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MRCS part B- JMB > Examinations > Flashcards

Examinations Flashcards

1
Q

6Ss

A

Site, size, shape, symmetry, skin overlying, scares

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2
Q

Lump palpation mnemonic?

A

SEC FFP TR

Surface
Edges
Consistency
Flutuance
Fixation
Pulsatile/Expansile
Transiluminable
Reducible
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3
Q

Lumps and Bumps exam?

A 
Start- wash hands , introduce, expose
Inspection- 6Ss
Pain
Temp
Palpation- SEC FFP TR
Auscultate- if appropriate
Percuss- retrosternal goitre
Complete- LNs, NVI, Other examinations, Cosmetic and quality of life
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4
Q

How to examine ulcers?

A 
BEDS!
Base- sloughy vs granulation tissue
Edges- sloping/cut out
Discharge- serous, serosanginous, purulent
Structures visible?
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5
Q

DDx for a lump?

A

Cutaneous- Benign (AKs, Naevi, Campbell de Morgan spots, Seb Ks, Dematomfibrosis, Keratocanthoma
Malignant- BCC, SqCC, melanoma

Subcutaneous
Fat- lipoma
Arterial- aneurysm
Venous- varicosity
Nerves- Neuroma
LNs
Muscle- leiomyoma/leimyosarcoma
Bone- sarcoma/osteoma
Ganglion/Organomegaly/Hernia
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6
Q

What is an Actinic Keratosis?

A

Most common type of pre malignant skin cancer- Pre SqCC
Display hyperkeratosis and acanthosis (thickening of prickle cell layer) and dysplasia
Sun exposed area
Can cryo off/chemo cream (5-florouracil)
Srugery- cry, cautery, excisional biospy

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7
Q

Campbell de Morgan spots?

A

Cherry haemangiomas- proliferation of dilated venules

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8
Q

Dermatofibroma?

A

Benign neoplasm of dermal fibroblasts
Dimple sign
At site of previous trauma

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9
Q

Furnucle vs Carbuncles?

A

Furnucle is an infected hair follicle- Stahp A
Carbuncle is a collection of furnucles
Seen in diabetics
Back of necks

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10
Q

What is a Keratocanthoma

A

Benign overgrowth of hair follicles with a central keratin plug
Enlarge in weeks, static for months then disappear
Difficult to differentiate between these and SqCC
Quite often excisional biopsy for diagnostic purposes

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11
Q

What is a naevus?

A

Benign proliferation of normal constituents of cells of the skin
Melanocytic Naevi
Vascular naevi- strawberry
Epidermal naevi
Connective tissue- Shagreen patches- Ash leaf lesions- Tuberous sclerosis

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12
Q

Seborrhoeic Keratosis?

A

Benign of overgrowth of epidermis
Hyperkeratosis, acanthosis, hyperplasia
Stuck on skin warty appearance

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13
Q

What are neurofibromas?

A

Benign hamartoma of the peripheral schwann cells
Can lead to altered sensation and pressure symptoms
Type 1- >6 cafe au lait spots + multiple cutaenous neurofibromas

Type 2- Bilateral acoustic neuromas
CN Schwanomas
Intracranial meningioma

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14
Q

Sebaceous cyst?

A

Abnormal membrane lined sac of epithelial cells containing a caseous substance
Central punctum

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15
Q

Treatment of ulcers

A

Investigate- Arterial vs venous, malignant/infective?
Conservative- Dressings, elevation, compression stockings, podiatry and foot wear
Medical- Abx, treat underlying cause
Surgical- Varicose vein surgery, Surgical excision, skin graft

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16
Q

Describe a thyroid exam?

A

Intro- expose
Inspect- Lumps- 6S, Swallow with water and sticking tongue out
Thyroid status- hands, eyes, pretibial myoxedema, hair/face/weight
Palpate (from behind)- SEC FFP TR- good then bad side
Feel below lump- retrosternal extension
Swallow water, stick tongue out
Trachea central?
LNs

Auscultate- bruits- graves
Percuss- sternum
Ankle reflexes
Complete
Vocal cord inspection- fibre optic nasoendoscopy +- FNA
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17
Q

Questions in a thyroid Hx?

A

Swallowing difficulties
Breathing difficulties
Hoarse voice!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Hot/cold
Palpitations/bradycardia
Tired/agitated
Depression/Anxiety
Sweating
D vs C
Menorrhagia vs oligomenorrhea

Lymphadenopathy
Weight loss/gain
Meds/Operations
Autoimmune associations- DM, Coeliac, pernicious anaemia

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18
Q

Parotid examination?

A 
Intro
Inspect- GSs, other lumps, CN7 exam, Oral cavity
Palpate- SEC FFP TR
Inside oral cavity
Palpate Stensons duct
Milk the duct
LNs
Contra L side
Complete- Taste sensation change on ant 2/3 of tongue
Full ENT exam
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19
Q

Submandibular Gland Exam?

A

Intro
Inspect- 6Ss, marginal mandibular nerve, Lingual nerve, CNXII, oral cavity
Palpate- SEC FFP TR, Bimanual, Wharton’s duct, LNs, ContraL side
Complete- ENT exam

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20
Q

What is the embryology of the thyroid gland?

A

1st endocrine organ to develop at Day 24- descent continue to week 10
Develops from foramen caecum- between 1st and 2nd pocuh
Descends via the thyroglossal duct
Comes to lie over 2nd to 4th tracheal rings

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21
Q

Complications of thryoid development?

A

Lingual thyroid- remnant at foramen caecum

Thyroglossal cysts

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22
Q

Investigation of thyroid Lump?

A 
Hx and exam
Bed side tests
Bloods- Standard + TFTs and autoAbs + calcitonin
USS +- FNA
Core biopsy
CT/MR
Hemithyroidectomy
Radioisotope scan- Hot nodules unlikely to be malignant
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23
Q

DDx of a thyroid lump?

A

Nodular- solitary nodule (80% adenomas, 10% cysts/10%cancer)

Diffuse- Iodine deficiency, graves, hashimotos, multinodular, lymphoma

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24
Q

Management of benign thyroid swellings? Indications for surgical treatment?

A

Hyper vs hypothyroid
C- iodine supplementation
M- hyper- carbimazole + propanolol
Hypo- levothyroxine

S- hyper- lobectomy/total

Indications- Diagnostic purposes, compressive symptoms, refractory to medical treatment, cosmetic

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25
Q

Types of thyroid cancer and surgical management

A

Papillary- 70%- in kids, lymphatic spread (90% have mets at Px), <1cm hemi + thyroid suppression, >1cm total + level 6 neck dissection + radioiodine ablation

Follicular- 20%- 50 yo, Haematogenous spread, difficult to differentiate from adenoma- therefore hemithyroidectomy, if cancer for total + level 6 + radioiodine ablation therapy

Medullary Ca- 5%- Parafollicular C cells, calcitonin producing- MEN 2 association!, Total thyroidectomy + level 6 neck dissection + F/U calcitonin for lifelong

Anaplastic- <5%, elderly, worse prognosis- 1 year, direct spread. Surgery indicated for debulking +- chemo/radio

Lymphoma

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26
Q

Multiple Endocrine Neoplasia types?

