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Clinical Signs

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CLINICAL SIGNS Abdominal Mass Exp: Palpation of an abnormal structure in the abdominal cavity Int: (+) Carcinoma of bowel or stomach, Crohn s disease, !od"#in s disease, appendicea) abscess, pancreatic tumour, aortic aneurysm, pre"nancy, uterine fibroid or tumour, ovarian tumour or cyst, hydatid cyst, distended "all bladder, enlar"ed liver (see !epatome"aiy), enlar"ed spleen (see $plenorne"aly), enlar"ed #idney (see %idney, &ar"e), umbilical hernia, in"uinal hernia, post'traumatic scarrin", pyloric stenosis, bladder carcinoma, vertebral tumours Phys: (ny or"an in the abdominal cavity may become diseased and distended Abdominal Rigidity Exp: )nrelaxable firmness of the abdominal wall on palpation Int: (+) (ppendicitis, pancreatitis, perforated viscus (e*"* peptic ulcer), acute Crohn s disease, intraperitoneal haemorrha"e, ectopic pre"nancy, ruptured ovarian cyst, peritonitis, pelvic inflammatory disease Phys: Involuntary muscular spasm due to irritation of the peritoneum by blood, pus, acid, en+ymes or inflamed tissue $ee (lso Camett s ,est Adenitis See Symptoms: (denitis and &ymphadenopathy Adson's Test Exp: Patient is seated with hands on thi"hs, and ta#es and holds a very deep breath* ,he nec# is then hyperextended, and the head turned from side to side* Positive if radial pulse on one side is obliterated Int: (+) Cervical rib syn*, thoracic outlet syn*, scalenus anticus syn* Phys: Compression of subclavian artery a"ainst abnormal cervical rib or scalenus anticus Adventitious Sounds $ee Crepitations, Pulmonary- Crepitations, ,issue- Rhonchi; Symptoms: $tricter Amphoric reathing Exp: !i"h pitched, metallic toned, bronchial breathin" heard on auscultation Int: (+) .pen pneumothorax, tuberculous cavities Phys: /amed after 0ree# amphora (pottery vessel), as breath sounds similar to blowin" over the top of a bottle Anaesthesia See $ymptoms: Anaesthesia An!le Clonus Exp: $harp dorsiflexion of foot causes repeated spasm of calf muscles and plantar flexion of foot Int: (+) )pper motor neurone lesions and disease, functional nervous disorders, epilepsy, tuberous sclerosis, 1ilson s disease, uraemia, encephalitis, multiple sclerosis, C2(, cirrhosis, Creut+feldt'3a#olb disease, encephalitis lethar"ica, alcohol withdrawal, dru"s, beni"n idiopathic

Phys: 1ith an upper motor neurone lesion there is no inhibition of the tendon stretch reflex $ee (lso Ankle Jerk An!le "er! Exp: 1ith patient #neelin" on a chair, or supine, the (chilles tendon is struc# firmly, causin" spasm of the calf musculature Int: (') Peripheral neuropathies, polio, tabes dorsalis, posterior root tumour, spinal tumours, subacute combined de"eneration of the cord, syrin"omyelia,4 multiple sclerosis, hypothyroidism, diabetes mellitus, beriberi, often absent in elderly(++) )pper motor neurone lesions, encephalitis, anxiety, tetanus, hype rlhyroidism, cord transection Phys: 5eflex absence due to interruption of the reflex are or muscular disease Exa""eration due to lac# of suppression of reflex by cortical centres* (cts at &67, &8, &9 $ee (lso other si"ns listed under Reflexes An!le #edema Exp: $wellin" of the an#le due to excess fluid accumulation Int: (+) Con"estive cardiac failure, venous valve incompetence, venous thrombosis, hypoproteinaemia, malnutrition, cirrhosis, "lomeruionephritis, nephrotic syn*, secondary hyperaidosteronism, intra'abdominal tumour, filariasis, cellulitis, "out, $&E, pre"nancy, pre'eclampsia, prolon"ed sittin" or rest, heat, dru"s (e*"* felodipine, nitedipine) Phys: 5educed venous return from the le"s, excess body fluid load or localised inflammation $ee (lso Pittin" .edema- $ymptoms: Oedema Ape$ eat Exp: Palpation of the cardiac apex beat and assessin" its duration, force, site (see (pex :eat ;isplacement below) and area covered* <elt with patient supine, or erect and leanin" forwards Int: <orceful, displaced laterally, sli"htly prolon"ed ' !ypertension ;isplaced laterally, rapid rise and fall, brief duration ' (ortic or mitrai re"ur"itation Powerful, prolon"ed, not displaced ' (ortic stenosis Ape$ eat %isplacement Exp: Palpation of chest wall with flat of fin"er tips to detect point of maximal cardiac pulsation* /ormally = to >? em to left of midline in @th intercostal space Int: ;isplaced to left ' Cardiome"aly (e*"* valvular disease, hypertension, pulmonary disease, cardiomyopathies, con"enital heart disease, aneurysm, rheumatic fever), pulmonary fibrosis, scoliosis* pectus excavatum, elevated diaphra"m, bronchiectasis ;isplaced to ri"ht ' Pneumothorax, pleural effusion, dextrocardia Phys: Commonly due to cardiac or pulmonary disease Apley's Grind Test Exp: 1ith the patient prone, flex the #nee to be tested to A?>* (pply pressure to the bottom of the heel in order to force the tibia into femoral articulation, then twist the tibia* If pain is felt at the #nee, the test is positive

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Int:

(+) Cartila"e dama"e in #nee Boint, septic arthritis

Areolar &igmentation Exp: ;ar#enin" of areola and nipple Int: (+) Present or past pre"nancy, hormone therapy, familial, racial Phys: Enlar"ement of Cont"omery s follicles in areola should also be noted in current pre"nancy or hormone therapy Argyll Robertson &upil Exp: $mall, irre"ular, uneDual pupils that do not react to li"ht, but do react to conver"ence Int: (+) /eurosyphilis, tabes dorsalis, diabetes Phys: ;ama"e to the midbrain section of the optic tract Arit's Line Exp: Cicatricial scarrin" of upper eyelid causin" entropion Int: (+) Chronic trachoma Phys: Chronic inflammation of subepithelial tissue of the tarsus See Also Entropion Arrhythmias' Cardiac $ee Bradycardia; Dicrotic Pulse- Extrasystolic :eats- 0allop Rhythm; Tachycardia; n!esti"ation: Arrhythmias# $ardiac $ee Also si"ns listed under !eart- Pulse Arteriovenous Nipping' Retinal Exp: .phthalmoscopic or slit lamp examination of the retina reveals narrowin" of venu)es where they are crossed by arlerioles Int: (+) !ypertension, arteriosclerosis Phys: Increased pressure on the venule in the shared adventitial sheath where vessels cross Ascites $ee Shiftin" Dullness; Thrill# %luid; $ymptoms: (scites Asteri$is $ee %lappin" ,remor Ata$ia Exp: &ac# of proper coordination* (n unsteady, uncontrolled "ait andEor a clumsy nose'tin"er test Int: (+) $ubacute combined de"eneration of cord, multiple sclerosis, <riedreich s ataxia, tabes dorsalis, cerebellar lesions posterior column lesions, poliomyelitis, hydrocephalus, postviral transient ischaemic attac#, foramen ma"num lesions, Creut+feldt'3a#ob disease, metabolic disorders, alcohol abuse, (n"elman syn*, :assen'%orri+wei" syn* &ouis':ar syn*, 5oussy'&evy syn*, $hy';ra"er syn*, 1ernic#e'%orsa#off syn* Phys: $ensory (posterior column) and motor (cerebellar) forms* <ormer may be compensated for by ocular impressions (poorer coordination with eyes shut) $ee (lso &eel'(nee Test#) /ose'<in"er ,estRom*er")s Si"n; Investi"ation** (chilles ,endon 5upture Athetosis Torsion %ystonia Exp: Involuntary, slow, writhin" movementsparticularly of hands and arms Int: (+) Infantile hemiple"ia, extrapyramidal lesions, basal "an"lia lesions, cerebral

palsy, encephalitis lethar"ica, 1ilson s disease, Buvenile !untin"ton s chorea, &esch'/yhan disease, #ernicterus, !allervorden'$pat+ disease, idiopathic and paroxysmal dystonias, dru"s (e*"* phenothia+ines, dia+oxide) Phys: 5elease mechanism associated with various forms of dama"e to basal "an"lia and related motor pathways, particularly in children with birth trauma or anoxia $ee (lso Choreiform +o!ements Atrial (ibrillation Exp: .n an EC0, numerous disor"anised waves (f waves) can be seen circulatin" rapidly and randomly throu"h the atria at a rate between 8?? and F?? per minute int: (+) Ischaemic heart disease, myocardial infarct, mitral valve disease, rheumatic valve disease, con"estive cardiac failure, card iomyopath i es, myocarditis, pericarditis, thyrotoxicosis, 1olff'Par#inson'1hite syn*, cardiac trauma, cardiac tumours &hys) (2 node receives f waves at a rate hi"her than it can conduct* ( random minority of these pulses are transmitted to the ventricles, "ivin" the irre"ular pattern of beats $ee (lso Irre"ularly Irre"ular Pulse Atrophy' Muscular Exp: 1astin" of musculature in one or more limbs* Careful comparative measurements of limbs advisable Int: (+) &ower motor neurone lesions, muscular dystrophies, rheumatoid arthritis, dystrophia myotonica, peroneal muscular atrophy, polio, motor neurone disease, prolon"ed immobilisation Phys: Interruption to muscular nerve supply or disuse due to pain causes wastin" Auspit*'s Sign Exp: 1hen white scale is removed from a plaDue of scale covered dermatitis on the shins, a bleedin" area results Int: (+) Psoriasis Phys: In psoriasis, the plaDue has a microcapillary circulation that is disrupted by its removal Austin+(lint Murmur Exp: 1hen listenin" to the cardiac apex, a murmur is heard that has its onset associated with a 8rd heart sound, is loudest at mid'diastole and may have some presystolic accentuation Int: (+) (ortic re"ur"itation Phys: ,he full openin" of the mitral valve is prevented by the re"ur"itant Bet from the aortic valve defect and the more rapid rise in the left ventricular than the left atrial diastolic pressure* InadeDuate function of the mitral valve subseDuent to the aortic re"ur"itation produces the characteristic murmur abins!i's Sign &lantar Re,le$ Exp: /ormally, slow dorsiflexion of the "reat toe and fannin" of the other toes occurs when the lateral side of the sole is stro#ed firmly with a pointed obBect, from the heel towards the toes* Positive with extension of "reat toe Int: (+) Corticospinal tract lesions, coma, post epileptic sei+ure, upper motor neurone lesions, multiple sclerosis, C2(, subacute combined de"eneration of cord, paraple"ia, normal infants Phys: (cts at $>, $7 level ar,ord Test Exp: Place both le"s in mirror'ima"e positions* ( stethoscope is placed over the symphysis pubis, and a comparison is made between the sound heard from a vibratin" >7G !+ tunin" for# placed on each medial femoral condyle or patella in turn*

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Positive if reduced conduction of sound occurs on the inBured side Int: (+) <racture of nec# of femur Phys: <racture disrupts conduction of sound from distal femur to pelvis arlo- Test Exp: 1ith the infant supine, the hips are adducted with the examiner s thumb over the medial aspect of the femoral head* Pressure is applied forwards and laterally by the thumb in an attempt to dislocate the hip* ,he hip is then abducted, and a clun# will be felt if the hip Boint has been displaced* ,est should be done without any si"nificant force bein" applied Int: (+) )nstable hip that has the potential for dislocation $ee (lso .rtolani ,est arrel Chest Exp: Chest fixed in inspiration* Increased anteroposterior diameter to "ive impression of a cylindrical chest Int: (+) Emphysema, asthma Phys: Permanent overinflation of distal air spaces due to chronic infections or expiratory airway obstruction See Also ,ink Puffer attle's Sign Exp: 5etromastoid bruisin" behind the ear Int: (+) <racture of the petrous bone Phys: :lood trac#s to this subcutaneous point from fracture site $ee Also Racoon Si"n eau's Line $ee /ail Rid"in" eighton Score $ee Joint &ypermo*ility iceps "er! Exp: 1ith elbow flexed and forearm sli"htly pronated, a fin"er placed on the biceps tendon is struc# firmly* /ormal reaction is flexion of the elbow Int: (') Polio, peripheral neuropathy (e*"* diabetes, alcoholism), tabes dorsalis, posterior root and cord tumours, syrin"omyelia, subacute combined de"eneration of cord, cord trauma, muscular dystrophy, coma, peripheral nerve lesions, elderly (++) )pper motor neurone lesions, tetanus, encephalitis Phys: (cts at [email protected], CF level $ee (lso other si"ns listed under Reflexes lac! .yes' ilateral Exp: :oth eyelids spontaneously blac#ened after trauma excluded* Cay be precipitated by si"moidoscopy Int: (+) (rnyloiclosis Phys: ,he 2alsalva manoeuvre of si"moidoscopy may be a precipitant lac! /rine $ee )rine, A*normal $olour lood &ressure $ee &ypertension; &ypotension lue loater Exp: .edematous patient with cyanosis at rest, warm extremities, "eneralised plethora, shortness of breath, productive cou"h, polycythaemia and a lar"e heart Int: (+) :ronchitic chronic obstructive airways disease

Phys: 0reatly increased airways resistance and cardiac failure See Also ,ink Puffer lue Cervi$ and 0agina Exp: 2a"ina and cervix are a dar# blue to purple colour on speculum examination Int: (+) Pre"nancy Phys: Increased pro"esterone levels cause venous dilatation $ee Also !e"ar s $i"n- (reolar ,i"mentation lue Line on Gums Exp: :lue line that cannot be cleaned away noted at "um mar"ins Int: (+) &ead poisonin" Phys: ;eposit of lead sulficle in "ums lue Sclera Exp: Int: Car#edly blue sclera (not iris) noted (+) <ra"ilitas ossium (osteo"enesis imperfecta) Phys: Con"enital disease transmitted by a dominant mutant "ene lue S!in $ee Symptoms: $yanosis# $entral; $yanosis# ,eripheral orborygmus Exp: 0reatly exa""erated, hi"h pitched, tin#lin" abdominal sounds Int: (+) Intestinal obstruction or infection, food poisonin", toxic enteritis Phys: $ound due to compression of air'fluid mixture by excessive peristaltic movements of "ut attemptin" to overcome obstruction or bein" irritated by infection ossing See %rontal Bossin" ouchard's Nodes Exp: :ony prominences at the dorsal mar"ins of proximal interphalan"eal Boints Int: (+) $evere osteoarthritis $ee (lso &e*erden)s -odes ounding &ulse Exp: <ull, exa""erated arterial pulsation Int: (+) ,hyrotoxicosis, fever, pre"nancy, anaemia, other hyper#inetic circulatory states, dru"s (e*"* adrenaline) Phys: 2asodilatation and increased cardiac output exa""erates peripheral pulsations outonniere 1 utton 2ole3 %e,ormity Exp: Painful, fixed flexion of proximal interphalan"eal fin"er Boint with mar#ed prominence of distal end of proximal phalanx and swellin" of Boint Int: (+) ;isruption of central slip of extensor di"itorum tendon allows Boint to protrude between medial and lateral slips of extensor tendon Phys: Cay be associated with a fracture avulsion of central slip which will reDuire sur"ical repair if displaced radycardia Exp: Int: $low heart (pulse) rate, "enerally below F? per minute (+) !ealthy athlete, elderly, fri"ht, cold, postinfective states, increased

