!

Physical)Examination)
Table&of&Contents&
GENERAL'EXAMINATION'

3!

THE'CARDIOVASCULAR'EXAMINATION'

7!

GENERAL'INSPECTION'
INSPECTION'
PALPATION'
AUSCULTATION'
COMPLETION'OF'EXAMINATION'
SUMMARY'OF'TIMINGS'OF'MURMUR'
SIGNS'OF'LEFT'&'RIGHT'VENTRICULAR'FAILURE'
FOLLOWING'CARDIOVASCULAR'INVESTIGATIONS'
SUMMARY'OF'SIGNS'OF'COMMON'ILLNESSES'

7!
10!
10!
11!
13!
13!
14!
14!
14!

THE'RESPIRATORY'EXAMINATION'

19!

GENERAL'INSPECTION'
19!
INSPECTION'
20!
PALPATION'
21!
PERCUSSION'
21!
AUSCULTATION'
22!
COMPLETION'OF'EXAMINATION'
22!
SUMMARY'OF'SIGNS'OF'MOST'IMPORTANT'FOCAL'ABNORMALITIES25!
FOLLOWING'RESPIRATORY'INVESTIGATIONS'
25!
SUMMARY'OF'SIGNS'OF'COMMON'ILLNESSES'
26!
THE'GASTROINTESTINAL'EXAMINATION'

30!

GENERAL'INSPECTION'
INSPECTION'

30!
31!

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Joyce!Kwan!

PALPATION'&'PERCUSSION'
AUSCULTATION'
COMPLETION'OF'EXAMINATION'
FOLLOWING'GASTROINTESTINAL'INVESTIGATIONS'
SUMMARY'OF'SIGNS'OF'COMMON'ILLNESSES'

31!
33!
34!
34!
34!

THE'NEUROLOGICAL'EXAMINATION'

37!

GENERAL'INSPECTION'
CRANIAL'NERVES,'II''XII'
UPPER'LIMBS'
LOWER'LIMBS'
FOLLOWING'NEUROLOGICAL'INVESTIGATIONS'
SUMMARY'OF'SIGNS'OF'COMMON'ILLNESSES'

37!
38!
48!
52!
54!
55!

THE'THYROID'EXAMINATION'

58!

GENERAL'INSPECTION'
INSPECTION'
PALPATION'
PERCUSSION'
AUSCULTATION'
FOLLOWING'THYROID'INVESTIGATIONS'
SUMMARY'OF'SIGNS'OF'COMMON'ILLNESSES'

58!
59!
60!
60!
60!
61!
61!

THE'RHEUMATOLOGICAL'EXAMINATION'

63!

GENERAL'INSPECTION'
INSPECTION'(LOOK)'
PALPATION'(FEEL)'
MOVE'
FOLLOWING'RHEUMATOLOGICAL'INVESTIGATIONS'
SUMMARY'OF'SIGNS'OF'COMMON'ILLNESSES'

63!
63!
64!
64!
64!
65!

CLINICAL'INVESTIGATIONS'

67!

BLOOD'TESTS'

67!

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Joyce!Kwan!

General&Examination&&
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Always!approach!the!patient!on!the!R!side!
Whichever!part!of!the!body,!always!
Inspection!
Palpation!
Percussion!
Auscultation!!

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General!state!
Febrile,!comfortably!lying!on!the!bed!
Alert,!confused,!drowsy,!resentful!
Wasted,!cachexic,!fat!
Skin!
! Colour!(jaundice,!pigmentation,!vitiligo)!
! Texture!(hydrated,!thickened)!
Rash!
! Position!(butterfly'rash:!SLE)!!
! Size!
! Discrete/confluent!
! Flat!&!impalpable!!Macular!
! Raised!!
Papular:'!in!skin,!localized,!<!0.5!cm!
Plaque:!larger,!>2!cm!
Nodules:!deeper!in!dermis,!>!0.5!cm!
Wheal:!oedema!fluid!(often!white!+!red!margin)!
Vesicles:!contain!fluid,!<!0.5!cm!
Bullae:!large!vesicles,!>!0.5!cm!
Pustular:!contains!pus!
! Borders!(diffuse/well!demarcated)!
! Colour!
! Surface!(scaly/shiny)!
! Temperature!
! Tenderness!
! Pruritus!(itchiness)!
! Blanches! on! pressure! (petechiae! are! small,! red!
haemorrhages,! non.tender! macules,! that! do! not! blanch! on!
pressure)!

1. General'Inspection'

2. Hands'
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Temperature!
! Unduly!cold!!low.cardiac.output?!
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Joyce!Kwan!

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! Unduly!warm!!thyrotoxicosis?!
! Cold!&!sweaty!!anxiety/sympathetic.overactivity!
Nails!
! Leuconychia'!white!nails!
Due!to!hypoalbuminaemia,!occurring!in!cirrhosis!
! Koilonychia!!spoon.shaped!nails!
Iron.deficiency.anaemia.
! Clubbing!!loss!of!angle!at!base!of!nail!
Heart! ! infectious.endocarditis,.cyanotic.congenital.
heart.disease!
Lungs! ! carcinoma. of. the. bronchus,. mesothelioma,.
bronchiectasis,. lung. abscess,. empyema,. fibrosing.
alveolitis!!
Liver'.cirrhosis!
Crohns.disease.
Congenital..
! Splinter' haemorrhages! ! blood! clots! running! vertically!
under!nails!
Infective.endocarditis..
! Onycholysis! ! detachment! of! nail! from! nail! bed! starting!
from!distal/lateral!attachments!!
Psoriasis.
Fungal.infections.
Raynauds.phenomenon.
! Nailfold' telangiectasia/erythema! ! small,! dilated! blood!
vessels!in!the!skin!at!the!margin!of!the!nails!
Systemic.lupus.erythematosus..
Dermatomyositis.
Systemic.sclerosis.
Palms.
! Dupuytrens' contracture! ! tethering! of! skin! in! palm! to!
flexor!tendon!of!4th!finger.
Stigmata.(signs).of.chronic.liver.disease.
! Palmar'erythema!!redness!of!the!palm.
Can!be!normal!or!stigmata.of.chronic.liver.disease.
! Sweaty'palms!!can!be!normal!or!signifies!CO2.retention.
! Spider'naevi!!stigmata.of.chronic.liver.disease.

3. Mouth'
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Tongue!
! Cyanosed'!blue!tongue;!right.to.left!shunt!
Cyanotic.congenital.heart.disease.
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Joyce!Kwan!

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Lung.disease.(COPD).
! Dry'!dehydration!!
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4. Eyes'
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Sclera!!
! Jaundiced!!upper!conjunctival!membrane!
Pre.hepatic! (malaria,. sickle. cell. anaemia,. G6PD.
deficiency)!
Hepatocellullar!(HCC,.liver.cyst,.cirrhosis,.hepatitis)!
Post.hepatic! (gallstones,. liver. flukes,. pancreatitis,.
cholangiocarcinoma)!
! Pallor!!lower!conjunctival!membrane!

Bedside!environment!
! Head!of!bed!(fall!prevention,!NPO)!
! Machines! (continuous! ECG,! pulse! oximetry! monitoring,!
ventilator)!
! Bedside!table!(sputum!bottle,!oral!inhalers)!

5. Vital'signs'

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Masses+
Site'
Size'!cm!or!finger!breath!
Shape'
Scars'
Skin'changes!!punctum!!
Surface'
Attachment'
! Skin!!sebaceous!cyst!
! Underlying!muscle!!
Border'
Consistency'
Tender!
Pulsatile!
Mobile!
Fluctuant!
Temperature!change!
Dull!on!percussion!

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Joyce!Kwan!

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Primary+skin+lesions+
Macule'!non.palpable!area!of!altered!colour!
Papule'!palpable!elevated!small!area!of!skin!(<0.5!cm)!
Plaque'!palpable!flat.topped!discoid!lesion!(>2!cm)!
Nodule'!solid!palpable!lesion!within!the!skin!(>0.5!cm)!
Papilloma'!pedunculated!lesion!projection!from!the!skin!
Vesicle!!small!fluid.filled!blister!(<0.5!cm)!
Bulla'!large!fluid.filled!blister!(>0.5!cm)!
Pustule'!blister!containing!pus!
Wheal' !elevated!lesion,!often!white!with!red!margin!due!
to!dermal!oedema!
Telangiectasia'!dilatation!of!superficial!blood!vessel!
Petechiae'!pinhead.sized!macules!of!blood!
Purpura' ! larger! petechiae! which! do! not! blanch! on!
pressure!
Ecchymosis!!large!extravasation!of!blood!in!skin!(bruise)!
Haematoma'!swelling!due!to!gross!bleeding!
Comedo' ' dark! horny! keratin! &! sebaceous! plugs! within!
pilosebaceous!openings!!
Burrow' ! Linear! or! curved! elevations! of! the! superficial!
skin!due!to!infestation!by!female!scabies!mite!
Erythema'!redness!of!the!skin!
Poikiloderma' ! atrophy,! reticulate! hyperpigmentation! &!
telangiectasia!

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Joyce!Kwan!

&The&Cardiovascular&Examination&
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45!of!the!patient!
General'Inspection'

1. Introduction,'wash'hands'&'gain'consent''
2. Exposure' only' after' general' inspection:' whole' upper'
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trunk'
3. Comment'on'general'condition'of'the'patient'

Oxygen!supplement!
Respiratory!distress/dyspnea/orthopnoea!!

4. Nails'
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Clubbing! ! stigmata. of. infective. endocarditis,. cyanotic. heart.

disease!
Koilonychia!!iron.deficiency.anaemia!
Splinter' haemorrhage! ! stigmata. of! infective. endocarditis,.
vasculitis!
Oslers'nodes!!tender!nodules!at!finger!pulps!of!hand!
! Stigmata.of.infective.endocarditis.
Janeway' lesions!!non.tender,!small!erythematous!at!palms!of!
hand!
! Stigmata.of.infective.endocarditis.

5. Fingers'

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Xanthomata!!intracutaneous!yellow!cholesterol!deposits!occur!
around!the!eyes!
! Hyperlipidaemia!(type!V!or!VI)!
Xanthoma!!tendon!deposits!around!finger!tendons!&!Achilles!
tendon!
! Hypercholesterolaemia..

6. Radial'pulse''

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Palpated! just! medial! to! the! radius! with! two! forefingers,! lateral!
to!flexor!carpi!radialis!tendon!
Pulse!rate!!15!s!*!4!
! Tachycardia.>.100.bpm.
! Bradycardia.<.50.bpm.
Rhythm!
! Regular:! normal! sinus! arrhythmia! for! <! 50! y.o.! (! in! deep!
inspiration!&!!deep!expiration)!
! Regularly! irregular:! pulses' bigeminous,! coupled'
extrasystoles!(digoxin.toxicity),!Wenkebach'heart'block!
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Joyce!Kwan!

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! Irregularly! irregular:! multiple' extrasystoles,' atrial'
fibrillation'(if!present,!pay!attention!to!MS!or!MR)!
Collapsing' pulse! ! pulse! pressure! greater! than! diastolic!
pressure!!
! Aortic.regurgitation.(AR).
! Elderly.arteriosclerotic.patient.(most.common).
! Gross.anaemia.
! Thyrotoxicosis.
! Pregnancy..
Radio.radial!delay!
! Arterial.atherosclerotic.plaque.
! Aneurysm..
Radio.femoral!delay!
! Coarctation.of.aorta.
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7. Blood'pressure'(rarely'performed)'
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Wrap!cuff!neatly!&!tightly!around!either!upp!arm!
Gently! inflate! the! cuff! until! the! radial! artery! is! no! longer!
palpable!
Using! the! stethoscope! listen! over! the! brachial! artery! for! the!
pulse!to!appear!as!you!drop!the!pressure!slowly!!
Systolic!pressure:!appearance!of!sounds!!Korotkoff!phase!1!
Diastolic! blood! pressure:! disappearance! of! sounds! ! Korotkoff!
phase!5!
165/95!mmHg:!hypertension!
Wide!pulse!pressure:!AR!
Narrow!pulse!pressure:!AS!

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Pallor!
Central!cyanosis!

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Pulsation!!Corrigan!sign!(AR)!!
Character!
! Normal:!60!!100!bpm!
! Slow!rising!&!plateau!(anacrotic)!!moderate/severe!aortic.
stenosis.(AS)!
! Bisferiens!!moderate!AS!with!severe!incompetence!
! Pulses' paradoxus! ! pulse! weaker! or! disappears! on!
inspiration!
Constrictive.pericarditis.
Tamponade.
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Joyce!Kwan!

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8. Face'
9. Carotid'pulse'

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Status.asthmaticus..
! Pulsus'alternans!!alternating!strong!&!weak!beats!
Left.ventricular.failure..
Volume!!
! Small!volume!!low!cardiac!output!(haemorrhagic.shock)!
! Large!volume!!CO2.retention,.thyrotoxicosis,.anaemia!

10. Jugular'venous'pressure'(JVP)'

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Tell!patient!to!look!to!the!left!
Observe! height! of! JVP! (ask! patient! for! abdominal! discomfort!
before! performing! hepatojugular! reflux:! JVP! should! rise!
transiently!then!return!to!original!position)!
! IJV:!medial!or!deep!to!SCM!
! EJV:!lateral!to!SCM!
. Assess! vertical! height! above! manubriosternal! angle! (normally!
within!supraclavicular!fossa!~3cm)!
Carotid'pulse'
JVP'
1!wave!form!per!cardiac!cycle!
2!wave!form!per!cardiac!cycle!
Not! affected! by! hepatojugular! Affected!by!hepatojugular!reflux!
reflux!
Pulsatile!on!palpation!
Generally! not! palpable! (except!
in!TR)!
Does!not!alter!with!respiration!&! Alters! with! respiration! &!
positioning!
position!
Pulsatile!!
Obliterated! by! finger! pressure!
on!vein!
. Character!
! Elevated!JVP!>!5cm!
Right.heart.failure.
Fluid.overload.
Tricuspid.regurgitation/stenosis.
! Kussmauls' sign! (venous! pressure! rises! on! inspiration;!
normally!falls)!
Constrictive.pericarditis.
Pericardial.effusion..
! Cannon' a' wave! ! complete.heart.block! when! right! atrium!
occasionally!contracts!against!closed!tricuspid!valve.
! Absent'a'wave!!atrial.fibrillation.
! Giant'v'wave'.tricuspid.regurgitation..
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Joyce!Kwan!

!
Inspection'

1. Scars'
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Thoracotomy!!sides!of!chest!!back:!valvular.replacement!
Sternotomy!!midline!scar:!valvular.replacement!
Submammary!!under!breasts:!mitral.valve.replacement!
Infraclavicular!!left!upper!trunk:!pacemaker!

2. Visible'pulsation'
Palpation'

1. Apex'beat'
.

Site!
! Point! furthest! out! &! down! where! the! pulsation! can! be!
distinctly!felt!
! Normal:!5th!ICS,!mid.clavicular!line!
! Displaced! with! reference! to! ICS! &! finger! breaths! displaced!
laterally/medially!from!mid.clavicular!line!
! If!cannot!be!palpated,!remember!to!palpate!right!side!
Character!
! Tapping'!palpable!first!heart!sound!!
Mitral.stenosis.
! Hyperdynamic'!pressure!overload,!sustained!apex!beat!
Aortic.stenosis!
Gross.hypertension.!
! Hypervolemic! ! volume! overload:! thrusting! displaced!
apex!beat!
Mitral.regurgitation!
Aortic.regurgitation!