A

MEN 1- Pituitary adenoma, primary hyperparathyroidism, pancreatic islet cell tumour
MEN2a- Phaeochromocytoma, Medullary thyroid Ca, Primary hyperPTH
MEN 2b- Phaeochromcytoma, medullary thyroid ca, marfanoid habitus, neuromas

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27
Q

Neck lump DDx?

A

Standards- skin/subcutaneous lesions
Lymphadenopathy
Anterior triangle- congential- thyroglossal cysts
Acquired- thyroid swellings, carotid artery aneurysms, carotid body tumours, pharyngeal pouches, parotid/submandibular swellings, BRANCHIAL Cyst- failure of obliteration of branchial arches- young adults

Posterior triangle- Congenital- cystic hygromas-lymphangioma (lymphatic system blockage)
Acquried- lipoma, subclavian artery aneurysm, cervical ribs

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28
Q

Lymph node levels?

A 
Level 1- submental/submandibular
Level 2- upper 1/3 of IJV
Level 3- middle 1/3 of IJV
Level 4- Lower 1/3 of IJV
Level 5- Posterior triangle
Level 6- pretracheal/prethyroid
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29
Q

What is a radical neck dissection?

A

Removal of levels 1-5 +- 6

+- removal of accessory nerve/SCM/IJV

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30
Q

What forms the EJV?

A

Retromandibular vein + post auricular

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31
Q

What forms the IJV?

A

Pertrosal sinus

Lingual/pharyngeal, sup and middle thyroid and facial vein drain into it

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32
Q

What forms the anterior jugular vein?

A

Drains laryngeal veins
Some small thyroid veins

Ends up in EJV/subclavian vein

Variable in nature

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33
Q

How to investigate a parotid lump?

A

Hx and exam
Bloods- FBC, UEs, CRP, LFTs, Ca, Coag, RF and autoAbs- sjorgrens- anti Ro/La
USS +- FNA
Sialogram- anatomy of duct and can be theraputic

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34
Q

DDx of a parotid gland swelling?

A

Infective- viral- mumps/HIV, bacterial- staph/TB
Inflam- Sjorgrens
Drugs- Alcohol/COCP
Neoplastic
Sialectasis- stones
Metabolic- bulaemia, cushings, cirrhosis
Mimics- lumps and bumps- cyst, lipoma, CNVII neuroma, masseter hypertrophy

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35
Q

Types of parotid gland tumours?

A

Benign- Pleomorphic adenomas- 80%, slow growing, 5th decade of life
Warthin’s tunmours- men, 7th decade
Variable- mucoepidermoid carcinoma- commonest paediatric
Malignant-Adenoic cystic carcinoma- commonest, 6th decade
Adenocarcinoma
Lymphoma

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36
Q

How to differentiate between upper and lower CN7 palsies?

Causes?

A

UMN- bilateral innervation of levator palpabrae
Can raise eyebrows
CVA/MND

LMN- hemiparesis of face
Bells palsy-?viral
Trauma
Ramsay Hunt syndrome- Shingles- HZV- vesicles in ear canal
Tumour- parotid/extrinsic pressure intracranially/ acoustic neuroma
Infection

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37
Q

What is Sjorgren’s syndrome?

A

Automimmune disease classically presenting 5th decade of women with dry eyes and mouth, characterised by periductal lymphocytes
primary and secondary (RA and SLE)
1 in 6 go on to develop lymphoma

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38
Q

How do you diagnose and treat sjorgrens?

A

Dx- schmirer’s test- hyposecretion in eyes
AutoAbs- Anti Ro, La and RF
Biopsy of salivary glands

Rx- C- tear replacements, good oral hygiene
M- immunosuppression/steroids
S- Lacrimal punctum diathermy

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39
Q

Aetiology of tonsilitis?

A

Viral- influenza, adenovirus, rhinovirus- EBV/Infectious mononeucleosis
Bacterial- Hi, Strep pneumoniae, GAS/GBS

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40
Q

What is the centor criteria

A

Need 3 or more to justify Abx treatment

Exudate on tonsils
Fever above 38
No cough
Anterior lymphadenopathy

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41
Q

When would you consider a tonsillectomy for tonsilitis?

A

Recurrent tonsilities

>5 episodes in two consecutive years

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42
Q

Complications of tonsilitis?

A 
Sepsis
Airway obstruction
Quinsy
Acute otitis media
Recurrent
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43
Q

Aetiology of epistaxis?

A

Anterior-from little’s area- Klessielbachs plexus
Post Woodruffs plexus

Causes
Infective- rhinits
Trauma
Neoplastic
On anticoagulation
Clotting abnormalities
Substance abuse
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44
Q

Management of Epistaxsis?

A

C- pinch bridge of nose for 20 mins, rapid rhino if unsuccessful
M- Resuscitate, reverse anticoagulation, FFP/cryo, nasceptin post bleed, adrenaline spray
S- cautery, embolisation/ligation
Culprit vessels are often- sphenopalatine, post/ant ethmoidal, maxillary

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45
Q

Breast exam process?

A

Intro- expose, 45o on couch, chaperone
Inspect- hands by side, above head, pressed into hips
6Ss, peau d’orange, nipple changes, discharge, tethering (astley cooper ligaments), lymphoedema
Palpate- pain?, temp, SEC FFP TR, good then bad, clock face, axillary LNs, suprclavicular LNs, nipple discharge
Complete- Liver, lung, brain and bone, post op N palsies- long thoracic, intercostobrachial, thoracodorsal
Triple assessment- Mammogram/USS + biopsy

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46
Q

What are the types of benign breast disease?

A

15-25 yo- Fibroadenomas
25-40- Cyclical nodularity and mastalgia
35-55- cystic disease, duct ectasia, periductal mastitis, hyperplasia

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47
Q

Types of breast neoplasms?

A

Benign- fibroadenomas, intraductal papillomas, lipomas
Malignant- Lobular/Ductal carcinomas in situ

Ductal carcinoma- 80%
Lobular- 10%
Medullary/mucinous/tubular/papillary carcinomas

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48
Q

Difference between in the breast of paget’s disease and eczema?

A

Paget’s disease involves the nipple

Eczema rarely involves the nipple

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49
Q

Describe the abdominal examination?

