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Tachycardia

 
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Overview

  • Ask About

  • Time spent exercising - per day or per month
  • Type of exercise - e.g. walking, running, cycling, team sports
  • Ask About

  • Travel to other countries - especially developing countries
  • Prophylaxis before travelling - vaccines, malaria prophylaxis
  • Exposure to animals - especially bites or scratches
  • Food intake - especially raw meat, fish, unpasteurised dairy products
  • Contact with fresh water
  • Contact with sick people
  • Insect bites
  • Sexual contacts
  • Needle exposures
  • Ask About

  • Any past surgeries the patient has had.
The patient's past medical history provides the medical context that underpins their current presentation. By understanding the natural history and course of their existing medical conditions, it is possible to predict their risk of complications and narrow down the differential diagnosis of their presenting complaint.
  • Ask About

  • Meals - number per day, whether they eat meals at the same time each day, skipping meals
  • Snacks between meals
  • Where they eat - at home, restaurants, fast food
  • What they eat - on a typical day, or in the last 24 hours
  • Foods they cannot eat
  • Foods they do not like
  • Any special diets - and whether it is medically necessary (e.g. for coeliac disease, allergy or food intolerance)
  • Vitamin / mineral supplements
  • Ask About

  • Whether the patient takes any recreational drugs
  • How long they have been taking the drug for
  • How often they take the drug
  • Whether they have injected drugs
  • Past attempts to quit
  • Willingness to cut down or stop
  • Ask About

    The patient's ability to perform important tasks around the house and outside, and whether they have any assistance from family, friends or home services.
  • Shopping
  • Cooking
  • Cleaning
  • Laundry
  • Toiletting
  • Showering
  • Administering medications
Smoking tobacco places patients at risk of multiple respiratory, cardiovascular and other complications. By understanding our patients' smoking history and overall exposure to tobacco it is possible to estimate this risk and guide them in attempting to quit smoking.
These questions are incredibly valuable for elderly patients who are poorly mobile, though are likely to be inappropriate in younger patients who are fit and active.
  • Ask About

    Any allergies that the patient may have.
  • Known or potential allergens - pollen, dust, pets, certain foods, latex, medications
  • Symptoms of allergy - itch, rash, wheeze, rhinorrhoea, red eyes, swelling, vomiting, diarrhoea, anaphylaxis
  • How long after exposure the symptoms begin
  • Timing - age that the allergy first started, frequency of reactions, whether the reaction is seasonal
  • Severity of the reaction - hospital / ICU admissions
  • Treatment - medications given and response, epipen
  • Family history of allergy (atopy) - asthma, eczema, hay fever, food allergies
  • Ask About

  • Any conditions in the family
  • If passed, what their family members passed away due to
The patient's medication history is a very important aspect of their medical history. Documenting a comprehensive list of a patient's medications allows for correct charting of medications as well of the identification of potential drug interactions or adverse effects.
  • Ask About

    Any reactions to medications.
  • What specific drug they have had a reaction to
  • What happens when they take the drug in question
  • How long after exposure to the drug the reaction began
  • How severe the reaction was
  • Whether the reaction resolved after cessation or dose-reduction of the drug
  • When this reaction first / last happened
Alcohol abuse, binging and dependence is very common in the community, and can result in significant acute and chronic complications. A tactful history will aid in understanding the patient's pattern of alcohol intake and their attitude toward alcohol.
  • Ask About

  • Diagnosis - cause of chronic kidney disease, stage
  • Complications - acidosis, fluid overload, electrolyte derangements, cardiovascular disease, anaemia, mineral bone disease, malnutrition
  • Management - management of complications, dialysis, renal transplant
  • Dialysis - commencement, modality, access, timing, fluid removal
  • Ask About

  • Commencement - when they started dialysis; indication
  • Modality - haemodialysis / peritoneal dialysis
  • Access - vascath / fistula / graft (HD), Tenckhoff catheter (PD)
  • Timing - frequency and duration
  • Fluid removal - dry/ideal weight, amount of fluid removed
  • Complications
Renal transplantation is a complex field and requires a detailed understanding of the patient's physical, psychological and social factors. This page contains basic questions to ask in order to better understand the history of a patient who has had a renal transplant.
  • Ask About

  • Diagnosis - when diagnosed, clinical phenotype
  • Family history of multiple sclerosis
  • Relapses - symptoms, frequency, duration, partial / complete resolution of symptoms
  • Management - lifestyle changes, immunomodulators
  • Ask About

  • Diagnosis - when the diagnosis was made
  • Manifestations - tremor, bradykinesia, rigidity, postural instability
  • Management - dopamine replacement, MAO-B inhibitors, COMT inhibitors
  • Ask About

  • Diagnosis - when diagnosed, EEG changes, MRI changes
  • Family history of seizures / epilepsy
  • Manifestations - type of seizures, prodrome, postictal period
  • Severity - frequency of seizures, last seizure
  • Management - avoidance of precipitants, medications
  • Ask About

  • Diagnosis - type of MND, when diagnosed, disease course
  • Manifestations - dysphagia, dysarthria, spasticity, weakness
  • Management - physiotherapy, respiratory support, optimisation of nutrition, psychological support, pharmacologic agents
  • Prognosis - expected trajectory of disease
  • Ask About

  • Diagnosis - when diagnosis was made, symptoms on presentation
  • Manifestations - past myaesthenic crisis / issues with anaesthetics in the past
  • Management - anticholinesterase agents, immunosuppression, thymectomy, past IVIg / plasmapheresis for crisis
  • Drugs that Can Cause Megaloblastic Anaemia

  • Interference with DNA Synthesis

  • Folate antagonists - methotrexate, trimethoprim
  • Purine analogues - azathioprine, 6-mercaptopurine, allopurinol, cladribine, fludarabine
  • Pyramidine antagonists - 5-fluorouracil, cytarabine, gemcitabine, capecitabine
  • Anticonvulsants - valproate, phenytoin
  • Reverse transcriptase inhibitors - abacavir, emtricitabine, entacavir, lamivudine, zidovudine, tenofovir, efavirenz
  • Malabsorption of B12 / Folate

  • Colchicine
  • Isoniazid
  • Metformin
  • Cholestyramine
  • Proton pump inhibitors
  • Histamine 2 receptor antagonists
  • Other

  • Ethanol
  • Sulfasalazine
  • Nitrous oxide
  • Medications Associated with Neutrophilia

  • Glucocorticoids
  • Adrenaline
  • Lithium
  • Granulocyte colony stimulating factor (G-CSF)
  • Medications Associated with Immune Haemolysis

  • Methyldopa
  • Quinine / quinidine
  • IV immunoglobulin
  • Penicillins - especially piperacillin
  • Cephalosporins - especially cefotetan and ceftriaxone
  • NSAIDs - especially diclofenac
  • Medications Associated with Bleeding

  • NSAIDs - ibuprofen, diclofenac, meloxicam, naproxen, ketorolac, indomethacin, celecoxib
  • Antiplatelets - aspirin, clopidogrel, prasugrel, ticagrelor, abciximab, eptifabitide, tirofiban, dipyridamole
  • Anticoagulation - heparin, enoxaparin, dalteparin, warfarin, dabigatran, rivaroxaban, apixaban,
  • SSRIs - citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
  • Medications Associated with Thrombosis

  • Hormonal therapies - oral contraceptives, hormone replacement therapy, SERMs
  • COX-2 inhibitors - celecoxib
  • Erythropoietin
  • Warfarin (initially)
  • Medications Associated with Pure Red Cell Aplasia

  • Recombinant human erythropoietin
  • Antibacterials - linezolid, chloramphenicol, sulfamethoxazole
  • Antimycobacterials - isoniazid, rifampicin, dapsone
  • Antivirals - interferon alpha, lamivudine, zidovudine
  • Anticonvulsants - valproate, carbamazepine
  • Immunosuppressants - azathioprine, mycophenolate
  • Medications Associated with Eosinophilia

  • Antibiotics - penicillins, cephalosporins, glycopeptides, sulfamethoxazole
  • Anticonvulsants - phenytoin, carbamazepine, phenobarbitone
  • Antipsychotics - chlorpromazine
  • H2 receptor antagonists - ranitidine
  • Proton pump inhibitors - omeprazole, lansoprazole
  • Sulfonylureas
  • ACE inhibitors
  • NSAIDs
  • Medications Associated with Sideroblastic Anaemia

  • Isoniazid
  • Pyrazinamide
  • Chloramphenicol
  • Cycloserine
  • Ethanol
  • Causes of Drug-Induced Thrombotic Microangiopathic Anaemias

  • Acute Immune Reactions

  • Antiplatelets - clopidogrel, ticlodipine
  • Quinine
  • Cocaine
  • Toxic

  • Chemotherapy - mitomycin, cisplatin, oxaliplatin, gemcitabine, vincristine
  • Immunotherapy - interferons, bevacizumab
  • Immunosuppressants - cyclosporine, tacrolimus, sirolimus
  • Medications Associated with Immune Thrombocytopaenia

  • Glycoprotein IIb/IIIa inhibitors - abciximab, eptifibatide, tirofiban
  • Heparins - heparin sodium, low molecular weight heparins
  • Anticonvulsants - carbamazepine, phenytoin, valproate
  • Antibacterials - rifampicin, linezolid, vancomycin, sulfamethoxazole
  • Antimalarials - quinine, quinidine
  • NSAIDs - diclofenac, naproxen
  • Paracetamol
  • Hydrochlorothiazide
  • Medications Associated with Heparin-Induced Thrombocytopaenia

  • Unfractionated heparin - heparin sodium
  • Low molecular weight heparin - enoxaparin, dalteparin
  • Causes of Drug-Induced Thrombotic Microangiopathic Anaemias

  • Acute Immune Reactions

  • Antiplatelets - clopidogrel, ticlodipine
  • Quinine
  • Cocaine
  • Toxic

  • Chemotherapy - mitomycin, cisplatin, oxaliplatin, gemcitabine, vincristine
  • Immunotherapy - interferons, bevacizumab
  • Immunosuppressants - cyclosporine, tacrolimus, sirolimus
  • Medications Associated with Aplastic Anaemia

  • NSAIDs - ibuprofen, indomethacin, diclofenac, aspirin
  • Antirheumatic drugs - sulfasalazine, penicillamine, gold
  • Antithyroid drugs - propylthiouracil, carbimazole, methimazole
  • Anticonvulsants - carbamazepine, phenytoin
  • Antibacterials - chloramphenicol, sulfamethoxazole
  • Chloroquine
  • Medications Associated with Neutropaenia

  • NSAIDs - ibuprofen, indomethacin, diclofenac, aspirin
  • Antirheumatic drugs - sulfasalazine, penicillamine, gold
  • Antithyroid drugs - propylthiouracil, carbimazole, methimazole
  • Anticonvulsants - carbamazepine, valproate, phenytoin
  • Antipsychotics - clozapine, risperidone, haloperidol
  • Antibiotics - penicillins, cephalosporins, vancomycin, gentamicin, ciprofloxacin, metronidazole, sulfamethoxazole, chloramphenicol
  • Antimalarials - quinine, chloroquine
  • Antihistamines - ranitidine, cimetidine
  • Cardiovascular drugs - procainamide, digoxin, nifedipine, beta blockers
  • Chemotherapy agents
  • Rituximab
  • Medications that can Trigger Haemolysis in G6PD Deficiency

  • Flutamide
  • Dapsone
  • Methylene blue
  • Naphthalene
  • Nitrofurantoin
  • Primaquine
  • Sulfamethoxazole
An allogeneic stem cell transplant involves depleting a patient's bone marrow using chemotherapy, and then transfusing another (matched) patient's stem cells. This serves purposes of both replacing their haematopoietic cells with normal cells, and providing some degree of graft-vs-disease effect.
  • Medications Associated with Erythrocytosis

  • Anabolic steroids
  • Erythropoietin (EPO)
An autologous stem cell transplant refers to the process of mobilising and collecting a patient's stem cells, providing chemotherapy to deplete the bone marrow, and then retransfusing their stem cells. This process is less complex and has less potential side effects than an allogeneic stem cell transplant.
  • Ask About

  • Diagnosis - when the diagnosis was made, cause
  • Exercise tolerance
  • Frequency of exacerbations
  • Colonisation - bacteria that have been isolated in the past (e.g. Moraxella, Haemophilus, Pseudomonas, Staphylococcus aureus, Burkholderia cepacia, Mycobacterium)
  • Complications - infections, haemorrhage, cor pulmonale
  • Management - sputum clearance strategies, long-term antibiotics

Aetiology

  • Causes of Chest Pain

  • Cardiac

  • Stable angina
  • Acute coronary syndrome - unstable angina, NSTEMI, STEMI
  • Other cardiac ischaemia - vasospasm (prinzmetal angina), severe aortic stenosis, hypertensive ischaemia, rate-related ischaemia, dilated cardiomyopathy, Tako-tsubo cardiomyopathy
  • Non-ischaemic - pericarditis, myocarditis, myocardial contusion
  • Non-Cardiac

  • Vascular - aortic dissection, pulmonary embolism
  • Respiratory - pneumonia with pleurisy, pneumothorax, lung cancer
  • Gastrointestinal - peptic ulcer, gastritis, oesophagitis, oesophageal spasm, oesophageal rupture
  • Musculoskeletal - costochondritis, osteomyelitis, rib fracture, cervical spinal disease
  • Psychogenic - panic disorder, malingering

Overview

  • Ask About

  • Diagnosis - when ILD was diagnosed, cause
  • Pace of progression
  • Exacerbations
  • Management - lifestyle, pharmacologic, supportive, surgical measures
  • Complications
  • Ask About

  • Diagnosis - presenting symptoms, type of lung cancer
  • Functional status
  • Risk factors - environmental exposures, chronic scarring
  • Family history of lung cancer
  • Management - surgery, chemotherapy, radiotherapy, targetted therapy
  • Complications - pleural effusion, metastases, local compression, paraneoplastic
  • Ask About

  • Time spent exercising - per day or per month
  • Type of exercise - e.g. walking, running, cycling, team sports
Patients with asthma are at risk of exacerbations, which may cause significant morbidity or mortality. By understanding the natural history of their airways disease it is possible to create a management plan that prevents complications in the future.
Smoking tobacco places patients at risk of multiple respiratory, cardiovascular and other complications. By understanding our patients' smoking history and overall exposure to tobacco it is possible to estimate this risk and guide them in attempting to quit smoking.
  • Ask About

  • Travel to other countries - especially developing countries
  • Prophylaxis before travelling - vaccines, malaria prophylaxis
  • Exposure to animals - especially bites or scratches
  • Food intake - especially raw meat, fish, unpasteurised dairy products
  • Contact with fresh water
  • Contact with sick people
  • Insect bites
  • Sexual contacts
  • Needle exposures
  • Ask About

  • Diagnosis - when diagnosed, sleep study results
  • Severity - symptoms, impact on function
  • Management - weight loss, CPAP, surgery
  • Complications - cardiovascular disease, pulmonary hypertension, depression
Tuberculosis is the disease caused by the bacteria Mycobacterium tuberculosis, and may affect almost any organ in the body resulting in a wide range of clinical presentations. In patients with a history of tuberculosis, it is important to understand the risk factors, natural history and past treatment of disease.
Chronic obstructive pulmonary disease is a severely functionally limiting condition primarily affecting previous tobacco smokers. Management is targeted to the severity of the disease, and underpinned by smoking cessation.
  • Ask About

  • Diagnosis - age at diagnosis, presenting symptoms, mutation
  • Family history of cystic fibrosis
  • Respiratory - symptoms, bacteria colonised, frequency of admission
  • Pancreatic - steatorrhoea, diet, insulin requirement
  • Gastrointestinal - constipation, reflux, cirrhosis
  • Musculoskeletal - joint pain, osteoporosis
  • Fertility - previous infertility, plans to conceive, genetic counselling
  • Other - symptoms of depression
  • Ask About

  • Diagnosis - provoked or unprovoked PE, preceding DVT
  • Management - anticoagulation
  • Complications - infarction, right heart failure, pulmonary hypertension
  • Ask About

  • Any medications the patient is on
  • What pharmacy they get their medications from
  • Whether they use any dosing aids, such as a Webster pack
  • Ask About

  • Meals - number per day, whether they eat meals at the same time each day, skipping meals
  • Snacks between meals
  • Where they eat - at home, restaurants, fast food
  • What they eat - on a typical day, or in the last 24 hours
  • Foods they cannot eat
  • Foods they do not like
  • Any special diets - and whether it is medically necessary (e.g. for coeliac disease, allergy or food intolerance)
  • Vitamin / mineral supplements
Heart failure can be functionally debilitating, though proper management can have a significant positive effect on a patient's mortality risk and quality of life.
  • Ask About

  • Any medications the patient is on
  • What pharmacy they get their medications from
  • Whether they use any dosing aids, such as a Webster pack
Smoking tobacco places patients at risk of multiple respiratory, cardiovascular and other complications. By understanding our patients' smoking history and overall exposure to tobacco it is possible to estimate this risk and guide them in attempting to quit smoking.
  • Ask About

  • Diagnosis - when hypertension was diagnosed
  • Severity - blood pressure measurements
  • Management - nonpharmacologic / pharmacologic
  • Complications - cardiovascular, cerebrovascular, ocular, renal
  • Ask About

  • BMI - height, weight
  • Associated diseases - metabolic syndrome, IHD, stroke, OSA, GI, PCOS, OA, gout
  • Management - attempts to lose weight, diet, level of exercise, pharmacologic or surgical approaches
  • Ask About

  • Meals - number per day, whether they eat meals at the same time each day, skipping meals
  • Snacks between meals
  • Where they eat - at home, restaurants, fast food
  • What they eat - on a typical day, or in the last 24 hours
  • Foods they cannot eat
  • Foods they do not like
  • Any special diets - and whether it is medically necessary (e.g. for coeliac disease, allergy or food intolerance)
  • Vitamin / mineral supplements
  • Ask About

  • Whether the patient takes any recreational drugs
  • How long they have been taking the drug for
  • How often they take the drug
  • Whether they have injected drugs
  • Past attempts to quit
  • Willingness to cut down or stop
Alcohol abuse, binging and dependence is very common in the community, and can result in significant acute and chronic complications.
  • Ask About

  • Diagnosis - when pulmonary hypertension was diagnosed, symptoms, cause
  • Severity - functional impact, last echo / right heart catheter result
  • Management - treatment of underlying disease, PAH drugs
  • Complications - particularly right ventricular failure
Patients with stable ischaemic heart disease are at great risk of cardiovascular death in the future. By taking a thorough history and understanding the natural history of their disease it is possible to estimate this risk, and identify ways to prevent future complications.
Atrial fibrillation is an often insidious condition involving irregular contraction of the ventricles due to fibrillation of the atria. If not properly managed this condition can result in significant complications including cardioembolic stroke.
  • Ask About

  • Diagnosis - when diagnosed, primary / secondary, lipid results
  • Management - lifestyle changes, medications
  • Complications - atherosclerotic complications, NAFLD
Dyspnoea, or shortness of beath, refers to the feeling of ‘not getting enough air' or ‘air hunger'. Thi may herald cardiorespiratory disease, though may also occur in the context of many other acute and chronic conditions.
  • Ask About

  • Diagnosis - cause of chronic kidney disease, stage
  • Complications - acidosis, fluid overload, electrolyte derangements, cardiovascular disease, anaemia, mineral bone disease, malnutrition
  • Management - management of complications, dialysis, renal transplant
  • Dialysis - copmmencement, modality, access, timing, fluid removal
Diabetes is a common disease, and is often poorly controlled. When assessing a patient with diabetes it is important to get an idea of how long they have had diabetes, what microvascular and macrovascular complications they have had, how good their control is, and whether they have had any hypoglycaemic episodes.
  • Ask About

  • Time spent exercising - per day or per month
  • Type of exercise - e.g. walking, running, cycling, team sports
  • Ask About

  • Diagnosis - when diagnosed, presenting symptoms
  • Family history of colorectal cancer
  • Stage - tumour size, lymph node involvement, metastases
  • Complications - bleeding, obstruction, perforation, management-related
  • Management - surgery, chemotherapy, targetted therapies
Inflammatory bowel disease (IBD) is a heterogeneous autoimmune condition that encompasses Crohn's disease and ulcerative colitis. Flares of IBD should be diagnosed and treated promptly.
  • Ask About

  • Diagnosis - when diagnosed, risk factors
  • Complications - hepatic, cardiometabolic, malignant
  • Management - previous attempts at weight loss
  • Ask About

  • Any medications the patient is on
  • What pharmacy they get their medications from
  • Whether they use any dosing aids, such as a Webster pack
Smoking tobacco places patients at risk of multiple respiratory, cardiovascular and other complications. By understanding our patients' smoking history and overall exposure to tobacco it is possible to estimate this risk and guide them in attempting to quit smoking.
  • Ask About

  • Meals - number per day, whether they eat meals at the same time each day, skipping meals
  • Snacks between meals
  • Where they eat - at home, restaurants, fast food
  • What they eat - on a typical day, or in the last 24 hours
  • Foods they cannot eat
  • Foods they do not like
  • Any special diets - and whether it is medically necessary (e.g. for coeliac disease, allergy or food intolerance)
  • Vitamin / mineral supplements
  • Ask About

  • Pretransplant history - cause and complications of chronic liver disease, past transplant, medical and social considerations
  • Peritransplant history - timing, indication, donor, graft type, anastomosis
  • Complications - past rejection episodes, infections, cardiovascular, metabolic, malignancy
  • Post-transplant management - immunosuppression, infective prophylaxis, cancer screening
A detailed travel history can help to define a patient's risk of certain infectious diseases. A patient presenting with fevers after recent travel to a developing country may have a much wider range of potential infections than a patient who resides in a developed country and has not recently travelled.
Gastroesophageal reflux disease is a condition in which there is incompetence of the lower oesophageal sphincter, resulting in reflux of gastric acid.
  • Ask About

  • Whether the patient takes any recreational drugs
  • How long they have been taking the drug for
  • How often they take the drug
  • Whether they have injected drugs
  • Past attempts to quit
  • Willingness to cut down or stop
Alcohol abuse, binging and dependence is very common in the community, and can result in significant acute and chronic complications.
Peptic ulcer disease is a common condition where ulcers may form in the stomach or duodenum. This may be as a result of Helicobacter pylori infection, medications, stress or dietary factors.
  • Ask About

  • Diagnosis - when their cirrhosis was diagnosed, cause of cirrhosis
  • Severity - Child-Pugh grade, MELD, compensated / decompensated
  • Complications - ascites, varices, encephalopathy
  • Management - diet, treatment of complications, HCC and variceal surveillance
  • Liver transplant - whether this has been discussed
  • Ask About

  • Diagnosis - cause (if known), when diagnosed
  • Manifestations - cirrhosis, lichen planus, cryoglobulinaemia, glomerulonephropathy
  • Management - direct acting antivirals, surveillance
  • Ask About

  • Diagnosis - cause (if known), when diagnosed
  • Manifestations - cirrhosis, polyarteritis nodosa, membranous glomerulonephropathy
  • Management - antivirals, surveillance
Scleroderma is also known as systemic sclerosis.
  • Ask About

  • Time spent exercising - per day or per month
  • Type of exercise - e.g. walking, running, cycling, team sports
These questions are incredibly valuable for elderly patients who are poorly mobile, though are likely to be inappropriate in younger patients who are fit and active.
  • Ask About

  • Diagnosis - when OA was diagnosed, what joints are involved
  • Risk factors - occupation, sport, trauma, obesity
  • Functional limitation
  • Management - non-pharmacologic / pharmacologic
  • Ask About

  • Diagnosis - when rheumatoid arthritis was diagnosed, presentation, duration of symptoms
  • Family history of rheumatoid arthritis
  • Manifestations - extent / severity of articular involvement, extra-articular disease
  • Functional impact
  • Management - non-pharmacologic, steroids, DMARDs
  • Ask About

  • Diagnosis - when gout was diagnosed, joints affected
  • Severity - frequency of flares, monoarticular / polyarticular
  • Complications - tophi, joint destruction, nephropathy
  • Management - during flares, dietary changes, urate-lowering therapy
  • Ask About

  • Diagnosis - when lupus was diagnosed, active or in remission, causes of flares
  • Family history of SLE
  • Manifestations - systemic, skin, MSK, cardiovascular, respiratory, neurologic, haematologic, renal
  • Management - sun avoidance, smoking cessation, hydroxychloroquine, immunosuppression
  • Role

  • Special sensory (sight).
  • Roles

  • Special sensory - equilibrium (vestibular nerve) and hearing (cochlear nerve)
The term nystagmus is used mainly to refer to jerk nystagmus, abnormal rhythmic eye movements that may occur due to peripheral nervous system, central nervous system or vestibular pathology.
Also known as the 'gag' reflex.
  • Role

  • Special sensory (smell)
Pseudobulbar palsy is a neurologic syndrome that occurs due to an upper motor neuron lesion affecting cranial nerves IX, X and XII.
The glabellar reflex is a primitive reflex - normally present in infants and absent in adults. In patients with frontal lobe damage or or Parkinsonism, ‘frontal release' signs such as glabellar, grasp, suck, snout and palmomental reflexes will be present.
  • Roles

  • V1 Ophthalmic Nerve

  • Somatic sensory: forehead, cornea, nasal cavity, oral cavity
  • V2 Maxillary Nerve

  • Somatic sensory: maxillary face, palate, nasal cavity, oral cavity
  • V3 Mandibular Nerve

  • Somatic sensory: mandibular face
  • Motor: muscles of mastication
  • Role

  • Somatic motor - intrinsic and extrinsic tongue muscles.
  • Roles

  • Somatic motor - pharyngeal & laryngeal muscles, palatoglossus
  • Visceral motor (parasympathetic) - pharynx, larynx, thoracic and abdominal viscera
  • Somatic sensory - back of ear, external auditory meatus, external tympanic membrane
  • Visceral sensory -larynx, oesophagus, trachea, thoracic and abdominal viscera, aortic arch stretch receptors, aortic body chemoreceptors
  • Special sensory (taste) - epiglottis
  • Role

  • Special sensory (smell).
  • Role

  • Somatic motor - eye abduction (lateral rectus).

II Optic Nerve

  • Role

  • Special sensory (sight)

Overview

Receptors
Cornea
 
 
Foramen
Superior orbital fissure
V1
Ophthalmic branch
 
Trigeminal Ganglion
 
 
Spinal nucleus
Pons, medulla
 
 
Intermediate neuron
 
 
Facial Motor Nucleus
Pons
 
Foramen
Internal auditory meatus
 
Geniculate Ganglion
 
Facial Nerve (VII)
Temporal & zygomatic branches
 
 
Muscle
Orbicularis oculi
  • Roles

  • Special sensory (taste) - anterior ⅔ of tongue
  • Somatic sensory - external ear, posterior auricle (Ramsay-Hunt zone)
  • Somatic motor - facial expression, eye closing
  • Visceral motor (parasympathetic) - submandibular & sublingual salivary glands, lacrimal glands, nasal & palatine glands
  • Signs of Multiple Sclerosis

  • Signs of optic neuritis - reduced visual acuity, central visual loss, optic disc atrophy
  • Internuclear ophthalmoplegia - inability to adduct one eye, with nystagmus in the other eye
  • Lhermitte’s sign - electric sensation in the limbs on neck flexion
  • Upper motor neuron weakness - increased tone, reduced power, hyperreflexia
  • Dorsal column (vibration / proprioception) sensory loss
  • Signs of cerebellar involvement - ataxia, dysarthria, dysmetria, dysdiadochokinesis, nystagmus

V Trigeminal Nerve

  • Roles

  • V1 Ophthalmic Nerve

  • Somatic sensory: forehead, cornea, nasal cavity, oral cavity
  • V2 Maxillary Nerve

  • Somatic sensory: maxillary face, palate, nasal cavity, oral cavity
  • V3 Mandibular Nerve

  • Somatic sensory: mandibular face
  • Motor: muscles of mastication

XI Accessory Nerve

  • Role

  • Motor: laryngeal & pharyngeal muscles, sternocleidomastoid, trapezius

Overview

Light Receptors
Rods / cones of retina
 
 
Bipolar Cells
Retina
 
Foramen
Optic canal
Optic Nerve (II)
Optic chiasm, optic tract
 
Pretectal nucleus
Midbrain
 
 
Edinger-Westphal nucleus
Superior colliculus (midbrain)
 
Oculomotor Nerve (III)
Foramen
Superior orbital fissure
 
 
Ciliary Ganglion
 
 
Muscle
Constrictor pupillae, ciliary muscles
  • Role

  • Motor - laryngeal & pharyngeal muscles, sternocleidomastoid, trapezius

XII Hypoglossal Nerve

  • Roles

  • Somatic motor: intrinsice and extrinsic tongue muscles

Overview

  • Role

  • Somatic motor - eye intorsion and depression (through contraction of the contralateral superior oblique).
The patient's level of consciousness is an assessment of their wakefulness and responsiveness to external stimuli.
  • Look For

  • The size of the pupils (dilated, normal, constricted) and equality of size bilaterally.

Oculomotor Nerve (III) Palsy

  • Look For

  • Eye deviated down and out
  • Diplopia
  • Ptosis
  • Mydriasis (pupillary dilatation)
  • Loss of pupillary reflexes

Overview

Bulbar palsy is a neurologic syndrome that occurs due to a lower motor neuron lesion affecting cranial nerves IX, X and XII.
Patients with myaesthenic syndromes exhibit muscle fatigability, or the inability to maintain contraction of muscles over time.
  • Roles

  • Special sensory (taste) - posterior ⅓ of tongue
  • Visceral sensory - carotid sinus baroreceptors, carotid body chemoreceptors
  • Somatic sensory - external ear, internal tympanic membrane, upper pharynx, posterior ⅓ of tongue
  • Somatic motor - stylopharyngeus
  • Visceral motor (parasympathetic) - parotid gland
When performing a cranial nerve examination, always ask to perform fundoscopy. This may provide valuable information regarding ocular or cranial nerve pathology, and reveals signs of diabetic or hypertensive nephropathy.
  • Signs of Myotonic Dystrophy

  • Myopathic facies - temporalis wasting, mandibular wasting, frontal baldness
  • Flaccid dysarthria - nasal speech, breathiness, monotony, impaired articulation
  • Warm-up phenomenon - grip myotonia, repeated eye closure
  • Percussion myotonia - muscle contraction with percussion of the thenar eminence
  • Wasting of the forearm and small muscles of the hand
  • Distal muscle weakness
  • Hyporeflexia
  • How to Elicit

  • Ask the patient to open their mouth and say ‘ahh'. Move the tongue using a tongue depressor, and use a light to visualise the oral cavity.
  • Signs of Cerebellopontine Angle Syndrome

  • Trigeminal (V) nerve palsy - reduced facial sensation
  • Facial (VII) nerve palsy - facial droop / weakness
  • Vestibulocochlear (VIII) nerve palsy - unilateral sensorineural hearing loss, nystagmus, ataxia

VII Facial Nerve

  • Roles

  • Special sensory (taste) - anterior ⅔ of tongue
  • Somatic sensory - external ear, posterior auricle (Ramsay-Hunt zone)
  • Somatic motor - facial expression, eye closing
  • Visceral motor (parasympathetic) - submandibular & sublingual salivary glands, lacrimal glands, nasal & palatine glands

Horner’s Syndrome

Horner's syndrome is a classic triad that occurs due to compression of the sympathetic chain.

Overview

  • Roles

  • Somatic motor - eye movement, eye opening
  • Visceral motor (parasympathetic) - pupillary & ciliary muscles

Facial Asymmetry

  • Look For

  • Drooping of one side of the face. Compare the angles of the mouth on both sides. Determine whether the eyebrow is spared on the affected side or not.

VIII Vestibulocochlear Nerve

  • Roles

  • Special sensory: equilibrium (vestibular nerve), hearing (cochlear nerve)

Overview

Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
Femoral - palpate within the inguinal region, halfway between the pubic symphysis and iliac crest.
Capillary refill time is a marker of perfusion, and prolonged refill time suggests poor perfusion of the area being examined.
Blood pressure is a measure of the arterial pressure during systole and diastole; this may also be used to calculate the mean arterial pressure. Low blood pressure can result in poor organ perfusion, which high blood pressure puts patients at risk of cardiac, cerebrovascular, retinal and renal complications.

The Abdominal Aorta

  • How to Assess

  • Place the hands on either side of the midline and identify the outermost margin of the aorta.

Overview

  • How to Assess

  • Light touch - Ask the patient to close their eyes. Using a cotton ball or microfilament, gently touch each dermatome / nerve distribution and ask the patient if they can feel the stimulus. Compare sides and proximally / distally.Spinothalamic tract & dorsal column - medial lemniscus pathway
  • Pain - demonstrate a sharp stimulus by touching the patient lightly on the chest with a neurotip. Ask the patient to close their eyes, and test each dermatome / nerve distribution alternating between sharp and dull sides of the neurotip. Ask the patient if they feel sharpness or dullness.Free nerve endings → spinothalamic pathway → sensory cortex
  • Vibration - with the patient’s eyes closed, place a vibrating 128hz tuning fork over the IP joint of the great toe. Ask the patient to describe the sensation. If they can feel it vibrating, progressively diminish the vibration until they cannot feel it. If they cannot feel it vibrating, test on the medial / lateral malleolus and then the tibial tuberosity.Pacinian corpuscles → dorsal column → medial lemniscus → sensory cortex
  • Proprioception - ask the patient to observe as you move the great toe up and down, holding either side of the IP joint. With their eyes closed, slowly move the joint up or down. Ask the patient whether the toe has moved up or down. Repeat several times, and repeat on the other side.Neuromuscular spindles → dorsal column → medial lemniscus → sensory cortex

Lower Limb Erythema

  • Look For

  • Redness - unilateral, bilateral, localised or diffuse.

Overview

  • How to Perform

  • Ask the patient to cross their arms over their chest and take deep breaths in and out through their mouth. Auscultate the lung fields, alternating from left to right. Make sure to auscultate the axillae and supraclavicular fossae.
Skin changes and overall poor skin condition of the lower limb may occur due to soft tissue disease; arterial, venous or lymphatic insufficiency; loss of afferent nerve supply or simply poor self-care.
The presence of ballotable or tender kidneys may provide a significant amount of information about the cause of a patient's renal disease, and in particular the presence of polycystic kidney disease.
Inspect the abdomen for skin changes, scars, distension or visible masses.
  • How to Perform

  • Ask the patient to lean forward and hold their breath in full expiration.
  • How to Perform

  • With the patient sitting, place one palm over the costovertebral angle and use the ulnar aspect of the other hand (in a fist) to gently percuss the kidneys.

Palmar Crease Pallor

  • Look For

  • Loss of colour in the creases of the palm.

Rashes Associated with Renal Disease

Xerosis cutis: abnormally dry skinCold weather, excessive bathing, irritants, advanced age, uraemia, diabetes, hypothyroidism

Overview

Asterixis, also known as hepatic flap or uraemic flap, is an important sign of metabolic encephalopathy that occurs due to dysregulation of the diencephalic motor centers in the brain that regulate innervation of muscles responsible for maintaining position.
  • How to Assess

  • Palpate the common carotid arteries, located in the anterior neck medial to the sternocleidomastoid. Palpate the arteries one at a time. Care should be taken to avoid stimulating the carotid sinus.

Oral Candidiasis

  • Look For

  • Creamy white lesions present on the tongue or inner cheeks, which may be associated with angular cheilitis or glossitis.

Overview

  • How to Elicit

  • Listen over the abdomen for bruits
  • Look For

  • Swelling of the lower limb due to fluid accumulation.

Heart Rate

  • How to Measure

  • Count the number of beats over 15, 30 or 60 seconds and multiply to estimate beats per minute.

Purpura

  • Look For

  • Red / purple lesions that do not blanch with pressure. May be present over the head, arms, legs, chest or abdomen.

Overview

  • How to Perform

  • Auscultate within the triangle bound by the mandible, sternocleidomastoid and thyroid cartilage. Ask the patient to hold their breath.
The jugular venous pulsation can often be difficult to visualise, though can be a useful indicator of the fluid status of a patient. The JVP can also provide valuable clues regarding the presence of right ventricular failure, pulmonary hypertension and tricuspid regurgitation.
The patient's body habitus provides insight into a patient's diet and metabolic status as well as their overall risk of cardiovascular and non-cardiovascular complications in the future. While static measures such as body habitus and waist-hip ratio can estimate future risk, unexpected change in weight may suggest active disease.
In patients with renal disease, always ask to perform fundoscopy. This may provide valuable information regarding the presence of hypertensive or diabetic retinopathy.
Assessing a patient's fluid status can often be very difficult, and relies on multiple different clinical measurements.

Halitosis

Also known as foetor ex ore, oral malodour and ‘bad breath'.

Overview

Ulcers, or non-healing open wounds, may occur in the lower limb in the context of arterial disease, venous disease or peripheral neuropathy.
Patients with chronic kidney disease may exhibit signs in the nails such as leukonychia or onycholysis.
  • Interpretation

  • Palpate the lower back, assessing for the presence of oedema.
  • How to Assess

  • With the back of the hand, feel from the top of the calf to the dorsum of the foot. Note if there is any change in temperature distally.
  • Signs of Chronic Kidney Disease

  • General Signs

  • Sallow complexion
  • Leukonychia
  • Sarcopaenia
  • Signs Suggesting a Cause

  • Finger prick markings (diabetes)
  • Palpable polycystic kidneys
  • Signs of Complications

  • Acidosis - tachypnoea
  • Fluid overload - hypertension, raised JVP, sacral / pedal oedema, pulmonary crepitations
  • Anaemia - palmar crease pallor, conjunctival pallor
  • Uraemia - scratch marks, confusion, asterixis, pericardial rub
  • Signs of Management

  • Haemodialysis - VasCath, arteriovenous fistula, graft
  • Peritoneal dialysis - Tenkhoff catheter
  • Scars - nephrectomy, renal transplant, parathyroidectomy
  • Palpable renal transplant (usually right lower quadrant)
  • How to Assess

  • The thumb is flexed anteriorly, away from the palm.

Wrist Drop

  • Look For

  • Abnormal flexion of the wrist, due to inability to extend the joint

Overview

The pattern of joint involvement in arthritis can be used clinically to identify the most likely pathology.
There are several pathognomonic signs in the hand and wrist that are suggestive of rheumatoid arthritis or osteoarthritis. This page outlines these findings.
  • How to Assess

  • The wrist joint is extended posteriorly.
  • How to Assess

  • The thumb is moved diagonally across the palm.

Elbow Lesions

  • Feel For

  • Firm masses over the dorsum of the elbow, noting associated swelling, erythema or tenderness.

Overview

  • Signs of Scleroderma

  • General Signs

  • Calcinosis cutis: hard masses beneath the skin, due to calcium deposition
  • Raynaud’s phenomenon: areas of white, blue or red change in the hands
  • Sclerodactyly: thickening of the fingers / toes
  • Telangiectasia: visible dilated blood vessels
  • Reduced oral aperture
  • Nailfold abnormalities
  • Tendon friction rubs (severe disease)
  • Signs of Complications

  • Evidence of pulmonary hypertension - prominent a wave, parasternal heave, loud / palpable P2
  • Evidence of interstitial lung disease - fine fibrotic crepitations
  • Evidence of renal crisis - significant hypertension
  • How to Assess

  • The fingers are moved apart in the coronal plane.
  • Signs of Rheumatoid Arthritis

  • General Signs

  • Symmetrical arthropathy with sparing of DIP joints
  • Prominence of the ulnar styloid
  • Radial deviation of the wrist
  • Ulnar (medial) deviation of the MCP joints
  • Volar (palmar) subluxation of the MCP joints
  • Swan neck deformity: hyperextension at the PIP joint with flexion at the MCP and DIP joints
  • Boutonniere deformity: flexion at the PIP joints with hyperextension at the MCP and DIP joints
  • Z-thumb deformity: flexion at the IP joint of the thumb with hyperextension at the MCP joint
  • Signs of Complications

  • Evidence of compressive neuropathy - e.g. signs of carpal tunnel syndrome
  • Evidence of vasculitis - palpable purpura
  • Evidence of interstitial lung disease - fine fibrotic crepitations
  • Splenomegaly (Felty’s syndrome)
  • Signs of Gout

  • Active monoarthritis - particularly of the first MTP joint (podagra) or tarsal joint
  • Asymmetric polyarthritis
  • Gouty tophi - particularly over joints; the olecranon bursa at the elbow; the helix of the ear; the infrapatellar and achilles tendons
  • How to Assess

  • The thumb is angulated laterally, away from the hand.
  • How to Assess

  • The wrist is angulated laterally.

Soft Tissue Landmarks of the Wrist

Flexor retinaculum - arches anteriorly over the carpals, covering the carpal tunnel.

Overview

  • Signs of Psoriatic Arthritis

  • General Signs

  • Symmetric polyarthritis affecting digits as a whole (rather than in rays of digits)
  • Nail changes - onycholysis, pitting, crumbling of the nail plate
  • Psoriatic plaques - particularly on the extensor surfaces of joints, scalp, periumbilicus, skin folds
  • Dactylitis: ‘sausage-like’ digits due to synovitis of each joint
  • Enthesitis: inflammation of a tendon insertion; affecting the Achilles tendon or the plantar fascia
  • Evidence of sacroiliitis - tender sacroiliac joints
  • Signs of Complications

  • Evidence of iritis - painful, erythematous eye

Muscles Acting on the Wrist Joint

Flexors (anteromedial) - flexor carpi radialis, palmaris longus, flexor carpi ulnaris

Overview

  • How to Assess

  • The wrist is flexed anteriorly.
  • How to Assess

  • The thumb is angulated medially, toward the palm.
  • Signs of Osteoarthritis

  • Muscle wasting
  • Evidence of active arthritis - swelling, erythema, tenderness
  • Reduced joint range of motion
  • Heberden’s nodes: firm swelling over the distal interphalangeal joints
  • Bouchard’s nodes: firm swelling over the proximal interphalangeal joints
  • Varus knee deformity
  • How to Assess

  • The fingers are flexed anteriorly, with closing of the fist.

Tinel’s Sign

  • Test For

  • Carpal tunnel syndrome (median nerve compression)

Overview

  • How to Assess

  • The fingers are extended posteriorly, with opening of the fist.
  • How to Assess

  • The fingers are moved together in the coronal plane.
Examination of the nails may reveal pathognomonic signs suggestive of rheumatologic disease.
  • How to Assess

  • The wrist is angulated medially.
If present, Cushing’s syndrome is potentially an indicator of significant steroid use in the treatment of the patient’s musculoskeletal disease.

Bony Landmarks of the Wrist

Head of ulna - proximally, articulating with the radial head.

Overview

  • How to Assess

  • The thumb is extended posteriorly, toward the palm.
  • How to Assess

  • Ask the patient to shrug their shoulders.
  • How to Assess

  • Ask the patient to hold their arms by their sides, and push inward.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Bony Landmarks of the Shoulder

Sternoclavicular joint - the articulation of the proximal end of the clavicle and the clavicular notch of the manubrium

Overview

  • Look For

  • Deformity of the shoulder joint, both anteriorly and posteriorly.
  • How to Assess

  • Ask the patient to ‘hug' themselves, moving the scapulae apart.
  • How to Assess

  • With the elbow flexed to 90°, ask the patient to rotate their forearm outwardly. Repeat the movement passively.
  • How to Assess

  • After asking the patient to shrug their shoulder (elevation), ask them to then drop them as far as they can.
  • How to Assess

  • Ask the patient to move their arm forward. Then ask them to relax as the shoulder is flexed passively.
  • How to Assess

  • Ask the patient to move their arm out to the side and then as far upward toward their head as possible. Repeat the movement passively.

Muscle Wasting

  • Look For

  • Decreased muscle mass. Note whether wasting is isolated to a single muscle or muscle group, isolated to the upper limb or generalised.

Muscles Acting on the Shoulder Joint

Flexors - pectoralis major, anterior deltoid, biceps brachii

Overview

  • How to Assess

  • Ask the patient to push their shoulders back, bringing the scapulae together.
  • How to Assess

  • Ask the patient to move their arm backward. Then ask them to relax as the shoulder is extended passively.
  • Look For

  • Generalised swelling over one or both shoulders. May be associated with redness, tenderness or warmth.
The Hawkins-Kennedy test is used to assess for coracoacromial impingement, by attempting to precipitate the pain of impingement of the subscapularis tendon against the coracoacromial ligament.
  • How to Assess

  • With the back of the hand, feel from the top of the shoulder to the forearm. Compare both sides.
  • How to Assess

  • With the elbow flexed to 90°, ask the patient to rotate their forearm inwardly. Repeat the movement passively.
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis

Measuring Blood Pressure

  • Prior to Testing Blood Pressure

  • Ask the patient whether they have had dialysis (have an AV fistula), whether they have had breast cancer surgery (and lymph node dissection) or whether there is some other reason their blood pressure should not be measured on a particular arm.

Overview

  • How to Assess

  • Ask the patient to extend their hip (forward), and then relax the joint as it is flexed passively.

Hip Disclocation

  • Look For

  • Posterior dislocation - flexion, internal rotation, adduction of the hip with shortening of the leg
  • Anterior dislocation - flexion / extension and external rotation of the hip with less shortening of the leg

Overview

  • How to Assess

  • Ask the patient to extend their hip (backward), and then relax the joint as it is extended passively.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
  • Look For

  • Generalised swelling over one or both lower limbs. May be associated with redness, tenderness or warmth.

Muscles Acting on the Hip Joint

Flexors (anterior) - iliacus, psoas major and minor, rectus femoris, sartorius, tensor fascia lata, pectineus, gracilis

Overview

  • How to Assess

  • Inspect the patient's posture while they are standing, sitting and squatting. Inspect from laterally, anteriorly and posteriorly.
  • How to Assess

  • Ask the patient to flex their knee to 90° and everttheir knee (point the toes outwardly). Then relax the joint as it is externally rotated passively.
The straight leg raise is a rest for lumbar radiculopathy, particularly of the L5 and S1 nerve roots.
  • How to Assess

  • Ask the patient to abduct their hip (laterally, away from the midline), and then relax the joint as it is abducted passively.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

  • How to Assess

  • Ask the patient to flex their knee to 90° and invert their knee (point the toes inwardly). Then relax the joint as it is internally rotated passively.

Bony Landmarks of the Hip

Iliac crest - the highest point of the pelvis, extending anterior to posterior.

Overview

Examine for herniae while sitting on a stool with the patient standing.
  • How to Assess

  • Ask the patient to adduct their hip (medially, into the midline), and then relax the joint as it is adducted passively.

Muscle Wasting

  • Look For

  • Decreased muscle mass. Note whether wasting is isolated to a single muscle or muscle group, isolated to the upper limb or generalised.

Overview

Marfan syndrome occurs due to one of many mutations in the gene encoding the extracellular matrix protein fibrillin 1.

Abdominal Distension

  • Causes of Abdominal Distension

  • FatCentral obesity
  • FaecesLifestyle, age, obstruction, drugs, endocrine / neurological
  • FlatusIrritable bowel syndrome, mechanical or paralytic gut obstruction
  • FluidAscites, blood, pus, urine, bile, lymph, enteric contents
  • FoetusPregnancy
  • MassCancer, abscess, abdominal wall fibrosis

Overview

A ventricular septal defect, or hole in the ventricular wall, manifests as a harsh pansystolic murmur best heard over the left lower sternal edge.
During the cardiovascular examination, inspection of the palms may reveal signs suggestive of anaemia, dyslipidaemia or infective endocarditis.
The respiratory rate is an important vital sign that is an early marker of deterioration.
The body mass index (BMI) is used an an estimate of body habitus that assesses the patient's weight in the context of their height, allowing for a more accurate measurement.
The first heart sound (S1) indicates closure of the mitral and tricuspid valves.
Auscultation of the carotids may identify a carotid bruit due to turbulent flow, or radiation of a murmur.
  • Look For

  • Enlargement of the distal segments of the fingers and / or toes, due to proliferation of connective tissue.
In the context of the cardiovascular examination, inspection of the nails can aid in identifying evidence of anaemia, cyanosis and endocarditis.

Down Syndrome

Trisomy 21

Overview

Left heart failure typically manifests with interstitial and pulmonary oedema, and is most commonly caused by pathology affecting the left ventricular myocardium.
When auscultating the heart, systematically listen to each of the cardiac regions for a heart sounds, murmurs or a rub. If added heart sounds or a murmur are noted, determine which area the extra sound is loudest in, and then perform manoeuvres to further isolate the added sound.
In the context of the cardiovascular examination, inspecting the mouth can reveal information about the patient's dentition, reveal evidence of hypoxia or suggest the presence of a hereditary or congenital disorder.

Pacemakers

  • Look For

  • A mass in the left subclavicular area.

Overview

Skin changes and overall poor skin condition of the lower limb may occur due to soft tissue disease; arterial, venous or lymphatic insufficiency; loss of afferent nerve supply or simply poor self-care.
  • How to Assess

  • Auscultate while palpating the pulse (preferably the carotid). Identify whether the murmur is systolic (between S1 and S2), diastolic (between S2 and S1 of the next cardiac cycle) or continuous.
Palpating the praecordium for palpable heaves and thrills may provide valuable clues regarding the patient's cardiac pathology.
The main priorities in auscultating the lung fields during the cardiovascular examination are to assess for evidence of pulmonary oedema or a pleural effusion.
Listening for cardiac murmurs in different positions as well as in inspiration and expiration can be used to narrow down the potential cause for the murmur.
Right heart failure typically manifests with peripheral overload - resulting in findings such as a raised JVP, peripheral oedema, pleural effusions and ascites.
  • How to Assess

  • With the back of the hand, feel from the top of the calf to the dorsum of the foot. Note if there is any change in temperature distally.
Aortic stenosis manifests as an ejection (mid) systolic murmur best heard over the base of the heart, associated with narrowed pulse pressure and reduced intensity of S2.
Blood pressure is a measure of the arterial pressure during systole and diastole; this may also be used to calculate the mean arterial pressure. Low blood pressure can result in poor organ perfusion, which high blood pressure puts patients at risk of cardiac, cerebrovascular, retinal and renal complications.
  • How to Assess

  • With the tips of the fingers, palpate for the most inferior and lateral point at which the cardiac impulse is clearly palpable.
Oedema or swelling of the lower limb occurs due to fluid accumulation, and may be either pitting or non-pitting.
In the context of the cardiovascular examination, inspection of the skin can provide important information about the patient's peripheral perfusion and oxygenation.
Aortic regurgitation manifests as a descrescendo diastolic murmur, heard loudest on sitting forward on expiration.
Mitral regurgitation examines as a pan-systolic murmur best heard over the apex with a volume-loaded heart, soft S1 and present S3 with or without evidence of left ventricular failure.
Right ventricular failure may manifest as hepatomegaly, splenomegaly and ascites; demonstrating these findings can help to clinch the clinical diagnosis. An important target for palpation in the cardiovascular examination is also the abdominal aorta, as an undiagnosed aneurysm may be fatal in the future.
Scars on the chest can suggest past surgery, trauma, burns or healed skin conditions.
There are several pathognomonic and diagnostic signs to be found on inspection of the eyes.
Whether a delay occurs between two radial arteries or between the radial artery and femoral artery depends on whether the lesion is proximal or distal to the branching of the left subclavian.
Palpation of the rate and rhythm of the radial pulse is a useful screening tool for the presence of cardiac arrhythmias.
Down syndrome occurs as a result of trisomy 21, or three copies of chromosome 21.
Hypertrophic Cardiomyopathy (HCM) is a disorder that  causes left ventricular hypertrophy (particularly of the interventricular septum), which may be obstructive or non-obstructive.
Pulmonary hypertension refers to a heterogeneous and functionally limiting group of disorders that result in increased pressure within the pulmonary arteries.
Mitral stenosis manifests as a low-pitched, mid-diastolic murmur best heard in the apex in the left lateral position.
Turner syndrome occurs secondary to monosomy X, where all or part of an X chromosome is missing, or due to duplication of the long arm of one X chromosome.
When performing a cardiovascular examination, always ask to perform fundoscopy. This may reveal signs of diabetic or hypertensive nephropathy.
Pulmonary stenosis manifests as an ejection systolic murmur heard loudest over the pulmonary area on inspiration, and may be associated with a split S2 and S4.
The second heart sound (S2) indicates closure of the aortic (A2) and pulmonary (P2) valves.
A patent ductus arteriosus is the persistence post birth of a blood vessel connecting the pulmonary artery and the aorta.
Tricuspid regurgitation manifests as a pan-systolic murmur best heard at the left lower sternal edge on inspiration.
Dynamic manoeuvres are useful for distinguishing between hypertrophic cardiomyopathy and aortic stenosis in the presence of a systolic murmur.
The waist circumference and waist-hip ratio are markers of central obesity, with evidence to support their use in estimating cardiovascular risk.

Resting Tremor

  • Look For

  • Tremor while at rest, that decreases with target-directed movement.

Anosmia

Loss of sense of smell is a classic early finding in Parkinson’s disease.

Overview

Postural hypotension may be present in a patient with Parkinson’s disease, as they may develop autonomic neuropathy.
  • How to Assess

  • Ask the patient to relax and allow you to move their arms. Move the shoulder, elbow, wrist and fingers passively through their range of motion, looking for rigidity.
The mask-like facies seen in Parkinsonism is also referred to as hypomimia, and occurs as a manifestation of bradykinesia and hypokinesia.
  • Ask About

  • Time - day, date, month, year, season
  • Place - floor, building, city, state, country
  • Person - full name, date of birth, address
  • Situation - why the patient is in hospital, who the prime minister is
  • Clinical Features

  • Resting tremor
  • Rigidity - leadpipe, cogwheel
  • Akinesia - hypokinesia (small movements), bradykinesia (slow movements)
  • Postural instability - reduced postural reflexes
  • How to Elicit

  • Percuss repeatedly between the eyebrows, looking for reactive blinking.
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
Patients with myaesthenic syndromes exhibit muscle fatigability, or the inability to maintain contraction of muscles over time.
The patellar and ankle reflexes are the major motor reflexes of the lower limb. The strength of the reflex, elicited by tapping on the appropriate tendon, can aid in localising a patient's weakness to the upper motor neuron or lower motor neuron.

Abnormal Posturing

  • Look For

  • Abnormal flexion and / or extension of limbs, in an uncomfortable position.

Cutaneous Manifestations of Neurologic Disease

  • Signs of Neurofibromatosis Type 1 (NF1)

  • Neurofibromata: non-painful rubbery skin tumours
  • Cafe au Lait spots: flat (macular) patches of hyperpigmentation

Overview

Peripheral mononeuropathy is a type of peripheral neuropathy affecting a single peripheral nerve.
Pain sensation is conveyed via the spinothalamic pathway, and mapping of this can be used to determine the distribution of a patient's sensory loss.
Power assessment is a key part of the motor examination, and can be used to identify focal or global weakness.
  • Sensory Modalities

  • Dorsal column pathway - proprioception and vibration sensation; soft touch
  • Spinothalamic pathway - pain and temperature sensation; soft touch
Assessment of tone is the first part of the motor assessment, and is a good starting point and screening tool in that abnormal tone can immediately suggest an upper motor neuron lesion or Parkinsonism.
  • Look For

  • Intermittent shock-like jerks.
  • Look For

  • Spontaneous, abrupt, irregular movements. May manifest in the face, neck, torso, arms or legs.
  • Look For

  • Intermittent stereotyped movements or vocalisations that are suppressible and preceded by an urge.
  • How to Perform

  • Ask the patient to stand still with their heels together, and look for loss of balance.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
  • Signs of Chronic Inflammatory Demyelinating Polyneuropathy

  • Foot drop
  • Symmetrical lower motor neuron weakness - distal predominance affecting the upper limb more than the lower limb
  • Sensory loss distally (glove and stocking distribution)
  • Signs of Lower Motor Neuron Weakness

  • Muscle wasting
  • Fasciculations
  • Reduced tone
  • Reduced power
  • Hyporeflexia
  • Downgoing plantar reflex

Muscle Wasting

  • Feel For

  • Decreased muscle mass. Note whether wasting is isolated to a single muscle, muscle group, limb, or is generalised.

Overview

Mononeuritis multiplex (also known as mononeuropathy multiplex and multiple mononeuropathy) is a peripheral neuropathy that affects two or more peripheral nerves.
  • Look For

  • Sustained or intermittent muscle contractions resulting in abnormal movements or abnormal posturing.
  • Signs of Motor Neurone Disease

  • Bulbar palsy (LMN) - nasal speech, absent gag reflex, tongue wasting and fasciculations, absent palate rise, absent (i.e. normal) jaw jerk
  • Pseudobulbar palsy (UMN) - dysarthria, increased / normal gag reflex, tongue spasticity, absent palate rise, increased jaw jerk
  • Upper motor neuron signs - increased tone, clonus, reduced power, hyperreflexia, upgoing plantar reflex
  • Lower motor neuron signs - muscle wasting, fasciculations, reduced tone, reduced power, hyporeflexia, downgoing plantar reflex
Proprioception is the sense of position and movement of the body in the absence of vision.
  • Look For

  • Rhythmic, involuntary vibration of one or more body parts. Note whether the tremor is worse with movement and whether it increases with target-directed movement (increases on approaching a target).
Soft touch is transmitted via multiple sensory pathways, and can be used as a screening tool to assess for sensory loss.
Also known as pallesthesia
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
Mixed upper and motor neuron signs can occur rarely, and there are few conditions which are able to cause both. The major differential would be the presence of two separate pathologies.
Segmental syndrome - sensory loss and upper motor neuron weakness below the affected level, with bladder and bowel dysfunctionComplete transection of the cord
  • Signs of Upper Motor Neuron Weakness

  • Minimal muscle wasting
  • Spasticity (clasp-knife rigidity) - velocity-dependent increase in tone
  • Clonus - rhythmic contractions in response to a sudden stimulus, e.g. sudden ankle dorsiflexion
  • Reduced power
  • Hyperreflexia
  • Upgoing plantar reflex
Proximal weakness is most commonly a manifestation of muscular pathology, though may also occur in certain neurologic conditions.
  • Signs of Multiple Sclerosis

  • Signs of optic neuritis - reduced visual acuity, central visual loss, optic disc atrophy
  • Internuclear ophthalmoplegia - inability to adduct one eye, with nystagmus in the other eye
  • Lhermitte’s sign - electric sensation in the limbs on neck flexion
  • Upper motor neuron weakness - increased tone, reduced power, hyperreflexia
  • Dorsal column (vibration / proprioception) sensory loss
  • Signs of cerebellar involvement - ataxia, dysarthria, dysmetria, dysdiadochokinesis, nystagmus
  • Clinical Features

  • Resting tremor
  • Rigidity - leadpipe, cogwheel
  • Akinesia - hypokinesia (small movements), bradykinesia (slow movements)
  • Postural instability - reduced postural reflexes
  • Manifestations of Radiculopathy

  • Lower motor neuron weakness affecting a myotomal distribution
  • Sensory loss affecting a dermatomal distribution

Motor Assessment

  • Upper and Lower Motor Neuron Signs


Overview

Distal weakness is more commonly a manifestation of neuropathy, though may also occur in certain muscular conditions.
Peripheral polyneuropathy presents with motor, sensory or mixed deficits affecting multiple (usually symmetrical) nerve distributions, without a clear pattern of involvement affecting a nerve root or peripheral nerve distribution.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

Biceps tendon - anteriorly, inserting onto the radial tuberosity.
  • How to Assess

  • Ask the patient to rotate their wrist, with the palm facing downward. Repeat this movement passively.

Muscles Acting on the Elbow Joint

Flexors (anterior) - biceps brachii, brachialis, brachioradialis, pronator teres

Overview

  • How to Assess

  • Ask the patient to open their elbow joint. Then ask them to relax as it is extended passively.

Bony Landmarks of the Elbow

Olecranon - posterior projection of the ulna

Overview

  • How to Assess

  • With the back of the hand, feel from the top of the shoulder to the forearm. Compare both sides.
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
  • Look For

  • Generalised swelling over one or both upper limbs. May be associated with redness, tenderness or warmth.

Muscle Wasting

  • Look For

  • Decreased mass of the muscles affecting the elbow. Note whether wasting is isolated to a single muscle or muscle group, isolated to the upper limb or generalised.

Overview

  • How to Assess

  • Ask the patient to rotate their wrist, with the palm facing upward. Repeat this movement passively.
  • How to Assess

  • Ask the patient to close their elbow joint. Then ask them to relax as it is flexed passively.
  • How to Assess

  • Ask the patient to push their foot upwardly, or push their toes toward their head.
Achilles tendon - posteriorly, attaching the planteris, calcaneus and soleus muscles to the calcaneus.
  • Look For

  • The height of the foot arch - high, normal or flattened.

Muscle Wasting

  • Look For

  • Decreased mass of the muscles affecting the ankle. Note whether wasting is isolated to a single muscle or muscle group, isolated to the lower limb or generalised.

Bony Landmarks of the Ankle

Medial malleolus - of the distal tibia.

Overview

  • How to Assess

  • Ask the patient to push their foot downwardly, or push their toes toward the floor.
  • How to Assess

  • With the back of the hand, assess the temperature around the ankle joint. Compare both sides.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

  • How to Assess

  • Ask the patient to roll their ankle inwardly, such that the sole of the foot is pointing toward the other foot.
Tibiotalar joint - articulation of the talus with the tibia medially and the fibula laterally, allowing for dorsiflexion and plantar flexion.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
Posterior tibial - palpate posteriorly and inferiorly to the medial malleolus.
  • Look For

  • Generalised swelling over one or both lower limbs. May be associated with redness, tenderness or warmth.

