OSCE Flashcards
General inspection in a cardio exam - what are you looking for?
- Cyanosis
- SOB
- pallor
- Malar flush
- oedema
Cyanosis on general examination indicates?
poor circulation e.g hypovalaemia or inadequate oxygenation of the blood e.g. right-to-left cardiac shunting).
SOB on general examination indicates?
cardio disease e.g. congestive heart failure, pericarditis OR
respiratory disease (e.g. pneumonia, pulmonary embolism).
Pallor on general exam indicates?
Underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure).
Malar flush in a cardio exam indicates?
mitral stenosis
Oedema on cardio exam indicates?
most likely congestive heart failure
What are you looking for in the hands in a Cardio exam and why?
Colour - cyanosis may indicate poor perfusion
Tar staining - smoking is a risk factors for cardiovascular disease
Xanthomata - seen in hyperlipidaemia
arachnodactyly - long slender fingers - may be seen in marfans syndrome which is associated with aortic/mitral prolapse and aortic stensosis
Clubbing - congenital cyanotic heart disease, infective endocarditis and atrial myxoma
splinter haemorrhages, janeway lesions and oslers nodes - associated with endocarditis.
What could splinter haemorrhages in nails suggest?
infective endocarditis
sepsis
vasculitis
psoriatic nail disease
What could the temperature of the hands in the context of a cardio exam tell you?
They should be symmetrically warm. If cold then could indicate poor perfusion (e.g. congestive HF) or if Cold and sweaty then acute coronary syndrome
Causes of radio-radial delay?
Subclavian artery stenosis (e.g. compression by cervical rib)
aortic dissection
aortic coarctation
Causes of collapsing pulse?
- normal physiological states (e.g. fever, pregnancy)
- cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
- high output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)
What is slow rising pulse associated with?
aortic stenosis
what is bounding pulse associated with?
aortic regurgitation
CO2 retention
what is thready pulse associated with?
intravascular hypovolaemia in conditions such as sepsis
Definition of hypotension?
<90/60mmHg
Definition of narrow pulse-pressure?
<25mmHg between systolic and diastolic
Causes of narrow pulse pressure?
aortic stenosis
congestive heart failure
cardiac tamponade.
Definition of wide pulse pressure?
> 100mmHg between systolic and diastolic
Causes of wide pulse pressure?
aortic regurgitation
aortic dissection
BP difference of over 20mmHg in each arm causes?
aortic dissection
Why should you auscultate carotid pulse before palpating?
if bruit is present then this could suggest carotid stenosis making palpation potentially dangerous as this could dislodge plague causing ischaemic stroke
Patient instructions for auscultating carotid pulse?
deep breath in and hold while listening
which murmur can radiate to the carotids causing a bruit sound?
aortic stenosis
causes of raised JVP?
INDICATES VENOUS HYPERTENSION:
Right sided HF
tricuspid regurgitation
constrictive pericarditis
What does a +ve hepatojugular reflex indicate?
the right ventricle is unable to accommodate an increased venous return -
- Constrictive pericarditis
- Right ventricular failure
- Left ventricular failure
- Restrictive cardiomyopathy
what is a +ve hepatojugular reflex result?
If the rise in JVP is sustained (>2-3 cardiac cycles) and equal to or greater than 4cm
conjunctival Pallor in eyes is suggestive of?
anaemia
Eye signs of hypercholestolaemia?
corneal arcus
xanthelasma
Kayser-fleisher rings in eyes suggestive of?
Wilsons disease
Displacement of apex beat is suggestive of?
ventricular hypertrophy
What is a heave and what does it suggest?
parasternal heave is a precordial impulse that can be palpated.
ventricular hypertrophy
What is a thrill?
A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur).
what are the valve locations?
- Mitral valve: 5th intercostal space in the midclavicular line.
- Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
- Pulmonary valve: 2nd intercostal space at the left sternal edge.
- Aortic valve: 2nd intercostal space at the right sternal edge.
What is the diaphragm used to hear?
more effective at detecting high-frequency sounds,
(ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic regurgitation and the pansystolic murmur of mitral regurgitation)
What is the bell used to hear?
more effective at detecting low-frequency sounds, (mid-diastolic murmur of mitral stenosis)
ejection systolic murmur which can radiate to carotids = ?
aortic stenosis
Special test for aortic regurgitation?
Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration to listen for an early diastolic murmur caused by aortic regurgitation.
Special test for mitral regurgitation?
Roll the patient onto their left side and listen over the mitral area with the diaphragm of the stethoscope during expiration to listen for a pansystolic murmur caused by mitral regurgitation. Continue to auscultate into the axilla to identify radiation of this murmur.
Special test for mitral stenosis?
With the patient still on their left side, listen again over the mitral area using the bell of the stethoscope during expiration for a mid-diastolic murmur caused by mitral stenosis.
Coarse crackles on auscultation of lung fields?
pulmonary oedema (associated with left ventricular failure).
Absent air entry on auscultation of lung fields and stony dullness on percussion?
pleural effusion (associated with left ventricular failure).
How to calculate HR on ECG?
regular rhythm - 300/no. of large squares in R-R
irregular - no. of complexes x 6
+ve lead I, II and III = ? axis
normal
+ve lead I, -ve lead II and III = ? axis
left axis deviation
-ve lead I, +ve lead II and III = ? axis
right axis deviation
heart on wrong side of chest name?
dextrocardia
normal length of PR interval?
120-200ms (3-5 small squares)
What is a prolonged PR?
> 200ms (5 small squares) suggests the presence of atrioventricular delay (AV block).
What is 1st degree heart block?
fixed prolonged PR interval (>200 ms).
What is 2nd degree heart block (type 1)?
progressive prolongation of the PR interval until eventually the atrial impulse is not conducted and the QRS complex is dropped.
What is 2nd degree heart block (type 2)?
consistent PR interval duration with intermittently dropped QRS complexes due to a failure of conduction.
The intermittent dropping of the QRS complexes typically follows a repeating cycle of every 3rd (3:1 block) or 4th (4:1 block) P wave.
What is complete heart block?
No electrical communication between the atria and ventricles due to a complete failure of conduction.
Typical ECG findings include the presence of P waves and QRS complexes that have no association with each other, due to the atria and ventricles functioning independently.
Delta waves on ECG suggest?
Wolff-parkinson-white syndrome
How many seconds is a broad / narrow QRS?
narrow - <0.12s (normal)
broad - >0.12s
Which bloods in upper GI bleed?
Haemoglobin (FBC)
Urea (U&E’s)
Coagulation (INR, FBC for platelets)
Liver disease (LFT’s)
Crossmatch
Difference between group and save and crossmatch?
Group and save - lab checks blood group and saves sample in case they need to match blood to it
Crossmatch - lab finds blood, tests compatibility and keeps it so it is ready
Large rise in ALT + small rise or normal ALP = ?
Hepatocellular injury
Large rise in ALP + small rise in ALT = ?
Cholestasis
What is important to assess if ALP is high?
GGT - if both high then highly suggestive of cholestasis
ALP raised but GGT normal = ?
non-biliary cause of rise such as bony metastases or bony tumour, vit D deficiency, recent bone fracture
Isolated rise in bilirubin?
Gilbert syndrome
or
haemolysis
What is the liver’s main synthetic functions?
- Conjugation and elimination of bilirubin
- Synthesis of albumin
- Synthesis of clotting factors
- Gluconeogenesis
Normal urine + normal stool + jaundice = what cause?
pre-hepatic (unconjugated hyperbilirubaemia) he.g. haemolysis, gilberts, impaired hepatic intake
Dark urine + normal stool + jaundice = what cause?
Hepatic
Dark urine + pale stool + jaundice = what cause?
Post-hepatic (obstruction)
Causes of a fall in albumin?
- Liver disease resulting in a decreased production of albumin (e.g. cirrhosis).
- Inflammation triggering an acute phase response which temporarily decreases the liver’s production of albumin.
- Excessive loss of albumin due to protein-losing enteropathies or nephrotic syndrome.
A ALT > AST ratio = ?
Chronic liver disease (NAFLD or NASH)
A AST > ALT ratio = ?
acute liver disease (cirrhosis or acute alcoholic hepatitis)
common causes of acute hepatocellular injury?
