Clinical Examination

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CLINICAL EXAMINATION

ENT HEAD AND NECK Examination of theThyroid

NEUROLOGIC EXAMINATION Cranial Nerve Examination - Inspection: scar marks, asymmetry of face, eyes, pupils, wasting - I – ask patient to smell - II – PEARL, Funduscopy, VA, pinhole test, visual fields, - III, IV, VI – ptosis; presence of asymmetry of eyes and pupils; extraocular movements; accommodation - V – sensation (ophthalmic, maxillary, and mandibular) and motor (clench teeth - masseter; open mouth and push to close – pterygoid muscles; if weakened jaw deviates to affected side); corneal reflex; jaw jerk (UMN) - VII – close eyes and don’t let me open them, smile, wrinkle forehead, puff up cheeks - VIII – whisper test; rinne test and weber (256) - IX and X – hoarseness; cough; ask to sip water to check problems with swallowing; Gag reflex and uvula - XI – raise shoulder and SCM - XII – tongue TIA Examination - Face: asymmetry of face, ptosis, eyes/pupil of equal size, redness/swelling; PEARL; ophthalmoplegia; accommodation; funduscopy - JVP, carotid pulse and bruit - Upper/Lower limb neurologic examination Neurological Examination of the Upper Limb - Inspection: signs of head injury, facial asymmetry, ptosis, muscle wasting and fasciculation - Palpate muscles for tenderness, Pronator drift (UMN/cerebellar lesion), tremors, - Tone - Power (shoulder grasp, biceps and triceps power, flexion and extension of wrist, grasp, flexion and extension of fingers; adduction and abduction of fingers - Reflexes: biceps, triceps, brachioradialis - Sensation - Vibration and Proprioception - Finger-to-nose test and alternating movements (dysdiadochokinesia) Neurological Examination of the Lower Limb - Inspection: wasting of muscles, tremors, fasciculations, surgery marks, deformity - Gait assessment: observe for limping - Walk on heels: L5 - Walk on toes: S1 - Squatting - Romberg test - Heel-Toe Walking - Palpation for tenderness of muscles - Power (hip flexion and extension, knee flexion and extension, adduction, abduction, inversion, eversion, plantar flexion, dorsiflexion) - Reflexes (knee, ankle, babinski, clonus) - Sensation - Vibration and Proprioception - Cerebellar: Heel-to-shin, foot tapping test

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IF you feel any pain or discomfort during the examination, please let me know and I will stop. I will be gentle. Ask patient to remove clothing and wash hands! Inspection: o General appearance: appropriate dressed for the weather  hyperthyroidism: anxious/restless/agitated, weight loss  hypothyroidism: depressed/sad/dull/apathic/anxiou s/restless/agitated/ hoarse voice/sluggish o Neck: look for swelling, scar marks, dilated veins (retrosternal extension), redness (thyroiditis) o Ask patient to sip water and look for movement during deglutition; check border; ask patient to protrude tongue MASS: 4S (site, size, shape, suface), 4C (color, consistency, contour, compressibility), 3T (temperature, tenderness, transillumination), 2F Fluctuation, Fixation), pulsatile, reducible, signs of inflammation Palpation (from behind) o Palpate both lobes and isthmus o Sip of water and look for all characteristics of the mass (soft: adenoma; cystic: cyst; firm: goiter; hard: cancer; tenderness: thyroiditis; immobile: cancer); palpable thrill o Cervical lymph nodes (submental – submandibular – preauricular – postauricular – anterior cervical – posterior cervical – occipital) o Look at position of trachea from front (if displaced may be retrosternal extension) Percussion: from upper part of manubrium from one side to the other (change from resonant to dull indicates restrosternal goiter) Auscultation: listen for each lobe for any bruit (increased blood supply due to hyperthyroidism) Pemberton sign: ask patient to lift both arms as high as possible and look for plethora, cyanosis, respiratory distress, or neck vein distention  signifies thyroid gland is closing the thoracic inlet and impedes venous flow to the heart Hands, nails and skin o Hyperthyroidism: warm, sweaty, palmar erythema; onycholysis (nail separating from bed); tremors; shiny and smooth o Hypothyroidism: cold, dry, swollen, thick skin, anemia; dry and coarse Pulse for rate and rhythm and Blood pressure Reflexes o Hyperthyroidism: brisk reflexes o Hypothyroidism: delayed relaxation Proximal myopathy: hyperthyroidism Face o Hyperthyroidism: fine shiny hair, proptosis, lid lag and retraction, chemosis (edema of conjunctiva), conjunctivitis, corneal ulceration, ophthalmoplegia