Muscles Acting on the Ankle Joint

Plantar flexors (posterior) - peroneus longus, peroneus brevis, soleus, gastrocnemius, plantaris, tibialis posterior, flexor digitorum longus, flexor hallucis longus

Overview

  • How to Assess

  • Ask the patient to roll their ankle outwardly, such that the sole of the foot is pointing away from the other foot.
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
Biceps tendon - lateral, inserting posteriorly onto the fibular head.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Muscles Acting on the Knee Joint

Flexors (posteriorly) - biceps femoris, semitendinosus, semimembranosus, sartorius, gracilis, popliteus, gastrocnemius

Overview

  • How to Assess

  • Inspect the patient's posture while they are standing, sitting and squatting. Inspect from laterally, anteriorly and posteriorly.
  • How to Measure

  • Bend the patient's knee to 90 degrees, gently grasp both sides of the knee joint and palpate within the popliteal fossa posteriorly.
  • Look For

  • Generalised swelling over one or both lower limbs. May be associated with redness, tenderness or warmth.
  • Look For

  • Shoulder drop
  • Abducted arm swing
  • Lateral pelvic tilt
  • Leg circumduction
  • Excessive knee flexion
  • How to Assess

  • Move the knee joint passively through flexion and extension. Note whether any clicks, cracks, snaps or clunks are present.
  • Feel For

  • Tenderness or fullness of the joint line. Palpate in both internal and external rotation.
The medial and lateral collateral ligaments may be palpated on either side of the knee joint.

Muscle Wasting

  • Look For

  • Decreased mass of the muscles affecting the knee. Note whether wasting is isolated to a single muscle or muscle group, isolated to the lower limb or generalised.

Overview

  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
  • How to Assess

  • With the back of the hand, assess the temperature around the knee joint. Compare both sides.
  • How to Assess

  • Ask the patient to actively extend their knee, and then ask them to relax the joint as it is extended passively.
  • How to Assess

  • With the knee in a neutral position, ask the patient to rotate their foot inwardly. Repeat at 30-90 degrees of flexion.

Bony Landmarks of the Knee

Patella - palpate the superior and inferior poles of the patella, noting its position and mobility.

Overview

Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
  • How to Assess

  • Ask the patient to actively flex their knee, and then ask them to relax the joint as it is flexed passively.

Major Bursae of the Knee

Prepatellar bursa - between the patella and the overlying subcutaneous tissue. Bursitis presents as pain and swelling over the patella.

Overview

  • How to Assess

  • With the knee in a neutral position, ask the patient to rotate their foot inwardly. Repeat at 30-90 degrees of flexion.
Listen to the patient speak on order to assess for a potential speech disorder. Listen to the rate of speech, volume, quantity, fluency and tonality.
The ability to recall old memories prior to significant brain injury or psycho-trauma.
  • How to Assess

  • Serial sevens - ask the patient to subtract 7 from 100. Ask them to repeat this subtraction five times.
  • DLROW - ask the patient to spell WORLD backward.
  • Months - ask the patient to recite the months of the year backward.
  • How to Assess

  • Ask the patient to tap once when you tap once. Tap once several times.
  • Ask the patient to not tap when you tap twice. Tap twice several times.
  • Alternate randomly between tapping once and tapping twice, asking the patient to tap once when you tap once and not tap when you tap twice.
  • Overlapping pentagons - ask the patient to copy a diagram of overlapping pentagons.
  • Overlapping pentagons - ask the patient to copy a diagram of overlapping pentagons.
The ability form new memories after significant brain injury or psycho-trauma.
The patient's level of arousal is an assessment of how awake and active they are. Patients may be hyperactive or display psychomotor agitation, or conversely show evidence of psychomotor retardation or even stupor.
  • Look For

  • Rhythmic, involuntary vibration of one or more body parts. Note whether the tremor is worse with movement and whether it increases with target-directed movement (increases on approaching a target).
Thought form refers to the formation and coherence of a patient's thoughts. Formal thought disorders are derangements of this form, resulting in thoughts that are often difficult to follow or understand.
Obsessions: preoccupying and repetitive thoughts or impulses, often accompanied by compulsive behaviour.
Ask the patient to make up and write a sentence. Note whether it contains a subject and a verb.
  • How to Assess

  • Gestures - ask the patient to mirror both meaningful (waving) and non-meaningful (hand positioning) movement.
  • Fist-palm-edge - ask the patient to place a fist onto the table (or onto their knee), and then their palm, and then the edge of their hand. Begin by performing these tasks with the patient and then watch as they attempt them alone.
  • Ask the patient to demonstrate how they would use a hammer, comb or scissors.
Hallucinations are abnormal sensory symptoms that may manifest as visual, auditory, tactile or extraordinary disturbances. Hallucinations may be caused by organic disease or psychiatric disorders.
  • How to Assess

    Ask the patient to identify the similarity between two objects, such as:
  • Bananas and oranges are... both fruit
  • Trains and bicycles are… both modes of transport
  • A watch and a ruler are… both used for measurement
  • Ask About

  • Recent decision-making or by posing a practical dilemma (what should you do if you see smoke coming out of a house?)
  • Look For

  • Lack of grooming to half of the body
  • Eating half of a plate of food
  • Not acknowledging someone standing to their left / right
  • How to Assess

  • Ask the patient to name as many words as they can beginning with the letter ‘A’.
  • Ask the patient to name as many animals as possible in one minute.
  • Ask About

  • Time - day, date, month, year, season
  • Place - floor, building, city, state, country
  • Person - full name, date of birth, address

Richmond Agitation-Sedation Scale

A scale used to assess level of sedation, mainly in ICU patients.

Overview

  • How to Assess

  • Tell the patient a series of numbers and ask them to immediately repeat them back. Start with three digits (e.g. 6 2 3) and increase until the patient is unable to repeat them back correctly.
Unreasonable beliefs that the patient spends a large amount of time and energy on.

Comprehension

Written comprehension - show a written instruction, e.g.

Overview

Show the patient a list of words and ask them to read the words out loud, or ask them to read a few sentences from a newspaper.
Rigidly held false beliefs not consistent with a person's background.
The patient's level of consciousness is an assessment of their wakefulness and responsiveness to external stimuli.
  • How to Assess

  • Place a hand on the right shoulder and ask the patient to tilt their head to the right. Provide resistance by placing a hand just above the right ear. Repeat the movement on the opposite side.
  • Feel For

  • Costochondral & sternochondral jointsBetween the sternum and the ribs anteriorly. Especially palpate for tenderness.
  • Spinous processesPosterior processes of the vertebrae
  • Interspinous & supraspinous ligamentsConnecting adjacent spinous processes posteriorly
  • Facet jointsBetween vertebrae, lateral to the midline. Especially palpate the cervical facet joints.
  • Costovertebral jointsOf the thoracic vertebrae
  • Sacroiliac joint

Muscle Wasting

  • Look For

  • Decreased muscle mass. Note whether wasting is isolated to a single muscle or muscle group, isolated to the back or generalised.

Overview

  • How to Assess

  • Place a hand on the patient's upper back to stabilise the thoracic spine and ask them to look upward. Provide resistance by placing the palm of the other hand on the patient's occiput.
  • How to Assess

  • Ask the patient to lean forward as if to touch their toes.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
  • How to Assess

  • Ask the patient to run their hand down the side of their right leg, without leaning forward or backward. Repeat on the opposite side.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

  • How to Assess

  • Ask the patient to lean backward.
  • How to Assess

  • Place a hand on the patient's sternum to stabilise the thoracic spine and ask them to look downward. Provide resistance by placing the palm of the other hand on the patient's forehead.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

  • How to Assess

  • Stabilise the pelvis and ask the patient to turn their body to the right side. Repeat on the opposite side.
  • Look For

  • The amount of antero-posterior curvature of the cervical spine.
  • How to Assess

  • Place a hand on the right shoulder and ask the patient to turn their head to the left. Provide resistance by placing a hand on the patient's jaw. Repeat the movement on the opposite side.
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
  • Look For

  • The amount of antero-posterior curvature of the thoracic spine. Especially pronounced if the patient leans forward.
  • Look For

  • The amount of antero-posterior curvature of the lumbar spine.

Muscles Acting on the Cervical Spine

Flexors - sternocleidomastoid, scalenes, longus muscles, rectus capitis

Overview

The oropharynx performs both respiratory and digestive functions, and allows for passage of air into the lower airways. Oropharyngeal examination can reveal pathology of the mucosa or tonsils.
Tactile fremitus is an assessment of the low-frequency vibration of a patient's chest, which is used as an indirect measure of the amount of air and density of tissue present within the lungs.
Breath sounds are normally heard on auscultating the chest, and their intensity and character can be used to assess for the presence of pulmonary pathology.
There are several pathognomonic and diagnostic signs to be found on inspection of the eyes.
Watch the patient's pattern of breathing, taking into account the rate, regularity and depth of respiration. Specific patterns of breathing may suggest an underlying pathology.
Chest wall deformities may be an external sign of an underlying disease, or may themselves cause significant restrictive pulmonary disease.

Heart Rate

  • How to Measure

  • Count the number of beats over 15, 30 or 60 seconds and multiply to estimate beats per minute.

Overview

Vocal resonance is an assessment of the density of lung tissue, performed by auscultating the chest and asking the patient to speak. Increased vocal resonance suggests increased density, while reduced vocal resonance suggests an increase in the amount of air present.
  • How to Measure

  • Count the patient's breaths over 30 seconds to one minute while ostensibly measuring the pulse.
The nasal cavity warms, filters and adds moisture to inhaled air. By inspecting the nasal cavity it may be possible to assess for obstruction impeding respiration, inflammation or other pathology.
Carefully inspect the patient's fingers, looking for discolouration of the nail beds and distal digits.

Wasting of Hand Muscles

In the context of the respiratory examination, we examine for muscle wasting as a sign of denervation secondary to an apical lung tumour. A Pancoast tumour in the apex of the lung may compress the brachial plexus and result in localised wasting of the hand.

Digital Clubbing

  • Look For

  • Enlargement of the distal segments of the fingers and / or toes, due to proliferation of connective tissue.

Overview

Chest percussion is used to assess the resonance of the lungs as a surrogate for the amount of air in the alveoli.
The character of a patient's cough suggest of the cause of their respiratory illness.
  • Signs of Lung Cancer

  • General Signs

  • Oxygen
  • Respiratory distress - tachypnoea, pursed lip breathing, accessory muscle use, intercostal / subcostal recession
  • Cough
  • Sputum - purulent, bloody
  • Lymphadenopathy - cervical, supraclavicular, axillary
  • Signs of Complications

  • Pleural effusion - dull percussion note, reduced breath sounds, reduced vocal resonance
  • Laryngeal nerve involvement - hoarse voice, dysphonic cough
  • SVC obstruction - facial swelling, plethora, upper limb oedema, positive Pemberton’s sign
  • Pancoast tumour - Horner’s syndrome (partial ptosis, miosis, anhydrosis), wasting of the small muscles of the hand
  • Hypertrophic pulmonary osteodystrophy
  • Signs of Management

  • Scars - from lobectomy or pneumonectomy
  • Radiation tattoos
  • Signs of Bronchiectasis

  • Oxygen requirement - reduced SpO2, nasal prongs
  • Halitosis
  • Cough - moist
  • Sputum - purulent / haemoptysis
  • Clubbing
  • Central cyanosis
  • Coarse crepitations
  • Wheeze
  • Signs of Complications

  • Evidence of empyema - dull percussion note, reduced breath sounds, reduced vocal resonance
  • Evidence of right ventricular failure - raised JVP, ascites, pleural effusions, peripheral oedema
  • Evidence of pulmonary hypertension - raised JVP, parasternal heave, loud / palpable P2
  • Signs of Interstitial Lung Disease

  • General Signs

  • Dry cough
  • Cyanosis
  • Reduced chest expansion
  • Crepitations - fine, end-expiratory
  • Signs Suggesting a Cause

  • Symmetric arthropathy (rheumatoid arthritis)
  • Skin thickening (scleroderma)
  • Lymphadenopathy (sarcoidosis)
  • Signs of Complications

  • Cor pulmonale - raised JVP, ascites, pleural effusions, peripheral oedema
  • Pulmonary hypertension - prominent a wave, parasternal heave, loud / palpable P2
The oxygen saturation is a reflection of the percentage of haemoglobin that is bound to oxygen.
Adventitious sounds are abnormal sounds heard on the chest in inspiration or expiration, in addition to the normal breath sounds.
  • Signs of Pleural Effusion

  • Oxygen requirement - reduced SpO2, oxygen delivery
  • Dull percussion note
  • Reduced tactile fremitus
  • Reduced breath sounds
  • Reduced vocal resonance
Several clinical signs allow for the clinical suspicion of chronic obstructive pulmonary disease, which can then be confirmed with pulmonary function testing.
  • How to Assess

  • The thumb is extended posteriorly, toward the palm.
  • How to Assess

  • The fingers are moved apart in the coronal plane.

Muscles Acting on the Wrist Joint

Flexors (anteromedial) - flexor carpi radialis, palmaris longus, flexor carpi ulnaris

Overview

  • How to Assess

  • The thumb is angulated laterally, away from the hand.
  • Test For

  • Carpal tunnel syndrome (median nerve compression)
  • How to Assess

  • With the back of the hand, feel over the joints of the hands and wrist. Compare both sides.
  • How to Assess

  • The fingers are moved together in the coronal plane.
  • Test For

  • Carpal tunnel syndrome (median nerve compression)
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
  • How to Assess

  • The fingers are flexed anteriorly, with closing of the fist.
  • How to Assess

  • The wrist is angulated laterally.
  • How to Assess

  • The thumb is flexed anteriorly, away from the palm.
  • How to Assess

  • The thumb is moved diagonally across the palm.

Muscle Wasting

  • Look For

  • Decreased mass of the thenar and/or hypothenar eminence.

Bony Landmarks of the Wrist

Head of ulna - proximally, articulating with the radial head.

Overview

  • How to Assess

  • The wrist joint is extended posteriorly.

Wrist Drop

  • Look For

  • Abnormal flexion of the wrist, due to inability to extend the joint.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Soft Tissue Landmarks of the Wrist

Flexor retinaculum - arches anteriorly over the carpals, covering the carpal tunnel.

Overview

  • How to Assess

  • The wrist is angulated medially.
  • How to Assess

  • The thumb is angulated medially, toward the palm.
  • How to Assess

  • The fingers are extended posteriorly, with opening of the fist.
  • Look For

  • Generalised swelling over a joint, which may be unilateral, bilateral or widespread. May be associated with redness, tenderness or warmth.
  • How to Assess

  • The wrist is flexed anteriorly.
  • Look For

  • Swelling of the lower limb due to fluid accumulation.
  • How to Assess

  • Palpate the common carotid arteries, located in the anterior neck medial to the sternocleidomastoid. Palpate the arteries one at a time. Care should be taken to avoid stimulating the carotid sinus.
Skin changes and overall poor skin condition of the lower limb may occur due to soft tissue disease; arterial, venous or lymphatic insufficiency; loss of afferent nerve supply or simply poor self-care.
Femoral - palpate within the inguinal region, halfway between the pubic symphysis and iliac crest.

Inspection of Pupils

  • Look For

  • The size of the pupils (dilated, normal, constricted) and equality of size bilaterally.

Rashes Associated with Diabetes

Xerosis cutis: abnormally dry skinCold weather, excessive bathing, irritants, advanced age, uraemia, diabetes, hypothyroidism

Overview

In diabetics, always ask to perform fundoscopy. This may provide valuable information regarding the presence of diabetic retinopathy.
Inspection of the colour of the lower limbs in diabetics can suggest the presence of arterial insufficiency, venous insufficiency or infection.
  • How to Assess

  • Ask the patient to relax and allow you to move their upper limbs. Move the shoulder, elbow, wrist and fingers passively through their range of motion, looking for rigidity. Repeat to assess the lower limbs.
The patient's body habitus provides insight into a patient's diet and metabolic status as well as their overall risk of cardiovascular and non-cardiovascular complications in the future. While static measures such as body habitus and waist-hip ratio can estimate future risk, unexpected change in weight may suggest active disease.

Cheyne-Stokes Respiration

  • Look For

  • Periods of hyperventilation interspersed with periods of apnoea or bradypnoea.

Overview

Power assessment is a key part of the motor examination, and can be used to identify focal or global weakness.

Oral Candidiasis

  • Look For

  • Creamy white lesions present on the tongue or inner cheeks, which may be associated with angular cheilitis or glossitis.

Dehydration

  • Look For

  • Abnormal obs - tachycardia, hypotension
  • Fluid balance chart - negative fluid balance, oliguria
  • Weight loss - an acute decrease in weight may indicate short-term change in fluid status
  • Dry mucous membranes - especially the tongue
  • Sunken eyes
  • Increased capillary refill time (>2 seconds)
  • Weak radial pulse
  • Decreased skin turgor - pinch a fold of skin on the patient’s arm and then release it. Decreased skin turgor is present if the fold takes an abnormal time to return to its normal contour.

Overview

Capillary refill time is a marker of perfusion, and prolonged refill time suggests poor perfusion of the area being examined.
  • How to Elicit

  • Biceps - ask the patient to relax their arms in their lap and strike the biceps tendon with a tendon hammer.
  • Supinator - ask the patient to relax their arms in their lap and strike the brachioradialis tendon, proximal to the wrist on the lateral aspect of the forearm.
  • Triceps - lift the patient’s shoulder into abduction and internal rotation, with the arm flexed to 90°. Strike the triceps tendon with a tendon hammer.
  • Patellar - with the patient supine, support the knee from underneath providing slight flexion and strike the patellar tendon below the patella.
  • Achilles - flex the knee, externally rotate the hip and dorsiflex the foot. Strike the Achilles tendon of the heel.
Diabetics often exhibit onycholysis of the nails, and poor diabetic control can lead to increased infection risk and paronychias.
  • How to Assess

  • Ask the patient to cover one eye, look at a Snellen chart (wall-mounted at 6m or handheld at arm's length) and identify the smallest line that they can read.
  • How to Perform

  • Auscultate within the triangle bound by the mandible, sternocleidomastoid and thyroid cartilage. Ask the patient to hold their breath.
  • Look For

  • Fixed flexion deformity of one or more fingers, associated with a nodule or cord over the palm proximal to the deformity.
Ulcers, or non-healing open wounds, may occur in the lower limb in the context of arterial disease, venous disease or peripheral neuropathy.
  • How to Assess

  • Light touch - Ask the patient to close their eyes. Using a cotton ball or microfilament, gently touch each dermatome / nerve distribution and ask the patient if they can feel the stimulus. Compare sides and proximally / distally.Spinothalamic tract & dorsal column - medial lemniscus pathway
  • Pain - demonstrate a sharp stimulus by touching the patient lightly on the chest with a neurotip. Ask the patient to close their eyes, and test each dermatome / nerve distribution alternating between the sharp and dull sides of the neurotip at random. Ask the patient if they percieve the stimulus as sharp or dull.Spinothalamic tract
  • Vibration - with the patient's eyes closed, place a vibrating 128hz tuning fork over the interphalangeal joint of the great toe. Ask the patient to describe the sensation. If they can feel it vibrating, progressively diminish the vibration until they cannot feel it. If they cannot feel it vibrating, test on the medial / lateral malleolus and then the tibial tuberosity.Dorsal column - medial lemniscus pathway
  • Proprioception - ask the patient to observe as you demonstrate upward and downward movement of the great toe. With their eyes closed, slowly move the joint over one to two seconds to the upward or downward position. Ask the patient to report whether the toe has been moved up or down. Repeat several times, and then repeat on the other side.Dorsal colun - medial lemniscus pathway
  • How to Assess

  • With the back of the hand, feel from the top of the calf to the dorsum of the foot. Note if there is any change in temperature distally.

Comprehension

Written comprehension - show a written instruction, e.g.

Overview

  • How to Assess

  • Gestures - ask the patient to mirror both meaningful (waving) and non-meaningful (hand positioning) movement.
  • Fist-palm-edge - ask the patient to place a fist onto the table (or onto their knee), and then their palm, and then the edge of their hand. Begin by performing these tasks with the patient and then watch as they attempt them alone.
  • Ask the patient to demonstrate  how they would use a hammer, comb or scissors.
The patient's level of consciousness is an assessment of their wakefulness and responsiveness to external stimuli.
  • Overlapping pentagons - ask the patient to copy a diagram of overlapping pentagons.
  • Overlapping pentagons - ask the patient to copy a diagram of overlapping pentagons.
  • Look For

  • Rhythmic, involuntary vibration of one or more body parts. Note whether the tremor is worse with movement and whether it increases with target-directed movement (increases on approaching a target).
  • Signs of Myotonic Dystrophy

  • Myopathic facies - temporalis wasting, mandibular wasting, frontal baldness
  • Flaccid dysarthria - nasal speech, breathiness, monotony, impaired articulation
  • Warm-up phenomenon - grip myotonia, repeated eye closure
  • Percussion myotonia - muscle contraction with percussion of the thenar eminence
  • Wasting of the forearm and small muscles of the hand
  • Distal muscle weakness
  • Hyporeflexia
The patient's ability to perform fine motor tasks is an indicator of their ability to perform functional tasks such as writing and cooking.
The biceps, triceps and supinator reflexes are the major motor reflexes of the upper limb. The strength of the reflex, elicited by tapping on the appropriate tendon, can aid in localising a patient's weakness to the upper motor neuron or lower motor neuron.
Segmental syndrome - sensory loss and upper motor neuron weakness below the affected level, with bladder and bowel dysfunctionComplete transection of the cord
  • Signs of Radiculopathy

  • Lower motor neuron weakness affecting a myotomal distribution
  • Sensory loss affecting a dermatomal distribution
Assessment of tone is the first part of the motor assessment, and is a good starting point and screening tool in that abnormal tone can immediately suggest an upper motor neuron lesion or Parkinsonism.

Cutaneous Manifestations of Neurologic Disease

  • Signs of Neurofibromatosis Type 1 (NF1)

  • Neurofibromata: non-painful rubbery skin tumours
  • Cafe au Lait spots: flat (macular) patches of hyperpigmentation

Overview

  • Signs of Brachial Plexopathy

  • Lower motor neurone weakness affecting multiple myotomes / peripheral nerve distributions
  • Sensory loss affecting multiple dermatomes / peripheral nerve distributions
  • Horner’s syndrome - miosis, partial ptosis, anhydrosis
  • Test For

  • Carpal tunnel syndrome (median nerve compression)
Peripheral polyneuropathy presents with motor, sensory or mixed deficits affecting multiple (usually symmetrical) nerve distributions, without a clear pattern of involvement affecting a nerve root or peripheral nerve distribution.
Neurological causes of weakness may be delineated into upper motor neuron (brain, brainstem or spinal cord) or lower motor neuron (nerve root, plexus or peripheral nerve) causes. These two broad groups manifest with specific findings elicitable on examination.
Power assessment is a key part of the motor examination, and can be used to identify focal or global weakness.
Patients with myaesthenic syndromes exhibit muscle fatigability, or the inability to maintain contraction of muscles over time.
  • Signs of Multiple Sclerosis

  • Signs of optic neuritis - reduced visual acuity, central visual loss, optic disc atrophy
  • Internuclear ophthalmoplegia - inability to adduct one eye, with nystagmus in the other eye
  • Lhermitte’s sign - electric sensation in the limbs on neck flexion
  • Upper motor neuron weakness - increased tone, reduced power, hyperreflexia
  • Dorsal column (vibration / proprioception) sensory loss
  • Signs of cerebellar involvement - ataxia, dysarthria, dysmetria, dysdiadochokinesis, nystagmus
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
Peripheral mononeuropathy is a type of peripheral neuropathy affecting a single peripheral nerve.
Mononeuritis multiplex (also known as mononeuropathy multiplex and multiple mononeuropathy) is a peripheral neuropathy that affects two or more peripheral nerves.
Sensation is a key aspect of the nervous system, and includes many different modalities. By thoroughly assessing the pattern of sensory loss it is possible to characterise and localise a central or peripheral nervous lesion.
  • Signs of Motor Neurone Disease

  • Bulbar palsy (LMN) - nasal speech, absent gag reflex, tongue wasting and fasciculations, absent palate rise, absent (i.e. normal) jaw jerk
  • Pseudobulbar palsy (UMN) - dysarthria, increased / normal gag reflex, tongue spasticity, absent palate rise, increased jaw jerk
  • Upper motor neuron signs - increased tone, clonus, reduced power, hyperreflexia, upgoing plantar reflex
  • Lower motor neuron signs - muscle wasting, fasciculations, reduced tone, reduced power, hyporeflexia, downgoing plantar reflex
  • Signs of Chronic Inflammatory Demyelinating Polyneuropathy

  • Foot drop
  • Symmetrical lower motor neuron weakness - distal predominance affecting the upper limb more than the lower limb
  • Sensory loss distally (glove and stocking distribution)
  • Clinical Features

  • Resting tremor
  • Rigidity - leadpipe, cogwheel
  • Akinesia - hypokinesia (small movements), bradykinesia (slow movements)
  • Postural instability - reduced postural reflexes
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.

Abnormal Posturing

  • Look For

  • Abnormal flexion and / or extension of limbs, in an uncomfortable position.

Overview

Proximal weakness is most commonly a manifestation of muscular pathology, though may also occur in certain neurologic conditions.
Asterixis, also known as hepatic flap or uraemic flap, is an important sign of metabolic encephalopathy that occurs due to dysregulation of the diencephalic motor centers in the brain that regulate innervation of muscles responsible for maintaining position.
In the context of the gastrointestinal examination, it is important to inspect for jaundice as well as bronzing of the skin, as these signs may suggest the presence of liver disease or haemochromatosis.
The patient's body habitus provides insight into a patient's diet and metabolic status as well as their overall risk of cardiovascular and non-cardiovascular complications in the future. While static measures such as body habitus and waist-hip ratio can estimate future risk, unexpected change in weight may suggest active disease.

Candidiasis

  • Look For

  • Creamy white lesions present on the tongue or inner cheeks, which may be associated with angular cheilitis or glossitis.

Overview

Examination of the supraclavicular lymph nodes is of particular importance in the gastrointestinal exam, as enlargement of Virchow's node (the left supraclavicular node) may occur due to embolisation of a GI tumour.
Examination of the lips may provide valuable insights into a patient's nutritional and immune status. Localised pathology may also be picked up by examining the lips.
During the gastrointestinal examination, inspection of the hands is important as it may reveal signs of chronic liver disease or anaemia.
Examination of the skin of the abdomen can reveal significant clues regarding the presence of portal hypertension, previous abdominal distension and previous abdominal procedures.
Palpation of the liver can be used to assess the liver span and consistency, as well as for tenderness over the liver or gallbladder.

Digital Clubbing

  • Look For

  • Enlargement of the distal segments of the fingers and / or toes, due to proliferation of connective tissue.

Overview

During the gastrointestinal examination, inspection of the skin can reveal skin changes that can point toward a specific GI or hepatobiliary pathology.

Rectal Masses

  • Feel For

  • A mass within the rectum.

Renal Bruits

  • How to Elicit

  • Listen over the upper abdomen, approximately 2cm superior and lateral to the umbilicus on either side.

Common Signs on the Tongue

Dry TongueDehydration

Overview

During the gastrointestinal examination the flanks are often ignored in favour of the abdomen, however there is valuable information to be gained from inspecting and palpating the flanks routinely.
  • How to Assess

  • Use the palpating finger to assess the resting tone of the anus. Ask the patient to squeeze down against the finger.

Poor Dentition

  • Look For

  • The number and overall health of the teeth, and the presence of any carious or erosive lesions.

Overview

Peritonism refers to inflammation of the peritoneum, which suggests acute abdominal pathology that should be rapidly diagnosed and treated.
There are several pathognomonic and diagnostic signs to be found on inspection of the eyes.

Dehydration

  • Look For

  • Abnormal obs - tachycardia, hypotension
  • Fluid balance chart - negative fluid balance, oliguria
  • Weight loss - an acute decrease in weight may indicate short-term change in fluid status
  • Dry mucous membranes - especially the tongue
  • Sunken eyes
  • Increased capillary refill time (>2 seconds)
  • Weak radial pulse
  • Decreased skin turgor - pinch a fold of skin on the patient’s arm and then release it. Decreased skin turgor is present if the fold takes an abnormal time to return to its normal contour.

Overview

Patients with hepatic encephalopathy in the setting of acute or chronic liver disease may be confused or have a reduced level of consciousness.
Auscultation for the character of the bowel sounds may reveal evidence of hyperactive or underactive bowels.
Consent - ask for the patient's consent to perform a digital rectal examination. Explain what to expect.
Lymphadenopathy refers to enlargement of the lymph nodes, which is often painful. It is important to carefully assess for lymph node enlargement, this suggests infective, inflammatory or malignant pathology.
Nail signs such as leukonychia and koilonychia are useful external signs of gastrointestinal or hepatobiliary pathology.
The patient's breath may reveal information about their oral hygiene, or suggest the presence of metabolic disease.
Ask the patient to indicate where on the abdomen is painful. Superficially palpate the nine segments of the abdomen to elicit tenderness and assess for masses. If no tenderness is present, palpate more deeply.
Ascites (fluid within the peritoneal cavity) may be caused by many conditions - particularly cirrhosis, heart failure and hypoalbuminaemia. Ascites can be difficult to diagnose on examination, however shifting dullness and the fluid wave can assist in assessing for abdominal fluid.
Appendicitis is an emergency that should be rapidly diagnosed and treated, however this is often difficult clinically - especially in female patients. Signs such as tenderness in McBurney's point as well as the Rosving sign can suggest acute appendicitis.
It is possible to identify an abdominal aortic aneurysm by clinical examination; the aneurysm may be visible on inspection or become apparent on palpation.
The arms can provide a lot of information regarding a patient's liver disease; spider naevi and Bier spots are signs of chronic liver disease, purpura may suggest an underlying coagulopathy and scratch marks suggest an obstructive cause of liver disease.
Inspection of the chest during the gastrointestinal exam can reveal disease specific rashes, as well as signs of cirrhosis such as spider naevi and loss of normal chest hair distribution.

Gingival Inflammation

Gingivitis - generalised swelling and erythema.Viral / bacterial / fungal infection, trauma, lichen planus, pemphigoid, erythema multiforme, SLE, drugs, malnutrition

Overview

The kidneys are often missed during examination of the abdomen, though the presence of ballotable or tender kidneys can provide a significant amount of information about the cause of their presentation.

First Steps

Consent - ask for the patient's consent to perform a digital rectal examination. Explain what to expect.

Overview

Chronic liver disease is a common condition most often caused by alcohol, fatty liver disease or viral hepatitis. This condition can be difficult to diagnose, and the examination is crucial for identifying evidence of portal hypertension, oestrogen excess encephalopathy and other complications of cirrhosis.
  • Look for

  • The patient’s current weight
  • Change in weight - compare to past weights
  • Time course of weight change - sudden or over time

Joint Swelling

  • Look For

  • Generalised swelling over one or both lower limbs. May be associated with redness, tenderness or warmth.

Focal Abdominal Tenderness

Right hypochondrium - liver, gallbladder, stomach, hepatic flexure of colon, lungGallstones, peptic ulcer

Overview

Inspecting the patient's skin for evidence of pallor, plethora or jaundice provide information regarding the presence of anaemia, polycythaemia or haemolysis.
The nails can reveal signs suggestive of haematologic disease. While pallor of the nail bed is a sign of anaemia, koilonychia suggests potential iron deficiency.

Chest Wall Tenderness

  • How to Elicit

  • Gently palpate the chest wall, checking for tenderness. Ask the patient where is tender, and watch their face for nonverbal cues.

Palmar Crease Pallor

  • Look For

  • Loss of colour in the creases of the palm.

Overview

The axillary lymph nodes drain from the neck, chest wall, breast and upper limbs. Enlargement of these lymph nodes can suggest pathology affecting these regions or a systemic process that is infective, inflammatory or malignant.
Splenomegaly is present if the spleen is palpable. This may be a sign of portal hypertension due to liver, vascular or pulmonary disease; splenomegaly also occurs with certain infections and haematologic malignancies.

Bony Tenderness

  • How to Elicit

  • Gently press over the bony prominences of the lower limb, asking the patient if this elicits pain.

Hepatomegaly

  • Feel For

  • The size of the  liver, by estimating the location of the upper and lower liver edges.

Joint Swelling

  • Look For

  • Generalised swelling over one or both upper limbs. May be associated with redness, tenderness or warmth.

Purpura

  • Look For

  • Red / purple lesions that do not blanch with pressure. May be present over the head, arms, legs, chest or abdomen.

Overview

Lymphadenopathy refers to enlargement of the lymph nodes, which is often painful. It is important to carefully assess for lymph node enlargement, as this suggests infective, inflammatory or malignant pathology.

Oropharyngeal Inspection

  • How to Perform

  • Ask the patient to open their mouth and make an ‘ahh' sound, in order to contract the palate and uvula. Depress the tongue if required in order to visualise the posterior pharynx.

Overview

  • Feel For

    A palpable mass within the abdomen, noting its:
  • Location
  • Size
  • Shape
  • Consistency
  • Mobility
  • How to Perform

  • Using the pulps of the fingers, gently palpate the lymph nodes along the inguinal ligament and down the medial aspect of the thigh.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
The term nystagmus is used mainly to refer to jerk nystagmus, abnormal rhythmic eye movements that may be a sign of cerebellar disease.
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
  • Interpretation

  • Ask the patient to walk with the heel of the front foot making direct contact with the first toe of the back foot.

Testing for Station

  • How to Assess

  • Ask the patient to stand still with their heels together.

Overview

The finger-nose test is used to assess coordinated, target-driven movement of the upper limb; this is lost in the context of cerebellar pathology.
Dysdiadochokinesis is the inability to perform rapidly alternating contractions of agonist and antagonist muscles.
  • How to Perform

  • With the patient supine, ask them to place their left heel onto their right shin just below the knee. Ask them to slowly and accurately run their heel down the length of the shin to the top of the foot. Ask the patient to repeat this several times, and then perform the same test on the other side.
  • How to Elicit

  • Ask the patient to rapidly tap your hand with the dorsum of their foot (dorsiflexion and plantar flexion).
  • Interpretation

  • Ask the patient to walk on their toes.
  • How to Assess

  • Ask the patient to walk on their heels.
  • Signs of Conductive Dysphasia

  • Inability to repeat phrases
  • Recognition of errors (unlike in receptive dysphasia)
  • Paraphasias: switching of a word in a sentence for another incorrect word
  • Neologisms: new words created by the patient
Ataxic dysarthria is also know as ‘scanning speech’ or ‘drunken speech’.

Facial Asymmetry

  • Look For

  • Drooping of one side of the face. Compare the angles of the mouth on both sides. Determine whether the eyebrow is spared on the affected side or not.

Overview

  • Signs of Flaccid Dysarthria

  • Hypernasal speech
  • Breathiness of voice
  • Monotone speech - single pitch, single loudness
  • Impaired articulation - imprecise consonants
  • Shortened phrases
  • Drooling
  • How to Perform

    Ask the patient to repeat back words or sentences of increasing complexity.
  • Orange
  • Watch
  • Hippopotamus
  • Aubergine
  • Emerald
  • Perimeter
  • No ifs, ands or buts
  • British constitution
  • The orchestra played and the audience applauded
  • How to Perform

  • Ask the patient to read a paragraph aloud, or count to twenty.
  • Ask About

  • Time - day, date, month, year, season
  • Place - floor, building, city, state, country
  • Person - full name, date of birth, address
Agrammatism is the incorrect use of grammar.
Repetition of simple sounds is useful for identifying weakness of the muscles involved in articulation

Dysphonia

  • Signs of Dysphonia

  • Hoarse voice
  • Bovine cough

Overview

  • Aspects of Fluency

  • Rate of speech - words or syllables per minute
  • Continuity of speech - lack of hesitation or pauses
  • Effort of speech - due to muscular, word-finding or sentence structure difficulty
  • Interjections - added sounds such as um, ah
  • Repetition - word or syllable repetition, e.g. stuttering
  • Paraphasias: switching of a word in a sentence for another incorrect word
  • Neologisms: new words created by the patient
Also known as Wernicke’s dysphasia.
  • Signs of Hyperkinetic Dysarthria

  • Involuntary movements - single or repetitive
  • Harsh voice - strained-strangled quality
  • Signs of Spastic Dysarthria

  • Slow speech
  • Harsh voice - strained-strangled quality
  • Impaired articulation - imprecise consonants
  • Signs of Hypokinetic Dysarthria

  • Hypophonia: quiet speech
  • Monotonous speech
  • Reduced mouth opening
  • Short runs of speech with inappropriate silences
Also known as Broca’s dysphasia.
  • Signs of Nominal Dysphasia

  • Anomia: the inability to name objects
  • Circumlocution: talking around a specific word, rather than saying it directly. E.g. ‘a tool that I use to write with’ rather than ‘pen’
  • Look For

  • The pulsation of the jugular vein, between the sternal and clavicular heads of the sternocleidomastoid.
Listen to each of the cardiac areas for normal / pathologic heart sounds, a pericardial rub and for the presence of a murmur.
Blood pressure is a measure of the arterial pressure during systole and diastole; this may also be used to calculate the mean arterial pressure. Low blood pressure can result in poor organ perfusion, which high blood pressure puts patients at risk of cardiac, cerebrovascular, retinal and renal complications.
Human body temperature is a balance of heat production and heat dissipation, and tends to vary very little within an individual. Temperature is regulated by the hypothalamus, which drives thermoregulatory processes that include vasoconstriction / vasodilation, sweating and shivering.
Decreased skin turgor is a sign of dehydration.
  • Assessing for Airway Patency

  • If the patient is talking then this suggests that their airway is patent (however, this is not always the case)
  • Look, listen and feel for movement of air
  • Stridor (musical, high-pitched sounds) suggests upper airway obstruction
  • Snoring is a sign of airway compromise
  • Paradoxical abdominal movement is a sign
The respiratory rate is an important vital sign that is an early marker of deterioration.
Auscultate the abdomen for bowel sounds. First listen in one quadrant and if an abnormality is discovered then listen in each of the three other quadrants.
Palpate the radial pulse for at least thirty seconds and determine whether the beats fall in time or are irregular.
Look for swelling of the lower limbs; apply pressure to the anterior aspect of the tibia for fifteen seconds and then release to assess for pitting oedema.
The oxygen saturation is a reflection of the percentage of haemoglobin that is bound to oxygen.
The Glasgow Coma Scale (GCS) is a 15-point scale indicating level of consciousness.

Breath Sounds

  • Interpretation

  • Vesicular breath sounds: soft, non-musical, heard in inspiration and early expiration
  • Bronchial breath sounds - hollow sounds similar to those normally heard over the trachea

Abdominal Tenderness

Ask the patient to indicate where on the abdomen is painful. Superficially palpate the nine segments of the abdomen to elicit tenderness. If none is present, palpate more deeply.

Overview

The heart rate is an invaluable vital sign that is commonly used as part of the assessment of a patient's haemodynamic state.

Assessing the Calves

Look at and feel the patient’s calves, looking for signs of deep venous thrombosis.

Overview

The blood sugar should be tested in every acutely unwell person, mainly because hypoglycaemia is an underdiagnosed cause of reduced consciousness, and can mimic stroke symptoms.
There are multiple clinical signs that suggest hypoperfusion, or shock.

Inspection of Pupils

  • Look For

  • The size of the pupils (dilated, normal, constricted) and equality of size bilaterally.

Overview

The presence of respiratory distress indicates that the patient has significant pathology (respiratory or otherwise) that requires immediate assessment and management.
Human body temperature is a balance of heat production and heat dissipation, and tends to vary very little within an individual. Temperature is regulated by the hypothalamus, which drives thermoregulatory processes that include vasoconstriction / vasodilation, sweating and shivering.
The oxygen saturation is a reflection of the percentage of haemoglobin that is bound to oxygen.

  • The respiratory rate is an important vital sign that is an early marker of deterioration.
Blood pressure is a measure of the arterial pressure during systole and diastole; this may also be used to calculate the mean arterial pressure. Low blood pressure can result in poor organ perfusion, which high blood pressure puts patients at risk of cardiac, cerebrovascular, retinal and renal complications.
The heart rate is an invaluable vital sign that is commonly used as part of the assessment of a patient's haemodynamic state.
The residual volume is the volume left in the lungs after a maximal expiration.
While spirometric values such as FEV₁ and FVC can be suggestive of restrictive lung disease,  a reduced total lung capacity (TLC) of 80% predicted is diagnostic.
Lung volumes are measures of the amount of gas present within the lungs during each phase of the respiratory cycle. These volumes can be used clinically to diagnose respiratory disease.
The volume-time graph is a graphical representation of spirometry results.
Flow-volume loops are produced by asking the patient to breath out then in as forcefully as possible, and may reveal a characteristic pattern suggestive of restrictive, obstructive or other pulmonary disease.
Diffusing Capacity of Lung for Carbon Monoxide (DLCO) is a measure of the efficiency of lung gas transfer. This test is used to further characterise a respiratory defect following spirometry and lung volume testing, to provide evidence supporting a specific respiratory pathology.
The total lung capacity refers to the volume of air within the lungs after a maximal inspiration.
The functional residual capacity (FRC) is the volume left in the lungs after passive expiration, i.e. without use of accessory muscles.
Correct spirometry technique is vital for collecting an accurate sample, and poor compliance with the test may result in a false positive or false negative result.
    • Normal Range

    • 25 - 40 sec
  • Important Lab Points

  • Measures the level of anti-Xa activity in a sample.
  • Performed by adding a known amount of factor Xa to a plasma sample and then measuring the residual Xa level; this is inversely proportional to the amount of anti-Xa activity.
  • The result is measured against a curve specific to the medication being monitored - e.g. low molecular weight heparin, rivaroxaban, dabigatran, fondaparinux or danaparoid.
Coagulation testing is useful for assessing patients' ability to clot; for investigating the cause of a patient's coagulopathy; and for therapeutic monitoring of certain anticoagulant medications. The classical coagulation profile includes the prothrombin time and activated partial thromboplastin time, though other tests may be performed as required.
The thrombin time (TT) is not routinely performed as part of a coagulation screen.
    • Normal Range

    • 1.5 - 4.5 g/L
Fibrin D-dimer is a measurement of cross-linked fibrin degradation products, generally indicative of clot formation with active clot breakdown.
The prothrombin time (PT) and international normalised ratio (INR) are measures of the extrinsic coagulation pathway. 
Mixing studies are used to determine the cause of prolonged PT/INR and/or APTT.
    • Normal Range

    • 5 - 20 cmH₂O
    • Normal Range

    • <5 x 10⁶
    • Normal Range

    • <10 x 10⁶
    • Normal Range

    • 15 - 45 mg/dL
Analysis of cerebrospinal fluid is used to identify infections affecting the central nervous system. CSF testing (particularly of proteins) also be used in the diagnosis of demyelinating diseases such as Guillain-Barre syndrome and multiple sclerosis.
The colour and consistency of a patient’s urine can provide significant information regarding the cause of their urinary complaint. 
The urine specific gravity is a measure of the amount of solute compared to water. Pure water has a specific gravity of 1.000.
Urine pH is a measure of the acid content in urine. This often reflects the acidity of serum, however there are certain cases (e.g. renal tubular acidosis) in which the urine pH does not match the serum pH.
There are many ways in which a urine sample can be collected. The method of collection depends on the type of test performed, and certain patient factors.
Leukocyte esterase (LE) is an enzyme produced by white blood cells. If leukocyte esterase is present in urine then this is indicative of an increase in leukocytes in urine, also known as pyuria. 
First degree sinoatrial exit block is due to delayed transmission of an impulse from the sinoatrial node, and is not detectable on ECG.
Type II second degree AV block occurs when there is an intermittently missed QRS complex due to failure of conduction through the AV node.
Also known as Wenkebach SA exit block.
Type I second degree AV block occurs when there is progressively delayed AV transmission eventually resulting in a missed QRS complex.
Sinoatrial exit block is a delay in conduction between the sinoatrial node and atrial myocardium.
Atrioventricular (AV) block occurs due to delayed conduction of an impulse between the atria or ventricles, due to intrinsic or extrinsic causes.
In advanced or ‘high-grade' second degree heart block, multiple beats are blocked and it is difficult to distinguish between Mobitz type I and II.
Complete atrioventricular block represents complete failure of conduction between the atria and ventricles.
First degree AV block indicates delayed conduction between the atria and the ventricles.
In third degree sinoatrial exit block, there is complete failure of transmission to the atria - this is indistinguishable from sinus arrest on ECG.
Type II second degree sinoatrial exit block occurs when there is an intermittently missed P wave due to failure of conduction to the atrial myocardium.
Reticulocytes are non-nucleated immature red blood cells. They are not normally present in the circulation in high numbers, though may be seen if the bone marrow is producing large numbers of red cells.
Neutrophils are the most prevalent white blood cells in circulation. They are a type of polymorphonuclear (PMN) leukocyte, with 3-5 nuclear lobes and fine granules within the cytoplasm.
Eosinophils are granulocytes with a bilobed nucleus, blue cytoplasm and orange-red cytoplasmic granules
Anaemia is a very common condition that may occur in the context of reduced red blood cell production, increased red blood cell production, or red blood cell loss.
Beta thalassaemia is an inherited defect in beta globin chains of haemoglobin, resulting in defective haemoglobin synthesis.
The mean cell volume (MCV) is a measure of the average volume of a red blood cell.
Lymphocytes are small leukocytes with a large nucleus, though they may be larger with a low nuclear : cytoplasmic ratio if they are reactive.
  • The mean corpuscular haemoglobin (MCH) and mean corpuscular haemoglobin concentration (MCHC) are red blood cell indices which confer whether a cell is normochromic, hyperchromic or hypochromic.
  • Mean corpuscular haemoglobin (MCH) - the average amount of haemoglobin per red blood cell
  • mean corpuscular haemoglobin concentration (MCHC) - the average concentration of haemoglobin within red blood cells
Red cell distribution width (RDW) is the amount of variation in red blood cell size. Cells may be relatively uniform in size and have a low RDW, or have a wide range of sizes and have a high RDW.
Platelets are very small non-nucleated cells that derive from fragmentation of megakaryocytes. They play an important role in clot formation and haemostasis.
Reflects the number of circulating red blood cells.
Alpha thalassaemia is an inherited condition affecting the alpha chains of haemoglobin, resulting in defective haemoglobin synthesis.
Leukocytes represent a variety of cells derived from myeloid and lymphoid lineages that perform a variety of immune functions.
Basophils are relatively uncommon white blood cells. Morphologically they are granulocytes with large bluish (basophilic) granules. 
Haemoglobin is a tetrameric protein found within red blood cells, composed of a haem (iron-containing) molecule, two alpha and two beta globin subunits.
Monocytes are large leukocytes of myeloid origin with blue-grey ground glass cytoplasm and horseshoe-shaped nucleus.
The haematocrit, also known as the packed cell volume (PCV), is the volume of red blood cells as a percentage of total blood volume.
The anaemia of chronic disease is a common condition that is associated with chronic infection, inflammation or malignancy where patients develop a non-specific anaemia.
Sickle cell anaemia is an inherited disorder affecting haemoglobin synthesis, resulting in 'sickling' of red blood cells and resultant complications.
The PaO₂ on an arterial blood is only relevant for assessing for hypoxia when the patient is on room air.  If they are receiving supplemental oxygen this will artificially increase the PaO₂ which may appear normal.
Respiratory acidosis is a process by which reduced effective ventilation results in carbon dioxide retention.
The bicarbonate level is significantly influenced by acid-base buffering system, and can by affected by the presence of a respiratory process. The base excess is an indicator of a metabolic process that is independent of this buffering system.
The serum pH is a measure of the acidity of alkalinity of the blood, based on an inverse log of the hydrogen ion concentration. This can be used in conjunction with the HCO₃ and PaCO₂ to determine whether there is an acid-base disorder present.
Serum lactate is an important marker of prognosis and resolution in many critical illnesses.
  • Look For

  • Alkalaemia with raised bicarbonate.
Metabolic acidosis is a process in which an external agent or internal process is causing excessive acidity in a way that is metabolic (i.e. non-respiratory).
The PaO₂ is the partial pressure of oxygen dissolved in plasma. This is a marker of the amount of oxygen available to be delivered to tissues, and a reduced PaO₂ is indicative of hypoxia.
  • Primary Abnormality

  • Alkalaemia with decreased PaCO₂.
The gap-gap ratio is used to further assess patients with a high anion gap metabolic acidosis (HAGMA).
The anion gap is used to further assess a patient with metabolic acidosis. 
Oxyhaemoglobin refers to the percentage of haemoglobin that is bound to oxygen.
The PaCO₂ is the arterial partial pressure of carbon dioxide, as measured on an arterial blood gas.
Bicarbonate (HCO₃) is one of the major alkali present in the blood, and plays a crucial role in acid-base balance.
Atelectasis refers to alveolar volume loss resulting in collapse of a portion of the lung.
Normally, six anterior ribs and nine posterior ribs should be seen above the diaphragm.
Potential bony lesions visible on chest x-ray include rib fractures, lytic (punched out) lesions and sclerotic (hyperopacified) lesions.
The chest x-ray is a useful tool for determining the type of cardiac device present.
An endotracheal tube should be below the larynx and above the carina, optimally at the level of the aortic knuckle.
The chest x-ray has low sensitivity and specificity for the diagnosis of interstitial lung disease, and a high resolution CT is the imaging modality of choice.
A nasogastric or orogastric tube should be visualised below the diaphragm. If not then there is a chance that it is in the airway.
  • Signs of Pulmonary Oedema on Chest X-Ray

  • Bat-wing appearance - opacities extending laterally in a fan shape from each hilum
  • Kerley A lines - 5-10cm lines extending from the hila to the periphery (fluid in the deep septa)
  • Kerley B lines - 1.5-2cm lines seen in the periphery of the lower lung extending into the pleura (interlobular septal thickening)
  • Air bronchograms - tubular outlines of the smaller airways
  • Upper lobe diversion (cephalisation) - enlarged upper lobe vessels and smaller lower lobe vessels
  • Associated cardiomegaly (cardiogenic)
The projection of the chest x-ray refers to the direction that the x-rays travel through the body. This is determined by the placement of the x-ray generator and the x-ray plate.
  • Chest X-Ray Signs of Pneumonia

  • Pulmonary consolidation without volume loss - may be lobar (lobar pneumonia) or multifocal
  • Air bronchograms - tubular outlines of the smaller airways
  • Silhouette signs - obliteration of normally clear outlines between lung fields and adjacent structures
Breast shadows are normal on chest xrays, and should not be mistaken for opacities within the lungs.
Before interpreting findings on a chest x-ray, it is important to assess the x-ray's quality.
  • Look For

  • The presence of a drain within the pleural cavity.
A wide range of large bore and central catheters are used in clinical practice. The chest x-ray is used to confirm that such catheters are in the correct position and are safe to use.
The patient's position during a chest x-ray can have a large impact on the interpretation of the x-ray. There is generally a marking over the chest x-ray to indicate whether the patient was erect (standing, or at least sitting up) or supine (lying down.
  • Normal Position

  • The right diaphragm is usually 1cm higher than the left, due to the presence of the liver.
The left hilum is normaly 1-2cm higher than the right hilum.
  • Signs of Pneumothorax on Chest X-Ray

  • Reduction in lung markings in the apices (erect)
  • Deep sulcus sign - abnormally sharp costophrenic angle (supine)
  • Diaphragmatic flattening
  • Signs of Tension Pneumothorax

  • Tracheal deviation away from the pneumothorax
  • Mediastinal shift away from the pneumothorax

Silhouette Signs

  • Look For

  • Obliteration of normally clear outlines between the lung fields and adjacent structures such as the heart, aorta or hemidiaphragm.

Overview

  • Chest X-Ray Signs of Pleural Effusion

  • Loss of the costophrenic angle
  • Increased density of the affected hemithorax
  • Pseudo-elevation of the diaphragm
  • Loss of lower lobe vessels
  • Chest X-Ray Signs of Emphysema

  • Hyperinflation - hyperlucency of lung fields, diaphragmatic flattening, mediastinal narrowing
  • Bullae
  • Lung scarring
The cardiac silhouette is normally ovoid in apperance, with the apex pointing toward the left.
Anti-dsDNA is a subset of antinuclear antibodies (ANA) directed toward double-stranded DNA.
The complement pathway plays an important role in inflammatory processes, and involves many different measureable components including C1q, C3, C4 and factor B.
  • Look For

    Joint disassociation.
  • Shoulder - anterior / posterior / inferior
  • Finger - interphalageal / metacarpophalangeal
  • Elbow - posterior / posterolateral / posteromedial
  • Patella - lateral / medial
  • Hip - posterior / anterior
  • Wrist - lunate / perilunate
  • Look For

  • Obvious protrusion of bone through the soft tissues
  • Air within the soft tissues
The Salter-Harris classification is a system for classifying fractures involving the growth plate. Such fractures have the potential of interrupting the proliferative zone, halting bone growth; higher grade fractures are at higher risk.
The ascitic fluid cell count provides a measure of the number of red blood cells, white blood cells and white cell differential; this information can be used to guide the differential diagnosis of a patient with ascites.
The serum-ascites albumin gradient (SAAG) is used to differentiate between portal hypertension and other causes of ascites.
Cirrhosis / CCFMalignancySBPPancreatitis
AppearanceClearMilky / BloodyTurbidMilky / Turbid
SAAG≥1.1 g/dL<1.1 g/dL<1.1 g/dL<1.1 g/dL
LDHNormal / ReducedElevatedNormal / ElevatedNormal / Elevated
GlucoseNormalReducedReducedReduced
AmylaseNormalNormal / ElevatedNormalElevated
Neutrophils<300/µL≥500/µL

Cirrhosis / CCFMalignancySBPPancreatitis
AppearanceClearMilky / BloodyTurbidMilky / Turbid
SAAG≥1.1 g/dL<1.1 g/dL<1.1 g/dL<1.1 g/dL
LDHNormal / ReducedElevatedNormal / ElevatedNormal / Elevated
GlucoseNormalReducedReducedReduced
AmylaseNormalNormal / ElevatedNormalElevated
Neutrophils<300/µL≥500/µL

Sinoatrial exit block is a delay in conduction between the sinoatrial node and atrial myocardium.
Atrioventricular (AV) block occurs due to delayed conduction of an impulse between the atria or ventricles, due to intrinsic or extrinsic causes.
Atrial escape is an impulse generated by an atrial focus in the context of a long sinus pause, such as due to sinus arrest or third degree sinoatrial exit block.
Junctional escape is an impulse generated by a focus at the AV junction when the supraventricular conduction system fails, such as due to sinus arrest or complete AV block.
Bradycardia may generally be caused by sinus node dysfunction, atrioventricular block or escape rhythms in the setting of either of the above.
Atrial flutter is typically a regular, narrow complex tachycardia with 2:1 or even higher levels of AV block. In some patients the AV block is variable; this may be either idiopathic or in the context of complete heart block.
Sinus arrhythmia occurs physiologically due to changes in intrathoracic pressure and resultant variation in vagal tone through the respiratory cycle.
Atrial fibrillation is most commonly associated with a rapid ventricular response, though AF with a slow ventricular response may occur when there is reduced conduction of fibrillatory waves through the conduction pathways.
Tachycardia-bradycardia syndrome is a manifestation of sinus node dysfunction where bradycardia is interspersed with periods of supraventricular tachycardia.
Ventricular escape is an impulse generated by a ventricular focus when the conduction system fails, most commonly due to complete heart block.
Sick sinus syndrome (SSS) occurs when the sinus node is not functioning correctly, due to either intrinsic or extrinsic causes.
Sinus arrest is the temporary interruption of sinoatrial node automaticity, that may occur due to intrinsic or extrinsic factors affecting the sinoatrial node.
Sinus bradycardia is initiated by the sinus node, and occurs in the setting of reduced automaticity due to either intrinsic or extrinsic causes.

Poikilocytosis

Abnormally shaped red blood cells.

Overview

Haptoglobin is an alpha-2 glycoprotein secreted mainly by the liver that binds plasma free haemoglobin following red cell lysis, and as such is reduced in the presence of haemolysis (particularly intravascular haemolysis).
Lactate dehydrogenase (LDH) is an enzyme present in the cytoplasm of most cells that catalyses the conversion of lactate to pyruvate.
Reticulocytes are non-nucleated immature red blood cells.
  • Markers of Intravascular Haemolysis

  • Elevated plasma free haemoglobin
  • Elevated urine haemoglobin - urine dipstick positive for blood but no RBC
  • Elevated urine haemosiderin - brownish urine due to excess iron stored as haemosiderin
Bilirubin is a breakdown product of haem that is conjugated in hepatocytes with glucuronic acid and then excreted in bile.
  • Causes of Pleural Effusion

  • Exudative

  • Malignancy
  • Infection - parapneumonic effusion, empyema, viral, fungal, TB, ruptured abscess / cyst
  • Pulmonary embolism (90% exudative)
  • Autoimmune disease - rheumatoid pleuritis, SLE
  • Pancreatitis
  • Haemothorax
  • Chylothorax
  • Asbestosis
  • Uraemia
  • Oesophageal rupture
  • Transudative

  • Heart failure
  • Cirrhosis
  • Hypoalbuminaemia
  • Nephrotic syndrome
  • Pulmonary embolism (10% transudative)
  • Myxoedema
  • Meig’s syndrome
  • Constrictive pericarditis
  • SVC obstruction
  • Urinothorax
Iron overload refers to an excess of total body iron stores. This may be due to haemochromatosis, or one of several secondary causes.
Ferritin is an intracellular iron storage protein whose levels are indicative of the body's total iron stores.
Iron is an important mineral that plays a role in multiple physiologic processes including oxygenation, protein synthesis and cellular respiration. The metabolism of iron is outlined below.
Iron deficiency may occur due to poor intake, poor absorption or loss of iron. The most common complication of iron deficiency is anaemia, which presents as a microcytic, hypochromic anaemia.
Total serum iron is a measure of the ferric (Fe3+) ions bound to serum transferrin. There is significant variation of iron levels with due to multiple factors, and therefore the serum iron is a poor marker of iron status.
The transferrin saturation (TSat) is the percentage of transferrin that is bound to iron. This is a more accurate measure of total body iron than the serum iron concentration, which fluctuates significantly.
Transferrin receptors are receptors on cell surfaces that internalise transferrin.
Transferrin is an transport protein that binds to iron in plasma.
Monocytes are large leukocytes of myeloid origin with a blue-grey ground glass cytoplasm and an irregularly shaped nucleus. Monocytes often contain vacuoles.
Megaloblastic anaemia is a condition where the bone marrow produces large immature red blood cells called megaloblasts which go on to become large, ineffective red blood cells.
Extra staining of blood films may reveal red blood cell findings not seen using typical stains.
Poikilocytosis refers to the presence of abnormally shaped red blood cells on a blood film. There are a wide variety of red cell morphological changes which may suggest various hereditary or acquired conditions.
Eosinophils are granulocytes with a bilobed nucleus, blue cytoplasm and orange to red cytoplasmic granules.
Assessment of red blood cell size - the presence of normocytosis, microcytosis or macrocytosis - is the first step in the assessment of patients with anaemia as it can rapidly be used to narrow down the likely causes.
Certain characteristic findings on a blood film are suggestive of hyposplenism or asplenism. This may be congenital, iatrogenic (particularly post splenectomy) or associated with acquired medical conditions.
Neutrophils are the most prevalent white blood cells in circulation. They are a type of polymorphonuclear (PMN) leukocyte, with 3-5 nuclear lobes and fine granules within the cytoplasm.
Platelets are very small non-nucleated cells with fine granules that derive from fragmentation of megakaryocytes.
Lymphocytes tend to be small leukocytes with a large nucleus, though may be larger with a lower nuclear:cytoplasmic ratio if reactive. These cells play several key roles in the adaptive immune response.
Mature red blood cells are anuclear, as they extrude their nuclei in the bone marrow prior to entering circulation. The presence of nucleated red blood cells is an abnormal finding.
Red blood cell inclusion bodies are pieces of stainable material within red blood cells, mainly due to retained remnants of cellular components.
A leukoerythroblastic blood film refers to the presence of granulocyte left shift as well as nucleated red blood cells on the same blood film.
The intensity of the colour of red blood cells is representative of the red blood cell haemoglobin concentration.
Basophils are granulocytes with large bluish (basophilic) granules. These uncommon cells play a role in the pathogenesis of allergy.
Free T3 is a measure of the triiodothyronine not bound to serum proteins such as thyroid-binding globulin, albumin or transthyretin.
Triiodothyronine (T3) and thyroxine (T4) are secreted by the thyroid gland and produce a variety of effects on metabolism. Their release is mediated via a negative feedback loop involving the hypothalamus and anterior pituitary gland.
Thyroid stimulating hormone (TSH) is secreted by the anterior pituitary, in response to the stimulating effect of thyroid releasing hormone (TRH) from the hypothalamus. TSH acts on the thyroid gland to stimulate release of T3 and T4.
Hypothyroidism refers to underactivity of the thyroid, with reduced circulating thyroid hormones. This is usually accompanied by typical signs and symptoms of hypothyroidism.
Nonthyroidal illness (also known as sick euthyroid syndrome) is an adaptive response of the thyroid to acute of chronic illness.
Free T4 is a measure of the thyroxine not bound to serum proteins such as thyroid-binding globulin, albumin or transthyretin.
The TSH is a useful screening tool for thyroid disease. If the TSH is elevated or reduced, then the T4 is the next useful test for distinguishing the pattern of derangement.
Hyperthyroidism refers to hyperactivity of the thyroid gland, with increased circulating thyroid hormones. This tends to be accompanied by typical signs and symptoms of thyrotoxicosis such as those listed below.
Caeruloplasmin is a copper-containing protein that may be measured for use as an inflammatory marker, however it is very uncommonly used in this fashion.
Ferritin is an intracellular iron storage protein whose levels are indicative of the body's total iron stores; ferritin is also an acute phase reactant.
Albumin is a group of serum proteins produced by the liver that maintain oncotic pressure and transport certain hydrophobic compounds.
Fibrinogen is a coagulation factor that is converted to fibrin and is essential for the formation of a clot. Inflammation and coagulation are tightly linked, and as such the fibrinogen level will rise in the presence of acute inflammation.
The acute phase response is a facet of the innate immune system that occurs in response to infection, trauma or other insults. Certain mediators, known as acute phase reactants, are increased or decreased in the context of acute inflammation. These markers are commonly measured in clinical practice as indicators of acute illness.
Haptoglobin is an alpha-2 glycoprotein secreted mainly by the liver that binds plasma free haemoglobin following red cell lysis, and as such is reduced in the presence of haemolysis (particularly intravascular haemolysis).
Urinary casts are tubular structures formed by the precipitation of Tamm-Horsfall mucoprotein. These may contain red cells, white cells or other substances, and their presence may suggest specific disease processes.
There are many ways in which a urine sample can be collected. The method of collection depends on the type of test performed, and certain patient factors.
Squamous epithelial cells seen in urine originate from the urethral wall. If these are present in urine then this suggests a contaminated, non-midstream urine sample that likely also contains urethral normal flora.
The cardiac axis represents the overall direction of depolarisation of the cardiac conduction system, and is assessed by looking at the depolarisation of the individual leads.
The ST segment on an ECG trace reflects early ventricular repolarisation, and is classically used to assess for cardiac ischaemia.
The U wave reflects repolarisation of mid-myocardial cells, between the endocardium and epicardium. It is not normally visible on the electrocardiogram.
The QRS complex indicates ventricular depolarisation.
The QT interval indicates of the time from ventricular depolarisation (phase 0) to ventricular repolarisation (phases 1-3). It is the duration of activation and recovery of the ventricular myocardium.
When assessing rhythm on an ECG, look at both the regularity of P waves (sinoatrial rhythm) and R waves (ventricular rhythm).
Correct technique in recording ECGs is imperative for the diagnosis of electrical disorders of the heart. Incorrect technique may result in artefact, an unusable result or even misinterpretation of the ECG.
The PR interval is the time between atrial depolarisation and ventricular depolarisation. It is an indicator of atrioventricular conduction time, involving conduction from the atria, through the AV node and down the His-Purkinje system.
A poor quality ECG trace can be incredibly difficult to interpret and, more dangerously, may be misinterpreted.
The P wave on an ECG trace is indicative of atrial depolarisation, which may be initiated by the sinoatrial node or by an ectopic atrial focus.
The heart rate is the ventricular rate, or the rate of ventricular depolarisation.
  • Square Sizes

    The standard ECG is recorded at a speed of 25mm/sec and gain of 10mm/mV.
  • 40ms = 1mm = 1 small square
  • 200ms = 5mm = 1 large square
  • 0.1mV = 1mm = 1 small square
The T wave on an ECG trace is indicative of ventricular repolarisation.

