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CLINICAL EXAMINATION
NEUROLOGIC EXAMINATION
Cranial Nerve Examination ‐ Inspection: scar marks, asymmetry of face, eyes, pupils, wasting ‐ I – ask patient to smell ‐ II – PEARL, Funduscopy, VA, pinhole test, visual fields, ‐ III, IV, VI – ptosis; presence of asymmetry of eyes and pupils; extraocular movements; accommodation ‐ V – sensation (ophthalmic, maxillary, and mandibular) and motor (clench teeth - masseter; open mouth and push to close – pterygoid muscles; if weakened jaw deviates to affected side); corneal reflex; jaw jerk (UMN) ‐ VII – close eyes and don’t let me open them, smile, wrinkle forehead, puff up cheeks ‐ VIII – whisper test; rinne test and weber (256) ‐ IX and X – hoarseness; cough; ask to sip water to check problems with swallowing; Gag reflex and uvula ‐ XI – raise shoulder and SCM ‐ XII – tongue
TIA Examination ‐ Face: asymmetry of face, ptosis, eyes/pupil of equal size, redness/swelling; PEARL; ophthalmoplegia; accommodation; funduscopy ‐ JVP, carotid pulse and bruit ‐ Upper/Lower limb neurologic examination
Neurological Examination of the Upper Limb ‐ Inspection: signs of head injury, facial asymmetry, ptosis, muscle wasting and fasciculation ‐ Palpate muscles for tenderness, Pronator drift (UMN/cerebellar lesion), tremors, ‐ Tone ‐ Power (shoulder grasp, biceps and triceps power, flexion and extension of wrist, grasp, flexion and extension of fingers; adduction and abduction of fingers ‐ Reflexes: biceps, triceps, brachioradialis ‐ Sensation ‐ Vibration and Proprioception ‐ Finger-to-nose test and alternating movements (dysdiadochokinesia)
Neurological Examination of the Lower Limb ‐ Inspection: wasting of muscles, tremors, fasciculations, surgery marks, deformity ‐ Gait assessment: observe for limping ‐ Walk on heels: L ‐ Walk on toes: S ‐ Squatting ‐ Romberg test ‐ Heel-Toe Walking ‐ Palpation for tenderness of muscles ‐ Power (hip flexion and extension, knee flexion and extension, adduction, abduction, inversion, eversion, plantar flexion, dorsiflexion) ‐ Reflexes (knee, ankle, babinski, clonus) ‐ Sensation ‐ Vibration and Proprioception ‐ Cerebellar: Heel-to-shin, foot tapping test
ENT HEAD AND NECK
Examination of theThyroid
- IF you feel any pain or discomfort during the examination, please let me know and I will stop. I will be gentle.
- Ask patient to remove clothing and wash hands!
- Inspection: o General appearance: appropriate dressed for the weather hyperthyroidism: anxious/restless/agitated, weight loss hypothyroidism: depressed/sad/dull/apathic/anxiou s/restless/agitated/ hoarse voice/sluggish o Neck: look for swelling, scar marks, dilated veins (retrosternal extension), redness (thyroiditis) o Ask patient to sip water and look for movement during deglutition; check border; ask patient to protrude tongue
- MASS: 4S (site, size, shape, suface), 4C (color, consistency, contour, compressibility), 3T (temperature, tenderness, transillumination), 2F Fluctuation, Fixation), pulsatile, reducible, signs of inflammation
- Palpation (from behind) o Palpate both lobes and isthmus o Sip of water and look for all characteristics of the mass (soft: adenoma; cystic: cyst; firm: goiter; hard: cancer; tenderness: thyroiditis; immobile: cancer); palpable thrill o Cervical lymph nodes (submental – submandibular – preauricular – postauricular – anterior cervical – posterior cervical – occipital) o Look at position of trachea from front (if displaced may be retrosternal extension)
- Percussion: from upper part of manubrium from one side to the other (change from resonant to dull indicates restrosternal goiter)
- Auscultation: listen for each lobe for any bruit (increased blood supply due to hyperthyroidism)
- Pemberton sign: ask patient to lift both arms as high as possible and look for plethora, cyanosis, respiratory distress, or neck vein distention Æ signifies thyroid gland is closing the thoracic inlet and impedes venous flow to the heart
- Hands, nails and skin o Hyperthyroidism: warm, sweaty, palmar erythema; onycholysis (nail separating from bed); tremors; shiny and smooth o Hypothyroidism: cold, dry, swollen, thick skin, anemia; dry and coarse
- Pulse for rate and rhythm and Blood pressure
- Reflexes o Hyperthyroidism: brisk reflexes o Hypothyroidism: delayed relaxation
- Proximal myopathy: hyperthyroidism
- Face o Hyperthyroidism: fine shiny hair, proptosis, lid lag and retraction, chemosis (edema of conjunctiva), conjunctivitis, corneal ulceration, ophthalmoplegia
o Hypothyroidism: brittle, dry and coarse, alopecia, loss of eyebrows, periorbital edema, facial puffiness, xanthelasma (lipid deposits over the lower eyelids), swollen tongue
- Other signs (Hypocalcemia): o Schvostek: twitching of facial muscles upon tapping of the facial nerve along the angle of the mandible o Trousseau: flexion of wrist and MCP joints upon inflating the BP cuff above systolic.
