peripheral

lower limb arterial examination:

lower limb chronic Ischemia( intermittent claudiaction)
Permission( explain the procedure)
INSPECTION: (with the patient lying on the couch)
1. Inspect the hands looking for nicotine staining, tendon xanthomata, nail fold
infarcts and splinter haemorrhages and nail changes
2. Look at the skin and hair for changes suggestive of arterial disease, i.e.,
thin/shiny skin and hair loss.
Specific
1- Look at the legs for Colour of the legs do they appear pale, cyanosed or red?
2- Scars suggestive of previous surgery (e.g., femoro-distal bypass) or
amputated digits
3- Signs of venous insufficiency such as lipodermatosclerosis, venous eczema
and atrophy
3- Venous guttering seen when veins collapse in limbs with peripheral vascular
disease and appear as shallow grooves
4- Ulceration comment on the location, shape depth and size of the ulcer
NB: Arterial ulcers typically have a “punched out” appearance and are
generally found around pressure areas, i.e., lateral and medial malleoli, tips of
the toes, head of the 1st and 5th metatarsals, the heel and the interdigital
clefts –so remember to look between toes and under the heel. (May often be
confused with neuropathic ulceration; venous ulceration commonly occurs
around the gaiter region (medial side) of the leg)
1- Compare the temperature on both legs using the dorsum of your hand.
- 2- Check the capillary refill time in toes of both feet. ( NB: normal = <2 sec)
- 3- Say you would like to perform BUERGERS TEST:With the patient lying
supine, ask if they have any pain or restriction in hip movements. Then lift
both legs slowly (ideally in about 10 degree increments and waiting for 10
seconds at each stage) and evaluate the angle at which the leg becomes pale
or white . This is known as Buerger’s angle
–in normal subjects it should be greater than 90 degrees (even if the limb is
flexed further at the hip, there should be no colour change in the limb). In
patients with peripheral vascular disease, the limb may go pale as it is lifted
and reaches a certain angle. If the angle is less than 25-30 degrees,
it suggests severe ischemia.Once you have established Buerger’s angle, sit the
patient up and swing the legs over the side of the couch. Watch for the foot to
reperfuse –in normal subjects there should be no colour change but in patients
with peripheral vascular disease, you will observe the legs becoming a dusky
crimson/purple colour, which is caused by reactive hyperaemia. Thisrepresents
a positive test.
4- Palpate the pulses on both legs:
- Femoral –felt in the mid-inguinal point , halfway between the pubic
symphysis and ASIS.
Popliteal –felt deep in the midline of the popliteal fossa with the knee flexed to
~30 degrees
- Posterior tibial –felt posterior to medial malleolus, 2/3rd of the way between
the medial malleolus and the insertion of the Achilles tendon
- Dorsalis pedis felt in the 1st webspace, just lateral to the extensor hallucis
longus tendon on the dorsal surface of the foot (dorsiflexion of the hallux may
aid palpation)
- Remember also to check the radial pulse and assess for radio-femoral delay.
Auscultation : for iliacs and femoral bruits
ABPI: =Ankle Systolic Pressure/Brachial Systolic Pressure
The ABPI gives an indication of the severity of peripheral vascular disease
where present
. A normal ABPI is >1.0
. If the ABPI is: 0.7 –1 = mild disease (i.e., patient may present with
intermittent claudication)
- 0.5 –0.7 = moderate disease (i.e., likely to have rest pain)
- < 0.5 –0.3 (or absolute pressure <50mmHg) = severe disease (i.e., critical
ischemia)
Complete the exam: Say you would like to:
- Perform a complete neurological examination of the lower limbs
- Perform a full cardiovascular examination
- Perform a vascular examination of the upper limbs
- Feel the abdomen for any evidence of an aortic aneurysm and auscultate for
renal and aortic bruits.
Discussion:
A male/female patient who presents with leg pain on walking. He seemed
generally stable, but I noticed a toe amputation on the right. On closer
examination he had difficult to palpate dorsalis pedis and posterior tibial
pulses on the right,ABPI was 0.9 on the left and 0.5 on the right, consistent
with claudication in the right leg. My main differential would be atherosclerotic
or diabetic peripheral vascular disease.
Management:
- Diagnosis:
Imaging: arterial duplex
CT angiography
MR angiography
Lab.: Blood glucose level, Lipid profile ( LDL)
- treatment:
1- the patient should have an assessment of their risk factors and be actively
discouraged from smoking, have their cholesterol, blood pressure and blood
sugar control optimised and be considered for an antiplatelet agent.
2- The patient will probably need surgical or endovascular intervention.
Options include
endovascular stenting of a stenosed portion of an artery, surgical bypass or
amputation of the affected part of the limb.
3- Conservative treatment alone is only an option if the patient were unfit or
unwilling to have
surgery.
Critical limb ischemia: Critical ischaemia can be defined by the presence of
ischaemic pain at rest, or tissue loss in the
form of gangrene or ulcers. It is consistent with an ABPI of < 0.4.

Thyroid : ( goiter)
Inspection:
- lumb
- 6s: site ,size, shape, symmetry, overlying skin, scars
- Neck veins.
- Swallow water .
- Protrude tongue.
Palpation: Explain to the patient that you will examine him from behind
- feel the lumb: surface,edge,consistency,fixity,pulsatility
- Feel below the lumb:
- Trachea :
- Swallow water
- Protrude tongue
- Lymph nodes: submental, submandibular, preauricular, postauricular,
occipital, post. Cervical,
ant. Cervical, pretracheal, supravlavicular.
Percussion: Sternum
Auscultation : Bruits
Thyroid status:
- 1- Hands:
- radial pulse
- tremors:
- Ask the patient to place their arms straight out in front of them
- Place a piece of paper across the backs of their hands
- Observe for a tremor (the paper will quiver)
- 2- Eyes: exophthalmos: examine from above
- lid lag: Hold your finger high & ask the patient to follow it with their eyes
(head still), Move your finger downwards
* Observe the upper eyelid as the patient follows your finger downwards
- eye movement:
* Ask the patient to keep their head still & follow your finger with their eyes
* Move your finger through the various axis of eye movement (“H“ shape)
* Observe for restriction of eye movements & ask the patient to report any
double vision or pain
- 3- Leg: pretibial myxoedema, ankle reflex, proximal myopathy:
*Ask patient to stand from a sitting position with arms crossed
*An inability to do this suggests proximal muscle wasting
Discussion:
Differntial diagnosis:
simple MNG
- thyroid neoplasm
- Graves diseaes
- Thyroditis
How would you manage this patient?
I would perform a triple assessment, taking a history as well as my
examination, arrange an ultrasound and a fine needle aspiration or a biopsy.
If the patient come back with pain on swallowing, difficulty in breathing few
months later, does it change your management?
Yes, these are obstrucive symptoms requiring thyroidectomy
Her FNA comes back showing a follicular cell tumour. The report says “unable
to differentiate carcinoma from adenoma”. Why is this?
Follicular carcinomas are differentiated from follicular adenomas as they
invade the tumour capsule or surrounding vessels. Therefore histology rather
that simply cytology is needed.
What is the next step in the patient's management following this histological
result?
This lady needs to be discussed in the MDT and worked up for a total or
hemithyroidectomy
5year survival rate of follicular carcinoma: 99%

Parotid:
Inspection:
- 6s
- The contralateral side
- Facial nerve: raise your eyebrow, shut your eyes aganist resistence, blow out
your cheek, show
your teeth, tense your neck muscles.
- Oral cavity: inspect the stensen's duct ( at the level of the upper 2nd molar
tooth)
Palpation:
Explain to the patient that you will examine him from behind
- palpate the lumb: ( ask the patient to clench his teeth) surface, consistency,
fixity, edges,
pulsatility
- Lymph nodes( as above)
- Palpate the stensen's duct
- Bimanual examination
- Palpate the contralateral side
Discussion :
Diffrential diagnosis of parotid lump:
- infective: parotitis
- Inflammatory: sjögren syndrome, mikulicz's syndrome
- Bengin neoplasm: pleomorphic adenoma, warthin's tumour
- Malignant neoplasm: mucoepidermoid carcinoma, adenoid cystic carinoma,
adenocarcinoma,
lymphoma
Investigations:
- CT , MRI to assess the extent of local, bony, or perineural invasion
- Us
- FNAC
Submandibular gland :
Inspection :
- 6s
- The contralateral side
- The oral cavity : wharton duct on either side of the lingual frenulum
- Marginal mandibular nerve: show your teeth
- Hypoglossal nerve: take out your tongue ( deviation to the affected side)
Palpation:
Explain to the patient that you will examine him from behind
- palpate the lump: surface, edges, consustency, fixity, pulsatility
- Wharton duct
- Bimanual
- Lymph nodes
- Lingual nerve: touch sensations to ant. 2/3 of the tongue
- Palpate the contralateral side
Discussion:
Examination revealed a diffusely enlarged left / right submandibular gland,
approximately 4cm in diameter. There was no associated cervical
lymphadenopathy and there was normal flow of clear
saliva into the oral cavity. The neck examination was otherwise normal.
What is your differential diagnosis?
Submandibular sialolithiasis
Dental infection
Submandibular neoplasm
How would you investigate this patient?Sialogram if a salivary stone is
suspected
X- ray, CT scan
FNA if a neoplasm is suspected
What are the treatment options? Conservative management: Analgesia, oral
antibiotics, good hydration and gland massage, Sialogram can occasionally be
therapeutic, as the injection of contrast can 'wash out' the gland. If the stone is
within the duct then the duct can be laid open and the stone retrieved. The
duct is then left open as suturing would result in a stricture, . Sialendoscopy:
stone retrieval via endoscopic techniques, Submandibular gland excision.

