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MRCS Part B > Physical Examinations > Flashcards

Physical Examinations Flashcards

1
Q

1) Symptoms + Signs + Manifestations
2) Causes (4)
3) Thyroid Hormone Synthesis
i) T4 vs T3
ii) Iodine transport
iii) Iodide oxidisation
iv) Thyroglobulin synthesis
v) Iodinated thyroglobulin –> T3/T4
vi) T4–> T3
vii) plasma constituents

A

1)

Symptoms - Fatigue, Cold Intolerance, Weight Gain, Dry skin, Coarse Hair, Hoarse voice,

Signs - Periorbital oedema, slow relaxing reflexes, bradycardia, proximal myopathy, Lateral third eyebdrow (sign of hertoghe)

Manifestations - Pericardial effusion, High Cholesterol, Menstrual abnormalities, Hyponatraemia,

2) Causes -

Primary - autoimmune, iatrogenic, iodine deficiency

Secondary - Pituitary

3) Thyroid Hormone Synthesis

i) T4 - 2 iodine atoms in outer ring (4 in total) + T3 - 1 iodine atom in outer ring (3 in total)
ii) Iodine - Against gradient into follicular cells
iii) Iodine transported by pendrin into exocytic vesicles within which they’re oxidised to tyrosyl residues on thyroglobulin catalyzed by thyroid peroxidase
iv) Thyroglobulin is synthesised by RER in follicular cells
v) The iodinated TG is resorbed from colloid back into follicular cells. Phagosomes engulf them in which TG becomes hydrolysed –> T3 + T4
vi) Deiodination recaction by deiodinases
vii) Mainly protein bound - TBG, transthretin, albumin

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2
Q

Treatment:

i) Medical
ii) Surgical

A

i)

Symptomatic - beta blockade

Carbimazole - Pregnancy. TPO inhibitor

Propylthiouracil - Relatively safe in first trimester of pregnancy. TPO inhibior + inhibitor of peripheral deiodinasation.

Radioiodide - Orbitopathy/ pregnancy are contraindications

Lugol’s Iodine - Inhibits hormonal secretion + by the Wolf-Chaikoff effect prevents organification of iodine in the gland.

Steroids - prevent peripheral conversion of T4-T3

ii) Surgical

Indications: Orbitopathy, Large goitre, Intolerance/refractory to anti-thyroid treatment + CI to radioiodine, Suspicious nodules

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3
Q

1) Gross Anatomy

2) Relations (Where are the nerves)

3) Vasculature

4) What is divided in thyroid surgery

5) Name strap muscles

6) Embryological origin of thyroid gland

A

1) Ant.to Trachea (attached to 2nd-4th tracheal rings) and Post.to Strap Muscles

Invested by pretracheal fascia (thickens into ligament of berry and attached to the larynx) + has a true capsule

2 Lateral Lobes + isthmus (central)

2) relations:

Ant. - Strap muscles, SCM, Pretracheal fascia

Post. - Larynx, trachea, oesophagus, Pharynx,

Lat. - Carotid Sheath

RLN - Groove tracheoesophagal groove (Near Inf. Thyr Art)

SLN - Deep to upper thyroid pole (near the sup. thyr. art)

3) Vasculature:

Art. - Sup. Thyroid Art. (From ECA)

Inf. Thyr. Artery. (From ThyrCerv Br of SCA)

(Sometimes Thyr. Ima from the Aort. Arch)

Venous - Sup. + Mid Thyr. Vein –> IJV

Inf. Thyr Vein (LL + Isthmus) –> Brachiocephalic Vein

4) Sup to deep:

Skin, Platysma, Inv. Fascia (longitudinally to preserve Ant. Jug Vein), Strap Muscle (upper half to preserve ansa cervicalis nerve supply) , Pretracheal fascia

5) Sternohyoid, Sternoyhyroid, Omohyoid, Thryohyoid,
6) Foramen Caecum of the tongue

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4
Q

1) Unilateral - Manifestations
2) Unilateral - Treatments
3) Bilateral - Manifestations
4) Bilateral - Treatments

