Composite deck Flashcards
Aortic stenosis signs/severity
Narrow pulse pressure, anacrotic/plateau pulse
Afib
Pressure loaded apex beat (forceful, sustained) LV hypertrophy
Mid/Ejection systolic murmur.
Radiates to carotids
Louder expiration
Quieter isometric handgrip and valsalva
Quiet second heart sound
Signs severity
-Plateau pulse, Aortic thrill, Longer duration, Quiet second heart sound 4th Heart sound, LVF (RVF preterminal)
Tricuspid regurgitation signs
JVP= large v waves, elevated if RV failure
RV heave on palpation -
Pansystolic murmur, loudest at lower end of sternum on inspiration.
Quieter w valsava
Pulsatile, large and tender liver +/- ascites, oedema w pleural effusions
Pulmonary hypertension signs
Dominant a wave
Right ventricular impulse
palpable p2, Loud P2
Pulmonary regurgitation
Tricuspid regurgitation
ECG- p pulmonale- peaked p wave lead II
Aortic regurgitation signs/severity
Collapsing pulse
Volume loaded apex (forceful, not sustained)
Displaced apex
Diastolic murmur
Loudest over left lower sternal edge on full expiration
Signs Severity
-Collapsing pulse, wide pulse pressure, Longer decrescendo murmur, Third heart sound, Soft A2 (aortic component second heart sound), Austin flint murmur, diastolic rumble, LVFailure
Mitral regurgitation signs/severity
Volume loaded apex beat (forceful, not sustained)
Displaced apex
Soft S1 +/- split S2 +/- 3rd heart sound
Pansystolic murmur to apex.
Radiates to axilla
Louder w isometric handgrip
Quieter w valsalva
Signs severity
-Enlarged LV +/- LVF, Pulmonary HTN (late). Soft first heart sound +/- Third heart sound,-Small volume pulse
Mitral stenosis signs/severity
Tapping apex beat
Mid-Late diastolic murmur
Signs severity -small pulse pressure, -Early opening snap (raised LA pressure), -Longer duration of murmur, -Pulmonary HTN
HOCM signs
Pulse- sharp rising or bifid carotid impulse
JVP- prominent a wave
Double/triple impulse apex beat
Late systolic ejection murmur at left sternal edge, +/- pan systolic murmur at apex= MR +- fourth heart sound
Louder w Valsalva
Quieter w isometric handgrip Quieter w squatting
Mitral Valve prolapse signs
Late systolic click murmur
Louder w isometric handgrip
Louder w valsalva
more women not always with MR
A/W marfans, atrial septal defect
Murmur grade
Diastolic
1= barely audible 2= audible, soft 3= easily audible 4= loud
Systolic
1= barely audible 2= audible, soft 3= easily audible 4= easily audible w thrill 5= loud w thrill and barely steth to chest 6= loud w thrill, no steth
Heart Sounds
1= mitral tricuspid
2= aortic pulmonary
3= overload
4= stiff- not if afib
Mitral stenosis causes
Rheumatic, calcification, after MR repair, congenital
Mitral stenosis ECG findings
P mitrale in sinus. Bifid in lead II,
A fib = chronicity,
RAD
Mitral stenosis indications for surgery
SOBOE, <1cm
Mitral regurgitation causes
o Chronic= degenerative Dx, MVProlapse, rheumatic, papillary muscle (LVF, ischaemia), CT Dx (RA, ank spond), Congenital Acute= IE, MI, Surgery, trauma
Mitral regurgitation ECG findings
AFib
Right axis deviation
Mitral regurgitation indications for surgery
Chronic- NYHA 3-4 or LVF (EF<60% (>30%), end systolic dimension >40
Acute- haemodynamic compromise
Aortic Regurgitation Causes
