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clinical skills Flashcards

1
Q

shoulder normal ranges for abduction and adduction

A

90 and 50

*180 for elevation (beyond 90 of abduction) - when performed actively

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2
Q

shoulder normal ranges for external and internal rotation

A

65 and 90

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3
Q

How do you ask the patient to actively test internal rotation?

A

Ask them to reach behind their back with their thumb as high as it will go

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4
Q

shoulder normal ranges for flexion and extension

A

180 and 65

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5
Q

What’s the likely underlying disease if a patient has painful limitation of movement in all directions of the shoulder?

A

intra-articular disease

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6
Q

What’s the likely underlying disease if the patient has painful limitation of movement in one plane?

A

tendinitis

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7
Q

What’s the likely underlying disease if the patient has painless weakness of the shoulder?

A

tendon rupture of neurological lesions

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8
Q

How can you test for supraspinatus tendonitis?

A

The tendon is just under the anterior surface of the acromion. Test for it by placing a finger over the head of the tendon while the shoulder is in extension. This moves the tendon forward against the finger, and the movement will be painful. When the shoulder is then flexed the tendon moves away and the pain disappears.

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9
Q

What may cause anterior swelling at the shoulder?

A

A large effusion

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10
Q

What should you look for in a shoulder examination?

A
  • limited forward, backward and upward movements while the patient undresses.
  • symmetric outline of the acromioclavicular joints.
  • deltoid wasting
  • feel for anterior swellings of the shoulder
  • look for asymmetry
  • scars as a result of past injury and surgery
  • erythema
  • lacerations
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11
Q

What is a probable underlying disease for patients who complain of pain when they internally rotate the shoulder/ or reach up behind their back with their thumb?

A

rotator cuff problems

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12
Q

Where should you look in a shoulder examination

A

All around: back checkin for wasting of infra- and supraspinatus.

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13
Q

What is asking the patient to press against a wall with their hands testing?

A

Winging of scapula - long thoracic nerve damage - weakness to serratus anterior.

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14
Q

In the abdominal exam, what are general wasting and jaundice signs of?

A

liver disease

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15
Q

Re abdominal exam, what is an altered mental state a sign of?

A

hepatic encephalopathy, due to decompensated advanced cirrhosis (chronic liver failure) or fulminant hepatitis (acute liver failure)

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16
Q

Re abdominal exam, what is pigmentation a sign of?

A

chronic liver disease, especially haemochromatosis
*due to haemosiderin (iron complex only in cells, not blood, stores iron but isn’t readily available when iron is needed) stimulating melanocytes to produce melanin

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17
Q

abdo: What is general wasting (cachexia and loss of weight) signs of?

A

liver disease. May also be the result of gastrointestinal malignancy or alcoholic cirrhosis.

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18
Q

abdo: What is sun kissed pigmentation of the nipples, palmar creases, pressure areas and mouth a sign of?

A

(=Addisonian-type pigmentation). Sign of malabsorption

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19
Q

abdo: What is leuconychia/or - opacification of the nail bed except for a rim of pink nail bed at the top - a sign of?

A

hypoalbuminaemia as a result of chronic liver or other disease

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20
Q

abdo: What are Muehrcke’s lines (transverse white lines) a sign of?

A

hypoalbuminaemic states including cirrhosis.

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21
Q

abdo: What are blue lunulae a sign of?

A

Wilson’s disease (hepatolenticular degeneration): metabolic disorder = accumulation of copper in the brain

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22
Q

abdo: What is clubbing a sign of?

A

1/3 of patients with cirrhosis have clubbing.
inflammatory bowel disease.
coeliac disease - with longstanding nutrition depletion.

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23
Q

abdo: what is palmar erythema a sign of?

A

chronic liver disease.

also thyrotoxicosis, rheumatoid arthritis, polycythaemia, chronic febrile diseases or chronic leukaemia

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24
Q

What is dupuytren’s contracture a sign of?

A

alcoholism, or in some manual workers, often familial. Contracted palmar fascia contains abnormal amounts of xanthine.

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25
Q

What is hepatic flap (15 secs) a sign of?

A 
hepatic encephalopathy 
(can also occur in cardiac, respiratory, renal failure and in hypoglycaemia, hypokalaemia, hypomagnesaemia, barbiturate intoxication).
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26
Q

abdo: what might an apparent tremor/choreathetosis be a sign of?

A

Wilson’s disease

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27
Q

abdo: what might a fine resting tremor be a sign of?

A

alcoholism

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28
Q

abdo: What are ecchymoses (large bruises) on the arms a sign of?

