Optic atrophy
An atrophic optic disc is pale. Subtle changes are hard to interpret - it is helpful to compare the two discs, as marked asymmetry in colour is significant. The terms primary, secondary and consecutive optic atrophy are confusing and are best avoided. Optic atrophy is usually associated with decreased vision and afferent pupillary defects. It is not a diagnosis but a sign. Glaucomatous optic atrophy is illustrated in Fig. 7.20. The Disorders box lists the causes. Fig. 7.20 Optic disc atrophy...
Single lesions
The extent and nature of the dysfunction will often enable the location of a lesion to be deduced fairly precisely. Cerebral cortex. Although the cerebral cortex functions in an integrated manner, certain cortical areas are associated with specific functions. The effects of lesions at different sites in the parietal, frontal, occipital and temporal lobes are summarised in Figure 6.51. Impairment of specialised functions results in dementia, dysphasia, apraxia, astereognosis and other forms of...
Abdominal distension bloating
The principal causes of abdominal distension arc far. flatus, faeces, fluid aiul fetus Table 5.10 . Increasing abdominal girlh is usually due to adiposity and should alert the clinician to the possibility of alcohol abuse. Its development in a patient who is otherwise becoming thinner suggests intra-abdominal disease. Ascites, the accumulation of fluid in the peritoneal cavity, is usually due to cirrhosis of the liver, malignancy, nephrotic syndrome, tuberculous peritonitis, cardiac or...
Physical Examination Of The Locomotor System
TABLE 8.6 Conditions in which the family history may be diagnostically helpful Diseases linked to the HLA-B27 tissue type - ankylosing spondylitis, iritis, reactive arthritis, weaker association with psoriasis, inflammatory bowel Psoriasis - psoriatic genes may be expressed in either skin, joints or both in any order and at any time Hypermobile joints - Marian's syndrome. Ehlers-Danlos syndrome, benign familial hypermobllity. floopy prolapsing mitral valve
Anatomy and normal structures
Quiei respiration is predominantly diaphragmatic, particularly in males, so that the abdominal wall moves out during inspiration. In healthy subjects, it may be possible to feel the colon in the left iliac fossa. The caecum and sometimes the transverse colon may also be palpable, especially if the latter contains hard faeces. The aorta, the liver edge and the lower pole of the right kidney arc often palpable Fig. 5.9 . Faeces are commonly palpable in the sigmoid Fig. 5.6 Contents of the...
Acute limb ischaemia
The features of the acutely ischaemic limb are conveniently known as the 6 Ps Table 3.33 . Of these, loss of motor ability to wiggle the toes fingers and or sensory function light touch over the forcfoot dorsuin of the hand are the most important and indicate nerve ischaemia. Once these features are present the limb will become irreversibly damaged unless the circulation is restored within a few hours. Calf muscle tenderness is another grave sign indicating impending muscle infarction. The...
Bones
in fractures of the scaphoid the only finding may be tenderness localised in the anatomical snuffbox. Occasionally the bones of the hand, particularly the phalanges, may be involved in granulomatous or other generalised disorders such as sarcoidosis, Paget's disease or hyperparathyroidism. Acute dactylitis is characteristic of sickle ceil disease in children. Craves' disease, autoimmune hyperthyroidism, may be associated with finger clubbing and periosteal new-bone formation in the phalanges....
Paroxysmal nocturnal dyspnoea
PND is acute, severe, brcathlessness that wakes the patient from steep. The patient has to sit upright gasping in bed or sitting on the edge of the bed. The patient may even get out of bed, occasionally throwing open the windows in an attempt to relieve the distress. The intensity of the symptom is often described as akin to suffocation. Characteristically, the patient has a cough producing frothy sputum which may be streaked with blood. The mechanism is explained in Figure 3.2, which also...
Common abnormalities Kax
Rate. The causes of tachycardia and bradycardia are shown in Table 3.16. An important cause of bradycardia is complete heart block 3rd degree atrioventricular block TABLE 3.16 Causes of a fast or slow pulse Fast heart rate tachycardia, gt 100 min Slow heart rate bradycardia, lt 60 min TABLE 3.17 Causes of an irregular pulse TABLE 3.17 Causes of an irregular pulse Atrial flutter with variable response Second degree heart block with variable response when the heart rhythm is regular and the rate...
THE HISTORY Presenting complaints
The severity of the symptoms may bear little relationship to the gravity of the underlying pathology. For example life-threatening, deep venous thrombosis DVT may be asymptomatic. There are four cardinal symptoms of lower limb venous disease. 1. Pain. Patients with uncomplicated varicose veins may complain of an aching discomfort in Ihe leg, itching and a feeling of swelling. Symptoms arc typically aggravated by prolonged standing and are often worse towards the end of the day. The pain of deep...
