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112 Cards in this Set
- Front
- Back
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Aortic Stenosis |
Pulse: SR, slow rising, low volume - Mid systolic or ejection systolic murmur (should be able to hear the S2), loudest in 2RICS rad to carotids - Soft A2 (due to poorly mobile aortic valve) - Softer with valsalva manoeuvre Causes: Calcification (elderly), calcific bicuspid valve, RHD Signs of severity: slow rising pulse, narrow pulse pressure, aortic thrill, length or murmur and a late peaking murmur, signs of LVF, signs of pulm HT Severe AS is area <1cm2 and mean gradient >40-59mmHg |
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Aortic Stenosis |
Investigations ECG: LVH, LAD, LA dilatation & hypertrophy CXR: aortic valve calcification, features of LVF and pulm HT
Indications for surgery - Symptomatic pt (dyspnoea, chest pain, syncope - urgent) - Symptomatic on treadmill test - Severe LVH or critical obstruction (area<0.7) |
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Systolic murmur |
Pansystolic/rad. to axilla/louder on exp. --> MR (RHD, BE, CTD eg marfans, LV dilatation) Ejection systolic/rad. to carotids/louder on exp. --> AS (Degenerative, Bicuspid valve, RHD, BE) Pansystolic/louder on insp./RV heave/Raised JVP v wave/pulsatile hepatomegaly --> TR (RHD, BE, congenital, carcinoid, RV dilatation) Holosystolic/localised to 3rd and 4th LICS/thrill --> VSD (Congenital, MI, EtOH, thalidomide, rubella infection during pregnancy) Ejection systolic/louder on insp/RV heave/soft P2/raised JVP a wave --> PS (congenital, RHD, carcinoid) |
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Diastolic murmur |
Early diastolic/louder on leaning forwards and exp/displaced apex beat/pistol shot femoral --> AR (RHD, BE) Early diastolic/louder on insp./associated Pul art HT --> PR (Pulm HTN) Mid, rumbling diastolic/bell on apex/loud S1, raised JVP --> MS (RHD) Mid diastolic/tricuspid area/pulsatile hepatomegaly/louder on inspiration/raised JVP --> TS (RHD, carcinoid, associated other valve lesions) |
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Aortic Regurgitation |
Pulse: SR, collapsing or bounding, large volume
- Early diastolic murmur (3LICS) (Louder on leaning forward and expiration) - Mid systolic murmur may be present - Pistol shot femora's, widened pulse pressure - Chronic AR: apex beat is displaced lat. & downwards, longer AR murmur Causes: RHD, congenital, Ankylosing spondylitis, Marfans (chronic) Acute: IE, HTN, dissecting aortic aneurysm Signs of severity: collapsing pulse, wide pulse pressure, longer murmur, S3, soft A2, LVF |
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Aortic Regurgitation |
Investigations
ECG: LV hypertrophy CXR: aortic valve calcification, signs of L heart failure, massive dilation of aorta (e.g. Marfans) Indications for surgery - Chronic severe AR with heart failure symptoms - Chronic severe AR with no sx but EF<55% or LV dilatation (LVESD>55mm) - Moderate AR with pt undergoing CABG or aortic surgery |
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Mitral Stenosis |
- Mid diastolic murmur (heard with bell on apex. Pt lies down on left) - Loud opening snap, loud S1 - JVP raised if there is back pressure with pulmonary HTN, large a waves - RV heave, rapping but not displaced apex beat Causes: RHD, congenital (rare) Normal valve area = 4cm, severe MS has area <1cm2 Signs of severity: narrow pulse pressure, early opening snap, longer murmur, thrill at apex, pulmonary HTN signs |
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Mitral Stenosis |
Investigations - ECG: LA enlargement/p mitrale (biphasic wave in V1, double hump in II), AF (a sign of chronic disease), RAD, RV hypertrophy (sign of severity) - CXR: MV calcification, big LA appendage/convex LA, signs of pulm HTN (large pulm arteries), signs of L heart failure (bat wing oedema) Indications for surgery - Severe MS (valve area <1.5cm2) and symptoms - Valve area <1.5cm, no symptoms but with PASP >50mmHg |
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Mitral Regurgitation |
- Pansystolic murmur rad from apex to axilla
- Soft S1 - Raised JVP, prominent v wave - Thrusting, displaced apex beat Causes Chronic: degenerative, ischaemia, dilated CM, MVP, RHD, CTD (Marfan syndrome) Acute: BE, rupture of chord tendineae, trauma Signs of severity: small volume pulse, S3, early diastolic rumble, soft S1, enlarged LV, signs of LVF, pulm HTN |
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Mitral Regurgitation |
Investigations: ECG: LA enlargement/p mitrale (biphasic V1, double hump in II), AF (sign of chronic disease), RAD CXR: enlarged LA appendage/convex LA Indications for surgery Acute MR Chronic MR with - Class III/IV sx - Progressive LV dilatation - New AF - New pulm HTN |
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Tricuspid Regurgitation |
- Raised JVP (large v waves)
- RV heave, loud P2 - Pansystolic murmur loudest in tricuspid area (4LICS), max at inspiration (TR can be diagnosed without a murmur based on peripheral signs alone) - Abdomen: pulsatile, enlarged liver, ascites - Feet: pitting oedema (sign of RHF) Causes: Funcitonal (with RVF), RHD, Congenital (Ebstein's anomaly) Acute: RV papillary muscle infarct, trauma, BE |
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Tricuspid Regurgitation |
Investigations ECG: RAD, RVH, LVH CXR: signs of pulm HTN (enlarged pulm trunk) Notes on management - Trivial regurgitation is a common and normal finding which does not need surgery - Surgery is recommended for severe TR in young patients with - progressive cyanosis - NYHA class III/IV heart failure symptoms |
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Special Manoeuvres |
Handgrip (increases afterload)
'Please grip this cloth and squeeze until your hand gets tired" Louder: AR, MR, MVP, VSD Softer or no effect: HOCM, AS, MS Valsalva (decreases preload) "Breathe in, pinch your nose and blow out" Louder: HOCM, MVP Softer: most murmurs (AS, PS, TR) |
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Apex Beat |
Causes of missing apex beat
DR POPE (Dextrocardia, behind a Rib, Pericardial effusion, Obesity, Pleural effusion, Emphysema) Causes of displaced apex beat (Long MRCP) LV enlargement - apex is down and more lateral Mediastinal shift - check to see if trachea is also displaced RV enlargement Cardiomegaly in general Pectus excavatum - Tapping (often not displaced) --> MS (occurs in time with S1) - Not sustained, more diffuse and displaced --> LV dilatation - Sustained and displaced --> LV hypertrophy (AS, CM) |
