Table of contents
- 1. Breast
- 2. Urologic
- 3. ENT
- 3.1. Ear
- 3.2. Nose+sinuses
- 3.3. Throat
- 4. Ophthalmic exam
- 5. Peripheral Vascular
- 6. HIV Exam
ASCM2 – specialized exams
Breast
History
- Pain
- Masses (size, shape, symmetry, skin changes)
- Nipple changes (ulceration, discharge)
- Constitutional sx (fever, wt loss, sweats/chills, appetite)
Inspection
- Sit upright, arms on thighs facing examiner
- Comment on Size, Symmetry, shape, skin changes
- Nipples: Size, Symmetry, Shape, skin, secretion, supernum. Nipples
Palpation:
Nodes: (patient sitting upright)
- Supraclavicular
- Infraclavicular
- Axillary (pectoral/anterior, subscapular/post., lateral, central)
Breast: (patient supine, arms at sides)
- Start with Axymptomatic breast
- Masses: (location, size, shape, consistency, tenderness, mobility)
Urologic
History
- Irritative: Frequency, urgency, nocturia, dysuria
- Obstructive: Straining, hesitancy, incomplete empty…
- Hematuria: pain/clots, part of stream?
- Stress incontinence?
- Erectile dysfunction? Firmness, initiating, maintaining, ejaculation
- Blood in semen
- Discharge
- Swelling/masses
Exam
Penis
- Size
- Skin
- Curvature
- Glans (ask to retract: check for phimosis, or paraphimosis)
- Meatus (hypospadius?) discharge?
- Palpate: using both hands along corpora cavernosa (peyronie’s disease?)
- Open urethra to check for secretions
Testes
- Inspect: swelling, masses, varicoceles, skin changes
- Warm hands…
- Palpate both hands (one hand top/bottom, other left/right)
- Comment size/shape/consistency/tenderness/nodules/masses
- If mass present, transilluminate (solid vs cystic)
- Palpate: epididymus, spermatic cord
Inguinal
- Masses/swellings (ask to valsalva for hernias)
- Stand up?
- Palpate (standing?): palpate each inguinal region
- Put index finger through scrotum along spermatic cord to external and then internal ring, ask to cough.
- Auscultate for bowel sounds (maybe?)
Other:
- Inguinal, left supraclavicular nodes
Kidneys
- Percuss bilaterally? Maybe do the hand strike technique?
Prostate
- Patient in Sims position, glove both hands, lubricate finger
- Use non-exam hand to spread buttocks for exam
- Inspection: inflam, warts, nodules, tumors, bleeding, hemorrhoids
- Palpation:
- Warn pt that lube will feel cold,
- ask to take deep breath in
- Check sphincter tone, resistance
- Turn finger to examine rectal wall (polyps, masses, irregularities)
- Palpate anterior rectum + prostate
- Median sulcus
- Lateral lobes
- Look for size, symmetry, masses, tenderness, nodules
- Warn before withdrawing
- Normal: bilobed, heart-shaped, 4cm diam, smooth, firm
ENT
Ear
- Loss fluctuating? Unilateral? Frequency? Drugs?
- Otalgia, Ottorhea, vertigo, tinnitus, hyperacusis
- Hx of ear infections
- Exam: (sit arms at sides)
- Inspection: pinna, helix, antihelix, tragus, lobule, EAM
- Cauliflower?
- Tophi?
- Discharge?
- Palpation:
- Pinna
- Mastoid process
- Pain when pulling pinna or press on tragus (OE)
- Whisper test
- Rinne Test
- Weber Test
- Otoscope:
- Exernal ear canal: redness, swelling, tenderness, dicharge
- Tympanic Membrane:
- Color (pearly grey), Integrity, transparency (semi-transparent), position, (ovoid shape), landmarks
- Pars tensa, handle of malleus, cone of light
Nose+sinuses
- Infections
- Nasal obstruction (noisy breathing, allergy, rhinorrhea, etc.)
