Basic of Clinical Examination for OSCE

Basic of Clinical Examination for OSCE

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Semester III 1) Cardiovascular system a. Physical examinations b. Blood pressures c. JVP and it’s concept d. Peripheral vascular disease e. ECG* and murmurs 2) Respiratory system a. Physical examinations b. Peak flow meter 3) Hematological system a. Cervical / Neck b. Axillary c. Inguinal 4) Gastrointestinal system a. Abdominal examination b. Fluid thrill & shifting dullness c. Examination for hepatosplenomegaly d. Per rectum

Semester V 1) Endocrine system a. Diabetes b. Thyroid gland (hyper & hypo thyroidism) 2) Reproductive system a. Breast examination b. Pelvic examination (PAP smear) c. Gestational examination 3) Renal system 4) Musculoskeletal system a. Shoulder b. Hip c. Spine (plus neck) 2

5) Nervous system a. Motor b. Sensory c. Cranial nerves

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HISTORY TAKING

History Taking 4

Always follow sequence 1-Personal details 2-Presenting complaints 3-Past medical history 4-Social history

5-Family history 6-Drugs history *always use open ended questions **systemic history for SEM 5

Personal details 1) 2) 3) 4) 5) 6)

Social history

Name Age Address Occupation* Religion / race Marital status

1) Smoking a. How many per day b. How long the patient have been smoking 2) Alcohol a. Type of alcohol b. How much c. How long has the patient been drinking 3) Home a. Type of housing b. Environment 4) Work a. Working environment b. Stress levels at work 5) Diet a. Meal habits b. Type of food 6) Hobbies a. Exercise b. Any other activities

Past medical history 1) Hospitalization a. Year b. Reason for admission c. Diagnosis d. Where / medical center e. Duration of stay f. Treatment 2) Surgery a. Diagnosis / reason for surgery b. Year c. Where / medical center d. Treatment 3) Long standing illness a. Year & how long b. Diagnosis c. treatment 4) Allergy a. Type of allergy i. Drugs ii. Food iii. Animal iv. Others b. What happens when in contact (reaction) with the allergens

Family history 1) Must cover 3 generation a. Parents b. Siblings c. Wife/husband d. Children 2) If alive a. Age b. Major illness 3) If passed away a. When b. Why

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History of presenting illness (HOPI)

Sputum 1) Amount 2) Volume 3) Color 4) Smell 5) Consistency 6) Blood

GENERAL I. Onset II. Site / character III. Aggravating / relieving factors IV. Timing – progression, duration, time of the day V. Severity VI. Associated symptoms VII. What have you done about it? VIII. medication

Stool / Vomitus 1) Amount 2) Volume 3) Color 4) Blood 5) Smell 6) Consistency

Pain (chest / abdomen) =SOCRATES 1) Site 2) Onset 3) Character 4) Radiation/spread 5) Associated symptoms 6) Timing 7) Elevating/relieving factor 8) Severity

Constipation 1. Frequency 2. Feeling of incomplete evacuation 3. Consistency of feaces 4. Acute / chronic 5. Associated symptoms – pain, bleeding. 6. Time spent straining 7. Stool? 8. Aggravating / relieving factors

*further explanation will be at The 15 wisdom of Dr. Htin Aung >>>

Shortness of breath (SOB) 1) Onset 2) Duration 3) Progression 4) Aggravating / relieving 5) Severity? Affecting sleep? 6) Associated symptoms

Diarrhea 1. Everything about stool, especially on consistency 2. Frequency 3. Urgency of defecation 4. Abdominal pain 5. Aggravating / relieving factors 6. Severity

Cough 1) Productive/non productive 2) Intermittent / continuous 3) Time of the day 4) Blood 5) Severity 6) Aggravating / relieving factors 7) Progression 8) Associated symptoms

Dysphagia 1. Liquid / solid 2. Painful 3. Regurgitates? Into nose? 4. Where (specific location) the food sticks 6

The History “THY FORMAT” – from Dr. Htin Aung 1) Site : site of pain 2) Duration : a. /12 (month) b. /7 (days) c. /24 (hours) d. /60 (minutes)

MI: >10min AP: 5-10min

3) Onset : rate of s/s comes / spread a. Sudden: - vascular - injury - mechanical b. Slowly : - infection - metabolic - endocrine 4) Triggers : what cause the pain 5) Progression: getting worse, comparing workload. 6) Timing : intermittent / continuous (if intermittent, ask how long the pain last and how long rest needed) 7) Character : a. Stabbing IHD b. Crushing c. Gripping d. Shooting ; e.g. headache e. Sharp tearing ; inflamed, sliding, pleurae, two surface sticking f. Burning pain ; chemicals (gastric acid in the esophagus) g. Cramping h. Colliding ; GIT, colon, esophagus, urinary tract i. Dull aching ; organs with coverings 8) Frequency    

How often? Increase lately? Time of the day? Etc

Breathlessness Dyspnoea On Exertion/Non-exertion/Resting

9) Severity : mild / dull  B/D o NE  B/D o E

 B/D o R  B/D o less exertion than normal 7

10) Spread : IHD -

neck, jaw, left arm nerve cardiac plexus C4-T1 “REFERRED PAIN”

11) Implication: a. Weight b. Work c. Appetite d. Sleep e. Micturation f. Bowel 12) Aggravating factor 13) Relieving factor 14) Seen other doctors 15) Associated symptoms

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CVS

RESPIRATORY

Complaint: Chest tightness SOB: Dyspnoea, Orthopnea, Paroxysmal Nocturnal Dyspnoea, Palpitation, Chest pain. Heart failure: ankle edema, Cough, SOB PAD / PVD Intermittent claudication (claudication distance for PAD) 1. Rheumatic fever Sore throat (relapsing RF) Fever, sweat ,chills ( exposure to rain) Relieve: panadol Worries: excessive sweating, embarrassing history of RF, check family 2. IHD (Angina Pectoris) Pain: Location, Radiation, Duration, Exertion, Frequency, Progression, Severity, Precipitating Factors Risk: F/H, Diet (hi salt / fat), exercise, stress, smoke and alcohol. E.g.: Severity

Past 3mth Can do work

Frequency

Twice a wk

Precipitating factors

Carry >20kg

Past 1wk Crushing, limited activities everyday Carry >5kg climb 3 stairs

3. Peripheral Arterial Disease (PAD) Pain and cramp at unilateral limb Aggravate: walking claudication dist Relieve: sit down, rest F/H of arterial disease: HT, Heart attack Worry: unable to move leg anymore Systemic review: over wt Actions: Low fatty diet, light exercise, decrease smoke and wt Not PVD as PVD has edema, warm, and pain anytime.

Epistaxis, hemoptysis, SOB, cough, sputum color Asthma, Smoking Wheezing due to narrowed airway DD for Supra-clavicular swelling Metastasis: solid, hard, fixed Infection: warm, tender Lymphoma: firm 1. TB: Productive cough, high fever with night sweats, wt loss, lymphadenopathy, decrease appetite Investigation: AFB culture, CXR, Mantoux 2. Pneumonia SOB Sputum: color, consistency, volume, blood, frothy Relieve, aggravator Investigation: Sputum culture, PBS.

X-ray Heart (boot shaped) Tetralogy of Fallot Cardiophrenic angle Costophrenic angle Kerley B line (heart failure) Air fluid level (pleural effusion) Pneumoconiosis TB coin lesion, consolidation and cavitation Renal IVP - hydroureter, calculi Fracture - colles (radial bone), dinner fork Osteoarthritis - osteophyte Osteosarcoma - sunburst Rheumatoid arthritis - Pannus

HAEMATOLO

GIT 9

GY Bleeding disorder Haemophilia A/ B Malabsorption/Gastrectomy: IDA Vegetarian/ Pernicious anemia: B 12 def Folate: no vegetables, pregnant Iron: Vegetables and liver and meat Malaria Hodgkin lymphoma: Reedsternberg cell (owl's eye) 1. Hemophilia A / B (A more common) -X-link recessive Pain of knee, swelling, hemoarthroses Significant Past medical history Profuse bleeding on tooth extraction, wound Hemoarthoses, hematoma, bruise PT, BT norm, APTT prolonged F8/F9 assay F8/9 concentrate 2. Lymphoma with metastases to bone Pain in left leg Other: swelling of painful leg, swelling n lump at groin area, Polyuria, Polydipsia (due to Na, Hypercalcemia, Sugar in DM) F/H Leukemia Ix: BM aspiration, BM trephine biopsy, Serology 3. Haemolytic Anemia with pneumonia Yellow eye (pre-hepatic jaundice) Cough, with bloody, yellowish phlegm Aggravate by cold relieve cough syrup and antibiotic, Assoc symptoms: fever, muscle ache, tiredness, SOB Causative organism atypical mycoplasma pneumonia Ix: Sputum culture, PBS, Coombs test, serology. Test for blirubin Palpable LN: question to ask How long? Lump changed size? Painful? Lost wt? Generally well?

