OSCE-Surgery Block.pdf

Introduction  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: o o o o o o

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General Surgery Orthopedics Anesthesia Ophthalmology ENT Plastic Surgery

Quick Review for OSCE | AlBrahim-Al-Enezi

 Reviewed and edited by: o Abdulaziz Asiry  Coordinator: o Sulaiman AlHefzi  Special thanks to: o Mazin AlRasheed o Abdulaziz AlTurki o Hamad AlThiab o Mohammed AlMahmood o Faisal Abuabah o Ahmad Batarfi o Eiad Gutub o Faisal AlAnbar o Waleed AlHumaid o Hussain AlMulla o Abdulmalik AlAjroush o Mohammed Mater  Don't forget us from your Dua'a and best of luck in your exam and your future career.

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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 patient’s 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              

Age and gender. When did he/she notice the lump? Is it the first time? What made the patient notices the lump? Site. Predisposing events. Symptoms of the lump: pain, discharge, disfiguring, or restrain certain movements, respiratory or swallowing, change in voice. If discharge: Quantity, quality, color, smell. Associated Symptoms: fever, weight loss, night sweats, fatigue. Has the lump changed? Size, shape, color, tenderness since first notice Does the lump ever disappear? On lying down or exercise. Previous exposure to radiation to the neck. Any other lump. Treatment done for this lump before. What does the patient think caused the 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.

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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.

 Examination of an inguinal hernia: Always examine bilaterally.  Ask the patient to stand up o During a routine supine abdominal examination, you discover a lump that looks like hernia, complete the examination then ask the patient to stand up in order to determine the size correctly.  Inspection: From the front. o Site and shape. o Inguinal hernia: Above the crease of the groin. o Femoral hernia: More medial and inferior.  Palpation: From the front. o Scrotum and its content. o In men, examine its upper edge. If you can get above it  Scrotal swelling NOT hernia.  Palpation: From the side. o On the same side as the hernia. Place one hand in the patients back to support him, and your examining hand on the lump with your fingers and arms roughly parallel to the inguinal ligament. o You must ascertain the following facts about the lump:  Position, size, shape.  Temperature, tenderness, and tension.  Composition (solid, fluid, or gaseous).  Reducibility.  Expansile cough impulse: o Compress the lump firmly with your fingers then ask the pt. to cough.  Is the swelling reducible? o Ask the patient to reduce it him/herself. o If the patient can't reduce it, press firmly to reduce the tension of the lump. Then gently compress the lower part of the swelling. As the lump gets softer, lift it up towards the external ring. Once it has all passed in through this point, slide your fingers upwards and laterally towards the internal ring to see if the hernia. o If there is any difficulty in reducing the hernia, ask the patients to lie down and try again.

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 Remove your hand and watch the hernia reappear o Indirect hernia: Slide obliquely downwards along the line of the canal. o Direct hernia: Project directly forwards.  Percuss and auscultate the lump o If there is gut in the sac, it may be resonant and there may be audible bowel sounds.  Examine the other side: o Inguinal hernia is commonly bilateral, particularly when it is direct.  Examine the abdomen o Raised intra-abdominal pressure, such as a large bladder, an enlarged prostate, ascites, chronic intestinal obstruction, or pregnancy.  Cardiovascular and respiratory assessment: Fitness for operation.

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 Burn Injury           

Time of burn, duration, mechanism. Type: Thermal, chemical, electrical. Associated injuries. Closed or opened Space. Loss of Consciousness. Treatment done before presentation. Past History (Medical + Surgical). Medication and allergy. Social especially smoking. Family history. Systemic review.

Management of Burn Injury         

ABC, intubate if indicated, start fluid (LR 1L in adult, 20 ml/kg in children). If CO inhalation is suspected (closed space), administer 100% O2. Assess area of burn if 2nd or 3rd degree by rule of 9s or the palm of the pt. = 1%. Analgesia (IV morphine). Apply cold saline soaks for analgesia if <25% BSA. Cover burns with silver sulfadiazine/clean sheet and then warm blanket. Elevate burned areas if possible to prevent edema. Basic labs: ABG, CBC, electrolyte, carboxyhemoglobin. Weigh the patient. Continue fluid as per Parkland formula: 4 ml/kg/%BSA. Half in the 1st 8 hours from the time of burn and the remainder for the next 16 hours.  Foley catheter, ECG, NGT.  Tetanus vaccine. Page |7


History of an Ulcer/Wound           

When did he notice the ulcer? Is it the first time? What made the patient notice the ulcer? Site. Predisposing events: Trauma, surgery, immunocompromised. Symptoms of the ulcer: pain, discharge (mucous, purulent, blood). If discharge: Quantity, quality, color, smell. Associated Symptoms: fever. Has the ulcer changed? Size, shape, color, tenderness since first notice Any other lump. Treatment done for this ulcer before. Systemic diseases: DM, HTN, CAD, atherosclerosis.

