Beruflich Dokumente
Kultur Dokumente
These notes are just a guide for a quick review of the most important clinical
examinations and history taking in surgery block. For more details, you can go
back to your reference book.
Before OSCE:
o Sleep well: Sleeping well is more beneficial than studying all night long.
o Bring all your equipment: Stethoscope, ophthalmoscope"
o The key to OSCE success is practice.
o Behave in a polite, professional way.
Before starting any examination:
o Wash your hands.
o Introduce yourself.
o Explain to the patient, take permission and maintain privacy.
o Before examining the patient, you should comment on:
Consciousness and alertness.
Is the patient in distress, pain or comfortable.
Connection to: O2, ECG monitor or IV line access.
o After you finish, thank the patient and cover him\her.
References:
o Nicholas J Talley Clinical Examination, 6th Edition.
o Browses's Introduction to the Symptoms & Sign of Surgical Disease,
4thEdition.
o Lecture Notes Ophthalmology, 11th Edition.
o The Hand Examination and Diagnosis, 3rd Edition.
o Toronto Notes (Orthopedic, Ophthalmology, Otolaryngology-Head &
Neck Surgery), 2010.
o Notes during Clinical Skills Sessions at KSAU-HS.
Contents:
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Page |1
General Surgery
Orthopedics
Anesthesia
Ophthalmology
ENT
Plastic Surgery
Page |2
General Surgery
Abdominal Examination
Position and Exposure:
Lying flat with both hands on the side & expose from nipples to mid-thigh.
Inspection: Best done from the patients feet side of the bed.
o Hernias: Let the patient stand, and then ask the pt. to cough and sit.
o Contour and Distention (5 F: Feces, fetus, flatus, Fat, Fluid).
o Symmetry: Movement with respiration (pattern of breathing).
o Scars: Appendectomy, peritoneal dialysis, nephrectomy, ascites.
o Prominent veins "portal HTN", caput medusa around the umbilicus.
o Umbilicus "inverted or everted".
o Striae, bruising, rashes, visible peristalsis, pigmentation.
Palpation: Ask if there is any pain and observe the patient's face.
o Tenderness:
Superficial: Guarding, rigidity, rebound.
Deep: deep masses, Murphy's sign.
o Organomegaly:
a) Liver: Palpate the liver edge & percuss for span "8-12 cm" from above.
b) Spleen: You can't go above it, has a notch, and enlarges inferomedially.
Palpate "pt. flat" & "pt. lying over his right side".
Percuss over left costal margin-anterior Axillary line with
full expiration.
c) Kidneys: bimanual examination "balloting".
d) Bladder: percussion.
Percussion: The whole abdomen.
o Ascites (Shifting dullness & fluid thrill "huge ascites").
Auscultation:
o Bowel sounds: Exaggerated: Proximal to the obstruction.
Absent: paralytic ileus or distal to the obstruction".
o Bruit: Renal "Renal artery stenosis. Liver "Hepatocellular carcinoma".
Others:
o Special test for appendicitis: Obturator, Psoas, Rovsing signs.
o Lymph nodes: including supraclavicular (Virchow's node).
o Rectal and genitalia examination + Back & leg examination (edema).
Page |3
History of a Lump
Examination of a Lump
Wear gloves and proper exposure (If in the limb, expose both for comparison).
Inspection:
o Site, size, shape, color, surface, and edge (well or ill defined), symmetry.
o Discharge (color, quantity, quality-mucous, purulent, blood- , and smell).
o Skin changes, scar, and area around the mass.
Palpation:
o Temperature, tenderness.
o Consistency (stony hard, firm, rubbery, soft), Surface (smooth or
irregular)
o Mobility, fixation to skin, attached to underlying tissue, going above it.
o Pulsatility, reducibility, fluctuation, translumination (fluid-filled lesion).
Percussion: Resonant or dull, fluid thrill.
Auscultation: Bruit if A-V malformation.
Surrounding tissues:
o Regional lymph nodes.
o Local tissues: skin, muscles, vessels, and nerve supply.
Page |4
Abdominal Hernia
Common physical signs to all hernias but are not always present:
o Congenital or acquired weak spots in the abdominal wall.
o Most hernias can be reduced.
o Most hernias have an expansile cough impulse.
The last two signs may be absent, especially if the hernia is tightly constricted at its neck.
Page |5
Rectal Examination
Position and Exposure:
o Lying flat on left side while flexing the hip & knee.