2. Parasternal'heave'
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Palpate!firmly!the!left!border!of!the!sternum!
Use!flat!of!your!hand!&!wrist!+!elbow!at!90C!
Suggestive!of!right!ventricular!hypertrophy!!
!

3. Thrills'
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Palpate! praecordium! with! hand! horizontally! placed! at! 2nd! ICS,!

4th!ICS!&!apex!beat!
Thrills!are!palpable!murmus!
If!present!!grade!4!murmur!(6!grades!altogether)!
!
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Joyce!Kwan!

!
Auscultation'

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After! above! examination,! auscultation! should! be! used! for!

confirming!suspicion!!
4!main!areas!
! Apex!(5th!ICS,!left!mid.clavicular)!+!axilla!if!murmur!heard!
(MR)!
Bell:! mitral. stenosis! (mid.diastolic! rumbling!
murmur)!
! Tricuspid!area!(left!lower!sternal!border)!
! Aortic!area!(right!upper!sternal!border)!+!carotid!(AS)!
! Pulmonary!area!(left!upper!sternal!border)!!
Listen! over! 4! main! areas! for! the! heart! &! concentrate! in!
determining!
! Heart'sounds!(while!palpating!radial!pulse)!
! Added' sounds! ! best! heard! with! bell! with! patient! on! left!
side!
! Murmurs''
High.pitched!better!heard!with!diaphragm!
Low.pitched!better!heard!with!bell!!
Best'heard''
Radiation'
Grade''
Listen!to!carotid!artery!
! AS!radiation!.!Ask!patient!to!hold!breath!at!expiration!!
! Carotid!bruit!
!
Normal+heart+sounds+
S1!!Mitral!&!tricuspid!valve!closure!at!onset!of!systole!
. Loud!in!MS!
. Soft'.!mitral.incompetence,.AS,.LBBB!
. Variable!.!complete.heart.block!&!AF.
S2! ! aortic! &! pulmonary! valve! closure! following! ventricular!
ejection!
. Physiological'splitting!splitting!during!inspiration!
. Exaggerated'splitting'!RBBB!
. Reversed'splitting'!LBBB!or!AS!
. Fixed!splitting!!
. Loud'.!hypertension!
. Soft'.!AS!or!pulmonary.stenosis!!
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Joyce!Kwan!

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Added!sounds!
S3!&!S4!!low.frequency!sounds!occur!early!&!late!in!diastole!
respectively!
. Characteristic!gallop!to!cardiac!rhythm,!best!heard!at!
apex!with!bell!
. Caused! by! abrupt! tensing! of! ventricular! walls!
following!rapid!diastolic!filling!!
. S3:!physiological!in!people!<!40!y.o.!&!pathological!in!
left!ventricular.failure,.MS!or.constrictive.pericarditis!
. S4:! physiological! in! elderly! &! pathological! in! non.
compliant! ventricle! (hypertension,. AS! or! hypertrophic.
cardiomyopathy)!
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Murmurs+
Site!&!radiation!
! MR!!axilla!
! AS!!carotids!&!apex!
! AR!!sternum!!
Character!
! Loud/soft!
!
Grade!1:!barely!audible!
Grade!2:!soft,!&!not!heard!at!first!
Grade'3:'moderate;'no'thrill'
Grade'4:'audible'+'thrill'
Grade!5:!very!loud!+!thrill!easily!palpable!
Grade! 6:! extremely! loud! +! can! be! heard!
even!without!placing!stethoscope!on!chest!
! Pitch!
(squeaking/rumbling/scratchy:!
pericardial)!
! Length!
Ejection.systolic!(AS)!
Pan.systolic:! throughout! systole! after! S1!
including!S2!(MR)!
Early.diastolic:!after!S2!(AR,.TR)!
Mid.diastolic!(MS)!
! Posture!
Sit!forward!!louder!AR!
Lie!left!side!!louder!MS!
! Respiration!
Inspiration!.!!right!heart!lesion!
Expiration!.!!left!heart!lesion!
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Joyce!Kwan!

!
Completion'of'examination'

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Auscultate! lung! base! for! crepitations' from! left. ventricular.

failure!
Palpate!liver!!
! Pulsatile'!TR!
! Hepatomegaly!!right.heart.failure!
Peripheral!oedema!!ankle/sacral!
Ophthalmoscopy!
! Hypertensive!retinopathy!
! Aryll'Robertson'pupils!!bilateral!small!pupils!with!intact!
accommodation!reflex!but!absent!light!reflex!(AR)!
Summary'of'timings'of'murmur'

1. EjectionOsystolic'murmur'
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Aortic.stenosis.(AS).
Tricuspid.stenosis.(TS).
Atrial.septal.defect.(ASD).
Hypertrophic.cardiomyopathy.(HCOM).

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Mitral.regurgitation.(MR).
Tricuspid.regurgitation.(TR).
Ventricular.septal.defect.(VSD).

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Mitral.valve.prolapse.(clickXmurmur.syndrome).
Papillary.muscle.dysfunction.(2.to.ischaemia/HCOM).
Coarction.aorta.(extending.in.diastole.to.machinery.murmur).

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Aortic.regurgitation.(AR).
Tricuspid.regurgitation.(TR).

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Mitral.stenosis.(MS).
Tricuspid.stenosis.(TS).
Austin.Flint.murmur.in.aortic.incompetence..
CareyXCoombs.murmur.of.acute.rheumatic.fever.

Patent.ductus.arteriosus.(PDA).
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2. PanOsystolic'murmur''

3. LateOsystolic'murmur'

4. EarlyOdiastolic'murmur'
5. MidOdiastolic'murmur'

6. Continuous'murmur'

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Joyce!Kwan!

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Signs'of'left'&'right'ventricular'failure'

Left'heart'failure'
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Dyspnoea!
Basal!crepitations!(fine!crepitations!upon!coughing)!
3rd!or!4th!heart!sound!in!older!patients!

Right'heart'failure'
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Raised!jugular!venous!pressure!
Enlarged!tender!liver!
Pitting!oedema!(sacral/ankle)!
Following'cardiovascular'investigations'

1. Chest'XOray'
2. Echocardiogram'(ECG)'
3. Treadmill'exercise'test'with'ECG'
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Ischaemia!

Sonar!radar!of!heart!for!
! Muscle!&!ventricle!size!
! Contractility!
! Valve!function!!

Arrthymia!

Pressure!measurements,!blood!oxygenation!&!angiogram!

4. Echocardiograph''

5. 24'hour'ECG'tape'(holter'monitor)''
6. Cardiac'catheterization'''
7. Radioactive'scan'

Image!live,!ischaemia!or!dead!cardiac!muscle!
Summary'of'signs'of'common'illnesses'

Mitral'stenosis'(MS)'
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Malar!flush!(two!cheeks!+!not!crossing!nose!bridge)!
Peripheral!cyanosis!!
Pulse:!small!&!fibrillating!(can!cause!AF)!
JVP!only!raised!if!heart!failure!
Tapping!apex!!
Parasternal!heave!(RV++,!LVo)!
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Joyce!Kwan!

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Loud!S1!&!P2!if!pulmonary!hypertension!
Opening! snap! (OS)! in! early! diastole! .! indicating! leaflets! are!
pliable!
Mid!diastolic!murmur!!
! Apex!only!
! Low.pitched!
! Rumbling!
dub!dub!rooofooo!lub!from!S2!OS!murmur!S1!
Causes!
! Rheumatic.heart.disease.
! Congenital.

Mitral'regurgitation'(MR)'
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Dyspnoea!(pulmonary!congestion)!
Fatigue!(decrease!CO2)!!
Pulse:!Fibrillating!!
JVP!only!raised!if!heart!failure!
Hyperdynamic!apex!beat!
Systolic!thrill!(RV+,!LV++)!
Soft!S1!&!Loud!P2!if!pulmonary!hypertension!!
Pan.systolic!murmur!!
! Apex!radiating!to!axilla!
! Best!detected!on!expiration!
S3:!rapid!LV!filling!in!early!diastole!
lub!rooofooooo!from!S1!murmur!(overlapping!S2)!
Causes!
! Mitral.valve.prolapse.(MVP).
! Rheumatic.heart.disease.
! Left.ventricle.dilatation.
! Infective.endocarditis.

Tricuspid'regurgitation'(TR)'
.
.
.
.
.

JVP:!giant!v!wave!!atrial!filling!
Pansystolic!murmur!
! Best!heard!at!lower!sternal!edge!
! Upon!inspiration!
Pulsatile!liver!!
lub!rooofooooo!from!S1!murmur!(overlapping!S2)!
Causes!
! Dilation.of.right.ventricle.
! Cor.pulmonale.
15!
! ! !
!
Joyce!Kwan!

!
! Inferior.MI.

Aortic'stenosis'(AS)'
.
.
.
.
.
.
.
.
.
.

Exertional!dypsnoea!
Exertional!chest!pain!&!syncope!
Plateau!pulse!!narrow!pulse!pressure!
Hyperdynamic!undisplaced!apex!beat!
JVP!only!raised!if!heart!failure!!
Systolic!thrill!(LV++)!
Soft!A2!with!paradoxical!split!(!Ejection!click)!
!
Ejection!systolic!murmur!
! Apex,!left!sternal!edge!&!aortic!area!radiating!to!carotids!
! Lean!forward!&!full!expiration!!
lub!roofoooo!dub!from!S1!murmur!S2!
Causes!
! Rheumatic.heart.disease.
! Calcified.bicuspid.aortic.valve.
! Degenerative.calcification.

Aortic'regurgitation'(AR)'
.
.
.
.
.
.
.
.
.
.

.
.

Water.hammer!(collapsing)!pulse!
Wide!pulse!pressure!
Corrigans!sign!(carotid!pulsation)!
Quinckes!sign!(pulsating!nails)!
JVP!only!raised!if!heart!failure!
LV++!with!dilation!
Ejection!click!
Displaced,!hyperdynamic!apex!beat!
Loud!P2!(pulmonary!hypertension)!
Early!diastolic!murmur!
! Best!heard!at!left!sternal!border!
! Lean!forward!&!full!expiration!
! High!pitched!
lub!dub!roofooo!from!S1!S2!murmur!
Causes!
! Marfans.syndrome..
! Ankylosing.spondylitis.(AS).
! Rheumatoid.arthritis.(RA).
! Bicuspid.aortic.valve.
16!

! ! !

Joyce!Kwan!

!
Austin'Flint'murmur'
.

Mid!diastolic!murmur!(like!MS)!
! Aortic.incompetence! due! to! regurgitant! stream! of! blood! on!
anterior!cusp!mitral!valve!

Atrial'septal'defect'(ASD)'
.
.
.
.

JVP!only!raised!if!failure!or!tricuspid!regurgitation!
RV!++!LVo!
Widely!fixed!split!S2!
Pulmonary!systolic!murmur!
! MidXsystolic.murmur.
! Tricuspid.diastolic.flow.murmur..

Ventricular'septal'defect'(VSD)'
.
.

RV+!LV+!
Pan.systolic!murmur!
! Best!heard!at!left!sternal!edge!
! Loud!if!small!defect!

Patent'ductus'arteriosus'(PDA)'
.
.

Systolic!!diastolic!machinery!
Continuous!murmur!below!left!clavicle!

Metal'prosthetic'valves'
.

Loud!clicks!with!short!flow!murmur!
! Aortic!systolic!
! Mitral!diastolic!

Pericardial'rub'
.
.

Scratchy,!superficial!noise!heard!in!systole!&!diastole!
Brought! out! by! stethoscope! pressure! and! sometimes! variable!
with!respiration!

Infectious'endocarditis'(subacute'bacterial'endocarditis)'
.
.
.
.
.
!

Febrile,!unwell,!anaemia!
Clubbing!
Splinter!haemorrhages!
Oslers!nodes!
Janeway!lesions!
17!

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Joyce!Kwan!

.
.

!
Cardiac!murmur!
Splenomegaly!!

Rheumatic'fever'
.
.
.
.
.

Flitting!arthralgia!
Erythema! nodosum! (inflammation! of! fat! cells! under! skin)! or!
erythema!marginatum!(pink!rings!on!trunks!&!inner!surfaces!of!
limbs)!
Tachycardia!
Murmurs!
Syndenhams!chorea!

.
.
.
.

Facies+
Downs'syndrome:!VSD,.PDA!
Marfans!syndrome:!AR!
Turners'syndrome:!coarctation!
Thyrotoxicosis:!AF!

18!

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Joyce!Kwan!

The&Respiratory&Examination&
.!45!of!the!patient!!
General'Inspection'

1. Introduction,'wash'hands'&'gain'consent''
2. Exposure' only' after' general' inspection:' whole' upper'
trunk'

3. Comment'on'general'condition'of'the'patient'

.
.
.
.
.
.
.

Respiratory!distress!
Cyanosis!
Tachypnea!
Pursed!lip!breathing!
Oxygen!supplement!
Sputum!bottle!
Bronchodilators!on!the!bedside!

.
.
.

Nicotine'on!fingers!
Clubbing!!carcinoma.of.bronchus,.mesothelioma,.bronchiectasis,.
lung.abscess,.empyema,.fibrosing.alveolitis!!
Peripheral'cyanosis'

.
.
.

Sweaty'palms!!CO2.retention!!
Bounding'pulse!!CO2.retention!
Flapping'tremor!!CO2.retention!

.
.

Pallor!!anaemia!
Central' cyanosis' ' cor. pulmonale,. fibrosing. alveolitis,.
bronchiectasis..
Horners' syndrome' (meiosis)! ! compression! of! cervical!
sympathetic!ganglion!(e.g.!CA.lung)'

4. Nails'

5. Hand'

6. Face'

7. JVP'
.

Raised!in!cor'pulmonale!
! COPD.
! Bronchiectasis..
! Fibrosis..
.
19!

! ! !

Joyce!Kwan!

8. Pattern'of'breathing'
.

.
.
.
.
.

Cheyne'Stokes!!alternating!hyperventilation!&!apnoea!
! Severe.increased.intracranial.pressure.
! Left.ventricular.failure.
! High.altitude..
Pursed'lip'breathing!!expiration!against!partially!closed!lips!
! Chronic. obstructive. airway. disease! to! delay! closure! of!
bronchioles!
Use' of' accessory' muscle! ! sternocleidomastoid! &! strap!
muscles!
Wheezing'
Stridor!!harsh,!high.pitched!respiratory!sound!e.g.!inspiratory!
sound!often!heard!in!acute!laryngeal!obstruction!
Hoarse'voice!!abnormal!vocal!cords!
! Recurrent!laryngeal!palsy!(CA.lung)!
Inspection'

1. Scars'

.
.
.
.

Infragmammary''
Sternotomy'
Thoracotomy''
Radiation'marks''

.
.

Pectus!excavatum!!sunken!sternum!
! Marfans!syndrome!!
Pectus!carinatum!!pigeon!chest!
Barrel!chest!!lower!costal!recession!on!deep!inspiration,!cricoid!
cartilage! close! to! sternal! notch! &! chest! appears! to! be! fixed! in!
inspiration!
! Obstructive!airways!disease!!
Kyphoscoliosis!!
Harrisons!sulcus!

