mechanisms clinical signs

of

Mark DennisWilliam Talbot Bowen

Lucy Cho

mechanismsclinical signs

of

mechanismsclinical signs

of

Mark Dennis MBBS(Honours)Resident, The Wollongong Hospital

Lucy Cho MBBS, MIPH, BAResident, The Wollongong Hospital

William Talbot Bowen MBBS, MD, BSResearch Coordinator, Olive View-UCLA Medical Center,

Department of Emergency Medicine

Sydney Edinburgh London New York Philadelphia St Louis Toronto

Churchill Livingstoneis an imprint of Elsevier

Elsevier Australia. ACN 001 002 357(a division of Reed International Books Australia Pty Ltd)Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067

This edition © 2011 Elsevier Australia

This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher.

Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation.

This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication.

National Library of Australia Cataloguing-in-Publication Data

Author: Dennis, Mark,

Title: Mechanisms of clinical signs / Mark Dennis, William Talbot Bowen, Lucy Cho.

ISBN: 9780729540759 (pbk.)

Notes: Includes index.

Subjects: Symptoms–Handbooks, manuals, etc. Diagnosis–Handbooks, manuals, etc.

Other Authors/Contributors: Bowen, William Talbot. Cho, Lucy.

Dewey Number: 616.075

Publisher: Sophie KalinieckiDevelopmental Editor: Neli BryantPublishing Services Manager: Helena KlijnProject Coordinator: Geraldine MintoEdited by Linda LittlemoreProofread by Andy WhyteIllustrations by Toppan Best-set Premedia LimitedDesign by Stan Lamond of Lamond Art & DesignIndex by ••Typeset by Toppan Best-set Premedia LimitedPrinted by ••

v

Contents

Contents by Condition . . . . . . . . . . . . . . . . . . . . 000Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Acknowledgements . . . . . . . . . . . . . . . . . . . . . . 000Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Expert Reviewers . . . . . . . . . . . . . . . . . . . . . . . . 000Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Chapter 1Musculoskeletal Signs . . . . . . . . . . . . . . . . . . . 000

Anterior drawer test. . . . . . . . . . . . . . . . . . . . . . 000Apley’s grind test . . . . . . . . . . . . . . . . . . . . . . . . 000Apley’s scratch test . . . . . . . . . . . . . . . . . . . . . . 000Apparent leg length inequality (functional

leg length) . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Apprehension test (crank test) . . . . . . . . . . . . . 000Apprehension–relocation test (Fowler’s

sign) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Bouchard’s and Heberden’s nodes . . . . . . . . . 000Boutonnière deformity . . . . . . . . . . . . . . . . . . . 000Bulge/wipe/stroke test . . . . . . . . . . . . . . . . . . . . 000Butterfly rash (malar rash) . . . . . . . . . . . . . . . . 000Calcinosis/calcinosis cutis . . . . . . . . . . . . . . . . . 000Charcot’s foot . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Crepitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dropped arm test . . . . . . . . . . . . . . . . . . . . . . . 000Finkelstein’s test . . . . . . . . . . . . . . . . . . . . . . . . . 000Gait abnormalities (Ch 5) . . . . . . . . . . . . . . . . . 000Gottron’s papules . . . . . . . . . . . . . . . . . . . . . . . . 000Hawkins’ impingement sign . . . . . . . . . . . . . . . 000Heberden’s nodes . . . . . . . . . . . . . . . . . . . . . . . 000Heliotrope rash . . . . . . . . . . . . . . . . . . . . . . . . . 000Iritis (Ch 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Kyphosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Lachman’s test/sign . . . . . . . . . . . . . . . . . . . . . . 000Livedo reticularis . . . . . . . . . . . . . . . . . . . . . . . . 000McMurray’s test . . . . . . . . . . . . . . . . . . . . . . . . . 000Neer’s impingement sign . . . . . . . . . . . . . . . . . 000Patellar apprehension test . . . . . . . . . . . . . . . . 000Patellar tap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Patrick’s test (FABER test) . . . . . . . . . . . . . . . . . 000Phalen’s sign. . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Proximal myopathy . . . . . . . . . . . . . . . . . . . . . . 000Psoriatic nails/psoriatic nail dystrophy . . . . . . 000Raynaud’s syndrome/phenomenon . . . . . . . . . 000Saddle nose deformity . . . . . . . . . . . . . . . . . . . 000Sausage-shaped digits (dactylitis) . . . . . . . . . . 000Scleritis (Ch 6) . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sclerodactyly . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Shawl sign. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Simmonds–Thompson test . . . . . . . . . . . . . . . . 000Speed’s test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Subcutaneous nodules (rheumatoid

nodules) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Sulcus sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Supraspinatus test (empty can test) . . . . . . . . . 000Swan-neck deformity . . . . . . . . . . . . . . . . . . . . . 000Telangiectasia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Thomas’ test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tinel’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Trendelenburg’s sign . . . . . . . . . . . . . . . . . . . . . 000True leg length discrepancy (anatomic

leg length discrepancy) . . . . . . . . . . . . . . . . . 000Ulnar deviation . . . . . . . . . . . . . . . . . . . . . . . . . . 000V-sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Valgus deformity . . . . . . . . . . . . . . . . . . . . . . . . 000Varus deformity . . . . . . . . . . . . . . . . . . . . . . . . . 000Yergason’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Chapter 2Respiratory Signs . . . . . . . . . . . . . . . . . . . . . . . 000

Accessory muscle breathing . . . . . . . . . . . . . . . 000Agonal respiration . . . . . . . . . . . . . . . . . . . . . . . 000Apneustic breathing (also apneusis) . . . . . . . . 000Apnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Asterixis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Asymmetrical chest expansion . . . . . . . . . . . . . 000Asynchronous respiration . . . . . . . . . . . . . . . . . 000Ataxic (Biot’s) breathing . . . . . . . . . . . . . . . . . . 000Barrel chest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Bradypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Bronchial breath sounds . . . . . . . . . . . . . . . . . . 000Clubbing (Ch 3) . . . . . . . . . . . . . . . . . . . . . . . . . 000Cough reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Crackles (rales) . . . . . . . . . . . . . . . . . . . . . . . . . 000Cyanosis (Ch 3) . . . . . . . . . . . . . . . . . . . . . . . . . 000Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Funnel chest (pectus excavatum) . . . . . . . . . . . 000Grunting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Haemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Harrison’s sulcus (also Harrison’s groove) . . . 000Hoover’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hypertrophic pulmonary osteoarthropathy

(HPOA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Kussmaul’s breathing . . . . . . . . . . . . . . . . . . . . 000Orthopnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Paradoxical abdominal movements (also

abdominal paradox) . . . . . . . . . . . . . . . . . . . 000Paradoxical respiration/breathing . . . . . . . . . . 000Paroxysmal nocturnal dyspnoea (PND) . . . . . . 000Pemberton’s sign (Ch 7) . . . . . . . . . . . . . . . . . . 000Percussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Percussion: dullness . . . . . . . . . . . . . . . . . . . . . . 000Percussion: resonance/hyper-resonance . . . . . 000Periodic breathing . . . . . . . . . . . . . . . . . . . . . . . 000Pigeon chest (pectus carinatum) . . . . . . . . . . . 000

Contentsvi

Platypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pleural friction rub . . . . . . . . . . . . . . . . . . . . . . . 000Pulsus paradoxus (Ch 3) . . . . . . . . . . . . . . . . . . 000Pursed lips breathing . . . . . . . . . . . . . . . . . . . . . 000Sputum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Stertor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Stridor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Subcutaneous emphysema/surgical

emphysema . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tachypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tracheal tug . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Trepopnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Vesicular breath sounds . . . . . . . . . . . . . . . . . . 000Vocal fremitus versus vocal resonance . . . . . . 000Vocal resonance . . . . . . . . . . . . . . . . . . . . . . . . . 000Wheeze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Chapter 3Cardiovascular Signs . . . . . . . . . . . . . . . . . . . . 000

Abdominojugular reflex . . . . . . . . . . . . . . . . . . . 000Apex beat (also cardiac impulse) . . . . . . . . . . . 000Apex beat: displaced . . . . . . . . . . . . . . . . . . . . . 000Apex beat: hyperdynamic apical

impulse/volume-loaded . . . . . . . . . . . . . . . . 000Apex beat: left ventricular heave/sustained

apical impulse/pressure-loaded apex . . . . . 000Arterial pulse . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Arterial pulse: anacrotic . . . . . . . . . . . . . . . . . . 000Arterial pulse: bigeminal . . . . . . . . . . . . . . . . . . 000Arterial pulse: dicrotic . . . . . . . . . . . . . . . . . . . . 000Arterial pulse: pulsus alternans . . . . . . . . . . . . 000Arterial pulse: pulsus bisferiens . . . . . . . . . . . . 000Arterial pulse: pulsus parvus . . . . . . . . . . . . . . 000Arterial pulse: pulsus tardus . . . . . . . . . . . . . . . 000Arterial pulse: sinus arrhythmia . . . . . . . . . . . . 000Arteriovenous nipping or nicking . . . . . . . . . . . 000Bradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Buerger’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cannon a-waves . . . . . . . . . . . . . . . . . . . . . . . . 000Cardiac cachexia . . . . . . . . . . . . . . . . . . . . . . . . 000Cardiac impulse . . . . . . . . . . . . . . . . . . . . . . . . . 000Carotid bruit . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Carvello’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cheyne–Stokes breathing . . . . . . . . . . . . . . . . . 000Clubbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Copper wiring. . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cotton wool spots . . . . . . . . . . . . . . . . . . . . . . . 000Crackles (also rales) . . . . . . . . . . . . . . . . . . . . . 000Cyanosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cyanosis: central . . . . . . . . . . . . . . . . . . . . . . . . 000Cyanosis: peripheral . . . . . . . . . . . . . . . . . . . . . 000Ewart’s sign. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Friedrich’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Giant a-waves . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Graham steell murmur . . . . . . . . . . . . . . . . . . . 000Hepatojugular reflux (also

abdominojugular reflux) . . . . . . . . . . . . . . . . 000Hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Hypertensive retinopathy . . . . . . . . . . . . . . . . . 000Hypertensive retinopathy: arteriovenous

