PACES Exams

Question 1

Resp exam - do not forget what?

Pleural effusion, pneumothorax, lung collapse, lung fibrosis, consolidation on resp exam?

Answer 1

Hands/arms:

• CRT, clubbing (PF, lung cancer, CF, bronchiectasis, sarcoidosis/TB)
• Co2-retention flap (T2RF) - check pulse while doing
• RR (arm over chest while taking pulse)

Head/neck: JVP, tracheal assessment (3 fingers, palpate either side of trachea), cricosternal distance (<3 fingers = lung hyperinflation), cervical LNs

Chest:

• Apex beat
• Chest expansion (front/back)
• Percussion, auscultation, vocal resonance (front/back incl. supraclavicular + axillae)
• NOTE: make sure to auscultate in axilla

Other: peripheral oedema, DVT

Question 2

In cardiac exam - what should I not forget?

Answer 2

Hands/arms:

• CRT, clubbing, arm bruising
• Radio-radial delay
• Collapsing pulse (lightly palpate radial and brachial pulses –> feel stronger for a few pulses) = AR
• BP standing/sitting

Head/neck:

• Check for carotid bruits before taking carotid pulse (character, volume) - slow rising = AS, bounding = AR
• JVP + hepatojugular pressure (RUQ), rockstar hand
  
  • PQRST: Pul HTN/PE/Pericarditis/Pericardial effusion, Quantity of fluid, RHF, SVC obstruction, Tamponade/TR

Auscultation:

• Feel carotid pulse while listening to all below heart valves
• Mitral valve - diaphragm mitral + axilla (MR) –> roll onto left side and listen mitral with bell + hold on expiration (MS - low tones)
• Tricuspid valve
• Pulmonary valve - listen for loud P2 (loud vs A2 = pul HTN)
• Aortic valve - aortic area then lean forward & listen at left sternal edge + expiration (AR)
• Listen @carotids (radiation = AS + bruits)
• NOTE: on woman listen at submammary fold not on top of breast
• NOTE: right valves heard best on inspiration; left heard best on expiration

Other: lung bases (pul HTN), peripheral oedema (RHF)

Question 3

Abdo exam - don’t forget what?

Answer 3

Hands/arms:

• Leukonychia (hypoalbuminaemia in liver cirrhosis), Koilonychia (IDA), clubbing (IBD, cirrhosis, coeliac), palmar erythema (liver disease/pregnant)
• Liver flap
• Feel for HR/RR

Neck/chest: lymphadenopathy (incl Virchow’s node), inspect back/chest for spider naevi (>5 sign), gynecomastia, loss of axillary hair etc.

Abdo: distension (fluid, fat, foetus, flatus, faeces)

• Hepatomegaly - mets/HCC, cirrhosis, hepatitis, RVF, haem (leukaemia/lymphoma)
• Splenomegaly - portal HTN, haem (lymphoma/leukaemia/myelofibrosis), malaria
• Check for Murphy’s/Rovsing’s if relevant
• Spleen vs kidney - can’t get above spleen, spleen notched, spleen not ballotable, spleen moves down on inspiration
• AAA palpation (expansile = AAA)
• Bowel sounds (tinkling = obstruction, absent = paralytic ileus/peritonitis)

Other: ankle oedema = hypoalbuminaemia (liver disease)

Question 4

Neuro examination Qs:

1. Good acronym for general inspection?
2. What screens do you do for upper and lower limbs?
3. What are you feeling for on examining tone?
4. What to do before checking power against resistance?
5. How to find the tendon for each reflex?
6. How do you accentuate neuro reflexes?
7. What to remember when doing the finger-to-nose test?