- Chest: gynecomastia in hyperthyroidism; pleural effusion (hypothyroidism)
- CVS: hyperdynamic circulation (arrhythmia and cardiac failure) and systolic flow murmurs; pericardial effusion (hypothyroidism)
- Myopathy: sit and stand Æhyperthyroidism
- Legs: pretibial myxedema (bilateral firm, elevated, dermal nodules on the shin, may be of different colors
Examination of a Patient with Facial Trauma
- Ask for consent
- Inspection (Look): there is a bruise on the left side of the cheek; no obvious asymmetry or swelling is noted; no obvious fracturers; in the eyes there is no raccoon eyes (purplish discoloration around the eyes: orbital floor fracture) or any swelling or redness; on the nose there is no obvious fracture; no obvious drainage of fluid. Ask patient to open the mouth and look for any loss of tooth or injury. On the ears look for any injury, bleeding, or fluid. There is no battle sign (discoloration of mastoid due to basal skull fracture) On the neck and head, there is no obvious swellings, bumps, deformities
- Feel: feel surrounding area for fracture or tenderness; take torch to look for pupillary light reflex; do EOM (diplopia); ask for funduscopy and visual acuity; take pin to check for sensation; clench teeth; corneal reflex; close eyes and do not let patient open them; open teeth and smile for me; feel head for any injury or swelling; feel cervical spine and paraspinal muslces to look for tenderness;
- Move: do ROM of neck;
Pleiomorphic Adenoma
Case: A middle-aged man comes in to your GP clinic with a swelling on the left side of his face just above the angle of his jaw between the mastoid and mandible. A picture of the swelling is provided.
Task a. History (lump x 5 years noticed when he was shaving; slowly growing, not painful, came in due to cosmetic reasons, + smoker x1/2 pack) b. Physical examination (3x3, irregular, firm, nontender, rounded/bosselated, well-circumscribed, no punctum, redness, discharge or scar marks, no LN enlargement, facial nerve examination) c. Diagnosis and management
History ‐ Can you tell me more about it? When? Is it growing suddenly or slowly? Painful or not painful? Does it move when you feel it? It is firm or hard when you feel it? Any ulceration, infection or bleeding from this site? Any other lumps and bumps in the body? Any weight loss or change in appetite? Did you notice any
asymmetry of the face? Any disturbance in function of your face? Any change in taste sensation? Any problems with swallowing, hearing or breathing? Hoarseness? do you have any pain or swelling in the gum while chewing? ‐ How is your general health? ‐ PMHx of cancer or radiation therapy? ‐ FHx of cancer ‐ SADMA?
Physical examination ‐ General appearance ‐ Vital signs ‐ ENT: Inspection, palpation (site, size, shape, surface, contour, consistency, compressibility, temperature, tenderness, transillumination, fixation, fluctuation, reducible, pulsatile, signs of inflammation, discharge, ulceration, vascularity), Lymph nodes (submandibular, submental, anterior and posterior auricular, occipital, anterior and deep cervical LN), Facial nerve testing: asymmetry, close eyes and don’t allow to open them, smile, clench teeth, Do check oral cavity using mouth and torch (dental problem or ulcers of mouth and tongue); parotid duct:: palpate from inside of the mouth and check for discharge and salivary stone
Diagnosis and Management ‐ For examiner: We are presented with a middle-aged man who presents with a long-standing mass on the face which is suggestive of a parotid enlargement. On examination, the mass is noted to be well- circumscribed firm mass without signs of facial nerve involvement which is highly suggestive of a benign tumor called pleiomorphic adenoma.