Valvular- Rheumatic, congenital (bicuspid valve, VSD), seronegative arthropathy (esp AS)
Aortic root- Marfan’s, Aortitis, Dissecting aneurysm, old age
Acute -Valvular= IE, Aortic root= Marfan’s, HTN, dissecting aneurysm
Aortic Regurgitation indications for surgery + echo
Symptoms- SOBOE
Worsening LV function (Low EF)
Progressive LV dilatation (end systolic dimension >5cm, end diastolic >7)
Aortic Stenosis Causes
Degenerative calcified AS, rheumatic, calcified bicuspid
Aortic stenosis
Echo findings + indications for surgery
Echo- Severe- area<1cm, mean gradient >50, jet velocity >4
Surgery-
Symptoms- exertional angina, SOBOE, Exertional syncope (normal or exericse induced)
Other heart surgery
EF<50%
Tricuspid regurgitation causes
Functional- RV failure Rheumatic Infective endocarditis- IVDU Congenital- ebsteins anomaly Tricuspid valve prolapse RV papillary muscle infarction Trauma
HOCM consequences
Heart failure Arrhythmias Mitral regurgitation (systolic anterior motion of the mitral valve leaflets) Sudden cardiac death
HOCM ECG
LVH, lateral ST and T wave changes, deep q waves, conduction defects
ASD ECG
RAD + RBBB + RVH
Aortic stenosis ECG
LVH
Bundle branch block
axis devition
Aortic regurg ECG
LVH
LAD
UIP pattern
Basal, subpleural Reticulation and Honeycombing Traction bronchiectasis Minimal ground glass
NSIP pattern
Ground glass WITH reticulation + traction bronchiectasis Minimal honeycombing Still often basal predominant
UIP associations
IPF connective tissue diseases (primarily rheumatoid arthritis), drug toxicity, chronic hypersensitivity pneumonitis, asbestosis
NSIP associations
connective tissue disease which includes systemic sclerosis, polymyositis/dermatomyositis, rheumatoid arthritis, and Sjogren syndrome.
Causes upper lobe fibrosis
Silicosis, sarcoidosis coal workers pneumoconiosis Histiocytosis Ank Spond ABPA Radiotherapy TB
Causes lower lobe fibrosis
RA Asbestosis Sceroderma Cryptogenic (IPF) Drugs- MTX, amiodarone, bleomycin, busulfan, hydralazine, nitrofurantoin
Bronchiectasis causes
Childhood infections- pertussis, measles, TB
Bronchial obstruction- foreign body, chronic aspiration, endobronchial tumour, LNs (TB, sarcoid, Ca), granuloma (TB, sarcoid)
Fibrosis- long standing pulmonary fibrosis, fibrosis complicating TB, sarcoid, pneumonia
Clearance defects- CF, kartageners
Immunodeficiency- AIDs, hypogammaglobulinaemia
ABPA
AI disease- RA, sjogrens, IBD
Congenital anatomical defects
Idiopathic
ILD associations
- IPF
- Rheumatological diseases- RA, scleroderma, SLE, myositis, sjogrens, mixed CTDx, AS, Psoriasis
- Vasculitis- PAN, EGPA, GPA, goodpastures
- Eosinophilic lung disease- drugs (nitrofurantoin, sulphasalazine), aspergillosis
- Inhaled agents- allergic, asbestosis, silicosis, beryliosis
- Other resp Dx- sarcoid, TB
- Drugs- amiodarone, nitrofurantoin, busulphan, bleomycin, gold, MTX
- Radiation
- Other- NF, tuberous sclerosis, LAM
Lights criteria effusions–> exudate
- Pleural:serum protein>0.5*
- Pleural:serum LDH>0.6*
- Pleural LDH >2/3 ULN serum*
-
Exudate- high protein (>30)
- Cancer, CTDx, infection, infarction, subdiaphragmatic (pancreas, liver), drugs, asbestosis, sarcoidosis, chylothorax
-
Transudate- normal protein (<30)
- CCF, pericarditis, hypoalbuminaemia, nephrotic syndrome, cirrhosis, PD, uraemia, hypothyroidism