Monomorphic Ventricular Tachycardia

Monomorphic VT is a focal or reentrant ventricular rhythm that requires rapid assessment and management, due to its risk of haemodynamic instability and collapse.

Overview

Supraventricular tachycardias in the presence of either bundle branch block or pre-excitation (accessory pathway) will present with a regular wide complex tachycardia that is often difficult to distinguish from ventricular tachycardia.
Multifocal atrial tachycardia is an irregular rhythm that occurs due to multiple atrial ectopic foci.
Atrial flutter is most commonly due to a right atrial macro-reentrant circuit, and has significant crossover with atrial fibrillation in its pathogenesis.
Sinus tachycardia originates from the sinus node and is a physiologic response that occurs due to changes in autonomic regulation - either sympathetic activation or reduction in parasympathetic tone.
AV reentrant tachycardias occur when an atrial impulse is conducted through an accessory pathway - either retrogradely following AV conduction (orthodromic) or anterogradely (antidromic).
Focal atrial tachycardia is a rapid atrial rhythm originating from a single atrial focus.
Atrial fibrillation in the presence of either bundle branch block or pre-excitation (accessory pathway) will result in an irregular wide complex tachycardia that may be mistaken for polymorphic VT. It is important to carefully check the ECG for the typical highly irregular rhythm of atrial fibrilation.
Atrial fibrillation is a common cardiac arrhythmia that originates from an ectopic atrial focus.
Ventricular fibrillation is a chaotic ventricular rhythm that is not compatible with haemodynamic stability.
AV nodal reentrant tachcardia (AVNRT) is the most common type of paroxysmal supraventricular tachycardia (pSVT), and occurs due to a reentrant loop within the AV node.
Serum protein electrophoresis (EPG) separates serum proteins based on their electrical charge, producing a characteristic pattern.
MGUS and smouldering myeloma by definition do not manifest clinically. Multiple myeloma presents classically with hypercalcaemia, renal dysfunction, anaemia and lytic bony lesions (denoted by the acronym CRAB); myeloma should be suspected in patients with any of these manifestations without any other clear cause.
Antibodies are secreted by plasma cells, and are made up of two identical heavy chains and two identical light chains. There are two types of light chain - κ (Kappa) and λ (Lambda).
Immunoglobulins, secreted by plasma cells, are made up of five classes - IgG, IgM, IgA, IgD and IgE.
Immunofixation is used with serum electrophoresis to determine the type and amount of monoclonal protein (M-protein, or paraprotein) present in a patient with a suspected plasma cell neoplasm, such as MGUS or multiple myeloma.
Urea is a nitrogenous waste product that allows the kidneys to excrete nitrogen; it also drives the countercurrent exchange system within the nephron.
    • Normal Range

    • 50 - 120 µmol/L
In the presence of raised creatinine, urea disproportionately higher than creatinine suggests a prerenal cause such as hypovolaemia, heart failure or shock.
eGFR is the most common means for estimating glomerular filtration rate (GFR) in clinical practice in the context of assessing chronic kidney disease; equations rely on serum creatinine measurements and are adjusted depending on the patient's demographic information.
    • Normal Range

    • 3.0 - 8.0 mg/dL
Measured creatinine clearance is an estimate of the GFR based on a 24-hour urine sample. It was previously more popular and is now not often used in clinical practice due to newer eGFR formulae that are based on serum creatinine.
Pulmonary embolism can produce a wide variety of ECG changes. 
Catacholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited disorder that occurs due to mutations in the ryanodine receptor, affecting calcium release from the sarcoplasmic reticulum.
Hypothermia refers to a reduction in body temperature below 35 degrees celcius. ECG findings may be seen with profound hypothermia, and particularly below 32 degrees.
Brugada syndrome is an inherited condition that strongly predisposes to sudden cardiac death. The condition is autosomal dominant in inheritance and involves a loss of function mutation in sodium channels, predominantly affecting the right ventricle.
Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited disorder in which there is fibro-fatty replacement of the right ventricular myocardium. The condition is the second most common of sudden cardiac death in young people.
Acute myocardial infarction (MI) may be diagnosed using a 12 lead ECG. 
Patients with acute stroke - ischaemic or haemorrhagic - may develop ECG findings that mimic an acute myocardial infarction, in the abscence of significant cardiovascular disease.
Hypercalcaemia, or an increased serum calcium concentration >2.60 mmol/L, shortens action potentials which primarily results in early ventricular repolarisation (shortened QT) on ECG.
Pericardial effusions tend to cause ECG changes only when they are massive, and ECG changes are a poor indicator of pericardial effusions overall.
Certain ECG findings suggest myocardial ischaemia without infarction. These may be seen in a patient following exertion (e.g. during an exercise stress test), or may occur at rest (in unstable angina or non-ST elevation myocardial infarction).
Several hereditary conditions are associated with a prolonged QT interval, which increases the risk of life-threatening arrhythmia.
The electrocardiogram is a useful tool in the diagnosis of pericarditis, which can often present with chest pain that is similar in nature to an acute coronary syndrome.
Potassium is important in maintaining membrane potentials, particularly in cardiac myocytes. 
Hypocalcaemia, or a reduced serum calcium concentration >2.15 mmol/L, prolongs action potentials which primarily results in delayed ventricular repolarisation (prolonged QT) on ECG.
Potassium is important in maintaining membrane potentials, particularly in cardiac myocytes. 
Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac pre-excitation syndrome that occurs due to the presence of an accessory conduction pathway.
A wide variety of medications achieve a therapeutic effect by blocking sodium channels. Toxicity of these medications can produce characteristic ECG findings.
Early repolarisation syndrome (ERS) refers to the presence of J point elevation on an ECG. 
Digoxin is a cardiac glycoside which can be associated with significant toxicity. Certain ECG findings are characteristic.
Folate, also known as vitamin B9, is an important coenzyme in DNA and amino acid metabolism pathways.
Vitamin B12, also known as cobalamin, is an important cofactor in the homocysteine metabolism, haemoglobin synthesis and myelination.
A copper-containing protein produced by the liver that binds ~90% of plasma copper.
Lactate dehydrogenase (LDH) is an enzyme present in the cytoplasm of most cells that catalyses the conversion of lactate to pyruvate.
AST and ALT are enzymes that are commonly used in conjunction to identify active hepatocellular injury.
Bilirubin is a breakdown product of haem that is conjugated in hepatocytes with glucuronic acid and then excreted in bile.
A nitrogen-containing compound that is normally cleared by the liver.
Alkaline phosphatase (ALP) is an enzyme normally found in liver, bone, intestine, late placenta and kidney. Its elevation is often used to diagnose cholestatic liver dysfunction, though it may also be elevated in bone disease as well as certain other conditions.
AST and ALT are enzymes that are commonly used in conjunction to identify active hepatocellular injury.
    • Normal Range

    • Prothrombin time - 11 - 15 sec
    • INR - 0.9 - 1.3
Gamma glutamyl transferase (GGT) is an enzyme found in hepatocytes and biliary epithelial cells, and is a sensitive yet non-specific marker of hepatocyte damage.
Albumin is a group of serum proteins produced by the liver that maintain oncotic pressure and transport certain hydrophobic compounds.
  • Look For

    Pelvic disruption with fracture-dislocation both anteriorly and posteriorly, resulting in a ‘floating' acetabulum.
  • Anteriorly - superior & inferior pubic rami, or pubic symphysis
  • Posteriorly - sacroiliac joint, ilium or sacrum
  • Look For

  • Transverse fracture of a vertebral body, usually of the lumbar spine.
The Weber classification is used to class lateral malleolar fractures, based on the location of the fibular fracture - below, at the level of or above the distal tibiofibular joint. The Weber classification indicates the stability of the fracture, and is used to guide treatment.
  •  
    Oral
    Ezetimibe
    Ezetrol 
  •  
    Oral
    Amlodipine
    Amlo, Norvasc 
  •  
    Oral
    Atenolol
    Tenormin, Noten 
  •  
    Oral
    Hydrochlorothiazide
    Diathiazide 
  •  
    IV / IM / Oral
    Frusemide
    Lasix 
  •  
    Oral / Subling / IV / Topical / Patch
    Glyceryl Trinitrate (GTN)
    Anginine tablet, Nitrolingual spray, Nitro-Dur Patch 
     
    Very short acting, to be used PRN when symptomatic
  •  
    IV / Oral
    Verapamil
    Isoptin 
  •  
    IV / IM / Subcut
    Atropine

  •  
    Oral / IV
    Flecainide

  •  
    IV / Oral
    Amiodarone
    Cordarone 
  •  
    Oral
    Propranolol
    Deralin / Inderal 
  •  
    Oral
    Prazosin
    Minipress 
  •  
    IV
    Adenosine

  •  
    Oral
    Captopril
    Capoten 
  •  
    IV / Oral
    Verapamil
    Isoptin 
  •  
    Oral
    Nicorandil
    Ikorel 
  •  
    Oral / IV
    Quinidine

  •  
    Oral / IV
    Magnesium Sulfate

  •  
    Oral
    Fenofibrate
    Lipidil 
  •  
    Oral
    Atorvastatin
    Lipitor, Trovas 
  •  
    Oral
    Atenolol
    Tenormin, Noten 
  •  
    Local / Regional / Topical / Nasal / IV
    Lidocaine / Lignocaine / Xylocaine

  •  
    Oral
    Indapamide
    Natrilix 
  •  
    Oral
    Candesartan
    Atacand 

Cardiomyocyte Action Potentials

Action potentials in non-pacemaker cells are governed by balanced opening and closing of fast sodium channels, slow calcium channels and potassium channels.
  •  
    Oral
    Spironolactone
    Aldactone, Spiractin 
  •  
    Oral / IV
    Hydralazine
    Alphapress 
  •  
    IV / Oral
    Digoxin
    Lanoxin 
  •  
    Oral
    Pyrazinamide

  •  
    Oral
    Ethambutol

  •  
    Oral
    Dapsone

  •  
    Oral / IV
    Rifampicin
    Rifadin 
  •  
    Oral
    Isoniazid
    Tuberculosis only
  •  
    Oral / IV
    Dipyridamole
    Persantin 
  •  
    IV
    Idarucizumab
    Praxbind 
  •  
    Oral / IV
    Phytomenadione
    Konakion 
  •  
    IV
    Whole Blood Plasma
    Plasma separated from whole blood collection
  •  
    IV
    Urokinase
    Abbokinase 
  •  
    IV
    Adexanet Alfa
    AdexXa 
  •  
    Subcut / IV
    Heparin Sodium

  •  
    Oral
    Apixaban
    Eliquis 
  •  
    Subcut
    Enoxaparin
    Clexane 
  •  
    IV / Intraarterial
    Alteplase
    Actilyse 
  •  
    Oral / IV
    Tranexamic Acid
    Cyklokapron 
  •  
    IV
    Protamine Sulfate

  •  
    IV
    Prothrombinex

  •  
    Oral
    Warfarin
    Coumadin, Marevan 
  •  
    Oral
    Clopidogrel
    Plavix 
     
    A prodrug that requires enzymatic activation
  •  
    Oral
    Dabigatran
    Pradaxa 
  •  
    Oral
    Aspirin
    Aspro, Astrix 
  •  
    IV
    Abciximab
    Reopro 
     
    Long half-life (8-12 hours) and effect (haemostasis 72 hours)

Overview

  •  
    IV / Subcut
    Rituximab
    Mabthera 
  •  
    IV infusion
    Trastuzumab-Emtansine
    Kadcyla 
  •  
    Subcut
    Denosumab
    Prolia, Xgeva 
     
    Six-monthly injections
  •  
    IV infusion / Subcut
    Trastuzumab
    Herceptin 
     
    Inhibits ligand-independent HER signalling
  •  
    IV
    Gemtuzumab-Ozogamicin
    Mylotarg 
Monoclonal antibodies are named based on standard nomenclature that describes the target and species of origin of the antibody.
  •  
    IV infusion
    Atezolizumab
    Tecentriq 
  •  
    IV
    Cetuximab
    Erbitux 
  •  
    IV
    Alemtuzumab
    MabCampath (CLL), LemTrada (MS) 
  •  
    IV infusion
    Ipilimumab
    Yervoy 
  •  
    IV infusion
    Nivolumab
    Opdivo 
  •  
    IV
    Bevacizumab
    Avastin 
  •  
    Oral / IV
    Fluconazole
    Diflucan 
  •  
    IV
    Amphotericin B

  •  
    IV
    Caspofungin

  •  
    Oral
    Anastrozole
    Arimidex 
  •  
    Oral
    Bicalutamide

  •  
    Oral
    Cyproterone

  •  
    IM
    Fulvestrant
    Faslodex 
     
    Monthly injections
  •  
    Oral
    Tamoxifen
    Genox 
  •  
    Oral
    Abiraterone
    Zytiga 
  •  
    Goserelin
    Zoladex 
     
    Implant
  •  
    Inhaled
    Desflurane
    Airway irritant - causes cough, apnoea, laryngospasm
  •  
    IV
    Ketamine
    Ketalar 
  •  
    Local / Regional / Epidural
    Bupivacaine
    Marcain 
  •  
    IV
    Atracurium
    Onset 2 minutes
    Duration 40 minutes
  •  
    IV / IM
    Suxamethonium / Succinylcholine

  •  
    IV
    Propofol

  •  
    Oral
    Fludrocortisone
    Florinef 
  •  
    Oral
    Propylthiouracil
    PTU
  •  
    Oral
    Calcitriol

  •  
    Oral
    Pioglitazone
    Actos 
  •  
    Oral
    Metformin
    Diabex, Diaformin 
     
    Reduce dose in renal insufficiency
  •  
    Subcut
    Insulin Glargine
    Lantus, Toujeo 
     
    Once daily dosing
  •  
    Subcut
    Teriparatide
    Forteo 
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Oral
    Carbimazole
    Neo-Mercazole
  •  
    Subcut
    Liraglutide
    Victoza 
  •  
    Oral
    Linagliptin
    Trajenta 
  •  
    Subcut / IV
    Insulin Aspart
    Novorapid 
  •  
    Oral
    Strontium Ranelate
    Protos 
  •  
    Oral
    Calcium Carbonate
    Caltrate 
  • Mechanism of Action

  • Insulin is an hormone normally produced by pancreatic beta cells that is responsible for regulation of glucose, fat and protein metabolism.
  •  
    Subcut
    Neutral + Isophane Insulin
    Humulin 30/70, Mixtard 30/70, Mixtard 50/50 
  •  
    Subcut
    Isophane Insulin
    Protaphane, Humulin NPH 
  •  
    Oral
    Empagliflozin
    Jardiance 
  •  
    Oral
    Raloxifene
    Evista 
  •  
    Subcut
    Denosumab
    Prolia, Xgeva 
     
    Six-monthly injections
  •  
    Oral
    Cholecalciferol
    Ostelin, Ostevit-D 
  •  
    Oral
    Thyroxine
    Oroxine, Eutroxig 
     
    Adjust every 6-8 weeks according to TSH
  •  
    Subcut / IV
    Neutral Insulin
    Actrapid, Humulin R 
     
    Given 30 minutes before meals
  •  
    Oral
    Gliclazide
    Diamicron 
  •  
    Oral
    Alendronate
    Fosamax 
     
    Once weekly dosing
  •  
    Oral
    Amantadine
    Symmetrel 
  •  
    Oral
    Atazanavir
    Reyataz 
  •  
    Oral
    Dolutegravir
    Tivicay 
  •  
    IV
    Foscarnet
    Foscavir 
  •  
    Oral
    Abacavir

  •  
    IV
    Cidofovir
    Empovir 
  •  
    Oral / IV
    Aciclovir
    Herpex, zovirex 
     
    20% bioavailability; mainly used for HSV and VZV
  •  
    Oral
    Efavirenz

  •  
    Oral
    Tenofovir TAF

  •  
    Oral
    Oseltamivir
    Tamiflu 
  •  
    Oral
    Alprazolam
    Alpraz, Xanax 
     
    Very short half-life – used for panic disorder
    [Peak] 1 hour
    Half-life 6-26 hours
  •  
    Oral / IV / IM
    Diazepam
    Valium 
     
    [Peak] 1-2 hours
    Half-life 20-48 hours
  •  
    Oral
    Citalopram
    Cipramil, Celexa 
     
    First line agent for depression
  •  
    IM / IV
    Midazolam
    Used to induce anaesthesia
  •  
    Oral
    Mirtazapine
    Avanza 
  •  
    Oral / IV
    Sodium Valproate
    Epilim, Valpro 
  •  
    Oral / IV
    Chlorpromazine
    Largactil 
  •  
    Oral
    Carbamazepine
    Tegretol 
  •  
    Oral
    Amitriptyline
    Endep 
  •  
    Oral
    Moclobemide

  •  
    Oral
    Amisulpride
    Solian 
     
    Pure D2/D3 receptor blocker
    Used for patients with predominantly negative symptoms
  •  
    Oral
    Lithium Carbonate
    Lithicarb 
  •  
    Oral
    Desvenlafaxine
    Pristiq 
     
    Some additional inhibition of dopamine reuptake
  •  
    Oral
    Trimethoprim
    Alprim 
  •  
    Oral / IV
    Trimethoprim + Sulfamethoxazole
    Bactrim, Septrin 
  •  
    Oral / IV / PR
    Metronidazole
    Flagyl 
  •  
    Oral / IV
    Flucloxacillin
    Flopen, Fluclox, Staphylex 
  •  
    IV / oral
    Azithromycin
    Zithromax 
  •  
    Oral / IV
    Vancomycin
    May be used in patients allergic to beta lactams
  •  
    Oral / IV
    Clindamycin

  •  
    Oral / IV
    Linezolid

  •  
    Oral
    Cefuroxime
    Useful against Haemophilus influenzae
  •  
    Oral / IV
    Rifampicin
    Rifadin 
  •  
    IM / IV
    Benzylpenicillin (Penicillin G)
    BenPen 
  •  
    IV
    Cefepime
    Useful against Pseudomonas spp.
  •  
    IV
    Cefotaxime

  •  
    Oral
    Amoxycillin-Clavulanate
    Augmentin 
  •  
    IV
    Meropenem
    For severe infections suspected to be resistant to other antibiotics
  •  
    Oral
    Amoxicillin
    Amoxil, alphamox 
  •  
    Oral
    Doxycycline

  •  
    Oral / IV
    Ciprofloxacin
    Cipro 
  •  
    Oral
    Cephalexin
    Keflex 
     
    Alternative to fluclox / diclox in patients hypersensitive to penicillins
  •  
    IV / IM
    Gentamicin

  •  
    IV infusion / IM
    Oxytocin
    Syntocinon 
  •  
    Oral
    Nifedipine
    Adalat 
  •  
    IM
    Ergometrine + Oxytocin
    Syntometrine 
  •  
    MDI / Nebule
    Salbutamol
    Ventolin, Asmol 
  •  
    IV / IM
    Ergometrine

  •  
    IV
    Apheresis Platelets
    Blood is removed, platelets collected and blood returned to patient
  •  
    IV
    Recombinant Factor VIII
    Advate, Kogenate, Xyntha 
  •  
    IV
    Whole Blood Plasma
    Plasma separated from whole blood collection
  •  
    IV
    Recombinant Factor IX
    BeneFIX 
  •  
    IV
    Whole Blood Cryoprecipitate
    Plasma separated from whole blood collection and then cryoprecipitate isolated from plasma
Transfusion of blood products is often a life-saving intervention, however blood products are associated with multiple infective and non-infective complications that patients should be monitored for.
  •  
    IV
    Prothrombinex

  •  
    IV
    Antithrombin-III
    Thrombotrol, Thrombate III 
  •  
    IV
    Factor VIII + Von Willebrand Factor
    Biostate 
  •  
    MDI
    Salmeterol
    Serevent 
  •  
    MDI
    Budesonide / Formoterol
    Symbicort, DuoResp 
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Subcut
    Omalizumab
    Xolair 
  •  
    MDI / Nebule
    Ipratropium Bromide
    Atrovent 
     
    Short-acting – best for acute COPD / asthma
  •  
    Inhaler
    Beclomethasone
    Qvar 
  •  
    MDI / Nebule
    Salbutamol
    Ventolin, Asmol 
  •  
    MDI
    Tiotropium
    Spiriva 
     
    Long-acting – best for COPD maintenance
  •  
    MDI
    Fluticasone / Umeclidinium / Vilanterol
    Trelegy Ellipta 
  •  
    Oral
    Montelukast
    Singulair 
  •  
    Subcut
    Mepolizumab
    Nucala 
  •  
    MDI
    Tiotropium / Olodaterol
    Spiolto Respimat 
  •  
    MDI / Nebule
    Salbutamol
    Ventolin, Asmol 
  •  
    Oral
    Donepezil
    Aricept 
  •  
    Oral / IV
    Sodium Valproate
    Epilim, Valpro 
  •  
    Oral
    Eletriptan
    Relpax 
  •  
    Oral
    Pizotifen
    Sandomigran 
  •  
    IV
    Alemtuzumab
    MabCampath (CLL), LemTrada (MS) 
  •  
    Oral / IV
    Sodium Valproate
    Epilim, Valpro 
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Oral
    Topiramate
    Topamax 
  •  
    Oral
    Propranolol
    Deralin / Inderal 
  •  
    IM / Subcut
    Interferon Beta-1a
    Avonex 
  •  
    Oral
    Amitriptyline
    Endep 
  •  
    Oral
    Ethosuxamide
    Zarontin 
  •  
    Oral
    Fingolimod
    Gilenya 
  •  
    IV
    Natalizumab
    Tysabri 
  •  
    Oral
    Topiramate
    Topamax 
  •  
    Oral / IV / IM
    Diazepam
    Valium 
     
    [Peak] 1-2 hours
    Half-life 20-48 hours
  •  
    Oral / IV
    Phenytoin
    Dilantin 
  •  
    Oral
    Carbamazepine
    Tegretol 
  •  
    Oral
    Pramipexole
    Sifrol 
  •  
    Oral
    Levodopa + Carbidopa
    Sinemet 
  •  
    Oral / IV
    Levetiracetam
    Keppra 
  •  
    Oral / IV
    Paracetamol / Acetaminophen
    Panadol, Tylenol, Dymadon, Panadol Osteo (SR) 
  •  
    Oral / Topical
    Ibuprofen
    Advil / Brufen / Nurofen 
  •  
    Oral / IM
    Promethazine
    Phenergan 
  •  
    IM / Subcut / Nebule
    Adrenaline / Epinephrine
    Used for anaphylaxis
  •  
    Oral
    Cetirizine
    Zyrtec 
There are many varied means for achieving contraception, each of which is associated with a risk of unintended pregnancy. This section lists the efficacy of possible contraceptive methods, both for correct and consistent use as well as the use typically seen.
  •  
    Oral
    Levonorgestrel Emergency Contraceptive
    Levonelle, Postinor, Plan B 
  •  
    IUS
    Levonorgestrel Intra-Uterine Device
    Mirena 
     
    Inserted into the uterus for five years of contraception
    May cause pelvic inflammatory disease and uterine perforation
  •  
    IM
    Methoxyprogesterone Acetate
    Depo-Provera 
     
    Depot injection for 12 weeks of contraception
    Should be given within the first five days of the menstrual cycle
    Causes decreased bone mineral density
  •  
    Subdermal
    Etonogestrel
    Implanon NXT 
     
    Implanted into the upper arm for 3 years of contraception
  •  
    Vaginal
    Ethinyloestradiol + Etonogestrel
    NuvaRing 
  •  
    Oral
    Ethinyloestradiol + Levonorgestrel
    Levlen, Eleanor 
     
    Lower risk of DVT
  •  
    Oral
    Clomiphene Citrate
    Clomhexal, Serophene 
  •  
    Oral
    Levonorgestrel
    Microlut 
  •  
    Oral
    Mifepristone (RU486)
    Given initially to prepare the genitourinary tract
  •  
    IM
    Hydroxocobalamin

  •  
    IV
    5% Dextrose

  •  
    IV / IM
    Physostigmine

  •  
    IV
    N-Acetylcysteine
    Acetadote 
  •  
    IV
    Protamine Sulfate

  •  
    IM
    Desferrioxamine

  •  
    IV
    Fomepizole
    Antizol 
  •  
    IV
    Flumazenil

  •  
    IV / IM
    Glucagon

  •  
    IV
    Naloxone
    Narcan 
  •  
    Oral
    Succimer

  •  
    IV
    Sodium Calcium Edetate

  •  
    Oral / IV
    Phytomenadione
    Konakion 
  •  
    Oral
    Penicillamine

  •  
    IV / IM / Subcut
    Atropine

  •  
    IV / NG
    Ethanol 10%

  •  
    IV
    Sodium Thiosulfate

  •  
    IV
    50% Dextrose

  •  
    Subcut / IV
    Ustekinumab
    Stelara 
  •  
    Oral
    Baricitinib
    Olumiant 
     
    Selective inhibitor of JAK1 and JAK2
  •  
    IV
    Infliximab
    Remicade 
     
    Chimaeric monoclonal antibody to TNF
  •  
    IV
    Basiliximab
    Simulect 
  •  
    IV / Subcut
    Abatacept
    Orencia 
  •  
    IV
    Eculizumab
    Soliris 
  •  
    IV / Subcut
    Rituximab
    Mabthera 
Monoclonal antibodies are named based on standard nomenclature that describes the target and species of origin of the antibody.
  •  
    IV / Subcut
    Tocilizumab
    Actemra 
  •  
    Subcut
    Canakinumab
    Ilaris 
  •  
    IV
    Belimumab
    Benlysta 
  •  
    Subcut
    Anakinra
    Kineret 
  •  
    Subcut
    Secukinumab
    Cosentyx 
  •  
    Subcut
    Omalizumab
    Xolair 
  •  
    Subcut
    Mepolizumab
    Nucala 
  •  
    IV
    Alemtuzumab
    MabCampath (CLL), LemTrada (MS) 
  •  
    Oral / IV
    Cyclophosphamide
    Cyclonex, Endoxan 
  •  
    Oral
    Everolimus
    Certican 
     
    Half-life ~30 hours
  •  
    Oral / IV
    Azathioprine
    Imuran 
  •  
    IV
    Anti-Thymocyte Globulin
    Thymoglobuline 
  •  
    Oral / IV
    Methotrexate
    Weekly dosing
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Oral / IV
    Mycophenolate Mofetil
    CellCept, Myfortic 
  •  
    Oral
    Leflunomide
    Arava 
  •  
    Oral / IV
    Cyclosporin
    Sandimmun, Neoral 
  •  
    IV
    Intravenous Immunoglobulin (IVIg)
    Intragam, Octagam, Privigen, Flebogamma 
  •  
    IV
    3% Sodium Chloride (Hypertonic Saline)

  •  
    IV
    5% Dextrose

  •  
    Oral
    Spironolactone
    Aldactone, Spiractin 
  •  
    Oral
    Oral Potassium Chloride
    Chlorvescent, Slow K, Span K, Duro K 
  •  
    IV
    0.9% Sodium Chloride

  •  
    IV
    20% Albumin

  •  
    Oral
    Calcium Polystyrene Sulfonate
    Resonium 
  •  
    IV
    Compound Sodium Lactate (Hartmanns)

  •  
    Subcut / IV
    Insulin Aspart
    Novorapid 
  •  
    Oral / IV
    Magnesium Sulfate

  •  
    IV
    4% Albumin

Opioids are a group of natural, semi-synthetic and synthetic medications that are used for pain relief. Though opioids can be useful in certain situations, they are associated with adverse effects and a significant risk of dependence.
  •  
    Oral / IV / IM / Subcut / Topical / Epidural
    Fentanyl
    Durogesic patch 
     
    Strong µ receptor selectivity
    Short duration of action, though patches create a reservoir in the skin
  •  
    IV / Oral
    Tramadol
    Tramal 
  •  
    Oral
    Pregabalin
    Lyrica 
  •  
    Oral / IV
    Paracetamol / Acetaminophen
    Panadol, Tylenol, Dymadon, Panadol Osteo (SR) 
  •  
    Oral / Intrathecal
    Baclofen

  •  
    Oral
    Oxycodone
    Endone, Oxycontin (SR) 
     
    Better tolerated than morphine / codeine
  •  
    Oral / Rectal / IV / IM / Subcut
    Morphine
    Kapanol, MS Contin (SR) 
     
    Predominant µ receptor selectivity
    Good absorption but significant first-pass metabolism – bioavailability of 30%
  •  
    Oral
    Gabapentin
    Neurontin 
  •  
    Local / Regional / Epidural
    Bupivacaine
    Marcain 
  •  
    Oral
    Celecoxib
    Celebrex 
  •  
    Oral / Topical
    Ibuprofen
    Advil / Brufen / Nurofen 
  •  
    IV / Subcut
    Abatacept
    Orencia 
  •  
    IV
    Infliximab
    Remicade 
     
    Chimaeric monoclonal antibody to TNF
  •  
    Oral / IV
    Azathioprine
    Imuran 
  •  
    Oral
    Apremilast
    Otezla 
  •  
    Oral / IV
    Cyclosporin
    Sandimmun, Neoral 
  •  
    Oral
    Leflunomide
    Arava 
  •  
    Subcut / IV
    Ustekinumab
    Stelara 
  •  
    IV / Subcut
    Tocilizumab
    Actemra 
  •  
    Oral
    Colchicine
    Colgout 
  •  
    Subcut
    Anakinra
    Kineret 
  •  
    Oral / IV
    Methotrexate
    Weekly dosing
  •  
    IV / Subcut
    Rituximab
    Mabthera 
  •  
    Oral
    Baricitinib
    Olumiant 
     
    Selective inhibitor of JAK1 and JAK2
  •  
    Oral
    Hydroxychloroquine
    Plaquenil 
  •  
    Oral
    Allopurinol
    Zyloprim, Progout 
     
    May be associated with increased cardiovascular risk
  •  
    Oral
    Sulfasalazine
    Salazopyrin 
     
    Not absorbed well – therefore most effective within the gut
  •  
    Oral
    Imatinib
    Glivec 
  •  
    Oral
    Crizotinib
    Xalkori 
  •  
    Oral
    Erlotinib
    Tarceva 
     
    Acneiform rash can be a major concern
  •  
    Oral
    Dabrafenib + Trametinib
    Tafinlar + Mekinist 
  •  
    Oral
    Sorafenib
    Nexavar 
  •  
    Oral
    Vemurafenib
    Zelboraf 
     
    Given as monotherapy or in combination with cobimetinib (MEK inhibitor)
  •  
    Oral
    Olaparib
    Lynparza 
  •  
    Oral
    Ribociclib
    Kisqala 
  •  
    Oral / IM / PR
    Prochlorperazine
    Stemetil 
  •  
    Oral / IV
    Omeprazole
    Losec 
  •  
    Oral / Rectal
    Mesalazine
    Salofalk 
  •  
    Oral / Subling / IM / IV
    Ondansetron
    Zofran 
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Oral
    Magnesium Sulphate
    Epsom Salt 
  •  
    Oral / IV
    Azathioprine
    Imuran 
  •  
    Oral
    Docusate Sodium
    Coloxyl 
     
    Generally combined with Senna
  •  
    Oral
    Psyllium
    Metamucil 
  •  
    Oral / IV
    Methotrexate
    Weekly dosing
  •  
    IV
    Infliximab
    Remicade 
     
    Chimaeric monoclonal antibody to TNF
  •  
    Oral / IM / IV
    Metoclopramide
    Maxolon, Pramin 
     
    Selectively binds D2 receptors
  •  
    Oral
    Sennosides
    Senna 
     
    Generally combined with docusate (coloxyl)
  •  
    Subcut / IV
    Ustekinumab
    Stelara 
  •  
    Oral / IV
    Ranitidine
    Zantac 
  •  
    Oral
    Doxycycline

  •  
    Oral
    Primaquine
    Primacin 
  •  
    Oral
    Mefloquine
    Lariam 
  •  
    Oral
    Artemether + Lumefantrine
    Riamet 
     
    Uncomplicated malarial infection
  •  
    Oral
    Atovaquone + Proguanil
    Malarone 
  •  
    Oral
    Chloroquine

  •  
    Oral / IV / IM
    Quinine
    Quinate 
  •  
    Oral / IV / PR
    Metronidazole
    Flagyl 
  •  
    Oral / IV
    Methotrexate
    Weekly dosing
  •  
    IV
    Actinomycin D / Dactinomycin

  •  
    Oral / IV
    Cyclophosphamide
    Cyclonex, Endoxan 
  •  
    IV
    Cladribine
    Leustatin 
  •  
    IV
    Mitoxantrone

  •  
    IV
    Cytarabine / Cytosine Arabinoside

  •  
    IV
    5-Fluorouracil (5-FU)

  •  
    Oral
    Procarbazine

  •  
    IV
    Carboplatin
    Paraplatin 
  •  
    IV
    Vincristine
    Oncovin 
  •  
    IV
    Irinotecan
    Camptosar 
  •  
    IV
    Dacarbazine

  •  
    IV
    Docetaxel
    Inhibits the cell cycle primarily in S phase
  •  
    IV
    Doxorubicin
    Adriamycin 
  •  
    IV
    Etoposide

  • Equipment Required for Intercostal Catheter Insertion

The Safe Triangle

  • How to Perform

    Using the pen, mark the area bound by the:
  • Superiorly - base of the axilla
  • Anteriorly - lateral edge of pectoralis major
  • Inferiorly - 5th intercostal space
  • Posteriorly - lateral edge of latissimus dorsi

Blockage

  • Clinical Features

  • Catheter is not draining
  • Fluid in the drainage system is not swinging with respiration
  • Pain

Overview

  • Timing

  • Glucose / glucose tolerance testing - fast for 8-10 hours
  • Triglycerides (fasting lipids) - fast for 10-12 hours
  • Equipment Required for Phlebotomy

Troubleshooting

No flashback (not in the vein) - try advancing further or pulling back and inserting slightly medially or laterally

Positioning

Changing from a supine to an upright position can increase haematocrit, red blood cells, white cell count, calcium, thyroxine, AST, ALP, immunoglobulins, total protein, albumin, lipids, adrenaline, noradrenaline and renin levels.

Overview

Find out when the patient took the last dose of the drug in question, and determine the best time to take the blood level.
  • Significance

  • Taking blood from the same limb that a heparin infusion is running into will falsely elevate the APTT.
Apply the tourniquet and feel for a straight, firm, round, elastic, non-pulsatile vein.
  • Clinical Features

  • Red / purple discolouration
  • Swelling
  • Tenderness

Sample Clotting

  • Causes of Sample Clotting

  • Leaving blood sitting for too long before placing them in the correct tubes
  • Inadequate mixing of blood in tube

Overview

Tourniquets are a very useful tool for identifying veins when taking blood or inserting a cannula. However, leaving a tourniquet on for too long can affect the interpretation of blood test results.
  • Effects of Late Testing

  • Ongoing cellular metabolism will occur as specimens are left without being tested.
  • Decreased pO2 and increased pCO2 - due to ongoing metabolism
  • Decreased pH - due to increase in pCO2
  • Decreased calcium - due to increased binding to protein at a lower pH
  • Increased glucose - due to glycolysis
  • Increased lactate - due to glycolysis

Sample Haemolysis

  • Causes of Sample Haemolysis

  • Vigorous mixing of sample
  • Drawing blood from a haematoma
  • Drawing too quickly
  • Using a needle that is too small
  • Forcing the blood into a collection tube using a syringe

Phlebotomy Collection Tubes

  • Order of Draw

  • Blood culture tubes
  • Citrate tube - coags
  • SST tube - chemistry, immunology, serology, blood bank
  • Heparinised tube - lithium level, ammonia level
  • EDTA - haematology, blood bank
  • Acid-citrate-dextrose - HLA typing, paternity testing, DNA studies
  • Glucose inhibitor tube

Stress

  • Effects on Blood Results

  • Transiently elevated white cell count, cortisol and catecholamines
  • Hypocapnia - due to hyperventilation

Overview

Low flow oxygen devices deliver an amount of gas that is less than the patient’s total minute ventilation.
Non-invasive ventilation should occur in an appropriate venue with sufficiently trained staff, such as a respiratory ward, HDU or ICU.
Reservoir systems include a reservoir bag, which allows for oxygen to accumulate between breaths. This allows for a higher concentration of oxygen to be inspired.
Invasive ventilation is performed following either intubation or tracheostomy.
High flow devices deliver an amount of gas that is sufficient to meet the patient’s total minute ventilation, allowing for delivery of a precise amount of oxygen.
Supplemental oxygen is a drug and should be used rationally for specific indications, at the lowest concentration and for the shortest time possible.

Troubleshooting

No flashback - insert the needle slightly deeper or withdraw slightly and reattempt at a slightly different angle
  • No flashback - insert the needle slightly deeper or withdraw slightly and reattempt at a slightly different angle

Overview

  • Clinical Features

  • Pain
  • Pallor
  • Pulselessness
  • Paralysis
  • Paraesthesia
  • Poikilothermia
  • Clinical Features

  • Numbness
  • Paraesthesia
  • Equipment Required for Arterial Line Insertion

  • Clinical Features

  • Erythema
  • Pain / tenderness
  • Warmth
  • Swelling
  • Pus from the site
  • Clinical Features

  • Blood pressure not reading properly
  • Clot in the line
  • Kinking of the line
  • Pain
  • Clinical Features

  • Bruising
  • Active bleeding from the site
When identifying an artery for insertion of an arterial line, place the index and middle fingers over the desired artery and palpate for the area of maximal impulse.
Raise the bed to waist level to allow for comfortable collection.

Indications for Arterial Lines

  • Indications

  • Fluctuant blood pressure
  • Titration of vasoactive infusions
  • Frequent blood testing

Overview

Raise the bed to waist level to allow for comfortable collection.
  • Clinical Features

  • Bruising
  • Active bleeding from the site

Troubleshooting

No flashback - insert the needle slightly deeper or withdraw slightly and reattempt at a slightly different angle

Overview

  • Clinical Features

  • Numbness
  • Paraesthesia
  • Equipment Required for Arterial Blood Gas Collection

  • Clinical Features

  • Pain
  • Pallor
  • Pulselessness
  • Paralysis
  • Paraesthesia
  • Poikilothermia
When looking for an artery, place the index and middle fingers over the desired artery and feel for the area of maximal impulse.
  • Equipment Required for Catheter Insertion

Use of Catheters

  • Indications

  • Bladder drainage - for relief of acute urinary retention or bladder outlet obstruction
  • Prevention of urinary retention due to clots
  • Measurement of urine output
  • Perioperative use - urologic surgery, prolonged surgery, large volumes of intraoperative infusion or diuretics, intraoperative urine output measurement
  • Urine specimen collection in patients who are unable to voluntarily void
  • To assist in the healing of perineal wounds in incontinent patients
  • Instillation of medications into the bladder
  • Indications

  • Bladder drainage - for relief of acute urinary retention or bladder outlet obstruction
  • Prevention of urinary retention due to clots
  • Measurement of urine output
  • Perioperative use - urologic surgery, prolonged surgery, large volumes of intraoperative infusion or diuretics, intraoperative urine output measurement
  • Urine specimen collection in patients who are unable to voluntarily void
  • To assist in the healing of perineal wounds in incontinent patients
  • Instillation of medications into the bladder

Catheter-Associated UTI

  • Clinical Features of Cystitis

  • Burning around the catheter
  • Urge to urinate despite passing urine
  • Lower abdominal pain
  • Cloudy urine
  • Haematuria
  • Foul smelling urine
  • Low grade fevers

Overview

Right internal jugular: 16 - 18cmHeight / 10
Internal jugular vein - identify the vein using ultrasound. Place the probe between the two heads of the sternocleidomastoid and look for a large-bore, non-pulsating, collapsible vessel lateral to the carotid artery.
  • Equipment Required for Central Venous Catheter Insertion

Confirming Venous Placement

Flashback - the flashback from a needle in a vein should be dark red with slow flow. Bright red blood that pulsates indicates arterial catheterisation; the needle should be removed and pressure placed for at least five minutes.

Overview

  • Clinical Features

  • Bruising
  • Active bleeding from the site
  • Clinical Features

  • Pain, swelling, erythema of the upper arm (subclavian line) or leg (femoral line)
  • Symptoms / signs of pulmonary embolism
Internal jugular vein - identify the vein using ultrasound. Place the probe between the two heads of the sternocleidomastoid and look for a large-bore, non-pulsating, collapsible vessel lateral to the carotid artery.
  • Do

  • Think about the future plan for this patient, and whether this site will be needed for any other access
No flashback (not in the vein) - try advancing further or pulling back and inserting slightly medially or laterally
  • Clinical Features

  • Bright red, pulsating blood from the needle
  • Haematoma formation
  • Needle or guidewire in the artery on ultrasound
  • Indications for CVCs

  • Administration of certain medications - high-dose potassium, vasopressors, TPN, certain chemotherapy
  • Haemodynamic monitoring - central venous pressure
  • Difficult peripheral venous access - with need for frequent blood samples
  • Ongoing large transfusion requirement
The Trendelenburg or supine position is best for central venous catheter insertion, in order to avoid air embolisation.

Inserting the Guidewire

Do not forcefully insert the guidewire, as this may damage the guidewire or surrounding structures.

Overview

  • Look For

  • Placement of the CVC in the right atrium or beyond.
  • Clinical Features

  • Unable to flush the line
  • Kinking of the line
  • Pain
  • Clinical Features

  • Erythema
  • Pain / tenderness
  • Warmth
  • Swelling
  • Pus from the site
  • Fevers / systemic features
  • Equipment Required for Nasogastric Tube Insertion

Confirming NG Placement

Instil air - use a syringe to inject air into the NG while auscultating over the epigastrium, listening for a gurgling sound. This should not be used as the sole method of checking placement.

Avoiding Incorrect NG Placement

Oesophageal (i.e. not far enough) - measure the intended insertion length (nose to earlobe to xiphoid process) prior to insertion, and check NG position via pH of aspirate or chest x-ray prior to using the NG.

Difficult NG Insertion

Provide the patient with a cup of water and ask them to take small sips and swallow as you advance the tube

Identifying the Right Site

With the patient in the lateral or sitting position, use the index and middle fingers on either side to palpate the tops of the iliac crests. Once identified, bring the thumbs together into the midline and feel for the intervertebral space - this is L4/L5.

Overview

Lateral position - patient lying in lateral decubitus with lumbar spine flush with edge of the bed and knees drawn upward toward the chest
  • Clinical Features

  • May occur hours or days after LP
  • Headache
  • Nausea / vomiting
  • Dizziness
  • Equipment Required for Lumbar Punctures

CSF collection for lab analysis
  • Prevention

  • Do not perform an LP on a patient with raised intracranial pressure, as this can result in the severe complication of cerebral herniation.
  • Absolute

  • Papilloedema
  • Signs of raised ICP on CT - mass lesion, ventricular compression, midline shift, obstructive hydrocephalus
  • Don’t insert a needle through infected tissue
Lateral position - patient lying on one side with the back at the edge of the bed and knees upward toward the chest

Identifying the Right Site

With the patient in the lateral or sitting position, use the index and middle fingers on either side to palpate the tops of the iliac crests. Once identified, bring the thumbs together into the midline and feel for the intervertebral space - this is L4/L5.

Measuring Opening Pressure

  • How to Measure

  • Attach the manometer with three way tap directly onto the needle.

Troubleshooting

Do not forcefully insert the guidewire, as this may damage the guidewire or surrounding structures.

Overview

  • Equipment Required for PICC Line Insertion

Jugular Placement

  • Look For

  • Placement of the PICC line in the jugular vein on chest xray.

Overview

  • Clinical Features

  • Pain, swelling, erythema of the upper arm
  • Symptoms / signs of pulmonary embolism

Troubleshooting

No flashback (not in the vein) - try advancing further or pulling back and inserting slightly medially or laterally

Overview

  • Clinical Features

  • Inability to flush the line
  • Kinking of the line
  • Pain
The most common sites for PICC line insertion are the cephalic vein (laterally) or basilic vein (medially) within the antecubital fossa or just above.
  • Clinical Features

  • Bruising
  • Active bleeding from the site
  • Clinical Features

  • Erythema
  • Pain / tenderness
  • Warmth
  • Swelling
  • Pus from the site
  • Symptoms / signs of sepsis
  • Clinical Features

  • Erythema
  • Pain / tenderness
  • Warmth
  • Swelling
  • Pus from the site
  • Clinical Features

  • Red / purple discolouration
  • Swelling
  • Tenderness
  • IVC visibly out of the vein
  • Clinical Features

  • Swelling around the site
  • Coolness
  • Pain / tightness
  • Infusion no longer working
  • Clinical Features

  • Infusion not running due to pressure in the line
  • Blood / clot in the line
  • Kinking of the line
  • Pain
  • Clinical Features

  • Erythema
  • Oedema
  • Pain
  • Swelling
  • Tracking along the course of the vein

Troubleshooting

No flashback (not in the vein) - try advancing further or pulling back and inserting slightly medially or laterally

Overview

24 - paediatrics, fragile veins
  • Equipment Required for Inserting IV Cannulas

Potential Cannula Sites

Dorsum of the hand - small veins, and more likely to clot

Overview

  • Equipment Required for Intramuscular Injection

  • Potential Sites for IM Injection

  • Deltoid (1-2mL) - 2-3 finger breadths below the acromian in the mid-axillary lineThe small size of this muscle limits the volume injectable
  • Ventrogluteal (2-3mL) - with the palm over the greater trochanter of the femur, make a V shape with the index and middle finger along the iliac crest then inject within the VThis area has good muscle bulk and a lack of nerves / vessels
  • Dorsogluteal (3-4mL) - in the upper quadrant of the buttock, above and lateral to the imaginary line between the greater trochanter and PSISIt is possible to inject a large volume here, but this has the slowest absorption rate
  • Vastus lateralis (2-3mL) - within the lateral middle third of the thigh

Injection of Incorrect Site

  • Prevention of Subcutaneous Injection

  • Don’t bunch up the skin prior to injection
  • Avoid the dorsogluteal region in obese patients

Pain Associated with Local

  • Strategies for Reducing Pain

  • Warm the solution to 37 degrees prior to injection
  • Buffer the solution with sodium bicarbonate, to increase the pH
  • If injecting a laceration, inject directly into the wound rather than through intact skin
  • Use the finest needle possible
  • Inject slowly - use a small syringe to have greater control over the rate and volume injected

Overview

  • Equipment Required for Local Anaesthetic Injection

Pain Associated with Local

  • Strategies for Reducing Pain

  • Warm the solution to 37 degrees prior to injection
  • Buffer the solution with sodium bicarbonate, to increase the pH
  • If injecting a laceration, inject directly into the wound rather than through intact skin
  • Use the finest needle possible
  • Inject slowly - use a small syringe to have greater control over the rate and volume injected

Overview

  • Equipment Required for Ascitic Taps

Indications for Ascitic Tap

Diagnostic tap - for investigation of new-onset ascites, or for investigation of suspected spontaneous bacterial peritonitis (SBP)

Overview

  • How to Assess

  • If the patient is talking then this suggests that their airway is patent (however, this is not always the case)
  • Look, listen and feel for movement of air
  • Stridor (musical, high-pitched sounds) suggests upper airway obstruction
  • Snoring is a sign of airway compromise
  • Paradoxical abdominal movement is a sign

Bag-Valve-Mask

The bag-valve-mask system is a self-inflating device that is able to deliver high-flow oxygen, expiratory pressure and inspiratory pressure.

Overview

Airway manoeuvres are used to relieve upper airway obstruction, and maintain a patent airway.
Airway adjuncts are used to relieve upper airway obstruction.

Injection of Incorrect Site

  • Prevention of Intramuscular Injection

  • Bunch up the skin prior to injection

Overview

  • Equipment Required for Subcutaneous Injection

Avoid burns, infections, oedema or moles when assessing for a site to inject.
Patients with renal or urological disease may present with a wide variety of symptoms, from alterations in their urine to severe pain or systemic symptoms. Patients with chronic kidney disease pose a wide variety of diagnostic and management issues, which may be further complicated by a history of dialysis or renal transplantation.
Careful history-taking can be used to identify and localise a patient's neurological pathology. By understanding the circumstances and natural history of a neurologic event, it is possible to narrow down the list of likely causes for a patient's presentation.
Haematologic conditions such as leukaemia, lymphoma and the anaemias can be difficult to diagnose. The history is an important first step in this diagnosis, and provides information about the patient's baseline level of function prior to presentation.
A thorough history is valuable in the diagnosis of symptoms such as cough, dyspnoea and chest pain, and can be used to understand a patient's baseline respiratory function.
A thorough history is vital for the diagnosis of patients with issues such as chest pain, heart failure symptoms, palpitations or syncope. The cardiovascular history may also provide important insight into patients' cardiac status, and their risk of future cardiovascular disease in the future.
Gastrointestinal disease can present with a wide variety of symptoms affecting oral intake, the abdomen, bowel motions and the patient's constitution. By taking a thorough history it is possible to narrow down the differential diagnosis and guide clinical examination.
The cranial nerve examination is a complex mix of examination techniques designed to localise pathology to one or more of the twelve cranial nerves. 
Examination of the cardiovascular system is easy to learn but difficult to master. Careful inspection and palpation for peripheral findings, coupled with attentive auscultation of the praecordium, may allow for clinical diagnosis of a patient's cardiac pathology prior to any further investigations.
The urine dipstick is used to assess for a wide variety of renal, urinary tract and systemic pathologies. Using a paper strip containing several reagent-containing squares corresponding to blood, glucose, protein and other analytes, it is possible to gain a significant amount of insight into the cause of a patient’s presentation.
The full blood count provides information about a patient's red cells, white cells and platelets. This may be used for several purposing including diagnosing anaemia, monitoring infection or uncovering haematologic disorders.
The arterial blood gas is useful for assessing a patient's oxygenation, and identify acid-base disorders. This section outlines an approach to interpreting ABGs.
X-rays are commonly used in clinical practice to diagnose fractures. Characteristics of the fracture such as the type, deformity and soft tissue / joint involvement are used to guide management.
Haemolysis is the destruction of red blood cells prior to the end of their normal 120-day lifespan, and should be considered in anaemic patients with risk factors or no obvious cause of anaemia. Serum markers may be used to diagnose haemolysis and suggest a cause.
Iron is an important mineral that is involved in red blood cell metabolism and oxygen transport. Iron studies are used to identify iron deficiency or overload states, and are a common test performed as part of the anaemia screen.
The acute phase response is a facet of the innate immune system that occurs in response to infection, trauma or other insults. Certain mediators, known as acute phase reactants, are increased or decreased in the context of acute inflammation. These markers are commonly measured in clinical practice as indicators of acute illness.
Examining urine under the microscopy reveals the presence of cells, crystals, casts and other findings that can suggest the cause of a patient's renal or urinary complaint.
Venipuncture, or phlebotomy, is the process of collecting blood for testing. This section outlines the process for taking blood, with pitfalls and clinical pearls.
Supplemental oxygen is a drug and should be used rationally for specific indications, at the lowest concentration and for the shortest time possible.
The arterial blood gas is useful in acutely unwell patients for assessing acid-base balance and oxygen status. This section outlines the approach for collecting an ABG.
Urinary catheters are used for a wide variety of indications including to relieve urinary retention, measure urine output and collect urine samples.
Intravenous cannulas are inserted every day into hospitalised patients in order to provide IV fluids and medications. IVCs should be inserted using a no-touch technique and assessed regularly in order to avoid complications.
Several manoeuvres and devices can be used to restore patency in patients with a threatened airway. This page outlines the basic interventions that can be provided in these patients.
Note-taking is a key part of the study process. We use notes to collect, categorise, synthesize and review the large amount of information that we learn in medical school. 
Learning is a constant process during medical school, and we will take in a massive amount of information over a few short years. Before diving in and trying to absorb everything, it is useful to have an understanding of how we learn. This can then guide your note-taking, studying and overall approach to university.
We learn a plethora of information during our time at medical school, and we need to make it stick - both for exams, and for our clinical practice in the future. There are several methods for improving your memory and ensuring that you recall information when required.
Studying is a key part of the medical school experience - whether it is alone or in a group. You’ll be spending plenty of long days or nights in the books, on your laptop or with a plethora of study tools.
Taking notes is a key part of many students’ learning process. If done correctly, they allow you to filter, process and actively learn information, and are a very useful tool when studying. Notes can be returned to multiple times or turned into questions, flashcards or other learning tools.
Left anterior fascicular block occurs due to failure of conduction down the left anterior fascicle.
Myelodysplasia refers to the presence of morphologically and functionally abnormal blood cells. 

Manifestations

  • Clinical Signs

  • Calcinosis cutis: hard masses beneath the skin, due to calcium deposition
  • Raynaud’s phenomenon: areas of white, blue or red change in the hands
  • Sclerodactyly: thickening of the fingers / toes
  • Telangiectasia: visible dilated blood vessels
  • Reduced oral aperture
  • Nailfold abnormalities
  • Tendon friction rubs (severe disease)

Overview

Digoxin is a cardiac glycoside which can be associated with significant toxicity. Certain ECG findings are characteristic.
Nonthyroidal illness (also known as sick euthyroid syndrome) is an adaptive response of the thyroid to acute of chronic illness.
Metabolic acidosis is a process in which an external agent or internal process is causing excessive acidity in a way that is metabolic (i.e. non-respiratory).

Pathogenesis

  • Causes of Hypomagnesaemia

  • Reduced intake - malnutrition, TPN
  • Urinary loss - acute tubular necrosis (polyuric phase), postobstructive diuresis, loop / thiazide diuretics, ACE inhibitors, renal tubular acidosis, aminoglycoside toxicity, hypercalcaemia, genetic tubular defects
  • GI loss - diarrhoea, laxative abuse, malabsorption, vomiting, NG aspirates, GI fistula, short bowel syndrome, long-term PPI use
  • Compartmental shift - refeeding syndrome, hyperparathyroidism, hyperthyroidism, acute pancreatitis, hungry bone syndrome

Overview

Atelectasis refers to alveolar volume loss resulting in collapse of a portion of the lung.

Diagnosis

  • Signs of Psoriatic Arthritis

  • General Signs

  • Symmetric polyarthritis affecting digits as a whole (rather than in rays of digits)
  • Nail changes - onycholysis, pitting, crumbling of the nail plate
  • Psoriatic plaques - particularly on the extensor surfaces of joints, scalp, periumbilicus, skin folds
  • Dactylitis: ‘sausage-like’ digits due to synovitis of each joint
  • Enthesitis: inflammation of a tendon insertion; affecting the Achilles tendon or the plantar fascia
  • Evidence of sacroiliitis - tender sacroiliac joints
  • Signs of Complications

  • Evidence of iritis - painful, erythematous eye

Overview

When the right bundle branch and the left bundle branch (or both left-sided fascicles) are blocked, complete heart block occurs. However, several patterns suggest ‘incomplete' or ‘impending' trifascicular block.

Diagnosis

  • Signs of Osteoarthritis

  • Muscle wasting
  • Evidence of active arthritis - swelling, erythema, tenderness
  • Reduced joint range of motion
  • Heberden’s nodes: firm swelling over the distal interphalangeal joints
  • Bouchard’s nodes: firm swelling over the proximal interphalangeal joints
  • Varus knee deformity

Overview

Hypertrophic Cardiomyopathy (HCM) is a disorder that  causes left ventricular hypertrophy (particularly of the interventricular septum), which may be obstructive or non-obstructive.
Ventricular fibrillation is a chaotic ventricular rhythm that is not compatible with haemodynamic stability.
Focal atrial tachycardia is a rapid atrial rhythm originating from a single atrial focus.
Marfan syndrome occurs due to one of many mutations in the gene encoding the extracellular matrix protein fibrillin 1.
Vitamin B12, also known as cobalamin, is an important cofactor in the homocysteine metabolism, haemoglobin synthesis and myelination.

Pathogenesis

  • Causes of Pleural Effusion

  • Exudative

  • Malignancy
  • Infection - parapneumonic effusion, empyema, viral, fungal, TB, ruptured abscess / cyst
  • Pulmonary embolism (90% exudative)
  • Autoimmune disease - rheumatoid pleuritis, SLE
  • Pancreatitis
  • Haemothorax
  • Chylothorax
  • Asbestosis
  • Uraemia
  • Oesophageal rupture
  • Transudative

  • Heart failure
  • Cirrhosis
  • Hypoalbuminaemia
  • Nephrotic syndrome
  • Pulmonary embolism (10% transudative)
  • Myxoedema
  • Meig’s syndrome
  • Constrictive pericarditis
  • SVC obstruction
  • Urinothorax

Overview

Most hepatitis A assays measure both IgM and IgG levels.
Respiratory acidosis is a process by which reduced effective ventilation results in carbon dioxide retention.
Vitamin B12, also known as cobalamin, is an important cofactor in the homocysteine metabolism, haemoglobin synthesis and myelination.
Hypernatraemia is a serum sodium concentration >145mmol/L. This may be caused by losing water, gaining salt or by redistribution of water within the body.

Pathogenesis

  • Causes of Hyperphosphataemia

  • Excessive Phosphate Intake / Production

  • Phosphate replacement
  • Rhabdomyolysis
  • Tumour lysis syndrome
  • Reduced Excretion

  • Renal failure - acute or chronic
  • Hypoparathyroidism
  • Vitamin D deficiency
  • Bisphosphonates
  • Osteoblastic metastases

Overview

Down syndrome occurs as a result of trisomy 21, or three copies of chromosome 21.
AV reentrant tachycardias occur when an atrial impulse is conducted through an accessory pathway - either retrogradely following AV conduction (orthodromic) or anterogradely (antidromic).
Atrioventricular (AV) block occurs due to delayed conduction of an impulse between the atria or ventricles, due to intrinsic or extrinsic causes.
Peptic ulcer disease is a common condition where ulcers may form in the stomach or duodenum. This may be as a result of Helicobacter pylori infection, medications, stress or dietary factors.
Hypothyroidism refers to underactivity of the thyroid, with reduced circulating thyroid hormones. This is usually accompanied by typical signs and symptoms of hypothyroidism.
Hypokalaemia, or a reduced serum potassium concentration of <3.5mmol/L, is associated with hyperpolarisation of cardiac myocytes. If severe, hypokalaemia causes abnormal ventricular automaticity which may result in ventricular arrhythmias.
Multiple myeloma is a plasma cell neoplasm: a condition involving clonal expansion of plasma cells that secrete paraprotein or free light chains.

Pathogenesis

  • Causes of Pneumothorax

  • Primary Spontaneous Pneumothorax

  • Idiopathic (ruptured pleural bleb / bulla)
  • Secondary Spontaneous Pneumothorax

  • Connective tissue disease - Marfan syndrome, Ehlers-Danlos syndrome, rheumatoid arthritis, scleroderma, ankylosing spondylitis, dermatopolymyositis
  • Airway disease - emphysema (bullous rupture), cystic fibrosis, severe asthma
  • Infections - PJP pneumonia, tuberculosis, necrotising pneumonia
  • Interstitial lung disease
  • Lung cancer
  • Thoracic endometriosis
  • Non-Spontaneous

  • Traumatic - blunt, penetrating
  • Iatrogenic - CVC placement, transthoracic procedures, mechanical ventilation
  • Causes of Ventricular Septal Defect

  • Congenital - associated with Down syndrome
  • Acquired - septal myocardial infarction, iatrogenic

Overview

Left posterior fascicular block occurs due to failure of conduction down the left posterior fascicle.
A patent ductus arteriosus is the persistence post birth of a blood vessel connecting the pulmonary artery and the aorta.
Pulmonary embolism is the complete or partial obstruction of the pulmonary arterial system due to an embolus, most commonly as a complication of lower limb deep venous thrombosis.
Sick sinus syndrome (SSS) occurs when the sinus node is not functioning correctly, due to either intrinsic or extrinsic causes.
Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited disorder in which there is fibro-fatty replacement of the right ventricular myocardium. The condition is the second most common of sudden cardiac death in young people.
Right heart failure typically manifests with peripheral overload - resulting in findings such as a raised JVP, peripheral oedema, pleural effusions and ascites.

