RECALL RANDOM_DR CCY

1. Vertigo examination
Your next patient in GP is a 40 yr old Mike c/o feeling dizzy. The patient describes the symptoms
like being in merry go round, since yesterday.
Task
Perform PE and explain pt about what you are going to do

Causes of vertigo
Central lesion
• PICA
• Cerebellar degeneration
• Migraine
• MS
Peripheral cause
• labyrinthitis (hearing impaired)
• vestibular neuritis (no hearing impaired)
• Meniere (hearing impaired)
• BPPV (hearing impaired)
• Cervical spondylosis
• Chr suppurative otitis media
PE summary
BP – sitting, lying, standing
T- for infection

Hearing test

 Whispering - from 60 cm
 Tuning fork – 512 Hz
o Rinne test
o Weber test

Eye examination
• MS – optic neuritis – 2nd CN
• Cerebral degeneration – 3rd 4th 6th CN
• Cerebellar cause - Romberg, Speech, coordination
• PICA – stroke/ AF/ hypercholesterol

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 RECALL RANDOM_DR CCY
o Tone Power Sensory – paralysis/ weakness on ipsilateral side of face, contra lateral
side of body
o CVS – bruit, AF, heart failure
• BPPV - Hallpike maneuver
• acoustic neuroma - 5th 7th 8th CN

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 RECALL RANDOM_DR CCY

2. Pre eclampsia

36 wk GA woman presents with BP 150/100, protein 2 +, head engaged

Task

 Explain further exam and speculum examination

 Counsel pt and tell findings to pt

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 RECALL RANDOM_DR CCY

3. Osteoarthritis Hip

Your next patient in GP is a 65 year old M c/o painful right hip for 6 months. Pain aggrevated by walking
and relieved by rest.

Task
 Perform PE
 Explain to pt what you are going to do
 Explain PDx with reasons to examiner
 DDx to examiner

OA Positive findings
 deep tenderness on palpation,
 restriction of jt (both active and passive),
 Trendelenburg (+),
 Thomas test (+)
 fixed flexion deformity (+)

1. Trendelenburg test
**positive Trendelenburg test (sound side sag)
- Gluteus Medius weakness
2. Thomas test – fixed flexion deformity test
Could you pls bend your knee on both sides and bring towards the chest? and pls straight your
left leg. (start on normal side and the affected side)

3. Patrick test (Faber test) -SI joint test

I’ll bend your knee of your affected leg and bring the heel toward the knee of other side and
will gently press on your knee and hip. Pls let me know if you have pain.
 F – flexion
 Ab- abduction
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 Er – external rotation of hip
Affected side of hip jt – make as figure 4 and gently press on the hip and knee joint of examined
leg.

**Positive Patrick test,

 Hip jt, (deep hip pain)
 Sacroiliac (pain at bottom of back)
 jt, m/s around hip jt. (pain around thigh or distal thigh)

4. leg length measurement

 True length – start with normal side (from ASIS to medial malleolus)
 Apparent length – from umbilicus to medial malleolus
**Reduced length (fall h/o sometime given)
 #
 arthritis degeneration

5. Squeeze test
Please bend your knee and both feet keep putting on bed. I’ll put my fist between your knees. I
want you to squeeze my fist with your knee as much as you can.

**Positive squeeze test

 Abd tendonitis – pain (+)

6. Pelvic compression test

I want you to lie on your lt (lie on normal side), I will put slight press on your hip (press on
greater trochanter, ASIS/ PSIS)

**Positive pelvic compression test If Groin pain and tenderness (+)

 abductor tendonitis and osteitis pubis

**Positive Pelvic compression test on both ASIS

 trochanteric bursitis (localize tenderness + with limping gait and the rest are normal)

4. gynecomastia PE
A 52 y/o man Ben who goes to bodybuilding center has come with c/o large breasts.
Tasks:
- Perform PE (the examiner gives you the result of physical examination once you’ve done
examination)
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 RECALL RANDOM_DR CCY
- explain the most likely diagnosis and give reasons

positive findings
BMI – 27
only breast tissue enlargement bilaterally and all other normal.