1. Peptic ulcer (benign) Clinical indication: Pain aggravate by eating (Gastric Ulcer) Relieve by eating (Duodenal Ulcer) Relieve: Biscuits, Antacid Aggravate: hard liquor, smoking, stress, NSAIDs Assoc symptoms: dyspepsia, vomiting, nausea, diarrhea, melena, blood in vomit F/H 3 Cx of ulcer Perforation => peritonitis Bleeding of stomach => hemorrhage Cancer 2. Hernia Occupation: wt lifter, pregnant Sign: swelling in left groin, size, pain, radiation Aggravate: wt lifting, standing up, cough Relieving: lie down Risk factor, chronic coughing, constipation, obesity 3. Cholecystitis Aggravate: Fatty food, egg Associated symptoms: nausea, burping, indigestion, fever, diarrhea, vomiting

4. Colorectal Cancer: Wt loss, appetite, bowel habits, nature of stool, strain and pain (tenesmus) What he done, laxative (useful?) Risk factor: F/H altered bowel habits, wt loss, age Left side: Constipation, blood in stool Right: IDA, diarrhea, melena 5. Diarrhea Food poisoning Melena / hematemesis Hernia (Inguinal (direct/indirect), umbilical. etc) Environment clean food / water supply

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ENDOCRINE 1. Hypothyroid Afraid of cold, gain wt, depression, croaky voice (hoarseness), menorrhagia Aggravating for hoarseness: sour food Myxoedema (legs fatter) Common cause: iodine deficiency, Hashimoto's thyroiditis 2. Hyperthyroid Intolerant of heat, lost of wt, increase appetite, irritable, tearful Palpitations, Diarrhea, amenorrhoea 3. Diabetes Very thirsty, Polyuria, polydipsia, nocturia (disturbed sleep) Diminished sensation (numbness), muscle wasting, vaginal discharge ( immunosuppressive - candida) diabetic retinopathy (blurred vision), nephropathy metformin / insulin (injection or oral or both) Inquire more on drugs, compliance, and latest blood glucose level and check up. F/H Pregnant mother: big babies 4. Cushing Truncal obesity, thin skin, bruising, pink/purple striae, HT, Proximal muscle weakness 5. Acromegaly (pit adenoma) Complaint: headache, vision affected, bitemporal hemianopia Change in appearance: big hands / feet / macroglossia, oily skin, dentures not fitting. excessive sweating +ve symptoms: visual deterioration (double vision) 6. Prolactinoma Complaint: white watery discharge from breasts Assoc symptoms: headache; irregular period, amenorrhea. Ix: MRI, CT scan of pit gland, Serum PRL level

RENAL Urination (further refer to paper)  When's last time  when started, for how long  Frequency  Nocturia (Sleep Disturbed)  Quantity (normal – l500ml, Polyuria, Oliguria UTI, dyspareunia Systemic: Headache / fever (UTI) Sleep disturbance due to nocturnal Work condition (with lack of water) Renal Calculi Eg. Drink too much mineral water as work require on the go. Pain from loin to groin, hi uric acid level. Hematuria. Prostate Problem that caused the urgency. IX: FBC, UFEME, X-ray KUB, Ultrasound. IVP Urine sample: Casts, Crystals, Pyuria, and Protein. Uraemia Weakness, lethargy, oedema, proteinuria, HT, uraemic frost.

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Menarche ( primary amenorrhea) Cycles, days, heaviest on when Regular/Irregular (can predict?) Flow (no of pads/soak/half soak) -menorrhagia, oligomenorrhea clots, spotting Pain - Dysmenorrhea e.g. endometriosis Associated Symptoms: Nausea, vomiting, headache, diarrhea, water retention, pelvic congestion, breast tender and swelling Tx: Diuretics (congestion), NSAIDS(mediators), diazepam(nerve)

ED: duration. onset, progress, severity, freq, - Implication: depress, suspicion, stress/affect at work, wife, sad, frustration, - His own remedy: Viagra, porn, - Risk: HT, diabetes, psychology, drugs(bblocker, Heart disease), SID, - Ask about size, swelling of scrotum/penis if present. - Other symptoms swelling of legs, fatigue, weakness, anemia

SEXUAL HX

OBSTETR1C HX - "I think I'm pregnant!"

- Dyspareunia e.g. endometriosis - Itchy (pruritus), Rash, Discharge - Blood: menstruation, miscarriage, cancer, cervical erosion/polyps - Purulent: Vaginitis, cervicitis, endometritis, retained tampon T.vaginalis: frothy, watery, pale, yellow white discharge Candida (white thrush): thick cheesy, with excoriations and pruritus

l. Amenorrhea: LMP, EDD Sickness (nausea/vomiting) marked at 12-21 wks, maybe precipitated by strong odors. So don't get near 2. Sickness (nausea/vomiting) Marked at 12-21 wks 3. Breast: Breast tenderness (tingling-frank pain) Engorgement Enlargement of Montgomery's tubercles (68wks of gestation) Colostrum at 16th wk 4. Quickening (1st perception of fetal movements)18-20 wks in primigravidas, 1 mth earlier in multiparas 5. Urinary Frequency (norm 3-5/day and 1/night) Nocturia, as increase intra-abdominal pressure

Case: Leucorrhea, foul smelling, pruritis, embarrassing Associated symptoms: burning urination, fever, dyspareunia, dysuria, spotting, lower abdominal pain. - Infertility (PRL), Lower abdominal pain ( PID, ectopic pregnancy) - Sexual activity, Contraception - Approach: explain, confidentiality, Have Boyfriend before? Husband? Are u very close/intimate with him/her? Is it a sexual relationship? Sexually active? Is it protected? What type of protection? All the time? If not, r u sure he his your only partner? Man: Penis discharge, ulcer Non painful (syphilis) burning sensation urinating (gonorrhea)

Mom: - How many children their gender, birth wt, breast feed? Complications of pregnancy. Need to know each & every one. - Antenatal care booking; 4 wks =0-32 wks 2 wks = 32-36wks Weekly after that - Problems with pregnancy - Color coding: red, yellow, green, white - Diet (Ca, Fe, Folate) - Health (DM, HT, preeclampsia) *glycosuria; SBP>30; DBP >15 - Fetal movement. Abortion/Full term - Delivery types- vaginal/caesarian /assisted - Complications - Health of Baby, antenatal/postnatal - Immunization of baby/mother HIV, Hep B - Eg.G3P2Al. P is viable birth 22 weeks, before that is A

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MSK

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● Age: ElderlyOA YoungRheumatoid, Ankylosing Spondylitis ● Gender: M AS, F RA ● Onset/Duration: Suddendisc prolapsed Acuteacute osteomyelitis, septic arthritis SA InsidiousOA, AS, RA ● Site: Large wt bearing joint(hip/knee)OA Small joint (wrist, MP, PIP)  RA Low backOA, AS Sacro-Illiac joint AS Big ToeGout ● Progression, Swelling (infection/inflammation) ● Symmetrical involvementRA ● Radiation: hip-knee. Sciatica-post thigh ● Char: ThrobbingSA, AOM, acute hemathrosis, Dull acheOA, RA Shooting sciaticaPID Night criesTB, malignant tumor (due to release of protective muscular spasm at night) ● Painkiller, Frequency ● Severity: Very severePID, AOM, SA, Gout Mild to moderateRA, OA ● Early Morning Stiffness: RA>30min OA no EMS or relieve by movement ● Deformities: Advanced RA (swan neck) Advanced OA, AS (bamboo spine) ● Giving Away: knee, due to weightbearing, cartilage damage or muscular weak (polio)