Inspection:
o Thrombosed external hemorrhoid.
o Skin tags, rectal prolapse, anal fissure.
o Ask the patient to bear down then inspect.
Palpation:
o Wear gloves & lubricate your finger.
o Place finger at anus until the patient relaxes then gently insert your finger
and note sphincter tone at the anal verge.
o Ask the pt. to bear down; this will bring high rectal masses down.
o Palpate all walls of the rectum for masses, tenderness, or polyps.
o Palpate the prostate then check your finger for signs of bleeding.
Rectal Bleeding
Bleeding:
o Onset, frequency, progression, color (bright red or mixed), amount.
o On stool, mix or on towel paper & stool shape.
o Aggravating and relieving factors.
o Associated Symptoms: pain, change in bowel habits, defecation problem
(tenesmus or straining), abdominal mass, weight loss, and fatigue.
o Previous bleeding & bleeding from other sites.
o Anemia: Tiredness, shortness of breath, palpitation.
Past History & medication: ulcers, abdominal surgery.
Family History: Cancer, IBD and anemia.
Social History: Travel, dietary habits, effects on life, smoking, and alcohol.
Page |6
Endoscope
Explain procedure
o Indications: Dysphagia, diagnosis of ulcer, UGI bleeding etc.
o Pre-endoscopy "PT-aPTT", NPO 24 hours abdominal examination.
o Inside the unit IV cannula, sedation, throat spray.
Complication bleeding, perforation.
Post endoscope:
o Rest at home & no driving for 12 hours "come to hospital if complication"
Colonoscopy: Bowel prep
o Chemical bowel prep for 3 days.
o Golyt "4 L, 4 cups-4 doses-" one day before.
History of an Ulcer/Wound
Examination of an Ulcer/Wound
Wear sterile gloves, proper exposure, and take vital signs.
Inspection:
o Site, size, shape, depth.
o Base: Color and type of tissue (scab, Eschar, granulation tissue).
o Edge:
Sloping venous, healing ulcer.
Punched out ischemia.
Undermined TB.
Rolled Basal Cell Carcinoma.
Everted Squamous Cell Carcinoma.
Thyroid Examination
Position and Exposure:
o Sitting & expose the neck and the chest. Mention about dressing.
Hand:
o
o
o
o
o
Acropachy "thyrotoxicosis".
Palms: "Sweaty or dry".
Palmer Erythema.
Pulse (rate, rhythm "atrial fibrillation", collapsing pulse thyrotoxicosis-).
Tremor (ask the pt. to extend his hand with the fingers separated).
o
o
o
o
o
Eye:
Neck:
Inspection:
o Swelling, bulging, Scars, color, dilated veins "thoracic inlet block".
o Swallow water "thyroid swelling".
o Put out the tongue. If it moves with protruding it thyroglossal cyst.
Palpation: Thyroid is usually not palpable.
o Little bit flexed , From Behind R and L lobes (Push with one hand and
examine with the other).
o If nodule, describe: site, size, shape, mobility, consistency, tenderness,
and surface,overlying skin. "Same for lymph node/lump description".
o Lymph nodes (Cervical and supraclavicular).
o Tracheal deviation.
Auscultation: Ask the pt. to hold the breath to listen for bruit "thyrotoxicosis".
Lower Limb
Pretibial myxedema (Non pitting, Itching, Anterior Chin) "Grave's disease".
Reflexes:
o Hyperthyroidism: Brisk movement (hyperreflexia).
o Hypothyroidism: slow relaxation phase.
Proximal muscle weakness: Ask the patient to stand up without using his
hands & test the power of arm abduction.
Page |9
Breast examination
Before examining the patient, maintain privacy and ask for a nurse.
Inspection:
Hand in natural position:
o Symmetry: Size, shape, and contour.
o Skin changes: Dimpling, erythema, ulceration, pea du orange.
o Lump and visible veins.
o Nipple: nipple retraction and spontaneous discharge.
Hands over head:
o Any changes in the breast.
o Assess the axilla.
Hands against the hip: to contract pectoralis muscles.
Example how to comment: Both breasts look symmetrical and the apparent
size looks the same. There is erythema on lower outer quadrant at the right
breast, there is peudo orange on the upper inner quadrant of the left breast
between 2 and 4 oclock, there is dimpling on the outer upper quadrant of the
right breast at 10 oclock.
Palpation:
The patient lay down in 45 degree with the hands behind her head.
Palpate the normal size first.