A

Patient flat in bed
Inspect- hands- nails, flap, dupytren’s
Wrists- pulse, tatoos, exoriations
Face- eyes, mouth
Neck- LNs
Chest- gynaecomastia, spider naevi
Abdomen- 6Ss, distention, visible perastalsis, pulsatations, scars!!
Pain?
Temp
Palpation- 9 regions- soft for guarding, deep for masses
Liver, Spleen, Kidneys, Aorta
Percuss- Liver spleen, shifting dullness
Auscultate- bruits- bowel sounds, renal, iliac, aortic
Peripheral oedema
Complete- Inguinal LNs, Hernial orifices, Exeternal genitalia, preg test/urine dip, DRE/PV exam, fluid and stool charts

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50
Q

What are spider naevi?

A

Related to exess oestrogen:testosterone levels
Dilated BVs, fill from inside out
>5 is pathognomic

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51
Q

What is clubbing and what are the stages of it?

A 
Pathological swelling of the distal phalanges
1- Congestion
2- Loss of angulation
3- Increase AP angle
4- drumsticking
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52
Q

Aetiology of clubbing?

A 
Idiopathic
2o
Endocarditis/ cyanotic heart disease
Lung ca/Pulmonary fibrosis/COPD/Bronchiectasis
GI cancer/IBD/Coeliac
Thyroid acropatchy
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53
Q

Aetiology of dysphagia?

A

Intramural- foreign body/food bolus
Mural-Oesophageal ca, oesophagitis, GORD, strictures, pharyngeal pouches, achalasia, oesophageal webs
Extramural- thyroid/lung ca/retrosternal goitre/hilar lymphadenopathy
MND/stroke
Traumatic

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54
Q

What is plummer vinson syndrome?

A

Chronic IDA deficiency leads to oesophagea webs
Dysphagia to solids more than liquids
Propsenity to go on and become SqCC

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55
Q

Epigastric masses DDx

A

Any mass- skin/subcutaneous/lipoma/ AAA/epigastric herniation/ epigastric hernia/panceratic pseudopolyps, pancreatic ca/gastric ca/ lymphadenopathy

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56
Q

Aetiology of hepatomegaly?

A 
Physiology- Ridele's lobe
Infective- hepatitides/CMV, malaria, TB/abscess
Cancer- 1/2/lymphoma/leukaemia
Cirrhosis- alcohol, wilson's, amyloid
Vascular- RHF, Budd chiari
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57
Q

What is Budd chiari syndrome?

A

Heptaic vein obstruction

Due to thrombosis/ cancer

Clin feats of abdominal pain, hepatomegaly, jaundice, ascites

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58
Q

Cirrhosis definition and aetiology?

A

Fibrosis of the liver secondary to long term damage, causing decrease function of the liver

Aetiology- alcohol
Viral, bacterial, protozoan
Autoimmune heptatitis
NAFLD
RHF
Sarcoid
Wilson's/Alpha 1 antitrypsin
PBC and PSC
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59
Q

What are the autoAbs tests for PBC and PSC?

A

PBC- fat women forty, anti AMA

PSC- UC association, pANCA

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60
Q

Aetiology of portal HTN?

A

Pre hepatic- splenic/portal vein thrombosis
Hepatic- cirrhosis/liver ca
Post hepatic- Budd chiari/ RHF

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61
Q

What are Caput Medusae?

A

Engorged and dilated periumbilical veins that form part of the portal system and become dilated due to porto-systemic shunting
Due to either Portal HTN or IVC blockage

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62
Q

What are the causes of ascites?

A

Transudate- SAAG >1.1/Protein <30,
Hypoalbunaemia- Liver failure, nephrotic, starvation
Increased venous pressure- Heart failure, Portal htn, budd chiari, pregnancy, volume overload

Exudate (increased permeability)- Malignancy, infective, pancreatitis
Peritoneal radiation, pancreatitis, peritonitis, peritoneal mets

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63
Q

Management of ascites?

A 
Treat underlying cause
C- salt and fluid restriction
M- spironolactone
S- pacacentesis
TIPSS
Liver transplat
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64
Q

Functions of the spleen?

A

FFISH
Filtering of encapsulated organisms- s.pneuomnia, n.menigitidis, Hi
Immunological- Ab production and opsonisation
S- storage of platelets
Haematopoesis in fetus
F- reticuloendothelial system- filtering RBCs/WBCs/Platelts

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65
Q

Aetiology of splenomegaly?

A 
Infective- HIV/abscess/TB/malarial
Leukaemia and lymphoma (CML/NHL/myelofibrosis)
Sickle cell and thalassaemia
Splenic thrombosis/budd chiari syndrome
RA/Sarcoid
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66
Q

Types of PCKD?

A

ADPCKD- Adult, 5th decade, chronic renal failure/haematuria, good response to dialysis, 40% have berry aneurysms

Infantile- ARPCKD, Renal mass and poor renal function, hepatic fibrosis, liver transplant needed

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67
Q

Clinical features of Chronic renal failure?

A 
Think kidney functions
HTN, HF
Peripheral oedema
2o hyperparathyroidism
Osteoporosis, hypocalcaemia
Anaemia
Uraemia leading to puritus, peripheral uropathy, gout
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68
Q

Definition of IBD?

Stool sample test for it?

A

Inflammatory bowel disease with an autoimmune and genetic component

Faecal calprotectin

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69
Q

UC macroscopic and microscopic appearance?

A 
Non smokers
Colonic and rectal disease
Continous
Submucosal inflammation
Pseudopolyps and cryptal abscess

Thumbprinting and lead piping on barium enema

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70
Q

Complications of UC?

A 
Cancer
PSC
Toxic megacolon
Perforation
Obstruction
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71
Q

Macro and microscopic appearance of Crohn’s?

A 
Smokers
Any part of GI tract
Skip lesions
Transmural ulceration with cobblestone pattern
Granulomas
Fistulas and strictures
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72
Q

Complications of Crohns?

A

Fistulas
Strictures
Obstruction
Infection

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73
Q

Extra-intestinal IBD manifestations?

A

Mouth Ulcers and Perianal skin tags- Crohns

IBD in general
Eyes- Iritis and uveitis
Arthritis
Ank spon
Skin- erythema nodosum and pyoderma gangrenosum
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74
Q

Crohns treatment pathway?

A

C- diet altering, stop smoking
M- Steroids, azathioprine, infliximab
S- segmental resections, strictuloplasty, fistulotomies- setons, open

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75
Q

UC treatment?

A

C- dietary changes
M- steroids, sulfasalazine
S- Proctocolectomy +- end ileostomy +- ileoanal pouch (curative)

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76
Q

Indications for surgical management of IBD?

A

Medical management not working

Complications

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77
Q

Definition of sinus and fistula?

A

Sinus is a blinding ending epithelial lined tract

Fistula is an abnormal connection between 2 epithelial lined surfaces

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78
Q

Cryptoglandular sepsis theory?

