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How to Be A Doctor

SHORT CASEFor 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 – 15-20minsHello, this is exam; sorry for time restraints; you can tell me anything you knowWhat is wrong? Why are you in hospital this time? Do you know your diagnosis?

HPC Presenting symptomsIs 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 + stepsSmoking, ETOH, drugsHobbies (animals, chemicals, dusts), marital status, sexual problems and preferenceImmunisationEducation and language

Place of birth, overseas travelLevel of Fx in community; level of help in communityInvolvement of ancillary: physio, SW, OTPsychological impact of disease

FH

Examination – be finished by 20-35minsWhat did examiners examine? Did they comment on signs?

EndIs 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 wardSystems review

PMH Active problems – some detailActive problems that are not relevant to current presentationNon-active problems

DH + A – reference what medication is used forFHSH – include non-clinical issuesExamination cardinal signs and other signs; general appearance; vital signs; most important system first; relevant +ives and -ives

Summary statementIn 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 EDInvestigations and justification for (beside, lab, imaging) – comment on results if givenManagement and management goals – inc supportive care, disposition etc…

Primary ED points in this case are

CVHistory

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 longRehab program; RF control

IE Symptoms Malaise, fever, anaemia

Cause / RF’s Recent dental / endoscopic / OTRF, 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 discussedA 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 aboveFor cardiomyopathy: ETOH, FH of same, haemachromatosis

PMH HTN, IHD, RF, valve disease, congenital heart disease, cardiomyopathy, prev cardiac OTOE 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; persistencyRF’s IHD, AS, cardiac OT, congenital heart disease, thyrotoxicosis, WPW, recent ETOH binge, PE,

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

SH Ability to manage multiple blood tests and trips to labFH Sudden cardiac death (long QT, Brugada, HOCM)

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

Recent INR’s + Warfarin doses

Generic detailsImmunisation status (influenza, hep A, hep B, Pneumococcus)Compliance with meds

ExaminationWhat did examiners examine? Did they comment on signs?Stand back and lookSit patient at 45 degrees and expose neck and chest

General Temperature chart; ?IV cannula; ?infusion runningSyndromes Marfan’s, Turner’s, Downs, Cushings, acromegalyGeneral Uraemia, SOB, cyanosis

CCF Precipitating factorOedema Nutrition, myxoedema

Put hands on thighs in front of them

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

Pemberton’s signHOCM Jerky / sharp pulseAR Collapsing pulse; Quincke’s sign

Hyperlipid Tendon xanthomataSVC 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 flushValve Jaundice (haemolysis)Marfan’s Arched palate

SVC obst Plethoric cyanosed face, periorbital oedema, exopthalmos, conjuctival injection, Horner’s syndrome, fundi for venous dilation

Neck JVPHeight, 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), HOCMDominant v wave = atrial filling: TRCannon a wave: CHB, nodal tachycardia, VT, pacemakerElevation: RVF, TS, TR, pericardial effusion, constrictive pericarditis, SVC obstruction, fluid

overload, hyperdynamic circulation (eg. Fever, thyrotoxicosis)Carotids Character; carotid bruit

AS Slow risingAR Corrigan’s = prominent, water hammer

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

Chest Inspection Scars, deformity, visible pulsations, pacemakerPalpation Apex beat (position in ICS, mid clavicular line, character)Pressure loaded = forceful + sustained = AS, HTNVolume loaded = forceful + unsustained = AR, MRTapping = MSDouble / triple = HOCMAbsent = constrictive pericarditis

Thrills: across L side chest horizontally = palpable murmur = AS, MS, VSDParasternal impulse: L sternal edge verticallyRV Heave = RVH, LA enlargement = MR

Auscultate Bell + diaphragm at apexDiaphragm at lower and upper L sternal edge, R upper sternal edgeIf murmur, time with carotid pulse

Listen below L clavicle for PDA murmurL lateral position: rpt apex and bell in mitral area (for MS)Sitting forward in expiration: rpt thrill, listen lower L sternal edge with diaphragm; ?ARIf ?HOCM (ie. Pure systolic murmur) – Valsalva, resp phases, hand grip, standing, squatting at lower left sternal edge with diaphragm