- Poisoning (paracetamol overdose)
- Infection (Hepatitis A and B)
- Liver ischaemia
Common causes of chronic hepatocellular injury?
- Alcoholic fatty liver disease
- Non-alcoholic fatty liver disease
- Chronic infection (Hepatitis B or C)
- Primary biliary cirrhosis
(less common causes - wilsons, haemochromatosis, alpha-1 antitrypsin deficiency)
Nail bed pulsation (Quincke’s sign) = ?
aortic regurgitation
Bowel obstruction causes?
- adhesions (SB)
- hernias (sb)
- malignancy (LB)
Why might you see deltoid wasting on a MSK exam?
Disuse atrophy
axillary nerve injury
What might trapezius muscle asymmetry suggest?
suggestive of muscle wasting secondary to misuse or spinal accessory nerve lesion
What might Supraspinatus and infraspinatus asymmetry suggest?
muscle wasting secondary to chronic rotator cuff tear or suprascapular nerve lesion
How do you assess for a winged scapula?
ask the patient to push against a wall with both hands spaced shoulder-width apart whilst you inspect the back.
What is a winged scapula suggestive of?
ipsilateral serratus anterior muscle weakness, typically secondary to a long thoracic nerve injury.
What could increased temperature of a joint indicate?
Septic arthritis / inflammatory arthritis
For the shoulder exam - how do you test:
1. external rotation + abduction
2. internal rotation + adduction
- hands behind head with elbows out
- hands behind back and reach up as far as they can
Shoulder exam - how do you test:
1. Active shoulder flexion
2. Active shoulder extension
3. Active abduction
4. Active adduction
5. External rotation
6. Internal rotation
- Ask the patient to raise their arms forwards until they’re pointing up towards the ceiling.
- Ask the patient to stretch out their arms behind them.
- Ask the patient to raise their arms out to the sides in an arc-like motion until their hands touch above their head.
- Ask the patient to keep their arms straight and move them across the front of their body to the opposite side.
- Ask the patient to keep their elbows by their sides flexed at 90° whilst they move their forearms outwards in an arc-like motion.
- Ask the patient to place each hand behind their back and reach as far up their spine as they are able to.
How do you assess cranial nerve I + what nerve + what does it do?
Ask if any changes in smell.
olfactory - sense of smell.
How do you assess cranial nerve II + what nerve + what does it do?
Optic nerve
- Inspect eyes - size, shape, colour and external features.
- Snellen chart:
- Ishihara plate
- direct pupil reflex
- consensual papillary reflex
- accommodation reflex
- visual neglet
- visual fields
- blind spot
- swinging light reflex - checks for relative afferent pupillary defect
- fundoscopy
‘sunny storm appearance’’ on fundoscopy = ?
central retinal vein occlusion
‘cherry red spot’ on macula = ?
central retinal artery occlusion
ptosis + dilated pupil = ?
ptosis + constricted pupil = ?
nerve III palsy
horner’s syndrome
‘up and out’ eye = which nerve affected?
cranial nerve IV (trochlear)
Characteristic chest signs of pneumonia?
- Bronchial breath sounds - harsh breath sounds equally loud on inspiration and expiration. These are caused by consolidation of the lung tissue around the airway.
- Focal coarse crackles. These are air passing through sputum in the airways similar to using a straw to blow in to a drink.
- Dullness to percussion due to lung tissue collapse and/or consolidation.
What is FEV1 + when would it be reduced?
Forced expiratory volume in 1 second.
Reduced if there is any obstruction to the air flow out of the lungs.
What is FVC + when will it be reduced?
Forced vital capacity - total amount of air a person can exhale after a full inhalation.
reduced if restriction on the capacity of lungs
Lung function test patterns for obstructive and restrictive lung disease?
Obstructive:
- FEV1 less then 75% of FVC (FEV1:FVC ratio <75%)
Restrictive:
- FEV1 and FVC both reduced + FEV1:FVC ratio >75%
What is the ‘triangle of safety” for chest drain insertion?
- The 5th intercostal space (or the inferior nipple line)
- The mid axillary line (or the lateral edge of the latissimus dorsi)
- The anterior axillary line (or the lateral edge of the pectoris major)
Signs and symptoms of pulmonary hypertension?