Obstruction on spirometry
-
Lung function tests- airflow obstruction
- FEV1<80% predicted
- FEV1/FVC <70%
Pneumoectomy/lobectomy indications
Lobectomy
- Indications- bronchiectasis, cancer, solitary nodule, CF, TB, abscess
- Pneumoectomy*
- Indications- bronchiectasis, cancer, TB
Splenomegaly causes
Massive- CML, myelofibrosis, lymphoma, hairy cell leukaemia, malaria
Moderate- portal HTN, leukaemia (chronic or acute), thalassaemia, storage diseases
Mild- other myeloproliferative Dx (PRV ET), haemolytic anaemia, infection (EBV, hepatitis, IE), CT Dx or vasculitis (RA, SLE, PAN), infiltration (amyloidosis, sarcoidosis)
Hepatomegaly causes
Massive= mets, ETOH, myeloproliferative Dx, RHF, HCC
Moderate= haemochromatosis, haem(CML, lymphoma), fatty liver (obesity, DM, toxins)
Mild (>15cm)= hepatitis (viral, drugs), cirrhosis, biliary obstruction, granulomatous disorders, hydatid disease, amyloidosis/other infiltrative Dx, HIV, ischaemia
Causes hepatosplenomegaly
Chronic Liver Dx w portal HTN
Haem Dx (MPF, lymphoma, leukaemia, pernicious anaemia, sickle cell anaemia)
Infection (acute viral hepatitis, EBV, CMV)
Infiltration (amyloidosis, sarcoidosis)
CT Dx- SLE
Acromegaly
thyrotoxicosis
Portal HTN signs
Varices- PR exam malena, anaemia
Ascites
Caput medusae
Splenomegaly
Thrombocytopaenia
Signs Chronic Liver Disease
Nail clubbing
Palmar erythema
Spider nevi
Bruising
Gynaecomastia
Feminising hair distribution
Testicular atrophy
Gupuytrens, large parotids
Signs Chronic Liver Disease Decompensation
Encephalopathy- confusion, drowsiness, asterixis,
Jaundice
Ascites +/- SBP
Variceal bleed
Signs Chronic Liver Disease Severity= Childs Pugh Score
Albumin
Bilirubin
Coagulopathy
Distension (ascites)
Encephalopathy
Spleen vs Kidney
Spleen no palpable upper border
Spleen has notch
Spleen moves inferomedially on respiration
No resonance over splenic mass
Spleen not ballotable
Friction rub may be heard over spleen
Causes goitre
Idiopathic
Puberty, pregnancy, postpartum
Graves disease
Thyroiditis- hashimotos, subacute (Tender), chronic fibrosing (riedel’s)
Iodine deficiency
Goitrogens- iodine excess, drugs (lithium etc)
Inherited disorders/inborn errors
Ank Spond XR findings
SIJ - erosions, ankylosis, juxtaarticular osteosclerosis
Lumbar spine
- Loss of lordosis
- Squaring of vertebrae
- Syndesmophytes- thoracolumbar region
- Bamboo spine (bony bridging of vertebrae) and osteoporosis
- Apophyseal joint fusion
Serology for Rheum/CTDx
SLE- ANA, DsDNA, Anti smith, complement
RA- RF, anti CCP
SSc- ACA (limited- pulm HTN, fibrosis), Scl70 (Diffuse- fibrosis). RNA pol III
RA pattern on XR
Erosions Soft Tissue Swellings osteoporosis- initially juxta articular Joint space narrowing PIP, MCP, ulnar styloid NO DIP Symmetric Later: Subchondral cyst subluxation
OA pattern on XR
Joint space narrowing (asymmetric) Sclerosis at joint margins Osteophytes Joint erosions subchondral cysts
PsA pattern on XR
Enthesitis marginal bone erosions pencil in cup deformities bone proliferation periostitis- new bone layer arthritis mutlians
Marfans
