Royal College Summaries

    .

    BLUE = JAMA Rational Clinical Exam Key Points

     

     

    Cardiac

    Volume Status

    • Initial: Introduction, Wash Hands, Drape
    • Vitals (Supine): Tachycardia? Tachypnea? Hypotension? Hypoxemia?
      • Orthostatic Vitals  (supine for 2min, measure HR+BP, then stand (if unable to stand, have them sit and dangle legs off bed) x2 min.  Re-measure HR+BP)
        • Positive = HR incr >30, sBP drop >20, dBP drop > 10, presyncope/syncope symptoms
    • Inspection
      • Pallor
      • Sunken Orbits
      • Mucous Membranes
    • Palpation
      • Axillary Dryness
      • Capillary Refill (>5s)
      • Skin Turgor (gently pinch skin fold on forearm btwn examiner's thumb&middle finger), positive if delay in recoil time. (unreliable in elderly - loses elasticity)
      • Pedal Edema (press pre-tibial area up to 10s, check for pitting)
      • Sacral Edema (while seated, ask to lean forward)
    • JVP
      • Incline head of bed 45°, elevate/recline to visualize JVP column.
      • Differentiate from carotid (biphasic, varies with position, varies with respiration, non-palpable, non-compressible, responsive to AJR)
      • Measure height of highest pulsation above ankle of Louis (aka sternal angle)
      • Kussmaul's Sign - Rise in JVP during inspiration (abnormal)
      • Abdominojugular Reflux -
        • inflate BP cuff partially (6bulbs), apply to abdomen with pressure 20-35mmHg.  Press for 15-30s.  Positive if JVP rises ≥4cm for >10s. 
    • NOTES:
      • Best Test to Rule in: Orthostatic tachycardia and cap refill >5s  (LR+ 6.9)
      • Best Test to Rule out dehydration: Mucous membranes not dry (LR- 0.3)

     

    Endocrine

    Hyperthyroidism

    • Initial: Introduction, Wash hands, Drapes Patient
    • Vitals: Temp (fever), HR (tachy), BP (hypertension), RR O2 sat

     

    • Extra-Thyroidal Manifestations

      • HEENT  (* = Graves only)
        • Lid Lag & Stare (top eyelid lags behind upper iris on downward gaze, same opposite with lower lid)
        • Proptosis*
        • Impaired Extraocular Movements*
        • Chemosis*
        • Periorbital Edema*
      • Hand:
        • Hyperhidrosis
        • Palmar Erythema
        • Tremor of Outstretched arms
        • Clubbing (not real clubbing, called acropachy)
      • Neuro:
        • Hyperreflexia - accelerated relaxation phase
        • Proximal muscle weakness
      • Skin:
        • Pretibial myxedema

     

    • Thyroid Exam

      • See thyroid section below

         

    Hypothyroidism

    • History: Weight loss, tremor, altered BM, sweating, sleep, menstrual changes
    • Initial: Introduce, Wash
    • Vitals:
      • Bradycardia
      • Narrow pulse pressure (high dBP)
      • Hypothermia
      • Weight increase (fluid retention)

     

    • Extra-Thyroid Exam:
      • Hands
        • Cool
        • Rough Skin (Xerosis)
        • Yellow discoloration (carotene)
      • Head & Neck
        • Voice: Hoarseness
        • Hair: Coarse, Thick
        • Eyes: Periorbital edema, loss of lateral eyebrows (Queen Anne's Sign)
        • Mouth: Macroglossia
      • Skin
        • Vitiligo
        • Non-pitting edema
      • CVS
        • Pericardial Effusion
        • Diastolic HTN
      • Resp: Pleural Effusion
      • Neuro
        • Power: Proximal Muscle Weakness
        • Reflexes: Delayed relaxation phase
        • Length-dependent peripheral neuropathy (less common)

     

    • Thyroid Exam:
      • See thyroid section below

     

    Thyroid Exam

    • Inspection (scars/asymmetry/neck swelling/goitre/erythema)
      • Scars? Nodules? Redness? Masses?
      • Extend Neck --> inspect thyroid cartilage to sternal notch
      • Inspect ANTERIOR & LATERAL (with and without swallowing water)
        • Contour? (should be straight line from cricoid to SS notch)
        • Size? >2mm = abnormal (measure protrusion from where you think neck should be)  
      • Ask to swallow --> observe thyroid movement
    • Palpation
      • (Examine from front or back - [no consensus])
      • Landmark
        • Identify cricoid cartilage
        • Isthmus of thyroid directly below this
        • Each lobe is lateral to this --> palpate with 2-3 fingers. 
        • Slightly flex and rotate neck to ipsilateral to lobe being palpated
          • Nodules? Thrills?
          • Consistency? (normal is rubbery, Hashimoto is firm, Malignancy is stony hard)
          • Pain? (Thyroiditis = pain, rarely malignancy)
          • Mobility? (Fixed = cancer)
          • Size? (compare to distal thumb phalanx)
            • "Goiter Ruled Out" Thyroid not visible with neck extended
              "Goiter Ruled In"