SOB - main presenting symptom
syncope
tachycardia
raised JVP
hepatomegaly
peripheral oedema
ECG changes in pulmonary hypertension?
Right ventricular hypertrophy - larger R waves in V1-3 and S waves in V4-6.
Right axis deviation
Right bundle branch block
Pulmonary hypertension X-ray changes?
dilated pulmonary arteries
right ventricular hypertrophy
Options for smoking cessation?
- Nicotine replacement therapy - patches or oral - can be used for up to 8 weeks
Bupropion - inhibits reuptake of dopamine, noradrenaline and seratonin
Verenicline - partial nicotinic acetylcholine receptor agonist.
Pericardial rub on auscultation = ?
pericarditis
What is cardiac output?
volume of blood ejected by the heart per minute
What is stroke volume?
volume of blood ejected during each beat
How do you calculate cardiac output?
stroke volume x heart rate
What is the 1st heart sound?
Caused by the closing of the atrioventricular valves (the tricuspid and mitral valves) at the start of the systolic contraction of the ventricles.
What is the 2nd heart sound?
caused by the closing of the semilunar valves (the pulmonary and aortic valves) once the systolic contraction is complete.
What is a 3rd heart sound and what does it indicate?
Heard roughly 0.1 seconds after the second heart sound. Rapid ventricular filling causing the chordae tendineae to pull to their full length and twang like a guitar string.
Can be normal in young people (15-40y)
Heart failure in older patients.
What is a 4th heart sound and what does it indicate?
Heard directly before S1. Always abnormal. It indicates a stiff or hypertrophic ventricle and is caused by turbulent flow from that atria contracting against a non-compliant ventricle.
How do you assess a murmur (SCRIPT)?
S – Site: where is the murmur loudest?
C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter)
R – Radiation: can you hear the murmur over the carotids (aortic stenosis) or left axilla (mitral regurgitation)?
I – Intensity: what grade is the murmur?
P – Pitch: is it high-pitched or low and rumbling? Pitch indicates velocity.
T – Timing: is it systolic or diastolic?
What are the grades of murmurs?
Grade I: Difficult to hear
Grade II: Quiet
Grade III: Easy to hear
Grade IV: Easy to hear with a palpable thrill
Grade V: Audible with stethoscope barely touching the chest
Grade VI: Audible with stethoscope off the chest
How do you differentiate essential tremor and parkinsons tremor?
Parkinsons - asymmetrical, worse at rest, improves with intentional movement, no change with alcohol
essential tremor - symmetrical, improves with rest, worsens with intentional movement, improves with alcohol
GI exam - hands - what are you looking for?
Palmar erythema,
Clubbing
Koilonychia
Leukonychia
Dupuytren’s contracture,
asterixis (liver flap),
coarse tremor
GI exam - eyes - what are you looking for?
conjunctival pallor
scleral jaundice
corneal arcus
xanthelasma
Kayser-Fleisher rings
GI exam - mouth - what are you looking for?
angular stomatitis - associated with iron deficiency.
buccal mucosa ulceration - IBD
candidiasis
leukoplakia
quality of dentition
hyperpigmented macules - associated with Peutz-Jeghers syndrome.
glossitis - associated with B12 deficiency
What is spider naevi and what causes it?
vascular malformation - may be spontaneous or may be induced by circulating oestrogen.
Causes:
- pregnancy
- COCP use
- liver disease (cirrhosis) - this is because liver is meant to metabolise oestrogen but if its damaged it may not do that = increased oestrogen = vasodilation.
- thyrotoxicosis
What causes caput medusae?
Portal hypertension (they are essentially varicose veins on the abdomen)
What causes splenomegaly?
Infections - infectious mononucleosis, parasitic infections (malaria and leishmania) and bacterial infections, such as bacterial endocarditis.
Cancer - leukaemia, lymphoma
portal hypertension - cirrhosis, liver disease
Other - haemolytic anaemia, sickle cell disease, SLE, RA
What is leukonychia associated with?
hypoalbuminemia (end stage liver disease, protein losing enteropathy)
What is koilonychia associated with?
iron deficiency anaemia
What is clubbing associated with in the GI system?
- malabsorption
- IBD
- lymphoma
- cirrhosis
Risk factors for dupuyteryn contracture?
