Clinical Examination Skill (Step by Step) (Nov 30, 2008)_(8184486421)_(JBMP)

Step by Step®

Clinical Examination Skills

Step by Step®

Clinical Examination Skills

Farrukh IqbalMBBS (Pb) MRCP (UK) FRCP (Edin) FRCP (London)

Professor of MedicineShaikh Zayed Postgraduate Medical Institute

Consultant PhysicianShaikh Zayed Hospital

Lahore, Pakistan

ForewordMuhammad Akbar Choudhary

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Step by Step® Clinical Examination Skills

© 2009, Farrukh Iqbal

All rights reserved. No part of this publication and Interactive DVD ROMs should be reproduced, storedin a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying,recording, or otherwise, without the prior written permission of the author and the publisher.

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First Edition: 2009ISBN 978-81-8448-642-1Typeset at JPBMP typesetting unitPrinted at Ajanta Offset & Packagings Ltd., New Delhi

FOREWORD

I am delighted to write a Foreword to this book whichis written by a clinician and a medical educator, who hasan excellent academic record throughout his career.

This book lays special emphasis on bedside medicinesand gives an excellent concept of clinical skills, thebackbone of a thorough clinical examination whichultimately leads to a proper diagnosis and hence themanagement. Each system has been divided into differentsections and a beautiful attempt has been made for thestep-by-step examination of each part, hence the nameStep by Step Clinical Examination Skills.

Simple, readable and fluent presentation adds to thevalue of this book. One feels pleasure and satisfaction aftergoing through it. This book shall prove an extra aid tounder and postgraduate medical students who arepreparing for the clinical part of their FCPS (Medicine),MRCP (UK) and MD (Medicine) examinations. Theaddition of interactive DVD-ROMs will further add to itsvalue as a visual impact is long lasting.

The script is simple to follow and comprehend by thereaders. Being myself, a life long teaching physician ina clinical setting, I find this book an excellent contributionto the subject of clinical medicine.

CLINICAL EXAMINATION SKILLSvi

I have full confidence that this book will receive respectand admiration from the medical community and will bea valuable addition to other books on clinical examinationand will prove to be an excellent companion for themedical students.

Prof Muhammad Akbar ChoudharyMRCP (UK) FRCP (Edin) FRCP (Lon) FPAMS (Pak) FACC (USA)

Principal, Professor and HeadDepartment of Medicine

Fatima Jinnah Medical CollegeSir Ganga Ram Hospital

Lahore, PakistanInternational Advisor

Royal College of Physicians of London, UKMember Surveillance Regional Advisory Group

WHO EMRO RegionMember Influenza Pandemic Task Force, WHO

CONTENTS viiPREFACE

The field of medical science is extremely vast and itencompasses many disciplines. The art of clinicalexamination at the bedside of the patient can only be learntwith continuous practice and with the help of standardtextbooks on this subject.

In this book, an attempt has been made to writeexamination of the clinical skills in an easy andunderstandable way. I would request the readers to gothrough it from the beginning and I am sure that theywill definitely enjoy it. The language is very easy andcomprehensible and emphasis has been laid on to keepthe continuity of the material discussed in the relevantsections.

Farrukh Iqbal

I feel immense pleasure to thank all my teachers,colleagues and especially my students who motivated meto write this book.

I am indebted to my mentor, Dr Asif Kamal FRCP(London), FRCP (Edin), Consultant Physician, Lincoln CountyHospital, Lincoln, Lincolnshire, UK and Chief Investigatorfor PLAB (GMC London) for perpetually encouraging meto write for medical students.

I am thankful to my colleague Dr Atiya Mahboob FCPS(Derm), Associate Professor of Dermatology for writing avery useful chapter on dermatological examination. Shealways came up with academic activity whenever she wasasked.

I am also indebted to Dr Shahid Anwar FCPS (Neph)for writing useful chapter on nephrological examination.

I am grateful to Dr Muhammad Suhail M Phil (Anatomy)Associate Professor of Anatomy for reviewing the chapteron Neurological and Musculoskeletal System Examination.

It would not be fair if I do not mention the nameof Mr Shahid Rauf for efficiently typing and formattingthe manuscript of this book.

Last but not the least, I am thankful to my wife Shahina,my daughters Saliha and Zunaira and my son Aizad forextending their full cooperation while writing this book.

I shall warmly welcome any comments and suggestionsregarding this book to improve it further in future.

ACKNOWLEDGEMENTS

CONTENTS

1. Introduction .................................................................. 1

2. Skills in Medical Education ..................................... 9

3. History Taking ........................................................... 13

4. Instruments Required .............................................. 23

5. General Physical Examination ............................... 25General Instructions .................................................. 27Case Writing Tips ..................................................... 31Step by Step Examination of thePatient as a Whole .................................................... 32Common Commands ................................................. 36

6. Examination of Respiratory System ..................... 65Principles of Examination ofRespiratory System .................................................... 66Step by Step Examination ofRespiratory System .................................................... 72Case Writing Tips ..................................................... 74Common Commands ................................................. 76

7. Examination of Cardiovascular System ............... 93Principles of Examination of CardiovascularSystem .......................................................................... 94Step by Step Examination of CardiovascularSystem ........................................................................ 102Case Writing Tips ................................................... 104Common Commands ............................................... 107

8. Examination of Gastrointestinal System(Abdomen) ................................................................ 123Principles of Examination of GastrointestinalSystem ........................................................................ 124Step by Step Examination of AlimentarySystem ........................................................................ 130

CLINICAL EXAMINATION SKILLSx

Case Writing Tips ................................................... 133Common Commands ............................................... 137

9. Examination of Genitourinary System .............. 157Check List for NephrologicalExamination .............................................................. 158Case Writing Tips ................................................... 161

10. Examination of Nervous System ........................ 165Basic Principles ........................................................ 166Neurological Examination as a Whole ............... 168Case Writing Tips ................................................... 170Common Commands ............................................... 176Cranial Nerves ......................................................... 181Motor System ............................................................ 215Check Power of the IndividualMuscles ...................................................................... 220Muscles of the Upper Limb .................................. 221Abdominal Muscles ................................................. 241Trunk Muscles .......................................................... 242Muscles of Lower Limbs ........................................ 244Coordination of Movements .................................. 254Reflexes ...................................................................... 258

Superficial Reflexes ............................................ 258Deep Reflexes ..................................................... 264Miscellaneous Reflexes ..................................... 273

Gait ............................................................................. 276Involuntary Movements .......................................... 277Sensory System ......................................................... 281

Superficial Sensations ....................................... 281Deep Sensations ................................................. 285Cortical Sensations ............................................ 290

General Principles for ExaminingSensory System ......................................................... 295Cerebellar System ..................................................... 297

CONTENTS xi

Signs of Meningeal Irritation ................................ 299Check for Brainstem Death or Brain Death ...... 306Check Elicit Pain in the Patient .......................... 307Elicit Focal Neurological Signs in anUnconscious Patient ................................................ 309

11. Dermatological Examination ................................ 313Principles of Dermatological Examination ......... 314Step by Step Examination of the Skin ................ 315

12. Examination of Musculoskeletal System .......... 321Principles of Examination of MusculoskeletalSystem ........................................................................ 322Examination of Musculoskeletal System ............. 325Examine this Patient’s Vertebral Column ............. 331Examination of the Upper Limb .......................... 336Examine the Hands ................................................ 344Examine the Knee Joint .......................................... 348

13. Patient’s Record ....................................................... 355

14. Investigations ........................................................... 359Routine Investigations ............................................ 361Systemic Investigations ........................................... 362

Bibliography ....................................................................... 369

Index ....................................................................... 371

INTRODUCTION 1CHAPTER 1

Introduction

CLINICAL EXAMINATION SKILLS2

The value of clinical medicine cannot be denied even inthis modern era of medicine where most sophisticated testsand investigations are available in many teachinghospitals and medical centres. During the last threedecades, numerous sensitive, specific and complicatedlaboratory investigations have been in fashion to reachand confirm a diagnosis and every day their number isincreasing and the methodology continues to change.However, these are very expensive tests and the afford-ability is sometimes beyond the capacity of a common man.Therefore, it is very important to emphasize on clinicalacumen so that common illnesses are diagnosed andtreated promptly, rather waiting for the laboratory tests.This does not mean that the importance of these tests isdenied. They are of course a great help in this context.

The laboratory investigations cannot supersede a goodclinical acumen and these are required to establish orexclude a diagnosis. This point has to be emphasized onyoung doctors during their training. A sound knowledgeof clinical examination skills can make these young doctorssuper clinicians of the future. It is better to realize thisearlier than later.

It is rightly said that medical knowledge is a sciencebut on the contrary medical practice is an art. We haveseen many doctors over the years who had bloomingknowledge of medicine but ultimately they were notsuccessful as a good practitioners which ultimately matters.

There is no doubt that a sound basic knowledge ina particular field makes a strong foundation but itsapplication in a right way is most important. Above all,a good practitioner should be a good human too. Thedoctor-patient relationship is very pious and taking adetailed history and a physical examination assures thepatient that the doctor has done his best to diagnose his

INTRODUCTION 3

ailment and this further builds the confidence of the patientand he becomes more co-operative. It is very well-said thatclinical medicine blossoms human medicine into humanemedicine. Clinical diagnosis and assessment of severity ofdisease are based on history, thorough clinical examinationand investigations and the importance of these threesources is well known to every good clinician.

It is also worth noting that when medical students enterfrom the basic sciences of anatomy and physiology to theclinical years, they are in a different environment becausethere they were learning with frogs, dogs, rabbits and deadhuman bodies (cadavers), but now they will learn on livinghumans with various diseases. There will be both maleand female patients and understanding and respectingtheir feelings is most important. This leads us to say thatgood mannerism, kindness and politeness do matter a lot.This approach makes the patient realize that this particulardoctor is kind, friendly and is interested to treat him orher. To learn on the living human patients one needs theirco-operation and one should be grateful to them that theyhave co-operated with their full effort in spite of infirmhealth. Otherwise, if the patient does not co-operate thenlearning clinical medicine and mastering clinicalexamination skills may become very difficult and not lessthan a major problem.

Clinical methods are the skills which every doctorshould achieve before they enter in real independentclinical practice. As it is obvious, this skill is acquiredduring a life time of practice. No doubt the methods inclinical examination keep on evolving and changing butnot to such an extent as laboratory investigations. Clinicalskills are learnt by a combination of mutual study andexperience.


It is also important to know that various teachers havetheir own way of examination of different systems but allof them have some basics in common which is a healthyexercise. Sometimes students experience difficulty from thiswhile in actual examination. It is therefore advised thatall the doctors should follow a well-known standard textbook of clinical examination and can quote reference fromthat book to the examiner rather than naming a particularperson, which the examiner may not like. But undueargumentations should not be done with the examiner onthese points of controversy as the candidates should nottake any “risks” at all during examination.

DC Corrigan (1802-1880) a renowned clinician said,The trouble with doctors is not that they don’t know enough,but they don’t see enough.

The skills required for a competent clinical examinationcan only be learnt and mastered by practice at the bedside of a patient. Each patient is like a book and unlessyou open it and explore, you would not get enoughknowledge about the disease. It is also worth noting thatfew patients have multiple pathologies and one can comeacross these problems very often and should be able totackle them with confidence. A thorough basic knowledgeof anatomy, physiology and pathology adds towards“perfection.”

It is also important to note that most medical problemscan be solved by a careful history and clinical examinationwithout subjecting the patient to many unwanted,expensive, undesired and painful investigations.

The author has tried to put his experiences as a student,teacher, examiner and a practitioner in this book. A lotof care has been taken to design this book to create interestin the medical students, both undergraduate and post-graduate to understand importance of clinical examinationskills.

INTRODUCTION 5

This book will not only enhance the clinical knowledgeof already practicing clinicians but will also helptremendously to undergraduate and postgraduate medicalstudents to get through their examinations, i.e. MBBS(final), MCPS (Medicine), MD (Medicine), FCPS (Medicine),MRCP (UK) and other medical examinations.

The set up of this book is simple and effort has beenmade to discuss part of the examination step-wise thusthe name “step by step in clinical examination skills”.Various commands given by the examiners to the examineefrom various systems have been described. Help ofphotographic material is also provided to the student inthe book. A few examples of various commonly askedcommands are quoted below:

“Examine this patient’s pulse”“Examine the fundus of this patient”“Look at this patient’s face and do the relevant

examination”“Listen to the pre-cordium.”It is therefore of utmost importance to listen carefully

what the examiner says about the command or readcarefully if the command is written on a piece of paperat the patient’s bedside and proceed accordingly, ratherthan going into more details of those aspects which arenot asked at all. Time factor is very vital in theseexaminations and you have to satisfy the examiner thatyou know the art of doing clinical examination perfectlyunder examination environment and under the specifiedtime limit. It may be difficult but by no means impossible.The answer to this difficulty is to do more practice ofclinical examination even on normal human subjects, e.g.your brother, friend or colleague etc. It is an old but wellsaid saying “practice makes one perfect” therefore get yourselfawake, tighten up all your strengths, straighten your aim,


spend your time honestly with the patients and practiceday and night and I can assure you that you will feelthat you have achieved confidence in examining thepatients correctly.

Also remember that for a good clinical examination,besides basic working knowledge you should also be wellequipped with your instruments of basic needs whichshould be kept in order in a small brief case. At timesI have seen students searching their pockets for needles,measuring tape, ophthalmoscope or a tongue depressorwhich wastes a lot of important and vital time which canbe spent in a more useful and fruitful way on the patient.

In the end a well-dressed, groomed, well and softspoken clinician adds to the beauty of the all this drill.You should have nails and beard (if you have it) trimmed,or clean shaved with polished shoes. But this does notmean that you should think that by examining the patientsyou will get dirty rather it is impressive to the examinerand the patient.

When I appeared for my membership examination(MRCP) in London in 1986, I was told by my teachersthat even if you are wearing a three piece brand new suitand if you have to examine abdomen at the level of thebed, kneel down on the ground! This further adds to theconfidence of the patient and gives impression to theexaminer that how dedicated you are in conducting athorough clinical examination. I was told by a very eminentteacher that in the examination it is not only the knowledgewe test but we also take notice of the overall appearanceof the examinee and his mannerisms. The examinee maybe very good in knowledge but if the bed side mannersare bad then the chances of that candidate to pass arevery grim.

I must also stress that the history and a thoroughphysical examination are two important pillars in patient’s

INTRODUCTION 7

management to follow later. If you want to become anaccomplished physician or clinician, you have to polishyour clinical skills and should continue polishing it forthe rest of your life. The experience grows and expandsidentifying the symptoms, problems and abnormalfindings, listing them to an underlying process ofpathophysiology and establishing a set of most relevantlaboratory investigations more easily.

Bern and Lown said that today’s physicians seem at timesmore interested in laying on tests than laying on hands. SirWilliam Osler, another renowned clinician once saidmedicine is an art of probabilities and a science of uncertaintiesand that these aspects are inseparable very much likeSiamese twins for whom trying to separate one from theother would only kill them both.

Sir William Osler encouraged students of medicine inalmost all his books. In one of his books, he has writtenlearn to see, learn to hear, learn to feel, learn to smell and toknow that by practice alone you can become an expert. It stillapplies in this modern era of science and technology. Weneed to listen to our patients very patiently; we need tounderstand their complaints or symptoms and we needto observe them with critical sense to elicit physical signs.These skills can be achieved by every doctor but requiresincere and strenuous effort and perpetual practice.

I would request the readers that having passed theirexaminations; they should continue following the best ofclinical examination skills in future and pass on theirknowledge to their students and juniors.

In the end, I must thank all my students and colleagueswho continuously hammered me to write a book in asimple and easy way to learn the clinical skills in physicalexamination. I have tried to write very simple languageand hope that this will be another useful addition to atreasure of books on this subject.

SKILLS IN MEDICAL EDUCATION 9CHAPTER 2

Skills in MedicalEducation


When a new medical graduate is given responsibilitiesto look after a patient, he has to develop certain othersskills as well which will help him in attaining fullresponsibility and therefore appropriate management ofthe patient. Those skills are mentioned in a little detailas follows:

COMMUNICATION SKILLS

A doctor should be able to communicate with the patientin patient’s own language and should be versatile. Rarelythere is a need for an interpreter. Having mastered thelinguistic aspect of communication skills, one should beable to discuss difficult problems with the patient in aneasy and understandable language if they have seriousillness and the doctor should also be able to break badnews to the patient in such a way that does not hurt himtoo much. He should also be able to consent with thepatient, his relatives and other logistic aspects and shouldbe able to make them understand the condition of thepatient if communicating to the relatives. The doctor shouldbe able to communicate and discuss the patient’s problemswith his other colleagues, seniors, nurses and otherpersonnels involved in the patient’s care.

CLINICAL SKILLS

They will be described in detail later but are summarizedas follows:

i. Take good history, physical examination and suggestappropriate investigations.

ii. The interpretation of the history obtained and of anysigns which were picked up in the physicalexamination and evaluation of the investigations.

SKILLS IN MEDICAL EDUCATION 11

iii. Make a list of the problems with the patient and withthe most important one on the top and then try tounwind those problems one by one with appropriatejustification for further investigations.

iv. Utilize the hospital and social services for thediagnosis and management of the patient.

v. Consolidate clinical knowledge with evidence basedscientific and clinical facts and facts from otherresources.

ORGANIZATIONAL SKILLS

The good doctor utilizes the facilities and resourcesavailable in that particular hospital where he is working.He should, therefore be able to organize such facilitieslocally and in other hospitals.

CLERICAL SKILLS

These involve recording and updating patients’ record,properly filling of the forms for different investigations,appropriately doing the discharge summaries and writingdown the daily progress notes as follows, i.e. one shoulduse the synonym “SOAP” where ‘S’ stands for Subjectiveassessment, in other words “symptoms” of the patient,“O” stands for Objective assessment, in other words“signs,” ‘A’ stands for overall “Assessment” afterconsidering these symptoms and signs and “P” standsfor working “Plan” for the patient. It is so easy toremember!

ETHICAL SKILLS

These are of utmost importance now-a-days and oneshould be well aware of this aspect of medicine in thepresent era. There is plenty of material on this subject insome good Textbooks of Medicine.


PROCEDURAL SKILLS

These include carrying out simple bed side or ward side-room procedures, e.g. insertion of intravenous cannulae,nasogastric tubes, putting up an infusion, pleural aspira-tion, peritoneal aspiration, and insertion of indwellingurinary catheters etc.

Last but not the least a doctor should be skilled enoughto manage most common medical emergencies and shouldask for help from his seniors if need be arise. He shouldhave a keen sense of observation while working with hisseniors.

It is important to mention that having acquired all theseskills, one should undergo self-assessment now and then,to become aware of the fact whether he has achievedwhatever he wanted to. It is better to keep record of allthe activities performed during one’s career but this mayseem very cumbersome for some individuals. (The Collegeof Physicians and Surgeons Pakistan has made itcompulsory for the candidates for FCPS (Medicine) to keepall the record of patients and clinical procedures performedduring their period of training).

Auditing is a new aspect of all these activities andthis reminds one of one’s mistakes so that they shouldbe corrected and not to be repeated in future.

Reviews by seniors or peers are also important andmake the basis of good reference for next career post.In conclusion, postgraduate medical education continuesinto life long medical education and one keeps on learningnew things in one’s life perpetually and should have adesire to remain abreast with the current knowledge. Thiswill assure the individual that they are providing optimalcare to the patient and therefore they should be satisfiedof achieving their aim by serving humanity.

HISTORY TAKING 13CHAPTER 3

History Taking


History taking is the foundation pillar of patient’s manage-ment and it should be recorded in patient’s own languagewithout involving too many technical terms. It should beelaborate and encompass the patient’s data and detailsof the symptoms, a systemic review and other components.There are so many books only on clinical examinationwhich have comprehensive chapters on history taking,therefore I have skipped that from this book but haveoutlined major headings based on which one can get acomprehensive history from the patient including all itsaspects.

Patients data, i.e. name, age, sex, address, telephonenumber, medical record number, profession, marital status,number of children, social status, monthly incomeresidential accommodation, etc. should be recordedcomprehensively for future reference.

HISTORY OF PRESENT ILLNESS

1. Chief complaints or presenting complaints should benoted down in chronological order with the mostimportant complaint on the top with its duration.

2. History of present illness should elaborate all thepresenting complaints one by one in more detail. Patientshould be allowed to narrate his own story in his ownwords without being prompted. Then one should askspecific questions using words or terms which can bereadily understood by the patient. If the patient is apoor historian or cannot give an appropriate history,then help of immediate relative should be sought. Itshould also be documented that the history was takenfrom the friend or relative of the patient.

3. Previous history of present complaints is also worthnoting as patient may be having these symptoms inthe past including any treatment or investigations.

HISTORY TAKING 15

PAST MEDICAL HISTORY

One should carefully outline the details of any illnesses,hospitalizations, surgical operations or procedures andaccidents in the past with exact or approximate dates. Thismay or may not be related to the current illness. Chronicillnesses should also be noted.

FAMILY HISTORY

It is important to note down any history of illnesses inthe family, i.e. parents, uncles, aunts, brothers and sistersespecially in context with the current illness.

PERSONAL AND SOCIAL HISTORY

Ask about the details of work and income, theaccommodation and whether living with family or alone.Then ask about the number of children, and whether thepatient is married, divorced or separated etc. Whethersmoker, if so how many pack years of smoking. Ask aboutany history of alcohol intake and if so how much andhow often and type of the hard drink. Ask about anyhistory of substance or drug abuse.

MENSTRUAL HISTORY

This is important to ask from all female patients. The onsetof menarche, the regularity of menstrual cycle, the quantityof blood loss per menstrual cycle and the age of menopauseand then any dysfunctional uterine bleeding are importantquestions to be asked. Ask about use of contraceptive pillsand any vaginal discharge.

DRUGS AND ALLERGIES

Note down any history of drugs (Medicines) being takenby the patient at present or in the past for any illness.


It is often useful to see the pills oneself if the patient hasbrought them to the clinic or to the hospital. Allergies toany drugs should also be noted but it is important to probein this aspect in more detail to elicit what does the patientmean from allergy?

NEGATIVE DATA Sometimes it is important to ask and record a symptomwhich was not present if you suspect a disease as yourdiagnosis. Having had a detailed account of the history,it is time to go for a systemic review. As you know, patient’spresenting complaints are pertaining to one major systemcommonly but enquiries should be made for symptomsfrom other systems which may be directly or indirectlyrelated to that particular disorder. A list of non-specificsymptoms should also be noted. In this book only the mainitems are highlighted.

Respiratory System

Ask about

1. Cough — Dry or productive2. Sputum — Colour, amount, blood stained, time of the

day3. Dyspnoea and its grades4. Chest pain pertaining to respiratory problems5. Fever6. Wheezing.

Cardiovascular System

Ask about

1. Breathlessness — at rest, on exertion or even on lyingdown

HISTORY TAKING 17

2. Chest pain — Site, duration, character, radiation,relieving and aggravating factors

3. Palpitations4. Cough5. Abdominal pain (dissecting aortic aneurysm)6. Oliguria7. Oedema (swelling)8. Syncope9. Fever.

Gastrointestinal System

Ask about and Look for

1. Pain2. Dyspepsia3. Appetite4. Vomiting5. Odynophagia6. Dysphagia7. Flatulence8. Jaundice9. Water brash

10. Heart burn11. Diarrhoea12. Constipation13. Malaena14. Distension.

Urogenital System

Ask about

1. Dysuria2. Polyuria, poor stream, feeling of incomplete evacuation3. Frequency, urgency, hesitancy4. Haematuria, post-micturition dribbling, urethral

discharge, strangury


5. Oliguria6. Anuria7. Puffiness of face8. Lower abdominal pain9. Fever with chills.

Haematological System


1. Pallor2. Weakness3. Lack of concentration4. Dyspnoea5. Ankle oedema6. Easy bruisability7. Skin lesions8. Nose bleeding9. Gum bleeding

10. Glandular enlargement11. Bone pains12. Fever with infections.

Central Nervous System (CNS)

Ask about and look for

1. Headache2. Sleep disturbances3. Vomiting4. Visual disturbance5. Altered sensorium6. Convulsions7. Dizziness8. Speech, memory9. Sense of smell, vision, hearing, gustation (taste)

10. Weakness, diplopia, twitching

HISTORY TAKING 19

11. Involuntary movements12. Wasting13. Stiffness14. Bulk of muscles15. Unsteadiness16. Paraesthesia17. Dysaesthesia18. Anaesthesia19. Difficulty in performing voluntary activities20. Incontinence of urine or faeces21. Urinary retention.

Nonspecific


1. Generalized weakness2. Headaches3. Fever – Continuous, remittent to intermittent4. Jaundice5. Body pain6. Generalized numbness7. Generalized swelling of body

8. Weight loss9. Giddiness

10. Sinking of heart.

Locomotor System


1. Pain2. Swelling3. Fever4. Limitation of movements5. Stiffness of joints with time and duration6. Wasting


7. Contractures8. Deformity9. Limping.

Endocrine System


1. Weight loss or gain2. Abnormal distribution of hair3. Polydipsia4. Craving for salt5. Pigmentation6. Striae7. Headaches8. Increased sweating9. Blurring of vision

10. Vomiting11. Increased/decreased libido12. Hair loss13. Voice changes14. Frequency of shaving15. Frontal baldness16. Erectile dysfunction17. Early morning erections/tumescence18. Normal distributions of body hairs19. Breast size, gynaecomastia in males20. Heat or cold intolerance.

Dermatological System

Ask about and look for

1. Rashes2. Macules3. Papules

HISTORY TAKING 21

4. Pustules5. Vesicles, bullae6. Lumps and bumps7. Pruritus8. Sensitivities — Drug and photosensitivity9. Change in hair and nails

10. Ulcers11. Bruises12. Change in colour — pigmentation/depigmentation.

Having asked a detailed history, and after detailedsystemic review and systemic examination you should beable to present you history and findings to the examinerin a coordinated smooth, fluent way, i.e. summarize thecase.

Sometimes you may encounter problems during historytaking. They are:1. A depressed, confused or demented patient: You

should try your level best to elicit history but do notwaste time when you are getting nothing from thepatient. On the contrary, seek information from therelatives or close friends.

2. Hostile patient: Sometimes one can encounter hostilityfrom a patient due to many reasons, e.g. depression,confusion, agitation and other known to the patients.However, you should stand by asking the reason ofhostility and take patient into confidence. If hostilitypersists, then discontinue asking questions and takehelp of staff nurse and/or immediate relative or closefriend of the patient.

3. Provocative patient: Sometimes patient is severelyprovocative especially in the presence of femaleassistant. Change over to a male chaperon. If notavailable, then postpone the examination.

4. Less educated patient: Patient with low education levelor less vocabulary may cause difficulties in obtaining


a good history. Many nebulous terms are used inmedicine, i.e. numbness, sciatica, stroke etc. You haveto ask in more details from the patient to be sure whatactually he mean.

5. If a patient uses specific diagnosis for past history thenask more details about it. Sometimes recall of all eventsis difficult by the patient, therefore don not press hardas it may offend the patients.

INSTRUMENTS REQUIRED 23CHAPTER 4

InstrumentsRequired


As mentioned before, prior to clinical examination, youshould be “well-equipped” with all necessary gadgets forexamination purpose including from a small common pinto a sphygmomanometer. I think that ideally the brief caseof the candidate should have the following items for amore detailed and comprehensive examination:

1. Small Snellen’s chart2. Sterile common pins3. Cotton wool4. Bottle of different odours5. Tuning fork of freque-

ncy of 128, 256 Hz6. Patellar hammer7. Measuring tape8. Ophthalmoscope/Auro-

scope9. Wooden spatulae

10. Stethoscope

11. Thermometer12. Disposable gloves13. Sphygmomanometer14. Callipers or two point

retractor15. Goniometer16. Paper cup17. Tissue papers18. Bottles or test tubes for

hot/cold water19. Sugar, vinegar, salt,

quinine20. Coins, keys.

All these instruments/items should be placed in orderso that the candidate knows their whereabouts and at thetime of examination does not have to search here and therethus wasting time unnecessarily when every second counts!

25GENERAL PHYSICAL EXAMINATIONCHAPTER 5

General PhysicalExamination


The physical examination is divided into:A. General physical examination.B. Systemic examination.

This includes:1. Respiratory system2. Cardiovascular system3. Gastrointestinal system4. Urogenital system5. Nervous system6. Musculoskeletal system or Locomotor system7. Dermatological system.

PEARLS

The aim is to keep the patient comfortable, relaxed andreassured. Let the patient know what you are going todo, so that he is not apprehensive therefore ensuring fullcooperation from him. In cold weather a warm environmentand warm hands are essential. Privacy with natural lightis also desired.

It is advised to develop the art of routine performingphysical examination, routinely, which should be prompt,accurate and less distressing to the patient. It is alwaysadvised to plan examination according to patient’s mainor presenting symptoms.

It is important to know that one should be thoroughin performing different steps in clinical examination, ofwhich one becomes an expert with experience and onegets more confident in looking directly for certain signssuggested by history and examination. As you approachthe patient, re-establish both verbal and eye contact.

27GENERAL PHYSICAL EXAMINATION

GENERAL INSTRUCTIONS FOR CONDUCTINGEXAMINATION

1. Use a couch which can be adjusted with a back rest.2. To provide privacy, draw screens.3. Make sure the light is natural and adequate.4. Wash your hands prior to examination of the patient.5. Stand on the right side of the patient’s couch.6. Greet him and introduce yourself to him.7. Ask permission for examination.8. Explain the procedure and ask for his cooperation.9. Warm the chest piece of stethoscope and your hand.

10. Undress the patient with his cooperation to a certainreasonable modesty.

11. Examine both sides of the patient and compare thefindings.

12. Examine systematically i.e., first while the patient islying, then sitting and then standing. Do not ask thepatient to sit, lie down, sit again, stand, walk andthen lie down again.

13. Cover or dress the patient after the examination andhelp him doing so if need be arise.

14. Thank the patient for his cooperation.15. Wash your hands at the end of full examination or

a specific examination. It is better to wipe off withtissue papers rather than blow dry.

GENERAL PHYSICAL EXAMINATION

Before doing the general physical examination youshould have a panoramic view of the patient and thishelps to make a rapid assessment of the severity of illness.This of course does not help in diagnosis but can leadto so many other points to recall in working for a diagnosis.


Even talking to the patient may reveal a number ofimportant points during the act of history taking. Simpletasks like dressing, undressing, holding a glass of watermay reveal so many clues in clinching the ultimatediagnosis. It is also important to note that some seriouslyill patients may not complain a lot and sometimes oneencounters an apparently healthy person who may haveserious underlying pathology.

It has been said that the experienced doctor begins theexamination on meeting the patient and continues taking thehistory until the consultation ends.

Following steps are important to follow whileconducting a general physical examination:

“Step by Step” in General Physical Examination:1. Stands on the right side of patient.2. Greets, introduces himself to the patient and asks for

permission to examine.3. Exposes the patient adequately observing the modesty.4. Makes sure that the light is natural and adequate.5. Checks for built, nutritional status by picking up skin

fat and noting its thickness and general look of thepatient.

6. While doing this, checks for the higher mentalfunctions by asking simple questions, i.e. name, dateof birth, address, time and recognition of peoplearound etc.

7. Does a panoramic view of the patient, i.e. patient’slook as a whole.

8. Smells any unfamiliar odours coming from the patientwhich may be of any of the followings:• Alcoholic smell• Acetone smell• Mousy smell• Halitosis (bad breath).


9. Examines the head for any abnormality and feels fortexture of hair. Moves his hand over the scalp forevidence of tenderness, depressions (lumps andbumps) and swellings.

10. Examines the eyes from front and sides with a torchif necessary.

11. Pulls up the upper eyelid and asks the patient to lookdown and looks for jaundice.

12. Pulls down the lower conjunctiva and asks the patientto look up to see pallor, cyanosis or haemorrhages.

13. Turns up the tip of the nose with left thumb andshines light from a torch holding that in right handto see inside the nose and notes down any abnor-mality.

14. Presses over the paranasal sinuses, i.e. maxillary,frontal and ethmoidal sinuses with the tip of rightthumb to elicit any tenderness.

15. Looks for any abnormality of the pinna or nodules(tophi) or any vesicles or discharge by shining lightin the ear.

16. Looks at the cheeks for buccal pad of fat or anyerythema or rash.

17. Looks at the lips.18. Looks into the mouth with the help of a torch and

a wooden tongue depressor with proper instructionsto the patient (described later).

19. Looks carefully at the gums, teeth and tongue andnotes down any abnormalities.

20. Looks into the throat for especially examining tonsilsand posterior pharyngeal wall and the uvula,movement of soft palate.

21. Inspects the neck from the front and sides.22. Asks the patient to swallow and observes the

movement of the larynx.


23. Palpates the neck for thyroid swelling or cervicallymph nodes.

24. Examines the hands from palmar and dorsal aspect.25. Looks at nails for clubbing, pallor, cyanosis,

koilonychia, colour, splinter haemorrhages.26. Looks at the palmar aspect of hand for any erythema/

pallor/pigmented creases or Dupuytren’s contrac-tures.

27. Feels the radial pulse either for one minute (or 15seconds then multiply by 4), compares both radialpulses, checks for radio femoral delay.

28. Checks blood pressure in supine position.29. Records any vital signs i.e. pulse, temperature and

respiration in the initial stage of examination.30. Checks the axillary lymph nodes and checks blood

pressure in sitting position if indicated.31. Briefly looks at chest for any deformity and abdomen

for any distension.32. Feels for any inguinal lymph nodes if present.33. Checks oedema in the lower limbs by pressing the

leg above the medial malleolus.34. Checks the dorsalis pedis artery for pulsations.35. Examines the skin as a whole and looks for any

abnormal pigmentation, depigmentation, skineruptions and subcutaneous emphysema.

36. Looks for any abnormal deformities of bones andjoints.

37. Rechecks blood pressure when patient stands to noteany orthostatic hypotension.

38. Observes the gait if patient is able to walk (It is bestobserved when patient walks into the consultationroom).

39. Asks the patient to re-dress and provides help ifnecessary.


40. Thanks the patient at the end of the examination forhis cooperation.

This seems a very lengthy process but actually it shouldtake hardly 5-7 minutes if one has done practice and ifone knows that what one is trying to look for. Therefore,it should not seem difficult at all.

CASE WRITING TIPS

It is better to start from head, face, neck, hand, upper limbs,axillae, chest, abdomen, lower limbs, back (sitting up),standing up and then to look for gait.

1. General appearance2. Head3. Hair4. Eyes5. Face6. Mouth7. Pharynx8. Neck9. Hands

10. Upper limbs11. Axillae12. Thorax13. Abdomen14. Lower limbs15. Spine16. Gait.


STEP BY STEP EXAMINATION OF THE PATIENTAS A WHOLEThis section is written for the convenience of the candidatein which the examination of the patient is described fromstep one to the last step including salient examinationskills of all the important systems briefly including thegeneral physical examination. The candidate is advisedto master this schema as much as possible as it will actas a “skeleton” or “frame work” when he performsindividual systemic examination. For more detailedsystemic examination skills the candidate is advised togo through the section on individual systems.

The Candidate1. Stands on the right side of the bed of the patient.2. Greets, introduces himself to the patient and asks for

permission to examine.3. Exposes the patient adequately and makes sure the

light is adequate, modesty should be observed.4. While doing this, checks for higher mental functions

by asking questions as name, date of birth, address,recognition of people around etc.

5. Does a general survey (panoramic view) of the patientwhile exposing.

6. Examines the head and feels for the texture of hair.7. Examines the eyes from front and sides with a torch

if necessary.8. Examines the oral cavity with the help of a torch and

tongue depressor with proper instructions to thepatient.

9. Inspects the neck from front and sides, asks the patientto swallow and observes, palpates for the cervicallymph nodes and thyroid.

10. Examines hands from palmar and dorsal aspects andlooks at nails.


11. Feels for the radial pulse, compares both, checks forradio-femoral delay and measures blood pressure insupine position.

12. Inspects the chest and abdomen from front and sides,looks at the apex beat with his eyes at the level ofthe chest and from the foot end of bed and countsfor the respiratory rate.

13. Palpates for trachea, sternum, left para-sternal area.14. Localizes apex beat and turns the patient to the left

if necessary.15. Checks movements of the chest and vocal fremitus

anteriorly.16. Percusses the chest above, over and below clavicles

and for cardiac dullness and upper border of the liver.17. Auscultates for breath sounds and vocal resonance,

auscultates heart sounds at the base, parasternal area,epigastrium and mitral area.

18. Auscultates mitral area with diaphragm and bell ofthe stethoscope in supine position while palpatingthe carotids simultaneously. Auscultates adjacentarea towards axilla for radiation if indicated.

19. Turns the patient to the left side and clearly instructshim on how to hold his breath in complete expiration.

20. Auscultates mitral area with bell of the stethoscopein this position with breath held in expiration.

21. Asks the patient to resume breathing immediatelyafterwards.

22. Auscultates tricuspid area with diaphragm and bellin supine position and notes the effects of respiration.

23. Auscultates pulmonary and both aortic areas withdiaphragm, in supine position and notes the effectsof respiration.

24. Auscultates over carotids and left sternal borderwhile instructing the patient to hold his breath.


25. Auscultates over other areas if indicated (for anyradiation).

26. While palpating abdomen makes sure the hands arewarm.

27. Asks the patient to relax and makes him in acomfortable position, with legs slightly flexed.

28. Asks about any tender area in the abdomen.29. Performs light palpation in an “S” shaped manner.30. Palpates the liver from right iliac fossa upwards.31. Palpates the kidneys bimanually and elicits any

ballottement.32. Palpates the spleen first in the supine position starting

from right iliac fossa across to left hypochondriumwhile asking the patient to breath deeply. If the spleenis not palpable then:

33. Palpates the spleen by turning the patient to the rightlateral position supporting the back of the left chestby the left hand with light compression anteriorlyand using right hand to feel the spleen in deepinspiration. If the spleen is still not palpable then:

34. Palpates the spleen in the above mentioned positionbut with the left arm of the patient under his head.

35. Palpates with dipping method if there is tense ascites.36. Percusses the liver and splenic dullness and measures

the liver and splenic span in centimetres.37. Percusses for shifting dullness and elicits fluid thrill

if the shifting dullness is positive.38. Auscultates bowl sounds for at least 30 seconds and

listens for any visceral bruits. If bowel sounds areabsent, listens for 3 minutes.

39. Demonstrates succussion splash if appropriate.40. Raises the head against resistance while looking at

abdomen for any divarication of recti and anyappearance or disappearance of abdominal masses.


41. Checks for springing of sacroiliac joints.42. Examines the upper limbs for bulk of the muscles

and abnormal movements.43. Assesses the tone of the muscles of upper limbs.44. Assesses the power of the muscles of upper limbs

actively and passively.45. Checks the biceps, triceps and supinator jerks.46. Checks for coordination of movements by performing

finger nose test or tapping of the palms.47. Checks for superficial and deep sensations in the

upper limbs.48. Examines the legs and feels for calf tenderness,

dorsalis paedis, and posterior tibial pulses.49. Inspects the feet and notes for any poedal oedema.50. Inspects the bulk of muscles and any abnormal

movements in the lower limbs.51. Assesses the tone of the muscles of lower limbs.52. Assesses the power of muscles of lower limbs actively

and passively.53. Checks for knee jerk, ankle jerk and plantar responses.54. Checks for coordination of movements in the lower

limbs by performing heel shin test.55. Checks for superficial and deep sensations in the

lower limbs.56. Checks for signs of meningeal irritation.57. Makes the patient sit up at 45° and examines the

jugular venous pressure (JVP).58. Makes the patient sit up at right angle and examines

the chest from the back, looks for any spinal deformityand elicits spinal tenderness and sacral oedema.

59. Checks the blood pressure if indicated in this position.60. Checks for the cranial nerves.61. Makes the patient stand, asks him to cough and looks

for hernial orifices.62. Checks the blood pressure if required in this position.


63. Measures height and weight if desired.64. Performs heel-occiput and Schober’s test, Romberg’s

test if indicated, after taking permission from patientand examiner.

65. Asks the patient to walk on a straight line to see thegait (Tendem walking).

66. Performs fundoscopy, rectal and pelvic examinationif required but with the permission of the examiner.

67. Thanks the patient for his cooperation and asks himto dress up and helps him if necessary.

GENERAL PHYSICAL EXAMINATION

Common Commands Asked during Examination

1. Assess the nourishment or nutritional status2. Look for pallor3. Look for cyanosis4. Look for jaundice5. Look for clubbing6. Palpate lymph nodes in the neck7. Check for peripheral oedema8. Check arterial pulses9. Check for radial pulse

10. Check the blood pressure11. Check the temperature12. Look at this patient’s face13. Examine the thyroid gland14. Examine the breasts15. Examine the oropharynx (throat)16. Examine the tongue.


GENERAL PHYSICAL EXAMINATION COMMANDS

Assess the Nutritional Status of the Patient

The Candidate

1. Stands on the right side of patient2. Greets, introduces himself to the patient and asks

permission for examination.3. Exposes the patient adequately, observing the

modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Does anthropometric measurements.7. Notes the distribution of fat.8. Notes the weight and height of the patient.9. Checks for wasting of muscles e.g. sunken eyes,

temporal wasting, facial wasting and small muscleof hands.

10. Examines skin for dryness and cracks.11. Feels texture of hair.12. Checks for subcutaneous fat at biceps, triceps and

suprailiac regions.13. Picks up the skin and fat and notices its thickness,

uses callipers if well versed with using them.14. Looks at angle of mouth and tongue for any

nutritional deficiency status.15. Helps the patient redressing.16. Thanks the patient for his cooperation.17. Notes down all the findings and comments while

presenting his case to the examiner.