A

clotting abnormalities e.g. from hepatocellular damage or obstructive jaundice

29
Q

abdo: What is Murphy’s sign?

A

cholestasis; on inspiration, palpate the gall bladder (mid clavicular line, 9th costal cartilage)

30
Q

abdo: What are petechiae? What are they caused by?

A

pinhead bruises over the arms.

  • chronic excessive alcohol consumption may lead to bone marrow depression causing thrombocytopenia
  • splenomegaly secondary to portal hypertension can cause hypersplenism, with resultant excessive destruction of platelets in the spleen
  • diffuse intravascular coagulation in severe liver disease
31
Q

abdo: What is muscle wasting a sign of?

A

late manifestation of malnutrition in alcoholic patients.

32
Q

abdo: What might cause proximal myopathy?

A

Alcohol

33
Q

abdo: What are scratch marks a sign of?

A

Obstructive or cholestatic jaundice (itchiness = pruritus)
= common primary presenting symptom of primary biliary cirrhosis
- current consensus on mechanism of itchiness is bile acid

34
Q

abdo: What are spider naevi a sign of?

A
  • cirrhosis, most frequently due to alcohol
    = central arteriole from which radiate numerous small vessels
  • range in size: largest at half a centimetre in diameter
  • distributed in SVC drainage areas: arms, neck and chest wall
  • occur transiently in viral hepatitis
  • can appear in 2-5th months of pregnancy, disappear a few days after delivery
35
Q

abdo: What is palmar erythema a sign of?

A

(caused by oestrogen excess) chronic liver disease

36
Q

abdo: differential diagnosis of spider naevi?

A

Campbell de Morgan spots: on abdomen and front of chest - do not blanch on pressure and are very common and benign
venous stars: can occur on the dorsum of the foot, legs, back and lower chest, occur due to elevated venous pressure, not obliterated by pressure
- blood flow is from the periphery to the centre
hereditary haemorrhagic telangiectasia: ? occasionally resemble spider naevi

37
Q

abdo: what is angular stomatitis, what is it a sign of?

A

inflammation of the corners of the mouth due to folate, iron or vitaminB6 or B12 deficiency

38
Q

abdo: What is cheilosis?

A

cracked and dry lips, due to folate deficiency

39
Q

abdo: What is acanthosis nigricans, what is it caused by?

A
  • Found in the axillae or nape of the neck. Brown-to-black velvety elevations of the epidermis due to confluent papillomas.
  • Rarely associated with gastrointestinal carcinoma (particularly of stomach), lymphoma, acromegaly - abnormal growth of the hands, feet and face caused by overproduction of growth hormone by the pituitary gland, diabetes mellitus, other endocrinopathies
40
Q

abdo: What are causes of localised lymphadenopathy of the axillary lymph nodes?

A

infections of the upper limb, sexually transmitted disease, abdominal or pelvic malignancy, immunisations

41
Q

abdo: What are causes of localised lymphadenopathy of the right supraclavicular lymph nodes?

A

malignancy from the chest or oesophagus

42
Q

abdo: What are causes of localised lymphadenopathy of the left supraclavicular lymph nodes?

A
  • in some countries, most common reason is tuberculosis - metastatic malignancy from the chest, abdomen (especially stomach - Troisier’s sign), pelvis e.g. lung cancer, gastric cancer, other gastrointestinal malignancy
43
Q

abdo: What is Troisier’s sign?

A

the presence of a large left supraclavicular node with carcinoma of the stomach

44
Q

abdo: What are the 5 groups of axillary lymph nodes to palpate?

A

central, lateral (above and lateral), pectoral (medial), infraclavicular, subscapular (most inferior)

45
Q

abdo: What is yellow sclera a sign of?

A

jaundice

46
Q

abdo: What is pale conjunctiva a sign of?

A

anaemia

47
Q

abdo: What are Bitot’s spots? What are they a sign of?

A

yellow keratinised areas of the sclera. = result of severe vitamin A deficiency due to malabsorption or malnutrition.

48
Q

abdo: What are Kayser-Fleischer rings a sign of?

A

Wilson’s disease. Due to deposits of excess copper in Descent’s membrane of the cornea. Wilson’s disease = a copper storage disease that causes cirrhosis and neurological disturbances.
- also appears in patients with cholestatic diseases.

49
Q

abdo: What is iritis a sign of?

A

inflammatory bowel disease

50
Q

abdo: What are xanthelasmata?

A

yellowish plaques in the subcutaneous tissues in the periorbital region and are due to deposits of lipids

  • may indicate protracted elevation of serum cholesterol
  • cholestasis, primary biliary cirrhosis
51
Q

abdo: What is black eye syndrome or periorbital purpura caused by?

