The nervous system

General observation 192 Gait 193 Arm drift 194 Speech 194 The neck and cervical spine 196 Examination of the cranial nerves 196 The olfactory nerve 196 The optic nerve 197 The oculomotor, trochlear and abducent nerves 200 The trigeminal nerve 203 The facial nerve 205 The vestibulocochlear nerve 207 The glossopharyngeal and vagus nerves 210 The accessory nerve 212 The hypoglossal nerve 213 The motor system 214 Tone 216 Power 218 Deep tendon reflexes 218 Superficial reflexes 221 Coordination...

Urinary incontinence

This is categorised as urge incontinence when an urgent need to urinate cannot be resisted, and stress incontinence when leakage of urine occurs in response to coughing, sneezing or laughing some patients have both. An information checklist is shown in Table 5.22. Many parous women experience stress incontinence because of weakness of the anterior wall of the vagina, often accompanied by a degree of uterine prolapse. Incontinence may also arise from neurological disorders of bladder function....

Patterns of presentation

Visceral abdominal pain results from distension of hollow organs, mesenteric traction or excessive smooth muscle contraction. The sympathetic innervation of the abdominal viscera (spinal cord segments T5-L2) is responsible for the conduction of visceral pain parasympathetic afferents do not convey pain sensation. Accurate localisation of somatic pain due to irritation of the parietal peritoneum is provided by intercostal (spinal) nerves, which innervate the parietal peritoneum and...

Back pain

A careful history and examination to establish the onset, site distribution of pain and any associated neurological symptoms is critical to establishing the differential diagnosis of back pain. imaging is widely used in the investigation of back pain. The choice of imaging is dependent on what information is being sough (Table 8.14). Plain radiographs give limited information and often give false positive or false negative results. For example, in a patient with chronic low back pain and...

Radiological investigations

The effects of ionising irradiation depend upon the dose rate, the tissue distribution and the type of radiation, i.e. photon (gamma-rays and X-rays) or particulate (alpha- and beta-particles). Since different types of radiation have different effects on different tissues, the effective dose equivalent, measured in sieverts (I Sv 100 rem), is used to express the equivalent dose of uniform whole-body TABLE 5.40 Special investigations in gastrointestinal, hepatobiliary and genitourinary disorders...

Wind flatulence

Repeated belching, excessive or offensive rectal flatus, abdominal distension and even borborygmi (audible bowel sounds) may all be called wind', a term which the patient should be asked to clarify. Belching often results from air swallowing (aerophagy) which occurs without the patient's awareness. Belching itself is of no major significance, although it may indicate anxiety, and sometimes occurs in an attempt to relieve abdominal pain or discomfort. The normal volume of flatus per rectum...

The Physical Examination

There is no correct sequence of performing a physical examination. It is important for all doctors to develop their own approach. By so doing the clinician will reduce the risk of making mistakes. The time-honoured sequence of physical examination is These have to be integrated into the examination and can be altered as deemed necessary. For example, it may be advisable to listen in bowel sounds before palpating die abdomen. Although the tendency is to teach the techniques of physical...

Measurement Of Height Weight And Temperature

A clinical examination should include the measurement of weight and height, both for their immediate value and for I'ulure reference. Measurements such as span, sitting height and pubis to ground height are made only where a more precise evaluation of growth and development is required, especially in infants and young children. In an adult 70-kg male, total body water 42 kg accounts for 60 of body weight and fat accounts for about 10 kg. In females, there is a greater percentage of total body...

Further Investigations

In many cases it is possible to make a reliable diagnosis from the history and clinical examination. I his applies, for example, to conditions such as bronchial asthma, chronic bronchitis and lo some cases of pneumonia and pulmonary infarction. At other times clinical examination fails to reveal any abnormality and the diagnosis depends entirely on specialised investigations, particularly radiology. Pulmonary tuberculosis and bronchial carcinoma are two important diseases which may not give...

Thoracic spine

The presenting symptoms of pathology in the thoracic spine are usually localised spinal pain see Disorders box or pain radiating round the chest wall or, less frequently, symptoms of paraparesis including sensory loss, leg weakness, and loss of bladder or bowel control. Disc lesions are rare and may be accompanied by girdle pain radiating around the chest, mimicking cardiac or pleural disease. Pain arising from joints at the thoracolumbar junction can occur in ankylosing spondylitis and again...