Using one hand (the other one to support) with the palm of your fingers,
palpate the whole 4 quadrants including the axillary tail.
Palpate the nipple-areola complex by squeezing it looking for discharge.
If you find a lump, describe it: SSSSS: Site - Size Shape - Skin attachment (or
muscle attachment) Surface - (consistency and mobility)
Consistency: Soft firm hard. Mobility: Mobile fixed.
Hard as a skull, firm like a nose, soft like the cheek.
Lymph nodes: Setting position, wear gloves.
Supraclavicular.
Axillary: Hold patient's left hand with your right hand and examine using your
left hand (anterior, posterior, medial, lateral, and axial)
Cervical.
P a g e | 10
Other:
Examination of the limbs: Swelling, neurovascular abnormality.
General examination chest, abdomen, spine for metastasis.
Breast history
ID: name, age, marital status, pregnancy.
Present complaint: lump, bleeding, discharge, skin changes, pain (if advanced or
inflammatory).
o Breast lump: onset, site, how did you notice it, trauma, progression,
painful, skin changes, relation to menstruation (fibrocystic change),
previous history.
o Breast pain: Complete history of pain, relation to menstruation.
o Nipple discharge: Uni/bilateral, color (bloody, milk), volume.
o Nipple retraction: Uni/bilateral, symmetry.
Hormonal History: Menarche, menopause, number of pregnancies, breastfeeding, hormonal use (HRT or OCP).
Others: weight loss, anorexia, fatigue.
Metastasis:
o Bone pain.
o Cord compression: Back pain, sensory, motor, urinary/bowel symptoms.
o Liver: Jaundice, itching, RUQ pain.
o Lung: Cough, pain, shortness of breath.
o Brain: Seizure, mental changes, headache.
Past history, medication and allergy: previous radiation exposure, personal
history of cancer "ovarian or colon", regular screening mammography, breast selfexam, previous investigation.
Family history: 1st degree, age of diagnosis, uni\bilateral.
Social History: Smoking, alcohol, obesity.
Systemic review.
Differential Diagnosis:
Fibroadenoma.
Fibrocystic change including breast cyst.
Mastitis.
Breast cancer.
P a g e | 11
D
Glasgow Coma Scale (GCS).
Pupil: Size and reaction.
Moving all limbs & feeling all limbs.
E
Expose patient: front, lateral and back (log rolling).
Cover with blanket to prevent hypothermia.
P a g e | 12
F: Foley's catheter.
G: Gastric tube (NGT)
Secondary survey:
History (AMPLE): Allergy, medication (tetanus), past history, last meal, event.
Head to toe examination including the back.
Radiological assessment: CXR, pelvic X-ray and cervical X-ray lateral and PA +
Full body CT scan.
Orthopedics
Spine Examination
Look: The patient is standing and from the back and side.
Deformity: Normal lordosis and kyphosis, abnormal sceliosis.
Muscle wasting and swelling.
Skin changes: Scars, redness, caf au lait spot, hair patches.
Feel:
Cervical: Spine and trabezius.
Lower: Spines, sacroiliac J., paraspinal muscles.
Move:
Cervical: Flexion, extension, 2 lateral bending, 2 rotations.
Lower: The same while holding the patient's pelvis.
Special test:
Straight leg raising (L5): Flex the hip and extend the knee then raise the leg.
Femoral stretch test (L3-L4): Extend the hip and flex the knee
Cervical:
o Dermatomes: C4: Supraclavicular. C5: Lateral Forearm. C6: Thumb. C7:
Middle finger. C8: Little finger. T1: Medial forearm. T4: Nipple. T10:
Umbilicus.
o Myotomes: C4: Shoulder elevation. C5, 6: Elbow flexion. C6, 7: Wrist
flexion. C7, 8: Elbow & wrist extension. C8, T1: Finger abduction.
o Reflexes: C5: Biceps. C6: Brachioradialis. C7: Triceps.
Lower:
o Dermatomes: L2: Anterior thigh. L3: Knee. L4: Medial Leg. L5: Lateral Leg.
S1: Sole. S2: Posterior thigh.
o Myotomes: L2, 3: Hip flexion. L3, 4: Knee extension. L4, 5: Ankle
dorsiflexion. L5: Big toe dorsiflexion. S1, 2: Planter flexion.
o Reflexes: L4: Patellar. S1: Achilles.
P a g e | 13
Shoulder Examination
Look:
Muscle wasting (anterior: Pectoralis major, lateral: Deltoid and posterior:
Trabezius), symmetry, skin changes (redness, caf au lait spot, hair patches),
deformity, and swelling.
