Understand 2nd year medicine

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This page will cover the following topics...

Please use the search function of your browser to find your desired topic 

e.g. Hold Ctrl F then type in "ECG" to find ECG related OSSE station

  • ECG, vital signs, measuring blood pressure, temperature, recording vital signs
  • General exam, history
  • Respiratory exam, PEFR, Inhaler 
  • GI Exam, Scrotal exam, urine dip
  • Cardiovascular exam, Prothrombin time, blood smear, glucose prick test
  • Neuro exam 
  • Gait, gals, specific examination (hands, spine, hip, knee, shoulder)
  • AED, primary survey
  • Pharmacology: Drugs and eye
  • Near vision using near card, Near point convergence using RAF rule, Near accommodation using RAF rule, Blind spot testing using Bjerrum screen, Measuring visual acuity, Distance vision, Astigmatism, Opthalmoscopy
  • Weber's test, Rinne's test, Auriscope
  • Venepuncture
  • Microbiology

 

Units

1dL = 100mL = 0.1L
1gram= 1000 mg (milligram)
1 mg = 1000milligram
µg ( microgram)


ECG electrocardiogram

  1. Ask the patient to undress down to the waist and lie down
  2. Remove excess hair where necessary
  3. Attach limb leads (on bony prominents)
  4. Attach the chest leads:
  5. V1 and V2: either side of the sternum on the fourth rib (count down from the sternal angle, the second rib insertion)
  6. V4: on the apex of the heart (feel for it)
  7. V3: halfway between V2 and V4
  8. V5 and V6: horizontally laterally from V4 (not up towards the axilla)
  9. Ask the patient to relax
  10. Press record
  11. The standard ECG uses 10 cables to obtain 12 electrical views of the heart.




Vital Signs

- Pulse: Peripheral vascular disease
*Always compare!

  1. Femoral: Patient lie down, mid-point between ASIS and pubic symphysis
    1. branches: put my leg down please
  2. Superficial Temporal (branch of external carotid: : Anterior to ear
  3. Carotid: Common carotid artery (Bifurcation at C4)

Never do both at once!

Character

  • Small volume - low output (heart failure, MS, AS - slow rising)
  • bounding pulse - leaping and forceful pulse that quickly disappears (high BP and SV) - fluid overload
  • thready (weak) - shock
  • Collapsing - AR
  • Pulsus paradoxus (exaggeration of inspiration with decreases BP and increased HR) - cardiac tamponade or severe asthma
  • normal inspiration: decrease in intrathoracic pressure --> more blood flow to right heart --> stretch to right ventricle and more blood remain in lungs --> drop in systolic BP <10mmHg
  • tamponade: fluid in pericardial cavity - the stretch is not transmitted to rigth ventricle but to the the IV septum  --> dramatically reduce left ventricular filling --> decrease SV >10mmHg
  1. Brachial pulse: In cubital fossa, medial to biceps tendon! (NMAN - radial nerve, biceps muscle, brachial artery, median nerve)
  2. Radial
  3. Ulnar
  4. Popliteal: Patient flex knee at 90 degrees at bed and push up
Popliteal fossa contents: Serve and volley next ball
two Semi's: Semimembranosus (medial) and Semitendonosus. (atop - superficial)

external iliac --> common femoral -> deep and superficial femoral → superficial femoral to popliteal at popliteal fossa → and then below to tib anterior and tib posterior.


popliteal artery (a continuation of the femoral artery which lies DEEPEST in the popliteal fossa), popliteal vein, tibial nerve, common peroneal nerve (most superficial --> more prone to nerve block), biceps femoris

no popliteal nerve... just sciatic to tibial and common peroneal
  1. Posterior tibial artery: Posterior to medial malleolus
  2. Dorsalis pedis: Branch of tibial anterior artery - lateral to adductor hallucis longus

Comment on
  1. Rate (15s x 4)
    1. <60bpm = bradycardia, >100bpm = tachycardia
    2. Ask ptnt’s drug history (B-blocker will reduce HR),  medical history (hyperthyroid will increased HR)
  2. Rhythm
    1. regular - sinus rhythm, if fast - SVT, AF
    2. irregular: if irregular measure for 30s instead of 15 s
      1. regularly irregular - sinus arrhythmia, second degree heart block type 1
      2. irregularly irregular - AF atrial fibrillation (which can cause stroke, PE! pulmonary embolus)
  3. Character
    1. Slow rising - AS aortic stenosis
    2. Collapsing - AR (aortic regurgitation Aortic pressure collapses rapidly during diastole due to the incompetent valve allowing ejected blood to flow back into the ventricle rather than maintaining diastolic pressure. As too much blood rushes back into the ventricle it causes volume overload in the ventricle with eventual dilation and LV failure.)(like water hammer) big pulse pressure
      1. Pain in shoulder?
      2. Raise arm
        1. Other signs of AR
  1.  
    1.  
      1. Big pulse pressure (unable to maintain DP) - low in AS!
      2. Quinke's sign - visible pulsation in the nailbed
      3. Corrigan's sign - visible carotid pulsation.
      4. de Musset's sign - head bobbing in time with the pulse.
      5. Early diastolic murmur - heard best at the left lower sternal edge with the patient sitting forward
    2. Radioradio delay - Aorta coarctation or aortic dissection
      1. dissection: Intima damage causing blood to go into muscular wall of BV
      2. coarctation before left sub. artery
        1. compromised left arm blood flow, therefore, radioradial delay and different volume (normal right arm but weak left).
        2. Radiofemoral delay on one arm only: normal right arm (delayed left arm) and delayed femoral pulse in either sides
      3. coarctation after left sub. artery,
        1. radioradial delay
        2. Radiofemoral delay on BOTH arms
  2. Volume: An indication of how well perfused the tissue is
    1. Low: Weak heart, shock
    2. High: Pyrexia (e.g. infxn) -> Vasodilation

Congenital
- Marfan - MR and AR
- Down’s syndrome (up face): ASD
- Turner’s syndrome (girl’s bottom): VSd and aortic coarctation

Measuring blood pressure
Prep
  1. Confirm patient’s name
  2. History
    1. Medicaiton (oral contraceptive)
    2. PMH
    3. Smoke
    4. Drink
  3. Patient’s leg to be uncrossed
  4. Patient arm at heart level (use pillow to rest elbow)
  5. Explain procedure - is it OK?
  6. Explain possible pain with inflation cuff, let me know if unbearable pain, try and relax,
Procedure
  1. Feel for brachial artery first (medial to biceps tendon)
  2. Needle to read zero, cuff fully deflated (release air if needed),
  3. Place cuff 2cm above cubital fossa
  4. Use right size cuff
  5. Close cuff around arm with tube above brachial artery
  6. Inflate
  7. Release air until pulse is present - remember estimate BP
  8. Wait 1 minute
  9. Inflate again until 30+estimate
  10. Deflate
    1. 1st korsakoff sound - systolic
    2. 5th/final - disatolic

Temperature (Hypothermia <35C, Core = 37C, Fever >38.5)
- Oral
- Axillary
- Rectal
- Tympanic (same blood supply as hypothalamus)
  1. Observe
  2. Palpate
  3. Do the job - tell patient it might be uncomfortable
    1. Use right hand if right ear to operate the thingy
    2. Other hand to Pull pinna up and back
Hyperthermia: Depresses hypothalamus so no thermoregulation (-->  heat stroke)
15s pulse, 60s resp

Respiratory rate (REAR) for 1 minute (DO NOT say to patient, do subtly after doing BP)
- Normal: 12-20/min
  • Effort: use of accessory muscles?
  • Abnormal noise? (Stridor etc.)
  • Rate: Increased if metabolic acidosis
- Altered by activity of central (H+ and CO2) and peripheral (all 3... H+, CO2 and low O2) chemoreceptors





General Exam (Bottom to up)
  • Intro
  • Look around: O2 monitor? NG tube?
  • Patient’s behavior, face (jaundice - anemia, liver problems, prosthetic valve - damage RBC!; pale, acromegaly - acne, cushings - moonface, parkinson - expressionless, malar flush - MS), breath sound, odor
  • Hand
  • Prone and supine
    • see: Pigmentation (Addison’s), Depig. (Vitiligo), dupuytren’s contracture (liver diseases - thickened, shortened fibrous tissue), ulnar dev. (RA), palmar erythema (alcoholic), creces (anemia), cyanosis, raynaud’s phenomenon
    • feel: MCP swelling (RA), muscle wasting (thenar), temp., unilateral DIP (OA), bilateral PIP and knuckle MCP (RA)
  • Nails
    • Capillary refill
    • Clubbing (drumstick finger)
      • cyanotic heart
      • lung
        • atelectasis
        • bronchiectasis
        • cf
        • don’t say copd
        • empyema
        • fibrosis
      • ulcerative colitis
      • biliary cirrhosis
      • birth defect
      • infective endocarditis
  • Splinter haemorrhages
  • Osler's nodes = tender (painful), red, raised lesions found on the hands and feet
    • osler’s - ouch!
    • nodes - nodular
  • Janeway lesions - same as osler’s except non-tender! infective endocarditis
  •  
    • neoplasm
    • gi malabsorption
  • Cyanosis
  • Cigarette
  • Beau’s lines: Horizontal grooves in nail (temporary arrest of nail growth because of acute severe illness/chemo)
  • Scleroderma - nail pitting, sausage finger
  • Hepatic encephalopathy/co2 retention - flapping tremor
  • Koilonychia (spoon-shaped nails - iron-def anemia)
  • Leuconchyia (whit enail b/c hypoalbuminemia)
  • Onycholysis (nail separate from nail bed b/c fungal infxn)

onukh = nail


  • Skin (of arm)
    • Rash
    • Trackmarks
    • Spider nevi
Head to down...
  • Eye
    • Remove glasses
    • Look up -> Pull eyelid
      • Jaundice
      • anemia
      • hate light - meningitis
      • corneal arcus (grey cornea margin)
    • Eyelid: Xanthelesma: yellow cholesterol beneath skin

  • Mouth
    • Angular chelitis - anemia
    • Buccle pigment: Addison’s (MSH)
    • Gingivitis
    • Tongue
      • Enlarged: Hypothyroid
      • Movement - stroke
  • Ears
    • Pull on earlobe -if pain - otitis externa (external ear infxn)
    • Press the tip of mastoid with thumb - if pain - otitis media
  • Neck
    • Inspection in FRONT of patient and hyperextend neck - Scar?
    • Palpation by standing BEHIND patient
      • thyroid Diffusely enlarged - preg., Hashimoto, Grave’s, iodine deficiency
      • solitary enlargement
      • lymphadenopathy - infxn, metastasis

GALS gait arm leg spine examination - always do BOTH SIDES!!!
Gait - see above terminologies
When moving joints, feel for crepitus

 


Normal Gait



1. Stance/support phase (60%) from Heel strike to toe off, foot is on ground

  1. Contact phase (20%): Posterior outside of heel hits ground
  2. Midstance phase (30%): Body weight passes
  3. Propulsion phase (50%): Foot pushes off ground (Ball of big toe to big toe)

l
l
l
l
22222
     3
     3

2. Swing phase (40%) from toe off to heel strike of other foot


1 gait cycle = Heel strike to heel strike of the SAME foot


Double support phase: When both feet is on ground (e.g. walking)
Running: No double support phase!