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intracranial pressure, Baundice, cerebral tumours, hypothyroidism (myxoedema)* syncope, anaphyiaxis, myocardial infarct, heart bloc#, sic# sinus syn*, con"estive cardiac failure, $to#es'(dams syn*, vasova"al syn*, dru"s (e*"* di"italis, propranolol, morphia, other narcotics) Phys: /ormal heart rate maintained by cardiac sinus and appropriate conduction by bundle of !is to ventricles* 2a"al centres in medulla slow heart rate with increased cerebral pressure reathing $ee Barrel Chest- Blue Bloater; Bronchial Breathin"; $a!ernous Breathin"; $heyne'Stokes Respiration; $repitations# ,ulmonary; &yper!entilation; &ypo!entilation; (ussmaul)s Breathin" or Si"n; Rhonchi; ,ink ,uffer; ,leural Effusion ronchial reathing Exp: !arsh, clear, breath sound that is eDual in inspiration and expiration Int: (+) Pneumonia, pulmonary tumours, ,:, pulmonary consolidation Phys: $uppression of vesicular component of breath sound when alveoli not wor#in" results in bronchial breathin" rud*ins!i's Sign Exp: ,he head is flexed on the chest, causin" the lower limbs to be drawn up Int: (+) Cenin"eal irritation, menin"itis, cerebral abscess, subdural empyema, subarachnoid haemorrha"e, other cerebral haemorrha"es, typhus, leptospirosis Phys: ,raction of the inflamed menin"es on spinal nerves causes a protective flexor reflex $ee (lso -eck Stiffness; (emi")s Si"n ruit See Thrill# $ardiac See (lso si"ns listed under +urmur# $ardiac u,,alo 2ump Exp: Excess deposition of fatty tissue over upper thoracic vertebrae Int: (+) Cushin" s disease, steroid medication uphthalmos See Exophthalmos utter,ly Rash Exp : Erythematous, scaly rash spreadin" across both chee#s and meetin" on the nasal brid"e Int: (+) $&E, photodermatitis, discoid lupus, atopic dermatitis, serum sic#ness Phys: .ccurs in [email protected] of patients with $&E utton 2ole %e,ormity See Boutonniere .Button &ole/ Deformity Cache$ia Exp: 1idespread muscular wastin", "rey pallor, dry and wrin#led s#in Int: (+) Cali"nant diseases (e*"* carcinoma of lun", stomach, ovary), !od"#in s disease, leu#aemia, anorexia nervosa, chronic renal or hepatic disease, advanced diabetes, chronic ,:, malnutrition, chronic cardiac failure, chronic malaria,

ancylostomiasis, sprue, scurvy, (ddison s disease, fluorosis, thyrotoxicosis, $immonds disease, lead or mercury poisonin" Phys: Cany serious diseases, particularly when chronic, cause the loss of protein and #etones throu"h the urine* ( loss of muscle tissue and anaemia results $ee (lso $ymptoms: 1ei"ht 0oss Ca,e+au+Lait Spots Exp : &i"ht brown spots on s#in Int: (+) 2on 5ec#lin"hausen s disease of multiple neurofibromata, pityriasis versicolor, tuberous sclerosis $ee (lso $ymptoms: ,i"mentation of Skin# Excess Cal, S4uee*e Test Simmond's Test Exp: &ie Patient prone with both feet extendin" beyond the end of the couch by >? cm* 1ith one hand, "rip the sides of the "astroenemiusEsoleus and sDuee+e* <oot should plantar flex Compare with other side Int: (+) /ormal (chilles tendon (') 5uptured (chilles tendon Phys: ( complete rupture of the (chilles tendon may be missed because the foot may be plantar flexed usin" the deep lon" flexors* ,his test specifically demonstrates the inte"rity of the (chilles tendon Caloric Stimulation Exp: Irri"ation of the external auditory canal with ice'cold water causes the "a+e to turn laterally towards the side of the irri"ated ear Int: (+):rain stem intact (') :rain stem dama"e Phys: )sed for assessin" comatose patients* Chec# that there is no excess wax in ear canal and that tympanic membrane is intact before proceedin"

Cardiac %isplacement $ee (pex Beat Displacement Cardiomegaly See Apex Beat Displacement; $or ,ulmonale Carnett's Test Exp: In cases of abdominal tenderness, locate point of maximal tenderness, as# patient to cross arms and sit half way forward, and palpate area a"ain* Positive if tenderness increases Int: (+) (bdominal wall tenderness, not visceral pain Phys: ;ifferentiates intra'abdominal source of pain from abdominal wall pain in cases of acute abdomen $ee Also A*dominal Ri"idity Carpal Spasm See Obstetri' &and Cat Cry See $ri'du'$hat Cataract See 0ens Opacity Cavernous reathing Exp: !ollow Duality, low toned breath sound that is eDual in inspiration and expiration Int: (+) .pen pneumothorax, lun" cavities (e*"* ,:, bronchiectasis, pulmonary abscess) Phys: ;ue to lun" cavity surrounded by partially consolidated lun" tissue Central 0enous &ressure

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See Ju"ular 1enous ,ressure Cervical (leche Exp: 1ith heels and bac# placed a"ainst wall, patient tries to touch wall with bac# of head without raisin" chin above hori+ontal* Positive if unable to do so Int: (+) (n#ylosin" spondylitis, cervical vertebral trauma Phys: Indicates involvement of cervical vertebrae in disease Cervi$' Tender Exp: Pain on movement of cervix by examinin" doctor s fin"ers Int: (+) Pelvic inflammatory disease, ectopic pre"nancy, ovarian cysts, advanced carcinoma of cervix, endometriosis, salpin"itis, pelvic abscess Charcot's "oints Exp: ( totally disor"anised and apparently severely arthritic maBor Boint which remains completely pain free Int: (+) ,abes dorsalis, syrin"omyelia, diabetic neuropathy, myelomenin"ocele, leprosy Phys: Impairment of pain and proprioceptive sensation deprives the Boint of the normal protective reflexes when exposed to stress

hype rthyroidis m, $&E, cerebral tumours, C. poisonin", basal "an"lia disease, senility, chorea "ravidarum, oral contraceptive sensitivity, polycythaernia rubra vera, neuroleptic or phenytoin overdose, #ernicterus, hemiballismus Phys: ;ama"e in the area of the caudate nucleus and putamen Chvoste!'s Sign Exp: ( li"ht tap on the facial nerve as it emer"es from the stylomastoid forame. causes contraction of the facial muscles on that side Int: (+) !ypoparathyroidism, hypocalcaenlia, ric#ets, al#alosis, ma"nesium deficit, some normal people Phys: &ow serum calcium or ma"nesium causes muscular hype rexcitabi > ity and may lead to tetany See Also Trousseaus Si"n Circumoral &allor Exp - Relati!ely 2hite area around mouth (+) <ever of any cause (e*"* scarlet Int* fever) Phys : ;ilatation of superficial blood vessels in looser s#in further away from mouth causes dar#enin" and reddenin" of that area (rather than blanchin" of circumoral tissue) Clasp+5ni,e Rigidity Exp: 1hen a limb Boint is flexed by an examiner, there is considerable initial resistance which, once overcome, results in relative ease of movement Int: (+) )pper motor neurone lesion, spasticity Phys: ( len"thenin" reaction due to hyperactivity or sensitivity of alpha or "amma motor neurones $ee Also $o"2heel Ri"idity Cla- 2and +ain'en'3ritte Exp: Chronic spasmodic hand position characterised by flexion of wrist and interphalan"eal Boints and extension of metacarpophalan"eal Boints Int: (+) &ower motor neurone lesions, pro"ressive muscular dystrophy, uinar and median nerve paralysis, "ar"oylism, carpal tunnel syn* Phys: ;ue to wastin" of small hand muscles and overactivity of lon" muscles with interruption to peripheral motor nerve supply Clay Stool See %aeces# A*normal $olour Clonus See Ankle $lonus Clubbing o, (ingers Exp : $oft terminal part of fin"ers andEor toes immediately proximal to nail is bulbous, and nail is excessively curved in lateral Int: and lon"itudinal planes (+) Chronic diseases of heart, lun"s or alimentary system (e*"* lun" carcinoma, pneumoconioses, bacterial endocarditis, ,:, bronchiectasis, sarcoidosis, cirrhosis, lun" abscess, re"ional enteritis, tetralo"y of <allot), con"enital, in association with hypertrophic pulmonary osteoarthropathy, subphrenic abscess, cystic fibrosis, fibrosin" alveolitis, asbestosis, arteriovenous fistula, atrial myxoma, Crohn s disease, beni"n intrathoracic tumours, thoracic empyema, mesothelioma, familial Phys: ;ue to over"rowth of soft tissues and subBacent periosteum* Exact cause un#nown but may be due to increase in peripheral blood flow and reduced p., $ee Also Schamroth)s Si"n

Chaussier's Sign Exp: Epi"astric pain in a pre"nant woman with pre'eclampsia Int: (+) Imminent eclampsia Cheyne+Sto!es Respiration Exp: 5espirations that "radually decrease in freDuency until a temporary cessation occurs* 5espiration then restarts and the freDuency builds to a maximum before the cycle repeats itself Int: (+) C2(, menin"itis, uraemia, narcoti* *, barbiturate overdose, advanced cardia, disease (e*"* left ventricular failure), terminal sta"e of many chronic diseases, cerebral tumours, raised intracranial pressure Phys: ;ama"e to cerebral respiratory centre* .ne full cycle eDuates to twice the circulation time See Also ,apilloedema Chip Sign Exp: $#in blotches covered with fine, nonadherent scabs that are easily removed by a fin"ernail or blunt ed"e Int: (+) Pityriasis versicolor Phys: $uperficial fun"al infection Chloasma Exp: Iellow'brown spotty s#in pi"mentation, often on upper chee#s and forehead Int: (+) Pre"nancy, oral contraceptives, sun exposure, syphilis, malaria, ,:, cirrhosis, chronic trauma, some dru"s Phys: Celanocyte stimulation Chorel,orm Movements Exp: Irre"ular, spontaneous, rapid, random, purposeless movements of the lar"er Boints* Increased by voluntary effort and emotion Int: (+) $ydenham s chorea, !untin"ton s chorea (slower movements), encephalitis, rheumatic fever,

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Co,,ee+Grounds 0omitus Exp: ;ar# brown "ranular vomitus > nt: (+) Peptic ulcer, stomach carcinoma, oesopha"eal varices, portal cirrhosis, yellow fever Phys: (lteration of blood due to action of "astric acid Cog-heel Rigidity Exp: 5esistance to passive movement diminishes in Ber#y steps Int: (+) Extrapyramidal lesions, athetosis, paralysis a"itans (par#insonism), cerebral palsy Phys: $tatic tremor mas#ed by ri"idity See Also 0ead',ipe Ri"idity#) $lasp'(nife Ri"idity See %estination under 3ait# A*normal Coilonychia See (ofionychia Coin Test Exp: 1hen a coin on the chest wall is struc# by another coin, a metallic noise is heard throu"h a stethoscope placed on the chest wall at a distance from the coin ,wo sides of chest should be compared Int: (+) Pneumothorax Phys: Conduction of sound is altered by the partial collapse of a lun" Collapsing &ulse $ee 4ater'&ammer ,ulse Consensual Re,le$ Exp: &i"ht shone into one eye causes the pupils of both eyes to contract Int: (') (only opposite eye contracts) 5etrobulbar neuritis, multiple sclerosis Phys: (fferent path of reflex arc is interrupted, but efferent path remains intact Consolidation o, Lung $ee ;ull Percussion /ote, ,horacic Convulsions $ee $ymptoms: Convulsions Cor &ulmonale Exp: Pulmonary arterial hypertension and ri"ht ventricular enlar"ement* Confirmed by EC0 and chest J'ray Int: (+) Chronic obstructive airways disease, pulmonary vascular disease, multiple pulmonary emboli, diffuse interstitial pulmonary disease, sleep apnoea, #yphoscoliosis, neuromuscular diseases of chest wall, Pic#wic#ian syn*, hi"h altitude sic#ness Phys: Primarily a si"n of obstructed circulation of blood throu"h the lun"s, and not cardiac disease* Con"enital heart disease and left heart disease must be excluded Corneal Anaesthesia Exp: &oss of comeal sensation to li"ht touch Int: 5iley';ay syn* Corneal Re,le$ Exp: &i"htly touchin" one cornea with a piece of cotton wool produces blin#in" in both eyes Int: (' bilateral) Coma, "eneral anaesthesia, death (' unilateral) &esion of =th or ophthalmic

division of @th nerve Phys: ,ests for anaesthesia of cornea, or interruption of reflex arc Corrigan's Sign Exp: 2i"orous, Ber#y pulsation of maBor arteries causin" ears to move or head to nod Int: (+) (ortic re"ur"itation, patent ductus arteriosus, ventricular septal defect $ee (lso 1ater'!ammer Pulse Cough $ee $ymptoms: Cou"h

Courvoisier's LaExp: ( distended "all bladder (found by palpation) in the presence of Baundice is due to some cause other than "allstone Int: (+) Carcinoma of head of pancreas, cholelithiasis not absolutely excluded Phys: Chronic "allstones cause fibrosis of the "all bladder, thus preventin" its later expansion $ee (lso !epatome"aly Cremasteric Re,le$ Exp: 5etraction of the testicle by the cremaster muscle when the inner side of the thi"h is "ently stro#ed, or pressure is applied to the subsartorial canal Int: ('bilateral) .ld a"e ('unilateral) Corticospinal lesions Phys: (cts at &> level* ;o not confuse with ;artos reflex where scrotum contracts with cold Crepitations' &ulmonary Moist Rales Exp: Coist sounds on chest auscultation that vary from bubblin" (coarse) to crac#lin" (medium) and inspiratory tin#lin" (fine) Int: (Coarse +) :ronchiectasis, bronchitis (<ine +) Pneumonia, ,:, pulmonary collapse, pulmonary oedema, pulmonary embolism, elderly Phys: ;ue to passa"e of air throu"h fluid (mucus, pus, oedema fluid, exudate, etc*) Crepitations' Tissue Exp: $pon"y crac#lin" sensation andEor sound when affected tissue is palpated Int: (+) $ubcutaneous emphysema (e*"* lun" trauma, sur"ery, fractured rib), "as "an"rene, crepitant cellulitis, "ross tissue trauma, laryn"eal or tracheal trauma Phys: ;ue to "as (air) in subcutaneous tissues Cri+du+Chat Exp: Cat'li#e cry in newborn infant Int: (+) Cri'du'chat syn* (see $yndromes) Phys: ,emporary maldevelopment of larynx that corrects with a"e* ;ue to deletion of short arm of @th chromosome Cullen's Sign Exp: $pontaneous umbilical bruisin" Int: (+) 5uptured ectopic pre"nancy, carcinoma of pancreas, haemorrha"ic pancreatitis, other causes of haemoperitoneum Phys: ,rac#in" of tree intraperitoneal blood to )mbilicus Cyanosis $ee $ymptoms: Cyanosis, Central- Cyanosis,

F

Peripheral %ance's Sign exp: Palpable ri"ht iliac fossa depression in a distressed infant Int: (+) Intussusception Phys: intussusception causes lar"e bowel (normally present in ri"ht iliac fossa) to be drawn into centre of abdomen %artos Re,le$ $ee Cremasteric 5eflex %ehydration Exp: K @H ' ,hirst, dry mucous membranes, normal pulse, depressed fontanelle in infant @'>?H ' &oss of s#in tur"or, sun#en eyes, tachycardia, oli"uria, mar#edly depressed fontanelle in infant L >?H ' (ltered mood or consciousness (irritable or drowsy), wea# pulse, poor peripheral circulation, mar#ed loss of s#in tur"or Int: (+) ;ehydrated because of excess fluid loss (e*"* diarrhoea, excess sweatin", diabetes insipidus, diuretic abuse), or reduced fluid inta#e (e*"* fluid deprivation) $ee (lso $ymptoms: ;iarrhoea- $weatin", Excessive and (bnormal %ermographia Exp: 5aised red or white weals appear in response to movin" a blunt obBect firmly over the s#in Int: (+) (ller"ic conditions Phys: $#in hype rsen sitivity* .ften found in asthma and hay fever %iarrhoea $ee $ymptoms: ;iarrhoea %iastolic Murmur Exp : (uscultation reveals a murmur between the 7nd and > st heart sounds Int: (+) Citral stenosis, aortic incompetence, ventricular septal defects, hyperdynamic conditions (e*"* anaemias, thyrotoxicosis), pulmonary incompetence, patent ductus arteriosus, tricuspid stenosis, carcinoid syn*