2 Hypothyroidism: brittle, dry and coarse, alopecia, loss of eyebrows, periorbital edema, facial puffiness, xanthelasma (lipid deposits over the lower eyelids), swollen tongue Other signs (Hypocalcemia): o Schvostek: twitching of facial muscles upon tapping of the facial nerve along the angle of the mandible o Trousseau: flexion of wrist and MCP joints upon inflating the BP cuff above systolic. Chest: gynecomastia in hyperthyroidism; pleural effusion (hypothyroidism) CVS: hyperdynamic circulation (arrhythmia and cardiac failure) and systolic flow murmurs; pericardial effusion (hypothyroidism) Myopathy: sit and stand hyperthyroidism Legs: pretibial myxedema (bilateral firm, elevated, dermal nodules on the shin, may be of different colors – hyperthyroidism o

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Examination of a Patient with Facial Trauma -

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Ask for consent Inspection (Look): there is a bruise on the left side of the cheek; no obvious asymmetry or swelling is noted; no obvious fracturers; in the eyes there is no raccoon eyes (purplish discoloration around the eyes: orbital floor fracture) or any swelling or redness; on the nose there is no obvious fracture; no obvious drainage of fluid. Ask patient to open the mouth and look for any loss of tooth or injury. On the ears look for any injury, bleeding, or fluid. There is no battle sign (discoloration of mastoid due to basal skull fracture) On the neck and head, there is no obvious swellings, bumps, deformities Feel: feel surrounding area for fracture or tenderness; take torch to look for pupillary light reflex; do EOM (diplopia); ask for funduscopy and visual acuity; take pin to check for sensation; clench teeth; corneal reflex; close eyes and do not let patient open them; open teeth and smile for me; feel head for any injury or swelling; feel cervical spine and paraspinal muslces to look for tenderness; Move: do ROM of neck;

Pleiomorphic Adenoma Case: A middle-aged man comes in to your GP clinic with a swelling on the left side of his face just above the angle of his jaw between the mastoid and mandible. A picture of the swelling is provided. Task a. b.

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History (lump x 5 years noticed when he was shaving; slowly growing, not painful, came in due to cosmetic reasons, + smoker x1/2 pack) Physical examination (3x3, irregular, firm, nontender, rounded/bosselated, well-circumscribed, no punctum, redness, discharge or scar marks, no LN enlargement, facial nerve examination) Diagnosis and management

History - Can you tell me more about it? When? Is it growing suddenly or slowly? Painful or not painful? Does it move when you feel it? It is firm or hard when you feel it? Any ulceration, infection or bleeding from this site? Any other lumps and bumps in the body? Any weight loss or change in appetite? Did you notice any

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asymmetry of the face? Any disturbance in function of your face? Any change in taste sensation? Any problems with swallowing, hearing or breathing? Hoarseness? do you have any pain or swelling in the gum while chewing? How is your general health? PMHx of cancer or radiation therapy? FHx of cancer SADMA?

Physical examination - General appearance - Vital signs - ENT: Inspection, palpation (site, size, shape, surface, contour, consistency, compressibility, temperature, tenderness, transillumination, fixation, fluctuation, reducible, pulsatile, signs of inflammation, discharge, ulceration, vascularity), Lymph nodes (submandibular, submental, anterior and posterior auricular, occipital, anterior and deep cervical LN), Facial nerve testing: asymmetry, close eyes and don’t allow to open them, smile, clench teeth, Do check oral cavity using mouth and torch (dental problem or ulcers of mouth and tongue); parotid duct:: palpate from inside of the mouth and check for discharge and salivary stone Diagnosis and Management - For examiner: We are presented with a middle-aged man who presents with a long-standing mass on the face which is suggestive of a parotid enlargement. On examination, the mass is noted to be wellcircumscribed firm mass without signs of facial nerve involvement which is highly suggestive of a benign tumor called pleiomorphic adenoma. -