Practical considerations
The positions in which the percussion note on the two sides should be compared are as follows Anterior chest wall Fig. 4.17 a clavicle b infraclavicular region c second to sixth intercostal spaces. Lateral chest wall Fig. 4.17 fourth to seventh intercostal spaces. Posterior chesi wall Fig. 4.18 a trapezius, percussing downwards over the lung apex b above the level of spine of scapula c at intervals of 4 5 cm from below the level of spine of scapula down to the eleventh rib. The lung apices are...
Abnormal findings Kmm
Gaseous distension of the abdomen is resonant to per cussion. The gravid uterus, bladder enlargement, ovarian cysts, and other solid pelvic masses extend out of the pelvis into the abdomen to produce central abdominal dullness with resonance of the flanks caused by gas in the surrounding displaced gut. In contrast, ascites is suggested by the presence of dullness in the flanks with central abdominal resonance. Ascites is often first suspected from the convexity of the abdomen and flanks on...
Dyspepsia indigestion
indigestion' is a common complaint, it is essential that the patient explains in detail what is meant by this vague term. Indigestion might describe nausea, heartburn, epigastric discomfort, abdominal pain, belching or a feeling of postprandial bloating. It may even be used to describe angina pectoris. Peptic ulcers usually produce characteristic symptoms, as shown in Table 5.7. Differentiation between oesophageal, gastric or duodenal ulcers on Ihe basis of symptoms alone is often unreliable....
Anatomy Dfj
The anatomy of he radial, brachial and carotid pulses have been described I p. 83 . Femoral artery. The I'emoral artery is situated just below the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis mid-inguinal point . It is immediately lateral to the femoral vein and medial to the femoral nerve. In the obese it can be difficult to feel. Popliteal artery. At the level of the knee crease, the artery lies deep in the popliteal fossa and the pulse is...
Measurement of ankle brachial pressure index ABPI
Measurement of ABPI is performed using a hand-held Doppler 111 ID and a sphygmomanometer. The probe is held over the three pedal arteries posterior tibial, dorsalis pedis, perforating peroneal in turn while a blood pressure TABLE 3.35 Investigation of peripheral arterial disease Ankle pressure ankle brachial pressure index ABPI , pulse waveform analysis Abdominal aortic aneurysm, popliteal artery aneurysm Carotid artery stenosis, vein bypass graft surveillance Abdominal aortic aneurysm,...
Cyanosis
This is discussed on page 126. Melanin The amount and distribution of melanin is modified in a number of situations see Table 2.3 . Vitiligo and albinism may affect any race, whereas the characteristic pallor of hypopituitarism is only apparent in while races. The overproduction of melanin in adrenal insufficiency results in the development of brown pigmentation of the skin, particularly in creases, in scars, overlying bony prominences and on areas exposed to pressure from belts, braces and...
Jaundice
Jaundice is the result of excess bilirubin circulating in the blood. Most bilirubin originates from the catabolism of haemoglobin in the reticuloendothelial system. Unconjugated bilirubin bound to albumin cannot be excreted into the urine. Following hepatic glucuronidation, bilirubin dtglucuronide enters the gut lumen via the biliary tree and is metabolised by the gut microflora to urobilinogen Fig. 5.1 . Urobilinogen is then reabsorbed anil enters the entero-hepatic cycle in health, it is...
Facial expression
Facial expression, including the presence or lack of eye-to-eye contact, is a useful index of physical and psychological well-being see Table 2.2 . Fig. 2.1 Examples of the value of 'spot diagnoses. El Blue sclera In a patient with osteogenesis Imperfecta. E Scleroderma facies with 'Peaking' of nose and taut skin around mouth. BE The facies In acromegaly. S Leg of elderly male with scurvy showing large ecchymosis In thigh 'woody leg with perifollicular haemorrhages in calf. Fig. 2.1 Examples of...
Percussion and auscultation
The principal value of abdominal percussion is to discin guish between distension due to gas. ascites, cystic or solid tumours. Normal peristaltic activity of the gut creates characteristic gurgling sounds which may be heard from time to time by the unaided ear borboiygmi . Through the stethoscope, they can be heard every 5-10 seconds, though the interval varies greatly and they occur more frequently after meals. D Percussion from resonance to dull. Place the percussing finger on the trunk...