(AV) nipping (or AV nicking) . . . . . . . . . . . . 000Hypertensive retinopathy: copper and

silver wiring . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hypertensive retinopathy: cotton wool

spots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hypertensive retinopathy:

microaneurysms . . . . . . . . . . . . . . . . . . . . . . 000Hypertensive retinopathy: retinal

haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . 000Janeway lesions . . . . . . . . . . . . . . . . . . . . . . . . . 000Jugular venous pressure (JVP) . . . . . . . . . . . . . 000JVP: Kussmaul’s sign . . . . . . . . . . . . . . . . . . . . . 000JVP: raised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000JVP: the normal waveform . . . . . . . . . . . . . . . . 000JVP waveform variations: a-waves –

cannon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000JVP waveform variations: a-waves –

prominent or giant . . . . . . . . . . . . . . . . . . . . 000JVP waveform variations: v-waves – large . . . . 000JVP waveform variations: x-descent –

absent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000JVP waveform variations: x-descent –

prominent . . . . . . . . . . . . . . . . . . . . . . . . . . . 000JVP waveform variations: y-descent –

absent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000JVP waveform variations: y-descent –

prominent (Friedrich’s sign) . . . . . . . . . . . . . 000Microaneurysm . . . . . . . . . . . . . . . . . . . . . . . . . 000Mid-systolic click . . . . . . . . . . . . . . . . . . . . . . . . 000Mitral facies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs – systolic: aortic stenotic

murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs – systolic: mitral regurgitation

murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs – systolic: pulmonary stenotic

murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs – systolic: tricuspid regurgitation

murmur (also Carvello’s sign) . . . . . . . . . . . 000Murmurs – systolic: ventricular septal

defect murmur . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs – diastolic: aortic regurgitation

murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs – diastolic: eponymous signs of

aortic regurgitation . . . . . . . . . . . . . . . . . . . . 000Murmurs – diastolic: Graham Steell

murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs – diastolic: mitral stenotic

murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs – diastolic: opening snap (OS) . . . . 000Murmurs – diastolic: pulmonary

regurgitation murmur . . . . . . . . . . . . . . . . . . 000Murmurs – diastolic: tricuspid stenotic

murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Murmurs – continuous: patent ductus

arteriosus murmur . . . . . . . . . . . . . . . . . . . . 000Osler’s nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Contents vii

Pericardial knock . . . . . . . . . . . . . . . . . . . . . . . . 000Pericardial rub . . . . . . . . . . . . . . . . . . . . . . . . . . 000Peripheral oedema . . . . . . . . . . . . . . . . . . . . . . 000Pulse pressure . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pulse pressure: narrow . . . . . . . . . . . . . . . . . . . 000Pulse pressure: widened . . . . . . . . . . . . . . . . . . 000Pulsus paradoxus . . . . . . . . . . . . . . . . . . . . . . . . 000Radial–radial delay . . . . . . . . . . . . . . . . . . . . . . 000Radio-femoral delay . . . . . . . . . . . . . . . . . . . . . 000Rales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Raynaud’s phenomenon (Ch 1) . . . . . . . . . . . . 000Retinal haemorrhage . . . . . . . . . . . . . . . . . . . . . 000Right ventricular heave . . . . . . . . . . . . . . . . . . . 000Roth’s spots . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000S1 (first heart sound): accentuated . . . . . . . . . 000S1 (first heart sound): diminished . . . . . . . . . . 000S3 (third heart sound) . . . . . . . . . . . . . . . . . . . . 000S4 (fourth heart sound) . . . . . . . . . . . . . . . . . . 000Silver wiring . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Splinter haemorrhages . . . . . . . . . . . . . . . . . . . 000Splitting heart sounds . . . . . . . . . . . . . . . . . . . . 000Splitting heart sounds: paradoxical

(reverse) splitting . . . . . . . . . . . . . . . . . . . . . . 000Splitting heart sounds: physiological

splitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Splitting heart sounds: widened splitting . . . . . 000Splitting heart sounds: widened splitting –

fixed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tachycardia (sinus) . . . . . . . . . . . . . . . . . . . . . . 000x-descent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Xanthelasmata . . . . . . . . . . . . . . . . . . . . . . . . . . 000y-descent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Chapter 4Haematological/Oncological Signs . . . . . . . . 000

Angular stomatitis . . . . . . . . . . . . . . . . . . . . . . . 000Atrophic glossitis . . . . . . . . . . . . . . . . . . . . . . . . 000Bone tenderness/bone pain . . . . . . . . . . . . . . . 000Chipmunk facies. . . . . . . . . . . . . . . . . . . . . . . . . 000Conjunctival pallor . . . . . . . . . . . . . . . . . . . . . . . 000Ecchymoses, purpura and petechiae . . . . . . . . 000Gum hypertrophy (gingival hyperplasia) . . . . . 000Haemolytic/pre-hepatic jaundice . . . . . . . . . . . 000Hepatomegaly (Ch 6) . . . . . . . . . . . . . . . . . . . . 000Koilonychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Leser–Trélat sign . . . . . . . . . . . . . . . . . . . . . . . . 000Leucoplakia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Lymphadenopathy . . . . . . . . . . . . . . . . . . . . . . . 000Neoplastic fever . . . . . . . . . . . . . . . . . . . . . . . . . 000Peau d’orange . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pete chiae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Plethora (Ch 7). . . . . . . . . . . . . . . . . . . . . . . . . . 000Prostate (abnormal). . . . . . . . . . . . . . . . . . . . . . 000Pruritic scrath marks/pruritus (Ch 6) . . . . . . . . 000Purpura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Rectal mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Splenomegaly (Ch 6) . . . . . . . . . . . . . . . . . . . . . 000Trousseau’s sign of malignancy . . . . . . . . . . . . 000

Chapter 5Neurological Signs . . . . . . . . . . . . . . . . . . . . . . 000

Abducens nerve (CN6) palsy . . . . . . . . . . . . . . 000Anisocoria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Anosmia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Argyll Robertson pupils . . . . . . . . . . . . . . . . . . . 000Ataxic gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Atrophy (muscle wasting) . . . . . . . . . . . . . . . . . 000Babinski response . . . . . . . . . . . . . . . . . . . . . . . 000Bradykinesia (parkinsonism) . . . . . . . . . . . . . . 000Broca’s aphasia (expressive aphasia) . . . . . . . 000Brown-Séquard syndrome . . . . . . . . . . . . . . . . 000Cavernous sinus syndrome . . . . . . . . . . . . . . . . 000Clasp-knife phenomenon . . . . . . . . . . . . . . . . . 000Clonus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cogwheel rigidity . . . . . . . . . . . . . . . . . . . . . . . . 000Corneal reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Crossed-adductor reflex . . . . . . . . . . . . . . . . . . 000Dysarthria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dysdiadochokinesis . . . . . . . . . . . . . . . . . . . . . . 000Dysmetria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dysphonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Essential tremor . . . . . . . . . . . . . . . . . . . . . . . . . 000Facial muscle asymmetry . . . . . . . . . . . . . . . . . 000Fasciculations . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Gag reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Gerstmann’s syndrome . . . . . . . . . . . . . . . . . . . 000Glabellar reflex . . . . . . . . . . . . . . . . . . . . . . . . . . 000Global aphasia . . . . . . . . . . . . . . . . . . . . . . . . . . 000Grasp reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hand dominance . . . . . . . . . . . . . . . . . . . . . . . . 000Hearing impairment. . . . . . . . . . . . . . . . . . . . . . 000Hemineglect syndrome . . . . . . . . . . . . . . . . . . . 000High stepping gait . . . . . . . . . . . . . . . . . . . . . . . 000Hoarseness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hoffman’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Horner’s syndrome . . . . . . . . . . . . . . . . . . . . . . 000Hutchinson’s pupil . . . . . . . . . . . . . . . . . . . . . . . 000Hutchinson’s sign . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperreflexia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyporeflexia and areflexia . . . . . . . . . . . . . . . . 000Hypotonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Intention tremor . . . . . . . . . . . . . . . . . . . . . . . . . 000Internuclear ophthalmoplegia (INO) . . . . . . . . 000Jaw jerk reflex . . . . . . . . . . . . . . . . . . . . . . . . . . 000Light – near dissociation . . . . . . . . . . . . . . . . . . 000Myotonia – percussion, grip . . . . . . . . . . . . . . . 000Oculomotor nerve (CN3) palsy . . . . . . . . . . . . 000Optic atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Orbital apex syndrome . . . . . . . . . . . . . . . . . . . 000Palmomental reflex . . . . . . . . . . . . . . . . . . . . . . 000Papilloedema . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Parkinsonian gait . . . . . . . . . . . . . . . . . . . . . . . . 000Parkinsonian tremor . . . . . . . . . . . . . . . . . . . . . 000Photophobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Physiological tremor . . . . . . . . . . . . . . . . . . . . . 000Pinpoint pupils . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pronator drift . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Contentsviii

Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Relative afferent pupillary defect (RAPD)

(Marcus Gunn pupil) . . . . . . . . . . . . . . . . . . . 000Rigidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Romberg’s test . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sensory level . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sensory loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Spastic gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sternocleidomastoid and trapezius

weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tongue deviation . . . . . . . . . . . . . . . . . . . . . . . . 000Trochlear nerve (CN4) palsy . . . . . . . . . . . . . . . 000Truncal ataxia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Uvula deviation . . . . . . . . . . . . . . . . . . . . . . . . . 000Vertical gaze palsy (supranuclear palsy) . . . . . 000Visual acuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Visual field defects . . . . . . . . . . . . . . . . . . . . . . . 000Waddling gait . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Wallenberg’s syndrome (lateral medullary

syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Wernicke’s aphasia (receptive aphasia) . . . . . . 000

Chapter 6Gastroenterological Signs . . . . . . . . . . . . . . . . 000

Angular stomatitis (Ch 4) . . . . . . . . . . . . . . . . . 000Ascites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Asterixis (also hepatic flap) . . . . . . . . . . . . . . . . 000Bloody vomitus . . . . . . . . . . . . . . . . . . . . . . . . . 000Bowel sounds . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Bowel sounds: absent . . . . . . . . . . . . . . . . . . . . 000Bowel sounds: hyperactive

