Internal Medicine > OHCEPS - General Examination > Flashcards

OHCEPS - General Examination Flashcards

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1
Q

From the moment you set eyes on the patient, what questions should be asked?

A
  1. Is the patient comfortable or distressed?
  2. Is the patient well or ill?
  3. Is there a recognizable syndrome or facies?
  4. Is the patient well nourished and hydrated?
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2
Q

Mention some examples about bed-side clues regarding patient’s state.

A
  1. Oxygen tubing
  2. Inhalers
  3. GTN spray
  4. Insulin injections
  5. Glucose meter
  6. Cigarettes
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3
Q

What are the vital signs?

A
  1. Temperature
  2. BP
  3. Pulse
  4. Oxygen sat
  5. Respiratory rate
  6. Blood glucose
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4
Q

What must be done BEFORE the beginning of the physical exam?

A
  1. Ensure that the patient has adequate privacy to undress.
  2. Make sure that you will not be disturbed.
  3. Check that the examination couch or bed is draped/covered by a clean sheet or disposable towelling.
  4. If the patient is accompanied, ask them if they would like their companion to stay in the room.
  5. Check that any equipment you will require is available (torch, cotton wool, tendon hammer, stethoscope etc.)
  6. When ready, the patient should ideally be positioned supine with the head and shoulders raised to -45degrees.
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5
Q

What should we look regarding color?

A
  1. Pallor
  2. Central or peripheral cyanosis
  3. Jaundice
  4. Abnormal skin pigmentation
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6
Q

Of what is facial pallor often a sign?

A

SEVERE anemia –> Inspecting the palpebral conjunctiva - nail beds - and palmar skin creases.

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7
Q

Is pallor of the palpebral conjunctiva a reliable sign?

A

Not always - Not in:

  1. Shocked patients
  2. Those with vascular disease
    - -> Peripheral vasoconstriction or poor blood flow causes skin and conjunctival pallor, even in the absence of blood loss.
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8
Q

What is the amount of deoxygenated Hb for cyanosis to occur?

A

At least 2.5g/dL.

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9
Q

Central cyanosis can occur with what conditions?

A
  1. Lung disease with V/Q mismatch –> COPD +/- cor pulmonale + massive pulmonary embolus.
  2. Polycythemia
  3. Hemoglobinopathies (methemoglobinemia, sulphemoglobinemia)
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10
Q

When is jaundiced best appreciated?

A

In fair-skinned individuals in natural sunlight.

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11
Q

With what should jaundice NOT be confused?

A

Carotenemia –> Yellow discoloration of the skin, but the sclera remain white.

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12
Q

Mention other distinctive color patterns.

A
  1. Classic slate-grey –> hemochromatosis.
  2. Silver-grey –> argyra (silver poisoning)
  3. Incr. skin-fold pigmentation –> Addison
  4. Non-pigmented patches –> Vitiligo
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13
Q

What is the diurnal variation of temperature?

A

Peak –> 6-10pm

Lowest –> 2-4am

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14
Q

Persistent pyrexia may be a sign of what?

A
  1. Malignant hyperthermia
  2. Drug fever (halothane, suxathonium)
  3. Typhus
  4. Typhoid fever
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15
Q

Intermittent pyrexia may be a sign of what?

A
  1. Lymphomas

2. Pyogenic infections such as milliary TB.

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16
Q

A relapsing high temperature or Pel-Ebstein fever is usually indicative of what?

A

Hodgkin disease –> 4-5days of persistent fever which then returns to baseline before rising again.

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17
Q

Fever with rigors (uncontrollable shaking) may accompany what?

A
  1. Biliary sepsis

2. Pyelonephritis

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18
Q

What is hypothermia?

A

Core (rectal) temperature of <35C.
Occurs usually from cold exposure (e.g. near drowning) or secondary to an impaired level of consciousness (e.g. following excess alcohol or drug OD), or in the elderly (myxedema).

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19
Q

What are the signs of patients with hypothermia?

A
  1. Pale
  2. Cold, waxy skin
  3. Stiff muscles
  4. Consciousness often reduced
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20
Q

At what temperature level do patients typically lose consciousness?

A

<27C.

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21
Q

Mention some conditions that may result in dehydration?

A
  1. Sepsis
  2. Bleeding
  3. Bowel obstruction
  4. Vomiting
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22
Q

Beginning the examination for dehydration, what should be inspected?

