How to Be A Doctor
SHORT CASE
For short case: findings; relevant +ive and –ives
Differential – and things that back up likely diagnosis or go against it
Markers of severity
Complications
LONG CASE
History – 15-20mins
Hello, this is exam; sorry for time restraints; you can tell me anything you know
What is wrong? Why are you in hospital this time? Do you know your diagnosis?
HPC Presenting symptoms
Is there an action plan?
What did the doctors do for you in ED? What did they do for you in the ward?
What management and investigastions do the doctors have planned for you?
What consultations have you had?
What were the results of investigations?
PMH List in order of importance; do you have a list of your medical problems? Active / non-active
Generic details
DH
Immunisation status (influenza, hep A, hep B, Pneumococcus)
Systems review – SOB, bowels etc…
Do you have a list of medications?
A
SH
Occupation, adequacy of income, current housing, ability to cope, mobility + steps
Smoking, ETOH, drugs
Hobbies (animals, chemicals, dusts), marital status, sexual problems and preference
Immunisation
Education and language
Place of birth, overseas travel
Level of Fx in community; level of help in community
Involvement of ancillary: physio, SW, OT
Psychological impact of disease
FH
Examination – be finished by 20-35mins
What did examiners examine? Did they comment on signs?
End
Is there anything else I should know? Has anyone else asked you questions I haven’t asked? Did anyone else examine
anything I didn’t?
Presentation
Intro:
Is this management / diagnostic or investigative problem: demographics, patient issues, intro
Mrs X is a 77 year old lady who lives with and is struggling to care for her unwell husband
(social). She presented to the ED with the challenging investigative, management &
resuscitation problem of shortness of breath and palpitations with likely cardio-respiratory failure
(emergency problem). This is on a background history of cardiac failure, ischaemic heart disease,
ventricular tachycardia, mitral valve replacement, non compliance with her medications
(contributing RF’s) including warfarin, recent dental procedures, renal impairment, smoking &
possible bronchospasm.
HPC:
Presenting problem – much detail; relevant history; relevant +ives and –ives; Type of presentation; date; current
GP, specialist and ward
Systems review
Active problems – some detail
Active problems that are not relevant to current presentation
Non-active problems
DH + A – reference what medication is used for
FH
SH – include non-clinical issues
Examination cardinal signs and other signs; general appearance; vital signs; most important system first; relevant +ives and ives
PMH
Summary statement
In conclusion; Mrs X (demographics) is now recovering from cardio-respiratory failure 2 weeks
post admission. It seems likely that this was due acute pulmonary oedema (key issues).
Contributing factors are multi-factorial but likely include ischaemic heart disease, AMI, occluded
coronary artery bypass grafts, renal impairment and arrhythmias. Further investigations would be
required to determine the severity of these factors and to determine other contributing factors.
Optimal medical management is required as well as considering her suitability or non-suitability
for more invasive future management. Mrs X may struggle to live independently and this has
implications for her husband who has been largely dependent on her.
Differential diagnosis and findings that support / refute – with relevant weightings
What would you do if this patient came into ED? Or may need to postulate on possible presentations of this patient to the ED
Investigations and justification for (beside, lab, imaging) – comment on results if given
Management and management goals – inc supportive care, disposition etc…
Primary ED points in this case are
CV
History
IHD RF’s
Complications
Trt
IHD, incr lipids, DM, HTN, +ive FH, smoking, OCP, premature menopause, obesity, physical
inactivity, long term NSAIDs, erectile dysfunction
Arrhythmia, CCF, angina, emboli; OT
Angioplasty / thrombolysis / CABG (number of grafts; drug eluting stent?)
Anticoagulants and how long
Rehab program; RF control
IE
Symptoms
Malaise, fever, anaemia
Cause / RF’s
Recent dental / endoscopic / OT
RF, congenital heart disease, valve lesions, heart OT, IVDU, immune suppression
Trt
Embolic: CVA, loin pain
Antibiotic prophylaxis (constant – for RF; before procedure – IE)
A
if prev IE, prosthetic heart valve, congenital heart malformation (unrepaired cyanotic heart
disease, residual defect, recent OT), cardiac transplant with valve disease --> dental
procedure, oral surgery
?valve replacement discussed
Abx allergy
OE
Clubbing, splinter haem (also vasculitis, RA, PAN, haematological malignancy, trauma), Osler’s
Complications
nodes (finger, painful), Janeway lesions (palms and pulps, non-tender); Source of infection; Roth’s
spots, conjunctival petechiae; dentition; Regurg/stenosis; prosthetic valve; PDA; VSD; coarctation of
aorta; Signs of CCF
CCF Symptoms
Precipitant (arrhythmia, med change, MI, anaemia, infection, thyrotoxicosis, OT, PE, salt intake,
Cause
NSAIDs, XS exertion, pregnancy)
As above
For cardiomyopathy: ETOH, FH of same, haemachromatosis
HTN, IHD, RF, valve disease, congenital heart disease, cardiomyopathy, prev cardiac OT
Precipitant; Postural BP (?beta-B, ACEi)
RF’s
PMH
OE
HTN Symptoms
Cause
Risk factors
Complications
Trt
OE
Arrhythmia
SOB, PND, orthopnoea, oedema, ascites, nausea; chest pain
Classify by NYHA
Measurements
Endocrine, phaemochrom Sx; RAS; coarctation of aorta, adrenal Ca
DM, lipids; ETOH, exercise, salt intake, smoking
CVA, CCF, PVD, renal failure
SE’s of trt
Fundi (silver wiring, AV nipping, flame haemorrhages, cotton wool spots, hard exudates, Papilloedema);
LVF; coarctation
Symptoms
RF’s
SH
FH
Trt
Palpitations, effect of Valsalva, syncope; persistency
IHD, AS, cardiac OT, congenital heart disease, thyrotoxicosis, WPW, recent ETOH binge, PE,
HTN
RF for embolic events (prev emboli, MV disease, CCF, HTN, DM, thyroid)
Ability to manage multiple blood tests and trips to lab
Sudden cardiac death (long QT, Brugada, HOCM)
IV/PO? manouvres? shock? SE’s of trt? Ablation? AICD?
Recent INR’s + Warfarin doses
Generic details
Immunisation status (influenza, hep A, hep B, Pneumococcus)
Compliance with meds
Examination
What did examiners examine? Did they comment on signs?
Stand back and look
Sit patient at 45 degrees and expose neck and chest
General
Temperature chart; ?IV cannula; ?infusion running
Syndromes
Marfan’s, Turner’s, Downs, Cushings, acromegaly
General
Uraemia, SOB, cyanosis
CCF
Precipitating factor
Oedema
Nutrition, myxoedema
Put hands on thighs in front of them
Hand
Pulse (rate, rhythm – NOT CHARACTER); radio-radial; clubbing; peri cyanosis
Pemberton’s sign
HOCM
AR
Hyperlipid
SVC obstr
Clubbing = RS
CV
GI
-
Jerky / sharp pulse
Collapsing pulse; Quincke’s sign
Tendon xanthomata
Arm oedema
Lung Ca, bronchiectasis, lung abscess, empyema, pul
fibrosis, asbestosis, CF, mesothelioma
IE, cyanotic congenital heart disease
IBD, cirrhosis, coeliac
Thyrotoxicosis, familial, pregnancy, 2Y hyperPT
Take BP: (boths arms, lying and standing if HTN; legs if young and HTN) – estimate SBP via radial pulse
Face
Xanthelasma; petetchiae; cyanosis; scleral pallor; Argyl-Robertson pupil (AR)
MS
Malar flush
Valve
Jaundice (haemolysis)
Marfan’s
Arched palate
SVC obst
Plethoric cyanosed face, periorbital oedema, exopthalmos, conjuctival injection, Horner’s
syndrome, fundi for venous dilation
Neck
JVP
Carotids
SVC obstr
Chest
Inspection
Palpation
Auscultate
Height, character, change with respiration; do hepatojugular reflex (15 secs in epigastrium –
?sustained)
Dominant a wave = atrial contraction: TS, PS, pul HTN (eg. 2Y to MS), HOCM
Dominant v wave = atrial filling: TR
Cannon a wave: CHB, nodal tachycardia, VT, pacemaker
Elevation: RVF, TS, TR, pericardial effusion, constrictive pericarditis, SVC obstruction, fluid
overload, hyperdynamic circulation (eg. Fever, thyrotoxicosis)
Character; carotid bruit
AS
Slow rising
AR
Corrigan’s = prominent, water hammer
Raised non-pulsatile JVP; ?large thyroid gland; LN’s; stridor
Scars, deformity, visible pulsations, pacemaker
Apex beat (position in ICS, mid clavicular line, character)
Pressure loaded = forceful + sustained = AS, HTN
Volume loaded = forceful + unsustained = AR, MR
Tapping = MS
Double / triple = HOCM
Absent = constrictive pericarditis
Thrills: across L side chest horizontally = palpable murmur = AS, MS, VSD
Parasternal impulse: L sternal edge vertically
RV Heave = RVH, LA enlargement = MR
Bell + diaphragm at apex
Diaphragm at lower and upper L sternal edge, R upper sternal edge
If murmur, time with carotid pulse
Listen below L clavicle for PDA murmur
L lateral position: rpt apex and bell in mitral area (for MS)
Sitting forward in expiration: rpt thrill, listen lower L sternal edge with diaphragm; ?AR
If ?HOCM (ie. Pure systolic murmur) – Valsalva, resp phases, hand grip, standing, squatting at
lower left sternal edge with diaphragm
S1
S2
Loud MS, TS
Hyperdynamic
Soft
MR
1st deg HB, LBBB
Loud AS
HTN
Soft
AR, PS
AV closes then PV usually on inspiration = physiological splitting
Wide = Incr splitting on inspiration PS, MR, VSD, RBBB
Fixed splitting
ASD
Reversed
AS, CoA, PDA, LBBB
S3
S4
Rapid diastolic filling = AR, MR, VSD, PDA, failure, constrictive pericarditis
High atrial pressure = AS, PS, MR, HTN, HOCM, IHD
Systolic
Diastolic
Continuous
HOCM
SVC obstr
Early MR, TR
VSD
Mid
AS, PS
ASD, HOCM
Late
MVP
HOCM
Pan
MR, TR
VSD, AP shunt
Early AR, PR
Mid
MS, TS, AR
RF, Austin Flint of AR, atrial myxoma
Late
MS, TS
Atrial myxoma
PDA, AV fistula, venous hum, AP connection, mammary souffle
Ejection and pan-systolic murmur
Louder with Valsalva, standing, jogging
Softer with squatting, raising legs, forceful handgrip
Distended collaterals
 patient is now sitting up
Back
Inspection
Palpation
Auscultate
Scars, deformity, oedema
Percuss for pleural effusion
?LVF – crackles
 lie flat
Abdo
Lie flat with 1 pillow
Inspection
Palpation
Radio-femoral (if PMH of HTN)
Liver (megaly = RVF, constrictive pericarditis; pulsatile = TR), spleen if ?IE (megaly = IE,
constrictive pericarditis), aorta, femoral arteries; renal mass (HTN)
Auscultate
Femoral arteries; renal bruit (in HTN; R+L above umbilicus; over flanks)
Oedema
Ascites; collaterals; liver
Legs
Cyanosis, cold, trophic changes, ulceration, peri pulses (dorsalis pedis, post tibial), oedema, calf tenderness;
varicose veins
Oedema
Inguinal nodes; delayed ankle jerk (hypothyroid)
Neuro
IE
FND; fundi
Presentation
Intro, summary
Differential diagnosis
Findings that support / refute diagnosis; always tailor to specific patient
IE
Atrial myxoma, occult malignant neoplasm, SLE, PAN, post-strep GN, PUA, cardiac
thrombus
Incr trop
Thrombus
Infection
Trauma
Tox
Other cardiac
Non cardiac
MI
Myocarditis
Cardiac contusion, cardioversion, biopsy; cardiac OT; stent; angioplasy
Cardiotoxic; Irukandji syndrome
CCF; aortic dissection; HOCM; AS; AR; arrhythmia; cardiomyopathy; rhabdo
Sepsis; renal failure; PE; pul HTN; burns; exertion; CVA; SAH
Investigations
Ask for 1-2 recent investigations and reason for ordering
Comment on results, even normal
Bedside
Lab
Imagin
Echo (vegetations; valve S/R; RWMA; LVEF); ECG; Temp chart
Trops; Na, K, Ur, Cr, BNP, Hb; TFT
IE: cultures (3-6x over 24hrs; strep viridans, strep faecalis, strep bovis, staph epidermidis, HACEK, fungi);
FBC, ESR, serology (immune complexes, C3, C4, RF, ANA); urine; Haematuria, proteinuria, RBC casts
HTN: ?cushings
ETT, stress echo, angiogram; CXR; RV biopsy; renal angio in HTN; Holter
Management
Suggest management and set management goals
IE
Benpen 6-12g OD for 4-6/52
Valve replacement: if resistant, mod-severe failure, persistent +ive blood culture, conduction disturbance
CCF Remove cause
Inotropes (dobutamine, dopamine, Levosimendan)
Implantable defib if malignant rhythm / severe
Decr activity; diuretics; low salt diet; fluid restriction; daily weighs; ACEi / AR blocker, beta-blockers, digoxin
HTN Remove cause
Lifestyle factors (weight, exercise, ETOH, salt)
Meds
Arrhythmia
Drugs; pacing; AICD; rate vs rhythm control; AVN ablation; DC cardioversion
CHADS2
RS
History
HPC Bronchiectasis Symptoms
PMH
DH
Mng
OE
Ix
Lung Ca
Clubbing;
Large vol purulent sputum;
Coarse crackles; Pneumonia,
pleurisy, empyema, lung abscess; Signs of R heart failure, cor pulmonale
Bloods
Ig levels; ABG
Other
Sputum results; PFT’s (restrictive/obstructive); cilliary Fx; sweat test;
bronchogram
Imaging
CXR (cystic lesions, thick bronchial walls, streaky infiltration), CT scan
Symptoms
Cause
Haemoptysis, SOB, wheeze, sinusitis, recurrent pneumonia, weight loss, fever,
anorexia, CCF); When began
Childhood pertussis, measles; LRTI; flu; CF, TB, HIV, 1Y cilliary akinesia, aspergillosis
RA, Sjogren’s syndrome
Abx; bronchoD
Physio, postural drainage, lung resection
Haemoptysis, cough, SOB, chest pain, systemic Sx) How diagnosed?