Answer 4

1. SWIFT - scars, wasting, involuntary mov, fasciculations, tremors
2. Screens:
   
   • Upper - hands out pronate (tremor?), supine hands and close eyes (pronator drift = UMN lesion)
   • Lower:
     
     • Stand up from chair with hands crossed (prox power)
     • Gait assessment - normal, only on heels/toes (distal power), tandem walk (balance)
     • Stand with both feet together (balance) –> Romberg’s test if they could do prior (eyes closed - proprioception).
3. Tone:
   
   • “Clasp-knife spasticity” = pyramidal (UMN) lesion - velocity/direction-dependent e.g. stroke/spinal cord compression/MND
     
     • CLONUS also present in UMN lesion
   • Rigidity = extrapyramidal lesion - velocity/direction independent, types:
     
     • “Lead-pipe” = NMS (anti-psychotics)
     • “Cogwheeling” = Parkinson’s (tremor on rigidity)
4. Check power against gravity - raise arms/legs (if so MRC is 3+)
5. Eliciting reflexes:
   
   • Biceps - thumb over cubital fossa (from lateral side) while they move hand towards shoulder (should be central) - place nail over tendon and hit nail. Get patient to rest hand on knee
   • Brachioradialis - first 2 fingers 1/3 up arm from wrist, lateral arm. Get patient to rest hand on knee
   • Triceps - hold out patient arm at 90 degrees takin the weight of the patient’s arm, stand behind patient, hit just above the olecranon
   • Knee jerk - if patient supine, support behind knee
   • Ankle jerk - if patient supine, cross one leg over the other, dorsiflex foot, strike ankle tendon OR keep straight, dorsiflex foot and strike ball of the foot (just below ball under toes)
6. Jendrassik maneuver - clench hands together/clench jaw at the same time as eliciting reflex
7. Put finger just beyond reach so they have to stretch

Question 5

What are the nerve innovations for deep tendon reflexes in upper and lower limb neuro examination?

Answer 5

Nerve innovations:

• S1,2 - buckle my shoe - ankle jerk (Achilles tendon)
• L3,4 - kick the door - knee jerk (patellar tendon)
• C5,6 - pick up sticks - biceps, brachioradialis reflex
• C7,8 - lay them straight - triceps reflex

Question 6

Neurology Ix depending on UMN/LMN signs?

Answer 6

ALL: involve MDT for full functional assessment (physio & OT)

UMN:

• Imaging (brain ± spinal cord)
• CSF (LP)
• Brain biopsy

LMN:

• Nerve conduction studies & electromyography (NCS & EMG)
• Bloods (metabolic, abs)
• Muscle/nerve biopsy

Question 8

What should I not forget in upper limb neuro exam?

Answer 8

Upper limb:

• Pronator drift (palms up)
• Power - stabilise joint, chicken, boxer, arms out straight, , separate fingers separate + hold paper, thumb straight up in air (abduction)
• Reflexes - nerve innovations:
  
  • Biceps/brachioradialis - C5/6 - pick up sticks
    
    • Brachioradialis - feel for radial tubercle then go several cm lower
  • Triceps - C7/8 - lay them straight
• Coordination - finger-nose test (put elbow out like chicken) & dysdiadokokinesia
• Sensation - dorsal column: “does this feel normal?”
  
  • Fine-touch - glove & stocking or dermatomal:
    
    • C5 - deltoid area
    • C6 - thumb
    • C7 - middle finger
    • C8 - little finger
    • T1 - medial forearm
    • T2 - medial upper arm
  • Vibration - 128Hz tuning fork (IPJ thumb, hit on elbow to trigger, ask patient to say yes when it stops)
  • Proprioception (hold either side of thumb)
• Sensation - spinothalamic:
  
  • Pain - neurotip
  • Temperature - prongs of tuning fork (sternum then dorsum of hand)
• Sensation pathology:
  
  • Radiculopathy (dermatome - nerve root)
  • Glove & stocking - peripheral neuropathy e.g. DM

Question 9

What bits not to forget in lower limb neuro exam?

Answer 9

Lower limb:

• Gait & Romberg’s test
• Tone - clonus
• Power - stabilise joint (contralateral-side if hip)
• Nerve innovations of reflexes:
  
  • Knee - L3/4 - kick the door
  • Ankle - S1/2 - in the shoe
• Babinski reflex
• Coordination = heel-shin test
• Sensation - dorsal column:
  
  • Fine-touch - glove & stocking or dermatomal: “does this feel normal?”
    