Cardiovascular exam(Aortic root dilatation and Aortic regurgitation) PLUS Hands and arms- arachnodactyly (spider fingers), joint hypermobility, long thin limbs. Ask for arm span and height (will exceed) WRIST AND THUMB SIGN Face- long and narrow face. Eyes- Lens dislocation or replacement. Blue sclera. Mouth- high arched palate Chest- pectus carinatum or excavatum Back- kyphoscoliosis and hypermobility Skin- striae
Polycystic Kidneys Exam
Abdo exam- massive kidneys +/- liver and spleen Blood pressure Urinalysis – blood (haemorrhage), protein Evidence anaemia (CKD) or polycythaemia (excess EPO) Hepatic cysts or splenic cysts
Haemochromatosis Exam
As per GI exam PLUS Bronze pigmentation Arthropathy- typically degenerative arthritis of MCP joints of index and middle fingers. Pseudogout may occur Testicular atrophy due to iron deposition to the pituitary gland Dilated cardiomyopathy Glycosuria due to DM
Cushings Exam
Observation- front, back, sides -Central obesity, thin limbs (peripheral sparing) -Skin bruising and atrophy -Pigmentation extensor areas- ectopic ACTH secreting tumour (Rare) or bilateral adrenalectomy with ACTH secretin g pituitary adenoma -Poor wound healing Arms -Purple striae proximally -Proximal myopathy Face -Plethora, hirsuitism, acne, telangectasia -Moon shape -Visual fields (pituitary tumour), fundi (atrophy, papilloedema, signs of HTN and DM) -Mouth-Thrush Neck -Supraclavicular fat pads, acanthosis nigricans Back -Buffalo hump (interscapular fat pad) -Kyphoscoliosis (osteoporosis) -Tenderness of vertebrae (osteoporotic fractures) Legs -Squat (proximal myopathy) -Striae (thighs) -Bruising, oedema Mental state -Depression -Psychosis -Irritability Abdomen -Purple striae -Adrenal masses, adrenalectomy scars -Liver (tumoru deposits) Other -Urinalysis (glycosuria, evidence renals tone disease) -Blood pressure (hypertension) -Signs of ectopic tumour (e.g. lung small cell carcinoma or carcinoid)- rare
Acromegaly exam
Diagnostic facies- Prominent supraorbital ridge, broad nose, acne, large lips, overbite, prognathism, tongue enlargement, and coarsening features Hands -Spade like, OA changes -Phalens- carpel tunnel Arms -Ulnar nerve thickening at elbow -Proximal myopathy Axillae -Skin tags -Acanthosis nigricans -Greasy skin Face -Frontal bossing- large supraorbital ridge -Hirsuitism -Acne -Macroglossia -Prognathism- enlargement lower jaw -Splaying of teeth -Hoarseness of voice/deep/husky/resonant Eyes -Visual fields- esp bitemporal hemianopia -Cranial nerves 4. 5. 6 -Fundi- optic atrophy, papilloedema, angioid streaks +/- diabetic/hypertensive changes Neck -Thyroid gland- diffuse or nodular goitre Heart- Cardiac failure Abdomen- Organomegaly Lower limbs -Osteoarthritis, pseudogout -Entrapment neuropathy- foot drop - Heel pad thickening Other Urinalysis- glycosuria Rectal examination Colonic polyps Blood pressure- hypertension Sleep apnoea Ask for photographs Evidence activity -Skin tag number -Excessive sweating -Presence of glycosuria -Increasing visual field loss or development of cranial nerve palsies of 3, 4, 6 and 5 -Enlarging goitre -Hypertension -Symptoms of headache -Increasing ring size, shoe size or dentures
Addisons Exam
Observation - Pigmentation- esp palmar creases, elbows, gums, buccal mucosa, genital areas and scars. Vitiligo due to AI Dx associations. - Rarely ear lobe calcification Blood pressure - Lying+standing Other - Urinalysis- glucosuria- DM A/W addisons