              Large goiter or lateral prominence >2mm

              (LR+ Considered infinite)

              - Small goiter (1-2x normal)

              - Large Goiter (>2x normal)

              "Inconclusive" If does not fit above
        • Swallow sip of water (palpate as they swallow, as thyroid moves under SCM muscle)
    • Percussion
      • Percussion for retrosternal thyroid
      • Pemberton's Sign (raise arms over head 2min, if retrosternal goiter = suffusion of face/syncope)
    • Auscultation
      • Thyroid Bruit (can hear with goiter)
    • If Time Permits
      • Causes:
        • Lymph Node Exam
        • Pituitary Insufficiency (GH deficiency, adrenal insufficiency, central DI)
      • Consequences
        • 3rd spacing of fluid (pericardial, pleural fluid ascites)
        • MMSE (cognition)

    Diabetic Foot

    • Initial
      • Introduction
      • Wash Hands
      • Drapes
    • Vitals (HR, BP, RR< O2)
    • Inspection
      • Skin (atrophic skin? dystrophic nails?, pallor? absence of hair?)
      • Ulcers (arterial = punched out on toes, venous stasis = medial calf, Diabetic = plantar foot, heel)
      • Joints (claw toes, charcot foot)
    • Palpation:
      • Temperature
      • Pulses (DP + PT)
      • Bruit (popliteal, etc.. any lower extremity = PAD)
    • Neuro:
      • Touch: Monofilament 10g
        • Touch forehead --> so sensation understood.
        • Ask say "yes" each time it is felt.
        • Eyes closed, apply monofilament to dorsum of great toe, proximal nail bed.
        • Bend for 1s then left.
        • Do 4 stimulus per foot in arrhythmic fashion (1 point for each CORRECT stimuli = give score /8).
          • 7-8 rules out
      • Vibration: Screen with 128Hz tuning fork:
        • Apply tuning fork to forehead to understand sensation
        • Eyes closed, apply fork to bony prominence at dorsum of 1st toe, proximal to nail bed
        • Ask if vibration sensation is perceived... then ask when vibration stops (+ dampen fork)  --> do TWICE
        • 1 point for each "vibration on" and 1 point for each "vibration off" --> twice, each foot = 8 points
          • 7-8 rules out neuropathy
      • Reflexes
    • Vascular:
      • Venous Filling: Supine patient, empty vein by elevation to 45° for 1min.
        • Patient sits up and dangles leg on side of bed ---> if veins refill in >20s = POSITIVE
      • Capillary refill: 5s of pressure of distal greal toe.  >5s to refill = POSITIVE
      • Buerger's Test (Pallor on elevation, rubor on dependency)
        • Patient supine, elevate leg to 90° x2min.  Dangle perpendicular to table edge x2min. 
        • Pallor with elevation, dusky rubor with dependency = POSITIVE
      • ABI: Patient supine, at rest 15min, place BP cuff around upper arm and ankle.  Use dopler to find systolic pressure. ABI = ankle pressure / brachial pressure
        • Index < 0.9 = POSITIVE for claudication, <0.5 = CRITICAL ISCHEMIA.

     

    Vitamin B12 Deficiency

    • Initial: Introduce, Wash Hands, Drape
    • Vitals
    • MMSE (dementia?) 
    • Head & Neck: 
      • Eyes:
        • PERL normal, no nystagmus
        • Visual Acuity
        • Fundoscopy (Optic atrophy, pale disc - very rare)
        • Conjunctival pallor
      • Atrophic glossitis
    • Neuro:
      •  Dorsal Columns
        • Decreased vibration sense: Toes, ankle, shin, knee
        • Decreased position sense: Toes
      • Corticospinal Tract
        • Spasticity
        • Weakness Legs > Arms summetric
        • Hyperreflexia (Patella & Bainski) Ankle reflex. (lost?)
        • Clonus
      • Gait:
        • Wide Based, high steppage, spastic scissor gait
        • Romberg positive = stand, eye closed --> unsteady
      • Special:
        • Lhermitte's Syndrome = shock like senation radiates to feet on neck flexion
    • Causes:
      • Malabsorption, Celiac, Pernicious anemia, pancreatic insufficiency, drugs. 
      • Malnutrition
      • Dermatitis herpetiformis rash
    • Consequences:
      • Anemia
      • Jaundice
      • Osteoporosis