(borborygmus). . . . . . . . . . . . . . . . . . . . . . . . 000Bowel sounds: tinkling . . . . . . . . . . . . . . . . . . . 000Caput medusa . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cervical lymph nodes (Ch 4) . . . . . . . . . . . . . . 000Cheilitis granulomatosa . . . . . . . . . . . . . . . . . . . 000Clubbing (Ch 3) . . . . . . . . . . . . . . . . . . . . . . . . . 000Coffee ground vomiting/bloody vomitus/

haematemesis . . . . . . . . . . . . . . . . . . . . . . . . 000Conjunctival pallor (Ch 4) . . . . . . . . . . . . . . . . . 000Courvoisier’s sign . . . . . . . . . . . . . . . . . . . . . . . . 000Cullen’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Erythema nodosum . . . . . . . . . . . . . . . . . . . . . . 000Grey Turner’s sign . . . . . . . . . . . . . . . . . . . . . . . 000Guarding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Gynaecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . 000Haematemesis . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hepatic encephalopathy . . . . . . . . . . . . . . . . . . 000Hepatic foetor. . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hepatic venous hum . . . . . . . . . . . . . . . . . . . . . 000Hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . 000Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Kayser–Fleischer rings . . . . . . . . . . . . . . . . . . . . 000Leuconychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Leucoplakia (Ch 4). . . . . . . . . . . . . . . . . . . . . . . 000Melaena . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Mouth ulcers (aphthous ulcer) . . . . . . . . . . . . . 000Muehrcke’s lines . . . . . . . . . . . . . . . . . . . . . . . . 000Murphy’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Obturator sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Palmar erythema . . . . . . . . . . . . . . . . . . . . . . . . 000Peripheral oedema (Ch 3) . . . . . . . . . . . . . . . . 000Petechiae (Ch 4) . . . . . . . . . . . . . . . . . . . . . . . . 000Pruritic scratch marks/pruritus . . . . . . . . . . . . . 000Psoas sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pyoderma gangrenosum . . . . . . . . . . . . . . . . . . 000Rebound tenderness . . . . . . . . . . . . . . . . . . . . . 000Rigidity and involuntary guarding . . . . . . . . . . 000Rovsing’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Scleral icterus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sialadenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sister Mary Joseph nodule . . . . . . . . . . . . . . . . 000Spider naevus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Steatorrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Striae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Uveitis/iritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Xanthelasmata (Ch 3) . . . . . . . . . . . . . . . . . . . . 000

Chapter 7Endocrinological Signs . . . . . . . . . . . . . . . . . . 000

Acanthosis nigricans (AN) . . . . . . . . . . . . . . . . . 000Angioid streaks . . . . . . . . . . . . . . . . . . . . . . . . . . 000Atrophic testicles . . . . . . . . . . . . . . . . . . . . . . . . 000Ballotable kidney . . . . . . . . . . . . . . . . . . . . . . . . 000Bitemporal hemianopia (Ch 5) . . . . . . . . . . . . . 000Bruising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Chvostek’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cushing body habitus . . . . . . . . . . . . . . . . . . . . 000Diabetic amyotrophy (lumbar plexopathy) . . . 000Diabetic retinopathy . . . . . . . . . . . . . . . . . . . . . 000Frontal bossing . . . . . . . . . . . . . . . . . . . . . . . . . . 000Galactorrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Goitre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Granuloma annulare . . . . . . . . . . . . . . . . . . . . . 000Graves’ opchothalmopathy (orbitopathy) . . . . 000Graves’ orbitopathy . . . . . . . . . . . . . . . . . . . . . . 000Gynaecomastia (Ch 6) . . . . . . . . . . . . . . . . . . . . 000Hirsutism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hypercarotinaemia/carotenoderma . . . . . . . . . 000Hyperpigmentation and bronzing . . . . . . . . . . 000Hyperreflexia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperthyroid tremor . . . . . . . . . . . . . . . . . . . . . 000Hyporeflexia/delayed ankle jerks

(Woltman’s sign) . . . . . . . . . . . . . . . . . . . . . . 000Hypotension . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Macroglossia. . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Necrobiosis lipoidica diabeticorum (NLD) . . . 000Onycholysis (Plummer’s nail) . . . . . . . . . . . . . . 000Pemberton’s sign . . . . . . . . . . . . . . . . . . . . . . . . 000Periodic paralysis . . . . . . . . . . . . . . . . . . . . . . . . 000Plethora . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Polydipsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Polyuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Contents ix

Polyuria: Cushing’s syndrome . . . . . . . . . . . . . 000Pre-tibial myxoedema (thyroid

dermopathy) . . . . . . . . . . . . . . . . . . . . . . . . . 000Prognathism . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Proximal myopathy . . . . . . . . . . . . . . . . . . . . . . 000Skin tags (acrochordon) . . . . . . . . . . . . . . . . . . 000

Steroid acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Striae (Ch 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Trousseau’s sign . . . . . . . . . . . . . . . . . . . . . . . . . 000Uraemic frost . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Vitiligo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Webbed neck (pterygium colli deformity) . . . . 000

x

Contents by Condition

Acidotic states – diabetic ketoacidosisKussmaul’s respiration . . . . . . . . . . . . . . . . . . . 000

AcromegalyFrontal bossing . . . . . . . . . . . . . . . . . . . . . . . . . . 000Acanthosis nigricans . . . . . . . . . . . . . . . . . . . . . 000Prognathism . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Skin tags . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Addison’s diseaseHyperpigmentation . . . . . . . . . . . . . . . . . . . . . . 000Hypotension . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Vitiligo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Airway obstructionStertor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Stridor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Anaemia and nutrient deficiencyDyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Angular stomatitis . . . . . . . . . . . . . . . . . . . . . . . 000Atrophic glossitis . . . . . . . . . . . . . . . . . . . . . . . . 000Koilonychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Palmar crease pallor . . . . . . . . . . . . . . . . . . . . . 000Conjunctival pallor . . . . . . . . . . . . . . . . . . . . . . . 000Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cyanosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperdynamic/volume-loaded beat . . . . . . . . . 000Carotid bruit . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Widened pulse pressure . . . . . . . . . . . . . . . . . . 000Shortened S1 . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Ankle/foot signsCharcot’s foot . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Simmonds–Thompson test . . . . . . . . . . . . . . . . 000Valgus deformity . . . . . . . . . . . . . . . . . . . . . . . . 000Varus deformity . . . . . . . . . . . . . . . . . . . . . . . . . 000

Aortic regurgitationHyperdynamic/volume-loaded beat . . . . . . . . . 000Pulsus bisferiens. . . . . . . . . . . . . . . . . . . . . . . . . 000Diastolic murmur . . . . . . . . . . . . . . . . . . . . . . . . 000Austin–Flint murmur . . . . . . . . . . . . . . . . . . . . . 000Becker’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Corrigan’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000De Musset’s sign . . . . . . . . . . . . . . . . . . . . . . . . 000Duroziez’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Gerhard’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hill’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Mayne’s sign. . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Müller’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Quincke’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Traube’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Widened pulse pressure . . . . . . . . . . . . . . . . . . 000

Aortic stenosisLeft ventricular heave/sustained apical

impulse/pressure-loaded apex . . . . . . . . . . . 000Displaced apex beat . . . . . . . . . . . . . . . . . . . . . 000Anacrotic pulse . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pulsus parvus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pulsus tardus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Ejection systolic murmur . . . . . . . . . . . . . . . . . . 000Narrow pulse pressure . . . . . . . . . . . . . . . . . . . 000S4 (fourth heart sound) . . . . . . . . . . . . . . . . . . 000Paradoxical splitting of the heart sounds . . . . 000

AphasiaWernicke’s aphasia . . . . . . . . . . . . . . . . . . . . . . 000Broca’s aphasia . . . . . . . . . . . . . . . . . . . . . . . . . 000Global aphasia . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Atrial septal defect/ventricular septal defectPlatypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperdynamic/volume-loaded beat . . . . . . . . . 000Displaced apex beat . . . . . . . . . . . . . . . . . . . . . 000Pansystolic murmur . . . . . . . . . . . . . . . . . . . . . . 000

AsthmaTachypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Respiratory distress signs . . . . . . . . . . . . . . . . . 000Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Wheeze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pulsus paradoxus . . . . . . . . . . . . . . . . . . . . . . . . 000Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Paradoxical respiration . . . . . . . . . . . . . . . . . . . 000

BronchiectasisCough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Crackles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Paradoxical respiration . . . . . . . . . . . . . . . . . . . 000Sputum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Cardiac tamponade/pericardial effusionBigeminal pulse . . . . . . . . . . . . . . . . . . . . . . . . . 000Ewart’s sign. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Jugular venous pressure (JVP) – raised . . . . . . 000JVP – prominent x-descent . . . . . . . . . . . . . . . . 000JVP – absent y-descent . . . . . . . . . . . . . . . . . . . 000Pulsus paradoxus . . . . . . . . . . . . . . . . . . . . . . . . 000

Contents by Condit ion xi

Cerebellar signsDysdiadochokinesis . . . . . . . . . . . . . . . . . . . . . . 000Dysmetria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dysarthria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hypotonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Truncal ataxia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Romberg’s test . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pronator drift . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Chronic renal failureBruising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Uraemic frost . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pruritic marks . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Peripheral oedema . . . . . . . . . . . . . . . . . . . . . . 000

