Extra

Cardiovascular

• • Read the stem
    1. Take out torch light and BP cuff
    2. Go through exam steps in your head 
  • Enter the room – start stopwatch while entering 
    1. Wash hands
    2. Introduce – Hi my name is Shahed, thank you for letting me examine you today. Are you in any pain? I am just going to start by looking around the room. 
    3. Inspect – room + patient 
    4. Position – 45 degrees on the bed
    5. Expose – take gown off if men, off but covering breasts if women
  • General Inspection in detail
    1. Room
    2. Patient
  • Hands
    1. Nails – nicotine stains, clubbing, cyanosis
    2. Palms – palmar erythema, janeway lesions, osler nodes 
    3. Radial – Radial delay
    4. Radial pulse – count over 10 seconds and * by 6

• Water hammer pulse

• • Arms
    1. Inspect for any drug use 
    2. Blood pressure
  • Face
    1. Eyes – pull eyelids down
    2. Mouth – put tongue up
  • Neck
    1. JVP
    2. Hepatojugular reflex
    3. Palpate Carotids
  • Chest
    1. Inspect
    2. Count – 5th intercostal midline – apex beat
    3. Heaves
    4. Thrills
    5. Auscultate
       1. Apex -> Axilla -> Apex again -> Left lower sternal border -> Left upper sternal border -> Right upper sternal border
       2. Auscultate apex region and move left
          1. If no murmur heard anywhere in step 1, do this carefully & slowly
       3. Manoeuvres – 
          1. Breath in (hold) and breath out (hold) when on left
          2. Breath in (hold) and breath out (hold) x4 at all valve areas 
       4. Carotid bruit (hold your breath)
       5. Listen to any murmur found while palpating carotids
       6. Auscultate left lower sternal border + valsalva
       7. Aortic regurgitation sit forward
       8. Aortic area for aortic stenosis when sitting forward 
  • Back
    1. Inspect

• Sacral oedema

• • 1. Lung bases
  • Legs
    1. Warm, well perfused
    2. Check for pitting oedema
  • Abdomen
    1. Liver (pulsatile)
    2. Hepatomegaly

• Abdominal aorta

• 1. auscultate
• What else would you like to do?
  1. Full set of obs including temperature and oxygen saturation 
  2. Fundoscopy – Roth spots 
  3. Urinalysis for any haematuria 

 

Differentials

• Pansystolic murmur
  • MR
    • Pansystolic murmur loudest at Apex radiating to Axilla
    • Loudest on expiration
  • TR
    • Pansystolic murmur loudest on LLSE
    • Louder on inspiration
  • VSD
  • AS with Gallavardin phenomenon 
• Ejection Systolic
  • AS
  • HOCM – Hypertrophic obstructive cardiomyopathy
  • ASD
    • Ejection systolic murmur heard loudest on LUSE
  • Pulmonary Stenosis
    • Ejection systolic murmur heard loudest on pulmonary area loudest on inspiration, seen in Noonan’s syndrome. 
  • Coarctation of Aorta 
• Late systolic 
  • MVP
    • Might sound like a diastolic but really loud
    • Causes: Marfans, Ehler danlos, Osteogenesis imperfecta, PCKD
• Early diastolic
  • AR
    • Look for peripheral signs of water hammer pulse and wide pulse pressure 
  • PR
• Mid diastolic
  • MS – has an opening snap can sound like a loud P2 and make you think of pulmonary HTN
• Congenital – Look for cyanosis in fingers + toes + lips and clubbing 
  • PDA – Continuous machine like murmur loudest on LUSE
  • VSD
  • ASD
  • Tetralogy of Fallot – Pulmonary Stenosis -> Repair -> Pulmonary Regurgitation 
• Prosthetic valves
  • Mechanical vs Bioprosthetic
  • First heart sound – mitral
  • Second heart sound – Aortic 
• Pulmonary HTN
  • Loud P2
  • Should have other signs – Raised JVP – a wave, palpable P2, RV heave, pulsatile leave 
• Continuous murmur
  • Machine like, loudest on LUSE/pulmonary area and can be heard on left scapula – PDA
• Eisenmenger’s Syndrome (right to left shunt)
  • Clubbing + Cyanosis
  • Likely murmurs: VSD (pansystolic), ASD (Ejection systolic), PDA (continuous murmur)
  • If no murmurs could have shunt reversed

 

Notes

• If sounds like a loud diastolic think MVP
• If can hear a loud P2 in apex area and no other murmur think MS with opening snap
• AS murmur – hard sounding and shorter, goes down/stops abruptly
• MR murmur – smoother sounding and longer, stops slowly 

 

Respiratory

 

1. 1. Read Stem 
      1. Take out torch light and BP cuff
      2. Go through exam steps in your head 
   2. Enter the room
      1. Wash hands
      2. Introduce – Hi my name is Shahed, thank you for letting me examine you today. Are you in any pain? I am just going to start by looking around the room. 
      3. Position – sit at the edge of bed

• Expose – look for scars anteriorly + posteriorly

• If women look under breasts 

1. 1. General inspection – I am just going to start by looking around the room 
      1. Room – look for mobility aids, oxygen, inhalers, sputum cup
      2. Patient

