Examinations Flashcards
6Ss
Site, size, shape, symmetry, skin overlying, scares
Lump palpation mnemonic?
SEC FFP TR
Surface Edges Consistency Flutuance Fixation Pulsatile/Expansile Transiluminable Reducible
Lumps and Bumps exam?
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
How to examine ulcers?
BEDS! Base- sloughy vs granulation tissue Edges- sloping/cut out Discharge- serous, serosanginous, purulent Structures visible?
DDx for a lump?
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
What is an Actinic Keratosis?
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
Campbell de Morgan spots?
Cherry haemangiomas- proliferation of dilated venules
Dermatofibroma?
Benign neoplasm of dermal fibroblasts
Dimple sign
At site of previous trauma
Furnucle vs Carbuncles?
Furnucle is an infected hair follicle- Stahp A
Carbuncle is a collection of furnucles
Seen in diabetics
Back of necks
What is a Keratocanthoma
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
What is a naevus?
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
Seborrhoeic Keratosis?
Benign of overgrowth of epidermis
Hyperkeratosis, acanthosis, hyperplasia
Stuck on skin warty appearance
What are neurofibromas?
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
Sebaceous cyst?
Abnormal membrane lined sac of epithelial cells containing a caseous substance
Central punctum
Treatment of ulcers
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
Describe a thyroid exam?
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
Questions in a thyroid Hx?
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
Parotid examination?
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
Submandibular Gland Exam?
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
What is the embryology of the thyroid gland?
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
Complications of thryoid development?
Lingual thyroid- remnant at foramen caecum
Thyroglossal cysts
Investigation of thyroid Lump?
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
DDx of a thyroid lump?
Nodular- solitary nodule (80% adenomas, 10% cysts/10%cancer)
Diffuse- Iodine deficiency, graves, hashimotos, multinodular, lymphoma
Management of benign thyroid swellings? Indications for surgical treatment?
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
Types of thyroid cancer and surgical management
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
Multiple Endocrine Neoplasia types?
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
Neck lump DDx?
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
Lymph node levels?
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
What is a radical neck dissection?
Removal of levels 1-5 +- 6
+- removal of accessory nerve/SCM/IJV
What forms the EJV?
Retromandibular vein + post auricular
What forms the IJV?
Pertrosal sinus
Lingual/pharyngeal, sup and middle thyroid and facial vein drain into it
What forms the anterior jugular vein?
Drains laryngeal veins
Some small thyroid veins
Ends up in EJV/subclavian vein
Variable in nature
How to investigate a parotid lump?
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
DDx of a parotid gland swelling?
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
Types of parotid gland tumours?
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
How to differentiate between upper and lower CN7 palsies?
Causes?
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
What is Sjorgren’s syndrome?
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
How do you diagnose and treat sjorgrens?
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
Aetiology of tonsilitis?
Viral- influenza, adenovirus, rhinovirus- EBV/Infectious mononeucleosis
Bacterial- Hi, Strep pneumoniae, GAS/GBS
What is the centor criteria
Need 3 or more to justify Abx treatment
Exudate on tonsils
Fever above 38
No cough
Anterior lymphadenopathy
When would you consider a tonsillectomy for tonsilitis?
Recurrent tonsilities
>5 episodes in two consecutive years
Complications of tonsilitis?
Sepsis Airway obstruction Quinsy Acute otitis media Recurrent
Aetiology of epistaxis?
Anterior-from little’s area- Klessielbachs plexus
Post Woodruffs plexus
Causes Infective- rhinits Trauma Neoplastic On anticoagulation Clotting abnormalities Substance abuse
Management of Epistaxsis?
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
Breast exam process?
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
What are the types of benign breast disease?
15-25 yo- Fibroadenomas
25-40- Cyclical nodularity and mastalgia
35-55- cystic disease, duct ectasia, periductal mastitis, hyperplasia
Types of breast neoplasms?
Benign- fibroadenomas, intraductal papillomas, lipomas
Malignant- Lobular/Ductal carcinomas in situ
Ductal carcinoma- 80%
Lobular- 10%
Medullary/mucinous/tubular/papillary carcinomas
Difference between in the breast of paget’s disease and eczema?
Paget’s disease involves the nipple
Eczema rarely involves the nipple
Describe the abdominal examination?
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
What are spider naevi?
Related to exess oestrogen:testosterone levels
Dilated BVs, fill from inside out
>5 is pathognomic
What is clubbing and what are the stages of it?
Pathological swelling of the distal phalanges 1- Congestion 2- Loss of angulation 3- Increase AP angle 4- drumsticking
Aetiology of clubbing?
