse to assess if there is a pulse deficit. Tricuspid (T) - located in the 4th intercostal space on the left lower sternal border Mitral (M) - located in the 5th intercostal space on the midclavicular line S1 sound (lub): beginning of systole, closure of mitral and tricuspid valves S2 sound (dub): beginning of diastole, closure of aortic and pulmonic valves S3 – ventricular gallop: S3 can be physiologic in children or athletic young adults (<40yrs). It occurs in two cardiac pathologies: congestive heart failure and regurgitation/shunts. S4 – atrial gallop: S4 is always pathological. It occurs in hypertension, ischemic cardiomyopathy, hypertrophic cardiomyopathy and aortic stenosis (basically, cardiac conditions that are characterized by ventricular stiffening, either by hypertrophy or fibrosis). Aortic Regurgitation (AR) Acute: Infective endocarditis (water hammer pulse) Chronic: bicuspic aortic valve, connective tissue diseases Mitral Stenosis (MS) Rheumatic fever SLE RA vegetations or tumour Mitral Regurgitation (MR) Degenerative Endocarditis Ischemic heart disease Rheumatic fever Pulsus parvus et tardus (weak + delayed carotid upstroke) Aortic Stenosis (AS) Calcification of aortic valve  Rheumatic fever Turner’s syndrome (bicuspid valve) Syncope Angina Dyspnea Mitral Valve Prolapse Connective tissue disorders: Ehlers-Danlos syndrome, Marfan syndrome Polycystic kidney disease Rheumatic heart disease Infective endocarditis Ventricular Septal Defect (VSD) Genetic abnormalities: Down syndrome, Edward syndrome, Patau syndrome, Cri-du-chat syndrome TORCH infections Jugular venous pressure Bikini draping Patient lying supine Examine the right side of the patient’s neck as these veins have a direct route to the heart.  Either the external or internal jugular veins may be used to estimate pressure because measurements in both should be similar.  Raise the head of the table so that the patient’s head is elevated to the level at which the top of the neck veins are revealed (approx. 30-45 degrees). The top of the neck veins are indicated by either the point above which the external jugular vein disappears or the point above which the bi-phasic pulsations of the internal jugular vein become imperceptible.  After locating the top of the internal or external vein, measure the vertical distance from the top of the vein and the sternal angle Top of the neck veins are 3cm or less above sternal angle JVP is abnormally elevated if: The top of the neck veins are more than 3cm above the sternal angle. Left heart disease, lung disease, primary pulmonary hypertension, and pulmonic stenosis increase the central venous pressure and make the neck veins visibly distend Auscultation: posterior and/or anterior chest Bikini draping when supine (anterior auscultation) Gown open on posterior side Posterior Patient sitting down Instruct the patient to cross their arms over their chest and "give themselves a hug".  Use the diaphragm of your stethoscope to auscultate the lungs.  Instruct the patient to breathe through their mouth. Auscultate one full breath cycle in each location.  Avoid auscultating over the scapulae. Same ladder pattern as percussion Anterior Patient lying supine Same technique as posterior Ladder pattern in percussion section Normal sounds A) Vesicular Pitch: Low pitched  Intensity: Softer  Locations: Heard over most of the lung fields bilaterally  Duration of sound: Inspiratory vesicular sounds are longer than expiratory vesicular sounds. B) Bronchial Pitch: High Pitched  Intensity: Louder  Locations: Heard over the manubrium  Duration of sound: Expratory bronchial sounds are longer than inspiratory bronchial sounds C) Bronchovesicular  Pitch: Intermediate pitched Intensity: Intermediate intensity  Locations: Heard in the first and second intercostal spaces anteriorly  Locations: Heard in between the scapulae posteriorly  Duration of sound: Inspiratory and expiratory bronchovesicular sounds are equal in duration.  D) Tracheal  Pitch: High-pitched  Intensity: Very loud  Locations: Over the trachea  Duration of the sound:  Inspiratory and expiratory tracheal sounds are equal in duration. A) Wheezing  High-pitched  Continuous Musical  This sound has a shrill/hissing quality  Causes: Narrowed airways as in COPD or Asthma "Like dashes in time" 1 B) Rhonchi Low-pitched  Continuous Musical  This sound has a snoring quality  Causes: secretion in airways  Clears with coughing in chronic bronchitis  "Like dashes in time" 1 C) Crackles (Rales) Discontinuous  Short  Non-musical  Intermittent  Late inspiratory crackles: Congestive Heart Failure, Interstitial Lung Disease  Early inspiratory crackles: Chronic Bronchitis  Mid-inspiratory and expiratory crackles: bronchiectasis.  "Like dots in time" 1 Fine Crackles: High-pitched and soft; Duration: 5 to 10 milliseconds.  Coarse Crackles: Low-pitched and loud; Duration: 20-30 milliseconds.  