Short Cases 2003

Crosswell, Davis, Duhovic, Mitchell, Mulholland and Ozorio

Table of contents Medical Cardiovascular Gastrointestinal Haematological Neurological Respiratory Surgical Acute abdomen/scrotum Breast Hernia Neck and thyroid Peripheral vascular disease Orthopaedic GALS Spine Hip Knee Foot and Ankle Shoulder Lacerated wrist Miscellaneous Ophthalmology Rheumatology (Hand and wrist) 3 7 14 16 22 26 30 33 37 39 41 42 47 49 51 55 57 58 62

CARDIOVASCULAR EXAM General inspection esp. bedside medications (GTN, infusions, O2), cachectic etc. Clubbing Congenital cyanotic heart disease, infective endocarditis Splinter haemorrhages, Oslers nodes, Janeway lesions Pallor/peripheral cyanosis Tendon xanthomata (type II hyperlipidaemia), palmar xanthomata (type III hyperlipidaemia) Nicotine stains Radial pulse rate, rhythm Radio-radial delay/radio-femoral delay Water-hammer sign Brachial pulse character, volume Collapsing = AR, patent DA, arteriosclerotic aorta; slow-rising = AS; jerky = cardiomyopathy. Small volume = AS, pericardial effusion. Blood pressure both arms, lying and standing Sclera/conjunctiva Xanthelasma Dentition/central cyanosis Carotid palpation JVP height and character The JVP is a complex waveform, non-palpable, decreases with inspiration, obliterated with pressure at the base of the neck, increases with hepatojugular reflux. Dominant a wave = TS, PS, pulmonary hypertension. Dominant v wave = TR. Inspection of the chest Apex beat position and character Sustained = aortic stenosis, hypertension; diffuse (not localised) = left ventricular dysfunction (anterior MI); double impulse (for every one systole) = hypertrophic cardiomyopathy; tapping (S1 is palpable) = mitral/tricuspid stenosis. In essence one should simply describe if the character is diffuse or sustained. A normal AB begins before the onset of the carotid pulse, in a sustained AB they occur at the same time. Parasternal heave and thrills Percuss heart border Auscultate heart; S1 and S2 Loud S1 = mitral/tricuspid stenosis, reduced filling time (tachycardia); soft S1 = prolonged diastolic filling time (1st degree heart block), delayed onset of ventricular systole (LBBB), mitral regurgitation. Loud S2 = systemic hypertension (loud A2), pulmonary hypertension (loud P2), congenital aortic stenosis; soft S2 = aortic regurgitation. Splitting of S1 = RBBB.

Physiological splitting of S2: P2 (later) heard in pulmonary area splitting wider on inspiration. Increased normal splitting = RBBB, PS, MR, VSD; fixed splitting (not wider on inspiration) = ASD. Reversal of S2 (P2 then A2) = LBBB, severe AS, coarctation, PDA. S3 (low-pitched, mid-diastolic sound) Pathological S3 is due to reduced ventricular compliance, filling sound produced when diastolic filling is not particularly rapid (as occurs in physiological S3). LV S3 (louder on expiration) = CO, LVF, AR, MR, VSD, PDA; RV S3 (louder on inspiration) = RVF, constrictive pericarditis. S4 (high-pitched, late-diastolic sound) Pathological S4 due to high pressure atrial wave reflected back from a poorly compliant ventricle. LV S4 = AS, MR, HTN, IHD, advanced age; RV S4 = PS, pulmonary HTN. Opening snap High-pitched sound heard at a variable distance after S2 = MS, TS. Systolic ejection click Early systolic high-pitched sound heard over the aortic or pulmonary areas = AS, PS (followed by ESM). Non-ejection systolic click High-pitched sound heard in systole at the mitral area = mitral valve prolapse (common finding). Diastolic pericardial knock Abrupt cessation in ventricular filling due to constrictive pericardial disease. Murmurs position of loudest intensity, grade, radiation Dynamic manoeuvres: Murmurs on the right side of the heart become louder with inspiration; left-sided murmurs are unchanged or softer; expiration has the opposite effect. Deep expiration involves the patient sitting forward and breathing all the way out; this accentuates AR (listening in the apex); pericardial friction rub also heard best with this manoeuvre. Valsalva manoeuvre makes hypertrophic cardiomyopathy louder and mitral valve prolapse longer Exercise (sitting up and down in bed several times) accentuates MS. Pericardial friction rub Scratching sound, not confined to systole or diastole = pericarditis. Sacral oedema Percuss/auscultate base of lungs Pulsatile liver Splenomegaly Palpable aorta Ascites Peripheral pulses femoral, dorsalis pedis, posterior tibial Dependent oedema ?Calf tenderness ?Fundoscopy

Murmur

Systolic

Diastolic

Continuous

Late systolic

Pansystolic

Ejection systolic (crescendodecrescendo)

Early diastolic (decrescendo)

Mid-diastolic/ pre-systolic

VALSALVA
HCM (louder) MVP (longer)

DYNAMIC BREATHING MR (E) TR (I) AS (E) PS (I) AR (E) PR (I) MS (E) TS (I) PDA

General signs

Pulse/BP

JVP

Palpation
displaced AB; diffuse and hyperdynamic parasternal impulse

Auscultation

MR

tachypnoea

normal AF common

normal

soft/absent S1 PSM

MS

tachypnoea mitral facies peripheral cyanosis Argyll-Robertson pupil

decreased volume AF may be present collapsing/waterhammer slow-rising

normal/ prominent a wave

tapping AB

loud S1 MDM

AR

normal

displaced AB hyperkinetic

EDM

AS

normal

narrow pulse pressure

normal

AB displaced hyperdynamic

ESM may have ejection click

TR

pulsatile liver

raised elevated v wave raised giant a wave

parasternal heave

PSM

TS PR PS
peripheral cyanosis normal/reduced volume

MDM

EDM normal/JVP giant a wave parasternal heave S4 ESM

HCM

sharp, jerky

prominent a wave

double/triple AB

S4 LSM

GASTROINTESTINAL EXAMINATION
POSITIONING lying flat with head on single pillow GENERAL INSPECTION Weight + Wasting cachexia/wasting of muscles measure weight malabsorption GI malignancy alcoholic cirrhosis folds of loose skin recent weight loss obesity fatty infiltration of liver (non-alcoholic steatohepatitis) with abnorm LFTs muscle bulk ?anabolic steroids (also cause liver adenomas + HPCC) Skin Jaundice hyperbilirubinaemia Pigmentation chronic liver disease e.g haemochromatosis malabsorption Addisonian-type pigmentation of nipples, palmar creases, pressure areas + mouth Peutz-Jeghers syndrome freckle-like spots around mouth + on buccal mucosa, fingers + toes (ass. with hamartomas of small bowel + colon present with bleeding or intussusception, risk of GI adenoCa) telangiectasia hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). On lips + tongue, anywhere on skin. Can cause chronic blood loss. Sometimes ass. with an AVM. porphyria cutanea tarda fragile vesicles on exposed skin areas, heal with scarring. Chronic disorder of porphyrin metabolism, ass. with alcoholism, liver disease + Hep C. Has dark urine. systemic sclerosis tense tethering of skin ass. with GO reflux + GI motility disorders Mental state hepatic encephalopathy due to decompensated advanced cirrhosis (chronic liver failure) or fulminant hepatitis (acute liver failure) HANDS Nails clubbing cirrhosis (1/3 of pts with cirrhosis are clubbed), IBD, coeliac disease cyanosis ass. with severe chronic liver disease leukonychia (opacified nail beds, thumb + index nails) hypoalbuminaemia e.g chronic liver disease Muehrckes lines (transverse white lines) hypoalbuminaemia incl. cirrhosis blue lunulae Wilsons disease

Back of hands xanthomata

Palms Pale palmar creases anaemia (GI blood loss, malabsorption of folate/B12, haemolysis from hypersplenism, chronic disease) Palmar erythema chronic liver disease, pregnancy, thyrotoxicosis, RA, polycythaemia, chronic febrile diseases, chronic leukaemia, normal finding (esp. in ) Dupuytrens contracture (thickening + contraction of palmar fascia causing permanent flexion) alcoholism, manual workers, familial Hepatic flap hepatic encephalopathy (liver failure). Also seen in cardiac, resp + renal failure, hypoglycaemia, hypokalaemia, hypomagnesaemia, barbiturate intoxication apparent tremor Wilsons disease fine resting tremor alcoholism ARMS Bruising large bruises (ecchymoses) clotting abnormalities hepatocellular damage protein synthesis clotting factors (except VIII) obstructive jaundice bile acids absorption of vit K (fat-sol vitamin) essential for production of clotting factors II (prothrombin), VII, IX, X Petechiae (pinhead-sized bruises) chronic excessive alcohol consumption BM depression thrombocytopenia splenomegaly 2o to portal HT hypersplenism destruction of platelets severe liver disease (e.g acute hepatic necrosis) DIC Wasting late sign malnutrition in alcoholics (alcohol can cause proximal myopathy) Scratch marks (due to severe pruritus) obstructive or cholestatic jaundice presenting feature of 1o biliary cirrhosis Spider naevi (central arteriole with radiating numerous small vessels, up to 0.5cm diameter, usually in area drained by SVC arms, neck, chest wall, >2 abnormal) cirrhosis usually due to alcohol viral hepatitis transient pregnancy 2-5mths, disappear within 8wks of delivery Campbell de Morgan spots (flat, slightly circular red lesions on abdo + front of chest) normal venous stars (2-3cm lesions on dorsum of feet, legs, back, lower chest) due to elevated venous pressure FACE Eyes

sclera jaundice, anaemia, iritis (IBD) cornea Kayser-Flaischer rings (brown-greenish rings around cornea) Wilsons disease (copper storage disease cirrhosis + neuro disturbances, other cholestatic liver disease) iritis IBD xanthelasma (yellowish plaques in subcut tissue in periorbital region due to deposits of lipid) cholesterol, 1o biliary cirrhosis periorbital purpura (following proctosigmoidoscopy) amyloidosis