- Face pain
- Anosmia
- Exam:
- Inspection:
- Size
- Swelling
- Trauma
- Deviation
- Nares
- Ask to occlude one nostril, try to exhale through the other
- Palpation
- Nose: tenderness, firmness
- Sinuses: maxillary, frontal sinuses for tenderness
- Special inspection
- Position: left hand on pt forehead, thumb pulling on tip of nose
- Uses scope or light source
- Look at:
- Septum, Vestibule, Nasal mucus membranes, Little’s area (Kiesselbachs plexus), Middle/inferior turbinate’s
- Inspect:
- Exudates
- Swelling
- Bleeding
- Trauma
- Masses,
- Polyps
- Discharge
- Inspection:
Throat
- cough? Productive? Hemoptysis? Dyspnea? Chest pain?
- Dysphagia
- Hoarseness
- Inspection
- Open Jaw (comment on jaw)
- Lips, buccal mucosa, gingivae, teeth, tongue, floor, palate, ductal orifices
- Note:
- Swelling
- Color
- Lesions (ulcerations, herpetic, mucoceles)
- Patency of salivary orifices
- Plaques, Papules, bleeding, teeth
- Palpation:
- Palpate tongue (use gauze to hold tongue with one hand) (most ca at margins)
- Bimanual palpate floor of mouth, (tenderness, masses)
- Examine CN XII
- Pharynx
- Use light and tongue depressor
- Tonsins: (size, debris, exudate)
- Post pharynx wall (discharge, masses, erythema) “say ahh”
- Gag reflex
- Larynx
- Use dental mirror
Ophthalmic exam
- Hx burning, tender, red, pain, pain movement, headache/nausea, discharge
- Exam
- Visual acuity
- Visual fields
- EOM
- Inspect:
- Ocular symmetry
- Orbit (exophthalmos)
- Eye lids
- Conjunctiva, etc.
- Opthalmoscope:
- Approach 15’’ away, at 15°, move to 2’’ from eye
- Optic disk
- Margins: (sharp)
- Color: (pinkish or yellow-orange)
- Cup: (central, C:D is <0.5)
- Papilledema?
- Retinal vessels (normal, slight venous pulstations)
- Macula:
- Colour: (reddish orange, no lesions)
Peripheral Vascular
- Pain? SEVERE?
- 6 P’s: Pain, pallor, Paralysis, parasthesia, pulsenessness, polar
- Claudication: Pain with exercise, Predictable (same exercise), Disappears at rest.
- Critical ischemia?: Rest Pain, Numbness, Night Pain, Non-healing ulcers
- Ulcers? Where? (brownish ulcers near ankle – venous; ulcers at distal,lateral,dorsal – arterial; bottom of foot btwn toes - diabetic)
- Risk factors: smoking, HTN, DM, dyslipidemia, FHx, Lifestyle, dialisys
- Recent surgery, cancer, OCP, pregnancy, FHx clotting.
- Inspection:
- Size, symmetry
- Edema
- Varicose/dilated veins
- Skin thickness
- Ulcers
- Pallor
- Nails
- Lips
- Palpation
- Tempearture (warmth, erythema = venous; cold = art.)
- Edema (pitting, venous)
- Leg sizes (smallest ankle, largest calf, thigh – compare both sides > 2cm = change atrophy or swelling è venous)
- Cap refill (norm <3s)
- Pulses
- Carotid, brachial, radial, AA, renal, femoral, popliteal, post. Tibial, dorsalis pedis (0-4, 2 norm)
- Special Tests
- Allen test – make tight first, occlude ulnar and rad arteries, release each one and see how long to return pink color to hand (try each first)
- Pallor/Rubor – Normal: pink color returns 10 s, veins refill @ 15s.
- ABI
HIV Exam
- Inspection
- Skin: Kaposi sarcoma. Check entire skin (cancer of connective tissue, painless purplish-red to brown plaquelike lesions).
- Pharynx: Thrush, oral hairy leukoplakia (EBV - raised white plaques on sides of tongue).
- Palpate
- Neck, Clavicle, Axillae & Groin for LN enlargement by NH-Lymphoma.
- Examine abdomen for hepatic/splenic enlargement.
- +++ TODO.. other exam features (section unfinished)
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