D) Stridor  An inspiratory wheeze  Pitch: High-pitched Intensity: Loud  Quality: Musical Locations: Heard loudest over the anterior neck  Partial laryngeal or tracheal obstruction  Mainly an inspiratory sound  Cause: upper respiratory tract obstruction. Croup can cause inspiratory stridor.  E) Pleural Friction (Rub)  Causes: Pleural surfaces rubbing against each other due to inflammation  Can resemble crackling sounds  Egophony, bronchophony, and/or whispered pectoriloquy (bilateral) Bikini draping if supine (anterior inspection) Gown open back with patient sitting for posterior side Patient sitting down, hugging themselves As per auscultation of the lungs (previous) Use the diaphragm of your stethoscope to auscultate the lung fields bilaterally.  Use the ladder pattern to compare the symmetrical areas, bilaterally.  Egophony Ask the patient to say "E" every time your stethoscope contacts their skin.  Use a ladder pattern to compare symmetrical lung fields bilaterally.  Bronchophony  When you auscultate over the large airways, the spoken words can be heard louder and clearer, compared to the peripheral airways. This is called bronchophony.  Ask the patient to say "ninety-nine" every time your stethoscope contacts their skin.  Use the ladder pattern to compare symmetrical lung fields, bilaterally.  Whispered pectoriloquy (exaggerated bronchophony) Ask the patient to WHISPER "ninety-nine" every time your stethoscope contacts their skin.  Use the ladder pattern to compare symmetrical lung fields, bilaterally.  Egophony: The sound should be heard as "E" on auscultation Bronchophony: The spoken words are usually heard Whispered pectoriloquy: The whispered words are usually very faintly heard.     Egophony: Hearing "A" instead of "E" on auscultation suggests consolidation.  Bronchophony: Hearing bronchophony over the lung tissue suggests consolidation (air has been replaced by a fluid such as blood or water) as in pneumonia, hemorrhage or pulmonary edema. If you hear the spoken words louder and clearer in an area of the lung tissue, compared to the rest of the lung fields, that suggests consolidation.  Whispered pectoriloquy (exaggerated bronchophony): If you hear the spoken words louder and clearer in an area of the lung tissue, compared to the rest of the lung fields, that suggests consolidation.  Percussion: posterior and/or anterior chest Bikini for anterior with patient supine Gown open on back with patient sitting for posterior Place your non-dominant hand’s middle finger on the intercostal spaces, and use the tip of your dominant hand’s middle finger to hit your other hand’s distal interphalangeal joint Anterior chest pattern: use the latter pattern, start percussing above the clavicles Posterior chest pattern: patient hugs themselves, use the ladder pattern, starting above the scapulae and going between them Tympany, resonance (over lungs), or dullness (over solid tissue) Resonance Hallow quality.   This finding can be normal or heard in left-sided heart failure or chronic bronchitis.  Dullness Pleural effusion, lung tumours and pneumonia can cause dullness, and atelectasis (percussing over the airless lung fields sounds dull).  Note the superficial cardiac dullness on the left side of the sternum, between the third and fifth intercostal spaces.  Note the liver dullness, starting at the superior border of the liver on the right side.  Hyperresonance  Abnormally long Low-pitched  Causes: Emphysema, Pneumothorax, COPD DTR: biceps, brachioradialis, and/or triceps (bilateral) none Patient seated Biceps: examiner tests the biceps reflex using the thumb on the biceps tendon, pointy edge of hammer Brachioradialis: examiner tests the reflex by using thumb on the brachioradialis tendon, pointy edge of hammer Triceps: examiner tests the triceps reflex with the patient seated and elbow flexed, flat edge of hammer 0  No response; reflex is absent 1+ Trace/decreased response (hypoactive) 2+ Normal response 3+ Exaggerated/brisk response (hyperactive) 4+ Sustained response (hyperactive with clonus) If you have trouble eliciting a reflex, you may use reinforcement techniques (isometric contractions of other muscle groups for up to 10 seconds). For example, ask the patient to clench their teeth or squeeze their thigh with the opposite hand if you have trouble eliciting an upper limb reflex Lower motor neuron lesions depress reflex Upper motor neuron lesions increase reflex DTR: patellar and/or Achilles/ankle reflex (bilateral) none Patient seated for both tests Patellar: patient seated with feet hanging, use weighted hammer on patella bone, flat edge Achilles: When testing the Achilles reflex, you should passively dorsiflex the foot at the ankle. Observe for plantar flexion as you strike the Achilles tendon with your hammer, flat edge If you have trouble eliciting a lower limb reflex, ask the patient to perform the Jendrassik maneuver (patient interlocks fingers of