%o-ager's 2ump Exp: !ump caused by crush fractures of the upper thoracic vertebrae Int: (+) .steoporosis %ull &ercussion Note' Thoracic Exp: .ne index fin"er is laid flat on the chest wall and is struc# firmly with the other index fin"er* &ower than normal pitch of percussion is dullness Int: (+) Pneumonia, fibrosis, consolidation, ,:, pleural effusion, extensive carcinoma Phys: $olid lun" tissue does not reflect sound as readily as aerated lun" See Also Tympany# Thoracic; ,ectorilo5uy# 4hisperin"; ,leural Effusion %ysdiadocho!inesia Exp: 1ith the arms are extended in front, patient pronates and supinates the forearms rapidly* Positive if action is uncoordinated Int: (+) Cerebellar lesions (e*"* tumours, abscess, C2(), other extrapyramidal motor lesions Phys: ("onist and anta"onist muscle bundles cannot be coordinated due to hypotonia secondary to the central lesion See Also Tremor# ntention; Ataxia %ys!inesia' Tardive Exp: Impairment of voluntary movement causin" incomplete or partial actions Int: (+) $ide effects of dru"s used for psychoses (e*"* phenothia+ines, tricyclics, droperidol, haloperidol, pimo+icle, thioxanthines) and Par#inson s disease (e*"* biperiden, ben+hexol) and other dru"s (e*"* phenytoin, antihistamines) Phys: latro"enic See Also n!esti"ation: Dyskinesia# Tardi!e %ysmetria See Tremor# ntention %ystonia' Torsion See Athetosis .ar Lobe Crease Exp: ;ia"onal crease across ear lobe Int: (+) Increased ris# of aortic and coronary atheroscierosis Phys: $tatistically si"nificant correlation* 5eason un#nown .ctopic eats $ee Extrasystolic Beats .dema See Oedema# ,ulmonary6 ,ittin" Oedema; Symptoms: Oedema .ly's Sign Exp: 1ith patient prone, flexion of #nee causes pelvic elevation and hip abduction Int: (+) $acroiliac disease, contracture of lateral fascia of thi"h .mphysema' Subcutaneous See $repitations# Tissue

Phys: ;ama"ed valve or increase in flow rate causes turbulence %icrotic &ulse Exp: (rterial palpation reveals a double pulsation, the latter bein" lesser in stren"th, for each heart beat Int: (+) (cute infections (e*"* typhoid fever) Phys: $mall stro#e volume causes brief pulsation, and subseDuent closure of aortic valve causes further pulsation* /ormally the two are mer"ed %isplacement o, 2eart See Apex Beat Displacement %oll's 2ead Manoeuvre Exp: In a comatose patient, rollin" the head to one side causes counter'rollin" of the eyes to the other side Int: (+) :rain stem intact (') :rain stem dama"e Phys: )sed in assessment of comatose patient* $hould not be used if there is any possibility of nec# inBury

=

.ngorgement' 0enous See Ju"ular 1enous ,ressure .nophthalmos Enophthalmia Exp: 5ecession of eyeballs within soc#ets Int: (+) ;ehydration, cachexia, malnutrition, advanced carcinoma, other wastin" diseases, lacrimal "land tumour, !omer s syn* Phys: ,a#e care to avoid confusion with ptosis, ;ue to loss of tur"or of tissue supportin" eyeball .ntropion Exp: Inversion of eyelid ed"e that may result in eyelashes rubbin" on eye surface to cause irritation Int: Chronic conBunctivitis, chronic trachoma, blepharitis, iritis, eyelid trauma, con"enital, obesity, elderly See Also Ar t)s 0ine; Trichiasis .rythema' "oint See Joint Erythema .$ophthalmos &roptosis Exp: Protrusion of eye*alls 2ithin soc#ets* Car#ed amount of sclera visible above iris in normal forward vision Int: (+) !yperthyroidism, cerebral tumour, optic or orbital tumour, Cushin" s disease, cavernous sinus thrombosis, !and'$chueller'Christian disease, pituitary tumours, osteomas, neurofibromatosis, 1e"ener s "ranulomatosis, metastatic carcinoma, xanthomas, mali"nant hypertension, uraemia, cellulitis, vascular malformation, lacrimal tumours, mucocele, rhabdomyosarcoma, (perfs syn*, Crou+on s syn*, $tur"e'1eber syn* Phys: Increase in the volume of orbital contents .$trasystolic eats Exp: .ccasional irre"ularities noted when feelin" pulse or listenin" to heart* Cay disappear when heart rate increases Int: (+) Idiopathic, stress, anoxia, dru"s (e*"* tobacco, caffeine, alcohol, sympathomimetics, di"oxin), exercise, myocardial infarct, hypertension, cardiomyopathy, anaphylaxis, rheumatic heart disease, valve prostheses, hypo#alemia, hyperthyroidism, maybe associated with all forms of heart disease Phys: Premature beatin" of heart or missed beat due to failure of normal pacema#er andEor conduction mechanisms .$udates' Retinal See Retinal Exudates .ye Signs See Arit)s 0ine; Blue Sclera; $onsensual Reflex; Corneal Reflex; Enophthalmos; Entropion; Exophthalmos#) %oster (ennedy Si"n; (ayser'%leischer Rin"; -ysta"mus; Optic Atrophy#) ,apilloedema; ,aralysis of 7p2ard 3a8e; Retinal Exudates; Retinal &aemorrha"es; #Retinal pi"mentation; Third Eyelid of +or"an'Denny; Trichiasis; 4hite ,upit 9anthelasma; Symptoms;,tosis (acies See parkinsonian %acies; +oon %ace; Risus Sardonicus

(aeces' Abnormal Colour Int: ;ar# ' 5ed wine, certain fruits, iron or bistmuth medications 0reenEyellow (excess bile) ' Intestinal hury, bowel infections, starvation 0anary yellow ' ;iet primarily of dairy products Clay ' &ac# of bile from biliary obstruction Pale yellow ' $teatorrhoea (excess fat) 5ed ' :lood from lower intestine (e*"* haemorrhoids, cancer, polyps) :lac# ' Celaena, excess iron See Also Symptoms: +elaena and Rectal Bleedin" (asciculation' Muscular T-itching Exp :<ibrillary twitchin" of voluntary muscles visible throu"h the s#in* Exacerbated by tappin" muscle bundles Int: (+) ;epolarisin" dru"s, muscular dystrophies, amyotrophic lateral sclerosis, lower motor neurone lesions, motor neurone disease, poliomyelitis, 0uillain':arre syn*, syrin"omyelia, hypocalcaemia, severe viral diseases , thyrotoxicosis, polymyositis Phys :Cay occur without neurolo"ical cause* ;ue to uncoordinated depolarisation of muscle fibres See Also Tremor# ntention; Tremor# ,ostural; Tremor# Restin"#' +yotonia (astination See 0ait, A*normal#6 $o"2heel Ri"idity (etal Gro-th' Reduced See ntrauterine 3ro2th Retardation (ever See Symptoms: %e!er (inger Clubbing See $lu**in" of %in"ers (in!elstein's Test Exp: ,he patient folds the thumb into the palm, with the fin"ers folded over the thumb* ,he doctor rotates the wrist medially (towards the uinar) to stretch the involved tendons* Positive if pain worsened or reproduced Int: (+) ;e Muervain s disease of stenosin" tenosynovitis Phys: (bductor pollicus lon"us andEor extensor pollicus brevis are tendons involved Caused by repetitive wrist action (laccid &aralysis $ee Paralysis, %laccid (lapping Tremor Asteri$is Exp: 1ith arms, hands and fin"ers outstretched, the patient dorsiflexes the wrists and spreads the fin"ers* (n irre"ular but synchronous tremor of a flappin" nature is seen, with maximum activity at the wrist and metacarpophalan"eal Boints* Cay also involve feet and ton"ue Int: (+) Encephalopathy, liver failure, metabolic diseases, subdural haematomas, cerebral infarcts in diencephalon re"ion

G

Phys: ;istortion of proprioceptive cerebral pathways and inappropriate motor stimulation (lint+Austin Murmur $ee Austin'%lint +urmur (luid Thrills $ee ,hrill, %luid (lush See Symptoms: %lush (oot Lesions $ee Pes Cavos (oster 5ennedy Sign Exp: )nilateral papilioedema with contralateral optic atrophy Int: (+) Cerebral tumour adBacent to optic nerve of atrophied eye Phys: Pressure on one optic nerve causes optic atrophy while increasin" intracranial pressure to cause papilloedema of the other eye (remitus $ee 2ocal <remitus (riction Rub' &ericardial Exp: Cardiac auscultation reveals a localised or "eneralised "ratin" sound associated with each contraction Int: (+) Pericarditis, pleurisy, rheumatic fever, pneumonia, ,:, myocardial infarct, uraemia, dissectin" aortic aneurysm Phys: <riction between the two pericardial layers in the presence of an exudate (riction Rub' &leural Exp: Chest auscultation reveals a "ratin" sound associated with each breath Int: (+) Pleurisy, pulmonary thrombosis, lun" cancer, empyema Phys: <riction between the two inflamed layers of pleura (roment's Sign Exp: Patient holds a piece of thin cardboard with both hands with thumbs on top of cardboard and closed hands under cardboard so that each thumb presses down throu"h the cardboard onto the side of index fin"er proximal interphalan"eal Boint* ;octor holds opposite side of cardboard in same way* ;octor and patient both try to pull cardboard towards themselves* $i"n positive if the interphalan"eal Boint of the patient s thumb flexes to hump upwards Int: (+) )inar nerve paralysis Phys: )inar nerve may be compressed at the olecranon or 0uyton s canal* (lternatively, the nerve roots in the nec# may be compressed (rontal ossing Exp: Protruberant enlar"ement of the front*, bones Int: 5ic#ets, con"enital syphilis, bruisin,

Int:

)pper le" is hyperextended* Positive if sacroiliac pain (+) $acroiliac Boint involved in disease (e*"* an#ylosin" spondylitis, li"amentous tear)

Gag Re,le$ $ee ,haryn"eal Reflex Gait' Abnormal Exp: (taxic "ait ' )nsteady, unbalanced, lac# of confidence Extrapyramidal "ait ' $low, ri"id "ait, no arm swin"in" <estination ' Muic#, shufflin", trun# bent Carche'a'petit'pas ' 0ait of little steps , Ber#y, unbalanced, muscle spasm, feet stic# to floor on turnin" or startin", asymmetrical bris# reflexes $cissors "ait ' &e"s cross left to ri"ht and vice versa when wal#in" $pastic ataxic "ait ' Cuscle spasm, Ber#y, unsteady, unbalanced 1addlin" "ait ' Exa""erated elevation of the hip on the steppin" side and abnormal yieldin" of the hip on the "rounded side, "ivin" excessive lateral movement to the trun# Int: (taxic "ait ' (+) ;ru" induced cerebellar ataxia, alcoholic cerebellar de"eneration, hypothyroidism, transient ischaemic attac#, other cerebellar disease Extrapyramidal "ait ' (+) Par#inson s disease, dru" induced par#insonisrn (e*"* prochlorpera+ine, metoclopramide) <estination ' (+) Par#inson s disease, extrapyramidal lesions Carche'a'petit'pas ' (+) Cultiple lacunar stro#es $cissors "ait ' (+) Cerebral diple"ia, diseases of hip Boint, spastic paraple"ia $pastic ataxic "ait ' (+) Cultiple stro#es, transient ischaemic attac#s, cerebral palsy, vitamin :>7 deficiency, cervical myelopathy, spinocerebellar de"eneration 1addlin" "ait ' (+) Pro"ressive muscular dystrophy, con"enital dislocation of hips, !untin"ton s chorea, pseudohypertrophic muscular paralysis Phys: (taxic "ait ' Cidline or vermian cerebellar de"eneration <estination ' Cuscular ri"idity Carch e'a'petit'pas ' Pseudobulbar lesion* Commonly confused with par#insonian "aits scissors "ait ' (cute adduction of both hips frorn hip Boint disease or adductor muscle contracture $pastic ataxic "ait ' Cay be associated with incontinence and co"nitive disturbances in elderly 1addlin" "ait ' 1ea#ness of "luteal muscles See Also Co"wheel Ri"idity#) ,arkinsonism Gallop Rhythm ,riple Rhythm Exp: Cardiac auscultation reveals a triple rhythm with a 8rd or 9th heart sound Int: Protodiastolic 8rd sound ' ;istended heart, mitral incompetence or stenosis, &eft ventricular failure, alveolitis, constrictive pericarditis, physiolo"ical Prosystolic 9th sound ' &eft ventricular failure, aortic stenosis, atrial hypertrophy, prolon"ed P5 interval Phys: 2anous flow and valve movement abnormalities Geographic Tongue

Gaensien's Sign Exp: Patient lies on side on firm couch* :ottom le" is hyperflexed onto abdomen*

A

Exp: $mooth red patches with "reyish mar"in scattered on ton"ue Int: (+) <iliform papillae desDuamation (beni"n condition), ,:, aller"ies $ee (lso $trawberry ,on"ue Glaucoma $ee &ori8ontal 0i"ht Test; S2in"in" ,orch Si"n Goitre $ee $ymptoms: 0oitre Golden's Sign Exp: Pallor of cervix Int: (+) Ectopic pre"nancy, cervical infections or infiltrations Gottron's Sign Exp: $caly patches over dorsum of proximal interphalan"eal and metacarpophalan"eal Boints, subun"ual erythema and cuticular telan"iectasiae Int: (+) Polymyositis, dermatomyositis Phys: )n#nown Go-er's Manoeuvre Exp: Child attempts to rise by wal#in" hands uple"s Int: (+) ;uchenne muscular dystrophy Phys: Cuscular wea#ness prevents risin" to standin" position in normal manner Graham Steell Murmur Exp: $oft, hi"h pitched murmur heard in the 7nd left intercostal space on early diastole Int: (+) Pulmonary hypertension or pulmonary artery dilatation in association with severe mitral stenosis or septal defects Phys: Pulmonary vascular re"ur"itation Grasp Re,le$ Exp: (utomatic "raspin" of obBects placed a"ainst palm of hand Int: (+) /ormal neonate, upper prefrontal lobe lesions and tumours Phys: Prefrontal lobes concerned with intellect and the ori"ination of motor movements* Patient is unable to prevent a primitive reflex with lesions to this area Green /rine See 7rine# A*normal $olour Gums' lue Line on See Blue 0ine on 3ums 2aematuria See Symptoms: &aernaturia and Red 7rine; ,atholo"y66 &aematuria 2aemorrhages See Retinal &aemorrha"es; Splinter &aemorrha"es; &ess Test; Symptoms: ,urpura and ,etechiae; Symptoms: Bleedin"# Excessi!e 2air' Transverse %epigmentation Exp: :and across hair of different (usually li"hter) colour from rest of hair Int: (+) Protein deficiency, copper deficiency 2arrison's Sulcus

