PACES Flashcards
Valve replacement normal signs
midline sternotomy
abnormal S1 = mitral
abnormal S2 = aortic
advanced signs to look out for in valve replacement
- assess for valve function (regurg/stenosis)
- any cardiac decompensation/ HF
- any IE
- complications of over-anticoagulation
- assess for haemolysis
signs of HF
- tachypnoea/tachycardia
- cool peripheries
- raised JVP
- displaced apex
- S3 (ventricular gallop)
- bi basal fine creps
- peripheral oedema
signs of VSD
pansystolic murmur (loudest at LL sternal edge)
associated thrill
RV heave
loud P2
any signs of complications = RHF
signs of cor pulmonale
plethoric face
central cyanosis
raised JVP
giant V waves + pansystolic murmur if TR
R ventricular heave
loud S2
pedal oedema
what else to look for in cor pulmonale
signs of cause:
- end inspiratory creps (pulmonary fibrosis)
- clubbing (idiopathic PF)
- signs of COPD
HOCM signs
- pacemaker
- jerky pulse
- double apex beat
- ESM (LL sternal edge)
- S4
- signs of complications (HF)
JVP vs carotid pulse
JVP has double waveform
JVP not palpable
JVP changes with position
Abdominal pressure inc JVP
DDx for crescendo-decrescendo systolic murmur
aortic stenosis
aortic sclerosis
HOCM
AS mummur
ejection systolic
upper right sternal edge
loudest on expiration
radiates to carotids and apex
symptoms and signs of AS
Sx: exertional dyspnoea, syncope, angina
Signs: slow rising pulse, narrow PP, heaving apex beat, softy/absent S2, signs of LVF
aortic sclerosis murmur
ejection systolic
upper right sternal edge
does not radiate
sx and signs of aortic sclerosis
no symptoms
no abnormal signs
differentiate from AS by normal pulse, apex and S2
mitral regurg murmur
pansystolic
apex, loudest on expiration
radiates to axilla
symptoms of MR
dyspnoea
orthopnoea
PND
fatigue
palpitations
signs of MR
AF
displaced thrusting apex (volume-loaded)
soft S1
signs of pulmonary HTN (RV heave, loud P2)
may be signs of LVF (S3, pulmonary oedema)
causes ofMR
papillary muscle dysfunction (post-MI)
dilated cardiomyopathy
IE
congenital
connective tissue
mitral valve prolapse murmur
mid systolic click +/- late systolic murmur
apex, loudest on expiration
radiates to left axilla and back
TR murmur
pansystolic
differentiate from MR by:
- louder on inspiration (on right)
- giant JVP
- non-displaced apex
symptoms and signs of TR
sx: fatigue, ascites, peripheral oedema
signs: giant V waves in JVP, backflow signs (oedema, ascites, heptomegaly), signs of pulmonary HTN
causes of TR
- RV dilation in pulmonary HTN
- rheumatic heart disease
- IE
assess severity of AS
- pulse volume (slow-rising)
- pulse pressure narrows
- S2 intensity reduces
- louder murmur
general indications of valve replacement
- Left sided valve dysfunction (LVF, symptomatic)
- infective endocarditis + HF/uncontrolled infection/high embolic risk
risks and complications of valve replacement
- perioperative: arrhythmias, stroke/TIA, VTE, bleeding
- valve complications: leakage, obstruction, haemolytic anaemia, IE
- warfarin side effects: bleeding
aortic regurg murmur
early diastolic
upper right sternal edge
loudest on expiration
symptoms and signs of AR
sx: fatigue, SOB, palpitations
signs:
- collapsing pulse
- wide PP
- displaced thrusting apex beat
- Corrigan’s, de Musset, Quincke’s
- austin flint murmur
causes of aortic regurg
acute causes: IE, aortic dissection
chronic causes:
- aortic root dilatation (HTN, vasculitis)
- connective tissue disorders
- rheumatic heart disease
mitral stenosis murmur
low rumbling mid-diastolic
apex in left lateral position
loudest on expiration
symptoms of MS
dyspnoea
fatigue
haemoptysis
chest pain
signs of MS
malar flush
AF
tapping apex
loud S1
signs of pulmonary HTN
pulmonary fibrosis signs
oxygen therapy
dry cough
tachypnoea
reduced expansion
fine end inspiratory crackles
what else to look for in pulmonary fibrosis
- signs of aetiology (hand deformity, clubbing, CREST sx, butterfly rash, radiation burns)
- signs of complications: steroid use, pulmonary HTN
COPD signs
bedside inhalers/nebs
accessory muscle use
tar stained fingers
tachypnoea
lip pursing
reduced cricosternal distance (<3 fingers)
tracheal tub
indrawing of intercostals
hyper-resonance
quiet breath sounds
wheeze
prolonged expiratory phase
signs of pneumonectomy
unilateral chest flattening
thoracotomy scar
tracheal deviation (towards)
reduced expansion
dull percussion note
dec breath sounds
bronchial breathing in upper zone (due to deviated trachea_
what to look for if pneumonectomy?
