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2. Thyroid
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Thyroid History
💠 Introduce, permission, privacy
💠 Personal data
💠 Complain/duration
💠HPI
🟫History of the lump
How Discovered
Onset
Progression
Multiplicity
Causes/trauma
Associated symptoms
▪️Pain
▪️Fever
▪️Discharge

🟫Pressure Symptoms
Shortness of breath
Discomfort swallowing
Hoarsness

🟫History of metabolic status &systemic review for mets
🔻Non specific:
Increase sweating/dryness
Heat/cold intolerance
Generalize fatigue
Loss of hair
🔻CNS:
Metabolic; nervousness, irritability, Insomnia, proximal myopathy.
Systemic review; Weakness, headage
🔻GIT:
Metabolic; Diarrhea/constipation, weight loss/gain, Increase/decrease appetite.
SR; jaundice, abdominal pain/distension
🔻Cardiorespiratory:
Metabolic; palpitation
SR, chest pain, hemoptysis, cough
🔻Genitourinary:
Menses; stop? regular? amount?
Urine; color, amount, frequency

🟫Eye symptoms
Double vision
Blurred vision
Eye pain
Difficult eye closue

💠Past medical history
Similar condition
Admission
Surgery
Blood transfusion
Radiation
FNA
Asthma, DM, HTN

💠Family history
similar condition
Malignancy

💠Drug history
current
chronic
allergy

💠Social
Smoking
Alcohol
Insurance

Thyroid Examination
💠Great, introduce, permission, privacy, wash
💠General:
well,
sitting,
comfortable,
not agitated,
thin/fat
his/her cloth suitable for room temperature
💠Exposure: from nipple line & above

🟫 Inspection: 6Ss
1⃣Swallowing/tongue protrusion
2⃣Site
3⃣Size
4⃣Shape
5⃣Skin over it
▪️scar
▪sinus/discharge
▪️discoloration
▪️dilated veins/ vesible pulsation
▪️ulcer
6⃣Suprasternal notch

🟫Palpation
From anterior: 4Ts
ask about the pain
Temperature
Tenderness
Trachea
Thrill

From posterior
🔸Tell the pt you want to examine him from posterior!
🔸Relax muscle
🔸Support with one ✋and palpate with the other for:
▪️site
▪️size
▪️shape
__
▪️surface
▪️consistency
▪️edge
__
▪️attachment to skin
▪️attachment to muscle
__
▪️palpate isthmus
▪️Movement with swallowing + Retrosternal extension (palpate the lower edge by your little fingers and ask the pt to swallow)
🔸Lymphnodes
▪️submental
▪️submandibular
▪️pre/post auricular
▪️anterior/posterior cervical
▪️occipital
▪️supra/infra clavicular
🔸Skull for swelling

🟫Percussion
clavicle
sternum (from resonant area)

🟫Ascultation
over the swelling
above the swelling

🟫General examination
🔹Upper limp
moist/dry
cold/hot
palmar erythema
acropathy
Vitiligo
fine tremors
pulse
PB
temp
Proximal myopathy (resist abduction of the arm)

🔹Eye
Passive
1⃣lid retraction: sclera above the iris
2⃣exophthalmos: from behind and above the pt
3⃣chemosis
4⃣loss of lateral eye brows
5⃣periorbital edema or redness
Active
6⃣ophthalmoplegia
7⃣convergnce
8⃣lid lag

🔹Reflexes
🔹pretibial myxedema
🔹cardiovascular ex

Breast Examination
💠Great, introduce, permission, privacy, wash
💠Position:
Inspection➡️sitting
Palpation➡️supine
axilla➡️sitting
or all the procedure at 45°!
💠Exposure:
ideally untill the waist
💠Well, comfortable, lie