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.

o Discharge (color, quantity, quality- serous, mucous, purulent, blood- , and smell).  Palpation: o Tenderness. o Temperature around ulcer.  Relations: o To its surrounding tissues. o Adherent or invading deep structures such as tendons or periosteum.  Surrounding tissues: o Induration, pigmentation and scars. o Local lymph nodes. o Blood supply of the local tissue: Capillary refill, pulses, Ankle-brachial index (ABI) for peripheral arterial disease. Page |8


o Nerve supply: Motor and sensory.

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

6 Cardinal eye movement, ask if there is diplopia to any of the direction. Exophthalmos, proptosis "Grave's". Lid lag (the lid lag behind the orbit… should be performed slowly). Anemia, Jaundice. Mouth: Macroglossia "Hypothyroidism".

 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.

 Position and Exposure: o Sitting & expose from clavicle to the waist (both breast).

 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 o’clock, there is dimpling on the outer upper quadrant of the right breast at 10 o’clock.

 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.

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 Investigations: Triple test.  History and Physical Exam.  Imaging: US or mammogram.  FNA or core biopsy.

Assessment of a Trauma Patient Primary survey:  A: Elicit the pt. response by shouting out loud your name.  While stabilizing patient's head, assess airway patency by asking the patient to talk e.g. asking his/her name.  If not, assess for obstruction. (Chin lift if no C-spine injury and jaw thrust).  Consider: Nasophargeal, orophargeal, ETT intubation, cricothyroidotomy.  C-collar & spine immobilization (sand bags).

 B: Exclude flail chest, pneumothorax and hemothorax and manage them.    

Look: Rate & depth of respiration, chest injury, and asymmetry. Feel: Palpate the trachea (central or deviated). Listen: percussion & auscultation. Attach pulse Oximeter.

 C    

Control visible bleeding by direct pressure. Look for signs of shock: JVP, pulse, heart sounds & blood pressure. All peripheral pulses & capillary refill: Radial: 90, Femoral: 80, Carotid: 70. Place 2 large cannula (14-16 gauges). o Take a blood sample for: Type and cross, CBC, coagulation, chemistry, LFT, amylase. o Start 2L of warm LR or 20 ml/kg in children.  Rectal examination (tone, blood, prostate) after log rolling.

 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, café 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, café 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.

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 Neurological: Triceps reflex C7. o Axillary (M: Abduction, S: Area of deltoid) o Musculocutanous (M: Elbow flexion, S: Lateral cutanous n. of forarm) o Ulnar (M: Ab/adduction of MCPJ, S: little finger). o Radial (M: Good sign, S: Dorsum 1st web space). o Median (M: OK sign, S: index finger) Note: In all orthopedic examination you have to mention that you would examine the function of the joint and you would examine joint above and joint below the joint you are examining).

Elbow Examination  Look: 

Rheumatic nodule, deformity, skin changes, and muscle atrophy.

 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

Medial epicondylitis (Golfer's elbow): Resisted flexion. Lateral epicondylitis (Tennis elbow): Resisted extension. Varus and valgus stress test: Supinated and flexed 5 degree. | 15 Quick Review for OSCE | AlBrahim-Al-Enezi

 Neurological: ulnar, median and radial nerves.

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.

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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.

 Special tests: lying down.  Fluid displacement test: o Patellar tap test and milking test.  Patellar Apprehension test: Push the patella of the extended knee laterally then flex the knee. If there is pain  patellar dislocation.  Varus/valgus stress test: extended knee and flexed 30 knee. o Varus stress test: Lateral ligament torn. o Valgus stress test: Medial ligament torn.  Cruciate ligaments test: o Ant/Post drawer test (ACL & PCL): Flexed knee 90 degree. o Lachmann test (Sensitive to ACL): Flex knee 20 degree. o Posterior sag sign (PCL): Flex both hips and knees.  McMurray’s test: flexed hip and knee 90, then look for pain. o Rotate the foot externally and abduct then extension: Medial meniscus. o Rotate the foot internally and adduct then extension: Lateral meniscus.