A

1) Unilateral - Breathy Voice, Aspiration Risk, Not usually risk of airway compromise
2) Unilateral- Injection laryngoplasty (lateral to vocal fold to help medially displace the vocal fold), Medialisation thryoplasty (implant placement) or RLN reinnervation
3) Bilateral - Less ofa voice problem. Dyspnoea ranging through to stridor - significant risk of airway compromise
4) Bilateral. Aim is to provide a safe airway. Tracheotomy, Vocal Fold lateralisation, Vocal Cord/Aryetenoid resection, RLN reinnervation

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5
Q

What organs are palpable in a normal abdomen?

A

Aorta, Lower pole of R Kidney

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6
Q

Surface marking for the neck of pancreas?

Surface marking for the liver?

Surface marking for the gallbladder?

Surface marking for the spleen?

A

Pancreas - L1 - Transpyloric Plane

Liver- Superior - T4 (nipple line) From right 5th itnercostal space –> left 5th intercostal space

Inferior - Right 10th Rib

Gallbladder - 9th costal cartilage in midclavicular line. L1 transpyloric plane

Spleen - behind 9th-11th Left ribs

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7
Q

Examination features of compartment syndrome?

Treatment - Describe?

A

Early:

Pain out of keeping with injury, Leg swelling, Pain on passive ankle stretching

Late:

Pulseless, Paraesthesia, paralysis

Fasciotomy:

(Four compartment)

Consent + explain etc.

Two incisions, debride + divide fascia :

Anterior - 2 cm anterior to fibula

Longitudinal incision from tib. tub –> just sup. to ankle

posterior - just medial to posteromedial tibial border

Longitudinal incision from tib. tub –> 5cm above medial malleolus

Forearm Treatment:

Volar Incision Along ulnar border

Dorsal incision (from lateral humeral epicondyle to mid-wrist)

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8
Q

Abdominal Examination

A

WIPER

General Inspection - Pain, Look around the bed - fluids/ infusions/ medications

Hands - Duputryen’s, palmar erythema, Any nail signs, Liver Flap, Pulse

Face - Scleral icterus, Frenulum, Tongue (glossitis/macroglossia), Apthous Ulcers, pigmentation

Neck - JVP, L Supraclavicular fossa (Virchow’s Node), Spider Naevi

Abdomen - Scars, Drains, hernias (deep breath in/out, cough, lift head off bed), Distended Veins, Size

Palpation - Soft, Deep, Organomegaly, Aorta

Percuss - Ascites, bladder, Liver

Auscultate - Bowel Sounds, Aortic + Renal Bruits

Legs - Pedal Oedema

Complete - DRE, External Genitalia Exam, Observations, Urinalysis, Urine pregnancy test with consent,

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9
Q

Breast Examination

A

WIPER

General Inspection - Asymmetry, Scars, Nipple inversion, Dimpling, Skin changes, Lumps, Discharge ( ask patient to self express if they say there is any), Scars

Inspection - Hands on hips, Hands behind head, Lean forwards, Look at back

Palpation - (ask for pain first)

Normal breast first - Hand behind head

Palpate four quadrants

Areolar region

Inframammary fold

Axillary region

Axillary tail (ask patient to rest their hand on yours

Supraclavicular nodes

Palpate thoracic spine

Complete - Full history, neurological exam, respiratory exam, abdominal exam

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10
Q

i) Risk Factors for Breast Cancer

ii) Work up for breast cancer

A

i) Early Menarche / Late Menopause

Nulliparous

FH

HRT

BRCA1 / BRCA 2

ii) Triple Assessment - +ve

Receptor Status

Bloods - incl LFTs + Bone Profile

CXR +/- CT TAP +/- Bone Scan

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11
Q

Surgical Treatments for Breast Cancer

A

Wide Local Excision - Small tumours/ large breasts

+ SLNB - Blue Dye + Radionucleotide detection

Mastectomy - Tumours >4 cm, Small breasts, Multifocal tumours, Prophylaxis, Central tumours, areolar/peri-areolar