Pathogenesis

  • Causes of Pulmonary Oedema

  • Cardiogenic

  • Heart failure
  • Fluid overload
  • Renal failure
  • Transfusion-associated circulatory overload (TACO)
  • Non-Cardiogenic

  • Acute respiratory distress syndrome
  • Pulmonary embolism
  • Re-expansion pulmonary oedema (e.g. with drainage of a pleural effusion or pneumothorax)
  • Neurogenic pulmonary oedema
  • Transfusion-related acute lung injury (TRALI)
  • High altitude pulmonary oedema (HAPE)

Overview

Atrial flutter is most commonly due to a right atrial macro-reentrant circuit, and has significant crossover with atrial fibrillation in its pathogenesis.
Gastroesophageal reflux disease is a condition in which there is incompetence of the lower oesophageal sphincter, resulting in reflux of gastric acid.

Pathogenesis

  • Risk Factors for Ischaemic Heart Disease

  • Family history of ischaemic heart disease
  • Advanced age
  • Smoking
  • Hypertension
  • Hyperlipidaemia
  • Diabetes mellitus
  • Physical inactivity
  • Obesity

Overview

Tuberculosis is the disease caused by the bacteria Mycobacterium tuberculosis, and may affect almost any organ in the body resulting in a wide range of clinical presentations.
Several hereditary conditions are associated with a prolonged QT interval, which increases the risk of life-threatening arrhythmia.
Brugada syndrome is an inherited condition that strongly predisposes to sudden cardiac death. The condition is autosomal dominant in inheritance and involves a loss of function mutation in sodium channels, predominantly affecting the right ventricle.
  • Types of Lung Cancer

  • Non-Small Cell Lung Cancer - adenocarcinoma, squamous cell carcinoma, large cell carcinoma
  • Small Cell Lung Cancer
Pulmonary hypertension refers to a heterogeneous and functionally limiting group of disorders that result in increased pressure within the pulmonary arteries.
Monomorphic VT is a focal or reentrant ventricular rhythm that requires rapid assessment and management, due to its risk of haemodynamic instability and collapse.
Turner syndrome occurs secondary to monosomy X, where all or part of an X chromosome is missing, or due to duplication of the long arm of one X chromosome.
Sinus tachycardia originates from the sinus node and is a physiologic response that occurs due to changes in autonomic regulation - either sympathetic activation or reduction in parasympathetic tone.

Pathogenesis

  • Causes of Mitral Stenosis

  • Rheumatic heart disease
  • Congenital mitral stenosis
  • Mitral annular calcification

Overview

Thyrotoxicosis refers to hyperactivity of the thyroid gland, with increased circulating thyroid hormones. This tends to be accompanied by typical signs and symptoms of thyrotoxicosis such as those listed below.

Pathogenesis

  • Causes of Aortic Regurgitation

  • Acute

  • Infective endocarditis
  • Dissecting aneurysm
  • Hypertension
  • Trauma
  • Chronic

  • Rheumatic heart disease
  • Congenital bicuspid aortic valve
  • Ankylosing spondylitis
  • Marfan syndrome / Ehlers-Danlos syndrome
  • Aortitis

Overview

Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac pre-excitation syndrome that occurs due to the presence of an accessory conduction pathway.
Multifocal atrial tachycardia is an irregular rhythm that occurs due to multiple atrial ectopic foci.
Bifascicular block occurs when there is failure of conduction down the right bundle branch as well as either the left anterior or left posterior fascicle.
  • Ask About

  • Diagnosis - cause (if known), when diagnosed
  • Manifestations - cirrhosis, lichen planus, cryoglobulinaemia, glomerulonephropathy
  • Management - direct acting antivirals, surveillance
  • Classification

    Based on body mass index (BMI)
  • Underweight - <18.5
  • Normal - 18.5 - 24.9
  • Overweight - 25 - 29.9
  • Obese - 30 - 34.9
  • Severely obese - 35 - 39.9
  • Morbidly obese - 40+
AV nodal reentrant tachcardia (AVNRT) is the most common type of paroxysmal supraventricular tachycardia (pSVT), and occurs due to a reentrant loop within the AV node.
Chronic obstructive pulmonary disease is a severely functionally limiting condition primarily affecting previous tobacco smokers. Management is targeted to the severity of the disease, and underpinned by smoking cessation.
Beta thalassaemia is an inherited defect in beta globin chains of haemoglobin, resulting in defective haemoglobin synthesis.

Diagnosis

  • Signs of Chronic Inflammatory Demyelinating Polyneuropathy

  • Foot drop
  • Symmetrical lower motor neuron weakness - distal predominance affecting the upper limb more than the lower limb
  • Sensory loss distally (glove and stocking distribution)

Overview

Chronic liver disease is a common condition most often caused by alcohol, fatty liver disease or viral hepatitis. This condition can be difficult to diagnose, and the examination is crucial for identifying evidence of portal hypertension, oestrogen excess encephalopathy and other complications of cirrhosis.

Pathogenesis

  • Risk Factors for Rheumatoid Arthritis

  • Female sex
  • Family history of rheumatoid arthritis
  • Infections - EBV, CMV, E coli, periodontal disease (Porphyromonas gingivalis)
  • Smoking

Overview

Hypophosphataemia refers to a reduced serum phosphate concentration of <0.8 mmol/L. This may occur in the context of reduced intake, compartmental shift or increased excretion of phosphate.
Sinus bradycardia is initiated by the sinus node, and occurs in the setting of reduced automaticity due to either intrinsic or extrinsic causes.

Pathogenesis

  • Risk Factors

  • Male gender
  • Obesity
  • Chronic kidney disease
  • Drugs - diuretics, ethambutol, certain chemotherapeutic agents
  • Excess purine-rich foods - beer, shellfish, liver, marmite
  • Excess sucrose / fructose intake
  • Alcohol excess

Overview

Sinoatrial exit block is a delay in conduction between the sinoatrial node and atrial myocardium.
Hyponatraemia is an imbalance between sodium and water balance in the body, producing a reduced serum sodium concentration of <135 mmol/L.
Sickle cell anaemia is an inherited disorder affecting haemoglobin synthesis, resulting in 'sickling' of red blood cells and resultant complications.
Iron deficiency may occur due to poor intake, poor absorption or loss of iron. The most common complication of iron deficiency is anaemia, which presents as a microcytic, hypochromic anaemia.

Pathogenesis

  • Causes of Myotonia

  • Myotonic Dystrophy

  • Dystrophia myotonia
  • Myotonia congenita
  • Non-Dystrophic Myotonia

  • Paramyotonia congenita
  • Acid maltase deficiency

Overview

  • Ask About

  • Diagnosis - cause (if known), when diagnosed
  • Manifestations - cirrhosis, polyarteritis nodosa, membranous glomerulonephropathy
  • Management - antivirals, surveillance
Right bundle branch block occurs due to failure of conduction down the right bundle, resulting in slowed right ventricular depolarisation.
Folate, also known as vitamin B9, is an important coenzyme in DNA and amino acid metabolism pathways.
  • Ask About

  • Diagnosis - when the diagnosis was made
  • Manifestations - tremor, bradykinesia, rigidity, postural instability
  • Management - dopamine replacement, MAO-B inhibitors, COMT inhibitors
Hypocalcaemia, or a reduced serum calcium concentration >2.15 mmol/L, prolongs action potentials which primarily results in delayed ventricular repolarisation (prolonged QT) on ECG.
  • Chest X-Ray Signs of Pneumonia

  • Pulmonary consolidation without volume loss - may be lobar (lobar pneumonia) or multifocal
  • Air bronchograms - tubular outlines of the smaller airways
  • Silhouette signs - obliteration of normally clear outlines between lung fields and adjacent structures
Catacholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited disorder that occurs due to mutations in the ryanodine receptor, affecting calcium release from the sarcoplasmic reticulum.
The anaemia of chronic disease is a common condition that is associated with chronic infection, inflammation or malignancy where patients develop a non-specific anaemia.

Pathogenesis

  • Causes of Aortic Stenosis

  • Calcific degeneration
  • Rheumatic heart disease
  • Congenital bicuspid aortic valve
  • Infective endocarditis

Overview

Left bundle branch block occurs due to failure of conduction down the left bundle branch, resulting in depolarisation of the left ventricle after the right ventricle.
Sinus arrest is the temporary interruption of sinoatrial node automaticity, that may occur due to intrinsic or extrinsic factors affecting the sinoatrial node.
Alpha thalassaemia is an inherited condition affecting the alpha chains of haemoglobin, resulting in defective haemoglobin synthesis.
  • Classification

    Hypertension is defined as persistently elevated blood pressure, based on at least two readings over at least two visits.
  • Normal <120 / 80
  • Pre-hypertension 120 / 80 - 139 / 89
  • Stage I hypertension 140 / 90 - 159 / 99
  • Stage II hypertension >160 / 100
Heart failure can be functionally debilitating, though proper management can have a significant positive effect on a patient's mortality risk and quality of life.
Atrial fibrillation is an often insidious condition involving irregular contraction of the ventricles due to fibrillation of the atria. If not properly managed this condition can result in significant complications including cardioembolic stroke.
Hypercalcaemia, or an increased serum calcium concentration >2.60 mmol/L, shortens action potentials which primarily results in early ventricular repolarisation (shortened QT) on ECG.

Pathogenesis

  • Causes of Tricuspid Regurgitation

  • Rheumatic heart disease
  • Infective endocarditis (particularly associated with IV drug use)
  • Ebstein’s anomaly
  • Carcinoid syndrome
  • Trauma
  • Causes of Mitral Regurgitation

  • Acute

  • Acute myocardial infarction
  • Infective endocarditis
  • Trauma
  • Chronic

  • Mitral annular calcification
  • Mitral valve prolapse
  • Rheumatic heart disease
  • Papillary muscle dysfunction
  • Connective tissue disease - systemic lupus erythematosus, rheumatoid arthritis

Overview

Left heart failure typically manifests with interstitial and pulmonary oedema, and is most commonly caused by pathology affecting the left ventricular myocardium.
  • Conditions Associated with Physical Inactivity

  • Obesity
  • Type 2 diabetes mellitus
  • Dyslipidaemia
  • Ischaemic heart disease
  • Stroke
  • Cancers - especially colorectal and breast
  • Significance

  • Travel to certain countries is associated with increased infection risk, especially with organisms rarely seen in developed countries.
  • Long plane journeys are associated with increased risk of DVT.
  • For Each Procedure

  • Timing - when they had the procedure
  • Surgeon - who performed the procedure
  • Indication - why the procedure was performed, and what symptoms they were experiencing prior
  • Complications - whether the surgery resulted in any undesired effects, such as infection, bleeding or pain
  • Follow up - whether they continue to see their surgeon
  • Ask About

  • Medical conditions
  • Recent hospital admissions
  • Admissions to the intensive care unit

IV Drug Use

  • Ask About

  • What drug they inject
  • Where they get their needles from
  • Whether they have tried to quit
  • How they tried to quit - methadone / suboxone program, cold turkey

Overview

  • Significance

  • Without support, patients who are unable to perform their activities of daily living are at risk of living in squalor and of significant deterioration in health.
  • Ask About

  • Everyone

  • Whether the patient currently smokes or has smoked
  • What age they started smoking
  • How many years they smoked in total
  • How many cigarettes per day
  • Heavy Smokers

  • Past attempts to quit
  • Length they were able to quit for
  • Cravings between cigarettes
  • Aids used in attempting to quit - nicotine gum / patches, champix
  • Willingness to cut down or stop
  • Ask About

  • Steadiness - how steady the patient feels on their feet with or without mobility aids
  • Walking aids - whether the patient requires any aids to mobilise, such as a walking stick, 4-wheel walker or rollator frame
  • Transfers - whether the patient can transfer from bed to chair or chair to toilet independently, with assistance, or if they require hoist transfers
  • Stairs - whether the patient is able to climb stairs independently
  • Modifications - whether the patient has had anything added onto their home, such as ramps or toilet / shower rails
  • Common Allergens

  • Pollens - grass, tree, weed
  • Spores
  • Animals - cats, dogs, small pets, birds, horses, cockroaches
  • Food - peanuts, tree nuts, legumes, seafood, soy, fruits, eggs, wheat
  • Drugs - antibiotics, NSAIDs, ACEi, oestrogens, contrast, anaesthetic drugs
  • Venom - bees, wasps
  • Latex
  • Specific Conditions to Ask About

  • Heart disease
  • Stroke
  • Autoimmune conditions
  • Cancers
  • Ask About

  • Any medications the patient is on
  • What pharmacy they get their medications from
  • Whether they use any dosing aids, such as a Webster pack
  • Significance

  • Generally, avoid the drug in question
  • Not all adverse drug reactions are absolute contraindications - e.g. many medications cause nausea / vomiting
  • Not all adverse drug reactions are true - they may be misinterpretations
  • Ask About

  • Everyone

  • Whether they drink alcohol regularly
  • How often - daily, weekly, monthly, or on social occasions only
  • What type of alcohol they drink
  • How many drinks on each occasion / each day
  • The most they drink at any given time
  • Where they drink - restaurants, bars, parties, at home
  • Amount spent on alcohol
  • Heavy Drinkers

  • Withdrawal symptoms - sweating, rigors, nausea, past seizures
  • Alcohol free days
  • Past attempts to quit drinking
  • Willingness to cut down or stop

Diagnosis

  • Causes of Chronic Kidney Disease

  • Diabetic nephropathy
  • Hypertensive nephropathy
  • Glomerulonephritis
  • Tubulointerstitial disease - analgesic nephropathy, reflux nephropathy
  • Congenital disease - polycystic kidney disease

Overview

  • Dialysis Modalities

  • Home haemodialysis
  • In-centre haemodialysis
  • Continuous ambulatory peritoneal dialysis (CAPD)
  • Automated peritoneal dialysis (APD)
  • Ask About

  • Pretransplant history - cause and complications of CKD, dialysis, past transplant, medical and social considerations
  • Peritransplant history - timing, indication, donor
  • Complications - past rejection episodes, infections, cardiovascular, metabolic, malignancy
  • Post-transplant management - immunosuppression, infective prophylaxis, osteoporosis prophylaxis, cancer screening
  • Clinical Phenotypes of Multiple Sclerosis

  • Clinically isolated syndrome - a single episode of symptoms
  • Relapsing-remitting - relapses with improvement between episodes
  • Primary progressive - progression without relapses
  • Secondary progressive - progressive disability with fewer relapses and no return to baseline between episodes

Differential Diagnosis

  • Causes of Parkinsonism

  • Parkinson’s disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
  • Parkinson’s Plus Syndromes

  • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
  • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
  • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
  • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
  • Others

  • Drugs - antipsychotics, metoclopramide, lithium
  • Normal pressure hydrocephalus
  • Hypoxic brain injury
  • Wilson’s disease

Overview

  • Causes of Epilepsy

  • Genetic
  • Trauma - open or closed head injury, neurosurgery
  • Cerebrovascular - haemorrhage, ischaemia, arteriovenous malformation
  • Malignancy - glioma, meningioma, metastasis
  • CNS infection - meningitis, encephalitis, malaria, tuberculosis
  • Autoimmune - systemic lupus erythematosus
  • Degeneration - Alzheimer’s, multiple sclerosis
  • Idiopathic
  • Clinial Phenotypes of Motor Neuron Disease

  • Amyotrophic lateral sclerosis (ALS) - mixed upper and lower motor neuron involvement
  • Primary lateral sclerosis - mainly upper motor neuron involvement
  • Progressive muscular atrophy - mainly lower motor neuron involvement
  • Progressive bulbar palsy - mainly bulbar involvement

Manifestations

  • Manifestations of Myaesthenia Gravis

  • Fatiguing muscle weakness (worse with use and improved with rest) affecting the eyes, face, oropharynx, trunk and limbs
  • Myaesthenic crisis (respiratory failure)

Overview

  • Pearls

  • Warfarin is initially procoagulant in the first few days of its use, due to its inhibition of natural anticoagulants protein C and protein S.
  • Though tranexamic acid is a procoagulant, there is very little evidence that it increases thrombosis risk in a statistically significant way.
Allogeneic stem cell transplants are associated with a high risk of complications and mortality, and require long-term immunosuppression.
  • Ask About

  • Peritransplant history - when the transplant was done, indication, mobilisation, conditioning
  • Complications
  • Post-transplant management - infective prophylaxis
  • Prognosis
  • Causes of Bronchiectasis

  • Congenital

  • Cystic fibrosis
  • Primary ciliary dyskinesia (e.g. Kartegener’s syndrome)
  • Hypogammaglobulinaemia
  • Acquired

  • Recurrent pneumonia (e.g. in the setting of immunosuppression) - bacterial, tuberculous, fungal
  • Chronic obstructive pulmonary disease (COPD)
  • Allergic bronchopulmonary aspergillosis (ABPA)
  • Autoimmune diseases - rheumatoid arthritis, Sjogren’s syndrome, ulcerative colitis
  • Chronic aspiration (e.g. secondary to gastroesophageal reflux)
  • Airway foreign body

History of Presenting Complaint

  • Site  

    Where the pain is - central, the left or right side, the ribs, or generalised.
  • Retrosternal chest painReflux, angina
  • Pain in chest wall / ribs - unlikely to be anginalSuggestive of a musculoskeletal cause

Overview

  • Causes of Interstitial Lung Disease

  • ILD of Known Association

  • Connective tissue disease - rheumatoid arthritis, scleroderma, systemic lupus erythematosus, Sjogren’s syndrome, polymyositis / dermatomyositis
  • Medications - methotrexate, nitrofurantoin, bleomycin
  • Occupational exposure - silicosis, asbestosis
  • Granulomatous ILD

  • Sarcoidosis
  • Hypersensitivity pneumonitis
  • Idiopathic Interstitial Pneumonias

  • Idiopathic pulmonary fibrosis
  • Others - idiopathic non-specific interstitial pneumonia, acute interstitial pneumonia, cryptogenic organising pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia
  • Risk Factors for Lung Cancer

  • Genetic factors
  • Smoking (active or passive)
  • Air pollution
  • Occupational exposure - asbestosis, silicosis,
  • Chronic scarring - interstitial lung disease, tuberculosis, COPD
  • Alcohol
  • Conditions Associated with Physical Inactivity

  • Obesity
  • Type 2 diabetes mellitus
  • Dyslipidaemia
  • Ischaemic heart disease
  • Stroke
  • Cancers - especially colorectal and breast
  • Ask About

  • Diagnosis - when asthma was diagnosed, risk factors, triggers
  • Severity - symptoms, FEV1, exacerbations
  • Management - lifestyle, pharmacologic, supportive
  • Complications
  • Ask About

  • Everyone

  • Whether the patient currently smokes or has smoked
  • What age they started smoking
  • How many years they smoked in total
  • How many cigarettes per day
  • Heavy Smokers

  • Past attempts to quit
  • Length they were able to quit for
  • Cravings between cigarettes
  • Aids used in attempting to quit - nicotine gum / patches, champix
  • Willingness to cut down or stop
  • Significance

  • Travel to certain countries is associated with increased infection risk, especially with organisms rarely seen in developed countries.
  • Long plane journeys are associated with increased risk of DVT.
  • Risk Factors for Obstructive Sleep Apnoea

  • Obesity
  • Male gender
  • Craniofacial abnormalities - retrognathia
  • Upper airway narrowing - enlarged tonsils, macroglossia, narrow nasal cavity
  • Alcohol excess
  • Smoking
  • Ask About

  • Diagnosis - symptoms, affected organs, how TB was diagnosed
  • Risk factors - immunosuppression, alcohol, malnutrition, diabetes
  • Travel history - immigrant status, recent travel
  • Management - which medications over how long
  • Public health implications - exposure to contacts, family
  • Ask About

  • Diagnosis - when their COPD was diagnosed, risk factors
  • Severity - symptoms, FEV1, exacerbations
  • Management - lifestyle, pharmacologic, supportive, surgical
  • Complications - respiratory, cardiovascular, haematologic

Complications

  • Complications of Cystic Fibrosis

  • Respiratory

  • Bronchiectasis
  • Respiratory infections
  • Sinusitis
  • Pancreatic

  • Exocrine - fat malabsorption, malnutrition, vitamin A/D/E/K deficiency
  • Endocrine - diabetes mellitus
  • Pancreatitis
  • Gastrointestinal

  • Meconium ileus
  • Distal intestinal obstruction syndrome (DIOS)
  • Gastroesophageal reflux
  • Biliary cirrhosis
  • Malnutrition
  • Musculoskeletal

  • Arthropathy
  • Osteoporosis
  • Reproductive

  • Infertility - congenital absence of vas deferens, thick cervical mucus
  • Risk of transmission to children
  • Other

  • Significant functional impact
  • Depression

Overview

  • Risk Factors for Pulmonary Embolism

  • Genetic Predisposition

  • Inherited hypercoagulability - protein C or S deficiency, factor V Leiden, prothrombin gene mutation, sickle cell disease, hyperhomocysteinaemia, antithrombin III deficiency
  • Family history of VTE
  • Patient  Factors

  • Advanced age
  • Past history of VTE
  • Acquired hypercoagulability - antiphospholipid syndrome, hyperviscosity, PNH, TTP, HITS
  • May-Thurner syndrome (anatomical variant where the right common iliac artery overlies and compresses the left common iliac vein)
  • Malignancy
  • Hormonal therapy - oestrogen-containing oral contraceptives, hormone replacement, SERMs
  • Venous pathology - varicose veins, superficial vein thrombosis
  • Environmental Triggers

  • Trauma
  • Surgery - particularly hip / knee surgery or major surgery
  • Pregnancy / peripartum period
  • Continuous immobilisation >72 hours - bedrest, neurologic pathology, cast
  • Hospital or nursing home admission
  • Long-distance travel (air, land or sea)
  • Sources of Medication Lists

  • It is often best to derive your list from at least two sources, especially when there is doubt.
  • The patient - sometimes patients present with a useful list of their medications
  • Collateral - from family or friends
  • Medication boxes - often patients present with their medications; ask if there are any missing
  • The patient's file - especially discharge summaries
  • Other hospitals - especially discharge summaries or transfer letters
  • The patient's GP
  • The patient's pharmacy
  • Ask About

  • Diagnosis - when heart failure was diagnosed, symptoms, cause
  • Severity - exercise tolerance / NYHA class, ejection fraction
  • Functional impact of disease
  • Management - non-pharmacologic, pharmacologic, devices
  • Complications - arrhythmias, peripheral oedema, pulmonary oedema, pulmonary hypertension
  • Sources of Medication Lists

  • It is often best to derive your list from at least two sources, especially when there is doubt.
  • The patient - sometimes patients present with a useful list of their medications
  • Collateral - from family or friends
  • Medication boxes - often patients present with their medications; ask if there are any missing
  • The patient's file - especially discharge summaries
  • Other hospitals - especially discharge summaries or transfer letters
  • The patient's GP
  • The patient's pharmacy
  • Ask About

  • Everyone

  • Whether the patient currently smokes or has smoked
  • What age they started smoking
  • How many years they smoked in total
  • How many cigarettes per day
  • Heavy Smokers

  • Past attempts to quit
  • Length they were able to quit for
  • Cravings between cigarettes
  • Aids used in attempting to quit - nicotine gum / patches, champix
  • Willingness to cut down or stop
  • Classification

    Hypertension is defined as persistently elevated blood pressure, based on at least two readings over at least two visits.
  • Normal <120 / 80
  • Pre-hypertension 120 / 80 - 139 / 89
  • Stage I hypertension 140 / 90 - 159 / 99
  • Stage II hypertension >160 / 100
  • Classification

  • Based on body mass index (BMI)

  • Underweight - <18.5
  • Normal - 18.5 - 24.9
  • Overweight - 25 - 29.9
  • Obese - 30 - 34.9
  • Severely obese - 35 - 39.9
  • Morbidly obese - 40+

IV Drug Use

  • Ask About

  • What drug they inject
  • Where they get their needles from
  • Whether they have tried to quit
  • How they tried to quit - methadone / suboxone program, cold turkey

Overview

In the context of the cardiovascular history, alcohol is an important risk factor for hypertension and dilated cardiomyopathy; it is also a precipitant for atrial fibrillation.
  • Causes of Pulmonary Hypertension

  • Type 1: Pulmonary Arterial Hypertension

  • Idiopathic
  • Inherited
  • Drugs / toxins
  • HIV-related
  • Connective tissue disease - scleroderma, mixed connective tissue disease
  • Portopulmonary hypertension
  • Congenital heart disease
  • Schistosomiasis
  • Type 2: Left Heart Disease

  • Left ventricular systolic / diastolic dysfunction
  • Valvular disease - aortic stenosis, aortic regurgitation, mitral stenosis
  • Type 3: Lung Disease

  • Chronic obstruction pulmonary disease
  • Interstitial lung disease
  • Mixed lung disease
  • Sleep-disordered breathing
  • Alveolar hypoventilation
  • Type 4: Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

  • Chronic pulmonary emboli
  • Type 5: Other

  • Haematologic - chronic haemolytic anaemia, myeloproliferative disorders, splenectomy
  • Systemic - sarcoidosis, pulmonary histiocytosis, lymphangioleiomyomatosis
  • Metabolic - glycogen storage disorders, Gaucher disease
  • Other - tumour obstruction, chronic kidney disease
  • Ask About

  • Diagnosis - when diagnosed, presentation
  • Past myocardial infarction
  • Family history of ischaemic heart disease
  • Severity - exercise tolerance, stress test results, echo results, angiogram results
  • Management - revascularisation, risk factor management, CABG
  • Complications - particularly heart failure
  • Ask About

  • Diagnosis - when diagnosed, persistence
  • Management - previous DC cardioversion, rate / rhythm control, anticoagulation
  • Complications - past stroke, heart failure
  • Causes of Hyperlipidaemia

  • Primary

  • Familial lipoprotein lipase deficiency
  • Familial hypercholestolaemia
  • Familial combined hyperlipidaemia
  • Familial dysbetalipoproteinaemia
  • Familial hypertriglyceridaemia
  • Secondary: Predominantly LDL

  • Hypothyroidism
  • Cholestatic liver disease
  • Nephrotic syndrome
  • Secondary: Predominantly TAGs

  • Obesity
  • Diabetes
  • Alcohol abuse
  • Chronic kidney disease
  • Drugs - corticosteroids, antipsychotics, immunosuppressants, protease inhibitors, oral contraceptive pill, hormone replacement therapy
  • Pregnancy

Aetiology

  • Causes of Acute Dyspnoea

  • Respiratory

  • Obstruction - asthma, COPD
  • Bronchiectasis - cystic fibrosis, ABPA
  • Vascular - pulmonary embolus, pulmonary hypertension
  • Interstitial lung disease
  • Pneumonia
  • Aspiration
  • Lung cancer
  • Pneumothorax
  • Pleural effusion
  • Anaphylaxis
  • Obesity hypoventilation syndrome
  • Cardiovascular

  • Heart failure
  • Pulmonary oedema
  • Myocardial ischaemia
  • Cardiomyopathy
  • Congenital heart disease
  • Valvular disease - aortic stenosis, aortic regurgitation
  • Tamponade
  • Other

  • Anaemia
  • Kyphoscoliosis
  • Metabolic acidosis
  • Late pregnancy
  • Neurologic - Guillain Barre, motor neuron disease
  • Muscular dystrophy
  • Anxiety

Diagnosis

  • Causes of Chronic Kidney Disease

  • Diabetic nephropathy
  • Hypertensive nephropathy
  • Glomerulonephritis
  • Tubulointerstitial disease - analgesic nephropathy, reflux nephropathy
  • Congenital disease - polycystic kidney disease

Overview

  • Ask About

  • Diagnosis - type of diabetes; age at diagnosis; presenting symptoms
  • Control - HbA1c, home BSL monitoring, admissions
  • Complications - acute, microvascular, macrovascular, infections
  • Hypoglycaemia - awareness, symptoms, frequency, BSLs, management
  • Management - non-pharmacologic, oral hypoglycaemics, insulins
  • Follow up - who manages their diabetes (e.g. GP or endocrinologist); regular podiatry visits; regular optometrist visits
  • Conditions Associated with Physical Inactivity

  • Obesity
  • Type 2 diabetes mellitus
  • Dyslipidaemia
  • Ischaemic heart disease
  • Stroke
  • Cancers - especially colorectal and breast
  • Risk Factors for Colorectal Cancer

  • Familial syndromes - Lynch syndrome, familial adenomatous polyposis
  • Family history of colorectal cancer
  • Past polyps / colorectal cancer
  • Inflammatory bowel disease
  • Dietary factors - red meats, processed meats; lack of fruit and vegetables
  • Physical inactivity
  • Obesity
  • Smoking
  • Alcohol
  • Ask About

  • Diagnosis - presenting symptoms
  • Family history of inflammatory bowel disease
  • Severity - number of bowel motions, systemic symptoms, frequency of flares
  • Complications - intestinal / extra-intestinal
  • Management - nutritional status, smoking cessation, medications, surgery
  • Risk Factors for Non-Alcoholic Fatty Liver Disease

  • Obesity
  • Type 2 diabetes
  • Hypercholesterolaemia
  • Hyperuricaemia
  • Sources of Medication Lists

  • It is often best to derive your list from at least two sources, especially when there is doubt.
  • The patient - sometimes patients present with a useful list of their medications
  • Collateral - from family or friends
  • Medication boxes - often patients present with their medications; ask if there are any missing
  • The patient's file - especially discharge summaries
  • Other hospitals - especially discharge summaries or transfer letters
  • The patient's GP
  • The patient's pharmacy
  • Ask About

  • Everyone

  • Whether the patient currently smokes or has smoked
  • What age they started smoking
  • How many years they smoked in total
  • How many cigarettes per day
  • Heavy Smokers

  • Past attempts to quit
  • Length they were able to quit for
  • Cravings between cigarettes
  • Aids used in attempting to quit - nicotine gum / patches, champix
  • Willingness to cut down or stop

Pretransplant History

  • Ask About

  • Chronic liver disease - underlying cause, complications
  • Past liver transplant
  • Medical comorbidities - particularly cardiovascular and respiratory
  • Psychological factors - depression / anxiety
  • Social situation - family, living arrangement, occupation
  • Adherence - to management plan, dialysis, medications

Overview

Additionally, long plane journeys are a risk factor for deep venous thrombosis and this should be considered in a patient with shortness of breath, chest pain or leg swelling after a long flight.
  • Ask About

  • Diagnosis - years since diagnosis, risk factors, symptoms
  • Severity - frequency of symptoms
  • Complications - benign / malignant
  • Management - lifestyle changes, medications, surgery

IV Drug Use

  • Ask About

  • What drug they inject
  • Where they get their needles from
  • Whether they have tried to quit
  • How they tried to quit - methadone / suboxone program, cold turkey

Overview

In the context of the gastrointestinal history, alcohol is an important cause of acute hepatitis, cirrhosis, pancreatitis and oesophagitis.
  • Ask About

  • Diagnosis - cause, location of ulcer(s), symptoms
  • Complications - bleeding, perforation, obstruction
  • Management - H pylori eradication,
  • Causes of Cirrhosis

  • Chronic hepatitis - B or C
  • Alcoholic liver disease
  • Non-alcoholic fatty liver disease
  • Autoimmune hepatitis
  • Obstructive disease - primary biliary cirrhosis, primary sclerosing cholangitis, chronic biliary obstruction
  • Infiltration - haemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, sarcoidosis, glycogen storage disease type IV
  • Hepatocellular carcinoma
  • Drugs - methotrexate, methyldopa, amiodarone
  • Budd-Chiari syndrome (hepatic vein occlusion)
  • Right heart failure (cardiac cirrhosis)
  • Risk Factors for Hepatitis C Infection

  • Certain ethnic groups
  • Children of hepatitis C positive mothers
  • Iatrogenic exposure - surgery, colonoscopy, haemodialysis, blood transfusion prior to 1990
  • Healthcare workers
  • IV drug use
  • Prisoners
  • Tattoos
  • Risk Factors for Hepatitis B Infection

  • Certain ethnic groups
  • Children of hepatitis B positive mothers
  • Iatrogenic exposure - surgery, colonoscopy, haemodialysis, blood transfusion prior to 1990
  • High risk sexual behaviour
  • Healthcare workers
  • IV drug use
  • Prisoners
  • Tattoos
  • Ask About

  • Diagnosis - when scleroderma was diagnosed, presenting symptoms, limited or diffuse
  • Manifestations - cardiovascular, GI, respiratory, renal, MSK, neurological
  • Functional impairment
  • Management
  • Conditions Associated with Physical Inactivity

  • Obesity
  • Type 2 diabetes mellitus
  • Dyslipidaemia
  • Ischaemic heart disease
  • Stroke
  • Cancers - especially colorectal and breast
  • Ask About

  • Steadiness - how steady the patient feels on their feet with or without mobility aids
  • Walking aids - whether the patient requires any aids to mobilise, such as a walking stick, 4-wheel walker or rollator frame
  • Transfers - whether the patient can transfer from bed to chair or chair to toilet independently, with assistance, or if they require hoist transfers
  • Stairs - whether the patient is able to climb stairs independently
  • Modifications - whether the patient has had anything added onto their home, such as ramps or toilet / shower rails
  • Risk Factors for Osteoarthritis

  • Advanced age
  • Obesity
  • Past trauma
  • Joint overuse (occupational / sport-related)
  • Risk Factors for Rheumatoid Arthritis

  • Female sex
  • Family history of rheumatoid arthritis
  • Infections - EBV, CMV, E coli, periodontal disease (Porphyromonas gingivalis)
  • Smoking
  • Risk Factors for Gout

  • Male gender
  • Obesity
  • Chronic kidney disease
  • Drugs - diuretics, ethambutol, certain chemotherapeutic agents
  • Excess purine-rich foods - beer, shellfish, liver, marmite
  • Excess sucrose / fructose intake
  • Alcohol excess
  • Risk Factors for Systemic Lupus Erythematosus

  • Family history of SLE
  • Female sex
  • Smoking
  • Obesity

Optic Nerve Palsy

  • Abnormalities

  • Loss of visual acuity
  • Visual field loss
  • Loss of light reflexes
  • Loss of accommodation

Vestibulocochlear Nerve Palsy

  • Abnormalities

  • Sensorineural hearing loss
  • Vertigo
  • Nystagmus

Overview

  • How to Elicit

  • Ask the Patient to open their mouth and gently touch the soft palate with a tongue depressor. Warn the patient beforehand.
  • Abnormality

  • Anosmia
  • Signs of Pseudobulbar Palsy

  • Increased jaw jerk
  • Absent palate rise
  • Increased / normal pharyngeal reflex
  • Tongue spasticity
  • Spastic dysarthria - strained-strangled, slow speech
  • How to Elicit

  • Percuss repeatedly between the eyebrows, looking for reactive blinking.

Trigeminal Nerve Palsy

  • Abnormalities

  • Decreased facial sensation
  • Weak muscles of mastication
  • Increased / decreased jaw jerk
  • Loss of corneal reflex

Hypoglossal Nerve Palsy

  • Abnormalities

  • Tongue atrophy
  • Fasciculations (nuclear lesion)
  • Diversion of tongue toward lesion
  • Inability to point tongue away from the side of lesion

Vagus Nerve Palsy

  • Abnormalities

  • Dysphagia
  • Palate droop
  • Diversion of uvula to one side
  • Hoarseness
  • Loss of gag reflex

Olfactory Nerve Palsy

  • Abnormality

  • Anosmia.

Abducens Nerve Palsy

  • Abnormalities

  • Inwardly-turned eye
  • Horizontal diplopia
  • Strabismus
  • Inability to look laterally

II Optic Nerve

  • Abnormalities

  • Loss of visual acuity
  • Visual field loss
  • Loss of light reflexes
  • Loss of accommodation

Facial Nerve Palsy

  • Abnormalities

  • Facial droop / weakness
  • Inability to close eye
  • Loss of taste
  • Dry eyes / mouth

V Trigeminal Nerve

  • Abnormalities

  • Decreased facial sensation
  • Weak muscles of mastication
  • Increased / decreased jaw jerk
  • Loss of corneal reflex

XI Accessory Nerve

  • Abnormalities

  • Shoulder drop
  • Inability to turn head to contralateral side

Accessory Nerve Palsy

  • Abnormalities

  • Shoulder drop
  • Inability to turn head to contralateral side

XII Hypoglossal Nerve

  • Abnormalities

  • Tongue atrophy
  • Fasciculations (nuclear lesion)
  • Diversion of tongue toward lesion
  • Inability to point tongue away from the side of lesion

Trochlear Nerve Palsy

  • Abnormalities

  • Eye deviation upward and rotation outward
  • Vertical diplopia
  • Inability to look down and in - difficulty descending stairs
  • Head tilting away from the side of the lesion

The Glasgow Coma Scale (GCS)

15-point scale indicating level of consciousness.

Overview

  • Normal Pupillary Size

  • In the dark: 4-8mm
  • Under bright light: 2-4mm

Oculomotor Nerve (III) Palsy

  • Causes of Occulomotor Nerve Palsy

  • Small-vessel ischaemia
  • Midbrain infarct
  • Head trauma
  • Tumour
  • Aneurysm (commonly PCA)

Overview

  • Signs of Bulbar Palsy

  • Absent jaw jerk
  • Absent palate rise
  • Absent pharyngeal reflex
  • Tongue wasting and fasciculations
  • Flaccid dysarthria - nasal speech with impaired articulation and shortened phrases
  • Signs of Myaesthenia Gravis

  • Skeletal Muscle Fatiguability

  • Simpson’s test - ptosis on sustained upward gaze
  • Peek sign - inability to maintain sustained eye closure
  • Bulbar fatiguability - development of nasal speech with reading
  • Proximal muscle fatigability - inability to maintain arms above the head
  • Signs of Management

  • Thymectomy scar

Glossopharyngeal Nerve Palsy

  • Abnormalities

  • Loss of pharyngeal sensation / gag reflex
  • Loss of taste of posterior ⅓ of tongue
  • Xerostomia (dry mouth)

Overview

  • How to Perform

  • Dim the lights and examine the fundus using a traditional direct or PanOptic ophthalmoscope.
  • Causes of Myotonia

  • Myotonic Dystrophy

  • Dystrophia myotonia
  • Myotonia congenita
  • Non-Dystrophic Myotonia

  • Paramyotonia congenita
  • Acid maltase deficiency
  • Significance

  • Caused by malignancy affecting the cerebellopontine angle.

VII Facial Nerve

  • Abnormalities

  • Facial droop / weakness
  • Inability to close eye
  • Loss of taste
  • Dry eyes / mouth

Horner’s Syndrome

  • Look For

  • Partial ptosis: drooping of the eyelid
  • Miosis: pupillary constriction
  • Anhidrosis: lack of sweating

Occulomotor Nerve Palsy

  • Abnormalities

  • Eye deviated down and out
  • Diplopia
  • Ptosis
  • Mydriasis (pupillary dilatation)
  • Loss of pupillary reflexes

Facial Asymmetry

  • Interpretation

  • Eyebrow sparing (central palsy) - upper motor neuron lesionIschaemia, haemorrhage, tumour, trauma
  • Eyebrow involvement - facial nerve (VII) lesionBell’s palsy, herpes zoster (Ramsay-Hunt Syndrome), tumour, skull fracture

VIII Vestibulocochlear Nerve

  • Abnormalities

  • Sensorineural hearing loss
  • Vertigo
  • Nystagmus

Overview

  • Look For

  • Wide-based, ataxic gait
  • Dysarthria
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Muscle wasting
  • Nystagmus
Popliteal - bend the patient's knee to 90 degrees, gently grasp both sides of the knee joint and palpate using tips of fingers within the popliteal fossa posteriorly.
  • How to Elicit

  • Apply pressure to the nail bed until it blanches, release and measure the time taken for colour to return.
    • Normal Blood Pressure

    • <120 / 80mmHg

The Abdominal Aorta

  • Interpretation

  • Absent / diminished pulse - aortic coarctation
  • Pulsatile mass - abdominal aortic aneurysm

Overview

  • Interpretation

  • Central - tends to involve an entire upper and / or lower limbIschaemia, SAH / ICH, tumour, trauma, encephalitis, vasculitis, MS, ADEM, PML, sarcoidosis
  • Axon - Begins distally and migrates proximally → ‘glove and stocking’ distributionDiabetes, hypothyroidism, B12 / folate deficiency, alcoholism, connective tissue disease, amyloid / sarcoidosis, toxins
  • Myelin sheath (demyelination) - impaired proprioception and vibration sensation with intact pain sensationGuillain-Barré syndrome, CIDP, Charcot-Marie-Tooth
  • Nerve root - in the distribution of a single dermatomeTrauma, radiculopathy, neoplasm
  • Peripheral nerve - in the distribution of a peripheral nerveTrauma, entrapment, focal ischaemia, neoplasia, shingles, nerve block
  • Skin receptors - localised to an area not in keeping with a dermatomal or peripheral nerve patternTrauma, local anaesthesia, full thickness burns

Lower Limb Erythema

  • Causes of Lower Limb Erythema

  • CellulitisTender, red, swollen, warm calf ± site of injury
  • Skin conditionsMacules, papules, patches or plaques - localised / diffuse
  • Lipodermatosclerosis (fibrosis of subcutaneous fat)Inverted bowling pin appearance with erythema / induration
  • LymphoedemaNon-pitting oedema, usually bilateral
  • Deep venous thrombosisRed, swollen, tender calf
  • Superficial ThrombophlebitisTender area with erythema tracking along the course of a superficial vein
  • Venous insufficiencyHyperpigmentation that may be associated with varicose veins or oedema.
  • Dependent rubor(peripheral arterial disease)Dusky-red discolouration when the leg is elevated above the heart

Crepitations

  • Listen For

  • Short popping sounds. May be fine or coarse, and may be cleared by coughing (if due to secretions).

Venous Skin Changes

  • Look For

  • Oedema
  • Venous eczema
  • Hyperpigmentation
  • White scar tissue (atrophie blanche)
  • Induration - fibrosis of subcutaneous fat (lipodermatosclerosis)

Overview

  • How to Perform

  • With the patient supine, place one hand on the abdomen over the kidney and the other hand over the flank posteriorly. Attempt to ballot the kidney between the two hands. Repeat on both sides.

Abdominal Scars

Scars on the abdomen can suggest past surgery, trauma, burns and healed skin conditions.

Overview

  • Listen For

  • A superficial, scratching sound present in mid-systole, mid-diastole and late diastole.
  • Significance

  • Flank tenderness to percussion is a relatively sensitive sign for renal pathology, especially pyelonephritis and perinephric abscess.

Palmar Crease Pallor

  • Causes of Palmar Crease Pallor

  • Anaemia
  • Low cardiac output, due to cardiac disease
  • Peripheral shutdown, due to increased sympathetic activity

Rashes Associated with Renal Disease

Livedo reticularis: mottled, lace-like lesions, commonly on the legsBenign, cholesterol emboli, calciphylaxis, cryoglobulinaemia, anticardiolipin syndrome, SLE, rheumatoid arthritis, malignancy

Overview

  • How to Elicit

  • Ask the patient to place their arms up and out in front of them with the wrists extended.
  • Look for an intermittent loss of tone in the wrists, with the appearance of a flap.

Contour

Rapid rate of risePremature ventricular contraction, mitral regurg, VSD, aortic regurgitation, HOCM

Oral Candidiasis

  • Significance

  • Infection with Candida species.

Overview

  • Listen For

  • Aortic bruits - over upper abdomen in the midline.
  • Renal bruits - over the upper abdomen, approximately 2cm superior and lateral to the umbilicus on either side.
  • Iliac bruits - over the lower abdomen, either side of the midline.

Pitting Oedema

  • How to Elicit

  • Apply pressure to the anterior aspect of the tibia for fifteen seconds and then release.

Heart Rate

    • Normal Range

    • 60 - 100bpm

Purpura

  • Causes of Purpura

  • Trauma

  • Platelet Disorders

  • Idiopathic thrombocytopaenic purpura (ITP)
  • Thrombotic thrombocytopaenic purpura (TTP)
  • Disseminated intravascular coagulation (DIC)
  • Bone marrow failure - aplastic anaemia, leukaemia, chemotherapy
  • Platelet sequestration - splenomegaly, haemangioma
  • Haemolytic-uraemic syndrome
  • Inherited disorders of platelet function
  • Disorders of Coagulation

  • Factor deficiencies - haemophilia, Von Willebrand disease
  • Vitamin K deficiency - malabsorption, poor diet
  • Anticoagulants
  • Disseminated intravascular coagulation (DIC)
  • Vascular Disorders

  • Connective tissue diseases - Ehlers-Danlos, scurvy
  • Infection - mengingococcal, streptococcal, viral
  • Henoch-Schönlein purpura
  • Senile purpura
  • Steroids

Overview

  • Interpretation

  • Hum - low, constant murmurNormal jugular venous hum
  • Bruit - abnormal systolic sound (turbulent flow)Carotid stenosis, transmitted murmur of aortic stenosis
  • Look For

  • The pulsation of the jugular vein, between the sternal and clavicular heads of the sternocleidomastoid.

Weight

  • Look for

  • The patient’s current weight
  • Change in weight - compare to past weights
  • Time course - sudden / gradual

Overview

  • How to Perform

  • Dim the lights and examine the fundus using a traditional direct or PanOptic ophthalmoscope.
An accurate fluid status assessment can be useful for assessing for dehydration or overload, and for titrating a patient's fluid management - whether that be by giving more fluid or removing fluid through diuresis or dialysis.

Halitosis

  • Smell For

  • An offensive odour that may resemble rotten eggs / meat / fish or faeces.

Arterial Ulcers

The presence of white, painful ulcers suggests a partial or complete arterial occlusion.

Leukonychia

  • Look For

  • Whiteness of the nail beds.

Overview

  • Significance

  • In patients with fluid overload, lying down for an extended period, fluid may migrate from the legs to the sacral region.
  • Causes of Cool Extremities

  • Peripheral arterial disease
  • Compartment Syndrome
  • Shock
  • Low cardiac output, due to cardiac disease

Aetiology

  • Causes of Chronic Kidney Disease

  • Diabetic nephropathy
  • Hypertensive nephropathy
  • Glomerulonephritis
  • Tubulointerstitial disease - analgesic nephropathy, reflux nephropathy
  • Congenital disease - polycystic kidney disease

Overview

  • Muscles Involved

  • Flexor pollucis longus, flexor pollucis brevis

Wrist Drop

  • Significance

  • Radial nerve lesion.

Overview

Arthritis may affect one joint or multiple joints in a symmetric or asymmetric pattern.
  • Muscles Involved

  • Extensor carpi radialis longus & brevis, extensor carpi ulnaris
  • Muscles Involved

  • Opponens pollucis

Elbow Lesions

  • Differential Diagnosis of Elbow Mass

  • Rheumatoid nodules
  • Gouty tophi
  • Olecranon bursitis

Complications

  • Complications of Scleroderma

  • Pulmonary hypertension
  • Pulmonary fibrosis
  • Scleroderma renal crisis
  • Oesophageal dysmotility
  • Pericarditis
  • Arrythmias
  • Erectile dysfunction

Overview

  • Muscles Involved

  • Dorsal interossei, abductor digiti minimi (5th finger)
  • Signs of Severity

  • Evidence of active synovitis
  • Severe deformity
  • Rheumatoid nodules (indicate seropositive disease)
  • X-Ray Findings in Gout

  • Soft tissue swelling
  • Joint space preservation (no joint space narrowing)
  • Tophi - periarticular radiolucent masses
  • Juxta-articular ‘punched-out’ erosions
  • Joint destruction (late)
  • Muscles Involved

  • Abductor pollucis longus, abductor pollucis brevis
  • Muscles Involved

  • Flexor carpi radialis, extensor carpi radialis longus & brevis

Soft Tissue Landmarks of the Wrist

Ulnar canal (Guyon’s canal) - medial & volar aspect of the hand, superficial to the flexor retinaculum

Overview

  • X-Ray Findings in Psoriatic Arthritis

  • Pencil-in-cup deformity: erosions with new bone formation
  • Dactylitis: soft tissue swelling in all of the joints of a single digit
  • Fluffy periostitis: cortical thickening
  • Ankylosis: fusion of joints
  • Sacroiliitis

Muscles Acting on the Wrist Joint

Extensors (posterolateral) - extensor carpi radialis longus & brevis, extensor carpi ulnaris

Overview

  • Muscles Involved

  • Flexor carpi radialis, palmaris longus, flexor carpi ulnaris
  • Muscles Involved

  • Adductor pollicis
  • X-Ray Findings in Osteoarthritis

  • Reduced joint space - generally asymmetric
  • Subchondral sclerosis - increased bone deposition surrounding the joint
  • Subchondral cysts: cystic formations around the joint
  • Osteophytes: bony projections along the joint line
  • Muscles Involved

  • Flexor digitorum profundus & superficialis, flexor digiti minimi brevis (5th finger)

Tinel’s Sign

  • How to Perform

  • Percuss over the flexor retinaculum.

Overview

  • Muscles Involved

  • Extensor digitorum, extensor digiti minimi, extensor indicis
  • Muscles Involved

  • Palmar interossei
  • Muscles Involved

  • Flexor carpi ulnaris, extensor carpi ulnaris
  • Signs of Cushing’s Syndrome

  • Central obesity (95% of cases)
  • ‘Moon’ face
  • Buffalo hump (fat pad over the posterior shoulders / neck
  • Thin skin
  • Peripheral oedema
  • Striae (stretch marks)
  • Bruising
  • Proximal myopathy

Bony Landmarks of the Wrist

Styloid process of ulna - distally.

Overview

  • Muscles Involved

  • Extensor pollicis longus, extensor pollucis brevis
  • Muscles Involved

  • Trapezius, rhomboid major & minor
  • Muscles Involved

  • Pectoralis major, trapezius, teres major, latissimus dorsi

Active Movement

  • Significance

  • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

Bony Landmarks of the Shoulder

Clavicle - medial to lateral, comparing both sides.

Anterior Shoulder Dislocation

  • Look For

  • Abduction and external rotation of the shoulder with anterior fullness of the shoulder joint.

Overview

  • Muscles Involved

  • Pectoralis major, serratus anterior
  • Muscles Involved

  • Posterior deltoid, infraspinatus, teres minor
  • Muscles Involved

  • Pectoralis major, trapezius
  • Muscles Involved

  • Pectoralis major, anterior deltoid, biceps brachii
  • Muscles Involved

  • Lateral deltoid, supraspinatus

Muscle Wasting

  • Causes of Muscle Wasting

  • Normal aging
  • Disuse
  • Malnutrition - poor diet, malabsorption, cancer
  • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
  • Muscular disorders - inflammatory myopathy, muscular dystrophies
  • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

Muscles Acting on the Shoulder Joint

Extensors - pectoralis major, posterior deltoid, teres major, trapezius, latissimus dorsi, triceps brachii

Overview

  • Muscles Involved

  • Trapezius, rhomboid major & minor
  • Muscles Involved

  • Pectoralis major, posterior deltoid, teres major, trapezius, latissimus dorsi, triceps brachii
  • Causes of Shoulder Swelling

  • Trauma - fracture, patellar dislocation, muscle sprain or rupture, compartment syndrome
  • Bursitis - commonly subacromial
  • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
  • Skin / soft tissue infection - cellulitis, abscess
  • Vascular - acute ischaemia, DVT, superficial thrombophlebitis
  • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition
  • How to Perform

  • Flex the patient's elbow and shoulder to 90°, stabilitse the shoulder joint and forcibly internally rotate the shoulder.
  • Causes of a Warm Joint

  • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
  • Bursitis
  • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
  • Vascular - DVT, superficial thrombophlebitis, venous insufficiency
  • Muscles Involved

  • Pectoralis major, anterior deltoid, teres major, subscapularis, latissimus dorsi
  • Tip

  • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.

Measuring Blood Pressure

Ask the patient not to talk or move while the blood pressure is measured as this can cause a false elevation in BP.

Overview

  • Muscles Involved

  • Iliacus, psoas major and minor, rectus femoris, sartorius, tensor fascia lata, pectineus, gracilis.

Hip Disclocation

  • Causes of Hip Disclocation

  • Congenital - hip dysplasia
  • Acquired - major trauma e.g. road traffic accidents or sporting injuries

Overview

  • Muscles Involved

  • Biceps femoris, semitendinosus, semimembranosus, gluteus maximus.
Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
  • Causes of Joint Swelling

  • Trauma - fracture, dislocation, muscle sprain or rupture, compartment syndrome
  • Musculoskeletal - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, bursitis
  • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
  • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
  • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition

Muscles Acting on the Hip Joint

Extensors (posterior) - biceps femoris, semitendinosus, semimembranosus, gluteus maximus

Overview

  • Look For

    The relationship between the positions of the head, trunk, upper and lower limbs.
  • Head & neck - tilt and rotation
  • Shoulders - level of shoulders, scapular prominence
  • Chest - deformities
  • Spine - kyphosis, lordosis and scoliosis
  • Pelvis - pelvic tilt
  • Legs - angle between thigh and leg (genu valgum / varum)
  • Feet - position, pronation
  • Muscles Involved

  • Sartorius, gluteus maximus, iliacus, psoas major and minor, obturator internus and externus, piriformis, quadratus femoris.
  • How to Perform

  • With the patient supine, lift their leg so as to flex the hip while maintaining a straight leg.
  • Muscles Involved

  • Gluteus maximus, medius and minimus; tensor fascia lata, sartorius, piriformis.

Active Movement

  • Significance

  • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

Overview

  • Muscles Involved

  • Pectineus; gluteus medius and minimus; tensor fascia lata.

Bony Landmarks of the Hip

Anterior superior iliac spine - a sharp notch anterior to the iliac crest.

Overview

  • Look For

  • Bulge, above or below the inguinal crease. Examine with an light source shone at an oblique angle. Ask the patient to cough.
  • Muscles Involved

  • Pectineus; adductor longus, brevis and magnus; gracilis, pectineus.

Muscle Wasting

  • Causes of Muscle Wasting

  • Normal aging
  • Disuse
  • Malnutrition - poor diet, malabsorption, cancer
  • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
  • Muscular disorders - inflammatory myopathy, muscular dystrophies
  • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

Overview

  • Signs of Marfan Syndrome

  • Musculoskeletal

  • Wrist sign: when the patient wraps their thumb and fifth finger around their opposite wrist, the thumb and fifth finger overlap
  • Thumb sign: when the patient adducts their thumb, it extends beyond the ulnar border of the palm
  • Pectus carinatum: forward angulation of the sternum
  • Hindfoot deformities - particularly hindfoot valgus
  • Pes planus: flat foot
  • Scoliosis / lumbar kyphosis
  • Reduced upper segment / lower segment ratio (with the pubic symphysis separating the upper and lower segments)
  • Increased arm span / height ratio (i.e. arms longer than the patient’s height)
  • Facial

  • Dolichocephaly: abnormally long head (anterior-posterior)
  • Enophthalmos: posterior displaceemnt of the eye within the orbit
  • Downslanting palpebral fissures (the line between the medial canthus and the lateral canthus of the eye)
  • Malar hypoplasia: underdeveloped cheek bones
  • Retrognathia: posterior displacement of the mandible
  • Other

  • Reduced elbow extension
  • Skin striae
  • Signs of Ventricular Septal Defect

  • Central Signs

  • Volume-loaded apex beat - displaced apex with forceful, non-sustained impulses
  • Soft first heart sound (S1)
  • Harsh pan-systolic murmur loudest at the left lower sternal edge
  • Signs of Complications

  • Evidence of mitral regurgitation
  • Evidence of pulmonary hypertension - raised JVP, parasternal heave, loud / palpable P2
  • Evidence of Eisenmenger’s syndrome - cyanosis, clubbing
The diaphragm has both somatic and autonomic innervation, and thus the respiratory rate can be altered both voluntarily and and involuntarily in response to physiologic or pathologic stimuli.
However, the BMI has several limitations - particular in its overestimation of obesity in people with a significant amount of muscle bulk.
S1 is normally heard best over the apex.
  • How to Perform

  • Auscultate within the triangle bound by the mandible, sternocleidomastoid and thyroid cartilage. Ask the patient to hold their breath.
  • Causes of Clubbing of the Toes

  • Cyanotic congenital heart disease
  • Pulmonary malignancy - lung cancer, lymphoma, mesothelioma
  • Chronic infection / inflammation - bronchiectasis, lung abscess, empyema, interstitial lung disease, coeliac disease, IBD, infective endocarditis
  • Cirrhosis

Down Syndrome

  • Look For

  • Short stature
  • Brachycephaly: flat head
  • Flat nasal bridge
  • Open mouth with protuberant tongue
  • Epicanthal folds: a fold of skin of the upper eyelid that covers the inner corner of the eye
  • Ligamentous laxity
  • Hypotonia: low muscle tone
  • Brachydactyly: short fingers and toes
  • Fifth finger clinodactyly: bending of the little finger toward the ring finger
  • Broad hands, single palmar crease
  • Wide 1-2 toe gap
  • Intellectual disability

Overview

  • Signs of Left Ventricular Failure

  • Sarcopaenia (muscle wasting)
  • Tachycardia
  • Pulsus alternans: regular alternation between strong and weak beats
  • Displaced apex
  • Presence of third heart sound (S3)
  • Pulmonary crepitations / wheeze
You may find it useful to start at the left sternal edge (tricuspid area) as an initial screening test, and then listen to the other areas.

Pacemakers

  • Indications

  • AV block
  • Symptomatic bradycardia

Pallor of the Lower Limb

  • Look For

  • Loss of colour in one or both lower limbs.

Overview

  • Interpretation

  • 1/6: The faintest murmur, audible with the most careful auscultation.
  • 2/6: A faint murmur that is easily heard.
  • 3/6: Prominent, louder than the heart sounds.
  • 4/6: A loud murmur, accompanied by a thrill.
  • 5/6: A very loud murmur that can be heard with the edge of the stethoscope in contact with the skin.
  • 6/6: A murmur audible with the stethoscope off the chest.
  • How to Perform

  • Ask the patient to cross their arms over their chest and take deep breaths in and out through their mouth. Auscultate over the lung fields, alternating from left to right. Make sure to auscultate the axillae and supraclavicular fossae.

Inspiration & Expiration

Inspiration and expiration can be used when assessing for murmurs in order to localise a murmur to the left or right side of the heart.

Overview

  • Signs of Right Ventricular Failure

  • Sarcopaenia (muscle wasting)
  • Tachycardia
  • Raised jugular venous pressure
  • Right ventricular heave
  • Palpable P2
  • Loud second heart sound (P2)
  • Pleural effusions - reduced breath sounds with dull percussion note basally
  • Ascites - fluid thrill / shifting dullness
  • Tender hepatomegaly
  • Peripheral oedema - sacral / pedal
  • Signs of Aortic Stenosis

  • Peripheral Signs

  • Anacrotic pulse - small volume pulse with a slow upstroke and a notched wave on the upstroke
  • Narrow pulse pressure
  • Central Signs

  • Aortic thrill
  • Pressure-loaded apex beat - forceful and sustained impulses
  • Soft second heart sound (S2)
  • Ejection systolic murmur - heard best over the aortic area in expiration
  • Signs of Complications

  • Evidence of left ventricular failure - pulsus alternans, pulmonary crepitations
    • Normal Blood Pressure

    • < 120 / 80 mmHg
  • Signs of Aortic Regurgitation

  • Peripheral Signs

  • Collapsing Pulse
  • Widened Pulse Pressure
  • Central Signs

  • Soft A2 - loss of normal splitting of S2 on inspiration
  • Volume-loaded apex beat - displaced apex with forceful, non-sustained impulses
  • Decrescendo diastolic murmur loudest on sitting forward, in expiration
  • Signs of Complications

  • Evidence of left ventricular failure - pulsus alternans, pulmonary crepitations
  • Signs of Mitral Regurgitation

  • Peripheral Signs

  • Small volume pulse
  • Central Signs

  • Apical thrill (palpable murmur)
  • Soft or absent first heart sound (S1)
  • Presence of a fourth heart sound (S4)
  • Volume-loaded apex beat -  displaced apex with forceful, non-sustained impulses
  • Pansystolic murmur heard greatest over the apex on expiration
  • Radiation to the left sternal edge and neck - suggests posterior mitral valve leaflet prolapse
  • Radiation to the axilla - suggests anterior mitral valve leaflet prolapse
  • Signs of Complications

  • Evidence of pulmonary hypertension - elevated JVP, parasternal heave, loud / palpable P2
  • Evidence of left ventricular failure - pulsus alternans, presence of S3, pulmonary crepitations

Heart Rate

The heart rate is an invaluable vital sign that is commonly used as part of the assessment of a patient's haemodynamic state.