    • (L1 - higher upper inner thigh)
    • L2 - upper inner thigh
    • L3 - medial just above knee
    • L4 - medial upper calf
    • L5 - lateral calf
    • S1 - plantar aspect of the foot (sole)
  • Vibration - 128Hz tuning fork (IPJ big toe, hit on elbow to trigger, ask patient to say yes when it stops)
  • Proprioception (hold either side of big toe)
• Sensation - spinothalamic:
  
  • Pain - neurotip
  • Temperature - prongs of tuning fork (sternum then dorsum of foot)
• Sensation pathology:
  
  • Radiculopathy (dermatome - nerve root)
  • Glove & stocking - peripheral neuropathy e.g. DM

Question 10

Hand & wrist examination? DDx structure? Ix? Common hand pathology? Hand muscles anatomy?

Answer 10

Intro - WIPE (wash, intro, pain & position, explain)

Look

• General - RASS (Redness, Asymmetry, Swelling, Scars)
• Tops:
  
  • Bones:
    
    • OA - Heberden’s nodes (DIP), Bouchard’s nodes (PIP)
    • RA - swan neck deformity, boutonniere’s deformity, Z-shaped thumb, ulnar deviation, MCP palmar subluxation
  • Skin - scars, thinning, rashes, bruising (steroids)
  • Muscle - wasting
  • Nails - psoriatic changes (pitting, onycholysis), clubbing, nailfold vasculitis
• Palms - thenar (thumb-side), hypothenar muscle wasting, palmar erythema (RA), carpal tunnel release scar, swellings (e.g. ganglions)
• Extensor surfaces - psoriasis, rheumatoid nodules, gouty tophi (white uric acid crystals under the skin - fingers/elbows)

Feel

• TST (Temperature, Swelling, Tenderness)
• Palms:
  
  • Bulk of thenar/hypothenar prominences
  • Tendon thickening - flexor tendon sheaths (hypertrophy/contraction –> Dupytren’s)
  • Flex each finger individually and then feel the tendon base as extend (trigger digit)
• Tops:
  
  • Temp - forearm, wrist, MCP
  • Squeeze joints & feel for bony swelling, effusion, synovitis, deformity
    
    • Distal radio-ulnar joint + radial & ulnar styloid
    • Anatomical snuffbox (tender = scaphoid fracture)
    • Carpals (bimanual palpation)
    • MCP (squeeze along row then bimanual palpation if pain elicited)
    • Base of thumb (squaring = OA)
    • IP joints (bimanual palpation of each - nodes = OA)
  • Tendon tenderness
    
    • Around radial styloid (1st extensor compartment) = de Quervain’s tenosynovitis
    • Around ulnar styloid = extensor carpi ulnaris tendinitis

Move (active > passive - feel for crepitus, get a few more degrees)

• Wrist movements - active (prayer sign & reverse prayer sign) & passive (feel for crepitus)
• Finger movements - make fist (tendon, small joint involvement), straighten fully (against gravity - joint disease, extensor tendon rupture, neuro damage)
• Thumb movements - abduction (away from hand upward), adduction (thumb to palm), flexion (thumb to little finger) extension (lateral away from hand), opposition (thumb and little finger)

​Functional:

• ​Power grip = Grip fingers
• Pincer grip on finger
• Ask about writing with pen, button-up shirt

Brief neuro hand exam:

• Motor (against resistance):
  
  • Radial (extensor forearm) - wrist extension
  • Ulnar (some of flexor forearm + hand) - finger abduction
  • Median (flexor forearm + thumb) - thumb abduction
• Sensory:
  
  • Ulnar (up to halfway through ring finger dorsum/palm) - hypothenar eminence
  • Median (rest of the palm + fingertip to PIP dorsal index, middle and half of the ring finger) - thenar eminence
  • Radial (dorsum of hand excluding above) - dorsal base of the thumb

Special tests

• Phalen’s test - reverse prayer sign >1 min (pain/paraesthesia = Carpal tunnel syndrome)
• Tinel’s test - median nerve at its course in the wrist - tap (paraesthesia = Carpal tunnel syndrome)
• Finkelstein’s test - hand closed around thumb + ulnar deviation (pain = de Quervain’s tenosynovitis)