.
.

Symmetry!
Pathology!always!on!the!side!with!diminished!chest!movement!

Normal!!10!!20!breaths/min!
!
!

20!

2. Chest'wall'deformities''
.
.

3. Chest'expansion'
4. Respiratory'rate'

! ! !

Joyce!Kwan!

!
Palpation'

.
.
.

Mediastinum!position!
! Position!of!trachea!!
Supraclavicular!lymph!nodes!
! Tuberculosis!
! CA!bronchus!
Apex!beat!!
! May!be!displaced!because!of!enlarged!heart!&!not!a!shift!in!
mediastinum!
! May!not!be!palpated!!
Hyperinflated'chest!!COPD!
Massive'pleural'effusion'
Chest!expansion!
! Lay! hand! comfortably! on! either! side! of! upper! chest! with!
thumb! extended! (as! a! gauge),! assessing! if! there! is!
diminution!of!one!side!during!inspiration!
! Wrap! hands! from! posterior! ! anterior,! having! thumbs!
touching! at! midline! (as! a! gauge),! assessing! for! middle! and!
lower!zone!chest!expansion!on!deep!inspiration!!
Tactile!vocal!fremitus!
Percussion'

.
.
.
.

Percuss! both! side! of! the! chest! for! resonance! at! supraclavicular!
fossa,!clavicle!&!the!upper,!middle!+!lower!segments!
Compare! sides! &! if! abnormal! also! compare! the! front! &! back! of!
chest!
Dull! area! ! map! out! its! limits! by! percussing! from! resonant! to!
dull!area!
Percuss!the!level!of!diaphragm!from!above!downwards!
! Increased!resonance!in!
Pneumothorax.
Emphysema.
! Decreased!resonance!in!
Effusion:!stony'dull!
Solid!lung!
Consolidation.
Collapse.
Abscess.
Neoplasm.
.
21!

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Joyce!Kwan!

!
Auscultation'

Use!bell!of!stethoscope!&!listen!to!supraclavicular!fossa!

Ask!patient!to!breathe!through!his!mouth!moderately!deeply!
! Use! diaphragm! &! listen! at! top,! middle! and! bottom! of! both!
sides!of!the!chest!and!then!in!the!eaxilla!
Listen!for!breath!sounds,!comparing!both!sides!
! Vesicular:!normal!breath!sound!
! Bronchial:!patent!bronchi!&!conducting!tissue!
Consolidation.(usually.pneumonia).
Neoplasm.
Fibrosis.
Abscess.
NOT! collapse,! effusion! (except! occasionally! at!
surface)!!
! Diminution! ! either! no! air! movement! (e.g.! obstructed!
bronchus)!or!air/fluid!preventing!sound!condution!
Effusion.
Pneumothorax.
Emphysema.
Collapse.
Pneumothorax.
Large.neoplasm...
! Added'sounds!!
Vocal!resonance!!
Alteration!of!breath!sounds!and!vocal!resonance!depend!on!the!
same!criteria!&!alter!together!
Ask!patient!to!repeat!3.5.3!whilst!listening!to!the!chest!in!the!
same!areas!as!auscultation!
! Louder!!consolidation!!
If! vocal! resonance! is! gross,! whispering! pectoriloquy,! can! be!
elicited!by!asking!patient!to!whisper!3.5.3!

1. Breath'sounds'

.
.
.

Completion'of'examination'
.
.
.

Ask!for!patient!performance!on!peak!flow!meter!
Temperature!chart!
Sputum!bottle!
! Mucoid!!bronchitis,.bronchiectasis,.asthma!
! Purulent!!infection!!
! Frothy!!pulmonary.oedema!!
22!

! ! !

Joyce!Kwan!

!
! Bloodstained!!TB,.bronchi,.embolus,.lung.cancer!
! Rusty!!pneumococcal.pneumonia!!

Respiratory+failure+
Type'I'respiratory'failure!!!PaO2!(<!8kPa/60!mmHg)!
. Lung!failure!
. Hypoxia!respiratory!failure!
. Mechanism!!
! Ventilation.perfusion!mismatch!
! Right.to.left!shunt!
! Diffusion!abnormalities!
. Causes!
! Conducting!airway!problem!!asthma!
! Alveolar! problem. . pneumonia,. pulmonary. oedema,.
adult.respiratory.distress.syndrome.(ARDS),.atelectasis!
! Pulmonary! vasculature. . pulmonary. embolism,. fat.
embolism!
+
Respiratory+failure+
Type'II'respiratory'failure!!!PaO2!(<!8!kPa/60!mmHg)!&!!
PaCO2!(>6.7!kPa/50!mmHg)!
. Pump/ventilator!failure!
. Hypercapnic!respiratory!failure!
. Mechanism!
! Low!minute!ventilation!
! High!dead!space!ventilation!
. Causes!
! Central! depression! of! respiration! ! stroke,.
compression.of.brain.stem!
! Peripheral!neuropathy!!GuillainXBarre.syndrome!
! Neuromuscular! junction! disturbance! ! myasthenia.
gravis!
! Severe! disturbance! of! gas! exchange! ! emphysema,.
enlarged.thyroid,.enlarged.tonsils!
! Severe!mechanical!ventilator!defect!!kyphoscoliosis.!
! Respiratory! muscle! defect! ! muscular. dystrophy,. flail.
chest!

23!

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Joyce!Kwan!

!
!
Added+sounds+
Pleural' rub! ! pleurisy! (inflammation! due! to! infection! or!
infarction)!
. Both!parietal!&!visceral!pleura!are!roughened!
. Causes:!
! Pneumonia.
! Pulmonary.infarction.
! Pleural.inflammation..
!
Rhonchi/wheezing! ! constricted! air! passages! giving! dry!
tubular!sounds,!often!maximal!on!expiration!
. Higher!the!pitch,!higher!velocity!of!air!
. Usually!continuous!due!to!significant!airway!narrowing!!
. Louder! in! expiration! as! airways! normally! dilate! during!
inspiration!&!narrow!during!expiration!
. Causes:!
! COPD.
! Asthma.
!
Rles/crepitations/crackles! ! loss! of! stability! of! peripheral!
airway! which! collapse! on! expiration! thus! during! inspiration,!
high!airflow!cuases!abrupt!opening!of!alveoli!producing!sound!
! Crepitations!(fine!crackles)!.!rubbing!of!hair!!
Abrupt! opening! of! alveoli! thus! usually! late.
inspiratory!
Causes:!!
Heart!failure!
Alveolitis!
! Medium!!
Abrupt! opening! of! bronchioles! thus! usually!
mid.inspiratory!
Causes:!
Infection!!
! Rles!(coarse!crackles)!!air!bubbling!through!fluid!in!
large!bronchioles!
Abrupt!opening!of!proximal!airways!!
Causes:!!
Bronchiectasis!!
!!
Stridor!!obstruction!of!main!airway!
. Croaking!noise!loudest!on!inspiration!
. Medical!emergency!
!
!
'
24!
! ! !
!
Joyce!Kwan!

!
Summary'of'signs'of'most'important'focal'abnormalities'

!
Following'respiratory'investigations'

1. Spirometry'
2. Peak' flow' meter' ' reduced' peak' expiratory' flow' rate'
(PERF)'for'asthma'
.
.
.

Measure! of! airways! obstruction! in! the! peak! rate! of! flow! of! air!
out!of!lungs!
Normal:!300!!500!litre/min!

3. Arterial'blood'gas''

Reduction' of' oxygenation' of' blood! in! lung! conditions! e.g.!

COPD.

4. Sputum'culture'&'sensitivity'
5. Sputum'culture'&'sensitivity'for'acidOfast'bacilli'
!

25!

! ! !

Joyce!Kwan!

6. Sputum'cytology'
7. Chest'XOray'for'infections'
.
.
.
.
.

PA'view!!erect!!
AP'view!!sitting!
Decubitus' view! ! patient! supine! to! differentiate! between!
pleural.effusion!&!consolidation!
Lateral'view'
Lordotic' view! ! to! visualise! apex! of! the! lung! e.g.! pancoast!
tumour!

8. Flexible'bronchoscopy'
.

Biopsy!for!lung.tumours!to!obtain!tissue!samples!for!histological!
examination!!

9. Bronchoscopic'aspirate''

Usually!for!viral!culture!in!upper.respiratory.tract.infection!

Examination!of!the!pleural!cavity!&!biopsies!taken!!

10. Thoracoscopy''
Summary'of'signs'of'common'illnesses'
Asthma'
.
.
.
.
.
.
.

Patient!distressed,!tachypnoiec!&!unable!to!talk!easily!!
Wheeze!audible!or!on!auscultation!
Dry!or!productive!cough!
Over.inflated!chest!with!hyper.resonance!
Prolonged!expiration!phase!&!FET:!!peak!flow!&!!FEV1!
If!central!cyanosis:!critically!ill,!artificial!ventilation!
Pulsus!paradoxus!(may!be!normal!between!attacks)!
! BP!drops!>!10!mmHg!during!inspiration!!

Bronchiectasis'
.
.
.
.
.

Clubbing!
Constant!green/yellow!phlegm!!intermittent!haemoptysis!!
Coarse!rles!over!affected!area!upon!inspiration!
! Cleared!by!coughing!
Lung!base!dull!on!percussion!
Causes:!
! Chronic! infection! of! bronchi! &! bronchioles! ! permanent!
dilatation!of!these!airways!
! Cystic.fibrosis.
26!

! ! !

Joyce!Kwan!

!
! Primary.ciliary.dyskinesia!(Kartageners.syndrome)!
! Bronchial!obstruction!!tumour,.foreign.body!
! Infective!insult!!tuberculosis,.pneumonia,.pertussis!!

Chronic'Obstructive'Pulmonary'Disease'(COPD)'

1. Chronic'Bronchitis:'Blue'Bloater'
.
.
.
.
.
.
.
.
.
.
.
.
.

Loss!cough!&!sputum!
Central!cyanosis!
Signs! of! CO2! retention! ! flapping! tremor,! sweaty! palms,!
bounding!pulse!!
Obese!
Not!dyspnoeic!
Ankle!oedema:!may!or!may!not!have!right!heart!failure!!
Hyperinflated!chest!
Hoovers! sign! .! Depressed! diaphragm:! indrawing! lower! costal!
margin!on!inspiration!
Use!of!assessory!muscles!!
Diminished!chest!expansion!!
Hyper.resonance!!
Breath!sounds!reduced!with!
! End.expiratory!wheezes!&!early!inspiratory!crackle!
Causes:!
! Smoking.
! Recurrent.bronchial.infection..

2. Emphysema:'Pink'Puffer'

.
.
.
.
.
.
.
.
.

Dyspnoeic!!
Hyperinflated,!barrel.shaped!chest!
Pursed! lip! breathing! ! expiration! through! partly! closed! lips!
increases!the!end.expiratory!pressure!&!keeps!airways!open!
! Reduces!air!trapping!thus!prolonged!expiration!
Use!of!accessory!muscles!
Hoovers!sign!
Reduced!chest!expansion!&!decreased!breath!sounds!
Hyperresonant!with!decreased!liver!dullness!
No!wheeze!!
Causes!
! Smoking.
! XAntitrypsin.deficiency.
.
.
27!

! ! !

Joyce!Kwan!

!
Lung'Fibrosis'
.
.
.
.
.
.
.
.

Exertional!dyspnoea!
Central!cyanosis!
Clubbing!
Tracheal!deviated!to!affected!side!
Decreased!chest!expansion!on!affected!side!
Percussion!note!dull!on!affected!site!
Mid.late!fine!inspiratory!crepitations!
! Not!cleared!by!coughing!
! Decreased!when!leaning!forward!
Causes:!
! Upper!lobe:!TRASHPASS!
Tuberculosis.
Radiotherapy..
Aortic.stenosis.
Silicosis.(progressive.massive.fibrosis).
Histiocytosis.
Pneumoconiosis..
Allergic.bronchopulmonary.aspergillosis.
Sarcoidosis.
SLE.
! Lower!lobe:!SCAR!
Scleroderma..
Cryptogenic.fibrosing.alveolitis.
Asbestosis.
Rheumatoid.arthritis.(RA).

Pleural'Effusion'
.

.
.
.
.
.

Collection!of!fluid!in!pleural!space!
! Haemothorax!!blood!
! Chylothorax!!lymph!
! Empyema!!pus!!
Trachea!deviated!to!unaffected!side!in!large!effusion!
Stony!dull!percussion!note!on!affected!site!
Diminished! breath! sounds! on! affected! side! ! bronchial! breath!
sounds!above!the!area!of!dullness!!
Vocal!resonance!decreased!on!the!affected!side!
Causes!
! Exudate'(protein!>!30g/L)!
CA.lung.
28!

! ! !

Joyce!Kwan!

!
!

!
!
!

Pneumonia.
Tuberculosis..
Transudate'(protein!<30g/L)'
Nephrotic.syndrome.
Cardiac.failure.
Liver.failure.
Haemothorax''
Trauma.
Chylothorax'
Trauma.to.thoracic.duct.
Lymphoma.
Empyema'
Pneumonia.
Lung.abscess.
Bronchiectasis.
Tuberculosis..

&

29!

! ! !

Joyce!Kwan!

The&Gastrointestinal&Examination&
General'Inspection'

1. Introduction,'wash'hands'&'gain'consent''
2. Exposure' only' after' general' inspection:' whole' upper'
trunk'
3. Comment'on'general'condition'of'the'patient'
.
.

Conscious!&!alert!
Oxygen!supplement!

.
.
.

Clubbing!!cirrhosis,.crohns.disease!
Leukonychia!!hypoalbuminaemia!
Koilonychia'!iron.deficiency!

.
.
.
.
.
.

Flapping'tremor!.!hepatic!encephalopathy!!
Tattoos/needle'punctures!!risk!of!hepatitis!B/C!infections!
Palmar'erythema!!stigmata.of.chronic.liver.disease!
Dupytren'contracture!!alcoholism!
Bruises!!stigmata.of.chronic.liver.disease!!
AV'fistulas!!haemodialysis!

.
.

Pallor!!gastrointestinal.blededing!
Jaundice!!stigmata.of.chronic.liver.disease,.haemolytic.anaemia,.
biliary.obstruction!
Glossitis!!iron.deficiency!
Dry'mucosal'membrane!!dehydration.!
Telanglectasia'!chronic.liver.disease!
Enlargement'of'parotid'glands!!alcoholism,.mumps!

4. Nails'

5. Hands'

.
.
.
.
.
.
.
.

6. Face'

7. Neck'&'Chest'wall'

Enlargement'of'Virchows'node'!!metastasis!from!abdominal!
organs!!
Loss'of'axillary'hair!!stigmata.of.chronic.liver.disease!
Gynaecomastia!!stigmata.of.chronic.liver.disease!
Spider'naevi!!only!seen!in!SVC!drainage!area!(>6)!
! Stigmata.of.chronic.liver.disease.!

8. Legs'
.

Pitting' oedema! ! stigmata. of. chronic. liver. disease,.

hypoalbuminaemia!!
'
30!
! ! !
!
Joyce!Kwan!