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Cardiovascular System Examination |
HELP (hello, exposure, lighting, positioning) Inspection: dyspnoea, cyanosis, cachexia ?sydnromic diagnosis) Hands: clubbing, osler's nodes, splinter haemorrhages, pallor, radial pulse, collapsing pulse, BP Face: conjunctivae, malar flush, mouth Neck: JVP, carotids
Chest wall Inspection: Front Palpation: Apex, parasternal, base of heart Auscultation: apex (bell then diaphragm), tricuspid, pulmonary, aortic Dynamic moves: roll to left, sitting forwards, valsalva
Back: Inspect, palpate, percuss auscultate
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Cardiovascular System Examination |
Abdomen: liver, spleen, aorta, shifting dullness
Legs: inspect (scars, signs of PVD), palpate (pulses, oedema), auscultate (bruits) Anything else? Would like to check fundi, urinalysis, temp chart |
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Secondary Hypertension |
Renal artery stenosis
Typically pt with vascular disease, age>50, unexpected deterioration in Cr after introduction of ACE-I Digital subtraction angiography Nephrotic/nephritic syndromes Hx of kidney impairment, FHx, urinalysis abnormalities, urine PCR Adrenal tumour (Phaeo) Paroxysms of headache/palpitations/sweating with high BP. Test urine and plasma metanephrines |
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Secondary Hypertension |
Coarcatation of aorta Upper limb BP>lower limb BP. Lack of femoral pulsation, rad-fem delay, left arm BP Conn's syndrome/Hyperaldosteronism Look for low K, High Na v High ALD to renin ratio OSA Suspect in obese patients Hypothyroidism TFT |
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Pulmonary Hypertension |
Primary/Idiopathic
Secondary - Chronic hypoxia (COPD, OSA, high altitude) - Disease of pulm arterioles (Scleroderma) - Thromboembolic disease (Chronic PE) - Left to right shunts (ASD, VSD) - RV restriction (constrictive pericarditis, cardiomyopathy) Treatment - Treat underlying condition - If vasoreactivity test is positive, try CCB first - Prostacyclin analogues (Bosentan or Sildenafil) may be used in IPH) - Anticoagulation (ie Warfarin) - Diuretics - Surgery/Transplantation may be indicated |
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Jugular Venous Pressure |
a: Atrial contraction
c: Closure of tricuspid valve v: due to venous return to right heart x: atrial relaxation y: blood flow into RV Raised a wave - TS - PS - RVH Very large a wave - Complete heart block Large v wave - TR |
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Cyanotic Congenital Heart Disease |
- Pt has cyanosis and may have clubbing
- If there are signs of pulmonary HTN, consider Eisenmenger syndrome Causes 1. Eisenmenger syndrome - pulm HT (palp P2, RV heave) with a communication between L and R circulations 2. Tetralogy of Fallot - no features of pulm HT 3. Complex lesions - Ebstein's anomaly with an associated ASD, univentricular heart |
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Eisenmenger syndrome |
Systemic to pulmonary cardiovascular communication leading to pulmonary hypertension and cyanosis
Inspection: Cyanosis, clubbing, raised JVP (a or v waves) Palpation: RV heave, palpable P2 Auscultation: - PSM with single S2 - VSD - Fixed split S2 - ASD - Machinery murmur (systole and diastole), differential cyanosis - PDA Investigations ECG: RV hypertrophy, p pulmonale CXR: prominent pulmonary artery, RV and RA enlargement, increased hilar markings, attenuated peripheral vessels |
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Cranial Nerve Examination |
Inspection: Facial asymmetry, eyes (ptosis, proptosis, pupils), scars/rashes (eg behind ear)
Olfactory: Ask pt re sense of smell Optic and Oculomotor (NB): Close inspection (pupils), acuity, reflexes, accommodation, visual fields, fundoscopy, movement Trigeminal: Sensory (cornea and face), Motor (mouth and jaw jerk) Facial: Motor (muscles of face), Sensory (taste test to anterior 2/3 of tongue) Vestibulocochlear: Hearing (whisper in ear, Rinne's & Weber's tests) & Rhomberg's test Glossopharyngeal & Vagal: "Say Aaah", gag reflex, speech, cough Hypoglossal: Look for tongue wasting/fasciculation, then test protrusion Accessory: "Please shrug shoulders and move neck" |
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Nystagmus |
Describe as horizontal or vertical and give direction of fast phase
Horizontal: Can be uni or bilateral, peripheral or central cause. Peripheral nystagmus has beats away from side of lesion Sustained, horizontal and bidirectional: Drugs (Phenytoin, Barbiturates, Benzodiazepines) or Cerebellar lesion Vertical: Stroke, tumour, MS, Wernicke's encephalopathy, drugs as above Pendular: Multiple sclerosis Physiological: Generally only up to 3 beats on extreme gaze Causes: Peripheral: Meniere's, head trauma, otitis media, vestibular nerve damage associated with deafness & tinnitus Central: stroke, tumour, MS, alcohol abuse |
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Motor neurone disease |
Suspect with presence of upper motor neurone lesions (Spasticity/hyperreflexia) with lower motor neurone lesions (Wasting, fasciculations) and weakness in one region of body. Most commonly patients present with asymmetrical weakness
Amyotrophic lateral sclerosis (most common): bulbar (cr n9-12) and limb lesions, frontotemporal cognitive decline Progressive bulbar palsy: bulbar & limb lesions. Wasting/fasciculation of tongue (motor nuclei of cranial nerves, LMH lesion medulla) Pseudobulbar palsy: bulbar & limb lesions, stiff spastic tongue (bilat corticobulbar disease, UMN lesion mid pons) Progressive spinal muscular atrophy: limb lesions (LMN lesion affecting the anterior horn cells of spinal cord) Primary lateral sclerosis: purely an UMN lesion in the limbs |
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Bulbar palsy and Pseudobulbar palsy |
Bulbar palsy
(Lesion of the cranial nerves at the medullary bulb) LMN lesion of 9, 10, 11, 12 - tongue is wasted with faciculations, Nasal speech Causes: Myasthenia gravis, MND, GBS, Syringobulbia, Neurosyphilis, Neurosarcoid, Poliomyelitis Pseudobulbar palsy UMN lesion of the cranial nerves 9, 10, 11, 12 - stiff and slow tongue, brisk jaw jerk, Hot potato speech Causes: CVA (bilateral internal capsular lesions), multiple sclerosis, MND, PSP, Brainstem lesions |