Examination steps
1-General appearance
-weight, height.
-comfortable etc…
2-Vital signs (all)
3-Hands and arms
-clubbing, cyanosis (CLD)
-palmar erythema (thyroid+ CLD)
-sweating (thyroid)
-tremor (fine tremor when hand outstretched and using paper + flapping tremor when hands
cocked back) (thyroid+ CLD)
-spider nevi, scratching marks, petechial, bruising, rashes (chronic liver D).
4-Face
-moon face (steroid)
-pallor, jaundice (chronic liver D)
-thyroid eye signs (thyroid)
-visual field + Fundoscopy (pituitary)
5-Neck
-thyroid
-cervical Lymph nodes
6-Breast (4 position)
look (no need to position the patient)
-asymmetry
-scars

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 RECALL RANDOM_DR CCY
-skin changes: (erythema, puckering or dimpling of the skin)
-visible lump or not
-nipples (retraction, distortion, ulceration, discharge), ask the patient to squeez the nipple

Feel (like female breast ex) + axillary LN + Temperature!

7-Abdomen
inspection
-central obesity, distension, dilated veins
palpation
-superficial and deep tenderness
-liver and kidney
8-Genitalia with consent and chaperone
-testicular mass, hypogonadism + inguinal LN

Diagnosis and Differential diagnosis

1-Steroid induced (most likely in this case)
2-Phsiological
3-Chronic liver disease
4-Thyrotoxicosis
5-Pituitary tumour (headache and blurring of vision)
6-Breast cancer
7-Liver, adrenal cancer
8-Testicular cancer
9-Other medications (estrogen, spironolactone, cimetidine, digoxin, marijuana)
10-Klienfilter syndrome

5. Linear rash (PE)

Young patient presented with linear rash picture provided.
Tasks:
-History
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 RECALL RANDOM_DR CCY
-Perform Physical examination
-Diagnosis and differential diagnosis

DDx

 Lympahgitis
 Cellulitis
 Insect bite
 thrombophlebitis

Positive findings
(He has painful rash)
(I worked in the garden two days back)

History
1-open ended question: I can see from the notes that you have this rash along your arm. Can
you tell me more about it?
2-pain questions
-How severe is your pain from 1-10? 1 is the least 10 is the most. Ask about allergy then give
him painkillers
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 RECALL RANDOM_DR CCY
3-rash questions
-how long have you had this rash? When did it actually start?
-has it suddenly appeared?
-is it getting worse?
-any change in size or shape since it started?
-what were you doing at that time?
-apart from pain. Is it itchy?
-is it hot to touch?
-is there rash anywhere else?
-any swelling or lumps and bumps around your body? Weight loss?
-any cat and scratches from cat?

4-Differential diagnosis questions

-any chance you had an insect bite?
-any trauma?
-do you use any drugs or medication intravenous? Any needles?
-do you have any fever?
-any recent air travels?
-have you been in contact with someone with similar symptoms?
-do you have allergies to anything?

5-General questions
-do you take any medications like steroid or any OTC?
-any history of Diabetes, infections, clot in the vein of your legs, blood disorder?
-any recent surgical operations?

Perform Physical Examination

1-WIPE + Consent

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 RECALL RANDOM_DR CCY
I need to examine you now to look for the cause this would involve me having a look, feeling
down your on arms and feeling glands around your neck and armpits would that be all right?

2-General appearance and Vital signs

-pulse (ask examiner for a watch and measure the pulse)

-blood pressure
-Temperature (in the exam there will be ear thermometer so put speculum)

3-Rash examination
Inspection
-site and extension of the rash
-colour
-entry point
-trauma, bruising, skin changes
-compare with the other arm and look for rash anywhere else

Palpation
-tenderness
-temperature, if hot to touch
-elevated or not
-blanchable or not
-is it cord like

Lymph nodes examination

-Epitrochlear LN
-axillary LN
-Cervical LN

Diagnosis and differential diagnoses

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 RECALL RANDOM_DR CCY

most likely have a condition called lymphangitis, which is an inflammation or infection of the
lymphatic channels, which is part of our immune system. This condition occurs due to infection
by bug bacteria at a site distal to the channel.
Other possibilities are:
Could be due to cellulitis which is infection of the skin and area under the skin may be due to
an insect bite while working in the garden causing bug entry into the skin.
Could also be due to thrombophlebitis is an inflammatory process that causes a blood clot to
form and block one or more veins but it’s unlikely.
I still needed to R/O by doing a test called duplex USG.