Increased walking speed:
Stance phase and double support phase decreases
swing phase increases


Step = heel strike of one foot to heel strike of other foot
Stride = Heel strike of one foot to heel strike of same foot (i.e. 1 gait cycle)

Gait pattern description

Time (temporal)
  • Stride - duration of a full gait cycle
    • <1
  • step - duration of complete right/left step
    • reciprical of cadence
  • stance - Duration when foot is on the ground in one gait cycle
    • 60%
  • single support
    • duration when only 1 foot is on the ground in 1 gait cycle
  • double support
    • duration when only both is on the ground in 1 gait cycle
  • swing time
    • duration when foot is in hair


Distance (Spatial)
  • Stride (1 gait cycle!)
    • Normal = double step length
  • Step
    • Right step length = left step length
  • Step width (lateral distance between both heel centers of 2 consecutive foot contacts)
    • 7cm
  • Foot angle (angle between line of progression and long axis of foot)
    • 7 degrees

Speed
  • Cadence (steps/min) - 100steps/min
  • Walking speed (m/min) = Step length (m) x cadence (steps/min)
    • Lower if tall
    • Higher if short

Pathological gait

Waddling / Trendelburg: Weak hip abductor (Gluteus medius and minimus) due to damaged superior gluteal nerve (located above piriformis), therefore, contralateral hemipelvis drop


Lateral hip rotators: PGOGOQ
  • piriformis
  • gemellus superior
  • obturator internus
  • gemellus inferior
  • obturator externus
  • quadratus femoris


Patient History

Greet patient
Intro self
Gain consent for interview

Patient details: Name, age, sex

CC: Keep in succint

 

HPC:

  • Let patient tell story
  • Trigger
  • Progression
  • Relieving/worsening factors
  • SOCRATES for pain (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity)


PMH

  • M: (Other) Medical conditions
  • I: Inpatient admission?
  • S: Surgery
  • T: Trauma

DH
  • m: medication: drug, indication, dosage, regimen,
  • o: OTCs
  • h: herbal/alternate
  • i: illicit
  • a: allergy

FH
  • anyone with condition?
  • death age?
  • family tree if needed

SH
  • Family: Live with
  • A: alcohol (units.. if high  do CAGE; 1 unit = half a pint [1 pint is 567mL) of beer , 1 small glass of wine, 1 short spirit).. if pint... just x2 to get units!
  • S: smoke (pk years = x/20 x years): do you smoke? before? when smoke - how many pks a day/stop smoking! if smoke again, smoking cessation service approach b4? if fail, why didn’t it work?
  • Travel
  • Ideas, concerns, expectations



Systemic enquiry
GGG NHx CRIMED  - General, gastro, geniturinary, Neuro, haematological, CVS, Resp, integument, MSS, Endocrine, drugs

General

fever, appetitie, weight, nausea, vomtiing


Neuro: lost of conscioussness, headache, fits, change in smell/taste/vision, bowel/bladder, motor/sensory hanges

 
Terms to know
Dysarthria: Difficulty speaking (oral... motor lesion)
Dysphagia: (gut) Difficult swallowing
Dysphasia/aphasia: 2 types

  • Receptive: Can’t understand (Wernicke’s lesion)
  • Expressive: Can’t produce (Broca’s lesion)
Anosmia: Can’t smell
Parosmia: Can’t identify smell
Endocrine

Heat/cold intolerance

CVS: Chest, respi, and legs

Chest pain on exertion (angina)

SOB

Palpitations

N&V

ankle swelling

MSS (Musculoskeletal)

Joint pain, stiff, swelling
Mobility

Respiratory:

 

Upper resp: Temp, myalgia, runny/congested nose, sore throat, hoarase voice

Lower resp

A sequence of walk, cough, sputum, wheeze

SOB?
Walk for how long?
Cough? If so, what colorr

  • mucoid: asthma/COPD
  • yellow: asthma (eosinophil), acute lower resp infxn
  • green: dead neutrophil (chronic infxn - pneumonia, bronchiectasis, CF)
  • rusty red: strep pneumonia (lysis RBC?)
Wheezes and sounds
Breathless when ying flat (orthopnea), at night (paroxysmal nocturnal dyspnea)

Integumentary

Bruising?
Skin rash?
Genito: 4 P’s

Partners: number
Pain: in sex?
Pus: Discharge? and menstruation (Menarache, intermenstrual bleeding, menopause)
Pregnancy

Urinary: freq, nocturia, frank haematuria, stream, continence, urgency, pains,

GI

Difficulty swallowing? Vomiting?
Heartburn?
Bowel - abdo Pain, bloating, cobh, discharge (stool color and consistency/blood/mucus/pus)

Jaundice specific: Itching, eyes, pale stools, dark urine  



Summarize
Any questions?
Thanks.



GALS

3 questions
  1. Difficult going up stairs
  2. DIfficulty putting on clothes
  3. Pain/stiffness in muscles/joint

Gait

Observe:
  1. Patient standing: Front (knee swelling) , bank (shoulder, spine, iliac crest, popiteal, calf, ankle), lateral (normal cervical and sacral Lordosis, lumbar kyphosis)
  2. Patient walk and turn

Arms
  1. Hands behind head and then back
  2. Palms up and down - observe swelling
  3. Precision pinch
  4. Grip strength
  5. MCP metacarpophalangeal joint squeeze

Legs
  1. Lie on couch
  2. Hip internal and external rotation
  3. Knee: Flex and extend
  4. Patellar  tap
  5. MTP metataralphalangeal squeeze
  6. Feet sole - callus (thick skin)

Spine
  • Ear to shoulder
  • Touch toes

Report findings
….........

Specific examination - Look for Symmetry, muscle wasting, scars  SMS

Hands
  • On pillow
  • Look
    • Palm and other wise: swelling, bruise, erythema (alcoholic), loss of redness in palmar crease (anemia) deviation, muscle wasting, SCARS(carpal tunnel release), symmetry, joints (MCP metacarpophalangeal, DIP distal interPhalangeal, PIP proximal inter phalangeal, carpal)
    • Nails: see above
  • Feel
    • Temperature using back of hand
    • Squeeze - MCP - ask ptnt if hurts
    • Feel MCP (2 finger above and below), DIP and PIP (index and thumb only) - ask ptnt if hurts
    • Patient’s nerves - median, the ulnar, and the radial nerves
    • Pulse - Radial pulse
    • Elbow - rheumatoid nodule, gouty tophi
  • Move: Active and passive
    • Wrist
      • Prayer’s sign
      • Phalen sign
      • Wrist extension and flexion
    • Fan fingers out against force and gravity (no pillow)
      • Also see for
    • Fist
      • Form fist
      • Power grip my hands
      • Precision pinch
      • Pick up object

Spine
  • Look
    • Muscle wasting
    • Cervical lordosis, thoracic kyphosis, lumbar lordosis
  • Feel
    • Spinous process
    • Sacroiliac joint
  • Move
    • Cervical: Lateral flexion,  rotation, flexion and extension
    • Thoracic: Sit to fix pelvis and cross armed, rotate body
    • Lumbar
      • 2 fingers along lumbar spine
        • Apart = flexion
        • Together = extension
    • Sacral.. no... spine!
      • Lie on couch
      • Straight leg raises then dorsiflex
        • Tender? Nerve entrapment
      • Tendon reflex
      • Babinski

Hip examination

Look
  • Lie flat
  • Compare symmetry
    • Femur fracture: One leg short and is externally rotated
    • Distance from ASIS to medial malleolus

Feel:
  • Greater trochanteric palpation - bursitis

Move: Feel for crepitus
  • Flexion
  • Internal and external rotation with leg at 90 degrees
  • Two tests
    • Thomas
      • Hand behind patient’s back and patient flex legs
      • + (Fixed flexion deformity) is contralateral leg rise
        • Normal: Contralateral hips extend so contralateral leg stays on couch
    • Trendelberg
      • Stand on one leg
      • + is contralateral drop of hip
        • Cause: Weak abductors: Superior gluteal nerve for gluteus medius and minimus

Walk: Observe gait

Knee examination

Look
  • From end of bed
  • Valgus (knees together)
  • Varus: (knees repel - apart)
  • Rash, scar, muscle wasting

Palpate
  • Temperature: Feel with back of hand - thigh, knee, tibia
  • Patella
    • Front: (Patellar tap: Push down on suprapatellar and press) - knee effusion
    • Around: patella border
    • Behind: Popliteal cyst

Move (Active and passive): Feel for crepitus
  • Extension and flexion
  • Special test for ligament
    • Anterior draw test: ACL damage?
      • 90 flex
      • Cuff knee with thumb over tibia and pull to self
  • Posterior sag test
    • Hips and knees at 90. Support patient’s legs at ankle and observe is tibia shifts posteriorly compared to other knee.
  • Collateral ligament:
    • Flex 15 and push joint laterally and medially


Function: Walk to observe


Shoulder examination

Look: Symmetry, scars, muscle wasting
  • Front
  • side
  • Back

Feel
  • Temperature over joint
  • Bony landmarks (acromion, clavicle)
  • Muscles (Rotator cuff muscles - SITS suprascapularis, infrascauparis, teres minor, subscapularis)

Move: Feel for crepitus
  • Hands behind head and back
  • 90 tucked in and internal and external rotate - frozen shoulder
  • Extend and flex shoulder
  • Adduct and abduct

Respiratory exam



Intro
explain and consent
confidentiality
patient at 45 and remove top
wash hands
General inspection
  • things around patient: inhaler, mucus pot etc.
  • general/head
    • appearance? (nutritional status, sob, cyanosed, sit up to breathe, pursed lips - COPD)
    • rate, depth, regularity
  • neck: use of accessory muscles
  • chest
    • deformity (pectus excavatum - sunken chest - congenital, pectus carinatum - pigeon chest - congenital, barrel chest - emphysema due to high lung compliance)
    • SMS: scars, muscle wasting, symmetry
  • leg
    • edema?


