Hx and Examination Flashcards
why in renal disease might we want to look for central obesity, moon shaped face, purple striae and thin limbs on examination?
assess for features of cushing’s syndrome that may occur with long term use of corticosteroids e.g. in the treatment of glomerulonephropathies e.g. IgA nephropathy.
how do we assess how quickly a rheumatological disease developed, and what information does this give us?
how did it start? how long did it take for the pain to reach the amount of pain you feel now/maximal pain?
sudden onset-acute pathology e.g. septic arthritis, reactive arthritis, gout, pseudogout
slow and progressive-days/weeks-inflammtory, mnths/yrs-degenerative e.g. OA
important systemic features to assess for in general rheumatological hx?
fatigue-?fibromyalgia, espec. if sleep unrefreshing
weight loss-can occur in RA, PMR and malignancy
fever-septic arthritis, SLE
eyes-dry eyes e.g. Sjogren’s sydrome, painful red eye-anterior uveitis/iritis e.g. RA, seronegative spondyloarthopathies e.g. AS
ulcers-SLE, reactive arthritis, Behcet’s disease
dysphagia-scleroderma
headache-GCA
important points to help with differentials and management in social hx of pt with rheumatological disease hx?
smoking-RA, OP
alcohol-gout
occupation-physical stress on joints e.g. knee, leading to OA, impact of symptoms on work, time off work?-may be yellow flag sign in predicting LT chronicity and disability
social support and imapact on AODL, ability to walk up and down stairs, dress themselves, stand up from sitting, getting into and out of a car/bath.
if 2 storey house with stairs and pt has poor mobility, may require OT referral to assess situation at home.
what are we looking at when assessing a patient’s gait?
difficulty with transfer-sitting and standing from a chair
phases of gait-heel strike, stance, push-off, and swing
antalgic/painful gait
walking aid use
loss of symmetry
why should a patient’s elbows be exposed in a hand and wrist examination?
look for rheumatoid nodules
summary of how we would examine the spine
LOOK, FEEL, MOVE
look: from front, from back-muscle bulk, curvature e.g. scoliosis-lateral curvature, from side- normal cervical lordosis, thoracic kyphosis and lumbar lordosis, and look for abnormal kyphosis and fixed flexion deformity.
feel: any tenderness along VBs
move- ask pt to put ear on their shoulder to elicit lateral flexion of neck
ask pt to bring head down towards chest and back to see flexion and extension
ask pt to try and touch toes to elicit normal flexion of lumbar spine
ask pt to turn their body either side to elicit spinal rotation
what are we looking for on inspection of the hands and wrist?
dorsum of hand:
nails-pitting, onycholysis-psoriatic changes, nail fold vasculitis
DIPJs-swelling, deformities, Heberden’s nodes
PIPJs-swelling, deformities, Bouchard’s nodes
MCPJs-swelling, deformities, ulnar deviation, volar subluxation
boutonniere deformity, swan neck deformity, Z-deformity of thumb
skin changes-bruising/thinning-LT steroid use?
scars-carpal tunnel release surgery-at wrist
tophi
wrist swelling, atrophy, deformity
palms-palmar erythema (RA), dupuytren’s contracture, muscle wasting-thenar and hypothenar eminences
rheumatoid nodules around elbow
what should be palpated on hand and wrist examination?
temperature-forearm, wrist, MCPJs muscle bulk and tendon thickening ulnar, median and radial nerve sensation radial pulse gently squeeze over MCPJs palpate PIPJs and DIPJs and wrist and CMCJs elbow for rheumatoid nodules
what movements are assessed at hand and wrist
all done actively and passively
wrist-F and E, ulnar and radial deviation, forearm pronation and supination
fingers-make fist and open again-F and E, ask pt to spread fingers out with palm facing downwards-abduction, push fingers downwards to assess extensor power, and abduction.
thumb-F, E, Ab, Ad and opposition
can do resistance testing for power with all F and E, ab and ad
function: pincer grip- pinch examienr’s finger
power grip-squeeze my fingers
pencil grip
pick up a small object e.g. coin
special tests:
phalen’s for CTS-wrist dorsiflexion and hold 30-60s-+VE test if burning, pain or tingling felt over median nerve distribution as median nerve compressed in carpal tunnel, and tinel’s
what do we want to know in the hx of presenting complaint about a fall/fit when considering what happened before the fall?
