How to Be A Doctor



How to Be A Doctor

SHORT CASE

For short case: findings; relevant +ive and –ives

Differential – and things that back up likely diagnosis or go against it

Markers of severity

Complications

LONG CASE

History – 15-20mins

Hello, this is exam; sorry for time restraints; you can tell me anything you know

What is wrong? Why are you in hospital this time? Do you know your diagnosis?

HPC Presenting symptoms

Is there an action plan?

What did the doctors do for you in ED? What did they do for you in the ward?

What management and investigastions do the doctors have planned for you?

What consultations have you had?

What were the results of investigations?

PMH List in order of importance; do you have a list of your medical problems? Active / non-active

Generic details Immunisation status (influenza, hep A, hep B, Pneumococcus)

Systems review – SOB, bowels etc…

DH Do you have a list of medications?

A

SH Occupation, adequacy of income, current housing, ability to cope, mobility + steps

Smoking, ETOH, drugs

Hobbies (animals, chemicals, dusts), marital status, sexual problems and preference

Immunisation

Education and language

Place of birth, overseas travel

Level of Fx in community; level of help in community

Involvement of ancillary: physio, SW, OT

Psychological impact of disease

FH

Examination – be finished by 20-35mins

What did examiners examine? Did they comment on signs?

End

Is there anything else I should know? Has anyone else asked you questions I haven’t asked? Did anyone else examine anything I didn’t?

Presentation

Intro:

Is this management / diagnostic or investigative problem: demographics, patient issues, intro

Mrs X is a 77 year old lady who lives with and is struggling to care for her unwell husband (social). She presented to the ED with the challenging investigative, management & resuscitation problem of shortness of breath and palpitations with likely cardio-respiratory failure (emergency problem). This is on a background history of cardiac failure, ischaemic heart disease, ventricular tachycardia, mitral valve replacement, non compliance with her medications (contributing RF’s) including warfarin, recent dental procedures, renal impairment, smoking & possible bronchospasm.

HPC: Presenting problem – much detail; relevant history; relevant +ives and –ives; Type of presentation; date; current

GP, specialist and ward

Systems review

PMH Active problems – some detail

Active problems that are not relevant to current presentation

Non-active problems

DH + A – reference what medication is used for

FH

SH – include non-clinical issues

Examination cardinal signs and other signs; general appearance; vital signs; most important system first; relevant +ives and -ives

Summary statement

In conclusion; Mrs X (demographics) is now recovering from cardio-respiratory failure 2 weeks post admission. It seems likely that this was due acute pulmonary oedema (key issues). Contributing factors are multi-factorial but likely include ischaemic heart disease, AMI, occluded coronary artery bypass grafts, renal impairment and arrhythmias. Further investigations would be required to determine the severity of these factors and to determine other contributing factors. Optimal medical management is required as well as considering her suitability or non-suitability for more invasive future management. Mrs X may struggle to live independently and this has implications for her husband who has been largely dependent on her.

Differential diagnosis and findings that support / refute – with relevant weightings

What would you do if this patient came into ED? Or may need to postulate on possible presentations of this patient to the ED

Investigations and justification for (beside, lab, imaging) – comment on results if given

Management and management goals – inc supportive care, disposition etc…

Primary ED points in this case are

CV

History

IHD RF’s IHD, incr lipids, DM, HTN, +ive FH, smoking, OCP, premature menopause, obesity, physical

inactivity, long term NSAIDs, erectile dysfunction

Complications Arrhythmia, CCF, angina, emboli; OT

Trt Angioplasty / thrombolysis / CABG (number of grafts; drug eluting stent?)

Anticoagulants and how long

Rehab program; RF control

IE Symptoms Malaise, fever, anaemia

Cause / RF’s Recent dental / endoscopic / OT

RF, congenital heart disease, valve lesions, heart OT, IVDU, immune suppression

Complications Embolic: CVA, loin pain

Trt Antibiotic prophylaxis (constant – for RF; before procedure – IE)

if prev IE, prosthetic heart valve, congenital heart malformation (unrepaired cyanotic heart

disease, residual defect, recent OT), cardiac transplant with valve disease --> dental

procedure, oral surgery

?valve replacement discussed

A Abx allergy

OE Clubbing, splinter haem (also vasculitis, RA, PAN, haematological malignancy, trauma), Osler’s

nodes (finger, painful), Janeway lesions (palms and pulps, non-tender); Source of infection; Roth’s

spots, conjunctival petechiae; dentition; Regurg/stenosis; prosthetic valve; PDA; VSD; coarctation of

aorta; Signs of CCF

CCF Symptoms SOB, PND, orthopnoea, oedema, ascites, nausea; chest pain

Classify by NYHA

Cause Precipitant (arrhythmia, med change, MI, anaemia, infection, thyrotoxicosis, OT, PE, salt intake,

NSAIDs, XS exertion, pregnancy)

RF’s As above

For cardiomyopathy: ETOH, FH of same, haemachromatosis

PMH HTN, IHD, RF, valve disease, congenital heart disease, cardiomyopathy, prev cardiac OT

OE Precipitant; Postural BP (?beta-B, ACEi)

HTN Symptoms Measurements

Cause Endocrine, phaemochrom Sx; RAS; coarctation of aorta, adrenal Ca

Risk factors DM, lipids; ETOH, exercise, salt intake, smoking

Complications CVA, CCF, PVD, renal failure

Trt SE’s of trt

OE Fundi (silver wiring, AV nipping, flame haemorrhages, cotton wool spots, hard exudates, Papilloedema);

LVF; coarctation

Arrhythmia Symptoms Palpitations, effect of Valsalva, syncope; persistency

RF’s IHD, AS, cardiac OT, congenital heart disease, thyrotoxicosis, WPW, recent ETOH binge, PE,

HTN

RF for embolic events (prev emboli, MV disease, CCF, HTN, DM, thyroid)

SH Ability to manage multiple blood tests and trips to lab

FH Sudden cardiac death (long QT, Brugada, HOCM)

Trt IV/PO? manouvres? shock? SE’s of trt? Ablation? AICD?

Recent INR’s + Warfarin doses

Generic details

Immunisation status (influenza, hep A, hep B, Pneumococcus)

Compliance with meds

Examination

What did examiners examine? Did they comment on signs?

Stand back and look

Sit patient at 45 degrees and expose neck and chest

General Temperature chart; ?IV cannula; ?infusion running

Syndromes Marfan’s, Turner’s, Downs, Cushings, acromegaly

General Uraemia, SOB, cyanosis

CCF Precipitating factor

Oedema Nutrition, myxoedema

Put hands on thighs in front of them

Hand Pulse (rate, rhythm – NOT CHARACTER); radio-radial; clubbing; peri cyanosis

Pemberton’s sign

HOCM Jerky / sharp pulse

AR Collapsing pulse; Quincke’s sign

Hyperlipid Tendon xanthomata

SVC obstr Arm oedema

Clubbing = RS Lung Ca, bronchiectasis, lung abscess, empyema, pul

fibrosis, asbestosis, CF, mesothelioma

CV IE, cyanotic congenital heart disease

GI IBD, cirrhosis, coeliac

- Thyrotoxicosis, familial, pregnancy, 2Y hyperPT

Take BP: (boths arms, lying and standing if HTN; legs if young and HTN) – estimate SBP via radial pulse

Face Xanthelasma; petetchiae; cyanosis; scleral pallor; Argyl-Robertson pupil (AR)

MS Malar flush

Valve Jaundice (haemolysis)

Marfan’s Arched palate

SVC obst Plethoric cyanosed face, periorbital oedema, exopthalmos, conjuctival injection, Horner’s

syndrome, fundi for venous dilation

Neck JVP [pic]

Height, character, change with respiration; do hepatojugular reflex (15 secs in epigastrium –

?sustained)

Dominant a wave = atrial contraction: TS, PS, pul HTN (eg. 2Y to MS), HOCM

Dominant v wave = atrial filling: TR

Cannon a wave: CHB, nodal tachycardia, VT, pacemaker

Elevation: RVF, TS, TR, pericardial effusion, constrictive pericarditis, SVC obstruction, fluid

overload, hyperdynamic circulation (eg. Fever, thyrotoxicosis)

Carotids Character; carotid bruit

AS Slow rising

AR Corrigan’s = prominent, water hammer

SVC obstr Raised non-pulsatile JVP; ?large thyroid gland; LN’s; stridor

Chest Inspection Scars, deformity, visible pulsations, pacemaker

Palpation Apex beat (position in ICS, mid clavicular line, character)

Pressure loaded = forceful + sustained = AS, HTN

Volume loaded = forceful + unsustained = AR, MR

Tapping = MS

Double / triple = HOCM

Absent = constrictive pericarditis

Thrills: across L side chest horizontally = palpable murmur = AS, MS, VSD

Parasternal impulse: L sternal edge vertically

RV Heave = RVH, LA enlargement = MR

Auscultate Bell + diaphragm at apex

Diaphragm at lower and upper L sternal edge, R upper sternal edge

If murmur, time with carotid pulse

Listen below L clavicle for PDA murmur

L lateral position: rpt apex and bell in mitral area (for MS)

Sitting forward in expiration: rpt thrill, listen lower L sternal edge with diaphragm; ?AR

If ?HOCM (ie. Pure systolic murmur) – Valsalva, resp phases, hand grip, standing, squatting at

lower left sternal edge with diaphragm

S1 Loud MS, TS Hyperdynamic

Soft MR 1st deg HB, LBBB

S2 Loud AS HTN

Soft AR, PS

AV closes then PV usually on inspiration = physiological splitting

Wide = Incr splitting on inspiration PS, MR, VSD, RBBB

Fixed splitting ASD

Reversed AS, CoA, PDA, LBBB

S3 Rapid diastolic filling = AR, MR, VSD, PDA, failure, constrictive pericarditis

S4 High atrial pressure = AS, PS, MR, HTN, HOCM, IHD

Systolic Early MR, TR VSD

Mid AS, PS ASD, HOCM

Late MVP HOCM

Pan MR, TR VSD, AP shunt

Diastolic Early AR, PR

Mid MS, TS, AR RF, Austin Flint of AR, atrial myxoma

Late MS, TS Atrial myxoma

Continuous PDA, AV fistula, venous hum, AP connection, mammary souffle

HOCM Ejection and pan-systolic murmur

Louder with Valsalva, standing, jogging

Softer with squatting, raising legs, forceful handgrip

SVC obstr Distended collaterals

( patient is now sitting up

Back Inspection Scars, deformity, oedema

Palpation Percuss for pleural effusion

Auscultate ?LVF – crackles

( lie flat

Abdo Lie flat with 1 pillow

Inspection

Palpation Radio-femoral (if PMH of HTN)

Liver (megaly = RVF, constrictive pericarditis; pulsatile = TR), spleen if ?IE (megaly = IE,

constrictive pericarditis), aorta, femoral arteries; renal mass (HTN)

Auscultate Femoral arteries; renal bruit (in HTN; R+L above umbilicus; over flanks)

Oedema Ascites; collaterals; liver

Legs Cyanosis, cold, trophic changes, ulceration, peri pulses (dorsalis pedis, post tibial), oedema, calf tenderness;

varicose veins

Oedema Inguinal nodes; delayed ankle jerk (hypothyroid)