Hands and upwards

Hands
  • inspect: color, clubbing, cigarette, capillary refill
  • feel temperature
  • Flapping tremor - patient extend arm and dorsiflex (CO2 retn)
  • radial pulse: character, rate, rhythym (DO resp. rate at same time 60s pulse 15s but don’t say!!!)

Face
  • Apperance: Cushingoid (steroid)
  • Eyes: Anemia
  • Mouth - central cyanosis (tongue out and up)
  • Angle chelitis around mouth
  • Neck (front to side)
    • Trachea palpation
      • warn patient first
    • Lymph node
    • JVP jugular venous pressure (IJV internal jugular vein- between two heads of SCM sternocleidomastoid x base clavicle): normally height 3cm or less above sternal angle
      • turn head to left side
      • IJV located from medial end of clavicle to the ear lobe under medial aspect of the sternocleidomastoid.
      • Vertical height of the highest point of pulsation above the sternal angle: Normal is 3cm or less
        • R. atrium lies 5cm below the sternum so total is 8cm. This corresponds to the right atrial pressure (total height x 0.75; i.e. 8 x 0.75 = 6mmHg)
        • RAP Right atrial pressure greater than 6mmHg is a right heart problem (e.g. right sided heart failure, pulmonary disease) or Superior vena cava obstruction, tricuspid regurgitation
        • A low pressure indicates heart is underfilled (hypovolemia)
        • A low pressure indicates heart is underfilled (hypovolemia)
      • Hepatojugular reflUx: Use pressure below right costal margin to elevate JVP to confirm
      • Internal Jugular Vein is in straightline with right atrium, thus is a good measure of central venous pressure
      • Pulsation:
        • (presystolic) a wave - right atrial systole, before carotid pulse
          • absent if AF
          • large if tricuspid stenosis, right heart failure, pulmonary HT
        • (isovolumetric) c wave - bulging of tricuspid valve to right ventricle
        • x wave - right atrial relaxation
        • (systolic) v wave - ventricular systole, venous return to right atrium, after the carotid pulse
          • height indicates right heart filling pressure (high in heart failure)
        • y wave - opening of tricuspid valve, blood flows to right ventricle
        • early V then steep Y → TR


Chest
  • inspect: SMS scars (lobectomy, pneumonectomy, chest drain) muscle wasting, symmetry (hands at rib side at bottom of chest)
  • palpate: percuss apex beat (collapse in affected side or pushed from other side)
  • percuss (do both sides in a row to compare)
    • clavicle -> 3 more (top, middle, base zones not lobes) -> 2 axillary (top and bottom)
      • resonance: emphysema, pneumothorax
      • dull: consolidation (e,.g empyemia - pus , fibrosis)
  • auscultate using diaphragm (hears abnormal - high freq; bell is for low freq - normal only...)
    • deep breath through mouth
    • apex -> same places
    • breath sound?

LocationIntensityPitchLocationDescription
TrachealLoudHighTracheaInsp. = Exp.
Vesicular (Rustling of dry leaves)SoftLowMost of lungsInsp. > Exp.
Bronchial (trachea)LoudHighNormal - Trachea and manubrium

Abnormal: Consolidated areas
HOLLOW sound

Gap between insp. and exp

Exp. > than insp.
BronchiovesicularMediumMediumNormal: 1st and 2nd IC space between scapula

Abnormal: Consolidation
Insp = Exp
Adventitious (abnormal)



Crackles (Rales)

- Caused when previously closed small airways open on inspiration

- Air bubble through secretion



Heard on inspiration

Discontinuous

Non-musical

Scarred: PUl. fibrosis

Fluid stuff: ARDS, asthma, bronchiectasis, bronchitis, consolidation, CHF, pul. edema
Wheeze
High pitch
- Monophonic - tumor
- Polyphonic - general obstruction (asthma)

Continuous on expiration (through narrowed!!!)

Asthma
Bronchitis
RhonchiLowMusical
Continuous

Similar to wheezes

Obstruction of large airway (secretion, tumor etc.)
Stridor (EMERGENCY!!!)

Obstructed trachea/larynx

Musical wheezeTracheaInspiration
Pleural rub
Insp. and Exp.LocalizedInflamed pleura rub together

Pleural effusion
Pneumothorax
Mediastinal crunch

(EMERGENCY)

Synchronized with heart beatPatient in left lateral decubitisCrackles

Pneumoediastinum


Back
  • inspect - equal symmetry?
  • percuss 3 zones
  • auscultation: in and out through mouth

Special test only if problem
  • vocal resonance: 99 louder on consolidated lung using ascultation
  • TVF: feel using edge of hand (increased if consolidation)
  • whispering petrolique: whisper 99 (hear louder through consolidated lung) using auscultation

Thank you.


PEFR peak expiratory flow rate

- Intro
- Check patient’s understanding of asthma
- Explain imp’t of PEFR, what it does is measures the fastest rate that you can blow air out of ur lungs (not about time)
- Explain to be done first thing in morning
- Say
  1. slide marker to 0
  2. sitting straight
  3. inhale deeply
  4. seal lips tightly, hold horizontally and keep fingers away from marker
  5. exhale as forcefully and quickly until all air is cleared
- repeat 3x - best of 3
- record
- Any qns?
- I demo
- You do


Forced exp. time (Obstructive lung disease >6s)


Inhaler
  1. Intro
  2. Check patient’s understanding of asthma
  3. Explain what inhaler does
    1. bronchodilator
    2. relatively free of sfx
  4. Say
    1. shake inhaler
    2. remove cap
    3. hold inhaler between index and thumb
    4. see expiry date and press once to see if contents
    5. breathe out
    6. seal lips, breathe in deeply, and press inhaler
    7. hold breathe for 10s
  5. any qns?
  6. i demo
  7. ptnt demo


GI Exam

Introself
Patient expose from nipple to ASIS anterior superior iliac spine

Relax on FLAT bed
Chaperone?
Eyes: Remove glasses, look up, pull down → Jaundice, anemia?
Mouth - Tongue, angular colitis (anemia)
Hands - Capillary refill, clubbing, flapping tremor, palmar erythema

Inspect

  1. 5F’s: fat, fetus, feces, flatus, fluid
  2. scars, striae (rapid weight gain)
  3. vascular - aneurysm, caput meduase (paraumbilical veins), Grey turner’s sign (acute pancreatitis - flank bruising), cullen sign (bruising around umbilicus - acute pancreatitis)

Palpation - not massage...
  1. ask patient if pain in ab? and let me know when it hurts
  2. Observe patient emotion
  3. all 9 regions
    1. light tenderness
      1. murphy’s sign: firmly placing hand at costal margin in the RUQ right upper quadrant and ask patient to breathe → if acute cholecystitis (inflammed gallbladder) → pain → patient catches breath as it descends
      2. abdominal guarding: peritonitis: press on ab → contract
      3. rebound tenderness: Mcburney’s point for appendicitis ASIS to umbilicus (distal ⅓)  
    2. deep mass
  4. all 9 regions
  5. liver: moves on resp (move in before patient breathes in - when breathe in it will descend so you can feel it)
  6. spleen: movting (push together)es on resp (move in before patient breathes in - when breathe in it will descend so you can feel it)
  7. kidney: cuff rib behind back x front → blot
  8. ascities
    1. shifting dullness
      1. percuss down until dullness
      2. turn to other side
      3. percuss up until resonant
    2. fluid thrill
      1. patient place hands between
      2. doc put one hand on one side and the other
      3. push and feel for vibrations on other side
Percussion
  1. all 9 regions
  2. Liver span (down and up)
  3. spleen: last interspace in left anterior axilary line. percuss then ask patient to inhale and percuss again. if decrease tympany (i.e. decreased resonance due to dullness) -> enlargeds pleen

Auscultation

  1. Bruit?
  2. General: Loud (obstruction), none (paralytic ileus)

Go on to do
  • Hernial orifice
  • Rectal
  • Testicular examination

Rectal exam
  1. Chaperone?
  2. Gauze + gel, apron, gloves
  3. Warn patient about finger up
  4. Fetal position to left
  5. Inspect perianal area: Bleeding, fistula (Crohn’s), hemorrhoid
  6. Insert: Superficial then deep
    1. anterior: prostate
  7. inspect: glove for blood

Scrotal exam
  1. brush penis to side
  2. ask patient which testes tender
  3. feel non-tender first
  4. one behind one front - smooth, lumpy?
    1. epidymal cyst: smooth non-tender
    2. testicular cancer: young people, high cure
    3. testicular torsion: 4 hours then die
  5. feel both

Cardiovascular exam

Intro
explain and consent
confidentiality
patient at 45 and remove top
wash hands
General inspection
  • things around patient
  • face: malar flush
  • precordium: scars (median stertomy: CABG, valve), pulsation, pacemaker
  • leg
    • edema? (CHF)


Hands and upwards

Hands
  • inspect nail: color, clubbing (endocarditis, cyanotic heart), cigarette, capillary refill, curvature (koilonychia - iron deficiency)
  • feel temperature
  • radial pulse: character, rate, rhythym (Do resp. rate at same time 60s pulse 15s but don’t say!!!)
  • pulse in other arm -> radioradio delay? (aortic coarctation/dissection)
  • AR
    • pain in shoulder? if no, raise arm - radial pulse (AR - collapsing pulse)
    • Arm BP measurement

Face
  • Apperance: malar flush (MS mitral stenosis)
  • Eyes: Anemia, corneal arcus (cholesterolemia) ; eyelid - xanthalesma (fatty lump - cholesterolemia)
  • Mouth - central cyanosis (tongue out and up)
  • Angle chelitis around mouth
  • Neck (front to side)
    • Trachea palpation
      • warn patient first
    • JVP (IJV): normally height 3cm or less above sternal angle
      • turn head to left side
      • IJV located from medial end of clavicle to the ear lobe under medial aspect of the sternocleidomastoid.
      • Vertical height of the highest point of pulsation above the sternal angle: Normal is 3cm or less
        • R. atrium lies 5cm below the sternum so total is 8cm. This corresponds to the right atrial pressure (total height x 0.75; i.e. 8 x 0.75 = 6mmHg)
        • RAP greater than 6mmHg is a right heart problem (e.g. RSHF, pul. disease) or SVC obstruction, tricuspid regurgitation
        • A low pressure indicates heart is underfilled (hypovolemia)
      • Hepatojugular reflUx: Use pressure below right costal margin to elevate JVP to confirm
    • carotid pulse
      • feel both pulses: medical to SCM
      • auscultate (deep breathe in, hold it) - ejection murmur?
        • unilateral: stenosis - bruit (soft high pitched shshing)
        • both sides: heart valve


Chest
  • inspect: precordium
  • palpate
    • ask patient if experience chest pain
    • lean foward if hard to palpate
    • hands on apex beat (5th intercostal midclavicular)
      • displaced? if lateral - hypertrophy
      • tapping (opening snap) - MS (in AS aortic stenosis - ejection click)
      • thrill (due to blood through stenosis!)- AS
      • heaving (due to pressure overload)- left ventricular hypertrophy, AR aortic regurgitation
      • hyperdynamic apex (diffuse forceful, ill-sustained)
        • ventricular dilation (AR, hyperdynamic circulation)
      • absence (DRPOPE)
        • dextrocardia, rib (behind), pericardial effusion, obesity, pleural effusion, emphysema (COPD)
    • hands on either sternum side
      • heaves
        • left parasternal: left vent. heart strain
        • right parasternal: right vent. heart strain
      • thrill
        • 2nd IC: Pul. a. stenosis
  • auscultation (hold breath so no lung movement to distract, always time with carotid artery!)
    • aortic, pul., tricus, bicus


Murmurs - turbulent blood flow

http://intmedweb.wfubmc.edu/grand_rounds/1998/cardiac.html#Characterization%20of%20Murmurs


Low frequency sounds (S3, S4, MS rumble) are best heard with the bell applied lightly, whereas high frequency sounds (clicks, OS, MR) are best heard with the diaphragm

Mitral murmurs radiate to left axilla
aortic murmurs radiate to left carotid artery.

special tests for MS (bell) and AR (diaphragm)!!!
MS lean left, AR lead forward

Chest palpation: equal chest expansion by palpating

MTAP" for the order of valve closure during the cardiac cycle


• AS and MR= Systolic.