🟫Inspection:
from in (nipple) to out (axilla)
◾️Symmetry
◾️Nipple-areola complex (6 Ds +R)
1. Direction
2. Displacement (from nipple line)
3 .Deviation
4. Discharge
5. Distruction
6. Dublication
7. Retraction
◾️Skin:
1. Scar
2. Sinus
3. Discoloration
4. Dilated viens or pulsation
5. Dimpling
6. Peau d'orange
7. Ulcer
8. Vesible lump (4s)
9. Inframammary fold for scar
◾️Axilla
1. Skin tethering
2. Axillary swellings (LN)
3. Arm swelling (LN & lymphedema)

🟫Palpation
👉Ask about the pain
👉Use both hands if large breast
👉Start with normal site,
👉Anticlock,
👉6 areas,
👉Palpate nipple area with the palm!
◾️Tenderness
◾️Temperature
◾️Palpate mass
1. size
2. site,
3. shape,
4. surface
5. consistency,
6. edge,
7. attached to skin
8. attached to underlying structure (ask her to push againt the waist then move the lump)
◾️Press the areola for discharge
◾️Axillary LN + Supra and Infra clavicular joint
👉Your right hand with right hand of the patient & vice vera
👉If palpable comment on:
1. site
2. size
3. shape
4. consistency
5. fixity
6. single or multible
7. molten together
🔸anterior
🔸posterior
🔸lateral
🔸pectoral
🔸apical

🟫Other area to examine
◾️chest for pleural effusion
◾️abdomen for organomegally
and ascitis
◾️back for tenderness
◾️general examination

انضمووووووا 😴 القناة👇👇👇


خاصة بـتجميعات م.الثورة


https://t.me/Althorahospital22332

https://t.me/Gomhorihospital


تجارب الجمهوري

The boundaries of hesselbach triangle:
✨inferior epigastric aretery
✨inguinal ligament
✨lateral border of rectus sheath

الــ floor عبارة عن:
✨fascia transervalis
✨conjoint tendon

✨✨✨✨✨

What is the diferential diagnosis of a thyroid nodule?
Multinodular goiter
Hyperfunctioning adenoma
Cyst
thyroiditis
Carcinoma
lymphoma

What is the differential diagnosis of a groin mass?
Lymphadenopathy,
hematoma,
seroma,
abscess,
hydrocele,
femoral artery aneurysm,
EIC,
undescended testicle,
sarcoma,
hernias,
testicle torsion.

🌸 Snake bite 🌸

🔰 Analgesics are contraindicated in snake bite
🔰 No cover it
🔰 No use cautery
🔰 No sucking
🔰 No use tourniquet
🔰 Calm the patient because stress increase toxicity and reached to heart 👌
🔰 Snake bite( dry_ moist)
🔰 may come with hypovolemic shock

🔰 May complicated by compartment syndrome and treated by fasciotomy and use vaccine

في العلاج نهتم بالتالي التي نعطيها أو نراقبها 👇

RR, UOP, conscious , vaccine, Antibiotics, fluid

كلما كانت العضه قريبه من الرقبه تكون خطيره وقاتله

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4. (Ulcer)
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History:
💠 Great, Introduce, Permission
💠Personal data
💠 Complain+duration
💠 History of presenting illenss

🟫History of the ulcer
◾️how discovered
◾️progression (eg: change in size)
◾️associated symtoms:
pain, fever, discharge (analyse it)
◾️ulcer in other area
◾️action taken
◾️ulcer in the past:
analyse it:
site,
association,
continue for how long,
what did for it?
◾️The cause:
1. trauma
2. hx of dilated vien (varicose)
3. Heart diseases
4. pain during exercise(claudication)
distance?
🔸This distance like the past?
🔸For how long you stop for rest?
🔸Rest pain?
🔸Socrates
5. Diabetes (then jump to the hx of Diabetes below⬇️)

🟫 History of Diabetes
◾️For howe long
◾️Medications/dose
◾️Adherence to medications
◾️Follow up and last blood sugar chack up

🟫 Systemic effects of DM (systemic review)
CNS: Loss of sensation, Weakness, numbness, blurred vision
Cardiovascular: chest pain, dysnea, cough
️GIT: abdominal pain (after meals!), constipation, diarrhea, jaundice
Urinary: urine color, amount,
frequency