The optic II nerve
Examination of the optic nerve involves testing Much of the examination of the optic nerve is described in Chapter 7. This section deals with the pupillary reflexes and with the visual lields. The optic nerve transmits the axons of the retinal ganglion cells. It begins at the back of the globe and passes through the optic canal of the sphenoid bone into the cranium, where it joins with the contralateral nerve to form the optic chiasma. The optic tract then passes posteriorly to the lateral...
Lumbar spine
The lumbar spine has a smooth lordosis which may be lost in certain disorders such as ankylosing spondylitis and lumbar disc protrusion Disorders box . The main surface markings are the spinous processes of 1,4 5 which are level with the pelvic brim and the. 'dimples of Venus which lie over the sacroiliac joints. The principal movements are flexion, extension, lateral flexion and rotation. It is important to appreciate the normal range of spinal movements. Most patients will he able to bring...
Anatomy Ljg
The cochlear branch subserves hearing, The fibres arise from the end organs in the inner ear. They pass centrally along the internal acoustic meatus and cross the cerebellopontine CSF cistern to enter the lateral brain stem at the Fig. 6.21 Types of facial weakness. Caused in IB by lesion of precenfral area or pyramidal Iract upper motor neurone El by lesion of facial nerve or nucleus lower motor neurone , also showing Bell's phenomenon. Fig. 6.21 Types of facial weakness. Caused in IB by...
General Inspection
It is important to take time to overview the appearance of the face and head before making a detailed inspection of the eyes. An abnormal head posture suggests problems with ocular motility, asymmetry of the face or head or facial Common abnormal findings in eye disease Retinal haemorrhages and exudates Optic atrophy Papilledema dysmorphia can indicate developmental abnormalities, eczema can suggest the likelihood of associated allergic eye disease. Observation of behaviour may suggest the...
Anatomy Fzm
The radial pulse is readily felt just lateral to the tendon of the flexor carpi radialis muscle Fig. 3.12 , It is particularly useful for assessing the rale and rhythm of the pulse. The brachial artery can be felt in the brachial fossa immediately medial to the biceps tendon. The carotid pulse is palpable in the neck and provides a better indicator of volume and character than is obtained from the radial pulse. Fig. 3.12 The radial pulse. H Locating and palpating the radial pulse, b I Feeling...
The sensory modalities
From the clinical viewpoint, the important sensory modalities are joint position sense tproprioception , light touch, pin prick, vibration, temperature and two-point discrimination. Other sensory functions are important but will be covered under the section on the cortical examination see Table 6.24 . It is unusual for a patient to experience only one sensory symptom. The aims of sensory testing are to determine if any modalities are impaired to determine the site of any lesion from the...
Deep venous thrombosis
Deep venous thrombosis occurs most often in the leg, but can also affect the arm axillary vein thrombosis . TABLE 3.37 Clinical features of deep venous thrombosis of the lower The leg. The clinical features of leg DVT depend upon its site and extent and whether it is occlusive or not Table 3.37 . The 'classical' features of DVT relate to well-established occlusive thrombus. In contrast, most patients who die from pulmonary embolus have non-occlusive thrombosis and normal legs on clinical...
The Upper Respiratory Tract
The upper respiratory tract extends from the external nares to the junction of the larynx with the trachea, it includes the nasal cavity, the nasopharynx, the nasal sinuses, the oropharynx and the larynx. Clinical examination of the nose, throat and mouth is an essential part of the assessment of patients with respiratory disease. In normal subjects, the upper 4-5 cm of the trachea can be felt in the neck between the cricoid eartilagc and the suprasternal notch, but in ihick-set or obese...
Breast lump
T he commonest cause of a breast lump varies with age. Carcinoma of the breast. This is one of the commonest malignancies in women in the UK, affecting I in 12 women. Its incidence increases with age, but any mass must be regarded as potentially malignant until proven otherwise. Cancer of the male breast is uncommon and there is a strong genetic factor. Characteristically carcinomas are solid masses with an irregular outline, often painless but firm or hard, contrasting in consistency with the...
Examination of the hernial orifices
The inguinal canal extends from the pubic tubercle to the anterior superior iliac spine and has an internal ring at the mid-inguinal point and an external ring at the pubic tubercle. The femoral canal lies below the inguinal ligament. Since hernias may reduce spontaneously as the patient lies supine, examination is better undertaken with the patient standing. Ask the patient to stand, carefully inspect the inguinal and femoral canals and the scrotum for hernias ask the patient to cough and...
Menstrual and obstetric history
The menstrual history should include the age at onset of menstruation menarche and of cessation of menstruation menopause as appropriate. Details of the menstrual cycle should also include the date of the first day of the last menstrual period and the duration of menses Table 5.23 . The norma age of the menarche varies from the ages 10-15. Thereafter, patients who fail to menstruate at all, primary amenorrhoea, should be investigated for possihle gynaecological or endocrinological...
