examination Flashcards
superficial lumps are most likely?
lipomas abcesses epidermal cysts and dermoid cysts
ddx for a lump in the anterior triangle of the neck
brachial cyst sinus fistula
carotid body tumour (chemodectoma)
carotid artery aneurysm
salivatory gland and lymphadenopathy
ddx for lump in the posterior triangle
lymphatic malformation, cervical rib, pharngeal pouch, subclavian aneurysm and lymphadenopathy
how do you tell if the lump in the neck is attached to the muscle?
ask the patient to nod their head against resistance
hard lump ddx
malignancy
rubbery lump
lymphoma or a chronic inflammatory (TB)
soft lump lymph node
acute inflammatory lymph nodes
fluctuant lumps
brachial cysts cystic hygrometer, paryngeal pouches, laryngoceles, cold abcess epidermal cysts, dermoid cyst
what should you also check for in a parotid swelling?
facial nerve
A lump that is tethered to the underlying muscle in the anterior triangle of the neck is a what? until proven otherwise?
squamous cell carcinoma metastasised to the lymph nodes until proven otherwise.
Pembertons sign
elevation of arms above the head results in venous congestion and plethora due to thoracic inlet obstruction by a retrosternal mass.
virchow node
supraclavicular node positive in oesophageal carcinoma
patient with dysphagia one exam 5 things
- CN bulbar palsy
- GI exam for malignancy
- neck mass goitre
- features of cREST syndrome
- koilonychia (iron deficiency anaemia) plummer vinson syndrome with esophageal webbing
tender cervical lymphadenopathy in a patient with cough
upper respiratory tract infection
sign of raised co2
asterisks
wasting of dorsal interossei
due to apical lung cancer due to T1 nerve root invasion.
causes of clubbing cardio
cardio infective endocarditis congenital cyanosis heart disease atrial myxoma axillary artery aneurysm brachial arterovenous fistula
resp cause of clubbing
pulmonary fibrosis
suppurative lung disease- abcess, empyema, CF, bronchiectasis
bronchial carcinoma, mesothelioma, TB
gastro causes of clubbing
IBD cirrhosis malabsorption= coeliac disease gastric lymphoma liver abcess liver or bowel ca
other causes of clubbing (not cardio, resp, or GI)
congenital clubbing
thyroid acropachy
cholesterol deposits on the back of the hand or bony prominences
xanthomata
cholesterol deposits around the eyelids
xanthelasmata
you are listening to a patient’s chest with COPD what are you expecting to hear?
reduced air entry, and prolonged expiratory phase
may have wheeze if exacerbated COPD
you are listening to a patient with asthma’s chest what are you expecting to hear?
polyphonic wheeze
you are listening to a patient with interstitial lung disease’s chest what are you expecting to hear?
late inspiratory fine crackles (heard best at the apex or the bases depending on the aetiology)
what are some signs of heart failure on exam
displaced apex beat (LVH)
third and fourth heart sound
crackles in both lung bases
raised JVP hepatolmegaly, peripheral oedema (ankles and sacrum)
what would you be looking for on examination if you wanted to rule out ankylosing spondylitis?
hands - mono-arthritis mostly tenderness or stiffness in the large joints
dactylitis inflammation of the entire digit (sausage digit) due to soft tissue oedema and tenosynovial and joint inflammation
progressive loss of spinal movement GALS examination
look for signs of sacroiliitis
question mark posture.
Schooners test asking the patient to touch the toes to test spine flexion.
look at the achilles’ tendon- achilles tendinitis and plantar fasciitis
bruising around the umbilicus or flank what sign is it? nad what does it indicate?
grey turners sign and it indicated in severe pancreatitis
How do you illicit murphy’s sign
palpate the abdomen underneath the right 9th costal cartilage apply pressure and ask the patient to take in a deep breath. Gallbladder will brush against the fingers and patient will arrest inspiration this is suggestive of inflamed gallbladder.
if in your differential is even a thought of pancreatitis what investigation would you look for?
serum amylase or lipase levels.
Prehn’s sign
relief from epididymitis when elevating the testes
Roving sign positive
when you palpate the left illiac fossa this results in greater degree in RIF pain than the left… acute appendicitis
Mcburney’s point
two thirds of the distance from the umbilicus laterally towards the anterior illiac spine.
patient with LIF pain that is writhing in pain
ureteric colic
phalen’s test
test to induce the symptoms of carpal tunnel syndrome in the patients that have it.