Congestive heart failureCough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Wheeze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Crackles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tachypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Orthopnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Paroxysmal nocturnal dyspnoea. . . . . . . . . . . . 000Pulsus alternans . . . . . . . . . . . . . . . . . . . . . . . . . 000S3 (third heart sound) . . . . . . . . . . . . . . . . . . . . 000Ascites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Caput medusae . . . . . . . . . . . . . . . . . . . . . . . . . 000Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Displaced apex beat . . . . . . . . . . . . . . . . . . . . . 000Bigeminal pulse . . . . . . . . . . . . . . . . . . . . . . . . . 000Dicrotic pulse . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pulsus alternans . . . . . . . . . . . . . . . . . . . . . . . . . 000Cardiac cachexia . . . . . . . . . . . . . . . . . . . . . . . . 000Cheyne–Stokes respiration . . . . . . . . . . . . . . . . 000Cyanosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hepatojugular reflux . . . . . . . . . . . . . . . . . . . . . 000Hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . 000Raised jugular venous pressure . . . . . . . . . . . . 000Kussmaul’s sign . . . . . . . . . . . . . . . . . . . . . . . . . 000Peripheral oedema . . . . . . . . . . . . . . . . . . . . . . 000Narrow pulse pressure . . . . . . . . . . . . . . . . . . . 000Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Chronic obstructive pulmonary disease (COPD)Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Harrison’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tachypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pursed lips breathing . . . . . . . . . . . . . . . . . . . . . 000Barrel chest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Crackles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Wheeze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . 000Clubbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Paradoxical respiration . . . . . . . . . . . . . . . . . . . 000Hyper-resonance to percussion . . . . . . . . . . . . 000

Vocal fremitus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Vocal resonance . . . . . . . . . . . . . . . . . . . . . . . . . 000

Cranial nerve signsVisual acuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Oculomotor (CNIII) palsy . . . . . . . . . . . . . . . . . 000Trochlear (CNIV) palsy . . . . . . . . . . . . . . . . . . . 000Abducens (CNVI) palsy . . . . . . . . . . . . . . . . . . . 000Facial asymmetry . . . . . . . . . . . . . . . . . . . . . . . . 000Gag reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Relative afferent pupillary defect (Marcus

Gunn pupil) . . . . . . . . . . . . . . . . . . . . . . . . . . 000Jaw jerk reflex . . . . . . . . . . . . . . . . . . . . . . . . . . 000Corneal reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tongue deviation . . . . . . . . . . . . . . . . . . . . . . . . 000Sternocleidomastoid weakness . . . . . . . . . . . . . 000Uvula deviation . . . . . . . . . . . . . . . . . . . . . . . . . 000Hoarseness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dysarthria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hearing impairment. . . . . . . . . . . . . . . . . . . . . . 000

Cushing’s syndromeBruising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Central adiposity . . . . . . . . . . . . . . . . . . . . . . . . 000Buffalo hump . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Moon facies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Striae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hirsutism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Plethora . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Polyuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Proximal myopathy . . . . . . . . . . . . . . . . . . . . . . 000Steroid acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Gynaecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Cystic fibrosisHarrison’s sulcus . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Sputum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

DermatomyositisShawl sign. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Gottron’s papules . . . . . . . . . . . . . . . . . . . . . . . . 000V-sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Proximal myopathy . . . . . . . . . . . . . . . . . . . . . . 000Calcinosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Heliotrope rash . . . . . . . . . . . . . . . . . . . . . . . . . 000Telangiectasia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

DiabetesAcanthosis nigricans . . . . . . . . . . . . . . . . . . . . . 000Charcot’s foot . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Diabetic amyotrophy . . . . . . . . . . . . . . . . . . . . . 000Diabetic retinopathy . . . . . . . . . . . . . . . . . . . . . 000Granuloma annulare . . . . . . . . . . . . . . . . . . . . . 000Necrobiosis lipoidica diabeticorum . . . . . . . . . 000Polyuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Polydipsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Skin tags . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Steroid acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Cotton wool spots . . . . . . . . . . . . . . . . . . . . . . . 000Xanthelasmata . . . . . . . . . . . . . . . . . . . . . . . . . . 000

EndocarditisClubbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Janeway lesions . . . . . . . . . . . . . . . . . . . . . . . . . 000Roth’s spots . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Osler’s nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Splinter haemorrhages . . . . . . . . . . . . . . . . . . . 000

Gait abnormalitiesAtaxic gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000High stepping gait . . . . . . . . . . . . . . . . . . . . . . . 000Parkinsonian gait . . . . . . . . . . . . . . . . . . . . . . . . 000Spastic gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Waddling gait . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

HaemochromatosisHyperpigmentation . . . . . . . . . . . . . . . . . . . . . . 000

Heart blockBradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cannon a-waves . . . . . . . . . . . . . . . . . . . . . . . . 000

Hip signsApparent leg length . . . . . . . . . . . . . . . . . . . . . . 000Patrick’s test (FABER test) . . . . . . . . . . . . . . . . . 000Thomas’s test . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Trendelenburg’s test . . . . . . . . . . . . . . . . . . . . . 000True leg length discrepancy . . . . . . . . . . . . . . . 000Valgus deformity . . . . . . . . . . . . . . . . . . . . . . . . 000Varus deformity . . . . . . . . . . . . . . . . . . . . . . . . . 000

HypertensionLeft ventricular heave/sustained apical

impulse/pressure-loaded apex . . . . . . . . . . . 000Displaced apex beat . . . . . . . . . . . . . . . . . . . . . 000AV nipping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Copper wiring. . . . . . . . . . . . . . . . . . . . . . . . . . . 000Silver wiring . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Microaneurysms . . . . . . . . . . . . . . . . . . . . . . . . . 000Retinal haemorrhage . . . . . . . . . . . . . . . . . . . . . 000Cotton wool spots . . . . . . . . . . . . . . . . . . . . . . . 000S4 (fourth heart sound) . . . . . . . . . . . . . . . . . . 000

HyperthyroidismGynaecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . 000Palmar erythema . . . . . . . . . . . . . . . . . . . . . . . . 000Goitre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Graves’ ophthalmopathy . . . . . . . . . . . . . . . . . . 000Lid lag . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Von Grafe’s sign . . . . . . . . . . . . . . . . . . . . . . . . . 000Chemosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Lagophthalmos . . . . . . . . . . . . . . . . . . . . . . . . . . 000Abadie’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dalrymple’s sign . . . . . . . . . . . . . . . . . . . . . . . . 000Griffith’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Diplopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Ballet sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Proptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Riesman’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperreflexia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperthyroid tremor . . . . . . . . . . . . . . . . . . . . . 000Onycholysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pemberton’s sign . . . . . . . . . . . . . . . . . . . . . . . . 000Periodic paralysis . . . . . . . . . . . . . . . . . . . . . . . . 000Pre-tibial myxoedema . . . . . . . . . . . . . . . . . . . . 000Proximal myopathy . . . . . . . . . . . . . . . . . . . . . . 000Vitiligo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Hypertrophic obstructive cardiomyopathyLeft ventricular heave/sustained apical

impulse/pressure-loaded apex . . . . . . . . . . . 000Pulsus bisferiens. . . . . . . . . . . . . . . . . . . . . . . . . 000Narrow pulse pressure . . . . . . . . . . . . . . . . . . . 000S4 (fourth heart sound) . . . . . . . . . . . . . . . . . . 000

HypocalcaemiaChvostek’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000Trousseau’s sign . . . . . . . . . . . . . . . . . . . . . . . . . 000

HypothyroidismGoitre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyporeflexia – delayed ankle jerks . . . . . . . . . 000Hypotension . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Macroglossia. . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pemberton’s sign . . . . . . . . . . . . . . . . . . . . . . . . 000Proximal myopathy . . . . . . . . . . . . . . . . . . . . . . 000

HypovolaemiaNarrow pulse pressure . . . . . . . . . . . . . . . . . . . 000Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Inflammatory bowel diseaseScleritis/uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . 000Erythema nodosum . . . . . . . . . . . . . . . . . . . . . . 000Mouth ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pyoderma gangrenosum . . . . . . . . . . . . . . . . . . 000

Knee signsAnterior drawer test. . . . . . . . . . . . . . . . . . . . . . 000Apley’s grind test . . . . . . . . . . . . . . . . . . . . . . . . 000Bulge/wipe/stroke test . . . . . . . . . . . . . . . . . . . . 000Crepitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Lachman’s test . . . . . . . . . . . . . . . . . . . . . . . . . . 000McMurray’s test . . . . . . . . . . . . . . . . . . . . . . . . . 000Patellar apprehension test . . . . . . . . . . . . . . . . 000Patellar tap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Valgus deformity . . . . . . . . . . . . . . . . . . . . . . . . 000Varus deformity . . . . . . . . . . . . . . . . . . . . . . . . . 000

Left bundle branch blockParadoxical splitting of heart sounds . . . . . . . . 000

Leukaemia/lymphomaLymphadenopathy . . . . . . . . . . . . . . . . . . . . . . . 000Gum hypertrophy . . . . . . . . . . . . . . . . . . . . . . . 000Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Contents by Condit ion xiii

Liver disease/cirrhosisAscites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Atrophied testicles . . . . . . . . . . . . . . . . . . . . . . . 000Hepatic flap/asterixis . . . . . . . . . . . . . . . . . . . . . 000Caput medusae . . . . . . . . . . . . . . . . . . . . . . . . . 000Clubbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Gynaecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hepatic encephalopathy . . . . . . . . . . . . . . . . . . 000Hepatic foetor. . . . . . . . . . . . . . . . . . . . . . . . . . . 000Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . 000Leuconychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Muerhcke’s lines . . . . . . . . . . . . . . . . . . . . . . . . 000Palmar erythema . . . . . . . . . . . . . . . . . . . . . . . . 000Platypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pruritic marks . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Scleral icterus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Spider naevus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Peripheral oedema . . . . . . . . . . . . . . . . . . . . . . 000

Lung cancer malignancy – primary or secondaryHypertrophic pulmonary

osteoarthropathy . . . . . . . . . . . . . . . . . . . . . . 000Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Haemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Bronchial breath sounds . . . . . . . . . . . . . . . . . . 000Crackles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Pemberton’s sign . . . . . . . . . . . . . . . . . . . . . . . . 000Sputum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Vocal fremitus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Vocal resonance . . . . . . . . . . . . . . . . . . . . . . . . . 000

Malignancy – otherBone pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Lymphadenopathy . . . . . . . . . . . . . . . . . . . . . . . 000Leser–Trélat sign . . . . . . . . . . . . . . . . . . . . . . . . 000Virchow’s node . . . . . . . . . . . . . . . . . . . . . . . . . . 000Neoplastic fever . . . . . . . . . . . . . . . . . . . . . . . . . 000Trousseau’s sign of malignancy . . . . . . . . . . . . 000Hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sister Mary Joseph nodule . . . . . . . . . . . . . . . . 000