Parotid glands inspect + palpate get pt to clench masseter, parotid behind masseter + in front of ear bilat enlargement alcoholism, mumps tender, warm swollen parotititis post acute illness or surgery lump mixed tumour (pleomorphic adenoma), Ca (may facial nerve palsy) feel in mouth parotid calculus (at duct orifice, opp upper 2nd molar) Submandibular gland palpate with one finger on floor of mouth beside tongue + fingers behind body of mandible enlargement calculus, chronic liver disease Mouth breath faulty oral hygiene, fetor hepaticus, ketosis, uraemia, alcohol, paraldehyde, putrid, cigarettes teeth status, real/false (remove false teeth) gums hypertrophy (phenytoin, gingivitis, pregnancy, leukaemia (monocytic), scurvy pigmentation (heavy metals, drugs e.g antimalarials or OCP, Addisons disease, Peutz-Jeghers syndrome, malignant melanoma) bleeding oral thrush immunosuppression, broad spectrum antibiotics, bad oral hygiene, Fe def, DM mouth ulcers aphthous most common, cause unknown. May occur with Crohns + celiac disease tongue macroglossia congenital (e.g Downs), endocrine disease, tumour infiltration (e.g haemangioma, lymphangioma), amyloid infiltration (amyloidosis) lingua nigra (black tongue from accumulation of keratin) aetiology unknown geographical tongue (slowly changing red rings/lines) riboflavin (vit B2) def coating smokers, rarely sign of disease leucoplakia (white thickening of mucosa of tongue + mouth) premalignant causes: Sore teeth, Smoking, Spirits, Sepsis, Syphilis also occurs on larynx, anus, vulva

atrophic glossitis (smooth tongue, poss. erythematous) causes: FE, folate, vit B (12) def, alcoholism, carcinoid syndrome ulceration lips angular stomatitis (vit B6, B12, folate, Fe def), ulceration, Peutz-Jeghers pigment. telangiectasia (on lips + tongue) hereditary haemorrhagic telangiectasia CERVICAL/AXILLARY REGION lymphadenopathy left supraclavicular node advanced gastric or other GI malignancy, lung Ca (this node with gastric Ca = Troisiers sign) acanthosis nigricans brown/black velvety elevations of epidermis due to confluent papillomas, in axillae + nape of neck. Rare ass. with GI Ca (stomach), lymphoma, acromegaly, DM

CHEST Spider naevi Gynecomastia (unilat/bilat, may be tender) chronic liver disease cirrhosis (esp. alcoholic), chronic active hepatitis spironolactone (often used to treat ascites) alcoholics without liver disease due to damage to Leydig cells of testis drugs digoxin, cimetidine Body hair ABDOMEN Expose from nipples to pubic symphysis Inspect - scars previous surgery or trauma (old white, recent pink) - stomas - prominent veins determine direction of flow portal HT portalsystemic flow thru umbilical veins occurs so flow away from umbilicus (caput Medusae) IVC obstruction engorged veins providing collateral circulation for blood from legs so direction is towards the heart - striae Cushings, ascites, pregnancy, recent weight gain - bruising over flanks (Grey-Turners sign) acute pancreatitis blue umbilicus haemoperitoneum + acute pancreatitis (Cullens sign) - pigmentation - herpes zoster lesions can be cause of abdo pain with no apparent cause - Sister Joseph nodule metastatic tumour deposit in umbilicus (b/c close ot peritoneum) - visible peristalsis normal in thin ppl, can be intestinal obstruction e.g pyloric obstruction as result of peptic ulceration or tumour - pulsations - ?AAA
10

- distension fat, fluid, fetus, flatus, faeces, filthy big tumour look at umbilicus buried in fat obesity, everted + down fluid, up pregnancy - localised masses - ?enlargement of abdo/pelvic organ - hernia (protrusion of intra-abdominal structure through abnormal opening) Palpation light palpation (of 9 regions) tenderness, rigidity, masses deep palpation organomegaly (liver, spleen, kidney), deeper masses guarding (resistance to palpation due to contraction of abdo muscles) tenderness, anxiety, peritonitis (if involuntary) abdo masses: site temperature tenderness size + shape surface - reg vs irreg edge reg vs irreg consistency hard vs soft mobility + movement with insp pulsatility can get above it? Percussion/Palpation liver begin RIF, advance hand with each expiration, keep still in inspiration feel edge +/- surface of liver hard/soft, ?tender, ?irreg, ?pulsatile measure liver span (in midclavicular line) normal palpable liver: ptosis due to emphysema, asthma, subdiaphragmatic collection, Riedels lobe (tongue-like projection of liver from right lobe) note: small liver common is common in advanced cirrhosis gallbladder s/t palpable below right costal margin Murphys sign if cholecystitis suspected pt catches his/her breath when inflamed g/bladder presses on examiners hand lying at costal margin note Courvoisiers law: if g/bladder enlarged + pt jaundiced cause is unlikely to be gallstones more likely Ca pancreas or lower biliary tree obstructive jaundice spleen enlarges inf + med so feel for edge below umbilicus in midline initially use 2 handed technique with left hand placed post-lat over left lower ribs with right hand on abdo below umbilicus note: if not palpable, roll pt onto right side + repeat palpation to confirm spleen: cant get over it palpable notch moves inf-med on insp
11

not usually ballotable percussion note dull friction rub occasionally heard over spleen kidneys bimanual method of balloting kidneys e.g right kidney, put left hand underneath back with heel of hand under right loin, place right hand over right upper quadrant ascites percussion note over abdo normally resonant out to flanks early sign of ascites (2L fluid) = dull percussion note in flanks late ascites = dullness closer to midline shifting dullness percuss out to left flank until dullness reached, mark pt, roll pt towards examiner, wait 30s-1min, then repeat percussion over marked pt. Present if area of dullness has changed to resonance. fluid thrill ask assistant to place medial edges of both palms on centre of abdo, examiner flicks side of abdo wall + pulsation (thrill) felt by hand placed on other abdo wall other abdo masses stomach + duodenum - gastric outlet obstruction succussion splash (shake pt side to side + listen for splashing sound) pancreas swelling above umbilicus aorta arterial pulsation in epigastrium bowel constipation, sigmoid colon often palpable, Ca rare bladder (impalpable if empty) - regular, smooth, firm + oval-shaped swelling Auscultation bowel sounds soft gurgling character, occur intermittently. Describe as present/absent paralytic ileus complete absence (>3mins) obstructed bowel louder, high pitched sound, tinkling intestinal hurry/rush (diarrhoea etc) loud gurgling sounds (borborygmi) friction rubs abnormality of parietal + visceral peritoneum due to inflamm., rare venous hums heard between xiphisternum + umbilicus, indicates portal HT, rare bruits over liver HPCC, acute alcoholic hepatitis, AVM, transiently after liver bx renal (either side of midline above umbilicus) renal artery stenosis epigastrium chronic intestinal ischaemia from mesenteric arterial stenosis spleen tumour of body of pancreas, splenic AV fistula GROIN Genitalia Lymph nodes inguinal lymph nodes Hernial examination LEGS Bruising liver disease Oedema liver disease Neuro signs (e.g coarse tremor, peripheral neuropathy, memory loss) alcoholism

12

OTHER Rectal examination inspect

palpate

(haemorrhoids, skin tags, rectal prolapse, anal fissure, anal fistula, anal warts, anal Ca, pruritus ani, excoriation from diarrhoea) ask pt to strain incontinence, leakage of faeces/mucus, abnorm descent of perineum, pain external sphincter tone normal vs reduced ant wall of rectum prostate in , cervix in post wall, lat walls check for blood/malaena/mucus/pus/faecal colour on glove

BP renal disease CVS cardiac failure, cardiomyopathy, constrictive pericarditis Temperature infxn Nodes, breast + chest if evidence of malignant disease e.g firm, irreg hepatomegaly

13

HAEMATOLOGICAL EXAM Position the patient as for a gastrointestinal exam. General inspection racial origin (thalassaemia), pallor, jaundice, bruising, scratch marks Raynauds phenomenon/digital infarction Pallor Evidence of rheumatoid or gouty arthritis Feltys syndrome is an association of RA, splenomegaly and neutropaenia (it can also be associated with thrombocytopaenia, haemolytic anaemia). Gout may be a manifestation of a myeloproliferative disease. Radial pulse Tachycardia due to anaemia (increased CO). Petechiae/purpura/scratch marks on arms ?Hess test On the upper arm, inflate a blood pressure cuff 10mmHg greater than the diastolic pressure; wait for five minutes and deflate the cuff, waiting another five minutes before interpreting the result: <5 2 2 petechiae per cm is normal, >20 per cm is definitely abnormal, suggesting thrombocytopaenia, abnormal platelet function or capillary fragility. Epitrochlear nodes Place the palm of the right hand under the patients right elbow, with the thumb palpating proximal and slightly medial to the medical epicondyle; an enlarged node is pathological (local infection, non-Hodgkins lymphoma). The left hand is used on the left elbow. Axillary nodes central, lateral, pectoral (medial), infraclavicular, subscapular Jaundice/subconjunctival haemorrhage/injection (polycythaemia) Hypertrophy of gums (AML) Atrophic glossitis (Fe deficiency anaemia, megaloblastic anaemia) Cervical and supraclavicular nodes Bone tenderness spine (fist), sternum and clavicles (heel of hand), shoulders (squeeze together) Abdominal exam especially splenomegaly, hepatomegaly, para-aortic nodes, inguinal nodes Para-aortic lymphadenopathy can be detected as a central deep abdominal mass; this strongly suggests lymphoma or lymphatic leukaemia. Testicular masses PR exam Petechiae/purpura (HSP)/scratch marks on legs Leg ulcers Leg ulcers may occur above the medial or lateral malleoli in association with haemolytic anaemia (as a result of tissue infarction due to abnormal blood viscosity). Can also occur with thalassaemia, polycythaemia, thrombotic thrombocytopaenic purpura, macroglobulinaemia. Popliteal nodes Peripheral neuropathy (vitamin B12 deficiency)

14

Fundoscopy An increase in blood viscosity (macroglobulinaemia, myeloproliferative disease) can engorge retinal vessels and later cause papilloedema. Haemorrhages can occur because of a haemostatic disorder.

15

NEUROLOGICAL EXAM 1. Sitting Cranial nerves, Upper Limb tone, power, reflexes, coordination and sensation 2. Standing Lower limbs inspection and gait 3. Supine Lower limbs tone, power, reflexes, coordination and sensation CRANIAL NERVE EXAMINATION General Inspection posture hemiplegia or inattention wasting proximal, distal, generalised, symmetry movements absence of movement, fasciculations, fibrillations, tremor, chorea, myoclonus, hemiballismus, dystonia, diskinesia skin Caf au lait, cutaneous angioma, shingles, scars CN 1 - Olfactory Nerve have you noticed any change in your sense of smell? check nasal passages are patent - occlude one nostril and sniff through other CN 2 - Optic Nerve pupils at rest - shape, size and symmetry visual acuity - wear spectacles if required - test each eye separately: 1. Snellens chart at 6m or reading chart at 12 inches 2. count fingers at 3 meters ! 1 meter 3. hand movements 4. light and dark differentiation visual fields - with moving fingers, test both eyes simultaneously remove spectacles optic fundi CN 3, 4 and 6 - Oculomotor, Trochlear And Abducens pupillary light reflexes direct, consensual ptosis, lid lag eye movements - keep head still, follow finger in H-shaped horizontal / vertical pursuit eye movements: LR6SO4AO3 ! abnormal convergent gaze ! horizontal nystagmus at 30 - vestibular lesion, cerebellar lesion, drugs ! vertical nystagmus ! diplopia at extremes?