Exp: ;ia"onal "roove on anterior and lateral side of chest alon" line of attachment of diaphra"m Int: (+) (sthma, ric#ets Phys: Chest deformity from over exertion of diaphra"matic muscle 2eart See Apex Beat Displacement; Atrial %i*rillation# Extrasystolic Beats; Bradycardia; 3allop Rhythm; &eart Sounds; Tachycardia; Thrill# $ardiac; Ju"ular 1enous ,ressure; Split &eatl Sounds See Also si"ns listed under +urmur# $ardiac; Pulse 2eart Sounds Phys: <irst sound ' Closure of mitral and tricuspid valves at be"innin" of systole $econd sound ' Closure of aortic and pulmonary valves at end of systole ,hird sound ' 5apid ventricular fillin" in early diastole <ourth sound ' (trial contraction in late ;iastole 2eberden's Nodes Exp: :ony prominence at the dorsal mar"ins of distal interphalan"eal Boints Int: (+) .steoarthritis, osteoarthrosis Phys: Core common in women* Cay be due to a sin"le autosomal "ene $ee Also Bouchard)s -odes 2eel+5nee Test Exp: 1hile supine, the patient is told to touch one #nee with the opposite heel, and then to run the heel down the shin Int: (+) (taxia (e*"* tabes dorsalis, posterior column lesions, cerebellar lesions, <riedreich s ataxia), poliomyelitis Phys: &oss of inte"rity of sensory pathway alon" posterior columns to cerebellum See Also Ataxia; Rom*er")s Si"n; -ose'%in"el Test 2egar's Sign Exp: .n bimanual examination of va"ina in empty softened area can be palpated between the firmer cervix and "lobular uterus Int: (+) Pre"nancy between Fth and >?th wee#s Phys: !ormones of pre"nancy cause softerlinc of uterus, but fetus occupies only upper pole in early sta"es See Also Areolar ,i"mentation; Blue Cervix 2enoch+Schoenlein &urpura Exp: Extensive elevated purpuric or ecchymotic lesions on extensor surfaces of arms and le"s* Cay be recurrent and can occur on the face, in the "ut (causin" haemorrha"e and colic), and in the #idney (causin" haematuria) Int: (+) ldiopathic, after sensitisin" foods, poststreptococcal infection, dru"s Phys: immunolo"ical reaction, more common in children See Also Syndromes: &enoch'Schoenlein Syndrome 2epatomegaly Exp: Palpation of abdominal 5). reveals a mass that may extend below the umbilicus, may be hard or soft, and may betender Int: (+) Con"estive cardiac failure, hepatitis, amoebiasis, hepatic abscess, actinomycosis, polycystic disease, hepatic fibrosis, ,:, primary or

>?

metastatic tumour, cirrhosis, sarcoid, haemosiderosis, amyloidosis, diabetes mellitus, "lyco"en stora"e diseases, "aiactosaemia, iipidoses, anaemias, pericarditis, polyarteritis nodosa, schistosomiasis, 0aucher s disease, !and'$chueller'Christian disease, histiocytosis J, hydatid, infectious mononucleosis, thalassaemia, fatty liver, lymphoma, leu#aemia, bile duct obstruction, hepatic vein thrombosis, protein deficiency, starvation, malaria, other infectious a"ents, syphilis, rheumatoid arthritis, (ndersen s syn*, :udd'Chiari syn*, carcinoid syn*, Cori s syn*, <eity s syn*, !unter s syn*, !urler s syn*, &etterer'$iwe syn*, Cauriac s syn*, Pompe s syn*, $anfilippo s syn*, $cheie syn*, $ly syn*, von 0ier#e s syn*, dru"s and innumerable other causes (false +) ;epressed ri"ht diaphra"m, subdiaphra"matic abscess, 5iedel s lobe, asthma Phys: &iver enlar"ement may be due to vascular, biliary tract, infiltrative, inflammatory or tumorous causes $ee (lso Courvoisier s 0a2 2erald &atch Exp .val, discoid or annular, solitary, reddish, sli"htly raised and scaly patch on the trun#* <ollowed by multiple smaller lesions

Int: (+) Pityriasis rosea, dru" eruptions Phys: Pityriasis rosea is a self'limitin" 2ering+ reuer Re,le$es Exp: ,he desire to inspire when the breath is held in expiration, and vice versa Int: /o clinical si"nificance Phys: (ctivated throu"h receptors 2ess Test Exp: ( sphy"momanometer cuff inflated to G? mm!" (>?*F #Pa) around the upper arm for five minutes causes purpuric spots to appear below the Int: cuff (+) ;iseases associated with purpura (e*"* thrombocytopenia, diseases of vascular endothelium, thromboasthenia, Phys:uraemia) ,ests the resistance of capillaries to increased venous pressure $ee Also Symptoms: ,urpura and ,etechiae Exp: $hine a bri"ht narrow beam of li"ht hori+ontally onto the eye from its temporal aspect* .bserve the iris shadow pattern 2o,,mann's Sign or Re,le$ Exp: ;orsiflexion of the foot produces calf muscle spasm andEor pain Int: (+) ,hrombophlebitis of deep vein of calf, cellulitis of calf, musculos#eletal trauma 2oover's Sign Exp: 1ith the patient lyin", the doctor cups both heels in his or her hands, and as#s the patient to push down with the heel on the affected side* /ormally, the heel on the unaffected side becomes li"hter in the examiner s hand as counterpressure is exerted* Positive if this does not occur > nt: (+) Cuscular power in affected le" is limited by pain, 2ori*ontal Light Test Exp: $hine a bri"ht narrow beam of li"ht hori+ontally onto the eye from its temporal aspect* .bserve the iris shadow pattern Iris evenly illuminated or shadow on temporal side ' ;eep anterior chamber ("laucoma unli#ely) $hadow on nasal side ' $hallow anterior chamber (potential for acute an"le closure "laucoma) Phys: ,he iris is normally concave, but when convex it narrows the anterior chamber and casts a shadow on the nasal side See Also S2in"in" Torch Si"n 2ydrocephalus Exp: (ccumulation of excess C$< under presssure to cause s#ull enlar"ement in children and cerebral dama"e in adults Int: (+) Con"enital malformations, ventricular colloid cyst, pineal tumours, intraventricular haemorrha"e, aDueduct stenosis, pituitary tumours, craniopharyn"ioma, ependymoma, choroid plexus disease or tumour, astrocytoma of cerebellum, medulloblastoma, (rnold'Chiari malformation Int:

Int: (+) Pityriasis rosea, dru" eruptions Phys: Pityriasis rosea is a self'limitin" inflammatory condition 2ering+ reuer Re,le$es Exp: ,he desire to inspire when the breath is held in expiration, and vice versa Int: /o clinical si"nificance Phys: (ctivated throu"h receptors sensitive to stretch and deflation 2ess Test Exp: ( sphy"momanometer cuff inflated to G? mm!" (>?*F #Pa) around the upper arm for five minutes causes purpuric spots to appear below the cuff Int: (+) ;iseases associated with purpura (e*"* thrombocytopenia, diseases of vascular endothelium, thromboasthenia, uraemia) Phys: ,ests the resistance of capillaries to increased venous pressure $ee Also Symptoms: ,urpura and ,etechiae 2o,,mann's Sign or Re,le$ Exp: ;orsiflexion of the foot produces calf muscle spasm andEor pain Int: (+) ,hrombophlebitis of deep vein of calf, cellulitis of calf, musculos#eletal trauma Phys: ,ensin" of muscle bundle puts pressure on thrombosed and inflamed vein 2oover's Sign Exp: 1ith the patient lyin", the doctor cups both heels in his or her hands, and as#s the patient to push down with the heel on the affected side* /ormally, the heel on the unaffected side becomes li"hter in the examiner s hand as counterpressure is exerted* Positive if this does not occur Int: (+) Cuscular power in affected le" is limited by pain, malin"erin", or hysterical reaction 2ori*ontal Light Test

>>

Phys: (ny obstruction of the C$< circulation will lead to hydrocephalus 2ydrophobia Exp: Patient as#s for water, but when offered, there is spasm of inspiratory muscles and inexplicable terror Int: (+) 5abies 2ydrothora$ Exp: <luid transudate in pleural cavity proven by pleural tap Int: (+) /ephrotic syn*, Cei"s syn*, con"estive cardiac failure, obstruction of thoracic veins and lymphatics, other renal diseases 2ypertension Exp: :lood pressure above >F? mm!" (7>*8 #Pa) systolic andEor [email protected] mm!" (>7*F #Pa) diastolic Int: (+) (nxiety, exertion, essential hypertension, renal artery stenosis, acute and chronic "lomerulonephritis, other renal diseases, phaeochromocytoma, aortic coarctation, eclampsia of pre"nancy, raised intracranial pressure (tumour or traurna) oral contraceptives, over distended neuro"enic bladder, polyarteritis nodosa, $&E, scleroderma, Conn syn mali"nant hypertension, Cushin" syn, porphyria, ovarian tumours, lead poisonin", diabetes mellitus, pseudohermaphroditism, polycystic #idneys, adreno"enital syn*, &iddle syn, lru#andBi syn*, nephrotic syn*, 5iley';ay syn*, alcoholism, dru" and food interactions (e*"* C(.is and cheese), dru"s (e*"* anal"esics, anorectics, antidepressants, cyclosporin, carbenoxolone, liDuorice, C(?>s, /I$(I;s, oral contraceptives, steroids) Phys: [email protected] essential form* 0enerally due to increased peripheral resistance, abnormalities of the renin'an"iotensin'alclosterone systern, increased levels of adrenaline or noradrenaline, or increased cardiac output (e*"* thyrotoxicosis) 2ypertonicity Exp: Involuntary resistance is encountered when limb is passively moved* Cuscles are firm to touch Int: (+) )pper motor neurone lesions, extrapyramidal system lesions, C2(, par#insonism, cord transection, postasphyxia, #ernicterus, premature infant, encephalitis, cerebral oedema, trauma, menin"itis, hydrocephalus, cerebral space occupyin" lesion, cerebral palsy Phys: ;isinhibition of the stretch reflex See Also +yotonia 2yperventilation Exp: 5apid respiratory rate ("enerally above [email protected] breaths per minute in adult) Int: (+) (nxiety, pain, fever, hysteria, pulmonary embolism, metabolic acidosis (diabetic #etoacidosis, renal disease), most infections, cerebral haemorrha"e, pneumothorax, anoxia, con"enital heart lesions, dru"s (e*"* adrenaline), 5ett s syn* Phys - ;ue to low p?7, hi"h pC?7, or direct cerebral action See also %ussmaul s :reathin" or $i"n 2ypotension Exp - :lood pressure below >?? mm!" (>8*8 #Pa) systolic andEor @? mm!" (F*F #Pa) diastolic Int: (+) Cardiac failure, cardio"enic shoc#, acute blood loss, orthostatic

hypotension, fri"ht, familial, myocardial infarct, anaphylaxis, acute maBor pulmonary embolus, coma, haernorrha"ic nephrosonephritis, carcinoid syn*, dehydration, sympathectomy, (ddison s disease, diabetes mellitus, autonomic de"eneration, amyloiclosis, alcoholism, prolon"ed rest or standin", excess heat or humidity, fever, septicaemia, micturition syncope, electrolyte imbalance, pre"nancy, anaemia, "astrectomy, malnutrition, constrictive pericarditis, heart bloc#, carcinomatosis, bradycardia, hypothyroidism, hypopituitarism, porphyria, Conn syn*, 5iley';ay syn*, $heehan s syn*, $hy';ra"er syn*, toxic shoc# syn*, vasova"al syn*, neurolo"ical trauma, autonomic disease or trauma ;ru"s (e*"* diuretics, antian"inal nitrates, hypnotics, tranDuilli+ers, tricyclic antidepressants, levodopa, antipsychotics, insulin excess) Phys: .verdilatation of peripheral blood vessels, loss of blood volume or low cardiac output 2ypotonia Exp: Passive limb movement freely accomplished with "reater ran"e than usual* Cuscles are soft and flabby Int: (+) &ower motor neurone lesion, cerebellar lesions, "rossly debilitatin" diseases, poliomyelitis, tabes dorsalis, spinal shoc#, myopathies, $ydenham chorea, premature infant Phys: &oss, or bloc#in", of motor innervation of Cuscles 2ypoventilation Exp: &ow respiratory rate ("enerally below >? breaths per minute) Int: (+) 5aised intracranial pressure (e*"* tumour, abscess, haemorrha"e), dru"s (e", sedatives), pleural effusion, pulmonary collapse, asthma, pneumonia, pneumothorax, bronchiectasis, neuromuscular disease, #yphoscoliosis Phys: ;irect action on respiratory centre, or physical limitation of lun" expansion

Intrauterine Gro-th Retardation Exp: <ailure of fetus to achieve its full "rowth potential antenatally* (ssessed clinically and by ultrasound Int: (+) Caternal hypertension, con"enital abnormalities, "enetic and chromosomal abnormalities, cerebral palsy, rubella, toxoplasmosis, herpes, cytome"alovirus, other fetal infections, cytotoxics, irradiation, twins, alcoholism, heavy smo#er, hi"h altitude, abruptio placentae, diabetes, chronic renal disease, malnutrition, anaemia, family history, dru" abuse Phys: ;ue to fetal, maternal or placental factors $ee (lso Investi"ation: <ailure to ,hrive Irregularly Irregular &ulse Exp: Pulse that is totally random in its rate and volume Int: (+) (trial fibrillation, multiple extrasystoles, thyrotoxicosis

>7

Phys: (trial rate of 9??'F?? per minute (due to ischaemia, pressure or metabolic influences) is transmitted randomly via the (2 node to the ventricles* Pulse deficit notable See (lso (trial %i*rillation Itard+Chole-a's Sign Exp: (naesthesia of tympanic membrane, anaesthesia of external auditory meatus, deafness Int : (+) .tosclerosis "acobsen+2oldsnedt &henomenon Exp: Expiratory and inspiratory chest J'rays ta#en* Positive if mediastinum displaced away from affected side on expiration Int: )nilateral obstructive emphysema Phys: 2alve'li#e mechanism allows air to enter lun" but not escape* Cay be due to forei"n body or tumour "ane-ay Lesion Exp: $mall purplishEred nodule on palms or soles Int: (+) Infective endocarditis Phys: Infected embolic lesion See Also Splinter &aemorrha"es "a- "er! Exp: 1ith the Baw relaxed and the mouth han"in" open, a fin"er is placed across the front of the Baw and struc# with a rubber hammer* Contraction of masseters may result Int: (+) &esion of both corticospinal tracts Phys: (cts at the level of the pons "oint .rythema Exp: Int: 5edness and inflammation of tissue overlyin" a Boint (+) $eptic arthritis, cellulitis, "out, pseudo"out, rheumatoid arthritis, reactive arthropathy, 5eiter s syri* (see $yndromes), !eberden s node, :ouchard s node, erythema nodosum, inflammatory osteoarthritis, rheumatic fever

cardiomyopathies, superior mediastinal tumour, enlar"ed thymus, obstructed superior vena cava, increased intrathoracic or intra'abdominal pressu,, &ow ' $hoc#, dehydration, severe infections Phys: Increased bac# pressure due to obstructed flow throu"h the ri"ht side of the heart causes an increase in systemic venous pressure* :lood loss or vasodilatation causes it to drop 5ayser+(leischer Ring Exp: 0reenish'brown rin" at the outer ed"e of the cornea Int: (+) 1ilson s disease Phys: ;eposition of copper compounds in cornea (dia"nostic si"n) 5ehr's Sign Exp: &eft shoulder tip pain, acute abdomen Int: (+) 5uptured spleen Phys: 5eferred pain via phrenic nerve, caused by irritation of diaphra"m See Also Shoulder Tip ,ain 5erley Lines

Exp: ( plain (P J'ray of the chest shows fine hori+ontal lines in the lower +ones of the lun"s, lateral to the down curve of the diaphra"m Int: (+) Interstitial pulmonary oedema Phys: Perilymphatic oedema 5ernig's Sign Exp: .ne hip of supine patient is fully flexed* (ny subseDuent attempt to strai"hten the #nee results in painful spasm of the hamstrin"s when positive Int: (+) Cenin"eal irritation, bacterial and aseptic menin"itis, cerebral or spinal cord abscess, subdural empyema, subarachnoid haemorrha"e, encephalitis, typhus, leptospirosis, other cerebral haemorrha"es Phys : (ctivation of protective flexor reflexes which shorten and immobilise the spine See Also -eck Stiffness; Brud8inski)s Si"n

"oint 2ypermobility Exp: :ei"hton $core: &ittle fin"er extension L A? de"ree(> point each fin"er) Extend thumb parallel to forearm (> point each thumb) Extend elbow L >? de"ree, (> point each elbow) Extend #nee L >?de"ree, (> point each #nee) ,ouch floor with palms while #eepin" #nees strai"ht (> point) $core of F or more positive for Boint hypermobility Int: (+) Increased incidence of di$locati* enthesopathy, Carfan s syn*, Ehiers';anios syn*, acrome"aly Phys: .ften familial "ugular 0enous &ressure 6"0&7 Exp: 1ith patient reclinin" at 8?>, the distance that a distended Bu"ular vein rises vertically above the hori+ontal leve of the sternal an"le is noted* /ormally veins are collapsed above this level Int: !i"h ' Con"estive cardiac failure, constrictive pericarditis, tricuspid stenosis, pulmonary stenosis,