Mitral regurgitationHyperdynamic/volume-loaded beat . . . . . . . . . 000Displaced apex beat . . . . . . . . . . . . . . . . . . . . . 000Pansystolic murmur . . . . . . . . . . . . . . . . . . . . . . 000Right ventricular heave . . . . . . . . . . . . . . . . . . . 000Diminished S1 . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Mitral stenosisMitral facies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Diastolic rumbling murmur . . . . . . . . . . . . . . . . 000Opening snap . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Narrow pulse pressure . . . . . . . . . . . . . . . . . . . 000

Right ventricular heave . . . . . . . . . . . . . . . . . . . 000Accentuated S1. . . . . . . . . . . . . . . . . . . . . . . . . . 000Diminished S1 . . . . . . . . . . . . . . . . . . . . . . . . . . 000Plethora . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

OsteoarthritisCrepitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Boutonnière deformity . . . . . . . . . . . . . . . . . . . 000Heberden’s nodes . . . . . . . . . . . . . . . . . . . . . . . 000Bouchard’s nodes . . . . . . . . . . . . . . . . . . . . . . . 000

Parkinson’s diseaseClasp-knife phenomenon . . . . . . . . . . . . . . . . . 000Rigidity and cogwheel rigidity. . . . . . . . . . . . . . 000Parkinsonian tremor . . . . . . . . . . . . . . . . . . . . . 000Glabellar reflex/tap . . . . . . . . . . . . . . . . . . . . . . 000Bradykinesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Patent ductus arteriosisHyperdynamic/volume-loaded beat . . . . . . . . . 000Displaced apex beat . . . . . . . . . . . . . . . . . . . . . 000Pulsus bisferiens. . . . . . . . . . . . . . . . . . . . . . . . . 000Continuous/machinery murmur . . . . . . . . . . . . 000

Pericarditis/constrictive pericarditisKussmaul’s sign . . . . . . . . . . . . . . . . . . . . . . . . . 000Pericardial knock . . . . . . . . . . . . . . . . . . . . . . . . 000Pericardial rub . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Pleural effusionAsymmetrical chest expansion . . . . . . . . . . . . . 000Bronchial breath sounds . . . . . . . . . . . . . . . . . . 000Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Dullness to percussion . . . . . . . . . . . . . . . . . . . 000

PneumoniaAsymmetrical chest expansion . . . . . . . . . . . . . 000Bronchial breath sounds . . . . . . . . . . . . . . . . . . 000Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Wheeze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Crackles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Paradoxical respiration . . . . . . . . . . . . . . . . . . . 000Dullness to percussion . . . . . . . . . . . . . . . . . . . 000Pleural rub . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sputum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Vocal fremitus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Vocal resonance . . . . . . . . . . . . . . . . . . . . . . . . . 000

PneumothoraxHyperresonance to percussion . . . . . . . . . . . . . 000Vocal fremitus . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tachypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Asymmetrical chest expansion . . . . . . . . . . . . . 000

PowerWeakness – various patterns . . . . . . . . . . . . . . 000Muscle wasting . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Psoriatic arthritisOnycholysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Psoriatic nails . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sausage-shaped digits . . . . . . . . . . . . . . . . . . . . 000

Pulmonary embolusTachypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Haemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000Paradoxical respiration . . . . . . . . . . . . . . . . . . . 000Pleural rub . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Right ventricular heave . . . . . . . . . . . . . . . . . . . 000Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Pulmonary fibrosisCrackles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Tachypnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Harrison’s sulcus . . . . . . . . . . . . . . . . . . . . . . . . 000Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . 000Intercostal recession . . . . . . . . . . . . . . . . . . . . . 000

Pulmonary hypertensionRaised jugular venous pressure . . . . . . . . . . . . 000Right ventricular heave . . . . . . . . . . . . . . . . . . . 000Kussmaul’s sign . . . . . . . . . . . . . . . . . . . . . . . . . 000Giant a-waves . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Large v-waves . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Graham Steell murmur . . . . . . . . . . . . . . . . . . . 000Split S1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Pulmonary regurgitationDiastolic murmur . . . . . . . . . . . . . . . . . . . . . . . . 000

Pulmonary stenosisEjection systolic murmur . . . . . . . . . . . . . . . . . . 000Right ventricular heave . . . . . . . . . . . . . . . . . . . 000

Pulmonary stenosisSplit S1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

ReflexesJaw jerk reflex . . . . . . . . . . . . . . . . . . . . . . . . . . 000Gag reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Crossed adductor reflex . . . . . . . . . . . . . . . . . . 000Corneal reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Grasp reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Palmomental reflex . . . . . . . . . . . . . . . . . . . . . . 000Glabellar reflex/tap . . . . . . . . . . . . . . . . . . . . . . 000

Hyperreflexia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Hyporeflexia and areflexia . . . . . . . . . . . . . . . . 000

Renal failureGynaecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . 000Leuconychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pruritic marks . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Rheumatoid arthritisSubcutaneous rheumatoid nodules . . . . . . . . . 000Swan neck deformity . . . . . . . . . . . . . . . . . . . . . 000Ulnar deviation . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pleural friction rub . . . . . . . . . . . . . . . . . . . . . . . 000

Right bundle branch blockSplit S1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

SclerodermaSclerodactyly . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Telangiectasia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Splinter haemorrhages . . . . . . . . . . . . . . . . . . . 000

SensationSensory loss patterns. . . . . . . . . . . . . . . . . . . . . 000Sensory level . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

SepsisBigeminal pulse . . . . . . . . . . . . . . . . . . . . . . . . . 000Dicrotic pulse . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Widened pulse pressure . . . . . . . . . . . . . . . . . . 000

Shoulder signsApley’s scratch test . . . . . . . . . . . . . . . . . . . . . . 000Apprehension test (Crank test) . . . . . . . . . . . . . 000Apprehension – relocation test (Fowler’s test) 000Dropped arm test . . . . . . . . . . . . . . . . . . . . . . . 000Hawkin’s impingement sign/test . . . . . . . . . . . 000Neer’s impingement sign . . . . . . . . . . . . . . . . . 000Speed’s test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Sulcus sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Supraspinatus test (empty cans test) . . . . . . . . 000Yergason’s sign . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Systemic lupus erythematosusMouth ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Butterfly rash . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Telangiectasia . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Calcinosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Livedo reticularis . . . . . . . . . . . . . . . . . . . . . . . . 000Pleural friction rub . . . . . . . . . . . . . . . . . . . . . . . 000Raynaud’s syndrome . . . . . . . . . . . . . . . . . . . . . 000

Solid malignanciesBone pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Lymphadenopathy . . . . . . . . . . . . . . . . . . . . . . . 000Leser–Trélat sign . . . . . . . . . . . . . . . . . . . . . . . . 000Virchow’s node . . . . . . . . . . . . . . . . . . . . . . . . . . 000Neoplastic fever . . . . . . . . . . . . . . . . . . . . . . . . . 000

Contents by Condit ion xv

Trousseau’s sign of malignancy . . . . . . . . . . . . 000Hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . 000

ThrombocytopeniaPetechiae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Ecchymoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Purpura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

ToneClasp-knife phenomenon . . . . . . . . . . . . . . . . . 000Hypotonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Myotonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

TremorEssential tremor . . . . . . . . . . . . . . . . . . . . . . . . . 000Intention tremor . . . . . . . . . . . . . . . . . . . . . . . . . 000Parkinsonian tremor . . . . . . . . . . . . . . . . . . . . . 000Physiological tremor . . . . . . . . . . . . . . . . . . . . . 000

Tricuspid regurgitationLarge v-wave . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Raised jugular venous pressure . . . . . . . . . . . . 000Absent x-descent of jugular venous

pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pansystolic murmur . . . . . . . . . . . . . . . . . . . . . . 000Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Tricuspid stenosisDiastolic murmur . . . . . . . . . . . . . . . . . . . . . . . . 000

Vision defects/neurological eye signsVisual acuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Altitudinal scotoma . . . . . . . . . . . . . . . . . . . . . . 000Bitemporal hemianopia . . . . . . . . . . . . . . . . . . . 000Central scotoma . . . . . . . . . . . . . . . . . . . . . . . . . 000Tunnel vision . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Homonymous hemianopia with macular

sparing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Homonymous hemianopia . . . . . . . . . . . . . . . . 000Homonymous quadrantanopia . . . . . . . . . . . . . 000Horner’s syndrome . . . . . . . . . . . . . . . . . . . . . . 000Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Papilloedema . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Photophobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Orbital apex syndrome . . . . . . . . . . . . . . . . . . . 000Optic atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Intranuclear ophthalmoplegia. . . . . . . . . . . . . . 000Relative afferent pupillary defect (Marcus

Gunn pupil) . . . . . . . . . . . . . . . . . . . . . . . . . . 000Pinpoint pupils . . . . . . . . . . . . . . . . . . . . . . . . . . 000Light–near dissociation (Argyll Robertson

pupil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Anisocoria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000Supranuclear gaze palsy . . . . . . . . . . . . . . . . . . 000

xvi

Preface

Throughout our medical training, we are always learning how to look, listen and feel. These skills allow us to elicit critical signs that help narrow the differential diagnoses and identify the disease process causing our patient’s illness. This allows us to narrow the field when initiating investigations into the cause – be it a virus or gene, trauma, immunological insult etc.

This book is not designed to show you how to elicit these signs. There are a number of texts, most notably Talley and O’Connor’s Clinical Examination and the similarly named Macleod’s, which can guide the novice through the many and varied system examinations. Nor will it explain the disease process in minute pathological detail as, again, there is a plethora of medical references available for that purpose.

The focus of this text is on the mechanism underlying the clinical sign – or why particular signs occur and what they mean. Most medical students and junior doctors can recall numerous occasions when they have been asked why clubbing occurs, what the mechanism of peripheral oedema is in hepatic failure, or similar questions that often lead to a stunned silence in front of their favourite (or least favourite) professor. This book will not only help you prepare for the Q and A session most consultants love to spring on students and junior doctors, it will also help you study for practical examinations such as OSCEs and long cases. In short, if you can explain the mechanism, you know not just the sign but its significance as well. This knowledge will serve you in good stead not only as a student or junior but in your own capacity as educator. The most common questions you will hear from patients and their families are ‘What causes that?’ and ‘What does it mean?’ The ability to provide answers simply and without jargon will go a long way towards creating an impression of you as an able practitioner.