PEARLS

a. The candidate should know the definition of the termslike metabolic rate, BMI, caloric value of fats, sugarsand proteins.

b. The candidate should know a checklist of causes ofwasting or cachexia.

c. He should also know the normal waist circumferencein males and females and types of obesity. He shouldknow waist-to-hip ratio in both males and females.

Look for Pallor

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Everts both lower eyelids.7. Asks the patient to look upwards.8. Asks the patient to open the mouth and looks under

the tongue and angles of the mouth.9. Examines the palms for pallor of creases as well (see

below) and compares with his own palms.10. Helps the patient re-dressing if necessary.11. Thanks the patient for his cooperation.12. Finally, comments on presence or absence of pallor

while presenting his case to the examiner.


PEARLS

a. The candidate should know important causes of pallorin the form of a check list. The candidate should knowthe difference between pallor and anaemia. Pallor isclinical assessment of degree of anaemia. Anaemia isa laboratory finding.

b. Normally the creases are pinker than the palm andHb is estimated to be 12-14 g/dl. If the palm is palebut creases are pink then approximate Hb is around10 g/dl. If the creases are also pale then the Hb is< 8 g/dl. Anaemia is one of the causes of pallor.

Look for Cyanosis

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Examines the lips, tongue and oral mucosa.7. Examines the cheeks, ear lobes and tip of the nose.8. Examines the hands and nail beds for any bluish

discolouration.9. Comments on the type of cyanosis, i.e. whether

peripheral or central.10. If in doubt asks the patient to exert for a couple of

minutes. (This will make central cyanosis moreprominent).

11. Helps the patient re-dressing.12. Thanks the patient for his cooperation.13. Finally comments on presence or absence of cyanosis

and its type while presenting his case to the examiner.


PEARLSThe candidate should know the types of cyanosis, theircauses and the differences between various types.

Look for Clubbing

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Examines the finger nails at a tangent bringing his

eyes at the same level to see the angle between nailfold and the nail plate called Lovibond angle.

7. Brings nails of the fingers or thumbs of both handstogether and opposes their dorsal surfaces,(Schamroth’ sign) and looks for the space betweenthe two nails.

8. Holds the nail bed with thumbs and tips of his indexfingers of his both hands.

9. Palpates the nail bed to elicit fluctuation.10. Looks for clubbing in all the fingers and toes and

does its grading (see below).11. Compares the findings in hands with those in the

toes.12. Looks for widening and tenderness of the ends of

long bones for evidence of hypertrophic osteo-arthropathy.

13. Helps the patient re-dressing.14. Thanks the patient for his cooperation.15. Comments whether clubbing is present or absent and

if present tells the grading of clubbing.


PEARLS

Grading of clubbingThey are divided in four grades.Grade 1: Fluctuation at the bed of nailGrade 2: Obliteration or increase in the angle between

nails bed and nail plate.Grade 3: Beaking of the nail.Grade 4: Drum-stick appearance.a. You should be aware of the causes of clubbing and

types of clubbing.b. If the examiner asks you “Which single question would

you ask from this patient to know the cause ofclubbing?” You should ask from the patient. “Is thisabnormality present since childhood?” This will ruleout or rule in the congenital causes of clubbing.Therefore the things may get easier.

c. You can see the angle by putting a paper verticallyon the nail plate and nail bed. A space will be seenif angle is not obliterated.

Look for Jaundice

The Candidate

1. Stands on the right side of the patient.2. Greets, introduces himself to the patient and asks


modesty.( if wearing a veil)4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Lifts the upper eyelids and asks the patient to look

down.7. Examines the soft palate, and under surface of the

tongue.


8. Examines the palms and the skin.9. Helps the patient re-dressing.

10. Thanks the patient for his cooperation.11. Comments on presence or absence of jaundice and

its severity.

PEARLS

a. Sclera and soft palate become yellow earlier than skin.Severe jaundice is present if all the sites are stained.

b. Bilirubin has an affinity for elastic tissue which iscomposed of elastin, and it is abundant in sclera,therefore the earliest and best site to look for jaundice.

c. Lemon yellow colour indicates mild jaundice, orangeyellow indicates moderate jaundice and greenishyellow indicates severe jaundice. They also indicatethe underlying cause, i.e. haemolytic, hepato-cellularand obstructive jaundice respectively.

Check for Lymphadenopathy

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient sit comfortably.7. Notes any sinuses opening on to the skin or

cicatrization or scarring of the skin.8. Flexes the patient’s neck forward.9. Approaches the patient from behind the neck.

10. Flexes the neck on the side of examination. (eitherright or left).


11. Palpates the lymph nodes on that side by pushingthe fingers from above downwards.

12. Examines all the groups of lymph nodes systemati-cally i.e., submental, submandibular, jugulo-digastric,pre-auricular, post-auricular and occipital lymphnodes.

13. Palpates especially for scalene lymph node (seepearls)

14. Examines both sides of the neck.15. Helps the patient redressing.16. Thanks the patient for his cooperation.17. Comments on the location, size, tenderness, texture

and degree of fixation to the skin above.

Check Lymph Nodes in Axilla

The Candidate

1. Stands on the right side of patient.2. Greets, introduces himself to the patient and asks


modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient sit up on a chair.7. Approaches from front of the patient.8. Abducts patient’s left arm and rests patient’s fore arm

over his (candidate) left arm.9. Inserts his right hand in patient’s left axilla and feels

the apex and medial wall by sliding movements ofthe fingers.

10. Places patient’s left arm over his (candidate) rightarm, and feels the lateral wall of the left axilla byhis left (candidate) hand.


11. Abducts patient’s right arm and rests patient’s rightpre free arm over his (candidate) right arm and inserthis left hand in right axilla and feels the apex andmedial wall by sliding movements of the fingers.

12. Places patient’s right-arm over his left arm and insertsright hand, palm facing laterally in patient’s rightaxilla to feel the lateral wall of right-axilla.

13. Palpates the anterior axillary fold between the fingersand the thumb.

14. Goes behind the patient and palpates the posterioraxillary folds.

15. Helps the patient redressing.16. Thanks the patient for his cooperation.17. Comments on the size, tenderness, texture and degree

of fixation of the lymph nodes while presenting tothe examiner.

Check Lymph Nodes in the Inguinal Region

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie supine7. Asks the patient to flex the opposite thigh.8. Palpates above and below the inguinal ligament.9. Examines on the both sides and compares the

findings.10. Helps the patient redressing.11. Thanks the patient for his cooperation.


12. Comments on the findings while presenting to theexaminer.

PEARLS

a. Complete relaxation of the part to be examined isimportant for palpation of even smaller lymph nodes.

b. Movements should be slow and gentle in rotatorymanner.

c. In normal subjects, only few inguinal lymph nodes areusually palpable.

d. Sometimes the examiner asks about the external andinternal rings of Waldayer, and the candidate shouldknow its location and components of both these rings.The external ring is composed of submental, sub-mandibular, jugulodigastric, pre-auricular, post-auricular and occipital lymph nodes, where as theinternal ring is composed of lingual tonsils, palatinetonsils, tubal tonsils and the adenoids.

e. The scalene lymph node is present deeply between thesternal and clavicular head of sternocleidomastoidmuscle. The patient’s neck is slightly flexed and rotatedto the opposite side (towards left). The examiner putstip of his right index finger facing downwards andmedially towards apex of the heart and asks the patientto take a deep breath in. The lymph node if enlarged,can be felt as a firm object touching the pulp of finger.Scalene lymph node is palpable in case of carcinomabronchus.

Look for Peripheral Oedema

The Candidate


permission for examination.


3. Exposes the patient adequately, observing themodesty.

4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Uses thumb for exerting pressure.7. Applies pressure for 5-30 seconds over the part

of leg behind medial malleolus or lower part of theshin.

8. Looks for any pitting and feels it with his finger fora “well” or a “dimple.”

9. Does same manoeuvre over the sacrum.10. Examines abdominal wall for oedema.11. Makes sure to examine both sides.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments whether pitting or nonpitting oedema,

unilateral or bilateral and the side of oedema.

PEARLS

If the dimple or pitting caused by pressure fills up within 30-40 seconds it is called fast oedema but if it takes morethan 40 seconds, it is called slow oedema. In the formercase, hypo-albuminaemia and in the later case cardiacoedema can be quoted as examples.

CHECK PERIPHERAL PULSES

Check for Radial Pulse

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Semi pronates the fore arm of the patient keeping it

by his side.7. Flexes the wrist slightly.8. Uses the distal parts of the three fingers (index, ring

and middle) of his right hand to compress the vesselagainst lower end of radius.

9. Examines the femoral pulse simultaneously with hisleft hand and checks for any radiofemoral delay.

10. Counts for at least 15-30 seconds.11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on rate, rhythm, volume, character, and

consistency of vessel wall while presenting to theexaminer.

PEARLS

a. Check for pulse deficit if the pulse is irregularlyirregular. The candidate should know how to examineother pulses i.e., brachial, axillary, superficial temporal,femoral, popliteal, posterior tibial and dorsalis pedisarteries.

b. To know the condition of the vessel wall, roll the vesselwall against a hard area i.e., lower end of radius tofeel the consistency of vessel wall.

Check the Carotid Pulse

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to look straight ahead.7. Exerts slight pressure with his left thumb on the mid

cervical region backwards at the level of sterno-mastoid muscle and lateral to the thyroid cartilage.

8. Counts for at least one minute.9. Does not palpate both carotids simultaneously (see

pearls).10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on the findings while presenting to the

examiner.

PEARLS

a. Never palpate both carotids simultaneously as it canstimulate carotid body leading in turn to para-sympathetic stimulation. This causes severebradycardia leading to hypotension and patient maycollapse.

b. The character of pulse is best felt in the carotids orbrachial artery as they are more close to the aorta.Axillary artery is technically difficult to palpate.

c. The candidate should know different characters of thepulse i.e., anacrotic pulse, bisferiens, jerky pulse,dicrotic pulse, collapsing pulse and pulsus paradoxus.


Check Collapsing (water hammer) Pulse

The Candidate

1. Stands on the right side of the patient2. Greets, introduces himself to the patient and asks


modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient if he has any painful condition of

the shoulder on the same side.7. Pronates patients forearm fully.8. Places palm of the right hand on the radial pulse.9. Supports the patient’s elbow with his left hand after

straightening patient’s arm.10. Raises the patient’s arm above the level of his head

briskly.11. Feels the thrust of the radial pulse over the palm

around the wrist.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on its presence or absence while presenting

to the examiner.

PEARLS

Candidate should know causes of collapsing pulse.

Check Pulsus Paradoxus

The candidate:1. Stands on the right side of the patient2. Greets, introduces himself to the patient and asks




4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Feels the pulse at brachial artery.7. Applies the cuff of the sphygmomanometer over the

upper forearm.8. Inflates the cuff above systolic pressure.9. Asks the patient to take deep breaths throughout.

10. Places the diaphragm of his stethoscope over thebrachial artery.

11. Lowers the mercury column slowly by deflating thecuff.

12. Notes the level of mercury at which Korotkoff’s soundare heard only during expiration.

13. Notes the level of mercury at which the sounds areheard during inspiration.

14. Notes the difference between these two levels.15. Helps the patient redressing.16. Thanks the patient for his cooperation.17. Comments on the findings while presenting to the

examiner.

PEARLS

a. Pulsus paradoxus is said to be present if the differencein the level of mercury is more than 10 mm.

b. Another method is to palpate the pulse, which maynot be palpable during inspiration but becomespalpable during expiration.

Check the Blood Pressure

The Candidate




3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Patient is either sitting or lying in the bed.7. Ensures he is under basal conditions i.e., not

distressed, has not smoked recently or has not hada recent meal.

8. Ensures that the patient’s arm is at patient’s heartlevel.

9. Places the sphygmomanometer at the side of patientat the level of his eyes. The candidate’s eyes shouldalso be at level of mercury in the sphygmomanometer.

10. Applies the appropriate sized cuff over the upperlimb.

11. Makes sure that the lower border of the cuff is about2.5-5.0 cm above the cubital fossa and 2.5 cm belowthe axilla. The rubber tubing should be in line withthe brachial artery.

12. Inflates the cuff with the bulb.13. Determines systolic pressure by palpation.14. Raises the pressure in the cuff to about 30-40 mm

of the systolic pressure. (which is already known withthe palpatory method)

15. Brings back the level of sphygmomanometer to zerobefore inflating the cuff.

16. Places the diaphragm of the stethoscope lightly overthe brachial artery.

17. Deflates slowly the bladder so that the column ofmercury drops at a rate of 3-5 mm per second.

18. Records the pressure when the sounds appear.19. Keeps deflating and records pressure when sounds

become muffled or disappear.20. Records BP in all the limbs if indicated in examination

of that particular case.


21. Checks the blood pressure in supine and standingpositions to check for postural hypotension.

22. Helps the patient redressing.23. Thanks the patient for his cooperation.24. Comments on the findings while presenting to the

examiner.

PEARLS

a. If pulse is irregular then take at least three readingsand get an average.

b. In palpatory method, systolic blood pressure is whenthe pulse is felt. Keep on deflating the bladder, untilthe pulse from bounding quality comes to a normalquality. This level is approximately diastolic pressure.

c. Application of cuff should not be loose.d. Cuff should be at the same level as of the heart.

Check Blood Pressure in Lower Limbs

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Uses larger cuff for this purpose.7. Makes the patient lie prone.8. Palpates popliteal artery.9. Applies the cuff at mid thigh with tubings in the line

with the popliteal artery.


10. Places diaphragm of stethoscope over popliteal artery(as over brachial artery in the upper limb).

11. Inflates and deflates and notes the readings.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on the findings while presenting to the

examiner.

If Large Cuff is Unavailable

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to lie supine.7. Applies the cuff (ordinary size) at the middle of the

calf.8. Palpates posterior tibial artery or dorsalis paedis

artery.9. Inflates and deflates the cuff and listens over the

posterior tibial or dorsalis paedis arteries.10. Notes down the readings.11. Helps the patient redressing.12. Thanks the patient for his co-operation.13. Comments on the findings while presenting to the

examiner.

PEARLS

Krotokoff’s soundsThey are five in number and represent various degreesof intensity of the heart sounds.


• Tapping sounds• Like a bruit (hissing)• Loud sharp sounds• Muffled sounds• No sounds (disappear).

4th phase is the one which is recorded more precisely.a. Normal BP is 100-140/60-80 mm of Hg.b. Systolic BP in the right upper limb is 10 mmHg more

than the left.c. Systolic BP in the lower limbs is usually not more than

20mm of Hg and the diastolic BP is not more than10mm Hg than the upper limbs.

d. Record BP form non paralyzed side if the patient hashemiplegia.

Check Temperature

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Uses a sterile thermometer if possible.7. Looks at its level, shakes it down, and looks at it

again to see the mercury level is below the normaltemperature mark.

8. Explains to the patient what is he going to do.9. Makes sure that the patient has not had any thing

hot either liquid or solid.10. Asks the patient to open the mouth and lift the tongue

up.


11. Puts the bulb of thermometer on the side of fraenulumlinguae.

12. Asks the patient to lower the tongue and close themouth but keep the lips closed and warns not to bitethe thermometer with teeth and instructs to breaththrough nose.

13. Keeps the thermometer at least for one minute.14. Asks the patient not to rub the tongue against the

bulb of the thermometer while in the mouth.15. Takes the readings immediately.16. Thanks the patient for his cooperation.17. Comments on the findings while presenting to the

examiner.

PEARLS

a. During routine examination insert the oral thermometer;count the radial pulse and respiration rate. This savestime and you get all the three readings in one minuterather than spending one minute each on these vitalsigns. This is more important when the candidate isasked to see a short case with general physicalexamination when the time is also very short!

b. Avoid axillae or groins as far as possible for recordingtemperature. The reading may not be accurate.

c. Reader should be aware of the types of fever i.e.,continuous, intermittent, remittent and quotidian,quartan and tertian fever, Pel-Epstein fever andundulant fever, etc.

Examine the Thyroid

The Candidate




3. Exposes the patient adequately, observing the modesty(if the patient is a female and is wearing a veil)

4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Looks at the neck from the front and the sides.7. Asks the patient to put some water in the mouth but

to keep it there till asked further.8. Asks the patient to swallow that water which was

kept in his mouth.9. Looks for movement of any swelling in front of the

neck while swallowing that water.10. Asks to protrude the tongue and observes any

movements of the swelling in front of the neck.11. Stands behind the patient.12. Flexes the neck slightly forwards.13. Feels for any swelling with his fingers of both hands

by putting thumbs over the patient’s occiput.14. Feels the isthmus first in the midline over tracheal

rings.15. Flexes and rotates the neck towards the side of

palpation. Pushes the larynx to the same side andwith the other hand palpates the lobe of thyroid onboth sides.

16. Notes the position of the trachea as well.17. Percusses the suprasternal area for any retrosternal

extension.18. Listens for any bruit over the isthmus and lobes of

thyroid by lightly pressing the diaphragm of thestethoscope and asking the patient to hold breath fora while.

19. Looks for any relevant signs i.e., carotid pulsation,Horner’s syndrome, tremors of the out stretched handsand eye signs.

20. Help the patient re-dressing (if wearing the veil).


21. Thanks the patient for his cooperation.22. Comments on the findings and a probable diagnosis

while presenting to the examiner.

PEARLS

a. Fine tremors are more obvious if a piece of paper isplaced over the out stretched hands avoiding anydraught of air.

b. Look at the side of face and over the forehead fromthe back at a tangent for exophthalmos.

c. Feel palms for warm sweat (cold sweat is felt in anxiety)d. Feel pulse for tachycardia.e. Feel for the carotid pulse which is not palpable in

malignant swellings of thyroid where as it is palpablebut displaced laterally in simple goitres whatever istheir size.

f. Pemberton’s sign: Ask the patient to raise both arms andbring closer to the ears until their medial sides touchboth his ears. Hold up for sometime and look forcongestion of the face, cyanosis and distress whichoccur in a retro-sternal goitre.

g. Kocher’s test: Press the lateral lobes of thyroid and notefor any stridor which occurs due to compressedtrachea.

Examine the Breasts

This is an important aspect of clinical examination in viewof the increasing incidence of breast cancers in females.It is also important to have a female chaperon whileexamining breasts of a female patient.


The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient sit on a chair in front of himself.7. Looks for bumps in the breasts, axillae, flattening of

breasts and any skin dimpling.8. Looks for asymmetry of nipple any discharge and

areola for any abnormality.9. Asks the patient to place her hands at either side of

her hips or over her thighs.10. Asks the patient to press her hips with her hands

already placed over them. Looks for any asymmetry.11. Asks the patient to raise the hands and place both

palms of the hands behind her head and pressforwards. Looks for any asymmetry.

12. Asks the patient to lean forward.13. Observes for any asymmetry of the nipples and

oedema of the arm.14. Makes the patient lie down on the couch with a pillow

below her chest and the arm under the head on theside of examination.

15. Palpates the breast with the palm of his hand rollingover the breast against chest wall in all fourquadrants.

16. Feels for any masses or ulcers and notes its size, shape,tenderness, mobility, overlying skin and dischargefrom the nipple.

17. Palpates the normal breast first.18. Palpates the areola and express any discharge from

the nipple.


19. Palpates the corresponding axilla, supraclaviculararea and scalene area for any lymphadenopathy.

20. Helps the patient redressing.21. Thanks the patient for his cooperation.22. Comments on the findings and a probable diagnosis

while presenting to the examiner.

PEARLSa. Follow the technique of palpating upper inner quadrant

then lower inner, then lower outer and then upper outerquadrant. Examination finishes after palpating axillaon the same side.

b. Expression of the nipple can be done in medio-lateraldirection or supero-inferior direction.

c. Normal breast tissue is nodular and can be engorgedpremenstrually.

d. In doubtful cases the examination is repeated atdifferent time of the menstrual cycle.

e. Any definite lump in breast should be palpated bi-manually.

f. General examination is not complete, unless the breasts(both) are examined. In our set up due to social reasons,this examination is commonly omitted or missedcompletely which should not happen as a routine.

g. Breast is examined in many positions to detect earlychanges.• By sitting up the patient and hands on thighs

causing relaxation of pectorales muscles.• By pressing hands on hips causing contraction of

pectorales muscle.• By raising the arms above the head and both palms

placed behind head causing the breast, to bestretched along with the skin.

• By leaning the patient forwards causing breasts tobecome pendulous.


• By making patient lie down with the same armbehind the head and putting a pillow underneaththe shoulder blade causing the breast moreprominent.

Examine the Patient’s Throat

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty

(in case the patient is wearing a veil)4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient whether he had eaten any meals

recently. If so how recently?7. Asks the assistant to hold the head.8. Asks the patient to open the mouth and advises him

to keep the tongue inside and relax. Looks at lipsfor ulcers or telangiectasias and also looks at thegums, teeth and inner sides of the cheeks.

9. Holds a wooden tongue depressor in his left handand depresses the tongue at its posterior 1/3 andmiddle 1/3.

10. Shines the light held in his right hand.11. Touches the tonsillar pillars to elicit a gag reflex.12. Looks at the posterior pharyngeal wall.13. Thanks the patient for his cooperation.14. Comments on the findings of his examination while

presenting to the examiner.


PEARLS

a. The question of recent meals is important to ask asif the patient has had a meal recently and duringexamination of throat, the gag reflex is stimulated,patient may vomit instantly on to the examiner.

b. It is very important to ask the patient to keep his tonguein the mouth as it does not obstruct the view of thethroat because it is relaxed while in the mouth.

Examine the Patient’s Tongue

The Candidate



modesty.(in case the patient is wearing a veil)4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to open the mouth and keep the

tongue in side.7. Looks for colour, moistness, furring and surface of

the tongue.8. Looks for any asymmetry or fibrillation of the tongue.9. Asks the patient to protrude the tongue and looks

for any evidence of deviation, ankylosis in case oftongue-tie or atrophy of the tongue.

10. Asks the patient to touch his palate with the tip ofhis tongue, and looks under the surface of the tongue,fraenulum linguae or for any telangiectasias and thefloor of the mouth.

11. Looks for ulcers (if so then feels for the indurationunderneath), leukoplakia, nodules or blackening ofthe tongue.


12. Asks the patient to wiggle the tongue on the innerside of each cheek and pushes it in opposite directionsfrom outside to see the strength of the tongue.

13. Thanks the patient for his cooperation.14. Comments on the findings of this examination while


PEARLS

a. The candidate should be aware of various types of“tongues” in medicine i.e., normal, black hairy,fissured, beefy, macroglossia, geographical tongue,scrotal tongue, bald tongue, candidiasis, leukoplakia,strawberry tongue, mucosal neuromas, aphthousulcers, lichen planus and coated tongue and manyothers.

b. Some time it is important to hold the tip of the tonguewith a gauze piece and thoroughly examine it.

c. If any neurological deficit is suspected then check thesense of taste as follows:• Wipe the tongue to make it dry.• Instruction to the patient is very important. Ask him

to raise index finger if sweet, middle finger if saltish,and little finger if bitter taste is felt.

• Put a drop of solution on both halves of the tongueseparately.

• Ask the patient to raise the respective finger whenhe feels the taste.

d. Palpation makes an important part of the examinationof the tongue. Following steps are important to follow:• Put on a disposable pair of gloves.• Ask the patient to remove any dentures.• Ask the patient to elevate the tongue and move to

one side.


• Place the index finger of right hand beneath thetongue on one side of fraenulum of the tongue andrun the finger back on the floor of mouth. Run thefinger on the lateral side of tongue and then overthe same half on the dorsum and then towards thebuccal side of the gums up to the mucosa ofascending ramus and then examine both buccal andpalatal aspects of the teeth of the upper jaw.

e. For bimanual examination:• Place the right index finger in the floor of the mouth

and press with the fingertips of left hand beneaththe mandible and exert little pressure in betweenthese two.

• Sometimes one has to hold the tongue with a gauzepiece between fingers and thumb of the other handand palpate the tongue with right index and thumb.

• Palpation of posterior 1/3 of tongue is difficult asit can cause gag reflex and patient may vomit.

CHAPTER 6

Examination ofRespiratory

System


This system is discussed under four headings as follows:1. Principles of examination of respiratory system2. Examination of the respiratory system as a whole (for

long cases)3. Schematic out line of respiratory system4. Common commands in respiratory system (for short

cases)

PRINCIPLES OF EXAMINATION OF RESPIRATORYSYSTEM

Before starting, one should know briefly the surfacemarkings of the lungs in particular relation with the ribs,sternum and scapulae and certain principles of theexamination of respiratory system. These principlesinclude inspection, palpation, percussion and auscultation.

Principles of Inspection

The patient should be undressed to the waist and in caseof females, modesty should be observed and breasts shouldbe covered properly. However, the patient should beexplained the need of proper exposure.

The patient may be lying on the couch at 45° or shouldbe seated on the bed with legs hanging over the side. Theexaminer stands back and looks at the front, side and backof the chest for any abnormality, structurally orfunctionally i.e., shape, symmetry, scars, kypho-scoliosis,barrel chest, prominent veins, respiratory movements,dyspnoea etc, or pattern of breathing i.e., Cheyne stokesand Kussmaul’s breathing. The examiner should alsolisten for any abnormal audible sounds coming from thechest i.e., noises, wheezing, stridor or hoarseness if thepatient speaks. The examiner should also inspect themovements of the chest with respiration and abnormalities

67 EXAMINATION OF RESPIRATORY SYSTEM

of the supra sternal notch in the form of asymmetricalfilling indicating mediastinal shifting.

One should look for clubbing and cyanosis, tar stainingof the fingers and nails and pallor of the hands. Also checkfor wasting of muscles and elicit asterixis or metabolictremors. Wrists should be palpated for any bony tenderness(hypertrophic pulmonary osteo-arthropathy). Look at theface for ptosis and constricted pupil, swelling of face andsuffusion of the face, fullness of supra clavicular fossaefor superior vena caval (SVC) obstruction along withdilated veins in front of the chest. If there is a fresh sampleof sputum, then it should be examined for colour,consistency, froth and quantity.

Principles of Palpation

The position of trachea should be palpated first either byone finger or three fingers method. Try to insert fingerbetween medial borders of each sternomastoid musclesand feel any resistance. The trachea is then deviated tothe site of resistance. Just slide index finger forward overthe supra sternal notch and if it touches a firm object, thenthe trachea is central. The other method is the three-fingermethod where index and ring fingers are placed on bothsternoclavicular joints and the middle finger is used topalpate trachea.

Feel for the tracheal tug which is done by putting index,middle and ring finger vertically above the supra-sternalnotch and patient is asked to breathe in, the cricoidcartilage along with trachea moves downward duringinspiration. (presence indicates pulmonary fibrosis)

Supraclavicular lymph nodes should be palpated fortheir presence and fullness of the fossae. Palpate also forscalene lymph node (described later). Now palpate for the


movements of the chest wall by gripping the sides withfingers of both hands as far back as possible and bringthe thumbs in the midline but keep the thumbs off thechest wall. Movements of the chest cause movement ofthe thumbs away from the midline. At apex, there is upand down movements, at mammary areas the movementis in horizontal direction and in the intra-scapular areathe movement is again in the horizontal direction.

Vocal fremitus is palpated with either palm or ulnarborder of palm alternately on right and left side and byasking the patient to say “99” or “123” repeatedly. Checkfor inter-costal tenderness by pressing with thumb andlook at the patient’s face for any pain when he winces.Palpate also for any subcutaneous emphysema.

Principles of Percussion

It requires considerable practice and in turn indicates howmuch time a student has spent “in the wards”. Thepercussion should start from a resonant to dull area soas to easily appreciate the change. The left middle fingeris used as pleximeter finger and the tip of the right middlefinger as plexor (vice versa if one is left handed!).

The movement should be at wrist joint rather than atthe elbow. Pleximeter should be placed firmly on the partto be percussed and placed parallel to the border of theorgan to be percussed. Bones are percussed directly withthe percussing finger (plexor) without placing pleximeterfinger, called direct percussion.

Middle phalanx of the pleximeter should be percussedwith plexor and direction of stroke should be perpendicularrather at any other angle. Try not to strike more than twostrokes and avoid discomfort to patient by doing heavypercussion.


After stroking the pleximeter, the plexor should beraised immediately like ball thrown to the wall as itprevents damping the percussion note. However, in obeseand very muscular subjects, heavy percussion is advised.The important signs to be elicited are resonance, dullness,pain and tenderness. Both sides should be comparedsystematically.

In coarse percussion three or four fingers are tappedtogether lightly on each side and comparison is made. Onthe back, the scapulae should be moved out by askingthe patients to put his hands over his shoulders onopposite sides to elicit percussion in a better way.

Do not forget to percuss the lateral aspect of chest byasking the patient to keep both hands over his head.

Principles of Auscultation

For auscultation of the respiratory system, the diaphragmof a stethoscope is used. It is a misnomer as with a “scope”you see but with it you hear! Before one goes on toauscultate the chest, it is important to know how to usestethoscope and one should make oneself familiar to itsuse to increase the utility of stethoscope.

General Instructions for the Use of Stethoscope

1. Ear pieces should fit snugly into the external auditorymeatus.

2. They should be parallel to the long axis of the externalauditory meatus.

3. Warm the chest piece before putting it on the chestof the patient by rubbing it over on to your palm.

4. Chest piece should be placed directly on the skin andnot over the clothes.

5. If the chest is hairy, moisten the hair with some water.


PEARLS

Diaphragm is for high-pitched sounds and the bell is forlow-pitched sounds. The former is suitable for highfrequency (300Hz) and the later is useful for low frequency(150-200Hz). Low frequency sound disappears whenstethoscope is placed firmly on the skin. As most ofpulmonic and cardiac sounds are low-pitched, thereforeusing the bell of the stethoscope seems logic.

Auscultation is done under the following headings:

1. Type of breath sounds.2. Intensity of breath sounds.3. Adventitious sounds.4. Vocal resonance.5. Succussion splash if there is shifting dullness.6. Coin test (if pneumothorax is suspected).

General Principles of Auscultation

1. Patient is usually sitting on a bed.2. Bell of the stethoscope is used.3. Patient breathes in and out deeply with the mouth

open.4. Avoid auscultation too close to the midline due to

normal bronchial element.5. Hairy chest wall should be moistened with water or

the chest piece should be pressed firmly.6. Note character of inspiration/expiration.7. Duration and loudness of the inspiration and

expiration.8. Presence or absence of pause at the end of inspiration

and beginning of expiration.9. Presence of added sounds.


10. May ask the patient to cough during auscultation andnote any change in the auscultatory findings.

11. Patient is shaken during auscultation to elicitsuccussion splash if there is fluid in the pleural cavityespecially in hydro-pneumothorax.

12. Patient is asked to whisper or say 123 or 99 to elicitvocal resonance.

13. Auscultate all areas anteriorly, laterally andposteriorly.

14. Comparison of both sides is important and is requiredon the examination.

15. Comment on character of breathing, i.e., normal orabnormal sounds including crackles, wheezing(sibilant and sonorous), fixed monophonic, randommonophonic, inspiratory or expiratory polyphonicand aeogophony, bronchophony and pleural rub.


STEP BY STEP EXAMINATION OFRESPIRATORY SYSTEM (FOR LONG CASES)

The Candidate

1. Stands on the right side of the bed of the patient.2. Greets, introduces himself to the patient and asks for

permission of examination.3. Exposes the patient adequately and makes sure the

light is adequate.4. While doing this, checks for higher mental functions


5. Does a general survey (panoramic view) of the patient,while exposing.

6. Looks at the neck and inter-costal spaces for exertionof accessory muscles of respiration.

7. Looks at the neck for engorgement of neck veins,abnormal pulsations during respiration and anyabnormality in supraclavicular fossae anddemonstrates pulsus paradoxus if indicated.

8. Looks from the front and side for any chest deformity(barrel shaped chest, pectus excavatum, pectuscarinatum, kyphosis, etc).

9. Looks at the lips, tongue and finger tips for cyanosisboth central and peripheral.

10. Examines the nails for clubbing i.e., demonstratesfluctuation and notes the nail angle obliteration etc.

11. Inspects the chest for rate, depth and type of breathing.12. Looks at the skin closely for pigmentation, scars and

any abnormal blood vessels, abnormal swellings andgynaecomastia.

13. Locates the apex beat from the front and side of thepatient at a level and notes any abnormality inpulsation.


14. Inspects the patient from the foot end for movementsand expansion of the chest.

15. Palpates the trachea and notes any tracheal tug.16. Palpates for apex beat, parasternal heave and supra-

sternal/epigastric pulsations.17. Palpates the movements of the chest, both in upper

and lower zones (i.e. above and below the nipples).18. Palpates for vocal fremitus on both sides of the chest.19. Percusses the chest with correct technique as

mentioned previously (see principles of percussion),above, on and below the clavicles.

20. Percusses for cardiac dullness and upper border ofthe liver.

21. Percusses in the axillary areas.22. Auscultates (on corresponding areas).23. Auscultates for breath sounds on normal and deep

breathing.24. Elicits whispering pectoriloquy if bronchial breathing

is present.25. Auscultates any added sounds on deep breathing and

coughing26. Auscultates for vocal resonance on front and sides.27. Makes the patient sit up in appropriate position (i.e.

squatting with hands on opposite shoulders and backturned towards the candidate).

28. Inspects for any deformity, swelling and scars.Inspects for any asymmetry of movements in the chest.

29. Palpates any obvious swelling or deformity.30. Palpates the movements at the apices.31. Palpates for the movement of the rest of the chest.32. Measures the chest expansion with a measuring tape.33. Palpates and compares vocal fremitus on both sides.34. Percusses on corresponding areas.35. Percusses for spinal tenderness and notes the quality

of resonance.


36. Auscultates for breath sounds with normal and deepbreathing.

37. Auscultates for whispering pectoriloquy; if bronchialbreathing is noted.

38. Auscultates for post-tussive crackles after asking thepatient to cough.

39. Auscultates for vocal resonance after coughing.40. Thanks the patient for his cooperation and asks him

to dress up and helps him doing so if necessary.41. Comments on the findings while presenting to the

examiner.

CASE WRITING TIPS (RESPIRATORY SYSTEM)

A. Upper respiratory tract (inspection)1. Nose2. Para nasal air sinuses3. Oropharynx

a. Tonsilsb. Tonsillar pillarsc. Posterior pharyngeal wall.

B. Lower respiratory tract (inspection)1. Shape of the chest2. Symmetry3. Position of mediastinum

a. Tracheab. Apex beat.

4. Movements with respirationa. Rateb. Rhythmc. Typed. General expansione. Comparisonf. Scars


g. Pulsationsh. Prominent blood vesselsi. Fullness of neck veins and supra-clavicular

fossae.C. Palpation:

1. Position of mediastinuma. Tracheab. Apexc. Tracheal tug.

2. Movements: Compare and measure both sides3. Vocal fremitus4. Intercostal space tenderness.

D. Percussion:1. Superficial cardiac dullness (sometimes not

necessary)2. Upper border of the liver3. All over the chest on both sides over the lung and

pleural area4. Shifting dullness especially in hydro-pneumothorax

E. Auscultation:1. Type of breath sounds2. Intensity3. Adventitious sounds4. Vocal resonance5. Succussion splash (hydro-pneumothorax)6. Coin test (pneumothorax)7. Aeogophony/bronchophony


COMMON COMMANDS

These may be useful during short cases and may be singleor combined. The candidate may be asked to do any aspectof the examination of the chest either from front or backor both.

For example:• Inspect and palpate the chest (whole)• Percuss and auscultate the chest (whole)• Inspect and auscultate the chest (whole)• Palpate and auscultate the chest (whole).

Therefore a variety of combination of commands may beasked from the candidate from the following list:1. Inspect the chest from the front2. Palpate the chest from the front3. Percuss the chest from the front4. Auscultate the chest from the front5. Inspect the chest from the back6. Palpate the chest from the back7. Percuss the chest from the back8. Auscultate chest from the back.


RESPIRATORY SYSTEM

Commands for Short Cases

Following section is based on common commands givento the candidates for examination of the respiratory systemand it is very essential to listen carefully what the examinersays or read carefully what ever instructions are writtenon the wall near the bed of the patient. One should followthat strictly to save the time and to present the caseproperly. Therefore, repeated practice is required.

The commands may include a single aspect ofexamination or two at the most i.e. inspection only orinspection and palpation or percussion and auscultation.Sometimes the commands may be to examine the patient’schest form the front or from the back, then you have torepeat all the steps one by one i.e., inspection, palpation,percussion and auscultation in a systematic way. Neverforget to examine the lateral aspect of the chest.

Therefore it is of utmost importance to listen to the exa-miner carefully and then carry out the relevant examination.

If you have ample time left, then you can have a quickgeneral physical examination looking only for those cluesin particular, which might help reaching the diagnosis.But this should be done at the end of your case whensome time is left. For this, you can either ask permissionfrom the examiner or do at your own to “impress” theexaminer.

Make sure that when you give an instruction to thepatient then after doing that particular manoeuvre, askhim to undo that e.g., if you asked the patient to holdthe breath then ask him again to breath normally, if thepatient is asked to clench the teeth then ask him againto relax, if the patient is asked to put the tongue out thenask him again to put it back, etc.


COMMON COMMANDS (EXAMINATION OF THERESPIRATORY SYSTEM)

Inspect the Chest (See also Principles of Inspectionon Page 66)

(The candidate will inspect both the anterior lateral andposterior aspects of the chest)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Examines and comments on the findings of upper

respiratory tract and looks for any abnormalpulsations, scars, blood vessels and swellings overthe chest.

7. Checks the respiratory rate.8. Goes at the end of the bed and inspects the shape

of the chest wall.9. Notes down the symmetry of the chest wall.

10. Notes the movements of the chest.11. Notes the type of breathing i.e., thoracoabdominal or

abdominothoracic.12. Comments on the apical impulse by looking at a

tangent to the chest wall.13. Looks particularly to the intercostal muscles and in-

drawing of the subcostal area during respiratoryeffort.


For the inspection on the back of chest the candidates doesfollowing:1. Asks the patient to sit up on a stool or at the edge

of the bed with his legs hanging down and arms crossedin front of the chest and hands placed on oppositeshoulders.

2. Goes on to the back of the patient.3. Looks carefully at the back of the chest.4. Looks for any deformity of the chest wall including

spine.5. Notes any scars, swellings, or other lesions.6. Comments on movements of the chest.For inspection of the lateral chest wall, the candidate asksthe patient to place his hands over his head and repeatsall the steps of inspection on both the lateral side of thechest and comments on his findings.

PEARLS

a. The candidate should be able to pick up and definedeformities like barrel chest, funnel chest, pectusexcavatum, pectus carinatum, kyphosis, gibbusdeformity, rickety rosary and Harrison’s sulcus.

b. The candidate should be well aware of the types ofrespirations, shapes of the chest.

Palpate the Chest (See also Principles of Palpationon Page 67)

Palpates the chest from front and back. Also palpates theapical impulse.

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Palpates for trachea, checks for tracheal tug if

indicated and notes the findings.7. Palpates for any tenderness on the front of the chest

and feels for epigastric pulsations.8. Palpates the apex beat and locates it. Notes down

it character.9. Checks and comments on the movements of the chest

and compares it during inspiration and expiration.10. Checks and compares movements at apices, infra-

clavicular areas and upper interscapular areas.11. Checks for vocal fremitus and compares on both sides

noting whether increased or decreased or absent.12. Palpates in various intercostal spaces for any

tenderness. Mention the lateral aspect of the chest:-13. Asks the patient to sit up on a chair or at the edge

of the bed with his legs hanging down and armscrossed in front of the chest and hands placed onopposite shoulders.

14. Goes on to the back of the patient.15. Does the same steps as mentioned above on the back

of the patient.16. Also palpates lightly the spine for any tenderness.17. Palpates with the same method on the lateral aspects

as well.18. Helps the patient redressing.19. Thanks the patient for his cooperation.20. Comments on the findings of his examination while



PEARLS

a. Ulnar border of hand is most sensitive therefore it iscommonly used to feel for vocal fremitus.

b. Compare three levels anteriorly, one or two laterallyand three posteriorly.

Percuss the Chest (See also Principles of Percussionon Page 68)

To do this examination, it is advised to make the patientsit up on a stool or edge of the bed. If the patient is lyingon the mattress, it may lead to damping effect resultingin difficulty in eliciting this examination.

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Starts from the apices.7. Percusses the clavicles either directly or stretches the

skin over the clavicles with index and ring fingersof his left hand (if right handed and vice versa) oneach side in parallel to clavicle and uses them aspleximeter including clavicle so that area above,behind and below clavicle is percussed with theplexor of the right hand.

8. Percusses following the principles of percussion(already discussed) and compares both sides on thefront.


9. Percusses the upper border of the liver.10. Asks the patient to put his hands over his head and

percusses the lateral chest walls including axillae andcompares them.

11. Repeats the same procedure on the back of the chestbut asking the patient to put his hands on theopposite shoulders with arms crossed in front of hischest.Repeats the same procedure for lateral sides of thechest after asking the patient to put his hands overhis head.

12. Percusses the spine to elicit any tenderness.13. Helps the patient redressing.14. Thanks the patient for his cooperation.15. Comments on the findings of his examination while


PEARLS

a. Candidate should know types of different resonancesi.e., tympanitic, resonant, hyper-resonant, impaired,dull, stony dull, cracked pot (cavity with a patentbronchus) and bell tympani.

b. The normal lower limits of the lung in mid-inspirationare the sixth space in the mid-claivcular, eighth spacein mid-axillary and tenth space in mid-scapular line.

