Escolar Documentos
Profissional Documentos
Cultura Documentos
Dr Kamalika Herath
ARIMGSAS
Peripheral Vascular disease
• 65 year old man comes with pain in leg during
walking.
• Task
– Hx
– PE relevant
– Dx and Mx
1. Pain
2. Pain questions
-aggravated by walking/climbing stairs
-relieved by rest
-is there pain at rest/when lying down at night
-Does it get better when leg hung down from bed
-does it get better when you lean forward (neurogenic claudication)
3. Associated
- pins and needles
- weakness
-swelling
-fever
4. Ddx
- smoking, HPTN + on beta blocker, Fmhx of heart disease
-prolonged travel
-trauma/injury
-insect bite
-what’s your occupation, do you stand for a long time
• 1.General look
– 65 male sitting down comfortably
– No walking aids near him
2. Gait
- no neuropathic or antalgic gait
- heel and toe walking normal
- Can you do a full squat – no proximal myopathy
• 3. Inspection (lie down)
– Comparing both legs
– No deformity
– No muscle wasting
– No colour change of skin
– Skin not shiny
– No pigmentation or varicosity
– Hair distribution normal
– No discolouration of feet
– No nail changes
– No signs of infections
– No ulcers
– No pressure sore on soles
• 4. Palpation
– No coldness of limb
– CRFT normal
– Pulses – up to femoral normal (get permission before
palpating the femoral like in cvs exam)
5. Auscultate
- Femoral bruit
-Abdominal aorta
-renal bruit
• 6. Special tests
– Buerger’s
Pallor on elevation
Reactive hyperemia on dangling
- SLR
( just to exclude neurogenic claudication- but not critical error if you
miss)
• ( Cystic – Hydrocele)
• (Firm – Tumor)
• John I am going to retract the foreskin to look for
any bleeding or discharges.
• Now I will do some special tests
• 4. John can you cough please
• Cough impulse is positive in varicocele
• • Discard gloves.
• John I have examined you and I have found a mass on the left testes
it could be due to
• 1. Hydrocele* (soft cystic mass trans transillumination positive)
fluid filled sac surrounding the whole testicle that is mostly
harmless
• 2. Varicocele* (bag of worms feeling, cough test positive)
collection of dilated veins with defected valves causing dilatation
• 3. Spermatocele fluid filled sac with dead sperm
• 4. Epididymal cyst benign mass in part of testicle called
epididymis
• 5. Tumor* ( fixed hard mass) it could also be due to a nasty
growth
• 6. Epididimoorchitis infection
Abdomen
• WIPE
• Hemodynamic stability
• 1. General look
• 50 year old male ill-looking
• Lying down in bed
• 2. Hands
• No palmar erythema
• No dupuytren’s contracture
• No koilonychia,leuconychia, clubbing
• 3. Forearm
• No scratch marks, needle marks
• Pulse is of good volume regular
• Examiner I would like to measure the rate and blood pressure
• John put your hands out, there is no flapping tremor
• 4.Face
• John look up no pallor
• Look down no jaundice
• No parotid enlargement (palpate)
• No signs of angular stomatitis
• Open your mouth no glossitis
• No dry mucous membranes
• 5. Neck
• I would like to check the JVP ideally at 45
degree angle
• 6. Chest
• No spider naevi or gynaecomastea
• 7. Abdomen
• Head to toe
• Abdomen
• Introduce
• Hemodynamic stability
• Abdomen
• Move to resuscitation
• Call for help
• Follow DRSABCD protocol
• 2 wide bore IV cannulae
• Blood for initial investigations, including beta HCG
• Pain relief
• Examine once stable
• Abdomen
• Inspection
• Palpation
• Mcburney’s
• Rovsing’s
Since patient is in pain I will not proceed
with psoas and obturator signs
• Percussion
• Auscultation
• I have examined you and the cause of pain and blood in stools
can be due to a condition called diverticulosis
• It is the outpouching of wall of your bowel due to
constipation, sometimes gets infected
• Admit
• Arrange all ix
• Send stool for microscopy and culture
• You might be put on AB
• 4. Acute abdomen (acute abd for 2
hours,vomit 2 times,alcoholic,back pain last
week)
• Hemodynamic stability
• Abdomen
• Inspection
• Palpation
• Cannot proceed with palpation due to pain
• There is diffused guarding and rigidity all over
the abdomen
• I will check the liver and spleen
• Special tests mcburneys etc …cannot perform
• Auscultate
• I have examined you and there is pain and
rigidity all over the tummy
• Consistent with an acute abdomen
• In which there would be rupture perforation
or obstruction of either organ or intestine
• It is an emergency
• Admit
• Senior
• Erect CXR abd to look for gas under diaphragm
• Blood ix
• Serum amylase lipase BG crossmatch
• NPO
• Iv analgesics
• IVF
• IV AB
Hydration Assessment
• 30 year old female with vomiting and 4 episodes
of diarrhoea and tummy discomfort. No history
of travel.