Clearly, there is an almost infinite number of clinical signs in medicine and there is limited yield in knowing each and every one of them. Consequently, some of

the more esoteric signs have not been included here unless we thought they would provide specific value to the reader. Our focus is explaining classic signs that you may encounter every day and helping you to understand what they mean.

In a world of evidence-based medicine, it is important to understand the value of the clinical sign with regard to both its presence and absence. Does it even matter if a sign is present or not? In writing this textbook, we have been surprised by both the value and lack of value of a number of signs used every day in the diagnostic process. Small sections on evidence, whether it is strong or poor, have been included for as many signs as possible to help the reader.

The text has been designed to work as an easy reference guide. As such, chapters are organised by body system and signs are generally listed in alphabetical order. When one sign crosses multiple body systems, easy reference between chapters has been provided. We have also included a table of contents by condition or disease, which enables the reader to easily reference all the signs that relate to a particular condition, for example, Cushing’s syndrome. Wherever possible, illustrations and simplified flow diagrams have been used to assist explanation. If the mechanism of a sign is not a proven fact, the most current theories have been summarised. Where no such theory exists, the mechanism has been referred to as unknown and perhaps will stimulate the reader to do their own research.

There is one unique feature in the ‘Neurological signs’ chapter. In writing this expansive chapter, it became apparent that, to understand the mechanisms of neurological signs, an understanding of the anatomical pathways involved is key. In order to simplify matters, we have added a ‘topographical anatomy’ section, which identifies the relevant neuroanatomy with regard to that sign.

We hope you find this textbook not only enhances your understanding of clinical signs and their causes, but also furthers your ability to communicate that

Preface xvii

knowledge to your patients, peers and seniors.

All the best,

CAVEAT:While researching this book, the authors used reference texts as well as Medline, PubMed, Embase, SCIRUS and other databases – firstly to identify all relevant

signs and secondly to find the most up-to-date information about them. Every attempt has been made to provide the reader with the most recent information; however, with knowledge in medicine expanding at an exponential rate, it is possible that current thinking regarding causes may have been superseded by the time of publication.

AuthorsMark Dennis MBBS(Honours)Resident, The Wollongong Hospital

Lucy Cho MBBS, MIPH, BAResident, The Wollongong Hospital

William Talbot Bowen MBBS, MD, BSResearch Coordinator, Olive View-UCLA Medical Center, Department of Emergency Medicine

xviii

AcknowledgementsThanks are due to Associate Professor Gabriel Shannon, a great physician and tutor whose interest in clinical signs inspired the principal author Mark Dennis to develop his own awareness of the value of the physical examination.

Invaluable feedback from past tutors and experts was received from Professor Stephen Twigg, Dr Raj Puranik, Professor Joshua Douglas, Professor Ivan Young, Dr Keith Wong, Dr John Carmody, Associate Professor Meng Ngu and Professor Leo Davies. The authors are indebted to these specialist clinicians for their generous input and guidance. Dr Jonathon Pham must be noted for his assistance on the ‘Gastroenterological signs’ chapter.

Thanks are also due to Neli Bryant, Sophie Kaliencki and Geraldine Minto at Elsevier, who took on novice writers and were patient and helpful throughout the process.

All three authors are deeply grateful to their parents, families and friends for their constant and endless support.

ReviewersDavid Adam MBBSUniversity of Western Australia

Edmond IpSixth-year Medical Student, University of Western Australia

Sarah Jensen JMO, PGY1The Canberra Hospital

Claire Seiffert BPhysio (Hons), MBBSWagga Wagga Base Hospital

Selina Watchorn MBBS, BNurs, BAThe Canberra Hospital/Australian National University

xix

Expert ReviewersRESPIRATORY CHAPTER:

Dr Keith Wong MBBS(Hons) MMed(Clin Epi) PhD FRACPResearch Fellow, Sleep and Circadian Research Group, Woolcock Institute of Medical Research; Staff Specialist, Depart-ment of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, University of Sydney

Professor Ivan Young PhD FRACPClinical Professor, Central Clinical School (Medicine), University of Sydney; Depart-ment of Respiratory Medicine, Royal Prince Alfred Hospital

CARDIOLOGY CHAPTER:

Dr Rajesh Puranik MBBS PhD FRACPConsultant Cardiologist, Royal Prince Alfred Hospital, NHMRC/NHF Postdoctoral Fellow, University of Sydney

HAEMATOLOGY/ONCOLOGY CHAPTER:

Professor Douglas Joshua MDProfessor of Internal Medicine, University of Sydney; Head of Institute of Haematol-ogy, Royal Prince Alfred Hospital

NEUROLOGY CHAPTER:

Dr John Carmody MB BCh MRCPI FRACPStaff Specialist Neurologist, Hon. Clinical Senior Lecturer, University of Wollongong

Associate Professor Leo Davies MD MB BS FRACPSub-Dean and Head of Assessment, Sydney Medical School, University of Sydney; Australian & New Zealand Association of Neurologists; Australian Association of Neurologists

GASTROENTEROLOGY CHAPTER:

Associate Professor Meng C Ngu MBBS(Hons) BMedSc(Hons) PhD FRACPClinical Associate Professor, University of Sydney; Consultant Gastroenterologist

ENDOCRINOLOGY CHAPTER:

Professor Stephen Twigg MBBS (Hons) PhD FRACPProfessor in Medicine, Central Clinical School and the Bosch Institute, University of Sydney; Senior Staff Specialist in Endocrinology, Royal Prince Alfred Hospital

xx

Abbreviations

5-HT 5-hydroxytryptamine (serotonin)

AC acromioclavicularACA anterior cerebral arteryACE angiotensin-converting

enzymeACL anterior cruciate ligamentACTH adrenocorticotropic hormoneADP adenosine diphosphateADH antidiuretic hormone

(vasopressin)AIDS acquired immune deficiency

syndromeAION anterior ischaemic optic

neuropathyAN acanthosis nigricansANR atrial natriuretic responseANS autonomic nervous systemAP anteroposteriorAR aortic regurgitationARDS acute respiratory distress

syndromeASD atrial septal defectAV arteriovenousAV (node) atrioventricular (node)AVM arteriovenous malformationBMI body mass indexBP blood pressureBPH benign prostatic hypertrophyBPPV benign paroxysmal positional

vertigocAMP cyclic adenosine

monophosphateCCK cholecystokininCG ciliary ganglionCGL chronic granulocytic

leukaemiaCGRP calcitonin gene-related

peptideCHF congestive heart failureCI confidence intervalCLL chronic lymphocytic

leukaemiaCMC carpometacarpalCML chronic myeloid leukaemiacMOAT canalicular multispecific

organic anion transporterCMT Charcot–Marie–Tooth

(disease)CMV cytomegalovirusCN cranial nerveCNS central nervous systemCOPD chronic obstructive

pulmonary disease

COX cyclo-oxygenaseCRAO central retinal artery

occlusionCREST calcinosis cutis, Raynaud’s

phenomenon, (o)esophageal dysfunction, sclerodactyly, telangiectasia syndrome

CRH corticotrophin-releasing hormone

CRVO central retinal vein occlusion

CS cavernous sinusCSA central sleep apnoeaCSF cerebrospinal fluidCT computerised tomographyCV cortical veinsCVP central venous pressureDAS dorsal acoustic striaDHEA-S dehydroepiandrosterone

sulfateDI diabetes insipidusDIP distal interphalangealDM diabetes mellitusDRE digital rectal examinationDVT deep vein thrombosisEBV Epstein–Barr virusEGFR epidermal growth factor

receptorEMH extramedullary

haematopoiesisENAC epithelial sodium (Na)

channelEOM extraocular muscleEW Edinger–Westphal nucleusFA femoral arteryFABER flexion abduction external

rotationFGFR fibroblast growth factor

receptorFSH follicle-stimulating hormoneG6PD glucose-6-phosphate

dehydrogenaseGABA gamma-aminobutyric acidGAS group A streptococcusGBS Guillain–Barré syndromeGH growth hormoneGI gastrointestinalGnRH gonadotrophin-releasing

hormoneGORD gastro-oesophageal reflux

diseaseGP glycoproteinGPe globus pallidus pars externaGPi globus pallidus pars interna

Abbreviat ions xxi

Gs guanine nucleotide-binding protein that couples to TSH receptor

GV great vein of GalenHb haemoglobinHbSC sickle cell haemoglobin ChCG human chorionic

gonadotropinHIV human immunodeficiency

virusHLA human leukocyte antigenHOCM hypertrophic obstructive

cardiomyopathyHPOA hypertrophic pulmonary

osteoarthropathyHPV human papilloma virusHSV herpes simplex virusIAS intermediate acoustic striaIBD inflammatory bowel diseaseICA internal carotid arteryICP intracranial pressureICV internal cerebral veinIFN interferonIGF-1 insulin-like growth factor-1IJ internal jugular veinIL interleukinINC interstitial nucleus of CajalINO internuclear ophthalmoplegiaIO inferior oblique (muscle or

subnucleus)IR inferior rectus (muscle or

subnucleus)ISS inferior sagittal sinusIVC inferior vena cavaJVP jugular venous pressureLA left atrialLBBB left bundle branch blockLBT long head of biceps tendonLGN lateral geniculate nucleusLH luteinising hormoneLPS lipopolysaccharidesLR lateral rectus (muscle)LR likelihood ratioLR livedo reticularisLS lateral sinusLTB4 leukotriene B4