Cardiovascular examination:
[ mitral reguarge , aortic stenosis, valve replacement, pacemaker]
Patient going for elective hernia repair
Inspestion+palpation:
- General: walking aids, o2, medications, observation charts, ECG, midline
sternotomy scar
- Hands: . Signs of IE( splinter Hges, janeway lesions)
- Tar staining
- Capillary refill
- Palpate the radial pulse ( rate , rhythm, radioradial delay, collapsing pulse)
- Clubbing
- Blood pressure measurement
- Neck: JVP assesment, palpate the carotid pulse
- Eye: mucous membranes, corneal arcus, xanthelasma
- Mouth: oral hygiene, central cyanosis
- Face: malar flush
- Chest : scars( sternotomy, thoracotomy, infraclavicular)
Visible apex pulsations
Palpate for: apex beat( 5 ICS midclavicular line)
Heaves( ventricular hypertrophy)
Thrills ( palpable murmurs)
Auscultation:
(Put your left hand on the carotid pulse to time systole and diastole)
- Mitral area: 5th ICS midclavicular line
Pan systolic murmur radiating to the axilla
- Tricuspid area: 4th ICS left parasternal edge
- Pulmonary area: 2nd ICS left parasternal edge
- Aortic area: 2nd ICS right parasternal edge
Ejection systolic murmurs radiating to the carotids
- Accentuation maneuvers:
These maneuvers cause particular murmurs to become louder DURING
expiration:
*Roll onto left side & listen to mitral area with bell during expiration – mitral
murmurs (stenosis & regurgitation)
*Lean forward & listen over aortic area during expiration – aortic murmurs are
louder (stenosis & regurgitation)
- Metallic heart sounds:
One metalic click corresponding to S1= mitral valve replacement
Two metalic clicks corresponding to s2 = aortic valve replacement
- Carotid bruits
- Lung bases
Check lower limb for : Edema
Vein graft harvest scars
Discussion:Male patient who I assessed in preadmission clinic. On examination
of his cardiovascular system from the end of the bed I noted a midline
sternotomy scar. There were no peripheral stigmata of cardiovascular disease,
he was haemodynamically stable with a narrow pulse pressure of 120/100
millimetres of mercury, and slow rising pulse. On closer inspection of his chest,
there was an old midline sternotomy scar; the apex beat was not displaced. On
auscultation I heard a metallic second heart sound, but no murmur. There
were no signs of heart failure; however I noted abdominal bruising, perhaps
consistent with the use of subcutaneous heparin injections, and a vein
harvest scar over the right great saphenous area. His signs are consistent with
a CABG and metallic aortic valve replacement for which he is on
anticoagulation. I am slightly concerned that he has signs of aortic stenosis - a
slow rising pulse and narrow pulse pressure although I did not hear murmur -
despite the valve replacement, therefore I would investigate this thoroughly.
What investigations would you order preoperatively?
This patient appears well, but would require a baseline ECG and echo
preoperatively. In addition he would require bloods including an INR as he is on
warfarin.
How would you manage this patient’s anticoagulation?
The patient presents with fever 5 days postoperatively:
Might have infective endocarditis

Note the pacemaker spikes, no p- waves
Indications of pacemaker:

Who would you inform about the pacemaker?
An anaesthetist, ideally the consultant who will be doing the case. I would
ensure it is clearly documented in the notes.
What precautions would you take?I would arrange a pacemaker check pre- and
postoperatively and contact their pacemaker follow-
up clinic to inform them of the operation and ask for advice.
During the operation I would avoid monopolar completely, or limit its use to
short bursts only.
The return electrode should be placed so that the pathway between the
diathermy electrode and
return electrode is as far away from the pacemaker and leads as possible
I’d ensure that appropriate resuscitation equipment was available

Respiratory examination:
Inspection+ palpation:
- general: o2 , medications, SOB, ask to take a deep breath and cough
- Hand: tar satining, clubbing, radial pulse, repsp. Rate
- Mouth: central cyanosis
- Lymph nodes: cervical
- Trachea: central or not
- Chest:
*Scars for thoracotomy: can you put your hand on your hips and bend your
elbows forward for me please. Chest expansion:
-Place your hands on the patient’s chest, inferior to the nipples
-Wrap your fingers around either side of the chest
-Bring your thumbs together in the midline, so that they touch
- Ask patient to take a deep breath
- Observe movement of your thumbs, they should move apart equally
 - If one of your thumbs moves less, this suggests reduced expansion on that
side
Reduced expansion can be caused by lung collapse / pneumonia
Percussion :1st : supraclavicular
2nd: medial 1/3 of the clavicle
Auscultation: from the same levels of percussion:
Ask patient to take deep breaths in and out through their mouth.
* Assess quality – Vesicular (normal) / Bronchial (harsh sounding) –
consolidation
* Assess volume – quiet breath sounds suggest reduced air entry –
consolidation / collapse /
* Added sounds:
- Wheeze – asthma / COPD
- Coarse crackles – pneumonia / fluid
- Fine crackles – pulmonary fibrosis
*‫ ء‬Vocal resonance:
Ask patient to say “99” repeatedly & auscultate the chest again
Increased volume over an area suggests increased tissue density –
consolidation/fluid/tumour
Back of the chest:
- repeat *chest expansion
*Percussion and auscultation
*Vocal resonance
Discussion:
What is your differential diagnosis?
Main diagnosis is COPD in a smoker of this age; however asthma is also a
possibility
Who would you inform about this?
I would inform an anaesthetist, ideally the consultant who will be doing the
case, otherwise the coordinating anaesthetic consultant and the operating
surgeon.
What further investigations would you arrange?
A chest X-ray to rule out a preop pneumonia or underlying malignancy
Spirometry and respiratory function tests
A baseline ABG to identify preoperative paO2 and PaCO2
How could you try to reduce the risks in a patient with COPD about to undergo
an operation?
I would ask the GP to optimise medication before the operation and refer to a
respiratory medic if necessary.
Any infection should be treated before the operation.
The patient should be encouraged to stop smoking
I would arrange chest physio before and after surgery to encourage excretion
of excess mucus, In addition I would inform HDU in case more intensive care is
required post operatively, Use open surgery , not laparoscopic because of co2
pneumoperitoneum, Use regional anathesisa instead of grneral anathesia.

Cranial nerve examination: ( bitemporal hemianopia,

conductive hearing loss -
anterior cranial fossa tumour)
-olfactory nerve:
With eyes closed, ask patient to identify various scents – e.g. coffee,vinegar
- optic nerve: (5)
. Visual acuity:
Colour vision :( not done)
. Pupils: Direct reflex– shine torch into eye – look for pupillary constriction in
that eye
- Consensual reflex – shine torch into eye – look for pupillary constriction in
opposite eye
- Swinging light test– move light in from side of each eye rapidly – relative
afferent pupillary defect.
- Accommodation reflex:
1. Ask patient to focus on a distant point (clock on a wall / light switch).
2. Place your finger/object approximately 15cm in front of the eyes.
3. Ask the patient to switch from looking at the distant object to the nearby
finger / object.
4. Observe the pupils, you should see constriction & convergence bilaterally.
. Visual fields( visual inattention, confrontation):
Visual inattention (visual neglect):
1. Ask patient to focus on your face & not move their head or eyes during the
assessment.
2. Hold both arms out, with one hand in the upper right and the other in the
upper left quadrant of
your visual field.
3. Remind the patient to keep their head still & their eyes fixed on your face.
4. Move one of your fingers (on only one hand) and ask the patient to point at
the hand on which
the finger is moving.
5. Move the finger on the left and right hand individually in whichever order
you prefer.
6. Then move the finger of both hands simultaneously.
7. If patient only reports a finger on one of the hands moving (whilst both are
moving
simultaneously), it suggests the presence of visual neglect.
8. Repeat the process with your hands in the lower quadrants of vision.
Confrontation:
1. Ask the patient to cover their left eye with their left hand.
2. You should cover your left eye and be staring directly at the patient (mirror
the patient).
3. Ask patient to focus on your face & not move their head or eyes during the
assessment.
4. Ask the patient to tell you when they can see your fingertip wiggling.
5. Outstretch your arms, ensuring they are situated at equal distance between
yourself & the patient.
6. Position your fingertip at the outer border of one of the quadrants of your
visual field.
7. Slowly bring your fingertip inwards, towards the centre of your visual field
until the patient sees It
8. Repeat this process for each quadrant – at 10 o’clock /2 o’clock / 4 o’clock /
8 o’clock.
9. If you are able to see your fingertip but the patient cannot, this would
suggest a reduced visual field.
10. Map out any visual field defects you detect.
11. Repeat the same assessment process on the other eye.
. Fundoscopy: Assess for red reflex
1. Position yourself at a distance of around 30cm from the patient’s eyes.
2. Looking through the ophthalmoscope observe for a reddish / orange
reflection in the pupil, An absent red reflex may indicate the presence of
cataract, or in rare circumstances neuroblastoma.Move in closer & examine
the eye with the fundoscope
- Begin medially & assess the optic disc – colour / contour / cupping
- Assess the retinal vessels – cotton wool spots / AV nipping /
neovascularization, Finally assess the macula – ask to look directly into the light
– drusen noted in macular degeneration
- occulomotor + trochlear+ abducent:( eye movement)
- Eye movements:
- 1. Ask the patient to keep their head still & follow your finger with their eyes.
- 2. Move your finger through the various axis of eye movement (“H” shape).
- 3. Ask the patient to report any double vision.
- 4. Observe for restriction of eye movement

