"... Do not look for friends here, you won't find them. None of these people have the capacity to understand you, they never will. If you're lucky one day when you are old and shrivelled... until then read a good book. You have greatness in you Yang, don't disappoint"

General Examinations

So now that I'm done with medical school, I thought I'd post something useful for other medical students.

It's not a full list of the general examination but this is what I used for my exams and modified it depending on the case scenario.

Remember, there's always the relevant general examination and vitals. I start with vitals first, it helps me remember the general and calm down.

In a 15 minutes examination: Leave 7 minutes for questions and so try and finish Vitals, General Examination and Systemic Exam in 8 minutes. Sounds hard but the one thing I've learnt and I guarantee will come handy is PRACTICE. It is so important. Observing someone once is fine but any number of time more than that is utterly USELESS. Do it yourself.

Relevant General Examination for Each System:

CVS relevant general examination:

·         Appearance

·         Patient’s surrounding (IV cannula, oxygen mask, etc.)

·         Pallor

·         Clubbing

·         Splinter haemorrhage in the nail bed

·         Cyanosis (central and peripheral)

·         Edema

·         Xanthelasma

·         HR (rate, rhythm, volume, character) with peripheral pulses, radio-radial delay, radio-femoral delay, carotid pulse. *collapsing pulse only done if pulse volume is high.

·         RR (Inspiratory rise in JVP)

·         Temperature

·         BP (in both arms to check for co-arctation of the aorta, and other heart diseases)

·         JVP

·         Flapping tremor

·         Poor oral hygiene for IE

After completion of the CVS examination:

·         Auscultate base of lung to hear basal crepitations (only if there are signs or symptoms of pulmonary congestion/edema and heart failure)

·         Palpate and check for tender hepatomegaly (only if there are signs of RHF)

·         Tell the examiner that you would like to check the patient’s chest X-ray

Respiratory system relevant general examination:

·         Appearance

·         Patient’s surrounding (IV cannula, oxygen mask, MDIs etc.)

·         Pallor

·         Icterus (seen in CF)

·         Clubbing

·         Cyanosis

·         Lymph nodes (supraclavicular, cervical nodes are the most important for Lung Ca)

·         Edema (cor pulmonale leads to RHF which will lead to edema)

·         Tar stains on the fingers

·         Any nicotine stains in the teeth

·         HR (rate, regularity and volume)

·         RR

·         Temperature

·         BP

·         JVP

·         Flapping tremor

·         Check arms for wasting, tingling, numbness or pain in the shoulder and inner aspect of the arm (Pancoast’s syndrome is tumor of the apex of the lung compressing on the brachial plexus)

·          

      Check for symptoms of Horner’s syndrome (ipsilateral partial ptosis, small pupil, hypohydrosis of the face)

At the end of the examination:

·         Tell the examiner that you would like to check the patient’s chest X-ray

·         Tell the examiner that you would like to check the patient’s spirometry

Abdominal system relevant general examination:

*Expose patient from nipple to mid-thigh* or at least mention it..

·         Appearance

·         Patient’s surrounding (IV cannula, oxygen mask, etc.)

·         Pallor

·         Icterus (if this is present you suspect liver disease. So when there is icterus, check for palmer erythema, Dupytrene’s contracture, sparse axillary hair, gynecomastia, spider nevi, caput madusae, bruising, xanthelasma, and parotid swelling)

·         Clubbing

·         LN

·         Edema

·         HR

·         RR

·         Temperature

·         JVP (only if there are signs of heart failure such as edema and tender hepatomegaly)

·         BP

·         Flapping tremor

After completion of abdominal examination:

·         Tell examiner that you must check for the external genitalia (atrophy) and perform a PR.

CNS relevant general examination:

·         Appearance and higher mental functions and posture and dysmorphic features (e.g. ptosis, deviation of mouth, etc.)