Feel:
o Temperature.
o Bones: Manubriosternal J., manubrioclavicular J., clavicle, coracoid,
acromion, spine of scapula, inferior angle.
o Soft tissues: Anterior: Pectoralis major, lateral: Deltoid, posterior:
Trabezius.
Move:
Extension, flexion, abduction, adduction, lateral & medial rotation,
circumduction, then passive movement and feel for any crepitus.
Special tests:
Serratus anterior: push on the wall then see the back (winged scapula).
Shoulder stability (if you suspect dislocation):
o Apprehension test: abduction and external rotation.
o Relocation test: Apprehension is relieved by post. pressure.
o Sulcus sign: Subacromial indentation with distal traction.
o Posterior apprehension test: adduction, internal rotation.
Rotator cuff tests (if you suspect rotator cuff pathology):
o Apley scratch test: Quick screening test.
o Jobe's test (Empty can test): Supraspinatus
o Lift-off test: Subscabularis.
o Posterior cuff test: Infraspinatus & teres minor.
o Cuff impingement: Neer's test and Hawkins-Kennedy test.
P a g e | 14
Elbow Examination
Look:
Feel:
Triangle1: medial epicondyle, lateral epicondyle, olecranon(triangular in
flexion, linear in extension).
Triangle2: lateral epicondyle, olecranon and radial head.
Soft tissues: biceps tendon, triceps tendon.
Move:
Extension, flexion, pronation, supination.
Special tests:
Page
Hip Examination
Look: (Patient Standing &Supine)
Deformity (flexion deformity) & Leg length discrepancy.
Ant. Sup. Iliac spine symmetry.
Scars, skin changes, swelling.
Feel:
Greater trochanter and Ant. sup. Iliac spine.
Move:
Flexion, extension.
Lateral and medial rotation (in knee extension and flexion).
Abduction & adduction (The pelvis by on hand and the leg by the other one).
Special test:
Thomas test: For flexion deformity (flex the other leg and put your hand under
his back and check the lordosis then check the leg raising and push on it).
Trendelunburg: Put your hands behind on the pelvis then ask the pt. to raise
his leg then see if your hand dropped on the other pelvis, if it is +, check the
superior gluteal nerve.
Faber test: For sacroiliac j. (Flexion, abduction and external rotation then push
on the leg to see if he has any pain). Not IMP.
Rectus femoris: Like stretch femoral test but if the pain on the back(nerve) or
on the thigh( rectus femoris).
Neurological:
o Femoral nerve (M: Knee extension, S: Ant. Of the thigh, medial of the
thigh and leg-saphanous n.).
o Obterator n. (M: Thigh adduction).
o Sciatic n. (M: knee flexion).
o Tibial n. (M: Planter flexion, S: Planter of the foot).
o Deep peroneal n. (M: Dorsiflexion, S: First web space).
o Superficial peroneal n. (M: Eversion, S: Dorsum of the foot)
Gait: For antalgic and trendelenburg gaits.
P a g e | 16
Knee examination
Look: setting position.
Swelling, scars, skin changes, deformity (valgus and varus).
Inspect the back of the knee.
Feel:
Temperature: Anterior and posterior.
Tenderness and effusion:
o Bones: Patella, tibial tuberosity, fibula, joint line.
o Muscles: Quadriceps, hamstring.
o Ligaments: patellar ligament.
o Popliteal fossa.
Move:
Active: Flexion: 130-140 and Extension: should be 0.
Passive: For tenderness and crepitation.
Gait
P a g e | 17
Ankle examination
Look: Setting position.
Scars, swelling, skin changes, deformity, wounds, and dryness.
Foot arch while standing.
Special test:
Anterior drawer test: Lying down then check the stability of the ankle by
holding the leg and moving the foot.
Talar tilt: Foot is stressed in inversion.
Reflex:
Calcaneal tendon S1
Neurological:
Deep peroneal, superficial peroneal and tibial nerve.
Gait:
On the toes and on the ankle then complete the regular gate.
P a g e | 18
Look:
Deformity (proximal and distal), swelling, bleeding, and exposed bone.
Describe the wound:
o Size, site, shape, edge.
o Floor: depth, visible structure, foreign body.
Neurovascular Examination:
Upper limb:
o Vascular: Radial pulse, ulnar pulse, allen's test, and capillary refill.
o Neurological: Radial, median and ulnar nerves (sensory and motor).