16

CN 5 - Tigeminal Nerve sensation - light touch in 3 divisions, on both sides of face + corneal reflex wasting - clench jaw and palpate masseters and temporal fossa power - open jaw against resistance CN 7 - Facial nerve abnormal movements - fasciculations and abnormal movement at rest symmetry at rest - forehead wrinkles, nasolabial folds, angle of mouth power - wrinkle forehead, shut eyes tightly, smile, show teeth, puff cheeks CN 8 Vestibulo-Cochlear nerve usually wear hearing aid? otoscopy - inspect ear canals and ear drums for obstruction hearing - patient repeats whispered numbers from 1 arm length distance from ears tuning fork testing - if hearing decreased determine if hearing loss is sensorineural or conductive (256Hz) Rinnes test placed on mastoid process, then prongs close to ear normally AC (air conduction) > BC (bone conduction) place 256Hz on mastoid process when tone diminishes place near ear can the patient hear the tone? Rinnes positive sensorineural deafness Rinnes negative AC absent following diminution of BC tone (conductive hearing loss) Webers test - base of tuning fork placed on middle of patients forehead ! where is tone heard loudest (middle, or to side)? unilateral sensorineural deafness " louder in normal ear conduction deafness ! louder in bad ear (as if compensating for # conduction)

CN9, 10 and 12
symmetry - observe soft palate at rest + during phonation aaaahhhh penlight sensation - sensation on posterior tongue normal on both sides? ! gag-reflex CN9/10 swallowing - ask if patient ever has difficulty swallowing?
17

! swallow saliva or small sips of water speech repeat eeeeee - intact phonation ! swallow water " repeat eeeeee and presence of gurgling after swallowing inspection - tongue at rest in floor of mouth - wasting or fasciculations protrude tongue: ! unilateral weakness " tongue deviates towards weak side ! bilateral weakness " tongue cannot be protruded power push tongue against finger on cheek rapid alternating movement " say la la la la la rapidly

CN 11 - Accessory Nerve observe SCM and trapezius at rest ! wasting ! fasciculations ! abnormal sustained contractions (dystonia or torticollis) power: ! turn head to side and return to face me ! push against hand, palpate ipsilateral SCM ! shrug shoulders GENERAL NEURLOGICAL EXAMINATION Upper limb (Sitting) inspection shake hands power drift arms extended forwards, supinated ! close eyes tone supination/pronation; elbow and wrist flexion/extension; raise arms and drop ! cogwheel rigidity, myotonia, spasticity power symmetry reflexes biceps C5,6, triceps C7,8, finger C8 grade 0 - 4 coordination finger-nose-finger, RAM, rebound (cerebellar hypotonia) sensation pain, vibration, proprioception, light touch, 2 point discrimination, stereognosis, graphaesthesia, sensory inattention Lower limb (Standing ! Supine) inspection posture standing from bed gait walk away, turn quickly, walk back, heel-toe walking, walk on toes, walk on heels, squat and stand Romberg test stand feet together, eyes closed, try pushing tone proximal tone, rigidity, spasticity, clonus, pendular movements on reflex power - symmetry, particular groups, proximal, distal, general

18

reflexes knee L3,4, ankle S1, plantar reflex coordination heel-knee-shin, RAM (toe tapping) sensation pain, vibration, proprioception, light touch

Higher mental function overall sensorium greet and shake hand ask hand dominance level of consciousness alert, stuporous etc.. demeanour regard for surroundings attitude regard for examiner emotional state orientation person, place, time, day of week, month, season, year concentration serial 7s retention teach and ask patient to remember an address- allow patient to learn long-term memory address, phone-number, childrens names, length of time in hospital language observe language (fluency, approp. vocab, grammar) ! nomation watch, strap, face ! repitition no ifs, ands or buts ! follow instruction touch left ear with right thumb, and stick out your tongue short-term memory recall address 35 Lake Road, Takapuna

Notes: Movements absence of movement tremor resting or intention chorea irregular spasmodic involuntary movements, often with hypotonia, lesion site unknown myoclonus shock-like contractions of muscle groups UMN lesion hemiballismus involuntary contracture of proximal limb musculature causing jerking, flinging movements of extremity lesion of/near contralateral subthalamic nucleus lesion dystonia / athetosis abnormal (hypo/hyper) tone of muscles resulting in impairment of voluntary movement + slow, writhing movements dyskinesia uncontrollable movements due to # concentration of L-Dopa Parkinsons fasciculations irregular non-rhythmical contractions of groups of muscle fibres, LMN coarser contractions than fibrillations fibrillations rapid contractions of muscle fibrils, but not whole muscle; caused by: motor neuron disease ventral root compression (disc prolapse, ALS)
19

perpheral neuropathy (diabetes) primary myopathy thyrotoxicosis

Grading power
0 no movement 1 flicker 2 movement without gravity 3 movement overcoming gravity 4 moderate power against resistance 5 normal power Myotomes Shoulder abduction adduction Elbow flexion extension Wrist flexion extension Fingers flexion extension abduction adduction Hip flexion extension Knee flexion extension Ankle plantarflex dorsiflexion C5,6 C7,8 C5,6 C7,8 C6,7 C7,8 C7,8 C7,8 C8,T1 C8,T1 L2,3 L5, S1 L5,S1 L3,4 S1,2 L4,5

Reflexes biceps C5,6 ! brachioradialis C5,6 triceps C7,8 finger jerk C8 knee L3,4 ankle S1 plantar upwards plantar reflex UMN/pyramidal lesion or coma Grading reflexes 0 absent + - present but # ++ - normal +++ - $ ++++ - pathologically $ clonus
20

Dermatomes C4 shoulder tip C5 lateral upper arm C6 thumb C7 middle finger C8 little finger T1 medial elbow T2 axilla T4 nipple T10 umbilicus L1 inguinal L2 lateral thigh L3 anteromedial knee L4 medial maleolus L5 big toe and lateral leg S1 sole and lateral foot S2 posterior thigh S3,4,5 perianal area, coccyx

21

EXAMINATION OF THE RESPIRATORY SYSTEM

Introduction General Inspection - The patient can be lying 45, or sitting on the side of the bed. - Observation from the end of the bed for presence of oxygen mask or nasal prongs, pulse oximeter, sputum pot (inspect the sputum volume, type (purulent, mucoid, or mucopurulent, and presence of any blood), inhalers, or peak-flow meter. - General inspection: o Awake and alert, general comfort, cachexia. o Comment on the patients ability to speak and quality of the voice. o Is the patient cyanosed? (colour of lips). o Skin appearance pallor? o Work of breathing speaking in sentences, nasal flaring, tracheal tug, use of accessory muscles (sternocleiomastoids, platysma, and strap muscles of the neck used to elevate the shoulders and improve chest expansion), and count the respiratory rate. Hands - Look at the hands: o Warmth. o Colour: ! Peripheral cyanosis finger pulps, and nail bed. Cyanosis is due to the presence of deoxygenated Hb in the superficial vessels. DeoxyHb must be >5g/100mL, or SaO2 must be <90% for peripheral cyanosis to be obvious, and even more for central cyanosis (so it is a late sign of hypoxaemia). An anaemic patient will require more desaturation for cyanosis to be evident. ! Pallor palmar creases. o Clubbing look at the nail angle. o Nicotine stains. - Feel the pulse for rate and presence of pulsus paradoxus. - Hold out arms in front with fingers spread CO2 retention flap (asterixis). - Comment on blood pressure and that it may be indicated to confirm pulsus paradoxus (hyperinflated lungs restrict cardiac filling, leading to reduced cardiac output and a fall in blood pressure on inspiration) characteristic of severe asthma. Face - Eyes: o Inspect the eyes for Horners syndrome caused by apical lung tumour compressing the sympathetic nerves in the neck look for partial ptosis, miosis, and anhydrosis. o Conjunctival pallor.

22

o Subconjunctival haemorrhage. Nose: o Inspect for patency. o Inspect for presence of nasal polyps. o Is there septal deviation? Mouth: o Moisture. o Pharynx for infection, and tonsillar enlargement. o Tongue colour of underside (central cyanosis).

Neck - Comment on JVP, and that it may be indicated for evidence of cor pulmonale. - Palpate lymph nodes of the neck submental, submandibular, posterior auricular, jugular chain, supraclavicular, and posterior triangle. - Palpate the position of the trachea, is there a similar gap on each side? Chest - Expose the chest: - Inspection: o Comment on presence of scars (previous surgery, chest drains). o Presence of pectus carinatum (outward) or pectus excavatum (inward), or Harrisons sulcus (inward displacement of lower ribs). o Comment on the symmetry of the chest. o Comment on use of accessory muscles intercostal indrawing (increased negative pressure in the thoracic cavity). o Observe chest expansion comment on movement of the chest wall, and symmetry. - Palpation: o Measure chest expansion on the chest place hands firmly on the chest with fingers extending around the sides. The thumbs should almost meet in the midline and lifted slightly off the chest so they are free to move with respiration. Thumbs should move about 5cm apart. o Palpate the apex beat if it is impalpable, it may mean the lungs are hyperinflated. - Percussion: o Clavicles, supraclavicular fossae, upper, middle, and lower zones, bilaterally. - Auscultation (interpret below): o Include the apices and sides. o Quality normal (vesicular) or bronchial breath sounds. o Intensity normal or reduced. o Added sounds: ! Wheeze inspiratory, expiratory or both. ! Crackles fine or coarse. ! Pleural rub.

23

o Ask the patient to cough to see if any added sounds that are present, disappear. Back - Inspection: o Look for any scars on the back. o Look for abnormalities of the spine, e.g. scoliosis. o Look for increased anteroposterior diameter. o Measure chest expansion on the back place hands firmly on the back with fingers extending around the sides. The thumbs should almost meet in the midline and lifted slightly off the back so they are free to move with respiration. Thumbs should move about 5cm apart. - Percussion: o Upper, middle, and lower zones bilaterally. o Get the patient to bring elbows together to move the scapulae out of the way. - Auscultation as above. - Vocal resonance: o To confirm any signs of consolidation that were picked up on auscultation. o Listen to the chest while the patient says 99, the sound will be muffled over normal lung, and clear over consolidated lung. Other - Comment on the need for a cardiovascular examination, focussing on the signs of cor pulmonale. - Comment on the need of an abdominal examination, focussing on liver signs e.g. ptosis from emphysema, or enlargement from lung cancer metastases. Chest Signs In Common Respiratory Disorders Mediastinal shift None Chest expansion Reduced over affected area Ipsilateral Reduced over shift affected area Heart Reduced over displaced to affected area opposite side (and trachea if massive) Tracheal Reduced over deviation to affected area the opposite side if tension Percussion Dull Dull Stony dull Breath sounds Bronchial Added sounds Crackles

Consolidation Atelectasis Pleural effusion

Pneumothorax

Resonant

Absent or Absent reduced Absent over Absent fluid may be bronchial at upper border Absent/ Absent greatly reduced

24

Bronchial asthma Interstitial fibrosis

None None

Reduced symmetrically Reduced symmetrically (minimal)

Normal/ decreased Normal

Normal/ decreased Normal

Wheeze Fine inspiratory crackles over affected lobes unaffected by cough or posture