Tinel test
percussion over the median nerve to illicit nerve irritation in those with carpal tunnel syndrome
oligouria definition
reduced urine output
less than 400 ml/day
less than .5 ml/kg/hour
less than 30 ml/hr
what can cause bilateral crackles in the lung bases?
atelectasis or heart failure
when you are examining a groin lump what are you looking for?
where is the neck of the swelling? Is it superior and medial to the public tubercle? inguinal
Or is it inferior and lateral to the pubic tubercle? femoral
if the groin lump extends to the scrotum what do you think it is?
indirect hernia as opposed to direct.
Palpation of a groin lump what are the steps?
- determine the site
- size
- tenderness
- pulsation?
- solid or fluctuant
- is there a cough impulse
- is the lump reducible
How do you differentiate between a direct and indirect hernia clinically?
You reduce the hernia and place your finger at the level of the deep inguinal ring in order to preclude the space. The deep inguinal ring is at the midpoint of the inguinal ligament. Then you ask the patient the cough. If the hernia reappears then you know that the hernia was direct.
What is the scale used to grade limb weakness?
5 normal power 4 can move the limb against gravity and some resistance 3. can move limb against gravity 2. movement in a horizontal plane 1. flicker 0 no movement
hemiparesis definition
implies half the body paresis weakness
hemiplegia
half the body not able to move (plegia)
paraparesis
para (lower limb) paraseis (muscle weakness)
paraplegia
lower limb not able to move
quadriplegia
not able to move the upper or lower limbs.
What are trophi?
They are deposits of urate crystals that have a characteristic chalk like appearance when they break through the skin. they are found anywhere on the body, but mostly on joints and bones.
What are rheumatoid nodules?
subcutaneous nodules classically found on the elbows and ears. They are pathognomonic of rheum arthritis.
What are the nail signs of psoriasis
pitting, subungual hyperkeratosis and onycholysis
What are you looking for in suspected DVT
you measure 10 cm below the tibial tuberosity looking for a difference in circumference greater than 3 cm (measure three times)
What is also important to assess if you suspect DVT beside just measuring?
neurovascular status of the limb.
tenderness on active and passive movement.
What is the wells score?
scoring system to assess risk of the patient having a deep vein thrombosis entire leg swollen calf swollen greater than 3 cm pitting oedema on the effected side paralysed leg bed rest greater than 3 days tenderness in the deep veins collateral superficial veins (not varicose) active ca previous DVT (alternative diagnosis for DVT -2) If greater than 2 it is likely a DVT
What is the diagnostic approach for a DVT
if the wells score is less than 2
just D dimer if neg discharge
if less than 2 plus pos d-dimer than US required
if high risk and d dimer neg than Us req
if high risk and d dimer pos than 2 US req
what do you give as treatment for DVT
low molecular weight heparin
compression stocking if ABI greater than 0.9-1.3 worn 1 week after diagnosis worn for 2 years.
what are the features of compartment syndrome?
a tense, shiny swollen limb that is painful to passive movement and that has progressed to neurovascular compromise.
What is the pathology of compartment syndrome?
limbs has inflexible fascia separating the muscle groups. The inflammation therefore can cause increased pressure occluding the deep veins. This leads to a vicious cycle of increased swelling and therefore further occlusion leading to necrosis of the tissues of it is not surgically decompressed.
What is complication of compartment syndrome?
Volkmann’s contracture =- irreversible atrophy of the limb.
What is the treatment for compartment syndrome?
surgical decompression via fasciotomy.
Describe a fasciotomy procedure?
skin, subcutaneous tissue, and tight fascia surrounding the effected limb are divided and left open.
two longitudinal incisions
(anterior and lateral compartments
superficial and deep posterior compartments via medial incision)
management of cellulitis
FBC bacterail infection (neutrophillia)
antibiotics- cover strep and staph such as flucloxacillin
demarcation- pen for progression or getting better
elevation- reducing swelling
if suspect an allergic reaction topical steroids and oral antihistamines
What is a ruptured baker’s cyst
rupture of the synovial sac protruding from the knee in the popliteal fossa. the fluid can tract int he calf producing signs of a DVT. US can differentiate between the two.
Treatment of a bakers cyst
elevation
aspiration of the fluid
injection of corticosteriods
