Short case

Tongy

5 2011

Short describe
1.Cushing syndrome 2.Acromegaly 3.Graves disease 4.Postsurgical hypocalcemia 5.Short stature 6.DM
5 2011

Cardio
MS with AF with
PHT

MR AS AR PS
5 2011

VSD ASD PDA Coarctation of Aorta

Takaysu


General appearance & BP First& Pulse

Tachycardia,Bounding pulse,wide PP,Systolic hypertension

5 2011

Hyperthyroidism
Diffuse aloplacia, ne hair

Eye
Eye Exopthalmos From lateral view Lid Lag Retraction Proptosis Chemosis Corneal ulcer EOM

5 2011

Thyroid gland
Surgical scar Bruit * Size estimation Consistency&tender Nodule Lymph node
5 2011

Thyroid Examination
Thyroid Gland Thyroid Cartilage

Thyroid Gland
5 2011

Hyperthyroidism
1.Tachycardia,AF 2. MPV 3. Gynecomstria
Leg Pretibial myxedema
(Plaqe )
Neuro Motor: Proximuscle weakness Reex: Hyperreexia
5 2011

Hyperthyroidism
Skin Vitiligo Moist&Warm Palmar erythema Acopachy ( clubbing) Suggest autoimmune Onycholysis Plummer nail() Tremor
5 2011

Hyperthyroidism
Skin Vitiligo Moist&Warm Palmar erythema Acopachy ( clubbing) Suggest autoimmune Onycholysis Plummer nail() Tremor
5 2011

Hyperthyroidism
Skin Vitiligo Moist&Warm Palmar erythema Acopachy ( clubbing) Suggest autoimmune Onycholysis Plummer nail() Tremor
5 2011

Special Test

Pemberton test

5 2011

Hypothyroids
PR BP General appearance
1. 2. 3. 4. 5. 6. Apathy Puffy face Coase hair Loss of Latateral 1/3 of eye brown Macroglossia Husky voice

Thyroids Skin: Coarse,Yellow hand Ext:edema Motor Slow relaxation,Myoedema

5 2011

CUSHINGS

General appearance & BP First

5 2011

1.Moon face 2.Pletora 3.Cataract 4.Acne 5.Hirsutism 6.Tenagiectasia 7.Oral tush,Hyperpigmentation

1.AN 2.Buffalo hump 3.Supraclavicular fat pad

1.VF 2.Moods
5 2011

Proximal Myopathy

Truncal obesity Board violaceous cutaneous Striae Bimanual palapation

Thin skin Easy bruising (s) Palmar crease

Kyphosis,compression
5 2011

Turner

General appearance & BP +Pulse(4)+First,??

5 2011

 5 2011

HEENT "8"

5 2011

HEENT "8"

1.Low set ear 2.Low posterior hair line 3.Fish like mouth 4.High arch palate 5.Micronathia 6.Hearing with OM 7.Posterior web neck 8.Thyroids??

5 2011

 5 2011

Chest =2

5 2011

Chest =2 CVS

5 2011

Chest =2 CVS Abdomen

5 2011

Chest =2 CVS Abdomen EXT=6

5 2011

Chest =2 CVS Abdomen EXT=6

1.BP 4 extremities 2.Cubitus valgus,Genu 3.Short of 4,5 metacarpal bone 4.Madelung deformities 5.Nail dysplasia 6.Lymphedema

5 2011

No Secondary Sex characteristic*** 1.No Breast Development 2.No Axillary hair 3.No Pubic hair 4.Infertility(Amennorhea) Work up 1.FSH/LH (increase) 2.Estradiol(Decrease) 3.Chromosome study(45/XO)
5 2011

Acromegaly
General appearance & BP First,??