Check for Liver Dullness (Upper border)(Explain the procedure to the patient)

The Candidate



modesty.


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Percusses the right cardiac border first by percussing

in parallel to the border.7. Percusses downward spacewise from the right second

intercostal space in the mid clavicular line.8. Keeps the finger parallel to the lower edge of the lung.9. Continues downwards until the liver dullness is

observed. (This is the upper border of the liver)10. Localizes the upper border of the liver by counting

the inter costal spaces starting from 2nd intercostalspace (in reference with the angle of Louis)

11. Defines the liver dullness in mid-clavicular, mid-axillary and mid-scapular lines.

12. Helps the patient re-dressing.13. Thanks the patient for his cooperation.14. Comments on the findings of his examination while


PEARLS

A huge cardiomegaly can give the impression that theupper border of the liver is quite high. Therefore,cardiomegaly should be ruled out first.

Auscultate the Chest (See also Principles ofAuscultation on Page 69)

The Candidate



modesty.4. Makes sure the light is adequate and natural.


5. Does a general survey of the patient.6. Makes the patient in sitting position.7. Asks the patient to keep on taking deep breaths in

and out regularly.8. Uses diaphragm of the chest piece of the stethoscope.9. Auscultates all areas of the lung on the front, back

and lateral sides of the chest.10. Compares the auscultatory findings simultaneously.11. Auscultates if necessary after making the patient

cough.12. Auscultates for vocal resonance having instructed the

patient to say “123” or “99”.13. Compares vocal resonance on corresponding areas.14. Helps the patient re-dressing.15. Thanks the patient for his cooperation.16. Comments on the findings of this examination while


PEARLS

a. Normal breathing is vesicular, other types are bronchialbreathing which may be tubular, cavernous oramphoric or it may be bronchovesicular breathing.Candidates should be able to pick them up duringauscultation.

b. Other sounds are called adventitious sounds e.g.,wheezing which may be fixed, monophonic,polyphonic, sibilant, and sonorous (depending on thesize of the airway constricted). Others include crackles(fine or coarse) and pleural rub.

c. In normal vocal resonance, sound appears to beproduced at the chest piece. If sounds are producednear the ear, it indicates increased vocal resonance.In bronchophony, sounds appear to be produced atthe ear piece. In whispering pectoriloquy even the low


intensity spoken sounds are clearly heard right in theears of the examiner. In aeogophony the sounds havea nasal quality due to high pitch.

Check for the Tracheal Tug

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient sit up.7. Approaches from the front.8. Raises the chin of the patient straight up.9. Puts first three fingers of the right hand (vice versa

if left handed) together (index, ring, and middle)vertically over the supra-sternal notch.

10. Asks the patient to breathe in.11. Notes the movement of trachea during inspiration.12. Feels for the cricoid cartilage.13. Notes the findings.14. Helps the patient re-dressing if necessary.15. Thanks the patient for his cooperation.16. Comments on the findings of his examination while


PEARLS

a. Tracheal tug is felt in case of pulmonary fibrosis. Itis also felt in cases of aortic arch aneurysms.

b. In case of aortic arch aneurysm, one feels a downward“tug” for each heart beat.


Check for Tracheal Position

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie down supine.7. Puts his index finger on the right sternoclavicular

joint and ring finger on the left sternoclavicular joint.8. Feels the trachea with middle finger and notes its

position.9. Helps redressing the patient.

10. Thanks for his cooperation.11. Comments on the findings.

PEARLS

In one finger method, the patient is supine and thecandidate uses his index finger sliding through the supra-sternal notch and feels for trachea and comments on thefindings.

Percuss for Ellis’s Curve (See also Principles ofPercussion on Page 68)

The Candidate



modesty.


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient in sitting position.7. Percusses the upper level of pleural effusion

anteriorly placing patient’s upper limbs by his side.8. Asks the patient to raise his hands over his head

and percusses the upper level of effusion laterally.9. Asks the patient to put his hands on opposite

shoulders crossing his limbs on the front of chestand percusses the upper level of effusion posteriorlyor on the back.

10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on the findings of his examination while


PEARLSa. In moderate pleural effusion, the upper level of effusion

is higher in the axillary area due to capillary actionof the pleural surfaces and it forms a curve withconcavity upwards called Ellis’s curve on a chestX-ray.

b. If the level is same on the front side and back of thechest with hyper-resonant area above, this indicateshydropneumothorax.

Elicit Succussion Splash

The Candidate



modesty.


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient sit up on the bed.7. Stabilizes the opposite shoulder of the patient.8. Shakes the ipsi-lateral shoulder strongly.9. Listens on the same side for succussion splash with

stethoscope.10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on the findings of his examination while


PEARLS

a. Another method for eliciting succession splash is tomake the patient lie down in left decubitus postureand shake the right side and listens for splash on thesame side with stethoscope

b. It is heard if there is a large pneumothorax withmoderate amount of fluid.

N.B.: This part of examination is rarely asked to do now-a-days!

Examine for Diaphragmatic Palsy

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient sit up.


7. Percusses the chest posteriorly from above.8. Asks the patient to take a deep breath and hold it.9. Percusses again to determine the lower level of

percussion (this indicates lower border of the lung).10. Asks the patient to exhale fully and hold the breath

in full expiration.11. Determines the lower level of percussion (in full

expiration).12. Examines and compare both sides.13. Helps the patient redressing.14. Thanks the patient for his cooperation.15. Comments on the findings of his examination while


PEARLS

a. The movements are absent in diaphragmatic paralysison that particular side. Normal gap should be about2 intercostal spaces but in palsy it is absent. Themovements are reduced in pleural and pulmonarydiseases.

b. Another method is a bit simple, involves patient to bein supine position. The palm of one hand is placedon the lower inter costal space and the other hand isplaced over the abdominal wall on the same side belowthe sub costal margin. Ask the patient to breathe inand out normally. Normally during inspiration bothhands move upwards where as in diaphragmatic palsythe hand placed on abdomen will move downwardscalled paradoxical movement.

c. A third method involves the patient to lie down supinewith light coming from window, the examiner facesthe patients. The arms are placed under the head ofthe patient. The examiner inspects the seventh to tenthribs in the mid axillary line and looks for movement


of rib shadows which moves either up or down andexamines and compares both sides. The diaphragm isattached from 7th to 10th rib. If the diaphragm isparalyzed the movement of shadows is absent.

d. Right diaphragm is slightly above the left (approxi-mately 2.5 cm).

Check for Spinal Tenderness (See also Principles ofPercussion of Page 68)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient sit on a stool or a couch.7. Palpates the cervical, upper thoracic, lower thoracic

and lumbar spinous processes separately pressingwith his right thumb.

8. Percusses lightly on these spinous process forevidence of tenderness with four fingers joinedtogether. (This is called light percussion)

9. Makes a fist and with the ulnar border percusses fromupper thoracic area to lumbar region.

10. Places the palm of left hand over the spine and withthe ulnar border of the of right hand, taps stronglythe dorsum of the left hand and moves from abovedown to the lumbar area. (This is called heavypercussion).

11. Notes the findings.12. Helps the patient redressing.


13. Thanks the patient for his cooperation.14. Comments on the findings of his examination while


PEARLS

Spinal tenderness may be due to some infective, traumaticor malignant process.

Do the Coin Test

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Instructs the patient properly about the procedure.7. Makes the patient sit up.8. Places firmly one coin flat on the anterior part of the

right or left chest.9. Percusses the coin with an another coin (for step 8-

9 examiner needs assistance)10. Listens on the back with the diaphragm of the

stethoscope on the same side.11. Notes the findings.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on the findings of his examination while



PEARLS

a. The coin test is positive if high-pitched ringing soundsare heard along with each percussion step. The testis negative if low-pitched butting sound is heard.

b. The sites for percussion and auscultation can bechanged. But make sure it is over a hyper resonantarea. Coin and diaphragm of the stethoscope shouldbe as away as possible.

c. This test is performed in pneumothorax and hydro-pneumothorax when there is free air in the pleuralcavity.

d. You can note that it is a combination of percussionand auscultation simultaneously, therefore, you needan assistant to place the coin on the chest wall andpercuss it with another coin for you.

CHAPTER 7

Examination ofCardiovascular

System


This system is discussed under four headings as follows:1. Principles of examination of cardiovascular system2. Examination of the cardiovascular system as a whole

(for long case)3. Schematic out line of cardiovascular system4. Common commands in cardiovascular system (for

short cases).

PRINCIPLES OF EXAMINATION OFCARDIOVASCULAR SYSTEM

Before starting one should know briefly the surfacemarkings of the heart and certain principles of theexamination of the cardiovascular system. These principlesinclude inspection, palpation, percussion and auscultation.

Principles

The examination of the cardiovascular system (CVS) startswith the basic knowledge of surface anatomy of the heartand great vessels. For the purpose of examination, the CVSis subdivided into two:1. Peripheral cardiovascular system (CVS)2. Central cardiovascular system (CVS)

A detailed cardiac history is mandatory before goingover to the examination of the system.

A methodical approach is advised with inspection ofthe patient with particular stress on any deformity of thechest, on the JVP, the radial pulse, the carotid pulse andother pulsations in the precordium. Then palpation of theapex beat and auscultation of all the four areas and otherswhere indicated. Percussion is not done very frequentlyin cardiovascular system examination. Auscultation of thelungs and bases and its percussion along with theexamination of peripheral pulses including carotid orfemoral bruits is important and should not be overlooked.

95EXAMINATION OF CARDIOVASCULAR SYSTEM


Expose the patient properly and then give a generalpanoramic view of the patient and note down any strikingabnormality.

Chest deformity is easily picked up in the form of pectusexcavatum or carinatum. Look for any visible precordialpulsations. Inspect the apex beat at a tangent from theleft side and the JVP while the patient is lying in the bedwith the head raised at an angle of 45° from the rightside. If apex beat is not seen, state that “the apex beatis not seen.” Look closely for any collateral blood vesselsover the chest wall in the front, back and lateral sidesof the chest. Look carefully at the pulmonary, aortic, leftparasternal, epigastric, suprasternal notch and carotidareas. Inspect for pallor, cyanosis, rashes, clubbing andsplinter haemorrhages in the nails, Janeway lesions andOsler’s nodes in the hands over the palms and finger pulpsrespectively. Also look for oedema which will be visibleas shiny, stretched skin of lower limbs.


Palpation of CVS starts from the pulses especially theradial pulse and its characteristics are noted down i.e.,rate, rhythm, volume, character, arterial wall condition,comparison with other radial pulse and the radio femoraldelay is noted. (It is discussed under examination of thepulses in more detail). Next important step is themeasurement of the blood pressure in both supine anderect posture. (It is discussed in detail under theexamination of blood pressure). Then palpate for the apicalimpulse inferolateral to the anterior chest wall in themidcalvicular line on the left side of the chest and pointout exact location of the apex with the pulp or tip of your


index finger making a perpendicular. To locate its exactposition, count down from the left midclavicular area,intercostal space wise and note down exact location ofthe apex beat. You can also relate its location in referenceto anterior axillary or mid axillary line. During palpation,look for character of the impulse and note down whethertapping or heaving by lying patient on left lateral position.Feel for any thuds, heaves or thrills at different areas ofthe precordium. Feel also for metallic sounds in case ofartificial heart valves. Also check for poedal or sacraloedema by pressing firmly with thumb for at least 15-30seconds and note any pitting oedema over there.

Principles of Percussion

This part of the examination is usually not performed asa routine but by percussing the various borders of the heartin their line may indicate enlargement of the cardiac size.

However, it is sometimes necessary to percuss rightborder of heart before percussing upper border of the liver.Comment and describe dullness in different areas.

Left border is percussed in supine position afterlocalization of the apex beat. Start percussing one inter-costal space above and about 1-2 cm lateral to the apexbeat and proceed medially till the site of impairedpercussion note is noted and mark with a skin pencil,and proceed space wise and mark again. A line joiningthese points of the heart will indicate left border.

Right border is in 3rd and 4th intercostal spaces onthe right side of the chest extending just lateral to the rightborder of the sternum (not more than 1cm). First locatethe upper border of the liver (described alreadyunder respiratory system) and then start percussion at themid-clavicular line, one space above the liver surface


towards the medial side. Normal liver dullness is in the5th intercostal space in mid clavicular line. If it is extendingat 4th intercostal space then cardiac border can beidentified in the 3rd intercostal space and if upper borderof liver is in the 3rd intercostal space then one cannotidentify the right cardiac border by the method ofpercussion.

If liver is pushed down i.e., in the 8th intercostal space,one needs not to percuss the cardiac border in the 7thspace. Percussion should be done in the usual space i.e.,4th and 3rd intercostal spaces.

Upper border of heart is in 3rd intercostal space nearthe sternum and the dullness is masked by the lungresonance.

Sternum is percussed by direct method.

Principles of Auscultation

The vicinity should be quiet and it should be timed withthe carotids. This aspect of examination makes the actualbackbone of the CVS examination. This also requires alot of practice to become tuned to various sounds producedat the precordium by various pathologies of the valvesmyocardium and pericardium.

(Please read the section on the use of the stethoscopeon page 69.)

Follow a set pattern for auscultation and during thissimultaneously palpate carotid for timing the sounds andmurmurs at the apex, the epigastric, the pulmonary andthe aortic areas or in the reverse order.

Auscultate in all the areas of pre-cordium (4 areas)and listen for 1st heart sound at mitral area and tricuspidarea and second heart sound at the pulmonic and aorticarea and note down intensity in terms of normal, muffled


or loud. Note particularly any opening snap and for thispurpose, use the diaphragm of the stethoscope and tiltthe patient towards his left side if indicated. You shouldpractice to listen to 3rd and 4th heart sounds and commenton their presence or absence.

Listen carefully for murmurs at mitral, aortic,pulmonary and tricuspid area and note down its relationto cardiac cycle whether systolic, diastolic, the site it isbest heard, and make position of the patient for betterhearing if you have to do so. You should know whichmurmur is heard better with either diaphragm or belldepending upon its pitch. Note also the relationship ofthe murmurs with respiration i.e., inspiration orexpiration. Note the high or low pitched murmurs andsite of radiation in the surrounding area.

Listen carefully for any pericardial rub and instructthe patient accordingly to hold breath when it is heardboth during systole and diastole.

Listen for the bruit at carotid area and also over thescapulae in case of coarctation of aorta.

PEARLS

a. Bell is used for low-pitched sounds of mid diastolicmurmur of mitral stenosis or the third heat sound ofcardiac failure. Diaphragm is ideal for second heartsound, for ejection and mid systolic clicks and soft highpitched early diastolic murmur of aortic regurgitation.

b. For auscultation, start from apex (i) then left lowersternal edge (ii) then left upper sternal edge (iii) andthen right upper sternal edge (iv). These locationscorrespond with the mitral, tricuspid, pulmonary andaortic areas respectively.


c. 4th heart sound occurs late in the diastole. When 3rdheart sound is also present they give a “gallop” to thecardiac rhythm. Both are best heard with bell at cardiacapex.

d. Listen over the base of the lungs for crackles and forthe evidence of cardiac failure.

e. If tricuspid regurgitation is suspected palpate the liverfor pulsatility.

f. Also elicit hepato-jugular reflux.g. Ask for valsalva manoeuvre for changing character or

intensity of the murmurs.

PEARLS

Grading of the MurmursGrade I: Just audible with the stethoscope in quiet

roomGrade II: Quite readily audible with stethoscopeGrade III: Easily heard with stethoscopeGrade IV: Loud obvious murmurGrade V: Very loud, not only on the precordium but

elsewhere in the body.

Other system of grading is as follows:Grade I: Heard only with special manoeuvresGrade II: Faintly heardGrade III: Well-heard but without thrillGrade IV: Well-heard but thrill is presentGrade V: LoudGrade VI: Very loud, heard with a stethoscope where

chest piece is held a few millimetres awayfrom the chest wall.


Dynamic Auscultation

In this certain manoeuvres are made to intensify themurmur. They are useful to hear a murmur which is oflow intensity. These manoeuvres include sustained handgrip, transient arterial occlusion which usually increasethe murmurs of mitral and aortic regurgitation, squattingwhich increases intensity of most of the murmurs, valsalvamanoeuvre and standing which decrease intensity of mostmurmurs except mitral valve prolapse and hypertrophicobstructive cardiomyopathy (HOCM). Nitrates increase theintensity of murmur of aortic stenosis.

First heart sound is best heard at apex. Second heartsound is best heard at the base.

For murmurs, comment as follows:1. Systolic or diastolic2. Grading of the murmurs (I-VI see above)3. Pitch of the murmur4. Shape of the murmur5. Area best heard6. Area of selective conduction7. Dynamic auscultation

Do not limit auscultation at 4 areas of valvesrespectively but proceed towards the left axilla from mitralarea, to the epigastric region from the tricuspid area, tothe left 1st intercostal space from the pulmonary area, tothe right 3rd and 4th intercostal spaces from the aorticarea and also to the carotid arteries for radiation.

These accessory areas can act as gold mine ofinformation when main area may appear silent. Somecardiac murmurs may be heard up to the occiput or tothe coccyx.

Murmurs originating on the right side of heart are betterheard during inspiration and murmurs on left side of theheart are better heard during expiration.


Ask the patient to breathe normally as if patientbreathes deeply, the distance between chest wall and heartincreases, therefore intensity of the murmur may decreasegiving wrong impression.

Valsalva manoeuvre is performed by asking the patientto blow hard on the back of his or her hand or forearmwithout releasing air. It usually changes the murmurs ofHOCM and mitral valve prolapse.


STEP BY STEP EXAMINATION OFCARDIOVASCULAR SYSTEM (FOR LONG CASE)

The Candidate




by asking questions such as name, date of birth,address, recognition of people around etc.

5. Positions him at 45° in the bed.6. Starts with the examination of the hands and looks

at nails.7. Looks for capillary pulsations [presses the tip of nail]8. Looks for clubbing at tangent and tests for fluctuation

at the nail bed.9. Palpates the finger pulps for any tender nodules.

10. For checking the radial pulse, makes proper position[semi-prone forearm with and wrist slightly flexedand counts for at least 30 seconds. Notes the effectof deep inspiration, and lifts the arm with supportfor checking collapsing pulse.

11. Compares the two radial pulses simultaneously.12. Checks for radio-femoral delay13. Examines the face for any associated clues i.e.,

Cushingoid, polycythaemic and mitral facies etc.,depresses lower eyelids, looks inside oral cavity withtorch and tongue depressor, and asks for protrusionof the tongue.

14. Inspects the JVP at 450 and asks the patient to takedeep breaths. Inspects carotids for any abnormalpulsations

15. Palpates the carotids one at each time.


16. Elicits hepato-jugular reflux.17. Inspects the chest for any asymmetry. [from feet]18. Inspects the apex beat. [with his eyes at a tangent

to the chest level]19. Inspects abnormal abdominal pulsations.20. Palpates the chest at apex, left parasternal area and

base of the heart.21. Auscultates while palpating the carotid artery (at the

start).22. Auscultates mitral area with diaphragm and bell in

supine position.23. Turns the patient to the left and palpates for the apex

beat and clearly instructs him on how to hold hisbreath in complete expiration.

24. Auscultates mitral area with bell of the stethoscopein this position with breath held in expiration andasks patient to resume breathing immediatelyafterwards.

25. Auscultates tricuspid area with the diaphragm andbell of the stethoscope in supine position and notesthe effects of respiration.

26. Auscultates pulmonary and both aortic areas withthe diaphragm in supine position and notes theeffects of respiration.

27. Sits the patient up and clearly instructs him on howto hold his breath after complete expiration whileleaning forward.

28. Auscultates the base of the heart with diaphragm inthis position and asks the patient to resume breathingimmediately afterwards.

29. Auscultates over carotids and left sternal border.30. Auscultates over other areas if indicated (for any

radiation).31. Auscultates the lung bases.


32. Checks for sacral oedema.33. Makes the patient stand up and notes effect of exercise

if indicated (dyspnoea, chest pain and disappearanceof VPBs)

34. Notes down any postural drop in blood pressure.35. Makes the patient lie down and palpates the liver.36. Palpates the spleen [if indicated]37. Examines the legs for ankle oedema, calf tenderness,

and leg pulses.38. Performs fundoscopy (if required)39. Thanks the patient for his cooperation and asks him

to dress-up and helps him if necessary.40. Notes down all the findings and comments while


CASE WRITING TIPS

Peripheral CVS1. Radial pulse:

• Rate• Rhythm• Volume• Character• Condition of arterial wall• Comparison of volume• Radio-femoral delay

2. Other peripheral pulses3. Blood pressure:

• Lying• Standing.

4. Signs of CCF:• Raised JVP• Tender hepatomegaly• Bibasal crackles• Poedal oedema


5. Miscellaneous:• Clubbing• Cyanosis• Pallor.

Central CVS1. Inspection:

• Shape of precordium• Apex beat• Pulsation in other areas

a. Pulmonaryb. Parasternalc. Aorticd. Necke. Epigastricf. JVP

2. Palpation:i. Apex beat localization

ii. Pulsation in following areas• Pulmonary• Parasternal• Aortic

iii. Thrills:• Mitral• Aortic• Carotid artery• Pulmonary• Parasternal

iv. Palpates liver for hepatojugular reflux,v. Feels for pulsatile liver

vi. Palpates for oedema.3. Percussion:

i. Cardiac borders:• Left• Right• Upper (base).


ii. Superficial cardiac dullnessiii. Pulmonary areaiv. Sternum

• Upper part• Lower part.

v. Aortic area4. Auscultation:

i. Heart sounds:• Mitral area M1• Pulmonary area P2• Aortic area A2• Tricuspid area M1• Opening snap

ii. Murmurs:• Mitral area• Aortic area• Bruit over carotids• Pulmonary area• Tricuspid area• Parasternal area

iii. Pericardial rubiv. Listening to the base of lungs.


COMMON COMMANDS1. Look for the JVP2. Inspect the precordium3. Palpate the precordium4. Auscultate the precordium5. Auscultate the apical area (Mitral area)6. Auscultate the base of the heart (Aortic and pulmonary

areas)7. Auscultate aortic area and palpate the apex beat8. Look for signs of cardiac failure.

Look at the Jugular Venous Pressure (JVP) orExamine the JVP

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie in the bed at an angle of 45°

between his trunk and hip.7. Supports the neck on a pillow to relax the muscles

of the neck.8. Turns the face slightly to the opposite side to avoid

shadow of the lower jaw.9. Looks at internal jugular vein tangentially.

10. Maintains patient’s trunk and neck in one line.(donot tilt the neck forward)

11. Puts one scale at the sternal angle perpendicular tothe bed.


12. Puts another scale from the highest point of JVPparallel to the bed to meet the vertical scale.

13. Measures the height of the vertical scale from thesternum. Thus indicating the JVP in centimetres ofwater.

14. Checks the disappearance of pulse wave form bypressing lightly at the base of the neck.

15. Performs hepatojugular reflux.16. Helps the patient redressing.17. Thanks the patient for his cooperation.18. Comments on the findings of this examination while


PEARLS

a. Candidate should know the causes of raised JVP.b. The junction of the distended and the collapsed vein

is the upper level of the JVP.c. The wave occurring just before carotid pulse is ‘a’ wave

and that occurs with down stroke of carotid pulse is‘v’ wave.

d. The jugular veins are in direct communication withthe right atrium, they act as manometer to reflect thepressure changes of the right atrium.

e. Kussmaul’s sign is the rise of JVP during inspiration(normally it should fall) and usually occurs inconstrictive pericarditis or cardiac temponade. i. ‘a’ is produced by atrial systole. (Ascent)ii. ‘c’ is produced by tricuspid valve ring closure

(Descent)iii. ‘x’ is produced by lowering of tricuspid valve

(Descent)iv. ‘v’ is produced by rising atrial pressure due to

tricuspid valve closure. (Ascent)


v. ‘y’ is produced by opening of tricuspid valveresulting in lowering of pressure (Descent)

Inspect the Precordium (See also Principles ofInspection on Pages 66 and 95)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie supine in the bed (Makes him

sit if orthopnoeic).7. Looks for any bulge over the precordium tangentially

from the side and from the foot end of the bed.8. Looks for any scar of previous valvotomy or

sternotomy or vessels by closely observing it.9. Localizes the apex beat.

10. Looks for pericardial pulsations in the suprasternal,sternal, aortic, parasternal, inter costal and epigastricareas.

11. Looks for any chest deformities i.e., kyphosis, scoliosis,pectus excavatum, pectus carinatum, barrel shapedchest etc.

12. Comments about JVP if there is some spare time.13. Helps the patient redressing.14. Thanks the patient for his cooperation.15. Comments on the findings of this examination while



PEARLSAll you can do it without touching the patient, thereforea close look is required, so that not much is over looked.

Palpate the Precordium (See also Principles ofPalpation on Pages 67 and 95)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Looks for the apex beat.7. Warms his hands, places the right hand on the left

precordium.8. Locates the apex beat by using ulnar part of the palm

of the right hand preferably finger placed in line withthe intercostal space (In females lifts the breast)

9. Localizes the exact position (maximum impact) of theapex beat with the tip of index finger placed vertically.(In reference to mid clavicular line and intercostalspace).

10. Assesses the character of apex beat by asking thepatient to turn to left slightly.

11. Times with the carotid artery for any paradoxicalimpulse of apex beat.

12. Uses 3 fingers (for 2nd, 3rd and 4th in each ICSrespectively to detect mild heave near the borders ofthe sternum.

13. Uses ulnar border of his right hand placing parallelto the border of the sternum for evident heave.


14. Feels for any palpable heart sounds and thrills.15. Feels for any palpable pulsations in the epigastrium

or supra sternal notch16. Palpates the pulse if time permits.17. Helps the patient redressing.18. Thanks the patient for his cooperation.19. Comments on site, character of apex beat, palpable

sounds or thrills or any parasternal heave orepigastric or suprasternal pulsations.

PEARLSa. First inspect the apex and then palpate the point of

maximum impact.b. If it is difficult then look for it in sitting position

making the patient to hold breath in expiration orinspiration.

c. In left lateral position, apex beat shifts about 2-3 cmlaterally and comes closer to the chest wall. If breathis held in expiration the apex beat is felt well as thismanoeuvre reduces the volume of lung over layingthe heart.

d. For palpating thrills, the palm is used as it is moresensitive and for assessing movements, fingers arebetter option.

e. Normal apex beat lasts for a very short time (< 1/3 of systole) in an area of 1 cm in diameter. Hyper-dynamic apex beat lasts < 2/3 of systole, in area >3 cm diameter).

f. Heaving apex beat lasts more than 2/3 of systole andin an area < 2.5 cm diameter.

g. As regards “precordial impulse”, it should not beconfused with apical impulse.

h. In right ventricular heave, parasternal area shows anoutwards and upwards thrust. In left ventricularheave, the thrust is outwards and laterally.


i. In case of both left and right ventricular impulses,both apex and parasternal areas show a thrustoutwards.

j. A double apex beat is usually due to left ventricularaneurysm.

k. Thrills can occur both in systole or diastole.

Percuss the Heart (See also Principles of Percussionon Pages 68 and 96)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to hold his hands over his head.7. Percusses first the upper border of the liver.8. Holds pleximeter parallel to border of the heart to

be percussed.9. Percusses from resonant to dull area.

10. Percusses and defines the right border, the left borderand the base of the heart (great vessels i.e., aortic andpulmonary areas)

11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on his findings while presenting to the

examiner.


PEARLS

In a thin person, directly percussing the intercostal spaceshelp out lining the borders of the heart easily.

Auscultate the Precordium (See also Principles ofAuscultation on Pages 69 and 97)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Localizes the apex beat by inspection and palpation.7. Places bell of the stethoscope at the apex.8. Puts his left thumb over the right carotid for timing

of the sounds (makes sure to do this when everauscultating any area of the heart for timing).

9. Turns the patient to the left position a little and listensto the apical area.

10. Asks the patient to hold his breath in expiration toclearly listen for the opening snap or a murmur ofmitral stenosis.

11. Listens up to the axilla if there is any radiation ofthe murmur i.e., mitral regurgitation.

12. Listens at tricuspid area by inching method.13. Performs dynamic auscultation if necessary.14. Listens at aortic area by asking the patient to hold

his breath in full expiration while leaning forwards.15. Auscultates the carotids for radiation of the murmur.16. Listens at the pulmonic areas and asking the patient

to hold his breath in inspiration or expiration to assesssplitting of the second heart sound.


17. Listens at both parasternal areas for any addedsounds.

18. If in doubt, also listens at the scapulae for a machinerymurmur (coarctation of aorta)


examiner.

PEARLS

a. All the sounds and murmurs should be timed bysimultaneously palpating the right carotid.

b. Always comment on intensity of the heart sounds, typeof murmur, timing with the cardiac cycle and itsintensity (grading I-VI)

c. One should be able to perform dynamic auscultation,if required.

d. One should be well aware of the use of stethoscope(see general section page 69).

e. One should be well aware of the surface anatomy ofthe heart and the location of different valves.

f. One should not limit auscultation to only four cardiacvalvular areas but should proceed to axilla, epigastric,intercostal spaces and even on the back at interscapularregion.

g. The candidate should know what to listen at each areaas regards sounds, murmurs and other sounds at eacharea.

h. Do not forget to listen to a pericardial rub whilelistening over the whole precordium and asking thepatient to hold his breath in expiration to make it clear.

i. The candidate should know where to use the bell andwhere to use the diaphragm of the stethoscope.


Auscultate the Heart for Gallop (See Principles ofAuscultation on Page 97)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. While the patient is lying in supine position, localizes

the apex beat.7. Places the bell of the stethoscope at the apex and

tricuspid area.8. Makes the patient tilt to left lateral position with breath

held in expiration.9. Listens to 3rd and 4th heart sound.

10. Times the sounds with his thumb on the right carotids.11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on his findings while presenting to the

examiner.

PEARLS

a. S3, S4 are low pitched sounds, therefore heard with thebell.

b. Auscultate mitral area for left sided gallop.c. Auscultate tricuspid area for right sided gallop.d. Gallop sounds are better heard in supine left lateral

position, with raising legs or compressing the abdomen,during expiration and after exercise (Almost all threemanoeuvres increase the venous return to the heartthus making these sounds a bit more prominent.


e. S1, S2, S3 sounds like running of a horse and this iscalled “gallop” rhythm. It is also called S3 gallop orproto-diastolic gallop.

f. S1, S2, S4 is called S4-gallop or presystolic gallop.g. S1, S2, S3, S4 is called quadruple rhythm.h. If S1, S2, are fused and S3 and S4 are separately heard,

it is called summation gallop.i. S3 occurs in normal and hyperdynamic heart states and

is called physiological. It occurs due to rapid fillingof the ventricles during early phase of diastole. In thepresence of cardiac failure, it is called pathological.

j. S4 occurs late in diastole following AV valve openingand contraction of atria. S4 may be physiological in theelderly (>50 years) but most of the time it is pathologicalwhen the left ventricular compliance is reduced.

k. Clicks are audible only, if the valve cusps are pliantand noncalcified and are more prominent incongenitally bicuspid valves (clicks produced by mitralvalve prolapse).

l. Snaps are produced by forcible opening of thethickened valve leaflets (e.g., opening snap of mitralstenosis).

m. The candidate should be able to comment correctly onejection systolic, pansystolic, late-systolic, earlydiastolic, middiastolic and presystolic murmurs withaccentuation and continuous murmurs.

n. The candidate should also be able to comment correctlyon the findings of mitral stenosis, mitral regurgitation,mitral valve prolapse, aortic stenosis, aorticregurgitation and pulmonary stenosis, pulmonaryregurgitation, ventricular septal defect (VSD), atrialseptal defect (ASD), co-arctation of aorta and patentductus arteriosus.


o. The candidate should be able to pick up auscultatoryfindings of the pathology of two valves simultaneouslyand this needs a lot of practice of auscultation.

p. The candidate should know how to elicit pulsatile liverand hepatojugular reflux in tricuspid regurgitation.

q. Always listen to the base of the lungs and feel forperipheral oedema at the end of cardiac examination.

Look for Aortic Regurgitation

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Locates the apex beat.7. Listens to it carefully.8. Listens at the aortic area.9. Times the murmur of aortic regurgitation or aortic

stenosis by placing left thumb over the right carotid.10. Makes the patient sit and lean forward.11. Instructs him to inhale, then exhale fully and hold

his breath in full expiration.12. Listens for early diastolic murmur of aortic

regurgitation at the left lower parasternal area withdiaphragm of the stethoscope.

13. Looks for other signs of aortic regurgitation as follows.14. Checks for the collapsing pulse (see examination of

the pulse on page 49).15. Looks at the carotids for Corrigan’s sign.16. Looks at the head for nodding called the Demusset’s

sign.


17. Looks at the uvula for pulsation called the Muller’ssign.

18. Looks for the alternate capillary pulsations at the insideof the lips and capillary bed of the nails by pressinglightly with a glass slide called the Quinke’s sign.

19. Listens at femoral arteries for pistol shot sounds.20. Presses the femoral artery with the distal edge of the

diaphragm of the stethoscope lightly to listen adiastolic murmur and presses the proximal edge ofthe diaphragm of the stethoscope to listen a systolicmurmur called Durozie’s murmur.

21. Measures BP in lower limbs (If the difference is morethan 40 mm Hg in lower limbs and upper limb thenit is called Hill’s sign).

22. Performs fundoscopy to see pulsations of the retinalvessels in aortic regurgitation.


examiner.

Palpate for the Apex Beat (See also thePrinciples of Palpation on Pages 67 and 95)

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Inspects the pre-cordium for apical impulse and a

gets a rough idea of its location in supine position.7. Places the palm of the right hand at the precordium

over the left nipple.


8. In case of females, elevates the left breast and placeshis right hand.

9. Feels for the impact of the apical impulse.10. Tilts the patient slightly on the left side if feels

difficulty in locating the apex beat.11. Notes down its location in relation to mid-sternal,

mid-clavicular or mid-axillary line by the pulp of hisindex finger placed perpendicularly over the impulseof the apex beat.

12. Counts for the intercostal space where this is located.13. Notes down its character i.e. tapping, heaving, forcible,

double impact etc.14. Helps the patient redressing.15. Thanks the patient for his cooperation.16. Comments on his findings while presenting to the

examiner.

PEARLSOne should master the methods for palpation, localizationand character of the apex beat.

Look for the Signs of Cardiac Failure

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie down at an angle of 45° with

the lower limbs.7. Keeps the head, neck and upper trunk in line.


8. Asks the patient to slightly turn his head towardsthe left side.

9. Looks at the JVP.10. Presses lightly over the lower part of the neck to see

the filling or any wave form.11. Measures the level of JVP with standard method if

raised.12. Percusses the upper border of the liver.13. Palpates the lower border of the liver.14. Comments on the size, surface, edge, any tenderness

or pulsations of the liver.15. Does a hepato-jugular reflux if indicated.16. Checks for poedal oedema (pitting).17. Listens to the base of both lungs for crackles.18. Checks for sacral oedema while the patient is sitting

up.19. Helps the patient redressing.20. Thanks the patient for his cooperation.21. Comments on his findings while presenting to the

examiner.

Auscultate the Base of the Heart (See also Principlesof Auscultation on Page 97)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Localizes the apex beat.


7. Listens at aortic area for any systolic murmurs andtimes with carotid artery pulsation by placing his leftthumb over it.

8. Listens for radiation of the murmur to the carotidsby slowly moving upwards at the root of the neckin front and then over the carotids.

9. Listens at the pulmonary area for second heart soundor murmurs.

10. Asks the patient to take a deep breath and holds thebreath and listens for any splitting of the 2nd heartsound.

11. Does the same manoeuvre during expiration.12. Makes the patient sit up and asks him to lean

forwards.13. Asks him to breathe in fully then breathe out fully

and then hold the breath in full expiration.14. Listens for early diastolic murmur of aortic

regurgitation at the left lower para-sternal area.15. Asks the patient to breath normally.16. Helps the patient redressing.17. Thanks the patient for his cooperation.18. Comments on his findings while presenting to the

examiner.

PEARLS

By doing repeated practice, one should master the art ofauscultation and come up with the correct findings andthis is only possible by listening the hearts of as manypatients as possible.

CHAPTER 8

Examination ofGastrointestinal

System (Abdomen)


This system is discussed under four headings as follows:1. Principles of examination of gastrointestinal system.2. Examination of the gastrointestinal system as a whole

(for long cases).3. Schematic out line of gastrointestinal system.4. Common commands in gastrointestinal system (for

short cases).

PRINCIPLES OF EXAMINATION OFGASTROINTESTINAL SYSTEM

Before going on to that it is important to know that whenyou are asked to examine abdomen, then it should notbe taken purely as gastrointestinal tract but other organsare also examined e.g., spleen, kidneys, adrenal and anylymph nodes.

Abdomen is divided into nine (9) imaginary areas orquadrants by two vertical lines and two horizontal lines.The vertical lines are either from mid clavicular pointsperpendicularly downwards or from mid inguinal pointsvertically upwards. The first horizontal line touches thesubcostal margin i.e., tips of tenth costal cartilages. Thesecond horizontal line joins the highest points of the iliaccrests on both sides.

Thus the nine quadrants hence formed are called leftiliac fossa (LIF), left lumbar quadrant, left hypochondrium(LHC), epigastrium, umbilical area, hypogastrium, rightiliac fossa (RIF), right lumbar quadrant and righthypochondrium (RHC).

If the candidate is asked to examine alimentary systemthen he should start from mouth and end the examinationat the anal area but of course including the abdominalexamination. This includes the examination of handsfollowed by mouth, then conjunctivae and sclerae andultimately rest of the neck for any lymphadenopathy.

125EXAM. OF GASTROINTESTINAL SYSTEM (ABDOMEN)

In hands, nutritional status (wasting, guttering), canbe estimated and nails may give quite a bit of information.Palms can show Dupuytren’s contracture, palmarerythema or spider nevae. Other features to look for includeclubbing, pallor, koilonychia and leukonychia etc.

Mouth examination includes inspection and palpationincluding the lips, angle of mouth, number and state ofteeth, state of gums, tongue (see on page 61) and innerside of buccal mucosa, soft and hard palate and any otherabnormalities.

The four principles of examination of gastrointestinal systemapply as follows:1. Inspection of abdomen.2. Palpation of abdomen.3. Percussion of abdomen.4. Auscultation of abdomen.

PRINCIPLES OF INSPECTION IN ABDOMINALEXAMINATION

The patient lies flat with arms by his sides. The patientshould be exposed properly i.e., in males up to the nipplesand then to the pubic symphysis while taking in to carethe modesty. The candidate looks carefully at the abdomenfrom the sides and then from the foot end of the bed.Candidate makes a note of the shape of the abdomen i.e.,looks for generalized fullness or distension (5-F’s i.e., fluid,fat, faces, flatus or foetus), and localized distension. Heshould also note the position, shape and any otherabnormality of the umbilicus. He should inspect themovements of the abdominal wall and note its normalityor abnormality. He should also look for visible pulsationsin the epigastric and at umbilical region and also lookfor visible peristalses of the stomach or small bowl. He


should closely look at colour of the skin of abdomen, anystriae, distended or tortuous veins and scars. The candidateshould inspect groins, testicles and penis in the male andlook at pubic hair as well (it is advised to take permissionfrom the examiner for this part of inspection of thealimentary system). If you want to distinguish betweenthe intra-abdominal and abdominal wall swellings, askthe patient to raise the head without supporting it, theintra abdominal swelling will disappear, whereasswellings in the abdominal wall become more prominent.

Ask the patient to draw abdomen in and then belowout as much as possible. These movements willdemonstrate limitation of movements of the abdominalmuscles and may localize an area of pathology.

An imaginary line joining the anterior iliac spine andumbilicus is called spinoumbilical line. Shift of umbilicusis indicated by the inequality of these lines on both sides.

In the males the respiration is abdomino-thoracicwhere as in the females it is thoracoabdominal.

Look for recent wounds, dressings, fistulae, sinuses,stomas and old scars.

Ask the patient to cough and observe the abdominalwall for hernias i.e., inguinal or incisional and divaricationof the recti.

Look for any normal or abnormal bulge of theabdominal wall and it is more obvious if seen at a tangenti.e., at the level of the abdominal wall.

Lastly, ask the patient to point out any tender part inthe abdomen.

PRINCIPLES OF PALPATION OF ABDOMEN

The most of abdominal viscera are not palpable in theirnormal state. Patient should be in supine position and


abdomen should be relaxed. Both knees are flexed andboth hips are flexed and feet are relaxed as well (Someexaminers do not ask for it). The hands should be warmedby rubbing together if not already warm enough beforeyou put your hands on his abdomen. The patient is askedto point any tender areas in the abdomen before you placeyour hand on his abdomen so that the palpation shouldbe started away from that area. Indulge the patient inconversation to avert his/her attention for completerelaxation. Try to maintain palpating hand, wrist andelbow at the same level. Use the finger tips and palmeraspect (radial side) of the hands and try to use single handtechnique but some prefer to use both hands, then applypressure with the upper hand and try to feel with thelower hand.

Palpation can be superficial, deep, bimanual, ballotte-ment and by dipping method. In light palpation, you shoulduse pressure not moving deeper more than ¼ to ½ inches.The hand is moved with fingers together all over the abdomenstarting from left iliac, left lumbar, left hypo-chondrial thenepigastric, umbilical, hypo-gastric and then to right iliacfossa, right lumbar region and ends at right hypo-chondrium.It assumes a shape of an ‘S’ placed horizontally as “ S”.One should feel for the tone of the abdominal musclesand tenderness by looking continuously at patient’s facialexpression. You should look for any masses and theirmobility, local temperature, effect on cough impulse, theirreducibility and note any abnormality to look in more detailsduring deeper palpation.