● Systemic Features: FeverRA, AOM,SA,SLE RashSLE Wt gain, fever, weakness, fatigue ● Occupation: Manual workerOA Maid's Anee, carpet worker’s knee (Bursitis) ● Sexual exposure (gonorrhea,syphilis) ● F/HHemophilia (hemoarthroses), gout, TB, RA Cases Osteoarthritis: Wt bearing joint, Elderly, Insidious onset, dull ache, morning stiffness less than 30min. History of trauma over wt. Aggravate by walking, squatting, relieve by painkiller and rest Malignancy: Pain (night cries) associated symptoms: stiffness, swollen Appetite decrease, lost of wt, Risk factor: smoking, HT, Diabetes, Sedentary lifestyle, over wt. Metastatic normally to spine (breast Ca)

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CNS Pain: common Characteristic ,severity, site, onset, duration, temporal relationship, factors Headache, back pain, facial pain Numbness Special symptoms  Fits, faints turns  Dizziness & vertigo (cerebellar)  Altered vision, hearing and smell (CN)  Difficult in walking  Incontinence  Loss of memory and intellect (dementia)  Altered speech

2. DM: ◘ Peripheral neuropathy ◘ S/S Tingling n numbness ◘ Slipping out a slippers ◘ Autonomic neuropathy(GI) Indigestion, decrease peristalsis, bloating, vomiting after meals, diarrhea and constipation intersperse ◘ Gangrene, amputation, ◘ Other clinical symptoms: retinopathy, CHD nephropathy 3. Transient ischemic Attack (TlA) ◘ Headache ◘ Char: Pounding/Throbbing ◘ Frequency/Duration/Site. ◘ Symptoms preceding attack: Dizziness, nausea, visual disturbance Cases: (ischemia of ophthalmic artery during 1. Fits TIA) ◘ When, where, frequency ◘ Associated symptoms: Nausea, ◘ Events leading to attacks of lethargic, weakness, vomiting, convulsion: sleep deprivation, stress, disturbed vision fever, exhaustion, alcohol ◘ Precipitating factors: stress (work, ◘ Symptoms of aura with duration: single), cheese, bright light, before hallucination, “dejavu” (feel like menstruation experiencing 2nd time) . ◘ Relieving factors: ponstan, sleep in ◘ Features: tongue biting, dark incontinence, cyanosis, excessive ◘ F/H salivation, aura, hallucination, 4. SOL jerking of limbs, loss of ◘ Complaint: Left weakness 1 month, consciousness, how long numbness 1 week, left vision field ◘ How he knows? Who else is affected 3 days around? ◘ One sided heavy headache - 1 month ◘ Post-ictal symptoms & duration: ◘ Social: Smoke, Drink Drowsiness, lethargic, tired for ◘ Mental Behaviour changes: several hrs. ◘ Forgetful, short tempered ◘ Diurnal variation? ◘ Dx: Slowly growing space occupying ◘ Hobbies: Mt climbing, swimming, lesion, brain tumor, Toxoplasma speed sports.( dangerous) gondii, Hydratid, Amoeboid Cyst 5. Strokes Assoc with atherosclerosis, HT, Slurred speech, hemiplegia

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Physical examination

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Cardiovascular System

Checklist Headings 1. Introduce 2. Permission 3. General Inspection

Action

4. Hands

1. Put the bed into 45° angle 2. Wash hands 3. Adequate exposure 1. Name, age, gender, racial 2. Conscious 3. Alert 4. Communicative 5. Well built – not chacectic 6. No general discoloration 7. No respiratory distress 8. Not in obvious pain 9. No gadget attached

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1. Color (Cyanosis, Jaundice, Pallor) 2. Temperature 3. Moisture 4. Capillary refill 5. Clubbing 6. Splinter hemorrhage 7. Xanthomata 8. Osler’s nodes (pain) 9. Janeway lesion

1. Radial 2. Brachial 3. Carotid 4. Femoral 5. Popliteal 6. Posterior tibialis 7. Dorsalis pedis

5. Pulse

Palpation

Comment on: 1. Rate (for 1min, unless told) 2. Rhythm (R, RI, II) 3. Strength 4. Symmetry (radio-radial, radio-femoral) 5. Character See behind Eyes: 1- sclera (yellowish) 2- conjunctiva (pallor) 3- corneal archus 4- xanthelasma Mouth: - oral hygiene

6. BP 7. Face

Headings 8. Neck (JVP)

9. Precordium Inspection

Auscultation

10. Pitting edema 11. Thanks

scoliosis) 6. Visible pulsation (especially at the apex region) 1. Apex beat (comment!) 2. Parasternal heave 3. Thrill over the 4 region -mitral -tricuspid -aortic -pulmonary Auscultation over the 4 region for* 1. S1 & s2 2. Added sound 3. Murmurs

Always remember to thank the patient

Action 1. Inspection 2. Measurement of JVP height 3. Hepatojugular reflux 1. 2. 3. 4. 5.

Size Shape Symmetry Scars Deformity (excavatum, carinatum, kyphosis,

SIGNS/EXAMINATIONS

SIGNIFICANCE

INTRO

 Wash & Warm hands.  45 degrees  Adequate exposure

Greet, Introduce, Explain, Permission (GIEP)

GE

Age, gender, ethnic group, height, E.g. Mr. Chan is a middle aged Chinese man of weight, built, nutrition average height and built. He is well nourished and of

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NERAL INSPECTION

Mention: (1) conscious (2) alert (3) co-operative (4) no respiratory distress (5) not in obvious pain (6) no general discoloration

HANDS

(1) Moisture & Temperature (2) Color (normal = pinkish) (a) cyanosis (blue)

(b) jaundice (yellow) (c) pallor (3) Clubbing 5 stages of clubbing: (a) Increase nail fold fluctuation (b) Loss of nail bed angle (c) Increased Curvature (d) Drumstick shape (e) Pain

average weight. He is conscious, alert, and cooperative. He is not in any respiratory distress, no general discoloration and he is not in obvious pain. Respiratory distress: 1. Tachypnoea 2. Use of accessory muscle 3. Flaring of nostrils (ala-nasi movement) 4. Stridor/wheezing 5. Cyanosis Hypercapnea

(a) Peripheral deoxygenating Cyanosis = blue discoloration of the skin and mucous membrane, due to presence of deoxygenated Hb in blood vessels (>50mg/L) *does not occur in anemia *central cyanosis in congenital heart disease (b) Right heart Failure (c) Anemia

= increase in angle between proximal nail and nail Seen in: Cyanotic Congenital Heart Disease Infective Endocarditis

(4) Capillary refill (Normal < 2s) Press for at least 10s.

Impaired blood circulation e.g. atherosclerosis

(5) Splinter Hemorrhage

= linear hemorrhages lying parallel to the long axis of nail -Talley. Vasculitis of nail bed caused by IE

(6) Osler's Nodes (7) Janeway Lesion

= red, raised tender nodules on pulps of the fingers (or toes) or on the thenar or hypothenar eminences Seen in IE = non tender, erythematous maculopapular lesions containing bacteria which occur rarely on the palms or pulps of the fingers in patient with IE

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(8) Tendon Xanthomata PULSE

(1) Rate (normal 60-90 bpm) (2) Rhythm (3) Volume

=yellow or orange deposits of lipid in the tendons that occur in Type II hyperlipidaemia.  Tachycardia (>100bpm)  Bradycardia ( Thalassaemia 2. Pallor =>Anemia 3. Bruising =>Platelet disorder 4. Jaundice =>Hemolytic anemia 5. Scratch marks =>Pruritis =>Lymphoma =>Myloproliferative disorder 1. Koilonychias =>dry, brittle, ridged, spoon-shaped nails =>Fe deficiency anemia =>Fungal infections => Raynaud's phenomenon 2. Pallor (nail bed) =>Anemia 3. Digital infarction =>Abnormal globulin (cryoglobulinamia) 4. Palmar creases pallor =>Anemia 5. Gouty arthritis: Felty's Syndrome 1. Thrombocytopenia 2. Hemolytic anemia 3. Myeloproliferative disease

4. Skin pigmentation 5. Leg ulceration 6. Hemophilia

6. Pulse - tachycardia =>Anemia 7. Purpura, petechiae, ecchymoses =>Thrombocytopenia or platelet dysfunction =>Coagulation disorder =>Systemic vasculitis

THE FOREARMS

Hess test  BP cuff on upper arm  Inflated to 10 mmHg above diastole  5min  Deflate  Petechiae (+)

=>Thrombocytopenia =>Capillary fragility

THE FACE

1.