To complete exam

• Examine the elbow, full neurovascular exam

DDx: degenerative, infective, inflammatory, traumatic, congenital

Ix: AP & lateral views (2 views) + imaging of joints above and below as well

Hand/wrist pathology:

• RA - chr AI disorder –> symmetrical deforming polyarthropathy
  
  • Synovitis, bony deformities, palmar erythema, small muscle wasting, reduced RoM, tendon rupture/subluxation
  • DIP joints sparred
  • Mx: NSAIDs, steroids, DMARDs (methotrexate), surgery
• OA - mechanical joint degradation w/ degen of articular cartilage, periarticular bone remodelling & inflammation
  
  • Signs: joint crepitus, limited RoM, bony deformities
  • Mx: analgesia, CS injection, physio/splints, surgery
• Carpal tunnel syndrome - median nerve entrapment neuropathy from compression of the median nerve in carpal tunnel
  
  • Intermittent paraesthesia, pain/burning & numb thumb, first, middle fingers and radial half of ring finger
  • Worse @night
  • Signs: loss of power + wasting of thenar eminence, sensory loss in median nerve distribution
  • Mx: splints, CS inj, carpal tunnel decompression
• Trigger finger - thickening of flexor tendon sheath causing entrapment at A1 pulley
  
  • Discomfort/bump at base of digit and catching/clicking during extension
  • Mx: splints, NSAIDs, CS inj, surgical release

Hand muscles anatomy:

• Median nerve - LOAF (all thumb muscles except adductor pollicis)
  
  • Lateral 2 lumbricals
  • Opponens pollicis
  • Abductor pollicis brevis
  • Flexor pollicis brevis
• Ulnar nerve (extrinsic hand muscles except most of thumb)
  
  • Adductor pollicis
  • Lumbricals (flex MCP, extend IP)
  • Palmar interossei (ADduct fingers) = PAD
  • Dorsal interossei (ABduct fingers) = DAB
• Radial nerve = extensors

Question 12

Knee examination? Presentation? Ddx structure? Ix? Common pathologies?

Answer 12

Intro - WIPE (wash, intro, pain & position, explain)

Function - Gait (Antalgic, waddling = abductor dysfunction)

Look:

• General - RASS (Redness, Asymmetry, Swelling, Scars)
• Standing up - front (quads wasting, knee swelling), side (fixed flexion deformity, foot arches), back (varus/valgus deformity, baker’s cyst)
• Lying on bed - scars (TKR, arthroscopic ports on either side), wasting, deformity

Feel:

• TST (Temperature, Swelling, Tenderness)
• Effusion:
  
  • Patellar tap (push down thigh & hold, press down on patella with middle finger)
  • Sweep test (push down thigh, back of hand sweeps up medial x3, other back of hand sweeps down lateral, +ve is swelling on the medial side)
• Palpation:
  
  • Leg straight - quadriceps tendon, medial & lateral borders of patella, patella tendon
  • Knee @90 degrees:
    
    • Patella tendon, tibial tuberosity (down from tendon), medial joint margin
    • Lateral joint margin, head of the fibula (slightly lateral and distal to knee), collateral ligaments (hands around upper calf)

Move (active > passive - feel for crepitus, get a few more degrees)

• Knee extension:
  
  • Active = push knee down into bed
  • Passive = lift entire leg up @ ankle (hyperextension >10 degrees)
• Knee flexion:
  
  • Active = bring heel towards bum (posterior sag?) then straighten
  • Passive = same mov, leave knee flexed (for next part)

Special tests = 3Cs of knees – Cartilage (McMurray’s), Collaterals, Cruciates – Lachman’s, A/P-drawer)

• Anterior & posterior drawer (ant- bring towards = ACL; post - push away = PCL)
• Lachman’s test (flex knee to 30 degrees, right hand pulls, left hand stabilises the femur, checks ACL)
• Collateral ligament assessment:
  