    Vascular

    DVT

    • History  (Well's Score for DVT)
      • Active Cancer?
      • Immobilized? (Bedridden ≥3d or major surgery within 12w)
      • Hx of DVT
      • Alternative Diagnosis at least as likely (-2 points)
    • Introduction, Wash Hands, Drape
    • Vitals (RR, O2 sat, Temp, HR, BP)
    • Inspection
      • Entire Leg Swelling
      • Collateral Superficial Veins (nonvaricose)
    • Palpation
      • Pitting Edema
      • Calf swelling ≥ 3cm in symptomatic leg - 10cm inferior to tibial tuberosity
      • Local tenderness along deep vein system (palpate superior to popliteal)
    • JAMA RCE:
      • Well's DVT Score: 4 history + 5 physical exam
        • Low (5%) < 2
        • Likely (28%) ≥ 2
    • Mnemonic: (there are many)
      • 4 historical features, 2 inspection, 3 palpation
      • some people use C3PO, D2R2

     

    PE

    • History:
      • Hemoptysis
      • Other Dx
      • Immobilized
      • DVT/PE Hx
      • Cancer?
    • Initial: Intro, wash hands, drape
    • Vitals (HR > 100?, hypotension? Pulsus paradoxus? Fever? Hypoxia?)
    • JVP Elevated, prominent A-wave, C-V wave if TR
    • Cardiac Exam:
      • Loud P2
      • S2 > S1
      • Pulmonary HTN Findings:
        • Wide split/narrow fixed split S2
        • R-sided S4
        • Pulmonary Regurg,
        • TR murmur
    • Causes: DVT Exam
    • Consequences: Vitals, Pulmonary HTN exam
    • JAMA RCE:
      • Wells:
        • DVT Features on Exam: +3
        • Other dx less likely + 3
        • HR > 100 +1.5
        • Immobilized >3d + 1.5
        • Hemoptysis + 1
        • Cancer + 1
      • Score:
        • Low (3%) < 2
        • Unlikely (28%) < 7
        • Likely (78%) ≥ 7
    • Mnemonic:
      • 5 history (3, 3, 1.5, 1.5, 1, 1) - Cancer, hemoptysis 1.
      • 1 vitals (1.5pts)
      • 1 DVT (3pts)

    Respirology

     

    Airflow Limitation

    Taken from JAMA rational clinical exam series:

    • History:
      • Background Info
        • Exposure to sigarette smoke (≥70 pack-yrs LR+ 8.0, never smoked LR- 0.16)
          • UPDATE: >40 pak years of smoking is a single best historical feature.
          • Length of smoking works as least as well as pack years (studied).
        • Occupational & Environmental pollutants.
        • Personal/family history of atopic diseases.
        • Age: (AL is not part of normal aging process!!, but age is proxy for toxin/smoke exposure).
      • Symptoms:
        • Wheezing, coughing, sputum production.
          • Sputum production ≥1/4 cup (LR+ 4)
          • Wheeze (LR+ 3.8)
          • (No symptom useful for ruling-in or ruling-out).
        • Chronic bronchitis: sputum production for at least 3 consecutive months in at least 2 years.
    • Exam:
      • Inspection
        • Work of Breathing
          • (Tripod? Accessory use - intercostals, scalenes, rectus, costal margin indrawing - Hoover sign)
        • Breathing
          • Pursed lip? Pradoxical?
        • Cough? (intermittent, poor k=0.29)
        • Look for A-P diameter - POSITIVE if > 1:1  (very specific, esp in children Sp 99%)
      • Vital signs:
        • Pulsus Paradoxus (Sn 45%, Sp 88% - most sensitive 2nd to Match test)
          • During tidal breathing, BP cuff inflated above systolic.  Slowly deflate until hear sound only during expiration, continue to deflate until hear during inspiration.
          • Expiration BP > Inspiration BP
          • ≥15mmHg differnece = positive.  [>10 is abnormal, >15 is higher LR+ as per JAMA)
      • Palpation
        • Palpate cardiac apex (in hyperinflation apex shifts centrally).  (LR 4.6 specific, not sensitive, useful if present)
          • Either cannot palpate or palpate centrally in subxiphoid.
        • Tracheal Deviation
        • Chest Expansion @ T4  (<5cm abnormal???unclear)
        • Laryngeal Height (< 4cm abnormal)
      • Percussion
        • Hyperresonance? (very precise, and quite accurate.  LR+ 4.8 LR-0.73, Sn 32% Sp94%. one of most sensitive tests).
        • Diaphragmatic Excursion (normal 5cm, decreased in COPD)
        • Decreased cardiac dullness
      • Auscultation
        • Auscultate bilaterally over lower, middle, and upper lung fields posteriorly, anteriorly, and along mid-axillary line. 
        • Types of sounds:
          • Wheezing - high pitched musical tones during expiration. (most precise, Sn 15%, Sp 99.6%, rules in if heard!)
          • Rhonchi - Lower pitched wheeze
          • Intensity of breath sounds (decr. in COPD). (less precise k=0.30-0.63, poor scoring)
      • Special Tests
        • Forced Expiratory Time:
          • Take deep breath and forcefully exhale until no more air can be expelled. (keep mouth + glottis open as if yawning).
          • Listen over larynx or trachea with stethoscope the duration of airflow (measure with stopwatch, record to 0.1s).
          • Can do multiple measurements and average
          • Results:
            • <6 seconds --> decrease in likelihood of AL  (LR+ 0.45)
            • 6-9s --> great increase in likelihood of AL  (LR+ 2.7)
            • 9s --> FEV1/FVC of 70%, a level that dx an airflow limitation. (LR+ 4.8)
        • Match test
        •   (most sensitive) 
          • Hold burning match at 10cm from pt's widely opened mouth.  If match is still burning w/ forced expiration --> positive.
          • DO NOT DO if patient is on O2.
        • Peak Flow Meter:  Only useful in assessing response to therapy.
      • JAMA RCE: 
        • Best Test To Rule IN: FET > 9sec + Laryngeal height < 4cm + >40pkyr smoking
        • Best Test To Rule OUT: No best test to rule out (match test is closest)