signs of cancer
signs of lobectomy on examination
thoracotomy scar
may be no other signs due to compensatory hyperexpansion of remaining lobes
may be dec expansion, dullness to percussion, dec air entry
pleural effusion signs
reduced expansion
stony dull percussion note
dec breath sounds
dec tactile fremitus and vocal resonance
bronchiectasis signs
productive cough
inspiratory clicks
clubbing
coarse, late expiratory creps
what signs of aetiology can you see in bronchiectasis
young and thin (CF)
lymphadenopathy (malignancy)
dextrocardia (Kartagener’s)
lung cancer signs
cacheixa
clubbing
tar stained fingers
irregular, hard lymphadenopathy
radiation burns
causes of upper zone pulmonary fibrosis
coal
AS
radiation
TB
EAA
causes of lower zone pulmonary fibrosis
connective tissue disorders
asbestos
Idiopathic PF
drugs
transudative vs exudative pleural effusion
high protein content (>30g/L) = exudate
low protein content = transudate
Light’s criteria
- pleural fluid protein/serum protein = >0.5
- pleural fluid LDH/serum LDH = >0.6
- pleural fluid LDH = >2/3 upper limit of normal serum LDH
transudate causes
HF
hypoalbuminaemia (liver cirrhosis, nephrotic )
exudate causes
infection (e.g. empyema)
inflammation
infarction (PE)
malignancy
what does TLCO measure
total diffusing capacity of lung
(reduced in restrictive/obstructive due to reduction in total ventilation)
what does KCO measure
diffusing capacity of lung per unit volume (TLCO corrected for lung volume)
- in restrictive is normal: normal lung tissue and inc pulmonary capillary blood volume per alveolar volume
investigations and imaging to consider to investigate peripheral arterial disease
- bedside: ABPI, BP
- imaging: duplex USS, MR/CT angio, catheter angio
- bloods: lipid levels, fasting glucose, FBC
management of PAD
- lifestyle: exercise, foot care, smoking cessation, weight reduction
- medical: anti-plt, lipid control, BP, diabetes control
- surgical: angioplasty, surgical reconstruction, amputation
varicose veins associated skin changes
change in pigmentation
ulceration
venous eczema
lipodermatosclerosis
haemosiderin deposits
management of varicose veins
conservative: weight loss, avoid prolonged standing, exercise, compression stocking (look at ABPI first)
surgical: endothermal ablation, foam sclerotherapy, vein ligation and stripping
chronic liver disease signs
clubbing
leukonychia
palmar erythema
dupuytren’s contracture
jaundice
spider naevi
gyanecomastia
loss of axillary hair
distended abdominal veins
hepatomegaly
splenomegaly (portal HTN)
ascites
what would be signs of decompensation of CLD
asterixis
encephalopathy (confusion)
jaundice
ascites
transplanted kidney signs
old AV fistula
rutherford morrison scar (usually RIF)
smooth mass underlying scar (transplanted kidney)
if hepatomegaly, what signs to look for?
signs of CLD
lymphaednopathy (malignancy/lymphoma)
peripheral oedema/rasied JVP (R ventricular failure)
if splenomegaly, what signs to look out for?
