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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
CoordinationFinger– nose, dysdiadochokinesia, tapping, heel– shin.
Romberg’s This is tested with patient standing with eyes open then closed,
positive if more unbalanced with eyes closed; suggests sensory ataxia.
SensationPinprick, light touch, vibration, joint position; the spinal dermat-
omes of the front and back are shown in Fig.3.2. For spinal tract anatomy
and function, see Table3. and Fig.3.3.
Fig.3.2 Dermatomes of the front (L)and back(R).
133NEUROLOGICAL
Fig.3.3 Cross- section of the spinal cord showing spinal tracts.
Table3. Spinal tracts and anatomy
Tract Modality Crosses (decussates) at
Lateral corticospinal (pyramidal) Motor Medulla
Anterior corticospinal Motor Level of exit of the cord
Posterior columns (dorsal) Light touch,
Spinothalamic Hard touch, pain,
vibration, position
temperature
Medulla
Level of entry to the cord
134 CHAPTER3 History and examination
Nerves ofthe handSee Table3.2 and Fig.3.4.
Table3.2 Innervation ofhand movements
Movement Nerve
Finger abduction and adduction Ulnar
Thumb opposition and abduction Median
Finger extension Radial
Fig.3.4 Sensation of thehand.
Gait This forms an essential and highly informative part of the examin-
ation of both the central and peripheral nervous systems; see Table3.3.
Table3.3 Gait examination
Gait Description Cause
Antalgic Painful gait, limping, short weight- bearing
Apraxic Unable to lift legs despite normal power,
Ataxic Uncoordinated, wide based, unsteady (as
Festinating A shuing gait with accelerating steps Parkinson’s
Hemiparetic Knee extended, hip circumducts and drags
Myopathic Waddling, leaning back, abdomen sticking
Shuing Short, shued steps, stooped, no arm
Spastic Restricted knee and hip movements, slow,
Steppage High steps with foot slapping, ‘foot drop’ Peripheral
on painful side
magnetic steps/ stuck to oor
if drunk), worse with eyes shut if sensory
leg; elbow may be exed up
out
swing
shuing, ‘wading through water’
Mechanical injury,
sciatica
Hydrocephalus,
frontal lesions
Cerebellar, sensory
Hemiplegia, eg CVA
Proximal myopathy
Parkinson’s
Pyramidal tract
lesion, eg MS
neuropathy
Endocrine
History
Symptoms Weight loss, weight gain, appetite, sweating, heat/ cold intol-
erance, tremor, weakness, tiredness, dizziness, hirsutism, joint pain/
swelling, change in appearance (skin, hair, nails, face, eyes), change in
clothes/ shoe/ hat size, altered sensation, ulcers, visual problems.
Cardiorespiratory features Chest pain, breathlessness, palpitations, sleep
apnoea.
GI/ urinary features Diarrhoea, constipation, nausea, vomiting, abdominal
pain, thirst, polyuria.
Reproductive features Menstrual irregularities, infertility, gynaecomastia,
galactorrhoea, impotence.
Psychiatric features Anxiety, mood changes, memory problems.
Eye featuresBlurred vision, visual eld defects, bulgingeyes.
Past medical historyHypercholesterolaemia (thyroid function aects lipid
levels), thyroid surgery, stroke, heart failure, liver failure, renal artery
stenosis, renal failure, adrenal surgery, brain surgery.
Drug historySteroids, diuretics, OCP, HRT, levothyroxine, insulin.
Family historyDM, thyroid disease, pituitary tumours.
Examination (lying at45°)
General inspection Body habitus, ‘bualo hump’, facial appearance
(‘moon face’), striae, bruising, muscle wasting, hyperpigmentation,
coarse skin, prominent jaw and brow ridge, goitre, gynaecomastia, hirsutism, acanthosis nigricans, vitiligo, acne, necrobiosis lipoidica, pre- tibial
myxoedema.
Hands Temperature, sweating, size, tremor.
Eyes Lid lag, proptosis, exophthalmos, bitemporal hemianopia, cranial
nerve III, IV, or VI palsy, fundoscopy.