A
  1. Any obvious clues –> Fluid restriction signs, catheter bag, nutritional supplements.
  2. Sunken orbits (sign of moderate-severe dehydration).
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23
Q

What are the main sites that should be inspected during examination for hydration?

A
  1. Mucous membranes
  2. Skin turgor
  3. Capillary refill
  4. Pulse rate
  5. BP
  6. JVP
  7. Edema
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24
Q

Is skin turgor reliable in elderly patients?

A

NO - The skin may have lost its normal elasticity.

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25
How is capillary refill tested?
Raise the patient's thumb to the level of the heart, pressing hard on the pulp for 5 sec and then releasing. Measure the time taken for the normal pink color to return. Normal capillary refill time should be Prolongation is indicative of poor blood supply to the peripheries.
26
What is one of the most sensitive ways of judging intravascular volume?
Assessing the height of the JVP. Low --> Dehydration High --> Fluid overload (pulmonary edema)
27
How do we examine for edema?
Palpate the distal shaft of the tibia for edema by gently compressing the area for up to 10 sec with the thumb. --> If edema is present, note its upper level. Edema may also involve the anterior abdominal wall and external genitalia.
28
When lying down, what happens to edema?
Fluid moves to the new dependent area causing a sacral pad. --> This can be checked for by asking the patient to sit forwards, exposing the lower back and sacral region, and again applying gentle pressure with your finger-tips.
29
Mention some local causes of leg swelling.
1. Cellulitis (usually unilateral) 2. Ruptured baker's cyst (usually unilateral) 3. Occlusion of a large vein --> DVT, thrombophlebitis, extrinsic venous compression. 4. Chronic venous insufficiency - pigmentation induration, inflammation, lipodermatosclerosis. 5. Lipomatosis 6. Gastrocnemius rupture - swelling and bruising around the ankle joint and foot.
30
Mention some systemic causes of leg swelling.
1. CHF 2. Hypoproteinemia (nephrotic syndrome, liver cirrhosis, protein-losing enteropathy, kwashiorkor). 3. Hypothyroidism 4. Hyperthyroidism 5. Drugs (corticosteroids, NSAIDs, vasodilators)
31
Mention some conditions associated with malnutrition.
1. Any very ill patient 2. Malignancy 3. Metabolic disease (renal failure) 4. GI disease (especially small bowel) 5. Sepsis 6. Trauma 7. Post-surgery 8. Psychosocial problems (depression, anorexia nervosa, social isolation) 9. Dementia
32
Mention some conditions associated with obesity.
1. Simple obesity (psychosocial) 2. Genetic - Prader-Willi, Lawrence-Moon-Biedl syndrome. 3. Endocrine - Cushing, hypothyroidism. 4. Drug-induced --> Corticosteroids. 5. Hypothalamic damage due to tumor or trauma.
33
What must be done during palpation of the head-neck lymph nodes?
Nodes should be examined with the patient in an upright position and the examiner standing behind - similar to the examination of the thyroid gland.
34
What must done for the examination of the nodes in axillae?
RIGHT axilla examination: 1. Patient should be sitting comfortably and you should stand at the right-hand side. 2. Support their right arm abducted to 90degrees with your right hand. 3. Examine the axilla with your LEFT hand.
35
How do we examine the inguinal nodes?
1. Patient supine --> Palpate their inguinal region along the inguinal ligament --> Same position as for hernia or femoral pulse. 2. There are 2 chains of superficial inguinal nodes --> Horizontal + Vertical.
36
How do we examine the epitrochlear nodes?
Place the palm of the right hand under the patient's slightly flexed right elbow and feel with your fingers in the groove above and posterior to the medial epicondyle of the humerus.
37
How do we examine the popliteal nodes?
Best examined by passively flexing the knee and exploring the fossa with the fingers of both hands - much like feeling for the popliteal pulse.
38
During palpations of lymph nodes, what features should be assessed?
1. Site 2. Number 3. Size 4. Consistency 5. Tenderness 6. Fixation 7. Overlying skin
39
Mention some causes of generalized lymphadenopathy.
