all discussion final

Modified by MAW 2009

تعالى الله لوجه وقف الورق اذهالحاالت على األسئلة ألهم تلخيص وهو على المحتوى السكيمة لورق تابع وهو

الفحص تفاصيل و خطوات

MRCS Clinical Examination Qs & As of 69

لطلب الجميع ووفق به الناس الله نفع العلم

CASES

VASCULARLONG: V.V.– Ischemia– PTS– Diabetic foot.SHORT: V.V.– Ischemia– PTS– Diabetic foot– Venous ulcer– AVF –Lymphedema –Amputation. RARE SHORT: UL pulses- Aortic/ popliteal aneurysm– SVC obst.– neuropathic ulcer– subclavian steel syndrome– cong. AVF– Thoracic outlet/cervical rib– Osler Weber rendu S– Raynaud’sKlippel Trenauny S– Hyperhydrosis– Temporal arthritis.

ABDOMENLONG: Abdomen → CLD– HSM– Jaundice– Abdominal mass (usually, RIF, LIF, Lumbar or Epigastric)– Epigastric Hernia/mass. SHORT: Groin hernia (Inguinal/Femoral)– epigastric H– incisional H–

PUH– varicocele– vag. hydrocele– encysted hydrocele of cord–Epididymal cyst (including spermatocele)– undescended testis– testicular tumor– Pilonidal sinus.

RARE SHORT: Spegelian H. – Stoma– Peutz Jhegar– Crohn’s– Pleural eff.

ORTHOPEDICSLONG: Spine– Hip– Knee.SHORT: Specific Knee (e.g, stability or effusion)– Specific Hip– Specific spine–

Rheumatoid Hand– Ulnar n.inj.– Median n.inj./carpal tunnel– Radial n.inj.– Combined n.inj (ulnar+median)– Hallux valgus/bunion– Shoulder–

RARE SHORT: Elbow– Ankle– Dupuytren– Volkman– Osteoarthritis of hand– External fixators– Ant.knee swelling– Post.knee swelling– Trigger/Mallet finger– Erb– Klumpke– claw toe– hammer toe– Paget– pes cavus (+) – ankylosing sponyolitis– Exostosis– rupture biceps– charcot– winging scapula– acromegaly.

SUPERFICIAL LESIONS– BREAST & THYROIDLONG: Breast– Thyroid– Parotid– Submand. gl./L.N. – Neck (N/mass)SHORT: Lipoma (esp, back– thigh)– Dermoid cyst– Sebaceous cyst– ganglion– Neck (N/L.N.)– Parotid– Submandibular gl./L.N. – rhinophyma.


RARE SHORT: Neck mass (thyroglossal cyst, branchial cyst/fistula/sinus (+) , carotid body t., pharyngeal pouch, cystic hygroma)– pyogenic granuloma– skin tag– seborrhic keratosis– H.suppurativa– skin tumor (SCC,BCC, malign.melanoma)– naevus– hemangioma– neurofibroma– Dermatofibroma– keloid– hypertrophic scar– keratoacanthoma– boil– carbuncle– ulcer–.

SWELLING

What is the most imp. Q. to be answered in swelling examination?Is it benign or malignant by

1- Attachments to skin & muscles2- L.N.s3- Neurovascular status of limb (distal pulsation. is it felt?)

What is rhinophyma? Hypertrophy of nasal sebaceous gls with aging

Lipoma

What is lipoma? Benign tumor of fat cells

What are common sites? Back, Shoulder, Thigh, Trunk, Neck, forearm

What are types of lipoma?1-Subcutaneous (superficial to ms → more prominent on contraction)2- Intramuscular & Subfascial (deep to ms → less prominent on contraction)3- retroperitoneal4- extradural5- Submucous(intest.)

What are diagnostic signs by examination?Lobulated surface (SC)Slippery edge (more with SC)

What is Adiposa Delerosa (Dercum disease)? Multiple painful lipomas (usually in back)

Can Lipoma be painful? Yes as above

Can lipoma turn malignant? Never, liposarcoma arise de nevo


D.D. lipoma?1- sebaceous cyst2- dermoid cyst3- Benign muscle tumor4- aneurysm (pulsatile)

What is diagnosis of Lipoma? Example (Lipoma of thigh)soft mass in thigh, 7X5 cm, Slippery edge, lobulated surface, soft consistencynot fluctuant, not attached to skin or muscles (knee extensors or hip adductors), inguinal L.N.s not felt (vertical or horizontal group), distal pulse felt (post. tibial , bec. D.pedis may be absent)→ Lipoma of Rt thigh,

Ask pt. one Q? how long do you have this swelling: if long=benign

What is ttt of lipoma? Ask pt. how it is affecting his life1- conservative2- surgery: excision via incision smaller than lipoma because it can be squeezed,

along bl.vs or with cosmetic lines (e.g, lipoma of thigh excised by smaller incision longitudinal to avoid inj. femoral vessels)

LA (usually) or GA (if communic. with joint)3- Liposuction (new)

How to test relation to muscles in lipoma of back? By inspection & palpationLatissmus dorsi: elbow backwardSerratus ant.: push the wall → if mass ↑= superficial to ms (SC) → if mass ↓= deep to ms (intramuscular or subfascial)

What is ccc of liposarcoma by inspection? Dilated veins over it

OSCE advanced QsWhat are types of liposarcoma?1- well diff2- poorly diff3- pleomorphic(mixed)

What are Syndromes associated with lipoma?Angiolipoma= lipoma with vascular element


Hibernoma= brown fatCowden dis.= lipoma + vitelligo + palmar keratosisBannayan- Zonana synd.= Lipoma+ macrocephaly + hemangioma

Dermoid cyst

What is dermoid cyst? Cyst lined by skin but lies under skin

What are common sites? According to type see next Q

What are types of dermoid cyst?1- Congenital (Sequestration) dermoid cyst: at lines of fusion (int.angular, ext.angular,

preauricular, postauricular) & in midline of neck, trunk & back (never in limbs).2- Acquired (implantation) dermoid cyst: at site prev. oper or Tr due to implanted skin3- Tubodermoid dermoid cyst (in int. organs): thyroglossal cyst & branchial4- Teratomatous dermoid cyst: Ovarian & testicular

What are diagnostic signs by examination?Paget test +veTransillumination +ve in 10%

Is dermoid cyst always translucent? NO. only in 10% of cases

What is diagnosis of dermoid cyst? ExampleSoft Mass above Lt eyebrow, 1X1 cm, scar in overlying skin 2cm healed by 1ry intentionfluctuant, translucent (transimmunable)not attached to skin or ms (occiptofrontalis)L.N.s (preauricular) not felt (if felt → examine rest of neck L.N.s)→ Implantation Dermoid cyst

What is D.D. of dermoid cyst?1- sebaceous cyst2- Lipoma3- Benign muscle tumor4- aneurysm (pulsatile)

How to surly diagnose dermoid cyst? Excisional biopsy


What is ttt dermoid cyst? Ask pt. how it is affecting his life1- conservative2- surgery: excision (if cosmetic or pain)

- cong. dermoid cyst in head: X-ray or CT for intracranial extension → surgery under GA by senior surgeon.

If intracranial extension may need bone graft (synthetic or iliac crest)

Sebaceous cyst

What is dermoid cyst? Retention of sebum in sebaceous gl.

What is the origin of sebaceous cyst? Structures around hair follicle (Cuticle)

What are common sites? Hairy area (not in palm or sole) (common in scrotum)

What are types of sebaceous cyst?Epidermal cyst (SC): from infandibulum of hair follicleTrichelemmal cyst (TC): from epithelium of hair follicle

What is the consistency of sebaceous cyst? Soft or Firm (thick sebum) (common)

What is a cyst? Cavity lined by epithelium

What are diagnostic signs by examination?Punctum = point of attachment of sebaceous cyst to skin (may be multiple) (need to tract skin aside to find punctum) (found in 50% of cases)

How to diagnose Sebaceous cyst? ExampleSwelling above Rt eyebrow, 1X1 cm, well defined edge, smooth surface, soft consistency, attached to skin at punctum, not attached to underlying ms (occipto-fr)→ Sebaceous cyst of forhead

What are complications of sebaceous cyst?Inf., hemorrhage, calcification, sebaceous horn, malignancy (rare)

How to treat sebaceous cyst?Excision (for fear complic.) by elliptical incision including punctum

OSCE advanced Qs


What is cock‘s peculiar tumor? TC that grows rapidly and ulcerates (D.D. with SCC)What is gardner syndrome? Seb.cyst+ L.I. polyps+ skull osteoma+ desmoid tumor

Ganglion

What is ganglion? Myxomatous (cystic) degeneration of fibrous tissue of tendon or joint synovium (may be communicating with joint or non-communicating)

What are common sites? Near tendon or joint (esp, dorsum hand or foot or ventral wrist)

What are diagnostic signs by examination?Paget test +veTransillumination +ve in 10%Along tendons (esp, dorsum hand at wrist)Mobility in single plain & become limited by tendon contraction

How to treat ganglion? Ask pt. how it is affecting his life1- Conservative2- Excision under GA or regional (because a tourniquet is needed for bloodless field

(painful if LA) (20% recurrence, ↓ to 5% if neck excised)3- Aspiration & 3 weeks immobilization (30 – 50% recurrence + risk of inf.)

What are complic. of ganglion excision?1- wound: inf., scar, hematoma2- injury to nerves & vessels3- recurrence (20% & ↓ to 5% if neck excised

D.D. neck swelling

D.D. neck swelling?1- Midline swellings: thyroid (solid & moves with swallowing only) & thyroglossal cyst (cystic +move with prot.tongue & swallowing) & L.N. (pre-laryngeal & pre-tracheal)2- Ant. Triangle: Chemodectoma (= carotid body tumor solid), Branchial cyst, cold abscess (=collar stud abscess = T.B. L.N. complication) & L.N. 3- Within sternomastoid: sternomastoid tumor (hematoma)4- Post. Triangle: Pharyngeal pouch (reducible), Cystic hygroma (cystic), L.N.5- Parotid region: Endemic parotitis, parotid ts, obstructing stone


[+ swelling from skin & SCT: lipoma, sebaceous cyst, dermoid cyst]

OSCE advanced QsThyroglossal cyst: aetio, diagnostic signs, investig., ttt?Def: Remnant patent part of throglossal tract (attached to foramen cecum of tongue) → moves with protrusion of tongue & swallowingSigns: +ve paget & transilluminationInv.: clinical diagnosis +/- U/S or Ct for extent to tonguettt: Cis-trunk oper. = excision with all tract to base tongue & middle part of hyoid bone

Branchial cyst or sinus or fistula: aetio, diagnostic signs, investig., ttt?Def.: Remnants of 2nd pharyngeal arch (lack fusion 2nd * 3rd arch), in young adultSigns: +ve paget & transillumination- Sinus= blind end tract lined by epith. Or granulation tissue- Fistula= abnormal tract connecting 2 epithelial surfaces Clinically both (sinus & fistula) are considered sinusInv.: clinical diagnosis + FNAC→ cholesterolTtt: complete excision

Chemodectoma (Carotid body t.) (potato t.): aetio, diagnostic signs, investig., ttt?Def: Benign t. at carotid bifurcation infront sternomastoidSigns: Pulsatile itself or transmits pulsation underlying carotid arteries, usually bilat.Inv.: Angiography (goldstandard), U/S or CT (for extent)Ttt: small & bilat. → observe Enlarging or invasive → excision or radiotherapyCold abscess: aetio, diagnostic signs, investig., ttt?

Sternomastoid t. : aetio, diagnostic signs, investig., ttt?

Pharyngeal pouch: aetio, diagnostic signs, investig., ttt?Def.: Herniation of pharyngeal mucosa through ms coat between thyropharyngeus & cricopharyngeus (Kellian dehiscence) → asymptomatic or dysphagiaSigns: palpation → squelching soundInv.: Ba swallow (diagnostic) (can be done routin befor any UGIE) or endosc: if t.Complic.: aspiration → chest inf & rarely neoplasia(1%)Ttt: if small, asympt.→ conservative, otherwise → excision open or endoscopic

Cystic hygroma: aetio, diagnostic signs, investig., ttt?Def.: cong. Cystic lymphatic malformationSigns: +ve cross fluctuation & transilluminationInv.: CXR, CT, MRI (for extent)Complic.: obstructed delivery (at birth), dyspnea or dysphagia (later)Ttt: aspiration or excision (partial or complete)

Thyroid


How to differentiate between thyroid swelling & thyroglossal cyst?By protrusion of tongue & swallowing:1- Thyroid swelling: does not move with protrusion tongue & moves with swallowing2 Thyroglossal cyst: moves with protrusion of tongue & swallowing

Why thyroid swelling moves with swallowing? Attachment to pretracheal fascia

Why thyroglossal cyst move with swallowing & protrusion tongue? Attachment to foramen cecum at base tongue

Do we have to test every swelling by protrusion of tongue? NO, if butterfly swelling → not thyroglossal cyst, do only swallowing to confirm it is thyroid

What Qs to ask pt. about thyroid status?Intolerance of hot weather (hyperthyroidism) or col weather (hypothyroidism)

الشتا ال و الصيف بتحبWhy hyperthyroid pt. (thyrotoxic pt.) have tachycardia? Because thyroid H. ↑ effect of catecholamines on heartWhy thyroid swelling moves up & down with deglutition (swallowing)?Due to attachment to pre-tracheal fascia

Where to feel carotid pulsation? Anterior to sternomastoid ms in carotid triangle in ant.triangle of neck

ورق رزمة و زجاجة و ماء كوب قدامه تالقى حالة thyroid دايما

What is normal relation between cornea & eyelid?Normal eye: upper 1/5 cornea covered & lower edge just touching lower lid (no rim)

What is n. supply of LPS ms? Only ocular ms with Dual n. supply1- Somatic: occulomotor2- Sympathetic:

What is difference between exophthalmos & Proptosis? Not imp.