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For patient: From history and examination you have a condition called pleiomorphic adenoma of the parotid gland. Let me assure that it is a benign swelling and to further confirm it, I will refer you to the surgeon. He will do a CT scan or MRI to see the overall dimension and tissue invasion and FNAC to determine whether the tumor is benign or malignant. Differential Diagnosis: Warthin’s tumor, Sebaceous cyst, lymphoma, metastasis from primary growth, parotid abscess, lipoma, pre-auricular adenoma, Chronic parotitis Once confirmed the surgeon will remove it through a procedure called Superficial parotidectomy. In this surgery, the lump is removed and the facial nerve is preserved. Complications include: hemorrhage, anesthetic complications (aspiration), facial nerve injury, salivary fistula, recurrence Reading materials, refer and review. For cancer: Total parotidectomy or block neck dissection with radiotherapy

RESPIRATORY SYSTEM EXAMINATION Examination of the Respiratory System -

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Consent Inspection: sitting comfortably on the bed and does not appear to be SOB, conscious and alert, not cyanosed, not attached to oxygen, no medications, or IV lines. He does not appear cachectic. Hands: cyanosis, clubbing, nicotine stains, test patient's resistance to adduction (brachial plexus involvement in pancoast/apical lung tumor), press wrist and note tenderness (hypertrophic pulmonary osteoarthropathy - results from periosteal

3 inflammation secondary to pancoast tumor), pulse and RR, wrist extension for 30 mins and look for flapping tremors for CO retention -

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Face: pallor, jaundice, Horner syndrome, check for tenderness of maxillary and frontal sinuses, nose for swelling, polyps, and deviated nasal septum, open mouth to check for focus of infection, speak a sentence for hoarseness, ask px to cough for bovine cough

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Do Peak expiratory flow rate (PEFR) o F: 400L/min and M: 600L/min

CARDIOVASCULAR AND PERIPHERAL VASCULAR Cardiovascular Examination Position patient to 45 degrees and expose neck and chest up to lower abdomen General inspection: lying comfortably at 45 degrees, not cyanosed and dyspneic, not cachectic (cardiac cachexia  weight loss due to heart failure), no features of down, marfan, turner syndrome, not attached to oxygen, ECG monitor or drugs on the side of the patient Hands/nails: check for cyanosis, splinter hemorrhages, clubbing, CRT, nicotine stains, palmar erythema, Janeway lesions (painless red macular patches on palms), Osler nodes (tender nodules on the pulp of the fingers), anemia/pallor, tendon xathomas Arms: Radial artery pulse for rate and rhythm, compare both pulses for Radioradial delay (subclavian artery stenosis) or Radiofemoral delay (COA), collapse impulse (AR), BP (sitting and standing) Face: anemia, jaundice, xanthelasma, malar flush (SLE, MS, pulmonary stenosis), tongue and lip for central cyanosis, high-arched palate (marfan syndrome), petechia, telangiectasia (IE), stomatitis/gingivitis; Neck: carotid pulse, JVP (patient at 45 degrees: use 2 ruler: 1 ruler straight up at manubrio-sternal angle then measure in cm  add 5cm  >8cm is raised JVP) Precordium: o Inspection: scars (middle sternotomy/thoracotomy), pacemaker (below clavicle, subcutaneous), kyphoscoliosis, pulsations, deformity o Palpation: apex beat (5th mleft ICS, 1cm medial to the midclavicular line; check whether forceful/tapping/displaced/diffuse/parasterna l impulse), heave (palm), thrill at base of heart (pulmonary and aortic area  using fingers)

Auscultation: bell of stethoscope at apex beat; 

Neck: Lymph node and trachea, JVP (if indicated)

Chest Inspection: pectus carinatum/excavatum, deformities, scars, radiation marks, erythema and signs of inflammation, tattoos, barrel-shaped chest, kyphoscoliosis, spine central Palpation: check chest expansion (breathe in and out by mouth): upper lobe expansion (equal rising of clavicles), middle and lower lobe: thumbs should move at least 5cm, sacral edema, tactile fremitus (with hands over chest) Percussion: supraclavicular area Auscultation: air entry, added sounds, vocal fremitus Examine anterior chest as well -

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MS: mid-diastolic (bell); ask patient to turn on left side  feel hand for palpable thrill; auscultate murmur heard clearly; MR: pansystolic (diaphragm); radiates to axilla; AS: ejection systolic murmur; Neck; AR: early diastolic murmur; ask patient to lean forward; then breathe in and out  hand and auscultate Systolic murmurs: radiate Diastolic murmurs: accentuated by change of position Dynamic auscultation: Pinch nose and ask patient to breathe in and try to breath out thru the ears valsalva  auscultate at left sternal edge for systolic murmur of HOCM