Hair - grey hair & blue eyes 2. Eyes - jaundice & conjunctiva pallor 3. Mouth Gum hypertrophy Atrophic glossitis Waldayer' s ring

2. Lateral (above & lateral) 3. Pectoral (medial) 4. Infraclavicular

CERVICAL & SUPRACLAVICULAR NODES (NECK)

AXILLARY NODES

1. Apex/central

~Monocytic leukemia ~Megaloblastic anemia ~NHL 1. Submental

5. Subscapular

2. Submandibular 3. Jugular chain 4. Posterior triangle 5. Supraclavicular 6. Preauricle 7. Postauricle 8. Occipital

1. Site (position/extent) Localized = Local infection, early lymphoma Generalized = Late lymphoma 2. Size: normal= BM depression => TCP Petechiae  Splenomegaly 2ndary to portal HT => hypersplenism =>excessive destruction of pits in spleen  Acute hepatic necrosis => DIC can occur Muscle Late manifestation of malnutrition in alcoholic pts. Alcohol can also cause a proximal myopathy Wasting Due to severe itch (pruritus) CAUSES:  Obstructive or cholestatic jaundice Scratch marks  Commonly the presenting feature of primary biliary cirrhosis  Retention of an unknown substance normally excreted in bile? Bile salt deposition in the skin? o Consist of a central arteriole from which radiate numerous small vessels which look like spiders' legs o Range in size from just visible to half a centimeter in diameter o Their usual distribution is in the area drained by the SVC, so they are found on the arms, neck and chest wall o Can occasionally bleed profusely o Pressure applied with a pointed object to the central arteriole causes blanching of the whole lesion. o Rapid refilling occurs on release of the pressure. Spider naevi o >2 anywhere in the body»»likely to be abnormal CAUSE:  Cirrhosis (usually due to alcohol), transiently occurs with viral hepatitis, 2nd to 5th months of pregnancy; disappears within 8 weeks of delivery.  Traditionally attributed to oestrogen excess Normal hepatic function =>> inactivation of oestrogens(impaired in chronic liver disease) Oestrogens =>> dilatation effect on the spiral arterioles of the endometrium Flat or slightly elevated red circular lesions which occur on the abdomen or the front

Campbell de of the chest. Morgan spots Do not blanch on pressure and are very common

Venous stars

 2-3cm lesions which can occur on the dorsum of the feet, legs, back and the lower chest  Due to elevated venous pressure and are found overlying the main tributary to a large vein.  Not obliterated by pressure.  Blood flow> from periphery to the centre of the lesion

EYES Jaundice

Sclera

Anemia

Conjunctiva - pallor Brownish green rings occurring at the periphery of the cornea, affecting the upper pole more than the lower Slit-lamp examination-often necessary to show them

CAUSE: Kayser Due to deposits of excess copper in Descemet's membrane of the cornea Fleischer rings  Found in : Wilson's disease(a copper storage disease which causes cirrhosis and neurological disturbances) Usually present by the time neurological signs have appeared Pts with other cholestatic liver diseases can also have these rings

Iritis

Xanthelasma

IBD Yellowish plaques in the subcutaneous tissues in the periorbital region Due to deposits of lipids May indicate protracted elevation of the serum cholestrol Pts with cholestasis: an abnormal lipoprotein (LP X) found in plasma and is assoc with elevation of the serum cholesterol.  Common in pts with primary biliary cirrhosis    

Periorbital purpura

Following proctosigmoidoscopy ('black eye syndrome') - characteristic sign of Amyloidosis (perhaps related to factor X deficiency) Very rare

Fetor (bad breath)

Causes:  Faulty oral hygiene  Ketosis (diabetic ketoacidosis – excretion of ketones in exhaled air)  Uremia (fish breath, an ammonical odor)  Alcohol, paraldehyde  Putrid (anaerobic chest infections with large amount of sputum)  Cigarettes

Sweet smell CAUSE: Severe hepatocellular disease and may be due to methylmercaptans Fetor hepaticus These sub-exhaled in breath and may be derived from methionine when this amino acid is not demethylated by a diseased liver. Severe FH- fills the pts room-bad sign and indicates a precomatose condition in many cases. Ask pt -exhale through the mouth

TONGUE Lingua nigra(black tongue)

 Elongation of papillae over the posterior part of the tongue which appears dark brown  because of the accumulation of keratin, also due to bismuth compounds  No known cause

Geographical tongue

Leucoplakia

Glossitis

Aphthous ulceration

Angular stomatitis

 Slowly changing red rings and lines which occur on the surface of the tongue  Not painful, comes and goes  Not of any significance, can be a sign of vitamin Bl2 deficiency  White - colored thickening of the mucosa of the tongue and mouth  Premalignant  Often no cause is apparent  May also occur on the larynx, anus and vulva “S” CAUSES: Sore Teeth(Poor Dental Hygiene), Smoking, Spirits, Sepsis Or Syphilis  Smooth appearance of the tongue which may also be erythematous  Due to atrophy of the papillae and in later stages there may be shallow ulceration  Often due to nutritional deficiencies to which the tongue is sensitive because of the rapid turnover of mucosal cells CAUSES: Deficiency of the iron, folate and the vitamin B group especially B 12, common in alcoholics, and in the rare carcinoid syndrome  Commonest type of ulcer.  Begins as a small painful vesicle on the tongue or mucosal surface of the mouth which may break down to forma painful shallow ulcer  Heal without scarring  Unknown cause, may indicate: Crohn’s or coeliac disease Cracks at the corners of the mouth CAUSES: VitB6, Vitamin B12, folate and iron deficiency.

NECK

Cervical LN

 Palpate-especially supraclavicular nodes on the left side  May be involved with advanced gastric or other gastrointestinal malignancy, or with lung cancer  Large left supraclavicular LN in combination with carcinoma of the stomachTroisier's sign

 May be a sign of chronic liver disease in males  May be unilateral or bilateral and the breasts may be tender  May be a sign of cirrhosis (especially alcoholic cirrhosis) or of chronic active hepatitis Gynaecomastia  CLD - changes in the oestradiol to testosterone ration may be responsible  Cirrhotic pts - spironolactone, used to treat ascites is also a common cause  May occur in alcoholics without liver disease due to damage to the Leydig cells of the testis from alcohol ABDOMEN

Scars

Distension

   

Indicates previous surgery or trauma Around the umbilicus for laparoscopic surgical scars Older scars are white and recent scars are pink because the tissue remains vascular Presence of stomas or fistulae.

Generalized abdominal distention may be present.  Shape of umbilicus gives clue: buried in fat-eats too much,  When peritoneal cavity is filled with large volumes of fluid (ascites) from whatever cause, the abdominal flanks and wall appear tense and the umbilicus is shallow or everted and points downwards.  Pregnancy, also the presence of a huge ovarian cyst- umbilicus pushed upwards by the uterus enlarging from the pelvis “F”s CAUSES: fat(gross obesity), fluid(ascites), fetus, flatus(gaseous distention due to bowel obstruction), feces, 'filthy' big tumor (ex: ovarian tumor or hydatid cyst) or 'phantom' pregnancy

Local swellings

Enlargement of one of the abdominal or pelvic organs

Hernia

Protrusion of an intra-abdominal structure through an abnormal opening CAUSES:  previous surgery weakening the abdominal wall,  congenital abdominal wall defect,  chronically increased intra-abdominal pressure