NeckGoitre, thyroidlumps.
Cardiorespiratory idHR, idBP, postural hypotension, irregular pulse, per-
ipheral oedema, bibasal crackles(LVF).
Neurological Cranial nerve III/ IV/ VI palsy, peripheral neuropathy, slow
relaxing reexes, weakness (myopathy).
Other Joints, skin, genitalia, fundoscopy, urine analysis, U+E, early
morning cortisol, TFTs, short Synacthen
specialist tests on advice from an endocrinologist.
®
test (E p. 599), GTT— more
135ENDOCRINE
136 CHAPTER3 History and examination
Skin
History
Presenting skin complaint TimingHow long present for, sudden or gradual
onset, getting better orworse;
sites aected;
bleeding, weeping;
light (seasonal variability), pet dander, night- time, water;
torsEmollient cream, topical/ systemic steroids.
Current health Anorexia, diarrhoea, fever, headache, fatigue, weight loss,
depression, sore throat, jointpain.
Past medical history Previous skin disease, DM, IBD, asthma/ atopy, vari-
cose veins, peripheral arterial disease, cardiac problems, endocrine
disease, coeliac disease, neurological problems, ulcers, trauma, sarcoid,
porphyria, SLE, malignancy, sensitivity of skin to sun exposure, lifelong
history of sun exposure or use of sunbeds.
Drug history Dermatological agents being used at present and their ef-
fects, previous drugs used and their eects, oral and topical steroids,
other drugs being taken, immunosuppressants, drug allergies.
AllergyHayfever, pet dander, dust mite,etc.
Occupational historyCurrent and previous jobs and eect of work upon
skin, exposure to chemicals; hobbies and recreational activities.
Family history Anyone else in the family aected; need to dierentiate
inherited pathology versus infectious pathology.
Travel historyRecent foreign travel and relationship of any travel to skin
disease— vaccinations/ prophylaxis taken for foreign travel.
FunctionRestricted actions, eect on life, mobility, occupation, dominant
hand, hobbies/ sports, smoking, social support.
Symptoms Itch (localized or generalized), pain, burning,
Exacerbating factorsDietary components, drugs, sun-
Examination
The whole body should be examined in good natural light; patients complaining of a rash on their arm may well have other tell- tale signs elsewhere on the body. Ask patients to fully undress to enable a full skin
inspection. Remember the importance of gaining consent and having a
chaperone present.
Distribution Solitary lesion, exor aspects of limbs/ trunk, extensor
aspects of limbs/ trunk, scalp/ eyebrows/ gutters of nose, sun- exposed
sites, tip of nose, helix of ear, webspaces of hands or feet, periumbilical.
Morphology Noting or describing the appearance of the rash using the
terms dened in Boxes 3.4– 3.7 renes the list of dierential diagnoses.
Hair Alopecia (hair loss) may be generalized or localized and scarring/
non-scarring. Hirsutism (hair in the typical male distribution),
hypertrichosis (excessive hair growth).
NailsClubbing, pitting, ridging, onycholysis, nail loss, thinning of nail plate,
discolouration.
Location Original site and subsequent
Relieving fac-
K Box 3.4 Non- palpable skin lesions
EcchymosisBruising; discolouration from blood leaking into theskin.
MaculeFlat, well- dened area of altered skin pigmentation.
PetechiaNon- blanching, pinpoint- sized purple macule.
Purpura Purple lesion resulting from free red blood cells in the skin,
non- blanching.
Telangiectasia Abnormal visible dilatation of blood vessels (spider naevi).
K Box 3.5 Palpable skin lesions
NoduleSolid, mostly subcutaneous lesion (>0.5cm diameter).
PapuleRaised, well- dened lesion (<0.5cm diameter).
PlaqueRaised, at- topped lesion (usually >2cm diameter).
Weal Transient, raised lesion with pink margin.
UrticariaWeals with pale centres and well- dened pink margins.