S1 Loud MS, TS HyperdynamicSoft MR 1st deg HB, LBBB

S2 Loud AS HTNSoft AR, PSAV closes then PV usually on inspiration = physiological splittingWide = Incr splitting on inspiration PS, MR, VSD, RBBBFixed splitting ASDReversed AS, CoA, PDA, LBBB

S3 Rapid diastolic filling = AR, MR, VSD, PDA, failure, constrictive pericarditisS4 High atrial pressure = AS, PS, MR, HTN, HOCM, IHD

Systolic Early MR, TR VSDMid AS, PS ASD, HOCMLate MVP HOCMPan MR, TR VSD, AP shunt

Diastolic Early AR, PRMid MS, TS, AR RF, Austin Flint of AR, atrial myxomaLate MS, TS Atrial myxoma

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

HOCM Ejection and pan-systolic murmurLouder with Valsalva, standing, joggingSofter with squatting, raising legs, forceful handgrip

SVC obstr Distended collaterals

patient is now sitting up

Back Inspection Scars, deformity, oedemaPalpation Percuss for pleural effusionAuscultate ?LVF – crackles

lie flat

Abdo Lie flat with 1 pillowInspectionPalpation 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)

NeuroIE FND; fundi

PresentationIntro, summary

Differential diagnosisFindings 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 MIInfection MyocarditisTrauma Cardiac contusion, cardioversion, biopsy; cardiac OT; stent; angioplasyTox Cardiotoxic; Irukandji syndrome

Other cardiac CCF; aortic dissection; HOCM; AS; AR; arrhythmia; cardiomyopathy; rhabdoNon cardiac Sepsis; renal failure; PE; pul HTN; burns; exertion; CVA; SAH

InvestigationsAsk for 1-2 recent investigations and reason for orderingComment on results, even normal

Bedside Echo (vegetations; valve S/R; RWMA; LVEF); ECG; Temp chartLab 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 castsHTN: ?cushings

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

ManagementSuggest management and set management goals

IE Benpen 6-12g OD for 4-6/52Valve replacement: if resistant, mod-severe failure, persistent +ive blood culture, conduction disturbance

CCF Remove causeInotropes (dobutamine, dopamine, Levosimendan)Implantable defib if malignant rhythm / severeDecr activity; diuretics; low salt diet; fluid restriction; daily weighs; ACEi / AR blocker, beta-blockers, digoxin

HTN Remove causeLifestyle factors (weight, exercise, ETOH, salt)Meds

Arrhythmia Drugs; pacing; AICD; rate vs rhythm control; AVN ablation; DC cardioversion CHADS2

RSHistory

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 syndromeDH Abx; bronchoDMng 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; ABGOther Sputum results; PFT’s (restrictive/obstructive); cilliary Fx; sweat test;

bronchogramImaging 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 dependentsOE 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; LFTOther Sputum cytology; PFT’s biopsy / FNA; bronchial brushings / washings; pleural

biopsy; stagingImaging CXR (hemidiaphragm changes; peri = adenoCa; central = squamaous; hilar =

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

COPD Symptoms SOB, cough, sputum, wheeze, exercise tolerance, wegith lossPrecipitants URTI, pneumonia, meds, RVF, smoking, aspiration, GORD; Smoking (age started, how

many)DH Steroids, bronchoD; home O2SH Occupation (air pollution, plastics factory toluene)FH Alpha-1 ATOE Look at sputum; cachexia; SE of trt (eg. tremor in salbutamol, steroids); Early

coarse insp creps; Pursed lip; exp time; WOBIx 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 durationPMH Scleroderma, SLE, Sjogren’s, RA, sarcoidosis, asthma, Churg Strauss, Goodpasture’s,

PAN; Prev radiotherapy, aspiration pneumonia, miliary TBDH Amiodarone, hydralazine, procainamide; Methotrexate, penicillamine, bleomycin,

cyclophosphamide; Nitrofurantoin, bromocriptineSH Mineral dust (silicosis, asbestosis, coal), chemicals (NO2, Cl, NH3), birds, farmer, flax,

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

Erythema nodosum; signs of steroid SE’sIx Bloods ABG; ESR; LDH; eosinophilia; serology for CT diseases

Other PFT’s (restrictive usually); Bronchoalveolar lavage; biopsyImaging 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, tearingDH Steroids, NSAIDs, cyclosporins, cyclophosphamideOE 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 biopsyDD 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 prolapseNo. prev hospital admits

SH Support network; understanding of inheritanceMng 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 defOther Sputum culture; PFT’s; sweat testImaging 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; TRIx Bloods ABG

Other PFT’sImaging 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 diagnosisPMH 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 SOBAsk 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, CFLung 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

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 breastsPercussion Clavicles directly, then lowerAuscultate 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 failurePalpate

Legs Peri oedema

InvestigationsPleural fluid analysisCXR, plus ask to see lateral

EndIs there anything else I should know?