Sputum
All patients should be specifically asked about sputum. When present, further information should be obtained as lo amount, character, viscosity and taste or odour. Amount. This can seldom be accurately estimated by the patient, although statements that it is very large e.g. a tcacupful per day or very small one or two spits per day are usually reliable. Most children and some adults swallow their sputum, even large amounts. The sound of the cough, if it is loose or moist, will, however,...
Common abnormalities Wpe
The inability to localise tactile discrimination in the various parts of the body occurs with lesions in the posterior inferior parietal cortex. Finger agnosia is a particular type of this deficit. The inability to recognise objects by touch alone astereognosis suggests an abnormality of the angular and supramarginal gyra in he parietal lobe. An inability to rccognisc symbols written on the palm of the hand dysgraphaesthesia also suggests an abnormality of the parietal sensory association...
Skin changes
It is important to differentiate between simple skin dimpling due to retraction of the skin and indrawing of the skin due to infiltration of the dermis by lumour Fig. 2.56 . In the former the skin remains mobile over the lumour in the latter the tumour is fixed to the skin. Likewise in tethering to the chest wall he tumour is solid with the chest wall when the pcctoral muscle is contracted, bin when it is relaxed it is possible to move the lesion separately, Tumours which infiltrate the chest...
Abnormalities in the shape of the chest
Those of clinical importance are as follows. Increase in anteroposterior diameter. In some patients with emphysema, the posterior AP diameter is increased and the two measurements may approximate barrel chest . The degree of chest deformity in emphysema is not a reliable guide to the severity of the functional defect. An increase in anteroposterior diameter may also be due to thoracic kyphosis unrelated to respiratory disease Fig. 4.12 . Thoracic kyphoscoliosis. This ranges in degree from the...
Common abnormalities Jsv
Inspection. Much can be learned by inspecting the pre-cordium. Chest deformities including pectus excavatum posterior displacement of the lower sternum can affect the rest of the examination. A midline sternotomy scar usually indicates previous coronary bypass surgery, or valve replacement. A left submammary scar is usually the result of a mitral valvotomy. Pulsations are most readily identified by a combination of inspection best for inward movements and palpation best for outward movements ....
Cardinal symptoms
Patients with heart disease may be asymptomatic. Their cardiac pathology may be diagnosed during 'routine' examination or because of the development of a complication e.g. atrial fibrillation in mitral stenosis . I lowever, the cardinal symptoms of heart disease are chest discomfort, hreathlessness, palpitations, syncope and peripheral oedema. None of these symptoms indicate that heart disease is definitely present because they are not specific see Table Angina Pericarditis Aortic dissection...
Common abnormalities 1
Distribution. The temptation to examine skin lesions closely should be resisted until the distribution of the rash has been noted at arm's length. This may be the most valuable clue to the diagnosis. For example, it is not easy to diagnose herpes ,osier by the appearance of the individual lesions, but it becomes simple once the dermatomal distribution is appreciated Fig. 2.19A , Similarly, a photosensitive basis for a rash becomes obvious when it is noted that only exposed areas are involved...
Polyuria
Polyuria is an increase in urinary volume, regardless of the frequency of micturition. The patient's assessment of urine volume can be misleading and should be confirmed by 24-hour urinary collections. The most common cause of polyuria is an abnormally high fluid intake. In extreme cases, this may be a manifestation of psychiatric disease it is termed psychogenic polydipsia polydipsia excessive thirst and may result in urine flows of up to 12 litres daily. In other cases, polyuria is the...
Anatomca considerations
The regions of the thorax over which a resonant percussion note is normally found correspond approximately to the surface marking of the lungs Fig. 4.11 . Percussion over the heart or the liver will elicit a dull note, but the area of dullness is less extensive than would be expected from anatomical surfacc markings, since aerated lung is interposed between part of the viscus and the chest wall. Pulmonary consolidation Pulmonary collapse Pulmonary fibrosis Pulmonary consolidation Pulmonary...
Polyarthritis
The clinical history, a search for extra-articular features and careful identification of the joints involved should narrow the differential diagnosis, which may include seropositive or seronegative rheumatoid arthritis RA , systemic lupus erylhematosus SLE , psoriatic arthritis, reactive arthritis and viral arthritis. Any investigations should be interpreted in the light of the clinical findings none of the available tests is wholly reliable and none can be considered diagnostic. X-rays of the...