Idiopathic 2o Endocarditis/ cyanotic heart disease Lung ca/Pulmonary fibrosis/COPD/Bronchiectasis GI cancer/IBD/Coeliac Thyroid acropatchy
Aetiology of dysphagia?
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
What is plummer vinson syndrome?
Chronic IDA deficiency leads to oesophagea webs
Dysphagia to solids more than liquids
Propsenity to go on and become SqCC
Epigastric masses DDx
Any mass- skin/subcutaneous/lipoma/ AAA/epigastric herniation/ epigastric hernia/panceratic pseudopolyps, pancreatic ca/gastric ca/ lymphadenopathy
Aetiology of hepatomegaly?
Physiology- Ridele's lobe Infective- hepatitides/CMV, malaria, TB/abscess Cancer- 1/2/lymphoma/leukaemia Cirrhosis- alcohol, wilson's, amyloid Vascular- RHF, Budd chiari
What is Budd chiari syndrome?
Heptaic vein obstruction
Due to thrombosis/ cancer
Clin feats of abdominal pain, hepatomegaly, jaundice, ascites
Cirrhosis definition and aetiology?
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
What are the autoAbs tests for PBC and PSC?
PBC- fat women forty, anti AMA
PSC- UC association, pANCA
Aetiology of portal HTN?
Pre hepatic- splenic/portal vein thrombosis
Hepatic- cirrhosis/liver ca
Post hepatic- Budd chiari/ RHF
What are Caput Medusae?
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
What are the causes of ascites?
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
Management of ascites?
Treat underlying cause C- salt and fluid restriction M- spironolactone S- pacacentesis TIPSS Liver transplat
Functions of the spleen?
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
Aetiology of splenomegaly?
Infective- HIV/abscess/TB/malarial Leukaemia and lymphoma (CML/NHL/myelofibrosis) Sickle cell and thalassaemia Splenic thrombosis/budd chiari syndrome RA/Sarcoid
Types of PCKD?
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
Clinical features of Chronic renal failure?
Think kidney functions HTN, HF Peripheral oedema 2o hyperparathyroidism Osteoporosis, hypocalcaemia Anaemia Uraemia leading to puritus, peripheral uropathy, gout
Definition of IBD?
Stool sample test for it?
Inflammatory bowel disease with an autoimmune and genetic component
Faecal calprotectin
UC macroscopic and microscopic appearance?
Non smokers Colonic and rectal disease Continous Submucosal inflammation Pseudopolyps and cryptal abscess
Thumbprinting and lead piping on barium enema
Complications of UC?
Cancer PSC Toxic megacolon Perforation Obstruction
Macro and microscopic appearance of Crohn’s?
Smokers Any part of GI tract Skip lesions Transmural ulceration with cobblestone pattern Granulomas Fistulas and strictures
Complications of Crohns?
Fistulas
Strictures
Obstruction
Infection
Extra-intestinal IBD manifestations?
Mouth Ulcers and Perianal skin tags- Crohns
IBD in general Eyes- Iritis and uveitis Arthritis Ank spon Skin- erythema nodosum and pyoderma gangrenosum
Crohns treatment pathway?
C- diet altering, stop smoking
M- Steroids, azathioprine, infliximab
S- segmental resections, strictuloplasty, fistulotomies- setons, open
UC treatment?
C- dietary changes
M- steroids, sulfasalazine
S- Proctocolectomy +- end ileostomy +- ileoanal pouch (curative)
Indications for surgical management of IBD?
Medical management not working
Complications
Definition of sinus and fistula?
Sinus is a blinding ending epithelial lined tract
Fistula is an abnormal connection between 2 epithelial lined surfaces
Cryptoglandular sepsis theory?
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
Management of fistulas and perianal abscesses?
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
Explain Goodsall’s rule
9 till 3- normal course
3 till 9 abnormal course
Difference between Lanz and Gridiron incisions?
Lanz medial to lateral
Gridiron is along Langer’s lines
Describe a hernia examination?
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
Describe a scrotal exam?
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
DDx of inguinal canal mass/lump?
Inguinal hernia Femoral hernia Saphena Varix Undescended testis Femoral Artery A Lymphadenopathy Skin lesions
What is a hernia?
Abnormal protusion of a tissue or organ through the wall of its normal cavity
Types of hernial repairs?
Open vs Lap herniotomy and herniorrhapy
Lichentstein’s- uses mesh to reinforce defect
Shouldice- if infection concerns, 4 layers of opposing muscle
Why are femoral hernia more likely in women?