PresentationDraft intro statement

Differential diagnosisFindings that support / refute diagnosis

Pul fibrosis Upper lobe Toxin Silicosis, coal worker’s pneumoconiosis, radiationInfection TB; CF; aspergillosis; PCPInfiltrative Sarcoidosis, histiocytosis, aspergillosis; eosinophilicRheum Ank spond

Lower lobe Toxin Asbestosis, hydralazine, amiodarone, bleomycinInfective Bronchiectasis, aspiration

Infiltrative Cryptogenic fibrosis alveolitisRheum RA, scleroderma

Large hilum LN Lymphadenopathy; CaVessel Pul venous HTN (upper half hilum; LVF, MS, MR)

Pul artery HTN (1Y pul HTN, lung disease)Incr pul blood flow (LR shunt, hyperdynamic circulation)

Focal consolidation Infective Pneumonia; AtelectasisVascular Pul infarction; intrapul haemorrhageCa Alveolar cell carcinoma

Diffuse airspace disease Infective Pneumonia (mycoplasma, pneumocystis); interstitial pneumonitisVascular Pul oedema; contusion; PECa Alveolar cell Ca; lymphomaAutoimmune Goodpasture’s; alveolar proteinosis

Fine reticular = ILD Vascular Pul oedemaInfective Interstitial pneumonitis (mycoplasma, viral); atypical pneumoniaCa Lymphangitis metasasisAutoimmune 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 fibrosisReticulonodular 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

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

Vascular Septic emboli; pul infarctCa SCC, Hodgkin’sAutoimmune Granulomatosis; sarcoid; Wegener’s; RAOther


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

GIHistory

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

PMH Dyspepsia; DM; thyroid; hyperPT; CT disease; prev ulcer OTDH Digoxin, KCl, PO Abx, NSAIDs, ETOH; PPI; H pylori trt; steroids; anticoagulantsFH 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, neomycinFH Coeliac disease, IBDOE 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 symptomsUC – bloody diarrhoea, malaise, fever, weight lossCD – pain, diarrhoea, weight loss, malabsorption, intestinal obstructionComplications 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, OCPSH Sexual preference (proctitis is DD); smoking (protective in UC); domestic arrangements

and employmentFH Of same, bowel Ca

OE Nutrition, hydration; signs of Cushing syndrome; Clubbing; Lesions, anaemia; Uveitis; Tenderness; abdo masses; anal lesions; signs of liver diseaseDD 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, cystitisPMH Polyps; IBD; Peutz-Jehger’s syndrome; DM; acromegalySH Determine if understands diagnosis; social support networkFH FAP (if present ask if children have been screened); ovarian / endometrial CaOE Changes of radiotherapy, pigmentation of Peutz-Jehger’s; Abdo masses, scars, PR

CLD Symptoms Jaundice, ascites, AP, bleeding, encephalopathy, weaknessComplications Encephalopathy, portal HTN, ascites, varices, erectile dysfunctionPMH Hepatitis, jaundice, prev transfusions, DM, CCF, haemachromatosis; hepatitis status;

Wilson’s disease; For NASH – obesity, type II DM, incr lipidsDH Methyldopa, isoniazid, nitrofurantoinSH ETOH intake, drug addiction, sexual orientation, tattoos, overseas travelOE 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 massDD 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


Investigations PUD Endoscopy, barium meal, H pylori (serology / biopsy)IBD Follow up colonscopiesColon Ca Staging results; surveillance colonoscopyCLD Liver biopsy