The wrist and elbows should not move but thereshould be movement at metacarpophalangeal joints.

Avoid sudden poking with finger tips. Ask the patientto breathe in and then push your hand gently to feel theedge of any moving organ. In an obese patient or a very


muscular patient put left hand over the top of right handas mentioned before and then palpate accordingly.

It is important to note that the abdomen should berelaxed completely for a successful palpation.

A possible order for routine palpation is to startpalpation of liver at right hypochondrium, then move overto epigastric area, then left hypochondrium for spleen, thenmove down towards umbilicus then hypogastrium andthen into each iliac fossae. The lumbar region are left untillast as they are examined bimanually by putting left handbehind the area and right hand in front and both handspressing the structures in between i.e., right and left kidneyand ascending and descending colon in those areasrespectively.

It is emphasized that prior to all this procedure, oneshould be well aware of these underlying organs and theiranatomy.

During ballottement, the hands of the examiner arebeing placed for bimanual palpation, steady pressure isapplied with the right hand whereas a sudden push isapplied by the left hand with finger tips and if the masstouches anterior hand, it is said that ballottement ispresent. It is usually performed to palpate the kidneys andthe masses related to them.

In dipping method, the finger tips of one or both handsare brought together in the same line and are dipped intoabdomen with sudden jerk so as to displace the fluid(as in massive ascites) and to feel the underlying organ.By this method details are not known. You shouldsay that the mass or organ is not felt with even dippingmethod.

The palpation of individual organs is described indetail under the heading of “Commands” on page 136.

Bimanual palpation is also important in abdominalaortic aneurysm or any intra-abdominal pulsating mass.


PRINCIPLES OF PERCUSSION OF ABDOMEN

It provides a gentle means of localizing abdominaltenderness and differentiates between solid and gaseousfilled structures and therefore the borders of solid organscan be defined.

To start with, percussion is started from RIF to RHCthen to LHC to the LIF then localization of the lower andupper border of liver. Afterwards, percuss for spleen,bladder and uterus and in the end look for any dullnessin the lumbar areas or flanks. If later is detected then gofor shifting dullness. Start with gentle percussion thenheavy percussion but keep on looking at patent’s facialexpressions for any pain. Always percuss from resonantto dull area.

Movement should be at wrist rather than at elbow ofthe hand with plexor and lift up soon after striking thepleximeter to avoid damping effect.

Percussion of individual organs and ascites isdescribed in individual commands section.

PRINCIPLES OF AUSCULTATION OF ABDOMEN

This is to detect intestinal peristaltic sounds, bruits overdifferent viscera e.g., liver, spleen, renal artery, aorta andto listen for other sounds e.g., hepatic or splenic rub,succussion splash etc.

It is important to note that the stethoscope should bewarmed by rubbing over your own palm and placed gentlyover the abdomen. You should wait for few seconds tominutes to hear peristaltic sounds even in normalindividuals.

Make sure that the atmosphere is quiet. Bruits may beheard in the epigastrium down to the umbilicus and upto inguinal regions. In portal hypertension venous hums


can be heard which are usually increased on inspirationand during valsalva manoeuvres.

Renal artery bruit may be heard over the renal angleafter turning the patient in semi-prone or lateral decubitusposition.

For bowel sounds, stethoscope should be placed overthe right side of umbilicus and one should wait for a while.

While listening to succussion splash, place thestethoscope holding in your in right hand over theepigastrium while the patient is supine, then roll thepatient from side to side to listen a splashing sound ofwater. Other way is to ask the patient to keep the chestpiece of stethoscope over his epigastrium and the examinerjottles the patient with both hands to elicit splash.

For bruits, the stethoscope is placed lightly onabdominal wall above and to the left of umbilicus. Itindicates turbulent flow in underlying vessels due tostenosis or aneurysm.

Friction rubs over liver abscesses and splenic infarctsshould be distinguished form a pleural rub of pulmonarydisease.

STEP BY STEP FOR EXAMINATION OFALIMENTARY SYSTEM (FOR LONG CASE)

The Candidate




by asking questions as name, date of birth, address,recognition of people around, etc.


5. Does a general survey (panoramic view) of the patient,while exposing.

6. Looks at the hands and arms for (clubbing,koilonychia, leukonychia, shiny nails, palmarerythema, flapping tremors, Dupuytren’s contractures.pulse rate, blood pressure (may ask for BP apparatus).Looks for spider naevi, scratch marks on skin,ecchymotic spots, tattooing).

7. Looks at the axillae (hair line, lymph nodes,acanthosis nigricans).

8. Looks at the neck (lymph nodes, thyroid, JVP, parotidenlargement).

9. Looks at eyes for jaundice, pallor, Kayser-Fleischer’sring, xanthelasmae, iritis, eyes signs of thyrotoxicosis).

10. Looks at the nipples and breasts in the males(gynaecomastia).

11. Looks in the mouth and examines oral cavity (angularstomatitis, Peutz-Jagher’s pigmentation, telangiecta-sias, aphthous ulcers, buccal pigmentation, candi-diasis, geographical tongue, atrophic glossitis, leuko-plakia of the tongue and smells foetor hepaticus).

12. Looks at the chest wall (spider naevi).13. Examines extremities for (oedema, pyoderma

gangrenosum, erythema nodosum, thrombophlebitismigrans).

14. Examines the abdomen and inspects from the side,at level and from the foot end of the bed.

15. Inspects the hernial orifices and asks the patient tocough.

16. Notes shape and contour of the abdomen (normal,scaphoid, distended, asymmetrical bulge, visibleperistalsis, surgical scars, striae, visible veins, Cullen’ssign, Grey-Turner’s sign).

17. Determines the direction of blood flow if veins arevisible (Harvey’s sign).


18. Palpates the abdomen.19. Makes sure the hands are warm in cold weather.20. Asks the patient to relax, may ask the patient to bend

the knees and flex the hip.21. Asks if there is any tender area.22. Performs light palpation in “S” shaped manner

(visceromegaly, masses or tender areas)23. Performs deep palpation.24. Palpates the liver and measures the span (determines

the upper border of the liver).25. Palpates the spleen, first in supine position, if not

palpable than in right lateral position and compressesleft lower chest wall anteriorly with left hand, whilepalpating in deep inspiration.

26. Palpates right and left kidneys bimanually and elicitsballottement.

27. Palpates the gallbladder, urinary bladder, and feelsfor the divarication of recti, paraaortic lymph nodesand other abnormal masses.

28. Palpates the hernial orifices.29. Examines the testes for testicular atrophy (always asks

for the patient’s and, examiner’s permission).30. Percusses for liver and splenic dullness, measures

enlarged liver, spleen and total liver span (incentimetres).

31. Percusses the urinary bladder.32. Percusses for the shifting dullness.33. Percusses for fluid thrill.34. Auscultates bowel sounds (30 seconds minimal and

for 3 minutes if absent). Notes its character.35. Listens for hepatic bruit and hepatic rub, renal bruit,

aortic bruit and splenic rub and venous hums of portalhypertension.

36. Demonstrates succussion splash if appropriate.


37. Asks the permission for rectal examination of thepatient from the examiner.

38. Asks the patient to stand up; checks BP again fororthostatic changes (if appropriate), looks forabdominal veins, (if they fill now while patient isstanding) looks at the hernial orifices (asks him tocough).

39. Thanks the patient for his cooperation and asks himto dress up and helps him doing so if necessary.

CASE WRITING TIPS

Inspection

General: Encephalopathy, weight loss, obesity, cachexia,dehydration, hypo or hyper pigmentation.

Hands: Palmar erythema, telangiectasia, Dupuytren’scontracture, skin laxity, muscle wasting, liver flap,

Nails: Clubbing, koilonychia, leukonychia, pallor.

Head and Neck: Conjunctival pallor, jaundice, xanthelasmae,halitosis, tongue, gingivitis, dentition, cervical lymphnodes, salivary glands for enlargement and tenderness.

Abdomen: Supine, single pillow under the head and theabdomen should be relaxed with proper exposure but withthe genitalia covered.

Inspection: Skin laxity, scars, fistulae, sinus, stomas, scratchmarks, pigmentation, striae, hair distribution, veins,divarication of the recti, abnormal pulsations, abnormalbulges, visible peristalsis.

Umbilicus: Position, hygiene, nodules or discharge.

Shape of abdomen: Distension, scaphoid, respiratorymovements.


Enlarged organs: Liver, spleen, kidneys, gallbladder,uterus, urinary bladder, any other masses.

Discomfort on blowing out/drawing in abdominal walland response on coughing.

Percussion: Percuss in four quadrants, note reboundtenderness, hyper resonance, position of the liver, spleen,bladder and uterus, masses, ascites, shifting dullness.

Palpation: Watch patient’s face throughout.

Superficial palpation: Tone, tenderness, masses,

Deep palpation: Liver, spleen, kidney and any othermasses.Dipping method in moderate to massive ascites.Ask the patient where does it hurt. Superficial

palpation in ‘S’ shaped manner. Deep palpation in allareas. Elicit tenderness, rigidity, guarding and palpate forthe organs e.g. liver, kidney, spleen, uterus, gallbladderand aorto-iliac aneurysms.

Feel for ballottable organs/masses, fluid thrill, sacraloedema.

Auscultation: Gut sounds whether normal, absent, increasedor tinkling

Friction rubs: Hepatic, splenic

Briuts: Renal, aortic, superior mesenteric and ileo-femoral bruits.Succussion splash.

Inguinal/femoral hernia: Ask the patient to cough, if notobvious, then stands and coughs again.Inspection: See overlying skin.

Cough impulse.


Palpation: Reduction by the patientTendernessCough impulseReducibilityAnatomical position of the neck of the herniaControllabilityInguinal/axillary and supraclavicular lymph nodes.

External genitalia(Male) Draw scrotum on to the front of thighs

Inspection: Look for symmetry/skin/scars/rashes/swellings i.e., inguinoscrotal, scrotal e.g., testicular andepididymal)

Palpation: Testis, epididymis, spermatic cordRelation of cyst/mass to testisPenis — Circumcisions, foreskin position, shape of

meatus, balanitis, discharge, rectal examination.


COMMANDSInspect this patient’s teethPalpate the liverPalpate the spleenPalpate the kidneysLook for distended vesselsExamine for ascites

• Look for shifting dullness• Elicit fluid thrill

Perform rectal examination.


COMMON COMMANDS

Inspect the Teeth

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to grimace to show teeth.7. Asks to remove the dentures if worn.8. Asks the patient to open the mouth widely.9. Retracts the lips and cheeks to see the teeth.

10. Looks for tartar deposit, staining (beetle chewer,tetracycline) horizontal bands, chalk white patchesdue to flourosis with pitting and brown staining(Malden’s teeth).

11. Looks for shape of teeth, spacing in between (splayingas in acromegaly), transverse ridging and otherabnormalities in shape.


examiner.


PEARLS

Breath of patient can also give enormous information. Thecommonest is foul smelling breath called halitosis.However, characteristic odours may also be recognized.

i. Sweet or fruity breath in ketosis.ii. Fishy or ammoniacal smell in uraemia.

iii. Mousy smell in hepatic failure.iv. Putrid smell in suppurative conditions of the lungs.v. Stale apple smell in bronchiectasis.

vi. Paraldehyde and alcohol also have their own typicalodours.

PALPATE THE LIVER

The Candidate (See also Principles of Palpation onPage 126)


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to relax the abdominal wall and

instructs him to breathe quietly.7. Starts from the right iliac fossa.8. Uses the flat of right hand with the thumb tucked

under the palm, placing it parallel to the right sub-costal margin.

9. Keeps index finger parallel to the costal margin.10. Moulds the hand over abdominal wall.11. Asks the patient to breathe in and out through his

mouth.12. Tucks in his palm gently when the patient breathes

out.13. Keeps it there during expiration.


14. Keeps it there during inspiration.15. Feels the descending edge of an enlarged liver.16. Tries to feel the border of liver which touches the index

finger.17. Proceeds inch by inch upwards until he feels it.18. Comments on size, margin, surface, consistency,

tenderness and pulsation of the liver.19. Repeats this manoeuvre to the left of midline to detect

an enlarged left lobe of liver.20. Helps the patient redressing.21. Thanks the patient for his cooperation.22. Comments on his findings while presenting to the

examiner.

PEARLS

It is important to locate upper border of liver by the methodof percussion.

OTHER METHODS TO PALPATE LIVER

Method 1

The Candidate

1. Stands on the right side of the patient facing the headend of the patient.

2. Greets, introduces himself to the patient and askspermission for examination.

3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Places finger tips of both hands joined together

parallel with the right costal margin.7. Asks the patient to breath in and out.8. Presses the abdominal wall inwards and upwards

during inspiration.


9. Feels for the descending liver edge during inspiration.10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on his findings while presenting to the

examiner.

Method 2

The Candidate

1. Stands on the right side of the patient and facing thefoot end of the patient.



4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Places both his palms side by side.7. Points the fingers towards inguinal region but parallel

to the costal margin.8. Places the palm on right sub-costal area lateral to

rectus muscle.9. Presses the tips of fingers inwards and upwards (i.e.

making a hook)10. Asks the patient to breath in and out.11. Tucks in during inspiration.12. Feels the edge of the liver with pulps of the fingers.13. Moves towards the mid line in epigastric area to feel

for left lobe of liver.14. Helps the patient redressing.15. Thanks the patient for his cooperation.16. Comments on the findings while presenting to the

examiner.


Method 3

The Candidate

1. Stands on the right side of the patient and facing thehead end of the patient.



4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Places palm of one hand parallel to the right rectus

muscle.7. Feels for the movements of the liver edge under palm

with each cycle of respiration.8. Helps the patient redressing.9. Thanks the patient for his cooperation.

10. Comments on his findings while presenting to theexaminer.

PEARLS

This method is useful in those cases, where liver is notpalpable by classical method.

Method 4

The Candidate

1. Stands on the right side of the patient and facing thehead end of the patient.




4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Begins with percussion below the sub-costal margin

downwards.7. Notes the resonant area.8. Palpates by classical methods below the percussed

lower border of liver dullness.9. Continues towards the epigastrium for the left lobe

of liver.10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on his findings while presenting to the

examiner.

PEARLSThe candidate should comment as follows:a. Whether liver is palpable or not.b. Whether it is enlarged or displaced.c. What is the extent of enlargement below the costal

margin? (Avoid using “finger breadth” as it varies fromperson to person. Be precise by measuring themaximum span with a measuring tape either incentimetres or in inches in the mid clavicular line)

d. Comment on tenderness, surface whether smooth,granular or nodular.

e. Comment on the margin (lower edge).f. Whether enlargement is uniform.g. Comment on the consistency i.e., soft, hard or firm.

Advice to the Reader

1. The patient’s abdomen should be completely relaxedfor a good abdominal examination, especially forpalpation of enlarged viscera.


2. For liver, begin from right iliac fossa upwards as itis the direction, towards which liver enlarges. Anenlarged liver can be missed if its palpation is notbegun from the right iliac fossa.

3. Left lobe of the liver is normally palpable in the midline but hardly goes beyond the mid point betweenxiphisternum and umbilicus.

4. Left lobe of liver should not be missed for an enlargedxiphisternum or bulky tense recti muscle.

5. For enlarged gallbladder i.e. tumour or mucocoele etc.,the patient should be rolled at 45° to the opposite sideto facilitate its palpation.

6. Murphy’s sign is elicited when the hand is placed atgallbladder site and is pushed in when patient breathesin resulting in pain and sudden holding of breath.

PALPATE THE SPLEEN (See also Principles ofPalpation on Page 126)

Spleen is again sub-diaphragmatic and enlarges from lefthypochondrium across the umbilicus to the right iliac fossa.The spleen can be palpated by five methods:

Method 1

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to relax abdominal muscles.7. Keeps the fingers of the right hand and palm in the

same plane.


8. Starts from the right iliac fossa.9. Moves across the umbilicus and towards the left sub-

costal margin.10. Keeps asking the patient to breathe in and out.11. Lessens the inward pressure but maintains upward

pressure allowing fingers to drift in the direction ofdescending spleen.

12. Feels for the border of spleen and the notch.13. Turns the patient slightly towards right for easier

detection of spleen.14. Helps the patient redressing.15. Thanks the patient for his cooperation.16. Comments on his findings while presenting to the

examiner.

Method 2

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Places left hand over the posterior aspect of the left

lower chest.7. Turns the patient slightly towards right (towards

himself).8. Exerts pressure from the back of the left side of chest

with his left hand in a forward direction.9. Moves his right hand from right iliac fossa across

the umbilicus towards the left hypochondrium andfeels for the spleen.



examiner.

Method 3

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Tilts the patient slightly towards right side (towards

himself)7. Asks the patient to place palm of his left hand under

his head (This will push up the left sub-costal margin)8. Asks him to breathe deeply.9. Feels for the splenic enlargement starting from right

iliac fossa across the umbilicus towards the left sub-costal area.


examiner.

Method 4

The Candidate

1. Stands on the left side of the patient.2. Greets, introduces himself to the patient and asks




4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Faces towards the foot end of the patient.7. Places both palms together over the front of lower

chest.8. Joins together the fingers.9. Turns his finger tips inwards and upwards (making

a hook).10. Asks the patient to breathe in and out.11. Feels the spleen during inspiration.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on his findings while presenting to the

examiner.

Method 5

Dipping method (in ascites)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Pushes swiftly downwards in a jerky way with both

of his hands joined together.7. Feels for the edge of floating spleen which is felt when

the fluid is displaced by dipping method.8. Helps the patient redressing.9. Thanks the patient for his cooperation.


10. Comments on his findings while presenting to theexaminer.

PEARLS

a. An enlarged spleen may be completely missed if notpalpated from right iliac fossa.

b. The normal splenic dullness should never extendbeyond the mid axillary line. Therefore, it is sometimesimportant to percuss quickly afterwards by askingpermission from the examiner.

c. Splenic enlargement may be mild, moderate or severe.

Mild is when lower pole is less than half way to theumbilicus or is 1-3 cm from the left costal margin.

Moderate is when lower pole is up to the level of theumbilicus or is 3-7 cm from the left costal margin.

Severe is when lower pole is below the level of umbilicusand is more than 7 cm from the left costal margin.

One should be able to differentiate between an enlargedspleen and left kidney as it is sometimes very confusing.Following is a table showing the differences between leftrenal and splenic swellings.

Enlarged Spleen Enlarged (L) Kidney

1. Renal angle is not full. 1. Renal angle is full.2. Bimanually not palpable. 2. Bimanually palpable.3. Not ballotable 3. Ballotable4. Enlarges towards right 4. Enlarges vertically up and

spinoumbilicus line. down may be forward.5. Notch is felt. 5. No notch is felt.6. No tenderness in renal angle. 6. Tenderness is in renal angle.7. Moves with respiration. 7. Does not move or moves very

little.

Contd...


Enlarged Spleen Enlarged (L) Kidney

8. Fingers cannot be insinuated 8. Can be insinuated.between costal margin andspleen.

9. Poles are angular. 9. Poles are rounded.10. Finger can be dipped 10. Cannot dip the fingers.

between renal angles.11. Bulge in the left 11. Bulge in the loin.

hypochondrium12. Situated superficially. 12. Situated deeply.13. Renal angle is resonant. 13. Renal angle is dull.14. Dullness on percussion. 14. Resonant on percussion as

descending colon is lyinganteriorly.

Palpate the Kidneys (Bimanual palpation) (See alsoPrinciples of Palpation on Pages 126 and 128)

The Candidate



modesty.4. Makes sure that the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie down in supine position close

to the edge of the bed.7. For palpation of right kidney:

i. Tucks in the left hand posteriorly in the right lumbararea.

ii. Places the tips of the fingers of left hand in theright renal area.

Contd...


iii. Places the right hand with stretched palm andfingers anteriorly over the right lumbar region belowthe right costal margin at right angle to the marginand lateral to the right rectus muscle.

iv. Asks the patient to breathe in deeply.v. Presses fingers of both hands together finally and

attempt to catch the lower pole as it descends downbetween two hands during inspiration.

8. For palpation of left kidney:i. Tucks in his left hand‘s palmar surface posteriorly

in the left flank.ii. Places the fingers of the curved left hand in the

left renal angle.iii. Places middle three fingers of the right hand below

the left costal margin lateral to the left rectus at apoint opposite the left hand.

iv. Presses both hands towards each other and ask thepatient to breathe in deeply.

v. Feels the lower pole of left kidney slipping betweenthe hands or the enlarged kidney.


examiner.

Examine this Patient for Ascites

The Candidate



modesty.4. Makes sure that the light is adequate and natural.5. Does a general survey of the patient.


6. Makes the patient lie down in supine position.7. Moves towards the foot end of the bed and observes

the fullness of the flanks.8. Notes the shape and position of the umbilicus.9. Asks about any pain in abdomen.

10. Starts percussion from the epigastrium.11. Comes down to umbilicus area in the mid line.12. Moves gradually to each flank by placing pleximeter

finger parallel to the dull edge by a distance, eachof two centimetres. e.g., left flank.

13. Keeps the pleximeter finger there.14. Turns the patient to the opposite side at 45° for a

few seconds i.e., right side.15. Keeps on percussing to the same side i.e., left side

(Notes for resonant area which was dull before).16. Keeps percussing back to the umbilicus i.e., right side.17. Notes area of dullness again.18. Asks the patient to turn towards opposite side at 45°

(now the left side).19. Waits for a few seconds.20. Keeps percussing towards right side until it becomes

resonant.21. Performs fluid thrill in case of tense ascites.22. Asks the patient to put ulnar border of his right or

left hand in the centre of abdomen and press slightly.23. Places left hand over patient’s left flank with

moderate pressure.24. Taps the right flank with a flick of right index finger

and thumb to set up vibration.25. Feels the vibration with the palm of left hand in the

left flank.26. Helps the patient redressing.27. Thanks the patient for his cooperation.28. Comments on his findings while presenting to the

examiner.


PEARLS

a. Performs the dipping method for palpation of anyvisceromegaly as it displaces the fluid by a forcefuljerk and the underlying organ hits the finger. Thisneeds a lot of expertise.

b. In eliciting fluid thrill, the patient’s hand is placedover his abdomen for damping the conduction ofvibration through the abdominal fat.

c. While performing shifting dullness, a few seconds waitresults in shifting of fluid to the opposite side but moreimportantly one has to wait for the air distended smallbowel to come up to produce resonance in a previouslydull area.

d. Fluid thrill and shifting dullness may be absent in verymassive or tense ascites.

e. Continuous dullness over flanks, iliac fossae, hypo-gastric area with resonance over umbilical andepigastric area is called “horse shoe” shaped dullness.

f. In minimum ascites, it is difficult to detect ascites ordullness in supine position. However, in knee chestposition or knee elbow position, the umbilical areabecomes dull on percussion (puddle sign) but it is veryinconvenient and difficult.

g. In mild ascites flanks are full, horse shoe shapeddullness is absent, shifting dullness is present but fluidthrill is absent.

h. In moderate ascites, flanks are full, horse shoe shapeddullness is present, shifting dullness is present butfluid thrill is absent.

i. In massive ascites flank are bulged, whole abdomen isdull to percussion, shifting dullness is absent but fluidthrill is present.

j. At least 1500 millilitres of ascitic fluid must be presentfor shifting dullness to be elicited.


k. Fluid thrill indicates that ascitic fluid is under tensionand is usually more than 1500 millilitres.

l. In gross ascites the epigastrium is tympanitic, in largeovarian cyst or distended bladder the hypogastric areais dull and there is no shifting dullness and the areasin the lumbar and epigastrium are tympanitic. In intes-tinal obstruction, the whole abdomen is tympanitic.

m. Position of umbilicus and its shape is important. Inascites, it is displaced downwards and may be flat orbulged or like a slit in horizontal direction. In largeovarian cyst it may be displaced upwards and maybe of normal shape. In intestinal obstruction it maybe flat but not displaced in any direction.

Perform Ballottement (See also BimanualPalpation of Kidneys on Pages 126 and 128)It is usually done for renal enlargement/masses.

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Places left hand behind the right lumbar area for right

kidney.7. Places the right hand over the front of right lumbar

area.8. Places finger tips of the right hand just lateral to the

right rectus muscle.9. Applies steady pressure with right hand posteriorly.

10. Pushes the swelling with his left hand upwards.11. Feels the renal mass striking the right hand.



examiner.

PEARLS

Ballottement is typical feature of kidney enlargement.

Examine the Engorged Abdominal Veins andDetermine the Flow of Blood

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to stand upright if he can stand but

if not then asks the patient to lie down on the couch.7. Exposes the abdomen quite well.8. Chooses a segment of vein without any tributary.9. Places index fingers or thumbs of right and left hands

parallel over that segment and milks out the vein fora length of 3-5 cm.

10. Lifts one finger and observes the filling of vein.11. Replaces the first finger and lifts up the second finger

and looks for the filling if no filling occurred inprevious step.


examiner.


PEARLSa. In standing position the abdominal veins become more

prominent due to gravity as compared to supineposition.

b. One can use two tongue depressors in stead of indexfingers or thumbs of either hand.

c. The direction in which the vein fills in a faster speedis the direction of flow of blood.

d. If the segment chosen has tributaries, the milked outsegment can be filled by them or cannot be milked outsatisfactorily. Therefore make sure that the segment ofvein chosen has no tributaries.

e. Venous hum is often heard over the portal collateralswhereas it is usually absent over vena caval collaterals.

f. In normal persons, the abdominal veins are not visible.g. In normal subjects the blood flow is away from the

umbilicus.h. There is no rule that which finger should be taken away

or lifted up first.i. Direction of blood flow should be determined above

and below the level of umbilicus.j. Normal blood flow is vertically above and below the

umbilicus.k. In portal hypertension, the distended vein radiate all

round the umbilicus towards the periphery called caputmedussae. However, in obstruction of the inferior venacava, the flow is from below the umbilicus upwardsin oblique tributaries which may be tortuous.

Perform a Digital Rectal Examination

Explain the procedure to the patient first as some patientsmay refuse to undergo rectal examination.


The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes him lie down in the left lateral position. Buttock

should project over the side of the couch.7. Asks the patient to draw his right knee upwards close

to his abdomen while keeping left leg straight.8. Puts gloves on both hands (preferred).9. Stands behind the patient’s buttocks facing his feet.

10. Separates the buttocks gently and inspect the anusand peri-anal area.

11. Asks the patient to bear down to see any prolapseof piles or mucosa of anal canal.

12. Lubricates the index finger of right hand withlubricant jelly.

13. Places the pulp of the right index at anus (Does notinsert the tip yet).

14. Puts the left hand on right buttock and presses hislubricated finger firmly and slowly in a backwarddirection.

15. Feels the tone of anal sphincter.16. Pushes the finger forwards and sweeps around in

an anticlock wise direction up to 180° also pronatingthe wrist to examine anterior part of rectum includingthe prostate.

17. Notes the size, consistency, mobility, median sulcusand mobility of mucosa over the prostate.

18. Rotates the finger clock wise to examine the right sideof the pelvis and asks the patient to strain.


19. Places the left hand over the suprapubic area andpresses it backwards for bimanual palpation (ifindicated).

20. Withdraws the finger.21. Looks for any mucus, pus or blood on the finger.22. Wipes the patient clean.23. Tells the patient that examination is over.24. Helps the patient redressing.25. Thanks the patient for his cooperation.26. Comments on his findings while presenting to the

examiner.

PEARLSa. Careful inspection of anal area can give a lot of

information.b. During palpation, resistance at anal sphincter can

easily be over come by asking the patient to strain asif daefecating.

c. Tone of anal sphincter can be appreciated by askingthe patient to contract the anus.

d. Anus and rectum are empty in a normal person.e. Push the finger about 2, 5 and 8 cm inwards until it

cannot be pushed at all.f. In women, either the cervix is felt or more anteriorly

the fundus of a retroverted uterus, fibroid, ovarian cystor a pelvic abscess can be felt.

g. If in doubt, wipe the finger on a white gauze pieceor swab to see the type of discharge from the rectum.

CHAPTER 9

Examination ofGenitourinary

System


A set examination of genitourinary system is not routinelyperformed. However, if renal disease is suspected byhistory then certain signs must be sought.

The basic principles of inspection, palpation,percussion and auscultation also apply during theexamination of this system. Few of the steps in thisexamination are similar to that of abdominal examinationwith special importance and concentration on kidneys.

CHECK LIST FOR NEPHROLOGICAL EXAMINATION(FOR LONG CASES)

The Candidate




by asking questions as name, date of birth, address,recognition of people around, etc.

5. Examines the patient as a whole (stature, cushingoidappearance, renal osteodystrophy, deformity, mousyodour, lipodystrophy, acidotic breathing).

6. Examines the skin for (skin turgor, texture, pigmenta-tion, scratch marks, angiokeratoma, vasculitis, butter-fly or other rashes, cellulitis, xanthomata, herpes,Kaposi’s sarcoma, uraemic frost, scabies, spiders,tattooing)

7. Examines body hair, feels the texture and looks forhair distribution (alopecia, hypertrichosis).

8. Examines and compares both hands (obviousdeformity, tremors, short metacarpals, ulnar deviation,joint deformity, carpal tunnel syndrome, Dupuytren’s

159EXAMINATION OF GENITOURINARY SYSTEM

contracture, wasting, palmer erythema, Osler’s nodes,Janeway’s lesions, and oedema).

9. Examines the nails (polished nails, Muehreke’s lines,Beau’s lines, leuconychia, reversal of nail pattern, twotone nails, onychomycosis, onycholysis)

10. Checks for clubbing.11. Records pulse compares pulses, checks for radio-

femoral delay, respiratory rate, and blood pressurein supine position.

12. Examines forearms and arms for arteriovenousfistulae.

13. Performs Allen’s test if patient is a candidate forarteriovenous fistula.

14. Examines face for (deformity, asymmetry, cushingoidfacies, butterfly rash, pigmentation, and temporalvessels).

15. Examines eyes with a torch (periorbital oedema,xanthelasma, ptosis, arcus, jaundice, anaemia, bandkeratopathy, keratoconus, squint, pupils, cataracts,fundoscopy).

16. Examines nose (herpes nasolabialis, nasal deformityWagener’s granulomatosis)

17. Examines lips, mouth and oral cavity with a torchand tongue depressor and instructs the patientproperly (orodental hygiene, oral thrush, angularstomatitis, perioral pigmentation, tongue and itsunder surface, mucosa, gums, teeth, tonsils, palateand pharynx)

18. Checks ears for (hearing, tophi, deformity).19. Examines the neck for (JVP, Kussmaul’s sign, engorged

neck vein, thyroid, lymph nodes)20. Positions the patient comfortably and correctly and

exposes the entire abdomen.


21. Inspects the abdomen generally (peristalsis, fullnessin flanks (polycystic kidneys) and looks for operationscars, peritoneal dialysis, catheter placement scarsetc.)

22. Notes type of respiration and movement of abdominalwall and counts the respiratory rate.

23. Checks for integrity of recti.24. Examines external genitalia for (varicocoele),

hydrocoele, patent processus vaginalis, hernialorifices.

25. Performs light palpation in “S” shaped manner.26. Palpates liver, spleen, urinary bladder and kidneys

(bimanually).27. Palpates deeply for masses, colon, and glands.28. Percusses for liver, splenic and urinary bladder

dullness.29. Percusses for fluid thrill, shifting dullness etc.30. Auscultates for renal artery bruit, venous hum, and

bowel sounds.31. Examines lower limbs for (oedema, rashes, ulcers,

varicose veins, peripheral pulses).32. Records blood pressure in lower limbs. (if necessary)33. Records blood pressure in sitting position. (if

necessary)34. Inspects the back (looks for swelling in renal areas,

spinal deformity).35. Elicits any spinal or renal angle tenderness.36. Notes for sacral oedema and auscultates lung bases

for fluid overload.37. Examines axillae for dehydration, temperature record

and axillary lymph nodes38. Examines for caput medusae, varicocoele and hernias

in standing position.39. Cheeks pulse and blood pressure in standing position

for any postural hypotension.


40. Measures weight and height if required.41. Examines gait if required.42. Takes permission and performs rectal examination,

assesses for prostate size and its consistency.43. Instructs the patient to put on clothes and helps him

if necessary.44. Thanks the patient for his cooperation and asks him

to dress-up and helps him if necessary.

CASE WRITING TIPS

General appearance.Look for:

• Hyperventilation• Hiccup• Uraemic fetor (mousy smell)• Sallow complexion (dirty brown appearance)• Twitching (myoclonic jerks).

The hands

Examine nails for:• Muehrcke’s bands (paired white transverse lines

near end of nails)• Half and half nails, or Terry’s nails (at least 1 mm

distal brown arc)• Mee’s lines (a single transverse white band)• Beaus’s lines (non-pigmented indented transverse

bands)• Shiny nails (due to scratching).

Examine palms for:• Palmar crease pallor• Asterixis.

Examine wrist and forearm for:• Surgically created arterio-venous fistula


• Scars from previous failed fistula or carpel tunnelsyndrome surgery

• Look for signs of carpal tunnel syndrome• Check pulse (supine)• Check blood pressure• Count respiratory rate• Check temperature.

The Arms:• Bruising• Skin pigmentation• Scratch marks• Uraemic frost• Purpuric vasculitic lesions• Tophi• Tendon xanthomata• Palpate axillae for dryness or wetness for hydration

status

The Face:Examine eyes for:

• Anaemia• Jaundice• Band keratopathy• Eyeball pressure for hydration status.

Examine mouth for:• Uraemic fetor• Mucosal ulcers• Thrush.

Examine face for:• Rash, skin tethering• Mask like face• Skin turgor.


The Neck:• JVP• Carotid bruit• Skin turgor over sternum for hydration status.

The legs and Feet:• Oedema• Purpura• Pigmentation• Scratch marks• Peripheral pulses.

The Abdominal Examination:Inspection:

• Roll the patient over and look in the region of loinsfor nephrectomy scars

• Inspect right or left iliac fossa for renal transplantscar

• Look in midline below umbilicus and lowerabdomen for scars of catheter placement used forperitoneal dialysis

• Distension because of large polycystic kidneys orascites

• Inspect scrotum for masses and genital oedema

Palpation• Hepatosplenomegaly• Palpable kidneys• Distended bladder• Abdominal aortic aneurysm

Percussion• Ascites• Enlarged bladder

Auscultation• Renal bruit above umbilicus 2 cm to left or right

of midline


Rectal and pelvic examination:• Left varicocoele• Perform rectal examination for prostatic enlargement

The Back:• Strike the vertebral column with the base of fist to

elicit bony tenderness• Gently strike the fist over renal angle for tenderness

(Murphy’s punch)• Sacral oedema• Auscultate both flanks for renal bruit

The Chest:Examine heart and lungs and look for signs of:

• Congestive cardiac failure• Pericardial rub• Pleural effusion• Lung infection

The nervous system:Examine legs and arms for:

• Peripheral neuropathy• Myopathy

The fundi• Diabetic retinopathy• Hypertensive retinopathy.

CHAPTER 10

Examinationof Nervous

System


BASIC PRINCIPLES

A detailed examination of the nervous system can be verylengthy and difficult to do at one sitting as it involvesdifferent aspects of the system. Therefore it is necessaryto examine the nervous system step by step and to practicethis as much as possible.

Please bear in mind that it can be tiring and taxingfor the patient as well as for the examiner. If a patientis tired after having gone through systemic examinationother than neurological examination, he may become non-cooperative and mislead to the diagnosis.

Broadly speaking, the nervous system is divided intothe central, peripheral, and autonomic nervous system.Diseases may affect single cortical area, cranial nerves,peripheral nerves and spinal tract, alone or in combination,thus leading to a variety of neurological deficits.Localization of disease is helped by a precise history.However, it is important to keep an open mind, as it iseasy to follow a wrong lead as to the level of the lesionand there may be a possibility of disease at other levelsor multiple sites.

It is important to exactly note down the findings asthere is change in neurological signs and symptoms eithervery shortly or over a long period of time. A well-recordedhistory and neurological examination is very rewarding.

The most important questions in the neurologicalexamination include:1. Where is the lesion?2. What is the lesion?

The first impression of neurological function isobtained by the posture, facies, gait, abnormal movementsand speech of the patient. A well-recorded history providesclues to the temporal profile and possible aetiology of thelesion.

167EXAMINATION OF NERVOUS SYSTEM

If responses become erratic during examination it isbetter to abandon examination and return later for re-examination.

Always remember to turn the patient over when supineto see any pathology over the back or spine. The musclesof shoulders and pelvis should also be examined. Asalready stressed, always record your findings in full andavoid abbreviations e.g., SOMI for “signs of meningealirritation,” PERLA for “pupils equal, reacting to light andaccommodation.”

It is also advised to repeat the examination to look forchanging neurological signs.


NEUROLOGICAL EXAMINATION AS A WHOLE(FOR LONG CASE)

The Candidate



light is adequate.4. While doing this checks for higher mental functions


5. Examines the cranial nerves while the patient is sittingup.

6. Checks olfactory nerve by testing smell in each nostrilseparately, closing the nostril not being examined.

7. Checks optic nerve by testing visual acuity, visualfields, fundoscopy, and colour vision.

8. Checks the pupils for their size, shape, reaction tolight both direct and consensual and accommodationreaction.

9. Tests eye movements in all quadrants looking fordisconjugate gaze, strabismus and nystagmus andasking for diplopia.

10. Tests sensation in ophthalmic, maxillary andmandibular divisions of trigeminal nerves (sensorypart).

11. Asks the patient to open the mouth against resistanceand protrude and move the jaw from side to side.Asks the patient to clench the teeth and checkstemporal and masseter muscles on each side (motorpart).

12. Checks corneal reflex properly (see later)13. Instructs the patients to look up, to shut the eyes, to

smile and to inflate mouth for facial nerve (motor part)


14. Tests sensation of taste on anterior part of tongue.[sensory part]

15. Tests hearing and performs Rinne’s test and Weber’stest (if indicated) with a tuning fork of frequency of256 Hz.

16. Tests palatal movements, movement of the uvula andpalatal reflex for glosso pharyngeal and vagus nerve.

17. Examines the tongue while keeping it in the mouth,asks to protrude the tongue and checks movementsin all directions for hypoglossal nerve.

18. Asks the patient to shrug the shoulders againstresistant and to move the neck side ways and forwardand upwards against resistance to check integrity ofaccessory nerve.

19. Examines the upper limbs for bulk of the musclesand abnormal movements, looks for fasciculations.

20. Assesses the tone of the muscles of the upper limbs.21. Checks the jaw, biceps, triceps and supinator jerks.22. Assesses the power of the muscles of upper limbs

actively and passively (proximally and distally),grades the power properly (0-5).

23. Checks for coordination of movements by performingfinger nose test or tapping of the palms.

24. Checks for superficial and deep sensations in theupper limbs.

25. Checks for position and vibration sensations (tuningfork of 128 Hz).

26. Checks temperature sensation both hot and cold.27. Elicits tactile localization and two point

discrimination.28. Performs superficial reflexes i.e., abdominal and

cremesteric.29. Inspects the bulk of muscles and any abnormal

movements in the lower limbs.


30. Assesses the tone of the muscles of lower limbs.31. Assesses the power of the muscles of lower limbs both

actively and passively (proximally and distally)grades the power properly (0-5).

32. Elicits clonus (grade 0-4).33. Checks for knee jerk, ankle jerk and plantar responses.34. Checks for coordination of movements in the lower

limbs by performing heel shin test.35. Checks for superficial and deep sensations in the

lower limbs.36. Checks for position and vibration sensations (tuning

fork 128 Hz).37. Checks temperature sensation both hot and cold.38. Elicits tactile localization and two point discrimi-

nation.39. Elicits neck stiffness.40. Performs Kernig’s and Brudzinski’s manoeuvre

looking for signs of meningeal irritation.41. Examines gait, tandem walking and Romberg’s test.42. Checks for retropulsion and propulsion.43. Thanks the patient for his cooperation and asks him

to dress-up and helps him if necessary and offers tohelps.

CASE WRITING TIPS

The neurological examination can easily be performed ifone adheres to the following guidelines: it is under 12headings with sub-headings:1. Higher mental functions

a. Level of consciousnessb. General behavioursc. Intelligenced. Memory


e. Orientation in place and time and personf. Hallucinations and delusionsg. Emotional stateh. Insight.

2. Speech (Ask about right or left handedness)a. Spontaneous speechb. Comprehension of written commandsc. Naming of objectsd. Simple numerical calculation?

3. Cranial NervesI. Check smell, separate nostrils.

II. 1. Visual acuity2. Visual fields3. Fundoscopy.

III, IV, VI1. Pupillary response to direct light consensual/

accommodation2. Size of pupil, regularity3. Enophthalmos4. Exophthalmos5. Ptosis—partial or complete6. Nystagmus7. Extraocular movements.

V. 1. Motor part—muscles of mastication2. Sensory part – Sensation in ophthalmic,

maxillary and submandibular divisions3. Corneal reflex4. Jaw jerk.

VII. 1. Muscles of facial expression2. Test hearing3. Check anterior 2/3 of the tongue for taste.

VIII. (a) Auditory1 Hearing— tickling watch, scratch hair in front

of pinna


2 Rinne’s test3 Weber’s test

(b) VestibularDix. Hall pike manoeuvre.

IX. 1. Say ‘Aah’2. Gag reflex3. Taste on the posterior 1/3 of tongue.

X. 1. Voice2. Cough3. Uvular deviation.

XI. 1. Shrugging of shoulders2. Rotation of neck.

XII. 1. Tongue bulk—wasting etc2. Abnormal movements, fasciculations3. Deviation of the tongue after protruding4. Myotonia by percussing the tongue.