A

The level of anorectal fistula denotes the level of the anorectal abscess

Subcutaneous fistula = perianal abscess
Intersphincteric fistula = intersphincteric abscess
High anal fisutal = ischiorectal abscess
Low anal fistula = ischiorectal abscess
Pelvirectal fistula = supralevator abscess

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79
Q

Management of fistulas and perianal abscesses?

A 
Full Hx and exam
Bloods- IV Abx for infection
IBD investigations/DM investigations
MRI
Proctoscopy/sigmoidoscopy

Surgery- do not explore fistulas acutely- just drain abscess

In post acute phase
Subcutaneous/Low anal fistulas- Laid open
High anal/interspincteric- setons
Complicated fistulas may need fistulotomy +- flap

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80
Q

Explain Goodsall’s rule

A

9 till 3- normal course

3 till 9 abnormal course

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81
Q

Difference between Lanz and Gridiron incisions?

A

Lanz medial to lateral

Gridiron is along Langer’s lines

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82
Q

Describe a hernia examination?

A

Inspect- expose + chaperone, standing
6Ss, cough
Palpate- pain?, temp
SECFFPTR
Cough
Can patient reduce it- reducible when lying
Reduce and cover superficial and deep ring

Auscultate

Complete
LNs
ContraL
Scrotal examination
Abdo exam
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83
Q

Describe a scrotal exam?

A 
Expose, standing chaperone
Inspect- 6Ss, cough impulse?
Pain, temp?
Palpate- SEC FFP TR
Can you get above lump- if not do hernia exam
Define anatomy- separate to testis?
Feel testis and epipdyimis + vas
Complete- LN, contraL side
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84
Q

DDx of inguinal canal mass/lump?

A 
Inguinal hernia
Femoral hernia
Saphena Varix
Undescended testis
Femoral Artery A
Lymphadenopathy
Skin lesions
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85
Q

What is a hernia?

A

Abnormal protusion of a tissue or organ through the wall of its normal cavity

86
Q

Types of hernial repairs?

A

Open vs Lap herniotomy and herniorrhapy

Lichentstein’s- uses mesh to reinforce defect
Shouldice- if infection concerns, 4 layers of opposing muscle

87
Q

Why are femoral hernia more likely in women?

Also types of femoral hernia repair?

A

In women- as increase stretch of femoral canal during pregnancy- increased venous return
Also fat regression during menopause- more space

Lockwood’s repair- low repair of reducible femoral hernia
McVedy’s high repair of irreducible femoral hernia

88
Q

Other types of hernia?

A 
Umbilical
Paraumbilical
Brainstem
Littre's- meckel's diverticulum
Amyand- appendix
Richter's- one side of bowel wall
Hiatus
Epigastric
Spigelian- through semilunaris
89
Q

DDx of a scotal lump?

A

Hernia- cant get above them
Separate to testis- varicocele, epidymitis, epidyimal cyst, spermatocele
Cant separate from testis- hydrocele, cancer, orchitis, haematocele

90
Q

Types of undescended testis and complications?

A

Undescended- premature stopping of descent down gubernaculum
Retractile
Ectopic

Complications- torsion, tumour (seminoma risk is 30x normal), infertility

91
Q

Treatment of undescended testis?

A

Wait till 1 year then orchidoplexy
Or orchidectomy

Or GnRH/bhCG may encourage descent

92
Q

What is a hydrocele?

Aetiology?

A

Fluid collection within tunica vaginalis
Can also include Vas deferens

1o- patent processus vaginalis
2o- tumour, torsion, infection

93
Q

Treatment of hydrocele?

A

C- in 1o can wait till 1 year old as it may resolve
Scrotal support
Analgesia

S- aspiration, phenol injection
Lord’s plication- sac incised and plicated behind testis
Jaboulay’s plication- sac incised and partially excised

94
Q

Aetiology of epipyimal orchitis?

A

Viral- mumps, infectious mononeucleosis

Bacterial- e.coli vs chlamydia

95
Q

What is a variocele and treatment?

A

Dilated and tortous pampiniform plexus

seen on standing
98% on the left- Left testicular vein drain into left renal
Colon compresses/left RCC

Treat if symptomatic
Emobilisation
Ligation

96
Q

Types of benign testicular tumours?

A

Leydig cell tumours- can cause precocious puberty

Sertoli cell tumours- gynaecomastia

97
Q

Types of malignant testicular tumours?

A

Seminomas- 30-40 yo, 40%, produce Beta HCG only
Teratomas- contain all 3 elements of the germ layer, 30%, produce AFP and BHCG
Mixed- 20%
Lymphoma

98
Q

Investigation and management of testicular cancer?

A

Staging= TNM or Royal Marsden

Bloods + LDH + AFP +BHCG
Scrotal USS
CT CAP

Orchidectomy via inguinal approach
Chemo for seminomas and teratomas
DTx for seminomas

99
Q

Stoma examination?

A

Expose abdomen full, take off bag
Sheets/chaperone

Insepct- site, bag and contents, spout vs flush, Lumens, mucosa (inflammed/ulcerated), scars, old stoma sites
Complications- prolapse/reactraction/stenosis/hernia
Excoriations
Rectal opening?
Pain
Temp
Palpate- lumen, parastomal hernia, stoma bag in 1 or 2 pieces
Auscultate
Completion- abdo exam

100
Q

What are the types of stomas?

A

Ileostomy vs colostomy
End vs loop

End ileostomy- panprotcocolectomy
End colostomy- colonic resections- AP/Hartmann’s
Loop ileostomy- protect distal anastomosis
Loop colostomy- diversion pre chemo/DTx/palliative

101
Q

Indications for Stomas?

A

PEG feeding
Diversion to protect distal anastomosis
Emergency/planned resections

102
Q

Inspection for all ortho exams?

A 
4Ss + MDE
Scars, sinus, symmetry, swellings
Muscle wasting
Deformity
Erythema
103
Q

C-spine/Neck exam?

A

Look- 4S MDE
Feel- tenderness, stepping off, cervical rib, LNs, thyroid?
Move- + examine with downward pressure on neck whilst slight ear to shoulder- exaggerates intervertebral foramen stenosis symptoms
Special- looking for thoracic outlet syndrome
Roos- arm abducted and ext rotated, hand flex/exten for 3 mins
Adson’s- palpate pulse and abduct +extend and ext rotation + turn head to same sign

104
Q

Describe a spinal examination?