25

Surgical Abdominal Examination Preparation Have the patient lying flat with one pillow and arms by their side. Expose the patient from the nipples to knees. Ask the patient to breath regularly and slowly. o If unable to relax the abdo muscles in this position the hips can be flexed to 45 and the knees to 90o. You must sit or kneel beside the patient in order for your hand to be level with their abdomen. Inspection Look generally for cachexia, pallor and jaundice. Assess the patients vital signs reduced circulating blood volume tachycardia, postural hypotension, tachypnoea, vasoconstricion and sweating. Look at the abdomen for asymmetry if asymmetrical note the position, shape and size of any bulge if it changes with respiration. If symmetrical note the shape of the abdomen flat, distended, hollow. Look for scars, sinuses, fistulae, distended veins, visible peristalsis. Watch the patients reaction to coughing or moving. Palpation Ask the patient if they are tender anywhere and palpate this part last. Do a general percussion first. Then start with light palpation systematically over all areas of the abdomen. Assess the degree of tenderness: - mild just causes pain - moderate guarding - severe percussion Do deep palpation next for masses and normal solid viscera (liver, spleen, kidneys). If a mass is found describe its position, shape, size, surface, edge and composition (consistence, fluctuation, fluid thrill, resonance, pulsatility). Palpate the supraclavicular fossa for lymph nodes. Feel the hernial orifices (external inguinal ring, femoral canal, umbilicus) at rest and when the patient is coughing. Feel the femoral pulses. Examine the external genitalia. Percussion Percuss over the whole abdomen and any masses that are found. Masses can be percussed to feel for a thrill. Percuss for shifting dullness seen in ascites. Percussion can also be used to assess the extent of a tender area. Auscultation Listen for bowel sounds:

26

normal low pitched gurgles occurring every few seconds absent no peristalsis. If heart and breath sounds are heard over a 15-30s period but no bowel sounds there is probably a paralytic ileus. - distension high pitched tinkling sounds. - increased peristalsis increases the volume and frequency of sounds. Listen along the aorta, renal arteries and iliac arteries for systolic bruits. If obstruction is suspected hold the patient at the hips and shake the abdomen from side to side listening for a succussion splash. Rectal Exam Finish with a rectal exam. Tell the patient what you are going to do. Place the patient in the left lateral position, hips flexed to 90o and knees flexed to 110o. Part the buttocks and inspect the anus and peritoneum looking for skin rashes, excoriation, faecal soiling, blood, mucus, scars, fistulae, lumps, ulcers. Place the gloved and lubricated pulp of your finger on the anus. As you insert your finger pull backwards to counteract the tone in the puborectalis muscle. Note the tone of the sphincter, any pain, any thickening and any masses. If a mass is felt try to decide if it is inside the rectum or outside by testing the mobility of the mucosa over it. Feel for the prostate normally firm, rubbery and bilobed. If a mass is felt at your fingertip ask the patient to strain down to bring the mass closer. Turn you finger around to feel any masses between the rectum and the bladder or uterus. Look at the finger when you remove it to note the colour of the faeces and the presence of blood or mucus.

27

Male Genitalia Observe Penis - wear gloves - retract the foreskin to expose the glans penis - note the size and shape of the penis and the colour of skin - inspect the external urethral meatus - mucosal ulceration (Reiters syndrome, STD etc) - urethral discharge milk the penis if there is a hx of this Scrotum - with patient standing - note the size, shape and symmetry - L usually hangs lower - look for oedema, sebaceous cysts, scabies and other skin lesions - remember to look at the posterior aspect - assess the texture of the body of the penis - palpate the whole length of the urethra down to the perineal membrane. - each testis using fingers and thumb, check that there are two. - normally the testes are of equal size, smooth, firm and not tender. - if absent may be due to surgery, undescended testis, retractile testis. - define the anatomy of the scrotum by feeling for the position and nature of each testis, epididymis and spermatic cord. - feel posteriorly for the epididymis and upwards for the vas deferens and spermatic cord. - feel in the inguinal canal for an undescended testis. - a varicocele will feel like a bag of worms and is not present when lying down (!L renal cell carcinoma and L renal v. thrombosis) - if there is a mass: Is the lump confined to the scrotum? (can you get above it?) Does the lump transilluminate? Does the lump have an expansile cough impulse?

Palpate Penis Scrotum

The perineum and anus examine the perineum, the anal canal and the rectum. Rectal exam - Patient lies on the side with knees drawn up and back to examiner - palpate the prostate gland

Causes of genital skin lesions: Herpes simplex Syphillis Malignancy Chancroid Behcets syndrome (rare systemic) Balanitis (Reiters) Venereal warts

28

Primary skin disease (psoriasis etc) Differential of a scrotal mass: First answer: Can you get above the swelling? Can you identify the testis and epididymis? Is the swelling translucent? Is the swelling tender? Swellings not confined to the scrotum: Hernia cough impulse, reducible, testis palpable, opaque. Infantile hydrocele no cough impulse, not reducible, testis not palpable, translucent. Swellings confined to the scrotum: Testis and epididymis not definable: Chronic hematocele, syphilitic gumma, tumour non-tender, opaque. Torsion, severe epididymo-orchitis, acute haematocele tender, opaque. Hydrocele translucent, non-tender. Testis and epididymis definable: Epididymal cyst translucent. Tumour, tuberculous epididymis non-tender, opaque. Acute epidiymo-orchitis tender, opaque.

29

Examination of the Breast

Introduce yourself to the patient Position and expose the patient. You need to see the entire upper half of the body, so take shirt and bra off. Have the patient initially sitting upright, then position at 45 with arms relaxed at the sides. General inspection LOOK at both breasts at rest Look at: asymmetry of the breasts (normal to have some slight asymmetry) the size and contour of the breasts any skin changes (puckering, ulceration, nodules/lumps, loss of skin integrity, discolouration, peau de orange) any changes in the nipples and areolae (are both nipples present? Are there accessory nipples? retraction, displacement, deviation, discolouration, Pagets disease of the nipple, any evidence of discharge look in the bra to check for discharge; what colour is it?) the arms, the axillae and the supraclavicular fossa to check for enlarged lymph nodes, lymphoedema, distended vein, muscle wasting Ask the patient to raise her hands above her head Look for: smooth flow of action (watch the breasts move up as she raises her arms) any skin changes or asymmetry which may have been hidden before the skin under the breast you may have to lift it up if you cannot see the entire underside of the breast puckering, lumps, oedema, or ulceration in the axillae Ask the patient to press her hands against her hips This tenses the pectoral muscles to reveal any lumps that may not have been visible before It will accentuate any tethering or skin fixation. It also accentuates any lumps that are fixed/tethered to the muscles beneath. PALPATE both breasts Position patient at 45 as above. It may be helpful to have the patient with the left arm behind her head, lying on her right side when you are palpating the left breast (and vice versa). This brings the breast tissue in the axillae forward. Start with the normal side. This will give you a guide to the normal texture of the breast. Feel the breast with the flat of the fingers. There are 3 accepted methods of palpating the breast pick the one that is right for you. Quadrants (the breast is divided into quadrants, and you palpate outwards form the nipple in each quadrant) -

30

Strip method (the breast is divided into strips and you feel each strip going down then up the next strip) Spiral method (start at the armpit and work towards the nipple in a spiral pattern or vice versa) You can use your other hand to support the breast while you palpate it. It doesnt matter which method you use as long as you make sure you cover the entire breast. Remember under the nipple and the axillary tail. If a lump is found, ascertain: size (in 3D if possible) shape position surface (smooth, lumpy etc) composition (hard, soft, fluid) tethering/fixation to skin (1) tethering/fixation to underlying muscle (2) tenderness temperature 1. tethering = when the lump can be moved independently of the skin within a limited distance. This is due to malignant disease spreading along Coopers ligaments making these shorter and inelastic, and the skin will be pulled inwards as the lump moves. This can be demonstrated by moving the lump from side to side and watching for puckering at extremes of movement (same principle as raising the arms) fixation = when the lump and the skin cannot be moved separately at all. This implicates widespread infiltration of the skin by the underlying tumour. it is difficult to differentiate between tethering and fixation to muscle. To determine the relationship to the muscle, ask the patient to rest her hand on her hip with arm relaxed. Estimate the mobility of the lump in this position (if lump has spread beyond muscle to chest wall it will be immobile even at rest). Now ask the patient to press against her hip to tense the muscle, and re-estimate the mobility of the lump. If mobility is reduced this suggests tethering or fixation to the underlying muscle.

2.

Feel the nipple. If the nipple is retracted, gently try to evert it (remember this may be a normal variant). If there is discharge, find the source by pressing on each part of the breast and areolae. Does it come from one or many ducts? Is it blood, serum, pus, or milk? Take a swab for culture. Palpate the axillae Use the shaking hands method. Ask the patient to shake your hand, but instead of taking your hand, hold you at the elbow. Support their arm in this position, while yu feel all 5 areas of the axillae (4 walls and roof) for enlarged lymph nodes.

31

Palpate the supraclavicular fossae Check for lymph nodes in the supraclavicular area and the lower deep cervical area. GENERAL EXAMINATION ARMS : for evidence of swelling, neurological and vascular abnormalities ABDOMEN: for hepatosplenomegaly and ascites BONES: for tenderness and limited range of movements (often complain of backache) LUNGS: for effusion (may have dyspnoea and pleuritic pain) BRAIN: for mental changes and ask about fitting

32

EXAMINATION OF A HERNIA
Introduction Inguinal Hernia HISTORY: - Age inguinal hernia occur at any age, but the peak times of presentation are first few months of life, late teens to early twenties, and between age 40 and 60. - Occupation work involving heavy lifting. - Local symptoms discomfort and pain dragging, aching sensation in the groin, which worsens over the course of the day. Pain may indicate strangulation. There may also be swelling that is painless. - Systemic symptoms colicky abdominal pain, vomiting, abdominal distension, and absolute constipation. - Was there a known cause? Lifting a heavy weight, persistent coughing, constipation, and other reasons for abdominal strain. - Social history is the lump affecting their ability to work? INSPECTION: - The examination should be started with the patient standing up. - The patient should be fully exposed from the thigh to the upper abdomen. - General inspection: o Scars, obvious lumps and swellings, and patient comfort. - Inspect the lump from the front: o Comment on the site and shape of the lump. o Does the lump extend down into the scrotum, and are there any scrotal swellings? o Are there any swellings on the normal side? 10% of hernias are bilateral. PALPATION: - Display the key landmarks symphysis pubis and ASIS are the only landmarks palpable comfortably the pubic tubercle is 3cm lateral to the symphysis pubis. Work out where the inguinal ligament would be between ASIS and pubic tubercle, and the internal ring is at the midpoint of this. - Feel the lump from the front: o In males examine the upper edge with thumb and index finger to distinguish scrotal swelling from a hernia if you cannot feel its upper edge, it is likely to be an inguinal hernia, because it will pass into the inguinal canal. - Feel the lump from the side: o Stand at the side of the patient, on the same side as the hernia. o Place one hand on the small of the back to support the patient, and place your examining hand on the lump with fingers and arm roughly parallel to the inguinal ligament. o Decide on:

33

Position usually above and medial to the pubic tubercle (i.e. the position where the hernia reduces into the abdominal wall). ! Temperature skin may be hot if hernia is strangulated. ! Tenderness painful if strangulated. ! Shape usually pear-shaped with the stalk at the external ring. ! Size. ! Tension. ! Composition solid, fluid, gaseous. o Is there an expansile cough impulse? compress the lump firmly with fingers, and ask the patient to turn their head to the opposite side, and cough. If the swelling expands (i.e. gets bigger and more tense) with coughing, there is a positive cough impulse. This is almost diagnostic of a hernia, but a negative test does not rule out a hernia, because there may be adhesions. Note if the cough impulse is fast or slow (abnormal) rising. At this point, lay the patient on the bed for reducing. o Is the swelling reducible? Press firmly on the lump to reduce tension. Then gently squeeze the lower part of the swelling. Lift it up towards the external ring, and slide your finger upwards and laterally towards the internal ring to see if the hernia can be kept controlled by pressure at this point. If the lump reduces into or through the abdominal wall at a point above and medial to the pubic tubercle, it is an inguinal hernia. If it can be reduced below and lateral to the pubic tubercle, it is a femoral hernia. o Does the hernia reappear on removing your hand? An indirect hernia will seem to slide obliquely along the line of the canal, whereas a direct hernia will project directly forwards.