4. Motor Systema. Bulk—Hypertrophy, wastingb. Tone—Spasticity, flaccidity, clonus, rigidityc. Power—Hand gripd. Coordination—finger – nose, heel shin test,

dysdiadochokinesiae. Involuntary (abnormal) movements e.g., tremors,

fasciculations, choreiform movements, athetoidmovements, convulsions, ticks

f. Reflexesg. Gait (some includes in motor system, it has been

discussed under separate headings).5. Sensory System

Nerve root levelSpinal cord levelHemi-anaesthesia.

A. SuperficialLight touch — cotton woolPain — pinprick


Temperature — finger, tuning fork, test tubes withhot and cold water.

B. DeepVibration—start distallyPosition of joints — hold sides of the digitsPosition of limbs — should place other limb in thesame position or tell if unable to move the otherlimb as well

C. CorticalTactile localization — use callipersTactile discrimination — use compassStereognosis — use coins or keys.

6. ReflexesA. Superficial:

1. Corneal and conjunctival2. Palatal3. Pharyngeal4. Abdominal

• Upper• Middle• Lower

5. Cremesteric in males6. Plantar

B. Deep:1. Face (jaw jerk)2. Upper limb (biceps, triceps and supinator jerks)3. Lower limb (knee and ankle jerks).

C. Organic reflexes:1. Micturition2. Defaecation3. Deglutition4. Respiration

D. Primitive reflexes:1. Glabellar tap


2. Palmomental3. Moro’s reflex4. Pout and snout

7. Signs of Meningeal Irritation1 Neck stiffness2 Brudzinski’s neck sign3 Brudzinski’s leg sign4 Kernig’s sign

8. Cerebellar Signs1. Nystagmus2. Speech3. Tone4. Coordination5. Disdiadochokinesia6. Rebound phenomenon7. Pendular jerks8. Gait.

9. Spine and Skull1. Scar2. Deformity3. Tenderness in spine.

10. GaitAll types

1. Festinant2. Hemiplegic3. Stamping4. Ataxic5. Shuffling6. Spastic7. Cerebellar8. Waddling9. Ataxia abasia

10. Hysterical.


11. Fundoscopic Examination1. Retinoscopy2. Proper fundus examination.

12. Carotid Atresia/Stenosis for bruits13. Cardiovascular Auscultation for Atrial Fibrillation14. Autonomic Nervous System

1. Sweating2. Postural hypotension3. Heart rate response to Valsalva’s manoeuvre.

15. Abnormal Peripheral Nerve — thickening, neurofibromata16. Neuropathic, Disorganized Joints — Charcot’s joints.


COMMON COMMANDS (SHORT CASES)

How would you check the level of consciousness?

The Candidate

1. Stands on the right side of the patient.2. Makes sure the light is adequate and natural.3. Does a general survey of the patient and notes if he

is fully alert and conscious.4. Calls the patient with his name and tries to converse.5. Notes whether the patient opens his eye, and talks

relevant (Verbal stimuli are responded verbally).6. Checks whether patient is stuporosed by arousing

him with painful stimuli.7. Observes the response of patient by verbal commands.

Notes any restlessness or spontaneous movements.8. Checks whether patient is semi-comatosed by exerting

painful stimuli or shaking him and notes anywithdrawal of any part by the patient and anygrimaces or other movements.

9. Notes any muttering by the patient.10. Checks for coma by deep painful stimuli or any other

kind of stimuli and notes any response (Usually veryminimal response).

11. Helps the patient redressing.12. Comments on his findings while presenting to the

examiner.

How would you check memory of the patient?

The Candidate



modesty.


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Checks short term memory by showing a sequence

of objects e.g., pen, paper, watch, coin etc.7. Asks the patient to repeat in the same sequence after

a minute.8. Asks to repeat 7 numbered digits after a minute.9. Asks him to tell five digits backwards.

10. Checks recent memory by asking what the patienthad this morning to eat, today’s news if he had readthe newspaper and duration of illness in days.

11. Checks long term memory by asking his date of birthor date of wedding or by asking him the name ofhis school or college.

12. Notes down all the relevant information in thiscontext.

13. Thanks the patient for his co-operation.14. Comments on his findings while presenting to the

examiner.

How would you check the speech?

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks him whether he is right handed or left handed.7. Observe spontaneous speech and notes its type.8. Gives verbal commands to do little manoeuvres e.g.,

to open the month, to put the tongue out, to touchthe nose, etc.


9. Gives written commands to lift up his hands or showhis teeth.

10. Asks the patient to read aloud from the book.11. Asks the patient to write as per dictation.12. Asks the patient to name objects e.g., pen, pencil or

a book.13. Asks him to calculate simple numerical problems.14. Thanks the patient for his cooperation.15. Comments on his findings while presenting to the

examiner.

PEARLS

1. Dysarthria is inability to pronounce due to defect inthe articulating muscles. Before diagnosing this, localcauses e.g., edentulous state, tongue tie etc., should beexcluded.

2. Dysphasia is due to defective function due to diseasesof the speech centre.

3. In motor dysphasia (expressive) patient is able tounderstand but unable to express.

4. In sensory aphasia (receptive), the patient does notunderstand but can speak otherwise.

5. In patient with global aphasia, he is unable tounderstand or speak either.

Check the Patient for Apraxia

The Candidate





5. Does a general survey of the patient.6. Confirms that the patient can understand whatever

you say.7. Confirms intact motor, sensory and cerebellar

functions.8. Confirms the right or left handedness of the patient.9. Checks construction apraxia by asking him to make

a square from match sticks.10. Checks dressing apraxia by asking him to unbutton

his shirt or remove the shirt.11. Notes whether these defects are unilateral or bilateral.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on his findings while presenting to the

examiner.

PEARLS

1. In ideational apraxia, the patient has no concept touse the object or objects for a task.

2. In ideomotor apraxia, the concept is present but motorfunction is not there to carry out that particular idea.

Check the Patient for Agnosia

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Confirms that motor sensory and cerebellar functions

are intact.


6. To check visual agnosia, asks the patient to walk tillthe door and then asks him to come back. Asks thepatient to name common objects when shown to him.Asks the patient to tell the different colours of theobjects when shown to him.

7. To check tactile agnosia, asks the patient to close hiseyes and try to recognize objects by touching or feelingthem e.g., coins, keys, pen, watch etc.

8. To check auditory agnosia, asks the patient to closehis eyes and to recognize different sounds i.e., shakingof coins, tinkling of water, ringing of bell or tickingof a watch.

9. Asks questions i.e., which is the index finger, rightor left etc to check whether patient can recognize hisown body, either right or left side.

10. Check whether these defects are unilateral or bilateral.11. Thanks the patient for his cooperation.12. Comments on his findings while presenting to the

examiner.

PEARLS

a. When there is denial of illness in its extreme form itis called anosognosia.

b. Constructional agnosia includes inability to draw afigure or construct an object or map the surroundings.

c. Inability to recognize faces is called prosopagnosia.d. In visual agnosia, one can ask the patient to manipulate

the objects a little bit to see if the recognition isimproved.


CRANIAL NERVES

Both right and left cranial nerves should be examinedseparately and the finding should be compared.

Olfactory Nerve

This nerve is not so commonly tested although theexamination starts from this nerve.

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Uses common materials for testing the sense of smell

i.e., soap, tooth paste, lemon, spirit, etc.7. Asks the patient to close his eyes.8. Asks the patient to close his one nostril.9. Brings forward the material to be smelled and asks

the patient to take a couple of good sniffs.10. Asks him whether he can smell or not.11. Asks the patient to identify the smell and makes a

note of its correctness.12. Tests the other nostril in the same way.13. Helps the patient redressing.( if wearing a veil)14. Thanks the patient for his cooperation.15. Comments on his findings while presenting to the

examiner.


PEARLS

a. Do not use pungent odours like ammonia, ether, vinegaras these can stimulate trigeminal nerve.

b. It is better to test one nostril at one time. The patientis asked to sniff through the nostril to be tested. Makesure that it is patent and then place the odour to betested under the nostril.

c. Some patients cannot name the odour in particular butthey do recognize it. This is sufficient as well.

d. The interval between the different odours to be testedshould be sufficient enough so that the previous odourshould disappear by the time second odour is tested.

e. In anosmia, there is complete absence of sense of smell.f. In parosmia pleasant odours seem offensive and foul

smelling.g. In temporal lobe epilepsy one can get olfactory

hallucinations.h. Candidate should know a check list of causes of

anosmia.

Optic Nerve

The optic nerve is not a simple nerve to examine and thecandidate has to examine their important components,which are as follows:i Visual acuity (VA)ii Field of visioniii Colour vision

The visual acuity is very vital step but if the patientis blind, then there will be no point to test for field ofvision and colour vision.Visual Acuity (VA)For far vision Snellen’s chart is used but finger countingmethod is also useful.


The Candidate



modesty.(especially if the patient is wearing a veil)4. Makes sure the light is adequate and natural.5. Asks the patient to cover one eye with his hand on

the same side.6. The candidate holds his own hand extended and

fingers abducted in front of the patient’s openeye.

7. Starts asking him to count the fingers at a distanceof one foot and moves away asking him to countthe fingers (different numbers) and go up to sixmeters.

8. If the fingers can not be seen by the patient even verynear to him, then determines whether the patient cansee hand movements (HM) or light perception (PL)after showing him some light.

9. Tests near vision with Jaeger’s chart of different sizesfonts.

10. Checks colour vision with Ishihara’s chart.11. Tests each eye separately.12. Notes any abnormality and comments on that.13. Helps the patient redressing ( if wearing a veil)14. Thanks the patient for his cooperation.15. Comments on his findings while presenting to the

examiner.

PEARLS

Colour vision can also be tested with Holmgren’s woolor Farnsworth-Munsell coloured tiles.

Use alternative test type for illiterate people i.e., ‘E’ test.


Snellen’s chart: The chart has 8 rows which can be seenby a normal eye at 60, 36, 24, 18, 12, 8, 6 and 5 metersrespectively. The upper number is the distance of thesubject from the chart and it is usually 6 meters.

The lower number is the distance of the smallest linethat can be read easily. At 6 meters it is the 7th line, whichshould be read at 6 meters as already mentioned, so theVA will be 6/6. But if a subject can read only the 7st lineat 6 meters (which should be read at 60 meter) then thevisual acuity will be 6/60. If the VA is less than 6/60,then the subject is moved towards the chart i.e., 3/60. Ifthe top line cannot be read at a distance of one meter i.e.,worse than 1/60 then VA is reported as counting fingers(CF), seeing hand movements (HM) or only perception oflight (PL).

Field of Vision

To elicit this, patient must be able to see the fingers froma distance of at least 3 feet or one meter.

Ideally, the field of vision is measured by perimetrybut in the clinical set up in the wards, confrontationmethod is applied. Following steps are to be followed:

The Candidate


2. Exposes the patient adequately, observing themodesty.(especially if the patient is wearing a veil)

3. Makes sure the light is adequate and natural.4. Makes the patient sit opposite to him at the same

level about a meter apart.5. Asks the patient to close his one eye e.g., left eye with

his left hand.


6. Asks the patient to look and focus his right eye onhis (candidate’s) left eye.

7. The candidate closes his right eye with his right palmon the same side.

8. The candidate focuses his left eye on the patient righteye ball for any movements. (The patient looks atcandidate’s opened eye and the candidate looks atpatient’s opened eye)

9. The candidate out stretches his left upper limblaterally as far as possible midway between patientand himself with index finger extended and otherfingers flexed.

10. The candidate wiggles his extended index finger andbrings his hand with the wiggling finger near thepatient.

11. Instructs the patient to tell immediately when theindex finger of the candidate is seen wiggling.

12. Makes sure that patient’s eye ball does not move orfollow the index finger of the candidate.

13. When the candidate sees wiggling index finger, thepatient should also be able to see it providedcandidate’s field of vision is normal.

14. The candidate tests this in all the directions orquadrants.

15. Checks the field of vision of other eye in the samemanner.

16. Helps the patient redressing (if wearing a veil)17. Thanks the patient for his cooperation.18. Comments on his findings while presenting to the

examiner.


PEARLSa. Another crude method called “Menace reflex” is used

when the patient is not cooperative. In this method,the patient is asked to look ahead and the examinerbrings palm of his hand rapidly towards the patientin front of his face from one side. The patient blinksreflexly. Examine each quadrant and also the other eyein a similar way.

b. One should move finger from blind area to area ofvision.

c. A wiggling or moving finger is easily appreciated thana static finger.

d. One can use a red, white or green coloured “hat pins”in turn. The visual fields for coloured objects are smallerthan for white objects. They are useful to plot scotomas.

e Visual inattention defects are assessed by the examinermoving fingers of both hands separately or togetherand the subject is asked to identify which finger ismoving. Examiner’s both upper limbs are out stretchedhorizontally but in opposite directions. Visual field onaverage extends about 100° outwards (temporally), 60o

degree upward (superiorly), 60° inwards (nasally) and75° downwards (inferiorly).

f A more precise method of mapping of the peripheralfields is by perimetry.

g Alternatively, a Bjerrum screen is used with a whiteor red disc being moved radially inwards against ablack background. Loss of parts of visual fields calledscotomas can easily be mapped out. Therefore,assessment can be made as far as damage to optic nerve,optic chiasma, optic tract and optic radiation.

h. Colour Vision: In the wards, a simple method may beused i.e., showing objects of different colours e.g., book,pen, clothes, neck tie to the patient and then ask about


the colour. Both eyes should be tested separately. Red,green and blue colours are called primary colours.Normal colour vision is declared if the patient is ableto identify these colours.

CHECK LIGHT AND ACCOMMODATION REFLEXES

Light Reflex

The Candidate


2. Exposes the patient adequately, observing the modesty(especially if the patient is wearing a veil).

3. Patient should be in a shade or indirectly illuminatedroom.

4. Examines each eye separately.5. Asks the patient to look into distance to relax

accommodation.6. Shines a bright light into one eye.7. Observes papillary constriction and notes that it

immediately relaxes (dilates) and after a fewcontractions settles down to a smaller size.

8. Observes that switching of light dilates the pupilwhich goes back to its original size.

9. Tests the consensual light reflex by keeping one eyein shade while shining light into other eye (puts hisstretched hand vertically over the patient’s bridge ofthe nose).

10. Observes the pupil of non-illuminated eye.11. Helps the patient redressing.(if wearing a veil)12. Thanks the patient for his cooperation.13. Comments on his findings while presenting to the

examiner.


PEARLS

a. In optic neuritis Gunn pupil is observed which is dueto an afferent defect i.e., lesion in optic nerve.

b. Wernicke pupil reaction though is difficult to elicit,involves less active papillary light reaction when thebeam is shown from the hemi-anopic side, than whenshown from normal side.

Accommodation Reflex

The Candidate


2. Exposes the patient adequately, observing the modesty(especially if the patient is wearing a veil).

3. Makes sure the light is adequate and natural.4. Asks the patient to hold his head straight.5. The candidate holds his index finger close to

patient’s nose.6. Asks him to look far away from it.7. Asks him to look quickly at the finger (it is better to

lift the eye brows for a good response).8. Notes the convergence of the eyes.9. Notes that the pupils also constrict.

10. Asks the patient to hold his finger about 30 cm infront of his face if his vision is impaired.

11. Asks him to look at the finger.12. Notes convergence of eye balls and constriction of

the pupils.13. Helps the patient redressing (if wearing a veil).14. Thanks the patient for his cooperation.15. Comments on his findings while presenting to the

examiner.


PEARLS

a. Argyll Robertson’s pupil is a classical papillaryabnormality of neurosyphilis. The pupil is small,irregular; it does react briskly to accommodation butdoes not react to light. The response of pupil tomydriatics is slow. One side may be involved morethan the other. The lesion is in the pretectal region ofthe mesencephalon.

b. Adie’s pupil or tonic pupil has absent or delayedpapillary constriction to light and accommodation.Once constricted it dilates slowly. It varies in sizeduring the day, time to time but never reacts promptlyto light. It is associated with absent tendon reflexesoften on the same side as the papillary abnormalitycalled Holmes-Adie syndrome.

c. Candidate should know various types of papillarycharacters, features of Horner’s syndrome, differentcauses of small and large pupils and other associatedconditions.

Examine this Patient for Squint

The Candidate


2. Exposes the patient adequately, observing the modesty(especially if the patient is wearing a veil)

3. Makes sure the light is adequate and natural.4. Places an object about a meter in front of the patient.5. Asks the patient to look at this object with both eyes.6. Looks at the patient for any obvious squint (primary

deviation).7. Covers the patient’s eye which is apparently fixing.


8. Looks for any deviation of the uncovered eye andnotes any movement of the eye trying to fixate.

9. Shifts the cover to the other eye.10. Looks for any deviation of the uncovered eye making

any movement in taking up fixation (secondarydeviation).

11. Moves and shift the cover quickly from one eye toother eye to confirm findings.

12. Helps the patient redressing. (if wearing a veil)13. Thanks the patient for his cooperation.14. Comments on his findings while presenting to the

examiner.

PEARLSa. In case of paralytic squint, diplopia occurs. However,

no paralytic squint usually occurs in childhood andis due to a lazy eye unable to focus at any object dueto some pathology in the retina or due to refractiveerror.

b. Primary deviation is the deviation of the paralysedmuscle where as secondary deviation is the deviationof non-paralysed muscle. Primary deviation is equalto secondary deviation in non-paralysed squint.

Perform Fundoscopic Examination

OrLook into this patient’s fundusOrPerform ophthalmoscopy(Explain the procedure to the patient)

The Candidate



2. Exposes the patient adequately, observing themodesty.(especially if the patient is wearing a veil)

3. Makes sure the examination is done in a darkenedenvironment.

4. Uses mydriatics before the examination. (firstly ruleout close angle glaucoma)

5. Asks the patient to look straight ahead and fix bothhis eye on a selected distant object.

6. Holds the ophthalmoscope in his right hand withits lens at ‘0’ and places in front of his right eye,as close as possible pressing it at the side of noseand superior orbital margin and with the index fingerover the lens rotator.

7. Places his left hand over the head of the patient withleft thumb, elevating the right eye brow of the patientand also holding the head.

8. Switches on the light of ophthalmoscope.9. Starts examination at a distance of about 20-30 cm

away from patient’s eye.10. Performs slight twisting movements of the

ophthalmoscope to see a red reflex (any opacity inthe field will look dark).

11. Proceeds close to the patient’s eye seeing the red reflex.12. Comes as close to the patient as possible without

touching his eye lashes or cornea.13. Looks at the retinal blood vessels and notes its

character.14. Looks in all four quadrants by slightly angulating

the “head” of ophthalmoscope.15. Moves the lens of rotator to focus clearly on the

fundus.16. Looks carefully on the disc and its margins.17. Asks the patient to look directly into the light of

ophthalmoscope and observes the macula.


18. Examines both eyes in turn.19. Helps the patient redressing (if wearing a veil).20. Thanks the patient for his cooperation.21. Make notes of the abnormalities and comments on

optic disc, retinal arteries, veins, background of retinaand macula and any other abnormal findings whilepresenting to the examiner.

PEARLS

a. The rule of thumb for ophthalmoscopic examinationis simple i.e., for patient’s right eye, the examiner useshis right eye and holds the ophthalmoscope in his righthand and for examination of left eye of the patient,holds the ophthalmoscope in his left hand and useshis left eye. This procedure will avoid any direct contactof the face of examiner with that of the patient andtherefore would not breathe directly into his face whichcan be very irritating to patient as well as to theexaminer. This also allows the patient to see far awaywith his unobstructed eye so that the pupils remainrelaxed.

b. If lenses are numbered in black they are positive lenses(convex) and indicate hypermetropia, if the lenses arenumbered in red they are negative lenses (concave) andindicate myopia.

Examine Ocular Movements

The command actually tests the oculomotor (3rd), trochlear(4th) and abducent (6th) cranial nerve simultaneously.They all supply the extraocular muscles which rotate theeyeballs in different directions.

These nerves are tested as follows to elicit.i. Movements of eyeball

ii. Nystagmus


iii. Ptosisiv. Size and shape of the pupilsReaction to light (direct and consensual) and toaccommodation has already been discussed previously (Seeon page 187).

The Candidate

1. Stands in front of the patient.2. Greets, introduces himself to the patient and asks

permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks for any history of diplopia.7. Fixes the patient’s head and asks him to look far

away.8. Stabilizes the head of the patient in the centre by

holding it with his left hand placed over the vertex.9. Holds the right index finger about a foot’s distance

in front of the patient’s eye.10. Notes any squint obviously present in resting

position.11. Notes the papillary size.12. Notes for the presence of ptosis.13. Instructs the patient to follow the finger when it moves

without moving his head.14. Moves the finger horizontally to either direction i.e.,

right and left.15. Moves the finger upward and downwards when the

eyes are either adducted or abducted (sometimesnystagmus can be seen as well).

16. Checks separately each eye.


17. Checks both eyes simultaneously.18. Helps the patient re-dressing.( if wearing a veil)19. Thanks the patient for his co-operation.20. Comments on any abnormal findings.

PEARLS

a. Do not adduct or abduct eyes to extremes asspontaneous nystagmus occurs normally.

b. Eye normally moves 50° medially, 30° upwards and50° downwards.

c. Normal gaze is conjugate gaze i.e., both visual axismove parallel.

d. Patient complains of diplopia when eye ball is turnedin the direction of action of weak muscle.

e. In third nerve palsy, eye ball is deviated downwardsand laterally with dilated pupil and partial or completeptosis.

f. In forth nerve paralysis medial deviation occurs.g. In sixth nerve palsy, medial deviation occurs.h. In 4th nerve palsy, adducted eye does not move

downwards and in sixth nerve palsy the eye does notabduct fully.

i. See previous pages for examination of patient withsquint

Examination this Patient for Nystagmus

The Candidate



(in females wearing the veil).


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Holds his index finger about 12 inches away in front

of the patient’s eyes.7. Asks him to keep looking at his finger.8. Looks for rhythmical movements of the eye balls if

nystagmus is present.9. Moves the finger to the left and right, upwards and

downwards.10. Maintains deviation on each side for at least

5 seconds.11. Avoids deviation to the extreme of the lateral gaze.12. Notes the presence of nystagmus or absence of

nystagmus.13. Makes a note of nystagmus whether:

• Horizontal, vertical or rotatory• Pendular or jerky• Direction of fast component• Severity of nystagmus• Possible aetiology of nystagmus.

14. Helps the patient redressing (if wearing a veil).15. Thanks the patient for his cooperation.16. Comments on any abnormal findings.

PEARLS

a. Nystagmus cannot occur in a comatosed patient, asit requires fixation of the eyes and a comatosed patientcannot do that.

b. One should not hold the object either too close to tooextreme to the lateral sides, as it can lead tospontaneous jerky movements.

c. It may take 5 seconds for nystagmus to occur. Therefore,one should maintain deviation for at least 5 seconds.


d. The direction of the fast component is the directionof the nystagmus.

e. Grading of nystagmus is done as follows:• First degree — Occurs only on looking in the

direction of the fast component.• Second degree — Occurs while looking straight

ahead.• Third degree — Occurs even looking in the direction

of slow component.f. Congenital nystagmus is associated with albinism.g. Traveller’s nystagmus is seen during travelling in train

looking outside through the window while the trainis moving.

Examine the Trigeminal NerveIt is a mixed nerve and has ophthalmic and maxillarydivisions which are sensory whereas mandibular divisionis both sensory and motor. The examination of this nervecomprises the following components:

Checking touch pain and temperature sensations inthe above three divisions.1. Checking conjunctival and corneal reflexes.2. Checking the muscles of mastication.3. Eliciting jaw jerk (deep reflexes).

For conjunctival and corneal reflexes, ophthalmicdivision is sensory and facial nerve is motor and closureof the eyes is mediated by orbicularis occuli.

The Candidate



modesty (in females wearing the veil).


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Checks symmetry of the temporal fossae.7. Checks that angles of jaw are symmetrical.8. Asks the patient to clench his teeth.9. Palpates the temporalis muscles simultaneously.

10. Palpates the masseter muscles simultaneously.11. Examines and compares both sides.12. Asks the patient to open the mouth after placing hand

under his jaw and applying resistance upwards.13. Places one hand on each side of the jaw of the patient

and asks him to move from side to side againstresistance to check for lateral pterygoid muscles.

14. Checks for jaw jerk (see details under reflexes onpage 266).

15. Takes a wisp of cotton for light touch.16. Makes him feel the feeling of cotton wisp by lightly

touching on his forearm.17. Asks him to shut his eyes.18. Touches near the midline of forehead, upper front of

the sides of nose, malar region, upper lip, chin andanterior 2/3 of the tongue.

19. Asks the patient to say “yes” when he feels it.20. Compares with the opposite side simultaneously.21. Similarly checks for pain sensation with a pin.22. Checks for temperature sensation with warm and cold

water filled test tubes.23. Avoids angle of the jaw while testing this.24. Goes up to the vertex to check for ophthalmic division.25. Helps the patient redressing (if wearing a veil).26. Thanks the patient for his cooperation.27. Comments on any abnormal findings.


PEARLSa. Avoid checking the trigeminal nerve in the midline as

the fibres cross on the opposite side as well.b. Skin over the angle of jaw is supplied by second and

third cervical segments and not by trigeminal nerves.c. Check all types of sensations i.e. touch, temperature

(hot and cold) and pain.

Check for Corneal Reflex

The Candidate



(in females wearing the veil).4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Uses a wisp of cotton wool (Better if moistened with

water).7. Patient is asked to look at one side upwards and

inwards. (finger can be shown for this direction).8. Brings cotton wisp from the outer (lateral) side.9. Touches the cornea at its junction with conjunctiva.

10. Avoids touching eyelashes or eyelids.11. Observes the positive reflex (Sudden closure of the

eye shows normal reflex).12. Tests the other eye in the same way.13. Helps the patient redressing (if wearing a veil).14. Thanks the patient for his cooperation.15. Comments on any abnormal findings.


PEARLS

a. Avoid touching middle of the cornea as it can bedamaged thus resulting in serious visual impairment.

b. Alternately a puff of air can be used instead of a cottonwisp.

c. Try to avoid patient seeing the cotton wisp approachingto his eyes. If he sees it, reflex blinking can occur.

d. Wisp is moistened so as the avoid damage to thecornea.

e. Corneal reflex is absent in 5-10% of normal subjects.f. Blinking of eye being touched is called direct corneal

reflex and of the opposite eye is called “consensualcorneal reflex.”

Examine the Facial Nerve

The 7th nerve supplies the muscles of facial expressionand platysma except levator palpebrae superioris.

This nerve also has two parts. A motor part, whichsupplies muscles of facial expression and the sensory part,which carries taste sensations from the anterior 2/3 ofthe tongue.

The Candidate



(in females wearing the veil).4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Inspects the face for any obvious asymmetry.7. Inspects the wrinkles on the forehead.8. Observes the nasolabial folds.


9. Looks at both palpebral fissures.10. Observes any involuntary movements, excessive

lacrimation and salivation from either angle of themouth.

11. Asks the patient to wrinkle forehead and observe thesymmetry.

12. Asks the patient to shut his eyes and observes theattempt to close eye and notes the upward rollingof the eye ball on either side (Bell’s phenomenon).

13. Attempts to open the tightly closed eyes by his fingersand notes which side opens easily.

14. Asks the patient to show the teeth and notes whichside the angle of mouth is deviated (non-paralysedside)

15. Asks the patient to whistle.16. Asks the patient to blow his mouth and while the

air is the patient’s mouth tries to push it with hisfingers from outside and notes which side it leaksfrom.

17. Everts the lower lip and asks the patient to say “eeee”.(This manoeuvre checks for platysma)

18. Notes down abnormalities and also inspects the backof ear especially for any parotid swelling (extension)or discharge, vesicles on the ear pinna and mastoidarea.


PEARLS

a. Candidate should differentiate between upper motorneurone (UMN) and lower motor neurone (LMN)lesions of facial nerve by interpreting wrinkles onforehead and ability to close both eyes.


b. While asking patient to close his eyes, look at the anglesof mouth which are normally drawn upwards on bothsides.

c. In comatosed patient, during expiration air emergesout from the angle of mouth on the paralysed side andis an important sign to detect the side of paralysis inan unconscious patient.

d. Bell’s phenomenon is present in LMN lesion.e. It is important to test for lacrimation, salivation and

taste to know exactly the level of the lesion in casesof LMN facial palsy.

f. Hyperacusis is due to paralysis of stapedius muscle.g. In UMN the lower part of face is affected and forehead

is spared as it has bilateral cortical supply.

Check for Taste Sensation

The Candidate



(in females wearing the veil).4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Explains the procedure to the patient.7. Uses solution of salt, sugar, and vinegar.8. Asks the patient to protrude his tongue.9. Holds the tip of the tongue with a sterile gauze piece.

10. Applies the solution on the side of the tongue aboutan inch behind the tip.

11. Instructs the patient not to speak but raise the indexfinger if he tastes sweet, middle finger if bitter andthumb if saltish taste is experienced.


12. Asks the patient to rinse the mouth with water aftertesting with each taste (Quinine is applied in the endto check bitter taste).

13. Both sides are examined and compared andcomments are made.


PEARLS

1. While testing the taste, patient should not speak aswhen he speaks, the pooled saliva will spread thesolution to be tested on both sides.

2. Bitter taste is tested in the end as its effect lasts longer.3. Loss of taste is called ageusia and the lesion can be

any where from tongue to the central course of fibres.

Check the Auditory Part of Eight Nerve

Eight nerve has two parts, the auditory component andthe vestibular component. The former is for hearing andthe later is for keeping equilibrium of eyes, head and body.

The Cochlear Part of 8th Nerve

The Candidate



modesty.(in females wearing the veil)4. Makes sure the light is adequate and natural and

there is no noisy surrounding atmosphere.5. Does a general survey of the patient.


6. Makes sure that the external auditory meatus is freeof wax and fungus ball.

7. Tests one ear at one time while the other ear is tightlyclosed.

8. Brings a ticking watch near the ear form a distance.9. Asks the patient to tell when he hears the ticking of

watch (normally heard with in a distance of two feet).10. Tests both ears separately.11. Compares the distance to his own ear provided his

hearing is normal (It is better to estimate the distanceon a normal individual first).

12. Talks to the patient with ordinary loud voice withone ear closed.

13. Talks with low voice, and then talks in a whisperif patient can hear.

14. Notes and makes comments on that examination(If deafness is detected should, differentiate betweenconduction deafness and neural deafness)

15. Performs Rinne’s test—explains to the patient.16. Uses a tuning fork of 256 or 512 Hz.17. Holds a fork from stem in one hand.18. Strikes the prongs on the thenar eminence of the other

hand.19. Places the base of the fork on the mastoid process

of the patient and asks the patient whether he hearsany buzzing sound.

20. Places the prongs near his external auditory meatuswithout touching the ears.

21. Asks the patient whether he can hear the buzzingsound now or not.

22. Comments as Rinne’s positive or negative.23. Repeats the same procedure on the other ear.24. Comments as Rinne’s positive or negative.25. Performs Weber’s test.


26. Uses a tuning fork of 256 or 512 Hz.27. Holds the stem and strike the blades over the thenar

eminence of other hand.28. Places the base of fork in the midline over the vault

of skull or midline of the forehead.29. Asks the patient whether he can hear equally or not

in both ears.30. Comment as whether the test is lateralized to right

or left side.31. Helps the patient redressing (if wearing a veil)32. Thanks the patient for his cooperation.33. Comments on any abnormal findings.

PEARLSa. Sometimes the hairs in front of the ear are massaged

and patient is asked to tell whether he can hear ornot.

b. Wax or any foreign body in external acoustic meatusshould be ruled out before labelling a person deaf.

c. Positive Rinne’s means that air conduction is betterthan bone conduction and Rinne’s negative means thatbone conduction is better than air conduction.Normally, air conduction is better than boneconduction.

d. In nerve deafness, sound of a tuning fork is not heardor equally less heard either through air or through bone.

e. In Weber’s test, in normal ears sound is heard equallyon both sides. If sound is heard better in deaf ear thannormal side, conduction deafness is present in thatear, if it is nerve deafness in that ear, sound will bebetter heard in normal ear. Tricky!


Vestibular Part of 8th Nerve (Caloric test)

The Candidate



(in females wearing the veil).4. Makes sure the light is adequate and natural and

there is no noisy surrounding atmosphere.5. Does a general survey of the patient.6. Positions the patient’s head at 30° angle.7. Rules out any perforation in the tympanic membrane

or any infection or obstruction in the external acousticmeatus.

8. Asks the patient who is lying supine to focus at onepoint (preferably at the ceiling).

9. Fills a syringe with 20-30 millimetres of either coldor warm sterile water (The temperature of cold watershould be 30°C and of hot water should be 44°C, insequence).

10. Irrigates each ear with either cold or warm water for40 seconds.

11. Notes occurrence of any nystagmus, its duration anddirection.

12. Examines both sides alternately.13. Helps the patient redressing (if wearing a veil).14. Thanks the patient for his cooperation.15. Comments on any abnormal findings.


PEARLS

a. The head is brought to 30° to bring the horizontalcanals in vertical plane.

b. If ear drum is perforated, hot or cold air can beinsufflated.

c. If there is canal paraesis, the duration of nystagmusis reduced (normal is 2½ minutes).

d. In coma with intact pathways, cold water causes slowconjugate deviation of the eyes to the same side.

e. Mnemonics like COWS i.e., cold opposite, warm sameside direction of nystagmus and other is ACTH i.e.,away from cold and towards hot are worth rememberingfor quick recall.

f. Nystagmus cannot occur in a comatosed patient, asthe eyes have to be fixed. However, gaze direction canbe elicited in the comatosed patient.

Examine Glossopharyngeal and Vagus Nerves

Both these nerves are mixed nerves and share most of theirfunctions; therefore these two nerves are testedsimultaneously for most of their functions.

Vagus nerve is the only cranial nerve with maximumlength.

Abducent nerve is the cranial nerve with the longestintracranial route.

The Candidate



(in females wearing the veil).


4. Makes sure the light is adequate and natural andthere is no noisy surrounding atmosphere.

5. Does a general survey of the patient.6. Asks the patient whether he had recent meal.7. Asks the patient to open the mouth while keeping

the tongue inside the mouth.8. Uses a tongue depressor if necessary.9. Looks for any pooling of saliva in the floor of mouth

and throat.10. Notes any symmetry of the palatal arches and

pharynx.11. Asks the patient to say “Aah” and observes the

movements of the palatal arches and pharynx.12. Asks the patient to say mug, egg to note any nasal

twang in case of palatal palsy.13. Looks for any asymmetry of fauces.14. Touches the palate or pharynx on one side with a

cotton swab or tongue depressor.15. Notes the gag reflex i.e., contraction of palate, pharynx

and posterior one third of tongue.16. Examines both sides.17. Helps the patient redressing. (if wearing a veil)18. Thanks the patient for his cooperation.19. Comments on any abnormal findings.

PEARLS

a. Sensation of taste can be examined in the posterior1/3 of tongue in the same way as the anterior twothird of tongue but it is more cumbersome anduncomfortable to the patient.

b. If the patient has had a meal recently, then gag reflexshould not be elicited as it can cause vomiting, thereforeit is mandatory to ask the patient about a recent mealbefore such examination is carried out.


c. Position of uvula is variable at rest even in health andshould not be used as a reference point for the deviationof the soft palate to one side.

d. Muscles move towards the normal side in unilateralpalatal and pharyngeal paralysis.

e. If hoarseness is there and vocal cords are involved,it indicates pure vagal nerve involvement.

f. If palatal movements are normal on ‘Ah’ test but noresponse to tickling the soft palate occurs, this indicatesloss of sensation.

g. If ninth nerve is affected on both sides (sensory) but10th nerve is normal no response is seen on gag reflexbut ‘Ah’ test shows normal response.

h. In a patient with unilateral involvement of the 9th nervebut a normal 10th nerve, full response is seen bytickling normal side but no response is noted by ticklinginvolved side.

i. If 10th nerve is involved on one side but both 9th nerveare normal, the posterior pharyngeal wall is pulled tonormal side when the patient is asked to say ‘Ah’ andthe palatal movement is also according to ‘Ah’ test.

j. If on both sides, 10th nerve is involved but the 9thnerves are normal, contraction of muscles is absent,so naturally tickling is more important to see whetherresponse can be seen; patient shows facial expressionof discomfort or the patient may stop examiner byholding his hands and he might cough. In ‘Ah’ testthe palatal movements are absent.

k. It is the response to ‘Ah’ test that palatal andpharyngeal reflexes together help to decide about thefunctions of 9th and 10th nerve.


Examine Accessory NerveIt is purely a motor nerve and supplies sternomastoid andtrapezius muscles.

The Candidate


2. Exposes the patient adequately, observing the modesty.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Stands on the back side of the patient.6. Inspects and compares trapezius muscles on both

sides.7. Asks the patient to raise the shoulders and then tries

to push them down with his hands on patient’sshoulders (This tests the upper 1/3 of trapeziusmuscles).

8. Asks to retract scapulae against resistance andpalpates the suprascapular region for musclecontraction (This tests the middle 1/3 of trapeziusmuscles).

9. Asks the patient to face a wall and extend his armsat elbow and with both palms placed on wall, advisesthe patient to push or exert force with his both limbs.

10. Looks and feels for the fibres of lower 1/3 of trapeziusmuscles.

11. Examines both sides and compares the findings.12. Inspects the right and left side of the neck for wasting.13. Asks the patient to turn his face towards one side

against resistance by his hand placed on the sameside of the chin and mandible.

14. Feels the opposite sternomastoid for contraction.15. Examines both sides and compares the findings.


16. Asks the patient to bend his head forwards againstresistance offered by his hand placed under patient’schin and feels for both sterno mastoids for contraction.

17. Helps the patient redressing.18. Thanks the patient for his cooperation.19. Comments on any abnormal findings.

PEARLS

a. Accessory nerve supplies only upper 1/3 of trapeziuswhereas remaining 2/3 of trapezius is supplied bycervical roots C3-C4 from the spinal cord.

b. Bilateral paralysis of both sternomastoid leads to fallingof the neck to the back with inability to flex the neck.

c. If you ask the patient to bend his head forwards againstresistance, then both sternomastoid muscles contract.

d. Flexion of neck will occur only on normal side whereason the paralyzed side, the neck will not flex.

e. Ask the patient to get up from a supine position. Thehead normally leaves the pillow first.

Examine Hypoglossal Nerve

This is purely a motor nerve and supplies the musclesof the tongue and depressor of the hyoid bone.

The Candidate



modesty.(in females wearing the veil)4. Makes sure the light is adequate and natural and

there is no noisy surrounding atmosphere.


5. Does a general survey of the patient.6. Asks the patient to open the mouth and keep the

tongue inside (this relaxes tongue and inspection ismade lot easier).

7. Looks for any wasting, wrinkling or twitching of thetongue.

8. Asks the patient to protrude the tongue as far aspossible in the midline.

9. Asks the patient to move the tongue side to side andthen turn upwards.

10. Asks the patient to push his cheek from inside withthe tip of his tongue and feels the resistance fromoutside the respective cheek by pressing the tonguefrom outside with some resistance.

11. Tests on both sides.12. Palpates the tongue using a gauze piece while the

tongue is inside the mouth, resting on the floor ofmouth.

13. Helps the patient redressing. (if wearing a veil)14. Thanks the patient for his cooperation.15. Comments on any abnormal findings.

PEARLS

a. In unilateral hypoglossal lesions, protruded tonguedeviates to the side of the lesion.

b. Wasting of tongue appears as wrinkling and furrowingon that side and is also called scrotal tongue.

c. Fasciculations are observed while the tongue is restingin the floor of the mouth.

d. Normal twitching movements and fasciculations oftongue should be differentiated from true fasciculationswhich occur in motor neurone disease (MND) by theinconsistent nature and absence of associated wastingof tongue.


e. In facial paralysis, there might be an apparent deviationof the tongue to one side. Compare the position of themedian raphe of the tongue in relation to the centralupper incisors.

f. When the tongue is palpated which is protruded out,it feels apparently firm.

g. In myotonia, tapping the tongue with a sharp objectresults in the appearance of a dimple.

h. If the marks of indentation of teeth occur on the lateralside of the tongue, the tongue is presumed to beenlarged.

i. The candidate should be aware of different types oftongues.

j. The candidate should be able to differentiate betweenupper and lower motor neuron lesions of the tongues.

Examine for Horner’s Syndrome

This is due to the involvement of sympathetic nervoussystem affecting the cervical sympathetic ganglia andchain.

The Candidate



modesty. (in females wearing the veil)4. Makes sure the light is adequate and natural and

there is no noisy surrounding atmosphere.5. Does a general survey of the patient.6. Examines the eyes for partial ptosis.7. Looks for sunken eye (enophthalmos).8. Looks at conjunctiva for any congestion.


9. Looks at iris and comments on any depigmentation.10. Looks at pupil size using dull light.11. Compares both sides.12. Examines for light and accommodation reflex.13. Feels for presence or absence of sweating on the face,

neck, arms and upper trunk.14. Elicits ciliospinal reflex.15. Helps the patient redressing. (if wearing a veil)16. Thanks the patient for his cooperation.17. Comments on any abnormal findings.