Overview

  • Signs of Down Syndrome

  • Short stature
  • Brachycephaly: flat head
  • Flat nasal bridge
  • Open mouth with protuberant tongue
  • Epicanthal folds: a fold of skin of the upper eyelid that covers the inner corner of the eye
  • Ligamentous laxity
  • Hypotonia: low muscle tone
  • Brachydactyly: short fingers and toes
  • Fifth finger clinodactyly: bending of the little finger toward the ring finger
  • Broad hands, single palmar crease
  • Wide 1-2 toe gap
  • Signs of Hypertrophic Cardiomyopathy

  • Peripheral Signs

  • Double carotid impulse
  • Prominent a waves within the jugular venous pulsation
  • Central Signs

  • Double apical impulse
  • Paradoxical splitting of the second heart sound (S2): single S2 during inspiration and split S2 during expiration
  • Presence of a fourth heart sound (S4)
  • Late systolic murmur (LV outflow tract obstruction) that increases with valsalva manoeuvre and decreases with squatting
  • Pansystolic murmur loudest at the apex (mitral regurgitation)
  • Signs of Pulmonary Hypertension

  • General Signs

  • Raised JVP
  • Parasternal heave
  • Palpable P2
  • Loud second heart sound (P2)
  • Evidence of tricuspid regurgitation - pansystolic murmur loudest at the lower left sternal edge on inspiration
  • Signs Suggesting a Cause

  • Evidence of connective tissue disease - Raynaud’s, sclerodactyly, skin thickening, telangiectasia, synovitis
  • Evidence of portal hypertension - caput medusae, ascites, splenomegaly
  • Evidence of left ventricular failure - pulsus alternans, presence of S3, pulmonary crepitations
  • Evidence of pulmonary disease - hypoxia, hyperexpansion, crepitations, wheeze
  • Signs of Complications

  • Evidence of right ventricular failure - raised JVP, ascites, pleural effusions, peripheral oedema
  • Signs of Mitral Stenosis

  • Peripheral Signs

  • Narrow pulse pressure
  • Central Signs

  • Apical diastolic thrill
  • Early opening snap - high frequency sound after S2 in early diastole, heard best between the apex and left sternal edge
  • Loud first heart sound (S1)
  • Low-pitched, mid-diastolic murmur loudest in the apex in the left lateral position
  • Signs of Complications

  • Evidence of pulmonary hypertension - elevated JVP, parasternal heave, loud / palpable P2
  • Signs of Turner Syndrome

  • Female
  • Short stature
  • Puffy hands and feet (congenital lymphoedema)
  • Added skin folds on the back of the neck
  • How to Perform

  • Dim the lights and examine the fundus using a traditional direct or PanOptic ophthalmoscope.
  • Signs of Pulmonary Stenosis

  • Peripheral Signs

  • Prominent a wave within the jugular venous pressure
  • Central Signs

  • Parasternal heave
  • Splitting of the second heart sound (S2)
  • Presence of a fourth heart sound (S4)
  • Ejection systolic murmur best heart in the pulmonary area on inspiration
  • Signs of Complciations

  • Evidence of right heart failure - raised JVP, ascites, pleural effusions, peripheral oedema
The second heart sound normally splits on inspiration and is single during expiration, and A2 (closure of the aortic valve) is louder than P2 (closure of the pulmonary valve), even in the pulmonary area.
  • Signs of Patent Ductus Arteriosus

  • Peripheral Signs

  • Peripheral cyanosis
  • Collapsing pulse
  • Widened pulse pressure
  • Central Signs

  • Displaced apex beat
  • Continuous murmur
  • Paradoxical splitting of the second heart sound (S2): single S2 during inspiration and split S2 during expiration
  • Evidence of Eisenmenger’s syndrome - cyanosis, clubbing
  • Signs of Tricuspid Regurgitation

  • Peripheral Signs

  • Prominent V wave within the jugular venous pulsation
  • Central Signs

  • Right ventricular heave
  • Pansystolic murmur that is maximal at the lower end of the sternum; louder on inspiration
  • Large, pulsatile, tender liver
  • Signs of Complications

  • Evidence of right heart failure - raised JVP, ascites, pleural effusions, peripheral oedema

Valsalva Manoeuvre

The valsalva manoeuvre reduces preload, which makes the murmur of hypertrophic cardiomyopathy louder.

Overview

  • How to Assess

  • Measure the waist circumference at the midpoint between the lowest palpable rib and the top of the iliac crest. Measure the hip circumference around the widest part of the buttocks. Divide the first measurement by the second.

Resting Tremor

The tremor of Parkinsonism is classically pill-rolling, meaning that the thumb and forefinger and rubbed together, at a rate of 3-6hz.

Anosmia

  • How to Perform

  • Ask the patient whether their sense of smell has been abnormal recently. Ask them to close their eyes and present common smells such as hand sanitizer, coffee, peppermint etc. and ask the patient to identify them.

Overview

  • How To Perform

  • Measure the blood pressure with the patient lying down, and then remeasure it after the patient has been standing for one minute.
  • Interpretation

  • Increased: resistance to passive movementUpper motor neuron lesion
  • Normal: minimal resistance
  • Decreased: no resistanceLower motor neuron or cerebellar lesion
  • Look For

  • An expressionless face (like the person is wearing a mask)
  • Reduced blinking
  • Drooling
  • Significance

  • Orientation is a quick way of assessing patients for confusion.
  • Causes of Parkinsonism

  • Parkinson’s disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
  • Parkinson’s Plus Syndromes

  • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
  • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
  • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
  • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
  • Others

  • Drugs - antipsychotics, metoclopramide, lithium
  • Normal pressure hydrocephalus
  • Hypoxic brain injury
  • Wilson’s disease
  • Interpretation

  • Decreased - no blinking in response to stimulusOphthalmic nerve (V1) / facial nerve (VII) palsy, pons / medullary lesion
  • Normal - up to five blinks and then no further blinking following habitualization
  • Look For

  • Wide-based, ataxic gait
  • Dysarthria
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Muscle wasting
  • Nystagmus
  • Signs of Myaesthenia Gravis

  • Skeletal Muscle Fatiguability

  • Simpson’s test - ptosis on sustained upward gaze
  • Peek sign - inability to maintain sustained eye closure
  • Bulbar fatiguability - development of nasal speech with reading
  • Proximal muscle fatigability - inability to maintain arms above the head
  • Signs of Management

  • Thymectomy scar
  • How to Elicit

  • Patellar - with the patient supine, support the knee from underneath providing slight flexion and strike the patellar tendon below the patella.L3 / L4 myotome
  • Ankle - flex the knee, externally rotate the hip and dorsiflex the foot. Strike the Achilles tendon of the heel.L5 / S1 myotome

Abnormal Posturing

  • Interpretation

  • Decorticate - flexion, adduction and internal rotation of the arms; supination of the forearms and extension of the legs.Damage to cerebral hemispheres with brain stem preservation
  • Decerebrate - extension of the arms, pronation of the forearms extension of the legsDamage to upper brain stem
  • Opisthotonic - secerebrate posturing with posterior arching of the neck and back.Severe damage to the upper brain stem

Cutaneous Manifestations of Neurologic Disease

  • Signs of Tuberous Sclerosis Complex (TSC)

  • Angiofibromata: pink papules in the nasolabial folds
  • Shagreen patches: soft flesh-coloured patches on the trunk
  • Ash leaf macules: hypopigmented flat spots

Overview

  • Causes of Peripheral Mononeuropathy

  • Compression (particularly carpal tunnel and ulnar tunnel) - prolonged pressure, hereditary neuropathy with liability to pressure palsies (HNPP)
  • Trauma - blunt trauma, penetrating injury (e.g. knife, gunshot, glass)
  • Nerve ischaemia - trauma, thromboembolism, diabetes, atherosclerosis, excessive tourniquet use
  • Radiation injury
  • How to Assess

  • Demonstrate a sharp stimulus by touching the patient lightly on the chest with a neurotip. Ask the patient to close their eyes, and test each dermatome / nerve distribution alternating between the sharp and dull sides of the neurotip at random. Ask the patient if they percieve the stimulus as sharp or dull.
  • How to Perform

  • Ask the patient to move their hips, knees and ankles through each movement.
  • Causes of Sensory Loss

  • Central Nervous System

  • Brain lesion - ischaemia, haemorrhage, tumour, trauma, encephalitis, vasculitis, demyelination
  • Spinal cord lesion - infarct, haemorrhage, abscess, transverse myelitis
  • Peripheral Nervous System

  • Nerve root pathology - trauma, radiculopathy, neoplasm
  • Brachial plexopathy - trauma, tumour, brachial neuritis
  • Focal peripheral nerve pathology - trauma, entrapment, focal ischaemia, sarcoidosis, tumour
  • Mononeuritis multiplex - vasculitis, diabetic neuropathy, Lyme disease, leprosy, paraneoplastic, amyloidosis, sarcoidosis
  • Peripheral polyneuropathy - diabetic neuropathy, hypothyroidism, B12 deficiency, alcohol, paraneoplastic, Guillain-Barre, CIDP
  • Other

  • Poor compliance with examination
  • How to Assess

  • Ask the patient to relax and allow you to move their arms. Move the shoulder, elbow, wrist and fingers passively through their range of motion, looking for rigidity.
  • Causes of Myoclonus

  • Physiological (e.g. while falling asleep)
  • Epilepsy
  • Parkinson’s disease
  • Drugs - lamotrigine, carbamazepine, TCAs, anaesthetic / analgesic withdrawal
  • Psychogenic
  • Causes of Chorea

  • Inherited disorders - Huntington’s disease, Friedrich’s ataxia, ataxia-telangiectasia, tuberose sclerosis, benign hereditary chorea, mitochondrial disease
  • Vascular - ischaemic / haemorrhagic stroke
  • CNS tumour
  • Drugs - levodopa, antiepileptics, antipsychotics, stimulants, benzodiazepines, OCP, lithium
  • Infectious - Sydenham’s chorea (rheumatic fever), herpes simplex encephalitis, HIV, prions
  • Metabolic - pregnancy, thyrotoxicosis
  • Autoimmune - SLE, antiphospholipid, scleroderma
  • Causes of Tics

  • Tourette’s disorder
  • Drugs - lamotrigine, stimulants
  • Significance

  • Loss of balance with the feet together suggests the presence of a cerebellar lesion (as the patient normally compensates by keeping their feet apart), though this can also occur in the setting of vestibular pathology and visual abnormalities.
Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
  • Interpretation

  • Weakness affecting a single myotome  - likely due to spinal nerve root pathology
  • Weakness affecting a single peripheral nerve distribution - likely due to a focal peripheral nerve palsy
  • Weakness affecting multiple peripheral nerve distributions - potentially due to a brachial plexus lesion or mononeuritis multiplex
  • Generalised weakness - suggests a polyneuropathy, neuromuscular pathology or myopathy

Muscle Wasting

  • Causes of Muscle Wasting

  • Normal aging
  • Disuse
  • Malnutrition - poor diet, malabsorption, cancer
  • Denervation - trauma, motor neurone disease, Guillain-barré Syndrome, peripheral neuropathy, polio
  • Muscular disorders - inflammatory myopathy, muscular dystrophies
  • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

Overview

  • Signs of Mononeuritis Multiplex

  • Lower motor neuron weakness affecting two or more distinct peripheral nerve distributions
  • Sensory loss affecting two or more distinct peripheral nerve distributions
  • Causes of Dystonia

  • Genetic mutations
  • Perinatal brain injury
  • Vascular - ischaemic or haemorrhagic stroke
  • CNS tumour
  • Encephalitis
  • Drugs - metoclopramide, calcium-channel blockers, antipsychotics
  • Psychogenic
Motor neurone disease does not present with sensory involvement or ocular palsy.
  • How to Assess

  • Ask the patient to observe as you demonstrate upward and downward movement of the great toe.
  • With their eyes closed, slowly move the joint over one to two seconds to the upward or downward position. 
  • Ask the patient to report whether the toe has been moved up or down.
  • Repeat several times, and then repeat on the other side.

Resting Tremor

  • Look For

  • Tremor while at rest, that decreases with target-directed movement.

Overview

  • How to Assess

  • Ask the patient to close their eyes. Using a cotton ball or microfilament, gently touch each dermatome / nerve distribution and ask the patient if they can feel the stimulus. Compare sides and proximally / distally.
  • How to Assess

  • With the patient's eyes closed, place a vibrating 128hz tuning fork over the interphalangeal joint of the great toe. Ask the patient to describe the sensation. If they can feel it vibrating, progressively diminish the vibration until they cannot feel it. If they cannot feel it vibrating, test on the medial / lateral malleolus and then the tibial tuberosity.
  • Look For

  • Wide-based, ataxic gait
  • Dysarthria
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Muscle wasting
  • Nystagmus
  • Causes of Coexistent UMN and LMN Weakness

  • Separate UMN and LMN lesions
  • Motor neurone disease (amyotrophic lateral sclerosis)
  • Cervical myelopathy
  • Syringomyelia
Central cord syndrome - bilateral upper motor neuron weakness affecting the upper limbs more than the lower limbs, and loss of proprioception and vibration sensation (dorsal column)Commonly due to trauma or hyperextension of the cervical spine
  • Significance

  • The presence of upper motor neuron weakness suggests a lesion within the central nervous system, involving the cerebrum, brainstem or spinal cord.
  • Differential Diagnosis of Proximal Weakness

  • Proximal myopathy
  • Neuromuscular disorder - myaesthenia gravis, Lambert-Eaton myaesthenic syndrome
  • Neurologic disorder - polyneuropathy, motor neurone disease
  • Causes of Parkinsonism

  • Parkinson’s disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
  • Parkinson’s Plus Syndromes

  • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
  • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
  • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
  • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
  • Others

  • Drugs - antipsychotics, metoclopramide, lithium
  • Normal pressure hydrocephalus
  • Hypoxic brain injury
  • Wilson’s disease
  • Causes of Radiculopathy

  • Intervertebral disc herniation
  • Osteoarthritis (osteophytosis)
  • Diabetes
  • Haematoma - epidural / subdural
  • Malignancy - spine, spinal cord
  • Infection - epidural abscess, tuberculosis, Lyme disease, syphilis, herpes zoster

Motor Assessment

  • Causes of Weakness

  • Upper Motor Neuron

  • CNS lesions - decreased power with increased tone, clonus and reflexes.Ischaemia, SAH / ICH, tumour, trauma, encephalitis, vasculitis, MS, ADEM, PML, sarcoidosis, prions
  • Lower Motor Neuron

  • Nerve root pathology - loss of a single myotomeTrauma, radiculopathy, neoplasm
  • Focal peripheral nerve pathology - in the muscles supplied by a single nerveTrauma, entrapment, focal ischaemia, sarcoidosis, neoplasia, Bell’s palsy (face)
  • Axonal pathology (peripheral neuropathy)Diabetes, motor neurone disease, hypothyroidism, B12 / folate deficiency, alcoholism, connective tissue disease, amyloid / sarcoidosis, toxins
  • Peripheral demyelinationGuillain-Barré syndrome, Charcot-Marie-Tooth
  • Other

  • Neuromuscular pathologyMyasthenia gravis, amyloidosis
  • Muscular pathologyPolymyositis, rhabdomyolysis
  • Poor compliance with examination

Overview

  • Signs of Distal Weakness

  • Wasting of the small muscles of the hand
  • Foot drop
  • Distal weakness - particularly affecting the hands, wrists and ankles
  • Distal functional impairment - difficulty opening jars, turning a key, buttoning a shirt
  • Signs of Peripheral Polyneuropathy

  • Lower motor neuron weakness affecting multiple nerve distributions
  • Sensory loss affecting multiple nerve distributions

Active Movement

  • Significance

  • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

Overview

Triceps tendon - posteriorly, inserting onto the olecranon.
  • Muscles Involved

  • Pronator teres, pronator quadratus, brachioradialis.

Muscles Acting on the Elbow Joint

Extensors (posterior) - triceps brachii, aconeus

Overview

  • Muscles Involved

  • Triceps brachii, aconeus.

Bony Landmarks of the Elbow

Medial epicondyle - medial projection of the humerus.

Overview

  • Causes of a Warm Joint

  • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
  • Bursitis
  • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
  • Vascular - DVT, superficial thrombophlebitis, venous insufficiency
  • Tip

  • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.
Look between the olecranon, radial head and lateral epicondyle for a subtle concavity - loss of this is indicative of joint effusion.

Muscle Wasting

  • Causes of Muscle Wasting

  • Normal aging
  • Disuse
  • Malnutrition - poor diet, malabsorption, cancer
  • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
  • Muscular disorders - inflammatory myopathy, muscular dystrophies
  • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

Overview

  • Muscles Involved

  • Supinator, biceps brachii, barchioradialis
  • Muscles Involved

  • Biceps brachii, brachialis, brachioradialis, pronator teres.
  • Muscles Involved

  • Tibialis anterior, extensor digitorum longus, extensor hallucis longus.
Peroneal tendons (peroneus longus and brevis) - laterally, passing posterior to the lateral malleolus.

Muscle Wasting

  • Causes of Muscle Wasting

  • Normal aging
  • Disuse
  • Malnutrition - poor diet, malabsorption, cancer
  • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
  • Muscular disorders - inflammatory myopathy, muscular dystrophies
  • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

Bony Landmarks of the Ankle

Lateral malleolus - of the distal fibula.

Overview

  • Muscles Involved

  • Peroneus longus, peroneus brevis, soleus, gastrocnemius, plantaris, tibialis posterior, flexor digitorum longus, flexor hallucis longus.
  • Causes of a Warm Joint

  • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
  • Bursitis
  • Baker’s cyst
  • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
  • Vascular - DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema

Active Movement

  • Significance

  • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

Overview

  • Muscles Involved

  • Tibialis anterior, tibialis posterior
Subtalar joint - articulation of the talus and calcaneus, allowing inversion and eversion of the ankle.
Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
Dorsalis pedis - palpate lateral to the extensor tendon of the great toe. This can be identified by asking the patient to extend their great toe.
  • Causes of Joint Swelling

  • Trauma - fracture, muscle sprain or rupture, compartment syndrome
  • Musculoskeletal - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, tenosynovitis
  • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
  • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
  • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition

Muscles Acting on the Ankle Joint

Dorsiflexors (anterior) - tibialis anterior, extensor digitorum longus, extensor hallucis longus

Overview

  • Muscles Involved

  • Peroneus longus, peroneus brevis
  • Tip

  • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.
Semitendinosus tendon - medial, inserting posteriorly onto the medial body of the tibia. More lateral and more superficial than the semimembranosus tendon.

Active Movement

  • Significance

  • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

Muscles Acting on the Knee Joint

Extensors (anteriorly) - rectus femoris, vastus medialis, vastus lateralis, vastus intermedius

Overview

  • Look For

    The relationship between the positions of the head, trunk, upper and lower limbs.
  • Head & neck - tilt and rotation
  • Shoulders - level of shoulders, scapular prominence
  • Chest - deformities
  • Spine - kyphosis, lordosis and scoliosis
  • Pelvis - pelvic tilt
  • Legs - angle between thigh and leg (genu valgum / varum)
  • Feet - position, pronation
  • Causes of Absent Pulse

  • Trauma
  • Atherosclerosis
  • Abdominal aortic aneurysm
  • Shock
  • Causes of Joint Swelling

  • Trauma - fracture, patellar dislocation, muscle sprain or rupture, compartment syndrome
  • Popliteal (Baker’s) cyst
  • Bursitis
  • Tenosynovitis
  • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
  • Skin / soft tissue infection - cellulitis, abscess
  • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
  • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition

True Leg Length Discrepancy

  • How to Assess

  • Measure from the anterior superior iliac spine (ASIS) to the medial malleolus

Overview

  • Significance

  • Joint line tenderness and fullness are both indicative of menisceal tears.
The anterior and posterior cruciate ligaments lie within the knee joint and therefore may not be palpated.

Muscle Wasting

  • Causes of Muscle Wasting

  • Normal aging
  • Disuse
  • Malnutrition - poor diet, malabsorption, cancer
  • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
  • Muscular disorders - inflammatory myopathy, muscular dystrophies
  • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

Overview

  • Tip

  • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.
  • Causes of a Warm Joint

  • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
  • Bursitis
  • Baker’s cyst
  • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
  • Vascular - DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
  • Muscles Involved

  • Rectus femoris, vastus medialis, vastus lateralis, vastus intermedius
  • Muscles Involved

  • Popliteus, semimembranosus, semitendinosus

Bony Landmarks of the Knee

Tibial tuberosity - palpate for the attachment of the patellar tendon. Note any tenderness, which may be indicative of avulsion fracture or inflammation of the insertion of the patellar tendon (Osgood Schlatter disease)

Overview

Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
  • Muscles Involved

  • Biceps femoris, semitendinosus, semimembranosus, sartorius, gracilis, popliteus, gastrocnemius

Major Bursae of the Knee

Infrapatellar bursa - superficial or deep; inferior to the patella. Bursitis presents as a palpable swelling inferior to the patella.

Overview

  • Muscles Involved

  • Biceps femoris, sartorius
Mood is the patient's subjective assessment of their emotional status.
  • Causes of Abnormal Speech

  • Psychiatric disorder - mood disorder, anxiety, schizophrenia
  • Confusion - delirium, dementia, intellectual disability
  • Dysphasia / aphasia
  • Dysarthria - stroke, brain injury, Parkinson’s, MS
  • Dysphonia - laryngitis, neuropathology, trauma, mass, atrophy, systemic disease
  • Hearing impairment
  • English as a non-native language
  • Intoxication
  • Ask About

  • Recent memory - what is my name; what did you have for breakfast; what meds did you take today?
  • Remote memory - when and where did you get married?
  • Causes of Distractability

  • Normal behaviour
  • Mania
  • Depression
  • Anxiety
  • Psychosis
  • Advanced age
  • Significance

  • A test of ability to inhibit, a part of frontal lobe executive function.
  • Wire cube - ask the patient to copy a diagram of a wire cube.
  • Wire cube - ask the patient to copy a diagram of a wire cube.
  • How to Assess

  • Ask the patient to remember three words (colour, animal, object) and ask them to repeat them in five minutes.

Resting Tremor

  • Look For

  • Tremor while at rest, that decreases with target-directed movement.

Normal Variations of Thought Form

Concrete thinking: thought that is almost exclusively informed by immediate sensory experiences, rather than abstractions.

Overview

Generalised anxiety: heightened anxiety with no specific cause.
  • Causes of Disordered Writing

  • Confusion - delirium, dementia, intellectual disability
  • Apraxia - frontotemporal dementia, Alzheimer’s
  • Poor compliance

Apraxia

The inability to perform movements despite intact motor and sensory systems.

Overview

  • Types of Hallucinations

  • Auditory hallucinations - including commentary, insulting voices, Gedanklautwerden, echo de la pensee
  • Visual hallucinations - may be simple (such as flashes or colours) or complex (such as people, animals or objects)
  • Olfactory / gustatory hallucinationsSuggestive of frontal / temporal injury
  • Tactile hallucinationsCan occur in delerium tremens or with cocaine
  • Extracampine hallucinations: sensations that would be physically impossible, such as seeing through walls
  • Significance

  • Loss of abstract processing is common in fronto-temporal dementia.
  • Causes of Impaired Judgement

  • Organic disorder
  • Acute intoxication
  • Schizophrenia
  • Bipolar disorder
  • How to Assess

  • Give the patient a page with many lines oriented at various angles. Ask the patient to cross every line. Examine the page to see whether they have missed one side of the page.
  • Ask the patient to draw a clock face, looking for missing numbers on one side of the clock.
  • Significance

  • Difficulty with categories may be a result of dysphasia, dysarthria, confusion or poor compliance.
  • Significance

  • Orientation is a quick way of assessing patients for confusion.

Richmond Agitation-Sedation Scale

  • Interpretation

  • +4
    Combative: violent, immediate danger to staff
  • +3
    Very agitated: pulling or removing tubes; aggressive
  • +2
    Agitated: Frequent non-purposeful movements; fights ventilator
  • +1
    Restless: anxious without aggressive or vigorous movement
  • 0
    Alert and calm
  • -1
    Drowsy: Not alert, but sustained eye contact to voice (>10 seconds)
  • -2
    Light sedation: briefly awakens with eye contact to voice (<10 seconds)
  • -3
    Moderate sedation: movement or eye opening to voice with no eye contact
  • -4
    Deep sedation: no response to voice, movement or eye opening to physical stimulation
  • -5
    Unrousable: no response to voice or physical stimulation

Overview

  • Normal Span

  • 6 ± 1 digits
Anorexia / bulimia nervosa - a belief that they are overweight.

Comprehension

CLOSE YOUR EYES

Overview

  • Causes of Disordered Reading

  • Pure alexia - reading of words letter-by-letter.
  • Surface dyslexia - ability to phonetically sound out words (breed, steam), but difficulty reading words with irregular spelling (debt, colonel, broad, steak).
  • Phonological dyslexia - inability to read non-words (neg, bluck, deak) with otherwise normal reading of words.
  • Deep dyslexia - semantic errors (e.g. reading the word ‘table’ as ‘chair’ or ‘street’ as ‘road’), and inability to read plausible non-words (neg, bluck, deak).Stroke, traumatic brain injury
  • Neglect dyslexia - the patient omits or substitutes part of a word, especially at the beginning of the word. For example, island / land or fish / dish.Dominant hemispheric damage
Grandiose delusions - of wealth / powerAcute mania

The Glasgow Coma Scale (GCS)

The Glasgow coma scale (GS) is a 15-point scale that uses three components - eye opening, response to voice and motor response - to indicate a patient's level of consciousness. Originally developed for use in trauma patients, this scale is now used on an every day basis to assess patients in an acute setting.

Overview

  • Muscles Involved

  • Scalenes, levator scapulae

Vertebral Landmarks

C1 - feel for the transverse processes between the angle of the mandible and the mastoid, asking the patient to turn their head.

Muscle Wasting

  • Causes of Muscle Wasting

  • Normal aging
  • Disuse
  • Malnutrition - poor diet, malabsorption, cancer
  • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
  • Muscular disorders - inflammatory myopathy, muscular dystrophies
  • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

Overview

  • Muscles Involved

  • Splenius muscles, semispinalis muscles, erector spinae, trapezius
  • Muscles Involved

  • Rectus abdominis, internal & external oblique.
Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
  • Muscles Involved

  • Quadratus lumborum, internal & external oblique, multifidus

Active Movement

  • Significance

  • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

Overview

  • Muscles Involved

  • Erector spinae, latissimus dorsi.
  • Muscles Involved

  • Sternocleidomastoid, scalenes, longus muscles, rectus capitis

Active Movement

  • Significance

  • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

Overview

  • Muscles Involved

  • Internal & external oblique, multifidus.
  • Significance

  • The cervical spine is normally lordosed, and loss of lordosis or hyperlordosis may result in neck pain and headaches.
  • Muscles Involved

  • Sternocleidomastoid, splenius muscles, levator scapulae, erector spinae
  • Tip

  • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.

Muscles Acting on the Cervical Spine

Extensors - splenius muscles, semispinalis muscles, erector spinae, trapezius

Oropharyngeal Examination

  • How to Perform

  • Ask the patient to open their mouth and make an ‘ahh' sound, in order to contract the palate and uvula. Depress the tongue if required in order to visualise the posterior pharynx.

Overview

  • How to Assess

  • Palpate the patient's posterior chest and ask them to say ‘ blue balloons'. Start at the top of the chest and move to the bottom, comparing both sides.
  • How to Assess

  • Ask the patient to take deep breaths in and out through their mouth. Auscultate from left to right, noting symmetry of breath sounds.

Conjunctival Pallor

Conjunctival pallor is a useful sign of severe anaemia.

Heart Rate

    • Normal Range

    • 60 - 100bpm

Overview

  • How to Assess

    Auscultate the patient's chest, starting at the top and moving to the bottom, as they perform the following:
  • Bronchophony - ask the patient to say ‘ blue balloons’.
  • Egophony - ask the patient to say ‘eeee’.
  • Whispered pectoriloquy - ask the patient to whisper ‘blue balloons’.
    • Normal Range

    • 12 - 20 breaths per minute
  • How to Perform

  • Use an otoscope to inspect straight backward into the nasal cavity.

Wasting of Hand Muscles

  • Look For

  • Decreased mass of the thenar and/or hypothenar eminence.

Digital Clubbing

  • Causes of Digital Clubbing

  • Cyanotic congenital heart disease
  • Pulmonary malignancy - lung cancer, lymphoma, mesothelioma
  • Chronic infection / inflammation - bronchiectasis, lung abscess, empyema, interstitial lung disease, coeliac disease, IBD, infective endocarditis
  • Cirrhosis

Overview

  • How to Perform

  • Place your left middle finger over the patient's chest, and strike the distal interphalangeal joint with your right middle finger. Tap 2-3 times, rotating the right wrist and allowing it to fall with consistent force.

Pathogenesis

  • Risk Factors for Lung Cancer

  • Genetic factors
  • Smoking (active or passive)
  • Air pollution
  • Occupational exposure - asbestosis, silicosis,
  • Chronic scarring - interstitial lung disease, tuberculosis, COPD
  • Alcohol

Overview

  • Causes of Bronchiectasis

  • Congenital

  • Cystic fibrosis
  • Primary ciliary dyskinesia (e.g. Kartegener’s syndrome)
  • Hypogammaglobulinaemia
  • Acquired

  • Recurrent pneumonia (e.g. in the setting of immunosuppression) - bacterial, tuberculous, fungal
  • Chronic obstructive pulmonary disease (COPD)
  • Allergic bronchopulmonary aspergillosis (ABPA)
  • Autoimmune diseases - rheumatoid arthritis, Sjogren’s syndrome, ulcerative colitis
  • Chronic aspiration (e.g. secondary to gastroesophageal reflux)
  • Airway foreign body

Pathogenesis

  • Causes of Interstitial Lung Disease

  • ILD of Known Association

  • Connective tissue disease - rheumatoid arthritis, scleroderma, systemic lupus erythematosus, Sjogren’s syndrome, polymyositis / dermatomyositis
  • Medications - methotrexate, nitrofurantoin, bleomycin
  • Occupational exposure - silicosis, asbestosis
  • Granulomatous ILD

  • Sarcoidosis
  • Hypersensitivity pneumonitis
  • Idiopathic Interstitial Pneumonias

  • Idiopathic pulmonary fibrosis
  • Others - idiopathic non-specific interstitial pneumonia, acute interstitial pneumonia, cryptogenic organising pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia

Overview

    • Normal Range

    • >90%
  • Causes of Pleural Effusion

  • Exudative

  • Malignancy
  • Infection - parapneumonic effusion, empyema, viral, fungal, TB, ruptured abscess / cyst
  • Pulmonary embolism (90% exudative)
  • Autoimmune disease - rheumatoid pleuritis, SLE
  • Pancreatitis
  • Haemothorax
  • Chylothorax
  • Asbestosis
  • Uraemia
  • Oesophageal rupture
  • Transudative

  • Heart failure
  • Cirrhosis
  • Hypoalbuminaemia
  • Nephrotic syndrome
  • Pulmonary embolism (10% transudative)
  • Myxoedema
  • Meig’s syndrome
  • Constrictive pericarditis
  • SVC obstruction
  • Urinothorax
  • Signs of Chronic Obstruction Pulmonary Disease

  • General Signs

  • Respiratory distress - tachypnoea, pursed lip breathing, accessory muscle use, intercostal / subcostal recession
  • Barrel chest (emphysema)
  • Tar-stained fingers (smoking)
  • Asterixis (CO2 retention)
  • Reduced chest expansion
  • Reduced breath sounds
  • Wheeze
  • Signs of Complications

  • Infective exacerbation - fevers, green sputum
  • Cor pulmonale - raised JVP, ascites, pleural effusions, peripheral oedema
  • Pulmonary hypertension - prominent a wave, parasternal heave, loud / palpable P2
  • Polycythaemia - polycythaemic facies
  • Steroid complications - Cushing’s syndrome, oral candidiasis
  • Signs of Management

  • Oxygen
  • Inhalers
  • Lung transplant scar
  • Muscles Involved

  • Extensor pollicis longus, extensor pollucis brevis
  • Muscles Involved

  • Dorsal interossei, abductor digiti minimi (5th finger)

Muscles Acting on the Wrist Joint

Extensors (posterolateral) - extensor carpi radialis longus & brevis, extensor carpi ulnaris

Overview

  • Muscles Involved

  • Abductor pollucis longus, abductor pollucis brevis
  • How to Elicit

  • Percuss over the flexor retinaculum.
  • Causes of a Warm Joint

  • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
  • Bursitis
  • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
  • Vascular - DVT, superficial thrombophlebitis, venous insufficiency
  • Muscles Involved

  • Palmar interossei
  • How to Perform

  • Ask the patient to forcibly flex their wrists into a reverse prayer sign for 30-60 seconds.
  • Tip

  • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.
  • Muscles Involved

  • Flexor digitorum profundus & superficialis, flexor digiti minimi brevis (5th finger)
  • Muscles Involved

  • Flexor carpi radialis, extensor carpi radialis longus & brevis
  • Muscles Involved

  • Flexor pollucis longus, flexor pollucis brevis
  • Muscles Involved

  • Opponens pollucis

Muscle Wasting

  • Causes of Localised Wasting

  • Forearm flexor wasting - median nerve lesion, e.g. entrapment at or above the cubital fossa
  • Thenar wasting - median nerve lesion, e.g. entrapment at or above the carpal tunnel
  • Hypothenar wasting (ulnar nerve) - ulnar nerve lesion e.g. entrapment at or above the cubital fossa

Bony Landmarks of the Wrist

Styloid process of ulna - distally.

Overview

  • Muscles Involved

  • Extensor carpi radialis longus & brevis, extensor carpi ulnaris

Wrist Drop

  • Significance

  • A classical sign of radial nerve lesion.

Active Movement

  • Significance

  • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

Soft Tissue Landmarks of the Wrist

Ulnar canal (Guyon's canal) - medial & volar aspect of the hand, superficial to the flexor retinaculum

Overview

  • Muscles Involved

  • Flexor carpi ulnaris, extensor carpi ulnaris
  • Muscles Involved

  • Adductor pollicis
  • Muscles Involved

  • Extensor digitorum, extensor digiti minimi, extensor indicis
  • Causes of Wrist Swelling

  • Trauma - fracture, muscle sprain or rupture, compartment syndrome
  • Musculoskeletal - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, tenosynovitis
  • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
  • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
  • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition
  • Muscles Involved

  • Flexor carpi radialis, palmaris longus, flexor carpi ulnaris

Pitting Oedema

  • How to Elicit

  • Apply pressure to the anterior aspect of the tibia for fifteen seconds and then release.

Contour

Rapid rate of risePremature ventricular contraction, mitral regurg, VSD, aortic regurgitation, HOCM

Venous Skin Changes

  • Look For

  • Oedema
  • Venous eczema
  • Hyperpigmentation
  • White scar tissue (atrophie blanche)
  • Induration - fibrosis of subcutaneous fat (lipodermatosclerosis)

Overview

Popliteal - bend the patient's knee to 90 degrees, gently grasp both sides of the knee joint and palpate using tips of fingers within the popliteal fossa posteriorly.

Inspection of Pupils

  • Normal Pupillary Size

  • In the dark - 4-8mm
  • Under bright light - 2-4mm

Rashes Associated with Diabetes

Granuloma annulare: smooth, ring-like erythematous plaquesBenign, diabetes

Overview

  • How to Perform

  • Dim the lights and examine the fundus using a traditional direct or PanOptic ophthalmoscope.

Lower Limb Erythema

  • Look For

  • Redness - unilateral, bilateral, localised or diffuse.

Overview

  • Interpretation

  • Spacticity (clasp knife): velocity dependant, quick flexion / extension of the joint (works best on knee / elbow)Upper motor neuron lesion
  • Lead pipe rigidity: continuous and not velocity dependant, slow flexion / extensionParkinsonism / Parkinson’s disease, contractures
  • Cogwheel rigidity: rigidity associated with tremor, resulting in jerky stop / start movement of the jointParkinsonism / Parkinson’s disease
  • Normal: minimal resistance
  • Decreased: no resistanceLower motor neuron or cerebellar lesion

Weight

  • Look for

  • The patient’s current weight
  • Change in weight - compare to past weights
  • Time course - sudden / gradual

Cheyne-Stokes Respiration

  • Significance

  • Cheyne-Stokes respiration occurs when hyperventilation lowers the arterial CO₂ below the apnoeic threshold.

Overview

  • How to Assess

  • Ask the patient to move their fingers, thumb, wrist, elbow and shoulder through each movement.

Oral Candidiasis

  • Significance

  • Infection with Candida species.

Dehydration

  • Causes of Dehydration

  • Poor fluid intake
  • Fluid loss - diarrhoea, vomiting, sweating, diuresis (diabetes, diuretics)

Overview

  • How to Assess

  • Apply pressure to the nail bed until it blanches, release and measure the time taken for colour to return.
If the reflex is difficult to elicit, reassess the reflex while the patient clenches their teeth.

Onycholysis

  • Look For

  • Separation of the nail from the nail bed, either distally or laterally.

Overview

If the patient wears corrective lenses, perform the test with and without them.
  • Interpretation

  • Hum - low, constant murmurNormal jugular venous hum
  • Bruit - abnormal systolic sound (turbulent flow)Carotid stenosis, transmitted murmur of aortic stenosis
  • Significance

  • Due to thickening of the palmar and digital fascia, resulting in fibrous band formation and flexion contractures of the MCP and PIP joints.

Arterial Ulcers

The presence of white, painful ulcers suggests a partial or complete arterial occlusion.

Overview

  • Interpretation

  • Central - tends to involve an entire upper and / or lower limbIschaemia, SAH / ICH, tumour, trauma, encephalitis, vasculitis, MS, ADEM, PML, sarcoidosis
  • Axon - Begins distally and migrates proximally → glove and stocking’ distributionDiabetes, hypothyroidism, B12 / folate deficiency, alcoholism, connective tissue disease, amyloid / sarcoidosis, toxins
  • Myelin sheath (demyelination) - impaired proprioception and vibration sensation with intact pain sensationGuillain-Barré syndrome, CIDP, Charcot-Marie-Tooth
  • Nerve root - in the distribution of a single dermatomeTrauma, radiculopathy, neoplasm
  • Peripheral nerve - in the distribution of a peripheral nerveTrauma, entrapment, focal ischaemia, neoplasia, shingles, nerve block
  • Skin receptors - localised to an area not in keeping with a dermatomal or peripheral nerve patternTrauma, local anaesthesia, full thickness burns
  • Causes of Cool Extremities

  • Peripheral arterial disease
  • Compartment Syndrome
  • Shock
  • Low cardiac output, due to cardiac disease

Comprehension

CLOSE YOUR EYES

The Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is a 15-point scale indicating level of consciousness.

Overview

  • Wire cube - ask the patient to copy a diagram of a wire cube.
  • Wire cube - ask the patient to copy a diagram of a wire cube.
  • Causes of Myotonia

  • Myotonic Dystrophy

  • Dystrophia myotonia
  • Myotonia congenita
  • Non-Dystrophic Myotonia

  • Paramyotonia congenita
  • Acid maltase deficiency
  • How to Assess

  • Buttoning: ask the patient to button and unbutton their shirt front or shirt cuff.Fine motor coordination
  • Unscrewing: ask the patient to unscrew a jar or bottle cap.Hand strength
  • Key turning: ask the patient to demonstrate how they would pick up a key, insert it into a lock and unlock the door.Fine motor coordination
  • How to Elicit

  • Biceps - ask the patient to relax their arms in their lap. Identify the biceps tendon within the antecubital fossa and strike it with a tendon hammer.C5 / C6 myotome
  • Supinator - ask the patient to relax their arms in their lap and strike the brachioradialis tendon, proximal to the wrist on the lateral aspect of the forearm.C7 myotome
  • Triceps - lift the patient's shoulder into abduction and internal rotation, with the arm flexed to 90°. Identify the triceps tendon on the posterior aspect of the arm proximal to the olecranon, and strike it with a tendon hammer.C6 myotome
Central cord syndrome - bilateral upper motor neuron weakness affecting the upper limbs more than the lower limbs, and loss of proprioception and vibration sensation (dorsal column)Commonly due to trauma or hyperextension of the cervical spine
  • Causes of Radiculopathy

  • Intervertebral disc herniation
  • Osteoarthritis (osteophytosis)
  • Diabetes
  • Haematoma - epidural / subdural
  • Malignancy - spine, spinal cord
  • Infection - epidural abscess, tuberculosis, Lyme disease, syphilis, herpes zoster
  • How to Assess

  • Ask the patient to relax and allow you to move their arms. Move the wrists and elbows passively through their range of motion, assessing for rigidity.

Cutaneous Manifestations of Neurologic Disease

  • Signs of Tuberous Sclerosis Complex (TSC)

  • Angiofibromata: pink papules in the nasolabial folds
  • Shagreen patches: soft flesh-coloured patches on the trunk
  • Ash leaf macules: hypopigmented flat spots

Overview

  • Causes of Brachial Plexopathy

  • Trauma - shoulder dystocia, motor vehicle accident, blunt trauma, penetrating injury
  • Malignancy - apical lung tumour, metastasis
  • Neurogenic thoracic outlet syndrome
  • Brachial neuritis
  • Radiation
  • How to Perform

  • Ask the patient to forcibly flex their wrists into a reverse prayer position for 30-60 seconds.
  • Signs of Peripheral Polyneuropathy

  • Lower motor neuron weakness affecting multiple nerve distributions
  • Sensory loss affecting multiple nerve distributions
  • How to Perform

  • Ask the patient to move their fingers, thumb, wrist, elbow and shoulder through each movement.
  • Signs of Myaesthenia Gravis

  • Skeletal Muscle Fatiguability

  • Simpson’s test - ptosis on sustained upward gaze
  • Peek sign - inability to maintain sustained eye closure
  • Bulbar fatiguability - development of nasal speech with reading
  • Proximal muscle fatigability - inability to maintain arms above the head
  • Signs of Management

  • Thymectomy scar
  • Look For

  • Wide-based, ataxic gait
  • Dysarthria
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Muscle wasting
  • Nystagmus
  • Causes of Peripheral Mononeuropathy

  • Compression (particularly carpal tunnel and ulnar tunnel) - prolonged pressure, hereditary neuropathy with liability to pressure palsies (HNPP)
  • Trauma - blunt trauma, penetrating injury (e.g. knife, gunshot, glass)
  • Nerve ischaemia - trauma, thromboembolism, diabetes, atherosclerosis, excessive tourniquet use
  • Radiation injury
  • Signs of Mononeuritis Multiplex

  • Lower motor neuron weakness affecting two or more distinct peripheral nerve distributions
  • Sensory loss affecting two or more distinct peripheral nerve distributions
  • Sensory Modalities

  • Dorsal column pathway - proprioception, vibration sensation, soft touch
  • Spinothalamic pathway - pain sensation, temperature sensation, soft touch
Motor neurone disease does not present with sensory involvement or ocular palsy.
  • Causes of Parkinsonism

  • Parkinson’s disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
  • Parkinson’s Plus Syndromes

  • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
  • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
  • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
  • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
  • Others

  • Drugs - antipsychotics, metoclopramide, lithium
  • Normal pressure hydrocephalus
  • Hypoxic brain injury
  • Wilson’s disease
  • Look For

  • Wide-based, ataxic gait
  • Dysarthria
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Muscle wasting
  • Nystagmus

Abnormal Posturing

  • Interpretation

  • Decorticate - flexion, adduction and internal rotation of the arms; supination of the forearms and extension of the legs.Damage to cerebral hemispheres with brain stem preservation
  • Decerebrate - extension of the arms, pronation of the forearms extension of the legsDamage to upper brain stem
  • Opisthotonic - secerebrate posturing with posterior arching of the neck and back.Severe damage to the upper brain stem

Overview

  • Differential Diagnosis of Proximal Weakness

  • Proximal myopathy
  • Neuromuscular disorder - myaesthenia gravis, Lambert-Eaton myaesthenic syndrome
  • Neurologic disorder - polyneuropathy, motor neurone disease
  • How to Elicit

  • Ask the patient to place their arms up and out in front of them with the wrists extended. 
  • Look for an intermittent loss of tone in the wrists, with the appearance of a flap. 

Weight

  • Look for

  • The patient’s current weight
  • Change in weight - compare to past weights
  • Time course - sudden / gradual

Candidiasis

  • Significance

  • Infection with Candida species.

Overview

  • How to Assess

  • Using the pulps of the fingers, gently palpate each of the lymph node groups within the cervical and axillary regions.

Digital Clubbing

  • Causes of Digital Clubbing

  • Cyanotic congenital heart disease
  • Pulmonary malignancy - lung cancer, lymphoma, mesothelioma
  • Chronic infection / inflammation - bronchiectasis, lung abscess, empyema, interstitial lung disease, coeliac disease, IBD, infective endocarditis
  • Cirrhosis

Rashes Associated with GI Disease

Dermatitis herpetiformis: itchy papules and vesicles found on the scalp and extensor surfaces.Coeliac disease

Rectal Masses

  • Causes of Rectal Masses

  • Haemorrhoid (thrombosed / prolapsed)
  • Polyp / cancer
  • Perianal abscess
  • Prostatic enlargement - BPH, prostatitis, cancer
  • Malpositioned pessary

Renal Bruits

  • Significance

  • Turbulent blood flow due to renal artery stenosis - either fibrotic or atherosclerotic.

Common Signs on the Tongue

Microglossia: small tonguePseudobulbar palsy

Overview

The internal anal sphincter (IS, autonomic) is responsible for the majority of resting anal tone, while the external sphincter (ES, voluntary) is responsible for the act of squeezing.

Poor Dentition

  • Causes of Poor Dentition

  • Poor oral hygiene
  • High-sugar diet
  • Malnutrition
  • Lack of fluoride
  • Diabetes
  • Alcoholism
  • Smoking

Overview

  • Causes of Peritonitis

  • Infection post perforation - appendix, diverticulitis, IBD, perforated ulcer, surgical anastomosis
  • Spontaneous bacterial peritonitis (SBP)
  • Blood - endometriosis, ruptured ovarian cyst, trauma
  • Bile - post-surgical
  • Urine - pelvic trauma
  • Pancreatic fluid - pancreatitis

Xanthelasma

  • Look For

  • Yellowish plaques on the eyelids.

Dehydration

  • Causes of Dehydration

  • Poor fluid intake
  • Fluid loss - diarrhoea, vomiting, sweating, diuresis (diabetes, diuretics)

The Glasgow Coma Scale (GCS)

15-point scale indicating level of consciousness.

Overview

Chaperone - where possible, have a chaperone present.
  • How to Elicit

  • Using the pulps of the fingers, gently palpate the lymph nodes along the inguinal ligament and down the medial aspect of the thigh.

Segments of the Abdomen

For the purposes of clinical examination, the abdomen is broken into nine segments, each of which contain important organs to assess.

Overview

  • Causes of Ascites

  • Cirrhosis
  • Heart failure
  • Constrictive pericarditis
  • Peritonitis - tuberculous, neoplasmic, bacterial
  • Hypoalbuminaemia - nephrotic syndrome, malnutrition
  • Pancreatitis
  • Cancer - liver, stomach, pancreas, adrenals, gut
  • Thrombosis - portal vein, mesenteric vessels
  • Ovarian disease
  • Hypothyroidism
  • Dialysis
  • How to Assess

  • Place the hands on either side of the midline and identify the outermost margin of the aorta.

Rashes Associated with GI Disease

Dermatitis herpetiformis: itchy papules and vesicles found on the scalp and extensor surfaces.Coeliac disease

Gingival Inflammation

Abscess - localised swelling and erythema.Bacterial infection

Renal Percussion

Flank tenderness to percussion is a relatively sensitive sign for renal pathology, especially pyelonephritis and perinephric abscess.

First Steps

Chaperone - where possible, have a chaperone present.

Overview

  • Signs of Chronic Liver Disease

  • General Signs

  • Sarcopaenia
  • Jaundice (a late sign)
  • Leukonychia
  • Signs Suggesting a Cause

  • Obesity (NAFLD)
  • Scratch marks (cholestasis)
  • Tattoos (viral hepatitis)
  • Kayser-Fleischer rings (Wilson’s disease)
  • Cerebellar signs (alcohol misuse)
  • Signs of Complications

  • Portal hypertension - splenomegaly, caput medusae
  • Ascites - shifting dullness, fluid thrill
  • Oestrogen excess - palmar erythema, spider naevi, gynaecomastia
  • Encephalopathy - confusion, asterixis
  • Hepatic hydrothorax - reduced breath sounds, dull percussion note
  • Spontaneous bacterial peritonitis - fever, rigid / tender abdomen
  • Coagulopathy / thrombocytopaenia - bruising, bleeding
  • Signs of Management

  • Dressing over recent abdominocentesis site
  • Liver transplant scar
  • Causes of Weight Gain

  • Dietary intake
  • Physical exercise
  • Endocrine - hypothyroidism, Cushing’s, PCOS
  • Medications - steroids, antidepressants, antipsychotics, OCP
  • Fluid overload - excessive IV fluids, renal disease, heart failure
  • Genetic (rare)

Joint Swelling

  • Significance

  • May be a sign of an intra-articular bleed.

Focal Abdominal Tenderness

Epigastrium - liver, gallbladder, stomach, transverse colon, pancreas, heartPancreatitis, peptic ulcer, reflux

Pallor

Skin pallor is a sign of anaemia.

Chest Wall Tenderness

  • Causes of Chest Wall Tenderness

  • Trauma - sprain, strain, haematoma, rib fracture
  • Costochondritis
  • Fibromyalgia
  • Rheumatic disease - rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, lupus, septic arthritis
  • Neoplastic bone pain

Palmar Crease Pallor

  • Causes of Palmar Crease Pallor

  • Anaemia
  • Low cardiac output, due to cardiac disease
  • Peripheral shutdown, due to increased sympathetic activity

Overview

  • How to Assess

  • Using the pulps of the fingers, gently palpate each of the lymph node groups within axillary region.
  • How to Elicit

  • Apply gentle pressure to the right lower quadrant. Ask the patient to take a deep breath in. Move the hand superiorly and medially each time the patient breathes out and repeat until the left costal margin is reached. Repeat with the patient in the right lateral decubitus position.

Bony Tenderness

  • Significance

  • May be an indicator of malignancy.

Hepatomegaly

  • How to Perform

  • Percussion of upper liver edge - Percuss down the midclavicular line from the level of the third rib, with the struck finger held horizontal to the ribs. Once the top edge of the liver is percussed the percussion note will become dull.

Joint Swelling

  • Significance

  • May be a sign of an intra-articular bleed.

Purpura

  • Significance

  • Liver disease can result in purpura due to both clotting factor deficiency (intrahepatic) and vitamin K malabsorption (obstructive).

Overview

  • How to Perform

  • Using the pulps of the fingers, gently palpate each of the lymph node groups within the cervical and axillary regions.

Oropharyngeal Inspection

  • Look For

  • Erythema
  • Swelling of tonsils
  • Exudate
  • Ulcers - viral infection, neoplasm
  • Petechiae on soft palate - pathognomonic for bacterial infection

Abdominal Mass

Right hypochondrium - liver, gallbladder, head of pancreasHepatomegaly, gallbladder enlargement, pancreatic head carcinoma

Overview

  • Feel For

  • Size - normally <10mm
  • Tenderness
  • Consistency - hard (metastasis), rubbery (lymphoma), soft (reactive)
  • Mobility - mobile or tethered to underlying structures
Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.

Jerk Nystagmus

  • How to Perform

  • Ask the patient to look at your finger, held ~50cm in front of their eyes (in primary position). Repeat in the extremes of left and right lateral gaze, as well as in superior and inferior gaze.

Overview

  • Look For

  • Wide-based, ataxic gait
  • Dysarthria
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Muscle wasting
  • Nystagmus
  • Significance

  • Patients with cerebellar disease will have particular difficulty with this task as it eliminates their normally wide-based gait.

Testing for Station

  • Abnormal If

  • Loss of balance.

Overview

  • How to Assess

  • Ask the patient to touch their nose with the tip of their index finger, and then touch your finger. Repeat after moving your finger. Repeat with the other side.
  • How to Elicit

  • Ask the patient to place one hand in the palm of the other hand. Demonstrate rapidly flipping (pronation and supination) of the hand, asking for them to mimic this movement.
  • Significance

  • If the motor and sensory modalities are intact, inability to perform this test smoothly is suggestive of ipsilateral cerebellar disease.
  • Abnormal If

  • Inability to rapidly alternate movements.
  • Significance

  • Inability to maintain plantar flexion is indicative of muscular weakness or an S1 lesion.
  • Interpretation

  • Inability to maintain dorsiflexion is indicative of muscular weakness or an L4/L5 lesion.
  • Significance

  • Suggests a lesion affecting the arcuate fasciculus of the dominant hemisphere, which connects Wernicke’s and Broca’s areas.
  • Signs of Ataxic Dysarthria

  • Slurred speech - imprecise consonants
  • Slow speech rate - e.g. inability to say ‘eye-aye’ repeatedly
  • Irregular errors in speech

Facial Asymmetry

  • Interpretation

  • Eyebrow sparing (central palsy) - upper motor neuron lesionIschaemia, haemorrhage, tumour, trauma
  • Eyebrow involvement - facial nerve (VII) lesionBell’s palsy, herpes zoster (Ramsay-Hunt Syndrome), tumour, skull fracture

Overview

  • Significance

  • Occurs in the setting of a lower motor neuron lesion (bulbar palsy), neuromuscular or muscular weakness.
  • Interpretation

  • Nasal speech - a sign of flaccid dysarthriaLower motor neuron lesion
  • Strained-strangled speech - a sign of spastic dysarthriaUpper motor neuron lesion 
  • Slurred / ‘scanning’ speech - a sign of ataxic dysarthriaCerebellar lesion
  • Incorrect repetition (e.g. ifs no buts) - suggestive of conductive dysphasiaArcuate fasciculus lesion
  • Significance

  • The progressive development of hypernasal speech while reading is suggestive of fatigability, a sign of myaesthenia.
  • Significance

  • Orientation is a quick way of assessing patients for confusion.
  • How to Assess

    Ask the patient to repeat back single syllable sounds:
  • Pa pa paLip muscles
  • Ta ta taTongue muscles
  • Ka ka kaPalatal muscles
  • Ba ba baVocal cords
  • Aye-eyeSlow repetition suggests a cerebellar lesion

Dysphonia

  • Causes of Dysphonia

  • Neurological

  • Trauma - vagus / recurrent laryngeal nerve
  • Small-vessel ischaemia
  • Infection  - meningitis, diptheria
  • Tumour
  • Multiple sclerosis
  • Parkinson’s disease
  • Neuromuscular / Muscular

  • Myasthenia gravis
  • Spasmodic dysphonia
  • Upper Respiratory

  • Irritation - alcohol, tobacco, reflux, pollutants, inhaled chemicals
  • Laryngitis - viral, bacterial, fungal
  • Vocal cord trauma - direct trauma, chronic cough, vocal abuse
  • Vocal cord mass - nodules, polyps, cyst, tumour
  • Medications - ACE inhibitors, antihistamines, inhaled steroids
  • Other

  • Psychogenic

Overview

  • Signs of Receptive Dysphasia

  • Normal speech fluency
  • Poor comprehension
  • Lack of awareness of errors
  • Inability to follow commands - simple, two-step or three-step commands
  • Paraphasias: switching of a word in a sentence for another incorrect word
  • Neologisms: new words created by the patient
  • Significance

  • Suggests a lesion within the basal ganglia.
  • Significance

  • Spastic dysarthria occurs in the setting of an upper motor neuron lesion (pseudobulbar palsy).
  • Significance

  • Suggestive of Parkinsonism.
  • Signs of Expressive Dysphasia

  • Non-fluency of speech
  • Relatively preserved comprehension
  • Agrammatism - poor use of grammar
  • Telegraphic speech - using short sentences with verbs, nouns and no joining words (e.g. boy throw ball)
  • Inability to describe objects
  • Significance

  • Suggests a lesion affecting the angular gyrus of the dominant hemisphere
  • How to Perform

  • Position the patient at 45 degrees and ask them to turn their head to the left. Hold a flashlight tangentially to the skin of the neck and inspect for the highest level of the jugular venous pulsation. Measure the vertical distance between the sternal angle and this level.

Heart Sounds

  • Heart Sounds

  • Normal

  • First heart sound (S1) - indicates closure of the mitral and tricuspid valves (a loud S1 suggests MS; a soft S1 suggests MR)
  • Second heart sound (S2) - indicates closure of the aortic (A2) and pulmonary (P2) valves (a loud P2 suggests pulmonary hypertension; a soft A2 suggests severe AS / AR)
  • Abnormal

  • Third heart sound (S3) - a pathological finding associated with rapid ventricular filling (left ventricular failure, severe MR / AR, constrictive pericarditis)
  • Fourth heart sound (S4) - a pathological finding associated with turbulence during atrial systole (hypertension, AS, PS, MR, HOCM, MI)

Overview

    • Normal Blood Pressure

    • < 120 / 80 mmHg
    • Normal Range

    • 36.0 - 37.5°C
  • How to Assess

  • Pinch a fold of skin on the patient’s arm and then release it. Decreased skin turgor is present if the fold takes an abnormal time to return to its normal contour.
  • Causes of Upper Airway Obstruction

  • Soft tissue swelling - anaphylaxis, burns, peritonsillar abscess, epiglottitis, laryngotracheobronchitis (croup)
  • Foreign body aspiration
  • Deformity - laryngomalacia, laryngeal mass / web, tracheomalacia
  • Tongue enlargement / displacement
  • Vocal cord lesion / paralysis
The diaphragm has both somatic and autonomic innervation, and thus the respiratory rate can be altered both voluntarily and and involuntarily in response to physiologic or pathologic stimuli.
In order to be sure that bowel sounds are absent, it is important to listen for at least five minutes.
  • Interpretation

  • Regular: sinus rhythm
  • Sinus arrhythmia: rhythmic variations in vagal tone with respiration
  • Regularly irregular (regular heart rate with occasional missed or extra beats): sinus arrhythmia, second degree heart block, premature ventricular contractions
  • Irregularly irregular: atrial fibrillation
  • Causes of Oedema

  • Pitting

  • Fluid overload - excessive IV fluids, renal failure, heart failure
  • Right ventricular failure
  • Venous pathology - thrombosis / insufficiency
  • Dependency (the effect of gravity)
  • Hypoalbuminaemia - malnutrition, malabsorption, nephrotic syndrome, liver (synthetic) failure
  • Non-Pitting

  • Impaired lymphatic drainage
  • Pretibial myxoedema (hypothyroidism)
    • Normal Range

    • Most patients: >95%
    • Chronically hypoxic patients: 88 - 92%
  • How to Assess

  • If the patient is not spontaneously opening their eyes, begin by attempting to elicit a response verbally. If this is unsuccessful then apply a painful stimulus such as a trapezius squeeze or a sternal rub.

Breath Sounds

  • Causes of Reduced Breath Sounds

  • Shallow breathing - e.g. due to anxiety or CNS depression
  • Obstruction - foreign body, tumour, asthma, COPD
  • Pleural effusion
  • Pneumothorax
  • Obesity

Abdominal Tenderness

  • Interpretation

  • Right hypochondrium - liver, gallbladder, stomach, hepatic flexure of colon, lungGallstones, peptic ulcer
  • Epigastrium - liver, gallbladder, stomach, transverse colon, pancreas, heartPancreatitis, peptic ulcer, reflux
  • Left hypochondrium - spleen, pancreas, stomach, splenic flexure of colon, lungPeptic ulcer, pancreatitis
  • Right lumbar - ascending colon, kidneyKidney stone, pyelonephritis
  • Umbilicus - small bowel, aortaPancreatitis, early appendicitis, peptic ulcer, IBD
  • Left lumbar - descending colon, kidneyKidney stone, diverticulitis, IBD
  • Right iliac fossa - appendix, terminal ileum, caecum, ovary, fallopian tube, ureterAppendicitis, caecal diverticulitis, ovarian pathology, ectopic pregnancy, PID, inguinal hernia
  • Hypogastrium - uterus, bladder, sigmoid colonCystitis, appendicitis, diverticulitis, IBD, uterine pathology
  • Left iliac fossa - sigmoid colon, ovary, fallopian tube, ureterSigmoid diverticulitis, ovarian pathology, ectopic pregnancy, PID, inguinal hernia

Overview

    • Normal Range

    • 60 - 100bpm

Assessing the Calves

  • Signs of DVT

  • Erythema
  • Swelling
  • Tenderness

Hypoglycaemia

A blood sugar level of ≤3.9 is generally considered to indicate hypoglycaemia. This is a clinical emergency and should be rapidly treated.

Overview

Inspection of Pupils

    • Normal Pupillary Size

    • In the dark - 4-8mm
    • Under bright light - 2-4mm

Overview

  • Signs of Respiratory Distress

  • Tachypnoea
  • Psychomotor agitation
  • Nasal flaring
  • Pursed lips
  • Speech - phrases → words → none
  • Tripod position - sitting forward with hands on thighs
  • Accessory muscle use
  • Intercostal recession
  • Subcostal recession
  • Paradoxical abdominal breathing
    • Normal Range

    • 36.0 - 37.5°C
    • Normal Range

    • Most patients: >95%
    • Chronically hypoxic patients: 88 - 92%
The diaphragm has both somatic and autonomic innervation, and thus the respiratory rate can be altered both voluntarily and and involuntarily in response to physiologic or pathologic stimuli.
    • Normal Blood Pressure

    • < 120 / 80 mmHg
    • Normal Range

    • 60 - 100bpm
  • Pulmonary Function Test Findings

  • FEV₁ reduced (<80% predicted)
  • FVC reduced (<80% predicted)
  • FEV₁:FVC ratio normal (>0.7)
  • Reduced volume in flow-volume loop
  • TLC <80% predicted
  • DLCO normal (extrapulmonary) or decreased (parenchymal)
  • Methods for Estimating Lung Volumes

  • Nitrogen washout - the patient exhales fully and breaths 100% oxygen; the exhaled nitrogen concentrations are used to assess lung volumes
  • Helium equilibration - the patient exhales fully and then breaths a combination of oxygen and helium; helium concentrations are used to assess lung volumes
  • Body plethysmography - the patient sits in an airtight room and breaths into a spirometer; the pressures in the room are used to assess lung volumes
A reduced ;FEV₁:FVC ratio of <0.7 is diagnostic of obstructive lung disease.