What are eye signs in hyperthyroidism? Fix head while examiningStaring lookInfrequent blinking


Lid retraction: rim above cornea (due to spasm of Muller part of Levator pulpeprae superioris (LPS) due to ↑ sympathetic tone)

Apparent exophthalmos: rim below cornea & above = sclera visible allaround (due to eyeball protrusion)

Lack Wrinkling (Joffroy’s sign): when eyeball look upward (due to exophthalmos not need to wrinkle to extend field)

Lid Lag (VonGrave’s sign): upper lid lags while eyeball looks down (as lid retraction)Lack convergance (Mobiu’s sign): (due to weakness of med. rectus = converging ms)Exophthalmos examination from behind while extending head (Naffziger’s) [Naffziger test replaces the obsolete ophthalmometer to detect mild exophthalmos] NO ophthalmoplegia = no (examine if asked) cover contralat. Eye & follow my indexNormal Visual acuity = optic n. not infiltrated (examine if asked)

What is diagnosis of Thyroid case? ExampleThyroid status: Pt. not warm, hands not sweaty, no fine tremors, no tachycardia, no water hammer pulse, no pretibial myxedema, no lidlag, no apparent exophthalmous Thyroid: butterfly swelling infront lower neck in ant. triangle 5X7 cm, does not move with protrusion of tongue & moves with swallowing, edge well defined surface nodular, firm consistency, not attached to skin or sternomastoid ms, no L.N. enlargement or carotid displacement or infiltrationCase of thyroid enlargement with euthyroid status, propably simple nodular goiter

D.D. Thyroid swelling (Goitre)?Diffuse: Non-toxic→ Simple colloid goitre → Thyroiditis (Hashimoto, Riedle's, De Quervain) Toxic → Grave's diseaseNodular: Solitary Nodule Multi-nodular goiter (M.N.G.)Any of above may be toxic or malignant or undergo changes

How to investigate case thyroid enlargement?Lab.: TSH, T3, T4 & routine Lab for oper.Neck U/S: → Solid or CysticFNAC: if cystic, if malign. cyst→ total thyroidectomy+/- Thyroid scan: (for solitary nodule) → Cold or Hot+/- CXR: (for retrosternal extension) Ask pt. Q to suspect malignancy? How long have the swelling? If Long → benign

How to prepare pt. for thyroidectomy?


Inderal (either stop gradually before oper. or continue)Carbimazole = neomercazole

Why some of eye signs not +ve? Because pt. may be on medical ttt

What is medical ttt hyperthyroidism?1- Inderal: ↓ effect of thyroid H. on heart2- Neomercazole: ↓ synthesis thyroid Hs (T3, T4)

OSCE advanced QsSimple colloid goitre: aetio, investig., ttt? Commonest causeAetio.: hyperplasia of gl. To meet demands Thyroid h.

1- I deficiency2- ↑ demand: puberty, preg, lactation3- Goitrogens (Lithium & antithyroid)4- ↓ Thyroid h. production (rare)

Inv.: no (except if suspect toxic, malign., retrosternal ext)Ttt: conservative Grave's disease: aetio, investig., ttt? Common in female 9:1Aetio.: Ab (Ig) against TSH receptors → persistent stmulation → ↑ thyroid hsCcc: thyroid eye ds, pretibial myxedema, other autoimmune ds (IDDM, pernicious anemia)Inv.: as aboveTTT: medical: inderal & neomercazole → Radioactive I (if failed medical) Surg.: (failed medical) Bilat. Subtotal thyroidectomy (leave 4-10gms for T3,4 and PTH)Multi-nodular goiter (M.N.G.) : aetio, investig., ttt?Aetio.: progression from simple diffuse goiter, Family history +ve, Inv.: if suspect toxic, malign., retrosternal ext. (as above)Ttt: conservative (if not toxic, no pr. S/S & not malignant, no cosmetic) If toxic→ medical →(fail)→radio I →(fail)→ Bilat. Subtotal thyroidectomy If pr. S/S → Bilat. Subtotal thyroidectomy If malign. → Total thyroidectomy (as below)Solitary thyroid Nodule: aetio, investig., ttt?Aetio.: middle age female

1- nodule in M.N.G.2- adenoma (follicular)3- cyst (rarely pure but mostly hge into necrotic nodule) → FNAC4- carcinoma5- thyroiditis

inv.: all of abovettt: according to cause as M.N.G. (cold nodule is considered carcinoma till proved otherwise).Why FNAC not differentiate follicular adenoma from carcinoma? Because no capsule presentedDifference between Grave's ds & toxic M.N.G.?Grave's ds: young, eye signs, associated with autoimmune ds toxic M.N.G.: old, no eye signs, not associated with autoimmune ds, AF is common


What are causes Hyperthyroidism? Grave's ds, toxic M.N.G. & functioning adenomaWhat are causes Hypothyroidism? 1ry myxedema & Hashimoto thyroiditisWhat is benign thyroid tumor? Follicular adenoma (not differentiated from carcinoma by FNAC)Compare types thyroid malignancy?Papillary Follicular Anaplastic Medullary Lymphoma75% 10% 5% 8% 2%Young Middle age Old age 90% sporadic, 10%

familial (MEN II)Lymph spread Bl. spread Direct spread From parafollic.

cellstotal thyroidectomy total thyroidectomy Debulking+radio

+chemotherapytotal thyroidectomy Chemotherapy

What is Pemberton sign?Elevation arms 3 mins above head → face congestion & dizziness = retrosternal extensionHow test myopathy with hyperthyroidism? Squat then stand upWhy ENT examinat. Before thyroidectomy? Medicolegal (unilat. Cong. Paralysis 2-5%)How test n. inj. after thyroidectomy? لله الحمد RLN→ hoarsness & SLN→ weak voice قولCause Exophthalmos? Retro-orbital cell deposition & edemaCause congested neck vs with goiter? Retrosternal extensionWhich ms first affected by ophthalmoplegia? Sup. Rectus (up) & Inf.Obl. (up & out) What is chemosis? Edema of conjunctivaComplications of thyroidectomy?Hge & Hematoma → airway obst. (clip remover beside bed)Hoarsness (RLN inj.) or weak voice (SLN inj.)Hyperthyroidism (thyroid storm)HypothyroidismHypoparathyroidism → HypocalcemiaWound: inf, hypertrophic scar or keloid

Parotid Gland

What is nerve supply of masseter ms? Mandibular branch of trigeminal

What does facial nerve supplies? Ms of face: Occiptofrontalis by Temporal branch Orbicularis occuli by Zygomatic br. Buccinator by Buccal br. Orbicularis oris by mandibular br.

platysma by cervical br.post. Belly of digastricStapediusChorda tympani (taste to ant. 2/3 of tongue)


How to diagnose case of parotid enlargment? Example:Swelling in parotid region bilaterally measure 4X4 cm, edge well defined, smooth surface, soft consistency, ↑ with clenching teeth, cervical L.N.s not felt, facial n. intact, superficial temp. a. pulsation felt bilaterallyCase of bilateral parotid gland enlargment

Ask pt. some questions about his case (Parotid swelling)?How long you have this swelling: if long → benignYou have CLD, Bilhariziasis, alcoholic?You took radio- or chemotherapy?How this swelling is affecting your life?

What is D.D. of this swelling?skin & SCT: lipoma, sebaceous cystms: masseter hypertrophyL.N.: preauricularGl.: parotid enlargement

What are causes (D.D.) of parotid enlargement? 1- unilat.: acute inflammation (bac: strept, staph & viral), obstructing stone,

pleomorphic adenoma & other as bilat. (see below)2- bilat.: chrذonic inflammation = endemic parotiditis due to debilitating ds (CLD,

Alcohol (worldwide), Bilhariziasis (Egypt), mumps, autoimmune ds (Sjogren, Mickulciz ds)

What are ccc Sjogren ds? Parotid enlargement & eye inflamm. & dry secretions +/- CT disorder (arthritis) + high incidence of B-cell lymphoma

What are types of Sjogren ds? 1ry (no CT disorders) &2ry (CT disorders)

What are ccc Mickulciz ds? Parotid & lacrimal gl. enlargement & dry secretions (dry eye & dry mouth) due to sarcoidosis, lymphoma or T.B.

How to surely identify facial nerve? Nerve stimulation

OSCE advanced QsWhat are Types, investing. & ttt of salivary tumors?Types:


Benign: Pleomorpic adenoma (mixed t.) & Monomorphic adenoma (commonest is adenolymphoma= Warthin's tumor)Malignant: Mucoepidermid carcinoma (parotid) & Adenoid cystic carcinoma (submand. & minor gls)Investig.: FNAC (exclude malign. & MRI (if malign. or huge size to asses deep lobe involvement)Ttt: Benign + no deep lobe → Superficial conservative parotidectomy (preserve facial n.) Benign + deep lobe involved → Total conservative parotidectomy Malig. → radical parotidectomy (should include facial n. BUT may try to spare it)What are causes of facial palsy?Idiopathic= Bell's palsyIntracranial: CVA, meningitis, acoustic neuromaIntratemporal: skull base Fr., O.M., SCC middle earParotid: parotid malignancyCommonest gl. For stones? Submandibular gl.Commonest gl. For tumors? Parotid but mostly banignComplications of parotidectomy? General & Specific →Wound: hematoma, inf., Facial inj.Salivary fistulaFrey syndrome (auriculotemporal syndrome)= gustatory sweating d.t. regrowth of symp.n. into skinGreater auricular n.inj. → Loss sensation of pinna

Submandibular Gland vs L.N.

How to differentiate submandibular gl. Enlargement from submandibular L.N.?History Ask Qs about

1- You have other swellings: multiple swellings → L.N., Single → submand.gl.2- What ↑ the swelling? If ↑ by sour food → submand.gl.

Examination1- multiple or single?2- Bimanual examination (hand at ts ramus mandible & gloved hand inside)

If felt bimanually → submand.gl.If not felt bimanually & only rolled from outside → submand. L.N.

Where is the duct of submand.gl.? beside frenulum of tongue

How to surely diagnose submandibular gl. Stone? Sialogram

What type of L.N. biopsy is usually done? Excisional biopsy (NO FNAC)

Do we usually do palpation parotid gl.? NO, bec rare stone, pain, difficult

Why salivary stones more common on submand. Gl. Than parotid gl.?


Bec. Submandib.gl. → thick secretion & duct less dependent

Lymph nodes (esp, Submandibular)

Causes of Lymph node enlargement ? (LIST)1- Lymphoma / Leukemia

Hodgkin’s Non-Hodgkin’s

2- Infective Nonspecific Bac. : Tuberculosis Viral: IMN (Glandular fever) - Syphilis Protozoal: Filariasis- Toxoplasmosis (Cat scratch fever)

3- Sarcoidosis 4- Tumor

How to investigate enlarged L.N.? first look for other L.N.s & for RES (HSM)

1- FBC (differential count)2- Specific tests: IMN (monospot test) & T.B. (…..)3- Bone marrow biopsy (Sternal puncture)4- Lymph node biopsy: excisional biopsy (if suspect tumor) But FNAC recommended in T.B (avoid chr. ulcer) & SCC

N.B. Some surgeons start by FNAC then proceed accordingly (see below)

Name 1 imp. L.N. of deep cervical? Jugulo-digastric draining ……

OSCE advanced QsWhat are surgical options for excision of cervical lymphadenopathy?

1- open L.N. excision biopsy2- Block dissection of neck & limited block neck dissection3- Radical neck dissection

How to proceed according to FNAC of L.N.?If Lymphoma, adenocarcin. or inflamm.(except T.B.) → excisional biopsy & search for 1ry or causeIf T.B. → ttt T.B.If SCC → refere to ENT to find 1ry

BREAST

What is the commonest site of breast cancer? Upper outer quadrant

What are positions for breast examination?