A

Expose + chaperone
Look
Feel- pain, temp, stepping, chest expansion
Move- cervical as standard, thoracic in chair, lumbar
Specials- Schober’s find PSIS- 5cm above and 10cm below, forward flex, should increase by 5cm
Sciatic nerve stretch- dorsiflex worsens it and, knee flex and hip flex worsens it
Femoral nerve stretch test
Pelvic compression- pain if ank spond
Lhermitte’s- c spine flexion
Beevor’s sign- T6-12 spinal injury, lying supine, arms above head, flexes c spine, umbilicul deviates away from affected side
Abdo reflex- umbilicus twitch
Complete- LNs, Full NVI + vascular exam, QOL and sleep, dress, imaging

105
Q

Describe the shoulder exam

A

Shoulder exam- standing, expose neck and elbow and shoulder
4S MDE
Walk and arm swing
Feel- around joint + axilla for lymphadenopathy
Move- active and passive + stabilise scapula (push down on shoulder)
Global fnx- arms behind head, arms behind back
Power- supraspinatus lift off test, deltoid resistance, internal rotation, subscap lift off test
Specials- Jobes- supraspinatus
Neers- pronation and forward flexion
Scapula winging
Whilst on couch supine- multidirectional instability
Complete- LN, NVI, above and below, QOL &sleep, dress, imaging

106
Q

Elbow exam?

A 
Look- expose to shoulder and wrist
Arm carrying angle?
4S MDE
Pain
Temp
Feel- lat/medial epicondyle and olecranon
Radial head whilst supinating/pronating
Rhemuatoid nodule
Ulnar N
Move
Complete-NVI, above and below, LN, QOL, Sleep, Dress, Imaging
107
Q

Hip Examination describe?

A

Look- Expose, above and below, walk and turn
Trendelenburg’s whilst standing- hold their hands- abductor weakness
4S MDE
Pain
Temp
Feel- whilst lying- fem head, trochanter, adductor longus insertion, ischial tuberosity
Crepitus
LN
Apparent leg length- xiphi to medial malleolus- abductor or adductor deformities
True leg length- ASIS to medial malleolus- femoral shaft/tibial deformity

Move- Thomas’s test- fixed flexion deformity
Extend (whilst pronated)
All others, active and passive
Complete- NVI, above and below, LN, QOL, Sleep, Dress, Imaging

108
Q

Describe a knee examine?

A 
Look- expose above and below, walk + standing
4S MDE
Pain
Temp
Feel- joint line
measure quads
effusion test
synovial thickening test (RA)-lift patella
Flexion deformity

Move- SLR, flex/extension

Special- Ant/post draw
Post sag test
Collateral ligs
McMurray’s- medial meniscus- externally rotate +aduct
Lateral meniscus- internal rotate in adduct
Patella tests- move it, push down and contract femur (OA), apprehension- displace lat and flex knee

Complete- LN, NVI, above and below, QOL and sleep, Dress, imaging

109
Q

Ankle and foot exam describe

A 
Inspect- above and below exposed
Ask to walk- perform all ankle movements
Standing inspect and in chair
Look between toes and on heel and plantar surface
Inspect shoes
4S MDE

Pain
Temp
Feel- Soft tissues and bones, squeeze metatarsals
Move- ankle and subtalar, midtarsal, toes
Special- tenosynovitis- plantarflex and invert/evert
Simmonds test
Tinnel tarsal tunnel

Complete- NVI, above and below, LN, QOL sleep, dress, imaging

110
Q

What are the phases of gait?

A 
60% stance, 40% swing phase
Stance phase- heel strike
Foot flat
Mid stance
Toe off
111
Q

Types of gait pathology?

A 
Shuffling- parkinsons
High stepping- Common peroneal deformity
Antalgic- one side affected
Ataxic gait/broad gait- cerebellar
Trendelenburg- duck waddling
112
Q

What is rheumatoid arthritis?

A

Chronic systemic inflammatory disorder with an autoimmune component that primarlary affects the joints
4:1 women to men, <1% of population

113
Q

Clin feats of RA?

A

Symmetrical polyarthropathy and joint deformity
EMS

Extra-articular
Skin- rheumatoid nordules/erythema nodosum
CVS- pericardial effusion/pericarditis
Eyes- uveitis/episcleritis
Kidneys- amyloidosis
Lungs- pulmonary fibrosis
Neuro- carpal tunnel
Felty's pancytopenia, splenomeglay, lymphadenopathy
114
Q

Diagnosis of RA?

A

HX and exam
Bloods- FBC, UEs, CRP, ESR
RF, ANA, HLA D4
LESS (swelling, erosions, subluxation)
American college of rheumatologist criteria
EMS, >3 joint groups involved, hand joints, symmetrical, rheumatoid nodules, RF +ve, erosions on xrays

115
Q

Treatment of RA?

A 
C- hot and cold packs, patient education, weight loss, OT/PT
M- WHO Ladder, steroids
Methotrexate
Sulfasalzine
Infliximab
S- athroplasty/athrodesis/synovectomy
116
Q

Epidemiology of Ank spond?

A

Seronegative spondyloarthropathy, presenting mainly with EMS back pain in young men

RF negative
HLA B27 +ve

117
Q

Clin feats and Dx factors for Ank Spond

A

Intra articular feats- back pain, stiffness, decrease function, fractures, tendon inflammation
Extra-articular- myocarditis, ant uveitis, pulmonary fibrosis, cauda equina

HLA B27 positive
SI joint fusion
Bamboo spine with bridging osteophytes

Sacroilitis on MRI

118
Q

Treatment of ank spond?

A

C- lifestyle changes, OT and PT
M- WHO, steroids, infliximab
S- osteotomy, athroplasty/desis

119
Q

Paget’s disease of the bone- what is it?

A

Osteitis deformans
Abnormal osteoblast and clast activity with unknown aetiology

3 phases
Osteolytic then mixed then blastic

120
Q

Clinical features and complications of Paget’s?

A

Bone pain and weakness
CNV and 8 defects
Eythema around sites- due to increased vascularity

#s and OA
HF due to increased vascularity
2o hyperpth
Hypercalcaemia
osteosarcoma conversion in 1%
121
Q

How to Dx Paget’s?

A

Bloods- raised ALP,normal Ca/PTH/TFTs
Urinary hydroxproline- collagen breakdwon
Imaging

122
Q

Treatment of paget’s?

A

C- lifestyle and PT/OT
M- WHO, bisphosphonates- decrease bone turnover, calcitonin- inhibt osteoclast activity
S- standard

123
Q

Aetiology of a pain shoulder?

A 
Trauma
Rotator cuff tears
Adhesive capsulitis
OA
Bursitis
Septic
Neoplastic
MI- referred
124
Q

What is adhesive capsulitis?

And how to manage it?

A

Frozen shoulder, idiopathic decreased ROM and pain
External rotation is normally worse affected
Stiffness that leads to underuse and glenoid adhesions

C- physio
M- R/O rotator cuff tear and infection
Steroid injections/analgesic ladder
S- MUA/athroscopic release

125
Q

What is shoulder impingment syndrome?

A

Compression of supraspinatus tendon as it passess through the subacromial space

Painful arc from 60-120 and anterior shoulder instability

126
Q

Causes of shoulder impingment syndrome?

A

Subacromial bursitis
Trauma/overuse
Bony spur from ACJ

127
Q

Management of Shoulder impingmenet syndrome?

