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...

Transition Point Between Distended And Collapsed Veins

Radiofemoral Delay

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...

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...

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...

Palpation during inspiration

Bimanual Palpation Technique

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...

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...

Tests for nerve root compression

Nerve Root Anatomy

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...

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...

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...

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...

Palpate Brachial Pulse

Brachial Pulse Examination

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...

Common abnormalities

Allergic Dermatitis Insect

The temptation to examine skin lesions closely should be resisted until the distribution of the rash has been noted at arm's length. This may be the most valuable clue to the diagnosis. For example, it is not easy to diagnose herpes ,osier by the appearance of the individual lesions, but it becomes simple once the dermatomal distribution is appreciated Fig. 2.19A , Similarly, a photosensitive basis for a rash becomes obvious when it is noted that only exposed areas are involved...

The Physical Examination

Scalene Lymph Node

Fig. 4.3 Palpation of the right scalene lymph node. The patient should tilt the head forwards and to the right to relax the sternomastoid during the examination. Fig. 4.3 Palpation of the right scalene lymph node. The patient should tilt the head forwards and to the right to relax the sternomastoid during the examination. Abnormal findings. The speed with which a paiieni can dress or undress is often a useful index of respiratory disability. Evidence of recent w eight loss may suggest...

The pharynx and buccal mucosa

Addisons Disease Lips

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...

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...

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...

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...