• Ask to Cough + deep breath

1. 1. 1. Look for pursed lip breathing, cyanosis
2. Hands
   1. Nails – nicotine stain, clubbing, cyanosis
   2. Check for T1 weakness
   3. Palmar erythema
   4. Wrist pain – HPOA (if clubbing present)
   5. Flap
      1. Count RR during this team – no of breaths in 10 sec * 6
3. Arms
   1. Proximal myopathy
   2. Pemberton’s
4. Face
   1. Eyes – check for horners
   2. Sinus
   3. Mouth
5. Neck
   1. Trachea
   2. Lymph nodes
6. Chest
   1. Back – Inspect, Palpate, Percuss, Auscultate
      1. Closely inspect for scars including under the armpits
      2. Ask to breath out and do chest expansion
      3. Percuss all areas including axilla and if dull at bases percuss up till resonant
      4. Auscultate from top including axilla
      5. Auscultate by asking to say 99 – vocal resonance
   2. Front – Inspect, Palpate, Percuss, Auscultate
      1. Place hands on chest and breath in and out
      2. Tap on clavicle and percuss rest
      3. Auscultate 6 areas
7. Cardiac – do this by moving to 45 degrees 
   1. JVP
   2. Heave/thrills
   3. Auscultate
8. Abdomen
   1. Pulsatile liver
   2. Ascites
9. Legs
10. What else would you like to do?
    1. Full set of obs including oxygen saturation 
    2. Bedside Peak flow
    3. CV – to look for any other causes of dyspnoea 

 

Differentials

• Thoracotomy scar 
  • Lobectomy
  • Pneumonectomy
• Bilateral Fine creps
  • ILD
  • Pulmonary oedema secondary to CCF
  • Infective such as pneumonia 
  • Bronchiectasis
• Coarse crepitations 
  • Bronchiectasis
  • Infective such as pneumonia
  • Pulmonary oedema secondary to CCF
  • ILD
• Dullness to percussion 
  • Pleural effusion
  • Abscess or Empyema
  • Malignancy
  • Elevated diaphragm
  • Lung Collapse 

 

Notes

• It is crucial to look for scars, either a thoracotomy or lung transplant as clam shell or rarely could be anterior mediastinum 

 

Neuro – Upper Limb

 

1. 1. Enter the room
      1. Wash hands
      2. Introduce
      3. Position – sitting edge of bed
      4. Exposure – both upper limbs as well as back
   2. Inspect
      1. Room 
         1. Look for hand devices, gait aids
      2. Patient

• Inspect for scars on the neck and back

1. 1. 1. Look for resting tremor
2. UL drift
   1. Raise hands to check for pronator drift
      1. Down – UMN due to muscle weakness
      2. Up – Cerebellar – upward due to hypotonia
      3. Any direction – loss of proprioception due to dorsal column loss
3. Inspect – Closely 
   1. Scars
   2. Wasting/atrophy in shoulder, arms, forearms and hands
   3. Look for fasciculation
4. Tone
   1. Check for tone & clonus
   2. Distract them by getting to do figure 8 on the other hand or checking for bradykinesia
5. Power
   1. Check power of shoulder, elbow, wrist, fingers
      1. Shoulder abduction – C5
      2. Shoulder adduction
      3. Elbow flexion – C6
      4. Elbow extension – C7
      5. Wrist extension – C7 (radial)
      6. Wrist flexion
      7. Finger flexion – C8
      8. Finger abduction – T1 (ulnar)
      9. Thumb abduction (median)
6. Reflexes
   1. Biceps, Triceps, Brachioradialis, Supinator
      1. Biceps – C5, C6
      2. Triceps – C7, C8
      3. Brachioradialis – C5, C6
      4. Finger jerk
   2. Hoffman reflex – flick distal phalanx of middle fingers and watch for a flexion of thumb
7. Coordination
   1. Finger to nose
   2. Dysdiadochokinesia
8. Sensation
   1. Pain – C5, C6, C7, C8, T1
   2. Keep going up till you find a level
9. Vibration
10. Proprioception

 

Tally Notes

• Start with general inspection of the face looking for myopathic face, parkinsonian face or a droopy stroke face

• Lesion localisation 

• UMN

• LMN

• Anterior horn cell

• Nerve root and brachial plexus lesions

• Peripheral nerve

• Neuromuscular junction disorder 

• Myopathy

• Inspect back and neck for scars or surgery

 

Differentials

• Possible cases
  • Brachial plexus lesion
  • Muscular dystrophy – Myotonic dystrophy
  • Myopathy/Myositis
  • Parkinson’s disease
  • Cervical myelopathy/other spinal cord lesions
  • Spinal cord lesions/Syringomyelia
  • Motor Neuron Disease
  • Cerebrovascular lesions – strokes – Hemiparesis or lateral medullary syndrome
  • Cerebellar disease
  • Multiple sclerosis 
  • Polyneuropathy – Pure motor or sensorimotor
  • Polyneuropathy – Charcot Marie Tooth
  • Polyneuropathy – CIDP
  • Hereditary spastic paraparesis
  • Friedreich’s ataxia/ Spinocerebellar ataxia
• LMN in UL + UMN in LL
  • Syringomyelia

• Cerebellar signs + loss of ankle jerks + upgoing babinski
  • Friedreich’s Ataxia
  • Other Spinocerebllar syndromes – SCA
• LMN Right UL + UMN signs in other 3 limbs + cerebellar signs
  • Must be dual pathology. – R brachial plexus injury + something in UMN

Notes

• Make sure to inspect back and look for scar
• Make sure to look for atrophy 

Neuro – Tremor

1. Enter the room
   1. Wash hands
   2. Introduce
   3. Position
   4. Exposure
2. Inspect
   1. Room 
   2. Patient
      1. Look for resting tremor especially a pill rolling tremor
      2. Ask patient to count back from 21
3. Tone
   1. Closely do tone looking for parkinsons
   2. Ask to do circles with other arm
4. Check for Bradykinesia 
5. Power 
   1. Quickly do it just proximal and distal
6. Reflexes
7. Coordination 
   1. Be careful to differentiate between true impaired coordination vs just being slow
8. Sensation
   1. Quickly do it just proximal and distal
9. Then move to gait
10. If Parkinson’s do PD exam as below 

