Physical Examinations Flashcards
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
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
Treatment:
i) Medical
ii) Surgical
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
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
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
1) Unilateral - Manifestations
2) Unilateral - Treatments
3) Bilateral - Manifestations
4) Bilateral - Treatments
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
What organs are palpable in a normal abdomen?
Aorta, Lower pole of R Kidney
Surface marking for the neck of pancreas?
Surface marking for the liver?
Surface marking for the gallbladder?
Surface marking for the spleen?
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
Examination features of compartment syndrome?
Treatment - Describe?
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)
Abdominal Examination
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,
Breast Examination
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
i) Risk Factors for Breast Cancer
ii) Work up for breast cancer
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
Surgical Treatments for Breast Cancer
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
i) Hormone treatments available for breast cancer
ii) Breast screening in UK
i) Tamoxifen - Selective Oestrogen Receptor Modulator
Trastazumab - MAB against HER2
Anastrazole - Aromatase inhibitor
ii) 50 - 70 year olds : Every 3 years mammography
Which grafts can be used for CABG
Intermal Mammary
Great Saphenous Vein
Radial Artery
Prosthetic Grafts
What is the sciatic stretch test
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
i) Dermatomes tested in Lower Limb Examination
ii) Which nerve roots are the lower limb reflexes interrogating
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
5 Red Flag Symptoms for cauda equina syndrome
Severe Back Pain
Bilateral Sciatica
Sexual Dysfunction
Visceral Dysfunction
Saddle Anaesthesia
How to complete cranil nerve exam
Snellen Chart
Ishihara Plates
Smelling Salts
Fundoscopy
Reflexes - Gag, Corneal and Jaw Jerk
Causes of Loss of SMell
Senile Anosmia
Nasal - Tumours, Polyps
Frontal lobe pathology - Meningioma, Trauma, Viruses, Hydrocephalus
i) Cranial nerve VII Nuclei
ii) Branches of Facial nerve given off within the facial canal
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
What does CNIX Do?
- 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
Ear Exam
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
Describe Weber’s And Rhinne’s Test
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
Causes of conductive hearing loss
External Auditory Canal - Wax, Foreign Body, Otitis Externa, Tumour in ear canal, Perforation of tympanic membrane
Middle Ear - OM, Haemotypanum, Cholesteatoma, Otosclerosis
Do a lump exam
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
Lumps Separate from the Testes
Transilluminates- Hydrocele or Epididymal Cyst
Does not transolluminate - Epididymitis or Spermatocoele
Hand Exam
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
i) What is rheumatoid arthritis
ii) Pathology
iii) Extraarticular features
iv) Mx
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
Hip Examination
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
Normal values of hip movements
Knee Exam
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
neck Examination
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
i) How to examine the submandibular exam
ii) Rx options for submandibular gland stone
iii) Nerves at risk in submandibular gland surgery
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
i) What is a branchial cyst
ii) Ix for sinuses
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
Differential Diagnosis for :
Midline Neck Lump
Lateral Neck Lump
Midleine - Thyroid pathology, Thyroglossal Cyst, Dermoid Cyst, Ranula
Lateral - Branchial Cyst, Cystic Hygroma, Pharyngeal poch, Thyroid pathology, Glomus Tumour, Carotid body tumour, Lymph nodes
peripheral arterial exam
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
i) ABPI Measurements
ii) Definition of Critical Limb Ischaemia
i) >1 - Diabetic Calcification
0. 9-1 - normal
0. 4-.07- intermittent claudication
<0.4 - Severe PAD
ii) CLI:
Rest pain or tissue loss
Complete lower limb neurolgoical examination
History
Upper limb + Cranial Nerve Examination
Bladder scan
Rectal Examination
Observations
Spinal Examination
What is lasegue’s Sign?
Pain on SLR Beyond 45 degrees
Causes of lower limb sesnory loss
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
Venous Examination
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
Venous Eczema
lipodermatosclerosis
Causes of varicose veins
Valve incompetance - Primary, 2o to phelbitis / thrombosis / Proximal Obstruction
Deep vein thrombosis - Deep venous insufficeinc y
Pregnancy
Klippel Trenauny Syndrome
How does doppler work
It utilises the doppler effect to assess the velocity and direction of fluid in relation to the probe by picking up sound waves.
respiratory examination
i) Extra bits at the beginning
ii) Optomising a COPD patient pre-op
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
Causes of rotator cuff injury in younger person/ older person
Older person - more likely to have degenerative tears
Younger person:
Recurrent dislocation
High impact injury
Overuse
Tendinitis
Ligament Laxity conditions
Shoulder Exam
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
Normal ROM of shoulder joint
Spinal Exam
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
Stoma Examination
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
Causes of kyphosis
Osteoporotic Fracture
Spondylosis (Degenerative)
Malignancy
Infection
Schuerman’s Disease
Upper back muscle weakness
i) Define Stoma
ii) Considerations when siting a stoma
iii) Stoma COmplications
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,
Submandibular Gland Examination
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
i) Where is the submandibular Gland?
ii) Where does the submandibular duct open?
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
Thyroid Exam
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
Psammoma Body
Papillary Thyroid Cancer
- SPiral of calcium
Ankle Exam
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
What is preload?
What influences Preload?
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
Cerebellar Exam
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
Suture types
Rutherford Criteria
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