Metastatic symptoms (rib, nerve involvement, SVC obstruction, dysphagia,
lymphangitis, lymph nodes, bone, brain)
Smoking, occupation
SH
OE
No of dependents
Haemoptysis, Weight loss, cachexia, fever, gynaecomastia, opportunistic infections;
Clubbing; lower brachial plexus inj  weak finger abduction; hypertrophic
pulmonary osteoarthropathy; Ptosis and constricted pupils (Horner’s); SVC
Ix
COPD
obstruction; Fixed insp wheeze; Pleural / pericardial effusion, tracheal
obstruction; Oesophageal obstruction, hepatomegaly; Lymphangitis, cervical
adenopathy, dermatomyocytis, thrombophlebitis, acanthosis nigricans, scleroderma,
purpura; Pancoast tumour, RLN palsy, diaphragmatic paralysis, FND, Eaton
Lambert’s, peri/autonomic neuropathy, SACD
Bloods
Incr Ca (PTH), decr Na (ADH), ACTH, glu; FBC; LFT
Other
Sputum cytology; PFT’s biopsy / FNA; bronchial brushings / washings; pleural
biopsy; staging
Imaging
CXR (hemidiaphragm changes; peri = adenoCa; central = squamaous; hilar =
small cell; infiltrate = bronchoalveolar); CT; bronchoscopy;
Symptoms
Precipitants
DH
SH
FH
SOB, cough, sputum, wheeze, exercise tolerance, wegith loss
URTI, pneumonia, meds, RVF, smoking, aspiration, GORD; Smoking (age started, how
many)
Steroids, bronchoD; home O2
Occupation (air pollution, plastics factory toluene)
Alpha-1 AT
OE
Look at sputum; cachexia; SE of trt (eg. tremor in salbutamol, steroids); Early
coarse insp creps; Pursed lip; exp time; WOB
Ix
Bloods
Other
Imaging
ILD
Symptoms
PMH
DH
SH
OE
Ix
DD
Sarcoidosis
ABG; Hb (polycythaemia); alpha-1 AT; albumin; Ca, phos
PEFR; PFT’s (decr FEV1/FVC; 15% incr with bronchoD); sputum culture; BMI;
ECG (RVH, multifocal atrial tachy)
CXR (hyperinflation, cor pulmonale, pneumoniae, bullae); CT;
SOB, cough, lethargy, malaise, fever, rash, arthralgia, haemoptysis; Onset and duration
Scleroderma, SLE, Sjogren’s, RA, sarcoidosis, asthma, Churg Strauss, Goodpasture’s,
PAN; Prev radiotherapy, aspiration pneumonia, miliary TB
Amiodarone, hydralazine, procainamide; Methotrexate, penicillamine, bleomycin,
cyclophosphamide; Nitrofurantoin, bromocriptine
Mineral dust (silicosis, asbestosis, coal), chemicals (NO2, Cl, NH3), birds, farmer, flax,
hemp dust
Clubbing; Ant uveitis; Fine dry late/pan insp creps; Cyanosis; upper vs lower;
Erythema nodosum; signs of steroid SE’s
Bloods
ABG; ESR; LDH; eosinophilia; serology for CT diseases
Other
PFT’s (restrictive usually); Bronchoalveolar lavage; biopsy
Imaging
CXR; CT
Idiopathic interstitial pneumonia, CT disease (eg. see above), GVHD, Crohn’s, 1Y biliary
cirrhosis, occupational, radiation, aspiration pneumonia, drugs (see above), gases,
hypersensitivity
Symptoms
DH
Fever, weight loss, malaise, cough, SOB, arthralgia, blurred vision, eye pain, tearing
Steroids, NSAIDs, cyclosporins, cyclophosphamide
OE
Ant uveitis, yellow conjunctival nodules, papilloedema; basal
end-insp
crackles; RV failure, cardiomyopathy, arrhythmia, pacemaker, AICD;
Ix
Bloods
Hepatomegaly, splenomegaly; Erythema nodosum, lymphadenopathy, parotid
enlargement, plaques, rash (erythematous spots with waxy flat top), subC nodules,
lupus pernio on face (purple shiny swollen nodules); facial nerve palsy
FBC (decr WCC, incr eosinophils); incr ESR; ACE; ABG
PFT’s (decr lung vol, normal FEV1/FVC); LN biopsy; ECG (CHB, V
arrhythmias); lung/LN biopsy
Imaging
CXR (hilar lymphadenopathy, pul infiltration, paratracheal lymphadenopathy,
reticulonodular changes, cavitation, pleural effusion, linear atelectasis); CT
chest; bronchoscopy and biopsy
TB, histoplasmosis
Other
DD
CF
Symptoms
SH
Mng
OE
Ix
Pul HTN
PMH
OE
Ix
TB
OE
Ix
Examination
Clubbing;
Conditioning; BMI;
Quality of cough; examine sputum; chest wall
Development; fecal loading
Bloods
FBC (AOCD or malabsorption; WCC); U+E; LFT; ADEK def
Other
Sputum culture; PFT’s; sweat test
Imaging
CXR (compare with prev films; incr lung markings; cystic changes; mucus
plugs; atelectasis; pneumoT); CT
Collagen vascular disease, shunts, portal HTN, HIV, splenectomy, myeloproliferative
disorders, L heart disease, COPD, ILD, thromboembolic obstruction, scleroderma,
congenital heart disease
DVT; RV heave; palpable P2; TR
Bloods
ABG
Other
PFT’s
Imaging
CXR (RV dilation, large prox pul arts); ECG (R heart strain, hypertrophy), CT
angiogram, VQ scan, echo; R heart catheterisation
Symptoms
PMH
SH
Mng
Generic details
Age of diagnosis; presenting Sx (eg. recurrent LRTI, FTT); cough, sputum,
haemoptysis, wheeze, SOB, nasal polyps, sinusitis, weight loss, diarrhoea,
steatorrhoea, constipation, bowel obstruction, abdo distension; occasionally biliary
cirrhosis --> portal HTN --> jaundice, varices; DM; rectal prolapse
No. prev hospital admits
Support network; understanding of inheritance
Physio, antibiotics, bronchoD, pancreatic enzyme
Weight loss, sweats, fever, cough, chest pain; Time of diagnosis
Malnutrition, alcoholism, HIV, DM
Recent immigration; Social effects of disease; continue work? do friends know
diagnosis? does occupation present public health risk? screening of friends/family?
family members treated?
Meds, how long for, supervised / unsupervised, SE’s (hepatitis, ototoxicity, optic neuritis,
peri neuropathy, diarrhoea)
Conditioning; LN’s; 1Y: pleural effusion, empyema, lobar collapse; 2Y: upper lobe
crackles, wheeze; Pericarditis, tamponade; Loin tenderness, abdo nass
Bloods
rpo gene if resistant; PCR for rapid; tuberculin testing; fasting BSL (for DM)
Other
Sputum (3 samples on separate days), Ziehl-Neelsen; LN biopsy; bronchial
washings; sensitivities; Mantoux (5mm high risk, 15mm low risk)
Imaging
CXR (infiltrates, cavities (2Y); focal shadowing and enlarged LN’s = 1Y Ghon
complex; may be normal if HIV)
Immunisation status (influenza, hep A, hep B, Pneumococcus)
Undress to waist and sit up in bed – watch for SOB
Ask to see sputum and temp chart
General
Sputum; SOB at rest; RR; WOB; cachexia; ask to cough (loose, dry, bovine (RLN inj)); PEFR; FET
(abnormal if >3secs); audible wheeze; breathing pattern
Put hands out in front to look for flap
Hands
Clubbing = RS Lung Ca, bronchiectasis, CF
Lung abscess, empyema, pul fibrosis, asbestosis,
mesothelioma
CV IE, cyanotic heart disease
GI IBD, cirrhosis, coeliac
thyrotoxicosis, familial, pregnancy, 2Y hyperPT
Peri cyanosis; nicotine staining; anaemia; small muscle wasting (weak finger abduction = lower brahcial plexus
inj from lung Ca); wrist tenderness (hypertrophic pulmonary osteoarthropathy); pulse (pulsus paradoxicus);
flapping tremor
Face
Ptosis and constricted pupils (Horner’s); central cyanosis; press maxillary sinus and percuss frontal sinus;
say a few words if voice sounds hoarse
Neck
Position of trachea (deviation suggests upper lobe abnormality); tracheal tug; LN’s
Sit up with legs over side of bed to examine back
Back
Inspection
Palpation
Percussion
Auscultate
CCF
Sit back in bed
Kyphoscoliosis; ank spond (assoc with fibrosis); scars; prominent veins; radiotherapy skin
Changes; needle marks from prev aspirations
Expansion (upper = look at clavicles from behind to ensure moving; and lower – aim 5cm
separation)
Inc supraclavicular
BS (bronchial / vesicular; normal / decr; crackles, wheeze; early/mid/late/pan; insp/exp)
Vocal resonance (say 99)
Medium late/pan insp creps
Chest
Inspection
Palpate
Percussion
Auscultate
Chest deformity; symmetry of movement; distended veins; radiotherapy and radiotherapy
marks; scars
Supraclavicular, axillary LN; apex beat; chest expansion; palpate breasts
Clavicles directly, then lower
In high axillae also
JVP
Pul HTN
Abdomen
Inspection
Palpate
Signs of liver failure
Legs
Peri oedema
Lie to 45 deg
Incr JVP; large V wave on JVP
Lie flat
Investigations
Pleural fluid analysis
CXR, plus ask to see lateral
End
Is there anything else I should know?