Differentials

• Parkinsons – resting tremor 
• Cerebellar lesion – intention tremor
• Thyroid – positional tremor
• Essential tremor 

Notes

 

Neuro – Shoulder girdle examination 

In Facioscapulohumeral muscular dystrophy stem can be difficulty lifting objects above the head

1. Enter the room
   1. Wash hands
   2. Introduce
   3. Position
   4. Exposure
2. Inspect
   1. Room 
   2. Patient
      1. Inspect face for wasting of masseter and temporalis muscles
      2. Inspect from the back as well 
3. Back/Front
   1. Serratus anterior – ask patient to push against wall and look for winging of scapula
   2. Trapezius – elevate shoulders front and look for winging of scapula
   3. Rhomboids – ask patient to pull shoulder blades together
   4. Supraspinatus – abduct arm at 15 degrees
   5. Deltoid – abduct arm after 15 degrees
4. Do a quick neuro with ITP and RCS
   1. Sensation should be normal in muscular dystrophy 

Differentials

• FSH – mixed peripheral and proximal myopathy
• Limb girdle dystrophy

Notes

Neuro – Lower Limb

1. Enter the room
   1. Wash hands
   2. Introduce
   3. Position
   4. Exposure – ensure legs exposed and socks removed 
2. Inspect
   1. Room – Gait Aids, shoes 
   2. Patient – 
      1. Diagnostic face – Parkinson’s, myotonic dystrophy
      2. Back for any scars
3. Gait
   1. What you ask them to do
      1. Walk
      2. Heel to shin 
      3. Walk on heels (L4-L5)
      4. Walk on toes (S1)
   2. What you look for
      1. Ability to stand up
      2. Patten – ataxic, parkinson’s likely, reduced foot clearance 
      3. Posture
      4. Ability to turn around
      5. Arm swing
4. Romberg’s test
   1. Eyes open +ve – cerebellum
   2. Eyes closed +ve – Dorsal column
5. Inspect legs
   1. Closer look
   2. Lower limbs – Scar, Wasting/Atrophy, Fasciculations, Tremor (SWFT)
   3. Look for pes cavus – high arch + clawing of taws
6. Tone + Clonus
   1. Check for tone
   2. Check clonus
7. Power 2/5 if can’t lift against gravity 
   1. Check power
      1. Hip flexion – L2/L3
      2. Hip extension – L4,L5
      3. Hip adduction – L2-3-4
      4. Hip abduction – L4, L5-S1
      5. Knee flexion – L5/S1
      6. Knee extension -L3/L4
      7. Ankle dorsiflexion – L4/L5
      8. Ankle plantarflexion – S1/S2
      9. Ankle inversion – L4
      10. Ankle eversion – L5
8. Reflexes
   1. Knee – L3, L4, quadriceps
   2. Ankle – S1, S2  calf
   3. Babinski
9. Coordination
   1. Heel to shin
   2. Toe – finger
   3. Feet tapping
10. Sensation
    1. Pain – L2, L3, L4, L5, S1
    2. Keep going up till you find a level
11. Vibration
12. Proprioception

Differentials

• Possible cases
  • Polyneuropathy – Pure motor or Pure sensory or Sensorimotor
  • Muscular dystrophy – Myotonic dystrophy
  • Cranial nerve lesions – including pituatory tumors
  • Multiple sclerosis 
  • Myopathy/Myositis
  • Polyneuropathy – Charcot Marie Tooth
  • Motor Neuron Disease
  • Parkinson’s disease
  • Cerebrovascular lesions – strokes – Hemiparesis or lateral medullary syndrome
  • Polyneuropathy – CIDP
  • Hereditary spastic paraparesis
  • Spinal cord lesions/Syringomyelia
  • Other LMN lesions
  • Friedreich’s ataxia/ Spinocerebellar ataxia
  • Cerebellar disease
  • Cervical myelopathy/other spinal cord lesions
  • Brachial plexus lesion
• Cerebellar + Sensory loss
  • Dual pathology – Cerebellar lesion + Peripheral neuropathy
  • Toxins – ETOH
  • Paraneoplastic
  • Hereditary – SCA
• Pes Cavus
  • CMT or Friedreich’s ataxia or HSP
• Distal weakness with no sensory loss
  • Myopathy (Myotonic dystrophy)  or LMN disease (polio)
• UMN + loss of dorsal column
  • HSP
• Proximal myopathy
  • Congenital myopathy: Muscular dystrophies: Myotonic dystrophy
  • Inflammatory myopathy Myositis – IBM (look for long flexors in the hand wasting), Polymyositis, dermatomyositis, antisynthetase
  • Toxin/Meds: Alcohol, Statin/Steroids
  • Paraneoplastic
  • Metabolic: Diabetes, Hypothyroid, Cushingoid 

Notes

• Give differentials later. Eg: Bilateral symmetrical lower limb length dependent sensory loss in a LMN pattern most likely in keeping with a  peripheral neuropathy which is sensorimotor/predominantly sensory/motor for which I have a number of differentials