• AR and MS= Diastolic.

Systolic murmurs easier to hear than diastolic: high pressure ventricular contractions.


AR (lean forward to left, hold breath in expiration)

Blowing, high pitched (arrrrr)

aka aortic incompetence
Collapsing pulseThrusting cardiac apexEarly-Diastolic murmur best heard at tricuspid)

Decrescendo
*
Radiate to carotid significant!!! - increases ventricular pre-load, resulting in ejection of an augmented stroke volume
MR

Blowing
Displaced pulseThrusting cardiac apexPan-systolic murmur best heard at mitral areaRadiate to axilla (armpit... mr...)
AS

(Common in men)
Slow rising pulseHeaving cardiac apexMid-systolic (i.e. crescendo-decresendo [start softly, loudest in mid-systole, then decrease], after S1) murmur (ejection systolic click - aortic valve open) best heard at aortic area

When the stenosis becomes more severe, the point at which the murmur is loudest (i.e. its peak intensity) occurs later in systole, as it takes longer to generate the higher ventricular pressure required to push blood through the tight orifice.


Radiate to (both) carotids
MS (bell and lean forward to left, hold breath in expiration)
Does MS ring any bells from SSC?

Low pitch (mmmm) rumbling

(More common in women, 4x more common than MR, left atrial dilation, hypertrophy, AF, thrombus, pul. congestion, pul. a. pressure increase -> RHF)


Mid-diastolic murmur (Opening snap
- Stiff valve makes noise as it opens) best heard in axilla
Mallar flush
MVP (Mitral valve prolapse)

Apical mid-systolic click


Blood flowing through small calcified valves, low pitch  - STENOSIS (MS or AS)
- AS aortic stenosis: Mid-systolic, radiates to carotid, crescendo-decresendo (two extremes)
- MS mitral stenosis: Mid- Diastolic (after passive filling...), RUMBLING, crescendo, opening snap!!!

High pitch (in mouth), blowing as as sound goes back to valve -  Regurgitation
- AR aortic regurgitation: Descresendo (first to last letter), diastolic, radiate to left sternal border
- MR mitral regurigtation: Holo/Pansystolic, radiate to left axillary line, best heard at apex, same loudness (M and R almost same)

Location, timing, pitch, pattern (creseneodo,), quality (rubmling), intesntiY

Murmur grading: 1 - Not audible, 6 - See murmur and verly audible


Normal heart sounds
Lub (S1) dubb (S2)
Louder if thin person
Softer if fluid around heart


Lub - S1 (M1 T1) - Closure of mitral and tricuspid - Beginning of Systole
- T1 (T1 later because venous return from entire body) occurs just slightly after M1 so in effect only one heart sound is heard
- M1 is louder than T1 due to higher pressure gradient in left side of heart  (radiate to cardiac apex)
- Splitting (i.e. do not close at same time)
  • Best heard at tricuspid area because M1 is too loud and will just dominate otherwise
  • Mitral valve closes significantly before tricuspid
    • Normal when inspiration: venous return delays tricuspid closure, or RBBB (impulse reaches left ventricle before right)
- No split S1
  • LBBB: Impulse reaches right before left ventricle (tricuspid valve closes earlier so overlap between M1 and T1)
- Loud S1: MS (opening  snap!!!)
- Soft S1: MR




Between S1 and S2 is the pulse


Dubb - S2 (A2 P2) - Closure of aortic then pulmonary - Begining of Diastole
  • P2 (P2 later because venous return from entire body) occurs just slightly after A2 so in effect only one heart sound is heard
  • A2 is louder than P2 due to higher pressure gradient
    • Even louder if hypertension (left ventricle has to work harder to close the semilunar valves) [Aortic HTN: Aortic component louder A2, Pulmonary HTN: Pulmonary component louder P2]
  • Splitting
    • Best heard at pulmonary area because A2 is too loud and will just dominate otherwise
    • Physiological split on inspiration (inspiration delays right heart emptying due to increased venous return -> Pulmonary valve opens longer so closes later  so A2...........................P2, common in young (deep breath and hold it)
    • Abnormal splitting when
      • widened (persistent) - during entire resp. phase
        • Inhale AND exhale but splits greater when inhale - RBBB (P2 closes later) or MR (stroke volume enters left atrium causing the left ventricular pressure to decrease faster so A2 closes early)
      • Fixed - during entire resp. phase
        • Inhale AND exhale  (same amount of splitting regardless!) - ASD/VSD (extra blood return during inspiration gets equalized between the left and right atrium due to the communication between the atria/ventricle)
      • Paradoxical
        • Exhale only - (caused by delayed aortic valve closure e.g. LBBB, AS)
          • exhale only b/c during insp., pul valve closes later!
  • Softer if AR, AS


Diastole lasts LONGER than systole.

Abnormal heart sounds
S3 and S4 - diastole (passive filling then atrial contraction respectively) are called gallops.
Common if young, pathology if old patient

S1   S2    S3  
Ken TUC  ky (soft and low pitch S3)

Cause of S3 (ventricular gallop): Passive filling (after S2) of blood to overly compliant left ventricle in early diastole
  • Fluid overload (pregnant) Heart failure (dilated LV), normal in young people


S4   S1    S2

(soft and lower pitch than S1) a    STIFF  wall

(wall... four) S4 before S1!!!
Cause of S4 (atrial gallop): Atrial contraction (just before S1)-> Blood hitting non-compliant i.e. stiff/thickened ventricle wall
  • ventricular hypertrophy due to hypertension

Thrill: Vibration and murmur

S4 and S4 heard via apex - soft low pitch extra sounds (S3 is after S2 and S4 is before S1)
If can’t hear - position patient to lean to the left

S3 and S4 - summation gallop.


Respiratory function

Compliance: Ability that lung can stretch
Resistance: Difficulty for airway to be driven through airways

Restrictive: Lungs unable to expand (e.g. fibrosis, kyphoscoliosis)
Obstructive: Asthma, COPD

  1. Switch on vitalograph spirometer (green knob on left)
  2. Set chart carrier fully to left by depressing black rocker switch (on the right) to the left. Then switch to center (for paper…).
  3. When in center position, insert chart upside down. Lift stylus and slide paper under it.
  4. The stylus should be pointing the zero point. Insert mouthpiece to tube. Noseclip to subject and breathe normally.
  5. Black rocker switch to left then to right. (During test is right)
  6. Maximal inspire, seal lips around mouthpiece, Expire as fast and completetely (continue until plateau is reached) – chart moves…
  7. Return to original position (i.e. black rocker switch to left – reset is left). Remove mouthpiece and replace.
  8. Repeat to have 3 recordings (i.e. black switch to left -> once mouthpiece is removed, replace again -> left -> right)

Write patient details to chart

For other tests
Restrictive: Normal inspire, expire as fast
Obstructive: Cardboard mouthpiece, 4 holes using tape (MUST secure lips)


Prothrombin time

BLOOD
Pointy stuff (needles and pipette to yellow sharp)
  • Gloves, others Yellow bag
  1. Venepuncture to collect venous blood
  2. Mix blood by inverting tube (do not shake)
  3. Centrifuge
  4. Transfer the plasma (label neat plasma)
  1. Label thromboplastin (tissue factor) tube
  2. Pipette Thromboplastin and calcium chloride into tube, invert
  3. tube to water for 1 minute and plasma for 1 minute
  4. Add plasma stock to thromboplastin tube
  5. Start timer
  6. Periodically remove to see if fibrin has formed
  7. Stop timer and record time

INR international normalized ratio = (PT test  / PT normal)^ISI
x /12 ^1.05
ISI = 1.05
PT (prothrombin time) normal 12s

1 in 10 dilution of the plasma (e.g. 1ml of plasma, add 9mL of saline)

Measuring blood flow
  1. Record control radial pulse
  2. Measure forearm blood flow
    1. Cuff around arm
    2. Stretch transducer to lower arm just below elbow
    3. Finger pulse transducer in middle finger
  3. Ischemia (inflate above systolic): 2 minutes then release
    1. Balloon to rapidly inflate/deflate
  4. Exercise ipsilateral arm
    1. Squeeze dynamometer
  5. Exercise contralateral arm
    1. Squeeze dynamometer


Beta-adrenergic agonist effects on BP
- BP, Pulse pressure (SP-DP)
- HR
- PEFR
- Exercise
- Drugs: Propanolol and salbutamol and placebo
Time related to exercisePulseSPDPPP
-10



-5



Exercise



5



10



15



20





Systolic BP
- Related to stroke volume (or CO) which is determined by
  • Blood volume
  • Inotropic (Contractility)
  • Chromotropic (HR)
Diastolic BP
- Related to TPR of arterioles (Viscosity/radius^4)
  • Vasodilation - TPR: Decrease TPR and Increase Venous return (e.g. NO, Histamine)
  • Vasoconstriction - TPR: E.g. a-adrenergic, ATII

Decrease HR → +Systolic and -Diastolic
  • +Systolic to maintain perfusion
  • -Diastolic to allow increase perfusion

Normal resting pulse pressure: 40 (120-80)

High pulse pressure during exercise: Increased stroke volume (+Systolic) whilst decreasing TPR (- diastolic) to maintain perfusion!!!