PERCUSSION AND AUSCULTATION - Percuss and auscultate the lump: o For resonance and bowel sounds, if gut is involved. Palpate the other side for bilateral herniae. Get the patient to cough while feeling the inguinal canal on the other side, even if there is no lump on palpation.

SCROTAL EXAMINATION (as for genitourinary examination) Is the hernia direct or indirect? - An indirect inguinal hernia protrudes through the internal inguinal ring (just above the mid-point of the inguinal ligament halfway between the pubic tubercle and the ASIS). - An indirect hernia can be controlled by pressure over the internal ring. A direct inguinal hernia pushes into the inguinal canal posteriorly through a weakness called Hasselbachs triangle (bordered by rectus sheath, inferior epigastric vessels and inguinal ligament. - An indirect hernia can (and often does) descend into the scrotum. - A direct hernia reduces upwards and then backwards, and can be controlled by pressure over the external ring.

34

A direct hernia rarely extends into the scrotum. It may be difficult to distinguish between these two types of inguinal hernia in obese patients. Femoral Hernia Examination is as above. Extra Points About Femoral Herniae: - Unusual before the age of 50 years. The majority are women aged 60 to 80 (but in women, the most common hernia in the groin is still an inguinal hernia). - Other history as for inguinal herniae. - Note that femoral herniae are often bilateral. - The neck of a femoral hernia (i.e. the point at which it disappears into the abdomen) is below and lateral to the pubic tubercle. - The majority of femoral herniae are small and almost spherical, feel firm and are dull to percussion because they contain omentum, and they often cannot be completely reduced and have a negative cough impulse because of adherence to peritoneum. - Femoral herniae tend to smooth out the groin crease, whereas inguinal accentuates it. Inguinal hernia External ring Pubic tubercle Femoral canal Femoral hernia

Differential Diagnosis - A solitary lump above the inguinal ligament: o Inguinal hernia. o Undescended testis (will present as a lump exiting the external ring feel for presence of both testes but will not have a cough impulse). o Cyst of the canal of Nuck. o Encysted hydrocoele or lipoma of the cord. o Iliac node. o Large femoral hernia (rare). - A solitary lump below the inguinal ligament: o Femoral hernia. o Lymph node.

35

o Saphena varix sensation of a jet of water on palpation, disappears when supine. o Femoral aneurysm will be pulsatile. o Psoas abscess associated with fever, flank pain, and flexion deformity. o Ectopic testis. o Lipoma.

36

NECK EXAM Since the neck exam is a surgical examination it is appropriate to proceed straight to the neck to begin the examination. General inspection esp. obvious signs of thyroid disease Inspection of the neck look from the front for any masses, scars, muscle wasting, skin changes, dilated veins look from the side to assess as to whether any swelling is localised or diffuse Look at the eyes from the side for proptosis Have the patient take a sip of water and swallow to see if the mass moves If the mass moves it is attached to the larynx which means it is typically a thyroglossal cyst or a thyroid mass. Have the patient stick out their tongue to see if the mass moves If the mass moves it is fixed to the hyoid bone. If appropriate test for lid lag Have patients follow your finger from the upper pole of the visual field to the lower pole; in hyperthyroidism the upper lid lags behind the descent of the eyeball. Pembertons sign Lift both arms as high as possible; watch the face for signs of congestion and cyanosis. Look at the neck for venous congestion. Ask the patient to take a deep breath in a listen for stridor. From behind: Palpate thyroid gland Describe the gland in terms of (approximate) size and whether a lower pole is palpable, shape incl. isthmus, consistency (diffuse goitre, multinodular, solitary nodule, hard), tenderness, relation to local structures. Check the gland for a thrill Have the patient sip and swallow water again while palpating the gland Palpate cervical lymph nodes preauricular, submandibular, submental, posterior auricular, occipital, jugular chain (actually wrap behind SCM), supraclavicular If a lymph node is felt it should be described in terms of position, size, shape, surface, rubbery, relation to underlying structures, local skin changes, tenderness etc. Palpate anterior and posterior triangles From the front: Palpate thyroid gland using thumbs Palpate trachea A displaced trachea may be due to a retrosternal goitre. Carotid arteries Absence of a carotid pulsation may be due to infiltration by thyroid Ca. Palpate parotid gland Percuss for a retrosternal goitre Auscultate for thyroid bruits

37

THYROID EXAM If asked to examine a patients thyroid gland it is pertinent to begin as always at the hands. General inspection signs of hypothyroidism/thyrotoxicosis Thyrotoxicosis Inspect hands for a fine tremor (place a piece of paper over extended hands to accentuate) Onycholysis Thyroid acropachy (clubbing, but not called clubbing) Palmar erythema, warmth and sweatiness Pulse (sinus tachycardia, AF) The pulse may have a collapsing nature due to high CO ?Proximal myopathy and brisk reflexes Inspect eyes esp. sclerae visible below the lower pole of the iris Complications of exophthalmos include chemosis and conjunctivitis. Test lid lag Examine neck as above Examine chest for flow murmurs and CHF Check for pretibial myxoedema (elevated dermal nodules and plaques) Caused by mucopolysaccharide accumulation. ?Proximal myopathy and brisk reflexes in the lower limb Hypothyroidism Inspect hands for peripheral cyanosis (reduced CO) Cool and dry peripheries (may also be swollen) Thickened skin due to mucopolysaccharide deposition Hypercarotenaemia on the palms There is a decrease in hepatic metabolism of carotene. Pallor Pulse (slow, small volume) Slow relaxation of biceps reflex Inspect face for hypercarotenaemia and xanthelasma Alopecia/dry hair Periorbital oedema Thinning of the lateral third of eyebrows Swollen tongue/croaking speech Examine neck as above Examine chest for pericardial and pleural effusions Delayed relaxation of reflexes Non-pitting oedema Peripheral neuropathy

38

PERIPHERAL VASCULAR EXAM

Supine exposed to underwear General inspection

Hands
colour cyanosis splinter haemorrhages capillary refill anaemia xanthomata temperature

Arms
radial pulse rate, rhythm radio-radial delay brachial pulse character, volume BP lying, standing, both arms carotid pulse carotid bruits aortic bruit

Abdomen
abdominal aortic pulse abdominal, aorto-iliac bruits

Legs
colour capillary refill hair distribution skin condition dry/flaky, pigmentation, swelling, ulceration (check between toes), blistering, bruising nails thick and crusty wasting - toe pulp wasting, muscles posterior aspect of legs + pressure points calluses leg temperature femoral pulse, femoral bruit, radiofemoral delay
39

popliteal pulse dorsalis pedis pulse posterior tibial pulse

Special tests
BP ABPI Beurgers angle reactive hyperaemia

Notes ABPI Ankle-Brachial Pressure Index brachial BP systolic pressure determined with sphygmomanometer ankle BP systolic pressure determined with sphygmo cuff + Doppler USS ABPI ankle systolic / brachial systolic normal 1.0 1.2 ischaemic arterial disease 0.5 (intermittent claudication) Buergers angle (vascular angle): raise leg until turns white record angle normal legs toes remain pink at 90 ischaemic leg toes turn white at 15 - 30 pedal artery pressure estimation height (cm) between sternum and heel at the vascular angle Reactive hyperaemia: sphygmomanometer cuff inflated above systolic occlude for 5 minutes transient distal ischaemia produced by cuff pressure results in vasodilation and venous pooling a period of hyperaemic blood flow following cuff release ! normal leg 1 2 seconds ! ischaemic leg may never appear time between cuff release and red-flush of skin ! fall in ABPI reactive hyperaemia correlates to the # ABPI following exercise treadmill testing has greater indication of patients overall disability and cardiorespiratory function

40

GALS Examination Exposure Underwear Questions Do you get pain/stiffness in your arms, legs or back? Do you have trouble getting up or down stairs? Can you dress yourself completely without difficulty? Gait Ask patient to walk in a straight line and do a U-turn briskly. Look for smoothness and symmetry of leg, pelvis and arm movements. Is stride length normal? Is there an unusual gait? Ability to turn quickly. Spine While standing: Observe the back - it is straight, are the iliac crests level, is there normal and symmetrical muscle bulk, comment on lumbar lordosis and thoracic kyphosis. Ask the patient to touch the toes and assess the distraction of the lumbar spine. From the side - look at spinal curvatures. Neck - assess cervical spine lateral flexion and trapezius mid-point tenderness. Arms Ask the patient to take a seat. Hands - observe looking for nail changes, swelling, deformities, scars, wasting etc. Ask the patient to pronate and supinate to observe both sides as well as testing function. - squeeze the MCPs en bloc looking for tenderness - Ask the patient to make a tight fist, pincer grip and prayer sign. Elbows- Ask the patient to fully extend and flex their elbows. - Look at elbows (psoriasis) - Palpate for nodules. Shoulders - Check for full abduction and external rotation by asking them to put their hands behind their head and pull back. Legs Ask the patient to lie down. Feet - Inspect the nails, soles, toes and between toes looking for nail changes, deformities, ulcers, swelling, scars, callosities, etc. - squeeze the MTPs en bloc for tenderness. Knee - Look for swelling, scars etc. - Do the bulge and wipe sign - Flex and extend the knee joint while feeling for crepitus Hips - Check for normal internal rotation of the hip joint at 90o flexion.