trigeminal nerve:
Sensory: close your eyes, use a cotton wool
Ophthalmic : forehead , corneal reflex ( not done)
Maxillary: cheek bones
Mandibular: jaw angles
Motor: muscles of mastication
Close and open your jaw against resistance
Clench your teeth and feel temporalis and masseter
Reflexes: corneal reglex , jaw jerk ( not done)
- facial nerve:
*Temporal ( raise your eye brows)
*Zygomatic ( close your eyes against resistance)
* Buccal ( blow your cheeks)
* Marginal mandibular( show your teeth)
* Cervical ( tense and flare your neck muscles)
* Chorda tympani( is there any taste sensations)
vestibulochoclear nerve:
*Whisper no. And repeat
* Rinne test :
1. Tap a 512HZ tuning fork & place at the external auditory meatus & ask the
patient if they are
able to hear it (air conduction)
2. Now move the tuning fork (whilst still vibrating), placing its base onto the
mastoid process (bone
conduction)
3. Ask the patient if the sound is louder in front of the ear (EAM) or behind it
(mastoid process)
Normal = Air conduction > Bone conduction (Rinne’s positive)
Neural deafness = Air conduction > Bone conduction (both air & bone
conduction reduced equally)
Conductive deafness = Bone conduction > Air conduction (Rinne’s negative)
* Weber test:
1. Tap a 512HZ tuning fork & place in the midline of the forehead.
2. Ask the patient where they can hear the sound:
Normal = sound is heard equally in both ears
Neural deafness = sound is heard louder on the side of the intact ear
Conductive deafness = sound is heard louder on the side of the affected ear
- glossopharyngeal+ vagus:
*Open your mouth and say AAH ( look for any deviation of uvula and soft
palate)
* Ask the patient to cough( asses adduction of both vocal cords by vagus
nerve)
* Gag reflex( not done)
- spinal accessory:Trapezius( shrug shoulder against resistance)
Sternomastoid ( turn head against resistance)
- hypoglssal nerve:Protrude your tongue ( deviation towards the affected side)
Discussion:
[Bitemporal hemianopia]
Where might the lesion be to cause this symptoms?
A bitemporal hemianopia is suggestive of a lesion affecting the optic chiasm,
where the more medial fibres cross over to the contralateral eye. This may be
either a lesion of the optic chiasm itself or a mass pressing on it (e.g. a pituitary
tumour).
If a mass arises from above the chiasm (e.g. pituitary craniopharyngioma), the
initial symptoms
may be of a bitemporal inferior quadrantanopia, progressing to a bitemporal
hemianopia.
Conversely, masses arising below the chiasm may present at first with
bitemporal superior
quadrantanopia.
What else might you expect if a pituitary tumour were the cause of this lady's
bitemporal
hemianopia?
The other signs and symptoms of a pituitary tumour can be general or specfic
to hormone production:
General - raised intracranial pressure may cause papilloedema (as seen on
fundoscopy) or headaches.
Specific - hyperpituitarism: this depends on the type of hormone secreted. The
most common are growth hormone and prolactin from pituitary adenomas.
The former causes acromegaly and the latter hyperprolactinaemia.
Signs of acromegaly - prognathism, prominent brow, macroglossia, thickening
of the skin, enlargement of hands and feet, hyperhidrosis, carpal tunnel
syndrome. Signs of hyperprolactinaemia - increased lactation, loss of libido,
erectile dysfunction in males, amenorrhoea and infertility (anovulatory) in
females.
Management:
Invesigations: hormone assays
MRI, CT (disadvantages: poor soft tissue visualization, need for contrast)
Treatment: antiprolactin ( bromocryptine)
Surgery( trans-sphenoidal, trans-frontal)
[Hemotympanium: ]


.
Cause of conductive hearing loss in this patient:
Hemotypnum secondary to skull base fracture
What cranial nerves to examine together:
Vestibulochoclear+ facial ( they exit together from IAM)
How to fit otoscope: Pull the pinna upwards & backwards – to straighten the
external auditory meatus, Position otoscope at the external auditory meatus:
Otoscope should be held in your right hand for the patient’s right ear and vice
versa, Hold the otoscope like a pencil and rest your hand against the patient’s
cheek for stability. Advance the otoscope under direct vision.
4. Look for any wax, swelling, erythema, discharge or foreign bodies
5. Examine the tympanic membrane:
-Colour – pearly grey & translucent (normal) / erythematous (inflammation)
-Erythema or bulging of the membrane? – inspect for a fluid level e.g. otitis
media
-Perforation of the membrane? – note the size of the perforation
-Light reflex present? – absence / distortion may indicate ↑ inner ear pressure
e.g. otitis media
-Scarring of the membrane? – tympanosclerosis – can result in significant
hearing loss
6. Withdraw the otoscope carefully
Management:
Ct brain ,audiogram , ENT review
[ anterior cranial fossa tumour]:
Do AMTS:
Abbreviated mental test scoring:
*How old are you?
*What time is it to the nearest hour?
*Can you remember this address? 24 West St. I will ask you this at the end
*What year is it?
*What is the name of this place?
*What is my job? And what is the job of this person (e.g. a nurse)?
*What is your date of birth?
*When did WW2 end?
*Who is the current prime minister?
*Can you count backwards from 20-1?
*What was that address I asked you to remember?
Score less then 6/10 suggests dementia / delerium
What do you want to look for in fundoscopy:
Ophthalmoscopy serves to identify:
- Papilloedema suggestive of sustained raised intracranial pressure (e.g. caused
by a tumour or
hydrocephalus). This may be absent in the context of acutely raised intracranial
pressure, or there
may be atrophic changes in longstanding chronic disease.
- Haemorrhage into the vitreous humour (Terson's syndrome) or other
intraocular haemorrhage
secondary to a subarachnoid haemorrhage.
Differential diagnosis of anterior cranial fossa tumour:
Meningioma, olfactory neuroblastoma, sinonasal malignancies
Management:
- CT scan
- MRI with gadolinium
- Streotactic biopsy
- Involve neuro-oncology MDT
- treatment is by surgical resection and proton beam radiotherapy.