Inspection: 45o with hands beside →elevation hands (axilla & arm) → hand on waist (pect.maj. cont. for teethering)→ pt. elevate br. (for big breasts- usual in Egypt)Palpation: 45o with hands beside → hand on waist (for mass attach to pect.maj.)

How to palpate breast? 4 quadrants, areola, axillary tail, back breastBy flat of middle 3 fingers to screen for massesif find mass → palpate by tip of fingers

How to manage case of breast swelling? Triple assessment1- clinical: history & examination2- radiological: <35 years → breast U/S >35 years → mammography3- Pathological: FNAC or trucut or excisional biopsy (if small)

What are finding in mammography indicating malignant mass? microcalcification & speculations (irregular swelling)

What are other investigations (investigation for malignancy)?Abdominal U/S (for abdominal mts & Bone Scan (for bone scan)

How to treat breast cancer 2cm?WLE (wide local excision) with 1 cm safety margin + axillary clearance or axillary L.N. sampling+ radiotherapy of breast & axilla (if no clearance & sampling +ve)

How to manage treat breast cancer 6cm?Radio & Chemotherapy (to downstage & ↓ size tumor)

What is diagnosis of breast case? ExampleMass in the Lt breast lower lateral quadrant, 2X2 cm, ill defined edge, smooth surface, firm consistency, not teethered or fixed to skin or underlying muscle, axillary L.N.s not felt, → case of breast mass for triple assessment

How to treat breast abscess?Drainage by radial incision (to avoid interruption of lactating unit)

How to differentiate benign from malignant breast mass?Triple assessment


1- history: duration & age of pt.2- examination: consistency, relation to skin & ms3- pathological: FNAC

D.D. Breast mass?Physiological: Fibroadenosis (ANDI)→ pain with menstruationTr.: fat necrosisInf.: abscess, mastitisNeoplastic: Benign: Fibroadenoma (breast mouse), Duct papilloma, phylloides t. Malig.: 1ry (ductal carcinoma or lobular carcinoma) or 2ry

OSCE advanced QsWhat are pathologies of nipple? 7D: Destruction, Depression, Deviation, Displacement, Discoloration, Discharge, DuplicationWhat is dimple, buckering, teethering, fixation?Dimple= dip in skin, buckering= multiple dimples, teethering= induced dimpling & mass can be moved for limited distance independent of skin (d.t. infiltration or fibrosis of Cooper's ligs)fixation= mass can not be moved independent of skin (d.t. infiltration of skin)How to differentiate causes of nipple retraction? Cong.→ can be everted, cancer→ can notCauses of nipple discharge? Bl.→duct papilloma or carcinoma, watery or green→fibroadenosis, black→ obstructed duct, milk→ lactation or gonorrhea, yellow= pus→ acute or chr. Mastitis, N.B. duct ectasia ← any discharge except bl.How to examine post-mastectomy case?Insp: (in all positions as breast)

skin→ scars, dilated vs, ulcers or nodules= recurrence, radiotherapy marks: erythema & ink marks (recent) or telangectasia (previous)

Ms (axillary folds): ant.= pectoralis major & post. = latissmus dorsiMs examination: pectoralis maj., L.D., serratus ant. Palpation: continue as breast examination


VASCULAR

ISCHEMIA

What are causes of chr. ischemia = causes of ischemic ulcer?Atherosclerosis (commonest cause) – Large vessel dsThrombangitis obliterans (Beurger ds) – Large vessel dsDM – Large (cause atherosclerosis) & Small vessel dsPAN – Small vessel dsRh.Arthritis – Small vessel ds

What are risk factors of ischemia? Smoking-ISHD-DM-HTN-hyperlipidemia

What is presentation of PVD (peripheral vascular disease)= chr. ischemia?Claudication pain Rest pain Critical ischemia

Site Aorta & CIA → ButtocksEIA → ThighFemoral → Calf

Forefoot & Toes 1-Ulcer or gangrene2-Rest pain > 2ws3-Ankle pr <50 mmHg

What ↑ Exercise (fixed distance)(d.t. accumulation metab.)

Rest & Sleep(d.t. ↓ COP, V.D. skin bl.v)

What ↓ rest Walk & hang leg out bedTTT Conservative Angioplasty +/- stent (if short segment)

Bypass Graft (if long segment) Amputation (if failed)

What is definition of critical ischemia?European working group definition

1- presence ofarterial ulcer or gangrene OR2- rest pain ≥ 2 weeks relieved only by opioids OR3- absolute ankle pr. < 50mmHg

Other features4- ABPI < 0.55- Burger vangle < 30o

ExaminationScars?Ts Lt to umbilicus: Lumbar sympathectomy or retroperitoneal approach to aortaTs (as above) & long. Bilaterally at skin crease: aorto-bifemoral bypass


Long. at skin crease: femoral embolectomyLong. at skin crease & popliteal fossa: femoro-popliteal bypass with synthetic graftMultiple scars from skin crease downwards to knee: multiple stab avulsion (for V.V.) or femoro-popliteal bypass with vein graft (natural)

Where to feel pulses UL?Subclavian: just behind mid-clavicle from behindAxillary: bicepital groove (medial humerus) bimanualBrachial: med. bicepital aponeurosisRadial: lat. to FCR- radial boneUlnar: lat. to FCU – pisiform bone

Where to feel pulses LL?AAA: above umbilicus, just Lt midlineFemoral: midinguinal point (midway SP & ASIS) at skin creasePopliteal: knee 160 degrees (relax muscles) in popliteal fossa (variable site)Posterior tibial: midway between med. malleolus & tendo-achilisDorsalis pedis: lat. to ext. hallucis longus tendon on navicular bone

Commonest sites of leg ischemic ulcers?1- heel 2- head of metatarsals3- between toes4- sole

Is Burger test practical? NO, now replaced by ABPI (ankle-brachial pr. Index)

Is capillary filling a good test for ischemia? NO, because may be normal due to return of venous blood

How to measure & interpret ABPI?Measure ankle pr. by cuff above med. malleolus & hear post. Tibial by dopplerMeasure brachial pr. By dopplerDivide ankle / brachial pr.If >1 → DM (rigid vessel wall)If 0.9 – 1 → normalIf 0.5 -0.9 → chronic ischemiaIf < 0.5 → critical ischemia


Why in DM pulse felt till late &ABPI is higher than even Normal >1?Because of calcification of vessel wall

Diagnosis, D.D. & managementDiagnosis of case of Ischemia? Example,Color & trophic changes, ulcer with punched out edge, necrotic floor & deep, Beurger angle < 30o, sluggish capi. Circulation, pulses not felt below femoral→ Critical ischemia LL for ABPI & Angiography

How to diagnose pt. with ischemia?1- angiography (goldstandard)- now CT angio.2- Duplex (less invasive)

What to do for pt. with only femoral pulse felt? (Common on exam)Angiography (standard)

Which artery is commonest to be occluded? Superficial femoral

What is ttt of chronic ischemia in most cases ? in most of cases superficial femoral occluded → Femoro-popliteal bypass

What is value for angiography?1- diagnostic: site (aorto-iliac, femoral-popliteal or distal) & extent of thrombus &

distal run-off (=good collaterals =good prognosis)2- therapeutic: ballon angioplasty +/- stent (if short segment)

What are precautions of angiography in DM pt.?ensure normal S.Cr., good hydration & non-ionized dye (usually mild renal

impairment)stop metformin (cause lactic acidosis with dye)

What is ttt of ischemia?Conservative ttt: (if claudication pain)

→ stop smoking, control DM, HTN & hypercholest, regular aspirin 75mg, analgesia acc. to analgesic ladder (paracetamol→NSAIDS oral→IM→oral opioids →IM)

Surgery with conservative ttt: (if claudic. & failed conservative OR critical ischemia OR rest pain)→ Angioplasty +/- stent (if short segment) Bypass Graft (if long segment)


Amputation (if failed or no distal run-off) Lumbar sympathectomy (if ischemic ulcer)

What are contraindications of sympathectomy?DM (autosympathectomy) & Gangrene

What is ttt of this pt. with clasudication pain & trophic changes?Conservative ttt

What is ttt of this pt. with ischemic ulcer? Angioplasty +/- stent (if short segment)Bypass Graft (if long segment)Amputation (if failed)

What are types of bypass grafts? 1- natural: saphenous v.2- synthetic: Dacron or PTFE (Gortex)

D.D. claudication pain?1- Vascular: PVD or DVT or PTS2- Neurological: spinal stenosis (spinal claudication) or sciatica3- Musculoskeletal: pathology of hip, knee orankle (e.g, osteoarthritis)

OSCE advanced QsPathology of ischemia by DM? Mixed

1- Vasculopathy: Macro- angiopathy & Micro- angiopathy 2- Periph. Neuropathy:3- Inf.: → Macro & Micro- angiopathy

Which type of DM is worest?IDDM (type I) because:

usually P.N. (poorvresponse to surg.)↓ immunity → more inf.More plat. Aggregation

Ask this pt. with diabetic toe 1 question? Are you on insulin or not?If on insulin (type I) → amputation (no ischemia but neuropathy=bad prognosis)If on oral hypoglycemics (type II) → angioplasty (ischemia due to vasculopathy)

What is thoracic outlet syndrome? ……

What if auscultate over carotid & bruit is heared?


Do duplex if carotid stenosis for intervention → angioplasty or endarterectomy

What is endarterectomy. How it is done?Done in carotid thrombosis onlyPeel Intima & part of media (leave part of media + adventitia)

PTS (Post-Thrombotic syndrome)

Cause PTS? DVT1- deep v. system reflux post-DVT (90%)2- deep v. system obstruction post-DVT (10%)

Presentation of PTS? pain & Signs chr.venous insuffeciency=chronic skin changes (edema, eczema, hyperpigmentation, lipodermatosclerosis, V.V., venous ulcer)

Ask pt. 2 questions? heparin inj. or oral anticoagulant (=DVT) & operations

ExaminationWhat is lipodermatosclerosis? Skin & SCT Subfascial fibrosis

Ccc of venous ulcer? Floor healthy granulation tissue Edge sloping (means healing)

ShallowArea surrounding → signs chr.v. insuffeciency

Diagnosis, D.D. & managementDiagnosis of case PTS? Example,Edema of Rt LL, dark periphery, purple central area, with multiple ulcers with floor of healthy granulation tissue & sloping edge, also there is a punch of v.v.s propably a case of PTS. I would like to examine pulse (to exclude mixed pathology) & ask pt. to stand to examine for v.v.

How to investigate case venous ulcer or case of PTS or deep system? Duplex Other rare options (ambulatory venous pr., venography, varicography)

Another method to asses deep system (clinically)? Perthe’s test or modified perthe’s test (close superficial system by tourniquet & walk or tip toe → pain) (not used because painful)


Role of duplex in PTS? diagnostic: for deep system patency & competence (exclude DVT which

contraindicate surg.) & superficial system SFJ & perforator competencetherapeutic: superficial system (not in PTS)

(it is contraindicated to treat 2ry V.V. (V.V. + prev. DVT) because surgery worsen v.ischemia) So, any case of V.V. + ulcer → do duplex

What are causes of Venous ulcer?PTSV.V.Muscle pump failure (NM ds, stroke, stiff ankle)

Can varicose vein cause this picture (ulcer) without PTS? Yes, severe V.V.

How is treatment different between varicose ulcer due to PTS or 1ry V.V.?varicose ulcer due to PTS → compression dressing (4 layer bandage)varicose ulcer due to 1ry V.V. → surgery for v.v.

What is treatment of venous ulcer ?

1- Conservative:

1- Elevation of leg

2- Compression bandage (Four-layer bandage)

& after ulcer healing use G II compression stocking for life (for V.V.)

2- Surgical: ulcer base excision & skin grafting (after biopsy from edge to exclude

marjolin ulcer = SCC)

What are differences between types of ulcers?Venous Ischemic Neuropathic

Size large Small mediumSite Gaiter area Distal & pr. area Pr. areaShape irregularEdge sloping Punched out Punched outSurrounding CVI Trophic & color

changes & lost pulseLost sensation

OSCE advanced QsWhat are the 4 layers of 4 layer bandage (not used now)?1- non-adherent & absorbable (wool)


2- crepe bandage 3- blue line4- tape (plaster)Exchange / week

What are results of conservative management for ulcer (4 layer bandage)?Very good at 3ms→ 50-70% healing & at 12 ms 80-90% healing

What is venous gangrene?Rare complication of Iliofemoral DVT:

Phlegmasia alba dolens: white legPhlegmasia cerula dolens: blue legGangrene: in foot or extend to leg (due to acute ischemia)

What are types granulation tissue?Healthy: red, not bleed easy, flat & Unhealthy: blue, bleed easy & raised

Varicose Vein

What is pathogenesis V.V.? fibrous tissue invades intima & media & broke ms tone

What are tributaries of Saphenous vein ?