‐ For patient: From history and examination you have a condition called pleiomorphic adenoma of the parotid gland. Let me assure that it is a benign swelling and to further confirm it, I will refer you to the surgeon. He will do a CT scan or MRI to see the overall dimension and tissue invasion and FNAC to determine whether the tumor is benign or malignant. ‐ Differential Diagnosis: Warthin’s tumor , Sebaceous cyst, lymphoma, metastasis from primary growth , parotid abscess , lipoma, pre-auricular adenoma, Chronic parotitis ‐ Once confirmed the surgeon will remove it through a procedure called Superficial parotidectomy. In this surgery, the lump is removed and the facial nerve is preserved. Complications include: hemorrhage, anesthetic complications (aspiration), facial nerve injury, salivary fistula, recurrence ‐ Reading materials, refer and review. ‐ For cancer: Total parotidectomy or block neck dissection with radiotherapy
RESPIRATORY SYSTEM EXAMINATION
Examination of the Respiratory System
- Consent
- Inspection: sitting comfortably on the bed and does not appear to be SOB, conscious and alert, not cyanosed, not attached to oxygen, no medications, or IV lines. He does not appear cachectic.
- Hands: cyanosis, clubbing, nicotine stains, test patient's resistance to adduction (brachial plexus involvement in pancoast/apical lung tumor), press wrist and note tenderness (hypertrophic pulmonary osteoarthropathy - results from periosteal
Examination of the Lower Extremities
- Introduce yourself. I understand from your notes that you’re having pain on the leg. My task is to do the physical examination. During this examination, I will look and will be palpating/feeling some parts of the leg. I will also need to listen to some of the vessels on your leg with the use of my stethoscope.
- AT this moment I would like to ask you if you have any pain. I will ask for your permission to expose your thighs and legs (usually up to the nipple area but cover abdomen and expose only when required). While you undress I would just like to wash my hands.
- Inspection: o Abdomen: check for visible pulsation (AAA – left of the midline), scar marks; o Groin: pulsation, scar marks; o thigh and legs: muscle wasting, joint deformities, atrophy of the skin, loss of hair, change of color of skin, shiny skin; o feet: obvious deformity, ulcers (include toes, raise legs, under heels), hallus valgus; discoloration/cyanosis/blackening of nails; look for signs of amputation in toes; obvious edema and signs of inflammation
- Palpation: check for capillary refill time (<3secs); feel for temperature (with dorsum of hands); pinch shins for any edema; feel the PULSES (dorsalis pedis, posterior tibial, popliteal, femoral, abdomen);
- Auscultation: listen for bruits (AAA); both sides (renal) then femoral; Buerger test: raise your legs 45 deg for 10-15 seconds (if there is pallor – suspect PVD) then I would like you to sit down and hang your legs from the edge of the bed (check for cyanosis or dusky red)
- What is the ABI?
Examination of Varicose Veins (Case 148R8)
Risk factors
- Female sex
- Family history
- Pregnancy
- Multiparity
- Age
- Occupation
- Diet (low fiber)
Examination
- Inspection: o Distribution: Below the femoral vein in the groin to medial side of the thigh to lower leg Æ saphenous vein Back of leg to calf area Æ short saphenous vein o Signs of inflammation, cutaneous venous flares, pigmentation, edema, lipodermatosclerosis, dermatitis/eczema, venous ulcers, loss of hair, atrophy of skin, color change of the skin (deep blue, black, purple), venous impulse at saphenofemoral junction
- Palpation o Hard: thrombosis; tender: thrombophlebitis o Temperature o cough impulse Place fingers over line of vein immediately below the fossa ovalis (saphenofemoral junction)Æ ask patient to cough
Æ impulse or thrill will be felt expanding and travelling down the long saphenous vein Marked dilated long saphenous vein in fossa ovalis (saphena varix) will confirm incompetence Æ disappearas when patient lies down
- Special tests: Trendelenburg test (checks the level of incompetence) Æ long saphenous vein, short saphenous vein and perforators