Neuro – Cranial Nerve

1. Enter the room
   1. Wash hands
   2. Introduce
   3. Position
   4. Expose 
2. General inspection
   1. Room
   2. Patient
3. CN I – Olfactory nerve
   1. Test smell
4. CN II- Optic
   1. Test visual acuity using snellen chart
      1. Can have patients spectacles on 
      2. One eye at a time
   2. Test visual fields
      1. One eye at a time
      2. Use hands from each side to bring red pin to centre of vision
   3. Offer fundoscopy
5. CN II/III  – Optic/Oculomotor
   1. Look at the Pupils. (Note the shape, relative size & associated ptosis.
   2. Shine light into pupils, check for PEARL, check for RAPD (paradoxical dilatation of pupil when light is shone)
   3. Test accommodation by asking the patient to look into the distance and then at your red hat pin placed about 15 cm from his or her nose.
6. CN III/IV/VI – Oculomotor/Trochlear/Abducens nerve
   1. Test eye movements – right left, up & down, ask for diplopia
      1. Ask to look at left and look at R eye for adduction 
      2. Ask to look at right and look at R eye for abduction
      3. Then look at left eye for adduction
      4. Ask to look at left again and look at L eye for abduction 
   2. Check for diplopia + nystagmus 
7. CN V – Trigeminal
   1. Test facial sensation in the three divisions: ophthalmic, maxillary and mandibular.
   2. Examine the motor division by asking the patient to clench teeth(feeling the masseter muscles) and open the mouth & don’t let me close
   3. Test jaw jerk – increased jaw jerk occurs in pseudobulbar palsy.
   4. Offer Corneal reflex
8. CN VII- Facial
   1. Check facial expression – look up and winkle forehead, puff cheeks, smile
   2. Shut eyes and try to open
9. CN VIII – Vestibulocochlear
   1. Whisper a number softly about 0.5 m away from each ear and ask the patient to repeat the number. 
   2. Perform Rinne’s and Weber’s tests with a 256 Hz tuning fork.
10. CN IX/X – Glossopharyngeal/Vagus
    1. Testing the gag reflex
    2. Look at the palate and note any uvular displacement. Ask the patient to say ‘aaah’ and look for asymmetrical movement of the soft palate
    3. Ask the patient to speak (to assess hoarseness) and to cough (listen for a bovine cough, which may occur with a recurrent laryngeal nerve lesion)
11. CN XI – Spinal accessory 
    1. Ask the patient to shrug his or her shoulders and then feel the trapezius bulk and push the shoulders down.
    2. Then instruct the patient to turn the head against your hand
12. CN XII – Hypoglossal
    1. While examining the mouth, inspect the tongue for wasting and fasciculation

 

Differentials

• Stem: Test vision, diplopia, Swallowing, Speech (dysarthria)
• Hemianopia: Quadrantanopia,  Homonymous hemianopia, Bitemporal hemianopia

Notes

• Horizontal ophthalmoplegia – Medial or Lateral Rectus
• Vertical ophthalmoplegia – Medial or Superior oblique 
• Tongue away from lesion in UMN and towards the lesion in LMN
• Cavernous sinus – 3,4,6 + upper divisions of 5th

 

Neuro – Eyes

 

Stem: Difficulty reading / Diplopia eye and proceed
– Proceed part will essentially be a cranial nerve exam

 

• Enter the room

1. 1. 1. Wash hands
      2. Introduce
      3. Position
      4. Expose 

• General inspection

1. 1. 1. Room
      2. Patient
      3. Look closely at patient then face then eyes including sclera
      4. Need to look from above patient for exophthalmos/proptosis – Sclera all around the eye is abnormal – think thyrotoxicosis 
      5. Quickly check for any scars 
      6. Lift the eyelids while asking to look forward – ask to look down and look up
         (This above should take 30-35 seconds)
      7. Palpate around temporals and then eye on orbit for bony changes to see if any tenderness to look for fall or fractures 
      8. If glasses is on don’t want to take it on and off so leave it for now

• Visual acuity

1. 1. 1. Keep glasses on
      2. ‘What is the lowest line you can read with glasses on’ 
      3. If they can’t read anything then try to do with fingers a metre apart

• Visual field

1. 1. 1. Bitemporal hemianopia – optic chiasm lesion such as pituitary tumour or sella meningioma
      2. Homonymous hemianopia – Optic tract to occipital cortex lesions such as vascular or tumour

• Pupils:

1. 1. 1. Can use ophthalmoscope
      2. Can leave glasses on  
      3. Direct and consensual response 
      4. RAPD: when light shone on diseased eye -> no response. It is not abnormal to have some dilation  
      5. Ophthalmoscope to look inside – right eye to right eye from side, left eye to left eye from the side

• Colour Vision:

1. 1. 1.  ask if red pin is red by closing each eye 

• Eye movements

1. 1. 1. Keep your head still and just move your eyes, I’ll gently put my hands on your chin, and let me know if anything is double.
      2. Start with asking to look at patients left
         1. you look at R eye and ask
            1. Can R eye adduct?
      3. Then ask to look at patients right 
         1. You look at R eye and ask
            1. Can R eye abduct?
         2. You look at L eye and ask can it adduct
      4. Then ask to look at patients left again
         1. Can L eye abduct 
      5. Then go up and down – check fatigability here
      6. Confirm findings 
         1. Check for nystagmus
         2. Check for CN 6 movements – abduction of eye
         3. Check for CN 3 movements – adduction, upward and downward movements
         4. Check for CN 4 movements – down and inwards
   2. Nystagmus -> fast phase and slow phase 
      1. unidirectional nystagmus – Vestibular pathology & towards the lesion
      2. Bidirectional nystagmus – central 
      3. Gaze evoked nystagmus  – Ddx: cerebellar, brainstem, phenytoin, alcohol

• Check for fatigability – Test for fatigability and lid lag  

• Offer to do fundoscopy

1. Corneal reflex, don’t let me open eyes
2. Then do rest of the cranial nerves – V, VII, VIII, IX, X, XII
3. Then options are to do
   1. Myasthenia gravis exam 
      1. check power then ask to do chicken wings then check power again 
      2. Count back to 20
   2. Thyroid exam quickly 

• inspect, palpate, swallow
• check for tremor 
• Ask for bowels

Differentials

• • Ptosis
    • Unilateral – 3rd nerve palsy, Horner syndrome
    • Bilateral – Myasthenia gravis, Muscular dystrophies – Myotonic dystrophy, Ocular myopathy

• 3rd nerve palsy Ddx – P|PD|PDO -> Ptosis | Pupil dilated | Pupil down and out

• • Pupil involved in 3rd nerve palsy – compressive problem
  • Pupil sparing 3rd nerve palsy – microvascular
  • Vascular – ischaemic, diabetes
  • Space occupying lesions, tumours cavernous sinus lesions
  • Demyelination 
  • Trauma

Right 3rd nerve palsy so right eye cannot adduct or supra/infraduct

 

4th nerve palsy Ddx

• Trauma

On looking to the left, the right eye rides up. The head is tilted to the left. The patient has weakness of the right superior oblique muscle, usually due to a trochlear (IVth) nerve palsy.