A

MRI- identify rotator cuff pathology
C- pt/limit activity
M- WHO, steroid injection
S- rotator cuff repair, subacromial decompression

128
Q

What are claw toes?

A

Flexion deformity of PIPJs/DIPJs
Seen in RA and charcot marie tooth disease
Treated by tendon transfer/arthrodesis

129
Q

What is hallux valgus

A

Bunions etc
Promience of 1st MT head
Due to chronic forefoot splaying
Rx- buinionectomy and realignment osteotomy

130
Q

What is club foot

A

Talipes equinovarus

platar flex, add, inverted ankle
Congenital deformity

Treat by plaster/splinting
Surgical correction- tibialis ant lengthening

131
Q

What is charcot’s arthropathy?

A

Neuropathic arthropathy
Progressive destruction of a weight bearing joint to peripheral neuropathy
Leads to skin breakdown and ulceration as well

132
Q

Describe the hand exam?

A

Look- elbows exposed on pillow
4S and MDE
OA signs- Bouchards- prox and Herbeden’s- distal, CMJ squaring
RA signs- ulnar deviation, rheumatoid nodules, swan necking/boutonniaires/z thumbing

Pain
Temp
Feel
CRT, dupytrens, nodules, bimanual palpation/mcp squeeze
sensation

Move- all joint actions, passive and active

ROM- prayer and reverse prayer, fist, spread fingers, oppose, pronate and supinate

Thumb power
Digit power- bullhorns

Special- Tinnels, Phalens, finklesteins (dequervain’s tenosynovitis), pincer grip stuff, two point descrimination

Complete- NVI< above joint, LN, QOL and sleep, Dress, imaging

133
Q

What is dupytren’s disease?

A

Fibrotic disease of the palmar and digital fascia

Seen more often in white old males with diabetes

Smoking and infection risk factors

134
Q

What is associations are there with Dupytren’s?

A

Peyronie’s disease- fibrosis of corpus callosum

Ledderhose’s disease- plantar fascia fibrosis

135
Q

What is the management of dupytren’?

A

Indications for op when flexure contracture >30o
Pain and increasing disability

C- lifestyle mods
M- WHO
S- fasciotomy, fasciectomy, dermatofasciectomy +- flap, amputation

136
Q

What are the complications of Dupytren’s fasciectomy treatment?

A 
NVI
infection, flap necrosis, haematoma
10% reocurrence
Scar contracture
Wound breakdown
137
Q

What is a ganglion?

A

Mucinous filled cyst near joint/tnedon

70% on dorsum of wrist

138
Q

What are trigger fingers?

A

Difficult in extending finger from flexed position
Trapping of flexor tendons

1o idiopathic/congenital
2o trauma, infection, inflammation- DM/RA/renal disease/amyloidosis

Narrowing of the tendon sheath leads to increase friction and inflam=> downward spiral
Tendon become stuck in A1

Night splinting
Steroid injection of sheath
Surgical division of A1

139
Q

Describe the Vascular Exam?

A

Patient on bed, trousers off, shirt unbuttoned
Inspect- skin, nails, ulcers (BEDS), scars, venous guttering
Chronic venous congestion?
Pain
Temp
Palpate
CRT and pulses (radial, brachial, carotid, aorta, femoral, popliteal, DP and PT)
Odema
Buerger’s (Lift leg off- not angle of pallor<20 is severe PAD + reactive hyperaemia when placing leg off bed)
Allen’s test
Auscultat- carotid, aorta, femoral and iliac
Completion- ABPI, varicose vein exam, cardiac exam, distal NVI, BP/HR, Doppler + further investigations

140
Q

Varicose vein exam describe?

A

Inspect- 6Ss,
Chronic venous insufficiency- haemosiderin deposits, lipodermatosclerosis, venous eczema
Ulcers, Sacrs (groin/popliteal fossa, small and multiple)

Pain
Temp

Palpate- SECFFRTR, Saphena varix
Tap test
Trendelenberg test- milk and empty varicosities/ occlude SFJ and stand up
Tourniquet test- same as above but use tourniquet to find incompetency level
Perthes disease- deep venous incompetence- calf raises with tourniquet- painful
Doppler has replaced this- place over SFJ/SPJ, squeeze calf- one whoosh is ok, two is bad

Auscultate femoral As
Complete- abdo exam, ABPI, investigations, dress patient

141
Q

What are the 6ps of PAD?

A

pulseslness, pale, perishingly cold, parasthetsia, paralysis, painful

142
Q

What are the symptoms of peripheral arterial disease?

A

Intermittent claudication on exertion, + cvs risk factors
Fontaine’s critertia
1- asymptomatic
2a- intermittent claudication on walking >200m
2b- intermittent claudication on walking <200m
3- rest pain/nocturnal pain
4- gangrenous/necrosis

143
Q

What are the criteria of ABPI and pathology?

A

> 1,3- calcified vessels-?diabetic
0.9-1.3- normal
<0.9- moderate critical disease
<0.5- severe critical disease

144
Q

What is spinal stenosis?

A

Typically have pain from the back radiating down the lateral aspect of the leg (tensor fascia lata), often have symptoms on initial movement or symptoms that are relieved by sitting rather than standing- flexed position on spine
Narrowing of spinal canal or of neural foramina

145
Q

What is the difference between acute and chronic limb ischaemia?

A

Acute generally less than 14 days
Can be acute on chronic
Acute more likely to be an embolic event

146
Q

what is a AAA?

A

Abnormal dilation of abdominal aortic artery- >4.5cm

147
Q

Risk of AAA rupture?
And monitoring criteria?
Indications for Op?

A

<1% when <5.5cm, 5.5-6.5cm= 10%

Monitoring once >3cm- annual US
4.5-5.5 cm every 3 months

Referral for op if
Symptomatic
>5.5cm
>1cm growth in 1 year

148
Q

What is subclavian steal syndrome?

A

Proximal subclavian artery lesion
Leading to ischaemic arm symptom and brain symp on exercise
Vertebral artery reverses flow to compensate

149
Q

What is thoracic outlet syndrome?

A

Compression of Subclavian NAV at clavicle/1 st rib area

150
Q

Aetiology of thoracic outlet syndrome?

A

Congenital- cervical rib
Acquire-#/scalene hypertrophy
Neoplastic compression

151
Q

How to identify thoracic outlet syndrome?

A

Roo’s/Adson’s test
USS
CT

152
Q

What is raynaud’s syndrome?

A

Digital vasospasm with 3 clear transition stages
White- ischaemic
Blue- cyanotic
Red- Hyperaemic

153
Q

Aetiology of Raynaud’s?

A 
1o- idiopathic
2o- RA/scleroderma
Traumatic/chronic use
Athersclorotic
B blockers
Polycythaemia
154
Q

Management of Raynaud’s?