Back: o

Inspect: scars, deformity, bamboo spine (PR) o Feel: sacral edema, pleural effusion o Auscultation: crepitation, pleural effusion (no breath sound) o Radiofemoral delay: listen to scapula  COA Abdomen: lying flat with one pillow o Abdomino-jugular reflex o Palpate liver and spleen o Ascites o Aortic aneursym Lower limbs for edema, pulse Urine dipstick, funduscopic, hematuria, HTN changes, Roth spots in infective endocarditis

Murmurs: MS: normal pulse, reduce in volume MR: pounding pulse AS: slow-rising pulse AR: collapse pulse Systolic murmur at aortic area (DDx) AS radiate to carotid Aortic Sclerosis (doesn’t radiate) HOCM functional systolic murmur Pregnancy Thyrotoxicosis Fever Anemia Main causes of AS Increased age Congenital bicuspid valve Main causes of MR Rheumatic fever MVP/rupture of chordate tendinae MI Infective endocarditis Dilated cardiomyopathy

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Examination of the Lower Extremities -

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Introduce yourself. I understand from your notes that you’re having pain on the leg. My task is to do the physical examination. During this examination, I will look and will be palpating/feeling some parts of the leg. I will also need to listen to some of the vessels on your leg with the use of my stethoscope. AT this moment I would like to ask you if you have any pain. I will ask for your permission to expose your thighs and legs (usually up to the nipple area but cover abdomen and expose only when required). While you undress I would just like to wash my hands. Inspection: o Abdomen: check for visible pulsation (AAA – left of the midline), scar marks; o Groin: pulsation, scar marks; o thigh and legs: muscle wasting, joint deformities, atrophy of the skin, loss of hair, change of color of skin, shiny skin; o feet: obvious deformity, ulcers (include toes, raise legs, under heels), hallus valgus; discoloration/cyanosis/blackening of nails; look for signs of amputation in toes; obvious edema and signs of inflammation Palpation: check for capillary refill time (20cm - Ask patient to sit at edge of the bed and test reflexes (ankle and knee, clonus and babinski); hip flexion against resistance, then sensory levels - ROM of hip: hip flexion with knee extended - 90, and with knee flexed 135, Internal and external rotation

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(look at position of patella), flexion and extension of knee, inversion/eversion and flexion/extension of foot, dorsiflexion and plantar flexion of great toe, extension of hip; Power of hip and knee against resistance

Modified Straight leg-raising Test (L4-S1)  tests root tension L3-4, L4-5, L5-S1  passively lift the leg while the patient is supine to maximum he can tolerate, raise the leg to just below the level and dorsiflex the foot Slump Test: patient at the edge of the bed and slumping and bed head forward to maximum, lift up head as if doing SLR test, release leg until pain disappears, and put pressure by putting dorsiflexion, release neck and dorsiflexion Clinical Features Weakness of Iliopsoas muscle (Hip flexion) Loss of sensation over the thigh and the lower part of the groin Reflex: None Weakness of quadriceps (Knee extension) Loss of sensation over the patella Reflex: Knee jerk Weakness of quadriceps and inversion at subtalar (Ankle dorsiflexion and cannot walk on the heel) Reflex: Knee Extensor hallucis and digitorum longus (Great toe dorsiflexion and long extensors and everters) Reflex: None

L2

L3 L4 L5

S1

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Management of axillary nerve injury - In many cases, spontaneous resolution happens spontaneously and no treatment is needed. It may take as long as one year. - If there is any pain, we can give you medication such as paracetamol in mild pain or if severe/stabbing pain, other medications such as gabapentin or TCAs can also be given. - If not controlled refer to surgery and surgical options include nerve grafting/reconstruction. - Refer to physiotherapy to regain muscle strength and function of nerve. Examination of the Hand -

Flexor hallucis and digitorum longus and tendon Achilles: weakness of Plantar flexion and foot eversion (Toe walking) Reflex: Ankle Jerk Do PR