Low Pulse Pressure
- Low stroke volume (so less CO → Less SP) due to significant blood loss, CHF, shock
- Aortic stenosis (less CO)
- Heart unable to expand (pericardial effusion, collapsed lung due to pneumothorax) - low pulse pressure


High pulse pressure
- PDA: Low pressure pulmonary circuit linked to systemic circulation.
Low DP - blood empties out into pulmonary during diastole
High SP - heart has to increase CO to meet systemic demands (due to the shunt...)

AV Fistula: Artery blood shunted to venous → Increased venous return → Increased SV and CO
Body autoregulates this by decreasing TPR → Decreased diastolic so more compliant venous system
Stiff artery - High systolic (arterial system is non-compliant) and normal diastolic → WIDENED PP

Sympathetic nervous system releases NE whilst adrenal medulla release EP

Heart
  • B-1 receptors - +inotropic, chronotropic
Vasculature
  • alpha1-receptors on VSM (especially on arteriole) -> vasoconstriction
  • Beta receptors cause vasodilation in skeletal and coronary circulation

Parasympathetic

Heart
  • Dorsal motor nucleus: Slow heart rate
Vasculature
  • No effect on TPR (except for erection)

MAP = ⅓ SP + ⅔ DP (as Diastolic is longer)

Exercise
Low dose - EP stimulates B receptors - vasodilation
High dose - EP stimulates alpha-receptors -> vasoconstriction
EP is positive chronotropic, inotropic
Much stimulation of B receptors: +inotropy → +CO → + Systolic BP
Less stimulation of alpha-receptors → Vasodilation - less TPR → - Diastolic BP
WIDENED PP


Supply for BV
alpha1(Gq): Vasoconstriction (Gq... Calcium...) for non-essential bits (e.g. skin - vasoconstriction when frightened - sympathetic)
Beta2 (Gs): VasoDILATION (Gs... PKA-inhibit MLCK) - think about it... fight or flight essential muscles need perfusion!

Exercise
+ Pulse (B1-adrenergic - heart)
+ Systolic BP only (NOT diastolic - no change in TPR)

Propanolol: Nonselective B-blocker
- B2 (vasodilation) inhibited, but alpha1 still constricting thus, vasoconstriction (TPR)

Salbutamol (B2-selective) agonist
- B2 receptors on skeletal muscle -> muscle tremor (and glycogenolysis)
- Vasodilation -> Reflex tachycardia (+HR)


Pharmacology: Drugs and eye

Drug

Tropicamide (m4)Antagonist of M4 receptor (Block constrictor pupillae) thus allow mydriasis (pupil dilation)Shorrt half-life, thus, used for eye examination to see better insidesfx: Glaucoma
Phenyllephrine (ephrine...alpha1 adreno)Alpha-1 agonist (-> dilator pupillae) -> Mydriasisused with tropicamide to dilate pupilGlaucoma
Pilocarpine

non-selective... two functions -
Nonselective receptor agonist - cause ciliary muscle to contract, opening the trabecular meshwork for drainage through schlemm.

It also causes sphincter pupillae to contract (miosis)
Glaucoma


Administer drug to ONE EYE ONLY- Press on punctum so drug won’t drain into nasolacrimal duct. Discard immediately after!!!
TimePupil size (mm): Pupil gaugeLight responseNear point (cm)Near vision
(near card)
Far vision (Snellen chart)








N5... 15 cm...

Near vision using near card (Test for hyperopia and presbyopia)
Explain patient testing near vision
Seat patient
Use room lights only
Patient hold card 30cm away
Cover one eye and read smallest N-notation text (always encourage to try smaller)
Record N....
Repeat the other
Binocular vision

N5 is normal

Near point convergence using RAF rule
Asthenopia - eye strain

Wearing glasses
Position light behind the subject and illuminate the object
Explain to patient - a test on how well eyes converge (I am going to move this line towards you. I want you to tell me when it begins to go double)
Slowly move line to patient
Watch their eyes to see if one eye loses focus
If patient reports double line when 15cm away, repeat

Near accommodation using RAF rule

Wearing glasses
Position light behind the subject and illuminate the object
Explain to patient -test to see amount of focusing power of the eyes, tell me when it becomes blurry
Slowly move TEXT to patient
Cover one eye and read N5
Note diopeters on side!
Repeat the other
Binocular vision

Blind spot testing using Bjerrum screen



Scotoma: Altered field of vision
Assess using visual field test
Say to patient to focus on center and tell me when the thing I wave dissapears
Assess rod function
Use large white disk and seat patient 1m from screen wearing glasses.
Occlude one eye.
Direct patient to look at center of chart the entire time
If testing left eye, stand on left vice versa
Start at outer edge and snake-like towards blind spot
Test to see adjacent areas to confirm
Record result
For the same eye, pass the target for the other side
Repeat for other eye

Octopus: NO BLIND SPOT!!!!

Measuring visual acuity


Snellen chart for testing distance vision
  1. have patient seated 6m
  2. remove glasses
  3. now we shall test what you can see
  4. cover one eye
  5. what is the smallest line you can read? if can’t see at 6m move patient closer (but when writing results it is the test distance / smallest line)
  6. record visual acuity (test distance i.e. 6m / number of the smallest line on which most letters are visible e.g. 6/9)
    1. for wrong words... 6/9-2
    2. i.e. 2 words wrong
  7. repeat for other eye
  8. then for binocular

always fog with + (black)
insert corrective lens behind frame, for astigmatism, insert them in front
Fixing spherical errors
  1. fit trial frame and adjust (discomfort?)
  2. fog one eye with black +1D to relax the accommodation reflex
  3. check to see that VA has reduced by 3 lines based on results above
  4. correct other eye using red frames -0.25D  diverging lens
  5. better or worse? and continue as long as vision continues to improve
  6. record result
  7. repeat for other eye
  8. binocular vision by putting the lens and removing fogging lens



Distance vision

Like opthalmoscope... + for anterior - for posterior structures

OD (dominant) for right eye, OS (shi*) for left side

Hyperopia (long sighted): Short (e.g. babies... small eyes!)/weak eye so use + lens (converging lens) to bring the image forward to focus on the fovea
  • Example of prescription using spherical lens: OD +1 OS +2

Myopia (short sighted): Long/strong eye so use - lens (diverging) to bring the image back to focus on the fovea
  • Example of prescription using spherical lens: OD -1 OS -2



Test for astigmatism using fan and block
  1. Keep corrective lens in place!
  2. Occlude one eye with blank disc (blue rim)
  3. Test the other eye
    1. add +0.25D lenses (black) until subject VA drops by one line
    2. illuminate fan and block
    3. does any of the liens stand out?
      1. if none add a further +0.5D  - if equal(/blur) then no astigmatism
      2. if stand out, record the number above that line (axis of astigmatism)
    4. point V to line that appears darkest
    5. confirm astigmatism by asking the patient which of the boxes stand out (should be the one with lines parrallel to the dark line)
    6. start adding -0.25D (red) lens in front of the frame and rotate until the white lines are lined up with the angle of astigmatism
    7. keep adding in -0.25d until boxes are just as clear as each other
    8. remove the +D lens until VA is or better than 6/6
  4. repeat for other eye


Astigmatism: Some shallow some thick CORNEA (not perfectly round like bball but like a rugby ball)
  • Horizontal and vertical waves focus differently
  • Correction using cylinder (power along one median only) - see diagram above

In this image, the cylinder allows only light of horizontal thus correcting the horizontal one

Glasses prescription
Fix prescription error (spherical) + Astigmatism (cylinder + axis)
e.g. +2 + 1 45degrees


Presbyopia: Stiff lens so can’t focus on retina... image focuses on back of eye
Correction using + lens
Fan block for astigmatism,

Otoscope - Examining ear
Inspect
  • Pinna - erythema?
  • behind ear: scars, hearing aids
  • Discharge from meatus?

Palpation - warn patient
  • Pinna - tender?
  • Tragus - tender?
  • Feel lymph nodes

Auriscope
  1. Explain procedure to patient
  2. Check light
  3. Use largest speculum possible
  4. Use left hand for patient’s left ear - hold auriscope between finger and thumb with ulna border of hand against patient’s cheek (limit trauma)
  5. Pull pinna up and back for adult, down and back for children
  6. Inspect
    1. External auditory meatus - wax, infection
    2. Tympanic membrane (RBC)
      1. reflex: light reflex
      2. bone - Malleus
      3. Color - healthy (translucent), otitis media (red
      4. Other landmarks: Umbo, handle of malleus

LM = lateral process of the malleus; I = incus; U = umbo; LR = light reflex; A = annulus of tympanic membrane; PI = posterior inferior quadrant

Left ear: malleus pointing to the left


The TM is divided into two parts
  • pars flaccida (the portion superior to the insertion of the malleus)
  • pars tensa (inferior)

The point at which the manubrium inserts into the TM - umbo.


Weber’s test

Normal: Bilateral
Abnormal: Lateralize
  • to affected ear in conductive deafness (sounds louder because not picking up background noise - pays more attention to bone conduction e.g. earwax - solid - better transmission)
  • to unaffected normal ear in Sensorineural deafness (affected ear has sensorineural deafness - less effective at picking up sound)



Rinne’s test

Bone conduction: waves travel to the inner ear apparatus through the bones of the skull
  • Normal or sensorineural (bone and air conduction are decreased by the same amount... so same ratio): AC (air conduction better than >BC bone conduction (+)
  • conductive: BC > AC (-)







Weber without lateralization

Weber Lateralizes Left (Louder in Left)

Weber Lateralizes Right (Louder in Right)

Rinne Both Ears AC>BC

Normal

Sensorineural Loss in Right

Sensorineural Loss in Left

Rinne Left BC>AC


Confirm Conductive Loss in Left


Rinne Right BC>AC



Confirm Conductive Loss in Right




Weber Lateralizes Left & Rinne both ears AC > BC = sensorineural in right
Weber Lateralizes Right & Rinne both ears AC > BC = sensorineural in left

Rinne Left BC>AC & Weber's lateralized to the left = conduction in left
Rinne Right BC>AC & Weber's lateralized to the right = conduction in right

Ophthalmoscopy
Intro
Explain
Consent
Use mydriatic drops
Remove patient’s glasses
Darken room
Remove own glasses
See how much dioptres for me when seeing text
Ask patient to fix on far object straight ahead
Check ophthalmoscope - turn on to hand
Place hand on patient’s head so won’t bump!
Stand away from patient: Set lens at +10 (total of mine + patient’s refractive error + anterior structures use big number diopters), bring it to my right eye to view patient’s right eye and vv.
Hold ophthalmoscope in the same hand as eye (i.e. if patient’s right eye, use my right eye and right hand)
30 cm away: Look at red reflex
As you move in to patient; rotate ring anticlockwise (more negative - posterior deep structures)
  • optic disc (yellow/orange ,well-demarcated?, cup:disk ratio normally <1:2, if high - glaucoma), vessels in all 4 quadrants (from disc to periphery -> upper/lower nasal/temporal), hemorrhage?
    • optic disc is where the optic nerves leave
    • quadrants: nasal, temporal
  • exudate?
  • macula (2 discs away from optic disc) - patient sees look straight into light - contains fovea
    • fovea contains densely packed cones for phototopic vision (color)
    • central depression

optic nerve from optic canal thus it is nasal side!!!
Right eye
Temporal
Sphenoid bone: optic canal: optic nerve and ophthalmic artery
Superior orbital fissure: Sphenoid bone (3,4,v1,6). Live frankly to see absolute no insult (lacrimal, frontal trochlear, trochlear, superior division of occulomotor, abducens, nasociliary and inferior division of occulomotor nerve)
inferior orbital fissure  sphenoid bone - maxillary nerve



Right eye bright spot in right side!!!
loss of peripheral vision so that if the disease progresses unchecked, in the final stages of the disease vision is reduced to a central tunnel of vision.