PEARLS

a. In Horner’s syndrome following components arepresent:• Enophthalmos• Miosis• Ptosis• Anhidrosis• Loss of ciliospinal reflex.

b. The light and accommodation reflexes are normal inHorner’s syndrome because pathways involved forthese reflexes are not sympathetic.

c. Adrenalin 1:1000 eye drops dilate the pupil only inpostganglionic Horner’s syndrome due to denervationhypersensitivity. Cocaine dilates the pupil only in pre-ganglionic Horner’s syndrome. Both these agents donot have any effect on normal pupil.

d. Conjunctivae become congested in Horner’s syndromedue to loss of vasoconstrictor activity due to sympatheticparalysis.

e. In congenital Horner’s syndrome, the iris isdepigmented.

f. In bilateral Horner’s syndrome, only ptosis can givea clue.


g. Absence of sweating occurs only in central Horner’ssyndrome, the area of anhidrosis depends upon thelevel of lesion. However, in peripheral Horner’ssyndrome there is no anhidrosis.

h. Migraine can lead to intermittent Horner’s syndrome.


MOTOR SYSTEMAs already mentioned, motor system is examined underthe following headings:• Bulk of muscles• Tone of muscles• Power of muscles• Coordination• Involuntary movements• Reflexes• Gait.

The three principles of inspection, palpation andpercussion are beautifully applied in this system. Inspectfor the bulk of muscles, involuntary movements, wasting,and palpate for the tone/pain and thickened peripheralnerves, percuss (taping) the course of nerve to producetingling sensations or fasciculation, etc.

Examination of Bulk of Muscles

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Compares and looks at the muscles to have a general

idea about their size.7. Takes a point from anterior superior iliac spine to

the middle of thigh on both sides for lower limbs.8. Measures and compares the circumference.9. Takes a point from the tibial tuberosity to the middle

of the calf on both sides.


10. Measures and compares the circumference.11. Takes a point from the medial epicondyle to middle

of upper arm on both sides for upper limbs.12. Measures the circumference and compares.13. Takes a point from styloid process of ulna to the

middle of forearm on both sides.14. Measures the circumference and compares.15. Helps the patient redressing.16. Thanks the patient for his cooperation.17. Comments on any abnormal findings.

PEARLSa. Muscles of face, hands, feet, neck, and trunk are not

accessible for measurement. This is assessed by generallook e.g., guttering of the small muscles of hands,prominent intercostal spaces, sunken abdomen,prominent temporal fossae, etc.

b. For upper limbs a point from olecranon process 10 cmabove and below can be used to measure the bulk ofupper arm and forearm. Similarly, a point 18 cm aboveand 10 cm below the tibial tuberosity can be used tomeasure the circumference of the thigh and legrespectively.

c. Undue prominence of the bony points can give a clueto wasting as well.

d. Candidate should know a check list of muscle atrophy,hypertrophy especially causes of wasting of smallmuscles of hand.

Check for Tone of MusclesIt is state of tension or contraction found in healthy muscleor resistance felt during passive movements. Tone isassessed in the upper and lower limbs by passivemovements at the major joints.


The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to relax the limbs e.g., lower limbs.7. Makes the patient lie supine.8. Places one palm under the knee joint and the other

palm over the knee joint.9. Moves the knee joint side to side rapidly to relax the

muscles.10. Lifts up the knee joint suddenly by placing palms

of both hands together behind the popliteal fossa.11. Observes the behaviour at the heels.12. Compares both sides.13. Helps the patient redressing.14. Thanks the patient for his cooperation.15. Comments on any abnormal findings.

PEARLS

a. Normal tone must be appreciated by candidates byexamining hundreds of patients.

b. Normal tone can not be defined in words but betterfelt.

c. Another alternative method is to hold up both limbspassively and dropping them suddenly. A hypotoniclimb drops faster than a normal one. The heels slipdown slowly if there is normal tone, rapidly if thereis hypotonia and very slowly if there is hypertonia.

d. Tone is also felt by moving the limbs at joints and feelingfor any resistances.


e. Tone is best felt during extension of the limb.f. Spasticity is appreciated by rapid movements where

as rigidity is better appreciated by slower movements.g. Rigidity is enhanced by asking the patient to clench

his opposite fist (Jendrassinks’ manoeuvre).h. To elicit rigidity in Parkinson’s disease or extra

pyramidal involvement, the movements should beperformed in small steps to feel for cog wheeling orlead pipe rigidity.

i. Candidate should be well aware of different types ofrigidities i.e., clasp knife, cogwheel and lead pipe etc.

j. Candidate should also be aware of hypotonia,hypertonia and their causes as a check list to beremembered.

k. Another method to elicit tone is to place right handover the shin and the left hand on the middle of thethigh and roll these hands from side to side rapidly.In hypotonia the movement of the feet is seen as flabbyat the ankles.

Test the Power of Muscles

To test the power of muscle is to resist the action of amuscle or a group of muscles and comment on the power,depending on the power to be used by the examiner toresist patient’s power. One should be well aware of nervesupply and action of the muscles to be tested. Activemovements are performed by the patient whereas passivemovements are elicited by the examiner and this helpslocating the joint pain and stiffness.

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Examines the position of the limbs e.g., lower limbs

to be tested.7. Positions the limbs properly in the opposite directions

of the movement to be tested. (For example, ifadductors of hip joints are to be tested, keep the legin full abduction at the hip joint and vice versa).

8. Examines and compares both sides.9. Gives a grade to the power of the muscle to be tested.


PEARLS

a. The grading should involve the followings:i. Grade 0: No movement at all, complete paralysis.

ii. Grade 1: A flicker is present, but there is nomovement at joint.

iii. Grade 2: Patient can move limbs when gravity iseliminated.

iv. Grade 3: Patient can move and hold against thegravity but not against examiner’s resistance.

v. Grade 4: Movements are possible against gravityand moderate resistance.

vi. Grade 5: Normal power is present.b. It is important to note that in UMN lesions, groups

of muscles with similar joints function are affected.Therefore, in hemiplegia, major joints are tested asregards their movements.

c. In LMN lesions i.e., at individual level, each muscleis tested individually.


d. Each movement during this assessment of power iscompared with examiner’s own strength or with hisjudgment for the comparable age and built of thepatient.

e. Very simple commands should be given rather longexplanation to the patient.

f. A demonstration or gesture is more effective than anyverbal explanation.

g. Certain muscles and muscle groups are more importantthan others representing particular function as a wholeor a group.

h. Certain peripheral nerves when involved requireexamination of individual muscles they supply.

i. To elicit abnormal movements e.g., fasciculations, therubber part of patellar hammer or even the tips of threefingers are tapped on muscle to elicit any abnormaltwitching of its fibres which is called fasciculations.The muscles on the medial side of the thigh or calfare used normally to elicit this response.

j. The candidate should know certain manoeuvres toshow the power of group of muscles or individualmuscle and it is obtained after repeated rehearsals andpractice.

Check Power of the Individual Muscles

In this section, a simple plan is outlined for checking powerof individual muscles and an attempt has been made toinclude almost all muscles. Simple instructions are givento the patients to check power of the muscles and theseinstructions should be remembered by the candidate sothat he should not face any difficulty during examinationand this can only be achieved by continuous practice oncolleagues or actual patients. For example, measurementof power of spinal flexion can be obtained by asking the


subject to raise his head and shoulders off the couch whilesupporting his thighs. Resistance can then be added withpressure which is applied to sternum. In checking resistedmovements, the subject is asked to prevent the examinerfrom moving the part away from a fixed position. Unlessthe candidate remembers these instructions to be told tothe patient and act thereafter, he would not be able tocheck the power properly.

MUSCLES OF THE UPPER LIMB

Deltoid (C5, C6)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to hold arm in abduction more than

30° but less than 90°.7. Presses the arm of the patient towards him.8. Looks at the muscle contracting and feels with the

other hand the contracting middle fibres of the muscle.9. Moves the abducted arm forwards to 60° and back

wards to 50-60° and observes and feels anterior andposterior fibres respectively.



Supraspinatus (C4, C5, C6)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to keep the arm by his side.7. Asks him to abduct the arm against his (candidate’s)

resistance e.g., initial 30° of movement.8. Palpates the muscle in the supraspinous fossa.9. Examines both the sides.


Infraspinatus (C5, C6)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to adduct arm at the shoulder and

bend the elbow at 90o.7. Asks the patient to turn the flexed forearm backwards

against resistance which is offered in oppositedirection by him (candidate).


8. Feels for the muscle in the infraspinous fossa.9. Examines and compares on both sides.


Subscapularis [C5,C6,(C7) ]

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to adduct the arms fully at the

shoulder.7. Asks the patient to flex his elbow at 90°.8. Asks the patient to turn the forearm medially against

resistance (offered by the candidate in oppositedirection).


Rhomboids (C4 C5)

The Candidate



modesty.


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to place his palm on his hip.7. Asks the patient to push his elbows backwards

against resistance (offered by the candidate in oppositedirection).

8. Feels the muscle contracting in the infrascapularregion.

9. Examines and compares on both sides.10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on any abnormal findings.

Latissimus Dorsi (C6, C7, C8)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to abduct arms to > 90° at shoulder.7. Asks the patient to adduct the arms against resistance

(offered by the candidate in opposite direction).8. Feels for the muscle contracting in the posterior

axillary fold.9. Examines and compares on both sides.



PEARLS

There are two other alternative methods to test latissimusdorsi muscle as follows:

Method 1

• Patient arm is abducted to > 90°.• He is asked to cough forcibly.• Feel the muscle contracting in the posterior fold of axilla.

Method 2

• Patient puts his hands behind his back.• Candidate stands behind the patient.• Candidate offers resistance to the downwards and

backwards movement of the hands.• Feels the muscle which stands out clearly.• Examines and compares both sides.

Serratus Anterior (C5, C6, C7)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to stand in front of a wall and directs

him to extend his arms.7. Asks the patient to place his palms over the wall and

directs him to push the wall with force.8. Stands at the back of the patient and observes winging

of scapulae if the muscles are paralysed.



PEARLS

The patient will have difficulty in abducting the arm above90° at the shoulder. The deformity becomes more apparentas he tries to do so.

Pectoralis Major

Clavicular part (C5, C6)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to raise the arms forwards.7. Asks him to adduct against resistance (offered by the

candidate in opposite direction).8. Observes the clavicular part which is seen contracting.9. Helps the patient redressing.

10. Thanks the patient for his cooperation.11. Comments on any abnormal findings.

Sternocostal Part (C7, C8 and T1)

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to abduct the arms to about 60° and

directs him to keep elbows flexed at 90o.7. Asks him to bring the hands together against


8. Observes the sternal part contracting.9. Examines and compares both sides.


Biceps Brachii (C5, C6)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to extend the arm at the elbow joint

and directs the patient to keep the forearm insupination.

7. Grips the wrist of the patient.8. Asks the patient to flex his arm at elbow against


9. Observes and feels the biceps muscle contracting.10. Examines and compares both sides.



Triceps (C6, C7, C8)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to flex the elbow joint.7. Holds the patient’s wrist with his hand.8. Asks the patient to extend the forearm against


9. Feels and sees the triceps muscle contracting.10. Examines both sides and compares.11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on any abnormal findings.

Supinator (C5, C6)

The Candidate





5. Does a general survey of the patient.6. Asks the patient to extend the elbow at the elbow

joint.7. Asks the patient to hold his forearm in full pronation.8. Asks the patient to supinate the forearm against


9. Examines and compares both sides.10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on any abnormal findings.

PEARLS

It is important to know that supinator muscle cannot beeither seen or felt. It is important to note that the elbowshould be extended, because if it is flexed then bicepscomes into action, which again is a supinator.

Brachioradialis (C5, C6 and C7)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to flex the elbow at 90° and directs

the patient to keep the fore arm in semipronatedposition.

7. Holds the wrist of the patient with his hand.


8. The patient is asked to flex his elbow further againstresistance (offered by the candidate in oppositedirection).

9. Observes for the brachioradialis muscle contractingnear the upper half of the forearm.


In checking different movements at hand, it is importantto keep hand in anatomical position i.e. the hand is placedon a flat surface with the palm or volar surface facingup.

Extensor Carpi Ulnaris (C7, C8)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to extend his fingers and holds them

with his (candidate) hand. Patient’s palm facingdown.

7. Asks the patient to extend the wrist towards the ulnarside while maintaining resistance (offered by thecandidate in the opposite direction).

8. Examines and compares both sides.9. Thanks the patient for his cooperation.

10. Comments on any abnormal findings.


Extensor Carpi Radialis Longus (C6, C7)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to extend the fingers partially and

he (candidate) holds them. Patient’s palm facingdown.

7. Asks the patient to extend the wrist towards the redialside while examiner exerts resistance (offered by thecandidate in opposite direction).

8. Examines and compares on both sides.9. Thanks the patient for his cooperation.


Extensor Digitorum (C7, C8)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to extend the fingers at metacarpo-

phalangeal joint.7. Asks the patient to flex them at metacarpo-phalangeal

joint with force and asks the patient to keep thatextended.


8. Notes any weakness of the muscles.9. Examines and compares both sides.


Flexor Carpi Radialis (C6, C7)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to place forearm with volar surface

facing up.7. Asks the patient to flex the wrist against resistance

(offered by the candidate in opposite direction)towards radial side.

8. Examines and compares on both sides.9. Thanks the patient for his cooperation.


Flexor Carpi Ulnaris (C7, C8)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.


6. Asks the patient to place forearm with volar surfacefacing up.

7. Asks the patient to flex the wrist against resistance(offered by the candidate in opposite direction) onthe ulnar side.

8. Examines and compares on both side.9. Thanks the patient for his cooperation.


Abductor Digiti Minimi (C8,T1)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to extend his elbow with the palm

facing upwards on a table.7. Asks the patient to move his little finger away from

him.8. The candidate applies resistance (offered by the

candidate in opposite direction) with his hand.9. Examines and compares both sides.


Flexor Digitorum Superficialis (C7,C8 and T1)

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to flex the fingers at proximal

interphalangeal joint (PIP).7. Applies resistance on the middle phalanges.8. Tests the medial four fingers.9. Examines and compares on both sides.

10. Thanks the patient for his co-operation.11. Comments on any abnormal findings.

Flexor Digitorum Profundus (C8 and T1)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to flex distal interphalangeal (DIP)

joints.7. Fixes the middle and proximal phalanges in

extension.8. The candidate applies resistance (offered by the

candidate in opposite direction) on the distalphalanges.

9. Tests the medial four fingers.10. Examines and compares both sides.11. Thanks the patient for his cooperation.12. Comments on any abnormal findings.


First Palmar and Dorsal Interossei (C8 and T1)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to keep the hands flat on the table.7. Asks the patient to adduct his fore-finger against

resistance (offered by the candidate in oppositedirection) (palmar interossei).

8. Asks the patient to abduct his forefinger againstresistance (offered by the candidate in oppositedirection) (dorsal interossei).

9. Examines and compares both sides.10. Thanks the patient for his cooperation.11. Comments on any abnormal findings.

Lumbricals (C8 and T1)First and second lumbricals by median nerve, third andfourth by deep branch of ulnar nerve.

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to extend his fingers at MP joints

and flexed at IP joints.


7. Asks the patient to extend the proximal or the distalIP joint against resistance (offered by the candidatein opposite direction).

8. Examines the medial four fingers.9. Examines and compares the findings on both sides.


Abductor Pollicis Longus (C7,C8)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to place the back of his hand flat

on the table.7. Asks the patient to point his thumb towards the

ceiling.8. Tries to resist this movement with his (candidate)

index finger.9. Examines and compares both sides.


Abductor Pollicis Brevis (C8,T1)

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to place back of his hand flat on

a table.7. Places on object e.g., a pencil or a piece of a paper

between the thumb and the base of the first finger.8. Asks the patient to keep that pencil or piece of paper

over there while exerting force against resistance(offered by the candidate in opposite direction).

9. Examines and compares both sides for anyabnormalities.


PEARLS

a. This muscle comes into action only in the terminal partof the abduction of the thumb. Initial part of themovement is performed by abductor pollicis longus.

b. It is the first muscle to show weakness in carpal tunnelsyndrome.

Opponens Pollicis (C8 and T1)

The Candidate





6. Directs the patient to keep his hand flat on a tablein such a way that the plane of thumb should remainparallel to the plane to the palm.

7. Asks the patient to touch the pulp of the other fingersof the same hand with the tip of the thumb.

8. The candidate tries to dislodge the contact byintroducing his index finger by making a hook.

9. Examines and compares both sides.10. Thanks the patient for his cooperation.11. Comments on any abnormal findings.

Adductor Pollicis (C8 and T1)

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to hold a paper between the thumb

and the palmer aspect of the forefinger.7. The candidate tries to pull the paper while the patient

tries to hold it.8. Examines and compares on both sides for any

abnormalities.9. Thanks the patient for his cooperation.


Extensor Pollicis Longus (C7,C8)

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to extend the distal phalanx of the

thumb against resistance (offered by the candidatein opposite direction).

7. Examines and compares on both sides for anyabnormalities.


Extensor Pollicis Brevis (C7,C8)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to extend the proximal phalanx of

the thumb (at the MP joints) against resistance.7. Examines and compares on both sides.8. Thanks the patient for his cooperation.9. Comments on any abnormal findings.

Flexor Pollicis Longus (C8 and T1)

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to flex the distal phalanx of the thumb

against resistance (offered by the candidate in oppositedirection).

7. Examines and compares on both sides.8. Thanks the patient for his cooperation.9. Comments on any abnormal findings.

Interossei (C8, T1) (Dorsal)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to abduct the fingers away from

midline.7. The candidate offers resistance (offered by the

candidate in opposite direction).8. Examines and compares both sides.9. Helps the patient redressing.


Interossei (C8 T1) (Palmar)

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to adduct the abducted fingers

(extended at DIP/PIP joints) towards midline.7. The candidate applies resistance (offered by the

candidate in opposite direction).8. Examines and compares both sides.9. Helps the patient redressing.

10. Thanks the patient for his co-operation.11. Comments on any abnormal findings.

PEARLS

Paralysis of lumbricals and interossei muscles can leadto claw hand.

Trunk Muscles (Abdominal muscles) (T7 to T12 and L1)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to lie supine.7. Asks him to place his both arms across his chest.8. Asks him to get up without support.9. Notes any weakness of the abdominal muscles

looking at the umbilicus and its movement.10. Helps the patient re-dressing.



PEARLS

a. Umbilicus is displaced towards the healthy (non-paralysed muscle)

b. In paralysis of lower abdominal muscles the umbilicusis pulled upwards and in paralysis of upper abdominalmuscles the umbilicus is displaced downwards. Thisis called Beevor’s sign.

Trunk Muscles (Erector spinae)

Nerve supply: Dorsal rami of cervical, thoracic and upperlumbar nerves.

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to lie down in the prone position.7. Asks the patient to clasp his both hands over his

back.8. Asks him to raise the head over his shoulders off the

bed by extending his neck.9. Observes for the erector spinae muscles which stands

out prominently.10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on any abnormal findings.


Iliopsoas (Iliacus-L2, L3), (Psoas-L1, L2, L3)

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to lie supine with both hips extended.7. Asks the patient to flex the thighs against resistance.8. Helps the patient redressing.9. Thanks the patient for his cooperation.


PEARLS

This muscle is a flexor of the hip but as it is intra-abdominal, therefore it cannot be seen or felt.

Diaphragm (C3, C4, C5)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to take a deep breath.7. Observes closely the movements of abdominal wall.8. Helps the patient redressing.9. Thanks the patient for his cooperation.



PEARLS

In paraesis of one side of diaphragm the abdominal wallmovements with respiration over that side are less,compared to normal side. Abdominal wall recession isnoted instead of expansion over the concernedhypochondrium.

MUSCLES OF LOWER LIMBS

Sartorius (L2, L3)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to lie supine.7. Abducts the thigh partially and rotates laterally.8. Asks the patient to flex the knee against resistance

offered by him in opposite direction. 9. Examines and compares on both sides. 10. Helps the patient redressing. 11. Thanks the patient for his cooperation. 12. Comments on any abnormal findings.

Adductors of the Hips (L5 and S1)

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Places patient’s extended lower limb in abducted

position.7. Asks the patient to bring it towards midline or bring

it inwards against resistance.8. Notes any weakness.


Abductors of the Hips (L2, L3, L4)

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Places the patient’s lower limb in adducted position.7. Asks the patient to bring it out against resistance.8. Notes any weakness.



Extensors of the Thigh (L5, S1, S2)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to lie supine.7. Asks the patient to raise the extended limbs off the

bed.8. Applies force upwards from below and the patient

is asked to push it down. 9. Examines and compares on both sides.10. Notes any inability on the part of the patient to do

so.11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on any abnormal findings.

PEARLS

Another method is that the patient lies supine with hisknees flexed and is then asked to extend his knees againstresistance.

Flexors of the Thigh (L1, L2, L3)

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to lie in supine position.7. Instructs the patient to keep his lower limbs in

extended position.8. Asks the patient to raise the thigh off the bed.9. Applies resistance downwards and asks the patient

to push his limb in upward direction. 10. Notes any decrease in the power of the muscles. 11. Examines and compares on both sides. 12. Helps the patient re-dressing. 13. Thanks the patient for his co-operation. 14. Comments on any abnormal findings.

Rotators of the Thigh (Medial and Lateral L5, S1, S2)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie in supine position.7. Positions the lower limbs in extended position.8. Asks the patient to roll his limbs inwards and

outwards against resistance which the candidateapplies in opposite direction.

9. Notes down any weakness in the muscles. 10. Examines and compares on both sides. 11. Helps the patient redressing. 12. Thanks the patient for his cooperation. 13. Comments on any abnormal findings.


Extensors of the Knee (L2, L3, L4)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie in supine position.7. Positions his hips and knees in semi-flexed position.8. Asks the patient to extend the knee while he

(candidate) exerts resistance by grabbing the lowerpart of the leg.

9. Notes any weakness in the muscles.10. Examines and compares on both sides11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on any abnormal findings.

Flexors of the Knee (L5, S1, S2)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie in a supine position with his

hips and knees in a semi flexed-position.7. Asks the patient to flex the knee.


8. Grabs lower leg of the patient and exerts resistancein opposite direction.

9. Examines and compares on both sides 10. Helps the patient redressing. 11. Thanks the patient for his cooperation. 12. Comments on any abnormal findings.

Dorsiflexors of the Ankle [(L4, L5 and S1) (Dorsiflexion)]

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie in a supine position.7. Positions the legs in extension.8. Asks the patient to pull his foot up at ankle.9. Applies resistance in opposite direction by placing

his hand over the forefoot. 10. Notes any weakness in that group of muscles. 11. Examines and compares on both sides 12. Helps the patient redressing. 13. Thanks the patient for his cooperation. 14. Comments on any abnormal findings.

Plantar Flexors of the Ankle [(L4, L5 and S1, S2,S3) (Plantar flexion)]





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie supine.7. Extends the leg of the patient at his knee joint.8. Asks the patient to push down the foot at ankle.9. Applies resistance in the opposite direction by placing

his palm under the fore foot of the patient.10. Performs the same examination on the other side.11. Notes any weakness in that group of muscles.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on any abnormal findings.

Eversion (L5 and S1, S2) Inversion (L4, L5 and S1)

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie supine.7. Asks the patient to keep the foot in planter flexed

position and keep it above the bed not touching thebed sheet.

8. Directs the patient to turn the foot inwards (inversion)and outwards (eversion).

9. Exerts resistance in opposite direction of thesemovements.

10. Performs the same examination on the other side.11. Notes any weakness in that group of muscles.



PEARLS

Eversion and inversion are movements that occur at thesub-talar joints. For these movements, the heel should nottouch the ground. Similar movements which are attemptedwhile the heel is touching the ground are actuallyabduction and adduction occurring at the mid tarsal joint.

Small Intrinsic Muscles (S1, S2)

They are very difficult to evaluate.

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie supine.7. Asks the patient to “fan out” his digits.8. Checks for abduction and adduction of the digits by

exerting pressure in opposite direction.9. Performs the same examination on the other side.

10. Notes any weakness in that group of muscles.11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on any abnormal findings.


PEARLS

If the small muscles of the foot are involved, the foot resultsin “Claw foot” deformity.

Extensor Hallucis Longus (L5 and S1)

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie supine.7. Asks the patient to dorsiflex the great toe.8. Exerts resistance in opposite direction.9. Performs the same examination on the other side.

10. Notes any weakness in that group of muscles.11. Helps the patient re-dressing.12. Thanks the patient for his co-operation.13. Comments on any abnormal findings.

Extensor Digitorum Longus (L5 and S1)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie supine.7. Asks the patient to dorsiflex the toes other than great

toe.


8. Exerts resistance in opposite direction.9. Performs the same examination on the other side.

10. Notes any weakness in that group of muscles.11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on any abnormal findings.


COORDINATION OF MOVEMENTS

Purposeful coordinated movements require intact sensory,cerebellar and motor systems with efficient control byhigher centres. If there is weakness of muscles, thecoordination may be disturbed and becomes invalid.

Coordination should be tested both in the upper andlower limbs on both sides, first with eyes open and laterwith eyes closed.

Check for Coordination in the Upper LimbsMethod No. 1

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to sit on the edge of the bed if he

can do so or makes him lie down supine on the bed.7. Asks the patient to outstretch his upper limb.8. Asks him to extend his index finger and flex other

fingers of one hand.9. Asks the patient to touch his (patient’s) own nose

with his (patient’s) outstretched index finger.10. Notes any swaying of the finger.

Method No. 2

1. Candidate holds his index finger in front of the patientand asks to look at it.

2. Asks the patient to point out his index finger.3. Asks the patient to touch candidate’s finger.


4. The candidate keeps on changing the position of hisfinger.

5. The candidate checks that the patient follows his indexfinger accurately.

6. Notes any swaying of the finger.

Method No. 3

1. Candidate holds his index finger in front of thepatient.

2. Asks the patient to touch his candidate’s index finger,with his (patient’s) finger.

3. Asks him to touch his (patient’s) nose.4. Keeps on doing this while changing position of his

candidate’s hand.5. Notes any swaying of the finger.6. Performs the same examination on the other side.7. Notes any weakness in that group of muscles.8. Helps the patient redressing.9. Thanks the patient for his cooperation.


Check for Dysdiadochokinesia

Method No. 1

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to sit on the edge of the bed if he

can do so or makes him lie down supine on the bed.


7. Asks the patient to flex his elbow.8. Directs him to rapidly supinate and pronate both

hands as if rolling a bulb.9. Checks for any irregularity in the rhythm of the

movements.

Method No. 2

1. Asks the patient to hold his one palm in supine positione.g., left palm.

2. Asks him to hold his right palm in a prone position.3. Directs him to tap the palm of left hand with alternate

prone and supine positions of his right hand.4. Notes any irregularity in the rhythm of the movements.5. Asks the patient to perform the same manoeuvre on

the other side.6. Helps the patient redressing.7. Thanks the patient for his cooperation.8. Comments on any abnormal findings.

Heel Shin Test or Heel Knee Tibia Test

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie down supine on the bed.7. Instructs him first about the test.8. Candidate holds his index finger 18 inches above the

patient’s foot e.g, right foot.


9. Asks the patient to touch it with his great toe by liftingthe leg.

10. Asks the patient to place his heel of the elevated footover the same knee and slide it down over the sameshin.

11. Directs him to touch the index finger of the examineragain.

12. Asks the patient to place his heel down on the bedagain.

13. Performs the same manoeuvre on other side14. Notes down any abnormality in the coordination.15. Helps the patient redressing.16. Thanks the patient for his cooperation.17. Comments on any abnormal findings.

PEARLS

a. It is important to check coordination only if the powerof muscles is greater than grade 3. Marked muscleweakness makes this test invalid.

b. The procedure to be performed by patient in testingcoordination should always be explained to patientbefore the test with proper instructions.

c. Both sides should be examined and compared.d. All the tests should be done with both eyes open. In

case of sensory ataxia, the incoordination worsenswhen the eyes are closed. In cerebellar ataxia, nodifference is noted.

e. When testing the lower limbs, make sure that thepatient should not fall down.

f. While doing the tests for coordination, smoothness ofmovements, steadiness of the limbs is to be tested.


REFLEXES

Reflexes are described under two headings:i. Deep reflexes (Tendon reflexes)

ii. Superficial reflexesLets us discuss first the methods to test for superficial

reflexes.

SUPERFICIAL REFLEXES

Abdominal Reflex (T7-T12 and L1)

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie down supine on the bed.7. Exposes the patient’s abdomen adequately keeping

the modesty.8. Asks the patient to keep abdominal muscles relaxed.9. Uses either a key or an orange stick.

10. Strokes in all quadrants from outer to inner sidetowards mid line. (at the end of expiration)

11. Notes the direction of movement of umbilicus whichindicates contraction of superficial abdominal muscle.

12. Performs the same manoeuvre in all the quadrantsof the abdomen.

13. Notes down any abnormality in the contraction ofabdominal muscles.

14. Helps the patient redressing.



PEARLS

a. The stroking should be from lateral to medial side atthree levels.• Along subcostal area (upper abdominal muscles—

T6, T7, T8)• At the level of the umbilicus (middle abdominal

muscles—T9, T10, T11)• Along the line of inguinal ligament (lower abdominal muscles—T11, T12, L1) .

c. Abdominal reflexes are absent in the pyramidaldiseases and may be absent in old age and in peoplewith laxity of abdominal wall.

Cremasteric Reflex (L1 and L2)

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Makes the patient lie down supine on the bed.6. Explains to the patient about the test.7. Exposes the inguinal area properly.8. Gives a linear stimulus along the medial aspect of

the upper part of the thigh.9. Observes the elevation of the testicle on the same side.

10. Performs the same manoeuvre on the other side.11. Notes down any abnormality in the elevation of testicles.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on any abnormal findings.


PEARLS

Alternatively, when the sartoruis muscle is pressed in thelower third of the Hunter’s canal, the same sided testismoves upwards.

Bulbocavernosus Reflex (S2, S3, and S4)

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Makes the patient lie down supine on the bed.6. Explains to the patient about the test.7. Exposes the perineal area properly keeping modesty.8. Palpates the bulbous part of urethra using tips of

thumb and fingers of his right hand.9. Pinches the skin over glans penis with his other hand.

10. Feels the contraction of the bulbocavernosus muscle.11. Notes down any abnormality in the contraction of

the bulbocavernosus muscle.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on any abnormal findings.

Superficial Anal Reflexes (S2, S3 and S4)

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.


5. Explains to the patient about the test.6. Makes the patient lie down in the left lateral position

on the bed.7. Exposes the anal area properly keeping modesty.8. Strokes the skin near the anal area lightly.9. Looks for the contraction of the superficial anal

sphincter.10. Performs the same test on both sides of anus.11. Notes and compares any abnormal response elicited.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on any abnormal findings.

Plantar Response (L5-S1)

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Explains to the patient about the test.6. Makes the patient lies down in supine position with

his legs relaxed.7. Holds the distal part of the patient’s leg with his left

hand.8. Tells the patient that he is going to scratch his sole.9. Applies a linear stimulus to patient’s sole at the outer

side.10. Starts with moderate pressure from the heel moving

towards little toe.11. Stops short of the ball of the great toe.12. Examines and compares both sides.


13. Notes down as flexor or extensor response orequivocal response.


PEARLS

a. The above mentioned procedure is called Babinski’ssign.

b. When the firm pressure is applied on the skin of thetibia from above downwards, extensor response isnoted called Oppenheim’s sign.

c. When tendo-Achiles is pinched, the extensor plantarresponse occurs and it is named as Gordon’s sign.

d. When the dorsum of the foot is stroked linearly nearthe lateral border starting from below the lateralmalleolus to the little toe, extensor response occurs andthis is called Chaddik’s sign.

e. When calf muscles are pinched, extensor responseoccurs called Schaefer’s sign.

f. Bring’s sign is extensor response when dorsum of thefoot is pricked gently with a pin.

g. Gouda’s sign is extensor response when forcefulsnapping of the second to fourth toes is done. All theseoccur in advanced lesions of pyramidal tracts.

h. In advanced lesions of pyramidal tracts, in additionto extensor plantar response, flexion of hips and kneesalso occur called withdrawal response.

i. Extensor response is present in very young childreni.e., up to 12-18 months. It is also present during deepsleep and coma without the presence of pyramidaldisease.


j. Reinforcement is done to distract the attention of thepatient to elicit these reflexes appropriately.

k. Decreased response may occur if the knee is kept flexedor if the limb is cold.

l. Patient should be completely relaxed otherwise anxietymay cause up going plantar.

m. In true extensor response, the extension of the greattoe occurs only when the scratching object reaches tothe middle or even to the foremost area of the foot.Whereas, in the pseudoextensor response, it occurs inthe beginning of the stimulus.

n. Sharp object should not be used as it causes pain andthen withdrawal response.

o. The stimulus should be firm enough to produce enoughresponse.

p. The ball of the great toe is avoided as it causes flexionof the great toe as a part of grasp reflex. This can occureven if there is pyramidal lesion.

q. In flexor response, all the toes flex and are drawntogether whereas in extensor response extension ofgreat toe occurs first followed by fanning out of theother toes.

r. Incomplete response is called equivocal i.e., either onlyfanning or great toe extension.

s. “In minimal plantar response” the leg is laterallyrotated at the hip and flexed at knee. One should lookat the contraction of the adductor magnus. It is alsotaken as a sign of pyramidal lesion.

t. The lateral aspect of the sole is used as the skin onthe rest of sole is quite thick and not as much sensitiveas the lateral margin.


DEEP REFLEXES

The response of these reflexes depends upon the way itis performed, the position of the part to be tested and properinstructions to the patient. Following are few tips to elicitthese reflexes appropriately:

I. It is important to brief the patient about the procedureto be done. He should be shown the hammer anddomonstrate to him the impact of the hammer bystriking it on your own hand. This makes the patientfeel assured that it will not hurt him at all. Preferablythe old standard hammer is required which is flexibleand has a rounded rubber.

II. The hammer should be held from the other end andthe reflexes should be elicited by a swingingmovement in an arc before the tendon is struck.

III. Feel first the tendon to be struck.IV. Limb is placed in particular position to elicit the reflex

appropriately.V. Exposure of contracting muscle belly is important.

One should not look for the movement of the limbbut for the contraction of the muscles.

VI. Both sides should be examined and compared andnote should be made for any abnormal response.

VII. Try reinforcement method if the response in not elicitedappropriately. This can be done by either asking thepatient to clench his teeth or clench the fist of oppositehand and for lower limb either asking to clench histeeth or to interlock fingers of both hands and pullingthem apart when the reflex is being elicited. Thismanoeuvre is called Jendrassik’s manoeuvre. Reflexesmay normally be absent in 3-8% of normal people.After eliciting reflex ask the patient not to clench histeeth or fists any more.


VIII. Normal response is the contraction of muscles withsudden displacement of the limb, which then rapidlyreturns to its original position.

IX. To elicit some reflexes, the tendon is hit directlywhereas in others, the examiner places his finger andthen the tendon is struck on it.

X. The reflexes are graded according to the response i.e.it can be normal, sluggish or absent or exaggeratedor very much exaggerated. This depends a lot on thepersonal experience of the examiner as well.

Different grading is done as follows:• The reflex is absent• The reflex is present• The reflex is brisk• The reflex is very brisk• The clonus is present.

If the stimulated muscle is weak, the stimulus thenproduces movement in the powerful antagonist muscle(paradoxical or inverted reflex).

Other way of grading is as follows:0. Not elicited1. Elicited with reinforcement.2. Normal3. Brisk4. Unsustained clonus5. Sustained clonus.

General Principles

1. Patient is put at ease and asked to relax as much aspossible.

2. Make sure the atmosphere is warm.3. Use same type of hammer.


4. Adopt a sequence of examining the reflexes in the samemanner. Follow a sequence and do not do examinationhaphazardly. One should standardize the technique.

5. Reassure the patient that the hammer is soft and isnot going to hurt him.

6. Repeat the test if necessary.7. Some clinicians prefer to check the tendon reflex while

the patient is sitting over the edge of the couch butmajority of clinicians prefer these tests while the patientis lying on the bed.

INDIVIDUAL TENDON REFLEXES

Jaw Jerk

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Explains to the patient about the test.6. Asks the patient to open his mouth slightly.7. The candidate places his left index finger below the

patient lower lip.8. Gives a gentle tap with a patellar hammer, in an arc

in a downward direction, over his left index fingeralready placed on patient’s lower lip.

9. Notes that there is an upward jerk of the jaw aspresent, absent or exaggerated.



Biceps Jerk (C5, C6)

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes the part to be examined keeping in mind the

modesty.6. Explains to the patient about the test.7. Makes the patient either in lying in supine or sitting

position.8. Keeps the patient’s elbow in flexed position at 90°

and supports it with his left hand.9. The candidate keeps the arm in semi-prone position.

10. Stands on the right side and grasps the flexed elbowwith left hand from the lateral side with the thumbover the biceps tendon and strikes the thumb withthe hammer in the form of an arc.

11. Notes that there is an upward jerk of the fore armwhich flexes at elbow.

12. Examines and compares both sides. 13. Helps the patient redressing. 14. Thanks the patient for his cooperation. 15. Comments on any abnormal findings.

PEARLS

There may be “inversion” of the biceps jerk when theelicited response is either absent, or there is only bicepscontraction or contraction of the triceps muscle or flexionof the fingers.


Triceps Jerk (C6, C7, C8)

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly the part to be examined keeping

in mind the modesty (Exposes the arm up to deltoid).6. Explains to the patient about the test.7. Makes the patient lie supine.8. Flexes the patient’s elbow with his forearm resting

on the front of his trunk across his chest.9. Strikes the patellar hammer in the form of an arc

directly 2-4 cm above the tip of the olecranon process. 10. Notes that there is contraction of the triceps extending

the arm at elbow. 11. Examines and compare on both sides. 12. Helps the patient redressing. 13. Thanks the patient for his cooperation. 14. Comments on any abnormal findings.

PEARLS

Triceps jerk is said to be paradoxical when instead ofextension at the elbow, flexion occurs.

Supinator Jerk (C5, C6)

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.


4. Does a general survey of the patient.5. Exposes properly the part to be examined keeping

in mind the modesty.6. Makes the patient lie supine or sit up at the edge

of the bed.7. The candidate flexes the patient’s elbow and supports

it with his left hand.8. Places the patient’s fore arm in semi prone position

(to avoid contraction of brachioradialis muscle).9. Strikes with a patellar hammer in the form of an arc

over the distal end of the radius about 2.5 cm abovethe radial styloid process.

10. Notes for the supination of the elbow which followsthis manoeuvre.

11. Performs and compares on both sides.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on any abnormal findings.

PEARLS

The jerk is said to be inverted when there is absentcontraction of the biceps and the brachioradialis musclebut finger flexion does occur.

Knee Jerk (L2, L3, L4)

The Candidate



in mind the modesty. (in this case quadriceps muscleis exposed properly).


6. Makes the patient lie supine on the couch.7. Flexes the knees of the patient at 15° and supports

with his left forearm sliding under both poplitealfossae.

8. Feels for the patellar tendon.9. Strikes the tendon with the patellar hammer moving

in the form of an arc.10. Observes and notes the contraction of the quadriceps

muscle on both sides.11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on any abnormal findings.

Method No. 2

The Candidate

1. Lifts up the right knee with the palm of left hand, byplacing it under the right popliteal fossa.

2. Feels the tendon of the patella.3. Strikes with the hammer.4. Notes contraction of the quadriceps femoris muscle.5. Straightens the right knee, lifts up the left knee with

left hand by doing the same manoeuvre.6. Strikes the patellar tendon with hammer.7. Comments and notes contraction of quadriceps muscle.

Method No. 3

The Candidate

1. Pushes the dorsum of his left forearm under the rightknee.

2. Rests the palm of left hand over the front of left knee.(The right knee becomes flexed).

3. Strikes the patellar tendon of the right knee with thepatellar hammer.


4. Takes out the left arm and now puts the dorsum ofhis left forearm over the right knee.

5. Places the palm of his left hand under the left knee.6. Bends the left knee.7. Strikes the patellar tendon of the left knee with the

hammer.8. Notes and comments on the findings.

Method No. 4

The Candidate

1. Makes the patient sit at the edge of the bed.2. Asks the patient to hang down his legs freely.3. The candidate stands by the side of patient with his

back facing as the patient’s back.4. Strikes the patellar tendon with the hammer on each

side.5. Notes the contraction of the quadriceps femoris muscle.

Ankle Jerk (S1, S2)

The Candidate



in mind the modesty in this case calf muscles areexposed properly.

6. Makes the patient lie supine on the couch.7. Instructs the patient to place the lower limb in

abduction and externally rotated position at the hipand slightly flexed at the knee.


8. Dorsiflexes the foot at the ankle with left hand.9. Holds the patellar hammer in his right hand.

10. Strikes the Achilles tendon with the hammer in a semiarc movement.

11. Notes the contraction of gastrocenemius muscle.12. Performs the same manoeuvre on the other side and

compares it.13. Helps the patient redressing.14. Thanks the patient for his cooperation.15. Comments on any abnormal findings.

Method No. 2

The Candidate

1. Flexes the patient’s right limb at the knee.2. Places the shin part of the limb on the shin of opposite

limb.3. Dorsiflexes the foot slightly with his left hand.4. Strikes the Achilles tendon with the patellar hammer

in a semi-arc movement.5. Same manoeuvre is repeated on the opposite side.6. Notes the contraction of gastrocenemius muscle.

PEARLSBy doing this method, the other foot does not come in theway of patellar hammer during striking.

Method No.3

The Candidate

1. Asks the patient to kneel over the seat of a chair withhis/her feet hanging out the edge of the seat.

2. Exposes the lower legs adequately keeping in mindthe modesty.


3. Asks the patient to relax.4. Strikes the tendo-Achilles alternatively to see the

response.5. Notes the contraction of gastrocenemius muscle.6. Notes any delayed relaxation of the ankle jerk (better

noted in cases of hypothyroidism).