MUSCULOSKELETAL EXAMINATION OF UPPER LIMBS Examination of the Shoulder Book Case: Consent Inspection: check for symmetry; check joints both shoulders are equal; contour of muscles; no muscle atrophy; bone, muscle, skin and joint; comment on neck (neurocutaneous stigmata of associated disease, bruise, deformities, erythema, neck contour is fine), temperature is equal, musculoskeletral structures look in place. Injury to circumflex nerve if there is shaving of deltoid Palpation: both clavicles, acromioclavicular joint, bursa, bicipital tendon, suprasinous muscles, midline and paraspinal areas and infraspinatus, examine police patch (circumflex nerve), compare pulse, Check full ROM: flexion and extension of shoulder joint, abduction to glenohumeral joint, scapula sliding over thoracic cage, adduction to 0 and across the body, internal and external rotation, touch tip of scapula and scratch thumb between scapula (combined adduction and internal rotation) then combined abduction and external rotation, then circumduction Stool: passive movement Test power of muscles: resists hands on biceps (full flexion and extension); do chicken wings (abduction/adduction); full external/internal rotation Pulses!

Neurocutaneous structures: use pin and cotton Throw a ball: apprehension test: impending dislocation/subluxation/joint unstable if positive

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Joints, Pulse, Nerves, Muscles and Tendons!!! If with trauma: Pulse, nerve function, tendons, joint, muscle If rheumatological examination: joint, tendons/nerves, muscles, pulse Inspection: nails  psoriatic nails (pitting, onycholysis, hyperkeratosis), subluxation, muscles, shiny, tighetened skin, thickening of tendons, erythema, clubbing, deformity of small joints of the hand (phalanges, MCP or wrist joint), nodules on the level of elbow swelling, signs of inflammation, deformity, no muscle wasting or thickening of hypothenar or thenar muscles, pallor, dupuytren contracture o Radial deviation of wrist o Z deformity thumb – flexion of MCP and extension of PIP (RA) o Boutonierre deformity – flexion of PIP, extension of DIP (RA) o Swan neck deformity – flexion of DIP and extension of PIP (RA) o Heberden – DIP (OA) o Bouchard nodes – PIP (OA) o Sausage-shaped fingers – telescoping of fingers (psoriasis and scleroderma) Palpation: temperature; elbow, radius, ulna, lower end of the ulnar styloid processes with 2nd finger, (denotes RA  especially radial styloid and associated with de Quervain tenosynovitis, severe OA), wrist and bones of the hand (with thumb), press from the side and up to detect for any effusion, crepitation, dupuyren contracture, wasting of thenar/hypothenar muscles, radial pulse, CRT, sensation ROM (Active then passive); open and close hand to check for crepitus/tenosynovitis o Elbow: flexion and extension o Wrist: flexion, extension, lateral and medial deviation, supination and pronation; degree of flexion and extension o Thumb: flexion, extension, adduction, abduction, opposition o Hand: abduction and adduction Power Nerve Tests: o Pin touch test: median nerve o Crush finger with thumb: ulnar nerve o Full extension of wrist: radial nerve o Fromen’s test Vibration and Proprioception: may avoid

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Carpal tunnel o Phalen test o Tinnel o Finkelstein

Functions of the hand o Grip strength o Key hole test o Comb hair o Write name o Undo buttons

Other features of RA Skin: rheumatoid nodules Head: scleritis in eyes Lungs: nodules, fibrosis, Caplan syndrome (pneumoconiosis) Heart: pericarditis Abdomen: splenomegaly Hematologic: neutropenia (felty syndrome = RA + neutropenia + splenomegaly), anemia

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Osteoarthritis Usually carpometacarpophalangeal and DIP MUSCULOSKELETAL EXAMINATION OF THE LOWER EXTREMITY

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Examination of the Hip (Trochanteric Bursitis) Case: A 45-year-old female complained of pain in the right outer hip that travels down to her legs since last week.

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Examine the patient Diagnosis and management

Features: Inflammation of bursitis or tendinopathy of the gluteus medius tendon Common in patients on sports or gardening, increased weight/BMI Pain around lateral aspect of hip traveling down the leg Trendelenburg test may be positive Female >45-50 Tenderness of the greater trochanter and/or pain on abduction Treatment: NSAIDS, RICE, strengthening exercises, injection therapy Differential Diagnosis Avascular necrosis of femoral head Osteoarthritis of the hip Lumbar spine radiculopathy Iliopsoas tendinitis (flexors of the hip)  pain on stretching of the hip flexor or resisted hip flexion Examination Expose from waist down Assess gait (limping), walk on heels (L5) then toes (S1); squat and stand; Trendelenberg test (checks abductors of the hip  gluteus medius):  leg which the patient is standing is the one being tested  SOUND/NORMAL side is going to SAG o Tests gluteus medius muscles

o Problem in hip joint (severe OA) o Shortening of neck of femur due to fracture o SCFE (kids) Inspection: both hips straight, swelling, deformity, signs of inflammation, wasting of the muscles, flexion deformity (side), back (spine is centered, wasting, deformity)