+/- Axillary Clearance - dependent on nodal status at SLNB

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12
Q

i) Hormone treatments available for breast cancer

ii) Breast screening in UK

A

i) Tamoxifen - Selective Oestrogen Receptor Modulator

Trastazumab - MAB against HER2

Anastrazole - Aromatase inhibitor

ii) 50 - 70 year olds : Every 3 years mammography

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13
Q

Which grafts can be used for CABG

A

Intermal Mammary

Great Saphenous Vein

Radial Artery

Prosthetic Grafts

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14
Q

What is the sciatic stretch test

A

Passive SLR:

  • Where the pain is preciptated flex the knee.
  • If with knee flexion the pain disappears the likely aetiology of the pain is the sciatic nerve
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15
Q

i) Dermatomes tested in Lower Limb Examination

ii) Which nerve roots are the lower limb reflexes interrogating

A

i) L1 - Inguinal

L2 - Upper thigh

L3 - Knee

L4 - Medial calf

L5 - Lateral calf

S1 - Sole of foot

ii) knee - l3/4

Ankle - S1/S2

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16
Q

5 Red Flag Symptoms for cauda equina syndrome

A

Severe Back Pain

Bilateral Sciatica

Sexual Dysfunction

Visceral Dysfunction

Saddle Anaesthesia

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17
Q

How to complete cranil nerve exam

A

Snellen Chart

Ishihara Plates

Smelling Salts

Fundoscopy

Reflexes - Gag, Corneal and Jaw Jerk

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18
Q

Causes of Loss of SMell

A

Senile Anosmia

Nasal - Tumours, Polyps

Frontal lobe pathology - Meningioma, Trauma, Viruses, Hydrocephalus

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19
Q

i) Cranial nerve VII Nuclei

ii) Branches of Facial nerve given off within the facial canal

A

i) Motor Nucleus

Sensory Nucleus ( CNV)

Parasympathetic Nuclei:

Lacrimal (–> Pterygopalatine Ganglion –> Greater petrosal nerve –> Lacrimal glands)

Superior Salivary Nucleus (–> Submandibular Ganglion –> These fibers become chorda tympani –> Submandibular Ganglion)

Sympathetic:

Nucleus of tractus solitaries (Taste)

ii) Within the Facial Canal:

Sensory nerve to external auditory meatus

Nerve to stapedius

Greater petrosal Nerve

Chorda Tympani

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20
Q

What does CNIX Do?

A
  • GS to palate, posterior 1/3 tongue, pharynx, tonsils, middle ear
  • SS from the Carotid Body/Sinus (CN X does aortic body) + Taste from posterior 1/3 tongue
  • Motor fibers to Stylopharyngeus

- Innervates the parotid gland:

Gives off a tympanic branch which synapses with the otic ganglion. Then fibers run in the auriculotemporal nerve (V3) to the parotid gland

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21
Q

Ear Exam

A

WIPER

Inspection - Away from a wall so you can walk behind

Palpation - Mastoid bone + pinna

Whisper Test

Rhinne’s - 512 hz

Weber’s - 512 hz

CNVII

Romberg’s - Balance impaired eyes open = cerebellar

Balance impaired eyes closed = proprioceptive loss

Otoscopy

Tonsillar Examination

Complete -

Full Cranial Nerve Exam

Otolaryngoscopy - to see the vocal cords

Cervical Node Examination

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22
Q

Describe Weber’s And Rhinne’s Test

A

Weber

256 Hz tuning fork in middle of forehead

Localises to affected side if conductive loss

Localises to the unaffected side if sensorineural loss

Rhinne’s Test

256 Hz tuning fork on mastoid bone and then in front of ear.

If bone > air then conductive hearing loss

If air > bone + localises to the other side + Rhinne’s test on other side is normal then sensorineural hearing loss

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23
Q

Causes of conductive hearing loss

A

External Auditory Canal - Wax, Foreign Body, Otitis Externa, Tumour in ear canal, Perforation of tympanic membrane