5idney'Large Exp : &ar"e #idney(s) noted on abdominal palpation or J'ray Int: (+) )nilateral ' (cute or chronic obstruction, ureteric or renal stone, acute pyelonephritis, duplicate pelvicalyceal system, subcapsular renal haematoma, renal cyst, renal vein thrombosis, renal neoplasm, compensatory hypertrophy (+) :ilateral ' $&E, polyarteritis nodosa, aller"ic an"fitis, diabetes, 1e"ener s "ranulomatosis, acute "lomerulonephritis, multiple myeloma, leu#aemia, lymphoma, amyloidosis, acrome"aly, polycystic #idneys, acute tubular necrosis Phys: ;epends on individual disease process 5idney' Small Exp: (bnormally small #idney(s) noted on abdominal J'ray or ultrasound Int: (+) )nilateral ' Infarction or ischaemia, renal artery stenosis, reflux pyelitis, postobstructive atrophy, postinflammatory atrophy, partial nephrectomy, irradiation atrophy, con"enital

>8

(+) :ilateral ' (myloidosis, chronic "lomerulonephritis, papillary necrosis, bilateral ischaemia, medullary cystic disease, urate nephropathy 5nee "er! Exp : 1ith the Patient seated and one #nee crossed over the othdr, the patellar tendon is tapped firmly* Muadriceps contraction and #nee extension occurs Int: $ustained ' Chorea Pendular ' (cute cerebellar disease (++) !ype rthyroidism, encephalitis, upper motor neurone lesion, anxiety, tetanus, cord transection (') Peripheral neuropathies, polio, tabes dorsalis, posterior root tumours, cord tumours, subacute combined de"eneration of cord, syrin"omyelia, cord shoc#, coma, muscular dystrophies, hypothyroidism, beriberi Phys: (cts at &7, &8, &9 level See Also si"ns listed under Reflexes 5oilonychia Exp: Int: $poonin" of nails (+) Iron deficiency anaemias, Plummer'2inson syn*

Ri"idity Lens #pacity Exp: 1hile opacity within pupil Int: (+) Cataract, diabetes, interstitial #eratitis, "alactosaemia, con"enital syphilis, hypoparathyroidism, hypocalcaemia, dru"s (e*"* chlorproma+ine, steroids) Phys: Inflammation, senile de"eneration, radiation or disordered metabolism See Also $ymptoms** Blindness# ,artial or ,otalCataract Leser+Trelat Sign Exp: (brupt appearance, and rapid increase in si+e, of many seborrhoeic #eratoses Int: (+) )nderlyin" carcinoma (e*"* adenocarcinoma) Phys: Cay also occur durin" lysis of tumour with cytotoxics Leucocoria $ee 1hite Pupil Liver' .nlarged See !epatome"aly Lung Consolidation $ee ;ull ,ercussion -ote# Thoracic# ,racheal ;isplacement Machinery Murmur Exp: Continuous cardiac murmur that waxes and wanes Int: (+) Patent ductus arteriosus (maximal in aortic and pulmonary areas), arteriovenous fistula, aortic coarctation, aorlopulmonary septal defect Macroglossia See Ton"ue# Enlar"ed Main d'Accoucheur See O*stetric &and Mass Re,le$ Exp: 2arious stimulations to a point below thelevel of the neurolo"ical lesion causes sudden drawin" up of the le"s, evacuation of the bladder and sweatin" below lesion level Int: (+) $evere spinal cord lesions, Paraple"ia McMurray Sign Exp: .ne hand "rasps an#le firmly, other hand rests on patient s #nee* ,he #nee is fully flexed and the tibia is fully laterally rotated* ,he #nee is then extended while rotation is maintained* ( clic# or clun# felt by the hand on the #nee is a positive si"n* ,he test is repeated from varyin" an"les of #nee flexion Int: (+) ,orn #nee meniscus Phys: Canoeuvre attempts to catch torn ta" of meniscus between bone ends to cause a clic# Mediastinal Mass Exp: Cass detected in mediastinum by J'ray or C, scan Int: (+) $uperior mediastinum ' :roncho"enic cyst, retrosternal "oitre, ectopic thyroid tissue, oesopha"eal entero"enous cyst (+) Inferior mediastinum ' !iatus hernia,

5ussmaul's reathing or Sign Exp: (n increased depth and freDuency of respirations associated with increased respiratory effort* .ften described as hissin" respiration Int: (+) ;iabetic acidosis, uraemia, other causes of acidosis, neuro"enic hyperpnoea, midbrain and upper pontine brain lesions Labyrinth Tests Exp: Each ear is irri"ated with hot or cold water to produce verti"o andEor nysta"mus* ,he response from both ears should be eDual Int: )neDual ' Inner ear dysfunction (nonspecific) Lachman's Test Exp: 1ith the #nee in nearly full extension, the femur is held firmly in one hand and the tibia is moved forward on the femoral condyle* Positive test if si"nificant forward movement elicited Int: (+) (nterior cruciate li"ament laxity Phys: 5upture or stretchin" of the anterior cruciate li"ament allows excess tibial movement Lasegue's Sign Exp: 1ith patient supine, the extended le" is lifted from the bed* ,he presence of pain and amount of passive elevation possible is noted and compared to other le" and normal person Int: (+) 5adiculopathy (e*"* disc herniation), other musculos#eletal disorders of the bac# Phys: Elevatin" extended le" stretches nerve roots and causes pain if they are inflamed Lead+&ipe Rigidity Exp: !eavy passive stiffness of limb throu"hout ran"e Int: (+) Extrapyramical lesions, par#insonism, basal "an"lia disease Phys: Chronic overactive len"thenin" reaction See Also $o"2heel Ri"idity; $lasp'(nife

>9

abscess, pericardial cyst (+) Posterior mediastinum ' /euro"enic tumours, neurofibroma, neuroblastorna, paravertebral abscess, aortic aneurysrn (+) (nterior mediastinum ' ,hymic tissue, thymoma, ectopic thyroid tissue, "erm cell tumour, teratoma, dermoid cyst, aortic aneurysm (+) 2aried position in mediastinum ' $arcoidosis, ,:, lymphoma, !od"#in s disease, metastatic carcinoma Phys: (ny of the structures of the mediastinurr may become enlar"ed, infected or neoplastic* C, scans and C5N can accurately position mass and sornetirnes determine its structure Miosis Exp: (bnormally contracted pupils .diameter 7 mm) Int: (+) :ri"ht li"ht, conver"ence, syphilis (tabes dorsalis), narcotics, sympathetic nerve paralysis, pontine lesions, con"enital, hysteria, !omer s syn*, !olmes'(die syn*, dru"s (e*"* pilocarpine, physosti"mine, narcotics) Moon (ace Exp: <at, rounded face with loss of s#in wrin#les Int: (+) Cushin" s syri* and disease Phys: Excess intrinsic or extrinsic cortisol causes deposition of fat in face and trun#, but loss from limbs See (lso :uffalo !ump Morgan+%enny .yelid See Third Eyelid of Cor"an';enny Movement' Abnormal See Athetosis#$horeiform +o!ements#6 Dyskines#Tardi!e; %lappin" Tremor; 3ait# A*normal#Tremor# ntention; Tremor# ,ostural; Tremor# Restin"; Symptoms: $horea; Murmur' Cardiac See +achinery +urmur6 Systolic +urmur6 Diastolic +urmur#3raham Steell +urmur#6 3allop Rhythm; Thrill# $ardiac; Split &eart Sounds Murphy's LaExp: 3aundice due to cholelithiasis is preceded by colic* 3aundice due to neoplasm or external obstruction of the biliary tract has no history of colic Murphy's Sign Exp: 1ith the examiner s fin"ers pressed firmly over the patient s abdominal 5)C, the patient inhales slowly and deeply* ( momentary interruption of inhalation occurs due to pain Int: (+) Cholecystitis Phys: ,he inflamed "all bladder is pressed a"ainst the examiner s fin"ers by the descendin" diaphra"m Muscular Spasm See +yotonia Muscular 8ea!ness See ,aralysis# %laccid# &ypotonia Mydriasis Exp: (bnormal dilatation of pupils Int: (+) ;ar# room, hyperthyroidism, anxiety,

iritis, traumatic or inflammatory adhesions, iris sphincter paralysis, iris dilator muscle spasm, syphilis, botulism, diphtheria, syrin"omyelia, micibrain lesions, Parinaud s syn*, ,olosa'!unt syn*, !olmes'(die syn*, coma, dru"s (e*"* atropine, cocaine, amphetamines, cannabis) Phys: ;ama"e to or inhibition of the iris and its musculature or innervation Myoclonus See Ankle $lonus Myotonia Exp: ;elayed muscular relaxation followin" forceful muscular contraction (e*"* repeated muscular fasciculation after tap with rubber hammer) Int: (+) Cyotonic dystrophy, myotonia con"enita, hyper#alaemia, ,alma s disease Phys: )sually reduced by repeated activity* .ften worse in cold $ee (lso &ypertonicity6 %asciculation# +uscular Nail anding Exp: ,ransverse white bands across nails Int: (+) !ypoalbuminaemia (see (lbumin, $erum in Patholo"y), steroid therapy, cytotoxics, arsenic Phys: 5eturn to normal after serum albumin corrected $ee (lso :eaus line in /ail Rid"in" Nail Changes $ee (oilonychia; $lu**in" of %in"ers; Splinter &aemorrha"es; /ail Discolouration; -ail Pittin"/ail Rid"in"; Onycholysis; Onycho"ryphosis Nail %iscolouration Exp: /ail or subun"ual tissue colour chan"e Int: :lac# ' !aematoma, melanoma, naevi, pseudomonas infection, fun"al infection, chronic paronychia :rown ' )raemia, psoriasis, nicotine, (ddison s disease, mercury poisonin", silver poisonin", chemical stains Iellow ' ,inea, Baundice, yellow nail syn*, slow "rowth, lymphoedema, tetracyclines :lue ' Cyanosis, mepacrine, chloroDuine, 1ilson s disease, ar"yria, amodiaDuine 1hite ' ,rauma, cardiac disease, renal disease, psoriasis, dermatophyte infection, hypoalbuminaemia, cytotoxics, arsenic, liver disease 5ed ' !aemorrha"e, con"estive cardiac failure (half moons red), cold exposure 0reen ' Pseudomonas, asper"illus or candida infections Nail &ain $ee $ymptoms: /ail Pain Nail &itting Exp: $mall isolated or confluent pits on the nail plate Int: (+) Psoriasis, chronic paronychia, di"ital ec+ema, alopecia areata, familial Phys: Inflammatory dama"e to nail matrix Nail Ridging

>@

Exp: &on"itudinal or transverse rid"in" of nail plate Int: (+) &on"itudinal ' Elderly, nail matrix tumours, lichen planus, alopecia areata, rheumatoid arthritis, ;arier s disease mucous cyst of matrix, peripheral vascular disease, nail dystrophy (+) Cultiple transverse ' Ec+ema, chronic paronychia, habit tics, chronic inflammation of di"it, chronically wet nails (e*"* housewor#), severe dysmenorrhoea, 5aynaud s disease, severe carpal tunnel syn*, protein deficiency (+) $in"le transverse :eau s line '.ccurs after severe physical or emotional illness of any cause Phys: ,ransverse rid"in" due to temporary cessation of nail formation* 1hen cause removed, nail "rowth resumes, and the rid"e moves forward with the nail plate "rowth See Also Splinter &aemorrha"es Nail' 2ypoplastic Exp: )nderdeveloped nails Int: (+) Coffin'$iris syn*, fetal alcohol syn*, 0olt+ syn*, nail'patella syn* Nail' Separation ,rom ed $ee Onycholysis Nail' Thic!ened Exp: ,hic#er than usual nail plate Int: (+) .nycho"ryphosis, psoriasis, lichen planus, chronic fun"al infection, chronic paronychia, con"enital Nec! Sti,,ness Exp: Passive flexion of the nec# causes undue tautness of nec# muscles > nt: (+) Cenin"eal irritation (e*"* aseptic or bacterial menin"itis, encephalitis, cerebral abscess, subdural empyema, typhus, leptospirosis, subarachnoid or other cerebral haemorrha"e, mi"raine), cervical arthritis, torticollis and other nec# muscular spasms and strains, adenitis Phys: ,raction of inflamed menin"es on spinal nerves activates a protective reflex which shortens and immobilises spine $ee (lso Brud8inski)s Si"n; %emi" s $i"n.pisthotonos Nose+(inger Test Exp: )sin" the index fin"er, patient touches own nose then examiner s fin"er, bac# and forth as rapidly as possible* Examiner chan"es position of fin"er between touches* Positive if clumsy Int: $ee (taxia Phys:$ee (taxia See Also &eel'(nee Test Nuchal Rigidity See -eck $tiffness Nystagmus Exp: Involuntary rhythmic movement of eyeball* ,wo types: Pendular (oscillatin") ' with re"ular movements 3er# (rhythmic) ' with movement faster in one direction than the other Int: (+) /ormal with acute lateral vision and watchin" a movin" obBect, barbiturates, labyrinthine and vestibular disease, brain stem lesions (often vertical nysta"mus), demyelinatin" diseases (e*"* multiple sclerosis), brain tumours, syrin"obulbia, Parinaud s syn*, diencephalic syn*, pinealoma, central vision loss (e*"* albinism, retinaN disease), other visual disturbances,

al#alosis (e*"* renal insufficiency, hypoparathyroidism, Phys: hyperventilation, &ow levels of blood calcium cause neuromuscular hype rexcitab i $ee Also ,rousseaus Si"n; $h!ostek)s Si"n #edema' &itting See ,ittin" Oedema; Symptoms6) Oedema #edema' &ulmonary Exp: <luid detected in the lun"s by auscultation (see Crepitations, Pulmonary) or characteristic J'ray appearance > nt: (+) &eft ventricular failure, atrial fibrillation, hypertensive heart disease, severe asthma, lymphatic bloc#a"e, diffuse pulmonary infections, aspiration, shoc#, adult respiratory distress Phys:syn*, Physiolo"y dependent upon cause* Primarily due to an imbalance in $tarlin" s forces as related to capillary pressure "radients #liguria See Symptoms: Oli"uria and Anuria #nychogryphosis Exp: 0ross thic#enin" of the nail plate > nt: (+) Chronic trauma from poorly fittin" shoes, subun"ual tinea, psoriasis, subun"ual hyper#eratosis, old a"e Phys: Chronic inflammation of nail bed #nycholysis Exp: ;istal separation of nail plate from nail bed > nt: (+) ,rauma, chemicals, fun"al infections, psoriasis, ec+ema, 56iynaud s phenomenon, diabetes mellitus, other causes of impaired peripheral cerebral abscess, coma, <riedreich s ataxia, con"enital, alcohol, some normal infants Phys: 3er# form more common and is neurolo"ical in aetiolo"y* Pendular is due to a visual defect* ;irection of nysta"mus can "ive further clue to localise lesion See Also &all pike Test #bstetric 2and +ain d:Accoucheur $arpal spasm Exp : ,he fin"ers and wrist are in painful spasrn* ,he fin"ers are ti"htly apposed, the thumb is opposed across the palm, the terminal phalan"es hyperextended and the wrist flexed Int: (+) ,etany from hypocalcaemia or al#alosis (e*"* renal insufficiency, hypoparathyroidism, hyperventilation, "astrointestinal diseases, calcium or ma"nesium deficiency) Phys: &ow levels of blood calcium cause neuromuscular hype rexcitability $ee Also ,rousseaus Si"n; $h!ostek)s Si"n

Int: or

the terminal phalan"es hyperextended and the wrist flexed (+) ,etany from hypocalcaemia

