Hematologic PE Flashcards
Hematologic Examination
Keypoints:
- all the palpable groups of lymph nodes
- size of spleen
GA: cachexia, pallor, jaundice, scratch marks
Hands: koilonychia, clubbing, pulse - tachycardia
Arm: epitrochlear lymph nodes, axillary lymph nodes (CLIPS)
Characteristics: size, consistency, tenderness, fixation, overlying skin
Mouth: hypertrophy of the gum, atrophic glossitis, enlargement of the Waldeyer’s ring
Neck: cervical lymph nodes (submental, submandibular, jugular, posterior triangle, pre & post auricular, occipital, supraclavicular)
Bone tenderness: spine, clavicle, sternum
Palpation of spleen: two-handed technique
Percussion of spleen: Castell method
Inguinal lymph nodes: along the inguinal ligament, along the femoral vessels
Purpuric Rash Examination (ITP)
Your next patient is a 27 year old man who has presented to you complaining of a rash on his legs. He gives a history of URTI 10 days ago. Vitals are stable, temp 36.5 and ENT exam is normal.
Tasks:
1. Describe rash to medical student
2. Explain your PE to the medical student
Differential Diagnoses:
- Infections: meningococcemia, viral (measles)
- Hematologic: ITP, malignancies, coagulation disorder (DIC)
- Vasculitis: HSP
- Others: CLD, NAI
*ITP is a diagnosis of exclusion
Describe rash:
Petechiae/Ecchymosis/Purpuric
Primary morphology
Site, size, shape
Discrete/Confluent
Borders
Color
Secondary morphology
Distribution
Temperature
Tenderness
Blanching
GA: scratch marks, LOC, cachexia, pallor
Arms: Epitrochlear LN, Axillary LN (CLIPS)
Face: Fundoscopy - papilledema
Neck: Cervical LN, bone tenderness, neck stiffness
Abdomen: palpate spleen & liver, percuss spleen
Inguinal LN
Joint exam for arthritis
Purpuric Rash Examination (HSP)
Your next patient is a 7 year old child who presents with a rash on the buttocks and legs. He has a history of URTI 2 weeks ago. He is complaining of intermittent abdominal pain. Temp 36.8. Vitals are stable. Urine dipstick: (+) blood
Investigation: Platelets normal
Task:
1. Describe the rash
2. Explain PE to medical student and mention what you are looking for
GA: scratch marks, LOC
Check blood pressure
Hands: mention full joint examination to check for arthritis
Arm: epitrochlear LN, axillary LN
Face: ENT examination
Neck: cervical LN, bony tenderness
Abdomen: palpation for tenderness, rigidity & guarding, palpate the spleen, liver, percuss the spleen, auscultate bowel sounds
Inguinal: inguinal LN, testicular exam
Strawberry Tongue Examination
Your next patient is a 3 year old boy who has presented to your GP with his mother. He has been unwell and feverish for 2 days.
Tasks:
1. Explain photo to the medical student
2. Explain PE to examiner
3. Explain diagnosis and differentials
Differentials:
- Kawasaki disease
- Scarlet fever
- Allergic reaction
VS: Temperature
GA: Drooling, noisy breathing
Hands: hyperemia, edema, desquamation in palms and soles
Arm: Rash
- Kawasaki: generalized polymorphous rash
- Scarlet: sandpaper rash
Full joint examination for signs of arthritis
Head: redness in both eyes
Throat: tonsils
-Kawasaki: non-exudative
- Scarlet: exudative
Neck: cervical lymph nodes with at least 1 LN > 1.5cm
Respiratory - auscultation for added sounds
CVS: carditis features
Psoriasis Physical Examination
Your next patient is a 25 year old lady who presented to you concerned of a rash behind her neck and on her hairline.
Tasks:
1. Describe rash to the examiner/medical student
2. Explain further systemic PE to support your diagnosis
3. Request investigations
*Psoriasis lesions: raised, clear margin, silverish scales
Auspitz sign: attempt to remove the scale, bleeding under the scale
Describe rash:
- Primary morphology: plaque
- Site
- Borders: well-demarcated
- Color: pale pink base
- Secondary morphology: silverish scales
- Temperature, tenderness
- Surface: rough
- Blanching: expect to be blanching
Look for other psoriatic rashes: extensor surfaces of elbows and knees, confirm with Auspitz sign
Nails: pitting, ridging, yellowish discoloration, onycholysis
Hand arthritis
Dactylitis
Axial involvement - back exam
Entesopathy: plantar fasciitis, achilles tendinitis
Dx is usually clinical unless there is doubt then skin biopsy
Associations of psoriasis:
- DM: FBS/Hba1c
- Hyperlipidemia: lipid profile
-Fatty liver: LFTs
Mx: Topical management: steroids, calcipotriol, tar preparations
Seborrheic Dermatitis Examination
A 27 year old man presents to your General Practice complaining of a rash behind his ear. He has history of dandruff which is well-controlled with a special shampoo the pharmacist gave him. (probably ketoconazole + salicylic acid shampoo - Nizoral)
Tasks:
1. Describe the rash to the medical student
2. Explain further head & neck examination and mention specific findings to support your diagnosis
Seborrheic rash:
- Pale pink, ill-defined erythematous rash characterized by loose, flaky scale
- Scale may be yellow and greasy
- Dandruff a feature of scalp area
- Worse with stress & fatigue
- It is a chronic, recurring condition
Task 1: Describe the rash
- Primary morphology: Patch
- Site
- Borders: Ill-defined
- Color: Pale salmon pink
- Secondary morphology: yellowish greasy scales
- Temperature, Tenderness
- Surface: dry, rough
- Blanching: expect it to be blanching
- Auspitz sign: negative
Head & Neck Exam:
Check for red, flat patches with yellowish greasy scales on the scalp, eyebrows, eyelids, nasolabial fold
Blepharitis on eyelids
DDx: Psoriasis, atopic dermatitis, rosacea, discoid lupus
Mx: topical steroids, shampoos w/ salicylic acid + ketoconazole, lotions
EBV Examination: Case 1
A 5 year old child has been brought to your GP by his father. He was diagnosed with tonsillitis 2 days ago and started on Amoxicillin. He developed a rash this morning. His father is concerned.