Prominent veins

Visible pulsation s Visible peristalsis

 If present, direction of venous flow should be elicited at this stage.  A finger is used to occlude the vein and blood is then emptied from the vein below the occluding finger with a second finger. The second finger is removed and if the vein refills, flow is occurring towards the occluding finger.  Flow should be tested separately in veins above and below the umbilicus  Severe PORTAL HYPERTENSION: portal to systemic flow occurs through the umbilical veins, which may, rather rarely, become engorged and distended.  Direction of flow is then away from the umbilicus.  Due to their engorged appearance-been likened to the mythical Medusa's hair after Minerva had turned it into snakes. This sign-called a  caput Medusa (head of Medusa very rare usually only 1 or 2 veins (often epigastric) are visible  Engorgement - can occur due to IVC OBSTRUCTION (usually due to a tumor or thrombosis but sometimes due to tense ascites) (abdominal veins enlarge to provide collateral blood flow from the legs, avoiding the blocked IVC-direction of flow is upwards towards the heart.  To differentiate CM and IVC obstruction- determine the direction of flow below the umbilicus  Prominent superficial veins can sometimes be congenital An expanding central pulsation in the epigastrium suggests an AAA The abdominal aorta, however can be seen to pulsate in normal thin people  May occur in very thin normal people occasionally  Usually suggests intestinal obstruction

 Pyloric obstruction due to peptic ulceration or tumor may cause visible peristalsis, seen as a slow wave of movement passing across the upper abdomen from left to right  Obstruction of the distal small bowel- similar movements in a ladder pattern in the centre of the abdomen

Vesicles of herpes zoster (occur in a radicular pattern-localized to only 1 side of the abdomen in the distribution of a single nerve root). H. Zoster can be responsible for severe abdominal pain -mysterious in origin till the rash appears

Skin lesions

Sister Joseph nodule- a metastatic tumor deposit in the umbilicus, the anatomical region where the peritoneum is closest to the skin Discoloration of the umbilicus where a faintly bluish hue is present - very rarely found in cases of extensive haemoperitoneum and acute pancreatitis( Cullen's sign- the umbilical 'black eye') Acute pancreatitis (severe cases)- rarely skin discoloration occurs in the flanks ( Grey Turner's sign)

Striae

Stretching of the abdominal wall severe enough to cause rupture of the elastic fibers in the skin  produce pink linear marks with a wrinkled appearance  When these are wide and purple colored -Cushing's syndrome may be the cause  Much more common causes: ascites, pregnancy or recent wt loss  Squat down beside the bed-pts abdomen at eye level

Asymmetrical  Ask pt to take slow deep breaths through the mouth and watch for evidence of asymmetrical movement- indicates the presence of a mass movement

 In particular- a large liver may be seen to move below the right costal margin or a large spleen below the left costal margin

Size Site Shape Mobility Hinge test Reducibility Cough impulse Internal ring occlusion test Consistency Fluctuation test Transillumination test

Hernia Bigger Inguinal – (goes to) scrotum Guard (elongated) Cannot get above swelling (-) Reducible (+) Reducible during coughing (DIR)

Hydrocele Smaller Purely scrotum Pear (oval) Can get above swelling (+) Irreducible (-) Not reducible

Soft (bowel) (-) Does not pass through (bowel)

Cystic (water) (+) Light pass through (water)

1) Permission *** 2) Lying down – left lateral facing 3) Bent the knees to the chest – both or right leg 4) Patient at side / edge 5) Inspection a. Scars b. External hemorrhoids c. Erythema d. Changes in color e. Sign of itching f. Anal fissuring (skin crack) g. Pus / discharge (STD) h. Anal tags 6) Palpation a. 1st = post wall b. 2nd= lateral wall c. 3rd= anterior wall for prostate (size & consistency) d. 4th= ask to constrict to see tone

7) Fingers pulled out to look for: a. Blood b. Pus c. Stool 8) THANK THE PATIENT

Endocrine System

INTRO

Greet, Introduce, Explain, Permission (GIEP)

GENERAL INSPECTION

Age, gender, ethnic group, height, weight, built, nutrition

 Wash & Warm hands.  Adequate exposure Mention: (1) conscious (2) alert (3) co-operative (4) no respiratory distress (5) not in obvious pain (6) no general discoloration

HANDS

(1) Moisture

hyperactivity of sympathetic system causes increase in sweatiness

(2) Temperature

Especially in the case of hyperthyroidism, there might increase in body temperature.

(3) Acropachy (Clubbing) (4) Onycholysis (5) Fine tremors PULSE

(1) Rate (normal 60-90 bpm)

ARMS

(2) Rhythm (3) Volume (4) Symmetry (delay) 1. Texture 2. Myxoedema 3.

Scratched marks

4.

Biceps reflex

5.

BP

Acropachy is a clubbing in Grave’s disease. =separation of nail from nail bed Seen in Grave’s disease Test with a piece of paper. It is due to sympathetic over activities in hyperthyroidism or Grave’s disease.  Tachycardia (>100bpm) = hyperthyroidism  Bradycardia (nitrogen retention causing impaired PT consumption thus causes decrease in platelet factor III Seen in CRF Uraemic pruritis Fine white powder present on the skin where high concentrations of urea have precipitated out of sweat. Seen in CRF. =>failure to excrete urinary pigments Seen in CRF Seen in CRF

(6) Pulse & BP EYES

(1) Jaundice (2) Pallor (3) Band keratopathy

Hypertension related renal disease. Postural hypotension in ARF. Liver hemachormatosis Hemolysis causing anemia Ca ion deposition beneath corneal epithelium in line with interpalpebral fissures Seen in 2ndary or 3rtiary hyperparathyroidism and CRF treatment complication

(1) Oral trash MOUTH

(2) Uraemic fetor (3) Hydration (4) Jaundice (5) Mucosal ulcer

(1) JVP

CRF Thickening of gums Complication of treatment for kidney transplant patient Intravascular volume status

(2) Jugular vein puncture

Vascular access insertion (vaseath) - hemodialysis

(6) Gingival hyperplasia NECK CHEST (rare) ABDOMEN

Seen in generalized atherosclerosis or CRF (3) Carotid bruits Observe for CRF: 1. inspect for chest wall and  CCF deformities  HPT (Na +H2O retention) 2. inspect for obvious breast  Pulmonary oedema (uraemic lung disease, and skin discoloration volume overload, uraemic cardiomyopathies) 3. symmetry of respiratory  Pericarditis (pericardial rub or cardiac movement temponade) 4. visible apex beat  Lung infections (immunosuppression) Examine for: 1. symmetrical percussion 2. chest expansion 3. auscultation for added sound 4. apex beat 5. heart sound (do normal abdominal examinations-similar to those in GI) Pay attention to: Inspection: 1. Nephrectomy Scars (May have to roll patient over to look at posterior aspect) 2. Peritoneal dialysis scars 3. Abdominal Distention

Palpation: 1. Bimanual ballotment (ask the patient to breath deeply as you ballot) [size, surface and consistency] 2. Palpate for enlarged bladder Percussion: 1. Shifting dullness 2. Percuss for enlarged bladder Auscultation: 1. Renal bruit – 2cm left and right to umbilicus

BACK

(1) Vertebral column punch (gentle) (2) Murphy’s kidney punch (the kidney punch) (3) Sacral oedema

LEGS

Look for 1. Oedema 2. Purpura 3. Pruritus 4. Pigmentation 5. Gouty tophi

Spleen No palpable upper border

Kidney Upper border palpable

Has splenic notch

No notch

Moves inferiormedially on inspiration

Moves inferiorly

Not ballot able

Ballot able

Dull on percussion Friction rub audible

Resonance on percussion Not audible

Punch on vertebral column with the base of fist Punch at the renal angle for tenderness in infections.