Palpation: hip lying on the same level by palpating with thumb the ASIS, greater trochanter (tenderness if there is subtrochanteric bursitis), femoral pulse midpoint between ASIS and pubic tubercle), palpate lateral to femoral pulse to check for tenderness on femoral head (osteoarthritis), muscles on the inner side of the hip and front (adductor tendinitis) Measure leg length: Apparent and true leg length (measuring tape) discrepancy in true leg length signifies pathology of hip joint; if in apparent leg length means tilting of pelvis Active and Passive Movements then Power: o Hip flexion: raise leg to chest o Extension: can ask patient to lower the leg down or at the back ask patient to raise the leg while knee is flexed; palpate the dimple of venus or press hip (sacroiliac joint tenderness  sacroilitis) o Abduction and Adduction (support hip) o Internal and external rotation (flex and support the knee) Thomas Test: flexion deformity of the hip; keep hand under spine and flex both hips and knees and ask the patient to lower one leg; if not done properly, flexion deformity will be disguised by lumbar lordosis compensatory movement Squeeze Test: flex knee at 90 degrees ask patient to squeeze thighs in hand  (+) in adductor tendinitis/osteitis pubis Tests for Sciatica o Modified Straight Leg Test (L4-S1) o Tibial Nerve Stretch Test (L4-S3) o Femoral nerve Stretch Test (L2-4)

Diagnosis and Management Most likely you have a condition called trochanteric bursitis. The bony prominence of the thigh bone in the upper part is the greater trochanter. There is a protective shock absorber over the bone called “bursa”. The muscles of the buttock is also attached to this bone by the tendons. If there is inflammation of the tendon or bursa, it is called trochanteric bursitis or tendinitis. You need to rest and reduce the activity for about a few days. Put an ice pack on the painful side and I will give you some painkillers to relieve the pain or analgesic creams for massage. Please avoid sleeping on the affected side. You can use sheep skin mat or a small pillow to elevate the involved area I will refer you to a physiotherapist for strengthening exercises. If severe pain: local anesthetic + corticosteroids; surgery (rarely) Investigations: XRay  rule out osteoarthritis; USD: can demonstrate the pathology Overweight: lifestyle modification Gait and Hip Examination (Osteoarthritis of the Hip) Case: A 64-year-old man with a history of pain on his right hip joint for the last 6 months comes to your GP clinic. The pain is worse with activity. He tried panadol but didn’t get relief from the pain.

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Relevant hip examination and give commentary (limping, unable to walk heels and toes and squat, trendelenburg unable to do on the right side because of the pain, leg length is normal, tenderness over the

right femoral head, flexion deformity on right side, limited in range of movements on the right side, thomas test positive) Diagnosis and management

Case 2: You are working in a hospital followup outpatient clinic. This 35-year-old man sustained a posterior dislocation of the right hip in a MVA years ago. There were no associated injuries, the dislocation was reduced and he had a period of bed rest within traction followed by graduated ambulation and weight bearing. He has been well since and has no problems apart from occasional aching on prolonged exercise. He presents to you for a checkup for insurance purposes. Task: a. b. c.

Perform PE of the hip with commentary Advise patient of your opinion about the condition of his hip Advise patient of any further test which are required

Diagnosis and management - It is a condition called osteoarthritis of the hip. It is a condition resulting from wear and tear as a result of excessive use of your joints over the years and also due to old injuries in the affected joint. The cartilage the covers and protect s the ends of the bones gradually wears away causing the joint to become rough and stiff. Most cases are mild and with treatment, you can cope with it. - Investigation: I will do an Xray of the hip joint to check for bony spurs and narrowing of joint spaces. - Management: o Relative rest during acute pain, analgesia and crutches o Weight loss o Heat: hot water bottle, warm shower, electric blanket to reduce stiffness and pain o Refer to physiotherapy for strengthening of muscles and o Occupational therapist for walking aids o Surgery: hip joint is replaced by metal or plastic and is successful in >90% Adductor Tendinitis Case: Your next patient in GP practice is a 20-year-old man complaining of pain in the right groin. Task a.