Obstructive & Restrictive Patterns

  • Obstructive & Restrictive Patterns

Overview

  • Procedure

    Performed with the patient breathing into a pneumotachograph:
  • Maximal breath in
  • Forced expiration as hard and fast as possible
  • Maximal breath in as fast as possible
  • Procedure

  • The patient inhales a mixture of helium (10%), carbon monoxide (0.3%), oxygen (21%) and nitrogen (68.7%), hold their breath for ten seconds and then exhale fully.
  • The levels of exhaled helium and carbon monoxide are used to calculate DLCO
  • The results may need to be corrected for the patient’s haemoglobin
    • Normal Range

    • 80 - 120% predicted
  • Significance

  • A marker of compliance of the lungs and chest wall.
  • How to Perform

  • Attach the mouthpiece to spirometer
  • Ask the patient to breath in deeply
  • Ask the patient to blow into the spirometer as hard and as fast as possible, until there is no breath left
  • Encourage the patient to keep blowing out for at least six seconds
  • Repeat the procedure three times total, ensuring that the best two are within 100mL or 5% of each other
  • Calculate the predicted values based on the patient’s sex, age and height
  • Calculate the percent predicted, based on the patient’s results
  • Important Lab Points

  • Collected in a sodium citrate tube to prevent coagulation prior to testing.
  • Performed by contact activation - methods vary between labs.
  • Tests the intrinsic and common pathways - kininogen, prekallikrein, XII, XI, IX, VIII, X, V, II, fibrinogen
  • Practical Points

  • The factor Xa level may be used to monitor the efficacy of medications that inhibit factor Xa, such as low molecular weight heparins, rivaroxaban, apixaban, fondaparinux and danaparoid.
  • Monitoring of low molecular weight heparins (enoxaparin / dalteparin) using factor Xa is not routine and is reserved for specific circumstances such as renal impairment, pregnancy or obesity.
  • Monitoring of factor Xa inhibitors (rivaroxaban / apixaban), fondaparinux and danaparoid is generally not performed except in certain circumstances as guided by a haematologist.
  • The target range depends on the medication, dose and frequency.
    • Normal Range

    • Prothrombin time - 11 - 15 sec
    • INR - 0.9 - 1.3
    • APTT - 25 - 40 sec
    • Thrombin time - <24 sec
    • Fibrinogen - 1.5 - 4.5 g/L
    • Normal Range

    • <24 seconds
  • Important Lab Points

  • Fibrinogen is not routinely measured as part of a coagulation screen.
  • The ‘derived’ fibrinogen level is often reported with the coag result and is estimated based on the prothromin time curve. It is not an accurate estimate of fibrinogen concentrations and should not be used.
  • A dedicated fibrinogen assay should be ordered to determine the fibrinogen concentration.
    • Normal Range

    • <250 ng/mL
    • Normal Range

    • Prothrombin time - 11 - 15 sec
    • INR - 0.9 - 1.3
When performing mixing studies, the patient's plasma is mixed 50:50 with control plasma, and then the PT/INR or APTT is measured.
NormalViralBacterialFungal / TB
Opening
Pressure
5-20 cmH2ONormal /
Elevated
ElevatedElevated
AppearanceClearClearTurbidClear / Turbid / Opaque
WBC<5
No PMNs
10-1000>100
>80% PMNs
50-500
RBC<10<10<10<10
Protein15-45
mg/dL
ElevatedElevatedElevated
Glucose>60%
serum
>60%
serum
<40%
serum
<40%
serum
OtherPCR for
HSV/VZV
Gram stain & 
culture
Fungal culture, AFB

Urine Colour

Urine is normally clear and pale yellow. Dark yellow or brown urine is classically a sign of dehydration, though urine may be a variety of colours that suggest underlying pathology.

Overview

This is an indicator of the kidney’s ability to concentrate or dilute urine, and correlates with the urine osmolality. 
    • Normal Range

      4.5 - 8.0
    • Types of Urine Collection

    • Random urine - taken at any time; Used for testing of electrolytes etc.
    • Morning urine - the first urine of the day is the most concentrated, increasing the yield; Used for urinalysis, microscopy and beta-HCG testing
    • Clean catch / midstream urine - the first few mL are discarded and then urine is collected, removing urethral bacterial flora from the sample; Best for urine culture and sensitivity testing
    • 24 hour urine - all of the urine passed over 24 hours is collected; Used to measure certain analytes, such as creatinine, protein, electrolytes, uric acid, cortisol, catecholamines / metanephrines
    • Catheterised sample - e.g. from an in and out / indwelling / suprapubic catheter
    • Suprapubic aspiration - a needle is used to aspirate urine; May be required if a patient cannot be catheterised, or if sterile urine absolutely must be collected
    • Causes of Pyuria

    • Infection - urethritis, prostatitis, cystitis, pyelonephritis, tuberculosis
    • Neoplasm - renal, bladder, protate
    • Inflammation - interstitial nephritis, interstitial cystitis, Kawasaki disease, SLE
    • Foreign body - renal calculus, indwelling catheter, ureteric stents
    • Polycystic kidney disease
    • Pelvic irradiation
    • Pregnancy
    • Look For

    • Constant PR interval with intermittently dropped QRS complexes.
    Type I second degree sinoatrial exit block occurs when there is progressively delayed SA transmission eventually resulting in a missed P wave due to failure of conduction to the atrial myocardium.
    • Look For

    • Initial normal PR interval with progressive prolongation of PR interval followed by a dropped QRS complex.
    • Causes of Sinoatrial Exit Block

    • Intrinsic

    • Idiopathic degeneration
    • Myocardial infarction
    • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
    • Connective tissue disease - SLE, scleroderma, RA
    • Cardiac surgery - valvular surgery, correction of congenital heart disease
    • Infections - Lyme disease, endocarditis
    • Extrinsic

    • Physiologic - sleep, athletes
    • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
    • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, ivabradine, clonidine, acetylcholinesterase inhibitors
    • Hypothyroidism
    • Hypothermia
    • Hyperkalaemia
    • Obstructive sleep apnoea
    • Raised intracranial pressure
    • Causes of Atrioventricular Block

    • Intrinsic

    • Idiopathic degeneration
    • Myocardial infarction
    • Congenital - congenital heart disease, neonatal lupus
    • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
    • Cardiac procedures - valvular surgery, correction of congenital heart disease, catheter ablation
    • Systemic lupus erythematosus
    • Myocarditis
    • Extrinsic

    • Physiologic - sleep, athletes
    • Autonomic - carotid sinus massage, carotid sinus hypersensitivity
    • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, amiodarone
    • Hyperkalaemia
    • Hypothyroidism
    • Look For

    • Two or more consecutive p waves without subsequent QRS complexes
    • May be in a 3:1, 4:1 or higher pattern
    • Look For

    • Complete dissociation of P waves and QRS complexes.
    • Look For

    • Prolonged PR interval >200ms (5mm).
    • Look For

    • Complete lack of P waves and QRS complexes
    • An escape rhythm may be present
    • Look For

    • A constant PP interval, with a pause that is a multiple of the PP interval.
      • Normal Range

      • Absolute reticulocyte count: 50 - 100 x 10‎⁹/L
      • Reticulocyte percentage: 0.5 - 2.5%
      • Normal Range

      • 2.0 - 8.0 x 10⁹
      • 40 - 75% of total leukocytes
      • Normal Range

      • 0.0 - 0.5 x 10‎⁹/L
      • 1 - 4% of total leukocytes
    • Look For

    • Reduced serum haemoglobin (Hb) concentration
    • Reduced haematocrit (HCT) / packed cell volume (PCV)
    • Reduced red cell count (RCC)
    Beta thalassaemia is common in people from Mediterranean countries, South East Asia and India. It is rarely seen in those of caucasian descent.
    Assessment of red blood cell size - the presence of normocytosis, microcytosis or macrocytosis - is the first step in the assessment of patients with anaemia as it can rapidly be used to narrow down the likely causes.
      • Normal Range

      • 1.0 - 4.0 x 10‎⁹/L
      • 20 - 40% of total leukocytes
      • Normal Range

      • 11 - 15%
      • Normal Range

      • 150 - 400 x 10‎⁹/L
      • Normal Range

      • Males: 4.3 - 5.7 x 10¹²/L
      • Females: 3.9 - 5.0 x 10¹²/L
    Four alpha chain genes are inherited (two from each parent), and the type of alpha thalassaemia depends on how many of the four alpha chains are defective.
      • Normal Range

      • Males: 3.7 - 9.5 x 10‎⁹/L
      • Female: 3.9 - 11.1 x 10‎⁹/L
      • Normal Range

      • 0.0 - 0.1 x 10‎⁹/L
      • 0.5 - 1% of total leukocytes
    Haemoglobin transports oxygen and other molecules in the blood.
      • Normal Range

      • 0.2 - 1.0 x 10‎⁹/L
      • 2 - 8% of total leukocytes
    This value is often calculated by an automatic analyser based on the red cell count and mean cell volume (MCV).

    Pathogenesis

    • The condition is multifactorial, and occurs in the context of:
    • Reduced effective incorporation of iron into haemoglobinDue to increased production and release of hepcidin and cytokines
    • Reduced responsiveness to erythropoietin
    • Reduced red cell survival

    Overview

    Sickle cell disease is a more broad term that includes sickle cell anaemia, sickle beta thalassaemia and haemoglobin SC disease.
    The PF ratio is an assessment of PaO2₂ taking into account the FiO₂ - correcting for this discrepancy.
    • Look for

    • Reduced pH (acidaemia) with increased PaCO₂.
    The base excess is the amount of strong acid that is required to return a patient's sample to a pH of 7.4, pCO₂ to 40mmHg and temperature to 37°.
      • Normal Range

      • 7.35 - 7.45
      • Normal Range

      • 0.5 - 2.2 mmol/L
    • Expected Compensation

    • Increase in PaCO₂ = 0.8 x HCO₃ + 20
    • Look For

    • Acidaemia with reduced bicarbonate.
      • Normal Range

      • 80-100mmHg on room air
    • Secondary Response

    • Acute respiratory alkalosis - 2mmol/L [HCO₃] decrease for every 10mmHg PaCO₂ below 40mmHg
    • Chronic respiratory acidosis - 4mmol/L [HCO₃] decrease for every 10mmHg PaCO₂ below 40mmHg
    In these patients, it is difficult to determine whether the HAGMA is the only process occurring, or whether there is additional process present such as a normal anion gap metabolic process, or a metabolic alkalosis.
    It is a calculation of the unmeasured anions and cations in the blood, based on anions and cations that we can measure (sodium, chloride and bicarbonate). This assumes that the body is electrochemically neutral, i.e.:
      • Normal Range

      • >90%
    An increase or decrease in the PaCO₂ level suggests the presence of a respiratory process causing an acid-base imbalance. This can either be primary (the derangement is due to a respiratory issue) or secondary (there is respiratory compensation for a metabolic issue).
      • Normal Range

      • 22 - 26 mmol/L
    • Signs of Atelectasis on Chest X-Ray

    • Pulmonary opacification
    • Air bronchograms - tubular outlines of the smaller airways
    • Silhouette signs - obliteration of normally clear outlines between lung fields and adjacent structures
    • Evidence of Volume Loss

    • Crowding of pulmonary vessels
    • Underinflation
    • Hemidiaphragmatic elevation
    • Tracheal deviation toward the area of atelectasis
    • Mediastinal shift toward the area of atelectasis
    • Hilar displacement
    Both PA and lateral films should be used to identify the location of leads associated with a cardiac device.
    • Examples

    Interstitial lung disease may be suggested by reticular or reticulonodular opacities on chest x-ray.
    • Indications for Nasogastric Tube Placement

    • Aspiration or drainage of gastric contents
    • Feeding
    • Enteral administration of medications
    • Causes of Pulmonary Oedema

    • Cardiogenic

    • Heart failure
    • Fluid overload
    • Renal failure
    • Transfusion-associated circulatory overload (TACO)
    • Non-Cardiogenic

    • Acute respiratory distress syndrome
    • Pulmonary embolism
    • Re-expansion pulmonary oedema (e.g. with drainage of a pleural effusion or pneumothorax)
    • Neurogenic pulmonary oedema
    • Transfusion-related acute lung injury (TRALI)
    • High altitude pulmonary oedema (HAPE)
    Different projections are used in various clinical situations, and can affect the interpretation of the x-ray.
    • Classification

    • Community-acquired pneumonia
    • Hospital-acquired pneumonia
    • Ventilator-associated pneumonia
    • Look For

    • Exposure - underpenetrated or overpenetrated
    • Inspiratory film - the x-ray should be taken in deep inspiration
    • Rotation - look at the medial ends of the clavicles, and the vertebrae
    • Examples

    Central Venous Catheters (CVCs)

    A central venous catheter is a large bore catheter inserted into a large vein for the purpose of central venous access.

    Erect Film

    The erect film is the standard film, and is performed with the patient standing. This type of film makes it easier to identify pleural effusions and pneumothoraces.

    Overview

    • Causes of Pneumothorax

    • Primary Spontaneous Pneumothorax

    • Idiopathic (ruptured pleural bleb / bulla)
    • Secondary Spontaneous Pneumothorax

    • Connective tissue disease - Marfan syndrome, Ehlers-Danlos syndrome, rheumatoid arthritis, scleroderma, ankylosing spondylitis, dermatopolymyositis
    • Airway disease - emphysema (bullous rupture), cystic fibrosis, severe asthma
    • Infections - PJP pneumonia, tuberculosis, necrotising pneumonia
    • Interstitial lung disease
    • Lung cancer
    • Thoracic endometriosis
    • Non-Spontaneous

    • Traumatic - blunt, penetrating
    • Iatrogenic - CVC placement, transthoracic procedures, mechanical ventilation

    Silhouette Signs

    • Significance

    • Loss of normal borders appears when the adjacent area of lung is consolidated or collapsed.

    Overview

    • Examples

    • Examples

    The presence of anti-ds-DNA antibodies is highly suggestive of systemic lupus erythematosus (SLE), with a specificity of 97%.
    • Interpretation

    • Simple - dislocation without fracture
    • Complex - dislocation with fracture of any of the bones involved
    • Interpretation

    • Simple (closed) fracture - doesn’t communicate with the skin surface
    • Compound (open) fracture - communicates with the skin surface

    Red Blood Cells

    Red blood cells within ascitic fluid may simply be due to a traumatic tap or inadvertent sampling from an abdominal vessel; blood may also be present within ascites in the presence of an intra-abdominal bleed as well as certain other conditions.

    Overview

    • Formula

    • SAAG = [serum albumin] - [ascitic albumin]
    • Causes of Sinoatrial Exit Block

    • Intrinsic

    • Idiopathic degeneration
    • Myocardial infarction
    • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
    • Connective tissue disease - SLE, scleroderma, RA
    • Cardiac surgery - valvular surgery, correction of congenital heart disease
    • Infections - Lyme disease, endocarditis
    • Extrinsic

    • Physiologic - sleep, athletes
    • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
    • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, ivabradine, clonidine, acetylcholinesterase inhibitors
    • Hypothyroidism
    • Hypothermia
    • Hyperkalaemia
    • Obstructive sleep apnoea
    • Raised intracranial pressure
    • Causes of Atrioventricular (AV) Block

    • Intrinsic

    • Idiopathic degeneration
    • Myocardial infarction
    • Congenital - congenital heart disease, neonatal lupus
    • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
    • Cardiac procedures - valvular surgery, correction of congenital heart disease, catheter ablation
    • Systemic lupus erythematosus
    • Myocarditis
    • Extrinsic

    • Physiologic - sleep, athletes
    • Autonomic - carotid sinus massage, carotid sinus hypersensitivity
    • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, amiodarone
    • Hyperkalaemia
    • Hypothyroidism
    • Look For

    • Ventricular rate <60bpm
    • Abnormal P wave morphology (e.g inverted or biphasic)
    • Look For

    • Bradycardia with rate 40 - 60 bpm
    • Narrow QRS complexes
    • Absence of P waves
    • Bradyarrhythmias

    • Regular

    • Sinus bradycardia
    • Sinus arrest with escape rhythm
    • Complete heart block with escape rhythm
    • Irregular

    • Sinus arrhythmia
    • Sinus arrest
    • Second or third degree sinoatrial exit block
    • Atrial fibrillation with slow ventricular rate
    • Atrial flutter with variable block
    • Second or third degree AV block
    • Look For

    • Irregular rhythm
    • Saw-toothed baseline ‘flutter’ waves at ~300bpm
    • Variable atrioventricular block (inconsistent number of flutter waves between QRS complexes)
    • Look For

    • Irregular RR interval
    • Normal PR interval with P waves preceding each QRS complex
    • Normal axis - positive P waves in leads I and II
    • Look For

    • Bradycardia with ventricular rate <60
    • Irregular rhythm
    • No P waves, with oscillating baseline waves
    • Look For

    • Alternating episodes of bradycardia and supraventricular tachycardia (AF, flutter, atrial tachycardia or AVNRT).
    • Look For

    • Bradycardia with ventricular rate <40bpm
    • Wide QRS complexes (120ms)
    • Regular non-conducted P waves (complete heart block) or no P waves (sinus arrest)
    • Manifestations of Sinus Node Dysfunction

    • Sinus bradycardia
    • Sinus arrhythmia
    • Sinus pause / arrest
    • Sinoatrial exit block
    • Tachy-brady syndrome
    • Look For

    • A pause of at least three seconds, without P waves or QRS complexes
    • An escape rhythm may be present
    • Look For

    • Decreased heart rate - <60bpm (or 50bpm when asleep)
    • Regular rhythm - normal PR interval with P waves preceding each QRS complex
    • Normal axis - positive P waves in leads I and II

    Poikilocytosis

    • Significance

    • Certain red cell morphologies may be more suggestive of certain causes of haemolysis.

    Overview

      • Normal Range

      • 36 - 195 mg/dL
      • Normal Range

      • 120 - 280 U/L
      • Normal Range

      • Absolute reticulocyte count: 50 - 100 x 10‎⁹/L
      • Reticulocyte percentage: 0.5 - 2.5%
    • Causes of Intravascular Haemolysis

    • Microangiopathic haemolytic anaemia - TTP, HUS, DIC, preeclampsia / HELLP, SLE, malignant hypertension, severe burns, brown snake bite
    • Intravascular trauma - valvular leaks, cardiac prostheses, renal replacement, ECMO, march haemoglobinuria
    • Alloimmune haemolysis - transfusion of mismatched red blood cells, haemolytic disease of the newborn, post stem cell transplant
    • Infection - severe malaria, Clostridium toxin
    • Copper (Wilson’s disease)
    • Certain cold agglutinin haemolysis disorders
    • Paroxysmal nocturnal haemoglobinuria
    • G6PD deficiency
      • Normal Range

      • Total bilirubin - <1 mg/dL or <20 μmol/L
      • Direct (conjugated) bilirubin - <0.3 mg/dL or <7 μmol/L

    Aetiology

    • Causes of Iron Overload

    • Haemochromatosis
    • Iron loading anaemias - thalassaemias, sideroblastic anaemia, congenital dyserythropoietic anaemia
    • Multiple blood transfusions
    • Excessive iron administration

    Overview

      • Normal Range

      • 15 - 300μg/L
    • Roles of Iron

    • Oxygen transport (as haemoglobin)
    • Muscle oxygenation (as myoglobin)
    • Synthesis of DNA, RNA and proteins
    • Cellular respiration (as cytochromes)
    • Immune function
    • Myelin sheath formation

    Aetiology

    • Causes of Iron Deficiency

    • Nutritional deficiency
    • Malabsorption - e.g. coeliac disease, gastric surgery, PPIs
    • Blood loss - particularly menstrual and gastrointestinal loss; regular blood donation
    • Pregnancy

    Overview

      • Normal Range

      • 10-30 µmol/L
      • Normal Range

      • Males: 15 - 45%
      • Females: 15 - 55%
    An increased soluble transferrin receptor level can aid in the diagnosis of iron deficiency if uncertain, particularly in differentiating iron deficiency from anaemia of chronic disease. Haemolysis will also caused a raised level.
      • Normal Range

      • 1.5 - 3.2 g/L
    •  
    • Blood Film Findings in Megaloblastic Anaemia

    • Macrocytic hyperchromic anaemia (may be normocytic in early disease)
    • Anisocytosis: variation in size of red blood cells
    • Macroovalocytes: large, round cells
    • Teardrop cells
    • Hypersegmented neutrophils (5 or more nuclear lobes)
    •  
    Patients with hyposplenism are at increased risk of infections - particularly with encapsulated bacteria (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae).

    Neutrophil Physiology

    • Morphology

    • Mature neutrophils exhibit 3-5 nuclear lobes, with immature forms exhibiting less lobes and hypersegmented exhibiting more. Females may display a 'drumstick' that protrudes from the nucleus.

    Overview

    •  
    •  
    Myelodysplasia refers to the presence of morphologically and functionally abnormal blood cells. 
    This is always an abnormal finding, and may indicate a major acute stress or bone marrow infiltration.
    •  
      • Normal Range

      • 2.0 - 3.5 pg/mL
    The release of TSH is suppressed by circulating thyroid hormone, and its levels are affected by small changes in circulating T3 and T4 such that TSH changes in a logarithmic scale compared to the linear scale of the thyroid hormones.
    • TFT Interpretation

    • Primary hypothyroidism - elevated TSH with reduced T4
    • Subclinical hypothyroidism - elevated TSH with normal T4
    • Central hypothyroidism - reduced TSH with reduced T4
    • Causes of Nonthyroidal Illness

    • Starvation
    • Sepsis
    • Burns
    • Trauma
    • Surgery
    • Myocardial infarction
    • Malignancy
    • Chronic liver disease
    • Chronic kidney disease
      • Normal Range

      • 0.8 - 1.8 ng/dL
    Low TSHHigh TSH
    Low T4Central HypothyroidismPrimary hypothyroidism
    Normal T4Subclinical hyperthyroidismSubclinical hypothyroidism
    High T4Primary hyperthyroidismCentral hyperthyroidism
    • TFT Interpretation

    • Primary hyperthyroidism -  reduced TSH with elevated T4
    • Subclinical hyperthyroidism - reduced TSH with normal T4
    • Central hyperthyroidism - elevated TSH with elevated T4
    • Causes of Elevated Caeruloplasmin

    • Infection
    • Inflammation
    • Malignancy - particularly lymphoma
    • Alzheimer’s disease
    • Pregnancy
      • Normal Range

      • 15 - 300μg/L
      • Normal Range

      • 32 - 45 g/L
      • Normal Range

      • 1.5 - 4.5 g/L

    Pathogenesis

    The acute phase response is predominantly mediated by the pro-inflammatory cytokines tumour necrosis factor (TNF), interleukin 1 (IL-1) and interleukin 6 (IL-6) secreted by macrophages and other immune cells.

    Overview

      • Normal Range

      • 36 - 195 mg/dL
    • Interpretation

    • Acellular Casts

    • Hyaline casts (solidified mucoprotein) - dehydration, exercise, diuretics
    • Granular casts (degenerated cells) - glomerulonephritis, acute tubular necrosis, pyelonephritis
    • Muddy brown casts (likely denatured haemoglobin) - acute tubular necrosis
    • Waxy casts (severely degenerated cells) - severe acute or chronic renal failure
    • Fatty casts (lipids) - nephrotic syndrome, diabetic nephropathy
    • Pigment casts (haemoglobin, myoglobin, bilirubin) - haemolysis, rhabdomyolysis, liver disease
    • Cellular Casts

    • Red cell casts (bleeding through the glomerulus or into the tubules) - glomerulonephritis, acute interstitial nephritis
    • White cell casts (interstitial or glomerular inflammation) - pyelonephritis, glomerulonephritis, acute interstitial nephritis
    • Renal tubular epithelial cell casts (sloughed cells) - acute tubular necrosis, acute interstitial nephritis
    • Bacterial casts - pyelonephritis
    • Types of Urine Collection

    • Random urine - taken at any time; Used for testing of electrolytes etc.
    • Morning urine - the first urine of the day is the most concentrated, increasing the yield; Used for urinalysis, microscopy and beta-HCG testing
    • Clean catch / midstream urine - the first few mL are discarded and then urine is collected, removing urethral bacterial flora from the sample; Best for urine culture and sensitivity testing
    • 24 hour urine - all of the urine passed over 24 hours is collected; Used to measure certain analytes, such as creatinine, protein, electrolytes, uric acid, cortisol, catecholamines / metanephrines
    • Catheterised sample - e.g. from an in and out / indwelling / suprapubic catheter
    • Suprapubic aspiration - a needle is used to aspirate urine; May be required if a patient cannot be catheterised, or if sterile urine absolutely must be collected
      • Normal Axis

      • -30° to +90°
    • Look For

    • The section between the end of the QRS complex (J point) and the beginning of the T wave.
    • Look For

    • A low amplitude deflection after the T wave, most evident in the precordial leads.
    • Look For

    • Q wave - an initial negative deflection
    • R wave - a positive deflection
    • S wave - a negative deflection after the R wave
      • Normal Range

      • Men 390 - 450ms
      • Women - 390 - 460ms
    ECG Rhythm is best assessed using the rhythm strip, which is usually lead II.
    • How to Perform

    • 1
      Prepare the skin - ensure that it is dry; shave excessive chest hair; gently abrade the skin if required
    • 2
      Place the electrodes as below
    • 3
      Ask the patient to remain still, not speak and breath slowly (if possible)
    • 4
      Record the ECG - at speed 25mm/sec and gain 10mm/mV
    • 5
      Look for electrical interference and baseline wander, and assess need to rerecord ECG
    • 6
      Consider a rhythm trace if arrhythmia is evident
      • Normal Duration

      • 120-200ms (3-5mm)
    •  
      • Normal Range

      • 60 - 100bpm

    The ECG Trace

    A normal ECG trace includes a P wave, a QRS complex and a T wave.

    Overview

    • Look For

    • A deflection following the QRS complex that is normally asymmetrical, with a slow upslope and a rapid downslope. Usually positive, though negative T waves are normal in aVR and V1.

    Monomorphic Ventricular Tachycardia

    • Look For

    • Heart rate >100bpm
    • Regular rhythm (RR interval)
    • Broad QRS complexes >120ms

    Overview

    • Look For

    • Heart rate 100-250bpm
    • Regular rhythm
    • Broad QRS complex >120ms
    • On Old ECGs

    • Bundle branch block
    • Wolff-Parkinson-White pattern
    • Look For

    • Heart rate >100bpm
    • At least three different P wave morphologies
    • Variable PP intervals
    • An isoelectric baseline (to differentiate from atrial fibrillation or flutter)
    • Look For

    • Heart rate ~150bpm
    • Regular rhythm (RR interval)
    • Saw-toothed baseline ‘flutter’ waves at ~300bpm
    • Atrioventricular block (not every flutter wave is followed by a QRS complex)
    • Look For

    • Heart rate >100bpm
    • Regular rhythm (RR interval)
    • Each P wave followed by a QRS complex
    • Positive P wave in leads I and II
    • Look For

    • Orthodromic AVRT (90%) - regular narrow complex tachycardia with no P waves (hidden in QRS) or P waves after QRS complex. No delta wave will be seen.
    • Antidromic AVRT (10%) - regular broad complex tachycardia (easily mistaken for VT)
    • Look For

    • Narrow complex tachycardia
    • Regular ventricular rhythm
    • Abnormal P wave morphology (e.g. inverted or biphasic) that is consistent
    • An isoelectric baseline (to differentiate from atrial fibrillation or flutter)
    • Look For

    • Heart rate 100-250bpm
    • Irregular rhythm
    • Broad QRS complex >120ms
    • On Old ECGs

    • Atrial fibrillation
    • Bundle branch block
    • Wolff-Parkinson-White pattern
    • Look For

    • Ventricular rate 100-180bpm (may be <100 with block or medications)
    • Irregular rhythm
    • No P waves, with oscillating baseline waves
    • Look For

    • Irregular, rapid, chaotic electrical activity without P waves, QRS complexes or T waves.
    • Look For

    • Heart rate 100-250bpm
    • Regular rhythm
    • Late P waves - may be hidden within the QRS complex, cause a pseudo S wave in inferior leads / pseudo R wave in right precordial leads (slow-fast AVNRT), or appear after the QRS complex (fast-slow AVNRT)
    Electrophoresis is a useful screening test for plasma cell neoplasms such as multiple myeloma and MGUS. If a plasma cell neoplasm is suspected then serum EPG should be ordered in conjunction with immunofixation electrophoresis (IFE) in order to quantify a paraprotein if present.
    • Manifestations of Multiple Myeloma

    • Classical (CRAB)

    • Calcium - hypercalcaemia
    • Renal failure (multifactorial) - due to cast nephropathy, glomerular light chain deposition, hypercalcaemia, amyloidosis
    • Anaemia - normocytic, normochromic
    • Bone lesions - lytic lesions, due to osteoclastic change
    • Other

    • Hyperviscosity syndrome - due to hypergammaglobulinaemia
    • Amyloidosis - GI, cardiac, hepatic, renal, muscular or nerve infiltration
    • Recurrent infections - due to relative hypogammaglobulinaemia
    Serum free light chains is a measure of the light chains (Bence-Jones protein) not bound to antibody.
    • Roles of Immunoglobulins

    • IgG - the most abundant immunoglobulin; also crosses the placenta
    • IgM - the first immunoglobulin secreted in response to foreign antigens
    • IgA - present in saliva, sweat, tears, breast milk and blood
    • IgD - bound to B-cell membranes; triggers B-cell activation
    • IgE - present in skin, mucous membranes and the lungs; involved in certain hypersensitivity reactions and response to parasitic infection
    Immunofixation electrophoresis (IFE) is performed by separating plasma proteins by electrophoresis, followed by addition of specific antisera against each type of immunoglobulin.
      • Normal Range

      • 3.0 - 8.0 mmol/L
    • Key Concepts

    • Creatinine is mainly produced by creatine metabolism from muscle breakdown; it is also present in dietary sources like cooked meat
    • Approximately 15% of creatinine is actively secreted into the tubules
    • Patients with stable renal function will have stable creatinine levels with daily variability ~8%
    • Interpretation

    • Elevated ratio: >100:1
    • Reduced ratio: <40:1
    eGFR calculators can be found in the tools section of the app.
    • Formula

    • Creatinine clearance = (urine creatinine x volume) / serum creatinine
    The most common ECG finding in PE is sinus tachycardia. The S1Q3T3 pattern is a classic finding, however this is uncommon and is only seen in ~12% of cases.
    Catacholaminergic polymorphic ventricular tachycardia may present as syncope or sudden cardiac death due to polymorphic ventricular tachycardia, following an adrenergic stress such as exercise.
    Osborn waves, or J waves, are a classic finding in hypothermia. They may also be seen in hypercalcaemia and early repolarisation syndrome. A J wave is a hump-like deflection after the J point, which is the junction between the QRS complex and the ST segment. 
    •  
    The most classic ECG finding in ARVD is epsilon waves. Patients with ARVD may develop ventricular tachycardia, which is of right ventricular origin (with left bundle branch morphology).
    ST elevation MI (STEMI) requires immediate coronary intervention and as such rapid assessment of the patient and ECG is imperative. Non-ST elevation MI may present with many features of STEMI, without ST elevation.
    •  
    The classical ECG changes in pericardial effusion are sinus tachycardia, low QRS voltage and electrical alternans.
    • ECG Findings in Myocardial Ischaemia

    • Downsloping ST depression
    • T wave flattening / inversion
    • U wave inversion
    A prolonged QT interval represent delayed ventricular repolarisation, and increases the risk of a re-entry circuit from froming (i.e. Torsade de Pointes).
    The important distinguishing factor on ECG is the fact that the ST elevation affects all leads (i.e. is global), as opposed to the localised ST elevation in myocardial infarction. PR depression is also a characteristic finding.
    Hypokalaemia, or a reduced serum potassium concentration of <3.5mmol/L, is associated with hyperpolarisation of cardiac myocytes. If severe, hypokalaemia causes abnormal ventricular automaticity which may result in ventricular arrhythmias.
    Hyperkalaemia, or an increased serum potassium concentration of >5mmol/L, shortens action potentials and reduces conduction velocity in cardiac myocytes.
    Normal cardiac impulses are conducted from the atria to the ventricle via the AV node. In WPW, an accessory pathway (the Bundle of Kent) is present which bypasses the normal conduction pathway. This produces a classic preexcitation pattern on ECG, and places the patient at risk of arrhythmias.
    Sodium channel blockers prevent influx of sodium into cardiac myocytes during phase 0 of the action potential, resulting in widening of the QRS complex.
    Early repolarisation syndrome is also known as benign early repolarisation (BER) and was previously considered a normal variant, however the condition is associated with an increased risk of ventricular arrhythmias and sudden cardiac death.
    Digoxin inhibits the Na+/K+ ATPase pump, which results in sodium influx and potassium efflux. This subsequently increases the activity of the Na+/Ca2+ exchange pump, resulting in calcium influx which increases automaticity and has a positive inotropic effect (increases contractility). Digoxin also increases parasympathetic (vagal) tone, causing reduced conduction through the AV node.
      • Normal Range

      • Serum folate: ≥9 nmol/L
      • Red cell folate: 360 - 1400 nmol/L
      • Normal Range

      • 150 - 750 pmol/L
    Caeruloplasmin is an acute phase reactant.
    As LDH is present in all tissues, its elevation is a nonspecific marker of cell damage. Elevation of specific LDH isoenzymes may point toward a specific pathology, as below.
    AST is found in the liver, cardiac muscle, skeletal muscle, kidneys, brain, pancreas, lungs, leukocytes and erythrocytes.
      • Normal Range

      • Total bilirubin - <1 mg/dL or <20 μmol/L
      • Direct (conjugated) bilirubin - <0.3 mg/dL or <7 μmol/L
      • Normal Range

      • 35 - 100 U/L
    AST is found in the liver, cardiac muscle, skeletal muscle, kidneys, brain, pancreas, lungs, leukocytes and erythrocytes.
    • Significance

    • PT/INR is often elevated in patients with significant liver disease.
      • Normal Range

      • Males: <50 U/L
      • Females: <30 U/L
      • Normal Range

      • 32 - 45 g/L
    • Mechanism

    • High-energy pelvic trauma.
    • Mechanism

    • Hyperflexion of the spine, often in car accidents with patients wearing a lap seatbelt without a shoulder strap.
    • Mechanism of Action

    • Inhibits intestinal absorption of cholesterol.
    •  
      Oral
      Lercanidipine
      Zanidip 
    •  
      Oral
      Bisoprolol
      Bicor 
       
      Used to treat stable heart failure only
    • Mechanism of Action

    • Inhibit sodium-chloride transporters in the distal convoluted tubule, resulting in reduced sodium and chloride reabsorption.
    •  
      Oral
      Bumetanide

    •  
      Oral / sublingual
      Isosorbide Dinitrate
      Isordil 
    •  
      Oral
      Diltiazem
      Cardizem 
       
      Less cardio depression than with verapamil
    • Mechanism of Action

    • Inhibits the action of acetylcholine on muscarinic receptors, resulting in reduced vagal (parasympathetic) stimulation of the heart.
    • Mechanism

    • Bind to and inhibit fast sodium channels responsible for rapid depolarisation during phase 0 of the cardiomyocyte action potential.
    •  
      IV / Oral
      Sotalol

    •  
      Oral
      Carvedilol
      Dilatrend 
       
      β1, β2 and α1 antagonist effects
    •  
      Oral
      Tamsulosin
      Flomaxtra 
       
      Preferred agent for urinary obstructive symptoms related to BPH
    • Mechanism of Action

    • A naturally ocurring purine nucleoside that supresses the sinoatrial node, shortens phase 2 of the cardiomyocyte action potential and supresses AV nodal conduction through effects on potassium and calcium currents.
    •  
      Oral
      Enalapril
      Renitec 
    •  
      Oral
      Diltiazem
      Cardizem 
       
      Less cardio depression than with verapamil
    • Mechanism of Action

    • Stimulates opening of ATP-dependant potassium channels in vascular smooth muscle, resulting in arterial dilatation and reduced afterload. Also has nitrate activity, resulting in venous dilatation and reduced preload.
    •  
      Oral / IV
      Procainamide

    • Mechanism of Action

    • Normalises serum magnesium concentrations in the case of hypomagnesaemia.
      Magnesium is involved in many physiologic processes including cardiac Na⁺ / K⁺ ATPase, and hypomagnesaemia can result in depolarisation and torsades de pointes.
    •  
      Oral
      Gemfibrozil
      Lopid 
    •  
      Oral
      Pravastatin
      Lipostat 
    •  
      Oral
      Bisoprolol
      Bicor 
       
      Used to treat stable heart failure only
    • Mechanism

    • Bind to and inhibit fast sodium channels responsible for rapid depolarisation during phase 0 of the cardiomyocyte action potential.
    • Mechanism of Action

    • Not completely known, though believed to have an effect at the distal convoluted tubule. Also thought to stimulate production of prostaglandin E2, resulting in vasodilation and decreased total peripheral resistance.
    •  
      Oral
      Irbesartan
      Avapro, Karvea 

    Cardiomyocyte Action Potentials

    • Cardiomyocyte Action Potentials

    Overview

    • Mechanism of Action

    • Inhibit the action of aldosterone on sodium-potassium exchange pumps in the distal convoluted tubule.
    • Mechanism of Action

    • Relaxes vascular smooth muscle (predominantly arterioles) through opening of potassium channels, resulting in reduced afterload.
      • Mechanism of Action

      • Inhibits mycobacterial membrane transporters, disrupting membrane potentials.
      • Mechanism of Action

      • Believed to inhibit the incorporation of mycolic acids into the mycobacterial cell wall.
      • Mechanism of Action

      • Inhibits dihydrofolate synthesis by competitively inhibiting dihydropteroate synthetase (DHPS).
      • Mechanism of Action

      • Inhibit bacterial RNA polymerase, resulting in disruption of DNA transcription.
      • Mechanism of Action

      • Inhibits lipid and nucleic acid biosynthesis through an unknown mechanism.
      •  
        Oral
        Aspirin + Dipyridamole
        Asasantin 
      • Mechanism of Action

      • A monoclonal antibody that strongly binds to dabigatran, preventing its effect on prothrombin.
      • Mechanism of Action

      • Repletes the body's stores of vitamin K, overcoming the effect of warfarin on its inhibition of the clotting cascade.
      •  
        IV
        Apheresis Plasma
        Blood is removed, plasma collected and blood returned to patient
      • Mechanism of Action

      • Activates plasminogen, resulting in its activation to plasmin and thus fibrinolysis.
      • Mechanism of Action

      • Inactivated recombinant factor Xa that strongly binds the factor Xa inhibitors apixaban and rivaroxaban, inactivating them and preventing their anticoagulant effect.
      Unfractionated heparin has a short half life, and is often used in an inpatient setting for rapidly titratable anticoagulation.
      •  
        Oral
        Rivaroxaban
        Xarelto 
      •  
        Subcut
        Dalteparin
        Fragmin 
      •  
        IV
        Reteplase
        Rapilysin 
      • Mechanism of Action

      • Blocks lysine binding sites on plasminogen, preventing its conversion to plasmin and thus preventing fibrinolysis.
      • Mechanism of Action

      • Binds to and inactivates heparin.
      Prothrombinex contains purified coagulation factors specifically prepared for the reversal of warfarin.
      • Mechanism of Action

      • Inhibits regeneration of vitamin K from vitamin K epoxide, resulting in reduced synthesis of clotting factors II, VII, IX and X, as well as proteins C and S.
      •  
        Oral
        Prasugrel
        Effient 
         
        A prodrug that requires enzymatic activation
      • Mechanism of Action

      • Reversibly inhibit factor IIa (thrombin), resulting in reduced fibrin clot formation.
      • Mechanism of Action

      • Inhibit cyclooxygenase, the enzyme responsible for production of thromboxanes, prostacyclin and prostaglandins from arachidonic acid.
      •  
        IV
        Eptifibatide
        Integrilin 
         
        Short half-life (2.5 hours) and effect (haemostasis 3-4 hours)
      • Mechanism of Action

      • A monoclonal antibody that targets CD20, a transmembrane protein on the surface of B cells, resulting in antibody-dependent and complement-dependent cytotoxicity.
      • Mechanism of Action

      • Contains a monoclonal antibody directed toward HER2 (trastuzumab), linked to a chemotherapeutic agent (DM1), allowing for targeted delivery of cytotoxic chemotherapy to HER2-positive tumour cells.
      • Trastuzumab inhibits HER2 signalling pathways resulting in cell cycle arrest, and also mediates antibody-dependent cell-mediated cytotoxicity.
      • DM1 is a cytotoxic agent that binds to tubulin, preventing polymerisation and resulting in cell cycle arrest in the G2/M phase.
      • Mechanism of Action

      • An IgG monoclonal antibody that binds to and inhibits RANK ligand, a cytokine normally responsible for stimulation of osteoclastic maturation and function.
      •  
        IV infusion
        Pertuzumab
        Inhibits ligand-dependent HER2 dimerisation and signalling
      • Mechanism of Action

      • Contains a monoclonal antibody directed toward CD-33, linked to a chemotherapeutic agent, allowing for targeted delivery of cytotoxic chemotherapy to CD33-positive cells.
      • The chemotherapeutic agent, N-acetyl gamma calicheamicin, is activated within targeted cells and induces double-standed DNA breaks.
      • Nomenclature

        Monoclonal antibodies are named based on a combination of the following:
      • Prefix - random
      • Substem A - based on the target
      • Substem B - based on the species of origin of the antibody
      • Stem - mab
      •  
        IV infusion
        Durvalumab
        Imfinzi 
      •  
        IV
        Panitumumab
        Vectibix 
      • Mechanism of Action

      • A humanized monoclonal antibody that binds to CD-52 receptors found on mature lymphocytes, initiating complement-mediated and antibody-dependent cell-mediated cytotoxicity.
      • Mechanism of Action

      • A monoclonal antibody against cytotoxic T-lymphocyte antigen 4 (CTLA-4), a T cell inhibitory molecule that binds to B7 and prevents its binding to CD28.
      • The B7 : CD28 complex normally potentiates the binding of T cell receptors to MHC/antigen complexes on antigen-presenting cells, stimulating T cell proliferation and differentiation.
      • CTLA-4 is expressed on the surface of T cells after activation, and provides inhibitory signalling to T cells by binding B7.
      • Binding to anti-CTLA-4 antibodies to CTLA-4 leaves B7 free to continue to bind to CD28 and provide ongoing T cell costimulation.
      •  
        IV infusion
        Pembrolizumab
        Keytruda 
      • Mechanism of Action

      • A humanised monoclonal antibody directed against vascular endothelial growth factor (VEGF), whose expression is up-regulated during angiogenesis in certain cancers. Binding to VEGF reduces tumour bloodflow by promoting breakdown of tumour vasculature and inhibiting new blood vessel growth.
      •  
        Oral
        Itraconazole
        Cover against years and moulds
      •  
        IV
        Liposomal Amphotericin B
        AmBisome 
         
        Lipid suspension results in binding directly to the fungal cell, resulting in low doses and significantly less toxicity
      •  
        IV
        Anidulafungin
        Eraxis 
         
        No liver metabolism - can be used in patients with liver failure
      •  
        Oral
        Exemestane

      •  
        Oral
        Enzalutamide
        Xtandi 
      • Mechanism of Action

      • Directly inhibit the binding of androgens to androgen receptors.
      • Mechanism of Action

      • Antagonise oestrogen receptors without agonist activity.
      • Mechanism of Action

      • Antagonise oestrogen receptors in breast tissue and agonise oestrogen receptors in endometrial tissue and bone.
      • Mechanism of Action

      • Inhibits 17-α hydroxylase / C17,20-lyase (CYP17) which is expressed in prostatic tumour tissue and is required for androgen synthesis.
      •  
        Subcut
        Leuprorelin / Leuprorelide
        Lucrin, Eligard 
      •  
        Inhaled
        Halothane
        Pleasant odour - preferred for paediatrics
      • Mechanism

      • Acts as a non-competitive antagonist at the NMDA receptor
      • Reduces presynaptic release of glutamate
      • Agonises α and β adrenoceptors
      • Agonises opioid σ receptors
      •  
        Local / Regional
        Lignocaine
        Xylocaine 
      •  
        IV
        Cisatracurium
        More potent isomer of atracurium
        Onset 3 minutes
        Duration 40 minutes
      Depolarising muscle relaxants such as suxamethonium are ultra short-acting medications that cause depolarisation of voltage-gated channels, resulting in muscle relaxation due to inability to further depolarise muscle cells.
      • Mechanism of Action

      • Augments the inhibitory action of GABA by decreasing the rate of dissociation of GABA from GABAA receptors.
      • Mechanism of Action

      • Bind to aldosterone receptors, resulting in sodium / water retention and potassium excretion through the kidneys, gut, salivary and sweat glands.
      • Mechanism of Action

      • Prevents utilization of iodine by the thyroid by inhibiting thyroperoxidase-catalysed iodination of tyrosine residues within the thyroid
      • Suspected to have immunosuppressive effects by affecting signaling pathways between thyroid cells and T cells.
      • Also inhibits conversion of T4 to T3.
      • Mechanism of Action

      • Synthetic 1,25-dihydroxy-vitamin D₃, which stimulates intestinal calcium / phosphate absorption and increased expression of RANK-ligand on osteoblast cell surfaces, resulting in a net increase in serum calcium and phosphate.
      •  
        Oral
        Rosiglitazone
        Avandia 
      Metformin is an oral hypoglycaemic of the biguanide class that reduces serum glucose without directly stimulating insulin secretion.
      •  
        Subcut
        Insulin Detemir
        Levemir 
      • Mechanism of Action

      • Synthetic parathyroid hormone (PTH). Continuous PTH administration primarily stimulates osteoclast differentiation, while intermittent PTH administration (daily teriparatide) primarily stimulates osteoblast differentiation.
      •  
        IV / Topical
        Hydrocortisone
        Cortef 
      • Mechanism of Action

      • Prevents utilization of iodine by the thyroid by inhibiting thyroperoxidase-catalysed iodination of tyrosine residues within the thyroid
      • Suspected to have immunosuppressive effects by affecting signaling pathways between thyroid cells and T cells.
      •  
        Subcut
        Exenatide
        Byetta (daily), Bydureon (weekly) 
      •  
        Oral
        Sitagliptin
        Januvia 
      •  
        Subcut / IV
        Insulin Lispro
        Humalog 
      • Mechanism of Action

      • Stimulates osteoblastic differentiation / activity, and inhibits osteoclastic differentiation / activity.
      Calcium carbonate is a calcium preparation used to treat hypocalcaemia and hyperphosphataemia.
      • Effects

      • Glucose

      • Increased glycogen synthesis
      • Reduced hepatic glycogenolysis (glycogen breakdown)
      • Reduced hepatic gluconeogenesis (glucose formation)
      • Increased GLUT-4 mediated glucose uptake into adipose tissue and skeletal muscle
      • Fat

      • Increased triglyceride synthesis
      • Reduced lipolysis
      • Protein

      • Increased amino acid uptake
      • Reduced protein breakdown
      • Potassium

      • Increased cellular potassium uptake
      •  
        Subcut
        Lispro + Isophane Insulin
        Humalog Mix25, Humalog Mix50
      Intermediate-acting insulins such as protaphane have a moderate onset of action and intermediate duration, making this medication a useful part of combination insulin preparations.
      •  
        Oral
        Dapagliflozin
        Forxiga 
      • Mechanism of Action

      • A selective oestrogen receptor modulator (SERM) that agonises oestrogen receptors in bone and antagonises oestrogen receptors in the breast and uterus. Prevents bone resorption and thus presents bone loss.
      • Mechanism of Action

      • An IgG monoclonal antibody that binds to and inhibits RANK ligand, a cytokine normally responsible for stimulation of osteoclastic maturation and function.
      • Mechanism of Action

      • Synthetic vitamin D₃, which stimulates intestinal calcium / phosphate absorption and increased expression of RANK-ligand on osteoblast cell surfaces, resulting in a net increase in serum calcium and phosphate.
      • Mechanism of Action

      • Synthetic T4 is converted to T3 that binds to nuclear thyroid hormone receptors, inducing alterations in gene transcription and subsequent effects on metabolism.
      Short-acting insulins such as actrapid have an incredibly rapid onset and short duration, meaning that they are useful for bolus dosing and insulin infusions.
      •  
        Oral
        Glimepiride
        Amaryl 
      •  
        IV
        Pamidronate
        Aredia 
         
        Used to treat lytic lesions / hypercalcaemia of malignancy
      •  
        Oral
        Rimantadine
        Flumadine 
      • Mechanism of Action

      • Inhibit HIV-1 protease, suppressing processing of viral polyproteins and preventing the formation of mature virions.
      •  
        Oral
        Raltegravir
        Isentress 
      • Mechanism of Action

      • Directly inhibit the pyrophosphate binding sites of viral DNA polymerase, resulting in premature DNA termination.
      •  
        Oral
        Emtricitabine

      • Mechanism of Action

      • Analogues of nucleotides that are incorporated into viral DNA by viral DNA polymerase, resulting in premature DNA termination.
      •  
        Oral
        Valaciclovir
        Prodrug of aciclovir, with 55% bioavailability
      • Mechanism of Action

      • Prevent viral reverse transcription of single-stranded RNA into double-stranded DNA, by inhibiting HIV reverse transcriptase.
      • Mechanism of Action

      • Analogues of deoxyribonucleotides. Prevent viral reverse transcription of single-stranded RNA into double-stranded DNA, by inhibiting HIV reverse transcriptase.
      • Mechanism of Action

      • Selectively inhibit viral neuroaminidase on the viral surface, preventing release of the virus from infected cells.
      •  
        Oral / IV
        Clonazepam
        Paxam, Rivotril 
         
        [Peak] 2-3 hours
        Half-life 18-50 hours
      • Mechanism of Action

      • Positively modulate GABAA receptors (BZ1 and BZ2), augmenting the inhibitory effects of the GABA neurotransmitter.
      •  
        Oral
        Escitalopram
        Lexapro 
      Midazolam is a short-acting benzodiazepine with a rapid onset and offset, making it useful for acute sedation and termination of seizures.
      • Mechanism of Action

      • Inhibit the action of noradrenaline on alpha-2 receptors, resulting in increased serotonin release.
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels, preventing propagation of action potentials and thus suppressing seizure activity. Also inhibits enzymes that breakdown GABA, resulting in increased GABA-mediated inhibition.
      •  
        IM
        Flupenthixol
        Depot – fortnightly / monthly dosing for schizophrenia
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels, preventing the propagation of action potentials and thus suppressing seizure activity.
      •  
        Oral
        Doxepin
        Deptran 
      •  
        Oral
        Phenelzine
        Nardil 
      •  
        Oral / IM
        Aripiprazole
        Abilify 
         
        Partial agonist of D2 and 5-HT1A and antagonist of 5-HT2A receptors
      • Mechanism of Action

      • Modulates neurotransmission through complex effects on signal transduction mechanisms including  glycogen synthase kinase-3β, cyclic AMP-dependant kinase and protein kinase C.
      •  
        Oral
        Duloxetine
        Cymbalta 
         
        Primarily inhibits noradrenaline reuptake
      • Mechanism of Action

      • Inhibits the production of dihydrofolate reductase (DHFR), resulting in reduced conversion of dihydrofolic acid to active tetrahydrofolic acid - interfering with bacterial synthesis of nucleic acids.
      • Mechanism of Action

      • Trimethoprim inhibits the production of dihydrofolate reductase (DHFR), resulting in reduced conversion of dihydrofolic acid to active tetrahydrofolic acid - interfering with bacterial synthesis of nucleic acids.
      • Mechanism of Action

      • Broken down into its active form selectively by anaerobic and protozoal cells. Binds to and disrupts DNA, resulting in DNA degradation and cell death.
      •  
        Oral
        Dicloxacillin

      •  
        Oral
        Clarithromycin
        Biaxin 
      •  
        IV
        Teicoplanin
        Alternative to vancomycin if severe red man syndrome
      •  
        IV / IM
        Lincomycin

      • Mechanism of Action

      • Inhibit bacterial protein synthesis by preventing initiation of translation.
      •  
        IV
        Cefoxitin
        Useful against anaerobes
      • Mechanism of Action

      • Inhibit bacterial RNA polymerase, resulting in disruption of DNA transcription.
      •  
        IM
        Benzathine Penicillin
        Bicillin 
         
        Benzathine is a stabiliser - weekly / fortnightly dosing
      • Mechanism of Action

      • Beta lactam antibiotics, which inhibit bacterial cell wall synthesis.
      •  
        IV
        Ceftriaxone

      •  
        IV
        Piperacillin-Tazobactam
        PipTaz, Tazosin 
         
        Used for severe infections only
      • Mechanism of Action

      • Beta lactam antibiotics, which inhibit bacterial cell wall synthesis.
      •  
        IV
        Ampicillin

      • Mechanism of Action

      • Inhibit protein synthesis by binding to the 30s ribosomal subunit, resulting in inaccurate mRNA translation.
      •  
        Oral
        Norfloxacin
        Noroxin 
      •  
        IV
        Cephazolin
        Used for severe infections and for surgical prophylaxis
      •  
        IV
        Amikacin
        Second-line treatment when other aminoglycosides ineffective
      • Mechanism of Action

      • Naturally occurring hormone that binds to oxytocin receptors (G-protein coupled receptors).
      • Mechanism of Action

      • Inhibit L-type calcium channels, resulting in myometrial smooth muscle relaxation.
      Combination oxytocics combine both oxytocin and an ergot alkaloid, which stimulate contraction of uterine and vascular smooth muscle.
      • Mechanism of Action

      • Bind to β2 adrenoceptors, stimulating smooth muscle relaxation through induction of cAMP with resulting phosphorylation of muscle regulatory proteins and modification of cellular calcium concentration.
      • Mechanism of Action

      • Stimulate contraction of uterine and vascular smooth muscle, through agonism of alpha-adrenergic, dopaminergic and serotonin (5-HT) receptors.
      •  
        IV
        Pooled Platelets
        Equivalent to 5 units of apheresis platelets
      • Composition

      • Concentrated factor VIII.
      •  
        IV
        Apheresis Plasma
        Blood is removed, plasma collected and blood returned to patient
      • Composition

      • Concentrated factor IX.
      •  
        IV
        Apheresis Cryoprecipitate
        Blood is removed, plasma collected, blood returned to patient and then cryoprecipitate is isolated from plasma
      Many of these adverse effects are avoided by testing donors and donated for infection, as well as correctly typing and identifying patients who will be transfused.
      Prothrombinex contains purified coagulation factors specifically prepared for the reversal of warfarin.
      • Composition

      • Concentrated antithrombin-III.
      • Composition

      • Concentrated factor VIII and Von Willebrand factor.
      •  
        MDI / Neb
        Formoterol
        Oxis 
      •  
        MDI
        Fluticasone / Salmeterol
        Seretide 
      •  
        IV / IM / Oral
        Methylprednisolone
        Medrol 
      • Mechanism of Action

      • A humanised monoclonal antibody directed toward immunoglobulin E (IgE).
      • Mechanism of Action

      • Inhibit muscarinic (M3) receptors, leading to bronchial smooth muscle relaxation and bronchodilation through reduction in acetylcholine-mediated vagal tone.
      •  
        Inhaler / Nebule
        Budesonide
        Pulmicort 
      • Mechanism of Action

      • Directly bind to airway β2 adrenoceptors, stimulating smooth muscle relaxation and bronchodilation through induction of cAMP with resulting phosphorylation of muscle regulatory proteins and modification of cellular calcium concentration.
      •  
        MDI
        Aclidinium
        Bretaris Genuair 
      These combination inhalers contain a long-acting muscarinic agent (LAMA) and a long-acting beta 2 agonist (LABA) as bronchodilators, as well as an inhaled corticosteroid (ICS) to reduce airway inflammation.
      •  
        Oral
        Zafirlukast
        Accolate 
      • Mechanism of Action

      • A humanised monoclonal antibody directed against IL-5, a cytokine that stimulates maturation, growth and activation of eosinophils.
      •  
        MDI
        Aclidinium / Formoterol
        Brimica Genuair 
      •  
        MDI
        Terbutaline
        Bricanyl 
      •  
        Oral
        Galantamine
        Galantyl 
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels, preventing propagation of action potentials and thus suppressing seizure activity. Also inhibits enzymes that breakdown GABA, resulting in increased GABA-mediated inhibition.
      •  
        Oral
        Naratriptan
        Naramig 
         
        Slow onset
      • Mechanism of Action

      • Inhibits histamine H1 and serotonin receptors.
      • Mechanism of Action

      • A humanized monoclonal antibody that binds to CD-52 receptors found on mature lymphocytes, initiating complement-mediated and antibody-dependent cell-mediated cytotoxicity.
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels, preventing propagation of action potentials and thus suppressing seizure activity. Also inhibits enzymes that breakdown GABA, resulting in increased GABA-mediated inhibition.
      •  
        IV / IM / Oral
        Methylprednisolone
        Medrol 
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels and enhances GABA-mediated inhibition, resulting in suppression of seizure activity.
      • Mechanism of Action

      • Competitively inhibit the action of adrenaline and noradrenaline on β1 and β2 receptors, resulting in suppression of the sympathetic nervous system.
      •  
        Subcut
        Interferon Beta-1b
        Betaferon 
      • Mechanism of Action

      • Block presynaptic reuptake of serotonin (5-HT) and noradrenaline (NA) through an unknown mechanism.
      • Mechanism of Action

      •  Inhibits T-type calcium channels in the thalamus, preventing propagation of action potentials and thus suppressing seizure activity

      Clinical Use

      • Mechanism of Action

      • Inhibits the release of T cells from lymph nodes, resulting in redistribution of T cells and decreased entry into the central nervous system.