41

Orthopaedic examination of the spine

Key points in history Red flags Any symptoms of neurological disease Weakness Numbness Parasthesiae Any features suggestive of cauda equina syndrome Genitourinary symptoms (think about possible prostate Ca here also) Saddle anaesthesia Bilateral focal neurology History of traumatic injury ?Risk of Steroid use osteoporosis, Age >50 years vertebral # Recent weight loss Risk of Malaise, night sweats or other constitutional symptoms metastatic History of cancer (in another part of the body prostate, breast, colon, disease/tumou thyroid, renal, lung, liver) Fever Risk of infection IV drug use Severe constant night time pain More likely to be infection, Pain worse on lying down tumour or inflammatory Aim to distinguish treatable causes of back pain from functional back pain. You want to avoid worsening disability (eg permanent cauda equina) and prevent potential health problems (eg lung disease associated with RA, ankylosing spondylitis). Ruling out possible traumatic injury eg fracture, infection, tumour or cauda equina is most important. Also consider rheumatological disorders eg ankylosing spondylitis, rheumatoid arthritis as a cause of pain. Yellow flags Factors that may cause disability in those with functional back pain Psychosocial factors Attitudes and beliefs towards illness Behaviours (sickness behaviours) Issues around compensation Family and work issues Diagnostic and treatment issues

42

Examination of the spine Introduce yourself to the patient Expose the patient appropriately shirt off, in shorts/underwear Gait observe them walking - normally - on their toes (tests balance, S1-S2 function) - on their heels (tests L4-L5 function) Look for limping/antalgic gait, foot drop (S1-2), trendelenberg gait (hip adductor weakness may suggest hip pathology?) stiff hip and short leg gait. Observe the time spent on each leg, time spent in swing-through phase, fluidity of movement and posture. Watch them as they walk and when they turn to come back; they should be able to turn in one fluid movement if not, it may suggest a problem with balance (observe carefully particularly in elderly puts at risk of falls). From the front, sides, back and above.

LOOK!

Wasting Confirm scoliosis by asking the patient to sit (will disappear if due to LLD; then bend forward (visible rib Alignment Increase of normal lumbarhump if scoliosis is fixed) or due to hip lordosis spondylolisthesis, Flattened lordosis prolapsed disc, OA, infections, ankylosing spondylitis. Scars level of the shoulders and pelvis. Simian Posture Check thefixed kyphosis by asking patient to bracestance in spinal stenosis open up the Confirm back the shoulders to
chest. Angular kyphosis = fracture, TB or congenital

Swellings bony and soft tissue (including supraclavicular lymph nodes) Symmetry
Also look for paravertebral muscle spasm, hairy patches, pits in the skin, fat pads (spina bifida occulta), or caf-au-lait spots (neurofibromatosis). FEEL for bony tenderness and stepping between vertebrae. Start at the top of the spine and move down. Remember to feel the IV discs and the sacroiliac joints. Tenderness at the lumbosacral junction is common with prolapsed disc. Feel the paravertebral muscles for tenderness or spasm. Other areas to check include the cervical lymph nodes, thyroid (?mets) and for renal angle tenderness (?referred pain). Percuss the spine with the patient bent forwards/standing straight using a fist and starting at the root of the neck down to the sacrum. Tenderness suggests infection.

43

MOVE

watch range and fluidity of movement. Use active movements. Normal range of movement 8-10 cm increase between L1 and S1. <3 cm increase between L1 and S1 is pathological. Comments Ask them, can you touch your toes? Assess degree of spinal movement by placing two fingers on two separate spinous processes or using Schrobers method (1). Ask them to arch their back. Help by steadying the pelvis Ask them to slide their hand down the side of their leg Ask them to twist around to each side. Hold the pelvis steady so they cant use their legs to help. Most rotation occurs in the thoracic spine.

Movement Forward flexion

Extension Lateral flexion Rotation

30 30 to either side, or down to knees 40 (measured between the plane of the shoulders and the pelvis. In practice this is hard to estimate.)

1.

Schrobers method: find the dimples of Venus and mark a point 10 cms above this. Hold the top of the tape measure at the mark and ask the patient to bend forwards. Note any increase in the distance on the tape.

Repeat these movements in the cervical spine. SPECIAL TESTS Straight leg raise tests for sciatica (L4-S1 nerve root irritation) - keeping the knee extended, raise the leg off the bed while watching the patients face. Stop when the patient complains - pain or paraesthesiae down the leg is a positive test - Ignore hamstring tightness. Back pain suggests central disc prolapse - Cross over pain = pain in good leg when raising affected leg - If you get a positive test, confirm by lowering the leg slightly, and trying to reproduce the pain by passively dorsiflexing the foot - Bowstring test = raising leg to level of pain, then bending the knee (no pain) and trying to reproduce the pain by pressing over the popliteal fossa - Well-leg raise = pain in affected leg when the good leg is raised (highly suggestive of nerve root irritation)

44

Femoral stretch test

- tests for femoratica (L2-3 nerve root irritation) - with the patient prone or on their side, bend the knee and extend the hip. Pain with a bent knee, aggrevated by extension of the hip is a positive test.

Tests to distinguish functional back pain from nerve root irritation - ask the patient to sit up with legs straight on the bed. If there is true sciatica, the patient will not be able to do this without bending the knees slightly. - Apply pressure to the head if this aggregates the pain it suggests it is functional - Pinch the skin at the sides. This should not produce deep back pain - Ask the patient to twist around with you holding the pelvis. Note where/if the pain starts. Now ask them to twist around with their arms firmly by their sides the rotation now occurs in the legs and should not lead to pain. If this causes pain again, then it is likely to be functional. Note: these tests are not done routinely Neurology Check for wasting, tone, power, reflexes, co-ordination and sensation. Nerve root S1-S2 L4-L5 L5 L4 L3-L4 Nerve root S1-S2 L3-L4 UMN T5-T6 T7-T8 Dermatome L1 L2 L3 L4 L5 Motor Movement plantarflexion dorsiflexion Dorsiflexion of big toe Inversion of foot Knee extension Comments Extensor hallicus longus very reliable test of L5 quadriceps

Reflexes Reflex Ankle jerk Knee jerk Babinski Biceps and brachioradialis Ticeps Sensation (pin prick and light touch) Area Pocket area Top of thighs Knees Medial calf to top of foot Lateral calf and big toe

45

S1 S2 S3 S4

Side of foot (including little toe) this is the most commonly affected dermatome Back of calf Back of thigh Perianal area

Vascular tests General observations warmth, colour, nails skin, hair, capillary refill Check foot pulses dorsalis pedis, posterior tibial ( + popliteal and femoral if you have time) Check the sacro-iliac joints pelvic compression with patient on their side With patient on their back, flex the hip and knee, and forcibly adduct the hip. Pain suggests sacro-iliac joint involvement, but beware false positives with this test. Examine the hip (check for referred back pain) Examine the abdomen for masses including aortic aneurysm, and kidneys Measure chest expansion (will be decreased in ankylosing spondylitis) Rectal examination for tone and sensation of sphincter, rectal Ca, sacro-coccygeal joint (hold coccyx between thumb (on outside) and forefinger (inside rectum) and see if coccyx is tender and mobile. Vaginal examination in women

46

EXAMINATION OF THE HIP

Introduction Gait Adequately expose the patient e.g. wearing shorts. Do they have any walking aids? Look at the patients shoes for orthotics or other adjustments, and look at the pattern of wear. Watch the patient walking, and observe their gait look for 3 normal stages heel strike, mid-stance, and push off: o Antalgic gait patient will have a quick swing-through phase of the good leg in order to spend less time on the painful leg. o Short leg gait shoulders will fall then rise during walking, if one leg is shorter than the other. o Trendelenburg (moment-sparing) gait patient cannot tilt the pelvis to keep the body straight when one leg is in the swing phase, so the whole upper body is shifted over the pelvis, to keep it level. o Stiff hip gait patients use their lumbar spine to walk this is difficult to pick up. Ask the patient to walk on their heels and tip toes (assesses triceps surae).

Look - Ask the patient to stand in front of you. - Inspect for scars, swelling, lumps, bruising, or skin changes. - Look for muscle wasting (particularly quads, gluteals, and calves), abnormal alignment (e.g. pelvic tilt from leg length discrepancy compare the alignment of both ASIS), fixed flexion contracture (from osteoarthritis), genu varum (bow legs) and genu valgum (knock-knee), and deformity (increased lumbar lordosis). - Observe from the sides and back also. - Trendelenburg test for weakness of gluteus medius and minimus patient stands on one leg, and a positive test is when the pelvis will tilt (towards the bad leg when standing on the good leg, because the pelvis cannot be brought up to maintain level). - Lie the patient down on the bed, watching them for any pain or problems getting onto the bed. - Inspect the legs and feet: o Inspect for scars, swelling, lumps, bruising, or skin changes. o Look at how the legs are positioned when lying. o Look at the soles of the feet for flat feet. - Measure leg lengths: o True leg length from ASIS to medial malleolus indicates hip disease on shorter side. o Apparent leg length from umbilicus to medial malleolus indicates tilting pelvis. - Measure quadriceps circumference for wasting.

47

Feel -

Flex both legs about 90 to bring the knees up and keep them together observe from side on for any length discrepancy, and decide if it is femoral or tibial. Palpate for increased temperature and tenderness: o Femoral head (just lateral to femoral pulse). o Iliac crests. o Anterior superior iliac spines. o Greater trochanters.

Move - Flexion flex the hip and bring the knee towards the chest normal range is 120. Thomas test for fixed flexion deformity place one hand under the lumbar spine to correct lumbar lordosis and flex the hip maximally. If there is fixed flexion, the other leg (should be flat on the bed) will lift off. - Abduction hold the pelvis with one arm, and abduct one leg at a time normal range is 40 to 45. - Adduction hold the pelvis with one arm, and adduct one leg at a time normal range is 20 to 30. - Internal rotation flex the hip 90 and swing the foot laterally. You can also test in extension by rolling the leg and watching the patella to assess rotation. Loss of internal rotation (normal range is 30 to 35) is one of the earliest signs of degenerative hip disease. - External rotation flex the hip 90 and swing the foot medially. You can also test in extension by rolling the leg and watching the patella to assess rotation normal range is 40 to 45. - Lie the patient prone, and palpate the sciatic nerve (half way between the greater trochanter and the ischial tuberosity), PSIS, ischial tuberosity, and ischial spines. - Extension only useful if Thomas test was negative apply downward pressure to the sacrum with one hand, and lift the thigh with the other hand normal range is 10 to 15. Special Tests - FABER test flex, abduct, and externally rotate the hip, and press down on the knee to test for sacroiliac joint tenderness (or test abduction against resistance with patient on their side). - Abdominal palpation for appendicitis, psoas abscess. Neurovascular - Pulses femoral, popliteal, posterior tibial, dorsalis pedis. - Power flexion (iliopsoas L1-L3), extension (gluteus maximus L5-S2), abduction (gluteus medius and minimus L4-S1). - Reflexes. - Sensation. Test the joints above and below.