5 2011

 5 2011

1. Cutis veracities gyrata 2. Frontal brossing 3. Prominent supraorbital ridge 4. Coarse face 5. Big nose 6. Thick lip 7. Malocclusion 8. Teeth separation () 9. Macroglossia 10. Deep and hollow sound***** 11. Prognatism***** 12. VF(The last): Bitemporal hemianopia

5 2011

1. Cutis veracities gyrata 2. Frontal brossing 3. Prominent supraorbital ridge 4. Coarse face 5. Big nose 6. Thick lip 7. Malocclusion 8. Teeth separation () 9. Macroglossia 10. Deep and hollow sound***** 11. Prognatism***** 12. VF(The last): Bitemporal hemianopia

1.Thyroid enlargement 2.Skin tag 3.AN

5 2011

 5 2011

Cardiomegaly Galactorrhea

5 2011

Cardiomegaly Galactorrhea
Proximal myopathy

5 2011

Cardiomegaly Galactorrhea
Proximal myopathy

Hepatomegaly Splenomegaly

5 2011

Cardiomegaly Galactorrhea
Proximal myopathy

Hepatomegaly Splenomegaly

1.Spade like nger 2.(Heel pad thickening) 3.CTS 4.Ring tigthening 5.Oily skin 6.Hyperhydrosis
5 2011

Acromegaly
GH producing pituitary tumor Bronchial carcinoid Small cell lung cancer

5 2011

Marfan

5 2011

1. Frontal brossing 2. Long narrow face Palate High arched palate Crowding of teeth Chest 1. Pectus excavatun 2. Pneumothorax 3. ICD scar

Tall

1. 2. 3. 4.

Blue sclera Ectopia lentis Myopia Iridodonesis

Heart 1. MVP 2. AR 3. Coarc Hernia Hand 1. Hypermobile of joint 2. Arachnodactyly 3. Thumb sign 4. Wrist sign Foot Flat feet(pes Panus)

Spine 1. Scoliosis 2. Kyphosis 3. Dural ectasia Skin Small papule in neck, Striae distensae Soulder Lumbar region
5 2011

Hypocalcemia

5 2011

1. Brittle hair with Aloplacia 2. Cataract 3. Papilledema 4. Chvostek sign 5. Teeth hypoplasia 6. Thyroids scar 7. Bronchospasm 8. Extremity :Dry puffy,Coarse skin,dermatitis 9. Neuro: Parkinsonism 10.HOA 11.Mucocutaneous candidiasis

Troussaau sign
BP SBP+20 2-5 min Result:

Add of thumb+ Flex MCP,wist, Extension of IP (spreading of nger)

5 2011

DM
Peripheral pulse: Dorsalis pedis,Post Tibail a. Sensation Proprioception () Skin(Dry skin)

5 2011

Neurology
Facial weakness Entrapment Neuropathy:CTS Tremor: Parkinsons disease,ET Ptosis:CN III palsy Visual eld defect: Occipital lobe lesion Generalized weakness
5 2011

Facial Palsy
CN VII( Upper&Lower)
Motor: ,,,

5 2011

CN V(Motor&Sensory) CN VIII(Hearing) Cerebellar function (Lesion,Retroauricular pain),Mastoids,Parotid

Sensory: Anterior 2/3 Reflex:Corneal reflex EOM

DDx
1. Ramsay-Hunt syndrome 2. CP angle Tumor (7,8>5+ Cerebellar ) 3. Parotid gland tumor 4. Otitis media 5. Facial trauma

5 2011

Bilateral Ddx
MG GBS Basal arachnoiditis Muscular dystrophy MD,FSHMD,OPMD Bilat Bell
5 2011

Carpal Tunnel syndrome

Key Muscle

LOAF
Lumbricoides: First,Second Opponen pollicis Abductor pollicis brevis Flexure pollicis brevis

5 2011

Step
: Thenar atrophy,Sx scar Pinprick sensation Key muscle: Intrinsic&Extrinsic hand Tinels and Phalen test

5 2011

 5 2011

 5 2011

 5 2011

Etiology
DM/Ischemia RA Hypothyroids Acromegaly

5 2011

PTOSIS

5 2011

 5 2011

Ptosis
,Complete or incomplete Pupil EOM

5 2011

MG
1.Ptosis +Pupils 2.Enhance ptosis 3.EOM 4.CN:Facial diplegia, Gag 5.Tounge: Trifurrow tounge 6.Nasal voice 7.Jaw jerk 8., 9.Thyoird 10.Neck muscle 11.Motor 12.DTR 13.Fatigability : weak

5 2011

 5 2011

Radial nerve

5 2011

Wasting Hand
Cord: Syringomyelia,Central cord tumor Motor neoron: ALS Root: C pondylosis,Brachial plexus Nerve: Neuropathy=> Poly or Mono Muscle: Dysuse

