Exams Flashcards
Ankle Exam
Look, Feel, Move
Walking, weight bearing, general inspection (wounds, deformity, swelling, bruise, asymmetry)
Feel for swellings, temperature, palpate each bone, and major joints/tendons, pulses, vascular compromise (CRT)
Palpate - Posterior tibialis tendon, Medial malleolus, deltoid ligament, navicular tuberosity, peroneal tendons then lateral malleolus, follow along peroneus brevis to 5th meta-tarsal, ATFL anterior to lateral malleolus, calcaneo-fibular ligament interiorly, PTFL posteriorly
Active movements - dorsi and plantar flexion, inversion and eversion/pronation
Tests - Anterior drawer - 20 degree dorsiflex and quick anterior pull, Thompson - squeeze calves
Complete exam with full neurological exam and knee exam (joint above)
Ankle block:
Introduce self to patient, consent for procedure with risks, ask about blood thinners. Systemic reaction to anaesthetic. Ensure there is a nurse available to assist. Small dose of pain relief prior.
Collate all equipment and laid out neatly.
Good lighting
General considerations:
- 4 terminal branches of sciatic nerve (deep and superficial peroneal, tibial and sural and 1 cutaneous branch of the
femoral nerve (saphenous)
- all nerves needs to be anaesthetised to ensure adequate foot blockade
Chlorhexidine prep and drape
MEDIAL TO LATERAL
Start with tibial nerve - Find PT pulse, go 1-2cm above medial malleolus and infiltrate behind artery
Now at that same level I will do a superficial injection medial to saphenous nerve
Continue along that line sort of like a ring block superficial - superficial peroneal
Continuing along the same line - lateral malleolus and achilles –> aural nerve
Conclude - EHL and TA inject between them hit bone perpendicular and inject whilst retracting
MOA of local anaesthetic:
DOSE DEPENDENT blockade of Voltage gated sodium channels on nerves –> AP blocked –> no sensation of pain
Lower PKA - faster but also means that in acidotic environment going to have more ionised form and thus less effective
Higher hydrophobicity = greater potency
Increased protein binding is longer duration
The main symptoms of local anesthetic toxicity involve the CNS and cardiovascular system. The earliest signs of an overdose or inadvertent intravascular injection are numbness or tingling of the tongue or lips, a metallic taste, light-headedness, tinnitus, or visual disturbances. Signs of toxicity can progress to slurred speech, disorientation, and seizures. With higher doses of local anesthetics, cardiovascular collapse will ensue
Fluid balance
Total fluid requirement = Maintenance + Replacement of deficit + Replacement of ongoing losses
Bowel dilatation associated with compression of mucosal lymphatics leading to significant bowel wall oedema + increased secretory activity = large 3rd space fluid shifts with loss of electrolytes and proteins into the intestinal lumen
Calculate fluid requirements from lean body weight as fat relatively inert
60% of body weight is TBW - if detected losses but no circulatory collapse likely around 10-15% loss
Want to check end points of BP including posturals, tachycardia, urine >0.5mL/kg/hr
ADH and aldosterone contribute to fluid losses
300-400mL lost in faeces per day, 300mL endogenous metabolism, 700mL loss from skin - this can all be increased in pyrexia or tachypnoea
Potassium released by damaged tissues
Give 5% glucose with NaCl vs hartmann’s
Hyperchloraemic metabolic acidosis
They react with bicarbonate in an attempt to buffer the pH. However, this will deplete bicarbonate stores leading to an acidotic state. Large volume resuscitation with normal saline leads to an overload of chloride ions into the blood. As stated previously, chloride and bicarbonate work together to maintain an ionic balance of the cellular space. Hyperchlorhydria forces bicarbonate to move intracellularly to maintain ionic equilibrium, thus reducing the available bicarbonate for the pH buffering system leading to net acidosis.
Calculated using the “4-2-1” Rule:
For 0-10 kg: 4 mL/kg/hr
For >10-20 kg: 40 mL + 2 mL/kg/hr for every kg >10 kg
For >20 kg: 60 mL + 1 mL/kg/hr for every kg >20 kg
Ischaemic Ulcer
Site - Tips of toes and pressure areas
Shape - Small to large
Edge and base - Punched out, clean, potentially slough. Sometimes infected - no granulation tissue as no good blood supply - Deep + penetrating to bone
Surrounding skin - Grey/blue
Feel - Temperature
Peripheral pulses of both legs
Small vessel vs large vessel disease
Can be extremely painful!