Management PUD Blood transfusion, injection in peptic ulcer base, surgical oversewingMalabsorption Diet, pancreatic supplements, Vit supplements, cholestyramine, AbxIBD Sulfasalazine, mesalazine, olsalazine, steroids, metronidazole, Azathioprine, infliximabColon Ca RadiotherapyCLD 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 naeviPalpate Breasts if think intra-abdo CaAuscultate 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 naeviTake 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; kidneysPercuss 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 againRIF mass: appendix abscess, caecal Ca, CD, pelvic kidney, ovarian Ca/cyst, carcinoid,

psoas abscess, ileocecal TBLIF mass: faeces, colon Ca, diverticular disease, ovarian Ca/cyst, psoas abscessUpper 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 dullnessAuscultate 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, oedemaNeuro: peri neuropathy; prox myopathy; cerebellar syndrome

Sit up 45 deg

JVP

InvestigationsUrine

PUD Bloods If atypical, fasting serum gastrin, gastric juice pH, secretin test; incr Ca ?MEN IOther Endoscopy (?active bleeding or clean ulcer base); biopsy resultImaging USS (biliary tract); CT (pancreas, ZES)

MalabsorptionBloods 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; parasitesImaging 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; CEAOther Colonoscopy, Ba enema, FOB testingImaging 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 varicesImaging USS; CT abdo; Doppler flow studies for varices



IBD Grade severity (mild <4 stools/day; mod 4-6, severe 6-10, fulminant >10)CLD Grade severity (Child’s classification)


Ascites Liver Cirrhosis, alcoholic hepatitis, fulminant hepatic failure, Budd-Chiari syndromeCardiac CCF, veno-occlusive diseaseEndocrine MyxoedemaCa Peritoneal Ca Infective TB, pancreatitisRenal 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 CaInfective Epididymitis

Hepatomegaly Infective Hepatitis, hydatid disease, HIV, CMV, IMNCancer Mets (S), CML, lymphoma, HCC (S), myeloproliferative (S)Toxins ETOH (S)Auto-immune Granulomatous, amyloid, sarcoid, SLEOther Biliary obstruction, fatty liver, CCF (S), CLD with portal HTN

Firm irregular liver: cirrhosis, mets, hydatid, granuloma, amyloid, cysts, HCCTender liver: hepatitis, RHF, Budd-Chiari, hepatocellular CaPulsatile liver: TR, hepatocellular Ca, vascular abnormalities

Splenomegaly Infective IMN, hepatitis, IE, malaria (S), CMVCancer Myeloproliferative (S), lymphoma S), leukaemia, CML (S)Autoimmune RA, SLE, PAN, amyloid, sarcoidOther Haemolysis, megaloblastic anaemia, portal HTN,

storage diseases

Hepatosplenomegaly: Infective: hepatitis, CMV, IMN, EBVCancer: myeloproliferative, lymphoma, leukaemia Autoimmune: SLE, amyloid, sarcoidOther: CLD with portal HTN; pernicious anaemia; SCA;

acromegaly; thyrotoxicosis

Ballot kidneys

Big kidneys: Infective PyonephrosisCancer RCC, lymphoma, Wilm’s tumour, neuroblastomaAutoimmune AmyloidTrauma Perirenal haematomaOther PCKD, hydronephrosis, renal vein thrombosis, acromegaly


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 transplantHepatitis: antivirals, interferon

HAEMHistory

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


DH Haemolytic anaemia Methyldopa, penicillin, quinidine, antimalarials, sulfonamides, nitrofurantoinThrombophilia 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 + stepsHobbies (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 cellThrombophilia Of thrombosis; family members tested

Investigation results

Management

ExaminationWhat did examiners examine? Did they comment on signs?Lie supine, head on 1 pillowAsk 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), pigmentationThrombophilia 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); candidaFundiHaemolytic 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 frontGeneralised lymphadenopathy: Infection: CMV, HIV, IMN, TB, toxoplasmosis,

Cancer: lymphoma, CLL, ALL, mets,Autoimmune: RA, SLE, sarcoidOther: phenytoin

,

Bones Sternum; clavicle; shoulders; spine tenderness

Chest Haemolytic Prosthetic valve, severe AS, CCF

Lie down again

Abdomen Splenomegaly, hepatomegaly, signs of CLDAsk to do a rectal examThrombophilia Abdo wall bruising; abdo mass

Groin Inguinal LN; pelvic tendernessAsk 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

InvestigationsUrine (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; haemosiderinImaging

Thrombophilia Bloods FBC, ESR, Factor V Leiden, APL ab (incr lupus anticoagulant, anticardiolipin ab), AT III, protein C+S, PT gene mutation, plasma homocysteine




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


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

RHEUMHistory

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


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



RA Coping; mobility; ADL; fine motor skills; work; support servicesSLE Understanding of implications of disease

FH RA Of same

Investigations

Management RA Initial trt; other trt; complications of trt

ExaminationWhat did examiners examine? Did they comment on signs?

