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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
Tympanic membrane
(pars accida)
mpanic membrane
P
quadrant
quadrant
Inf
Superior turbinate
Hard palate
of
phar
of tongue
First premolar
r
Handle of malleus
Antero-superior
quadrant
Ty
(pars tensa)
ostero-superior
Postero-inferior
Fig.3.7 Structures and quadrants of the right tympanic membrane (eardrum) as
seen on otoscopy.
Frontal sinus
Cone of light
Antero-inferior
quadrant
143HEAD AND NECK
Middle turbinate
erior turbinate
Nostril Nasopharynx
Fig.3.8 Anatomy of thenose.
Posterior wall
oropharynx
Palato-
yngeal
arch
Palato-
glossal
arch
Dorsum
Fig.3.9 Anatomy of the mouth and oropharynx.
Soft
palate
Uvula
Central incisor
Lateral
incisor
Canine
Hard palate
Palatine
raphe
Palatine
tonsil
Sphenoid sinus
Eustachian tube
Soft palate
Second
premolar
First mola
Second
molar
Third
molar
(wisdom
tooth)
144 CHAPTER3 History and examination
r
Obturator f
Musculoskeletal
History
Symptoms Joint pain, swelling, deformity, morning stiness, instability,
sensory changes, back pain, limb pain, muscle/ soft tissue aches, cold
ngers and toes, dry eyes and mouth, red eyes, systemic symptoms
(fatigue, weight loss, tight skin, fever, rash, diarrhoea), injury/ trauma
(mechanism, timing, change in symptoms since), bleeding tendency.
Past medical historyPrevious trauma/ surgery, recent infections (strepto-
coccal, gonorrhoeal, TB, etc), insect/ tick bites, IBD, skin disease (psoriasis), childhood arthritis, haemophilia.
Drug history Previous antiarthritic agents (NSAIDs, steroids (oral/ intra-
articular), DMARDs) with benecial/ side eects, long- standing steroids,
2+
Ca
supplements, vitamin D analogues, bisphosphonates, other concur-
rent medications (antihypertensives etc), allergies.
Activities ofdaily living Ability to:bathe, dress (and undress), eat, transfer
from bed to chair and back, use of the toilet; ?change with symptoms.
Social history Domestic arrangements (who else is at home, location of
bathroom in relation to bed), smoking history, drug and alcoholuse.
Family historyRheumatoid, gout, osteoarthritis, haemochromatosis, IBD,
haemophilia, psoriasis, ankylosing spondylitis.
Examination
Each joint has a specic examination routine, though the underlying
principles for each are very similar. Always examine the joint above and
belowtoo.
General inspectionOverall appearance of the patient and theirgait.
LookClose inspection of the joint, comparing left to right if possible.
Feel Assessment of warmth, tenderness, crepitus, eusions,etc.
Move Active (patient moving the joint) and passive (examiner moving
joint) movements; stressing joint where appropriate.
MeasureRange of movements (in degrees) and degree of joint laxity.
Pubic tubercle
oramen
Ischium
Lesser trochanter
Fig.3.0 Anatomy of the left hipjoint.
Pubis
Ilium
Anterior superio
iliac spine
Femoral head in
acetabulum
Greater
trochanter
Femur
Hip(Fig.3.0; E OHCS11p. 488.)
Lateral Medial
ollateral ligament
Lateral c
Lateral meniscus
InspectionLeg shortening, internal rotation (hip dislocation), external ro-
tation (fractured neck of femur), scars, sinuses, cellulitis, bruising.
Palpation Check bony landmarks (greater trochanter, anterior superior
iliac crest) are symmetrical, warmth, crepitus and clicks on movement.
Supine Active and passive range of movement; exion (straight leg exion
0– 90°, exion with knee bent 0– 35°), abduction (0– 50°), adduction, internal (0– 45°) and external (0– 45°) rotation, xed exion deformity (with
hand in lumbar lordosis, check the popliteal fossa can touch the couch).
Prone Active and passive range of movement; extension (0– 20°).
Gait Trendelenburg gait (E p. 34), walkingaids.