Tx:
Risk factors modification
Avoid beta blockers
Aspirin sometimes
IV Prostaglandins
Lumbar sympathectomy for diabeteics - vasodilatation
Neuropathic ulcer
Ddx:
TB
Pyoderma gangrenosum
Syphilis
AV fistulae
RA
SCC
Sickle cell disease
SIte - pressure areas, metatarsal heads, sole of foot, balls of toes, heel
Shape - Irregular, correspond to shape of pressure point
Edge and base - Clean edge, base may be deep
Surrounding skin - normal blood supply so usually normal
Temperature normal
Peripheral pulses normal
PainLESS
Associated sensory loss - pinprick
Complete with a full neurological exam including cranial nerves
Causes
Systemic disease - Diabetes, SLE, Hypothyroid, B12 deficiency
Drugs - Alcohol, toxins, amiodarone
Infections - TB, leprosy, HIV
Carcinomas - Lung cancer
Idiopathic
Peripheral neuropathy - glove and stocking, sometimes motor impairment, claw toes, prominent metatarsal head
Autonomic neuropathy - reduces sweating –> cracking
Repetitive painless injury –> progressive skin loss and ulceration
Shoulder exam
Inspection
Palpation
Range of Motion
Neurovascular
Provocative tests
INSPECTION
Important to compare both shoulders
skin
scars
symmetry
swelling
atrophy
hypertrophy
scapular winging
Palpation:
All bony prominences including
cervical spinous processes
sternoclavicular joint
clavicle
acromioclavicular joint
acromion
coracoid process
scapular spine
Muscles and soft tissues including
paraspinal muscles
periscapular region
deltoid
rotator cuff tendon insertion / greater tuberosity
long head of the biceps tendon in groove
ROM:
Cervical spine range of motion
flexion
extension
lateral flexion
rotation
Shoulder range of motion
Order of tests:
AC - Scarf’s - Adduct arm across body
Subacromial Impingement - Neer’s - Flex and rotate thumb down, Hawkin’s - 90 degree dab then quickly internally rotate
Supraspinatus - Empty can
Infra+Teres - External rotation
Subscapularis - Lift off test
Bicep’s - Speeds test
O’Brien’s test - Anterior labrum
Apprehension - Labral tear
Claudication
Risk factors:
HTN
T2DM
Smoking
Dyslipidaemia
IHD
CVA
AAA
Aetiology:
Atherosclerosis
Thromboangitis obliteratans
Vasculitis
Arterial trauma
Cystic adventitial disease of popliteal artery/popliteal artery entrapment
Ddx:
Spinal canal disease
Sciatica
Peripheral neuropathy
Exam:
HTN, cardiac dysfunction
Carotid bruit
Chronic airways disease
Abdomen for AAA
Peripheral pulses
Leg for evidence of ischaemia (pale when leg elevated but pink in dependent)
Ulceration and necrosis, dry gangrene
Muscle atrophy
ABI!!
- y comparing the blood pressures in the brachial (which is assumed to be normal) and the vessels at the ankle (dorsalis pedis and posterior tibial), an estimation can be made of the adequacy of arterial blood flow in the leg. In an individual with normal arteries the ankle–brachial index is expected to be 0.9–1.2, Most claudicants often have an ABI of 0.5–0.9. A value below 0.5 is often associated with rest pain and when the ratio gets to less than 0.3, viability of the limb may be in jeopardy
First level investigations
- BSL, Lipid profile, Biochemistry (renal impairment), HBA1c
Options - percutaneous vs operative (only if symptoms disabling or CLI) + Aggressive risk factor control
CLI have 40% limb loss at 1 year, 20-30% mortality 1 year (cardiovascular)
Thyroid exam
Thyroid part:
Inspection from front - ask to swallow and stick tongue out
Stand behind - ask to stick tongue out and then swallow with fingers on each lobe
Palpate each lobe
Lymph nodes
Thyroid bruit
Percuss over sternum from notch downwards - retrosternal extension
Tracheal deviation
Ask them to speak to check phonation
Hands - sweating, palmar erythema, thyroid acropathy, oncoolysis, vitiligo
Pulse - AF/Tachy
Fine tremor
Eyes - Loss of outer third of eye bows, lid retraction, lid lag, ophthalmoplegia when looking up and out usually - ask if any diplopia, exopthalmus, chemises, proptosis
Shins for pre-tibial myxoedema
Complete by looking for proximal myopathy, reflexes
Cardiac failure
Brachial Plexus
Start with general inspection:
Horner’s, wasting, scars, any obvious position - Erb’s, ulnar claw, winged scapula
Then start with dermatome’s and myotome’s as a screening
Sensory first
Motor - C5 shoulder abduction - axillary, C6 Elbow flexion - MSC, C7 Elbow extension - Radial, C8 Wrist flexion, T1 Finger abduction
After this will do tests for major nerves - Axillary - regiment patch, shoulder abduction, Radial - Extension - Already done, Elbow flexion already done from musculocutaneous already done - also does supination, Then do ulnar nerve - which is already done from finger abduction but can also do Froment’s if concern for injury. Median nerve can do okay sign test
Median= anterior division of all
Radial - posterior division of all
Ax - C5-7 posterior division
MSC - C5-6 anterior division
Then can work backwards depending on wherever I think things are
Medial cord - Medial arm sensory, medial pectoral
Posterior cord - Thoracodorsal, upper and lower subscapular