1. Hematological malignancies (lymphoma, acute/chronic lymphatic leukemias) 2. Infections --> Viral (HIV, IM, CMV) 3. Bacterial (TB, syphilis, brucellosis) 4. Infiltrative diseases (sarcoidosis, amyloidosis) 5. Autoimmune diseases (SLE, RA) 6. Drugs (phenytoin causes a "pseudolymphoma")
40
Mention the groups of cervical and supraclavicular lymph nodes?
1. Supraclavicular 2. Posterior triangle 3. Jugular chain 4. Preauricular 5. Postauricular 6. Submandibular 7. Submental 8. Occipital
41
Mention the group of the axillary lymph nodes.
1. Lateral 2. Pectoral 3. Central 4. Subscapular 5. Infraclavicular
42
Examination of the dorsum and palm of the hand may give what diagnoses?
1. RA 2. Systemic sclerosis 3. Psoriasis 4. Ulnar nerve palsy
43
What should be kept in mind regarding skin color of the hand?
1. Palmar erythema 2. Vasculitis 3. Digital ischemia 4. Purpura 5. Consistency of the skin - -> Note that pathological palmar erythema can also be found on the thenar and hypothenar eminences and also continues along the digits.
44
What are the main sites that should be inspected during examination of the hand?
1. Dorsum/Palm 2. Skin color 3. Discrete lesions 4. Muscles --> Wasting or fasciculation. 5. Joints --> DIP, PIP, MCP, wrist. 6. Bony deformities 7. Nails
45
What are the most commonly affected digits in Dupuytren's contracture?
Usually the 4th and 5th digits.
46
Dupuytren contracture is more common in men or women?
In MEN.
47
What is the cause of Dupuytren contracture?
UNKNOWN: 1. Alcoholism 2. Familial 3. Use of anticonvulsants 4. Diabetes
48
What happens in swan neck finger joint deformity?
Fixed flexion of the DIP and extension of the PIP joints --> RA.
49
What happens in Butonniere finger joint deformity?
Fixed extension at the DIP and flexion at the PIP joints --> RA.
50
What happens in Z-shaped thumb?
Flexion at the MCP joint of the thumb with hyperextension at the interphalangeal joint --> RA
51
What happens in ulnar deviation of the hand?
Feature of RA + other --> Fingers are deviated medially (toward the ulnar aspect of the forearm) at the MCP joints.
52
What happens with wrist subluxation?
Deviation (either ulnar or radial) at the wrist.
53
What are the Heberden's nodes?
Swelling (due to ostophytes) at the DIP joints - a feature of osteoarthritis.
54
What are the Bouchard's nodes?
Similar to Heberden's node but at the PIP joints - a feature of osteoarthritis.
55
Mention some important nail/finger-tips signs.
1. Leukonychia 2. Koilonychia 3. Muehrcke's lines 4. Blue lanulae 5. Xanthomata 6. Osler's nodes 7. Janeway lesions 8. Splinter hemorrhages 9. Pitting 10. Onycholysis 11. Beau's lines 12. Paronychia 13. Onychomycosis
56
What happens with digital clubbing?
Incr. curvature of the nails. | Loss of the angle at the base of the nail (Lovibond angle) - and eventually to gross curvature and deformity.
57
How do we objectively check for clubbing?
By putting patients nails back-to-back - Clubbing leads to loss of diamond-shaped gap. (Schamroth's sign)
58
Mention some main causes of clubbing?
Pulmonary --> Chronic interstitial diseases, chronic lung infections (bronchiectasis), cystic fibrosis, lung abscess, asbestosis, fibrosing alveolitis, lung cancer. Cardiac --> Cyanotic CONGENITAL heart disease, infective endocarditis. Other --> Liver cirrhosis, IBD
59
What should be done during palpation of the hand?
1. Palpate any abnormalities identified during inspection. 2. Ask the patient if there is any tenderness and palpate those areas last. 3. Pay attention to areas of temperature changes. 4. It is WORTH REMEMBERING TO PALPATE THE ANATOMICAL SNUFFBOX.
60
Why it is worth remembering to palpate the anatomical snuffbox?
At the base of the snuffbox is the SCAPHOID + TRAPEZIUM bones --> Tenderness here may be the only sign of scaphoid damage --> Pathology here is easily missed.
61
Why should we ask the patient to open and close their hands quickly?
To test for signs of myotonic dystrophy --> Hands will be slow to relax.
62
What active movements should be tested during examination of the hand?
1. Wrist extension/flexion 2. Finger extension/flexion 3. Dorsal interossei (ulnar nerve) 4. Palmar interossei (ulnar nerve) 5. Abductor pollicis brevis (median nerve) 6. Opponens pollicis (median nerve)
63
How do we examine wrist extension/flexion?
Extension --> Prayer sign | Flexion --> Reverse prayer sign
64