 

• 6th nerve palsy Ddx
  • Vascular – ischaemic, diabetes
  • Raised ICP
  • Trauma

Right eye 6th nerve palsy hence unable to abduct right eye

 

• Multiple nerve palsy, ie: complex ophthalmoplegia
• Diplopia, ptosis and eye movement abnormalities not explained by cranial nerve problems, consider an ocular myopathy (e.g. mitochondrial myopathy)
• Horner’s syndrome
  • Vascular (brainstem stroke), tumors, trauma
• INO – cannot adduct ipsilateral eye and nystagmus in other eyes
  • MS or brain stem infarction
• Pupil involved in 3rd nerve palsy – compressive problem
• Pupil sparing – microvascular
• PSP – upward gaze palsy
• Bell’s palsy 

• can’t blink properly with affected eye, the side with the effect may look abnormal  
• Eyelid is the clue – don’t fully close
• Will have forehead involvement

 

Notes

• Always ask if any of it is double
• Start with looking into right eye
• Diplopia
  • Horizontal – 6th nerve, INO
  • Vertical – 3rd nerve, 4th nerve 
  • If you cover eye – image generated by abnormal eye is farthest away 

 

Neuro – Speech

Enter the room

• Wash hands
• Introduce
• Position
• Exposure

Inspection

• Room – glasses, hearing aids
• General inspection
• Face inspection for asymmetry

General questions

• Ask full name, 
• Orientation
• ask re glasses and dominant hand

Comprehension

• Commands 
  • Raise eyebrows
  • Poke your tongue out
  • Touch right ear with left hand
  • Point to the ceiling after you point to the floor
• Written comprehension – close your eyes

Repetition

• Papa, Tata, Lala kaka, aye-eye – looks for dysarthria
• Blue sky, British constitution/ Baby hippopotamus, we went to the circus and had a good time, no ifs and or buts 
• Count back from 20 to check fatigability 

Nominal

• Point 3 objects and ask to name
• Ask patient to point to objects – go from easy to hard things 

Description

• Describe cookie jar image

– If aphasia found then move to visual fields and UL + LL power and sensation
– If dysarthria/dysphonia, then move on to cranial neuro exam; starting of with bulbar/lower cranial nerves – IX, X, XI and XII;

– So ask to open mouth, stick tongue out and say aah (look for tongue, uvula deviation) can use tongue depressor here
– Offer to do gag reflex
– Check sternocleidomastoid and shoulders

Then move to CN 5 so sensation and 7 so facial movements and then to eyes.

Differentials

• Aphasia
• Dysarthria
  • Cerebellar
    • Staccato speech
    • Peripheral cerebellar signs
  • Pseudobulbar
    • Spastic tongue
    • Spastic speech
    • Heavy stop and start speech
    • UMN signs – brisk jaw jerk + Peripheral sign of increased tone and brisk reflexes
  • Bulbar
    • Fasciculations of tongue
    • Nasal speech
    • LMN signs – absent jaw jerk + Peripheral sign of reduced tone and areflexia 

Notes

Neuro – Higher Centre

Enter the room

• Wash hands
• Introduce
• Position
• Exposure

Inspection

• Room – glasses, hearing aids
• General inspection
• Face inspection for asymmetry

General questions

• Ask full name, 
• Orientation
• ask re glasses and dominant hand
• 3 things to remember; pen, ball and hat

Comprehension

• Commands 
  • Raise eyebrows
  • Poke your tongue out
  • Touch right ear with left hand
  • Point to the ceiling after you point to the floor
• Written comprehension – close your eyes

Repetition

• Papa, Tata, Lala kaka, aye-eye – looks for dysarthria
• Blue sky, British constitution/ Baby hippopotamus, we went to the circus and had a good time, no ifs and or buts 
• Count back from 20 to check fatigability 

Nominal

• Point 3 objects and ask to name
• Ask patient to point to objects – go from easy to hard things 

Description

• Describe cookie jar image

Parietal lobe

• Dominant – ALFA
  • Acalculia – simple math, 5+2, 10+5
  • Left/right disorientation – show me your right hand
  • Finger agnosia – can you name your fingers
  • Agraphia – write a sentence
• Non dominant
  • Dressing apraxia – turn a piece of clothing upside down and ask patient to dress
  • Visual inattention – which finger is moving
  • Sensory inattention – identify objects on hand
  • Draw a clock, cube
• Temporal lobe
  • Ask patient to recall the 3 thing
  • When did WW2 happen? Or name of prime minister
• Frontal lobe
  • Reflexes – palmomental, grasp, pout
  • Behaviour – labile?
  • Interpret proverb – don’t judge a book by its cover
  • Gait
• Occipital lobe
  • Visual field

 

Differentials

• Dominant parietal lobe signs
  • If they have right sided weakness
• Brain lesions affecting different lobs
  • VITAMINS
    • Vascular – Stroke (ischaemic, haemorrhage)
    • Infection – Abscess
    • Trauma
    • Autoimmune – MS
    • Metabolic – encephalopathy
    • Idiopathic – prion disease 
    • Neoplasm – brain tumours
    • Seizures – epilepsy 