Microaneurysm: Earliest clinical change in diabetic retinopathy (localized dilation usually saccular - round, appear as dots/clusters)
Intraretinal hemorrhage  (dot/blot hemorrhage or flame shaped)
Hard exudates: Distinct yellow-white deposits made up of lipid leaked from capillary (associated with retinal edema)
Cotton wool spots: greyish-white patches of discoloration in the nerve fibre layer which havefluffy  edges - due to local ischemia causing disrupted axoplasmic flow
Neovascularization: from large vein usually

Retinal detachment: White...

Background aka non-proliferative retinopathy: Microaneurysm to +small hemorrhage (dot/flame)

Preprolif: Cototn wool spot . Prolif: New vessel



Tonometry, or the measurement of the pressure within the eye


IOP is measured by a tonometer, which will be one of two types: either a contact tonometer or a non-contact tonometer. Contact tonometry, as the name suggests, measures the IOP by directly touching the (anaesthetized) eye. It is considered to be the most accurate method of IOP measurement. (Pictured below)



Venepuncture using vacutainer
  1. Intro self
  2. Check correct patient
  3. Explain procedure, warn patient appropriately (cold → sharp scratch)
  4. Plastic apron and collect materials
  5. Break open (without gloves first)
  6. Inspect and palpate vein
  7. Clean with alcohol (clean 30s, dry 30s)
  8. Tourneqeue
  9. Insert needle to container and twist
  10. Bevel up, use dominant hand to insert like poker stick in the direction of vein
  11. Switch hands, then use dominant hand to insert bottle (REMEMBER to fill bottles in correct order)
  12. When blood rushes in, release tournqte
  13. When full, remove and immediately invert
  14. Release for other bottle(s)
  15. Hold cotton wall over site
  16. Remove needle from vein
  17. Dispose sharps to bin immediately
  18. Remove gloves
  19. Label sample and request form at bedside
  20. Remove apron and wash hands
  21. Discuss what happens next
Restart kit if fail!

Parkinsons

* Tremor at rest
* Rigidity
* Akinesia (actually dyskinesia, which is the presence of involuntary movements)
* Postural instability

Neuro exam

Limb examination: SCRIPT G
  • Sensation
  • Coordination
  • Reflex
  • Inspection
  • Power
  • Tone
  • Gait

Sensory

Upper limbs: From shoulder to lateral aspect of arm to medial side (C4 to T2)
Lower limb: From groin to front of leg to posterior (L1 to S3)

Light touch and pin prick (sharp touch)
  • Light touch: Cotton wool (touch not stroke!)
    • Patient to close eyes and tell when felt
    • Compare both sides!
    • Irregular timing
  • Pin: Immediately dispose after use
    • As light touch

Temperature
  • Touch tuning fork - cold

Proprioception
  • Test DIP of index finger
    • Hold middle phalanx with thumb and finger
    • Hold the medial and lateral sides (not top and bottom) of the distal phalanx with the other
    • Move the distal phalanx up and down, showing the patient the movement first.
    • Patient to close eyes →  move the distal phalanx up and down randomly → Direction?
    • Test on both hands.

Vibration sense
  • Vibrating tuning fork on sternum - feel?
  • To DIP

Two point discrimination
  • Patient close eyes
  • Patient's index finger pulp with either one or two use discriminator
  • Patient say whether feel 1 or 2
  • Minimal distance between (normal is 5mm)
  • Repeat for other index finger and both thumbs

Spine
  • Straight leg raising test:
  • • Pt tries to lift straight leg.
  • • Full lifting will be prevented if slipped disc.

Motor

Inspect:
Symmetrical?
Muscle wasting/hypertrophy
Muscle fasciculation (wave like): LMN lower motor neuron disease - Spontaneous firing of an entire motor unit as denervated muscle is overexcitable
Upper limbs: Deformities (wrist drop, waiter’s tip, claw hand), tremor
Lower limbs:Quads, tib anterior

Tone:
Hypertonia: UMN upper motor neuron Lesion, Hypotonia: LMN
  • Upper limb: Patient to let their shoulders/arms/elbow/wrist floppy → flex and extend passively
  • Lower limb
    • Patient to let legs floppy → internally and externally rotate
    • Lift knees off bed → ankle raise?

The flexor-pronator from the medial epicondyle, extensor supinator from lateral epicondyle
  • deltoids - arm abduction - C5 C6 (axillary)
  • biceps - elbow flexion - C5 C6 (musculocutaneous)
  • triceps - elbow extension - C6 C7 C8 (radial)
  • thumb flexion - C6 C7 (median)
  • wrist extensors - C7 C8 (radial)
  • interossei of hand - finger abduction/adduction - C8 T1 (ulnar)
  • hip flexion - L1 L2 L3 (femoral)
  • hip adduction - L2 L3 L4 (obturator)
  • hip abduction - L4 L5 S1 (superior gluteal)
  • knee extension - L2 L3 L4 (femoral)
  • knee flexion - L5 S1 S2 (sciatic)
  • ankle dorsiflexion - L4 L5 (deep peroneal)
  • ankle plantar flexion - S1 S2 (tibial)
  • foot inversion - L4 L5 (posterior tibial)
  • foot eversion - L5 S1 (superficial peroneal)

Power against mine (I will push... don’t let me push it up)
  • flexors > extensors in upper limbs
  • extensors > flexors in lower limbs
  • Upper limb:
    • Abduction, adduction, flexion and extension of the shoulder: Deltoid (axillary nerve: C5)
    • Pronator drift: extend and raise both arms in front of them as if carrying a pizza. Ask the patient to keep their arms in place while they close their eyes and count to 10. Normal: Remain in place. If upper extremity weakness/UMN lesion (supination weaker than pronation): affected arm will pronate and fall.
    • Flexion (Biceps - MC nerve: C5&6) and extension (Triceps - Radial nerve: C7&8) of the elbow
    • Flexion (C7: Radial nerve) and extension (C6: Radial nerve) of the wrist
    • Supination (supinator and biceps brachii) and pronation (pronater teres) of the forearm
    • Examine hand muscle wasting (thenar, hypothenar)
  • Lower limb:
    • hips
      • flexion (L1/2; Femoral nerve)
      • extension (Gluteus maximus: inferior gluteal nerve s1)
      • adduction (L2: together... )
      • abduction (L4: 4 far apart)
    • knees
      • extension (Quadricep femoral nerve L3 ): one hand below knee and the other on top of leg
      • flexion (Hamstring sciatic nerve S1): one hand above knee and the other below leg
    • ankles
      • dorsiflexion: L4 peroneal nerve - holding on ankle
      • plantar plexion: S1 tibial nerve - holding on bottom of foot

Reflex: Accentuate by clenching teeth and compare sides
Deep tendon reflex using tendon hammer
Clonus? Large 5 beats or more motions initiated by a reflex. (e.g. ankles - rapidly dorsiflex, knees - pushing the patella owards the toes)
Upper limb:
  • Hoffman reflex: rest DIP of patient’s middle finger on the side of your right index finger. Use the tip of your right thumb to flick down on the finger tip. Watch if fingers flex. Normally no movement.
    • UMN lesion of upper limb
  • supinator jerk (C5, C6): ask the patient to relax their arm across their abdomen. Elicit the reflex by tapping over the supinator tendon (brachioradialis) just above the wrist. brachioradialis and brachialis makes it still possible to flex elbow. Normal: Elbow flex
  • biceps jerk (C5, C6):
  • triceps jerk (C6, C7):

Abdominal reflex T8-T12
  • Stroke towards umbilicus

Lower limb:
  • Knee jerk (L3, L4):
  • Ankle reflex (S1): Holding the relaxed foot with one hand and striking the Achilles tendon with the hammer and noting plantar flexion
  • Clonus: Test if reflex is hyperactive - hold relaxed lower leg in your hand, and sharply dorsiflex the foot and hold it dorsiflexed. oscillation between flexion and extension? Normal: None
  • Plantar reflex (Babinski - UMN): Running end of the reflex hammer up the lateral aspect of the foot from heel to big toe
    • Normal: Toe flexion
    • Abnormal: Toe extend and toes fan out
    • UMN of lower limb

Isolated loss of a reflex can point disc prolapse.




Coordination: Cerebellar function
Upper limb
  • Finger-nose test
  • The patient should keep their eyes open.
  • Hold one of your fingertips up in front of and a short distance (about 30-40cm) from the patient.
  • Ask the patient to touch the tip of their nose and then to touch your fingertip alternately and repeatedly.
  • Then continuously change your fingertip position to make the test more difficult.
  • sensory ataxia by asking the patient to close their eyes and to touch the tip of their nose using their outstretched finger.
  • Rapid alternating movement
  • place their hands on their thighs
  • rapidly turn their hands over and lift them off their thighs.
  • repeat it rapidly for 10 seconds.

Lower limb
Heel-shin test
  • Ask the patient to lift one of their legs and flex it at the knee, keeping the other leg straight.
  • They should then place the heel of the flexed leg on the knee of the other leg and run it down the shin towards the ankle and back again towards the knee.
  • Ask them to repeat this a number of times.
Heel-toe test
  • This tests balance mechanisms that rely on the cerebellar, vestibular and proprioceptive systems.
  • The patient either needs to be barefoot or wearing flat shoes
  • They should walk in a straight line so that the heel of the second foot touches the toes of the first foot. This should be repeated so that the heel of the first foot then touches the toes of the second foot etc., each time with the patient moving forward.