Knee examination:[ LCL + meniscus injury] or

[OA]
Look:
- Swelling: pre-patellar / infra-patellar Scars Muscle wasting Erythema
- Deformities (valgus and varus)
- Asymmetry
- Baker’s Cyst in Popliteal Fossa
- Accessories , e.g., walking stick / crutches
- Observe gait :Ask the patient whether he/she uses any walking aids, then ask
him/her to walk across the room
Feel:
Ask the patient if there are any areas of localized pain
- assess temp.
- Palapte joint lines:
Palpate the following with the knee flexed at 90°:Patella – palpate the borders
for tenderness / effusion
Tibial tuberosity
Head of the fibula – irregularities / tenderness
Tibial & Femoral joint lines – irregularities / tenderness
Collateral ligaments – both the medial and lateral
Popliteal fossa – feel for any obvious collection of fluid (e.g. a Baker’s cyst)
- Measure quadriceps circumference and compare( 10 cm above patella)
- Effusion: patella tab test( large effusuions) :
1. Empty the suprapatellar pouch by sliding your left hand down the thigh to
the patella.
2. Keep your left hand in position and use your right hand to press downwards
on the patella with your fingertips.
3. If fluid is present you will feel a distinct tap as the patella bumps against the
femur.
Bulge test ( small effusions);
1. Empty the suprapatellar pouch with one hand whilst also emptying the
medial side of the joint using an upwards wiping motion.
2. Now release your hands and do a similar wiping motion downwards on the
lateral side of the joint.
3. Watch for a bulge or ripple on the medial side of the joint.
4. The appearance of a bulge or ripple on the medial side of the joint suggests
the presence of an effusion.
Move:
- ROM: test active and passive flexion and extension + feel crepitus
- Hyperextension: lift the leg from the heel and look
Special tests:
- post. Sag sign: (post. Cruciate)
- Ant. Drawer and post. Drawer test:
1. Flex the patient’s knee to 90º.
2. Inspect for evidence of posterior sag as this can give a false positive anterior
drawer sign.
3. Wrap your hands around the proximal tibia with your fingers around the
back of the knee.
4. Rest your forearm down the patient’s lower leg to fix its position.
5. Position your thumbs over the tibial tuberosity.
6. Ask the patient to keep their legs as relaxed as possible (tense hamstrings
can mask pathology).
7. Pull the tibia anteriorly – significant movement suggests anterior cruciate
laxity /rupture
8. Push the tibia posteriorly – significant movement suggests posterior cruciate
laxity /rupture
- Lachman's test( ant. Cruciate);
The knee is flexed at 20–30 degrees with the patient supine.
The examiner should place one hand behind the tibia and the other grasping
the patient's thigh.
It is important that the examiner's thumb be on the tibial tuberosity.
The tibia is pulled forward to assess the amount of anterior motion of the tibia
in comparison to the
femur
- Valgus stress test: (MCL)
1. Extend the patient’s knee fully.
2. Hold the patient’s ankle between your elbow and side.
3. Place your right hand along the lateral aspect of the knee.
4. Place your left hand on the lower limb (e.g. calf or ankle).
5. Push steadily inward with your right hand whilst supplying an opposite force
with the left.
6. If the MCL is damaged your hand should detect the medial aspect of the
joint opening up.
- Varus stress test: (LCL)
1. Extend the patient’s knee fully.
2. Hold the patient’s ankle between your elbow and side.
3. Place your right hand along the medial aspect of the knee.
4. Place your left hand on the lower limb (e.g. calf or ankle).
5. Push steadily outward with your right hand whilst supplying an opposite
force with the left.
6. If the LCL is damaged your hand should detect the lateral aspect of the joint
opening up.
If after this assessment the knee appears stable you can further assess the
collateral ligaments by
repeating this test with the knee flexed at 30°. At this position the cruciate
ligament are not taught
so minor collateral ligament laxity can be more easily detected.
- Mcmurray's test ( medial and latetal menisci)
To test the medial meniscus, the examiner palpates the postero-medial aspect
of the knee while
extending the knee and externally rotating the tibia.
To test the lateral meniscus, the examiner palpates the postero-lateral joint
line while extending
the knee and internally rotating the tibia.
If pain is felt by the subject or if a ‘click’ is felt by the subject or examiner, the
test is considered
positive
Discussion:
Male pateient had a non-contact sporting injury where he twisted his knee. On
examination he has
an antalgic gait, . His range of passive movement was not affected, but active
movement was
limited by pain. He did not have localised joint tenderness. Varus stress test
and mcmurray's test
were positive, fitting with lateral collateral ligament and meniscal tear.
What is your differential diagnosis?
Medial collateral ligament tear
Cruciate injuries
Combination injuries
Bony injuries
What investigations would you perform?
Initially I would arrange a weight bearing X-ray of the knee; however the most
important
investigation would be a knee MRI.
What to look for in MRI?
-increased internal signal intensity in the meniscus.
-abnormal meniscus shape
Management:
Nonoperative treatments:
Rest (with weight bearing as tolerated or with crutches)
Ice
Compression bandaging
Elevation of the affected limb to minimise acute swelling and inflammation.
Operative :
Repair or partial menisectomy
X ray of OA:
There are four main radiographic signs in osteoarthritis:
• Narrowing of the joint space
• Subchondral sclerosis
• Cyst formation
• Osetophyte formation
How is osteoarthritis of the knee managed?
Conservative
• Maintain or achieve a healthy weight i.e. aim to decrease weight, and
therefore force, going
through a joint
• Regular exercise, with particular attention to strengthening the muscles
around the joint.
For example in OA of the knee, cycling is beneficial
• Analgesia: care to be taken with NSAID's with relation to gastric irritation
• Heat application to the joint may offer relief
• Physiotherapy
• Intra-articular steroids
Surgical:
• Arthroscopy and arthrocentesis
• Realignment osteotomy
• Total or partial knee replacement

Hip examination: [hip ostearthritis]

Look:
- front ,sides,post.
- gait( antalgic gait, telendenberg's gait)
- Walking aids
- Scars, pelvic tilt, quadriceps wasting, gluteal wasting, lumbar lordosis
Do telendenberg's test:
1. Place hands on the iliac crests on either side of the pelvis.
2. Ask the patient to stand on one leg for 30 seconds.
3. Observe your hands to see which moves up or down.
4. Normally the iliac crest on the side with the foot off the ground should rise
up.
5. Repeat the test on the opposite side.
The test is deemed positive (abnormal) if the pelvis falls on the side with the
foot off the ground, abnormal result suggests weak hip abductors on the
contralateral side of the pelvis
Feel:
- palpate the joint( tenedrness or warmth)
- Palpate the greater trochanter
- Measure ( apparent leg length:umbilicus to the tip of medial malleolus)
( true leg length: ASIS to the tip of medial malleolus)
Do Thomas test:
1. Place hand under patient’s spine.
2. Passively flex both legs (hips/knees) as far as you are able to.
3. Your hand should detect that the lumbar lordosis is now flattened.
4. Ask patient to fully extend the hip you are assessing:
Incomplete extension suggests a fixed flexion deformity at the hip joint.
5. Repeat the test to assess the contralateral hip joint
Move:
- ROM ( active+ passive ) , crepitus:
- Flexion( bring your knee towards your chest)
- Adduction
- Abduction
- Internal rotation(passive only)
- External rotation( passive only)
- Extension( prone or lateral, passive)- ( don't perform if Thomas +ve)
To complete my examination I would assess the neurovascular status of the
lower limbs and
examine the joint above and below - knee and spine.
Discussion:
Male patient who presents with right sided hip pain. I note that he has an
antalgic gait and a scar overlying the left hip suggesting a previous operation.
Positive findings include reduced range of movement in hip flexion, extension
and internal and external rotation on the right. Trendelenburg and Thomas’
test were negative and there was no discrepancy with respect to true or
apparent leg length.
What is your differential diagnosis?
My top differential for this patient with hip pain and reduced range of
movement is osteoarthritis. Other arthritides should be considered. These
include rheumatoid arthritis, pseudogout, gout, inflammatory or infective
arthritis and a reactive arthritis.
How would you investigate and manage this patient?
I would take routine bloods, paying particular attention to raised inflammatory
markers, which
would alert me to possible infection, and order hip and knee X-rays. If required
an MRI of the affected joint could also be ordered but may be unnecessary.
If this patient had osteoarthritis then management is aimed at alleviating pain
and improving the patient’s functional status. Non-operative measures include
weight loss, exercise, physical and occupational therapy. Simple analgesia such
as regular paracetamol and prn NSAID can be prescribed. More invasive
measures such as a corticosteroid injection can be considered, but ultimately
the patient may need surgery in the form of an arthroplasty.

Spine + peripheral neurological examination:

[ disc prolapse+ sciatica]
Look:
- general: walking aids- gait
- Behind: scars, muscle wasting, scoliosis, abnormal hair growth
- Side: cervical lordosis, thoracic kyphosis, lumbar lordosis
- Front: posture of the head and neck, symmetry of shoulders
Feel:
Palpate: spinous processes and sacroiliac joints
Paraspinal muscles
Move:
Assess active movements
Cervical spine: flexion, extension, lateral flexion, rotation
Lumbar spine: flexion , extension, lateral felexion
Thoracic spine: rotation
Special tests:
- straight leg raise: +ve in sciatic nerve root impingement due to prolapsed disc
1. Position the patient supine on the bed.
2. Holding the ankle, raise the leg (passively flexing the hip) – keeping the knee
straight
3. Normal ROM is approximately 80-90º of passive hip flexion.
4. Once the hip is flexed as far as the patient is able, dorsiflex the foot.
5. The test is positive if the patient experiences pain in the posterior thigh /
buttock.
If this causes pain in lower back /thigh/ buttocks, it suggests sciatic nerve root
impingement.
- Femoral nerve stretch: +ve in femoral nerve root compression
1. Position patient prone
2. Flex knee
3. Extend hip
4. Plantar-flex foot
Positive test = pain felt in thigh/ inguinal region.
Peripheral neurological examination:
TOPCARS
Tone:
1.leg roll:roll the patient’s leg & watch the foot – it should flop independently
of the leg
2. Leg lift – briskly lift leg off the bed at the knee joint – the heel should remain
in contact with the
bed
3. Ankle clonus:
Position the patient’s leg so that the knee & ankle are 90º flexed
Rapidly dorsiflex & partially evert the foot
Keep the foot in this position
Clonus is felt as rhythmical beats of dorsiflexion/plantarflexion (>5 is abnormal)
Power:
Hip:
- flexion ( L2,L3):raise your leg off the bed & stop me from pushing it down
- Extension ( L4,L5):stop me from lifting your leg off the bed”
Knee:
- extension ( L3,L4) :
- Flexion ( L5, S1):bend your knee & stop me from straightening it”
Ankle:
- dorsiflexion ( L4,L5):point your foot towards your head & don’t let me push it
down”
- Plantar flexion (S1,S2):press against my hand with the sole of your foot
Big toe:
- halux extension( L 5):don’t let me push your big toe down”
Co-ordination:
Heel to shin test:
run your heel down the other leg from the knee & repeat in a smooth motion”
Reflexex:
- knee jerk : ( L3, L4)
- Ankle jerk: ( L5,S1)
Sensations:
- light touch ( dorsal column)
- Pin - prick ( spinothalamic tract)
Discussion:
I examined the peripheral neurology of the lower limbs of this patient with
back pain. His gait was normal, he had a positive Lasegue’s sign on the right,
with normal tone, power, co-ordination and reflexes throughout both lower
limbs. He had impaired sensation over the L5 dermatome on the
right leg, to both light touch and pin prick.
Diffrentials:
-Disc herniation between L4-5 impinging on the L5 spinal nerve.
- spinal canal stenosis
-Diabetes Mellitus (peripheral neuropathy)
-Vitamin B12 deficiency(subacute combined degeneration of the cord)
-Drug therapy (e.g. anti-retrovirals, thalidomide, phenytoin)
-Heavy metal/chemical exposure (lead, arsenic, mercury)
-Carcinoma (most likely spinal metastases)
-Tabes dorsalis (syphilitics myelopathy).
Management:
Imaging : x ray on lumbosacral spine
MRI of lumbosacral spine
Treatment: conservative
Surgical : discecctomy , laminectomy

Ankle examination:
Simulated patient, played soccer, sprained ankle
Look:
(Gait)
Is the patient demonstrating a normal heel strike / toe off gait?
Is each step of normal height? – increased stepping height is noted in foot drop
Is the gait smooth & symmetrical?
Swelling / erythema of the foot or ankle – may suggest injury / inflammatory
arthritis / infection
Scars – suggestive of previous injury / surgery
Feel:
Ask the patient to lay on a bed. Assess temperature & compare between legs –
↑ temperature may indicate inflammatory pathology
Assess pulses in both feet – posterior tibial & dorsalis pedis
Palpate the achilles tendon – assess for thickening or swelling
Palpate the joints / bones
Work distal to proximal – assess for tenderness / swelling / irregularity
Squeeze MTP joints – observe patient’s face for discomfort
Tarsal joint
Ankle joint
Medial / lateral malleoli
Proximal fibula
Move:
Assess each of the following movements actively & passively (feeling for
crepitus).
Foot plantarflexion – “push your feet downwards, like pushing a car pedal” –
30-40 º
Foot dorsiflexion – “point your feet towards your head” – 12-18 º
Foot inversion – grasp ankle with one hand & heel with the other – turn sole
towards midline –
passive assessment only
Foot eversion – grasp ankle with one hand & heel with the other – turn sole
away from midline –
passive assessment only
Special tests:
Simmonds’ test
Simmonds’ test is used to assess for rupture of the achilles tendon
1. Ask patient to kneel on a chair with their feet hanging off the edge.
2. Squeeze each calve in turn.
3. Normally the foot should plantarflex.
4. If the achilles tendon is ruptured there will be no movement of the foot.
Differentials:
- Ankle llgament sprain
- Fracture lateral maleolus, cuboid, cuneforms
Management: x-ray on ankle joint
Xray showed undisplaced fracture of fibula with swelling of the ankle?
Management
- Backslab and analgesia
- Rest , ice , elevation to reduce edema

Inguinoscrotal examination: (inguinal hernia,

hydrocele)
Expose the patient from umblicus to feet
- inspect the lumb , ask the patient to cough
- Palpate the other side
- Palpate the lumb: ask the patient to cough
- Id ASIS, Pubic tubercle: show the position of the lumb in relation to the
inguinal ligament
- Ask the patient to reduce the hernia
- Perform DIR test
- Auscultate the lumb
- Examine the scrotum : scrotal neck, transillumination, testis seprable or not
Discussion:
Diffrentials:
What are the differentials for a scrotal swelling?
Common differentials include a hernia e.g. a inguinal or femoral hernia, lymph
nodes, varicocoele or a swelling related to the testes, such as a hydrocoele,
epididymal cyst, lipoma of the cord or testicular tumour. Other differentials
include infection such as orchitis or epididymitis, testicular torsion, and a
spermatocoele
Management:
Inguinal hernia: mesh repair
Hydrocele : evacuation and eversion of the tunica vaginalis

Abdominal examination:
Acute cases: ( all will be presented with observational charts,
lab. Data + ECG)
- pod6 (post left hemicolectomy anastmotic leakage)- CCRISP
APPROACH
- Acute diverticulitis
- Acute cholecystitis
- Acute appendicitis
Chronic cases:
- paraumblical hernia
- Incisional hernia
POD6 ANASTMOTIC LEAKAGE ( after left hemicolectomy)
Stem : patient is presented with shotness of breathing, left shoulder tip
pain,abdominal lower midline covered scar with dressing)
- WIPER
- Note that the patient will simulate SOB , Note the nearby O2 mask
- Ask the patient if he is having any pain at the moment, the patient will point
to his abdomen
- Tell the patient that you will examine his tummy and that you will be gentle,
and take verbal permission
- Start by light palpation of the RIF , Note : the patient will jump in pain
simulating acute abdomen
- Tell the examiner that the patient is experiencing severe abdominal pain , so
further abdominal
examination can not be continued, and that you are going to start assessing
the patient using the CCRISP
- AIRWAY : the patient was talking so his airway is patent
- BRAETHING :
* look for any central cyanosis
* Look for chest wall movements , equal or not
* Palpate for chest expansion
* Percuss the anterior and lateral chest wall only
* Auscultate anterior and lateral chest walls
- CIRCULATION:
* look for the neck veins
* Look for signs of dehydration (dry tongue, sunken eyes)
* Auscultate the heart
- DISABILITY : ( consciousness level), the patient is alert
- EXPOSURE:
* Offer to remove the dressing to expose the laparotomy wound
* Look and squeeze for the calfs to rule out DVT and PE
- CHARTS: EWS charts( rising temp., risinig pr, incresing o2 requirements) FBC (
leucocytosis) ,
ECG ( AF)