💠Past medical history:
1. similar condition
2. ️admission
3. ️blood transfusion
4. ️surgery
5. ️amputation
6. ️revascularization
7. ️chronic dx: HTN, Asthma, renal dx, stroke or ischemic heart diseases

💠Family History
Family hx of similar condition
️Family hx of DM, HTN, Stroke, IHD, Kidney dx

💠Social Hx
️Smoking
️Alcohol
️Health insurance

💠Drug Hx
Current drugs
Chronic drugs
️Allergy

Examination
💠Great, Introduce, Permission, Privacy, Wash
💠Exposure: both legs
💠General examination:
well, flat, comfortable, pale & jaundice

🟫Inspection:
1⃣Site
2⃣Size and depth
3⃣Shape
4⃣Single or multible (look between the toes)
______
5⃣Floor:
1. discharge
2. granulation (healthy or not)
3. sloughs
4. color
6⃣Margin: regular or not
7⃣Edge
1. flat (sloping) ➡️ shallow, traumatic, healing, venous
2. punched out ➡️ trophic ucler, ischemia, DM, tertiary syphilis, chronic infection
3. Undermined➡️ TB, bed sore
4. Elevated➡️ carcinoma
5. Rolled (raised)➡️ Basal cell carcinoma
______
8⃣Skin changes:
1. Trophic changes:
🔸loss hair
🔸shiny skin
🔸muscle wasting
🔸nail changes (brittle)
2. Other changes
🔸Dilated viens or venous guttering
🔸Discoloration:
Hyperpigmentation (venous)
Hypopigmentation (non healing)
🔸Deformity
🔸Bruising
🔸Blisters
🔸Gangrene

🟫Palpation
1⃣Tenderness
2⃣Temperature
_____
3⃣Floor
(exposed surface of the ulcer)
for consistency
4⃣Base
(tissue in which ulcer rest)
feel around the margin
for consistency
if firm (indurated)➡️ inflammation
5⃣Edge
1. Discharge
2. soft: healing
3. firm: non-healing
4. hard: malignant
6⃣Fixity to underlying structure
____
7⃣Neurological ex
1. proproiception
2. light tough
3. pain (by 10 gram monofilament test)
4. motor
8⃣Peripheral pulses
9⃣LNs

🟫complete by
1. examining the other limp
2. Cardiovascular ex
3. Special tests
🔸if Ischemic ulcer➡️ Burger's test & Ankle brachial index
🔸if Varicose ulcer➡️Tourniquit(Trendlenburg test)

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5. Varicoce
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History:
💠 Great, introduce, Permission
💠 Personal data
1. Name
2. Age ➡️ All age groups
3. Sex ➡️ 10:1 F:M
4. Occupation ➡️ job involve long standing
5. Residency ➡️ more in Europe and north america
6. Marital status

💠 Complain/Duration:
1. Disfiguring effect of the viens
2. Pain
3. Mild swelling at the end of the day
4. Night crumps and itching
5. Pain ful lumps

💠History of present illness:
1⃣Onset ➡️ gradually
2⃣Progression ➡️
1. how discovered ,
2. disappear? ,
3. difference between start and now
3⃣Aggravated by:
4⃣Associted with
▪️Pain:
1. Site : calf or lower leg
2. Onset
3. Character : dull , Night crumps or heaviness
4. Radiation
5. Aggravate: standing
6. Relieve: lying down
7. Association : fever
8. timing: night
9. Severity
▪️Itching
▪️Swelling
▪️Skin changes / ulcer
5⃣Other sites
6⃣Risk factors:
🔸long standing
🔸trauma
🔸DVT
🔸multiple parity

💠Systemic review:
Abdomen: pain, distention " asictes, pregnancy "

💠Past medical history:
Admission , blood transfusion, surgery , DVT , clotting disorders , pelvic tumors , DM or HTN

