Systems Review and focused history taking

Anatomical position

• Standing erect with palms and feet facing forward

• Palms face anteriorly with thumbs pointed away from the body

Positioning diagram

Anatomical Reference points diagram

Lateral definitions

• Unilateral - pertaining to 1 side

• Ipsilateral - on the same side as the reference point

• Bilateral - pertaining to both sides

• Contralateral - on the opposite side of the reference point

Terms of motion diagram

What are the anatomical plans?

1. Sagittal plane

2. Transverse plane

3. Coronal plane

Explicit and implied/implicit consent definitions

Explicit consent:

• Can be spoken or written when a patient gives you permission to do something

Implied/implicit consent:

• When consent is indicated indirectly e.g. by bringing a prescription for dispensing. It’s only valid if the patient understands what they are consenting to

General survey (inspection) - observing the patient

• Level of consciousness

• Mental awareness – agitation/ drowsiness/ confusion

• Cachexia/obesity

• Position/posture

• Oxygen/therapeutic adjuncts

• Walking aids

• How comfortable?

• Able to talk in sentences

• Cyanosis/pallor/mottling

• Feverish?

• Effort in breathing – accessory muscles

• Fever

• Audible wheeze/stridor/grunting

• Intercostal recession

• Sweating

• Tremor/Fasciculations/Unintended movements

Vital signs

• Blood pressure - lying, standing, inter arm difference

• Pulse - rate, rhythm, volume, character

• Temperature

• Respiratory rate

• Height/weight

• Capillary Refill Time

• Pulse Oximetry

Familiarise yourself with normal ranges

Peripheral Examination

• Skin: i.e. turgor/colour/lesions/temperature/integrity

• Finger nails: i.e. clubbing (check Schamroth’s window sign)/ koilonychia (spooning)/splinter haemorrhages/ leukonychia (white)

• Hands: i.e. palmer erythema/Dupuytren's contractures/ wasting /Herberdens Nodes/ Oslers nodes/ xanthomas/ Janeway lesions/ tremor / asterixis

• Arms: i.e. radial/ brachial pulses, blood pressures, Collapsing Pulse

• Eyes: i.e. conjunctival pallor/ xanthalasma/ corneal arcus/ sclera/ petechial haemorrhages/ Kayser Fleischer rings

• Face: i.e. Malar Flush

• Mouth: i.e. dentition/cyanosis/angular chelitis (stomatitis)/ glossitis/ulceration/hydration

• Neck: lymph nodes, central venous pressure, carotid pulse

• Legs: pulses, skin, oedema

Focused Systems Review - IPPA

• Inspection - use of vision, hearing and smell to detect characteristics and physical signs

• Palpitation - using the hands to touch and make measurements of physical signs

• Percussion - striking the body’s surface with a finger to produce a vibration

• Ausculation - listening to sounds created in body organs to detect variations from the normal

Jugular Venous Pressure

JVP provides an indirect measure of central venous pressure (right atrium)

The jugular venous pulse is:

• Not palpable

• Obliterated by pressure

• Characterised by a double waveform

• Variable with respiration - it decreases with inspiration

• Enhanced by the hepatojugular reflux

JVP can be difficult to detect and has been superseded by other diagnostic methods

Measurement of JVP

• Stand at patients RHS – patient supine, reclined at 45 degrees

• Look across the neck from the patients RHS – good light source

• Locate the surface markings of the IJV - this runs from the medial end of the clavicle to the ear lobe, under the medial aspect of the sternocleidomastoid muscle

• Identify the jugular vein pulsation ( 2 beats per heartbeat) in the suprasternal notch or behind the sternocleidomastoid muscle

• Use LUQ pressure to confirm it is the JVP

• Measure the JVP as the vertical height in cm between the upper limit of the venous pulsation and the sternal angle (junction of the manubrium and sternum at the level of the second costal cartridges)

• JVP in health = ≤ 4cm above the sternal angle

Lymph node distribution palpitation diagram