5 2011

Syringomyelia
Cervical: Upper thoracic Clinical
Segmental sensory loss Pain,Temp cross cord => Dissociative sensory loss(Preserve propioception) motor neuron => LMN hand atrophy,Decrease reex Cord dilate=> Pressure UMN+BBK+Hyperreexia,Bowel bladder Sacral sparing Horner syndrome(C8-T1) Charcot joint at Shoulder/Elbow sensory

5 2011

Motor neuron Dz
PLS: UMN lateral colum ,Spatic paralysis,Muscle ALS: UMN( Spastic c Hyper reexia+ LMN(Muscle atrophy)

Spinobulba muscular atrophy Kenerdy syndrome Bulba atrophy+Limb atrophy

5 2011

C Spondylosis
Cord,Root Common C6-C8 : Limit movement Lhermitte sign +ve (Flex neck Electrical sense Limb)

5 2011

Wrist drop
Saturday night palsy Sensory: Loss at dorsum of Thumb & Index nger Motor:
Brachioradialis Extensor carpi radialis brevis/Longus Supinator Extensor Digitorum communis Extensor Digiti Minimi Extensor pollicis Longus/Brevis Abductor pollicis longus

Spare:Tricep brachii

5 2011

Ulnar

5 2011

5 2011

General appearance Unilateral Deformities Atrophy fasciculation: , Scar,Fracture

Motor Reex Sensory Nerve,Spine

5 2011

Motor
Tone Power Formet sign Key muscle Flexor carpi ulnaris Flexor digitiminmi Flexor di pro 3,4 Opponen di

5 2011

Foot Drop
Weakness of tibialis anterior ( common peroneal nerve, L4-5 root, corticospinal tract) Common perneal nerve-->peroneal muscles (foot eversion) L4-5 root --> tibialis posterior (foot inversion)

5 2011

 5 2011

Foot drop
Obsevation
5 2011

Unilateral/Bilateral Foot deformities/Scar Scars or bruises: esp. at the head of the bular Muscle atrophy/Fasciculation General appearance:thin Have a pateint walk/GaitGait :High stepping gait (comon peroneal n.)

Motor examination Sensory examination

Pattern Recognition
Weakness of dorsiexion and eversion--> common peroneal nerve weakness of EHL, normal reex, typical sensory loss scar at bular head Weakness of dorsiexion, normal eversion,sensory loss at rst web space--> deep peroneal nerve Weakness of dorsiexion and inversion--> L4-5 root or plexus lesion weakness of hip abduction and sensory loss at L4-5 dermatome, reex

5 2011

Foot drop
Common Peroneal nerve Sensory:As Figure Motor
1.Extensor hallucis lungus/Brevis 2.Extensor digitorum longus/Brevis 3.TA 4.Peroneous longus/Brevis

5 2011

 5 2011

Tremor
Resting PD Essential Hyperthyroids Cerebellar

5 2011


Tremor
Rigidity
Bradykinesia

,Masked face,Decrease eye blinking,Resting tremor, Pill roling,drooling, hand posture

PD

Action Reemerging tremor

Cogwheel rigidity,Tone( Spastic,Hyper or Hypotone

Finger tapping,Rapid alternated movement

1.Stooped posture 2.Difcult to initiating 3.Short step 4.Freezing gate 5.Festinating gait 6.Loss of arm swing 7.En block turning 8.Tandem 9.Rhomberg 10.Pull test

5 2011

: Monotone

PD

:Micrographia

EOM Cerebellar signs Motor,DTR,Sensation

5 2011

Gait Ataxia
CN
Nystagmus(KF ring,Retinitis pigmentosa) Scanning speech

Trucal ataxia
Wide base gait Rhomberg sign(sensory ataxia=posterior column ) Tandem gait

Cerebellar
Finger to nose test,intention tremor Diadokokinesia Limb ataxia and over shoot Check and rebound Rebound phenomenon of Gordon and Holmes Heel to shin test
5 2011

Gait Ataxia
Motor Proproception DTR Frontal lobe sign 1.Palmomental reex 2.Glabella 3.Grasp