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Oculomotor nerve palsy |
- Eye is 'Down and Out'
- Pupillary dilatation (pupils often spared in microvascular disease) - Ptosis (often complete) - Loss of direct and accommodation reflexes Causes Central lesions: 1. Stroke or haemorrhagic lesion involving the ipsilateral midbrain at the level of the superior colliculus 2. Meningitis 3. Demyelination Peripheral lesions: 1. Compression of the oculomotor nerve via a tumour 2. Aneurysm of the posterior communicating artery 3. Ischaemia or infarction of the oculomotor nerve Anatomically in: The Nucleus, Fascicles, Subarachnoid space, The Cavernous sinus or the Orbital apex |
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Horner's syndrome |
Partial ptosis, constricted pupil, enophthalmos
1. Check forehead for lack of sweatiness 2. Corneal reflex - absence suggests orbital or retroorbital lesion 3. Lack of sensation over ipsilateral face and contralateral arm, hoarse voice suggests Brainstem infarct/lateral medullary syndrome 4. Ipsilateral arm weakness/hyporeflexia suggests Brachial plexus avulsion or pan coasts tumour Causes: Central: Stroke (lateral medullary syndrome), tumour inv. brainstem Peripheral: Tumour infiltration at lower cervical/upper thoracic level (pan coasts tumour) or avulsion injury to brachial plexus At ptosis should be checked for fatiguability |
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6th Nerve Palsy |
- Failure of lateral movement of the affected eye
- Eye may be deviated medially - Diplopia - Images are parallel and separated in the horizontal plane Causes Unilateral Central - ipsilateral pontine lesion (stroke, tumour, Wernicke's, MS) Peripheral - HTN, diabetes, trauma, idiopathic, raised ICP (false localising sign) Bilateral Raised ICP, Wernicke's encephalopathy, trauma, basal meningitis |
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7th Nerve Palsy |
- Weakness of facial muscles of one half of face (trouble squeezing eyes shut or moving angle of mouth)
- UMN lesions affect contralateral side and forehead is spared - LMN lesions affect ipsilateral side with involvement of whole face Causes UMN - stroke or trauma (supranuclear lesion) LMN - stroke, tumour, MS (pontine lesion, 5/6th nerve may be involved), cerebellopontine angle lesion (5th and 8th nerve may be involved), Bell's palsy, Ramsay Hunt syndrome, fracture, otitis media, parotid tumour |
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Parinaud syndrome |
- Loss of vertical upward gaze
- Convergence - retraction nystagmus - Pupillary light - near dissociation Causes: Central: lesion is in the dorsal midbrain - pinealoma, stroke, MS Peripheral: HTN, diabetes, idiopathic, trauma, raised ICP |
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External Ophthalmoplegia |
Myasthenia Gravis: Proximal limb and eyelid weakness and fatiguability (+) Ach receptor Ab and tensilon test
Miller Fisher Syndrome: Ataxia, areflexia (+) Anti GQ1b Ab Mitochondrial myopathy: Retinitis pigmentosa, cardiac conduction defects, developmental delay. Raised CSF protein, "Ragged Red fibres" on muscle biopsy Oculopharyngeal dystrophy: Slowly progressive myopathy with ptosis, dysarthria, dysphagia and extremity weakness. Elevated CK, "Rimmed" vacuoles and variation in fibre size on muscle biopsy Thyrotoxicosis: Tremor, tachycardia, lid lag. TFT |
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Lower Limb Examination |
Inspection: Room (walking aids), Face/body for syndromes, consider Parkinson's/Cushing's/Marfans, Wasting of MND
Gait: Check normal --> heel to toe --> walk on toes --> walk on heels --> stop --> examine back --> Romberg's --> Squat and stand up --> Bed Inspection of legs: wasting, fasciculations, lack of hair, scars Palpation: Tone: clonus at ankle and patella Power: Reflexes: Knee (L3/4), Ankle (S1/2), Plantar response (S1) Coordination: foot tap, heel to shin, toe to finger Sensation: Sharp, vibration, proprioception, light touch, temperature Anything else? - check upper limbs, cranial nerves, test fatiguability |
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Poor heel-toe walk |
Dorsal column lesion
Ataxia much worse on closing eyes Poor 2 point discrimination (>1cm) Poor vibration/proprioception Astereognosia (inability to recognise objects by touch) Paraesthesia Cerebellar lesion Ataxia present even with eyes open Nystagmus Upward arm drift, dysdiadochokinesis Poor heel-shin and poor finger-nose movement |
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Spastic paraparesis |
Key findings: Bilaterally increased tone, hyperreflexia and up going plantars (UMN), scissoring gait with trouble squatting
Inspection: No evidence of muscle wasting or fasciculations Tone: Increased with clonus Power: Pyramidal weakness (Weak hip/knee flexion and dorsiflexion) Reflexes: Hyperreflexia with up going plantars, check adductor reflex. Generally normal coordination, look for sensory level Pathology at: Spinal cord or bilateral cerebral hemispheres (rarer) Causes: Ischaemic/haemorrhagic cord lesion, compression (tumour, AVM), myelopathy secondary to spondylosis, demyelination (eg MS, transverse myelitis), trauma, hereditary (HSP), tabes dorsalis, syringomyelia, MND |
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Peripheral neuropathy |
Peripheral neuropathy that mainly affects motor fibres:
- GBS, CIDP (if slow to improve) LP mark, IDC, areflexia - Charcot-Marie-Tooth disease "Champagne" legs, pes cavus, clawing of toes, reflexes present - Multifocal motor neuropathy Asymmetric, distal lesions, fasciculations, no UMN signs - Alcohol & diabetes, lead, organophosphates Peripheral neuropathy that mainly affects sensory fibres: - Alcohol & diabetes - Vitamin B12 deficiency Positive Rhomberg's test, sensory ataxia - Uraemia related to CRF - Leprosy |
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Myotomes - Lower Limb |
Hip
- Flexion L1-3 (femoral - psoas) - Extension L5-S2 (inferior gluteal - gluteus maximus) - Abduction L4-S1 (superior gluteal - gluteus medius) - Adduction L2-4 (obturator - adductor longus) Knee - Flexion L5-S1 (sciatic - hamstrings, biceps femoris) - Extension L3-4 (femoral - quadriceps femoris) Ankle - Plantarflexion S1-2 (sciatic - gastrocnemius, plataris) - Dorsiflexion L4-5 (common peroneal - tibialis anterior) - Inversion L5-S1 (sciatic - tibialis posterior) - Eversion L5-S1 (common peroneal - peroneus longs, brevis) Toes - Flexion S1-S2 (sciatic) - Extension L5-S1 (common peroneal) |