The General Examination

Malar Flush

The general inspection of patients has been discussed in Chapter 2. In particular, the hands p. 46 , the optic fundi Ch. 7 and the face Figf3.7 may provide important signs of cardiac disease. Features which are relevant to a cardiac diagnosis include whether or not the patient appears breathless, distressed or anxious or if there is evidence of alcohol abuse Fig. 1.9 or tobacco consumption Fig. 1.8 , TAB LE 3.15 Scheme of cardiovascular exami nation '' ' 1 '' '' -i ' --- --- ------ 1 Get a...

Dyspnoea at rest

Lead Ecg Anterior Infarct

This represents the most advanced form of cardiac dyspnoea and indicates the presence of severe heart failure. When it occurs in patients with known cardiac disease and is preceded by a history of worsening effort dyspnoea, orthopnoea and PND and perhaps ankle swelling, a cardiac cause is self-evident. However, patients presenting de novo with acute dyspnoea at rest or who have both lung and heart disease may be more difficult to assess. Other causes include pneumothorax and pulmonary embolism....

Facial and body hair

Panhypopituitarism Pictures

Hirsutism is an excessive growth of coarse hair in the female on the face, trunk and limbs in the pattern normally seen in males. The pubic hair spreads from its normal Hat-topped distribution up towards the umbilicus, this being described as a male escutcheon. Mild hirsutism is a common condition, often associated with higher than average levels of testosterone. In some subjects it may be a cause of considerable psychological distress. Some increase in facial hair is common after the...

The lips

Exposure to cold commonly causes dryness followed by desquamation and cracking of the lips. Somewhat resem bling this is the much rarer cheilosis of riboflavine deficiency causing red. denuded epithelium at the line of closure of the lips, peeling towards the mucocutaneous junction. A similar appearance may result from the use of lipstick to which the patient is hypersensitive. Angular stomatitis, consisting of painful inflamed cracks at the corners of the mouth, is often caused by ill-fitting...

Abdominal aortic aneurysm AAA

AAA are present in 5 of men aged over 65 years and arc three times commoner in men than women. Patients may present with abdominal and or back pain or an awareness of pulsation. Many patients are asymptomatic until the Fig. 3.41 Pallor of the hand with mottling ol the lingers following occlusion of the right axillary artery. Fig. 3.42 Arteriogram showing axillary embolus. Arterial insufficiency in the internal carotid territory typically presents with ocular and or hemispheric features Ocular,...

Pain a common presenting complaint

Pain is the commonest presenting problem, accounting for ahout half of all consultations. Specific presentations of pain that arise in each system are described in the chapters Cardiovascular system No cardinal symptoms Gastrointestinal system Nausea reported Other relevant gastrointestinal symptoms reported or absent Establish how much of a problem for the patient Fig. 1.6 The layers of the HPC. In the absence of cardinal cardiorespiratory symptoms, the clinician rapidly proceeded to eliciting...

Tests for nerve root compression

Femoral Stretch Test

Prolapse of intervertebral discs occurs most frequently at the L4 5 or L5 SI level, producing compression of the L5 and SI nerve roots respectively. Tension can be applied to these nerve roots by flexing the hip with the knee straight -the so-called straight leg raising test. Normally, about 90 degrees of hip flexion should be possible but this varies considerably 70-120 degrees . When the root is stretched over a prolapsed disc, straight leg raising will be restricted and pain will usually be...

Arm drift

Romberg Test

A very useful but non-specific sign in clinical neurology is termed 'drift'. A positive sign suggests some underlying abnormality in nervous function and is an indication for performing a more detailed neurological examination. Ask the patient to close the eyes and outstretch die limbs, placing palms uppermost and the fingers extended and adducted, and then to maintain this position. Normally the limbs do noi drift with eyes closed. Abnormality may involve a subtle change in finger position...

Dysuria frequency and urgency

These are cardinal symptoms of urinary tract infection, the commonest condition to affect the urinary tract. Dysuria is pain experienced prior to. during or following micturition, usually in the urethra or suprapubic region. When due to urinary infection, it is often described as a burning sensation, even akin to passing broken glass. Urinary frequency describes an increased frequency of micturition without implying any increase in the total urine volume. Urgency is a strong desire to pass...