opposite hands together and pull one hand against the other), 0  No response; reflex is absent 1+ Trace/decreased response (hypoactive) 2+ Normal response 3+ Exaggerated/brisk response (hyperactive) 4+ Sustained response (hyperactive with clonus) Plantar reflex (test for Babinski response) none Patient lying supine The plantar reflex is a cutaneous stimulation reflex. It is elicited by stroking the skin on the sole of the foot with a blunt instrument (such as the end of your reflex hammer), starting from the lateral heel and moving upward in a curved pattern to the ball of the foot.. 0  No response; reflex is absent 1+ Trace/decreased response (hypoactive) 2+ Normal response 3+ Exaggerated/brisk response (hyperactive) 4+ Sustained response (hyperactive with clonus) Normal response in adults: downward flexion of the toes Abnormal response in adults: Babinski’s sign (also known as a positive Babinski response or positive plantar reflex) where the big toe dorsiflexes and other toes fan out. This is a sign of an upper motor lesion (a central nervous system lesion in the corticospinal tract). Rapid alternating movements (upper and lower body) (bilateral) none Upper body: Patient seated - Ask the patient to repeatedly tap their palm on the thigh, lift the hand, flip it over, and tap the back of the hand down on thigh as rapidly as possible. This should be tested bilaterally. The examiner should observe the speed, rhythm and smoothness of the patient’s movements, noting any slowed or awkward movements. Lower body: Patient seated - For the lower limbs, ask the patient to use the ball of each foot to repeatedly tap the palms of your hands as rapidly as possible. Normal: rapid, rhythmic, smooth coordinated movement Abnormal: dysdiadochokinesis (slow, irregular, awkward movements) may indicate cerebellar disease, basal ganglia disease, or upper motor neuron weakness Point-to-point testing (Finger-to-Nose and Heel-to-Shin tests) (bilateral) none Finger to nose Ask the patient to use their index finger to alternate between touching their nose and touching your index finger. You should move your finger to different positions so the patient needs to switch directions and extend the arm fully to reach your finger. This should be tested bilaterally.  Heel to shin Ask the patient to slide their heel down their opposite shin and back up. This should be tested bilaterally. Finger to nose -- Normal: smooth, accurate movements Heel to shin -- Normal: smooth, accurate movements Abnormalities indicate cerebellar dysfunction! Finger to nose -- Abnormal: clumsy, unsteady movements that vary in speed, force, or direction; dysmetria (finger may undershoot or overshoot target); intention tremor (involuntary rhythmic oscillatory muscle contractions during a directed and purposeful motor movement) Heel to shin -- Abnormal: clumsy, unsteady movements that vary in speed, force, or direction; dysmetria (heel may undershoot or overshoot target); heel may oscillate from side to side when running down shin Gait assessment (normal walking, tandem/heel-to-toe, toes, heels) none Gait assessment should include observing the patient’s posture, balance, swinging of their arms, and movement of the legs. Observe the patient: Walking across the room, turn around, and come back Walking heel-to-toe in a straight line (tandem walking) Walking on toes Walking on heels  Arm swings opposite to leg stepping forward, normal rhythm, hips level Hemiplegic Gait When walking, the patient will hold his or her arm to one side and drags his or her affected leg in a semicircle (circumduction) due to weakness of distal muscles (foot drop) and extensor hypertonia in lower limb. This is most commonly seen in stroke. With mild hemiparesis, loss of normal arm swing and slight circumduction may be the only abnormalities. Diplegic Gait (Spastic Gait) The patient walks with an abnormally narrow base, dragging both legs and scraping the toes. This gait is seen in bilateral periventricular lesions, such as those seen in cerebral palsy. There is also characteristic extreme tightness of hip adductors which can cause legs to cross the midline referred to as a scissors gait. Neuropathic Gait (Steppage Gait, Equine Gait) Seen in patients with foot drop (weakness of foot dorsiflexion), the cause of this gait is due to an attempt to lift the leg high enough during walking so that the foot does not drag on the floor. If unilateral, causes include peroneal nerve palsy and L5 radiculopathy. If bilateral, causes include amyotrophic lateral sclerosis, Charcot-Marie-Tooth disease and other peripheral neuropathies including those associated with uncontrolled diabetes. Myopathic Gait (Waddling Gait) Hip girdle muscles are responsible for keeping the pelvis level when walking. If you have weakness on one side, this will lead to a drop in the pelvis on the contralateral side of the pelvis while walking (Trendelenburg