Notes

Neuro – Parkinsons

Inspection

• Inspect for marked facies
• Look for resting tremor

Gait

• Start with gait – shuffling, destination (momentum walking), slow to turn
• Rhombergs test 
• Retropulsion test 

Hand 

• Resting tremor (distract with count backwards 10)
• Action/position tremor
• Intention tremor 
• Tone
• Cogwheel rigidity
• Check bradykinesia

Rest of UL neuro

• Power
• reflexes 
• Coordination
• Sensation

Offer to do postural BP

Face 

• inspect for mask facies
• Eyes looking for gaze palsy

Frontal release signs

• Glabellar tap
• Palmomental
• Grasp reflexes 

Lower limbs

• check tone 
• Stomp on ground to check for bradykinesia

Differentials

• Parkinsonism
  • Idiopathic parkinson’s disease
  • Progressive Supranuclear Palsy
  • MSA
  • Corticobasal degeneration 

Notes

Rheum – Hand

• Read stem
  • Take out jar + needles + torch + BP cuff 
  • Go through exam in head 
• Enter the room

1. Wash hands
2. Introduce
3. Position – sit up and hands on pillow
4. Expose

• General Inspection
  1. Room
  2. Patient
• Look
  1. Hands dorsum – skin, swelling, distribution, deformities, DIP involvement 
     1. MCP – swelling, ulnar devation, Z deformity 
     2. PIP – Boutonneres
     3. DIP – Swan neck
     4. Nails – pitting, ridging, onycholysis, discoloration 
  2. Hands palm 
     1. Palmar erythema 
     2. Muscle wasting 
  3. Elbow
  4. Behind neck
  5. Prayer + Tinel sign
• Feel – effusion, synovitis, crepitus 
  1. Elbow – nodules, psoriatic rash
  2. Warmth
  3. Skin
  4. Joints from DIP in a row up to wrist
• Move
  1. Fingers – make a fist & open
  2. Right and left
  3. Flip hands and cock wrist down and up
• Special test
  1. Test power
     1. Radial – wrist extension
     2. Median – OK sign
     3. Unar fingers
  2. Test sensation
     1. Nerves + Dermatomes
  3. Open jar + remove key
• Move on
  1. Feet
  2. Eyes
  3. Mouth
  4. Posterior chest
  5. Heart
  6. Abdomen

 

Differentials

• Rheumatoid Arthrtis
• Scleroderma
• Psoriatic Arthropathy
• Ankylosing Spondylitis
• Gout
• Others – Haemochromatosis, SLE

Notes

Rheum – Back

• Enter the room
  • Wash hands
  • Introduction
  • Expose

• General Inspection
  1. Room
  2. Patient – look for Ank spon features 
• Gait
  1. Assess gait
• Look
  1. Look from font, back and sides
     1. Look for kyphosis and loss of lumbar lordosis
• Feel 
  1. Palpate each vertebral body for tenderness
• Move
  1. Ask to move cervical spine – up, down, side to side
  2. Then ask to touch toes, move back, side to side
  3. Then to modified schooners test – identify the dimple and put 5cm then with 0cm below and 15cm above, ask to bed and should increase more then 5cm
  4. Then check for occipital to wall distance
  5. Then ask to sit in chair and ask for thoracic movements
• Special test
  1. Ask to lie down and test for active sacroiliac disease by springing of anterior iliac spine
  2. Check for Achilles for plantar fasciitis 
• Move on
  1. Eyes
  2. Mouth
  3. Heart/Lungs
  4. Abdomen – IBD
• Ddx
  1. Ank spond
  2. Seronegative arthropathies – psoriatic arthritis
  3. Reactive arthritis
  4. Enteropathic arthritis
• Imaging
  1. Ank spend X-ray – loss of joint space, squaring of vertebrae, syndesmophytes, bamboo spine, join fusion

Differentials

• Ank Spond
• Psoriatic arthritis

Notes

• Remember gait
• Remember Schober’s test
• Remember Occiput to wall distance

Rheum – Feet

• Just think through the exams

Rheum – Knees

• Just think through the exams

Abdo – Gastro/Renal

If stem is abdominal exam then start with abdomen but if Gastrointestinal exam start with hands

1. Read the Stem
   1. Remove torch light, tape measure and BP cuff 
2. Enter the room
   1. Wash hands
   2. Introduce – Hi my name is Shahed, thank you for letting me examine you today. Are you in any pain?
   3. Position – lie flat and hands to the side
   4. Exposure – expose abdomen + chest 
3. Inspect
   1. Room 
   2. Patient – jaundice
      1. Distension 
      2. Catheters, tenkoff – below umbilicus 
      3. Look for fistula in the arms 
      4. Colostomy bags
      5. Scars – renal transplant – look at groin
4. Abdomen
   1. Inspect – look carefully for scars especially in RIF and LIF and point them out
   2. Palpation
      1. Superficial palpation – before starting ask if any pain
      2. Deep palpation
      3. Palpate liver
      4. Palpate spleen
      5. Ballot kidneys
   3. Percuss
      1. Liver span + measure
      2. Spleen span
      3. Shifting dullness
   4. Auscultate – bowel sounds
5. Then cover up and move to hands 
6. Hands
   1. Nails
   2. Clubbing
   3. Dupuytren’s contractures
   4. Hepatic flap
7. Arms
   1. Tatoos
   2. Brusing
8. Blood pressure
9. Face
   1. Eyes
   2. Mouth
10. Then sit up
11. Neck
    1. Lymph nodes
12. Listen to lungs and lie 45
13. Chest
    1. Inspect – spider naevi, gynaecomastia
14. Cardiac
    1. JVP
    2. Right ventricular heave
    3. Auscultate
15. Legs – oedema, bruising
16. What else would you like to do?
    1. Check for inguinal lymph nodes
    2. digital rectal exam