General symptom systemic inquiry

Alcoholic Myopathy Symptoms

It is inconceivable that any patient will require to be asked all the questions that may be important on some occasions. For example, enquiry about contact with birds may be critical in a patient with atypical pneumonia but is a waste of time in many situations. It follows that the choice of questions selected to ensure that the history, as obtained, is sufficiently comprehensive is a matter of clinical judgement. As a general principle, it is important for the clinician to pay particular...

The shoulder

Painful Arc Syndrome

During the examination of the shoulder, it is necessary to determine which joint or structure is responsible for any limitation of movement. While examining for flexion and abduction, it is important to place a restraining hand on the scapula or acromion . Once the limits of movement of the glcnohumeral joint are reached, any movement of the scapula on the thorax is immediately detected. Loss of external rotation at the shoulder usually indicates glcnohumeral joint pathology. Where there is a...

Nails

Lupus Vasculitis Fingera

Growth is slowed by acute illness and ischacmia. It is increased In psoriasis. Injury to the nail matrix is by far the most common cause of changes in the nails and may permanently impair their growth. Some Important changes in the nails are indicated in Table 2.10. Longitudinal ridging and beading of the nail plate increases with age and is not abnormal. Similarly, occasional white transverse flecks striate leuconychia are seen frequently in normal nails they are probably caused by minor and...

Sequence On The Cough

This is the most frequent symptom of respiratory disease. It may be caused by stimuli arising in ihe mucosa of the respiratory tract from the pharynx to the smaller bronchi. Stimuli arising in Ihe parietal pleura may, 011 rare occasions, also produce cough, for example during ihe aspiration of a pleural effusion. The frequency, severity and character of cough are dependent on several factors including a the situation and nature of the lesion responsible, b the presence or absence of sputum and...

Common abnormalities

Aortic Diastolic Murmur

The causes of systolic murmurs are listed in Table 3.27. Ejection systolic murmurs can be caused by an increased stroke volume How murmur , or a stenosed aortic or pulmonary valve. Causes of flow murmurs include pregnancy, fever, bradycardia and atrial septal defect. The murmur of aortic stenosis is usually audible all over the preeordium. including the apex Fig. 3,31 . ft may be harsh, or high pitched and musical, and radiates to the upper right sternal edge and carotids. The...

Associated phenomena

Subarachnoid Hemorrhage Scan

Nausea and vomiting typically accompany migraine whereas raised intracranial pressure headache may be associated with vomiting, but often without nausea. Tension headache is not usually accompanied by Liny of these symptoms. Migraine is often accompanied by intolerance to lighl photophobia or noise phonophobia , irritability, food cravings and hunger, In 15-20 of patients visual disturbances teichopsia and fortification spectra and or peripheral and circumoral paraesthesiae occur, usually...

Temperature

Facial Appearance Cushings Disease

The warmth of the skin to the touch usually provides a good indication of fever, but the skin of a patient with a normal temperature may feel cold, and an apparently normal skin temperature does not exclude hypothermia. Fever is usually due to organic disease. An otherwise inexplicable transient rise may be due to a recent hot drink Fig. 2.7 Insulin-induced lipodystrophy. Fig. 2.7 Insulin-induced lipodystrophy. or a hot bath. Individuals sometimes falsify their temperatures by a variety of...

Blood Pressure

Correct Measurement Blood Pressure

Blood pressure is usually measured using a sphygmomanometer cuff wrapped round the upper arm, This is shown in Figure 3.17. Attention to detail is needed for accurate blood pressure measurement. A checklist is given in Table 3.19. It is important to use the correct size of cuff. A bladder length of 30-35 cm and width of 12 cm is suitable for most adults. D Support the arm comfortably at about heart level. Identify the brachial pulse. Inflate the cuff until the pulse is impalpable. Note the...

The pharynx and buccal mucosa

Buccal Pigmentation Addisons

Small lymphatic nodules can normally be observed on the posterior wall. With infection in the nose or sinuses, mucus or pus may be visible trickling down the back of the throat. Koplik's spots. In measles small white spots on an erythematous background arc distributed over the mucosa of the cheeks opposite the molar teeth and sometimes throughout the mouth. These Koplik's spots are of diagnostic value as they appear before the rash. Aphthous stomatitis. This is characterised by ulcers on the...