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Dermatomes - Lower Limb |
L2 - Upper lateral thigh (lateral cutaneous of the thigh)
L3 - Knee (Femoral) L4 - Medial leg (Saphenous nerve, branch of femoral) L5 - Lateral leg (lateral cutaneous nerve of the calf [sciatic], superficial peroneal nerve [common peroneal nerve]) L5 - top of foot (superficial peroneal nerve) S1 - sole of foot (many branches of sciatic nerve) L5/S1 - tips of toes (medial plantar and sural nerve) L5/S1 behind leg over the calf (sural and saphenous nerve) S2 - behind the leg over thigh (posterior cutaneous nerve) |
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Dermatomes - Lower Limb |
Picture
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Innervation of the Hand |
Median nerve: palmar thumb to half 4th finger and tips of thumb, 1st & 2nd fingers
Ulnar nerve: dorsum and palmar half 4th and 5th finger Radial nerve: dorsum thumb to half 4th finger Actions Median: thumb abduction, flexion of MCP, PIP, DIP (radial half) Ulnar: Finger ab/adduction, flexion of MCP, PIP, DIP (ulnar half) Radial: Wrist and finger extension |
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Hand wasting |
Patterns of hand wasting/weakness - Median nerve Carpal tunnel syndromeAtrophy: thenar eminence Weakness: thumb abduction, flexion and opposition Sensory deficit: median nerve distribution (hand) Pronator teres syndrome Atrophy: thenar eminence Weakness: pronation, pincer grip Sensory deficit: lateral palm, thenar eminence Anterior interosseous neuropathy Atrophy: Thenar eminence Weakness: Cannot make 'o' with thumb and 1st finger Sensory deficit: generally none |
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Hand wasting |
Patterns of hand wasting/weakness - Ulnar nerve
Wrist Atrophy: hypothenar muscles and 1st DI Weakness: finger adduction/abduction, thumb adduction Sensory deficit: ulnar nerve sensory distribution Elbow Atrophy: hypothenar muscles and 1st DI Weakness: mild intrinsic muscle weakness to weakness in little finger flexion (severe) Sensory deficit: ulnar nerve sensory distribution |
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Hand wasting |
Patterns of hand wasting/weakness - Radial nerve Posterior interosseous lesion Cause: mononeuritic multiplex (e.g. from diabetes) Weakness: Wrist (ECU) and finger extensors, brachioradialis spared Sensory deficit: none Spiral groove Cause: Saturday night palsy Weakness: Brachioradialis, wrist and finger extensors, triceps spared Sensory deficit: Radial nerve distribution C7/8 or plexus lesion Cause: Cervical spondylosis or brachial plexus injury Weakness: Triceps, wrist and finger extensors. Brachioradialis may be weak if C5/6 involved Sensory deficit: dermatomal distribution of sensory loss |
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Foot Drop |
UMN
- Corticospinal tract LMN - L4/5 roots - Common peroneal nerve - Tibialis anterior |
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Foot Drop |
Mixed motor and sensory pathology
Common peroneal nerve lesion - high stepping gait with no upper limb weakness/loss of arm swing, weak eversion, weak big toe extension, sensory loss in typical distribution. Injury over head of fibula L4/5 nerve root lesion or lumbosacral plexus injury - weak inversion and eversion, L4/5 sensory loss +/- weak hip abduction & knee extension Obstetric injury to lumbosacral trunk, cauda equina tumour, prolapsed disc Mainly motor pathology Muscular dystrophies & Inclusion body myositis Charcot Marie Tooth disease (CMT) & CIDP/GBS |
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Foot Drop |
Weakness of all movements of foot (Normal hip power)
Peripheral neuropathy: bilateral weakness, loss of ankle reflex, stocking pattern sensory loss Sciatic nerve lesion: weak knee flexion, loss of ankle reflex, extensive sensory loss Pressure (disc herniation), Tumour, trauma, vasculitis Cauda equina: loss of ankle reflex, saddle anaesthesia, loss of anal tone urinary incontinence (emergency) Tumour, trauma, prolapsed disc Anterior horn cell disease: muscle wasting, fasciculations, variable reflexes, normal sensation poliomyelitis, MND |
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Tremors |
Resting tremor: (Parkinsons) pill rolling, persists in walking, worse on stressing pt (e.g. serial 5s), worse unilaterally; look for shuffling gait, lack of arm movements
Intention tremor: (Cerebellar lesion) only as hand approaches target, and worse with intention; look for dysarthria, nystagmus Kinetic tremor: May be present at rest and worse as hand approaches target, no cerebellar signs Postural tremor: Present with arms outstretched (2 types) Physiological: Anxiety, thyrotoxicosis, drugs Essential: Generally benign cause Dystonic tremor: (eg due to PD drugs) - coarse and asymmetrical Holmes tremor: (Midbrain lesion) - coarse, proximal upper limb tremor, worse on reaching target |
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Upper Limb Examination |
Inspection: muscle wasting, scars, fasciculations, flexion deformity of stroke
Screen: Hold arms out - look for tremor or drift -- Down ?UMN lesion - Up ?Cerebellar lesion - All over ?Proprioceptive loss Tone: Power: Froment's sign (Ulnar n lesion) Reflexes: Biceps (C5/6), Triceps (C7/8), Supinator (C5/6) Coordination: Finger-nose, dysdiadochokinesis, rapid alt finger moves (if suspect CVA) or piano play (Parkinsons) Sensation: Sharp, vibration, proprioception, light touch, temperature Anything else? - Check lower limbs, cranial nerves, test fatiguability |
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Myotomes - Upper Limb |
Shoulder - Abduction C5/6 (axillary) - Adduction C6/7/8 Elbow - Flexion C5/6 (musculocutaneous) - Extension C7/8 (radial) Wrist - Flexion C6/7 (median and ulnar) - Extension C7/8 (radial) Fingers - Flexion C7/8 (median and ulnar) - Extension C8/T1(radial) - Abduction C8/T1(ulnar) - Adduction C8/T1(ulnar) Thumb - Abduction C8/T1 (median - abductor pollicis brevis - note abductor pollicis longus is via the radial nerve) - Adduction C8/T1(ulnar) |
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Dermatomes - Upper Limb |
C5 - lateral upper arm C6 - thumb C7 - middle finger C8 - 5th finger T1/2 - medial aspect of the arm |
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Dermatomes - Upper Limb |
Picture
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Speech Examination |
Is it dysarthria or aphasia?
1. Inspect: Spastic upper limb, face/eye muscle weakness, Dementia?, Parkinson's? 2. Get pt to read a sentence 3. Show pic and ask them to describe it, listen to articulation, sentence structure, stuttering 4. Say "Constabulary, Monotonous, Baby Hippopotamus, Artillery" 5. Get pt to write a sentence |
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Speech Examination - Dysarthria |
1. Assess severity "Zip, zipper, zippering"
2. Say "puh" (lip weakness), "tuh" (tongue weakness) "kuh" palate weakness) 3. Cough - bovine cough with recurrent laryngeal nerve palsy 4. Examine - Nystagmus, jaw jerk, facial weakness, uvular/tongue deviation - Finger-nose test, dysdiadochokinesis, gait - Consider Parkinson's examination LMN lesion (bulbar palsy) - nasal voice, facial weakness, weak tongue with fasciculations, weak palate loss of gag reflex - consider MND UMN lesion (pseudobulbar palsy) - hot potato voice, brisk jaw jerk, stiff tongue - consider PSP/MND, hemiparesis suggests CVA Cerebellar lesion - nystagmus, tremor, gait ataxia Parkinson's - Soft voice, cogwheel rigidity, lead pipe rigidity |
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Speech Examination - Dysphasia |
Confirm - 'no ifs ands or buts' Dysphasia leaves words out (paraphrasic error)
Test comprehension - Are you in hospital? Are we in your house? Is it night or day?, Do you put your shoes on before your socks? - Using your finger, touch your chin then your nose, then year ear Is it Expressive or Receptive Expressive - Stuttering/slurring, Comprehension and sentence structure ok. Lesion in Broca's area in Frontal lobe, look for hemiparesis Receptive - Fluent but impairment of comprehension/wrong sentence structure, lesion in temporoparietal lobe, look for Homonymous hemianopia |
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Speech Examination - Dysphasia |
Summary
' Mr X has evidence of dysphasia' Comment on Fluent or non-fluent (fluent --> Receptive dys, non-fluent --> Expressive or global dys) Comprehension is intact/not intact (Intact --> Expressive dys, not intact: Receptive or Global dys) Paraphasic errors (sink = sing) or neologism (room = boof) Repetition (can be impaired with any dysphasia) 'These findings point to an Expressive Dysphasia/Receptive Dysphasia' |
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Respiratory System Examination |
Room inspection O2, puffers, IV lines, sputum cup
General RR (time this), accessory muscle use, stridor/wheeze, facial plethora, ptosis or eye abnormality Hands clubbing, cyanosis, nicotine stains, pallor, HPOA, wasting, asterixes, pulse Arms blood pressure Face eyes/ptosis, nose, mouth (cyanosis, dentition) Sinuses palpate/tap Neck tracheal tug, shortening, deviation Ask pt to cough, then speak, perform FET, Consider Pemberton's |
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Respiratory Exam (Anterior Chest) |
Inspection shape, scars, erythema
Palpation chest expansion, apex beat, ribs, subcutaneous emphysema Percussion clavicles, chest, axillae Auscultation chest, axillae, vocal resonance +/- whispering pectoriloquy |
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Respiratory Exam (Posterior Chest) |
Inspection Shape, scars, movement (of anterior chest)
Palpation cervical/axillary LN, chest expansion Percussion posterior fields and axillae Auscultation posterior fiels and axillae, vocal resonance |
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Respiratory Examination (Other) |
Chest
- Palpate apex beat (if mediastinal shift suspected) - Look for signs of pulmonary hypertension - raised JVP, RV heave, loud P2 Abdomen - Palpate liver - 'Falls' in COPD, Enlarged (in Metastases or congestive hepatomegaly Lower Limbs Anything else? - Check sputum mug, temperature chart, peak flow meter readings - Examine breasts in females |
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Clubbing |
- Clubbing, pursed lip breathing, barrel chest, reduced chest expansion, prolonged expiration: consider COPD (emphysema)
- Clubbing, reduced chest expansion, bibasal crepitations: consider pulmonary fibrosis - Clubbing, chest wall deformities, copious sputum, bibasal coarse crepitations: consider bronchiectasis Causes of Clubbing Respiratory: Bronchogenic Carcinoma (HPOA), Mesothelioma, Pulmonary fibrosis, Lung abscess, Empyema, Bronchiectasis Cardiac: Bacterial endocarditis, Cyanotic congenital heart disease Gastrointestinal: Cirrhosis, Inflammatory bowel disease Other: Thyrotoxicosis, Familial |
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Crackles |
Early inspiratory crackles
- COPD (must be early, v few crackles) Pan/Late inspiratory crackles - Pulm oedema - bilateral crackles, look for S3, raised JVP, pitting oedema, hepatomegaly - Consolidation - uni or bilateral crackles, look for gurgly cough, dirty sputum, fever - Bronchiectasis - uni or bilateral crackles, look for gurgly cough with copious dirty sputum - Pulm fibrosis - bilateral, fine & numerous crackles, dry cough Amount of crackles: Pulm fibrosis>consolidation/LVH>COPD |
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Tracheal displacement |
To the side of lesion
- Upper lobe collapse or fibrosis - Pneumonectomy Away from side of lesion (uncommon) - Massive pleural effusion - Tension/large pneumothorax - Mediastinal mass (eg. goitre or thymoma) |
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Reduced chest expansion |
Ipsilateral
- Localised pulm fibrosis - Consolidation - Collapse - Pleural effusion - Pneumothorax Bilateral - COPD - Pulm fibrosis |
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Bronchiectasis |
- Coarse late inspiratory crackles in the lower zones bilaterally
- Heavy purulent sputum production - Kyphosis/chest wall deformity - Finger clubbing - Tenderness over the sinuses Anything else? - Amount of sputum production, temp chart - History of weight loss - History of recurrent childhood infections Causes: Cystic fibrosis, post recurrent LRTI (TB, pertussis, measles), Allergic Bronchopulmonary Aspergillosis, Mechanical obstruction (eg tumour), immotile cilia syndrome (eg Kartagener's syndrome) DDx Pulm fibrosis, LRTI |
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Bronchiectasis |
Investigations
FBC, CXR, HRCT (96% sens), Bronchoscopy results CXR - cystic opacities with air-fluid levels, 'tram-tracking' of bronchioles, and ring-like opacities (Bronchioles seen end on) HRCT - dilation of airway lumen, lack of tapering of an airway toward periphery, multiple cysts Upper lobe involvement - CF, ABPA Lower lobe involvement - MAC Complications of Bronchiectasis Pneumonia, Sinusitis, Haemoptysis (may be life threatening), Brain abscess, amyloidosis |
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Pulmonary fibrosis |
- Fine inspiratory crackles in the lower zones bilaterally (in IPF)
- Dyspnoea, cyanosis, clubbing - Ipsilateral tracheal deviation (localised fibrosis) - Reduced chest expansion - Dull percussion Causes Upper lobe SCART - Sarcoidosis/Silicosis, Coal worker's pneumoconiosis, Ankylosing spondylitis, Radiation induced fibrosis, Tuberculosis (primary) Generalised/Lower lobe RASIO - Rheumatoid Arthritis, Asbestosis, Scleroderma/SLE, Idiopathic pulm fibrosis, Others (eg Bleomycin, Amiodarone) |
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Pulmonary fibrosis |
Investigations
ABG, PFT, CXR HRCT - Peripheral & basal honeycombing suggestive of usual interstitial pneumonia and idiopathic pulmonary fibrosis - Ground glass opacification with heterogeneous reticular changes suggestive of non-specific interstitial pneumonitis Lung biopsy may be needed if HRCT changes are not typical Treatment - Generally ineffective - Antifibrotic agents Nintedanib or Pirfenidone - Consider Sildenafil if there is pulmonary hypertension - Lung rehabilitation program, consider lung transplant |
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Pneumothorax |
- Tracheal deviation (none in small, to the side in large, away from side in tensioning pneumothorax)
- Ipsilateral reduced chest expansion - Ipsilateral hyperresonance to percussion - Ipsilateral reduced breath sounds with increased vocal resonance May mention: "if the pt was tachycardic (>135), hypotensive with a pulses paradoxes, I would suspect a tension pneumothorax" Causes: Spontaneous, Marfan syndrome, Traumatic, Emphysema related |
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Lobectomy |
Ipsilateral
- Thoracotomy scar - Tracheal deviation (in upper lobectomy or pneumonectomy) - Ribs may be pulled in - Reduced chest expansion - Dull percussion note - Reduced breath sounds with possible overlying bronchial breathing - Possible displaced apex beat |
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Pleural effusion |
- Mention aspiration markings
- Contralateral tracheal deviation - Ipsilateral reduced chest expansion - Ipsilateral dullness to percussion (stony dull), try to identify level - Ipsilateral reduced breath sounds and vocal resonance Commonest causes Congestive heart failure, parapneumonic effusion, malignancy Investigations CXR, and following confirmation of pleural effusion perform a pleurocentesis |
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Pleural effusion |
Fluid analysis - Protein, albumin, LDH, pH - Microscopy and culture and cytology - Exudate: Fluid protein>0.5 x serum protein or fluid LDH >0.6 x serum LDH (lights criteria) - pH<7.2 suggests an empyema
Exudate: Pneumonia, bronchogenic cancer, pulmonary infarction, connective tissue disease (RA/SLE), mesothelioma Transudate: Heart failure, nephrotic syndrome, hypothyroidism Haemorrhagic: Tuberculosis, malignancy, pulmonary embolism, trauma |
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Kartagener syndrome (Part of Primary Ciliary Dyskinesia) |
- Prominent heart sounds on RHS
- Apex beat palpable on the RHS "These findings are suggestive of Dextrocardia" - Dullness to percussion in the left upper quadrant instead of the right suggesting that the liver is on the left which is suggestive of situs inverses In addition: - Crackles in the lung bases suggestive of bronchiectasis "These findings suggest Kartagener syndrome" (Chronic sinusitis, situs inverses, bronchiectasis) Further hx to note: sinus infections, childhood infections, infertility (in males) |
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Gastrointestinal System Examination |
General Inspection: - obesity, encephalopathy, jaundice
Hands: nails (clubbing, leukonychia), palms (erythema, contractures), back of hand (haemachromatosis, xanthomata) Arms: bruising, scratch marks, needle tracks, arteriovenous fistula, spider naevus Face: Eyes: anaemia, jaundice, Kayser Fleischer rings Parotids: feel Mouth: angular chelitis, lips, tongue, teeth & gums, breath Neck & Axillae: lymph nodes Chest: gynaecomastia & spider naevi |
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Abdominal Examination |
Inspection: Distension, scars, pulsatile masses, bruising, striae, caput medusae
Palpation: ask re tenderness, superficial, deep (liver, spleen, kidneys, AAA) Percussion: shifting dullness, spleen size Auscultation: bowel sounds, bruits, liver (venous hum) Groin: Lymph nodes, hernia (get pt to cough) Legs: bruising, oedema, signs of peripheral neuropathy Anything else? PR & genital exam (Gastro case), fundoscopy (renal case) +/- examine CVS system (if suspecting heart failure) or CNS system (if suspecting encephalopathy), check UA, temp chart, BP (all cases) |
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Hepatomegaly |
Causes
1. Congestive heart failure: look for raised JVP, S3, crackles, pitting oedema 2. Hepatitis: viral (Hep A/B/C, EBV, CMV), Alcoholic, Drug induced 3. Cirrhosis: Early stages (Alcohol, NASH, PBC) 4. Secondary metastasis in the liver: Ask re colonoscopy results 5. Tumours: HCC, hydatid cyst, pyogenic abscess 6. Haemachromatosis 7. Infiltrative diseases: Leukaemia, Amyloidosis, Sarcoidosis 8. Autoimmune hepatitis Causes of Tender liver 1. Congestive heart failure 2. Acute hepatitis (Alcoholic, viral, EBV) 3. Malignancy 4. Vascular (Portal vein thrombosis/Budd Chiari syndrome) |
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Tender/Enlarged liver - Investigations |
Abdominal ultrasound to confirm findings
Inflammatory markers - FBC, CRP, ESR, LFT, Fasting BSL Viral studies - Hep A, B, C serology ANA and AMA levels (consider Anti LK Ab, Anti Sm Ab) Iron studies, Cu, Ceruloplasmin levels alpha1-AT levels Consider a liver biopsy if these investigations are not helpful Investigations: Chronic liver disease/cirrhosis Consider as above + UE, Albumin, INR, ascitic fluid analysis (looking for PMN count >250) which would suggest SBP |
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Hepatosplenomegaly |
Causes
1. Vascular: Chronic liver disease with portal HTN 2. Infective: Acute viral hepatitis, EBV, CMV 3. Haematological: Myeloproliferative disease, Leukaemia, Lymphoma, Thalassaemia, Sickle cell anaemia 4. Connective tissue disease: Systemic Lupus Erythematosus 5. Others: Acromegaly, Amyloidosis, Sarcoidosis |
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Splenomegaly |
Infections: EBV, CMV, HIV, Malaria, Schistosomiasis, Leismaniasis, Filariasis, Endocarditis
Haematological condition: Haemolytic anaemia, Polycythaemia rubra vera, essential thrombocytosis, CML, CLL, other leukaemia/lymphoma Vascular condition: Cirrhosis or portal HTN, splenic vein thrombosis, Budd-Chiari syndrome Rheumatological condition: SLE, RA (Felty's syndrome), Amyloidosis, Sarcoidosis Splenomegaly without lymphadenopathy is more likely to be due to a myeloproliferative condition (e.g. CML), but in the presence of lymphadenopathy is more likely due to a lymphoproliferative condition (e.g. CLL or lymphoma) |
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Ascites |
Causes
1. Portal HTN with cirrhosis - Look for varicosities, stigmata of CLD 2. Abdominal malignancy (Mesothelioma, Peritoneal metastases from primary tumour) - Look for palpable tumour, peripheral lymphadenopathy 3. CCF - Look for raised JVP, bibasal creps, pitting oedema 4. Protein loss in urine (Nephrotic syndrome) or with Protein losing enteropathy 5. TB Peritonitis 6. Portal vein thrombosis |
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Ascites - Investigations |
- Urinalysis, Urine PCR: To confirm heavy protein loss in urine
- WCC, CRP, LFT, Markers of liver function (INR, Bili, Alb) - Tests to look for underlying liver disease (see tests for enlarged liver) - Abdominal ultrasound and Diagnostic Paracetesis (MC&S and look for PMN >250 which suggests SBP) - Measure SAAG (Serum to Ascites-Albumin Gradient) SAAG>11 in portal HTN, CHF SAAG<11 in pancreatitis, peritoneal cancer/TB, nephrotic syndrome |
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Jaundice |
Pre-hepatic
- EBV infection - Fever, lymphadenopathy, sore throat, hepatosplenomegaly - Haemolytic anaemia Hepatic - Hepatitis - Viral, drug induced or alcoholic - Chronic liver disease - Spider naevi, Gynaecomastia, Hepatic flap, Signs of portal HTN (varicosities, ascites) Post-hepatic - Obstructive jaundice - Dark urine suggests obstructive cause of jaundice (Look for pale stools), Gallstones in the CBD, Malignancy at head of Pancreas - Primary biliary cirrhosis - Scratch marks over forearms - Jaundice with abdominal pain - Gallstones, Cholecystitis, Cholangitis |
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Jaundice |
Anything else?