K Box 3.6 Blisters
AbscessFluctuant swelling containing pus beneath the epidermis.
BullaFluid- lled blister larger than a vesicle (>0.5cm diameter).
PustuleWell- dened pus- lled lesion.
VesicleFluid- lled blister (<0.5cm diameter).
K Box 3.7 Skin defects
AbrasionScraping o supercial layers of the skin (a graze).
Atrophy Thinning and loss of skin substance.
CrustDried brownish/ yellow exudates.
ErosionSupercial break in the continuity of the epidermis.
ExcoriationLinear break in the skin surface (a scratch).
FissureCrack, often through keratin.
Incisional woundBreak to the skin by sharp object.
LacerationBreak to the skin caused by blunt trauma/ tearing injury.
LichenicationSkin thickening with exaggerated skin markings.
ScaleFragment of dryskin.
UlcerLoss of epidermis and dermis resulting inscar.
137SKIN
138 CHAPTER3 History and examination
Oncological/ haematological
History
Symptoms Weight loss, anorexia, weakness, lethargy, fatigue, cough,
haemoptysis, shortness of breath, postural dizziness, nausea, vomiting,
diarrhoea, constipation, PR bleeding, lumps, swelling, pain, fractures, bone pain, polyuria, prostatism, bruising, recurrent epistaxis,
haemarthrosis, heavy menstrual loss, recurrent miscarriage, recurrent
VTE, fevers, infections, focal neurology.
Past medical history DM, asthma, iBP, IHD, liver disease, jaundice, thy-
roid problems, anaemia, malignancy (and radiotherapy), epilepsy, gastric
or small bowel surgery, malabsorption, chronic disease (eg RA), blood
transfusions, splenectomy.
Drug history Chemotherapy (regimen, date of last dose, response, side
eects), iron, vitamin B
post- splenectomy, long- term antibiotics, OCP, allergies.
Social historySmoking, alcohol, family support, living circumstances, home
help, occupation, previous exposure to dyes/ asbestos/ coal tar, racial
origin, diet (vegan, vegetarian), recreational druguse.
Family history Malignancy, thalassaemia, sickle- cell anaemia, haemo-
philia, von Willebrand’s disease, pernicious anaemia, spherocytosis,
thrombophilia.
Examination
General inspection Bruising, pigmentation, rashes and nodules,
ulceration, cyanosis, plethora, jaundice, excoriations, racial origin
(haemoglobinopathies and thalassaemias).
Hands Nails (koilonychias, pallor, clubbing), palmar crease pallor,
arthropathy.
FaceEyes (jaundice, pallor), mouth (gum hypertrophy or bleeding, ulcer-
ation, candida, atrophic glossitis, angular stomatitis, gingivitis).
Lymph nodesCervical, axillary, epitrochlear (elbow), inguinal.
BonesBony pain in sternum, spine, clavicles, scapulae.
AbdomenHepatomegaly, splenomegaly, para- aortic nodes, ascites.
LegsVasculitis, bruising, pigmentation, ulceration, neurologicalsigns.
OtherFundi (haemorrhages, engorged veins, papilloedema), temperature
chart, urinalysis.
/ folate, aspirin, anticoagulants, vaccinations
2
Breast (male and female)
(a)
Supraclavicular
11% lo
quadrant
(b)
History
LumpSize, duration, mobility, pain, nipple discharge/ bleeding/ inversion,
skin changes, previous breastlumps.
Past obs/ gynae history Number of pregnancies, age of rst pregnancy,
breastfeeding, menarche, menopause.
Past medical history DM, asthma, iBP, IHD, clotting problems, liver
disease, anaemia, previous malignancy, epilepsy.
Family historyBreast cancer (male/ female), gynae cancer— age of relative
at their diagnosis.
Drug historyHRT, COCuse.
Examination (lying at45°)
Ensure a chaperone is present and document their details in the notes
(name, job title).
Examine both breasts (normal side rst):
Inspection Asymmetry, scars, skin changes, nipple discharge/ inversion,
skin tethering, erythema, oedema. Ask the patient to tense pectoral
wall by putting their hands on hips and tensing. Ask the patient to lean
forward. Look for any skin tethering.
Palpation Ask the patient to show you where the lump is, palpate all four
quadrants (Fig.3.5) and axillary tail, assess any palpable masses.
Lymphadenopathy Axilla, cervical, supraclavicular. The patient must be
fully relaxed for you to adequately palpate the axillary nodes. Take the
weight of their arm in yours as you palpate.
OtherLiver,spine.
139BREAST (MALE AND FEMALE)
lymph nodes
50% upper
outer
quadrant
wer
outer
Fig.3.5 Anatomy of the breast. (a)Quadrants of the breast showing proportion
of breast cancer by location. (b)Glands and lymphatics of the right breast.
15% upper
inner quadrant
18% nipple
6% lower
inner quadrant
Axillary
lymph nodes
140 CHAPTER3 History and examination
er
Pupil
Eyes
History
Symptoms Reduced/ impaired vision or visual loss, red eye, discomfort
(gritty or FB sensation), pain of the eye or soft tissues around the eye,
dry eyes or excessive watering, itch, swelling, photophobia or haloes
around lights, oaters or ashing lights, diplopia, discharge.
Past ophthalmic history Glaucoma, myopia, cataracts, previous surgery,
glasses/ contact lens prescription and last optometry check- up.
Past medical history Numerous systemic diseases can aect the eye,
including DM, iBP, vascular disease, RA, SLE, thyroid disease,MS.
Drug history Ophthalmic medications, steroids, anticholinergics, medica-
tions for coexisting disease; allergies.
Family historyGlaucoma, retinoblastoma, retinitis pigmentosa.
Social history Ability to self- care, impact eye disease has upon ADLs and
home support received/ needed, driving.
Upper eye lid
Limbus
Conjunctiva ov
sclera
Lateral canthus
Lower eye lid
Fig.3.6 Surface anatomy of the righteye.
Examination
InspectionExophthalmos, proptosis, jaundice, pallor, xanthelasma, eyelids
(cysts, inammation), red eye, corneal arcus, periorbital cellulitis (Fig.3.6).
Visual acuity This must be tested in all patients:
• Use a Snellen chart at 6m to test visualacuity
• Make sure the patient is using the correct glasses for the test (reading vs
distance); if in doubt, use a pin- hole in a piece ofcard
• If visual acuity is very bad, assess ability to count ngers, awareness of
movement (waving hand), or perception of light (pen torch).
Pupillary response and reexes Check the pupils are equal, reacting to light
and accommodation (PERLA) and for a relative aerent papillary defect.
Look for the red reex (absent in dense cataracts). An absent red reex at
the 6wk baby check is a red ag (treat this as a same- day urgent referral).
Visual elds Confrontation testing to identify any visual eld loss and to
establish if the defect is unilateral or bilateral (Ep. 31).
Ocular movementsLook for diplopia, loss of conjugate gaze, or nystagmus.
Medial canthus
Iris with lens
beneath
Ophthalmoscopy
• With the ophthalmoscope set on +0 the cornea and anterior chambers
can be examined. or 2 drops of uorescein highlights corneal ulcers,
abrasions, and foreign bodies, especially under the bluelight
• With the ophthalmoscope set on 0 the user can visualize the retina. It
is important to dilate the pupil with or 2 drops of a weak mydriatic
(Box 3.8) (eg 0.5% or % tropicamide) to allow full visualization of
the retina. The risk of causing acute glaucoma with mydriatics issmall.
K Box 3.8 Descriptive terms inophthalmology
Accommodation Alteration in lens and pupil to focus on near/ far objects.
Acuity Ability of the eye to discriminate ne detail.
Anterior chamberBetween cornea and iris, containing aqueous.
AqueousFluid- like jelly in the anterior chamber of theeye.
BlepharitisInammation/ infection of eyelids.
CanthusMedial or lateral junction of the upper and lower eyelids.
ChemosisConjunctival oedema.
ChoroidLayer sandwiched between retina and sclera.