 Reflexes: Patellar ligament L3, 4.  Neurological:  Deep peroneal, superficial peroneal and tibial nerves.

 Gait

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Ankle examination  Look: Setting position.  Scars, swelling, skin changes, deformity, wounds, and dryness.  Foot arch while standing.

 Feel: always compare.  Temperature.  Pulse: Dorsalis pedis and tibialis posterior.  Tenderness: systematically palpate then compress the whole foot.

 Move: Active then passive.  Extension, flexion, inversion, and eversion.  MTP joint , IP joint

 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.

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Open Fracture Management  Trauma survey: ATLS protocol to roll out other injuries.  Primary survey: ABCDE  History (AMPLE): Allergy, medication (tetanus), past history, last meal, event.  Secondary survey: Head to toe exam then local exam to the open fracture.

 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:      

Remove obvious foreign material. Cover wound with sterile dressing soaked in warm normal saline. Realign the limb and splint. Reexamine the neurovascular. X-ray. IV antibiotics: o Gustilo class 1 (<1cm)  cefazolin 72 hrs. (gram +ve) o Gustilo class 2 (1-10 cm)  cefazolin + gentamicin. (gram +ve and -ve) o Gustilo class 3 (>10 cm)  cefazolin + gentamicin + penicillin. (+,-, clostridia)  Tetanus vaccine.  NPO and prepare for OR  Open reduction indications: NO CAST (No union, Open fracture, neurovascular Compromise, intra-Articular fracture, Salter-Harris 3,4,5, and polyTrauma) + Pathologic fracture, failed closed reduction, can't apply traction, potential improved function.

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How to Read X-Ray for Bone Fracture  Rule of two: Bilateral, AP & lateral, 2 joints, pre/post reduction.  Reading steps: o Patient information, date and study. o X-ray view: AP or lateral. o Side: Left or right bone. o Site: epiphyseal, metaphyseal, or diaphyseal. o Type of fracture: Transverse, oblique, spiral…etc. o Displacement: Dorsal, frontal, medial, lateral. o Distraction: Fragments are separated by a gap. o Translation: Percentage of overlapping bone. o Angulations: Direction of fractured apex (varus/valgus) o Rotation: fragment rotated about long axis of bone.  Example o Patient X and date. o Lateral x-ray for Right femur showing hip, pelvis and knee there is oblique fracture in mid shaft and dorsal displacement and 3 cm overlapping also there's angle superiorly about 45 degree the knee is rotated internally. o I would like to see AP view.

Closed Fracture Examination  Start with ABC: Rule out other injuries or open fracture.  Look: o Expose both limbs “look at each limb”. o Deformity, shortening of limb, or open fracture. o Swelling, bruising or bleeding.  Feel: o Gently for tenderness and crepitus.  Move: Joint above and below.  Neurovascular: o Pulses and capillary refill. o Nerve: Motor and sensory.  Management: o Splint the limb. o Give analgesia. o Obtain x-ray: Bilateral, AP & lateral, 2 joints, pre/post reduction. o Call orthopedic.

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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.

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 Intubation:           

Assess your equipment. Wear gloves. Pre-oxygenation: important step (decreases hypoxia time from 1 to 5 minutes) Position: Sniffing position to put all 3 axes togother. Hold the laryngoscope in the left hand. Insert it from the right side and push the tongue to the left. Elevate to the ceiling and try to visualize the vocal cords. Insert endotreacheal tube and connect to machine. Auscultate both lungs. Fix the tube to the mouth. If you fail intubation (88% due to position): o Call for help. o Bag-mask ventilation: Hold it in C-E technique. If it's not OK, put airway and try to ventilate. o If you are not medical student, put laryngeal mask airway (LMA).

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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. P a g e | 23


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.