1- Superficial circumflex iliac

2- Superficial inferior epigastric

3- Superficial external pudendal

4- Deep external pudendal

5- Antero-lateral & postero-medial veins of the thigh

ExaminationWhat is fegan test (sign)?palpation of fascial defects

Where is the SFJ (saphenofemoral junction) by doppler?1 cm below & medial to femoral a. (mid-inguinal point = midway bet. S.P. &ASIS)OR 4 cm below & lat. to P.T. (1st prominrnce med. to ing. Lig. Or attachment of adductor longus by abd. & ext.rot. hip)

How to asses SFJ incompetence?1- palpation =thrill


2- tourniquet test3- Doppler

How to use Doppler to asses SFJ (saphenofemoral junction) incompetence?Carried by examiner or in your pocket (not by pt.)At site of thrill: Locate artery (below skin crease) then vein just below &med. (1cm)Squeeze quadriceps (punch of veins) or ask pt. to coughHear 2nd sound (bidirectional flow)

How to use Doppler to asses SPJ (sapheno-popliteal j.) incompetence? (rare)Flex knee (to relax muscles)Locate artery in midline & vein lies beside artery

Diagnosis, D.D. & managementWhat is Diagnosis of v.v. case? Examplev.v. at medial side of leg at distribution LSV, pigmentation in gaiter area, no v.v. in course SSV, incompetent SFJ by thrill, tourniquet test & DopplerV.V. with incompetent SFJ & competent perforators

What are indications of duplex in V.V.? Some surgeons perform it as routine buthistory DVTvenous ulcerrecurrent V.V.pre-operative: for perforators & SPJ (both are variable anatomicaly)if cannot determine SFJ incompetence

What is role of duplex in V.V.?3- diagnostic: for deep system patency & competence (exclude DVT which

contraindicate surg.) & Superficial system SFJ & perforator competence4- therapeutic: site of perforators & SPJ for surg. (both are variable anatomicaly)

What is treatment of v.v.?

1- Conservative: graduated pr. Compression stockings G II & lifestyle modification

(exercise & ↓ weight & ↓ standing)

2- Surgical

1- Open surgery:

For LSV →SF Ligation (Trendlenberg oper. (ligate LSV 1 cm from fem. v.)+

Stripping till just below knee (avoid saph.n.) + Multiple avulsions.


For SSV do SP ligation & avulsion (no stripping to avoid sural inj.)

2- Injection sclerotherapy (cosmetic) use ethanolamine oleate or sclerovein

3- injection of foam

4- Subcutaneous Endosc. Perforator Surg. (SEPS) for severe skin changes or ulcer

5- Radiofrequency (intraluminal)…. new

6- Laser (intraluminal)…. New

What is treatment of this case (severe V.V. + SFJ incomp. + perforator incomp.)?

Surgery (skip conservative) ….most of exam cases

Why stripping of LSV till just below knee?

To avoid inj. saphenous v. (near LSV in leg) → parathesia & numbness med. leg

Why no stripping of SSV? To avoid inj. sural n. → parathesia & numbness lat. leg

OSCE advanced QsWhat to tell pt. about his surgery (consent for stripping)?

1- daycase2- no driving 1 wk3- may not improve skin changes4- may not improve aching pain5- risk inj. saphenous or sural n.6- risk DVT7- risk recurrent vs (20 % at 5 years)

What are common sites for perforators?Mid-thigh, Above med. malleolus by 2, 4, 6 & Above lat. malleolus by 1, 3, 5 inches

Where is gaiter area? Lower 2/3 of leg

What is Klippel Trenauny syndrome? Severe V.V. in abnormal site (e.g, lat.thigh)+ giant limb+ portwine stain

AVF

What is diagnosis? Dilated pulsatile vessels on front of forearm, scar over it, thrill over it, → Surgically induced AVF for dialysis +/- venous hypertension


What is AVF ? type of vascular malformation

What is the most dangerous AV malformations? Berry aneurysm → subarachnoid hemmorhage

What is its ttt? Transfemoral embolization or coiling

How to access carotid (e.g, transluminal angioplasty)? Transfemoral

Where are the sites of surg. AVF? Start by non-dominant hand & distal firstRadiocephalicBrachiocephalicBrachiobasilic (need superficialization)

What are types?Direct: end to side (better), side to side Graft: bridge or loop (natural=saphenous or synthetic graft=PTFE)

How to know dominant artery of hand? Allen test

What to do before AVF? Allen test (in exam done on examiner hand not pt.)Elevate hand & make a fistPress to close On site of radial & ulnar artery Ask pt. to open & close fist many times till hand blanches(evacuate blood)Release one of them & notice refilling time (usually 6 secs radial)Compare time of refilling between radial & ulnar, the longer the time the less dependent is the artery

What is usual dominant artery of hand? Ulnar artery

What if radial is the dominant? Do brachiocephalic (instead of radio-cephalic)

Is there is ulno-basilic. Why? NO, becausedifficult access of canula (applied from lat. Side) basilic v. is deep in most of its course

What are complications?1- Failure (thrombosis)2- Inf.3- Rupture & bleeding4- Steal syndrome (ischemia due to blood stealed to veins)


Ttt→ ligation of distal vein5- high COP HF

What is ttt steal syndrome? ligation of distal vein

OSCE advanced QsHow to determine degree of shunt & general effect of AVF?Branham test: measure carotid pulse before & closure fistula by cuffIf pulse ↓ > 10 = general effect (Lt to Rt shunt)

What else you want to do?Ask about hemodialysis or prev. transplantationExamine neck for prev. access & abdomen for transplantation scar

What does thrill & needle marks indicate? Functioning AVF

What does pulsation indicate? Distal obstruction

What is Parkes Weber synd.? Multiple AVF + limb hypertrophy

Lyphedema

What is your diagnosis & why? Lymphedema of LL because:

In dorsum of foot

Unhealthy skin (due to recurrent lymphangitis → obstructed lymphatics → ↑

lymphedema)

Preserved ankle crease

+/- Fungal inf. (between toes)

What are causes of lymphedema?Congenital = Millor’s ds (congenita- precox- tarda)Acquired: 1- inf. (filariasis = W.Bancrofti) 2- trauma 3- iatrogenic: after radiotherapy or oper. (block dissection axilla or groin) 4- neoplastic What is the ttt?Conservative only: leg elevation & foot hygiene & stockings & ttt cellulites (AB)(Now no role for lymphovenous shunts or debulking)


What are degrees of stockings?G I (1st degree): pressure 10 - 20 mmHg → prophylactic against DVTG II (2nd degree): pr. 20 - 30 mmHg → ttt V.V.G III (3rd degree): pr. 30 – 40 mmHg → ttt lymphedema

What are complic. lymphedema? Lymphangitis (cellulites), tinea pedis, vesicles

D.D. LL edema (Swollen leg)?A- General causes: Heart failure, Hepatic, Nephrotic, hypoAlb., HypothyroidismB- Local causes: Venous: PTS, V.V., klippel trenaunay synd.

LymphedemaCong. AVFAngioedema

What are difference between Venous edema & Lymphedema?Venous edema: in ankle, unilat.Lymphedema: in dorsum of foot, preserved crease & bilat.


ABDOMEN

Abdominal Examination & signs CLD

What are signs of CLD?Clubbing: Obliteration of angle between nail & nail bed – chr. diseasePalmar erythema: (sign of decompensated CLD) in hypothenar, thenar, head of

metacarpals & tip fingersFlapping tremors: sign decompansated CLDDupuytren’s contracture: nodular or cord like fibrosis of palmar fascia of ring +/- little

finger in (alcohol, CLD, DM, drug, manual workers) – D.D. ulnar claw handJaundice: sign decompensated CLD - seen in scleraHepatic fetor: sign decompansated CLDSpider naevi: is sign CLD- central arteriole with radiating branches – in H & N

(distribution of SVC)- > 6 in distribution SVC is pathologicalGyaencomastia: is sign CLD- other causes: physiological- drugs (cimitidine-

spironolactone)- hormonal ttt – tumors secr hs (testicular or adrenal)Encephalopathy

What are signs of decompansated CLD?EdemaAscitesJaundiceFlapping tremorsEncephalopathyBleedingFetor hepaticus

What are signs P.H.? Splenomegaly, ascites & caput medusa (rare)

What are the porto-systemic shunts? ………………………..

In abdominal palpation keep hand & forearm at same level

Where is traub’s area? Lower rib cage ant. to MAL ( Above: 6th rib, below: costal margin, lat.: MAL )

Difference between splenic & renal swelling? Splenic swelling has following ccc


cannot insinuate hand between it & C.M.not felt in renal anglecontinous with dullness over Traub’s area cannot get above itno area of resonance above it

renal swelling is the reverse

What is diagnosis of this case (CLD)? Example,Tinge of jaundice, pallor, clubbing, Liver enlarged- Rt lobe 5 cm below C.M., well defined edge, smooth surface, firm consistency, Lt lobe 5 Cm below C.M. ,………., liver span is 18 cm, spleen enlarged 7 cm below C.M., no masses felt→ Case of HSM propably CLD

Evaluation of CLD?Lab: FBC (anemia from bleeding or chr.ds, thrombocytopenia, leucopenia from

splenomegaly)T.Bilirubin ↑ (mixed but mainly indirect)AST, ALT ↑Alb. ↓Bleeding profile

Abdominal U/S: Liver size (enlarged/shrunken), spleen (N/enlarged), P.V. (P.H.), HCC

UGI Endoscopy

What are the Lethal complications CLD?hematemesisencephalopathyHCC (malignant change)SBP (spontaneous bac. Peritonitis) C/O: F & abdominal pain

What is ttt CLD?If compensated → liver supportive tttIf uncompensated → liver transplantation (according to Child score: 5items: Bil, Alb, INR, encephalopathy & ascites)

What is Koilonychia? Spoon shaped nails in iron deficiency anaemia

What is Leuconychia? White nails (due to hypoalbuminemia)

How to suspect Ascites? LL edema (Gen.exam.) & full flanks by inspection


How to examine for ascites? Mild → U/S, Moderate → shifting dullness, Severe→ fluid thrill

Causes of clubbing?1- GIT: liver cirrhosis, Inflamm.B.D., malabs.2- Resp.: Bronchial carcinoma, mesothelioma, suppurative lung ds3- Cardiac: cong. Cyanotic ht. ds, IEC4- Familial & occupational

What does oral pigmentation indicate? Peutz Jhegar syndrome = oral pigmentation + intestinal polyps

What does supraclavicular L.N. indicate? Abdominal malignancy (e.g, stomach & pancreas)

What are diseases of umbilicus?PUHMetastatic nodulesDischarge (urine or pus)Dilated veins (caput medusa) = P.H.

What are causes of Hepatomegaly?1- Inf.: viral→hepatitis B & C, CMV, IMN (EBV), Bac→T.B., abscess,

Protozoa→ Bilharz., amoeba, malaria2- Neopl.: 1ry (HCC), 2ries, lymphoma, leukemia3- Metab. & storage ds: Alcohol, Glycogen storage d, Wilson, Hemochromatosis4- CHF

What are causes of Splenomegaly?

1- Inf.: viral→ CMV, IMN (EBV), Bac→ abscess, Protozoa→ Bilharz., malaria, Leishmaniasis (Kala azar)

2- Neopl.: lymphoma, leukemia3- Metab. & storage ds: amyloidosis & sarcoidosis4- Blood ds: Hemolytic anemia

What are causes of massive Splenomegaly?1- CML2- Malaria3- Kala azar (Leishmaniasis)


4- Myelofibrosis

What are causes of HSM?1- Portal hypertension2- Inf.: viral→ CMV, IMN (EBV), Bac→ abscess, Protozoa→ Bilharz., malaria3- Neopl.: lymphoma, leukemia

What are causes of ascites?General causes: CLD, CHF (Rt VF), Nephrotic (rare), HypoalbuminemiaLocal causes: abdominal malign., T.B., chylous ascites (lymphatic obstr.) (rare)

OSCE advanced QsHow to interpret ascetic tap? Taken under complete Aseptic condition Transudate: protein < 30gm/L, due to CHF or TraumaExudate: protein > 30gm/L, due to Cirrhosis or malign.What is ttt ascites?

1- diuretics2- salt restriction3- weight reduction4- Shunts (if above failed): Lee veen shunt to IJV or TIPSS (bet P.V. & Hep V.)

What is Portal Hypertension? ↑ P.V. pr. > 10mmHg (N=5-10mmHg)→ reverse or ↓ flow in liverCauses P.H.? Extrahepatic: P.V. or Splenic v. thrombosisIntrahepatic: Cirrhosis, CHF, Bilharz.(ova obstr, portal venules), sarcoidosisIndic. Splenectomy? Trauma, Hypersplenism (hemolytic anemia, ITP, CML)Post-splenic blood film? ↑plat., ↑ WBCs. Howell jolly bodiesFunctions of spleen? Immunity (IgM & opsonization, capsulated orgs as pneumococci, H.inf, Meningococci), Bl.storage, Fe storagePost-splenectomy precautions? Vaccines (Pneumococci, H.inf, Meningococci), LAP, beware malariaWhat is jaundice? Yellowish discoloration of sclera & mucus membrane (best seen in soft palate)To see jaundice in sclera T.Bil > 50 μmol/L (N= 17 μmol/L)Causes Jaundice?