  • Varus stress test (LCL) - put the knee in varus positon while palpating the lateral knee joint line
  • Valgus stress test (MCL) - put the knee in valgus position while palpating the medial knee joint line
• Menisci assessment - McMurray’s test - say “would consider doing but may be too painful for the patient”
  
  • Passively flex the knee, hold the right foot with right hand apply external pressure with the left hand palpating the knee (abducting at the hip) while fixating and external rotating with the right hand, slowly extend at the knee watching for a click/discomfort = medial meniscus tear
  • Opposite movements to test for lateral meniscus tear

To complete exam:

• Assess NV status
• Examine joints below and above (hip and ankle)
• Further imaging if indicated (X-ray)

Presentation:

• Normal gait, no obvious deformities of either knee, on palpation there was no pain and there was a full range of active and passive movement
• There was no evidence of laxity in the knee ligaments bilaterally

DDx: degenerative, infective, inflammatory, traumatic, congenital

Ix: AP & lateral views (2 views) + imaging of joints above and below as well

Common pathologies:

• ACL tear - twisting injury, ‘pop’ swelling within 1 hour, very painful for 2wks
  
  • Increased laxity on anterior drawer test/Lachman’s test
  • Mx: physio/surgical reconstruction (if ongoing instability)
• PCL tear - high energy trauma (multi-ligament knee injury/hip dislocation/fracture)
  
  • Increased laxity on posterior drawer test
  • Mx: physio/surgical reconstruction
• Meniscal tear - twisting injury, swelling after a few hrs, sharp localised medial/lateral pain worse on hyperflexion/twisting, knee may lock/give way
  
  • Tender over medial/lateral joint line, good RoM unless knee locked, +ve McMurray’s
  • Mx: MRI/arthroscopy to confirm, tear usually excised arthroscopically
• Collateral ligament tear
  
  • Varus/valgus laxity, effusion, tenderness over affected ligaments
  • Mx: rest, physio, hinged brace
• OA - pain & stiffness, reduced RoM, crepitus
• Prepatellar bursitis - localised swelling over patella, precipitated by period of kneeling
  
  • Signs: tender over patella, normal RoM
  • Mx: rest, NSAIDs, aspiration/CS inj

Question 13

Hip examination? Presentation? DDx structure? Ix? Mx (for OA)? Common pathology?

Answer 13

Intro - WIPE (wash, intro, pain & position, explain)

Function - Gait (Antalgic, Trendelenburg - waddling = abductor dysfunction)

Look

• General - RASS (Redness, Asymmetry, Swelling, Scars)
• Standing inspection:
  
  • Front (pelvic tilt, quads wasting), side (lumbar lordosis, knee flexion, foot arches), behind (scoliosis, gluteal atrophy, iliac crest alignment)
  • Trendelenburg’s test:
    
    • ​Place hand resting lightly above both hips
    • Bend one knee - if the hip dips on the bent side = contralateral abductor muscle weakness
• Lying inspection: compare symmetry & rotation (shortened & externally rotated = fractured NoF), hip scars, dressings, skin changes

Feel - check for pain, start on the normal side

• TST (Temperature, Swelling, Tenderness)
• Bony landmark tenderness:
  
  • Feel around hip joint (tenderness, warmth, effusion)
  • Feel along greater trochanter (lateral edge of thigh - trochanteric bursitis) run a hand up to greater trochanter (trochanteric bursitis)
  • Feel ASIS –> pubic rami
• Measure true/apparent leg lengths:
  
  • Apparent = umbilicus to medial malleolus (unequal = spinal/pelvic deformity e.g. scoliosis)
  • True = ASIS to ipsilateral medial malleolus (unequal = true limb shortening e.g. fracture)

Move (active > passive - feel for crepitus, get a few more degrees)

• Roll side to side
• Flexion:
  
  • Active (as far as can) then passive feeling for crepitus
  • Passive internal & external rotation (while knee is bent to 90 degrees, lose IR early in OA)
• Passive abduction & adduction - place a hand on the contralateral pelvic crest to detect mov (crossing over leg for adduction)
• Passive extension - lie face down, scars/muscle wasting? place hand on pelvis/lumbar spine to detect mov

