Knee Examination

diabetic foot examination
د عبد المجيد الأسطى
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breast examination .
للدكتور عبد المجيد الأسطى
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urology examination د عبد الفتاح المشيطي
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urology instuments د عبد الفتاح المشيطي

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abdominal examination د نور الدين عريبي
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general examination د اسماعيل ابو خريص
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neck examination د اسماعيل ابو خريص
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#clinic ⬆️⬆️

#Long_case
#goiter
🔖Checklist for history
• Onset related to puberty, pregnancy
• Residence: Endemic area or not
• Ingestion of goitrogens
• Intolerance to hot/cold temperature
• Increased appetite with loss of weight (Hyper￾thyroidism)
• Gain in weight (Hypothyroidism)
• Change in menstrual cycle
• Bowel habit—diarrhea (hyper), constipation
(hypo)
• Difficulty in swallowing
• Difficulty in breathing
• Hoarseness of voice
• Postural cough during sleeping (retrosternal
extension)
• Historyofpalpitation/shortnessofbreathonexertion
• Insomnia, loss of concentration (hyper)
• Irritability/nervousness (hyper).
🔖Checklist for examination of thyroid
• Always check the pulse for tachycardia before examining the thyroid
• Look for tremor of hands and tongue before examining the thyroid
• Ask the patient to take a sip of water and to hold it in his/her mouth. Then ask the patient to swallow (goiter
moves on swallowing)
• Ask the patient to put out the tongue (thyroglossal cyst moves up)
• Stand behind the patient and palpate the thyroid (ask the patient to take another sip of water)
• Decide whether it is diffuse enlargement,single nodule, multiple nodules and the nature of the surface
• Decide the consistency
• Look over the top of the head for exophthalmos (look for lid lag, lid retraction and other eye signs)
• Check the eye movements, double vision
• Now stand in front of the patient for palpation of the trachea for deviation, for assessing the lower limit by
‘getting below’
• Assess the plane of the swelling (stretch the deep fascia by extending the neck and see whether it becomes less
prominent, contract the sternomastoid muscle against resistance and see whether it becomes less prominent
• Do Pemberton’s test for retrosternal extension
• Percuss the manubrium sterni for dullness (seen in retrosternal extension)
• Palpate the carotids on both sides
• Examine the regional lymph nodes
• Feel the skin (dry in hypothyroidism, shiny skin in hyperthyroidism)
• Look for pretibial myxedema (hyperthyroidism)
• Assess the build of the patient (Thin—hyperthyroidism, obese—hypothyroidism)
• Examine the palms—warm, moist and changes of acropachy in hyperthyroidism
• Assess the behavior of the patient (agitated in toxic, lethargic in hypothyroidism)
• Ask the patient to rise from squatting position without using hands for support (proximal myopathy in
hyperthyroidism)
• Test the biceps reflex and look for slow relaxing reflex suggestive of hypothyroidism.
Final checklist for clinical examination of thyroid
1. Look for signs of toxicity
2. Look for signs of malignancy
3. Look for signs of retrosternal extension
4. Look for position of carotid artery
5. Look for position of trachea
6. Look for cervical lymph nodes
🔖Discussion
🏷️Why is the swelling a goiter?
🏷️How do you grade a goiter ?
🏷️How will you confirm your diagnosis of
toxicity?
🏷️How you will manage thyrotoxicosis?
🏷️Why technetium is preferred over radio￾iodine for diagnostic scanning?
🏷️ What is Berry’s sign?
🏷️What is Kocher’s test?
🏷️ What are the signs of retrosternal extension?

#clinic

#Long_case
#Submandibular Sialadenitis
🔖Checklist for history
1. History of systemic diseases responsible for
sialadenosis like—DM, drugs (antiasthmatic,
guanethidine), endocrine disorders, alcoholism,
pregnancy, bulimia (eating disorders)
2. History of salivary colic
3. Increase in size during salivation
4. History of collagen diseases
5. History of similar swelling on the contralateral side.
🔖Checklist for examination
🏷️1. Bidigital palpation with a gloved finger inside the
oral cavity
🏷️2. Palpation of the Wharton’s duct for stones in the
floor of the mouth
🏷️3. Examine the opening of the duct (sublingual papillae
on the side of the frenulum) for inflammation and
for purulent discharge
🏷️4. Look for regional lymph nodes
🏷️5. Look for induration/ulceration of the overlying
skin—suggestive of malignancy
🏷️6. Look for other salivary glands on both sides.
Contd

#clinic

#Long_case
#lipoma discussion.
🏷️Q 1. What is your clinical diagnosis in this case?
Lipoma.
🏷️Q 2. What is lipoma?
It is a benign tumor arising from adult fat cells.
lipoma back
🏷️Q 3. What are the diagnostic points for lipoma?
1. Lobulation
2. Slip sign
3. Soft swelling with pseudofluctuation
4. Transillumination positive if it is subcutaneous
5. The overlying skin may show prominent veins
when the lesions are large.
🏷️Q 4. What is the cause for pseudofluctuation?
Intracellular fat is fluid at body temperature.
Therefore, the swelling will be soft and fluctuation
will be elicited in one plane. For a true cyst
one should elicit fluctuation in two planes at
right angles to each other that is not possible
in the case of lipoma and therefore, it is called
pseudofluctuation.
🏷️Q 5. What is slip sign?
If the edge of the lump is pressed, the swelling
slips from beneath the finger. This can be easily
demonstrated in the case of a subcutaneous lipoma
and it is said to be pathognomonic.