    Pulmonary Hypertension

    • Initial (introduce, wash hands, drape)
    • Vitals: (BP narrow pulse pressure, HR, O2sat, temp)
    • Head & Neck:
      • JVP: elevated, prominent a-wave, c-v wave if TR
      • Carotid + Peripheral Pulses: small, hypodynamic pulse
    • Precordial:
      • Palpation:
        • RV Heave
        • Palpable P2
      • Auscultation
        • R-sided S4
        • Loud P2: 
        • S2 > S1 everywhere but pulmonic
        • S2: Narrow, fixed split (Normal RV), Wide split S2 (Failing RV)
        • Pulmonary Regurg Murmur (Graham-Steel Murmur, louder w inspiration)
        • TR murmur (louder with inspiration)
    • Consequences:
      • R-sided Failure:
        • Hepatomegaly
        • Pulsatile liver
        • Peripheral Edema
        • Ascites
    • Causes: (mention, too much to do)
      • Pleural Effusion, COPD Exam, OSA, PE, DVT, etc..

     

    Obstructive Sleep Apnea

    • Initial: Intro, Wash Hands, Drape
    • Vitals: Temp, HR, BP (hypertension?), RR, O2 sat, BMI > 30 (obese)
    • HEENT
      • Inspection:
        • Open Mouth
          • Mallampati Score
            • I = full view of soft palate
            • II = Full view of uvula visible
            • III = Base of uvula visible
            • IV = No soft palate visible
          • Airway Lesions (Tonsillar/adenoid hypertrophy, septal deviation)
          • Overjet (show teeth.  Upper incisor overjets lower incisor >3mm distance = abnormal)
        • Thyromental Distance (horizontal distance from vertical plane of Mandible to vertical plane of thyroid)
        • Thyromental Angle (Angle of cricoid - thyroid - mandible)
        • Retrognathia (abnormal > 0.5cm retroposition of chin contour from vertical plane of nasal bone)
        • Neck Circumference (>50cm sleep apnea clinical score, >43/41cm (m/f) STOP-BANG screen)
          • Measure at upper aspect of cricothyroid membrane
        • Cricomental Space?? (Normal >1.5cm)???  Perpendicular distance to midline of Cricoid – mandible line
    • Consequences:
      • CVS
        • Pulmonary HTN (Elevated JVP, prominent CV wave, palpable P2, RV heave, Loud P2, wide split P2, TR, PR, edema)
      • Hypoxemia
      • Hypercapnea (asterixis)
      • LVH
    • STOP-BANG Score  (>4 = high risk for OSA)
      • S - Snoring
      • T - Tired during day
      • O - Observed Apnea
      • P - Pressure (high BP)
      • BMI > 35
      • Age > 50
      • N - Neck Circumference >16in (>43cm male, >41cm female)
      • G - Gender Male
    • JAMA - RCE
      • Nocturnal gasping/choking (LR+ 17-35)
      • Morning Headaches (LR+ 8-20)

     

     

     

    Pancoast Tumor (SVC/Horners)