Special tests

• Thomas’s test (not if hip replacement –> dislocation):
  
  • ​Place a hand under the lumbar spine (check no lumbar lordosis)
  • Flex hip on one side (knee bent)
  • If contralateral thigh forced off the ground = fixed flexion deformity (of the side forced off the ground)
  • NOTE: need to flex hip on the opposite side to that examining

To complete exam - examine shoulder and knee, full neurovascular exam distal to joint

Presentation:

• Normal gait, no obvious deformities on inspection
• On palpation, there was no pain with a full range of passive and active movement and no fixed flexion deformity and no abductor muscle weakness

DDx: degenerative, infective, inflammatory, traumatic, congenital

Ix: AP & lateral views (2 views) + imaging of joints above and below as well

Mx (for OA):

• Conservative – physio, exercise, weight loss
• Medical – analgesia, IA CS injection
• Surgical – arthroplasty

Common pathology:

• Hip OA - pain, crepitus, reduced ROM (internal rotation lost first)
• Hip fracture - shortened and externally rotated limb
• Hip dislocation - shortened and internally rotated limb
• Abductor muscle weakness - Trendelenburg’s positive
• Trochanteric bursitis - pain over the greater trochanter
• Childhood - dislocation, Perthes, SUFE

Question 14

How do you approach an MSK X-ray?

Describing a fracture on XR approach?

Answer 14

MSK X-RAY APPROACH:

• NOTE: likely knee or hip x-ray in the exam

General:

• Name, DoB ±PC
• XR - date & time, views (AP/lateral), area of body, rotation, penetration (RI_P_E)
• NOTE: always do ≥2 views, compare to previous X-rays, look at imaging for joints above and below

ABCS approach: Alignment & joint space, Bone texture, Cortices, Soft tissues

• Alignment & joint space:
  
  • Changes suggest –> fracture, subluxation (still touch) or dislocation
  • Displacement - describe the position of fragment distal to fracture site described
  • Joint space:
    
    • Narrowing due to cartilage loss/calcification (chondrocalcinosis)/new bone (osteophytes)
    • Subchondral sclerosis is increased bone density along joint lines (OA)
• Bone texture - altered density (subchondral cyst - increased density, OA)/disruption (blurry - osteomyelitis) in trabeculae (inside of bone)/cortex (outer coating)
• Cortices - trace around outside of each bone
  
  • Step = possible pathology:
    
    • Fracture
    • Bony destruction - inf or tumour (primary/secondary)
  • Periosteal reaction (new bone in response to injury/stimuli, appears as pale bone on the outside) - can be only sign of stress/healing fracture, mild osteomyelitis, tumour)
• Soft tissues - swelling, foreign bodies (lipohaemarthrosis caused by fracture), effusions

DESCRIBE A FRACTURE:

Where - what bone? location (proximal, middle, distal OR epiphysis, metaphysis, diaphysis)? Does it involve articular surface (intra/extra-articular)?

Types:

1. Simple vs Compound:

• Simple: closed fracture i.e. only bone involved
• Compound: open fracture i.e. bone exposed to the external environment - (↑risk of infection → ↑fracture non-union) Open fractures are emergencies and require urgent management with:
  
  • IV antibiotics
  • Tetanus prophylaxis
  • Wound debridement

2. Subtype:

• Complete (all the way through the bone)
  
  • Transverse: perpendicular to long axis of bone
  • Oblique: tangential to long axis of bone
  • Spiral: oblique and rotating around the shaft
  • Comminuted: > 2 fragments –> CT to further assess
  • Impacted: broken ends of bone are jammed together by the force of injury, fracture line is indistinct
  • Linear: parallel to axis of the bone
  • Avulsion: bone attached to tendon/ligament is pulled away from main bone
• Incomplete (not whole cortex, most common in children):
  
  • Greenstick: bone bends and cracks, occurs < 10yrs
  • Salter-Harris: growth plate involvement

Displacement - describe the position of distal fragment to body (anterior/posterior)

• Angulation: change in bone axis (varus/valgus, dorsal/palmar, radial/ulna)
• Translation: movement of fractured bones away from each other (% of bone width)

OVERALL: 1) Type (simple/compound > subtype) 2) Relevant region, side and name of bone 3) Displacement (& angulation, translation)

• Example: Simple oblique fracture of the proximal right tibia with posterior displacement

Question 16

Vascular exam - upper, abdo & lower? Arterial & venous anatomy?