Chronic venous insufficiency

Venous Guttering

Chronic venous insufficiency produces skin changes in the lower leg varicose eczema, lipodermatosclerosis. ulceration due to sustained venous hypertension which in turn is due to reflux 90 and or obstruction 10 in the superficial and or deep veins. TABLE 3.38 Clinical features of venous and arterial ulceration Typically first develops at 40-60 years but many do not present to medical attention until many years later multiple recurrences are the norm Typically affects patient for the first time...

The face and eyes

Palpable Artery Temporal Arteritis

The face may provide important diagnostic information Fig. 2.34 . Some facial appearances are characteristic of specific diseases Table 2,11 . The eyes are discussed in Chapter 7. Normal ears vary widely in size, shape and form. There are some genetic deformities. For example, in Down's syndrome the auricles are usually small and the lobule may be rudimentary or absent. The helix of the ear is a recognised site of gouty tophi - white chalky nodules consisting of sodium biuratc crystals...

The nose and sinuses

Perforation Nasal Septum

The nose may be deformed as a result of an old fracture, or enlarged, red and bulbous rhinophyma in the late stages of rosacea Fig. 2.36, p. 53 . Fig. 2,34 The face as a diagnostic aid. 0 Facial telangiectasia in 69-year-old lady with CREST syndrome. E The characteristic rash of systemic lupus erythematosus. A cone of Sight is reflected from its lower end downwards and forwards to the periphery of the drum see Fig. 2.31 A . The common abnormalities on inspection of the drum are acute...

Single lesions

Constructional Apraxia

The extent and nature of the dysfunction will often enable the location of a lesion to be deduced fairly precisely. Cerebral cortex. Although the cerebral cortex functions in an integrated manner, certain cortical areas are associated with specific functions. The effects of lesions at different sites in the parietal, frontal, occipital and temporal lobes are summarised in Figure 6.51. Impairment of specialised functions results in dementia, dysphasia, apraxia, astereognosis and other forms of...

Abdominal distension bloating

The principal causes of abdominal distension arc far. flatus, faeces, fluid aiul fetus Table 5.10 . Increasing abdominal girlh is usually due to adiposity and should alert the clinician to the possibility of alcohol abuse. Its development in a patient who is otherwise becoming thinner suggests intra-abdominal disease. Ascites, the accumulation of fluid in the peritoneal cavity, is usually due to cirrhosis of the liver, malignancy, nephrotic syndrome, tuberculous peritonitis, cardiac or...

The History Presenting complaints

The severity of the symptoms may bear little relationship to the gravity of the underlying pathology. For example life-threatening, deep venous thrombosis DVT may be asymptomatic. There are four cardinal symptoms of lower limb venous disease. 1. Pain. Patients with uncomplicated varicose veins may complain of an aching discomfort in Ihe leg, itching and a feeling of swelling. Symptoms arc typically aggravated by prolonged standing and are often worse towards the end of the day. The pain of deep...

Abnormal findings

Bowel Sounds

Gaseous distension of the abdomen is resonant to per cussion. The gravid uterus, bladder enlargement, ovarian cysts, and other solid pelvic masses extend out of the pelvis into the abdomen to produce central abdominal dullness with resonance of the flanks caused by gas in the surrounding displaced gut. In contrast, ascites is suggested by the presence of dullness in the flanks with central abdominal resonance. Ascites is often first suspected from the convexity of the abdomen and flanks on...

Dyspepsia indigestion

Indigestion' is a common complaint, it is essential that the patient explains in detail what is meant by this vague term. Indigestion might describe nausea, heartburn, epigastric discomfort, abdominal pain, belching or a feeling of postprandial bloating. It may even be used to describe angina pectoris. Peptic ulcers usually produce characteristic symptoms, as shown in Table 5.7. Differentiation between oesophageal, gastric or duodenal ulcers on Ihe basis of symptoms alone is often unreliable....

Anterior Tibial Artery Palpation

Dorso Flexi Pedis

The anatomy of he radial, brachial and carotid pulses have been described I p. 83 . Femoral artery. The I'emoral artery is situated just below the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis mid-inguinal point . It is immediately lateral to the femoral vein and medial to the femoral nerve. In the obese it can be difficult to feel. Popliteal artery. At the level of the knee crease, the artery lies deep in the popliteal fossa and the pulse is...