General Cushingoid; weight; iritis; scleritis; obvious other joint disease; gait if walked into roomRA Cushings; BMISLE Cushings, weight loss; mental state, BP, tempDiscoid 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 vasculitisDorsal and palmar

Palpate Do you have any pain anywhere? Inc ulnar styloid tendernessSynovitis, 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 AbnormalThumb power – abduction, aduction, flexion, opposition

Function Grip strength; key grip turning, opposition strength (a-OK), practical ability (undo button)Sensation If function mentionned, test thisRA Symmetrical wrist, MCP and PIPJ swelling; undo a buttonOA Sweling of PIPJ and DIPJ (Bouchard’s and Heberden’s nodes)Psoriatic Sausage shaped fingers and telescoping of fingers; predominant IPJ diseaseSLE Nail fold infarcts, vasculitis, arthropathy

Arms BPInspect 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 nodesSLE Livedo reticularis, purpura, prox myopathy

READ SHOULDERS

Face Iritis, scleritisRA Eyes (as above); fundi; parotids; mouth (dry, ulcers, caries, TMJ)SLE Malar rash; Alopecia, eyes (as above), mouth ulcers, rash, CN lesions, LNAnk spond Uveitis

Neck RA Spine, LN

Chest RA Pericarditis, murmurs, effusion, fibrosis, infarct, nodules, TBSLE Endocarditis, pleural effusion, pleurisy, ful fibrosis, collapse

Ank spond Decr chest expansion; AR, MVP

Abdomen Palpate Spring pelvisRA Splenomegaly, epiG tenderness, inguinal LNSLE Hepatosplenomegaly, tendernessAnk spond Evidence of IBD; hepatosplenomegaly

Knees Expose and lie on backInspect Quads wasting; scars; rashes; swelling; deformity; walk; squat and look at space under kneesFunction 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 cystsApley’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 compressionSLE Feet, prox myopathy, cerebellar ataxia, neuropathy, hemiplegia, mono multi

Back Inspect Deformity from back and side; loss of kyphosis / lumbar lordosisPalpate Tenderness and muscle spasmMovement 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)


RA Bloods RF; anti-CCP; ESR; CRP; FBC (AOCD); U+E (if on NSAID)Other Urine protein, bloodImaging 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 neuroImaging MRI




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

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


RA Education; physio; exercise; OT; aspirin, NSAID, COX-2 inhibitors; DMARDs (Methotrexate); gold; penicillamine; local steroid injection; OT if severe

RENALHistoryHello, this is examWhat 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, haemoptysisLong term prognosisDialysis; if not, has it been discussed; transplant list?; complications – shunt blockage, thrombosis, infection,

access problems, pericarditis, peritonitisComplications: anaemia, bone disease, gout, pericarditis, HTN, CCF, peri neuropathy, pruritis, PUD, cognition

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


DH CRF NSAIDs and other analgesics, contrast, infection, ACEi?doses altered for renal failure

A



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


CRF General Mental state, sallow complexion, hydration, fever, CushingoidHands Nails (brown lines), shunt, asterixis, neuropathyArms Bruising, pigmentation, scratch marks, myopathy, BPFace Anaemia, jaundice, band keratopathy, dry mouth, fetor, rash, saddle nose (WG), fundoscopyChest Pericarditis, CCF, lungs, venous humAbdo Scars, renal mass, Tenchkoff, bladder, liver, LN, ascites, bruits, rectalLegs Oedema, bruising, pigmentation, scratch marks, gout, neuropathyBack Tender, oedema


CRF Blood GFR, Cr, electrolytes, phos, uric acid, Ca, alb; FBC (Burr cells, anaemia); Fe, Ferritin; PTH?hep B/C, HIV, ANAOther Urine: specific gravity, pH, glucose, blood, protein, casts; renal biopsy; urine cytologyImaging USS; KUB; IVP; CT; cystoscopy; retrograde pyelography; renal angiogram





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

NSHistoryHello, this is examWhat 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; RAGBS Of same