 

Differentials

• GIT
  • Hepatomegaly
  • Hepatosplenomegaly
  • Ascites
  • Not much in abdomen, peripheral signs of CLD – jaundice, dupytnyes, spider naevi
• Renal
  • Polycystic kidneys
  • Renal transplant – Unilateral RIF mass 
• Cardiac
  • Pulsatile liver -> Do cardiac exam

 

Notes

• Always check BP

Abdo – Haem

If stem is abdominal exam then start with abdomen 

1. Read the Stem
   1. Remove torch light, tape measure
   2. Think through steps 
2. Enter the room
   1. Wash hands
   2. Introduce – Hi my name is Shahed, thank you for letting me examine you today. Are you in any pain? I am just going to start by looking at you from the end of the bed. 
   3. Position – lie flat and hands to the side
   4. Exposure – expose abdomen + chest 
3. Inspect
   1. Room 
   2. Patient – bruising – petechiae,  ecchymoses, pigmentationm, plethora
4. Hands
   1. Nails – koilonychia
   2. Palmar crease pallor
   3. Pulse
5. Arms
   1. Epitrochlear nodes
   2. Axillary nodes
   3. BP
6. Face
   1. Eyes – jaundice, pallor
   2. Mouth – gum hypertrophy
7. Lie flat here if not already and expose 
8. Inspect chest 
9. Abdomen
   1. Inspect – look carefully for scars and point them out
   2. Palpation
      1. Superficial palpation – before starting ask if any pain
      2. Deep palpation
      3. Palpate liver
      4. Palpate spleen
      5. Ballot kidneys
   3. Percuss
      1. Liver span + measure
      2. Spleen span
      3. Shifting dullness
   4. Auscultate – bowel sounds
10. Sit up here 
11. Neck
    1. Lymph nodes
12. Bony tenderness – Spine + listen to back 
13. Move to 45
14. Cardiac
    1. JVP
    2. Right ventricular heave
    3. Auscultate
15. Legs – vasculitic changes
16. What else would you like to do?
    1. Check for inguinal lymph nodes
    2. digital rectal exam
    3. urine analysis 

Differentials

• Splenomegaly 
• Hepatosplenomegaly
• Abdominal lymphadenopathy
• Abdominal masses. 

 

Notes

• Look for petechia
• Can feel axilla for lymph nodes 
• Measure spleen from coastal margin to tip and > 7cm is marked splenomegaly 
• Why do you think it is a spleen & not kidney
  • Can’t get on above it 
  • Has a notch
  • Moves down and medially with respiration
  • Dullness to percussion, kidney is resonant
  • Not ballotable 

 

Endocrine – diabetic foot

 

Endocrine – thyroid

 

• • General: thyroid eye disease, MNG, goiter, restless 
  • Neck:
    • Inspect: enlarged, scar
    • Swallow water: inspect from side (thyroid should move up/down with swallowing, asymmetrical consistent with nodules) 
    • Palpation from behind, then anterior 
      • Size, symmetry, consistency, masses
      • Hold the thyroid with one hand and use the other to palpate. Palpate for the inferior border (retrosternal extension) 
      • Lymph nodes
      • Test SCM function 
      • Then move to the front: Tracheal deviation, thyroid, carotid artery 
    • Percuss across the clavicle and sternal head to check for retrosternal extension 
    • Auscultate thyroid: bruit (low pitch, symmetrical)-> ddx between thyroid and carotid + auscultate carotid 
  • Hands: 
    • put a paper on top to check for tremor 
    • Palm: erythema, sweating, dry skin
    • Nail: acropathy, onicholysis 
    • Radial pulse 
    • Brachial reflex
  • Arms: Check for proximal myopathy (shoulder abduction and sitting up from chair arms crossed) 

• Face

• • Eyebrow loss, sweating 
  • If thyroidectomy scar-> look for Chvostek’s sign 
• Eyes:
  • Look from the front, side and from behind 
  • Lid retraction (hyperthyroidism)
  • Periorbital and conjunctival edema or inflammation
  • Exophthalmos 
  • Make sure they can close their eyes 
  • Lid lag (hyperthyroid, vertical gaze only)
  • Eye movement -> check inferior oblique (first one to be lost) 
• Legs: pretibial myxodema, swelling 
• Pemberton’s sign 
• Heart for murmur, lungs for signs of fluid overload 
• Abdo for hepatosplenomegaly 

Extra:

• ECG, eye movement further 
• TFTs, thyroid antibodies

 

Differentials

• Differentials of thyroid mass
  • MALIGNANT
    • Metastasis 
    • Adenoma Benign nodule such as adenoma
    • Lymphoma
    • Inflammation Thyroiditis
    • Goitre – Multinodular gotire
    • Neoplasm – Primary thyroid cancer
    • Autoimmune – Hashimotos
    • Nodular hyperplasia 
    • Thyroglossal duct cysts

Notes

Endocrine – Acromegaly

 

• 1. GENERAL INSPECTION 
  • Diagnostic facies 
• 2. HANDS 
  • Shape 
  • Sweat 
  • Phalen’s test (carpal tunnel) 
• 3. ULNAR NERVE Thickened 
• 4. PROXIMAL MYOPATHY 
• 5. AXILLAE 
  • Skin tags 
  • Acanthosis nigricans 
  • Greasy skin 
• 6. FACE 
  • Frontal bossing 
  • Hirsutism 
  • Macroglossia 
  • Prognathism (Enlargement of lower jaw)
  • Hoarseness 
• 7. EYES 
  • Visual fields – look for bitemporal hemianopia
  • Cranial nerves III, IV, VI, V 
  • Fundi – papilledema or angoid streaks
• 8. NECK 
  • Thyroid gland (diffuse or nodular goitre) 
• 9. HEART 
  • Cardiac failure 
• 10. ABDOMEN 
  • Organomegaly 
• 11. LOWER LIMBS 
  • Hips Knees – OA
  • Entrapment neuropathy 
  • Heel pad thickening 
• 12. OTHER 
  • Urine analysis (glycosuria) 
  • Rectal examination – colonic polyps (correlate with skin tags) 
  • Blood pressure (hypertension)
  • Sleep apnoea. 