Features - Most common form of hip disorder - Intrinsic disorder of articular cartilage or to secondary OA - Risk factors: previous trauma, DDH, septic arthritis, acetabular dysplasia, SCFE, past inflammatory arthritis - M=F, usually bilateral; insidious; worse with activity, relieved by rest and then nocturnal and after resting; stiffness, limp and deformity; referred pain to groin, medial aspect of thigh, buttock or knee - PE: antalgic gait, gluteal and quadriceps wasting, first hip movements lost: IR and extension, fixed flexion deformity, hip held in flexion and ER (atfirst)  IR, extension, abduction, adduction, flexion, ER - Treatment: o Weight loss o Relative rest o Crutches for acute pain o Analgesia o Walking stick o Physiotherapy o Physical therapy (isometric exercise) o Surgery: with severe pain or disability unresponsive to conservative measures; total hip replacement (old); femoral osteotomy (younger patients); hip resurfacing (90% achieve good results; last 15-20 years) Differential Diagnosis - Osteoarthritis - Avascular necrosis

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History for 2 minutes (playing football when suddenly twisted and heard popping sensation; upper groin pain radiating to the thigh) Perform Physical examination Diagnosis and management

Case: David aged 27 years presents to your surgery in a busy afternoon. He tells you he is having pain in his right leg and finds it hard to play Footy nowadays. He is a professional player and represents his team at state level. He had no injury or trauma and denies any fall also. He had got some treatment by team Physio and had used Panadol and Neurofen with no relief. David is otherwise well and works as a salesman in a wellreputed firm Task a. b. c.

Further history (right leg 2-3 weeks especially in the right upper medial thigh or groin area) Physical examination (resisted adduction increases pain, + Squeeze test, Probable diagnosis and management advise

Differential Diagnosis - Adductor tendinitis - Iliopsoas problems - Stress fracture of femoral neck - Osteitis pubis (chronic pain) inflammation of periosteal bone of symphysis pubis; pain on lower tummy/pubic bone; point tenderness in symphisis pubis; - Hernia (Sport inguinal-femoral) - Referred pain from lumbosacral spine - Osteoarthritis of the hip joint - Urologic disorders

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Features - Acute groin pain with history of twisting injury and popping/snapping - Pain  inner thigh

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History -

Tenderness on palpation of the inner muscles of the thigh and pain on adduction; squeeze test (+) RICE Prevention: stretching;

Task

Can you tell me more about what happened? SORTSARA? Were you able to walk after that? Is it for the first time? Did you have any numbness, tingling or weakness? Swelling? Bruising? Did you take any medications? Previous medications? General health? History of joint problems?

Palpation Temperature (of knee is 1 degree lesser than body), Pulses (while seated – popliteal, dorsalis pedis, posterior tibial), sensation (pain and light touch), reflexes, Passive movement Knees flexed: palate quadriceps, suprapatellar pouches, patella, patellar tendon, shin of tibia, lateral malleolus and fibula, head of the fibula, and joint line, iliotibial band, knee hip joint, adductor muscle, gastrocnemius, Achilles tendon Patellar tap test and bulge test (mild effusion  effusion Valgus and Varus stress test (+ if more than 10 degrees) Anterior and posterior drawser (+ if more than 10 degrees) Menisci o Apley’s Grinding test o External rotation, valgus and flexion or internal rotation, varus and extension Patellar apprehension test (impending subluxation or dislocation of patella)

Diagnosis and management - Most likely you have a condition called Groin strain or adductor tendinitis. It happens because of too much stress on the muscles of your groin/thigh called adductor muscles. If these muscles are tensed too forcefully or suddenly they can tear causing pain. It is a common condition during sports activity. - Avoid activity until pain gets settled. Apply for 20-30 minutes for 3-4 hours until pain-free. You can also compress the thigh with the help of elastic bandage or tape. - I will give painkillers and refer you to physiotherapy. If still not relieved, I can refer you for corticosteroid injection. - Please come back if the pain is persistent. If we might do ultrasound and Xray. -

occasion, apprehensive when twisting to the right. Between attacks of pain he can walk normally with only a minor feeling of pain on the inner side of the knee. He is otherwise well. This is the first time he has consulted a doctor about this problem.