Answer 16

NOTE: if press harder and it is there = my own pulse; if press weaker and it is there = their pulse

• If can’t feel pulses can use doppler USS: triphasic signal
  
  • 1st phase - forward rush of blood
  • 2nd phase - reverse flow from elastic recoil (in arterial wall)
    
    • Lost in arterial disease = biphasic/monophasic signal
  • 3rd phase - forward flow on vessel relaxing

EXAMINATION:

General inspection – smoking, inhalers, diabetic meds, fistula, dressings, walking stick

Upper:

• Hands – splinter haemorrhages, nicotine stains, missing digits (more common in trauma, Buerger’s disease), temperature + CRT
• Supra-aortic pulses:
  
  • Radial – rate, rhythm, radio-radial delay
  • Brachial pulse – character
  • Subclavian pulse, in supraclavicular fossa
  • Carotid pulse
• BP
• Listen for bruits in neck, breathe in and out slowly

Abdo:

• Inspect for scars, look around sides
• Palpate for aneurysms - abdominal aortic pulse
• Listen for aortic and renal bruits (above umbilicus and to either side)

Lower:

• Inspect (colour, swelling, scars, varicose veins)
• Palpate:
  
  • Temp in feet, calves, thighs (run back of hand along)
  • Tenderness - squeeze ankles/calves (DVT)
  • CRT, pitting oedema
  • Measure leg diameter 10cm below tibial tuberosity (If <3cm between = not significant)
• Femoral arteries (ASIS & pubic symphysis midpoint):
  
  • Feel simultaneously as weak femoral pulse difficult to determine
  • Radio-femoral delay
  • Auscultate femoral pulse for bruits (can also listen to iliacs - below umbilicus on either side) –> sometimes only picked up on exercise
• Popliteal arteries – reach around back of knee, behind the knee, slightly lateral, lift leg up to 30 degrees so weight resting on fingers
• Pedal arteries – anterior (dorsalis pedis) & posterior tibial (behind medial malleolus)
• BUERGER’S TEST (for peripheral vascular disease)
  
  • Both feet held up – angle foot goes white is Buerger’s angle –> when foot blanches swing legs over side of bed and let them hand down –> ischaemic foot will go brick red = severe peripheral vascular disease of lower limb = SUNSET SIGN
  • Ideally, I should hold feet for 1 minute but still say -ve test if no blanching
• ABPI:
  
  • BP cuff above ankle with leads upwards – find dorsalis pedis pulse with doppler USS
  • Inflate cuff until signal disappears – let down cuff until signal reappears = ankle pressure
  • Repeat procedure in arm using brachial artery signal to record the brachial pressure
  • ABPI = ankle pressure/brachial pressure
  • 0.5-0.8 = claudication (mild-moderate disease); <0.5 = rest pain (severe disease); <0.2 = gangrene

Finally - complete relevant neuro exam, vascular exam where not been done in exam, CV & abdo exams

• Bloods - FBC, U&E, coag
• D-dimer, duplex USS (venous - DVT/arterial - perfussion) –> CTPA (PE)
• Tx: DOAC/Warfarin if high-risk DVT

Leg Anatomy:

• Arterial:
  
  • External iliac artery > femoral artery (pulse):
    
    • Profunda artery (minor branch)
    • Superficial femora artery (main branch) > Popliteal artery (pulse):
      
      • Anterior tibial artery - form dorsalis pedis artery (pulse)
      • Posterior tibial artery - goes around medial malleolus (pulse)
        
        • Peroneal artery (branch of PTA)
• Venous:
  
  • Great-saphenous vein (medial) - meets deep femoral vein in medial upper thigh (as goes into groin)
  • Small-saphenous vein (lateral)
  • Connected via perforating vein

Question 20

Breast anatomy? Breast exam? Triple assessment?