#clinic

#Long_case
#Inguinal hernia
🔖Checklist for history
• History of chronic cough, asthma, bronchitis
• History of heavy weight lifting
• History of constipation (straining to pass motion)
• History of urinary complaints: night frequency,
hesitancy-difficulty to initiate the act of micturition
and urgency, etc.
• History of pain in the groin
• History of epigastric pain (dragging on the
mesentery)
• History of appendicectomy (damage to ilio￾inguinal nerve)
• History of abdominal pain and vomiting.

#clinic

#Long_case
#(The Breast)
#General information
 The breasts are modified sweat glands.
 Composed from lobes  lobules  lactiferous duct
 Pigmented skin covers the areola and the nipple, which
is erectile tissue.
 The openings of the lactiferous ducts are on the apex of
the nipple.
 The nipple is in the fourth intercostal space in the mid￾clavicular line, but accessory breast/nipple tissue may
develop anywhere down the nipple line (axilla to groin).
 The adult breast is divided into the nipple, the areola and four quadrants, upper and
lower, inner and outer, with an axillary tail projecting from the upper outer quadrant.
 upper lateral quadrant  the most quadrant that affect by malignancy
 99% of breast cancer occur in female and only 1% in male (more aggressive in male)
 The breast is bounded by the clavicle superiorly, the lateral border of the latissimus
muscle laterally, the sternum medially, and the infra-mammary fold inferiorly.
 Conservative breast surgery  radiotherapy + removal of the breast.
 If there is metastases to the spine there will be tenderness and pain on raising the leg
and absent knee jerk due to damaging effects on the nerves.
#Lymph nodes
 Lymph drainage of the breast:
o 70% to the axillary LN
o 20% to the supraclavicular LN or along the internal mammary vessels
o 10% to the abdominal LN
 Axillary L.N divided into five groups:
o Anterior (Pectoral)
o Posterior (Subscapular)
o lateral
o Medial (Sub-clavicular)
o Central (intermediate)
 Surgical levels of axillary L.N:
o Level I  bottom level, below the lower edge of the pectoralis minor muscle
o Level II  lies underneath/posterior the pectoralis minor muscle
o Level III  above/medial the pectoralis minor muscle
When there is breast cancer and axillary L.N affected  means metastatic and
systemic disease.
 Sentinel L.N (first L.N adjacent to the cancer)  to see if there is metastases make
injection of methylene blue or radioactive substance then take biopsy and examine
it.
#History
 Questions:
o How long have symptoms been present?
o What changes have occurred?
o Is there any relationship to the menstrual cycle?
o Does anything make it better or worse?
 Age:
o young patient (15-25 years)  fibro-adenoma
o middle age (25-40 years)  ANDI (Aberrations in the normal development and
involution) due to hormonal changes like prolactin and sex hormones
o old age (more than 40 years)  cancer of the breast
 Questions of lump (Cause - first symptoms - onset - duration - associated symptoms
– progression - multiplicity)
 Presentation: discharge – lump – skin changes
 History of trauma: lead to fat necrosis which appears as a mass
 History of breast surgery and biopsy
 Family history: 5-10% of breast cancer run in family
 Risks that increase the probability of breast cancer occurrence:
o Number of menstruation (increased number more risk)
o Nulliparous (more risk)
o Unmarried (more risk)
o Lactation (protective)
 Drug history: estrogen – progesterone
 Obesity: increase the level of estrogen
 Sex related hereditary diseases
 Menstrual history: Menarche, menopause, changes during the menstrual cycle,
pregnancies, lactation.
 Social history: smoking – alcohol – diet (fat, animal meat, low fiber, pickles)
#We should examine the following for complete breast exam:
 Both breasts
 The axilla
 The supraclavicular LN
 The abdomen for a-Hepatomegaly b-Ascites

#clinic

#Long_case
Varicose vein
Checklist for history
History of
• Major surgery
• Majorillness necessitating prolonged recumbency
• Recentlong airtravel (economy classsyndrome)—
deep vein thrombosis
• Sudden undue strain
• Drug intake—hormone containing pills (like
contraceptives)
• Computer professionals requiring long hours in a
sitting posture—E thrombosis
• Occupation demanding prolonged standing
• Family history of varicose veins.
Examination موجود ف الشيت
#clinic