Diabetes Exam
Observation -Weight- obesity -cushings, acromegaly -Pigmentation- haemochromatosis etc Legs -Skin- Diabetic dermopathy- small, rounded plaques with raised borders lying linearly over shins -Hair loss, skin atrophy -Fat-Atrophy or hypertrophy -Injection sites -Quadriceps wasting- femoral nerve mononeuritis (aka diabetic amyotrophy Feet -Joint destruction- charcots foot -Ulcers -Capillary return -Peripheral pulses ==Femoral PLUS auscultate for bruit ==Popliteal ==Posterior tibial ==Dorsalis pedis -Oedema Neurological Ax -Proximal muscle power -Reflexes -Dorsal column loss- diabetic pseudotabes Upper limbs -Blood pressure and pulse- lying and standing Eyes -Visual acuity -Eye movements- Third nerve palsy- pupillary sparing (vs compressive lesions) -Fundi- Diabetic retinopathy Mouth -Candida Abdomen -Hepatomegaly due to fatty infiltration Urinalysis- glycosuria, proteinuria Weight
Hypopituitary Exam
Observation -Short stature if GH failure before growth complete -Pale skin -No 2 sex characteristics if gonadotrophin failure pre puberty -Reduced body hair, including absence of axillary hair -Increased abdominal fat -gynaecomastia Face -Fine skin wrinkles around eye and mouth- growth hormone deficiency -Hypophysectomy scar- forehead near inner canthus of eye -Facial hair over chin area Eyes -Signs pituitary tumour o Visual fields (esp bitemporal hemianopia) o Fundi (optic atrophy) o Cranial nerves 3, 4, 6 and first division 5 Genitals -Loss of pubic hair -Treticular atrophy Neurology -Slowed ankle jerks hypothyroidism Blood pressure -Postural insufficiency with ACTH deficiency
Hypertension Exam
Observe- Cushings? Acromegaly? Polycythaemia? Uraemia? BP- both arms, lying/standing, legs if young Pulse- radio-radial, radiofemoral Hands- Vasculitic changes Face- Conjunctival injection (polycythaemia) Fundi-Hypertensive changes- silver wiring, haemorrhages, exudates +/- papilloedema Cardiovascular system LV failure, coarctation of aorta, 4th heart sound may be present in severe HTN. Abdomen -Renal masses + bruits, adrenal masses, abdominal aneurysm Ask for: UA, consider neurological exam for deficits due to HTN caused stroke
Ankylosing Spondylitis
Undress to undies and stand Look (general) - Rashes, abdominal scars, iritis/uveitis, walking aids - nails- psoriatic changes Look (back) - deformity (kyphosis, loss of lumbar lordosis), scars Move - Flexion- finger to floor distance - Extension - Lateral flexion Schobers test - L5 (iliac rests) 10cm above 5cm below- touch toes, increase by >5cm Occiput to wall distance Sit down on edge bed Move - L/T spine and C spine rotation Palpate spine + paraspinal Palpate SIJ + spring hips (Activity) Achilles tendon, plantar fasciitis Other - Chest expansion - Ausc lungs (apical fibrosis), heart (AR, MVP) - Abdo exam - LL Neuro exam - UA
Cardio Exam
Expose + Position Wash Hands Inspect- ?marfans, dyspnoea Hands- clubbing, signs IE, cyanosis, xanthomata, anaemia Pulse + radio-radial BP- <40, >70 Eyes- arcus, pallor, xanthelasma Mouth- palate, dentition, cyanosis Neck- JVP, carotids CHEST Obs- scar, deformity, device Palpate- apex, heaves/thrills Ausc x 4 (start bell at mitral area) Murmur- insp/exp, carotid/axilla Positions(left lateral, sit up full expiration)- palpate, ausc Manouvres- valsalva, isometric Complete Back- percuss, auscultate, oedema Abdo- Liver Legs- Oedema Proceed - Peripheral pulses, - UA, temp for IE - Fundoscopy HTN IE Ask ECG, CXR, Echo
