Year 1 Semester 2 Revision: Clinical Skills, Physiology & Microbiology Part 2

Shoulder Exam Look

Inspect contour, posture, skin, swelling, muscle bulk, deformity, and signs of pain.

Shoulder Exam Feel

Palpate tenderness, warmth, swelling, bony landmarks, joints, bicipital tendons, bursa, and muscles.

Shoulder Exam Move

Start in anatomical position; assess glenohumeral joint movements and use the Apley scratch test.

Internal Rotation Test

Get the patient to touch their thumb as high on their back as possible.

Supraspinatus Function

Responsible for the first 20 degrees of shoulder abduction.

Deltoid Function

Responsible for the remainder of shoulder abduction past 20 degrees.

Isaac's Case Finding

Loss of deltoid function causes trouble initiating abduction, as supraspinatus handles the first 20 degrees.

Hawkin's & Neer's Tests

Special tests for shoulder impingement assessing rotator cuff tendons or subacromial bursa.

Apprehension Test

Assesses instability of the shoulder joint.

Empty Can / Jobe's Test

Positive test indicates supraspinatus tendinitis or tear.

Lift-Off Test

Resisted internal rotation testing subscapularis.

External Rotation (Shoulder)

Tests infraspinatus and teres minor.

Elbow Inspection LOOK

Inspect contour, posture, valgus angle (5-10 degrees), skin, swelling, and muscle bulk.

Elbow Inspection FEEL

Assess temperature, tenderness at epicondyles, swelling, and anatomical bony landmarks.

Golfer's Elbow Test

Medial epicondylitis test: supination, closed fist, flexed wrist, try to resist.

Tennis Elbow Test

Lateral epicondylitis test: pronation, closed fist, extend wrist, try to resist.

Wrist Inspection FEEL

Bimanual palpation for tenderness, crepitus, swelling, and anatomical landmarks like anatomical snuff box.

Hand OA Nodes

Bouchard's nodes at PIP joints and Heberden's nodes at DIP joints.

Hand RA Deformities

Swan neck, boutonniere, and Z deformity.

Phalen's Test

Flex both wrists for 30 seconds; pins and needles indicate carpal tunnel syndrome.

Tinel's Sign

Tap volar surface of the wrist; pins and needles indicate median nerve compression.

Finkelstein Test

Test for De Quervain's tenosynovitis; radial styloid tip pain if positive.

PNS Muscle Symptoms

Includes facial pain, neck/back pain, headache, paraesthesia, and anaesthesia.

PNS 'Brain' Symptoms

Includes seizures, fainting, dizziness, vertigo, altered cognition, and visual/hearing/smelling disturbances.

PNS Generalised Tone

Assessed by freedom of passive movement: hypertonia, hypotonia, rigidity, or spasticity.

Finger-Nose / Heel-Shin Test

Cerebellar tests assessing for intention tremor, dysmetria, and dyssynergia.

Radial Nerve Pathology

Characterised clinically by wrist drop.

Median Nerve Innervation

Innervates LOAF muscles (Lumbricals, Opponens pollicis, APB, FPB).

Ulnar Nerve Pathology

Characterised by hand wasting and clawing of the 4th and 5th digits.

Trendelenburg Test

Assesses hip abductor muscle strength; non-weight bearing hip rises when standing.

True Leg Length

Measured from ASIS to medial malleolus; differences indicate hip disease on the shorter side.

Apparent Leg Length

Measured from umbilicus to medial malleolus; differences due to pelvic tilting or deformity.

Thomas Test

Assesses fixed flexion deformity of the hip by keeping the pelvis flat on the bed.

Knee Effusion Tests

Patellar tap for large effusion; bulge sign for smaller effusion.

Collateral Ligament Tests

Valgus stress tests MCL; varus stress tests LCL at 20-30 degrees flexion.

Cruciate Ligament Tests

Anterior drawer tests ACL, posterior drawer tests PCL; Lachman test is more accurate for ACL.