Method No. 4

The Candidate

1. Keeps the patient’s lower limb in extension at knee.2. Faces towards the feet of the patient.3. Places his left hand over the fore foot of the patient

and dorsiflexes passively the fore foot.4. Strikes with patellar hammer on his fingers of the left

hand already placed on patient’s fore foot.5. Notes and feels that the foot is plantar flexed due to

contraction of calf muscles.

MISCELLANEOUS REFLEXES

Check for Finger Flexion Jerk

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Asks the patient to keep his hand flat on the table

with the palm facing the ceiling.6. Places tips of his middle and index fingers across

the palmar aspect of the proximal phalanges of thepatient’s relaxed fingers.

7. Taps lightly on his own fingers with the hammer.


8. Notes flexion (whether slight or brisk) of the patient’sfingers.

9. Performs the same manoeuvre on the other side andcompares it.


PEARLS

This jerk is brisk in pyramidal tract lesion.

Check for Hoffman’s Sign

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Asks the patient to keep his hand relaxed.6. Holds the middle finger of the patient by the sides

at the distal interphalangeal joint7. Flexes that distal interphalangeal joint.8. With the other hand holds the tip of the same middle

finger and flicks into extension.9. Notes the flexion of the thumb of the same hand.

10. Performs the same manoeuvre on the other side andcompares it.


PEARLS

In pyramidal tract lesion the thumb flexes quickly andmay be accompanied by flexion of the other fingers aswell. This is called positive Hoffman’s sign.


Elicit Wartenberg’s Sign

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Asks the patient to keep his arm supinated with

fingers flexed.6. The candidate keeps his arm prorated and flexes his

fingers.7. The candidate inter locks his fingers in to patient’s

fingers.8. Both pull against each other’s resistance.9. Notes the extension of the thumb of the patient which

occurs normally.10. Performs the same manoeuvre on the other side and

compares it.11. Thanks the patient for his cooperation.12. Comments on any abnormal findings.

PEARLS

In pyramidal tract lesion, the thumb adducts and flexesstrongly.


GAIT

It is the mode of walk of an individual. Gait varies fromindividual to individual even if they are normal. However,few gaits are specific for a particular neurological disease.

Before the gait is assessed it is very important to askthe patient whether he can walk at all or not. It is alsovery important to note the following points duringexamination:

The Candidate

1. Exposes the legs of the patient properly keepingmodesty.

2. Asks the patient to take off his shoes and socks.3. Instructs the patient to walk away from him freely.4. Asks the patient to turn around at a certain distance

e.g., 10 meters away from him.5. Closely observes while the patient is coming towards

him.6. The candidate notices the type of gait, whether normal

or abnormal and also notes presence of the swingingof the arms.

7. Comments on the findings.

PEARLS

a. Important points to note are the posture of the bodywhile walking, the position and movement of the arms,the distance between the feet, the smoothness of themovements of the legs, the ability to maintain a straightcourse, the ease of turning and finally stopping.

b. This test becomes more reliable if the patient is askedto do tandem walking.

c. The candidate should be aware of different types ofgaits and should be able to recognize them immediately


e.g., hemiplegic gait, festinant gait, scissor gait,staggering gait, waddling gait, stamping gait, highstepping gait, shuffling gait, ataxic gait etc.

Few important points worth remembering include thefollowing:1. Can the patient walk at all?2. How much help is needed?3. Can the patient walk in a straight line or is there a

deviation to one side or the other?4. Does the patient tend to fall?5. If so, in which direction he tends to fall?6. Can the patient turn quickly at 180°?7. Is there a recognizable gait disorder?

INVOLUNTARY MOVEMENTS

These movements are not under the control of the will,therefore they occur involuntarily.Following points should be observed:

1. Which part of the body is affected?2. What is the pattern of the movement?3. Is it repetitive or non repetitive?4. Is it symmetrical or asymmetrical?5. What is its frequency?6. What relieves it?7. What aggravates it?8. Does it persist during sleep?9. Is it acute or insidious?

10. Is it temporary or progressive?11. What is the type of movement?

It is better to observe the patient at a distance.The candidate should be aware of different types of

involuntary movements and hence should be able to spotdiagnosis. For more details of these involuntary


movements, the candidate should consult a Textbook ofMedicine or for detailed account of these movements, astandard Textbook on Neurology.

These involuntary movements include tremors, pillrolling movements, chorea, athetosis, choreoathetoidmovements, myoclonus, hemiballismus, dystonia,myokymia, diskinesia, blepharospasm, ticks, hemifacialspasms, torticolis, fasciculations, convulsions, tetany, etc.

CLONUS

When sustained stretch is maintained on a tendon of amuscle, then rhythmic contraction and relaxation of theconcerned muscle occurs. This is called clonus. It is usuallya sign of pyramidal tracts lesion. If these movements arenot sustained, it is called pseudoclonus.

Patellar Clonus

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly the lower limb up to the mid thigh

position keeping in mind the modesty.6. Makes the patient lie supine on the couch with the

knee fully extended.7. Holds the lateral parts of patella with the thumb and

index finger of the left hand.8. Pushes it down towards patient’s feet with a sudden

jerk.9. Maintains some pressure in the same position.

10. Notices sustained up and down movements of patellawhich are elicited.


11. Notes and comments on the findings after examiningboth sides.


Ankle Clonus

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly the lower limb up to the mid thigh

keeping in mind the modesty.6. Makes the patient lie supine on the couch.7. Flexes the knee partially and supports it form the

popliteal fossa with left hand.8. Everts the foot slightly with the right hand and

suddenly dorsiflexes the distal part of foot with thesame hand in the form of a jerk.

9. Maintains stretch in the same position for fewseconds.

10. Notes sustained rhythmical movements of dorsi-flexion and plantar flexion of the foot.

11. Examines and compares both sides.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on any abnormal findings.

Wrist Clonus

The Candidate




3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly the upper limb up to the elbow

keeping in mind the modesty.6. Holds the forearm of the patient with his left hand.7. Extends the wrist passively with some force.8. Maintains the stretch for a while.9. Feels the rhythmic movements of extension and

flexion at wrist.10. Examines both sides.11. Comments on clonus present or absent.12. Helps the patient redressing.13. Thanks the patient for his cooperation.14. Comments on any abnormal findings.

PEARLS

If the number of contractions is less than six, then it iscalled ill sustained and if they are more than six it is wellsustained clonus.

True clonus is associated with extension response andis stopped by flexion of that particular joint.


SENSORY SYSTEM

The sensory system is divided into three parts:1. Superficial sensations.2. Deep sensations.3. Cortical sensations.

SUPERFICIAL SENSATIONS

These include:a. Touchb. Painc. Deep paind. Temperature.

Touch

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Takes a wisp of cotton wool.7. Shows it to the patient and instructs him properly.8. Touches the patient’s skin lightly.9. Asks him to close the eyes before he touches him with

a cotton wisp. 10. Asks the patient to say ‘yes’ when he feels it. 11. Tests the sensations from scalp to sole. 12. Proceeds downwards dermatome by dermatome. 13. Avoids hairy areas of the body. 14. Notes the area of abnormality.


15. Compares on the opposite side. 16. Helps the patient redressing. 17. Thanks the patient for his cooperation. 18. Comments on his findings while presenting to the

examiners.

PEARLS

a. The tip of wisp of cotton wool should be fine and areashould be touched with its tip because if cotton istouched as a whole fluff; the area of stimulation is quitelarge and can mislead the findings.

b. It is also advised to touch lightly once and not to scratchover the skin.

c. The candidate should know the following terms whilechecking for the sensation of touch:• Hypoaesthesia• Hyperaesthesia• Anaesthesia• Paraesthesia

Pain

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Uses a sharp common pin.7. Shows it to the patient and instructs him properly.8. Asks him to close the eyes before he touches him with

a pin.


9. Touches the patient’s skin lightly.10. Asks the patient to say ‘yes’ when he feels it.11. Tests the sensations from scalp to sole.12. Proceeds downwards dermatome by dermatome.13. Avoids hairy areas of the body.14. Notes the area of abnormality.15. Compares on the opposite side.16. Helps the patient redressing.17. Thanks the patient for his cooperation.18. Comments on his findings while presenting to the

examiner.

Elicit Deep Pain

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Informs the patient that he is going to squeeze one

of his muscles or tendons.7. Squeezes the muscle or tendon.8. Looks at patient’s face for expression of pain.9. Notes the area of abnormality.

10. Compares on the opposite side. 11. Helps the patient redressing. 12. Thanks the patient for his cooperation. 13. Comments on his findings while presenting to the

examiner.


PEARLS

a. An ordinary domestic pin is preferred over ahypodermic needle because the hypodermic needle cutsthe skin relatively painlessly and therefore it is notsuitable for sensory testing.

b. Patient should recognize the stimulus as pain and notas touch.

c. Single prick may not always register as pain. Onerequires multiple stimuli.

d. Look at patient’s face because if he feels pain he willwince.

e. The candidate should know the following terms whilechecking for the pain sensation:• Analgesia• Hypoalgesia• Hyperalgesia.

Temperature

To perform this test warm and cold water should be keptin two tests tubes. The warm water should be 37-40°Cand cold water should be at a temperature of 30-32°C.

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Takes hot and cold test tubes which should be

identical.7. Touches the patient’s skin lightly.8. Touches the skin of the patient with cold and warm

water haphazardly.


9. Asks the patient to say ‘yes’ when he feels whetherhot or cold.

10. Tests the sensations from scalp to sole.11. Proceeds downwards dermatome by dermatome.12. Avoids hairy areas of the body.13. Notes the area of abnormality.14. Compares on the opposite side.15. Helps the patient redressing.16. Thanks the patient for his cooperation.17. Comments on his findings while presenting to the

examiner.

PEARLS

a. Another crude method is to touch with a metal of clipboard or handle of patellar hammer for warm and coldresponse respectively. This method is applicable whenthere is no availability of the test tubes.

b. Loss of temperature is called thermoanaesthesiac. Presence of touch sensation with loss of pain and

temperature senses is called dissociated sensory loss.

DEEP SENSATIONS

These include:a. Sense of vibrationb. Joint sensec. Sense of positiond. Romberg’s sign.

Sense of Vibration

The Candidate




3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Uses a 128 Hz tuning fork.7. Strokes on the ball of the thumb the prongs of the

fork.8. Demonstrate the vibrating and non-vibrating tuning

fork to the patient.9. Asks him to close the eyes and places vibrating fork

over medial, lateral maleoli then tibial tuberosity andthen anterior superior iliac spine while checking senseof vibration in the lower limbs.

10. Places the stem of vibrating tuning fork at theolecranon process then sternum and the forehead.

11. Compares on the both sides and notes anyabnormality.

12. Helps the patient redressing. 13. Thanks the patient for his cooperation. 14. Comments on his findings while presenting to

examiner.

PEARLS

a. Bony prominences are used as the vibration sense isamplified on these prominences.

b. For minimal vibration loss following method is used:• Places the stem of the fork on the patient.• Asks him when the vibrations are no more felt.• Places the fork on himself to know whether the

vibration are still perceived nor not.c. 128 Hz tuning fork is used because it has a long

“decay” time i.e., 15-20 seconds which is enough timeto perform this test successfully.


Sense of Joint Position

It is very important to explain to the patient about thisaspect of examination. Proper instructions to the patientwill yield better elicitation of this test.

Method No. 1

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Selects the great toe for checking the sense of position

in the lower limbs.7. Fixes proximal phalanx of big toe with fingers of the

left hand and thumb.8. Holds the lateral sides of the big toe with his index

finger and thumb of the right hand.9. Move it up and down first and shows it to the patient

as well and makes sure that he understands theinstructions.

10. Asks the patient to close his eyes. 11. Moves the toe up and down in small movements. 12. Asks again from the patient whether it moves up or

down or does not move at all. 13. Notes the findings. 14. Compares on both sides. 15. Helps the patient redressing. 16. Thanks the patient for his cooperation. 17. Comments on his findings while presenting to

examiner.


PEARLSa. The joint should be moved in small movements and

it should be slow and should not be over stretchedas the patient comes to know which direction the jointhas moved. This makes the sensitivity of the test invalid.

b. A normal person can appreciate 12°-15° movements.c. One should hold the toe from side without touching

other toes to minimize the contact area which becomesmuch more if the toe is held from dorsal and ventralside.

Method No.2

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Asks the patient of close his eyes.7. Places one limb of the patient in any position.8. Asks him to keep the opposite limb in the same

position.9. Tests both the upper and lower limbs.

10. Notes the findings. 11. Compares on both sides. 12. Helps the patient redressing. 13. Thanks the patient for his cooperation. 14. Comments on his finding while presenting to the

examiner.

Methods No.3

The Candidate

1. Asks the patient to extend his arms outwards.2. Instructs him to close his eyes.


3. Asks the patient to bring his two index fingers together.4. Notes whether he can do it or not.5. Notes down the abnormality.6. Comments on the findings.

PEARLS

In normal individual, error in approximating the fingersshould be less than one centimeter.

Method No. 4

The Candidate

1. Places patient’s arm in a particular position.2. Moves it away.3. Asks him to replace it in previous position.4. Asks the patient to place the opposite limb in a similar

position.

PEARLS

a. At least six successive responses are correct, the testis deemed to be normal.

b. If patient is not able to understand the maneuver atall, then move his joint and ask whether the joint movedat all or not.

c. In joint position impairment, the distal parts are firstaffected; therefore the test is started from the distal partof the limbs. If the test is positive at distal part thenthere is no point to test proximally.

Romberg’s Sign




3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Asks the patient to stand with both feet close together.7. Observes whether he is steady in posture or not (with

eyes open)8. Asks him to close his both eyes.9. Observes any change of steadiness or posture.


PEARLS

If unsteadiness occurs on closing the eyes, it is positiveRomberg’s sign. It indicates defect in the sense of positionand is called sensory ataxia.

In case of cerebellar or vestibular diseases, unsteadinessis present even with the eyes open and it does not increasesignificantly if the eyes are closed.

CORTICAL SENSATIONS

These inclue the followings:i. Tactile localization

ii. Tactile discriminationiii. Graphaesthesiaiv. Stereognosisv. Sensory inattention.

Tactile Localization

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.


4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Asks the patient to close his eyes.7. Touches the patient’s skin with wisp of a cotton wool.8. Asks the patient to localize with his finger tip where

the cotton was touched.9. Asks the patient to tell the site of touch if the patient

is paralyzed. 10. Tests on both sides, from head to toe and different

parts of the body. 11. Helps the patient redressing. 12. Thanks the patient for his cooperation. 13. Comments on his findings while presenting to the

examiner.

PEARLS

The touch localization is more precise at the peripheryof the limb than at the proximal parts.

Tactile Discrimination

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Takes a divider or two pins in each hand.7. Shows it to the patient and explains the test to him

before actually doing it.8. Asks the patient to close his eyes.9. Stimulates the skin simultaneously at two points

making sure that and intensity of both stimuli shouldbe the same.


10. Starts with the divider’s prongs as apart as possibleand then brings them together gradually.

11. Notes whether the patient is able to recognize thestimulus as one or as two different stimuli or noneat all.

12. Examines fingers, palms, feet and the back. 13. Examines both sides and compares the same areas. 14. Helps the patient redressing. 15. Thanks the patient for his cooperation. 16. Notes and comments on the findings.

OrThe Candidate

1. Brings the two stimuli close together until the patientrecognizes them as one.

2. Examines fingers, palms, feet and the back.3. Examines both sides and compares the same areas.4. Notes the findings and compares on both sides.

PEARLS

a. Do not use sharp objects as it causes discomfort andpain to the patient.

b. Normal two point discrimination is:• 2-5 mm on the finger pulps.• 1-2 cm over the palms.• 2-3 cm over the soles.• 3-5 cm over the trunk.

c. Patient’s eyes should be closed during this test.

Stereognosis

Before doing this, make sure that the sensations are presentin the palm. Make sure that the small joints of hands andthe muscles are normal too as the patient has to feel for


the objects given to him with eyes closed and he has tomake certain movements of the hand to recognize it.

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Asks the patient to close his eyes.7. Places common objects in patient’s palms i.e., coin,

keys, pen, wallet etc.8. Asks him to recognize them with his eyes closed.9. Waits for the patient to recognize things only by

touch.10. Compares the speed and accuracy on both sides.11. Thanks the patient for his cooperation.12. Comments on the findings.

PEARLS

Loss of ability to identify objects is called astereognosis.

Graphaesthesia

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Explains the test to the patient.


7. Uses a blunt object.8. Holds the patient’s palm in his hand.9. Asks him to close the eyes.

10. Draws legible numbers or letters on the patient’s palmwith that blunt object (Skin of the forearm can alsobe used).

11. Starts with easy numbers i.e., 1, 2, 7, then with difficultone 0, 6, 8, and then double numbers.

12. Compares the findings on both sides. 13. Helps the patient redressing. 14. Thanks the patient for his cooperation. 15. Notes and comments on the findings.

PEARLS

Before performing this test it is important to know theeducation level of the patient.

Sensory Inattention

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Explains the test to the patient.7. The candidate holds two blunt objects i.e, pin heads

in his hand.8. Stimulates the skin with this on one side as well as

on the opposite sides of the body simultaneously.9. Asks the patient to indicate which side or sides are

touched. 10. Helps the patient redressing.


11. Thanks the patient for his cooperation. 12. Notes and comments on the findings.

PEARLS

a. In sensory inattention, while on stimulating both sides,one side is not perceived.

b. Similar principles can be used to test for visualinattention and auditory inattention.

GENERAL PRINCIPLES FOR EXAMININGSENSORY SYSTEMFollowing important points should be followed whileexamining the sensory system:1. Explain the procedure to the patient in full detail.2. Make sure that he understands all the instructions

given to him.3. Both the patient and the examiner should have patience

in performing the examination of this system.4. Patient’s eyes are covered properly during examination.5. Move the stimulus from impaired area of sensation to

normal area for early localization of the abnormalsensory area.

6. Uniform stimuli should be produced while testingsensations.

7. Both sides of the body should be checked and compared.8. Mark out the area of sensory disturbances and look

whether they correspond to specific nerve distribution.9. The spinal segments are not necessarily at the level

of corresponding vertebrae. They correspond tovertebral level only in higher cervical region.

10. To determine which spinal segment is related to a givenvertebral body following scheme is used:• For cervical vertebrae — add 1 level• For thoracic vertebrae — 1–6 add 2 levels


• For thoracic vertebrae — 7–9 add 3 levels• 10th thoracic arch lies over L1 and L2 segments• 11th thoracic arch lies over L3 and L4 segments• 12th thoracic arch lies over L5 segment• First lumbar arch lies at sacral and coccygeal

segments• In the lower thoracic region, the tip of the spinous

process makes the level of the body of vertebraebelow.


CEREBELLAR SYSTEM

Cerebellum is an important part of the nervous systemas it completes the circuit by processing information aboutthe state of motor activity and modifying cortical activity.It is important part in coordination, relaxation of agonistand antagonist muscles. Its diseases can lead to presenceof involuntary movements. It also plays an important rolein maintaining the position of different parts of the bodyat will.

Most of the signs of cerebellar diseases occur due totwo cardinal features i.e., hypotonia and in-coordination.

Start examining as follows:

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Notes any involuntary movements or altered posture.7. Looks for spontaneous nystagmus.8. Elicits it if not present (See on page 194).9. Talks to the patient and notes any change in the

character of speech (See on page 177).10. Checks for hypotonia.11. Tests for coordination and performs finger to finger

or finger to nose test and heel shin test.12. Performs dysdiadochokinesia.13. Performs rebound phenomenon as follows:

i. Asks the patient to hold his arm semi-flexed at elbow.ii. Holds his arm and asks him to flex against power

exerted by examiner.


iii. The candidate takes off his hands from the patient.iv. Notes whether flexion movement is quickly arrested

or not.14. (In positive test, the patient hits his face or side with

his limb as he has no control over his movements)15. Performs the knee jerk, and notes that it is pendular.16. Checks gait and notes its type by asking the patient

to walk on straight line.17. Notes and comments on the findings.


SIGNS OF MENINGEAL IRRITATIONThese signs are elicited to help diagnosing meningitis.

The Candidate1. Stands on the right side of the patient.2. Greets, introduces himself to the patient and asks

permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Makes the patient lie down flat in supine position.7. Keeps the patient’s lower limbs in extended position.8. Places his palm of left hand under the occiput of the

patient.9. Keeps the right palm over the front of chest to stabilize

the upper trunk. 10. Tries to flex the neck of the patient passively. 11. The candidate feels for the stiffness in the neck of

the patient. 12. Flexes the hip at 90° and the knee at 90o. 13. Extends the patient’s knee passively. 14. Notes that the patient complains of pain and restricts

him to further examine him. 15. Flexes the neck passively. 16. Notes flexion of both the knees. 17. Flexes one leg passively. 18. Notes that other limb is also flexed. 19. Helps the patient redressing. 20. Thanks the patient for his co-operation. 21. Notes and comments on the findings.


PEARLS

a. Normally one can touch one’s chin without anydiscomfort.

b. Normally the knee can be extended up to 135° withoutproducing pain.

c. The steps number 8-11 indicate neck stiffness.d. The steps number 12-14 indicate Kernig’s sign.e. The steps number 15-16 indicate Brudzinski’s neck

sign and steps numbers 17-18 indicate Brudzinski’sleg sign.

f. Absent neck rigidity but positive Kernig’s sign indicatesmeningeal irritation at the level where spinal nerveroots supplying the hamstring muscle emerge out.


PRIMITIVE REFLEXES

These are present in normal newborn infants and as theygrow older, these reflexes disappear varying up to the ageof 4 months to 18 months. The absence in new born mayindicate some abnormality and ironically, their presencein the adults indicate abnormality in the neurologicalsystem.

These reflexes are as follows:

Palmomental Reflex

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Asks the patient to place his hand over a flat surface

with the palm facing upward.7. Scratches the skin near the thenar eminence.8. Notes a brief puckering at the chin.9. Examines both sides and notes any abnormality.

10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on his findings white presenting to

examiners.

PEARLS

One can do this on the soles but that is not as strongas palmar response


Grasp Reflex

The Candidate



with the palm facing upward.7. Strokes gently the radial aspect of the palmar surface

of patient’s hand.8. Begins proximally and proceeds distally between the

patient’s thumb and index finger up to the finger tips.9. Notes that the patient flexes the thumb and fingers

to grasp the stimulus.10. Notes that the grip increases with increasing traction.11. Examines both sides and notes any abnormality.12. Thanks the patient for his co-operation.13. Comments on his findings while presenting to the

examiners.

Avoidance Reflex

The Candidate



with the palm facing upward.


7. Strokes the ulnar aspect of the patient’s hand.8. Notes that it moves away from the stimulus.9. Examines both sides and notes any abnormality.

10. Thanks the patient for his cooperation.11. Comments on his findings while presenting to the

examiners.

PEARLS

This reflex is elicited if grasp reflex is present.

Snout Reflex

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Presses or taps gently the patient’s lip when mouth

is closed.7. Notes the puckering or pouting of the lips and

contraction of the facial muscles on the same side.8. Examines both sides and notes any abnormality.9. Thanks the patient for his cooperation.

10. Notes and comments on the findings.

Suckling Reflex

The Candidate




3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Asks the patient to close his mouth.7. Strokes the angle of the mouth which is already closed

(tactile). (Or brings his index finger near the angleof the mouth, while the patient is looking at it (visual).

8. Notes that anticipatory opening of the patient’s mouthoccurs.

9. Examines both sides and notes any abnormality.10. Thanks the patient for his cooperation.11. Notes and comments on the findings.

Glabellar Tap

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Asks the patient to keep his eyes open and look ahead.7. The candidate stands behind the patient.8. Brings the middle finger or index finger from above

and strikes gently at the place between the twoeyebrows (glabella).

9. Notes that the patient blinks his eyes with each tap.10. Thanks the patient for his cooperation.11. Notes and comments on the findings.


PEARLS

a. In normal subjects, 3-4 blinks occur initially and thenblinking stops even if one continues to tap at theglabella.

b. The finger should be brought from behind because ifit is brought from front, it directly stimulates blinkingtherefore the test becomes invalid.

c. Glabellar tap is usually positive in patients who haveParkinson’s disease or extrapyramidal tract lesions.

d. Sometimes the eyelids continue to blink even if thestimulus is no more there which strongly supports thediagnosis of Parkinson’s disease or conditionsinvolving extrapyramidal system and in dementia.

e. Again to mention that all the above reflexes arenormally present in the new born and disappeararound 4-6 months of age in normal babies. They arealways pathological in adults.

f. The avoidance reflex is released in the contra lateralparietal lobe lesion.

g. The palmomental and grasp reflexes are released onthe same side in case of contralateral frontal lobedisease.

h. If all these reflexes are released on both sides, they donot carry any significance.


CHECK FOR BRAINSTEM DEATH OR BRAIN DEATH

The brain is an important part of the body and controlsall functions appropriately and in order. The brain stemwhich is formed of mid brain, pons and medulla alongwith upper part of spinal cord is more important as itcarries all the tracts in a condensed form and also hascardiorespiratory centers, which control circulation andrespiration. Therefore any damage to brain stem can provefatal.

If a patient is in deep coma, then the out come is notvery good as the patient is in a vegetative state. The patientmay be on ventilatory support and inotropic support tokeep going the cardiorespiratory functions. However, thiscannot be pulled on for a long time and one has to performcertain tests on daily basis to know or confirm Brain Death.These tests are as follows:

The Candidate

1. Shines the light into patient’s eyes and sees the sizeof the pupils and their response to the light.

2. Checks for the corneal reflex with a wisp of cottonwool.

3. Performs cilospinal reflex to see the response (seeunder Horner’s syndrome).

4. Presses the skin with underlying bony structure andsees the response to this painful stimulus.

5. Checks for the gag reflex and notes whether presentor absent.

6. Checks for spontaneous respiratory effort by placinga thin paper in front of the patient’s nostril or hishand.

7. Checks caloric test and interprets it.


8. Checks for doll’s eye phenomenon as follows: • Grasps the head of the patient with both hands

from the temples. • Uses thumbs to gently hold the upper eyelids and

try to open it. • Rapidly rotates the patient’s head side ways to

about 90°. • Notes the movements of the eye balls. • Flexes and extends the neck alternately. • Notes the movements of the eye balls.


PEARLS

a. When the brain stem is intact the patient’s eyes deviateto opposite side of the head while moving the neck.However in case of brain stem death, the eyes are fixedand move in the same direction of the head. In theformer it is called doll’s eye present and the later doll’seye absent. It is the “doll’s eye absent” which confirmsbrain stem death.

b. When the assessment of brain death is made, the CO2

and O2 level must be with in normal range.

CHECK ELICIT PAIN IN THE PATIENTFor this purpose, the examiner should be well aware ofthe points where more pain can be elicited. Such objectivecan be achieved by pressing or pinching with yourknuckles or fingers respectively.

The Candidate1. Stands on the right side of the patient.2. Greets, introduces himself to the patient and asks



3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Pinches the trapezius muscle with his index finger

and thumb and notes the response of the patient.7. Presses the manubrium sternii with his knuckles of

the fist and notes the response of the patient.8. Presses the patient’s nail at the nail bed with some

hard object i.e., pen or chest piece of the stethoscopeand notes the response of the patient.

9. Places a pencil or a pen between the two fingers andsqueezes them and notes the response of the patient.

10. Pinches the adductor longus muscle just above theknee on the medial side and notes the response ofthe patient.

11. Squeezes the tendo-Achilles and notes the responseof the patient.

PEARLS

The supra orbital ridge is not used as the site for elicitingpain (by pressing at the supra orbital notch) because thethumb can slip over the supraorbital ridge and can causedamage to the eye. One should avoid this.


ELICIT FOCAL NEUROLOGICAL SIGNS IN ANUNCONSCIOUS PATIENT

This examination requires a good basic knowledge ofanatomy and neurological examination techniques. Stillit is impossible to identify all the signs; however fewdetectable signs help to localize the lesion.The candidate should follow important points listed below:1. In cerebral lesion the neck is rotated to the side of lesions

along with eyes which are deviated to the same side.2. In third nerve paralysis, the pupil on the affected side

is dilated and does not react to light. The eye ball isdeviated in outwards and downwards direction.

3. In 7th nerve paralysis, there is loss of nasolabial foldon the same side. The angle of the mouth is deviatedtowards healthy side. The mouth puffs duringexpiration on the affected side. There may be droolingof saliva from that side as well.

4. To see the side of paralysis, raise the upper limb andallow falling freely. If it is paralyzed, it will fallsuddenly and will adopt any posture; even it can hurtthe patient by falling on him. Non paralyzed limb fallsslowly as compared to the paralyzed limb.

5. To see which limb is paralyzed e.g., lower limbs, whilethe patient is lying supine in the bed, note the positionof the limbs. If it is paralyzed, the lower limb is rotatedlaterally as compared to nonparalyzed limb. If oneallows it to fall freely, same scenario will be seen asin the upper limbs.


HOW TO CONFIRM THAT PATIENT ISPRETENDING PARALYSIS?

For Upper Limbs

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Makes the patient lie in supine position.7. Lifts up one of his arms (claimed to be paralyzed)

with his (candidate) arm.8. Throws that arm over patient’s face or chest.9. Observes and notes which way the limb lands.

10. Helps the patient redressing. 11. Thanks the patient for his cooperation. 12. Comments on findings while presenting to the

examiner.

PEARLS

In paralysis (true) the limb will fall freely any where overthe patient even hurting him, where as in pretendedcondition, the limb does not fall freely and usually awayfrom the face or chest to avoid injury.

Other Method

The Candidate

1. Asks the patient to press down his (candidate’s) handswith both of his (patient’s) hands.

2. Feels the pressure under the so called paralyzed hand,as the patient un intentionally grips down that hand


as well. If it was paralyzed, then there would be nopressure felt.

For Lower Limbs

The Candidate


permission for examination.3. Makes sure the light is adequate and natural.4. Does a general survey of the patient.5. Exposes properly keeping in mind the modesty.6. Makes the patient lie down supine.7. Puts his one hand over the lower part of patient’s

non-paralysed shin.8. Puts the other hand under the lower part of the

patient’s “paralysed” shin on the other side.9. Asks the patient to lift the normal leg upwards.

10. Feels the pressure over the other hand under the“paralysed” side.

11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Notes and comments on the findings.

PEARLS

If one side is truly paralyzed, one will not feel any pressureand if the side is not paralyzed, one will feel downwardspressure on the “paralyzed” side when the normal legis lifted up.

CHAPTER 11

DermatologicalExamination


This system is discussed under four headings as follows:-1. Principles of examination.2. Dermatological examination as a whole.3. Schematic out line of dermatological examination.4. Common commands.

PRINCIPLES OF DERMATOLOGICALEXAMINATIONBefore examination, one should know that skin is thelargest organ of the body. It comprises sixteen percent oftotal body weight. It functions as a sensory organ, organof metabolism that has synthesizing, excretory andabsorptive function, a protective barrier against the externalenvironment and an important factor in temperatureregulation. One should also know that skin is synergisticwith internal organ systems; therefore it reflects pathologicprocesses that are either primary else where or shared incommon with other tissues. The diseases initiallycharacterized as solely cutaneous e.g., SLE, have oftensubsequently been found to involve several systems.


The examination should be done in well-lighted room withnatural light if possible or a ‘daylight’ type of lamp. Thepatient should be exposed properly. When feasible thepatient should be gowned and examined completelysystematically in sections, quadrants or from head to toe.The examination should commence with a generalassessment of the patient as a whole. The survey shouldinclude an appreciation of the colour, degree of moisture;turgor and texture of the skin colour, design of the materialof which the clothing of the patient is made of shouldalso be noted.

315DERMATOLOGICAL EXAMINATION

In the examination of the skin, one should examinethe morphology of individual lesions, their overall pattern,spatial relationship to each over and their distribution.Specific attention to hair, nails and the mucous membranesis required. In addition to naked eye examination in naturallight, one should use special techniques while examiningthe skin lesion e.g., magnification with hand lens, subduedlighting in the examining room, oblique lightening of theskin lesion in a darkened room, wood’s lamp examinationor diascopy of the skin lesion.


Palpation of rashes or localized lesions imparts additionalinformation about texture, consistency, thickness,tenderness and temperature. Gentle scratching or rubbingalters visibility of scaling or may elicit dermo-graphism.The main touch modalities in examining the skin include.Simple palpation, blunt pressure, linear or shearingpressure, squeezing, pinching, scratching, scrappingscorching with or without picking off the scales of skinlesions, diascopy, dermoscopy or iodine-starch test.Additional simple clinical examination includes. Wettingof the skin lesion, application of heat or cold to skin, pinprick examination or pressing of the skin lesion. Glovesshould be worn for examination of the mouth, genitalsor perianal region or while examining an infective lesion.

STEP BY STEP FOR EXAMINATION OF THE SKIN(FOR LONG CASES)

The Candidate

1. Stands on the right side of the patient.2. Greets, introduces himself to the patient and asks for

permission of examination.


3. Exposes the patient properly and makes sure the lightis natural and adequate.

4. Does a general survey of the patient as a whole. Notesthe colour and degree of moisture of the skin.

5. Notes colour, design and material of which theclothing of the patient is made of.

6. Establishes the morphology of the lesion: macule,papule, nodule, tumor, wheal, vesicle, bulla, pustule,crust, scale, erosion, ulcer, fissure, atrophy, scar,poikiloderma, pachyderma or lichenification.

7. Notes the size of the lesion; pin point, pin head, milletseed, lentiform, coin or plaque.

8. Notes the shape of the lesion; discoid, petaloid,arcuate, annular, polycystic, livedoreticularis, targetlesions, stellate, rosettes, digitate, linear, serpiginousor whorled.

9. Notes the margins/borders of the lesions; diffuse,well-defined, regular, irregular, rolled, underminedor punched out.

10. Notes the colour of the skin and of lesion; white-ivory,black, blue, blue-grey, brown, red, scarlet-red, yellow,orange, purple, voilaceous or green.

11. Notes the pattern of the lesions; aggregate, grouped,satellite, confluent, scattered, disseminated, spared,linear, zosteriform.

12. Assesses the distribution of lesions; unilateral,bilateral, symmetrical, asymmetrical, localized,generalized, follows lines of Blaschko, nervous orvascular supply, limited to distribution of skinappendages or sun/chemical exposed areas.

13. Examines the hair, nails, and mucous membranes ofeye, nose, and mouth and anogenital area.

14. Palpates the skin in general and lesions in particular.


15. Applies blunt, linear or shearing pressure to elicitdermo-graphism or Nikolsky’s sign.

16. Squeezes, pinches, scratches or rubs the lesion whenrequired.

17. Performs additional simple procedures like wettingor oiling the lesion, application of heat or cold, pinprick test or paring the skin.

18. Does wood’s lamp examination of lesions.19. Performs simple microscopy for hair, nail or skin

scrapings.20. Thanks the patient for his co-operation and asks him

to dress up and helps him if necessary.21. Comments on the finding while presenting to the

examiners.

CASE WRITING TIPSA. Inspection

1. General Survey of the patient:a. Colour of skinb. Degree of moisture of skin.

2. Clothingsa Colourb Designc Material.

3. Skin lesiona. Morphologyb. Sizec. Shaped. Margins/borderse. Colourf. Patterng. Distributionh. Hair, nail, mucous membranes.


B. Palpation1. Pressure

a. Simpleb. Bluntc. Linear or shearing.

2. Scratchinga. Wetting or oiling the skinb. Application of heat or coldc. Pinprick sensationd. Paring the skin

C. Simple microscopya. Hairb. Nailc. Skin scrapings


COMMANDS

These ma]y be useful during short cases and may be singleor combined.For example:

Examine the hand.Examine the foot.Examine the arm.Examine the front or back of the trunk.After examining the required region, examine the other

related sites, hair, nails and mucous membranes. Performsimple procedures when required.

CHAPTER 12

Examination ofMusculoskeletal

System


PRINCIPLES OF EXAMINATION OFMUSCULOSKELETAL SYSTEM

The musculoskeletal system comprises the following:i. Joints

ii. Bonesiii. Muscles

Normally this system is not well read by the candidatesand occasionally one can be asked to examine a particularjoint e.g. shoulder, elbow, knee or hip joint.

Sometimes it is asked to demonstrate spinal movementseither at cervical spine or thoracolumbar region.

It is mandatory therefore that all the students shouldlearn and practice how to examine a joint.

In the examination of musculoskeletal system, goodold principles prevail including inspection, palpation,movement, measurements and if need be arise one cango for an X-ray (Certainly not during examination).

The percussion is done to elicit tenderness or todemonstrate patellar tap. Auscultation is out in thisexamination and crepitus in a joint is felt rather heard.This system is studied as follows:1. Basic principles2. Examination of musculoskeletal system as a whole3. Overview of the musculoskeletal system4. Commands

BASIC PRINCIPLES

This examination is done as look, feel, move, measure andX-ray.

Inspection (Look)

For proper inspection, the patient should be appropriatelyexposed. It is essential to compare both sides i.e., rightand left and vice versa. The skin should be inspected forany change in colour, redness, creases, scars, sinuses, and

323EXAMINATION OF MUSCULOSKELETAL SYSTEM

contractures. The shape of joint should be noted as well.Any deformity may be either due to postural or structuraldefects, paralytic or compensatory. The deformity may bemobile or fixed and it may be symmetrical or asymmetrical.The degree of deformity may be mild or severe. The posturein which limb is placed is also important to note. Oneshould look for wasting of any muscles or any otherabnormal movements.

Palpation (Feel)

Feeling of the joint should detect warmth due toinflammation and secondly tenderness. Feeling the skinwith the dorsum of the hand by gently stroking will helpguessing the temperature. Patient’s face should be watchedduring this for any tenderness when he winces with pain.Any swelling should also be palpated. One should be ableto differentiate between effusion in a joint and synovialthickening. It is important to feel any altered sensationin the skin. Synovial thickening has a boggy and softcharacter where as effusion is fluctuant and fluid can bemade to shift with in the joint.

Similarly, tenderness and its intensity are palpated.The crepitus in the joint is also felt by putting one handover the joint and moving the joint with other hand.

Similarly, the patellar tap is performed by pressinggently the patella which displaces the fluid and hits thefemur.

Movements (Move)

Before you check for the movements at a particular joint,it is mandatory to ask for any pain at that particular joint.Firstly, it is important to see active movements which thepatient performs without any help. Afterward, passive


movements are checked thoroughly when examiner movespatient’s limb at a particular joint to know full range ofmovements (ROM). Movements by patient againstresistance elicit tenderness in tendons or muscles at aparticular joint. This is called “resisted movementtechnique.” For this, examiner should know the action ofeach muscle and apply appropriate force in oppositedirection of contraction of the muscle. During elicitingpassive movements, it is important to do gently and keeplooking at patient’s face for any evidence of pain by takingpatient into full confidence. One can elicit full range ofmovements. Crepitus can also be felt by performing passivemovements.

Movements involve both neurological and musculo-skeletal system. Power, tone, coordination and reflexeshave already been discussed in the examination ofneurological system. However, the emphasis is on activeand passive movements measurements.

The candidate should master all the techniques ofassessing active, passive movements and testing powerof the muscle.

Measurements (Measure)

The measurements of the movements at a joint areimportant to perform. This indicates the range ofmovements at a particular joint provided one knows thenormal movements. Exact measurements are performed bya goniometer but generally most of the clinicians justestimate the range of movements at a particular joint byexperience.


EXAMINATION OF MUSCULOSKELETAL SYSTEMAS A WHOLE (FOR LONG CASE)

The Candidate1. Stands on the right side of the bed of the patient.2. Greets, introduces himself to the patient and asks for




5. Interphalangeal jointsi. Inspects the proximal interphalangeal and distal

inter-phalangeal joints for any deformity.ii. Checks their active movements (0°-90°).

iii. Palpates for any tenderness, Haberden’s nodes ondistal inter-phalangeal joint.

iv. Checks passive range of movement of these joints(0°-90°).

6. Metacarpophalangeal jointsi. Inspects the metacarpophalangeal joint for any

deformity.ii. Checks their active range of movements (0°-90°)

and functional disability if any.iii. Palpates for any tenderness and nodes.iv. Checks passive ROM at these joints (0°-90°).

7. Wrist jointsi. Inspects for any deformity.

ii. Checks active range of movement i.e (0°-90°).iii. Palpates for nodes, synovial thickening, crepitus

and ganglions etc.iv. Checks passive range of movement at these joints

(0°-90°).v. Elicits signs of carpal tunnel syndrome.


8. Elbow jointsi. Inspects and compares both elbow joints for

nodules, tophi, bursae, carrying angle and tendonxanthomas.

ii. Performs active range of movements (0°-130°).iii. Palpates bursae, nodules, tophi etc, tennis and

golfer’s elbow.iv. Checks passive range of movements at these joints

(0°-130°).9. Shoulder joints

i. Inspects for wasting deformity or dislocation.ii. Checks active movements, i.e. flexion, extension,

adduction, abduction and circumduction.iii. Palpates for tenderness, swelling and crepitus

especially bicipital tendenitis.iv. Checks for passive range of movement.

10. Temporomandibular jointsi. Inspects for any deformity or swelling.

ii. Checks for active movements by asking him to openhis mouth.

iii. Palpates for dislocation or crepitus.11. Cervical spine

i. Inspects for deformity or craning.ii. Checks for active flexion, extension, lateral rotation,

and lateral flexion and notes limitation ofmovements.

iii. Palpates for any tender areas and crepitus.iv. Checks for passive movements in the same way.