>F

#edema' &itting See ,ittin" Oedema; Symptoms6) Oedema #edema' &ulmonary Exp: <luid detected in the lun"s by auscultation (see Crepitations, Pulmonary) or characteristic J'ray appearance Int: (+) &eft ventricular failure, atrial fibrillation, hypertensive heart disease, severe asthma, lymphatic bloc#a"e, diffuse pulmonary infections, aspiration, shoc#, adult respiratory distress syn*, various neuro"enic causes, heroin toxicity, hi"h altitude Phys: Physiolo"y dependent upon cause* Primarily due to an imbalance in $tarlin" s forces as related to capillary pressure "radients #liguria See Symptoms: Oli"uria and Anuria #nychogryphosis Exp: 0ross thic#enin" of the nail plate Int: (+) Chronic trauma from poorly fittin" shoes, subun"ual tinea, psoriasis, subun"ual hyper#eratosis, old a"e Phys: Chronic inflammation of nail bed #nycholysis Exp: ;istal separation of nail plate from nail bed Int: (+) ,rauma, chemicals, fun"al infections, psoriasis, ec+ema, 56iynaud s phenomenon, diabetes mellitus, other causes of impaired peripheral circulation, hypothyroidism, hyperthyroidism, dru"s (e*"* tetracycline) Phys: Impaired viability of distal nail bed #pisthotonos Exp: (cute ri"id archin" of the body due to spasm of the bac# muscles Int: (+) ,etanus, spinal meninDitis, infantile menin"itis, cerebellar lesions, other causes of menin"eai irritation Phys: .veractivation of protective flexor reflexes desi"ned to shorten and immobilise spine $ee (lso -eck Stiffness; (erni")s Si"n #ptic Atrophy Exp: .n ophthalmoscopic examination of retina, a pale optic disc with blurred mar"ins is noted* ;isc cuppin" may also occur, and patient complains of reduced visual acuity* <ield defects may be found Int: (+) 0laucoma, arteriosclerosis, retinal ischaemia, optic neuritis, Pa"et s disease, tumour pressin" on optic nerve, retinitis pi"mentosa, vitamin : deficiency, methanol poisonin" Phys: Ischaemia or chronic inflammation of optic disc #ptic %isc' Abnormal Exp: Characteristics noted durin" ophthalmoscopic examination of retina* Int: (+) Extra vascularity ' .ptic neuritis (+) Papilloedema (bul"in" of disc) ' Increased intracranial pressure (+) (trophy (reduced vascularity) 'optic, nerve disease (see .ptic (trophy) (+) Pale disc ' Central retinal artery occlusion (+) !aemorrha"es ' Central retinal vein occlusion

See Also Optic $uplDisc Ratio #range /rine See 7rine# A*normal $olour #rtolani Test Exp: Child is placed on a firm surface with tr #nees and hips flexed at A? ,he le"s are "rasped by the examiner so that the #nee is in the palm, the fin"6 tips are behind the "reater trochanters and the thumb rests on the anteromeO surface of the thi"h ,he hips are then abducted to A?? 1hen resistance is felt, forward pressure is applied by the fin"ertips to the bac# of the "reater trochanters ,est is positive if a distinct clun# is felt as the head of the femur slips forward into the acetabulum Int: Con"enital dislocation of the hip #sler's Manoeuvre Exp: Inflate sphy"momanometer to level tha6 obliterates radial pulse Positive if a sclerotic radial artery can b6 palpated a"ainst the underlyin" radius Int: (+) (rteriosclerosis Phys: Cay result in si"nificant overestimation of systolic blood pressure See Also Ear 0o*e $rease; Arterio!enous -ippin"# Retinal &apanicolaou Smear $mear ,est Exp * )sin" a va"inal speculum, the cervix is exposed, and a wooden or plastic spatula is used to scrape cells from the cervical os and body ,he scrapin" is then smeared onto a "lass slide which is immediately fixed in alcohol ,he slide is later stained and examined for abnormal cells, bacteria, fun"i, trichomonads, etc* Int: 5eported as showin" no mali"nant cells, dysplasia, atypical cells or carcinoma* Inflammatory or infected elements are also reported Phys:$creenin" test that should be performed at re"ular intervals to exclude pre'cancerous chan"es of the cervix &apilloedema Exp: .n ophthalmoscopic or slit lamp examination, the optic disc is noted to be flattened, swollen or protruberant bilaterally with blurred ed"es (bsent venous pulsation, dilated retinal veins, and flame shaped haemorrha"es may also be noted Int: (+) Increased intracranial pressure (e*"* haemorrha"e, tumour, menin"itis, cerebral abscess, emphysema, hypoparathyroidism), optic neuritis, hypertension, multiple sclerosis, 0uillain':arre syn* Phys: Increased C$I< pressure, due to an increase in C$I< volume (caused by haemorrha"e or increased protein content) or bloc#ed C$I< circulation, is transmitted alon" the sheath of the optic nerve to the optic disc* 2ision remains unimpaired in early sta"es See Also $heyne'Stokes Respiration &aralysis o, /p-ard Ga*e Exp : )nable to loo# upwards Int: (+) Pinealoma

>=

&aralysis' (laccid Exp : 5elaxed and flabby muscles that cannot Int: be moved voluntarily (+) Poliomyelitis, infantile muscular atrophy, cerebral atonic diple"ia, amIotonia con"enita, "lyco"en stora"e diseases (wea# rather than paralysed Cuscles), plexus palsies, multiple sclerosis, hyper#alaemia, Conn syn*, spinal cord shoc#, botulism, poisons (e*"* or"anophosphates), neuropathies, motor neurone disease, encephalitis, other lower motor neurone lesions, 0uillain':arrF syn*, myasthenia "ravis, hysteria, dru"s (e*"* curare derivatives) Phys: Inflammation, interruption or disease of motor nerve supplyin" a muscle prevents the voluntary contraction of that muscle 5eflexes usually absent &aralysis' Spastic Exp: Involuntary spasm of muscles Int: (+) $pinal cord transection, cerebral or cord tumours, vascular accide cerebrum or cord, cerebral or cord infections, upper motor neurone lesions, multiple sclerosis Phys: &oss of inhibition of reflex arc by pyramidal centres causes hyperreflexia and recurrent muscular spasm &araplegia See ,aralysis# %laccid; ,aralysis# Spastic; Symptoms: ,araple"ia and ;uadriple"ia &ar!insonian (acies Exp: 5i"idity of facial muscles that "ives a characteristic loss of facial expressiveness Int: (+) Par#inson s disease (paralysis a"itans), encephalitis lethar"ica, cerebral arteriosclerosis, 1ilson s disease, phenothia+ines, man"anese poisonin" Phys: ;e"eneration of or dama"e to the basal "an"lia results in muscular hypertonicity &ar!insonism Exp: !ypo#inesia, tremor and ri"idity Int: (+) Par#inson s disease, familial, encephalitis lethar"ica, syphilitic mesencephalitis, tuberculoma, brain stem tumours, dru"s (e*"* phenothia+ines, butyrophenones, tetrabena+ine, rauwolfia al#aloids) Phys: Par#inson s disease and iatro"enic causes most common* Caused by de"eneration of the substantia ni"ra and locus ceruleus $ee Also Co"wheel Ri"idity; %estination; 0ead',ipe Ri"idity# ,arkinsonian %acies; Tremor# Restin" See Also %estination under 3ait# A*normal &atellar Tap Exp: .ne hand is used to apply pressure to the suprapatellar pouch forcin" fluid out of this and under the patella* ,he middle and index fin"ers of the other hand are used to push down sharply on the patella* ( tap is felt when the patella hits the femoral condyles Int: (+) %nee effusion from trauma, arthritis or other cause of inflammation Phys: (ny inflammatory process causes the production of an exudate (excess synovial fluid) within the #nee Boint &atric!'s Sign Exp: In supine patient, heel of le" bein" tested is placed on opposite #nee* %nee of le" bein" tested is then pushed down

Int:

to the couch by the examiner* Positive if pain and involuntary muscular spasm occur (+) !ip Boint disease, musculos#eletal trauma (') $ciatic cause of hip pain

&ectorilo4uy' 8hispering Exp: (uscultation of the chest while the patient whispers (often the phrase ,ninety'nine is repeated)* If intense broncophony is present, individual syllables can be identified Int: (+) &un" consolidation or cavitation, ,:, pneumonia Phys: $olid lun" tissue conducts sound better than normally aerated tissue &el+.bstein &henomenon Exp: ,emperature chart over several wee#s shows a remittent fever that occurs daily, reaches a pea# level after about a wee#, then "radually subsides, to recycle a"ain Int: (+) !od"#in s disease, other lymphadenomas, undulant fever .Brucelia abortus, :* melitensis) Phys: Calaria, relapsin" fever, etc* cause a more rapid alternation &elvic Mass Exp: (bnormal mass felt in pelvis on va"inal andlor abdominal palpation Int: (+) Pre"nancy, faecal impaction, uterine fibroids, con"enital uterine abnormality, lymphoma, endometriosis, pelvic mali"nancy, pelvic inflammatory disease, ovarian cyst or mali"nancy, teratoma, ectopic pre"nancy, hydrosalpinx, pelvic abscess, rectal carcinoma, bladder carcinoma, pelvic #idney &emberton's Sign Exp: 1hen patient raises both hands above head, dyspnoea, verti"o, facial flushin", dyspha"ia and syncope occur Int: (+) &ar"e intrathoracic "oitre Phys: $uperior mediastinal pressure on the trachea, oesopha"us and surroundin" veins and arteries &ercussion See Dull ,ercussion -ote# Thoracic; Tympany# Thoracic &ericardial (riction Rub See %riction Ru*# ,ericardial &eristalsis' 0isible Exp: .bservation of abdomen in relaxed patient reveals peristaltic waves movin" va"uely across an often distended abdomen Int: (+) Pyloric stenosis, acute "astrointestinal obstruction at any level, con"enital adrenal insufficiency, thin children Phys: :loc#a"e of the intestine causes dilatation of the "ut above the bloc#a"e and increased peristaltic activity by the "ut in an attempt to overcome the obstruction* lleus results from prolon"ed bloc#a"e &es Cavus Exp: Excessive concave curvature of sole (foot) Int: (+) <riedreich s ataxia, peroneal muscular atrophy, familial, spina bifida, sacral dermoid, cerebral palsy, poliomyelitis Phys: Pro"ressive wastin" of extensor muscles of foot andEor spasm of flexor muscles of foot- idiopathic

>G

&halen's Sign Exp: ,in"lin" or sudden pain in hand within one minute of acute wrist flexion Int: (+) Carpal tunnel syn* Phys: Cedian nerve compression* ,he faster the test is positive, the more li#ely sur"ery will be reDuired See Also ,inel s $i"n &haryngeal Re,le$ Exp : ( spatula li"htly touched a"ainst pharynx causes contraction of pharyn"eal muscles and "a""in" Int: (') Ath cranial nerve lesions, hysteria, anaesthesia Phys: Innervation of the pharynx is via a reflex arc involvin" the "lossopharyn"eal (Ath) nerve &hlebitis Exp: Inflammation of a vein Int: (+) 2enous thrombosis, trauma (e*"* I2 cannula), infection, syphilis, ,:, typhoid, pulmonary embolism, antiphospholipid syn*, "out, puerperal phlebitis &igmentation See Areolar ,i"mentation; -ail Discolouration; Symptoms: ,i"mentation of +outh; ,i"mentation of Skin# Excess &in! &u,,er Exp: )nderwei"ht patient who is very breathless on exertion, has mar#edly pin# mucous membranes and an overinflated chest* /arrow heart on J'ray Int: (+) Emphysematous chronic obstructive airways disease Phys: .verinflation and underperfusion of lun"s See Also Blue Bloater; Barrel $hest &itting #edema Exp: Persistent indentation of s#in followin" pressure Int: (+) Con"estive cardiac failure, nephrotic syn*, acute "lomerulonephritis, cirrhosis, cellulitis, hypoproteinaemia (marasmus, #washior#or), beriberi, thrombophlebitis, lymphan"itis, filariasis, operative disruption of lymphatic or venous draina"e, pre"nancy and eclampsia, premenstrual Phys: Covement of fluid from vascular to extravascular tissue occurs with increases in interstitial colloid osmotic pressure or intravascular hydrostatic pressure See Also Ankle Oedema; Symptoms: Oedema &lantar Re,le$ See Ba*inski)s Si"n &lateau &ulse Exp: Prolon"ed duration of pulse summit on palpation Int: (+) (ortic stenosis, aortic coarctation Phys: $ystole sustained due to slowin" of blood flow &leural .,,usion Exp: 5estricted chest wall movement, reduced vocal fremitus, dullness on percussion, and decreased breath sounds may be noted* Cay be found by chest J'ray Int: (+) ,ransudate ' Cardiac failure, hepatic cirrhosis, nephrotic syn*, Cei"s syn*, constrictive pericarditis (+) Exudate ' Primary or metastatic

pleural mali"nancy, lymphoma, ,:, pulmonary infarct, infection, subphrenic abscess, pancreatitis, $&E, rheumatoid disease, trauma, hypothyroidism, postmyocardial infarct, dru"s (e*"* methyser"ide) Phys: Exudate and transudate distin"uished biochemically after thoracocentesis See Also 1ocal %remitus; Dull ,ercussion -ote# Thoracic &leural (riction Rub See %riction Ru*# ,leural &neumothora$ Exp: Presence of "as in pleural space, detected clinically or radiolo"ically Int: (+) $pontaneous, traumatic, asthma, bacterial pneumonia, whoopin" cou"h, cystic fibrosis, emphysema, chronic bronchitis, con"enital bullae, positive pressure assisted ventilation, ,:, oesopha"eal rupture, pleural mali"nancy, subphrenic abscess, tuberous sclerosis, histiocytosis J, sarcoidosis, iatro"enic (e*"* biopsy of lun", aspiration cannula, external cardiac massa"e) See Also n!esti"ation: ,neumothorax# Spontaneous &recocious &uberty Se$ual &recocity Exp: Premature "enital, axillary and facial hair- breast, clitoris or penis enlar"ement- voice chan"es- or menstruation Int: (+) (drenal cortical hyperplasia, cerebral or pineal tumours, (lbri"ht s syn*, hypothalamic cysts or tumours, "onadal tumours, postencephalitic or postmenin"itic lesions, hypothyroidism, constitutional Phys: Premature release of "onadotrophic hormones from the hypothalamus occurs with various forms of stimulation of that part of the cerebrum &roprioceptive Sense' Loss o, Exp: Inability to detect vibration or Boint movement Int: (+) Posterior column lesions, tabes dorsalis, subacute combined de"eneration of cord, medullary lesions, spinal tumours Phys: Proprioceptive fibres run independent of pain, temperature and some touch fibres, not decussatin" until the medial lemniscus $ee (lso Rom*er")s Si"n; (taxia- !eel'%nee Test &roptosis See Exophthalmos &rostatomegaly Exp: 5ectal di"ital examination reveals an enlar"ed prostate "land Int: (+) :eni"n hyperplasia, adenocarcinoma, prostatitis Phys: :eni"n hyperplasia very common over @? years due to hyperplasia of fibromuscular stroma* Cause un#nown* Carcinomas often involve posterior lobe and present late due to minimal urethral obstruction &tosis See Symptoms: ,tosis &uberty See ,recocious ,u*erty &u,, Re,le$ See Santmyer S2allo2