DH MG Drugs that may interfere with neuro (streptomycin, gent, quinidine, procainamide)TIA OCP, sedatives, hypoG drugs, anticonvulsants, antiarrhythmics

A



FH

Investigations MG Blood test / electrophysiological studies

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


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 clearlyVisual 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

PtosisEye 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 eyesIn V nerve palsy (sensation): both eyes fail to blinkIn 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 touchIn pontine lesion: loss of light touch, preservation of pain and temp

Muscles of mastication: clench teeth and feel masseters; open mouth and try to closeIn lesion: jaw deviates towards affected side

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

VII Facial asymmetryLook up, wrinkle forehead look for loss of wrinkles and push down on each side

Loss of forehead power = LMN lesionShut eyes try to openGrin compare nasolabial foldsIf LMN lesion, check ear and palate for veiscles of herpes zosterSay would check taste of anterior 2/3 tongue

VIII Whisper beside ear and ask repeat; rub auricle on other earRinne’s: on mastoid process until no longer heard then beside ear

Normal / sensorineural = note audible via airConductive = note not audible via air

Weber’s: in centre of foreheadNormal = heard in middleSensorineural = 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 sideGag reflex – check patient can feel spatula, patient should only gag if hyperreactiveSpeechCough - ?bovine (RLN lesion)

Say would check taste of posterior 1/3 tongueXII Inspect tongue for wasting / fasciculation

Ask to stick tongue out

Tongue goes Towards abnormal sideXI 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 FaciesOrbits Palpate for tenderness; auscultate for bruitLid lag, ptosis, exopthalmos (look from behind and above patient)Eyes AcuityFields as aboveEye mvmt: mvmt, diplopia, nystagmus, fatiguability (30secs looking up)Pupils: shape, size, symmetry, RAPD, accomodation

Sclera for jaundice, pallor, injectionCornea for arcus, band keratopathy, KF rings

Fundi: humour, disc; changes of DM, HTN, optic atrophy, papilleodema, retinal detachment, venous / artery thrombosisCorneal reflex

Pancoast Eye Nystagmus to side of lesion; miosis; ptosis; enopthalmosFace Symp Decreased sweating on brow with back of fingerV Ipsilateral loss of pain and tempIX, X Uvula deviated away from lesion; loss of gag reflex; hoarseness (RLN compression)NS Ipsilateral cerebellar signsFinger abduction (lower brachial plexus lesion = thoracic outlet syndrome)Signs of lung Ca: Clubbing, chest examinationSigns of other Ca: LN, thyroid examOther: carotid bruit

Adie’sEye Mydriasis; decr direct and consensual light response; slow accomodationNS Decr tendon reflexes

A-R Eye Miosis; irregular pupil; no reaction to light; good accomodationNS 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 handsOrientation Person – his name, who I amPlace – present location (country, city, building)Date – day, month, year

Temporal Short term memory: rose, orchid, tulip repeat immediatelyLong term memory: dates of 2nd World War

Parietal Dominant Acalcula = serial 7’sAgraphia = write your nameAgnosia, fingerL-R disorientation = put R hand on L ear, then vice versa

Non-dominant Apraxia, Dressing = turn pyjama top inside out and put it onBoth Sensory and visual inattentionCortical Agraphaesthesia = draw number on palm

Astereognosis = name key placed in handApraxia, Constructional = draw clock face and numbers

Recall Rose, orchid, tulip againLanguage Nominal Name watch and pen (temporal, angular gyrus)

Repetition Repeat phrase – no ifs, ands, or buts fluency, comprehension, repetitionReceptive 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 kaFrontal Primitive reflexes: Grasp

PoutPalmar-mental

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

Examine visual fields; carotid bruits; HTN; focal neurology

MMSE Orientation Time: year, month, day, date, time /5Place: country, town, district, hospital, ward /5Registration Rose, orchid, tulip repeat /3Attention + calc Serial 7’s /5Recall Rose, orchid, tulip remember /3Language Name watch and pen /2Repeat no ifs and or buts /13 stage command: clap hands, touch nose, point to ceilling /3Read “close your eyes” and obey /1Write a sentence /1Copying Copy pair of intersecting pentagons /1

Speech Say name, age and present locationSay “British Constitution”