    • Initial: Introduction, Wash hands, Drape
    • Vitals: Temp, HR, BP, RR, Tachypnea, O2 sat low/normal
    • Inspection:
      • LOC (decreased if severe SVC)
      • Clubbing
      • Muscle Wasting (temporalis, deltoids, thenar, hypothenar)
    • Horner's Syndrome
      • Ptosis - Mild, ipsilateral side (sympathetic nerve paresis)
      • Miosis - Ipsilateral side (turn off light, pupil not dilating)
      • Enopthalmos - Posterior displacement of eyeball within orbit (impression, small palpebral fissure)
      • Anhydrosis - Ipsilateral side.  Hyperhydrosis/flushing of contralateral side
    • Recurrent Laryngeal & Phrenic nerve (Lung Exam)
      • Horseness in voice
      • Decreased chest expansion (T10) level (≥ 5cm is normal))
      • Dullness & decreased breath sounds to bases (atelectasis)
      • At tumor:  Incr tactile fremitus, dullness, decr breath sounds +/- crackles.
    • SVC Syndrome
      • Periorbital edema, conjunctival injection
      • Papilloedema on fundoscopy
      • Plethora (red face)
      • Edema on face/arm
      • Engorged vessels in neck/chest
      • Elevated JVP
      • Pemberton's Sign - raise arms over head x1min (positive = flushing)
    • Neurologic  (C8/T1/T2 involved (examine but not full neuro signs)
      • Atrophy, fasiculations, unilateral edema (thoracic outlet obstruction)
      • Intrinsic muscle wasting (C8/T1)
      • Hypotonic (decr. tone), ocassional spastic (spine cord lesion)
      • Handgrib, finger abduction (C8, T1) strength
      • Triceps reflex (C8)
      • Sensation
        • C8 (4-5th digit)
        • T1: ulna aspect of forearm
        • T2: distal to axilla

    Diabetic Foot

    • Initial
      • Introduction
      • Wash Hands
      • Drapes
    • Vitals (HR, BP, RR< O2)
    • Inspection
      • Skin (atrophic skin? dystrophic nails?, pallor? absence of hair?)
      • Ulcers (arterial = punched out on toes, venous stasis = medial calf, Diabetic = plantar foot, heel)
      • Joints (claw toes, charcot foot)
    • Palpation:
      • Temperature
      • Pulses (DP + PT)
      • Bruit (popliteal, etc.. any lower extremity = PAD)
    • Neuro:
      • Touch: Monofilament 10g
        • Touch forehead --> so sensation understood.
        • Ask say "yes" each time it is felt.
        • Eyes closed, apply monofilament to dorsum of great toe, proximal nail bed.
        • Bend for 1s then left.
        • Do 4 stimulus per foot in arrhythmic fashion (1 point for each CORRECT stimuli = give score /8).
          • 7-8 rules out
      • Vibration: Screen with 128Hz tuning fork:
        • Apply tuning fork to forehead to understand sensation
        • Eyes closed, apply fork to bony prominence at dorsum of 1st toe, proximal to nail bed
        • Ask if vibration sensation is perceived... then ask when vibration stops (+ dampen fork)  --> do TWICE
        • 1 point for each "vibration on" and 1 point for each "vibration off" --> twice, each foot = 8 points
          • 7-8 rules out neuropathy
      • Reflexes
    • Vascular:
      • Venous Filling: Supine patient, empty vein by elevation to 45° for 1min.
        • Patient sits up and dangles leg on side of bed ---> if veins refill in >20s = POSITIVE
      • Capillary refill: 5s of pressure of distal greal toe.  >5s to refill = POSITIVE
      • Buerger's Test (Pallor on elevation, rubor on dependency)
        • Patient supine, elevate leg to 90° x2min.  Dangle perpendicular to table edge x2min. 
        • Pallor with elevation, dusky rubor with dependency = POSITIVE
      • ABI: Patient supine, at rest 15min, place BP cuff around upper arm and ankle.  Use dopler to find systolic pressure. ABI = ankle pressure / brachial pressure
        • Index < 0.9 = POSITIVE for claudication, <0.5 = CRITICAL ISCHEMIA.

     

    GI

     

    Hepatomegaly

    • Initial (Introduction, Wash hands, Drape patient)
    • Vitals (Weight, Temp, HR, BP, RR, O2sat)
    • Percussion:
      • Mid Clav. Line: precuss start superiorly, move down till dullness.
      • Normal < 12cm.
    • Palpation
      • Liver edge: MCL and R-costal margin (or start RLQ and palpate superiorly on inspiration).
    • Auscultation:
      • Friction Rub
      • Venous Hum (low pitch systolic/diastolic) with portal HTN.
    • JAMA:
      • Scratch Test NOT useful.
      • Percussion of liver span (<12cm MCL) agrees with Ultrasound (K coeff. 0.9)
      • Palpation of liver edge = hepatomegaly (LR +2)

     