LV left ventricularMAOI monoamine oxidase inhibitorMCA middle cerebral arteryMCP metacarpophalangealMD muscular dystrophyMDMA methylenedioxymetham

phetamine (ecstasy)MDPK myotonic dystrophy protein

kinaseMEN multiple endocrine neoplasiaMLF medial longitudinal

fasciculus

MMP matrix metalloproteinaseMPTP 1-methyl-4-phenyl-1,2,3,6-

tetrahydropyridine (toxicity)MR medial rectus (muscle)MRF midbrain reticular formationMRI magnetic resonance imagingmRNA messenger ribonucleic acidMSH melanocyte-stimulating

hormoneMTP metatarsophalangealMV mitral valveNAA N-acetyl-L-aspartateNF-κB nuclear factor kappa-light-

chain-enhancer of activated B cells

NHL non-Hodgkin lymphomaNLD necrobiosis lipoidica

diabeticorumNLR negative likelihood ratioNO nitric oxideNPV negative predictive valueOCP oral contraceptive pillOS opening snapOSA obstructive sleep apnoeaPAI-1 plasminogen activator

inhibitor-1PASP pulmonary artery systolic

pressurePC posterior commissurePCA posterior cerebral arteryPComm posterior communicating

arteryPCOS polycystic ovarian syndromePCP phencyclidine (toxicity)PCWP pulmonary capillary wedge

pressurePDA patent ductus arteriosusPDGF platelet-derived growth factorPFO patent foramen ovalePGE prostaglandin EPGH prostaglandin HPGI2 prostaglandin I2

PICA posterior inferior cerebellar artery

PIP proximal interphalangealPLR positive likelihood ratioPND paroxysmal nocturnal

dyspnoeaPPRF paramedian pontine reticular

formationPPV positive predictive valuePOMC pro-opiomelanocortinPR (interval)

measured from the beginning of the P wave to the beginning of the QRS complex

PR pulmonary regurgitationPS petrosal sinus

Abbreviat ionsxxii

PSA prostate-specific antigenPSP progressive supranuclear

palsyPTH parathyroid hormonePTH-rp parathyroid hormone-related

proteinPTN pretectal nucleusRA rheumatoid arthritisRA right atrialRAA(S) renin–angiotensin–

aldosterone (system)RANK(-L) receptor activator of nuclear

factor kappa (ligand)RAPD relative afferent pupillary

defectRAR rapidly adapting receptorRBBB right bundle branch blockRBC red blood cellriMLF rostral interstitial medial

longitudinal fasciculusRN red nucleusRNA ribonucleic acidRR relative risk or risk ratioRTA renal tubule acidosisRV right ventricularSA (node) sinoatrial (node)SC superior colliculusSCA superior cerebellar arteriesSCC squamous cell carcinomaSCFE slipped capital femoral

epiphysisSLAP superior labrum anterior

posteriorSLE systemic lupus

erythematosusSNc substantia nigra pars

compactaSNr substantia nigra pars

reticulataSO superior oblique (muscle)SPS stiff-person syndromeSR superior rectus (muscle or

subnucleus)

SS sigmoid sinusSS straight sinusSSS superior sagittal sinusSSRI selective serotonin reuptake

inhibitorSTN subthalamic nucleusSVC superior vena cavaT3 triiodothyronine (thyroid

hormone)T4 thyroxine (thyroid

hormone)TA tricuspid annulusTB tuberculosisTF tissue factorTGF-β transforming growth

factor-betaTH torcular HerophiliTh-1 helper T cell type 1TIA transient ischaemic attackTNF tumour necrosis factorTPA tissue plasminagen activatorTRH thyrotrophin-releasing

hormoneTS transverse sinusTSH thyroid-stimulating hormoneTSHR thyroid-stimulating hormone

receptorTTP thrombotic

thrombocytopenic purpuraTXA thromboxaneURTI upper respiratory tract

infectionV2 (receptor)

arginine vasopressin receptor 2

VAS ventral acoustic striaVEGF vascular endothelial growth

factorVIP vasoactive intestinal

peptideVL ventral lateralVSD ventricular septal defectvWF von Willebrand factorVZV varicella zoster virus

1

1

1

Musculoskeletal Signs

CHAPTER 1

Anter ior drawer test2

Anterior drawer test

FIGURE 1.1 Anterior drawer test for anterior cruciate ligament deficiency

90º

DESCRIPTIONOn grasping the leg in the upper one-third of the tibia and pulling it anteriorly, there is noticeable laxity and movement of the tibia forward on the femur.

CONDITION/S ASSOCIATED WITH

• Anterior cruciate ligament (ACL) injury/tear

MECHANISM/SThe ACL acts as the primary restraint on forward movement of the tibia on the femur, so when torn the restriction is released and the tibia is able to move further anteriorly.

SIGN VALUEThe anterior drawer test is a questionable test for ACL injuries.

There have been wide variances in the results of available research. In one review the sensitivity of the sign was 27–88%; however, the specificity only ranged from 91–99% and the positive LR was 11.5,1 making it valuable if present. In another meta-analysis,2 the positive LR was 3.8 and the sensitivity was 9–93% and the specificity was 23–100%; however, this study included small trials that may have skewed the results.

On balance, it appears a relatively specific but not sensitive test.

Apley’s g r ind test 3

1Apley’s grind test

FIGURE 1.2 Apley’s grind test

DESCRIPTIONWith the patient lying on the stomach and the knee flexed to 90°, downward pressure is applied to the heel, compressing the tibia onto the femur. The examiner then internally and externally rotates the tibia

on the femur. If this produces pain, the test is considered positive.

CONDITION/S ASSOCIATED WITH

• Meniscal injury

MECHANISM/SDirect pressure from the tibia towards the femur is aimed at ‘catching’ or hitting the damaged meniscus. If damage is present, pain will be elicited.

SIGN VALUEA few heterogeneous studies have been completed. A systematic review of seven of these studies found a pooled sensitivity of 60.7% and specificity of 70.2% with an odds ratio of 3.4,3 making Apley’s test not a particularly useful diagnostic test of meniscal injury. These findings were borne out in another meta-analysis.4 In addition, many practitioners no longer perform Apley’s grind test as the pain produced can be excruciating if an injury is present.

Apley’s scratch test4

Apley’s scratch test

DESCRIPTIONPerformed by asking the patient to reach and ‘scratch’ at the opposite scapula, both from above and below. Pain, limitation or asymmetry on performing these movements can be considered ‘positive’.

FIGURE 1.3 Apley’s scratch test

Based on Woodward T, Best TM, Am Fam Phys 2000; 61(10): 3079–3088.

CONDITION/S ASSOCIATED WITH

CommonMany types of shoulder joint injuries will produce pain on Apley’s scratch test.

• Rotator cuff tear/tendonitis• Sub-deltoid bursitis• Acromioclavicular joint sprain

MECHANISM/SThe global range of movement and, more specifically, abduction/adduction and internal/external rotation of the shoulder joint are examined by this test. Although thought to elicit rotator cuff pathology, in particular supraspinatus injury, almost any capsular, ligamentous, muscle or bony injury to the shoulder joint may cause a positive test.

SIGN VALUEApley’s scratch test is a good test of overall function of the shoulder joint; however, it is not specific to a particular part of the anatomy and is more a general screen of range of motion.

Apparent leg length inequal i ty ( funct ional leg length) 5

1Apparent leg length inequality (functional leg length)

A B C

FIGURE 1.4 Measurement of leg lengths

A The apparent leg length is the distance from the umbilicus to the medial malleolus. B Pelvic obliquity causing an apparent leg-length discrepancy. C The true leg length is the distance from the anterior superior iliac spine to the medial malleolus.

Based on Firestein GS, Budd RC, Harris ED et al, Kelley’s Textbook of Rheumatology, 8th edn, Philadelphia: WB Saunders, 2008: Fig 42-24.

DESCRIPTIONWhen measuring from the umbilicus to the medial malleolus of each leg, there is disparity between the two limbs. Technically described as unilateral asymmetry of the lower extremities without any concomitant shortening of the osseous (bony) components of the lower limb.

CONDITION/S ASSOCIATED WITH

• Altered foot mechanics• Adaptive shortening of soft tissues• Joint contractures• Ligament laxity• Axial mal-alignments

MECHANISM/SAn apparent or functional leg length inequality may occur at any point from the ileum to the inferior-most aspect of the foot5 for a number of reasons.

Ligament laxityIn this situation, the bones are the same length; however, the ligaments on one side (e.g. in the hip joint) may be more flexible or longer than their counterparts on the

other side, making the femur sit lower in the joint capsule and appear longer on measurement.

Joint contractureJoint contractures create stiffness and do not allow a full range of movement. If the knee joint is contracted in a flexed position, the affected side will not be as long as the opposite side even if in a fully extended position.

Altered foot mechanicsExcessive pronation of the foot eventuates in and/or may be accompanied by a decreased arch height compared to the ‘normal’ foot, resulting in a functionally shorter limb.5

SIGN VALUEAs in true leg length inequality, considerable variation in what is thought to be a clinically significant discrepancy and accuracy in clinical measurement has been reported.5 It therefore has limited value as a diagnostic or prognostic test. If there is significant variation in leg length (>2 cm) coupled with clinical signs, further investigation is warranted.

Apprehension test (crank test)6

Apprehension test (crank test)

FIGURE 1.5 Apprehension test

The arm is abducted and in an externally rotated position. Note the right arm of the examiner is providing anterior traction on the humerus, pulling the posterior part of the humeral head forward. The same test can be done from the back, with the patient sitting up and the examiner pushing forward on the posterior head of the humerus.

DESCRIPTIONThe apprehension test tries to determine whether glenohumeral joint instability is present. With the patient sitting or supine, the shoulder is moved passively into a fully abducted and externally rotated position. Forward pressure is then applied to the posterior part of the humeral head6 (see Figure 1.5). The test is positive if the patient feels apprehension that the shoulder may dislocate. It is NOT positive if it produces only pain.

CONDITION/S ASSOCIATED WITH

More common – traumatic• Humeral head subluxation or

dislocation• Rotator cuff damage• Anterior rim damage• Detachment of the joint capsule from

ligaments

Less common – atraumatic• Ehlers–Danlos syndrome• Marfan’s syndrome

• Congenital absence of glenoid• Deformities of the joint or proximal

humerus

MECHANISM/SThe primary cause of a positive apprehension test is damage or dysfunction of the capsule, labrum, ligaments or muscles that maintain stability in the shoulder joint. Anterior subluxation/dislocation occurs in 95% of dislocations.