sign). With bilateral weakness, you will have dropping of the pelvis on both sides during walking leading to waddling. This gait is seen in patient with myopathies, such as muscular dystrophy. Choreiform Gait (Hyperkinetic Gait) This gait is seen with certain basal ganglia disorders including Sydenham's chorea, Huntington's Disease and other forms of chorea, athetosis or dystonia. The patient will display irregular, jerky, involuntary movements in all extremities. Walking may accentuate their baseline movement disorder. Ataxic Gait (Cerebellar) Most commonly seen in cerebellar disease, this gait is described as clumsy, staggering movements with a wide-based gait. While standing still, the patient's body may swagger back and forth and from side to side, known as titubation. Patients will not be able to walk from heel to toe or in a straight line. The gait of acute alcohol intoxication will resemble the gait of cerebellar disease. Patients with more truncal instability are more likely to have midline cerebellar disease at the vermis. Parkinsonian Gait (Festinating Gait, Propulsive Gait) In this gait, the patient will have rigidity and bradykinesia. He or she will be stooped with the head and neck forward, with flexion at the knees. The whole upper extremity is also in flexion with the fingers usually extended. The patient walks with slow little steps known at marche a petits pas (walk of little steps). Patient may also have difficulty initiating steps. The patient may show an involuntary inclination to take accelerating steps, known as festination. This gait is seen in Parkinson's disease or any other condition causing parkinsonism, such as side effects from drugs. Sensory Gait The sensory ataxic gait occurs when there is loss of this propioreceptive input. In an effort to know when the feet land and their location, the patient will slam the foot hard onto the ground in order to sense it. A key to this gait involves its exacerbation when patients cannot see their feet (i.e. in the dark). This gait is also sometimes referred to as a stomping gait since patients may lift their legs very high to hit the ground hard. This gait can be seen in disorders of the dorsal columns (B12 deficiency or tabes dorsalis) or in diseases affecting the peripheral nerves (uncontrolled diabetes). In its severe form, this gait can cause an ataxia that resembles the cerebellar ataxic gait. Romberg Test none The patient should stand unsupported with feet together and eyes open for 30-60 seconds, then with eyes closed for 30-60 seconds. The examiner should stand close to the patient with outstretched arms in front and behind the patient just in case the patient may lose balance and fall Normal: the patient maintains upright posture with minimal swaying Abnormal: a positive Romberg sign (the patient loses balance when eyes are closed) may indicate sensory ataxia. This can arise from many causes including conditions affecting the dorsal column such as tabes dorsalis (due to neurosyphilis) and vitamin B12 deficiency. Pronator Drift test none Ask the patient to stand for 20-30 seconds with their feet shoulder-width apart, arms outstretched straight forward with palms facing up (forearms supinated), and eyes closed Normal: the patient can maintain the position of their arms (arms remain supinated in horizontal plane) Abnormal: pronator drift (forearm pronates with or without downward drifting of the arm) may indicate a motor neuron lesion in corticospinal tract Extraocular movements none The movements of the eye are controlled by CN III (oculomotor nerve), CN IV (trochlear nerve), and CN VI (abducens nerve). These 3 nerves can be tested together with the test of extraocular movements (also known as the H-test). Patient seated Have them follow your finger as you draw an H pattern Both eyes follow finger Abnormal findings include: Dysconjugate gaze Nystagmus Lid lag Pupillary response to light and accommodation none To assess the pupillary response to light, you may need to dim the lights in the room. Ask the patient to look into the distance and shine a light at an oblique angle into each pupil in turn. A direct response is elicited when the pupil constricts in response to direct illumination. A consensual response is elicited when the opposite pupil constricts. Test both pupils for direct and consensual responses. Patient should put hand in between eyes Accommodation Test the pupil near reaction (also known as the accommodation test). This should be done in a room with normal lighting. Hold your finger or penlight about 10 cm away from the patient and ask them to look alternately at your finger/penlight and into the distance. You should see the pupils constrict when looking at the nearby object, and pupils dilate when looking into the distance. The acronym PERRLA (which stands for “pupils equal, round, and reactive to light and accommodation”) is often used in medical