• Task :
• 1. Assess her hydration status
• 2. Perform Abdominal examination
• 3. Likely diagnosis
• WIPE
• 1. General look
• 30 year old Jenny lying down on the couch mildly distressed due to pain.
• 2. Hands
• Jenny let me take a look at your hands.
• The palms are cold and clammy, the CRFT is normal, the pulses are regular
and of good volume, examiner I would like to measure the rate (perform),
I would like to measure the blood pressure with postural drop. Jenny I am
going to check the water content of your skin I will pinch the wrist. Skin
turgor is good.
• 3. Eyes
• On inspection of the eyes, they are not
sunken. Can you look up, no signs of anemia,
can you look down, no signs of jaundice.
• 4. Mouth
• I can see there are dry lips, can you open your
mouth, the mucous membranes are dry.
• 5. Chest
• I am going to listen to your heart now, S1 and
S2 heard no murmurs, air entry is equal, I
would like to measure the RR and saturation.
• 6. Abdomen
• On inspection from the side and foot end, the
abdomen is flat, moves with respiration, no visible
masses, umbilicus is central
• Jenny where id the tummy pain, on palpation there is
no tenderness guarding or rigidity of any quadrant, no
signs of organomegaly
• Jenny I am going to check for any fluid, there is no
dullness.
• I will listen to your bowel sounds, there are normal.
• With consent of the patient I would like to look at the
hernia orifices and DRE ( examiner says normal)
• 7. Legs
• The lower limbs are cold and CRFT is normal
• 8. Examiner I would like to measure the temperature,monitor the
urine output with input output chart.
• 2. 55 year old John came for investigation results. His GGT was
increased. He is a long time alcoholic
• Task
• PE
• Dx, Mx
• For case 1 :
• WIPE
• Examiner can I know the hemodynamic stability
unstable
• I will shift patient to resuss cubicle
• Call for help
• Follow DRSABCD protocol
• Insert 2 wide bore IV cannulae
• Take blood for initial investigations
• Start on IVF NS bolus 20ml/kg
• I will continue once patient is stable
• 1. General look
• Average built man lying down, mildly distressed due to pain
• He is conscious
• No yellowish discolouration of body
• No pigmentation
• 2. Hands
• No clubbing
• No leuconychia, koilonychia
• There is no palmar erythema, no muscle wasting
• No dupuytren’s contractures
• No flapping tremor
• PR regular, good volume
• Examiner I want to check rate and blood pressure
• 3. Forearms
• No scratch marks
• Few spider naevi seen
• 4. Face
• No plethora
• No parotid enlargement
• No anemia
• no jaundice in eyes
• No angular stomatitis or cheilitis
• Open your mouth no gingivitis or glossitis
• No fetor hepaticus
• 5. Cervical LN no enlargement
• 6. Chest
• Few spider naevi present
• No gynaecomastea
• Heart sounds normal
• Air entry equal
• 7. Abdomen
• On inspection of the abdomen from side and foot end, there are no prominent veins, no bruising or
scratch marks, no distension, moves with respiration
• I will need adequate exposure for the examination so I will give you
privacy while you take off the gown.