Respiratory Examination
Expose + Position Wash hands Sputum Mug Voice + Cough Hands- clubbing, cyanosis, staining, wasting, anaemia Finger Abduction HPOA Rep Rate + Pulse Asterixis Pembertons Forced Expiratory TIme Eyes- horners, anaemia Mouth-cyanosis Trachea- position, tug POSTERIOR CHEST Obs- scar, deformity, RTx Palpate- supraclav + cervical LNs, oedema, expansion (inc observe supraclav- upper lobe), fremitus (back + axilla) Percuss Ausc- BS + resonance ANTERIOR CHEST Obs Palpate- axilla LNs, expansion, fremitus Percuss Ausc- BS + resonance CV exam Reposition JVP Apex beat Auscultate Liver Peripheral oedema Proceed - Temperature chart - Fundi - CO2 If ?Ca or effusion- examine breasts, abdomen, rectum, LNs
Gastrointestinal Examination
Expose + Position Wash hands Observe- pigment, xanthomata Orientation/mental state Hands- clubbing, leukonychia, palmar erythema, duyuytrens, arthropathy Asterixis Arms- naevi, bruise, wasting, scratches Face Eyes-jaundice, anaemia, iritis, kayser-fleischer Parotids Mouth/lips/tongue/gums- stomatitis, leukoplakia, ulcer, pigment, gingivitis, gum hypertrophy, glossitis LNs- Cervical + axillary + supraclav Chest- gynaecomastia, hair, naevi Abdo Obs- scar, distension, veins, striae, bruising, masses. Deep in and out breath Feel - light, deep - Liver + percuss - Spleen + percuss - Kidneys + ballot Ascites Ausc - kidneys, spleen, liver, bowels, portal venous hum Groin- LNs, hernias Legs- bruise, oedema, neuro signs Proceed - rectal exam - UA - BP - CV exam - Neuro - Temp chart
Neck Exam
Expose + position Wash hands Voice Pembertons Observe neck front + side (scars, swelling, veins) Swallow POSTERIOR palpation- size, shape, consistency, borders (esp lower), mobility, nodules, pain LNs- cervical, supraclavicular ANTERIOR palpation Carotid pulse + pulse rate Trachea position SCM function Manubrium percussion Auscultate- thyroid, carotids PROCEED Hyperthyroid- - Eyes- exopthalmos (sclera below cornea) lid retraction (sclera above), conjunctival chemosis, Proptosis, Eye movements (lid lag, ophthalmoplegia) - Arms- tremor, nails (onycholysis, clubbing), palmar erythema, pulse rate + rhythm + collapsing, proximal strength, tap reflexes Legs- Pretibial myxoedema, vitiligo, proximal strength, reflexes Other- cardiac exam, abdo exam, If thyroidectomy scar- Chvosteks (facial nerve) Trousseaus (BP cuff) Hypothyroid -Hands- cyanosis, skin cold and dry, pallor palm - Arms- pulse, tinnel/phanels, delayed relaxation biceps jerk, proximal weakness - Eyes- oedema, eyebrow hairloss, xanthomata - Hair- alopecia - Sensorineural deafness - Legs- delayed ankle jerk, peripheral neuropathy, proximal weakness, cerebellar syndrome - Chest- pleural/pericardial effusions
Haem Exam
Position, expose, wash hands Observe- pigment, jaundice Hands- nails, palm pallor Arms- bruising, scratch marks, vasculitis LNs- epitrochlear, axillary Eyes- jaundice, pallor, injected sclera polycythaemia, haemorrhage Mouth- gum hypertrophy, ulcers, candida, glossitis, stomatitis, Tonsils + adenoids POSTERIOR EXAM LNs- Cervical, supraclavicular Spine tenderness Hip Tenderness Abdominal Exam Inguinal nodes Legs- ulcers, sensation