ConjunctivaMucous membrane covering sclera and cornea anteriorly.
CycloplegiaCiliary muscle paralysis preventing accommodation.
DacryocystitisInammation of the lacrimalsac.
EctropionEyelids evert outwards (away from the cornea).
EntropionEyelids invert towards the cornea (lashes irritate cornea).
FoveaHighly cone- rich area of the macula (yellow- spot).
Fundus Area of the retina visible with the ophthalmoscope.
HyphaemaBlood in the anterior chamber seen as a red uidlevel.
HypopyonPus in the anterior chamber seen as a white uidlevel.
LimbusBorder between cornea and sclera.
MaculaRim around the fovea, rich in conecells.
Miotic Agent resulting in pupillary constriction (eg pilocarpine).
Mydriatic Agent resulting in pupillary dilatation (eg tropicamide).
Optic cupDepression in the centre of the opticdisc.
Optic discOptic nerve head seen as white opacity on fundoscopy.
Posterior chamberChamber between the iris and lens.
Presbyopia Age- related reduction in near acuity (long- sightedness).
PtosisDrooping eyelid(s).
Sclera The visible white brous layer of theeye.
ScotomaDefect resulting in loss of a specic area of vision.
StrabismusSquint, loss of conjugate gaze.
Tonometer Apparatus for indirectly measuring intraocular pressure.
VitreousJelly- like matter which occupies the globe behind thelens.
141EYES
142 CHAPTER3 History and examination
Head andneck
History
As well as a good general history, specic symptoms to note include:
Ears Pain, blocked ears, wax, discharge, tinnitus, deafness, unilateral/
bilateral features, vertigo, trauma, itching, FBs, noise exposure, occupation.
NoseBlocked nose, watery discharge, sneezing, itching, coughing, change
in voice, altered sensation of smell/ taste, external deformity/ recent
trauma, epistaxis, sinusitis; ask about daytime variation in symptom
severity, pattern of obstruction, eects on speech and sleep. Are symptoms uni/ bilateral?
ThroatDysphagia, pain on swallowing, hoarseness, diculty opening jaw
(trismus), stridor, sleep apnoea/ snoring; ask about neck lumps, vomiting,
heartburn, waterbrash (acid regurgitation or lling of mouth with saliva).
Examination
Ears Inspect The pinna, auditory meatus, tenderness over pinna or
mastoid;
(colour, bulging/ retraction, perforation, exudate);
lowing ‘Hearing tests’text.
Nose Look for Obvious scars, deviations/ deformities, tilt the head back
and look down each nostril (Fig.3.8);
spray rst), look for polyps, inamed turbinates,pus.
Throat Inspect The lips, around and inside themouth; Examine The tongue
and tonsils using a torch and tongue depressor, check palate movements
by asking the patient to say ‘ah’ (Fig.3.9).
Neck Look for Swellings, asymmetry,scars; Ask The patient to swallow,
protrude the tongue;
to take a sip of water;
tenderness;
Otoscopy Examine all four quadrants of the eardrum (Fig.3.7)
Test hearing See fol-
Rhinoscopy (Administer lidocaine
Palpate The neck from behind and ask the patient
Feel for Tracheal deviation, lymphadenopathy,
AuscultateFor abruit; Examine Any lumps (Epp. 472–3).
Hearing tests(E OHCS11p. 390.)
WhisperWhisper a dierent number into each ear, standing 30cm away
while blocking the other ear. Ask the patient to repeat it inturn.
Tuning forktests
Rinne’s testPlace the tuning fork on the patient’s mastoid bone until it is
no longer heard; then place the fork near the external auditory meatus
where it is still heard in a normal ear, but not in an ear with conductive
deafness. Normally air conduction > bone conduction. Confusingly, a
normal result is called Rinne positive.
Weber’s testPlace the tuning fork in the middle of the forehead and ask
which side the sound is loudest; in sensorineural deafness the sound is
loudest in the normal ear, in conductive deafness the sound is loudest in
the abnormalear.