NOTES FROM FIRST EXAMINATIONS


APPROACH

1. Remember to examine a patient from afar when you approach them:

- Are they sick or unwell?

- Are there vomit bowls around them, blood, IVs, nasogastric tubes?

- Are there any visible scars on the patient?

- Are they on oxygen?

2. Approach examinations in order: hands, arms, mouth, head, neck, torso, body

3. When you finish an examination, do not just state every possible test that could be run. Start with the least invasive, and only those relevant to the findings from the case.

CLINICAL

- If you detect tracheal deviation, it could be a tension pneumothorax, in which case, you need to perform a pleural effusion:

you insert the largest needle you can find in the second intercostal space, in the midclavicular line, avoiding the neuromuscular bundles which are found just below the ribs.

- When performing percussions, you always compare LIKE FOR LIKE, so you don't go down one side of the chest and then down the other, but you compare one side to the other side.

- If you hear a crackle with the stethoscope that clears with a a cough, this is normal secretions. If it doesn't it isn't. A crackle at the bottom of the lungs could indicate oedema.

- The apex beat is found in the 5th intercostal space, in the midclavicular line.

- Hepato-jugular reflux: you palpate the liver, pushing the blood out of it and into the veins, increasing JVP transiently, which can be observed as a JVP change.

- Rebound tenderness is when the patient does not experience discomfort during palpation, but as you release pressure.

- Guarding is when the abdominal muscles tense during examination: usually happens with children or when there is pathology. You ask the patient to relax, go back to lighter palpations and slowly increase the pressure.

- You start with softer palpations farthest from the area the patient describes as being painful: this is to form better rapport with the patient, and to help localise the area of pain.

PATHOLOGY

Clubbing of nails: Hypotrophic Osteoarthropathy

Causes: Lung cancer (29% of lung cancer patients and 90% of patient's with clubbing), other lung conditions, congenital heart disease (tetralogy of Fallot), gastrointestinal (celiac sprue, cirrhosis, Crohn's, ulcerative colitis), hypothyroidism, Grave's disease

Diagnosed by the lack of the Lovibond angle.

Diagnostic tests after finding clubbing: CT for lung cancer, EKG to evaluate heart, arterial blood gases/lung function tests to evaluate lungs, blood tests for liver or thyroid function.

Virchov's node (stomach cancer)

Located between the two heads of the sternocleidomastoid muscles. It is superficial, so it's enlargement is a good diagnostic tool for GI malignancy.

It is a sign of advanced disease.

Can also enlarge in non-GI malignant disease such as breast cancer, oesophageal, testicular cancers.

Sinus arrhythmia

Refers to the general irregular heartbeat. Can be normal in the young, as the heartbeat does change rhythmically with each breath.

When it does occur in older individuals it can be associated with heart disease or other heart conditions.

#generalclinical