 

Shorts presentation Schpeils

Simple templates

1) Cardio 

Today I examined ____ cardiovascular system. Salient features on examination included a  _____ murmur with associated peripheral findings of and evidence of _____(complications).  This is indicative of _____ with at least/at most moderate severity. My findings in more  detail…… 

2) Resp 

Today I examined____ respiratory system. Salient features include  

crepitations/wheeze/dullness/reduced breath sounds in the _____. This was associated with  percussion/vocal resonance/expansion findings of _____ and peripheral findings of____.  This is consistent with a diagnosis of _____ but there are other differentials. 

My findings in more detail 

3) Abdo  

Today I examined _______ abdomen and my main finding were … mass consistent with  spleen/ kidney/ liver or multiple . Given these finding I went on to complete a renal/ GI/  hematological examination and my peripheral findings were ….. This is consistent with a  dignisis of …. But my differentials are  

4) Neuro 

Today I examined ____ lower limb. Pertinent findings with that weakness in XXX with  tone/reflexes/co-ordination/sensory findings of ______. These findings are in keeping with  an upper/lower/mixed motor neuron pattern consistent with a lesion at the XXXXX. My  differentials are: 

5) Hands 

Today I examined ____ hands. He/she had evidence of a symmetrical/asymmetrical,  deforming/non-deforming arthropathy involving x joints. There was evidence/no evidence of  disease activity and sparing/involvement of the DIPs. Extra articular features  included________. This leads me to a diagnosis of______ but there are other differentials. My findings in more detail—— 

6) Gait 

Today I was asked to examin_____ gait, which was______. Given these findings I went on to  examine Lower limb neuro, co-ordination/cerebellar/parkinsons. My findings were_____  consistent with and my differentials are 

The differentials are: 

For and against each 

The investigations I would like to review are: 

 

Complex Templates

Neurology

Upper Limb

Ulnar neuropathy

My most salient findings were of resting flexion of the interphalangeal joints on the 4th and 5th digits of his left hand.This is accompanied by wasting of the first dorsal interossei and also the hypothenar eminence. There Is weakness of finger abduction and altered sensation in the region of the ulnar nerve. This is most likely due to an Ulnar lesion – either due to a trauma or a surgical procedure. 

 

Lower Limb

1. Peripheral neuropathy
   Version 2: My most salient findings are bilateral symmetrical lower limb length dependent sensory loss in a LMN pattern most likely in keeping with a  peripheral neuropathy which is sensorimotor/predominantly sensory/motor for which I have a number of differentials

 

Version 1: My most salient findings are bilateral symmetrical length dependent predominantly sensory abnormality along with areflexia in a LMN pattern, I will discuss my differentials later.

In further detail: ITPRCS
John was sitting comfortably on the edge of the bed. There was no gait aid

noticed.  There was no scar over the cervical spine.
On inspection of upper limbs, there is no obvious muscle wasting or fasciculations.
Tone was normal. 

Power was normal 5/5 throughout. 

Reflexes were normal. Coordination was normal. 

Both pin-prick and vibration sensation were decreased distally in a length dependent manner. 

On lower limbs exam, there were similar length dependent sensory abnormalities. 

 

In summary, Rob has a glove and stocking sensory abnormality along with areflexia. The differential of which could be:

Differentials:

1. 1. Metabolic – diabetes mellitus, hypothyroidism.
   2. Alcohol/Drugs and toxins – isoniazid, vincristine, phenytoin, nitrofurantoin, cisplatinum, amiodarone, large doses of vitamin B 6 , heavy metals.
   3. Nutritional – B12 deficiency, B1 deficiency, Folate deficiency 
   4. Hereditary – Hereditary sensory/motor neuropathy (Charcot Marie Tooth)
   5. Immune-mediated – Guillain–Barré syndrome, CIDP

• Paraneoplastic – lung Ca

1. Connective tissue diseases or vasculitis – SLE, polyarteritis nodosa.

 

How would you investigate further?

– Firstly, I would request a full blood count to look for signs of macrocytosis.
– Fasting glucose and a glucose tolerance test to rule out diabetes, including HbA1c

– Vitamin b12 and folate levels.

– Urea and electrolytes to look for uremia and renal failure.

– autoimmune antibodies such as ANA, ENA and antineutrophil cytoplasmic antibodies for vasculitis.

– TFTs for any thyroid abnormalities

– SPEP, Serum-FL chains for myeloma screen

 

– I would also like to do a nerve conduction study to determine if it is axonal or demyelinating.

– An electromyogram would be useful to confirm denervation.

-I would also like to consider performing a sural nerve biopsy and a spinal tap to look for raised protein in the CSF.

 

Blood test including

• BSL, HbA1c, UEC, LFT, TFTs, Autoimmune screen (RF, ANA), B12, folate, ESR, SPEP, Serum- FL chains and the kappa/lambda ratio is more sensitive than SPEP

 

• Pts with a mononeuropathy multiplex: should have a vasculitis workup, including ANCA, cryoglobulins, hepatitis serology, HIV, and CMV titer.

 

2. Proximal Myopathy

Version 2: My most salient findings are bilateral symmetrical lower limb proximal myopathy which I have a number of differentials that I will discuss later. 

 

Ddx: