Spot Dx and Specific/Rarer Exams

Question 1

Marfans

Answer 1

Cardiovascular exam(Aortic root dilatation and Aortic regurgitation) PLUS Hands and arms- arachnodactyly (spider fingers), joint hypermobility, long thin limbs. Ask for arm span and height (will exceed) WRIST AND THUMB SIGN Face- long and narrow face. Eyes- Lens dislocation or replacement. Blue sclera. Mouth- high arched palate Chest- pectus carinatum or excavatum Back- kyphoscoliosis and hypermobility Skin- striae

Question 2

Polycystic Kidneys Exam

Answer 2

Abdo exam- massive kidneys +/- liver and spleen Blood pressure Urinalysis – blood (haemorrhage), protein Evidence anaemia (CKD) or polycythaemia (excess EPO) Hepatic cysts or splenic cysts

Question 3

Haemochromatosis Exam

Answer 3

As per GI exam PLUS Bronze pigmentation Arthropathy- typically degenerative arthritis of MCP joints of index and middle fingers. Pseudogout may occur Testicular atrophy due to iron deposition to the pituitary gland Dilated cardiomyopathy Glycosuria due to DM

Question 4

Cushings Exam

Answer 4

Observation- front, back, sides -Central obesity, thin limbs (peripheral sparing) -Skin bruising and atrophy -Pigmentation extensor areas- ectopic ACTH secreting tumour (Rare) or bilateral adrenalectomy with ACTH secretin g pituitary adenoma -Poor wound healing Arms -Purple striae proximally -Proximal myopathy Face -Plethora, hirsuitism, acne, telangectasia -Moon shape -Visual fields (pituitary tumour), fundi (atrophy, papilloedema, signs of HTN and DM) -Mouth-Thrush Neck -Supraclavicular fat pads, acanthosis nigricans Back -Buffalo hump (interscapular fat pad) -Kyphoscoliosis (osteoporosis) -Tenderness of vertebrae (osteoporotic fractures) Legs -Squat (proximal myopathy) -Striae (thighs) -Bruising, oedema Mental state -Depression -Psychosis -Irritability Abdomen -Purple striae -Adrenal masses, adrenalectomy scars -Liver (tumoru deposits) Other -Urinalysis (glycosuria, evidence renals tone disease) -Blood pressure (hypertension) -Signs of ectopic tumour (e.g. lung small cell carcinoma or carcinoid)- rare

Question 5

Acromegaly exam

Answer 5

Diagnostic facies- Prominent supraorbital ridge, broad nose, acne, large lips, overbite, prognathism, tongue enlargement, and coarsening features Hands -Spade like, OA changes -Phalens- carpel tunnel Arms -Ulnar nerve thickening at elbow -Proximal myopathy Axillae -Skin tags -Acanthosis nigricans -Greasy skin Face -Frontal bossing- large supraorbital ridge -Hirsuitism -Acne -Macroglossia -Prognathism- enlargement lower jaw -Splaying of teeth -Hoarseness of voice/deep/husky/resonant Eyes -Visual fields- esp bitemporal hemianopia -Cranial nerves 4. 5. 6 -Fundi- optic atrophy, papilloedema, angioid streaks +/- diabetic/hypertensive changes Neck -Thyroid gland- diffuse or nodular goitre Heart- Cardiac failure Abdomen- Organomegaly Lower limbs -Osteoarthritis, pseudogout -Entrapment neuropathy- foot drop - Heel pad thickening Other Urinalysis- glycosuria Rectal examination Colonic polyps Blood pressure- hypertension Sleep apnoea Ask for photographs Evidence activity -Skin tag number -Excessive sweating -Presence of glycosuria -Increasing visual field loss or development of cranial nerve palsies of 3, 4, 6 and 5 -Enlarging goitre -Hypertension -Symptoms of headache -Increasing ring size, shoe size or dentures

Question 6

Addisons Exam

Answer 6

Observation - Pigmentation- esp palmar creases, elbows, gums, buccal mucosa, genital areas and scars. Vitiligo due to AI Dx associations. - Rarely ear lobe calcification Blood pressure - Lying+standing Other - Urinalysis- glucosuria- DM A/W addisons

Question 7

Diabetes Exam

Answer 7

Observation -Weight- obesity -cushings, acromegaly -Pigmentation- haemochromatosis etc Legs -Skin- Diabetic dermopathy- small, rounded plaques with raised borders lying linearly over shins -Hair loss, skin atrophy -Fat-Atrophy or hypertrophy -Injection sites -Quadriceps wasting- femoral nerve mononeuritis (aka diabetic amyotrophy Feet -Joint destruction- charcots foot -Ulcers -Capillary return -Peripheral pulses ==Femoral PLUS auscultate for bruit ==Popliteal ==Posterior tibial ==Dorsalis pedis -Oedema Neurological Ax -Proximal muscle power -Reflexes -Dorsal column loss- diabetic pseudotabes Upper limbs -Blood pressure and pulse- lying and standing Eyes -Visual acuity -Eye movements- Third nerve palsy- pupillary sparing (vs compressive lesions) -Fundi- Diabetic retinopathy Mouth -Candida Abdomen -Hepatomegaly due to fatty infiltration Urinalysis- glycosuria, proteinuria Weight

Question 8

Hypopituitary Exam

Answer 8

Observation -Short stature if GH failure before growth complete -Pale skin -No 2 sex characteristics if gonadotrophin failure pre puberty -Reduced body hair, including absence of axillary hair -Increased abdominal fat -gynaecomastia Face -Fine skin wrinkles around eye and mouth- growth hormone deficiency -Hypophysectomy scar- forehead near inner canthus of eye -Facial hair over chin area Eyes -Signs pituitary tumour o Visual fields (esp bitemporal hemianopia) o Fundi (optic atrophy) o Cranial nerves 3, 4, 6 and first division 5 Genitals -Loss of pubic hair -Treticular atrophy Neurology -Slowed ankle jerks hypothyroidism Blood pressure -Postural insufficiency with ACTH deficiency

Question 9

Hypertension Exam

Answer 9

Observe- Cushings? Acromegaly? Polycythaemia? Uraemia? BP- both arms, lying/standing, legs if young Pulse- radio-radial, radiofemoral Hands- Vasculitic changes Face- Conjunctival injection (polycythaemia) Fundi-Hypertensive changes- silver wiring, haemorrhages, exudates +/- papilloedema Cardiovascular system LV failure, coarctation of aorta, 4th heart sound may be present in severe HTN. Abdomen -Renal masses + bruits, adrenal masses, abdominal aneurysm Ask for: UA, consider neurological exam for deficits due to HTN caused stroke

Question 10

Oedema Exam

Answer 10

Location oedema If Pitting- ?DVT, Varicose veins, Vein harvesting scars. Feel inguinal nodes Abdomen- abdominal wall oedema, abdominal wall veins (IVC obstruction), ascites, any abdominal masses, evidence liver disease. Pulsatile liver (tricuspid regurgitation), evidence malignancy JVP Ax RHF or constrictive pericarditis. Ax node groups. Examine delayed ankle jerks (hypothyroidism) Urinalysis. Non pitting- lymphoedema (malignant infiltration, congenital disease, filariasis, milroys disease) and myxoedema Ax cushingoid appearance (tumour or steroid Tx). Plethoric cyanosed face with periorbital oedema. Exophthalmous and conjunctival injection pupils (horners syndrome due to chest mass), fundi (venous dilatation Neck- JVP, thyroid, JVP, supraclavicular LN. listen to trachea for stridor Chest- distended venous colalterals