How do we examine finger flexion?
Ask patient to make a fist.
65
How do we examine finger extension?
Ask patient to straighten fingers out - ALSO tested with the prayer and reverse prayer positions.
66
How do we examine the dorsal interossei (ulnar nerve)?
Ask patient to spread fingers apart (abduction) and resist your attempts to push them together.
67
How do we examine the palmar interossei (ulnar nerve)?
Ask patient to hold a piece of paper between their fingers and resisting your attempts to pull it free.
68
How do we examine the abductor pollicis brevis (median nerve)?
Ask patient to put their hand out, palm upwards, and then point their thumb at the ceiling. You should then try to push thumb back towards the hand while they resist you.
69
How do we examine the opponens pollicis (median nerve)?
Ask patient to put thumb and little finger together in an "O" and again instructing the patient to try to stop you pulling them apart.
70
What should we look during examination of the elbow?
1. Elicit any clues of joint pathology. 2. Rheumatoid nodules 3. Psoriatic plaques 4. Xanthomata 5. Scars
71
How do we examine the function of the hand?
1. Write their name 2. Pour a glass of water 3. Fasten and unfasten a button 4. Pick a coin up from a flat surface
72
How do we perform the Allan's test (for hand perfusion)?
1. Ask patient to make a fist. 2. Occlude BOTH radial/ulnar arteries by applying pressure over them for 5 sec. 3. Ask patient to open palm --> Should be now white. 4. Release the pressure from the radial artery and look at the color of the palm --> If perfusion is adequate, it should change from pale to pink. 5. Repeat for the ulnar artery.
73
What is Tinel's sign?
Test for nerve compression --> Commonly used at the wrist to test median nerve compression in carpal tunnel syndrome.
74
How do we perform the test for obtaining Tinel's sign?
1. Percuss the nerve over the site of possible compression (at the wrist, gently tap centrally near the flexor palmaris tendon). 2. If the nerve is compressed, the patient will experience tingling in the distribution of the nerve on each tap.
75
What is Froment's sign?
A test of ulnar nerve function. Ask the patient to grasp a piece of paper between their thumb and forefinger - alternatively ask them to make a fist. If there is ulnar nerve damage, the thumb will be unable to adduct so will flex instead.
76
What is the Finkelstein's test?
Ask the patient to flex the thumb then flex and ulnar deviate the wrist. Pain is indicative of De Quervain's tenosynovitis (tendons of abductor pollicis longus and extensor pollicis brevis).
77
What are the feature of the face in Down?
1. Oblique orbital fissures 2. Epicanthic folds 3. Hyperterolism (widely spaced eyes) 4. Conjunctivitis 5. Lenticular opacities 6. Small low set ears 7. Flat nasal bridge 8. Mouth hanging open 9. Protruding tongue (large, heavily fissured)
78
What are the features of the hands in Down?
1. Single palmar crease (not pathognomonic) 2. Short broad hands 3. Curved little finger 4. Hyperflexible joints with generalized hypotonia
79
Mention other visible features of Down.
1. Mental deficiency 2. Wide gap between 1-2nd toes. 3. Short stature 4. Dementia of Alzheimer type 5. Hypothyroidism
80
What are the features of the face in Turner?
1. Micrognathia (small chin) 2. Epicanthic folds 3. Low set ears 4. Fish-like mouth 5. Hypertelorism 6. Ptosis 7. Strabismus
81
What are the features of the neck in Turner?
1. Short 2. Webbed neck 3. Redundant skin folds at the back of neck 4. Low hairline
82
What are the chest features of Turner?
1. Shield-like chest | 2. Widely-spaced nipples
83
What are the features of the upper limb in Turner?
1. Short 4th metacarpal or metatarsal 2. Hyperplastic nails 3. Lymphedema 4. Incr. carrying angle of the elbow
84
What are the facial features in Marfan?
1. Long, narrow face 2. High-arched palate 3. Lens dislocation 4. Heterochromia of iris 5. Blue sclera 6. Myopia
85
What are the features of the limbs in Marfan?
1. Tall stature 2. Armspan>Height 3. Hyperextensibility of joints 4. Recurrent dislocations
86
What are the features of the hands in Marfan?
Elongated fingers and toes (arachnodactyly).
87
What are the features of the chest in Marfan?
1. Funnel or pigeon chest 2. Pectus excavatum 3. Kyphoscoliosis 4. Aortic incompetence