o Patient lies down and leg is elevated to 45 deg. To empty the veins o Apply torniquet with sufficient pressure to prevent reflux over the upper thigh o Patient stands o Long saphenous system will remain collapsed if there are no incompetent veins below the level of fossa ovalis. When pressure is released, the vein will fill rapidly if the valve at the saphenofemoral junction is incompetent o Doubly POSITIVE: is when veins fill rapidly before the pressure is released and then with a rush when released (coexisting incompetent perforators and long saphenous vein)
- Perthes Test o Put tourniquet on mid-thigh Æ ask patient to stand and up and down on the toes for 10x after releasing some of the blood. o Collapsed veins are normal o If superficial veins increase in prominence or pain Æ deep vein are occluded or perforators are incompetent o If veins are unusual in distribution Æ exclude pelvic neoplasm/mass that is obstructing the deep vein system
- Confirmatory: venous Doppler ultrasound
Management
- Refer for Doppler ultrasound for accurate diagnosis
- Use supportive stockings (apply in the morning before standing out of the bed)
- Avoid scratching skin over the veins
- Sit with legs on a foot stool
- Maintain ideal weight
- Eat high fiber diet
- Treatment options o Sclerotherapy (use a small volume of sclerosing agent Æ particularly below the knee) o Surgical ligation and stripping Æ remove obvious varicosities and strip perforators
Complications
- Superficial thrombophlebitis
- Skin eczema
- Skin ulceration
- Bleeding
- Calcification
- Marjolin ulcer (SCC)
EXAMINATION OF THE ABDOMEN
Recent hematemesis in a 50-year-old man (Chronic Liver Disease)
Case (Condition 70): You are an intern in the ED and a 50-year- old male having had hematemesis for about 500ml of fresh blood 2 hours ago accompanied by transient feeling of lightheadedness and sweating. The patient is alcoholic and likely to have chronic liver disease on the basis of history that you have taken.
Task a. Perform relevant and focused PE of the patient b. Explain actions and what you are looking for to examiner c. Describe findings as you proceed d. No need to take further history
Physical examination
- Is my patient hemodynamically stable
- Consent
- Exposure: midchest to symphysis pubis
- Inspection: o General appearance: Patient lying comfortably. Abdomen moving with respiration. He is not cachectic. There is no obvious jaundice or pigmentation. He is well oriented. IV drug marks o Hands: clubbing, cyanosis, leukonychia, pallor, CRT, palmar erythema, dupuytren contractures o Raise hands Æ flapping tremor/asterixis (20-30 seconds) o Arm: Spider nevi, bruising/petechia, scratch marks, IV drug marks, tattooing or body piercing o Face: anemia and jaundice, Kayser- Fleischer rings, parotid gland enlargement, fetor hepaticus, flushing/congestion of the face; Mouth: stomatitis, gingivitis, ulcerations, telangiectasias o Lymph nodes: cervical, axillary, inguinal o Chest: spider nevi and gynecomastia
- Abdomen o Inspection: distention, caput medusa, visible pulsations, visible peristalsis, striae, bruising, hernia orifices o Inspect at level of tummy: ask patient to breathe in and out through the mouth Æ look for visible masses o Palpation: Ask if patient has pain anywhere in the stomach; Relax and breathe in and out; mass or tenderness on superficial palpation; deep palpation; palpate liver o Liver span: from midclavicular line (Normal: 6-12) o Spleen o Percussion: shifting dullness for ascites (percuss from right towards left side) o Auscultation: bowel sounds and venous hum (between umbilicus and xiphisternum) o Testicular atrophy o Scratch marks in legs and edema; sensations o DRE!!!!
Perforated Peptic Ulcer
Case: You are an HMO in ED and a middle-aged man comes to you because of acute abdominal pain. He had low back pain last week and was prescribed NSAIDs. He is a smoker and an alcoholic beverage drinker.
Task a. Focused examination b. Diagnosis and management
Case 2: John aged 45 years presents to ED of a local hospital where you are working as HMO 1. He had severe abdominal pain since this morning which is getting worse now. He had vomited once but now had only dry retching. He took panadol and neurofen but with no relief. He had not experienced such pain in the past. He is a smoker and drinks moderate amount of alcohol on weekends.