- genetics
- age
- alcohol
- male
- diabetes
What are the underlying causes of asterixis (flapping tremor)?
- uraemia -> renal failure
- hepatic encephalopathy -> increased ammonia
- CO2 retention -> type 2 resp failure
What does corneal arcus indicate?
high cholesterol levels
What might you see on endoscopy for crohns disease?
Deep ulcers
skip lesions - ‘cobble-stone’ appearance
What might you see on endoscopy for UC?
Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
What might you see on imaging for Crohns + what imaging?
Small bowel enema
strictures: ‘Kantor’s string sign’
proximal bowel dilation
‘rose thorn’ ulcers
fistulae
What might you see on imaging for UC + what imaging?
Barium enema
loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’
Most common site to be affected by crohns?
terminal ileum and proximal colon
What does an enlarged virchow’s node indicate / where is it?
Left supraclavicular lymph node
metastatic intrabdominal malignancy (most commonly gastric cancer)
what does a enlarged right supraclavicular lymph node indacate?
Gets lymphatic drainage from the thorax so could indicate oesophageal cancer
What does acanthosis nigricans indicate?
- May be normal (in darker skinned individuals)
- insulin resistance (type 2 diabetes)
- GI malignancy (stomach cancer)
Why can you get gynaecomastia in GI disease?
Liver damage = impaired oestrogen metabolism = increased circulating oestrogen = gynaecomastia
(can also be caused by medications)
What is Murphey’s sign (associated with which condition)?
deep palpation of the RUQ causes respiratory arrest
acute cholecystitis
What is Charcot’s triad (+ indicates which condition)?
jaundice, RUQ pain and fever
acute cholangitis
What is Cullen’s sign (+ association with which condition)?
Bruising around the umbilicus
haemorrhagic pancreatitis
What is the grey turner’s sign (+ associated with what?)
bruising around the flanks
haemorrhagic pancreatitis
If a stoma is located in the right/left iliac fossa then it is = ?
right - ileostomy
left - colostomy
A stoma for urine is called?
ureostomy
What is pulsatile hepatomegaly associated with?
severe tricuspid regurgitation
Causes of hepatomegaly?
C - cancer
R - right heart failure
A - alcoholic liver disease
M - myeloproliferative
F - fatty liver
A - amyloidosis
I - iron (haemochromatosis)
L - lymphoma
L - leukaemia
other - biliary duct obstruction, infection, autoimmune, tricuspid regurg
Signs in the hands of OA?
Heberden’s nodes (DIP joints)
Bouchard’s nodes (PIP joints)
squaring of the thumb
weak grip
reduced range of motion
Signs in the hands of RA?
- Z shaped deformity to the thumb
- Swan neck deformity (hyperextended PIP with flexed DIP)
- Boutonnieres deformity (hyperextended DIP with flexed PIP)
- Ulnar deviation of the fingers at the knuckle (MCP joints)
On palpation of descending aorta, hands move outwards = ?
Presence of expansile mass (e.g. AAA)
Tinkling bowel sounds indicate?
bowel obstruction
Absent bowel sounds indicate?
- complete bowel obstruction
- ileus
- peritonitis
How do you listen for aortic bruits // what do they indicate?
use diaphragm and auscultate above umbilicus
AAA
How do you listen for renal bruits // what do they indicate?
use bell and auscultate above and lateral to umbilicus
renal artery stenosis
What is pyoderma gangrenosum associated with?
Crohns
What is erythema nodosum associated with?
NO - no cause (idiopathic)
D - drugs (e.g. antibiotics)
O - oral contraceptives
S - sarcoidosis
U - UC/crohns
M - microbes
also infections.
What is Rovsing sign?
palpating LLQ causes pain in RLQ
Difference between acute cholecystitis and acute cholangitis?
cholecystitis - inflammation of gall bladder (usually due to gallstones) - RUQ pain + fever
cholangitis - inflammation of bile ducts (infection) - RUQ pain, fever , jaundice
causes of gout (H Delay)?
H - hyperuriceamia, hereditary
D - diuretics
E - ethanol
L - leukaemia
A - renal impairement
Y - lesch-nyhan syndrome
Causes of peripheral neuropathy?