The details of abdominal examinations in RENAL system 1. Inspection a. Tenchkhoff catheter = peritoneal dialysis b. Surgical scars = nephrectomy scars c. Renal transplant scars = right / left iliac fossa d. Distended abdomen = large polycystic kidney disease and ascitis (nephritic syndrome or peritoneal dialysis e. Scrotum masses f. Genital oedema (IVC obstruction) 2. Palpation a. Forward bulging = kidney enlarged b. Backward bulging = perinephric abscesses c. Left iliac fossa kidney = transplanted kidney d. Renal (loin) tenderness = pylonephritis Kidney: 1. region = lumbar 2. edges = smooth rounded 3. on percussion = resonance 4. ballotable

*** Palpation BREATH IN =>> deep and superior BREATH OUT =>> move to next stage

3. Balloting a. Left hand (balloting hand) i. Under renal angle ii. Finger moves not palm b. Right hand (examining) i. Anterior lumbar region ii. Pressed downwards 4. Percussions a. Fluid thrill b. Shifting dullness c. Percuss for enlarge bladder (percuss on the midline downwards) d. Auscultatory-percussion 5. Auscultation a. Bruit i. Listen with diaphragm ii. Next ask the patient to sit down to hear better b. Diastolic bruit i. Renal artery stenosis ii. Atherosclerosis c. Systolic bruit i. Rarely renal artery stenosis ii. Maybe from aorta or spleen

Musculoskeletal System

INTRO

Greet, Introduce, Explain, Permission (GIEP)

 Wash & Warm hands.  Sitting down  Adequate exposure

GENERAL INSPECTION INSPECTION

Age, gender, ethnic group, height, weight, built, nutrition E.g. Mr. Chan is a middle aged Chinese man of Mention: average height and built. He is well nourished and of (1) conscious average weight. He is conscious, alert, and co(2) alert operative. He is not in any distress, no general (3) co-operative discoloration and he is not in obvious pain. (4) distress / restlessness (5) not in obvious pain (6) no general discoloration (pallor)  3D inspections (front, side and behind)  Start with normal  Sitting down comfortably  Proper exposure and warm hands (1) Shape (a) normal / equal (b) rounded / deformity (c) swelling / wasting (2) Skin • Redness • Discoloration • Scars • Abrasion Shoulder (3) Attitude (4) Movement (5) Symmetry

PALPATION

     

Tenderness Exploration Joints tendons ligaments ligaments

Levels of shoulder Hanging / supported This is done by asking the patient to unbutton his / her shirt to see if there are any limitations in movement. Compare the two shoulders  Bursae  compare Comment on:  pain  deformities – swelling, temperature & mass  intact bones

(1) Sternoclavicular Joint (2) Clavicle (3) Acromioclavicular

(4) Spinous (Scapula)

(5) Infraclavicular Fossa (6) Acromion (7) Greater Tuberosity Note: (Extra) Triangle Of Symmetry 1. Corocoid (Thumb) 2. Acromion (2nd Finger) 3. Greater Tuberosity (Middle Fingers)

MOTION SPECIAL TEST

To see if the patient is able / unable to perform certain motion Range of movement 0°=anatomical position Comment: “range of movement is from zero (0) to…” – on your findings, not what’s the normal (1) Abduction Look from anterior (2) Adduction (3) Extension Look from lateral (4) Flexion (5) Internal Rotation Look from posterior (6) External Rotation Look from anterior (7) Extension On Internal Rotation (8) Flexion On External Rotation = 90° abduction and light extension PLUS 90° external rotation (1) Apprehension test Done in shoulder dislocation    

(2) Neer’s test (RARE!)

Bursitis - subacromial impingement - acromion processes impinge on bursa

(3) Hawkin’s test (RARE!)

Rotator cuff injuries

INTRO

Greet, Introduce, Explain, Permission (GIEP)

 Wash & Warm hands.  Lie down flat  Adequate exposure

GENERAL INSPECTION

Age, gender, ethnic group, height, Comment especially on: weight, built, nutrition  Pallor  Pain  Distress

INSPECTION

 3D inspections (front, side and behind)  Start with normal  Proper exposure and warm hands (a) normal / equal (b) rounded / deformity (1) Shape (c) swelling / wasting • Redness • Discoloration (2) Skin • Scars • Abrasion Shoulder • Laceration Standing / supine (3) Attitude

(5) Movement – Gait Ask the patient to walk.

(6) Symmetry

Antalgic gait = associated with painful leg or foot Short leg gait = the patient will dip down the short leg on walking or bear weight bearing Scissor gait = legs are adducted. Seen in cerebral palsy Waddling gait = proximal myopathy High stepping gait = foot drop Trendelenburg's = pelvis tilts down to the opposite site instead tilts up. Seen when hip is painful, weak, dislocated or fractured Stiff leg = whole leg swung outwards to clear ground to compensate (circumduction). Seen when hip / knee arthrosed or cannot bend. Compare the two hips on standing.

PALPATION

Comment on:  pain  deformities – swelling, temperature & mass  intact bones (6) Femur Head (7) Ischial Tuberosity (8) Iliac Tubercle (9) Iliac Crest

MOTION

 Tenderness  Exploration  Skin temperature (1) Pubic Symphysis (2) Pubic Crest (3) Pubic Tubercles (4) ASIS (5) Greater Trochanter Note: (extra) Some of us did muscle on palpation which includes; gluteus, quadriceps, adductors and hamstrings.  To see if the patient is able / unable to perform certain motion  Range of movement  0°=anatomical position  Comment: “range of movement is from zero (0) to…” – on your findings, not what’s the normal (1) Abduction Look from anterior (2) Adduction (3) Extension Look from lateral (4) Flexion (5) Internal Rotation Look from posterior (6) External Rotation Look from anterior (7) Extension On flexion of knee (8) Flexion On flexion of knee

MEASUREMENT

Apparent length True length

**square the pelvis first!! (2) True length True–shortening in:part of medial ASIS toSeen upper Can be due to old fractures of maleolus femur or (3) Apparent length tibia. – Apparent shortening xiphisternum to upper part of Seen in: medial maleolus

Adduction contracture of the hip which has to be compensated for see next pageby(extra) more info tilting for of the pelvis.

Fig. 10.41 True and apparent lengths of the lower limbs.

SPECIAL TEST

(1) Thomas test The test must be performed with the patient lying face up a hard surface.

Thomas's test measures fixed flexion deformity (incomplete extension). This deformity may be masked by compensatory movement at the lumbar spine or pelvis and increasing lumbar lordosis.

 Place your left hand palm upwards under the patient's lumbar spine.  Passively flex both the patient's legs (hips and knees) as far as possible.  Keep the non-test hip maximally flexed (you will feel that the lordotic curve of the lumbar spine remains eliminated). Now ask the patient to extend the test hip.  Incomplete extension in this position indicates a fixed flexion deformity at the hip  Picture on right shows Thomas test on left leg.

(2) Trendelenburg's test  Stand in front of the patient and ask the patient to stand on one leg for 30 seconds and to repeat with another leg.  Normally, the iliac crest on the side with foot off the ground should rise.  The test is abnormal if the hemipelvis falls below the horizontal line.  It maybe caused by gluteal weakness or inhibition from hip pain e.g. osteoarthritis or structural abnormality e.g. coxa vara

(3) Straight leg test

Trendelenburg's sign. Powerful gluteal muscles maintain the position when standing on the left leg; weakness of the gluteal muscles results in pelvic tilt when standing on the right

Site of shortening The exact site of shortening is important. Firstly it is important to determine if it is above or below the knee. This is best assessed by flexing both knees to 90°, as illustrated. Above the knee

Below the knee

Normal

Shortening above the knee In assessing shortening above the knee, it is important to decide whether it occurs above the greater trochanter, or below the trochanter in the femoral shaft itself

Shortening above the greater trochanter can be determined by: 1. Placing one's thumbs on the AS IS with the middle fingers on the tip of the greater trochanters (both side) and compare, using the sense of proprioception (muscle sense). 2. Bryant's Triangle is drawn as follows. The patient lays supine and a line drawn from the ASIS down towards the bed. A second line is then drawn from the ASIS to the tip of the greater trochanter. The third side of the triangle is a horizontal line, drawn proximally from the greater trochanter in the line of the femur to meet the first line drawn. This third line shows the amount of upward or downward displacement of the hip compared to the normal side. ASIS

Greater trochanter

Normal

Superior displacement

Inferior displacement

1. CERVICAL INTRO

Greet, Introduce, Explain, Permission (GIEP)

 Wash & Warm hands.  Sitting down  Adequate exposure

INSPECTION

(1) Swelling (2) Skin • Redness • Discoloration • Scars • Abrasion Shoulder (3) Neck deformity

(4) Torticolis

(5) Congenital webbing of the neck

(6) Symmetry PALPATION

 Tenderness  Swelling

Torticollis / wryneck muscles of the neck contract ~ neck is twisted to an unnatural position cause: -protective spasm due to trauma -tonsillar infection -vertebral body disease -sternomastoid tumor (infant) Webbing of the neck Absence of 1 or more cervical vertebrae e.g. Turner's Syndrome Check asymmetry in supraclavicular fossa Comment on:  pain  deformities – swelling, temperature & mass  intact bones

MOTION (1) Extension – look up (2) Flexion – look down (3) Rotation – look to right / left (4) Lateral flexion - ask patient to tilt head onto