Other jointsKnee (Fig.3.) and lower spine/ sacroiliac (Ep. 47).
Knee(E OHCS11p. 494.)
InspectionSwelling, erythema, resting position, varus (bow- legs) or valgus
(knock- knees) deformity, scars, sinuses, cellulitis, muscle wasting of thigh
muscles compared to the other side (especially vastus medialis).
Palpation Temperature, bony landmarks (head of bula, medial and lat-
eral joint lines, patella), eusion (if large, infra- patella sulci will be bulging
outwards with a positive patella tap; if small, try milking uid down from
thigh and stroking uid from one side to the other), crepitus, clunks or
clicks on movement, patella position, tenderness, and mobility.
Supine Active and passive movement; exion (0– 35°), extension(0°).
PronePopliteal fossa cysts or aneurysms.
Stressing CruciatesFlex knee to 90°, immobilize the patient’s foot by sitting
on it and check the integrity of the anterior and posterior cruciate ligaments by pulling and pushing the lower leg, respectively;
Collaterals Flex
knee to 30°, x the thigh with your left hand, and test medial collateral (pull
lower leg laterally) and then lateral collateral (push lower leg medially).
GaitLimp, walkingaids.
Other jointsHip (see previous section) and ankle (Ep. 46).
145MUSCULOSKELETAL
Femur
Patella
ollateral
ligament
Head of fibula
Fig.3. Anatomy of the right kneejoint.
Medial c
Articular cartilage
Medial meniscus
Tibia
146 CHAPTER3 History and examination
Medial malleolus
Lateral malleolu
Distal phalanx
Proximal phalanx First metatarsal
Cuneiforms
s
TarsalsPhalanges Metatarsals
Ankle(Fig.3.2.)
InspectionSwelling, erythema, resting position (consider fracture– disloca-
tion and get immediate senior help if there is marked deviation of the
foot following trauma; Epp. 456–9).
Palpation Temperature, bony landmarks (medial and lateral malle-
olus, tibiotalar joint), crepitus, pain, swelling, eusion, crepitus.
Palpate proximal bular head to exclude its fracture, check foot
trauma
pulses (E p. 26), distal sensation, and capillary rell.
Movement Active and passive movement; plantarexion (0– 50°), dorsi-
exion (0– 5°), inversion (0– 30°), eversion (0– 5°).
GaitLimp, walking aids, ability to walk 2 paces unaided.
Other jointsKnee (E p. 45) and foot (Ep. 46).
$ Ottawa ankle rulesAnkle X- ray only required in adults and children >6 yr
if any pain in malleolar area and bony tenderness over any of:distal 6cm of
posterior edge of tibia or bula, or tip of medial or lateral malleolus or if
unable to bear weight both immediately and in the ED for 4steps.
After
Fibula
s
Calcaneus
Cuboid
Fig.3.2 Anatomy of the right anklejoint.
Tibia
Talus
Navicular
FootSee Fig.3.3.
InspectionSwelling, erythema, resting position, high arch, bunions.
Palpation Temperature, pain, or crepitus along each metatarsal and phalanx,
forefoot bones (navicular, cuboid, and medial, intermediate, and lateral cuneiform), foot pulses (E p. 26), distal sensation, and capillary rell.
Movement As for ankle examination but also adduction and abduction
across the talonavicular and calcaneocuboid joints.
GaitLimp, walking aids, ability to walk 2 paces unaided.
Other joints Ankle (Ep. 46).
Medial phalanx
Fig.3.3 Anatomy of the leftfoot.
(of great toe)
(lateral, middle, medial)
Navicular
Cuboid Calcaneus
Talu
Back(Fig.3.4; E OHCS1p. 478.)
Thoracic
kyphosis
Thoracic
Inspection Deformity, loss or exaggeration of thoracic kyphosis or
lumbar lordosis, lateral deviation from the midline (scoliosis).
Palpation With patient standing in front, palpate each vertebra for pain;
with patient prone, palpate each side of pelvis for sacroiliac tenderness.