Pre-hepatic Hepatic Post-hepaticCause Hemolytic anemia

Heridetary (Gilbert ds)HepatitisDecompansated CLd

Stone in CBDCancer head of pancreascholestatic

Type Bilirubin Unconjugated Conjugated (+/- un) ConjugatedLevel Bilirubin ↑ ↑↑↑ ↑ALT ↑ ↑↑↑ ↑ALP ↑ ↑↑ ↑↑↑Investigation of jaundice case?Lab: FBC, LFT, KFT (hepato-renal), Bl.profile. , Radio: U/S (liver size, CBD dilatation), CT


Causes Post-operative jaundice? Prehepatic→bl.transfusion, Hep→anesthesia, sepsis, PostH→bilary injuryWhat is Malgaigne bulge? Bulge above lat. Part of ing.lig. with straining due to weak ms in old

D.D. Abdominal mass

D.D. mass RIF (Rt iliac fossa)?1- GIT: Cecal carcinoma (presented by persistent anemia +/- mass +/- I.O.)

Crohn’s disease2- Urinary: Ectopic kidney, transplanted kidney3- Male: Undescended testis with malignancy4- Female: Ovarian mass or fibroid uterus5- Inflammation (appendicular mass, T.B., Psoas abscess, Crohn’s) 6- L.N.

D.D. mass LIF?1- Sigmoid carcinoma (presentation acute I.O. +/- mass)2- Diverticular disease (esp, Diverticular abscess)

D.D. mass in epigastrium?1- epigastric hernia2- GIT: Lt lobe of liver, cancer stomach, cancer pancreas & pseudo-pancreatic cyst 3- Vascular: AAA4- paraaortic L.N. (esp, 2ry to testicular tumor)

D.D. mass in groin?1- Skin & SCT: lipoma, seb.cyst, impl. Dermoid cyst2- GIT: Hernia (inguinal or femoral)3- GenitoUrinary T: ectopic testis +/- tumor, transplanted kid.4- Vascular: a.→femoral a. aneurysm, v.→saphena varix, lymphatic→L.N.5- ms: psoas abscess

What is tidal percussion? Percussion of upper border of liver & differentiate from lung dullnessPercuss in intercostals spaces (4th opposite nipple in males) or from 2nd (sternal angle)Dullness found usually in 5th spaceAsk pt. to take deep inspiration & hold breathPercuss again if change note → liver, if still dull → lung consolidation

What is diagnosis of abdominal case? Example


Case 1: Mass in Rt iliac fossa, solid, welll defined edge, smooth surface, firm consistency, measure 5 X 5 cms, not reducible, not pulsatile. →Mass in the RIF & Considering age (old) have to exclude cancer by:

1- Colonoscopy & Biopsy2- CT scan3- exploration

How to manage abdominal mass suspected to be cancer?1- Colonoscopy & Biopsy2- CT scan3- exploration

How to diagnose mass RIF?U/S (to exclude ectopic kidney, aneurysm, L.N., female causes)Scrotal examination to exclude undescended testisColonoscopy & biopsy for suspected cancer cecumAbd. Exam. L.N. are multiple, irregular, rubbery (not in exam)Abd. Exam. Inflamm. (appendicular mass) Tender, signs inflamm., irregular, fixed (not in exam)

How to manage ectopic kid. (mass RIF)?Reassurance (not appendicitis)Abdominal U/S: for diagnosisIVU or Renal scan: for functionIf non-functioning → nephrectomy ????????

How to manage tumor in undescended testis?U/SCT abdomen, pelvis, chest (for metastasis)Tumor markers (α-FP, β-HCG, LDH)Prepare for exploration & orchiectomy

How to manage in normally descended testis? U/SCT abdomen, pelvis, chest (for metastasis)Tumor markers (α-FP, β-HCG, LDH)Prepare for radical orchiectomy (inguinal)

How to treat tumor in normally descended testis? Radical orchiectomy via inguinal incision


How to treat cecal mass? Exploration & asses resectabilityif resectable → Rt hemicolectomy if irresectable → palliative Ileotransverse anastomosiswhat does groin L.N. mean with cancer cecum? Infiltration of AAW

What is cryptorchidism? Absent both testes

What is difference between Undescended testis & Ectopic testis?Undescended testis Ectopic testis

Scrotum Undeveloped (not pass ext. ring) developedSites 1- abdominal

2- Int. ring3- Ing. Canal4- Ext. ring

1- Superficial ing. Pouch2- Femoral triangle3- Base of penis4- Perineum

OSCE advanced QsHow to investigate case of unilat. undescended testis with prev. exploration? Trans-aortic testic. angiography

Groin Hernia (Inguinal/ Femoral)

How to diagnose inguinal hernia?Mass in (Rt/Lt/bilat.) groinExp.imp. on cough Reducible (Reducible/ not /Partially)Example: Rt side oblique inguinal hernia non-complicated

Is ext. ring or 3 finger test used now? NO, obsolete due to pain

How to clinically differentiate inguinal from femoral hernia? Relation to P.T.Above & med. → inguinal. Below & lat. → femoral

How to define P.T.? 1st bony prominence med. To inguinal lig. (rolled) OR attachment of tendon adductor longus (flex, abd & ext.rot. thigh) على رجلرجل

How to clinically differentiate oblique from direct hernia? Internal ring test


How to do int. ring test? Better supine, standing if examiner asked locate ASISlocate P.T. (1st bony prominence med. to ASIS)locate mid-point ing.canal (int.ring) is half way between ASIS & P.T.control by 2 fingersstand & cough: if contolled → indirect (oblique) / if not controlled → direct

How to differentiate inguinal from femoral hernia? Inguinal H. Femoral H.Usually male Usually femaleAbove & med. To P.T. Below & lat. To P.T.Usually reducible & give expansile imp. Usually irreducible & no expansile imp.globular rounded

How to clinically differentiate Oblique (indirect) from Direct inguinal hernia? Oblique (indirect) Inguinal H. Direct Inguinal H.Remnant patent processus vaginalis Weak post. Wall of ing. canalPass through int. ring Pass through post. Wall of ing. canalPass through inguinal canal with cord Not in canal & not related to cordCan descend to scrotum never

What is ttt inguinal hernia? Surgery (for fear complications- as all hernias)1- Lechnestein Open repair with mesh via inguinal incision (standard)2- Laparoscopic H repair: if bilateral or recurrent

Why surgery for hernia? Because it is liable for complications

What is complications of hernia?1- Irreduciblity & inflammation2- strangulation3- obstruction of contents (I.O.)

What is complication of hernial operations? General & Specific→1- inf. (suspect mesh=F.B.)2- recurrence (recurrence in repair with mesh is < 2% = 0.5-2%)3- hematoma4- testicular atrophy5- injury of vas6- Urinary retention, pain


what is rate of recurrence in repair with mesh? < 2%

D.D. mass in groin?1- Skin & SCT: lipoma, seb.cyst, impl. Dermoid cyst2- GIT: Hernia (inguinal or femoral)3- GenitoUrinary T: ectopic testis +/- tumor, transplanted kid.4- Vascular: a.→femoral a. aneurysm, v.→saphena varix, lymphatic→L.N.5- ms: psoas abscess

What Qs can you ask for pt. with inguinal H.? ask about ppfbowel problems (ascites & chr.constipation → straining)urinary problems (BPH → straining)chest problem (chr. Cough)occupation

OSCE advanced QsWhat is position of hernia examination? It can be examined in 2 positionsStanding: should start standing to see & feel hernia easilySupine: easier to define anatomical landmarks (But NO time in exam)Causes of lost exp.imp. on cough? Omentum (omentocele), obstruction, strangulationWhat is ttt femoral hernia? Surgery (fo fear complications)

Low approach: (commonest) easy- for elective cases – risk of narrowing femoral v.McEvedy (abdominal): for emergency (strangulated H.)- pfannsteil or midlineInguinal (rare): if suspect inguinal vs femoral

What is consent for Inguinal H. repair?1- LA or GA2- Daucase surg.3- Risk of testicular damage, recurrence, hematoma, retention, pain, inf.

What are instructions to pt.?1- Early mobilization2- Keep area clean3- Avoid ppf (cough→antitussive, strain→laxative, no wt. lifting)

Epigastric Hernia

What is Epigastric hernia? Protrusion fat +/- peritoneal contents (rare) through linea alba (midway between umbilicus & xiphisternum)The usual content is fat (so called, Fatty hernia of linea alba)

How to diagnose any hernia?


Mass at anatomical siteExpansile impulse on cough (=more prominent with cough or straining)Reducible or partially reducible or history irreducibility

How to diagnose epigastric hernia?Mass or fullness above umbilicusExp.imp. on cough Partially reducible (because it contains omentum)Defect can be felt /not

What is presentation of pt. with epigastric hernia? Usually dyspepsia +/- mass

What is the ttt of epigastric hernia? Repair: longitudinal incision to repair weak linea alba & repair fatty h. of linea alba

What Qs can you ask for pt. with epig.H.? ask about ppf as above

D.D. mass in epigastrium? See above

PUH

What is difference between Umbilical & Para-Umbilical H.?PUH: beside umbilicus pushing ubmbilical scar (crescent) to side [BUT umb. scar is preserved] – usually > 40ys, ppf are ↑ intra-abd. Pr. (ascites, preg., COPD, obesity)Umbilical H.: Hernia through umbilicus itself (umbilical scar is lost) – in neonate resolve by time (usually regress before puberty) – ttt: if not corrected → Mayo oper.

How to diagnose PUH (para-umbilical hernia)?Mass above umbilicus + umb. scar preserved + scaly skin + dilated vs?????Exp.imp. on cough Reducible ( reducible/ not)

How to identify contents of hernia?Palpation →gurgling = intest. / doughy → omentumAuscultation → bowel soundsX-ray lat. → intest. Gases

What are complications of PUH? (if huge)1- Irreduciblity (if huge) & inflammation & ulceration (in huge PUH)


2- Strangulation (rare due to wide defect) (if huge)3- obstruction of contents (I.O.) (if huge)

What is ttt PUH? SurgeryMayo oper.= dissection sac, reduction &overalp lower edge over upper edge + mesh- If uncomplicated → Elective surgery (for fear complications) - If huge & irreducible → semi-urgent surgery

Incisional Hernia

What is incisional H.? Protrusion peritoeal content through weak abd. Scar (partial wound dehiscence= skin intact)

What are ppf. Of Incisional H.?Pre-oper: old, immunocompromised, cancer, abd. Distension (ascites, HSM)Oper.: poor technique, drain through same stab (should be through separate stab)Post-oper: inf., hematoma, chest inf & atelectasis

What is ttt Incisional H.?Surg: if fit, after control of ppf. → repair with mesh (good dissection sac, reduction

contents, cut sac, closure in layers +/- drain)Conservative: if unfit with persistent ppf.

OSCE advanced QsWhat are other types of H. you know & their anatomy?Spigelian, Lumbar (greater or lesser triangle), Gluteal, Obturator, Sciatic

Stoma

What type of stoma is this (Spot diagnosis)?Rt side: ileostomy, urostomy (bag contains urine) or colostomyLt side: descending colostomy (after Hartman’s or abdomino-perineal resection)

How to examine stoma? Comment onSite, abdominal scar, stoma itself (mucosa, spout or flush with skin, type (end, loop, 2 separate openings))content (urine, stool, intest.contents)Bag


Varicocele

What is varicocele? Dilated tortous pampiniform plexus of vs of testis [Rt → Rt testicular (gonadal) v. → drain to IVC] & [Lt → Lt testicul. v. → drain to Lt renal v.]