• During my examination, I will be taking a look at your breasts,
feeling for the lump and I will be examining your armpits for lumps
as well.
• If you feel uncomfortable at any time please stop me,
• Is that alright?
1. General look
• My patient is 50 yr old Jenny she is sitting comfortably no signs of
trauma bruising or bleeding.
• Inspection of the breasts (while sitting)
• Jenny can you keep your arms by your side ;
• With arms by side
• No asymmetry of breasts
• No visible mass
• No engorged vessels
• No skin dimpling/ tethering and colour changes
• No peau de orange skin
• Can you raise your arms above and behind your head and lower them slowly?
Thank you
• With arms raised above and behind the headlower arms slowly
• No accentuation of tethering of nipples or skin
• No nipple shifting
• No visible masses in the axillae
• BINDS hx
• Birth, NVD/ csec? Term/preterm?
• Any resuscitation required?
• Heel prick test done?
• Initial immunizations given ?
• Who else is at home?
• Medications given?
• Jenny I am going to examine John now, I will
look at him from head to toe and I will be
gentle as I can. For this I require proper
exposure can you please take his clothes off,
keep the nappy on.
• 1. Gen look
– 10 day old baby boy
– In flexed normal posture
– Skin is pink
– No visible rashes
– No Jaundice
• 2. Head
– On palpation no cephalohematomas
– Anterior fontanelle not bulging or depressed
– The head circumference is 33 cm (perform with tape)
• Face
No dysmorphic features
No epicanthic folds flat nasal bridge
No no micrognathia
No cleft lip
• 4. Chest
– No deformities of the chest
– Both nipples at the same level
– No engorged veins
– No palpable thrills in 4 areas
– S1 S2 heard in all 4 regions, no added sounds, no murmurs
– No chest retrations
– Air entry is bilaterally equal
• 5. Abdomen
– Abdomen not distended
– Umbilical stump looks healthy
– On palpation no masses
– On deep palpation no hepatomegaly or
splenomegaly
• Genitals
• Jenny can I examine his genitalia, can you please
remove the nappy.
• Bilateral testes palpable in scrotum
• Meatus is normal
• (Female- No labial fusion ambiguous genitalia)
• 7. Legs
– Legs are symmetrical
– No additional digits
• 8. Back
• Jenny I will turn the baby over to check the back
• No spinal deformities or spina bifida
• Anus is intact
9. Hip examination
– I am going to do some special tests to check for hip
instability
– The groin creases are symmetrical
– Barlow
• Flexion
• Adduction
• Push back
- Ortolani
- Flexion
- Abduction
- Pull forward
• 10. Neurology
– Will check the nerve function
– Tone is not floppy or hypertonic
– Rooting reflex positive
– Grasp reflex present
– Jenny I will gently drop his head to check his nerve
function, don’t worry I will support him – Moro
reflex is normal
• 11. Fundoscope and Otoscope
– I am going to look at his eyes and ears with this
instrument
– Looking for the red reflex
– No discharges from the ear
• Jenny I have examined John and everything is good.
• His heart is good , the basic nerve functions are
good, there is no problem with his breathing, and
hips are stable.
• The height weight and the size of his head is
appropriate as well.
• You can take him home now, if he has fever, difficulty
in breathing, loose stools etc please come to me or
go to ED.
Rash DDX hematology examination
• 27 year old lady presented with non pruritic, non blanching,
maculopapular rash in lower limbs. Had viral URTI one week
back.
• Task
• 1. General look
• 27 year old lady sitting comfortably, no rashes except in
lower limbs
• Rash:
• Apical
• Central(medial
• Anterior(pectoral)
• Lateral
• Posterior (subscapular)
• Infraclavicular and supraclavicular
• https://www.youtube.com/watch?v=-
dmrXVye7lA
• 4. Face
• No frontal bossing
• No anemia and jaundice
• No cheilitis stomatitis
• Open mouth no gum bleeding/gum hypertrophy
• No mucosal pigmentation
• I am going to check the back of our throat, no
tonsillar enlargement or congestion
• 5. Neck
• All LN of cervical group normal
• 7. Abdomen
• Do you have any pain?