Presentation
Draft intro statement
Differential diagnosis
Findings that support / refute diagnosis
Pul fibrosis
Upper lobe
Toxin
Infection
Infiltrative
Rheum
Silicosis, coal worker’s pneumoconiosis, radiation
TB; CF; aspergillosis; PCP
Sarcoidosis, histiocytosis, aspergillosis; eosinophilic
Ank spond
Lower lobe
Toxin
Infective
Asbestosis, hydralazine, amiodarone, bleomycin
Bronchiectasis, aspiration
Infiltrative
Rheum
Large hilum
LN
Vessel
Cryptogenic fibrosis alveolitis
RA, scleroderma
Lymphadenopathy; Ca
Pul venous HTN (upper half hilum; LVF, MS, MR)
Pul artery HTN (1Y pul HTN, lung disease)
Incr pul blood flow (LR shunt, hyperdynamic circulation)
Focal consolidation
Infective
Vascular
Ca
Pneumonia; Atelectasis
Pul infarction; intrapul haemorrhage
Alveolar cell carcinoma
Diffuse airspace disease
Infective
Vascular
Ca
Autoimmune
Pneumonia (mycoplasma, pneumocystis); interstitial pneumonitis
Pul oedema; contusion; PE
Alveolar cell Ca; lymphoma
Goodpasture’s; alveolar proteinosis
Fine reticular = ILD
Vascular
Infective
Ca
Autoimmune
Coarse reticular
Reticulonodular
Miliary nodular (2-3mm)
Nodular (>3cm)
Pul oedema
Interstitial pneumonitis (mycoplasma, viral); atypical pneumonia
Lymphangitis metasasis
Sarcoidosis; histicytosis; SLE; RA; scleroderma; polymyositis; hypersensitivity
pneumonitis; eosinophilic granuloma; collagen vascular disease; fibrosing
alveolitis
Toxin
Inhalation injury; asbestosis, silicosis, farmer’s lung, coal, methotrexate,
amiodarone
End-stage pul fibrosis
As per reticular
TB, fungal, nocardia, varciella, silicosis, coal worker’s pneumoconiosis, sarcoidosis, eosinophilic
granuloma, neoplastic
Mets; lymphoma; benign tumours; fungal; parasitic; septic emboli; RA; Wegener’s
Granulomatosis
Cavitating lesions
Infective
Vascular
Ca
Autoimmune
Other
Staph aureus, klebsiella, anaerobes, aspiration, G-ives, TB, fungal (aspergillosis,
cryptococcal)
Septic emboli; pul infarct
SCC, Hodgkin’s
Granulomatosis; sarcoid; Wegener’s; RA
Management
Suggest management and set management goals
Bronchiectasis
Abx; bronchoD; inhaled steroids; postural drainage; pred; vaccines; trt of CCF; Ig if Ig def; embolisation
if massive haemoptysis; smoking cessation; OT if localised disease; transplant if end stage
Lung Ca
OT (if non-small cell); radiotherapy; maybe chemo
COPD
Nicotine replacement; Abx; bronchoD; inhaled steroids; vaccine; steroids; pul rehab; home O2; trt CCF; BiPAP
ILD
Remove exposure; steroids; maybe immunosuppression (cyclophosphamide, colchicine); vaccines; home O2;
lung transplant
Sarcoidosis
Prednisone; if longer term, Methotrexate, Azathioprine; infliximab
CF
Physio; Abx; bronchoD; pancreatic enzymes; lung transplant
TB
Isoniazid, Rifampicin, ethambutol, pyrazinamide; IREP initially until sensitivies available --> IRP for 2/12 --> IR
4/12; may need to be supervised; repeat sputum cultures until become negative; resistant if +ive after 3/12
GI
History
HPC PUD
Symptoms
Pain, relief, recurrences, GI bleed; Weight loss, recurrent vomiting
PMH
DH
FH
OE
DD
Malabsorption Symptoms
PMH
DH
FH
OE
DD
IBD
Dyspepsia; DM; thyroid; hyperPT; CT disease; prev ulcer OT
Digoxin, KCl, PO Abx, NSAIDs, ETOH; PPI; H pylori trt; steroids; anticoagulants
Of same (?MEN I)
Anaemia; Epigastric tenderness; scar; melaena; abdo mass (?Ca)
GORD, gastric Ca, biliary pain, pancreatitis, pancreatic Ca, chronic mesenteric
ischaemia; varices; Mallory-Weiss tear; erosions; angiodysplasia
Pale, bulky offensive stools; weight loss; weakness (K def); anaemia (Fe def); bone pain
(osteomalacia); glossitis and angular stomatitis (Vit B def); bruising (Vit K def);
oedema (protein def); peri neuropathy (vit B def); eczema, dermatitis herpetiformis;
amenorrohoea (protein def)); time of onset and duration
Cause: gastrectomy, prev bowel OT, liver / pancreatic disease, Crohn’s disease, prev
radiotherapy, DM, HIV
ETOH, neomycin
Coeliac disease, IBD
Weight, conditioning; Clubbing; Bruising, dermatitis herpetiformis, erythema
nodosum, pyoderma gangrenosum, stomatitis, pigmentation, perianal lesions,
anaemia; Scars, chronic liver disease signs
Coeliac disease, tropical sprue, giardiasis, lymphoma, Whipple’s disease, IBD, chronic
pancreatitis, CF, biliary obstruction, chronic liver disease, bacterial overgrowth, SI
ischaemia, SI resection, HIV
Symptoms
Reason for admission, number of hospital admissions; Current symptoms
UC – bloody diarrhoea, malaise, fever, weight loss
CD – pain, diarrhoea, weight loss, malabsorption, intestinal obstruction
Complications Toxic megacolon, perf, haemorrhage, strictures, fistula, anorectal disease, abscess,
obstruction, perf, gallstones, Ca, liver disease (fatty liver, 1Y sclerosing cholangitis,
cirrhosis, cholangiocarcinoma, amyloidosis); anaemia; Fe def; thromboembolism;
arthropathy; ank spond; erythema nodosum; pyoderma gangrenosum; apthous ulcers;
uveitis / conjunctivitis / episcleritis, renal stones, osteomalacia
DH
NSAIDs, retinoic acid, OCP
SH
Sexual preference (proctitis is DD); smoking (protective in UC); domestic arrangements
and employment
FH
Of same, bowel Ca
OE
DD
Nutrition, hydration; signs of Cushing syndrome; Clubbing; Lesions, anaemia;
Uveitis; Tenderness; abdo masses; anal lesions; signs of liver disease
Pseudomembranous colitis, radiation, ischaemic colitis, diversion colitis, toxic exposure,
lymphocytic colitis
Colon Ca
Symptoms
Change in bowel habit, PR bleeding, anaemia, AP, constipation, vomiting; bladder Sx
from invasion; neuro pain from sacral plexus
Complications Proctitis, cystitis
PMH
Polyps; IBD; Peutz-Jehger’s syndrome; DM; acromegaly
SH
Determine if understands diagnosis; social support network
FH
FAP (if present ask if children have been screened); ovarian / endometrial Ca
OE
Changes of radiotherapy, pigmentation of Peutz-Jehger’s; Abdo masses, scars, PR
CLD
Symptoms
Jaundice, ascites, AP, bleeding, encephalopathy, weakness
Complications Encephalopathy, portal HTN, ascites, varices, erectile dysfunction
PMH
Hepatitis, jaundice, prev transfusions, DM, CCF, haemachromatosis; hepatitis status;
Wilson’s disease; For NASH – obesity, type II DM, incr lipids
DH
Methyldopa, isoniazid, nitrofurantoin
SH
ETOH intake, drug addiction, sexual orientation, tattoos, overseas travel
OE
Racial origin; Clubbing; Tattoos; scratch marks; xanthelasma; collaterals; hair loss;
spider naevi; Kayser Fleishcer rings (Wilson); bilat VI nerve palsy (Wernickes); CCF;
TR; constrictive pericarditis; Signs of chronic liver disease / portal HTN; splenomegaly;
ascites; oedema; melaena; liver bruit; abdo mass
ETOH; Hep B/C; NASH; drugs (methyldopa, chlorprom, isoniazid, nitrofurantoin,
Methotrexate, amiodarone), autoimmune; haemachromatotis; Wilson’s disease; 1Y
sclerosing cholangitis; 1Y/2Y biliary cirrhosis; alpha-1 AT def; CF; Budd-Chiari
syndrome; CCF; constrictive pericarditis; idiopathic
DD
Generic details
Immunisation status (influenza, hep A, hep B, Pneumococcus)
Investigations
PUD
IBD
Colon Ca
CLD
Endoscopy, barium meal, H pylori (serology / biopsy)
Follow up colonscopies
Staging results; surveillance colonoscopy
Liver biopsy
Management
PUD
Malabsorption
IBD
Colon Ca
CLD
Blood transfusion, injection in peptic ulcer base, surgical oversewing
Diet, pancreatic supplements, Vit supplements, cholestyramine, Abx
Sulfasalazine, mesalazine, olsalazine, steroids, metronidazole, Azathioprine, infliximab
Radiotherapy
Protein restriction, fluid restriction, ETOH abstinence, steroids, Lactulose, neomycin,
TIPS procedure
Examination
What did examiners examine? Did they comment on signs?