How to diagnose varicocele?Inguinoscrotal swelling or fullness (Rt/ Lt/ Bilat.)Sensation bag wormsThrill on coughEvacuated on elevation of scrotum (1ry)Example: Rt side 1ry varicocele

What is thrill? Transmitted pulsation

What are types of varicocele?1ry varicocele: 15% of male at puberty (98% Lt side)2ry varicocele: renal tumor, pelvic tumor or retroperitoneal tumor or fibrosis

Why 1ry varicocele more common on Lt side (98%)?1- Lt testicular v. more vertical2- Lt testicular v. liable to compression by colon3- Lt testicular v. longer4- Lt testicular v. has no valves at its termination

What is presentation of varicocele (what bring pt. to clinic)?1- pain2- infertility

How to investigate pt.? varicocele is clinical diagnosis butScrotal DuplexSemen analysis

What is ttt varicocele?Surgery: because it worsen with age (till surgery use Conservative: scrotal support & avoid long standing)

1- Open Surgery2- Laparoscopic ligation3- Transfemoral embolization


What are approaches for Open varicocelectomy?1- high approach (Balomo): (complics: hematoma, recurrence, 2ry hydrocele)2- Inguinal approach: not done now3- Subinguinal:

Hydrocele

What is Hydrocele? Accumulation of excess fluid in part or whole of processus vaginalis

How to diagnose hydrocele?Non-tender purely scrotal swellingFluctuant (cystic)Translucent (Transimmunable) (clear) or not (due to complication)No testicular massesExample: Rt side 1ry vaginal Hydrocele not complicated

What are types hydrocele?1ry: due to patent processus vaginalis (4 types)

1- Vaginal: fluid in tunica vaginalis2- Encysted Hyd. Of cord: fluid in unobliterated part of proc.vag. around cord3- Cong Hyd.: fluid in all proc. vag. & communicating with abdomen4- Infantile Hyd.: fluid in all proc. vag. & NOT communicating with abdomen

2ry: Post-oper. (varicocele, hernia), inf. or testicular tumor

Why some hydroceles are not translucelt (transimmunable)? Complications

What are complications of hydrocele?Inf. , hge, rupture (rare)

Why this hydrocele 1ry (no tumors)? Age (old) & no testicular masses

What if bilat. Hydrocele? Do abdominal examination

Why not aspirate hydrocele anymore? NO, due to high incidence inf. & recurrence

How to differentiate hydrocele, encysted hydrocele of cord & spermatocele (sperm cyst)?


hydrocele: purely scrotal, not separable from testis, fluctuant, translucent / notEncysted H cord: scrotal, separable with space bet. It & testis,……..Spermatocele: scrotal, separable from testis by small gap,……….

What is ttt Hydrocele? Ask pt. How it affect his life1- Conservative2- Surgery: Lord (placation) or Jaboulay (excision excess sac)3- Aspiration: → recurrence & inf.

Epididymal Cyst (Spermatic cyst) (Spermatocele)

What is epididymal cyst?Cyst in head of epididymis (retention cyst)If full with sperms called Spermatocele (opaque) may be complication of vasectomy

What is ttt Epididymal cyst?1- Conservative: for fear fibrosis → infertility2- Surgery: if pain or cosmetic by Excision (rarely may need epididymectomy)

Pilonidal sinus

What is pilonidal sinus? Sinus +/- inf. At site of a hair in natal cleft

What is ttt pilonidal sinus? Conservative: good hygiene, shave, keep drySurgery: drainage if abscess

What is complication of drainage pilonidal sinus & how to treat?Recurrence & ttt by open technique


ORTHOPEDICSExamine this pt. L.L.? (open Q) = Vascular + Orthopedic + Neurological + L.N.

Lumbar Spine

What is pathology of lumbar disc prolapse? Rupture nucleus pulposus & herniation through annulous fibrosus

LOOK:

Why inspection of SC swellings is important in spine case?Multiple neurofibromatosis are neuromas from n.sheath that can compress n.roots → C/P similar to disc prolapsePresented by multiple swellings & caffe au lait patches

How to level tender spinal segment? Line between liac crests at L4,L5At level = L4-L5 disc & below = L5-S1 discIf above = high lumbar disc L2-L3 or L3-L4(rare), if even above (last rib)= lower dorsal disc (v.rare)

In pt. with scoliosis, How to differentiate spine pathology from lowerdown causes by inspection? By leveling iliac crests (detect pelvic tilt)Put thumbs on level at iliac crestsIf no pelvic tilt (iliac crests leveled) → spine pathologyIf pelvic tilt (iliac crests not leveled) → lowerdown pathology (e.g, hip adductor deformity) → short limb → pelvic tilt same side & compensatory scoliosis other side)

Scoliosis may be on same or other side of spine pathology

How to differentiate spine problem from hip problem by lumbar lordosis?Spine → loss of lordosis (flattened) due to paravertebral ms spasmHip → hyperlordosis compensatory to fixed flexion deformity (or severe kyphosis)

What if calf wasting found during inspection of spine? May be reflex wasting(confirm later by measurement (while supine))

Can calf wasting occur with knee pathology? Yes, as reflex wasting


What is difference between Sciatic list & scoliosis? Only X-ray findingSciatic list: is a one plane deformity (pedicles equal & lined up at both sides)Scoliosis: is a 3D deformity (pedicles not equal & not lined up)

GAIT

Types of abnormal gait you know?Antalgic gaitTrendlenburg gaitHigh steppage gait in common peroneal nerve injury (common) or sciatic (rare)High steppage gait in Hemiplegia Shuffling gait in parkinsonismlimbing gait in short limb

- You can say abnormal gait if donot know type ?????????

What are common gait abnormalities in spine?Normal: most commonHalf shut knife: keep nerve away from its root ½ مفتوحة غزال قرن مطواةHigh steppage gait: due to foot drop in L4,L5 disc prolapse (rare because emergency)

What are common gait abnormalities in hip problem? Trendlenburg or antalgic

What are common gait abnormalities in knee problems? antalgic

MOVE

Comment on movement? full range mvt (……-….. degrees) & painlessor limited mvt (……-….. degrees) due to painor limited mvt (……-….. degrees) due to mechanical block (rare)

How to test for lat. rotation? Rotation is performed at dorsal spine (thoracic vertebrae) & may be limited in acute disc prolapseSit down (to fix pelvis)Range is normally 45 degrees

Why test for lat. rotation?


1- check joint above (dorsal spine)2- may be limited in acute prolapse (by severe paravertebral ms spasm)

SPECIAL TESTS

Value of SLR (straight leg raising test)?1- Active SLR = knee stability test for extensor mechanism (quadriceps muscle , quadriceps tendon, patella, patellar tendon & tibial tuberosity).2- Passive SLR (Lasegue test) = for sciatic stretch (L4,5, S1)

Passive SLR interpretation? If pain below knee (e.g, calf muscle) → +veIf pain above knee (hamstring) → -ve (may be due to spondyolitis or disc)

Site of pain (not imp)? Inside of leg= L4, outside of leg = L5, dorsum of leg = S1

What are sciatic nerve tests? SLR & sciatic stretch test

What is crossed leg raising test? SLR of one side causes pain on other side below knee. So stop test and 10 degrees below perform sciatic stretch testDue to huge central disc (usually L4,5) with more prominence to one sideMore sensitive test to spine than SLR

Is SLR specific to spine? NO, SLR may be +ve in spine or hip problems BUT, crossed leg raising test is specific to spine

NEUROLOGICAL EXAMIN.

What is main root affected in disc? The nerve below disc is the main root affectedL4-L5 disc → mainly L5L5-S1 disc → mainly S1

What is full neurological exam.? SLR & neurological (sensory, motor & reflexes)

How to perform full neurological examination of LL?1- SLR test: part of neurological examination (to know side of disc compression)2- Sensory (Dermatome)3- Motor Power (Myotome)4- Reflexes


What to do if hyosthesia of L1? affected L1 = high disc or combined disc. → Test sensory level at umbilicus (T10),

Where is autonomus area of L5? 1st web space

How to test for knee reflex? L2,3,4 (mainly L3)Flex &elevate knee with Lt hand and ankle just touch couchTap on patellar tendon & look at quadriceps ms -may do clenching of teethIntact or absentCompare both sides (may be absent bilaterally = normal)

How to test for ankle reflex? S1Ext. rotation leg & dorsiflexion of ankle (to stretch tendoachilis)Tap on tendoachilis & look at calf ms -may do clenching of teethIntact or absentCompare both sides (may be absent bilaterally normally)

How to interpret reflexes?Bilat. Absent knee or ankle → NormalUnilat. Absent reflex → root affectionUnilat. Exaggerated reflex → UMNL

What are characters of UMNL & LMNL?UMNL: ms weakness, ↑ tone, hyperreflexiaLMNL: ms weakness, ↓ tone, hyporeflexia

PRONE

When & how to perform femoral stretch test (Reverse Lesague test)? If suspect high disc (L2-L3 or L3-L4)Prone position & flex knee then extend hipIf pain infront thigh → +ve

How to suspect high lumbar disc?Tenderness above iliac crests (above L4, 5)Dermatome & Myotome affection at L2-L3 or L3-L5Lost knee reflex → confirm by Femoral stretch test


Why examine joint above & below? For referred pain

Why neurovascular examination? For priority of ttt (PVD or neurological previous to orthopedic intervention) & differentiate spinal from vascular claudications

Table for low lumbar disc prolapse (common in exam)?

L4-L5 disc prolapse L5-S1 disc prolapseMain root L5 S1Dermatome(Sensory)

Med. leg (L4)Lat. leg & 1st web space (L5)

Lat. leg & 1st web space (L5)Sole (S1)

Myotome(Motor power)

Ankle dorsiflexion (L4)Big toe dorsiflexion (L5)

Big toe dorsiflexion (L5)Ankle plantar flexion (S1)

Reflexes ------------- Ankle reflex (S1)

What are indications of urgent intervention in disc prolapse?1- foot drop2- cauda equine lesion (usually presented by retention)

What is urgency of cauda equine lesion? Irreversible if no urgent intervention → retention early & incontinence laterCan present as isolated lesion

Diagnosis, D.D. & management

Diagnosis of spine case? (in spine & Knee we reach diagnosis by examination unlike hip diagnosis is hip problem needs X-ray) for example,Rt Backpain with tender segment at L4-L5 level, sensory affection at level L4-L5 myotome affection at level L4-L5 → nerve root L4,L5 affection due to acute disc prolapse

How to manage? (in investigations start by cheap & non-invasive)Lab: ESR, CRP, ASOT, Rheumatoid profile X-ray: plain X-ray spine 2 views at leastCT: If suspect fracture (better 3D CT) MRI: If suspect pathology

What is TTT?Conservative ttt: bed rest, analgesic (NSAIDs+SMR), lifestyle modif., physiotherapySurgery: if failed conservative ttt inform of Diskectomy +/- Laminectomy


(after general assessment for fitness to surgery)

D.D. Spine pathology?Disc prolapse (most common)Cong.: spondylolithiasis, spondylolysisTraumatic: fracture, spondylolithiasisInflammatory: T.B. (rare)Neoplastic

What is common pathology involving different spine levels?1- lumbar area: disc prolapse2- Dorsal area: trauma3- Dorso-lumbar: T.B. or metastasis

HIP

What to do if examiner asked to examine Rt hip?“ I should start examination by the normal (Lt) side”Examiner will propably ask to stick to Rt side

LOOK

Can you examine hip in supine position? Yes, if pt. cannot stand or examiner asked. but will skip: pelvic tilt & scoliosis by inspection, trendlenberg test, gait.

Scars? Lat.=lat. Exposure, Anterolat.=anterolat.exposure, posterolat.=posterolat. Exposure, Iliac crest= donor site for bone graft 2scars at knee joint line = arthroscopy 2 scars at tibial tuberosity = skeletal traction to keep limb length Midline scar = total knee replacement

If Scar healed by 2ry intention.What does it mean? inf.

What is cause of pelvic tilt? Hip problem or limb shortening

What is cause of scoliosis in this case? Compensatory to pelvic tilt & to other side


What is compensatory scoliosis? scoliosis on opposite side of pelvic tilt

Cause of compensatory lumbar hyperlordosis?1- compensatory to fixed flexion deformity of hip2- compensatory to severe dorsal kyphosis

How to differentiate structural from scoliosis? By sitting down1- Compensatory scoliosis will be corrected2- Structural scoliosis will remain

What does compensatory scoliosis & Hyperlordosis mean? Long term pathology

Cause of compensatory lumbar hyperlordosis (exaggerated lordosis)?1- compensatory to fixed flexion deformity of hip2- compensatory to severe dorsal kyphosis

Wating of hip ms start by which part? Glutei then hamstring then quadriceps

What is cause of Severe Glutei wasting? T.B. (rare) usually with sinus back of hip

SPECIAL TEST → GAIT

What are common gait abnormalities in hip problem? Trendlenberg or antalgic

What does trendlenburg test asseses? Function of hip abductors (gluteus medius & minimus) on side pt. standing on, which supports elevated side (action paradox) -SSS (sound side sags)

Why trendlenburg before gait? If +ve → Trendlenberg gait, if –ve →antalgic gait

What is meant by antalgic gait? Painful gait due to short stance phase of gait due to pain of knee or hip

Phases of gait? Heel strike - stance (heel & toes on ground) – toe off - swing

Effect of weak hip abductors? Unilateral → trendlenburg gait, Bilateral → waddling gait

SPECIAL TEST → MOVE


How to detect common hip deformities?1- Flexion deformity (weak extensors): by Thomas test2- Adductor deformity (weak abductors): by apparent length

What is Thomas test? Test for fixed flexion deformity (weak hip extensors)Put hand behind pt. spine to feel obliteration of compensatory hyperlordosis (to fixed flexion deformity).Flex one limb & notice flexion of other limbIf other hip flexed (elevated from couch) = +ve Thomas test (fixed flexion deformity due to weak hip extensors)

What is cause of bilat. FFD? Ankylosing spondyolitis (also there is kyphosis) (D.D. with disc prolapse)

How to differentiate FFD hip or knee? By knee extensioncan extend knee = Hip FFD cannot extend knee = Knee FFD

How to test hip movement? do passive only- fix hip by Lt hand & elbow to avoid pelvic rotation

test for hip flexion? While knee flexed to relax hamstring

test for hip extensors? in prone position (do not test in side where FFD found)

Test for hip rotation? While hip 90° & knee 90° to relax all ligaments & muscles.