Answer 20

Breast anatomy - Lobules > ducts > nipple

• Ligaments suspending breast = Cooper’s ligaments
• Most lymphatic drainage to axilla (& intercostal, interthoracic LNs)
• Blood supply - perforating intercostal arteries

Intro - WIPE + chaperone

Inspection:

• SITTING Positions:
  
  • Relaxed arms
  • Hands rested on thighs
  • Hands-on hips - tense pectoralis
  • Hands behind head - accentuate dimpling/asymmetry
  • Lift breasts - submammary fold (ask patient)
• Look for:
  
  • Asymmetry, local swelling, scars (look under breasts)
  • Skin changes:
    
    • Dimpling/puckering - tethering due to cancer
    • Peau d’orange - lymphatic oedema due to cancer
  • Nipple changes:
    
    • Paget’s disease of breast - unilateral nipple = cancer
    • Eczema - areola (rarely nipple), bilateral
    • Inversion - normal variant/cancer

Palpation: LYING DOWN + hand on the side being examined behind head + check for pain (start on normal side)

• Use palmar surface of middle 3 fingers to feel for any lumps starting in centre and going round in concentric circles
• Pinch along axillary tail (first 2 fingers & thumb)
• Ask patient to squeeze each nipple to check for discharge
• Localise + describe lump: 3Ss, 3Cs, 3Ts
  
  • Site, Size, Shape
  • Consistency, Contours, Colour
  • Tenderness, Temperature, Tethering/Transillumination
• Lymph nodes:
  
  • Axillary - ask patient to hold bicep:
    
    • Palpate apical, lateral, medial, anterior, posterior aspects
  • Cervical LN exam
• Offer to examine lungs and liver for mets

Triple assessment:

• Examination
• Imaging (USS <35yrs; MMG + USS ≥35yrs)
• Biopsy (FNA if cystic, core biopsy if solid)

Question 21

Comparing different types of vascular ulcers:

• Hx
• Location
• Characteristics - ulcer & surrounding skin
• Tx

Answer 21

Venous:

• Hx: varicose veins, previous DVT, obesity, preg, recurrent phlebitis
• Location: lower calf-medial malleolus
• Characteristics: mild pain
  
  • Ulcer - shallow/flat margins, exudate, sloughing @base, granulation tissue
  • Surrounding skin - haemosiderin staining, eczematous, oedematous, thickening skin, (normal CRT)
• Tx: compression bandaging, leg elevation, surgical Mx

Arterial:

• Hx: HTN, DM, smoking, prev vascular disease
• Location: pressure points, toes/feet, lateral malleolus, tibia
• Characteristics: painful
  
  • Ulcer - punched-out/deep, irreg shape, necrosis, no exudate (unless inf)
  • Surrounding skin: thin, shiny, reduced hair, 6Ps (pallor, pain, perishingly cold, pulselessness, paraesthesia, paralysis)
• Tx: revascularization (e.g. bypass), anti-platelet, manage RFs

Neuropathic:

• Hx: DM (peripheral neuropathy), trauma, prolonged pressure
• Location: plantar foot, tip of toe, lateral-fifth metatarsal
• Characteristics: no pain
  
  • Ulcer - deep, surrounded by callus, insensate (no feeling)
  • Surrounding skin - dry, cracked, callus, insensate
• Tx: off-loading pressure, topical GF

Pressure:

• Hx: limited mobility
• Location: bony prominence, heel
• Characteristics:
  
  • Ulcer - deep, macerated (moist, wrinkly)
  • Surrounding skin - atrophic skin, lost muscle mass
• Tx: off-loading pressure, reduced moisture, increased nutrition

Question 23

Breast triple assessment?

Answer 23

Clinical examination

Breast imaging (MMG, USS)

Breast biopsy

Question 24

Describing a lump?

Answer 24

Localise + describe lump: 3Ss, 3Cs, 3Ts

• Site, Size, Shape
• Consistency, Contours, Colour
• Tenderness, Temperature, Tethering