Discussion :
I examined this patient presented by SOB , Left shoulder tip pain. On general
inspection, the
patient looks obviously having SOB and generalized abdominal pain. I started
by doing light palpation on his RIF , which showed that the patient was having
severe abdominal tenderness,so this patient looked critically ill and therefore i
started assessing the patient according to the
CCRISP .
- his airway is patent
- breathing: no central cyanosis, equal chest wall movements, percussion note
was normal, equal
air entry with no added sounds
Circulation: no congested neck veins, no signs of dehydration,normal heart
sounds
- The patient was alert
- There was no any swelling or pain in his calves
- His charts showed: rising temp., rising pr, increasing o2 requirements
- FBC ( leucocytosis) ,
- ECG ( AF)
So, my main diagnosis for that case is generalized peritonitis secondary to
anastomotic leakage which caused the patient to have sepsis.shoulder tip pain
in such case may be due to the presence of intrabdominal collection causing
irritation of the diaphragm
Managment:
- NBM
- Urinary carheter to monitor output
- NG tube for suction and bowel rest
- May refer the patient to HDU to insert a central line and monitor
- Fluid resuscitation by crystalloids
- I.V antibiotics
- Bloods: ABG, U&E
- Chest x-ray to rule out any respiratory problem
- CTPA to rule out PE
- Abdominal ultrasound to detect any abdominal collections
- CT with gastrograffin enema to identify the leaking anastomosis
This patient will need urgent laparotomy : Harman's procedure plus good
peritoneal toilet plus drainage
ACUTE DIVERTICULITIS:
Perform classic abdominal examination----> tenderness on LIF, otherwise
normal findings
Note: do not do deep palpation on LIF
Read the patient charts after completing examination-----> fever, mild
tachycardia
Stem: severe left side abdominal pain in patient with a long standing history of
constipation
General examination: from the end of the bed
- Does the patient look comfortable?
- How is the general appearance and nutritional status?
- Is there any obvious pallor or jaundice?
- THE HANDS : Nails, Anaemia, Clubbing (Crohn’s disease, Ulcerative colitis,
Cirrhosis)
Leuconychia (Caused by hypoproteinaemia associated with liver disease),
Koilonychia (Spoon
shaped nails seen in iron deficiency anaemia) ! Asterixis( liver flap), seen in
decompensated
liver disease.
- THE FACE Eyes Anaemia (pale conjunctiva) , Jaundice, Mouth Dentition-
Ulcers (Inflammatory bowel disease, herpes simplex) , Tongue Dehydration-
red, beefy (B12 deficiency) - Angular stomatitis Caused by iron, folate and
vitamin B/ C deficiency Also seen in herpes simplex and oral candidiasis-
Hepatic Foetor
- THE ARMS & TRUNK: Spider Naevi are found along the distribution of the
Superior Vena Cava
(i.e., above the nipple line) and are associated with oestrogen excess , Purpura,
petechiae Can be caused by low platelets or raised prothrombin time,
Gynaecomastia , Signs of pruritus –scratch marks
- SUPRACLAVICULAR LYMPH NODES: Virchow’s Node in the left supraclavicular
fossa can be enlarged in gastric cancer
Local examination:
Inspection:
- Scratch marks
- Swelling,
- distension
- Caput medusae
- Skin changes (bruising, signs of weight loss)
- Scars Striae
- Any visible pulsations
- Ask the patient to cough or lift his/ her head off the bed to reveal any herniae
or signs of peritonism (the patient will exprience pain in LIF)
Palpation:
Tips:
- Kneel down at the patient’s right side
- Ask the patient if there is any generalized pain or localized pain
- Palpate all nine distinct areas of the abdomen starting furthest from you,
unless the patient indicates an area of pain, in which case palpate this area last
- Look at patient’s face for signs of pain while palpating
- Palpate the abdomen with flattened fingers
- start by superficial palpation of the 9 quadrants then by deep palpation and
feel the presence of any masses
- Liver: Start in the right iliac fossa, asking the patient to take deep breaths in
and out. Move your hand upwards towards the costal margin during
inspiration until you feel a liver edge on expiration.
If the liver is palpable check the:
* Size (record enlargement in cm below costal margin)
* Texture (soft / firm / hard / nodular)
* Edge (smooth / irregular) An irregular liver edge suggests metastases
- Murphy’s test: With your hand in the position of the gallbladder, fingers
pointing up, ask the patient to take a deep breath in and out. Pain on
expiration as the gallbladder comes to rest against your fingertips is a positive
Murphy’s test.
- Spleen: Start palpating in the right iliac fossa, using the same breathing
technique as for liver palpation. However, this time move gradually towards
the left upper quadrant . Note the size, texture and edge of the spleen.
- Kidneys: ‘Ballot’ the kidneys using both hands
- Abdominal aorta: Palpate in the region of the lower epigastrium/ upper
umbilical area, slightly towards the left of the mid-line, deeply for a pulsatile
mass. Note the approximate diameter by using both hands to feel the lateral
edges of the mass.
Percussion:
- Upper liver border
- Spleen
- Bladder
- Ascites: Start by percussing in the midline towards either flank and note any
change in pitch from resonant to dull, indicating fluid . If there is dullness, keep
your finger on this area and ask patient to roll onto his/ her side so that the
dull area is now superior.Percuss again and note
any change in pitch back to resonance . If present, this is shifting dullness.
Auscultation:
- Over the left iliac fossa for bowel sounds
- Over the liver for a bruit
- Over the aorta, iliac vessels and the renal arteries for bruits.
Say you would like to :
- Feel the hernial orifices
- Examine external genitalia (e.g., for testicular atrophy in chronic liver disease)
- Perform a rectal examination
- Examine the lower limbs for peripheral oedema
Questions:
If CT shows only sigmoid wall thickening with one locule of gas seen, what will
be your management?
- antibiotics: co-amoxiclav, garamycin, clindamycin
- Bowel rest
- DVT prophylaxis
If no response to antibiotics , what will you do?
- percutaneous drainage
- Hartman's procedure
ACUTE CHOLECYSTITIS
Stem: right hypochondrial pain since 4 days
Perform classic abdominal examination ----> positive murphy sign, otherwise
normal examination
Note: do not do percussions on the liver
Read the patient charts ------> fever, undetectable urobilinogen in urine,
increased liver enzymes
Differentials:
- Acute cholecystitis
- Ascending cholangitis
- PUD
- Lower lobe pneumonia
- Acute pancreatitis
- Renal pathology
Investigations:
- liver function tests
- Urea and electrolytes
- Full blood count
- Crp
- Abdominal ultrasound may show dilated CBD and IHBR or my show CBD stone
- MRCP
Treatment:
- conservative treatment: (nil by mouth, intravenous fluids, antibiotics /3rd
generation Cephalosporins + metronidazole, nasogastric suction if
appropriate)
- Surgical treatment:cholecystectomy in 5 days if conservative treatment fails
ACUTE APPENDICITIS:
Stem : RIF pain in simulated young lady
Perform classic abdominal examination ------> RIF pain , positive rebound,
Rovsing , obturator, Psoas signs
Examine the patient charts : fever, mild tachycardia, leucocytosis
Special signs:
- Rovsing's sign: Pressure in the LIF causes pain in the RIF with appendicitis.
Obturator sign: Ipsilateral hip and knee are flexed; internal rotation of the hip
(heel moves outwards) stretches obturator internus, which causes pain if in
contact with an inflamed appendix
- Psoas sign : Inflammatory processes in the retroperitoneum irritate the psoas
muscle, causing
ipsilateral hip flexion, Straightening the leg causes further pain.
Differentials:
• acute appendicitis
• leaking duodenal ulcer
• pelvic inflammatory disease
• salpingitis
• ureteric colic
• inflamed Meckel's diverticulum
• ectopic pregnancy
• Crohn's disease
• Complicated ovarian cyst
Investigations:
- urine analysis
- Urea and electrolytes
- Full blood count
- Abdominal ultrasound
- Ct abdomen and pelvis
Treatment :
Appendectomy ( open - laparoscopic )
What will you do if you encountered blood in the peritoneal cavity while doing
appendectomy?
- i will call for an obstetric surgeon ( may be ruptured ectopic pregnancy)
- I will order group and save
- I will have to perform appendectomy eventually
PARAUMBLICAL HERNIA AND INCISIONAL HERNIA:
Perform classic abdominal examination.
Inspection: Describe any scars and look for other scars, stomas etc
- Ask the patient to lift their head off the bed and look for bulging of the hernia
or the scar
Palpation:
- Enquire about tenderness and palpate the hernia, commenting on any defect
you can feel, Ask the patient to cough and demonstrate weakness in the scar
or abdominal wall, feeling for bulging of abdominal contents against your hand
- Try to determine the size of the defect
- If there is a midline longitudinal abdominal bulging with no scar, consider
divarication of the Recti.
Auscultation: Listen for bowel sounds
Questions;
Treatment: open or laparoscopic mesh repair is possible. At open surgery, the
mesh can be inserted as an
onlay, inlay, sublay or intraperitoneal position

Chest pain ( pulmonary embolism) : (

POD8)
This is a potentially unwell patient, therefore you should approach him in
an ABC manner
A – you know his airway is patent as he is talking to you
B – inspect chest for respiratory movement, is it equal? Look for central
cyanosis, use of accessory
muscles,
Feel for chest expansion, tracheal position, Percuss the chest for dullness /
hyper-resonance, test vocal fremitus
Listen for bilateral air entry, crackles of consolidation or pulmonary oedema
Measure the respiratory rate, Look for ABG and chest X-ray
C- Inspect for cyanosis, and look at the JVP
Feel the pulse, making note of any rhythm abnormalities and tachycardia,
and peripheries (cold, poorly perfused v hot and septic)
Auscultate the heart – muffled heart sounds could indicate tamponade, a
murmur could suggest a significant valve lesion
Measure the blood pressure ,Look for ECG
D – GCS / AVPU
E – make a point of checking the calves for a DVT
Check the drug chart for SC heparin and TEDS – have they been signed for
Check the fluid chart to ensure they are not overloaded
Discussion:
This patient presented with acute pleuritic chest pain and shortness of
breath 8 days after a hip operation. I note from their drug chart that they
have missed two dose of their subcutaneous heparin.
He is haemodynamically stable, but had saturations of 88% on 2L. This
improved with high flow oxygen. They also had a swollen left calf.
Otherwise examination showed a clear chest with good bilateral air entry
and a normal percussion note making a pneumonia and pneumothorax
unlikely.
An MI is possible but less likely due to the nature of the pain, however I am
awaiting an ECG and troponin. My top differential is a pulmonary embolus.
What investigation would you arrange now?
- Assuming renal function was within acceptable limits I would arrange a
CTPA to exclude a PE
- Chest x-ray
- D- dimer
- ABG : respiratory alkalosis
- ECG:
* Right ventricular strain pattern – T wave inversions in the right precordial
leads (V1-4) ± the inferior leads (II, III, aVF).
* Right axis deviation
* SI QIII TIII pattern – deep S wave in lead I, Q wave in III, inverted T wave in
III
What is the management of a pulmonary embolism?
Management follows the usual ALS sequence of securing the airway before
moving on to breathing where high flow oxygen is essential and then
circulation. Assuming this was all done, the management can be spilt into
massive PE and non-massive PE. Massive PE is characterised by
haemodynamic compromise and may require thrombolysis. I would put out
a crash call if the patient presented in this way to get urgent help.
If the patient is stable, treatment initially with a therapeutic dose of
subcutaneous heparin, followed by warfarin is warranted. I would involve
the appropriate medical team to follow this patient up.
If you were scrubbed in a the theatre and have been updated with the
patient condition, what will you do?
I will put a crash call immediately