Neuro IE FND; fundi

Presentation

Intro, summary

Differential diagnosis

Findings that support / refute diagnosis; always tailor to specific patient

IE Atrial myxoma, occult malignant neoplasm, SLE, PAN, post-strep GN, PUA, cardiac

thrombus

Incr trop Thrombus MI

Infection Myocarditis

Trauma Cardiac contusion, cardioversion, biopsy; cardiac OT; stent; angioplasy

Tox Cardiotoxic; Irukandji syndrome

Other cardiac CCF; aortic dissection; HOCM; AS; AR; arrhythmia; cardiomyopathy; rhabdo

Non cardiac Sepsis; renal failure; PE; pul HTN; burns; exertion; CVA; SAH

Investigations

Ask for 1-2 recent investigations and reason for ordering

Comment on results, even normal

Bedside Echo (vegetations; valve S/R; RWMA; LVEF); ECG; Temp chart

Lab Trops; Na, K, Ur, Cr, BNP, Hb; TFT

IE: cultures (3-6x over 24hrs; strep viridans, strep faecalis, strep bovis, staph epidermidis, HACEK, fungi);

FBC, ESR, serology (immune complexes, C3, C4, RF, ANA); urine; Haematuria, proteinuria, RBC casts

HTN: ?cushings

Imagin ETT, stress echo, angiogram; CXR; RV biopsy; renal angio in HTN; Holter

Management

Suggest management and set management goals

IE Benpen 6-12g OD for 4-6/52

Valve replacement: if resistant, mod-severe failure, persistent +ive blood culture, conduction disturbance

CCF Remove cause

Inotropes (dobutamine, dopamine, Levosimendan)

Implantable defib if malignant rhythm / severe

Decr activity; diuretics; low salt diet; fluid restriction; daily weighs; ACEi / AR blocker, beta-blockers, digoxin

HTN Remove cause

Lifestyle factors (weight, exercise, ETOH, salt)

Meds

Arrhythmia Drugs; pacing; AICD; rate vs rhythm control; AVN ablation; DC cardioversion

CHADS2

RS

History

HPC Bronchiectasis Symptoms Haemoptysis, SOB, wheeze, sinusitis, recurrent pneumonia, weight loss, fever,

anorexia, CCF); When began

PMH Childhood pertussis, measles; LRTI; flu; CF, TB, HIV, 1Y cilliary akinesia, aspergillosis

RA, Sjogren’s syndrome

DH Abx; bronchoD

Mng Physio, postural drainage, lung resection

OE Large vol purulent sputum; Clubbing; Coarse crackles; Pneumonia,

pleurisy, empyema, lung abscess; Signs of R heart failure, cor pulmonale

Ix Bloods Ig levels; ABG

Other Sputum results; PFT’s (restrictive/obstructive); cilliary Fx; sweat test;

bronchogram

Imaging CXR (cystic lesions, thick bronchial walls, streaky infiltration), CT scan

Lung Ca Symptoms Haemoptysis, cough, SOB, chest pain, systemic Sx) How diagnosed?

Metastatic symptoms (rib, nerve involvement, SVC obstruction, dysphagia,

lymphangitis, lymph nodes, bone, brain)

Cause Smoking, occupation

SH No of dependents

OE Haemoptysis, Weight loss, cachexia, fever, gynaecomastia, opportunistic infections;

Clubbing; lower brachial plexus inj ( weak finger abduction; hypertrophic

pulmonary osteoarthropathy; Ptosis and constricted pupils (Horner’s); SVC

obstruction; Fixed insp wheeze; Pleural / pericardial effusion, tracheal

obstruction; Oesophageal obstruction, hepatomegaly; Lymphangitis, cervical

adenopathy, dermatomyocytis, thrombophlebitis, acanthosis nigricans, scleroderma,

purpura; Pancoast tumour, RLN palsy, diaphragmatic paralysis, FND, Eaton

Lambert’s, peri/autonomic neuropathy, SACD

Ix Bloods Incr Ca (PTH), decr Na (ADH), ACTH, glu; FBC; LFT

Other Sputum cytology; PFT’s biopsy / FNA; bronchial brushings / washings; pleural

biopsy; staging

Imaging CXR (hemidiaphragm changes; peri = adenoCa; central = squamaous; hilar =

small cell; infiltrate = bronchoalveolar); CT; bronchoscopy;

COPD Symptoms SOB, cough, sputum, wheeze, exercise tolerance, wegith loss

Precipitants URTI, pneumonia, meds, RVF, smoking, aspiration, GORD; Smoking (age started, how

many)

DH Steroids, bronchoD; home O2

SH Occupation (air pollution, plastics factory toluene)

FH Alpha-1 AT

OE Look at sputum; cachexia; SE of trt (eg. tremor in salbutamol, steroids); Early

coarse insp creps; Pursed lip; exp time; WOB

Ix Bloods ABG; Hb (polycythaemia); alpha-1 AT; albumin; Ca, phos

Other PEFR; PFT’s (decr FEV1/FVC; 15% incr with bronchoD); sputum culture; BMI;

ECG (RVH, multifocal atrial tachy)

Imaging CXR (hyperinflation, cor pulmonale, pneumoniae, bullae); CT;

ILD Symptoms SOB, cough, lethargy, malaise, fever, rash, arthralgia, haemoptysis; Onset and duration

PMH Scleroderma, SLE, Sjogren’s, RA, sarcoidosis, asthma, Churg Strauss, Goodpasture’s,

PAN; Prev radiotherapy, aspiration pneumonia, miliary TB

DH Amiodarone, hydralazine, procainamide; Methotrexate, penicillamine, bleomycin,

cyclophosphamide; Nitrofurantoin, bromocriptine

SH Mineral dust (silicosis, asbestosis, coal), chemicals (NO2, Cl, NH3), birds, farmer, flax,

hemp dust

OE Clubbing; Ant uveitis; Fine dry late/pan insp creps; Cyanosis; upper vs lower;

Erythema nodosum; signs of steroid SE’s

Ix Bloods ABG; ESR; LDH; eosinophilia; serology for CT diseases

Other PFT’s (restrictive usually); Bronchoalveolar lavage; biopsy

Imaging CXR; CT

DD Idiopathic interstitial pneumonia, CT disease (eg. see above), GVHD, Crohn’s, 1Y biliary

cirrhosis, occupational, radiation, aspiration pneumonia, drugs (see above), gases,

hypersensitivity

Sarcoidosis Symptoms Fever, weight loss, malaise, cough, SOB, arthralgia, blurred vision, eye pain, tearing

DH Steroids, NSAIDs, cyclosporins, cyclophosphamide

OE Ant uveitis, yellow conjunctival nodules, papilloedema; basal end-insp

crackles; RV failure, cardiomyopathy, arrhythmia, pacemaker, AICD;

Hepatomegaly, splenomegaly; Erythema nodosum, lymphadenopathy, parotid

enlargement, plaques, rash (erythematous spots with waxy flat top), subC nodules,

lupus pernio on face (purple shiny swollen nodules); facial nerve palsy

Ix Bloods FBC (decr WCC, incr eosinophils); incr ESR; ACE; ABG

Other PFT’s (decr lung vol, normal FEV1/FVC); LN biopsy; ECG (CHB, V

arrhythmias); lung/LN biopsy

Imaging CXR (hilar lymphadenopathy, pul infiltration, paratracheal lymphadenopathy,

reticulonodular changes, cavitation, pleural effusion, linear atelectasis); CT

chest; bronchoscopy and biopsy

DD TB, histoplasmosis

CF Symptoms Age of diagnosis; presenting Sx (eg. recurrent LRTI, FTT); cough, sputum,

haemoptysis, wheeze, SOB, nasal polyps, sinusitis, weight loss, diarrhoea,

steatorrhoea, constipation, bowel obstruction, abdo distension; occasionally biliary

cirrhosis --> portal HTN --> jaundice, varices; DM; rectal prolapse

No. prev hospital admits

SH Support network; understanding of inheritance

Mng Physio, antibiotics, bronchoD, pancreatic enzyme

OE Conditioning; BMI; Clubbing; Quality of cough; examine sputum; chest wall

Development; fecal loading

Ix Bloods FBC (AOCD or malabsorption; WCC); U+E; LFT; ADEK def

Other Sputum culture; PFT’s; sweat test

Imaging CXR (compare with prev films; incr lung markings; cystic changes; mucus

plugs; atelectasis; pneumoT); CT

Pul HTN PMH Collagen vascular disease, shunts, portal HTN, HIV, splenectomy, myeloproliferative

disorders, L heart disease, COPD, ILD, thromboembolic obstruction, scleroderma,

congenital heart disease

OE DVT; RV heave; palpable P2; TR

Ix Bloods ABG

Other PFT’s

Imaging CXR (RV dilation, large prox pul arts); ECG (R heart strain, hypertrophy), CT

angiogram, VQ scan, echo; R heart catheterisation

TB Symptoms Weight loss, sweats, fever, cough, chest pain; Time of diagnosis

PMH Malnutrition, alcoholism, HIV, DM

SH Recent immigration; Social effects of disease; continue work? do friends know

diagnosis? does occupation present public health risk? screening of friends/family?

family members treated?

Mng Meds, how long for, supervised / unsupervised, SE’s (hepatitis, ototoxicity, optic neuritis,

peri neuropathy, diarrhoea)

OE Conditioning; LN’s; 1Y: pleural effusion, empyema, lobar collapse; 2Y: upper lobe

crackles, wheeze; Pericarditis, tamponade; Loin tenderness, abdo nass

Ix Bloods rpo gene if resistant; PCR for rapid; tuberculin testing; fasting BSL (for DM)

Other Sputum (3 samples on separate days), Ziehl-Neelsen; LN biopsy; bronchial

washings; sensitivities; Mantoux (5mm high risk, 15mm low risk)

Imaging CXR (infiltrates, cavities (2Y); focal shadowing and enlarged LN’s = 1Y Ghon

complex; may be normal if HIV)

Generic details Immunisation status (influenza, hep A, hep B, Pneumococcus)

Examination

Undress to waist and sit up in bed – watch for SOB

Ask to see sputum and temp chart

General Sputum; SOB at rest; RR; WOB; cachexia; ask to cough (loose, dry, bovine (RLN inj)); PEFR; FET

(abnormal if >3secs); audible wheeze; breathing pattern

Put hands out in front to look for flap

Hands Clubbing = RS Lung Ca, bronchiectasis, CF

Lung abscess, empyema, pul fibrosis, asbestosis,

mesothelioma

CV IE, cyanotic heart disease

GI IBD, cirrhosis, coeliac

- thyrotoxicosis, familial, pregnancy, 2Y hyperPT

Peri cyanosis; nicotine staining; anaemia; small muscle wasting (weak finger abduction = lower brahcial plexus

inj from lung Ca); wrist tenderness (hypertrophic pulmonary osteoarthropathy); pulse (pulsus paradoxicus);

flapping tremor

Face Ptosis and constricted pupils (Horner’s); central cyanosis; press maxillary sinus and percuss frontal sinus;

say a few words if voice sounds hoarse

Neck Position of trachea (deviation suggests upper lobe abnormality); tracheal tug; LN’s

Sit up with legs over side of bed to examine back

Back Inspection Kyphoscoliosis; ank spond (assoc with fibrosis); scars; prominent veins; radiotherapy skin

Changes; needle marks from prev aspirations

Palpation Expansion (upper = look at clavicles from behind to ensure moving; and lower – aim 5cm

separation)

Percussion Inc supraclavicular

[pic]

Auscultate BS (bronchial / vesicular; normal / decr; crackles, wheeze; early/mid/late/pan; insp/exp)

Vocal resonance (say 99)

CCF Medium late/pan insp creps

Sit back in bed

Chest Inspection Chest deformity; symmetry of movement; distended veins; radiotherapy and radiotherapy

marks; scars

Palpate Supraclavicular, axillary LN; apex beat; chest expansion; palpate breasts

Percussion Clavicles directly, then lower

Auscultate In high axillae also

Lie to 45 deg

JVP Pul HTN Incr JVP; large V wave on JVP

Lie flat

Abdomen Inspection Signs of liver failure

Palpate

Legs Peri oedema

Investigations

Pleural fluid analysis

CXR, plus ask to see lateral

End

Is there anything else I should know?