Question 11

Knee Exam

Answer 11

Expose knees and thighs fully, lie on back Look - Aids, syndromic appearance, rash - Knees- scars, swelling, deformity Feel+Move -Quadriceps wasting -Warmth - Effusions- Patella tap, side swipe -Passive flexion + extension = deformity, ROM, crepitus -Ligaments –Lateral and medial collateral- hold leg in one arm, and steady thigh with the other. Move leg laterally and medially. Laxity >5-10 degrees abnormal –Cruciate ligaments- steady foot with elbow and move knee anteriorly and posteriorly w other hand. >5-10 deg abnormal -Meniscus –Mcmurrays- hold lower leg and foot, flex and extend the knee while internally and externally rotating the tibia. Pain or clicking suggestive of meniscal tear -Bakers cyst –Stand, extend knee- palpate popliteal fossa

Question 12

Feet Exam

Answer 12

Look - appearance, aids, rashes - Ankle, feet, toes– skin (scar, rash, ulcer), swelling, deformity, muscle wasting Esp- hallux valgus (RA), pes cavus, charcot -Nails- psoriatic changes - arches Feel, move - all joints - ankle dorsi/plantar, eversion, inversion, rotate Achilles tendon nodules inferior heel- plantar fasciitis function- pinprick, proprioception, walk

Question 13

Ankylosing Spondylitis

Answer 13

Undress to undies and stand Look (general) - Rashes, abdominal scars, iritis/uveitis, walking aids - nails- psoriatic changes Look (back) - deformity (kyphosis, loss of lumbar lordosis), scars Move - Flexion- finger to floor distance - Extension - Lateral flexion Schobers test - L5 (iliac rests) 10cm above 5cm below- touch toes, increase by >5cm Occiput to wall distance Sit down on edge bed Move - L/T spine and C spine rotation Palpate spine + paraspinal Palpate SIJ + spring hips (Activity) Achilles tendon, plantar fasciitis Other - Chest expansion - Ausc lungs (apical fibrosis), heart (AR, MVP) - Abdo exam - LL Neuro exam - UA

Question 14

Eye Exam

Answer 14

Observe- Dx facies Cornea- arcus + other Sclera- jaundice, pallor, injection Ptosis Exophthalmos- behind and above patient Eyelids- xanthelasma Lid Lag Orbits - palpate tenderness Auscultate eyes with bell for bruit, hold rbeath Neuro exam - acuity - fields -pupils- shape, symmetry, direct, consensual, RAPD, accomodation - eye movements - Fatiguability - Corneal reflex Fundi - cornea, lens, humour, colour of disc, state of cup, retina Dependent on findings- cranial nerves+/- long tract signs

Question 15

Higher centres exam

Answer 15

Obsrv- Dx facies, obvious CN or limb neuro lesions assess level of consciousness Ask -handedness -level of education Orientation- T/P/P Speech- - name objects - repeat words - comprehension (Verbal, written) - writing Parietal Lobes - sensory inattention - visual inattention - agraphaesthesia (number on palm) -asterognosis (object on pam) - Constructional apraxia- clockface - Dressing apraxia (shirt inside out, ask them to put on- non dominant) Temporal Lobe- - short term memory (3 items) (Cat, orange, pen) - Long term (twin towers) Frontal lobe - reflexes- grasp, pout, palmar-mental - proverb interpretation (rolling stone gathers no moss) - gait apraxia Proceed - fundi, - isual fields - carotid bruits - BP

Question 16

Speech exam

Answer 16

Obsrv0 Dx facies, asyemmtry Ask - language, hearing, handedness Cough Orientation- T/P/P Description/fluency= boston cookie theft Comprehension 1- poke out your tongue 2- touch left hand to right ear 3- Touch your nose, then your chin, then your forehead Tricky- point to the ceiling after you point to the floor Written- close your eyes Repetition “say what i say” hippopotomus, british constitution no ifs ands or buts the orchestra played and the audience clapped Pa(lips), Ta(tongue), Ka(palate) PATAKA (motor speech) Naming- thumb, ring finger, knuckles Fatiguability- 1 to 20 PROCEED Language= Dysphasia - read a phrase, write a phrase Articulation= dysarthria as per findings - cerebellar exam- drift/overcorrection, finger nose, dysdiado, nystagmus, ataxia - lower cranial nerves with jaw jerk - Movement disorder- gait, tone, bradykinesia, gaze palsy - UMN/LMN- tone, reflexes, jaw jerk, CN9-12 (GVAH)