Gait
  • Trendelenberg gait (proximal myopathy): pelvic girdle muscles are most weak - can’t stabalize pelvis so left leg to step forward and pelvis tilts to non-weight bearing leg - waddling gait
  • Choreiform gait: hyperkinetic gait, basal ganglia disorders - irregular jerky involuntary movement
  • Shuffling gait (Parkinson's): tremor at rest, rigidity (stiff muscle), akinesia (absence/slow movement), postural instability (impaired balance)
  • Steppage gait (foot drop): Can’t dorsiflex (personeal nerve lesion)
  • Hemiplegic gait [swinging one leg in lateral arc] (usu. stroke).
  • Walk heel to toe (hard: midline cerebellar).
  • Walk on heels (hard: L4-5 footdrop).
  • Squat or sit then stand up (proximal myotrophy).

Rhomberg Test
patient stand still with their heels together
Ask the patient to remain still and close their eyes
  • if lose balance - positive





Respiratory quotient!

RQ = Volume of CO2 produced / Volume of O2 consumed

For each 5mL of O2 absorbed from lungs to tissues, 4mL excreted from tissues to lungs.

Normal: 0.7 to 1
CPF....

1.0 - Carbohydrate oxidation
0.8 - 0.9  Proteins


0.7 - pure fat oxidation

balanced diet: 0.825.

If an organism's respiratory quotient rises above 1.0, it is an indicator that the organism is relying on anaerobic respiration for energy.

Normal
Initial exercise: Using mixed blood nutrients (RQ: 0.825)
Adrenaline and glucagon release: Glucose (RQ: 1)
Less glycogen for energy usage so proteolysis (RQ: 0.9) and lipolysis (RQ: 0.7) for glucongeogesnsis (as it would happen in fasting)

  1. Subject sit on bikewith mouthpiece, nose piece and T valve opened
  2. Adapt by pedalling at 60x/minute
  3. Set workload to 0 and cycle for 5 minutes
  4. Close T valve to route to douglas bag and cycle 5 min (start timer)
  5. 2x syringe (2x50mL)  to remove
  6. 1x syringe (1x5mL) to gas analyzer
  7. Douglas bag to gas meter for analysis (recorded volume + 150mL)

Metabolic rate (kJ/min) = VO2 (L/min) x Energy output (kJ)

Microbiology

Yellow flame when not working → Blue flame when working
NO GLOVES!!!! (flammable...)
Howie style labcoat fastened to NECK
Wash hands before working
Label base (NOT LID) plate - initial, date, organism
Store plate lid down
Dispose swab immediately to virkon!
Virkon disinfect working area when finished


Mannitol salt agar: Selective media (encourage growth of certain bacteria and inhibiting others)
  • High salt concentration: Good for Staphylococci
  • Gram + staphylococci fermenting mannitol: Media turns yellow
  • Gram + staphylococci not fermenting mannitol: Media does not change color (pink)
  • Gram + streptococci: inhibited growth
  • Gram - : inhibited growth


Blood agar: Differential media
β-hemolytic(yellow) - complete lysis of RBC by colony - Streptococcus haemolyticus
α-hemolysis (green) - partial lyse - Streptococcus viridans
γ-hemolysis: Non-hemolytic

MacConkey agar
Contain bile salt to inhibit gram +
And to see if lactose fermenting

Gram Stain
  • Gram cyrstal violet (1min)  → Iodine to promote retention (1min) → Acetone to dcolorize (30 sec) → Safranin counter stain (1min) → Remove slide from cradle and wipe back of slide (NOT FRONT where bacteria is placed)
  • Wash and drain in between onto paper
Gram +: Blue
Gram -: Pink (sfranin)
Motility test
  • Stab culture into semi-solid medium
  • +: Motile as the bacteria is established throughout
  • -: Stab shown (non-motile - stay in stab only)

Isolating culture
  1. Label agar
  2. Bunsen to blue
  3. Loosen (NOT REMOVE) vial  cap for culture
  4. Innoculating loop in flame until red
  5. Use pinky to open cap
  6. Flame vial neck briefly
  7. Touch loop to inner surface of vial to allow it to cool down
  8. Dip and remove
  9. Flame vial neck again and replace lid
  10. Touch loop to agar to cool down
  11. Make streaks on agar to create hexagon (streak from end of first streak)
  12. Flame loop and close plate


To make an even spread e.g. for antibiotic disk testing
Draw swab straight across plate, then rotate 90, then rotate 90, finally draw around circumference.
Dispose swab to virkon immediately
  1. Dip tweezers in alcohol
  2. flame tweezer
  3. select disc
  4. tap onto agar according to guide
  5. resterilize


Staph grow as grapes
Strep grow as pairs

Catalase test
Working under sterile conditions
Patient plasma + 1 drop of the bacteria
mix by inversion
catalase + (e.g. staph aureus - solid state)
catalase - (e.g. staph epidermidis - liquid state)







Blood smear
  1. Rub hands
  2. Alcohol swab
  3. Press lancet against index finger
  4. Dispose lanet to sharp pin immediately
  5. Blood to clean slide
  6. Use second clean slide to spread
  7. Air dry
  8. Add Leishman’s stain and leave to dry (stay on slide... not wash!!!)
  9. Water to slide (stay on slide.. not wash!)
  10. Finally drain slide with water


AED Automated external defibrillator
  • Remove clothing
  • Put pads on (see diagram)
  • All clear?
  • Press
  • Immediately compression after done
How AED works
  • depolarize all at once

airway adjuncts  used to maintain a patent (open) airway
  • oropharyngeal airway (Guedel)


If wrong size: Stimulate vomiting... via gag reflex

preventing the tongue from covering the epiglottis
When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway.[1]

Pocket mask

Oxygen 15L/minute


Bag valve mask
Oxygen 15L/minute
2 person technique - and make sure completely covers mouth!


Primary Survey

Environment safe?
Hello how are you?
Call for help
Assistants?
Gloves, glowned glasses

Suspect cervical spine injury if patient is not fully consciousness, complaining of neck pain, numbness/weakness, can move neck without pain → C-collar

Assistant stabalize head

Jaw to trapezius: Number of fingers

Collar - Black stud to plastic (not foam)

Cushion and micropore neck and jaw


A: Airway with cervical control
  • Open airway and check for breathing in head
    • Look: Cyanosis, neck injury, anything in mouth
    • Listen: Gasping, wheezes, breathing, silence
    • Feel: breathing air
  • Chin left and Guedel (OPA) (measure n from mouth to angle of jaw) if unconscious/ nasopharyngeal tube (NPA) (measure n from nose to earlobe)
    • OPA (oropharyngeal airway)
      • from mouth to angle
      • insert upside down to depress tongue and rotate 180 degrees to assure tongue is secured with the back of the throat
    • NPA (/NG)
      • see if anything in nose
      • NPA: n from nose to earlobe
      • NG: nose to earlobe to xiphoid sternum
      • lubricate tube’s entry
      • pull up nose and insert until feel resistance
      • flex head forward and swallow the whole time to prevent gag reflex (place hand back of head)
      • to see if in gastric, aspirate the acid and do limit test or put air in and auscultate xiphernum to hear if bubbles
      • open mouth to see if correctly inserted
  • Give 15L/min oxygen using pocket mask / big valve mask
  • Put pulse oximeter

B: Breathing and ventilation
  • Remove clothing
  • Look: Chest movement, chest injury
  • Palpate: Feel on ribs for symmetrical chest movement?, tracheal deviation?
  • Percuss: Resonance (hyper-pneumo, dull-blood)
  • Auscultate: Air entry into all zones?
C: Circulation and hemorrhage control
  • Hands: Temperature, capillary refill
  • Pulse: Radial pulse
  • Arm: IV access and IV, BP
    • IV access - large cannulae in each antecubital fossa THEN begin IV Fluid
      • FBC full blood count
      • LFT liver function test
      • Amylase
      • U&E urea & electrolytes
      • Crossmatch / G&S group and save
      • Clotting
    • IV intravenous
      • warm saline
  • Neck: Carotid
  • Heart: Apex, ECG
  • Abdomen
  • Pelvis
  • Legs
  • Inspect abdomen, palpate pelvis, palpate for long bone fractures, on the floor
  • ICE: ice compression elevation
D: Disability and neurological evaluation
  • Pupil size and reaction
  • AVPU - 4 outcomes only (anyone not alert require immediate attention)
    • a: open eyes
    • v: respond to voice (e.g. say are you ok and nod)
    • p: response to pain (e.g. pinch patient's ear)
    • unconscoius
  • GCS (EMV - eyes 1-4, verbal 1-5, motor, 1-6, thus 3 is lowest, 15 is highest)
    • E3V3M5 = GCS 11
    • CT scan if GCS <13
    • 9 to 12 is moderate
    • 8 or less is severe  and considered coma (endotracheal intubation)
E: Exposure and control of environment
  • Remove all clothing
  • Blanket to prevent hypothermia
  • XRay

Secondary Survey: Head to toe evaluation


Defibrillation for VF and pulseless VT
Otherwise basic CPR

Glucose Prick test
disposable tissue
gloves
make hands warm
wipe area with alcohol
allow to dry
make a fist and press the thumb to infdex finger
use pen + lancet: click the pen → attach lancet → remove lancet tip → press → discard lancet (not the pen!) to sharps bin
Turn on
Insert capillary (the card)
Blood in horizitaonl plane
Once done, dispose capillary in sharps bin (treat blood like sharps!)
clear bench
wash hands

Effects of atropine - antimuscarinic
  • Heart rate m2 - so incrase
  • Pupil diameter m4 - so dilate
  • Near point - line
  • Salivation m3 - so decrease
  • Sweating m3 (sympathetic) - so decrease

Urine dip stick
Dip test pad and remove immediately while dragging the edge of the strip against container rim to remove any excess
Compare test pad with time
Discard the stick


Normal urine volume: 1-2L/day

LOOK then TEST

LOOK
Urine color:
ColorPossible causes
light yellownormal
dark yellowconcentrated
colorlessdilute
red hematuria
greenish tintbilirubinuria


Cloudy due to: Increased cells, bacteria, lipiduria

Test
Glucose -  DM..
Ketone - fasting, DKA
Specific gravity - related to urine osmolality (e.g. DM)
  • density of urine compared to pure water (increasing USG: Salt, urea, glucose, protein, albumin)
Blood - hematuria
pH (normally slightly acidic)
Nitrite - Bacteria (esp. gram -’ve rods e.g. E. Coli)
Protein - proteinuria is >3.5g/day (Nephrotic syndrome)
WBC - Esterase (enzyme released by WBC) test (normal is negative, if positive - UTI)



Flare and wheel response

Triple response (of Lewis): Erythema (immediate) due to histamine release → Flare and Wheal (edema)

Make scratches (without breaking skin!) using neurotip
Place on each scratch a swab soaked in histamine
Remove swab
Observe and record in mm

Pain / Anesthesia
  1. Lidocaine decreasing concentrations (1% + adrenaline, 1% and 0.5%), and saline
  2. Gloves
  3. Clean area
  4. Label
  5. Inject intradermally (raise a blister)
  6. Start timer
  7. See if painful by counting number of pin-pricks felt as pain applied to BLISTER area (apply 6 and record the ones felt as pain e.g. if 4 then 4/6)
Duration of anesthesia (min)1%+Adrenaline1%0.5%Saline
0
5
10
15
6/6
3/6
1/6
6/66/66/6


Field block is a technique of injecting anesthetic around a (inject in all 4 directions around it) wound rather than into the wound itself (spread the infection, also may not deliver the drug to the nerves of the underlying tissue due to the pus, pus H+ acidic inhibits action of drug).  

