PLAB 2 Physical Examination Skills — Questions and Answers
Question 1: When performing a cardiovascular examination, in which order should you proceed?
- Auscultation, palpation, percussion, inspection
- Inspection (general + hands + face + JVP), palpation (apex beat, heaves, thrills), auscultation (heart sounds + murmurs), then peripheral findings and completion (Correct answer)
- Auscultation, inspection, percussion, palpation
- Palpation, auscultation, inspection, percussion
Correct answer: Inspection (general + hands + face + JVP), palpation (apex beat, heaves, thrills), auscultation (heart sounds + murmurs), then peripheral findings and completion
The standard cardiovascular examination sequence: inspect generally (comfortable at rest, dyspnoea, cyanosis), inspect peripherally (hands — clubbing, splinter haemorrhages; face — malar flush; JVP; carotid pulse), then cardiac palpation (apex position, heaves, thrills), then auscultation (four areas, radiation, dynamic manoeuvres).
Question 2: Where is the normal apex beat located and what does a displaced apex beat suggest?
- 5th intercostal space, midsternal line; displaced laterally suggests aortic stenosis
- 5th intercostal space, midclavicular line; displacement laterally suggests cardiomegaly (e.g., dilated cardiomyopathy, left ventricular failure, mitral regurgitation) (Correct answer)
- 4th intercostal space, anterior axillary line; displacement indicates normal variant
- 6th intercostal space, midclavicular line; displacement suggests right heart failure
Correct answer: 5th intercostal space, midclavicular line; displacement laterally suggests cardiomegaly (e.g., dilated cardiomyopathy, left ventricular failure, mitral regurgitation)
The apex beat is normally in the 5th intercostal space, midclavicular line. Lateral displacement (to the anterior axillary line or beyond) indicates cardiomegaly, caused by left ventricular dilation (dilated cardiomyopathy, severe MR, volume overload). A thrusting apex is volume overloaded; a heaving apex is pressure overloaded (hypertension, AS).
Question 3: During abdominal examination, what is the correct sequence?
- Palpation, auscultation, percussion, inspection
- Inspection, auscultation, light palpation, deep palpation, percussion, then special tests (Correct answer)
- Percussion, palpation, auscultation, inspection
- Palpation, percussion, inspection, auscultation
Correct answer: Inspection, auscultation, light palpation, deep palpation, percussion, then special tests
Abdominal examination sequence: Inspect (scars, distension, movement with respiration, visible pulsation, stomas), Auscultate (before palpation to avoid artificially altering bowel sounds), Lightly palpate (tenderness, guarding, rigidity), Deeply palpate (organomegaly), Percuss (liver, spleen, shifting dullness), Special tests (hernial orifices, rectal exam if indicated).
Question 4: When examining a patient for jaundice, which additional examination findings would suggest a hepatic cause rather than post-hepatic (obstructive) jaundice?
- Pale stools and dark urine
- Spider naevi, palmar erythema, leukonychia, caput medusae, hepatic encephalopathy, ascites, and splenomegaly — stigmata of chronic liver disease (Correct answer)
- Right upper quadrant mass and rigors
- Pruritus without other hepatic signs
Correct answer: Spider naevi, palmar erythema, leukonychia, caput medusae, hepatic encephalopathy, ascites, and splenomegaly — stigmata of chronic liver disease
Hepatic (hepatocellular) jaundice is associated with stigmata of chronic liver disease: spider naevi (>5 is significant), palmar erythema, leukonychia, Dupuytren's contracture, caput medusae, gynaecomastia, testicular atrophy, asterixis, ascites, splenomegaly. Obstructive jaundice features pale stools, dark urine, and often a palpable gallbladder (Courvoisier's sign if non-tender).
Question 5: During a neurological examination of the lower limbs, what does 'clonus' indicate?
- Reduced reflexes due to lower motor neurone lesion
- Rhythmic, involuntary muscle contractions elicited by sudden passive stretch, indicating upper motor neurone lesion with hyperreflexia (Correct answer)
- Flaccid muscle tone
- A cerebellar sign indicating ataxia
Correct answer: Rhythmic, involuntary muscle contractions elicited by sudden passive stretch, indicating upper motor neurone lesion with hyperreflexia
Clonus is a series of rhythmic involuntary muscle contractions triggered by sudden passive dorsiflexion of the ankle (or other joint). Sustained clonus (>5 beats) is pathological and indicates an upper motor neurone lesion (e.g., stroke, cord compression), reflecting loss of descending inhibitory control on stretch reflexes.
Question 6: When examining cranial nerve V (trigeminal nerve), what do you assess?
- Eye movements and pupillary reactions
- Facial sensation (three divisions: ophthalmic, maxillary, mandibular), muscles of mastication (masseter, temporalis — jaw clench), and the corneal reflex (afferent limb) (Correct answer)
- Facial expression and taste on anterior 2/3 of tongue
- Hearing, balance, and the gag reflex
Correct answer: Facial sensation (three divisions: ophthalmic, maxillary, mandibular), muscles of mastication (masseter, temporalis — jaw clench), and the corneal reflex (afferent limb)
CN V (trigeminal nerve): sensory — facial sensation in three divisions (forehead/ophthalmic V1, cheek/maxillary V2, jaw/mandibular V3); motor — muscles of mastication (masseter, temporalis, pterygoids); special — afferent limb of corneal reflex. Testing: light touch and pin-prick in all three divisions; jaw clench and opening against resistance.
PLAB 2 Physical Examination Skills
When performing a cardiovascular examination, in which order should you proceed?