Look from lateral Look from “above” Look from anterior

his right / left shoulders *abnormalities may be due to cervical spondylosis 2. THORACIC & SACRAL INTRO

Greet, Introduce, Explain, Permission (GIEP)

INSPECTION

(1) Deformities  Scoliosis = lateral bending  Kyphosis = AP bending  Gibbus = localized kyphosis  Lumbar curvature / lordoisis  Swelling (2) Skin • Scars • Sinuses • Color change • Hair tuft • Discoloration • Dimpling at base of spine • Soft tissues swelling

PALPATION

Comment on:  pain  deformities – swelling, temperature & mass  intact bones (1) Tenderness

MOTION

(2) Muscle wasting (3) Muscle pain (4) Steps (1) Extension - lean backwards (2) Flexion - touch your toes with your knees straight (3) Lateral Flexion - slide your hands at the side of your hip try to touch your knee (4) Rotation - ask the patient to sit and to twist around to each side

 Wash & Warm hands.  Standing  Adequate exposure

Gibbus: TB of spine 1. Hair tuft. discoloration or dimpling at the base of the spine indicates spina bifida 2. Soft tissue swelling may be due to: -infection -trauma -tumors

Feel for bony contour

Seen in:- fracture - TB - Infection

SPECIAL TEST

(1) Schober’s Test  A point is marked 10cm above a line connecting the dimple of Venus.  5cm below the line  Upper end is anchored.  Ask pt to try and touch toes (flex). Norm >5-10cm Pathology indicates ankylosing spondylitis

(2) Straight Leg Raising Test Stretch Test – Sciatic Nerves (A) neutral position (B) straight leg raising limited by prolapsed disc (C) tension increased by dorsiflexion of foot (D) root tension relieved by flexion at knee

(3) Stretch Test – Femoral Nerves

Nervous System

INTRO

Greet, Introduce, Explain, Permission (GIEP)

INSPECTION

(1) Overall about the patient (2) Muscle bulk (3) Muscle wasting

 Wash & Warm hands.  Sitting  Adequate exposure (e.g. position, gait…etc)

(5) Involuntary movement - Tics/twitches - fasciculation - tremors

TONE** ask the patient to relax

(1) Upper limb  Test muscle tone at the shoulder, elbow, joint, and wrist joint. Say: Let your arms go loose and let me move them for you. (2) Lower limb Test tone by internally and externally rotating the resting leg and by raising the knee off the bed. Say: Let your leg go loose and lax, and let me move it for you. (3) Patella clonus  With the pt in the supine position, grasp the upper edge of the patellar between the thumb and index finger and apply a quick constant pressure in a downwards direction. (4) Ankle clonus  Ensure that the pt's knee is semi-flexed and the foot relaxed.  The foot is suddenly pushed dorsally with moderate force and held there.

 Flex and extend wrists passively (to elicit cogwheel rigidity)  Flex and extend at the elbows, pronate and supinate at the forearm (to elicit the lead-pipe rigidity and clasp-knife spasticity)  Passively flex and extend the leg at the knee and hip.  Roll the extended leg, feeling for resistance.  Put your hand behind the knee and pull it upwards, observing the foot to check whether or not it flops.  If there is spasticity and increased tone, then test for ankle clonus and patellar clonus.

 In upper motor lesion the patella may manifest a few jerks (unsustained clonus) or a constant jerking as long as the pressure is applied. (sustained clonus) *avoid prolonging this maneuver as it is often painful to the pt



In the upper motor lesions the posterior muscles of the leg will enter into a persistent contraction.

POWER

UPPER LIMBS (1) Shoulder abduction: 'hold your arms outwards at your sides and keep them up, don't let me stop you' (2) Shoulder adduction: 'push your arms in towards you and don't me stop you' (3) Elbow flexion: 'bend your elbows and pull me towards you, don't let me stop you' (4) Elbow extension: “straighten your elbows and push me away, don't let me stop you” (5) Wrist extension: 'clench your fist and cock your wrists up, don't let me stop you' (6) Wrist flexion: 'now push the other way' (7) Finger abduction: 'spread your fingers wide apart and don't me push them together' (8) Finger adduction: 'hold this piece of paper your fingers and don't me snatch it away' LOWER LIMBS (9) Hip flexion: 'lift your leg straight up and keep it there, don't me stop you' (10) Hip extension: 'push your leg downwards into your bed and don't let me stop you' (11) Hip adduction: 'push your thigh inwards against my hand' (12) Knee flexion: 'bend your knee and pull your heel towards you, don't let me stop you' (13) Knee extension: 'Straighten your knee and don't let me stop you'

Chief movers: deltoids C5

Chief movers: pectoral muscles C6-8 Chief movers: biceps C5 Chief movers: triceps C7 Chief movers: C7 Chief movers: C7 Chief movers: dorsal interossei TI Chief movers: palmar interossei TI

Chief movers: iliopsoas Ll-2

Chief movers: glutei L4-5

Chief movers: adductors of the thigh L2-4 Chief movers: hamstrings L5-S1

Chief movers: quadriceps L3-4

REFLEXES

(14) Plantar flexion: 'push your foot downwards against my' (15) Dorsiflexion: 'move your foot up and don't let me stop you' (16) Inversion of the foot: 'push your foot inwards against my hand' (17) Eversion of the foot: 'push your foot outwards against my hand' (18) Extension of the great toe: 'pull your toe upwards and don't let me stop you' (1) Biceps -Place the pt's hands on his/her abdomen. -Place your index finger on the biceps tendon and swing the hammer on to your finger. (2) Brachioradial -Place the arm flexed on to the abdomen, place the finger on the radial tuberosity, and hit the finger with the hammer. (3) Triceps -Draw the arm across the chest, holding the wrist with elbow at 90 degree. -Strike the triceps tendon directly with the tendon hammer (4) Knee -Place the arm under the knee so that the knee is at 90 degree. -Strike the knee below the patella. (5) Ankle Hold the foot at 90 degree with a medial malleolus facing the ceiling. -The knee should be flexed and lying to the side. -Strike the Achilles tendon directly.

Chief movers: gastrocnemius S 1 Chief movers: tibialis ant and long extensor L4-5 Chief movers: tibialis ant and post L4 Chief movers: extensor hallucis longus L5 Chief movers: extensor hallucis longus L5

Nerve: musculocutaneous n. Root: C5

Nerve: radial n Root: C6

Nerve: radial Root: C7

Nerve: femoral Root: L3-L4

Nerve: tibia Root: SI-S2

(6) Abdominal Scratch the abdominal wall

Afferent: segmental sensory nerve Efferent: segmental motor nerve Root: 1. above the umbilicus (T8T9) 2. below the umbilicus (TIO-TII)

(7) Plantar -Explain to the pt that you are going to stroke the bottom part of his foot. Positive Babinski's sign -Gently draw a stick up a 1. Hallux extends, the other toes spread. lateral border of the foot and 2. Indicates UMNL. across the foot pad. -Watch the big toe and the remainder of the foot. Reinforcement  If any reflex is unobtainable directly ask pt to reinforcement maneuver.  In the arms, ask the pt to clench his teeth as you swing the hammer.  In the legs, ask pt either to make a fist, or to link hands across his chest and pull one against the other, as you swing the hammer. COORDINATION

1) Supination-pronation

2) Finger to nose

3) Toe to finger

4) Heel-knee-shin

VI Simple concept for motor examination By Dr. Htin Aung I. Bulk        

Shape Wasting Convexity Comparisons Feel (inspection + palpation) UL=shoulder (e.g. deltoid) LL= hip (e.g. gluteus) Comment on: i. Shape ii. Formation iii. Equal on both side

II. Involuntary movement 1) Fasciculation a. Contraction of individual muscle bundles b. Twitching c. Bring about movement of limb d. Seen in LMN lesion 2) Tremors a. Resting i. Pill rolling ii. 5 Hz ( 5 times per seconds) iii. Parkinson b. Positional i. Fine / flapping ii. Flexion / extension iii. 10 Hz iv. Seen in: hyperthyroidism, sympathetic over activities…etc. c. Intentional / action i. Putting a string into a needle ii. Cerebella lesion 3) Tics  Predictable muscular movement  Causes unwanted motion and embarrassment  Usually affect the upper limb 4) Dystonia  Phasic, unpredictable movement