Also types of femoral hernia repair?
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
Other types of hernia?
Umbilical Paraumbilical Brainstem Littre's- meckel's diverticulum Amyand- appendix Richter's- one side of bowel wall Hiatus Epigastric Spigelian- through semilunaris
DDx of a scotal lump?
Hernia- cant get above them
Separate to testis- varicocele, epidymitis, epidyimal cyst, spermatocele
Cant separate from testis- hydrocele, cancer, orchitis, haematocele
Types of undescended testis and complications?
Undescended- premature stopping of descent down gubernaculum
Retractile
Ectopic
Complications- torsion, tumour (seminoma risk is 30x normal), infertility
Treatment of undescended testis?
Wait till 1 year then orchidoplexy
Or orchidectomy
Or GnRH/bhCG may encourage descent
What is a hydrocele?
Aetiology?
Fluid collection within tunica vaginalis
Can also include Vas deferens
1o- patent processus vaginalis
2o- tumour, torsion, infection
Treatment of hydrocele?
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
Aetiology of epipyimal orchitis?
Viral- mumps, infectious mononeucleosis
Bacterial- e.coli vs chlamydia
What is a variocele and treatment?
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
Types of benign testicular tumours?
Leydig cell tumours- can cause precocious puberty
Sertoli cell tumours- gynaecomastia
Types of malignant testicular tumours?
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
Investigation and management of testicular cancer?
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
Stoma examination?
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
What are the types of stomas?
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
Indications for Stomas?
PEG feeding
Diversion to protect distal anastomosis
Emergency/planned resections
Inspection for all ortho exams?
4Ss + MDE Scars, sinus, symmetry, swellings Muscle wasting Deformity Erythema
C-spine/Neck exam?
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
Describe a spinal examination?
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
Describe the shoulder exam
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
Elbow exam?
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
Hip Examination describe?
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
Describe a knee examine?
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
Ankle and foot exam describe
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
What are the phases of gait?
60% stance, 40% swing phase Stance phase- heel strike Foot flat Mid stance Toe off
Types of gait pathology?
Shuffling- parkinsons High stepping- Common peroneal deformity Antalgic- one side affected Ataxic gait/broad gait- cerebellar Trendelenburg- duck waddling
What is rheumatoid arthritis?
Chronic systemic inflammatory disorder with an autoimmune component that primarlary affects the joints
4:1 women to men, <1% of population
Clin feats of RA?
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
Diagnosis of RA?
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
Treatment of RA?
C- hot and cold packs, patient education, weight loss, OT/PT M- WHO Ladder, steroids Methotrexate Sulfasalzine Infliximab S- athroplasty/athrodesis/synovectomy
Epidemiology of Ank spond?
Seronegative spondyloarthropathy, presenting mainly with EMS back pain in young men
RF negative
HLA B27 +ve
Clin feats and Dx factors for Ank Spond
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
Treatment of ank spond?
C- lifestyle changes, OT and PT
M- WHO, steroids, infliximab
S- osteotomy, athroplasty/desis
Paget’s disease of the bone- what is it?
Osteitis deformans
Abnormal osteoblast and clast activity with unknown aetiology
3 phases
Osteolytic then mixed then blastic
Clinical features and complications of Paget’s?
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%
How to Dx Paget’s?
Bloods- raised ALP,normal Ca/PTH/TFTs
Urinary hydroxproline- collagen breakdwon
Imaging
Treatment of paget’s?
C- lifestyle and PT/OT
M- WHO, bisphosphonates- decrease bone turnover, calcitonin- inhibt osteoclast activity
S- standard
Aetiology of a pain shoulder?
Trauma Rotator cuff tears Adhesive capsulitis OA Bursitis Septic Neoplastic MI- referred
What is adhesive capsulitis?
And how to manage it?
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
What is shoulder impingment syndrome?
Compression of supraspinatus tendon as it passess through the subacromial space
Painful arc from 60-120 and anterior shoulder instability
Causes of shoulder impingment syndrome?
Subacromial bursitis
Trauma/overuse
Bony spur from ACJ
Management of Shoulder impingmenet syndrome?
MRI- identify rotator cuff pathology
C- pt/limit activity
M- WHO, steroid injection
S- rotator cuff repair, subacromial decompression
What are claw toes?
Flexion deformity of PIPJs/DIPJs
Seen in RA and charcot marie tooth disease
Treated by tendon transfer/arthrodesis
What is hallux valgus
Bunions etc
Promience of 1st MT head
Due to chronic forefoot splaying
Rx- buinionectomy and realignment osteotomy
What is club foot
Talipes equinovarus
platar flex, add, inverted ankle
Congenital deformity
Treat by plaster/splinting
Surgical correction- tibialis ant lengthening
What is charcot’s arthropathy?
