OSCE FINDINGS

clubbing causes cardiac

cyanotic congenital HD

infective endocarditis

atrial myxoma

clubbing causes resp

ILD

cancer

CF

empyema

bronchiectasis

clubbing causes GI

IBD

hepatic cirrhosis

GI lymphoma

coeliac

pitting oedema causes

raised venous pressure

• right sided HF

• chronic venous insufficiency

• volume overload/ renal failure

• pregnancy

• obesity a/w Na/ H2O retention

reduced oncotic pressure/ hypoalbunemia

• nephrotic syndrome

• cirrhosis/ liver failure

• protein losing enteropathy (i.e IBD)

drugs

• calcium channel blockers

• long term corticosteroids

• NSAIDS

non pitting oedema causes

• hypothyroid/ graves disease

• malignancy

• radiotherapy

• lymph node clearance

how to present a stoma

1. site

2. number of lumen

3. spout/ flush with skin or out

4. nature of effluent

5. state of surrounding skin

6. evidence of complication

7. likely type of stoma

8. possible procedure/ underlying pathology

end colostomy stoma

• left sided

• 1 lumen

• no spout

• effluent; hard stool

• surg; hartmann w/ rectum oversewn OR abdomino perineal resection

• if still pass stool; hartman, higher tumour

end ileostomy stoma

• right sided

• 1 lumen

• spout

• effluent; soft/ liquid stool

• surg: subtotal colectomy / panproctocolectomy (UC)

loop ileostomy stoma

• usually temporary

• right sided

• 2 lumens (joined)

• spout

• effluent; soft/ liquid stool

• surg: to defunction chrons/ obstruction (malignancy)/ newly formed anastomosis

loop colostomy stoma

• usually temporary

• upper abdomen

• 2 joined luemns

• no spout

• effluent is hard stool

• surg: to defunction chrons/ obstruction (malignancy)/ newly formed anastomosis

end colostomy and mucous fistula stoma

• usually left sided

• 2 separte lumen

• no spout

• effluent; hard stool

• surg; hartmann procedure with rectum brought to skin

urostomy stoma

• can be on either side

• 1 lumen

• spout

• effluent; urine

• surg; cystectomy (malignancy)

stoma complications

• haemorrhage

• necrosis

• prolapse

• retraction

• obstruction

• peristomal skin inflammation

• parastomal hernia

• high outpout

indirect inguinal hernia

• passes through inguinal canal ring → inguinal canal → external ring

• superior to pubic tubercle

• extension into scrotum is common

• can be very large

• usually reducible

• held by pressure on deep ring

• low risk of complication

• usually repaired as impossible to differentiate between direct hernia on clinical exam alone

direct inguinal hernia

• through weak point in posterioir wall of inguinal canal (hesselbach triangle → inferioir epigastric artery, inguinal ligament and lateral border of rectus muscle)

• superioir to pubic tubercle

• rarely extennd in scrotum

• moderate size

• almost always reducible

• not held by pressure on deep ring

• moderate risk of incarceration and complication

• surgical repair

femoral hernia

• through femoral canal and underneath inguinal ligament

• inferior tu pubic tubercle

• cannot extend in scrotum

• 3-5cm

• rarely reducible (absent cough impulse)

• not held by pressure on deep ring

• high risk of strangulation

• urgent surgical repair

types of hernia repair

• open mesh

• open suture

• laparoscopic

hernia risk factors

family history

older age

surgery

obesity

pregnancy

constipation

heavy lifting

causes cerebellar lesions

stroke

tumour

MS

alcohol abuse/ thiamine deficiency (wernicke encephalopathy)

anti epileptic meds

friederich’s ataxia

classic signs cerebellar lesions

DANISH

• dysdiadochokinesis

• ataxia

• nystagmus

• intention tremor

• slurred/ staccato speech

• hypotonia

signs central cerebellar lesions

• truncal ataxia standing and sitting

• poor heel-toe

• slurred staccato speech

signs cerebellar hemisphere lesion

• ipsilatral limb ataxia

• nystagmus

• unsteady gait

CNI palsy

olfactory

• poor smell/ changes in smell

causes

• trauma

• meningitis

• frontal lobe tumour

CNII palsy

optic

• snellen chart

• visual fields

• light torch test

• fundus w/ ophtalmoscopy

causes

• mono ocular; MS

• bitemporal; pituitary adenoma, internal carotid artery aneurysm

• homonymous hemaniopia; stroke/ tumour/ abscess

CN III/ IV/ VI palsy

oculomotor/ trochlear/ abducens

• eye movements

• accomodation

CN V palsy

trigeminal

• sensory; face

• motor; jaw opening against resistance/ masseter muscle palpation when clenching

causes

• idiopathic trigeminal neuralgia

• acoustic neuroma

• herpes zoster

CN VII palsy

facial

• facial expressions

causes

• bell’s palsy

• parotid tumour

• herpes zoster

• sarcoid

• stroke

CN VIII palsy

vestibulocochlear

• occlude other ear and ask patient to repeat other word behing them

• rinne

• weber

causes

• excessive noise levels

• gentamycin

• furosemide

CN IX/ x/ XII palsy

glossopharyngeal/ vagus/ hypoglossal

• open mouth and say ahhh → deviate away from weakness

• swallow water

• stick tongue out → deviate toward weakness

causes

• diptheria

• polio

• GBS

• myasthenia gravis

• MS

• strokes

CN XI palsy

accessory

• shrug shoulders vs resistance

• turn head against resistance

CN III palsy causes

oculomotor

• spared pupil; diabetic

• complete; PCA aneurysm/ raised ICP w/ tentorial herniation

CN IV palsy causes

rare

trochlear

orbit trauma

CN VI palsy causes

abducens

• petrous temporal bone fracture

• nasopharyngeal carcinoma

• raised ICP