A - alcohol
B - b12 deficiency
C - cancer and chronic kidney disease
D - diabetes and drugs (e.g. isoniazid, amiodarone and cisplatin)
E - every vasculitis
What is Cushing’s triad?
suggestive of brain stem compression
bradycardia
hypertension
irregular/abnormal breathing
How would retinal detachment look like on examination?
the swinging light test may highlight a relative afferent pupillary defect if the optic nerve is involved
fundoscopy:
- the red reflex is lost and retinal folds may appear as pale, opaque or wrinkled forms
- if the break is small, however, it may appear normal.
What is Psoas sign?
pain on extending hip - suggestive of retrocaecal appendicitis
What is Russels’ sign?
calluses on the knuckles or back of the hand due to repeated self-induced vomiting
What is the ‘double duct’ sign on CT?
A dilated common bile duct and dilated pancreatic duct - present in pancreatic cancer.
What is a ‘ataxic gait’?
wide-based gait and is unable to coordinate his lower limbs to walk in a heel-to-toe fashion
What causes an ataxic gait?
Cerebellar injury
What is an antalgic gait?
limping caused by pain that is worse when weight-bearing on the affected limb
What is a high stepping gait and what is it caused by?
patient lifting the affected leg up higher to prevent their foot from dragging across the floor as they walk.
occurs in patients that have foot drop (due to a common peroneal nerve injury)
What is an trendelenburg gait + causes?
the pelvis drops to the contralateral side causing the trunk to shift while walking
often due to congenital hip problems, hip fractures, and gluteus medius muscle weakness.
What is a waddling gait + causes?
due to weakness in the pelvic girdle and thigh muscles and is characterised by the patient circumducting their leg when walking to compensate for the weakness.
It is often due to pregnancy, muscular dystrophies and congenital hip problems.
Nerve roots for all the reflexes?
Ankle - S1-2
Knee - L3-4
Biceps - C5-6
Triceps - C7-8
What is Kernig sign?
Severe pain when extending knee when hip is lifted off bed
associated with meningitis
what is Uhthoff’s phenomenon ?
heat sensitivity in MS
RA hand findings?
Boutonniere nodes
ulnar deviation (dinner fork)
swan neck deformity
Z thumb
mitral regurgitation - type of murmur?
Pan-systolic
Mitral stenosis - type of murmur?
diastolic
Ejection systolic louder on expiration - what conditions?
aortic stenosis
HOCM
Ejection systolic louder on inspiration - what conditions?
pulmonary stenosis
atrial septal defect
pan-systolic murmur - what conditions (+how to differentiate)?
(high-pitched and blowing):
mitral regurgitation
tricuspid regurgitation - becomes louder on inspiration
ventricular septal defect (‘harsh’ in character)
Late systolic murmur - what conditions?
mitral valve prolapse
coarctation of the aorta
early diastolic murmur - what conditions?
aortic regurgitation (‘high pitched’ and ‘blowing’)
mid-late diastolic murmur - what conditions?
mitral stenosis
continuous machine-like murmur - which condition?
patent ductus arteriosus
Does dark/bright areas of CT indicate hypodense or hyperdense?
Dark - Hypodense
Bright - hyperdense
What is the daily maintenance fluid requirements for adults?
25-30mls/kg/day of water
1mmol of K+/Na+/Cl-
50-100g/kg of glucose
How much glucose (in g) is in 5% glucose solution?
5g per 100mls
CXR signs of heart failure?
A- alveolar oedema,
B - Kerley B lines (interstitial oedema),
C - cardiomegaly,
D - dilated upper lobe vessels,
E- effusion
ECG signs of hyperkalaemia?
absent P waves,
wide QRS
tall tented T wave
ECG signs of hypokalaemia?
U waves
small/absent T waves
prolonged PR
ST depression
long QT
(in hypokalaemia you have no pot and no T but a long PR and a long QT)
What is Trousseau’s sign and what is it associated with?
wrist flexion when taking BP
hypocalcaemia
PTH, Calcium, phosphate and ALP patterns in primary/secondary/tertiary hyperparathyrodism?
primary - PTH high (can be normal), calcium high, phosphate low, ALP high
Secondary - PTH high, calcium normal/low, phosphate high, ALP high
Tertiary - all high
Emergency contraception time frames?