Can A Lesion On The Pons Cause Hyperacusis And Opthalmoplegia
The motor nucleus of VII lies in the lower pons and its fibres initially pass posteriorly and medially to loop around the VI nucleus before turning forwards and emerging from the lateral pontomedullary junction see Fig. 6.19 . Fig. 6.19 Lesions of the pons. Lesions at 1. e.g. haemorrhage cause ipsilateral VI and or VII nerve palsies and contralateral pyramidal signs. Lesions at 2. e.g. basilar thrombosis cause ataxia on the side of the lesion damage to the cerebellar peduncles . There may also...
Transition Point Between Distended And Collapsed Veins
There are no valves between the right atrium and the internal jugular vein. It follows that the degree of distension in the vein equates to the pressure in the right atrium and the venous waveform provides information about cardiac function. The internal jugular vein enters the neck behind the mastoid process. Il runs deep to the sternomastoid muscle before entering the thorax between its sternal and clavicular heads. Because of its deep position the internal jugular vein can only be examined...
EXAMINATION OF THE UPPER LIMB The hand and wrist
Examination of the hand consists of inspection, palpation and assessment of function. Since a full examination of function is lengthy, it is necessary to tailor the examination to the clinical history and the nature of the problem. For example, in a patient with lacerations of the digits, a thorough assessment of he integrity of the tendons, nerves and circulation is essential. In contrast, in a patient presenting with stiffness, pain and swelling of Ihe hands the examination will he directed...
COMMON ABNORMALITIES Eyelids
The lids normally cover the upper and lower margins of the iris. The palpebral fissures should be symmetrical. The palpebral aperture is narrowed in blepharospasm spasm of the eyelids and photophobia light sensitivity , which are often associated with painful eye conditions. Photophobia also occurs in migraine and in association with meningeal irritation. Ptosis upper lid drooping can be due to congenital or acquired levator palpebnte paresis third nerve palsy , or to sympathetic paresis...
General Medical Background Family And Social History
The medical background may he important and a careful enquiry into past illnesses and medication often brings to light diagnostic clues, e.g. diuretics may precipitate gout. The family history may also be helpful Table 8.6 . The patient's domestic or working environment may be relevant lo the patient's symptoms. Inability to hold a pen or tools, to knee , stand for long periods or to use ladders may have profound social and economic consequences, particularly for those in manual or unskilled...
Anatomy Cjo
Sensory function. Sensation is provided through three major branches which join together to form the Gasserian ganglion which sits in Meckel's cave in the petrous temporal dura. The ophthalmic branch V, . This supplies sensation to the skin of the upper nose and eyelid, forehead and scalp see l-'ig. 6.15 as well as the cornea, conjunctiva, intraocular structures, parts of the mucosa of the frontal, sphenoidal and ethmoidal sinuses and the upper part of the nasal cavity. The ophthalmic branch...
The Chest
Physical examination of the chest makes use of the techniques of inspection, palpation, percussion and auscultation. in health, the trachea is central and the apex beat is in the normal place see p. 90 . The surface markings of the lungs are shown in Figure 4.11. The upper lobes are primarily in the front of the chest and the lower lobes are predominantly posterior, with the apex of the lower lobes at the level of the 4th thoracic vertebra, 3rd spinous process. In normal subjects the two sides...
Patellar instability
Recurrent subluxation of the patella may be associated w ith a small high-riding patella, genu valgum, joint hypermobility. trauma, or with wasting of the vastus medialis. If the patella has previously dislocated, the 'patellar apprehension lest' is usually positive. Slowly extend the knee, repeal the manoeuvre with the tibia in external and then internal rotation. If positive, a clunk is fell or heard as the cartilage fragment is displaced and the patient experiences discomfort McMurray's test...
Normal findings Wdm
The first heart sound. The first heart sound is caused by the closure of the mitral and tricuspid valves at the beginning of ventricular systole. It is best heard at the apex. The second heart sound. This is caused by the closure of the pulmonary and aortic valves at the end of ventricular systole and is best heard at the left sternal edge. It is louder and higher pitched than the first sound and normally the aortic component is louder than the pulmonary one. Physiological splitting of the...
The olfactory I nerve
The olfactory nerve subserves the sense of smell. Smell Fig, 6.8 Testing for meningeal irritation. H Neck rigidity IB Kernig's test. receptors are situated high in the nasal cavity, and these bipolar olfactory cells project axons through the cribriform plate of the ethmoid bone to the olfactory bulb. Second-order neurones mitral cells then project centrally together with the pyramidal cells of the olfactory nucleus down the olfactory tracts and stria to the primary olfactory cortex medial...