Lower limb:
o Vascular: Dorsalis pedic pulse and posterior tibial pulse.
o Neurological: Superficial peroneal, deep peroneal and tibial nerves.
Management:
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P a g e | 20
Anesthesia
Pre-Operative Assessment
History:
Name, age, weight, height.
Pre OP Diagnosis (proposed surgery).
o CVS: HTN, MI, other cardiac.
o Pulmonary: Asthma, COPD, recurrent URTI, sleep apnea.
o GI: GERD, last meal.
o Liver.
o Renal: Renal failure, dialysis.
o Endocrine: DM, thyroid.
o CNS: Seizure, stroke.
o Rheumatology: rheumatoid arthritis and other autoimmune diseases.
o Hematology: Coagulation problems.
o Ob/Gyn.
Previous surgeries, anesthesia, and complication.
Allergies & medications.
Smoking, alcohol, drug abuse.
Family History: malignant hyperthermia.
Examination:
Vital signs.
CVS & Respiratory.
Airway assessment:
o (I) Tempormandibular joint (TMJ) click.
o (II) Mouth opening: 2 fingers wide laryngoscope width-.
o (III) Thyromental distance: 3 fingers.
o (IV) Range of movement of the neck: should 30 degree.
o Mallampati score.
o Teeth and deformity.
Site for IV.
Investigations
o Labs: CBC, PT, PTT, Electrolytes, LFT, blood sugar, Beta HCG.
o CXR, ECG, Echocardiogram.
ASA and Plan of anesthesia.
Explain about eating, medications, and consent form.
P a g e | 21
Intubation:
P a g e | 22
Ophthalmology
Eye Examination
Inspection (both eyes):
o Swelling, conjectival injection, redness, and discharge.
o Squint, ptosis, proptosis, ectropion, and entropion.
Palpation:
o Tenderness.
o Swap for the discharge.
Visual acuity:
o Snellen chart at 6m with the patient's glasses.
o Each eye individually while covering the other.
o Pin hole to correct refractive error.
Visual field: Confrontation test.
o 1 meter distance and test each eye while you cover your eye.
o Ask the patient to look at your nose and move your finger
Eye movements:
o All 6 cardinal gazes, accommodation, and saccadic eye movements.
o Ask for diplopia and look for nystagmus.
Pupillary reaction:
o Inspect pupil size, shape, asymmetry (anisocoria).
o Light reflex (direct and indirect).
o Accommodation reflex.
o Swinging flash light test for relative afferent pupil defect (RAPD).
Fundoscpy (Direct ophthalmoscopy): the eye should be dilated (Tropicamide).
o Ask the patient to look at a distant object.
o Red reflex (cataract): 30 cm and Corneal reflex (squint).
o Optic disc: Indistinct margin (papilledema), pale (atrophy), cupping
(glaucoma).
o Macula and vessels: hemorrhage, exudates, cotton wall spots, A/V
nipping, detachment, neovascularization.
Color vision (Ishihara plate for both eyes).
The next two examinations are advanced and not for medical students.
Intraocular pressure by tonometer (contact Goldmann): 9-22 mmHg.
Slit lamp:
o Eye lid, conjunctiva, and eye lash.
o Cornea: Cloudiness, transparency, abrasion, ulcer.
o Anterior chamber: hypopion, cell, depth, iridocorneal angle.
o Iris and pupil: shape, vessels (pterygium), adhesion (synechia).
o Lens: cataract.
o Anterior vitreous.
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Loss of Vision
History:
Acute/chronic, painful/ painless.
Onset, duration, progression, frequency (constant, intermittent, diurnal
variation), uni/bilateral, distant/near, central/peripheral.
Associated symptoms: Pain (ocular or with movement), headache, diplopia,
redness, discharge, photophobia, flashes, glaring, floater.
Past history: Trauma, ocular diseases, systemic diseases (DM, HTN,
rheumatology, hematology).
Medications: steroid (cataract, glaucoma), ethambutol (optic neuritis),
chloroquine (maculopathy and pigmentation), OCP (vascular occlusion), and
anticholinergic.
Family history: Glaucoma, cataract, decreased vision.
Social history: Alcohol, smoking, sexuality.