EllaOne (ulipristal) + copper IUD = 120 hours
Levenelle - 72 hours
Which guidelines for competence in under 16y / contraception advice in under 16y?
Fraser - contraception
Gillick - the ability to consent for medical/surgical procedure <16yrs, without the need for parental permission or knowledge
How do check supraspinatus power?
Jobes/empty can test
How do you test infraspinatus power?
external rotation against resistance
How do you test subscapularis power?
Internal rotation against resistance (Patient places the back of their hand on their lower back. Ask them to push backwards against your hand)
Special tests for impingement of the shoulder?
- Painful arc
- Hawkins Kennedy test (Patient with shoulder flexed forward, elbow bent. Internally rotate the patient’s arm.)
- Jobe’s test
- scarf test (tests for ACJ pathology e.g. arthritis which is a differential of impingement)
Special tests for instability of the shoulder?
- sulcus sign
- anterior and posterior drawers test
- anterior relocation/apprehension test
- posterior apprehension test
How do you test for meniscal tear?
Steinman test (apply pressure to meniscus and then rotate foot away from side of injury)
What can joint line tenderness in knee suggest?
meniscal tear or arthritis
How do you test for carpal tunnel?
Tinels test (tap median nerve) or Phalen’s test (wrist in maximum flexion
How do you test for ulnar nerve palsy?
Froment’s test (hold piece of paper between thumb and index finger - pull object away. In palsy unable to hold paper and will flex the flexor pollicis longus)
How do you test the arm dermatomes?
C5 - deltoid area
C6 - thumb
C7 - middle finger
C8 - little finger
T1 - medial upper arm (next to elbow)
How do you test the leg dermatomes?
L1 - lateral hip
L2 -middle lateral thigh
L3 - medial knee
L4 - medial calf
L5 - big toe
S1 - pinkie toe
S2 - genitals
Which dermatome is the bellybutton?
T10
Which dermatome is the nipples?
T4
Which nerve root is responsible for the knee reflex?
L3/4 (kick the door)
Which nerve roots are responsible for the ankle reflex?
S1-2 (buckle your shoe)
Which nerve roots are responsible for the biceps reflex?
C5/6 (pick up sticks)
Which nerve roots are responsible for the triceps reflex?
C7-8 (lay them straight)
HINTS exam - what results would indicate peripheral /central cause?
peripheral - abnormal head impulse, none or unidirectional, test of skew - no vertical skew
Central - normal head impulse, bidirectional or vertical nystagmus and vertical skew
MSE - appearance - what would you comment on?
- personal hygiene
- clothing (appropriate for weather/circumstances?)
- physical signs of underlying difficulties (e.g. self harm scars or signs of IV drug use)
- stigmata of disease (e.g. jaundice)
- weight
- objects
MSE - behaviour - what would you comment on?
- engagement and rapport
- eye contact
- facial expression - appropriate?
- body language (e.g. threatening/withdrawn)
- psychomotor - e.g. restlessness
- abnormal movements or postures
MSE - speech - what would you comment on?
- Rate
- Quantity of speech
- tone e.g. monotone / tremulous
- volume
- fluency and rhythm e.g. stuttering, slurred, stilted
MSE - Emotion - what would you comment on?
Mood - subjective - what did they tell me?
Affect - how did they seem?
- range and mobility e.g. fixed affect or restricted or labile
- intensity e.g. blunted, heightened
- congruency (patients affect in-keeping with thoughts)
MSE - thought - what would you comment on?
- Thought form - speed, flow and coherence (abnormalities may include flight of ideas, circumstantiality, word salad)
- thought content - delusions? obsessions? compulsions? overvalued ideas? suicidal thoughts? violent thoughts?
- thought possession - insertion, withdrawal and broadcasting
MSE - perception - what would you comment on?
- hallucinations?
- pseudo-hallucination?
- illusions?
- depersonalisation?
- derealisation?
MSE - cognition - what would you comment on?
- orientated in time, place and person
- attention span / concentration levels
- short term memory
formal assessments - MMSE or abbreviated mental test score (AMTS)
MSE - insight (+judgement) - what would you comment on?
- do they know they are sick?