Middle Ear - OM, Haemotypanum, Cholesteatoma, Otosclerosis

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24
Q

Do a lump exam

A

Ss Ts and Cs

Size, Shape, Site

Transillumination, Tednerness, Temperature, Tethering

Colour, Compressibility, Consistency, Contour

Extras:

Cough Impulse

Auscultate

Pulsatility
Lymphadenopathy

Neurovascular status (in all limb lumps)

Completion:

Cardiorespiratory exam to assess for fitness for surgery

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25
Q

Lumps Separate from the Testes

A

Transilluminates- Hydrocele or Epididymal Cyst

Does not transolluminate - Epididymitis or Spermatocoele

26
Q

Hand Exam

A

WIPER ( above elbows exposed)

Inspect

Palpate :

  • Joint tenderness
  • Metacarpal squeeze test
  • Subcutaneous nodules on forearms

Peripehral Nerves:

Radial - Wrist Extension + Base of thumb

Median - Opposition of thumb from abducted position + lateral index finger

Ulnar - Abduction of digits + Medial hand

Movements:

Active + Passive movement of each joint

Power Grip

Fine motor (Do a button)

Special Tests:

Finkelsteins’s

Tinnel’s

Phalen’s

Reverse Phalen’s

Allan’s Test

Complete Exam:

Take history

MSK Exam of other joints

Exam for extra articular features of arthritis

Image joints

Fill out DAS score

Request blood tests

27
Q

i) What is rheumatoid arthritis

ii) Pathology

iii) Extraarticular features

iv) Mx

A

i) Symmetrical, inflammatory polyarthropathy with systemic manifestations:
ii) Increased inflammatory cells in joint - T Cells and macrophages

Granulation tissue formation (pannus)

Pannus produces enzymes which damage the underlying cartilage

iii) Rheumatoid Nodules

Vasculitis

Lymphadenopathy

SCleritis/ Episcleritis

Felty’s Syndrome - Splenomegaly, Neutropenia

Pulmonary Fibrosis

Atherosclerosis

Effusions

Anaemia of chronic disease

Iv) Conservative - Physiotherapy Stop Smoking

Medical - Analgaesia, DMARDs (Sulfasalazine, MTX) , immunologics (Etanercept, Infliximab)

Surgical - Referrals for pain/tendon compromise / nerve comrpomise/ Mobility/ Deformity

28
Q

Hip Examination

A

WIPER

Gait Assessment + Trendelenberg’s Test

Look (Back, front, sides) - Scars, Wasting, Swelling, Deformity

True (ASIS to med. mal.) and

Apparent Leg lengths ( Xiphisternum to med. mal.)

Feel - Temperature

Palpate (GT + AL Tendon)

Move - Thomas’ Test ( Fixed Flexion Deformity)

Active + Passive hip movements

Avoid - Thomas’ Test, Internal Rotation, Adduction in HIp Replacement patients

Complete -

Neurovascular Status

Joint Above + Below

Imaging

29
Q

Normal values of hip movements

A
30
Q

Knee Exam

A

WIPER

Gait assessment

Look (While standing from front, back and sides) - Scars, wasting, deformity, fasciculation, swelling, erythema, asymmetry

Quadriceps muscle asymmetry - 14cm from tibial tuberosity
Feel -

45 degrees- tibial epicondyltes, femoral condyles, popliteal fossa, patella, quadriceps tendons, patella tendon, joint line

Bulge test - milk medial side of patella and then press on the lateral side. If you feel pressure on the side of your medial hand this is a positive test

Patellar tap - milk superiorly and then press down on patella . If the patellar doesn’t touch the femur this is a positive test

Crepitus

Move - Active + passive

Start with hip flexion to test the knee extensor apparatus

Special Tests -

Valgus/ Varus Stress Testing - Colalteral ligaments

Mcmurray’s Test - Internal + External Knee rotation to assess both menisci

Posterior Drawer - At 90 degrees look for a discreapancy

Anterior Drawer - At 90 degrees. Sit on feet and try to pull tibia firmly forwards

Lachman’s - at 30 degrees. Push the distal femur down and the proximal tibia up.