Dysphasia Ask to name objectAsk to repeat statementAsk to follow commandsIf 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 nameDysarthria Say British Constitution, West Register Street, Me Me Me, Lah Lah LahCerebellar = irregular staccato Examine cerebellumLower CN = pseudoB = slow hesitant harsh strained voice Examine CN’sLower CN = bulbar = nasal speech with imprecise articulation

Arms Take off shirt and sit over edge of bedGeneral Facies (eg. Parkinsons, CVA); scars; skin (neurofibromata, café-au-lait); abnormal movements

Shake hands Myotonia if can’t let goInspect Wasting

Fasciculation (LMN = MND, root compression, peri neuropathy, myopathy, thyrotoxicosis)TremorDrift (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 lesionTone Wrist and elbow movement at varying velocitiesNeck movementPower 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=normalReflexes Augment if needed

C5-6 BicepsSupinator

C7-8 TricepsC8 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 dermatomeTemp Say you wouldPosterior Demonstrate on clavicles

Vibration: on ulnar wrist with eyes closed on elbow, on shoulder if abnormalAsk if can feel it; when feels stopProprioception: DIPJ of index finger; demonstrate with eyes open close eyes;

do wrist and shoulder if abnormalLight touch (both post and spinothalamic) with cotton wool

Legs General As above + urinary catheter; look for walking stick / special shoesGait Walk across room, turn around, come back – with legs uncoveredHemiparetic = foot plantar flexed and swung laterallyParaparetic = scissor gaitExtrapyramidal = hesitation starting, shuffling, freezing, festination, propulsionCerebellar = drunken, widebased or reeling on narrow base; staggers to affected sideApraxic = prefrontal = glued to floor when erect, move easily when supinePost column = clumsy slapping feet on broad baseHigh stepping = distal weaknessWaddling = prox weaknessHeel-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 abovePalpate As aboveTone Knee and ankle, inc clonus (push patellar sharply downwards) = UMN lesionPush into mePower 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 KneeS1-2 AnkleS1 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 levelTuning fork on MTPJProprioception with big toes; knee and hip if neededSaddle region sensation (S3-5)

Anal reflex (S2-4)Back Deformity, scars, tenderness, bruits; SLR

Abnormal co-ordination: do gait, tone, co-ordination tests (arms and legs), Romberg’sIf Romberg +ive but co-ordination OK, do vibration and position senseNystagmusSpeech (British Constitution, West Register Street)Truncal ataxia: fold arms; sit up; put legs over side of bedFundi for papilloedla; CN’s examination

LMN Weakness; wasting; hypotonicity; decr reflexes; fasciculationUMN Weakness (more marked in upper limb abductors and extensors, lower limb flexors); spasticity; clonus; incr

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

thumb sensationLower 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 massCervical 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 ribRadial nerve (C5-8): wrist and finger extension weakness loss of elbow extension if high

Loss sensation over ASBMedian 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 plexusFemoral nerve (L2-4): Weak knee extension, hip flexion; loss of knee jerk

Loss sensation over inner aspect thigh and legSciatic 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 kneeCommon 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 CancerAutoimmune: Polymyositis / dermatomyositis; sarcoidToxins: 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 weaknessNormal 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 atrophyCV Postural BP changes, arrhythmia

TIA Eyes ?emboli, hypertensive changes, diabetic changes, ischaemic retinopathy; visual fields; nystagmusCV Carotid bruit; pulses; postural BP; murmurs (?IE, AS, RHD, prosthetic valve); PVD; pacemaker; GCANS Dix-Hallpike if vertigo

InvestigationsAsk for 1-2 recent investigations and reason for orderingComment on results, even normalUrine (glucose); MRI/CT

MG Bloods Ach receptor abs; TFT’s; RF; ANAOther EMG; PFT’sImaging CXR, thoracic CT/MRI for thymoma

GBS Bloods Monospot; cold agglutinins; CMV; HIV; CampylobacterOther PFT’s; incr protein on CSF with relative lack of WBCs; EMG

TIA Bloods FBC, ESR, fasting BSL, chol, TFT; possibly ANA, anticardiolipin ab, coagOther Urine (?renovascular disease); ECG (?IHD / arrhythmia, long QT)Imaging CT/MRI; carotid USS; TOE