General
Jaundice, pigmentation (haemochromatosis), xanthomata (1Y biliary cirrhosis), mental state (encephalopathy);
wasting, cachexia; drowsiness; temperature
Hands
Clubbing (IBD, cirrhosis, coeliac), leuconychia, palmar erythema, Dupuytren’s contractures,
Arthropathy (haemachromatosis), hepatic flap (30secs)
Arms
Spider naevi, bruising, wasting, scratch marks (chronic cholestasis); ask for BP
Face
Sclera, jaundice (colon Ca, CLD), anaemia (PUD, colon Ca), iritis; parotids (ETOH); fetor hepaticus; stomatitis,
leukoplakia, ulceration, gingivitis, bleeding, atrophic glossitis; pigmentation
Sit up
Neck
From behind; LN’s (colon Ca, malabsorption)
Swing legs over side of bed
Axilla
Axillary LN’s
Sit back down on bed
Chest
Inspection
Palpate
Auscultate
Gynaecomastia, spider naevi
Breasts if think intra-abdo Ca
For pleural effusions / creps; HS for TR if pulsatile liver felt
Lie flat with 1 pillow, exposure abdo
Abdomen
Inspection
Palpation
Percussion
Auscultate
From foot of bed, from side; masses, scars, distension, prominent veins, striae, bruising,
Pigmentation; visible peristalsis; spider naevi
Take deep breaths and observe from side to look for moving liver
Ask if tender; light then deep palpation; liver, spleen; roll on R and palpate spleen again if not
Palpable; kidneys
Percuss liver / spleen size; estimate span with tape measure
Spleen: no palpable upper border; has notch; move inferomedially with respiration; no
resonance over splenic mass; not bimanually palpable; friction rub commonly he
If spleen not palpable lying flat, roll to R and try again
RIF mass: appendix abscess, caecal Ca, CD, pelvic kidney, ovarian Ca/cyst, carcinoid,
psoas abscess, ileocecal TB
LIF mass: faeces, colon Ca, diverticular disease, ovarian Ca/cyst, psoas abscess
Upper abdo mass: lymphadenopathy, AAA, stomach Ca, pancreatic Ca/cyst, PS, colon
Ca
Percuss for ascites; roll towards you if not resonant to flanks, to check for shifting dullness
Liver, spleen and renal areas
Bruits (hepatocellular Ca, alcoholic hepatitis)
Rubs (Ca, recent liver biopsy, infarct, gonococcal perihepatitis)
Venous hum (portal HTN)
Bowel sounds
Groin
Genitalia, LN’s, hernial orifices (standing and coughing – say that you would do this)
Ask if you can palpate testes
PR
Say you would do; inspect (fistulae, tags), palpable (masses, blood)
Legs
Bruising, oedema
Neuro: peri neuropathy; prox myopathy; cerebellar syndrome
Sit up 45 deg
JVP
Investigations
Urine
PUD
Bloods
Other
Imaging
Malabsorption Bloods
Other
Imaging
IBD
Bloods
Other
If atypical, fasting serum gastrin, gastric juice pH, secretin test; incr Ca ?MEN I
Endoscopy (?active bleeding or clean ulcer base); biopsy result
USS (biliary tract); CT (pancreas, ZES)
Fe, long PT, low Ca, low chol, low carotene, +ive Sudan stain of stool for fat; faecal fat
estimation; glucose / Lactulose breath hydrogen test for bacterial overgrowth; Schilling test for
ileal disease; FBC (?anaemia); Fe, Ferritin, folate, Vit B12, alb, Vit D level, Ca, Phos, ALP,
INR
Gastroscopy, SI biopsy (subtotal villous atrophy); histology; parasites
AXR (Crohn’s disease, diverticula, blind loops)
FBC (anaemia, WBC); ESR, CRP; LFT; U+E; alb; p-ANCA, ASCA (in CD)
Stool spec (amoebiasis, Shigella, Salmonella, Yersinia, Campylobacter, E coli, C diff,
lymphogranuloma venereum, gonorrhoea, syphilis; if immunocomp – herpes, CMV,
cryptosporidium); TB; sigmoidoscopy and biopsy; Ba enema (loss of haustrations, muscosal
Imaging
irregularity and ulcers, spasm, pseudopolyps, bowel shortening, extent of involvement,
strictures, Ca, thickening, cobblestoning, skip lesions, fistulas); colonoscopy (granulomas,
mucus) and biopsy
AXR (bowel wall thickening, gaseous distension, toxic megacolon)
Colon Ca
Bloods
Other
Imaging
Genetic screening (if +ive FH); LFT; CEA
Colonoscopy, Ba enema, FOB testing
Staging; CXR for mets
CLD
Bloods
LFT; alb; INR; FBC (anaemia, film, macrocytes, decr plt, decr WBC); Fe; folate; U+E (decr Na);
hepatitis serology; AMA (1Y biliary cirrhosis); ANA, ASMA (autoimmune hepatitis); p-ANCA
(UC + 1Y sclerosing cholangitis); AFP (liver Ca)
Ascitic tap (cell count, lactate, amylase, cytology, culture); liver biopsy; endoscopy for varices
USS; CT abdo; Doppler flow studies for varices
Other
Imaging
End
Is there anything else I should know?
Presentation
Draft intro statement
IBD
CLD
Grade severity (mild <4 stools/day; mod 4-6, severe 6-10, fulminant >10)
Grade severity (Child’s classification)
Differential diagnosis
Findings that support / refute diagnosis
Ascites
Liver
Cardiac
Endocrine
Ca
Infective
Renal
Cirrhosis, alcoholic hepatitis, fulminant hepatic failure, Budd-Chiari syndrome
CCF, veno-occlusive disease
Myxoedema
Peritoneal Ca
TB, pancreatitis
Nephrotic syndrome
Abdo distension
Fat, fetus, flatus, fluid, faeces, filthy great tumour, flipping enormous organs
Scrotal mass
Other
Ca
Infective
Hydrocoele, epididymal cyst, spermatocoele, cyst of hydatid of Morgagni, varicocele,
indirect inguinal hernia
Testicular Ca
Epididymitis
Hepatomegaly Infective Hepatitis, hydatid disease, HIV, CMV, IMN
Cancer
Mets (S), CML, lymphoma, HCC (S), myeloproliferative (S)
Toxins
ETOH (S)
Auto-immune
Granulomatous, amyloid, sarcoid, SLE
Other
Biliary obstruction, fatty liver, CCF (S), CLD with portal HTN
Firm irregular liver: cirrhosis, mets, hydatid, granuloma, amyloid, cysts, HCC
Tender liver: hepatitis, RHF, Budd-Chiari, hepatocellular Ca
Pulsatile liver: TR, hepatocellular Ca, vascular abnormalities
Splenomegaly Infective IMN, hepatitis, IE, malaria (S), CMV
Cancer
Myeloproliferative (S), lymphoma S), leukaemia, CML (S)
Autoimmune
RA, SLE, PAN, amyloid, sarcoid
Other
Haemolysis, megaloblastic anaemia, portal HTN,
storage diseases
Hepatosplenomegaly:
Infective: hepatitis, CMV, IMN, EBV
Cancer: myeloproliferative, lymphoma, leukaemia
Autoimmune: SLE, amyloid, sarcoid
Other: CLD with portal HTN; pernicious anaemia; SCA;
acromegaly; thyrotoxicosis
Ballot kidneys
Big kidneys:
Infective Pyonephrosis
Cancer
RCC, lymphoma, Wilm’s tumour, neuroblastoma
Autoimmune
Amyloid
Trauma
Perirenal haematoma
Other
PCKD, hydronephrosis, renal vein thrombosis, acromegaly
Management
Suggest management and set management goals
PUD
H pylori: PPI + amox + Clarithromycin; repeat gastroscopy if Sx not resolved; repeat biopsy / Ur breath test to
confirm cure; PPI better than H2A at healing; stop drug causing; misoprostol if NSAID
IBD
Correct electrolytes; avoid opiates; broad spectrum Abx if severe colitis; IV steroids if mod-severe; cyclosporin if
not responding to steroids; drugs as above; topical steroids to anus; colectomy
Colon Ca
OT; colonscopy and ?CEA surveillance; radiation if rectal; chemo
CLD
Fulminant liver failure: Remove blood from gut (eg. enema); low protein diet; treat infection; correct electrolyte
disturbance; avoid sedatives; Lactulose; Abx (neomycin, metronidazole); steroids if autoimmune; correct
clotting
Portal HTN: variceal band ligation; correct clotting; IV octreotide / terlipressin; sclerotherapy; SengstakenBlakemore; propanolol to reduce portal pressures; TIPS shunt; diuresis (spironolactone) to treat ascites; salt
restriction; therapeutic paracentesis with IV albumin replacement; liver transplant
Hepatitis: antivirals, interferon
HAEM
History
HPC Haemolytic anaemia
Presenting symptoms (fatigue, SOB, jaundice)
Of CT disease (joint pain, swelling – sickle cell; leg ulcers – spherocytosis and sickle cell)
Abdo / back pain (sickle cell); gallstones; spinal cord lesions; CVA (sickle)
Fever, neuro abnormalities – TTP
Thrombophilia
Reason for admission; arterial / venous thrombosis; whether diagnosis of thrombotic tendancy
made; dark urine at night
Is there an action plan?
PMH Haemolytic anaemia
Protein C, protein S, AT def, APC resistance, APL ab’s, PT gene mutation, factor V Leiden;
smoking, OCP, pregnancy, malignancy, recent OT / immobility; unexplained miscarriages
(APL syndrome); eclampsia; prev MI (factor V); chronic leg oedema; homocystinuria
Thrombophilia
Generic details
DH
Of same; SLE; lymphoma; mechanical heart valves; external trauma; disseminated malignancy,
TTP, HUS, gastro, transplant; Ca; recent glandular fever; hepatitis; mycoplasma infection
Immunisation status (influenza, hep A, hep B, Pneumococcus)
Haemolytic anaemia
Thrombophilia
Methyldopa, penicillin, quinidine, antimalarials, sulfonamides, nitrofurantoin
Anticoagulation; understanding of Warfarin; INR levels; doses; target INR; frequency of blood
tests; prophylaxis for OT
A
SH
FH
Occupation, adequacy of income, current housing, ability to cope, mobility + steps
Hobbies (animals, chemicals, dusts), marital status, sexual problems
Place of birth, overseas travel
Haemolytic anaemia
Thrombophilia
Ethnicity (G6PD – black; thalassaemia – Greek, Italian)
Transport to blood tests; how gets INR results and dose changes
Haemolytic anaemia
Thrombophilia
Of same; sickle cell
Of thrombosis; family members tested
Investigation results
Management
Examination
What did examiners examine? Did they comment on signs?