hand deformity (RA/Felty’s)
signs of CLD
pale conjunctiva (leukaemia/HA)
lymphadenopathy (lymphoma)
PCKD signs
AV fistula (if had dialysis)
HTN
pale conjunctiva (anaemia)
flank scar (if kidney has been removed)
bilateral ballotable flank massess
hepatomegaly (cysts)
signs of liver transplant
- signs of CLD
- Mercedes Benz modification scar
- signs of cause
- complications of immunosuppression: tremor, cushingoid/bruising, skin lesions/excisions
signs of combined kidney-pancreas transplant
- LIF scar (renal graft)
- RIF scar (pancreas graft)
- smooth mass underlying LIF scar (transplanted kidney)
- signs of diabetic complications
- renal graft functionality
- pancreas graft functionality
- previous RRT
- complications of immunosuppression
ways to prevent graft rejection after renal transplant
- HLA matching
- testing for donor specific antibodies
- immunosuppression
important aspects of hernia exam
- chaperone
- exam while standing up
- lumps and describe
- cough impulse
- check for reducibility (deep inguinal ring = midway between ASIS and pubic tubercle)
- percuss and auscultate lump (may reveal bowel is present)
features of direct inguinal hernia
- superior to pubic tubercle
- come directly out of abdomen in straight line
- emerges through superficial inguinal ring
- cannot be contained by applying pressure over deep inguinal ring
features of indirect inguinal ring
- herniated abdo contents run within inguinal canal
- emerges through deep inguinal ring
- if reduced, can be contained by applying pressure over deep inguinal ring
femoral hernia
inferior and lateral to pubic tubercle
signs in hands in renal exam
- tremors
- nails: leukonychia, koilonychia
- finger tips: cap glucose marks
- pulse: rate and volume
- arms: AV fistula, bruising, BP, skin lesions
what to look for in head and neck in renal?
- eyes: periorbital oedema, conjunctival pallor, corneal arcus/xanthelasma
- mouth: hydration, gingival hypertrophy
- neck: JVP, central line scar
important chest signs in renal exam
- scars
- cap refil
- HS
- auscultate lung base (?odema)
- inspect back for skin lesions
what to auscultate for in renal exams?
renal bruits
most common causes of end stage kidney disease
- diabetes
- HTN
- Glomerulonephritis
- PCKD
indications for dialysis
Acute renal failure: AEIOU
Chronic: when GFR <15ml/minute and symptoms/complications of kidney disease
complications of CKD
- renal bone disease (due to secondary hyperparathyroidism)
- CVS disease
- anaemia due to low EPO
- arrhythmia related to hyperkalaemia
lower limb neuro exam - what to assess in gait
- normal walking
- heel to toe if stable (ataxia = cerebellar)
- stand on heels and then toes (tests distal power)
- Romberg’s test (reduced stability = sensory ataxia due to proprioceptive deficit)
what would increased tone look like in LL exam?
roll leg side to side
if foot remains in line with knee
how would spasticity appear?