charting to describe the normal pupillary responses. Pupils should restrict in response to light From Stanford medicine 25 link in e-learning Asymmetric pupil size is termed aniscoria. Aniscoria is benign if the pupillary reactions are normal. If an optic nerve lesion is present the affected pupil will not constrict to light when light is shone in the that pupil during the swinging flashlight test. However, it will constrict if light is shone in the other eye (consensual response). The swinging flashlight test is helpful in separating these two etiologies as only patients with optic nerve damage will have a positive RAPD. Some causes of a RAPD include: optic neuritis ischemic optic disease or retinal disease severe glaucoma causing trauma to optic nerve direct optic nerve damage (trauma, radiation, tumor) retinal detachment very severe macular degeneration retinal infection (CMV, herpes) Adie's (Tonic) Pupil Either no or sluggish response to light (both direct and consensual responses) Associated with Holmes-Adie syndrome described with Adie's pupil and absent deep tendon reflexes Argyll Robertson Pupil This lesion is a hallmark of tertiary neurosyphillis Pupils will NOT constrict to light but they WILL constrict with accommodation Horner's Syndrome Loss of sympathetic innervation causing the clinical triad of: Ptosis (drooping eyelid): The superior tarsal muscle requires sympathetic innervation to keep the eyelid retracted Miosis (pupillary constriction): A loss of sympathetic input causes unopposed parasympathetic stimulation which leads to pupillary constriction. This degree of miosis may be subtle and require a dark room. Anhidrosis (decreased sweating): Also caused by a loss of sympathetic activity. The pattern of anihidrosis may help identify the lesion. Anhidrosis of the entire face is often associated with a lesion at the level of the carotid artery. Partial anhidrosis involving only the medial aspect of the forehead ipsilateral side of the nose is associated with a lesion distal to the carotid bulb. Causes of Horner's Syndrome include: carotid artery dissection pancoast tumors, nasopharyngial tumors lymphoproliferative disorders brachial plexus injury cavernous sinus thrombosis fibromuscular dysplasia Ophthalmoscopic exam (bilateral) none Patient sitting down Dim the lights in the room before the exam. If using a traditional ophthalmoscope, you will need to come very close to your patient’s face and want to avoid bumping into their nose. Hold your ophthalmoscope in your left hand and use your left eye to examine the patient’s left eye. Hold the ophthalmoscope in your right hand and use your right eye to examine the patient’s right eye. Adjust the focus of your ophthalmoscope. The lens disc should start at 0 diopters. Rotate to the red numbers to correct for myopic (-) refractive errors and green numbers to correct for hyperopic (+) refractive errors. Ask the patient to look into the distance directly past your shoulder. Hold the thumb of your opposite hand across the patient’s eyebrow and brace the patient’s head. Start about 15 inches away and approach the patient at a 15-degree angle from the patient’s line of vision. Shine the light beam into the pupil and look for the red reflex (an orange glow). Once you find the red reflex, follow it as you slowly move in closer until you can see the retina. When performing an ophthalmoscopic exam, you should visualize and comment on the following: Red reflex Background of the retina Optic disc and physiologic cup Arteries and veins Fovea and macula From standard medicine 25 website (link in e-learning) Pathological Optic Cupping Note cup-to-disc ratio at least 0.8 (physiologic limit of 0.5). Optic Disc Edema The optic disc is elevated and its surface is covered by cotton wool spots (damaged axons) and flame hemorrhages (damaged vessels). Four I's: increased intracranial pressure (papilledema), infarction, inflammation, infiltration (by cancer). Arterio-Venous (AV) Nicking Chronic hypertension stiffens and thickens arteries. At AV crossing points (arrow) arteries indent and displace veins. Cotton Wool Spots Caused by microinfarcts. Exploded ganglion cell axons extrude their axoplasm into retina. Long DDx: hypertension, diabetes, HIV, severe anemia or thrombocytopenia, hypercoagulable states, connective tissue disorders, viruses, and others. Emboli and Infarcts Small fleck a ‘Hollenhorst’ plaque caused from platelet/fibrin/cholestorol embolus. Resulting in an infarct (gray area above and right of the plaque). Roth Spot Pale-centered hemorrhage. Caused by several conditions, but usually bacterial endocarditis. This image was from a patient with staph endocarditis. Otoscopic exam (bilateral) none Patient sitting down You should use your left hand to handle the otoscope (pencil grip, with ulnar portion on cheek) when examining the patient’s left ear, and your right hand when examining