88
Mention other visible features in Marfan?
1. Cystic disease of the lungs (spontaneous pneumothorax, bullae, apical fibrosis, aspergilloma and brochiectasis) 2. Inguinal/femoral hernias.
89
What is another name for tuberous sclerosis?
Bourneville's disease of the skin - AD localized to chr. 16, 9.
90
What are the features of tuberous sclerosis?
1. Adenoma sebaceum 2. Shagreen patches (flesh-colored, lumpy plaques) 3. Ungal fibromata 4. Hypopigmented ash-leaf macules (trunk and buttocks) 5. Cafe-au-lait macules and patches.
91
What is another name for NF-1?
von Recklinghausen's disease - AD.
92
What are the skin features of NF-1?
1. Neurofibromata 2. Cafe-au-lait spots (especially in the axilla) 3. Axillary freckling
93
Mention other features of NF-1?
1. Kyphoscoliosis 2. Nerve root involvement or compression 3. Muscle wasting 4. Sensory loss (Charcot's joints) 5. Plexiform neuroma 6. Lung cysts
94
What are the skin findings in Peutz-Jegher's syndrome?
1. Sparse or profuse small brownish-black pigmented macules on lips, around mouth and on buccal mucosa, hands and fingers.
95
What happens in oculocutaneous albinism?
1. Marked hypomelanosis (pale skin) 2. White hair or faintly yellow blonde 3. Nystagmus 4. Photophobia 5. Hypopigmented fundus 6. Translucent iris (pink)
96
What are the facial features in myotonic dystrophy?
1. Myopathic face - drooping mouth and long, lean, sad, sleepy expression. 2. Frontal balding in men. 3. Ptosis 4. Wasting of facial muscles (especially temporalis and masseter) 5. Cataracts.
97
Mention other visible features of myotonic dystrophy.
1. Wasting of sternocleidomastoids, shoulder gridle and quadriceps. 2. Areflexia 3. Myotonia (percussion in tongue and thenar eminence, delay before releasing grip). 4. Cardiomyopathy 5. Slurred speech 6. Testicular atrophy 7. Diabetes 8. Intellect and personality deterioration in later stages
98
What is the face in Parkinson?
1. Expressionless, unblinking face 2. Drooling titubation 3. Blepharoclonus (tremor of the eyelids when eyes are closed)
99
What are the features of Parkinson gait?
1. Shuffling 2. Festinant 3. With reduced arm swinging
100
What are the features of Parkinson tremor?
1. Pill-rolling tremor 2. Lead-pipe rigidity 3. Cog-wheel rigidity 4. Glabellar tap positive 5. Small, tremulous, untidy hand writing (micrographia)
101
What is another name for Osler-Weber-Rendu syndrome?
Hereditary hemorrhagic telangiectasia (HHT).
102
What is the face in HHT?
1. Telangiectasia (on face, mouth, lips, tongue, buccal mucosa, nasal mucosa). 2. Telangiectasia may also be found in fingers. 3. Associated with epistaxis, GI hemorrhage, iron def. anemia, hemoptysis.
103
What are the features of face/hands in systemic sclerosis/CREST syndrome?
1. Telangiectasia + pigmentation 2. Pinched nose 3. Perioral tethering 4. Tight, shinny, adherent skin 5. Vasculitis 6. Atrophy of finger pulps 7. Calcinosis (fingers) 8. Raynaud's
104
Where is vitA found?
1. Dairy products 2. Eggs 3. Fish oils 4. Liver
105
What are the features of vitA def?
1. Night blindness 2. Xerophthalmia 3. Keratomalacia (corneal thickening) 4. Follicular hyperkeratosis
106
What happens in Menks' kinky hair syndrome?
Cu deficiency: 1. Growth failure 2. Mental deficiency 3. Bone lesions 4. Brittle hair 5. Anemia
107
Many elderly patients may run low blood pressures, often as a consequence of medication. A small drop from this point is easily overlooked, but may indicate what?
May be the only sign of a MI.
108
What may be the temperature of seriously unwell older people?
Below normal - Hypothermic.
109
Assessing hydration in older people may be difficult. What is a useful alternative?
Axillary palpation - Are they sweating?
110
What should we look in skin and nails of older patients?
Easily overlooked: 1. Asteatosis 2. Varicose eczema 3. Typical lesions in atypical places --> SCC notorious in this respect. 4. Footwear/toenails --> Onychogryphosis.
111
What are the 5 extremely common presentations of illness in older people?
1. Immobility 2. Instability 3. Incontinence 4. Intellectual impairment 5. Iatrogenic illness
112
What is the main examination framework?
1. Inspection 2. Palpation 3. Percussion 4. Auscultation
Internal Medicine
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