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 - 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
Inspection
Palpation of pulses, sapheno-varix, oedema, along the line of the veins
Tap test
Trendelenburg / Tourniquet test
Perthe’s
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
Salivary gland swelling
Ddx
In parotid
Pleomorphic adenoma, malignant tumour, lymphoma and leukaemia
Stones
Infection - mumps, sialadenitis, HIV
Autoimmune - Sjogrens
Sarcoidosis
Lymph node
Temporal artery aneurysm
Cirrhosis, DM, Pancreatitis, Acromegaly
Outside
Lipoma, infection, hypertrophy of master, winged mandible, transverse process of atlas/axis, infra temporal fossa and parapharyngeal tumours
Inspection - swelling, scars, asymmetry (7th nerve palsy)
Palpate - Tenderness - unilateral vs bilateral, fixed to skin? - Masseter + sternocleidomastoid, lymphadenopathy
Look inside mouth and look opposite second molar - floor of mouth as well - pus, stone, infection
Palpate parotid duct and submandular duct opening with pair of gloves
Bimanual submandibular gland with one in mouth and one angle of jaw
Test facial nerve, perform full ENT exam
Ix:
FNA
MRI to exclude deep nerve involvement
Superficial vs deep parotidectomy
Complications
Facial nerve transection
Haemorrhage
Infection
Neuropraxia
Fistula
Greater auricular nerve damage - loss of sensation to pinna
Wound dimple
Frey’s syndrome - increased sweating when eating - reinnervatino of divided sympathetic fibres
IF SUBMANDIBULAR - not facial/greater auricular but lingual or hypoglossal nerve for submandibular nerves)
80 in parotid, 80 of these benign, 80 of those benign being pleomorphic adenoma
10% of tumours occur in submandibular gland, 60% of submandibular tumours being benign (therefore submandibular more likely to be malignant than if parotid)
Surgical causes of hypertension
Secondary causes of hypertension =
Endocrine - Phaeo, Cushing’s, Conn’s (plasma metanephrine, plasma aldosterone to renal activity ratio, DST + early morning cortisol)
Renal - renovascular disease, renal disease (haematuria, infections, diabetes, stones)
Other - coarctation of aorta, OCP - Full drug alcohol and smoking history
Family history ohypertension, renal/endocrine, tumours
Associated diaphoresis, tremor, tachycardia, headache, blurry vision
Truncal obesity, easy bruising, acne, delayed wound healing, skin infections, facial redness, facial hair, period changes, muscle weakness, osteoporosis, polyuria/polydipsia, psychological changes
HTN + Hypokalemia = Conn’s
Need to do lying and standing blood pressure, RF delay, fundal examination, renal artery bruit
Inguinal hernia
Ddx
Lymph node / cord lipoma
Sapheno varies, skin lesions
Hernia
Aneurysmal dilatation of femoral artery
Psoas abcess / bursa
Ectopic / undescended testis
Breast Exam
When inspecting the nipple, or taking a history of
nipple symptoms, look for:
* Discolouration
* Discharge
* Depression (often referred to as inversion)
* Deviation
* Displacement
* Destruction
* (Duplication - unlikely in the exam).
- Surface: irregular or nodular
- Edge: poorly defined, with areas which are more like normal breast tissue in between more abnormal areas
- Consistency: breast tumours are usually firm, rather than hard
- Tenderness: usually non-tender
- Fluctuation: usually not fluctuant
- Fixation: to skin or the underlying chest wall * Any involvement of the nipple in the lump or
concurrent nipple changes
Malignant disease:
* Ductal carcinoma (also referred to as cancer of no specific type), accounts for -70% of cancers
* Lobular carcinoma, accounts for -20% of cancers
* Other (mucinous, tubular, medullary), accounts for -10% of cancers
Benign disease:
* Congenital abnormalities (supernumerary nipples, hypoplasia, etc.)
* Aberrations of normal development and involution (ANDI)
* Fibroadenomas
* Breast cysts
* Sclerotic/fibrotic lesions
* Non-ANDI conditions:
* Infective
* Lipomas
* Fat necrosis
Single lumps - cysts, fibroadenoma, necrosis or cancer
Flap reconstruction
* More extensive surgical scarring
* Scars extend over the back or abdominal
wall
* Look at the patient’s back and see the
recess where the latissimus dorsi has been
removed
* Ask the patient to lift their head off the bed (when lying flat) to see the recess in the rectus abdominis muscle.
Implant reconstruction
* Shape is rounder than a ‘normal’ breast
* Lie of the breast is usually higher
* A Becker implant may have a palpable
subcutaneous filling port in the axilla.
Post operative hypotension
4 causes of shock
Distributive, Hypovolaemic, Cardiogenic, Obstructive
Sepsis/anaphylaxis, haemorrhage/dehydration, MI, PE
CCRISP Algorithm
ABCDE - Airway, Breathing - Oxygen 100%, Circulation - Ensure 2 wide bore IV cannulas, commence fluid resuscitation at least 500mL bolus (hang 1L bag up) , D- GCS, E- Consider IDC insertion for fluid status monitoring, consider central line, ECG/CXR if required, consider starting IvAbx
When happy stable - focussed assessment of patient
Review chart, full history, full exam
- Ensure look at all drains, line sites, full head to toe, look for rashes, angioedema,
JVP elevated at 45 degrees and also whether collapsing when lying flat
Mucous membranes, skin turgor
Peripheral oedema, suggestion of DVT
Heart and lung auscultation and percussion
Full set of bloods including gas
Post operative confusion
Surgical causes - atelectasis, wound infection or abscess,n complications of anaesthesia/complications specific to surgery,
- Find out if acute and fluctuating - has it happened before, check co-morbidities, medications (any new), any issues intra-operatively, check obs, fluid balance, recent investigations
CCRISP, full chart review (bowels and bladder), history and exam
Essentially anything can cause confusion - want to look for infection, fluid status assessment, listen to heart and lungs, abdominal exam including bladder scan, consider PR exam (if suspected constipation), look for DVT, pressure sore/infection
Do an ECG, urine dipstick + MCS
Send off bloods
Collateral Hx if required - consider withdrawal
Treatment - find intending cause and treat that
Non-pharm and pharm
- Day night cycle
- Normalise environment similar to home
- 1 to 1 nursing
- Single room
Psychotropics only when necessary for safety
FBC, UEC, LFT, Cardiac enzyme, wound drain blood cultures, CXR, ABG
Collapsed man
Drug abuse track marks
Seizure - tongue biting or incontinence
Medication - bracket, iphone
Signs of chronic liver disease
Head injury
Trauma
Alcohol breath
Collateral, never forget BGL
Call for help
ABCDE
- Oxygen, 2 IVC, IV benzo (loraz) or Midaz - IM Midaz 5mg if unable to get access
- Bloods, tox screen, anti-epileptic drugs, ABG, pH
Vertigo
Eye for nystagmus, fundoscopy
Dysarthria
Facial sensory loss
Upper motor neurone signs - limb or gait ataxia
Ear - tympicanc membrane and hearing
Cranial nerves
Full neuro exam including UL + LL and Cranial nerves
HINTS
Caput Medusae exam
DDx
Portal hypertension - pre-hepatic (pericarditis, heart failure), hepatic (liver disease, schistosomiasis, budd-chiari syndrome), post-hepatic (malignancy - pancreatic, bowel, kidney, retroperitoneal fibrosis, post surgical), coagulopathy related
IVC obstruction (also malignancy etc.)
Pregnancy
Iatrogenic
Congenital
Begin at abdomen then move to hands, face, chest, rest of body
WIPE
FIRST OBS + GENERAL INSPECTION
Abdomen - Inspection, look at caput medusae - see where from, palpation, hepatic-splenomegaly, shifting dullness, murphy’s
Hands - leukonychia, palmar erythema, pallor of palmar crease, jaundice, pruritic marks, clubbing
Eyes - icterus, hepatic fetor
Neck - JVP at 45
Chest - spider naevi, heart, pericardial rub or knock,
Legs - same as hands and legs, peripheral pitting oedema
Paediatric Resus
EMST principles
A + C spine stabilisation - need to put spine board for toddler at occiput large
B - If tension pneumothorax if using 14/18 gauge needle need to make sure wary of needle length. Pre-oxygenate before intubation - 0.1mg/kg midaz, 0.6mg/kg roc
C - 45% blood volume loss = circulatory compromise. Estimate 80mL/kg plasma volume. Estimate weight as 2xage + 10
D- GCS
E - UO 1-2mL/hr at least depending on age.
Remember different ETT tube, remember can’t get large IVC in
Remember different CPR
Post operative confusion
WIPE
ABCDE
General inspection, vital signs
Hands - tremor (opioid withdrawal, metabolic disorder, hypercapnia), asterixis (uraemia), capillary refill time (hypo perfusion), cold or sweaty hands, peripheral cyanosis, pulse (AF)
Face - conjunctival pallor
Neck - Neck stiffness, carotid bruid, JVP
Chest - auscultation of heart + palpate apex beat, auscultate and percuss chest
Abdomen - inspection, palpation, bowel sounds, tenderness over bladder (bladder scan), DRE ?constipated
Legs - unilateral swelling, pitting oedema, peripheral neuropathy signs, cellulitis
Gross UL+LL+cranial nerve exam
Bedside - bladder scan, ECG, BSL, urine dipstick/MCS
Bloods - VBG (acidosis/alkalosis), fbc(infection, anaemia), crp (infection), uec (AKI, uraemia), LFT (drug reaction from anaesthetic/medications administered), coag (if concern for clot/dvt), blood cultures
CXR +/- CT PA/AP/other
Abdominal Exam
WIPE
General inspection
Exposure neck to pubis, pt. sitting on bed
Habitus, scars, jaundice, distension, masses
Hands
Koilonychia (spooning) – Fe Deficiency anaemia
Leukonychia (white marks on nails) – Trauma, Vitamin/Protein deficiency
Dupuytren’s contracture (EtOH) and palmar erythema
Clubbing
Asterixis, hepatic flap/tremor = Liver disease, uremia
Arms
Acanthosis Nigricans (axilla) – hyperpigmentation, in diabetes/tumours of stomach or liver
Face and eyes
Xanthelasma: cholesterol deposits
Conjunctival pallor: anaemia
Jaundice: raised bilirubin
Oral exam
Angular stomatitis – B12 deficiency/Iron deficiency
Oral candidiasis
Mouth ulcers
Glossitis – B12 deficiency
Neck
Lymph nodes
Supraclavicular nodes: left is Virchow’s (Gastric ca)
Chest
Spider naevi – Portal venous hypertension/cirrhosis
Gynaecomastia – liver disease
Abdomen
Position flat
Inspect
Scars & striae, masses, distension, pulsation, stomas
Palpation
Light and deep, monitor face for pain
Rebound tenderness
Palpate Liver/Spleen – breathe in, work up from RIF
Murphy’s sign – Gallbladder, pain on inhalation
McBurney’s point – rebound tenderness, 1/3 from ASIS to umbilicus
Rovsing sign is rebound tenderness on opposite side.
Ballot kidneys
Palpate the aorta
Percuss
Liver/spleen/bladder
Shifting dullness (ascites)
Percuss laterally from umbilicus until dullness
Roll pt. away dullness (percussing hand up top)
Wait 30s and percuss again
Auscultate
Bowel sounds
Aortic/renal artery bruits
Inguinal hernias, DRE, External genitalia if indicated
Hip Exam
Look
Adequate exposure (1 joint above and below)
Pt. standing, look for erythema, scars, wasting of gluteal muscles (damage of superior gluteal nerve during hip surgery), fixed flexion deformity, lumbar lordosis due to OA of hip
Walking aids?
Have pt. walk and assess gait
Observe gait cycle, symmetry
Trendelenburg gait (waddling gait): weakness of hip abductor muscle forcing pt. to use trunk muscles to lift pelvis high enough to swing leg through
Antalgic gait: short stance phase on affected side due to painful hip
Pt. lying flat on bed
Assess for leg length discrepancy (ensure ASIS are level with each other and assess whether leg is same length)
True discrepancy due to bones being of unequal length often due to previous fracture…measure from ASIS to medial malleolus
To determine which bone is the cause of leg length discrepancy, bend the knees forward at 90 degrees and assess femoral length
Apparent discrepancy is due to joint deformity e.g. fixed flexion deformity…measure from xiphisternum/umbilicus to medial malleolus of each leg
Feel
Skin: distal sensation, temperature
Soft tissue: tenderness, peripheral pulses (femoral, popliteal, dorsalis pedis, tibialis posterior)
Bone: Palpate greater trochanter on lateral hip (tenderness indicates greater trochanteric bursitis)
Move
Supine
Hip flexion: pt. actively flexes hips, then perform passively (normal range 120 degrees)
Hip extension: hold onto one leg and fully extend other leg, repeat on other side
If pressure on examiner’s hand under back lessens, then this suggests pt. has fixed flexion deformity and lifting pelvis in order to extend leg
Can also do with patient face down, lift leg off table
Hip rotation should be tested in mid-range
Flex hip and knee to 90 degrees, then internally and externally rotate hip passively (normal external and internal rotation ~45 degrees)
Reduced internal rotation early sign of OA
Hip Abduction and Adduction
Active
Passive: place hand on each hip and abduct and adduct, noting angle when pelvis starts to move under hand
Normal abduction 45 degrees, normal adduction 30 degrees
Special tests
Trendelenburg test (weakness of hip abductor due to chronic pain, hip injury, childhood diseases e.g. developmental dysplasia of hip)
Pt. standing facing you, hands on your hands
Pt. stands on one leg
Test is positive when pt. tries to stand on one leg and pelvis falls on side with foot off ground…pt. will react by pushing down on hands to hold position
Weak hip abductors on contralateral side to falling pelvis
Do Storck test at same time - SIJ
Thomas’ Test
Hand under back, passively flex unaffected leg as far as able, back should be pushed flat along hand
Positive test if contralateral affected thigh raises off bed indicating loss of extension in hip suggesting fixed flexion deformity in hip
FABER Test (flexion, abduction, external rotation of hip)
Hip pain indicates intra-articular pathology e.g OA
Back pain SIJ
FADIR (flexion, adduction, internal rotations of hip)
Anterolateral hip pain suggests femoral acetabular impingement
To complete exam;
Examine spine, knee
Neurovascular exam
Imaging
Lower Limb Neurological Exam
General inspection
Expose legs
SWIFT (scars, wasting, involuntary movements, fasciculations, tremor)
Walking aids
Standing unassisted, gait (speed, symmetry, balance, arm swing)
Tandem gait: one foot in front of other like on tightrope
Tip-toe gait: tests plantar flexion
Heel gait: tests dorsiflexion
Romberg test: feet together hands by side and close eyes, assesses proprioception with positive test = loss of balance…suggests any ataxia is sensory in nature
Tone
Patient lying down
Leg roll side to side
Ankle clonus: floppy ankle then sudden dorsiflexion
Power
Movement Nerve Root Pt. Action Examiner Action
Hip flexion L1/2 Pt. lifts leg off bed Examiner pushes leg to bed
Hip extension L5/S1 Pt. pushes leg into bed Examiner lifts leg off bed
Hip adduction L2/3 Pt. pushes legs together Examiner forces legs apart
Hip abduction L4/5 Pt. pulls legs apart Examiner forces legs together
Knee flexion S1 Examiner brings leg to 90 degrees, pt. pulls ankle to bottom Examiner pulls ankle to away from bottom (‘stop me from straightening leg’)
Knee extension L3/L4 Examiner brings leg to 90 degrees, pt. kicks ankle away Examiner pushes ankle to bottom (‘stop me from straightening leg’)
Dorsiflexion L4 Pt. pulls toes towards themselves Examiner pushes toes down
Plantar flexion S1/2 Pt. pushes toes away Examiner pulls toes towards pt. (‘push down against my hand’)
Ankle inversion L4 Pt. inverts foot Examiner everts foot (‘push foot towards hand’ on medial aspect of foot)
Ankle eversion L5/S1 Pt. everts foot Examiner inverts foot (‘push foot towards hand’ on lateral aspect of foot)
Reflexes
Movement Nerve Root
Knee jerk L3/4
Ankle jerk L5/S1
Plantar reflex S1 (should be downgoing)
Sensation (pt. should have eyes closed during assessment)
Touch
Light touch with cotton wool, sharp touch with neurotip
Compare sides
If sensation reduced peripherally, assess from distal point and move proximally to identify ‘stocking’ sensory loss
Vibration
Tuning fork
Place tuning fork on distal bony prominences (medial big toe, medial malleolus, knee, etc.)
Start distally, if patient is unable to sense vibration then assess at more proximal point
Vibrate fork and ask patient to tell you when it stops…should match when you stop fork
Proprioception
Hold distal phalanx of big toe by sides (don’t touch nailbed)
Explain to patient what ‘up’ is and what ‘down’ is
Coordination
Heel to shin test
Ankle to opposite knee, run down leg to opposite ankle, lift it off leg, bring back to knee and repeat
Impaired test: lower limb weakness, impaired joint proprioception, cerebellar disorder
Tap feet against hands
To complete exam;
CNS, upper limb neuro exams
Back exam
- Exposure – whole back and lower limbs
- Gait
- Look
o Scars
o Deformity – loss of lumbar lordosis, sciatic list (leaning to one side to reduce nerve root irritation), normal cervical lordosis, thoracic kyphosis - Feel
o Erector spinae muscle spasm/tenderness
o Warmth
o Spinal processes – alignment, irregularity, tenderness - Move
o Forward flexion (touch toes) – within 5cm of floor
o Extension (30)
o Lateral flexion – slide hand down outside of leg (30)
o Rotation – sit down, fold arms across chest (40) - Special tests
o Straight leg raise – Flex hip with knee full extended
Pain I back/buttock and thighs < 60 degrees suggest lumbosacral nerve irritation
SLR on unaffected side causes pain on affect side = lumbar disc herniation
o Sciatic straight test – dorsiflex foot in SLR
o Femoral nerve - Completion
o Neurological exam
Tone
Power
Reflexes (ankle, knee, plantar)
Sensation – dermatomal
o Peripheral pulses
o Femoral stretch with patient prone for L2/3/4 nerve root lesion (lift leg with knee flexed)
o PR exam
EMST
Personal protective equipment, safe to approach
Assistance
Response – Hello, what’s your name, can you open your eyes
Airway
- Assess patency
o Inspect for facial/neck swelling/deformities, stridor
o Alert – high flow O2, 15 L non-rebreather mask
o Altered Unconsciousness
Jaw thrust
Suction to clear foreign bodies – if no gag reflex
Guedel
* Intubation
* Cricothyroidotomy
15L O2 non-rebreather
C-spine
- Maintain c-spine in neutral position with manual immobilisation
- C-spine collar after airway
Breathing
- Expose chest
- Look
o Chest movement – symmetrical movement
o RR
o Accessory muscles
o Chest injuries
o Distended jugular vein
- Feel
o Percussion for dullness/hyper resonance
o Tracheal deviation
- Listen – Auscultate (4 spots)
- High concentration O2
- Treatments
o Not breathing
Bag and mask ventilation (12/minute)
o Treat tension pneumothorax, open pneumothorax
- Pulse oximetry
Circulation
- Assess
o Pulse (quality, rate, regularity) – carotid and radial
o Skin colour – pale, cool or clammy
o BP
- External source of bleeding
o Pressure
o Pneumatic compression device, tourniquet
- Large IV cannula x 2 (14/16 G)
- Send bloods (FBC, ELFT, preg, group + hold, glucose)
- IV fluid – warmed crystalloid, blood
- Internal source of bleeding
D – GCS and pupils
- Pupils size and response
- GCS
o Eye opening – (Can you open your eyes)
Spontaneous
Open to voice
Open to pain
None
o Verbal response (how are you feeling, what’s your name, do you know where you are)
Orientate
Confused
Inappropriate word
Incomprehensible
None
o Movement (can you squeeze me hands)
Obey command
Localise to pain
Withdrawal
Abnormal Flexion (decorticate)
Abnormal Extension (decerebrate)
None
E – Undress. Warming
REASSESS
Adjuncts
- ECG, ABG
- C-spine, CXR, pelvic exam
- NG, IDC
- Analgesia, ADT
Secondary Survey
- AMPLE history
Examination
- Head
o Scalp - lacerations, contusions, fractures, haematoma - Eyes
o Inspect - injuries, bleeding, pupils
o Visual acuity
o Eye movement - Look in ear, nose, mouth - blood and CSF
- Maxillofacial
o Palpate for tenderness, instability - Neck + c-spine
o Palpate for tenderness, subcutaneous emphysema, tracheal deviation
o Auscultate for carotid bruits (dissection/occlusion)
o Back – c-spine step off - Chest
o Inspect and palpate - clavicles, sternum, ribs
o Auscultate
o Heart sounds - tamponade (muffled heart sounds and reduced pulse pressure) - Abdomen
o Palpation
o Flank – bruising - Pelvis - stability
- MSK
o Pelvic fracture - bruising over iliac wings/pubis/labia. Gentle AP pressure over ASIS