Jaundice

Enterohepatic System And Urobilinogen

Jaundice is the result of excess bilirubin circulating in the blood. Most bilirubin originates from the catabolism of haemoglobin in the reticuloendothelial system. Unconjugated bilirubin bound to albumin cannot be excreted into the urine. Following hepatic glucuronidation, bilirubin dtglucuronide enters the gut lumen via the biliary tree and is metabolised by the gut microflora to urobilinogen Fig. 5.1 . Urobilinogen is then reabsorbed anil enters the entero-hepatic cycle in health, it is...

The optic II nerve

Red Hat Pin For Visual Field Exam

Examination of the optic nerve involves testing Much of the examination of the optic nerve is described in Chapter 7. This section deals with the pupillary reflexes and with the visual lields. The optic nerve transmits the axons of the retinal ganglion cells. It begins at the back of the globe and passes through the optic canal of the sphenoid bone into the cranium, where it joins with the contralateral nerve to form the optic chiasma. The optic tract then passes posteriorly to the lateral...

Dolls Eye Movement In Response To Irrigation Of Tympanic Membranes Of Ears

Weber Test

The cochlear branch subserves hearing, The fibres arise from the end organs in the inner ear. They pass centrally along the internal acoustic meatus and cross the cerebellopontine CSF cistern to enter the lateral brain stem at the Fig. 6.21 Types of facial weakness. Caused in IB by lesion of precenfral area or pyramidal Iract upper motor neurone El by lesion of facial nerve or nucleus lower motor neurone , also showing Bell's phenomenon. Fig. 6.21 Types of facial weakness. Caused in IB by...

Palpate Brachial Pulse

Carotid Pulse

The radial pulse is readily felt just lateral to the tendon of the flexor carpi radialis muscle Fig. 3.12 , It is particularly useful for assessing the rale and rhythm of the pulse. The brachial artery can be felt in the brachial fossa immediately medial to the biceps tendon. The carotid pulse is palpable in the neck and provides a better indicator of volume and character than is obtained from the radial pulse. Fig. 3.12 The radial pulse. H Locating and palpating the radial pulse, b I Feeling...

The sensory modalities

Peripheral Nerve Leprosy

From the clinical viewpoint, the important sensory modalities are joint position sense tproprioception , light touch, pin prick, vibration, temperature and two-point discrimination. Other sensory functions are important but will be covered under the section on the cortical examination see Table 6.24 . It is unusual for a patient to experience only one sensory symptom. The aims of sensory testing are to determine if any modalities are impaired to determine the site of any lesion from the...

The Upper Respiratory Tract

Cricosternal Distance

The upper respiratory tract extends from the external nares to the junction of the larynx with the trachea, it includes the nasal cavity, the nasopharynx, the nasal sinuses, the oropharynx and the larynx. Clinical examination of the nose, throat and mouth is an essential part of the assessment of patients with respiratory disease. In normal subjects, the upper 4-5 cm of the trachea can be felt in the neck between the cricoid eartilagc and the suprasternal notch, but in ihick-set or obese...

Breast lump

Juvenile Fibroadenoma

T he commonest cause of a breast lump varies with age. Carcinoma of the breast. This is one of the commonest malignancies in women in the UK, affecting I in 12 women. Its incidence increases with age, but any mass must be regarded as potentially malignant until proven otherwise. Cancer of the male breast is uncommon and there is a strong genetic factor. Characteristically carcinomas are solid masses with an irregular outline, often painless but firm or hard, contrasting in consistency with the...

Menstrual and obstetric history

The menstrual history should include the age at onset of menstruation menarche and of cessation of menstruation menopause as appropriate. Details of the menstrual cycle should also include the date of the first day of the last menstrual period and the duration of menses Table 5.23 . The norma age of the menarche varies from the ages 10-15. Thereafter, patients who fail to menstruate at all, primary amenorrhoea, should be investigated for possihle gynaecological or endocrinological...

Abnormalities in the shape of the chest

Rickets Chest

Those of clinical importance are as follows. Increase in anteroposterior diameter. In some patients with emphysema, the posterior AP diameter is increased and the two measurements may approximate barrel chest . The degree of chest deformity in emphysema is not a reliable guide to the severity of the functional defect. An increase in anteroposterior diameter may also be due to thoracic kyphosis unrelated to respiratory disease Fig. 4.12 . Thoracic kyphoscoliosis. This ranges in degree from the...