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 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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History of Eye Swelling  History:  Onset, duration, progression, aggravating and alleviating factors.  Precipitating events: Trauma, insect bite, sinus infection, URTI.  Associated symptoms: Vision change, pain, decreased eye movement, diplopia, red eye, fever, weight loss.  Past ophthalmologic history: Similar events, surgery, previous status of vision.  Past medical history: HTN, DM, allergy, medications.  Family history: eye diseases.  Social history: smoking, alcohol, environment.  Differential diagnosis: see the table below. Periorbital Septal cellulitis  Swelling  Red eye  Discharge Dx: CT orbital Rx: Oral Antibiotics, eye drops, antistaph Naficillin

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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


History of Red Eye  History:  Onset, duration, progression, aggravating and alleviating factors.  Uni/bilateral, acute/chronic, seasonal.  Precipitating events: Trauma, contact lens, sinus infection, URTI, Medication (eye drops, cream on the face).  Associated symptoms: vision change, itching, pain, discharge, photophobia.  Past ophthalmic history: Eye diseases, similar problem, and surgery.  Past medical history: HTN, DM, medication (anticoagulant subconjuctival hemorrhage), allergy, GI, Respiratory, Joint problems.  Family history: Eye diseases, similar problem.  Social history: Smoking, alcohol, environment.  Differential diagnosis: First exclude emergency (acute angle closure glaucoma, uveitis, and keratitis). See the table below.  Please read the lecture of Dr. Al-Debassi for more information. Trauma

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

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ENT History of Hearing Loss          

If the patient is a child, confirm hearing loss –response, speech … etc. Uni\Bilateral. Onset, duration, and progression. Any events happened before (trauma, infection-URTI-, drugs) Associated Symptoms: Tinnitus, vertigo, otalgia, otorrhea, and fever. Snoring and sleep apnea (wake up at night, daytime sleepiness…etc.). Impact on patient life: (severity). Past History: the same episodes, ENT problem, medical (asthma). Family History. Social life and occupation.

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.

 Otoscope: see normal,abnormal pictures. o o o o o

Explain "little uncomfortable". Clean the ear from wax. Pull the ear gently backward and upward. External canal: Redness, discharge, tumor. Tympanic membrane: Redness, retraction, bulging, light reflex.

 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  perforation–high ear canal volume- or effusion.

 Facial nerve assessment

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History of Nasal Problem  Uni,bilaterally.  Onset, duration, time, severity.  Associated Symptoms: Rhinorrhea, Itching, sneezing, snoring, mouth breathing, anosmia, facial pain, headache, fever, and post-nasal drip.  Hearing problem, sleep problem.  Possible causes: Asthma, eczema, URTI, allergies, trauma, and surgery.

Nose Examination  Inspection: o Deformity, scars, skin changes.

 Palpation: the nose and the paranasal sinuses.  Nose speculum: o Deviated nasal septum (DNS) o Discharge (mucous, purulent, bloody) o Polyps, turbinate hypertrophy.

 Mouth Examination: o o o o

Lips: Nevus, hemangioma. Mucosa, teeth, tongue and below it. Hard palate, soft palate, uvula, and oropharynx. Tonsils (between ant. and post. Pillars).

Neck Mass Evaluation

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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.

 Muscles: see the book for more illustration.  Extrinsic flexor muscles: o FCU, FCR & PL: Wrist flexion. o FPL: IP joint of the thumb flexion. o FDP: Flexion of DIP while the PIP is extended. o FDS: Flexion of PIP while stabilizing other fingers in extension. o FDP & FDS of the index are separate from the other fingers. o Nerve supply: Median except FCU and ulnar side of FDP which are Ulnar.  Extrinsic extensor muscles: 6 Compartments. 1. APL & EPB: bring the thumb out to the side and feel the tendon. 2. ECRL & ECRB: Wrist extension. 3. EPL: lift the thumb toward the dorsal aspect. 4. ED & EI: MCP extension & index MCP extension; the fingers are bent. 5. EDM: Small finger MCP extension. 6. ECU: Wrist extension with abduction. o Nerve supply: Radial.  Intrinsic muscles: o Thenar muscles: APB, FPB & OP: Abduction of the thumb & opposition. o AdP: Froment's sign "when holding a paper between the thumb & index". o Lumbrical muscles: Flex the MCP & extend IP. o Interosseous muscles: DorsalABduction "DAB", PalmerADduction "PAD". o Hypothenar muscles: ADM, FDM & ODM: bring the small finger away. o Nerve supply: Ulnar except Thenar & 1st,2nd lumbricals which are Median.

 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.

 Circulation: Allen Test. http:,,www.youtube.com,watch?v=jq0ai5uXx68 P a g e | 30


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