!
Inspection'

1. Scars'
.
.
.
.
.
.
.
.

Midline!!Abdominal.aortic.aneurysm,.laparotomy!!
Left'paramedian!!colectomy!
Kochers!.!cholecystectomy!
McBurneys/Gridiron!!appendectomy!
Lanz'!
Groin'incision!!inguinal.hernia!!
Pfannenstiel! ! cystectomy,. prostatectomy,. CXsection,.
hysterectomy.!
Vertical'groin'incision'!femoral.artery.emoblectomy!!

2. Abdominal'distension'(5Fs)'

.
.
.
.
.

Fat!
Flatus.
Foetus.
Flatuelence.
Fluid!!ascites.
! Hypoalbuminaemia..

Distended!&!engorged!paraumbilical!veins!
! Radiating!from!navel!.!Portal.hypertension!
! Flow!of!blood!superiorly!!IVC.obstruction!
! Flow!of!blood!inferiorly!!SVC!obstruction!

.
.

3. Dilated'veins'(caput'medusa)'

4. Masses'
5. Stoma'

Cough!for!parastomal!hernia!
Feel!surrounding!area!

6. Expansile'pulsation'in'aortic'aneurysm''
7. Hernia'
.

Cough!for!inguinal!hernia!
Palpation'&'Percussion'

.
.
.
.
!

Kneel!down!or!sit!when!palpating!the!patient!allowing!hand!to!
be!at!the!same!level!of!the!abdomen!
Palpate!with!your!palm!&!flat!of!your!fingers!!
Warn! patient! about! discomfort! and! tell! them! to! inform! you!
about!pain!
Look!at!the!patients!face!while!palpating!
!
31!

! ! !

Joyce!Kwan!

1. Light'palpation'
.
.

Tenderness!and!rebound!tenderness!
! Rebound!tenderness!.!peritonitis!
Ask! patient! if! he! experiences! any! pain! in! the! abdomen! before!
you!proceed!!
! Start!as!far!as!possible!from!the!tender!spot!

2. Deep'palpation'

.
.

Inform!patient!about!palpating!deeper!for!masses!
If! you! can! feel! any! mass,! tense! abdominal! muscles! to! see!
whether!it!is!attached!

Instruct! patient! to! inspire! &! expire! deeply! and! start! from! RLQ!
(right!lobe)!&!umbilicus!(left!lobe)!!
Move!hand!upward!when!patient!expires!and!press!down!when!
patient!inspires!
! Liver! should! descend! upon! inspiration! and! can! be! felt! if!
enlarged!
Murphys' sign! ! acute! cholecystitis! causes! severe! pain! when!
patient! inspires! deeply! thus! at! the! height! of! inspiration,!
breathing!stops!with!a!mass!felt!
! Sign! not! found! in! chronic! cholecystitis! or! uncomplicated!
cases!of!gallstones!
Courvoisiers' law! ! in! presence! of! jaundice! a! palpable!
gallbladder! makes! gallstone! obstruction! of! the! common! bile!
duct!an!unlikely!cause!
! Converse! is! not! true,! since! gallbladder! is! not! palpable! in!
many! patients! who! do! prove! to! have! malignant! bile! duct!
obstruction!!
!
Percuss!&!define!liver!border!(upper!and!lower)!
! Resonant!!dull!area!
! Measure! liver! span! along! mid.clavicular! line! &! how! many!
cm!below!costal!margin!!
! Normal!liver!span!=!6!!12!cm,!not!below!costal!margin!

3. Liver'
.

4. Spleen'

.
.

Instruct! patient! to! inspire! &! expire! deeply! and! start! from! RLQ!
along!Gardners!line!!
If!spleen!is!not!palpable,!turn!patient!to!perform!spleen!hook!
! Can! be! performed! after! shifting! dullness,! for! comfort! &!
convenience!of!the!patient!!
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Joyce!Kwan!

!
Percuss!along!gardners!line!!
! Should!be!resonant!all!the!way!!

5. Kidney''
.

Ballot!kidney!with!one!hand!below!the!patient!at!costovertebral!
angle!&!another!hand!lightly!placed!at!transpyloric!plane!
! Slowly! and! firmly! flex! metacarpal.phalangeal! joints! of! the!
lower!hand!
! Tenderness!
Infection.over.kidneys.
! Enlarged!
Tumour.
Polycystic.disease.
Hydronephrosis..

Fluid!thrill!test!!rarely!performed,!only!if!absolutely!necessary!
! Ask! another! person! (examiner)! or! patient! (not! preferred)!
to!place!their!hand!at!the!midline!of!the!abdomen!
! Hands!on!either!side!of!the!abdomen!
! Flick!the!abdomen!on!one!side!and!palpate!whether!there!is!
fluid!transmitted!to!the!other!side!of!the!abdomen!
!
Shifting!dullness!test!
! Starting! from! midline,! fingers! vertically,! percuss! along! the!
abdomen!towards!the!side!further!away!until!dull!
! Shift! the! patient! towards! you! and! wait! for! a! few! seconds!
before!percussing!back!to!midline!
! Negative:!axillary!area!should!remain!dull!
! Positive:!axillary!area!becomes!resonant!and!reaches!dull!at!
midline!!

6. Ascites'

Auscultation'

1. Bowel'sounds'
.
.

Sluggish!!ileus!
Hyperactive!!intestinal.obstruction!

.
.
.

Umbilicus!!abdominal.aorta!
Para.umbilical!area!.!renal.bruit!!
Around!liver!!alcoholic.hepatitis,.primary.or.secondary.hepatitis!

Around!liver!!portal.venous.hypertension..

2. Bruits'

3. Venous'hum'
!

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Joyce!Kwan!

!
Completion'of'examination'

.
.

Per.rectal!examination!
Examination!of!the!external!genitalia!!
Following'gastrointestinal'investigations'

1.
2.
3.
4.

Liver'function'test'
Renal'function'test'
Faecal'occult'blood'
Abdominal'XOray'

Intestinal!obstruction!

.
.

Detection!of!different!pathologies!where!OGD!is!contraindicated!
Barium!studies!contraindicated!when!
! Suspected!perforation!
! Hypersensitivity!reaction!towards!barium!!

5. Barium'Radiology'

6. Oesophagoegastroduodenoscopy'(OGD)''
.
.
.

Polyp!
Carcinoma!
Ulceration!!

7. Colonoscopy'
8. Sigmoidoscopy'
9. Protoscopy''
.

Internal!haemorrhoids!
Summary'of'signs'of'common'illnesses'

Ascites'
.
.
.

Pathological!accumulation!of!fluid!in!the!peritoneal!cavity!!
Exudate'(protein!>!25g/L)!
! Liver.cirrhosis.
! Abdominal.malignancy.
Transudate'(protein!<!25g/L)!
! Congestive.heart.failure.
! Hypoalbuminaemia.
! Liver.failure.
! Nephrotic.syndrome..
.
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Cirrhosis'
.
.
.
.
.
.

White!nails!(leuconychia)!
Clubbing!
Liver!palms!
Spider!naevi!
Jaundice!!
Firm!liver!!

Portal'hypertension'
.
.
.

Splenomegaly!
Ascites!
Caput!medusa!

Hepatic'encephalopathy'
.
.
.
.

Liver!flap!
Drowsy!!
Constructional!apraxia!(cannot!draw!5!pointed!star)!
Musty!foetor!!

Dehydration'
.
.
.
.
.
.

Dry!skin!
Collapsed!veins!
Diminished!skin!turgor!!pinched!fold!of!skin!remains!raised!
Dry!tongue!
Sunken!eyes!
Blood!pressure!low!with!postural!drop!(postural!hypotension)!

Intestinal'obstruction'
.
.
.
.
.
.
.

Abdominal!swelling!
Abdominal!pain!
Visible!peristalsis!
Vomiting!thus!dehydrated!
Constipation!!
Resonant!on!percussion!
Loud!tinkling!bowel!sound!!

Pyloric'stenosis'
.
.
!

Upper!abdominal!swelling!
May!have!!
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Joyce!Kwan!

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.

!
Succession!splash!on!shaking!abdomen!
Otherwise!like!intestinal!obstruction!

Appendicitis'
.
.
.

Slight!fever!
Deep!tenderness!in!right!iliac!fossa!or!per!rectum!
Otherwise!little!to!find!unless!has!spread!to!peritonitis!

Peritonitis'
.
.

Lies!still!
Abdomen!!
! No!movement!on!respiration!
! Guarding!on!palpation!
! Board!like!rigidity!on!palpation!
! Tender!&!rebound!tenderness!on!palpation!
! Absent!bowel!sounds!

Cholecystitis'
.

Murphys' sign! .! tender! right! hypochondrium,! particularly! on!

breathing!in!!

Jaundice'&'palpable'gall'bladder'
.
.

Courvoisiers' Law' ' obstruction! is! not! due! to! gall! stones! but!
from!anoter!obstruction!such!as!neoplasm!pancreas!
Gall! stones! would! have! usually! caused! a! fibrosed! gall! bladder!
which! cannot! dilate! from! back! pressure! from! gallstones! in!
common!bile!duct!

Splenomegaly''
.
.
.
.
.

Infective'
! Septicaemia.
! Subacute.bacterial.endocarditis.
Portal'hypertension'
! Cirrhosis.
Lymphoma.
Leukaemia!&!other'haematological'diseases!
Autogimmune'
! Systemic.lupus.erythmatosus.
! Feltys.syndrome!
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Joyce!Kwan!

The&Neurological&Examination&
General'Inspection'

1. Introduction,'wash'hands'&'gain'consent''
2. Exposure' only' after' general' inspection:' whole' upper'
trunk'
!
.
.
.

3. Comment'on'general'condition'of'the'patient'

Speech!and!mental!state!
Fall!prevention!&!orientations!
Movement!disorders!
! Akithesia! ! motor! restlessness;! constant! semi.purposeful!
movements!of!the!arms!&!legs!
! Asterixis' ! sudden! loss! of! muscle! tone! during! sustained!
contraction!of!an!outstretched!limb!
! Athetosis! ! writhing,! slow! sinuous! movements,! especially!
of!the!hand!&!wrists!
! Chorea!!jerky!small!rapid!movements,!often!disguised!by!
the! patient! with! a! purposeful! final! movement:! e.g.! jerky!
upward! arm! movement! is! transformed! into! a! voluntary!
movement!to!scratch!the!head!
! Dyskinesia! ! purposeless! &! continuous! movement,! often!
of!the!face!&!mouth;!often!a!result!of!treatment!with!major!
tranquillisers!for!psychotic!illness!
! Dystonia! ! sustained! contractions! of! groups! of! agonist! &!
antagonist! muscles,! usually! in! flexion! or! extremes! of!
extension;!it!results!in!bizarre!postures!!
! Hemiballismus!!an!exaggerated!form!of!chorea!involving!
one! side! of! the! body:! there! are! wild! flinging! movements!
which!can!injure!the!patient!(or!bystanders)!
! Myoclonic'jerk!!a!brief!muscle!contraction!which!causes!a!
sudden!purposeless!jerking!of!a!limb!
! Myokymia' ! a! repeated! contraction! of! a! small! muscle!
group;!often!involves!the!orbicularis!oculi!muscles!
! Tic'!a!repeated!irresistible!movement!which!is!purposeful!
or!semi.purposeful!
! Tremor'!a!rhythmical!alternating!movement!!
!
!
!
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!
Cranial'nerves,'II''XII'

CN'II''Optic'Nerve'

1. Visual'acuity'
.
.
.

.
.

.
.

Each!eye!tested!with!hand.held/Snellens!chart!(with!corrective!
lens!if!necessary),!while!the!other!is!covered!by!a!small!card!
! 6m!from!Snellens!chart!
Normal!visual!acuity:!6th!line!(6/6)!
! If! poor! visual! acuity! improves! when! using! pin.hole,!
refractive!error!is!the!cause!!
If!patient!unable!to!read!1st!line!should!be!asked!to!
! 1st!!count!fingers,!if!impossible!then!
! 2nd!!perception!of!hand!movement,!if!impossible!then!
! 3rd!!light!perception!
Blindness!
Bilateral'blindness'of'rapid'onset!!!
! Bilateral.occipital.lobe.infarction/trauma.
! Bilateral.optic.nerve.damage.
! MethylXalcohol.poisoning.
! Hysteria.
Sudden'blindness'in'one'eye!!!
! Retinal.artery/vein.occlusion.
! Temporal.arteritis.
! NonXarteritic.ischaemic.optic.neuropathy.
! Optic.neuritis/migraine.
Bilateral'blindness'of'gradual'onset!!!
! Cataract.
! Acute.glaucoma.
! Macular.degeneration.
! Diabetic.retinopathy.
! Bilateral.optic.nerve/chiasmal.compression.
! Bilateral.optic.nerve.damage.

2. Visual'fields'

Corrective! lens! should! be! removed,! with! examiner! and! patient!

at!same!eye.level!
! Patient!should!be!looking!at!examiner!nose!
Each! eye! tested! with! examiner! wiggling! fingers! with! an!
outstretched!hand,!while!the!other!is!covered!by!a!small!card!
! Patient! identifies! wiggling! fingers! as! the! examiner! brings!
fingers!in!
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.

!
!
Blind!spot!can!be!identified!by!asking!about!disappearing!of!the!
pin!around!the!centre!of!the!field!of!vision!of!each!eye!
! Red!pin!moved!slowly!across!field!of!vision!
Visual!field!defects!
! Tunnel'vision!!concentric!diminution!
Glaucoma.
Papilloedema.
Syphilis.
! Enlarged'blind'spot!!optic!nerve!head!enlargement!
! Central'scotomata!!optic!nerve!head!to!chiasmal!lesion!
Demyelination.
Toxic.
Vascular.
Nutritional.
! Unilateral'field'loss!!optic!nerve!lesion!
Vascular.tumour.
! Bitemporal'hemianopia!!optic!chiasm!lesion!
Pituitary.tumour.
Sella.meningioma.
! Homonymous'hemianopia!!optic!tract!to!occipital!cortex!
Vascular.
Tumour.
Incomplete.lesion..macular.sparing.
! Upper' quadrant' homonymous' hemianopia! ! temporal!
lobe!lesion!
Vascular.
! Lower'quadrant'homonymous'hemianopia'
Parietal.lobe.lesion..

3. Fundoscopy'

.
.
.
.
.
.
.

Use! corresponding! eye! to! examine! the! patients! eyes! &! set!
corrective!index!of!examiner!and!patient!
Ask!patient!to!stare!straight!ahead,!at!a!set!point!
Presence!of!red!reflex!
! Visualization!of!the!corneal!with!the!ophthalmoscope!
Cornea!
Iris!
Fundus!
Optic!disc!!
!
!
!
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!
CN'III''Oculomotor'Nerve,'CN'IV''Trochlear'Nerve'&'CN'VI''Abducens'
Nerve' '

1. Inspection'
.

Pupils!
! Size!
! Shape!
! Equality!
! Regularity!
Ptosis!of!one!or!both!eyelids!