Transition Point Between Distended And Collapsed Veins

Collapsed Vein

There are no valves between the right atrium and the internal jugular vein. It follows that the degree of distension in the vein equates to the pressure in the right atrium and the venous waveform provides information about cardiac function. The internal jugular vein enters the neck behind the mastoid process. Il runs deep to the sternomastoid muscle before entering the thorax between its sternal and clavicular heads. Because of its deep position the internal jugular vein can only be examined...

Scalp Nerve Pain

Cutaneous Nerve Distribution Scalp

Sensation is provided through three major branches which join together to form the Gasserian ganglion which sits in Meckel's cave in the petrous temporal dura. The ophthalmic branch V, . This supplies sensation to the skin of the upper nose and eyelid, forehead and scalp see l-'ig. 6.15 as well as the cornea, conjunctiva, intraocular structures, parts of the mucosa of the frontal, sphenoidal and ethmoidal sinuses and the upper part of the nasal cavity. The ophthalmic branch...

The Chest

Physical examination of the chest makes use of the techniques of inspection, palpation, percussion and auscultation. in health, the trachea is central and the apex beat is in the normal place see p. 90 . The surface markings of the lungs are shown in Figure 4.11. The upper lobes are primarily in the front of the chest and the lower lobes are predominantly posterior, with the apex of the lower lobes at the level of the 4th thoracic vertebra, 3rd spinous process. In normal subjects the two sides...

Heart Auscultation

Auscultation Aortic Regurgitation

The first heart sound is caused by the closure of the mitral and tricuspid valves at the beginning of ventricular systole. It is best heard at the apex. The second heart sound. This is caused by the closure of the pulmonary and aortic valves at the end of ventricular systole and is best heard at the left sternal edge. It is louder and higher pitched than the first sound and normally the aortic component is louder than the pulmonary one. Physiological splitting of the...

Altered bowel habit

The normal bowel habit varies between several evacuations per day to one every 3 days or so. Changes in bowel habit may be the first symptom of serious underlying disease. Constipation may be used by the patient to describe hard pellety stools, infrequent defecation or excessive straining at stool with difficulty in evacuation dyschezia . Similarly, diarrhoea may be used to describe frequent defecation, loose or fluid stools, urgency of defecation, Ihe persistent desire to defecate or faecal...

Common disorders of the mouth

Mucous Patches Syphilis

This is commonly due to the combination of a spirochacte and a fusiform bacillus which can be seen in a smear taken from one of the ulcers Vincent's infection . The condition is painful and foul smelling. Ulcerative stomatitis may complicate acute leukaemia or agranulocytosis and immunosuppression. In acute leukaemia the gums often bleed and may be so swollen that the teeth may be largely obscured. Agranulocytosis may present as a sore throat, which may progress to an...

Indications for a vaginal examination

Posterior Fornix

Surveillance for cervical carcinoma Symptoms of uterine prolapse Unexplained urinary tract obstruction P Ask the patient to empty Ihe bladder. Position the patient comfortably either on her back or in the left lateral position with her head on a pillow, hips and knees flexed and thighs abducted. P Use a lamp to illuminate the vulva adequately. P Use suitable gloves and lubricate the examining fingers. P Separate the labia minora with the forefinger and thumb of the left hand, bringing into...

Retinal vascular abnormalities

Fundus Stormy Sunset

Superficial retinal haemorrhages are flame shaped because of tracking of blood along the horizontally arranged nerve fibres. They occur in hypertension Fig. 7.17 . Deep haemorrhages arc dark-red blots contained by the vertically arranged deep retinal layers. Microaneurysms look very similar. Both occur in the dots and blots of diabetic retinopathy Fig. 7.22 . Preretinal haemorrhages obscure the underlying retina. Initially round, they form a flat-topped fluid level and may burst...

Ankle Jerk Reflex

Examination Supinator Reflex

A neurological reflex depends on an arc which consists of an afferent pathway, which is activated by a specific receptor, an efferent system, which activates a stereotyped response, and a simple or complex pathway that interconnects the afferent and efferent systems. Since the reflex response to an appropriate stimulus is involuntary, disturbances of reflexes afford objective signs of neural dysfunction. The deep tendon reflexes of the limbs provide essential information about Lhe status of the...