Hand Exam
Position, expose, wash hands Observe-cushingoid, washes, aids, other joints Eyes- iritis/scleritis Elbows/arm movements- rash, nodules SCREEN- open and close hands (tendon ruptures, fixed flexion deformities) LOOK FEEL MOVE General- scars, redness, pain, swelling, deformity, synovitis, ROM —DORSAL Skin atrophy/bruise, rashes, vasculitis, sclerodactyly, sausi fingers, muscle wasting Nails- psoriatic changes Wrist+ ulnar styloid pain MCs- MCPJs- (ulnar deviation, volar subluxation), PIPJ/DIPJ- (swan neck, boutonniere, z shape thumb)(bouchards PIP, heberdens DIP) —PALMAR Scars, erythema, muscle wasting, palmar tendon crepitus Special tests - Phalens Tinnels Function - Undoing button - Key grip - Grip strength - Opposition strength Neuro - Median nerve- sensation thumb, power thumb abduction - Ulnar nerve- sensation pinky finger, power finger abduction Proceed- other joints, further neuro ax, rash ax, lungs, heart, spleen ask- XR, serological tests
Cardio Exam
Expose + Position Wash Hands Inspect- ?marfans, dyspnoea Hands- clubbing, signs IE, cyanosis, xanthomata, anaemia Pulse + radio-radial BP- <40, >70 Eyes- arcus, pallor, xanthelasma Mouth- palate, dentition, cyanosis Neck- JVP, carotids CHEST Obs- scar, deformity, device Palpate- apex, heaves/thrills Ausc x 4 (start bell at mitral area) Murmur- insp/exp, carotid/axilla Positions(left lateral, sit up full expiration)- palpate, ausc Manouvres- valsalva, isometric Complete Back- percuss, auscultate, oedema Abdo- Liver Legs- Oedema Proceed - Peripheral pulses, - UA, temp for IE - Fundoscopy HTN IE Ask ECG, CXR, Echo
Hand Exam
Position, expose, wash hands Observe-cushingoid, washes, aids, other joints Eyes- iritis/scleritis Elbows/arm movements- rash, nodules SCREEN- open and close hands (tendon ruptures, fixed flexion deformities) LOOK FEEL MOVE General- scars, redness, pain, swelling, deformity, synovitis, ROM —DORSAL Skin atrophy/bruise, rashes, vasculitis, sclerodactyly, sausi fingers, muscle wasting Nails- psoriatic changes Wrist+ ulnar styloid pain MCs- MCPJs- (ulnar deviation, volar subluxation), PIPJ/DIPJ- (swan neck, boutonniere, z shape thumb)(bouchards PIP, heberdens DIP) —PALMAR Scars, erythema, muscle wasting, palmar tendon crepitus Special tests - Phalens Tinnels Function - Undoing button - Key grip - Grip strength - Opposition strength Neuro - Median nerve- sensation thumb, power thumb abduction - Ulnar nerve- sensation pinky finger, power finger abduction Proceed- other joints, further neuro ax, rash ax, lungs, heart, spleen ask- XR, serological tests
Haem Exam
Position, expose, wash hands Observe- pigment, jaundice Hands- nails, palm pallor Arms- bruising, scratch marks, vasculitis LNs- epitrochlear, axillary Eyes- jaundice, pallor, injected sclera polycythaemia, haemorrhage Mouth- gum hypertrophy, ulcers, candida, glossitis, stomatitis, Tonsils + adenoids POSTERIOR EXAM LNs- Cervical, supraclavicular Spine tenderness Hip Tenderness Abdominal Exam Inguinal nodes Legs- ulcers, sensation
Neck Exam