48

KNEE EXAM You must expose legs of the patient to shorts. Alignment of knees (varus/valgus) Normal in males is 5 valgus, females is 7 valgus. Patellae alignment (symmetrical vertical and horizontal alignment) Swellings suprapatellar, medial joint regions, popliteal fossa, joint line (meniscus) Quads/calf wasting Skin changes/scars Deformity Walk the patient Lie the patient down Inspect the knee closely Look specifically at the parapatellar gutters as these are obliterated with effusions. Measure thigh circumference Feel

Starting at the medial and lateral malleoli feel up the length of the fibula and tibia to the patella; palpate the patella from above, moving along the joint line to the posterior aspect of the knee, feeling in the popliteal fossa.
Patellar tap test Secure the suprapatellar aspect of the joint and then lightly ballot the patella for fluid thrills Patellar sweep test Secure the suprapatellar aspect of the joint, stoke the medial side of the joint from distal to proximal to displace any fluid from the main joint cavity to the lateral side; now stroke the lateral aspect (from distal to proximal) watching the medial side as any excess fluid will move across the joint and distend the medial side. Flexion of the knee Extension of the knee These should be done actively at first, if the patient is unable to complete these movements they can be done passively. Remember to do both sides looking at the normal first. Medial/lateral collateral ligament Drop knee 30 of flexion off the side of the bed, and test valgal and varus stress. Drop-back test The knees are flexed together at 90, and observed for any dropping back of the tibia below the femur. This is to ensure that if there are any signs on drawer testing that you are not saying positive anterior drawer when you are simply correcting a PCL tear. Anterior drawer sign With the knee at 90 of flexion stabilise the foot (by sitting on it), and grasp and pull the tibia anteriorly. Tests anteromedial bundle of the ACL ligament (30% of ligament). Lachmanns test Flex the leg to approx 30 and grasp the distal femur with one hand, steady the thigh and push posteriorly, while the other hand grasps the proximal tibia and pulls anteriorly. Tests posterolateral bundle of ACL ligament (70% of ligament). Posterior drawer sign Knee at 90 of flexion stabilise the foot (by sitting on it), and grasp and push the tibia posteriorly.

49

Medial meniscal grind test Flex knee passively to 90, palpate the joint line (find a depression in the knee and move 10 posterolaterally), internally rotate the hip and rotate the leg in a grinding fashion. Lateral meniscal grind test Flex the knee passively to 90, palpate the joint line, externally rotate the hip and rotate the leg in a grinding fashion. Patella apprehension test Sit on the edge of the bed with the leg abducted and the knee sitting on the examiners lap; slightly flex the knee and push the patella laterally watching the patient for signs of apprehension. Neurological exam L1 top of thigh L2 lateral mid thigh L3 knee L4 medial leg L5 lateral leg S1 sole of foot S2 middle of posterior thigh S3,4,5 target to anus Hip flexion/abduction L2,3 Hip extension/adduction L4,5 Knee extension L3,4 Knee flexion L5, S1 Knee jerk reflex L3,4 Ankle reflex S1,2 Vascular exam femoral pulse, popliteal pulse, dorsalis pedis pulse, posterior tibial pulse Ask to examine joint above and below.

50

FOOT AND ANKLE EXAMINATION

LOOK - Standing shoes and socks off, shorts Assess shoes for normal wear pattern normally more worn on lateral heel Muscle wasting calves, anterior or lateral compartments Alignment and deformity (weight-bearing) observe from front and behind halux valgus fixed lateral deviation of 1st MTP joint and toe crowding of the toes occurs in RA hammer toe deformity permanent 2nd MTP extension, PIP flexion and DIP extension (with usual corn development) due to weak lumbricle/interosseus muscles claw toes permanent MTP extension, PIP and DIP flexion of all 4 lateral toes usually callosities develop (corns) sausage deformities psoriatic arthritis, AS and Reiters disease transverse arch beneath the MTP joints medial to lateral longitudinal arch from 1st MTP to heel ! these 2 arches bear the weight of ht body, and may be flattened in arthritic conditions flat footedness 100% of PI, not important unless pain in the knees or feet alignment of calcaneus on talus best viewed posteriorly, slightly laterally ! stand on toes - calcaneus is usually pull medially if joint is normal and all tendons intact Gait watch gait when walking into exam room stand and walk normally tests for antalgic gait, foot drop and compensation stand and walk on tiptoes tests power of triceps suri (S1) and active ROM of tibio-talar (ankle) joint stand and walk on heels tests power of tibialus anterior (L4,5) and active ROM of tibiotalar joint stand and walk on inside of foot tests power of peroneus longus and brevis (L5,S1) and active ROM of subtalar joint stand and walk on outside of foot tests power of tibialis posterior (L4,5) and active ROM of subtalar joint testing ROM of subtalar joint tests for presence of a coalition fibrous fused joint with limited movement ensure no Gastrocnemius contracture by ensuring heels touch ground when knee fully extended

51

LOOK - Sitting Swelling lateral swelling may be due to peroneal tendonitis or subtalar joint disease Redness, Scars Skin changes nail changes psoriasis calluses over the metatarsal heads on the plantar surface may occur in subluxation or pressure points denoting deformity or malalignment FEEL Sitting Palpate bony and soft-tissue landmarks for tenderness, swelling and warmth superior tib-fib joint length of fibula and tibia from knee arhilles tendon for nodules (RA) and tenderness (archilles tendonitis) lateral maleolus and lateral ligament (posterior talofib, calcaneofibular and anterior talofib ligaments) base of 5th metatarsal talar dome plantarflex to expose anterolateral surface anterior ankle joint line tenderness and fluctuation of fluid medial maleolus and medial ligament (deltoid) sustenticulum tali - immediately inferior head of talus navicular tubercle 1st MTT joint (metatarsal-cuneiform joint) shaft of 1st metatarsal 1st MTP joint and bursa FEEL Supine Palpate plantar bony and soft-tissue landmarks metatarsal heads apply dorsal pressure sesamoid complex of distal 1st metatarsal head between metatarsals for Mortons neuroma plantar surface of calcaneus medial tubercle of calcaneus may not be able to feel, but sensitive for plantar fasciitis and heel spur MOVE - Sitting Alignment and deformity (non-weightbearing) Active then Passive ROM

52

actively movement assesses the combined movements of several joints passive movement assesses the single joint, and accounts for tendon/muscle disorders which may limit active movement Tibiotalar joint dorsiflexion 20, plantarflexion 50 cup heel and invert to eliminate forefoot motion Talocalconeal inversion 10, eversion 5 dorsiflex tibiotalar joint to lock the wider pole of the talus into the ankle joint cup heel and invert/evert tenderness of this movement is more important than ROM tarsal coalition may decrease subtalar motion

Midtarsal joints abduction 10, adduction 20, dorsiflexion, plantarflexion stabilising heel and subtalar joint a twisting/rotation movement is applied tenderness is more important than range of motion

MTP, PIP and DIP joints flexion and extension MTP joints - 40 flexion, 40 extension 1st IP joint - 90 flexion, 0 extension 2nd 5th PIP, DIP joints - 45 flexion, 70 extension while testing movement, swelling, stiffness and tenderness should be noted SPECIAL TESTS - Prone Anterior drawer test assesses the anterior talofibular ligament of the lateral ligament place thumbs on heel and wrap fingers around distal tibia, apply strong anterior force with fingers observe anterior movement of talus relative to tibia/fibula anterior instability due to ant. talofib laxity, commonly following a sprain injury the talus may clink out of the mortus Talar tilt test maximum inversion stress applied to talus at 30 plantarflexion, apply inversion stress and assess the space between the talus and calcaneus laterally feel for definite end-point tests anterior talofibular ligament and calcaneofibular ligaments of lateral ligament

53

Posterior thrust test Impingement test apply sharp plantarflexion and be alert for pain either side of archilles tendon Archilles squeeze test Thompson test squeeze bulk of relaxed triceps suri muscle and observe associated plantarflexion 25% of archilles ruptures are missed Homans sign forceably dorsiflex ankle to test for pain in calf VASCULAR EXAM Hair distribution Temperature Capillary refill blanching Pulses 2 pulses: Posterior tibial artery posterior to medial malleolus (between FHL and FDL tendons) Dorsalis pedis artery between 1st and 2nd metatarsal shafts, best 2 inches below ankle joint (between EHL and EDL tendons) NEUROLOGICAL EXAM Full examination including dermatomes, myotomes and reflexes

54

SHOULDER EXAMINATION
expose shoulder LOOK look for wasting, alignment, deformity, scars, swellings front prominent SC jt subluxation deformity of clavicle old # prominent AC jt subluxation, OA deltoid wasting disuse, axillary nerve palsy swelling infection, inflammation e.g calcifying supraspinatus tendinitis, trauma

side

behind scapulae normal shape, location - small + high Sprengels shoulder, Klippel-Feil syndrome (also webbed neck) - winging paralysis of serratus anterior muscle above swelling deformity of clavicle asymmetry of supraclavicular fossae

FEEL palpate bony landmarks from SC joint + move around to scapula clavicle tenderness dislocation, infection (TB), tumours, radionecrosis (breast Ca Rx) glenohumeral jt palpate ant + lat aspects. Diffuse tenderness infection, calcifying supraspinatus upper humeral shaft + head (via axilla) ?exostoses AC jt tenderness recent dislocation, OA (also lipping + crepitus) press below acromion + abduct arm tenderness tears, inflammatory lesions neurovascular: palpate radial pulse screen for distal sensation MOVE Active movements abduction abduct both arms look for smoothness + ROM (0-170o) difficulty initiating rotator cuff tear pain 70-120o rotator cuff impingement in region of acromion (supraspinatus)

55

pain 120o+ rotator cuff impingement in region of coraco-acromial ligament or AC jt, OA of AC jt hold arm in vertical position deltoid + axillary nerves intact adduction flexion extension lower arm to confirm presence of painful arc swing arm forwards + lift above head (view from side) look for smoothness + ROM (0-165o) swing arm directly backwards (view from side) look for smoothness + ROM (0-60o)

int rotation put hand behind band and reach to touch opposite scapula affected in frozen shoulder ext rotation hands locked behind head affected in frozen shoulder Passive movements do if patient cannot achieve full ROM with active movements Power SPECIAL TESTS rotator cuff tests robot infraspinatus + teres minor beer can supraspinatus lift off from back subscapularis try + supinate biceps shoulder instability apprehension tests ant + post

56

Lacerated Wrist Examination Expose - to above elbow Look - how many lacerations are there and where are they? - assess ABCs - attitude of the hand and fingers Feel - Arteries colour warmth capillary refill radial and ulnar pulses Allens test Radial (snuff box) Median (tip of index finger) Ulnar (tip of little finger) - extend fingers at MCP joints - extend wrist - pincer grip - abductor pollicis brevis - spread fingers - Froments test (with paper)

- Nerves

Move - Nerves

- Radial - Median - Ulnar

- Tendons

- compress the flexor compartment of the forearm to see if fingers move - make a fist - 1st layer FCU, FCR, PL flex and deviate wrist and palpate - 2nd layer FDS flex each PIP while extending others - 3rd layer FDP test each DIP individually - 4th layer EPL extend thumb and palpate tendon

57

Ophthalmic examination
Introduce yourself to the patient Position the patient sitting comfortably on a chair at the right height for you, in a room where you can dim the lights. General inspection from the end of the bed Look for: abnormalities of eye structure (proptosis, ptosis, exopthalmos, enopthalmos, periorbital/orbital cellulitis, ectropion, entropion etc) Strabismus Posturing (eg sit looking to left if R eye neglect; tilting of the head to correct diplopia) Fixation and tracking behaviour VISUAL ACUITY You need: Assess: Snellen chart, near vision chart, and pinhole one eye at a time, with glasses on if the patient usually uses them Far vision using Snellen chart (from 6 metres away, 6/6 is upper limit of normal for young person, 6/12 for an elderly person). If the patient cannot read the largest print on the Snellen chart, continue testing using fingers (how many fingers am I holding up?), and if they cannot see your fingers, test perception of light (can you see the light?) Near vision using a near reading chart (patient holds it at arms length). Ask them to read the line with the smallest print that they can see then move up or down accordingly. If you suspect the patient has a refractive error (eg history of blurry vision), use a pinhole to correct it. The pinhole vision suggests the best visual acuity that might be achieved with the correct glasses.