12. Thoracic spinei. Inspects for any deformity i.e., kyphosis, gibbus

or swelling.ii. Checks for chest expansion and measures it.

iii. Palpates for any tenderness in the spine.


13. Lumbar spinei. Before checking this makes the patient sit on the

chair so that pelvis is stabilized.ii. Inspects any deformity i.e., straightening etc. or

any swelling.iii. Checks for lateral rotation while patient is sitting,

forward flexion and backward extension whilestanding up.

iv. Palpates for any tenderness or swelling.v. Checks for Schober’s test.

vi. Makes the patient down supine.14. Straight leg raising on both right and left legs15. Sacroiliac joints

i. Inspects for shortening of limb or deformity.ii. Performs springing of both sacroiliac joints in

supine,lateral and prone position.

16. Hip jointi. Inspects the groin and gluteal region.

ii. Cheeks for active range of movement i.e., abduction(0°-60°) and adduction. (0°-30°), flexion (0°-90°),extension (0°-15°).

iii. Palpates for any swellings in groin or glutealregion.

iv. Checks passive range of movement i.e., abduction,and adduction, flexion and extension and notesany restriction of movements.

17. Knee jointi. Inspects both knees anteriorly, posteriorly for

swelling and position or deformity.ii. Checks active movements i.e., backward flexion

(which is limited by hamstrings)iii. Performs patellar tap.iv. Checks for dimple sign for fluid in the joint.


v. Palpates crepitus, stability. At 15° flexion of theknee, checks for collateral ligaments and at 80°flexion, while sitting on patients foot for anteriorand posterior cruciate ligaments.

vi. Performs passive movements as mentioned above.18. Ankle joint

i. Palpates for tenderness, temperature and crepitus.ii. Inspects medial and lateral malleoli for swelling

or any ankle deformity.iii. Cheeks for active movements i.e. plantar flexion

(0°-30°) and dorsiflexion (0°-15°)iv. Checks for passive movements i.e. plantar (0°-30°)

and dorsiflextion (0°-15°)19. Mid tarsal joint

i. Inspects any swelling around heal and foot.ii. Checks for inversion and eversion of foot.

iii. Feels for crepitus, swelling and tenderness.iv. Checks passive movements by inversion and

eversion.20. Meta-tarsophalangeal joint

i. Inspects for swelling, guttering, spacing betweentwo toes (sunray sign).

ii. Checks for active movements i.e., plantar flexion(0°-60°).

iii. Palpates swelling in between metatarsals.21. Toes

i. Inspects for deformity, hammer toe, riding on eachother.

ii. Checks for plantar flexion (0°-90°).iii. Palpates for deformity, crepitus, swelling

temperature and tenderness.iv. Checks passive movements i.e. dorsi-flexion

(0°-90°).22. Thanks the patient for his cooperation and asks him

to dress up and helps him if necessary.


OVERVIEW OF EXAMINATION OFMUSCULOSKELETAL SYSTEM

Inspection (Look)

i. Skin—creases, scars, colour, erythema, atrophy,rashes, sinuses.

ii. Shape—bone swelling, bursae, swelling, synovium,effusion, bony alignment, subluxation, dislocation,shortening, wasting, deformity.

iii. Position—at rest, during activity.iv. Hand deformities—swan neck, Boutonnière’s

deformity, finger drop, mallet finger, Dupuytren’scontracture, Heberden’s nodes, Bouchard’s nodes,and ulnar deviation.

v. Posture—kyphoscoliosis, neurological and myopathicabnormalities, Trendelenberg’s test.

Palpation (Feel)

i. Skin—soft tissue, warmth, coldness, tenderness,thickening, nodules, over growth, deformity.

ii. Abnormal bursae.iii. Effusion—reducible, fluctuant, ballottable, trans-

illumination.iv. Fractures—tenderness, deformityv. Palpate and percuss any abnormal nerves.

vi. Map out altered cutaneous sensations.

Movements (Move)

i. Active, passive and resisted movement at each joint.ii. Pain, power, tone, range, crepitus, creaking, triggering,

locking, hypermobility, telescoping, contractions,stability.

iii. Fracture—abnormality, mobility, crepitus.


iv. Deformity—mobile or fixed.v. Hand—ability to grip, pinch, do up shirt buttons.

vi. Gait—spastic, ataxic, waddling, limp, use of anymechanical aids.

Measurements (Measure)

i. Range of movements.ii. Limb circumference from a fixed bony point on each

side.iii. True and apparent shortening.

X-ray

It is advised to proceed to X-ray of the symptomatic areasin order to identify abnormal bone and soft tissues.


COMMANDS

Examine this Patient’s Vertebral Column

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Examines the patient in standing and sitting

positions.7. Notes any abnormality in the shape of spine.8. Palpates the spinous processes from above below to

elicit any tenderness.9. Examines each portion of the spine i.e., cervical,

thoracic lumbosacral and sacroiliac joints.10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on any abnormal findings.

Cervical Spine

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to touch his chin (flexion–80°).


7. Asks the patient to look up on the ceiling as farbackwards as possible (extension–50°).

8. Asks the patient to look over the right and leftshoulders (rotation–80°).

9. Asks the patient to touch each shoulder with his ears without liftingup of shoulders (lateral bending–45°).

10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on any abnormal findings.NB: Total flexion-extension at cervical spine is 130°.

Thoracolumbar Spine

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Examines the patient while he is standing.7. Asks the patient to touch his toes with knees straight

(flexion—0°-130°).8. Asks the patient to bend back wards while putting

his hands over his hips (extension—0°-35°).9. Asks the patient to slide his right or left hand down

his side of the thigh as far as possible (lateral flexion—0°-30°).

10. Asks the patient to sit on a chair with his armscrossed over his shoulders.

11. Asks the patient to twist around right and left as faras possible (lateral rotation—0°-40°).

12. Measures the chest expansion above and below the


nipples with a tape measure to note the movementsof thoracic cage at costovertebral joints.


Elicit Schober’s Test

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Notes the position of the dimple of Venus.7. Draws an imaginary line joining these two dimples.8. Draws a vertical line of 10 cm above that imaginary

line and 5 cm below that line with a tape measurewhile the patient is standing.

9. Asks the patient to bend forwards and measures thedistance between those two points of the vertical line.

10. Notes any increase or no increase in the total distance.11. Helps the patient redressing.12. Thanks the patient for his cooperation.13. Comments on any abnormal findings.

PEARLSa. In modified Schober’s test, a 10 cm line is drawn

vertically above from the imaginary line joining thetwo dimples of Venus and asks the patient to bendforwards. Then measures the length of that line again.


b. He should note whether there is increase in length orthere is no increase at all.

c. Normally after bending forward, the total distancebetween two points should increase more than 5 cm.

Demonstrate SLR Test

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie down in supine position with

both lower limbs in extended position.7. Lifts the patient’s right heel with his right hand

making sure the leg is in full extension at knee.8. Places left hand over the symphysis pubis to stabilize

the pelvis.9. Keeps moving up wards as much as possible.

10. Asks the patient if he feels any pain.11. Dorsiflexes the forefoot of the patient by using left

hand.12. Asks and looks at the patient’s face for accentuated

pain.13. Performs the same test on the opposite side and

compares it.14. Helps the patient redressing.15. Thanks the patient for his cooperation.16. Comments on any abnormal findings.


To Elicit Tenderness at Sacroiliac Joints

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Makes the patient lie supine with legs together and

extended at knees and hips.7. Places ball of thumbs of both hands over the anterior

super iliac spines of the patient and fingers placedover the lateral sides of the hips.

8. Exerts firm pressure vertically downwards aimingtowards sacrum.

9. Exerts inward pressure from both iliac bones.10. Turns the patient in right or left lateral position.11. Places his both hands over the lateral aspect of the

hip and exerts vertical pressure to elicit pain.12. Makes the patient in prone position.13. Puts each hand at dimple of Venus.14. Exerts downward pressure.15. Helps the patient redressing.16. Thanks the patient for his cooperation.17. Comments on any abnormal findings.

PEARLS

The other method is to flex the hip at 90° and exert firmpressure at the knee through the femoral shaft (only if theknee in not painful). So, there are four methods to elicitpain at sacroiliac joint.


Temporomandibular Joint

The Candidate



modesty. (if wearing a veil)4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Asks the patient to open and close his mouth.7. Looks for any side to side movement.8. Places his fingers on the joints on both sides in front

of tragus while the mouth is closed.9. Asks the patient to open the mouth.

10. Palpates the head of the mandible as it movesforwards and downwards.

11. Elicits any tenderness.12. Notes any feeling of clicking in the joint.13. Notes any other abnormality and compares on both

sides.14. Helps the patient redressing (if wearing a veil).15. Thanks the patient for his cooperation.16. Comments on any abnormal findings.

PEARLS

TMJ is usually involved late in case of rheumatoid arthritiswhen it develops ankylosis.

EXAMINATION OF THE UPPER LIMB

One should do initial few tests to localize upper limbabnormalities. For this purpose, one can ask the patientto perform the following tasks:


I. Pick up some object.II. Write few lines.

III. Put the hands together as if praying.IV. Comb the hair.V. Un button the shirt.

Then proceed to full regional examination, whichinvolves inspection palpation, movements and any otherabnormality.

Assessment of power and any neurological dysfunctionshould also be tested.

The movements of shoulder joint are composite andoccur at glenohumeral joint, scapula, clavicle and thethorax.

In neutral position, the upper arm is adducted at theshoulder, flexed at the elbow and supinated at the fore-arm. One should hold the scapula against the chest toexamine the shoulder. Avoid any other movements takingplace at that area.

EXAMINE THE SHOULDER JOINT

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Notes any swelling or deformity of the joint and

compares on the opposite side.7. Palpates for any tenderness at sternoclavicular,

acromioclavicular joint and sub-acromial bursa andthe head of humerus.


8. Keeps the shoulder joint in neutral position (Theneutral position of the shoulder is when the upperarm is adducted at the shoulder, flexed at the elbowand pronated at the fore arm).

9. Asks the patient to swing the arm forwards (flexion—165o).

10. Asks the patient to swing the arm backwards(extension—65o).

11. Asks the patient to take the arm outwards andupwards as much as he can (abduction—170°).

12. Asks the patient to carry the arm forwards across thefront of the chest (adduction—50°).

13. Asks the patient to scratch the back as up as possiblewith his thumb (internal rotation—90°).

14. Asks the patient to move his arm outwards as muchas possible with elbow flexed (external rotation—60°).

15. Performs on both sides and compares the findings.16. Helps the patient redressing.17. Thanks the patient for his cooperation.18. Comments on any abnormal findings.

PEARLS

If you ask the patient to the put the hand behind his neckand go as far as down as possible, it is abduction andexternal rotation which is being checked. If you ask thepatient to scratch his back as far up as possible with histhumb, this is the internal rotation and extension whichare being checked.

EXAMINE THE ELBOW JOINT

The Candidate





4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Notes any swelling or deformity of the joint and

compares on the opposite side.7. Keeps the elbow in neutral position (The neutral

position of the elbow joint is when the arm is flexedat 90° at elbow and the forearm is in supinatedposition.).

8. Inspects the olecranon process for any bursa, tophus,xanthoma or nodules.

9. Palpates the medial and lateral epicondyles,olecranon and head of the radius.

10. Palpates ulnar nerve behind the medial epicondyl forany thickening, also palpates for epitrochlear lymphnodes.

11. Palpates for tenderness at the lateral epicondyl forany evidence of tennis elbow.

12. Asks the patient to bend elbow as much as he can(flexion—150°).

13. Asks the patient to stretch the flexed elbow(extension—180°).

14. Flexes the forearm at 90° at elbow in a semi-proneposition.

15. Asks the patient to rotate the forearm medially(pronation—75°).

16. Asks the patient to rotate the forearm outwards orlaterally (supination—80°).

17. Palpates the radial styloid process during supination.18. Palpates ulnar styloid process during pronation.19. Performs on both sides and compares the findings.20. Notes any abnormality and comments on the findings.21. Helps the patient redressing.



PEARLS

a. Pronation and supination take place at superior andinferior radio ulnar joints respectively.

b. The neutral position of the elbow is when the elbowis flexed at 90o and the arm is supinated.

EXAMINE THE WRIST JOINT

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Inspects the wrist for any swelling, deformity

erythema or muscle wasting and compares on bothsides.

7. Palpates the wrist with both the thumbs of his handsby placing them on the dorsum of the wrist and hisfingers holding the ventral part of the wristsupporting it.

8. Palpates the anatomical snuff box for any tenderness.9. Asks the patient to approximate the dorsum of his

hands together and flex the wrist joint (flexion—75°).10. Asks the patient to put together both the palms then

extend the forearm (extension—75°).11. Places together the hypothenar eminences of the

palms which are facing upwards.12. Asks the patient to move away from the mid line but

keeping in touch the ulnar styloid processes.(abduction—20°, also called radial deviation).


13. Asks the patient to keep the same position of palmsbut now move in the tips of the fingers which aretouching each other (adduction—35°, also calledulnar deviation).

14. Palpates the flexor retinaculum on the volar surfaceof the wrist.

15. Percusses the median nerve to produce tinglingsensation in the area of its distribution (carpal tunnelsyndrome).

16. Performs on both sides and compares the findings.17. Helps the patient redressing.18. Thanks the patient for his cooperation.19. Comments on any abnormal findings.

PEARLS

a. The neutral position of the wrist is with the hand inthe line with the forearm and palm facing downward.

b. Flexor retinaculum is one inch square size and makesthe roof of the carpal tunnel through which flexortendons and median nerve pass.

c. The flexor retinaculum is attached proximally totubercle of scaphoid and the pisiform bone and distallyto the ridge of trapezium and hook of hammate.

EXAMINE THE METACARPOPHALANGEAL JOINTS

The neutral position of these joints is when the fingersare in extension.

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Inspects any swelling, redness, nodules or tophi.7. Notes any subluxation or dislocation of the proximal

phalanges.8. Notes any ulnar deviation of the fingers from the head

of the metacarpals.9. Applies lateral pressure by squeezing the MCP joints

with right hand.10. Applies anteroposterior pressure over each MCP joint

by both thumbs.11. Asks patient to bend fingers while keeping it straight

at PIP and DIP joints (flexion—90°).12. Asks to hyperextend the fingers while keeping them

straight (extension—20°).13. Performs the examination on the other sides and

compares the findings.14. Helps the patient redressing.15. Thanks the patient for his cooperation.16. Comments on any abnormal findings.

PEARLS

In Ehler-Danlos syndrome and other hyperelastoses, thefingers usually hyperextend in very bizarre posture.

EXAMINE THE INTERPHALANGEAL JOINTS

The Candidate



modesty.


4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Notes any deformity, abnormality, swelling, tophus,

nodules etc.7. Palpates the sides of the IP joints for any tenderness.8. Keeps the DIP joint straight.9. Asks the patient to bend PIP joint (flexion—120°).

10. Holds the middle phalanx with his thumb and finger.11. Asks the patient to bend finger at DIP joint (flexion—

80°).12. Performs the examination on the other sides and


EXAMINE THE MOVEMENTS OF THE THUMB

The natural position of thumb is when it lies along withside of the palm and the palm faces upward.

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Notes any deformity, abnormality, swelling, tophus,

nodules etc.7. Asks the patient to move the thumb away from the

side of the palm in the same plane (extension—75°).


8. Asks the patient to move the thumb medially overthe palm in the same plane (flexion—55°).

9. Asks the patient to move the thumb away from thepalm in a vertical plane so that its tip faces the ceiling(abduction—75°).

10. Asks the patient to hold tight the thumb against theradial border of palm (adduction—0°).

11. Asks the patient to touch the tips of his other fingerswith the tip of his thumb (opposition—60°).

12. Asks the patient to rotate the thumb in all directions(circumduction—360°).

13. Performs the examination on the other sides andcompares the findings.


EXAMINE THE HANDS

The golden rule is that before you examine the hands, itis better to ask whether they are painful or not.

The Candidate


permission for examination.3. Exposes the patient adequately, observing the modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Inspects the hand for its size, deformity, wasting of

small muscles, erythema, rashes, and length of fingers,nails, Dupuytren’s contracture and other importantconditions.


7. Asks the patient to extend and flex the fingerspassively and palpates the tendons for any crepitusor restriction of movements.

8. Asks the patient to make fist.9. Asks him to extend or flex against resistance.

10. Checks power of interossei muscles by spreadingfingers against resistance and by holding a paperbetween the fingers and pulling it out.

11. Asks the patient to flex the MCP at right angle withextended proximal and distal interphalangeal joint.

12. Checks for presence of functions by hand grip andpinch grip by asking the patient to hold a glass ofwater, undo buttons or to write few lines etc.

13. Performs the examination on the other side andcompares the findings.


PEARLS

a. If the examiner asks to exclude the thumb in testingfunction of grip, then introduce your two fingers inpatients palm from the ulnar aspect of his hand andask him to squeeze them. By doing this, thumbmovement and action is excluded in hand grip.

b. You can describe the rheumatoid hands by saying that“there is bilateral, symmetrical polyarthropathyinvolving the small joints of the hands”.

EXAMINE THE HIP JOINT

The natural position of hip is in extension with patellapointing forward (when the patient is standing) andupwards (when the patient is in supine position).


The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Inspects the joints as thoroughly as possible.7. Looks for the symmetry of the joint.8. Palpates greater trochanter for any tenderness.9. Looks at the position of the limb for any deformity.

10. Checks the relative position of the hip joints by placingthumb on the anteriorsuperior iliac spines and middlefingers on the greater trochanters.

11. Checks difference in leg length by bending both kneesand feet placed together.

12. Checks flexion by asking the patient to lift his extendedleg as much as possible (active flexion—90-100°).

13. Checks passive flexion by flexing the knee as well.(This range is more than active one)

14. Checks for fixed flexion by flexing the normal hipuntil the lumbar curve is flattened and to know thatplaces his left palm under the lumbar spine.

15. Notes degree of elevation of the contralateral thigh.16. Checks abduction by asking patient to move away

the extended limb from midline as much as possibleand while doing it places left hand over the sameanteriorsuperior iliac spine to stabilize pelvis(abduction—45°).

17. Checks adduction by asking patient to move theextended limb across the midline to the opposite side.Examiner’s left hand is placed over the same anterior-superior iliac supine to stabilize it (adduction—30°).


18. Checks movements of internal and external rotationsby asking the patient to flex at knees and hips (90°)while the feet and knees are attached to each other.

19. Asks the patient to move apart the knees as far aspossible while keeping the feet together. (externalrotation—45°).

20. Asks the patient to place his knees and feet in theprevious position and asks him to slide away the feetas far away as possible but keeping both knees incontact (internal rotation—20°).

21. Rotation can also be checked while the limbs are keptin extension and by asking the patient to rotate thefoot outwards and inwards. It is better to see thatfrom the foot end of the patient.

22. Checks extension by asking the patient to lie on theside and move his lower limb backwards as far aspossible or asks him to lie down prone and flex theknee then lift the knee off the couch as far as possible(extension—10-15°).

23. Checks again the movements of both internal andexternal rotation in this position.

24. Performs telescoping by gripping the flexed thighwith both hands and performs pulling movement.

25. Checks any apparent or true shortening of the legby asking the patient to lie straight on the bed.Measures from anteriorsuperior iliac spine to themedial malleolus for true shortening and for apparentshortening measures from umbilicus or manubriumsterni to the medial melleoli.

26. Asks the patient to stand and walk and notes anytilting of the pelvis by standing behind him(Trendelenberg’s test)

27. Performs the examination on the other sides andcompares the findings.



PEARLS

a. Hip joint is covered and surrounded by manyligaments and thick muscles, therefore inspection ofthe swelling may be difficult.

b. Trendelenberg’s test: Normally when the person standson one leg, the opposite side of pelvis is raised byabduction at the hip joint of the weight bearing leg.This is seen when the examiner stands behind theperson and observes an imaginary line connecting bothdimples of Venus. If the patient with diseased hip jointis standing, then the pelvis drops on the healthy side.This is called positive Trendelenberg’s is test.

c. Internal rotation at 90° flexion is 45° and externalrotation at 90° flexion is 45°. Internal rotation inextension is 35° and external rotation in extension is45°.

EXAMINE THE KNEE JOINT

The natural position of the knee joint is in extension.Therefore painful knee is always held in flexion.

The Candidate





6. Looks at both the knee joints and compares them.7. Notes skin changes, swelling, deformity, and scars.8. Looks for quadriceps wasting.9. Feels for any warmth indicating inflammation.

10. Feels for the surface, margins of patella and lowerend of femur and upper end of tibia along with lateraljoint margin.

11. Feels for the crepitus in the joint by moving it gently.12. Checks for fluid in the joint by sweeping/squeezing

the skin to produce a bulge around the knee joint.13. Checks patellar tap by squeezing the lower thigh with

left palm sliding down towards patella. Maintainsthat hand just above the upper border of the patella.Pushes the patella downwards with the right hand’sindex and middle fingers which produce a bony tapas the patella touches the underlying femur.

14. Asks the patient to bend his knee to check flexion(0-135°). Listens for any clicks or creaks duringflexion.

15. Places the left fist on the lateral side of the extendedknee pressing vertically the couch. Flexes the kneeto 15°. Supports the knee with the left fist and gripsthe ankle with right hand and tries to move the tibiaaway from the femur (medial collateral ligaments).

16. Places the left fist against the extended knee on themedial side pressing vertically downwards on thecouch. Flexes the knee to 15°. Supports the knee withleft fist and holds the ankle with right hand and triesto bring the tibia in wards. (lateral collateral ligament).

17. Asks the patient to bend the knee at 90°. Places hisright buttock (for right knee examination) on the rightforefoot of the patient.

18. Grips the upper end of calf with fingers of his bothhands while placing his both thumbs side by side


over the tibial tuberosity. Pulls forwards (checksintegrity of anterior cruciate ligament) and pushesbackwards (checks integrity of posterior cruciateligament).

19. Performs McMurray’s test to elicit any loose bodiesin the knee.

20. Asks the patient to stand up.21. Looks for any valgus, varus or recurvatum deformity.22. Observes the gait.23. Performs the examination on the other side and


PEARLS

a. Crepitus in knee joint is always felt and not auscultated.b. During examination, keep on looking at patient’s face

for any pain.c. Passive movements are 5° more than active movement

in flexion.d. There are no extension or rotation movements at knee

joint.e. Muscle wasting is assessed by measurement as

considered under general examination.f. McMurray’s test: (Right knee joint)

• Hold the ankle with right hand.• Hold the knee with left hand.• Flex the knee joint.• With the right hand rotate the foot in clock and

anti-clockwise.• Apply abduction force on the knee by both hands

while doing this manouvre.


• While doing this gradually extends the knee fromthe flexed position.

• Note for any pain or a click or protrusion of a lumpalong the joint margin.

PEARLS

Loose bodies or torn cartilages in the joint will be felt asclick, creaks or protrusions through the joint space.

EXAMINE THE ANKLE JOINT

The natural position of ankle joint is straight, in plantarflexion and slight inversion.

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Looks at both the ankle joints and compares them.7. Inspects closely the joint for swelling, change in skin

colour, scars, and deformity.8. Examines the soles for perforating ulcers or callosities.9. Notes for any small effusion in the joint by looking

in front of both malleoli and on each side of the tendo-Achilles.

10. Palpates for raised temperature.11. Palpates for any tenderness or swellings.12. Asks the patient to bend the foot upward i.e., to raise

the toes towards the knee (dorsiflexion—20°).


13. Asks the patient to bend the foot downwards i.e., tomove the toes towards the floor (plantar-flexion—50°).

14. Checks for abduction and adduction.15. Asks the patient to move the outer part of sole inwards

(inversion—30°).16. Asks the patient to move inner part of the sole

outwards (eversion-5°).17. Performs the examination on the other side and


PEARLS

a. Dorsiflexion and plantar flexion occur at ankle joint.b. Inversion and eversion take place at subtalar joint.c. Transmitted impulses may be obtained between the two

sides of tendo-Achilles if sufficient fluid is present inthe ankle joint.

d. Look for hallux valgus, claw foot and Charcot’s jointand abnormalities of transverse or longitudinal arches.

e. Palpate sole for deep tenderness especially for thecalcaneal spur.

EXAMINE METATARSOPHALANGEAL JOINTS

The Candidate





5. Does a general survey of the patient.6. Looks for any deformity on the dorsal and plantar

aspect of the foot.7. Holds the forefoot across metatarsophalangeal joints

with thumb and finger of his hand and squeezesacross.

8. Assesses metatarsophalangeal joints individually.9. Asks to bend upwards the great toe (dorsiflexion—

60°).10. Asks the patient to bend his toes downwards (plantar

flexion—40°).11. Performs the examination on the other side and


EXAMINE INTERPHALANGEAL JOINTS OF THE FOOT

The Candidate



modesty.4. Makes sure the light is adequate and natural.5. Does a general survey of the patient.6. Looks for any abnormality.7. Palpates for any tenderness, or increase in

temperature.8. Asks the patient to bend and spread his toes (fanning)

abduction.9. Performs the examination on the other side and

compares the findings.


10. Helps the patient redressing.11. Thanks the patient for his cooperation.12. Comments on any abnormal findings.Inversion of heel is 20° and eversion is 10°. Total supinationat forefoot level is 35° whereas total pronation is 20°.

As regards great toe, extension at MPJ is 90°, andextension is 65°. Flexion at IPJ is 60° where as extensionat the same joint is 0°.

355PATIENT’S RECORDCHAPTER 13

Patient’sRecord


It is very important to keep the patient’s record in the formof notes accurately, legibly and in a systematic way. Thiswill provide very vital information later on as a recordof what were the problems, what actions were taken andwhat improvement occurred and what was the ultimateoutcome.

These notes should be complete and comprehensiveas much as possible so that if another person wants togo through them, he should not face any difficulties orhurdles in getting the whole scenario and history of thepatient. All these documents have to be confidential asthey may have some medicolegal implications.

The daily progress notes should be written with dateand time in the corner and SOAP methodology shouldbe adopted where “S” indicates subjective symptoms, “O”indicates objective assessment by the physician, “A”indicates overall assessment and “P” indicates the furtherplanning for the management of the given problem. Thenotes should be written legibly and at the end the doctorshould put his name or signature and should also puta stamp showing his full name and title i.e., HO, SHO,registrar or senior registrar etc.

Simple diagrams can be used to quickly highlight theunderlying problems in a system. Measurements shouldbe added when required.

Avoid using abbreviations and short hand as this maycause a lot of confusion. Each discipline has its ownlanguage but the notes should always be meaningful toall health care workers who need to read them.

Summary of the problems should be written after eachcomprehensive history and examination and one shouldalso mention in order of preferences the differentialdiagnosis. Therefore, appropriate investigations are sentto include or exclude other diagnoses as multiplepathologies may also co-exist.

357PATIENT’S RECORD

Having done this, one writes appropriate treatmentplan for the most probable diagnosis on a properly printeddoctor’s order sheet and on the treatment chart.

It is very vital that a comprehensive note should bemade in the notes for all procedures either minor or majorperformed on the patient and the exact time and dateshould be mentioned along with the name and designationof the person who did the procedure. This practice helpsthe next on duty doctor to assess the importance of theresults if they have not come through yet e.g., cerebrospinal,pleural and ascitic fluid.

Notes are written in a meticulous way mentioningpatient’s daily progress during his stay in the hospital.

At the time of discharge from the hospital, a detailedproforma is filled in mentioning the problems andinvestigations performed or pending and treatment to takehome along with a brief summary. This is an importantdocument as whereever the patient goes he will have toproduce this for a quick reference of his current and pastailments and to produce when the patient comes to attendas an out patient for follow up and quickly the problemsand plan for further follow up is outlined withoutunnecessary delays or hurdles. It is, therefore, veryimportant that such a discharge summary should bewritten with great caution and important informationsshould not be missed.

The record of out patient attendance should also bekept in an organized way in folders which are properlylabeled and either these folders are different folders or theones kept with the folders having patient’s record whenhe was admitted as an inpatient.

359INVESTIGATIONSCHAPTER 14

Investigations


After taking a detailed history and performing a generalphysical and detailed systemic examination, one reachesto a most probable diagnosis and a list of commondifferential diagnoses is made, the step of sendingappropriate investigations comes there after.

The term “routine investigations” has to be justifiedand each investigation has to be weighed as regards itssignificance and implication in the management of thepatient. Investigations are performed to include or excludediagnosis. Before asking for investigations, clinician shouldknow the cost effectiveness as well. Try to order asminimum investigations as possible but this does not meanthat important investigations should not be asked for evenif they are expensive.

In the FCPS, MRCP (UK) examinations, during thetheory paper if the examiner has asked investigations, thentheir number is also specified e.g., give three or fourinvestigations and you have to write the most relevantinvestigations in order and you have to justify why areyou asking for them?

The clinical accuracy is the most important pillar ofmedicine and unnecessary investigations should not beasked or ordered. This implies especially in our socio-economic set up where economy plays an important roleas all the patients cannot afford all the investigations ifwritten without taking into consideration the social statusand income of the patient.

If investigations are ordered without any basis fordiagnosis, it leads to collection of a number of irrelevantinformation which further can muddle the actualdiagnosis. If in doubt about whether or not to performa test, the clinician should ask himself or herself whetherknowledge of the information obtained will influence thepatient’s management.

361INVESTIGATIONS

This chapter is written to cover some most importantinvestigations symptomwise. Most sophisticated andcomprehensive investigations can be looked into standardtext books for more details. Only the headings ofinvestigations are listed systemwise.

PEARLS

Sometimes investigations which are asked in the examinationcan be grouped as radiological investigations including,CXR, U/S, CT or MRI or haematological investigationsincluding CBC, ESR, peripheral picture and DLC etc.

Let us discuss first routine investigations:

ROUTINE INVESTIGATIONS

1. Complete blood count (CBC)2. ESR3. Peripheral blood picture4. Urea, creatinine and electrolytes5. Urine routine examination6. Blood sugar both fasting and random7. Lipid profile after 14 hours of over night fasting8. Liver function tests9. Chest X-ray PA view

10. ECG.

PEARLS

Not all the above investigations are required in every casebut these are the usual ones which one should know anddepict quite a few abnormalities as regards investigationsare concerned.


SYSTEMIC INVESTIGATIONS

A. Cardiovascular system investigations1. Electrocardiogram (ECG)2. Exercise tolerance test (ETT)3. 24 hours holter monitoring4. Echocardiography5. Radio isotope ventriculography6. Thallium stress test7. Cardiac catheterization8. Coronary angiography9. CT scan with multiple slices.

B. Respiratory system investigations1. Chest radiography2. Sputum examination for colour, micro-organisms,

AAFB and malignant cells3. Pulmonary function tests including:

PEFR (peak-expiratory flow rate) FEV1, FVC4. Estimation of lung volume5. Diffusion capacity of the lung, DLCO6. Arterial blood gases7. Bronchoscopy8. Transbronchial lung biopsy9. Bronchoalveolar lavage/washing/brushing

10. Open lung biopsy11. Transthoracic lung biopsy12. Pleural aspiration13. Pleural biopsy14. Thoracoscopy15. Mediastinoscopy16. CT chest—High resolution (HRCT)17. Ventilation perfusion scan18. Bronchography19. Spiral CT scan.

363INVESTIGATIONS

C. Immunological investigations1. Mantoux test2. Kveim test3. Intradermal allergen test4. Precipitin tests5. Bronchial challenge tests.

D. Gastrointestinal investigations1. Stools examination for ova and cysts, occult blood2. Plain radiography3. Barium swallow4. Barium meal and follow through5. Small bowel enema6. Barium enema7. Upper GI endoscopy and biopsy8. Rigid procto-sigmoidoscopy and biopsy9. Flexible sigmoidoscopy and biopsy

10. Colonoscopy and biopsy11. Endoscopic retrograde cholangiopancreaticography

ERCP12. Gastric function tests13. Faecal fat excretion14. Xylose excretory tests15. Lactose tolerance test16. Radioisotope breath test17. Hydrogen breath test18. Urease test, CLO test19. LFT’s: ALT, AST, alkaline phosphatase, albumin,

globulin, bilirubin, gamma GT, prothrombin time,activated partial thromboplastin time

20. Alpha fetoprotein21. Antinuclear antibody22. Antismooth muscle antibody test23. Antimitochondrial antibody test


24. HBsAg, Anti HCV Ab, Anti HAV IgG and IgM , AntiHEV IgG and IgM and other related markers

25. Ultrasound scanning26. Liver biopsy27. Radio-isotope scan28. Trans jugular intrahepatic portosystemic shunt-stent

and surgery TIPSSS29. Magnetic resonance cholangiopancreaticography

MRCPE. Urogenital/nephrological investigations

1. Urine routine examination2. Urea and creatinine3. Creatinine clearance4. Renal scan5. Ultrasound scan6. EDTA/DTPA scan7. Intravenous urogram IVU8. CT9. MRI

10. Angiography11. Renal biopsy12. Cystoscopy.F. Endocrinological investigations

a. General1. Blood glucose, fasting/random2. Oral glucose tolerance test (OGTT)3. Glycosylated haemoglobin (HbA1c)4. Urine routine examination5. Insulin and C-peptide levels.

b. Thyroid1. FT3, FT4

2. TT3, TT4

3. TSH4. Antibodies to thyroglobulin/microsome

365INVESTIGATIONS

10. Radioisotope scan of the thyroid11. Ultrasound scanning12. Fine needle aspiration and cytology (FNAC).

c. Adrenals1. Serum sodium and potassium2. Cortisol level at 9.00 AM3. Short synacthen test4. Urinary 24 hours VMA’s5. Urinary metanephrins6. Plasma catecholamines7. ACTH levels8. Small dose dexamethasone suppression test9. High dose dexamethasone test

10. Ultrasound examination11. CT, MRI12. Digital subtraction scintigraphy13. Methyl iodo benzyl guanidine scan (MIBG) scan14. Selective venous sampling.

d. Diabetes1. Insulin tolerance test2. Oral GTT3. Growth hormone level4. X-ray skull lateral view5. MRI.

e. Urogenital1. LH, FSH2. Oestradiol, testosterone.

f. Parathyroid1. Serum calcium and phosphorus2. Alkaline phosphatase3. Urinary hydroxy proline4. Parathyroid hormone (PTH)5. Urinary calcium6. Bone biopsy.


G. Rheumatological investigations1. Uric acid2. ESR3. Antinuclear antibodies (ANA)4. Rheumatoid factor (RA)5. Extractable nuclear antigens (ENA)6. X-ray joints7. Synovial fluid examination8. Microscopy of synovial fluid9. Anti-neutrophilic cytoplasmic antibodies (cANCA)

and (pANCA)H. Neurological investigations

1. Lumbar puncture2. CT/MRI3. Electroencephalogram EEG4. Sensory visual evoked potential (VEP)5. Nerve conduction studies (NCS)6. Electromyography (EMG)7. Radioisotope brain scan8. Myelography9. Muscle biopsy

10. Peripheral nerve biopsy11. Cerebral angiography12. Digital subtraction angiography13. MRI angiography14. Brain biopsy.I. Haematological investigations

1. Full blood count2. Peripheral blood film3. Blood volume4. Bone marrow aspiration, trephine biopsy5. Carboxy haemoglobin6. Cell marker studies

367INVESTIGATIONS

7. Chromosome analysis (karyography)8. Cytochemistry9. Acid phosphatase

10. Neutrophilic alkaline phosphatase11. 2,3-Diphosphoglyceridase12. Glucose-6-phospahte dehydrogenase (G-6-PD).

INDEX

A‘Ah’ test 208Abdominal distension 125Abdominal reflexes 258Abductor digiti minimi 233Abductor pollicis brevis 236Abductor pollicis longus 236Abductors of the hips 245Accessory nerve 209Accommodation reflex 188ACTH 206Adductors of the hips 244Adie’s pupil 189Agnosia 179Ankle clonus 279Ankle jerk 271Ankle joint 351Anosognosia 180Aortic regurgitation 117Apraxia 178Apex beat 105, 111Argyll Roberson’s pupil 189Ascites 149Auditing 12Auscultation of the chest 83Auscultation of the pre-

cordium 113Avoidance reflex 302

BBabinski’s sign 262Ballottement 128Base of the heart 120

Bell’s phenomenon 201Biceps brachii 227Biceps jerk 267Bjerrum screen 186Blood pressure 50Brachioradialis 229Breasts 57Bring’s sign 262Bulbocavernosus reflex 260Bulk of muscle 215

CCaloric test 205Caput medussae 154Cervical spine 331

thoraco-lumbar spine 332Schober’s test 333

Chaddik’s sign 262Claw foot 252Clonus 278Clubbing grades 40Cochlear part, 8th nerve 202Coin test 91Corneal reflex 198Corrigan’s sign 117COWS 206Cremasteric reflex 258Cullen’s sign 131Cyanosis 39


DDeep pain 283Deformities of chest 79Deltoid 221Demusset’s sign 117Diaphragm 243Diaphragmatic palsy 88Digital rectal examination 154

level of consciousness 176memory 176speech 177

Dipping method 128Dorsiflexor of the ankle 249Durozie’s murmur 118Dysdiadochokinesia 255

EElbow joint 338Ellis’s curve 86Engorged abdominal veins

153Eversion inversion 250Extension pollicis brevis 239Extension pollicis longus 238Extensor carpi radialis longus

231Extensor carpi ulnaris 230Extensor digitorm longus 252Extensor digitorum 231Extensor hallucis longus 252Extensors of the knee 248Extensors of the thigh 246

FFacial nerve 199Finger flexion jerk 273

First palmar and dorsalinterossei 235

Flexor carpi radialis 232Flexor carpi ulnaris 232Flexor digitorum profundus

234Flexor digitorum superficialis

233Flexor pollicis longus 239Flexors of the knee 248Flexors of the thigh 246Fundoscopic examination 190

GGallop rhythm 116General physical examination

27Glabellar tap 304Glossopharyngeal and vagus

nerves 206Gordon’s sign 262Gauda’s sign 262Graphaesthesia 293Grasp reflex 302Grey-Turner’s sign 131

HHarrison’s sulcus 79Heel shin test 256Hill’s sign 118History taking 13

allergy history 15drug history 15family history 15menstrual history 15past medical history 15personal history 15

INDEX 373

present illness 14social history 15

Hoffman’s sign 274Holmes-Adie syndrome 189Horner’s syndrome 189, 212Hypoglossal nerve 210

IIlio psoas muscle 243Infraspinatus 222Inspection of the chest 78Instruments required 23Interossei (dorsal) 240Interossei (palmar) 240Inter-phalangeal joints of

foot 353Inter-phalangeal joints 325Ishihara’s chart 183

JJaeger’s chart 183Jaundice 41Jendrassik’s manoeuvre 264Jew jerk 266JVP 107

KKnee jerk 269Knee joint 348Kocher’s test 57Krotokoff’s sounds 53Kussmaul’s breathing 66Kussmaul’s sign 108

L

Latissimus dorsi 224Light reflex 187Lovibond angle 40

Lumbricals 235Lymphadenopathy 42

M

Medical education skills 10clerical skills 11clinical skills 10communication skills 10ethical skills 11organizational skills 11procedural skills 12

Menace reflex 186Metacarpo-phalangeal joints

341Meta-tarso-phalangeal joints

352Movements of the thumb

343Muller’s sign 118Murmurs, grading 99

N

Negative data in history 16Nutritional status 37Nystagmus 195

Grading of 196Congenital 196Traveller’s 196

O

Ocular movements 192Oedema, fast 46Oedema, slow 46Olfactory nerve 181


Oppenheim’s sign 262Opponens pollicis 237Optic nerve 182

PPain 307Pallor 38Palmomental reflex 301Palpation of the chest 76, 79Patellar clonus 278Pectoralis major 226Pemberton’s sign 57Percussion of the chest 75, 81Plantar flexion of the ankle 249Pleximeter 68Plexor 68Power of muscles 218Primitive reflexes 173Puddle sign 151Pulse 46

carotid 47collapsing (water-

hammer) 49paradoxus 49radial 46

QQuinke’s sign 118

RReinforcement 248Reviews 12Rhomboids 223Rinne’s test 172Romberg’s sign 289Rotators of the thigh 247Routine investigations 361

SSacroiliac joints 335Sartorius 244Scalene lymph node 45Schaefer’s sign 262Schamroth’s sign 40Schober’s test 36Sense of joint position 287Sense of vibration 285Sensory inattention 294Serratus anterior 225Shoulder joint 337Signs of cardiac failure 119SLR test 334Small intrinsic muscles 251Snellen’s chart 184Snout reflex 303Spinal percussion 90

light 90heavy 90

Spinal tenderness 90Squint 189Stereognosis 292Stethoscope 88Subscapularis 223Succession splash 87Suckling reflex 303Superficial anal reflexes 260Supinator jerk 268Supinator 228Supraspinatus 222Systemetic review in 16

cardiovascular system 16central nervous system 18dermatological system 20endocrine system 20gastrointestinal system 17

INDEX 375

haematological system 18locomotor system 19respiratory system 16urogenital system 17

TTactile discrimination 291Tactile localization 290Tandem walking 36Taste sensation 201Teeth 126Temperature, sensation 284,

285Temperature 54Throat 60Thyroid 55Tone of muscles 216Tongue 61

Touch 281Tracheal position 86Tracheal tug 85Triceps jerk 268Triceps, muscle 228Trigeminal nerve 196

UUpper limb 336

VVestibule-cochlear nerve 188

WWaldayer’s ring 45Wartenberg’s sign 275Weber’s test 172Wrist clonus 279Wrist joint 340

Documents

Clinical Examination Skill (Step by Step) (Nov 30, 2008)_(8184486421)_(JBMP)