Neuropathic arthropathy
Progressive destruction of a weight bearing joint to peripheral neuropathy
Leads to skin breakdown and ulceration as well
Describe the hand exam?
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
What is dupytren’s disease?
Fibrotic disease of the palmar and digital fascia
Seen more often in white old males with diabetes
Smoking and infection risk factors
What is associations are there with Dupytren’s?
Peyronie’s disease- fibrosis of corpus callosum
Ledderhose’s disease- plantar fascia fibrosis
What is the management of dupytren’?
Indications for op when flexure contracture >30o
Pain and increasing disability
C- lifestyle mods
M- WHO
S- fasciotomy, fasciectomy, dermatofasciectomy +- flap, amputation
What are the complications of Dupytren’s fasciectomy treatment?
NVI infection, flap necrosis, haematoma 10% reocurrence Scar contracture Wound breakdown
What is a ganglion?
Mucinous filled cyst near joint/tnedon
70% on dorsum of wrist
What are trigger fingers?
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
Describe the Vascular Exam?
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
Varicose vein exam describe?
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
What are the 6ps of PAD?
pulseslness, pale, perishingly cold, parasthetsia, paralysis, painful
What are the symptoms of peripheral arterial disease?
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
What are the criteria of ABPI and pathology?
> 1,3- calcified vessels-?diabetic
0.9-1.3- normal
<0.9- moderate critical disease
<0.5- severe critical disease
What is spinal stenosis?
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
What is the difference between acute and chronic limb ischaemia?
Acute generally less than 14 days
Can be acute on chronic
Acute more likely to be an embolic event
what is a AAA?
Abnormal dilation of abdominal aortic artery- >4.5cm
Risk of AAA rupture?
And monitoring criteria?
Indications for Op?
<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
What is subclavian steal syndrome?
Proximal subclavian artery lesion
Leading to ischaemic arm symptom and brain symp on exercise
Vertebral artery reverses flow to compensate
What is thoracic outlet syndrome?
Compression of Subclavian NAV at clavicle/1 st rib area
Aetiology of thoracic outlet syndrome?
Congenital- cervical rib
Acquire-#/scalene hypertrophy
Neoplastic compression
How to identify thoracic outlet syndrome?
Roo’s/Adson’s test
USS
CT
What is raynaud’s syndrome?
Digital vasospasm with 3 clear transition stages
White- ischaemic
Blue- cyanotic
Red- Hyperaemic
Aetiology of Raynaud’s?
1o- idiopathic 2o- RA/scleroderma Traumatic/chronic use Athersclorotic B blockers Polycythaemia
Management of Raynaud’s?
C- warm gloves, avoid precipitants
M- nifedipine
S- sympathectomy- either digital or thorascopic T1-3
Indications of treatment of carotid artery stenosis?
If occlusion 50-99% and surgery done within 2 weeks of event
ASymptomatic, <75yo and >70% occlusion
Aetiology of DVTs?
Virchow’s triad- damage, stasis, hypercoagulable
75% are silent
Homan’s sig- pain on dorsiflexion?
DVT prevention stratergies?
C- early mobilisation, compression stockings, hydrate, flowtrons
M- LMWH, IVT, stop COCP 4 weeks prior to op
S- Avoid GA, vena cava filters
What is deep venous insufficiency?
Post DVT syndrome/congenital abscence of valves/AVM
Leading to increased venous pressure in superfiscial veins
Test with Perthe’s test
What are varicose veins and causes?
Tortous dilated superfiscial veins
1o
2o- DVT, pregnancy, overuse, long standing, klippel-trenaunary syndrome
Treatment of varicose veins?
C-weight loss, compression stockings S- sclerotherapy Multiple stab avulsions High ligation Low ligation Vein stripping Laser/radiofrequency ablations
What makes up an AMTS?
Age Time Street remember Year Current location DOB WW2 Prime minister Identify 2 people Count backwards Remember street
What makes up a MMSE?
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
Describe GCS?
Cranial Nerve examination?
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
Describe a peripheral nerve examination?
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
What are the myotomes for upper and lower limbs?
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
Reflex levels?
Biceps- C5/6
Triceps is C7/8
Ankle is S1/2
Knee is L3/4
What is the aetiology of lower back pain?
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
What is a disc prolapse and what are the stages?
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
Back pain red flags?