Patella Apprehension Test

Simm’s Test

Complete:

History

Examine joint above and below

Limb Neurovascular status

Imaging

31
Q

neck Examination

A

WIPER - Important that chair is away from wall and neck + Upper chest is accessible

Look- Inspection of patient ?thyroid disease.

Neck inspection - Scars, swellings, skin changes, respiratory discomfort

Protrude Tongue + Swallow a mouthful of water - From front and both sides

Feel - (patient should slightly look away from side you are feeling)

Palpate from behind

Palpate the swelling - tongue protrusion + swallow water

Palpate anterior traingle + posterior triangle + cervical lymphadenopathy

Palpate thyroid gland, hyoid bone, cartilages + Trachea (displace the laryngeal cartilage to each side)

Exam any lumps found in accordance with lump examination (incl. Transilluminance + Auscultation)

Listen - Thyroid Bruit + carotid Bruits

Complete:

History

Full ENT examination

Exam the mouth

?Full thyroid exam

Nasoendocsopic examination

?Assess for lymphadenopathy elsewhere

32
Q

i) How to examine the submandibular exam

ii) Rx options for submandibular gland stone

iii) Nerves at risk in submandibular gland surgery

A

i) Bimanual Examination:
- One hand inside the oral cavity behind the teeth and one hand pushing the submandibular gland externally near the angle of the mandible.
- Observe for clear flow of salia on palpation

Also neck exam

Complete:

- Orphopantomamogram

- Sialography

- FNA

ii) Conservative - Analgaesia, antibiotics, Gland Massage (Bimanual to milk it out), suck on citrus fruit to enhance salivation,

Intervention:

Sialogram can be therapuetic

Laying open duct

Sialendoscopy

Gland excision (Incision made 2cm back from horizontal ramus of mandible - to avoid the marginal mandibular nerve)

iii) Marginal Mandibular Nerve, Lingual Nerve, Hypoglossal Nerve

33
Q

i) What is a branchial cyst

ii) Ix for sinuses

A

Congenital lesion formed by incomplete involution of branchial cleft - usually the 2nd

  • Aspiration usualyl containts cholesterol granules
  • Mx involves- antibiotics for infections and excision within 6 months of presentation

Cx -

Infection

Mass Effect

Sinus Tract

Malignant Transformation

ii) Investigating a sinus:

Ultrasound

Sinogram

CT/MRI with Contrast to Plan for operation

34
Q

Differential Diagnosis for :

Midline Neck Lump

Lateral Neck Lump

A

Midleine - Thyroid pathology, Thyroglossal Cyst, Dermoid Cyst, Ranula

Lateral - Branchial Cyst, Cystic Hygroma, Pharyngeal poch, Thyroid pathology, Glomus Tumour, Carotid body tumour, Lymph nodes

35
Q

peripheral arterial exam

A

WIPER

Inspection - Walking aids, amputations, medications

Hands - Tar Staining

Face- Xanthelasma, Corneal arcuus

Neck - Carotid Endarterectomy scar

Chest/Abdomen - Scars

Legs - Ulcers (look beneath heels and between toes) , Scars, Skin Changes, Amputations

Palpation -

Upper Limb - Radial Pulse (Radial-Radial Delay +Radio-Femoral Delay), Brachial Pulse, Blood Pressure

Carotid Pulse

Abdominal Aorta

Lower Limb - Femorals, Popliteals, Tibialis Posterior, Dorsal Pedis

Foot capillary refill times, temperature, pitting oedema

Auscultate - Femoral Bruit, Carotid Bruit

Special Test:

Buerger’s Test - Lift leg off bed increasing angle and wait for increments of 30 seconds for foot to become white.