McMurray's Test

Assesses menisci by flexing the knee and rotating the heel before extending.

Achilles Tendon Integrity Test

Lie prone, flex knee 90 degrees, and squeeze midcalf; normal foot plantarflexes.

Schober's Test

Measures distance between PSIS and midline; should increase by 5cm+ on flexion (reduced in ankylosing spondylitis).

Straight Leg Raising Test

Lasegue's test; straight leg hip flexion to 90 degrees, positive at 30-70 degrees for L4-S2 roots.

Femoral Stretch Test

Prone position, flex one knee; pain in anterior/medial thigh indicates L2-L4 nerve root involvement.

Infective Endocarditis Hand Signs

Includes Osler's nodes, Janeway lesions, and finger clubbing.

First Heart Sound (S1)

Caused by bicuspid and tricuspid valves closing at the beginning of systole.

Second Heart Sound (S2)

Caused by aortic and pulmonary valves closing at the end of systole/beginning of diastole.

Third Heart Sound (S3)

Ventricular gallop heard in early diastole; normal in youth/athletes, pathological in heart failure.

Fourth Heart Sound (S4)

Atrial gallop heard in late diastole; almost always pathological (e.g., diastolic heart failure).

JVP A Wave

Caused by right atrial contraction pushing blood into the internal jugular vein.

JVP V Wave

Caused by filling of the right atrium while the tricuspid valve is closed.

ECG Small Box Measure

Each small box represents 0.04 seconds and 1 mm.

PR Interval Duration

Normal PR interval is 3 to 5 small squares (0.12 to 0.20 seconds).

QRS Complex Duration

Normal QRS complex duration is 0.12 to 0.16 seconds.

Left Ventricular Hypertrophy ECG

Largest S wave in V1/V2 plus largest R wave in V5/V6 > 35 mm indicates LVH.

Right Ventricular Hypertrophy ECG

Largest R wave in V1 plus largest S wave in V5/V6 > 10 mm indicates RVH.

Coronary Artery Lead Reflection

Leads I, aVL, V5, V6 reflect left coronary artery; II, III, aVF reflect right coronary artery.

First-Degree AV Block

Prolonged PR interval (>0.20 seconds) with no missed QRS beats.

Second-Degree Type I AV Block

Progressively lengthening PR interval until a QRS beat is dropped (Wenckebach).

Second-Degree Type II AV Block

Constant PR interval with fixed ratio of P waves to dropped QRS beats.

Third-Degree AV Block

Complete heart block where P waves and R waves are regular but completely independent.

STEMI ECG Feature

ST-segment elevation in target leads with reciprocal depression in anatomically opposite leads.

Systemic vs Pulmonary Circulation

Systemic is high pressure (~95 mmHg); pulmonary is low pressure (~15 mmHg).

Poiseuille's Law & Resistance

Vessel resistance is inversely proportional to the radius to the fourth power (R proportional to 1/r⁴).

Frank-Starling Law

Increased end-diastolic volume stretches cardiomyocytes, increasing actin-myosin overlap and contraction force.

Cardiac Pacemaker Rates

SA node: 60-100 bpm; AV node: 40-60 bpm; Purkinje fibres: 20-40 bpm.

Sympathetic Heart Innervation

Releases noradrenaline acting on B1 adrenergic receptors to increase heart rate and contractility.

Parasympathetic Heart Innervation

Vagus nerve (CN X) releases acetylcholine acting on M2 muscarinic receptors to decrease heart rate.

Funny Channels (If)

Responsible for spontaneous pacemaker depolarization; blocked to slow heart rate.

Aortic Pulse Pressure Formula

Pulse Pressure equals Systolic Blood Pressure minus Diastolic Blood Pressure.

Mean Arterial Pressure Formula

MAP equals Diastolic Blood Pressure plus one-third of Pulse Pressure.

Nephrotic Syndrome Edema Mechanism

Loss of plasma proteins decreases colloid oncotic pressure, increasing fluid filtration and causing edema.