Normal people have a certain degree of shoulder joint laxity or instability, which allows for the wide array of movements possible. Key to maintaining the stability of the shoulder joint are:

• capsuloligamentous or glenohumeral ligaments – primary stabilisation

• rotator cuff muscles – subscapularis is the most important for stability

• glenoid fossa and glenoid labrum.Disruption of any of these structures

predisposes the patient to a positive apprehension test and anterior joint instability.

In the apprehension test, external rotation ‘levers’ the glenoid head anteriorly and is assisted by the examiner pushing the head of the humerus forward. If there are any (or multiple) defects in the joint stabilisers, the head of the humerus will displace anteriorly – potentially even out of the joint socket. This causes discomfort and ‘apprehension’ of impending dislocation.

SIGN VALUEA reasonable test for glenohumeral joint instability, with very good specificity but only moderate sensitivity.

Initially reported by Rowe7 as having 100% specificity for anterior joint instability. A subsequent study of 46 patients found only modest sensitivity of 52.78% but good specificity of 98.91%.8

Specificity is improved even further when the test is combined with other tests including the ‘apprehension–relocation’ test (see ‘Apprehension–relocation test’ in this chapter).

Apprehension–relocat ion test (Fowler ’s s ign) 7

1Apprehension–relocation test (Fowler’s sign)

FIGURE 1.6 Apprehension–relocation (Fowler) test

Note that pressure is applied anteriorly to the proximal humerus.

DESCRIPTIONMost often used in conjunction with (and immediately after the completion of) the apprehension (crank) test (see ‘Apprehension test’ in this chapter). While either sitting or supine, the arm is passively moved into an abducted and externally rotated position. However, in this test the examiner’s right hand is on the anterior aspect of the proximal humerus and is used to push the head of the humerus backwards (posteriorly). The test is said to be positive if the patient gets relief from symptoms produced by the apprehension test. In short, if the examiner can elicit apprehension from forward movement that is relieved by backwards motion in the same plane, the test is positive.

CONDITION/S ASSOCIATED WITH

• Anterior joint instability – see disorders under ‘Apprehension test’

MECHANISM/SThe underlying anatomy and causes of anterior joint instability are outlined under ‘Apprehension test’ and apply equally here.

The main difference between the two tests is the symptomatic relief given by posterior pressure applied to the proximal humerus. This is thought to be caused by either of the following scenarios:

1 The humeral head, which is on the cusp of subluxation anteriorly, is pushed backwards and therefore reduced to its normal anatomical location.

2 The posterior pressure applied acts as a ‘support structure’ to the shoulder joint, giving the patient more confidence that subluxation will not occur and therefore relieving apprehension.9

SIGN VALUEThe relocation test is considered by some10 to be the gold standard test of anterior instability. When relief of apprehension and NOT pain is used as the indicator for a positive test, it has excellent specificity and PPV.

Studies completed by Speer et al11 and Lo et al8 found it to be a very specific test in diagnosing anterior instability with sensitivity of 68%, specificity of 100% and PPV of 100% and sensitivity of 31.94%, specificity of 100% and PPV of 100% in their respective studies.

However, when using pain or apprehension as an indicator of the test, Lo et al8 found less specific results with sensitivity of 45.83%, specificity of 54.36% and PPV of 56.26%.

In summary, if relief of apprehension is present in completing the apprehension–relocation test, anterior instability of the shoulder joint is almost certain to be present. Its usefulness is further increased if used in conjunction with the apprehension test.

Bouchard’s and Heberden’s nodes8

Bouchard’s and Heberden’s nodes

FIGURE 1.7 Prominent Heberden’s nodes

Based on Ferri FF, Ferri’s Clinical Advisor, Philadelphia: Elsevier, 2011: Fig 1-223.

DESCRIPTIONBouchard’s nodes are bony outgrowths or nodules found over the proximal interphalangeal joints of the hands.

Heberden’s nodes are located over the distal interphalangeal nodes.

CONDITION/S ASSOCIATED WITH

• Osteoarthritis• Familial

MECHANISM/SThe mechanism is unclear.

A number of studies have implicated bony osteophyte growth as the principle cause of Heberden’s and Bouchard’s nodes.12 Other contributing factors or theories include:

• genetic predisposition• endochrondral ossification of

hypertrophied cartilage as a result of chronic changes from the osteoarthritis process13

• traction spurs growing in tendons in response to excessive tension, repetitive strain or contracture.12

SIGN VALUEThe presence of Bouchard’s or Heberden’s nodes is a valuable sign with evidence that they are a strong marker for interphalangeal osteoarthritis14,15 and possibly a predisposition to generalised osteoarthritis.16,17 There is evidence that there is a correlation between the presence of these nodes and actual radiographic changes of osteoarthritis.18

Boutonnière deformity 9

1Boutonnière deformity

Central tendon slip

Funtional tendinous interconnections

between two extensor mechanisma

A

Lateral band

B

FIGURE 1.8 Digital extensor mechanism

A The proximal interphalangeal joint is extended by the central tendon slip (an extension of the hand’s dorsal extensor tendon). B The X is a functional representation of the fibrous interconnections between the two systems.

Based on DeLee JC, Drez D, Miller MD, DeLee and Drez’s Orthopaedic Sports Medicine, 3rd edn, Philadelphia: Saunders, 2009: Fig 20B2-27.

DESCRIPTIONUsed to describe a deformity of the finger in which the proximal interphalangeal (PIP) joint is permanently flexed towards the palm, while the distal interphalangeal (DIP) joint is bent away from the palm.

CONDITION/S ASSOCIATED WITH

• Traumatic injuries• Lacerations• Infections• Inflammatory conditions

MECHANISM/SCentral to the mechanism is disruption or avulsion of the central tendon slip. In fact, this sign derives its name from the appearance of the central tendon slip, which was thought to resemble a button hole (boutonnière in French) when torn.

The central tendon slip attaches to the base of the middle finger and its main job is to extend it specifically at the PIP joint with assistance of some other bands and tendons.

If the central tendon is disrupted or avulsed (pulled off the base of the middle phalanx), the actions of the flexor tendons (pulling the phalanx towards the palm) will be unopposed.

The DIP joint is hyperextended as the central tendon slip elastically retracts and pulls back on the lateral bands.

TraumaForced flexion of an extended PIP joint may cause detachment of the central tendon slip. In addition, crush injuries or any other trauma that damages the central tendon slip can cause a boutonnière deformity.

LacerationDirect lacerations of the central tendon slip will cause the deformity through the above mechanism.

InfectionInfections of the joint and/or skin can lead to inflammation and disruption of the central tendon slip.

InflammatoryPannus in the PIP joint (such as is seen in rheumatoid arthritis) may invade the central slip tendon and disrupt it and, therefore, lead to the characteristic changes.19

Alternatively, chronic inflammation and synovitis of the joint can push it into flexion, elongating the central slip tendon and ultimately leading to rupture. As a

Boutonnière deformity10

3

3

2

2

1

1

4

4

Central tendon slip

Central tendon slip pulls off bone and retracts

Through the connection to lateral band retracts it

The lateral band, in turn, extends the DIP joint

With no central tendon connection, P-2 flexes,

completing the full boutonnière deformity

Lateral band

FIGURE 1.9 Pathoanatomy of boutonnière deformity

The sequence is: rupture of the central tendon slip, which then simultaneously pulls on the lateral bands, pulling the DIP joint into extension as the middle phalanx, without central slip connection, collapses into some flexion.

Based on DeLee JC, Drez D, Miller MD, DeLee and Drez’s Orthopaedic Sports Medicine, 3rd edn, Philadelphia: Saunders, 2009: Fig 20B2-28.

result of this, the lateral bands proximal to the PIP joint are displaced. This places increased tension on the DIP joint extensor mechanism, leading to hyperextension and limited flexion of the DIP joint.20–23

SIGN VALUEBoutonnière deformity is by no means specific, although it is obviously always pathological. It is said to occur in up to 50% of patients with rheumatoid arthritis

Bulge/wipe/stroke test 11

1Bulge/wipe/stroke test

A

B

FIGURE 1.10 Demonstration of the bulge sign for a small synovial knee effusion

The medial aspect of the knee has been stroked to move the synovial fluid from this area (shaded depressed area in A). B shows a bulge in the previously depressed area after the lateral aspect of the knee has been tapped.

Based on Firestein GS, Budd RC, Harris ED et al, Kelley’s Textbook of Rheumatology, 8th edn, Philadelphia: WB Saunders, 2008: Figs 35-9A and B.

DESCRIPTIONThe bulge, wipe or stroke test is used to look for effusion in the knee joint. The patient lies flat and the examiner strokes upwards with the edge of the hand on the medial side of the knee to ‘milk’ fluid into the lateral compartment, and continues pushing this fluid downwards on the lateral side. The test is positive if the examiner can see a wave of fluid heading back towards the medial side of the knee.

CONDITION/S ASSOCIATED WITHAny condition causing a knee effusion, including:

More common• Osteoarthritis and overuse syndrome• Trauma• Arthritic disorders• Infection• Gout

Less common• Pseudogout (calcium pyrophosphate

deposition disease)• Tumour

MECHANISM/SThe mechanism causing this sign is simple mechanical manipulation of a swelling or effusion of the knee.

Knee effusions may arise from trauma, overuse or systemic disease but, regardless of aetiology, occur due to inflammation in and around the joint space. The wipe or bulge test is simply attempting to corral the effusion into one area and move it around, making it easier to see and quantify what may otherwise be spread over and around the knee joint.

SIGN VALUELimited evidence has been gathered on the value of this test as an individual sign. It has been suggested24 that this test may pick up on as little as 4–8 mL of swelling and be more sensitive in identifying small effusions than the patellar tap.

One small study25 showed a low sensitivity of 11–33% and higher specificity of 66–92% (depending on examiner) for identifying the presence of a knee effusion. This study showed the wipe test to be more specific than the patellar tap.

The presence of an effusion has been reviewed with other signs in regard to diagnosis of fractures and osteoarthritis. An effusion in the absence of acute traumatic injury or systemic disease is a reliable indicator of osteoarthritis.26 However, in the identification of a clinically significant knee fracture, a joint effusion only has moderate utility with a sensitivity of 54–79% and specificity of only 71–81%.1