>A

&ulmonary #edema See Oedema# ,ulmonary &ulse See Boundin" ,ulse; Bradycardia; $orri"an)s Si"n; Dicrotic ,ulse; Extrasystolic Beats; rre"ularly rre"ular ,ulse; ,lateau ,ulse; ,ulse# A*sent; ,uisus Altemans; ,uisus ,aradoxus; Tachycardia; 4ater'&ammer ,ulse See Also si"ns listed under &eart &ulse' Absent Exp: ;istal pulse absent or diminished Int: (+) (rteriosclerosis, diabetes mellitus, thrombosus, &eriche syn*, embolism &ulsus Alternans Exp: (lternate variation in si+e of pulse wave, often detected by sphy"momanometry Int: (+) Paroxysmal tachycardia, left ventricular failure, cardiomyopathy, hypertension, ischaemic heart disease Phys: /ot all fibres of myocardium able to contract with each beat due to disease &ulsus &arado$us Exp: Pulse volume decreases with inspiration, the reverse of normal Int: (+) ,horacic respiration, certain postures, pericardial effusion, constrictive pericarditis, pericardial tamponade Phys: ;ue to distension of ri"ht atrium and ventricle with venous return in inspiration, compressin" the left side of the heart and reducin" its output- or due to reduction in pressure "radient between pulmonary veins and left atrium &upil Changes See +iosis; +ydriasis; 0ens Opacity; 4hite ,upil &urpura See &ess ,est- $ymptoms: Purpura and ,etechiae 9uec!enstedt's Test Exp: Pressure on either or both Bu"ular veirll durin" lumbar puncture normally produces a rise in the C$< manomet(ic pressure, and then a drop when pressure on veins released Int: (') :loc# of spinal subarachnoid space or bloc#in" of C$< escape from cerebral cavity (e*"* vertebral fracture, ,:, tumours of cord or vertebrae, haematomas) Phys:Physical bloc# of fluid connection via Bu"ular veins, cerebral C$< and spinal C$< causes test to be ne"ative Racoon Sign exp: Periorbital ecchymosis (dar# bruise rin"s around eyes) Int: (+) <racture at base of s#ull Phys: J'rays may be ne"ative despite positive si"n* Caused by trac#in" of blood throu"h tissue planes from fracture site $ee (lso :attle s $i"n Radial "er! Exp: 1ith the elbow flexed at A?> and the forearm in neutral position, the styloid process of the radius is tapped with a rubber hammer* /ormal result is flexion of elbow and supination of forearm Int: (') &ower motor neurone lesion, peripheral neuropathy, polio, tabes dorsalis, posterior root tumours, syrin"omyelia, muscular dystrophies,

subacute combined de"eneration of cord, coma (++) )pper motor neurone lesion, tetanus, C2( Phys: ;ue to contraction of brachioradialis* (cts at C=, CG level See Also other si"ns listed under Reflexes Rainbo- 2alo Exp : 5ainbow coloured halo seen around li"hts, particularly at ni"ht Int: (+) (cute an"le closure "laucoma, Comeal oedema, incipent cataract, aller"ic conBunctivitis Phys: ;istortion of li"ht, as in a prism, by uneDual ali"nment of inner and outer surfaces of cornea Rales See $repitations# ,ulmonary; Rhonchi 5ash See symptoms listed under Rash in Symptoms Rash utter,ly $ee , Butterfly Rash Rebound Tenderness' Abdominal Exp: 0entle pressure on the abdomen followed by rapid removal of pressure causes sudden, acute pain Int: (+) Peritonitis, peritonism due to any inflamed intra'abdominal viscus (e*"* appendicitis, pancreatitis, perforated ulcer, cholecystitis, Crohn s disease, diverticulitis, cystitis, adenitis), intraperitoneal haemorrha"e (e*"* ectopic pre"nancy, lea#in" aneurysm, endometriosis) Phys: ,he sudden release of pressure causes movement of the viscus within an inflamed peritoneum, and thus pain See Also Symptoms: A*dominal ,ain Red /rine See 7rine# A*normal $olour; ,atholo"y66 &aematuria Re,le$es See $onsensual Reflex; Ankle Jerk; $remasteric Reflex; 3rasp Reflex; &erin"'Breuer Reflexes; $omeal Reflex; &offrnann)s Si"n or Reflex; +ass Reflex; ,haryn"eal Reflex; +oro Reflex; Ba*inski)s Si"n; Radial Jerk# (nee Jerk; Triceps Jerk; Santmyer S2allo2 Renal See (idney# 0ar"e; (idney# Small Retinal Arteriovenous Nipping See Arterio!enous -ippin"# Retinal Retinal .$udates Exp: .phthalmoscopic examination of retina reveals white fluffy patches Int: (+) ;iabetes mellitus, hypertension, increased intracranial pressure, massive blood loss Phys: .cclusion of retinal capillaries Retinal 2aemorrhages Exp: 5ed spots and patches adBacent to blood vessels are noted on ophthalmoscopic examination of the retina* 2arious types described as punctate, splinter and flame Int: (+) Pernicious anaemia, leu#aemia, aplastic anaemia, hypertension,

7?

diabetes mellitus, bacterial endocarditis, anticoa"ulants, haemorrha"ic disease Phys: ;ama"ed retinal capillaries Retinal &igmentation Retinitis ,i"mentosa Exp: Cells filled with epithelial pi"ment con"re"ate beside retinal blood vessels Int: (+) :assen'%orri+wei" syn*, &aurence'Coon':iedl syn*, other "enetic conditions Phys: /i"ht blindness and tunnel vision early $ymptoms Rhonchi Dry Rales Exp: Cusical whee+in" sounds caused by air flow throu"h narrowed or con"ested bronchi, heard on chest auscultation* ;eeper pitched sonorous rhonchi ori"inate in lar"e bronchi* !i"her pitched sibilant rhonchi ori"inate in smaller bronchi Int: (+) :ronchitis, tracheobronchitis, asthma, pulmonary tumours, bronchial oedema or spasm Phys: (ir passin" throu"h the narrowed part of a tube becomes turbulent and produces a sound See Also $repitations# ,ulmonary Rib Notching Exp: ( plain (P J'ray of the chest shows notchin" on the lower surface of the 9th to Gth ribs posteriorly* )sually bilateral Int: Con"enital coarctation of aorta Rigidity $ee 0ead',ipe Ri"idity; $o"2heel Ri"idity# A*dominal Ri"idity; $lasp'(nife Ri"idity; -eck Stiffness; Opisthotonos Rinne's Test Exp: ( vibratin" tunin" for# (@>7 cps) is placed on the mastoid process* 1hen it becomes inaudible to the patient, the vibratin" end is placed near the external auditory meatus* If heard at the external auditory meatus, air conduction is "reater than bone conduction (i*e* 5inne positive)* In reverse situation, if heard on mastoid process after air conduction lost, the test is 5inne ne"ative Int: (+) (ir conduction K bone conduction ' Conductive deafness (e*"* wax, perforated tympanum, otosclerosis, "lue ear, otitis media, forei"n body, dislocated ossicles, tumours, meatal stenosis, exostoses, barotrauma) (+) (ir conduction L bone conduction /ormal hearin" (+) 5educed time ' Perceptive deafness (e*"* presbycousis, vascular causes, measles, mumps, influen+a, menin"iti, labyrinthitis, con"enital causes Pmaternal rubellaN, trauma PblastN, prolon"ed noise exposure, dru"s (e*"* streptomycin, aspirin, Duinine), Ceniere s disease, late otosclerosis, C/$ tumours, haemorrha"e, leu#aemia, multiple sclerosis, vitamin : deficit), psycho"enic $ee (lso 4e*er)s Test Risus Sardonicus Exp: <ixed, immobile "rin Int: (+) ,etanus Phys: Excess tension of facial musculature Rogo,,s Sign Exp: Costovertebral an"le pain and tenderness Int: (+) (drenal crisis Phys: (drenal inflammation due to steroid withdrawal- or adrenal infection or destruction

Romania's Sign Exp: )nilateral persistent oedema of upper and lower eyelids Int: (+) Cha"as disease Phys: .ccurs when conBunctiva is portal of trypanasome entry Romberg's Sign Exp: Patient stands at attention with heels close to"ether and then shuts eyes* Positive when severe swayin" or failin" occurs Int: (+) ,abes dorsalis, posterior column lesion, subacute combined de"eneration of cord, intoxication Phys: ;ue to loss of proprioceptive sensation* /e"ative in cerebellar disease See (lso Ataxia; ,ropriocepti!e Sense# 0oss .t &eel'(nee Test; Tandem Rom*er" Test Rosary' Thoracic Exp: /odular swellin" of costochondral Bunctions of the ribs bilateral to the sternum in a child Int: (+) 5ic#ets Phys: Calcium deficient diet Rubin Test Exp : ( cannula of sufficient diameter to ma#e the os cervix airti"ht is introduced throu"h the cervix into the uterus* Carbon dioxide is passed throu"h the tube into the uterus, while a side arm to a manometer measures the pressure, which should not exceed 7?? mm!"* ( stethoscope is used to listen to "as bubbiin" throu"h tubular ostia* (ny abdominal or shoulder tip pain is also noted lnt: (' no "as heard) /onpatent fallopian tubes phys: ,est of tubal patency in infertility* Cay help clear mildly bloc#ed tubes* $hould be performed immediately after menstruation, before ovulation Saddle Nose Exp: Characteristic saddle or dip at Bunction of bony and cartila"inous parts of dorsum of nose Int: (+) 1e"ener s "ranulomatosis, con"enital syphilis Santmyer S-allo,uff Reflex Exp: :lowin" "ently on the face of an infant induces a reflex swallow Int: )seful procedure for easin" the passa"e of a naso"astric tube or medication* ;evelopmental assessment test ' should have disappeared by 79 months of a"e Scanning Speech Staccato Speech Exp: ( speech form in which there are mar#ed, and sometimes rhythmic, pauses between syllables andEor words Int: (+) Cerebellar ataxia, multiple sclerosis $ee (lso $lurred Speech Schamroth's Sign Exp: $ame fin"ers of both hands are held with nails touchin"* In normal nails, there is a "ap between the nails at their bases* If fin"ers are clubbed, "ap between nails occurs at tips of nails Int: (+) Clubbin" present

7>

Phys: )sed to note presence of clubbin" $ee (lso $lu**in" of <in"ers Schiller Test Exp: ,he cervix is painted with aDueous iodine solution* /ormal areas stain dar# brown Int: (+) /onstained areas ' Cervical carcinoma, erosion, eversion, scars, leucopla#ia, cystic mucous "lands Phys: /ormal cells ta#e up stain because they contain "lyco"en* ,est shows abnormal areas, but is not specific for any cause Schober's Test Exp: 1ith patient erect, mar# s#in over &@ level and a point >? cm above* Patient bends forward maximally and distance between mar#s is measured Int: (+) Increase K @ cm ' &umbar an#ylosin" spondylitis, other de"enerative lumbar vertebral disease Scissors Gait $ee 0ait, (bnormal Sclera' lue $ee :lue $clera Se$ual &recocity See Precocious Puberty Shi,ting %ullness Exp: Percussion of an abdomen with patient lyin" on one side reveals a dullness on the side nearest the bed, and a tympanic note on the hi"h side, re"ardless of which side the patient is lyin" Int: (+) <ree intraperitoneal fluid (ascites) (e*"* cirrhosis, intraperitoneal neoplasms, ,:, peritonitis, con"estive cardiac failure, nephrosis, hepatoma, constrictive pericarditis, hepatic vein obstruction, myxoedema, Cei"s syn*)* Phys: <luid flows from one side of abdomen to other as patient turns $ee (lso ,hrill, %luid; $ymptoms: (scites Shirmer's Test Exp: ( strip of filter paper @ mm x [email protected] mm is folded @ mm from one end* ,he short flap is inserted under the lower lid of each eye and the e > ye is closed li"htly* (fter @ minutes, len"th of strip from ciliary mar"in that has been dampened by tears is measured* /ormal L @ mm Int: (K @ mm) Jerophthalmia See Also $ymptoms: Jerophthalmia Shoulder Tip &ain Exp: Pain at tip of shoulder Int: (+) :lood, pus or air under diaphra"m inflammation of subphrenic or"ans (e*"* liver, spleen), after abdominal operations in which air may have been introduced (e*"* laparoscopy) Phys: 5eferred pain via phrenic nerve, caused by irritation of diaphra"m* Exclude local causes See (lso (ehr)s Si"n Simmond's Test See Calf S5uee8e Test Sister Mary "oseph's Nodule Exp: 5aised umbilical nodule, often erythematous and painless Int: (+) ;isseminated intra'abdominal mali"nancy (e*"* ovarian or "astric

carcinoma) Phys: 5etro"rade lymphatic spread of carcinoma to form an umbilical deposit S!in' Abnormal See Areolar Pi"mentation- :utterfly Rash; $afd'au'0ait Spots; $hip $i"n- ChloasmaDermo"raphia; 0ottron s $i"n- 0eser'Trelat $i"n- $pider -ae!i; 9anthomatosis See (lso symptoms listed under Skin Disorders in Symptoms Slurred Speech Exp: Car#ed difficulty or tremblin" in attempts to pronounce words of several syllables Int: (+) ;ru"s (e*"* alcohol, sedatives), "eneral paralysis of insane, <riedreich s ataxia, bulbar palsy See (lso Scannin" Speech Spalding's Sign Exp: .verlappin" of cranial bones seen or, J'ray examination of intrauterine fetus Int: (+) Intrauterine fetal death, labour Phys: &oss of tissue tur"or in death Spasm' Muscular See Cyotonia- &yperlonicilly Spastic &aralysis See Paralysis, Spastic Speech See Scannin" Speech; $lurred Speech Spider Naevi Telan"iectasia Exp: $#in area where several capillaries can be seen radiatin" from a central point Int: (+) Cirrhosis of liver, thyrotoxicosis, rheumatoid arthritis, pre"nancy, sun dama"ed s#in, carcinoid syn*, C5E$, syn*, &ouis':ar syn*, 5endu '.sler'1eber syn*, 5othmund',homson syn*, systemic sclerosis, acute alcoholic and viral hepatitis Spleen' .nlarged $ee $plenome"aly Splenomegaly Exp: Enlar"ed spleen found on bimanual palpation of abdominal &)M Int: (+) $ystemic infection, portal hypertension (due to cirrhosis, portal or splenic vein thrombosis or obstruction), 0aucher s disease, ,:, /iemann'Pic# disease, con"estive cardiac failure, &etterer'$iwe disease, <elty s syn*, sarcoidosis, leu#aemias, lymphoma, various haemo"lobinopathies, thalassaemia maBor, myelofibrosis, #ala'a+ar, hepatitis, subacute bacterial endocarditis, malaria, typhoid fever, infectious mononucleosis, $&E, polyarteritis nodosa, polycythaernia vera, spherocytosis, brucellosis, thrombocytopenia, haemolytic anaemias, splenic cysts or neoplasn s, septicaemia, !and'$chueller'Christian disease, arnyloidosis, (I;$, :udd'Chi,,n syn*, !unter s syn*, !urler s syn*, Plummer'2inson syn*, Pompe s syn*, $anfilippo s syn*, $cheie syn*, $ly $yn protein deficiency, starvation ;eposition of matter in the spleen, venous outlet obstruction or increased red blood cell production