2. Light'Reflex'
.

Shine! a! pocket! torch! from! the! side! into! one! of! the! pupils! and!
assess!reaction!to!light!
! Repeat!on!other!side!
! Direct' response! ! pupil! in! which! torch! is! shone! briskly!
constricts!
! Consensual' response!!other!pupil!constricts!in!the!same!
way!to!light!
Swinging!torch!test!
! Move!the!torch!from!one!pupil!to!another!
Afferent' pupillary' defect' (Marcus' Gunn'
pupillary' sign)! .! Affected! pupil! will! dilate!
paradoxically! after! a! short! time! when! the! torch! is!
moved!from!normal!eye!!abnormal!eye!
Optic.atrophy.
Severely.reduced.visual.acuity.

3. Accommodation''

Ask! patient! to! look! into! distance! ! focus! eyes! on! examiners!
finger!30!cm!in!front!of!nose!
! Look!out!for!normal!pupillary!constriction!
! Depends! on! pathway! from! visual! association! cortex!
descending!to!the!3rd!nerve!nucleus!
Accomodation!lesions!
! Argyll' Robertson' pupil' of' syphilis! ! absent! light! reflex!
with!intact!accommodation!reflex!
Midbrain.lesion.
! Adies' pupil!!tonically!dilated!pupil!caused!by!damage!to!
postganglionic!fibres!of!parasympathetic!innervation!
! Parinauds' syndrome' (dorsal' midbrain' syndrome)! !
paralysis!of!upgaze,!pseudo.Argyll!Robertson!pupils,!eyelid!
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Joyce!Kwan!

!
retraction,! convergence.retraction! nystagmus! &! setting.
sun!sign!
Upper.brainstem.lesion.

4. Eye'movements'
.

Inspect!for!strabismus/squint!(incorrect!eye!alignment)!
! Inconcomitant' squint! ! angle! of! alignment! changes!
depending!on!the!direction!of!gaze!
! Concomitant' squint! ! angle! of! alignment! identical! on!
different!direction!of!gazes!
Idiopathic.
Intracranial.mass.
Tell! patient! to! focus! on! pen! and! slowly! guide! patients! eyes! by!
drawing!a!H!in!mid.air!
! Ask!patient!to!notify!whether!there!is!diplopia!!
! Pay!attention!for!nystagmus!
Third' nerve' lesion! ! complete! ptosis,! divert! strabismus,!
dilated! pupil! which! is! unreactive! to! direct! light! &! unreactive!
accommodation!!
! Exclude! trochlear! nerve! lesion! when! 3rd! nerve! lesion! is!
present!by!tiling!head!to!same!side!of!lesion!
If!4th!nerve!intact!!affected!eye!will!intort!!
! Causes!
Compressive. lesion. (aneurysm. on. posterior.
communicating.artery,.tumour).
Nasopharyngeal.carcinoma.
Basal.meningitis.
Orbital. lesion. (TolosaXHunt. syndrome/superior.
orbital.fissure.syndrome).
Ischaemia/infarction. (arteritis,. diabetes. mellitus. &.
migraine).
Fourth' nerve' lesion! ! paralysis! of! superior! with! weakness! of!
downward!&!outward!movement!.
! Causes.
Idiopathic.
Related.to.trauma.(lesions.of.the.cerebral.peduncle).
Sixth' nerve' lesion! ! failure! of! lateral! movement,! convergent!
strabismus!&!diplopia!.
! Signs!are!maximal!on!looking!to!the!affected!side!.
! Causes.
Bilateral!lesions!.
Trauma..
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Joyce!Kwan!

!
Wernickes.encephalopathy..
Mononeuritis.multiplex.
Raised.intracranial.pressure.
Unilateral!lesions.
Idiopathic.
Trauma..
Raised.intracranial.pressure.
Diabetes.mellitus..
Abnormalities!in!conjugate!gaze!
! Paralysis'of'horizontal'conjugate'gaze'
Ipsilateral!paralysis!!brainstem.lesion!
Contralateral!paralysis!!frontal.lobe.lesion!

CN'V''Trigeminal'Nerve'

1. Corneal'reflex'
.
.
.
.
.

Lightly!touch!cornea!with!a!cotton!wool!brought!to!the!eye!from!
the!side!
! Avoid!eyelashes!
Reflex!blinking!of!both!eyes!is!a!normal!response!
Ask!patient!whether!cottonwool!is!felt!
Absence'of'corneal'sensation!!corneal.ulceration!
Blinking' only' occurs' with' contralateral' eye! ! ipsilateral.
seventh.nerve.palsy!

2. Facial'sensation'

3!divisions!of!the!nerves!tested!for!pinprick!sensation!and!touch!
sensation!
! Area! of! dull! sensation! should! be! mapped! by! testing!
pinprick!sensation!progressively:!dull!!sharp!area!

Temporal!&!masseter!muscles!
! Patient!clench!teeth!and!palpate!for!contraction!
Pterygoid!muscles!
! Patient! open! mouth! while! examiner! attempts! to! force! it!
shut!
! Unilateral! lesion! of! motor! division! causes! jaw! to! deviate!
towards!affected!side!!

3. Motor''

4. Jaw'jerk'
.

Patient!lets!mouth!fall!open!slightly!&!examiners!finger!placed!
on!tip!of!jaw!!tapped!with!tendon!hammer!
! Normally!slight!closure!of!the!mouth!or!no!reaction!at!all!
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!
! Exaggerated!jerk!!upper!motor!neurone!lesion!above!pons!
Pseudobulbar!palsy!!
Fifth'nerve'palsy''
! Central! (pons,! medulla! &! upper! cervical! cord)! ! vascular.
lesion,.tumour,.synringobulbia!
! Peripheral! (middle! fossa)! .! aneurysm,. tumour,. chronic.
meningitis!
! Trigeminal'ganglion!(petrous!temporal!bone)!!trigeminal.
neuroma,.meningioma,.fracture.of.the.middle.fossa.
! Dissociated'sensory'loss'(loss'of'pain'&'preservation'of'
touch)!!brainstem!or!upper!cord!lesion!!
Syringobulbia.
Foramen.magnum.tumour.
Infarction. in. the. territory. of. the. posterior. inferior.
cerebellar.artery.
! Dissociated' sensory' loss' (loss' of' touch' &' preservation'
of'pain)!!abnormality!of!the!pontine!nuclei!
Vascular.lesion..
Tumour.

CN'VII''Facial'Nerve'

1. Inspection'
.

Facial!asymmetry!!
! Unilateral! droop! of! the! corner! of! the! mouth,! smoothing! of!
the!wrinkled!forehead!&!nasolabial!fold!
! Bilateral!facial!nerve!palsies!symmetry!can!be!maintained!!

Ask!patient!to!look!up!
! Inspect!forehead!wrinkles!
! Preserved! in! upper! motor! neurone! lesion! due! to! bilateral!
cortical!representation!
Ask!patient!to!squeeze!eyes!shut!and!resist!opening!force!
! Look! for! Bells! phenomenon! ! upward! movement! of! the!
eyeball!and!incomplete!closure!of!the!eyelid!
Ask!patient!to!puff!out!cheeks!and!resist!poking!
! Look!for!asymmetry!!
Ask!patient!to!grin!
! Compare!nasolabial!grooves!
Seventh'nerve'palsy'
! Upper!motor!neurone!lesions!(supranuclear)!
Vascular.lesions.
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Joyce!Kwan!

2. Muscle'power'

.
.
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.

!
Tumours.
! Lower!motor!neurone!lesions!
Pontine' causes! .! vascular. lesions,. tumours,.
syringobulbia,.multiple.sclerosis!
Posterior' fossa' lesions! .! acoustic. neuroma,.
meningioma,.chronic.meningitis.!
Petrous' temporal' bone! ! Bells. palsy,. fracture,.
RamsayXHunt.syndrome,.otitis.media!
Parotid'gland!!parotiditis,.tumour,.sarcoidosis!
! Bilateral'facial'weakness'
GuillainXBarr.syndrome..
Sarcoidosis.
Bilateral.parotid.disease.
Lyme.disease.
Mononeuritis.multiplex.

CN'VIII''Vestibulocochlear'Nerve'
.
.
.
.

1. Inspection'

If!patient!is!wearing!hearin!aid!!remove!it!
Examine!pinna!&!look!for!scars!behind!the!ears!
Pull!on!pinna!gently!
! Tender!suggest!otitis.externa!
Feel!for!pre.auricular!&!post.auricular!nodes!
! Presence/tenderness!suggests!otitis.externa!

2. Inspection'of'external'auditory'meatus'

.
.
.

Pull!pinna!upwards!and!backwards!then!slowly!insert!otoscope!
Normal!tympanic!membrane!is!pearly!grey!&!concave!
Look! for! wax! or! obstructions! &! inspect! eardrum! for!
inflammation!or!perforation!

Covering! or! rubbing! tragus! of! opposite! auditory! meatus! with!

finger! (outstretched! arm)! while! asking! patient! to! repeat!
numbers!!
! ~60!decibels!
Repeated!with!examiner!whispering!
! ~30!decibels!

3. Hearing'test'

4. Rinns'test'

256!Hz!vibrating!tuning!fork!placed!on!mastoid!process!behind!
ear!until!sound!is!no!longer!heard!!placed!in!line!with!external!
meatus!
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!
! Ask!patient!whether!sound!can!be!heard!again!
Rinngpositive!!note!is!audible!at!external!meatus!
! Normal.
! Nerve.deafness.
Rinngnegative!!note!is!not!audible!at!external!meatus!!
! Conductive.deafness.

5. Webers'test'

.
.
.

Vibrating!256!Hz!tuning!fork!placed!on!centre!of!forehead!
Normally,!sound!is!heard!in!the!centre!of!the!forehead!
! Nerve!deafness!!sound!better!heard!in!the!normal!ear!!
! Conduction!deafness!!sound!louder!in!the!abnormal!ear!
Causes'of'deafness'
! Unilateral'nerve'deafness'
Tumour.(acoustic.neuroma).
Trauma.(fracture.of.petrous.temporal.bone).
Vascular.disease.of.internal.auditory.artery.
! Bilateral'nerve'deafness'
Environmental.exposure.to.noise.
Degeneration.(presbyacusis).
Toxicity.(aspirin,.streptomycin,.alcohol).
Infection.(congenital.rubella.syndrome).
Congenital.syphilis.
Mnires.disease.
! Conduction'deafness'
Wax.
Otitis.media.
Otoscleorsis.
Pagets.disease.of.bone.

6. Hallpike'maneuver'(usually'not'performed)'

.
.
.
.

Patient!sits!up!and!warn!patient!what!is!about!to!occur!
Examiner! grasps! patients! head! and! lies! them! back! quickly! so!
that!head!lies!30!below!horizontal!
! At!the!same!time,!head!rotated!30!towards!examiner!
Ask!patient!to!keep!eyes!open!and!note!for!vertigo!&!nystagmus!
towards!the!affected!ear!!
Causes!
! Benign' paroxysmal' positioning' vertigo' (BPPV)! !
disorder!in!the!utricle!
Infection.
Trauma.
Vascular.disease..
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! Presence'of'concretions'in'semicircular'canals''
Causes'of'vestibular'abnormalities'
! Labyrinthine'causes'
Acute.labyrinthitis'
Motion.sickness'
Streptomycin.toxicity'
Mnires.disease.
! Vestibular'causes'
Vestibular.neuronitis'
! Brainstem'causes'
Vascular.lesions'
Tumours.of.the.cerebellum/4th.ventricle'
Demyelination/vasospastic.conditions'

CN'IX''Glossopharyngeal'Nerve'&'CN'X''Vagus'Nerve'

1. Inspection'
.
.

Inspect!palate!with!a!torch!
! Note!displacement!of!uvula!!
Ask!patient!to!say!aah!and!note!rise!of!velum!
! If!uvula!drawn!to!one!side!!unilateral!10th!nerve!palsy!

2. Gag'reflex'
.
.
.
.

Touch! the! back! of! the! pharynx! on! each! side! with! a! tongue!
depressor!
! Normally,!reflex!contraction!of!soft!palate!
Absent!suggests!10th!nerve!palsy!
Reduced!gag!reflex!in!old!age!
Causes'of'ninth'&'tenth'nerve'palsy'
! Central'causes''
Vascular. lesions. (lateral. medullary. infarction,. due.
to. vertebral. or. posterior. inferior. cerebellar. artery.
disease).
Tumours.
Syringobulbia.
Motor.neurone.disease.
! Peripheral'(posterior'fossa)'lesions'
Aneurysms.at.base.of.the.skll.
Tumours.
Chronic.meningitis.
GuillainXBarr.syndrome.
.
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CN'XI''Accessory'Nerve'
.
.
.

Ask! patient! to! shrug! shoulders! against! examiners! hand! &! feel!
for!bulk!of!trapezius!muscles!
Ask! patient! to! turn! head! to! side! against! resistance! to! test! for!
SCM!strength!(weak!in!torticollis)!
Causes'of'eleventh'nerve'palsy'
! Unilateral'causes'
Trauma.(involving.neck.or.base.of.skull).
Syringomyelia.
Tumours.near.jugular.foramen.
! Bilateral'causes'
Motor.neurone.disease.
Poliomyelitis.
GuillainXBarr.syndrome..
Muscular.dystrophy.

CN'XII''Hypoglossal'Nerve'

1. Inspection'
.

Inspect!tongue!at!rest!
! Wasting!
! Fasciculations!

.!Ask!patient!to!protrude!tongue!
! May! deviate! towards! affected! side! if! there! is! unilateral!
lower!motor!!
Causes'of'twelfth'nerve'palsy'
! Bilateral'upper'neurone'lesions'
Vascular.lesions.
Motor.neurone.disease.
Tumours..
! Unilateral'lower'motor'neurone'lesions'
Central'cause'
Vascular.lesions.(thrombosis.of.the.vertebral.
artery).
Motor.neurone.disease..
Syringobulbia.
Peripheral'cause'
In!posterior!fossa!!
Aneurysms..
Tumours.

2. Motor'

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Joyce!Kwan!

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Chronic.meningitis.
Trauma..
In!upper!neck!
Tumours.
Lymphadenopathy.
ArnoldXChiari.
malformation!
(congenital! malformation! of! the! base!
of! the! skull! with! herniation! of! a!
tongue! of! cerebellum! &! medulla! into!
the!spinal!canal)!!
! Bilateral'lower'motor'neurone'lesions'
Motor.neurone.disease.
GuillainXBarr.syndrome..
Poliomyelitis..
ArnoldXChiari.malformation.

Multiple'cranial'nerve'lesions'
.
.
.
.
.
.

Lesion.in.the.cavernous.sinus!!unilateral!III,!IV,!V!&!VI!
Cerebellopontine.angle.lesion.(tumour)!!unilateral!V,!VII!&!VIII!
Jugular.foramen.lesion!!unilateral!IX,!X,!XI!
Bulbar. palsy. if. lower. motor. neurone. changes. are. present! !
combined!bilateral!X,!XII!&!XII!
Pseudobulbar. palsy. if. there. are. upper. motor. neurone. signs! !
combined!bilateral!X,!XI!&!XII!
Myasthenia. gravis! ! weakness! of! eye! &! facial! muscles! that!
worsens!with!repeated!contraction!
Upper'limbs'

General'Inspection'

1. Posture'
2. Muscle'bulk'
.

Muscle!weakness!!denervated!muscle,!primary!muscle!disease!
or!disuse!atrophy!

3. Abnormal'movements''
4. Skin'

.
.
!

Scars!
Neurofibromatosis!
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Utaneous!angiomata!
! Herpes!zoster!

