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Table Of Contents:
What’s included: Ready-to-study summaries of clinical skills and the various examinations
presented in succinct and logical downloadable PDF documents. Once downloaded, you may
choose to either print and bind them, or make annotations digitally on your ipad or tablet PC.

Free bonuses: 10x Exemplary clinical examination demonstration videos.

File List:
• Ear Exam & Hearing Tests (5p)
• Eye Exam (11p)
• Focussed Breast & Pelvic Exam (4p)
• Focussed Gynaecological History (1p)
• Focussed Male Genitourinary Exam (7p)
• Focussed Cardiovascular Exams (2p)
• Focussed Endocrine Exams (10p)
• Focussed GI Exams (2p)
• Focussed Haematological System Exams (6p)
• Focussed Head & Neck Exams (4p)
• Focussed Musculoskeletal Exams (5p)
• Focussed Neurological Exams (8p)
• Focussed Renal Exams (3p)
• Focussed Respiratory Exams (2p)
• Focussed Rheumatological Exams (2p)
• Preoperative Considerations (3p)
• Sexual History & OBGYN History (2p)
• Cardiovascular Pre-Op Assessment (1p)
• OSCE Conditions - Cardio (4p)
• OSCE Conditions - Endocrine Exams (8p)
• OSCE Conditions - Gastro Exams (19p)
• OSCE Conditions - Respiratory Exams (9p)
• OSCE Conditions - Gastro Exams (2p)
• Bonus Clinical Examination Demonstration Videos (See external folder in
downloads):
o The Cardiovascular System Examination
o Respiratory Examination
o The Gastrointestinal Examination
o Cranial Nerves Examination
o Upper Limb Neuro Examination
o Lower Limb Neuro Examination
o Hands & Wrists Examination
o Shoulders Examination
o Knee Examination
o Feet & Ankles Examination
 The Ear History & Hearing Tests:

The Interview – Ear Related History
1. Presenting Symptoms
• Pain,
• Discharge
• Itching,
• Vertigo
• Tinnitis
• Changing in Hearing
2. History of Presenting Symptoms
• Onset – weeks day, months
• Contributing factors – trauma, recent illness, exposure to sudden loud noise
• Which ear effected
• Does anything make it worse, does anything make it better.
3. Medical History – Note specifically
• Hypoxia at birth
• Low birth weight – less than 1500g
• Congenital abnormalities of the face or skull
• Maternal drug use
• Head trauma
• Ear trauma
• Genetic disease – Meniere’s Disease
• Chronic and acute infections – ear, sinus, colds, flu
4. Surgical History – Note specifically
• Ear surgery – grommets etc
• Sinus surgery
• Head and facial surgery
• Nerosugery
5. Medications: Many medications can be ototoxic. Note spefically:
• Large doses of Aspirin
• Gentamicin Sulphate
• Aminoglycosides
6. Social History – Note specifically:
• Exposure to loud noises at work, availability and us of PPE
• Exposure to Industrial noise
• Exposure to recreational noise
7. Family History – Note Specifically
• Family history of hearing loss
• Genetic disorders

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 Examination of the Ear
External structures:
- Briefly examine the outer structures
• Colour and texture of the skin
• Any moles, cysts, nodes, or deformities
- Any skin changes suggestive of cancer (e.g basal cell, melanoma,
• Any signs of swelling and/or redness
• Discharge – colour and odor
- Palpate the ear for pain, tenderness, skin texture and lesions.
1. If pain increases – external ear infection likely
2. No pain increase – middle ear infection likely
3. Tenderness in mastoid area – possible mastoiditis

External Auditory Canal and Tympanic Membrane:
- The Otoscope:
o The otoscope allows you to examine the external canal,, as well as the tympanic membrane and a
few inner ear structures. Use the biggest earpiece that can fit in to the ear canal.

Examination procedure:
Always examine the unaffected ear first.
1. Place the tip of the specula in the opening of the external canal.
2. Gently grasp the top of the left ear with your left hand and pull up and backwards. This straightens out the
canal, allowing easier passage of the scope.
3. Look through the viewing window with either eye. Slowly advance the scope, heading a bit towards the
patient's nose but without any up or down angle.
4. As you advance, pay attention to the appearance of the external canal. In the setting of infection, called
otitis externa, the walls becomes red, swollen and may not accommodate the speculum. In the normal
state there should be plenty of room.

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The Tympanic Membrane:
- The tympanic membrane (a.k.a. ear drum) should be visible.
Pay particular attention to:
a. The color: When healthy, it has a grayish, translucent appearance.
b. The structures behind it: The malleous, one of the bones of the middle ear, touches the drum.

An annulus fibrosus
Lpi long process of incus - sometimes visible through a healthy translucent drum
Um umbo - the end of the malleus handle and the centre of the drum
Lr light reflex - antero-inferioirly
Lp Lateral process of the malleus
At Attic also known as pars flaccida
Hm handle of the malleus

a. In the setting of infection within the middle ear, the drum becomes diffusely red and the light reflex
is lost.
b. fluid collecting behind the drum. This is called a middle ear effusion and can cause the drum to bulge
outwards.

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 Detecting Conductive v. Sensorineural Deficits:

1. Conduction: The passage of sound from outside to the level of the 8th cranial nerve. This includes
transmission of sound through the external canal and middle ears.
2. Sensorineural: The transmission of sound through the 8th nerve to the brain.

Hearing loss can occur at either level. To determine which is affected, the following tests are performed:

Weber Test:
1) Grasp the tuning fork by its stem and place the stem towards the back of the patient's head equidistant from
either ear. The bones of the skull will transmit this sound to the 8th nerve, which should then be appreciated
in both ears equally.
a. If there is a conductive deficit (e.g. wax in the external canal), the sound will be heard better in that
ear. This is because impaired conduction has prevented any competing sounds from entering the ear
via the normal route.
b. In a sensorineural abnormality (e.g. an acoustic neuroma, a tumor arising from the 8th CN), the
sound will be best heard in the normal ear.
2) If sound is heard better in one ear it is described as lateralizing to that side. Otherwise, the Weber test is said
to be mid-line.

Rinne Test:
1) Place the stem on the mastoid bone and instruct the patient to let you know as soon as they can no longer
hear the sound.
2) Then place the tines of the still vibrating fork right next to, but not touching, the external canal. They should
again be able to hear the sound. This is because transmission of sound through air is always better than
through bone.
3) This will not be the case if there is a conductive hearing loss which causes bone conduction to be greater
than or equal to air.
4) If there is a sensorineural abnormality (e.g. medication induced toxicity to the 8th CN), air conduction should
still be better then bone as they will both be equally affected by the deficit.

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 THE EYE EXAMINATION:

History: – (at least 80% o the diagnosis comes from the history)
- Take a meaningful, focussed history.
- Presenting complaint
o Nature of Presenting complaint:
§ 1. Abnormal Vision? (Eg. Flashing lights/blind spot/etc)
§ 2. Abnormal Sensastion? (Eg. Itching/throbbing/pain)
§ 3. Altered Appearance?
o Time course
§ Sudden onset/Rapid Onset?
§ Duration
§ Exacerbating (What makes it worse)
§ Relieving (what makes it better)
§ Associated (What is it associated with)
- Past History
o Meds / allergies
o Eg. Are they diabetic
o Eg. What environmental insults (Eg. Welder)
- Family history
- Social history

Possible Presenting Complaints:

1. Abnormal vision
- A) Reduced vision: (NB: If Sudden à Probably Vascular in Origin)
o Central Loss:
§ Far/Near/Both
o Peripheral Loss:
§ Partial/Total loss
§ Eg. Scotoma:
• An area of degenerated visual acuity in one's field of vision, which is surrounded by a
field of normal vision.

§ Hemianopia (bilateral):
• Type of partial blindness where vision is missing in the outer half of both the right and
left visual field.
• Usually associated with Optic Chiasm lesions.

o Impaired Night vision (Ie. “Night Blindness”):
§ (a symptom of several eye diseases) – Eg. From Vit.A Deficiency.
§ A condition making it difficult or impossible to see in relatively low light.
o Colour Blindness:
§ 8%males 0.5% females
§ (X-Linked Recessive)

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 - B) Floaters:
o Haemorrhage
o Inflammation
o Vitreous degeneration
o Muscae volitantes (Small Spots)

- C) Flashers:
o Due to Irritative stimulation of retinal or visual pathway (no sensation)
§ Unilateral (retinal)
§ Bilateral (Visual Pathway)(Eg. From migraine/basilar artery insufficiency)

- D) Haloes
o Rainbow coloured rings around lights
§ Due to Diffraction
§ Corneal oedema
§ Can suggest Increased intraocular pressure

- E) Metamorphopsia / Micropsia:
o Metamorphopsia = Apparent distortion of straight lines

o Micropsia = Objects are perceived to be smaller than they actually are
o Possible Causes:
§ Retinal oedema à Require urgent referral
§ Macular degeneration

- F) Diplopia (Double Vision):
o Binocular Diplopia:
§ When axes of both eyes are not directed to the same object
§ Causes:
• Muscle Weakness (Eg. Myasthenia)
• Nerve – Eg. CN-III with ptosis mydriasis
o Eg. CN-VI with head injury raised IC pressure
o Monocular Diplopia:
§ Patient sees double when viewing with only one eye.
§ Possible Causes:
• Corneal Surface Deformity
• Structural Defect in Eye
• Lesion in Visual Cortex
• Sub-Luxation of Lens

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2. Abnormal Sensation:
- A) (Stinging/scratching pain) Foreign body sensation:
o Causes include:
§ Entropion & Trichiasis (Eyelid folds inward àEyelashes touching cornea)
§ Conjunctivitis
§ Xerophthalmia (dry eye)
§ Can be minimal in IOFB (Intra-Ocular Foreign Body)
o Local anaesthetic relieves it.
- B) (Achy Pain):
o Eg. Photophobia (excessive sensitivity to light and the aversion to sunlight)
o Eg. Iritis (Inflammation of Iris)
o Eg. Keratitis (Corneal Inflammation)
- C) (Severe Deep Pain):
o Eg. Acute Closed Angle Glaucoma à requires Pupil Constriction to open the Canal of Schlemn.
o Eg. Herpes Zoster infection of the Eye.
- D) Asthenopia (eye strain):
o After intensive use of eyes
o Due to:
§ Inadequately corrected refractive error
§ Heterophoria (motion of the eyes are not parallel to each other)
- E) Watery eyes / discharge
o Overproduction of tears (ocular irritation/ FB)
o Faulty drainage of tears
o Instability of tears (Tears run down face instead of staying in the eyes àDry Eyes)

3. Altered Appearance
- Proptosis (Eye Dislocation)
o From Orbital Infection, trauma, mass
o Eg thyroid

- Ptosis (‘small’ eye)
o CN-III nerve lesions
o Levator abnormalities
o Local lid abnormalities eg infections

- Lid retraction
o Where the lid retracts or moves away from the surface of the eye.

- Lesions
o On lids
o On globe eg pterygium

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 - Diffuse redness

- Ciliary injection

- Corneal/Iris Opacities:

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TESTING THE VISUAL SYSTEM:
- 1. Visual Acuity Tests (Snellen’s Chart):
o All Australian charts are read at 6m (Or are standardised to 6m)
o Tests ‘Corrected’ visual acuity @ a distance. (Those with ‘corrected’ vision use their glasses)
o Each eye is tested Separately; Followed by vision with both eyes open.
§ Record results for:
• Right Eye
• Left Eye
• Both Eyes
§ The Results are Fraction:
• Numerator = the standardised distance that letter should be read at
• Denominator = The distance that it should be visible from with perfect vision
o Try using a Pinhole to Improve Visual Acuity (A pinhole eliminates the need for a lens)
§ If acuity improves with pinhole, it is a refractive error;
§ If acuity doesn’t improve, it is a retinal problem.
o IF they can’t read the snellens chart (even from up close), you need to ask them whether they can
see:
§ CF (count Fingers)
§ HM (Hand movements)
§ PL, NPL (Perception of Light/nil perception of light)(Shine a light in their eye)
o IF testing for Presbyopia – use a ‘Near-Reading Chart’.

- 2. Testing Extraocular Muscles (Eye Movement):
o Start with the target 6inches in front of your partner; Then move your target slowly and smoothly in an
wide “H” pattern.
§ Look for Conjugate Movement:
• Movement of both eyes in a coordinate manner
§ Look for Nystagmus:
• Rhythmic, involuntary oscillation of the eyes.
o Is movement Comitant/Incomitant?
§ (To the eyes move parallel to each other?)
§ (If there’s strabismus, is the same angle of misalignment maintained in all directions?)
o NB: Deviation greatest when move towards field of action of involved muscle.
o Test Convergence for near Vision.

“SO4, LR6, the rest are 3” - Superior Oblique by CN-IV; Lateral Rectus by CN-VI, and all the other recti by CN-III.

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 - 3. Visual field Test:
o Pt stares at your nose.
o A) Testing Peripheral Visual Field: Use your fingers to test vision in peripheries of each quadrant. (Best
to use a red-topped bottle/pin)
§ Sit in front of Pt with eyes at the same level, about an arm’s length away.
§ Cover your left eye.
§ Ask your Pt to cover their Right eye and to stare into your open eye.
§ Compare your partner’s peripheral visual field to your own:
• Hold up your finger midway between yourself and the Pt (so it is just out of your field of
vision).
• Move your finger slowly towards the centre asking the patient when they first see it.
• Test all four quadrants of the visual field (upper right, upper left, lower right, lower
left).
§ Repeat for the right eye.
§ Remember that the visual field and the retina have an inverted and reversed relationship:
• Upper field on the inferior retina
• Lower field on the superior retina
• Nasal field on temporal retina
• Temporal field on nasal retina.

This Diagram is What was Asked in the GLS

o B) Testing Central Visual Field: Use an Amsler Grid to test Pt’s Central Visual Field. (Pts with macular
disease may see wavy lines/missing lines)

Normal Eg. Macular Degen.

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 - 4. Colour vision (Ishihara Tests):
o Tests for colour blindness
o :. Tests Cone Receptors.
o NB: Men are Most Affected by Colour Blindness:
§ Because it is Sex-Linked Recessive (on the X-Chromosome), and therefore acts dominantly when
inherited in males (who only have 1x X-Chromosome).
§ Red-Green photoreceptor disorders are most common.
o People with normal colour vision can see numbers in the pics below:

- 5. Pupillary Reflexes:
o (NB: The constriction reflexes are Parasympathetic-Mediated)
o PERLA is Pupils Equal Round Reactive to Light and Accommodation.
o A bright source of light is used to test pupillary reflexes by swinging the light in front of right eye 2
times, while observing 1st right pupil and then the left. Test is then repeated for left eye.
1. Dim lights.
2. Ask Pt to stare at a target in the distance.
3. Turn on the light and look at the right pupil as you swing the light over the right eye. Watch as
the pupil constricts.
• This is the direct response.
4. Repeat the same procedure again but this time look at the left pupil as you swing the light over
the right eye. Does it also constrict?
• This is the consensual response.
5. Now repeat the procedure with the left eye. First looks at the left pupil as you shine the light
on the left eye, then look at the right pupil.
o Direct:
§ Eg. Right Pupil contracts when Right Eye exposed to Light.
o Consensual:
§ Eg. Left Pupil Contracts when Right Eye exposed to Light.
o Testing Accommodation-Mediated Pupillary Constriction:
§ (Pupil Constriction Associated with the Accommodation)
1. Ask your Pt to hold their finger about 8 inches from their nose.
2. Ask your Pt to look in the distance and then look at their finger.
3. Watch for convergence (crossed eyes) and pupillary constriction.
o NB: Corneal Opacities/Cataracts can Affect the Pupillary Response:
§ à Decreased pupillary response in both the affected eye (Direct response) and the other eye
(Consensual response) because less light falls on the retina of the affected eye.

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Ophthalmoscopy Technique:
- Ask pt to look straight ahead both eyes open
- Set to zero
- Use right hand and right eye for pt’s right eye, and left ditto for left eye
- Hold sight hole as close as possible to your eye, steady it against your nose
- Gently raise lid with your thumb
- Find red reflex (the reddish-orange reflection from the eye's retina when using an ophthalmoscope)
o Stand at arms length and focus on the pupillary area with ophthalmoscope
o Should be able to see an uniform orange glow
o This is due to light being reflected from the choroidal vessels
o Look for any opacity in the red reflex
o (Abnormal or absent reflex especially in children could mean sight threatening condition. Need to be
referred and treated quickly otherwise vision fails to develop)

- Follow it in at about 15 degrees temporal to line of vision
- Focus
- Find a blood vessel
- Follow it to the disc
- Systematically examine
o Vessels / Macula / Vessels
o Optic Disc
§ Colour (normal pink)
§ Margins – Well defined
§ Cup:Disc Ratio. Normal is less than half of the disc diameter. (If ratio is increased à Probably
Glaucoma)
o Retina:
§ Look for:
• Haemorrhages/Exudates/New Blood Vessels/Arteries/Veins (Bigger & Darker)
§ Common causes of retinal changes:
• Diabetic Retinopathy (leading cause of blindness in <60rys)
• Age Related macular degeneration (Leading cause of blindness in >60yrs)
• Hypertensive retinopathy
• Retinal Artery Occlusion
• Retinal Vein occlusion
o Macula:
§ Darker than rest of retina (Due to pigment and thick ganglion cell layer)
§ Temporal to the disc
§ Centre of macula is the fovea.
• No blood vessels overlying the fovea

Normal Fundus

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ABNORMAL OPTHALMOSCOPY FINDINGS

OPTIC DISC ABNORMALITIES
(NORMAL VS. ABNORMAL)

Optic Atrophy

Swollen Disc
(Notice disc margin is not well defined)

“Cupping of the Disc”

This ratio is approx. 0.6

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 RETINAL ABNORMALITIES
(NORMAL VS. ABNORMAL)

Exudates:

These are hard exudates because areas of leakage à protein & calcium deposits.

These are soft exudates (Aka: “Cotton wool Spots”) due to ischaemia

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 BLOOD VESSEL ABNORMALITIES
(NORMAL VS. ABNORMAL)

New Vessels (Proliferative Diabetic Retinopathy)

New Vessels (abnormal) - Proliferative diabetic retinopathy (Most common fundal abnormality that you’ll see)
These are dangerous because they are very fragile and can bleed very easily. à Impairs Vision



MACULAR ABNORMALITIES
(NORMAL Vs. ABNORMAL)

Age Related Macular Degeneration

- Loss of Vision in the Center of the Visual Field (the macula) due to Damage to the Retina.
- àCan make it Difficult/Impossible to Read or Recognize Faces, although enough peripheral vision remains to
allow other activities of daily life.
- Most common form of blindness in over 65s

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The Well-W man Heal h Check - (Breast, Pap Smear, Pelvic Exam):
Wash hands
Ask abo he ell oman s check
o Are they sexually active? When was their last pap smear? (Pap smears recommended every 2 years
starting 1-2 years after first sexual activity until death)
o Have they ever been screened for breast cancer? (Mammogram Screening is recommended every 2
years starting at age 50-70)
o Do they ish o be screened for STI s Gonorrhea Chlam dia HIV S philis Rec mmended F
< 25 years old for High Vaginal Swab Chlamydia +/- Urine Sample for Gonorrhoea)
Explain the examination & Get consent + ASK FOR A CHAPERONE.
Explain that the exam may be discontinued at their discretion
Ask px to undress and drape themselves in privacy and let you know when the re read
Ask: Any areas of concern?

The Breast Examination:

- General Inspection Pe d e O ange Skin P cke ing Ni le Re ac i n L m Ma e Di cha ge Te he ing :
o Sitting up with hands on hips
o Roll Shoulders forward
o Roll shoulders back
o Hands above head (do twice and look at both sides)
- Palpation:
o Sitting Up (Lymphadenopathy):
Lymph Nodes (Supraclavicular, Infraclavicular, Parasternal, Pectoral, Subscapular, Central,
Lateral)
o Lying Down with Arm Behind head (Firm Masses distinct from normal nodularity of breasts):
Zig Zag in a North-South Fashion starting at Upper Sternal Border, all the way across the breast,
and finish up in the tail (overlying the shoulder).
Start with light pressure, then deep pressure
Do not lift hand when moving to next area
Assess for Subareolar Masses
Assess for Nipple Discharge
NB: Whilst doing this, Educate Patient about Breast Awareness:
Do you do your own breast self examination? (Most lumps are found by themselves)
Yo don need a FamH o ge breas cancer > 90% breast cancer have no famHx)
Women with a FamHx of breast/ovarian cancer are at risk of developing breast cancer
Mammogram Screening is recommended every 2 years starting at age 50-70
o REMEMBER TO DO THE OTHER SIDE AS WELL!!
- Conclusion:
o E er hing looks heal h and normal
o Ok e are no going o mo e on o he pap smear and pel ic e amina ion Are o oka i h ha

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The Pelvic Examination

General Inspection & Palpation:

First I am going to inspect the external genitalia, you will feel my fingers palpating you, please put soles of feet
together and relax knees to side.
o Touch inner thigh before touching genitals
o Open labia majora
o Inspect labia minora, clitoral hood, urethral orifice, ask pt to bear down and inspect for
cyst/rectocele, urethra/uterine prolapse, inspect bartholins glands, fourchette, perineum, anus. Also
inspect skin, mons pubis, intertrigenous areas and hair distribution

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Speculum Examination & Pap Smear:
I will now insert the speculum so I can see your cervix and obtain a pap smear (and cultures)
o Pick up speculum in left hand. Apply lubricant to back 2/3 of speculum with right index finger. Switch
speculum to right hand
o Touch the inner thigh before touching genitalia
o Place bottom bill of speculum against the fourchette and introduce speculum into vagina with
downward pressure until it is fully inserted
o Open speculum by pressing on lever, open and adjust until cervix comes into view, tighten screw to
hold speculum in open position while accessing pap/culture supplies
o Obtain pap/cultures DON T FORGET TO SPRAY THE SAMPLES WITH FIXATIVE IMMEDIATELY
o Note position of cervix normal/prolapsed
o Note whether cervix is parous or nulliparous
o Note any discharge from cervix (mucoid, clear, yellow, bloody) or in vaginal vault
o Note if cervix is friable or has any lesions
o Note whether vagina is ruggae or is atrophic
o Release screw while keeping pressure on level (to avoid bills closing on cervix) remove speculum
approximately 1 cm and then release lever so speculum is closed as it is removed form the vagina
o Everything appears to the healthy and normal OR discuss abnormal findings after exam is completed
and px is dressed
Bimanual Pelvic Examination:
I am now going to do the bimanual exam this consists of inserting 2 gloved fingers into the vagina and
palpating the uterus and ovaries:
o Touch inner thigh before touching genitals
o Insert gloved index and middle finger of right hand into vagina with downward pressure on
fourchette, may say relax this muscle here
o Determine location of cervix, move fingers behind cervix and move cervix upward to test for cervical
mo ion enderness obser e p s face for reac ion
o Place fingers on cer i hile placing lef hand on p s abdomen and assess si e con our and mobility
of uterus
o Remove ringers a few cm and place along left side of cervix in fornix. Fingers point upward as left
hand palpates along left side of uterus to assess adnexa. Remove fingers a few cm and repeat on
right side
o Remove fingers and then glo es and sa o p e er hing appears heal h and normal I ll lea e so
o ma ge dressed I ill be back o ans er an q es ions o ma ha e
o Hand px box of tissues
o Rectal exam as indicated

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Clinical Investigations
Pap, GC/Chlamydia, other STI, urine pregnancy test, urinalysis, mammogram, breast/pelvic US.

Post Exam Education - explain

Any questions or concerns?
Explain Pap Smear:
o On is al inspec ion e er hing appeared Heal h and normal b e ill a ai he res l s of he pap
smear to see if there are any microscopic abnormalities.
o In the meantime, you may experience some mild spotting If this is severe go straight to the ED.
o Results are expected in one week. Arrange for call back.
o Would you like to be placed on the Pap Smear Register (free register which will inform you of when you
should come in for your next pap smear)
o Remind the patient that Screening pap smear is recommended every 2 years starting 1-2 years after first
sexual activity, and for as long as sexually active.
Thank the patient and conclude the examination.

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 Gynaecological History:

Introduction
Consent – Can I ask you some questions regarding your reproductive and sexual health?
Menstrual History
- Age of Menarche (& Menopause if relevant)?
- LMP – Last menstrual period? (& Was the last period ‘normal’?)
- Regularity of periods? (N ≈Predictable timing of menses)
o Duration of cycle? (N ≈28days)
o Duration of menstruation? (N ≈5days)
o (NB: Irregular can = PCOS/Stress/Anorexia/PID/Fibroids/etc)
- Quantity of bleeding? (Amenorrhoea, Menorrhagia)
- Intermenstrual Bleeding – Ie. bleeding between periods?
- Dysmenorrhoea – Ie. Painful periods?
- Dyspareunia – Painful Intercourse (Endometriosis)
- Associated Symptoms: Abdominal pain, Fever, Vaginal Discharge
Sexual History:
- Are you sexually active?
- Do you currently have one or more sexual partners?
- Heterosexal/Homosexual
- How many sexual partners have you had in the past 6 months?
- Have you ever been diagnosed with any STIs?
o Which ones?
o Treated?
- Last STI screen?
- Do you practice safe sex?
Contraceptive use:
- Any current contraceptives?
o Which one/s?
o For how long?
o Compliance?
o Understanding of how to use it effectively?
o Any side effects? (weight gain, mood swings)
- Any past contraceptives?
- Barrier protection
Past Gynaecological History?
- Up to date with Pap-Smears?
- Gardasil Vaccinations? – All 3?
- Results of last Pap-Smear?
- Any Previous Smear Abnormalities?
- Previous Colposcopy?
Past Gynaecological Surgeries?
- LLETZ Procedures? (For CIN1/3)
- Cone Biopsy? (For CIN1/3)
- Hysterectomy?
- Oophorectomy?
- Tubal Ligation? (For Contraception)

(Other History):
- Obstetric History
- PMH
- PSH
- Current Medications
- Allergies
- SocHx
- Systems Review
- Examination

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Male Genitourinary Exam
Sequence
1. Wash hands
2. Introduce your self
3. Ask the patient’s name
4. Ask the patients age
5. Explain the procedure
a. Involves inspection and palpation of the penis, testes and examination for hernia’s.
6. Ask the patient to gown or drape.
7. Ask the patient to expose their groin and genitalia
8. Px can be lying or standing standing preferable hernia’s are more easily seen this way
9. General appearance
a. Anxious
b. Comfortable
c. In distress
d. Unable to stand
10. Penis
a. GLANS TO SHAFT
i. Glans
1. Comment on circumcision
2. Urethra location hypospadia’s , discharge px may need to milk to penis
a. Press end to open urethra
3. Retract prepuce smegma, phimosis, paraphimosis
ii. Shaft
1. Inspect - vesicles, verruca (condyloma acuminatum), ulcerations, nodules, scars,
inflammation (balanitis)
2. Palpate for tenderness, induration, deformity,
iii. Skin at base of shaft
1. Excoriation, inflammation, burrows, nits, lice
iv. Hair of pubic region
b. Scrotum
i. Inspect
1. Rashes, epidermoid cyst, other lesions
2. View above, below, lift penis
ii. Palpate
1. Testis + epididymis
a. Size, shape, consistency, nodules
2. Spermatic cord
3. Transluminate mass
11. Hernia Evaluation
a. Inguinal
i. Inspect
1. Ask px to bear down, cough
ii. Palpate
1. Right index finger for right inguinal
2. Ask px to cough
3. A hernia will touch your finger
iii. Auscultate
1. Bowel sounds
b. Femoral
i. Inspect
ii. Palpate
1. Femoral artery hernia will be around there somewhere
2. Ask px to cough

RECOMMEND
Self examination of the testicles every month
Clean the inside of the penis if uncircumcised
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Male Digital Rectal Examination & Prostate Examination:
12. Patient in Left Lateral Position Get them to shuffle towards the edge of the bed until they touch your hip
13. General Inspection of Perineum (Scars, Fissures, Haemorrhoids, Skin Tags, Infection, Discharge)
14. “Ok we’re going to begin the rectal examination now
15. Lubricate Index Finger and place on the anus, tell the patient to exhale or bear down, and as they do, curl your
finger inside the anus.
16. Assess Sphincter tone & power by asking them to tighten their anus
17. Rotate finger a full 360o noting:
a. rectal masses, tenderness, faeces
b. Prostate: Normal rubbery & smooth with median sulcus? Nodular, hard and enlarged? Loss of median
sulcus? Tenderness (Prostatitis)
18. Advise patient that you’re removing your finger.
19. Wipe finger onto white towel and inspect for any blood, pus or mucus.
20. Wipe patient’s anus with towel
21. Advise patient to get dressed

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Pictures

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 Full & Focussed Cardiovascular Exams

Full Cardio Exam:

- Introduction + Consent + Wash Hands
- General Inspection:
o Body Habitus:
Cardiac Cachexia (Portal Hypertension/RHF)
Obesity (Diabetes/Dyslipidaemia/Poor Diet)
o Alert & Orientated?
o Dyspnoea/Respiratory Distress (CCF, Pulmonary Hypertension, Corpulmonale, MI)
o Discomfort/Pain (Angina, MI, Pericarditis, Tamponade)
o Diaphoresis (Angina, MI, Pain)
o Chest Deformities/Surgical Scars (CABG, Valve Repairs)
o Congenital Facies Marfan s Down s Turner s Syndromes
- Vital Signs:
o Pulse:
Tachycardia (Shock, MI, Pain, Anaemia)
Irregular (AF MI, Alcohol, Mitral Regurg/Stenosis)
Low Volume (Shock, MI, Tamponade)
o Respiratory Rate:
Tachypnoea (Shock, MI, Pain, Anaemia)
o Blood Pressures:
Hypertension (Pain, Essential Hypertension)
Hypotension (Shock, Heart Failure)
o Temperature:
Fever (Infective Endocarditis, Pericarditis, Myocarditis)
- Hands:
o Perfusion + CRT
o Pale Nails & Palmar Crease Pallor (Anaemia)
o Palmar Erythema (Polycythaemia)
o Peripheral Cyanosis (Heart Failure, Pulmonary Oedema)
o Clubbing (Chronic Cyanosis eg Cyanotic Heart
o Splinter Haemorrhages Osler s Nodes Painful Fingertips)/Janeway Lesions (Palms Infec.Endo)
o Xanthomata (Cholesterol in tendons - Dyslipidaemia)
o Dupuytren s Contracture Alcohol Dilated Cardiomyopathy)
- Arms:
o RR-Delay (Coarctation of the Aorta)
o RF-Delay (Coarctation of the Aorta)
o Track marks (IVDU/Infec.Endo)
- Face:
o Eyes:
Conjunctival Pallor (Anaemia)
Scleral Icterus (Jaundice)
Xantholasma (periorbital cholesterol)
Fundoscopy for Roth s Spots (Infective Endocarditis)
Arcus Senilis (Sign of CVD risk factors)
o Mitral Facies/Malar Rash (Mitral Stenosis)
o Mouth:
Hydration
Central Cyanosis/Peripheral Cyanosis (CCF - Pulmonary Oedema
Gum Pallor (Anaemia)
Poor Dental Hygeine (Infec.Endo)
High Arched Palate Marfan s Syndrome
- Neck:
o JVP (RVF, Pulmonary Hypertension) + Hepatojugular Reflex
o Jugular Venous Pulsations (Tricuspid Regurgitation)
o Carotid Pulses (Character/Volume)
o Carotid Bruits (Carotid Stenosis Atheroma)

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- Chest:
o Inspection:
Scars (CABG, Sternotomy)
Chest Deformities (Pectus Excavatum, Pectus Carinatum, Barrell Chest, Kyphosis, Lordosis)
Bruising
Visible Apex Beat
Pacemaker
o Palpation:
Apex Beat (Normally 5ICSMCL) Displaced in Cardiomegaly & Hypertrophic Cardiomyopathy.
Heaves (Mitral/Tricuspid Regurgitation)
Thrills (Palpable Systolic Murmurs)
o Percussion (NOT NECESSARY):
Heart Borders
o Auscultation:
Muffled Heart Sounds (COPD, Tamponade)
Murmurs (Mitral/Tricuspid/Aortic/Pulmonary Valves) (Bell Diastolic)(Diaphragm Systolic)
+/- Axillary/Carotid Radiation
Pericardial Friction Rub (Pericarditis)
- Back:
o (+ Respiratory if CCF – Basal Inspiratory Crackles)
o Sacral Oedema (RHF)
- Abdomen – LYING FLAT!!:
o Visible Pulsatile Masses (Aneurysm)
o Scars
o Tenderness
o Hepatomegaly (Portal Hypertension/RHF)
+ Pulsatile (If Tricuspid Regurg)
o Splenomegaly (Infec.Endo)
o Ascites/Shifting Dullness/Fluid Thrill (RHF)
o Aortic Width (Aneurysm)
o Renal Bruits
- Legs & Feet:
o Peripheral Oedema (RHF)
o Venous Stasis (Shiny Skin, Hair Loss, & Venous Ulcers)
o Calf Tenderness (PVD, PE)
o Arterial Ulcers
o Pulses (Popliteal/Dorsalis Pedis/Posterior Tibial)
o Cap Refill/Warm/Well Perfused
o Clubbing
o Splinters/Janeways/Oslers

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 Full & Focussed Endocrine Exams

Full Endocrine Exam:

- Introduction, Wash Hands, Consent,
- General Inspection:
o Facies:
Moon Facies (Cushings),
Frightened Stare (Graves - Hyperthyroidism)
Anhedonic + Puffy Eyes (Hashimotos Hypothyroidism)
Frontal Bossing, Enlarged Jaw/Tongue/Nose/Ear/Brow (Acromegaly)
H e igmen ed Wa ing Addi on
Hirsutism + Receding Hairline (PCOS)
o Body Habitus:
Obe i D M C hing H o h oidi m
Wa ing D M Addi on Hyperthyroidism)
Cen al Adi o i C hing Syndrome)
o Hair Distribution:
Hair Loss (Hypothyroidism)
Hi i m C hing PCOS
o Pigmentation:
Generalised Hyperpigmentation (Addisons, Haemochromatosis)
Acanthosis Nigricans (Diabe e C hing Ac omegal PCOS)
o Mental Changes:
Slowness (Hypothyroidism, DKA, HONC Addi on )
Affec H o h oidi m
- Vital Signs:
o Pulse:
Tachycardia (Hyperthyroidism, Phaeochromocytoma, DKA)
Bradycardia (Hypotension)
o Blood Pressure:
Hypertension (Hyper & Hypo h oidi m Phaeo C hing Conn PCOS Ac omegal
Hypotension (Addi on
o Respiratory Rate:
Typically Normal
Tachypnoea (DKA)
o Temperature:
Hyperthermia (Hyperthyroidism)
Hypothermia (Hypothyroidism)
- Hands:
o Warm, Well Perfused CRT,Erythema,Sweaty (Hyperthyroidism/Phaeochromocytoma/Acromegaly)
o Cool, Poorl Pe f ed CRT, P.Cyanosis, Dry (Hypothyroidism)
o Tremor (Hyperthyroidism, Phaeochromocytoma)
o Cl bbing Th oid Ac o a h G a e Di ea e[Hyperthyroidism])
o Pl mme Nail On chol i G a e s Disease [Hyperthyroidism])
o Brittle Nails (Hypothyroidism)
o Palma C ea e Pigmen a ion Addi on Di ea e
o Large, Spade-like Hands (Acromegaly)
o O eoa h i ic Hebe on Bo cha d Nod le Ac omegal
o Xanthomata (Hypothyroidism, Diabetes, Cushings, Acromegaly, PCOS)
- Arms:
o Proximal Myopathy (Hyperthyroidism, Hypothyroidism, C hing Acromegaly)
o Hyperreflexia (Hyperthyroidism); Hung Reflexes (Hypothyroidism)
o M cle Wa ing Diabe e Addi on

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- Face:
o (Conjunctival Pallor, Central/Peripheral Cyanosis)
o Receding Hairline + Loss of Lateral 1/3 Eyebrow + Periorbital Myxoedema (Hypothyroidism)
o Exophthalmos + Lid Lag (Hyperthyroidism)
o Xanthelasma (Hypothyroidism, Diabe e C hing Ac omegal PCOS
o Bitemporal Hemianopsia (Pituitary Adenomas C hing H e h oidi m Ac omegal
Prolactinoma, Conn )
o Fundoscopy (Hypertensive & Diabetic Retinopathy)
o B ccal H e igmen a ion Addi on
o Mouth Infections (Diabetes, Cushings)
o Facies:
Moon Facies (Cushings),
Frightened Stare (Graves - Hyperthyroidism)
Anhedonic + Puffy Eyes (Hashimotos Hypothyroidism)
Frontal Bossing, Enlarged Jaw/Tongue/Nose/Ear/Brow (Acromegaly)
H e igmen ed Wa ing Addi on
Hirsutism + Receding Hairline (PCOS)
- Neck:
o Thyroid Gland Examination:
General Inspection:
Thyroidectomy Scars
Goitre (Hyperthyroidism/Hypothyroidism)
Swallow Test (Is it mobile?)
Palpation From Behind:
Locate Thyroid Gland (2cm below laryngeal prominence)
Goitre (Hyper/Hypo) Size, Consistency, Tenderness, Mobility, Thrill
Swallow Test (Mobility)
Cervical Lymphadenopath G a e Ha himo o
Auscultate:
Thyroid Bruits (Hyperthyroidism)
Retrosternal Goitre?:
Pembe on Sign
Abdominojugular Reflux
JVP
Percuss Across Sternum
o Acan ho i Nig ican Diabe e C hing Acromegaly, PCOS)
o Buffalo Hump & Supraclavicular Fa Pad C hing
o Ca o id B i Diabe e C hing Ac omegal PCOS
- Chest:
o Hair Distribution (PCOS)
o Gynaecomastia (Hyperthyroidism, C hing Acromegaly)
o Bony Tenderness (Cushings[Osteoporosis], Hyperparathyroidism[Osteoclast], Acromegaly[Growth])
o Hypertrophic Cardiomyopathy (Acromegaly) Murmurs, Displaced Apex Beat
o Pericardial Effusion + Pleural Effusion (Hypothyroidism)
o Molluscum Fibrosum in Axilla (Acromegaly)
- Abdomen:
o Central Adiposity (Type2Diabe e C hing )
o Obesity (Type2Diabetes, C hing s, Hypothyroidism, PCOS[Metabolic Syndrome])
o S iae C hing
o Fat Atrophy @ Injection Sites (Diabetes)
o Hepatomegaly (Diabetes[fatty liver], PCOS[fatty liver], Acromegaly[GH stimulation])
o Hepatomegaly + Splenomegaly + Renal Enlargement (Acromegaly)
o Adrenal Masses (C hing Addi on Conn s, Phaeochromocytoma)
o Ovarian Masses (PCOS)
o Bo el So nd H e h oidi m Bo el So nd H o h oidi m

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- Legs:
o Proximal Myopathy (Hypethyroidism, Hypothyroidism, C hing Acromegaly)
o Quadriceps Atrophy (Diabetes)
o Fat Atrophy @ Injection Sites (Diabetes)
o Pretibial Myxodema (Hyperthyroidism); Non-Pitting Oedema (Hypothyroidism)
o Shiny, Hairless Skin + Pitting Oedema (Diabetes PVD)
o Cha co Join Diabe e
o Arterial/Venous Ulcers (Diabetes)
o Hyperreflexia (Hyperthyroidism); Hung Reflexes (Hypothyroidism)
o Foot-Drop (Acromegaly[Common Peroneal Nerve Entrapment])
- Feet:
o Tendon Xanthomata (Hypothyroidism, Diabe e C hing Ac omegal PCOS
o Wa m Well Pe f ed E hema CRT S ea H e h oidi m Acromegaly)
o Cool Poo l Pe f ed CRT P C ano i D H o h oidi m
- Diabetic Leg & Foot Exam:
o General Inspection:
Quadriceps Wasting (Diabetic Amyotropy)
Shiny Skin + Hair Loss + Pitting Oedema + Venous Stasis Ulcers
Arterial Ulcerations
Neuropathic Ulcerations
Necrobiosis Diabeticorum
Tendon Xanthomata
Peripheral Perfusion + CRT + Peripheral Pulses
Bunions (Hyperkeratosis on Pressure Points)
Halux Valgus, Pes Cavus, Loss of Transverse Arch, Hammer Toes
Fungal Infections of Nails & Between Toes
o Neurological Testing Pt s Eyes Closed
Monofilament[light touch] on 10 Areas of Feet
Monofilament[light touch] on All Dermatomes of Leg
Vibration Sense Start as distally as possible
Proprioception Sense
Pain Sense Over All Dermatomes of Leg
Muscle Power
Reflexes

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Diabetic Patient Focussed Examination:
- Introduction + Wash Hands + Consent
- General Inspection:
o Obese Body habitus
o Acanthosis Nigricans
o Xanthelasma
o Fat Atrophy @ Insulin Injection Sites
o Endoc ine Facie C hing Ac omegal PCOS
o Pigmentation (Haemochromatosis)
- Vital Signs:
o Tachycardia (if Dehydrated)
o Hypotension (if Dehydrated)
o Tachypnoeic (If DKA)
o Febrile (If Infection)
- Lower Extremities:
o General Inspection:
Quadriceps Wasting
Fat Atrophy @ Insulin Injection Sites
PVD: Hair Loss + Shiny Skin + Oedema + Venous Ulcers
Arterial Ulcers
Neuropathic Ulcers
Cha co Join
Pes Cavus, Loss of Transverse Arch, Hammer Toes, Halux Valgus
Fungal Nail Infections
Infections/Cuts Between Toes
o Palpation:
Muscle Wasting
Temperature
Perfusion (CRT & Pulses)
o Neurological Examination Patient s Eyes Closed
Soft Touch (Monofilament):
All 10 Areas of the foot
All Dermatomes of the Leg
Vibration:
Tuning Fork on Toes
Proprioception:
Big Toe
Pain:
All Dermatomes of Leg (But NOT the sole of foot)
Muscle Power:
All movements
Muscle Reflexes:
Patellar Tendon
Archilles Tendon
Babinski (Positive if Upgoing)(Normal = Downgoing)
o Further Examinations & Tests:
Cardiovascular Examination
Respiratory Examination
Eye Exam + Fundoscopy
BSL + Urine Dipstick + HBA1C
Candida Mouth Infections
Acetone Fetor
Carotid & Renal Bruits
Hepatomegaly (Fatty Liver/Haemochromatosis)

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Hyperthyroid Focussed Examination:
- Introduction + Wash Hands + Consent
- General Inspection:
o Weight Loss
o Flushing
o Sweating
o Anxiety
o Frightened Stare + Exophthalmos
o Goitre
o Hoarseness
- Vital Signs:
o Tachycardia
o Hyperthermia
o Hypertension
- Hands:
o Hand Wa m Well Pe f ed CRT S ea E hema o
o Hyperthyroid Acropathy (Clubbing, Swelling & Redness of Fingers)
o Onycholysis Pl mbe Nail (Separation of Nails from Nailbed)
o Hand Tremor
- Arms:
o Proximal Myopathy (Weakness Abducting Arm)
- Face:
o (Standard check for: Conjunctival Pallor, Central Cyanosis, Peripheral Cyanosis)
o Frightened Stare + Exophthalmos + LID LAG
o Bitemporal Hemianopsia (If Central Hyperthyroidism)
o Pembe on Sign
o Fundoscopy (hypertensive changes)
- Neck:
o Thyroid Examination:
General Inspection:
Thyroidectomy Scars
Goitre
Swallow Test
Palpation (From Behind):
Locate Thyroid (2cm below Laryngeal Prominence)
Palpate Size, Consistency, Nodules, Mobility, Thrills, Tenderness
Swallow test (Mobility)
Percuss:
Retrosternal goitre
Auscultate:
Thyroid Bruits
o Cervical Lymphadenopathy:
Submental/Submandibular/Pre-Auricular/Post-Auricular/Occipital/Jugular Chain/Posterior
Triangle)
- Chest:
o Gynaecomastia
- Abdomen:
o Hepatojugular Reflux (Retrosternal Goitre)
- Legs:
o Pretibial Myxoedema
o Proximal Myopathy
- Feet:
o Wa m Well Pe f ed CRT E hema S ea
- Thank Patient That concludes my examination, now I d like to run some tests

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Hypothyroid Focussed Examination:
- Introduction + Wash Hands + Consent
- General Inspection:
o Hypothyroid Facies (Apathetic, Puffy Eyes, Loss of Lateral Eyebrows, Thinning of Hair)
o Obesity
o Oedema
o Men al Slo ne Affec
- Vital Signs:
o Bradycardia
o Hypothermia
o Hypertension
- Hands:
o Cool Poo l Pe f ed CRT Pe i he al C ano i D
o Brittle nails
o Xanthomata
o Palmar Crease Pallor + Koilonychia (Menorrhagia)
o Inverse Prayer Test for Carpal Tunnel
- Arms:
o Proximal Myopathy (Abduction Weakness)
o Hung Reflexes
- Face:
o Conjunctival Pallor (Menorrhagia)
o Central/Peripheral Cyanosis
o Loss of Lateral 1/3 of Eyebrow
o Periorbital Myxoedema
o Xanthelasma
o Fundoscopy (Hypertensive Changes)
- Neck:
o Thyroid Examination:
General Inspection:
Thyroidectomy Scars
Goitre
Mobility (Swallow Test)
Palpation (From Behind):
Locate Thyroid Gland (2cm Below Laryngeal Prominence)
Goitre (Hyper/Hypo) Size, Consistency, Tenderness, Mobility, Thrill
Swallow Test (Mobility)
Cervical lymphadenopathy:
Submental/mandibular, Pre/Post-Auricular, Occipital, Jugular Chain, Post-Triangle
o Pembe on Sign (Retrosternal Goitre)
o JVP
- Chest:
o Percuss for Retrosternal Goitre
o Pericardial Effusion (Soft Heart Sounds)
o Plerual Effusion (Stony Dullness)
- Abdomen:
o Abdominojugular Reflux (Retrosternal Goitre)
o Obesity
- Legs:
o Non-Pitting Oedema
o Proximal Myopathy (Squat)
o Hung Leg Reflexes
- Feet:
o Cool Poo l Pe f ed CRT Pale D
o Xanthomata
- Thank patient that concludes my examination , I ll go organise further tests

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Cushing s Focussed Examination
- Introduction + Wash hands + Consent
- General Inspection:
o Central Adiposity
o Obesity
o Moon Facies
o Buffalo hump
o Striae
o Hirsutism
- Vital Signs:
o Hypertension
- Hands:
o Warm & Well Perfused, Normal CRT
o Standard: No Palmar Crease Pallor
o Xanthomata
- Arms:
o Easy Bruising
o Poor Wound Healing
o Proximal Myopathy (Ab/Adduction)
- Face:
o Characteristic Moon Facies
o Xanthelasma
o Fundoscopy (Hypertensive & Hyperglycaemic Changes)
o Bitemporal Hemaniopsia (if Pituitary Adenoma)
o Mouth Infections
- Neck:
o Carotid Bruits (Hypercholesterolaemia)
o Acanthosis Nigricans
- Chest:
o Gynaecomastia
o Bony Tenderness (Osteoporosis)
- Abdomen:
o Central Adiposity
o Striae
o Adrenal Masses
- Legs:
o Easy Bruising
o Poor Wound Healing
o Proximal Myopathy (Squat)
- Feet:
o Tendon Xanthomata

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Acromegaly Focussed Examination:
- Introduction + Wash Hands + Consent
- General Inspection:
o Acromegalic Facies Frontal Bossing, Prominent Jaw/Brow Ridge/Nose/Lips/Tongue
- Vital Signs:
o Hypertension
- Hands:
o Large Spade-Hands
o Wa m Well Pe f ed CRT Palmar Erythema, Sweaty-Greasy Hands
o Thickened Skin
o Xanthomata
o Osteoarthritis Hebe on Nod le Bo cha d Nod le
- Arms:
o Proximal Myopathy (Ab/Adduction)
- Face:
o Acromegalic Facies Frontal Bossing, Prominent Jaw/Brow Ridge/Nose/Lips/Tongue
o Xanthelasma
o Bitemporal Hemianopsia (Pituitary Adenoma)
o Fundoscopy (Hypertensive Changes)
- Neck:
o Acanthosis Nigricans
o Ca o id B i d e o chole e ol
- Chest:
o Gynaecomastia
o Bony Tenderness (Ribs & Spine) due to Osteoarthritis
o Molluscum Fibrosum in Axillae (Skin Tags)
o Hypertrophic Cardiomyopathy (Displaced Apex Beat, Murmurs & Signs of CCF)
- Abdomen:
o Hepatomegaly
o Splenomegaly
o Renal Enlargement
- Legs:
o Proximal Myopathy (Squat)
- Feet:
o Enlarged Feet
o Warm, Well-Pe f ed CRT E hema S ea
o Tendon Xanthomata
- Thank patient that concludes my examination , I ll go organise further tests

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Addison s Disease Focussed Examination
- Introduction + Wash hands + Consent
- General Inspection:
o Wasting (Weight Loss)
o Hyperpigmentation
o Obvious Fatigue
o Mental Slowness
- Vital Signs:
o Hypotension (Hypovolaemia)
o Tachycardia (Hypovolaemia)
- Hands:
o Warm & Well Perfused, Normal CRT,
o Palmar Crease Pigmentation
- Arms:
o Generalised Muscle Weakness
o Muscle Wasting
- Face:
o Wasting (thin face)
o Hyperpigmented + Pigmented Buccal Mucosae
o Dry Mucosae (Dehydration)
- Neck:
- Chest:
- Abdomen:
o Adrenal Masses
- Legs:
o Generalised Muscle Weakness
o Muscle Wasting
- Feet:
o Warm & Well Perfused, Normal CRT,

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PCOS Focussed Examination:
- Introduction + Wash Hands + Consent
- General Inspection:
o Hirsutism (Hair + Acne)
o Receding Hairline
o Obesity (Metabolic Syndrome)
o (Not Pregnant[infertile])
- Vital Signs:
o Hypertension
- Hands:
o Warm & Well Perfused
o No Palmar Crease Pallor
o Hirsutism (Hairy Dorsum of Hands)
o Xanthomata
- Arms:
o Hi i m Hai
- Face:
o Xanthelasma
o Fundoscopy (Diabetic & Hypertensive Retinopathy)
o Hirsutism (Facial Hair & Acne)
o Deepening Voice
- Neck:
o Acanthosis Nigricans (Metabolic Syndrome)
o Ca o id B i Chole e ol
- Chest:
o Hirsutism (Chest Hair)
- Abdomen:
o Ovarian masses/Tenderness
o PV Examination
o Central Adiposity (Metabolic Syndrome)
- Legs:
o Hirsutism (hair)
- Feet:
o Tendon Xanthomata

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 Full & Focussed GI Exams

Full GI/Abdo Exam:

- Introduction, Wash Hands, Consent,
- General Inspection:
o Alertedness/Orientation
i He a ic E ce ha a h (Ammonia)
in Uraemic Encephalopathy
o Pain/Distress (Acute Abdomen, Appx, Pancrx, Cholecystx, Diverticx, B.Obstrucx, Perforation, etc)
o Body Habitus:
Obesity (Fatty liver, Diabetes, Ascites, GORD)
Cachexia (Malignancy, Malabsorption, Crohns/UC)
o Colour:
Jaundice (Hepatitis, Cholelithiasis, Liver Failure, Cirrhosis, Haemolysis)
Pallor (Anaemia, Malignancy, Malabsorption, GI Bleeding)
Pigmentation (Haemochromatosis)
Bruising, Bleeding, Petechiae (Liver Failure, Haematological Malignancy)
- Vital Signs:
o Pulse:
Tachycardia (Anaemia, Blood Loss, Pain, Infection)
AF (Dilated Cardiomyopathy in Alcoholism)
o Blood Pressure:
Hypertension (Renal Failure, Pain)
Hypotension (Blood Loss, Shock)
Postural Hypotension (Anaemia)
o Respiratory Rate:
Tachypnoea (Pain, Anaemia)
o Temperature:
Fever (Infection)
- Hands:
o Perfusion + CRT
Warm & Sweaty (Carcinoid) + (Hyperthyroid, Phaeox, Acromegaly)
Cool & Dry (Shock, Hypovolaemia)
o Cl bbing C hn Di ea e Ulce a i e C li i Ca diac Re Di ea e Th id Ac a h
o Leukonychia & M e cke Line (Hypoalbuminaemia Liver Failure, Nephrotic Syndrome)
o Koilonychia (Iron Deficiency Blood Loss, GI Bleed, Malabsorption)
o B eL ae Wi C e Di ea e
o Palmar Crease Pallor + Pale Nails (Anaemia)
o Pa a E he a Oe ge i Li e Di ea e
o D e C ac e A c h ic He a i i Ci h i
o Xanthomata ( Ch e e Fatty Liver, Nephrotic Syndrome, Diabetes)
o Hepatic Flap (Asterixis Hepatic Encephalopathy)
- Arms:
o Bruising, Petechiae
o Scratch Marks (Uraemic Pruritis)
o Uraemic Frost
o Acanthosis Nigricans in Axilla (GI Malignancy)
- Face:
o Eyes:
Conjunctival Pallor (Anaemia)
Scleral Icteris (Jaundice)
Ke e F ei che Ri g Wi Di ea e
I i i C h s/Ulcerative Colitis)
Xa he a a Ch e e Biliary Obstruction, PBC, Cirrhosis, Diabetes)

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 o Mouth:
Hydration
Parotid Gland Enlargement (Alcoholism)
Central/Peripheral Cyanosis
M c a U ce C h UC
Glossitis/Angular Stomatitis (Anaemia, Alcoholism B12, Malabsorption B12)
Pe Jeghe Pig e a i
Fetor Hepaticus
Mucosal Petechiae
Leukoplakia (Spirits, Smoking, Sepsis, Syphilis, Shit teeth)
- Neck:
o S ac a ic a L h N de Vi ch N de GI L g Ma ig a c
- Chest:
o G aec a ia Oe ge Liver Failure)
o S ide Naei i Oe ge Liver Failure)
- Abdomen:
o Inspection:
Abdominal Distension (Ascites, Obstruction)
Scars
Visible Masses (Cancer, Hernias)
Visible Peristalsis (Obstruction)
Bruising, Petechiae (Liver Failure)
C e G e T e Sig Pa c ea i i Hae ei e
Caput Medusa (Portal HTN, Cirrhosis)
Striae
Vesicles (Shingles)
o Palpation:
Light Palpation Tenderness, Guarding, Rigidity, Rebound? (Peritonitis)
Deep Palpation Masses?
Hepatomegaly (Fatty Liver, Portal HTN, Hepatitis, Hepatocellular Carcinoma, Polycystic Liver)
Small Liver (Cirrhosis)
Pulsatile Liver (Tricuspid Regurg)
Splenomegaly (Infection, Haem.Malignancy)
Ballott Kidneys
Aortic Aneurysm
Para-Aortic Lymph Nodes (Malignancy, Infection)
o Special Tests:
Cholecystitis: M he Sig
Appendicitis: R i g s Sign, Pai Mcb e s Point, Psoas Sign, Obturator Sign.
Pyelonephritis/Renal Stones: M he s Kidney Punch
o Percussion:
Ascites & Shifting Dullness (Portal HTN, Liver Failure, Renal Failure) + (Heart Failure)
Percuss for Splenomegaly & Hepatomegaly
o Auscultation:
Bowel Sounds (Absent in Ileus)
Renal Bruits
o + Deferred PR Exam for Cancer, Blood, Malena.
- Legs:
o Pitting Oedema (Liver Failure, Renal Failure)
o Bruising, Petechiae (Liver Failure)
o Varicosities (Portal Hypertension)
- Feet:
o Perfusion & CRT
o Xa h a a Ch e e Biliary Obstruction, PBC, Cholelithiasis)
o Le k n chia M e cke Line (Hypoalbuminaemia Liver Failure, Nephrotic Syndrome)
o Cl bbing C hn Di ea e Ulce a i e C li i

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 Full & Focussed Haematology Exams

Full Haematology Exam:

- Introduction, Wash Hands, Consent,
- General Inspection:
o Wasting, Cachexia (Malignancy)
o Mediterranian Origin & Frontal Bossing (Thallassaemias)
o African Origin (Sickle Cell Anaemias)
o Gross Pallor (Anaemia & All Haem Malignancies)
o Jaundice & Scratch Marks (Haemolytic Anaemia)
o Cyanosis
o Facial Plethora (Polycythaemia, SVC obstruction from Lymphoma)
o Bruising, Bleeding, Petechiae, Purpura (Thrombocytopaenia, Haemophilia & All Haem Malignancies)
o Neck Swellings (Lymphoma & All Haem Malignancies)
o Abdominal Distension (Organomegaly due to Infection & All Haem Malignancies)
- Vital Signs:
o Pulse:
Tachycardia (Infection, Anaemia)
o Blood Pressure:
Postural Hypotension (Anaemia)
o Respiratory Rate:
Tachypnoea (Anaemia)
o Temperature:
Fever (Malignancy, Infection)
- Hands:
o Warm/Well Perfused + CRT
o Palmar Crease Pallor (Anaemia)
o Peripheral Cyanosis
o Koilonychia (Spoon Nails) and Pale Nails (Iron Deficiency Anaemia)
o Palmar Erythema (Polycythaemia, Chronic Leukaemias)
o Bl e L n lae Wil on Di ea e
o Digital Infarcts Ra na d (Rheumatoid, Multiple Myeloma)
o Arthropathy (Rheumatoid, Connective Tissue Disease, Haemophilia)
o Gouty Tophi Cell T rno er in Malignanc , Myeloproliferative Diseases & Hb Disorders)
o D p ren Contracture (B12 Deficiency, Alcoholism & Megaloblastic Anaemia)
- Arms:
o Bruising, Petechiae, Purpura (Haemophilia, Thrombocytopaenia & All Haem Malignancies)
o Scratch Marks (Jaundice Haemolytic Anaemia)
o Epitrochlear & Axillary Lymph Nodes (All Haem Malignancies)
Supraclavicular, Infraclavicular, Parasternal, Subpectoral, Subscapular, Central, Lateral
- Face:
o Conjunctival Pallor, Angular Stomatitis, Atrophic Glossitis (Anaemia)
o Scleral Icteris
o Central/Peripheral Cyanosis
o Facial Plethora (Polycythaemia)
o Pember on Sign SVC Ob r c ion d e o L mphoma
o Buccal Petechiae (Thrombocytopaenia, Haemophilia, Bleeding Disorders & All Haem Malignancies)
o Candidal Mouth Infections (All Haem Malignancies)
o Gum Hypertrophy + Bleeding (AML - Acute Myeloid Leukaemias)
o Gum Hypertrophy (Methotrexate Chemotherapy)
o Enlarged Tonsils (MALT Lymphoma)
o Wasting (All Haem Malignancies)

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- Neck:
o Cervical Lymph Nodes (Submenta/Submandibular/Pre/Post-Auricular/Occipital/Jugular/Post-Triangl)
(In All Haem Malignancies)
Firm, Non-Tender, Immobile = Malignancy
Tender, Mobile = Infection
Site
Size (>1cm)
Consistency (Hard Carcinoma; Rubbery Lymphoma)
Tenderness (Infection)
Mobility (Fixed if Malignant)
o Neck Swellings/Masses
o **Check for Dysphagia/Odynophagia (Plummer Vinson Oesophageal Web from Iron def. Anaemia)
o Thyroid Examination (As Hypothyroidism can menorrhagia)
o BCC/SCCs from Immunosuppression (Chemotherapy)
o Radiotherapy Tattoos
- Chest:
o Bruising, Petechiae, Purpura (Bleeding Disorders, Haemophilia, Thrombocytopaenia & All Haem
Malignancies)
o Chest Infections (Immunosuppression)
o Systolic Flow Murmur (Severe Anaemia)
o ***Bony Tenderness (ALL Haematological Malignancies) - Ribs, Clavicles, Spine, Hips.
- Abdomen:
o Bruising, Petechiae, Purpura (Bleeding Disorders, Haemophilia, Thrombocytopaenia & All Haem
Malignancies)
o Hepatomegaly, Splenomegaly (All Haem Malignancies)
o Para-Aortic Lymph Nodes
o Ascites
o Per Rectal Examination Blood on Stool
o Palpate Kidneys (Signs of Renal Failure Anaemia of Chronic Disease)
- Inguinal:
o Inguinal Lymph Nodes (All Haem Malignancies)
o Testicular Masses in Children (ALL Acute Lymphoblastic Leukaemia)
o DRE (Lymphoma)
- Legs:
o Bruising, Petechiae, Purpura (Bleeding Disorders, Haemophilia, Thrombocytopaenia & All Haem
Malignancies)
o Scratch Marks (Haemolytic Jaundice)
- Feet:
o Peripheral Perfusion & CRT
o Koilonychia & Pale Nails (Iron Deficiency Anaemia)
o Sole Erythema (Polycythaemia)
o Go Tophi Cell T rno er in M eloprolifera i e Di ea e Hb Di order

- Thank a ien ha concl de m e amina ion I ll go o gani e f he e

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Focussed Anaemia Examination:
- Introduction, Wash Hands, Consent,
- General Inspection:
o Alert & Oriented
o Racial Origin (African = Sickle Cell Anaemia; Mediterranean = Thallassemia)
o Gross Pallor (Anaemia), Jaundice (Haemolytic Anaemia), or Cyanosis.
o Scratch Marks (Jaundice from Haemolytic Anaemia)
o Bruising, Petechiae, Purpura (Thrombocytopaenia any Haem Malignancies)
- Vital Signs:
o Pulse:
Tachycardia
o Blood Pressure:
Postural Hypotension
o Respiratory Rate:
Tachypnoea
o Temperature:
Normal
- Hands:
o Warm & Well Perfused + CRT
o Koilonychia (Iron Deficiency Anaemia)
o Pale Nails (General Anaemia)
o Leukonychia (Chronic Kidney Disease Hypoalbuminaemia)
o Palmar Crease Pallor
o D p ren Con rac re Megalobla ic Anaemia from Alcoholism)
- Arms:
o Bruising/Petechiae/Purpura (Thrombocytopaenia due to Myelosuppression which also Anaemia)
o Scratch Marks (Haemolytic Jaundice Anaemia)
- Face:
o Conjunctival Pallor
o Scleral Icteris (Haemolytic)
o Central/Peripheral Cyanosis
o Angular Stomatitis (General Anaemia)
o Atrophic Glossitis (General Anaemia)
o Gum Bleeding (AML As a cause of Iron Deficiency Anaemia)
o Buccal Petechiae/Purpura (Thrombocytopaenia due to Myelosuppression which also Anaemia)
- Neck:
o Cervical Lymphadenopathy (Because All Haem Malignancies cause Anaemia)
o **Check for Dysphagia/Odynophagia (Plummer Vinson Oesophageal Web from Iron def. Anaemia)
o Thyroid Examination (As Hypothyroidism can menorrhagia)
- Chest:
o Bony Tenderness (All Haem Malignancies)
o Systolic Flow Murmurs (hyperdynamic circulation)
- Abdomen:
o C llen Gre T rner Sign of Haemoperi one m Haemorrhagic Anaemia
o Tenderness (Peptic Ulcer Disease, Crohns, Ulcerative Colitis)
o Hepatomegaly & Splenomegaly (All Haem Malignancies cause Anaemia)
o Per Rectal Examination Blood on Stool
o Palpate Kidneys (Signs of Renal Failure Anaemia of Chronic Disease)
- Legs:
o Peripheral Perfusion
- Feet:
o Peripheral Perfusion + CRT
o Koilonychia (Iron def Anaemia)
o Pale Nails (General Anaemia)

- Thank a ien ha concl de m e amina ion I ll go o gani e f he e

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Focussed Leukaemia Examination:
- Introduction, Wash Hands, Consent,
- General Inspection:
o Alert & Orientated?
o Wasting, Weight Loss
o Gross Pallor (Marrow Overcrowding - All Haem Malignancies)
o Lethargy
o Obvious masses (Neck/Abdomen)
o Bruising, Bleeding, Petechiae, Purpura (Thrombocytopaenia - All Haem Malignancies)
- Vital Signs:
o Pulse:
Normal
Tachycardia (If Anaemia)
o Blood Pressure:
Normal
Postural Hypotension (if Anaemia)
o Respiratory Rate:
Normal
Tachypnoea (If Anaemia)
o Temperature:
Febrile (All Haem Malignancies, Infection)
- Hands:
o Peripheral Perfusion + CRT
o Pale Nails & Palmar Crease Pallor (Marrow Overcrowding Anaemia)
o Palmar Erythema (Chronic Leukaemias)
o Gouty Tophi (High Turnover in Myeloproliferative)
- Arms:
o Bruising, Petechiae, Purpura (Marrow Overcrowding Thrombocytopaemia)
o Epitrochlear & Axillary Lymp Nodes (All Haem Malignancies)
Supraclavicular, Infraclavicular, Parasternal, Subpectoral, Subscapular, Central, Lateral
- Face:
o Gross/Conjunctival Pallor (Marrow Overcrowding Anaemia)
o Central/Peripheral Cyanosis
o Gum Hypertrophy & Bleeding (Acute Myeloid Leukaemia)
o Gum Hypertrophy (Methotrexate Side Effect)
o Candidal Mouth Infections (Neutropaenia - All Haem Malignancies)
- Neck:
o Cervical Lymphadenopathy (All Haem Malignancies)
o Meningism (Due to CNS Infiltration esp. ALL)
- Chest:
o Bruising, Petechiae, Purpura (Thrombocytopaenia)
o Bony Tenderness (Bony Infiltration - All Haem Malignancies)
o Chest Infections (Immunocompromise From Chemo or Neutropaenia)
- Abdomen:
o Bruising, Petechiae, Purpura (Thrombocytopaenia - All Haem Malignancies)
o Distension
o Hepatomegaly, Splenomegaly (All Haem Malignancies)
o Para-Aortic Lymph Nodes
- Legs:
o Inguinal lymph Nodes
o Testicular Masses (Acute Lymphoblastic Leukaemia)
o Bruising, Petechiae, Purpura (Thrombocytopaenia - All Haem Malignancies)
- Feet:
o Peripheral Perfusion + CRT
o Pale Nails (Anaemia)

- Thank a ien ha concl de m e amina ion I ll go o gani e f he e

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Focussed Lymphoma Examination:
- Introduction, Wash Hands, Consent,
- General Inspection:
o Alert & Orientated
o Wasting, Weight Loss
o Neck Swellings
o Facial Plethora (SVC Obstruction)
o Gross Pallor (Marrow Infiltration)
o Bruising, Petechiae, Purpura (Marrow Infiltration)
- Vital Signs:
o Pulse:
Normal
Tachycardia (if Anaemia due to BM Infiltration)
o Blood Pressure:
Normal
Postural Hypotension (if Anaemia due to BM Infiltration)
o Respiratory Rate:
Normal
Tachypnoea (If Anaemia due to BM Infiltration)
o Temperature:
Fever
- Hands:
o Peripheral Perfusion + CRT
o Peripheral Cyanosis
o Palmar Crease Pallor (Anaemia of BM Infiltration)
o Pale Nails (Anaemia of BM Infiltration)
o Scratch Marks (Pruritis of Lymphoma)
- Arms:
o Epitrochlear Lymph Nodes (All Haem Malignancies)
o Axillary Lymph Nodes (Supra/Infraclavicular/Parasternal/Pectoral/Subscapular/Central/Lateral)
*Painful
- Face:
o Conjunctival Pallor (Anaemia of BM Infiltration)
o Scleral Icteris
o Wasting
o Central/Peripheral Cyanosis
o Enlarged Tonsils (MALT Lymphoma)
o Candidal Mouth Infections (Immunocompromise - All Haem Malignancies)
- Neck:
o Painful Cervical Lymphadenopathy (All Areas)
- Chest:
o Chest Infections (Immunocompromise - All Haem Malignancies)
o Systolic Flow Murmurs (if Anaemia of BM Infiltration)
o Bony Tenderness (Bony Infiltration - All Haem Malignancies)
- Abdomen:
o Hepatomegaly (All Haem Malignancies)
o Splenomegaly (All Haem Malignancies)
o Para-Aortic Lymphadenopathy
o Abdominal Masses (MALT Lymphoma)
o Bruising, Petechiae, Purpura (Thrombocytopaenia of BM Infiltration)
- Legs:
o Bruising, Petechiae, Purpura (Thrombocytopaenia of BM Infiltration)
- Feet:
o Peripheral Perfusion + CRT
o Fungal Nail Infections (Pancytopaenia of BM Infiltration)

- Thank a ien ha concl de m e amina ion I ll go o gani e f he e

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Focussed Multiple Myeloma Examination:
- Introduction, Wash Hands, Consent,
- General Inspection:
o Wasting, Weight Loss
o Pallor (Anaemia of BM Infiltration)
o Bruising, Petechiae, Purpura (Thrombocytopaenia of BM Infiltration)
o Abdominal Masses (Hepatomegaly +/- Splenomegaly)
- Vital Signs:
o Pulse:
Tachycardia (Anaemia of BM Inifiltration)
o Blood Pressure:
Postural Hypotension (Anaemia of BM Inifiltration)
o Respiratory Rate:
Tachypnoea (Anaemia of BM Inifiltration)
o Temperature:
Fever (Due to Infection/Malignancy)
- Hands:
o Peripheral Perfusion + CRT
o Ra na d Phenomenon Digi al Infarc Blood H per i co i
o Palmar Crease Pallor & Pale Nails (Anaemia of BM Inifiltration)
- Arms:
o Bruising, Petechia, Purpura (BM Infiltration Thrombocytopaenia)
o Epitrochlear Lymphadenopathy (All Haem Malignancies)
o Axillary Lymphadenopathy (All Haem Malignancies)
- Face:
o Conjunctival Pallor
o No Central or Peripheral Cyanosis
o Mucosal Candida Infections (Immunocompromise & Neutropaenia)
- Neck:
o Cervical Lymphadenopathy (All Haem Malignancies)
- Chest:
o BONY TENDERNESS (Especially in Ribs & Lumbar Spine)
o Bruising, Petechiae, Purpura (BM infiltration Thrombocytopaenia)
- Abdomen:
o Bruising, Petechiae, Purpura (BM infiltration Thrombocytopaenia)
o Massive Hepatomegaly +/- Splenomegaly
o Signs of Renal Failure (Due to Ig-Deposition in Kidneys) Ascites, Uraemic Fetor, etc
- Legs:
o Peripheral Neuropathy (Due to Spinal Cord Compression)
o Bruising, Petechiae, Purpura (BM infiltration Thrombocytopaenia)
o Oedema (If Renal Failure)
- Feet:
o Peripheral Perfusion + CRT
o Peripheral Neuropathy (Due to Spinal Cord Compression)
o Fungal Nail Infections (Immunocompromise)

- Thank a ien ha concl de m e amina ion I ll go o gani e f he e

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 Full & Focussed Head & Neck Exams

Eye Examination:
- Introduction, Wash Hands, Consent,
- General Inspection of Patient:
o Guide Dog
o Walking Aids
o Visual Aids/Glasses/Eye Patch
- Vital Signs:
o Pulse:
Particularly Irregularity (AF can TIAs Transient Visual Loss “Amaurosis Fugax”)
o Blood Pressure:
Particularly Hypetension (Hypertensive Retinopathy)
o Respiratory Rate:
o Temperature:
Fever in Infection
- Eye Examination:
o Visual Acuity:
Snellens Charts
Unilateral Corrected + Bilateral Corrected
If Poor Visual Acuity Use a Pinhole to see if it is a REFRACTIVE ERROR?
Blind Spot (Enlarged in Macular Degeneration or Papilloedema)
o Colour Vision:
Ischihara Charts (Colour Blindness)
o Visual Inspection:
Eyelids:
Lid Retraction (Graves Hyperthyroid)
Lid lag (Graves Hyperthyroid)
P i Facial Ne e Pal H e S d e
Periorbital Oedema (Nephrotic Syndrome, Hashimoto Hypothyroidism, Allergies)
Xa hela a Li e Di ea e Diabe e CVD C hi g Ac egal H h idi
Skin Lesions (SCCs, BCCs)
Eyelashes (Trachoma)
Eyeball:
Exophthalmos/Proptosis G a e H e h id Leukaemias, Head Injury, C hi g
E h hal H e S d e Dehydration)
Conjunctiva:
Conjunctival Pallor (Anaemia)
Scleral Icteris (Liver Disease)
Subconjunctival Haemorrhages (Extreme Coughing)
Conjunctivitis (Inflammation + Pus)
Iris, Cornea & Lens:
Arcus Senilis (Sign of CVD Risk factors)
C e Ri g a d he I i Wil Di ea e
H e S d e U ila e al Mi i [pinpoint pupils])
Band Keratopathy (Hypercalcaemia, Hyperparathyroidism, Renal Failure)
Cataracts (Diabetes, Hypertension, Iodine Deficiency :. Hypothyroidism)
Corneal Ulceration (Herpes, Trachoma)
Pus/Blood in Anterior Chamber
o Pupil Reactivity To Light:
Pupil Size (normally 2.5mm-3.5mm)
Direct Response (If absent = Afferent OR Efferent Nerve Lesion in THAT Eye)
Consensual Response (If absent = Efferent Nerve Lesion in THAT Eye)
Marcus-Gunn Pupil (Swinging Torch Test both pupils should stay the same after a few
oscillations due to the Consensual Response) (If one pupil dilates whilst the torch is on the
other eye, then that is a Marcus-Gunn Pupil)

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o Visual Fields (Remove Glasses & in Confrontation Position + Patient covers one eye):
Betemporal Hemianopsia = Optic chiasm compression (Pituitary Adenoma)
Homonymous Hemianopsia = Optic Radiation Lesion
Unilateral Hemianopsia = Optic Nerve Lesion
+ Blind Spot (If enlarged May = Macular Degeneration, or Papilloedema)
o Extraoccular Movements:
Occulomotor = Superior Rectus, Medial Rectus, Inferior Rectus, Inferior Oblique
Trochlear = Superior Oblique (Down & Out) - :. In III-Nerve Palsy, eye faces Down & Out.
Abducens = Lateral Rectus
+ Nystagmus = Points to the side of a Cerebellar Lesion.
o Fundoscopy:
Papilloedema
Macular Degeneration
Diabetic Retinopathy
Hypertensive Retinopathy
R h S i I fec i e Ed ca di i

“Thankyou, that concludes my Examination”

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Ear, Nose & Throat Examination:
- Introduction, Wash Hands, Consent,
- General Inspection:
o Hair distribution (PCOS, Hypothyroidism)
o Hair Infestations (nits, lice)
o Oily, sweaty hair (Hyperthyroidism, Acromegaly)
o Thin, Dry Hair (Hypothyroidism)
o Scars
o Skull Deformities (Injuries, Congenital, Cleft Lip)
o High A ch Pala e Ma fa
o Skin lesions (SCCs, BCCs)
o Ski Pig e a i Addi Hae ch a i , Acanthosis Nigricans in Diab/Cush/PCOS/Acr)
o Skin Scaling (Psoriasis, Autoimmune Disorders)
o Abnormal Facies C hi g Ac egal Addi G a e H e h idi Ha hi
Hypothyroidism, D S d e T e S d e Fe ale )
o Facial Symmetry (Facial Nerve Palsies)
o Facial Muscle Fasciculations
o Eye Inspection (Conjunctival Pallor, Scleral icteris, Conjunctivitis, Discharge, Periorbital Oedema)
- Vital Signs:
o Pulse:
Tachycardia (Infection)
B ad ca dia if ICP
o Blood Pressure:
H e e i if ICP)
o Respiratory Rate:
B ad ea if ICP
o Temperature:
Fever (Infection)
- Ears:
o External Inspection:
Redness (Infection)
Swelling (Gouty Tophi)
Scars
Lesions (SCC/BCC)
Discharge
o Palpation:
Tug Test (for External Ear Infection)
Cervical Lymphadenopathy (Infection, Malignancy)
o Otoscopy:
Explain to the patient that it may feel uncomfortable
Pull Pinna Back and Upward to straighten the canal
Examine the Left Ear with the Left hand holding the Otoscope (and vice versa)
Look for:
Inflammation of External Ear Canal (Otitis Externa)
Discharge, Blood, Pus, CSF
Light Reflex of Tympanic Membrane (Eardrum)
Inflammation of Eardrum (Otitis Media)
Bulging of Eardrum (Otitis Media)
Visible Malleus (Normal)
Identify Borders (Pars Flaccida, Pars Tensa, Umbo)
Sclerosis (Chronic Otitis Media)
Tympanic Membrane Rupture
Impaction by Ceremun (earwax)
o Hearing:
Whisper Test Whilst distracting the other ear with your hand.
Weber’s Test Lateralising? (Conductive Deafness)
Rine’s Test Normally Air Conduction is better than bone conduction.

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- Nose:
o Visual Inspection:
Redness (Rosacea, SLE, Acne)
Enlargement (Rosacea, Acromegaly)
Skin Lesions (Comedones, BCCs, SCCs)
Scars, Deformities (Broken Nose)
Discharge, Pus, Blood (Epistaxis)
Nasal Deviation
Nasal Polyps (inflammatory from chronic URTI)
Septal deformities
Enlarged, Inflamed Turbinates (URTI)
o Palpation:
Tenderness
Swelling
Deformities
Block Each nostril & Assess for Obstruction
Sinuses:
Press/Percuss over Frontal Sinuses (Tenderness = Sinusitis/Congestion)
Press/Percuss over Maxillary Sinuses (Tenderness = Sinusitis/Congestion)
Transilluminate Maxillary Sinuses (Shine otoscope through Maxillae & observe
illumination in the mouth)
- Throat:
o Visual Inspection:
Hydration
Central or Peripheral Cyanosis
Mouth Ulcers (UC/Crohns/SCC/BCC)
Leukoplakia/Erythroplakia (Smoking Precancerous)
Buccal Petechiae (Leukaemias, Bleeding Disorders, DIC, Haemorrhagic Infections)
B ccal Pig e a i Addi Di ea e
Angular Stomatitis (Microcytic OR Macrocytic Anaemias)
Atrophic Glossitis (Microcytic OR Macrocytic Anaemias)
Gum Hyperplasia (AML, Methotrexate)
Bleeding Gums (AML)
Dentition & Dead Teeth (CVS Risk Factor)
High A ched Pala e Ma fa S d e
Inflamed, Enlarged Tonsils
Tonsillar Exudate
Inflamed Pharynx (URTI)
Sa Ah (Glossopharyngeal & Vagus Nerve Lesions)
Note any Fetor/Bad Breath (Uraemic, Hepatic, Acetone)
o Palpation:
Bimanual Palpation for enlarged Parotid Gland (Alcoholism, Sialolithiasis)
Feeling Tongue & Buccal Mucosa for Lumps/Tenderness/Ulcers
+ Cervical Lymph Nodes

- Thank patient “that concludes my examination”, I’ll go organise further tests.

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 Full & Focussed Musculoskeletal Exams

Musculoskeletal History:
- PC Injury/Pain/Stiffness/Movement Limitation.
- HxPC:
o Acute or Chronic problem?
o Mech of injury Utmost Importance!!
o Problems experienced:
Pain Vs Tenderness. (+ Be mindful of referred pain)
NILDOCARF
Movement limitation
Pain:
o Tendinopathy
o Impingement
o Sprain
o Labral
Mechanical Block:
o Stiffness/Creakiness + Time of day & Duration
o Labral
o Frozen shoulder
Instability (clicking/clunking)
Joint swelling
Night pain? (Lying on affected joint)
Eg. Rotator cuff
Eg. AC joint injury
Eg. Collateral Knee Ligaments
Eg. Bone Cancers
o Associated Rheumatologic Symptoms:
Fever, Weakness, Faituge, Weight Loss, Conjunctivitis/Iritis.
o Progression with time (Trending Better/worse/same)
- Pmh, Meds, Famhx, Sochx, Systems Review
- Red Flags? (Ie. Things that if you miss mortality/morbidity)
o Open fractures
o Neurovascular compromise
o Cauda equina syndrome
o Infections (Joints/Bones)
o Acute Compartment Syndrome
o Cancer
o Temporal arteritis (high risk in pts with PMR poly something rheumatica)
o Serious/life-threatening conditions that present with sx mimicking msk pain (eg. MI)
- Yellow Flags Condi ion ma e ading a m k condi ion
o Eg. Psychological depression & back pain.

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GALS Screen:
- Introduction, Wash Hands, Consent,
- Adequate Exposure!!! (Remove Shirt, Pants & Shoes)
- Gait (Observe for Fluidity, Symmetry, Limp, Compensation, Foot Drop[L4,L5]):
o Walk to the other side of the room, Turn around, and walk back to me.
- Arms:
o Shoulder & Elbow:
Raise hands up to the ceiling, then down behind your head. Push your shoulders backwards.
Touch your fingers on your shoulders, and raise your elbows as high as you can.
Lock your elbows into your side, and turn your arms outward as far as you can. (Ext.Rotation)
Run your thumb up the middle of your back. (Internal Rotation)
Push your hands as far back behind you as you can. (Extension)
Touch your left thigh with your right hand (and Vice Versa) (Adduction)
Supinate & Pronate your Hands
o Hands & Fingers:
Splay your fingers wide + Resist me squeezing them.
Fingers together + Resist me pulling them apart.
Grip my fingers as hard as you can + Assess Grip Strength
Make a fist
Touch each of your fingers with your thumb.
+ Metacarpophalyngeal Sqeeze Test (For Tenderness)
- Legs:
o 3x Half Squats (Patellofemoral Joint)
o 1x Full Squat (Knee Joint Proper)
o Ankle Eversion & Inversion
o Dorsiflexion & Plantarflexion
o Splay Toes & Scrunch Toes.
- Spine:
o (Feet shoulder-width apart)
o Observe for Lordosis, Kyphosis, Scholiosis.
o Bend from Lumbar Spine and reach for your toes
o Bend from Lumbar Spine and look at the ceiling
o Bend Sideways & Slide your hand down your thigh
o Neck Flexion (Chin on chest)
o Neck Extension (look at ceiling)
o Lateral Neck Flexion (Ear on Shoulder)
o Neck Rotation (Look to the side)

- Reporting on a GALS Screening. (WHAT YOU NEED TO DO IN THE EXAM)

o G Normal/Abnormal + Comments on Findings
o A Normal/Abnormal + Comments on Findings
o L Normal/Abnormal + Comments on Findings
o S Normal/Abnormal + Comments on Findings
o (Eg. Abnormal Arm (limited abduction of the shoulder to ?degrees))

- Thank o ha concl de m e amina ion

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Focussed Joint Exam Algorighm (Shoulder or Knee):
- Look (Visual Inspection)
o Symmetry? (Size, Shape, Position, Height)
o Scars
o Redness
o Bruising
o Lumps
o Atrophy
o Swelling
- Feel (Palpate Relevant Anatomy for Tenderness, Heat, Swelling, Crepitus):
o Objective Findings:
Tenderness
o Subjective Findings:
Warm (Inflammation, Trauma, Infection, Tumour)
Swelling (Effusion, Tumour)
Crepitus (Osteoarthritis, Tendinopathy, Fracture)
- Move (Active +/- Passive if Required):
o Symmetry?
o Active Movement in All Planes:
Range of Movement
Fluidity
Pain with Movement
o If a can do ome hing a k hem h Blockage eakne Ne o
o (Passive Only for Movements that were Limited)
- Measure (Range of Movement):
o Done a he ame ime a Mo e
o Compare with opposite side (ballpark doesn t ha e to be objecti e

- +/- Special Tests:

o Shoulder:
Empy Can Test (Supraspinatus Tear)
Drop Arm Test (Supraspinatus Tear)
Ha kin Kenned Te Im ingement)
Apprehension & Relocation Test (Instability)
o Knee:
Lachman Te Anterior Cruciate Ligament)
Thessaley Test (Meniscal Tear)
A le G ind Te Meni cal Tea
Varus & Valgus Stress Tests (Collateral Ligament Tears)
Half Squats (For Patellofemoral Maltracking Syndrome)

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Focussed Shoulder Examination:
- 1. EXPOSE THE PATIENT FULLY!!

- Look (Visual Inspection)

o Symmetry? (Size, Shape, Position, Height)
o Scars
o Redness, Bruising
o Lumps, Swelling
o Atrophy
- Feel (Palpate Relevant Anatomy for Tenderness, Heat, Swelling, Crepitus):
o Pal a e BOTH join Sa o d like o e amine he o he ide
o Palpate Definite Anatomical Structures for Tenderness:
Sterno-clavicular Joint
Clavicle
Acromio-clavicular Joint
Gleno-humoral Joint Line
Spine of Scapula
Edges of the Scapula
o Feel for Heat, Swelling, & Crepitus
o Eg Non tender to firm palpation
- Move (Active +/- Passive if Required):
o Symmetry?
o Active Movement in All Planes:
Range of Movement
Fluidity
Pain with Movement
o If a pt can do ome hing a k hem h Blockage eakne Ne o
o (Passive Only for Movements that were Limited)
o Eg. S mmetrical and f ll ROM in all planes
- Measure (Range of Movement):
o Done a he ame ime a Mo e
o Compare with opposite side (ballpark doesn t ha e to be objecti e
o Limited active extension of l-elbo to deg

- (Clinical Presentations Requiring Special Tests):

o Tears Eg. Supraspinatus Tear:
Special Tests:
D o A m Te Passi e abd ction of pt s arm let go and get them to lower
arm as slow as possible. Arm Drops at around Parallel = Positive.
Em Can Te Passi e abd ction of Pt s arm ith f ll internal rotation ie
Emptying can). Push down and get them to resist your movement. Pain &/or
Weakness = Positive.
o Impingement Eg. Of Subacromial Contents:
Subacromial contents get squashed between the humoral head and the acromion. (eg.
Supraspinitis, Subacromial Bursa)
Special test:
Ha kin e - Pain = Positive, No Pain = Negative
o Passive Internal Rotation of Shoulder with elbow in 90deg and humerus at
parallel to the ground.
o Instability Eg. Anterior Instability of Shoulder (ie. Post dislocation)
Eg. Dislocation/Post Dislocation/Stretch of Anterior Capsule of the Shoulder
Special Test:
A ehen ion Reloca ion Te Apprehension (not pain) in 1. Less
apprehension in 2. = Positive
o 1. Patient lies on bed while you Abduct & Externally Rotate their arm to
precipitate apprehension (Ie. High five position)
o 2. Same thing, but with pressure on the anterior capsule. (This should be
much more bearable for the patient.)

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Focussed Knee Examination:
- 1. EXPOSE THE PATIENT FULLY!!

- Look (Visual Inspection)

o Symmetry? (Size, Shape, Position)
o Scars
o Redness, Bruising
o Lumps, Swelling
o Atrophy/Wasting
- Feel (Palpate Relevant Anatomy for Tenderness, Heat, Swelling, Crepitus):
o Palpate BOTH Knees Sa o d like o e amine he o he ide
o Palpate Definite Anatomical Structures for Tenderness:
Quadriceps Tendon
Patella (+ Patella Tap test for Eff sion
Patella Tendon
Tibial Tuberosity
Joint Line
Collateral Ligament Attachments.
o Feel for Heat, Swelling, & Crepitus
o Eg Non tender to firm palpation
- Move (Active +/- Passive if Required):
o Symmetry?
o 3x Half Squats (Patellofemoral Joint)
o 1x Full Squat (Knee Joint Proper)
Range of Movement
Fluidity
Pain with Movement
o If a can do ome hing a k hem h Blockage eakne Ne o
o (Passive Only for Movements that were Limited)
o Eg S mmetrical and f ll ROM in all planes
- Measure (Range of Movement):
o Done a he ame ime a Mo e
o Compare with opposite side (ballpark doesn t ha e to be objecti e
o Limited active extension of l-elbo to deg

- (Clinical Presentations Requiring Special Tests):

o Acute Knee pain:
Cruciate Ligament Tear ent to change direction felt something pop and as s ollen
ithin ho rs ACL
Lachman Te Pt s pine e aminer s knee nder pt s knee stabilise fem r ith
one hand, move tibia ant-&-post firmly. Positive if displacement > other side.
Anterior Drawer (NB: Only really useful in an anaesthetised, paralysed pt. NB. A
conscious pt will guard). Pt s pine knee bent to deg Sit on pt s foot With hands
apply anterior force to the tibial head. Positive if Anterior Displacement is > than
other side.
Meniscal Tear
**Thessaly Test (For Meniscal Tear) Hold hands standing. Stand on 1 foot. Bend
the weight-bearing leg 20o. Do the Twist. Pain = Positive. (NB: Pt must point to
source of pain same place both times)
Collateral Ligament Sprains/Tears
Valgus & Varus Stress Tests Pt supine, support knee from below, 30deg flexion &
apply valgus & varus stresses. (Positive = Laxity/gaping.)
Patellofemoral Mal-Tracking Syndrome. Tracking of the Patella thro gh it s groo e isn t
right; or groove isn t straight or ast s medialis isn t orking properl
Pain with stairs/squatting
Half squats - Good indication of patella-femoral function

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 Full & Focussed Neurological Exams
(Cranial Nerves, Cerebellar, Upper Limb Motor/Sensory, Lower Limb Motor/Sensory)

Start of Every Neuro Exam:

- Introduction + Wash Hands + Consent
- General Inspection:
o Altered Level of Consciousness?
o Patient Alert? Oriented to Person Place & Time?
o Facial Asymmetry?
o Evidence of Trauma?
o Fasciculations/Tremors?
o Muscle Wasting?
o Speech Impediments (Dysphasia?/Dysarthria?/Dysphonia)
- Vital Signs:
o Pulse:
B ad ca dia C hi g T iad f ICP
o Blood Pressure:
H e e i C hi g T iad f ICP
o Respiratory Rate:
Che e S ke Re i a i C hi g T iad f ICP
o Temperature:
Febrile if Meningitis/Encephalitis

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Full Cranial Nerve Exam:
- Introduction, Wash Hands, Consent,
- General Inspection:
o Altered Level of Consciousness?
o Patient Alert? Oriented to Person Place & Time?
o Facial Asymmetry?
o Evidence of Trauma?
o Fasciculations/Tremors?
o Muscle Wasting?
o Speech Impediments (Dysphasia?/Dysarthria?/Dysphonia)
o Ptosis?
o Inability to Close the Eye?
o Facial Muscle Wasting?
o Facial Sweating?
- Vital Signs O dina il I d ge he i al ne b in he in e e f a ing ime da I ill m e n :
o Pulse:
o Blood Pressure:
o Respiratory Rate:
o Temperature:
- I - Olfactory:
o Ha e iced a cha ge i mell or taste la el
- II - Optic:
o Ha e iced a cha ge i i i la el
o C ec ed Vi al Ac i i Each E e Se a a el he b h e e S elle Cha
o Assess for Colour Blindness (Ischihara Charts)
o 6 Point Visual Field Testing (confrontation position. Use hat pin and cover ipsilateral eyes)
o Pupil Response to Light (Direct & Consensual + Swinging Torch Test)
o Fundoscopy (Cataracts/Diabetic Retinopathy/Hypertensive Retinopathy)
- III - Occulomotor, IV - Trochlear & VI - Abducens:
o Kee i g head ill f ll hi ha i i h e e
o Le me k if a a ime begi ee d ble
o Do the 6-speed gearbox positions
o Asymmetrical Movement of the Eyes
o Nystagmus (NB: This is a sign of Cerebellar Pathology and always points to the side of the lesion)
o Occulomotor: Superior Rectus, Medial Rectus, Inferior Rectus, Inferior Oblique
o Trochlear: Superior Oblique
o Abducens: Lateral Rectus
- V - Trigeminal:
o I m g ing be e ing facial en a i n n
o Fi I m g ing e Sha Pain en a i n and hi i ha i feel like n e n m
Pain: Ophthalmic Division, Maxillary Division, Mandibular Division
o ne i m g ing e ligh ch en a i n and hi i ha i feel like n e n m
Light Touch (Cotton Wool): Ophthalmic Division, Maxillary Division, Mandibular Division.
o Ok n l k aigh ahead i h e e ide en hank
Corneal Reflex (Cotton wool): touch rolled cotton wool onto the corneas from the sides
o Ne I m g ing e he m f nc i n f he igeminal ne e
Clench ja lea e Feel the Masseter Muscle
O en ja and e i me cl ing i Pterygoids
J en ja half a and ela and I m g ing a i i h hi Jaw jerk reflex

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- VII Facial Nerve:
o W i kle f ehead a d d le me fla e i
o Cl e e e a dd le me e hem
o Smile
o P ff cheek a d d le me a h hem
o (NB: UMN Lesions you lose the Lower Quadrant of the face on the Contralateral Side)
o (NB: LMN Lesions you lose the Whole Half of the face on the Ipsilateral Side)

- VIII Vestibulocochlear Nerve:

o Ne I m g i g e hea i g a d bala ce
o R mbe g Te S a d fee ge he a d cl e e e
o Webe Te Tell me if hea he dm ei e ea i i e al i b h Comment on
lateralisation. If it lateralises to one ear, then there is CONDUCTIVE DEAFNESS in that ear.
o Rinne Te Tell me he ca hea he da m e then move the blades close to
the ear canal Ca hea i
o Whisper Test N e ea ha I hi e 69, 100) Whilst distracting the other ear with rubbing
fingers.
- IX Glossopharyngeal & X Vagus:
o O e m h a d a AH
Look for asymmetrical elevation of the Uvula.
o Me i ha d al d he gag efle
o Ca a ame lea e Assess for Hoarseness
o Ca c gh lea e Assess for bovine cough.
- XI Accessory Nerve:
o T head he ide a d e i me m i g i Contralateral Sternocleidomastoids)
o Sh g h lde a d e i me hi g hem d Trapezius)
- XII Hypoglossal:
o P ke ge a fa a ca
o Assess for Asymmetry (The tongue will point to the side of the lesion)

Thank ha c ncl de m e amina i n

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Focussed Cerebellar Examination:
- Introduction + Wash Hands + Consent
- General Inspection:
o Patient Alert & Orientated?
o Tremor? Fasciculations
o Wasting?
o Evidence of Head Injury?
- Speech:
o Sa B i i h C i i (Listen for Dysphasia, Dysarthria, Dysphonia)
- Horizontal Nystagmus:
o Oscillations of the eyeball when looking from one side to the other.
o NB: Nystagmus always points to the side of the cerebellar lesion.
- Standing Coordination:
o R mbe g Te S and i h fee ge he and cl e e e f me SUPPORT THE PATIENT:
Loss of balance with eyes closed = Proprioceptive Dysfunction (Dorsal Column)
Loss of balance with eyes open = Cerebellar Dysfunction
o GAIT:
Walk Normally (Note any wide-based gait = Cerebellar Dysfunction)
o Heel to toe Walking:
Inability to do this = Cerebellar Dysfunction
o Pronator Drift - Ca e alm ai e am he f a d cl e e e :
Upward Drift = Cerebellar Dysfunction
Downward Drift = Pyramidal
o Rebound Ca ai e am he f a ick a ca a d he hem :
Rebound = Cerebellar Dysfunction
o Disdiodochokinesis:
Cla ha d like hi a fa a ca
o Finger nose Test (Past Pointing):
Touch your nose
Touch my finger
Etc.
- Supine Coordination:
o Heel-Shin Test:
Place heel k ee a d lide i d hi he lift off...then back to knee &
e ea
o Finger Toe Test (Past Pointing):
Touch My finger
Tough the bed
Etc.
o Disdiodochokinesis:
Ta m ha d i h fee al e a i g a fa a ca
o Clonus:
Flex the knee, externally rotate the hip, and Rapidly Dorsiflex (Sustained Rhythmic
Contraction = Clonus = Cerebellar Dysfunction)
- Truncal Ataxia:
o Ha e a ea C am a d ih i g ha d

Thank ha c ncl de m e amina i n

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Focussed Upper Limb Neurological Examination:
- Introduction, Wash Hands, Consent,
- General Inspection:
o Ca lea e ake hi ff
o Pa ie a ea ale a d ie ed a d i a ae ai di e
o Wasting (LMN Lesion)?
o Tremors (Parkinsons/Benign)? Fasciculations (LMN Lesion)?
o Scars? Deformities?
o Bruising? Injury?
o Asymmetry?
o Ae lef igh ha ded
- Vital Signs - O dina il I d ge he i al ne b in he in e e f a ing ime da I ill m e n :
o Pulse:
o Blood Pressure:
o Respiratory Rate:
o Temperature:
- Motor Function:
o Muscle Bulk/Wasting of:
Intrinsic Hand Muscles
Forearm
Biceps/Triceps
Shoulders
o Tone Hyertonia (UMN Lesion), Hypotonia (LMN Lesion), Cogwh./Leadpipe Rigidity (Parkinson’s :
Shoulder Abduction/Adduction
Shoulder Flextion/Extension
Elbow Flexion/Extension
Supination/Pronation
Wrist Flexion/Extension
Finger Flexion/Extension
o Power Graded 0 5 (0=None; 1=Flicker; 2=Gravity Limited; 3=Gravity Unlimited; 4=Fatigue; 5=Full)
Shoulder Abduction (C5, C6) Pick ick
Shoulder Adduction (C7, C8) La hem aigh
Elb Fle i C C Pick ick
Elb E e i C C la hem aigh
W i Fle i C C P i hea e
Wi E e i C C la hem aigh
Grip Strength (C C ma e ba e
Finger Adduction & Abduction (C8, T1)
Thumb Opposition (C8, T1)
o Reflexes Hyperreflexia (UMN Lesion); Hyporeflexia (LMN Lesion):
Triceps Reflex (C6, C7)
Biceps Reflex (C5, C6)
Brachioradialis (C5, C6)
o Coordination/Cerebellar Function:
Pronator Drift Ca e alm ai e am he f a d cl e
e e (Downward = Pyramidal; Upward = Cerebellar)
Rebound Kee ha d he e e e cl ed a d d le me m e am
OR Q ickl ai e your arms to the front and s
Disdiodochokinesis Cla ha d like hi a fa a ca
Past-Pointing (Cerebellar Dysfunction) T ch e T ch m fi ge

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- Sensory Function (Standardise on Sternum first):
o OVER ALL DERMATOMES:
C3 (Corporals Patch)
C4 (Corporals Patch)
C5 (Biceps)
C6 (Thumb)
C7 (Middle Finger)
C8 (Pinky)
T1 (Medial Forearm)
T2 (Medial Bicep)

o 1. Pain (Spinothalamic)
EYES CLOSED
(Temperature Not done)
o 2. Vibration (Dorsal Column)
Start Distally Move Proximally
o 3. Proprioception (Dorsal Column)
EYES CLOSED
o 4. Light Touch (Both Pathways)
EYES CLOSED

Thank ha c ncl de m e amina i n

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Focussed Lower Limb Neurological Examination:
- Introduction, Wash Hands, Consent,
- General Inspection:
o Standing:
Muscle Wasting? (LMN)
Fasciculations? (LMN)
Scars? Deformities?
Injury?
Involuntary Movements?
o GAIT Can alk he he end f he m n nd and alk back L k f
Foot Drop L4 + L5 Lesion (Common Peroneal/Fibular Nerve Palsy)
Cannot Walk on Toes S1 Lesion.
Shuffling Gait (Parkinsons)
Wide Based Gait (Cerebellar)
Poor Heel-Toe Walking (Cerebellar)
o R mbe g Te S and i h fee ge he and cl e e e f me SUPPORT THE PATIENT:
Loss of balance with eyes closed = Proprioceptive Dysfunction (Dorsal Column)
Loss of balance with eyes open = Cerebellar Dysfunction
- Motor Function On Examination Couch:
o Muscle Bulk:
Feel for any wasting (LMN Lesion)
o Tone H e nia UMN Le i n H nia LMN Le i n C g Lead i e Rigidi Pa kin n ):
Hip Flexion
Knee Flexion & Extension
Ankle Flexion & Extension
Toe Flexion & Extension
o Power:
Hip Flexion (L2, 3, 4) E f ce he La Wi h Roundhouse Kick)
Hip Adduction (L2, 3, 4) E f ce he La Wi h R dh e Kick
Hip Abduction (L2, 3, 4) E f ce he La Wi h R dh e Kick
Hip Extension (L5, S1) + (S2) Tense your bum
Knee Extension (L3, L4) Kick he Ball
Knee Flexion (L5, S1) Kick b m
Dorsiflexion (L4, L5) Walk Fi e
Plantar Flexion (S1) Fi d
o Reflexes:
Patellar Tendon (L3, L4) Kick he Ball
Archilles Tendon (S1) Fi d
Plantar Reflex/(Babi ki Positive if UMN Lesion)
o Coordination/Cerebellar Function:
Disdiodocokinesis:
Ta fee agai m ha d a ickl a ible
Finger-Toe Test (Past Pointing Test):
ch m fi ge ch he bed ch m fi ge
Heel-Shin Test:
Place your heel on your knee and slide it down your shin, lift off, and place back on
knee...Repeat.
+ Test for CLONUS (Cerebellar Dysfunction)

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- Sensation:
o OVER ALL DERMATOMES With EYES CLOSED:
L1 Garter Band 1
L2 Garter Band 2
L3 Anterior Knee
L4 Medial Calf
L5 Lateral Calf
S1 Lateral Foot (little toe)
S2 Posterior Thigh

o Pain
o Vibration
o Proprioception
o Light Touch

- Special tests for Meningitis:

o Ke nig Sign Neck pain on hip flexion & knee extension
o B d in ki Sign Involuntary Hip Flexion & knee Extension on Neck Flexion
o Neck Stiffness Pain on Neck Flexion

Thank ha c ncl de m e amina i n

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 Full & Focussed Renal Exams

Full Renal Exam:

- Introduction, Wash Hands, Consent,
- Expose Patient & General Inspection:
o Alert & Orientated? (Uraemic Encephalopathy, UTI in Elderly)
o Acute pain or distress (Renal Colic, Pyelonephritis)
o Signs of Fluid Overload (Ascites, Peripheral Oedema)
o Signs of Dehydration (Causing Pre-Renal Failure)
o Facial Oedema (Nephrotic Syndrome)
o Obesity
o Scars
o In-Dwelling catheter
o Uraemic Fetor/Tinge (Ammonia Smell from Hyperuricaemia)
o Easy bruising on Arms, Legs & Trunk
- Vital Signs:
o Pulse:
Normal
Tachycardia (Infection, Hypovolaemia, Anaemia)
o Blood Pressure:
Hypertension (Nephritic, Fluid Overload, Polycythaemia, Polycystic Kidney)
Postural Hypotension (Anaemia, Hyponatraemia, Addisons, Diabetic Neuropathy)
o Respiratory Rate:
Normal
Tachypnoea (if Renal Acidosis)
Bradypnoea (if Renal Alkalosis)
o Temperature:
Normal
Fever (Infection, Malignancy)
- Hands:
o Peripheral Perfusion + CRT
o Mee’s Lines [single horizontal bands] (Arsenic/Heavy metal Poisoning)
o Muercke’s Lines [paired horizontal bands] & Leukonychia (Hypoalbuminaemia due to Nephrotic
Syndrome)
o Palmar Crease Pallor & Pale Nails (Anaemia, Nephritic Syndrome)
o Palmar Crease Pigmentation (Addisons Disease Hyponatraemia & Hypovolaemia)
o Xanthomata (Diabetes, Obesity, Metabolic Syndrome)
o Gouty Tophi (Hyperuricaemia)
o Vasculitic Changes (Eg. Digital Infarcts – Sign of Autoimmune Glomerulonephritis)
- Arms:
o Uraemic Tinge/Uraemic Frost (Hyperuricaemia)
o Scratch Marks (Uraemia)
o AV-Fistulae (ESRD - Dialysis)
o Scars
o Asterixis (Uraemic Encephalopathy)
- Face:
o Butterfly Malar Rash of SLE (Cause of Renal Failure)
o Periorbital Oedema (Nephrotic Syndrome)
o Conjunctival Pallor (Anaemia, Nephritic Syndrome)
o Central/Peripheral Cyanosis
o Mouth Infections:
(Strep Pharyngitis can PSGN Nephritic Syndrome)
(Also Immunocompromise from Nephrotic Syndrome)
Thrush (Immunocompromise from diabetes)
o Xanthelasma (Diabetes, Nephrotic Syndrome)
o Band Keratopathy (calcification of cornea due to 2o Hyperparathyroidism due to Vit D Deficiency)
o Dehydration (Nephrotic Syndrome)
o +Fundoscopy (Diabetic Retinopathy)
o Gum Hyperplasia (Methotrexate – Transplant Medication)
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- Neck:
o Carotid Bruits (Hypercholesterolaemia, PVD, Diabetes)
o Vas Cath (Haemodialysis)
o Parathyroidectomy Scars (due to 2o Hyperparathyroidism due to VitD Deficiency)
o Acanthosis Nigricans (Diabetes, Metabolic Syndrome, Obesity)
- Chest:
o CCF & Pulmonary Oedema (Due to Fluid Overload – Ie. Nephrotic Syndrome, CKD, ESRD)
- Abdomen:
o Inspection:
Distension (Ascites in Nephrotic, Nephritic, Peritoneal Dialysis)
Surgical Scars
Peritoneal Dialysis Port
Visible Masses
o Palpation:
Renal masses (Polycystic Kidneys, Carcinoma)
Insulin Injection Sites
Polycystic Liver Hepatomegaly (Polycystic Kidneys)
Abdominal Aorta (Aneurysm Pre-Renal Failure)
Enlarged Bladder (Obstructive Uropathy)
o Auscultation:
Renal Bruits (Renal Artery Stenosis, Pre-Renal Failure)
Bowel Sounds Present
o Percussion:
Shifting Dullness (Ascites – Nephrotic, Nephritic, CKD)
- Back:
o Surgical Scars
o Costovertebral Angle Tenderness (Murphey’s Kidney Punch) – (Pyelonephritis/Stones)
o Bony Tenderness
o Sacral Oedema
- Legs:
o Pitting Oedema (Nephrotic, Nephritic, CKD, Diabetes, PVD)
o Scratches/Uraemic Frost (Hyperuricaemia)
- Feet:
o Xanthomata (Hypercholesterolaemia)
o Gouty Tophi (Hyperuricaemia)
o Mee’s Lines Arsenic/Heavy metal Poisoning
o Meurkhe’s Lines Leukonychia Hypoalbuminaemia – Nephrotic Syndrome)
o Peripheral Perfusion + CRT
o Peripheral Pulses
o (+ Diabetic Neuropathy & Foot Examination)
- + Urine Dipstick
o Blood (Nephritic, Pyelonephritis, Renal Stones)
o Protein (Nephrotic, Nephritic)

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Focussed Examinations:
- Pre-Renal Failure Exam (Hypovolaemia, CCF, Ascites, Renal Artery Stenosis/Thrombosis):

- Intra-Renal Failure (Nephrotics & Nephritics):

o Nephrotic (Less Serious) (Autoimmune [adults] or Post-URTI [child]):
Polyuria
Massive Proteinuria Hypoalbuminaemia, Oedema & Periorbital Oedema
Compensative Hyperlipidaemia (Xanthomata/Xanthelasma)
Immunosuppression (Loss of IgG in Urine)
Hypercoaguability (Loss of AT3 in Urine)
No Haematuria
o Nephritic (More Serious) (Post URTI [Adults] or Post Strep-Pharyngitis [Children]):
Anuria/Oliguria GFR
Modest Proteinuria (NB: NORMAL ALBUMIN) Oedema
Anaemia (PainLESS Haematuria)
Hypertension

- Post-Renal Failure (Obstructive Uropathy):

- Renal Carcinoma

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 Full & Focussed Respiratory Exams

Full Respiratory Exam:

- Introduction, Wash Hands, Consent
- General Inspection:
o Alert/Orientated
o Pain/Distress
o Body Habitus:
Obesity (Blue Bloaters)
Cachexia (Pink Puffers, Malignancy)
Chest Deformities (Pectus Excavatum, Pectus Carinatum, Barrel Chest, Kyphosis, Lordosis)
Chest Scars
o Respiratory Distress?
Tripoding
Pursed-Lip Breathing (Obstructive Lung Disease)
Dyspnoea
Audible Wheeze/Cough/Stridor (Obstructive Lung Disease)
Intercostal Recession & Tracheal Tug (Restrictive Lung Disease)
o Colour:
Cyanosis (Blue Bloaters)
Plethora (Pink Puffers)
Pallor (Anaemia)
- Vital Signs:
o Pulse:
Tachycardia (Anaemia, Cyanosis, Infection)
o Blood Pressure:
Typically Normal
Postural Variation (Severe Anaemia)
Pulsus Paradoxus (Severe COPD, Asthma, Tamponade, Pneumothorax)
o Respiratory Rate:
Tachypnoeic (Anaemia & All Lung Diseases)
o Temperature:
Fever (Infection)
- Hands:
o Perfusion/CRT
o Clubbing (Chronic Cyanosis)
o Pale Nails (Anaemia)
o Koilonychia (Iron Deficiency Anaemia)
o Palmar Crease Pallor (Anaemia)
o Tar Staining (Smoking)
o Intrinsic Hand Muscle Wasting *(Pancoast Tumour)
o Hand Muscle Weakness *(Pancoast Tumour)
o Asterixis (CO2 Retention)
- Arms:
o HPOA (Lung Tumour)
o Pe be Sig *(SVC Obstruction due to Pancoast Tumour)
- Face:
o Plethora (Polycythaemia, SVC Obstruction)
o Skin Lesions (SCC/BCCs)
o Conjunctival Pallor (Anaemia); Subconjunctival Haemorrhages (Severe Cough)
o Atrophic Glossitis/Angular Stomatitis (All Types of Anaemia)
o Hydration
o Central/Peripheral Cyanosis (All Lung Pathology)
o Leukoplakia/Erythroplakia (Premalignancy from Smoking)
o Tar-Stained Teeth (Smoking)
o HORNERS Syndrome (Sympathetic Nerve Palsy):
Unilateral Ptosis, Anhydrosis, Miosis (Pinpoint Pupil, Enophthalmos, Laryngeal Hoarseness

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- Neck:
o Vi ch N de (Supraclavicular) (Malignancy)
o Cervical Lymphadenopathy (Infection, Malignancy)
o JVP (SVC Obstruction Pancoast Tumour)(or Pulmonary Hypertension)
o Abdojugular Reflux (Negative if SVC Obstruction)
o Tracheal Deviation (Atelectasis, Pneumothorax)
o Tracheal Tug (Restrictive Lung Disease)
- Chest – ONCE FROM BEHIND, ONCE FROM THE BACK:
o Inspection:
Chest Deformities
Scars
Visualise Chest Expansion FROM BEHIND
o Palpation:
Chest Expansion >5cm = Normal (From Behind)
Tactile Fremitis (Consolidation)
H e Sig (Severe COPD, Emphysema, Asthma)
Chest Wall Tenderness (Malignancy)
o Percussion:
Dullness = Consolidation
Stony Dullness = Pleural Effusion
Hyperresonant = COPD/Emphysema/Asthma/Pneumothorax
Lung Borders for Hyperinflation (6th rib anteriorly = normal) (COPD, Emphysema, Asthma)
o Auscultation:
V cal Resonance
Breath Sounds:
Vesicular = Normal
Bronchial = Consolidation
Pleuritic Rub = Pleuritis/Mesothelioma
Muffled = Pleural Effusion
Inspiratory Crepitations/Crackles = Pulmonary Oedema/Pneumonia
Expiratory Wheezes = Bronchial Disease
o (+ Mention Cardiovascular Examination)
- Abdomen:
o Percuss & Palpate for Liver Ptosis (Lung Hyperinflation)
- Legs:
o Oedema
o Calf Tenderness & Erythema (DVT PE)
o Signs of Venous Stasis Shiny Skin, Hair Loss, Venous Ulcers (DVT PE)
- Feet:
o Perfusion/CRT
o Clubbing
o Koilonychia (Iron Deficiency Anaemia)
o Pale Nails (Anaemia)

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 Full & Focussed Rheumatological Exams

Full Rheumatological Exam:

- Introduction, Wash Hands, Consent,
- General Inspection:
o Cushingoid Appearance (Steroids Osteoporosis)
o Bird-like Facies (Scleroderma)
o Weight Loss (Autoimmune, Scleroderma)
o Butterfly Rash & Hair Loss (SLE)
- Vital Signs:
o Pulse:
o Blood Pressure:
o Respiratory Rate:
o Temperature:
Fever (Rheumatoid, SLE)
- Hands:
o Rheumatoid Arthritis:
Symmetrical PIP Synovitis (Red + Swollen + Tender)
Ulnar Deviation
Subluxation of MCP Joints
Z-Deformity of the Thumbs
Swan Neck Deformity of the Fingers
Vasculitic Splinters in the Fingers
Small Muscle Wasting
Palmar Tendon Crepitus
Carpal Tunnel (Inverse Prayer Test)
o Reiter s S ndrome
Syphilitic-like Lesions on Soles & Palms.
o Osteoarthritis:
Hebe on Node DIP Joints)
Bo cha d Node PIP Join
o Gouty Arthritis:
Gouty Tophi in Hands
o Scleroderma (CREST):
Calcinosis (Calcific Nodules in Skin of Fingers)
Ra na d Phenomenon
(+ Esophageal dysmotility)
Sclerodactyly
Telangiectasias on the Fingers
- Arms:
o Rheumatoid Nodules (Rheumatoid Arthritis)
o Gouty Tophi in Wrists & Elbows (Gout)
o Psoriatic Plaques on Extensor Surfaces (Psoriasis & Psoriatic Arthritis)
- Face:
o Rheumatoid Arthritis:
D E e Sjog en S nd ome
Cataracts (Steroid Side Effect)
Conjunctival Pallor (Anaemia from NSAIDs GI Bleeding)
Pa o id Gland Enla gemen Sjog en S nd ome
D ne of Mo h Sjog en S nd ome
Mouth Ulcers & Gum Hypertrophy (Methotrexate Side Effects)
TMJ Joint Crepitus
o Ankylosing Spondylitis:
Acute Iritis
o Reiter s Syndrome:
Conjunctivitis
Iritis
o Gout:
Gouty Tophi in the Ear
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 - Neck:
o Cervical Lymphadenopathy (Rheumatoid, SLE)
- Chest:
o Rheumatoid Arthritis:
Bony Tenderness (Particularly Spine)
Pleural Effusions
Pericardial Rub
Aortic Regurgitation Murmur
o Ankylosing Spondylitis:
Lordosis + Kyphosis
Lumbar Tenderness
Ma kedl ROM of Spine
** Che E pan ion
Aortic Regurgitation Murmur
Sacroiliac Joint Tenderness
- Abdomen:
o Rheumatoid & SLE:
**Splenomegaly
**Hepatomegaly
- Genitals:
o Reiter s S ndrome
Urethral Discharge
Balanitis
Prostatitis
- Legs:
o Rheumatoid Arthritis:
Quadriceps Wasting
Knee Crepitus
Valgus (Bowing) Deformity of the Knee
Bake C in Popli eal Fo a
Peripheral Neuropathy (***Including Foot Drop***)
o Ankylosing Spondylitis:
Achilles Tendonitis
Plantar Fasciitis
o Gouty Arthritis:
Tophi in Big Toe (75% of cases)
Tophi in Achilles Tendon
- Feet:
o Rheumatoid:
Foot Drop (Common Fibular Nerve Palsy)
MTP Joints Swelling & Subluxation
Archilles Tendon Nodules
Claw Toes
o Reiter s S ndrome
Sausage Toes
Plantar Fasciitis
Achilles Tendonitis
Syphilitic-like Lesions on Soles & Palms.

NB: Limited Cutaneous Scleroderma = CREST Syndrome =

- Calcinosis (Calcific Skin Nodules in the Fingers)
- Ra naud s Phenomenon
- Esophageal Dysmotility Dysphagia
- Sclerodactyly of fingers
- Telangiectasia on fingers

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 Preoperative Care:

1. Right Patient, Right Surgery, Right Side?

a. Time out is done in the OR X-References Pt info with Operation etc.
b. Ask Pt what surgery?
c. Mark the correct side.
2. Informed Consent (P570 oxford)
a. General Risks:
i. Anaesthetic Risks:
1. Atelectasis (Lung Collapse)
2. Pneumothorax (Lung Rupture)
3. Pneumonia
4. Aspiration
5. Mouth Injury
6. Sore Throat
7. Awareness
8. Coma
9. Malignant Hyperthermia (Rare, Inherited Rhabdomyolysis & Fever Usually
Fatal)
10. Anaphylaxis (Anaesthetic Reaction)
11. Cardiac Arrest
12. Death
ii. Surgical Risks:
1. Bleeding
2. Transfusion (+/- Reaction)
3. Wound (Pain, Scars)
4. Infection
5. DVT +/- PE
6. Disability
7. Death
8. Nerve Palsy
b. Specific Risks:
i. Brain Damage (Neurosurgery)
ii. Stroke (Carotid Endarterectomy)
iii. Hypothyroidism (Thyroidectomy)
iv. Hypoparathyroidism (Thyroidectomy)
v. CBD Dissection (Cholecystectomy)
vi. Ileus (Abdominal Surgery)
vii. Adhesions (Abdominal Surgery)
c. Final Words:
i. Consent is NOT a contract; It can be revoked at any time.
ii. Risks are relative & depend on Pt Health & Procedure.
iii. Anaesthetic Mortality 1/200,000 healthy pts.
iv. Benefits should outweigh Risks

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3. Anaesthetic Risk Assessment:
a. Cardiorespiratory Function
b. Co-Morbidities?
i. IHD
ii. Diabetes
iii. Asthma
iv. HTN
v. Epilepsy
vi. Jaundice
vii. Pregnant
c. Allergies
d. Smoker
e. Previous Anaesthesia + any complications?
f. FamHx of Malignant Hyperthermia
4. Drug Assessment:
a. Pt on Steroid Therapy?
i. Pts on steroids have suppressed adrenals :. need extra cortisol to cope with the stress of
surgery. Give Hydrocortisone 50-100mg IV with premeds, then TDS for <3days.
b. Pt on Anticoagulants?
i. Typically Aspirin is fine.
ii. Stop Warfarin >2-5days pre-op. (Emergency Reversal with Vitamin K +/- FFP.)
iii. Stop Heparin 6hrs pre-op. (Emergency Reversal with Protamine)
iv. (NB: When re-warfarinizing, DO NOT stop Heparin until INR is Therapeutic, as Warfarin is
Pro-Thrombotic in the early stages)
v. (NB: Avoid Epidural, Spinal & Regional Blocks)
c. Pt on OCP/HRT?
i. Oestrogen = DVT Risk, :. Stop OCP 4wks Pre-Op (major/leg surgery); Resume 2wks
Post-Op.
5. Pre-Operative Checklist:
a. Fast The Patient:
i. NBM <2hr Pre-Op
ii. Clear Fluids >2 Pre-Op
iii. No Solids >6hrs Pre-Op.
b. IV Cannula
c. Cathetarise (if Necessary)
d. Group & Hold/Crossmatch
i. G&H for Moderate Surgery (Eg. Mastectomy, Cholecystectomy)
ii. X-Match for Major Surgery (Eg. Caesarean=2U, Gastrectomy=4U, AAA=6U)
e. Usual Blood tests:
i. FBC (Hb)
ii. U&E (if Diabetic/on Diuretics/Burns Pt/Renal Dx/Liver Dx/Ileus/on TPN)
f. Specific Blood Tests:
i. LFT (if Jaundiced/Malignancy/ETOH Hx)
ii. Amylase (if Acute Abdomen)
iii. Drug Levels (eg. Digoxin/Lithium)
iv. TFT (if Thyroid Hx)
g. CXR (If Cardiac/Resp Hx, Possible Lung Mets, >65yrs)
h. ECG (If >55yrs/IHD/HTN/Other CVD)
i. Book any imaging

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 6. DVT Prophylaxis needed? (P580 oxford):
a. Graduated Compression Stockings (NOT FOR Vasculopaths!!!)
b. + Heparin 5000Units SC 2hr Pre-Op (OR LMWH/Enoxaparin 20mg/d SC); then BD Post-Op until
Walking
7. Prophylactic Antibiotics:

Procedure Likely Pathogen/s Antibacterial Cover

General Surgery:
- Appendectomy (Non Perfd) Enteric G-Negs Cefalexin / Gentamicin
- Colorectal Surgery Enteric G-Negs + G-Pos Enterococcus, Cefalexin + Metronidazole
Anaerobes
- Biliary/Duodenal Surgery Enteric G-Negs + G-Pos Cocci Cefalexin + Metronidazole
Orthopaedic Surgery Staphs + Streps + G-Neg Bacilli + Cefalexin / Gentamicin
Anaerobes
Vascular Surgery Staphs + G-Neg Bacilli + G-Pos Cefalexin / Gentamicin /
Enterococcus Augmentin
Urologic Surgery G-Neg Bacilli + G-Pos Enterococcus Cefalexin / Ciprofloxacin
Gynaecologic Surgery:
- C-Section Staphs + Strep + G-Pos Enterococcus Cefalexin / Gentamicin
- Hysterectomy Enteric G-Negs + Group B Strep + G-Pos Cefalexin / Gentamicin / Ampicillin
Enterococcus

Egs: Effective Antibiotics:

G. Positives (“-cocci”) Enterococcus Spp. Penicillins (Benz-Pen-G, Amoxicillin, Ampicillin, Fluclox)
Staphylococcus Spp. - (NB: Augmentin for β-lactamase resistant bacteria =
Streptococcus Spp. Amoxil + Clavulonate)
Cephalosporins (Ceftriaxione3, Cefipime4, Cepfalexin4)
[Vancomycin (For resistant G-Pos/ if Penicillin Allergy)]
G. Negatives E. Coli Aminoglycosides (Gentamicin, Tobramycin, Streptomycin)
Neisseria Spp. - (NB: Used with Penicillins/Cephs for Synergy)
Pseudomonas Tetracyclines (Tetracycline, Doxycycline)
Haemophilus Spp. Macrolides (Erythromycin, Azithromycin)
Klebsiella Spp. Quinolones (Ciprofloxacin, Norfloxacin)
Enterobacter Spp. Cephalosporins (Ceftriaxione3, Cefipime4, Cefalexin4)
[Benz-Pen-G (For Neisseria Gono/Mening)]
Anaerobes Bacteroides Spp. [Metronidazole (For Bacteroides)]
Clostridium Spp. [Vancomycin (For C.Diff)]
Atypicals Mycoplasma Tetracyclines (Tetracycline, Doxycycline)
Legionella Macrolides (Erythromycin, Azithromycin)
NB: Triple Therapy: –Ampicillin, Gentamicin, Metronidazole- give great 'Broad Cover'. (Remember by AGM
Annual General Meeting...If you want to be around next year, take these 3)

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Sexual Intro + Consent
History Presenting Complaint:
Any current symptoms? Unusual vaginal d/c or itching? Painful IC? Urinary complaints?
Menstrual problems?
Relationship Status, Sexual Orientation:
Are you in a relationship?
DO you have a regular partner? Male or female?
DO you partake in sexual activities with males, females or both?
How many partners?
How many partners have you had in the last 12 months?
Have you had sex with anyone different in the last 3 months
DO you know your partners? friends random s ha co n r are he from
Monogamous/Promiscuous?
Safe Sex
Do you use condoms? Effectively?
When was your last unprotected sex?
What type of sexual activities do you partake in?
Sex with Prostitutes
History of STIs
Ha e o had an STD s before?
When was your last Pap Smear?
Is there anything else you would like to add?

Follow up with OBGYN History

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OBGYN Intro + Consent
History Presenting Complaint:
Any current symptoms? Unusual vaginal d/c or itching? Painful IC? Urinary complaints?
Menstrual problems?
Date of Last Period –
Was it normal?
Regularity? –
Are your periods generally monthly (10-12 periods a year)?
Symptoms related to Periods? –
Do you have excessive bleeding or cramping with menses?
Age of Menarche –
How old were you when you started having periods?
Has Menopause Occurred? –
How old were you when you stopped having periods? (menopause = 1 year since last
menses)
Any vaginal bleeding since menopause?
Possibility of Pregnancy? –
Are you contracepting? Sexually active? New partner?
Any chance you might be pregnant now?
Maternal History? –
Gravida - # pregnancies
Para - # deliveries
Live births full term or premature
Still births
Multiple births
C-Sections?
Spontaneous abortions
Therapeutic abortions
Living children
“Well-Woman Screening” History:
When was last pap smear? Was it normal?
When was your last breast exam? Do you examine yourself regularly?
Any Family History of Female Cancers?
PMH/PSH:
Past STIs?
Any OB/GYN surgeries?

Follow up with Sexual History

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 Cardiovascular Pre-Op Assessment

1. Assess the Pump (Heart):

a. Power (Myocardium)
b. Valves (Stenosis/Regurg)
i. NB: Stenosis is worse than Regurg because they cap the CO under load/stress.
c. Piping (Vessels)
d. Control (Conduction)

2. CVS Systems Review:

a. Cardiac Failure:
i. Dyspnoea
ii. PND
iii. Orthopnoea
iv. Peripheral Oedema/Ascites
b. IHD:
i. Angina (Stable/Unstable)
ii. Prev. MI
iii. FamHx of IHD
c. Valve Disease:
i. Hx of Rheumatic Fever
ii. Old Age
d. PVD:
i. Claudication
ii. Smoker?/Diabetic?
iii. Dizziness/Blackouts/Prev. TIA
e. Conduction Deficits:
i. Palpitations
ii. Arrhythmias

3. CVS Examination:
a. Signs of Failure:
i. Basal Crepitations (LVF)
ii. Peripheral Oedema/Ascites/Organomegaly (RVF)
b. Signs of Structural Abnormality:
i. Displaced Apex (Dextrocardia/Cardiomegaly)
ii. Parasternal Heave
iii. Murmurs/Thrills
iv. Previous Surgery
c. Signs of PVD:
i. Peripheral Pulses
ii. CRT
iii. Ulcers (Arterial/Venous)
d. Signs of Arrhythmias:
i. Irregular Pulse
ii. Rapid Pulse
iii. ECG

4. Medications:
a. Diuretics – because they K+ & ↑Mg+
b. Antihypertensives
c. Antiarrhythmics
d. Anticoagulants – esp. Dagabatran (Irreversible)
e. Antibiotics

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 Likely Focussed Cardio Exams for OSCE
Heart Failures
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Left Heart Failure - Exertional Dyspnoea Vitals:
(LVF): - Orthopnea - Tachypnoea, Tachycardia (Low Volume), Hypotension
- Paroxysmal Nocturnal Dyspnoea Other:
- Whee ing C gh Ca diac A hma - CO C ld e i he ie CRT Pe i he al C an i Ce eb al H ef i n
(Inattention, Confusion)
(+ Syncope + Angina = Aortic Stenosis) - Pulmonary Congestion Central Cyanosis, Basal Lung Crepitations, Diffuse
(+ High Arch Palate of Marfans = Mitral Prolapse) Wheezes.
- Abdo-Jugular Reflux Positive.
- Laterally Displaced Apex Beat (LV Dilation)
Signs of Causes:
- Mitral Facies & Mitral Regurg (Pan-Systolic Murmur over Mitral/Apex)
- Mitral Facies, Mitral Stenosis (Pan-Diastolic Crescendo Murmur over Mitral/Apex)
- OR Aortic Stenosis (Syst-Ejection Murmur over R.Sternal Border)
- OR Aortic Regurg (Decrescendo Diastolic Murmur over R.Sternal Border)
- (Cardiac Cachexia if Right Heart Failure)
Right Heart Failure - Anorexia/Cardiac Cachexia (Portal HTN) Vitals:
(RVF): - Swollen Ankles, Sacrum & Abdomen, - Low-Volume Pulse
- Weight Gain (Fluid) Other:
- CO C ld e i he ie CRT Pe i he al C an i Ce eb al H ef i n
(+ Pulsatile Liver = Tricuspid Regurg) (Inattention, Confusion)
- RV-Heave
- Peripheral Congestion Peripheral Oedema (Sacral/Tibial), Ascites, Small
Pleural Effusions.
- JVP K ma l Sign JVP n In i a i n
- Portal Hypertension Ca diac Cache ia Ca Med a Tende
Hepatomegaly, Pulsatile Liver (TR),
Signs of Causes:
- COPD & Cor Pulmonale (RVF due to Pulmonary Hypertension)
- LVF (Pulmonary Congestion)
- Tricuspid Regurg (Pansystolic Murmur over Tricuspid + Pulsatile Liver)
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 Cardiac Causes of Chest Pain
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
IHD & Acute IHD: Vitals:
Myocardial Infarction: - Angina (Severe Central Crushing Chest Pain): - Tachycardia/Bradycardia
o Stable = Transient Exertional o +/-Arrhythmias (AF, VT, VF, Heart Block)
o Variant/Prinzmetal = Transient @ - Tachypnoea
Rest - Hypotension
o Unstable = Resting Angina of - Afebrile
Se e i F e enc Other:
- (+/- Diaphoresis, Dyspnoea, Anxiety) - Clammy, Sweaty Hands
AMI: - If LV Infarct LVF P lm na C nge i n CO C l Pe i he ie Cen al
- Angina (Severe Central Crushing Chest Pain) Peripheral Cyanosis, (Cardiogenic Shock)
o >20mins o If Papillary Muscle Dysfunction Mit.Regurg (Midsystolic Murm)
o Radiating to L-Arm, Neck & Jaw - If RV Infarct RVF JVP K ma l s Sign.
- Dyspnoea - If Transmural Pericardial Friction Rub
- Diaphoresis Signs of Causes:
- Anxiety - PVD, Hypertension, Diabetes, Hypercholesterolaemia, Obesity, Smoker.
Pulmonary Embolism: - Sudden, SEVERE Dyspnoea Vitals:
- Pleuritic Chest Pain - Fever, Tachycardia, Tachypnoea, Hypotension (LVF)
- (+/- Haemoptysis) Other:
- (+/- Syncope) - RVF C l Pe i he ie CRT Pe i he al C an i JVP RV-Heave, Tricuspid
Regurg Murmur
- Re p F nc ion Central Cyanosis
- Pleural Friction Rub,
Signs of Causes:
- DVT Calf Pain, Calf Tenderness, Calf Swelling/Erythema, Pedal Oedema.
o (B/G of Pregnancy, Air Travel, Recent Surgery, Clotting Disorders)
Acute Aortic - Sudden, Severe Tearing Chest/Abdo Pain Vitals:
Dissection: o Radiating to Back - Unequal Radial Pulse Pressures,
- (+/- Stroke) - Asymmetrical Blood Pressure
- (+/- ALOC due to Tamponade) Other:
- (+/- Sudden Death) - Pulsatile, Expansile Abdominal Masses, Renal Bruits
- Sign f Tam nade JVP Hea S nd L -Volume Pulse, etc)
- Aortic Regurg (Due to disruption of annulus) (Decrescendo Diastolic Murmur)
Signs of Causes:
- Ma fan Habi
Complications:
- Myocardial Infarction (Coronary Occlusion), Mesenteric Ischaemia (Mesenteric
Artery Occlusion), Pre-Renal Failure (Renal Artery Occlusion), Limb Ischaemia
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 Endocardial Diseases:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Rheumatic Fever/ (Preceding Strep Throat): Acute Rheumatic Fever:
Rheumatic Heart - Fever, Pharyngitis, Tonsillitis, Vitals:
Disease: Lymphadenopathy - Fever, Tachycardia, Tachypnoea
Rheumatic Fever (>2wks Post GABH Strep Other:
Pharyngitis): - Ataxia (due to polyarthritis)
- Fever - Pericardial Friction Rub (Fibrinous Pericarditis)
- Joints - Migratory Polyarthritis, Ataxia - Subcutaneous Nodules
- Heart - Pleuritic Chest Pain (Fibrinous - Erythema Marginatum (Red rings on trunk and limbs)
Pericarditis) - S denham Ch ea Ra id In l n a P ele Movements)
- Nodules Subcut Nodules
- Erythema Marginatum Red rings on trunk Rheumatic Heart Disease:
& limbs Vitals:
- Sydenham Chorea Rapid, Involuntary - Afebrile, Tachycardia (+/- AF), Tachypnoea (CCF), Hypotensive
Mvts. Other:
- in Indigen - Mitral Facies & Mitral Stenosis (+/- Mitral Regurgitation)
Rheumatic Heart Disease: - CCF In i a C e Pe i he al Cen al C an i JVP D n ea
- Palpitations (AF)
- LVF Exertional Dyspnoea, Orthopneoa, Signs of Cause:
PND - Indigenous, Low SES, Poor Hygeine
- Mitral Facies
Infective Endocarditis: - Acute PUO (+ Chills, Night-Sweats/Weight Vitals:
Loss) - Fever, Tachycardia, Tachypnoea
- Dyspnoea Other:
- Mild A h algia lick j in bi e he - Clubbing, Palmar Crease Pallor, Splinter Haemorrhages (Septic Emboli), Janeway
hea Lesions (Painless Maculopapular Bacterial Colonies on Palms), Painf l O le
- Palpitations Nodes (Tender, Red, Raised Nodules on Pulps of Fingers)
- Haematuria - Trackmarks (IVDU),
- Conjunctival Pallor, Retinal Roth Spo (Retinal Haemorrhages), Poor Dentition,
- New or Changing Murmur (Either side of heart) (Often Tricuspid), Prosthetic
Valve Click,
- Splenomegaly
Signs of Causes:
- IVDU, Poor Dentition, Open Heart Surgery.
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 Pericardial Diseases:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Acute Pericarditis: - Fever Vitals:
- Dyspnoea (+/- Dry Cough) - Tachycardia, Tachypnoea (Fast, Shallow), Febrile,
- Pleuritic Chest Pain (Worse on Supine) Other:
- Pericardial Friction Rub (Best heard when sitting forward + hold breath)
- IF Tamponade JVP Hea S nd Im al able a e CO
Signs of Causes:
- URTI, Post MI, Post Cardiac Surgery, Uraemia, SLE/Rheumatoid.
Acute Cardiac - Dyspnoea Vitals:
Tamponade: - Anxiety - Tachypnoea, Tachycardia (Low Volume & Pulsus Paradoxus), Hypotension,
- Syncope Afebrile
Other:
- JVP
- Im al able A e Hea S nd
- Left Lung: Dull & Bronchial Breathing @ Base (Compressed by Heart)
Hypertensive Diseases:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Pulmonary RVF Secondary to Pulmonary Hypertension: Vitals:
Hypertension & - COPD: Dyspnoea, Cough, Wheeze - Tachycardia (if LVF), Tachypnoea (if COPD/LVF), Hypotension (If LVF), Afebrile
Corpulmonale: - Pul HTN: Cough/Dyspnoea/PND/Orthopnea Other:
(LVF, COPD) - RVF: Swelling (Legs, Abdo), Chest Pain - If LVF: C l Pe i he ie CRT Pe i he al Cen al C an i L V l me P l e
- If COPD: Clubbing, Tar Staining, Peripheral & Central Cyanosis
- JVP a-Wave, RV-Heave, Loud S2 (closure of Pul.Valve) Abdojugular Reflux
Positive, Portal Hypertension (Tender Hepatomegaly), Ascites, Sacral/Pedal
Oedema,
Signs of Causes:
- LVF, Smoking, COPD, IPF
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 Running Tally of Diseases Learned
ENDOCRINE
Thyroid Disease (Temperature Intolerance + Weight Change + Menstrual Change + Appearance Change):
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Hyperthyroidism & Fatigue, Vitals:
Thyrotoxicosis: Weight Loss (Despite Appetite) - Tachycardia (Irreg.Irreg: AF), Hyperthermia, Hypertension,
(Eg. Graves Disease or Diarrhoea Other:
Central TSH) Heat intolerance, Sweating, Facial Flushing - Weight Loss, Flushing, Anxiety, Sweating, Tremor, Allopecia, Frightened Facies
Irregular Menstruation - Hands Warm & Well Perfused, Palmar Erythema, Sweaty Hands, Acropathy
Painless Goiter (Digital Clubbing & Swelling; Fingers & Toes) –GRAVES, Onycholysis (Plummer’s
Anxiety, Tremor, Insomnia, Nails = Separation of Nails from Nailbed), Hand Tremor,
Palpitations - Proximal Myopathy (Muscle Weakness) & Wasting, But HYPERREFLEXIA
- Exophthalmos (Frightened Facies), Lid Lag,
- Neck Scars (Thyroidectomy Exogenous Thyroid Hormone), Palpable Painless
(NB: May CCF in Elderly) Goitre (Diffuse if Grave’s Disease; Nodular if TMG), Mobile on Swallowing,
Cervical Lymphadenopathy (Graves)
- Thyroid Bruit
- Check Pemberton’s Sign (Retrosternal Goitre) & Percuss Across the Chest
- Gynaecomastia
- Pretibial oedema, HYPERREFLEXIA
Signs of Causes:
- Goiter
- Pituitary Adenoma (Bitemporal Hemianopsia)
Hypothyroidism & Early symptoms: Vitals:
Myxoedema: Fatigue, Depression - Bradycardia (Small Volume), Hypotension, Hypothermia
(Hashimoto Thyroiditis, Weight Gain (Despite Appetite) Other:
Iodine Deficiency or Constipation - Obesity, Oedema, Mental Sluggishness, Anhedonia, Slow Hypothyroid Speech,
Central TSH) Cold Intolerance, Dry Skin, Pale Skin Hoarseness, Apathetic (Emotionless) Face,
Menorrhagia - Hands Cool, Dry & Poorly Perfused, CRT, Peripheral Cyanosis, Brittle Nails,
Painless Goiter Palmar Crease Pallor (from Menorrhagia), Inverse Prayer Test for Carpal Tunnel,
Stupour, Memory Loss Xanthomata ( Cholesterol)
Muscle Pain - Proximal Myopathy (Muscle Weakness) & Wasting, with “HUNG REFLEXES”
Puffy Eyes, Hair Loss of Eyebrows - Facial Oedema, Periorbital Oedema, Allopecia, Loss of lateral 1/3 eyebrows,
Xanthelasma ( Cholesterol)
- Painless Goitre, Mobile on Swallowing,
- Pericardial Effusion, Pleural Effusions
- Pedal Oedema, Hung Leg Reflexes, Peripheral Paresthesia
Signs of Causes: Cretinism (Iodine Deficiency)
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 Parathyroid Disorders (Symptom Cluster):
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Hyperparathyroidism: (F>>M) Vitals:
( PTH Hypercalcaemia Asymptomatic Incidental Hypercalcaemia. - ?
& Hypophosphataemia) Symptomatic Bones Moans, Stones & Abdominal Other:
Groans : - Mental State (Hypercalcaemia can Coma & Convulsions)
- Bone: Pain/Osteoporosis/Fractures - Signs of Dehydration (Hypercalcaemia can Polyuria)
- CNS: Depression/Lethargy/Seizures - Band Keratopathy (Calcium Deposition underneath the Corneal Epithelium)
- Gallstones & Kidney Stones. - Bony Tenderness (Shoulders, Sternum, Ribs, Spine, Hips)
- Abdo: Constipation/Nausea/Ulcers - Pseudogout (Calcium Pyrophosphate deposition in the knee)
- Haematuria (Renal Stones)
Other Organs: Metastatic Calcification in Signs of Causes:
Stomach/Lungs/Myocardium/Heart Valves/ - PTH 2o to Chronic Renal Failure (CKD Signs + Osteoporosis)
&Vessels
Hypoparathyroidism: *Hypocalcaemia Neuromuscular **Tetany**: Vitals:
( PTH Hypocalcaemia - Distal Paraesthesias - ?
Tetany) - Cramping & Spasms Other:
- *Laryngospasm (Emergency) - T ea Sign (Tetany of hand after 2mins of arm ischaemia with BP Cuff)
(Typically Post-Operative - Seizures - Chvostek's sign (Unilateral Facial Twitch when the Facial Nerve Outlet is Struck)
after Thyroidectomy) (+/- CNS: Confusion/Depression/Psychosis) - Hyperreflexia
(+/- CVS: Characteristic Prolonged QT-Interval) - Fragile Nails
- Dry Skin
- Tooth Deformities
Signs of Causes:
- Neck Scars (Thyroidectomy)
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 Pancreatic Disorders - (PPP Polyuria, Polydipsia, Polyphagia):
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Type 1 Diabetes: Juvenile Disease; Rapid onset: Vitals:
Absolute Insulin - Polyuria, Polydipsia, Polyphagia - Tachycardia (Dehydration), Postural Hypotension (Dehydration), Tachypnoea
Deficiency - Rapid Weight Loss Despite Appetite (DKA)
- Nausea, Vomiting Other:
- Fatigue - Wasting (If Type 1), Obesity (If Type 2)
- Fat Atrophy @ Insulin Injection Sites
(+ LADA Slowly Progressing “Type I Diabetes”): Face:
- Typically Slim Adults (≈40yrs) - Visual Acuity, Fundoscopy (Retinopathy–Dots/Blots), Cataracts, Xanthelasma,
- Slow Progression to Insulin Dependency - Sweet Breath (DKA)
- Same symptoms as D1M. - Mouth Infections (Candida)
Type 2 Diabetes: Adult Disease; Slow, insidious onset: - Carotid Bruits (PVD)
Insulin Resistance - Polyuria, Polydipsia, Polyphagia - Acanthosis Nigricans
And/Or Relative Insulin - Usually Overweight (Central Obesity) Go From Face to Lower Limbs:
Deficiency - No Ketonuria - Inspection: Ulcers, Hyperkeratosis, Shiny Skin, Hair Loss, Fungal Nail Infections,
- Metabolic Syndrome Cellulitis, “Necrobiosis Lipoidica Diabeticorum” (Disgusting-looking Ulcer),
o 1. Central Obesity “Charcot’s Joint” (Poor Proprioception), Hallux Valgus, Pes Cavus, Hammer Toes,
o 2. Hypertension Loss of Transverse Arch
o 3. Impaired Glucose Tolerance - Palpation: Cool Feet, CRT, Distal Pulses, Pedal Oedema,
o 4. Dyslipidaemia ( TGLs, HDL) - Neurological: Monofilament (in 9 Areas of the Foot), Vibration, Proprioception,
Pain (All Leg Dermatomes EXCEPT on Soles of Feet), Reflexes
(+MODY: Genetic – Autosomal Dominant): Signs of Causes:
- Young People, Non-Obese - Cushings Facies, Acromegaly Facies, Pigmentation (Haemochromatosis)
- Syx of Hyperglycaemia – PPP Further Examination: CVS (PVD), CKD (Renal), Full Neurological,
Diabetic Ketoacidosis: - Polyuria, Polydipsia, Polyphagia Vitals:
(Only in D1M or LADA) - Ketoacidosis - Tachycardia (+/- Arrhythmia), Hypotension, Tachypnoea
o Hyperventilation Other:
o Headache/Altered Mental State - Sweet Breath (Acetone Breath)
o Vomiting Dehydration, Na, Ca, - ALOC ( GCS)
- Dehydration Signs (Loss of Skin Turgor, Enophthalmos, Dry Mucosae)
- K ssma l s Brea hing (A form of Hyperventilation: Deep, Laboured Breathing)
Signs of Causes:
- Diabetes (Insulin Injection Sites, Diabetes Bracelet, Peripheral Neuropathy, CKD)
(NB: Hypokalaemia in DKA is a RED FLAG)
Treatment:
- IV access Correct Dehydration
- Insulin + Potassium Supp. Correct Hyperglycaemia & Electrolytes
- Treat underlying cause (Infection)
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HONC Hyperosmolar (NB: NO Ketogenesis – Even Low Insulin is enough to Vitals:
Non-ketotic Crisis: Inhibit Ketogenesis). - Tachycardia (Dehydration), Hypotension (Dehydration)
(Only in D2M) - Hyperglycaemia Other:
- Polyuria (Osmotic Diuresis) & Dehydration - Signs of Dehydration
- Hyperviscosity Risk of Thrombosis - Tremor
- Mental Impairment (Stupor/Coma) - ALOC (Stupor/Coma)
- Neurology – (Sensory/Motor Impairment, Focal Seizures, Hyporeflexia, Tremors)
Treatment:
- IV Fluids
- Insulin + Potassium (Since Insulin causes K+ Shift Into Cells)
Hypoglycaemia - Polyphagia Vitals:
(BSL < 6.0mmol/L): - Tremor - Tachycardia,
- ALOC (Confusion, Drowsiness, Seizures, etc) Other:
(Eg. Insulinoma, - Sweating, Anxiety, Tremor, Palpitations
Insulin Overdose, - Confusion, Drowsiness, Visual Disturbances, Seizures, Coma
Missed Meal) Signs of Causes:
- Mental Illness (Suicide Attempt),
Treatment:
- #1 – Give conservative dose of Oral/IV Glucose (Jellybeans/Juice/Biscuits/etc.)
- OR – IM/IV Glucagon
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 Adrenocortical Hyperfunction Disorders (Symptom Cluster):
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Cushing’s Disease: - Weight Gain Vitals:
(Hyper-Cortisolism) - Change in Appearance (Moon Facies) - Hypertension
- Mood Swings/Depression/Psychosis Other:
(Central – Pituitary - + Hirsutism & Menstrual Abnormalities - Moon Facies, Central Adiposity (Weight Gain), Striae, Buffalo Hump,
Adenoma; or Supraclavicular Fat Pads
Exogenous Steroids) - Thin Skin, Easy Bruising, Poor Wound Healing
- Hirsutism (in Females)
- Visual Field Testing for Pituitary Tumour
- Immunocompromise (Candida in Mouth, Fungal Nail Infections)
- Ask Pt to Squat (Proximal Limb Muscle Atrophy & Weakness)
- Bony Tenderness or Vertebral Bodies (Osteoporosis)
- Cortisol Gluconeogenesis & Insulin Resistance 2oDiabetes:
o Hyperglycaemia Polyuria, Polyphagia, Polydipsia
- Osteoporosis, Backache
Signs of Causes:
- Bodybuilders? (Exogenous Steroid Use)
Diagnosis: Negative Dexamethasone Suppression Test
Conn’s Disease: ( Aldosterone Hypernatraemia(& Hypokalaemia)) Vitals:
(Hyper-Aldosteronism) Renal Fluid Retention - ***Hypertension
- ***Hypertension (Often the ONLY Syx) Other:
(Pituitary Adenoma, - Hypernatraemia Neuromuscular Syx - Paraesthesia/Weakness/VisualΔ/Tetany
Adrenal Hyperplasia, (Paraesthesia/Weakness/VisualΔ/Tetany) - Ballott Kidneys for Adrenal Tumours
Carcinoma) (NB: Hypertension can LVH, Risk of CVA & MI)
Phaeochromocytoma: Symptoms: Vitals:
(Hyper-Adrenalinism) - Palpitations/Tachycardia - Paroxysmal Hypertension, Tachycardia,
- Headache (Hypertension) Other:
(Idiopathic or MEN2 - Sweating/Hot Flushes - Warm Sweaty Peripheries, CRT, Facial Flusing, Pinpoint Pupils,
Tumour Syndrome) - Tremor - Cardiac Flow Murmurs (Hyperdynamic Circulation), Bowel Sounds,
- Anxiety - Ballott Kidneys for Adrenal Tumour
- Nausea/Vomiting Complications of Hypertension:
- Congestive Heart Failure & Pulmonary Oedema (Dyspnoea, PND, Orthopnoea,
Inspiratory Creps, RV Heave, JVP)
- Myocardial Infarction
- Ventricular Fibrillations
- CVAs
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 Adrenocortical Hypofunction Disorders (Symptom Cluster):
Addison’s Disease: ( Aldosterone & Cortisol) Vitals:
(CHRONIC Adrenal Insidious Onset: - Postural Hypotension (Hypovolaemia)
Insufficiency) - Weakness, Fatigue, Lethargy, Depression Other:
- Anorexia, Weight Loss, - Cachexia, Pigmentation (Palmar Creases, Elbows, Gums, Buccal Mucosa) [due to
(Autoimmune - Vomiting, Diarrhoea melanocyte-stimulating activity of ACTH],
Adrenalitis) - Skin Hyperpigmentation - Generalised Weakness
- Polyuria Dehydration ( Aldosterone) - Dehydration Signs (Loss of Skin Turgor, Enophthalmos, Dry Mucosae)
Diagnosis:
- Clinical Diagnosis
- Synacthen Test (Measure Cortisol & Aldosterone 30mins after ACTH Injection)
- Hypoglycaemia (Due to Glucocorticoid (Counter-Reg) Deficiency)
Waterhouse- Abrupt & Severe Clinical Course Vitals:
Friderichsen - Aldosterone Na & H2O Loss - Fever (Due to Meningococcal)
Syndrome: Hypovolaemic Shock Other:
(ACUTE Adrenal (Death in Hours-Days unless Treated) - Kernig’s Sign (Pain on Hip Flexion & Knee Extension) & Brudzinski’s Sign (Neck Flexion
Insufficiency due to causes Involuntary Hip & Knee Flexion), Photophobia, Headache,
Meningococcal Sepsis + Symptoms of Meningococcal: - Petechiae (Skin, Mucosae, Conjunctiva)
Adrenal Infarction) - Fever Signs of Causes:
- Headache - Typically Meningococcal Septicaemia
- Photophobia o :. Neck stiffness
- Neck Stiffness o :. DIC
Gonadal Disorders (Symptom Cluster):
Polycystic Ovaries ( Conversion of Androgens Oestrogen Vitals:
PCOS: Hyperandrogenism) - Hypertension
(Hyper-Androgenism) - 1. Infertility: Due to Anovulation Other:
- 2. Menstrual Changes: Amenorrhoea - Hirsutism (Facial hair, deepening voice, acne)
(Genetic – Sex-Limited Infertility - Metabolic Syndrome (Obesity, Xanthelasma, Xanthomata, Acanthosis Nigricans,
Autosomal Dominant) - 3. Masculinisation: Acne, Hirsutism ( Hair), Polyuria, Polydipsia, Polyphagia)
Deepening Voice - Palpate Abdomen for Ovarian Masses
- . Metabolic Syndrome Synd. X : Insulin Signs of Causes:
Resistance (+/- Obesity, D2M, Cholesterol)
Testicular Atrophy: High risk of Testicular Cancer Vitals:
Other:
Signs of Causes:
- Hypopituitarism, Chronic Alcoholism, Chemotherapy/Radiation, Chronic Anabolic
Steroid Use
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 Pituitary Disorders (Symptom Cluster):
- Space-Occupying Lesions (Eg. Adenomas):
o Compression of Optic Chiasm Visual Field Defect (Bitemporal Hemianopia)
o Compression of Extrinsic Ocular Muscles Oculomotor Palsies (“Ophthalmoplegia”)
o Increased Intracranial Pressure Headaches
- Increased Hormone Secretion Hyperpituitarism:
o Anterior Pituitary:
Eg. PRL – Due to Prolactinoma Galactorrhoea
Eg. GH – Pit. Tumour Gigantism (Kids)/Acromegaly(Adults)
Eg. ACTH – Pit. Tumour Cushing’s Disease
Eg. FSH/LH – Pit./Hypothalamic Tumour Precocious Puberty
Eg. TSH – (Rare) Pit. Tumour Primary Central Hyperthyroidism
o Posterior Pituitary:
Eg. ADH – Hypothal.Osmorecep.Dysfunction SIADH
- Decreased Hormone Secretion Pan-Hypopituitarism: (Eg. Sheehan’s Disease: Post-Partum Hypopituitarism)(Eg. Pituitary Apoplexy/ Infarction)
o Initially Asymptomatic
o Later:
2o Hypothyroidism
2o Adrenal Insufficiency (Similar to Addisons)
2o Dwarfism (GH Deficiency)
o In Sheehan’s Syndrome :
Agalactorrhoea (No Lactation)
/Amenorrhoea after Delivery.
-
Acromegaly/Gigantism: +/- Compressive Pituitary Adenoma Headache + Vitals:
(Excess GH due to Bitemporal Haemianopsia - Hypertension
Pituitary Adenoma) Other:
Insidious Onset -
Acromegaly Facies (Frontal Bossing, Prominent Jaw, Prominent Brow Ridge,
Mostly Middle-Aged Adults (But Gigantism if Enlarged Tongue, Thickened Lips)
before/during puberty) - Soft-Tissue Swelling (Hands, Feet, Nose, Lips, Ears, Skin, Carpal Tunnel, Thyroid)
Change in Appearance (Severe Disfigurement) - Bitemporal Haemianopsia, Fundoscopy (Papilloedema & Hypertensive Changes)
- Spade-Like Hands (Soft Tissue Enlargement), Warm & Sweaty, Thick Greasy Skin,
Complications: Osteoarthritis Heberton’s Nodules
- Hypertrophic Cardiomyopathy & Heart - Proximal Myopathy (Arms & Legs), Foot Drop (Common Peroneal Nerve Compres)
Failure - Kyphosis,
- Hypertension & Kidney Failure - Gynaecomastia, Skin Tags in Axillae (Molluscum Fibrosum),
- Hyperglycaemia & Diabetes Mellitis - CVS (Arrhythmias, Cardiomegaly, CCF)
- Accelerated Osteoarthosis - Hepatomegaly, Splenomegaly, Renal Enlargement
Possible Malignancy
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Prolactinoma: Bitemporal Haemianopsia Vitals:
Headaches Other:
Glactorrhoea - Bitemporal Haemianopsia
- Nipple Discharge
SIADH: - 1. Fluid Overload Without Oedema or Hypertension
(Hypothalamic - . Hyponatraemia Dilutional Excretion :
Dysfunction ADH) o If Severe Cerebral Oedema
Nausea/Vomiting
Headache/Confusion/Seizures/Coma
- 3. High [Sodium] in Urine
- 4. High Urine Osmolarity (relative to Plasma Osmolarity)
5. Normal Renal & Adrenal Function
Diabetes Insipidus: - Polydipsia (Extreme Thirst)
(ADH Deficiency or - Polyuria (Excessive Urination)
Renal ADH Insensitivity) - Risk of Hypokalaemia
Risk of Dehydration (If water isn’t available)
Multiple Endocrine Neoplasia Syndromes (Symptom Cluster):
(Autosomal Domimant)
MEN 1: Pituitary Adenomas
HyperParathyroidism
Insulinomas
MEN 2: Thyroid Cancer
Phaeochromocytoma
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 Running Tally of Diseases Learned
GIT
Oesophageal Disorders:
NB: Dysphagia Symptom NOT Disease:
- Types of Dysphagia:
o With Solids Only = Mechanical Obstruction – (Hiatus Hernia/Strictures/Plummer Vinson Web from Iron Deficiency/Tumours)
o With Solids & Liquids Mo ili – (Achalasia/Neural[Vagus Nv]/Scleroderma)
o With Liquids Only = Pharyngeal Disorders – (Globus Pharyngeus)
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Oesophagitis: - Dysphagia Vitals:
(Infection in Imm.comp - Heartburn - Fever, Tachycardia,
Or Eosinophilic/Allergic) - Sore Throat/Chest Pain (Oesophageal Pain) Signs of Causes:
- Immunocompromise (Eg. Oral Candidiasis)
Achalasia: - Chronic Dysphagia of BOTH Liquids & Solids Vitals:
(Oesophageal FROM THE ONSET. - Normal
Aperistalsis) - Regurgitation of food – Particularly at NightOther:
Can cause Aspiration Pneumonia - None
- Spontaneous Chest Pain (Due to
Oesophageal Spasm)
Mallory Weiss - Dysphagia & Odynophagia Vitals:
Syndrome Tear: - Chest Pain - Normal (Tachy if Pain/Dehydration/Blood Loss), Bradypnoeic (if Alkalotic from
= Oesophageal - Haematemesis Vomiting)
laceration – Other:
(Longitudianl tear) -
Signs of Causes:
- Obesity (Gluttony), Subconjunctival Haemorrhages (Severe Coughing), Low BMI
(Bulimia), Destroyed dentition (Bulimia)
- NB: Nothing to do with Alcohol.
Oesophageal Varices - Hematemesis Vitals:
(Due to Portal - Hematochezia - Normal unless Haemorrhage (Tachycardia, Tachypnoea, Hypotension)
Hypertension): - May Rupture Massive Bleeding Other:
(Often 2o to alcoholic - Portal HTN (Caput Medusa, Ascites, Hepatomegaly, Splenomegaly, Pedal Oedema)
cirrhosis) - If Cirrhosis (Palmar Erythema, Mee’s/Meurkhe’s/Leukonychia, Jaundice,
Xanthomata, Xanthelasma, Scleral Icteris, Hepatic Fetor, Hepatic Flap, Ascites,
Pedal Oedema)
Signs of Causes:
- Chronic Alcoholism (Dupuytren’s Contracture, Cerebellar Dysfunction)
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 Gastro-Oesophageal Junction Disorders
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Hiatus Hernia: - Mostly Asymptomatic Vitals:
- “Heartburn” GORD - Normal
- Epigastric Pain (Oesophageal Torsion) Other:
- Dyspnoea (Affect on Diaphragm) - None
- Palpitations (Irritation of Vagus Nerve)
GORD Barre s - Heartburn (Retrosternal Burning/Pain) Vitals:
Oesophagus & - Dysphagia - Normal
Oesophageal Tumours: Complications: Other:
- Bleeding, Stricture - None
- Barrett’s Oesophagus Signs of Causes:
- Malignancy Progressive Dysphagia (Solids - Obesity, Indian (Spicy Foods), Alcoholism, Pregnancy
Liquids), Weight Loss, Anorexia
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 Stomach Disorders
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Gastritis: - Epigastric Pain Vitals:
= Inflammation of the - Nausea/Vomiting - Tachycardia (if infection), all else normal
Stomach Lining - Indigestion (Dyspepsia) Other:
- Epigastric Tenderness
Signs of Causes:
- Infection
- Pernicious Anaemia (B12 Deficiency Peripheral Neuropathy & Macro.Anaemia)
- Alcohol Abuse (Dupuytren’s Contracture, Macro.Anaemia, Cerebellar Dysfunction)
Peptic Ulcer Disease: - Burning Epigastric Pain (Relieved by Food) Vitals:
(NSAIDs, H.Pylori, or - Haematemesis/Melena - Normal unless Perforated (Tachycardia, Tachypnoea, Hypotension)
Gastrinoma/ZE-Synd) - Nausea & Vomiting - If Anaemic from GI Bleeding (Tachycardia, Tachypnoea)
- (If Perforated Acute Peritonitis & Shock) Other:
- (If Pyloric Stenosis Irretractable Vomiting) - But may have weight-loss
- NB: May Gastric Ca. Weight Loss - If Anaemic from NSAIDs Pale Nails, Koilonychia ( Fe), Palmar Pallor, SC Pallor,
Atrophic Glossitis.
- If Ruptured Peritonism (Guarding, Rigidity, Rebound, Shoulder-tip Pain, Shallow
Breathing, Cullen’s Sign, Grey Turner’s Sign, Peripheral Shutdown, ALOC)
Zollinger Ellison - Abdominal Pain Vitals:
Syndrome: - Dyspepsia - Normal (unless hypovolaemic from diarrhoea)
(Adenoma/Gastrinoma) - Chronic Steato-Diarrhoea (Inactivation of Other:
Pancratic Lipase by Acid) - None
Signs of Causes:
(NB: Malignant Potential) - Abdominal Masses (but usually way too small to detect)
Gastric & Duodenal - Asymptomatic until Advanced Disease Vitals:
Cancers: - Early Syx: - Fever, Tachycardia (If Anaemia or Hypovolaemic), Tachypnoea (If Anaemia)
(“Fungating” – H.Pylori) - Epigastric Pain, Nausea/Vomiting, Other:
(“Leather Bottle” – Anorexia/Weight Loss, Adenopathy, - Virchow’s Node (L-Supraclavicular LN), Acanthosis Nigricans in Axillae,
Familial) Anaemia. - Anaemia (Pale Nails, Palmar Pallor, SC Pallor, Atrophic Glossitis)
- Late Symptoms: Malignant Ascites/Jaundice, - Metastases (Oesophagus, LN, Liver, Lungs)
Symptoms of Brain/Bone/Lung Mets Signs of Causes:
- Peutz Jegher’s Syndrome (Mouth Pigmentation, Clubbing)
- Alcoholism, Smoking
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 Intestinal Malabsorption Disorders
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Coeliac Disease: - Can Present at ANY Age (Peaks = Infancy, in Vitals:
(SI Gluten 50’s) - Normal
Hypersensitivity) - Fatigue, Malaise Other:
- Diarrhoea/Steatorrhoea - Weight Loss, Mouth Ulcers, Angular Stomatitis, Atrophic Glossitis,
- Abdo Pain/Discomfort/Bloating
Radiation Enteritis: - Acute Sx – Nausea, Vomiting, Diarrhoea, Vitals:
(Fibrosis from Abdo Pain. (Improves within 6wks of - Tachycardia (Hypovolaemia/Anaemia), Tachypnoea (Anaemia), Hypotension
Radiotherapy) Radiation) (Hypovolaemia)
- Chronic Sx – (Symptoms for >3mths) Pain Other:
due to Obstruction, Malabsorption, - Radiation Tattoos, Radiation Fibrosis of Skin (Abdomen/Back/Perineum), Anal
Diarrhoea, Tenesmus Fissures (Diarrhoea), Surgical Scars, Abdominal Distension
Tropical Sprue: - **Chronic Diarrhoea + Malabsorption Vitals:
“Severe Infective - Anorexia, Weight Loss - Fever, Tachycardia (Hypovolaemia/Anaemia/Infection), Tachypnoea
Malabsorption, - Abdo Distension (Anaemia/Infection), Hypotension (Hypovolaemia)
Accompanied by Other:
Diarrhoea & - Malabsorption Macro Anaemia (Pale Nails, Palmar Pallor, SC Pallor, Atrophic
Malnutrition” – But (Residents/Visitors of Affected Tropical Areas (Asia, Glossitis, Peripheral B12 Neuropathy)
Unknown Agent. Caribbean, S.America)) - Low BMI
Whipples Disease: - Initially – Arthritis & Arthralgia Vitals:
(Chronic Bacterial - YEARS Later Fever, Abdo Pain, Diarrhoea, - Fever, Tachycardia
Infection: Tropheryma Weight Loss MALABSORPTION Other:
Whipplei) - Lymphadenopathy, Poly Arthritis, Steatorrhoea, Oedema, Anaemia (Fe/B12),
Weight Loss
- Can Brain Damage (Mental Changes/Memory Loss)
- Can Endocarditis (Heart Murmur)
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 Specific Diarrhoeal Disorders
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Acute Bacterial Duration: Vitals:
Diarrhoeal Diseases: - Hyperacute (<24hrs) – Probably ETEC Toxin - Fever, Tachycardia, Tachypnoea, Hypotension (Hypovolaemic)
(ETE.Coli Traveller’s) - Sub-Acute (<3-5days) – Probably Infective Other:
(S.aureus & Salmonella Gastroenteritis (Food Poisoning) - Peripheral Shutdown, CRT, Low-Volume Tachycardia, Dry Mucosae,
= Food Poisoning) (If Chronic, more likely to be Parasitic than Bacterial) Enophthalmos, Loss of Skin Turgor)
(Shigella = Dysentery) Signs of Causes:
- Dysentery (Blood & Pus in Stools) = Shigella
Acute Viral Diarrhoea: - Vomiting Vitals:
(Rotavirus) - + Watery Diarrhoea - Fever, Tachycardia, Tachypnoea, Hypotension (Hypovolaemic)
- + Fever Other:
(Typically In a Child/Infant) - Typically In a Child/Infant Irritability, Poor Feeding
- Peripheral Shutdown, CRT, Low-Volume Tachycardia, Dry Mucosae,
Enophthalmos, Loss of Skin Turgor)
Signs of Causes:
- Hippie Mother Not Vaccinating!
Chronic Diarrhoea - Long-Term Diarrhoea Vitals:
(Usually Parasitic/ - Weight Loss - Normal
Irritable Bowel/ or - Fatigue Other:
Malignancy) - Anaemia (Microbleeding Pale Nails, Koilonychia, Palmar Pallor, SC Pallor,
Atrophic Glossitis), Anal Fissures.
- If CD/UC – Clubbing, Mucosal Ulcers, Red Eyes
Signs of Causes:
- Immunocompromise
- (Also Think Coeliac Disease & Colon Ca)
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 Unique Intestinal Infections:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Intestinal Tuberculosis - **Fever + Night Sweats Vitals:
Mycobacterium - **Weight Loss - Fever, Tachycardia, Tachypnoea (if Pulmonary TB)
tuberculosis - *Ileocaecal Area is most commonly Other:
affected RIF Abdominal Pain - Palpable Masses, Generalised Peritonitis, Bowel Obstruction, Anaemia
Signs of Causes:
- Immunocompromised (HIV/Drugs)
- Pulmonary TB
Pseudomembranous - Onset within 2days of Antibiotics; Vitals:
Colitis: Persists for 2wks After. - Fever, Tachycardia (Infection & Dehydration), Tachypnoea (infection),
Clostridium Difficile - Fever, Hypotension (Dehydration)
Overgrowth due to - Abdo Cramps Other:
Antibiotic Gut Flora - Profuse Water Diarrhoea (<10/day) - Abdo Pain, Haematochezia
(C.Diff is Directly Cytotoxic) - Faecal Urgency - (If Perforation – Peritonitis, Shoulder-tip Pain, Cullen’s/Grey-Turner’s, Shock)
- (If Toxic Megacolon – Abdominal Distension, Abdo Tenderness, Septic Shock, Loss
NB: Can Perforate of Bowel Sounds)
NB: Can Toxic Megacolon Signs of Causes:
- History of Antibiotic Usage
Diverticulosis/Diverticulitis: NB: Diverticulosis is Asymptomatic Vitals:
- Fever, Tachycardia,
NB: Diverticul-ITIS is Symptomatic: Other:
- Severe LEFT Iliac Fossa Pain - LIF Tenderness/Guarding/Rigidity
- Fever - GI Bleeding Anaemia (Pale Nails, Koilonychia, Palmar/SC Pallor, Glossitis)
- Constipation - (NB: If Perforation Peritionitis, Shoulder-Tip Pain, Sepsis, Shock, Death)
(IE. Similar to Appendicitis, but on the Left) Signs of Causes:
- Opioid Addicts (Chronic Constipation), Paraplegic, Multiparity.
Appendicitis: - Initially Umbilical Pain Severe RIGHT Vitals:
Iliac Fossa Pain - Fever, Tachycardia,
- Fever Other:
- Nausea/Vomiting/Anorexia/Diarrhoea(o - R-Iliac Fossa Pain/Tenderness/Guarding
ccasionally) - Ro sing s Sign Referred Rebound Pain in the RIF when the LIF is Pressed.
(Ie. Similar to Diverticulitis, but on the Right) - Psoas Sign: RIF Pain on Flexion of the Hip
- Obturator Sign: RIF Pain on Internal Rotation of the Hip
- Mcb rne s Sign: Deep tenderness at McBurney's point
If Ruptured Appendix:
- Sepsis, Shock, High Fever, Generalised Peritonitis (Guarding/Rigidity/Rebound)
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 Inflammatory (Autoimmune) Bowel Diseases:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Crohn s Disease: - Typically Starts @ Ileocecal Valve (RIF) Vitals:
(Mouth Anus) Common Symptoms (Both CD & UC): - Fever,
(Patchy) - **Abdominal Pain/Severe Internal Cramps Other:
- **Vomiting/Diarrhoea *(Porridge-like, Fatty) - Clubbing
- **Rectal Bleeding - Mouth Ulcers & Anus Involvement,
- GI Bleeding Anaemia (Pale Nails, Koilonychia, Palmar/SC Pallor, Glossitis)
(+ Fever, Weight Loss) Signs of Causes:
- Autoimmune (Arthritis, Iritis, Pyoderma Gangrenosum, Primary Biliary Cirrhosis)
Ulcerative Colitis: - Typically Starts @ Rectum (LIF) Vitals:
(Typically affects Colon) Common Symptoms (Both CD & UC): - Afebrile,
(Continuous) - **Abdominal Pain/Severe Internal Cramps Other:
- **Vomiting/Diarrhoea *(Bloody & Mucus – - Clubbing
but NO Pus. {Not Dysentery]) - No Mouth or Anus Involvement,
- **Rectal Bleeding - GI Bleeding Anaemia (Pale Nails, Koilonychia, Palmar/SC Pallor, Glossitis)
Signs of Causes:
(+ Tenesmus) - Autoimmune (Arthritis, Iritis, Pyoderma Gangrenosum, Primary Biliary Cirrhosis)
Functional Bowel Diseases:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Irritable Bowel - Chronic Abdo Pain/Discomfort Vitals:
S ndrome Spas ic - Alternating Bowel Habits (+ Tenesmus) - Normal
Colon : - (All Investigations Normal) Other:
(Umbrella Term) - Normal
Signs of Causes:
- *Stress/Anxiety/Depression, Chronic Pain, Gut Hypersensitivity.
Hirschspr ng s Disease Presentation within 2-3days after Birth: Vitals:
Congeni al - Delayed Meconium (First Defecation) - Normal
Aganglionic - Abdo Distension Other:
Megacolon - Vomiting - Abdominal Distension & Tenderness, Poor Feeding, Irritability, Anorexia
(Immotile Section of Signs of Causes:
Colon) - Baby
Meckel s Diverticulum: (NB: Majority are Asymptomatic) Vitals:
(Congenital SI True Presentation @ 2yrs Old: - Tachycardia (Pain/if infected), Tachypnoea (Pain), Hypertension (Pain)
Diverticulum) - Malena (Bleeding) Other:
- Severe Central Abdo Pain - Abdominal Distension, Abdominal Tenderness, Peritonitis & Sepsis (perforation),
(Obstruction/Volvulus/Intussusception) Loss of Bowel Sounds, Visible Peristalsis, Cullens/Grey-Turners (Hemoperitoneum)
Signs of Causes: Baby
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 Intestinal Tumours:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Colonic Polyps: - Asymptomatic in Early Stages Vitals:
- (+/- Change in Bowel Habits) - Normal
- (+/- Syx of Anaemia) Other:
(NB: Common in - None
Autosomal Dominant - If Anaemia (Koilonychia, Pale Nails, PC/SC Pallor, Atrophic Glossitis)
Peutz-Jeger’s Signs of Causes:
Syndrome) - Peutz-Jeger’s Syndrome (Clubbing + Melanin Pigmentation on Lips & Hands)
Bowel Cancers:
Sporadic Bowel Cancer: Bowel Ca. Common Symptoms: Vitals:
(Most Common) - (Asymptomatic in Early Stages) - Tachycardia (if Anaemia/Hypovolaemic/Perforation/Septic)
Descending Colon - Change in Bowel Habit & Stool Shape - Tachypnoea (if Anaemia/Perforation/Septic)
- Blood Mixed Within Stool (+/- Anaemia) - Hypotension (If Perforation/Septic/Shock)
- Abdominal Cramping & Bloating - Febrile (If Septic)
- Fevers/Night Sweats Other:
- Weight Loss - Acanthosis Nigricans in Axillae (Sign of GI Malignancy)
- Fatigue - If Anaemia (Koilonychia, Pale Nails, PC/SC Pallor, Atrophic Glossitis)
- (Late Bowel Obstruction +/- Metastasis) - If Shock ( CRT, Cool Peripheries, Peripheral Cyanosis, Low-Vol Pulse, Dry
Mucosae)
Inherited Bowel HNPCC; Amsterdam Criteria: - If Perf/Peritonism (Cullen’s/Grey-Turner’s Signs, Tenderness/Guarding/Rebound,
Cancer: - 1. Must have 3 Affected Relatives Rigidity, Shoulder-Tip Pain)
(Rare; Autosomal Dom) - 2. >One Relatives must be a 1st-Degree - If Metastasis to Liver (Obstructive Jaundice, Clubbing, Leukonychia, Muercke’s
Ascending Colon - 3. FamHx must span >2 Generations Lines, Mee’s Lines, Xanthomata, Palmar Erythema, Scleral Icteris, Hepatic Flap,
- 4. 1+ cases diagnosed @ <50yrs. Hepatic Encephalopathy, Xanthelasma, Hepatic Fetor, Hepatomegaly,
FAP: Gynaecomastia, Spider Naevi, Abdominal Distension, Caput Medusa, Ascites,
- APC Gene Mutation Pedal oedema, Bruising, Scratchmarks)
Signs of Causes:
- NB: Both HNPCC & FAP Risk of other Cancers (Endometrial/Gastric/Ovarian)
Carcinoid Tumour of - Hot Flushes Vitals:
the Intestines: - Watery Diarrhoea - Hypotension (Systemic Vasodilation; & Hypovolaemia), Tachycardia (Hypovol)
(Serotonin - Abdominal Pain Other:
Neuroendocrine - Palpitations - Cardiac Abnormalities – Pulmonary Stenosis or Tricuspid Regurgitation Tender
Tumour) Pulsatile Hepatomegaly.
(3 Common Sites = Appendix, Terminal Ileum, - “Pellagra” (Sign of Niacin/B3 Deficiency) Delusions, Confusion, Scaly Skin Sores.
Rectum; Also the R-Sided Heart Valves)
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 Back-Passage Disorders:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Haemorrhoids (Internal - Internal H.rhoids Painless Rectal Bleeding Vitals:
& External) - External H.rhoids Painful Rectal Bleeding - Normal
(Incompetent Valves in - (Blood on Toilet Paper) Other:
Rectal Vasculature) - (+/- Itching) - Normal
Signs of Causes:
- Previous Pregnancies, Weight-Lifters, Chronic Pain, Antiepileptics, Poor Diet,
Homosexual Men
Anal Fissures - Painful Defecation Vitals:
- Blood on Toilet Paper - Normal
Other:
- Usually extend Outwards from Anal Opening; Depth may be superficial or deep
Signs of Causes:
- Constipation/Prolonged Diarrhoea/Crohn’s Disease/Post-partum/Anal sex
Pilonidal - Extremely Painful, Tender Cyst/Abscess Vitals:
Sinuses/Cyst/Abscess: between the Buttocks. - Normal
Other:
- Cyst/Abscess between the buttocks that often contains hair and skin debris
Signs of Causes:
- Hairy Men, Adolescents, Poor Hygeine
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Clinical E al a ion of a P i h an Ac e Abdomen
- Conditions Requiring Laparotomy:
o Organ Rupture (Spleen/Aorta/Ectopic)
Shock
o Peri oni is Perf d PUD DUD Di er ic l m Appendi Bo el Gallbladder
Prostration, Shock, Lying Still, Tenderness (Guarding/Rebound/Percussion), Abdo Rigidity, No Bowel Sounds.
- Conditions NOT Requiring Laparotomy:
o Local Peritonitis (Diverticulitis, Cholecystitis, Salpingitis, Appendicitis)
Lying Still, Tenderness (Guarding/Rebound/Percussion), Abdo Rigidity
o Colic
Restlessness, Regularly Waxing/Waning Pain.
- Tests to Perform:
o U&E, FBC, Amylase, LFT, CRP, ABG, Urinalysis
o Erect CXR (look for Air under Diaphragm)
- Immediate Priorities:
o Resuscitation Before Surgery!! – NB: Anaesthesia compounds shock!!
Pathogenesis & Signs of Hepatic Encephalopathy (Hepatic Coma)
- Hepatic Encephalopathy ( Ammonia in Bloodstream due to Liver Breakdown)
o Forgetfulness/Confusion/Irritability
o Tremor/Asterixis (Due to Proprioception)
o Seizures/Coma
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 Background Info on Jaundice:
Disease: TYPICAL Symptoms/Presentation:
Unconjugated Jaundice + Neonate Physiological Neonatal Jaundice
(Prehepatic/Haemolytic) Jaundice + Dyspnoea + Fatigue Haemolytic Anaemia
Jaundice Jaundice + Young + Family Hx of Jaundice Gilbert’s Disease.
Jaundice + Young + Malaise Hepatitis
Jaundice Epidemic Hep A Virus
Jaundice + Recent Shellfish Consumption Hep A Virus
Jaundice + Hx of IVDU/Injections/Tattoos Hep B/C Viruses
Jaundice + Sodomy/Prostitution Hep B Virus
Jaundice + Elderly + Weight Loss Carcinoma
Conjugated Jaundice + Elderly + Weight Loss Carcinoma
(Posthepatic) Jaundice Jaundice + Abdo Pain Biliary Obstruction (Gallstones)
Jaundice + 50yr old Woman Priamry Biliary Cirrhosis
Jaundice + Dyspepsia + Steatorrhoea Head of Pancreas Tumour
Jaundice + Fevers/Rigors Cholangitis or Liver Abscess.
General Liver Syndromes:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Fulminant Hepatic - Jaundice, Pruritis Vitals:
Failure - Bleeding, Bruising - May be Febrile
(Acute Liver Failure): - RUQ Pain Other:
(Alcohol/Drugs/Chronic - Fetor Hepaticus - Jaundice, Scratch marks,
Hepatitis/Biliary - Cerebral Oedema, Vomiting - Bruising/Petechiae/Purpura,
Obstruction/Etc) - Hepatic Encephalopathy (within 2 wks) - Hepatic Flap, Hepatic Encephalopathy, Hepatic Fetor
- Death without transplant. - RUQ Tenderness
- Oedema
Hepatic Cirrhosis May be Asymptomatic Vitals: Normal
(Chronic Liver Failure): - RUQ Pain Other:
(Alcohol/Drugs/Chronic - Pruritis (Jaundice), Bruising (Liver Failure) - Jaundice, Ascites, Pedal Oedema
Hepatitis/Biliary - Abdominal Distension, Ankle Swelling, Caput - Clubbing, Leukonychia, Muercke’s Lines, Mee’s Lines, Xanthomata, Palmar
Obstruction/ Medusa (Portal Hypertension) Erythema, Bruising, Scratchmarks, Scleral Icteris, Hepatic Flap, Hepatic
Haemochromatosis/ - Gynaecomastia, Libido, Amenorrhoea, Encephalopathy, Xanthelasma, Hepatic Fetor, Shrunken Nodular Liver (Micro or
Wilson’s Disease/Etc) Palmar Erythema, Spider Naevi (Oestrogen Macro-Nodular depending on Aetiology), Splenomegaly, Gynaecomastia, Spider
Excess) Naevi, Abdominal Distension, Caput Medusa, Testicular Atrophy, Ascites, Pedal
- Confusion/Forgetfulness/Drowsiness/Flap/ oedema)
Coma/Seizures (Hepatic Encephalopathy) Signs of Causes:
- IVDU, Alcoholism, Tattoos, Skin Pigmentation (Haemochromatosis), Cachexia
(Ca), Xanthelasma/mata (Chronic Biliary Obstruction)
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 Hepatitis: Liver Inflammation:
(Acute <6mths; Chronic >6mths)
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Alcoholic Liver Disease - Jaundice Vitals:
(Alcoholic Hepatitis): - RUQ Tenderness - AF (If Dilated Cardiomyopathy)
- Palpitations Other:
- Gynaecomastia, Spider Naevi, Testicular - Fatty Liver Changes Hepatomegaly, RUQ Tenderness
Atrophy - If Portal Hypertension Hepatomegaly, Splenomegaly, Ascites, Pedal Oedema
- Abdo Distension - CLD (Clubbing, Leukonychia, Muercke’s Lines, Mee’s Lines, Xanthomata, Palmar
- (Ataxia) Erythema, Bruising, Scratchmarks, Scleral Icteris, Hepatic Flap, Hepatic
Encephalopathy, Xanthelasma, Hepatic Fetor, Hepatomegaly, Gynaecomastia,
Spider Naevi, Abdominal Distension, Caput Medusa, Testicular Atrophy, Ascites,
Pedal oedema)
Signs of Causes:
- Dupuytren’s Contracture
- ** Thiamine Wernicke/Korsakoff Syndrome, Cerebellar Degeneration,
Peripheral Neuropathy
- Dilated Cardiomyopathy
- Pancreatitis
- Anaemia (Macrocytic – B12 Deficiency) (Microcytic – if GI Blood Loss)
Paracetamol-Induced - Jaundice - Jaundice
Hepatitis: - RUQ Pain/Tenderness - RUQ Pain/Tenderness
- Abdo Distension - Abdo Distension
Autoimmune Hepatitis: May be Asymptomatic – Incidental Diagnosis. Vitals:
(Unknown Aetiology) - Or – Jaundice + Fatigue, Fever, Polyarthritis, - Fever
Pleurisy. Other:
- Jaundice, Striae, Ascites, Acne.
- Hepatomegaly, Splenomegaly
Signs of Causes:
- Associated Diseases – (Pernicious Anaemia/Thyroiditis/Coeliacs/AHA/Polyarthritis)
Non-Hepatitis-Virus Yellow Fever = Hepatitis (Jaundice) + Dengue-Like Syx (Fever + Fatigue + Myalgia + Haemorrhages)
Acute Hepa i is s Cytomegalovirus/HHV = Hepatitis in Immunocompromise
(Yellow Fever Virus, Epstein Barre Virus = Hepatitis (Jaundice) + Teenage + Fever + Pharyngitis + Lymphadenopathy + Hepato/Splenomegaly + Haemorrhages.
CMV, HHV, EBV)
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Hepatitis-Viruses Epidemics Common Vitals:
Acute Hepatitis: Acute Hepatitis ONLY: - Fever, Tachycardia
(Hep A & E) - Viraemia Flu-like Symptoms (Fever, Other:
(Faecal-Oral) Malaise, Anorexia, Nausea, Arthralgia) - Jaundice (Intrahepatic Cholestasis :. Pale Stools & Dark Urine)
(Acute ONLY) - Jaundice after 10days - +/- Hepatomegaly
- +/- Splenomegaly
(**NB: 20% Mortality of Hep.E in Pregnancy) - +/- Tender Lymphadenopathy
Hepatitis-Viruses Acute Non-Specific Viral Symptoms: Acute:
Chronic Hepatitis: - Viraemia Flu-like Symptoms (Fever, Vitals:
(Hep B, B+D, & C) Malaise, Anorexia, Nausea, Arthralgia) - Fever, Tachycardia
(Blood-Transmission) - (90% of Hep B Full Recovery) Other:
(Acute Chronic) - (10% of Hep C Full Recovery) - Jaundice (Intrahepatic Cholestasis :. Pale Stools & Dark Urine)
- +/- Hepatomegaly, +/- Splenomegaly, +/- Tender Lymphadenopathy
Chronic:
Chronic Chronic Hepatitis Symptoms: Vitals:
- May have Non-Specific Viral Syx if - (If Active Fever, Tachycardia)
Reactivation (Eg. “Chronic Active Hep B”) - If Subclinical Normal Vitals.
- OR...May be Completely Asymptomatic until Other:
Cirrhosis Liver Failure - Jaundice (Both Types),
- Small, Nodular Liver
- Signs of Portal HTN – (Telangiectasias, Caput Medusa, Ascites, Pedal Oedema,
Hepatomegaly, Splenomegaly, Gynaecomastia)
- Hep. Encephalopathy
Cirrhosis Liver Failure:
- Abdominal Distension +Ankle Swelling (10% of Hep B & 90% of Hep C) Cirrhosis Liver Failure:
- Pruritis (Jaundice), Bruising Signs:
- Gynaecomastia, Libido, Amenorrhoea - CLD (Clubbing, Leukonychia, Muercke’s Lines, Mee’s Lines, Xanthomata, Palmar
(Oestrogen Excess) Erythema, Bruising, Scratchmarks, Scleral Icteris, Hepatic Flap, Hepatic
- Confusion/Drowsiness/Coma/Flap (Hepatic Encephalopathy, Xanthelasma, Hepatic Fetor, Gynaecomastia, Spider Naevi,
Encephalopathy) Abdominal Distension, Caput Medusa, Testicular Atrophy, Ascites, Pedal oedema)
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 Genetic Liver Disorders:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Primary Biliary Mid-Aged Females!! Vitals:
Cirrhosis AKA Chronic, - Insidious Onset - Normal
Non-Suppurative Destructive - Pruritis, then (Cholestatic) Jaundice Other:
Ch la gi i ): - Fatigue Chronic Cirrhosis:
(Genetic Autoimmune) - Hepatomegaly - Jaundice, Ascites, Pedal Oedema
- Clubbing, Leukonychia, Muercke’s Lines, Mee’s Lines, Xanthomata, Palmar
Erythema, Bruising, Scratchmarks, Scleral Icteris, Hepatic Flap, Hepatic
Encephalopathy, Xanthelasma, Hepatic Fetor, Shrunken Nodular Liver (Micro or
Macro-Nodular depending on Aetiology), Splenomegaly, Gynaecomastia, Spider
Naevi, Abdominal Distension, Caput Medusa, Testicular Atrophy, Ascites, Pedal
oedema)
Signs of Causes:
- Mid-Age Female.
Gilber s S ndrome: - Asymptomatic Vitals:
(Genetic; Benign) - Occasional Mild Jaundice (Associated with - Normal
Fasting/Infection /Stress/Exertion). Other:
- Occasional Jaundice Precipitated by Stress/Infection/Exertion/etc.
Signs of Causes:
- Jaundice + Young + Family Hx of Jaundice
Haemochromatosis - Initially Asymptomatic Vitals:
(Primary Genetic; or - Early (Fatigue, Arthralgia, Loss of Libido) Other:
Secondary) - Later (Skin Bronzing, Abdo Pain, - Skin “Bronzing”
Hepatomegaly, Liver Cirrhosis) - Cirrhosis – (Jaundice, Bruising, Ascites, Oedema, etc.)
- Other Complications:
o Heart - Cardiomyopathy
o Endocrine Glands Failure of gland:
o Joints - Arthritis (Iron Deposition in the Joints)
Signs of Causes:
- (Acquired – Transfusions/Supplements/Haemolysis)
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 Other Random Liver Disorders:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Reye Syndrome Causes Multi-Organ Failure (Brain, Respiratory, & Vitals: ?
Liver) Other:
- Liver Failure (but NO jaundice) - Acute Encephalopathy(Irritability/Aggression/Confusion/Seizures/Coma)
- Acute Encephalopathy (Lethargy/Irritability/ - Respiratory Arrest
Aggression/Confusion/Seizures/Coma) Signs of Causes:
- Associated with Use of Aspirin in Vi al URTI Chicke I fl e a
Liver Abscesses: - Fever, Rigors, Malaise, Vitals:
(Infection – Typically - Anorexia, Weight Loss - Fever, Tachycardia, Tachypnoea, Hypotension (if Septic Shock)
E.Coli – 2o to Sepsis) - Vomiting, Abdo Pain Other:
(Similar to TB) - Sepsis, Jaundiced,
- Tender, Enlarged Liver
Signs of Causes:
- Intra-Abdominal Sepsis
Hydatid Disease of the - May be Asymptomatic Vitals:
Li er Hydatid Cysts - May have Dull Ache in RUQ - ?Fever
(Parasite Infection: Other:
Echinococcus - ?
Granulosus – Spread by Signs of Causes:
Dogs & Sheep) - ?
Liver Disorders Caused by Portal Hypertension:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Nutmeg Liver (AKA: - Often Asymptomatic (incidentally dx on LFT) Vitals:
Congestive - RUQ Pain (due to stretching of liver capsule) - Normal (+/- Low Vol Pulse due to RVF)
Hepatopathy): - Abdo Distension (Ascites) Other:
(Due to RH-Failure) - JVP with Large Pulsations (RVF), POSITIVE Hepatojugular Reflux, Tender Pulsatile
Hepatomegaly, Caput Medusa, Ascites, Peripheral Oedema
- Jaundice & Hepatic Encephalopathy
Signs of Causes:
- RVF (Tricuspid Stenosis/Regurg, Pulmonary Stenosis/Regurg)
Budd-Chiari Syndrome: - RUQ Pain (due to stretching of liver capsule) Vitals:
(Due to Hepatic Vein - Abdo Distension (Ascites) - Normal (+/- Low Vol Tachycardia due Venous Return to the Heart)
Obstruction/Occlusion) - Nausea/Vomiting Other:
- JVP with Large Pulsations (RVF), NEGATIVE Hepatojugular Reflux, Tender
Pulsatile Hepatomegaly, Caput Medusa, Ascites, Peripheral Oedema
Signs of Causes:
- Hypercoagulability (Eg. Polycythaemia), Thrombophilia, Leukaemia, Tumour
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 Liver Cancers:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Hepatocellular (NB: EXTREME RISK in Chronic Carriers of HBV, HCV) Vitals:
Carcinoma: (NB: EXTREME RISK in Cirrhotics) - Fever
(Primary Liver Tumour) - RUQ Pain Other:
- Fever, Anorexia, Weight Loss - RUQ Tenderness/Mass, Hepatomegaly,
- Ascites - Anorexia/Weight Loss
NB: Suspect HCC if you see these signs in a Cirrhotic. - Ascites/Peripheral Oedema
- (+/- Obstructive Jaundice)
Signs of Causes:
- Cirrhosis (Shrunken, Nodular Liver + Signs of Chronic Liver Failure)
(NB: Serum a-Fetoprotein) - HBV/HCV Infected (IVDU/Homosexual/Tattoos/Prostitutes/etc)
Liver Metastases: - RUQ Pain Vitals:
Secondar Li er Ca s - Jaundice (if Obstructive) - Fever
- Fever, Anorexia, Weight Loss Other:
(Most Common) - + Previous Hx of Cancer - RUQ Pain
- Fevers/Sweats
- Confusion
- Jaundice
- (**Will eventually progress to show signs of Chronic Liver Failure)
Signs of Causes:
- Typically from Colorectal Ca, Breast Ca, Lung Ca, Melanoma.
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 Biliary Tract Disorders:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Biliary Colic: NB: Cholelithiasis is typically Asymptomatic. Vitals:
(AKA Cholelithiasis ) HOWEVER if Gallstones get Stuck Biliary Colic: - Pain Tachycardia, Tachypnoea, Hypertension
- ( = Biliary Pain for <3hrs) Other:
- Severe, Colicky RUQ Pain - Positive Murphey’s Sign (RUQ pain in deep inspiration)
- Radiation to the R-Shoulder - Obstructive Jaundice (Pale Stools, Dark Urine)
- Fat Intolerance Clay Stools Signs of Causes:
(NB: Can Perforation or Obstructive Pancreatitis) - Xanthelasma/Xanthomata (Hypercholesterolaemia), Pregnancy, Obesity, Rapid
Weight LOSS, Cystic Fibrosis
Acute Cholecystitis: - ( = Biliary Pain for >3hrs) Vitals:
- Severe, Colicky RUQ Pain - Fever, Tachycardia, Tachypnoea, Hypertension
- Radiation to the R-Shoulder Other:
- *Pain Associated/Exacerbated with FOOD - Positive Murphey’s Sign (RUQ pain in deep inspiration)
- *Nausea, Vomiting - Obstructive Jaundice (Pale Stools, Dark Urine)
- Peritoneal Involvement – Rigidity/Guarding/Rebound
- RUQ Mass (Swollen Gallbladder)
Signs of Causes:
- Xanthelasma/Xanthomata (Hypercholesterolaemia), Pregnancy, Obesity, Rapid
Weight LOSS, Cystic Fibrosis
Biliary Cancers
Bile Duct Carcinoma - Fever, Chills Vitals:
Cholangiocarcinoma - Anorexia, Weight Loss - Fever
- Obstructive Jaundice Other:
- Obstructive Jaundice - (Icterus, Dark Urine, Pale Stools)
- RUQ/Epigastric Pain Radiating to Shoulder
Gallbladder Carcinoma: - Females Common Vitals:
(Commonly due to - Abdominal Pain - Fever
Chronic Gallstones) - Anorexia, Weight Loss Other:
- Alk Phos -
(Late Diagnosis Poor Prognosis) Signs of Causes:
- Cholelithiasis (Xanthelasma/Xanthomata, Nephrotic Syndrome)
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 Congenital Pancreatic Disorders:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Pancreatic Divism: - Predisposes to Chronic Pancreatitis Vitals:
(CBD & Pancreatic Duct Other:
FAIL TO FUSE) Signs of Causes:
-
Annular Pancreas: - Duodenal Obstruction Vitals:
(Head of Pancreas Other:
Encircles the Signs of Causes:
Duodenum) -
Cystic Fibrosis: - Chronic Pancreatitis (Malabsorption, Vitals:
(Autosomal Recessive) Diabetes Mellitis, Epigastric Pain, Vomiting, - Tachycardia (Infection), Tachypnoea (Pulmonary Disease), Hypertension
(CFTR Gene) Fatty, Liquid Stools) ( Aldosterone due to Hyponatraemia), Fever (Infection)
- Salty Sweat Other:
- Chronic Lung Obstruction/Infection - Clubbing, Thin (Malabsorption), Peripheral Cyanosis, Chronic Cough + Sputum,
Salt-Frost on Skin,
Pancreatitis:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Acute Pancreatitis: - Epigastric/Abdo Pain – Following Large Meal Vitals:
(50% - Gallstones OR Alcohol - Tachycardia (Shock), Hypotension (Shock), Tachypnoea (Shock)
40% - Alcohol) - Vomiting Other:
- Shock - Epigastric Tenderness,
- **Peritonitis Guarding, Rigidity, Rebound + Referred Shoulder Tip Pain
- If Haemorrhage (Cool Dry Peripheries, CRT, Peripheral Cyanosis, Low-Vol
Tachy, Dry Mucosae, Cullen’s & Grey-Turner’s Signs)
Signs of Causes:
- Alcoholism (Ataxia, Anaemia, Dupuytren’s, Wernicke-Korsakoff Syndrome)
- Cholelithiasis (Xanthelasma, Xanthomata)
Chronic Pancreatitis: - Intermittent Epigastric Pain Vitals:
**Alcohol Abuse - Weight Loss (Malabsorption) - ?
- Steatorrhea Other:
- Secondary Diabetes - Jaundice
- Weight Loss
(Can Pancreatic Cancer) - Epigastric Tenderness
Signs of Causes:
- Alcoholism (Ataxia, Anaemia, Dupuytren’s, Wernicke-Korsakoff Syndrome)
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 Pancreatic Tumours:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Gastrinoma (Zollinger - Abdominal Pain Vitals:
Ellison Syndrome): - Dyspepsia - Normal (unless hypovolaemic from diarrhoea)
(Adenoma/Gastrinoma) - Chronic Steato-Diarrhoea (Inactivation of Other:
Pancratic Lipase by Acid) - None
(Often in the Pancreas) Signs of Causes:
(NB: Malignant Potential) - Abdominal Masses (but usually way too small to detect)
Insulinoma: Hypoglycaemia: Vitals:
(Pancreatic Tumour - Hunger, Headache, Tremor, Anxiety, - Tachycardia
which produces too Seizures, Coma, Death Other:
much Insulin) - Sweating, Tremor, Seizures, Coma, Death
- Acanthosis Nigricans on Neck (Hyperinsulinaemia)
Pancreatic NB: Asymptomatic until Advanced Diasease Vitals:
Adenocarcinoma: - Pain – Mid Epigastrium Back - Fever,
(Ductal Tumour): - Migratory Venous Thrombosis (Trousseau Other:
Sign) - Obstructive Jaundice, Epigastric Pain (+/- Radiation to Back), Courvoisier’s
- **Anorexia & Weight Loss Palpable Gallbladder,
- **Extreme Fatigue - Low BMI, Migratory Venous Thrombosis (Trousseau Sign of Malignancy – Due to
- **Depression Hypercoaguability),
- + Steatorrhoea, Malabsorption - 2o Diabetes
- +/- Jaundice Signs of Causes:
- Smoking, Alcohol, Chronic Pancreatitis (Eg. CF/Alcohol), Diabetes
(NB: 25% 1yr Survival; 5% 5yr Survival) - Familial Syndromes – Eg. BrCA, Peutz-Jeger’s Syndrome, Heriditary Pancreatitis
Pancreatic Cysts & - If Small Asymptomatic Vitals:
Pseudocysts: - If Large Abdo Pain/Back Pain/Jaundice (If - Fever (if Infected), Tachycardia (if Infected)
(Simple Cysts of the Head.of.Panc)/Duodenal Obstruction Other:
Pancreas) - If Infected Fever/Chills/Sepsis - Jaundice (if Biliary Obstruction), Epigastric Tenderness
Signs of Causes:
- Congenital
- OR 2o to Pancreatitis (Acute or Chronic) (:. Alcoholic/Cholelithiasis)
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 Running Tally of Diseases Learned
RESPIRATORY
URTIs (Fever + Runny Nose + Sinusitis + Pharyngitis + Cough):
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
URTI: - Fever Vitals:
(Bacterial or Viral) - Sore-Throat - Fever, Tachycardia,
- Runny Nose, Sneezing, Hoarseness, Cough Other:
- Sinus Headache - Runny Nose, Inflamed Tonsils, Inflamed Pharynx, Sputum (From Post-Nasal Drip),
Hoarseness, Cough,
+ Non-Specific Viral (Fever, Malaise, Headache, - Cervical Lymphadenopathy
Myalgia) - NORMAL Chest Examination
Sinusitis: - Fever Vitals:
(Strep Pneumo) - Sinus Headache (Facial Pain) - Fever, Tachycardia
- Nasal Congestion/Obstruction Other:
- Post Nasal Drip & Purulent Nasal Discharge - Runny Nose (+ Purulent Nasal Discharge), Nasal Congestion, Tooth Pain,
Tenderness Over Sinuses, Headache Worse on Leaning Forward
+ Non-Specific Viral (Fever, Malaise, Headache, - Cervical Lymphadenopathy
Myalgia) - +/- Inflammatory Nasal Polyps, +/- Orbital Cellulitis
Tonsillitis: - Fever Vitals:
(GABS, Staph, HIB, EBV) - Sore Throat + (Referred Ear Pain) - Fever, Tachycardia
- Dysphagia, Odynophagia, Trismus (Jaw Other:
Spasm) - Inflamed Pharynx, Enlarged Inflamed Tonsils (+/- Exudates)
- Tender Cervical Lymphadenopathy
+ Non-Specific Viral (Fever, Malaise, Headache, Signs of Causes:
Myalgia) - Strawberry Tongue (SCARLET FEVER)
- Palatal Petechiae, Overwhelming Fatigue, Splenomegaly (GLANDULAR FEVER; EBV)
- Pseudomembrane on Tonsils & Pharynx (DIPTHERIA)
Epiglottitis: - Fever Vitals:
(HIB) - Sore Throat, Dribbling (Dysphagia) - Fever, Tachycardia, (+/- Tachypnoea if Obstruction)
- +/- Inspiratory Stridor & Dyspnoea Other:
- Dysphagia, Drooling, Pooling of Secretions, Inspiratory Stridor, Cyanosis
+ Non-Specific Viral (Fever, Malaise, Headache, Signs of Causes:
Myalgia) - Unvaccinated Child
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URTI CONCLUSION DIFFERENTIATING BETWEEN URTI s (Their Distinguishing Features):
- Typical URTI Symptoms:
o Fever, Malaise, Headache, Cough
- + Specific Symptoms:
o Adolescent + Sore Throat + Lymphadeopathy = EBV (Glandular Fever)
o Toddler + Drooling Saliva = Epiglottitis (Haemophylis Influenza)
o Photophobia + Neck Stiffness = Meningitis (Eg. Nesseria Meningiditis)
o Arthritis + New Cardiac Murmur after 2wks = GAB-Strep Pharyngitis Rh-Fever/Rh-Heart Disease
o Hx of Recurrent Pneumonia + SOB = Cystic Fibrosis/Immunocompromised/Smoker
o SOB + Weight Loss = Tuberculosis (Mycobacterium Tuberculosis)
o Community Outbreak + Travel History = SARS (SARS-Associated Coronavirus)
Bronchial Disorders (Wheezy Cough + Sputum +/- Fever):
Acute Bronchitis: - Fever Vitals:
(Rhinovirus) - Productive, Wheezy Cough, +/- Dyspnoea - Fever, Tachycardia, Tachypnoea
Other:
+ URTI Symptoms (Sore-Throat, Runny Nose, - End-Expiratory Wheezes
Sneezing, Hoarseness) Signs of Causes:
+ Non-Specific Viral (Fever, Malaise, Headache, - 2o to URTI
Myalgia)
Bronchial Asthma As mptomatic nless d ring an Attack Vitals:
(Variable Obstructive): - Wheezy Dry Cough, - Tachypnoea, Tachycardia,
- Dyspnoea Other:
- Anxiety - Peripheral Cyanosis, Wheals, Hives, Rhinitis
- Accessory Muscle Usage
If Severe: - Inspiratory Wheezes, Marked Expiratory Wheezes, Prolonged Expiratory Phase,
- Exhaustion - Che E an i n - Hyperinflated Lung Fields)
- Inability to Speak in Full Sentences - Reduced Breath Sounds (Silent if Severe)
- NO signs of Consolidation (Normal Fremitis, Percussion & Vocal Resonance)
- (+/- Pulsus Paradoxus if Severe)
Signs of Causes:
- Signs of Atopia (Wheals, Allergic Rhinitis, Hives)
- Family History
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Emphysema (Dry): Pink Puffers: Vitals:
- Wheeze - Tachypnoea, Tachycardia
- Severe Dyspnoea Other:
- Weight Loss - (NB: Does NOT cause Clubbing or Haemoptysis)
- Thin (No Oedema), Pink (No Cyanosis),
- (+/- Peripheral Oedema & Ascites in - Tachypnoea, Accessory Muscle Usage, Intercostal Recession, Tripoding (Stooping),
Corpulmonale) Pursed-Lip Breathing, Barrel Chest,
- Che E an i n H e Sign P i i e Tracheal Tug
- Hyperinflated Lungs Fields, Hyperresonant Percussion (Gas Trapping)
- Breath Sounds, Early Expiratory Crackles (Small Airway Disease), (+/- Wheeze).
- (+/- JVP A ci e Oedema if RVF D e C -Pulmonale)
Signs of Causes:
- Heavy Smoking (Tar Staining, Smoke Smell, Yellow Teeth, Leuko/Erythroplakia)
- (If Young Age Think Congenital a1-Antitrypsin Deficiency.)
Chronic Bronchitis Blue Bloaters: Vitals:
(Wet): - Wet, Wheezy Productive Cough - Tachypnoea, Tachycardia
(+/- Emphysema) - Chronic Sputum Production (>3mths/year Other:
for >2years) - (NB: Does NOT cause Clubbing or Haemoptysis)
- Severe Dyspnoea - Obese Patient, Gross Cyanosis (Central & Peripheral),
- Oedema - Cor-Pulmonale (Ascites, Oedema, Cyanosis JVP)
- Tachypnoea, Accessory Muscle Usage, Intercostal Recession, Tripoding (Stooping),
Pursed-Lip Breathing, Barrel Chest
- Che E an i n P i i e H e Sign T acheal T g
- Hyperinflated Lung Fields, Hyperresonant Percussion
- B ea h S nd End-Expiratory Wheezes (Bronchial Disease)
Signs of Causes:
- Heavy Smoking (Tar Staining, Smoke Smell, Yellow Teeth, Leuko/Erythroplakia)
Bronchiectasis: - Wheezy Productive Cough Vitals:
(Chronic Bronchial - Copious Purulent Sputum (Green/Yellow) - Tachypnoea, Tachycardia, (+/- Fever if Infection)
Thickening & Dilation + - (+/- Haemoptysis) Other:
Mucus Accumulation - Clubbing, Cyanosis, Cachexia,
d e M c cilia ) - Foul-Smelling Sputum (Sometimes Haemoptysis)
- Coarse Pan-Inspiratory Crackles, End-Expiratory Wheezes
- (+/- Cor-Pulmonale if Severe)
Signs of Causes:
- **Cystic Fibrosis (Clubbing, Peripheral Cyanosis, Sputum, Salty Frost, Wasting)
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 Chest Infections (Fever + Cough + Dyspnoea):
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Pneumonia - Acute High Fever + Chills + Rigors Vitals:
(Consolidation): - Productive Cough (+/- Haemoptysis) - Fever, Tachycardia, Tachypnoea
- Pleuritic Chest Pain Other:
- Appears Ill: P/C-Cyanosis, Exhaustion, Dyspnoeic, Respiratory Distress,
- Consolidation: Area of E an i n Tac ile F emi i Dull Percussion, Bronchial
B ea hing Vocal Resonance.
- Bronchial Breath Sounds, Pleural Friction Rub, Pan-Inspiratory Crackles
Signs of Causes:
- Broncho Pneumonia Diffuse, Patchy Consolidation
- Lobar Pneumonia Localised Consolidation
Melioidosis: Presents Similar to TB but with Pneumonia: Vitals:
(Burkholderia - PUO (Fever, Night Sweats, Chills, Rigors) - Fever, Tachycardia, Tachypnoea
Pseudomallei) - Skin Lesions (Abscesses/Ulcers) Other:
- Pneumonia (Dyspnoea, Cough, Sputum, - Cyanosis, Dyspnoea, Skin Lesions (Melioid Abscesses/Ulcers), Lymphadenopathy,
Pleuritic Chest Pain) - Consolidation: A ea f E an i n Tac ile F emi i D ll Percussion, Bronchial
(May Sepsis) B ea hing V cal Re nance
- Bronchial Breath Sounds, Pleural Friction Rub, Pan-Inspiratory Crackles
Signs of Causes:
- Living in Tropical NQ
Pulmonary - Fever, Night Sweats, Vitals:
Tuberculosis: - Chronic Productive Cough (+/- Haemoptysis) - Fever, Tachycardia, Tachypnoea
- Weight Loss Other:
- +/- Pleuritic Chest Pain - Cachexia, Dyspnoea, Lymphadenopathy, Hepatomegaly, Splenomegaly,
- (NB: Cavitation Can Pleural Effusion (Stony Dullnes), Haemoptysis, Atelectasis)
Signs of Causes:
- Immunocompromise (HIV), Immigrant, Overseas Travel,
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 Pulmonary Vascular Disorders (Dyspnoea + Fluid Overload):
Pulmonary Embolism: - Sudden, Severe Dyspnoea Vitals:
- Pleuritic Chest Pain - Fever, Tachycardia, Tachypnoea, Hypotension (LVF)
- (+/- Haemoptysis) Other:
- (+/- Syncope) - RVF C l Pe i he ie CRT Pe i he al C an i JVP, RV-Heave, Tricuspid
Regurg Murmur
- Resp F nction Central Cyanosis
- Pleural Friction Rub,
Signs of Causes:
- DVT Calf Pain, Calf Tenderness, Calf Swelling/Erythema, Pedal Oedema.
- (B/G of Pregnancy, Air Travel, Recent Surgery, Clotting Disorders)
Pulmonary RVF Secondary to Pulmonary Hypertension: Vitals:
Hypertension & - COPD: Dyspnoea, Cough, Wheeze - Tachycardia (if LVF), Tachypnoea (if COPD/LVF), Hypotension (If LVF), Afebrile
Corpulmonale: - Pul HTN: Cough/Dyspnoea/PND/Orthopnea Other:
(LVF, COPD) - RVF: Swelling (Legs, Abdo), Chest Pain - If LVF: C l Pe i he ie CRT Pe i he al Cen al C an i L V l me P l e
-
- If COPD: Clubbing, Tar Staining, Peripheral & Central Cyanosis
- RVF: JVP a-Wave, RV-Heave, Medium Pan-Inspiratory Crackles in Lung Bases,
Loud S2 (closure of Pul.Valve) Abdojugular Reflux Positive, Portal Hypertension
(Tender Hepatomegaly), Ascites, Sacral/Pedal Oedema,
Signs of Causes:
- LVF, Smoking, COPD, IPF
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 Pleural Disorders (Dyspnoea + Pleuritic Chest Pain):
Pneumothorax Similar Presentation to Pulmonary Embolism: Vitals:
(Including Tension Px): - Sudden, Severe Dyspnoea - Tachycardia, Tachypnoea, Hypotension (Mediastinal Compression),
(Air in Pleural Space) - Pleuritic Chest Pain Other:
- (+/- Syncope) - Cyanosis, Dyspnoea, Anxiety, Respiratory Distress,
(Emphysema, - Pe i he al Sh d n CRT C l Pale Pe i he ie Peripheral Cyanosis, Low-Vol
Iatrogenic, Trauma, Tachycardia)
Spontaneous, etc) - Tracheal Deviation AWAY from Affected Side (If Tension Ptx),
- @Site of Pneumothorax: Che E an i n Tac ile F emi i Hyperresonant
Percussion, Absent Breath Sounds, Absent Vocal Resonance.
- (IF KINKING OF GREAT VESSELS Syncope, Negative Abdojugular Reflux)
Signs of Causes:
- Signs of Trauma, Signs of Smoking (Emphysema), Mechanical Ventilation,
Atelectasis: - Dyspnoea Vitals:
(Collapsed Lung): - Chest Pain - Tachypnoea
(Due to Airway Other:
Obstruction by Foreign (May Quickly Pneumonia) - Dyspnoea,
Object or Cancer) - Tracheal Deviation TOWARDS the Affected Side.
- @Site of Atelectasis: Che E an i n Tac ile F emi i D ll Pe c i n
Bronchial Breath Sounds, Vocal Resonance
Signs of Causes:
- Mucous (Asthma, Cystic Fibrosis), Foreign Body Aspiration, Bronchial Ca (Cachexia)
Pleural Effusion: - Sudden Severe Pleuritic Chest Pain (Worse Vitals:
on Inspiration) - Fever, Tachypnoea, Tachycardia,
- Dyspnoea Other:
- Dry Cough - Tracheal Deviation AWAY from Effusion
- Displaced Apex Beat AWAY from Effusion
- @ Site of Effusion: Che E an i n Tac ile F emi i STONY DULLNESS,
B ea h S nd V cal Re nance
Signs of Causes:
- NB: ALWAYS Suspect Mesothelioma
- Portal Hypertension, Hypoalbuminaemia (CLD, Nephrotic Synd), Congestive L-
Heart Failure, Lung Injury, Lung Infection.
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 Disorders of the Pulmonary Interstitium:
Remeber the Cs Cough, Clubbing, Crackles!!!
Interstitial Lung (On a Background of Occupational Exposure) Vitals:
Diseases: - Chronic Cough (+/- Productive) - Tachypnoea
Pne moconioses - Dyspnoea (+/- Cyanosis) Other:
- Clubbing, Dyspnoea, Cyanosis, Cachexia, Accessory Muscle Usage, Intercostal
(Inhaled Dusts: Recession, Tracheal Tug.
Anthracosis, Asbestosis, - Cough
Silicosis) - Che E an i n
- Fine Pan-Inspiratory Crackles
- + Restrictive Pulmonary Function Tests.
Signs of Causes:
(Asbestosis is most severe and can Mesothelioma - Signs of Connective Tissue Diseases (Rheumatoid Arthritis, SLE, Scleroderma,
Pleural Effusions, Metastases) Sj g en
Idiopathic Pulmonary Gradual Onset of Symptoms Vitals:
Fibrosis: - Progressive Dyspnoea - Tachypnoea
(Idiopathic) - Dry Cough Other:
- Hypoxia/Cyanosis Clubbing
- Dry, Velcro-like inspiratory crackles
(Very Poor Prognosis 3yrs No Treatment) Signs of Causes:
- Restrictive Pattern n P lm na F nc i n Te VC TLC
Sarcoidosis: Systemic Disease (Lungs, Eyes, Skin, LNs, Liver & Vitals:
(Idiopathic Immune Spleen) - Tachypnoea
Non-Caseating - General: Fatigue, Weight Loss, Other:
Granulomas) - Lungs: Dyspnoea, Dry Hacking Cough - Dyspnoea, Cyanosis, Cachexia, Accessory Muscle Usage, Intercostal Recession,
- Eyes: Uveitis Tracheal Tug.
- Skin: Erythema Nodosum (Nodules on - Cough
Shins), Lupus Pernio (Red plaques), - Che E an i n
Hypertrophic Scars - Fine Pan-Inspiratory Crackles
- LNs: Lymphadenopathy - + Restrictive Pulmonary Function Tests.
- Liver/Spleen: Organomegaly
- MSK: Arthralgia, Finger Swelling
- Heart: Heart Block, Syncope, Corpulmonale
Wegener s - Many Non-Specific Symptoms (Arthralgia, Vitals:
Granulomatosis: Myalgia, Night Sweats, Weight Loss, Red - Fever, Tachycardia, Tachypnoea,
(Autoimmune) Eyes, URTI, Chronic Ear Infections, Fever) Other:
- BUT Relevant as it can Pneumonia: - Cachexia, Epistaxis, Nasal Sores, Various Skin Lesions, Haematuria, Conjunctivitis,
o Dyspnoea Chest Pain, Cough (+/- Haemoptysis), Dyspnoea, Weakness, Wheezing.
o Cough (+/- Haemoptysis)
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 Mediastinal & Lung Masses:
Mediastinal - Facial Plethora Vitals:
Compression: - Supraclavicular Lymphadenopathy - Depends
(Lung Ca, Lymphoma, - Hoarseness Other:
Retrosternal Goitre, - H ne S nd me - SVC Obstruction: Facial Cyanosis, Facial Ple h a P i i e Pembe n ,
Aortic Aneurysm) - Dyspnoea Pe i bi al Oedema N n-Pulsatile JVP
- Mechanical Compression: Stridor (Tracheal Compression), Tracheal Deviation,
Hoarseness
- Nerve Compression:
o H ne S nd me Unilateral Ptosis, Anhydrosis, Miosis, Enophthalmos,
Laryngeal Hoarseness)
o Unilateral Phrenic Nerve Paralysis Unilateral Diaphragm Paralysis
Asymmetrical Chest Expansion.
Signs of Causes:
- Th id Gland Retrosternal Goitre)
- Vi ch N de R-Supraclavicular Lymphadenopathy) for Lung Cancer.
Lung Cancers: Often Asymptomatic..But may : Vitals:
- Fever, Night Sweats, Weight Loss, Fatigue - Fever, Tachypnoea (late stages)
- Dyspnoea Other:
- Cough (+/- Haemoptysis) (+/- Wheeze if - General Signs:
Bronchial involvement) o Anorexia, Clubbing, HPOA (Wrist Tenderness), Intrinsic Hand Muscle
- Don t Forget +/- Paraneoplastic Syndrome) Wasting, Vi ch N de R-Supraclavicular Lymphadenopathy), Axillary
o H e calcaemia PTH Lymphadenopathy, Liver & Bony Tenderness (Metastases)
o H na aemia ADH - If Apical (Pancoaste) Tumour
o C hing ACTH o SVC obstruction Pembe n Sign Facial Ple h a
o Ca cin id S nd me Se nin o Sympathetic Nerve Compression Deficiency H ne S nd me
o G naec ma ia G nad hin (Unilateral Ptosis, Anhydrosis, Miosis, Enophthalmos, Laryngeal
Hoarseness)
o C8/T1 Nerve Lesion Intrinsic Hand Muscle Weakness & Wasting
- If Mesothelioma
o Pleuritic Chest Pain
o Pleural Effusion
o Tender Ribs
- If Bronchocarcinoma
o Wheezing (Partial Bronchial Involvement)
o Atelectasis (Complete Bronchial Obstruction)
o Haemoptysis
Signs of Causes:
- Smoker, Miner, Sand-Blaster, Builder,
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 Summary of Important Points for OSCE:

Causes of Dysphagia:
- Types of Dysphagia:
o With Solids Only = Mechanical Obstruction (Hiatus Hernia/Strictures/Plummer Vinson Web
from Iron Deficiency/Tumours)
o With Solids & Liquids = Motility (Achalasia/Neural[Vagus Nv]/Scleroderma)
o With Liquids Only = Pharyngeal Disorders (Globus Pharyngeus)
- Causes of Dysphagia:
o Oesophagitis: (Infection in Imm.comp Or Eosinophilic/Allergic)
o Achalasia: (Oesophageal Aperistalsis)
o Mallory Weiss Syndrome Tear:= Oesophageal laceration (Gluttony, Coughing, Bulimia)
o Oesophageal Varices:(Portal HTN, Cirrhosis)
o Hiatus Hernia:
o GORD, Barrett’s Oesophagus: (Obesity, Pergnancy, Alcoholism)
o Oesophageal Cancer: (Smoking, Alcoholism, Chronic GORD)

Causes of Epigastric Pain:

- Gastritis: (Alcoholism, Infection, Pernicious B12 Anaemia)
- Peptic Ulcer Disease: (NSAIDs, H.Pylori, or Gastrinoma/ZE-Synd)
- Gastric & Duodenal Cancers: (H.Pylori or Familial)
- Acute Pancreatitis: (50% - Gallstones, 40% - Alcohol)
- Chronic Pancreatitis: (**Alcohol Abuse)

Causes of Acute Abdomen:

- Appendicitis:
- Diverticulosis/Diverticulitis:
- Acute Cholecystitis:(AKA: “Cholelithiasis”)
- Acute Pancreatitis: (50% - Gallstones, 40% - Alcohol)
- Chronic Pancreatitis: (**Alcohol Abuse)
- Pseudomembranous Colitis: (Clostridium Difficile Overgrowth due to Antibiotic G F a (C.Diff is
Directly Cytotoxic))
- Bowel Obstruction

Causes of Jaundice:
Background Info on Jaundice:
Disease: TYPICAL Symptoms/Presentation:
Unconjugated Jaundice + Neonate Physiological Neonatal Jaundice
(Prehepatic/Haemolytic) Jaundice + Dyspnoea + Fatigue Haemolytic Anaemia
Jaundice Jaundice + Young + Family Hx of Jaundice Gi be Di ea e
Jaundice + Young + Malaise Hepatitis
Jaundice Epidemic Hep A Virus
Jaundice + Recent Shellfish Consumption Hep A Virus
Jaundice + Hx of IVDU/Injections/Tattoos Hep B/C Viruses
Jaundice + Sodomy/Prostitution Hep B Virus
Jaundice + Elderly + Weight Loss Carcinoma
Conjugated Jaundice + Elderly + Weight Loss Carcinoma
(Posthepatic) Jaundice Jaundice + Abdo Pain Biliary Obstruction (Gallstones)
Jaundice + 50yr old Woman Priamry Biliary Cirrhosis
Jaundice + Dyspepsia + Steatorrhoea Head of Pancreas Tumour
Jaundice + Fevers/Rigors Cholangitis or Liver Abscess.
General Signs of Liver Jaundice, Bruising, Scratchmarks, Ascites, Oedema, Hepatic Encephalopathy, Hepatic Flap
Disease: Le k chia M e cke Li e Xa h a a Pa a E he a Xanthelasma, Fetor
Gynaecomastia, Spider Naevi, Testicular Atrophy, Nodular Liver, Hepato/Splenomegaly,
Abdominal Distension, RUQ Tenderness, Caput Medusa, Ascites, Pedal oedema
Signs of Causes: IVDU, Alcoholism, Tattoos, Skin Pigmentation (Haemochromatosis),
Cachexia (Ca), Xanthelasma/mata (Chronic Biliary Obstruction)

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Inflammatory (Autoimmune) Bowel Diseases:
Inflammatory (Autoimmune) Bowel Diseases:
Disease: TYPICAL Symptoms/Presentation: TYPICAL Clinical Signs:
Crohn’s Disease: - Typically Starts @ Ileocecal Valve Vitals:
(Mouth Anus) (RIF) - Fever,
(Patchy) Common Symptoms (Both CD & UC): Other:
- **Abdominal Pain/Severe Internal - Clubbing
Cramps - Mouth Ulcers & Anus Involvement,
- **Vomiting/Diarrhoea *(Porridge- - GI Bleeding Anaemia (Pale Nails,
like, Fatty) Koilonychia, Palmar/SC Pallor, Glossitis)
- **Rectal Bleeding Signs of Causes:
- Autoimmune (Arthritis, Iritis, Pyoderma
(+ Fever, Weight Loss) Gangrenosum, Primary Biliary Cirrhosis)
Ulcerative - Typically Starts @ Rectum (LIF) Vitals:
Colitis: Common Symptoms (Both CD & UC): - Afebrile,
(Typically affects - **Abdominal Pain/Severe Internal Other:
Colon) Cramps - Clubbing
(Continuous) - **Vomiting/Diarrhoea *(Bloody & - No Mouth or Anus Involvement,
Mucus but NO Pus. {Not - GI Bleeding Anaemia (Pale Nails,
Dysentery]) Koilonychia, Palmar/SC Pallor, Glossitis)
- **Rectal Bleeding Signs of Causes:
- Autoimmune (Arthritis, Iritis, Pyoderma
(+ Tenesmus) Gangrenosum, Primary Biliary Cirrhosis)

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