the patient’s right ear. It is important to straighten out the patient’s ear canal before inserting the spectrum. It optimizes visualization of the tympanic membrane and helps to minimize patient discomfort as the exam is performed. In an adult patient, you can straighten out the ear canal by pulling the patient’s ear up, out and back with the opposite hand. When performing an otoscopic exam, you should visualize and comment on the following: External ear canal Tympanic membrane Cone of light (anterior side of ear) Bony landmarks Pars flaccida and pars tensa Ear drum should be light-gray, light should reflect, small hairs, possibly brown cerumen Link in e-learning not working, source was https://www.ucsfhealth.org/medical-tests/ear-examination#:~:text=The%20eardrum%20may%20be%20red,ear%20is%20pulled%20or%20wiggled. Eardrum may be red, bulging, amber liquid/bubbles – middle ear infection Eardrum may be red, tender, swollen, filled with yellowish-green pus – external ear infection Abdominal auscultation Window draping Patient supine Use the stethoscope’s diaphragm directly on the skin of the patient’s abdomen (all 4 quadrants) Normoactive or normal bowel sounds described as ‘clicks and gurgles’ or ‘rumbling’ at a frequency of 5-35 sounds per minute (or approximately one sound every 5-12 seconds). minimum take 2-5 seconds per location. Hypoactive bowel sounds are less than 5 sounds per minute. This may be suggestive of constipation. Absent bowel sounds suggest an emergent condition, such as bowel obstruction, peritonitis, intestinal ischemia, or paralytic ileus. Hyperactive bowel sounds are more than 35 sounds per minute. This may suggest diarrhea, gastroenteritis, inflammatory bowel disease, laxative use, gastrointestinal bleeding or bowel obstruction Abdominal palpation (light and deep) Window draping Patient supine Superficial or light palpation - This technique is performed before deep palpation to detect tenderness, muscle resistance and superficial organs or masses in a particular region. With gradual pressure, depress the abdomen to a depth of 1-2 cm and move the pads of your fingers in a circular or wave-like motion to assess the area of the abdomen Deep palpation (knees up/bent legs) - With gradual pressure, gently depress the abdomen to a depth of 4-5 cm using the palmar surfaces of your fingers. You can use one or two hands to complete deep palpation. If you are using the two-handed technique, the lower hand is used to assess the abdomen and the upper hand is used to apply firm and steady pressure. This technique is used primarily to assess masses and organomegaly, but it will occasionally elicit tenderness that light palpation did not uncover.  The normal consistency of the abdomen is soft or firm and without associated pain or tenderness upon light palpation. The consistency of the abdomen is influenced by the amount of adipose tissue and muscle, but this should be consistent throughout the abdomen Abdominal rigidity is the involuntary tightening of the abdominal musculature in response to underlying inflammation (i.e. as in peritonitis) Guarding is a voluntary contraction of the abdominal musculature to avoid pain or discomfort and tends to be generalized over the entire abdomen McBurney’s point tenderness Window draping Patient supine Located by drawing a straight line between the umbilicus and the anterior superior iliac spine (ASIS), then dividing the line into thirds. McBurney’s point is the meeting place of the upper 2 thirds and lower 1 third (approx. 5cm or 1.5-2 inches from ASIS) Palpate area for tenderness No tenderness Tenderness is maximal in cases of appendicitis or inflammation of the ileocecal area (e.g. Crohn’s disease, bacterial infection) Shifting dullness (ascites) Window draping Patient supine turn patient onto side Percuss the abdomen starting at the center or most protuberant part of the abdomen moving laterally toward the flank while listening for the transition from tympany to dullness.  Mark the location of dullness or keep your fingers there, then have the patient roll onto their side so that the dull area is now the most superior aspect of the abdomen.  Repeat percussion in that location after a few seconds. The amount of time to wait is not standardized, but 15 seconds is considered sufficient time for fluid to shift (range 15-60 seconds).  