💠Family history:
similar condition

💠 Social history:
Smoking , alcohol, health insurance

💠Drug history:
current , chronic, allergy

Examination
💠Great, introduce, permission, privacy wash
💠Position: Standing
💠General: well, standing comfortable
🟫Inspection for the veins
👉There is abnormal superficial elongated dialated tortuous vien/s
1⃣Site
🔸anterio-medial thigh and calf➡️ Great saphenous vein
🔸anterio-lateral thigh➡️ accessory saphenous vein
🔸Posterio-lateral of the calf➡️ Small saphenous vein
🔸above the inguinal ligament➡️ superficial circumflux iliac, superficial pudendal, superficial epigastric veins
🔸Other sites ➡️ Stray varicosit
2⃣Extent
3⃣Blow out + Saphena varix
(if +ve ask the pt to cough)
4⃣Raise the leg for collapsibility
🔸collapsed: primary
🔸not collapsed: secondary eg: DVT, pelvic tumor, & AV malformation
5⃣while the leg is raised ask the pt to cough➡️ morrissey test

🟫 Inspection for signs of venous hypertension
"THe PEAU D'orange"
1. Thicking or atrophic changes
2- Hemorrhage
3- Pigmentation
4- Edema: pitting and start distally
5- Ankle flare: small dilated venules (incompetent perforators)
6- Ulceration: over gater area
7- Dermatitis
8- Deformites: Talipes equinovarus (chronic ulcer▶️contracture) and ankylosis of the unkle


🟫Palpation
1⃣Temperature
2⃣Tenderness
3⃣Thrill ➡️ saphenofemoral junction & behind the knee while coughing
4⃣Lower third of the leg for
▪️thicking➡️ lipodermatosclerosis
▪️edema
▪️tenderness
▪️base of the ulcer if found
5⃣palpate for peripheral pulses

🟫 Percussion (Shwartz's test):
if +ve ➡️ incompetent valves

🟫 Auscultation
💠percuss proximally and auscultate distally if +ve ➡️incompetent valve
💠 Bruit: machinary continous (AV malformation)

🟫 Special Tests
◾️Trendelenburg test
◾️Mutlipe trendelenburg test
◾️Perthe's Tests

🟫Complete the examination by:
1. Abdominal Ex: for
▪ dilated collateral, do harvest test
▪ masses
2. Scrotum for varicocele and masses
3. Per-rectal & Per-vaginal Ex for
▪️️masses
▪️coexistnce hemorrhoids

(note: read about; Tredelenburg test, Mutlipe trendelenburg test, Perthe's Tests & shwart's test)

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6. abdomen
〰〰〰〰〰〰〰〰〰〰
History
🟣1. Cholecystitis
💠great, introduce, permission
💠complain/duration
💠HPI:
🟫 Pain: socrates
1. Site:
cholicystitis➡️ rt upper quadrant
biliary colic➡️ upper abdomen

2. Onset: sudden

3. Character:
▪️colicky;
stone ➡️
▪️dull burning;
cholicystitis ➡️
▪️throbbing;
pyocele? ➡️
▪️stabting

4. Radiation
tip of the rt shoulder

5. Association
▪️nausea
▪️fever/chills
▪️jaundice/itching

6. Timing
more than 6 hours➡️cholicystitis
less than 6 hours➡️ biliary colic
(biliary colic is constant and not true colic)

7. Exacerbating
▪️fatty food
▪️breathing/movement
Relieving
▪️biliary colic➡️only strong analgesic

8. Severity
▪️impair activity
▪️or from 10

🟫 GIT
Vomiting,
Constipation,
Diarrhea,
Dystension,
Dyspepsia,
Dysphagia
Bloody stool
Appetite
Weight loss

💠Systemic Review
Cardiovascular:
chest pain, dysnea, hemoptysis
Urinary:
color, amount
CNS: drowsness,

💠Past Medical History
1. Similar condition
2. admission
3. blood transfusion
4. surgery
5. history of jaundice, recurrent malaria, anemia, IHD, asthma, HTN, DM

💠Family hx
Similar condition

💠Social hx
smoking
alcohol
insurance

💠Drug hx
current
chronic: contraceptive pills
allergy