place hand under pt knee and briskly lift it up
if spasticity - foot kicks out involuntarily
hip flexion nerve roots
L2/L3
hip extension nerve roots
L4/L5
knee extension nerve roots
L3/L4
knee flexion nerve roots
L5/S1
ankle dorsiflexion nerve roots
L4/L5
ankle plantar flexion nerve roots
S1/S2
big toe extension
L5
MRC power grades
5: full power
4: some resistance
3: GRAVITY
2: gravity eliminated
1: flicker of muscle contraction
0: nothing
how to test sensation
- if suspect glove and stocking: test from distal to proximal in 2-3 straight lines
- if suspect nerve/root pathology: test dermatomes
dorsal column modalities
light touch
proprioception
vibration
spinothalamic modalities
temp
pain
3 causes of bilateral upper motor neurone lesion
MS
MND (normal sensation)
Myelopathy (cord compression, trauma, syringomyelia)
Brain stem stroke
Cerebral palsy
sensorimotor polyneuropathy differentials
Alcohol
B12/thiamine def
Charcot-Marie Tooth
Diabetes, Drugs
Every vasculitis and some infections (HIV, syphilis)
causes of unilateral UMN lesion and pattern of loss
- intracranial: stroke, SOL (hemisensory loss)
- brainstem: stroke, SOL (may be crossed signs)
- spinal cord: MS, infarct, SOL, disc prolapse (sensory level)
features of Brown-Sequard
- loss of power and proprioception on ipsilateral side
- loss of pain and temp on contralateral side (as spinothalamic decussates in spine)
hemiplegic
unilateral UMN
spastic
bilateral UMN
foot drop
LMN
ataxic
cerebellar
waddling
myopathic
festinating
parkinsonian
abnormalities in pronator drift
- pronator drift and distal flexion = pyramidal weakness
- upward drift = cerebellar pathology (accentuated by rebound)
shoulder abduction nerve root
C5
elbow flexion nerve root
C6
elbow extension nerve root
C7
wrist extension nerve root
C7
finger extension nerve root
C7
finger flexion nerve root
C8
finger abduction nerve root
T1
thumb abduction nerve root
T1
DDx for bilateral proximal weakness
DENIM
- Dystrophies: Beker’s/Duchenne
- Endocrinological: Cushing, thyroid, diabetic amyotrophy
- NM: MG, LEMS
- Inflammatory: dermato/polymyositis, viral myositis
- Metabolic/congenital
median nerve palsy causes
carpal tunnel
mononeuritis multiplex
pronator teres syndrome
radial nerve palsy causes
- trauma/compression at axilla (e.g. Saturday night palsy)
- humeral shaft fracture
- elbow trauma
which are the bulbar CN
- 10, 12
where is the lesion is there is visual inattention to one side?
contralateral parietal lesion
what should you offer to test in vision?
colour vision
blind spots (central scotoma, papilloedema)
opthalmoscopy to visualise optic disc
CN4 lesion
if eye cannot move down when facing medially
what to say if there are dramatically abnormal eye movements which do not fit with single nerve lesion?
complex opthalmoplegia
e.g. Graves/MG/brainstem lesion
medical vs surgical third nerve palsy
- medical: spares pupil (only outermost part of nerve affected)
- surgical: pupillary dilatation (affects whole nerve), painful
causes of medical nerve palsy
microvascular ischaemia (diabetes)
Migraine
MS/AI disease
causes of surgical nerve palsy
Posterior Communicating artery aneurysm
Cavernous sinus lesions
Cancer (SOL)
unilateral UMN and bilateral UMN sign
pyramidal weakness
patterns of unilateral LMN lesions and loss
- radiculopathy (dermatomal sensory loss)
- plexopathy (vast dermatomal sensory loss): brachial, lumbosacral
- peripheral nerve palsy (peripheral nerve sensory loss)
- mononeuritis multiplex
causes of radiculopathy
disc hernation
degenerative disc disease
OA
cause of distal motor neuropathy
chronic inflammatory demyelinating polyneuropathy
myotonic dystrophy
progressive muscular atrophy
prophyria
causes of acute flaccid paralysis
- GBS
- rare infections (rabies, polio)
- CES
- spinal cord shoxk
causes of mononeuritis multiplex
- vasculitis
- AI (RA, SLE)
- infectious (Lyme disease, HIV, leprosy)
- others (DM, amyloidosis, sarcoidosis)
UMN + LMN
- MND (no sensory deficit)
- Dual pathology (e.g. cervical myelopathy + polyneuropathy)
- myeloradiculopathy
- Subacute combined degeneration of cord
causes of cerebellar disease
MAVIS:
MS
Alcohol
Vascular - thomboembolic, haemorrhagic
Inherited - Friedreich’s ataxia, spinocerebellar ataxia
SOL
causes of a sixth nerve palsy
raised intracranial pressure
microvascular ischaemia
SOL
trauma
causes of bulbar palsy (LMN)
- MND
- brainstem infarct/SOL
- GBS
- Polio
- Syringobulbia
causes of pseudobulbar palsy (UMN)
- MND
- MS
- bilateral internal capsule infarcts
- TBI
multiple cranial nerve palsies - no pattern
- mononeuritis multiplex
- meningitis
- SOLs
- trauma
if CN 3-6 are involved, what are the causes?