Task a. History (started after breakfast, 10-11 in severity, epigastric, takes panadol and neurofen for knee pain) b. Physical examination (unwell, tired, BMI 24, PR: 120/min, mild dehydration, rebound, guarding and rigidity) c. Differential diagnosis and management
Examination
- Is my patient hemodynamically stable
- General appearance: lying on bed, unwell and in pain. offer painkiller (morphine 2.5mg IV + metoclopramide)
- Vital signs (BP with postural drop)
- Inspection: o Abdomen not moving with respiration o General inspection of abdomen: scars, distention, jaundice, pigmentation
- Palpation: o Where do you feel the pain? o Superficial palpation Æ tenderness o Guarding, boardlike rigidity, rebound tenderness on deep palpation
- Auscultation: Bowel sounds
- Hernia orifices
- DRE
Investigations
- FBE, ESR/CRP, blood group and crossmatching
- U&CE, LFTs, BSL,
- Amylase and lipase
- Erect CXR (free gas under diaphragm) and Xray of abdomen (supine and upright)
Differential Diagnosis
- Perforated viscus
- Acute pancreatitis
- Mesenteric ischemia
- Acute cholecystitis
- AMI
- If female: Ectopic pregnancy, ovarian cyst rupture/torsion; PID; miscarriage
Management
- Admit and call surgical registrar because it is an acute abdomen most likely due to peptic ulcer
- Pass 2 IV line and start fluids for full resuscitation
- Pass NGT to decompress stomach
- NPO
- Insert indwelling catheter to monitor I&O
- Start IV antibiotics
- Surgery (Exploratory laparotomy)
‐ Modified Straight leg-raising Test (L4-S1) Æ tests root tension L3-4, L4-5, L5-S1 Æ passively lift the leg while the patient is supine to maximum he can tolerate, raise the leg to just below the level and dorsiflex the foot ‐ Slump Test: patient at the edge of the bed and slumping and bed head forward to maximum, lift up head as if doing SLR test, release leg until pain disappears, and put pressure by putting dorsiflexion, release neck and dorsiflexion
Clinical Features L2 Weakness of Iliopsoas muscle ( Hip flexion ) Loss of sensation over the thigh and the lower part of the groin Reflex: None L3 Weakness of quadriceps ( Knee extension ) Loss of sensation over the patella Reflex: Knee jerk L4 Weakness of quadriceps and inversion at subtalar ( Ankle dorsiflexion and cannot walk on the heel ) Reflex: Knee L5 Extensor hallucis and digitorum longus ( Great toe dorsiflexion and long extensors and everters ) Reflex: None
S1 Flexor hallucis and digitorum longus and tendon Achilles: weakness of Plantar flexion and foot eversion ( Toe walking ) Reflex: Ankle Jerk ‐ Do PR
MUSCULOSKELETAL EXAMINATION OF UPPER LIMBS
Examination of the Shoulder
Book Case:
- Consent
- Inspection: check for symmetry; check joints both shoulders are equal; contour of muscles; no muscle atrophy; bone, muscle, skin and joint; comment on neck (neurocutaneous stigmata of associated disease, bruise, deformities, erythema, neck contour is fine), temperature is equal, musculoskeletral structures look in place.
- Injury to circumflex nerve if there is shaving of deltoid
- Palpation: both clavicles, acromioclavicular joint, bursa, bicipital tendon, suprasinous muscles, midline and paraspinal areas and infraspinatus, examine police patch (circumflex nerve), compare pulse,
- Check full ROM: flexion and extension of shoulder joint, abduction to glenohumeral joint, scapula sliding over thoracic cage, adduction to 0 and across the body, internal and external rotation, touch tip of scapula and scratch thumb between scapula (combined adduction and internal rotation) then combined abduction and external rotation, then circumduction
- Stool: passive movement
- Test power of muscles: resists hands on biceps (full flexion and extension); do chicken wings (abduction/adduction); full external/internal rotation
- Pulses!
- Neurocutaneous structures: use pin and cotton
- Throw a ball: apprehension test: impending dislocation/subluxation/joint unstable if positive
Management of axillary nerve injury ‐ In many cases, spontaneous resolution happens spontaneously and no treatment is needed. It may take as long as one year. ‐ If there is any pain, we can give you medication such as paracetamol in mild pain or if severe/stabbing pain, other medications such as gabapentin or TCAs can also be given. ‐ If not controlled refer to surgery and surgical options include nerve grafting/reconstruction. ‐ Refer to physiotherapy to regain muscle strength and function of nerve.
Examination of the Hand
- Joints, Pulse, Nerves, Muscles and Tendons!!!