      Overview

      • Mechanism of Action

      • Monoclonal antibody toward leucocyte adhesion molecules, resulting in slowed entry of T cells into the CNS.
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels and enhances GABA-mediated inhibition, resulting in suppression of seizure activity.
      •  
        Oral / IV
        Clonazepam
        Paxam, Rivotril 
         
        [Peak] 2-3 hours
        Half-life 18-50 hours
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels, preventing propagation of action potentials and thus suppressing seizure activity.
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels, preventing the propagation of action potentials and thus suppressing seizure activity.
      • Mechanism of Action

      • Act directly on dopamine D2 and D3 receptors, addressing the severe depletion of dopamine within the striatum pallidum and substantia nigra in Parkinson's disease.
      •  
        Oral
        Levodopa + Benserazide
        Madopar 
      • Mechanism of Action

      • Unknown, though anticonvulsant effects may be through inhibition of neuronal N-type calcium channels and reduced breakdown of GABA.
      • Mechanism of Action

      • Unknown mechanism, though believed to be a weak inibitor of prostaglanding synthesis. Also thought to inhibit COX-2, though without anti-inflammatory effects.
      •  
        Oral
        Diclofenac
        Voltaren 
      •  
        Oral
        Cyclizine Hydrochloride
        Nausicalm 
         
        Used to treat nausea / vomiting
      •  
        Oral
        Fexofenadine
        Allegra, Telfast 

      Efficacy of Contraceptive Methods

      Typical UseCorrect & Consistent Use
      No Method15%15%
      Spermicide72%82%
      Timing Method76%97%
      Withdrawal Method78%96%
      Female Condom79%95%
      Male Condom92%98%
      Diaphragm88%94%
      Oral Contraception91%99.7%
      Vaginal Ring91%99.7%
      Depot Injection94%99.8%
      Copper IUD99.2%99.4%
      Intrauterine System99.8%99.8%
      Implant99.95%99.95%
      Female Sterilisation99.5%99.5%
      Male Sterilisation99.85%99.9%

      Overview

      Contain a progestin ± an oestrogen, with a dose equivalent of ~25 contraceptive pills.
      • Mechanism of Action

      • Thicken cervical mucus, resulting in reduced sperm penetration through the cervix. Less of an effect on follicular development and prevention of ovulation than combined contraceptives.
      Depot injection for long-acting contraception.
      Implanted under the skin of the upper arm for long-acting contraception.
      • Mechanism of Action

      • Contain an oestrogen and a progesterone, which inhibit follicular development, prevent ovulation and thicken cervical mucus resulting in reduced sperm penetration.
      •  
        Oral
        Ethinyloestradiol + Drospirenone
        Yaz, Yasmin 
      • Mechanism of Action

      • A selective oestrogen receptor modulator (SERM) that inhibits hypothalamic oestrogen receptors, resulting in reduced negative feedback of oestrogen on FSH and LH release. Increased FSH and LH stimulates ovarian follicle maturation, ovulation and development of the corpus luteum.
      •  
        Oral
        Norethisterone
        Micronor, Primolut N 
      •  
        Oral
        Misoprostol
        GyMiso 
         
        Given 36 - 48 hours after mifepristone
      • Mechanism of Action

      • Binds to cyanide ions to form non-toxic cyanocobalamin.
      5% dextrose is a crystalloid fluid made up of glucose. This fluid is often used in hypoglycaemic or hyponatraemic patients, and is also used to balance out insulin administration in patients with diabetic ketoacidosis.
      • Mechanism of Action

      • Inhibits acetylcholinesterase, resulting in reduced breakdown of acetylcholine which overcomes anticholinergic agents' competitive inhibition of nicotinic and muscarinic receptors.
      • Mechanism of Action

      • Provides cysteine for use in the synthesis of glutathione, which facilitates metabolism of the toxic paracetamol metabolite N-acetyl-p-benzoquinoneimine.
      • Mechanism of Action

      • Binds to and inactivates heparin.
      • Mechanism of Action

      • An iron chelator that binds to iron molecules and forms a stable compound that is excreted by the kidneys.
      • Mechanism of Action

      • Directly inhibits ADH, which metabolizes methanol and ethylene glycol into toxic metabolites formic acid and glycolic acid respectively.
      • Mechanism of Action

      • Competitively inhibits the action of benzodiazepines on the GABAA receptor.
      • Mechanism of Action

      • A hormone naturally produced by pancreatic alpha cells that is responsible for regulation of glucose  and lipid metabolism.
      • Mechanism of Action

      • A competitive antagonist of μ, κ, and δ opioid receptors, reversing the action of exogenous opioids.
      • Mechanism of Action

      • A heavy metal chelator that binds to metals such as lead and arsenic, forming a stable compound that can be excreted.
      • Mechanism of Action

      • A heavy metal chelator that binds to metals such as lead and arsenic, forming a stable compound that can be excreted.
      • Mechanism of Action

      • Repletes the body's stores of vitamin K, overcoming the effect of warfarin on its inhibition of the clotting cascade.
      • Mechanism of Action

      • A heavy metal chelator that binds to metals such as lead, copper and arsenic, forming a stable compound that can be excreted.
      • Mechanism of Action

      • Competitively inhibits the action of acetylcholine on muscarinic receptors.
      • Mechanism of Action

      • Competitively inhibits ADH-mediated metabolism of methanol and ethylene glycol into toxic metabolites formic acid and glycolic acid, respectively.
      • Mechanism of Action

      • Enhances endogenous detoxification of cyanide by providing sulfur ions for rhodanese, an enzyme that converts cyanide and thiosulfate to non-toxic thiocyanate.
      50% dextrose is a strongly hypertonic fluid containing a high concentration of dextrose; it is used to treat patients with severe hypoglycaemia and raised intracranial pressure.
      • Mechanism of Action

      • A human monoclonal antibody directed against p40, a shared subunit present in both IL-12 and IL-23. Inhibition of IL-12 results in reduced differentiation of TH1 cells, while inhibition of IL-23 results in reduced induction of TH17 cells.
      •  
        Oral
        Tofacitinib
        Xeljanz 
         
        Inhibits JAK1, JAK2 and JAK3
      •  
        Subcut
        Adalimumab
        Humira 
         
        Human monoclonal antibody to TNF
      • Mechanism of Action

      • A mouse / human chimaeric monoclonal antibody that binds and inhibits IL-2 receptors (CD-25) on activated T cells, resulting in reduced T cell proliferation.
      • Mechanism of Action

      • A fusion protein with the Fc fragment of human IgG1 linked to the extracellular domain of CTLA-4. Binds to CD80 / CD86 on antigen presenting cells and prevents binding by CD28 on T lymphocytes, resulting in lack of a costimulatory response and reduced T cell activation.
      • Mechanism of Action

      • A humanised monoclonal antibody directed against the terminal complement protein C5 that inhibits its cleavage into C5a and C5b, thus preventing formation of the membrane attack complex.
      • Mechanism of Action

      • A monoclonal antibody that targets CD20, a transmembrane protein on the surface of B cells, resulting in antibody-dependent and complement-dependent cytotoxicity.
      • Nomenclature

      • Prefix - random
      • Substem A - based on the target
      • Substem B - based on the species of origin of the antibody
      • Stem - mab
      • Mechanism of Action

      • A humanised monoclonal antibody that binds to and inhibits IL-6 receptors, resulting in reduced IL-6 binding and a reduction in acute inflammation.
      • Mechanism of Action

      • A human monoclonal antibody that binds to IL-1β and inhibits its activity, resulting in reduced acute phase response.
      • Mechanism of Action

      • A human monoclonal antibody to B lymphocyte stimulator (BLyS, also known as BAFF), a member of the TNF family that inhibits B cell apoptosis and stimulates differentiation of B cells.
      • Mechanism of Action

      • Interleukin-1 receptor antagonist (IL1-RA) is a naturally occurring protein that inhibits the binding of IL-1 to its receptor.
      • Mechanism of Action

      • A human monoclonal antibody directed against IL-17A, a cytokine produced mainly by TH17 cells that activates neutrophils and promotes inflammation.
      • Mechanism of Action

      • A humanised monoclonal antibody directed toward immunoglobulin E (IgE).
      • Mechanism of Action

      • A humanised monoclonal antibody directed against IL-5, a cytokine that stimulates maturation, growth and activation of eosinophils.
      • Mechanism of Action

      • A humanized monoclonal antibody that binds to CD-52 receptors found on mature lymphocytes, initiating complement-mediated and antibody-dependent cell-mediated cytotoxicity.
      • Mechanism of Action

      • A prodrug that is metabolized by the liver into phosphoramide mustard. This active metabolite shares nitrogen atoms between guanine residues in DNA, creating intrastrand and interstrand DNA crosslinks. Disruption of DNA results in cytotoxicity.
      •  
        Oral
        Sirolimus
        Rapamune 
         
        Half-life ~60 hours
      • Mechanism of Action

      • A purine analogue that inhibits purine synthesis, disrupting DNA synthesis and reducing T cell activation.
      • Mechanism of Action

      • Rabbit immunoglobulin directed mainly against T cells that causes rapid central and peripheral lymphocyte depletion.
      • Mechanism of Action

      • Inflammatory diseases: inhibits interleukin-1 and interleukin 6 activity, and altering the numbers of different lymphocyte subsets.
      • In cancer treatment: inhibits dihydrofolate reductase (DHFR), reducing synthesis of folate, which is involved in synthesis of the purine and pyramidine precursors required for DNA / RNA and cell proliferation.
      •  
        IV / IM / Oral
        Methylprednisolone
        Medrol 
      • Mechanism of Action

      • A prodrug of mycophenolic acid (MPA), a non-competitive, reversible inhibitor of inosine monophosphate dehydrogenase (IMPD). IMPD is a key enzyme in the synthesis of guanosine triphosphate; T cells and B cells are critically dependent on this pathway and thus its inhibition results in impaired lymphocyte proliferation.
      • Mechanism of Action

      • Believed to inhibit the mitochondrial enzyme dihydroorotate dehydrogenase, which is involved in pyramidine synthesis.
      •  
        Oral / IV
        Tacrolimus
        Prograf 
      Contains pooled IgG antibodies from at least 1,000 donors.
      • Composition

      • Sodium 513mmol/L
      • Chloride 513mmol/L
      5% dextrose is a crystalloid fluid made up of glucose. This fluid is often used in hypoglycaemic or hyponatraemic patients, and is also used to balance out insulin administration in patients with diabetic ketoacidosis.
      • Mechanism of Action

      • Inhibit the action of aldosterone on sodium-potassium exchange pumps in the distal convoluted tubule.
      •  
        IV
        Intravenous Potassium Chloride
        Indicated if PO intake not possible / K⁺ <3.0mmol/L / ECG disturbances
        IV potassium should not be administered at a rate of greater than 10mmol/hour.
      0.9% sodium chloride is a crystalloid fluid commonly used for fluid resuscitation and maintenance. This fluid contains supraphysiologic amounts of sodium and chloride, and should be avoided in large quantities.
      • Composition

      • Human albumin 20g/L
      • Sodium 50-100mmol/L
      •  
        Oral
        Sodium Polystyrene Sulfonate
        Resonium A 
         
        Useful for patients with hypercalcaemia
      Hartmann's solution, also known as compound sodium lactate (or Ringer's lactate in a research setting) is a crystalloid that is more physiologic than 0.9% sodium chloride; this results in less metabolic acidosis.
      •  
        Subcut / IV
        Neutral Insulin
        Actrapid, Humulin R 
         
        Given 30 minutes before meals
      • Mechanism of Action

      • Normalises serum magnesium concentrations in the case of hypomagnesaemia.
        Magnesium is involved in many physiologic processes including cardiac Na⁺ / K⁺ ATPase, and hypomagnesaemia can result in depolarisation and torsades de pointes.
      • Composition

      • Human albumin 40g/L
      • Sodium 140mmol/L
      • Chloride 128mmol/L
      • Mechanism of Action

      • Act on opioid receptors (δ, κ and µ) and nociceptin orphanin FQ (NOF) receptors on neuronal cell membranes within the thalamus, diencephalon, midbrain and medulla, resulting in reduced neurotransmitter release.
      •  
        Oral / IV
        Methadone
        Dolophine 
         
        Used for long-term treatment of opioid addiction
      • Mechanism of Action

      •  Synthetic weak µ opioid agonist, and also inhibits nociception through enhancement of noradrenergic and serotonergic pathways.
      • Mechanism of Action

      • Not fully described, though effects are believed to be due to binding of the α2δ-1 subunit of voltage-gated calcium channels with resultant reduction in nociceptive neurotransmission.
      Acetaminophen in the US, Paracetamol in other countries.
      • Mechanism of Action

      • A GABA analogue that agonises GABAB receptors.
      •  
        Oral
        Oxycodone + Naloxone
        Targin 
         
        Includes a reversal agent, to reduce adverse effects (particularly constipation)
      •  
        Oral
        Codeine
        Weakly agonises all opioid receptors
        Up to 10% of the population lack the enzyme required to convert codeine (weak) to morphine (potent) – in these cohorts codeine has nearly no effect
      Gabapentin was developed as an anticonvulsant, however it is also used for the treatment of neuropathic pain.
      •  
        Local / Regional
        Lignocaine
        Xylocaine 
      • Mechanism of Action

      • Inhibit cyclooxygenase, the enzyme responsible for production of thromboxanes, prostacyclin and prostaglandins from arachidonic acid.
      •  
        Oral
        Diclofenac
        Voltaren 
      • Mechanism of Action

      • A fusion protein with the Fc fragment of human IgG1 linked to the extracellular domain of CTLA-4. Binds to CD80 / CD86 on antigen presenting cells and prevents binding by CD28 on T lymphocytes, resulting in lack of a costimulatory response and reduced T cell activation.
      •  
        Subcut
        Adalimumab
        Humira 
         
        Human monoclonal antibody to TNF
      • Mechanism of Action

      • Purine analogue that inhibits purine synthesis, disrupting DNA synthesis and reducing T cell activation.
      • Mechanism of Action

      • Inhibits phosphodiesterase 4 (PDE4), an enzyme that hydrolyses cAMP in many cell types. Increased cAMP results in reduced proinflammatory TNFα, IL-23 and IL-17, as well as increased anti-inflammatory IL-10.
      • Mechanism of Action

      • Inhibits T cell activation as well as transcription of IL-2 and other cytokines, through inhibition of calcineurin-mediated activation of NFAT.
      • Mechanism of Action

      • Believed to inhibit the mitochondrial enzyme dihydroorotate dehydrogenase, which is involved in pyramidine synthesis.
      • Mechanism of Action

      • A human monoclonal antibody directed against p40, a shared subunit present in both IL-12 and IL-23. Inhibition of IL-12 results in reduced differentiation of TH1 cells, while inhibition of IL-23 results in reduced induction of TH17 cells.
      • Mechanism of Action

      • A humanised monoclonal antibody that binds to and inhibits IL-6 receptors, resulting in reduced IL-6 binding and a reduction in acute inflammation.
      • Mechanism of Action

      • Inhibit microtubule polymerisation, resulting in reduced mitosis. Also inhibits the release of a crystal-derived factor from neutrophils.
      • Mechanism of Action

      • Interleukin-1 receptor antagonist (IL1-RA) is a naturally occurring protein that inhibits the binding of IL-1 to its receptor.
      • Mechanism of Action

      • Inflammatory diseases: inhibits interleukin-1 and interleukin 6 activity, and altering the numbers of different lymphocyte subsets.
      • In cancer treatment: inhibits dihydrofolate reductase (DHFR), reducing synthesis of folate, which is involved in synthesis of the purine and pyramidine precursors required for DNA / RNA and cell proliferation.
      • Mechanism of Action

      • A monoclonal antibody that targets CD20, a transmembrane protein on the surface of B cells, resulting in antibody-dependent and complement-dependent cytotoxicity.
      •  
        Oral
        Tofacitinib
        Xeljanz 
         
        Inhibits JAK1, JAK2 and JAK3
      While classically an anti-malarial medication, hydroxychloroquine is now used to treat rheumatologic disorders such as rheumatoid arthritis and lupus.
      •  
        Oral
        Febuxostat
        Adenuric 
      • Mechanism of Action

      • Inhibit 5-aminoimidazole-4-carboxamidoribonucleotide (AICAR) transformylase, which results in increased adenosine release at the inflamed site. Adenosine binds to A2 receptors on inflammatory cells resulting in reduced inflammation.
      •  
        Oral
        Dasatinib
        Sprycel 
         
        Binds both active & inactive conformation of Bcr-Abl kinase, resulting in reduced resistance
      •  
        Oral
        Ceritinib
        Zykadia 
         
        Better CNS penetration than crizotinib
      •  
        Oral
        Gefitinib
        Iressa 
         
        Acneiform rash can be a major concern
      •  
        Oral
        Vemurafenib + Cobimetinib
        Zelboraf + Cotellic 
      •  
        Oral
        Sunitinib
        Sutent 
      •  
        Oral
        Dabrafenib
        Tafinlar 
         
        Given as monotherapy or in combination with trametinib (MEK inhibitor)
      • Mechanism of Action

      • Inhibit poly ADP ribose polymerase (PARP) enzymes that repair single strand DNA breaks, resulting in DNA double strand breaks
      • In normal (BRCA wildtype) cells, these are repaired by homologous functional repair which requires functional BRCA genes
      • In BRCA (1 / 2) gene mutations (germline or somatic), these breaks are not repaired which results in genomic instability and cell death
      •  
        Oral
        Palbociclib
        Ibrance 
      • Mechanism of Action

      • Not fully elucidated, though effects are thought to be secondary to inhibition of dopamine D2 receptors and α-adrenoceptors within the chemoreceptor trigger zone.
      •  
        Oral / IV
        Esomeprazole
        Nexium 
      •  
        Oral
        Sulfasalazine
        Salazopyrin 
         
        Not absorbed well – therefore most effective within the gut
      • Mechanism of Action

      • Selectively antagonize serotonin (5-HT3) receptors within the central nervous system.
      •  
        IV / IM / Oral
        Methylprednisolone
        Medrol 
      •  
        Oral
        Macrogol 3350
        Movicol, Glycoprep, Osmolax 
         
        Iso-osmotic with the gut, preventing water and electrolyte loss
      •  
        Oral
        6-Mercaptopurine
        Purinethol 
      • Mechanism of Action

      • Act as a surfactant that increase fluid penetration into faeces, resulting in softening of the stool.
      • Mechanism of Action

      • Absorb water, resulting in increased faecal size and stimulation of peristalsis.
      • Mechanism of Action

      • Inflammatory diseases: inhibits interleukin-1 and interleukin 6 activity, and altering the numbers of different lymphocyte subsets.
      • In cancer treatment: inhibits dihydrofolate reductase (DHFR), reducing synthesis of folate, which is involved in synthesis of the purine and pyramidine precursors required for DNA / RNA and cell proliferation.
      •  
        Subcut
        Adalimumab
        Humira 
         
        Human monoclonal antibody to TNF
      •  
        Oral
        Domperidone
        Motilium 
         
        Binds D2 and D3 receptors; doesn’t cross the BBB
      •  
        Oral
        Sodium Picosulphate
        Picolax 
         
        2-3 sachets the day prior to the procedure, in 3-4 hour intervals
      • Mechanism of Action

      • A human monoclonal antibody directed against p40, a shared subunit present in both IL-12 and IL-23. Inhibition of IL-12 results in reduced differentiation of TH1 cells, while inhibition of IL-23 results in reduced induction of TH17 cells.
      • Mechanism of Action

      • Competitively inhibit action of histamine on parietal cell H2 receptors, directly resulting in suppression of acid secretion.
      • Mechanism of Action

      • Inhibit protein synthesis by binding to the 30s ribosomal subunit, resulting in inaccurate mRNA translation.
      • Mechanism of Action

      • Unknown.
      • Mechanism of Action

      • Believed to inhibit haem polymerisation, resulting in a buildup of toxic haem molecules into non-toxic haemozoin within the food vacuole of plasmodia.
      •  
        IV / IM
        Artesunate
        Severe falciparum malaria
      • Mechanism of Action

      • Atovaquone - inhibits nucleic acid and ATP synthesis through disruption of the protozoal electron transport chain.
      • Proguanil - inhibits dihydrofolate reductase, resulting in reduced parasitic synthesis of deoxythymidilate.
      • Mechanism of Action

      • Believed to inhibit haem polymerisation, resulting in a buildup of toxic haem molecules into non-toxic haemozoin within the food vacuole of plasmodia.
      • Mechanism of Action

      • Believed to inhibit haem polymerisation, resulting in a buildup of toxic haem molecules into non-toxic haemozoin within the food vacuole of plasmodia.
      • Mechanism of Action

      • Broken down into its active form selectively by anaerobic and protozoal cells. Binds to and disrupts DNA, resulting in DNA degradation and cell death.
      • Mechanism of Action

      • Inflammatory diseases: inhibits interleukin-1 and interleukin 6 activity, and altering the numbers of different lymphocyte subsets.
      • In cancer treatment: inhibits dihydrofolate reductase (DHFR), reducing synthesis of folate, which is involved in synthesis of the purine and pyramidine precursors required for DNA / RNA and cell proliferation.
      •  
        IV
        Bleomycin
        Cytotoxicity is cell cycle-specific to G2 phase
      •  
        IV
        Ifosfamide
        Ifex, Holoxan 
      •  
        Oral / IV
        Fludarabine

      • Mechanism of Action

      • Unknown, though appears to inhibit DNA synthesis through inhibition of topoisomerase II.
      • Mechanism of Action

      • Incorporated into DNA, resulting in disruption of DNA synthesis through inhibition of DNA polymerase activity.
      •  
        Oral
        Capecitabine
        Xeloda 
         
        Converted to 5-fluorouracil once absorbed orally
      • Mechanism of Action

      • Unknown, though believed to act as an alkylating agent.
      •  
        IV
        Cisplatin
        Platinol 
      •  
        IV
        Vinblastine

      • Mechanism of Action

      • Inhibits the activity of topoisomerase I, which is normally responsible for repairing DNA damage resulting from torsional strain.
      •  
        Oral
        Temozolomide

      •  
        IV
        Paclitaxel
        Taxol 
         
        Inhibits the cell cycle at the G2-M phase junction
      •  
        IV
        Daunorubicin

      • Mechanism of Action

      • Causes DNA strand breakage through inhibition of topoisomerase II.

      The Safe Triangle

      The chest drain is generally inserted into the 5th intercostal space in the midaxillary line.

      Blockage

      • Causes of Intercostal Catheter Blockage

      • Clot in the catheter / tubing
      • Kinking of the catheter / tubing
      • Catheter not in the correct position
      • Drainage system is above the level of the chest

      Troubleshooting

      Flashback but no blood coming out (penetrated too far, vein has collapsed) - pull back slightly, adjust the angle of the needle against the skin, pull back and try again

      Overview

      Trough levels - take the blood just prior to the next dose (do not withhold the dose while you wait for the result unless you're concerned that it's too high)
      • Prevention of Coag Contamination

      • Take the sample from a different limb
      • Turn off the infusion for 5-20 minutes prior to taking the sample
      • Potential Sites to Collect Blood From

      • Back of the hand
      • Cephalic or basilic veins
      • Antecubital fossa
      • Significance

      • Due to blood leaking from the vein into surrounding tissue.

      Sample Clotting

      • Affects

      • White cell count
      • Red blood cell indices
      • Platelets
      • Coagulation profile

      Overview

      Ideally the tourniquet should be left on for no longer than a minute at a time - if you are having difficulty finding a vein, then release the tourniquet, wait for blood flow to return, then reapply the tourniquet.
      • Prevention

      • Cool the sample to 0-4 degrees using ice if it is unlikely to be processed within 15 minutes.

      Sample Haemolysis

      • Affects

      • Potassium
      • LFTs
      • Amylase
      • CK
      • Folate
      • Glucose
      • LDH
      • Crossmatch

      Overview

      Place samples for cryoglobulins at 37 degrees.

      Stress

      • Prevention

      • Ensure that the patient is comfortable and have been resting for at least 15 minutes before collecting.

      Overview

      The oxygen from the circuit is passively mixed with room air as the patient inspires, resulting in a variable FiO2 that depends on many factors including the respiratory rate, tidal volume and whether the patient is breathing through their nose or mouth.

      CPAP

      Continous positive airway pressure (CPAP) splints the upper airways open, and relieves upper airway obstruction. This device does not actively ventilate the patient.

      Overview

      The  oxygen that enters the reservoir bag is passively mixed with room air, and therefore the amount of oxygen delivered by these systems is variable depending on the patient’s respiratory rate and tidal volume.
      • Indications for Invasive Ventilation

      • Airway

      • Inability to maintain airway patency (upper airway obstruction) - soft tissue swelling, deformity, obesity, tongue displacement
      • Inability to protect the airway - sedation (e.g. for procedures), upper airway bleeding, excessive secretions
      • Breathing

      • Inability to ventilate - unconsciousness, sedation, neuromuscular disease, exhaustion
      • Inability to oxygenate - severe acute respiratory failure
      • Circulation

      • Cardiac arrest

      Venturi Mask

      A Venturi mask contains an entrainment device that uses the Bernoulli principle to entrain a precise amount of oxygen along with room air. This allows for a predictable FiO2 in patients where this is required.

      Overview

      • Indications for Supplemental Oxygen

      • Hypoxia
      • Cardiac or respiratory arrest
      • Acute respiratory distress
      • Specific conditions - pulmonary hypertension, myocardial infarction, pneumothorax

      Troubleshooting

      Not pulsating blood - potentially in a vein
      Not pulsating blood - potentially in a vein

      Overview

      • Causes

      • Clotting
      • Vasospasm
      • Prevention

      • Ensure that the pulse is easily palpable before inserting the needle, and avoid advancing the needle multiple times.
      • Causes

      • Poor aseptic technique
      • Prolonged use of the same cannula
      • Causes

      • Clot in the cannula
      • Kinking of the cannula
      • Prevention

      • Avoid inserting an arterial line into a patient with a coagulopathy where possible, or consider reversing anticoagulation or withholding it and waiting
      • Place pressure on the insertion site for 3-5 minutes any time the needle or cannula is removed
      • Avoid too many attempts
      • Potential Sites for Arterial Line Insertion

      • Radial artery -laterally on the anterior aspect of the forearmThe most commonly used site
      • Brachial artery - medially within the antecubital fossa
      • Femoral artery - centrally within the femoral triangle, between the inguinal ligament, adductor longus and sartorius
      Radial - ask the patient to place their arm outward with palm up, wrist extended slightly. Place a towel underneath their arm. Consider taping the hand down to reduce movement.
      Radial - ask the patient to place their arm outward with palm up, wrist extended slightly
      • Prevention

      • Avoid performing an ABG on a patient with a coagulopathy where possible, or consider reversing anticoagulation / withholding it and waiting
      • Place pressure on the insertion site for 3-5 minutes once the needle is removed

      Troubleshooting

      Needle is not self-filling (may be a venous sample) - withdraw and try again

      Overview

      • Prevention

      • Ensure that the pulse is easily palpable before inserting the needle, and avoid advancing the needle multiple times.
      • Causes

      • Clotting
      • Vasospasm
      • Potential Sites for Arterial Blood Gas Collection

      • Radial artery - laterally on the anterior aspect of the forearmThe most commonly used site
      • Brachial artery - medially within the antecubital fossa
      • Femoral artery - centrally within the femoral triangle, between the inguinal ligament, adductor longus and sartorius

      Catheter Sizing

      Bigger is usually easier - go up a size rather than down if insertion is difficult

      Use of Catheters

      • Not Indications

      • Urinary incontinence
      • Confusion
      • Prolonged bed rest with no indication for catheterisation
      • Measuring urine output in patients who are able to void where hourly output is not required
      • Prolonged postoperative catheterisation without an indication
      • Not Indications

      • Urinary incontinence
      • Confusion
      • Prolonged bed rest with no indication for catheterisation
      • Measuring urine output in patients who are able to void where hourly output is not required
      • Prolonged postoperative catheterisation without an indication

      Catheter-Associated UTI

      • Clinical Features of Pyelonephritis

      • As with cystitis
      • Flank pain
      • Nausea / vomiting
      • Fevers / systemic features

      Overview

      Left internal jugular: 20 - 22cm(Height / 10) + 4
      Subclavian - identify the vein using landmarks. Identify the junction of the medial third and lateral two-thirds of the clavicle. The needle should be inserted 1cm inferior and lateral to this, pointing toward the sternal notch, upward and away from the underlying lung apex.

      Confirming Venous Placement

      Ultrasound - place the sterile probe over the insertion site and examine the vein both parallel and perpendicular to the direction of insertion, looking for presence of the needle / guidewire in the vein (a non-pulsatile, compressible vessel)

      Overview

      • Prevention

      • Avoid inserting a central line into a patient with a coagulopathy where possible
      • Place pressure on the insertion site for 1-2 minutes any time the needle is removed
      • Avoid too many attempts
      • Prevention

      • Use the smallest possible CVC
      • Minimise CVC duration where possible
      Subclavian - identify the vein using landmarks. Identify the junction of the medial third and lateral two-thirds of the clavicle. The needle should be inserted 1cm inferior and lateral to this, pointing toward the sternal notch, upward and away from the underlying lung apex.
      • Don't

      • Don’t insert a needle through a burn, oedema or infected tissue
      • Don’t insert a CVC into an area with localised deformity, e.g. clavicular or femoral fracture
      • Don’t insert a subclavian CVC on the same side as a pacemaker
      • Don’t insert a subclavian CVC into a coagulopathic patient
      • Avoid a femoral CVC in a patient who is incontinent - especially of faeces
      Flashback but no blood coming out (penetrated too far) - pull back slightly, adjust the angle of the needle against the skin, pull back and try again
      • Prevention

      • Use ultrasound guidance to identify the desired vessel
      • Proceduralist Position

      • Internal jugular - at the head of the bed
      • Subclavian - on the side of insertion, toward the head of the bed
      • Femoral - on the side of insertion, toward the bottom of the bed

      Inserting the Guidewire

      If unable to advance the guidewire, retract it and confirm that there is still flashback from the needle. If so, then gently re-attempt to insert the guidewire. If resistance is repeatedly met then remove the needle, place pressure on the site and start again.

      Overview

      • Prevention

      • Estimate the correct CVC insertion length prior to placement.
      • Causes

      • Clot in the cannula
      • Kinking of the cannula
      • Causes of Line-Related Infection

      • Poor aseptic technique
      • Prolonged use of the same cannula

      Types of NG Tube

      Feeding tubes - small bore (6-8 Fr), single lumen tubes that can be used for feeding but are unable to be aspirated

      Confirming NG Placement

      Aspirate - aspirate stomach contents and check the pH (<5.5) using litmus paper.

      Avoiding Incorrect NG Placement

      Oropharyngeal - ask the patient to open their mouth and check that the tube has not become looped around in the mouth. This should be suspected if there is excessive gagging.

      Difficult NG Insertion

      Try placing the NG tube in the fridge to make it more rigid and easier to insert.

      Identifying the Right Site

      The spinal cord ends at L1/L2, so the L3/L4, L4/L5 or L5/S1 interspaces can be used for lumbar puncture.

      Overview

      Sitting position - Patient sitting up, leaning against a table in front of them (shouldn't be used to measure CSF pressure)
      • Mechanism

      • Unknown, but thought to relate to reduced CSF pressure / compensatory venodilatation.
      CSF pressure measurement
      Perform a CT scan prior to performing an LP if concerns for raised ICP, e.g. decreased level of consciousness, papilloedema, focal neurological findings or recent seizures.
      • Relative

      • Coagulopathy - based on clinical situation
      Sitting position - Patient sitting up, leaning against a table in front of them (shouldn't be used to measure CSF pressure)

      Identifying the Right Site

      The spinal cord ends at L1/L2, so the L3/L4, L4/L5 or L5/S1 interspaces can be used for lumbar puncture.

      Measuring Opening Pressure

      Hold the 0 mark on the manometer at the level of the needle, and hold the manometer tubing up vertically.

      Troubleshooting

      If unable to advance the guidewire, retract it and confirm that there is still flashback from the needle. If so, then gently re-attempt to insert the guidewire. If resistance is repeatedly met then remove the needle, place pressure on the site and start again.

      Jugular Placement

      • Prevention

      • Ask the patient to abduct their arm and put their chin on the ipsilateral shoulder when inserting the PICC.

      Overview

      • Prevention

      • Use the smallest possible PICC line
      • Minimise PICC line duration where possible

      Troubleshooting

      Flashback but no blood coming out (penetrated too far, vein has collapsed) - pull back slightly, adjust the angle of the needle against the skin, pull back and try again

      Overview

      • Causes of PICC Blockage

      • Clot in the PICC
      • Kinking of the PICC

      Tips for Finding a Vein

      • Do

      • Ask the patient about their preference of arm
      • Use the nondominant arm if possible

      Overview

      • Prevention

      • Place pressure on the insertion site any time the needle or guidewire is removed.
      • Causes of PICC-Related Infection

      • Poor aseptic technique on insertion
      • Poor aseptic technique on accessing the line
      • Prolonged use of the same line
      • Causes of Line-Related Infection

      • Poor insertion technique
      • Prolonged use of the same site
      • Significance

      • Due to blood leaking from the vein into surrounding tissue.
      • Causes of Cannula Extravasation

      • Needle out of vein
      • Leakage around the cannula
      • Causes of Cannula Blockage

      • Clot in the cannula
      • Kinking of the cannula
      Explain the procedure and ask for patient's consent.
      • Causes of Thrombophlebitis

      • Injury
      • Irritation (e.g. potassium infusion)
      • Infection

      Troubleshooting

      Flashback but no blood coming out (penetrated too far, vein has collapsed) - pull back slightly, adjust the angle of the needle against the skin, pull back and try again

      Overview

      22 - paediatrics, fragile veins

      Potential Cannula Sites

      Cephalic vein (lateral) in the forearm - large vein, doesn't limit movement

      Choosing the Right Site

      • Do

      • Use the vastus lateralis where possible

      Injection of Incorrect Site

      • Prevention of Intravascular Injection

      • Inject into the correct site - avoid the medial / inferior gluteal muscle, the medial thigh etc.
      • Draw back to check for blood prior to injecting the medication

      Lignocaine

      • Strength

      • 1% (10mg/mL)

      Indications for Ascitic Tap

      Therapeutic tap - for symptomatic relief of ascites in haemdynamically stable patients

      Overview

      • Causes of Upper Airway Obstruction

      • Soft tissue swelling - anaphylaxis, burns, peritonsillar abscess, epiglottitis, laryngotracheobronchitis (croup)
      • Foreign body aspiration
      • Deformity - laryngomalacia, laryngeal mass / web, tracheomalacia
      • Tongue enlargement / displacement
      • Vocal cord lesion / paralysis

      Bag-Valve-Mask

      A bag-valve-mask system may be used with an oropharyngeal or nasopharyngeal airway in situ, to aid in opening the airway.

      Overview

      • Airway Manoeuvres

      • Head tilt and chin lift -  tilt the head backward into the sniffing position, opening the airway, and use the index and middle fingers to pull the mandible forward.
      • Jaw thrust - use the index and middle fingers on each hand to push the mandible anteriorly, moving the tongue forward.

      Oropharyngeal Airway

      An oropharyngeal airway is also known as a Guedel airway.

      Injection of Incorrect Site

      • Prevention of Intravascular Injection

      • Inject into the correct site - avoid the medial / inferior gluteal muscle, the medial thigh etc.
      • Draw back to check for blood prior to injecting the medication

      Overview

      • Potential Sites for Subcutaneous Injections

      • Abdomen - anywhere except around the umbilicusThe most commonly used site
      • Upper arm - posteriorly or laterallyHigher chance of injecting intramuscularly
      • Thigh - anterolaterallyHigher chance of injecting intramuscularly
      • Upper buttocks - laterallyHas the slowest absorption rate

      Presenting Complaint

      The first step in the renal history is to identify the main issue that the patient is presenting with.
      Start by asking the patient what their main reason for presenting was.
      Start by asking the patient what their main reason for presenting was.
      Start by asking the patient what their main reason for presenting was.
      The first step is to ask the patient why they presented with their current issue.
      Start by asking the patient about their main reason for presenting.

      First Steps

      Before commencing the cranial nerve exam, wash your hands, introduce yourself to the patient and gain consent.

      Overview

      When performing a cardiovascular examination, always try to get to the chest as quickly as possible.

      Urine Collection

      There are many ways in which a urine sample can be collected. The method of collection depends on the type of test performed, and certain patient factors.

      Red Cell Count & Haemoglobin

      The first step in the identification of red blood cell pathology is to look at the haemoglobin, haematocrit and red cell count. A reduction in each of these indices is used to diagnose anaemia, while an increase in these values is used to diagnose erythrocytosis.

      Assessing Oxygenation

      While oxygen saturations are a useful non-invasive test for assessing a patient’s oxygenation, greater information can be gained by assessing a patient’s arterial blood gas.

      Overview

      Concerns may be raised for the presence of haemolysis in patients with  anaemia, reticulocytosis or hyperbilirubinaemia.

      Iron Physiology

      Iron is an important mineral that plays a role in multiple physiologic processes including oxygen transport (as haemoglobin); muscle oxygenation (as myoglobin); synthesis of DNA, RNA and proteins; and cellular respiration (as cytochromes).

      Overview

      An acute phase reaction classically presents with fevers, rigors and tachycardia.

      Urine Collection

      There are many ways in which a urine sample can be collected. The method of collection depends on the type of test performed, and certain patient factors.

      Equipment

      • The following equipment is required for collecting blood:

      Overview

      • Indications for Oxygen Administration
      • Hypoxia
      • Cardiac or respiratory arrest
      • Acute respiratory distress
      • Specific conditions - pulmonary hypertension, myocardial infarction, pneumothorax
      Indications for arterial blood gas collection include to assess respiratory and acid base status, as well as for detection of carboxyhaemoglobin and methaemglobin.
      Male catheterisation can be more difficult and higher risk than female catheterisation due to the length and course of the male urethra.
      • Indications for IV Cannulation

      • Fluid administration
      • Medications
      • Blood products
      • IV contrast

      Airway Patency

      Before using any airway manoeuvres or adjuncts, first assess whether the airway is patent.

      Overview

      Many medical students take notes digitally, and there is a massive number of apps available for note-taking on different devices. This page is a guide to the most popular and most widely used note apps available.
      This section will outline different types of thinking, types of knowledge, learning styles and key resources to optimise each dimension of learning.

      How Memory Works

      • It is useful to understand a bit about how we form and solidify memories before focusing on how to improve recall. There are several steps involved in this process:
      • Encoding
      • Storage
      • Retrieval

      Overview

      The truth about study is that it adheres to the 80:20 principle: 80% of your learning will happen with 20% of your effort. This can mean that you may be hitting your head against a wall for a long time! Fortunately, there are ways to optimise your study time to get the most out of it.
      This section outlines some of the major note-taking methods, and provides tips about how to improve your notes.
      Myelodysplasia may be seen in the context of myelodysplastic syndromes (MDS), where clonal expansion of mutated stem cells results in ineffective haematopoiesis. This condition is at risk of transforming to acute myeloid leukaemia (AML).

      Manifestations

      • Complications of Scleroderma

      • Pulmonary hypertension
      • Pulmonary fibrosis
      • Scleroderma renal crisis
      • Oesophageal dysmotility
      • Pericarditis
      • Arrythmias
      • Erectile dysfunction

      Overview

      • Causes of Nonthyroidal Illness

      • Starvation
      • Sepsis
      • Burns
      • Trauma
      • Surgery
      • Myocardial infarction
      • Malignancy
      • Chronic liver disease
      • Chronic kidney disease

      Manifestations

      • Clinical Features

        Only occur in the presence of resultant biochemical abnormalities
      • Hypocalcaemia - hyperreflexia, tetany, seizures, heart failure
      • Hypokalaemia - weakness, hypotonicity, depression, constipation, ileus

      Diagnosis

      • X-Ray Findings in Psoriatic Arthritis

      • Pencil-in-cup deformity: erosions with new bone formation
      • Dactylitis: soft tissue swelling in all of the joints of a single digit
      • Fluffy periostitis: cortical thickening
      • Ankylosis: fusion of joints
      • Sacroiliitis

      Pathogenesis

      • Causes of Chronic Kidney Disease

      • Diabetic nephropathy
      • Hypertensive nephropathy
      • Glomerulonephritis
      • Tubulointerstitial disease - analgesic nephropathy, reflux nephropathy
      • Congenital disease - polycystic kidney disease

      Overview

      • Clinial Phenotypes of Motor Neuron Disease

      • Amyotrophic lateral sclerosis (ALS) - mixed upper and lower motor neuron involvement
      • Primary lateral sclerosis - mainly upper motor neuron involvement
      • Progressive muscular atrophy - mainly lower motor neuron involvement
      • Progressive bulbar palsy - mainly bulbar involvement
      • ECG Findings

      • Bifascicular block (RBBB and LAFB or LPFB) with first degree AV block
      • Alternating LBBB and RBBB
      • Fixed RBBB with alternating LAFB and LPFB
      • Complete heart block

      Pathogenesis

      • Causes of Bronchiectasis

      • Congenital

      • Cystic fibrosis
      • Primary ciliary dyskinesia (e.g. Kartegener’s syndrome)
      • Hypogammaglobulinaemia
      • Acquired

      • Recurrent pneumonia (e.g. in the setting of immunosuppression) - bacterial, tuberculous, fungal
      • Chronic obstructive pulmonary disease (COPD)
      • Allergic bronchopulmonary aspergillosis (ABPA)
      • Autoimmune diseases - rheumatoid arthritis, Sjogren’s syndrome, ulcerative colitis
      • Chronic aspiration (e.g. secondary to gastroesophageal reflux)
      • Airway foreign body

      Diagnosis

      • X-Ray Findings in Osteoarthritis

      • Reduced joint space - generally asymmetric
      • Subchondral sclerosis - increased bone deposition surrounding the joint
      • Subchondral cysts: cystic formations around the joint
      • Osteophytes: bony projections along the joint line

      Pathogenesis

      • Mechanism

      • Focal atrial tachycardia originates from a single source of micro reentry, most commonly in the right atrium.

      Manifestations

      • Clinical Features

      • Musculoskeletal

      • Wrist sign: when the patient wraps their thumb and fifth finger around their opposite wrist, the thumb and fifth finger overlap
      • Thumb sign: when the patient adducts their thumb, it extends beyond the ulnar border of the palm
      • Pectus carinatum: forward angulation of the sternum
      • Hindfoot deformities - particularly hindfoot valgus
      • Pes planus: flat foot
      • Scoliosis / lumbar kyphosis
      • Reduced upper segment / lower segment ratio (with the pubic symphysis separating the upper and lower segments)
      • Increased arm span / height ratio (i.e. arms longer than the patient’s height)
      • Facial

      • Dolichocephaly: abnormally long head (anterior-posterior)
      • Enophthalmos: posterior displaceemnt of the eye within the orbit
      • Downslanting palpebral fissures (the line between the medial canthus and the lateral canthus of the eye)
      • Malar hypoplasia: underdeveloped cheek bones
      • Retrognathia: posterior displacement of the mandible
      • Other

      • Reduced elbow extension
      • Skin striae

      Pathogenesis

      • Causes of B12 Deficiency

      • Atrophic gastritis - pernicious anaemia, H pylori infection
      • Malabsorption - coeliac disease, tropical sprue, Crohn's disease, alcohol abuse
      • Surgical resection - gastrectomy, gastric bypass, resection of terminal ileum
      • Pancreatic insufficiency - chronic pancreatitis
      • Inherited disorders - Imerslund-Gräsbeck syndrome
      • Causes of Epilepsy

      • Genetic
      • Trauma - open or closed head injury, neurosurgery
      • Cerebrovascular - haemorrhage, ischaemia, arteriovenous malformation
      • Malignancy - glioma, meningioma, metastasis
      • CNS infection - meningitis, encephalitis, malaria, tuberculosis
      • Autoimmune - systemic lupus erythematosus
      • Degeneration - Alzheimer’s, multiple sclerosis
      • Idiopathic

      Overview

      Hyperkalaemia, or an increased serum potassium concentration of >5mmol/L, shortens action potentials and reduces conduction velocity in cardiac myocytes.
      Hepatitis A IgM is detectable at the time of symptom onset, after an incubation period of 14-28 days.

      Pathogenesis

      • Causes of B12 Deficiency

      • Atrophic gastritis - pernicious anaemia, H pylori infection
      • Malabsorption - coeliac disease, tropical sprue, Crohn's disease, alcohol abuse
      • Surgical resection - gastrectomy, gastric bypass, resection of terminal ileum
      • Pancreatic insufficiency - chronic pancreatitis
      • Inherited disorders - Imerslund-Gräsbeck syndrome
      • Causes of Hypernatraemia

      • Water Loss

      • Inadequate water intake
      • Diabetes insipidus (neurogenic / nephrogenic)
      • Loop diuretics
      • Acute tubular necrosis (polyuric phase)
      • Osmotic diuresis (e.g. poorly controlled diabetes)
      • Non-urinary loss - insensible, sweat, burns, diarrhoea
      • Salt Gain

      • Excessive administration - dietary excess, hypertonic saline, hypertonic dialysis
      • Endocrine - hyperaldosteronism, Cushings
      • Water Redistribution

      • Strenuous exercise
      • Seizure

      Manifestations

      • Signs and Symptoms

        Generally asymptomatic unless severe.
      • Hypocalcaemia - hyperreflexia, tetany, seizures, heart failure
      • Clinical Features

      • Short stature
      • Brachycephaly: flat head
      • Flat nasal bridge
      • Open mouth with protuberant tongue
      • Epicanthal folds: a fold of skin of the upper eyelid that covers the inner corner of the eye
      • Ligamentous laxity
      • Hypotonia: low muscle tone
      • Brachydactyly: short fingers and toes
      • Fifth finger clinodactyly: bending of the little finger toward the ring finger
      • Broad hands, single palmar crease
      • Wide 1-2 toe gap

      Pathogenesis

      • Mechanism

      • AVRT requires the presence of a distinct accessory pathway, most commonly in the setting of Wolff-Parkinson-White syndrome.
      • Causes of Atrioventricular (AV) Block

      • Intrinsic

      • Idiopathic degeneration
      • Myocardial infarction
      • Congenital - congenital heart disease, neonatal lupus
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Cardiac procedures - valvular surgery, correction of congenital heart disease, catheter ablation
      • Systemic lupus erythematosus
      • Myocarditis
      • Extrinsic

      • Physiologic - sleep, athletes
      • Autonomic - carotid sinus massage, carotid sinus hypersensitivity
      • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, amiodarone
      • Hyperkalaemia
      • Hypothyroidism
      • Risk Factors for Non-Alcoholic Fatty Liver Disease

      • Obesity
      • Type 2 diabetes
      • Hypercholesterolaemia
      • Hyperuricaemia
      • Risk Factors for Obstructive Sleep Apnoea

      • Obesity
      • Male gender
      • Craniofacial abnormalities - retrognathia
      • Upper airway narrowing - enlarged tonsils, macroglossia, narrow nasal cavity
      • Alcohol excess
      • Smoking
      • Causes of Hypokalaemia

      • Inadequate intake
      • GI loss - vomiting, high NG output, diarrhoea, fistula, laxative abuse
      • Renal loss - Conns, Cushings, ectopic ACTH, loop diuretics, osmotic diuresis, corticosteroids, hypomagnesaemia, RTA
      • Compartmental shift - alkalaemia, insulin, refeeding, beta agonists
      Pulmonary emboli almost always originate from venous thrombi, most commonly in the deep veins of the leg. Proximal lower limb DVTs are significantly more likely to embolise than distal (below knee) DVTs. Less commonly, thrombi may form in the iliac veins, veins of the upper limb or within the right heart.
      • Causes of Sinus Node Dysfunction

      • Idiopathic degeneration
      • Myocardial infarction
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Connective tissue disease - SLE, scleroderma, RA
      • Cardiac surgery - valvular surgery, correction of congenital heart disease
      • Infections - Lyme disease, endocarditis

      Diagnosis

      The most classic ECG finding in ARVD is epsilon waves. Patients with ARVD may develop ventricular tachycardia, which is of right ventricular origin (with left bundle branch morphology).

      Pathogenesis

      • Causes of Right Ventricular Failure

      • Pulmonary hypertension - pulmonary arterial hypertension, left heart failure, lung disease, chronic pulmonary embolism
      • Right ventricular pathology - cardiomyopathy, myocarditis, ischaemic heart disease
      • Tricuspid regurgitation - rheumatic heart disease, infective endocarditis, Ebstein’s anomaly, carcinoid syndrome, trauma
      • Pericardial disease - constrictive pericarditis
      • Mechanism

      • Typical atrial flutter occurs as a macro-reentrant circuit around the tricuspid valve annulus, most commonly in a counter-clockwise direction. The slow aspect of the sawtooth wave occurs as the impulse is conducted through the cavotricuspid isthmus.

      Manifestations

      • Clinical Features

      • Angina - frequency, onset, management
      • Heart failure symptoms - exertional dyspnoea, orthopnoea, paroxysmal noctural dyspnoea, peripheral oedema
      • Exercise tolerance

      Overview

      • Classification

      • Nonsustained VT - three or more ventricular beats at a rate of >100bpm, lasting less than 30 seconds, without haemodynamic instability
      • Sustained VT - a ventricular rhythm at a rate of >100bpm, lasting at least 30 seconds or with haemodynamic instability

      Manifestations

      • Clinical Features

      • Female
      • Short stature
      • Puffy hands and feet (congenital lymphoedema)
      • Added skin folds on the back of the neck

      Pathogenesis

      • Precipitants of Myaesthenic Crisis

      • Infection
      • Surgical procedures
      • Drugs - neuromuscular blockers, aminoglycosides, macrolides, beta blockers, calcium channel blockers, corticosteroids
      • Pregnancy
      • Causes of Sinus Tachycardia

      • Physical exertion
      • Anxiety
      • Pain
      • Trauma
      • Fever
      • Infection
      • Hypovolaemia
      • Shock
      • Hypoxia
      • Anaemia
      • Pulmonary embolism
      • Coronary ischaemia / infarction
      • Hypoglycaemia
      • Thyrotoxicosis
      • Phaeochromocytoma
      • Drugs - beta agonists, anticholinergics, theophylline, caffeine, amphetamine, cocaine, alcohol

      Manifestations

      • Complications of Cystic Fibrosis

      • Respiratory

      • Bronchiectasis
      • Respiratory infections
      • Sinusitis
      • Pancreatic

      • Exocrine - fat malabsorption, malnutrition, vitamin A/D/E/K deficiency
      • Endocrine - diabetes mellitus
      • Pancreatitis
      • Gastrointestinal

      • Meconium ileus
      • Distal intestinal obstruction syndrome (DIOS)
      • Gastroesophageal reflux
      • Biliary cirrhosis
      • Malnutrition
      • Musculoskeletal

      • Arthropathy
      • Osteoporosis
      • Reproductive

      • Infertility - congenital absence of vas deferens, thick cervical mucus
      • Risk of transmission to children
      • Other

      • Significant functional impact
      • Depression

      Pathogenesis

      • Causes of Thyrotoxicosis

      • Primary

      • Grave’s disease
      • Toxic multinodular goitre
      • Toxic nodule
      • Thyroiditis - postviral, postpartum, lymphocytic
      • Thyroxine - excess replacement, thyrotoxicosis factitia
      • Drugs - amiodarone, iodine
      • Pregnancy-related - hyperemesis gravidarum, hydatidiform mole
      • Struma ovarii
      • Congenital hyperthyroidism
      • Secondary

      • TSH-secreting pituitary tumour
      • Causes of Multifocal Atrial Tachycardia

      • COPD exacerbation
      • Cor pulmonale
      • Ischaemic heart disease
      • Rheumatic heart disease
      • Hypokalaemia / hypomagnesaemia
      • Digoxin toxicity

      Diagnosis

      • ECG Findings

      • Right bundle branch block - wide QRS (≥120ms), RSR’ pattern in V1 or V2, slurred S wave in I, V5, V6
      • Either left (LAFB) or right (LPFB) axis deviation

      Pathogenesis

      • Risk Factors for Colorectal Cancer

      • Familial syndromes - Lynch syndrome, familial adenomatous polyposis
      • Family history of colorectal cancer
      • Past polyps / colorectal cancer
      • Inflammatory bowel disease
      • Dietary factors - red meats, processed meats; lack of fruit and vegetables
      • Physical inactivity
      • Obesity
      • Smoking
      • Alcohol

      Overview

      • Risk Factors for Hepatitis C Infection

      • Certain ethnic groups
      • Children of hepatitis C positive mothers
      • Iatrogenic exposure - surgery, colonoscopy, haemodialysis, blood transfusion prior to 1990
      • Healthcare workers
      • IV drug use
      • Prisoners
      • Tattoos

      Pathogenesis

      • Mechanism

      • The AV node normally contains two pathways - a slow pathway (short refractory period) and fast pathway (long refractory period) - that then combine to form a common pathway into the bundle of His. Normally, an atrial impulse is conducted down the two pathways with no recirculation of the impulse, as both pathways are within their refractory periods.
      • Risk Factors for Multiple Sclerosis

      • Female sex
      • Family history of multiple sclerosis
      • High lattitude (further from equator)
      • EBV infection
      • Smoking

      Overview

      Beta thalassaemia is common in people from Mediterranean countries, South East Asia and India. It is rarely seen in those of caucasian descent.
      Sinus arrhythmia occurs physiologically due to changes in intrathoracic pressure and resultant variation in vagal tone through the respiratory cycle.

      Manifestations

      • Manifestations of Rheumatoid Arthritis

      • Symmetrical inflammatory polyarthropathy with sparing of the distal interphalangeal (DIP) joints
      • Rheumatoid nodules
      • Tendon rupture
      • Atlantoaxial instability (severe cases)
      • Systemic features - fatigue, weight loss

      Pathogenesis

      • Causes of Hypophosphataemia

      • Reduced Intake / Uptake

      • Severe malnutrition - starvation, alcoholism, anorexia, TPN
      • Malabsorption
      • Vitamin D deficiency
      • Phosphate binders (CKD patients)
      • Antacids
      • Compartmental shift

      • Insulin - recovery post DKA, refeeding syndrome, insulin infusion, glucose infusion
      • Severe respiratory alkalosis
      • Hungry bone syndrome
      • Increased excretion

      • Hyperparathyroidism
      • Vitamin D deficiency
      • Diuretics - acetazolamide, thiazides, loop diuretics
      • Osmotic diuresis (e.g. poorly controlled diabetes)
      • Iron infusion
      • Post renal transplant
      • Fanconi syndrome

      Diagnosis

      • Clinical Signs

      • Active monoarthritis - particularly of the first MTP joint (podagra) or tarsal joint
      • Asymmetric polyarthritis
      • Gouty tophi - particularly over joints; the olecranon bursa at the elbow; the helix of the ear; the infrapatellar and achilles tendons

      Overview

      Hypothermia refers to a reduction in body temperature below 35 degrees celsius. 

      Pathogenesis

      • Causes of Sinoatrial Exit Block

      • Idiopathic degeneration
      • Myocardial infarction
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Connective tissue disease - SLE, scleroderma, RA
      • Cardiac surgery - valvular surgery, correction of congenital heart disease
      • Infections - Lyme disease, endocarditis

      Pathogenesis 

      • Causes of SIADH

      • Malignancy - lung cancers, pancreatic cancer, colorectal cancer, bladder cancer, lymphoma, sarcoma
      • CNS - tumours, demyelination, ischaemic stroke, haemorrhage, infection, vasculitis, traumatic brain injury
      • Pulmonary - pneumonia, tuberculosis, abscess, vasculitis
      • Drugs - desmopressin, SSRIs, TCAs, carbemazepine, levetiracetam, haloperidol, cyclophosphamide, vincristine
      • Postoperative state

      Overview

      Sickle cell disease is a more broad term that includes sickle cell anaemia, sickle beta thalassaemia and haemoglobin SC disease.

      Pathogenesis

      • Causes of Iron Deficiency

      • Nutritional deficiency
      • Malabsorption - e.g. coeliac disease, gastric surgery, PPIs
      • Blood loss - particularly menstrual and gastrointestinal loss; regular blood donation
      • Pregnancy

      Overview

      • Risk Factors for Hepatitis B Infection

      • Certain ethnic groups
      • Children of hepatitis B positive mothers
      • Iatrogenic exposure - surgery, colonoscopy, haemodialysis, blood transfusion prior to 1990
      • High risk sexual behaviour
      • Healthcare workers
      • IV drug use
      • Prisoners
      • Tattoos

      Differential Diagnosis

      • Causes of Parkinsonism

      • Parkinson’s disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
      • Parkinson’s Plus Syndromes

      • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
      • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
      • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
      • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
      • Others

      • Drugs - antipsychotics, metoclopramide, lithium
      • Normal pressure hydrocephalus
      • Hypoxic brain injury
      • Wilson’s disease

      Overview

      • Classification

      • Community-acquired pneumonia
      • Hospital-acquired pneumonia
      • Ventilator-associated pneumonia
      Catacholaminergic polymorphic ventricular tachycardia may present as syncope or sudden cardiac death due to polymorphic ventricular tachycardia, following an adrenergic stress such as exercise.

      Pathogenesis

      • The condition is multifactorial, and occurs in the context of:
      • Reduced effective incorporation of iron into haemoglobinDue to increased production and release of hepcidin and cytokines
      • Reduced responsiveness to erythropoietin
      • Reduced red cell survival

      Diagnosis

      • ECG Findings

      • A pause of at least three seconds, without P waves or QRS complexes
      • An escape rhythm may be present

      Overview

      Four alpha chain genes are inherited (two from each parent), and the type of alpha thalassaemia depends on how many of the four alpha chains are defective.

      Pathogenesis

      • Causes of Metabolic Alkalosis

      • Bicarbonate excess - milk alkali syndrome (antacids), massive transfusion, dialysis
      • GI acid loss - vomiting, NG aspirates, gastric fistula
      • Renal acid loss - diuretics, hyperaldosteronism, Cushing's, steroids
      • Compartmental shift - hypokalaemia
      • Causes of Heart Failure

      • Ischaemic heart disease
      • Cardiomyopathy
      • Myocarditis
      • Pericardial disease
      • Valvular disease
      • Congenital heart disease
      • Hypertension

      Overview

      • Classification

      • Paroxysmal AF - occurring for <7 days
      • Persistent AF - occurring for >7 days
      • Permanent AF - long-standing despite attempts at cardioversion

      Pathogenesis

      • Causes of Hyperlipidaemia

      • Primary

      • Familial lipoprotein lipase deficiency
      • Familial hypercholestolaemia
      • Familial combined hyperlipidaemia
      • Familial dysbetalipoproteinaemia
      • Familial hypertriglyceridaemia
      • Secondary: Predominantly LDL

      • Hypothyroidism
      • Cholestatic liver disease
      • Nephrotic syndrome
      • Secondary: Predominantly TAGs

      • Obesity
      • Diabetes
      • Alcohol abuse
      • Chronic kidney disease
      • Drugs - corticosteroids, antipsychotics, immunosuppressants, protease inhibitors, oral contraceptive pill, hormone replacement therapy
      • Pregnancy
      • Causes of Left Ventricular Failure

      • Ischaemic heart disease
      • Cardiomyopathy
      • Myocarditis
      • Pericardial disease
      • Valvular disease
      • Congenital heart disease
      • Hypertension

      Exercise Tolerance


      • Exercise tolerance is a strong prognostic marker for many chronic conditions such as ischaemic heart disease, heart failure, peripheral vascular disease and COPD.

      Overview

      • Important Travel-Related Infections

      • Diarrhoeal illnesses - giardia, amoeba, salmonella, shigella, cryptosporidia, cyclospora
      • Intestinal worms - strongyloidiasis, ascariasis, hookworm, whipworm, trichinosis, schistosomiasis
      • Mosquito-borne diseases - yellow fever, Japanese encephalitis, malaria, dengue fever, zika virus, chikungunya
      • Rickettsial illnesses - scrub typhus, spotted fevers
      • Tuberculosis
      • Other bacterial infections - meningococcal meningitis, typhoid fever, diptheria, leptospirosis, brucellosis, tetanus, lyme disease
      • Other viral infections - hepatitis A / B / C, HIV / AIDS, avian flu, measles, mumps, polio, rabies, ebola
      • Other parasitic infections - leishmaniasis
      • Specific Conditions To Ask About 

        Use simple terms when asking questions, rather than medical terms such as ‘hypertension' or ‘dyslipidaemia'.
      • Asthma
      • Diabetes
      • Heart disease
      • High blood pressure
      • High cholesterol
      • Cancer

      IV Drug Use

      • Consequences of IV Drug Use

      • Blood-borne viral infections - hepatitis B, hepatitis C, HIV
      • Bacterial septicaemia
      • Infective endocarditis - especially right-sided (tricuspid) disease
      • Cutaneous infection - skin abscess, cellulitis, necrotising fasciitis
      • Venous damage - superficial thrombophlebitis, deep venous thrombosis

      Overview

      • Consequences of Tobacco Smoking

      • Atherosclerosis - coronary artery disease, cerebrovascular disease, peripheral vascular disease
      • Cancer - lung, throat, liver, gastric, colorectal, pancreatic, genitourinary
      • Chronic obstructive pulmonary disease
      • Pregnancy / neonatal complications - infertility, growth restriction, placental abruption, preterm delivery, SIDS
      • Increased infection risk
      • Peptic ulcer disease
      • Osteoporosis
      Also ask about whether the patient's mobility has changed recently, and why.
      • For Each Condition

      • How many people in the family affected
      • How old they were when diagnosed
      • If passed, how old they were when they passed away
      • If a genetic condition - whether the patient or anyone else in the family has been tested
      • Sources of Medication Lists

      • It is often best to derive your list from at least two sources, especially when there is doubt.
      • The patient - sometimes patients present with a useful list of their medications
      • Collateral - from family or friends
      • Medication boxes - often patients present with their medications; ask if there are any missing
      • The patient's file - especially discharge summaries
      • Other hospitals - especially discharge summaries or transfer letters
      • The patient's GP
      • The patient's pharmacy
      • Types of Adverse Drug Reaction

      • Dose-related - narrow therapeutic index; generally improve with reduction in dose (may be required in renal or hepatic dysfunction)
      • Idiosyncratic - genetic susceptibility that is not dose-related
      • Allergic - occurs after sensitization
      • Consequences of Alcohol Abuse

      • Oesophagitis
      • Pancreatitis
      • Alcoholic liver disease - steatosis, hepatitis, cirrhosis
      • Cardiovascular disease - hypertension, dilated cardiomyopathy, atrial fibrillation
      • Neurologic complications - Wernicke encephalopathy, Korsakoff syndrome, cerebellar atrophy, peripheral neuropathy, myopathy
      • Malignancy - mouth, oesophagus, throat, liver, breast
      • Bone marrow suppression
      • Osteoporosis
      • Malnutrition
      • Trauma - high risk behaviour, MVA
      • Psychiatric disorders - depression, anxiety, suicide

      Diagnosis

      • Stages of Chronic Kidney Disease

      • GFR Categories (mL/min/1.73m²)

      • G1 - ⩾90
      • G2 - 60-89
      • G3a - 45-59
      • G3b - 30-44
      • G4 - 15-29
      • G5 - <15
      • Albuminuria Categories

      • A1 - <30mg/g / <3mg/mmol
      • A2 - 30-300mg/g / 3-30mg/mmol
      • A3 - >300mg/mg / >30mg/mmol

      Pretransplant History

      Before a patient is considered or listed for a transplant they must go through a comprehensive process that includes medical investigation, social assessment and counselling.

      Overview

      • Risk Factors for Multiple Sclerosis

      • Female sex
      • Family history of multiple sclerosis
      • High lattitude (further from equator)
      • EBV infection
      • Smoking

      Manifestations

      • Manifestations of Parkinson’s Disease

      • Muscular

      • Tremor
      • Slowless of movement (bradykinesia)
      • Dysarthria
      • Muscular stiffness
      • Hypophonia (quiet voice)
      • Shuffling gait
      • Gait freezing
      • Micrographia
      • Non-Muscular

      • Anosmia
      • REM sleep behavioural disorder (acting out dreams)
      • Autonomic dysfunction - constipation, postural hypotension, urinary hesitancy
      • Depressive symptoms - low mood, anhedonia, fatigue

      Overview

      • Potential Precipitants of Seizures

      • Sleep deprivation
      • Fatigue
      • Fasting
      • Drugs
      • Alcohol
      • Flashing lights
      • Fever
      • Stress
      • Menstruation
      • Missed antiepileptic dosing

      Management

      • Management Options for Motor Neuron Disease

      • Non-Pharmacologic

      • Physiotherapy
      • Non-invasive ventilation (NIV)
      • Speech pathology assessment
      • Consideration of PEG feeding
      • Psychological sypport
      • Pharmacologic

      • Rulizole
      • Anti-spasmodics - baclofen, diazepam, botox
      • Neuropathic agents - pregabalin, amitriptyline

      Manifestations

      • Precipitants of Myaesthenic Crisis

      • Infection
      • Surgical procedures
      • Drugs - neuromuscular blockers, aminoglycosides, macrolides, beta blockers, calcium channel blockers, corticosteroids
      • Pregnancy

      Overview

      • Ask About

      • Peritransplant history - when the transplant was done, indication, type of transplant, conditioning
      • Complications
      • Post-transplant management

      Complications

      • Complications of Bronchiectasis

      • Acute exacerbations
      • Pulmonary haemorrhage
      • Pneumothorax
      • Empyema
      • Lung abscess
      • Cor pulmonale

      History of Presenting Complaint

      • Onset

        Whether the pain began suddenly or gradually, and what the patient was doing at the time.
      • Onset at restSuggestive of acute coronary syndrome over stable angina if typical ischaemic pain
      • Onset during exertionSuggestive of stable angina if typical ischaemic pain
      • Onset post traumaMay represent pneumothorax or rib fractures

      Complications

      • Complications of Interstitial Lung Disease

      • Acute exacerbation of ILD
      • Cor pulmonale
      • Pulmonary hypertension
      • Lung cancer

      Diagnosis

      • Types of Lung Cancer

      • Non-Small Cell Lung Cancer - adenocarcinoma, squamous cell carcinoma, large cell carcinoma
      • Small Cell Lung Cancer

      Exercise Tolerance


      • Exercise tolerance is a strong prognostic marker for many chronic conditions such as ischaemic heart disease, heart failure, peripheral vascular disease and COPD.