Hang off the edge of the bed to assess for reactive hyperaemia

Complete:

History

Cardiovascular Examination

Venous Examination

ABPI

Doppler Examination

ARterial Duplex/Angiogram

36
Q

i) ABPI Measurements

ii) Definition of Critical Limb Ischaemia

A

i) >1 - Diabetic Calcification
0. 9-1 - normal
0. 4-.07- intermittent claudication

<0.4 - Severe PAD

ii) CLI:

Rest pain or tissue loss

37
Q

Complete lower limb neurolgoical examination

A

History

Upper limb + Cranial Nerve Examination

Bladder scan

Rectal Examination

Observations

Spinal Examination

38
Q

What is lasegue’s Sign?

A

Pain on SLR Beyond 45 degrees

39
Q

Causes of lower limb sesnory loss

A

Central - Vascular, Infective, Malignant, Inflammatory (demyelination, Tabes Dorsalis, SACD)

Mononeuropathy - Diabetic, Traumatic, Compressive

Peripheral-

Diabetes,

Alcohol,

B12/ B6 deficiencies,

Vitamin B12

Drugs (Vincristine, Anti retrovirals, Amiodarone amongst others>)

Heavy Metals

40
Q

Venous Examination

A

Examine standing

General Insepction - Mobility aids, medications, Compression stockings

Inspection - Let the patient stand on inspect legs from front back and both sides

Look for varicosities, ulcers, scars + Skin Changes

Skin Changes- Shiny Skin, Haemosiderrin deposition (darkening), Oedema, Lipodermatosclerosis (fibrotic change - inverse champagne glass), Atrophi Blanche, Hair loss, Venous Eczema

Palpate -

Temperature

Varicosities (Assess for tenderness)

Groin - Saphena Varix/ lymph nodes

Special Tests -

Tap Test - Tap varicosity above/ below. Retrograde (when tapped from above) is positive for valve incompetance

Cough Test - Palpate on SFJ (2.5cm inferolateral to pubic tubercle). If thrill is felt while they cough this indicates reflux at the SFJ.

Tourniquet Test - Lie patient supine. Lift leg and milk veins then apply the tourniquet high. Ask them to stand. Keep doing so at lower points until the varicositeis no longer refill. Where the tourniquet is when the varicosities no longer refill is approximately where the incompetent valve is.

DOPPLER -

SFJ - Medial to femoral artery. Squeeze calf and listen for forward flow (normal) and then retrograde flow (indicative of SFJ incompitance)

SSV + Popliteal vein - Same as above

Complete -

History

Arterial Exam

Cardiovascular Exam

Abdominal Exam

Further Investigations -

Venous Duplex

Blood Tests

Abdominal imaging

ECG/ CXR - for fitness for surgery

41
Q
A

Venous Eczema

42
Q
A

lipodermatosclerosis

43
Q

Causes of varicose veins

A

Valve incompetance - Primary, 2o to phelbitis / thrombosis / Proximal Obstruction

Deep vein thrombosis - Deep venous insufficeinc y

Pregnancy

Klippel Trenauny Syndrome

44
Q

How does doppler work

A

It utilises the doppler effect to assess the velocity and direction of fluid in relation to the probe by picking up sound waves.

45
Q

respiratory examination

i) Extra bits at the beginning

ii) Optomising a COPD patient pre-op

A

i) Take a deep breath in

Cough

ii) GP/Resp physician - to optomise medicines

Stop smoking

Treat Infection

Chest physio - pre + post op

Consider contaacting HDU pre op as they may need admission under HDU

46
Q

Causes of rotator cuff injury in younger person/ older person

A

Older person - more likely to have degenerative tears

Younger person:

Recurrent dislocation

High impact injury

Overuse

Tendinitis

Ligament Laxity conditions

47
Q

Shoulder Exam

A

Look - Posture, Asymmetry, Posture, Muscle wasting, Scars, Winging. Look in axillae too

Feel - For temperature, deformity/ asymmetry, pain

Bones - Sternoclavicular joint, Clavicles, Acromium, ACJ, Coracoid, Scapula, Glenohumeral Joint, Humerus