5 2011

Blurr vision
VA: 14 Snellen chart, VF EOM Pupilary light reex:
Direct Light Reex Consentual Light Reex Swinging light Accomodation

Fundoscope
5 2011

AIR
SSc RA SpA Chronic trophaceous Gout Dermatomyositis

5 2011

SSc
1.Loss of wrinkle and facial expression 2.Loss of 1/3 of eye brown 3.Salt and Peper appearance 4.Bird beak nose 5.Fish mouth 6.Telangiectasia
1.RV heaving, 2.P2, 3.Rub, 4.Arrhythmia

Chest &Abdomen Skin thickening and Telnagiectasis =>Crep,Bowel sound

1.Motor power 2.Joint 3.Flexion contracture

1.Calcinosis cutis 2.Tendon friction rub 3.Digital pitting scar 4.Loss of digital fat pad 5.Acrolysis 6.Capillary nail fold 7.Raynaud 8.Sclerodactyly c exor deformities 9.CTS

5 2011

RA
1.Episcleritis,Scleritis/Scleromalacia (Perforan) 2.Dry eye 3.lacrimal gland enlargement 4.Parotid gland enlargement 5.C spine tenderness: Flex/Extend
1.Dry tounge 2.Dental carries 3.Hoarseness (Cricroarythnoiditis)

Lung:ILD,Pleural effusion Heart:Rub,AR Abdomen:Splenomegaly

Fusiform swelling, Tenderness,Warm erythema at MCP,PIP,Wrist,elbow,Shoulder,Knee,Ankle Hand" Boutonniere/Swan's neck/ulnar deviation/Paino key signs/Z defomities Feet: Cock up toe/Hammer toe Rupture extensor tendon CTS Subcutaneous nodule(Scalp,,,,) Baker cyst SKIN: LCV,Ulcer
5 2011

DM

5 2011

V/S: Low grade fever GA:Head & SCalp,Hand and nail,Trunk(Upper chest &Trunk) SKin=> CVS RS: ILD,PHT, Joint: Arthalgia or arthritis Neuro sign: Proximal muscle weakness,Neck muscle weakness Nail fold:Periungual telangiectasia Raynaud phenomenon Mechanic hand

Skin
Scalp: Heliotrope V sign,Shawl sign Pokiloderma vasculare atrophican Calcinosis cutis and soft tisuue calcication Mechanic hand Gotton sign&Pauple

5 2011

AS
+expose+ C-->L Spine mobility SI joint Heart+ Peripheral pulse Peripheral joint

5 2011

+ expose+
Stoop posture Neck exion deformity Loss of L lordosis Increase T kyphosis

5 2011

Spine mobility
C spine:
5 2011

Flexion Extension Lateral Rotation Occiput to wall Tragus to wall(<10cm)

T spine L spine Finger to oor Lateral bending Modield Schobers test Chest expansion

SI joint
SI palpation Direct compression Provocative test Pelvic compression test Open book Closed book Patrick'S test(sign of 4) Gaenslen test' s test(sign of 4)
5 2011

Miscellaneous
Advice Insulin

5 2011

Short case (Thalasemia with secondary hemochromatosis )

GA Short stature Bronze skin Edema HEENT Frontal brossing Pale and jaundice Flattening of nasal bone Maxiilary marrow hyperplasia Chostek sign Protussion of upper teeth Heart RV heaving Loud P2+Pericardial rub

Abdomen Sx scar Hepatolenomegaly Chronic liver signs Hypogonad Ext Chronic ulcer Arthropathy Fracture Neuro sign

5 2011

Dyslipid
Cholesterol
Steinberger ST-2FPA

, If ,, FIber No smoking Excercise

5 2011

Cirrhosis
GA Jaundice BMI HEENT Pale and jaundice KF ring Fetor hepaticus Heart JVP RV heaving Loud P2+Pericardial rub TR murmur Chest: Gynecomastria Abdomen Distention Supercail vein dilatation Bruit Liver &Spleen HJR uid trill Shifting dullness Ext Clubbing of nger Leukonychiae Dupuytren contracture Pitting Edema of Leg Neuro sign

Testicular atrophy Axillary hair loss Pubic hair loss Skin Spider nevi Palmar erythema Bruit Scartch mark Tattoo Xanthelasma AN( NASH)

5 2011