5. Fasciculations'
6. Drift'
.

Ask! patient! to! hold! out! both! hands,! palms! upward! with! arms!
extended!and!eyes!closed,!looking!out!for!drifting!
! Upper'motor'neurone'(pyramidal)'weakness'
Drift!of!affected!limb(s)!due!to!muscle!weakness!!
downward!direction!
Drifting! typically! starts! distally! with! fingers! &!
spreads!proximally!
May!be!slow!pronation!of!wrist!&!flexion!of!fingers!
+!elbows!
!
! Cerebellar'disease'
Drift!usually!upwards!
Includes!slow!pronation!of!wrist!&!elbow!!
! Loss'of'proprioception'
Drift! is! a! searching! movement! &! usually! only!
affects!fingers!
Due! to! loss! of! joint! position! sense! &! can! be! any!
direction!

Palpation'

1. Tone'
.
.

.
.

Tested!at!both!wrists!&!elbows!
Rotation!of!wrists!!
! Cogwheel'rigidity!!Parkinsons!disease!!
Best! assessed! by! having! patient! move! the! other!
arm!up!&!down!!
Supination,!pronation!&!flexion!of!elbow!
! Claspgknife'rigidity'!stretch!reflex!with!rapid!decrease!in!
release!when!attempting!to!flex!a!joint!
Upper!motor!neurone!lesion!
Hypertonia!!upper!motor!neurone!lesion!
Hypotonia!!lower!motor!neurone!lesion!

2. Power'
.
.
!

Muscle! strength! assessed! by! gauging! examiners! ability! to!

overcome!patients!full!voluntary!muscle!resistance!
Shoulder!
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!
! Abduction' (C5,' C6)! ! shoulders! abducted! against!
resistance!with!elbows!flexed!
! Adduction' (C6,' C7)! ! shoulders! adducted! against!
resistance!with!elbows!flexed!
Elbow!
! Flexion' (C5,' C6)! ! elbows! flexed! against! resistance! with!
joint!stabilised!&!arms!next!to!body!
! Extension' (C7,' C8)! .! elbows! extended! against! resistance!
with!joint!stabilised!&!arms!next!to!body!
Wrist!!
! Flexion' (C6,' C7)! ! wrist! held! in! a! fist,! flexed! against!
resistance!with!joint!stabilised!!
! Extension' (C7,' C8)!!wrist!held!in!a!fist,!extended!against!
resistance!with!joint!stabilised!
Fingers!
! Extension' (C7,' C8)! ! fingers! extended! straight! against!
resistance!
! Abduction'(C8,'T1)!!fingers!abducted!against!resistance!
! Grip' strength' (C7,' C8)! ! all! fingers! gripping! around!
examiners!finger!as!hard!as!possible!!

.
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.

.
!

Medical+Research+Council+(MRC)+grading+
0!!complete!paralysis!!
1!!flicker!of!contraction!possible!
2!!movement!possible!when!gravity!is!excluded!
3!!movement!possible!against!gravity!however!not!if!any!
further!resistance!is!added!
4!!moderate!movement!against!resistance!
5!!full!power!

3. Reflexes''
Sudden!stretching!of!a!muscle!usually!evokes!brisk!contraction!
of!that!muscle/muscle!group!
Biceps'jerk'(C6)'
! One!forefinger!on!biceps!tendon!&!tap!with!tendon!hammer!
Triceps'jerk'(C7)'
! Tending!hammer!tap!over!triceps!tendon!
Brachioradialis'jerk'(C8)'
! With! arm! semi.pronated,! two! forefingers! placed! at! distal!
end! of! radius,! just! above! the! wrist! &! tap! with! tendon!
hammer!
Hyperreflexia!!upper!motor!neurone!lesion!
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Joyce!Kwan!

!
!
Hyporeflexia'
! Myopathy.
! Neuropathy.
! Anterior.spinal.cord.root.lesion.(spondylosis).
! Anterior.horn.cell.lesion.(poliomyelitis).
! Sensory.arc.lesion.(sensory.root/sensory.nerve).

4. Coordination'

.
.

Test!for!cerebellar!connections!
Finger.nose!test!
! Ask! patient! to! touch! their! nose! with! the! index! finger! then!
touch! examiners! outstretched! forefinger! at! nearly! full!
extension!of!shoulder!&!elbow!!repeat!
! Test!should!be!done!both!briskly!&!slowly!
! Look!for!
Intention'tremor'
Pastgpointing''
Rapidly!alternating!movements!
! Ask!patient!to!pronate!&!supinate!their!hand!on!dorsum!of!
other!hand!as!rapidly!as!possible!
! Dysdiadochokinesia!!slow!&!clumsy!movement!!
Rebound!!
! Ask!patient!to!lift!arms!up!with!closed!eyes!
! Examiner!presses!arm!down!!
Overshoots!in!cerebellar!disease!

5. Sensory'testing'

.
.

.
!

Dermatomes!
! C5!!lateral!arm!
! C6!!lateral!forearm!+!thumb!
! C7!!middle!finger!
! C8!!last!finger!
! T1!!medial!arm!
Spinothalamic!tract!
! Pinprick!testing!!using!toothpick/orange!stick!!
! Temperature!testing!!using!a!tuning!fork!
Posterior!column!
! Vibration!testing!!using!128!Hz!tuning!form!placed!at!DIP!
joints!!wrist!!elbow!!shoulder!!
! Proprioception!testing!!flex!DIP!upwards!or!downwards!!
! Light.touch!testing!!using!cotton!wool!!
Sensory'abnormalities'
! Dermatome!!spinal!cord!or!nerve!root!lesion!
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! Single'peripheral'neuropathy!!e.g.!glove!distribution!
! Hemisensory' loss! ! spinal! cord! or! upper! brainstem! or!
thalamic!lesion!!
Peripheral!nerves!
! Radial!nerve:!C5!!C8!
! Median!nerve:!C6!!T1!
! Ulnar!nerve:!C8!!T1!
Lower'limbs'

General'Inspection'
.
.
.
.
.
.
.

1. Gait'

Spastic' gait! ! stiff,! foot.dragging! walk! caused! by! long! muscle!

contraction!on!one!side!
Antalgic' gait! ! short! stance! phase! of! affected! limb,! indicating!
pain!
Ataxic/broadgbased' gait! ! unsteady,! staggering! gait! that! is!
broad,!with!heel!striking!hard!as!it!touches!the!ground!
Highgstepping'gait!!unsteady,!with!high!stepping!
Shuffling' gait!!small!shuffling!steps!with!general!hypokinesia!
and!lack!of!arm!swing!
Cerebellar'testing!!heel.toe!walking!
Rombergs'test'

2. Muscle'bulk'
3. Scar'
4. Fasciculations'
Palpation'
.
.
.

1. Tone'

Tell!patient!to!relax!
Roll!leg!on!bed!checking!if!foot!is!out!of!phase!
! Hypotonia!!oscillations!will!be!wider!and!more!prolonged!
Place! one! hand! under! chosen! knee! then! abruptly! pull! knee!
upwards,!causing!flexion!
! Hypertonia!!resistance!while!flexion!!

2. Power'

Hip!
! Flexion'(L2,'L3)!!lift!straight!leg!against!resistance!

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!
! Extension' (L5,' S1,' S2)!!lift!straight!leg!then!put!leg!back!
down!against!resistance!
Knee!
! Flexion'(L5,'S1)!!flex!knee!against!resistance!
! Extension' (L3,' L4)! ! flex! knee! and! extend! against!
resistance!until!fully!extended!(to!test!for!ROM)!
Ankle!
! Plantarflexion'(S1,'S2)!!step!down!against!resistance!!
! Dorsiflexion'(L4,'L5)!!extend!foot!against!resistance!
Toe!!!
! Plantarflexion!!extend!hallux!against!resistance!!

3. Reflexes''

Knee'jerk'(L4)'
! Comfortably! rest! semi.flexed! knee! on! one! arm! and! lightly!
tap!infrapatellar!tendon!with!a!tendon!hammer!
Ankle'jerk'(S1)'
! Flex! knee! and! foot! held! in! dorsiflexion! by! examiner! &!
Achilles!tendon!lightly!tapped!by!tendon!hammer!!
Ankle'clonus''
! Relaxing!ankle,!then!suddenly!dorsiflexing!ankle!
! Positive!if!ankle!violently!flexes!and!extends!

4. Coordination'
.

Heel.shin!test!
! Ask! patient! to! run! the! hell! of! one! foot! up! and! down! the!
opposite!shin!at!a!moderate!pace!
Note!for!
Oscillations!from!side!to!side!
Overshooting!
Foot.tapping!test!
! Rapidly!alternating!movements!tested!by!getting!patient!to!
tap!sole!of!foot!quickly!on!examiners!hand!

5. Sensory'testing'
.

.
!

Dermatomes!
! L2!!anterior!thigh!
! L3!!lateral!knee!
! L4!!medial!leg!
! L5!!lateral!leg!
! S1!!heel!&!sole!
! S2!!posterior!thigh!
Spinothalamic!tract!
! Pinprick!testing!!using!toothpick/orange!stick!!
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Joyce!Kwan!

!
! Temperature!testing!!using!a!tuning!fork!
Posterior!column!
! Vibration!testing!!using!128!Hz!tuning!form!placed!at!DIP!
joints!!medial!malleolus!!knee!!hip!!
! Proprioception!testing!!flex!DIP!upwards!or!downwards!!
! Light.touch!testing!!using!cotton!wool!!
Sensory'abnormalities'
! Dermatome!!spinal!cord!or!nerve!root!lesion!
! Single'peripheral'neuropathy!!e.g.!glove!distribution!
! Hemisensory' loss! ! spinal! cord! or! upper! brainstem! or!
thalamic!lesion!!
Following'neurological'investigations'

.
.
.
.

1. Lumbar'puncture'

Yellow'coloration'(xanthochromia)!
! Pathological! due! to! old. haemorrhage,. jaundice. or. excess. of.
protein!!
Turbidity'
! Infection.
! Subarachnoid.haemorrhage.
Bloodgstaining'
! Needle.injury.to.a.vessel.
! Subarachnoid.haemorrhage.
Cytology!!
! Gram'&'ZiehlgNeelsen'stain!.infection!
! Polymorphonuclear'CSF'
Bacterial.meningitis.
Viral.meningitis.
Syphilis.
! Malignant'cells!!lymphoma.!
Biochemistry!
! High'total'protein!!TB!or!CSF.obstruction!
! Abnormal'oligoclonal'IgG!!multiple.sclerosis!

2. Electroencephalography'(EEG)'

.
.
.

Epilepsy!
Encephalitis!
Dementia!!

3. Electromyogram'(EMG)'
.
!

Quantitative!analysis!in!the!diagnosis!of!primary!diseases!of!the!
muscle!
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Joyce!Kwan!

!
! Myopathies!
! Dystrophies!
! Myasthenia!gravis!

4. Nerve'conduction'studies'(NCS)'
Summary'of'signs'of'common'illnesses'
'

Upper'
motor' Lower'
motor'
neurone'lesion'
neurone'lesion'

Weakness'
Deep'
tendon'
reflexes'
Babinskis'reflex'
Atrophy'

Spastic!paralysis!
Hyperreflexia!

Fasciculations'
fibrillations'

Present!
Absent/due!
disuse!
&' Absent!

Flaccid!paralysis!
Hyporeflexia!!
Absent!
to! May!be!marked!
May!be!present!!

Upper'motor'neurone'lesions'
.
.
.
.

Upper!limb!drift!
Facial!weakness!
Hemiparesis!
Wrist!extensor!weakness!

Lower'motor'neurone'lesions'
.
.
.
.

Interrupt!spinal!reflex!arc!
Muscle!wasting!!
Reduced/absent!reflexes!
Sometimes!fasciculations!!

Motor'neurone'disease'
.

Pathological!changes!in!
! Anterior!horn!cells!
! Motor!nuclei!of!the!medulla!
! Descending!tracts!
Fasciculations!!

Peripheral'neuropathy'
.
.
!

Distal!parts!of!nerves!usually!involved!first!!
Symmetrical!glove!&!stocking!loss!to!all!modalities!!
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GuillainRBarr'syndrome'(acute'inflammatory'polyradiculoneuropathy)'
.
.
.

Flaccid!proximal!&!distal!muscle!paralysis!
! Ascends!from!lower!to!upper!limbs!
Sensory!loss!is!minimal!or!bascent!
Cranial!nerves!can!be!affected!

Multiple'sclerosis'
.
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.
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.
.

Spastic!paraparesis!
Posterior!column!sensory!loss!
Cerebellar!signs!
Loss!of!visual!acuity!
Optic!atrophy!
Papillitis!
Scotomata!!
Internuclear! ophthalmoplegia! ! weakness! of! adduction! in! one!
eye!as!a!result!of!damage!of!ipsilateral!MLF!
Pseudobulbar!palsy!
Charcots'triad'
! Nystagmus!
! Intention!tremor!
! Scanning!speech!
Lhermittes' sign!!electric.shock.like!sensation!in!the!libms!or!
trunk!following!neck!flexion!!

Spinal'cord'compression''
.
.

Lower!motor!neurone!signs!at!level!of!lesion!
Upper!motor!neurone!signs!below!level!

Spinal'cord'syndromes''
Brown3Squard)syndrome)
.
.
.
.
.

Upper!motor!neurone!signs!below!hemisection!on!same!side!of!
lesion!
Lower!motor!neurone!signs!at!level!of!hemisection!on!same!side!
Pain!&!temperature!loss!on!opposite!side!of!lesion!
Vibration!&!proprioception!lloss!on!same!side!
Detection!of!light!touch!normal!
!
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Subacute)combined)degeneration)of)cord)(vitamin)B12)deficiency)))
.
.
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.
.

Posterior!column!loss!symmetrically!causing!ataxic!gait!
Upper!motor!neurone!signs!in!lower!limbs!symmetrically!
Absent!ankle!reflexes,!knee!may!be!absent!or!exaggerated!
Peripheral!sensory!neuropathy!
Optic!atrophy!
Dementia!!

Syringomyelia'
.
.
.
!

Loss!of!pain!&!temperature!over!neck,!shoulders!&!arms!(cape!
distribution)!
Amyotrophy!(atrophy!&!areflexia)!of!arms!
Upper!motor!neurone!signs!in!lower!limbs!

&

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The&Thyroid&Examination&
.

.
.

Comprises!of!3!parts!
! Thyroid!gland!
! The!neck!.!structures!surrounding!the!thyroid!gland!
! Thyroid!status!
If! asked! to! examine! the! thyroid,! peripheral! examinations!
should!also!be!performed!
If! asked! to! examine! the! neck! then! proceed! to! examination! of!
the! neck! then! proceed! to! peripheral! examination! if! the! lump!
may!be!a!thyroid!gland!
General'Inspection'

1. Introduction,'wash'hands'&'gain'consent''
2. Exposure'only'after'general'inspection:'whole'neck'
3. Comment'on'general'condition'of'the'patient'
.
.
.
.

Nervous/irritated!
Thin/obeses!
Any!staring!appearance!
Hoarseness!of!voice!

.
.

Clubbing!!acropathy!in!Graves.disease!
!