Palpate - Deltoid Muscle, Trapezius Muscle

Palpate - axilla for lymphadenopathy

Move - Active + Passive (whilst feeling for crepitus)

Flexion, Extension, Abduction, Adduction,

External Rotation (Hand behind head with elbow flexed at 90 degrees)

Internal Rotation (Hand behind back as high as possible)

Special Tests-

Jove’s empty can test (Supraspinatus)

Geber’s lift off test (Subscapularis) - Hand behind back. Push against examiner’s hand

External Rotation (Infraspinatus/ Teres Minor) -

Shoulder Apprehension Test - Abduct shoulder to 90 then externally rotate. Simulatenously push shoulder from the back and externally rotate shoulder

Hawkin’s Test (supraspinatous/biceps) - Flex arm to 90 and flex elbow. Then passive internal rotation

Axillary nerve function

Scapula winging

48
Q

Normal ROM of shoulder joint

A
49
Q

Spinal Exam

A

WIPER

Gait, Ask them to remove an item of clothing (functional Ax), Ask them to touch their toes (spinal mobility)

Inspect - Cervical Spine - Asymmetry

Thoraco- Lumbar spine for:

i) Excessive lordosis - pregnancy, flexion deformity of hips, spondylolisthesis
ii) Loss of lordosis - slipped disc, OA, Infections, Ank Spond.
iii) Scoliosis
iv) Skin changes - Hot water bottle, cafe au lait (NF), Shagreen patch (Tuberous Sclerosis), Tuft of hair (spina bifida), scars

Palpate -

Neck - Anterior neck structures,

Supraclavicular fossae (masses, lymph nodes)

Cervical - Palpate axial spine then lateral vertebral processes (looking for pain or deformity)

ThoracoLumbar - Palpate spinous processes + vertebral processes +Musculature

Sacroiliac Joints - Palpate this

Sacrum - Slide down sacrum

PERCUSS Down spine

Move:

Cervical- Flexion - Chin to chest

Extension - Forehead horizontal

Lateral Flexion - Ear nearly to shoulder

Rotation - Nearly 90 degrees

Thoraco-Lumbar

Flexion - Shober’s (Find L5 - mark 5 cm below and 10 cm above. Change should be >5cm)

Extension - arch back

Lateral flexion - hand down thigh

Rotation - Sit patient down and rotate with arms across body

Special Tests;

Straight Leg Raise - lie patient down .

Complete (to consider)

History

Cardiovascular Exam (Kyphosis, Ank Spond etc.)

Peripheral nervous system exam (everyone)

Other joint exams

Hand exam

Investigation

Imaging (A/P + Lateral Films +/- Swimmer’s)

Bloods - ? Vitamin D ?calcium ?ALP ? FBC ? ESR

Bone density

50
Q

Stoma Examination

A

Inspection - General - look at patients/ surroundings/ abdominal scars may help guide what procedure they had

Closer - Stoma Characteristics:

Site, Content +Volume,

How many lumens?

Spouted / Non- spouted?

Any Hernia?

Evidence of Prolapse?

Evidence of retraction?

Palpate (Remove the bag - ensure no active inflammation/mucositis):

Palpate around stoma site for stoma

Gloved + Lubricated finger - insert into lumen and feel for stricture.

Illuminate stomal mucosa to look for ulceration

Reattach bag

Complete:

Abdominal Exam

Assess stoma position when standing and sitting

Examine the perineum

51
Q

Causes of kyphosis

A

Osteoporotic Fracture

Spondylosis (Degenerative)

Malignancy

Infection

Schuerman’s Disease

Upper back muscle weakness

52
Q

i) Define Stoma

ii) Considerations when siting a stoma

iii) Stoma COmplications

A

i) Connection of a body cavity to the external environment
ii) Stomas should be :

a) Away from bony prominences/scars/prominenet skin folds b) Within rectus abdominus muscle

c) away from belt line d) Well vascularised

e) visible and accessible to the patient

iii) Complications:

Early - Ischaemia, Necrosis, High OUtput, Retraction, Obstruction

Later - Hernia, Obstruction, Retraction, Prolapse, Stenosis, Abscess/granuloma/fistulation,

53
Q

Submandibular Gland Examination

A

WIPER

Inspect - Look at mandible (swelling, scars, skin changes, asymmetry of lower lip [2o to marginal mandibular nerve damage])

Patient opens mouth + lifts tongue up (look for inflammation, ductal thickening, stones, suspicious lesions, pus)

Palpate -

External submandibular - temperature, feel for a mass (assess mass + ask patient to push their tongue to the roof of the mouth)

Cervical Lymphadenopathy

Bimanual Examination of parotid gland + palpate duct.

Special:

Tongue Sensation (Lingual Nerve)

Tongue Movement (Hypoglossal Nerve)

Grimace (Marginal Mandibular Nerve)

Complete:

Examine contralateral submandibular gland and parotid glands

54
Q

i) Where is the submandibular Gland?

ii) Where does the submandibular duct open?

A

i) Submandibular GLand is wedged between the mandible and mylohyoid. Part of it hooks around the mylohyoid

ii) Warthin’s Duct - Sublingual Papilla on either side of the lingual frenulum

55
Q

Thyroid Exam

A

General inspection - Tremulous, Mood, Clothing

Inspection -

Hands - Nail Signs, Pulse, Tremor (paper on hands)

Face - Eyes from front, both sides, and behind

Eyebrows

Ophthalmoplegia + Lid Lag

Neck - Poke tongue out / Swallow water

Front and both sides

Palpate -

Thyroid (bimanual)

Poke tongue out / Drink Water

Cervical Lymphadenopathy

Retrosternal goitre

Auscultate Thyroid Bruit

Extra -

Pretibial Myxoedema

Proximal Myopathy

Slow Relaxin Reflexes

Pendleton’s Sign

56
Q
A

Psammoma Body

Papillary Thyroid Cancer

  • SPiral of calcium
57
Q
A
58
Q

Ankle Exam

A

Pain, History

Look - scars, swellings, erythema, asymmetry, calf muscle bulk

Front, both sides, back, tip-toe (inspect all sides)

Feel -

Extensor aspect of leg for nodules

Temperature of joints

Tib/fib - talar joint - Lateral + Medial Malleolus + Anterior Joint line

Bones of mid foot / Hind foot

bones of the forehoot

Metatarsal squeeze test

move (Active and Passive) :

Dorsiflexion

Plantarflexion

Inversion

Eversion

Abduction + Adduction while holding calcaneus

Toes - Spread toes, Bring together, Curl TOes, Striaghten toes

Special test:

Simmond’s Test

Power - Inversion + eversion

Sensation - Cutaneous Nerves

Pulses

59
Q

What is preload?

What influences Preload?

A

Preload is the Left Ventricular End Diastolic Volume however this is usually not measurable so a surrogate we use is central venous pressure.

Influencing Factors:

Cardiac:

Ventricular Wall Compliance

Heart Rate

Outflow Tract Obstruction

Contractility

Non-Cardiac:

Total Peripheral Resistance

Venous Volume

Obstructions to the SVC/IVC

Pump Mechanisms - Respiratory/ Calf

60
Q

Cerebellar Exam

A

WIPER

Have you noticed a tremor?

Any trouble with balance?

Stand from sitting - Truncal Ataxia

Walk - Gait Ataxia

Romberg’s - Eyes open = cerebellar

Limbs:

Dysdiadochokinesia

Dysmetria

Drift - Updrift = Cerebellar pathology

Intention tremor

Hypotonia

Face:

Nystagmus

Stacatto Speech

Neglect

Signs are ipsilateral

61
Q

Suture types

A
62
Q

Rutherford Criteria

A

I No paraesthsia/ No paralysis / Good doppler

II Some paraesthesia/ No paralysis/ Sometimes still signal

III - Marked paraesthesia / Mild paralysis / No signall

IV - Paraethesia/ Paralytical/ Inaudible

MRCS Part B (11 decks)

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