COLOUR VISION You need: Ishihara plates or red target Assess: One eye at a time With Ishihara plates get them to read the numbers With red target compare colour perception in each eye VISUAL FIELDS Test grossly using confrontation. For more precise mapping of the visual field you need to use a more specific test eg perimetry using automated Humphrey machine Technique: sit with your face level with the patients, approx 1m apart Firstly ask the patient if any parts of your face are missing Now test each eye separately Ask the patient to cover one eye (L eye with L hand and vice versa) Cover your eye on the opposite side compare your R eye to their L eye and your L eye with their R eye Ask the patient to look at your nose and keep looking there
58

Test each quadrant grossly using finger counting (How many fingers do you see?) or movement of the fingers (tell me when you see my finger move) Map each visual field grossly by bringing target in from periphery and asking the patient to point when they first see the target. Hold the target equidistant between you and the patient Make sure you hold the target at the extremes of your visual field; remember you are simply comparing their fields to yours, if you cant see the target they probably cant either OCULAR MOVEMENTS and DIPLOPIA You need: pen torch and eye cover Assess: corneal light reflex (should be symmetrical if eyes are aligned) Do the cover-uncover test to see if there is latent strabismus Test ocular movements by asking the patient to follow your finger into the 9 directions of gaze (9 points of union jack). This is most easily done by using the modified H

Look for nystagmus at extremes of gaze Check for diplopia at extremes of gaze If there is diplopia: ask if it is vertical or horizontal Find the position where the diplopia is maximal The outer image always comes from the affected eye and is the false image; cover each eye and the eye that is covered when the outer image disappears is the affected eye. Determine the weak muscle by the direction of the gaze PUPILLARY RESPONSES You need: pen torch or any direct source of light Assess: The size and shape of the pupils (in relation to each other) The direct and consensual responses For a relative afferent pupillary defect (RAPD) using swinging flashlight test Response to accommodation by looking at near target EXAMINATION OF THE EXTERNAL EYE You need: pen torch, slit lamp, fluorescein Look: at eyelids, eyelashes (entropion, ectropion, blepharitis, BCC, melanoma, SCC, stye, molluscum contagiosum, meibomian gland infections). Remember to evert the eyelid.

59

At conjunctiva (redness note distribution, subconjunctival haemorrhage, discharge, swelling/chemosis, papillae) At cornea (is it shiny and clear? Does it stain with flourescein? Are there any abnormal blood vessels? Keratoconus?) At anterior chamber (?depth, is there blood - hyphaema - or pus hypopion? Can you see the iris clearly? Any abnormalities of the iris?) OPHTHALMOSCOPY You need: ophthalmoscope, mydriatic (tropicamide is 1st choice), dark room Assess: red reflex The inner structures of the eye, especially the retina Technique: dilate the pupil (will get more information this way) Turn the lights off to help you Ask the patient to fix on a far target eg picture on the wall Using your right eye look in their right eye (this way you wont bump noses). You dont have to close your left eye (but initially it helps you to see the retina more easily). Check the red reflex Place one hand on the patients forehead so you dont bump into them (ask first). Use the width of your hand as a guide. Warn them that you are going to be close! Come in at 15 from the side, with your eye level with the patients Start with the ophthalmascope set to +5. As you get closer, adjust the focus down step by step. This will allow you to focus on the anterior layers of the eye, moving posteriorly as you move closer. Any black spots in any layer of the eye suggests an abnormality in that area eg opacity in the lens. Find the optic disc, it lies slightly nasally. Assess the shape, colour, borders, contours (use the streak setting to assess depth), and cup-disc ratio. At the edge of the cup there is usually kinking of the vessels. Next follow the vessels out into the four quadrants. Arteries are orangy-red with trilaminar structure, veins are darker red and tend to be wider than arteries. They tend to run together. Whilst looking in the four quadrants, look for haemorrhages, AV nipping, exudates, cotton wool spots, pigmentation, and proliferating vessels. The green filter blocks red light, so it may help you to see small haemorrhages and proliferating vessels more easily (will appear black). Finally, ask the patient to look at the light so you can assess the macula. This usually lies temporal to the optic disc. The fovea is bright in the middle, and the macula is slightly darker, surrounding it. Describe what you find in relation to the optic disc its position (superior, inferior, nasal, temporal), and size (eg haemorrhage half the size of the optic disc)

60

Guide to the extra-ocular muscles

Key points: Lateral rectus = CN VI, superior oblique = CN IV, all others (plus levator palpebrae) = CN III LR6SO4 The medial rectus of one eye and the lateral rectus of the other eye work as a pair to produce lateral eye movements. The eye lies laterally to the origin of the muscles. This means that the muscles that act vertically (sup oblique, sup rectus, inf rectus, inf oblique) do not act through the vertical axis of the eye. The eye needs to be slightly abducted or adducted for these muscles to be most effective. Diplopia is the most common presentation for those with problems with the extraocular muscles and the nerves that supply them. Actions of the extra-ocular muscles Muscle Nerve Medial rectus 3 Inferior rectus 3 Inferior oblique 3 Superior rectus 3 Superior oblique 4 Lateral rectus 6 Action Adduction of the eye, convergence Main depressor of the abducted eye Main elevator of the adducted eye Main elevator of the abducted eye Main depressor of the adducted eye, intorsion Abduction of the eye

3rd nerve palsy: Severe diplopia in all directions of gaze, except on lateral gaze on the side of the lesion (as lat rectus still in tact) Usually have total paralysis of the eyelid (lid is shut passively) At rest the eye is deviated outwards and slightly downwards Check the other nerves are intact note asking the patient to look down to test the sup oblique will produce intorsion as the eye cannot be adducted. The pupil may be normal OR dilated and fixed to light. The latter finding is usually associated with a surgical problem. 4th nerve palsy Frank diplopia when looking down and away from the side of the affected eye. This leads to problems going down stairs, and when reading. The patient may compensate for the diplopia by tilting the head away from the side of the affected eye At rest the eye is rotated slightly outwards, and be slightly elevated The unaffected eye looks down when the patient is fixing with the affected eye Bilateral 4th nerve palsy (common after head injury) can present like a superior rectus palsy on looking to the right or left, the outward looking eye will suddenly be pulled down to compensate for the weak sup oblique of the other eye. 6th nerve palsy Diplopia is very severe and annoying for the patient. Will often deliberately shut the affected eye to stop diplopia Diplopia in all directions of gaze except away from the affected eye At rest the eye is deviated towards the nose The patient may compensate for this by turning towards the affected muscle

61

RHEUMATOLOGY EXAMINATION HAND AND WRIST EXAMINATION

HISTORY pain -vague + diffuse CTS -localised arthritis stiffness -worse in am RA swelling -wrist arthritis, tendon sheath inflammation -individual jt arthritis deformity -RA (fingers + hand) -arthritis (fingers) -gouty tophi -sudden onset tendon rupture locking/snapping of finger (trigger finger) inflammation of flexor tendon sheath loss of fxn assess difficulties neuro sx -paresthesiae nerve compression EXAMINATION sit patient over side of bed + place hands on pillow with palms down GENERAL INSPECTION Cushingoid appearance due to steroid use weight - esp. weight loss iritis/scleritis obvious other joint disease LOOK wrist + forearm skin - scars, erythema, atrophy, rash swelling distribution deformity e.g ulnar + hyloid prominence muscle wasting intrinsic muscles of hand MCP jts skin - scars, erythema, atrophy, rash swelling distribution deformity ulnar deviation + volar subluxation RA skin - scars, erythema, atrophy, rash swelling distribution deformity swan neck, boutonnire, z deformity of thumb RA - Heberdens nodes (DIP + 1st CMC), Bouchards nodes (PIP) OA - sausage-shaped phalanges (IP arthritis + flexor tendon sheath oedema)

PIP + DIPs

62

 psoriatic arthropathy, ank. spon, Reiters disease - finger shortening (arthritis mutilans) psoriatic arthropathy

nails

psoriatic changes - pitting - onycholysis - hyperkeratosis - ridging - discolouration vasculitic changes - black/brown 1-2mm lesions skin infarction RA - splinter haemorrhages SLE - periungual telangiectases SLE, scleroderma, dermatomyositis

turn over hands palmar surfaces - scars tendon repairs or transfers - palmar erythema - muscle wasting thenar + hypothenar eminences disuse, vasculitic, peripheral nerve entrapment turn hands back to palm down FEEL AND MOVE wrists palpate with thumbs on dorsal surface, index fingers underneath - synovitis - effusions ROM note: tenderness, limitation, joint crepitus dorsiflex (to 75o) palmar flex (to 75o) radial + ulnar deviation (20o) ulnar styloid tenderness RA radial styloid tenderness de Quervains tenosynovitis anatomical snuffbox tenderness scaphoid injury tenderness distal to head of ulna extensor carpi ulnaris tendonitis MCPs palpate with thumbs on dorsal surface, index fingers underneath - synovitis - effusions ROM note: tenderness, limitation, joint crepitus volar subluxation (flex MCP jt with proximal phalanx held between thumb + forefinger) movement if ligamentous laxity or subluxation present

63

PIP + DIPs palpate with thumbs on dorsal surface, index fingers underneath - synovitis - effusions ROM note: tenderness, limitation, joint crepitus palmar tendon crepitus (palpate palm while flexing + extending MCPs) creaking + nodules tenosynovitis trigger finger RA Carpal Tunnel Syndrome Tests Phalens wrist flexion test flex both wrists for 30s to induce paresthesiae (over median nerve distribution) Active Movements wrist - flexion (prayer position) - extension (backwards prayer position) thumb - hold patients fingers flat to assess thumb movements, look for limitation + discomfort - extension (outwards) - abduction (upwards) - adduction (downwards) - opposition (touch little finger) MCP + IPs make fist + straighten out fingers (screen test individual fingers if abnormal) fingers individually if active flexion of 1 finger test superficial + profundus flexor tendons FUNCTION grip strength key grip opposition practical - squeeze 2 fingers or squeeze partially inflated BP cuff (to quantify) - hold tightly + try to separate - patient opposes thumb + fingers try to separate - e.g undo a button, write with a pen

NEUROLOGICAL assess neurological sx OTHER elbows - subcut nodules on elbows RA - psoriatic rash psoriasis

other joints signs of systemic disease

64