Horner’s SCC lung; thyroid Ca; brainstem Ca; mets; neurofibroma; base of skull lesion;Neck trauma; local OTcarotid aneurysm / dissection; lat medullary syndrome; central cord syndrome; AVM; cervical rib; aortic aneurysm; cavernous sinus thrombosiscluster headacheretro-orbital lesion; lower brachial plexus lesionMS; encephalitis; apical TBPostganglionic doesn’t affect sweating

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

Papilleodema SOL; retro-orbital masshydrocephalus (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 thrombosisGBS

PtosisSenile; 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 peduncleVI palsy Trauma; Wernicke’s encephalopathy; raised ICP; mononeuritis multiplex; vascular; Ca; MS; DMNystagmus 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; ETOHV 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 lesionCond Wax, OM, otosclerosis, Paget’s

IX palsy Lat medullary syndrome; Ca; MND; aneurysm; meningitis; GBSXII palsy Vascular; MND; Ca; MS; vertebral artery thrombosis; meningitis; trauma; Arnold-Chiari malformation; BSF; GBS;

PolioIX, X, XII Bulbar Infective Polio, neurosyphilis

Vascular Brainstem CVAOther MND; syringobulbia; GBS; meningitis due to Ca/lymphomaPseudoB Vascular Internal capsule CVAOther 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; haemorrhageOther Paraneoplastic syndrome; MS

Bilat cerebellar SOL LargeVascular Arnold-Chiari malformationTox Phenytoin, ETOH, LiOther Friedrich’s ataxia, hypothyroidism, paraneoplastic syndrome, MS, trauma

Peri neuropathy Motor Other GBS – others = PAN, porphyriaHereditary motor and sensory neuropathy; DM

Tox Lead poisoning; tick/snake bite; arsenic; botulismInfective Diptheria, polioPainful Tox ETOH, arsenic, thalliumOther DM; Vit B1/B12 def; porphyria


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

ENDOCRINEHistoryHello, this is examWhat 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 illnessSymptoms of hyperG: polyuria, thirst, weight loss, blurred visionAdmissions with DKASymptoms of hypoG and level of education: morning headaches / lethargy, night sweats, weight gain, seizuresOther systems: IHD, claudication, CVD, peri neuropathy, autonomic neuropathy, erectile dysfx, syncope, eyes, nocturia, oedema, HTN, boils, necrobiosis lipiodicaAction 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)


DH HyperCa Thiazide, lithium, Ca, vit D

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

A



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

FH HyperCa Of same, MENDM 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


Standing:

General Hypopit Pale skin, lack of hair; short stature; no 2Y sexual characteristicsCushings Central obesity; thin limbs; skin bruising and atrophy; skin pigmentation; poor wound healing;

look at patient standing from front, sides and behindAddisons Pigmentation, vitiligoDiabetes Weight, hydration, endocrine facies, pigmentation; signs of CRFHyperCa Neck scar; forearm scar; LN; evidence of renal failure; signs of thyroid; pigmentation of

Addisons; Evidence of sarcoid / TB; Prox weakness; corneal band keratopathy; PseudogoutDM 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 BPCushings Purple striae; prox myopathy; BPAddisons BP, postural dropDiabetes 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 atrophyChvostek’s sign if thyroidectomy (tap facial nerve 4cm infront of and below ear twitch = hypoCaFor 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; thrillFrom 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 nigricansDiabetes Carotid arteries palpate and auscultate

Chest Thyroid Gynaecomastia; ESM; CCFIf hypo: pleural and pericardial effusions; sandpaper skinHypopit Decr hair, pale skin, gynaecomastiaCushings 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 tumourDiabetes 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; reflexesIf hypo: reflexes; peri neuropathy

Hypopit Loss of pubic hair; testicular atrophyCushings Squat (prox myopathy; striae; bruising; oedemaDiabetes 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


HyperCa Bloods Ca; PTH; Vit DOther 24hrs urine CaImaging CXR (malignancy); XR (subperiosteal reabsorption)

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




Diffuse goitre Idiopathic; puberty, pregnancy, post-partumThyroiditis (Hashimoto’s, subacute, Riedel’s)Iodine def / XS; inborn errors of thryoid metabolismDrugs (eg. Li)


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 eczemaIschaemic 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, fungalNeuropathic← 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 paperSleeve of shirt with buttonCard to cover opposite eye on VA checkRed tipped hat pin

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