Lateral cord - Lateral pectoral
Superior trunk - suprascapular
C5-7 nerve roots - long thoracic nerve
Knee Exam
General inspection - scars, swelling, asymmetry, increased valgus/varus
Walk
Single leg squat - genu valgum
Whilst standing do Thessaly
Inspect and palpate with patient sitting down
- Quadriceps tendon
- Patella - move it medially and laterally to feel underneath it
- Patellar tendon
- Tibial tuberosity
- Medial meniscus
- MCL
- Pes anserine bursa
- Lateral meniscus
- LCL
- Balot fibular head
- ITB - above lateral femoral condyle
- Baker’s cyst
Tests:
Lachman - Won’t feel endpoint
Valgus MCL - Foot out
Varus LCL - Foot in
If varus or valgus stress when leg straight then ACL involved
Medial meniscus flexion extension whilst foot pushed in - look for click
Same thing but out for lateral
PCL - sag sign, posterior drawer
Can do anterior drawer for ACL (not as sensitive as Lachman)
To finish will do full lower limb neurological exam
Varicose veins + venous ulcer
3 S’s - Size and site of varicosities, skin for changes and scars, swelling of ankle
3 S’s State of skin/subcutaneous tissues, sites of fascial defect, sites of incompetence
LEGS - Lipodermatosclerosis, Eczema, Gaps in skin, Swelling
Trendelenburg / Tourniquet test
Bruits
Abdominal exam - masses, DRE
Doppler assessment
ABI - pre compression
Tx:
Compression, weight loss, exercise (do ABI before compression)
Sclerotherapy
Ligation - stripping, endovascular - 20% 5 year recurrence
Site/Shape/Edge+Base/SKin/Warmth
Immediate - thyroid storm, hoarseness, haemorrhage, infection, hypoparathyroidism, hypocalcaemia, hypothyroidism, hypertrophic scarring
Pigmented skin lesion
Suspicious = Loss of normal surface markings, ulceration, bleeding, variation of colour, brown pigment in skin around, satellite nodules of tumour around lesion
SCC - 1cm margin down to subcutaneous fat
BCC - 3-4mm for small lesion, tumours raised above skin 0.5cm, tumours not raised above skin and larger - may need larger than 5mm (can use Moh’s method)
Melanoma - 1cm margin down to deep fascia for<0.76mm lesion, unto 1mm - 2cm margin, over 1 mm 3cm margin
SCC
Ddx:
Keratoacanthoma
Sebhorreic wart
Solar keratosis
Pyogenic granulmoa
BCC
Amelanocytic melanoma
Predisposing
Congenital - xeroderma pigmentosum
Acquired - sunlight, radiation, carcinogens, pre-existing skin lesions, viral wards (HPV 5 + 8), Immunosuppression
Sun exposed spots
Vascular - red-brown, raised and everted edge, >1cm, Erosion of facial architecture, central ulceration
Melanoma
Risks
Congenital - xyderma pigmentosum, dysplastic naevus, large congenital naevi, family history 1.5x risk in first degree
Acquired - sunlight UV especially, pre-existing skin lesions, previous melanoma 3.5x risk
Legs of young women, trunk of middle-aged men
Presence of naevi - predictor
Commonest young person cancer, W>M
Superficial spreading - 70%, red + white + blue in colour, irregular edge, palpable but thin
Nodular - 15-30%, trunk, polypoid in shape and raised, smooth surface, irregular edge, ulcerated most of the time
Lentigo maligna - Face, dorm of hands and fore-arms, flat and brown to black with irregular outline, malignant area is thicker and darker
Acral lentiginous - Least common, hairless skin, irregular area of brown or black pigmentation
Always check draining lymph node
BCC
Ddx keratoacanthoma, SCC
Hair bearing sun exposed skin especially around eye
Raised above skin - nodular type with central ulceration and well-defined pearly edge OR cystic - large cystic nodule
Not raised - pigmented (not melanoma), sclerosis (flat depress, ill-defined edge, may be ulcerated), cicatricial (multiple superficial erythematous lesions with pale atrophic areas), superficial (erythematous scaly patches)
Palpate - make sure no fixation to deep skin
Congenital (rare):
* Xeroderma pigmentosum (familial condition associated with failure of DNA transcription, leading to defective DNA repair) - also known as Kaposi’s disease (see Cases 1 6 and 35)
* Gorlin’s syndrome (see below)
Acquired (very common):
* Sunlight (particularly ultraviolet light in the UVB range)
* Carcinogens, e.g. cigarette smoke, arsenic
* Previous radiotherapy
* Malignant transformation in pre-existing
skin lesions, e.g. naevus sebaceous.
Grafts and flaps
Where will a graft fail?
Unhealthy, necrotic and infected tissue
Irradiated tissue
Exposed cortical bone without periosteum
Tendon without peritendon
Cartilage without perichondrium
Harvest - from site that can be concealed, use dermatome or get full thickness
Skin flap = tissue / tissues transferred from one site of body to another while maintaining a continuous blood supply through a vascular pedicle
Flap when skin grafts won’t take, when aiming to reconstruct like for like, blood supply has to be imported
Ladder
Secondary intention and primary intention prior to reconstruction
SKin graft
Local flap
Distant flap
Composite flap
Island vs pedicle flap
Free tissue transfer
Neurovascular free tissue transfer