Difficulty in swallowing dysphagia

The swallowing mechanism involves the brain stem, the glossopharyngeal and vagal nerves and the cnteric nervous system of oesophageal smooth muscle. The swallowing reflex begins with an oral phase which drives the food bolus into the pharynx the pharyngeal phase ensues with closure of the larynx, relaxation of the upper pharyngeal sphincter cricopharyngeus and sequential contraction of the pharyngeal constrictors to propel the bolus into the Feeling of a lump in the throat globus Difficulty in...

Nausea and vomiting

The combination of nausea and vomiting usually suggests an upper gastrointestinal disorder but may also be a prominent feature of non-alimentary disorders see Disorders box . In most instances, vomiting is preceded by nausea, but in some cases, e.g. intracranial tumour, the vomiting can occur without warning. Vomiting may also result from severe pain, as in renal or biliary colic or myocardial infarction, from systemic disease, metabolic disorders and drug therapy. Vomiting may be self-induced...

Palpation during inspiration

Abdominal Palpation

The liver, gallbladder, spleen and kidneys should be examined in turn during deep inspiration. The key to success is to keep the examining hand still and wait for the organ to descend. One common error is to begin palpation of the liver too close to the costal margin, thereby missing Place the hand flat on the abdomen with the lingers pointing upwards and position the sensing fingers index and middle lateral to the rectus muscle so that the fingertips lie on a line parallel to lhe expected...

Palpating The Heart

Apex Beat Palpate

The normal apex beat lies in the 5th left intercostal space the space below the 5th rib within the midclavicular line which, in the male, is the intercostal space immediately below and approximately in line with the left nipple, The intercostal space can be located by counting down from the second rib which is at the level of the sternal angle. The normal apical impulse gently and briefly lifts the palpating lingers and is quite localised. I lowever, in some normal subjects, particularly if...

Complexion

Brownish Tinge Uraemia

Abnormalities of complexion may be tirst noticed by patients or by their friends or relations. Tile colour of the face depends upon variations in oxyhaemoglobin, reduced haemoglobin, melanin and, to a lesser extent. carotene-Unusual skin colours, excluding those which have been applied externally, are due to abnormal pigments such as the sallow brownish tinge seen in uraemia. The bluish tinge Fig. 2.2 Bilateral Dupuytren's contracture wilh thickening and shortening of palmar fascia resulting in...

Examination Of The Lower Limb The hip

Trendelenburg Walk

Ohserve ihe patient when standing and walking and note any abnormality of gait. n Observe the patient from behind and look for scoliosis and pelvic tilling which may conceal a hip deformity or true shortening of one leg Figs 8.22, 8.23, and 8.24 . If pelvic Lilt is present, examination of leg lengths is essential. Test for stability of the hip - Trendelenburg's test Ask the patient to stand first on one leg and then the other. Observe any change in pelvic tilt on the non-weight-bearing side...

Important points in the clinical examination of a patient with an acute abdomen

Rebound And Guarding Abdominal Exam

The examination may begin with the abdomen but should then include the other systems since the disorder may be non-alimentary in origin, The hernial orificcs, scrotal contents and rectum are important components of the examination. Rectal examination is uncomfortable. Repeated examination should be avoided. The examination is best performed by the clinician making the management decisions. Tenderness elicited by rectal and vaginal examination may be the sole sign of inflammation of the pelvic...

Scalp hair

Totalis Areata

Certain follicles of the scalp regress with age to produce tine vellus instead of coarse terminal hairs. This patterned baldness often starts as temporal recession, progressing to thinning of hair over the crown. It is common in males and is androgen dependent, prevented by prepubertal castration but not reversed by castration in maturity. Temporal recession is less common in women and may suggest virilisation. Loss or thinning of hair over the frontal region is an almost constant finding in...

The types and causes of oedema

Lymphangiectasia Post Radical Mastectomy

Oedema may be generalised or localised and it results from factors disturbing the physiological control of body fluid. Generalised oedema Fig. 2.9 . There are two principal causes of generalised oedema, hypoproteinaemiu and fluid overload. Clinically, these two causes can be distinguished because fluid overload usually results in a rise in JVP p. 89 . whereas the JVP is not elevated in hypoproteinaemia. Hypoproteinaemia. The osmotic pressure is mostly due to the serum albumin so that a fall in...