Tasks:
1. Explain examination steps to the father
2. Explain your physical examination to the medical student
3. You will be given PE findings at 7 minutes
4. Explain your diagnosis
GA: Describe the rash
Hands: epitrochlear, axillary LN
Throat exam: exudative tonsillitis, petechiae on palate
Cervical LN exam
Abdomen: palpate and percuss for splenomegaly
EBV Examination: Case 2
Your next patient is a 25 year old man who was diagnosed with infectious mononucleosis 2 days ago. He is now complaining of left upper quadrant abdominal pain.
Task:
1. Explain physical examination to the medical student
GA: Pallor
Arms: Rash (in EBV maculopapular blanching rash), epitrochlear & axillary LN
ENT examination: exudative tonsillitis, petechiae on palate
Cervical LN: in EBV posterior triangle involvement
Respiratory: auscultation (complication of EBV is pneumonia)
CVS: auscultation for added sounds (complication of EBV is myocarditis)
Full Abdomen exam:
Inspection: paradoxical movement of abdomen
Superficial and deep palpation: tenderness, splenomegaly, hepatomegaly
Percussion: splenomegaly
Mention neurological exam: neck stiffness, CN nerve exam (complication of EBV is meningitis)
Herpes Rash Examination: Case 1
Hands: Herpetic whitlow
ENT exam: throat & mouth, nose
Eye examination
- inspection: redness, discharge, vesicular rash
- Visual acuity
- Fluorescein staining & use cobalt blue light to assess for dendritic ulcers on the cornea (Herpes keratitis)
Neurologic exam
- neck stiffness
- CN nerve examination (CN II - fundoscopy for papilledema, CN III/IV/VI - eye movements, CN V - sensation, CN VII - facial movements)
- Upper & lower limb examination: tone & reflex
Herpes Rash Examination: Case 2
Your next patient is a 5 year old boy who has been brought to the ED unwell and has a rash on his cheek. He started having mild fever 3 days ago and the rash appeared 2 days ago. Since this morning, he has been drowsy with a 40 degree temperature. His mother has given him paracetamol but it has not helped.
Tasks:
1. Describe rash to the medical student
2. Explain further physical examination
Hands: Herpetic whitlow, rash & desquamation in palms (Kawasaki)
ENT exam: throat & mouth, nose
Eye examination
- inspection: redness, discharge, vesicular rash
- Fluorescein staining & use cobalt blue light to assess for dendritic ulcers on the cornea (Herpes keratitis)
Neurologic exam
- neck stiffness
- CN nerve examination (CN II - fundoscopy for papilledema, CN III/IV/VI - eye movements, CN V - sensation, CN VII - facial movements)
- Upper & lower limb examination: tone & reflex
- GCS score
Nappy Rash Examination
Your next patient is a 7 day old/4 weeks old baby who came in with a nappy rash.
Tasks:
1. Describe rash
2. PE to medical student
Structure:
1. r/o DDx
2. Neonatal examination
3. Hematologic examination
Differential Diagnoses:
- Diaper dermatitis
- Atopic dermatitis
- Contact dermatitis
- Seborrheic dermatitis
- Psoriasis
- Scabies
- Child abuse
- Cellulitis & sec bacterial infections
II. General Appearance
- Level of consciousness
- Dehydration features
- Bruises, burn marks (child abuse)
- Growth chart
III. Vital signs
- Temperature (secondary bacterial infections)
IV. Hands
- CRT, skin turgor
- Pulse volume
- Single palmar crease
- Grasping reflex
V. Arm
- Epitrochlear LN, axillary LN, LN characteristics
- Rash suggestive of psoriasis - extensor surfaces of elbow
VI. Head
- Rash suggestive of seborrheic dermatitis (yellowish greasy, scaly rash) in the cradle cap, behind the ear, eyebrow, nasolabial fold
- Fontanelles
- Red reflex
- Mouth: cleft lip, central cyanosis, rooting reflex
- Cervical LN
VII. Chest
- Rash
- Abnormal chest wall, gynecomastia
- Auscultation - respiratory and CVS
VIII. Abdomen
- Hernia
- Hepatosplenomegaly palpation
IX. Others
- Inguinal LN
- Hip examination: Barlow, Ortolani
- Anus - redness, ulcer, rash
- Moro reflex