Acute painful:
Acute angle closure glaucoma "corneal edema and clouding":
o Symptoms: blurred vision, pain, red eye, photophobia, and watering.
o History of recurrent attacks precipitated in the dark (pupillary dilation).
o Signs: decreased visual acuity, corneal clouding, high IOP, reduced
accommodation, fixed/dilated pupil, and red eye.
o Treatment:
Acetazolamide IV then oral (decrease secretion).
Topical pilocarpine (constrict pupil).
Beta-Blocker (decrease secretion).
Surgery (iridotomy/iridectomy).
Keratitis:
o Symptoms: Severe pain, red eye (peri-limbus), discharge, trauma history.
o Treatment:
Viral (HSV): Oral acyclovir, topical steroid unless dendritic
ulcer present.
Bacterial: Topical antibiotics.
Corneal ulcer/abrasion:
o Symptoms: Red eye, pain, watery, photophobia.
o Diagnosis: Fluorescein with blue light.
o Treatment: Antibiotics ointments +_ eye cover pad.
P a g e | 24
Uveitis:
o Symptoms: Red eye, pain, photophobia, autoimmune diseases.
o Diagnosis: decreased visual acuity, ciliary injection, kertitic preciptitate,
hypopyon, dilated vessels, synechiae, IOP might be increased, retinitis.
o Treatment: Anterior: topical steroid. Posterior: systemic or injections.
Endophthalmitis: following intraocular surgery or trauma.
Orbital cellulitis.
Acute transient:
Migraine and amaurosis fugax (shutter across vision).
Acute painless:
Vitreous hemorrhage.
Central vein/artery occlusion (whole visual field). Branch (peripheral field).
Retinal detachment: Floater, flashing, curtain like visual loss.
Ischemic optic neuropathy: Giant cell arteritis (jaw claudication, shoulder pain)
Acute bilateral:
Visual pathway lesion.
Uveitis.
Chronic painless:
Refractive error.
Cataract: decreased vision with glaring.
Chronic glaucoma.
DM macular edema.
Age related macular degeneration.
Chronic painful:
Chronic uveitis.
Corneal disease.
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Orbital
Orbital
Orbital cellulitis
Mucocele
Swelling
Red eye
Discharge
Decreased
vision
Decrease eye
movement
Fever
Systemic
Dx: blood cultures
+ Orbital CT
Rx:
IV broad Abx
Drain abscess
Visual test
for relative
afferent
papillary
defect
Trauma
Abrasion
Tumor
Head
Vomiting
Wt loss
Fever
Night
sweats
cavernous
Pulsation
Infection
-Subconjuctival
hemorrhage.
- Corneal
ulcer/abrasion.
- Chemical
irritation.
- Conjuctivitis:
Bacterial: topical
erythromycin.
Viral: symptomatic
decongestant
fungi:
- Blepharitis
Inflamatory
Medication
- Allergy
- Eye drop
for
glaucoma
- Dry eye
- Scleritis &
epi scleritis
- Uveitis: slit
lamp
- Keratitis:
Rx: Steroids
Bacterial
topical if
Viral: HSV
anterior.
"Dendritic" Rx Oral systemic or
acyclovir + topical retrobulbar if
steroid if not
posterior
dendritic.
Glaucoma
Dx :
1- slit lamp
2- increased IOP
3- Increased cup
to disc ratio
Rx:
- IV acetazolamide
- Topical pilocarpine
- B-blocker
- Definitive: surgery
- Endophthalmitis:
after surgery.
- Orbital cellulitis
P a g e | 27
ENT
History of Hearing Loss
Ear Examination
Inspection:
o Pinnae (Auricle): helix, antihelix, tragus, antitragus & behind the ear.
o Look for atresia, microtia, scars, redness, swelling, and discharge.
Palpation:
o Palpate for tenderness.
Hearing:
o Tuning fork test (512 Hz): Rinne's test & Weber test.
o Audiometry: if air-bone gap CHL. if both under 20 SNHL.
o Tympanometry: if flat perforationhigh ear canal volume- or effusion.
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Nose Examination
Inspection:
o Deformity, scars, skin changes.
Mouth Examination:
o
o
o
o
P a g e | 29
Plastic Surgery
Hand Examination
Look:
o Skin: Scars, redness, swelling & moisture.
o Abnormal posture.
o Muscle wasting & fingertip.
Feel: Ask about area of pain.
o Temperature, tenderness & swelling.
Nerve:
o Sensation: 2PD "dynamic < 3mm, static < 6mm"
o Motor: R: index extension, M: OK sign, U: Froment's sign.
o Carpal Tunnel syndrome: Phalen's & Tinel's signs.