cavernous sinus lesion
Miller-Fisher syndrome
if CN5-8 and cerebellar signs, where is lesion?
cerebellopontine lesion
e.g. vestibular schwannoma, meningioma, brain mets
if CN 9,10,11 involved
jugular foramen syndrome, mostly tumour
if CN 9-12
pseudobulbar palsy (MS, MND, head injury)
bulbar palsy (MND, GBS, syringobulbia)
CN 9-10, Horner’s syndrome + cerebellar + sensory disturbance (ipsilateral face, contralateral body)
lateral medullary (Wallenburg) syndrome
what is pyramidal weakness?
weakness that preferentially spares antigravity muscles
mostly causes weakness of upper limb extensors and lower limb flexors
= upper limb fixed flexion and lower limb extension
different causes of bitemporal hemianopia
pituitary tumours
craniopharyngioma
pregnancy
which hand muscles does the median nerve supply?
all thumb muscles except adductor pollicis - “LOAF”
Lateral two lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor Pollicis brevis
which hand muscles does the ulnar nerve supply?
all intrinsic hand muscles except most of thumb:
- adductor pollicis
- lumbricals
- palmar interossei
- dorsal interossei
which hand muscles does the radial nerve supply?
extensors
how would bulbar palsy affect speech?
flaccid
how would pseudobulbar palsy affect speech?
spastic
how would cerebellar lesion affect speech?
slurred, staccato (jerky), scanning (variability in pitch/volume)
how would myasthenia affect speech?
weak, quiet, fatiguable
Expressive (Broca’s) dysphasia
- pt knows what they want to say but can’t say it
= non-fluent speech - they still understand speech, have awareness of their speech difficulty
Receptive (Wernicke’s) dysphagia
fluent, effortless speech that is disorganized and lacks meaning ( talks Rubbish)
cannot understand language
they lack awareness of their speech difficulty
how you can test these?
- commands (unable to follow = receptive)
- naming objects (difficulty saying name = expressive, incorrect names = receptive)
tremor in Parkinson
asymmetrical resting pill-rolling
begins distally
reduced with finger to nose testing
worsened by distraction
gait in Parkinson’s
shuffling
hesitant (difficulty initiating and turning)
festinating (walk faster and faster)
lack of arm swing
unsteadiness
how can you accentuate the tone in Parkinson’s
by distraction
ask pt to move contralateral arm up and down
how to test bradykinesia
open and close thumb and index finger like clicking as fast as possible
to complete exam in Parkinsons…
- exclude Parkinson Plus syndromes by examining eye movements
- look for cerebellar signs (MSA)
- check postural BP (MSA)
- MMSE (LBD)
- review drug charts (Parkinsonism drugs)
4 key symptoms of Parkinsons
tremor
rigidity
bradykinesia
postural instability
different functions of cerebellum
- maintain balance and posture
- coordinate movement
- motor learning (fine tuning of movements)
differentiating sensory ataxia from cerebellar ataxia
Romberg’s test (tests proprioception caused by sensory disorder)
If cerebellar ataxia, patient ataxic prior to test
what to look for in shoulder exam?
- alignment and posture
- arm position (abducted, externally rotated = ant dislocation, adducted, internally rotated = post dislocation)
- bony prominences: Sternoclavicular joint, clavicle, AC joint
- skin
- muscle wasting
- axilla
what to feel for in shoulder exam?
- skin
- bony landmarks
- muscle bulk
- tendons (biceps tendon, suprapinatus attachment)
what movements in shoulder exam?