Nitric Oxide Vasodilation Pathway

Acetylcholine increases intracellular Ca2+, activating eNOS to produce NO, which activates guanylate cyclase to produce cGMP and relax smooth muscle.

RAAS Pathway

Renin converts angiotensinogen to angiotensin I; ACE converts Ang I to Ang II for vasoconstriction and aldosterone release.

Baroreceptor Reflex

Short-term BP control via stretch receptors in aortic arch (CN X) and carotid sinus (CN IX).

Atherosclerosis Initiation

Oxidized LDL and superoxide combine to form peroxynitrite, reducing nitric oxide and increasing adhesion molecules.

ACE Inhibitors Suffix & MOA

End in -pril; block conversion of Angiotensin I to Angiotensin II.

ACE Inhibitor Side Effect

Dry cough caused by increased bradykinin accumulation in the lungs.

ARBs Suffix & MOA

End in -sartan; block AT1 angiotensin II receptors.

Beta Blockers Suffix & MOA

End in -olol; selectively inhibit B1 receptors in the heart and kidneys to decrease heart rate and contractility.

Loop Diuretics MOA & Example

Furosemide; inhibits Na+/K+/2Cl- symporter in the Loop of Henle, causing hypokalaemia.

Thiazide Diuretics MOA

Hydrochlorothiazide; inhibits Na+/Cl- cotransporter in the distal convoluted tubule.

Spironolactone MOA

Potassium-sparing diuretic acting as an aldosterone receptor antagonist.

Digoxin MOA

Inhibits Na+/K+ ATPase indirectly increasing intracellular calcium to act as a positive inotrope.

Class I Anti-arrhythmics

Sodium channel blockers affecting phase 0 depolarization.

Class II Anti-arrhythmics

Beta blockers providing rate control by decreasing SA and AV node automaticity.

Class III Anti-arrhythmics

Potassium channel blockers (e.g., amiodarone) prolonging action potential duration and refractory period.

Class IV Anti-arrhythmics

Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) providing rate control.

Adenosine Clinical Use

Rapid conversion of paroxysmal supraventricular tachycardia (SVT) to sinus rhythm.

Statins MOA & Suffix

End in -statin; inhibit HMG-CoA reductase to block hepatic cholesterol synthesis.

Ezetimibe MOA

Blocks NPC1L1 transport protein in the intestinal brush border to inhibit dietary cholesterol absorption.

PCSK9 Inhibitors MOA

Monoclonal antibodies preventing PCSK9 from degrading LDL receptors, increasing LDL clearance.

Pathogen Definition

An organism capable of causing direct or indirect disease.

Virulence Factor Adhesins

Pili, fimbriae, and afimbrial adhesins that assist in bacterial colonization and tissue attachment.

Bacterial Biofilm

Polymer-encased bacterial colony adhered to surfaces, protecting against antibiotics and immune clearance.

Urease Virulence Factor

Cleaves urea to produce ammonia, neutralizing stomach acid (e.g., Helicobacter pylori).

Coagulase Function

Converts soluble fibrinogen into insoluble fibrin to wall off bacteria from immune responses (e.g., Staph aureus).

Endotoxin vs Exotoxin

Endotoxins are lipid A components of Gram-negative outer membranes; exotoxins are actively secreted protein toxins.

Botulinum Toxin Mechanism

Blocks acetylcholine release at the neuromuscular junction, causing flaccid paralysis.

Tetanus Toxin Mechanism

Blocks release of inhibitory neurotransmitters, causing spastic paralysis and muscle spasms.

Baltimore Virus Classification

Classifies viruses based on nucleic acid type, envelope presence, capsid symmetry, and mRNA replication pathway.

HIV Replication & Target

Retrovirus using reverse transcriptase and integrase; infects CD4+ T-helper cells, leading to AIDS when count is below 200.

Primary vs Secondary Cases

Primary is the first identified case; secondary cases result from subsequent transmission.