MEASURE

What is difference between true & apparent length?True length: measure length of bonesApparent length: measure length of bone & soft tissues

How to find ASIS? 1st bone from inguinal ligament

What if shortening in apparent length but normal true length? This meansMuscle deformity (usually adductor deformity → short limb)


What if shortening in apparent length & true length? This meansBone shortening (true) → femur or tibia →if femur → supra- or infra-trochanteric

How to detect Femur vs Tibia shortening without measurement? Rough testKnee to 90 degrees & heels together → limb in lower position is shorter

What does Supratrochanteric length include? Head femur, neck femur & acetabulum

What are causes of supratrochanteric shortening? Head femur (Fracture), neck femur (avascular necrosis) or acetabulum (Fracture)

What is ttt of short limb?Heel raise, crouches or correction osteotomy (may be hidden if < 2cm)


Diagnosis of hip case? For examplepainful limited movement (…., ….., ….), fixed flexion deformity by Thomas test, adductor deformity by difference between apparent & true length, & true shortening→ Rt hip problem (for investigation)

D.D. hip problem?1- cong.: slipped upper femoral epiphysis (SUFE), Cong.dislocation (CHD)2- Tr.: Fracture acetabulum, head of femur, neck of femur3- Inflammatory: Osteoarthritis (old pt.) or rheumatoid arthritis or T.B.4- Neoplastic5- avascular necrosis of femoral head (young)

How to manage?Lab: ESR, CRP, HLA-B27X-ray: plain X-ray hipIf suspect fracture → CTIf suspect pathology (ankylosing sponyolitis) → MRI

What is TTT? 1- conservative ttt: bed rest, analgesic, lifestyle modification2- Surgery: ………….(if failed conservative ttt) (after general assessment for fitness

to surgery)


What are surgical options for osteoarthritis of hip?Osteotomy – Arthroplasty (hip replacement) – Arthrodesis (=fix joint, rare now, used

if contraindication to arthroplasty)

What are complications of THR (total hip replacement)?How to prevent peri-operative DVT after THR?

KNEE

What to do if examiner asked to examine Lt knee?“ I should start examination by the normal (Rt) side”Examiner will propably ask to stick to Lt side

LOOK

Can you examine knee in supine position? Yes, if pt. cannot stand or examiner asked. but will skip: gait.

Scars?2 dimples on joint line: arthroscopy scars for 2 ports of arthroscopeScar on tibial tuberosity: site of skeletal traction to keep limb lengthScar on iliac crest: donor site for bone graft

Cause of sinus ? Inf. = Osteomyelitis O.M. or T.B. (rare).

Healed sinus? Healed SC inf.

Warmth? Inf. -Superficial= cellulites or -deep= O.M.

Swelling? Generalized = effusion or localized = bursa (e.g, infrapatellar)

Discolouration ? Hemoarthrosis (acute trauma).

Wasting of quadriceps starts by which part ? Vastus medialis.

Where to inspect for wasting? Vastus medialis (first muscle of quadr.gr to be wasted)


Knee deformity ? Genu varum =bow leg, Genu valgum=knock knee, Genu recurvatum=hyperextended knee (due to lax ligaments). Fixed flexion deformity=

WALK

What is common gait abnormalities in knee problems? Antalgic

What is meant by antalgic gait? Painful gait due to short stance phase of gait due to pain of knee or hip

FEEL

What is cause of tenderness during examination? Usually meniscal inj.Med.= usually med. meniscus inj., Lat. = usually lat. meniscus inj.In young → TraumaIn old → Osteoarthritis (meniscus degeneration)

What are causes +ve grinding test (tender patella)?Move patella on femur in 2 vertcal planes. If +ve =Young → chondromalacia patella (rare)Old → Patello-femoral Osteoarthritis (common)

MOVE

Test for Movement start by? Active then passive to avoid eliciting tenderness

Why passive test? To complete range to differentiate limited range due to pain or mechanical blockif due to pain → stopif due to mechanical block (e.g, myositis ossificans)→ try to complete range (rare)

What is tibial tuberosity? Part giving attachment to patellar tendon

Patellar tap test? For detection of moderate knee effusionLt hand press suprapatellar pouchRt hand firm continous pressure on patella (sharply) & notice ballotment


Stroke test (bulge test) (visible fluctuation)?For detection of mild knee effusionEmpty medial side knee from below upwardsSwipe across lateral side & notice medial bulge

Cross fluctuation test of knee?For detection of severe knee effusionLt hand press suprapatellar pouchRt thumb at side & rest of fingers on other press upwards & recieve fluctuation by Lt

How to differentiate knee effusion from pre-patellar bursa?By contraction of quadriceps ms (knee extension)If swelling ↑ → pre-patellar bursa (infront patella)If swelling ↓ → effusion (communicate to joint)

What is cause of effusion? Sympathetic (2ry to cruciate lig. or meniscal Inj.)

SPECIAL TESTS (KNEE STABILITY + McMURRAY)

Role of knee ligaments? Cruciate → prevent anterior-posterior displacement of tibia Collateral → prevent side displacement

How to examine extensor mechanism of knee? Active SLR test

What is value for active SLR? Test for extensor mechanism of knee. if +ve → weak ext. mechanism (5components)

1- quadriceps muscle2- quadriceps tendon3- patella4- patellar tendon5- tibial tuberosity

How to determine the affected part of extensor mechanism?Feel the 5 components for defect or tendernessIf no defect or tenderness → weak ms

Why in stress valgus or varus knee at 0o then at 20o ? To abolish effect of ACL, PCL, postero- capsule of knee (knee locking mechanism)

At 0 degrees stability of med. joint is by med. collateral lig., ACL, postero-med. capsule. So, +ve → combined inj. = severe trauma


At 0 degrees stability of lat. joint is by lat. collateral lig., PCL or ACL, postero-lat. capsule. So, +ve → combined inj. = severe trauma

At 20 degrees stability is by collateral lig. Only. So, +ve → isolated collat. lig. inj.

Posterior sag +ve. What does it mean? Complete PCL tear

Posterior sag –ve & posterior drawer +ve. What does it mean? Partial PCL tear

Why do posterior sag test before anterior drawer? To avoid false +ve ant. drawer

If +ve drawer test does it mean ACL inj.? NO, have to compare with other sideIf bilat. +ve → lax ACLIf unilat. +ve → torn ACL

Examine ACL? Start by post. Sag test1- post. Sag test: to avoid false +ve

ant. drawer2- Ant. drawer test3- Lachman test 4- Pivot shift

(idea)

Other tests for ACL? Lachman test (difficult than drawer test) & Pivot test (idea)mild flexion of kneeexaminer thigh below pt. kneehand on femur to fix & hand on tibia to move (keep hands A-P near joint to control)pull tibia up on femur

)Can be modified also to examine PCL(

McMurray test? For meniscal injuryIf pain or feel click → +ve because detached tag of meniscus dislodge from trap site between femur & tibia

Is McMurray test specific to meniscal injury? No, +ve if synovial fold or loose body in joint

if +ve McMurray test does it mean meniscal inj.? NO, have to compare with other sideIf bilat. +ve → lax meniscusIf unilat. +ve → meniscal inj.


MEASURE

Measurement of quadriceps circumference. Why 15 cm above patella?1 -above suprapatellar pouch to avoid effusion

2 -site of muscle bulk

Normal variation in thigh circumference? < 2 cm (but have to mention)

What to do for pt. with knee C/O? MRI or arthroscopy


D.D. Knee problems?D.D. Knee Pain

Cong.:Tr.: Cruciate lig. inj., Collat. lig. Inj. or meniscal inj.Inflammation: Osteoarthritis, Rheumatoid arthritis or T.B. (rare)

Knee stability: weak extensor mechanism (5 components), Lig. Or meniscal inj.Knee swellings: ant. knee or post. Knee (bursa or cyst or effusion)

D.D. Knee swelling?

Ant. knee: Pre-patellar bursa (Housemaid bursa), Infrapatellar bursa (Klegerman’s) or Effusion

Post. Knee: Above j.line (Med.) → Semimembraosus bursaBelow j. line → Baker cyst (old & patho. As Rh.Arth. or T.B.)

Popliteal cyst (Young & no patho.)How to diagnose bursa? Fluctuation & Transillumination

What is TTT bursa? Conservative or Aspiration or Excision

How to manage?Lab: ESR, CRP, HLA-B27X-ray: plain X-ray kneeIf suspect fracture → CTIf suspect pathology → MRI

What is TTT? 1- conservative ttt: bed rest, analgesic, lifestyle modification


2- Surgery: ………….(if failed conservative ttt) (after general assessment for fitness to surgery)

What are surgical options for osteoarthritis of knee?Osteotomy – Arthroplasty (hip replacement) – Arthrodesis (=fix joint, rare now, used

if contraindication to arthroplasty)Arthroscopic debridement & washout of meniscal debris & osteophytes

What are surgical options for Rh.Arthritis of knee?Osteotomy – ArthroplastyArthroscopic synovectomy & debridement

What are complications of total knee replacement ?

What are X-ray findings in Osteo-Arthritis?1- peri-articular osteoprosis (in O-A osteosclerosis)2- narrow joint space 3- destruction & subluxation joint

no new bone formation (no osteophytes) unlike O-A

What are stages of Rh.Arthritis? Proliferative → Destructive → Reparative

What are X-ray findings in Rheumatoid Arthritis? LOSS1- Loss of joint space2- Osteophyte formation3- Subchondral sclerosis4- Subchondral cysts

RHEUMATOID HAND & FOOT

What is rheumatoid arthritis? Part of rheumatoid disease usually affect hand or footPathogenesis: 1- synovitis (inflamm. Synovial fluid of small joints mainly)2- tenosynovitis (synov. fluid + tendon) → atresia & rupture of tendons (1+2 → deformity small joints & long tendons of hand)


Why affect long tendons rather than short? Because of much synovial sheath around → more tenosynovitis → more tendon rupture

LOOK

Scar?Wrist & palm (ulnar side of thenar ms 2 cm from distal wrist crease)= carpal tunnelWrist, Palm & finger = tendon repair2 scars on med. side forearm? Donor site for tendon repair (palmaris longus)

Why carpal tunnel scar upto 2 cm from wrist crease only?1- end of carpal tunnel (base of abducted thumb)2- to avoid deep palmar venous arch inj.

Why with rheumatoid may be wasting of all ms? Disuse atrophy

How to differentiate wasting due to rheum.Arth. from that due to n.inj?n.inj. → wasting specific group msdisuse atrophy → wasting all groups ms

Common hand deformity in Rheumatoid arthritis?Ulnar deviation of fingers (MPJ) & compensatory radial deviation of Wrist (Zig-Zag

mech.) (pathognomonic to rheumatoid hand)Swan-neck: rupture tendon FDS → PIPJ extended & DIPJ flexed by FDP (compens)Boutonniere deformity: rupture central slip of extensor expansion → PIPJ flexed &

DIPJ extended by 2 distal slipsZ-thumb: rupture Fl.Poll.longus tendon → MPJ flexed & IPJ extendedMallet finger: rupture extensor tendons → DIPJ flexed & cannot be extended except

passively (IPJ normal)Trigger finger (Stenosing tenosynovitis): inflamm.nodule prevent active extension of

finger PIPJ & DIPJ(cannot be extended except passively with lag & snap)

Piano key sign: subluxation of lower radio-ulnar joint → popup lower ulnaMPJ swellings (nodules or subluxation of head metacarpals)

What is trigger finger?Nodule at MPJ → lag on finger extension with snappingNodule can be felt at MPJ at distal palm crease

What are knuckles? Head of metacarpals


What are types of flexion deformity?1- fixed deformity: cannot be corrected (by feel) d.t. bone or joint patho. ttt: correction osteotomy2- mobile deformity: can be corrected (by feel) d.t. imbalance between fl. & ext.

Swelling in MPJ rheumatoid hand?Usually at MPJ due to Synovial swelling (synovitis) → soft swelling Displacement of knuckles (head of metacarpals) → hard swelling

Why there may be no rheumatoid nodules? Pt. under ttt

What type of bursa is common with rheum.Ar.? Olecranon bursa (so, must expose elbow) If found swelling → Transillumination If +ve = bursa

How to manage olecranon bursa?Transillumination → +ve, confirm by U/Sttt → Conservative or aspiration under complete aseptic condition

MOVE

Test for tendons?Test for FDS: extend other fingers & ask pt. to flex tested finger (stop mass action of

FDP)Test for FDP: fix middle phalanx of same finger & ask pt. to flex distal phalanx (stop

action of FDS)

What if flexion lost in PIPJ & DIPJ? Rupture tendon both FDS & FDP

What are the Flexors of thumb? Fl.Poll.Brevis → MPJ, Fl.Poll.Longus → IPJ


Diagnosis of rheumatoid hand case?Lesions of small joints & long tendons of hand inform of (ulnar deviation of fingers & rad.dev. wrist, finger drop middle finger, swan neck ring finger, Z-deformity of thumb)


→ Rheumatoid hand Notice that rheumatoid hand is usually bilateral & symmetrical (but not in exam)

How to manage?Lab: FBC (anemia), ESR, Rh.F.X-ray: (plain X-ray hand)

What are local complications of Rheumatoid arthritis in hand?1- carpal tunnel syndrome: d.t. thichened tendons2- rupture long tendons

How to test flexor tendons?1- FDS: fix other fingers & flex only the one examined2- FDP: fix middle phalanx by 2 fingers (to stop action of FDS)

What are X-ray findings in Osteo-Arthritis?4- peri-articular osteoprosis (in O-A osteosclerosis)5- narrow joint space 6- destruction & subluxation joint

no new bone formation (no osteophytes) unlike O-A

What are X-ray findings in Rheumatoid Arthritis? LOSS5- Loss of joint space6- Osteophyte formation7- Subchondral sclerosis8- Subchondral cysts

How to examine foot of Rheumatoid arthritis? Expose till kneeLook: skin, SCT → swelling = adventitious bursa due to dislocation of talus & friction (Bunion is bursa at MPJ of big toe) Muscles of foot (beware pes cavus) Deformity - Hallux valgus (medially deviated metatarsal head of big toe) -

- Hammer toe (Flexed MTPJ & Extended IPJ)- Claw toe (flexed MTPJ & IPJ)

FEELMOVE (ankle j.)


Hallux Valgus

What is hallux valgus?medially deviated metatarsal head of big toe + lateral rotation of big toe (usually bilat.

What is TTT of hallux valgus?1- Conservative: wear wide medical shoes 2- Surgery: (if pain or cosmetic) By correction osteotomy

What are complications of hallux valgus?BunionHammer 2nd toe

What is Hallux rigidus?Stiffness & pain of 1st metatarso-phalangeal joint (due to osteoarthritis) → no take-off phase

What is Bunion? Protective bursa at pressure areas (e.g, hallux valgus)

NERVE INJURY

If asked to examine hand. How to suspect n. inj. by inspection?Claw hand → ulnar n.inj. & D.D.Wasted Thenar (ape hand) → median n. injWrist & Finger drop (cannot be extended) → radial n.inj. (finger drop at MPJ is specific but wrist drop is according to level of inj.)

Why look (inspection) is imp.? For scars of inj. or surgery

Why ask for tender area in scar causing n.inj.? painful neuroma

How 3 nerves enter forearm? BetweenUlnar: between 2 heads of flexor carpi ulnarisMedian: between 2 heads of pronator teresRadial: between 2 heads of supinator

What are autonomus area of 3 nerves?Ulnar: middle & distal phalanx of little finger


Median: distal phalanx of index & middle fingerRadial: dorsal 1st web pace

Ulnar nerve

Course of ulnar nerve?Branch of med. Cord Br.Plex.Enter forearm between 2 heads of flexor carpi ulnarisIn forearm supply → FCU & med. ½ FDPPass in Guyan’s canal = ulnar tunnel (above flexor retinaculum & covered by a slip of

it) & gives palmar cut.branchIn hand supply → all hand muscles (except LOAF)= med. 2 lumbricals + interossei +

hypothenar + adductor poll. → sensory to med. palm & med. 1+1/2 fingers ant. & post.

What is group action of small ms of hand? Writing position (MPJ flex. & IPJ ext.)

LOOKWhy ulnar nerve inj. causes partial claw hand? Due to paralysis of med. 2 lumbricals & all interossei → unapposed action of long flexors → claw hand of med. 2 fingers (partial = not all fingers & not degree of paralysis)

Can thenar atrophy occur with isolated ulnar injury? Yes, some wasting due to adductor pollices wasting

What are types claw hand?1- Partial (med. 2 fingers) due to ulnar injury2- complete (med. 4 fingers) due to ulnar & median n. inj.

D.D. (causes) of claw hand?

A- Partial Claw Hand (med. 2 fingers)1- Ulnar n.inj.: clawing med. 2 fingers (ext. MPJ & flex. PIPJ+DIPJ)2- Duputyren contracture: clawing ring +/- little fingers due to cord like thickening of

palmar fascia (but motor & sensory intact)- Flex. All joints (PIPJ+DIPJ+MPJ)- Band of fibrosis felt below MPJ- no sensory or motor affection


A- Complete Claw Hand (med. 4 fingers)1- Combined ulnar & median n.inj.2- Volkman’s contracture: clawing med. 4 fingers due to ischemia of muscles of

flexor compartment due to tight cast or trauma → bone fracture or vessel inj. (volkman can affect any compartment)- Flex. All joints (PIPJ+DIPJ+MPJ)- extension → ↑ deformity & flexion → ↓ deformity- no sensory or motor affection

3- Klumpke’s paralysis (Lower trunk Br.Plex.):4- Others: advanced Rh.Arth. or spinal cord lesions

What is ulnar paradox?The higher the lesion, the less the deformity (less clawing) (reverse to normal)Because in higher lesion → paralysis med. ½ FDP → weak flex. → less clawing

Muscles of 1st web space? Wasting of 1st web space means:Palm: adductor pollices (ulnar)Dorsum: 1st dorsal interosseus (ulnar)

SENSORYWhat is cause of lost sensation little finger but intact palm sensation? Palmar cut. Branch inj. only

MOTOR & SPECIAL TESTHow to test for adductor poll. ? Froment’s test: when catch paper between thumb & other fingers have to flex thumb (due to weak adduction)N.B. if cannot catch paper at all = combined ulnar & median n.

How to test for palmar interossei? Finger adduction (PAD). if weak → +ve → do card test

LEVEL OF INJURYWhat are common sites of ulnar inj.?1- Elbow (High): supracondylar Fr., degenerative arthritis or tunnel syndrome

(repeated flex. Of elbow, O-A, Fr) or 2- wrist (Low): Trauma, ulnar tunnel syndrome (ganglion or Fr. hook hamate)

How to detect level of ulnar nerve injury?


1- scar2- degree of deformity (Ulnar paradox: higher lesion → less deformity)3- wasting med. forearm = higher inj. (FCU & ½ FDP wasting)4- test for med. ½ FDP & FCU (see below)

How to test for flex.carp.ulnaris (FCU)?Flexion & ulnar deviation of wrist & feel tendon

How to test for med. ½ FDP (supplied by ulnar)? Med. ½ of FDP flexes little & ring fingers (mainly little to avoid overlap)Fix middle phalanx of little finger & ask pt. to flex distal phalanx (To block effect of FDS on middle phalanx)

Median nerve & Carpal tunnel Syndrome

What is course of median nerve?Branch from med. & lat. CordEnters forearm between 2 heads of pronator teresIn forearm → muscles ant. Compartment (except med. ½ FDP & FCU) [FDS, lat. ½ FDP, pron.teres, pron.quadr., Fl.poll.longus, Palm.longus(+/- absent)]Enter hand in carpal tunnel (under flexor retinaculum)In hand supply → LOAF (2 lat. lumbricals + thenar (opp.poll., abd.poll.br.,

flex.poll.br.)) → sensory to lat. palm & lat. 3+1/2 fingers ant & post.

SENSORYWhat in carpal tunnel affected sensation fingers but intact palm sensation? Because palmar cutaneous branch of median arise before carpal tunnel & pass above it

MOTORHow to test for abduct.poll.br.?Rest hand on table (to block action of abduct.poll.longus coming from dorsum)Ask pt. to raise thumb away from table against resistancefeel Abduct.poll.br. (the most lat. Muscle of thenar group

What are nerves cause thumb abduction? abductor poll. Brevis supplied by median n.abductor poll. Longus supplied by radial n.


LEVEL OF INJ.What are common sites of median inj.?Elbow: dislocation, Fr, Pronator teres syndromeForearm: Fr. → inj. ant. interosseus n.Wrist: Tr. Or carpal tunnel syndrome

How to test for FDS?Fix all fingers except finger examined & ask pt. to flex it (same for all med.4fingers)Because FDP has mass action (needs 2 fingers intact at least to act)

How to test for lat. ½ FDP (supplied by median n.)?Lat. ½ of FDP flexes middle & index fingersFix middle phalanx of middle finger & ask pt. to flex distal phalanx (same for index)To block effect of FDS on middle phalanx

How to test for pronator teres & pronator quadratus?Fix elbow (to avoid med. Rotation of shoulder)Ask pt. to rotate wrist towards inside

Carpal tunnel Syndrome (CTS)What is CTS? Compression of median n. due to swelling Fl. retinaculum

Causes? Ganglion, lipoma of wrist, Colle’s Fr., Rh. Arth., gout, DM, Alcohol, Fluid imbalance (preg., hyperthyroidism)

Diagnostic tests? Phalen test & Tinnel test

Radial nerveCourse radial nerve?Branch of post.cord Br.Plex.It gives branches before entering compartmentsEnters forearm between 2 heads of supinator In arm → triceps & lat. ½ brachialisIn forearm → posterior interosseus → muscles forearm & → superficial radial → sensory to dorsal 1st web & lat. 3+1/2 fingers MOTORHow to examine wrist & finger extension? In prone position (against gravity) & fix proximal joint


Why wrist extension not completely lost in post. Inteross. Inj.?Because main radial supplies ABC (anconeus, ext.carpirad.longus & brachioradialis)

Is finger extension lost completely?NO, Finger extension is lost at MPJ, BUT, fingers can be extended at IPJ if MPJ fixed (by lumbricals which are weak extensors act only on IPJ)

LEVEL OF INJ.What are common sites of Radial n.inj.?Axilla (High): Saturday night palsy (neuropraxia by arm over back of chair)Midhumerus: Fr. (spiral groove)Elbow (Low): Fr. or dislocation → post. inteross. Inj.

How to detect level of nerve injury?- injury at axilla → wrist drop & finger drop- injury at head of radius (post.inteross.) → finger drop & weak wrist extension (but intact sensory)

Why wrist extension not completely lost in post. Inteross. Inj.?Because main radial supplies ABC (anconeus, ext.carpirad.longus & brachioradialis)

SHOULDER (rare)

What are causes of painful abduction?1- Pain in initiating abduction (0-30) → rotator cuff tear2- Pain (60-120) (painful arc) (impingment syndrome) → rotator cuff tendonitis or

minor tear3- Pain (120-180) (painful high arc) → ACJ osteoarthritis

What are ms of rotator cuff? SITS (supraspinatus, infraspinatus, teres minor, subscapularis)

How to determine site of pathology? According to site of painAnt. & med = sternoclavicular j.Ant. & lat. = acromioclavicularPosterior = scapular osteophytes

If painfull all range of abduction? Acromioclavicular osteoarthritis


If painful all shoulder movements? Acute Frozen shoulder. Later painless

What is painful arc? Painful range of abduction (e.g, 40 - 90 degrees) with no pain before or afterdue to supraspinatus tendonitispathology: supraspinatus tendon pass below acromioclavicular arch. Friction → inflammation → bursitis → atresion → rupture

What is pathology of frozen shoulder?Capsulitis → adhesions → early: painful limited all movements of shoulder → later: painless limited all movements of shoulder

What is apprehension test?Test for recurrent shoulder dislocationStand behind pt.Trial of abduction & external rotation of shoulder → pt. pulls arm

فجأة وقف األوتوبيس و فوق ماسك األوتوبيس فى واقف كأن

If pt. cannot do abduction by tricky movement (leaning to other side) how to stop it to demonstrate glenohumeral vs scapulohumeral joint affection?

Fix scapula (stop tricky mvt) & try to abduct → cannot = glenohumeral j. affection

Method of Reduction of Dislocated Shoulder? TEAR (Traction - External rotation - Adduction - Rotation (Internal) )

ELBOW (very very rare)

Is pronation & Supination part of elbow examination? NO, they occur at sup. & inf. radio-ulnar joints (N= 80 degrees) use vertical paper

ANKLE

What are ankle movements?Ankle (tibio-calcaneous): Dorsiflexion & Plantar flexionSubtalar: Inversion & EversionMidtarsal: Pronation & Supination

What is Simmond’s test? Test for tendoachilis


Pt. Prone → squeeze calf ms → if plantar flax. = intact tendoachilis


all discussion final

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