Varicose veins:
- Inspect:
* Inspect with the patient standing up
* Ensure that the patient is adequately exposed whilst dignity maintained.
* Inspect from all sides -easiest done by kneeling in front of the patient
then asking the patient to
turn around.
* Look for:
. Varicosities
. Skin changes and ulceration from chronic varicosities and their
complications especially the medial “gaiter” area
, Lipodermatosclerosis
. Venous eczema
. Haemosiderin staining
. “Atrophie blanche” –white patches found in areas of healed ulceration
. Oedema
. Scars from previous surgery, including avulsion scars
. sapheno varix in the groin
- Palpate for saphina varix
- palpate :
- Feel at the sapheno-femoral junction (~4cm below and lateral to the pubic
tubercle) for a Saphena varix. If a swelling is present check for a palpable
thrill and a cough impulse which indicates an incompetent valve between
the superficial and deep systems
- Feel down the leg over the course of the long saphenous and then short
saphenous veins for tenderness along the veins which may indicate
perforator incompetence.
- Special tests:
. Telendenberg's test:
* With the patient lying supine, lift his/her leg to about 45 degrees and
gently empty the veins (this may be aided by “milking” the veins)
* Occlude the sapheno-femoral junction and ask the patient to stand up
ensuring that the finger or thumb is firmly over the junction
* If the superficial veins do not fill and the varicosities are controlled at the
level of the sapheno-femoral junction by occluding it, it strongly suggests
sapheno-femoral incompetence. This can be confirmed by releasing the
pressure from the sapheno-femoral junction that will cause the blood
to return from the femoral vein into the saphenous vein (through the
incompetent sapheno- femoral junction), resulting in the varicosities
becoming prominent.
* As the patient stands, if the veins fill from below with the sapheno-
femoral junction occluded, incompetent perforators are the most likely
cause for the varicosities.
. Touniquet test follows the same principle but is easier to perform than
Trendelenberg’s test as it uses a tourniquet to control the sapheno-femoral
junction rather than the examiner’s fingers.
It also has the added advantage that if varicosities are due to perforator
incompetence, it can be performed further down the leg to identify the
level of the incompetence
* Once the superficial venous system has been controlled with the
tourniquet you can perform Perth test to assess the patency of the deep
venous system, particularly important if considering varicose vein surgery
. Perthe's test: With the patient standing and with the tourniquet still
around the thigh ask the patient to go up and down on his/her tiptoes or
ask him/her to walk, thus exercising the calf muscles. If the deep venous
system is intact, the calf pumps encourage venous return. However, if the
deep venous system is occluded or valves incompetent, when the patient
performs this action venous return is restricted and blood is forced into the
superficial system from the deep system, causing engorgement of the
superficial veins associated with a bursting pain.
- hand held doppler assesment: hold the Doppler probe at a 45 degree
angle to the skin at the level of the sapheno-femoral junction and the
squeeze the patient’s calf. In a patient with a competent sapheno-femoral
junction you will hear a short “swoosh” as you squeeze, but this ceases as
soon as you let go of the calf. If however, the sapheno-femoral junction is
incompetent, there is a more prolonged “swooooosh” of blood as it
regurgitates back down though the incompetent valve.
- to complete my examination i would examine the arterial system and the
abdomen
Discussion:
- On closer inspection of the legs, she has obvious varicosities bilaterally.
There were no ulcers,
but I noted venous eczema, lipodermatosclerosis and haemosiderin
deposition reflecting chronic venous insufficiency. Doppler assessment
demonstrated incompetence at the saphenofemoral Jn.
What further investigations would you arrange?
Venous duplex: Duplex ultrasound scan to determine the site of valvular
incompetence, ensure latency of the deep venous system
What are her management options?
Depends on symptoms and effect on quality of life.
 • Conservative: Graduated compression stockings, leg elevation, exercise
and avoidance of prolonged sitting or standing.
• Invasive, non-operative: Foam sclerotherapy, radiofrequency or
photocoagulation (Laser) ablation (under local anaesthesia).
• Invasive, operative (under general anaesthesia): Varicose vein surgery is
reserved for symptomatic patients with skin complications. It can involve
ligation of the vein (long or short saphenous) near the site of incompetence
and excision (for the long saphenous) by stripping through small skin
incisions to reduce the risk of recurrence.Varicose veins can be avulsed
through small stab incisions (phlebectomies), followed by compression
bandaging.

Stoma examination:
Inspection
Inspect from the end of the bed and the patient’s right hand side
-Site: quadrant
-Scars
-Contents – liquid stool (ileostomy), formed stool (colostomy), urine (ileal
conduit/urostomy)
-Output – high, normal, low (high output is associated with ileostomies)
-Lumen – single (end stoma) or double (loop stoma)
-Type - Spout (ileostomy) or flush (colostomy)
-Stoma health – pink, necrotic ulcerations, stenotic
-Surrounding skin – erythematous, excoriation (usually as a result of
ileostomy output)
-Retracted or prolapsed
-Parastomal herniation - ask the patient to lift their head off the bed
Palpation
-Digital stoma examination: remove bag and insert your finger into the
stoma to assess for patency and any stenosis.
-Transilluminate to assess mucosa for ulcerations
-Reattach the bag, thank the patient and wash your hands
Further considerations
-Abdominal examination
-Inspect perineum for scars and patency of anus
-Assess stoma position when standing and sitting
How are stomas classified?
Loop v End
Temporary v Permanent
Anatomical site
What is important to consider when siting an abdominal stoma?
It needs to be: Away from bony prominences, dominant skin folds and
scars, Within the rectus abdominus muscle, Away from the belt line , Visible
to the patient , Supplied with good vasculature
What are the possible complications of a stoma?
Early :
Ischaemia/necrosis
High output +/- electrolyte imbalance
Retraction
Obstruction
Late :
Obstruction
Stoma retraction or prolapse
Stenosis of the stoma
Parastomal hernia
Parastomal granulomas
Mucocutaneous separation
Fistula formation

Superficial lump
Inspection
-Site
-Size
-Shape - hemispherical
-Surface – smooth, irregular
-Skin – any overlying skin changes
-Scars
Palpation
-Tenderness
-Temperature
-Surface
-Margins
-Consistency
-Surrounding area
-Pulsatility
-Compressibility
-Reducability
-Fluctuation
Assess regional lymph nodes
Discussion:
What is your differential diagnosis?
Lipoma
Sebaceous cyst
Abscess
Soft tissue tumour
Bone tumour
Vascular malformation
Management:
Investigations:
Ultarsound
Tru- cut biopsy
Treatment:
Exicision