Lie supine, head on 1 pillow
Ask to see temperature chart
General
Bruising, pigmentation (lymphoma), cyanosis (polycythaemia), jaundice, scratch marks (myeloproliferative,
lymphoma), leg ulcers; frontal bossing; racial origin (thalassaemia = Asian, Greek; SCA = Black)
Haemolytic
Pallor, jaundice, LN (lymphoma, CLL), pigmentation
Thrombophilia Heparin infusion and rate; BMI
Hands
Koilonychia = spoon nails (Fe def); vasculitis; anaemia (palmar creases); RA; Felty’s syndrome; recurrent
haemarthroses; gout (myeloprolif)
Arm
Epitrochlear node (non-Hodgkin’s lymphoma, CLL, IVDU, sarcoid); bruising; petechiae; palpable purpura
(vasculitis); axillary LN’s
Skin
Thrombophilia
Signs of venous insufficiency; oedema; ulceration; peri pulses
Face
Jaundice; pallor; scleral injection (polycythaemia); gum hypertrophy (leukaemia), ulcers, haemorrhage; atrophic
Glossitis (Fe / B12 / folate def); angular stomatitis (Fe def); large tonsils (lymphoma); candida
Fundi
Haemolytic
Retinal detachment / infarcts / vitreal haem in SCD; KF ring
Sit up
Neck
LN’s (submental, submandibular, jugular chain, post triangle, postauricular, preauricular, occipital)
Supraclavicular LN’s from front
Generalised lymphadenopathy: Infection: CMV, HIV, IMN, TB, toxoplasmosis,
Cancer: lymphoma, CLL, ALL, mets,
Autoimmune: RA, SLE, sarcoid
Other: phenytoin
,
Bones
Sternum; clavicle; shoulders; spine tenderness
Chest
Haemolytic
Prosthetic valve, severe AS, CCF
Lie down again
Abdomen
Splenomegaly, hepatomegaly, signs of CLD
Ask to do a rectal exam
Thrombophilia
Abdo wall bruising; abdo mass
Groin
Inguinal LN; pelvic tenderness
Ask to examine testes
Legs
Vasculitis (HSP); bruising; pigmentation; ulceration (spherocytosis, thalassaemia, SCA); NS (SACD, peri
neuropathy from B12 def)
Haemolysis
Joints / bone pain (SCD); leg ulceration
Investigations
Urine (haematuria, bile)
Haemolytic anaemia Bloods
Other
Imaging
Thrombophilia
Bloods
Malaria; blood film (normochromic Normocytic usually; hypochromic microcytic in
thalassaemia); FBC; incr retic count; unconj bil; LDH; haptoglobin negative;
Schumm’s test (methaemalbumin); schisotcytes = valve / DIC / TTP / HUS; decr plt =
TTP / HUS; Coomb’s test (+ive if autoimmune); warm and cold agglutinins
Urobilinogen; Hb (?mostly at night = PNH); sediment; haemosiderin
FBC, ESR, Factor V Leiden, APL ab (incr lupus anticoagulant, anticardiolipin ab), AT III,
protein C+S, PT gene mutation, plasma homocysteine
End
Is there anything else I should know?
Presentation
Draft intro statement
Differential diagnosis
Findings that support / refute diagnosis
Haemolytic anaemia Warm / cold ab (lymphoma, CT disease, post-infection, drugs); microangiopathic (DIC, TTP, vasculitis),
heart valve, march Hburia, infection, malaria, cirrhosis, PNH, SCD, thalassaemia (target cells, tear drops, HbFm HbA),
spherocytosis, elliptocytosis, G6PD def
Management
Suggest management and set management goals
Haemolytic anaemia Steroids / azathioprine / splenectomy if immune; transfusion; hydration; repair valve; plasmapheresis +
steroids for TTP; splenectomy for ellip/sphero
Thrombophilia
LMWH; at least 6/12 warfarin; long term therapy of APC resistance; prophylaxis for OT or immobilisation
or pregnancy; compressive stocking / foot pumps; no smoking / OCP
RHEUM
History
HPC RA
SLE
Onset; presenting symptoms (fatigue, anorexia, pain, morning stiffness >1hr); joints involved; major
current problem (function, pain, NS); current activity of disease; no. of jts involved; severity; functional
ability; systemic involvement
Skin (Raynauds, leg ulcers); eyes (Sjogren’s syndrome, scleritis, cataracts); neck pain; RS (fibrosis,
pleural effusion, pleuritis); CV (pericarditis, valve disease); NS (peri neuropathy; mononeuritis
multiplex; SC compression; entrapment neuropathy); anaemia, Fe def, folate def; fever; weight loss;
vasculitis (ulcers)
Malaise, weight loss, N+V, thrombosis, arthralgia, myalgia, rash, alopecia, ulcers, fever,
neuropsychiatric, seizures, chorea, optic neuritis, CVA, headache, haematuria, oedema, renal failures,
pleurisy, pericarditis, myocarditis, valve lesions, anaemia, diarrhoea, obstruction, thrombophlebitis,
recurrent abortions
PMH RA
PUD; drug reactions; renal disease
Generic details
Immunisation status (influenza, hep A, hep B, Pneumococcus)
DH
Aspirin / NSAIDS (gastric erosions, renal impairment); Methotrexate (hepatic and pul toxicity, decr WBC
+ plt); penicillamine (nephrotic syndrome, decr plt, rashes, mouth ulcers, SLE, polymyositis, MG,
Goodpastures); cyclosporin (BP); hydroxychloroquine, sulfasalazine (rash, haem, LFT), antiTNF ab;
steroids
Procainamide, hydralazine, isoniazid, methyldopa, penicillamine, chlorprom, anticonvulsants
RA
SLE
A
SH
Occupation, adequacy of income, current housing, ability to cope, mobility + steps
Hobbies (animals, chemicals, dusts), marital status, sexual problems
Place of birth, overseas travel
RA
SLE
FH
RA
Investigations
Coping; mobility; ADL; fine motor skills; work; support services
Understanding of implications of disease
Of same
Management
RA
Initial trt; other trt; complications of trt
Examination
What did examiners examine? Did they comment on signs?
General
Cushingoid; weight; iritis; scleritis; obvious other joint disease; gait if walked into room
RA
Cushings; BMI
SLE
Cushings, weight loss; mental state, BP, temp
Discoid erythematous raised rash, photosensitivity, malar rash; scaling; hair loss
Patient sitting over edge of bed; Place patient’s hand on pillow, palms down
Hands
Inspect
Palpate
Power
Function
Sensation
RA
OA
Psoriatic
SLE
Arms
BP
Inspect
RA
SLE
Scars, redness, atrophy, rash, swelling, deformity, muscle wasting, deviation, subluxation, swan
necking, boutonniere, Z, sausage shaped; nails for pitting, ridging, onycholysis,
hyperkeraotisis, discolouration; palmar erythema; anaemia; skin atrophy; bruising (?steroid
use); signs of vasculitis
Dorsal and palmar
Do you have any pain anywhere? Inc ulnar styloid tenderness
Synovitis, effusion; passive ROM; crepitus inc of palmar tendons (open and close hand);
rheumatoid nodules on forearms
Grip strength  straighten fingers  each individual finger (FDP - distal, FDS - prox) if
Abnormal
Thumb power – abduction, aduction, flexion, opposition
Grip strength; key grip turning, opposition strength (a-OK), practical ability (undo button)
If function mentionned, test this
Symmetrical wrist, MCP and PIPJ swelling; undo a button
Sweling of PIPJ and DIPJ (Bouchard’s and Heberden’s nodes)
Sausage shaped fingers and telescoping of fingers; predominant IPJ disease
Nail fold infarcts, vasculitis, arthropathy
Wrists, elbows, shoulder – synovitis, effusions, ROM, crepitus, subluxation, palmar tendon
crepitus, carpal tunnel tests (Phalen – flexion for 30secs; Tinel = tap over carpal tunnel while
wrist held in extension), subcut nodules at elbows, psoriatic rash
Entrapment neuropathy; subC nodules; axillary nodes
Livedo reticularis, purpura, prox myopathy
READ SHOULDERS
Face
Iritis, scleritis
RA
SLE
Ank spond
Eyes (as above); fundi; parotids; mouth (dry, ulcers, caries, TMJ)
Malar rash; Alopecia, eyes (as above), mouth ulcers, rash, CN lesions, LN
Uveitis
Neck
RA
Spine, LN
Chest
RA
SLE
Ank spond
Pericarditis, murmurs, effusion, fibrosis, infarct, nodules, TB
Endocarditis, pleural effusion, pleurisy, ful fibrosis, collapse
Decr chest expansion; AR, MVP
Abdomen
Palpate
RA
SLE
Ank spond
Spring pelvis
Splenomegaly, epiG tenderness, inguinal LN
Hepatosplenomegaly, tenderness
Evidence of IBD; hepatosplenomegaly
Knees
Expose and lie on back
Inspect
Quads wasting; scars; rashes; swelling; deformity; walk; squat and look at space under knees
Function
Active ROM
Palpate
Quadriceps for wasting; tenderness; warmth; patella tap for effusion; for small, stroke up lateral
Knee then medial knee to look for bulge; passive ROM; crepitus; ligaments (>5-10deg
abnormal for all ligaments)
Lie on front
Palpate for Baker’s cysts
Apley’s grinding test: flex knee to 90deg, push down on knee into bed, ex and int rotate; grinding
/ pain / clicking = meniscal inj
Function
Stand up; walk around; sit down on chair; look for varus / valgus deformity
Feet
Inspect
Palpate
RA
SLE
Back
Inspect
Palpate
Movement
Scars, ulcers, rashes, swelling, deformity, muscle wasting; nail changes; transverse and
longitudinal arches; callus; possibly neuro examination; hallux valgus, sausage toes, claw
Synovitis; effusion; passive ROM (talar, subtalar (everson-inversion), midtarsal (rotating /
twisting); Achille’s tendon nodules; tenderness of plantar fasciitis; tenderness
Ulcers, peri neuropathy, mono multi, cord compression
Feet, prox myopathy, cerebellar ataxia, neuropathy, hemiplegia, mono multi
Deformity from back and side; loss of kyphosis / lumbar lordosis
Tenderness and muscle spasm
Finger-floor distance; extension; lateral flexion; rotation; Schober’s test (place mark at level of
post iliac spine, 10cm above and 5cm below; on bending, top and bottom marks should be
>20cm apart)
Investigations
Ask for 1-2 recent investigations and reason for ordering
Comment on results, even normal
RA
Bloods
Other
Imaging
RF; anti-CCP; ESR; CRP; FBC (AOCD); U+E (if on NSAID)
Urine protein, blood
XR (ST swelling, jt space narrowing, juxta-articular OP, jt erosions)
SLE
Bloods
Other
Imaging
ANA; anti-dsDNA; FBC (AOCD; maybe immune haemolytic; decr WBC + plt); ESR; CRP;
LP if suspect neuro
MRI
End
Is there anything else I should know?
Presentation
Draft intro statement
Differential diagnosis
Findings that support / refute diagnosis
Deforming polyarthropathy
RA
RA, seronegative arthritis (eg. Psoriasis), gout, pseudogout, OA
Psoriatic arthropathy, seronegative arthritides, chronic tophaceous gout, OA, SLE, rheumatic fever, amyloid
arthropathy
Management
Suggest management and set management goals
RA
Education; physio; exercise; OT; aspirin, NSAID, COX-2 inhibitors; DMARDs (Methotrexate); gold; penicillamine;
local steroid injection; OT if severe
RENAL
History
Hello, this is exam
What is wrong? Why are you in hospital this time?
HPC CRF
Presenting symptoms (nocturia, lethargy, loss of appetite)
GN – proteinuria, haematuria, oliguria, oedema, sore throat, sepsis, rash, haemoptysis
Long term prognosis
Dialysis; if not, has it been discussed; transplant list?; complications – shunt blockage, thrombosis, infection,
access problems, pericarditis, peritonitis
Complications: anaemia, bone disease, gout, pericarditis, HTN, CCF, peri neuropathy, pruritis, PUD, cognition
PMH CRF
PCKD, GN, childhood UTI, DM, HTN, SLE, scleroderma
Generic details
DH
CRF
Immunisation status (influenza, hep A, hep B, Pneumococcus)
NSAIDs and other analgesics, contrast, infection, ACEi
?doses altered for renal failure
A
SH
Occupation, adequacy of income, current housing, ability to cope, mobility + steps
Hobbies (animals, chemicals, dusts), marital status, sexual problems
Place of birth, overseas travel
CRF ADL, employment, coping, travel, sexual function, financial situation; travel to dialysis
FH
Investigation
CRF
Renal biopsy; transplant work up
Management
CRF
Meds, diet, salt, water, EPO, protein; dialysis – where, how often, hrs/wk, complications, shunts,
OT; transplant
Examination
What did examiners examine? Did they comment on signs?