- flexion
- extension
- abduction
- adduction
- external rotation
- internal rotation (touch scapula behind back)
special test for serratus anterior
press hands on wall and lean forwards
?scapula winging
testing deltoid
abduct shoulder against resistance at 90
testing supraspinatus muscle
Empty can test
“empty a can of coke”
ask them to push their wrist up against resistance
testing infraspinatus/teres minor
resisted external rotation
testing supscapularis
place dorsum of hand over their lumbar spine
move hand away posteriorly
testing impingement
stabilise scapula
internally rotate
passively flex it
pain = +ve
scarf test
pt hand over opposite shoulder
push elbow posteriorly
pain = acromioclavicular joint pathology
other tests to offer
Hawkins, apprehension
common shoulder pathology
- supraspinatus tendonitis (impingement) = painful arc
- rotator cuff tears = weakness of abduction initiation, supraspinatus wasting
- adhesive capsulitis
- OA
Boutonniere deformity
PIP joint flexion
DIP joint hyperextension
common hand pathologies
- RA
- OA
- Carpel tunnel syndrome
- Trigger finger
cause of trigger finger
thickening of flexor tendon sheath
causes entrapment at A1 pulley
RA exam findings
- swelling of MCP and PCP
- positive MCP squeeze
- Rh nodules
- ulnar deviation
- Z-thumb
- Swan neck deformity (hyperextended PIP, flexed DIP)
extra-articular manifestations of RA
- episcleritis and scleritis
- Atlanto-axial subluxation
- carpal tunnel syndrome
- pulmonary fibrosis
- pericarditis
- anaemia of CD
- splenomegaly
what conditions is trigger finger associated with?
- diabetes
- RA
- hypothyroidism
- gout
abnormalities in gait in hip exam
- Trendelenburg waddling gait (abductor dysfunction)
- Antalgic gait (limp)
special tests in hip
Thomas’s test
Trendelenburg’s test
common hip pathologies
- Hip OA
- Trochanteric bursitis
- Childhood problems
signs of Hip OA on exam
- pain and reduced range of movement (internal rotation often lost first)
- Thomas and Trendelenburg test +ve in severe disease
how would you manage intracapsular hip fractures?
- displaced >60y: THR or hemiathroplasty
- <60 or undisplaced: try cannulated screws
how would you manage extracapsular hip fractures?
- intertrochanteric: dynamic hip screw
- subtrochanteric: intra-medullary nail
complications of hip fractures
infection
blood loss
fracture non-union
avascular necrosis
DVT
valgus vs varus
valgus = knock knees
varus = bowed legs
varus force vs valgus force
varus force = force on lateral side
valgus force = force on medical side
how to do Lachman’s test
pt knee flexed to 30 degrees
one hand on top of thigh
other on back of tibia
pull tibia anteriorly
how to do McMurray’s test?
externally rotate foot
apply varus force to knee
extend knee joint
positive = painful click
collateral ligament tears signs and tx
signs: varus laxity or valgus laxity
effusion
tenderness over affected ligaments
tx: rest, physio, hinged brace
signs of OA
pain
stiffness
reduced ROM
crepitus
signs of prepatellar bursitis
localised swelling over patella
caused by period of kneeling
signs: tenderness over patella, normal ROM
unhappy triad of knee injuries
rupture of medial collateral ligament
damage to medial meniscus
rupture of ACL
position for breast exam
initially sitting
then lying at 30 degrees
aspects in inspection
- arms relaxed
- hands rested on thighs
- hands pressed into hips
- hands behind head leaning forward
- lift breast to look in submammary fold
what is DCIS?
abnormal cells in mammary ducts of breast
not invaded BM
pre-invasive Ca
what is LCIS?
abnormal cells inside lobules of breast
not cancerous
associated with small increased breast Ca risk
benign differentials for breast lump
fibroadenoma
fibrocystic disease
cyst
lipoma
fat necrosis
duct ectasia
duct papilloma
CP definition
non-progressive permanent neuro condition
caused by damage to developing brain
CP classified by limb involvement
- monoplegic: affects one limb
- hemiplegic: one side of body
- diplegic: symmetrical, lower limbs moer affected than upper
- quadriplegic: all 4 limbs severely affected
CP signs
mostly UMN lesion and signs
- hemiplegic (circumduction)/diplegic (scissoring) gait
- increased muscle tone and spasticity in legs
- brisk reflexes
- slightly reduced power
- tremors or jerky involuntary movements
CP management
MDT - physio, OT, SALT, dieticians, symptomatic relief (for spasticity, seizures, drooling etc)
CP complications and associated conditions
learning disability
epilepsy
kyphoscolisosis
muscle contractures
hearing/visual impairment
GORD
components of prosthetic knee
femoral component
plastic spacer
tibial component
compartments of knee
patellofemoral
medical
lateral