77

Splinter 2aemorrhages ExpInt: &inear haemorrha"es of the nail bed

$ubacute bacterial endocarditis, blood dyscrasias, psoriasis, ec+ema, rheumatoid arthritis, tinea, trauma Phys: ;ue to microemboli in subacute bacterial endocarditis See Also 3aneway 0esion Split 2eart Sounds

septal defect, patent ductus arteriosus, "ross anaemia, aortic stenosis, dilatation of base of aorta, hi"h fever, hype rthyroidism, pulmonary stenosis, aortic coarctation, tricuspid incompetence, carcinoid syn*, cardiomyopathies Phys: ;ue to flow disturbances within the heart* Citral incompetence and associated states tend to be heard at the apex- aortic valve disease is heard maximally at ri"ht sternaN mar"in in 7nd intercostal space Tachycardia !eart (pulse) rate si"nificantly hi"her than avera"e ("enerally L >?? per minute) Int: (+) Exercise, emotion, pain, shoc#, infections, sarcoidosis, thyrotoxicosis and other hypermetabolic diseases, endocarditis, hypotension, cardiac failure, atrial flutter and fibrillation, paroxysmal tachycardia, pacema#er an conductive anomalies, nodal tachycardia, sic# sinus syn*, anaphylaxis, pulmonary oedema, phaeochromocytoma, venous hypertension, mitral valve disease, coronary artery disease, pulmonary thromboembolism, polyarteritis noclosa, other connective tissue diseases, dumpin" syn*, lru#andBi syn*, dru"s (e*"* alcohol, adrenaline, atropine, amphetamines, cocaine) Phys: ;ue to metabolic or mechanical influences on the cardiac pacema#er, or the occurrence of a more rapidly depolarisin" ectopic pacema#er $ee (lso ,orsades de Pointes Tachypnoea $ee !yperventilation Tandem Romberg Test Exp: Patient stands with one foot in front of the other (toe to heel in tandem), then closes eyes* Positive if patient sways or is unsteady Int: (+) &abyrinth, posterior column lesions, tabes dorsalis, subacute combined de"eneration of cord, intoxication Phys: Core sensitive than standard 5omber" s si"n $ee (lso Rom*er")s Si"n Tardive %ys!inesia See Dyskinesia# Tardi!e Target Lesions Exp: 5ound, erythematous macule that becomes papular, enlar"es and develops concentric rin"s of colour to resemble a tar"et* Centre of lesion may blister, erode and crust* Cay become pi"mented durin" resolution Int: (+) Erythema multiforme Phys: Precursor tar"et lesion often not identified as erythema multiforme until widespread lesions erupt Third .yelid o, Morgan+%enny Exp: Extra fold of s#in above upper eyelid Int: (+) (topic ec+ema of eyelid, aller"ic conBunctivitis, other chronic irritatin" conditions of eye Phys: Caused by chronic rubbin" of eye Core common in children Thorn's Sign Exp: Int: $tiffness of cartila"e in ear (+) (ddison s disease Exp:

Exp: ;ouble heart sound in which the two elements are very close to"ether Int: (+) > st sound ' /ot patholo"ical (+) 7nd sound ' /ormal in inspiration, left bundle branch bloc#, atrial septal defect, aortic valve stenosis, patent ductus arteriosus, left ventricular failure due to hypertension or ischaemia Phys: (synchronous closure of mitral and tricuspid valves (> st sound) or pulmonary and aortic valves (7nd sound) Spooning Nails See (oflonychia S4uint See $ymptoms: S5uint Staccato Speech See Scannin" Speech Startle Re,le$ See +oro Reflex Steatorrhoea See ,atholo"y: %aecal %at Steell Murmur See 0raham Steell Curmur Stool' Abnormal Colour See %aeces# A*normal $olour Stra-berry Tongue Exp - 5ed "la+ed ton"ue with prominent papillae Int: (+) $carlet fever (may have thic# white fur between papillae for first 7 days) See Also 0eo"raphic ,on"ue Striae $ee $ymptoms: $triae Subcutaneous .mphysema See $repitations# Tissue S-inging Torch Sign Exp: In a dar#ened room, shine a torch in normal eye and there is immediate bilateral constriction of pupils* $win"in" torch to affected eye causes initial bilateral dilatation with subseDuent constriction* $win"in" torch bac# to normal eye results in immediate pupil constriction a"ain Int: (+) 0laucoma (more advanced in affected eye), optic nerve demyelination, tumour or disease Phys: (s the li"ht shifts from the less to the more diseased eye, the direct afferent stimulus passes alon" the more dama"ed optic nerve- it is now no lon"er sufficient in intensity to #eep the pupils as small as they had been when the better eye was illuminated, both pupils thus dilate Systolic Murmur Exp: Cardiac auscultation reveals a murmur between > st and 7nd heart sounds Int: (+) Physiolo"ical, exercise, mitral valve incompetence, atrial and ventricular

Thrill' Cardiac Exp: 2ibration that emanates from the heart or "reat vessels felt by the palpatin" hand* (nalo"ous to murmur Int: (+ systolic) (ortic stenosis, aortic aneurysm, pulmonary stenosis, infundibular stenosis, ventricular septal

78

defect, mitral re"ur"itation, patent ductus arteriosus, other arteriovenous aneurysms (+ diastolic) Citral stenosis, patent ductus arteriosus, pulmonary incompetence Phys: 5apid movement of blood throu"h abnormally narrowed or dilated passa"e $ee Also Diastolic +urmur; Systolic +urmur Thrill' (luid Exp: ,he patient or a third person places his or her hand vertically on ed"e alon" the linea alba* Examiner places flat of hand on one side of abdomen and sharply taps opposite flan#* ( sudden chan"e in abdominal pressure is noted by the palpatin" hand Int: (+) Intraperitoneal fluid (ascites) (due to cirrhosis, cardiac failure, hepatitis, carcinoma of liver, pericarditis, nephrotic syn*, etc*) Phys: <luid thrill may be felt due to subcutaneous fat transmission of impulse unless this is obstructed by hand on linea alba See Also Shiftin" Dullness; Symptoms: Ascites Thrombophlebitis See ,hle*itis Thyroid Glitter Exp: Int: Phys: 0litter of li"ht in the eyes (+) ,hyrotoxicosis ConBunctival oedema

Int -

/iacin deficiency

Torsades de &ointes ,wistin" of the Points Exp - 2ariant of ventricular tachycardia characterised by bursts of ventricular tachycardia complicatin" a Bunctional bradyeardia* .n an EC0, the bradycardia element shows a lon" M, interval, and the ventricular tachycardia shows a swin"in" axis (>wistin" of the points ) in a series of ectopic M5$ complexes that vary in their form* (bnormal , waves may be present in bradycardia phase Int: (+) Complete heart bloc#, acute myocardial infarction, myocarditis, hypo#alaemia, con"enital, dru"s (e*"* phenothia+ines, tricyclics, some antiarrhythmics) Phys: (bnormality in ventricular repolarisation* /ormally self 'terminatin" condition, but may terminate in syncope or sudden death Torsion %ystonia See Athetosis Torticollis Exp: $pasm of the muscles in one side of the nec# which causes the head to twist to that side* $trai"htenin" of the head usually causes pain Int: (+) Cuscle trauma, hysteria, rheumatoid arthritis, corpus striatum disease, adenitis of nec# "lands, nec# abscess, ocular diseases, >> th cranial nerve disease, fibrositis, thermal trauma to nec#, habitual tic, labyrinthine disease, tissue scarrin", con"enital Phys: $ternomastoid muscle most commonly involved Tracheal %isplacement Exp: ;eviation of the trachea from the midline to the suprasternal notch Int: (+towards lesion) Pulmonary fibrosis, ,:, pulmonary collapse (+ away from lesion) Pleural effusion, pneumothorax Phys: :ase of trachea moved laterally by variations in the normal volume of the chest contents $ee Also Dull ,ercussion -ote# Thoracic Tremor' Intention ;ysmetria Exp: (ttempt to touch nose with fin"er or perform any other definite movement causes increasin" sha#in" of hand until movement is completed* Precision movement lost Int: (+) Cerebellar lesions (e*"* tumours, C2(, abscess), multiple sclerosis, brain stem disease, <riedreich s ataxia, spinocerebeflar de"enerations, mercury poisonin" Phys: &oss of appreciation of the force and rate of muscular contraction necessary for a movement See Also Dysdiadochokinesia Tremor' &ostural Exp: ,remor obvious in certain postures such as outstretched hands Int: (+) (nxiety, thyrotoxicosis, alcohol, dru"s (e*"* bronchodilators, tricyclics), heavy metal poisonin", 1ilson s disease, neurosyphilis, cerebellar lesions, familial Phys: &oss of fine control of flexorEextensor reflex Tremor' Resting

Tinel's Sign Exp: ,in"lin" or sudden pain on volar wrist percussion Int: (+) Carpal tunnel syn* Phys: Cedian nerve compression See Also ,halen)s Si"n Tone' %ecreased Muscular See &ypotonia Toney Increased See &yperlonicity Tongue' Abnormal See %asciculation# +uscular; 3eo"raphic ,on"ue- Stra2*erry Ton"ue; Ton"ue# Discoloured; Ton"ue# Enlar"ed; Ton"ue# <issured Tongue' %iscoloured Exp: (bnormal ton"ue colour Int: 1hite ' ,hrush (fun"al infection), leucopla#ia, lichen planus, mil# curds, burns, 5eiter s syn* :lac# ' <iliform papillae hypertrophy, tobacco, penicillin, chromo"enic bacteria, antiarthritic dru"s, melanoma 5ed ' $carlet fever, poststreptococcal infection, pernicious anaemia, ariboflavinosis, pella"ra, sprue, vitamin : deficit, 5eiter s syn* :lue ' Central cyanosis from heart or lun" disease Patchy ' 0eo"raphic ton"ue Tongue' .nlarged Cacro"lossia Exp : .versi+e ton"ue for mouth Int: (+) ;own syn* (see $yndromes), haeman"ioma, lymphan"ioma, primary amyloidosis, acrome"aly, cretinism Tongue' (issured Exp - ;eep fissures on ton"ue surface

79

Exp: 5hythmic sinusoidal movement of limbs andEor head at rest Int: (+) Par#inson s disease (paralysis a"itans), postencephalitic, cerebral tumours, dru"s (e*"* reserpine, phenothia+ines) Phys: ;e"eneration of substantia ni"ra and associated pathways $ee %estination under 3ait# (bnormal See Also $o"2heel Ri"idity Trendelenburg Test Exp: .bserve patient from behind while each le" in turn is lifted from the "round and the hip flexed forward* Positive if pelvis tilts towards side on which le" is lifted Int: (+) /ormal (') &esion of contralateral "luteal nerve supply at radicular level, con"enital dislocation of hip, muscular dystrophy Phys: $uperior "luteal nerve separates from the sciatic distribution of the &9'@ nerve roots at lumbar plexus level Triceps "er! Exp: 1ith the elbows at A?de"ree and relaxed, the triceps tendon is tapped Bust above the point of the elbow* ,his results in extension of the elbow Int: (') Poliomyelitis, peripheral neuropathies, posterior root disease, tabes dorsalis, spinal cord tumours or de"enerations, spinal shoc#, syrin"omyelia, muscle dystrophies, coma (++) )pper motor neurone lesion, tetanus, hype rthyroidis m, anxiety, cord transection Phys: (cts at CF, C=, CG level* ;ue to contraction of triceps brachii muscle See Also other si"ns listed under Reflexes Trichiasis Exp: In"rown eyelash causes irritation of conBunctiva Int: (+) ,rachoma, eyelid trauma $ee (lso Entropion Triple Rhythm $ee 0allop 5hythm Trousseau's Sign Exp: Circumferential pressure (e*"* by sphy"monanometer cuff) on a limb causes carpopedal spasm Int: (+) !ypoparathyroidism, hypocalcaemia, ric#ets, al#alosis, :artter s syn* (see $yndromes) Phys: &ow serum calcium causes hyperexcitability of muscles that may lead to tetany $ee (lso $h!ostek)s Si"n T-itching See %asciculation# +uscular Tympany' Thoracic Exp: .ne index fin"er is laid flat on the chest and is struc# firmly with the other index fin"er* !i"her than normal pitch of percussion note is tympany Int: (+) Pneumothorax, overinflation of lun"s (e*"* asthma, emphysema), cavitation of lun"s Phys: &ar"e air masses reflect sound more readily /mbilical ruising See $ullen)s Si"n /rine' Abnormal Colour

Int: phenindione, rifampicin, desferrioxamine, phenothia+ines) :rownEblac# ' Porphyria, blood, melanin, dru"s (e*"* nitrofurantoin, methyldopa, cascara), foods (e*"* rhubarb, fava beans) .ran"e ' ;ehydration, dru"s (e*"* primaDuine, riboflavine, sulfasala+ine) :lueE"reen ' :iliverdin, dru"s (e*"* amitriptyline, triamterene, phenol, indi"o) /terus' .nlarged see pel!ic Cass 0enous .ngorgement and &ressure $ee Bu"ular 2enous Pressure 0ocal (remitus Exp: )inar border of hand is used to detect variations in the vibrations transmitted from the larynx throu"h the airways and lun"s to the chest wall when a patient repeats a phrase (e*"* ninety'nine ) Int: (') <eeble voice, bloc#ed bronchus from forei"n body, bronchial tumour, pleural effusion, pneumothorax, collapsed lun" (++) Pneumonia, consolidation around maBor bronchus, ,: Phys:2ariations depend on the de"ree of interference of vibration conduction throu"h lun" tissue See (lso Pleural Effusion 0omit See Symptoms: -ausea and 2omitin" 8addling Gait $ee 0ait, A*normal 8aiter's 2and Exp : ,he arm is adducted and extended at the elbow and the forearm is pronated, with the palm facin" bac#wards as Int: thou"h acceptin" a surreptitious tip (+) Erb';uchenne paralysis Phys:;ama"e (usually at birth) to the @th cervical anterior nerve root and subseDuent paralysis of deltoid, brachioradialis and biceps 8asting' Muscular Exp: Int: 5eduction in muscle bul# &ocalised ' Paralysis of muscle bundle (e*"* paraple"ia, motor neurone disease, plexus palsy), con"enital 0eneralised ' ;iabetes mellitus, thyrotoxicosis, (ddison s disease, phaeochromocytoma, occult carcinoma, hypopituitarism, anorexia nervosa, fad diets

8ater+2ammer &ulse Collapsing &ulse Exp: 1ith patient s hand raised as hi"h as possible above head, a pulse is felt that appears to hammer at the examiner s fin"ers and then suddenly collapse Int: (+) (ortic incompetence, arteriovenous fistula (e*"* patent ductus arteriosus), severe anaemia, ventricular septal defect, complete heart bloc#, fever, thyrotoxicosis, vasodilatory dru"s Phys: &ow diastolic pressure and subseDuent flaccidity of arterial walls $ee (lso $orri"an)s Si"n 8ea!ness' Muscular $ee ,aralysis# %laccid; &ypotonia 8ebbing o, Nec! Exp: (nterior aspect of nec# is broadened due to an exa""erated s#in fold from the mastoid process to the shoulder Int: (+) ,urner s syn* 8eber's Test

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Exp: 2ibratin" tunin" for# placed on midline of forehead or a central incisor, is normally heard at midline Int: In conductive deafness sound is referred to cleafer ear* In perceptive deafness sound is referred to the better ear Phys: .ften unreliable* In conductive deafness the cochlear is undisturbed by extraneous noises encountered by the better ear $ee (lso Rinne)s Test 8hite &upil 0eucocoria Exp: Pupil of eye is white and reflects li"ht Int: (+) Cataract, retinoblastoma, retinal fibroplasia, comeal scarrin", persistent tunica vasculosa lentis 8indlass Test Exp: Passive hyperextension of the hallux ("reat toe) causes the plantar medial lon"itudinal arch of the foot to reform in a flat'footed patient Int: (+) Physiolo"ical flatfoot (') Patholo"ical flat foot Phys: Physiolo"ical flat foot due to li"amentous laxity is asymptomatic, common and reDuires no treatment 8oda! Sign Exp: ,he patient is seated with bac# and elbows unsupported* 1ith the arms sli"htly extended, the patient points the index fin"ers while #eepin" the other fin"ers in a fist* ,he examiner sits opposite the patient and points his or her index fin"ers close to those of the patient, but has his or her elbows supported on the arms of a chair* ,he patient closes his or her eyes* Positive test if patient s fin"ers drift away from those of the examiner Int: (+) &abyrinth disease Phys: If nysta"mus of labyrinthine ori"in is present, the fin"ers will drift in the direction of the slow phase when the patient s eyes are closed 8rist %rop Exp: Inability to extend wrist Int: (+) 5adial nerve lesion, peripheral neuropathy, muscular dystrophy, lead poisonin" Phys: &ower motor neurone lesion of wrist extensors :anthelasma 9antheloma ,alpe*rarum Exp: Iellow'brown nodules in soft tissues around eye Int: (+) Primary biliary cirrhosis, elderly, hyperlipidaemia, cholestasis See Also 9anthornatosis :anthomatosis Exp: Cluster of pale yellow papules on patch of s#in, often on buttoc#s Int: (+) !ypertri"lyceridaemia, other hyperlipidaemias, diabetes mellitus, biliary cirrhosis, cholestasis Phys: ;eposition of excess circulatin" lipid s#in

(R#M MIMS C#M&ANI#N ;<<= R.&R# > ( R/%> M%

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