A

C- warm gloves, avoid precipitants
M- nifedipine
S- sympathectomy- either digital or thorascopic T1-3

155
Q

Indications of treatment of carotid artery stenosis?

A

If occlusion 50-99% and surgery done within 2 weeks of event

ASymptomatic, <75yo and >70% occlusion

156
Q

Aetiology of DVTs?

A

Virchow’s triad- damage, stasis, hypercoagulable

75% are silent
Homan’s sig- pain on dorsiflexion?

157
Q

DVT prevention stratergies?

A

C- early mobilisation, compression stockings, hydrate, flowtrons
M- LMWH, IVT, stop COCP 4 weeks prior to op
S- Avoid GA, vena cava filters

158
Q

What is deep venous insufficiency?

A

Post DVT syndrome/congenital abscence of valves/AVM

Leading to increased venous pressure in superfiscial veins

Test with Perthe’s test

159
Q

What are varicose veins and causes?

A

Tortous dilated superfiscial veins

1o
2o- DVT, pregnancy, overuse, long standing, klippel-trenaunary syndrome

160
Q

Treatment of varicose veins?

A 
C-weight loss, compression stockings
S- sclerotherapy
Multiple stab avulsions
High ligation
Low ligation
Vein stripping
Laser/radiofrequency ablations
161
Q

What makes up an AMTS?

A 
Age
Time
Street remember
Year
Current location
DOB
WW2
Prime minister
Identify 2 people
Count backwards
Remember street
162
Q

What makes up a MMSE?

A 
Orientation
Registration- remember 3 items
Attention- world backwards, serial 7s
Recall- 3 items
Language
name 2 items
Repeat phrase- no ifs and buts
Follow written instructions
Wrist sentence
Copy picture- interlocking pentagons
163
Q

Describe GCS?

A
164
Q

Cranial Nerve examination?

A

Inspect- general, facial assymetry, dyskinesias, speech

1- smell changes
2- visual acuity, snellen charts, ishihara charts, visual fields, Pupils (PERLA), fundoscopy
3/4/6- H
5- sensation in opthalmic/maxillary/mandibulary regions, muscles of mastication/temporalis, corneal reflex
7- taste on anterior 2/3s of tongue, facial expression
8- Whisper test, Rinne’s and weber’s
9/10- Swallow, gag, baby hippopotamus, inspect palate
11- traps and scm
12- tongue inspetion and protusion

165
Q

Describe a peripheral nerve examination?

A

Inspect The Patient Really Carefully
Inspect- front/back, gait, wasting, romberg’s
Cerebellar signs- Dysdiado/Ataxia/Nystagmus/Intention tremor/Speech sluring/hypotonia

Pain
Temo
Tone- upper + lower (clonus + knee lift)
Power- upper and lower
Reflexes
Coordination
Sensation- pain, temp, light touch, proprioception, vibration, 2 point discrimination
166
Q

What are the myotomes for upper and lower limbs?

A 
C5- shoulder abduction
C5/6- elbow flexion
C7/8 elbow extension
C8- Thumb flexion/MCPJ extension
T1- finger Abd
L2- hip flexion
L3/4- knee flexion
L4/5- ankle dorsi flexion
L5- big toe dorsi
S1/2- ankle plantar flexion
167
Q

Reflex levels?

A

Biceps- C5/6
Triceps is C7/8

Ankle is S1/2
Knee is L3/4

168
Q

What is the aetiology of lower back pain?

A 
Congenital 
Degenerative OA
Infective
Inflam- Ank spond
Metabolic- osteoporosis
Neuro- spinal canal stenosis/prolapsed disc/spinal haematoma (post LP)
Neoplastic
Function
Renal calculi
AAA
Pancreatitis
Trauma
169
Q

What is a disc prolapse and what are the stages?

A

Normally posterolater herniation of the nucleus propulus through the anulus fibrosis

90% happening and L4/5 and L5/S1

Dysfunction occurs first- injury of fibrosis
INstability- disc reabsoprtion and loss of height
Restabilisation- osteophyte formation and progressive stenosis

170
Q

Back pain red flags?

A 
Fever, weight loss, shocked
Bilateral radiculopathy
Bladder/bowel dysfnx
Preceeding trauma
Saddle anaesthesia
Incontinence
171
Q

3 classifications of Cauda equina syndrome?

A

CES suspected- bilateral radiculopathy, no other red flags
CES Incomplete- bilateral + altered bladder/bowel symptoms
CES Complete- painless retention, no sensation on defecation, absent anal tone

172
Q

Management of cauda equina syndrome?

A

Neurosurgical emergency
Nerve ischaemia at 6 hours
Requires surgical decompression
Reasonable recovery if done within 24 hours of onset of symptoms

173
Q

What are the CT head criteria?

A 
<1 hour
If GCS <13 on initial assessment in ED
GCS <15 2 hours after injury
Open/depressed skull fracture
Focal neurology
>2 focal vomiting episodes
>30 mins of retrograde amnesia
Seizures
174
Q

When to refer head injuries to neuorsurgery?

A 
GCS<8/ >2 points deterioration
Progressive neurology
Open injury
CSF leak
Seizure without full recovery
175
Q

Management of brain injuries?

A

Prevent 2o brain injuries- normotension, normoxia, normocapnia, normal ICP

Tier 1- elevate head to 45o, hyperventilate
Tier 2- increase sedation, induce hypothermia, mannitol
Tier 3- barbituate coma, burr hole/decompressive craniotomy

176
Q

Indications for NS intervention in a traumatic brain injury?

A

> 5mm midline shift on CT
Intercerebral haematoma with >40cm
Depressed/open skull #

177
Q

Causes of ICH?

A

Stroke- haemorrhagic
Trauma
SAH
Spontaneous

178
Q

RFs for spontaneous ICH?

A

Old
Hypertensive/blood dysacrias
Aneurysm/AVM
Cocaine/amphetamines

179
Q

Causes of SAH?

A 
Idiopathic
Aneurysmal- berry (ADPKD)
AVM
Endocarditis
Blood dysacrias
180
Q

How to diagnose SAH?

A

CT Head- 96% sensitivity if done before 6 hours

LP at 12 hours for bili levels

181
Q

How to investigate and treat cranial aneurysms?

A

CTA/MRA
Catheter angio

Rx- Interventional coiling
Operative clipping

182
Q

What is a defnition of a stroke?

A

Global or focal neurological deficit 2o to vascular cause lasting >24 hours

183
Q

Risk factors for stroke?

A

Age, FHx, HTN, hypercholestrolaemia, AF, anticoagulants, protein C deficiency, diabetes, poor diet, obestiy, smoking

184
Q

Where is CSF produced and absorbed?

A

Produced in choroid plexus
Absorbed by arachnoid villi

150mls circulating, 480mls produced a day

185
Q

Hydrocephalus definition and clinical features?