Movement Active Flexion (touch toes with knees together and legs
straight; most people can touch their shins), extension (leaning backwards), lateral bending (lateral exion), and rotation (best assessed with
patient seated so pelvis is xed);
Passive With patient supine, perform
straight leg raise by elevating each leg in turn (0– 85°).
Measure Schober’s test for lumbar exion (mark the level of the pos-
terior iliac spine in the midline; make a further two marks, one 5cm
below this and one 0cm above this; the distance between these two
new marks measured when the patient is standing and then in full
exion— an increase of <5cm suggests limited lumbar exion) (eg ankylosing spondylitis).
Other jointsHip (E p. 45) and knee (Ep. 45).
Cervical
147MUSCULOSKELETAL
Fig.3.4 Anatomy of thespine.
Lumbar
Sacrum
Coccyx
Lumbar
lordosis
148 CHAPTER3 History and examination
Sacral pr
pubis
Ischium
Sacrum
tuber
Anterior view Posterior view
vicular joint
Pelvis
The joints in the pelvis are xed, however the sacroiliac joint can be
palpated for tenderness from behind; in a trauma emergency, a senior
member of the trauma team may test the pelvis for instability. See Fig.3.5.
Sacroiliac joint
omontory
Anterior superior
iliac spine
Obturator
foramen
Symphysis
Fig.3.5 Anatomy of the pelvis.
Ilium
Pubis
Shoulder(Fig.3.6; E OHCS1p. 470.)
InspectionSwelling, erythema, deformity, resting position (check from the
front, side, and back), scars, sinuses, cellulitis, swelling, muscle wasting
(deltoid, supraspinatus, infraspinatus).
Palpation Temperature, bony landmarks (acromion, clavicle, spine of
scapula, cervical and upper thoracic vertebrae), crepitus, clicks.
Movement Active and passive movement; abduction (0– 90° with elbow
exed, 0– 80° with elbow extended), adduction, internal (0– 90°) and
external (0– 65°) rotation, exion (0– 80°), and extension (0– 65°),
passive abduction should be undertaken carefully if painful.
Stressing Impingement test Arm held at 90° abduction and internally
rotated, if pain detected it is a positivetest;
Scarf testPatient’s left hand
placed over their right shoulder and vice versa, if pain detected it is a
positive test (acromioclavicular joint pathology).
Other jointsElbow (E p. 49) and back (Ep. 47).
Acromion
Greater
tuberosity
Lesser
osity
Humerus
Fig.3.6 Anatomy of the right shoulderjoint.
Clavicle
Spine of scapula
Scapula
Acromiocla
Acromion
Elbow(Fig.3.7; E OHCS1p. 474.)
Anterior view Posterior view
le
Lateral epic
Metacarpals
Ra
Inspection Swelling, erythema, inamed bursae, rheumatoid nodules or
psoriatic plaques over the olecranon,scars.
Palpation Temperature, bony landmarks (medial and lateral epicondyles,
olecranon), crepitus, clicks, instability.
Movement Active and passive movement; exion (0– 50°) and extension
(0°); pronation, supination.
Other jointsShoulder (Fig.3.6) and wrist (Fig.3.8).
Medial
supracondylar
Medial condyle
Lateral condyle
ondyle
Capitulum
Head of radius
Neck of radius
Fig.3.7 Anatomy of the rightelbow.
crest
Coronoid fossa
Medial
epicondyle
Trochlea
Coronoid process
Olecranon fossa
Olecranon
Lateral epicondy
Head of radius
Neck of radius
Wrist(Fig.3.8; E OHCS1p. 476.)
InspectionSwelling, erythema, deformity (eg Colles’ fracture), features of
rheumatoid disease (E p. 512),scars.
Palpation Temperature, bony landmarks (styloid process of radius, head
and styloid process of ulna), scaphoid (base of the anatomical snu- box).
Movement Active and passive movement; exion (0– 75°), extension
(0– 75°), radial (0– 20°), ulnar deviation (0– 20°), pronation, supination.
Other jointsElbow (E p. 49) and hand (Ep. 50).
149MUSCULOSKELETAL
Trapezoid
Trapezium
Scaphoid
dial styloid process
Radius
Fig.3.8 Anatomy of the wrist andhand.