Presentation

Draft intro statement

Differential diagnosis

Findings that support / refute diagnosis

[pic]

Pul fibrosis Upper lobe Toxin Silicosis, coal worker’s pneumoconiosis, radiation

Infection TB; CF; aspergillosis; PCP

Infiltrative Sarcoidosis, histiocytosis, aspergillosis; eosinophilic

Rheum Ank spond

Lower lobe Toxin Asbestosis, hydralazine, amiodarone, bleomycin

Infective Bronchiectasis, aspiration

Infiltrative Cryptogenic fibrosis alveolitis

Rheum RA, scleroderma

Large hilum LN Lymphadenopathy; Ca

Vessel Pul venous HTN (upper half hilum; LVF, MS, MR)

Pul artery HTN (1Y pul HTN, lung disease)

Incr pul blood flow (L(R shunt, hyperdynamic circulation)

Focal consolidation Infective Pneumonia; Atelectasis

Vascular Pul infarction; intrapul haemorrhage

Ca Alveolar cell carcinoma

Diffuse airspace disease Infective Pneumonia (mycoplasma, pneumocystis); interstitial pneumonitis

Vascular Pul oedema; contusion; PE

Ca Alveolar cell Ca; lymphoma

Autoimmune Goodpasture’s; alveolar proteinosis

[pic]

Fine reticular = ILD Vascular Pul oedema

Infective Interstitial pneumonitis (mycoplasma, viral); atypical pneumonia

Ca Lymphangitis metasasis

Autoimmune Sarcoidosis; histicytosis; SLE; RA; scleroderma; polymyositis; hypersensitivity

pneumonitis; eosinophilic granuloma; collagen vascular disease; fibrosing

alveolitis

Toxin Inhalation injury; asbestosis, silicosis, farmer’s lung, coal, methotrexate,

amiodarone

Coarse reticular End-stage pul fibrosis

Reticulonodular As per reticular

Miliary nodular (2-3mm) TB, fungal, nocardia, varciella, silicosis, coal worker’s pneumoconiosis, sarcoidosis, eosinophilic

granuloma, neoplastic

Nodular (>3cm) Mets; lymphoma; benign tumours; fungal; parasitic; septic emboli; RA; Wegener’s

Granulomatosis

[pic]

Cavitating lesions Infective Staph aureus, klebsiella, anaerobes, aspiration, G-ives, TB, fungal (aspergillosis,

cryptococcal)

Vascular Septic emboli; pul infarct

Ca SCC, Hodgkin’s

Autoimmune Granulomatosis; sarcoid; Wegener’s; RA

Other

Management

Suggest management and set management goals

Bronchiectasis Abx; bronchoD; inhaled steroids; postural drainage; pred; vaccines; trt of CCF; Ig if Ig def; embolisation

if massive haemoptysis; smoking cessation; OT if localised disease; transplant if end stage

Lung Ca OT (if non-small cell); radiotherapy; maybe chemo

COPD Nicotine replacement; Abx; bronchoD; inhaled steroids; vaccine; steroids; pul rehab; home O2; trt CCF; BiPAP

ILD Remove exposure; steroids; maybe immunosuppression (cyclophosphamide, colchicine); vaccines; home O2;

lung transplant

Sarcoidosis Prednisone; if longer term, Methotrexate, Azathioprine; infliximab

CF Physio; Abx; bronchoD; pancreatic enzymes; lung transplant

TB Isoniazid, Rifampicin, ethambutol, pyrazinamide; IREP initially until sensitivies available --> IRP for 2/12 --> IR

4/12; may need to be supervised; repeat sputum cultures until become negative; resistant if +ive after 3/12

GI

History

HPC PUD Symptoms Pain, relief, recurrences, GI bleed; Weight loss, recurrent vomiting

PMH Dyspepsia; DM; thyroid; hyperPT; CT disease; prev ulcer OT

DH Digoxin, KCl, PO Abx, NSAIDs, ETOH; PPI; H pylori trt; steroids; anticoagulants

FH Of same (?MEN I)

OE Anaemia; Epigastric tenderness; scar; melaena; abdo mass (?Ca)

DD GORD, gastric Ca, biliary pain, pancreatitis, pancreatic Ca, chronic mesenteric

ischaemia; varices; Mallory-Weiss tear; erosions; angiodysplasia

Malabsorption Symptoms Pale, bulky offensive stools; weight loss; weakness (K def); anaemia (Fe def); bone pain

(osteomalacia); glossitis and angular stomatitis (Vit B def); bruising (Vit K def);

oedema (protein def); peri neuropathy (vit B def); eczema, dermatitis herpetiformis;

amenorrohoea (protein def)); time of onset and duration

PMH Cause: gastrectomy, prev bowel OT, liver / pancreatic disease, Crohn’s disease, prev

radiotherapy, DM, HIV

DH ETOH, neomycin

FH Coeliac disease, IBD

OE Weight, conditioning; Clubbing; Bruising, dermatitis herpetiformis, erythema

nodosum, pyoderma gangrenosum, stomatitis, pigmentation, perianal lesions,

anaemia; Scars, chronic liver disease signs

DD Coeliac disease, tropical sprue, giardiasis, lymphoma, Whipple’s disease, IBD, chronic

pancreatitis, CF, biliary obstruction, chronic liver disease, bacterial overgrowth, SI

ischaemia, SI resection, HIV

IBD Symptoms Reason for admission, number of hospital admissions; Current symptoms

UC – bloody diarrhoea, malaise, fever, weight loss

CD – pain, diarrhoea, weight loss, malabsorption, intestinal obstruction

Complications Toxic megacolon, perf, haemorrhage, strictures, fistula, anorectal disease, abscess,

obstruction, perf, gallstones, Ca, liver disease (fatty liver, 1Y sclerosing cholangitis,

cirrhosis, cholangiocarcinoma, amyloidosis); anaemia; Fe def; thromboembolism;

arthropathy; ank spond; erythema nodosum; pyoderma gangrenosum; apthous ulcers;

uveitis / conjunctivitis / episcleritis, renal stones, osteomalacia

DH NSAIDs, retinoic acid, OCP

SH Sexual preference (proctitis is DD); smoking (protective in UC); domestic arrangements

and employment

FH Of same, bowel Ca

OE Nutrition, hydration; signs of Cushing syndrome; Clubbing; Lesions, anaemia; Uveitis; Tenderness; abdo masses; anal lesions; signs of liver disease

DD Pseudomembranous colitis, radiation, ischaemic colitis, diversion colitis, toxic exposure,

lymphocytic colitis

Colon Ca Symptoms Change in bowel habit, PR bleeding, anaemia, AP, constipation, vomiting; bladder Sx

from invasion; neuro pain from sacral plexus

Complications Proctitis, cystitis

PMH Polyps; IBD; Peutz-Jehger’s syndrome; DM; acromegaly

SH Determine if understands diagnosis; social support network

FH FAP (if present ask if children have been screened); ovarian / endometrial Ca

OE Changes of radiotherapy, pigmentation of Peutz-Jehger’s; Abdo masses, scars, PR

CLD Symptoms Jaundice, ascites, AP, bleeding, encephalopathy, weakness

Complications Encephalopathy, portal HTN, ascites, varices, erectile dysfunction

PMH Hepatitis, jaundice, prev transfusions, DM, CCF, haemachromatosis; hepatitis status;

Wilson’s disease; For NASH – obesity, type II DM, incr lipids

DH Methyldopa, isoniazid, nitrofurantoin

SH ETOH intake, drug addiction, sexual orientation, tattoos, overseas travel

OE Racial origin; Clubbing; Tattoos; scratch marks; xanthelasma; collaterals; hair loss;

spider naevi; Kayser Fleishcer rings (Wilson); bilat VI nerve palsy (Wernickes); CCF;

TR; constrictive pericarditis; Signs of chronic liver disease / portal HTN; splenomegaly;

ascites; oedema; melaena; liver bruit; abdo mass

DD ETOH; Hep B/C; NASH; drugs (methyldopa, chlorprom, isoniazid, nitrofurantoin,

Methotrexate, amiodarone), autoimmune; haemachromatotis; Wilson’s disease; 1Y

sclerosing cholangitis; 1Y/2Y biliary cirrhosis; alpha-1 AT def; CF; Budd-Chiari

syndrome; CCF; constrictive pericarditis; idiopathic

Generic details Immunisation status (influenza, hep A, hep B, Pneumococcus)

Investigations PUD Endoscopy, barium meal, H pylori (serology / biopsy)

IBD Follow up colonscopies

Colon Ca Staging results; surveillance colonoscopy

CLD Liver biopsy

Management PUD Blood transfusion, injection in peptic ulcer base, surgical oversewing

Malabsorption Diet, pancreatic supplements, Vit supplements, cholestyramine, Abx

IBD Sulfasalazine, mesalazine, olsalazine, steroids, metronidazole, Azathioprine, infliximab

Colon Ca Radiotherapy

CLD Protein restriction, fluid restriction, ETOH abstinence, steroids, Lactulose, neomycin,

TIPS procedure

Examination

What did examiners examine? Did they comment on signs?