o Examine extremities - tenderness and abnormal movement, compartment syndrome - Perineum/Rectum/Vagina
o Perineum inspected for haematoma, lacerations, urethral bleeding
o Vaginal - blood and lacerations - Neurological exam
- Log roll
- DRE – blood, high riding prostate, rectal wall integrity, anal tone
Burns
o Multidiscplinary fashion
o PPE – for chemicals
o A - Inhalational injury signs – facial/neck burns, singed eyebrow/nose hairs, soot in throat or sputum, hoarseness/stridor, fire in enclosed space
Early intubation – size 8 tube preferred
High flow O2 for CO poisoning
o Stop burning the process, washing away residue chemical with copious warm saline
o C-spine collar
o B – full thickness/circumferential chest burn – consider escharotomy
o C – look for full circumference burns and compartment syndrome. Check pulses
Bloods including ABG, carboxyhaemoglobin level
o Fluid resuscitation
Parkland formula = 2-3ml/kg/% body surface area burnt of Hartman’s
½ in 8hrs, ½ in 16 hrs (from time of injury). UO 0.5ml/kg/hr
Also given maintenance fluid on top of this
* Children = 4ml/kg/hr for 1st 10kg, 2ml for next 10kg, 1ml/kg/hr thereafter
o Check peripheral circulation for compartment syndrome
o E – assess % body surface area (Lund Browder chart, Rule of 9, Palm = 1%)
Wash with warm saline to clear away chemicals
Silver dressing
o Analgesia
o Prevent hypothermia
o Tetanus
o NGT, IDC
o Toxic shock syndrome in children
o Consider transfer to burns centre
>10% TBSA
Burns to face, hands, perineum, major joints
Full thickness burns
Inhalation injury
Chemical burns/electrical burns
Circumferential burns
Other major injury
Facial Fractures
- ABCD
- Inspection
o Bleeding, bruising, swelling, asymmetry, lacerations
o Eyes – proptosis, enophthalomos, ptotsis, conjunctival haemorrhage, raccoon sign (midface #)
o Nose –
Deformities
Otoscopy – bleeding, CSF, septal haematoma
o Ear – CSF, haematotympanium
o Mouth –
Limited mouth opening (depression affecting temporalis muscle)
Bleeding, bruising
Occlusion – bite down, does your teeth feel like they fit together normally?
o Look from behind
Battle sign - Palpate
o Gently around orbital margins
Any tenderness
Crepitus
Feel for a step
o Zygomatic arch – depression in malar eminence
o Nasal and mandibles
o Mouth opening - bimanual
Le fort fracture of the maxilla - Medial buttress (side of the nose)
- Lateral buttress (prominence before it drops off side of the mouth)
- Grab the alveolar process of maxilla and see if stable
Mandibles - Usually fractured at 2 sites
- Sensation
o Forehead – supraorbital nerve (frontal bone #)
o Cheek – infraorbital nerve. Numbness of teeth. Lateral side of nose, upper incisors + gum (infraorbital nerve)
o Lower face – mental nerve (mental foramen of the mandible)
Within the mandible it’s the inferior alveolar nerve - Must include eye exam
o Acuity – Snellen chart, count fingers
o Ocular movements (orbital floor fracture). Any double vision
Orbital floor fracture – affect of inferior rectus – impaired upward gaze
o Pupilllary light reflexes - Facial nerve – facial movements
o Rise eyebrows, close your eyes, show me your teeth, puff out cheeks - Head and C-spine injury
- Fundoscopy. X-ray facial bones, C-spine, CT skull
Nasal Fractures - Clinical assessment
- CT for other facial fractures
- Epitaxis – pressure, topical vasoconstrictors, silver nitrate, tampon
- Mx – left 5-7 days or reduce fracture within 4hrs
Mandible - X-ray – OPG and PA mandible
- Mx – soft collar for stabilization and reduce pain, augmentin to prevent infection, ORIF
Zygoma+orbital fracture - Exclude retrobulbar haemorrhage
- Mx – ORIF, usually delayed
Orbital fracture - Usually the medial and inferior walls
- Delayed treatment if no visual impairment
- No blowing nose, no air travel
Maxillary fracture - CT and immediate referral (painful)
Retrobulbar haemorrhage - Intraconal haemorrhage – compartment syndrome of the orbit
- Proptosis, chemosis, opthalmoplegia, loss of visual acuity
- Need treatment within 2hrs
White eye blowout fracture - Orbital floor fracture with ischaemic impingement on ocular contents
- Diplopia, impaired upward gaze, nausea, vomiting
- Immediate referral