·         Skin check for (xanthelasma, rashes and limb ischemia from DVT)

·         Eyes for arcus senilis, diabetic and hypertensive changes

·         Vitals in order of importance: pulse, peripheral pulses for rate, rhythm and volume ESPECIALLY the carotid pulse, BP, temperature, RR

Extra steps

·         In motor system of upper limb, the extra reflexes are finger jerk and Hoffmann’s sign. ALWAYS tell the examiner that you would like to check the sensation after completing the motor system examination.

·         In cerebellar system, extra steps are pronator drift, rebound phenomenon and pendulum movement.

After completing the examination:

·         Check for neck stiffness

·         Check for Kernig’s sign and Brudzinski’s sign

I hope this helps.

Anything you want to add do so and let me know too.

Best of luck.

Medical Speciality Aptitude Test - UVa

University of Virginia's Medical Speciality Aptitude Test which was originally published in the book "How to Choose a Medical Specialty" by Anita Taylor.

My first 12.

I'm happy oncology is in there although dermatology is not my thing... :\

http://www.med-ed.virginia.edu/specialties/Home.cfm

The Cushings

Have you ever been confused with the different Cushing's?
There are four types of Cushing's:
Cushing's Disease, Cushing's Syndrome, Cushing's triad and Cushing's reflex. (If you have more, do tell....)

• Cushing's reflex/triad is not related to the syndrome and diseas and in order to know the disease, you need to know the syndrome.

• Cushing's syndrome is a due to chronic high blood levels of cortisol or corticosteroids and it produces a constellation of symptoms and signs.

• Cushing's disease is Cushing's syndrome that results from excessive pituiraty production of ACTH mostly due to a pituitary adenoma. Pituitary produces ACTH, remember.

• Cushing's triad belongs to the raised intracranial hypertension. It's a triad so there are 3 signs: systemic hypertension, bradycardia and irregular respiration (cheyne's stokes)

Now, the Cushing's reflex is what is confusing me. I believe due to the raised ICP there is decreased blood perfusion and so it gives rise to the classic triad of Cushing's... but I need to make sure.

Any questions or any corrections please do inform.

Erythromycin and Pertussis

Erythromycin is not given to children less than 1 month of age due to the chances of them getting Hypertrophic Infantile Pyloric Stenosis.

Floppy Baby Syndrome

Floppy baby syndrome, in simple terms, is hypotonia during infancy. It is muscle weakness or reduced muscle tone in a baby.Now as med students we know causes of hypotonia in adults but what could cause hypotonia/Floppy Baby Syndrome in infants?
SO MANY!!!


Causes:

1. Hypoxic Ischemic Encephalopathy, 
2. Administration of Fentanyl to the mother with baby still attached to cord.
3. Inborn metabolism disorder,
4. Prader-Willi syndrome,
5. Kernicterus,
6. Agenesis of the corpus callosum,
7. Transection of the spinal cord due to breech delivery,
8. Werdnig-Hoffman's disease (Infantile muscle dystrophy),
9. Metachromatic leukodystrophy,
10. Botulism,
11. Infantile Myasthenia Gravis,
12. Muscular Dystrophy,
13. Metabolic Myopathies,

{Alot of fancy names. Details about it, we'll all learn it in time.}


It can also happen during Forceps delivery, when the nurses use a forceps in an inexperienced way causing hemorrhage.

Just a note: Dengue Fever

• Dengue fever caused due to the ?virus spread by the Aedes mosquito, is a disease of the tropics. 
• The patient presents with high fever (saddle back fever) and a prominent maculopapular rash or just macular rash.
• Muscle and joint pain, Back pain, abdominal tenderness and jaundice are some of the added symptoms.
• Retro-orbital tenderness is prominent in patients too.
• One of the most important tests to do on the patient is his platelet count to make sure the patient does not enter Dengue Hemorrhagic Fever or Dengue Shock Syndrome. Probability of DIC is very high.
• A patient who has already had dengue before must be carefully monitored because the antigen-antibody complex might precipitate increasing the chances of DIC.
• One important point is the incubation period, it is usually 5 to 7 days. So, determining where the patient was 5 to 7 days before his symptoms began is most important because the area must be quarantined or reported to the infection control department of the hospital/state.
• 

==||==