- If with trauma: Pulse, nerve function, tendons, joint, muscle
- If rheumatological examination: joint, tendons/nerves, muscles, pulse
- Inspection: nails Æ psoriatic nails (pitting, onycholysis, hyperkeratosis), subluxation, muscles, shiny, tighetened skin, thickening of tendons, erythema, clubbing, deformity of small joints of the hand (phalanges, MCP or wrist joint), nodules on the level of elbow swelling, signs of inflammation, deformity, no muscle wasting or thickening of hypothenar or thenar muscles, pallor, dupuytren contracture o Radial deviation of wrist o Z deformity thumb – flexion of MCP and extension of PIP (RA) o Boutonierre deformity – flexion of PIP, extension of DIP (RA) o Swan neck deformity – flexion of DIP and extension of PIP (RA) o Heberden – DIP (OA) o Bouchard nodes – PIP (OA) o Sausage-shaped fingers – telescoping of fingers (psoriasis and scleroderma)
- Palpation: temperature; elbow, radius, ulna, lower end of the ulnar styloid processes with 2nd^ finger, (denotes RA Æ especially radial styloid and associated with de Quervain tenosynovitis, severe OA), wrist and bones of the hand (with thumb), press from the side and up to detect for any effusion , crepitation , dupuyren contracture, wasting of thenar/hypothenar muscles, radial pulse, CRT, sensation
- ROM (Active then passive); open and close hand to check for crepitus/tenosynovitis o Elbow: flexion and extension o Wrist: flexion, extension, lateral and medial deviation, supination and pronation; degree of flexion and extension o Thumb: flexion, extension, adduction, abduction, opposition o Hand: abduction and adduction
- Power
- Nerve Tests: o Pin touch test: median nerve o Crush finger with thumb: ulnar nerve o Full extension of wrist: radial nerve o Fromen’s test
- Vibration and Proprioception: may avoid
- Carpal tunnel o Phalen test o Tinnel o Finkelstein
- Functions of the hand o Grip strength o Key hole test o Comb hair o Write name o Undo buttons
Other features of RA
- Skin: rheumatoid nodules
- Head: scleritis in eyes
- Lungs: nodules, fibrosis, Caplan syndrome (pneumoconiosis)
- Heart: pericarditis
- Abdomen: splenomegaly
- Hematologic: neutropenia (felty syndrome = RA + neutropenia + splenomegaly), anemia
Osteoarthritis
- Usually carpometacarpophalangeal and DIP
MUSCULOSKELETAL EXAMINATION OF THE LOWER
EXTREMITY
Examination of the Hip (Trochanteric Bursitis)
Case: A 45-year-old female complained of pain in the right outer hip that travels down to her legs since last week.
Task a. Examine the patient b. Diagnosis and management
Features:
- Inflammation of bursitis or tendinopathy of the gluteus medius tendon
- Common in patients on sports or gardening, increased weight/BMI
- Pain around lateral aspect of hip traveling down the leg
- Trendelenburg test may be positive
- Female >45-
- Tenderness of the greater trochanter and/or pain on abduction
- Treatment: NSAIDS, RICE, strengthening exercises, injection therapy
Differential Diagnosis
- Avascular necrosis of femoral head
- Osteoarthritis of the hip
- Lumbar spine radiculopathy
- Iliopsoas tendinitis (flexors of the hip) Æ pain on stretching of the hip flexor or resisted hip flexion
Examination
- Expose from waist down
- Assess gait (limping), walk on heels (L5) then toes (S1); squat and stand;
- Trendelenberg test (checks abductors of the hip Æ gluteus medius): Æ leg which the patient is standing is the one being tested Æ SOUND/NORMAL side is going to SAG
- o Tests gluteus medius muscles o Problem in hip joint (severe OA) o Shortening of neck of femur due to fracture o SCFE (kids)
- Inspection: both hips straight, swelling, deformity, signs of inflammation, wasting of the muscles, flexion deformity (side), back (spine is centered, wasting, deformity) - Palpation: hip lying on the same level by palpating with thumb the ASIS, greater trochanter (tenderness if there is subtrochanteric bursitis), femoral pulse midpoint between ASIS and pubic tubercle), palpate lateral to femoral pulse to check for tenderness on femoral head (osteoarthritis), muscles on the inner side of the hip and front (adductor tendinitis) - Measure leg length: Apparent and true leg length (measuring tape)Æ discrepancy in true leg length signifies pathology of hip joint; if in apparent leg length means tilting of pelvis - Active and Passive Movements then Power: o Hip flexion: raise leg to chest o Extension: can ask patient to lower the leg down or at the back ask patient to raise the leg while knee is flexed; palpate the dimple of venus or press hip (sacroiliac joint tenderness Æ sacroilitis) o Abduction and Adduction (support hip) o Internal and external rotation (flex and support the knee) - Thomas Test: flexion deformity of the hip; keep hand under spine and flex both hips and knees and ask the patient to lower one leg; if not done properly, flexion deformity will be disguised by lumbar lordosis compensatory movement - Squeeze Test: flex knee at 90 degrees ask patient to squeeze thighs in hand Æ (+) in adductor tendinitis/osteitis pubis - Tests for Sciatica o Modified Straight Leg Test (L4-S1) o Tibial Nerve Stretch Test (L4-S3) o Femoral nerve Stretch Test (L2-4)
Diagnosis and Management
- Most likely you have a condition called trochanteric bursitis. The bony prominence of the thigh bone in the upper part is the greater trochanter. There is a protective shock absorber over the bone called “bursa”. The muscles of the buttock is also attached to this bone by the tendons. If there is inflammation of the tendon or bursa, it is called trochanteric bursitis or tendinitis.