A

following proctosigmoidoscopy: amyloidosis (related to X deficiency), extremely rare

52
Q

abdo: What causes parotid enlargement?

A
  • bilateral: alcoholism, mumps

- tender, warm, swollen partoid = parotiditis following acute illness or surgery

53
Q

abdo: What is the most common cause of a lump?

A
  • mixed parotid tumour (a pleomorphic adenoma)
54
Q

abdo: What might be the cause of a facial nerve palsy?

A

parotid carcinoma

55
Q

abdo: What might cause submandibular gland enlargement?

A

most often due to a calculus, chronic liver disease

56
Q

abdo: What is gum hypertrophy a sign of?

A

phenytoin, pregnancy, scurvy (vitamin C deficiency), gingivitis (e.g. from smoking, calculus, plaque), leukaemia (usually monocytic)

57
Q

abdo: What is pigmentation in the mouth a sign of?

A
  • heavy metals: lead or bismuth, iron
  • drugs: antimalarials, OCT
  • Addison’s disease
  • Peutz-Jeghers syndrome
  • malignant melanoma
58
Q

abdo: What might be the cause of (benign) mouth ulcers?

A 
loose-fitting false teeth
= 'aphthous stomatitis' 
- trauma
- drugs (gold, steroids)
- less common: Crohn's disease, coeliac disease, bacterial in syphilis, viral in herpes zoster and herpes simplex
59
Q

abdo: What might cause fetor?

A
  • decayed teeth
  • poor oral hygiene
  • fetor hepaticus (sweet smell): severe hepatocellular disease, may be due to methylmercaptans. If the smell fills the room, it indicates a precomatose condition in many cases.
  • ketosis (diabetic ketoacidosis results in excretion of ketones in exhaled air, causing a sickly sweet smell)
  • uraemia (fish breath: an ammoniacal odour)
  • alcohol
  • paraldehyde
  • putrid (due to anaerobic chest infections with large amounts of sputum)
  • cigarettes
60
Q

abdo: What is lingua nigra a sign of?

A

(black tongue) - from accumulation of keratins

e.g. bismuth compounds

61
Q

abdo: What is geographical tongue? What is it a sign of?

A

slowly changing red rings and lines on the surface of the tongue
not painful
- may be a sign of riboflavin / Vitamin B2 deficiency

62
Q

abdo: What is leukoplakia a sign of?

A

white-coloured thickening of mucosa of tongue and mouth = premalignant

  • ‘S’: smoking, spirits, sepsis, syphilis
  • can occur on the anus, vulva and larynx
63
Q

abdo: What is glossitis, specifically atrophic glossitis, caused by?

A
  • occurs as a result of nutritional deficiencies, commonly iron, folate, vitamin B group especially vitamin B12
  • common in alcoholics, rare carcinoid syndrome, elderly people
64
Q

abdo: What are creamy, white patches in the mouth that are removed only with great difficulty and leave a bleeding surface a sign of?

A

monilia, now known as candida albicans (fungal) infection

  • associated with immunosuppression or the use of broad-spectrum antibiotics which kill some normal flora
  • may also be caused by faulty oral hygiene, iron deficiency and diabetes mellitus
65
Q

abdo: What is telangiectasia of the lips caused by?

A

can be hereditary or secondary to e.g. Cushing’s syndrome

66
Q

abdo: What is gynaecomastia a sign of?

A

(enlargement of male breasts), sign of chronic liver disease or cirrhosis, particularly alcoholic cirrhosis, or chronic autoimmune hepatitis

  • can be uni or bilateral, breasts may be tender
  • can occur in alcoholics without liver disease because the alcohol damages Leydig cells of the testis
  • rarely caused by some drugs e.g. digoxin, cimetidine (H2 receptor antagonist)
67
Q

abdo: What is hair loss on the chest a sign of?

A

Addison’s disease

68
Q

abdo: What might the cause of abdominal distension be?

A

‘F’s ‘
- fat (gross obesity), fluid (ascites), foetus, flatus (gaseous distension due to bowel obstruction), faeces, ‘filthy’ big tumour (e.g. ovarian tumour or hydatid cyst), phantom pregnancy

69
Q

abdo: What causes prominent abdominal veins?

A
  • ‘caput medusae’ caused by severe portal hypertension, direction of flow from portal to umbilical veins which may become distended - so flow is away from the liver. Often seen in the epigastric region.
  • ## IVC obstruction: from a tumour or thrombosis but sometimes because of tense ascites

clinical skills (3 decks)

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