Cerebellar examination:
Gait:
1. Stance – a broad based gait is noted in cerebellar disease
2. Stability – can be staggering and often slow & unsteady – can appear
similar to a drunk person walking
3. Tandem (‘Heel to toe’) walking – Ask patient to walk in a straight line
with their heels to their toes
This is a very sensitive test and will exaggerate any unsteadiness.
4. Romberg’s test – ask patient to put their feet together, keep their hands
by their side and close their eyes (be ready to support them in case they are
unsteady!)
This is a test of proprioception – a positive Romberg’s test indicates that the
unsteadiness is due to a sensory ataxia (damage to dorsal columns of spinal
cord) rather than a cerebellar ataxia.
Head:
- speech ( stacatto): say british constitution
- Nystagmus : follow my fingers by your eyes
Arms:
*Pronator drift:
1. Ask patient to close eyes & place arms outstretched forwards with palms
facing up
2. Observe the hands / arm for signs of pronation / movement
A slow upward drift in one arm is suggestive of a lesion in the ipsilateral
cerebellum.
*Rebound phenomenon:
Whilst the patient’s arms are still outstretched and their eyes are closed:
1. Ask the patient to keep their arms in that position as you press down on
their arm.
2. Release your hand.
Positive test = Their arm shoots up above the position it originally was (this
is suggestive of cerebellar disease).
*Tone:
1. Support the patient’s arm by holding their hand & elbow.
2. Ask the patient to relax and allow you to fully control their arm.
3. Move the arm’s muscle groups through their full range of movements .
4. Is the motion smooth or is there some resistance?
* reflexes:
Assess the patient’s upper limb reflexes, comparing left to right.
1. Biceps(c5, c6)
2. Triceps (c7)
3. Supinator (c6)
In cerebellar disease, there is often mild hyporeflexia.
* Co-ordination
Finger to nose test
1. Ask patient to touch their nose with the tip of their index finger, then
touch your finger tip.
2. Position your finger so that the patient has to fully outstretch their arm
to reach it.
3. Ask them to continue to do this finger to nose motion as fast as they can
manage.
4. Move your finger, just before the patient is about to leave their nose, to
create a moving target
(↑sensitivity).
An inability to perform this test accurately (past pointing/dysmetria) may
suggest cerebellar pathology.
* Intentional tremors
* Dysdiadokinesia
1. Demonstrate patting the palm of your hand with the back/palm of your
other hand to the patient.
2. Ask the patient to mimic this rapid alternating movement.
3. Then have the patient repeat this movement on their other hand.
An inability to perform this rapidly alternating movement (very
slow/irregular) suggests cerebellar ataxia.
Legs:
- tone: leg roll, leg lift
- Reflexes: ( knee, ankle)
- Co-ordination ( heel to shin)
To complete my examination , i would do:
full neurological examination including:
Cranial nerves
Upper and lower limbs
Discussion:
Patient has (DANISH) : dysdiadokinesia, ataxic gait, nystagmus, intention
tremors, stacatto speech, hypotonia
My main diagnosis will be cerebellar ataxia due to posterior fossa tumour,
other diffrentials include:
- cerebellar metastases due to lung or breast cancer
- Head trauma
- cerebrovascular stroke
- TIA
- MS
Posterior fossa tumors:
- cerebellar astrocytoma
- Primary neuroectodermal tumors
- Medulloblastoma
- Ependymoma and ependymoblastoma
- Choroid plexus papilloma and carcinoma
- Dermoid tumors
- Hemangioblastoma
- Metastatic tumors
- Brainstem gliomas
Management:
- investigations:
* Plain x-ray skull: It may show calcification.
* MRI brain ( enhanced) with gadolinum
* CT brain : CT scan of the posterior fossa is inferior to MRI in diagnostic
value because of the Artifact produced from the surrounding thick bone.
However, CT scan is helpful for postoperative follow-up.
* CT ( whole body) to detect primary tumours
* guided biopsy
Treatment :
Excision
Hand examination:( carpal tunnel
syndrome)
Wash hands
Introduce yourself
Confirm patient details – name / DOB
Explain examination
Gain consent
Expose patient’s hands, wrists and elbows
Position patient with hands on a pillow
Ask if the patient currently has any pain
Look:
Dorsum :
- Inspect hand posture – asymmetry / abnormalities
- Scars or swellings
- Skin colour:

Erythema – e.g. cellulitis (erythema) / palmar erythema

Pallor – e.g. peripheral vascular disease / anaemia
- Deformities:

Bouchard’s nodes (PIP) / Heberden’s nodes (DIP) – OA

Swan neck deformity – distal interphalangeal (DIP) joint hyperflexion
with proximal
interphalangeal (PIP) joint hyperextension – RA
Z-thumb – hyperextension of the interphalangeal joint, in addition to
fixed flexion and subluxation of the metacarpophalangeal (MCP) joint – RA
Boutonnières deformity – PIP flexion with DIP hyperextension – RA
- Skin changes:
Skin thinning or bruising – long term steroid use
Rashes – e.g. psoriatic plaques
- Muscle wasting – may indicate chronic joint pathology or motor neurone
lesions
- Nail changes:
Nailfold vasculitis – small areas of infarction
 Pitting and onycholysis – associated with psoriasis
Palms:
Inspect hand posture – asymmetry / abnormalities (e.g. clawed hand)
- Scars – e.g. carpal tunnel release surgery
- Swellings
- Skin colour:

Erythema – e.g. cellulitis (erythema) / palmar erythema

Pallor – e.g. peripheral vascular disease / anaemia
- Deformity – Dupuytren’s contracture
- Thenar/ hypothenar wasting – isolated wasting of the thenar eminence is
suggestive of carpal tunnel syndrome
- Elbows – psoriatic plaques or rheumatoid nodules
Feel:
Dorsum
- Assess radial nerve sensation by touching:

First dorsal webspace- radial nerve

- Assess and compare temperature using the back of your hand:

Forearm

Wrist
MCP joints
- Gently squeeze across the metacarpophalangeal (MCP) joints – observe
for non-verbal signs of discomfort – tenderness may indicate inflammatory
arthropathy
- Bimanually palpate the joints of the hand (MCP / PIP / DIP / CMC) – assess
and compare for tenderness / irregularities / warmth
Metatarsophalangeal (MCP) joint,Proximal interphalangeal (PIP) joint, Distal
interphalangeal (DIP) joint, Carpometacarpal (CMC) joint of the thumb
(squaring of the joint is associated with OA)
- Palpate the anatomical snuffbox – tenderness may suggest scaphoid fracture
- Bimanually palpate the patient’s wrists
Elbows : Palpate the patient’s arm along the ulnar border to the elbow:
Note any rheumatoid nodules or psoriatic plaques (extensor surface)
Move: Assess each of the following movements actively first (patient does the
movements independently). Then assess movements passively, feeling for
crepitus and noting any pain.
. Finger extension – “open your fist and splay your fingers”
. Finger flexion – “make a fist”
. Wrist extension – “put palms of your hands together and extend wrists
fully”
. Wrist flexion – “put backs of your hands together and flex wrists fully”
- Test separately for both sets of flexor tendons:
Flexor digitorum profundus: stabilise the PIPJ and ask the patient to flex at
the DIPJ
. Flexor digitorum superficialis ,: isolate the finger being examined by
holding the other fingers in extension, then ask the patient to flex at the
PIPJ
- Assess all movements of the thumb –flexion, extension, abduction,
adduction and opposition
NB: To simply check for extension of the thumb, ask the patient to place
his/her hand palm down on the table and see if he/she are able to raise
his/her thumb off the table. Feel for integrity of the Extensor Pollicis Longus
tendon.
Function:
- Power grip – “squeeze my fingers with your hands”
-Pincer grip – “place your thumb and index finger together and don’t let me
separate them”
-Pick up small object or undo a shirt button – “can you pick up this small
coin out of my hand?”
Neurlogical examination:
Motor:
- Median Nerve:
 Test the function of abductor pollicis brevis; with patient’s palm facing up,
stabilise the rest of patient’s hand on the table and ask them to point with
the thumb to the ceiling.
- Ulnar Nerve:
Palmar interossei –adduct the fingers
Dorsal interossei –abduct the fingers
Froment’s sign: ask the patient to grasp a piece of paper between the index
finger and the thumb.
You then try to pull the paper away. If there is an ulnar nerve lesion, the
distal phalanx of the thumb flexes (due to action of the unaffected flexor
pollicis longus) to compensate for the weak muscle
(adductor pollicis) that is supplied by the ulnar nerve. This is a positive
Froment’s sign
- radial nerve: the patient to extend the fingers and wrist against
resistance.
Sensory:
• Volar aspect of index finger (median n. and C6)
• Volar tip of middle finger (C7).
• Volar tip of little finger (ulnar n. and C8).
• First dorsal web space (radial n).
Special tests:
Tinel’s test is used to identify nerve irritation and is therefore can be useful
in the diagnosis of carpal tunnel syndrome.
The test involves the following: Tap over the carpal tunnel, If the patient
develops tingling in the thumb and radial two and a half fingers this is
suggestive of median nerve irritation and compression.
Phalen’s test
Ask the patient to hold their wrist in complete and forced flexion (pushing the
dorsal surfaces of both hands together) for 60 seconds, If the patient’s
symptoms of carpal tunnel syndrome are reproduced then the test is positive
(e.g burning, tingling or numb sensation over the thumb.
To complete my examination , : a full neurovascular examination of the
upper limb, Examine the elbow joint.
Discussion:
-Sensory deficit present on the palmar aspect of the first three digits and
radial one half of the fourth digit.
- Motor examination: Wasting and weakness of the median-innervated
hand muscles (LOAF muscles) can be detectable.
- Positive phalen's and tinel's tests
Investigations:
- Electrophysiologic studies including electromyography (EMG) and nerve
conductions studies
(NCS) are the first-line investigations in suggested CTS.
- MRI scan can exclude underlying causes in the carpal tunnel.
- lanoratory: blood glucose, thyroid functions
Treatment:
- Treatment of underlying disease, if any.
- Conservative management of mild to moderate disease (EMG and NCS)
includes: –Splinting the wrist at night time for a minimum of three weeks –
Steroid injection into the carpal tunnel –Non-steroidal anti-inflammatory
drugs (NSAIDs) and / or diuretics
- Surgical treatment is indicated for severe disease, or when conservative
management fails and includes carpal tunnel release.