Area remains dull patient moves onto their side With ascites, the area that was first assessed to be dull should become tympanic (air rises to top) and the dullness shifts to the dependent side (central area of the abdomen which previously was tympanic) Fluid wave (ascites) Window draping Patient supine Requires the patient or an assistant to place the medial edges of both their hands firmly vertically down the midline of the abdomen to block transmission of the wave through subcutaneous fat. The clinician can then tap or flick one flank while using the other hand to feel for an impulse or thrill. No fluid wave felt A positive fluid wave or thrill finding is when that impulse or thrill is felt in the receiving hand after a barely perceptible lag Liver percussion (right side) Window draping Patient supine The technique for indirect percussion is the same as that used for the lung exam. To percuss the liver, the middle finger of your nondominant hand is hyperextended by pressing the distal interphalangeal (DIP) joint firmly on the surface to be percussed. With your middle finger of your dominant hand partially flexed, strike the hyperextended DIP joint. Avoid contact by any other part of the hand on the abdomen because this dampens vibrations Tympanitic (drum-like) sounds are produced by percussing over air filled structures. Dull sounds occur when percussing over a solid structure (e.g. liver) or fluid (e.g. ascites) in the region being examined Tympany and dullness Dullness may indicate ascites Liver palpation Window draping Patient supine Starting in the patient’s right lower quadrant, the clinician presses their palpating hand just lateral to the rectus abdominus. Ask the patient to take a deep breath in and as they inspire, the clinician tries to feel the liver’s edge move inferiorly into the clinician’s fingers. This is repeated as the clinician moves their palpating hand superiorly at 1-2cm increments until the lower border of the liver is felt.  A healthy liver can be slightly tender or nonpalpable. A healthy liver has a soft, sharp, regular and smooth edge Increased tenderness can suggest inflammation (e.g. hepatitis) or congestion (e.g. congestive heart disease) The edge of a diseased liver can feel firm, irregular, or rounded/blunted. Cirrhosis is usually associated with increased firmness, while (rock) hardness and umbilicated nodules along the edge are suggestive of malignancy. A palpable mass on the inferior liver edge may be an obstructed, distended gallbladder Liver span Window draping Patient supine Midclavicular Liver Span Starting to percuss in about the 3rd intercostal space on the midclavicular line, lightly percuss 2-3 times. The expected sound is resonant over the lungs. Continue to percuss inferiorly within the intercostal spaces until dullness denotes the liver’s upper border. Typically the 5th intercostal space is the expected estimated change in percussive sounds on the midclavicular line. Make note of the intercostal space at which dullness is elicited.  Start percussing just below the umbilicus on the midclavicular line in an area of tympany.  Continue to percuss superiorly until dullness indicates the liver’s inferior border and make note of where this dullness is elicited.  Use your measuring tape to measure the distance between the upper and lower points of dullness to estimate liver span on the midclavicular line (in centimeters, cm) Normal liver span on the midclavicular line is 6-12cm False positives for enlarged liver span can include conditions that create dullness in the lungs, such as right pleural effusion and right consolidated lung Thyroid inspection (including tangential lighting) none Patient sitting down Ask the patient to extend their neck slightly.  Using your penlight, shine tangential lighting on the thyroid, from the angel of the patient's chin.  Visualize the thyroid cartilage and the cricoid cartilage. The thyroid gland is located inferiorly to the cricoid cartilage.  Visualize the shadow of the lower border of the thyroid gland.  Ask the patient to swallow.  Visualize the thyroid gland rising and then returning to the resting position when the patient swallows, alongside the thyroid cartilage and the cricoid cartilage.  Note the thyroid gland's symmetry and contour.  Note any enlargement of the thyroid gland or goitre, if present A normal thyroid gland looks symmetrical, not enlarged and moves symmetrically upwards with swallowing Enlarged tbyroid: goiter An enlarged thyroid gland moves upwards with swallowing and goes back to the resting position afterwards May indicate hyperthyroidism (e.g. Grave’s Disease), or hypothyroidism Thyroid palpation none Patient sitting down From superior to inferior, palpate thyroid cartilage, cricoid cartilage, and then thyroid gland To palpate the right lobe:  A) Ask the patient to flex their neck slightly forward and tilt their head to the right slightly (10-15 degrees) to help relax the right sternocleidomastoid muscle.  B) Place the pads of your left 2nd, 3rd and 4th digits on the patient's right thyroid lobe.  C) Place the pads of your right 2nd, 3rd and 4th digits on the patient's left thyroid lobe.  D) Ask the patient to swallow.  E) Palpate the thyroid isthmus, and note it rising as the patient swallows.   F) With the fingers of your right hand push the trachea towards the side that you are palpating (the patient's right side).  G) Make circular motions with the palpating fingers.  