Expose + position Wash hands Voice Pembertons Observe neck front + side (scars, swelling, veins) Swallow POSTERIOR palpation- size, shape, consistency, borders (esp lower), mobility, nodules, pain LNs- cervical, supraclavicular ANTERIOR palpation Carotid pulse + pulse rate Trachea position SCM function Manubrium percussion Auscultate- thyroid, carotids PROCEED Hyperthyroid- - Eyes- exopthalmos (sclera below cornea) lid retraction (sclera above), conjunctival chemosis, Proptosis, Eye movements (lid lag, ophthalmoplegia) - Arms- tremor, nails (onycholysis, clubbing), palmar erythema, pulse rate + rhythm + collapsing, proximal strength, tap reflexes Legs- Pretibial myxoedema, vitiligo, proximal strength, reflexes Other- cardiac exam, abdo exam, If thyroidectomy scar- Chvosteks (facial nerve) Trousseaus (BP cuff) Hypothyroid -Hands- cyanosis, skin cold and dry, pallor palm - Arms- pulse, tinnel/phanels, delayed relaxation biceps jerk, proximal weakness - Eyes- oedema, eyebrow hairloss, xanthomata - Hair- alopecia - Sensorineural deafness - Legs- delayed ankle jerk, peripheral neuropathy, proximal weakness, cerebellar syndrome - Chest- pleural/pericardial effusions
Gastrointestinal Examination
Expose + Position Wash hands Observe- pigment, xanthomata Orientation/mental state Hands- clubbing, leukonychia, palmar erythema, duyuytrens, arthropathy Asterixis Arms- naevi, bruise, wasting, scratches Face Eyes-jaundice, anaemia, iritis, kayser-fleischer Parotids Mouth/lips/tongue/gums- stomatitis, leukoplakia, ulcer, pigment, gingivitis, gum hypertrophy, glossitis LNs- Cervical + axillary + supraclav Chest- gynaecomastia, hair, naevi Abdo Obs- scar, distension, veins, striae, bruising, masses. Deep in and out breath Feel - light, deep - Liver + percuss - Spleen + percuss - Kidneys + ballot Ascites Ausc - kidneys, spleen, liver, bowels, portal venous hum Groin- LNs, hernias Legs- bruise, oedema, neuro signs Proceed - rectal exam - UA - BP - CV exam - Neuro - Temp chart
Respiratory Examination
Expose + Position Wash hands Sputum Mug Voice + Cough Hands- clubbing, cyanosis, staining, wasting, anaemia Finger Abduction HPOA Rep Rate + Pulse Asterixis Pembertons Forced Expiratory TIme Eyes- horners, anaemia Mouth-cyanosis Trachea- position, tug POSTERIOR CHEST Obs- scar, deformity, RTx Palpate- supraclav + cervical LNs, oedema, expansion (inc observe supraclav- upper lobe), fremitus (back + axilla) Percuss Ausc- BS + resonance ANTERIOR CHEST Obs Palpate- axilla LNs, expansion, fremitus Percuss Ausc- BS + resonance CV exam Reposition JVP Apex beat Auscultate Liver Peripheral oedema Proceed - Temperature chart - Fundi - CO2 If ?Ca or effusion- examine breasts, abdomen, rectum, LNs
Cardio Exam
Expose + Position Wash Hands Inspect- ?marfans, dyspnoea Hands- clubbing, signs IE, cyanosis, xanthomata, anaemia Pulse + radio-radial BP- <40, >70 Eyes- arcus, pallor, xanthelasma Mouth- palate, dentition, cyanosis Neck- JVP, carotids CHEST Obs- scar, deformity, device Palpate- apex, heaves/thrills Ausc x 4 (start bell at mitral area) Murmur- insp/exp, carotid/axilla Positions(left lateral, sit up full expiration)- palpate, ausc Manouvres- valsalva, isometric Complete Back- percuss, auscultate, oedema Abdo- Liver Legs- Oedema Proceed - Peripheral pulses, - UA, temp for IE - Fundoscopy HTN IE Ask ECG, CXR, Echo