.
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Fine'tremor!!thyrotoxicosis.!
Sweaty'palms!.!thyrotoxicosis!
Palmar'erythema!!thyrotoxicosis!
Onycholysis!!thyrotoxicosis.!
Pulse:'rate'&'rhythm!!thyroid.status!
Carpel'tunnel'syndrome!.!hypothyroidism.

.
.

Periorbital'oedema''
Exophthalmos!(>18!mm!protrusion)!
! Both!lid!moved!away!from!centre!with!sclera!visible!below!
or!all!around!iris!
! Check!from!top!by!looking!over!forehead!&!at!the!side!
! Can!be!recorded!by!Hertel!exophthalmometer!!
Lid'retraction'
! Overactivity! of! involuntary! part! of! levator! palpebrae!
superioris!

4. Nails'

5. Hand'

6. Face'

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! Upper!lid!raised!&!lower!lid!normal!
Lid'lag'(Graefes'sign)'
! Ask!patient!to!follow!your!finger!up,!hold!for!1!second!then!
quickly!moving!finger!downward!
! Patients! eyelind! movement! lags! behind! the! movement! of!
the!eyeball!
Chemosis!(oedema!of!conjunctiva)!
! Obstruction! of! normal! venous! &! lymphatic! drainage! of!
conjunctiva!by!increased!retro.orbital!pressure!
Pupil'size''
Inspection'

1. Mass'
.
.
.
.
.

Location!
Symmetry!
Nodular/diffused!
Consistency!
Regularity!

2. Distended'veins'
3. Movement'of'goiter'as'pharyngeal'muscles'contract'
! Ask!patient!to!sip!water!&!hold;!swallow!when!examiners!
ready!

4. Scar'
! Collar/Kochers!scar!!thyroidectomy!!

5. Pembertons'sign'
.
.

Only!performed!when!mass!is!retrosternal!!
Pembertons' maneuver!!raising!both!of!patients!arms!above!
their!head!simultaneously,!as!high!as!possible!
! Facial!flushing!
! Distended!neck!&!head!superficial!veins!
! Inspiratory!stridor!
! Elevation!of!JVP!
Causes!
! Superior.vena.cava.obstruction..

6. Lower'extremities''
.
.

Pre.tibial!myxedema!!non.pitting!oedema!!
Proximal!myopathy!
! Ask!patient!to!rise!from!a!squatting!position!without!using!
hands!for!support!!
! Indication!of!thyroid!status!!!
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Palpation'

1. Trachea'
.

Performed!from!behind!

2. Thyroid'gland'
.
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.

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.

Size!
Site!
Tenderness!
! Tender'.!thyroidits!
Mobility!
! Fixed'to'surrounding'tissues!!carcinoma!
! Mobile!.!adenoma!
Consistency!!
! Firm'!simple.goiter!
! Rubbery'hard!!Hashimotos.thyroiditis!
! Stony,'hard'node!!carcinoma!
Ask!patient!to!swallow!again!and!confirm!whether!its!thyroid!
Attempt!to!get!below!the!mass!!

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.
.

Submental!
Submandibular!
Pre.auricular!
Post.auricular!
Anterior!triangle!
Jugular!chain!
Posterior!triangle!
Supraclavicular!
Infraclavicular!
Occipital!!

.
.

3. Regional'lymph'nodes'

Percussion'
.

Retrosternal!goiter!
! Percuss!clavicle!&!from!sternum!below!suprasternal!notch!
Auscultation'

.
.
!

Bruit!
! Thyroid!mass!
! Hypervascular'state!!Graves.disease!
Carotid!bruit!!
60!

! ! !

Joyce!Kwan!

!
Following'thyroid'investigations'

1. Thyroid'function'test''
.

Blood!test!for!!
! Thyroid!stimulating!hormone!(TSH)!
! Free!thyroxine!(fT4)!
! Free!triiodothyronine!(fT3)!

2. Fine'needle'biopsy'
3. Ultrasound''

With! nuclear! medicine! ! radioactive! technetium! or! iodine!

imaging!of!thyroid!
! Hot' nodule! +! lower! than! normal! TSH! ! non.cancerous!
nodule!
Summary'of'signs'of'common'illnesses'

Hyperthyroidism'
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

Fine!tremor!
Onycholysis!
Palmar!erythema!
Sweaty!palms!
Sinus!tachycardia!
Proximal!myopathy!
Exophthalmos!
Chemosis!
Corneal!ulceration!
Optic!atrophy!
Lid!retraction!
Lid!lag!
Thyroid!enlargement!
Gynaecomastia!
Pretibial!myxedema!!

Hypothyroidism'
.
.
.
.
.
.
!

Myxedema!
Cold!intolerance!
Muscle!pains!
Oedema!!
Constipation!
Hoarse!voice!
61!

! ! !

Joyce!Kwan!

.
.
.
.
.
.
!

!
Dry!skin!
Memory!loss!
Depression!
Weight!gain!!
Peripheral!cyanosis!!
Alopecia!!

&

62!

! ! !

Joyce!Kwan!

The&Rheumatological&Examination&
General'Inspection'

1. Introduction,'wash'hands'&'gain'consent''
2. Exposure'only'after'general'inspection:'whole'arm'
3. Comment'on'general'condition'of'the'patient'
.

Face!
! Expressionless! facies! with! adherent! shiny! skin,! sometimes!
with!telangiectasis:!systemic!sclerosis!
! Exophthalmos!
Inspection'(look)'

1. Posture'
2. Nails'
.
.
.
.
.
.

Vasculitis!!rheumatoid.arthritis!
Nail'pitting'.psoriasis!!
Onycholysis!!psoriasis!
Ridging!!psoriasis!
Hyperkeratosis!!psoriasis!
Discoloration'.psoriasis!

Joint!deformity!
! Swangneck'deformity!!rheumatoid.arthritis!
! Boutonniere'deformity!!rheumatoid.arthritis!
! Z'deformity'of'the'thumb'!rheumatoid.arthritis!
! Ulnar!deviation'of'the'finger!!rheumatoid.arthritis!!
! Heberdens'node'(DIP)!!osteoarthritis!!
! Bouchards'node!!osteoarthritis!!
! Gouty'tophi!!gouty.arthritis!!

Colour!
! Palmar'erythema'
! Pigmentation'of'the'skin'crease'
Consistency!
! Tight'&'shiny!!scleroderma!
! Papery'thin'with'purpuric'patches!!steroid.therapy!
! Thick!!acromegaly!
!

3. Hand'

4. Skin'

63!

! ! !

Joyce!Kwan!

5. Muscle'wasting'
.
.
.

Small' muscles' of' the' hand' !rheumatoid.arthritis,.ulnar.nerve.

palsy,.median.nerve.palsy,.T1.spinal.cord.level.lesion.
Thenar'wasting!!median.nerve.palsy!.
Generalised'wasting'sparing'thenar!!ulnar.nerve.palsy!
Palpation'(feel)'

1. Temperature'
.

Use! dorsum! of! hand! from! proximal! ! distal! .! active!

inflammation!

2. Tenderness'
3. Joint'swelling'
.
.
.

4!fingers!techniques!!joint!swelling!over!DIP!&!PIP!
! Fluid!
! Synovial!thickening!
3!fingers!techniques!!MCPJ!
2!fingers!techniques!!waist!(especially!ulnar)!
Move'

.
.

Active!then!passive!!if!limited,!determine!
! Fixed!joint!problem!
! Weakness!
Test!power!&!range!!
Following'rheumatological'investigations'

1. Blood'test'
.
.
.

Erythrocyte'sedimentation'rate'(ESR)!!active.inflammation!
Cgreactive'protein'(CRP)!!active.inflammation!especially!SLE!
Plasma' viscosity! ! (more! specific! marker! of! acute.phase!
response)!.!active.inflammation!!
Anaemia' &' thrombocytosis! ! inflammatory.disease! especially.
SLE!
Serum' complement! ! activation! due! to! immune! complex!
deposition!especially!SLE!
Uric'acid!!gout!!

Rheumatoid!arthritis!

.
!

Systemic!lupus!erythematosus!!!
64!

.
.

2. Rheumatoid'factor/antiOCCP'test'
3. Antinuclear'antibody'tests'(ANA)'
! ! !

Joyce!Kwan!

4. Uric'acid'
5. Synovial'biopsy'
.

Septic!arthritis!

6. Radiological'examination'
Rheumatoid&arthritis&
Symmetrical'polyarthritis'
Marginal'erosions'
Minimal'osteophyte'
General'osteopenia'

Osteoarthritis&
Asymmetrical!
Subchondral!sclerosis!!
Osteophyte!present!
Juxta.articular!osteosclerosis!

Summary'of'signs'of'common'illnesses'
Osteoarthritis'
.
.
.
.
.
.
.
.

Pain!on!movement!&!crepitus!
Background!pain!at!rest!
Initiating!pain!&!morning!stiffness!
Involvement!of!weight.bearing!joints!
Progressive!degeneration!&!osteophyte!formation!
Heberdens!nodes!(DIP!bony!enlargements)!
Bouchards!nodes!(PIP!bony!enlargements)!
Joint!effusion!of!the!knee!

Rheumatoid'arthritis''
.
.
.
.
.
.
.
.
.

Splinter.like!vasculitic!changes!
Symmetrical!small!joint!synovitis!(DIP!joints!are!usually!spared)!
Ulnar!deviation!
Volar!subluxation!of!MCP!
Z.deformity!of!thumb!with!swan!neck!&!boutonnire!deformity!
of!the!fingers!
Wasting!of!small!muscles!of!the!hand!
Palmar!erythema!
Median/ulnar!nerve!palsy!
Rheumatoid!nodules!around!the!elbows!!

Reiters'syndrome'(reactive'arthritis)'
.
.
.
!

Urethritis!
Conjunctivitis!
Arthritis!(usually!asymmetrical)!of!large!weightbearing!joints!
65!

! ! !

Joyce!Kwan!

!
Ankylosing'spondylitis'
.
.
.
.
.
.

Lumbar!lordosis!
Thoracic!kyphosis!
Severe!flexion!deformity!of!the!lumbar!spine!
Tenderness!of!lumbar!vertebrae!!
Tenderness!of!sacroiliac!joints!
Achilles!tendinitis!

Psoriatic'arthritis'
.
.
.
.
.

Monoarticular! &! asymmetrical! oligoarticular! arthritis! of! the!

hands!&!feet!&!other!joints!
Symmetrical! polyarthritis,! similar! to! rheumatoid! arthritis! (but!
seronegative)!
Distal! interphalangeal! joint! involvement! with! psoriatic! nail!
changes!
Destructive!polyarthritis!
Sacroiliitis!with!or!without!peripheral!joint!involvement!!

Gouty'arthritis'
.
.
.

Gouty!arthritis!of!MTP!joint!of!great!toe!
Gouty!arthritis!of!ankles!&!knees!
Gouty!tophi!chalk!stone!

Systemic'lupus'erythematosus''
.
.
.
.
.
.
.

Weight!loss!
Vasculitis.appearing!lesions!around!nail!bed!
Telangiectasia!&!erythema!of!skin!of!nail!bed!
Butterfly!rash!
Synovitis!of!the!proximal!&!MCP!joints!
Proximal!myopathy!!
Headache!!
!

&

66!

! ! !

Joyce!Kwan!

Clinical&Investigations&
Blood'Tests'
Full'Blood'Count'
Parameters'
WBC'
RBC'

Normal'range'
4!!11!x!109/L!
Men:!4.5!!6.5!x!109/L!
Women:!3.9!!5.6!x!109/L!
Haemoglobin'
Men:!13!!18!g/dL!!
Women:!11.5!!16!g/dL!
HCT'
Men:!0.4!!0.54!
Women:!0.37!!0.47!
MCV'
76!!96!fL!
MCH'
26!!32!pg!
MCHC'
300!!360g/L!
RDW'
11!.!16!
Platelet'count'
150!!400!x!109/L!
MPV'
7.5!!11.5!fL!
Parameters'
Normal!range!
Neutrophils'
1.7!!8.0!x!109/L!
Lymphocytes'
1!!4!x!109/L!
Monocytes'
0.2!!1.5!x!109/L!
Eosinophils'
0!!0.5!x!109/L!
Basophils'
<1!x!109/L!
%'Neutrophils'
40!!75%!
%'Lymphocytes'
20!!45%!
%'Monocytes'
1!!6%!
%'Eosinophils'
<1%!
%&Basophils&
<1%!
. WBC!!raised!in!infection!
! Neutrophilia''
Infections.(bacterial,.fungal).
Trauma.(surgery,.burns).
Acute.inflammation.(acute.MI,.infarct).
Inflammation.(gout,.RA,.UC,.Crohns.disesase).
Malignancy.(solid.tumours,.Hodgkin.lymphoma.
!

67!

! ! !

Joyce!Kwan!

!
Myeloproliferative. disease. (polycynthaemia. vera,.
CML).
Physiological.(exercise,.pregnancy).
! Lymphocytosis'
Acute. viral. infections. (hepatitis,. CMV. infection,.
infectious.mononucleosis).
Some.protozoal.infections.
Lymphoproliferative.disease.(CLL,.ALL,.lymphoma).
PostXsplenectomy..
Chronic.intracellular.infections.(TB,.brucellosis).
! Eosinophilia'
Allergic.reactions.!
Parasitic.infections!
Hodgkins.lymphoma!
SLE!
! Monocytosis'
Infection..
Myeloproliferative.disorders.
Chronic.neutropenia.
Hodgkins.lymphoma.
Certain.leukemias.
SLE.
Rheumatoid.arthritis..
Sarcoidosis..
! Basophilia''
Allergic.reactions.
Inflammation.
Endocrinopathy.(diabetes.mellitus,.hypothyroidism).
Iron.deficiency.
Myeloproliferative. disorders. (CML,. primary.
myelofibrosis).
Haemoglobin!!reduction!causes!anaemia.
! Macrocytic'hyperchromic'(MCV'&'MCH)+
B12,.folate.deficiency.
Liver/thyroid.diseases.
Cold.agglutinin.disease.
Haemolytic.anaemia..
! Normocytic'&'normochromic'(normal'MCV'&'MCH)+
Chronic.diseases.
Renal.disease.
Acute.blood.loss.

68!

! ! !

Joyce!Kwan!

!
BoneXmarrow.failure..
! Microcytic'hypochromic'(MCV'&'MCH)+
Fe.deficiency.
Thalassemia.
Chronic.diseases.
Lead.(Pb).poisoning.

Clotting'profile'
Parameters'
Normal'range'
INR'
0.9!!1.3!
Prothrombin'Time'
10!!15!seconds!
APTT'ratio''
0.7!!1.2!
Parameters'
Normal!range!
Thrombin'Time''
12!!16!seconds!
Fibrinogen'Level'
1.5!!4.0!g/L!
Dgdimer'
Negative!
. PT' measures' intrinsic' pathway' (factor' VII,' X,' V,'
prothrombin'&'fibrinogen)''prolonged'in'
! Administration.of.vitamin.K.antagonists.(warfarin).
! Liver.disease.
! Vitamin.K.deficiency.
! Factor.II,.V,.VII.&.X.deficiencies/inhibitors.
. APTT' measures' extrinsic' pathway' (factor' V,' VII,' IX,' X,' XI,'
XII,'prothrombin'&'fibrinogen)''prolonged'in'
! Factor.VIII,.IX,.XI,.XII.deficiency.
! Administration.of.heparin.
! Lupus.anticoagulant.
. TT'measures'fibrinogen'&'thrombin''prolonged'in'
! Hypofibrinogenaemia.(congenital,.DIC).
! Dysfibrinogenaemia.(inherited,.liver.disease).
! Presence.of.heparin,.paraprotines.
! Raised.concentration.of.fibrin.degradation.product.(DIC).
. Dgdimer' is' a' fibrin' degradation' product' ' presence' in'
thrombosis.
! Deep.venous.thrombosis.
! Pulmonary.embolism.
! Disseminated.intravascular.coagulation..
.
.
!