General Jaundice, pigmentation (haemochromatosis), xanthomata (1Y biliary cirrhosis), mental state (encephalopathy);

wasting, cachexia; drowsiness; temperature

Hands Clubbing (IBD, cirrhosis, coeliac), leuconychia, palmar erythema, Dupuytren’s contractures,

Arthropathy (haemachromatosis), hepatic flap (30secs)

Arms Spider naevi, bruising, wasting, scratch marks (chronic cholestasis); ask for BP

Face Sclera, jaundice (colon Ca, CLD), anaemia (PUD, colon Ca), iritis; parotids (ETOH); fetor hepaticus; stomatitis,

leukoplakia, ulceration, gingivitis, bleeding, atrophic glossitis; pigmentation

Sit up

Neck From behind; LN’s (colon Ca, malabsorption)

Swing legs over side of bed

Axilla Axillary LN’s

Sit back down on bed

Chest Inspection Gynaecomastia, spider naevi

Palpate Breasts if think intra-abdo Ca

Auscultate For pleural effusions / creps; HS for TR if pulsatile liver felt

Lie flat with 1 pillow, exposure abdo

Abdomen Inspection From foot of bed, from side; masses, scars, distension, prominent veins, striae, bruising,

Pigmentation; visible peristalsis; spider naevi

Take deep breaths and observe from side to look for moving liver

Palpation Ask if tender; light then deep palpation; liver, spleen; roll on R and palpate spleen again if not

Palpable; kidneys

Percuss liver / spleen size; estimate span with tape measure

Spleen: no palpable upper border; has notch; move inferomedially with respiration; no

resonance over splenic mass; not bimanually palpable; friction rub commonly he

If spleen not palpable lying flat, roll to R and try again

RIF mass: appendix abscess, caecal Ca, CD, pelvic kidney, ovarian Ca/cyst, carcinoid,

psoas abscess, ileocecal TB

LIF mass: faeces, colon Ca, diverticular disease, ovarian Ca/cyst, psoas abscess

Upper abdo mass: lymphadenopathy, AAA, stomach Ca, pancreatic Ca/cyst, PS, colon

Ca

Percussion Percuss for ascites; roll towards you if not resonant to flanks, to check for shifting dullness

Auscultate Liver, spleen and renal areas

Bruits (hepatocellular Ca, alcoholic hepatitis)

Rubs (Ca, recent liver biopsy, infarct, gonococcal perihepatitis)

Venous hum (portal HTN)

Bowel sounds

Groin Genitalia, LN’s, hernial orifices (standing and coughing – say that you would do this)

Ask if you can palpate testes

PR Say you would do; inspect (fistulae, tags), palpable (masses, blood)

Legs Bruising, oedema

Neuro: peri neuropathy; prox myopathy; cerebellar syndrome

Sit up 45 deg

JVP

Investigations

Urine

PUD Bloods If atypical, fasting serum gastrin, gastric juice pH, secretin test; incr Ca ?MEN I

Other Endoscopy (?active bleeding or clean ulcer base); biopsy result

Imaging USS (biliary tract); CT (pancreas, ZES)

Malabsorption Bloods Fe, long PT, low Ca, low chol, low carotene, +ive Sudan stain of stool for fat; faecal fat

estimation; glucose / Lactulose breath hydrogen test for bacterial overgrowth; Schilling test for

ileal disease; FBC (?anaemia); Fe, Ferritin, folate, Vit B12, alb, Vit D level, Ca, Phos, ALP,

INR

Other Gastroscopy, SI biopsy (subtotal villous atrophy); histology; parasites

Imaging AXR (Crohn’s disease, diverticula, blind loops)

IBD Bloods FBC (anaemia, WBC); ESR, CRP; LFT; U+E; alb; p-ANCA, ASCA (in CD)

Other Stool spec (amoebiasis, Shigella, Salmonella, Yersinia, Campylobacter, E coli, C diff,

lymphogranuloma venereum, gonorrhoea, syphilis; if immunocomp – herpes, CMV,

cryptosporidium); TB; sigmoidoscopy and biopsy; Ba enema (loss of haustrations, muscosal

irregularity and ulcers, spasm, pseudopolyps, bowel shortening, extent of involvement,

strictures, Ca, thickening, cobblestoning, skip lesions, fistulas); colonoscopy (granulomas,

mucus) and biopsy

Imaging AXR (bowel wall thickening, gaseous distension, toxic megacolon)

Colon Ca Bloods Genetic screening (if +ive FH); LFT; CEA

Other Colonoscopy, Ba enema, FOB testing

Imaging Staging; CXR for mets

CLD Bloods LFT; alb; INR; FBC (anaemia, film, macrocytes, decr plt, decr WBC); Fe; folate; U+E (decr Na);

hepatitis serology; AMA (1Y biliary cirrhosis); ANA, ASMA (autoimmune hepatitis); p-ANCA

(UC + 1Y sclerosing cholangitis); AFP (liver Ca)

Other Ascitic tap (cell count, lactate, amylase, cytology, culture); liver biopsy; endoscopy for varices

Imaging USS; CT abdo; Doppler flow studies for varices

End

Is there anything else I should know?

Presentation

Draft intro statement

IBD Grade severity (mild 10)

CLD Grade severity (Child’s classification)

Differential diagnosis

Findings that support / refute diagnosis

Ascites Liver Cirrhosis, alcoholic hepatitis, fulminant hepatic failure, Budd-Chiari syndrome

Cardiac CCF, veno-occlusive disease

Endocrine Myxoedema

Ca Peritoneal Ca

Infective TB, pancreatitis

Renal Nephrotic syndrome

Abdo distension Fat, fetus, flatus, fluid, faeces, filthy great tumour, flipping enormous organs

Scrotal mass Other Hydrocoele, epididymal cyst, spermatocoele, cyst of hydatid of Morgagni, varicocele,

indirect inguinal hernia

Ca Testicular Ca

Infective Epididymitis

Hepatomegaly Infective Hepatitis, hydatid disease, HIV, CMV, IMN

Cancer Mets (S), CML, lymphoma, HCC (S), myeloproliferative (S)

Toxins ETOH (S)

Auto-immune Granulomatous, amyloid, sarcoid, SLE

Other Biliary obstruction, fatty liver, CCF (S), CLD with portal HTN

Firm irregular liver: cirrhosis, mets, hydatid, granuloma, amyloid, cysts, HCC

Tender liver: hepatitis, RHF, Budd-Chiari, hepatocellular Ca

Pulsatile liver: TR, hepatocellular Ca, vascular abnormalities

Splenomegaly Infective IMN, hepatitis, IE, malaria (S), CMV

Cancer Myeloproliferative (S), lymphoma S), leukaemia, CML (S)

Autoimmune RA, SLE, PAN, amyloid, sarcoid

Other Haemolysis, megaloblastic anaemia, portal HTN,

storage diseases

Hepatosplenomegaly: Infective: hepatitis, CMV, IMN, EBV

Cancer: myeloproliferative, lymphoma, leukaemia

Autoimmune: SLE, amyloid, sarcoid

Other: CLD with portal HTN; pernicious anaemia; SCA;

acromegaly; thyrotoxicosis

Ballot kidneys

Big kidneys: Infective Pyonephrosis

Cancer RCC, lymphoma, Wilm’s tumour, neuroblastoma

Autoimmune Amyloid

Trauma Perirenal haematoma

Other PCKD, hydronephrosis, renal vein thrombosis, acromegaly

Management

Suggest management and set management goals

PUD H pylori: PPI + amox + Clarithromycin; repeat gastroscopy if Sx not resolved; repeat biopsy / Ur breath test to

confirm cure; PPI better than H2A at healing; stop drug causing; misoprostol if NSAID

IBD Correct electrolytes; avoid opiates; broad spectrum Abx if severe colitis; IV steroids if mod-severe; cyclosporin if

not responding to steroids; drugs as above; topical steroids to anus; colectomy

Colon Ca OT; colonscopy and ?CEA surveillance; radiation if rectal; chemo

CLD Fulminant liver failure: Remove blood from gut (eg. enema); low protein diet; treat infection; correct electrolyte

disturbance; avoid sedatives; Lactulose; Abx (neomycin, metronidazole); steroids if autoimmune; correct

clotting

Portal HTN: variceal band ligation; correct clotting; IV octreotide / terlipressin; sclerotherapy; Sengstaken-

Blakemore; propanolol to reduce portal pressures; TIPS shunt; diuresis (spironolactone) to treat ascites; salt

restriction; therapeutic paracentesis with IV albumin replacement; liver transplant

Hepatitis: antivirals, interferon

HAEM

History

HPC Haemolytic anaemia Presenting symptoms (fatigue, SOB, jaundice)

Of CT disease (joint pain, swelling – sickle cell; leg ulcers – spherocytosis and sickle cell)

Abdo / back pain (sickle cell); gallstones; spinal cord lesions; CVA (sickle)

Fever, neuro abnormalities – TTP

Thrombophilia Reason for admission; arterial / venous thrombosis; whether diagnosis of thrombotic tendancy

made; dark urine at night

Is there an action plan?

PMH Haemolytic anaemia Of same; SLE; lymphoma; mechanical heart valves; external trauma; disseminated malignancy,

TTP, HUS, gastro, transplant; Ca; recent glandular fever; hepatitis; mycoplasma infection

Thrombophilia Protein C, protein S, AT def, APC resistance, APL ab’s, PT gene mutation, factor V Leiden;

smoking, OCP, pregnancy, malignancy, recent OT / immobility; unexplained miscarriages

(APL syndrome); eclampsia; prev MI (factor V); chronic leg oedema; homocystinuria

Generic details Immunisation status (influenza, hep A, hep B, Pneumococcus)

DH Haemolytic anaemia Methyldopa, penicillin, quinidine, antimalarials, sulfonamides, nitrofurantoin

Thrombophilia Anticoagulation; understanding of Warfarin; INR levels; doses; target INR; frequency of blood

tests; prophylaxis for OT

A

SH Occupation, adequacy of income, current housing, ability to cope, mobility + steps

Hobbies (animals, chemicals, dusts), marital status, sexual problems

Place of birth, overseas travel

Haemolytic anaemia Ethnicity (G6PD – black; thalassaemia – Greek, Italian)

Thrombophilia Transport to blood tests; how gets INR results and dose changes

FH Haemolytic anaemia Of same; sickle cell

Thrombophilia Of thrombosis; family members tested

Investigation results

Management

Examination

What did examiners examine? Did they comment on signs?

Lie supine, head on 1 pillow

Ask to see temperature chart

General Bruising, pigmentation (lymphoma), cyanosis (polycythaemia), jaundice, scratch marks (myeloproliferative,

lymphoma), leg ulcers; frontal bossing; racial origin (thalassaemia = Asian, Greek; SCA = Black)

Haemolytic Pallor, jaundice, LN (lymphoma, CLL), pigmentation

Thrombophilia Heparin infusion and rate; BMI

Hands Koilonychia = spoon nails (Fe def); vasculitis; anaemia (palmar creases); RA; Felty’s syndrome; recurrent

haemarthroses; gout (myeloprolif)

Arm Epitrochlear node (non-Hodgkin’s lymphoma, CLL, IVDU, sarcoid); bruising; petechiae; palpable purpura

(vasculitis); axillary LN’s

Skin Thrombophilia Signs of venous insufficiency; oedema; ulceration; peri pulses

Face Jaundice; pallor; scleral injection (polycythaemia); gum hypertrophy (leukaemia), ulcers, haemorrhage; atrophic

Glossitis (Fe / B12 / folate def); angular stomatitis (Fe def); large tonsils (lymphoma); candida

Fundi

Haemolytic Retinal detachment / infarcts / vitreal haem in SCD; KF ring

Sit up

Neck LN’s (submental, submandibular, jugular chain, post triangle, postauricular, preauricular, occipital)

Supraclavicular LN’s from front

Generalised lymphadenopathy: Infection: CMV, HIV, IMN, TB, toxoplasmosis,

Cancer: lymphoma, CLL, ALL, mets,

Autoimmune: RA, SLE, sarcoid

Other: phenytoin

,

Bones Sternum; clavicle; shoulders; spine tenderness

Chest Haemolytic Prosthetic valve, severe AS, CCF

Lie down again

Abdomen Splenomegaly, hepatomegaly, signs of CLD

Ask to do a rectal exam

Thrombophilia Abdo wall bruising; abdo mass

Groin Inguinal LN; pelvic tenderness

Ask to examine testes

Legs Vasculitis (HSP); bruising; pigmentation; ulceration (spherocytosis, thalassaemia, SCA); NS (SACD, peri

neuropathy from B12 def)

Haemolysis Joints / bone pain (SCD); leg ulceration

Investigations

Urine (haematuria, bile)

Haemolytic anaemia Bloods Malaria; blood film (normochromic Normocytic usually; hypochromic microcytic in

thalassaemia); FBC; incr retic count; unconj bil; LDH; haptoglobin negative;

Schumm’s test (methaemalbumin); schisotcytes = valve / DIC / TTP / HUS; decr plt =

TTP / HUS; Coomb’s test (+ive if autoimmune); warm and cold agglutinins

Other Urobilinogen; Hb (?mostly at night = PNH); sediment; haemosiderin

Imaging

Thrombophilia Bloods FBC, ESR, Factor V Leiden, APL ab (incr lupus anticoagulant, anticardiolipin ab), AT III,

protein C+S, PT gene mutation, plasma homocysteine

End

Is there anything else I should know?

Presentation

Draft intro statement

Differential diagnosis

Findings that support / refute diagnosis

Haemolytic anaemia Warm / cold ab (lymphoma, CT disease, post-infection, drugs); microangiopathic (DIC, TTP, vasculitis), heart valve, march Hburia, infection, malaria, cirrhosis, PNH, SCD, thalassaemia (target cells, tear drops, HbFm HbA), spherocytosis, elliptocytosis, G6PD def

Management

Suggest management and set management goals

Haemolytic anaemia Steroids / azathioprine / splenectomy if immune; transfusion; hydration; repair valve; plasmapheresis +

steroids for TTP; splenectomy for ellip/sphero

Thrombophilia LMWH; at least 6/12 warfarin; long term therapy of APC resistance; prophylaxis for OT or immobilisation

or pregnancy; compressive stocking / foot pumps; no smoking / OCP

RHEUM

History

HPC RA Onset; presenting symptoms (fatigue, anorexia, pain, morning stiffness >1hr); joints involved; major

current problem (function, pain, NS); current activity of disease; no. of jts involved; severity; functional

ability; systemic involvement

Skin (Raynauds, leg ulcers); eyes (Sjogren’s syndrome, scleritis, cataracts); neck pain; RS (fibrosis,

pleural effusion, pleuritis); CV (pericarditis, valve disease); NS (peri neuropathy; mononeuritis

multiplex; SC compression; entrapment neuropathy); anaemia, Fe def, folate def; fever; weight loss;

vasculitis (ulcers)

SLE Malaise, weight loss, N+V, thrombosis, arthralgia, myalgia, rash, alopecia, ulcers, fever,

neuropsychiatric, seizures, chorea, optic neuritis, CVA, headache, haematuria, oedema, renal failures,

pleurisy, pericarditis, myocarditis, valve lesions, anaemia, diarrhoea, obstruction, thrombophlebitis,

recurrent abortions

PMH RA PUD; drug reactions; renal disease

Generic details Immunisation status (influenza, hep A, hep B, Pneumococcus)

DH RA Aspirin / NSAIDS (gastric erosions, renal impairment); Methotrexate (hepatic and pul toxicity, decr WBC

+ plt); penicillamine (nephrotic syndrome, decr plt, rashes, mouth ulcers, SLE, polymyositis, MG,

Goodpastures); cyclosporin (BP); hydroxychloroquine, sulfasalazine (rash, haem, LFT), antiTNF ab;

steroids

SLE Procainamide, hydralazine, isoniazid, methyldopa, penicillamine, chlorprom, anticonvulsants

A

SH Occupation, adequacy of income, current housing, ability to cope, mobility + steps

Hobbies (animals, chemicals, dusts), marital status, sexual problems

Place of birth, overseas travel

RA Coping; mobility; ADL; fine motor skills; work; support services

SLE Understanding of implications of disease

FH RA Of same

Investigations

Management RA Initial trt; other trt; complications of trt

Examination

What did examiners examine? Did they comment on signs?

General Cushingoid; weight; iritis; scleritis; obvious other joint disease; gait if walked into room

RA Cushings; BMI

SLE Cushings, weight loss; mental state, BP, temp

Discoid erythematous raised rash, photosensitivity, malar rash; scaling; hair loss

Patient sitting over edge of bed; Place patient’s hand on pillow, palms down

Hands Inspect Scars, redness, atrophy, rash, swelling, deformity, muscle wasting, deviation, subluxation, swan

necking, boutonniere, Z, sausage shaped; nails for pitting, ridging, onycholysis,

hyperkeraotisis, discolouration; palmar erythema; anaemia; skin atrophy; bruising (?steroid

use); signs of vasculitis

Dorsal and palmar

Palpate Do you have any pain anywhere? Inc ulnar styloid tenderness

Synovitis, effusion; passive ROM; crepitus inc of palmar tendons (open and close hand);

rheumatoid nodules on forearms

Power Grip strength ( straighten fingers ( each individual finger (FDP - distal, FDS - prox) if

Abnormal

Thumb power – abduction, aduction, flexion, opposition

Function Grip strength; key grip turning, opposition strength (a-OK), practical ability (undo button)

Sensation If function mentionned, test this

RA Symmetrical wrist, MCP and PIPJ swelling; undo a button

OA Sweling of PIPJ and DIPJ (Bouchard’s and Heberden’s nodes)

Psoriatic Sausage shaped fingers and telescoping of fingers; predominant IPJ disease

SLE Nail fold infarcts, vasculitis, arthropathy

Arms BP

Inspect Wrists, elbows, shoulder – synovitis, effusions, ROM, crepitus, subluxation, palmar tendon

crepitus, carpal tunnel tests (Phalen – flexion for 30secs; Tinel = tap over carpal tunnel while

wrist held in extension), subcut nodules at elbows, psoriatic rash

RA Entrapment neuropathy; subC nodules; axillary nodes

SLE Livedo reticularis, purpura, prox myopathy

READ SHOULDERS

Face Iritis, scleritis

RA Eyes (as above); fundi; parotids; mouth (dry, ulcers, caries, TMJ)

SLE Malar rash; Alopecia, eyes (as above), mouth ulcers, rash, CN lesions, LN

Ank spond Uveitis

Neck RA Spine, LN

Chest RA Pericarditis, murmurs, effusion, fibrosis, infarct, nodules, TB

SLE Endocarditis, pleural effusion, pleurisy, ful fibrosis, collapse

Ank spond Decr chest expansion; AR, MVP

Abdomen Palpate Spring pelvis

RA Splenomegaly, epiG tenderness, inguinal LN

SLE Hepatosplenomegaly, tenderness

Ank spond Evidence of IBD; hepatosplenomegaly

Knees Expose and lie on back

Inspect Quads wasting; scars; rashes; swelling; deformity; walk; squat and look at space under knees

Function Active ROM

Palpate Quadriceps for wasting; tenderness; warmth; patella tap for effusion; for small, stroke up lateral

Knee then medial knee to look for bulge; passive ROM; crepitus; ligaments (>5-10deg

abnormal for all ligaments)

Lie on front

Palpate for Baker’s cysts

Apley’s grinding test: flex knee to 90deg, push down on knee into bed, ex and int rotate; grinding

/ pain / clicking = meniscal inj

Function Stand up; walk around; sit down on chair; look for varus / valgus deformity

Feet Inspect Scars, ulcers, rashes, swelling, deformity, muscle wasting; nail changes; transverse and

longitudinal arches; callus; possibly neuro examination; hallux valgus, sausage toes, claw

Palpate Synovitis; effusion; passive ROM (talar, subtalar (everson-inversion), midtarsal (rotating /

twisting); Achille’s tendon nodules; tenderness of plantar fasciitis; tenderness

RA Ulcers, peri neuropathy, mono multi, cord compression

SLE Feet, prox myopathy, cerebellar ataxia, neuropathy, hemiplegia, mono multi

Back Inspect Deformity from back and side; loss of kyphosis / lumbar lordosis

Palpate Tenderness and muscle spasm

Movement Finger-floor distance; extension; lateral flexion; rotation; Schober’s test (place mark at level of

post iliac spine, 10cm above and 5cm below; on bending, top and bottom marks should be

>20cm apart)

Investigations

Ask for 1-2 recent investigations and reason for ordering

Comment on results, even normal

RA Bloods RF; anti-CCP; ESR; CRP; FBC (AOCD); U+E (if on NSAID)

Other Urine protein, blood

Imaging XR (ST swelling, jt space narrowing, juxta-articular OP, jt erosions)

SLE Bloods ANA; anti-dsDNA; FBC (AOCD; maybe immune haemolytic; decr WBC + plt); ESR; CRP;

Other LP if suspect neuro

Imaging MRI

End

Is there anything else I should know?

Presentation

Draft intro statement

Differential diagnosis

Findings that support / refute diagnosis

Deforming polyarthropathy RA, seronegative arthritis (eg. Psoriasis), gout, pseudogout, OA

RA Psoriatic arthropathy, seronegative arthritides, chronic tophaceous gout, OA, SLE, rheumatic fever, amyloid

arthropathy

Management

Suggest management and set management goals

RA Education; physio; exercise; OT; aspirin, NSAID, COX-2 inhibitors; DMARDs (Methotrexate); gold; penicillamine;

local steroid injection; OT if severe

RENAL

History

Hello, this is exam

What is wrong? Why are you in hospital this time?

HPC CRF Presenting symptoms (nocturia, lethargy, loss of appetite)

GN – proteinuria, haematuria, oliguria, oedema, sore throat, sepsis, rash, haemoptysis

Long term prognosis

Dialysis; if not, has it been discussed; transplant list?; complications – shunt blockage, thrombosis, infection,

access problems, pericarditis, peritonitis

Complications: anaemia, bone disease, gout, pericarditis, HTN, CCF, peri neuropathy, pruritis, PUD, cognition

PMH CRF PCKD, GN, childhood UTI, DM, HTN, SLE, scleroderma

Generic details Immunisation status (influenza, hep A, hep B, Pneumococcus)

DH CRF NSAIDs and other analgesics, contrast, infection, ACEi

?doses altered for renal failure

A

SH Occupation, adequacy of income, current housing, ability to cope, mobility + steps

Hobbies (animals, chemicals, dusts), marital status, sexual problems

Place of birth, overseas travel

CRF ADL, employment, coping, travel, sexual function, financial situation; travel to dialysis

FH

Investigation CRF Renal biopsy; transplant work up

Management CRF Meds, diet, salt, water, EPO, protein; dialysis – where, how often, hrs/wk, complications, shunts,

OT; transplant

Examination

What did examiners examine? Did they comment on signs?

CRF General Mental state, sallow complexion, hydration, fever, Cushingoid

Hands Nails (brown lines), shunt, asterixis, neuropathy

Arms Bruising, pigmentation, scratch marks, myopathy, BP

Face Anaemia, jaundice, band keratopathy, dry mouth, fetor, rash, saddle nose (WG), fundoscopy

Chest Pericarditis, CCF, lungs, venous hum

Abdo Scars, renal mass, Tenchkoff, bladder, liver, LN, ascites, bruits, rectal

Legs Oedema, bruising, pigmentation, scratch marks, gout, neuropathy

Back Tender, oedema

Investigations

Ask for 1-2 recent investigations and reason for ordering

Comment on results, even normal

CRF Blood GFR, Cr, electrolytes, phos, uric acid, Ca, alb; FBC (Burr cells, anaemia); Fe, Ferritin; PTH

?hep B/C, HIV, ANA

Other Urine: specific gravity, pH, glucose, blood, protein, casts; renal biopsy; urine cytology

Imaging USS; KUB; IVP; CT; cystoscopy; retrograde pyelography; renal angiogram

End

Is there anything else I should know?

Presentation

Draft intro statement

Differential diagnosis

Findings that support / refute diagnosis

Management

Suggest management and set management goals

CRF Folate supplements; EPO; Fe supplements; antihypertensives (ACEi); trt infection; correct fluid imbalance; alter

drugs if needed; trt incr Ca; trt lipids; salt and water intake; decr dietary protein; consider dialysis and

transplant

NS

History

Hello, this is exam

What is wrong? Why are you in hospital this time?

HPC MG Presenting symptoms (diplopia, ptosis, choking, dysarthria, chewing/swallowing probs, prox muscle weakness,

fatigue OE

GBS Presenting symptoms (ascending motor weakness, paraesthesia, anaesthesia, bulbar palsy, postural

hypotension, arrhythmias, sphincter dysfunction)

Recent resp / GI infection; recent OT, cavvincation, Ca, SLE, HIV

TIA Neck pain ?aortic dissection; CV RF (see above)

PMH MG Prev difficult anaesthesia (prolonged weakness); prev pneumonia; thymectomy; SLE; RA

GBS Of same

Generic details Immunisation status (influenza, hep A, hep B, Pneumococcus)

DH MG Drugs that may interfere with neuro (streptomycin, gent, quinidine, procainamide)

TIA OCP, sedatives, hypoG drugs, anticonvulsants, antiarrhythmics

A

SH Occupation, adequacy of income, current housing, ability to cope, mobility + steps

Hobbies (animals, chemicals, dusts), marital status, sexual problems

Place of birth, overseas travel

FH

Investigations MG Blood test / electrophysiological studies

Management MG Drug and doses, time of last dose, plasma exchange, immunosuppression

Examination

What did examiners examine? Did they comment on signs?

Sit over edge of bed

CN Inspect Craniotomy scars, neurofibromata, Cushing’s syndrome, acromegaly, Paget’s disease, facial

asymmetry, ptosis, proptosis, deviation of eyes, pupil inequality

I Have you noticed any problems with your sense of smell?

Say you would test smell, each nostril separately

Lesion: URTI, meningioma, ethmoid Ca, head Ca, meningitis, hydrocephalus

II VA with card to cover other eye; do you normally wear spectacles? ( with glasses on; read

lowest line you can see clearly

Visual fields with hat pin; head at arm’s length; look at my nose; bring hat pin / towards centre from

each corner and middle ( say yes when see; map out blind spot (lateral to central field of vision)

Look at fundi

III, IV, XI Pupils: shape, size; direct and consensual response; RAPD (affected eye will dilate after short

time when torch moved to it from normal eye = optic atrophy or v poor VA)

Absent light, present accomodation: Argyll-Robertson (midbrain lesion; neurosyphilis)

Adie’s (ciliary ganglion lesion; usually viral/bacterial infection)

bilateral RAPD (ant visual pathway lesions)

Miosis: Horner’s syndrome (ptosis, anhydrosis, miosis, apparent enopthalmos, slightly bloodshot)

Argyll-Robertson (absent light, present accomodation)

pontine lesion, narcotics, pilocarpine, old age

Mydriasis: atropine, cocaine

III palsy (ptosis, mydriasis, eye down and out)

Adie’s

Iritis, eye OT, traumatic, deep coma, cerebral death, congenital

Accomodation: look into distance then at hatpin 15cm from end of nose

Absent accomodation, present light: cortical blindness; midbrain lesion

Ptosis

Eye ROM: quickly look from L to R

( follow hatpin L (up and down) then R (up and down)

Ask about diplopia; look for failure of movement and nystagmus

If any abnormality, assess each eye separately

V Corneal reflex with cotton wool; ask if can feel; should blink both eyes

In V nerve palsy (sensation): both eyes fail to blink

In VII nerve palsy (motor): contralat eye still blinks, but loss of power to ipsilateral side

Facial sensation – opthalmic, maxillary, mandibular; use pin then light touch (cotton wool); also do back

of head and neck (C2 and 3); close eyes, say yes when feel it

In medulla / upper cervical lesion: loss of pain and temp, preservation of soft touch

In pontine lesion: loss of light touch, preservation of pain and temp

Muscles of mastication: clench teeth and feel masseters; open mouth and try to close

In lesion: jaw deviates towards affected side

Jaw jerk: incr jaw jerk in pseudobulbar palsy (=UMN)

VII Facial asymmetry

Look up, wrinkle forehead ( look for loss of wrinkles and push down on each side

Loss of forehead power = LMN lesion

Shut eyes ( try to open

Grin ( compare nasolabial folds

If LMN lesion, check ear and palate for veiscles of herpes zoster

Say would check taste of anterior 2/3 tongue

VIII Whisper beside ear and ask repeat; rub auricle on other ear

Rinne’s: on mastoid process until no longer heard then beside ear

Normal / sensorineural = note audible via air

Conductive = note not audible via air

Weber’s: in centre of forehead

Normal = heard in middle

Sensorineural = sound louder in normal ear (as abnormal is “turned off”)

Conductive = sound louder in abnormal ear (as is now “turned up”)

Ask for auricscope is abnormal

IX, X Uvular displacement; say aaaah and look for movement

Uvula goes Away from abnormal side

Gag reflex – check patient can feel spatula, patient should only gag if hyperreactive

Speech

Cough - ?bovine (RLN lesion)

Say would check taste of posterior 1/3 tongue

XII Inspect tongue for wasting / fasciculation

Ask to stick tongue out

Tongue goes Towards abnormal side

XI Shrug shoulders and feel trapezius bulk and push down; turn head against hand and feel SCM

Neck Carotid / cranial bruits (mastoids, temples, orbits)

Arm BP

Eyes General Facies

Orbits Palpate for tenderness; auscultate for bruit

Lid lag, ptosis, exopthalmos (look from behind and above patient)

Eyes Acuity

Fields as above

Eye mvmt: mvmt, diplopia, nystagmus, fatiguability (30secs looking up)

Pupils: shape, size, symmetry, RAPD, accomodation

Sclera for jaundice, pallor, injection

Cornea for arcus, band keratopathy, KF rings

Fundi: humour, disc; changes of DM, HTN, optic atrophy, papilleodema, retinal detachment,

venous / artery thrombosis

Corneal reflex

Pancoast Eye Nystagmus to side of lesion; miosis; ptosis; enopthalmos

Face Symp Decreased sweating on brow with back of finger

V Ipsilateral loss of pain and temp

IX, X Uvula deviated away from lesion; loss of gag reflex; hoarseness (RLN compression)

NS Ipsilateral cerebellar signs

Finger abduction (lower brachial plexus lesion = thoracic outlet syndrome)

Signs of lung Ca: Clubbing, chest examination

Signs of other Ca: LN, thyroid exam

Other: carotid bruit

Adie’s Eye Mydriasis; decr direct and consensual light response; slow accomodation

NS Decr tendon reflexes

A-R Eye Miosis; irregular pupil; no reaction to light; good accomodation

NS Decr reflexes

III palsy Eye Ptosis; eye down and out; mydriasis; unreactive to light (direct or consensual) and accomodation;

opposite eye has consensual reflex

IV palsy Eye Cannot look down and in (intort); patient walks with head tilted away from lesion

VI palsy Eye Can’t look out or deviated in; diplopia on looking laterally

SupraN palsy Eye Loss of upwards +/- downward gaze; pupils unequal; bilateral; reflex movements intact

Bulbar palsy = LMN IX, X, XII No gag; wasted fasciculating tongue; no palatal movement; maybe no jaw jerk; NASAL

SPEECH

PseudoB palsy = UMN bilateral IX, X, XII Incr gag; spastic tongue; no palatal movement; incr jaw jerk; DONALD DUCK

SPEECH; labile emotions

Higher centre General R or L handed?

Facies; obvious CN / limb lesions; level of education

Shake hands

Orientation Person – his name, who I am

Place – present location (country, city, building)

Date – day, month, year

Temporal Short term memory: rose, orchid, tulip ( repeat immediately

Long term memory: dates of 2nd World War

Parietal Dominant Acalcula = serial 7’s

Agraphia = write your name

Agnosia, finger

L-R disorientation = put R hand on L ear, then vice versa

Non-dominant Apraxia, Dressing = turn pyjama top inside out and put it on

Both Sensory and visual inattention

Cortical Agraphaesthesia = draw number on palm

Astereognosis = name key placed in hand

Apraxia, Constructional = draw clock face and numbers

Recall Rose, orchid, tulip again

Language Nominal Name watch and pen (temporal, angular gyrus)

Repetition Repeat phrase – no ifs, ands, or buts ( fluency, comprehension, repetition

Receptive Touch your nose, then your chin (temporal, Wernicke’s)

Read this then follow instruction

Expressive Describe where you are (frontal, Broca’s)

Dysarthria British constitution (cerebellum / CN)

Ta ta ta, pa pa pa, ka ka ka

Frontal Primitive reflexes: Grasp

Pout

Palmar-mental

Proverb interpretation: “people in glass houses shouldn’t throw stones”

Anosmia

Gait

Examine fundi

Examine visual fields; carotid bruits; HTN; focal neurology

MMSE Orientation Time: year, month, day, date, time /5

Place: country, town, district, hospital, ward /5

Registration Rose, orchid, tulip ( repeat /3

Attention + calc Serial 7’s /5

Recall Rose, orchid, tulip remember /3

Language Name watch and pen /2

Repeat no ifs and or buts /1

3 stage command: clap hands, touch nose, point to ceilling /3

Read “close your eyes” and obey /1

Write a sentence /1

Copying Copy pair of intersecting pentagons /1

Speech Say name, age and present location

Say “British Constitution”

Dysphasia Ask to name object

Ask to repeat statement

Ask to follow commands

If abnormal: as to read and write

?expressive (Broca’s area, frontal lobe)

?receptive (Wernicke’s area, temporal lobe)

?conductive (arcuate fasciculus, temporal lobe)

?nominal (angular gyrus, temporal lobe) – can’t name

Dysarthria Say British Constitution, West Register Street, Me Me Me, Lah Lah Lah

Cerebellar = irregular staccato Examine cerebellum

Lower CN = pseudoB = slow hesitant harsh strained voice Examine CN’s

Lower CN = bulbar = nasal speech with imprecise articulation

Arms Take off shirt and sit over edge of bed

General Facies (eg. Parkinsons, CVA); scars; skin (neurofibromata, café-au-lait); abnormal movements

Shake hands Myotonia if can’t let go

Inspect Wasting

Fasciculation (LMN = MND, root compression, peri neuropathy, myopathy, thyrotoxicosis)

Tremor

Drift (UMN lesion if down, cerebellar lesion if up, post column loss in any direction)

Pseudoathetosis

Palpate Muscle bulk; tenderness; thickened nerves (elbow and wrist); axilla for plexus lesion

Tone Wrist and elbow movement at varying velocities

Neck movement

Power Don’t let me…….

Shrug shoulders (1)

C5-6 Shoulder abduction (2)

Elbow flexion (4)

C6-7 Wrist flexion (6)

C7-8 Shoulder adduction (3)

Elbow extension (5)

Wrist extension (7)

Finger extension (8), flexion (9)

C8-T1 Finger abduction (10)

Ulnar Finger abduction and adduction – grasp paper between thumb and IF, thumb will flex if

abnormal

Median Thumb abduction – put hand palm up on table, adduct up to touch pen, then don’t let

me push thumb down

1=flicker 2=with no gravity 3=against gravity 4=weak 5=normal

Reflexes Augment if needed

C5-6 Biceps

Supinator

C7-8 Triceps

C8 Finger – palm upwards slightly flexed

Co-ordination Finger nose (intention tremor, past point); dysdiadokinesis; rebound (lift arms quickly from sides

then stop with palms up with eyes closed; hypotonia if unable to stop arms; and push arms)

Sensation Looks for scars that may cause nerve damage; close eyes

?dermatomal / peri nerve / peri neuropathy / hemisensory

Spinothalamic Pain Demonstrate on chest wall (does that feel sharp?)

Sharp/dull? Start prox and test each dermatome

Temp Say you would

Posterior Demonstrate on clavicles

Vibration: on ulnar wrist with eyes closed ( on elbow, on shoulder if abnormal

Ask if can feel it; when feels stop

Proprioception: DIPJ of index finger; demonstrate with eyes open ( close eyes;

do wrist and shoulder if abnormal

Light touch (both post and spinothalamic) with cotton wool

[pic]

Legs General As above + urinary catheter; look for walking stick / special shoes

Gait Walk across room, turn around, come back – with legs uncovered

Hemiparetic = foot plantar flexed and swung laterally

Paraparetic = scissor gait

Extrapyramidal = hesitation starting, shuffling, freezing, festination, propulsion

Cerebellar = drunken, widebased or reeling on narrow base; staggers to affected side

Apraxic = prefrontal = glued to floor when erect, move easily when supine

Post column = clumsy slapping feet on broad base

High stepping = distal weakness

Waddling = prox weakness

Heel-toe (cerebellar)

On toes and heels (S1 or L4/5 lesion)

Squat and stand (prox myopathy)

Romberg’s sign – feet together, arms forwards with palms up (eyes closed only = post column –

Rhomberg positive if worsens with eyes closed, eyes open also = cerebellar disease)

Inspect As above

Palpate As above

Tone Knee and ankle, inc clonus (push patellar sharply downwards) = UMN lesion

Push into me

Power L2-3 Hip flexion (1), adduction (4)

L3-4 Knee extension (6)

L4-5 Hip abduction (3)

Ankle dorsiflexion – toes aswell (8)

L5-S1 Hip extension (2)

Knee flexion (5)

Ankle eversion (also common peroneal nerve), inversion (9)

S1 Ankle plantar flexion – toes aswell (7)

Reflexes Reinforce if needed

L3-4 Knee

S1-2 Ankle

S1 Plantars (warn will be uncomfortable with key; look at big toe)

Co-ordination Heel-shin, toe-finger, foot tapping (tap hand with ball of foot)

Sensation As above; try to establish if sensory level

Tuning fork on MTPJ

Proprioception with big toes; knee and hip if needed

Saddle region sensation (S3-5)

[pic]

Anal reflex (S2-4)

Back Deformity, scars, tenderness, bruits; SLR

Abnormal co-ordination: do gait, tone, co-ordination tests (arms and legs), Romberg’s

If Romberg +ive but co-ordination OK, do vibration and position sense

Nystagmus

Speech (British Constitution, West Register Street)

Truncal ataxia: fold arms; sit up; put legs over side of bed

Fundi for papilloedla; CN’s examination

LMN Weakness; wasting; hypotonicity; decr reflexes; fasciculation

UMN Weakness (more marked in upper limb abductors and extensors, lower limb flexors); spasticity; clonus; incr

Reflexes

Upper brachial plexus (C5-6, Erb-Duchenne): loss of shoulder movement and elbow flexion; waiter’s tip; loss lateral arm and

thumb sensation

Lower brachial plexus (C8-T1, Klumpke): claw hand with paralysis of intrinsic muscles; loss sensation ulnar side of hand and

forearm; Horner’s syndrome; look for axillary mass

Cervical rib syndrome: claw hand and sensation loss as above; unequal radial pulses and BP’s; subclavian bruit; loss of pulse

on manouvring arm; palpable cervical rib

Radial nerve (C5-8): wrist and finger extension weakness loss of elbow extension if high

Loss sensation over ASB

Median nerve (C6-T1): thumb abduction weakness (APB) loss of Ochsner’s clasping test if high

Loss sensation over thumb, IF, MF, lat ½ ring finger (palmar)

Ulnar nerve (C8-T1): weak finger abduction and adduction and claw hand (Froment’s sign)

Loss sesnation over LF and medial ½ RF (palmar and dorsal) – not forearm like lower brachial plexus

Femoral nerve (L2-4): Weak knee extension, hip flexion; loss of knee jerk

Loss sensation over inner aspect thigh and leg

Sciatic nerve (L4-S2): Weak knee flexion, all muscle below knee ( foot drop; knee jerk OK; loss of ankle / plantars

Loss sensaton over post thigh and total loss below knee

Common peroneal (L4-S1): foot drop and loss of foot eversion; reflexes OK; inversion OK (unlike in L5 nerve root inj)

Loss sensation over dorsum of foot

Prox muscle weakness: myopathy, MG

Myopathy Cancer

Autoimmune: Polymyositis / dermatomyositis; sarcoid

Toxins: ETOH; drugs (eg. Steroids)

Other: periodic paralysis (hyper/hypoK); osteomalacia; endocrine (hypo/hyperthyroid, Cushings,

acromegaly, hypopit); paraneoplastic; CT disease

MG NS Muscle fatigue, esp eyes, bulbar (read aloud), prox muscles (hold arms up); Peek sign (close eyes hard

for 30secs, gets weak); neck flexion weakness

Normal reflexes; normal sensation; minimal muscle atrophy

Gen Thymectomy scar

GBS NS Distal (maybe prox) muscle weakness; arms > legs; decr reflexes; muscle tenderness; minimal

sensory loss; loss of vibration and proprioception

No atrophy

CV Postural BP changes, arrhythmia

TIA Eyes ?emboli, hypertensive changes, diabetic changes, ischaemic retinopathy; visual fields; nystagmus

CV Carotid bruit; pulses; postural BP; murmurs (?IE, AS, RHD, prosthetic valve); PVD; pacemaker; GCA

NS Dix-Hallpike if vertigo

Investigations

Ask for 1-2 recent investigations and reason for ordering

Comment on results, even normal

Urine (glucose); MRI/CT

MG Bloods Ach receptor abs; TFT’s; RF; ANA

Other EMG; PFT’s

Imaging CXR, thoracic CT/MRI for thymoma

GBS Bloods Monospot; cold agglutinins; CMV; HIV; Campylobacter

Other PFT’s; incr protein on CSF with relative lack of WBCs; EMG

TIA Bloods FBC, ESR, fasting BSL, chol, TFT; possibly ANA, anticardiolipin ab, coag

Other Urine (?renovascular disease); ECG (?IHD / arrhythmia, long QT)

Imaging CT/MRI; carotid USS; TOE

End

Is there anything else I should know?

Presentation

Draft intro statement

Differential diagnosis

Findings that support / refute diagnosis

Horner’s SCC lung; thyroid Ca; brainstem Ca; mets; neurofibroma; base of skull lesion;

Neck trauma; local OT

carotid aneurysm / dissection; lat medullary syndrome; central cord syndrome; AVM; cervical rib; aortic

aneurysm; cavernous sinus thrombosis

cluster headache

retro-orbital lesion; lower brachial plexus lesion

MS; encephalitis; apical TB

Postganglionic doesn’t affect sweating

A-R pupil Syphilis, DM, alcoholic midbrain degeneration, other midbrain lesions

Papilleodema SOL; retro-orbital mass

hydrocephalus (obstructive eg. Ca; communicating eg. Choroid plexus papilloma, venous compression,

subarachnoid space compression)

benign intracranial HTN (idiopathic, OCP, Addisons, drugs, lat sinus thrombosis, head trauma)

HTN; central retinal vein thrombosis; cerebral venous sinus thrombosis

GBS

Ptosis Senile; myotonic dystrophy; ocular myopathy; thyrotoxicosis; MG; botulism; snake bite; congenital; fatigue;

Horner’s; tabes dorsalis; III palsy

III palsy Brain stem infarct; Ca (eg. Nasopharyngeal); demyelination; trauma; aneurysm of PCOM; meningitis; DM;

arteritis; cavernous sinus lesions

IV palsy Trauma; lesions of cerebral peduncle

VI palsy Trauma; Wernicke’s encephalopathy; raised ICP; mononeuritis multiplex; vascular; Ca; MS; DM

Nystagmus Central Cerebellar lesion; INO (nystagmus in eye looking laterally, other eye fails to adduct; due to MLF lesion

eg MS, brainstem infarct); brain stem lesion; phenytoin; ETOH

V palsy Vascular; Ca; MS; aneurysm; meningitis; meningioma; # of middle fossa; cavernous sinus thrombosis;

Sjogren’s; SLE; toxins; if all 3 regions = @ ganglion; if just 1 = post-ganglionic; if loss of pain but not touch =

brain stem or upper cervical cord; if loss of touch but not pain = pontine nucleus

VII palsy Vascular; Ca; MS; acoustic neuroma; meningioma; Bell’s palsy; Ramsay Hunt syubdrome; OM; fracture;

sarcoid; GBS; parotid disease; mononeuritis multiplex

VIII palsy Nerve Degeneration, # petrous temporla bone, aspirin, ETOH, streptomycin, rubella, congenitla syphilis;

acoustic neuroma; brain stem lesion

Cond Wax, OM, otosclerosis, Paget’s

IX palsy Lat medullary syndrome; Ca; MND; aneurysm; meningitis; GBS

XII palsy Vascular; MND; Ca; MS; vertebral artery thrombosis; meningitis; trauma; Arnold-Chiari malformation; BSF; GBS;

Polio

IX, X, XII Bulbar Infective Polio, neurosyphilis

Vascular Brainstem CVA

Other MND; syringobulbia; GBS; meningitis due to Ca/lymphoma

PseudoB Vascular Internal capsule CVA

Other MND; MS; high brainstem SOL; HI

Multiple palsy NP Ca; chronic meningitis (eg. Carcinoma, TB, sarcoid); GBS; MFS; Arnold-Chiari malformation; brain stem

lesions; trauma; basal skull lesions (eg. Mets, meningioma, Paget’s); mononeuritis multiplex (DM)

MG Lambert-Eaton (power increases on repeat; may be prox muscle pain; ocular and bulbar muscles spared)

Midline cerebellar SOL Midline tumour

Other Paraneoplastic syndrome

Unilat cerebellar SOL Tumour, abscess, granuloma

Vascular CVA; haemorrhage

Other Paraneoplastic syndrome; MS

Bilat cerebellar SOL Large

Vascular Arnold-Chiari malformation

Tox Phenytoin, ETOH, Li

Other Friedrich’s ataxia, hypothyroidism, paraneoplastic syndrome, MS, trauma

Peri neuropathy Motor Other GBS – others = PAN, porphyria

Hereditary motor and sensory neuropathy; DM

Tox Lead poisoning; tick/snake bite; arsenic; botulism

Infective Diptheria, polio

Painful Tox ETOH, arsenic, thallium

Other DM; Vit B1/B12 def; porphyria

Management

Suggest management and set management goals

MG Anticholinesterases (pyridostigmine); may need mechanical ventilation; steroids if severe; immunosupp;

thymectomy; plasmapheresis if myasthenic crisis

GBS Physio, resp support, plasmapheresis, IVIG

TIA CV RF control; aspirin; carotid endarterectomy; ?warfarin if AF

ENDOCRINE

History

Hello, this is exam

What is wrong? Why are you in hospital this time?

HPC HyperCa Lethargy, weakness, confusion, anorexia, constipation, N+V, AP, polyuria, polydipsia; Sx of

thyrotoxicosis or phaeo; recent immobilisation

DM Age of diagnosis; presenting complaint (polyuria, polydipsia, weight loss, infection, DKA)

Adequacy of control – method of testing, BSL results, regularity of testing, which metre, dose adjustment

in illness

Symptoms of hyperG: polyuria, thirst, weight loss, blurred vision

Admissions with DKA

Symptoms of hypoG and level of education: morning headaches / lethargy, night sweats, weight gain,

seizures

Other systems: IHD, claudication, CVD, peri neuropathy, autonomic neuropathy, erectile dysfx, syncope,

eyes, nocturia, oedema, HTN, boils, necrobiosis lipiodica

Action plan for hypoG

PMH HyperCa Pituitary adenoma, metastatic breast Ca, lung / renal Ca, haem Ca, XS vit D, hyperthyroidism, renal

failure; PUD, renal colic; pseudogout; HTN; prev parathyroid probs

DM Cushings, phaeo; pregnancy; pancreatic disease; CLD

CV RF’s (see above)

Generic details Immunisation status (influenza, hep A, hep B, Pneumococcus)

DH HyperCa Thiazide, lithium, Ca, vit D

DM Steroids, OCP, thiazides, phenytoin; beta-blockers; ACEi for HTN

A

SH Occupation, adequacy of income, current housing, ability to cope, mobility + steps

Hobbies (animals, chemicals, dusts), marital status, sexual problems

Place of birth, overseas travel

DM ETOH, exercise; work; living conditions; finance; eating habits; acopia with insulin; driving

FH HyperCa Of same, MEN

DM Of same; obstretic history (eg. big babies)

Investigation results DM Fasting BSL >7 on 2 separate occasions; 2hr post-prandial BSL >11; HbA1c results

Management DM Insulin / oral hypoG and when started; diet control; normal dose 0.5iu/kg/day with 40% long

acting; where injected, by whom

Examination

What did examiners examine? Did they comment on signs?

Standing:

[pic]

General Hypopit Pale skin, lack of hair; short stature; no 2Y sexual characteristics

Cushings Central obesity; thin limbs; skin bruising and atrophy; skin pigmentation; poor wound healing;

look at patient standing from front, sides and behind

Addisons Pigmentation, vitiligo

Diabetes Weight, hydration, endocrine facies, pigmentation; signs of CRF

HyperCa Neck scar; forearm scar; LN; evidence of renal failure; signs of thyroid; pigmentation of

Addisons; Evidence of sarcoid / TB; Prox weakness; corneal band keratopathy; Pseudogout

DM Complications of disease

Sit down:

Hands Thyroid Tremor (place sheet over dorsal hand); onycholysis (separation from nail bed); thyroid

acropachy (looks like clubbing); palmar erythema; radial pulse (tachy, AF, collapsing pulse)

For hypo: cyanosis, swelling, dry skin, cold; anaemia; pulse (decr HR, small vol); test for carpal

tunnel syndrome (flex both wrists for 30secs ( paraesthesia)

Arms Thyroid Prox myopathy (more common in hyper); reflexes for briskness (delayed relaxation in hypo, fast

in hyper)

Trousseau sign if thyroidectomy (above SBP ( adducted thumb, extended PIP and DIPJ within

2mins)

Hypopit Lying and standing BP

Cushings Purple striae; prox myopathy; BP

Addisons BP, postural drop

Diabetes Injection sites; pulse (lying and standing for autonomic neuropathy); BP (postural hypotension);

nails for candida; lack of slowing of pulse with valsalva; loss of sweating

Face Thyroid Proptosis (amount of sclera, lid retraction, lid lag by asking to follow finger as goes down at

slow rate) – look from infront, behind over forehead; conjunctiva for chemosis; opthalmoplegia

(loss of IO power, then convergence, then others in thyrotoxicosis); fundi for optic atrophy

Chvostek’s sign if thyroidectomy (tap facial nerve 4cm infront of and below ear ( twitch =

hypoCa

For hypo: swelling, periorbital oedema, loss of outer 1/3 of eyebrows; xanthelasma; dry, fine

smooth skin; carotenaemia, alopecia, vitiligo; swollen tongue; speech hoarseness;

sensorineural deafness

Hypopit Skin wrinkles around mouth and eyes; hypophysectomy scar on forehead; bitemporal

hemianopia; fundi for optic atrophy; eye ROM; trigeminal nerve

Cushings Plethora; hirsutism; acne; telangectasia; moon shape; visual fields; fundi (atrophy,

papilloedema, signs of HTN / DM); oral thrush

Diabetes Fundi – cataracts, rubeosis, retinal disease, III nerve palsy (pupil spared); ROM eyes; mouth

and ears for infection; VA; Argyll-Robertson pupil; dot haemorrhage, blot haemorrhage, hard

exudates, soft exudates (cotton wool spots), microaneurysms, dilated veins, new vessels,

vitreous haemorrhage, scars, retinal detachment

Neck Thyroid Inspect Scars, swelling, prominent veins; swallow water and look for thyroid

Enlargement; voice hoarseness (RLN palsy)

Pemberton’s sign (lift arms over head and look for suffusion of face, elevation of

JVP, insp stridor = means there is retrosternal mass)

JVP = SVC obstruction

Palpate From behind with neck flexed; shape, consistency, distribution of enlargement;

single / multiple nodules; tenderness; ?retrosternal extension (can you feel

lower border); cervical LN’s; mobility; thrill

From infront: carotid arteries (no pulse if malignant infiltration); thryoid; note

tracheal position; supraclavicular LN’s; sternomastoid function

Percuss Across upper chest over upper manubrium for dullness (retrosternal extension)

Auscultate Bruit (active thyrotoxicosis); carotid bruit

Cushings Supraclavicular fat pads; acanthosis nigricans

Diabetes Carotid arteries palpate and auscultate

Chest Thyroid Gynaecomastia; ESM; CCF

If hypo: pleural and pericardial effusions; sandpaper skin

Hypopit Decr hair, pale skin, gynaecomastia

Cushings Buffalo hump (interscapular fat pad); kyphoscoliosis and tender vertebrae (osteoporosis)

Diabetes For signs of infection

Lie down:

Abdo Cushings Purple striae; adrenal mass; adrenalectomy scar; liver tumour

Diabetes Liver for fatty infiltration; insulin injection sites ( fat hypertrophy

Legs Thyroid Pretibial myxoedema (firm elevated dermal nodules and plaques, pink, brown or skin coloured);

vitiligo; prox myopathy; reflexes

If hypo: reflexes; peri neuropathy

Hypopit Loss of pubic hair; testicular atrophy

Cushings Squat (prox myopathy; striae; bruising; oedema

Diabetes Necrobiosis, hair loss, infection, pigmented scars, atrophy, ulceration, injection sites, muscle

wasting, joint destruction; temperature of feet + CRT; peri pulses; oedema; peri neuropathy

(including vibration and proprioception); diabetic dermopathy; femoral artery for bruits; prox

muscle power

Investigations

Ask for 1-2 recent investigations and reason for ordering

Comment on results, even normal

HyperCa Bloods Ca; PTH; Vit D

Other 24hrs urine Ca

Imaging CXR (malignancy); XR (subperiosteal reabsorption)

Urine (glucose; renal stone disease, ketones, protein)

End

Is there anything else I should know?

Presentation

Draft intro statement

Differential diagnosis

Findings that support / refute diagnosis

Diffuse goitre Idiopathic; puberty, pregnancy, post-partum

Thyroiditis (Hashimoto’s, subacute, Riedel’s)

Iodine def / XS; inborn errors of thryoid metabolism

Drugs (eg. Li)

Management

Suggest management and set management goals

HyperCa Parathyroidectomy; steroids; frusemide; rehydration; IV bisphosphonates; calcitonin

DM Diet; exercise; insulin; metformin preferred in overweight with type II; education; regular FU; mng BP (ACEi); control CV RF; statins; regular eye review; screen urine for protein

Venous stasis ulcer – most common

. Site: around malleoli

. Associated pigmentation, stasis eczema

Ischaemic ulcer

. Large artery disease (atherosclerosis, thromboangiitis obliterans): usually lateral side of leg (pulses absent)

. Small vessel disease (e.g. leucocytoclastic vasculitis, palpable purpura)

Malignant ulcer

. e.g. basal cell carcinoma (pearly translucent edge), squamous cell carcinoma (hard everted edge), melanoma, lymphoma, Kaposi’s sarcoma

Infection

. e.g. Staphylococcus aureus, syphilitic gumma, tuberculosis, atypical Mycobacterium, fungal

Neuropathic

. painless penetrating ulcer on sole of foot: peripheral neuropathy

. e.g. diabetes mellitus, tabes, leprosy)

Underlying systemic disease

. Diabetes mellitus: vascular disease, neuropathy or necrobiosis lipoidica (front of leg)

. Pyoderma gangrenosum

. Rheumatoid arthritis

. Lymphoma

Haemolytic anaemia (small ulcers over malleoli), e.g. sickle cell anaemia

Equipment:

Piece of paper

Sleeve of shirt with button

Card to cover opposite eye on VA check

Red tipped hat pin

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