A

CSF production and absorption balance

Leads to increased head size/headaches
RICP
Memory problems
Focal neurology
Seizures
Coma
186
Q

Aetiology of hydrocephalus?

A

Increased production- choroid papilloma
Decreased absorption- sinus thrombosis/NPH

Obstruction of flow- thalamic/cerebellar tumours

187
Q

Management of hydrocephalus?

A

Furosemide and decrease secretions
Serial anterior fontanelle taps/LPs

VP shunt
Vatrial shunt
Vpleural shunt

188
Q

Risk factors for brain tunmours?

A

Immunocomprimised
Genetic- Li fraumeni
FHx
Radiation exposure

189
Q

Types of intra axial brain tumours?

A

Gliomas- 70%
Astrocytomas, oligodendromas, ependyomas
Lymphomas 3%

190
Q

Extra-axial brain tumours?

A

Menigiomas
Pituitary
Cerebllopontin- acoustic neuromas

191
Q

Commonest metstastic brain tumours?

A

Lung (60%) and breast (20%)

192
Q

Imaging characteristics of brain tumours on CT?

A

Gliomas- large singular brain lesion with central area of necrosis and enhancing ring

Mets- small, multiple, disproportionately excessive peri-orbital oedema

193
Q

Treatment of brain tumours?

A

Depends on grade for gliomas
1- surgical resection +- radio- curative
2- Debulking and chemo- v likely for grade jump, 35% survival at 5 years
3- debulking + chemo + DTx- 2 year median survival
4- debulking + chemo + DTx- 10 month median survival

Mets- NSCLC- poor prognosis
Breast Ca- full resection gives good prognosis

194
Q

Describe a radial nerve exam?

A

Sitting, hands on pillows
Look for 4S, MDE
Pain
Temp

Palpate- sensation- 1st web space and dorsal forearm

Motor- EPL, EDC, EI and EDM, Elbow extension, Supination

Special- global and fine function

Complete

195
Q

What is teh course of the radial nerve?

A

C5-T1
Off posterior cord of brachial plexus
Through triangular interval
Spiral groove- between medial and lateral heads of triceps
Behind lateral epicondyle
Splits into PIN- around neck of radius and through 2 heads of supinator
SRN- goes beneath brachioradialis

196
Q

What does a high and low radial nerve defect cause?

A

High- wrist drop

Low MCPJ drop

197
Q

Describe a median nerve examination?

A

Sitting, pillow
Inspect- 4S MDE
Sensation- thenar eminence, 3.5 digital nerves

Motor- pronation, finger flexion, oppens pollicis, APB, FPL

Special- Tinnel, phalens, global and fine assessment

198
Q

Course of the median nerve?

A

Roots are C6-T1
Comes off median and lateral cords of the brachial plexus
Runs with brachial artery to the antecubital fossa
Medial to brachial artery here
Under PT and then under FDS
Gives AIN under PT- supplies FPL/FDP/PQ

Gives off palmar cutaneous branch before carpal tunnel
After carpal tunnel gives off recurrent motor branch
Digital cutaneous branch

199
Q

Describe an Ulnar nerve exam?

A

Sitting, pillow
Inspect- 4S MDE
Palpate- sensation over hypothenar eminence, medial 1.5 digital nerves
Motor- FCU, FDP, hand movements- DIPJ flexion of little finger, PAD DAB, Froment’s test (Adductor policis weakness)

Special- Tinnel’s, cubital tunnel syndrome- flexion and adduction of elbows

200
Q

Ulnar nerve course?

A

C8 and T1- medial cord of brachial plexus
Posteromedial aspect of the humerus and pierces intramuscular septum
Through cubital tunnel (arching fibres of FCU retinaculum)
Between the two heads of FCU
Runs in anterior compartment of the forearm beneath FCU
Gives off dorsal sensory branch- dorsal ulna sensation of the hand
Through Guyon’s canal
Giving off a deep motor branch and superfiscial sensory branch

201
Q

What sort of clinical signs does an ulnar nerver palsy give?

A

Claw
Further the Paw the worse the claw

Think opposite of interossei

Ulna paradox
High ulna defect leads to less of claw as paralysis of FDP

202
Q

Aetiology and presentation of Aortic stenosis?

A

Congenital bicuspid aortic valve
Rheumatic fever
Endocarditis

SOBOE/palpitations/exertional chest pain, LVF/syncope

Ejection systolic murmur in aortic region radiating to carotid
Slow rising pulse and forceful apex beat

203
Q

Aortic regurgitation aetiology and presentation?

A

Congential bicuspid, rehum f, endocarditis/aortic root pathology-aneurysm/marfans

Early diastolic murmur in aortic region
exertional dysponea
Collapsing pulse

204
Q

Mitral stenosis aetiology and presentation?

A

Rheum fever/endocarditis

SOBOE/palpitations/AF
Diastolic murmur in mitral region

205
Q

Mitral regurg aetiology and presentation

A

Commonest valvular abnormality in the world
Rheum/MI/myxomatous degeneration

SOBOE/palpitations

Pansystolic murmur to axilla/apex beat displacement

206
Q

Risk factors for atheroscleosis?

A 
HTN
Hypercholestrolaemia
DM
FHx
Smoking
Obesity
207
Q

What is Marfan’s disease?

A

Autosomal dominant damage to the FBN1 gene which leads to lack of fibrillin
Connective tissue disorder

Long limbs, hypermobile, high palate, pes excavatum, lens disloaction
Aortic aneurysms, mitral prolapse, aortic dissections
Pneumothoraces

208
Q

Describe the cardiac examination

A

Inspect and expose
Hands- clubbing, tar staining, xanthomas, marfanoid
Endocarditis hands- splinter haemorrhages, janeway’s, olser nodes (painful)

eyes- xanthomas, mouth- central cyanosis, Chest- scars, pes, pulsatations, pacemakers

Pulses- collapsing and radio-radial delay
JVP
Carotids

palpate- heaves and thrills
apex beat

auscultate + manouvers +bruits

Complete- auscultate lung bases, peripheral oedema and pulses, vein graft scars?

BP
ECG
Echo
PVD exam

209
Q

Describe the respiratory examination?

A

Inspect- hands, eyes, mouth, co2 retention flap
Palpate- pulse, JVP, LN, trachea, chest expansion, focal fremitus
Auscultate
Percuss

Peripheral oedema
DVT
O2 sats and resp rate
Peak flow
Temp
Sputum
210
Q

Types of lung cancers?

A

Small cell lung cancers
Neuroendocrine cells- smoking association, quick mets

Nonsmall cell
Sqcc, adenocarcinoma, large cell

211
Q

Spread of lung cancers?

Paraneoplastic disorders?

A

Local
Lymphatic
Mets- liver, brain, bone, adrenals, ContraL

Neuroendocrine disorders

Sqcc- PTHrP

SCLC- SIADH, Cushings

MRCS part B- JMB (10 decks)

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