- You need to rest and reduce the activity for about a few days. Put an ice pack on the painful side and I will give you some painkillers to relieve the pain or analgesic creams for massage. Please avoid sleeping on the affected side. You can use sheep skin mat or a small pillow to elevate the involved area
- I will refer you to a physiotherapist for strengthening exercises.
- If severe pain: local anesthetic + corticosteroids; surgery (rarely)
- Investigations: XRay Æ rule out osteoarthritis; USD: can demonstrate the pathology
- Overweight: lifestyle modification
Gait and Hip Examination (Osteoarthritis of the Hip)
Case: A 64-year-old man with a history of pain on his right hip joint for the last 6 months comes to your GP clinic. The pain is worse with activity. He tried panadol but didn’t get relief from the pain.
Task a. Relevant hip examination and give commentary (limping, unable to walk heels and toes and squat, trendelenburg unable to do on the right side because of the pain, leg length is normal, tenderness over the
‐ Tenderness on palpation of the inner muscles of the thigh and pain on adduction; squeeze test (+) ‐ RICE ‐ Prevention: stretching;
History ‐ Can you tell me more about what happened? SORTSARA? Were you able to walk after that? Is it for the first time? Did you have any numbness, tingling or weakness? Swelling? Bruising? Did you take any medications? Previous medications? General health? History of joint problems?
Diagnosis and management ‐ Most likely you have a condition called Groin strain or adductor tendinitis. It happens because of too much stress on the muscles of your groin/thigh called adductor muscles. If these muscles are tensed too forcefully or suddenly they can tear causing pain. It is a common condition during sports activity. ‐ Avoid activity until pain gets settled. Apply for 20- minutes for 3-4 hours until pain-free. You can also compress the thigh with the help of elastic bandage or tape. ‐ I will give painkillers and refer you to physiotherapy. If still not relieved, I can refer you for corticosteroid injection. ‐ Please come back if the pain is persistent. If we might do ultrasound and Xray.
‐ Prevention: Do warm and stretching before doing physical activity.
Examination of the Knee
Case (book pg229/280): A patient in your GP setting has past history of twisting his right knee 6 months ago when foot got caught on a broken pavement. He fell on the knee and it became swollen and painful on the inner side. The swelling caused a painful limp for several days and then subsided with easing of symptoms.
Since then he has had intermittent attacks of pain on the inner side of the knee with swelling, which settles within 24 hours, and has had difficulty in straightening the leg fully. He is, on occasion, apprehensive when twisting to the right. Between attacks of pain he can walk normally with only a minor feeling of pain on the inner side of the knee. He is otherwise well. This is the first time he has consulted a doctor about this problem.