• No tenderness on superficial palpation
• No organomegaly
• 1. Inspection
• I’m comparing both arms, there is a linear rash red in colour
extending from the cubital fossa to the axilla,
• I cannot appreciate any surrounding swelling, erythema,bleeding or
discharge,
• There are no scratch marks or iv canulation marks on the hands.
• John I am going to feel this area, there is no local rise of
temperature, on palpation there is mild tenderness, no cord
like structure felt. The pulses are regular (perform) and of
good volume, the CRFT is normal, examiner would like to
check the BP from the opposite arm(skip)
• Relax your arm I will check the armpit for lumps- axillary LN
not palpable
• Cervical LN group not palpable either
• https://www.youtube.com/watch?v=-
dmrXVye7lA
• John the rash could be due to infection of the soft
tissue, it could be due an insect bite, irritation of the
skin by a leaf or branch, infection of the blood tunes,
pooling of blood/clot within the blood tube.
• Ddx
• Cellulitis
• DVt
• Thrombophlebitis
• Contact dermatitis
• Insect bite
Gynaecomastea
• Young man complaining of breast
enlargement. Gym, uses anabolic steroids
• Task
– Perform relevant examination
– dx
• 1. General look
– Average body built man
– No moon facies
– No buffalo hump
– No jaundice
– No voice changes
• 2. Hands
– Not moist and sweaty
– No signs of CLD
– Pulses regular, I want to check rate and blood pressure
3. Face
No plethora
No icterus
I want to check visual field and also fundoscopy
4. Neck
No visible lump
I want to examine for thyroid enlargement
• 4. Chest
Inspection in 3 positions (like in breast exam)
• No visible lumps
• No enlargement (examiner will say +)
• No skin tethering, dimpling
• Nipples normal
Palpation
no disc like breast tissue(glandular tissue) palpable (examiner
says +)
No lumps in any quadrants
2. Hand neurology
Inspection
no thenar hypothenar wasting
no nicotine stains
PR regular
I want to check BP
Tone is good
Power (C8 and T1 reduced)
Reflexes normal
Sensations (skip)
2. Inspection
3. Palpation – no tenderness
4. Percussion
5. Auscultation – BS +
• John I am going to check your back passage
now. We will have chaperone with us.
• (wear gloves, lubricate index finger)
• John can you turn over to your left, bend the
right knee to your chest
• John I am going to remove the sheet now, is
that alright
• Inspection of the perianal region
• I am going to feel the back passage with
finger,it might be bit uncomfortable, take
deep breaths with your mouth open
• I am feeling for any masses in the rectum,
mucosa is smooth,mobile not fixed
• Remover finger-no blood in the glove
• Thank you john (cover the mannikin)
• I could not find any abnormalities during the examination.
• Since you have chest pain, it could be due to angina , that is
loss of blood supply to heart muscle. It could be caused by
block of vessels by fat plaques. But it can also be caused
due to bleeding resulting in anemia.
• it also could be because of mesenteric ischemia where part
of blood supply to the gut is cut off
• The bleeding from the back passage could have been due
to mesenteric ischemia, or bleeding from high up in tummy
ulcers
• It could be due to growths like polyps or nasty growth
• And also bleeding could be due to hemmaroids, that is
dilation of cushion at the rectum
Pelvic examination
• 60 year old lay with feeling of lump down
below.
• Task
– hx
– Perform PE
– dx
• Hx
– Lump coming out or not
– Back pain?
– Any incontinence of urine
– Any bleeding rashes or ulcers on bulge
- Bimanual
- https://www.youtube.com/watch?v=Z-O_JYtyQqE&t=195s
• Most likely vaginal vault prolapse
• The vaginal canal has been held in place following
the surgery with rope like structures
• Due to low estrogen in menopause, bad obstetric hx
cause weakened pelvic floor and inadequate repair
following surgery
• 26 year old with post coital bleeding
PE
dx