- Pale stools/dark urine (suggests biliary tract obstruction) - PR exam - Genital exam (looking for hypogonadism) Investigations - LFT, FBC, Haemolysis screen (LDH, haptoglobins, reticulocyte count, Direct Coombs test) - Tests for intrahepatic pathology (see investigations for enlarged liver) - EBV, CMV, Hep B&C serology, Hep A (1% of time causes fulminant hepatic failure) - Abdominal ultrasound (cause liver echotexture), abdominal CT (pancreatic disease) |
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Differentials for signs in GI system |
Spider naevi and Palmar erythema - (associated with raised oestrogen levels) - chronic liver disease, pregnancy, thyrotoxicosis, chronic leukaemia
Dupuytren's contractures - manual labourer ?Alcohol excess Asterixis - hepatic disease, cardiac/renal failure, hypoglycaemia or hypokalaemia Ddx of Spider naevus - telangiectasia secondary to HHT, venous stars, Campbell de morgan spots |
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Haemochromatosis |
Key findings: Generalised hyper pigmentation and a palpable liver edge/ascites
- Jaundice, palmar erythema, spider naevi over chest and gynaecomastia - Abdomen grossly distended with shifting dullness (suggests ascites), hepatomegaly - Displaced apex beat (suggests dilated cardiomyopathy) Would like to examine for: Testicular atrophy, PR exam and urinalysis for glycosuria (suggestive for diabetes) Ix Fe studies looking for ferritin >1000 & transferrin sat >45, genetic testing MRI of liver is useful for quantifying Fe stores and reduces sampling error Ferritin <500 and asymptomatic --> observe pt, retest in 1 year Ferritin >500 or symptomatic --> regular phlebotomy Ferritin >1000 or abnormal LFTs --> liver biopsy before regular phlebotomy |
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Alcohol dependence - physical characteristics |
General inspection: Jaundiced, confused, asterixis
Gait: (Cerebellar ataxia), squat test (proximal myopathy), Rhomberg's test (Peripheral sensory neuropathy) Upper limbs: Cerebellar signs (dysdiadochokinesis, tremor) Gastrointestinal: Hepatomegaly, signs of portal hypertension Eyes: ophthalmoplegia, nystagmus Apex beat: cardiomyopathy Lower limbs: peripheral neuropathy Anything else? PR exam, Genital Exam, Temp, UA |
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Chronic Liver Disease |
General inspection: Jaundice, pallor, bruising, pigmentation
Hands: asterixis, clubbing, leukonychia, dupuytren's contractures, palmar erythema Arms: scratch marks or needle marks Face: scleral jaundice, conjunctival pallor, fetor hepaticus, dentition Chest: gynaecomastia, spider naevi, loss of axillary hair Abdomen: Gross distension with shifting dullness (ascites), prominent varicose veins that drain away from the umbilicus, hepatosplenomegaly Lymphadenopathy: cervical or axillary areas Legs: ankle oedema, evidence of peripheral neuropathy |
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Chronic Liver Disease |
Summary statement: There are key findings of … which suggest Chronic liver disease and Portal hypertension likely due to underlying cirrhosis of the liver.The hepatic flap suggests Hepatic Encephalopathy which I would like to confirm with a test of cognition e.g. Number connection test. The cirrhosis is most likely due to alcohol/viral hepatitis/NASH, less commonly autoimmune liver disease and metabolic disease
Investigations: Assess severity (FBC, U&E, LFT, INR) Assess causes (Abdominal ultrasound, ascitic fluid analysis, viral studies etc) |
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Hand Examination |
General inspection: Hair, eyes, cushingoid appearance Inspection of: Hands: Skin, rashes (psoriasis, Gottron's - DM, vasculitis - RA), steroid use changes (atrophy, thinning, bruises), Sclerodactyly, calcification, muscle wasting Small joints: Swelling (?active), fixed flexion deformity, subluxation, nodules Nails: Psoriatic nail changes (discolouration, ridging, pitting, hyperkeratosis, onycholysis), periungual infarcts - SLE, RA, DM, Scleroderma Palm: Dupuytren's contractures, tenosynovitis, trigger fingers, palmar erythema, scars |
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Hand Examination |
Active Movement
"Open and close hands" - Look for evidence of tendon rupture or FFD - Feel for tendon crepitus, trigger finger "Put palms together - Look for FFD "Squeeze my fingers" - Check for individual finger flexion weakness Thumb movements - Extension, Adduction, Abduction, Opposition Wrist flexion and extension "Show me your elbows" and "Put your hand behind your head" - Tests global arm function |
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Hand Examination |
Passive Movement & Palpation
Move Wrist - gentle flexion, extension, radial & ulnar deviation Feel Skin of hands - temperature, thickness (tethering occurs with Scleroderma) Wrists Ulnar styloid, radial styloid, each carpal bone MCPs, PIPs, DIPs (Passively move them at same time) While examining, actively look for - Tenderness or swelling (boggy vs bony, effusion, tophi) - Joint stability and correct ability of ulnar deviation - Crepitus |
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Hand Examination |
Functional Assessment
Hand Dexterity - Do/undo button - Open Jar - Turn key Neurology - Power - Sensation - Tests for carpal tunnel syndrome |
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Osteoarthritis |
- PIP, DIP and 1st CMC joint involvement
- Bouchards nodes (PIP) and Heberden's nodes (DIP) - "Squaring of hands" due to 1st MCP subluxation - MCPs generally not involved - Generally no severe deformity, no nodules X-ray - Subchondral sclerosis and cysts - Irregular joint space narrowing - Osteophytes Joints involved: DIP, 1st CMC, Knees, Hips Associations: Hip/knee pain on walking or standing for a time, worse at end of day, better with rest |
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Rheumatoid arthritis |
Inspection: wasting of dorsal interossei, FFD, swelling of MCP, PIP, swan neck deformities, Boutonniere's deformity, Z thumb deformity, nailfold infarct, palmar erythema, rad/ulnar deviation, elbow nodules
Active movement: FFD, Poor fist/wrist movements, trigger finger Palpation: Active synovitis, subluxation at ulnar and MCP joints Passive movement: Flexion weakness due to tendon rupture, non-correctability of ulnar deviation Functional Assessment X-ray: - Regular joint space narrowing - Periarticular osteopaenia (progressives to involve whole phalanges) Joints involved: Wrists, MCP, PIP, atanto-axial joint, spine, knees Associations: Morning stiffness >30min, multi-organ involvement |