69!

! ! !

Joyce!Kwan!

!
Iron'profile'

Parameters'
Normal'range'
Fe'
6.6!!30.5!mol/L!
TIBC'
41!!77!mmol/L!
Fe'saturation''
33%!
Ferritin'
47!!889!pmol/L!
Parameters'
Normal!range!
Ceruloplasmin''
0.2!!0.6!g/L!
Total'serum'copper'
11!!12!mol/L!
24ghour'
urinary' 0.01!!0.06!mg/day!
copper'
. Iron'deficiency'
! !.!Serum!Fe!
! !.!TIBC!
! !.!%!Saturation!(<10%)!
! !.!Serum!ferritin!
! Confirmatory!test:!underlying'cause!
. Thalassemia'('&')'
! N!or!!.!serum!Fe!
! N!.!TIBC!
! N!or!!.!%!saturation!
! N!or!!.!serum!ferritin!
! Confirmatory!test:!haemoglobin'pattern!
. Chronic'inflammation/malignancy'
! !.!Serum!Fe!
! N!or!!!TIBC!
! .!%!Saturation!
! !.!Serum!ferritin!
! Confirmatory!test:!underlying'disease!
. Sideroblastic'anaemia'
! !.!Serum!Fe!
! N!!TIBC!
! !.!%!Saturation!(>80%)!
! !.!Serum!ferritin!
! Confirmatory!test:!bone'marrow!!
!
!
!
!

70!

! ! !

Joyce!Kwan!

!
Liver'Function'Test'

Parameters'
Normal'range'
Total'protein'
60!!80!g/L!
Albumin'
33!!49!g/L!
Globulin'
35!!51!g/L!
Bilirubin'
3!!17!mol/L!
Alkaline'phosphatase'(ALP)'
25!!110!IU/L!
Alanine'
aminotransferase' Men:!10!!50!IU/L!
(ALT)'
Women:!5!!38!IU/L!
Aspartate' aminotransferase' Men:!8!!40!IU/L!
(AST)'
Women:!6!!34!IU/L!
Gamma'
glutamyl' <!65!IU/L!
transpeptidase'(GGT)'
. Total!protein!&!albumin.X.Synthetic!function!of!the!liver!
! Liver.cirrhosis.!
. Globulin!!
! Raised!in!inflammation!
. Bilirubin!!Metabolic!&!excretory!function!
! High!bilirubin!
Jaundice!(>!30!mol/L:!detectable)!
Preghepatic!(unconjugated!bilirubin)!
ImmuneXmediated.haemolysis.
Non.immune!
mediated.
(G6PD.
deficiency,. hereditary. spherocytosis,.
thalassemia).
Resorption.of.haematoma.
Transfusion.error..
Hepatic'(conjugated!bilirubin)!!
Acute/chronic.liver.disease.
Viral.hepatitis.
DrugXinduced.liver.injury.
Liver.cirrhosis..
Infiltrative. disease. or. mass. lesion. in.
the.liver.
Abnormal! bilirubin! metabolism:.
CriglerXNajjer.syndrome..
Severe.sepsis.
Gilbers. syndrome:. problem! of!
conjugation! step! in! the! liver! thus!
!

71!

! ! !

Joyce!Kwan!

!
cannot!change!unconjugated!bilirubin!
!conjugated!bilirubin!!
Postghepatic''
Intraluminal! biliary! obstruction!
(stones,.blood,.Clonorchis.sinensis)!
Intramural!
biliary!
obstruction!
(cholangiocarcinoma,.strictures)!
Extraluminal! biliary! obstruction!
(tumour.compression,.lymph.nodes)!
Cholestasis! (drugs,. postXhepatitis,.
total. parenteral. nutrition,. primary.
biliary. cirrhosis,. primary. sclerosing.
cholangitis)!
ALP!!Bile!duct!enzyme!
! High'ALP'
Biliary.pathology.
Need!to!exclude!bone!pathology!(bone!profile,!ALP!
isoenzymes,!
gamma.glutamyl!
transpeptidase/GGT)!
ALT!&!AST!!Liver!enzyme!
! Commonly!used!interchangeably!however!
ALT!!cytoplasmic!enzyme!
AST! ! mitochondrial! enzyme,! which! may! be!
specific!to!!
Mitochondrial!
toxin!
e.g.!
alcohol,.
antiretroviral.drugs.
Ischaemic.hepatitis.
Cirrhosis:!High'AST/ALT'ratio!
AST! is! also! a! cardiac! enzyme! thus! will! be!
elevated!in!acute!MI!
!

72!

! ! !

Joyce!Kwan!

!
!
.
.

.
.

FollowKup+investigations+for+preKhepatic+jaundice+
Direct!bilirubin!
Lactate!dehydrogenase!(LDH)!
! Non.specific! marker! for! blood! cell! turnover! !
haemolysis!!high!LDH!
Haptoglobin!
! Haemolysis!!low!haptoglobin!level!(used!up)!
Reticulocyte!count!
! Blood! loss/haemolysis! ! bone! marrow! increases!
blood! production! &! pushes! reticulocytes! into! system!
to!support!vasculature!
Direct!Coombs!test!
! Support! diagnosis! of! immune! mediated! haemolytic!
anaemia!

!
'

Jaundice+
Preghepatic' Hepatic'

Urine'
Stool'

Normal!
Normal!

Dark!
Normal!

Urine'bilirubin'
Urine'
urobilirubinogen'
ALP'
ALT'
Prothrombin'
Time'

.!
+!

+!
+!

Nature'
bilirubin'

Postg
hepatic''
Dark!
Clay.
coloured!
+!
.!

Normal!
Normal!
Normal!

!
!
Prolonged,!
not!
correctable!
by! vitamin!
K!
of' Unconjugated! Conjugated!
(indirect)!
(direct)!

73!

! ! !

!
!
Prolonged,!
correctable!
by! vitamin!
K!
Conjugated!
(direct)!

Joyce!Kwan!

!
'

!
FollowKup+investigations+for+hepatitis+
Acute'hepatitis'
Chronic'hepatitis'

Viral'serology'

Autoimmune'
markers'

Metabolic''

Renal'Function'Test'

IgM!anti.HAV!
IgM!anti.Hbc!
HBsAg!
Anti.HCV!
HCV!
RNA!
(circulating!
virus)!
IgM!anti.HEV!
ANA! (sensitive!
but!not!specific)!
Anti.SMA!
(specific! but! not!
sensitive)!
Ig!
pattern!
(increased!
in!
autoimmune)!
Serum!
ceruloplasmin!
(Wilsons.disease)!

HBsAg!
Anti.HCV!

ANA!
(anti.nuclear!
antibody)!
Anti.SMA!
(anti.
smooth!
muscle!
antibody)!
Ig!pattern!!

Serum!ceruloplasmin!
Iron!
profile!
(hereditary.
!
haemochromatosis)!
Ferritin!
1.antitrypsin!!
Normal'range'
Drugs!
2.5!!6.7!mmol/L!
79!!118!mol/L!
135!!146!mmol/L!
3.5!!5.9!mmol/L!
2.20!!2.67!mmol/L!
7.35!!7.45!
35!!45!torr!
>79!torr!
22!!26!mmol/L!
.2!.!+2!mEq/litre!
95%!.!100%!!

Parameters'
Drugs''
Urea'
Creatinine'
Na+'
K +'
Ca2+'
pH'
pCO2'
pO2'
HCO3'
Base'Excess'
O2'Saturation'
. Blood!urea!nitrogen!(urea)!
! Nontoxic! substance! made! by! the! liver! to! dispose! of!
ammonia!resulting!from!protein!metabolism!
! Sensitive!indicator!of!renal!disease!!
!
74!
! ! !
!
Joyce!Kwan!

!
! Increased!BUN:!azotemia!
Increased!protein!catabolism!!
Increased.dietary.protein.
Severe!stress:!MI,.fever!
Rhabdomyolysis.
Upper.GI.bleeding.
Impaired!kidney!function!
Pregrenal'azotemia:!renal.hypoperfusion!
Renal'azotemia:!acute.tubular.necrosis!
Postgrenal'azotemia:!obstruction.of.urinary.
flow!
Creatinine!
! Breakdown! product! of! creatine! phosphate! released! from!
skeletal!muscle!at!steady!rate!
! Filtered!by!glomerulus!
! More!sensitive!&!specific!test!for!renal!function!
! Increased!serum!creatinine!caused!by!
Impaired.renal.function.
Anabolic.steroid.users.
Very. large. muscle. mass. (body. builders,. giants,.
acromegaly).
Rhabdomyolysis/crush.injury.
Athletes.taking.oral.creatine.
Drugs.
Probenecid.
Cimetidine.
Triamterene.
Trimethoprim.
Amiloride.
! Creatinine!clearance!used!to!estimate!GFT!!
BUN/Creatinine!ratio!
! High!!pre.renal:!dehydration!
! Low!!infra.renal:!renal.damage!!
Reduced! reabsorption! of! BUN! therefore! lowering!
ratio!!
Potassium!!
! Important!in!maintaining!of!osmotic!balance!between!cells!
and!interstitial!cells,!prevents!muscle!contraction!&!sending!
all!nerve!pulses!in!animals!through!action!potentials!
! Hyperkalemia! causes! malaise,! palpitations,! muscle!
weakness!
75!

! ! !

Joyce!Kwan!

!
Pseudohyperkalemia!
Haemolysis!
Overnight!storage!of!whole!blood!
Thrombocytosis/leukocytosis!
EDTA!contamination!
Reduced!renal!excretion!
Acute/chronic!renal!failure!
Potassium.sparing!
diuretics!
(spironolactone,!triamterene,!amiloride)!
ACE!inhibitors!
Mineralocorticoid!deficiency!
Release!from!cells!
Insulin!deficiency!(DM)!
Rapid!cell!breakdown!(crush!injury,!tumour!
lysis!syndrome)!
Digoxin!overdose!
! Hypokalemia! causes! cardiac! arrthymias,! myalgia,!
constipation,!hyporeflexia!
Excess'renal'loss'
Non.potassium! sparing! diuretics! (thiazides,!
frusemide)!
Osmotic!diuresis!
Metabolic!alkalosis!
Mineralocorticoid!excess!
Magnesium!deficiency!
Renal!tubular!acidosis!
Excess'nongrenal'loss'
Diarrhoea!
Laxative!abuse!
Villous!adenoma!
Bowel!fistulae,!ileostomies!
Increased!sweat!loss!
Reduced'intake'
Alcoholics!
Anorexics!
Transfer'into'cells'
Insulin!excess!
Metabolic!alkalosis!
2.sympathomimetics!(salbutamol)!
!

76!

! ! !

Joyce!Kwan!

!
!
Sodium!
! Osmolality!=!2!x!Na+!+!glucose!+!urea!!
! Osmolar' gap' =! measured! osmolality! ! calculated!
osmolality!
! Urine'osmolality:!500!!1200!mmol/kg!
! Serum'osmolality:!285!!295!mmol/kg!
! Used! in! regulation! of! blood! volume,! blood! pressure,!
osmotic!equilibrium!&!pH!
! Hypernatremia!!
Water!depletion!
Extra'renal'loss'
Osmotic.diuresis.
Diabetes.insipidus.
Excess'nongrenal'loss'
Vomiting.
Diarrhoea.
Gut.obstruction.
Burns.
Reduced'fluid'intake'
Unconscious..
Coma.
Salt!gain!
Oral'intake!.!sea.water.ingestion!
Parenteral' intake! .! hypertonic. saline.
infusion!
Reduced' Na+' excretion!.!mineralocorticoid.
excess!
Urine:plasma'osmolality'ratio'
~1!!osmotic.diuresis!
<1!!diabetes.insipidus!
>1!!check!urine!spot!sodium!
! Hyponatremia!
Dilutional'
SIADH.
Liver.cirrhosis,.nephrotic.syndrome,.CHF.
Excessive.IV.fluid.
Psychogenic.polydipsia.
Fluid!depletion!
Renal'loss'
Diuretics.
77!

! ! !

Joyce!Kwan!

!
Mineralocorticoid.deficiency.
SaltXlosing.nephritis.
Nongrenal'loss'
Vomiting!
Diarrhoea!
Burns!!
Plasma!osmolality!!
Increased:!hyperosmolar!sodium!!

ABG!
! Acidaemia/Alkalemia'
! Primary'respiratory/metabolic'disturbances'
Metabolic!acidosis:!!HCO3.!&!!pCO2!
Respiratory!acidosis:!!HCO3.!&!!pCO2!
Metabolic!alkalosis:!!HCO3.!&!!pCO2!
Respiratory!alkalosis:!!HCO3.!&!!pCO2!
! Compensation'
Respiratory!compensation'
Metabolic!acidosis!(winters!formula)!!
Expected! PaCO2! (mmHg)! =! 1.5! x!
HCO3.!+!8!
Measured! >! calculated! =! primary!
respiratory!acidosis!
Calculated! >! measured! =! primary!
respiratory!alkalosis!!
Metabolic!alkalosis!!
Expected! PaCO2! (mmHg)! =! 0.7! x!
HCO3.!+!21!
Fast!track:!
pH!=!7.30!!30!mmHg!PaCO3!
!
Only! applicable! if! pH!
between!7.05!!7.60!
Metabolic!compensation!
Acute!respiratory!acidosis!
Expected!HCO3.!=!

(!"#$!! !!")
!"

!+!24!

Chronic!respiratory!acidosis!
Expected!HCO3.!=!

(!"#$!! !!")
!

!+!24!

Acute!respiratory!alkalosis!
(!"!!!"#$!! )
Expected!HCO3.!=!
!+!24!
!

Chronic!respiratory!alkalosis!
78!
! ! !
!

Joyce!Kwan!

!
.!=!

(!"!!!"#$!! )

Expected!HCO3
!
! Anion'gap'(Na+'+'K+)''(Clg'+'HCO3g)'
Normal:!12!!14!mmol!
! 'Anion'gap/'HCO3g'
Calcium!
(!"!!"#!"#$)
! Calculated!Ca2+!=!
!+!measured!Ca2+!

!+!24!

!"

Thyroid'function'test'
'
sTSH'
increase'
sTSH'
normal'
sTSH'
decrease'

fT4'increase'
Secondary!
hyperthyroidism!
Acute! overdose!
of!thyroxine!
Hyperthyroidism!!

fT4'normal'
fT4'decrease'
Recently! treated! Hypothyroidism!
hypothyrodisum!
Normal!
!
Recently! treated! Secondary!
hyperthyroidism! hypothyroidism!
T3!toxicosis!
T3!toxicosis!

79!

! ! !

Joyce!Kwan!