      Overview

      • Risk Factors for Asthma

      • Family history of asthma
      • Atopy
      • Obesity
      • Consequences of Tobacco Smoking

      • Atherosclerosis - coronary artery disease, cerebrovascular disease, peripheral vascular disease
      • Cancer - lung, throat, liver, gastric, colorectal, pancreatic, genitourinary
      • Chronic obstructive pulmonary disease
      • Pregnancy / neonatal complications - infertility, growth restriction, placental abruption, preterm delivery, SIDS
      • Increased infection risk
      • Peptic ulcer disease
      • Osteoporosis
      • Important Travel-Related Infections

      • Diarrhoeal illnesses - giardia, amoeba, salmonella, shigella, cryptosporidia, cyclospora
      • Intestinal worms - strongyloidiasis, ascariasis, hookworm, whipworm, trichinosis, schistosomiasis
      • Mosquito-borne diseases - yellow fever, Japanese encephalitis, malaria, dengue fever, zika virus, chikungunya
      • Rickettsial illnesses - scrub typhus, spotted fevers
      • Tuberculosis
      • Other bacterial infections - meningococcal meningitis, typhoid fever, diptheria, leptospirosis, brucellosis, tetanus, lyme disease
      • Other viral infections - hepatitis A / B / C, HIV / AIDS, avian flu, measles, mumps, polio, rabies, ebola
      • Other parasitic infections - leishmaniasis

      Severity

      • Ask About

      • Symptoms - snoring, apnoeas, excessive daytime somnolence, poor concentration
      • Impact on functional status
      • Motor vehicle accidents
      • Sleep study result - apnoea-hypopnoea index

      Overview

      • Risk Factors for Tuberculosis

      • Immunosuppression - HIV, post transplant, autoimmune disease
      • Alcohol abuse
      • Malnutrition
      • Diabetes
      • Smoking
      • Risk Factors for COPD

      • Smoking
      • Occupational exposure - coal, toluene (plastics)
      • Environmental air pollution
      • Alpha-1 antitrypsin deficiency

      Management

      • Management Strategy

      • Pharmacologic Options

      • CFTR potentiator (G511D mutation) - ivacaftor
      • CFTR potentiator / corrector combination (delta F508 mutation) - ivacaftor / lumacaftor
      • Respiratory

      • Sputum clearance - bronchodilators, mucolytics, hypertonic saline, physiotherapy, postural drainage
      • Manage infection - monitor for colonisation, manage exacerbatons
      • Reduce inflammation - using macrolides (azithromycin)
      • Vaccinations - influenza, pneumococcus
      • Lung transplant
      • Pancreas

      • Exocrine - pancreatic enzyme replacement (creon), vitamin supplementation (A, D, E, K)
      • Endocrine - insulin if required
      • Gastrointestinal

      • Nutritional support
      • Constipation - aperients
      • Reflux - proton pump inhibitor
      • Biliary disease - ursodeoxycholic acid
      • Musculoskeletal

      • Arthropathy - NSAIDs
      • Osteoarthritis - calcium, vitamin D, bisphosphonates
      • Reproductive

      • Infertility - assisted pregnancy if required
      • Genetic counselling and testing of partner
      • Other

      • Maximise social supports
      • Treat depression

      Complications

      • Complications of Pulmonary Embolism

      • Disease-Related

      • Pulmonary infarction
      • Right heart failure
      • Chronic thromboembolic pulmonary hypertension (CTEPH)
      • Treatment-Related

      • Major bleeding

      Medication History

      • Prescription

      • Form - e.g. tablets, capsules, eye drops, nasal spray or injections
      • Administration - e.g. oral, IM or IV
      • Dose - the strength of the medication and how much they take eg how many tablets
      • Frequency - how often they take the medication

      Overview

      • Causes of Heart Failure

      • Ischaemic heart disease
      • Cardiomyopathy
      • Myocarditis
      • Pericardial disease
      • Valvular disease
      • Congenital heart disease
      • Hypertension

      Medication History

      • Prescription

      • Form - e.g. tablets, capsules, eye drops, nasal spray or injections
      • Administration - e.g. oral, IM or IV
      • Dose - the strength of the medication and how much they take eg how many tablets
      • Frequency - how often they take the medication

      Overview

      • Consequences of Tobacco Smoking

      • Atherosclerosis - coronary artery disease, cerebrovascular disease, peripheral vascular disease
      • Cancer - lung, throat, liver, gastric, colorectal, pancreatic, genitourinary
      • Chronic obstructive pulmonary disease
      • Pregnancy / neonatal complications - infertility, growth restriction, placental abruption, preterm delivery, SIDS
      • Increased infection risk
      • Peptic ulcer disease
      • Osteoporosis
      • Causes of Hypertension

      • Primary

      • Primary (essential) hypertension: chronically elevated blood pressure of unknown aetiology (the most common cause of hypertension in the community)
      • Secondary

      • Chronic kidney disease
      • Renovascular - fibromuscular dysplasia, atherosclerosis
      • Endocrine - hyperthyroidism, hypothyroidism, Cushing’s syndrome, primary aldosteronism, phaeochromocytoma, hyperparathyroidism
      • Drugs - NSAIDs, amphetamines, glucocorticoids, fludrocortisone, erythropoietin, VEGF inhibitors, calcineurin inhibitors
      • Aortic coarctation
      • Obstructive sleep apnoea
      • Factitious

      • White coat hypertension: falsely elevated blood pressure may occur due to by anxiety in a healthcare setting, recent exercise or recent caffeine intake.
      • Recent exercise or caffeine intake

      IV Drug Use

      • Consequences of IV Drug Use

      • Blood-borne viral infections - hepatitis B, hepatitis C, HIV
      • Bacterial septicaemia
      • Infective endocarditis - especially right-sided (tricuspid) disease
      • Cutaneous infection - skin abscess, cellulitis, necrotising fasciitis
      • Venous damage - superficial thrombophlebitis, deep venous thrombosis

      Overview

      • Ask About

      • Everyone

      • Whether they drink alcohol regularly
      • How often - daily, weekly, monthly, or on social occasions only
      • What type of alcohol they drink
      • How many drinks on each occasion / each day
      • The most they drink at any given time
      • Where they drink - restaurants, bars, parties, at home
      • Amount spent on alcohol
      • Heavy Drinkers

      • Withdrawal symptoms - sweating, rigors, nausea, past seizures
      • Alcohol free days
      • Past attempts to quit drinking
      • Willingness to cut down or stop

      Diagnosis

      • Symptoms of Pulmonary Hypertension

      • Fatigue
      • Exertional dyspnoea
      • Exertional chest pain
      • Exertional syncope
      • Symptoms of right heart failure - peripheral oedema, ascites

      Overview

      • Risk Factors for Ischaemic Heart Disease

      • Family history of ischaemic heart disease
      • Advanced age
      • Smoking
      • Hypertension
      • Hyperlipidaemia
      • Diabetes mellitus
      • Physical inactivity
      • Obesity
      • Classification

      • Paroxysmal AF - occurring for <7 days
      • Persistent AF - occurring for >7 days
      • Permanent AF - long-standing despite attempts at cardioversion

      Complications

      • Complications of Hyperlipidaemia

      • Atherosclerosis

      • Ischaemic heart disease
      • Ischaemic stroke
      • Erectile dysfunction
      • Peripheral vascular disease
      • Other

      • Non-alcoholic fatty liver disease

      Aetiology

      • Causes of Chronic Dyspnoea

      • Other

      • Anaemia
      • Late pregnancy
      • Kyphoscoliosis
      • Muscular dystrophy
      • ALS

      Diagnosis

      • Stages of Chronic Kidney Disease

      • GFR Categories (mL/min/1.73m²)

      • G1 - ⩾90
      • G2 - 60-89
      • G3a - 45-59
      • G3b - 30-44
      • G4 - 15-29
      • G5 - <15
      • Albuminuria Categories

      • A1 - <30mg/g / <3mg/mmol
      • A2 - 30-300mg/g / 3-30mg/mmol
      • A3 - >300mg/mg / >30mg/mmol

      Diabetic Diagnosis

      • Ask About

      • Type of diabetes - type 1, type 2, late autoimmune diabetes in adults (LADA), steroid-induced diabetes, gestational diabetes
      • When the patient’s diabetes was diagnosed
      • Symptoms at diagnosis - polyuria, polydipsia, thirst, weight loss, ketoacidosis, asymptomatic glycosuria
      • What test was used to diagnose their diabetes

      Exercise Tolerance


      • Exercise tolerance is a strong prognostic marker for many chronic conditions such as ischaemic heart disease, heart failure, peripheral vascular disease and COPD.

      Complications

      • Complications of Colorectal Cancer

      • Disease-Related

      • Lower GI bleeding
      • Bowel obstruction
      • Perforation
      • Management-Related

      • Surgical complications - bleeding, wound infection, anastomotic leak, intra-abdominal collection, ileus
      • Adverse effects of chemotherapy - fatigue, nausea / vomiting / diarrhoea, myelosuppression
      • Adverse effects of VEGF inhibitors - hypertension, arterial / venous thromboembolism, myelosupression
      • Adverse effects of EGFR inhibitors - acneiform rash, nausea / vomiting / diarrhoea, hypomagnesaemia

      Overview

      • Risk Factors for Inflammatory Bowel Disease

      • Family history of inflammatory bowel disease
      • Smoking (Crohn’s only - protective in ulcerative colitis)
      • Western diet - high fat, high sugar
      • Medications - NSAIDs, oral contraceptives
      • Not being breastfed
      • Psychological stress

      Complications

      • Complications of Non-Alcoholic Fatty Liver Disease

      • Cirrhosis
      • Cardiovascular disease
      • Type 2 diabetes mellitus
      • Chronic kidney disease
      • Colorectal cancer

      Medication History

      • Prescription

      • Form - e.g. tablets, capsules, eye drops, nasal spray or injections
      • Administration - e.g. oral, IM or IV
      • Dose - the strength of the medication and how much they take eg how many tablets
      • Frequency - how often they take the medication

      Overview

      • Consequences of Tobacco Smoking

      • Atherosclerosis - coronary artery disease, cerebrovascular disease, peripheral vascular disease
      • Cancer - lung, throat, liver, gastric, colorectal, pancreatic, genitourinary
      • Chronic obstructive pulmonary disease
      • Pregnancy / neonatal complications - infertility, growth restriction, placental abruption, preterm delivery, SIDS
      • Increased infection risk
      • Peptic ulcer disease
      • Osteoporosis

      Peritransplant History

      • Ask About

      • When
      • Indication for liver transplant
      • Graft type - orthotopic vs split graft
      • Anastomosis - duct to duct (recipient to donor) vs roux-en-y (no recipient bile duct)

      Overview

      • Ask About

      • Travel to other countries - especially developing countries
      • Prophylaxis before travelling - vaccines, malaria prophylaxis
      • Exposure to animals - especially bites or scratches
      • Food intake - especially raw meat, fish, unpasteurised dairy products
      • Contact with fresh water
      • Contact with sick people
      • Insect bites
      • Sexual contacts
      • Needle exposures
      • Risk Factors for Gastroesophageal Reflux

      • Family history of reflux
      • Advanced age
      • Obesity
      • Hiatus hernia
      • Pregnancy
      • Scleroderma
      • Smoking

      IV Drug Use

      • Consequences of IV Drug Use

      • Blood-borne viral infections - hepatitis B, hepatitis C, HIV
      • Bacterial septicaemia
      • Infective endocarditis - especially right-sided (tricuspid) disease
      • Cutaneous infection - skin abscess, cellulitis, necrotising fasciitis
      • Venous damage - superficial thrombophlebitis, deep venous thrombosis

      Overview

      • Ask About

      • Everyone

      • Whether they drink alcohol regularly
      • How often - daily, weekly, monthly, or on social occasions only
      • What type of alcohol they drink
      • How many drinks on each occasion / each day
      • The most they drink at any given time
      • Where they drink - restaurants, bars, parties, at home
      • Amount spent on alcohol
      • Heavy Drinkers

      • Withdrawal symptoms - sweating, rigors, nausea, past seizures
      • Alcohol free days
      • Past attempts to quit drinking
      • Willingness to cut down or stop
      • Causes of Peptic Ulcer Disease

      • Helicobacter pylori infection
      • Medications - NSAIDs, steroids, bisphosphonates, chemotherapy
      • Zollinger-Ellison syndrome
      • Gastric malignancy
      • Acute illness

      Complications

      • Complications of Cirrhosis

      • Ascites (due to portal hypertension, RAAS activation and splanchnic vasodilatation)
      • Varices (due to portal hypertension)
      • Splenomegaly (due to portal hypertension)
      • Hepatic encephalopathy (due to ammonia buildup)
      • Spontaneous bacterial peritonitis (due to gut translocation)
      • Hepatorenal syndrome (due to splanchnic vasodilatation)
      • Hepatic hydrothorax (due to leakage of ascitic fluid into the pleural space)
      • Portopulmonary hypertension (due to portal hypertension)
      • Hepatopulmonary syndrome (due to vasodilation / shunting)
      • Malnutrition / sarcopaenia
      • Coagulopathy (due to poor synthetic function + vitamin K malabsorption)
      • Thrombocytopaenia (due to splenic sequestration)
      • Hepatocellular carcinoma (HCC)

      Manifestations

      • Manifestations of Hepatitis C Infection

      • Hepatic

      • Chronic hepatitis
      • Cirrhosis
      • Extrahepatic

      • Dermatologic - lichen planus, porphyria cutanea tarda
      • Immune - essential mixed cryoglobulinaemia, Sjogren’s syndrome
      • Renal - membranoproliferative glomerulonephropathy
      • Non-Hodgkin lymphoma
      • Type 2 diabetes mellitus
      • Manifestations of Hepatitis B Infection

      • Hepatic

      • Acute hepatitis
      • Chronic hepatitis
      • Cirrhosis
      • Hepatitis D infection
      • Extrahepatic

      • Polyarteritis nodosa
      • Membranous glomerulonephropathy
      • Serum sickness-like syndrome (fevers, rash, myalgias, arthralgias)

      Overview

      • Types of Scleroderma

      • Limited scleroderma (CREST syndrome) - slowly progressive; less associated with cardiac disease and renal crisis
      • Diffuse scleroderma - rapidly progressive; associated with lung disease, renal crisis and cardiac disease

      Exercise Tolerance


      • Exercise tolerance is a strong prognostic marker for many chronic conditions such as ischaemic heart disease, heart failure, peripheral vascular disease and COPD.

      Overview

      Also ask about whether the patient's mobility has changed recently, and why.

      Management

      • Management Options

      • Non-Pharmacologic

      • Weight loss
      • Exercise - gym programs, tai chi, hydrotherapy
      • Physiotherapy
      • Walking aids
      • Joint protection - taping, splinting, orthotics
      • Pharmacologic

      • Simple analgesia - paracetamol, NSAIDs
      • Opioids (to be avoided)
      • Intra-articular corticosteroids
      • Surgical

      • Osteotomy (change in alignment)
      • Arthroplasty (joint replacement)
      • Arthrodesis (joint fusion)

      Manifestations

      • Manifestations of Rheumatoid Arthritis

      • Articular

      • Symmetrical inflammatory polyarthropathy with sparing of the distal interphalangeal (DIP) joints
      • Tendon rupture
      • Atlantoaxial instability (severe cases)
      • Extra-Articular

      • Rheumatoid nodules
      • Systemic - fatigue, weight loss
      • Skin - rheumatoid nodules
      • Ocular - sicca symptoms, scleritis, episcleritis, scleromalacia, scleromalacia perforans
      • Vasculitis - pulmonary hypertension, palpable purpura, distal gangrene
      • Neurologic - compressive neuropathies (e.g. carpal tunnel syndrome), mononeuritis multiplex
      • Cardiovascular - pericarditis
      • Respiratory - interstitial lung disease, pleurisy, lung nodules
      • Haematologic - Felty’s syndrome (arthritis, splenomegaly and neutropaenia)

      Complications

      • Complications of Gout

      • Gouty tophi - in bursae, tendons, subcutaneous tissues
      • Joint destruction
      • Nephrolithiasis
      • Urate nephropathy

      Overview

      • Precipitants of Lupus Flares

      • UV light
      • Stress
      • Infections
      • Pregnancy
      • Rapid tapering of immunosuppression
      • Drugs - procainamide, hydralazine, minocycline, quinidine, diltiazem, isoniazid, phenytoin, carbamazepine

      Optic Nerve Palsy

      • Causes of Optic Nerve Palsy

      • Intraorbital - trauma, ischaemia, aneurysm, tumour, optic neuritis, optic nerve hypoplasia
      • Optic chiasm - pituitary tumour, craniopharyngioma, pituitary apoplexy
      • Optic tract - ischaemia, trauma, tumour, MS

      Vestibulocochlear Nerve Palsy

      • Causes of Vestibulocochlear Nerve Palsy

      • Tumour - cerebellopontine angle, internal auditory canal
      • Meningitis
      • Guillain-Barre
      • Sarcoidosis
      • Congenital absence

      Overview

      • Causes of Palsy

      • Trauma - coup / contrecoup
      • Frontal lobe - trauma, ischaemia, tumour
      • Meningitis
      • Neurosyphillis
      • Causes of Pseudobulbar Palsy

      • Internal capsular stroke
      • Multiple sclerosis
      • Motor neurone disease
      • Head injury
      • Interpretation

      • Increased - ongoing blinking without habitualizationParkinsonism or frontal lobe pathology
      • Normal - up to five blinks and then no further blinking following habitualization
      • Decreased - no blinking in response to stimulusUpper or lower motor neuron weakness

      Trigeminal Nerve Palsy

      • Causes of Trigeminal Nerve Palsy

      • Trigeminal ganglion lesion - herpes zoster, tumour
      • Trigeminl (V) nerve lesion - trauma, tumour, ICA aneurysm, cavernous sinus thrombosis, SLE

      Hypoglossal Nerve Palsy

      • Causes of Hypoglossal Nerve Palsy

      • Tumour
      • Trauma
      • Infarction
      • Haemorrhage
      • Demyelination
      • Motor neurone disease

      Vagus Nerve Palsy

      • Causes of Vagus Nerve Palsy

      • Peripheral nerve trauma
      • Peripheral nerve ischaemia
      • Base of skull fractureInvolving the jugular foramen
      • Motor neurone disease

      Olfactory Nerve Palsy

      • Causes of Olfactory Nerve Palsy

      • Trauma - coup / contrecoup
      • Frontal lobe - trauma, ischaemia, tumour
      • Meningitis
      • Neurosyphillis

      Abducens Nerve Palsy

      • Causes of Abducens Nerve Palsy

      • Small-vessel ischaemia
      • Head trauma
      • Tumour
      • Aneurysm

      II Optic Nerve

      • Causes of Palsy

      • Intraorbital - trauma, ischaemia, aneurysm, tumour, optic neuritis, optic nerve hypoplasia
      • Optic chiasm - pituitary tumour, craniopharyngioma, pituitary apoplexy
      • Optic tract - ischaemia, trauma, tumour, MS
      • Optic radiation - ischaemia, demyelination, PML, tumour
      • Occipital lobe - ischaemia, trauma, trauma

      Facial Nerve Palsy

      • Causes of Facial Nerve Palsy

      • Supranuclear
      • Ischaemic stroke (lacunar or superior cerebellar artery)
      • Tumour - primary / secondary
      • Nuclear / Infranuclear
      • Bell’s palsy (idiopathic)
      • Ramsay-Hunt syndrome (Herpes zoster)
      • Tumour - primary / secondary
      • Parotid gland pathology
      • Otitis media / externa
      • Skull fracture
      • Guillain-Barre
      • Ischaemia
      • Lyme disease
      • Leprosy

      V Trigeminal Nerve

      • Causes of Palsy

      • CNS lesion - ischaemia, haemorrhage, tumour, syringobulbia, syringomyelia
      • Trigeminal ganglion lesion - herpes zoster, tumour
      • Peripheral nerve lesion - trauma, tumour, ICA aneurysm, cavernous sinus thrombosis, SLE

      XI Accessory Nerve

      • Causes of Palsy

      • Trauma - blunt, cervical stretch injury, iatrogenic (e.g. lymph node biopsy)
      • Tumour
      • Medullary infarction

      Accessory Nerve Palsy

      • Causes of Accessory Nerve Palsy

      • Trauma - blunt, cervical stretch injury, iatrogenic (e.g. lymph node biopsy)
      • Tumour
      • Medullary infarction

      XII Hypoglossal Nerve

      • Causes of Palsy

      • Tumour
      • Trauma
      • Infarction
      • Haemorrhage
      • Demyelination
      • Motor neurone disease

      Trochlear Nerve Palsy

      • Causes of Trochlear Nerve Palsy

      • Congenital absence
      • Closed head injury

      The Glasgow Coma Scale (GCS)

      • How to Assess

      • If the patient is not spontaneously opening their eyes, begin by attempting to elicit a response verbally. If this is unsuccessful then apply a painful stimulus such as a trapezius squeeze or a sternal rub.

      Trochlear Nerve (IV) Palsy

      • Look For

      • Head tilting away from the side of the lesion
      • Eye deviation upward and rotation outward
      • Vertical diplopia
      • Inability to look down and in - difficulty descending stairs

      Overview

      • Causes of Bulbar Palsy

      • Motor neurone disease
      • Guillain-barré
      • Polio
      • Neurosyphilis
      • Brainstem stroke

      Glossopharyngeal Nerve Palsy

      • Causes fo Glossopharyngeal Nerve Palsy

      • Tumour
      • Infarction
      • Base of skull fractureInvolving the jugular foramen
      • Diptheria

      Overview

      Dilate the eye if possible with tropicamide, atropine or phenylephrine eye drops.
      • Manifestations of Myotonic Dystrophy

      • Myotonia
      • Cognitive impairment
      • Cataracts
      • Hearing impairment
      • Endocrine - diabetes, hypogonadism, secondary hyperparathyroidism
      • Cardiovascular - arrhythmia, cardiomyopathy, sudden cardiac death
      • Respiratory - obstructive sleep apnoea
      • Gastrointestinal - transaminase elevation, constipation / diarrhoea
      • Hypogammaglobulinaemia
      • Causes of Cerebellopontine Angle Syndrome

      • Vestibular schwannoma
      • Meningioma
      • Cerebellar astrocytoma
      • Brain metastasis

      VII Facial Nerve

      • Causes of Palsy

      • Supranuclear
      • Infarction (lacunar or superior cerebellar artery)
      • Tumour - primary / secondary
      • Nuclear / Infranuclear
      • Bell’s palsy (idiopathic)
      • Ramsay-Hunt syndrome (Herpes zoster)
      • Tumour - primary / secondary
      • Parotid gland pathology
      • Otitis media / externa
      • Skull fracture
      • Guillain-Barre
      • Ischaemia
      • Lyme disease
      • Leprosy

      Horner’s Syndrome

      • Causes of Horner's Syndrome

      • Brain lesion - hypothalamus, thalamus, pons, medullaTumour, bleed
      • Spinal cord lesionTrauma, inflammation, AVM, demyelination, tumour, infarct
      • Apical lung lesion (Pancoast syndrome)
      • Brachial plexus lesion

      Occulomotor Nerve Palsy

      • Causes of Oculomotor Nerve Palsy

      • Small-vessel ischaemia
      • Midbrain infarct
      • Head trauma
      • Tumour
      • Aneurysm (commonly PCA)

      Facial Asymmetry

      Sparing of the eyebrows (i.e. absence of eyebrow droop) distinguishes an upper motor neuron lesion from a lower motor neuron lesion, as the eyebrows receive innervation from both cerebral hemispheres (collateral supply) and the lower face receives only contralateral supply.

      VIII Vestibulocochlear Nerve

      • Causes of Palsy

      • Tumour - cerebellopontine angle, internal auditory canal
      • Meningitis
      • Guillain-Barre
      • Sarcoidosis
      • Congenital absence

      Overview

      • Causes of Cerebellar Lesions

      • Trauma
      • Vascular - ischaemia, haemorrhage
      • Infection - abscess, tuberculosis
      • Malignancy
      • Demyelination - multiple sclerosis
      • Drugs / toxins - alcohol, lithium, phenytoin, chemotherapy
      • Inherited - Friedrich's ataxia, spinocerebellar ataxia
      • Paraneoplastic syndrome
      • Hypothyroidism
      Posterior tibial - palpate posteriorly and inferiorly to the medial malleolus.

      Extra Credit

      • Complications of Peritoneal Dialysis

      • Catheter obstruction
      • Catheter infection
      • Peritonitis
      • Pleural effusion
      • Pericatheter leak
      • Abdominal wall (Spigelian) hernia

      Overview

      • Abnormal If

      • >2 seconds

      Measuring Blood Pressure

      • Prior to Testing Blood Pressure

      • Ask the patient whether they have had dialysis (have an AV fistula), whether they have had breast cancer surgery (and lymph node dissection) or whether there is some other reason their blood pressure should not be measured on a particular arm.

      Hepatomegaly

      Apply gentle pressure to the right lower quadrant with the palpating hand parallel to the edge of the liver. Ask the patient to take a slow breath in to bring the liver edge toward the fingertips. Move the hand 2cm superiorly each time the patient breathes out and repeat until the lower edge of the liver is palpable.

      Peripheral Neuropathy

      • Look For

      • Loss of / altered sensation in the hands and / or feet, in a ‘glove and stocking distribution.

      Pallor of the Lower Limb

      • Look For

      • Loss of colour in one or both lower limbs.

      Crepitations

      • Causes of Pulmonary Crepitations

      • Fine Crackles

      • Pulmonary oedema - congestive cardiac failure, fluid overload
      • Pneumonia
      • Pulmonary interstitial fibrosis
      • Coarse Crackles

      • Chronic bronchitis
      • Bronchiectasis
      • Cystic fibrosis

      Venous Skin Changes

      • Significance

      • Venous insufficiency.

      Overview

      The kidneys are not palpable in most normal patients, though may be palpable in thin patients and children.

      Abdominal Scars

      • Abdominal Scars

      Overview

      • Significance

      • Pericarditis.
      • Causes of Flank Tenderness

      • Infection - pyelonephritis, perinephric abscess
      • Malignancy - renal cell carcinoma, transitional cell carcinoma
      • Renal infarction
      • Trauma

      Xanthomata

      • Look For

      • Red to yellow lipid-filled nodules, papules or plaques, which may overly tendons, extensor surfaces, flexor surfaces or the palms.

      Rashes Associated with Renal Disease

      Porphyria cutanea tarda: blisters over sun-exposed areas such as the scalp, dorsal hands and forearms, neck and face.Uraemia, liver disease

      Overview

      • Causes of Asterixis

      • Bilateral Asterixis

      • Hepatic encephalopathy
      • Uraemia (renal failure)
      • Hypercarbia
      • Medications - clozapine, carbemazepine, valproate, levodopa
      • Unilateral Asterixis

      • CNS lesions - thalamus, midbrain, basal ganglia, frontal lobe
      • Subdural haematoma

      Contour

      Slow rate of rise Aortic stenosis

      Oral Candidiasis

      • Risk Factors

      • Dry mouth
      • Inhaled steroids
      • Immunosuppression
      • Antibiotic use
      • Smoking
      • Diabetes

      Overview

      • Significance

      • Turbulent blood flow due to endothelial narrowing.

      Pitting Oedema

      • Look For

      • Persistence of the depressed area after pressure is removed.

      Heart Rate

      • Causes of Bradycardia (<60bpm)

      • Physiological - high cardiac fitness
      • Beta blockers
      • Hypothyroidism
      • Raised intracranial pressure
      • Heart block
      • Sick sinus syndrome

      Scratch Marks

      • Look For

      • Scratch marks over the skin of the face, arms, chest or abdomen.

      Overview

      Position the patient at 45 degrees and ask them to turn their head to the left. Hold a flashlight tangentially to the skin of the neck and inspect for the highest level of the jugular venous pulsation. Measure the vertical distance between the sternal angle and this level.

      Weight

      • Causes of Weight Gain

      • Dietary intake
      • Physical exercise
      • Endocrine - hypothyroidism, Cushing’s, PCOS
      • Medications - steroids, antidepressants, antipsychotics, OCP
      • Fluid overload - excessive IV fluids, renal disease, heart failure
      • Genetic

      Overview

      Dilate the eye if possible with tropicamide, atropine or phenylephrine eye drops.

      Dehydration

      • Look For

      • Abnormal obs - tachycardia, hypotension
      • Fluid balance chart - negative fluid balance, oliguria
      • Weight loss - an acute decrease in weight may indicate short-term change in fluid status
      • Dry mucous membranes - especially the tongue
      • Sunken eyes
      • Increased capillary refill time (>2 seconds)
      • Weak radial pulse
      • Decreased skin turgor - pinch a fold of skin on the patient’s arm and then release it. Decreased skin turgor is present if the fold takes an abnormal time to return to its normal contour.

      Halitosis

      • Significance

      • Suggestive of bacterial colonisation in the mouth, pharynx, respiratory or gastrointestinal tracts.

      Arterial Ulcers

      • Look For

      • Deep, painful white ulcers with blanched surrounding tissue, affecting the toes, heels and bony prominences. These ulcers may become black with necrosis.

      Leukonychia

      • Interpretation

      • True Leukonychia

      • Total leukonychia: generalised whitening of the nails.Inherited - rare
      • Transverse leukonychia (Mee’s lines): single white bands running parallel to the nail base, that do not disappear when depressed.Intermittent insult during nail growth - arsenic, chemotherapy, trauma, infection
      • Apparent Leukonychia

      • Muehrcke’s lines: double white bands that disappear when the nail is depressed.Chronic hypoalbuminaemia
      • Half and half nails (Lindsay’s nails): proximal white nail bed and distal brown nail, separated by a transverse ridge.Uraemia
      • Terry’s nails: white proximal nail bed with loss of the lunula (proximal white crescent-shaped area).Cirrhosis, CCF, diabetes, malnutrition, renal transplant

      Overview

      • Causes of Sacral Oedema

      • Excessive IV fluids
      • Renal disease
      • Heart failure
      • Causes of Warm Extremities

      • Systemic - fever / hyperthermia
      • Cellulitis
      • Lymphoedema
      • Venous abnormalities - deep venous thrombosis, superficial thrombophlebitis, venous insufficiency

      Complications

      • Complications of Chronic Kidney Disease

      • Disease-Related

      • Acidosis (poor clearance of hydrogen ions)
      • Fluid overload
      • Electrolyte derangements - hyperkalaemia, hyperphosphataemia
      • Cardiovascular disease - hypertension, increased cardiovascular / cerebrovascular risk
      • Anaemia (EPO deficiency)
      • Mineral bone disease (mediated by FGF23) - secondary hyperparathyroidism, hyperphosphataemia, hypocalcaemia; tertiary hyperparathyroidism
      • Uraemia - encephalopathy, uraemic pericarditis
      • Malnutrition
      • Treatment-Related

      • Lethargy
      • Muscle cramps
      • Restless legs syndrome
      • Access-related complications - thrombosis, infection

      Overview

      • Normal Range of Motion

      • 50°

      Benediction Hand

      • How to Perform

      • Ask the patient to make a fist. Benediction hand is present if the patient is unable to flex the index and middle fingers.

      Overview

      • Normal Range of Motion

      • 70°
      • Normal Range of Motion

      • 70°

      Psoriatic Plaques

      • Look For

      • Raised erythematous patches, particularly affecting the extensor surfaces of joints, scalp, periumbilicus, lower back and skin folds

      Overview

      • Normal Range of Motion

      • 20°
      • X-Ray Findings in Rheumatoid Arthritis

      • Reduced joint space - generally symmetric
      • Articular surface erosions: discontinuities in the bone plate
      • Periarticular osteopaenia - hypodensity of bone surrounding the joint
      • Soft tissue swelling

      Pathogenesis

      • Risk Factors for Gout

      • Male gender
      • Obesity
      • Chronic kidney disease
      • Drugs - diuretics, ethambutol, certain chemotherapeutic agents
      • Excess purine-rich foods - beer, shellfish, liver, marmite
      • Excess sucrose / fructose intake
      • Alcohol excess

      Overview

      • Normal Range of Motion

      • 70°
      • Normal Range of Motion

      • 20°

      Soft Tissue Landmarks of the Wrist

      Snuffbox - on the radial aspect of the dorsum of the hand, at the base of the thumb. Contains the scaphoid and trapezium. Snuffbox tenderness is characteristic of scaphoid fracture.

      Muscles Acting on the Wrist Joint

      Abductors - flexor carpi radialis, extensor carpi radialis longus & brevis

      Overview

      • Normal Range of Motion

      • 80°
      • Normal Range of Motion

      • 70°
      • Normal Range of Motion

      • Metacarpophalangeal joint - 80°
      • Proximal interphalangeal joint - 100°
      • Distal interphalangeal joint - 70°

      Tinel’s Sign

      • Abnormal If

      • Paraesthesia / reproduction of the patient’s symptoms.

      Overview

      • Normal Range of Motion

      • 0° or slightly more
      • Normal Range of Motion

      • 20°
      • Normal Range of Motion

      • 30°

      Bony Landmarks of the Wrist

      Head of radius - proxiamlly, articulating with the distal humerus and radial head.

      Overview

      • Normal Range of Motion

      • 10°
      • Normal Range of Motion

      • 40-50°
      • Normal Range of Motion

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Bony Landmarks of the Shoulder

      Acromioclavicular joint - the articulation between the distal end of the clavicle and the acromion of the scapula.

      Posterior Shoulder Dislocation

      • Look For

      • Internal rotation of the shoulder with prominent coracoid process and posterior fullness of the shoulder joint.

      Overview

      • Normal Range of Motion

      • 20°
      • Normal Range of Motion

      • 90°
      • Normal Range of Motion

      • 0-10°
      • Normal Range of Motion

      • 135°
      • Normal Range of Motion

      • 170°

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Muscles Acting on the Shoulder Joint

      Abductors - lateral deltoid, supraspinatus

      Overview

      • Normal Range of Motion

      • 15°
      • Normal Range of Motion

      • Abnormal If

      • Pain.
      • Normal Range of Motion

      • 70°

      Measuring Blood Pressure

      • Sizing the Blood Pressure Cuff

      • The blood pressure cuff should measure approximately 80% of the circumference of the arm.

      Overview

      • Normal Range of Motion

      • Active - 120°
      • Passive - 125°
      • Normal Range of Motion

      • Active - 15°
      • Passive - 20°
      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.

      Muscles Acting on the Hip Joint

      Adductors (medial) - pectineus; adductor longus, brevis and magnus; gracilis, pectineus

      Overview

      • Causes of Poor Posture

      • Structural - deformities of the spine, foot and ankle
      • Leg Length discrepancy
      • Poor foot posture
      • Muscular imbalance - habitual poor body position
      • Normal Range of Motion

      • Active - 35°
      • Passive - 40°
      • Abnormal If

      • Reproduction of the patient's symptoms - pain or paraesthesia.
      • Normal Range of Motion

      • Active - 40°
      • Passive - 45°

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • Active - 35°
      • Passive - 45°

      Bony Landmarks of the Hip

      Posterior superior iliac spine - the most posterior aspect of the iliac crest, identified by dimples at approximately the level of S2

      Overview

      • Feel For

      • Placing the fingers over the femoral region, external & internal inguinal rings, palpate for bulge or impulse on coughing.
      • Normal Range of Motion

      • Active - 20°
      • Passive - 25°

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Complications

      • Complications of Marfan Syndrome

      • Cardiovascular

      • Dilatation of the proximal aorta
      • Aortic root dissection
      • Mitral valve prolapse
      • Ocular

      • Ectopia lentis: lens displacement (pathognomonic)
      • Myopia: nearsightedness
      • Musculoskeletal

      • Protrusio acetabuli: displacement of the medial aspect of the femoral head beyond the ilio-ischial line
      • Other

      • Pneumothorax
      • Dural ectasia: ballooning of the dura in the spine resulting in enlargement of the neural canal

      Overview

      Smaller VSDs tend to be louder.
        • Normal Range

        • 12 - 20 breaths per minute
      BMI =
      WeightHeight²
      A hum will be heard normally, which is due to normal jugular venous flow.
      Clubbing was first described by Hippocrates in 400BC after noting the sign in a patient with empyema.

      Pallor of the Nail Bed

      • Look For

      • Whitening of the nail beds.

      Down Syndrome

      • Cardiac Sequelae

      • At Birth

      • Atrioventricular (AV) septal defects (45%)
      • Ventricular septal defects (35%)
      • Atrial (secundum) septal defect (8%)
      • Persistent ductus arteriosus (7%)
      • In Adolescence

      • Tetralogy of Fallor (4%)
      • Mitral valve prolapse (46%)
      • Aortic regurgitation (17%)

      Overview

      • Causes of Left Ventricular Failure

      • Ischaemic heart disease
      • Cardiomyopathy
      • Myocarditis
      • Pericardial disease
      • Valvular disease
      • Congenital heart disease
      • Hypertension

      Cardioverter-Defibrillators

      • Look For

      • A mass in the left subclavicular area.

      Pallor of the Lower Limb

      • Causes of Lower Limb Pallor

      • Peripheral vascular disease
      • Compartment syndrome
      • Low cardiac output, due to cardiac disease
      • Peripheral shutdown, due to increased sympathetic activity

      Overview

      Inspiration & Expiration

      • How to Perform

      • Ask the patient to take a deep breath in and hold it. Ask them to then take a deep breath out and hold it.

      Overview

      • Causes of Right Ventricular Failure

      • Pulmonary hypertension - pulmonary arterial hypertension, left heart failure, lung disease, chronic pulmonary embolism
      • Right ventricular pathology - cardiomyopathy, myocarditis, ischaemic heart disease
      • Tricuspid regurgitation - rheumatic heart disease, infective endocarditis, Ebstein’s anomaly, carcinoid syndrome, trauma
      • Pericardial disease - constrictive pericarditis
      • Causes of Aortic Stenosis

      • Calcific degeneration
      • Rheumatic heart disease
      • Congenital bicuspid aortic valve
      • Infective endocarditis

      Measuring Blood Pressure

      • Prior to Testing Blood Pressure 

        Ask the patient:
      • Whether they have had dialysis (have an AV fistula)
      • Whether they have had breast cancer surgery (and lymph node dissection)
      • Whether there is any other reason why their blood pressure should not be measured on a particular arm

      Overview

      • Normal Position

      • The fifth intercostal space in the midclavicular line.
      • Causes of Aortic Regurgitation

      • Acute

      • Infective endocarditis
      • Dissecting aneurysm
      • Hypertension
      • Trauma
      • Chronic

      • Rheumatic heart disease
      • Congenital bicuspid aortic valve
      • Ankylosing spondylitis
      • Marfan syndrome / Ehlers-Danlos syndrome
      • Aortitis
      • Causes of Mitral Regurgitation

      • Acute

      • Acute myocardial infarction
      • Infective endocarditis
      • Trauma
      • Chronic

      • Mitral annular calcification
      • Mitral valve prolapse
      • Rheumatic heart disease
      • Papillary muscle dysfunction
      • Connective tissue disease - systemic lupus erythematosus, rheumatoid arthritis
      • Common Thoracic Surgical Scars

      • A
        Sternotomy (midline)Most cardiac surgery, esp. CABG
      • B
        Anterior thoracotomy (submammary)Lung biopsy, pericardial surgery
      • C
        Posterolateral thoracotomy (axillary)Most non-cardiac thoracic procedures
      • D
        Clamshell (bilateral subpectoral)Lung transplantation
      • E
        Left subclavicularPacemaker insertion

      Heart Rate

        • Normal Range

        • 60 - 100bpm

      Complications

      • Complications of Down Syndrome

      • Cardiovascular: At Birth

      • Atrioventricular (AV) septal defects
      • Ventricular septal defect
      • Atrial (secundum) septal defect
      • Persistent ductus arteriosus
      • Tetralogy of Fallot
      • Cardiovascular: In Adolescence

      • Mitral valve prolapse
      • Aortic regurgitation
      • Other

      • Developmental Delay

      Overview

      • Causes of Pulmonary Hypertension

      • Type 1: Pulmonary Arterial Hypertension

      • Idiopathic
      • Inherited
      • Drugs / toxins
      • HIV-related
      • Connective tissue disease - scleroderma, mixed connective tissue disease
      • Portopulmonary hypertension
      • Congenital heart disease
      • Schistosomiasis
      • Type 2: Left Heart Disease

      • Left ventricular systolic / diastolic dysfunction
      • Valvular disease - aortic stenosis, aortic regurgitation, mitral stenosis
      • Type 3: Lung Disease

      • Chronic obstruction pulmonary disease
      • Interstitial lung disease
      • Mixed lung disease
      • Sleep-disordered breathing
      • Alveolar hypoventilation
      • Type 4: Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

      • Chronic pulmonary emboli
      • Type 5: Other

      • Haematologic - chronic haemolytic anaemia, myeloproliferative disorders, splenectomy
      • Systemic - sarcoidosis, pulmonary histiocytosis, lymphangioleiomyomatosis
      • Metabolic - glycogen storage disorders, Gaucher disease
      • Other - tumour obstruction, chronic kidney disease
      • Causes of Mitral Stenosis

      • Rheumatic heart disease
      • Congenital mitral stenosis
      • Mitral annular calcification

      Complications

      • Complications of Turner Syndrome

      • Cardiovascular

      • Bicuspid aortic valve
      • Aortic coarctation
      • Aortic dissection
      • Hyperlipidaemia
      • Reproductive

      • Ovarian failure
      • Poor breast development
      • Other

      • Osteoporosis
      • Horseshoe kidney
      • Autoimmune disorders - thyroiditis, coeliac disease
      • Ocular pathology - myopia (nearsightedness), strabismus
      • Ear pathology - sensorineural hearing loss, recurrent otitis media

      Overview

      Dilate the eye if possible with tropicamide, atropine or phenylephrine eye drops.
      • Causes of Pulmonary Stenosis

      • Congenital - rubella, Noonan’s syndrome, William’s syndrome, tetralogy of Fallot
      • Carcinoid syndrome
      • On Inspiration

      • Causes of Tricuspid Regurgitation

      • Rheumatic heart disease
      • Infective endocarditis (particularly associated with IV drug use)
      • Ebstein’s anomaly
      • Carcinoid syndrome
      • Trauma

      Valsalva Manoeuvre

      • How to Perform

      • While auscultating the chest, ask the patient to breath out against a closed mouth and nose.

      Overview

        • Normal Range

        • Males <0.9
        • Females <0.85

      Resting Tremor

      • Significance

      • Associated with Parkinsonism, either in the setting of Parkinson’s disease or secondary causes.

      Anosmia

      • Causes of Anosmia

      • Mechanical anosmia - inflammation of nasal mucosa, blockage of nasal passages
      • Olfactory anosmia - blunt trauma, frontal lobe damage, meningitis, neurosyphillis
      • Parkinson’s disease
      • Congenital anosmia

      Overview

      • Interpretation

      • Postural hypotension is present if there is a fall of >20mmHg systolic and >10mmHg diastolic blood pressure following standing.

      Spasticity

      Also known as clasp-knife rigidity.

      Overview

      • Causes

      • Delirium - stroke, infection, intoxication / withdrawal, metabolic, neoplastic, intra/post-ictal, sleep deprivation, severe pain, psychiatric
      • Dementia - Alzheimer’s, vascular dementia, lewy body dementia, frontotemporal dementia
      • Intellectual disability
      • Poor compliance
      The glabellar reflex is a primitive reflex - normally present in infants and absent in adults. In the case of frontal lobe damage, ‘frontal release' signs such as glabellar, grasp, suck, snout and palmomental reflexes will be present.
      • Causes of Cerebellar Lesions

      • Trauma
      • Vascular - ischaemia, haemorrhage
      • Infection - abscess, tuberculosis
      • Malignancy
      • Demyelination - multiple sclerosis
      • Drugs / toxins - alcohol, lithium, phenytoin, chemotherapy
      • Inherited - Friedrich's ataxia, spinocerebellar ataxia
      • Paraneoplastic syndrome
      • Hypothyroidism
      If the reflex is difficult to elicit, reassess the reflex while the patient clenches their teeth.

      Abnormal Posturing

      • Causes of Abnormal Posturing

      • Head injury
      • Intracranial bleed
      • Cerebral infarction
      • Intracranial hypertension
      • Encephalopathy - drugs, toxins, infection, hepatic
      • Tumour - primary or secondary

      Cutaneous Manifestations of Neurologic Disease

      • Signs of Meningitis

      • Purpura: non-blanching red / purple lesions
      • Maculopapular rash: blanching flat (macular) and raised (papular) lesions

      Overview

      • Peripheral Nerves of the Lower Limb

      • NerveSensoryMotor
        SciaticNilKnee flexion
        Lateral CutaneousLateral thighNil
        Common PeronealLateral calf
        Dorsum of the foot
        Dorsiflexion
        Eversion
        Toe extension
        Posterior TibialPlantar aspect of the footPlantar flexion
        FemoralAnterior thigh
        Medial calf
        Hip flexion
        Knee extension
      • Causes of Isolated Pain and Temperature Sensory Loss

      • Anterior spinal artery occlusion
      • Dorsolateral medulla / pons lesion
      Start by asking the patient to move against resistance (5 / 4). If the patient cannot move against resistance, ask them to move the joint against gravity (3). If they still cannot move the joint, eliminate gravity (2). In the absence of signficant movement of the joint look for flicker movement (1 / 0). Grade as appropriate, comparing both sides.
      • Interpretation

      • Sensory loss affecting an entire limb or entire side - likely due to central pathology
      • Sensory loss affecting a single dermatome  - likely due to spinal nerve root pathology
      • Sensory loss affecting a single peripheral nerve distribution - likely due to a focal peripheral nerve palsy
      • Sensory loss affecting multiple peripheral nerve distributions - potentially due to a brachial plexus lesion, or mononeuritis multiplex
      • Distal sensory loss (glove and stocking distribution) - suggests a peripheral polyneuropathy
      • Isolated dorsal column loss (impaired proprioception and vibration sensation with intact pain and temperature sensation) - suggests peripheral demyelination, e.g. Guillain-Barre, CIDP
      • Interpretation

      • Increased: resistance to passive movementUpper motor neuron lesion
      • Normal: minimal resistance
      • Decreased: no resistanceLower motor neuron or cerebellar lesion
      The term chorea derives from the Greek koreia, ‘dance'.
      • Interpretation

      • Swaying backward, forward or to either side - suggests a cerebellar vermis lesion
      • Swaying to either side - suggests ipsilateral cerebellar pathology, or ipsilateral vestibular pathology
      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.
      • Causes of Lower Motor Neuron Weakness

      • Spinal Nerve Root Pathology

      • Spinal trauma
      • Radiculopathy
      • Tumour
      • Brachial Plexopathy

      • Brachial plexus trauma
      • Brachial neuritis
      • Radiation injury
      • Tumour
      • Focal Peripheral Nerve Pathology

      • Trauma
      • Nerve entrapment (e.g. carpal tunnel syndrome)
      • Focal ischaemia
      • Peripheral nerve tumour
      • Sarcoidosis
      • Mononeuritis Multiplex

      • Vasculitis - polyarteritis nodosa, EGPA, GPA, cryoglobulinaemia, SLE, rheumatoid arthritis, Sjogren’s syndrome, scleroderma, Behcet’s disease
      • Diabetes
      • Infection - Lyme disease, leprosy, HIV, hepatitis B / C
      • Malignancy - lymphoma, small cell lung cancer
      • Amyloidosis
      • Sarcoidosis
      • Peripheral Polyneuropathy

      • Endocrine / nutritional - diabetic neuropathy, hypothyroidism, B12 deficiency
      • Demyelination - Guillain-Barré syndrome, Chronic inflammatory demyelinating polyneuropathy (CIDP)
      • Vasculitis - rheumatoid arthritis, polyarteritis nodosa, SLE
      • Infection - lyme disease, HIV neuropathy, leprosy, polio
      • Paraneoplastic syndrome
      • Multifocal motor neuropathy with conduction block
      • Motor neurone disease
      • Charcot-Marie-Tooth
      • Sarcoidosis
      • Drugs - ethambutol, certain chemotherapy agents, amiodarone, lithium
      • Toxins - alcohol, heavy metals, organophosphates

      Fasciculations

      • Look For

      • Spontaneous localised muscle contraction and relaxation.

      Overview

      • Causes of Mononeuritis Multiplex

      • Vasculitis - polyarteritis nodosa, EGPA, GPA, cryoglobulinaemia, SLE, rheumatoid arthritis, Sjogren’s syndrome, scleroderma, Behcet’s disease
      • Diabetes
      • Infection - Lyme disease, leprosy, HIV, hepatitis B / C
      • Malignancy - lymphoma, small cell lung cancer
      • Amyloidosis
      • Sarcoidosis
      • Clinical Phenotypes of Motor Neurone Disease

      • Amyotrophic lateral sclerosis (ALS) - mixed upper and lower motor neuron involvement
      • Primary lateral sclerosis - mainly upper motor neuron involvement
      • Progressive muscular atrophy - mainly lower motor neuron involvement
      • Progressive bulbar palsy - mainly bulbar involvement

      Trendelenburg Test

      • How to Perform

      • Support the patient by holding onto their hands, and then ask them to lift one leg off the ground.

      Overview

      Hold the medial and lateral sides of the interphalangeal joint of the great toe, in order to avoid giving away tactile clues.

      Resting Tremor

      • Causes of Resting Tremor

      • Parkinson’s disease
      • Drug-induced parkinsonism - antipsychotics, metoclopramide

      Overview

      • Ask About

      • Anaesthesia - loss of tactile sensation
      • Hypoaesthesia - decreased tactile sensation
      • Hyperaesthesia - increased tactile sensation
      This test is best performed on skin overlying bone rather than soft tissue.
      • Causes of Cerebellar Dysfunction

      • Ischaemia
      • Haemorrhage
      • Tumour
      • Trauma
      • Multiple sclerosis
      • Hypothyroidism
      • Paraneoplastic
      • Infection - abscess, tubrculosis
      • Drugs / toxins - alcohol, lithium, phenytoin, chemotherapy
      • Inherited - Friedrich’s ataxia, spinocerebellar ataxia
      Ventral cord syndrome - upper motor neuron weakness and loss of pain and temperature sensation (spinothalamic tract), with preservation of proprioception and vibration sensation (dorsal column)Anterior compression of the spinal cord, or anterior spinal artery pathology
      • Causes of Upper Motor Neuron Weakness

      • Ischaemia - ischaemic stroke, spinal cord infart
      • Haemorrhage - subarachnoid haemorrhage, intracerebral haemorrhage
      • Traumatic brain injury
      • Tumour - astrocytoma, meningioma, brain metastases, spinal cord neoplasia
      • Infection - encephalitis, PML, brain abscess
      • Demyelination - ADEM, multiple sclerosis
      • Hereditary spastic paraparesis
      • Idiopathic transverse myelitis
      • CNS vasculitis
      • Sarcoidosis
      • Syringomyelia
      • Prion disease

      Proximal Myopathy

      • Signs of Proximal Myopathy

      • General Signs

      • Proximal muscle wasting - biceps, deltoids, quadriceps, buttocks
      • Symmetrical proximal weakness - particularly the shoulder and hip muscles
      • Trendelenberg gait - dropping of the affected side during the stance phase
      • Trendelenberg test - dropping of the affected hip on standing on the opposite leg
      • Signs Suggesting a Cause

      • Dermatomyositis - heliotrope rash, Gottron’s papules
      • Paraneoplastic syndrome - surgical scars, e.g. in the chest

      Overview

      • Lumbosacral Nerve Roots

      • RootDermatomeMyotomeReflex
        L1Inguinal region  
        L2Anterior mid-thighHip flexion 
        L3Anterior kneeKnee extensionPatellar
        L4Medial lower legHip extension & abduction
        Ankle dorsiflexion
        Patellar
        L5Lateral lower leg
        Dorsum of the foot
        Dorsiflexion
        Toe extension
        Inversion & eversion
        Ankle
        S1Lateral foot
        Posterior lower leg
        Plantar flexionAnkle
        S2Posterior thighKnee flexion
        Toe flexion

      The Motor Pathway

      Upper Motor Nucleus
      Primary motor cortex (precentral gyrus)
       
      Central Pathway
      Corticobulbar tract
      (via cerebral peduncle)
      Decussation
      Medullary Pyramids
      Spinal Pathway
      Lateral corticospinal tract
       
      Lower Motor Nucleus
      Ventral horn at the level of entry into the spinal cord
       
      Neuromuscular Junction
       
       
      Muscle

      Overview

      • Causes of Distal Weakness

      • Unilateral

      • Radiculopathy (C8/T1)
      • Brachial plexopathy
      • Peripheral nerve lesion
      • Bilateral

      • Guillain-Barre syndrome
      • Chronic inflammatory demyelinating polyneuropathy
      • Multifocal motor neuropathy with conduction block
      • Motor neurone disease
      • Inclusion body myositis
      • Myotonic dystrophy
      • Congenital distal myopathies
      • Causes of Peripheral Polyneuropathy

      • Primarily Sensory

      • Diabetes mellitus
      • Vitamin deficiency - B12, pyridoxine
      • Hypothyroidism
      • Sarcoidosis
      • Paraneoplastic syndrome
      • Vasculitis - rheumatoid arthritis, polyarteritis nodosa, SLE
      • Protein-related - monoclonal gammopathy, amyloidosis, cryoglobulinaemia
      • Infection - lyme disease, HIV neuropathy, leprosy
      • Drugs - ethambutol, platinum-based chemotherapy, taxanes, vinca alkaloids
      • Primarily Motor

      • Guillain-Barre syndrome
      • Chronic inflammatory demyelinating polyneuropathy (CIDP)
      • Motor neurone disease
      • Multifocal motor neuropathy with conduction block
      • Polio
      • Sensorimotor

      • Alcohol
      • Charcot-Marie-Tooth
      • Drugs - amiodarone, lithium, nitrofurantoin
      • Toxins - heavy metals, organophosphates

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • 70°

      Muscles Acting on the Elbow Joint

      Pronators (anteromedial) - pronator teres, pronator quadratus, brachioradialis

      Overview

      • Normal Range of Motion

      Bony Landmarks of the Elbow

      Lateral epicondyle - lateral projection of the humerus.

      Overview

      • Causes of Elbow Swelling

      • Trauma - olecranon fracture, radial head dislocation, biceps / triceps rupture, compartment syndrome
      • Olecranon bursitis
      • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
      • Infection - cellulitis, abscess
      • Vascular - acute ischaemia, DVT, superficial thrombophlebitis
      • Fluid overload - cardiac / renal / hepatic failure

      Muscle Spasm

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Overview

      • Normal Range of Motion

      • 85°
      • Normal Range of Motion

      • 145°
      • Normal Range of Motion

      • Active - 20°
      • Passive - 22°
      Tibialis anterior - medially, passing anterior to the medial malleolus.

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Bony Landmarks of the Ankle

      Talus - a tarsal bone that articulates directly with the medial and lateral malleoli.

      Overview

      • Normal Range of Motion

      • Active - 45°
      • Passive - 50°

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • Active - 30°
      • Passive - 34°
      Chopart's joint (midtarsal joint) - articulation of the calcaneus with the cuboid and the talus with the navicular, allowing for flexion, extension, inversion and eversion of the foot.
      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.
      • Causes of Absent Pulses

      • Trauma
      • Atherosclerosis
      • Abdominal aortic aneurysm
      • Shock

      Muscles Acting on the Ankle Joint

      Inverters (anterior) - tibialis anterior, tibialis posterior

      Overview

      • Normal Range of Motion

      • Active - 15°
      • Passive - 20°
      Semimembranosus tendon - medial most tendon, inserting posteriorly onto the medial tibial condyle

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Muscles Acting on the Knee Joint

      Internal rotators - popliteus, semimembranosus, semitendinosus

      Overview

      • Causes of Poor Posture

      • Structural - deformities of the spine, foot and ankle
      • Leg Length discrepancy
      • Poor foot posture
      • Muscular imbalance - habitual poor body position

      True Leg Length Discrepancy

      • Causes of True Leg Length Discrepancy

      • Growth arrest - past fracture, bone infection, tumour or osteonecrosis
      • Bony dysplasia
      • Blount’s disease (tibia vara)

      Overview

      Joint line tenderness is approximately 85% sensitive and 30% specific for menisceal tears.

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Overview

      • Normal Range of Motion

      • Active - 5°
      • Passive -
      • Normal Active Range of Motion

      • Neutral position - 10°
      • In flexion - 25°

      Bony Landmarks of the Knee

      Femoral condyles - palpate the medial and lateral femoral condyles.

      Overview

      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.
      • Normal Range of Motion

      • Active - 130°
      • Passive - 140°

      Major Bursae of the Knee

      Suprapatellar bursa - between quadriceps tendon and femur. Presents as a palpable mass above the knee joint.

      Overview

      • Normal Active Range of Motion

      • Neutral position - 20°
      • In flexion - 45°
      Ask about their mood, and whether they have been happy or sad over recent months.

      Rate of Speech

      Slow speechPsychomotor retardation

      Overview

      • Causes of Amnesia

      • Intracranial - stroke, trauma, tumour, infection, epilepsy, degenerative disease
      • Substances - intoxication, withdrawal, Korsakoff’s
      • Psychiatric - schizophrenia, psychogenic amnesia
      • Insufficiency - liver, heart, kidneys
      • Hypoxia / anoxia
      • Malingering
      Clock - ask the patient to draw a clock face with numbers and the hands at the current time.
      • Causes of Amnesia

      • Intracranial - stroke, trauma, tumour, infection, epilepsy, degenerative disease
      • Substances - intoxication, withdrawal, Korsakoff’s
      • Psychiatric - schizophrenia, psychogenic amnesia
      • Insufficiency - liver, heart, kidneys
      • Hypoxia / anoxia
      • Malingering

      Resting Tremor

      • Causes of Resting Tremor

      • Parkinson’s disease
      • Drug-induced parkinsonism - antipsychotics, metoclopramide

      Normal Variations of Thought Form

      Abstract thinking: thought that is almost exclusively informed by cognitive abstractions, rather than immediate sensory experiences.

      Overview

      Phobias: unrealistic fears of objects, locations or situations that the patient subsequently attempts to avoid

      Apraxia

      • Causes of Apraxia

      • Frontotemporal dementia
      • Alzheimer’s disease

      Overview

      • Causes of Hallucinations

      • Psychiatric - schizophrenia, schizoaffective disorder, psychotic depression, delirium, Lewy body dementia
      • Neurological - space-occupying lesion, temporal lobe epilepsy, migraine
      • Metabolic - hepatic encephalopathy
      • Drugs - amphetamines, delirium tremens
      • Significance

      • Assessing judgement is important for deciding whether a patient is able to give consent.
      • Significance

      • Classically a sign of contralateral stroke, though may occur with any sort of contralateral brain lesion.
      • Causes of Confusion

      • Delirium - stroke, infection, intoxication / withdrawal, metabolic, neoplastic, intra/post-ictal, sleep deprivation, severe pain, psychiatric
      • Dementia - Alzheimer’s, vascular dementia, lewy body dementia, frontotemporal dementia
      • Intellectual disability
      • Poor compliance
      • Causes of Impairment

      • Delirium
      • Dementia
      • Aphasia
      Body dysmorphic disorder - a belief that one or more body parts are aesthetically displeasing and must be altered.

      Comprehension

      Simple verbal comprehension - name objects such as pen, watch and key, and ask the patient to point to them.

      Overview

      • Note

      • The term ‘dyslexia' is colloquially used to denote ‘developmental dyslexia', which is a global difficulty in reading beginning in childhood that may progress to adulthood. The dyslexias identified above are specific defects that are generally acquired rather than developmental.
      Hypochondriacal / somatic delusions - false convictions of fatal disease, infestations or degeneration of organsPsychosis, psychotic depression

      The Glasgow Coma Scale (GCS)

      • How to Assess

      • If the patient is not spontaneously opening their eyes, begin by attempting to elicit a response verbally. If this is unsuccessful then apply a painful stimulus such as a trapezius squeeze or a sternal rub.

      Overview

      • Normal Range of Motion

      • 45°

      Vertebral Landmarks

      C2 - palpate down from the occiput in the midline. The spinous process of C2 is the first palpable process.

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region or is generalised.

      Overview

      • Normal Range of Motion

      • 45°
      • Normal Range of Motion

      • 90°
      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.
      • Normal Range of Motion

      • 30°

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • 30°
      • Normal Range of Motion

      • 45°

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • 30°
      • Normal Range of Motion

      • 80°

      Muscles Acting on the Cervical Spine

      Lateral flexors - sternocleidomastoid, scalenes, levator scapulae

      Oropharyngeal Examination

      • Look For

      • Erythema
      • Swelling of tonsils
      • Exudate
      • Ulcers - viral infection, neoplasm
      • Petechiae on soft palate - pathognomonic for bacterial infection

      Overview

      Auscultate the chest anteriorly and posteriorly, as well as in the axillae and supraclavicular fossae.

      Conjunctival Pallor

      • How to Elicit

      • Pull the lower eyelid downward and inspect the inner eyelid. Conjunctival pallor is present if there is loss of the normal redness of the anterior rim of the conjunctiva.

      Heart Rate

      • Causes of Bradycardia (<60bpm)

      • Physiological - high cardiac fitness
      • Beta blockers
      • Hypothyroidism
      • Raised intracranial pressure
      • Heart block
      • Sick sinus syndrome

      Overview

      • Significance

      • The diaphragm has both somatic and autonomic innervation, and thus the respiratory rate can be altered both voluntarily and and involuntarily in response to physiologic or pathologic stimuli.
      • Look For

      • Nasal mucosa - swelling / erythema, ulcers, polyps, irregular masses, foreign bodies
      • Nasal septum - deviation, perforation
      • Nasal discharge - mucus or blood
      Clubbing was first described by Hippocrates in 400BC after noting the sign in a patient with empyema.
      Percuss the intercostal spaces from the bases to the apices, alternating from left to right and comparing the two sides.

      Complications

      • Complications of Lung Cancer

      • Pleural effusion
      • Metastases - brain, liver, adrenal, bone
      • Local compression - SVC obstruction, sympathetic chain compression (Pancoast tumour) , laryngeal nerve palsy, phrenic nerve palsy, brachial plexopathy
      • Paraneoplastic syndromes - hypercalcaemia, SIADH, Cushing’s, hypertrophic pulmonary osteoarthropathy, neurologic syndromes

      Overview

      • Complications of Bronchiectasis

      • Acute exacerbations
      • Pulmonary haemorrhage
      • Pneumothorax
      • Empyema
      • Lung abscess
      • Cor pulmonale

      Complications

      • Complications of Interstitial Lung Disease

      • Acute exacerbation of ILD
      • Cor pulmonale
      • Pulmonary hypertension
      • Lung cancer

      Reduced Oxygen Saturation

      The level of haemoglobin saturated by oxygen may be reduced in the context of reduced oxygen, right shift of the oxygen saturation curve, displacement of oxygen by carbon dioxide, or in the setting of haemoglobinopathies.

      Pathogenesis

      • Risk Factors for COPD

      • Smoking
      • Occupational exposure - coal, toluene (plastics)
      • Environmental air pollution
      • Alpha-1 antitrypsin deficiency

      Overview

      • Normal Range of Motion

      • 10°
      • Normal Range of Motion

      • 20°

      Muscles Acting on the Wrist Joint

      Abductors - flexor ca