Admission, opinion and further testing and treatment because he needed painkillers,
antibiotics and elevation of his arm.

6. Venous rash PE
A middle aged female presents with rashes and pigmentation on legs near medial melleolus, especially
on rt side. Photo is provided

Task

- PE on lower limbs
- Dx and DDx with reasons to pt

Positive findings

 varicose vein present along the inner side of rt leg up to groin

 no tenderness on vein
 cough impulse +ve on SF junction – 4 cm below and later pubic tubercle
 Trendelenburg test – full vein when untied the tourniquet
 Dilated vein is gone when doing Perthe test

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 RECALL RANDOM_DR CCY
WIPER

Look

Venous ulcer characters

- Medical malleolus
- Size 4-5 cm
- Irregular margin
- Granulation tissue in floor of ulcer
- Surrounding t/s inflamed around
- Pigmentation due to hemosiderin
- Rash medial aspect of malleolus
- Look itchy (eczema feature)
Feel (glove)

- Tem
- Tenderness (thromophelitis)
- Consisteny – hard (localized thrombosis – usually in cancer pt due to injection)
- CRT
- Pulse
Special test

Cough impulse (standing position)

Two fingers on SF junction – 4 cm below and later pubic tubercle

Feel impulse or thrill

See impulse down to long saphenous vein

Due to Incompetence of SF valve

Cough impulse disappear on lying

Trendelenburg test (for valve of superficial and deep vein) (lying position)

Raise leg

Torniquet below saphenofemoral junction

Ask to stand

Without removing torniquet

- keep empty – perforators are good

- vein dilate again – perforators are not good
Remove torniquet

- vein filling from upper – SF valve are not good

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 RECALL RANDOM_DR CCY
Perthe test (do if Trendelenburg test positive) to check the perforator prob

Torniquet below saphenofemoral junction on the Leg with dilated vein

Ask to walk around or exercise up and down of calf m/s (calf m/s to work)

Check if vein are

Empty – perforator are good

Dilate – perforator are not good or Deep vein blockage

Linton test

Raise leg

Check if vein empty or dilate

If dilate vein ever after raised leg – DVT so need doppler USG

Mx of varicose vein, ulcer, discoloration

- life style changes

o ideal weight
o eat fiber diet
- modify risk factors (prolong standing)
o raise/ elevate limb
- compression elastic stocking
- avoid scratching
- refer to vascular surgeon and discuss about further mx
o sclerotherapy (for small and below knee)
o ligation and strapping (large)

7. Hypothyroid examination

30 yr old pt presented to your clinic with feeling of lump in his neck particularly when
swallowing. he has family h/o of thyroid problem. so he concerned about it. when asking
history, no symptom of hyperthyroidism.
Task
do PE and running commentary to examiner what you are looking for
positive findings

 midline in neck
 move with swallowing of water
 no tenderness
 move with swallowing of water
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 RECALL RANDOM_DR CCY
 no move with tongue out
 delayed relaxation of ankle jerk

 Ddx
 Thyroid gld enlargement
 Cervical LN

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 RECALL RANDOM_DR CCY
8. Fracture lower end of Tibia
Your next pt in ED is a 25 year old male c/o painful rt ankkle which appeas as soon as he got injury to
that area while playing football recently. You can see swelling on that area as well.
Tasks
 Perfrom PE
 Order inv if you think necessary from examiner
 Explain Dx and mx for pt

Positive findings
 Patient cannot walk on weight bearing (rt)
 Swelling +ve on lateral side of ankle joint (rt)
 Localised bony tenderness on lateral bony tenderness on lateral part of rt ankle
 Painful ankle movement
 Cannot elicit special test because of pain
 Weber Stage

A – plaster cast (upper limb – 4 wk, lower limb 8 wk)

B – plaster cast
C – open reduction and int fixation (due to jt instability)

F/u
- After 24 hr , check for compartment $
- Review after 1 wk

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