eaten or drank any differently that day? alcohol?
what were they doing at the time? sat or standing or lying down? exercise-?CVS cause of syncope e.g. AS or HOCM
how did they feel?-?nauseated, light headed, blurring of vision from periphery, sweating
any aura-lights or sounds
identifiable triggers e.g. watching TV, loud noise, pain, heightened emotion
causes of dark urine?
dehydration
drugs
extrahepatic cholestasis-obstructive jaundice, and also hepatocellular jaundice sometimes due to conjugated hyperbilirubinaemia
haematuria
how can heartburn be distinguished from cardiac chest burn?
heartburn-burning sensation
upward radiation
assoc with acid reflux-taste acid in mouth
occurrence on lying flat or bending forward
what is waterbrash and what is it caused by?
sudden appearance of fluid in mouth
due to reflex salivation as result of GORD
or more rarely PUD
non-alimentary causes of abdominal pain?
MI-epigastric pain without tenderness, hypotension, cardiac arrhythmias
ruptured AAA
aortic dissection-tearing interscapular pain, asymmetry of femoral pulses, hypotension
DKA-cramp-like pain, vomiting, air hunger, tachycardia, ketotic breath
pleurisy-lateralised pain on coughing, pleural rub
herpes zoster-vesicular eruption, hyperaesthesia-very sensitivie to touch
PID, salpingitis, ectopic pregnancy-localised tenderness, nausea, vomiting, fever, PID-bilateral abdo pain, deep dyspareunia, abnormal bleeding, abnormal vaginal discharge-mucopurulent
testis/ovary torsion-nausea, vomiting, localised tenderness, lower abdo pain
sickle cell crisis
infectious mononucleosis
qns to ask regarding constipation?
what do you mean by this?
number of times bowels opened per week?
has this been lifelong or of recent onset?
how much time spent straining at stool?
change in appearance of stool, pellet like?
any change in drug therapy?
any diarrhoea?
any assoc abdo pain, anal pain on defecation or rectal bleeding
if/when stools passsed, any tenesmus?
any weight loss?
how do differentials change in haematemesis if pt has vomited a few times before blood appears?
increases likelihood of mallory-weiss tear=vomiting has caused a tear in lower oesophageal mucosa
why might chronic alcoholics present with an upper GI bleed?
ruptured oesophageal varices=portal hypertension
erosive gastritis
mallory-weiss tear-vomiting
causes of bleeding PR?
haemorrhoids anal fissure diverticular disease IBD ischaemic colitis colorectal Ca angiodysplasia upper GI bleed
ALARMS features in hx of a patient with dyspepsia?
anorexia-appetite loss weight Loss anaemia rapid progression of symptoms melaena/haematemesis dysphagia
what do we want to ask a pt with jaundice?
RFs for hepatocellular jaundice: tattoos, foreign travel, multiple sexual partners and contact hx, blood transfusion, IV drug abuse ? about recent and in past!, immunisations + travel-Hep A
drug hx-hepatitis-paracetamol, rifampicin, isoniazid
cholestatic jaundice-azathioprine, flucloxacillin, co-amoxiclav
appetite and weight loss
abdo pain, altered bowel habit, pale stools and dark urine
GI bleeding
pruritus-bile salt deposition under skin, rigors
PMH-biliary surgery, pancreatitis
prev jaundice or hepatitis
FH e.g. haemochromatosis-autosomal recessive, congenital spherocytosis, gilbert’s syndrome-autosomal dominant
what might painless diarrhoea indicate?
high alcohol intake
lactose intoelrance
gluten enteropathy-coeliac disease
what is the worry with a hard SC nodule palpable at the umbilicus?
may indicate metastatic Ca- Sister Mary Joseph’s nodule
cause of a pulsatile liver?
tricuspid regurgitation
how to do a thyroid examination?**
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abdominal scars to look out for specifically in a renal hx?
scar for a transplanted kidney- LIF or RIF=Rutherford-Morrison scar (J scar?)
kidney removed-loin scar may appear on back
how do we assess an AV fistula?**
look
feel-palpable thrill
listen-audible bruit
diabetes examination? **
neurological assessment*