Local Infiltration
  1. Lidocaine (/+EP to decrease bleeding and increase potency, bicarb to reduce local pain on injection)
  2. Use smallest needle
  3. Local infiltration by making wheal - slowly (if too quick 0 painful) inject (always aspirate syringe before injecting to see if in BV lumen).
  4. Once wheal formed, wait for 1 minute for lidocaine.
  5. Replace with longer needle and insert wheal perpendicular to get into deeper tissues (work on anesthetized tissues only)

EMG for median nerve and flexor digitorum superficialis
  • Intro
  • Explain procedure
  • neurological, cardiac disorder, pacemaker?
  • can stop at any time

Motor point - location on body surface where muscle is innervated close to the skin. If current to motor point, nerve stimulated so muscle will contract

First find the place of biggest twitch i.e. motor point
  1. Finger pulse transducer, stimulating bar electrode (color coded to socket) with bit of cream and placed parallel to arm
    1. patient hold bar using fingers of other hand
    2. turn power lab and stimulator switch on
    3. status light: orange when electrode isn't touchsing skin. green when touching.
  2. stimulate and mark area of greatest force on arm with pen
    1. upper graph - force measured by pulse transducer
    2. loewr - electrical stim
    3. Pick electrode and move it from place to place until position of largest twitches of fingers is located.
    4. wipe excess cream off skin.
    5. turn stimulator switch off after experimenting



Determine threshold stimulus amplitude
  • Gradually increase stimulus amplitude (milliamp) to determine smallest stimuli needed to produce a response (threshold stimulus amplitude) i.e. produce a twitch response
  • turn stimulator switch off after experimenting


effect of increasing stimulus intensity above threshold
  • always comment on amplitude increase
  • increase stimulius amplitude in small steps until resposne no longer increases).
  • turn stimulator switch off after experimenting

keep stimulus amplitude constant and examine fx of changing freuency of stimulation.
  • increase stimulus frequency (stimuli/sec), always comment on freq increase
  • turn stimulator switch off after experimenting

  1. Latent period: Action potential across sarcolemma and calcium release but no contraction yet because it hasn’t bind to troponin yet
  2. Contraction phase: Calcium binds to troponin and cross bridges form
  3. Relaxation phase: Longest phase
    1. gated Na+ channels close and Na/K+ atpase pump act to repolarize. This repolarization spreads to T-tubule so voltage-gated calcium channels close. Calcium is removed from sarcoplasm by SERCA.

Motor Unit Summation - the degree of contraction of a skeletal muscle is influenced by the number of motor units being stimulated (with a motor unit being a motor neuron plus all of the muscle fibers it innervates).

Fine control: A motor neuron control few msucle fibers (e.g. eye).
Less fine control: e.g. leg muscles: One MN to thousands of muscle fibers.

Size principle: Contraction begins with the activation of the smallest motor units in the stimulated muscle. force increment is small. Over time, larger motor units containing faster and more powerful muscle fibers are activated, and tension production rises steeply. The smooth but steady increase in muscular tension produced by increasing the number of active motor units is called recruitment, or multiple motor unit summation.

Asynchronous recruitment  (Alternating motor unit activity) (like a relay race) to delay fatigue.


increase grip strength from 25% to 50% to 75% to 100% of their maximum grip strength.



Multiple fiber summation

►More the fibers (motor units) taking part in contraction more will be the force of contraction

►For weak contraction, smaller and fewer motor units are stimulated

►For stronger contractions more & more motor units are stimulated (recruitment)

Frequency summation, tetanus or tetanization

►Sustained contraction due to repeated stimuli of high frequency


Peak tension production occurs when all motor units in the muscle contract in a state of complete tetanus. Such powerful contractions do not last long, however, because the individual muscle fibers soon use up their available energy reserves despite the asynchronous summation.

resting tension in a skeletal muscle is called muscle tone. A muscle with little muscle tone appears limp and flaccid, whereas one with moderate muscle tone is firm and solid.
►Due to continuous firing of some motor neurons
stabilizes the position of bones and joints.
Heightened muscle tone accelerates the recruitment process during a voluntary contraction, because some of the motor units are already stimulated.
Strong muscle tone also makes skeletal muscles appear firm and well defined, even at rest.

Graded Muscle Response
  1. Twitch: Normal response to 1 stimuli
  2. Treppe: Stimuli immediately AFTER relaxation ends- stronger contraction than previous then peak tension at 25% of tetanus
    1. due to increase in calcium and more efficient enzymes (heat + ATP generated...) and repetitive degradation of tropomyosin
    2. warm up!
  3. Summation: stimuli BEFORE relaxation ends - stronger contraction
    1. if a twitch lasts 20 msec (1/50 sec), subsequent stimuli must be separated by less than 20 msec--a stimulation rate of more than 50 stimuli per second. Rather than refer to stimulation rate, we usually use frequency (no./time) i.e. stimulus frequency greater than 50 per second produces wave summation, whereas a stimulus frequency below 50 per second will produce individual twitches.
  4. Incomplete (not fused) tetanus: summation continues to when peak tension of tetanus is reached, but still a bit of relaxation phase is still allowed to occur
  5. Complete tetanus: continuous stimuli firing - NO RELAXATION phase
    1. SR no time to reclaim Ca2+ using ca-atpase from cytoplasm so contraction is fused (not wave form...)
    2. Virtually all normal muscular contractions involve complete tetanus of the participating muscle fibers.



Potential difference in

Cardiac contractile: -60 to +20 (80mV!!!!!)
Nodal:-60 to 0mV → (60mV) only
Nerve-70 to +30mV


A denervated muscle cell will revert to a very slow type. It will have ACh receptors all over its membrane. Upon reinnervation, the muscle cell will become the type that the nerve cell previously served and ACh receptors will occur only under the synaptic junction at the same density that they were previously all over the cell membrane.

Nerve conduction velocity
Do not perform if papathologycemaker or heart
e.g. of Ulnar nerve
  • Stimulate ulnar nerve in 2 different places
    • Stimulus 1: elbow
    • Stimulus 2: wrist
  • Recording electrode on abductor digiti minimi
  • Measure distance between stimulus 1 and 2
  • Record time from T1 elbow / T2 wrist to recording electrode on digiti

Motor conduction velocity (MCV) = Distance between two electrode / (T1-T2)

What abnormal results mean - Most often, abnormal results are caused by some sort of neuropathy (nerve damage or destruction) including:
  • Demyelination (destruction of the myelin sheath)
  • Conduction block (the impulse is blocked somewhere along the nerve pathway)
  • Axonopathy (damage to the nerve axon)

slowing of the NCV usually indicates there is damage to the myelin. Another example, slowing across the wrist for the motor and sensory latencies of the median nerve indicates focal compression of the median nerve at the wrist, called carpal tunnel syndrome. On the other hand, slowing of all nerve conductions in more than one limb indicates generalized sick nerves, or generalized peripheral neuropathy. People with diabetes mellitus often develop generalized peripheral neuropathy.

Regeneration
  • Reserve cells ("satellite cells" in the endomysium → myoblasts)
  • Mitosis
  • Basophilic cytoplasm, central nuclei , obvious nucleoli (busy)


Neurogenic or Myopathic (LMN!)?
  • Shape of small muscle fibers
    • Round: Myopathic
    • Angular: Neurogenic e.g. denervation atrophy (does not cause myonecrosis so no elevated CK)
  • Distribution of atrophic fibers
    • Grouped: Denervation; Dystrophinopathies
    • Scattered: Acute neuropathy or myopathy

Acute or Chronic?
  • Acute
    • Myopathy: Muscle fiber degeneration & regeneration
    • Neuropathy: Isolated small angular muscle fibers
  • Chronic
    • Myopathy: Increased endomysial connective tissue; Muscle fiber hypertrophy
    • Neuropathy: Fiber type grouping (combined denervation and reinnervation by other neuron so motor units enlarge - polyphasic potential, and their fibers, instead of being scattered, come to lie adjacent to one another); Pyknotic nuclear clumps. When ultimately these motor units lose their innervation and there are no healthy axons left to connect with them, all their fibers shrink together (group atrophy).

distribution of the pathology?
  • Uniform (Similar in all parts of the biopsy): Dystrophy; Fiber type atrophy
  • Regional
    • Patchy fascicular changes: Inflammatory myopathy; Focal denervation
    • Groups of muscle fibers
      • Neuropathy: Progressive denervation with reinnervation
      • Myopathy: Myopathic grouping; Perifascicular atrophy
  • Scattered muscle fibers: Acute myopathy; Acute neuropathy


EMG
Myopathy: Short duration and high amplitude
Neuropathy: High amplitude and long duration

MG
a firm diagnosis is based upon
  • A characteristic history and physical examination, and
  • Two positive diagnostic tests, preferably serological (anti-AChR antibody) and electrodiagnostic.

Tensilon tests
  • May be readily performed at the bedside
  • Are not as sensitive
Inhibits acetylcholinesterase, Results in enhanced muscle strength. Rapid onset and lasts for a few minutes. Ask patient to smile


Repetitive nerve stimulation
  • Nerve to be studied is electrically stimulated six to ten times at 2 or 3 Hertz
  • Normal muscles: No change in CMAP amplitude with repetitive nerve stimulation
  • Myasthenia gravis
    • Progressive decline in CMAP amplitudes with the first 4 to 5 stimuli.
    • Positive RNS test features
      • Decrement in CMAP amplitude
        • Size: More than 10% in reduction in CMAP amplitude
          • Measure from 1st to 4th or 5th potential in train
        • Smallest CMAP is often 2nd or 3rd potential in train
      • Post-exercise exhaustion
        • Exercising muscle briefly before testing exacerbates decremental response
        • Occurs rapidly after initial stimulation
      • Post-tetanic potentiation
        • Reduction in decrement in minutes after exercise
        • Occurs after post-exercise exhaustion