CRF
General
Hands
Arms
Face
Chest
Abdo
Legs
Back
Mental state, sallow complexion, hydration, fever, Cushingoid
Nails (brown lines), shunt, asterixis, neuropathy
Bruising, pigmentation, scratch marks, myopathy, BP
Anaemia, jaundice, band keratopathy, dry mouth, fetor, rash, saddle nose (WG), fundoscopy
Pericarditis, CCF, lungs, venous hum
Scars, renal mass, Tenchkoff, bladder, liver, LN, ascites, bruits, rectal
Oedema, bruising, pigmentation, scratch marks, gout, neuropathy
Tender, oedema
Investigations
Ask for 1-2 recent investigations and reason for ordering
Comment on results, even normal
CRF
Blood
Other
Imaging
GFR, Cr, electrolytes, phos, uric acid, Ca, alb; FBC (Burr cells, anaemia); Fe, Ferritin; PTH
?hep B/C, HIV, ANA
Urine: specific gravity, pH, glucose, blood, protein, casts; renal biopsy; urine cytology
USS; KUB; IVP; CT; cystoscopy; retrograde pyelography; renal angiogram
End
Is there anything else I should know?
Presentation
Draft intro statement
Differential diagnosis
Findings that support / refute diagnosis
Management
Suggest management and set management goals
CRF
Folate supplements; EPO; Fe supplements; antihypertensives (ACEi); trt infection; correct fluid imbalance; alter
drugs if needed; trt incr Ca; trt lipids; salt and water intake; decr dietary protein; consider dialysis and
transplant
NS
History
Hello, this is exam
What is wrong? Why are you in hospital this time?
HPC MG
Presenting symptoms (diplopia, ptosis, choking, dysarthria, chewing/swallowing probs, prox muscle weakness,
fatigue OE
GBS
Presenting symptoms (ascending motor weakness, paraesthesia, anaesthesia, bulbar palsy, postural
hypotension, arrhythmias, sphincter dysfunction)
Recent resp / GI infection; recent OT, cavvincation, Ca, SLE, HIV
TIA
Neck pain ?aortic dissection; CV RF (see above)
PMH MG
GBS
Prev difficult anaesthesia (prolonged weakness); prev pneumonia; thymectomy; SLE; RA
Of same
Generic details
DH
MG
TIA
Immunisation status (influenza, hep A, hep B, Pneumococcus)
Drugs that may interfere with neuro (streptomycin, gent, quinidine, procainamide)
OCP, sedatives, hypoG drugs, anticonvulsants, antiarrhythmics
A
SH
Occupation, adequacy of income, current housing, ability to cope, mobility + steps
Hobbies (animals, chemicals, dusts), marital status, sexual problems
Place of birth, overseas travel
FH
Investigations
MG
Blood test / electrophysiological studies
Management
MG
Drug and doses, time of last dose, plasma exchange, immunosuppression
Examination
What did examiners examine? Did they comment on signs?
Sit over edge of bed
CN
Craniotomy scars, neurofibromata, Cushing’s syndrome, acromegaly, Paget’s disease, facial
asymmetry, ptosis, proptosis, deviation of eyes, pupil inequality
Inspect
I
Have you noticed any problems with your sense of smell?
Say you would test smell, each nostril separately
Lesion: URTI, meningioma, ethmoid Ca, head Ca, meningitis, hydrocephalus
II
VA with card to cover other eye; do you normally wear spectacles?  with glasses on; read
lowest line you can see clearly
Visual fields with hat pin; head at arm’s length; look at my nose; bring hat pin / towards centre from
each corner and middle  say yes when see; map out blind spot (lateral to central field of vision)
Look at fundi
III, IV, XI
Pupils: shape, size; direct and consensual response; RAPD (affected eye will dilate after short
time when torch moved to it from normal eye = optic atrophy or v poor VA)
Absent light, present accomodation: Argyll-Robertson (midbrain lesion; neurosyphilis)
Adie’s (ciliary ganglion lesion; usually viral/bacterial infection)
bilateral RAPD (ant visual pathway lesions)
Miosis: Horner’s syndrome (ptosis, anhydrosis, miosis, apparent enopthalmos, slightly bloodshot)
Argyll-Robertson (absent light, present accomodation)
pontine lesion, narcotics, pilocarpine, old age
Mydriasis: atropine, cocaine
III palsy (ptosis, mydriasis, eye down and out)
Adie’s
Iritis, eye OT, traumatic, deep coma, cerebral death, congenital
Accomodation: look into distance then at hatpin 15cm from end of nose
Absent accomodation, present light: cortical blindness; midbrain lesion
Ptosis
Eye ROM: quickly look from L to R
 follow hatpin L (up and down) then R (up and down)
Ask about diplopia; look for failure of movement and nystagmus
If any abnormality, assess each eye separately
V
Corneal reflex with cotton wool; ask if can feel; should blink both eyes
In V nerve palsy (sensation): both eyes fail to blink
In VII nerve palsy (motor): contralat eye still blinks, but loss of power to ipsilateral side
Facial sensation – opthalmic, maxillary, mandibular; use pin then light touch (cotton wool); also do back
of head and neck (C2 and 3); close eyes, say yes when feel it
In medulla / upper cervical lesion: loss of pain and temp, preservation of soft touch
In pontine lesion: loss of light touch, preservation of pain and temp
Muscles of mastication: clench teeth and feel masseters; open mouth and try to close
In lesion: jaw deviates towards affected side
Jaw jerk: incr jaw jerk in pseudobulbar palsy (=UMN)
VII
Facial asymmetry
Look up, wrinkle forehead  look for loss of wrinkles and push down on each side
Loss of forehead power = LMN lesion
Shut eyes  try to open
Grin  compare nasolabial folds
If LMN lesion, check ear and palate for veiscles of herpes zoster
Say would check taste of anterior 2/3 tongue
VIII
Whisper beside ear and ask repeat; rub auricle on other ear
Rinne’s: on mastoid process until no longer heard then beside ear
Normal / sensorineural = note audible via air
Conductive = note not audible via air
Weber’s: in centre of forehead
Normal = heard in middle
Sensorineural = sound louder in normal ear (as abnormal is “turned off”)
Conductive = sound louder in abnormal ear (as is now “turned up”)
Ask for auricscope is abnormal
IX, X
Uvular displacement; say aaaah and look for movement
Uvula goes Away from abnormal side
Gag reflex – check patient can feel spatula, patient should only gag if hyperreactive
Speech
Cough - ?bovine (RLN lesion)
Say would check taste of posterior 1/3 tongue
XII
Inspect tongue for wasting / fasciculation
Ask to stick tongue out
Tongue goes Towards abnormal side
Eyes
XI
Shrug shoulders and feel trapezius bulk and push down; turn head against hand and feel SCM
Neck
Arm
Carotid / cranial bruits (mastoids, temples, orbits)
BP
General
Orbits
Eyes
Facies
Palpate for tenderness; auscultate for bruit
Lid lag, ptosis, exopthalmos (look from behind and above patient)
Acuity
Fields as above
Eye mvmt: mvmt, diplopia, nystagmus, fatiguability (30secs looking up)
Pupils: shape, size, symmetry, RAPD, accomodation
Sclera for jaundice, pallor, injection
Cornea for arcus, band keratopathy, KF rings
Fundi: humour, disc; changes of DM, HTN, optic atrophy, papilleodema, retinal detachment,
venous / artery thrombosis
Corneal reflex
Pancoast
Eye
Face
Nystagmus to side of lesion; miosis; ptosis; enopthalmos
Symp Decreased sweating on brow with back of finger
V
Ipsilateral loss of pain and temp
IX, X Uvula deviated away from lesion; loss of gag reflex; hoarseness (RLN compression)
NS
Ipsilateral cerebellar signs
Finger abduction (lower brachial plexus lesion = thoracic outlet syndrome)
Signs of lung Ca: Clubbing, chest examination
Signs of other Ca: LN, thyroid exam
Other: carotid bruit
Adie’s
Eye
NS
Mydriasis; decr direct and consensual light response; slow accomodation
Decr tendon reflexes
A-R
Eye
NS
Miosis; irregular pupil; no reaction to light; good accomodation
Decr reflexes
III palsy
Eye
Ptosis; eye down and out; mydriasis; unreactive to light (direct or consensual) and accomodation;
opposite eye has consensual reflex
IV palsy
Eye
Cannot look down and in (intort); patient walks with head tilted away from lesion
VI palsy
Eye
Can’t look out or deviated in; diplopia on looking laterally
SupraN palsy Eye
Loss of upwards +/- downward gaze; pupils unequal; bilateral; reflex movements intact
Bulbar palsy = LMN IX, X, XII
No gag; wasted fasciculating tongue; no palatal movement; maybe no jaw jerk; NASAL
SPEECH
PseudoB palsy = UMN bilateral IX, X, XII
Higher centre General
Incr gag; spastic tongue; no palatal movement; incr jaw jerk; DONALD DUCK
SPEECH; labile emotions
R or L handed?
Facies; obvious CN / limb lesions; level of education
Shake hands
Orientation
Temporal
Parietal
Recall
Language
Person – his name, who I am
Place – present location (country, city, building)
Date – day, month, year
Short term memory: rose, orchid, tulip  repeat immediately
Long term memory: dates of 2nd World War
Dominant
Acalcula = serial 7’s
Agraphia = write your name
Agnosia, finger
L-R disorientation = put R hand on L ear, then vice versa
Non-dominant Apraxia, Dressing = turn pyjama top inside out and put it on
Both
Sensory and visual inattention
Cortical
Agraphaesthesia = draw number on palm
Astereognosis = name key placed in hand
Apraxia, Constructional = draw clock face and numbers
Rose, orchid, tulip again
Nominal
Name watch and pen (temporal, angular gyrus)
Repetition
Repeat phrase – no ifs, ands, or buts  fluency, comprehension, repetition
Receptive
Touch your nose, then your chin (temporal, Wernicke’s)
Read this then follow instruction
Describe where you are (frontal, Broca’s)
British constitution (cerebellum / CN)
Ta ta ta, pa pa pa, ka ka ka
Frontal
Primitive reflexes:
Grasp
Pout
Palmar-mental
Proverb interpretation: “people in glass houses shouldn’t throw stones”
Anosmia
Gait
Examine fundi
Examine visual fields; carotid bruits; HTN; focal neurology
Expressive
Dysarthria
MMSE
Orientation
Time: year, month, day, date, time
Place: country, town, district, hospital, ward
Registration
Rose, orchid, tulip  repeat
Attention + calc Serial 7’s
Recall
Rose, orchid, tulip remember
Language
Name watch and pen
Repeat no ifs and or buts
3 stage command: clap hands, touch nose, point to ceilling
Read “close your eyes” and obey
Write a sentence
Copying
Copy pair of intersecting pentagons
Speech
Say name, age and present location
Say “British Constitution”
Dysphasia
Dysarthria
Arms
/5
/5
/3
/5
/3
/2
/1
/3
/1
/1
/1
Ask to name object
Ask to repeat statement
Ask to follow commands
If abnormal: as to read and write
?expressive (Broca’s area, frontal lobe)
?receptive (Wernicke’s area, temporal lobe)
?conductive (arcuate fasciculus, temporal lobe)
?nominal (angular gyrus, temporal lobe) – can’t name
Say British Constitution, West Register Street, Me Me Me, Lah Lah Lah
Cerebellar = irregular staccato Examine cerebellum
Lower CN = pseudoB = slow hesitant harsh strained voice
Examine CN’s
Lower CN = bulbar = nasal speech with imprecise articulation
Take off shirt and sit over edge of bed
General
Facies (eg. Parkinsons, CVA); scars; skin (neurofibromata, café-au-lait); abnormal movements
Shake hands Myotonia if can’t let go
Inspect
Wasting
Fasciculation (LMN = MND, root compression, peri neuropathy, myopathy, thyrotoxicosis)
Tremor
Drift (UMN lesion if down, cerebellar lesion if up, post column loss in any direction)
Pseudoathetosis
Palpate
Muscle bulk; tenderness; thickened nerves (elbow and wrist); axilla for plexus lesion
Tone
Wrist and elbow movement at varying velocities
Neck movement
Power
Don’t let me…….
