Physical Examinations Flashcards

Question

**Lumps Separate from the Testes**

Answer 1

**Transilluminates-** Hydrocele or Epididymal Cyst **Does not transolluminate -** Epididymitis or Spermatocoele

Answer 2

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

Answer 3

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

Answer 4

**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

Answer 5

**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

Answer 6

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

Answer 7

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

Answer 8

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**

Answer 9

**Midleine -** Thyroid pathology, Thyroglossal Cyst, Dermoid Cyst, Ranula **Lateral -** Branchial Cyst, Cystic Hygroma, Pharyngeal poch, Thyroid pathology, Glomus Tumour, Carotid body tumour, Lymph nodes

Answer 10

**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**

Answer 11

i) \>1 - Diabetic Calcification 0. 9-1 - normal 0. 4-.07- intermittent claudication \<0.4 - Severe PAD ii) **CLI:** **Rest pain or tissue loss**

Answer 12

History Upper limb + Cranial Nerve Examination Bladder scan Rectal Examination Observations Spinal Examination

Answer 13

Pain on SLR Beyond 45 degrees

Answer 14

**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

Answer 15

**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

Answer 16

**Venous Eczema**

Answer 17

**lipodermatosclerosis**

Answer 18

**Valve incompetance -** Primary, 2o to phelbitis / thrombosis / Proximal Obstruction **Deep vein thrombosis -** Deep venous insufficeinc y **Pregnancy** **Klippel Trenauny Syndrome**

Answer 19

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

Answer 20

**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

Answer 21

**Older person -** more likely to have degenerative tears **Younger person:** Recurrent dislocation High impact injury Overuse Tendinitis Ligament Laxity conditions

Answer 22

**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**

Answer 23

**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

Answer 24

**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

Answer 25

Osteoporotic Fracture Spondylosis (Degenerative) Malignancy Infection Schuerman's Disease Upper back muscle weakness

Answer 26

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,

Answer 27

**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

Answer 28

**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

Answer 29

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

Answer 30

**Psammoma Body** **Papillary Thyroid Cancer** - SPiral of calcium

Answer 31

**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**

Answer 32

**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

Answer 33

**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**

Answer 34

**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