Prevention: Do warm and stretching before doing physical activity.

Examination of the Knee Case (book pg229/280): A patient in your GP setting has past history of twisting his right knee 6 months ago when foot got caught on a broken pavement. He fell on the knee and it became swollen and painful on the inner side. The swelling caused a painful limp for several days and then subsided with easing of symptoms. Since then he has had intermittent attacks of pain on the inner side of the knee with swelling, which settles within 24 hours, and has had difficulty in straightening the leg fully. He is, on

a. b.

Focused examination of the knee Differential diagnostic plan

Inspection: Landmarks Patella Tibial tuberosity Popliteal fossa Quadriceps femoris Suprapatellar pouch Medial and lateral pouches  Peripatellar pouches (obliterates when there is effusion) Anserine bursa Fractures, muscle wasting, scars (longitudinal  TKR, keyhole) , effusion, erythema, neurocutaneous stigmata Anterior plane: varus or valgus deformity Lateral: hyperextension or flexion abnormalities Posterior: swelling or baker cyst Observe gait: normal gait, limping, fixed flexion deformity Squat and stand up (power and ROM  full flexion and extension)

Examination of ankle joint Inspection: try to walk first; change in color of skin, bruises, deformity Palpation: o Lateral: lateral malleolus, posterior tip of lateral malleolus and 6 cm above, anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, peroneal tendons, base of 5th metatarsal, (sinus tarsi, distal syndesmotic ligament, anterior calcaneal process  not necessary) o Media: medial malleolus, medial joint line with 6 cm above, 3 strips of ligament,

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navicular, anterior joint line, Achilles tendon, heel, pulse, CRT ROM: plantar flexion, dorsiflexion, inversion, eversion, neurovascular sensation, reflexes, power Tests for ankle instability: anterior drawer, talar tilt, and squeeze tests (signals high ankle/syndesmotic injury  patient needs MRI and referral for ORIF

Lower Leg Examination of a Patient with Diabetes Mellitus (Diabetic Foot) Case: Your next patient is a 55-year-old female with longstanding diabetes. Task a.

Perform physical examination of the lower limbs.

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Ask patient to walk looking for gait and normal phases of gait  high-stepping gait (indicates loss of proprioception or joint position sense) Inspection: o Needle marks and fat hypertrophy/atrophy, wasting (especially quadriceps); charcot joints (deformed knee joints) o Skin: loss of hair, atrophy of the skin, redness, cyanosis, signs of inflammation, edema o Feet for obvious deformities, boils, corns and calluses, hammer toes (proximal phalanx is flexed); mallet toe (DIP is flexed); toe clawing (flexion of both DIP and PIP), hallux valgus, bunions, tinea o Nails (thickening, ingrown toe nail, change of color, cyanosis), toes (cracks, ulcers) Palpation: o CRT, temperature, edema, pulses o Neurologic examination: sensation, vibration (toe  medial/letaral malleolus knee  ASIS) proprioception, power (ankle and not knee), tone, reflexes (ankle, knee  may be decreased or absent) Urine dipstick, BSL, funduscopy

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Diabetic Foot care Keep diabetes under good control and do not smoke Check feet daily (sores, infection or unusual signs) Wash feet daily with lukewarm water, dry thoroughly especially toes and soften dry skin especially around the heels; applying methylated spirits between toes to help stop dampness Attend to toenails regularly (clip straight across with clippers, do not cut them deep into corners or too short across, file any rough edge) Wear clean cotton or wool socks daily Exercise your feet each day to help circulation Check insides of shoes to make sure no nails are pointing into the soles Annual foot examination in doctor’s office How to avoid injury Wear good-fitting, comfortable leather shoes Shoes should never be broken-in (should fit from the start) Shoes must not be too tight or too loose Do not walk barefoot especially outdoors Do not cut your own toenails if with poor eye sight Avoid home treatments and corn pads that contain acid Be careful when walking around the garden and home Do not use hot-water bottles or heating pads on your feet Do not test temperature of water with your feet Take extra care when sitting in front of an open fire or heater

Treating cuts and injuries Clean would with mild antiseptic (liquid savlon or dilute betadine) Cover with clean gauze See GP if does not heal within 2 days or there are signs of infection - Refer to podiatrist, dietitian, diabetic educator, ophthalmologist and nephrologist