Task a. Focused examination of the knee b. Differential diagnostic plan
Inspection: Landmarks
- Patella
- Tibial tuberosity
- Popliteal fossa
- Quadriceps femoris
- Suprapatellar pouch
- Medial and lateral pouches Æ Peripatellar pouches (obliterates when there is effusion)
- Anserine bursa
- Fractures, muscle wasting, scars (longitudinal Æ TKR, keyhole) , effusion, erythema, neurocutaneous stigmata
- Anterior plane: varus or valgus deformity
- Lateral: hyperextension or flexion abnormalities
- Posterior: swelling or baker cyst
- Observe gait: normal gait, limping, fixed flexion deformity
- Squat and stand up (power and ROM Æ full flexion and extension)
Palpation
- Temperature (of knee is 1 degree lesser than body), Pulses (while seated – popliteal, dorsalis pedis, posterior tibial), sensation (pain and light touch), reflexes,
- Passive movement
- Knees flexed: palate quadriceps, suprapatellar pouches, patella, patellar tendon, shin of tibia, lateral malleolus and fibula, head of the fibula, and joint line, iliotibial band, knee hip joint, adductor muscle, gastrocnemius, Achilles tendon
- Patellar tap test and bulge test (mild effusion Æ effusion
- Valgus and Varus stress test (+ if more than 10 degrees)
- Anterior and posterior drawser (+ if more than 10 degrees)
- Menisci o Apley’s Grinding test o External rotation, valgus and flexion or internal rotation, varus and extension
- Patellar apprehension test (impending subluxation or dislocation of patella)
Examination of ankle joint
- Inspection: try to walk first; change in color of skin, bruises, deformity
- Palpation: o Lateral: lateral malleolus, posterior tip of lateral malleolus and 6 cm above, anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, peroneal tendons, base of 5 th^ metatarsal, (sinus tarsi, distal syndesmotic ligament, anterior calcaneal process Æ not necessary) o Media: medial malleolus, medial joint line with 6 cm above, 3 strips of ligament, navicular, anterior joint line, Achilles tendon, heel, pulse, CRT
- ROM: plantar flexion, dorsiflexion, inversion, eversion, neurovascular sensation, reflexes, power
- Tests for ankle instability: anterior drawer, talar tilt, and squeeze tests (signals high ankle/syndesmotic injury Æ patient needs MRI and referral for ORIF
Lower Leg Examination of a Patient with Diabetes Mellitus (Diabetic Foot)
Case: Your next patient is a 55-year-old female with long- standing diabetes.
Task a. Perform physical examination of the lower limbs.
- Ask patient to walk looking for gait and normal phases
of gait Æ high-stepping gait (indicates loss of
proprioception or joint position sense)
- Inspection: o Needle marks and fat hypertrophy/atrophy, wasting (especially quadriceps); charcot joints (deformed knee joints) o Skin: loss of hair, atrophy of the skin, redness, cyanosis, signs of inflammation, edema o Feet for obvious deformities, boils, corns and calluses, hammer toes (proximal phalanx is flexed); mallet toe (DIP is flexed); toe clawing (flexion of both DIP and PIP), hallux valgus, bunions, tinea o Nails (thickening, ingrown toe nail, change of color, cyanosis), toes (cracks, ulcers)
- Palpation: o CRT, temperature, edema, pulses o Neurologic examination: sensation, vibration (toe Æ medial/letaral malleolus Æknee Æ ASIS) proprioception, power (ankle and not knee), tone, reflexes (ankle, knee Æ may be decreased or absent)
- Urine dipstick, BSL, funduscopy
Diabetic Foot care
- Keep diabetes under good control and do not smoke
- Check feet daily (sores, infection or unusual signs)
- Wash feet daily with lukewarm water, dry thoroughly especially toes and soften dry skin especially around the heels; applying methylated spirits between toes to help stop dampness
- Attend to toenails regularly (clip straight across with clippers, do not cut them deep into corners or too short across, file any rough edge)
- Wear clean cotton or wool socks daily
- Exercise your feet each day to help circulation
- Check insides of shoes to make sure no nails are pointing into the soles
- Annual foot examination in doctor’s office
How to avoid injury
- Wear good-fitting, comfortable leather shoes
- Shoes should never be broken-in (should fit from the start)
- Shoes must not be too tight or too loose
- Do not walk barefoot especially outdoors
- Do not cut your own toenails if with poor eye sight
- Avoid home treatments and corn pads that contain acid
- Be careful when walking around the garden and home
- Do not use hot-water bottles or heating pads on your feet
- Do not test temperature of water with your feet
- Take extra care when sitting in front of an open fire or heater
Treating cuts and injuries
- Clean would with mild antiseptic (liquid savlon or dilute betadine)
- Cover with clean gauze
- See GP if does not heal within 2 days or there are signs of infection
- Refer to podiatrist, dietitian, diabetic educator, ophthalmologist and nephrologist