    Cirrhosis

    • Initial: Introduce, Wash Hands, Drape
    • Vitals; Temp, HR, BP (orthostatic), RR, O2 sat, weight
    • MMSE
    • Inspection:
      • Hands
        • Palmar Erythema
        • Muscle Wasting (Thenar, Hypothenar Wasting)
        • Terry's nails (Loss of lunula - crescent-shaped white area at nail bed = low albumin)
        • Clubbing
        • Asterixis
        • Xerosis / Excoriations (HyperBili)
        • Dupytryn's Contracture
      • Head & Neck
        • Scleral Icterus (sclera, Bili > 50)
        • Temporalis/Deltoid Wasting
        • Fetor Hepaticus (portal HTN, HE)
      • Chest
        • Spider Nevi (>=3 signifiacant): central red arteriole with small extensions - blanchable
        • Gynecomastia (Estrogen)
      • Abdomen:
        • Dilated Veins (Caput Medusa)
          • Away from umbilicus = portal HTN
          • IVC obstruction = flow towards SVC
          • SVC obstruction= flow towards IVC
        • Organomegaly
      • Legs:
        • Proximal muscles: Quadriceps wasting & Hip flexion weakness
        • Peripheral edema
        • Testicular Atrophy
    • JVP: LOW
    • Cardiac: Flow murmur
    • Ascites
    • Hepatomegaly (normal 6-12cm)
    • Splenomegaly

     

    • Causes:
      • EtOH: Wernicke's, Dupytryn's Contracture, Testicular atrophy, neuropathies
      • Hemochromatosis: Bronze skin, mental status
      • NASH: Obesity, acyanthosis nigricans
      • Wilsons: Slit Lamp: Kaiser-Fleischer Rings
    • JAMA RCE:
      • BEST RULE IN cirrhosis

        Ascites (LR+ 7.2)  + Spider Nevi (LR+ 4.3) - Narrow CI

        Distended Abdomen (LR +11)

        Encephalopathy (LR+ 10) wider CI

        BEST Rule out

        No Hepatomegaly LR- 0.37

        Lack of Firm Liver LR- 0.37

        BEST Lab RULE IN

        Plt < 160,000, Alb < 35, abnormal INR

        Bonacini Discriminant Score > 7 (ALT:AST ratio, INR, Plts) (LR+ 9.4)

        BEST Lab RULE OUT Lok index < 0.2 (Plt, AST, ALT, INR) (LR- 0.03), Plt > 160,000

    Ascites

    • Initial (Introduction, Wash Hands, Drape)
    • Vitals
    • Inspection
      • Bulging Flanks?
      • Dilated Abdo Veins
      • Umbilical Hernia?
    • Percussion
      • Flank Dullness?
      • Shifting Dullness (percuss medial-to-lateral, mark border of tympany & dullness --> roll away from examiner --> percussion med-to-lateral mark border again ---> difference?)
    • Palpation
      • Fluid Wave - Ask patient to press medial edge of both hands down midline on abdo, flick or shap-tap one side, feel for wave on the other side.
      • Ankle Swelling
      • Pitting Edema
    • Causes:
      • Extraabdominal Signs of Liver Disease
    • JAMA RCE
      • Ruling IN: Increased Abdominal Girth & Fluid Wave
      • Ruling OUT: Ankle Swelling

    Splenomegaly

    • Background
      • Splenomegaly in adults require explanation. (infections, cancers, connective tissue disorders, nonspecific).
    • Anatomy:
      • Shaped curved wedge follows along the 10th rib.
      • Lies between the L-side of diaphragm, anterior axillary line, stomach, L-kindey.
      • Vertical diameter ≥13cm.
      • Normal spleen cannot be palpated. (Lies within the rib cage).
    • Initial: Introduce, Wash Hands, Drape
    • Vitals
    • Inspection
      • LUQ of abdomen for bulging mass descending on inspiration. (non-specific, rarely distorts abdomenal wall)
    • Percussion
      • Dullness to percussion is key! (impinges on adjacent air-filled lung, colon, stomach)
      • Three methods:
        • Nixon Method  (LR+ 3.6, LR- 0.41) - but BEST in 2009 update.
          • Patient in R-lateral decubitus position.
          • Start percussion midway along left costal margin --> percuss up perpendicular to costal margin.
          • Positive if percussion >8cm above costal margin (stomach creates initial dullness). 
        • Castell Method (LR+ 1.2, LR- 0.45, LR+ CI crosses 1) - WORST in 2009 update
          • Patient supine.
          • Percuss lowest intercostal space anterior-axillary line during bost expiration + inspiration.
          • Positive if percussion is dull or becomes dull on inspiration.
        • Traube Space (LR+ 2.3, LR- 0.48) - SECOND BEST in 2009 update
          • Supine with left arm slightly abducted to reveal Traube's space.
          • Space marked by: 6th rib, mid-axillary line, L-costal margin.
          • Percuss across ≥ 1 levels from medial-to-lateral.
          • Positive if dull to percussion.
          • NOTE: False-negatives with obesity, False-positives with recent food intake
    • Palpation:  (Sn 27%, Sp 98%)
      • Method 1 (Two-Handed Palpation):
        • Patient in R-lateral decubitus.
        • Examiner's L-hand behind the thorax (lower rib cage) lifting the lowermost ribcage anteriorly and medially
        • Examiner's R-hand tips of fingers just beneath the L-costal margin. (Or start RLQ)
        • Patient asked to take long, deep breath, and examiner palpates spleen.
          • If not palpated, move R-hand down 2cm towards umbillicus... repeat until confident no large spleen.
      • Method 2 (One-Handed Palpation)
        • Same as 2-handed palpation, except no counter-pressure.
      • Method 3 (Hooking Maneuver of Middleton)
        • Patient supine flat with L-fist under L-costovertebral angle.
        • Examiner to patient's L-side, both hands curled under L-costal margin, palpating with every breath.
      • NOTE: Impossible to get above upper border of spleen, if you can, suspect a mass.
    • Auscultation
      • Friction Rub
    • JAMA RCE:
      • Best RULE IN: Traube Space & 1 Handed Palpation
      • Best RULE OUT: Nothing (Ultrasound scan)
    • NOTE: Differentiate from Renal Mass
      •   Spleen Renal Mass
        Inspiration Moves InferoMedially Moves Inferiorly
        Notch on epigastrium Splenic Notch No Notch
        Auscultation Friction Rub No (too posterior)
        Ballotable? NOT Ballotable Ballotable
        Precussion NOT Tympanic Tympanic
        Superior Part NOT Palpable (impossible) Palpable