H) Ensure to palpate the thyroid lobe between the trachea and the sternocleidomastoid muscle.  I) Note the shape, texture, consistency and gland size. Note any enlargement or nodules.  Same thing but opposite side for left Feels soft In thyroid inspection section Cervical lymph node palpation (bilateral) none Patient sitting down Preauricular: Palpate them anterior to the ears bilaterally  Posterior Auricular: Palpate them posterior to the ears, over the mastoid process, bilaterally Occipital: Palpate them at the base of the skull, on the occipital lobe, bilaterally  Tonsillar: Palpate them at the angel of the mandible over the tonsils, bilaterally  Submandibular: Palpate them, midway between the tip of the mandible and the angel of the mandible, bilaterally.  Submental: Posterior to the tip of the mandible, on the midline.  Superficial Cervical: Over the sternocleidomastoid muscle. Palpate superficially.  Posterior Cervical: Posterior to the sternocleidomastoid muscles and anterior to the trapezius muscles.  Deep Cervical: Alongside and in between the heads of sternocleidomastoid muscles. Palpate deeply. You can ask the patient to flex their head slightly forward and to the side that you are palpating to relax the sternocleidomastoid muscles, and place your finger on each side of the SCM (Sternocleidomastoid) and deeply palpate. They are usually inaccessible.  Supraclavicular: Superior to the clavicles. Palpate deeply. You can ask the patient to shrug their shoulders to give you easier access for deeper palpation.  Infraclavicular: Along the inferior border of the clavicles.  A small, mobile, soft, non-tender and discrete lymph node can be a normal finding also known as Shotty nodes.  Lymphadenopathy: Defined as swelling of a lymph node. The causes of lymphadenopathy. include any type of infection (including bacterial, viral or fungal), and malignancies.  A hard and fixed lymph node is a red flag and requires further investigation.  The location of the palpable lymph node is also important. Even a small, palpable supraclavicular lymph node could indicate malignancy in the abdominal cavity.  Diffused lymphadenopathy could possibly suggest an HIV infection.     Spleen percussion (left side) Window draping Patient lying supine Castell's Sign (Splenic Percussion Sign)  Note: because of its accuracy and reliability, this technique should be your focus for practice and examination purposes Find the lowest intercostal space on the left anterior axillary line.  Start percussing continuously. The normal percussion sound in this area is tympanitic.  As you percuss the same point, ask the patient to take a deep breath in.  Upon inspiration, the diaphragm moves inferiorly and pushes the spleen inferiorly as well. Hence, it might push the spleen down under your percussing finger if it is enlarged.  Change of tympany to dullness when the patient takes a deep breath suggests splenomegaly and is a positive Castelle's sign.  If the spleen is not enlarged, the percussion remains tympanitic during inspiration..  If the spleen is not enlarged, the percussion remains tympanitic during inspiration ,  Change of tympany to dullness when the patient takes a deep breath suggests splenomegaly and is a positive Castelle's sign. Some of the causes of Spleenomegaly (enlargement of spleen):  Hematologic malignancies HIV infection  Mononucleosis  Portal hypertension  Splenic hematoma Splenic infarct Spleen palpation Window draping The patient is in the supine position.  The examiner stands on the patient's right side.  Reach over the patient and support the left lower rib cage with your left hand (the Stanford Medicine 25 video does not apply this technique, but Bate's does. Clinically anchoring the left lower rib with your left hand can improve your palpation technique; hence, we recommend using this technique).  Start palpating for the spleen way below the left costal margin with your right hand.  Keep your hand stationary, but apply some pressure.  Ask the patient to take a deep breath. Upon inspiration, the diaphragm moves inferiorly and hence, pushes the abdominal organs inferiorly as well. This would allow the spleen to move towards your palpating hand.  As the patient exhales, move your hand towards the left costal margin and ask them to take another deep breath and repeat the previous step. Keep your palpating hand in the next location, apply some pressure and wait for the spleen to hit your fingertips as the patient takes another deep breath in. Repeat these steps until your palpating hand palpates under the left costal margin.  If you can't palpate the spleen, you can ask the patient to turn to their right side. In this case, gravity will help the spleen to move to a position that makes palpation easier.  If you start too high to palpate the spleen, you might miss the edge of an enlarged spleen.  May feel soft border Causes of splenomegaly under spleen percussion