Question 17

Shoulder girdle Exam

Answer 17

Dx facies- esp masseter and temporalis Palpate muscle bulk When Ax movement- look for winging Shrug shoulder Push against wall Pull shoulder blades together hands on hips Abduct arms against resistance <15deg and >15 deg Adduct arms External rotate upper arm Internal rotate upper arm Sensation

Question 18

Myotonic Dystrophy

Answer 18

Observe Facial features= frontal balding, bilateral ptosis, dull triangular facies, temporalis + masseter + sternomastoid atrophy Cataracts +/- glasses Neck - sternocleidomastoid atrophy -weak neck flexion, preserved extension Upper limbs- OFTEN STEM -grip myotonia -percussion myotonia- tap over thenar eminence= contraction then slow relaxation of abductor pollicis brevis -wasting and weakness- more over forearm muscles -sensory changes may occur- peripheral neuropathy- usually mild -fingers- evidence finger pricks from diabetes Chest -gynaecomastia -cardiovascular system- cardiomyopathy +/- pacemaker Proceed -testicular atrophy -Lower limbs if time -Urinalysis for glycosuria -Mental status- common to have mental retardation -EMG

Question 19

Gait Exam

Answer 19

Obs- deformity, aids, obvious lesions (i.e. prev strokes), shoes, fasciculations, abnormal movements GAIT -Normal gait -Heel- toe- cerebellar -Toes- S1 -Heels- L4/5 Squat- proximal myopathy Rombergs -Eyes open= cerebellar disease -Eyes closed= proprioception(posterior columns) Proceed -Examine lower limbs

Question 20

Cerebellar Exam

Answer 20

Gait -Will stagger towards affected side, unless bilateral or vermis Legs -Tone -Coordination -Reflexes- pendular knee jerks Arms -Extend arms arm drift, static tremor (due to hypotonia of agonist muscles) -Pronator drift -Tone- Hypotonia in unilateral cerebellar disease -Coordination Finger nose- intention tremor, past pointing Rapid alternating movements- dysdiadochokinesis= inability to perform smoothly Face -Eyes- nystagmus- Jerky, horizontal. Increases when looking towards lesion -Speech- jerky, explosive, loud with irregular separation of syllables- Hippopotamus, Constitution, West register street Trunk -Truncal ataxia- fold arms, sit up Proceed -Assess for causes oCranial nerves Cerebellopontine angle tumour- 5th, 7th, 8th CN affected oLateral medullary syndrome -Fundi- papilloedema -Peripheral evidence of malignant disease

Question 21

Parkinsons exam

Answer 21

Observe - Lack of facial expression= mask like facies - Paucity of movement Gait - Ask to walk, turn quickly, stop and restart - Assess- Difficulty starting, shuffling, freezing, festination - If safe can assess for propulsion or retropulson, if not don’t! Arms -Resting tremor pill rolling- unilateral, or asymmetric if bilateral Finger nose testing- resting tremor diminishes, action tremor may appear -Wrist tone- cog wheel or lead pipe Reinforce by asking patient to turn head from side to side -Assess for involuntary movements dyskinesia associated with dopamine treatment -Rapid alternating movements -Pincer movements- gets smaller -Rolling hands- gets smaller Face -Observe- Tremor, absence of blinking, dribbling saliva, lack of expression -Glabellar tap- continues to blink after tapping sevral times from behind (note: must be out of site) -Speech- monotonous, soft, poorly articulated, faint -Ocular movements- supranuclear palsies Other -Write- micrographia -Frontal reflexes -Higher centres- dementia -Postural BP for hypotension Presentation -Degree of disability -Main problem being rigidity or tremor -Presence of autonomic dysfunction or gaze palsy