    Neurology

     

    Myasthenia Gravis

    • Background:
      • NMJ disorder (antibodies targeted against postsynaptic ACh Receptors).
        • Antibodies inhibit binding of Ach and internalize receptors (decreasing number), and damage the postsynaptic membrane.
        • Characterized by initially reversible weakness and fatigability of skeletal muscles, progressing to permanent weakness (permanent loss of AChR's)
        • Muscle Groups: Extraocular > Bulbar (LMN of CN IX-XII) > Neck > Limb Girdle > Distal Limb > Trunk
      • Classic Features:
        • Fatigability
        • Rapidly fluctuating asymmetric ptosis (rapid recovery with rest)
      • Associated with: Thymic Disease (thymic hyperplasia/tumors), Malignancies (SCLC, Hodgkins), Autoimmune (SLE, RA)
    • History: (fatigability in all muscle groups bulbar > arms/legs)
      • Eyelid drooping, Diplopia, Difficulty Chewing, Myasthenic snarl (transverse smile), dysphagia, dysarthria, hoarseness  (fatigable weaknes sin arms/legs less common)
      • JAMA RCE:
        • RULING IN:
          • 1.  Food in mouth after swallowing (LR+ 13, CI 0.85 - 212)
          • 2.  Speech unintelligible with prolonged speaking (LR+ 4.5)
        • RULING OUT:
          • No historical features help you rule out!!!
    • Head & Neck:
      • Inspection: (ask to fixate on point in front, refrain from blinking)
        • Expressionless face?
        • Ask to smile
        • Ptosis (measure palpebral fissure [eyelid opening])
          • Repeat palpebral fissure width after 30s
        • Eye position (strabismus?)
          • Note any esotropia, exotropia, hypertropia, hypotropia
      • CN Nerves
        • CN II (pupil exam - SHOULD BE NORMAL!)
        • CN III: EOM, can test saccadic movements (shift gaze between fingers fast).
          • Keep lateral+ upward gaze x30s (fatigability) --> ask if double vision (watch eyes)
        • CN VII:
          • Ask to smile ("Myasthenic sneer") mid lip rises, outer corners dont move
          • Orbicularis - Forced eye closure against examiner resistance.  Positive if can open eyes. 
        • IX and X: Pallate elevation.
          • Speech: Pa (CNVII), Ka (CNX), Ta (CNXII) - ask to repeat sounds (worsens)
        • XI (accessory)
          • Check neck/trapezius. 
        • XII (tongue- speech)
          • Hypophonic "nasal" or slurred speech.
          • Ask to read passage in book (positive = worse with prolonged speech)
    • Neuro:
      • POWER testing proximal >> distal
        • Can check each limb with repetitive movements. 
      • REFLEXES:
        • Normal, but fatigue on repeat testing
      • SENSATION --> Normal
    • Special Tests
      • Edrophonium (Tensilon) Test
        • Need monitored setting
        • Inject 2mg over 15s, improvement in 30s to 5min.
        • If no response, give 8mg additional and assess forimprovement
        • Have atropine nearby for S/E: Bracydardia, bronchoconstriction.
        • Contraindications (bradycardias, bronchoconstriction)
      • Test

        Description

        LR+

        LR-

        Peek sign

        As patient to close eyes.  Positive Sign = in 30s, eyelids will separate to reveal white sclera. 

        30

        [wide CIs]

        0.88

        [wide CIs]

        Ice Test

        Place latex glove finger filled with ice over ptotic eyelid x 2 mins and complete resolution or > 2 mm ­in palpebral fissure

        24

        0.16

        Rest Test

        Close eyelids for 2 minutes (sometimes put latex glove filled with cotton over ptotic eyelid (placebo).