 Usually affect the upper limb 5) Chorea  Ceaseless occurrence of rapid, jerky, dyskinetic involuntary movement  Upper limb  Faster  Rhythmic  Dance like 6) Athetosis  Smoother  Slower 7) Myoclonic jerk  Strong and contractions of flexors & extensors  epilepsy 8) Hemibalistic a. explosive III. Tone = tension in the muscle due to partially contracting muscles  it is the resistance offered by a muscle to pressure and stress  : cogwheel (extrapyramidal tract lesion) or lead pipe (UMNL)  : LMNL IV. Power = the ability to contract / make a movement  normally test the ISOMETRIC CONTRACTION  Do only one; either isometric / isotonic!! V. Reflex  exposed the part to be tested  ask the patient to relax or do the reinforcement  hold the tip of tendon hammer  use the flex, not the wrist  identify the tendon  7 spots namely (biceps, triceps, brachioradialis, abdominal, patella, tendo-achilis, plantar) VI. Coordination 1) Supination-pronation 2) Finger to nose 3) Toe to finger 4) Heel-knee-shin

COTTON WOOL

(1) Light touch testing (posterior column & anterior spinothalamic tract)  Touching the skin with cotton wool  Test it on anterior chest with patient's eyes open  Test each dermatome  Always compare both sides

1. I'm going use this cotton wool to touch on your skin 2. Can you feel it? (testing on the chest first) 3. Say "yes" when you can feel it 4. Please close your eyes (important!) 5. Are they the same in both sides? 6. Light touch sensation is normal/ reduced/ absent

PIN-PRICK (rarely done)

(2) Pain (pinprick) testing (lateral spinothalamic tract) 1. I'm going to use this pin/stick to test your pain sensation  Use new pin or sharp stick 2. This is sharp, and this is dull, can u differentiate  Test it on chest with patient's eyes open it? (chest)  Sharp or dull 3. say 'sharp' or 'dull'  Test each dermatome 4. please close your eyes  Compare right and left 5. Are both sides the same? 6. Pain sensation is normal/ reduced! absent

VIBRATION (128 Hz)

(3) Vibration testing (posterior column)  Use 128Hz tuning fork  Let patient feel for it on the chest  Place it on the distal interphalangeal joints  If distal part sensation lost, proceed to proximal jointwrist, elbow, shoulder  Compare

1. I'm going to do a vibration test on you (place it on the chest) 2. Can you feel that vibration? 3. say 'yes' when you can feel it, say 'stop' when it disappear 4. please close your eyes 5. vibration sensation is normal / reduced/ absent

J

(4) Propioception testing (posterior column)

 Use distal interphalangeal joint of index finger  Stabilize the proximal phalanx, move distal phalanx up and down  Tell patient which is up and which is down with eyes open  Ask patient close the eyes and repeat 'up and down movement' randomly  Sense of position will loss before movement  Little finger is affected before the thumb Olfactory [sensory]

1. Smell: Do you have runny nose? Can you please close your eyes and either nostril? Please smell and identify.

Optic

1. Far Vision

2. Near Vision

3. Color

1. I'm going to test your joint position

2. this is 'up' and this “down” 3. Please tell me this is up or down? 4. Sense of position is intact / lost

Ask the patient to identify the smell. Close one of the nostrils, and do with the patient closing eyes.  Coffee  Flower  Chocolates  Far vision test  Close one eye  Use Snellen’s chart  To determine farsighted / nearsighted  Report on fraction e.g. normal 20/20  Small print reading (e.g. newspaper)  Focal length (30cm)  To determine farsighted / nearsighted  Use Ishihara’s chart  To determine color blind  Ask the number or ask to follow the lines

4. Visual Field Instruction:  I’m going to test on your field of vision  I’m going to compare my and your field of vision, assuming mine is normal  Please look at my nose bridge all the time  I will move my finger inwards, tell me once you see it 5. Direct Light Reflex

6. Consensual Light Reflex

3,4,6 [motor]

7. Accommodation Reflex Instruction:  Could you please look as far as possible  Now look at my finger 8. Fundoscopy 1. H test Instruction:  I need to test the movement of your eyes  I need you to keep your head still  And please follow the movement of my fingers  Fingers put about 18 inches away Sensory (major): 1. Touch (cotton wool) 2. Pain (pinprick)

    

Distance of about 1 arm’s length Confrontation method Close one eye Close your eye too!! – practice needed See in EXTRA for explanation of abnormal findings

This is done in dim or less bright room Shone light from the side Brief exposure of light on the eye See the changes in size of pupils Ask the patient to put hands on the nose (nose bridge)  This is to minimize light shone to the testing eye  Shine light on right eye, left eye show changes in pupil size Accommodation reflex: 1. Convergence 2. pupil constriction 3. thickened lens (cannot be seen     

Comment on: 1. Nystagmus 2. Diplopia (ask the patient while doing)

Compare. Test at sternum or fingers

Trigerminal [sensory + motor]

Motor: 1. bulk 2. involuntary movement 3. tone 4. power 5. reflex

Facial [motor + sensory]

Sensory (minor): Sensation of anterior 2/3 of tongue Motor (major): 1) Bulk – check for symmetry

Muscle: 1. Masseter – Clench Teeth 2. Pterygoids – Open Mouth 3. Temporalis Power: 1) Open mouth – push up and side to side 2) Close mouth – open it! Reflex: 1. Jaw Jerk Open mouth, relax, put thumb in midline, tap the thumb 2. Corneal Reflex Explain that it will be uncomfortable, ask patient to look far, come from side, cotton just touch cornea.

Angle of eye at the same level Nasolabial fold at the same level

2) Involuntary movement

Fasciculation & tics

3) Power:

 Look up to wrinkle your forehead  Shut your eyes tightly and stop me from opening them  Puff out your cheeks  Smile & show me your teeth

1. Whispering Test

 Close one ear  Whisper from the back / side  Ask the patient to repeat (e.g. 1,1,2,9)  You can also do this test by destruction, that is, by destructing the other ear while whisper at the other( see Talley’s video)

2. Rinne’s Test

 Use 256 Hz tuning fork or 512 Hz  Hit (vibrate) the tuning fork then put on the mastoid  Process (just behind the ear)  Tell me if you hear sound  Tell me when it stops  Then put beside the ear  Do you hear any sound? Result:  Abnormal = louder on mastoid process  Conduction deafness  E.g. inflammation, fibrosis & perforation of tympanic membrane. ** remember air conduction is better than bone conduction

3. Weber’s Test

 Hit(vibrate) the tuning fork then place it on center of forehead  Ask pt if they can hear on both sides Result:  In conduction deafness, it will be louder on the affected side  In nerve deafness, sound is absent

Glossopharyngeal & vagus

1. Hoarseness of voice

 Recurrent laryngeal nerve (vagus)  Ask the patient to speak  Observe for hoarseness

2. Palate & uvula

      

3. Gag reflex (RARE!) 4. Taste (RARE!)

Open your mouth Put out your tongue Say “aaaahhh” Observe the movement of uvula Normal = symmetrical move upwards Sensory (glossopharyngeal) Motor (vagus)

Posterior 1/3 Muscle: 1. Sternocleidomastoid 2. Trapezius

Accessory [motor]

1. Bulk

2. Involuntary movement

3. Tone

4. Power

Hypoglossal [motor]

1. Bulk

2. Involuntary movement 3. Power

 Look and ask the patient to look to the side  Bulk is normal  Hypertrophied?  Wasting  Symmetry  Fasciculation  Tremors  Tics  Move head side to side  Shoulder up and down  Comment about the tone  SCM = turn your head against my hand. Note the SCM contraction.  Trapezius = shrug your shoulders, push up hard  Size (wasting?)  Positions  Symmetrical • Fasciculation • Tremors  Up  Down  Side to side along the lips  Press against cheek

Numerator / denominator (e.g. normal = 20/20) Numerator = patient’s Denominator = normal 6/6 = patient/normal

LINE 8

Patient can read from 6m what a normal person can read from 6m [NORMAL]

20/70 = patient/normal

LINE 3

Normal person can read at 70 feet, but patient can read at 20 feet [NEAR SIGHTED]

20/13 = patient/normal

LINE 10

Normal person can read at 13 feet, but patient can read at 20 feet [LONG SIGHTED]