Shrug shoulders (1)
C5-6 Shoulder abduction (2)
Elbow flexion (4)
C6-7 Wrist flexion (6)
C7-8
Shoulder adduction (3)
Elbow extension (5)
Wrist extension (7)
Finger extension (8), flexion (9)
C8-T1 Finger abduction (10)
Ulnar Finger abduction and adduction – grasp paper between thumb and IF, thumb will flex if
abnormal
Reflexes
Co-ordination
Sensation
Median Thumb abduction – put hand palm up on table, adduct up to touch pen, then don’t let
me push thumb down
1=flicker 2=with no gravity 3=against gravity 4=weak 5=normal
Augment if needed
C5-6 Biceps
Supinator
C7-8 Triceps
C8
Finger – palm upwards slightly flexed
Finger nose (intention tremor, past point); dysdiadokinesis; rebound (lift arms quickly from sides
then stop with palms up with eyes closed; hypotonia if unable to stop arms; and push arms)
Looks for scars that may cause nerve damage; close eyes
?dermatomal / peri nerve / peri neuropathy / hemisensory
Spinothalamic Pain
Demonstrate on chest wall (does that feel sharp?)
Sharp/dull? Start prox and test each dermatome
Temp Say you would
Posterior
Demonstrate on clavicles
Vibration: on ulnar wrist with eyes closed  on elbow, on shoulder if abnormal
Ask if can feel it; when feels stop
Proprioception: DIPJ of index finger; demonstrate with eyes open  close eyes;
do wrist and shoulder if abnormal
Light touch (both post and spinothalamic) with cotton wool
Legs
General
Gait
Inspect
Palpate
Tone
Power
As above + urinary catheter; look for walking stick / special shoes
Walk across room, turn around, come back – with legs uncovered
Hemiparetic = foot plantar flexed and swung laterally
Paraparetic = scissor gait
Extrapyramidal = hesitation starting, shuffling, freezing, festination, propulsion
Cerebellar = drunken, widebased or reeling on narrow base; staggers to affected side
Apraxic = prefrontal = glued to floor when erect, move easily when supine
Post column = clumsy slapping feet on broad base
High stepping = distal weakness
Waddling = prox weakness
Heel-toe (cerebellar)
On toes and heels (S1 or L4/5 lesion)
Squat and stand (prox myopathy)
Romberg’s sign – feet together, arms forwards with palms up (eyes closed only = post column –
Rhomberg positive if worsens with eyes closed, eyes open also = cerebellar disease)
As above
As above
Knee and ankle, inc clonus (push patellar sharply downwards) = UMN lesion
Push into me
L2-3
Hip flexion (1), adduction (4)
L3-4
Knee extension (6)
L4-5
Hip abduction (3)
Ankle dorsiflexion – toes aswell (8)
L5-S1 Hip extension (2)
Knee flexion (5)
Reflexes
Co-ordination
Sensation
Ankle eversion (also common peroneal nerve), inversion (9)
S1
Ankle plantar flexion – toes aswell (7)
Reinforce if needed
L3-4
Knee
S1-2
Ankle
S1
Plantars (warn will be uncomfortable with key; look at big toe)
Heel-shin, toe-finger, foot tapping (tap hand with ball of foot)
As above; try to establish if sensory level
Tuning fork on MTPJ
Proprioception with big toes; knee and hip if needed
Saddle region sensation (S3-5)
Anal reflex (S2-4)
Back
Deformity, scars, tenderness, bruits; SLR
Abnormal co-ordination: do gait, tone, co-ordination tests (arms and legs), Romberg’s
If Romberg +ive but co-ordination OK, do vibration and position sense
Nystagmus
Speech (British Constitution, West Register Street)
Truncal ataxia: fold arms; sit up; put legs over side of bed
Fundi for papilloedla; CN’s examination
LMN
UMN
Weakness; wasting; hypotonicity; decr reflexes; fasciculation
Weakness (more marked in upper limb abductors and extensors, lower limb flexors); spasticity; clonus; incr
Reflexes
Upper brachial plexus (C5-6, Erb-Duchenne): loss of shoulder movement and elbow flexion; waiter’s tip; loss lateral arm and
thumb sensation
Lower brachial plexus (C8-T1, Klumpke): claw hand with paralysis of intrinsic muscles; loss sensation ulnar side of hand and
forearm; Horner’s syndrome; look for axillary mass
Cervical rib syndrome: claw hand and sensation loss as above; unequal radial pulses and BP’s; subclavian bruit; loss of pulse
on manouvring arm; palpable cervical rib
Radial nerve (C5-8): wrist and finger extension weakness
loss of elbow extension if high
Loss sensation over ASB
Median nerve (C6-T1): thumb abduction weakness (APB)
loss of Ochsner’s clasping test if high
Loss sensation over thumb, IF, MF, lat ½ ring finger (palmar)
Ulnar nerve (C8-T1): weak finger abduction and adduction and claw hand (Froment’s sign)
Loss sesnation over LF and medial ½ RF (palmar and dorsal) – not forearm like lower brachial plexus
Femoral nerve (L2-4): Weak knee extension, hip flexion; loss of knee jerk
Loss sensation over inner aspect thigh and leg
Sciatic nerve (L4-S2): Weak knee flexion, all muscle below knee  foot drop; knee jerk OK; loss of ankle / plantars
Loss sensaton over post thigh and total loss below knee
Common peroneal (L4-S1): foot drop and loss of foot eversion; reflexes OK; inversion OK (unlike in L5 nerve root inj)
Loss sensation over dorsum of foot
Prox muscle weakness: myopathy, MG
Myopathy
Cancer
Autoimmune: Polymyositis / dermatomyositis; sarcoid
Toxins: ETOH; drugs (eg. Steroids)
Other: periodic paralysis (hyper/hypoK); osteomalacia; endocrine (hypo/hyperthyroid, Cushings,
acromegaly, hypopit); paraneoplastic; CT disease
MG
NS
Gen
GBS
TIA
NS
Muscle fatigue, esp eyes, bulbar (read aloud), prox muscles (hold arms up); Peek sign (close eyes hard
for 30secs, gets weak); neck flexion weakness
Normal reflexes; normal sensation; minimal muscle atrophy
Thymectomy scar
CV
Distal (maybe prox) muscle weakness; arms > legs; decr reflexes; muscle tenderness; minimal
sensory loss; loss of vibration and proprioception
No atrophy
Postural BP changes, arrhythmia
Eyes
CV
NS
?emboli, hypertensive changes, diabetic changes, ischaemic retinopathy; visual fields; nystagmus
Carotid bruit; pulses; postural BP; murmurs (?IE, AS, RHD, prosthetic valve); PVD; pacemaker; GCA
Dix-Hallpike if vertigo
Investigations
Ask for 1-2 recent investigations and reason for ordering
Comment on results, even normal
Urine (glucose); MRI/CT
MG
Bloods
Other
Imaging
Ach receptor abs; TFT’s; RF; ANA
EMG; PFT’s
CXR, thoracic CT/MRI for thymoma
GBS
Bloods
Other
Monospot; cold agglutinins; CMV; HIV; Campylobacter
PFT’s; incr protein on CSF with relative lack of WBCs; EMG
TIA
Bloods
Other
Imaging
FBC, ESR, fasting BSL, chol, TFT; possibly ANA, anticardiolipin ab, coag
Urine (?renovascular disease); ECG (?IHD / arrhythmia, long QT)
CT/MRI; carotid USS; TOE
End
Is there anything else I should know?
Presentation
Draft intro statement
Differential diagnosis
Findings that support / refute diagnosis
Horner’s
SCC lung; thyroid Ca; brainstem Ca; mets; neurofibroma; base of skull lesion;
Neck trauma; local OT
carotid aneurysm / dissection; lat medullary syndrome; central cord syndrome; AVM; cervical rib; aortic
aneurysm; cavernous sinus thrombosis
cluster headache
retro-orbital lesion; lower brachial plexus lesion
MS; encephalitis; apical TB
Postganglionic doesn’t affect sweating
A-R pupil
Syphilis, DM, alcoholic midbrain degeneration, other midbrain lesions
Papilleodema SOL; retro-orbital mass
hydrocephalus (obstructive eg. Ca; communicating eg. Choroid plexus papilloma, venous compression,
subarachnoid space compression)
benign intracranial HTN (idiopathic, OCP, Addisons, drugs, lat sinus thrombosis, head trauma)
HTN; central retinal vein thrombosis; cerebral venous sinus thrombosis
GBS
Ptosis
III palsy
Senile; myotonic dystrophy; ocular myopathy; thyrotoxicosis; MG; botulism; snake bite; congenital; fatigue;
Horner’s; tabes dorsalis; III palsy
Brain stem infarct; Ca (eg. Nasopharyngeal); demyelination; trauma; aneurysm of PCOM; meningitis; DM;
arteritis; cavernous sinus lesions
IV palsy
Trauma; lesions of cerebral peduncle
VI palsy
Trauma; Wernicke’s encephalopathy; raised ICP; mononeuritis multiplex; vascular; Ca; MS; DM
Nystagmus Central Cerebellar lesion; INO (nystagmus in eye looking laterally, other eye fails to adduct; due to MLF lesion
eg MS, brainstem infarct); brain stem lesion; phenytoin; ETOH
V palsy
Vascular; Ca; MS; aneurysm; meningitis; meningioma; # of middle fossa; cavernous sinus thrombosis;
Sjogren’s; SLE; toxins; if all 3 regions = @ ganglion; if just 1 = post-ganglionic; if loss of pain but not touch =
brain stem or upper cervical cord; if loss of touch but not pain = pontine nucleus
VII palsy
Vascular; Ca; MS; acoustic neuroma; meningioma; Bell’s palsy; Ramsay Hunt syubdrome; OM; fracture;
sarcoid; GBS; parotid disease; mononeuritis multiplex
VIII palsy
Nerve Degeneration, # petrous temporla bone, aspirin, ETOH, streptomycin, rubella, congenitla syphilis;
acoustic neuroma; brain stem lesion
Cond Wax, OM, otosclerosis, Paget’s
IX palsy
Lat medullary syndrome; Ca; MND; aneurysm; meningitis; GBS
XII palsy
Vascular; MND; Ca; MS; vertebral artery thrombosis; meningitis; trauma; Arnold-Chiari malformation; BSF; GBS;
Polio
IX, X, XII
Bulbar
Infective
Polio, neurosyphilis
Vascular
Brainstem CVA
Other
MND; syringobulbia; GBS; meningitis due to Ca/lymphoma
PseudoB
Vascular
Internal capsule CVA
Other
MND; MS; high brainstem SOL; HI
Multiple palsy NP Ca; chronic meningitis (eg. Carcinoma, TB, sarcoid); GBS; MFS; Arnold-Chiari malformation; brain stem
lesions; trauma; basal skull lesions (eg. Mets, meningioma, Paget’s); mononeuritis multiplex (DM)
MG
Lambert-Eaton (power increases on repeat; may be prox muscle pain; ocular and bulbar muscles spared)
Midline cerebellar
SOL
Midline tumour
Unilat cerebellar
Bilat cerebellar
Peri neuropathy
Other
SOL
Vascular
Other
SOL
Vascular
Tox
Other
Motor
Painful
Paraneoplastic syndrome
Tumour, abscess, granuloma
CVA; haemorrhage
Paraneoplastic syndrome; MS
Large
Arnold-Chiari malformation
Phenytoin, ETOH, Li
Friedrich’s ataxia, hypothyroidism, paraneoplastic syndrome, MS, trauma
Other
GBS – others = PAN, porphyria
Hereditary motor and sensory neuropathy; DM
Tox
Lead poisoning; tick/snake bite; arsenic; botulism
Infective
Diptheria, polio
Tox
ETOH, arsenic, thallium
Other
DM; Vit B1/B12 def; porphyria
Management
Suggest management and set management goals
MG
Anticholinesterases (pyridostigmine); may need mechanical ventilation; steroids if severe; immunosupp;
thymectomy; plasmapheresis if myasthenic crisis
GBS
Physio, resp support, plasmapheresis, IVIG
TIA
CV RF control; aspirin; carotid endarterectomy; ?warfarin if AF
ENDOCRINE
History
Hello, this is exam
What is wrong? Why are you in hospital this time?