- can ask what they would do in a fire.
MSE - risk - What questions can be asked?
“sometimes when people are going through a difficult time, they might have thoughts of harming themselves/others - is that something you’ve experienced?”
- screen for other risk - substance misuse, self-neglect
5 A approach to counselling patients?
A - assess - is patient at risk
A - ask (is it ok to discuss…)
A - advise
A - assist in making plan
A - action
Examples of distributions of skin lesions?
- acral (distal areas e.g. hands and feet)
- extensor
- flexor
- follicular (areas with increased sebaceous glands)
- dermatomal
- seborrheoic (areas with increased density of sebaceous glands e.g. scalp/face)
Examples of words describing configuration of skin lesions?
- refers to shape and outline
- discrete (clearly separated) or confluent (merging together e.g. urticaria)
- note shape e.g. linear (shape of line) or discoid or target or annular (ring like lesions)
- assess border (well/poorly defined)
Examples of words describing colour of skin lesions?
- erythematous (red, blanch on pressure)
- purpuric (reddish/purple, do not blanch)
- ecchymoses (purpura but larger >2mm)
- hyperpigmented
- hypopigmented
- depigmented
What is a macule / patch?
macule - flat area of altered colour <1.5cm
patch - flat area of altered colour >1.5cm
What is a papule / nodule?
papule - raised lesion palpable <1.5cm
nodule - raised lesion palpable >1.5cm
What is a plaque?
palpable flat lesion >1.5cm - can be raised and thickened.
What is a vesicle / bulla?
vesicle - raised, clear fluid filled lesion <0.5cm
bulla - raised, clear fluid filled lesion >0.5cm
What is a pustule?
pus containing lesion less than 0.5cm
What is a abscess?
localised accumulation of pus
what is a wheal?
oedematous papule or plague caused by dermal oedema
What is a boil / furuncle?
staphylococcal infection around or within hair follicle
What is a carbuncle?
staphylococcal infection of adjacent hair follicle (multiple boils/furnucle)
What is excoriation?
loss of epidermis associated with trauma
What is lichenification?
thickening of the epidermis with exaggerated skin lines, typically caused by chronic rubbing/scratching.
How do you asses a pigmented lesion?
A - asymmetry
B - borders
C - colour
D - diameter
E - elevation
What is oncholysis associated with?
psoriasis (it is the lifting of the nail from the nail bed)
What sign may be seen in the mouth with lichen planus?
Whickham’s striae
How do you assess if a CXR is adequate?
R - rotation (medial clavicles should be equal distance from nearest spinous process)
I - inspiration (at least 5-6 anterior ribs should be visible above diaphragm)
P - picture area (lung apices and costodiaphragmatic recesses should be visible; scapulae should be out of the way)
E - exposure (vertebral bodies should be just visible through the lower part of the cardiac shadow )
How do you interpret a CXR?
A - airway (e.g. tracheal deviation)
B - breathing (lung fields, pleura and hilar region)
C - circulation (heart size (should be <50% thorax diameter, shape and borders, great vessels, mediastinal width <8cm?)
D - position and shape, costophrenic angle, air below diaphragm
E - extra things (bones - fractures?, soft tissue swellings, subcut air, masses, calcification of aorta)
How do you describe abnormalities on CXR?
- density
- uniform (same colour) or non-uniform (blotchy)
- radiograph position (i.e. left/right which lobe?)
- size
- borders
Describe a ‘consolidation’ on CXR?
Non-uniform soft tissue density with visible air bronchogram
Pelvic XRAY - which line should you look for?
Shentons line
Difference between lytic and sclerotic bone lesions?
lytic - reduced bone density
sclerotic - increased bone density
Difference between lytic and sclerotic bone lesions?
lytic - reduced bone density
sclerotic - increased bone density
What to comment on pelvic xray interpretation?
- shenton line
- femoral head
- acetabulum
- pubic synthesis line
- sacro-illiac joints
- proximal femur
- shaft of femur
- main pelvic ring
- obturator foramen
What to comment on shoulder xray interpretation?
- clavicles
- scapula
- head of humerus
- shaft of humerus
- glenohumeral joint
- acromioclavicular joint
- caracoclavicular joint
- sternoclavocular joint