Fever, weight loss, shocked Bilateral radiculopathy Bladder/bowel dysfnx Preceeding trauma Saddle anaesthesia Incontinence
3 classifications of Cauda equina syndrome?
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
Management of cauda equina syndrome?
Neurosurgical emergency
Nerve ischaemia at 6 hours
Requires surgical decompression
Reasonable recovery if done within 24 hours of onset of symptoms
What are the CT head criteria?
<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
When to refer head injuries to neuorsurgery?
GCS<8/ >2 points deterioration Progressive neurology Open injury CSF leak Seizure without full recovery
Management of brain injuries?
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
Indications for NS intervention in a traumatic brain injury?
> 5mm midline shift on CT
Intercerebral haematoma with >40cm
Depressed/open skull #
Causes of ICH?
Stroke- haemorrhagic
Trauma
SAH
Spontaneous
RFs for spontaneous ICH?
Old
Hypertensive/blood dysacrias
Aneurysm/AVM
Cocaine/amphetamines
Causes of SAH?
Idiopathic Aneurysmal- berry (ADPKD) AVM Endocarditis Blood dysacrias
How to diagnose SAH?
CT Head- 96% sensitivity if done before 6 hours
LP at 12 hours for bili levels
How to investigate and treat cranial aneurysms?
CTA/MRA
Catheter angio
Rx- Interventional coiling
Operative clipping
What is a defnition of a stroke?
Global or focal neurological deficit 2o to vascular cause lasting >24 hours
Risk factors for stroke?
Age, FHx, HTN, hypercholestrolaemia, AF, anticoagulants, protein C deficiency, diabetes, poor diet, obestiy, smoking
Where is CSF produced and absorbed?
Produced in choroid plexus
Absorbed by arachnoid villi
150mls circulating, 480mls produced a day
Hydrocephalus definition and clinical features?
CSF production and absorption balance
Leads to increased head size/headaches RICP Memory problems Focal neurology Seizures Coma
Aetiology of hydrocephalus?
Increased production- choroid papilloma
Decreased absorption- sinus thrombosis/NPH
Obstruction of flow- thalamic/cerebellar tumours
Management of hydrocephalus?
Furosemide and decrease secretions
Serial anterior fontanelle taps/LPs
VP shunt
Vatrial shunt
Vpleural shunt
Risk factors for brain tunmours?
Immunocomprimised
Genetic- Li fraumeni
FHx
Radiation exposure
Types of intra axial brain tumours?
Gliomas- 70%
Astrocytomas, oligodendromas, ependyomas
Lymphomas 3%
Extra-axial brain tumours?
Menigiomas
Pituitary
Cerebllopontin- acoustic neuromas
Commonest metstastic brain tumours?
Lung (60%) and breast (20%)
Imaging characteristics of brain tumours on CT?
Gliomas- large singular brain lesion with central area of necrosis and enhancing ring
Mets- small, multiple, disproportionately excessive peri-orbital oedema
Treatment of brain tumours?
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
Describe a radial nerve exam?
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
What is teh course of the radial nerve?
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
What does a high and low radial nerve defect cause?
High- wrist drop
Low MCPJ drop
Describe a median nerve examination?
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
Course of the median nerve?
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
Describe an Ulnar nerve exam?
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
Ulnar nerve course?
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
What sort of clinical signs does an ulnar nerver palsy give?
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
Aetiology and presentation of Aortic stenosis?
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
Aortic regurgitation aetiology and presentation?
Congential bicuspid, rehum f, endocarditis/aortic root pathology-aneurysm/marfans
Early diastolic murmur in aortic region
exertional dysponea
Collapsing pulse
Mitral stenosis aetiology and presentation?
Rheum fever/endocarditis
SOBOE/palpitations/AF
Diastolic murmur in mitral region
Mitral regurg aetiology and presentation
Commonest valvular abnormality in the world
Rheum/MI/myxomatous degeneration
SOBOE/palpitations
Pansystolic murmur to axilla/apex beat displacement
Risk factors for atheroscleosis?
HTN Hypercholestrolaemia DM FHx Smoking Obesity
What is Marfan’s disease?
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
Describe the cardiac examination
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
Describe the respiratory examination?
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
Types of lung cancers?
Small cell lung cancers
Neuroendocrine cells- smoking association, quick mets
Nonsmall cell
Sqcc, adenocarcinoma, large cell
Spread of lung cancers?
Paraneoplastic disorders?
Local
Lymphatic
Mets- liver, brain, bone, adrenals, ContraL
Neuroendocrine disorders
Sqcc- PTHrP
SCLC- SIADH, Cushings