HPC HyperCa
DM
PMH HyperCa
DM
Lethargy, weakness, confusion, anorexia, constipation, N+V, AP, polyuria, polydipsia; Sx of
thyrotoxicosis or phaeo; recent immobilisation
Age of diagnosis; presenting complaint (polyuria, polydipsia, weight loss, infection, DKA)
Adequacy of control – method of testing, BSL results, regularity of testing, which metre, dose adjustment
in illness
Symptoms of hyperG: polyuria, thirst, weight loss, blurred vision
Admissions with DKA
Symptoms of hypoG and level of education: morning headaches / lethargy, night sweats, weight gain,
seizures
Other systems: IHD, claudication, CVD, peri neuropathy, autonomic neuropathy, erectile dysfx, syncope,
eyes, nocturia, oedema, HTN, boils, necrobiosis lipiodica
Action plan for hypoG
Pituitary adenoma, metastatic breast Ca, lung / renal Ca, haem Ca, XS vit D, hyperthyroidism, renal
failure; PUD, renal colic; pseudogout; HTN; prev parathyroid probs
Cushings, phaeo; pregnancy; pancreatic disease; CLD
CV RF’s (see above)
Generic details
Immunisation status (influenza, hep A, hep B, Pneumococcus)
DH
Thiazide, lithium, Ca, vit D
HyperCa
DM
Steroids, OCP, thiazides, phenytoin; beta-blockers; ACEi for HTN
A
SH
Occupation, adequacy of income, current housing, ability to cope, mobility + steps
Hobbies (animals, chemicals, dusts), marital status, sexual problems
Place of birth, overseas travel
DM
FH
ETOH, exercise; work; living conditions; finance; eating habits; acopia with insulin; driving
HyperCa
DM
Of same, MEN
Of same; obstretic history (eg. big babies)
Investigation results DM
Fasting BSL >7 on 2 separate occasions; 2hr post-prandial BSL >11; HbA1c results
Management
Insulin / oral hypoG and when started; diet control; normal dose 0.5iu/kg/day with 40% long
acting; where injected, by whom
DM
Examination
What did examiners examine? Did they comment on signs?
Standing:
General
Hypopit
Cushings
Addisons
Diabetes
HyperCa
DM
Pale skin, lack of hair; short stature; no 2Y sexual characteristics
Central obesity; thin limbs; skin bruising and atrophy; skin pigmentation; poor wound healing;
look at patient standing from front, sides and behind
Pigmentation, vitiligo
Weight, hydration, endocrine facies, pigmentation; signs of CRF
Neck scar; forearm scar; LN; evidence of renal failure; signs of thyroid; pigmentation of
Addisons; Evidence of sarcoid / TB; Prox weakness; corneal band keratopathy; Pseudogout
Complications of disease
Sit down:
Hands
Thyroid
Tremor (place sheet over dorsal hand); onycholysis (separation from nail bed); thyroid
acropachy (looks like clubbing); palmar erythema; radial pulse (tachy, AF, collapsing pulse)
For hypo: cyanosis, swelling, dry skin, cold; anaemia; pulse (decr HR, small vol); test for carpal
tunnel syndrome (flex both wrists for 30secs  paraesthesia)
Arms
Thyroid
Prox myopathy (more common in hyper); reflexes for briskness (delayed relaxation in hypo, fast
in hyper)
Trousseau sign if thyroidectomy (above SBP  adducted thumb, extended PIP and DIPJ within
2mins)
Lying and standing BP
Purple striae; prox myopathy; BP
BP, postural drop
Injection sites; pulse (lying and standing for autonomic neuropathy); BP (postural hypotension);
Hypopit
Cushings
Addisons
Diabetes
nails for candida; lack of slowing of pulse with valsalva; loss of sweating
Face
Thyroid
Hypopit
Cushings
Diabetes
Neck
Thyroid
Cushings
Diabetes
Chest
Thyroid
Proptosis (amount of sclera, lid retraction, lid lag by asking to follow finger as goes down at
slow rate) – look from infront, behind over forehead; conjunctiva for chemosis; opthalmoplegia
(loss of IO power, then convergence, then others in thyrotoxicosis); fundi for optic atrophy
Chvostek’s sign if thyroidectomy (tap facial nerve 4cm infront of and below ear  twitch =
hypoCa
For hypo: swelling, periorbital oedema, loss of outer 1/3 of eyebrows; xanthelasma; dry, fine
smooth skin; carotenaemia, alopecia, vitiligo; swollen tongue; speech hoarseness;
sensorineural deafness
Skin wrinkles around mouth and eyes; hypophysectomy scar on forehead; bitemporal
hemianopia; fundi for optic atrophy; eye ROM; trigeminal nerve
Plethora; hirsutism; acne; telangectasia; moon shape; visual fields; fundi (atrophy,
papilloedema, signs of HTN / DM); oral thrush
Fundi – cataracts, rubeosis, retinal disease, III nerve palsy (pupil spared); ROM eyes; mouth
and ears for infection; VA; Argyll-Robertson pupil; dot haemorrhage, blot haemorrhage, hard
exudates, soft exudates (cotton wool spots), microaneurysms, dilated veins, new vessels,
vitreous haemorrhage, scars, retinal detachment
Inspect
Scars, swelling, prominent veins; swallow water and look for thyroid
Enlargement; voice hoarseness (RLN palsy)
Pemberton’s sign (lift arms over head and look for suffusion of face, elevation of
JVP, insp stridor = means there is retrosternal mass)
JVP = SVC obstruction
Palpate
From behind with neck flexed; shape, consistency, distribution of enlargement;
single / multiple nodules; tenderness; ?retrosternal extension (can you feel
lower border); cervical LN’s; mobility; thrill
From infront: carotid arteries (no pulse if malignant infiltration); thryoid; note
tracheal position; supraclavicular LN’s; sternomastoid function
Percuss
Across upper chest over upper manubrium for dullness (retrosternal extension)
Auscultate
Bruit (active thyrotoxicosis); carotid bruit
Supraclavicular fat pads; acanthosis nigricans
Carotid arteries palpate and auscultate
Hypopit
Cushings
Diabetes
Gynaecomastia; ESM; CCF
If hypo: pleural and pericardial effusions; sandpaper skin
Decr hair, pale skin, gynaecomastia
Buffalo hump (interscapular fat pad); kyphoscoliosis and tender vertebrae (osteoporosis)
For signs of infection
Abdo
Cushings
Diabetes
Purple striae; adrenal mass; adrenalectomy scar; liver tumour
Liver for fatty infiltration; insulin injection sites  fat hypertrophy
Legs
Thyroid
Pretibial myxoedema (firm elevated dermal nodules and plaques, pink, brown or skin coloured);
vitiligo; prox myopathy; reflexes
If hypo: reflexes; peri neuropathy
Loss of pubic hair; testicular atrophy
Squat (prox myopathy; striae; bruising; oedema
Necrobiosis, hair loss, infection, pigmented scars, atrophy, ulceration, injection sites, muscle
wasting, joint destruction; temperature of feet + CRT; peri pulses; oedema; peri neuropathy
(including vibration and proprioception); diabetic dermopathy; femoral artery for bruits; prox
muscle power
Lie down:
Hypopit
Cushings
Diabetes
Investigations
Ask for 1-2 recent investigations and reason for ordering
Comment on results, even normal
HyperCa
Bloods
Other
Imaging
Ca; PTH; Vit D
24hrs urine Ca
CXR (malignancy); XR (subperiosteal reabsorption)
Urine (glucose; renal stone disease, ketones, protein)
End
Is there anything else I should know?
Presentation
Draft intro statement
Differential diagnosis
Findings that support / refute diagnosis
Diffuse goitre
Idiopathic; puberty, pregnancy, post-partum
Thyroiditis (Hashimoto’s, subacute, Riedel’s)
Iodine def / XS; inborn errors of thryoid metabolism
Drugs (eg. Li)
Management
Suggest management and set management goals
HyperCa
Parathyroidectomy; steroids; frusemide; rehydration; IV bisphosphonates; calcitonin
DM
Diet; exercise; insulin; metformin preferred in overweight with type II; education; regular FU; mng BP (ACEi);
control CV RF; statins; regular eye review; screen urine for protein
Venous stasis ulcer – most common
Site: around malleoli
Associated pigmentation, stasis eczema
Ischaemic ulcer
Large artery disease (atherosclerosis, thromboangiitis
obliterans): usually lateral side of leg (pulses absent)
Small vessel disease (e.g. leucocytoclastic vasculitis, palpable
purpura)
Malignant ulcer
e.g. basal cell carcinoma (pearly translucent edge), squamous
cell carcinoma (hard everted edge), melanoma, lymphoma, Kaposi’s
sarcoma
Infection
e.g. Staphylococcus aureus, syphilitic gumma, tuberculosis,
atypical Mycobacterium, fungal
Neuropathic
painless penetrating ulcer on sole of foot: peripheral
neuropathy
e.g. diabetes mellitus, tabes, leprosy)
Underlying systemic disease
Diabetes mellitus: vascular disease, neuropathy or necrobiosis
lipoidica (front of leg)
Pyoderma gangrenosum
Rheumatoid arthritis
Lymphoma
Haemolytic anaemia (small ulcers over malleoli), e.g. sickle cell anaemia
Equipment:
Piece of paper
Sleeve of shirt with button
Card to cover opposite eye on VA check
Red tipped hat pin