        After 2 mins of (rest), should be complete resolution of >2mm palpebral fissure rise.

        16

        [wide CIs]

        0.52

        Sleep Test

        Leave pt in dark room with instructions to close eyes x 30 mins.

        POSITIVE = >2mm increase in palpebral fissure width

        53

        [wide CIs]

        0.01

        Lid-Twitch Sign

        Have patient sustain downward gaze by following examiners finger. 

        Saccade back up to primary gaze.

         Positive = eyelid rises then falls back into ptosis (like twitch)

           

        Quiver eye movement

        Fast, jerk-like movements of eyes upon changing gaze direction

        4.1

        [wide CIs]

         

        Curtain sign

        Patient looks straight ahead àexaminer lifts more ptotic eyelid --> the other begins to droop (looks like curtain falling)

        N/A

        N/A

        Cover-uncover test (tests for subtle extraocular muscle weakness)

        Patient fixates on object in distance àexaminer covers 1 eye àasks pt to look laterally then upward àuncovered eye begins to drift

        N/A

        N/A

    • Causes:
      • LN Exam (Hodgkins and SCLC can be ass'd)
    • Consequences:
      • Resp rate, MIPs+ MEPs.

    Cerebellar Dysfunction

    • Initial: Introduction, Wash hands, Drapes Pt
    • Vitals: Weight included
    • MMSE: Orientation, Registration, Recall, Attention, Language
    • Head & Neck:
      • Eyes:
        • Nystagmus: Horizontal, rotatory, vertical (>2 fast beats = abnormal)
      • Speech:
        • Say "Ma-La-Ka"
        • Truncal Ataxia ("drunk walk" -overshooting turns)
    • Neuro:
      • Tone: Decreased muscle tone
      • Coordination: Finger-To-Nose, heel-to-shin
        • Dysdiadokinesis
      • Reflexes:
        • Pendular Reflex? (≥3 swings) [Sit on side of bed, do patellar reflex, and see how many times leg swings]
      • Sensation - normal
      • Gait
        • Wide based - sway, short stride, reel in all directions (titubation = truncal ataxia)
        • + Romberg (stand feet together, hands to sides, = sway?  then close eyes = sway? tests proprioception not a cerebellar sign!)
    • Special:
      • Rebound Phenomena: Resist against flexed below arm (Positive: hand overshoots when resistance released).
    • Causes:
      • Alcohol: WACO mnemonic (Wernicke's, ataxia, confusion, opthalmoplegia)

     

    NOTES (Questions)

    • Aortic Stenosis vs. Aortic Sclerosis
      • Aortic stenosis has:
    1. Murmur Radiates
    2. Presence of a thrill
    3. Soft S2

     

    Rheumatology

    Seronegative Spondyloarthropathies

     

    Extra-Articular Manifestation of Sero-Neg

    • Initial: Introduction, Wash Hands, Drapes Pt: Introduction, Wash Hands, Drapes Pt
    • Vitals: bradycardia (AV block), hypoxia (pulmonary fibrosis), pulsus paradoxus. 
    • Head & Neck
      • Rashes (Psoriatic Plaques,, discoid rashes)
        • Check scalp, behind ears.
        • Heliotrope/malar rash
      • Eyes (Uveitis, iritis)
        • Light Sensitivity, lacrimation, blurred vission, photophobia
        • EOM (should be normal)
      • Mouth
        • ulcers? (crohn's, SLE, Behcets)
        • nose ulcers?
    • Hands
      • Dactylitis
      • Psoriasis
      • Nails (pitting, onycholysis, leukonychia, oil drop spots)
      • Nailfold capillaries
      • Dactylitis, Gottron's papules
      • Raynaud's
      • Tuck Sign - extend hands, drop hands (effusion behind wrist disappears on flexion)
      • Enthesitis (epicondyles of elbows)
      • Gottron's Papules
    • JVP
      • Kussmaul Sign
      • A-wave (pulmonary HTN)
      • V-wave tricuspid regurg
    • Chest/Cardiac
      • Shawl sign, V-sign, telangectasias
      • Muffled heart sounds (effusion)
      • Pulmonary HTN
      • Aortic Insufficiency Murmur
      • Rub
    • Resp
      • Decreased breath sounds
      • Velcro Crackles (apical fibrosis)
      • Effusions
    • Feet
      • Dactylitis
      • Enthesitis
      • Nail changes
    • Rectal Exam (Fistulas, ulcers, fissures from IBD).
    • If Time permits
      • Neuro Exam - proximal muscle weakness (myositis), mononeurotis multiplex (vasculitis)
      • Vascular exam - bruits, pulse asymetry, BP. 

    Counselling Stations

    • IBRANTS
    • I - Indication
    • B - Benefits
    • R - Risks
    • A - Alternatives
    • N - Not doing the test (what will happen)
    • D - ? Tips/Tricks
    • S - Side Effects
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