Capitate
Hamate
Pisiform
Triquetrum
Lunate
Ulnar styloid
process
Ulna
Carpals
150 CHAPTER3 History and examination
Hand(Fig.3.9; E OHCS1p. 476.)
InspectionErythema, swelling, breaks to the skin, features of rheumatoid
disease (E p. 512) or osteoarthritis (E p. 512), deformity, dislocation,
muscle wasting, nail pitting.
Palpation Temperature, palpate each metacarpal and phalanx for pain or
crepitus, distal capillary rell and sensation.
Movement Active and passive movement; exion and extension of every
MTPJ, PIPJ, and DIPJ, abduction and adduction of every MTPJ, oppositionand circumduction of the thumb MTPJ; ask the patient to: hold a
pencil and write, pick up a mug, undo a button, oppose their thumb and
little nger (check strength of this against your own); check strength of
extension and exion following penetrating or lacerating trauma to identify tendon injury.
StressingCollateral ligaments of the digits following trauma or dislocation
by attempting to deviate the phalanges medially or laterally.
Other jointsWrist (E p. 49) and inspect theelbow.
Distal phalanx
Metacarpal bones
Pr
Middle phalanx
oximal phalanx
First metacarpal
151MUSCULOSKELETAL
Phalanges
Carpal bones
Radius
Fig.3.9 Anatomy of the hand, thumb, and ngers.
Ulna
152 CHAPTER3 History and examination
Urological
History
Symptoms Polyuria, anuria, prostatism (urgency, hesitancy, poor stream,
terminal dribble, nocturia, straining), haematuria, dysuria, oedema, renal
colic, incontinence, malaise, lethargy, N+V, anorexia, weight loss, itching,
passing stones in the urine, incontinence, impotence, infertility, bone pain,
genital discharge, genital/ perineal lesion, scrotal pain, dyspareunia (pain on
intercourse), FB (vaginal, urethral, anal), anal/ perianal problems.
Past medical historyDM, iBP, recurrent UTIs, renal/ ureteric stones, mye-
loma, known renal impairment/ failure, previous vesicoureteric reux,
gout, immunosuppression (steroids, HIV), neurological disease, longterm urinary catheter, STIs, spinal cord pathology;
recurrent balanitis, testicular pain/ swelling;
mode of delivery and any complications, last cervical smear and result.
Drug history Nephrotoxics (including NSAIDs, ACEi, aminoglycosides),
bladder neck relaxants, infertility or impotence drugs, antiandrogens;
allergies.
Social historyForeign travel, ability to cope with ADLs, sex abroad, illicit
drug use (smoke, oral,IV).
Sexual history
• Last sexual intercourse (LSI)— date, sex, type of intercourse (vaginal,
anal, oral), protected, relationship of partner (casual, long term),
problems or symptoms in partner, high- risk area, sexworker
• Repeat the above for all partners in the last3mth
• All men should also be asked if they have ever had sex with another
man in the past as this aects risk and types of STI to consider.
Occupational historyPast and present jobs, exposure todyes.
Family historyPolycystic kidney disease, DM,iB P.
Examination (lying at, supine)See Fig.3.20.
General inspection Mental state, RR (?Kussmaul breathing of metabolic
acidosis), hiccups, pallor, hydration (dehydrated: sunken eyes, dry lips/
tongue; uid- overload: peripheral oedema, pulmonary oedema).
HandsLeuconychia, brown nails, pale nailbeds.
Arms Bruising (purpura), pigmentation, scratch marks, stula, BP (lying
and standing).
FaceEyes (anaemia, jaundice), mouth (dehydration, ulcers, fetor),rash.
NeckJVP.
Abdomen Inspect (distended bladder, scars, transplanted kidney, dialysis
port), palpate (ballot kidneys, bladder, liver, spleen, lymph nodes), percuss
(enlarged bladder, ascites), auscultate (renal artery bruits), PR for prostate.
Rectum Size, surface, consistency, and symmetry of prostate in men,
faecal impaction (will worsen urinary retention).
BackOedema, loin tenderness on percussion.
Male Tight foreskin,
FemaleNumber of children,