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Psoriatic Arthritis |
- DIP joint involvement
- Sausage shaped fingers (due to tenosynovitis) - Psoriatic nail changes - Psoriatic plaques "reddish plaques with well defined edges and silvery white scales" X-ray: - Joint space narrowing - FLuffy periostitis - Marginal erosions (when extreme leading to pencil in cup deformity) - Distal tuft resorption Other joints involved: Feet, ankle, sacroiliitis Associations: Extreme exhaustion, plantar fasciitis, achilles tendonitis |
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Arthropathy - Haemachromatosis |
- MCP involvement (esp 2nd and 3rd MCP)
- Knees - Shoulders X-ray: - Subchondral cysts & sclerosis - Even joint space narrowing - Hook like osteophytes - Chondrocalcinosis of triangular fibrocartilage |
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Ankylosing Spondylitis |
- Kyphosis, loss of lumbar lordosis
- Restricted spine movements (back and neck) - Measure occiput to wall distance - Restricted chest expansion (<3cm) - Positive modified Schober's test - Sacroiliitis X-ray changes Spine: Kyphosis, Loss of lumbar lordosis, syndesmophytes, squaring of vertebrae with 'bamboo spine' in late stages SI joints: Loss of cortical outline, periarticular sclerosis & erosions with eventual joint space fusion Associations: Eyes (anterior uveitis), Chest (apical fibrosis), CVS (AR, MVP), Abdomen (Hepatosplenomegaly), Feet (Achilles tendonitis, plantar fasciitis) |
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Chronic symmetrical deforming polyarthropathy Arthritis plus nodules |
Chronic symmetrical deforming polyarthropathy - DDx - Generalised osteoarthritis - Rheumatoid arthritis - Chronic tophaceous gout - Psoriatic arthropathy and other Seronegative Spondyloarthritidies Arthritis plus nodules - DDx - Rheumatoid arthritis - Systemic lupus erythematosus - Rheumatic fever - Amyloid arthropathy Rheumatoid nodules are found on extensor and flexor surfaces whereas Gouty tophi are often over joints (e.g. the olecranon bursa) and tend to be harder |
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Painful, erythematous, monoarticular inflammation |
First thing to consider is Septic arthritis (due to haematogenous spread or direct penetrating injury) - Gout, pseudogout or hydroxyapatite arthropathy - Haemochromatosis - Traumatic joint effusion (shouldn't be as red) - Haemarthrosis - Seronegative spondyloarthritis |
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Scleroderma |
General inspection: Tight, thick skin over face, microstomia Hand examination: Tight skin, sclerodactyly, finger pulp atrophy, calcification, dilated capillary loops, vitiligo Reduced range of movement & subsequent flexion deformity Proceed to Peripheries: Look for calcification in elbows & extensor area of arms CVS: Features of CHF, irregular pulse (AF), pericardial rub, loud P2 Resp: Reduced chest expansion, bibasal crackles (pulmonary fibrosis) Abdominal: Hepatomegaly (primary biliary cirrhosis) Joints: Shoulders, Elbows, Knees, Ankles |
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Signs in Hand Examination |
Splinter haemorrhages: SLE and bacterial endocarditis Periungaual telangiectasiae: SLE, scleroderma, dermatomyositis Muscle wasting in the palmar surface: Disuse, vasculitis, peripheral nerve entrapment |
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Thyroid Examination |
Examine goitre first, then peripheries General Inspection: Hyperthyroidism (stare, lid lag, tremor) Hypothyroidism (dry, coarse, cool skin) Inspect Thyroid: Look from front and side Look at: scars & swelling, redness (supp thyroiditis), inferior border (if not present suggests retrosternal goitre) and prominent veins (thoracic inlet obstruction) 'Sip & Swallow water' (look for elevation of thyroid/thyroglossal cyst) 'Stick tongue out' (Thyroglossal cyst will elevate) Palpate: thyroid from front Move behind and look from above (look for exophthalmos) |
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Thyroid Examination |
Palpation: Stand behind the pt with their neck slightly flexed Mass: size, shape, consistency, tenderness, mobility, (thrill may indicate metabolic activity), can you get below it? Palpate with pt swallowing water Palpate all nodes in neck Palpate carotids (lack of pulsation may be from tumour infiltration) Check tracheal displacement Percussion: percuss manubrium for a retrosternal goitre Auscultation: Thyroid bruit (metabolically active thyroid) Pemberton's sign: Look for facial plethora, cyanosis, stridor, distended neck veins (due to thoracic inlet obstruction secondary to retrosternal mass) |
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Neck swelling |
Causes Midline: - Goitre - Thyroglossal cyst - Parathyroid gland - Submental lymph nodes Lateral: - Lymph nodes - Salivary/submandibular/parotid gland enlargement (stone or tumour) |
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Diffuse Goitre |
Causes 1. Unknown cause (this is the majority) 2. Pregnancy, postpartum and puberty (3Ps) 3. Grave's disease 4. Thyroiditis - Hashimoto's, Subacute (tender), Chronic fibrosing (Riedel's thyroiditis) 5. A lack or an abundance of iodine 6. Medications (lithium) 7. Inborn errors of thyroid hormone synthesis |
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Thyrotoxicosis |
Causes With a goitre (diffuse or nodular): - Grave's disease - Toxic adenoma - Toxic multinodular goitre - Subacute thyroiditis Without a goitre: - Early Grave's - Excessive thyroxine replacement - Post partum thyroiditis (goitre possible) - Hydatiform mole, Choriocarcinoma, Struma ovarii |
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Hypothyroidism |
Causes With a goitre: - Hashimoto's thyroiditis - Pituitary lesion - Drugs (Amiodarone, Lithium) - Severe Iodine deficiency Without a goitre: - Idiopathic atrophy - Agenesis or lingual thyroid - Post thyrotoxicosis treatment (e.g. with surgery or radioactive iodine) |
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Marfan Syndrome |
- Long limbs:arm span >height - Arachnodactyly - Thumb sign - Wrist sign - Eyes: blue sclera, lens subluxation - Mouth: high arched palate - CVS: pectus excavatum, signs of AR or MVP Other associations: Scoliosis, kyphosis Aortic root dilatation (Annual TTE needed to monitor aortic root. Need prophylactic graft placement when diameter >50-55mm) |
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Silent chest |
Dextrocardia MS PDA ASD TR |
